Original article 239
Subgingival microflora in inflammatory bowel disease
patients with untreated periodontitis
Fernanda Britoa, Cyrla Zaltmanc, Ana T.P. Carvalhob, Ricardo G. Fischera,
Rutger Perssond,e, Anders Gustafssonf and Carlos M.S. Figueredoa,f
Objective To analyze the subgingival microflora
composition of inflammatory bowel disease (IBD) patients
with untreated chronic periodontitis and compare them
with systemically healthy controls also having untreated
chronic periodontitis.
Method Thirty IBD patients [15 with Crohn’s disease (CD)
and 15 with ulcerative colitis (UC)] and 15 control
individuals participated in the study. All patients had been
diagnosed with untreated chronic periodontitis. From every
patient, subgingival plaque was collected from four
c 2013 Wolters Kluwer
gingivitis and four periodontitis sites with paper points.
Samples from the same category (gingivitis or
periodontitis) in each patient were pooled together
and stored at – 708C until analysis using a checkerboard
DNA–DNA hybridization technique for 74 bacterial species.
Results Multiple-comparison analysis showed that the
groups differed in bacterial counts for Bacteroides
ureolyticus, Campylobacter gracilis, Parvimonas micra,
Prevotella melaninogenica, Peptostreptococcus anaerobius,
Staphylococcus aureus, Streptococcus anginosus,
Streptococcus intermedius, Streptococcus mitis,
Streptococcus mutans, and Treponema denticola
(P < 0.001). CD patients had significantly higher levels
of these bacteria than UC patients either in gingivitis
or in periodontitis sites (P < 0.05). CD patients harbored
higher levels of P. melaninogenica, S. aureus, S. anginosus,
Introduction
Periodontal diseases are chronic inflammatory conditions
affecting the supporting structures of the teeth, which
might be divided into gingivitis and periodontitis. Plaque-
induced gingivitis is an inflammation of the gums
resulting from bacteria located at the gingival margin.
The common clinical findings of plaque-induced gingivi-
tis include erythema, edema, bleeding, sensitivity,
tenderness, and enlargement. In gingivitis, there is no
loss of supporting structures [1]. However, periodontitis
involves the destruction of the periodontal ligament,
bone, and gingival tissues, and can lead to tooth loss. The
inflammatory and immune responses in the gingival
pocket of periodontal patients are presumed to be
initiated and perpetuated by several bacterial species
residing in a biofilm on the tooth surfaces referred to as
dental plaque [2]. Destructive periodontal disease is
a consequence of the interaction of genetic, environmental,
host, and microbial factors. Periodontitis follows gingivitis;
0954-691X
c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and S. mutans compared with controls both at gingivitis
and at periodontitis sites (P < 0.05). UC patients harbored
higher levels of S. aureus (P = 0.01) and P. anaerobius
(P = 0.05) than controls only in gingivitis sites.
Conclusion Our study showed that even with similar
clinical periodontal parameters, IBD patients harbor higher
levels of bacteria that are related to opportunistic
infections in inflamed subgingival sites that might be
harmful for the crucial microbe–host interaction. Eur J
Gastroenterol Hepatol 25:239–245
Health | Lippincott Williams & Wilkins.
European Journal of Gastroenterology & Hepatology 2013, 25:239–245
Keywords: checkerboard DNA–DNA hybridization, inflammatory bowel
disease, periodontal disease, subgingival plaque
a
Departament of Periodontology, Faculty of Odontology, bDepartment
of Gastroenterology, Faculty of Medicine, Rio de Janeiro State University,
c
Department of Gastroenterology, Faculty of Medicine, Federal University of Rio
de Janeiro, Rio de Janeiro, Brazil, dDepartment of Periodontology, School of
Dental Medicine, University of Bern, Bern, Switzerland, eDepartment of Oral
Medicine, School of Dentistry, University of Washington, Seattle, Washington,
USA and fDepartment of Dental Medicine, Division of Perisodontology, Karolinska
Institutet, Stockholm, Sweden
Correspondence to Carlos M.S. Figueredo, PhD, Departament of Periodontology,
Faculty of Odontology, Rio de Janeiro State University, Boulevard 28
de Setembro 157, Pavilhão de Pesquisa, Vila Isabel, Rio de Janeiro
20551-030, Brazil
Tel/fax: + 55 212 868 8642; e-mail: cmfigueredo@hotmail.com
Received 12 July 2012 Accepted 5 September 2012
thus, prevention of gingivitis is the primary preventive
measure for preventing periodontitis [3].
Evidence suggests that the effect of periodontitis might
not be limited just to the oral cavity, but it might have
systemic consequences [4]. Periodontitis can elicit a
systemic inflammatory response by activating the hepatic
acute-phase response [5], and might represent one
distant source of low-grade systemic inflammation.
For this reason, periodontitis is significantly associated with
several systemic conditions, including myocardial infarction,
stroke, diabetes, and preterm low birth weight [4].
Studies have reported a high prevalence of periodontitis
in patients with inflammatory bowel disease (IBD) [6,7].
Our group found significantly more patients with period-
ontitis in ulcerative colitis (UC) (90.0%) and Crohn’s
disease (CD) (81.8%) than controls (67.6%) [8]. Period-
ontal pockets can harbor a total estimate of 415 species in
the subgingival plaque [9], and therefore, are appropriate
DOI: 10.1097/MEG.0b013e32835a2b70
240 European Journal of Gastroenterology & Hepatology 2013, Vol 25 No 2
ecological niches for hosting microorganisms that could
