SockIt Oral Pain Gel

Transcription

1 SockIt Oral Pain Gel Protects Wounds, Controls Pain, Prevents Microbial Infection, and Inhibits the of Microbes Required for the Preservative Challenge Test and Microorganisms Found in the Mouth Implicated in Dental Caries, Periodontitis, Endodontic Infections and Infective Endocarditis SockIt! Oral Pain Gel is composed of food ingredients that naturally control the growth of bacteria. We tested SockIt! gel against the organisms in the standard Preservative Challenge Test and other microorganisms commonly found in the mouth. The dental professional can have confidence in using SockIt! gel and not worry about it promoting the growth of any bacteria with which it may come in contact. There are three primary functions of wound dressings, they: physically protect the wound, optimize moisture, and prevent microbial infection. The optimization of moisture is limited in oral wound dressings due to the already moist environment. Most products that aim at inhibiting the growth of microorganisms are toxic when applied to the oral cavity. Moreover, the majority of the compounds designed to eliminate harmful microbes are not only synthetic, but they also cause severe damage to already compromised cells and tissues. Conversely, SockIt! gel is composed of 100% natural food ingredients at concentrations found in foods. So, there is no fear of additional damage, and the food ingredients found in SockIt! Oral Pain Gel are natural and effective antimicrobials. The data presented below illustrate the ability of SockIt! gel to control microbial growth in under 30 seconds. SockIt! Oral Pain Gel and the Preservative Challenge Test SockIt! Oral Pain Gel is a multi-use product, so it had to undergo the United States Pharmacopoeia (USP) <51> Preservative Challenge Testing. This test is required by law to ensure that bacterial contamination of the product will not occur during the time of use. These regulations were put in place to assure the consumer that the product will not promote the growth of common opportunistic microorganisms like Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, Candida albicans, and Aspergillus niger. Microbiological testing showed that, in a standard preservative challenge test (USP 51), SockIt! gel prevented growth of these organisms (See Below). Testing at 28 days found no growth (<10 cfu/ml). Concerns arise with the application of food ingredients to areas of recently exposed and damaged tissue after a dental procedure, because the components might serve as a food source for opportunistic and/or pathogenic bacteria implicated in such diseases as: dental caries, periodontitis, endodontic infections, and infective endocarditis. The literature was reviewed to identify the most common pathogens associated with these diseases. The tables below show the results of the Minimum Inhibitory Concentration (MIC) and the Time Kill (TK) tests in relation to commonly associated oral pathogens. The various tables below show the results of these studies. The first table under each section shows the results of the TK studies. The red shading

2 represents time points in which a reduction of 2 logs or higher was attained, for a log reduction of two (100 times lower) is considered antimicrobial by the Food and Drug Administration (FDA). The second table under each section shows the results for the MIC studies. The red shading denotes the dilutions that inhibited the growth of organisms. You will notice that SockIt! gel can be diluted with saliva and still be effective. Some naturally occurring polysaccharides, often used in the production of hydrogel wound dressings, control (i.e. inhibit or kill) bacteria by binding to bacterial mannose-binding lectins and sequestering free calcium (Ca ++ ) in the area of application. Seaweed and algae, both of which naturally contain these polysaccharides, often come in close or direct contact with sewage waste. Although this toxic sewage contains countless numbers and varieties of bacteria, the seaweed and algae both use this natural defense mechanism (i.e. binding to bacterial mannosebinding lectins and sequestering free calcium). In essence, foods can control bacteria mechanically. Mayonnaise, for example, is made of eggs, olive oil, and lemon juice; the citric acid and other dicarboxylic acids (found in lemon juice) bind free Ca ++ and prevent the growth of bacteria. All in all, choosing the right food ingredients will enable natural control of microorganisms, and, as SockIt! Oral Pain Gel is composed of ingredients that exhibit natural and superior antimicrobial activities, dental practitioners can use SockIt! Oral Pain Gel to control pain and protect any wound without concern for creating a medium in which bacteria will increase. SockIt! Oral Pain Gel Preservative Challenge Results Organism Inoculation level Day: 7 Day: 14 Day: 21 Day: 28 E. coli (ATCC 8739) 2.50 x 10 5 S. aureus (ATCC x 10 5 P. aeruginosa (ATCC 9027) 4.13 x 10 5 C. albicans (ATCC 10231) 7.76 x 10 5 A. niger (ATCC 16404) 2.15 x 10 5 SockIt! Oral Pain Gel and Bacteria Implicated in Dental Caries Dental caries is defined as the localized destruction of tooth crowns and roots by organic acids produced from bacterial fermentation of dietary carbohydrates. Dental caries is one of the most prevalent chronic diseases worldwide, and people are susceptible to it throughout their lifetime.

