The Official Patient's Sourcebook On Periodontitis

THE OFFICIAL PATIENT’S SOURCEBOOK

PERIODONTITIS

J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

ii

ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright Ó2002 by ICON Group International, Inc. Copyright Ó2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher's note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your dentist or oral surgeon. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified dentist or oral surgeon. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The Official Patient’s Sourcebook on Periodontitis: Revised and Updated for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83282-X 1. Periodontitis-Popular works. I. Title.

iii

Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.

Copyright Notice If a dentist or oral surgeon wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this sourcebook.

iv

Dedication To the healthcare professionals dedicating their time and efforts to the study of periodontitis.

Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to periodontitis. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.

v

About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

vi

About ICON Health Publications In addition to periodontitis, Official Patient’s Sourcebooks are available for the following related topics: ·

The Official Patient's Sourcebook on Diabetes-related Periodontal Disease

·

The Official Patient's Sourcebook on Dry Mouth

·

The Official Patient's Sourcebook on Gingivitis

·

The Official Patient's Sourcebook on Oral Cancer

·

The Official Patient's Sourcebook on Temporomandibular Joint Syndrome

·

The Official Patient's Sourcebook on Tooth Decay

To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

Contents vii

Table of Contents INTRODUCTION ....................................................................... 1 Overview ................................................................................................................................. 1 Organization ......................................................................................................................... 3 Scope .......................................................................................................................................... 3 Moving Forward................................................................................................................. 4

PART I: THE ESSENTIALS ..................................................................... 7 CHAPTER 1. THE ESSENTIALS ON PERIODONTITIS: GUIDELINES ............................................................................. 9 Overview ................................................................................................................................. 9 What Is Periodontal Disease? ................................................................................... 10 How Does Periodontal Disease Develop?.......................................................... 11 Who Gets Periodontitis? .............................................................................................. 12 What Can I Do to Prevent Periodontitis?......................................................... 12 Risk Factors ......................................................................................................................... 12 How Do I Know If I Have Periodontitis? .......................................................... 13 How Is Periodontitis Treated? ................................................................................. 13 Surgical Treatments ....................................................................................................... 16 Second Opinion ................................................................................................................. 17 Can Periodontal Disease Cause Health Problems Beyond the Mouth? ..................................................................................................................................................... 17

More Guideline Sources ............................................................................................... 17 Vocabulary Builder ......................................................................................................... 29

CHAPTER 2. SEEKING GUIDANCE ........................................ 33

Overview ............................................................................................................................... 33 Associations and Periodontitis................................................................................. 33 Finding Dentists............................................................................................................... 35 Selecting Your Dentist ................................................................................................. 36 Working with Your Dentist ...................................................................................... 37 Broader Health-Related Resources......................................................................... 39

CHAPTER 3. CLINICAL TRIALS AND PERIODONTITIS ......... 41 Overview ............................................................................................................................... 41 Recent Trials on Periodontitis .................................................................................. 44 Benefits and Risks ............................................................................................................ 47 Keeping Current on Clinical Trials ...................................................................... 50 General References .......................................................................................................... 50

viii Contents

Vocabulary Builder ......................................................................................................... 51

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL ....................................................................... 53 CHAPTER 4. STUDIES ON PERIODONTITIS ........................... 55 Overview ............................................................................................................................... 55 The Combined Health Information Database .................................................. 55 Federally-Funded Research on Periodontitis ................................................... 66 The National Library of Medicine: PubMed .................................................... 82 Vocabulary Builder ......................................................................................................... 83

CHAPTER 5. BOOKS ON PERIODONTITIS.............................. 89 Overview ............................................................................................................................... 89 Book Summaries: Federal Agencies ....................................................................... 89 Book Summaries: Online Booksellers ................................................................... 93 Chapters on Periodontitis............................................................................................ 94 General Home References ............................................................................................ 96 Vocabulary Builder ......................................................................................................... 97

CHAPTER 6. MULTIMEDIA ON PERIODONTITIS................. 101

Overview ............................................................................................................................. 101 Bibliography: Multimedia on Periodontitis.................................................... 101

CHAPTER 7. PERIODICALS AND NEWS ON PERIODONTITIS .............................................................................................. 105 Overview ............................................................................................................................. 105 News Services & Press Releases............................................................................ 105 Newsletter Articles........................................................................................................ 108 Academic Periodicals covering Periodontitis ................................................ 112 Vocabulary Builder ....................................................................................................... 112

CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES .. 115 Overview ............................................................................................................................. 115 NIH Guidelines ............................................................................................................... 115 NIH Databases ................................................................................................................ 116 Other Commercial Databases ................................................................................. 122 The Genome Project and Periodontitis.............................................................. 122 Specialized References ................................................................................................. 127 Vocabulary Builder ....................................................................................................... 128

CHAPTER 9. DISSERTATIONS ON PERIODONTITIS ............. 129 Overview ............................................................................................................................. 129

Contents

ix

Dissertations on Periodontitis ................................................................................ 129 Keeping Current ............................................................................................................. 130 Vocabulary Builder ....................................................................................................... 131

PART III. APPENDICES .......................................................................... 133 APPENDIX A. RESEARCHING YOUR MEDICATIONS ......... 135

Overview ............................................................................................................................. 135 Your Medications: The Basics ................................................................................ 136 Learning More about Your Medications.......................................................... 137 Commercial Databases ................................................................................................ 139 Contraindications and Interactions (Hidden Dangers) .......................... 140 A Final Warning ............................................................................................................ 141 General References ........................................................................................................ 142

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ... 143

Overview ............................................................................................................................. 143 What Is CAM? ................................................................................................................ 143 What Are the Domains of Alternative Medicine?...................................... 144 Can Alternatives Affect My Treatment? ......................................................... 147 Finding CAM References on Periodontitis .................................................... 148 Additional Web Resources ........................................................................................ 150 General References ........................................................................................................ 153

APPENDIX C. RESEARCHING NUTRITION ......................... 155 Overview ............................................................................................................................. 155 Food and Nutrition: General Principles ........................................................... 155 Finding Studies on Periodontitis.......................................................................... 160 Federal Resources on Nutrition............................................................................. 164 Additional Web Resources ........................................................................................ 164 Vocabulary Builder ....................................................................................................... 166

APPENDIX D. FINDING MEDICAL LIBRARIES .................... 169

Overview ............................................................................................................................. 169 Preparation ........................................................................................................................ 169 Finding a Local Medical Library .......................................................................... 170 Medical Libraries Open to the Public ................................................................ 170

APPENDIX E. YOUR RIGHTS AND INSURANCE ................. 177 Overview ............................................................................................................................. 177 Your Rights as a Patient ............................................................................................ 177 Patient Responsibilities .............................................................................................. 181

x

Contents

Choosing an Insurance Plan ................................................................................... 182 Medicare and Medicaid .............................................................................................. 184 NORD’s Medication Assistance Programs ................................................... 187 Additional Resources ................................................................................................... 188

ONLINE GLOSSARIES............................................................................. 191 Online Dictionary Directories ............................................................................... 193

PERIODONTITIS GLOSSARY ..................................................... 195 General Dictionaries and Glossaries .................................................................. 209

INDEX ................................................................................................................................... 212

Introduction

1

INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don't know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many healthcare providers and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3

Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1 2

2

Periodontitis

Since the late 1990s, healthcare providers have seen a general increase in patient Internet usage rates. Patients frequently enter their dentists’ offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that dentists often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Periodontitis has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to periodontitis, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on periodontitis. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on periodontitis should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique. Deciding on appropriate

Introduction

3

options is always up to the patient in consultation with their dentist and other healthcare providers.

Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching periodontitis (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to periodontitis. It also gives you sources of information that can help you find a dentist or oral surgeon in your local area specializing in treating periodontitis. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with periodontitis. Part II moves on to advanced research dedicated to periodontitis. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on periodontitis. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “free-to-use” options. Part III provides appendices of useful background reading for all patients with periodontitis or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with periodontitis. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with periodontitis.

Scope While this sourcebook covers periodontitis, your dentist, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that periodontitis is often considered a synonym or a condition closely related to the following: ·

Acute Periodontitis

·

Chronic Periodontitis

4

Periodontitis

·

Pyorrhea Gum Disease

·

Severe Gum Disease

·

Severe Gum Inflammation

In addition to synonyms and related conditions, healthcare providers may refer to periodontitis using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world's illnesses. Your dentist may use this coding system as an administrative or tracking tool. The following classification is commonly used for periodontitis:4 ·

523 gingival and periodontal diseases

·

523.3 acute periodontitis

·

523.4 chronic periodontitis

·

523.5 periodontosis

·

523.9 unspecified gingival and periodontal disease

For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to periodontitis. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians.

Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses. Some are written by patients or their family members. These generally take a layperson's approach to understanding and coping with an illness or disorder. They can be uplifting, encouraging, and highly supportive. Other guides are authored by dentists or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as 4 This list is based on the official version of the World Health Organization's 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”

Introduction

5

recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian. Why “Internet age”? All too often, patients diagnosed with periodontitis will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with periodontitis is even indexed in search engines, a non-systematic approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. While we focus on the more scientific aspects of periodontitis, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors

7

PART I: THE ESSENTIALS

ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on periodontitis. The essentials of a disease typically include the definition or description of the disease, a discussion of who it affects, the signs or symptoms associated with the disease, tests or diagnostic procedures that might be specific to the disease, and treatments for the disease. Your dentist or oral surgeon may have already explained the essentials of periodontitis to you or even given you a pamphlet or brochure describing periodontitis. Now you are searching for more in-depth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your dentist or oral surgeon has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.

Guidelines

CHAPTER 1. GUIDELINES

THE

ESSENTIALS

ON

9

PERIODONTITIS:

Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on periodontitis. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on periodontitis can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them.

The National Institutes of Health (NIH)5 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on periodontitis. Originally founded in 1887, the NIH is one of the world's foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years include the world's most illustrious scientists and physicians. Among them are 97 scientists who have won the Nobel Prize for achievement in medicine.

5

Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.

10 Periodontitis

There is no guarantee that any one Institute will have a guideline on a specific disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare diseases. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with periodontitis and associated conditions: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc. ) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Dental and Craniofacial Research (NIDCR); guidelines available at http://www.nidr.nih.gov/health/

Among these, the National Institute of Dental and Craniofacial Research (NIDCR) is particularly noteworthy.6 Its mission is to promote the general health of the American people by improving their oral, dental, and craniofacial health. Through nurturing fundamental research and the development of researchers, the NIDCR aims to promote health, to prevent diseases and conditions, and to develop new diagnostics and therapeutics. Knowledge acquisition through science and effective and efficient science transfer are the means used to contribute to improved quality of health. The following is NIDCR’s patient guideline on periodontitis.

What Is Periodontal Disease?7 If you have been told you have periodontal (gum) disease, you're not alone. An estimated 80 percent of American adults currently have some form of the disease. Periodontal diseases range from simple gum inflammation to serious disease that results in major damage to the soft tissue and bone that support the teeth. In the worst cases, teeth are lost.

6 Adapted from the NIDCR: http://www.nidr.nih.gov/about/mission.asp. For the remainder of the book, “adapted” indicates reproduction with attribution, with minor editorial adjustments, as needed. 7 Adapted from the National Institute of Dental and Craniofacial Research (NIDCR): http://www.nidcr.nih.gov/health/newsandhealth/gumDiseasesPub.asp.

Guidelines 11

Gum disease is a threat to your oral health. Research is also pointing to possible health effects of periodontal diseases that go well beyond your mouth (more about this later). Whether it is stopped, slowed, or gets worse depends a great deal on how well you care for your teeth and gums every day, from this point forward.

How Does Periodontal Disease Develop? Plaque and Tartar Our mouths are full of bacteria. These bacteria, along with mucus and other particles, constantly form a sticky, colorless “plaque” on teeth. Brushing and flossing help get rid of plaque. Plaque that is not removed can harden and form bacteria-harboring “tartar” that brushing doesn't clean. Only a professional cleaning by a dentist or dental hygienist can remove tartar.

Gingivitis The longer plaque and tartar are on teeth, the more harmful they become. The bacteria cause inflammation of the gums that is called “gingivitis.” In gingivitis, the gums become red, swollen and can bleed easily. Gingivitis is a mild form of gum disease that can usually be reversed with daily brushing and flossing, and cleaning by a dentist or dental hygienist. This form of gum disease does not include any loss of bone and tissue that hold teeth in place. Periodontitis When gingivitis is not treated, it can advance to “periodontitis” (which means “inflammation around the tooth.”) In periodontitis, gums pull away from the teeth and form “pockets” that are infected. The body's immune system fights the bacteria as the plaque spreads and grows below the gum line. Bacterial toxins and the body's enzymes fighting the infection actually start to break down the bone and connective tissue that hold teeth in place. If not treated, the bones, gums, and connective tissue that support the teeth are destroyed. The teeth may eventually become loose and have to be removed.

12 Periodontitis

Who Gets Periodontitis? People usually don't show signs of gum disease until they are in their 30s or 40s. Men are more likely to have periodontal disease than women. Although teenagers rarely develop periodontitis, they can develop gingivitis, the milder form of gum disease. Most commonly, gum disease develops when plaque is allowed to build up along and under the gum line.

What Can I Do to Prevent Periodontitis? Here are some things you can do to prevent periodontal diseases: ·

Brush your teeth twice a day (with a fluoride toothpaste)

·

Floss once a day

·

Visit the dentist routinely for a check-up and professional cleaning

·

Eat a well balanced diet

·

Don't use tobacco products

Risk Factors Risk factors of developing periodontal disease include the following: ·

Smoking. Need another reason to quit smoking? Smoking is one of the most significant risk factors associated with the development of periodontitis. Additionally, smoking can lower the chances of success of some treatments.

·

Hormonal changes in girls/women. These changes can make gums more sensitive and make it easier for gingivitis to develop.

·

Diabetes. People with diabetes are at higher risk for developing infections, including periodontal disease.

·

Stress. Research shows that stress can make it more difficult for our bodies to fight infection, including periodontal disease.

·

Medications. Some drugs, such as oral contraceptives, antidepressants, and some heart medicines can affect oral health because they lessen the flow of saliva. (Saliva has a protective effect on teeth and gums.)

·

Poor nutrition. A poor diet, especially one low in calcium, can lower your resistance to gum disease.

Guidelines 13

·

Illnesses. Diseases like cancer or AIDS and their treatments can also affect the health of gums.

·

Genetic susceptibility. Some people are more prone to severe periodontal disease than others.

How Do I Know If I Have Periodontitis? Symptoms are often not noticeable until the disease is advanced. They include: ·

Bad breath that won't go away

·

Red or swollen gums

·

Tender or bleeding gums

·

Painful chewing

·

Loose teeth

·

Sensitive teeth

Any of these symptoms may signal a serious problem, which should be checked by a dentist. At your dental visit: ·

The dentist will ask about your medical history to identify underlying conditions or risk factors (such as smoking) that may contribute to periodontal disease.

·

The dentist or hygienist will examine your gums and note any signs of inflammation.

·

The dentist or hygienist will use a probe to check for periodontal pockets and to measure any pockets. In a healthy mouth, the depth of these pockets is usually between 1 and 3 millimeters.

·

The dentist or hygienist may take an x-ray to see whether there is any bone loss.

·

The dentist may refer you to a periodontist, a specialist who treats gum diseases.

How Is Periodontitis Treated? The main goal of treatment is to control the infection. Treatment will vary, depending on the extent of the gum disease. Any type of treatment requires

14 Periodontitis

that the patient keep up good daily care at home. Additionally, modifying certain behaviors, such as quitting tobacco use, might also be suggested as a way to improve treatment outcome. Deep Cleaning (Scaling and Root Planing) The dentist, periodontist, or dental hygienist removes the plaque through a deep-cleaning method called scaling and root planing. Scaling means scraping off the tartar from above and below the gum line. Root planing gets rid of rough spots on the tooth root where the germs gather, and helps remove bacteria that contribute to the disease.

Medications A number of medications are now available to control the infection and reduce inflammation. Medications are generally used with treatment that includes scaling and root planing. Long-term studies will be needed to determine whether using medications reduces the need for surgery and whether they are effective over a long period of time. Here are some that are currently used: ·

Antimicrobial mouthrinse What is it? A prescription mouthrinse containing an antimicrobial called chlorhexidine. Why is it used? To control bacteria when treating gingivitis and after gum surgery. How is it used? It's used like a regular mouthwash.

·

Antiseptic “chip” What is it? A tiny piece of gelatin filled with the medicine chlorhexidine. Why is it used? To control bacteria and reduce the size of periodontal pockets.

Guidelines 15

How is it used? After root planing, it's placed in the pockets where the medicine is slowly released over time. ·

Antibiotic gel What is it? A gel that contains the antibiotic doxycycline. Why is it used? To control bacteria and reduce the size of periodontal pockets. How is it used? The periodontist puts it in the pockets after scaling and root planing. The antibiotic is released slowly over a period of about seven days.

·

Antibiotic fiber What is it? Thread-like fiber that contains the antibiotic tetracycline. Why is it used? To control bacteria and reduce the size of periodontal pockets. How is it used? These fibers are placed in the pockets. The medicine is released slowly over 10 days. The fibers are then removed.

·

Antibiotic microspheres What is it? Tiny, round particles that contain the antibiotic minocycline. Why is it used? To control bacteria and reduce the size of periodontal pockets. How is it used? The periodontist puts the microspheres into the pockets after scaling and root planing. The particles release minocycline slowly over time.

16 Periodontitis

·

Enzyme suppressant What is it? A low dose of the medication doxycycline that keeps destructive enzymes in check. Why is it used? To hold back the body's enzyme response -- If not controlled, certain enzymes can break down gum tissue. How is it used? This medication is in pill form. It is used in combination with scaling and root planing.

Surgical Treatments Flap Surgery Surgery might be necessary if inflammation and deep pockets remain following treatment with deep cleaning and medications. A periodontist may perform flap surgery to remove tartar deposits in deep pockets or to reduce the periodontal pocket and make it easier for the patient, dentist, and hygienist to keep the area clean. This common surgery involves lifting back the gums and removing the tartar. The gums are then sutured back in place so that the tissue fits snugly around the tooth again. Bone and Tissue Grafts In addition to flap surgery, your periodontist may suggest placing bone or tissue grafts. Grafting is a way to replace or encourage new growth of bone or gum tissue destroyed by periodontitis. A technique that can be used with bone grafting is called guided tissue regeneration, in which a small piece of mesh-like fabric is inserted between the bone and gum tissue. This keeps the gum tissue from growing into the area where the bone should be, allowing the bone and connective tissue to regrow. Since each case is different, it is not possible to predict with certainty which grafts will be successful over the long-term. Treatment results depend on many things, including severity of the disease, ability to maintain oral hygiene at home, and certain risk factors, such as smoking, which may lower the chances of success. Ask your periodontist what the level of success might be in your particular case.

Guidelines 17

Second Opinion When considering any extensive dental or medical treatment options, you should think about getting a second opinion. To find a dentist or periodontist for a second opinion, call your local dental society. They can provide you with names of practitioners in your area. Dental schools are also a good source for getting a second opinion.

Can Periodontal Disease Cause Health Problems Beyond the Mouth? Maybe. But so far the research is inconclusive. Studies are ongoing to try to determine whether there is a cause-and-effect relationship between periodontal disease and: ·

An increased risk of heart attack or stroke

·

An increased risk of delivering preterm, low birth weight babies

·

Difficulty controlling blood sugar levels in people with diabetes

In the meantime, it's a fact that controlling periodontal disease can save your teeth -- a very good reason to take care of your teeth and gums.

Participating in Research Studies To find out about participating in research studies on periodontal diseases go to clinicaltrials.gov.

More Guideline Sources The guideline above on periodontitis is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to periodontitis. Many of the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with periodontitis. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly.

18 Periodontitis

Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. From there you can either search using the alphabetical index or browse by broad topic areas. If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it only includes material linked within the MEDLINEplus system (mostly patient-oriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search.

The Combined Health Information Database (CHID) CHID Online is a reference tool that maintains a database directory of thousands of journal articles and patient education guidelines on periodontitis and related conditions. One of the advantages of CHID over other sources is that it offers summaries that describe the guidelines available, including contact information and pricing. CHID’s general Web site is http://chid.nih.gov/. To search this database, go to http://chid.nih.gov/detail/detail.html. In particular, you can use the advanced search options to look up pamphlets, reports, brochures, and information kits. The following was recently posted in this archive: ·

Gastrointestinal Tract in Scleroderma Source: Danvers, MA: Scleroderma Foundation. 1999. 6 p. Contact: Available from Scleroderma Foundation. 12 Kent Way, Suite 101, Byfield, MA 01922. (800) 722-4673 or (978) 463-5843. Fax (978) 4635809. E-mail: [email protected]. Website: www.scleroderma.org. Price: Single copy $1.00. Summary: This pamphlet provides people who have scleroderma with information on its gastrointestinal tract manifestations. The pamphlet focuses on manifestations involving the mouth, esophagus, stomach, and

Guidelines 19

small intestine and large intestines. People who have scleroderma may experience dry mouth, which may lead to impairment of early digestion and occurrence of dental caries and periodontitis. Involvement of the esophagus may cause heartburn, difficulty with swallowing, and aspiration. Stomach involvement occurs in only 10 percent of patients, but it can be associated with bloating, satiety, abdominal pain, nausea, and vomiting. Involvement of the small intestine may cause nausea, vomiting, bloating, diarrhea, and malabsorption, while muscle impairment of the large intestine may result in constipation, bloating, and diarrhea. The pamphlet also includes a glossary of terms. 1 figure. ·

Prevent Diabetes Problems: Keep Your Teeth and Gums Healthy Source: Bethesda, MD: National Diabetes Information Clearinghouse (NDIC), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health. 2000. 13 p. Contact: Available from National Diabetes Information Clearinghouse (NDIC). 1 Information Way, Bethesda, MD 20892-3560. (800) 860-8747 or (301) 654-3327. Fax (301) 907-8906. E-mail: [email protected]. Price: Single copy free. Summary: This illustrated booklet, written in nontechnical language, uses a question and answer format to provide people who have diabetes with information on preventing tooth and gum problems caused by diabetes. High blood sugar helps bacteria grow, which can lead to a condition called periodontitis. Symptoms of tooth and gum damage include red, sore, swollen gums; bleeding gums; gums pulling away from teeth; loose or sensitive teeth; bad breath; a bite that feels different; and poor fitting dentures. The booklet explains how a person and his or her dentist can keep teeth and gums healthy. The booklet also provides general tips for staying healthy. In addition, the booklet includes sources of information about diabetes and describes the activities of the National Diabetes Information Clearinghouse.

·

Mouth Care and Diabetes: Managing Periodontal Disease Source: San Bruno, CA: StayWell Company. 2000. [2 p.]. Contact: Available from StayWell Company. Order Department, 1100 Grundy Lane, San Bruno, CA 94066-9821. (800) 333-3032. Fax (650) 2444512. E-mail: [email protected]. Website: www.staywell.com. Price: $17.95 for a pack of 50; plus shipping and handling. Summary: This pamphlet provides people who have diabetes with tips for preventing and treating periodontal disease. People who have diabetes are at increased risk for periodontal disease. Periodontal disease

20 Periodontitis

occurs in three stages: gingivitis, periodontitis, and advanced periodontitis. Steps that people can take to prevent periodontal disease include using good oral hygiene, visiting the dentist every 3 to 4 months for examinations and cleanings, and keeping blood glucose at a healthy level. Treatment of periodontal disease involves scaling and root planing, taking antibiotics, and undergoing gum surgery. 13 figures. ·

Diabetes and Periodontal Disease: A Guide for Patients. [Enfermedad periodontal en los diabetics: Guia para los pacientes] Source: Bethesda, MD: National Institute of Dental Research. 1997. 12 p. Contact: Available from National Oral Health Information Clearinghouse (NOHIC). 1 NOHIC Way, Bethesda, MD 20892-3500. (301) 402-7364. Fax (301) 907-8830. E-mail: [email protected]. Price: Single copy free; bulk copies available. Summary: This brochure provides guidelines for the prevention of periodontal disease in patients with diabetes. Susceptibility to gum diseases, particularly with diabetes, may result from thickening of blood vessels, bacteria, or poor diabetes control. Pathogenesis of periodontal disease includes gingivitis, periodontitis, and tooth loss. Treatment consists of plaque removal and periodontal surgery. Dental caries, thrush and dry mouth are other oral complications associated with diabetes. Proper brushing and flossing on a daily basis, in conjunction with regular dental checkups are the best preventive measures for these oral diseases. This brochure is available in English or Spanish.

·

Periodontal Diseases: What You Need to Know Source: Chicago, IL: American Academy of Periodontology. 1996. 10 p. Contact: Available from American Academy of Periodontology. 737 North Michigan Avenue, Suite 800, Chicago, IL 60611-2690. (312) 7875518. Fax (312) 787-3670. Website: www.perio.org. Price: Single copy free; bulk orders available. Summary: This brochure uses a question and answer format to provide information on periodontal diseases, which are bacterial gum infections that destroy the attachment fibers and supporting bone that hold the teeth in the mouth. The most common forms of periodontal disease are gingivitis, mild periodontitis, and moderate-advanced periodontitis. Although plaque is the main cause of periodontal disease, other factors such as smoking or tobacco use, pregnancy and puberty, stress, medications, clenching or grinding the teeth, diabetes, poor nutrition, and systemic diseases, can affect gum health. The brochure lists the symptoms of periodontal disease and discusses their prevention and

Guidelines 21

treatment. It also includes four inserts that explain the relationship between periodontal disease and respiratory disease, pregnancy outcomes, diabetes, and heart disease. 6 figures. ·

Long-Term Complications of Diabetes: Good Self Care Makes a Difference Source: Lexington, KY: Lexington-Fayette County Health Department. 199x. 13 p. Contact: Available from Lexington-Fayette County Health Department. Division of Nutrition and Health Education, 650 Newtown Pike, Lexington, KY 40508. (606) 288-2333. Fax (606) 288-2359. Price: $38.00 per 25 copies plus shipping. Summary: This guide to the longterm complications of diabetes is one in a series of 22 diabetes education materials that combine practical tips and humorous drawings with current diabetes information. The series is written at a sixth grade reading level and is designed to teach and motivate patients to take good care of themselves. The booklet provides specific suggestions for readers to implement in their everyday diabetes management. The author emphasize the importance of a good program of diabetes care, including healthy eating, exercise, special medications, regular medical care, self care, and education in controlling diabetes and preventing complications. The authors also stress the importance of regular monitoring and early detection of any complications, in order to better manage them. Complications discussed include heart disease, eye problems (diabetic retinopathy, cataracts, glaucoma), kidney problems (diabetic nephropathy), nerve damage (diabetic neuropathy), sex problems (sexual dysfunction), foot problems, and dental problems (gingivitis, periodontitis). The booklet lists recommendations for preventing cardiovascular disease: do not smoke, check blood pressure regularly, lower the amount of fat intake, lower the amount of sodium, maintain a healthy weight, develop and follow a plan for exercise, see the health care team regularly, and control blood glucose.

·

Prevent Diabetes Problems: Keep Your Gums and Teeth Healthy Source: Bethesda, MD: National Diabetes Information Clearinghouse (NDIC), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH). 2000. 13 p. Contact: Available from National Diabetes Information Clearinghouse (NDIC). 1 Information Way, Bethesda, MD 20892-3560. (301) 654-3327. Fax (301) 907-8906. E-mail: [email protected]. Price: Single copy free.

