**Introduction**

discussed in this chapter. The importance of each biomarker involved has been enlisted. It

The next chapter (5) presents the best available knowledge on the association of periodontal status in adult orthodontic treatment. The main objective of this discussion is to make the clinicians aware of the parameters to consider prior, during, and after the orthodontic treat‐ ment in adult dental patients. The authors have illustrated the bidirectional relationship be‐ tween periodontal health and orthodontic treatment and the potential ways to standardize it. The authors have not only focused the pre-orthodontic parameters but also posttreatment aspects. Henceforth, this will be very useful information for both the clinicians to bring

This chapter (6) sheds light on the current literature concerning the role of microbiota in rheumatological conditions such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and systemic lupus. Here, the suggestive underlying mechanisms that link these systemic conditions to periodontal inflammation are reviewed. This chapter describes the role played by the oral microorganisms on host immunology and physiology, the under‐

This chapter (7) summarizes the role of innate and specific immune response involved in the pathogenesis of periodontitis. The subdivisions demonstrate the role of cells and inflamma‐ tory mediators contributing to the inflammatory process of the ligamentous supporting

The concluding chapter (8) highlights the application and advancement in the usage of bio‐ active membranes in guided tissue regeneration (GTR) that aid in periodontal tissue regen‐ eration. Here, the authors focus on a new biomaterial, namely, polycaprolactone, specifically Jagged1-coated PCL membrane. The added merits of coated PCL as they prevent the epithe‐

We are grateful to everyone who has supported and encouraged us in completing this project.

a successful

Augusta, USA

**Dr. Pachiappan Arjunan**

Dental College of Georgia

Augusta University (formerly GRU)

Assistant Professor, Department of Periodontics

about effective orthodontic results and patients for a desirable treatment outcome.

standing of which is very essential for the management of autoimmune disorders.

lium downgrowth in the lesion and promote formation of alveolar bone for

guided tissue regeneration are described in this section.

treatment to prevent adverse effects on the tooth-supporting structures.

a beneficial reference for the clinicians to decide on proper choice of orthodontic

will be

VIII Preface

structure and in bone resorption.

**Provisional chapter**

#### **Introductory Chapter: Periodontitis - A Useful Reference Reference**

**Introductory Chapter: Periodontitis - A Useful** 

DOI: 10.5772/intechopen.71386

Pachiappan Arjunan, Radhika Swaminathan, Brunner Mark and Christopher W. Cutler Brunner Mark and Christopher W. Cutler Additional information is available at the end of the chapter

Pachiappan Arjunan, Radhika Swaminathan,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.71386

#### **1. Etiology**

The oral cavity is a unique part of the human body and is considered the window of general health. Gingivitis is primarily caused by bacterial colonization called dental plaque, and it is one of the common oral diseases that are preventable [1]. Gingivitis can be resolved with proper oral hygiene and professional intervention. Periodontitis occurs if inflammation of the gingiva is not intervened and progresses, which leads to an active destruction of the periodontal supporting tissues including the alveolar bone. Periodontitis can occur either as a generalized or localized form. It can be chronic or aggressive in nature. The World Health Organization (WHO) estimates nearly 15–20% of the adult population aged between 35 and 44 years suffers from an advanced form of periodontitis [2]. The Center for Disease Control (CDC) reported that approximately 50% of the general population in the USA is affected with some types of periodontitis [2]. Periodontal inflammation establishes as a sequela of a complex interaction of mixed oral pathogens (*Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, Fusobacterium nucleatum, and Streptococcus gordonii*) in the endogenous plaque or the biofilm, and their toxic by-products exert pathogenicity on host tissues. This disruption develops a shift in the bacterial ecosystem [3] from good health to disease. The ultimate result is bone deterioration and tooth loss in vulnerable patients.

There is an extensive list of local and systemic risk factors associated with the periodontal disease [4]. These risk factors include smoking, diabetes, medications, hormonal imbalance in women, immunocompromised status, etc. Most commonly, periodontal disease occurs when plaque [5] is allowed to build-up along tooth and under the gingiva. Genetic and environmental factors also contribute to the progression of periodontitis. In addition to the exacerbated inflammatory responses and other risk factors, another important consideration is adverse

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

effects from undesirable tooth movement. Improper application of forces on the healthy teeth such as parafunctional habits like bruxism (teeth grinding), malocclusion, or even during orthodontic therapies itself induces and provokes gingival recession, clinical attachment loss, and extensive bone resorption. Periodontal disease most often occurs without overt symptoms and is rather painless. As far as periodontal disease is concerned, frequent professional maintenance and excellent home care are the best prevention before initiation of the disease.