act as opportunistic pathogens [10]. Guidelines for the
prevention of opportunistic infections in IBD patients
mention that the dental status needs to be evaluated and
appropriate dental care has to be performed. However, no
special mention is made of the periodontal condition
of these patients [11].
Some attempts to identify the oral IBD microflora have
been made through the years. van Dyke et al. [12] studied
the periodontal flora of IBD patients with and without
periodontitis and found a unique microflora composed
predominantly of small, motile, Gram-negative rods that
were most consistent with the genus Wolinella. Sundh
et al. [13] reported that CD patients had higher counts of
Streptococcus mutans than controls. More recently, Docktor
et al. [14] found a significant decrease in overall diversity
in the oral microbiome of pediatric CD. According to the
authors, further studies of the oral microbiome in IBD
may be of potential diagnostic and prognostic value.
The host–microbe interaction has been implicated in the
pathogenesis of IBD in genetically susceptible hosts, but
limited information exists about oral microbes in such
patients. Our hypothesis is that the presence of
pathogenic bacteria in the inflamed subgingival area
might be harmful for the crucial microbe–host interaction
in IBD patients. Therefore, our aim was to analyze the
subgingival microflora composition of IBD patients with
untreated chronic periodontitis and to compare with
systemically healthy controls also having untreated
chronic periodontitis.
Materials and methods
Selection of participants
The Committee on Ethics and Research of the University
Hospitals Pedro Ernesto and Clementino Fraga Filho, and
at the Karolinska Institutet (Stockholm, Sweden),
approved the study. All the selected patients signed an
informed consent.
Forty-five patients with untreated chronic periodontitis
were enrolled in the present study. Thirty of these
patients were diagnosed with IBD: 15 had CD (seven
women and eight men, mean age 38.2±11.4 years) and 15
had UC (eight women and seven men, mean age
45.0±10.5 years). Fifteen controls (eight women and
seven men, mean age 42.1±7.8 years) were examined for
comparisons. These individuals represent a subset sample
population of a previous study [8]. The patients
previously diagnosed with periodontitis were invited to
return for microbiological sampling. Among the patients
who returned, those who presented at least five inflamed
sites with probing pocket depths (PPDs) of at least 5 mm
and clinical attachment loss (CAL) of at least 3 mm
in different teeth were selected for the present study.
CD and UC patients were outpatients attending to the
IBD clinics at Pedro Ernesto University Hospital of the
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Rio de Janeiro State University and at the Clementino
Fraga Filho University Hospital of Federal University of
Rio de Janeiro, both in Rio de Janeiro, Brazil. Employees
at both University Hospitals, and who did not show any
clinical signs of present systemic disease other than
periodontitis, and who had not taken antibiotics, or anti-
inflammatory drugs for at least 6 months before the study,
were included in the control group. The smoking habit
was registered as current smokers (those who currently
smoke cigarettes daily) and nonsmokers (those who had
never smoked cigarettes or former smokers who had quit
smoking for >5 years).
The diagnosis of CD or UC had been established
previously by clinical, radiological, endoscopic, and
histological analyses. Crohn’s Disease Activity Index [15]
was used to assess disease activity in CD patients,
whereas Truelove and Witts’ index [16] was used to
assess disease activity in UC patients. CD patients were
taking immunomodulators (n = 7), aminosalicylates (n = 4),
and immunomodulators + aminosalicylates (n = 2). Two
CD patients were not taking any medication. In the UC
group, the disease was active in three patients and was in
remission in 12 of the patients. In the UC group, patients
were taking immunomodulators (n = 1), aminosalicylates
(n = 9), and immunomodulators + aminosalicylates (n = 5).
None of the individuals in the control group used any
prescribed medications.
Clinical examination
Clinical parameters were evaluated at six sites in all
teeth, excluding third molars. The parameters included
PPD, CAL, presence of plaque, and presence of bleeding
on probing (BOP). PPD, CAL, and BOP were measured
using a conventional periodontal probe (Hu-Friedy,
Chicago, Illinois, USA). After the diagnosis of chronic
periodontitis was made, the sites to be sampled were
selected. All the patients had moderate to severe chronic
periodontitis [17].
Microbiological sampling
Before sampling, supragingival plaque was removed and
the gingival margins were wiped dry with a sterile cotton
pellet. Samples were taken from inflamed sites: four
gingivitis sites (PPD r 3 mm) and four periodontitis sites
(PPD Z 5 mm). The sites were sampled from different
teeth. The paper point was inserted into the gingival
crevice for 5 s. The paper points from the same category
(gingivitis or periodontitis) in each individual were
pooled together and were stored in Eppendorf vials at
– 701C until analyzed with respect to microbiology.
To each vial with a subgingival bacterial sample, 0.15 ml
Tris-EDTA buffer (10 mmol/l Tris-HCL, 1.0 mmol/l
EDTA, pH 7.6) was added to each RNase-free, DNase-
free, DNA-free, and pyrogen-free sterile 1.5 ml natural flat-
cap microcentrifuge vials (Starlab GmbH, Ahrensburg,
Germany).
 Subgingival flora in IBD patients Brito et al. 241