22 Periodontitis

Summary: This booklet helps readers with diabetes mellitus avoid the tooth and gum problems that are associated with the disease. Written in nontechnical language, the booklet reviews strategies for readers to use every day to stay healthy and prevent diabetes problems with their teeth and gums. Topics include a definition of these complications, everyday dental care and hygiene, how diabetes can hurt the teeth and gums, the symptoms of damage to the teeth and gums, the role of the dentist in caring for the patient's teeth and gums, and where to get more information. The booklet focuses on the interplay between general health and good blood glucose levels, exercise, good nutrition, and good dental hygiene (brushing and flossing). Medical terms, such as periodontitis, are defined and a guide to their pronunciation is provided. The booklet includes line drawings of many of the concepts discussed. The booklet concludes with a brief description of a series of booklets, called Prevent Diabetes Problems, available from the National Diabetes Information Clearinghouse (NDIC), and a description of the activities of the NDIC itself. 9 figures. ·

Treating Periodontal Disease: Restoring the Health of Your Teeth and Gums. [Como Tratar las Enfermedades Periodontales: Recupere la Salud de Sus Dientes y Encias] Source: San Bruno, CA: Staywell Company. 1999. 16 p. Contact: Available from Staywell Company. 1100 Grundy Lane, San Bruno, CA 94066-3030. (800) 333-3032. Price: $2.50 per brochure plus shipping and handling. Order Number 1415 (English) or 1678 (Spanish). Summary: This booklet provides readers with an overview of periodontal disease and its treatment. Topics covered include the signs of periodontal disease; the need for a lifelong commitment to fighting periodontal disease; the role and training of the periodontist; the anatomy and physiology of healthy gums and teeth; how periodontal disease can progress from gingivitis, to periodontitis, to advanced periodontitis; the periodontal evaluation; steps for the home care aspects of periodontal therapy, notably flossing and brushing; nonsurgical options for treating periodontal disease, including scaling and root planing, antibiotics, bite correction, and splinting; surgical options for periodontal therapy, including flap surgery, gingivectomy, bone surgery, guided tissue regeneration, bone graft, and soft tissue graft; what to expect during and after the surgical experience; and the importance of regular monitoring and ongoing care to prevent periodontal disease. The brochure is illustrated with full-color line drawings of patients, as well as medical illustrations of the procedures discussed. This brochure is available in English and Spanish.

Guidelines 23

·

Mouth: Owner's Manual: Preventing and Controlling Gum Disease Source: San Bruno, CA: Staywell Company. 1998. 16 p. Contact: Available from Staywell Company. Order Department, 1100 Grundy Lane, San Bruno, CA 94066-3030. (800) 333-3032. Price: $1.35 plus shipping and handling; quantity discounts available. Order Number 1315. Summary: This full-color, illustrated patient education brochure presents a guide to preventing and controlling periodontal (gum) disease. Topics covered include a guide to diagnosing gum disease, including a patient checklist of symptoms; the anatomy of the mouth and the physiology of bacteria, plaque, and periodontal disease; the three stages of gum disease: gingivitis, periodontitis, and advanced periodontitis; the full dental evaluation, including dental history, exam, and pocket charting; a how-to guide to self-care, especially flossing and toothbrushing; and professional treatment options for periodontal disease. The brochure concludes with an overview of proper dental hygiene and a blank space for the dentist to record recommendations for the patient.

·

Diabetes and Periodontal Disease: A Guide for Patients Source: Bethesda, MD: National Institute of Dental and Craniofacial Research (NIDCR). 1997. [7 p.]. Contact: Available from National Oral Health Information Clearinghouse (NOHIC). 1 NOHIC Way, Bethesda, MD 20892-3500. Voice (301) 4027364. TTY (301) 656-7581. Fax (301) 907-8830. E-mail: [email protected]. Website: www.nohic.nidcr.nih.gov. Price: Single copy free, limit 25 copies. Item Number OP-07 (English). Summary: This brochure discusses periodontal disease (gum disease) in people with diabetes mellitus. Topics include the link between diabetes and periodontal disease, including the factors of diabetic control, blood vessel changes, bacteria, and smoking; how periodontal disease develops, including the conditions of gingivitis and periodontitis; how periodontal disease is treated, including plaque removal and periodontal surgery; other oral problems that are linked to diabetes, including cavities, thrush, and dry mouth; the importance of keeping natural teeth; and protecting teeth and gums with proper brushing and flossing and regular dental checkups.

·

Gum Disease: The Warning Signs Source: Chicago, IL: American Dental Association (ADA). 1996. [2 p.].

24 Periodontitis

Contact: Available from American Dental Association (ADA). Catalog Sales, P.O. Box 776, St. Charles, IL 60174. (800) 947-4746; Fax (630) 4439970; http://www.ada.org. Price: Single copy free; bulk orders available. Order Number W105. Summary: This mini-brochure, from the American Dental Association, provides basic information about the warning signs of gum disease. Illustrated with colorful line drawings, the brochure discusses the forms of gum disease, including gingivitis, and periodontitis; the causes of gum disease; what happens during a dental care examination and how the dentist determines if gum disease is present; and the role of good oral hygiene in preventing gum disease. ·

Who Knows What Danger Lies Just Beneath the Surface: A Guide to Periodontal Disease Source: Sacramento, CA: California Dental Association (CDA). 1996. [6 p.]. Contact: Available from California Dental Association (CDA). P.O. Box 13749, Sacramento, CA 95853. (916) 443-0505; http://www.cda.org/cda. Price: Single copy free. Summary: This health education brochure familiarizes readers with periodontal disease and its prevention. Periodontal disease, also known as gum disease, is the major cause of tooth loss in adults. There are several types and stages of the disease, all of which start with a bacterial infection of the gums that can move into the bones and ligaments that support the teeth. Topics include the causes of periodontal disease, notably plaque, as well as food or chemical irritants, smoking or chewing tobacco, poorly fitting bridges, badly aligned teeth, defective fillings, clenching or grinding teeth, poor diet, pregnancy or oral contraceptives, systemic diseases, or certain medications; the stages of periodontal disease, including gingivitis, periodontitis, and advanced periodontitis; the symptoms of periodontal disease; treatment options, including professional cleaning, scaling, root planing, and surgery; and prevention considerations.

·

Periodontal Diseases: A Major Cause of Tooth Loss Source: St. Charles, IL: American Dental Association (ADA). 1996. [6 p.]. Contact: Available from American Dental Association (ADA). Catalog Sales, P.O. Box 776, St. Charles, IL 60174. (800) 947-4746; Fax (630) 4439970; http://www.ada.org. Price: $21.00 per 50 copies; bulk orders available. Order Number W121.

Guidelines 25

Summary: This lengthy brochure outlines the steps to take to prevent periodontal diseases. The brochure notes that periodontal diseases are caused by bacterial infections that attack gums, ligaments, and bones. Topics include the causes of periodontal disease; warning signs; types of periodontal diseases (gingivitis, periodontitis); and factors that can increase the risk of periodontal diseases, including smoking, misformed bridges, clenching the teeth, poor diet, pregnancy or use of oral contraceptives, systemic diseases, and medications. The brochure also discusses preventive measures, including toothbrushing, flossing, using an antimicrobial mouthrinse, eating a balanced diet, and scheduling regular dental checkups; screening tests for periodontal diseases; treatment options, including cleaning, scaling, antibiotics, and surgery; and maintenance. The brochure emphasizes the need for regular dental checkups, including a periodontal exam, in order to find problems before the gums and bone have been seriously compromised. Full-color photographs and line drawings illustrate the brochure. 13 figures. ·

HIV Infection and Oral Health Source: Boston, MA: HIV Dental Ombudsperson Program, Division of Public Health, Boston Department of Health and Hospitals. 1994. 6 p. Contact: Available from HIV Dental Ombudsperson Program, Division of Public Health, Boston Department of Health and Hospitals. 1010 Massachusetts Avenue, Boston, MA 02118. (617) 534-4717. Price: Single copy free. Summary: This patient education brochure explores HIV infection and oral health. Good oral health and regular dental care become more important for persons infected with HIV, primarily because simple dental problems may become more serious in people with weakened immune systems. Topics covered include the basics of regular dental hygiene; signs of HIV infection in the mouth; common oral problems, including candidiasis, hairy leukoplakia, Kaposi's sarcoma, gingivitis and periodontitis, oral warts, herpes, and recurrent oral ulcers; the importance of weekly self-examination of the mouth, face and neck; how to examine the mouth, including the floor and roof of mouth, the tongue, the cheeks, and the lips and gums; and confidentiality and discrimination issues. The brochure concludes with a list of three resource organizations to contact for information and patient advocacy. Full-color photographs of the oral problems described are included.

26 Periodontitis

·

Brush for 2 Source: [Alexandria, VA]: National Healthy Mothers, Healthy Babies Coalition. [ ca. 2000]. 1 fact sheet (4 pp.), 1 brochure (2 pp.), 1 poster, 1 order form. Contact: Available from Leslie Dunne, National Healthy Mothers, Healthy Babies Coalition, 121 North Washington Street, Suite 300, Alexandria, VA 22314. Telephone: (703) 836-6110 / fax: (703) 836-3470 / e-mail: [email protected] / Web site: www.hmhb.org. Available at no charge. Summary: This information package explains to health professionals the Brush for 2 Campaign, a promotion to encourage good oral health in pregnant women to prevent preterm, low-birthweight babies that can be associated with severe gum disease (periodontitis). The package includes a sample brochure and a poster for use with patients. Includes an order form for the brochure. The National Guideline Clearinghouse™

The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “periodontitis” or synonyms. The following was recently posted: ·

Parameter on "refractory" periodontitis. Source: American Academy of Periodontology.; 1996 October (revised 2000 May); 2 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1553&sSearch_string=periodontitis

·

Parameter on aggressive periodontitis. Source: American Academy of Periodontology.; 1996 October (revised 2000 May); 3 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1556&sSearch_string=periodontitis

Guidelines 27

·

Parameter on chronic periodontitis with advanced loss of periodontal support. Source: American Academy of Periodontology.; 1996 October (revised 2000 May); 3 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1552&sSearch_string=periodontitis

·

Parameter on chronic periodontitis with slight to moderate loss of periodontal support. Source: American Academy of Periodontology.; 1996 October (revised 2000 May); 3 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1551&sSearch_string=periodontitis

·

Parameter on periodontitis.

occlusal

traumatism

in

patients

with

chronic

Source: American Academy of Periodontology.; 1996 October (revised 2000 May); 3 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1558&sSearch_string=periodontitis ·

Parameter on periodontitis associated with systemic conditions. Source: American Academy of Periodontology.; 1996 October (revised 2000 May); 4 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1559&sSearch_string=periodontitis

The NIH Search Utility After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to periodontitis. The drawbacks of this approach are that the information is not organized by theme and that the references are often a

28 Periodontitis

mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for relatively rare or specific disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html.

NORD (The National Organization of Rare Disorders, Inc.) NORD provides an invaluable service to the public by publishing, for a nominal fee, short yet comprehensive guidelines on over 1,000 diseases. NORD primarily focuses on rare diseases that might not be covered by the previously listed sources. NORD’s Web address is www.rarediseases.org. To see if a recent fact sheet has been published on periodontitis, simply go to the following hyperlink: http://www.rarediseases.org/cgibin/nord/alphalist. A complete guide on periodontitis can be purchased from NORD for a nominal fee.

Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats

·

drkoop.comÒ: http://www.drkoop.com/conditions/ency/index.html

·

Family Village: http://www.familyvillage.wisc.edu/specific.htm

·

Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/

·

Med Help International: http://www.medhelp.org/HealthTopics/A.html

·

Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/

·

Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/

·

WebMDÒHealth: http://my.webmd.com/health_topics

Guidelines 29

Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter: Antibiotic: A chemical substance produced by a microorganism which has the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Antibiotics: Substances produced by microorganisms that can inhibit or suppress the growth of other microorganisms. [NIH] Antidepressant: An agent that stimulates the mood of a depressed patient, including tricyclic antidepressants and monoamine oxidase inhibitors. [EU] Antimicrobial: Killing microorganisms, or suppressing their multiplication or growth. [EU] Antiseptic: A substance that inhibits the growth and development of microorganisms without necessarily killing them. [EU] Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Candidiasis: Infection with a fungus of the genus Candida. It is usually a superficial infection of the moist cutaneous areas of the body, and is generally caused by C. albicans; it most commonly involves the skin (dermatocandidiasis), oral mucous membranes (thrush, def. 1), respiratory tract (bronchocandidiasis), and vagina (vaginitis). Rarely there is a systemic infection or endocarditis. Called also moniliasis, candidosis, oidiomycosis, and formerly blastodendriosis. [EU] Cataract: An opacity, partial or complete, of one or both eyes, on or in the lens or capsule, especially an opacity impairing vision or causing blindness. The many kinds of cataract are classified by their morphology (size, shape, location) or etiology (cause and time of occurrence). [EU] Chlorhexidine: Disinfectant and topical anti-infective agent used also as mouthwash to prevent oral plaque. [NIH] Chronic: Persisting over a long period of time. [EU] Constipation: Infrequent or difficult evacuation of the faeces. [EU] Contraceptive: conception. [EU]

An agent that diminishes the likelihood of or prevents

30 Periodontitis

Dentures: An appliance used as an artificial or prosthetic replacement for missing teeth and adjacent tissues. It does not include crowns, dental abutments, nor tooth, artificial. [NIH] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Digestion: The process of breakdown of food for metabolism and use by the body. [NIH] Doxycycline: A synthetic tetracycline derivative with a range of antimicrobial activity and mode of action similar to that of tetracycline, but more effective against many species. Animal studies suggest that it may cause less tooth staining than other tetracyclines. [NIH] Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Gelatin: A product formed from skin, white connective tissue, or bone collagen. It is used as a protein food adjuvant, plasma substitute, hemostatic, suspending agent in pharmaceutical preparations, and in the manufacturing of capsules and suppositories. [NIH] Gingivitis: Inflammation of the gingivae. Gingivitis associated with bony changes is referred to as periodontitis. Called also oulitis and ulitis. [EU] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Heartburn: Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. [NIH] Herpes: Any inflammatory skin disease caused by a herpesvirus and characterized by the formation of clusters of small vesicles. When used alone, the term may refer to herpes simplex or to herpes zoster. [EU] Inflammation: A pathological process characterized by injury or destruction of tissues caused by a variety of cytologic and chemical reactions. It is

Guidelines 31

usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Intestines: The section of the alimentary canal from the stomach to the anus. It includes the large intestine and small intestine. [NIH] Irritants: Drugs that act locally on cutaneous or mucosal surfaces to produce inflammation; those that cause redness due to hyperemia are rubefacients; those that raise blisters are vesicants and those that penetrate sebaceous glands and cause abscesses are pustulants; tear gases and mustard gases are also irritants. [NIH] Ligament: A band of fibrous tissue that connects bones or cartilages, serving to support and strengthen joints. [EU] Ligaments: Shiny, flexible bands of fibrous tissue connecting together articular extremities of bones. They are pliant, tough, and inextensile. [NIH] Microspheres: Small uniformly-sized spherical particles frequently labeled with radioisotopes or various reagents acting as tags or markers. [NIH] Minocycline: A semisynthetic antibiotic effective against tetracyclineresistant staphylococcus infections. [NIH] Mucus: The free slime of the mucous membranes, composed of secretion of the glands, along with various inorganic salts, desquamated cells, and leucocytes. [EU] Nausea: An unpleasant sensation, vaguely referred to the epigastrium and abdomen, and often culminating in vomiting. [EU] Nephropathy: Disease of the kidneys. [EU] Neuropathy: A general term denoting functional disturbances and/or pathological changes in the peripheral nervous system. The etiology may be known e.g. arsenical n., diabetic n., ischemic n., traumatic n.) or unknown. Encephalopathy and myelopathy are corresponding terms relating to involvement of the brain and spinal cord, respectively. The term is also used to designate noninflammatory lesions in the peripheral nervous system, in contrast to inflammatory lesions (neuritis). [EU] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Puberty: The period during which the secondary sex characteristics begin to develop and the capability of sexual reproduction is attained. [EU] Refractory: Not readily yielding to treatment. [EU] Regeneration: The natural renewal of a structure, as of a lost tissue or part. [EU]

Retinopathy: 1. retinitis (= inflammation of the retina). 2. retinosis (= degenerative, noninflammatory condition of the retina). [EU]

32 Periodontitis

Saliva: The clear, viscous fluid secreted by the salivary glands and mucous glands of the mouth. It contains mucins, water, organic salts, and ptylin. [NIH] Sarcoma: A tumour made up of a substance like the embryonic connective tissue; tissue composed of closely packed cells embedded in a fibrillar or homogeneous substance. Sarcomas are often highly malignant. [EU] Stomach: An organ of digestion situated in the left upper quadrant of the abdomen between the termination of the esophagus and the beginning of the duodenum. [NIH] Tetracycline: An antibiotic originally produced by Streptomyces viridifaciens, but used mostly in synthetic form. It is an inhibitor of aminoacyl-tRNA binding during protein synthesis. [NIH] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Toxins: Specific, characterizable, poisonous chemicals, often proteins, with specific biological properties, including immunogenicity, produced by microbes, higher plants, or animals. [NIH] Ulcer: A local defect, or excavation, of the surface of an organ or tissue; which is produced by the sloughing of inflammatory necrotic tissue. [EU] Warts: Benign epidermal proliferations or tumors; some are viral in origin. [NIH]

Seeking Guidance 33

CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with periodontitis. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.8 In addition to support groups, your dentist can be a valuable source of guidance and support. Therefore, finding a dentist that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with periodontitis. The chapter ends with a discussion on how to find a dentist or oral surgeon that is right for you.

Associations and Periodontitis As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of an illness can be as taxing as the physical side.9 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, your expectations, and how well you cope with your condition can all Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 9 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 8

34 Periodontitis

influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information, by consulting all of them, you will have nearly exhausted all sources for patient associations.

The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about periodontitis. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797.

DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “periodontitis” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations. The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “periodontitis”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then, select your preferred language and the format option “Organization Resource Sheet.” By making

Seeking Guidance 35

these selections and typing in “periodontitis” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with periodontitis. You should check back periodically with this database since it is updated every 3 months. The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option called “Organizational Database (ODB)” and type “periodontitis” (or a synonym) in the search box.

Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMDÒ, for example, offers such a service at their Web site: http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your dentist or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective.

Finding Dentists One of the most important aspects of your treatment will be the relationship between you and your dentist or specialist. All patients with periodontitis must go through the process of selecting a dentist. While this process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:10 ·

If you are in a managed care plan, check the plan's list of dentists first.

·

Ask dentists or other health professionals who work with dentists, such as dental assistants and oral surgeons, for referrals.

10

This section is adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

36 Periodontitis

·

Call a dentist referral service, but keep in mind that these services refer you to dentists who pay to be members. The services do not have information on the quality of care that these dentists provide.

·

Some local dental societies offer lists of member dentists. Again, these lists do not have information on the quality of care that these dentists provide.

Additional steps you can take to locate dentists include the following: ·

Check with the associations listed earlier in this chapter.

·

You can log on to the American Dental Association’s “Find a Dentist” Web site at http://www.ada.org/public/disclaimer.html.

·

Contact the dental organization in your State. Information on how to find the dental organization in your State is available on the ADA’s Web site: http://www.ada.org/ada/resources/societies/searchconst.asp.

If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of physicians with expertise in various rare diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.

Selecting Your Dentist11 When you have compiled a list of prospective dentists, call each of their offices. First, ask if the dentist accepts your health insurance plan and if he or she is taking new patients. If the dentist is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen dentist. During the first visit you will have the opportunity to evaluate your dentist and to find out if you feel comfortable with him or her. Ask yourself, did the dentist: ·

Give me a chance to ask questions about periodontitis?

·

Really listen to my questions?

·

Answer in terms I understood?

·

Show respect for me?

·

Ask me questions?

11 This

section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

Seeking Guidance 37

·

Make me feel comfortable?

·

Address the health problem(s) I came with?

·

Ask me my preferences about different kinds of treatments for periodontitis?

·

Spend enough time with me?

Trust your instincts when deciding if the dentist is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your dentist to get to know each other.

Working with Your Dentist12 Research has shown that patients who have good relationships with their dentists tend to be more satisfied with their care and have better results. Here are some tips to help you and your dentist become partners: ·

You know important things about your symptoms and your health history. Tell your dentist what you think he or she needs to know.

·

It is important to tell your dentist personal information, even if it makes you feel embarrassed or uncomfortable.

·

Bring a “health history” list with you (and keep it up to date).

·

Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications.

·

Tell your dentist about any natural or alternative medicines you are taking.

·

Bring other medical information, such as x-ray films, test results, and medical records.

·

Ask questions. If you don't, your dentist will assume that you understood everything that was said.

·

Write down your questions before your visit. List the most important ones first to make sure that they are addressed.

This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

12

38 Periodontitis

·

Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers.

·

Ask your dentist to draw pictures if you think that this would help you understand.

·

Take notes. Some dentists do not mind if you bring a tape recorder to help you remember things, but always ask first.

·

Let your dentist know if you need more time. If there is not time that day, perhaps you can speak to a nurse or dental assistant on staff or schedule a telephone appointment.

·

Take information home. Ask for written instructions. Your dentist may also have brochures and audio and videotapes that can help you.

·

After leaving the dentist's office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your dentist, call for your test results. If your dentist recommended that you have certain tests, schedule an appointment to get them done. If your dentist said you should see an additional specialist, make an appointment.

By following these steps, you will enhance the relationship you will have with your dentist.

Seeking Guidance 39

Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:13 ·

Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html

·

Choosing a Oral Surgeon or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html

·

Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html

You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.

13

Clinical Trials 41

CHAPTER 3. CLINICAL TRIALS AND PERIODONTITIS Overview Very few medical conditions have a single treatment. The basic treatment guidelines that your healthcare provider has discussed with you, or those that you have found using the techniques discussed in Chapter 1, may provide you with all that you will require. For some patients, current treatments can be enhanced with new or innovative techniques currently under investigation. In this chapter, we will describe how clinical trials work and show you how to keep informed of trials concerning periodontitis.

What Is a Clinical Trial?14 Clinical trials involve the participation of people in medical research. Most medical research begins with studies in test tubes and on animals. Treatments that show promise in these early studies may then be tried with people. The only sure way to find out whether a new treatment is safe, effective, and better than other treatments for periodontitis is to try it on patients in a clinical trial.

The discussion in this chapter has been adapted from the NIH and the NEI: www.nei.nih.gov/netrials/ctivr.htm.

14

42 Periodontitis

What Kinds of Clinical Trials Are There? Clinical trials are carried out in three phases: ·

Phase I. Researchers first conduct Phase I trials with small numbers of patients and healthy volunteers. If the new treatment is a medication, researchers also try to determine how much of it can be given safely.

·

Phase II. Researchers conduct Phase II trials in small numbers of patients to find out the effect of a new treatment on periodontitis.

·

Phase III. Finally, researchers conduct Phase III trials to find out how new treatments for periodontitis compare with standard treatments already being used. Phase III trials also help to determine if new treatments have any side effects. These trials--which may involve hundreds, perhaps thousands, of people--can also compare new treatments with no treatment. How Is a Clinical Trial Conducted?

Various organizations support clinical trials at medical centers, hospitals, universities, and oral surgeons' offices across the United States. The “principal investigator” is the researcher in charge of the study at each facility participating in the clinical trial. Most clinical trial researchers are medical doctors, academic researchers, and specialists. The “clinic coordinator” knows all about how the study works and makes all the arrangements for your visits. All oral surgeons and researchers who take part in the study on periodontitis carefully follow a detailed treatment plan called a protocol. This plan fully explains how the healthcare providers will treat you in the study. The “protocol” ensures that all patients are treated in the same way, no matter where they receive care. Clinical trials are controlled. This means that researchers compare the effects of the new treatment with those of the standard treatment. In some cases, when no standard treatment exists, the new treatment is compared with no treatment. Patients who receive the new treatment are in the treatment group. Patients who receive a standard treatment or no treatment are in the “control” group. In some clinical trials, patients in the treatment group get a new medication while those in the control group get a placebo. A placebo is a harmless substance, a “dummy” pill, that has no effect on periodontitis. In other clinical trials, where a new surgery or device (not a medicine) is being tested, patients in the control group may receive a “sham treatment.” This

Clinical Trials 43

treatment, like a placebo, has no effect on periodontitis and does not harm patients. Researchers assign patients “randomly” to the treatment or control group. This is like flipping a coin to decide which patients are in each group. If you choose to participate in a clinical trial, you will not know which group you will be appointed to. The chance of any patient getting the new treatment is about 50 percent. You cannot request to receive the new treatment instead of the placebo or sham treatment. Often, you will not know until the study is over whether you have been in the treatment group or the control group. This is called a “masked” study. In some trials, neither researchers nor patients know who is getting which treatment. This is called a “double masked” study. These types of trials help to ensure that the perceptions of the patients or researchers will not affect the study results. Natural History Studies Unlike clinical trials in which patient volunteers may receive new treatments, natural history studies provide important information to researchers on how periodontitis develops over time. A natural history study follows patient volunteers to see how factors such as age, sex, race, or family history might make some people more or less at risk for periodontitis. A natural history study may also tell researchers if diet, lifestyle, or occupation affects how a disease or disorder develops and progresses. Results from these studies provide information that helps answer questions such as: How fast will a disease or disorder usually progress? How bad will the condition become? Will treatment be needed? What Is Expected of Patients in a Clinical Trial? Not everyone can take part in a clinical trial for a specific disease or disorder. Each study enrolls patients with certain features or eligibility criteria. These criteria may include the type and stage of disease or disorder, as well as, the age and previous treatment history of the patient. You or your dentist can contact the sponsoring organization to find out more about specific clinical trials and their eligibility criteria. If you are interested in joining a clinical trial, your dentist must contact one of the trial's investigators and provide details about your diagnosis and medical history. If you participate in a clinical trial, you may be required to have a number of medical tests. You may also need to take medications and/or undergo

44 Periodontitis

surgery. Depending upon the treatment and the examination procedure, you may be required to receive inpatient hospital care. Or, you may have to return to the medical facility for follow-up examinations. These exams help find out how well the treatment is working. Follow-up studies can take months or years. However, the success of the clinical trial often depends on learning what happens to patients over a long period of time. Only patients who continue to return for follow-up examinations can provide this important long-term information.

Recent Trials on Periodontitis The National Institutes of Health and other organizations sponsor trials on various diseases and disorders. Because funding for research goes to the medical areas that show promising research opportunities, it is not possible for the NIH or others to sponsor clinical trials for every disease and disorder at all times. The following lists recent trials dedicated to periodontitis.15 If the trial listed by the NIH is still recruiting, you may be eligible. If it is no longer recruiting or has been completed, then you can contact the sponsors to learn more about the study and, if published, the results. Further information on the trial is available at the Web site indicated. Please note that some trials may no longer be recruiting patients or are otherwise closed. Before contacting sponsors of a clinical trial, consult with your dentist who can help you determine if you might benefit from participation. ·

Complementary Naturopathic Medicine for Periodontitis Condition(s): Periodontitis Study Status: This study is not yet open for patient recruitment. Sponsor(s): National Center for Complementary and Alternative Medicine (NCCAM) Purpose - Excerpt: This study aims to assess selected naturopathic medicines for adult periodontitis and to identify variables that influence successful outcomes when traditional and alternative approaches to preventing and treating periodontal diseases are combined. Collaboration between Kaiser Permanente, Oregon Health Science University and the National College of Naturopathic Medicine provides an unsurpassed environment for such investigations. Periodontitis is a major cause of tooth loss and negatively impacts systemic health. The limitations of traditional periodontal treatment have compelled scientists and clinicians to investigate new remedies, and naturopathic medicine holds several promising interventions. Because they are used to improve

15

These are listed at www.ClinicalTrials.gov.

