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. 2018 Jul 26;97(13):1468–1476. doi: 10.1177/0022034518790941

Association between Oral Candida and Bacteriome in Children with Severe ECC

J Xiao 1,✉, A Grier 2, RC Faustoferri 1, S Alzoubi 1, AL Gill 3, C Feng 4, Y Liu 5, RG Quivey 1,2, DT Kopycka-Kedzierawski 1, H Koo 5, SR Gill 2,3
PMCID: PMC6262264  PMID: 30049240

Abstract

Candida albicans is an opportunistic fungal organism frequently detected in the oral cavity of children with severe early childhood caries (S-ECC). Previous studies suggested the cariogenic potential of C. albicans, in vitro and in vivo, and further demonstrated its synergistic interactions with Streptococcus mutans. In combination, the 2 organisms are associated with higher caries severity in a rodent model. However, it remains unknown whether C. albicans influences the composition and diversity of the entire oral bacterial community to promote S-ECC onset. With 16s rRNA amplicon sequencing, this study analyzed the microbiota of saliva and supragingival plaque from 39 children (21 S-ECC and 18 caries-free [CF]) and 33 mothers (17 S-ECC and 16 CF). The results revealed that the presence of oral C. albicans is associated with a highly acidogenic and acid-tolerant bacterial community in S-ECC, with an increased abundance of plaque Streptococcus (particularly S. mutans) and certain Lactobacillus/Scardovia species and salivary/plaque Veillonella and Prevotella, as well as decreased levels of salivary/plaque Actinomyces. Concurrent with this microbial community assembly, the activity of glucosyltransferases (cariogenic virulence factors secreted by S. mutans) in plaque was significantly elevated when C. albicans was present. Moreover, the oral microbial community composition and diversity differed significantly by disease group (CF vs. S-ECC) and sample source (saliva vs. plaque). Children and mothers within the CF and S-ECC groups shared microbiota composition and diversity, suggesting a strong maternal influence on children’s oral microbiota. Altogether, this study underscores the importance of C. albicans in association with the oral bacteriome in the context of S-ECC etiopathogenesis. Further longitudinal studies are warranted to examine how fungal-bacterial interactions modulate the onset and severity of S-ECC, potentially leading to novel anticaries treatments that address fungal contributions.

Keywords: Streptococcus mutans, early childhood caries, microbiota, glucosyltransferase, maternal influence, Candida species

Introduction

Although largely preventable, early childhood caries (ECC) remains the most common chronic childhood disease, with nearly 1.8 billion new cases per year globally (Dye et al. 2012; Vos et al. 2017). Severe ECC (S-ECC) occurs earlier in life than ECC, with more morbidity, often requiring total oral rehabilitation under general anesthesia with multiple tooth extractions, restorations, and crowns (Hajishengallis et al. 2017). The average cost of each total oral rehabilitation is nearly $7,000 in the United States (Rashewsky et al. 2012), and multiple interventions are common (Graves et al. 2004; Berkowitz et al. 2011), despite complementary pharmacologic treatments, such as topical fluoride/antibacterial applications and dietary counseling (O’Sullivan and Tinanoff 1996; Li and Tanner 2015). Hence, S-ECC constitutes a major challenge to the public health system (Dye et al. 2012) and demands enhanced understanding of disease etiopathogenesis and more effective therapeutic strategies to reduce recurrence and costs.

The microbial etiology of S-ECC has been linked with polybacterial infection of teeth. However, available microbiological data also show that fungal organisms are associated with this pediatric oral disease. In particular, Candida species (especially Candida albicans) were often detected at higher levels in the oral cavity of children with S-ECC as compared with caries-free (CF) children, and fungal presence positively correlated with caries severity and Streptococcus mutans carriage (as reviewed by Xiao et al. 2018). Moreover, laboratory findings provided plausible biological evidence of the cariogenic traits of C. albicans: 1) it is acidogenic and aciduric (Klinke et al. 2009); 2) it is capable of dissolving hydroxyapatite, a major tooth-enamel component (Nikawa et al. 2003); and 3) it increases S. mutans accumulation and extracellular matrix production in mixed-species biofilms (Gregoire et al. 2011; Metwalli et al. 2013; Falsetta et al. 2014; Sztajer et al. 2014; Hwang et al. 2015). Importantly, these in vitro findings were supported by rodent models showing that C. albicans can be cariogenic (Klinke et al. 2011) while synergizing with S. mutans to cause more severe and rampant caries on smooth surfaces (Falsetta et al. 2014).

Clinical findings combined with experimental in vivo data point toward active fungal participation in S-ECC and lead to the possibility that the presence of C. albicans is associated with changes in the oral bacterial community that promotes S-ECC. In this study of mother-child dyads (S-ECC and CF), we investigated whether the presence of C. albicans in S-ECC is correlated with a distinctive oral bacterial composition of saliva and plaque. Furthermore, we explored associations between the oral microbiota of the children and their mothers.

