Presented by
Dr. Priyanka Singh
MDS-IInd year,
Department of Oral Pathology,
SPIDMS.
CONTENTS
Introduction
Prokaryotic cell & eukaryotic cell
Bacteria
Staining of bacteria
Anatomy of bacteria
Growth and multiplication of bacteria
Growth regulation
Flora of the oral cavity
Dental plaque bio film
Calculus formation
Role of oral flora in systemic infection
Conclusion
Introduction
Human beings like other animals, harbour a wide array of
microorganisms either on or in their bodies. A knowledge of
normal flora of body is essential to an understanding of the
interaction between human beings and their pathogen laden
environment.
The oral cavity is accessible to the introduction of many
different types of microorganisms and consist of large number
of microorganisms including mycoplasma, fungi, protozoa nad
viruses.
Microorganisms
A heterogeneous group of several distinct classes of
living beings
Originally classified under plant and animal kingdoms
3rd kingdom protista was formed for them
Kingdom protista
Prokaryotes bacteria and blue-green algae
Eukaryotes fungi, algae, slime moulds and protozoa
Prokaryotic cell & eukaryotic cell
Characteristic Prokaryote Eukaryote
Nucleus Absent Present
Diameter of cell About 1m 10-100m
Cytoskeleton Absent Present
Cytoplasmic organelle Absent Present
DNA content Unorganized Organized
Chromosomes Single circular Multiple linear
DNA molecule DNA molecule
BACTERIA
Prokaryotic microorganisms
Do not contain chlorophyll
Unicellular
Do not show true branching except in Actinomycetes
Staining of bacteria
Live bacteria do not show much structural detail due to
lack of contrast
Stained to produce colour contrast
Depending upon the effect of stains on the viability of
microorganisms
Supravital staining
Toxic
Kill the cells
Intravital staining
Nontoxic
Cells remain viable
Routine methods
Simple stain
Methylene blue & basic fuchsin
Do not stain bacterial capsules
Imparts same colour to all bacteria
Negative stain
India ink or nigrosin
Uniformly colors background
Unstained bacteria in contrast
Useful for demonstration of bacterial capsules
Spirochetes which are very slender can be stained
Impregnation
Thin cellular structures can be seen
Thickened by impregnation of silver on the surface
Spirochetes and bacterial flagella
Differential stains
Imparts different colour to different bacteria or
bacterial structures
2 most widely used differential stains are
Gram stain
Acid fast stains
GRAMS STAIN
Devised by Christian Gram (1884)
Procedure
Primary staining with pararosaniline dye
e.g. crystal violet, methyl violet or gentian violet
Dilute solution of iodine
Decolorisation with an organic solvent e.g.- ethanol,
acetone or aniline
Counterstaining with a dye of contrasting colour
e.g. carbol fuchsin, Safranin or neutral red
Purpose of gram stain
Identification of bacteria
Therapy of bacterial infections - gram +ve bacteria are
more susceptible to penicillins
Principle
GRAM +ve
Relates to the permeability of the bacterial cell wall and
cytoplasmic membrane to the dye
Gram ve cells permits the outflow of the dye during
decolorisation
Gram positive cells resist decolorisation and also has got a
more acidic protoplasm and so retain the primary stain,
appearing violet
Gram ve bacteria are decolorised by organic solvents and so
take the counter stain, appearing red
GRAM -ve
ACID FAST STAIN
Discovered by Ehrlich after staining with aniline dyes
tubercle bacilli resist decolorisation with acids
Modified by Ziehl and Neelson
Smear stained with carbol fuchsin with application
of heat
Decolorised with 20 % sulphuric acid
Counterstained with a contrasting dye
i.e. methylene blue
Acid fast bacteria retain fuchsin (red) colour while
others take the counter stain
SIZE OF BACTERIA
0.2 1.5 m in diameter
3 5 m in length
SHAPE OF BACTERIA -
Cocci (kokkos berry) -
spherical or oval
Diplococci (in pairs)
Streptococci (in chains)
Grape like clusters
(staphylococci)
Bacilli (bacillus rod) rod shaped
Streptobacilli (in chains)
Corynebacteria (arranged at angles to
each other, presenting a cuneiform or
Chinese letter pattern)
Vibrios (comma shaped, curved rods)
characteristic vibratory motility
Spilrilla rigid spiral forms
Spirochetes (speira=coil ; chaite=hair)
flexuous spiral forms
Actinomycetes (actis = ray, mykes = fungus)
branching filamentous bacteria radiating
rays of the sun like appearance - due to