Clinical Trials 45

elements of host resistance that are known to be important in periodontal health and disease, three naturopathic medicines are potential adjuncts in preventing and treating periodontitis. Connective tissue components are enzymatically degraded in periodontitis. In naturopathy, Connective Tissue Nutrient Formula (CTNF) (vitamins A, C and D, glucosamine sulfate, oligoproanthocyanindins, copper, zinc, manganese, boron, silicon, magnesium, and calcium) is prescribed specifically to enhance the integrity of key connective tissue elements and improve their resistance to degradation. Periodontitis begins when permeability of the oral sulcular epithelium permits pathogenic bacterial components to invade deeper periodontal connective tissues. In naturopathy, glutamine is prescribed to reduce oral-intestinal epithelial membrane permeability. Chronic activation of the hypothalamic-pituitary-adrenal (HPA) axis during the stress response, is a risk factor for periodontitis. Adaptogenic herbs (AH) (Panax ginseng, Withania somnifera and Eleutherococcus senticosus) are prescribed by naturopathic physicians to reverse the impact of bacterial and psychosocial stressors. Because glutamine, CTNF and AH target pathophysiologic mechanisms known to underline periodontitis, they are compelling candidates in clinical and mechanistic investigations of complementary medicine approaches to the management of periodontitis. Kaiser Permanente adult periodontitis patients will serve as subjects and receive standard periodontal treatment. Three of the four randomly assigned groups will also receive supplements of glutamine, CTNF, or AH. We will determine the effects of these supplements on clinical outcomes (attachment loss, pocket depths, indicators of inflammation, plaque composition, need for periodontal surgery, acute periodontal problems, tooth loss). In addition to completing the battery of self-report measures (stress, coping, quality of life), study subjects will provide samples of blood, saliva, gingival cervicular fluid and bacterial dental plaque. These samples will be examined as part of the Laboratory Core to identify biologic and genetic characteristics that correlate with successful outcomes. Storage of portions of the samples will allow future examination of additional variables as part of the Developmental Projects carried out as the Craniofacial Complementary & Alternative Center is established and Phase III trials are undertaken. Phase(s): Phase II Study Type: Interventional Contact(s): Theresa Madden 1-503-494-8874 [email protected]; Oregon; The Oregon Health Sciences University (OHSU), Portland, Oregon, United States. Study chairs or principal investigators: Alex

46 Periodontitis

White, Principal Investigator; Center for Health Research, Kaiser Foundation Hospitals Web Site: http://clinicaltrials.gov/ct/gui/c/w2b/show/NCT00010634 ·

Treating Periodontal Infection Condition(s): Periodontal Disease; Diabetes Mellitus, Non-InsulinDependent Study Status: This study is not yet open for patient recruitment. Sponsor(s): National Institute of Dental and Craniofacial Research (NIDCR) Purpose - Excerpt: The purpose of this project is to obtain preliminary data about the effects of treating periodontal infection on blood glucose control in people with type 2 diabetes. This is a pilot study which will provide important information that will help in the design of a full scale clinical trial. 45 subjects with type 2 diabetes and periodontal disease will be treated and evaluated at 3-month intervals for 15 months to obtain information regarding the effects of the periodontal treatment procedures on changes in hemoglobin A1c (HbA1c). This project will also provide an opportunity to explore the effects of treating periodontal infection on levels of periodontitis- and glucose metabolism-related inflammatory mediators (TNFa,IL-1B,IL-6) and levels of serum cholesterol, triglyceride and lipids in patients with type 2 diabetes mellitus. The periodontal treatment that will be evaluated will include ultrasonic scaling, local antimicrobial treatment and oral systemic antibiotics. If results provide significant evidence that treating periodontal infection contributes to improved blood glucose control, then diagnosis and treatment of periodontal infection in patients with type 2 diabetes could be an important component in management of type 2 diabetes. Phase(s): Phase II Study Type: Interventional Contact(s): George W. Taylor, DMD, DrPH 734-764-1737. Study chairs or principal investigators: George W. Taylor, DMD, Dr.PH, Principal Investigator; University of Michigan Web Site: http://clinicaltrials.gov/ct/gui/c/w2b/show/NCT00016835

Clinical Trials 47

Benefits and Risks16 What Are the Benefits of Participating in a Clinical Trial? If you are interested in a clinical trial, it is important to realize that your participation can bring many benefits to you and society at large: ·

A new treatment could be more effective than the current treatment for periodontitis. Although only half of the participants in a clinical trial receive the experimental treatment, if the new treatment is proved to be more effective and safer than the current treatment, then those patients who did not receive the new treatment during the clinical trial may be among the first to benefit from it when the study is over.

·

If the treatment is effective, then it may improve health or prevent diseases or disorders.

·

Clinical trial patients receive the highest quality of medical care. Experts watch them closely during the study and may continue to follow them after the study is over.

·

People who take part in trials contribute to scientific discoveries that may help other people with periodontitis. In cases where certain diseases or disorders run in families, your participation may lead to better care or prevention for your family members. The Informed Consent

Once you agree to take part in a clinical trial, you will be asked to sign an “informed consent.” This document explains a clinical trial's risks and benefits, the researcher’s expectations of you, and your rights as a patient.

What Are the Risks? Clinical trials may involve risks as well as benefits. Whether or not a new treatment will work cannot be known ahead of time. There is always a chance that a new treatment may not work better than a standard treatment. There is also the possibility that it may be harmful. The treatment you receive may cause side effects that are serious enough to require medical attention. This section has been adapted from ClinicalTrials.gov, a service of the National Institutes of Health: http://www.clinicaltrials.gov/ct/gui/c/a1r/info/whatis?JServSessionIdzone_ct=9jmun6f291. 16

48 Periodontitis

How Is Patient Safety Protected? Clinical trials can raise fears of the unknown. Understanding the safeguards that protect patients can ease some of these fears. Before a clinical trial begins, researchers must get approval from their hospital's Institutional Review Board (IRB), an advisory group that makes sure a clinical trial is designed to protect patient safety. During a clinical trial, researchers will closely watch you to see if the treatment is working and if you are experiencing any side effects. All the results are carefully recorded and reviewed. In many cases, experts from the Data and Safety Monitoring Committee carefully monitor each clinical trial and can recommend that a study be stopped at any time. You will only be asked to take part in a clinical trial as a volunteer giving informed consent. What Are a Patient's Rights in a Clinical Trial? If you are eligible for a clinical trial, you will be given information to help you decide whether or not you want to participate. As a patient, you have the right to: ·

Information on all known risks and benefits of the treatments in the study.

·

Know how the researchers plan to carry out the study, for how long, and where.

·

Know what is expected of you.

·

Know any costs involved for you or your insurance provider.

·

Know before any of your medical or personal information is shared with other researchers involved in the clinical trial.

·

Talk openly with healthcare providers and ask any questions.

After you join a clinical trial, you have the right to: ·

Leave the study at any time. Participation is strictly voluntary. However, you should not enroll if you do not plan to complete the study.

·

Receive any new information about the new treatment.

·

Continue to ask questions and get answers.

·

Maintain your privacy. Your name will not appear in any reports based on the study.

Clinical Trials 49

·

Know whether you participated in the treatment group or the control group (once the study has been completed).

What about Costs? In some clinical trials, the research facility pays for treatment costs and other associated expenses. You or your insurance provider may have to pay for costs that are considered standard care. These things may include inpatient hospital care, laboratory and other tests, and medical procedures. You also may need to pay for travel between your home and the clinic. You should find out about costs before committing to participation in the trial. If you have health insurance, find out exactly what it will cover. If you don't have health insurance, or if your insurance company will not cover your costs, talk to the clinic staff about other options for covering the cost of your care. What Should You Ask before Deciding to Join a Clinical Trial? Questions you should ask when thinking about joining a clinical trial include the following: ·

What is the purpose of the clinical trial?

·

What are the standard treatments for periodontitis? Why do researchers think the new treatment may be better? What is likely to happen to me with or without the new treatment?

·

What tests and treatments will I need? Will I need surgery? Medication? Hospitalization?

·

How long will the treatment last? How often will I have to come back for follow-up exams?

·

What are the treatment's possible benefits to my condition? What are the short- and long-term risks? What are the possible side effects?

·

Will the treatment be uncomfortable? Will it make me feel sick? If so, for how long?

·

How will my health be monitored?

·

Where will I need to go for the clinical trial? How will I get there?

·

How much will it cost to be in the study? What costs are covered by the study? How much will my health insurance cover?

·

Will I be able to see my own dentist? Who will be in charge of my care?

50 Periodontitis

·

Will taking part in the study affect my daily life? Do I have time to participate?

·

How do I feel about taking part in a clinical trial? Are there family members or friends who may benefit from my contributions to new medical knowledge?

Keeping Current on Clinical Trials Various government agencies maintain databases on trials. The U.S. National Institutes of Health, through the National Library of Medicine, has developed ClinicalTrials.gov to provide patients, family members, and healthcare providers with current information about clinical research across the broadest number of diseases and conditions. The site was launched in February 2000 and currently contains approximately 5,700 clinical studies in over 59,000 locations worldwide, with most studies being conducted in the United States. ClinicalTrials.gov receives about 2 million hits per month and hosts approximately 5,400 visitors daily. To access this database, simply go to their Web site (www.clinicaltrials.gov) and search by “periodontitis” (or synonyms). While ClinicalTrials.gov is the most comprehensive listing of NIH-supported clinical trials available, not all trials are in the database. The database is updated regularly, so clinical trials are continually being added. The following is a list of specialty databases affiliated with the National Institutes of Health that offer additional information on trials: ·

For clinical studies at the Warren Grant Magnuson Clinical Center located in Bethesda, Maryland, visit their Web site: http://clinicalstudies.info.nih.gov/

·

For clinical studies conducted at the Bayview Campus in Baltimore, Maryland, visit their Web site: http://www.jhbmc.jhu.edu/studies/index.html

General References The following references describe clinical trials and experimental medical research. They have been selected to ensure that they are likely to be available from your local or online bookseller or university medical library. These references are usually written for healthcare professionals, so you may

Clinical Trials 51

consider consulting with a librarian or bookseller who might recommend a particular reference. The following includes some of the most readily available references (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

A Guide to Patient Recruitment : Today's Best Practices & Proven Strategies by Diana L. Anderson; Paperback - 350 pages (2001), CenterWatch, Inc.; ISBN: 1930624115; http://www.amazon.com/exec/obidos/ASIN/1930624115/icongroupinterna

·

A Step-By-Step Guide to Clinical Trials by Marilyn Mulay, R.N., M.S., OCN; Spiral-bound - 143 pages Spiral edition (2001), Jones & Bartlett Pub; ISBN: 0763715697; http://www.amazon.com/exec/obidos/ASIN/0763715697/icongroupinterna

·

The CenterWatch Directory of Drugs in Clinical Trials by CenterWatch; Paperback - 656 pages (2000), CenterWatch, Inc.; ISBN: 0967302935; http://www.amazon.com/exec/obidos/ASIN/0967302935/icongroupinterna

·

The Complete Guide to Informed Consent in Clinical Trials by Terry Hartnett (Editor); Paperback - 164 pages (2000), PharmSource Information Services, Inc.; ISBN: 0970153309; http://www.amazon.com/exec/obidos/ASIN/0970153309/icongroupinterna

·

Dictionary for Clinical Trials by Simon Day; Paperback - 228 pages (1999), John Wiley & Sons; ISBN: 0471985961; http://www.amazon.com/exec/obidos/ASIN/0471985961/icongroupinterna

·

Extending Medicare Reimbursement in Clinical Trials by Institute of Medicine Staff (Editor), et al; Paperback 1st edition (2000), National Academy Press; ISBN: 0309068886; http://www.amazon.com/exec/obidos/ASIN/0309068886/icongroupinterna

·

Handbook of Clinical Trials by Marcus Flather (Editor); Paperback (2001), Remedica Pub Ltd; ISBN: 1901346293; http://www.amazon.com/exec/obidos/ASIN/1901346293/icongroupinterna

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Boron: Boron. A trace element with the atomic symbol B, atomic number 5, and atomic weight 10.81. Boron-10, an isotope of boron, is used as a neutron absorber in boron neutron capture therapy. [NIH] Cholesterol: The principal sterol of all higher animals, distributed in body

52 Periodontitis

tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Epithelium: The covering of internal and external surfaces of the body, including the lining of vessels and other small cavities. It consists of cells joined by small amounts of cementing substances. Epithelium is classified into types on the basis of the number of layers deep and the shape of the superficial cells. [EU] Ginseng: An araliaceous genus of plants that contains a number of pharmacologically active agents used as stimulants, sedatives, and tonics, especially in traditional medicine. [NIH] Glutamine: A non-essential amino acid present abundantly throught the body and is involved in many metabolic processes. It is synthesized from glutamic acid and ammonia. It is the principal carrier of nitrogen in the body and is an important energy source for many cells. [NIH] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Lipid: Any of a heterogeneous group of flats and fatlike substances characterized by being water-insoluble and being extractable by nonpolar (or fat) solvents such as alcohol, ether, chloroform, benzene, etc. All contain as a major constituent aliphatic hydrocarbons. The lipids, which are easily stored in the body, serve as a source of fuel, are an important constituent of cell structure, and serve other biological functions. Lipids may be considered to include fatty acids, neutral fats, waxes, and steroids. Compound lipids comprise the glycolipids, lipoproteins, and phospholipids. [EU] Mediator: An object or substance by which something is mediated, such as (1) a structure of the nervous system that transmits impulses eliciting a specific response; (2) a chemical substance (transmitter substance) that induces activity in an excitable tissue, such as nerve or muscle; or (3) a substance released from cells as the result of the interaction of antigen with antibody or by the action of antigen with a sensitized lymphocyte. [EU] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Silicon: Silicon. A trace element that constitutes about 27.6% of the earth's crust in the form of silicon dioxide. It does not occur free in nature. Silicon has the atomic symbol Si, atomic number 14, and atomic weight 28.09. [NIH]

53

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL

ABOUT PART II In Part II, we introduce you to additional resources and advanced research on periodontitis. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on periodontitis. In Part II, as in Part I, our objective is not to interpret the latest advances on periodontitis or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with periodontitis is suggested.

Studies 55

CHAPTER 4. STUDIES ON PERIODONTITIS Overview Every year, academic studies are published on periodontitis or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or healthcare providers. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on periodontitis. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on periodontitis and teach you how to keep current on new studies as they are published or undertaken by the scientific community.

The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and periodontitis, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the

56 Periodontitis

format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type in “periodontitis” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is a sample of what you can expect from this type of search: ·

Relationship Between Bone Mineral Density and Periodontitis in Postmenopausal Women Source: Journal of Periodontology. 71(9): 1492-1498. September 2000. Contact: Available from American Academy of Periodontology. Suite 800, 737 North Michigan Avenue, Chicago, IL 60611-2690. (312) 573-3220. Fax (312) 573-3225. Summary: Systemic bone loss has been proposed as a risk factor for periodontal disease; however, the relationship between these two diseases is still not clear. This article reports on a study undertaken to assess the relationship between systemic bone density and periodontal disease (controlling for known cofounders). The study population included 70 postmenopausal Caucasian women aged 51 to 78 years (mean 62.10 years plus or minus 7.1 years). Skeletal bone mineral density (BMD) was assessed and periodontal disease severity was represented by clinical attachment loss (CAL) and interproximal alveolar bone loss (ABL). Other measures of periodontal status included probing depth (PD), supragingival plaque, gingival (gum) bleeding on probing, and calculus. Results showed that the mean alveolar bone loss was significantly correlated with BMD of the trochanter (the trunk end of the femur), Ward's triangle, and total regions of the femur (thigh bone). Mean CAL appeared to be related to BMD consistently at all regions of the skeleton, although the association did not reach statistical significance. The authors conclude that skeletal BMD is related to interproximal alveolar bone loss and, to a lesser extent, to clinical attachment loss, implicating postmenopausal osteopenia (subnormally mineralized bone) as a risk indicator for periodontal disease in postmenopausal Caucasian women. 1 figure. 4 tables. 45 references.

·

Periodontitis and Systemic Disease Source: New York State Dental Journal. 65(8): 30-32. October 1999.

Studies 57

Contact: Available from Dental Society of the State of New York. 7 Elk Street, Albany, NY 12207. (518) 465-0044. Summary: Recent evidence suggests that periodontal disease may play an etiologic (causative) role in the pathogenesis of several systemic illnesses, such as cardiovascular disease, diabetes mellitus, and preterm birth. This article reviews proposed mechanisms for such associations in these three situations and outlines studies currently aimed at clarifying this issue. The authors note that the widespread and growing interest in the relationship between periodontal disease and systemic illness underlies the importance of regular oral examinations and prompt dental and periodontal treatment. The authors predict that, as the mechanisms of this relationship becomes clearer, dentists' services to their patients will be broadened and consultation with the patients' physicians will be more frequent. 3 figures. 13 references. ·

Severe Periodontitis and Risk for Poor Glycemic Control in Patients with Non-Insulin-Dependent Diabetes Mellitus Source: Journal of Periodontology. 67(Supplement 10): 1085-1093. October 1996. Contact: Available from Journal of Periodontology. 737 North Michigan Avenue, Suite 800, Chicago, IL 60611-2690. (312) 573-3220. Fax (312) 5733225. Summary: This article reports on a study that tested the hypothesis that severe periodontitis in persons with noninsulin-dependent diabetes mellitus (NIDDM, or Type II) increases the risk of poor glycemic control. Data from a longitudinal study of residents of the Gila River Indian Community (most of whom are from the Pima tribe) were analyzed for dentate subjects aged 18 to 67. Severe periodontitis was specified in two ways for separate analysis: as baseline periodontal attachment loss of 6 mm or more on at least one index tooth, and baseline radiographic bone loss of 50 percent or more on at least one tooth. Clinical data for loss of periodontal attachment were available for 80 subjects; radiographic bone loss data were available for 88 subjects. Poor glycemic control was specified as the presence of HbA1 (glycosylated hemoglobin) of 9 percent or more at follow-up. Severe periodontitis at baseline was associated with increased risk of poor glycemic control at follow-up. Other statistically significant covariates were baseline age, level of glycemic control at baseline, having more severe NIDDM at baseline, duration of NIDDM, and smoking at baseline. These results support the conclusion that periodontitis is a risk factor for poor glycemic control and suggest that physicians treating patients with NIDDM should be alert to signs of severe periodontitis. 4 tables. 76 references. (AA-M).

58 Periodontitis

·

Periodontitis and Tooth Loss: Comparing Diabetics with the General Population Source: Journal of the American Dental Association. 124(12): 71-76. December 1993. Contact: Available from American Dental Association Publishing Company, Inc. Subscription Department, 211 East Chicago Avenue, Chicago, IL 60611. (312) 440-2867. Fax (312) 440-3538. Summary: People with diabetes may be at an increased risk for periodontal disease. This article reviews a study that investigated the periodontal health of adults with diabetes. Metabolic control of diabetes was measured with glycosylated hemoglobin (HbA1c) testing. Data for the group with diabetes was compared with the data for a group of employed adults representing the general population (n-15, 132), which was obtained in a national survey conducted in 1985 and 1986 by the National Institute of Dental Research. Results showed that while tooth loss and gingival attachment was similar for both groups, people with diabetes had a greater prevalence and extent of periodontal pockets. The authors conclude that poor metabolic control, calculus, and having had diabetes for a number of years may increase the risk of periodontitis. However, people who control both their diabetes and oral health through self care and regular professional care are at much lower risk for periodontitis and tooth loss. 3 tables. 12 references. (AA-M).

·

Smoking Affects the Subgingival Microflora in Periodontitis Source: Journal of Periodontology. 72(5): 666-671. May 2001. Contact: Available from American Academy of Periodontology. 737 North Michigan Avenue, Suite 800, Chicago, IL 60611-2690. (312) 5733220. Fax (312) 573-3225. Summary: Tobacco smoking has been identified as one major risk factor for destructive periodontal disease. Scaling and root planing have been shown to be less effective in smokers with periodontitis. This article reports on a study to compare the subgingival microbial flora of treated and untreated smokers and non smokers. Four independent adult patient groups with periodontitis were included in this investigation: 88 untreated smokers (US); 90 untreated nonsmokers (UNS); 119 treated nonsmokers (TNS); and 171 treated smokers (TS). Clinical variables included cumulative plaque index (CPI), probing depth (PD), clinical attachment level (CAL), cumulative bleeding index (CBI), and cumulative suppuration index (CSI). Paper point samples from the deepest bleeding pocket in each quadrant of the dentition were analyzed for the presence and levels of 6 periodontal bacterial pathogens using anaerobic culture

Studies 59

techniques. US showed a higher mean cumulative plaque index than UNS (3.5 versus 2.7). Mean PD and mean CAL were higher in the TS in comparison to the TNS group (7.0 versus 6.6 m and 5.6 versus 4.7 mm, respectively). Microbiological characteristics of US were a higher prevalence of Prevotella intermedia nigrescens and higher mean levels of Peptostreptococcus micros (Pm) and Fusobacterium necleatum (Fn). TS patients were characterized by higher prevalence of Bacteroides forsythus (Bf), Pm, and Campylobacter rectus (Cr) and higher mean levels of Pm and Fn. The relative risk to be infected with Bf, Pm, and Cr was statistically higher in smokers. The authors conclude that smoking is a determining factor for the composition of the subgingival microflora in adult patients with periodontitis and may select for a specific cluster of peridontal pathogens, notably Bf, Pm, Fn, and Cr. On the basis of these observations, smoking, among other criteria, may be one parameter to use in deciding to treat refractory (resistant to treatment) periodontitis in smokers with a systematic antibiotic therapy directed specifically against smoking associated periodontal bacteria. 1 figure. 4 tables. 30 references. ·

Relationship of Periodontopathic Bacteria with Early-Onset Periodontitis in Down's Syndrome Source: Journal of Periodontology. 72(3): 368-373. March 2001. Contact: Available from American Academy of Periodontology. 737 North Michigan Avenue, Suite 800, Chicago, IL 60611-2690. (312) 5733220. Fax (312) 573-3225. Summary: Down syndrome (DS) patients often develop severe early onset marginal periodontitis in early adulthood; however, there is little information available on the microbiology of DS periodontitis. This article reports on a study in which subgingival (under the gum) plaque specimens were taken from 67 DC young adults and 41 age matched systemically healthy individuals with mental disabilities (MD). The prevalence of 10 possible periodontal bacterial species was investigated in the subjects' plaque samples. Results showed that although DS subjects generally develop an earlier and more extensive periodontal breakdown than those with MD, no significant differences were observed in the bacterial profiles. The profiles of subjects with periodontitis were significant in DS, but not in MD. The prevalence of Porphyromonas gingivalis, Bacteroides forsythus, and Prevotella intermedia were significant in the DS periodontitis group, compared to DS gingivitis group. Moreover, the occurrence of P. gingivalis with the type II fimA genotype was significantly related to periodontitis in both DS and MD, with odds ratios in 6.32 and 12.03, respectively. These results suggest that early onset periodontitis in DS is mainly due to the more susceptible host

60 Periodontitis

for the causative microbial agents including P. gingivalis with type II fimA. 1 figure. 2 tables. 22 references. ·

Treatment of Aggressive Periodontitis by Osseointegrated Dental Implants. A Case Report Source: Journal of Periodontology. 72(3): 411-416. March 2001. Contact: Available from American Academy of Periodontology. 737 North Michigan Avenue, Suite 800, Chicago, IL 60611-2690. (312) 5733220. Fax (312) 573-3225. Summary: Generalized aggressive periodontitis is described as a clinical entity affecting both deciduous and permanent dentition with extensive alveolar bone loss, mobility, and exfoliation (loss) of all or many teeth. Controversy exists on the use of dental implants to restore missing dentition in younger patients. This article presents a case report of a patient diagnosed with aggressive periodontitis who has lost all but 4 of her teeth. Her personal and functional desires led the authors to include implant therapy in her treatment plan. The hematological data are presented, with an analysis of the patient's immunological profile. Dental implants were placed, and following 3 months of osseointegration (allowing the implants to integrate with the bone of the jaw), an implant supported prosthesis was completed. The patient was followed up for 36 months. The primary concern for placing dental implants in patients with aggressive periodontitis is whether the patient's quality of bone will maintain a healthy implant. The authors stress that this case report demonstrates an alternative treatment for rehabilitating dentition in a young patient treated for aggressive periodontitis. Similar case studies may help eliminate some of the controversy that exists regarding the use of dental implants in aggressive periodontitis patients. 5 figures. 2 tables. 37 references.

·

Relationship Between Rheumatoid Arthritis and Periodontitis Source: Journal of Periodontology. 72(6): 779-787. June 2001. Contact: Available from American Academy of Periodontology. 737 North Michigan Avenue, Suite 800, Chicago, IL 60611-2690. (312) 5733220. Fax (312) 573-3225. Summary: This article reports on a study undertaken to study a population of rheumatoid arthritis patients, determine the extent of their periodontal disease and correlate this with various indicators of rheumatoid arthritis. Consecutive patients (n = 65) attending a rheumatology clinic were examined for their levels of periodontitis and rheumatoid arthritis. A control group consisted of age and gender

Studies 61

matched people without rheumatoid arthritis. No differences were noted for the plaque and bleeding indices between the control and rheumatoid arthritis groups. The rheumatoid arthritis group did, however, have more missing teeth than the control group and a higher percentage of these subjects had deeper pocketing. When the percentage of bone loss was compared with various indicators of rheumatoid arthritis disease activity, it was found that swollen joints, health assessment questionnaire scores, levels of C reactive protein, and erythrocyte sedimentation rate were the principal parameters which could be associated with periodontal bone loss. The authors conclude that their results provide further evidence of a significant association between periodontitis and rheumatoid arthritis. This association may be a reflection of a common underlying disregulation of the inflammatory response in these people. 12 figures. 48 references. ·

Localized Aggressive Periodontitis in a Patient with Type 1 Diabetes Mellitus: A Case Report Source: Journal of Periodontology. 72(9): 1265-1270. September 2001. Contact: Available from American Academy of Periodontology. 737 North Michigan Avenue, Suite 800, Chicago, IL 60611-2690. (312) 5733220. Fax (312) 573-3225. Summary: Poor metabolic control of diabetes mellitus (DM) has often been associated with the severity of periodontal disease. This case report presents a 9 year old female with localized aggressive periodontitis who had a history of type 1 DM (diagnosed at age 3) and the outcome of her treatment. The patient had received medical, clinical, and radiographic periodontal examinations. Peripheral blood analysis was done as well. She had non surgical periodontal treatment, and medical management of her diabetes was performed at the same time. She was followed for 5 years. Medical examination revealed no pathological findings except for growth retardation. Laboratory tests showed that she had poor metabolic control, with 497 milligrams per deciliters fasting blood glucose and 15.6 percent HbA1c (a measure of blood glucose levels over a period of time). The random migration and neutrophil chemotasix were significantly reduced. Periodontal treatment and metabolic control of her diabetes resulted in significant improvement in her periodontal condition. No incipient periodontal breakdown was observed around the teeth after 5 years from baseline. This report demonstrates the effectiveness of periodontal therapy in the prevention of future periodontal breakdown in a systemically compromised patient. The authors conclude that in certain people who are predisposed to the aggressive forms of periodontitis, clinical and medical examinations and intervention to the

62 Periodontitis

systemic condition, in combination with periodontal treatment, are important in the management of these people. 5 figures. 3 tables. 38 references. ·

Smoking-Attributable Periodontitis in the United States: Findings from NHANES III Source: Journal of Periodontology. 71(5): 743-751. May 2000. Contact: Available from American Academy of Periodontology. Suite 800, 737 North Michigan Avenue, Chicago, IL 60611-2690. (312) 573-3220. Fax (312) 573-3225. Summary: This article reports on a study undertaken to examine the relationship between cigarette smoking and periodontitis, and to estimate the proportion of periodontitis in the United States adult population that is attributable to cigarette smoking. Data were derived from the Third National Health and Nutrition Examination Survey (NHANES III), a nationally representative multipurpose health survey conducted in 1988 to 1994. The authors found that 27.9 percent of dentate (with teeth) adults were current smokers and 23.3 percent were former smokers. Overall, 9.2 percent of dentate adults met the study's case definition for periodontitis, which projects to about 15 million cases of periodontitis among U.S. adults. Modeling with multiple logistic regression revealed that current smokers were about 4 times as likely as persons who had never smoked to have periodontitis (after adjusting for age, gender, race or ethnicity, education, and income to poverty ratio). Former smokers were also more likely than persons who had never smoked to have periodontitis. Among current smokers, there was a dose response relationship between cigarettes smoked per day and the odds of periodontitis. Among former smokers, the odds of periodontitis declined with the number of years since quitting. The authors calculated that 41.9 percent of periodontitis cases (.64 million cases) in the U.S. adult population are attributable to current cigarette smoking and 10.9 percent (1.7 million cases) to former smoking. Among current smokers, 74.8 percent of their periodontitis was attributable to smoking. The authors conclude that a large proportion of adult periodontitis may be preventable through prevention and cessation of cigarette smoking. 3 tables. 60 references.

·

Evidence of a Substantial Genetic Basis for Risk of Adult Periodontitis Source: Journal of Periodontology. 71(11): 1699-1707. November 2000. Contact: Available from American Academy of Periodontology. Suite 800, 737 North Michigan Avenue, Chicago, IL 60611-2690. (312) 573-3220. Fax (312) 573-3225.