To our knowledge, this study provides the first clinical evidence about the impact of fungi (C. albicans) on the oral bacteriome in S-ECC in mother-child dyads. Our results suggest a potential role of C. albicans in promoting a cariogenic bacteriome, indicating that future longitudinal and therapeutic studies may need to include the fungal component to assess children at risk for S-ECC and to maintain a healthy oral ecosystem.

Methods

Oral Examination and Sample Collection

Ethical approval of the study was obtained from the University of Rochester Research Subject Review Board. A cohort of mother-child dyads (S-ECC and CF) was enrolled from patients seen at the Eastman Institute for Oral Health Pediatric Dentistry Clinic, University of Rochester (2015 to 2016). Subjects who had severe systemic diseases or antibiotic treatment within the 3 previous months were excluded. Sociodemographic and oral hygiene behavior characteristics were collected. A comprehensive oral examination was performed on the day of the sample collection by 1 of 2 calibrated dentists (intraexaminer kappa = 0.82, interexaminer kappa = 0.82), who used a standard dental mirror and Community Periodontal Index probe with portable headlight. S-ECC was diagnosed per criteria of the American Academy of Pediatric Dentistry. The number of carious teeth and surfaces was charted with index variables of decayed, missing due to decay, or filled, according to the codes proposed by the World Health Organization’s Oral Health Surveys Basic Methods (1997). Plaque status for mothers and children were assessed separately according to criteria modified from Silness and Löe (1964) and Ribeiro Ade et al. (2002). Nonstimulated whole saliva was collected from subjects through a saliva jet connected to a suction pump at least 2 h after any toothbrushing, eating, or drinking. Supragingival dental plaque was collected from the whole dentition with a standard dental scaler. Sample collection devices were pretreated and tested as DNA free.

C. albicans Identification and Bacterial Community Profiling

Previous established methods were used to isolate and identify C. albicans (Xiao et al. 2016) and to perform oral microbiome sequencing and related bioinformatics analysis (Merkley et al. 2015; Grier et al. 2017), as detailed in the Appendix.

Glucosyltransferase Enzymatic Activity in Plaque

Plaque glucosyltransferase (Gtf) enzyme activity was examined with methods detailed in the Appendix.

Statistical Analysis

One-way analysis of variance with the Tukey-Kramer test was used to compare the proportions of the most populated genus/species relative abundance among 3 groups: CF, S-ECC C. albicans positive (S-ECC CA+), and S-ECC C. albicans negative (S-ECC CA–). DESeq2 negative binomial Wald test was used to compare the microbial abundance at species level among groups at each time: C. albicans conditions (positive and negative) among children with S-ECC, child and mother who were CF, and child and mother with S-ECC. Nonparametric t test and 2-sample t test were used to compare the alpha and beta diversity between groups at a time. Two-sample t test was used to compare plaque Gtf enzymatic activity differences between the S-ECC and CF groups and between the groups with the presence and absence of oral C. albicans. Spearman’s rank test was used to analyze the correlation between plaque Gtf activity and caries severity. P < 0.05 was considered statistically significant.

Results

Sample Characteristics

A total of 39 children (21 S-ECC and 18 CF) and 33 biological mothers (17 S-ECC and 16 CF) were enrolled in the study (6 children were not accompanied by their mothers at their study visits). Chi-square analysis (P > 0.05) revealed no significant sociodemographic or behavior differences between the S-ECC and CF groups with regard to age, sex, race, ethnicity, and toothbrushing frequency (Table). Notably, for children and mothers, the plaque score was significantly higher in the S-ECC group than the CF group (P < 0.05). Mothers with S-ECC had a higher score for decayed teeth than did mothers who were CF (P < 0.05).

Table.

Sociodemographic and Oral Examination Data from the Study Subjects.

Children
 Mothers
Variable S-ECC (n = 21) CF (n = 18) P Value S-ECC (n = 17) CF (n = 16) P Value
Age, y 4.0 ± 0.9 3.8 ± 1.6 0.52 31.8 ± 6.8 32.6 ± 7.1 0.87
Female 43 (9) 33 (6) 0.8
Race
 Caucasian 66 (14) 44 (8) 0.28 66 (11) 38 (6) 0.29
 African American 19 (4) 39 (7) 17 (3) 38 (6)
 Asian 14 (3) 17 (3) 17 (3) 24 (4)
Ethnicity: Hispanic 10 (2) 16.7 (3) 0.59 12 (2) 19 (3) 0.66
Toothbrushing, times/day
 2 52 (11) 88 (15) 0.15 70 (12) 94 (15) 0.13
 1 33 (7) 12 (2) 24 (4) 6 (1)
 <1 10 (2) 0 (0) 6 (1) 0 (0)
Plaque score 2.0 ± 0.7 0.8 ± 1.0 0.001 2.0 ± 0.6 1.0 ± 0.9 0.001
dmft/DMFT 10.3 ± 5.1 0 0.000 9.8 ± 6.9 3.8 ± 3.5 0.002
dmfs/DMFS 25.2 ± 13.9 0 0.000 24.6 ± 22.3 9.5 ± 14.1 0.01
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Values are presented as mean ± SD or % (n).

