Objective

To quantify the reasons for placing restorations on non-carious tooth defects (NCTD) by Dental Practice-Based Research Network (DPBRN) dentists, and associated tooth, patient and dentist characteristics.

Methods

Data were collected on placement of 1,301 restorations due to NCTD by 178 DPBRN dentists. Information included: (1) main clinical occurrence or reason, other than dental caries, for restoring previously un-restored permanent tooth surfaces, (2) characteristics of patients who received treatment, (3) dentists’ and dental practices’ characteristics, (4) tooth and surfaces restored, and (5) restorative materials employed.

Results

Restorations were most often placed to treat abrasion, abfraction, and erosion (AAE) lesions (46%) and tooth fracture (31%). Patients older than 40 years received restorations mainly due to AAE (p<0.0001). Premolar and anterior teeth were mostly restored due to AAE; molar teeth were mostly restored due to tooth fracture (p<0.0001). Directly placed resin-based composite (RBC) was largely used to restore AAE and tooth fracture (p<0.0001).

Conclusion

AAE and tooth fracture are the main reasons for restoring non-carious tooth surfaces among DPBRN practices. Premolar and anterior teeth of patients older than 40 years are most likely to receive restorations due to AAE; molars are most likely to receive restorations due to tooth fracture. Both types of NCTD are most often restored with RBC.

Alkali production by oral bacteria is believed to have a major impact on oral microbial ecology and to be inibitory to the initiation and progression of dental caries. A substantial body of evidence is beginning to accumulate that indicates the modulation of the alkalinogenic potential of dental biofilms may be a promising strategy for caries control. This brief review highlights recent progress toward understanding molecular genetic and physiologic aspects of important alkali-generating pathways in oral bacteria, and the role of alkali production in the ecology of dental biofilms in health and disease.

Summary

This study investigated the concordance between pre- and post-operative assessments of primary caries lesions depths by dentists from The Dental Practice-Based Research Network (DPBRN; www.DentalPBRN.org). A total of 229 DPBRN dentists collected data on 8,351 consecutive restorations inserted due to primary caries in 5,810 patients. Dentists estimated the pre-operative depth of caries lesions based on the diagnostic methods they typically used. The pre-operative depth was then compared to the post-operative depth, which dentists determined using actual clinical observation. Both estimated and observed depths were recorded as being in the outer ½ (E1) or inner ½ (E2) of enamel, or in the outer ⅓ (D1), middle ⅓ (D2) or inner ⅓ (D3) of dentin. Most restorations were placed to treat lesions that were pre-operatively assessed as extending to the D1 (53%) and D2 (25%) depths. Of the restored caries lesions, 10% were pre-operatively assessed as being limited to E2 depth and 3% to E1 depth. The majority of the restored enamel lesions were located on occlusal surfaces. Pre-operative estimates of caries lesion depth were more concordant with post-operative depths when the lesion was at an advanced stage: 88% concordance at the D3 depth; compared to 54% concordance at the E1 depth. DPBRN dentists can discriminate caries lesions at different depths, but the accuracy of their depth assessments was higher for dentin than for enamel lesions. In general, DPBRN dentists were more likely to underestimate than to overestimate depth of caries lesions, and the extent of underestimation was greater for enamel than for dentin lesions.

Objective

To identify and quantify the reasons for placing restorations on unrestored permanent tooth surfaces and the dental materials used by Dental Practice-Based Research Network (DPBRN; www.DentalPBRN.org) dentists.

Methods

A total of 229 DPBRN practitioner-investigators collected data on 9,890 consecutive restorations from 5,810 patients. Information included: (1) reasons for restoring; (2) tooth and surfaces restored; and (3) restorative materials employed.

Results

Primary caries (85%) and non-carious defects (15%), which included abrasion/ abfraction/ erosion lesions and tooth fracture, were the main reasons for placement of restorations. Restorations due to caries were frequently placed on occlusal surfaces (49%), followed by distal, mesial, buccal/facial, lingual/palatal, and incisal surfaces. Amalgam was used for 46% of the molar and 45% of the premolar restorations. Directly placed resin-based composite (RBC) was used for 48% of the molar, 49% of the premolar, and 92% of the anterior restorations.

Conclusion

Dental caries on occlusal and proximal surfaces of molar teeth are the main reasons for placing restorations on previously unrestored tooth surfaces by DPBRN practitioner-investigators. RBC is the material most commonly used for occlusal and anterior restorations. Amalgam remains the material of choice to restore proximal caries in posterior teeth, although there are significant differences by DPBRN region.

Bacteria adhere to a surface and, through cell division and coordinated expression of gene products, to develop into a structurally-complex population of adherent cells. This process, known as biofilm formation, requires that intrinsic and extrinsic signals are transduced into appropriate gene expression patterns as biofilms mature. Mutational analysis has begun to reveal the complexity of systems used by Streptococcus mutans to ensure proper biofilm formation. These studies have revealed new and unique targets for the design of broadly-effective anti-caries strategies.

The agmatine deiminase system was identified in seven strains of mutans streptococci. Genes encoding the AgDS of Streptococcus rattus FA-1 were sequenced and found to share homology with the agu genes of Streptococcus mutans UA159. Agmatine inhibited bacterial growth, suggesting that the AgDS degrades a deleterious substance into useful compounds.