Studies 63

Summary: A few previous studies have suggested that risk for adult periodontitis (AP) has a genetic (inherited) component. This article reports on a study in which the authors estimated genetic and environmental variances and heritability for gingivitis and adult periodontitis using data from twins reared together. One hundred seventeen (117) pairs of adult twins (64 monozygotic or MZ and 53 dizygotic or DZ pairs) were recruited. Probing depth (PD), attachment loss (AL), plaque, and gingivitis (GI) were assessed on all teeth by two examiners. Measurements were averaged over all sites, teeth, and examiners. Genetic and environmental variances and heritability were estimated using path models with maximum likelihood estimation techniques. Results showed that MZ twins were more similar than DZ twins for all clinical measures. Statistically significant genetic variance was found for both the severity and extent of disease. AP was estimated to have approximately 50 percent heritability, which was unaltered following adjustments for behavioral variables including smoking. In contrast, while MZ twins were also more similar than DZ twins for gingivitis scores, there was no evidence of heritability for gingivitis after behavioral covariates such as utilization of dental care and smoking were incorporated into the analyses. The authors conclude that the basis for the heritability of periodontitis appears to be biological and not behavioral in nature. 1 figure. 7 tables. 37 references. ·

Parameter on Periodontitis Associated with Systemic Conditions Source: Journal of Periodontology. 71(5 Supplement): 876-879. May 2000. Contact: Available from American Academy of Periodontology. Suite 800, 737 North Michigan Avenue, Chicago, IL 60611-2690. (312) 573-3220. Fax (312) 573-3225. Summary: The American Academy of Periodontology has developed this parameter on periodontitis associated with systemic conditions. Patients affected by periodontal disease who have concomitant (at the same time) systemic factors should be informed about the significance of the systemic condition(s) to the periodontal disease process. Patients should also be informed of the periodontal disease process, therapeutic alternatives, potential complications, expected results, and their responsibilities in treatment. Consequences of no periodontal treatment should be explained. Failure to treat periodontitis appropriately can result in progressive loss of periodontal supporting tissues, an adverse change in prognosis, tooth loss, and compromise of the dentition. Given this information, patients can then make informed decisions regarding their periodontal therapy. The systemic conditions covered in this parameter of care include diabetes mellitus, pregnancy, drug induced

64 Periodontitis

disorders, hematologic (blood) disorders (including leukemia), and immune system disorders, including infection with HIV. The article concludes with a discussion of outcomes assessment. 42 references. ·

Non-Hodgkin's Lymphoma and Periodontitis. A Case Report Source: Journal of Periodontology. 71(3): 504-509. March 2000. Contact: Available from American Academy of Periodontology. Suite 800, 737 North Michigan Avenue, Chicago, IL 60611-2690. (312) 573-3220. Fax (312) 573-3225. Summary: This article describes an unusual case of extranodal non Hodgkin's lymphoma that developed in the maxillae (upper jaw) associated with localized severe periodontitis in a 64 year old Caucasian male. The lymphoma was diagnosed less than 2 years following routine periodontal surgery and 8 weeks after the extraction of hopeless teeth in the associated area. Two months following the extractions, the patient experienced pain and swelling in the maxillary right edentulous (without teeth) area, mimicking an abscess, and reported for emergency care. An expansile lesion measuring 2.0 by 2.5 centimeters in diameter was noted on radiographic (x ray) examination to extend into the right maxillary sinus. A definitive biopsy diagnosis of high grade, small, non cleaved, diffuse non Hodgkin's lymphoma of the right posterior maxillae was established. The patient was subsequently treated by a combination of radiation, chemotherapy, and bone marrow transplantation. The maxillary tissues healed uneventfully, and the patient has been closely observed for approximately 5 years without symptoms or recurrence of the lymphoma. The authors conclude that this case highlights the need for careful debridement of extraction sockets associated with severe periodontitis and argues for the routine submission of extracted teeth with adjacent soft tissue for microscopic analysis, to assist in the early diagnosis of potentially life threatening malignancies (cancers). 5 figures. 1 table. 13 references.

·

Elevation of Systemic Markers Related to Cardiovascular Diseases in the Peripheral Blood of Periodontitis Patients Source: Journal of Periodontology. 71(10): 1528-1534. October 2000. Contact: Available from American Academy of Periodontology. Suite 800, 737 North Michigan Avenue, Chicago, IL 60611-2690. (312) 573-3220. Fax (312) 573-3225. Summary: Periodontitis is a common, often undiagnosed, chronic infection of the supporting tissues of the teeth, epidemiologically associated with cardiovascular diseases. This article reports on a study

Studies 65

that investigated whether C reactive protein (CRP) and other systemic markers of inflammation are elevated in patients with periodontitis. These markers have previously been identified as risk factors for cardiovascular diseases. The study included consecutive adult patients with periodontitis (localized n = 53, generalized n = 54), and healthy controls (n = 43), all without any other medical disorder. Patients with generalized periodontitis and localized periodontitis had higher media CRP levels than controls; 52 percent of generalized periodontitis patients and 36 percent of the localized periodontitis patients were seropositive for interleukin 6 (IL6), compared to 26 percent of controls. Plasma IL6 levels were higher in periodontitis patients than in controls. Leukocytes were also elevated in generalized periodontitis compared to localized periodontitis and controls. These current findings for periodontitis were controlled for other known factors associated with cardiovascular diseases, including age, education, body mass index (BMI), smoking, hypertension, cholesterol, and sero positivity for CMV, Chlamydia pneumoniae, and Helicobacter pylori. The authors conclude that periodontitis results in higher systemic levels of CRP, IL6, and neutrophils. These elevated inflammatory factors may increase inflammatory activity in atherosclerotic lesions, potentially increasing the risk for cardiac or cerebrovascular events. 1 figures. 4 tables. 36 references. ·

New Concepts in the Long-Term Management of Clients with Chronic Periodontitis Source: Access. 15(7): 16-19. August 2001. Contact: Available from American Dental Hygienists' Association. 444 North Michigan Avenue, Chicago, IL 60611. Summary: This article offers a summary of new concepts in the long term management of clients with chronic periodontitis. In dentistry and dental hygiene, health professionals are looking more to the model that incorporates environment, behavior, and heredity as modifiers of disease. Dental health care providers are incorporating strategies of evidence based care, and realizing that the skills of cognition, synthesis, and communication are vital when working with clients. The author uses the U.S. Surgeon General's report on Oral Health in America (2000) as a basis for discussing new research and diagnostic techniques, the oral-systemic link, the importance of the immune system, periodontal assessment and diagnosis, and treatment options. The goal of new diagnostic methods is the early diagnosis of disease, before significant destruction has occurred, and measures of successful treatment or disease arrest. Some new prognostic measures include genetic predictors of susceptibility; and

66 Periodontitis

physical, microbiological, biochemical, and immunological assessment tests. Advances in surgical procedures have allowed periodontal surgery to change its focus from resection (removal) to restoration. Regenerative periodontal therapy includes procedures specially designed to restore parts of the tooth supporting apparatus that have been lost due to periodontitis. 12 references.

Federally-Funded Research on Periodontitis The U.S. Government supports a variety of research studies relating to periodontitis and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.17 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site at http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to periodontitis and related conditions. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore periodontitis and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for periodontitis: ·

Project Title: Clonal Diversity of Oral Pathogens Principal Investigator & Institution: Chen, Casey C.; Periodontics; University of Southern California University Park Los Angeles, Ca 90007 Timing: Fiscal Year 2000; Project Start 1-JAN-1999; Project End 1-DEC2003 Summary: Actinobacillus actinomycetemcomitans and Eikenella corrodens are suspected pathogens in periodontitis but both also occur in

17 Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).

Studies 67

healthy individuals. This research plan will (1) examine the variabilities of clonal diversity and stability of these organisms within the host, (2) evaluate the synergism between these organisms in localized juvenile periodontitis, and (3) identify pathogenic clones within species. The degrees of clonal diversity of these organisms within the host vary among subjects. Juvenile periodontitis patients harbor greater numbers of distinct E. corrodens clones than healthy subjects; the differences may result from increased susceptibilities of the patients to repeated infections by exogenous clones. Repeated colonization/infection may result in a reduced clonal stability due to replacement of the resident clones by exogenous clones. Colonization/infection by one organism may predispose the host to colonization/infection by the other organism; the relationship is recognized as synergism between the organisms. Within A. actinomycetemcomitans and E. corrodens, strains associated with health may be relatively harmless while others recovered from infections may be more pathogenic. The objectives of this research plan are to: (1) Compare the degrees of clonal diversity, by AP-PCR, of subgingival A. actinomycetemcomitans and E. corrodens in periodontally healthy subjects and localized juvenile periodontitis patients. (2) Examine the clonal stability of subgingival A. actinomycetemcomitans and E. corrodens. Subjects will be sampled again in 9 and 18 months. A quantitative method will be used to assess and compare the clonal stabilities between subject groups. (3) Determine the correlations in the proportional levels or the degrees of clonal diversity between subgingival A. actinomycetemcomitans and E. corrodens. (4) Examine the genetic distinctions between A. actinomycetemcomitans and E. corrodens clones recovered from health and disease by serotyping, AP-PCR genotyping and mutilocus enzyme typing. The study subjects will be limited to Asian-Americans to avoid variations arising from using subjects with different ethnicities, and to examine an ethnic group which is underrepresented in previous periodontal disease research. This research plan will provide crucial information regarding the significance of clonal diversity and stability of A. actinomycetemcomitans and E. corrodens in periodontal disease and the synergism between these two organisms, and identify virulent clonal types within these species. The information will be important for the (1) future studies of bacterial virulence factors and (2) prevention and treatment of periodontitis associated with these organisms. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Effects of Calcium Intake on Alveolar Bone Principal Investigator & Institution: Bollen, Anne-Marie; University of Washington 3935 University Way Ne Seattle, Wa 98195

68 Periodontitis

Timing: Fiscal Year 2000 Summary: The benefits of sufficient levels of calcium intake in the prevention of osteoporotic fractures are well recognized. Since alveolar bone is influenced in the same manner as other bones, dietary calcium levels are assumed to also affect its density. It has been suggested that increased alveolar bone density may increased bone loss during periodontitis. The primary goal of this study is to evaluate the effects of calcium intake on alveolar bone, and its capacity to decrease periodontitis-induced bone loss at old age, in a rat model. Rats were chosen due to their previous extensive use in bone and periodontitis studies, and their relative short life span which allows evaluation of the effects of calcium intake at old age, when its benefits are of most value. Two calcium intake levels will be used: low, and high. The following aims will be addressed: 1. Test the difference in alveolar bone density at old age (20 months) between the two calcium intake groups. 2. Test the difference in periodontitis-induced alveolar bone loss at old age between the two groups. 3. Describe how bone density measures of cranial and post-cranial change during the study period in the two animal groups. Animals will be randomly assigned to one of the two calcium intake groups at age 1 month, and followed until the age of 20 months. At that time, some of the animals will be euthanized for invasive bone measurements for Aim 1. Periodontitis will be i induced in the remainder of the animals who will be followed until the age of 23 months. Noninvasive longitudinal data collected at the age of 1,3,8,13,20 and 23 months will include bone density measurements using dual x-ray radiography (cranial and non-cranial bones), as well as intra-oral radiographs of the molars (alveolar bone). The primary outcome variable for Aim 1 will be alveolar bone density, and for Aim 2 alveolar bone loss. Alveolar bone density will be measured on defleshed jaws using dual xray absorptiometry and pixel intensity on oral radiographs. Alveolar bone loss will be measured on the buccal of the molars using morphometry on defleshed jaws, and radiographically on intraoral radiographs. In addition, static and dynamic parameters of bone metabolism will be measured using histomorphometry. Power calculations indicate that 21 animals per group will be needed to detect a minimum of 5% in alveolar bone density (Aim 1). A total of 24 animals will be needed to detect a minimum of 10% difference in alveolar bone loss (Aim 2) between any of the two calcium intake groups with a power of 80% at a 0.05 significance level. To test the effect of calcium intake with equal precision in male and female rats, a equal sample size will be required for both genders. These calculations include an estimated 20% mortality rte in these elderly rats. This study may indicate the benefits of

Studies 69

dietary calcium intake on dental/orofacial health. This additional benefit may help to promoter this preventive therapy. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Fibrinogen Binding and Virulence of P Gingivalis Principal Investigator & Institution: Lantz, Marilyn S.; Professor; Oral Biology; Indiana Univ-Purdue Univ at Indianapolis 355 N Lansing Indianapolis, in 46202 Timing: Fiscal Year 2000; Project Start 1-SEP-1984; Project End 1-JAN2001 Summary: Periodontitis continues to be a major cause of tooth loss in adults. Porphromonas gingivalis (Pg) is an etiologic agent of periodontitis, however, the mechanisms by which it contributes to the tissue destruction characteristic of this disease remains unknown. The pathogenic mechanisms used by Pg must be understood at the molecular level before effective strategies to interfere with Pg-mediated tissue destruction can be designed. The long-range goal of this research is to design new Pg-specific anti-microbial agents to prevent the development and/or arrest the progression of periodontitis. Pg makes four closely related proteinase/adhesin/hemagglutinins denoted PrtP, Rgp-1, Rgp-2, and HagA that appear to be important virulence factors of this pathogen. Preliminary studies suggest that interference with their functions interferes with the development of periodontitis in the cynomolgus monkey model of ligature-induced periodontitis. We have developed the first system for expression of catalytically active PrtP, Rgp-1, and Rgp-2 in a heterologous prokaryotic host. It will allow us to use molecular biological and genetic methods to sort out structure/function relationships among these proteins at a level not possible in the Pg background. Five Specific Aims are proposed: 1) Determine the proteinase properties and substrate specificities of recombinant (r)PrtP, rRgp-1, rRgp-2, and rHagA, as well as the ability of each to mediate hemagglutination and bind and adhere to extracellular matrix and plasma proteins; 2) Characterize the structural and functional domains of the three recombinant proteinases and recombinant HagA, by (A) determining the identify of the limit peptides comprising the catalytic domains of rPrtP, rRgp-1, and rRgp-2, as well as the identify of the catalytic Cys and His residues of these proteinases, and (B) determining the limit peptides of the hemagglutinin and/or adhesin domains of rPrtP, rRgp-1, and rHagA; 3) Construct and characterize isogenic strains of Pg defective in the expression of prtP, rgp-1, rgp-2, and hagA, individually and in combination; 4) Use the Bacteroides fragilis expression system and the constructs obtained in Aim 2 and Aim 3 to examine the effects of each

70 Periodontitis

of these proteins on the extent of processing of the other three; 5) Examine transcription of these genes in wild type Pg, in Pg knockout mutants, and in the Bf expression system to (A) determine the number and sizes of transcripts made from prtP, rgp-1, rgp-2, and hagA, (B) construct transcript-specific probes, and (C) determine whether Bf is a good model in which to study transcription of Pg virulence genes. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Host Modulation/Periodontal Therapy Effects on Diabetes Principal Investigator & Institution: Ryan, Maria E.; Assistant Professor; Oral Biology and Pathology; State University New York Stony Brook Stony Brook, Ny 11794 Timing: Fiscal Year 2001; Project Start 0-SEP-2001; Project End 1-AUG2003 Summary: (provided by applicant): Of the approximately 16 million Americans suffering from diabetes mellitus, about 10 percent have Type 1 diabetes. The complication of this chronic disease, i.e. nephropathy, retinopathy, neuropathy, angiopathy, impaired wound healing and periodontitis, significantly, impact the diabetic individuals quality of life. In recent years new adjunctive treatments, to classic insulin therapy, targeting factors know to play a role in these long-term complications have been developed and are being tested clinically. Diabetics tend to have an exaggerated host response to local microbial factors resulting in unusually destructive periodontal breakdown. In addition, periodontal infections resulting in excessive production of cytokines (1L1, 1L-6 and TNF (a)) induce insulin resistance and decrease insulin action. Tetracycline's, including a sub-antimicrobial dose of doxycycline (SDD), by virtue of non-antimicrobial properties can reduce level of these cytokines and other factors (matrix metalloproteinase {MMPs}), nitric oxide [NO]) known to play a role in diabetic complications, including periodontitis. These biological properties make SDD a compelling candidate for use in diabetics with periodontitis. Therefore, the objective of this research is to investigate the therapeutic potential of SDD in diabetic complications, such as periodontitis. The hypothesis of this proposal is that adjunctive periodontal therapy with SDD (compared to placebo) can improve clinical and local biochemical parameters of periodontitis as well as systemic biochemical and physiological parameters indicative of the likelihood of he progression or severity of long-term complications of diabetes. Accordingly, the specific aim of this proposal is to use a 9 month double -blind, placebo-controlled trail of Type 1 diabetics to determine the effect of SDD on: a) the clinical efficacy

Studies 71

of non-surgical periodontal therapy; b) the oral microflora; c) oral, serum and urine levels of cytokines (1L-1, 1L6, TNF (a)), MMPs and NO; d) hemoglobin Aic, serum non-fasting glucose and fructosamine; and e) microalbuminuria and proteinuria. It is postulated that SDD, developed initially for the improved management of periodontitis, may be potential adjunct to insulin therapy in diabetic patients for the improved overall management of diabetes. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Identify Antigenic Determinants of Human Periodontitis Principal Investigator & Institution: Teng, Yen-Tung A.; University of Western Ontario 1151 Richmond St N London, Timing: Fiscal Year 2000; Project Start 1-JUN-2000; Project End 1-MAY2002 Summary: Human periodontal diseases (e.g., periodontitis) are heterogeneous and result from specific bacteria-host immune interactions. Periodontitis is the major cause of tooth loss in adults and has been recognised as a significant risk factor associated with coronary heart disease, stroke and bacterial pneumonia. The long-term objective of this research program is to identify bacterial antigens important for immune and inflammatory responses in human periodontitis. Engraftment of immunodeficient NOD/SCID mice with human peripheral blood leukocytes (HuPBL) provides an excellent model for studying immune responses to inoculated pathogens. The applicant proposes to use this unique system and a well characterized clinical entity, Actinobacillus actinomycetemcomitans:Aa-associated localized juvenile periodontitis (LJP), to study the immune basis of human periodontitis, for which no animal model exists and which, for ethical and practical reasons, cannot be directly studied in humans. The applicant has shown that oral inoculation of live Aa into NOD/SCID mice carrying high levels of (up to 60 percent) HuPBL from periodontitis patients can be achieved. Further, engrafted human leukocytes present in mouse periodontal tissues can functionally respond to Aa challenge. Therefore, microbial antigen-specific immune responses of LJP can be studied in this model. The specific aims of this proposal are: 1) to identify Aa-antigens involved in LJP using a genetic screening approach, and 2) to assess the periodontal immune responsiveness elicited by the identified Aa-antigens in the current animal model. Identification of Aa-antigens will be achieved by screening an Aa genomic-DNA library in transformed E. coli. This would allow the expressed Aa-antigens to be captured by patient's antigen-presenting cells which will present and activate the same host's periodontal CD4+T-cells carrying an activation

72 Periodontitis

marker for visual identification as probes. The Aa antigens identified will be assess by in vitro T-cell activation (by IL-2) and B-cell IgG antibody (by ELISA) assays for specificity and correlation analyses in LJP and LJPfree subjects. The new information obtained from the proposed studies will provide rationales and hypotheses to investigate the clinical correlates and significance for important bacterial antigens involved in Aa- associated LJP. Further, it will increase our knowledge of host immune-parasite interactions and could eventually lead to the development of new protocols (e.g., Mabs or vaccines) for the treatment of human periodontal diseases. Therefore, the patient's periodontal health will be improved, thereby their complications and health-care costs will be reduced. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Low-Dose Doxycycline Effects on Osteopenic Bone Loss Principal Investigator & Institution: Payne, Jeffrey B.; Surgical Specialties; University of Nebraska Medical Center 42Nd and Dewey Aves Omaha, Ne 68105 Timing: Fiscal Year 2001; Project Start 1-JUL-2001; Project End 0-JUN2006 Summary: Osteoporosis represents a major public health problem in the United States. Osteoporosis is associated with decreased systemic bone mineral density (BMD), an increased incidence of vertebrae, wrist and hip fractures, and tooth loss. The dominant pathogenic factor for osteoporosis in postmenopausal women is estrogen (E2) deficiency. In longitudinal NIH-supported clinical trials, we have shown accelerated alveolar crestal bone height and density loss in postmenopausal, E2deficient women with a periodontitis history relative to E2-sufficient women, and in osteoporotic/osteopenic women versus women with normal lumbar spine BMD. Because of this relationship between E2deficiency, osteoporosis and oral bone loss, it is desirable to test therapeutic strategies to mitigate alveolar bone loss in postmenopausal women. A recent discovery by Dr. Golub (Co-PI) showed that tetracyclines, including low-dose doxycycline (LDD), by virtue of a nonantimicrobial property, can: a) inhibit host-derived, tissue-destructive matrix metalloproteinases (MMPs), including collagenases, involved in bone resorption; and b) stimulate osteoblast activity and bone formation. These biological properties make tetracyclines compelling candidates for use in postmenopausal women with periodontitis. Therefore, the objective of this research is to investigate the therapeutic potential of LDD in postmenopausal osteopenia and periodontitis, diseases characterized by excess collagen breakdown and bone resorption. The

Studies 73

hypothesis of this proposal is that LDD (compared to placebo) can improve radiographic, clinical and biochemical parameters of periodontitis in E2-deficient, osteopenic postmenopausal women with periodontitis. Accordingly, the specific aim of this proposal is to use a 2year double-blind, placebo-controlled trial of E2-deficient women to determine the effect of LDD on: a) alveolar bone crestal and subcrestal density (measured by computer-assisted densitometric image analysis) and linear alveolar crestal bone height; b) clinical periodontal measurements such as probing depth and relative clinical attachment level; and c) gingival crevicular fluid markers of bone turnover (e.g., Cterminal telopeptide pyridinoline crosslinks [ICTP, a collagen breakdown fragment]). As a secondary aim, the study will evaluate the effect of LDD on systemic bone mineral density at the lumbar spine and femoral neck by dual-energy x-ray absorptiometry (DEXA) and the effect of LDD on serum and urine biochemical markers of bone turnover. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Maternal Periodontitis and Adverse Pregnancy Outcomes Principal Investigator & Institution: Pitiphat, Waranuch; Oral Health Policy & Epidem; Harvard University (Medical School) Medical School Campus Boston, Ma 02115 Timing: Fiscal Year 2001; Project Start 1-AUG-2001; Project End 1-JUL2003 Summary: (provided by applicant) We propose to evaluate whether periodontitis is a risk factor for adverse pregnancy outcomes. The published studies evaluating these associations are few, small, mostly retrospective and show inconsistent results; although relative risks as high as 7.5 have been reported. We plan to add an oral component to the ongoing Project Viva, a prospective study of 6,000 pregnant women, to evaluate this association. Maternal infection during pregnancy has been demonstrated to play an important role in etiology of preterm delivery. Periodontal infection can serve as a reservoir of gram negative anaerobic organisms and their products, and proinflammatory mediators which could target the placental membranes via systemic circulation thus leading to preterm delivery or fetal growth restriction. The primary aim of this study is to examine the effect of maternal periodontitis on length of gestation and fetal growth. The secondary aim is to explore the association between periodontitis and serum levels of TNF-alpha. The proposed prospective nested case-control study will request pre-existing radiographs from Viva participants. Cases will be mothers who give birth to a preterm infant and mothers who give birth to a restricted fetal growth infant. Controls will be mothers with normal pregnancy outcome.

74 Periodontitis

We will enroll all cases and a random sample of controls in a 1:3 ratio, frequency matched by race, age and smoking status. Periodontal bone loss as a result of chronic periodontitis will be evaluated from the preexisting radiographs. Viva participants who report having x-rays taken within last 5 years will be requested on the supplemental questionnaire after delivery to provide their existing dental radiographs or the name and address of the dentist who has these. We will then request the participants' dentists to provide existing bitewing radiographs. The radiographs will be interpreted by one well-calibrated dentist by using a visual categorization method. We will employ multivariate analyses to adjust for potential confounders. In addition, we will perform the analysis of TNF-alpha using blood samples that were pre-collected at first prenatal visit in Project Viva's pilot study (Pregval Study) to evaluate one potential pathway relating periodontitis and adverse pregnancy outcomes. The proposed study will help us clarify the relationships between periodontal disease and adverse pregnancy outcomes. Since periodontal disease is a highly prevalent condition that can be controlled, understanding these relationships is of significant importance, both for individuals and for public health policy aiming to improve the well-being of mothers and infants. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Microbial Characterization of Initial Periodontitis Principal Investigator & Institution: Van Dyke, Thomas E.; Professor; Boston University 121 Bay State Rd Boston, Ma 02215 Timing: Fiscal Year 2000; Project Start 1-DEC-1978; Project End 0-NOV2001 Summary: The focus of this proposal is to determine the microbial etiology of initial periodontitis in adults. The potential of microbial diagnosis to identify subjects at risk of disease, and the stability of the subgingival microbial over time, will also be evaluated. Identification of initial periodontitis pathogens will be allow other research studies, and patient prevention and therapy, to be targeted to the species associated with the infection. The specific aims explore the associations between recognized microbial risk markers- putative pathogens- particularly those associated with initial periodontal disease, with early signs of disease, and with progressing sites. The aims also seek new microbial risk markers, including recognized and new species of spirochetes, by studying a large diverse population. Microorganisms in 300 subjects (100 subjects at Boston University Dental School Site) will be examined using new molecular biology techniques for rapid species assay of subgingival and tongue samples. The tongue would provide a convenient sample for

Studies 75

microbial diagnosis of initial periodontitis. Information from this study will significantly advance understanding of the microbial etiology of initial periodontitis. This information will have a profound significance for basic studies in periodontal research, and in microbial identification of subjects at risk for periodontitis for clinical and epemiological studies. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Molecular Analysis of Subgingival Microbial Diversity Principal Investigator & Institution: Relman, David A.; Assistant Professor; Medicine; Stanford University Stanford, Ca 94305 Timing: Fiscal Year 2000; Project Start 1-SEP-2000; Project End 1-AUG2004 Summary: (Adapted from the Investigator's Abstract): Bacteria are the primary cause of plaque-associated gingivitis and chronic adult periodontitis. It is unclear, however, whether the microorganisms responsible for gingivitis also contribute to the development of adult periodontitis or whether a unique assemblage of microorganisms is responsible for periodontitis. Studies indicate that plaque-associated gingivitis progresses to chronic adult periodontitis in only a subset of individuals. Previous work on this topic has been hampered by the limitations of cultivation-based methods, taxonomic inconsistencies, insufficient microbial characterization and inter-patient heterogeneity. The proposed work relies upon sensitive molecular methods to identify predictive associations between specific bacterial and archaeal species and the onset of adult periodontitis. The short-term objectives are to determine the subgingival microbial markers of gingival health, plaqueassociated gingivitis and chronic adult periodontitis. The long-term objectives are to understand oral microbial ecology, to determine its relationship with local and systemic disease, and by so doing, to identify healthy individuals with increased risk of disease who would benefit from early intervention. The Specific Aims of this proposal are: Aim 1. Identify the bacterial and archaeal species within subgingival plaque from healthy sites in periodontitis patients. Phylogenetic analysis of 16S ribosomal DNA sequences and high density DNA microarrays will be used to identify the microbial species composition of subgingival plaque. Aim 2. Identify the bacteria and archaea from plaque-associated gingivitis and chronic adult periodontitis sites using the approach in Aim 1. Aim 3. Quantify differences in bacterial and archaeal contribution to the total microbial population within subgingival plaque associated with healthy gingiva, plaque-associated gingivitis and chronic adult periodontitis. Slot-blot and in situ hybridization methods will be applied with group- and species-specific 16S rDNA probes. Targeted organisms

76 Periodontitis

will include those implicated in the development of disease from the work in the above aims. Among the expected long-term benefits of this work will be the identification of organisms that can serve as predictors of intra-oral health and disease, and the development of broadly useful DNA microarray for microbial surveys and diagnostic studies. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Oral Health Works--A Community Intervention Principal Investigator & Institution: Strauss, Ronald P.; University of North Carolina Chapel Hill Chapel Hill, Nc 27514 Timing: Fiscal Year 2000 Summary: The proposed community dental intervention trial is an exceptional opportunity to apply public health knowledge and practice to affect significant oral health behavior change and improve the oral health status of community worksite employees. This proposal uses a multidisciplinary team to apply a successful health education and promotion intervention with an innovative oral health intervention within a community context. As new scientific knowledge and understanding abound about the nature of inflammatory processes and consequences of periodontitis on oral and systemic disease, effective strategies to prevent periodontitis become imperative. Moreover, application of those strategies to persons within their own communities rather than clinical settings offer the opportunity to accomplish broad, sustained healthy behaviors for participants and those in their arenas of influence. It is our hypothesis that markers of inflammation in the oral cavity, specifically, inflammatory mediators in gingival crevicular fluid (GCF), can be marginally reduced with introduction of individualized tailored health education and promotion messages. We further hypothesize that the introduction of a mechanical toothbrush into daily oral hygiene regimens will achieve significant sustained reduction of GCF inflammatory mediators, and thus periodontitis, above that effect achieved by education alone. The proposed experimental intervention has the potential to prevent the debilitating effects of chronic inflammatory processes of periodontitis and to intervene on its impact to systemic health in daily oral hygiene regimens without clinical intervention. Significant reductions at the individual level will coincide with reductions at the community level. Potential benefits accrue for the individual and for the workplace institution in health care cost savings. Controlled clinical trials have demonstrated that inflammatory processes of periodontitis can be significantly attenuated by the daily use of a sonic toothbrush. We propose that this association can be demonstrated in a community worksite context as well. Our team of scientists and

