Identification of Virulence-Associated Properties by Comparative Genome Analysis of Streptococcus pneumoniae, S. pseudopneumoniae, S. mitis, Three S. oralis Subspecies, and S. infantis

Streptococcus pneumoniae is one of the most important human pathogens but is closely related to Streptococcus mitis, with which humans live in harmony. The fact that the two species evolved from a common ancestor provides a unique basis for studies of both infection-associated properties and properties important for harmonious coexistence with the host. By detailed comparisons of genomes of the two species and other related streptococci, we identified 224 genes associated with virulence and 25 genes unique to the mutualistic species. The exclusive presence of the virulence factors in S. pneumoniae enhances their potential as vaccine components, as a direct impact on beneficial members of the commensal microbiota can be excluded. Successful adaptation of S. mitis and other commensal streptococci to a harmonious relationship with the host relied on genetic stability and properties facilitating life in biofilms. ABSTRACT From a common ancestor, Streptococcus pneumoniae and Streptococcus mitis evolved in parallel into one of the most important pathogens and a mutualistic colonizer of humans, respectively. This evolutionary scenario provides a unique basis for studies of both infection-associated properties and properties important for harmonious coexistence with the host. We performed detailed comparisons of 60 genomes of S. pneumoniae, S. mitis, Streptococcus pseudopneumoniae, the three Streptococcus oralis subspecies oralis, tigurinus, and dentisani, and Streptococcus infantis. Nonfunctional remnants of ancestral genes in both S. pneumoniae and in S. mitis support the evolutionary model and the concept that evolutionary changes on both sides were required to reach their present relationship to the host. Confirmed by screening of >7,500 genomes, we identified 224 genes associated with virulence. The striking difference to commensal streptococci was the diversity of regulatory mechanisms, including regulation of capsule production, a significantly larger arsenal of enzymes involved in carbohydrate hydrolysis, and proteins known to interfere with innate immune factors. The exclusive presence of the virulence factors in S. pneumoniae enhances their potential as vaccine components, as a direct impact on beneficial members of the commensal microbiota can be excluded. In addition to loss of these virulence-associated genes, adaptation of S. mitis to a mutualistic relationship with the host apparently required preservation or acquisition of 25 genes lost or absent from S. pneumoniae. Successful adaptation of S. mitis and other commensal streptococci to a harmonious relationship with the host relied on genetic stability and properties facilitating life in biofilms. IMPORTANCE Streptococcus pneumoniae is one of the most important human pathogens but is closely related to Streptococcus mitis, with which humans live in harmony. The fact that the two species evolved from a common ancestor provides a unique basis for studies of both infection-associated properties and properties important for harmonious coexistence with the host. By detailed comparisons of genomes of the two species and other related streptococci, we identified 224 genes associated with virulence and 25 genes unique to the mutualistic species. The exclusive presence of the virulence factors in S. pneumoniae enhances their potential as vaccine components, as a direct impact on beneficial members of the commensal microbiota can be excluded. Successful adaptation of S. mitis and other commensal streptococci to a harmonious relationship with the host relied on genetic stability and properties facilitating life in biofilms.

[1]  C. Whitney,et al.  Streptococcus infantis, Streptococcus mitis, and Streptococcus oralis Strains With Highly Similar cps5 Loci and Antigenic Relatedness to Serotype 5 Pneumococci , 2019, Front. Microbiol..

[2]  C. Whitney,et al.  Streptococcus mitis Expressing Pneumococcal Serotype 1 Capsule , 2018, Scientific Reports.

[3]  A. Boraston,et al.  Glycan‐metabolizing enzymes in microbe–host interactions: the Streptococcus pneumoniae paradigm , 2018, FEBS letters.

[4]  S. Bentley,et al.  Excision-reintegration at a pneumococcal phase-variable restriction-modification locus drives within- and between-strain epigenetic differentiation and inhibits gene acquisition , 2018, Nucleic acids research.

[5]  T. Feltwell,et al.  The Capsule Regulatory Network of Klebsiella pneumoniae Defined by density-TraDISort , 2018, mBio.

[6]  Tsute Chen,et al.  High-resolution profiles of the Streptococcus mitis CSP signaling pathway reveal core and strain-specific regulated genes , 2018, BMC Genomics.