3 Although preventable, this infectious and transmissible disease is recognized as the primary cause of oral pain and tooth loss. 20 The development of dental caries arises from interactions between numerous microorganisms in dental plaque and several host factors, including teeth and saliva. The formation of dental caries is associated with an increased consumption of fermentable sugars. Cariogenic bacteria cause a drop in ph, promote tooth enamel demineralization and lead to the formation of carious lesions. 1,20 Some of the microorganisms that are commonly recovered from carious lesions are the Mutans Streptococci (MS) (i.e. Streptococcus mutans and Streptococcus sobrinus) and species of Lactobacillus. 16 In general, cariogenic organisms like MS and Lactobacillus possess several virulence factors that contribute to the formation of caries, such as acidogenicity (acid production), acidury (the ability to live under acidic conditions), adhesins, and synthesis of extracellular glucans from sucrose. Other genera, like Actinomyces, Enterococcus, Veillonella, Bifidobacterium, Rothia and several others, have also been implicated in human caries, but not to the same degree. n-mutans Streptococci (NMS) (i.e. Streptococcus salivarius, Streptococcus sanguinis, Streptococcus parasanguinis, Steptococcus gordonii, Streptococcus mitis, and Streptococcus oralis) are also present in the oral cavity, and, even though some of these NMS species are acidogenic, they are typically less virulent than MS and Lactobacilli. 22 Both MS and NMS are classified under the Viridans Group Streptococci (VGS). 5 Even though the current approach for caries prevention is the fluoridation of water, a public health measure, different strategies are now under investigation. Studies suggest that it could be possible to prevent dental caries through the inhibition of pathogenic organisms and by interfering with environmental factors that modulate their selection. A recent study 14 found that strains of S. gordonii and other NMS reduce the cariogenic potential of S. mutans through attenuation of its virulence properties. In addition, it has been reported 17 that strains of S. sanguinis are able to use arginine as a source of carbon and energy, consequently releasing ammonia, which counteracts the harmful effect of low ph on teeth. The authors of these studies learned that when high levels of arginine and low levels of fermentable carbohydrates are present, non-cariogenic S. sanguinis is a more efficient survivor than the MS, which is a less cariogenic organism. Finally, a new caries prevention strategy involves the controlled release of therapeutic agents that are commonly used in caries prevention. The following are examples of these agents: 1) Oral fluoride is used for remineralization of teeth surfaces, but this compound is messy, difficult to use, and can be toxic when large quantities are swallowed (due to the fluoride causing the formation of hydrofluoric acid in the stomach); 2) Chlorhexidine is used as an antiseptic, but it can severely stain teeth and can be toxic to individual cells, therefore swallowing must be avoided; 3) Antibiotics and antibacterial peptides are used to kill pathogenic bacteria, but they are not as effective as they were in the past due to emerging and ever-increasing bacterial resistance; 4) ph buffers are used to maintain non-acidic ph; 5) Chelators are used to strip calcium from biofilm polysaccharides causing biofilm disruption, but their use could alter electrolyte balance; 6) Quorum sensing analogs are used for down regulation of biofilm polysaccharide synthesis; and 7) Xylitol is used for its antibacterial and remineralizing