Studies 77

educators are uniquely qualified to accomplish this study because of our experience in community settings, our established relationships with targeted worksites, and our expertise in longitudinal studies of periodontitis. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Periodontal Pathogens and Epidemiology Principal Investigator & Institution: Tran, Simon D.; University of Minnesota Twin Cities Twin Cities Minneapolis, Mn 55455 Timing: Fiscal Year 2000 Summary: The candidate (Simon Iran, D.M.D.) is presently pursuing a combined clinical/research program consisting of a certificate in Periodontology, a Ph.D. in Oral Biology, and a minor in Epidemiology. His goals are to learn to treat periodontal diseases and to develop molecular microbiological detection tests for the diagnosis and study of adult periodontitis. Research Plan: The most convincing evidence of periodontal pathogenicity accumulated to date suggests that Actinobacillus actinomyceterncomitans, Bacteroides forsythus, and Porphyromonas gingivalis are etiological agents in destructive periodontal disease. However, the microbial flora associated with sites showing attachment loss has been prospectively evaluated in only a few studies, and results were conflicting regarding the ability of any one microorganism to be predictive for the progression of periodontitis. A possible explanation for those conflicting results is that the subjects studied were those with the most advanced cases of periodontitis. The complex microflora of these severe periodontitis cases might not differentiate which bacterial species initiated disease or which species simply proliferate after disease progression. The candidate has access to stored plaque samples of a longitudinally-followed population, which has a low prevalence of periodontitis. This gives the advantage of longitudinal observations of early changes in the development or progression of periodontitis. This population may help to definitively determine the role of A. actinomyceterncomitans, B. forsythus, and P. gingivilais as risk factors for periodontitis. The candidate has developed a sensitive and specific multiplex PCR-based assay for simultaneous detection of low levels of A. actinomyceterncomitans, B. forsythus, and P. gingivalis. This research will test the hypothesis that the persistent presence of these periodontal pathogens in periodontally healthy sites is a risk factor for the onset of clinical attachment loss. The answer to be found will guide our approach to the treatment and understanding of the pathogenesis of periodontal diseases associated with these three bacterial

78 Periodontitis

species. Key Words: Periodontal pathogens, epidemiology, PCR, 16S ribosomal RNA, multiplex PCR Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Periodontitis and Systemic Disease-- Confounding? Principal Investigator & Institution: Hujoel, Philippe P.; Research Associate Professor; Dental Public Health Sciences; University of Washington 3935 University Way Ne Seattle, Wa 98195 Timing: Fiscal Year 2000; Project Start 1-SEP-2000; Project End 0-JUN2002 Summary: Periodontitis has been associated with systemic diseases such as cardiovascular disease and low birth weight. Establishing the causality of these associations is difficult; the compared groups, individuals with and without periodontitis, may differ on factors other than periodontitis. If these other factors are causally related to systemic disease risk, confounding may be present. The primary goal of this R03 proposal is to provide a methodological study of confounding by means of different approaches. This methodological work will be performed in three large databases: the First National Health & Nutrition Examination Survey (NHANES I) (n=31,973), the NHANES I Epidemiological Follow-up Study (NHEFS) (n=11,348), and the Third National Health & Nutrition Examination Survey (NHANES III) (n=30,818). Exhaustive information regarding most potentially confounding variables is present in these datasets (greater than 1000 variables per individual). Preliminary analyses of the NHANES I and NHEFS suggest that confounding is a significant methodological challenge. Periodontitis was associated with unexpected differences that may in and of itself cause other systemic diseases. Individuals with periodontitis, after adjustment for age and gender, were more likely to have an unhealthy diet (less fruit, less vitamin C, less riboflavin, and less linoleic acid), were more likely to have suffered a nervous breakdown, less likely to exercise, more likely to be overweight, and more likely to have high blood pressure. In addition, after adjustment for known risk factors, periodontitis was associated with a two-fold increase in lung cancer mortality, an unexpected finding that suggests that confounding may have a strong influence. The aims of this study are: 1) to provide a systematic evaluation of potentially confounding variables in NHANES I and NHANES III; 2) to provide a systematic evaluation of the association between periodontitis and the most common causes of mortality in NHEFS, 3) to assess the benefits of using alternate referent or unexposed groups in cohort studies in NHEFS; and 4) to perform a series of sensitivity analyses to assess the extent to which confounding variables may cause spurious associations. The

Studies 79

investigators believe the completion of these projects may play a pivotal role in determining whether the previously observed associations between periodontitis and systemic diseases are spurious or causal. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Plasminogen Activators in Periodontitis and Diabetes Principal Investigator & Institution: Decarlo, Arthur A.; President and Chief Science Officer; Oral Biology; University of Alabama at Birmingham Uab Station Birmingham, Al 35294 Timing: Fiscal Year 2000; Project Start 0-SEP-2000; Project End 1-AUG2001 Summary: Periodontal disease in individuals with diabetes mellitus is more frequent and more severe. Both periodontitis and diabetes patients present with extracellular matrix changes associated with the microvasculature. We propose that changes in the microvasculature are a common, fundamental process in the development of tissue pathology in both Adult Periodontitis and diabetes mellitus, and we offer this as an explanation for the increased incidence and severity of periodontitis in diabetics. Because the plasminogen activators (PA) and their inhibitors, plasminogen activator inhibitors (PAIs) are known to have a critical role in angiogenesis and angiopathies, as well as in extracellular remodeling and fibrinolysis, we propose to demonstrate a significant association of the Pas and PAIs with both periodontitis and diabetes severity, and to show that the exacerbation of periodontitis in diabetics is a function of Pas and PAIs. Diabetes-associated pathology will be measured as the level of diabetic retinopathy, previously demonstrated to correlate with periodontitis severity. Gingival microvasculature changes will be measured by morphometric analysis of histologic sections. We will measure Pas and PAIs in three different ways: genotypes, cellular response levels, and in vivo tissue levels. Our hypothesis states that POA/PAI parameters will be similarly associated with measurements of periodontitis and diabetes pathology but significantly different from levels found in healthy control participants. To address pathophysiology mechanisms which would link changes in PAs and PAIs in three different ways: genotypes, cellular response levels, and in vivo tissue levels. Our hypothesis states that PA/PAI parameters will be similarly associated with control participants. To address pathophysiological mechanisms which would link changes in PAs and PAIs with development of microangiopathy we will use an in vitro endothelial cell microvessel assay system, expression and activation of matrix metalloproteinases, and accumulation of matrix proteins such as type IV collagen and laminin. Anticipated results may focus the targeting of therapeutic

80 Periodontitis

intervention for pathology associated with periodontal disease and diabetes mellitus towards the Pas and PAIs and may allow earlier intervention for a patient population determined genotypically to be at risk. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Severe Periodontitis as a Rheologic Modifier Principal Investigator & Institution: Engebretson, Steven P.; Division of Periodontics; Columbia University Health Sciences Ogc New York, Ny 10032 Timing: Fiscal Year 2000; Project Start 1-FEB-2000; Project End 1-JAN2004 Summary: Cytokines play a key role in the host response to microbial infection. These mediators are induced following contact with Gram (-) bacteria, and have a wide range of effects including influencing hemostatic factors, which are risk indicators for thrombotic events. Experimental evidence has conclusively established that a low-dose endotoxin bolus in healthy human volunteers alters rheologic parameters via a cytokine cascade resulting in a transient procoagulant state. Further, recent case-control studies have shown severe periodontal disease to be a strong independent risk factor for myocardial infarct and stroke. While causation has not been established, the initiating step is likely the transient bacteremia that result when the highly vascular, chronically inflamed periodontium is mechanically irritated by chewing, toothbrushing, and dental procedures. We hypothesize that chronic Gram(-) infection of the periodontium represents a potential source of circulating endotoxin which may adversely effect the coagulation system via a transient bacteremia-induced cytokine cascade, resulting in a net procoagulant state. The goal of this study is to explore the association of severe periodontitis and hemostatic variables. We suggest that patients with severe chronic adult periodontitis are at risk for altered rheologic and hemostatic variables as has been shown in experimental endotoxemia studies. Specifically, we will monitor the sera of 20 adults with severe periodontitis during common dental manipulations and periodontal treatment to determine the temporal appearance of endotoxin, inflammatory cytokines, and coagulation products, and to test whether conservative therapy can reduce serum levels of acute phase proteins. This study will help to define the pathophysiology of the thrombotic disorder-periodontitis relationship, and identify future thrombotic disorder prevention strategies. This study will be the first to experimentally demonstrate whether periodontal disease is a systemic modifier of clinically relevant hemostatic variables, and is designed to

Studies 81

establish a molecular mechanism to explain this relationship. A positive finding in this regard should have broad ramifications for both dentistry and medicine. Dr. Engebretson will receive training in research methodology and molecular biology in order to explore the mechanisms of periodontal medicine through the conduct of human clinical studies as a career goal. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Spirochetes Indicate Susceptibility to Periodontitis Principal Investigator & Institution: Riviere, George R.; Professor; Pediatric Dentistry; Oregon Health & Science University 3181 Sw Sam Jackson Park Rd Portland, or 97201 Timing: Fiscal Year 2001; Project Start 1-AUG-2001; Project End 0-JUN2005 Summary: (Adapted from the Investigator's Abstract): The purpose of this research is to test the hypothesis that certain bacteria in plaque at sites of periodontal health are associated with the risk of periodontitis at infected sites. Porphyromonas gingivalis, Prevotella intermedia, Treponema amylovorum, T. denticola, T. maltophilum, T. medium, T. pectinovorum, T. socranskii, T. vincentii, and any new species of Treponema isolated from study sites that develop periodontitis will be evaluated as risk factors for disease. A quantifiable PCR assay will be used to further define risk by associating numbers of target bacteria with disease. Specific Aim 1: Correlate infection of health-associated plaque by each of seven oral Treponema species, P. gingivalis, P. intermedia, and new Treponema isolates with development of periodontitis. These studies will determine which disease-associated bacteria infect healthassociated plaque before clinical detection of periodontitis. Specific Aim 2: Isolate Treponema from new sites of periodontitis at study sites. One of the designated target species not previously evaluated, or a yet-to be discovered Treponema, may be an important risk factor for the transition from gingival health to periodontitis. Specific Aim 3: Use a quantifiable PCR to estimate numbers of study bacteria in plaque. Risk for disease may be associated with critical numbers of specific bacteria in healthassociated plaque before periodontitis is detected. The long-term goal of this research is to develop a means by which sites of periodontal health at risk for disease can be identified and treated before deterioration occurs. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

82 Periodontitis

The National Library of Medicine: PubMed One of the quickest and most comprehensive ways to find academic studies in both English and other languages is to use PubMed, maintained by the National Library of Medicine. The advantage of PubMed over previously mentioned sources is that it covers a greater number of domestic and foreign references. It is also free to the public.18 If the publisher has a Web site that offers full text of its journals, PubMed will provide links to that site, as well as to sites offering other related data. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals. To generate your own bibliography of studies dealing with periodontitis, simply go to the PubMed Web site at www.ncbi.nlm.nih.gov/pubmed. Type “periodontitis” (or synonyms) into the search box, and click “Go.” The following is the type of output you can expect from PubMed for “periodontitis” (hyperlinks lead to article summaries): ·

Therapy-resistant periodontitis. Psychosocial characteristics. Author(s): Axtelius B, Soderfeldt B, Nilsson A, Edwardsson S, Attstrom R. Source: Journal of Clinical Periodontology. 1998 June; 25(6): 482-91. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9667482&dopt=Abstract

·

Ultrastructure and histochemistry of the dental cuticle in adult periodontitis. Author(s): Friedman MT, Barber P, Newman HN. Source: J Periodontol. 1993 June; 64(6): 520-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8336252&dopt=Abstract

PubMed was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at Web sites of participating publishers. Publishers that participate in PubMed supply NLM with their citations electronically prior to or at the time of publication.

18

Studies 83

Vocabulary Builder Abscess: A localized collection of pus caused by suppuration buried in tissues, organs, or confined spaces. [EU] Actinobacillus: A genus of pasteurellaceae described as gram-negative, nonsporeforming, nonmotile, facultative anaerobes. Most members are found both as pathogens and commensal organisms in the respiratory, alimentary, and genital tracts of animals. [NIH] Adverse: Harmful. [EU] Anaerobic: 1. lacking molecular oxygen. 2. growing, living, or occurring in the absence of molecular oxygen; pertaining to an anaerobe. [EU] Antibody: An immunoglobulin molecule that has a specific amino acid sequence by virtue of which it interacts only with the antigen that induced its synthesis in cells of the lymphoid series (especially plasma cells), or with antigen closely related to it. Antibodies are classified according to their ode of action as agglutinins, bacteriolysins, haemolysins, opsonins, precipitins, etc. [EU] Antigens: Substances that are recognized by the immune system and induce an immune reaction. [NIH] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Bacteremia: The presence of viable bacteria circulating in the blood. Fever, chills, tachycardia, and tachypnea are common acute manifestations of bacteremia. The majority of cases are seen in already hospitalized patients, most of whom have underlying diseases or procedures which render their bloodstreams susceptible to invasion. [NIH] Bacteroides: A genus of gram-negative, anaerobic, rod-shaped bacteria. Its organisms are normal inhabitants of the oral, respiratory, intestinal, and urogenital cavities of humans, animals, and insects. Some species may be pathogenic. [NIH] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Biopsy: The removal and examination, usually microscopic, of tissue from the living body, performed to establish precise diagnosis. [EU] Buccal: Pertaining to or directed toward the cheek. In dental anatomy, used to refer to the buccal surface of a tooth. [EU] Campylobacter: A genus of bacteria found in the reproductive organs, intestinal tract, and oral cavity of animals and man. Some species are pathogenic. [NIH]

84 Periodontitis

Cardiac: Pertaining to the heart. [EU] Causality: The relating of causes to the effects they produce. Causes are termed necessary when they must always precede an effect and sufficient when they initiate or produce an effect. Any of several factors may be associated with the potential disease causation or outcome, including predisposing factors, enabling factors, precipitating factors, reinforcing factors, and risk factors. [NIH] Cerebrovascular: Pertaining to the blood vessels of the cerebrum, or brain. [EU]

Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Chlamydia: A genus of the family chlamydiaceae whose species cause a variety of diseases in vertebrates including humans, mice, and swine. Chlamydia species are gram-negative and produce glycogen. The type species is chlamydia trachomatis. [NIH] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Cognition: Intellectual or mental process whereby an organism becomes aware of or obtains knowledge. [NIH] Collagenases: Enzymes that catalyze the degradation of collagen by acting on the peptide bonds. EC 3.4.24.-. [NIH] Concomitant: Accompanying; accessory; joined with another. [EU] Coronary: Encircling in the manner of a crown; a term applied to vessels; nerves, ligaments, etc. The term usually denotes the arteries that supply the heart muscle and, by extension, a pathologic involvement of them. [EU] Cranial: Pertaining to the cranium, or to the anterior (in animals) or superior (in humans) end of the body. [EU] Cytokines: Non-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner. [NIH] Dentition: The teeth in the dental arch; ordinarily used to designate the natural teeth in position in their alveoli. [EU] Eikenella: A genus of gram-negative, facultatively anaerobic, rod-shaped

Studies 85

bacteria that occurs in the human mouth and intestine. Organisms of this genus can be opportunistic pathogens. [NIH] Endotoxemia: A condition characterized by the presence of endotoxins in the blood. If endotoxemia is the result of gram-negative rod-shaped bacteria, shock may occur. [NIH] Exogenous: Developed or originating outside the organism, as exogenous disease. [EU] Extraction: The process or act of pulling or drawing out. [EU] Femur: The longest and largest bone of the skeleton, it is situated between the hip and the knee. [NIH] Fibrinolysis: The natural enzymatic dissolution of fibrin. [NIH] Fructosamine: An amino sugar formed when glucose non-enzymatically reacts with the N-terminal amino group of proteins. The fructose moiety is dervied from glucose by the "classical" Amadori rearrangement. [NIH] Fusobacterium: A genus of gram-negative, anaerobic, rod-shaped bacteria found in cavities of humans and other animals. No endospores are formed. Some species are pathogenic and occur in various purulent or gangrenous infections. [NIH] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Gestation: The period of development of the young in viviparous animals, from the time of fertilization of the ovum until birth. [EU] Helicobacter: A genus of gram-negative, spiral-shaped bacteria that is pathogenic and has been isolated from the intestinal tract of mammals, including humans. [NIH] Hemagglutinins: Agents that cause agglutination of red blood cells. They include antibodies, blood group antigens, lectins, autoimmune factors, bacterial, viral, or parasitic blood agglutinins, etc. [NIH] Heredity: 1. the genetic transmission of a particular quality or trait from parent to offspring. 2. the genetic constitution of an individual. [EU] Hybridization: The genetic process of crossbreeding to produce a hybrid. Hybrid nucleic acids can be formed by nucleic acid hybridization of DNA and RNA molecules. Protein hybridization allows for hybrid proteins to be formed from polypeptide chains. [NIH] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU]

86 Periodontitis

Indicative: That indicates; that points out more or less exactly; that reveals fairly clearly. [EU] Invasive: 1. having the quality of invasiveness. 2. involving puncture or incision of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. [EU] Laminin: Large, noncollagenous glycoprotein with antigenic properties. It is localized in the basement membrane lamina lucida and functions to bind epithelial cells to the basement membrane. Evidence suggests that the protein plays a role in tumor invasion. [NIH] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Lumbar: Pertaining to the loins, the part of the back between the thorax and the pelvis. [EU] Lymphoma: Any neoplastic disorder of the lymphoid tissue, the term lymphoma often is used alone to denote malignant lymphoma. [EU] Mandible: The largest and strongest bone of the face constituting the lower jaw. It supports the lower teeth. [NIH] Maxillary: Pertaining to the maxilla : the irregularly shaped bone that with its fellow forms the upper jaw. [EU] Membranes: Thin layers of tissue which cover parts of the body, separate adjacent cavities, or connect adjacent structures. [NIH] Microbiological: Pertaining to microbiology : the science that deals with microorganisms, including algae, bacteria, fungi, protozoa and viruses. [EU] Microbiology: The study of microorganisms such as fungi, bacteria, algae, archaea, and viruses. [NIH] Microorganism: A microscopic organism; those of medical interest include bacteria, viruses, fungi and protozoa. [EU] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Neutrophil: Having an affinity for neutral dyes. [EU] Neutrophils: Granular leukocytes having a nucleus with three to five lobes connected by slender threads of chromatin, and cytoplasm containing fine inconspicuous granules and stainable by neutral dyes. [NIH] Orofacial: Of or relating to the mouth and face. [EU] Osteoporosis: Reduction in the amount of bone mass, leading to fractures after minimal trauma. [EU] Peptostreptococcus: A genus of gram-positive, anaerobic, coccoid bacteria that is part of the normal flora of humans. Its organisms are opportunistic

Studies 87

pathogens causing bacteremias and soft tissue infections. [NIH] Periodontics: A dental specialty concerned with the histology, physiology, and pathology of the tissues that support, attach, and surround the teeth, and of the treatment and prevention of disease affecting these tissues. [NIH] Plasminogen: The inactive precursor of plasmin (=enzyme that catalyses the hydrolysis of peptide bonds at the carbonyl end of lysine or arginine residues). [EU] Porphyromonas: A genus of gram-negative, anaerobic, nonsporeforming, nonmotile rods or coccobacilli. Organisms in this genus had originally been classified as members of the bacteroides genus but overwhelming biochemical and chemical findings indicated the need to separate them from other bacteroides species, and hence, this new genus was created. [NIH] Posterior: Situated in back of, or in the back part of, or affecting the back or dorsal surface of the body. In lower animals, it refers to the caudal end of the body. [EU] Prenatal: Existing or occurring before birth, with reference to the fetus. [EU] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. [NIH] Prevotella: A genus of gram-negative, anaerobic, nonsporeforming, nonmotile rods. Organisms of this genus had originally been classified as members of the bacteroides genus but overwhelming biochemical and chemical findings in 1990 indicated the need to separate them from other Bacteroides species, and hence, this new genus was established. [NIH] Progressive: Advancing; going forward; going from bad to worse; increasing in scope or severity. [EU] Proportional: Being in proportion : corresponding in size, degree, or intensity, having the same or a constant ratio; of, relating to, or used in determining proportions. [EU] Prosthesis: An artificial substitute for a missing body part, such as an arm or leg, eye or tooth, used for functional or cosmetic reasons, or both. [EU] Proteins: Polymers of amino acids linked by peptide bonds. The specific sequence of amino acids determines the shape and function of the protein. [NIH]

Radiography: The making of film records (radiographs) of internal structures of the body by passage of x-rays or gamma rays through the body to act on specially sensitized film. [EU] Recombinant: 1. a cell or an individual with a new combination of genes not found together in either parent; usually applied to linked genes. [EU] Recurrence: The return of a sign, symptom, or disease after a remission. [NIH]

88 Periodontitis

Resection: Excision of a portion or all of an organ or other structure. [EU] Resorption: The loss of substance through physiologic or pathologic means, such as loss of dentin and cementum of a tooth, or of the alveolar process of the mandible or maxilla. [EU] Rheumatology: A subspecialty of internal medicine concerned with the study of inflammatory or degenerative processes and metabolic derangement of connective tissue structures which pertain to a variety of musculoskeletal disorders, such as arthritis. [NIH] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Sedimentation: The act of causing the deposit of sediment, especially by the use of a centrifugal machine. [EU] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Substrate: A substance upon which an enzyme acts. [EU] Suppuration: The formation of pus; the act of becoming converted into and discharging pus. [EU] Transplantation: The grafting of tissues taken from the patient's own body or from another. [EU] Treponema: A genus of microorganisms of the order spirochaetales, many of which are pathogenic and parasitic for man. [NIH] Vaccine: A suspension of attenuated or killed microorganisms (bacteria, viruses, or rickettsiae), administered for the prevention, amelioration or treatment of infectious diseases. [EU] Virulence: The degree of pathogenicity within a group or species of microorganisms or viruses as indicated by case fatality rates and/or the ability of the organism to invade the tissues of the host. [NIH]

Books 89

CHAPTER 5. BOOKS ON PERIODONTITIS Overview This chapter provides bibliographic book references relating to periodontitis. You have many options to locate books on periodontitis. The simplest method is to go to your local bookseller and inquire about titles that they have in stock or can special order for you. Some patients, however, feel uncomfortable approaching their local booksellers and prefer online sources (e.g. www.amazon.com and www.bn.com). In addition to online booksellers, excellent sources for book titles on periodontitis include the Combined Health Information Database and the National Library of Medicine. Once you have found a title that interests you, visit your local public or medical library to see if it is available for loan.

Book Summaries: Federal Agencies The Combined Health Information Database collects various book abstracts from a variety of healthcare institutions and federal agencies. To access these summaries, go to http://chid.nih.gov/detail/detail.html. You will need to use the “Detailed Search” option. To find book summaries, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer. For the format option, select “Monograph/Book.” Now type “periodontitis” (or synonyms) into the “For these words:” box. You will only receive results on books. You should check back periodically with this database which is updated every 3 months. The following is a typical result when searching for books on periodontitis: ·

Oral Health for the Orthodontic Patient Source: Chicago, IL: Quintessence Publishing Co, Inc. 1999. 152 p.

90 Periodontitis

Contact: Available from Quintessence Publishing Co, Inc. 551 Kimberly Drive, Carol Stream, IL 60188. (800) 621-0387 or (630) 682-3223. Fax (630) 682-3288. Website: www.quintpub.com. Price: $58.00 plus shipping and handling. ISBN: 0867152958. Summary: This book guides orthodontists in helping their patients to achieve adequate oral hygiene and in identifying and guiding patients with poor oral hygiene. The authors explain the etiology and caries and periodontitis and the methods available for evaluating the patient's risk of experiencing these conditions. Subsequent chapters discuss means of minimizing the orthodontic patient's risk of caries and periodontitis through professional and at home reduction of oral bacteria. The final chapter presents a systematic program for preventing oral health problems in orthodontic patients. This analysis of the factors involved in the development and prevention of caries and periodontitis provides clinicians with the means to develop individualized preventive programs for patients with orthodontic appliances. The book concludes with an extensive section of references and a detailed subject index. The book is illustrated with numerous full color photographs, charts, and figures. 104 figures. 5 tables. 437 references. ·

Clinical Periodontology and Implant Dentistry Source: Copenhagen, Denmark: Munksgaard International Publishers Ltd. 1997. 973 p. Contact: Available from Munksgaard International Publishers Ltd. 35 Norre Sogade, P.O. Box 2148, DK-1016 Copenhagen K, Denmark. Phone +45 33 12 70 30; Fax +45 33 12 93 87; E-mail: [email protected]; http://www.munksgaard.dk. Price: $122.00 plus shipping and handling. ISBN: 8716120604. Summary: This textbook provides a wealth of information on clinical periodontology and implant dentistry. Thirty-three chapters cover topics including the anatomy of the periodontium, epidemiology of periodontal disease, dental plaque and calculus, microbiology of periodontal disease, pathogenesis of periodontitis, early onset periodontitis, necrotizing periodontal disease, trauma from occlusion, endodontics and periodontics, systemic disorders and the periodontium, tumors and cysts of the periodontium, examination of patients with periodontal disease, advances in periodontal diagnosis, treatment planning, cause-related periodontal therapy, antiseptics and antibiotics in periodontal therapy, access therapy in periodontal surgery, mucogingival therapy, regenerative periodontal therapy, esthetics in periodontal therapy, treatment of furcation-involved teeth, occlusal therapy, technical aspects of crown and bridge therapy, orthodontics and periodontics, supportive

Books 91

periodontal therapy (SPT), osseointegration, peri-implant mucosa, radiographic examination, surgical site, alveolar bone formation, and rehabilitation by means of implants. Full-color photographs, radiographs and line drawings illustrate each chapter. Extensive references are also provided with each chapter. A subject index concludes the volume. ·

Blue Book: Dental Prescription Handbook Source: Cleveland, OH: American Academy of Oral Pharmacology. 1996. 32 p. Contact: Available from Academy of Oral Pharmacology. 24200 Chagrin Boulevard, Cleveland, OH 44122. (216) 292-0229; E-mail: [email protected]. Price: $15.00 plus shipping and handling. Summary: This handbook includes over 50 dental product categories and more than 500 dental product entries. The chapters are alphabetical listings of dental conditions. Each chapter contains numerous listings of dental products in categories. These dental products are positioned as potential solutions to the dental conditions. Nineteen chapters are included: allergies, anxiety, aphthous ulcers and minor oral trauma, caries, dentinal hypersensitivity, diagnosis, nicotine addiction, gingivitis, halitosis, hepatitis B, infection control, infections, medical emergencies, oral surgery, pain, periodontitis, sinusitis, stained teeth, and xerostomia. Appendices cover infective endocarditis, AHA prophylactic regimens and guidelines, adult hypertension classifications, adult hematology and complete blood counts, gingival hyperplastic agents, metric weight and volume, the Blue Book Top-30 drug key, xerostomic agents, and 19961997 major dental meetings. (AA-M).