presence of rigid cell wall
Mycoplasma
Do not posses a stable morphology
protoplasts, spheroplasts or L-forms
Deficient cell wall due to drugs like
penicillin
Round or oval bodies
Some are pleomorphic
(pleo : many, morphic shaped)
ANATOMY OF BACTERIA
Consists of
Outer layer or cell envelop
Cell wall
Plasma membrane
Inner cytoplasm and
cytoplasmic inclusions
Ribosomes and
Mesosomes
Granules
Vacuoles
Nuclear body
Some bacterial cell
Enclosed by a viscid slimy
layer or organized as a
capsule
Filamentous appendages
protruding from the cell
surface flagella organs
of locomotion
Fimbriae organs of
locotion
STRUCTURES EXTERNAL TO CELL WALL
Flagella
Whip like long filaments
Used for locomotion
Guide the bacteria towards
nutritional and other sources
Composed of subunits of a
single protein flagellin
3 parts
Filament
Hook
Basal body
3-20 m long
0.01-0.013 m in diameter
Flagella of different bacteria have same chemical composition
but are antigenically different
Flagellar antigens induce specific antibody in high titers
Flagellar antibodies are useful in serodiagnosis
Flagella
Peritrichos
Polar
Monotrichos
Lophotrichos
Amphitrichos
Presence is usually detected by
motility of bacteria
Motility spreading type of
growth on a semisolid agar
medium
Present in all motile bacteria
except in spirochetes (move with
axial filament a flagellum like
structure)
Fimbriae & Pili
Fine hair like surface
appendages
Shorter than flagella
0.5 m long and 10 nm
thick
Present mainly on
gram ve bacteria
Consists of self aggregating monomers of pilin
Adhesion of bacteria to receptors on human cell
surface first step in initiation of infection
Cause hemagglutination a method of detection
Antigenic in nature
Sex pili
A specialized type of fimbriae
Forms attachment between male
(donor) and the female
(recipient) through conjugation
tube
Genetic material is transferred
from donor to recipient cell
Glycocalyx (slime layer)
Loose undemarcated
Polysaccharide or
polypeptide covering
Adhesion of bacteria to
structures like oral mucosa,
teeth, etc.
E.g. - leuconostoc
Capsule
An amorphous gelatinous layer
Surrounds entire bacteria
Composed of mainly polysaccharides
Antigenic
Demonstrable by serological methods
by antigenic differences of sugar
in polysaccharide capsule
Mediates adhesion of bacteria to human tissues
Hinders or inhibits phagocytosis
Quelling reaction
Described by Neufeld (1902)
Presence of antiserum against capsular polysaccharide,
swelling of the capsule
Protects the bacteria from deleterious agents in nature.
Helps in virulence of pathogenic bacteria
Inhibits phagocytosis
E.g. streptococcus mutans
Spores
E.g. bacillus & clostridium
Highly resistant resting stages
One bacteria forms one spore
on germination forms one
vegetative cell
Not a method of reproduction
Called endospores as are formed
inside the parent cell
Cause in response to adverse conditions
Contains bacterial DNA, cytoplasm, cell membrane,
peptidoglycan, water and a thick, keratin like coat
Consists of calcium dipicolinate
Resistant to heat, dehydration, chemicals
Metabolically inert
Remain dormant for many years
Types of spores
Central, budging
Central, not budging
Sub terminal, budging
Sub terminal, not budging
Terminal, budging
Terminal, not budging
When spores are transferred to favorable conditions
Spore loses its refractility
Swells
Spore wall is shed
Germ cell appears
Elongates to form vegetative bacterium
Can be destroyed by autoclaving at 120 for 15 mins
Bacillus stearothermophilus ensures sterilization efficacy of
autoclaves
Appears unattained in gram stain
Can be stained by Ziehl-Neelson stain due to its acid fast
nature
Cell wall
Confers rigidity upon
bacterial cell
Multilayered structure outside
protoplasmic membrane
Porous and semi permeable
Important in virulence and
immunity
Demonstrable by plasmolysis
Hypertonic solution
Osmosis
Cytoplasm loses water
Shrinkage of cell
But cell wall retains its original shape
Inner layer
Peptidoglycan
Scaffoldings formed by N-
acetyl glucosamine and N-
acetyl muramic acid
Present in chains which are
cross-linked by peptide
chains
Outer layer
Depends upon gram staining
property of bacteria
Bacteria with deficient or defective cell walls
Mycoplasma
Do not posses cell wall
May cause human disease
e.g. pneumonia
L - forms
E.g. streptobacillus moniliformis
Swollen cells