4 properties, since it has been well documented that this polyol possesses calcium-binding properties and that it is effective at killing organisms implicated in the formation of caries with minimal bacterial resistance observed. 1 To determine if SockIt! Oral Pain Gel had an effect on the growth of some of the most common cariogenic organisms, Time Kill and Minimum Inhibitory Concentration studies were initiated. It was found that SockIt! Gel possesses natural antibacterial activity against these organisms. The results of these studies are presented below. Time Kill (Log Reduction) with SockIt! (G0416A) Against Organisms Implicated in Dental Caries Microorganism 30 sec 5 min 1 hr 6 hr 12 hr 24 hr S. mutans (ATCC 33402) (Inoculation level = 1.04x10 6 ) Average (cfu/ml) Log Reduction S. sorbinus (ATCC 33478) (Inoculation level = 6.57x10 5 ) Average (cfu/ml) Log Reduction L. fermentum (ATCC 9338) (Inoculation level = 5.05x10 5 ) Average (cfu/ml) Log Reduction Actinomyces viscosus (ATCC 19246) (Inoculation level = 5.05x10 5 ) Average (cfu/ml) Log Reduction SockIt! gel is effective against all organisms tested within 30 seconds. MIC (Inhibition of ) with SockIt! (G0416A) Against Organisms Implicated in Dental Caries Microorganism 0.2/ / / / / / / / / /8.0 Streptococcus mutans G G G G NG NG NG NG NG NG (ATCC 33402) Streptococcus sorbinus G G G G NG NG NG NG NG NG (ATCC 33478) Lactobacillus fermentum G G G G G G NG NG NG NG (ATCC 9338) Actinomyces viscosus (ATCC 19246) G G G G G G G G G NG *G = GROWTH, *NG = NO GROWTH SockIt! gel is effective against S. mutans and S. sorbinus at a 10% concentration (1.0/9.0), L. fermentum at 14% (1.4/8.6), etc.

5 SockIt! Oral Pain Gel and Bacteria Implicated in Periodontitis Periodontal diseases are inflammatory, infectious diseases caused by microorganisms. There are several anaerobic, Gram-negative bacteria implicated in the development of periodontitis, and eight major pathogens have now been clearly identified as the culprits. 12 While over 400 different species 11,18 of microorganisms reside in the gingival crevice, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Tannerella forsythensis, and Fusobacterium nucleatum are the most pathogenic and prevalent isolates implicated in periodontitis. 4,8,23,26 During the course of infection, the number of commensal organisms 24 substantially increases in biofilms 26 and gingival regions. Among the microorganisms implicated in periodontitis is P. gingivalis, A. actinomycetemcomitans, T. forsythensis, and F. nucleatum are able to induce production of cytokines and other compounds responsible for inflammation and loss of the alveolar bone. 13 Current treatment of periodontitis involves the use of antibiotics and chlorhexidine. The problems arise with these treatments due to emerging and increasing resistance to antibiotics 2,7,15 and the cytotoxicity of chlorhexidine to the cells involved in healing. 6,25 More natural, effective and safer products 9 should be introduced into the market that are able stop the manifestations of periodontitis and return the gingival pockets to normal health. To determine if SockIt! Oral Pain Gel had an effect on the growth of some of the most common periodontal pathogens, kill rate and minimum inhibitory concentration studies were initiated. It was found that SockIt! gel possesses natural antibacterial activity against these organisms. The results of these studies are presented below and on the next page. Time Kill (Log Reduction) with SockIt! (G0416A) Against Organisms Implicated in Periodontitis Microorganism 30 sec 5 min 1 hr 6 hr 12 hr 24 hr A. actinomycetemcomitans (ATCC 43718) (Inoculation level = 1.41 x 10 6 ) Average (cfu/ml) Log Reduction T. forsythensis (ATCC 43037) (Inoculation level = 1.44 x 10 6 ) Average (cfu/ml) Log Reduction P. gingivalis (ATCC 49417) (Inoculation level = 5.05 x 10 5 ) Average (cfu/ml) Log Reduction F. nucleatum (ATCC 10953) (Inoculation level = 5.05 x 10 5 ) Average (cfu/ml) Log Reduction SockIt! gel is effective against all organisms tested within 30 seconds.