·

Atlas of Diseases of the Oral Cavity in HIV Infection Source: Copenhagen, Denmark: Munksgaard. 1995. 152 p. Contact: Available from Munksgaard. 35 Norre Sogade, P.O. Box 2148, DK-1016, Copenhagen K, Denmark. Telephone +45 33 12 70 30; Fax +45 33 12 93 87; E-mail: [email protected]; http://www.munksgaard.dk/publishers/. Price: DKK 400,000 plus postage; contact directly for current price in US dollars. ISBN: 8716115090. Summary: This atlas of oral diseases in HIV infection depicts and describes the oral manifestations of HIV in three sections. The authors stress that oral manifestations are often the key to an initial clinical diagnosis of HIV infection. The introductory material discusses epidemiology, the global aspects of HIV seropositivity, predictions for the future, and the classification of oral lesions associated with HIV

92 Periodontitis

infection. The first section covers lesions strongly associated with HIV infection including candidiasis, hyperplasia, angular cheilitis, hairy leukoplakia, periodontal diseases, linear gingival erythema, necrotizing gingivitis, stomatitis and periodontitis, Kaposi's sarcoma, and nonHodgkin's lymphoma. The second section covers lesions less commonly associated with HIV infection including tuberculosis, hyperpigmentation, pigmentation of the nails, enlargement of major salivary glands, lymphoepithelial lesion, thrombocytopenia, atypical ulceration, herpes labialis, herpetic stomatitis, herpes zoster, varicella, condyloma acuminatum, focal epithelial hyperplasis, and verruca vulgaris. The third section outlines lesions seen in HIV infection, notably Klebsiella pneumonia infection, bacillar epithelioid angiomatosis, toxic epidermal necrolysis, drug-induced ulcerations, cryptococcoses, mucormycosis, penicilliosis, facial nerve paralysis, aphthous ulceration, cytomegalovirus-induced oral ulceration, and molluscum contagiosum. A final section describes other lesions, including exfoliative cheilitis, impetigo contagiosa, secondary syphilis, lichenoid lesions of buccal mucosa, and oral cancer. The atlas depicts each manifestation with a fullcolor photograph and provides brief descriptions. The book concludes with a list of references, coding according to the international classification of diseases, and a subject index. 111 figures. 193 references. ·

Impact of Tobacco Use on Nonmalignant and Precancerous Oral and Dental Diseases and Conditions: An Indiana University School of Dentistry Teaching Monograph. A Comprehensive Review Source: Indianapolis, IN: Department of Preventive and Community Dentistry, Indiana School of Dentistry. June 1991. 80 p. Contact: Available from Indiana University School of Dentistry. Department of Preventive and Community Dentistry, 1121 West Michigan Street, Indianapolis, IN 46202-5186. Website: www.iusd.iupui.edu. Price: Single copy free. Summary: In addition to a number of intraoral malignancies (cancer), a wide variety of precancerous and nonmalignant oral and perioral diseases and conditions are also directly or indirectly linked to the use of smoked and smokeless (spit) tobacco (ST). This monograph is designed to help the reader understand the etiology, scope, and physical impact of these abnormalities as they relate to tobacco use. This document presents a comprehensive literature review on this topic. The authors reviewed over 800 scientific works and used 426 of these published articles as the basis for this document. The authors emphasize the oral effects of cigarette smoking, but they also review oral problems related to ST use. The literature review demonstrates how tobacco cessation benefits oral

Books 93

health, particularly regarding leukoplakia, stomatitis nicotina, impaired gingival bleeding, periodontitis, gingival (gum) recession, acute necrotizing ulcerative gingivitis, dental calculus, halitosis (bad breath) and dental staining, dental caries, delayed oral wound healing, smoker's melanosis, oral candidiasis, recurrent aphthous ulcers, and altered taste and smell. Information from this report can be used by oral health team members as they learn to recognize and deal with the tobacco related conditions which they diagnose in their patients. A subject index concludes the document. 4 tables. 426 references. ·

Instructions for Patients. 5th ed Source: Orlando, FL: W.B. Saunders Company. 1994. 598 p. Contact: Available from W.B. Saunders Company. Order Fulfillment, 6277 Sea Harbor Drive, Orlando, FL 32887-4430. (800) 545-2522 (individuals) or (800) 782-4479 (schools); Fax (800) 874-6418 or (407) 3523445; http://www.wbsaunders.com. Price: $52.00 (English); $49.95 (Spanish); plus shipping and handling. ISBN: 0721649300 (English); 0721669972 (Spanish). Summary: This book is a compilation of instructions for patients, published in paperback format. The fact sheets each provide information in three sections: basic information, including a description of the condition, frequent signs and symptoms, causes, risk factors, preventive measures, expected outcome, and possible complications; treatment, including general measures, medication, activity guidelines, and diet; and when to contact one's health care provider. Fact sheets are available on oral health topics including: herpangina, leukoplakia, lichen planus, salivary gland infection, benign mouth or tongue tumors, oral cancer, periodontitis, salivary gland tumors, Sjogren's syndrome, stomatitis, teething, temporomandibular joint syndrome (TMJ), oral candidiasis (thrush), thumbsucking, glossitis (tongue inflammation), bruxism (tooth grinding), necrotizing ulcerative gingivitis (trench mouth), and trigeminal neuralgia (tic douloureux). The fact sheets are designed to be photocopied and distributed to patients as a reinforcement of oral instructions and as a teaching tool.

Book Summaries: Online Booksellers Commercial Internet-based booksellers, such as Amazon.com and Barnes & Noble.com, offer summaries which have been supplied by each title’s publisher. Some summaries also include customer reviews. Your local

94 Periodontitis

bookseller may have access to in-house and commercial databases that index all published books (e.g. Books in PrintÒ). The following have been recently listed with online booksellers as relating to periodontitis (sorted alphabetically by title; follow the hyperlink to view more details at Amazon.com): ·

Biology of the Species Porphyromonas Gingivalis by Haroun N. Shah, et al (1993); ISBN: 0849366488; http://www.amazon.com/exec/obidos/ASIN/0849366488/icongroupin terna

·

Essential Endodontology: Prevention and Treatment of Apical Periodontitis by Dag Orstavik (Editor), et al; ISBN: 0632040890; http://www.amazon.com/exec/obidos/ASIN/0632040890/icongroupin terna

·

Oral Health for the Orthodontic Patient by Siegward D. Heintze (Editor), et al; ISBN: 0867152958; http://www.amazon.com/exec/obidos/ASIN/0867152958/icongroupin terna

·

Regeneration of the Periodontal Attachment in Humans by Mick R. Dragoo (1981); ISBN: 0812107861; http://www.amazon.com/exec/obidos/ASIN/0812107861/icongroupin terna

·

Value of New Serological Probes for the Study of Putative Periodontal Pathogens : A Survey After Five Years of Application by Rudolf Gmur (1997); ISBN: 0867153164; http://www.amazon.com/exec/obidos/ASIN/0867153164/icongroupin terna

Chapters on Periodontitis Frequently, periodontitis will be discussed within a book, perhaps within a specific chapter. In order to find chapters that are specifically dealing with periodontitis, an excellent source of abstracts is the Combined Health Information Database. You will need to limit your search to book chapters and periodontitis using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find book chapters, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Book Chapter.” By making these selections and typing in “periodontitis” (or synonyms) into the “For these words:” box, you will only

Books 95

receive results on chapters in books. The following is a typical result when searching for book chapters on periodontitis: ·

Gingivitis and Periodontal Disease Source: in McDonald, R.E. and Avery, D.A., eds. Dentistry for the Child and Adolescent. 7th ed. St. Louis, MO: Mosby, Inc. 2000. p. 440-484. Contact: Available from Harcourt Health Sciences. 11830 Westline Industrial Drive, St. Louis, MO 63146. (800) 325-4177. Fax (800) 874-6418. Website: www.harcourthealth.com. Price: $72.00 plus shipping and handling. ISBN: 0815190174. Summary: Gingivitis, a type of periodontal disease, is an inflammation involving only the gingival (gum) tissues next to the tooth. This chapter on gingivitis and periodontal disease is from a textbook on dentistry for the child and adolescent that is designed to help undergraduate dental students and postdoctoral pediatric dentistry students provide comprehensive oral health care for infants, children, teenagers, and individuals with various disabilities. The authors cover simple gingivitis, including eruption gingivitis, gingivitis associated with poor oral hygiene, and allergy and gingival inflammation; acute gingival disease, including that due to herpes simplex virus infection, recurrent aphthous ulcer (canker sore), acute necrotizing ulcerative gingivitis (ANUG), acute candidiasis (thrush, a fungal infection), and acute bacterial infections; chronic nonspecific gingivitis; chlorhexidine as a therapeutic plaque control agent; conditioned gingival enlargement, including puberty gingivitis, fibromatosis, and phenytoin (Dilantin) induced gingival overgrowth; scorbutic gingivitis (associated with vitamin C deficiency); periodontal diseases in children, including periodontitis, premature bone loss in primary dentition, Papillon Lefevre syndrome (precocious periodontosis), gingival recession, the differential diagnosis of self mutilation, abnormal frenum attachment, and frenectomy; the clinical assessment of oral cleanliness and periodontal disease; extrinsic stains and deposits on teeth; and dental calculus (seen with low frequency in children). 44 figures. 93 references.

·

Periodontitis (Gum Inflammation) Source: in Griffith, H.W. Instruction for Patients. 5th ed. Orlando, FL: W.B. Saunders Company. 1994. p. 340. Contact: Available from W.B. Saunders Company. Order Fulfillment, 6277 Sea Harbor Drive, Orlando, FL 32887-4430. (800) 545-2522 (individuals) or (800) 782-4479 (schools); Fax (800) 874-6418 or (407) 3523445; http://www.wbsaunders.com. Price: $52.00 (English); $49.95

96 Periodontitis

(Spanish); plus shipping and handling. ISBN: 0721649300 (English); 0721669972 (Spanish). Summary: This fact sheet on periodontitis is from a compilation of instructions for patients, published in book format. Periodontitis is inflammation and infection of the gums that can cause loss of supporting bone. The fact sheet provides information in three sections: basic information, including a description of the condition, frequent signs and symptoms, causes, risk factors, preventive measures, expected outcome, and possible complications; treatment, including general measures, medication, activity guidelines, and diet; and when to contact one's health care provider. The fact sheet is designed to be photocopied and distributed to patients as a reinforcement of oral instructions and as a teaching tool.

General Home References In addition to references for periodontitis, you may want a general home medical guide that spans all aspects of home healthcare. The following list is a recent sample of such guides (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · Dental Terminology by Charline M. Dofka, et al; Paperback - 312 pages, 1st edition (July 12, 1999), Delmar Publishers; ISBN: 0827390688; http://www.amazon.com/exec/obidos/ASIN/0827390688/icongroupinterna · Oral Medicine Secrets by Sonis; Paperback (August 15, 2002), Hanley & Belfus; ISBN: 1560534192; http://www.amazon.com/exec/obidos/ASIN/1560534192/icongroupinterna · The Perfect Smile: A Consumer's Guide to Dental Health and Cosmetic Dentistry by James Doundoulakis, Warren Strugatch; Paperback - 160 pages (May 2002), Hatherleigh Press; ISBN: 1578260957; http://www.amazon.com/exec/obidos/ASIN/1578260957/icongroupinterna · Prentice Hall Health: Complete Review of Dental Hygiene by Jacqueline N. Brian, Mary Danusis Cooper; Paperback - 612 pages, 1st edition (July 10, 2001), Prentice Hall; ISBN: 0130833282; http://www.amazon.com/exec/obidos/ASIN/0130833282/icongroupinterna

Books 97

Vocabulary Builder Anxiety: The unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict. Physiological concomitants include increased heart rate, altered respiration rate, sweating, trembling, weakness, and fatigue; psychological concomitants include feelings of impending danger, powerlessness, apprehension, and tension. [EU] Atypical: Irregular; not conformable to the type; in microbiology, applied specifically to strains of unusual type. [EU] Bruxism: A disorder characterized by grinding and clenching of the teeth. [NIH]

Cheilitis: Inflammation of the lips. It is of various etiologies and degrees of pathology. [NIH] Condyloma: C. acuminatum; a papilloma with a central core of connective tissue in a treelike structure covered with epithelium, usually occurring on the mucous membrane or skin of the external genitals or in the perianal region. [EU] Cyst: Any closed cavity or sac; normal or abnormal, lined by epithelium, and especially one that contains a liquid or semisolid material. [EU] Cytomegalovirus: A genus of the family herpesviridae, subfamily betaherpesvirinae, infecting the salivary glands, liver, spleen, lungs, eyes, and other organs, in which they produce characteristically enlarged cells with intranuclear inclusions. Infection with Cytomegalovirus is also seen as an opportunistic infection in AIDS. [NIH] Endocarditis: Exudative and proliferative inflammatory alterations of the endocardium, characterized by the presence of vegetations on the surface of the endocardium or in the endocardium itself, and most commonly involving a heart valve, but sometimes affecting the inner lining of the cardiac chambers or the endocardium elsewhere. It may occur as a primary disorder or as a complication of or in association with another disease. [EU] Epidermal: Pertaining to or resembling epidermis. Called also epidermic or epidermoid. [EU] Erythema: A name applied to redness of the skin produced by congestion of the capillaries, which may result from a variety of causes, the etiology or a specific type of lesion often being indicated by a modifying term. [EU] Glossitis: Inflammation of the tongue. [EU] Halitosis: An offensive, foul breath odor resulting from a variety of causes such as poor oral hygiene, dental or oral infections, or the ingestion of certain foods. [NIH]

98 Periodontitis

Hematology: A subspecialty of internal medicine concerned with morphology, physiology, and pathology of the blood and blood-forming tissues. [NIH] Hepatitis: Inflammation of the liver. [EU] Hyperpigmentation: Excessive pigmentation of the skin, usually as a result of increased melanization of the epidermis rather than as a result of an increased number of melanocytes. Etiology is varied and the condition may arise from exposure to light, chemicals or other substances, or from a primary metabolic imbalance. [NIH] Hyperplasia: The abnormal multiplication or increase in the number of normal cells in normal arrangement in a tissue. [EU] Hypersensitivity: A state of altered reactivity in which the body reacts with an exaggerated immune response to a foreign substance. Hypersensitivity reactions are classified as immediate or delayed, types I and IV, respectively, in the Gell and Coombs classification (q.v.) of immune responses. [EU] Impetigo: A common superficial bacterial infection caused by staphylococcus aureus or group A beta-hemolytic streptococci. Characteristics include pustular lesions that rupture and discharge a thin, amber-colored fluid that dries and forms a crust. This condition is commonly located on the face, especially about the mouth and nose. [NIH] Klebsiella: A genus of gram-negative, facultatively anaerobic, rod-shaped bacteria whose organisms arrange singly, in pairs, or short chains. This genus is commonly found in the intestinal tract and is an opportunistic pathogen that can give rise to bacteremia, pneumonia, urinary tract and several other types of human infection. [NIH] Melanosis: A disorder caused by a disturbance in melanin pigmentation; melanism. [EU] Mucosa: A mucous membrane, or tunica mucosa. [EU] Necrolysis: Separation or exfoliation of tissue due to necrosis. [EU] Neuralgia: Paroxysmal pain which extends along the course of one or more nerves. Many varieties of neuralgia are distinguished according to the part affected or to the cause, as brachial, facial, occipital, supraorbital, etc., or anaemic, diabetic, gouty, malarial, syphilitic, etc. [EU] Nicotine: Nicotine is highly toxic alkaloid. It is the prototypical agonist at nicotinic cholinergic receptors where it dramatically stimulates neurons and ultimately blocks synaptic transmission. Nicotine is also important medically because of its presence in tobacco smoke. [NIH] Paralysis: Loss or impairment of motor function in a part due to lesion of the neural or muscular mechanism; also by analogy, impairment of sensory function (sensory paralysis). In addition to the types named below, paralysis

Books 99

is further distinguished as traumatic, syphilitic, toxic, etc., according to its cause; or as obturator, ulnar, etc., according to the nerve part, or muscle specially affected. [EU] Perioral: Situated or occurring around the mouth. [EU] Phenytoin: An anticonvulsant that is used in a wide variety of seizures. It is also an anti-arrhythmic and a muscle relaxant. The mechanism of therapeutic action is not clear, although several cellular actions have been described including effects on ion channels, active transport, and general membrane stabilization. The mechanism of its muscle relaxant effect appears to involve a reduction in the sensitivity of muscle spindles to stretch. Phenytoin has been proposed for several other therapeutic uses, but its use has been limited by its many adverse effects and interactions with other drugs. [NIH] Sinusitis: Inflammation of a sinus. The condition may be purulent or nonpurulent, acute or chronic. Depending on the site of involvement it is known as ethmoid, frontal, maxillary, or sphenoid sinusitis. [EU] Stomatitis: Inflammation of the oral mucosa, due to local or systemic factors which may involve the buccal and labial mucosa, palate, tongue, floor of the mouth, and the gingivae. [EU] Thrombocytopenia: Decrease in the number of blood platelets. [EU] Toxic: Pertaining to, due to, or of the nature of a poison or toxin; manifesting the symptoms of severe infection. [EU] Tuberculosis: Any of the infectious diseases of man and other animals caused by species of mycobacterium. [NIH] Ulceration: 1. the formation or development of an ulcer. 2. an ulcer. [EU] Varicella: Chicken pox. [EU] Xerostomia: Dryness of the mouth from salivary gland dysfunction, as in Sjögren's syndrome. [EU]

Multimedia 101

CHAPTER 6. MULTIMEDIA ON PERIODONTITIS Overview Information on periodontitis can come in a variety of formats. Among multimedia sources, video productions, slides, audiotapes, and computer databases are often available. In this chapter, we show you how to keep current on multimedia sources of information on periodontitis. We start with sources that have been summarized by federal agencies, and then show you how to find bibliographic information catalogued by the National Library of Medicine. If you see an interesting item, visit your local medical library to check on the availability of the title.

Bibliography: Multimedia on Periodontitis The National Library of Medicine is a rich source of information on healthcare-related multimedia productions including slides, computer software, and databases. To access the multimedia database, go to the following Web site: http://locatorplus.gov/. Select “Search LOCATORplus.” Once in the search area, simply type in periodontitis (or synonyms). Then, in the option box provided below the search box, select “Audiovisuals and Computer Files.” From there, you can choose to sort results by publication date, author, or relevance. The following multimedia has been indexed on periodontitis. For more information, follow the hyperlink indicated: ·

Advanced ultrasonics in general practice periodontics . Format: Videorecording; Aurora, Mo.: Video Dent, c1996

·

Apically positioned partial thickness flap to eliminate periodontal pockets. Source: Veterans Administration Dental Training Center; Year:

Year: 1996;

102 Periodontitis

1968; Format: Motion picture; Washington: The Center: [for sale by National Audiovisual Center; Atlanta: for loan by National Medical Audiovisual Center, 1968] ·

Contiguous osseous tissue autograph in periodontics. Source: Veterans Administration Dental Training Center; Year: 1969; Format: Motion picture; Washington: The Center; [Chicago: for loan by American Dental Assn., Bureau of Audiovisual Services; Washington: for sale by U. S. Veterans Administration Central Office Film Library, 1969]

·

Elimination of a shallow infrabony pocket by ostectomy in retromolar area. Source: Veterans Administration Dental Training Center; Year: 1968; Format: Motion picture; Washington: The Center: [for sale by National Audiovisual Center; Atlanta: for loan by National Medical Audiovisual Center, 1968]

·

Endodontic emergency treatment. Source: Franklin S. Weine; [produced by Ritter Dental Supply Company]; Year: 1972; Format: Videorecording; Chicago: Chicago Dental Society; [Atlanta: for loan by National Medical Audiovisual Center, 1972]

·

Endodontics and apicurettage : mandibular anterior area. Source: [presented by] David Green; Year: 1959; Format: Motion picture; [Brooklyn, N.Y.: D. Green, 1959]

·

Flap procedure for periodontal lesions. Source: [presented by] University of Minnesota, School of Dentistry, Division of Periodontia; Year: 1957; Format: Motion picture; [Minneapolis]: The School, [1957]

·

Free osseous tissue autograft to eliminate an infrabony pocket. Source: Veterans Administration Dental Training Center; Year: 1968; Format: Motion picture; Washington: The Center: [for sale by National Audiovisual Center; Atlanta: for loan by National Medical Audiovisual Center, 1968]

·

Genetic risk for severe periodontitis--the new periodontics. Source: University of Southern California, 23rd Annual Periodontal Symposium, February 7 and 8, 1997, Los Angeles Omni Hotel; [presented by] A-V Health Promotions; Year: 1997; Format: Videorecording; [United States]: A-V Health Promotions, c1997

·

Gingival autograft in periodontics. Source: [produced by] Veterans Administration Dental Training Center; Year: 1968; Format: Videorecording; Washington, D.C.: The Center, [1968]

·

Gingival autograft in periodontics. Source: Veterans Administration Dental Training Center; Year: 1968; Format: Motion picture; Washington: The Center: [for sale by National Audiovisual Center; Atlanta: for loan by National Medical Audiovisual Center, 1968]

Multimedia 103

·

Gingival surgery in periodontal therapy. Source: presented by Massachusetts Dental Society and Wyeth Laboratories; Year: 1957; Format: Motion picture; [Philadelphia, Pa.]: The Laboratories, [1957]

·

Lesions of epithelial tissue origin. Source: Richard J. Oglesby; Year: 1975; Format: Slide; Washington: National Audiovisual Center, 1975

·

Modified flap. Source: produced by Veterans Administration Dental Training Center; Year: 1977; Format: Motion picture; Washington, D.C.: The Center, 1977

·

Modified Widman flap. Source: produced by Veterans Administration Dental Training Center; Year: 1977; Format: Motion picture; [Washington, D.C.]: The Center, 1977

·

Modified Widman flap. Source: Veterans Administration Dental Training Center; Year: 1967; Format: Motion picture; Washington: The Center; [Atlanta: for loan by National Medical Audiovisual Center, 1967]

·

Periodontal disease : prevention and early treatment. Source: produced by Low & Associates, Inc; Year: 1963; Format: Motion picture; United States: Dept. of the Navy, 1963

·

Periodontal implications of orthodontic therapy. Source: American Association of Orthodontists; Year: 1970; Format: Slide; St. Louis: The Association, [1970]

·

Periodontal surgery from resection to regeneration. Source: CDS; [edited by Robert M. Wood for Chicago Dental Society and Great Plains National, a service agency of the University of Nebraska]; Year: 1993; Format: Videorecording; [Chicago, Ill.]: Chicago Dental Society, c1993

·

Periodontal surgery. Source: [presented by] University of Minnesota, School of Dentistry, Division of Periodontia; Year: 1954; Format: Motion picture; United States: The University, [1954]

·

Periodontics for the general practitioner. Source: University of Nebraska Medical Center, College of Dentistry; produced for the Chicago Dental Society by WGN Continental Productions; Year: 1982; Format: Videorecording; [Lincoln, Neb.]: The College, c1982

·

Periodontitis : microscopic observations. Source: presented by Lion Corporation; produced by Hayashi Productions, Corp., Inc; Year: 1979; Format: Motion picture; [S.l.: s.n., 1979?]

·

Signs and symptoms of periodontitis. Source: David J. Mishkin, in cooperation with the Office of Education, College of Dental Medicine, Medical University of South Carolina; Year: 1978; Format: Slide; Atlanta: National Medical Audiovisual Center, 1978

104 Periodontitis

·

Surgical elimination of periodontal pockets. Source: produced by Veterans Administration Dental Training Center, VA Hospital; Year: 1977; Format: Videorecording; Washington, D.C.: The Center, [1977]

·

Surgical elimination of the periodontal pocket. Source: [presented by] the California Academy of Periodontology; Year: 1951; Format: Motion picture; United States: The Academy, [1951]

·

Surgical treatment of apical infections followed immediately by treatment and filling of the root canal. Source: [production company unknown]; Henry J. Droba; Year: 1940; Format: Motion picture; [United States: H.J. Droba, 1940]

·

Techniques in periodontal surgery. Source: [presented by] Department of Periodontics, Temple University School of Dentistry; Year: 1960; Format: Motion picture; United States: The School, [1960]

·

Treatment of the infrabony pocket with three osseous walls. Source: Veterans Administration Dental Training Center; Year: 1968; Format: Motion picture; Washington: The Center: [for sale by National Audiovisual Center, 1968]

·

Use of a bioabsorbable drug delivery system in local drug delivery of doxycycline hyclate to treat periodontitis. Source: University of Southern California, 23rd Annual Periodontal Symposium, February 7 and 8, 1997, Los Angeles Omni Hotel; by A; Year: 1997; Format: Videorecording; [United States]: A-V Health Promotions, c1997

Periodicals and News 105

CHAPTER 7. PERIODICALS AND NEWS ON PERIODONTITIS Overview Keeping up on the news relating to periodontitis can be challenging. Subscribing to targeted periodicals can be an effective way to stay abreast of recent developments on periodontitis. Periodicals include newsletters, magazines, and academic journals. In this chapter, we suggest a number of news sources and present various periodicals that cover periodontitis beyond and including those which are published by patient associations mentioned earlier. We will first focus on news services, and then on periodicals. News services, press releases, and newsletters generally use more accessible language, so if you do chose to subscribe to one of the more technical periodicals, make sure that it uses language you can easily follow.

News Services & Press Releases Well before articles show up in newsletters or the popular press, they may appear in the form of a press release or a public relations announcement. One of the simplest ways of tracking press releases on periodontitis is to search the news wires. News wires are used by professional journalists, and have existed since the invention of the telegraph. Today, there are several major “wires” that are used by companies, universities, and other organizations to announce new medical breakthroughs. In the following sample of sources, we will briefly describe how to access each service. These services only post recent news intended for public viewing.

106 Periodontitis

PR Newswire Perhaps the broadest of the wires is PR Newswire Association, Inc. To access this archive, simply go to http://www.prnewswire.com. Below the search box, select the option “The last 30 days.” In the search box, type “periodontitis” or synonyms. The search results are shown by order of relevance. When reading these press releases, do not forget that the sponsor of the release may be a company or organization that is trying to sell a particular product or therapy. Their views, therefore, may be biased. Reuters The Reuters' Medical News database can be very useful in exploring news archives relating to periodontitis. While some of the listed articles are free to view, others can be purchased for a nominal fee. To access this archive, go to http://www.reutershealth.com/frame2/arch.html and search by “periodontitis” (or synonyms). The following was recently listed in this archive for periodontitis: ·

Periodontitis may promote atheroma formation Source: Reuters Medical News Date: November 21, 2001 http://www.reuters.gov/archive/2001/11/21/professional/links/20011 121epid007.html

·

Eliminating periodontitis does not lower coronary heart disease risk Source: Reuters Medical News Date: July 24, 2001 http://www.reuters.gov/archive/2001/07/24/professional/links/20010 724clin013.html

·

Increased risk of periodontitis seen among patients with rheumatoid arthritis Source: Reuters Industry Breifing Date: June 25, 2001 http://www.reuters.gov/archive/2001/06/25/business/links/20010625 epid006.html

·

MI patients more likely to have periodontitis than healthy people Source: Reuters Medical News Date: November 13, 2000 http://www.reuters.gov/archive/2000/11/13/professional/links/20001 113epid008.html

Periodicals and News 107

·

Periodontitis common in patients requiring heart transplantation Source: Reuters Medical News Date: June 20, 2000 http://www.reuters.gov/archive/2000/06/20/professional/links/20000 620epid007.html

·

Abnormal gene linked to severe gum disease Source: Reuters Health eLine Date: February 18, 2000 http://www.reuters.gov/archive/2000/02/18/eline/links/20000218elin 008.html The NIH

Within MEDLINEplus, the NIH has made an agreement with the New York Times Syndicate, the AP News Service, and Reuters to deliver news that can be browsed by the public. Search news releases at http://www.nlm.nih.gov/medlineplus/alphanews_a.html. MEDLINEplus allows you to browse across an alphabetical index. Or you can search by date at http://www.nlm.nih.gov/medlineplus/newsbydate.html. Often, news items are indexed by MEDLINEplus within their search engine.

Business Wire Business Wire is similar to PR Newswire. To access this archive, simply go to http://www.businesswire.com. You can scan the news by industry category or company name.

Internet Wire Internet Wire is more focused on technology than the other wires. To access this site, go to http://www.internetwire.com and use the “Search Archive” option. Type in “periodontitis” (or synonyms). As this service is oriented to technology, you may wish to search for press releases covering diagnostic procedures or tests that you may have read about.

108 Periodontitis

Search Engines Free-to-view news can also be found in the news section of your favorite search engines (see the health news page at Yahoo: http://dir.yahoo.com/Health/News_and_Media/, or use this Web site’s general news search page http://news.yahoo.com/. Type in “periodontitis” (or synonyms). If you know the name of a company that is relevant to periodontitis, you can go to any stock trading Web site (such as www.etrade.com) and search for the company name there. News items across various news sources are reported on indicated hyperlinks.

BBC Covering news from a more European perspective, the British Broadcasting Corporation (BBC) allows the public free access to their news archive located at http://www.bbc.co.uk/. Search by “periodontitis” (or synonyms).

Newsletter Articles If you choose not to subscribe to a newsletter, you can nevertheless find references to newsletter articles. We recommend that you use the Combined Health Information Database, while limiting your search criteria to “newsletter articles.” Again, you will need to use the “Detailed Search” option. Go to the following hyperlink: http://chid.nih.gov/detail/detail.html. Go to the bottom of the search page where “You may refine your search by.” Select the dates and language that you prefer. For the format option, select “Newsletter Article.” By making these selections, and typing in “periodontitis” (or synonyms) into the “For these words:” box, you will only receive results on newsletter articles. You should check back periodically with this database as it is updated every 3 months. The following is a typical result when searching for newsletter articles on periodontitis: ·

Oral Health and Heart Disease Source: Harvard Health Letter. 11(7): 1-3. March 2001. Contact: Available from Harvard Health Publications. P.O. Box 420300, Palm Coast, FL 32142-0300. (800) 829-9045. Website: www.health.harvard.edu.

