Treatment of dental plaque biofilms using photodynamic therapy: a randomised controlled study.

INTRODUCTION: Photodynamic therapy (PDT) is a treatment modality involving a dye that is activated by exposure to light of a specific wavelength in the presence of oxygen to form oxygen species causing localised damage to microorganisms. AIM: To determine the most effective bactericidal incubation and irradiation times of erythrosine-based PDT on in vivo-formed dental plaque biofilms. METHODS: A randomised controlled study; 18-healthy adult participants wearing intraoral appliances with human enamel slabs to collect dental plaque samples in two separate periods of two weeks each for use in arm-1 and arm-2. These accumulated dental plaque samples were treated with PDT under different experimental conditions. Incubation times with photosensitiser (erythrosine) of 15 min and 2 min were used in arm-1 and arm-2, respectively, followed by light irradiation for either 15 min (continuous) or as a fractionated dose (5 × 30 sec). Following treatment, percentage reductions of total bacterial counts were compared between the different groups. In addition, confocal laser scanning microscopy (CLSM) and LIVE/DEAD® BacLight™ Bacterial Viability Kit were used to visualise the effect of PDT on in vivo-formed biofilms. RESULTS: Significant reductions in the percentage of total bacterial counts (~93-95%) of in vivo-formed biofilms were found when using either 2 min or 15min incubation times and applying 15 min continuous light. Although when applying fractionated light, there was more cell death when 15 min incubation time was used (~ 91%) compared with the 2 min incubation time (~ 64%). CLSM results supported these findings. CONCLUSION: Improving the clinical usefulness of PDT by reducing its overall treatment time seems to be promising and effective in killing in vivo-formed dental plaque biofilms.

A study of the control of oral plaque biofilms via antibacterial photodynamic therapy.

AIM: The aim of this study was to provide preliminary data on the most effective erythrosine concentration and light dose for the erythrosine-based photodynamic therapy (PDT) of oral plaque biofilms formed in vivo. METHOD: A randomised controlled study with 15 volunteers was carried out to investigate the effect of photo-sensitiser and light dose on the killing of bacteria in oral plaque biofilms formed in vivo. All volunteers wore a removable in situ appliance carrying six enamel slabs for two phases of 2 weeks each. During this time, plaque biofilms accumulated on the enamel slabs. The slabs were then removed from the appliances for PDT treatment in vitro. In the first phase of the study, erythrosine doses of 22 and 220 µM were used for the photodynamic treatment of the biofilms. In the second phase, the erythrosine concentration was kept constant, and the light dose was varied. Following treatment, the biofilms were disaggregated, and the total bacterial killing was determined using colony counting. RESULTS: The erythrosine dose of 220 µM caused the most cell killing relative to controls. Fifteen minutes of continuous irradiation with light and light fractionation of 5 × 1 min irradiation separated by 2-min-dark recovery periods were found to be the most effective bactericidal regimes. CONCLUSION: Erythrosine-based PDT shows promise as an antibacterial treatment for oral plaque biofilms. Further research is needed to prove its clinical and cost-effectiveness compared with current best practice.

Human C4orf14 interacts with the mitochondrial nucleoid and is involved in the biogenesis of the small mitochondrial ribosomal subunit.

The bacterial homologue of C4orf14, YqeH, has been linked to assembly of the small ribosomal subunit. Here, recombinant C4orf14 isolated from human cells, co-purified with the small, 28S subunit of the mitochondrial ribosome and the endogenous protein co-fractionated with the 28S subunit in sucrose gradients. Gene silencing of C4orf14 specifically affected components of the small subunit, leading to decreased protein synthesis in the organelle. The GTPase of C4orf14 was critical to its interaction with the 28S subunit, as was GTP. Therefore, we propose that C4orf14, with bound GTP, binds to components of the 28S subunit facilitating its assembly, and GTP hydrolysis acts as the release mechanism. C4orf14 was also found to be associated with human mitochondrial nucleoids, and C4orf14 gene silencing caused mitochondrial DNA depletion. In vitro C4orf14 is capable of binding to DNA. The association of C4orf14 with mitochondrial translation factors and the mitochondrial nucleoid suggests that the 28S subunit is assembled at the mitochondrial nucleoid, enabling the direct transfer of messenger RNA from the nucleoid to the ribosome in the organelle.