#### **2. Oral and general health**

The mouth serves as a diagnostic mirror for many systemic diseases. The dentist should be aware of all the associated systemic conditions that manifests in the oral cavity [6]. This assists both the clinicians and patients in early diagnosis, prevention, and better treatment results. In recent developments, a study on the pathological link between periodontal health and systemic ailments [7] invited more interest and follow-up among researchers and public health organizations. There are significant findings supporting the association between periodontal disease and systemic conditions [8] namely cardiovascular disease [9], cerebrovascular diseases, peripheral arterial disease, respiratory diseases, mental disorders, type 2 diabetes mellitus [10], digestive diseases, endocrine disorders, obesity, adverse pregnancy outcomes [11], renal disorders, and rheumatoid arthritis (RA). The risk associated with a bacteremia from a dental treatment prior to any invasive cardiac surgeries, organ transplants, and prosthesis implantations is being investigated. On the other hand, the optimization of dental health before high-risk surgeries and in patients with pre-existing systemic disorders like cardiovascular defects should be recognized and reinforced among patients and dental professionals. In recent days, there are numerous emerging clinical studies substantiating the links of chronic inflammation and predisposition to various cancers. The effect of chronic periodontitis on head and neck squamous cell carcinoma (OSCC) is of utmost priority in the world of research [12]. OSCC lesions have been reported to harbor very high levels of oral microbial colonies relative to contiguous healthy mucosa [13]. Hence, the importance of primary oral hygiene measures should be emphasized soon after the primary teeth erupts.

#### **3. Role of immune system**

Many of the latest studies enlighten a possible bidirectional link between the mechanism of periodontitis and metabolic diseases where both conditions could exacerbate each other. Various clinical studies determined any derangements in the equilibrium of immune system because of chronic inflammation of the periodontium that has a greater impact on the general body health of patients with this disease relative to those who are free of gum disease. It has also been postulated that periodontal inflammation can modify the host susceptibility to acquire other diseases. Experimental animal studies have shown elevated levels of inflammatory markers in periodontitis. A proper knowledge of immune pathogenesis during chronic periodontitis can be a reliable source for clinicians to apply and modify new therapeutic approaches. The innate immune response is the first line of defense against invasion of pathogens. The blood leukocytes, neutrophils, and monocytes possess arsenal of receptors that enable the detection of invading pathogens and production of reactive oxygen species, cytokines, and chemokines. There occurs a disorder in the immune homeostasis, which leads to further increase in bacterial population and release of additional inflammatory mediators [14]. These inflammatory mediators elicit exaggerated immune response in the body, which subsequently favors the pathogens like *P. gingivalis.*

#### **4. Host response to periodontitis**

effects from undesirable tooth movement. Improper application of forces on the healthy teeth such as parafunctional habits like bruxism (teeth grinding), malocclusion, or even during orthodontic therapies itself induces and provokes gingival recession, clinical attachment loss, and extensive bone resorption. Periodontal disease most often occurs without overt symptoms and is rather painless. As far as periodontal disease is concerned, frequent professional maintenance and excellent home care are the best prevention before initiation of the disease.

The mouth serves as a diagnostic mirror for many systemic diseases. The dentist should be aware of all the associated systemic conditions that manifests in the oral cavity [6]. This assists both the clinicians and patients in early diagnosis, prevention, and better treatment results. In recent developments, a study on the pathological link between periodontal health and systemic ailments [7] invited more interest and follow-up among researchers and public health organizations. There are significant findings supporting the association between periodontal disease and systemic conditions [8] namely cardiovascular disease [9], cerebrovascular diseases, peripheral arterial disease, respiratory diseases, mental disorders, type 2 diabetes mellitus [10], digestive diseases, endocrine disorders, obesity, adverse pregnancy outcomes [11], renal disorders, and rheumatoid arthritis (RA). The risk associated with a bacteremia from a dental treatment prior to any invasive cardiac surgeries, organ transplants, and prosthesis implantations is being investigated. On the other hand, the optimization of dental health before high-risk surgeries and in patients with pre-existing systemic disorders like cardiovascular defects should be recognized and reinforced among patients and dental professionals. In recent days, there are numerous emerging clinical studies substantiating the links of chronic inflammation and predisposition to various cancers. The effect of chronic periodontitis on head and neck squamous cell carcinoma (OSCC) is of utmost priority in the world of research [12]. OSCC lesions have been reported to harbor very high levels of oral microbial colonies relative to contiguous healthy mucosa [13]. Hence, the importance of primary oral

hygiene measures should be emphasized soon after the primary teeth erupts.

Many of the latest studies enlighten a possible bidirectional link between the mechanism of periodontitis and metabolic diseases where both conditions could exacerbate each other. Various clinical studies determined any derangements in the equilibrium of immune system because of chronic inflammation of the periodontium that has a greater impact on the general body health of patients with this disease relative to those who are free of gum disease. It has also been postulated that periodontal inflammation can modify the host susceptibility to acquire other diseases. Experimental animal studies have shown elevated levels of inflammatory markers in periodontitis. A proper knowledge of immune pathogenesis during chronic periodontitis can be a reliable source for clinicians to apply and modify new therapeutic approaches. The