Periodicals and News 109

Summary: This article explores the recent evidence that by averting gum disease, patients might actually be reducing their chances for developing heart disease. The author notes that, at the very least, it seems clear that people with worse dental health have a higher risk of heart attack. Recent findings link periodontal disease to cardiovascular disease. Periodontal disease is any disease, including gingivitis or periodontitis, that affects the gums and associated membranes. However, not all of these studies adequately controlled for other risk factors (for example, socioeconomic status, age, or unhealthy behaviors). Poor dental health may consequently have been an indication of poor personal hygiene or suboptimal health habits. The author cautions that the observed increase in heart disease risk among those with poor dental health may have reflected a general lack of health care, rather than a lack of dental care in particular. The article also reports on present Harvard studies that are evaluating the role of inflammation and diet as potential mediators. For example, periodontal disease and resulting tooth loss may lead to poor dietary habits that, in turn, might increase heart disease risk. The article concludes by hypothesizing the role of inflammation (the body's response to infection or injury) in heart disease. 1 figure. ·

Periodontal Disease and Sjogren's Syndrome Source: Moisture Seekers Newsletter. p. 1-2. February 2000. Contact: Available from Sjogren's Syndrome Foundation Inc. 333 North Broadway, Jericho, NY 11753. (800) 4-SJOGREN or (516) 933-6365. Fax (516) 933-6368. Summary: This newsletter article explores the problem of periodontal disease in individuals with Sjogren's syndrome (SS). The author first briefly reviews SS and its characteristics, noting that patients with SS have a 2.2 times higher risk of having periodontal disease than healthy subjects. The article then discusses the development of periodontal disease, explaining why the reduced saliva flow in patients with SS contributes to this problem. The author lists the more common symptoms of periodontal disease, reminds readers of the daily oral hygiene (brushing and flossing) strategies to prevent or control periodontal disease, and reviews the treatments for periodontal disease (the most common of which is scaling and root planing). The author concludes with a brief discussion of the destructive enzymes that are present in SS and the indications for drug therapy to block these destructive enzymes. In patients with SS who suffer from periodontal disease, the use of an enzyme inhibitor might not only help in the management of their periodontitis, but may also directly aid in slowing down the destruction of their salivary glands.

110 Periodontitis

·

Bad Teeth and Gums a Risk Factor for Heart Disease? Source: Harvard Heart Letter. 9(3): 6-7. November 1998. Contact: Available from Harvard Heart Letter. P.O. Box 420379, Palm Coast, FL 32142-0379. (800) 829-9171. E-mail: [email protected]. Website: www.countway.harvard.edu/publications/Health_Publications. Summary: This newsletter article informs readers about recent studies that are investigating the role of bad teeth and gums as risk factors for heart disease. Several studies found that patients with heart disease had more tooth decay and higher rates of gum disease. A link between oral health and heart disease was also found in epidemiological studies that examined people's teeth and then followed them for several years to see if those with poor dental health were more likely to get heart disease. For example, people with inflammation of the gums (periodontitis) had a 25 percent increased risk of heart disease over the follow up period, compared to those with minimal periodontitis. The author notes that one reason why many scientists have been skeptical about poor dental health as a cause of heart disease is that there was no obvious way in which the two conditions could be linked. Some experts now speculate that the bacteria that accumulate in the gums and teeth of people with poor dental hygiene cause inflammation that leads to an increase in blood clotting factors. If so, these clotting factors might increase the chances that a blood clot could form in the heart. Another theory considers the role of white blood cells that fight infection in the gums and elsewhere. The author concludes that these theories sound promising, but at present remain unproven.

·

Dental Care: How to Help Your Teeth Last a Lifetime Source: Mayo Clinic Health Letter. 15(10): 1-3. October 1997. Contact: Available from Mayo Clinic Health Letter. Subscription Services, P.O. Box 53889, Boulder, CO 80322-3889. (800) 291-1128. Summary: This health newsletter article reviews the basics of good oral hygiene and the role of preventive dental care. Written primarily for an audience of older adults, the article emphasizes that although aging can bring changes that make teeth more vulnerable, with proper care, the teeth can last a lifetime. Topics include dental plaque, gingivitis, periodontitis, dental risk factors associated with aging, and the adverse effects of medications (notably xerostomia, or dry mouth). The article concludes with a brief discussion of the risk factors for cavities and periodontal disease in older adults. These factors include co-existing medical conditions or systemic disease, a poor diet, lack of preventive

Periodicals and News 111

dental care, lack of fluoridated water, and lack of transportation to dental care. One sidebar provides a brief quiz for readers to determine if they need a dental check-up. 1 figure. ·

Xerostomia Source: Moisture Seekers Newsletter. 11(9): 1, 4-7. September 1993. Contact: Available from Sjogren's Syndrome Foundation, Inc. The Moisture Seekers, 333 North Broadway, Jericho, NY 11753. (800) 4SJOGREN or (516) 933-6365; Fax (516) 933-6368. Summary: Patients with xerostomia (dry mouth) may complain of a parched, rough, and sticky feeling in the mouth which is associated with diminished salivary secretion. This newsletter article, reprinted from Pharmacy Times, reviews the condition of xerostomia. It discusses the functions of saliva; dental caries associated with xerostomia; other oral manifestations, including periodontitis, mucositis, and candidiasis or herpetic infections; the causes of dry mouth; presenting symptoms or questions to ask a patient who might have xerostomia; treatment options; agents to replace or stimulate saliva production; parasympathomimetic drugs, including pilocarpine, bethanechol, and isoproterenol; antiinfective formulations; pain relievers; and saliva substitutes. Readers are encouraged to share the article with their pharmacists, to help them become more knowledgeable about Sjogren's syndrome and xerostomia. 2 tables.

·

Gum Disease: You Can Often Prevent This Cause of Tooth Loss Source: Mayo Clinic Health Letter. 10(12): 4-6. December 1992. Contact: Available from Mayo Clinic Health Letter. Subscription Services, P.O. Box 53889, Boulder, CO 80322-3889. (800) 333-9037. Summary: This newsletter article reminds readers of the steps to take in preventing gum disease, including gingivitis and periodontitis. Topics covered include the symptoms of these types of gum disease; how the dentist screens for gum disease; risk factors, including genetics, medications, smoking, pregnancy, and decreased immunity; and treatment options, such as scaling and root planing, antibiotic therapy, and surgery. The article concludes with a brief discussion on research and development of new treatment strategies. One sidebar summarizes daily tooth care recommendations. 6 figures.

112 Periodontitis

Academic Periodicals covering Periodontitis Academic periodicals can be a highly technical yet valuable source of information on periodontitis. We have compiled the following list of periodicals known to publish articles relating to periodontitis and which are currently indexed within the National Library of Medicine's PubMed database (follow hyperlinks to view more information, summaries, etc., for each). In addition to these sources, to keep current on articles written on periodontitis published by any of the periodicals listed below, you can simply follow the hyperlink indicated or go to the following Web site: www.ncbi.nlm.nih.gov/pubmed. Type the periodical's name into the search box to find the latest studies published. If you want complete details about the historical contents of a periodical, you can also visit http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi. Here, type in the name of the journal or its abbreviation, and you will receive an index of published articles. At http://locatorplus.gov/ you can retrieve more indexing information on medical periodicals (e.g. the name of the publisher). Select the button “Search LOCATORplus.” Then type in the name of the journal and select the advanced search option “Journal Title Search.” The following is a sample of periodicals which publish articles on periodontitis: ·

Histochemistry and Cell Biology. (Histochem Cell Biol) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Hi stochemistry+and+Cell+Biology&dispmax=20&dispstart=0

·

Journal of Clinical Periodontology. (J Clin Periodontol) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Jo urnal+of+Clinical+Periodontology&dispmax=20&dispstart=0

Vocabulary Builder Bethanechol: A slowly hydrolyzed muscarinic agonist with no nicotinic effects. Bethanechol is generally used to increase smooth muscle tone, as in the GI tract following abdominal surgery or in urinary retention in the absence of obstruction. It may cause hypotension, cardiac rate changes, and bronchial spasms. [NIH] Immunity: The condition of being immune; the protection against infectious disease conferred either by the immune response generated by immunization or previous infection or by other nonimmunologic factors

Periodicals and News 113

(innate i.). [EU] Isoproterenol: Isopropyl analog of epinephrine; beta-sympathomimetic that acts on the heart, bronchi, skeletal muscle, alimentary tract, etc. It is used mainly as bronchodilator and heart stimulant. [NIH] Parasympathomimetic: 1. producing effects resembling those of stimulation of the parasympathetic nerve supply to a part. 2. an agent that produces effects similar to those produced by stimulation of the parasympathetic nerves. Called also cholinergic. [EU] Pharmacists: Those persons legally qualified by education and training to engage in the practice of pharmacy. [NIH] Pilocarpine: A slowly hydrolyzed muscarinic agonist with no nicotinic effects. Pilocarpine is used as a miotic and in the treatment of glaucoma. [NIH] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU]

Physician Guidelines and Databases 115

CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES Overview Healthcare providers and medical researchers rely on a number of information sources to help patients with their conditions. Many will subscribe to journals or newsletters published by their professional associations or refer to specialized textbooks or clinical guides published for the medical profession. In this chapter, we focus on databases and Internetbased guidelines created or written for this professional audience.

NIH Guidelines For the more common diseases, The National Institutes of Health publish guidelines that are frequently consulted by healthcare providers. Publications are typically written by one or more of the various NIH Institutes. For physician guidelines, commonly referred to as “clinical” or “professional” guidelines, you can visit the following Institutes: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Institute of General Medical Sciences (NIGMS); fact sheets available at http://www.nigms.nih.gov/news/facts/

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines: http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Dental and Craniofacial Research (NIDCR); guidelines available at http://www.nidr.nih.gov/health/

116 Periodontitis

NIH Databases In addition to the various Institutes of Health that publish professional guidelines, the NIH has designed a number of databases for professionals.19 Physician-oriented resources provide a wide variety of information related to the biomedical and health sciences, both past and present. The format of these resources varies. Searchable databases, bibliographic citations, full text articles (when available), archival collections, and images are all available. The following are referenced by the National Library of Medicine:20 ·

Bioethics: Access to published literature on the ethical, legal and public policy issues surrounding healthcare and biomedical research. This information is provided in conjunction with the Kennedy Institute of Ethics located at Georgetown University, Washington, D.C.: http://www.nlm.nih.gov/databases/databases_bioethics.html

·

HIV/AIDS Resources: Describes various links and databases dedicated to HIV/AIDS research: http://www.nlm.nih.gov/pubs/factsheets/aidsinfs.html

·

NLM Online Exhibitions: Describes “Exhibitions in the History of Medicine”: http://www.nlm.nih.gov/exhibition/exhibition.html. Additional resources for historical scholarship in medicine: http://www.nlm.nih.gov/hmd/hmd.html

·

Biotechnology Information: Access to public databases. The National Center for Biotechnology Information conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information for the better understanding of molecular processes affecting human health and disease: http://www.ncbi.nlm.nih.gov/

·

Population Information: The National Library of Medicine provides access to worldwide coverage of population, family planning, and related health issues, including family planning technology and programs, fertility, and population law and policy: http://www.nlm.nih.gov/databases/databases_population.html

·

Cancer Information: Access to caner-oriented databases: http://www.nlm.nih.gov/databases/databases_cancer.html

Remember, for the general public, the National Library of Medicine recommends the databases referenced in MEDLINEplus (http://medlineplus.gov/ or http://www.nlm.nih.gov/medlineplus/databases.html). 20 See http://www.nlm.nih.gov/databases/databases.html. 19

Physician Guidelines and Databases 117

·

Profiles in Science: Offering the archival collections of prominent twentieth-century biomedical scientists to the public through modern digital technology: http://www.profiles.nlm.nih.gov/

·

Chemical Information: Provides links to various chemical databases and references: http://sis.nlm.nih.gov/Chem/ChemMain.html

·

Clinical Alerts: Reports the release of findings from the NIH-funded clinical trials where such release could significantly affect morbidity and mortality: http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html

·

Space Life Sciences: Provides links and information to space-based research (including NASA): http://www.nlm.nih.gov/databases/databases_space.html

·

MEDLINE: Bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the healthcare system, and the pre-clinical sciences: http://www.nlm.nih.gov/databases/databases_medline.html

·

Toxicology and Environmental Health Information (TOXNET): Databases covering toxicology and environmental health: http://sis.nlm.nih.gov/Tox/ToxMain.html

·

Visible Human Interface: Anatomically detailed, three-dimensional representations of normal male and female human bodies: http://www.nlm.nih.gov/research/visible/visible_human.html

While all of the above references may be of interest to healthcare providers who study and treat periodontitis, the following are particularly noteworthy.

The Combined Health Information Database A comprehensive source of information on clinical guidelines written for professionals is the Combined Health Information Database. You will need to limit your search to “Brochure/Pamphlet,” “Fact Sheet,” or “Information Package” and periodontitis using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For the publication date, select “All Years,” select your preferred language, and the format option “Fact Sheet.” By making these selections and typing “periodontitis” (or synonyms) into the “For these words:” box above, you will only receive results on fact sheets dealing with periodontitis. The following is a sample result:

118 Periodontitis

·

Recent Advances in Oral Health: Report of a WHO Expert Committee Source: Albany, NY: World Health Organization (WHO). 1992. 48 p. Contact: Available from World Health Organization (WHO). Publications Center, 49 Sheridan Avenue, Albany, NY 12210. (518) 436-9686; Fax (518) 436-7433. Price: $6.30 each; bulk orders available. Summary: This report is from a World Health Organization (WHO) Committee charged to consider advances in the fields of prevention, diagnosis, treatment, and computerization within the oral health profession; to advise on which measures should be implemented now and which after further development; to examine the polarity that has developed in oral health between tissue-invasive or other hightechnology interventions and preventive, control, and self care strategies; and to give guidance on the growing need to integrate many activities with different areas of the health profession and other sectors in the search for broader health strategies and involvement. Specific topics include fluoride, sealants, saliva, artificial saliva, diet, antimicrobials, modifying molecules, immunization, risk assessment, gingivitis, microbiology, risk factors for periodontal diseases, oral hygiene, oral cancer, treatment of gingivitis, tissue regeneration, juvenile periodontitis, necrotizing ulcerative gingivitis, malocclusion, dental implants, orofacial lesions, oral manifestations of HIV infection and AIDS, facial pain, oral surgical techniques, advances in technology, personnel issues, work environment and support, and professional education and training. The document concludes with recommendations in five areas: self care and low intervention oral health care; technology transfer; informatics developments in the advancement of oral health; enhancement of scientific research; and broadening the scope of oral health care. One appendix presents a classification of oral lesions associated with HIV infection. 22 references.

·

For a Lifetime of Smiles Source: Chicago, IL: American Dental Hygienists' Association (ADHA). 1993. [6 p.]. Contact: Available from American Dental Hygienists' Association (ADHA). 444 North Michigan Avenue, Chicago, IL 60611. (800) 243-2342 or (312) 440-8900; Fax (312) 440-8929; E-mail: [email protected]; http://www.adha.org. Price: $12.00 for set of 25 copies; $20.00 for set of 50 copies; nonmembers add 25 percent (Illinois residents add 8 percent sales tax). Order Number 3050. Summary: This brochure explains how consumers can maintain a healthy smile throughout their growing years. Topics covered in the brochure

Physician Guidelines and Databases 119

include proper toothbrushing and flossing; preventing baby bottle tooth decay; reducing the risk of oral health problems such as plaque, calculus, tooth decay, gingivitis and periodontitis; the use of fluoride and sealants; orthodontics; the role of nutrition in healthy teeth and gums; dental care and choosing the right dental office; infection control in the dental office; and special considerations for older adults. ·

Gum Disease: Are You At Risk? Source: Chicago, IL: American Dental Association (ADA). 1991. [4 p.]. Contact: Available from American Dental Association (ADA). Catalog Sales, P.O. Box 776, St. Charles, IL 60174. (800) 947-4746; Fax (630) 4439970; http://www.ada.org. Price: $19.00 for 50 copies; nonmembers add 50 percent; bulk orders available. Order Number W172. Summary: This brochure provides answers to some commonly asked questions about gum disease (periodontal disease). Topics include a description of periodontal disease, including gingivitis and periodontitis; the causes of gum disease; the symptoms of gum disease; times when gum disease is more likely to occur, such as puberty or pregnancy, and when certain lifestyle risks are present; how the dentist diagnoses gum disease; what patients can do to prevent gum disease; and how and by whom gum disease is treated. The brochure is illustrated with small photographs of patients representing various ethnic groups.

·

Common Oral Lesions Associated with HIV Infection Source: Columbus, OH: The Ohio State University. 1990. 30 p. Contact: Available from Ohio State University. The East Central AIDS Education and Training Center, Department of Family Medicine, Area 300, 1314 Kinnear Road, Columbus, OH 43212. (614) 292-1400. Fax: (614) 292-4056. Price: $1.00. Order Number 752-4669. Summary: Several signs of the human immunodeficiency virus (HIV) infection, such as candidiasis, hairy leukoplakia, and Kaposi's sarcoma, may first appear in the oral cavity. This pocket guide to the common oral lesions associated with HIV infection is designed to provide both the dental and medical practitioners with clinical photographs and descriptions of the common HIV-associated oral lesions. Included are fungal infections (four forms of candidiasis); neoplasms; viral infections, including oral warts, recurrent herpetic infections, and hairy leukoplakia; and bacterial infections, including gingivitis, periodontitis, necrotizing stomatitis. Diagnosis and treatment suggestions for each of the oral lesions are included as well. Illustrated with full-color photographs.

120 Periodontitis

The NLM Gateway21 The NLM (National Library of Medicine) Gateway is a Web-based system that lets users search simultaneously in multiple retrieval systems at the U.S. National Library of Medicine (NLM). It allows users of NLM services to initiate searches from one Web interface, providing “one-stop searching” for many of NLM's information resources or databases.22 One target audience for the Gateway is the Internet user who is new to NLM's online resources and does not know what information is available or how best to search for it. This audience may include dentists and other healthcare providers, researchers, librarians, students, and, increasingly, patients, their families, and the public.23 To use the NLM Gateway, simply go to the search site at http://gateway.nlm.nih.gov/gw/Cmd. Type “periodontitis” (or synonyms) into the search box and click “Search.” The results will be presented in a tabular form, indicating the number of references in each database category. Results Summary Items Found Category Journal Articles 12740 Books / Periodicals / Audio Visual 74 Consumer Health 3 Meeting Abstracts 28 Other Collections 4 Total 12849

Adapted from NLM: http://gateway.nlm.nih.gov/gw/Cmd?Overview.x. The NLM Gateway is currently being developed by the Lister Hill National Center for Biomedical Communications (LHNCBC) at the National Library of Medicine (NLM) of the National Institutes of Health (NIH). 23 Other users may find the Gateway useful for an overall search of NLM's information resources. Some searchers may locate what they need immediately, while others will utilize the Gateway as an adjunct tool to other NLM search services such as PubMed® and MEDLINEplus®. The Gateway connects users with multiple NLM retrieval systems while also providing a search interface for its own collections. These collections include various types of information that do not logically belong in PubMed, LOCATORplus, or other established NLM retrieval systems (e.g., meeting announcements and pre-1966 journal citations). The Gateway will provide access to the information found in an increasing number of NLM retrieval systems in several phases. 21 22

Physician Guidelines and Databases 121

HSTAT24 HSTAT is a free, Web-based resource that provides access to full-text documents used in healthcare decision-making.25 HSTAT's audience includes healthcare providers, health service researchers, policy makers, insurance companies, consumers, and the information professionals who serve these groups. HSTAT provides access to a wide variety of publications, including clinical practice guidelines, quick-reference guides for clinicians, consumer health brochures, evidence reports and technology assessments from the Agency for Healthcare Research and Quality (AHRQ), as well as AHRQ's Put Prevention Into Practice.26 Simply search by “periodontitis” (or synonyms) at the following Web site: http://text.nlm.nih.gov.

Coffee Break: Tutorials for Biologists27 Some patients may wish to have access to a general healthcare site that takes a scientific view of the news and covers recent breakthroughs in biology that may one day assist healthcare providers in developing treatments. To this end, we recommend “Coffee Break,” a collection of short reports on recent biological discoveries. Each report incorporates interactive tutorials that demonstrate how bioinformatics tools are used as a part of the research process. Currently, all Coffee Breaks are written by NCBI staff.28 Each report is about 400 words and is usually based on a discovery reported in one or more articles from recently published, peer-reviewed literature.29 This site Adapted from HSTAT: http://www.nlm.nih.gov/pubs/factsheets/hstat.html. The HSTAT URL is http://hstat.nlm.nih.gov/. 26 Other important documents in HSTAT include: the National Institutes of Health (NIH) Consensus Conference Reports and Technology Assessment Reports; the HIV/AIDS Treatment Information Service (ATIS) resource documents; the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (SAMHSA/CSAT) Treatment Improvement Protocols (TIP) and Center for Substance Abuse Prevention (SAMHSA/CSAP) Prevention Enhancement Protocols System (PEPS); the Public Health Service (PHS) Preventive Services Task Force's Guide to Clinical Preventive Services; the independent, nonfederal Task Force on Community Services Guide to Community Preventive Services; and the Health Technology Advisory Committee (HTAC) of the Minnesota Health Care Commission (MHCC) health technology evaluations. 27 Adapted from http://www.ncbi.nlm.nih.gov/Coffeebreak/Archive/FAQ.html. 28 The figure that accompanies each article is frequently supplied by an expert external to NCBI, in which case the source of the figure is cited. The result is an interactive tutorial that tells a biological story. 29 After a brief introduction that sets the work described into a broader context, the report focuses on how a molecular understanding can provide explanations of observed biology and lead to therapies for diseases. Each vignette is accompanied by a figure and hypertext links that lead to a series of pages that interactively show how NCBI tools and resources are used in the research process. 24 25

122 Periodontitis

has new articles every few weeks, so it can be considered an online magazine of sorts, and intended for general background information. You can access the Coffee Break Web site at the following hyperlink: http://www.ncbi.nlm.nih.gov/Coffeebreak/.

Other Commercial Databases In addition to resources maintained by official agencies, other databases exist that are commercial ventures addressing medical professionals. Here are a few examples that may interest you: ·

CliniWeb International: Index and table of contents to selected clinical information on the Internet; see http://www.ohsu.edu/cliniweb/.

·

Image Engine: Multimedia electronic medical record system that integrates a wide range of digitized clinical images with textual data stored in the University of Pittsburgh Medical Center's MARS electronic medical record system; see the following Web site: http://www.cml.upmc.edu/cml/imageengine/imageEngine.html.

·

Medical World Search: Searches full text from thousands of selected medical sites on the Internet; see http://www.mwsearch.com/.

·

MedWeaver: Prototype system that allows users to search differential diagnoses for any list of signs and symptoms, to search medical literature, and to explore relevant Web sites; see http://www.med.virginia.edu/~wmd4n/medweaver.html.

·

Metaphrase: Middleware component intended for use by both caregivers and medical records personnel. It converts the informal language generally used by caregivers into terms from formal, controlled vocabularies; see the following Web site: http://www.lexical.com/Metaphrase.html.

The Genome Project and Periodontitis With all the discussion in the press about the Human Genome Project, it is only natural that healthcare providers, researchers, and patients want to know about how human genes relate to periodontitis. In the following section, we will discuss databases and references used by healthcare providers and scientists who work in this area.

Physician Guidelines and Databases 123

Online Mendelian Inheritance in Man (OMIM) The Online Mendelian Inheritance in Man (OMIM) database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere. OMIM was developed for the World Wide Web by the National Center for Biotechnology Information (NCBI).30 The database contains textual information, pictures, and reference information. It also contains copious links to NCBI's Entrez database of MEDLINE articles and sequence information. Go to http://www.ncbi.nlm.nih.gov/Omim/searchomim.html to search the database. Type “periodontitis” (or synonyms) in the search box, and click “Submit Search.” If too many results appear, you can narrow the search by adding the word “clinical.” Each report will have additional links to related research and databases. By following these links, especially the link titled “Database Links,” you will be exposed to numerous specialized databases that are largely used by the scientific community. These databases are overly technical and seldom used by the general public, but offer an abundance of information. The following is an example of the results you can obtain from the OMIM for periodontitis: ·

Periodontitis, Juvenile Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?170650

Adapted from http://www.ncbi.nlm.nih.gov/. Established in 1988 as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information--all for the better understanding of molecular processes affecting human health and disease.

30

124 Periodontitis

Genes and Disease (NCBI - Map) The Genes and Disease database is produced by the National Center for Biotechnology Information of the National Library of Medicine at the National Institutes of Health. This Web site categorizes each disorder by the system of the body associated with it. Go to http://www.ncbi.nlm.nih.gov/disease/, and browse the system pages to have a full view of important conditions linked to human genes. Since this site is regularly updated, you may wish to re-visit it from time to time. The following systems and associated disorders are addressed: ·

Cancer: Uncontrolled cell division. Examples: Breast And Ovarian Cancer, Burkitt lymphoma, chronic myeloid leukemia, colon cancer, lung cancer, malignant melanoma, multiple endocrine neoplasia, neurofibromatosis, p53 tumor suppressor, pancreatic cancer, prostate cancer, Ras oncogene, RB: retinoblastoma, von Hippel-Lindau syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Cancer.html

·

Muscle and Bone: Movement and growth. Examples: Duchenne muscular dystrophy, Ellis-van Creveld syndrome, Marfan syndrome, myotonic dystrophy, spinal muscular atrophy. Web site: http://www.ncbi.nlm.nih.gov/disease/Muscle.html

·

Nervous System: Mind and body. Examples: Alzheimer disease, Amyotrophic lateral sclerosis, Angelman syndrome, Charcot-Marie-Tooth disease, epilepsy, essential tremor, Fragile X syndrome, Friedreich's ataxia, Huntington disease, NiemannPick disease, Parkinson disease, Prader-Willi syndrome, Rett syndrome, Spinocerebellar atrophy, Williams syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Brain.html

·

Signals: Cellular messages. Examples: Ataxia telangiectasia, Baldness, Cockayne syndrome, Glaucoma, SRY: sex determination, Tuberous sclerosis, Waardenburg syndrome, Werner syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Signals.html

·

Transporters: Pumps and channels. Examples: Cystic Fibrosis, deafness, diastrophic dysplasia, Hemophilia A, long-QT syndrome, Menkes syndrome, Pendred syndrome, polycystic kidney disease, sickle cell anemia, Wilson's disease, Zellweger syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Transporters.html

Physician Guidelines and Databases 125

Entrez Entrez is a search and retrieval system that integrates several linked databases at the National Center for Biotechnology Information (NCBI). These databases include nucleotide sequences, protein sequences, macromolecular structures, whole genomes, and MEDLINE through PubMed. Entrez provides access to the following databases: ·

PubMed: Biomedical literature (PubMed), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

·

Nucleotide Sequence Database (Genbank): Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Nucleotide

·

Protein Sequence Database: Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Protein

·

Structure: Three-dimensional macromolecular structures, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Structure

·

Genome: Complete genome assemblies, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Genome

·

PopSet: Population study data sets, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Popset

·

OMIM: Online Mendelian Inheritance in Man, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM

·

Taxonomy: Organisms in GenBank, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Taxonomy

·

Books: Online books, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=books

·

ProbeSet: Gene Expression Omnibus (GEO), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

3D Domains: Domains from Entrez Structure, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

NCBI's Protein Sequence Information Survey Results: Web site: http://www.ncbi.nlm.nih.gov/About/proteinsurvey/

To access the Entrez system at the National Center for Biotechnology Information, go to http://www.ncbi.nlm.nih.gov/entrez, and then select the database that you would like to search. The databases available are listed in

126 Periodontitis

the drop box next to “Search.” In the box next to “for,” enter “periodontitis” (or synonyms) and click “Go.”