Microbiological processing Statistical analysis

Samples were analyzed using the checkerboard DNA–
DNA hybridization technique and 74 bacterial species
were assayed (Table 1) as described elsewhere [18,19].
At the laboratory, 0.10 ml 0.5 mol/l NaOH was added to
each vial. Bacterial DNA was extracted, concentrated on
nylon membranes, and fixed by cross-linking using
ultraviolet light. The membranes with fixed DNA were
placed in a Miniblotter 45 (Roche Diagnostics GmbH,
Mannheim, Germany). Signals were detected by fluores-
cence using the Storm Fluor-Imager (Stratalinker 1800;
Stratagene, La Jolla, California, USA) with a setup of
200 mm and 600 V. The digitized information was analyzed
using a software program (ImageQuant; Amersham
Pharmacia, Piscataway, New Jersey, USA) allowing a
comparison of the density of 19 sample lanes against
the two standard lanes (105 or 106 cells). Signals were
converted into absolute counts by comparisons with these
standards. Patient-based mean values for the bacterial
counts of these species were calculated.
The Kolmogorov–Smirnov test was used to assess the
data distribution for each variable presented. A normal
distribution curve was found for age, the number of
remaining teeth, percentage plaque, mean PPD and PPD
for sites from which the bacterial samples were collected,
mean CAL, and CAL for sites from which the bacterial
samples were collected, and for the number of months
with a diagnosis of CD or UC. All other study variables
were identified as having non-normal distribution curves.
Multivariate analysis (post-hoc Bonferroni), Kruskal–
Wallis analysis of variance (ANOVA), as well as repeated
independent t-tests, and Mann–Whitney U-tests were
used as appropriate for data with a normal distribution or
not. For the microbiological data, significance was set at
P less than 0.001. Otherwise, P less than 0.05 was used to
indicate significance. The bacteria shown in the result
section are those that consistently showed agreement by
one-way ANOVA (post-hoc Bonferroni), and by Kruskal–
Wallis ANOVA with repeat Mann–Whitney U-tests.