CF, caries free; S-ECC, severe early childhood caries.

Sequencing Data

Illumina sequencing produced an average of >91,000 reads per sample after quality control and operational taxonomic unit identification among all sequenced samples. Five samples with markedly fewer reads than the threshold of 38,000 were excluded from all analyses (Appendix Fig. 1). The final taxonomic analysis included 37 salivary samples (19 S-ECC and 18 CF) and 69 plaque samples (children, 21 S-ECC and 15 CF; mothers, 17 S-ECC and 16 CF). Detection of C. albicans and other Candida species in the S-ECC and CF groups are shown in Appendix Figure 2, and C. albicans was the most prevalent isolate as compared with other Candida strains in children with S-ECC.

Saliva versus Plaque Microbiota

Overall, the operational taxonomic unit abundance of the microbiota in the S-ECC and CF groups was determined by sample type (saliva or plaque), caries status (S-ECC or CF), and presence of C. albicans (Fig. 1). The microbiota composition differed notably between saliva and plaque samples, regardless of caries status. At the genus level, the 2 most abundant genera in children’s saliva (Fig. 1A) were Streptococcus and Veillonella, whereas in plaque (Fig. 1B), the most abundant genera were Veillonella, Streptococcus, Actinomyces, Selenomonas, and Leptotrichia. At the species level, 3 dominant taxa represented 60% of the relative abundance in the salivary community (Fig. 1C): Streptococcus ET G 4d04, Veillonella atypica dispar parvula, and Streptococcus vestibularis salivarius. In contrast, the 5 most abundant species, representing 30% to 50% of the bacterial plaque community (Fig. 1D), were V. atypica dispar parvula, S. mutans, S. ET G 4d04, Streptococcus oral taxon B66, and Streptococcus gordonii.

Figure 1.

Figure 1.

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Relative abundance of bacterial genera and species in the microbiome of children by caries status and the presence of Candida albicans in saliva and plaque samples. One-way analysis of variance with Tukey-Kramer test was used to compare the proportions of the most populated genus/species relative abundance among 3 groups: CF and S-ECC C. albicans positive and negative. The upper graph reveals that the presence of C. albicans is associated with a distinctive oral microbiota in children with S-ECC, with highly acidogenic and acid-tolerant bacterial genera in addition to an increased abundance of Veillonella and Prevotella in (A) saliva and (B) plaque. (C) The lower graph shows low levels of S. mutans in saliva as compared with other streptococcal species. However, in (D) plaque, S. mutans abundance was dramatically increased in samples from the S-ECC group versus the CF group when C. albicans was present. *P < 0.05 between CF and S-ECC–C. albicans (–). P < 0.05 between CF and S-ECC–C. albicans (+). §P < 0.05 between S-ECC–C. albicans (–) and S-ECC–C. albicans (+). CF, caries free; S-ECC, severe early childhood caries.

Oral Microbiota in the Presence or Absence of C. albicans

The composition of the oral microbiota reflected more acidogenic and aciduric species in children with S-ECC versus those who were CF, and this difference was enhanced by the presence of C. albicans. To further compare the influence of caries status and C. albicans, saliva and plaque samples were grouped as follows: CF, S-ECC CA+, and S-ECC CA– (Fig. 1).

At the genus level, Streptococcus was the most abundant in all saliva samples; moreover, higher abundance of Streptococcus was detected in samples from the CF group (47%) as compared with the S-ECC CA– (40%) and S-ECC CA+ (37%) groups. There was an opposite trend with salivary Veillonella, which was most abundant in the S-ECC CA+ group (36%), decreased in S-ECC CA– (27%), and down to 22% in CF. Interestingly, when CF samples were compared with the S-ECC CA+ samples in regard to other species, we observed for S-ECC CA+ a significantly higher (P < 0.05) abundance of Prevotella, Cardiobacterium, Capnocytophaga, Kingella, Abiotrophia, Lactobacillus, Dialister, Fusobacterium, Atopobium, Allopre-votella, Bifidobacterium, Scardovia, Dolosigranulum, and Moraxella and a significantly lower abundance (P < 0.05) in Lautropia, Propionibacterium, and Porphyromonas. In parallel, when the plaque microbiota was compared between S-ECC CA+ and CF samples, a higher abundance (P < 0.05) of Veillonella was detected in S-ECC CA+, while a lower abundance (P < 0.05) was observed for Selenomonas, Leptotrichia, Capnocytophaga, Alloprevotella, Slackia, Parvimonas, Neisseria, Propionibacterium, Cardiobacterium, Tannerella, Dialister, Lactobacillus, and Atopobium.