[7]  H. Yoon,et al.  Functional insights into the Streptococcus pneumoniae HicBA toxin–antitoxin system based on a structural study , 2018, Nucleic acids research.

[8]  J. Weiser,et al.  Streptococcus pneumoniae: transmission, colonization and invasion , 2018, Nature Reviews Microbiology.

[9]  Andries J. van Tonder,et al.  Diverse Streptococcus pneumoniae Strains Drive a Mucosal-Associated Invariant T-Cell Response Through Major Histocompatibility Complex class I–Related Molecule–Dependent and Cytokine-Driven Pathways , 2017, The Journal of infectious diseases.

[10]  O. Skovgaard,et al.  In silico assessment of virulence factors in strains of Streptococcus oralis and Streptococcus mitis isolated from patients with Infective Endocarditis , 2017, Journal of medical microbiology.

[11]  H. Tettelin,et al.  Streptococcus pneumoniae in the heart subvert the host response through biofilm-mediated resident macrophage killing , 2017, PLoS pathogens.

[12]  H. Gingras,et al.  Complete Genome Sequence of Streptococcus pneumoniae Virulent Phage MS1 , 2017, Genome Announcements.

[13]  S. Schoonbroodt,et al.  Efficacy of a novel, protein-based pneumococcal vaccine against nasopharyngeal carriage of Streptococcus pneumoniae in infants: A phase 2, randomized, controlled, observer-blind study. , 2017, Vaccine.

[14]  Jonathan Crabtree,et al.  CloVR-Comparative: automated, cloud-enabled comparative microbial genome sequence analysis pipeline , 2017, BMC Genomics.

[15]  Andries J. van Tonder,et al.  Pneumococcal prophages are diverse, but not without structure or history , 2017, Scientific Reports.

[16]  C. McDevitt,et al.  Autoinducer 2 Signaling via the Phosphotransferase FruA Drives Galactose Utilization by Streptococcus pneumoniae, Resulting in Hypervirulence , 2017, mBio.

[17]  K. Henne,et al.  Streptococcus tigurinus is frequent among gtfR-negative Streptococcus oralis isolates and in the human oral cavity, but highly virulent strains are uncommon , 2017, Journal of oral microbiology.

[18]  H. Tettelin,et al.  Capsular Polysaccharide Expression in Commensal Streptococcus Species: Genetic and Antigenic Similarities to Streptococcus pneumoniae , 2016, mBio.

[19]  M. Kilian,et al.  Re-evaluation of the taxonomy of the Mitis group of the genus Streptococcus based on whole genome phylogenetic analyses, and proposed reclassification of Streptococcus dentisani as Streptococcus oralis subsp. dentisani comb. nov., Streptococcus tigurinus as Streptococcus oralis subsp. tigurinus comb , 2016, International journal of systematic and evolutionary microbiology.

[20]  S. Ahn,et al.  Understanding the Streptococcus mutans Cid/Lrg System through CidB Function , 2016, Applied and Environmental Microbiology.

[21]  M. Winkler,et al.  Physiological Roles of the Dual Phosphate Transporter Systems in Low and High Phosphate Conditions and in Capsule Maintenance of Streptococcus pneumoniae D39 , 2016, Front. Cell. Infect. Microbiol..

[22]  David S. Wishart,et al.  PHASTER: a better, faster version of the PHAST phage search tool , 2016, Nucleic Acids Res..

[23]  J. Veening,et al.  Time-resolved dual RNA-seq reveals extensive rewiring of lung epithelial and pneumococcal transcriptomes during early infection , 2016, Genome Biology.

[24]  Sudhir Kumar,et al.  MEGA7: Molecular Evolutionary Genetics Analysis Version 7.0 for Bigger Datasets. , 2016, Molecular biology and evolution.

[25]  P. Kappeler,et al.  Highly Variable Streptococcus oralis Strains Are Common among Viridans Streptococci Isolated from Primates , 2016, mSphere.

[26]  D. Stephens,et al.  Regulation of capsule in Neisseria meningitidis , 2015, Critical reviews in microbiology.

[27]  Andries J. van Tonder,et al.  Genomic analyses of pneumococci reveal a wide diversity of bacteriocins – including pneumocyclicin, a novel circular bacteriocin , 2015, BMC Genomics.