Table 1 Bacterial species and subspecies included in the DNA–DNA checkerboard kit
Species panel 1 Collection Species panel 2 Collectiona

1a. Aggregatibacter actinomycetemcomitans (strain a) ATCC 29523 1. Actinomyces neuii GUH 550898
1b. Aggregatibacter actinomycetemcomitans (Y4) ATCC 43718 2. Aerococcus christensenii GUH 070938
2. Actinomyces israelii ATCC 12102 3. Anaerococcus vaginalis GUH 290486
3. Actinomyces naeslundii (type I + II) ATCC 43146 4. Atopobium parvulum GUH 160323
4. Actinomyces odontolyticus ATCC 17929 5. Atopobium vaginae GUH 010535
5. Campylobacter gracilis ATCC 33236 6. Bacteroides ureolyticus GUH 080189
6. Campylobacter rectus ATCC 33238 7. Bifidobacterium biavati GUH 071026
7. Campylobacter showae ATCC 51146 8. Bifidobacterium bifidum GUH 070962
8. Capnocytophaga gingivalis ATCC 33612 9. Bifidobacterium breve GUH 080484
9. Capnocytophaga ochracea ATCC 33596 10. Bifidobacterium longum GUH 180689
10. Capnocytophaga sputigena ATCC 33612 11. Corynebacterium nigricans GUH 450453
11. Eikenella corrodens ATCC 23834 12. Corynebacterium aurimucosum pseudogenitalium GUH 071035
12. Eubacterium saburreum ATCC 33271 13. Dialister spp. GUH071045
13a. Fusobacterium nucleatum nucleatum ATCC 25586 14a. Enterococcus faecalis GUH170812
13b. Fusobacterium nucleatum polymorphum ATCC 10953 14b. Enterococcus faecalis ATCC 29212
13c. Fusobacterium nucleatum naviforme ATCC 49256 15. Escherichia coli GUH 070903
14. Fusobacterium periodonticum ATCC 33693 16. Gardnerella vaginalis GUH 080585
15. Lactobacillus acidophilus ATCC 11975 17. Haemophilus influenzae ATCC 49247
16. Leptotrichia buccalis ATCC 14201 18. Helicobacter pylori ATCC 43504
17. Parvimonas micra ATCC 19696 19. Lactobacillus crispatus GUH 160342
18. Neisseria mucosa ATCC 33270 20. Lactobacillus gasseri GUH 170856
19. Prevotella intermedia ATCC 25611 21. Lactobacillus iners GUH 160334
20. Prevotella melaninogenica ATCC 25845 22. Lactobacillus jensenii GUH 160339
21. Prevotella nigrescens ATCC 33563 23. Lactobacillus vaginalis GUH 0780928
22. Porphyromonas gingivalis ATCC 33277 24. Mobiluncus curtisii GUH 070927
23. Propionibacterium acnes (type I + II) ATCC11827/28 25. Mobiluncus mulieris GUH 070926
24. Selenomonasnoxia ATCC 43541 26. Peptoniphilus spp. GUH 550970
25. Staphylococcus aureus ATCC 25923 27. Porphyromonas endodontalis ATCC35406
26. Streptococcus anginosus ATCC 33397 28. Peptostreptococcus anaerobius GUH 160362
27. Streptococcus constellatus ATCC 27823 (M32b) 29. Prevotella bivia GUH 450429
28. Streptococcus gordonii ATCC 10558 30. Prevotella disiens GUH 190184
29. Streptococcus intermedius ATCC 27335 31. Prevotella mirabilis GUH 070918
30. Streptococcus mitis ATCC 49456 32. Pseudomonas aeruginosa ATCC 33467
31. Streptococcus oralis ATCC 35037 33a. Staphylococcus aureus (yellow) GUH 070921
32. Streptococcus sanguinis ATCC 10556 33b. Staphylococcus aureus (white) GUH 070922
33. Streptococcus mutans ATCC 25175 34. Staphylococcus epidermidis GUH 130381
34. Tannerella forsythia ATCC 43037 (338) 35. Staphylococcus haemolyticus GUH071047
35. Treponema denticola ATCC 35405 36. Streptococcus agalactiae GUH 230282
36. Treponema socranskii D40DR2 37. Varibaculum cambriense GUH 070917
37. Veillonella parvula ATCC 10790

ATCC, American Type Culture Collection; D, sample from Forsyth Institute (Boston, Massachusetts); GUH, Ghent University Hospital Collection (Ghent, Belgium).
a
Strain a bacteria evaluated.