**2. Oral and general health**

4 Periodontitis - A Useful Reference

**3. Role of immune system**

The interaction between host response and the dysbiotic microbial community is significant for causing periodontitis. The keystone pathogen, especially *P. gingivalis,* is known to influence the host directly by tissue damage and indirectly by stimulating and modifying the immune system to favor their survival and multiplication. In normal healthy status, the gingival epithelium [15] acts as the physical barrier against mechanical stress, exogenous substances, and pathogenic bacteria. When inflammation of the periodontium exists, *P. gingivalis* employs unique strategies to survive, sustain, and persist in the oral cavity, particularly in the antigen-presenting dendritic cells [16–18]. Hajishengallis discovered *P. gingivalis* surviving in the macrophages [19]. *P. gingivalis* causes inhibition of IL-8 production by the epithelial cells and impairs the protective functions of polymorphonuclear neutrophils (PMNs). During periodontal inflammation, the epithelial surface becomes ulcerated by proteolytic activity from the by-products of bacterial colonies, resulting in exposure of the connective tissues and blood capillaries to the bacterial biofilm, which allows further periodontal destruction and progression of the overall disease process. More studies are needed to specify how these pathogenic bacteria induced by biofilm affect the host immune homeostasis. Investigations should also focus on how bacterial dissemination to distant sites in the human system causes different conditions such as cardiovascular diseases, diabetes, rheumatoid arthritis (RA), macular degeneration [20], Parkinson, and Alzheimer's disease [21].

#### **5. Treatment planning, outcome, and impact**

A comprehensive periodontal diagnosis allows opportunity for appropriate treatment. A thorough assessment of the local cause (plaque), systemic factors, functional (presence of caries, occlusal status), and esthetic need (orthodontic therapy) induces an effective treatment plan. The chief goal of periodontal therapies is to control the prevailing infection and prevent further damage to the periodontium. Therapeutic control is accomplished with the least invasive methods and surgical treatments as needed. Nonsurgical strategies range from improvements in basic oral hygiene practices to professional scaling and root planning with antimicrobial medications. When treating severe periodontal destruction, surgical and regenerative therapies such as reconstructive tissue therapy guided tissue regeneration (GTR) with the aid of bioactive substitutes and bone grafts are indicated. A combined interdisciplinary approach with orthodontic management and periodontal therapy is most effective in adults with severe periodontitis to restore the disordered function, compromised esthetics, and overall well-being. On the other hand, it is vital to identify, eradicate, or modify the causal factors and risk factors associated with periodontitis.

It is appropriate to advance our knowledge of oral pathogens, their impact on host immune response, and the cellular level modifications, which occur during normal health, disease, and periodontal management. The collection of chapters in this book will be a valuable guide in this regard.

#### **Author details**

Pachiappan Arjunan\*, Radhika Swaminathan, Brunner Mark and Christopher W. Cutler

\*Address all correspondence to: parjunan@gru.edu

Department of Periodontics, Dental College of Georgia, Augusta University, GA, USA

#### **References**


[9] Bokhari SA, et al. Periodontitis in coronary heart disease patients: Strong association between bleeding on probing and systemic biomarkers. Journal of Clinical Periodontology. 2014;**41**(11):1048-1054

approach with orthodontic management and periodontal therapy is most effective in adults with severe periodontitis to restore the disordered function, compromised esthetics, and overall well-being. On the other hand, it is vital to identify, eradicate, or modify the causal

It is appropriate to advance our knowledge of oral pathogens, their impact on host immune response, and the cellular level modifications, which occur during normal health, disease, and periodontal management. The collection of chapters in this book will be a valuable guide in

Pachiappan Arjunan\*, Radhika Swaminathan, Brunner Mark and Christopher W. Cutler

Department of Periodontics, Dental College of Georgia, Augusta University, GA, USA

[1] Page RC, Schroeder HE. Pathogenesis of inflammatory periodontal disease. A summary of current work. Laboratory Investigation: A Journal of Technical Methods and

[2] Petersen PE, Ogawa H. The global burden of periodontal disease: Towards integration with chronic disease prevention and control. Periodontology 2000. 2012;**60**(1):15-39 [3] Hajishengallis G. Periodontitis: From microbial immune subversion to systemic inflam-

[4] Eke PI, et al. Risk indicators for periodontitis in US adults: NHANES 2009 to 2012.

[5] Ezzo PJ, Cutler CW. Microorganisms as risk indicators for periodontal disease. Periodon-

[6] Genco RJ, Genco FD. Common risk factors in the management of periodontal and associated systemic diseases: The dental setting and interprofessional collaboration. The

[7] Winning L, Linden GJ. Periodontitis and systemic disease: Association or causality?

[8] Nazir MA. Prevalence of periodontal disease, its association with systemic diseases and

factors and risk factors associated with periodontitis.

\*Address all correspondence to: parjunan@gru.edu

mation. Nature Reviews. Immunology. 2015;**15**(1):30-44

Journal of Evidence-Based Dental Practice. 2014;**14**(Suppl):4-16

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Current Oral Health Reports. 2017;**4**(1):1-7

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this regard.

**Author details**

6 Periodontitis - A Useful Reference

**References**