[28]  Raymond K. Auerbach,et al.  The In Silico Genotyper (ISG): an open-source pipeline to rapidly identify and annotate nucleotide variants for comparative genomics applications , 2015, bioRxiv.

[29]  Stephen D. Bentley,et al.  Diversification of bacterial genome content through distinct mechanisms over different timescales , 2014, Nature Communications.

[30]  Alexander N Gorban,et al.  A random six-phase switch regulates pneumococcal virulence via global epigenetic changes , 2014, Nature Communications.

[31]  David R. Riley,et al.  Parallel Evolution of Streptococcus pneumoniae and Streptococcus mitis to Pathogenic and Mutualistic Lifestyles , 2014, mBio.

[32]  Erika J. Thompson,et al.  Streptococcus mitis Strains Causing Severe Clinical Disease in Cancer Patients , 2014, Emerging infectious diseases.

[33]  Calum Johnston,et al.  Streptococcus pneumoniae, le transformiste. , 2014, Trends in microbiology.

[34]  A. Camilli,et al.  The Core Promoter of the Capsule Operon of Streptococcus pneumoniae Is Necessary for Colonization and Invasive Disease , 2013, Infection and Immunity.

[35]  Christina S. Thornton,et al.  Comparative Genomic Analyses of Streptococcus pseudopneumoniae Provide Insight into Virulence and Commensalism Dynamics , 2013, PloS one.

[36]  V. Nagaraja,et al.  Diverse Functions of Restriction-Modification Systems in Addition to Cellular Defense , 2013, Microbiology and Molecular Reviews.

[37]  N. Mueller,et al.  Streptococcus tigurinus sp. nov., isolated from blood of patients with endocarditis, meningitis and spondylodiscitis. , 2012, International journal of systematic and evolutionary microbiology.

[38]  M. Kilian,et al.  Occurrence and Evolution of the Paralogous Zinc Metalloproteases IgA1 Protease, ZmpB, ZmpC, and ZmpD in Streptococcus pneumoniae and Related Commensal Species , 2012, mBio.

[39]  M. Pichichero,et al.  PcpA of Streptococcus pneumoniae mediates adherence to nasopharyngeal and lung epithelial cells and elicits functional antibodies in humans. , 2012, Microbes and infection.

[40]  J. Hermoso,et al.  Pneumococcal surface proteins: when the whole is greater than the sum of its parts. , 2012, Molecular oral microbiology.

[41]  A. Ogunniyi,et al.  Identification of Genes That Contribute to the Pathogenesis of Invasive Pneumococcal Disease by In Vivo Transcriptomic Analysis , 2012, Infection and Immunity.

[42]  W. Vollmer,et al.  Biosynthesis of teichoic acids in Streptococcus pneumoniae and closely related species: lessons from genomes. , 2012, Microbial drug resistance.

[43]  J. Deutscher,et al.  A Functional Genomics Approach to Establish the Complement of Carbohydrate Transporters in Streptococcus pneumoniae , 2012, PloS one.

[44]  Jonathan Crabtree,et al.  Using Sybil for interactive comparative genomics of microbes on the web , 2011, Bioinform..

[45]  D. Stephens,et al.  Mitis Group Streptococci Express Variable Pilus Islet 2 Pili , 2011, PloS one.

[46]  Steven Salzberg,et al.  Improving pan-genome annotation using whole genome multiple alignment , 2011, BMC Bioinformatics.

[47]  J. Mitchell Streptococcus mitis: walking the line between commensalism and pathogenesis. , 2011, Molecular oral microbiology.

[48]  P. Andrew,et al.  Three Streptococcus pneumoniae sialidases: three different products. , 2011, Journal of the American Chemical Society.

[49]  J. Burton,et al.  Rapid Pneumococcal Evolution in Response to Clinical Interventions , 2011, Science.

[50]  Steven Salzberg,et al.  Mugsy: fast multiple alignment of closely related whole genomes , 2010, Bioinform..

[51]  M. Ouellette,et al.  Genome Annotation and Intraviral Interactome for the Streptococcus pneumoniae Virulent Phage Dp-1 , 2010, Journal of bacteriology.

[52]  P. Sansonetti,et al.  To be or not to be a pathogen: that is the mucosally relevant question , 2011, Mucosal Immunology.