6 MIC (Inhibition of ) with SockIt! (G0416A) Against Organisms Implicated in Periodontitis Microorganism 0.2/ / / / / / / / / /8.0 Aggregatibacter actinomycetemco mitans G G G G NG NG NG NG NG NG ATCC# Porphyromonas gingivalis ATCC# G NG NG NG NG NG NG NG NG NG Tannerella 1.0/ / / / / / / / / /4.5 forsythensis* ATCC# G G NG NG NG NG NG NG NG NG Fusobacterium nucleatum ATCC# G G G G G NG NG NG NG NG *G = GROWTH, *NG = NO GROWTH *(differing concentrations were applied to Tannerella forsythensis) SockIt! gel is effective against A. actinomycetemcomitans at a 10% concentration (1.0/9.0), P. gingivalis 4% (0.4/9.6), etc. SockIt! Oral Pain Gel and Bacterial Implicated in Endodontic Infections The etiology of endodontic infections is diverse. While primary infections are caused by multiple bacterial species (with gram-negative anaerobic rods being the most prevalent), secondary infections are usually caused by one or just a few bacterial species. Despite the apparent diversity of both primary and secondary infections, one organism has a key, if not the main, role in endodontic infections: Enterococcus faecalis. E. faecalis, a bacterial pathogen commonly associated with both primary and persistent endodontic infections, has been found in root canals as both the sole colonizer and as a major component of the flora. It has been reported 21 that E. faecalis is responsible for up to 40% of primary endodontic infections and up to 77% of root canal failures. Currently, the use of good aseptic technique, increased apical preparation sizes, and inclusion of full strength sodium hypochlorite and 2% chlorhexidine irrigants are the most effective methods to eliminate E. faecalis. 21 At the concentration required for endodontic infection control, both sodium hypochlorite and chlorhexidine can be somewhat toxic when swallowed and have extremely adverse effects on periodontal cells, especially to those involved in the healing process.

7 To determine if SockIt! Oral Pain Gel had an effect on the growth of Enterococcus faecalis, kill rate and minimum inhibitory concentration studies were conducted. It was found that SockIt! gel possesses natural antibacterial activity against this organism. The results of these studies are presented below and continued on the next page. Table 1: Time Kill (Log Reduction) with SockIt! (G0416A) Against Organisms Implicated in Endodontic Infections Microorganism 30 sec 5 min 1 hr 6 hr 12 hr 24 hr Enterococcus spp. (ATCC 19952) (Inoculation level = 6.06x10 5 ) Average (cfu/ml) Log Reduction E. faecalis (ATCC 51299) (Inoculation level = 9.85x10 5 ) Average (cfu/ml) Log Reduction SockIt! gel is effective against E. faecalis within 30 seconds. MIC (Inhibition of ) with SockIt! (G0416A) Against Organisms Implicated in Endodontic Infections Microorganism 0.2/ / / / / / / / / /8.0 Enterococcus spp. (ATCC 19952) Enterococcus faecalis (ATCC 51299) *G = GROWTH, *NG = NO GROWTH G G G G G NG NG NG NG NG G G G G G G G G G NG SockIt! gel is effective against E. faecalis at a 20% concentration (2.0/8.0). SockIt! Oral Pain Gel and Bacteria Implicated in Infective Endocarditis Infective endocarditis (IE) is a rare but serious bacterial infection associated with high morbidity and mortality, despite antibiotic treatment. Viridans Group Streptococci (VGS) are the principal