Named after Lister Institute, London
Develops
Spontaneously
Presence of penicillin
Other agents that interfere with
cell wall synthesis
Cause urinary and suppurative
infections
Spheroplasts (gram ve bacteria) & protoplasts (gram +ve bacteria)
Lack cell walls
Cannot replicate on laboratory media
Unstable
Osmotically fragile
Require hypertonic conditions for
maintenance
Produced in laboratory by action of
enzymes or antibiotics
Spheroplast Protoplast
Conversion of bacteria into protoplast and spheroplast
Cytoplasmic membrane
Thin inner layer lining the inner
surface of the cell wall
5 10 nm thick
Separates cell wall from cytoplasm
Semi permeable membrane
Passage through the membrane depends
upon-
Molecular size of the particles
Presence of specific enzymes
(permeases)
Consists of
Lipoprotein with small amounts of
carbohydrate
Sterols are absent except in mycoplasma
Cytoplasm
Colloidal system of organic and
inorganic solutes in a viscous watery
solution
Differs from eukaryotic cytoplasm
Absence of protoplasmic streaming
Absence of endoplasmic reticulum and
mitochondria
Stains uniformly with basic dyes
Contains ribosome, mesosome,
inclusions (volutin granules or Babes
Ernst granules) and vacuoles,
metabolites and various ions
Ribosomes
Centers of protein synthesis
Smaller than in eukaryotes
Sedimentation rate 70 s
Integrated in linear strands of mRNA to form
polysomes
Mesosomes (chondroids)
Convoluted or multilaminated structures
Invaginations of plasma membrane into
the cytoplasm
More prominent in gram + ve bacteria
Principal site of respiration
Analogous top mitochondria of eukaryotes
Nucleus
Demonstrated by acid or
ribonuclease hydrolysis
and subsequent staining
Oval or elongated
No nuclear membrane or
nucleolus
Genome consists of a single
molecule of double
stranded DNA arranged in a
form of a circle
Chromosome is haploid and
replicates by simple
binary fission
Plasmids or episomes
Extra nuclear genetic material
Carried by some bacteria
Consists of DNA
Cytoplasmic carriers of
genetic information
GROWTH AND MULTIPLICATION
OF BACTERIA
Divide by binary fission
On reaching certain size
Nucleus divides
Cell divides to form 2 daughter cells
Generation time or population doubling time time interval
between two cell divisions generally vary from 20 mins
in E. coli to 24 hrs in M. tuberculosis
Can be arrested by
deficiency of nutrients
Accumulation of toxins
Antibiotics like penicillin and acriflavin
Bacterial growth curve
Growth regulation
Regulated by nutritional environment
Intracellular
Extracellular
Intracellular
End-product inhibition first enzyme in metabolic
pathway is inhibited by end product of that pathway
Catabolic repression enzyme synthesis is inhibited by
catabolites
Extracellular factors
Temperature
Can grow in a wide range of temperature
Mesophiles 25 40 C majority of bacteria
Thermophiles 55 80 C
Psychrophiles below 20 C
pH
Optimal growth at physiological pH 7.2 7.4
Vibrio cholera high degrees of alkalinity
Oxygen requirement
Obligate aerobes require oxygen ATP generating
system is oxygen dependent e.g.-M. tuberculosis
Facultative anaerobes can survive in the absence
of oxygen - e.g.- Strep. Mutans & E. coli
Obligate anaerobes do not require oxygen -
e.g. Porphyromonas gingivalis
Microaerophiles grow best at low oxygen concentration
e.g. Campylobacter fetus
Light -
Grows well in absence of light
Sensitive to ultraviolet and other radiations
Osmotic effect
More tolerant to osmotic variation
Due to mechanical strength of the cell walls
Sudden exposure to hypertonic solutions plasmolysis
mostly in gram ve bacteria
Plasmoptysis sudden transfer from conc. Solution to
distilled water swelling and rupture of cell
Moisture and drying
Moisture is essential
Drying lethal
Highly sensitive for drying Treponema palladium
Antimicrobial therapy
Broad-spectrum antibiotics
Wipe out most of the endogenous flora
Favor fungal infection
FLORA OF THE ORAL CAVITY
Gram positive cocci
Streptococcus
Gram positive
Non motile, flagella usually absent
Occur in chains
Generally non capsulated
Facultative anaerobes
Causes haemolysis
Selective medium mitis salivarius agar
Various types are
Mutans group
High, convex, opaque colonies
Produce extra cellular polysaccharide
Site tooth surfaces
Causes Dental caries
Salivarious group
Appear in mouth of infants as early as 18 hrs to 1 month after birth.
