PERIODONTOLOGY 2000
ISSN 0906-6713
Periodontal medicine:
the emergence of a new branch
of periodontology
R AY C . W ILLIAMS & S TEVEN O FFENBACHER
We are pleased to present this volume of PERIODONTOLOGY 2000, which focuses on the subject of periodontal medicine. In many ways, periodontal medicine is a fairly new term in periodontology and likely
new to many in dentistry and certainly to most outside of dentistry. What, then, does the term periodontal medicine mean or imply? If one defines
periodontal as pertaining to the periodontium, and
medicine as treating disease by nonsurgical means,
periodontal medicine could be used to describe the
treatments for periodontal disease that are nonsurgical. Thus, this volume of PERIODONTOLOGY 2000
would focus on the emerging use of antimicrobials
and antibiotics, as well as host-modulating agents,
as adjuncts to scaling and root planing in the management of the periodontal diseases. And clearly a
new branch or arm of periodontology is emerging to
include a medical approach, in addition to a mechanical or surgical approach, in managing disease.
But this definition of periodontal medicine, while
adequate, seems short of the mark. Another possible
definition of periodontal medicine could be the
science of the treatment of the diseases of the periodontium. But this definition would necessarily include mechanical or surgical approaches and would
defeat the purpose of focusing on medicine. Thus,
this definition also does not appear to reflect current
understanding of the term periodontal medicine.
What, then, do the editors of this volume of PERIODONTOLOGY 2000 mean by periodontal medicine?
temic health was anecdotal at best, and all the writings through the ages were for the most part mythological musings by a diverse group of dentists and
physicians. Thus, it is in fact only very recently that
scientists and clinicians have begun to provide an
increasing body of scientific evidence suggesting
that moderate untreated periodontitis may affect an
individual systemically, and may contribute to cardiovascular disease, diabetes and pre-term low birth
weight. This is important new information indeed. It
appears that not just teeth are at stake in maintaining good oral health. Rather, oral health is an important component of general health, and individuals with periodontitis may be at risk for other diseases as well.
10
Infectious burden, cytokine responses, genetic cytokine polymorphisms, oxidative stress markers and
other tests are likely to be necessary in the armamentarium of the clinician of the future. Dentists are
not currently trained in applying these diagnostic
tools, because they have not done the necessary research to define the utility of these markers. It is
known that they are different in periodontitis patients, that they reflect increased risk, and that some
of them appear to change following periodontal
treatment with either mechanical or chemotherapeutic approaches. But the collective benefit of a historical empiricism gathered by master clinicians over
time to provide clinical guidance in periodontal
medicine is lacking. Dentists know how to diagnose
and treat periodontitis to save teeth but not how to
recognize periodontitis syndromes that have systemic involvement nor how to treat periodontitis to
alter systemic complications of periodontitis.
New therapies
Although multiple studies link periodontitis to systemic conditions such as cardiovascular disease (12),
no intervention studies have demonstrated the potential beneficial effects of periodontal therapy on
these systemic outcomes. Clinical scientists have no
experience to appreciate how to use this new information nor do they understand how the different
therapies may impact the surrogate markers of systemic diseases, such as monitoring C-reactive protein in cardiovascular disease. Some of the potential
microbial, cellular and molecular mechanisms
linking these conditions are being elucidated, but it
is not known whether the therapies designed to treat
periodontitis and retain the dentition are adequate
or appropriate to prevent systemic disease. For example, the pocket bacteria that are recognized
pathogens with regards to causing attachment, bone
or tooth loss may not be the same critical pathogens
for enhanced risk for myocardial infarction. Furthermore, the suppression of the oral microbial flora and
the local inflammatory response to prevent periodontal disease progression may not be sufficient to
prevent systemic complications in certain high-risk
patients. All of these uncertainties highlight the inability to counsel the dental profession on the optimal therapy for these patients. Nonetheless, the
challenge is clear. Understanding and managing the
impact that oral infection has on systemic health defines periodontal medicine. Filling this void in
knowledge would appear to be a timely and bold
11
challenge to the profession as well as an unprecedented opportunity for the development of novel
therapies.
12
References
1. Beck JD, Garcia RG, Heiss G, Volconos P, Offenbacher S.
Periodontal disease and cardiovascular disease. J Periodontol 1996: 67(suppl): 11231137.
2. Beck JD, Offenbacher S, Williams RC, Gibbs P, Garcia R.
Periodontitis: a risk factor for coronary heart disease? Ann
Periodontol 1998: 3: 127141.
3. DeStefano F, Anda LF, Kahn HS, Williamson DF, Rasell CM.
Dental disease and risk of coronary heart disease and mortality. BMJ 1993: 306: 688691.
4. Ebersole JL, Machen RL, Steffen MJ, Willman DE. Systemic
acute phase reactants, C-reactive protein and haptoglobin
in adult periodontitis. Clin Exp Immunol 1997: 107: 347
352.
5. Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: a two-way relationship. Ann Periodontol 1998: 3: 51
61.
6. Mattila KJ, Niemeier MS, Valtonen VV, Rasi VP, Kesaniemi
YA, Syrjala SL, Jungell PS, Isoluoma M, Hietaniemi K, Jokinen MJ. Association between dental health and acute myocardial infarction. BMJ 1989: 298: 779782.
7. Offenbacher S. Periodontal diseases. Pathogenesis. Ann
Periodontol 1996: 1: 821878.
8. Offenbacher S, Beck JD, Lieff S, Slade G. Role of periodontitis in systemic health: Spontaneous preterm birth. J
Dent Ed 1998: 62: 852858.
9. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor
G, McKaig R, Beck J. Periodontal disease as a possible risk
factor for preterm low birth weight. J Periodontol 1996:
67(suppl): 11031113.
10. Ridker P, Cushman M, Stampfer M, Tracy R, Hennekens C.
Inflammation, aspirin and the risk of cardiovascular disease in apparently healthy men. N Engl J Med 1997: 336:
973979.
11. Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens
CH. Plasma concentration of C-reactive protein and risk of
developing peripheral vascular disease. Circulation 1998:
97: 425428.
12. Scannapieco FA. Position paper. Periodontal disease as a
potential risk factor for systemic diseases. J Periodontol
1998: 69: 841850.
13. Soskolne WA. Epidemiological and clinical aspects of periodontal diseases in diabetics. Ann Periodontol 1998: 3: 3
12.
14. Slots J. Casual or causal relationship between periodontal
infection and non-oral disease? J Dent Res 1998: 77: 1764
1765.