Subunit structures in hydroxyapatite crystal development in enamel: implications for amelogenesis imperfecta.

Previous freeze-etching studies of developing enamel revealed collinear arrays of spherical structures (approximately 50 nM dia) of similar width to the crystals of mature tissue. Concomitant with matrix degradation/processing, spherical structures became less distinct until, coincident with massive matrix loss, only crystal outlines were seen. More recently, using Atomic force microscopy technology, early crystals exhibited topology reminiscent of these collinear spherical structures. After matrix loss these were replaced by similarly sized bands of positive charge density on the crystal surfaces. The data suggest enamel crystals may form from mineral-matrix spherical subunits. Matrix processing may generate mineral nuclei and lead to their fusion and transformation into long apatite crystals. Support for this view derives from the appearance of short crystal segments in amelogenesis imperfecta (hypoplastic AI) or abnormally large crystals alongside 50 nM diameter spherical mineral subunits (hypomaturation AI). Mutation of matrix or processing enzymes leading to defective processing may have impaired mineral initiation, fusion, and subsequent growth.

Copper ions inhibit the demineralisation of human enamel.

Cu2+ is cariostatic in rats reportedly due to it bacteriocidal properties. Here, we report the use of a simple abiotic model system to investigate whether Cu2+ has any inhibitory effect on the acid dissolution of human enamel. Crowns were exposed to a sequence of seven 10 mmol/l acetic acid challenges. The mineral dissolved during each challenge was then determined. CuSO4 (10 mmol/l) was present during the fourth of these challenges. Loss of calcium and phosphate were reduced by 57 and 63%, respectively, (P<0.0001) in the presence of Cu2+. Losses were also significantly reduced during the next acidic challenge in the absence of Cu2+. The degree of protection was found to approach maximum at about 5 mmol/l Cu2+. The well-known cariostatic properties of Cu2+ may therefore be due not only to its ability to inhibit bacterial growth but also to its ability to directly inhibit acid dissolution of enamel.

Altered morphology in cultured rat intestinal epithelial IEC-6 cells is associated with alkaline phosphatase expression.

Non-transformed, rat intestinal epithelial cells (IEC-6), and human intestinal colonic carcinoma cells (CACO-2) have both been used to study processes of epithelial cell differentiation. However, only CACO-2 cells have been described as spontaneously expressing phenotypic changes of differentiation in culture. We report here that when IEC-6 cells are grown in post-confluent culture, they develop structural changes similar to those seen in cells induced to differentiate by culture on Englebreth-Holm-Swarm (EHS) extracellular matrix proteins. Correlated with this morphological change is loss of nuclear localization of c-myc protein and development of cell surface alkaline phosphatase (ALP) enzymatic activity. Messenger RNAs for liver and intestinal isoforms of ALP were expressed in both pre- and post-confluent cells. Inhibition of ALP activity in post-confluent cells by levamisole indicated the expressed ALP activity to be of the liver isoform. We suggest the expression of ALP activity, which occurs concomitantly with morphological alterations in post-confluent IEC-6 cells, represents increased expression and localization to the cell surface of the liver isoform of ALP. Cultured IEC-6 cells may provide a non-transformed, in vitro alternative to CACO-2 cells for study of epithelial cell differentiation.

Inheritance pattern and elemental composition of enamel affected by hypomaturation amelogenesis imperfecta.