Large mucoid colonies
Produce extra cellular fructans (polymer of fructose with a levan
structure)
Site dorsum of tongue and saliva (especially in infants)
Not a major oral pathogen
Mitis group
Small, rubbery or non adherent colonies
Site tongue and cheeks
Causes Dental plaque bio films, Dental caries, Infective
endocarditis
Anaerobic streptococci
Strict anaerobes
Slow growing
Usually non hemolytic
Site teeth (carious dentin)
Causes Periodontal or Dentoalveolar abscess
Gram positive rods and cocci
Actinomyces
Strict and facultative anaerobes
Branched sun ray appearance
Ferments glucose characteristic patterns of short chain
carboxylic acids
Causes Dental caries (especially root caries) &
Gingivitis
Actinomycosis
Lactobacillus
Micro-aerophiic
Aciduric (optimal ph=5.5-5.8)
Selective medium Rogosa agar
Catalase negative
Site common oral inhabitats
Causes Dental plaque bio film
Advancing front of dental caries
Eubacterium
Pleomorphic
Obligatory anaerobes
Site plaque bio films and calculus
Causes Role in dental caries
Propionibacterium
Strict anaerobe
Produces propionic acid from glucose
Causes Root surface caries and Dento-alveolar infections
Gram negative cocci
Neisseria
Facultative anaerobe
Site tongue, oral mucosa, saliva and early plaque
Causes - not a major oral pathogen
Veillonela
Strict anaerobe
Site tongue, saliva and plaque bio film
Gram negative rods
(Facultative anaerobe an capnophilic genera)
Hemophilus
Growth on heated blood agar
Requires X (haemin) and V (NAD) for growth
Site - oral mucosa, saliva and plaque bio film
Causes Dentoalveolar infections,
Acute sialadenitis
Infective endocarditis
Actinobacillus
Produces virulent factors leucotoxin, epitheiotoxin,
cardotoxin
Site periodontal pockets
Causes - Periodontal disease
Gram negative rods (obligate anaerobic genera)
Produce brown black pigment on blood agar
Black pigmented anaerobes
Prevotella
Pleomorphic rods
Non-motile
Strict anaerobe
Require Vit. K and haemin for growth
Site gingival crevice and sub gingival plaque
Causes Chronic periodontitis and Dentoalveolar abscess
Fusobacterium
Sender, cigar shaped Gm ve rods with rounded ends
Site gingival crevice and tonsils
Causes periodontal infections
acute ulcerative gingivitis
dentoalveolar abscess
Treponema
Motile
Helical cells (large, medium, small)
Strict anaerobes
Require enriched media with serum to grow
Site gingival crevice
Causes - acute ulcerative gingivitis
destructive periodontal disease
Other bacterial genus present are
Angiogenous group
Stomatococcus group
Propionibacterium group
Actinobacillus group
Eikenella group
Capnocytophaga group
Leptotrichia group
Wolinella
Fungi and protozoa present in the oral cavity are
Fungi
Candida albicans
Candida tropicalis
Candida pseudo tropicalis
Cryptococcus
Protozoa -
Entameoba gingivalis
Factors in the oral cavity affecting growth
of micro flora
Anatomical factors -
Shape of teeth
Malalignment of teeth
Poor quality of restorations
Non-keratinized sulcular
epithelium
Difficult to clean
Favors accumulation of bacteria
Saliva
Consist of proteins, glycoproteins and various other ions
& metabolites
Modulate bacterial growth by
Adsorption on the tooth surfaces pellicle facilitates
bacterial adhesion
Acts as a primary source of nutrition
Helps in aggregation of bacteria plaque formation
Inhibits growth -
Due to presence of defense factors
Lysozyme, lactoferrin, IgA, etc
Bactericidal and fungicidal
Gingival crevicular fluid
Continuous but slow flow
Flushes microbes out of the crevice
Maintains pH level
Provide defense factors IgG ( also IgM & IgA)
Causes phagocytosis due to presence of neutrophils
Microbial factors