At the species level, salivary microbiota in S-ECC samples versus CF samples had a significantly higher abundance of V. atypica dispar parvula and S. vestibularis salivarius and a lower abundance of S. ET G 4d04, regardless of the presence of C. albicans. In plaque samples of children with S-ECC versus those who were CF, a drastically higher abundance of V. atypica dispar parvula and S. mutans was noted, and this difference was even greater when C. albicans was present. The abundance of a well-known cariogenic species, S. mutans, was markedly different across groups: 1% in CF, 2% in S-ECC CA–, and 12% in S-ECC CA+ (P < 0.05: CF vs. S-ECC CA+, S-ECC CA– vs. S-ECC CA+). In contrast, the abundance of several strains was significantly lower (P < 0.5) in S-ECC CA+ as compared with CF samples, including S. oral taxon B66, Actinomyces viscosus naeslundii oris, and Leptotrichia BU064. Conversely, we detected unique species in CF samples, such as Leptotrichia oral taxon 225 and Leptotrichia shahii.

Relative Change in Taxa Abundance Associated with C. albicans

We next determined the relative change in microbial abundance associated with C. albicans in children with S-ECC, as shown in Figure 2. The presence of C. albicans was associated with a significant fold change of taxa in saliva and plaque (P < 0.05). In saliva, C. albicans was associated with a higher abundance of Leptotrichia and a lower abundance of Capnocytophaga gingivitis, Aggregatibacter AY349380, Cardiobacterium hominis, Capnocytophaga granulosa, and Prevotella oral taxon 781. In plaque, C. albicans was associated with a 4-fold higher abundance of S. mutans, as well as a higher abundance of Lactobacillus gasseri and Lactobacillus vaginalis and a lower abundance of Lactobacillus plantarum.

Figure 2.

Figure 2.

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Relative fold change in abundance of species in (A) saliva and (B) plaque from children with S-ECC in the presence or absence of Candida albicans (Ca). Bars show the fold change for each species, calculated as abundance in the presence of C. albicans divided by the abundance in its absence. The DESeq2-negative binomial Wald test was used to compare the relative abundance of the listed bacterial species; all strains listed have a raw P value <0.05. Strains marked with an asterisk (*) have a significant difference in abundance with an adjusted P value <0.05.

Community Diversity and Cluster Analysis

Further analysis of the microbial community revealed that bacterial composition in the plaque was more diverse than in saliva, with a higher mean alpha diversity (Shannon index) value in the CF and S-ECC groups (P < 0.05; Fig. 3A). However, the presence of C. albicans did not alter the microbial alpha diversity in S-ECC salivary or plaque samples when compared within the same sample sources (P > 0.05; Fig. 3B). Appendix Figure 3 shows an additional rarefaction curve of the Shannon index of groups with different caries and C. albicans statuses. In addition, principal coordinate analysis of microbial community dissimilarity identified distinct profiles between plaque and saliva in the CF and S-ECC groups (P < 0.05; Fig. 3C). In the S-ECC group, however, the presence of C. albicans was not associated with community dissimilarity within saliva or plaque samples (Fig. 3D).

Figure 3.

Figure 3.

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Taxa (or operational taxonomic unit) diversity in plaque and saliva samples from CF versus S-ECC and Candida albicans (Ca) positive (+) versus negative (–). (A, B) Mean alpha diversity (measured by Shannon diversity indices with 95% CIs) is shown in the upper graphs. The range of alpha diversity is shown as a dashed line. Means are shown by red lines. (A) Comparisons between sample types (saliva and plaque) were significantly different between S-ECC and CF samples (P < 0.05). Species diversity was higher in plaque samples than in saliva samples. (B) The presence of C. albicans did not alter the microbial alpha diversity in S-ECC salivary or plaque samples when compared within the same sample sources (P > 0.05). (C) This graph depicts 2 main findings. Plaque and saliva samples had dissimilar beta diversity (P < 0.05), which was also different between CF and S-ECC saliva samples (P = 0.005) and plaque samples (P = 0.001). (D) This graph compares saliva and plaque samples in children with S-ECC only, in the presence or absence of C. albicans. Although the cluster pattern looks different in both C. albicans conditions (positive and negative), the differences are not statistically significant. CF, caries free; S-ECC, severe early childhood caries.

Maternal Influence on Children’s Oral Microbiota

To investigate maternal influence on the oral microbiome of children with S-ECC, we examined the species-level relative abundance and diversity between plaque samples obtained from mother-child pairs. Overall, the microbial composition between mother and child plaque samples was similar (Fig. 4A). Data analysis also revealed no significant differences in diversity or dissimilarity between mothers and children, within either CF or S-ECC dyads (P > 0.05; Fig. 4B, C). Thus, maternal and child microbiota were similar within dyads.

Figure 4.

Figure 4.

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Species relative abundance and taxa or operational taxonomic unit diversity (Shannon diversity) and dissimilarity (beta diversity) from plaque samples among mother-child dyads. (A) For species relative abundance among mother-child samples, a similar microbial composition was seen between mother and child plaque samples. (B) Beta diversity results indicate the dissimilarity of plaque microbiome in S-ECC samples between children and their mothers (P = 0.703, nonparametric P value) and in CF samples between children and their mothers (P > .99, nonparametric P value). (C) Alpha diversity is shown (mean Shannon diversity indices with 95% CIs). The range of plaque microbiome diversity is shown as a vertical dashed line, and means are shown as red lines. No alpha diversity difference was seen between the children and their mothers in the S-ECC or CF group (P > 0.05). CF, caries free; S-ECC, severe early childhood caries.