Hypomaturation amelogenesis imperfecta (AI) is characterized clinically by enamel of normal thickness that is hypomineralized, mottled, and detaches easily from the underlying dentin. Autosomal dominant, autosomal recessive, X-linked, and sporadic modes of inheritance have been documented. The present study investigated the elemental composition of the enamel of teeth from individuals demonstrating clinical hypomaturation AI from families representing three of these patterns of inheritance. The aim of the study was to determine if there was any commonality in microscopic phenotype of this defect between families demonstrating the various inheritance patterns. One section from each tooth was microradiographed and then viewed in a scanning electron microscope (SEM) equipped with an ultrathin window energy-dispersive x-ray spectroscopy (EDX) detector. In the SEM, prisms and constituent crystals in discrete areas appeared to be largely obscured by an amorphous material. EDX analysis showed enamel outside these areas to have a composition indistinguishable from control teeth. However, within these affected areas there was a large increase in carbon content (up to a fivefold increase). In some teeth there was also a detectable but smaller increase in the relative amounts of nitrogen or oxygen. The results suggest the defect in these teeth with a common clinical phenotype, irrespective of the pattern of inheritance, demonstrates a commonality in microscopic phenotype. The large increase in carbon content, not matched by an equivalent increase in nitrogen or oxygen, suggests a possible increased lipid content. In those teeth with elevated nitrogen levels there may also be retained protein.

Characterization of a porcine amelogenin preparation, EMDOGAIN, a biological treatment for periodontal disease.

EMDOGAIN is derived from porcine developing enamel matrix and has been shown to facilitate regeneration of the periodontium, although its mechanism of action is unknown. The aim of the present study was to identify enamel matrix proteins and proteolytic enzymes present in EMDOGAIN and compare them with those extracted from developing porcine enamel itself. Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE), Western blotting, and zymography were used to identify the proteins present and to determine their enzyme activity. The results showed that developing enamel contained amelogenins, albumin, amelin, and enamelin. EMDOGAIN, however, contained only amelogenins. Both metalloendoproteases and serine protease activity were revealed in both EMDOGAIN and developing enamel. The roles of the amelogenin and enzyme components, if any, in periodontal regeneration are unknown.

Enamelin compartmentalization in developing porcine enamel.

The tissue compartmentalization of enamelin-processing products has been investigated in developing pig enamel using a sequential extraction procedure. Only trace amounts of enamelin-processing products were detected in simulated enamel fluid extracts, suggesting that enamelins are not solubilized in the matrix to any great extent. Subsequent phosphate buffer extraction desorbed and extracted several enamelin-processing products that were presumably bound to the mineral phase. A 35-kD processing product dominated the phosphate extract, suggesting that enamelin processing leads to an accumulation of this mineral-bound molecule. Dissociative extraction with urea subsequently extracted the remainder of the enamelin-processing products present. This material was presumably present in the tissue in an aggregated insoluble state. Several enamelin-processing products were only extracted by specific extraction procedures, suggesting that different enamelin-processing products are differentially compartmentalized. This may indicate that specific enamelin-processing products have different functions. In contrast to amelogenins, which are processed in the deeper tissue to generate products having a low affinity for the mineral, enamelin processing appears to produce products (those enamelins desorbed by phosphate buffer) that have a high affinity for the mineral. These products, appearing in the deeper enamel layers, may serve to influence crystal growth kinetics in the absence of any mineral-binding amelogenins.

Changes in the structure and density of oral plaque biofilms with increasing plaque age.

In common with many biofilms in nature, oral plaque has been shown to have a heterogeneous structure as shown by confocal microscopy. In the present study we have used confocal laser scanning microscopy (CLSM) to determine changes in the structure of plaque biofilms with increasing plaque age. Natural human plaque biofilms were formed using the Leeds in situ device. Plaque biofilms were allowed to form for periods of 2 days, 1 week, 2 weeks and 4 weeks before removal of the devices and immediate imaging using the CLSM. Confocal imaging showed that the biofilms retained their heterogeneous appearance at each of the time points studied but appeared to have a tendency to become somewhat more dense with increasing time. Image analysis demonstrated that the percentage of biomass within each biofilm increased over time, particularly between 2 days and 1 week, and with increasing depth into the biofilms. In addition, using the CLSM we were able to demonstrate changes in the bacterial flora of the biofilms with time, with many more filamentous forms being present at the 2- and 4-week time points.

Vascular ultrasound surveillance after endovascular intervention for occlusive iliac artery disease.