Interaction of bacteria with each other may promote or
suppress the neighboring bacteria by
Competition for receptors for adhesion
Production of toxins by one may destroy same or other
bacterial species
Production of metabolic end products lowering of pH
Co-aggregation to form corn-cob formation with
Same (homotypic) or
Different (heterotypic) species
Distribution of oral flora
Oral micro flora does not represent a homogenous collection
of organisms through out the oral cavity but it is localized in 3
different foci
Gingival crevices
Dorsum of tongue
Areas that are not cleaned by mastication
Other areas that may be involved are
Lips
Palate
Saliva
Cheeks or buccal mucosa
Gingival crevices
The gingival crevice is not sterile, but harbors a microbial
flora in both health and disease
In healthy sulci, gram positive cocci are major macrophyte
and compose almost 2/3rd of total flora. Filamentous forms
and all spirochetes fusiforms are found.
In diseased conditions, gram positive as well a sgram
negative rods such as capnocytophaga, bacteroids,
compylobacter, fusobacterium can be isolated.
Tongue
The tongue with its complex surface structures (crypts and
papilla) forms large surface areas that support growth of a
wide variety of bacteria and serves as a reservior of
microorganisms in the mouths.
Predominant cultivative bacteria isolated from the tongue
falls in the following list of microorganisms which are -
Facultative streptococci
Veillonelle
Facultative diptheroids
Anaerobic diptheroids
Bacteroides
Peptostreptococcus
Neisseria
Vibrio
Fusobacterium
Provetella intermedia
Provetella melanogenicus
Lips
The lips form the border between the skin flora and
consists predominantly of staphylococcus.
Facultative anaerobic micro flora comprises a large part of
flora of the lips.
Veillonella and neisseria have been found
If commissures are moistened by saliva, then Candida
albicans, Staph. aureus and Strept. Pyogenes are common.
Cheeks/buccal mucosa
Predominant bacteria are Strept. sanguis and Strept.
salivarious.
Yeasts may also be isolated from carriers. Other organisms
may be hemophilus and neisseria sp.
Palate
Hard palate supports a streptococcal flora resembling the
cheek flora
Haemophillus and lactobacilli are also found regularly
Yeasts and lactobacilli are increased dramatically, in some
denture wearers and flora may alter substantially when the
palate is protected from the action of tongue and saliva by
denture base.
Soft palate also harbor respiratory tract bacteria like
hemophilus, corynebacterium, neisseria.
Saliva
Adult human saliva contains approx. 6 billion micro flora and
include
Streptococci
Peptostreptococci
Veillonella
Corynebacteria
Neisseria
Nocardia
Fusobacteria
Lactobacilli
Actinomycosis
Spirochetes
Fungi like Candida and Cryptococci
Teeth
On eruption, teeth are covered by organic structure of embryonic
origin.
After eruption, organic deposits form on the surfaces of teeth which
contain organic acids, bacterial and cytotoxic agents.
Williams demonstrated microscopically, the presence of thick mass of
microorganisms covering the surface of teeth
G.V. Black introduced the term gelatinous microbial plaque to describe
microbial colonies on the surface of teeth.
Microorganisms do not attach themselves directly to mineralized tooth
surface as teeth are covered by teeth by an acellular proteinaceous film.
DENTAL PLAQUE BIOFILM
Dental plaque is a tenacious microbial community which
develops on soft and hard surfaces of mouth, comprising of
living, dead and drying bacteria and their extra cellular
products, together with host compounds mainly derived from
saliva.