8 organisms implicated in the induction of IE (up to 80% of endocarditis cases are attributed to VGS). S. sanguinis, S. gordonii, S. mutans, S. oralis, S. mitis, and S. salivarius (all normal inhabitants of the oral cavity) are responsible for the majority of endocarditis cases. 28 IE develops when VGS enter the bloodstream following dental procedures (oral surgery, endodontic procedures, scaling and root planning, teeth cleaning), trauma to oral tissues, or common daily activities (chewing, use of toothpicks, brushing, flossing). Once IE has developed, they colonize damaged heart valve surfaces (either damaged endothelial cells or fibrin clots [sterile vegetations]). Earlier this year, the American Heart Association (AHA) published revised guidelines on IE prophylaxis, 27,28 pointing out that previous antibiotic regimes did little to prevent dental procedure related IE and that the risk of antibiotic associated adverse events exceeds benefits. Therefore, IE prophylaxis, based solely on an increased lifetime risk of acquisition of IE, is no longer recommended. w, therapy is restricted to patients with the highest risk of an adverse outcome from IE. Very few cardiac conditions call for the use of antibiotics before dental procedures that involve either the manipulation of the gingival tissue or periapical region of teeth or require perforation of the oral mucosa. If antibiotics are necessary before the procedure, the recommended regimen is a single dose of the prophylactic antibiotic, administered before the procedure. Amoxicillin is the preferred choice for oral therapy. For patients who are allergic to penicillins, the antibiotics cephalexin, clindamycin, azithromycin or clarithromycin are recommended. For patients who are allergic to ampicillin and are also unable to tolerate an oral agent, therapy is recommended with parenteral cefazolin, ceftriaxone or clindamycin. For patients who are already receiving antibiotics, the selection of an antibiotic from a different class, rather than an increase in the dosage of the current antibiotic, is recommended by the AHA. To determine if SockIt! Oral Pain Gel had an effect on the growth of common endocarditis causing organisms, kill rate and minimum inhibitory concentration studies were conducted. It was found that SockIt! possesses natural antibacterial activity against these organisms. The results of these studies are presented on the next page. Time Kill (Log Reduction) with SockIt! (G0416A) Against Organisms Implicated in Infective Endocarditis Microorganism 30 sec 5 min 1 hr 6 hr 12 hr 24 hr S. mutans (ATCC 33402) (Inoculation level = 10x1.04x10 6 ) Average (cfu/ml) Log Reduction S. sorbinus (ATCC 33478) (Inoculation level = 6.57x10 5 ) Average (cfu/ml) Log Reduction SockIt! gel is effective against all organisms tested within 30 seconds.

9 MIC (Inhibition of ) with SockIt! (G0416A) Against Organisms Implicated in Infective Endocarditis Microorganism 0.2/ / / / / / / / / /8.0 Streptococcus mutans G G G G NG NG NG NG NG NG ATCC# Streptococcus sorbinus ATCC# G G G G NG NG NG NG NG NG *G = GROWTH, *NG = NO GROWTH SockIt! gel is effective against S. mutans and S. sorbinus at a 10% concentration (1.0/9.0). SockIt! Oral Pain Gel and Streptococcus Pyogenes SockIt! gel will not sustain the growth of S. pyogenes, a bacterium that is found in the oropharynx and can cause streptococcocal pharyngitis (strep throat). Strep throat can progress to scarlet fever, rheumatic fever, glomerulonephritis, and other serious conditions. To determine if SockIt! Oral Pain Gel had an effect on the growth of Streptococcus pyogenes, kill rate and minimum inhibitory concentration studies were conducted. It was found that SockIt! gel possesses natural antibacterial activity against this organism. The results of these studies are presented below and continued on the next page. Microorganism 30 sec 5 min 1 hr 6 hr 12 hr 24 hr S. pyogenes (ATCC 33402) (Inoculation level = 10x1.04x10 6 ) Average (cfu/ml) Log Reduction SockIt! gel is effective against S. pyogenes tested within 30 seconds. Microorganism 1.0/ / / / / / / / / /4.5 Streptrococcus pyogenes ATCC# G NG NG NG NG NG NG NG NG NG *G = GROWTH, *NG = NO GROWTH SockIt! gel is effective against S. pyogenes at a 15% concentration (1.5/8.5).