[53]  David R. Riley,et al.  Structure and dynamics of the pan-genome of Streptococcus pneumoniae and closely related species , 2010, Genome Biology.

[54]  S. Ahn,et al.  The Streptococcus mutans Cid and Lrg systems modulate virulence traits in response to multiple environmental signals , 2010, Microbiology.

[55]  J. Hinds,et al.  Detection of Large Numbers of Pneumococcal Virulence Genes in Streptococci of the Mitis Group , 2010, Journal of Clinical Microbiology.

[56]  R. Wambutt,et al.  The Genome of Streptococcus mitis B6 - What Is a Commensal? , 2010, PloS one.

[57]  R. Ugalde,et al.  An Atypical Riboflavin Pathway Is Essential for Brucella abortus Virulence , 2010, PloS one.

[58]  S. King,et al.  Pneumococcal modification of host sugars: a major contributor to colonization of the human airway? , 2010, Molecular oral microbiology.

[59]  C. Orihuela,et al.  The Streptococcus pneumoniae adhesin PsrP binds to Keratin 10 on lung cells , 2009, Molecular microbiology.

[60]  A. Blom,et al.  Clinical Isolates of Streptococcus pneumoniae Bind the Complement Inhibitor C4b-Binding Protein in a PspC Allele-Dependent Fashion1 , 2009, The Journal of Immunology.

[61]  S. Bentley,et al.  Comparative Genomic Analysis of Ten Streptococcus pneumoniae Temperate Bacteriophages , 2009, Journal of bacteriology.

[62]  R. Hakenbeck,et al.  Versatility of choline metabolism and choline-binding proteins in Streptococcus pneumoniae and commensal streptococci. , 2009, FEMS microbiology reviews.

[63]  Adeline R. Whitney,et al.  Species-Specific Interaction of Streptococcus pneumoniae with Human Complement Factor H1 , 2008, The Journal of Immunology.

[64]  H. Tettelin,et al.  Evolution of Streptococcus pneumoniae and Its Close Commensal Relatives , 2008, PloS one.

[65]  J. Musser,et al.  The role of complex carbohydrate catabolism in the pathogenesis of invasive streptococci. , 2008, Trends in microbiology.

[66]  C. Donati,et al.  A Second Pilus Type in Streptococcus pneumoniae Is Prevalent in Emerging Serotypes and Mediates Adhesion to Host Cells , 2008, Journal of bacteriology.

[67]  H. Tettelin,et al.  Population Diversity and Dynamics of Streptococcus mitis, Streptococcus oralis, and Streptococcus infantis in the Upper Respiratory Tracts of Adults, Determined by a Nonculture Strategy , 2008, Infection and Immunity.

[68]  C. Orihuela,et al.  Regions of Diversity 8, 9 and 13 contribute to Streptococcus pneumoniae virulence , 2007, BMC Microbiology.

[69]  M. Nuhn,et al.  Diversity of Bacteriocins and Activity Spectrum in Streptococcus pneumoniae , 2007, Journal of bacteriology.

[70]  K. Rice,et al.  The cidA murein hydrolase regulator contributes to DNA release and biofilm development in Staphylococcus aureus , 2007, Proceedings of the National Academy of Sciences.

[71]  L. McDaniel,et al.  Pneumolysin, PspA, and PspC Contribute to Pneumococcal Evasion of Early Innate Immune Responses during Bacteremia in Mice , 2007, Infection and Immunity.

[72]  E. Tuomanen,et al.  Identification of a Candidate Streptococcus pneumoniae Core Genome and Regions of Diversity Correlated with Invasive Pneumococcal Disease , 2006, Infection and Immunity.

[73]  Jing-Ren Zhang,et al.  Streptococcus pneumoniae Recruits Complement Factor H through the Amino Terminus of CbpA* , 2006, Journal of Biological Chemistry.

[74]  M. Kilian,et al.  Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. , 2006, Journal of clinical periodontology.

[75]  K. Fennie,et al.  Variation in the Presence of Neuraminidase Genes among Streptococcus pneumoniae Isolates with Identical Sequence Types , 2006, Infection and Immunity.

[76]  Ernesto García,et al.  Characteristic Signatures of the lytA Gene Provide a Basis for Rapid and Reliable Diagnosis of Streptococcus pneumoniae Infections , 2006, Journal of Clinical Microbiology.