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242 European Journal of Gastroenterology & Hepatology 2013, Vol 25 No 2

Table 2 Clinical characteristics of patients with Crohn’s disease, ulcerative colitis, and control individuals
Crohn’s disease Ulcerative colitis Controls

Variables Mean SD Mean SD Mean SD ANOVA

Age 39.5 10.5 45.0 9.3 42.1 7.8 0.10

Number of teeth 22.8 5.6 21.0 5.1 23.8 4.2 0.19
Plaque index (%) 57.7 39.7 55.0 36.7 68.8 37.4 0.79
BOP (%) 37.1 – 29.5 – 31.5 – 0.84
Number of years with diagnosis of IBD 98.5 101.0 94.4 64.2 – – –
Smoking habit (%) – – – – – – 0.06
Smokers 21.4 – 6.7 – 6.7 – –
Nonsmokers 50.0 – 46.7 – 80.0 – –
Former smokers 28.6 – 46.7 – 13.3 – –

ANOVA, analysis of variance; BOP, bleeding on probing; IBD, inflammatory bowel disease.

The data were analyzed using a statistical software (IBM Discussion

SPSS 18.0; SPSS Inc., Armonk, New York, USA).
Results
Clinical data
The demographic data from CD, UC, and control
patients are reported in Table 2. Multiple-comparison
analysis showed that age, number of teeth, plaque index,
BOP, time of diagnosis of IBD, and smoking habit did not
differ significantly between the groups. Multiple-compar-
ison analysis did not show a significant difference
between the groups in any of the clinical parameters:
PPD, CAL, and percentage of sites with plaque between
the groups either in gingivitis or in periodontitis sites.
Our study showed that the concentrations of B. ureolyticus,
C. gracilis P. micra, P. melaninogenica, P. anaerobius, S. aureus,
S. anginosus, S. intermedius, S. mitis, S. mutans, and T. denticola
differed between patients with CH, ulcerative colitis, and
controls irrespective of the degree of periodontal
destruction in inflamed sites. Patients with CD harbored
the highest concentration of these bacteria. For the other
analyzed bacteria, no significant variation was observed
between the groups. The implication of these findings is
unknown, but it is evident that inflamed periodontal
regions can harbor harmful bacteria that can be impli-
cated not only in periodontal diseases but also in caries,
and most importantly, opportunistic infections.