Functional Correlation with Plaque Gtf Activity

Since the detection of C. albicans is associated with an increased abundance of S. mutans and acidogenic-aciduric species in plaque, we examined whether the activity of a cariogenic virulence factor (Gtfs) can be altered by the fungal presence. Insoluble glucans produced by streptococcal Gtfs were shown to be key virulence traits in ECC (Mattos-Graner et al. 2000; Vacca Smith et al. 2007). Thus, we determined the plaque Gtf enzymatic activity by measuring insoluble glucan synthesis via scintillation spectroscopy (Appendix Fig. 4). Interestingly, the Gtf activity was significantly higher in S-ECC than in the CF group (P < 0.05), and it was further elevated with the presence of C. albicans within S-ECC (P < 0.05). Moreover, Spearman’s rank test demonstrated a strong correlation between plaque Gtf activity and caries severity among children with S-ECC (r = 0.67, P < 0.05).

Discussion

Microbiome studies have largely focused on the bacterial components and their role in causing dysbiotic microbiota and ecologic shifts that result in oral diseases (Marsh 2018; Tanner et al. 2018). Here, our clinical findings demonstrate an association of C. albicans with alterations of the oral bacterial composition and virulence potentially more conducive for S-ECC. The presence of C. albicans was associated with an enrichment of a highly acidogenic-aciduric bacterial community, with an increased abundance of plaque Streptococcus (particularly S. mutans) and certain species of Lactobacillus/Scardovia and salivary/plaque Veillonella and Prevotella, as well as decreased levels of salivary/plaque Actinomyces. In parallel, our data indicate that C. albicans could play an important role in enhancing plaque Gtf activity, which is associated with caries pathogenesis, as demonstrated in rodent models and clinical studies (Bowen and Koo 2011). Therefore, fungal counterparts may play an active role in the caries microbiome and should be included in future longitudinal studies investigating the microbial etiopathogenesis of this costly and intractable disease.

Several studies characterized the oral microbiota in caries-active children (Tanner et al. 2011; Gross et al. 2012; Yang et al. 2012; Ma et al. 2015; Johansson et al. 2016; Richards et al. 2017) and identified S. mutans in addition to several caries-associated species, including Streptococcus salivarius, Streptococcus sobrinus, Strepto-coccus parasanguinis, Scardovia wiggsiae, Spodoptera exigua, Lactobacillus salivarius, Parascardovia denticolens, Porphy-romonas, Actinomyces, and Veillonella. Our study confirms the detection of higher levels of plaque S. mutans, Lactobacillus, and Scardovia species associated with the S-ECC condition and further underscores the potential C. albicans influence on the oral bacteriome, as the fungal presence appears to increase the abundance of these caries-associated bacteria.

Available in vitro and in vivo evidence indicates that the presence of C. albicans can promote the development of a cariogenic biofilm environment, which may involve complex physical, chemical, and metabolic bacterial-fungal interactions (O’Donnell et al. 2015; Bowen et al. 2018). For example, C. albicans promotes S. mutans carriage by inducing glucosyltransferase B and bacterial accumulation via chemical-metabolic interactions (Sztajer et al. 2014; Kim et al. 2017). Once together, cross-feeding interactions favor C. albicans and S. mutans growth while creating a Gtf activation loop, consistent with the increased abundance of S. mutans and plaque Gtf activity observed in this study. Enhanced carbohydrate metabolism via bacterial-fungal interactions can promote the creation of a highly acidified and selective biofilm microenvironment that favors the growth of acidogenic-aciduric and acid-consuming species, while nonaciduric and aerobic species may perish (Bowen et al. 2018). This pathogenic process could, at least in part, explain the increased abundance of L. gasseri, L. vaginalis, and S. mutans in C. albicans–positive S-ECC plaque samples. However, additional studies are needed to further determine whether Candida has an active role in causation or its presence is simply a result of a disrupted microbiota. In this context, C. albicans could enhance EPS production and acidification of cariogenic biofilms, or alternatively, the acidic environment in S-ECC biofilms could cause fungal proliferation. In addition, interaction of Candida with oral microbiota under healthy conditions needs further exploration (Janus et al. 2017), with the actual sequence of events elucidated by mechanistic animal and longitudinal clinical studies.

Interestingly, when we compared the oral microbiota of mother-child dyads, we observed that the microbial community structure and diversity within dyads were similar (although species abundance differed across pairs; see Fig. 4). Such strong maternal influence on the oral microbiota of children is supported by the recent observations of Chu et al. (2017), who found that infant and maternal oral microbiota had a similar community structure and taxonomic membership (classified at the genus level). Although C. albicans is a commensal strain, the detection rate in the first year of life is about 11% to 15% (Stecksen-Blicks et al. 2015). Vertical and horizontal transmissions were implicated for fungal colonization in neonates. In particular, the vertical transmission rate ranges from 14%, typed by electrophoretic karyotyping and restriction endonuclease analysis of genomic DNA with pulsed-field gel electrophoresis, to 41%, typed by DNA fingerprinting with a C. albicans strain–specific DNA probe (Waggoner-Fountain et al. 1996; Bliss et al. 2008). Given the existing evidence indicating the maternal contribution of C. albicans and S. mutans to infants (Caufield et al. 2005; Xiao et al. 2016), if the causative role of C. albicans is confirmed by further longitudinal cohort study, controlling oral C. albicans carriage in mothers who are at high caries risk could be an effective adjunctive approach to reduce or delay the C. albicans oral colonization in infants, in addition to addressing other behavioral and dietary factors to prevent S-ECC in children.