[77]  Julian Parkhill,et al.  Genetic Analysis of the Capsular Biosynthetic Locus from All 90 Pneumococcal Serotypes , 2006, PLoS genetics.

[78]  E. Tuomanen,et al.  Multifunctional Role of Choline Binding Protein G in Pneumococcal Pathogenesis , 2006, Infection and Immunity.

[79]  D. Huson,et al.  Application of phylogenetic networks in evolutionary studies. , 2006, Molecular biology and evolution.

[80]  P. Talaga,et al.  The teichoic acid (C-polysaccharide) synthesized by Streptococcus pneumoniae serotype 5 has a specific structure. , 2005, Carbohydrate research.

[81]  Ernesto García,et al.  Characterization of LytA-Like N-Acetylmuramoyl-l-Alanine Amidases from Two New Streptococcus mitis Bacteriophages Provides Insights into the Properties of the Major Pneumococcal Autolysin , 2004, Journal of bacteriology.

[82]  Jana N Radin,et al.  Microarray Analysis of Pneumococcal Gene Expression during Invasive Disease , 2004, Infection and Immunity.

[83]  M. Nuhn,et al.  Mosaic genes and mosaic chromosomes-genomic variation in Streptococcus pneumoniae. , 2004, International journal of medical microbiology : IJMM.

[84]  Jeremy S. Brown,et al.  phgABC, a Three-Gene Operon Required for Growth of Streptococcus pneumoniae in Hyperosmotic Medium and In Vivo , 2004, Infection and Immunity.

[85]  B. Bensing,et al.  Genes in the accessory sec locus of Streptococcus gordonii have three functionally distinct effects on the expression of the platelet‐binding protein GspB , 2004, Molecular microbiology.

[86]  H. Tettelin,et al.  Comparative Genomics of Streptococcus pneumoniae: Intrastrain Diversity and Genome Plasticity , 2004 .

[87]  T. Mitchell,et al.  The pathogenesis of streptococcal infections: from Tooth decay to meningitis , 2003, Nature Reviews Microbiology.

[88]  A. Camilli,et al.  Large‐scale identification of serotype 4 Streptococcus pneumoniae virulence factors , 2002, Molecular microbiology.

[89]  Jeremy S. Brown,et al.  Characterization of Pit, a Streptococcus pneumoniae Iron Uptake ABC Transporter , 2002, Infection and Immunity.

[90]  J. García,et al.  Molecular Peculiarities of the lytA Gene Isolated from Clinical Pneumococcal Strains That Are Bile Insoluble , 2002, Journal of Clinical Microbiology.

[91]  D. Briles,et al.  Role of Pneumococcal Surface Protein C in Nasopharyngeal Carriage and Pneumonia and Its Ability To Elicit Protection against Carriage of Streptococcus pneumoniae , 2002, Infection and Immunity.

[92]  B. Bensing,et al.  Proteins PblA and PblB of Streptococcus mitis, Which Promote Binding to Human Platelets, Are Encoded within a Lysogenic Bacteriophage , 2001, Infection and Immunity.

[93]  Elliot J. Lefkowitz,et al.  Genome of the Bacterium Streptococcus pneumoniae Strain R6 , 2001, Journal of bacteriology.

[94]  S. Salzberg,et al.  Complete Genome Sequence of a Virulent Isolate of Streptococcus pneumoniae , 2001, Science.

[95]  B. Green,et al.  Recombinant PhpA Protein, a Unique Histidine Motif-Containing Protein from Streptococcus pneumoniae, Protects Mice against Intranasal Pneumococcal Challenge , 2001, Infection and Immunity.

[96]  M. Lonetto,et al.  A functional genomic analysis of type 3 Streptococcus pneumoniae virulence , 2001, Molecular microbiology.

[97]  Jeremy S. Brown,et al.  A Streptococcus pneumoniae pathogenicity island encoding an ABC transporter involved in iron uptake and virulence , 2001, Molecular microbiology.

[98]  P. Jansson,et al.  Structures of two cell wall-associated polysaccharides of a Streptococcus mitis biovar 1 strain. A unique teichoic acid-like polysaccharide and the group O antigen which is a C-polysaccharide in common with pneumococci. , 2000, European journal of biochemistry.