Composition
Organisms surrounded by organic matrix 30%
Matrix acts as a food reserve for adhesion of further bacteria
Composition varies
At different sites on same tooth
At same site on different teeth
At different time on the same tooth site
Distribution
Found on dental surfaces
and appliances
Mainly in absence of oral
hygiene
May be -
Supra gingival mainly
aerobic bacteria
Sub gingival mainly
anaerobic bacteria
Plaque has been found to contain the following microorganisms in
percentages
Supragingival plaque -
Facultative streptococcus 87%
Facultative diphtheroids 23%
Anaerobic diphtheroids 18%
Peptostreptococcus 13%
Subgingival plaque -
Veillonella 6%
Bacteroids 4%
Fusobacteria 4%
Neisseria 3%
Vibrio 2%
Stages of Plaque Bio film formation
Pellicle formation
Thin layer of salivary glycoproteins
Deposited on the surface
Forms within minutes of exposure to the oral
environment
Oral bacteria attach to pellicle for the initiation of plaque
formation
Transport
Bacteria are transported to pellicle site by
Natural salivary flow
Brownian motion
Chemo taxis
Long range interactions
Between microbial cell surface and pellicle coated tooth
Called pioneer group-gram positive cocci and rods
Through Vander waals forces
Reversible
Short range interactions
Polymer bridging between organisms and the surface
After which organisms come and accumulate to
increase the microorganism mass
Forms corn-cob arrangements
Secondary invaders - gram negative cocci and rods and
later by fusobacteria, spirals, and spirochetes
Irreversible
Co-aggregation or co-adhesion
Fresh Bacteria now attach to the primary invaders
May be of same genus or different genera
Process of plaque bio film mass reaches a critical size at
which
Deposition = Loss of bacterial accumulation
Climax community
The bacteria in climax community- detached
Plank tonic phase suspended in saliva transported to
new colonization site
Bio film formation
Due to resultant confluent growth
Matures in complexity as time progresses
Occurs at inert surfaces e.g.- tooth enamel, dentures, etc.
Organisms may be arranged in columns or mushroom
shaped structures
Water channels that carry metabolites and nutrition are
interspersed within the organic matrix
A bio film is defined as a complex functional community
of one or more species of microbes encased in and
exopolysachharide matrix and attached to one another or to
solid surface
Major component of bio film is extra-cellular matrix
Microbial polysaccharides
Salivary glycoproteins
Calculus formation
Due to deposition of calcium and phosphate ions from saliva
within dental plaque
Bacteria in plaque as seeding agents of mineralization
Accelerated by bacterial phosphatases and proteases degrade
calcification inhibitors (Statherin and proline rich proteins) in
saliva
Formation of insoluble calcium phosphate crystals
Coalesce to form a calcified mass of plaque calculus
Mature calculus
Mineralized material 80%
Organic compounds 20%
Structure of calculus
Predominant flora cocci, bacilli, and filaments outer layers
Supra gingival calculus gram positive bacteria
Sub gingival gram negative bacteria
Outer surfaces of calculus
cocci attach
grow on surface of filamentous microorganism
corn cob arrangements
Filaments orient themselves at right
angles to enamel surface Palisade
effect (like books on a shelf)
Cytoplasm of bacteria is
Reduced
Contains glycogens like food
storage granules
Ready source of nutrition during
periods of adversity
Has enough surface
Porous
Ideal reservoir for bacterial toxins
harmful to periodontium
Role of oral flora in systemic infection
Plaque related oral diseases, especially periodontitis may alter
Cardiovascular disease
Infective endocarditis
Coronary heart disease
Bacterial pneumonia
Diabetes mellitus
Low birth weight babies
According to focal infection theory
3 mechanisms lining oral infections to secondary systemic disease
are
1. Metastatic infection
Gain entry into vascular system through breach in oral vascular
barrier
E.g. - bacteraemias during tooth extractions
2. Metastatic injury
Products of bacteria (catalytic enzymes, endotoxins, exotoxins)
gain access to cardiovascular system
3. Metastatic inflammation
Caused by immunological injury due to antigens produced by
oral organisms enter blood stream from oral route - react with
circulating antibodies - immune mediated disease
Factors for periodontitis predispose risk for systemic disease
Sub gingival bio films reservoir for gram ve bacteria
continuous source of lipopolysachharides (endotoxin) causes
Induction of major vascular responses
Up regulates endothelial cell adhesion molecules
Secretion of interleukin-1 and tumour necrosis factor-
Gain entry into vascular system
Although, there are various controversies regarding
exact roe of oral flora in dental health, it can definitely be
stated that good oral health is important not only to
prevent oral disease but also to maintain good general
health.