This paper describes vascular ultrasound surveillance after endovascular intervention for occlusive iliac artery disease. There were 105 patients who had 198 procedures in 155 limbs, consisting of 110 balloon dilatations and 88 stentings. The patients were referred to the vascular diagnostic service by several surgeons. All procedures had been considered to be initially technically successful. Colour-Doppler duplex ultrasound studies were performed shortly before and at serial intervals after operation to determine patency rates. Univariate life table analysis showed 69% primary and 96% assisted primary patency at four years. Primary patency rates at four years were significantly worse for stentings (60%) compared to balloon dilatations (71%) (P<0.05). Maximum peak systolic velocities (PSV) were recorded from the treated arteries. Receiver operating characteristics curves showed that PSV >300 cm/s was most accurate for predicting technical failure. Haemodynamic success rates at four years were 72% for PSV >300 cm/s. Results for procedures that were initially successful indicate that long-term primary patency rates for iliac endovascular intervention are acceptable and that assisted primary patency rates are excellent.

In vitro studies of the penetration of adhesive resins into artificial caries-like lesions.

Instead of removing the porous carious tissue at a relatively late stage in the disease process, attempts have been made to 'fill' the microporosities of lesions at a much earlier stage of lesion development. This would not only reduce the porosity and therefore access of acid and egress of dissolved material, but also afford some mechanical support to the tissue and perhaps inhibit further attack. Successful infiltration of materials into lesions has been demonstrated previously using resorcinol-formaldehyde which, however, was clinically unacceptable. The advent of dental adhesives with potentially suitable properties has prompted a re-examination of this concept. Artificial lesions of enamel were generated in extracted human teeth using acidified gels. A range of currently available adhesive materials was then used to infiltrate the porosities. The extent of occlusion of the lesion porosities was determined both qualitatively using light microscopy and quantitatively using a chloronaphthalene imbibition technique. The effect of such treatment upon subsequent exposure to acid gels was also investigated. Results showed that up to 60% of the lesion pore volume had been occluded following infiltration with some of the materials and that this treatment was capable of reducing further acid demineralization. The development of such treatment strategies could offer potential noninvasive means of treating early enamel lesions.

Amelin extracellular processing and aggregation during rat incisor amelogenesis.

Amelin (also known as ameloblastin and sheathlin) is a recently described protein that is secreted by ameloblasts during enamel formation. Here, the extracellular distribution and processing of amelin during rat incisor amelogenesis were investigated by Western blot probing using anti-recombinant rat amelin antibodies. In addition, the solubility behaviour and aggregative properties of rat amelin were investigated using a sequential extraction procedure involving (1) extraction with simulated enamel fluid to extract proteins most likely to be soluble in vivo; (2) extraction with phosphate buffer to desorb proteins bound to enamel crystal surfaces; (3) extraction with sodium dodecyl sulphate (SDS) to extract proteins present as insoluble aggregates; followed by (4) a final acid demineralization step to release any remaining proteins. Proteins immunoreactive to the anti-amelin antibodies were detectable in secretory- and transition-stage enamel. Maturation-stage enamel appeared devoid of amelin. The largest immunoreactive protein detected migrated at 68 kDa on SDS gels, corresponding to the M(r) of nascent amelin. Other immunoreactive bands at 52, 40, 37, 19, 17, 16, 15, 14 and 13 kDa were presumably amelin processing products. The sequential extraction procedure revealed that the 68-, 52-, 40-, 37- and 13-kDa amelins were completely extracted under solution conditions similar to those reported to exist in vivo. In contrast, the 19-, 17- and 16-kDa amelins were only partially extracted, whilst the 15- and 14-kDa amelins could not be extracted with simulated enamel fluid. A proportion of the remaining 17- and 16-kDa amelins was desorbed from the enamel crystals with phosphate buffer and appeared to have been mineral-bound. The 15- and 14-kDa amelins and the remainder of the 17- and 16-kDa amelins were extracted with SDS only, suggesting that these species were present in vivo as an insoluble aggregate. The results provide additional information on amelin processing and degradation, and on how such processing influences the solubility and aggregative properties of amelin-derived proteins.

Effect of experimental fluorosis on the surface topography of developing enamel crystals.