The strength of the study, although a case-control report, is the availability of a defined mother-child cohort to analyze the influence of C. albicans presence in the bacterial community in plaque and saliva samples and on the activity of a known cariogenic factor (Gtfs). Conversely, we recognize the limitations of this study: 1) it utilized a case-control design instead of a cohort design, so inferences about causation are limited in scope; 2) it was based at a single hospital site; 3) a limited sample size may have compromised the power of our multiple regression analyses, given that S-ECC is a multifactorial disease; and 4) plaque samples were not site specific, so data on the microbiota could not be localized to the site of carious lesions. Nevertheless, these limitations shall be addressed in a follow-up longitudinal study.

Conclusions

In conclusion, the presence of C. albicans appeared to be associated with significant differences in the oral bacteriome profiles between children who had S-ECC and those who were CF. The bacterial composition changes were characterized by an increased abundance of highly acidogenic and aciduric microbiota, such as S. mutans and specific Lactobacillus and Scardovia species, in addition to other bacteria commonly associated with S-ECC. The data also revealed that the presence of C. albicans enhanced the plaque Gtf activity, a virulence factor associated with caries. In addition, maternal and infant microbiota were highly related to each other, with a similar microbial community structure and diversity. Altogether, the data highlight the importance of including fungal components (e.g., mycobiome analysis) of the oral microbiome in future longitudinal studies assessing the potential risk factors and therapeutic approaches for S-ECC.

Author Contributions

J. Xiao, contributed to conception, design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript; A. Greier, Y. Liu, S.R. Gill, contributed to data acquisition, analysis, and interpretation, drafted and critically revised the manuscript; R.C. Faustoferri, R.G. Quivey, D.T. Kopycka-Kedzierawski, contributed to data interpretation, critically revised the manuscript; S. Alzoubi, A.L. Gill, contributed to data acquisition and analysis, critically revised the manuscript; C. Feng, contributed to data analysis and interpretation, drafted and critically revised the manuscript; H. Koo, contributed to data interpretation, drafted and critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of the work.

Supplemental Material

DS_10.1177_0022034518790941 – Supplemental material for Association between Oral Candida and Bacteriome in Children with Severe ECC
Click here for additional data file. (391.3KB, pdf)

Supplemental material, DS_10.1177_0022034518790941 for Association between Oral Candida and Bacteriome in Children with Severe ECC by J. Xiao, A. Grier, R.C. Faustoferri, S. Alzoubi, A.L. Gill, C. Feng, Y. Liu, R.G. Quivey, D.T. Kopycka-Kedzierawski, H. Koo and S.R. Gill in Journal of Dental Research

Footnotes

A supplemental appendix to this article is available online.

J. Xiao’s research was supported by the National Institute of Dental and Craniofacial Research / National Center for Advancing Translational Sciences (KL2TR001999) and faculty start-up funds from the Eastman Institute for Oral Health, University of Rochester. H. Koo’s research was supported by the National Institute of Dental and Craniofacial Research (R01DE025220).