[99]  E. Tuomanen,et al.  The Polymeric Immunoglobulin Receptor Translocates Pneumococci across Human Nasopharyngeal Epithelial Cells , 2000, Cell.

[100]  C. Dowson,et al.  Genetic Relationships between Clinical Isolates of Streptococcus pneumoniae, Streptococcus oralis, and Streptococcus mitis: Characterization of “Atypical” Pneumococci and Organisms Allied to S. mitis HarboringS. pneumoniae Virulence Factor-Encoding Genes , 2000, Infection and Immunity.

[101]  James R. Brown,et al.  A genomic analysis of two‐component signal transduction in Streptococcus pneumoniae , 2000, Molecular microbiology.

[102]  W. Holzapfel,et al.  The Genera of Lactic Acid Bacteria , 1999 .

[103]  H. Agaisse,et al.  PlcR is a pleiotropic regulator of extracellular virulence factor gene expression in Bacillus thuringiensis , 1999, Molecular microbiology.

[104]  E. Charpentier,et al.  Identification of a Streptococcus pneumoniae Gene Locus Encoding Proteins of an ABC Phosphate Transporter and a Two-Component Regulatory System , 1999, Journal of bacteriology.

[105]  D. Simon,et al.  Large-Scale Identification of Virulence Genes fromStreptococcus pneumoniae , 1998, Infection and Immunity.

[106]  K. Ekdahl,et al.  Duration of nasopharyngeal carriage of penicillin-resistant Streptococcus pneumoniae: experiences from the South Swedish Pneumococcal Intervention Project. , 1997, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[107]  S. Hammerschmidt,et al.  SpsA, a novel pneumococcal surface protein with specific binding to secretory Immunoglobulin A and secretory component , 1997, Molecular microbiology.

[108]  C. Rosenow,et al.  Contribution of novel choline‐binding proteins to adherence, colonization and immunogenicity of Streptococcus pneumoniae , 1997, Molecular microbiology.

[109]  Y. Todome,et al.  Purification and partial characterization of a novel human platelet aggregation factor in the extracellular products of Streptococcus mitis, strain Nm-65. , 1997, Advances in experimental medicine and biology.

[110]  M. Kilian,et al.  Biological significance of IgA1 proteases in bacterial colonization and pathogenesis: critical evaluation of experimental evidence * , 1996, APMIS : acta pathologica, microbiologica, et immunologica Scandinavica.

[111]  R. Whiley,et al.  The genus Streptococcus , 1995 .

[112]  G. Tannock,et al.  Lipoprotein receptors in oral streptococci. , 1995, Developments in biological standardization.

[113]  P. Francioli,et al.  Bacteremia due to viridans streptococcus in neutropenic patients with cancer: clinical spectrum and risk factors. , 1994, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[114]  P. Andrew,et al.  Molecular Analysis of The Pathogenicity of Streptococcus Pneumoniae: The Role of Pneumococcal Proteins , 1993 .

[115]  M. Kilian,et al.  Ecology of viridans streptococci in the oral cavity and pharynx. , 1991, Oral microbiology and immunology.

[116]  J. P. Li,et al.  Virulence, immunity, and vaccine related to Streptococcus pneumoniae. , 1991, Critical reviews in microbiology.

[117]  C. Douglas,et al.  Platelet aggregation by oral streptococci. , 1990, FEMS microbiology letters.

[118]  M. Kilian,et al.  Taxonomic Study of Viridans Streptococci: Description of Streptococcus gordonii sp. nov. and Emended Descriptions of Streptococcus sanguis (White and Niven 1946), Streptococcus oralis (Bridge and Sneath 1982), and Streptococcus mitis (Andrewes and Horder 1906) , 1989 .

[119]  E. Moxon,et al.  Genes involved in Haemophilus influenzae type b capsule expression are part of an 18-kilobase tandem duplication. , 1986, Proceedings of the National Academy of Sciences of the United States of America.

[120]  R. Austrian Some observations on the pneumococcus and on the current status of pneumococcal disease and its prevention. , 1981, Reviews of infectious diseases.

[121]  Jokinen Ma Bacteremia following dental extraction and its prophylaxis. , 1970 .

[122]  M. Jokinen Bacteremia following dental extraction and its prophylaxis. , 1970, Suomen Hammaslaakariseuran toimituksia = Finska tandlakarsallskapets forhandlingar.