Dental fluorosis is an increasing problem, yet the precise mechanism by which fluoride exerts its effects remains obscure. In the present study, we have used atomic force microscopy to image and quantitate surface features of enamel crystals isolated from specific developmental stages of fluorotic and control rat incisors. The results showed a significant decrease in crystal surface roughness with development in control tissue. Crystals from fluorotic tissue were significantly rougher than controls at all stages of development, did not decrease in roughness during the later stages of their development and had many morphological abnormalities. These data clearly demonstrate an effect for fluoride on enamel crystal surfaces which could reflect changes in the nature and distribution of growth sites and/or in mineral-matrix interactions. These would be expected to affect crystal growth during maturation, resulting in the characteristic porous appearance of fluorotic lesions in mature teeth.

Spatially related amelogenin interactions in developing rat enamel as revealed by molecular cross-linking studies.

A cleavable cross-linker (dithiobis[succinimidyl propionate], DTSP) was used to investigate the subunit structure of the developing enamel matrix. Intact matrix was cross-linked under conditions chosen to simulate those found in vivo. The cross-linked complexes were isolated by preparative sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) and their subunit composition determined by analytical SDS-PAGE following reductive cleavage of the cross-links. Western blotting using antiamelogenin antibodies was used to confirm the identity of the proteins involved. The results showed that nascent amelogenins tended to be cross-linked to other nascent amelogenins while amelogenin-processing products tended to be cross-linked to other processed molecules at the same stage of processing. The results suggest that nascent amelogenins are in close association after secretion and during extracellular processing, and that processed products are not free to associate with nascent molecules, presumably due to diffusion constraints in the tissue. This conclusion implies that individual amelogenin molecules within supramolecular aggregates (nanospheres) are processed in situ and remain in the same nanosphere while all the individual component amelogenins undergo processing. The biological function of amelogenin processing remains unclear but the fact that amelogenin-amelogenin associations are maintained during processing indicates that matrix stability is an important factor while the enamel layer is being deposited.

Distribution of exogenous proteins in caries lesions in relation to the pattern of demineralisation.

While it is believed that proteins may protect enamel from demineralisation, recent work has indicated that such material may also hinder remineralisation. For example, albumin will inhibit apatite crystal growth in vitro and is present in carious enamel in vivo. However, it is not clear whether (1) the distribution of proteins within lesions is restricted to specific lesion zones or (2) the origin of such proteins is endogenous (i.e. as a remnant of the developmental process) or exogenous, originating in the saliva or gingival crevicular fluid. The present study used a combination of immunohistochemistry and microradiography to determine the distribution of two proteins, serum albumin and salivary amylase, within natural white-spot carious lesions in relation to specific levels of demineralisation. The results indicated that albumin is found primarily in a region of between 10 and 20% demineralisation (an area of transition between the 'dark' zone and lesion 'body'), with smaller quantities occurring in the region between 0 and 10% demineralisation and trace amounts in the zone indistinguishable from sound enamel by microradiography. A similar distribution was found for amylase in that the heaviest labelling was within the 10-20% demineralisation zone, although little if any was present in the 0-10% zone. The presence of these molecules in a region of the lesion where some potential for reprecipitation may exist will have important implications with respect to lesion progression.

Architecture of intact natural human plaque biofilms studied by confocal laser scanning microscopy.

Determination of the structure of human plaque will be of great benefit in the prediction of its formation and also the effects of treatment. However, a problem lies in the harvesting of undisturbed intact plaque samples from human volunteers and the viewing of the biofilms in their natural state. In this study, we used an in situ device for the in vivo generation of intact dental plaque biofilms on natural tooth surfaces in human subjects. Two devices were placed in the mouths of each of eight healthy volunteers and left to generate biofilm for 4 days. Immediately upon removal from the mouth, the intact, undisturbed biofilms were imaged by the non-invasive technique of confocal microscopy in both reflected light and fluorescence mode. Depth measurements indicated that the plaque formed in the devices was thicker round the edges at the enamel/nylon junction (range = 75-220 microm) than in the center of the devices (range = 35-215 microm). The reflected-light confocal images showed a heterogeneous structure in all of the plaque biofilms examined; channels and voids were clearly visible. This is in contrast to images generated previously by electron microscopy, suggesting a more compact structure. Staining of the biofilms with fluorescein in conjunction with fluorescence imaging suggested that the voids were fluid-filled. This more open architecture is consistent with recent models of biofilm structure from other habitats and has important implications for the delivery of therapeutics to desired targets within the plaque.