Microbiological results In terms of bacteria involved with dental caries, CD

Gingivitis sites
Multiple-comparison analysis showed that Parvimonas
micra, Prevotella melaninogenica, Peptostreptococcus anaerobius,
Staphylococcus aureus, Streptococcus anginosus, Streptococcus
mitis, S. mutans, and Treponema denticola differed signifi-
cantly between the groups (P < 0.001). The independent
analyses showed that all these bacteria were significantly
higher in CD patients compared with UC patients.
P. micra, P. melaninogenica, P. anaerobius, S. aureus, S. anginosus,
and S. mutans were also significantly higher in CD
patients compared with controls. When UC patients
were compared with controls, P. anaerobius and S. aureus
were significantly higher, whereas P. micra, S. anginosus,
S. mitis, and S. aureus were significantly lower than those
of the control group (Table 3).
Periodontitis sites
Multiple-comparison analysis showed that Bacteroides
ureolyticus, Campylobacter gracilis, P. melaninogenica, S. aureus,
S. anginosus, Streptococcus intermedius, S. mitis, and S. mutans
differed significantly between the groups (P < 0.001).
The two independent analyses showed that all these
bacteria were significantly higher in CD when compared
with UC patients. Except for S. mitis, they were also
significantly higher in CD patients compared with
controls. UC and controls did not differ significantly
(Table 3).
patients had higher counts of S. mutans than controls and
UC patients. Our finding of S. mutans in subgingival
plaque is in agreement with other studies [20–22]. It has
been shown previously that Streptococcus spp. is predomi-
nant in the inflamed intestinal mucosa of 80% of all
bacteria in CD patients, but not in UC patients [23].
Although S. mutans is a major pathogen in dental caries,
this could to some extent explain the increased risk for
dental caries that has been reported earlier in CD
patients [24–26].
We also found that patients with CD had higher counts
of S. aureus than controls and UC patients. S. aureus is
commonly isolated from community and hospital infec-
tions affecting the lower respiratory tract, urinary tract,
skin, and bloodstream [27]. More than 70% of the
staphylococci isolated from bloodstream infections in the
ICU are of the species S. aureus, Staphylococcus epidermidis,
and Staphylococcus haemolyticus [28,29]. A high detection
level of S. aureus has also been identified in saliva from
hospitalized patients [30]. Besides, S. aureus has also been
identified in periodontitis [21,31,32]. Therefore, elim-
ination of inflamed sites in CD patients is not only
a measure to improve oral health but could also be
an important means to avoid nosocomial infections.
Similarly, CD patients had significantly higher counts of
S. anginosus in both gingivitis and periodontitis sites when

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 Subgingival flora in IBD patients Brito et al. 243

Table 3 Distributions of bacteria with differences in bacterial counts and significance levels, Crohn disease, ulcerative colitis, and control
groups in sites with gingivitis or periodontitis
Bacteria Patient group 25th 50th 75th Comparisons Significance

Gingivitis
Parvimonas micra Control 0.00 0.87 1.12 CD vs. UC 0.001
CD 0.98 1.36 2.53 CD vs. control 0.01
UC 0.00 0.47 0.85 UC vs. control 0.01
Prevotella melaninogenica Control 0.14 0.29 0.79 CD vs. UC 0.01
CD 0.80 1.26 2.01 CD vs. control 0.001
UC 0.22 0.30 0.89 UC vs. Control NS
Peptostreptococcus anaerobius Control 0.15 0.26 0.43 CD vs. UC 0.05
CD 0.31 0.62 1.04 CD vs. control 0.05
UC 0.14 0.21 0.54 UC vs. control 0.05
Staphylococcus aureus Control 0.28 0.36 0.71 CD vs. UC 0.01
CD 0.82 1.76 2.40 CD vs. control 0.001
UC 0.22 0.46 1.55 UC vs. control 0.01
Streptococcus anginosus Control 0.14 0.29 0.43 CD vs. UC 0.01
CD 0.53 0.97 1.82 CD vs. control 0.001
UC 0.12 0.19 0.41 UC vs. control 0.01
Streptococcus mitis Control 0.14 0.40 0.63 CD vs. UC 0.01
CD 0.24 0.74 1.25 CD vs. control NS
UC 0.10 0.21 0.25 UC vs. control 0.01
Streptococcus mutans Control 0.00 0.29 0.57 CD vs. UC 0.023
CD 0.00 0.78 1.66 CD vs. control 0.039
UC 0.00 0.18 0.33 UC vs. control NS
Treponema denticola Control 0.00 0.15 0.44 CD vs. UC 0.013
CD 0.20 0.54 1.39 CD vs. control NS
UC 0.00 0.17 0.22 UC vs. control NS
Periodontitis
Bacteroides ureolyticus Control 0.12 0.18 0.28 CD vs. UC 0.03
CD 0.30 0.48 0.62 CD vs. control 0.02
UC 0.14 0.21 0.28 UC vs. control NS
Campylobacter gracilis Control 0.14 0.38 0.71 CD vs. UC 0.001
CD 0.55 0.82 1.29 CD vs. control 0.05
UC 0.19 0.37 0.71 UC vs. control NS
P. melaninogenica Control 0.27 0.48 0.93 CD vs. UC 0.001
CD 0.74 1.34 2.32 CD vs. control 0.01
UC 0.25 0.46 0.69 UC vs. control NS
S. aureus Control 0.18 0.51 1.05 CD vs. UC 0.001
CD 0.78 1.34 2.33 CD vs. control 0.05
UC 0.28 0.47 0.63 UC vs. control NS
S. anginosus Control 0.14 0.32 0.54 CD vs. UC 0.001
CD 0.74 1.09 1.75 CD vs. control 0.001
UC 0.15 0.25 0.43 UC vs. control NS
S. intermedius Control 0.21 0.35 0.55 CD vs. UC 0.001
CD 0.55 0.78 1.25 CD vs. control 0.01
UC 0.20 0.34 0.49 UC vs. control NS
S. mitis Control 0.24 0.32 0.68 CD vs. UC 0.001
CD 0.44 0.66 1.00 CD vs. control NS
UC 0.12 0.29 0.41 UC vs. control NS
S. mutans Control 0.00 0.32 0.66 CD vs. UC 0.001
CD 0.34 0.86 1.49 CD vs. control 0.006
UC 0.19 0.22 0.48 UC vs. control NS