The RelA, RelP, and RelQ enzymes are responsible for the production of the alarmone (p)ppGpp in Streptococcus mutans. A strain lacking all three synthetases (ΔrelAPQ) does not grow in minimal medium lacking the branched-chain amino acids (BCAA) leucine or valine but grows well if isoleucine is also omitted. Here, we investigated whether there was a correlation between growth in the absence of leucine and valine with (p)ppGpp pools and the activation of CodY. By using a combination of single, double, and triple mutants lacking the (p)ppGpp synthetase enzymes, we demonstrated that the ability to grow in the absence of leucine or valine required basal levels of (p)ppGpp production by RelP and RelQ. The introduction of a codY mutation into the ΔrelAPQ strain fully restored growth in medium lacking leucine or valine, revealing that the growth-defective phenotype of ΔrelAPQ was directly linked to CodY. Lowering GTP levels through the addition of decoyinine did not alleviate CodY repression or affect the expression of genes involved in BCAA biosynthesis, suggesting that S. mutans CodY is not activated by GTP. The results of phenotypic studies revealed that the codY mutant had a reduced capacity to form biofilms and that its growth was more sensitive to low pH, showing a role for CodY in two key virulence properties of S. mutans. Microarray results revealed the extent of the CodY regulon. Notably, the identification of putative CodY-binding boxes upstream of genes that were downregulated in the codY mutant indicates that CodY may also function as a transcriptional activator in S. mutans.

CcpA globally regulates transcription in response to carbohydrate availability in many gram-positive bacteria, but its role in Streptococcus mutans remains enigmatic. Using the fructan hydrolase (fruA) gene of S. mutans as a model, we demonstrated that CcpA plays a direct role in carbon catabolite repression (CCR). Subsequently, the expression of 170 genes was shown to be differently expressed (≥2-fold) in glucose-grown wild-type (UA159) and CcpA-deficient (TW1) strains (P ≤ 0.001). However, there were differences in expression of only 96 genes between UA159 and TW1 when cells were cultivated with the poorly repressing substrate galactose. Interestingly, 90 genes were expressed differently in wild-type S. mutans when glucose- and galactose-grown cells were compared, but the expression of 515 genes was altered in the CcpA-deficient strain in a similar comparison. Overall, our results supported the hypothesis that CcpA has a major role in CCR and regulation of gene expression but revealed that in S. mutans there is a substantial CcpA-independent network that regulates gene expression in response to the carbohydrate source. Based on the genetic studies, biochemical and physiological experiments demonstrated that loss of CcpA impacts the ability of S. mutans to transport and grow on selected sugars. Also, the CcpA-deficient strain displayed an enhanced capacity to produce acid from intracellular stores of polysaccharides, could grow faster at pH 5.5, and could acidify the environment more rapidly and to a greater extent than the parental strain. Thus, CcpA directly modulates the pathogenic potential of S. mutans through global control of gene expression.

The production of (p)ppGpp by Streptococcus mutans UA159 is catalyzed by three gene products: RelA, RelP, and RelQ. Here, we investigate the role of the RelA (Rel) homologue of S. mutans in the stringent response and in the global control of gene expression. RelA of S. mutans was shown to synthesize pppGpp in vitro from GTP and ATP in the absence of added ribosomes, as well as in vivo in an Escherichia coli relA-spoT mutant. Mupirocin (MUP) was shown to induce high levels of (p)ppGpp production in S. mutans in a relA-dependent manner, with a concomitant reduction in GTP pools. Transcription profiling after MUP treatment of S. mutans revealed that 104 genes were upregulated and 130 were downregulated (P ≤ 0.001); mainly, genes for macromolecular biosynthesis, translation, and energy metabolism were downregulated. When a derivative of UA159 carrying a complete deletion of the relA gene was treated with MUP, 72 genes were upregulated and 52 were downregulated (P ≤ 0.001). The expression of 50 genes (P ≤ 0.001) was commonly affected by MUP treatment in the two strains, suggesting that S. mutans can mount a relA-independent response to MUP. Consistent with the gene expression profiling, RelA was shown to play major roles in the regulation of phenotypic traits that are required for establishment, persistence, and virulence expression by this oral pathogen. Thus, RelA is the major (p)ppGpp synthase controlling the stringent response in S. mutans, and it coordinates the expression of genes and phenotypes that contribute to the pathogenic potential of the organism.

Streptococcus mutans and Streptococcus sobrinus are the bacteria most commonly associated with human dental caries. A major virulence attribute of these and other cariogenic bacteria is acid tolerance. The acid tolerance mechanisms of S. mutans have begun to be investigated in detail, including the adaptive acid tolerance response (ATR), but this is not the case for S. sobrinus. An analysis of the ATR of two S. sobrinus strains was conducted with cells grown to steady state in continuous chemostat cultures. Compared with cells grown at neutral pH, S. sobrinus cells grown at pH 5.0 showed an increased resistance to acid killing and were able to drive down the pH through glycolysis to lower values. Unlike what is found for S. mutans, the enhanced acid tolerance and glycolytic capacities of acid-adapted S. sobrinus were not due to increased F-ATPase activities. Interestingly though, S. sobrinus cells grown at pH 5.0 had twofold more glucose phosphoenolpyruvate:sugar phosphotransferase system (PTS) activity than cells grown at pH 7.0. In contrast, glucose PTS activity was actually higher in S. mutans grown at pH 7.0 than in cells grown at pH 5.0. Silver staining of two-dimensional gels of whole-cell lysates of S. sobrinus 6715 revealed that at least 9 proteins were up-regulated and 22 proteins were down-regulated in pH 5.0-grown cells compared with cells grown at pH 7.0. Our results demonstrate that S. sobrinus is capable of mounting an ATR but that there are critical differences between the mechanisms of acid adaptation used by S. sobrinus and S. mutans.