10 Comparing the Antimicrobial Effects of SockIt! Oral Pain Gel and Other Standard-of- Care Dental Products Sodium hypochlorite is the active ingredient in various preparations (e. g. Clorox bleach, Dakin s solution). It is used as a disinfectant topically on skin, and is the most common disinfectant used in endodontics. A concentration of 0.5% is recommended to obtain acceptable cytotoxic levels; however, at least 30 minutes continuous contact at this concentration is required to inhibit the growth of S. aureus, E. faecalis and C. albicans, and at least 5 minutes was required for a concentration of 4.0%. 25 Unfortunately, these concentrations are also extremely toxic to human cells. In fact, concentrations of 0.025% and greater are cytotoxic to human periodontal ligament cells. 3,3 Chlorhexidine is used widely as an antimicrobial agent in periodontal disease and in caries prevention. However, a concentration of 0.2% requires 10 minutes of continuous contact to inhibit growth of S. aureus and C. albicans, and 2 hours for E. faecalis. 25 This is especially significant in the case of E. faecalis, which is found in the gingival sulcus, especially those of patients who have undergone endodontic treatment. 19 Also, chlorhexidine concentrations of % and greater are cytotoxic to human periodontal ligament cells. Chlorhexidine caused 100% cell death of human dermal fibroblasts at concentrations of 0.005% and greater. Thus, chlorhexidine is toxic to periodontal ligament cells and human dermal fibroblasts at concentrations up to 2400 times and 1200 times, respectively, below those used in clinical practice. 3,10 SockIt! Oral Pain Gel mechanically binds and holds the microorganisms and works by a mechanism different than an antiseptic. Antiseptics must be given enough contact time to penetrate the organism in order to be effective. These data indicate that SockIt! gel is equal to or superior to chlorhexidine and sodium hypochlorite in its ability to control microorganisms that are of concern in your dental practice, and will not cause damage to compromised tissues. Chlorhexidine takes 2 hours to inhibit the growth of E. faecalis, while SockIt! gel completely eliminates this organism in 30 seconds. Furthermore, SockIt! gel is effective against all potential intraoral pathogenic organisms that were tested. SockIt! Oral Pain Gel: Composition and Mechanism SockIt! Oral Pain Gel is made entirely of plant-based food ingredients at concentrations normally found in food. FDA has cleared SockIt! gel for the management of all oral wounds and the pain associated with the wounds. It forms a thin film that helps prevent further irritation. Additionally, SockIt! gel is not very viscous so it can flow over, cover and protect the entire wound. The gel contains poly-dispersed mannans from food sources. Polymannans are known for their high affinity for cations, which plays a major role in SockIt! gel s analgesic effect. An example of such a food source is wakame (Undaria pinnatifida), which is used in miso soup by the Japanese. It is a good source of polymannans and produces a stable hydrogel. This seaweed

11 has been used for centuries by several peoples of the Asian continent in foods and herbal medicines. Also, polymannans can mechanically bind to the mannose-binding lectin found on the surface of many bacteria, which helps prevent their adhesion and thus their infectivity. Polymannans naturally sequester Ca, which accounts for their antimicrobial properties. Plants in the sea secrete gels composed of polysaccharides as a protective barrier. SockIt! gel is flavored with a fraction of a percent of essential oils found in cinnamon, clove, oregano, and thyme. The combination of these food ingredients traps the bacteria, pulls Ca from the cell membrane, and disrupts the bacterial membrane. These structural changes cause hydrogen ion leakage, and as larger fissures form in the membrane, bacterial components like ATP, nucleic acids, and enzymes are also lost. 7,29 These food ingredients have been working for millions of years, and bacteria, viruses, and fungi have not been able to establish resistance. All of the ingredients in SockIt! gel have been reviewed by the Food and Drug Administration (FDA). ingredient warnings were required because it contains no food ingredients identified as potential allergens like dairy products, peanuts, etc. The ph is adjusted by dicarboxylic acids (i.e. citric acid) and buffered with mono-basic and di-basic phosphates to a neutral ph. Remember, phosphates are used throughout the body (i.e. ATP). SockIt! gel is made of all natural food components, consequently variations in color may be observed. It has a tendency to assume a more gold color with time. To date, it has passed one-year stability testing and further testing is underway. It is the unique combination of food ingredients used to make SockIt! Oral Pain Gel that accounts for its wide-range of properties. Apparently, Hippocrates was right. We should let our food be our medicine, and our medicine our food.