The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

References

  1. Berkowitz RJ, Amante A, Kopycka-Kedzierawski DT, Billings RJ, Feng C. 2011. Dental caries recurrence following clinical treatment for severe early childhood caries. Pediatr Dent. 33(7):510–514. [PubMed] [Google Scholar]
  2. Bliss JM, Basavegowda KP, Watson WJ, Sheikh AU, Ryan RM. 2008. Vertical and horizontal transmission of Candida albicans in very low birth weight infants using DNA fingerprinting techniques. Pediatr Infect Dis J. 27(3):231–235. [DOI] [PubMed] [Google Scholar]
  3. Bowen WH, Burne RA, Wu H, Koo H. 2018. Oral biofilms: pathogens, matrix, and polymicrobial interactions in microenvironments. Trends Microbiol. 26(3):229–242. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bowen WH, Koo H. 2011. Biology of Streptococcus mutans–derived glucosyltransferases: role in extracellular matrix formation of cariogenic biofilms. Caries Res. 45(1):69–86. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Caufield PW, Li Y, Dasanayake A. 2005. Dental caries: an infectious and transmissible disease. Compend Contin Educ Dent. 26(5 Suppl 1):10–16. [PubMed] [Google Scholar]
  6. Chu DM, Ma J, Prince AL, Antony KM, Seferovic MD, Aagaard KM. 2017. Maturation of the infant microbiome community structure and function across multiple body sites and in relation to mode of delivery. Nat Med. 23(3):314–326. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Dye BA, Li X, Thorton-Evans G. 2012. Oral health disparities as determined by selected Healthy People 2020 oral health objectives for the united states, 2009–2010. NCHS Data Brief. 104:1–8. [PubMed] [Google Scholar]
  8. Falsetta ML, Klein MI, Colonne PM, Scott-Anne K, Gregoire S, Pai CH, Gonzalez-Begne M, Watson G, Krysan DJ, Bowen WH, et al. 2014. Symbiotic relationship between Streptococcus mutans and Candida albicans synergizes virulence of plaque biofilms in vivo. Infect Immun. 82(5):1968–1981. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Graves CE, Berkowitz RJ, Proskin HM, Chase I, Weinstein P, Billings R. 2004. Clinical outcomes for early childhood caries: influence of aggressive dental surgery. J Dent Child (Chic). 71(2):114–117. [PubMed] [Google Scholar]
  10. Gregoire S, Xiao J, Silva BB, Gonzalez I, Agidi PS, Klein MI, Ambatipudi KS, Rosalen PL, Bauserman R, Waugh RE, et al. 2011. Role of glucosyltransferase b in interactions of Candida albicans with Streptococcus mutans and with an experimental pellicle on hydroxyapatite surfaces. Appl Environ Microbiol. 77(18):6357–6367. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Grier A, Qiu X, Bandyopadhyay S, Holden-Wiltse J, Kessler HA, Gill AL, Hamilton B, Huyck H, Misra S, Mariani TJ, et al. 2017. Impact of prematurity and nutrition on the developing gut microbiome and preterm infant growth. Microbiome. 5(1):158. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Gross EL, Beall CJ, Kutsch SR, Firestone ND, Leys EJ, Griffen AL. 2012. Beyond Streptococcus mutans: dental caries onset linked to multiple species by 16s rRNA community analysis. PLoS One. 7(10):e47722. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Hajishengallis E, Parsaei Y, Klein MI, Koo H. 2017. Advances in the microbial etiology and pathogenesis of early childhood caries. Mol Oral Microbiol. 32(1):24–34. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Hwang G, Marsh G, Gao L, Waugh R, Koo H. 2015. Binding force dynamics of Streptococcus mutans–glucosyltransferase B to Candida albicans. J Dent Res. 94(9):1310–1317. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Janus MM, Crielaard W, Volgenant CM, van der Veen MH, Brandt BW, Krom BP. 2017. Candida albicans alters the bacterial microbiome of early in vitro oral biofilms. J Oral Microbiol. 9(1):1270613. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Johansson I, Witkowska E, Kaveh B, Lif Holgerson P, Tanner AC. 2016. The microbiome in populations with a low and high prevalence of caries. J Dent Res. 95(1):80–86. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Kim D, Sengupta A, Niepa TH, Lee BH, Weljie A, Freitas-Blanco VS, Murata RM, Stebe KJ, Lee D, Koo H. 2017. Candida albicans stimulates Streptococcus mutans microcolony development via cross-kingdom biofilm-derived metabolites. Sci Rep. 7:41332. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Klinke T, Guggenheim B, Klimm W, Thurnheer T. 2011. Dental caries in rats associated with Candida albicans. Caries Res. 45(2):100–106. [DOI] [PubMed] [Google Scholar]
  19. Klinke T, Kneist S, de Soet JJ, Kuhlisch E, Mauersberger S, Forster A, Klimm W. 2009. Acid production by oral strains of Candida albicans and lactobacilli. Caries Res. 43(2):83–91. [DOI] [PubMed] [Google Scholar]
  20. Li Y, Tanner A. 2015. Effect of antimicrobial interventions on the oral microbiota associated with early childhood caries. Pediatr Dent. 37(3):226–244. [PMC free article] [PubMed] [Google Scholar]
  21. Ma C, Chen F, Zhang Y, Sun X, Tong P, Si Y, Zheng S. 2015. Comparison of oral microbial profiles between children with severe early childhood caries and caries-free children using the human oral microbe identification microarray. PLoS One. 10(3):e0122075. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Marsh PD. 2018. In sickness and in health—what does the oral microbiome mean to us? An ecological perspective. Adv Dent Res. 29(1):60–65. [DOI] [PubMed] [Google Scholar]