Evidence for charge domains on developing enamel crystal surfaces.

The control of hydroxyapatite crystal initiation and growth during enamel development is thought to be mediated via the proteins of the extracellular matrix. However, the precise nature of these matrix-mineral interactions remains obscure. The aim of the present study was to use a combination of atomic and chemical force microscopy to characterize developing enamel crystal surfaces and to determine their relationship with endogenous enamel matrix protein (amelogenin). The results show regular and discrete domains of various charges or charge densities on the surfaces of hydroxyapatite crystals derived from the maturation stage of enamel development. Binding of amelogenin to individual crystals at physiological pH was seen to be coincident with positively charged surface domains. These domains may therefore provide an instructional template for matrix-mineral interactions. Alternatively, the alternating array of charge on the crystal surfaces may reflect the original relationship with, and influence of, matrix interaction with the crystal surfaces during crystal growth.

The chemistry of enamel caries.

The chemical changes which occur during the process of carious destruction of enamel are complex due to a number of factors. First, substituted hydroxyapatite, the main component of dental enamel, can behave in a very complex manner during dissolution. This is due not only to its ability to accept substituent ions but also to the wide range of calcium phosphate species which can form following dissolution. In addition, the composition, i.e., the extent of substitution, changes throughout enamel in the direction of carious attack, i.e., from surface to interior. Both surface and positively birefringent zones of the lesion clearly illustrate that carious destruction is not simple dissolution. Selective dissolution of soluble minerals occurs, and there is the probability of reprecipitation. The role of fluoride here is crucial in that not only does it protect enamel per se but also its presence in solution means that rather insoluble fluoridated species can form very easily, encouraging redeposition. The role of organic material clearly needs further investigation, but there is the real possibility of both inhibition of repair and facilitation of redeposition. For the future, delivering fluoride deep into the lesion would appear to offer the prospect of improved repair. This would entail a delivery vehicle which solved the problem of fluoride uptake by apatite at the tooth surface. Elucidation of the role of organic material may also reveal putative mechanisms for encouraging repair and/or protecting the enamel mineral.

31P magnetic resonance spectroscopy as a predictor of efficacy in photodynamic therapy using differently charged zinc phthalocyanines.

Photodynamic therapy (PDT) is a developing approach to the treatment of solid tumours which requires the combined action of light and a photosensitizing drug in the presence of adequate levels of molecular oxygen. We have developed a novel series of photosensitizers based on zinc phthalocyanine which are water-soluble and contain neutral (TDEPC), positive (PPC) and negative (TCPC) side-chains. The PDT effects of these sensitizers have been studied in a mouse model bearing the RIF-1 murine fibrosarcoma line studying tumour regrowth delay, phosphate metabolism by magnetic resonance spectroscopy (MRS) and blood flow, using D2O uptake and MRS. The two main aims of the study were to determine if MRS measurements made at the time of PDT treatment could potentially be predictive of ultimate PDT efficacy and to assess the effects of sensitizer charge on PDT in this model. It was clearly demonstrated that there is a relationship between MRS measurements during and immediately following PDT and the ultimate effect on the tumour. For all three drugs, tumour regrowth delay was greater with a 1-h time interval between drug and light administration than with a 24-h interval. In both cases, the order of tumour regrowth delay was PPC > TDEPC = TCPC (though the data at 24 h were not statistically significant). Correspondingly, there were greater effects on phosphate metabolism (measured at the time of PDT or soon after) for the 1-h than for the 24-h time interval. Again effects were greatest with the cationic PPC, with the sequence being PPC > TDEPC > TCPC. A parallel sequence was observed for the blood flow effects, demonstrating that reduction in blood flow is an important factor in PDT with these sensitizers.