12 Reference List (1) Bryers JD, Ratner BD. Biomaterials Approaches to Combating Oral Biofilms and Dental Disease. BMC Oral Health. 2006;6:S15. (2) Buchmann R, Muller RF, Van Dyke TE, Lange DE. Change of antibiotic susceptibility following periodontal therapy. A pilot study in aggressive periodontal disease. J Clin Periodontol. 2003;30: (3) Chang Y-C, Huang F-M, Tai K-W, Chou M-Y. The effect of sodium hypochlorite and chlorhexidine on cultured human periodontal ligament cells. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology & Endodontics. 2001;92: (4) Colombo AV, da Silva CM, Haffajee A, Colombo AP. Identification of intracellular oral species within human crevicular epithelial cells from subjects with chronic periodontitis by fluorescence in situ hybridization. J Periodontal Res. 2007;42: (5) Facklam R. What Happened to the Streptococci: Overview of Taxonomic and menclature Changes. Clinical Microbiology Reviews. 2002;15: (6) Faria G, Celes MR, De RA, Silva LA, Silva JS, Rossi MA. Evaluation of chlorhexidine toxicity injected in the paw of mice and added to cultured l929 fibroblasts. J Endod. 2007;33: (7) Feres M, Haffajee AD, Allard K, Som S, Goodson JM, Socransky SS. Antibiotic resistance of subgingival species during and after antibiotic therapy. J Clin Periodontol. 2002;29: (8) Haffajee AD, Socransky SS. Microbiology of periodontal diseases: introduction. Periodontol ;38:9-12. (9) Han SJ, Jeong SY, Nam YJ, Yang KH, Lim HS, Chung J. Xylitol inhibits inflammatory cytokine expression induced by lipopolysaccharide from Porphyromonas gingivalis. Clin Diagn Lab Immunol. 2005;12: (10) Hidalgo E, Dominguez C. Mechanisms underlying chlorhexidine-induced cytotoxicity. Toxicology in Vitro. 2001;15: (11) Inagaki S, Onishi S, Kuramitsu HK, Sharma A. Porphyromonas gingivalis vesicles enhance attachment, and the leucine-rich repeat BspA protein is required for invasion of epithelial cells by "Tannerella forsythia". Infect Immun. 2006;74: (12) Joshi VM, Vandana KL. The detection of eight putative periodontal pathogens in adult and rapidly progressive periodontitis patients: an institutional study. Indian J Dent Res. 2007;18:6-10. (13) Kikkert R, Laine ML, Aarden LA, Van Winkelhoff AJ. Activation of toll-like receptors 2 and 4 by gramnegative periodontal bacteria. Oral Microbiol Immunol. 2007;22: (14) Kuramitsu HK, Wang BY. Virulence properties of cariogenic bacteria. feedback (15) Maestre JR, Bascones A, Sanchez P et al. Odontogenic bacteria in periodontal disease and resistance patterns to common antibiotics used as treatment and prophylaxis in odontology in Spain. Rev Esp Quimioter. 2007;20: (16) Nishikawara F, Katsumura S, Ando A et al. Correlation of cariogenic bacteria and dental caries in adults. Journal Of Oral Science. 2006;48:

13 (17) Rogers AH. Why be down in the mouth? Three decades of research in oral microbiology. Aust Dent J. 2005;50:2-5. (18) Schacher B, Baron F, Rossberg M, Wohlfeil M, Arndt R, Eickholz P. Aggregatibacter actinomycetemcomitans as indicator for aggressive periodontitis by two analysing strategies. J Clin Periodontol. 2007;34: (19) Sedgley C, Buck G, Appelbe O. Prevalence of Enterococcus faecalis at Multiple Oral Sites in Endodontic Patients Using Culture and PCR. J Endod. 2006;32: (20) Selwitz RH, Ismail AI, Pitts NB. Dental caries. The Lancet. 2007;369: (21) Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis: Its Role in Root Canal Treatment Failure and Current Concepts in Retreatment. J Endod. 2006;32: (22) Tanzer JM, Livingston J, Thompson AM. The microbiology of primary dental caries in humans. Journal of Dental Education. 2001;65: (23) Thiha K, Takeuchi Y, Umeda M, Huang Y, Ohnishi M, Ishikawa I. Identification of periodontopathic bacteria in gingival tissue of Japanese periodontitis patients. Oral Microbiol Immunol. 2007;22: (24) Van Winkelhoff AJ, Boutaga K. Transmission of periodontal bacteria and models of infection. J Clin Periodontol. 2005;32 Suppl 6: (25) Vianna ME, Gomes BPFA, Berber VB, Zaia AA, Ferraz CCR, de Souza-Filho FJ. In vitro evaluation of the antimicrobial activity of chlorhexidine and sodium hypochlorite. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology & Endodontics. 2004;97: (26) Walker C, Sedlacek MJ. An in vitro biofilm model of subgingival plaque. Oral Microbiol Immunol. 2007;22: (27) Wilson W, et.al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. Circulation (28) Wilson W, et.al. Prevention of infective endocarditis: Guidelines from the American Heart Association. J Am Dent Assoc. 2007;