  23. Mattos-Graner RO, Smith DJ, King WF, Mayer MP. 2000. Water-insoluble glucan synthesis by mutans streptococcal strains correlates with caries incidence in 12- to 30-month-old children. J Dent Res. 79(6):1371–1377. [DOI] [PubMed] [Google Scholar]
  24. Merkley MA, Bice TC, Grier A, Strohl AM, Man LX, Gill SR. 2015. The effect of antibiotics on the microbiome in acute exacerbations of chronic rhinosinusitis. Int Forum Allergy Rhinol. 5(10):884–893. [DOI] [PubMed] [Google Scholar]
  25. Metwalli KH, Khan SA, Krom BP, Jabra-Rizk MA. 2013. Streptococcus mutans, Candida albicans, and the human mouth: a sticky situation. PLoS Pathog. 9(10):e1003616. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Nikawa H, Yamashiro H, Makihira S, Nishimura M, Egusa H, Furukawa M, Setijanto D, Hamada T. 2003. In vitro cariogenic potential of Candida albicans. Mycoses. 46(11–12):471–478. [DOI] [PubMed] [Google Scholar]
  27. O’Donnell LE, Millhouse E, Sherry L, Kean R, Malcolm J, Nile CJ, Ramage G. 2015. Polymicrobial Candida biofilms: friends and foe in the oral cavity. FEMS Yeast Res. 15(7):fov077. [DOI] [PubMed] [Google Scholar]
  28. O’Sullivan DM, Tinanoff N. 1996. The association of early dental caries patterns with caries incidence in preschool children. J Public Health Dent. 56(2):81–83. [DOI] [PubMed] [Google Scholar]
  29. Rashewsky S, Parameswaran A, Sloane C, Ferguson F, Epstein R. 2012. Time and cost analysis: pediatric dental rehabilitation with general anesthesia in the office and the hospital settings. Anesth Prog. 59(4):147–153. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Ribeiro Ade A, Portela M, Souza IP. 2002. Relation between biofilm, caries activity and gingivitis in HIV+ children. Pesqui Odontol Bras. 16(2):144–150. [DOI] [PubMed] [Google Scholar]
  31. Richards VP, Alvarez AJ, Luce AR, Bedenbaugh M, Mitchell ML, Burne RA, Nascimento MM. 2017. Microbiomes of site-specific dental plaques from children with different caries status. Infect Immun. 85(8):e00106-17. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Silness J, Löe H. 1964. Periodontal disease in pregnancy: II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand. 22:121–135. [DOI] [PubMed] [Google Scholar]
  33. Stecksen-Blicks C, Granstrom E, Silfverdal SA, West CE. 2015. Prevalence of oral Candida in the first year of life. Mycoses. 58(9):550–556. [DOI] [PubMed] [Google Scholar]
  34. Sztajer H, Szafranski SP, Tomasch J, Reck M, Nimtz M, Rohde M, Wagner-Dobler I. 2014. Cross-feeding and interkingdom communication in dual-species biofilms of Streptococcus mutans and Candida albicans. ISME J. 8(11):2256–2271. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Tanner AC, Kent RL, Jr, Holgerson PL, Hughes CV, Loo CY, Kanasi E, Chalmers NI, Johansson I. 2011. Microbiota of severe early childhood caries before and after therapy. J Dent Res. 90(11):1298–1305. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Tanner ACR, Kressirer CA, Rothmiller S, Johansson I, Chalmers NI. 2018. The caries microbiome: implications for reversing dysbiosis. Adv Dent Res. 29(1):78–85. [DOI] [PubMed] [Google Scholar]
  37. Vacca Smith AM, Scott-Anne KM, Whelehan MT, Berkowitz RJ, Feng C, Bowen WH. 2007. Salivary glucosyltransferase B as a possible marker for caries activity. Caries Res. 41(6):445–450. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Vos T, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, Abdulkader RS, Abdulle AM, Abebo TA, Abera SF, et al. ; GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. 2017. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the global burden of disease study 2016. Lancet. 390(10100):1211–1259. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Waggoner-Fountain LA, Walker MW, Hollis RJ, Pfaller MA, Ferguson JE, 2nd, Wenzel RP, Donowitz LG. 1996. Vertical and horizontal transmission of unique Candida species to premature newborns. Clin Infect Dis. 22(5):803–808. [DOI] [PubMed] [Google Scholar]
  40. World Health Organization. 1997. Oral health surveys—basic methods. 4th ed. Geneva (Switzerland): World Health Organization. [Google Scholar]
  41. Xiao J, Huang X, Alkhers N, Alzamil H, Alzoubi S, Wu TT, Castillo DA, Campbell F, Davis J, Herzog K, et al. 2018. Candida albicans and early childhood caries: a systematic review and meta-analysis. Caries Res. 52(1–2):102–112. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Xiao J, Moon Y, Li L, Rustchenko E, Wakabayashi H, Zhao X, Feng C, Gill SR, McLaren S, Malmstrom H, et al. 2016. Candida albicans carriage in children with severe early childhood caries (S-ECC) and maternal relatedness. PLoS One. 11(10):e0164242. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Yang F, Zeng X, Ning K, Liu KL, Lo CC, Wang W, Chen J, Wang D, Huang R, Chang X, et al. 2012. Saliva microbiomes distinguish caries-active from healthy human populations. ISME J. 6(1):1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]

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Supplementary Materials

DS_10.1177_0022034518790941 – Supplemental material for Association between Oral Candida and Bacteriome in Children with Severe ECC
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Supplemental material, DS_10.1177_0022034518790941 for Association between Oral Candida and Bacteriome in Children with Severe ECC by J. Xiao, A. Grier, R.C. Faustoferri, S. Alzoubi, A.L. Gill, C. Feng, Y. Liu, R.G. Quivey, D.T. Kopycka-Kedzierawski, H. Koo and S.R. Gill in Journal of Dental Research

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