Numbers indicate  105 bacteria.

CD, Crohn’s disease; UC, ulcerative colitis.

compared with controls and UC patients. As S. anginosus is
an opportunistic bacterium that has been associated with
endocarditis [33–34], the diagnosis of periodontal dis-
eases and consequently the elimination of inflamed sites
through periodontal treatment is an important approach
to eradicate an important reservoir of opportunistic
bacteria in IBD patients.
Although the distribution of the 10 most dominating
species in CD, UC, and control individuals included more
or less the same species, the ranking order differed. Large
differences in bacterial counts were not expected because
of the fact that the participants had untreated period-
ontitis. Specifically, N. mucosa and Prevotella intermedia
were included among the 10 species in the control group
but not in CD or UC patients. Both S. aureus and
S. haemolyticus were included in CD patients, and
S. haemolyticus was found among the four highest-ranking
species both in CD and in UC patients but were not
included in the HC patients. Moreover, Firmicutes,
Bacteroidetes, and Proteobacteria identified as prevalent
species in CD [35] were found in subgingival samples
from our patients with CD and untreated periodontitis.
This may indicate a disturbed microbiota in CD patients
even presenting periodontal characteristics similar to
those of UC patients and controls.

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244 European Journal of Gastroenterology & Hepatology 2013, Vol 25 No 2
T. denticola, a motile microorganism, is recognized as a key
pathogen in periodontitis. It has been shown that
colonization by T. denticola above certain thresholds
increases significantly the risk of periodontal disease
progression in Chinese patients [36]. Besides, Byrne
et al. [37] have reported that the proportions of
Porphyromonas gingivalis and T. denticola in subgingival
plaque have the potential to help in the identification of
sites at significant risk for periodontitis progression.
It can be speculated that CD patients have a higher risk
of disease progression than UC. The difference was found
only in gingivitis sites, which indicated that major
differences may appear before CAL. This hypothesis
should be tested in a longitudinal study.
It is unknown how various medications influence the
growth of certain oral bacterial species. This may be
specifically important in patients who are medicated with
drugs that modulate the host inflammatory responses and
specifically as to how such medications may upregulate or
downregulate proinflammatory cytokines. This should be
investigated more carefully, although we are aware that it is
a difficult task to group IBD patients according to the same
oral condition and also according to the medications they
are taking. IBD treatment is individual and the medications
used can be altered any time according to the patient’s
needs [38]. Besides the medication, the composition of the
intestinal microflora might also be influenced by different
dietary habits. De Filippo et al. [39] have examined the
human intestinal microbiota from children exposed to
a modern Western diet and a rural diet, and reported that it
is important to preserve the microbial diversity from
ancient rural communities worldwide. We believe that
the patients analyzed in the present study were on a quite
similar diet; however, this information should be considered
in further investigations.
Conclusion
This study showed that even presenting similar clinical
periodontal parameters, IBD patients harbor higher levels
of bacteria that are related to opportunistic infections in
inflamed subgingival sites that might be harmful for the
crucial microbe–host interaction.
Acknowledgements
This study was supported in part by a grant from FAPERJ
(Grant Number E26/101.528/2010).
Conflicts of interest
There are no conflicts of interest.
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