FUTURE OFDENTISTRYmulations, and controlling tissue inflammation.
This is achieved in a number of ways:
u Plaque removal by the patient, and professional
plaque and calculus removal in the dental office;
u Use of chemotherapeutic agents (such as essential
oils, cetylpyridium chloride, and chlorhexidine)
delivered in toothpastes, mouth rinses, and occa-
sionally by oral irrigation devices;
u Systemic antibiotics, ideally targeted to susceptible
microorganisms, used only for advanced and aggressive
disease, or for medically compromised patients;
u Local (subgingival) delivery of antibiotics/antimi-
crobials, including tetracycline HCl incorporatedinto
a polyvinyl acetate carrier, doxycycline HCl incor-
porated into a thixotropic gel, and chlorhexidine in a
gelatin matrix; and,
u Host-modulating agents to decrease the inflam-
matory response (low-dose doxycycline, which has
been shown to block the action of matrix metallo-
proteinases).
The surgical treatment of periodontal disease has
focused on the elimination/reduction of excessive
probing depths. There is considerable interest in
surgical procedures that promote regeneration of
lost periodontal tissues:
u Placement of barrier membranes to promote re-
generation of the surgical wound with cells capable
of forming new periodontal tissues (Tatakis et al,
1999);
u Allogeneic and xenogeneic bone grafts (Nasr et al,
1999); and,
u Xenogeneic enamel matrix proteins that rely on
biomimicry to promote regeneration.
In addition, mucogingival surgical procedures are
widely used to cover exposed root surfaces and
improve esthetics (Wennstrom, 1996).
SYSTEMIC DISEASES
Systemic conditions, such as diabetes, have long
been known to affect oral tissues, and oral medicine
has focused on the diagnosis and treatment of these
oral manifestations of systemic diseases. Recently,
however, the results from epidemiologic studies
have shown a relationship between severe oral infec-
tions, especially periodontal diseases, and other
health problems: atherosclerosis, heart attacks,
strokes, chronic obstructive pulmonary disease, and
premature births. For example, it appears that peri-
odontal disease may increase the risk of dying from
a heart attack or having a stroke.
These early findings require confirmation by addi-
tional prospective and ultimately intervention stud-
ies, and many years of clinical and basic research
will be needed to determine whether the association
between cardiovascular/cerebrovascular conditions
and periodontal disease is actually causative in
nature. However, these associations provide the
impetus to move the profession of dentistry towards
periodontal medicine––a medical model of diagno-
sis, prevention, and therapy.
New studies are shedding light on how periodon-
tal organisms cause damage beyond the periodontal
pocket. These organisms are capable of entering the
bloodstream and can target certain organs, such as
the liver, major blood vessels, and the placenta, to
potentially cause inflammation at distant sites.
Three key organisms that are closely associated
with periodontal diseases, Porphyromonas gingi-
valis, Treponema denticola, and Bacteroides
forsythus,have been implicated in the periodontal
infection-systemic disease relationship. They do not
colonize easily and require a lush biofilm ecosystem
to support adherence, growth, and emergence.
They rely mainly on host serum proteins and blood
components for sustenance. These organisms have
special enzymes and proteins that enable them to
trigger mild host inflammation and enhanced gingi-
val crevicular flow to ensure an adequate food and
nutrient supply from the serum. These organisms
target the liver and activate the hepatic acute phase
response. Elevated levels of serum inflammatory
mediators and hepatic secretion of acute phase pro-
teins, such as C-reactive protein and haptoglobin,
characterize the acute phase response.
Theoretically, over the years, inflammatory mediators
and bacteria present in the systemic circulation, even at
low levels, cumulatively damage systemic health. Thus,
it is the direct systemic action of blood-borne oral bacte-
ria or bacterial products and the chronic inflammation,
caused by this hematogenous exposure, which are cur-
rently thought to provide a risk to health.Dental and Craniofacial Research