Jablonski's Multiple Congenital Anomaly/Mental Retardation (MCA/MR) Syndromes Database31 This online resource can be quite useful. It has been developed to facilitate the identification and differentiation of syndromic entities. Special attention is given to the type of information that is usually limited or completely omitted in existing reference sources due to space limitations of the printed form. At http://www.nlm.nih.gov/mesh/jablonski/syndrome_toc/toc_a.html you can also search across syndromes using an alphabetical index. You can also search at http://www.nlm.nih.gov/mesh/jablonski/syndrome_db.html. The Genome Database32 Established at Johns Hopkins University in Baltimore, Maryland in 1990, the Genome Database (GDB) is the official central repository for genomic mapping data resulting from the Human Genome Initiative. In the spring of 1999, the Bioinformatics Supercomputing Centre (BiSC) at the Hospital for Sick Children in Toronto, Ontario assumed the management of GDB. The Human Genome Initiative is a worldwide research effort focusing on structural analysis of human DNA to determine the location and sequence of the estimated 100,000 human genes. In support of this project, GDB stores and curates data generated by researchers worldwide who are engaged in the mapping effort of the Human Genome Project (HGP). GDB's mission is to provide scientists with an encyclopedia of the human genome which is continually revised and updated to reflect the current state of scientific knowledge. Although GDB has historically focused on gene mapping, its focus will broaden as the Genome Project moves from mapping to sequence, and finally, to functional analysis. To access the GDB, simply go to the following hyperlink: http://www.gdb.org/. Search “All Biological Data” by “Keyword.” Type “periodontitis” (or synonyms) into the search box, and review the results. If Adapted from the National Library of Medicine: http://www.nlm.nih.gov/mesh/jablonski/about_syndrome.html. 32 Adapted from the Genome Database: http://gdbwww.gdb.org/gdb/aboutGDB.html#mission. 31

Physician Guidelines and Databases 127

more than one word is used in the search box, then separate each one with the word “and” or “or” (using “or” might be useful when using synonyms). This database is extremely technical as it was created for specialists. The articles are the results which are the most accessible to non-professionals and often listed under the heading “Citations.” The contact names are also accessible to non-professionals.

Specialized References The following books are specialized references written for professionals interested in periodontitis (sorted alphabetically by title, hyperlinks provide rankings, information, and reviews at Amazon.com): · Advances in Operative Dentistry: Volume 1: Contemporary Clinical Practice by Jean-Francois Roulet (Editor), et al; Hardcover - 263 pages, 1st edition (August 15, 2001), Quintessence Publishing Co.; ISBN: 0867154020; http://www.amazon.com/exec/obidos/ASIN/0867154020/icongroupinterna · Behavioural Sciences for Dentistry by Gerry Humphris, Margaret S. Ling; Paperback - 149 pages, 1st edition (October 1, 2005), Churchill Livingstone; ISBN: 0443051909; http://www.amazon.com/exec/obidos/ASIN/0443051909/icongroupinterna · Burket's Oral Medicine: Diagnosis and Treatment by Martin S. Greenberg, Michael Glick; Hardcover, 10th edition (July 2002), Decker Periodicals; ISBN: 0781725372; http://www.amazon.com/exec/obidos/ASIN/0781725372/icongroupinterna · Churchill's Pocketbook of Clinical Dentistry by I. G. Chestnutt (Editor), J. Gibson (Editor); Hardcover 2nd edition (April 2002), Churchill Livingstone; ISBN: 0443070849; http://www.amazon.com/exec/obidos/ASIN/0443070849/icongroupinterna · A Color Atlas and Text of Oral Anatomy, Histology and Embryology by Berkovitz; Hardcover, 3rd edition (July 26, 2002), Mosby-Year Book; ISBN: 0723431817; http://www.amazon.com/exec/obidos/ASIN/0723431817/icongroupinterna · Essential Microbiology for Dentistry by L. P. Samaranayake; Paperback 293 pages, 2nd edition (January 15, 2002), W B Saunders Co; ISBN: 044306461X; http://www.amazon.com/exec/obidos/ASIN/044306461X/icongroupintern a

128 Periodontitis

· Essentials of Oral Medicine by Sol Silverman, Jr., et al; Paperback, Book & Cd-Rom edition (October 2001), B C Decker; ISBN: 1550091468; http://www.amazon.com/exec/obidos/ASIN/1550091468/icongroupinterna · Fundamentals of Oral Medicine: A Practical Guide by Crispian Scully, M.D., Ph.D.; Paperback (September 2001), Butterworth-Heinemann Medical; ISBN: 0723610746; http://www.amazon.com/exec/obidos/ASIN/0723610746/icongroupinterna · Medical Emergencies in Dentistry by Jeffrey D. Bennett, Morton B. Rosenberg; Paperback - 556 pages, 1st edition (January 15, 2002), W B Saunders Co; ISBN: 0721684815; http://www.amazon.com/exec/obidos/ASIN/0721684815/icongroupinterna · Oral Development and Histology by James K. Avery, D.D.S., Ph.D. (Editor), Hardcover, 3rd edition (October 2001), Thieme Medical Pub; ISBN: 1588900282; http://www.amazon.com/exec/obidos/ASIN/1588900282/icongroupinterna · Year Book of Dentistry 2001 by Lawrence H. Meskin; Hardcover (January 2002), Mosby-Year Book; ISBN: 0323015433; http://www.amazon.com/exec/obidos/ASIN/0323015433/icongroupinterna

Vocabulary Builder Neoplasms: New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. [NIH]

Dissertations 129

CHAPTER 9. DISSERTATIONS ON PERIODONTITIS Overview University researchers are active in studying almost all known diseases. The result of research is often published in the form of Doctoral or Master's dissertations. You should understand, therefore, that applied diagnostic procedures and/or therapies can take many years to develop after the thesis that proposed the new technique or approach was written. In this chapter, we will give you a bibliography on recent dissertations relating to periodontitis. You can read about these in more detail using the Internet or your local medical library. We will also provide you with information on how to use the Internet to stay current on dissertations.

Dissertations on Periodontitis ProQuest Digital Dissertations is the largest archive of academic dissertations available. From this archive, we have compiled the following list covering dissertations devoted to periodontitis. You will see that the information provided includes the dissertation’s title, its author, and the author’s institution. To read more about the following, simply use the Internet address indicated. The following covers recent dissertations dealing with periodontitis: ·

Analysis of Chemotactic Receptors in Localized Juvenile Periodontitis by Gwinn, Maureen Rose; Phd from State University of New York at Buffalo, 2001, 144 pages http://wwwlib.umi.com/dissertations/fullcit/9997950

130 Periodontitis

·

Controlled Drug Delivery Using Bioerodible Polymeric Systems for the Treatment of Periodontitis by Gates, Kimberly Ann; Phd from University of Toronto (canada), 1999, 173 pages http://wwwlib.umi.com/dissertations/fullcit/NQ41022

·

Enhanced Maintenance Using Povidone Iodine (pvp-i) Full-mouth Decontamination (pvp-i-fmd) and Ultrasonic Debridement in Patients with Recurrent Periodontitis: Clinical and Microbial Results by Campbell, David A.; Ms from University of Louisville, 1999, 184 pages http://wwwlib.umi.com/dissertations/fullcit/1397315

·

Familial Patterns of Microbial Infection in Periodontitis by Irfan, Uma Maheswari; Phd from Case Western Reserve University (health Sciences), 1999, 239 pages http://wwwlib.umi.com/dissertations/fullcit/9949271

·

Herpesviruses 6, 7 and 8 in Hiv- and Non-hiv Associated Periodontitis (immune Deficiency) by Mardirossian, Armen; Ms from University of Southern California, 2000, 63 pages http://wwwlib.umi.com/dissertations/fullcit/1405249

·

Lead Exposure and Periodontitis: a Cross-sectional Evaluation by Saraiva, Maria Da Conceicao Pereira; Phd from University of Michigan, 2001, 100 pages http://wwwlib.umi.com/dissertations/fullcit/3029423

·

Race and Periodontitis among the United States Adult Population: Fifteen-year Trends by Borrell, Luisa Nicia; Phd from University of Michigan, 2001, 122 pages http://wwwlib.umi.com/dissertations/fullcit/3000926

Keeping Current As previously mentioned, an effective way to stay current on dissertations dedicated to periodontitis is to use the database called ProQuest Digital Dissertations via the Internet, located at the following Web address: http://wwwlib.umi.com/dissertations. The site allows you to freely access the last two years of citations and abstracts. Ask your medical librarian if the library has full and unlimited access to this database. From the library, you should be able to do more complete searches than with the limited 2-year access available to the general public.

Dissertations 131

Vocabulary Builder Decontamination: The removal of contaminating material, such as radioactive materials, biological materials, or chemical warfare agents, from a person or object. [NIH] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Povidone: A polyvinyl polymer of variable molecular weight; used as suspending and dispersing agent and vehicle for pharmaceuticals; also used as blood volume expander. [NIH] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU]

133

PART III. APPENDICES

ABOUT PART III Part III is a collection of appendices on general medical topics which may be of interest to patients with periodontitis and related conditions.

Researching Your Medications 135

APPENDIX A. RESEARCHING YOUR MEDICATIONS Overview There are a number of sources available on new or existing medications which could be prescribed to patients with periodontitis. While a number of hard copy or CD-Rom resources are available to patients and dentists for research purposes, a more flexible method is to use Internet-based databases. In this chapter, we will begin with a general overview of medications. We will then proceed to outline official recommendations on how you should view your medications. You may also want to research medications that you are currently taking for other conditions as they may interact with medications for periodontitis. Research can give you information on the side effects, interactions, and limitations of prescription drugs used in the treatment of periodontitis. Broadly speaking, there are two sources of information on approved medications: public sources and private sources. We will emphasize free-to-use public sources.

136 Periodontitis

Your Medications: The Basics33 The Agency for Health Care Research and Quality has published extremely useful guidelines on how you can best participate in the medication aspects of periodontitis. Taking medicines is not always as simple as swallowing a pill. It can involve many steps and decisions each day. The AHCRQ recommends that patients with periodontitis take part in treatment decisions. Do not be afraid to ask questions and talk about your concerns. By taking a moment to ask questions early, you may avoid problems later. Here are some points to cover each time a new medicine is prescribed: ·

Ask about all parts of your treatment, including diet changes, exercise, and medicines.

·

Ask about the risks and benefits of each medicine or other treatment you might receive.

·

Ask how often you or your healthcare provider will check for side effects from a given medication.

Do not hesitate to ask what is important to you about your medicines. You may want a medicine with the fewest side effects, or the fewest doses to take each day. You may care most about cost, or how the medicine might affect how you live or work. Or, you may want the medicine your dentist believes will work the best. Do not be afraid to “bother” your dentist or oral surgeon with your concerns and questions about medications for periodontitis. You can also talk to a nurse or a pharmacist. They can help you better understand your treatment plan. Feel free to bring a friend or family member with you when you visit your dentist. Talking over your options with someone you trust can help you make better choices, especially if you are not feeling well. Specifically, ask your dentist the following: ·

The name of the medicine and what it is supposed to do.

·

How and when to take the medicine, how much to take, and for how long.

·

What food, drinks, other medicines, or activities you should avoid while taking the medicine.

·

What side effects the medicine may have, and what to do if they occur.

·

If you can get a refill, and how often.

33

This section is adapted from AHCRQ: http://www.ahcpr.gov/consumer/ncpiebro.htm.

Researching Your Medications 137

·

About any terms or directions you do not understand.

·

What to do if you miss a dose.

·

If there is written information you can take home (most pharmacies have information sheets on your prescription medicines; some even offer large-print or Spanish versions).

Do not forget to tell your dentist about all the medicines you are currently taking (not just those for periodontitis). This includes prescription medicines and the medicines that you buy over the counter. Then your dentist can avoid giving you a new medicine that may not work well with the medications you take now. When talking to your dentist, you may wish to prepare a list of medicines you currently take, the reason you take them, and how you take them. Be sure to include the following information for each: ·

Name of medicine

·

Reason taken

·

Dosage

·

Time(s) of day

Also include any over-the-counter medicines, such as: ·

Laxatives

·

Diet pills

·

Vitamins

·

Cold medicine

·

Aspirin or other pain, headache, or fever medicine

·

Cough medicine

·

Allergy relief medicine

·

Antacids

·

Sleeping pills

·

Others (include names)

Learning More about Your Medications Because of historical investments by various organizations and the emergence of the Internet, it has become rather simple to learn about the medications your dentist has recommended for periodontitis. One such

138 Periodontitis

source is the United States Pharmacopeia. In 1820, eleven physicians met in Washington, D.C. to establish the first compendium of standard drugs for the United States. They called this compendium the “U.S. Pharmacopeia (USP).” Today, the USP is a non-profit organization consisting of 800 volunteer scientists, eleven elected officials, and 400 representatives of state associations and colleges of medicine and pharmacy. The USP is located in Rockville, Maryland, and its home page is located at www.usp.org. The USP currently provides standards for over 3,700 medications. The resulting USP DIÒ Advice for the PatientÒ can be accessed through the National Library of Medicine of the National Institutes of Health. The database is partially derived from lists of federally approved medications in the Food and Drug Administration's (FDA) Drug Approvals database.34 While the FDA database is rather large and difficult to navigate, the Phamacopeia is both user-friendly and free to use. It covers more than 9,000 prescription and over-the-counter medications. To access this database, simply type the following hyperlink into your Web browser: http://www.nlm.nih.gov/medlineplus/druginformation.html. To view examples of a given medication (brand names, category, description, preparation, proper use, precautions, side effects, etc.), simply follow the hyperlinks indicated within the United States Pharmacopoeia (USP). It is important to read the disclaimer by the USP (http://www.nlm.nih.gov/medlineplus/drugdisclaimer.html) before using the information provided. Of course, we as editors cannot be certain as to what medications you are taking. Therefore, we have compiled a list of medications associated with the treatment of periodontitis. Once again, due to space limitations, we only list a sample of medications and provide hyperlinks to ample documentation (e.g. typical dosage, side effects, drug-interaction risks, etc.). The following drugs have been mentioned in the Pharmacopeia and other sources as being potentially applicable to periodontitis: Chlorhexidine ·

Implantation-Dental - U.S. Brands: PerioChip http://www.nlm.nih.gov/medlineplus/druginfo/chlorhexidineim plantationdenta203651.html

Though cumbersome, the FDA database can be freely browsed at the following site: www.fda.gov/cder/da/da.htm.

34

Researching Your Medications 139

Doxycycline for Dental Use ·

Systemic - U.S. Brands: Periostat http://www.nlm.nih.gov/medlineplus/druginfo/doxycyclineford entalusesystemi203724.html

Commercial Databases In addition to the medications listed in the USP above, a number of commercial sites are available by subscription to dentists and their institutions. You may be able to access these sources from your local medical library or your dentist's office.

Reuters Health Drug Database The Reuters Health Drug Database can be searched by keyword at the hyperlink: http://www.reutershealth.com/frame2/drug.html. The following medications are listed in the Reuters' database as associated with periodontitis (including those with contraindications):35 ·

Chlorhexidine Gluconate http://www.reutershealth.com/atoz/html/Chlorhexidine_Gluconate.htm

·

Doxycycline http://www.reutershealth.com/atoz/html/Doxycycline.htm

·

Minocycline http://www.reutershealth.com/atoz/html/Minocycline.htm Mosby's GenRx

Mosby's GenRx database (also available on CD-Rom and book format) covers 45,000 drug products including generics and international brands. It provides prescribing information, drug interactions, and patient information. Information in Mosby's GenRx database can be obtained at the following hyperlink: http://www.genrx.com/Mosby/PhyGenRx/group.html.

35

Adapted from A to Z Drug Facts by Facts and Comparisons.

140 Periodontitis

Physicians Desk Reference The Physicians Desk Reference database (also available in CD-Rom and book format) is a full-text drug database. The database is searchable by brand name, generic name or by indication. It features multiple drug interactions reports. Information can be obtained at the following hyperlink: http://physician.pdr.net/physician/templates/en/acl/psuser_t.htm.

Other Web Sites A number of additional Web sites discuss drug information. As an example, you may like to look at www.drugs.com which reproduces the information in the Pharmacopeia as well as commercial information. You may also want to consider the Web site of the Medical Letter, Inc. which allows users to download articles on various drugs and therapeutics for a nominal fee: http://www.medletter.com/.

Contraindications and Interactions (Hidden Dangers) Some of the medications mentioned in the previous discussions can be problematic for patients with periodontitis--not because they are used in the treatment process, but because of contraindications, or side effects. Medications with contraindications are those that could react with drugs used to treat periodontitis or potentially create deleterious side effects in patients with periodontitis. You should ask your dentist about any contraindications, especially as these might apply to other medications that you may be taking for common ailments. Drug-drug interactions occur when two or more drugs react with each other. This drug-drug interaction may cause you to experience an unexpected side effect. Drug interactions may make your medications less effective, cause unexpected side effects, or increase the action of a particular drug. Some drug interactions can even be harmful to you. Be sure to read the label every time you use a nonprescription or prescription drug, and take the time to learn about drug interactions. These precautions may be critical to your health. You can reduce the risk of potentially harmful drug interactions and side effects with a little bit of knowledge and common sense.

Researching Your Medications 141

Drug labels contain important information about ingredients, uses, warnings, and directions which you should take the time to read and understand. Labels also include warnings about possible drug interactions. Further, drug labels may change as new information becomes available. This is why it's especially important to read the label every time you use a medication. When your dentist prescribes a new drug, discuss all over-thecounter and prescription medications, dietary supplements, vitamins, botanicals, minerals and herbals you take as well as the foods you eat. Ask your pharmacist for the package insert for each prescription drug you take. The package insert provides more information about potential drug interactions.

A Final Warning At some point, you may hear of alternative medications from friends, relatives, or in the news media. Advertisements may suggest that certain alternative drugs can produce positive results for patients with periodontitis. Exercise caution--some of these drugs may have fraudulent claims, and others may actually hurt you. The Food and Drug Administration (FDA) is the official U.S. agency charged with discovering which medications are likely to improve the health of patients with periodontitis. The FDA warns patients to watch out for36: ·

Secret formulas (real scientists share what they know)

·

Amazing breakthroughs or miracle cures (real breakthroughs don't happen very often; when they do, real scientists do not call them amazing or miracles)

·

Quick, painless, or guaranteed cures

·

If it sounds too good to be true, it probably isn't true.

If you have any questions about any kind of medical treatment, the FDA may have an office near you. Look for their number in the blue pages of the phone book. You can also contact the FDA through its toll-free number, 1888-INFO-FDA (1-888-463-6332), or on the World Wide Web at www.fda.gov.

36

This section has been adapted from http://www.fda.gov/opacom/lowlit/medfraud.html.

142 Periodontitis

General References In addition to the resources provided earlier in this chapter, the following general references describe medications (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Drug Dictionary for Dentistry by J. G. Meechan, R. A. Seymour; Hardcover (March 2002), Oxford University Press; ISBN: 0192632744; http://www.amazon.com/exec/obidos/ASIN/0192632744/icongroupinterna

·

Drug Information Handbook for Dentistry, 2001-2002 by Richard L. Wynn, et al; Paperback - 1500 pages, 7th edition (August 15, 2001), Lexi Comp; ISBN: 1930598718; http://www.amazon.com/exec/obidos/ASIN/1930598718/icongroupinterna

·

Handbook of Commonly Prescribed Drugs by G. John Digregorio, Edward J. Barbieri; Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/0942447417/icongroupinterna

·

Johns Hopkins Complete Home Encyclopedia of Drugs 2nd ed. by Simeon Margolis (Ed.), Johns Hopkins; Hardcover - 835 pages (2000), Rebus; ISBN: 0929661583; http://www.amazon.com/exec/obidos/ASIN/0929661583/icongroupinterna

·

Mosby's Dental Drug Reference by Tommy W. Gage, Frieda Atherton Pickett; Paperback - 815 pages, 5th edition (October 2001), Mosby-Year Book; ISBN: 032301710X; http://www.amazon.com/exec/obidos/ASIN/032301710X/icongroupinterna

Researching Alternative Medicine 143

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE Overview Complementary and alternative medicine (CAM) is one of the most contentious aspects of modern medical practice. You may have heard of these treatments on the radio or on television. Maybe you have seen articles written about these treatments in magazines, newspapers, or books. Perhaps your friends or healthcare providers have mentioned alternatives. In this chapter, we will begin by giving you a broad perspective on complementary and alternative therapies. Next, we will introduce you to official information sources on CAM relating to periodontitis. Finally, at the conclusion of this chapter, we will provide a list of readings on periodontitis from various authors. We will begin, however, with the National Center for Complementary and Alternative Medicine's (NCCAM) overview of complementary and alternative medicine.

What Is CAM?37 Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices which are not taught in medical schools, used in hospitals, or reimbursed by medical insurance companies. Many CAM therapies are termed “holistic,” which generally means that the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual health. Some of these therapies are also known as “preventive,” which means that the practitioner educates and 37

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/faq/index.html#what-is.

144 Periodontitis

treats the person to prevent health problems from arising, rather than treating symptoms after problems have occurred. People use CAM treatments and therapies in a variety of ways. Therapies are used alone (often referred to as alternative), in combination with other alternative therapies, or in addition to conventional treatment (sometimes referred to as complementary). Complementary and alternative medicine, or “integrative medicine,” includes a broad range of healing philosophies, approaches, and therapies. Some approaches are consistent with physiological principles of Western medicine, while others constitute healing systems with non-Western origins. While some therapies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine. Complementary and alternative therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of complementary or alternative therapy include mind/body control interventions such as visualization and relaxation, manual healing including acupressure and massage, homeopathy, vitamins or herbal products, and acupuncture.

What Are the Domains of Alternative Medicine?38 The list of CAM practices changes continually. The reason being is that these new practices and therapies are often proved to be safe and effective, and therefore become generally accepted as “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologicallybased treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this sourcebook. Thus, only limited examples are provided within each. Alternative Medical Systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of, and often prior to, conventional biomedical approaches. Many are traditional systems of medicine that are

38

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/classify/index.html.

Researching Alternative Medicine 145

practiced by individual cultures throughout the world, including a number of venerable Asian approaches. Traditional oriental medicine emphasizes the balance or disturbances of qi (pronounced chi) or vital energy in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a thin needle. Ayurveda is India's traditional system of medicine. Ayurvedic medicine (meaning “science of life”) is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit. Ayurveda strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Other traditional healing systems have been developed by the world’s indigenous populations. These populations include Native American, Aboriginal, African, Middle Eastern, Tibetan, and Central and South American cultures. Homeopathy and naturopathy are also examples of complete alternative medicine systems. Homeopathic medicine is an unconventional Western system that is based on the principle that “like cures like,” i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic health practitioners believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body's defense mechanisms and healing processes in order to treat illness. Naturopathic medicine is based on the theory that disease is a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including the following: diet and clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy (the use of water in a range of temperatures and methods of applications), spinal and soft-tissue manipulation, physical therapies (such as those involving electrical currents, ultrasound, and light), therapeutic counseling, and pharmacology.

146 Periodontitis

Mind-Body Interventions Mind-body interventions employ a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms. Only a select group of mind-body interventions having well-documented theoretical foundations are considered CAM. For example, patient education and cognitive-behavioral approaches are now considered “mainstream.” On the other hand, complementary and alternative medicine includes meditation, certain uses of hypnosis, dance, music, and art therapy, as well as prayer and mental healing.

Biological-Based Therapies This category of CAM includes natural and biological-based practices, interventions, and products, many of which overlap with conventional medicine's use of dietary supplements. This category includes herbal, special dietary, orthomolecular, and individual biological therapies. Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and/or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.

Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure and function, primarily pertaining to the spine, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. In contrast, osteopaths place particular emphasis on the musculoskeletal system and practice osteopathic manipulation. Osteopaths believe that all of the body's systems work together and that disturbances in one system may have an impact upon function elsewhere in the body. Massage therapists manipulate the soft tissues of the body to normalize those tissues.

Researching Alternative Medicine 147

Energy Therapies Energy therapies focus on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields). Biofield therapies are intended to affect energy fields (the existence of which is not yet experimentally proven) that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, improve blood circulation, and enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that, by channeling spiritual energy through the practitioner, the spirit is healed and, in turn, heals the physical body. Therapeutic Touch is derived from the ancient technique of “laying-on of hands.” It is based on the premises that the therapist’s healing force affects the patient's recovery and that healing is promoted when the body's energies are in balance. By passing their hands over the patient, these healers identify energy imbalances. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Can Alternatives Affect My Treatment? A critical issue in pursuing complementary alternatives mentioned thus far is the risk that these might have undesirable interactions with your medical treatment. It becomes all the more important to speak with your healthcare provider who can offer advice on the use of alternatives. Official sources confirm this view. Though written for women, we find that the National Women’s Health Information Center’s advice on pursuing alternative medicine is appropriate for patients of both genders and all ages.39

39

Adapted from http://www.4woman.gov/faq/alternative.htm.

148 Periodontitis

Is It Okay to Want Both Traditional and Alternative Medicine? Should you wish to explore non-traditional types of treatment, be sure to discuss all issues concerning treatments and therapies with your healthcare provider, whether a dentist or practitioner of complementary and alternative medicine. Competent healthcare management requires knowledge of both conventional and alternative therapies you are taking for the practitioner to have a complete picture of your treatment plan. The decision to use complementary and alternative treatments is an important one. Consider before selecting an alternative therapy, the safety and effectiveness of the therapy or treatment, the expertise and qualifications of the healthcare practitioner, and the quality of delivery. These topics should be considered when selecting any practitioner or therapy.

Finding CAM References on Periodontitis Having read the previous discussion, you may be wondering which complementary or alternative treatments might be appropriate for periodontitis. For the remainder of this chapter, we will direct you to a number of official sources which can assist you in researching studies and publications. Some of these articles are rather technical, so some patience may be required. National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (http://nccam.nih.gov) has created a link to the National Library of Medicine's databases to allow patients to search for articles that specifically relate to periodontitis and complementary medicine. To search the database, go to the following Web site: www.nlm.nih.gov/nccam/camonpubmed.html. Select “CAM on PubMed.” Enter “periodontitis” (or synonyms) into the search box. Click “Go.” The following references provide information on particular aspects of complementary and alternative medicine (CAM) that are related to periodontitis: ·

Differential expression of IFN-gamma, IL-4, IL-10, and IL-1beta mRNAs in decalcified tissue sections of mouse lipopolysaccharideinduced periodontitis mandibles assessed by in situ hybridization. Author(s): Iwasaki Y, Hara Y, Koji T, Shibata Y, Nakane PK, Kato I.

Researching Alternative Medicine 149

Source: Histochemistry and Cell Biology. 1998 April; 109(4): 339-47. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9562383&dopt=Abstract ·

Double-blind evaluation of the clinical efficacy of an herbal dentifrice against gingivitis and periodontitis. Author(s): Emling RC. Source: J Clin Dent. 1988 Summer; 1 Suppl A: A27-9. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2855714&dopt=Abstract

·

Effect of different concentrations of EDTA on smear removal and collagen exposure in periodontitis-affected root surfaces. Author(s): Blomlof J, Blomlof L, Lindskog S. Source: Journal of Clinical Periodontology. 1997 August; 24(8): 534-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9266339&dopt=Abstract

·

Gingival Kaposi's sarcoma and periodontitis. A case report and suggested treatment approach to the combined lesions. Author(s): Shiboski CH, Winkler JR. Source: Oral Surg Oral Med Oral Pathol. 1993 July; 76(1): 49-53. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8351121&dopt=Abstract

·

Root cementum appearance in healthy monkeys and periodontitisprone patients after different etching modalities. Author(s): Blomlof J. Source: Journal of Clinical Periodontology. 1996 January; 23(1): 12-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8636451&dopt=Abstract

·

The effect of ascorbic acid supplementation on periodontal tissue ultrastructure in subjects with progressive periodontitis. Author(s): Aurer-Kozelj J, Kralj-Klobucar N, Buzina R, Bacic M. Source: Int J Vitam Nutr Res. 1982; 52(3): 333-41. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=6757168&dopt=Abstract

150 Periodontitis

·

Therapy-resistant periodontitis. Psychosocial characteristics. Author(s): Axtelius B, Soderfeldt B, Nilsson A, Edwardsson S, Attstrom R. Source: Journal of Clinical Periodontology. 1998 June; 25(6): 482-91. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9667482&dopt=Abstract

·

Ultrastructure and histochemistry of the dental cuticle in adult periodontitis. Author(s): Friedman MT, Barber P, Newman HN. Source: J Periodontol. 1993 June; 64(6): 520-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8336252&dopt=Abstract

Additional Web Resources A number of additional Web sites offer encyclopedic information covering CAM and related topics. The following is a representative sample: ·

Alternative Medicine Foundation, Inc.: http://www.herbmed.org/

·

AOL: http://search.aol.com/cat.adp?id=169&layer=&from=subcats

·

Chinese Medicine: http://www.newcenturynutrition.com/

·

drkoop.comÒ: http://www.drkoop.com/InteractiveMedicine/IndexC.html

·

Family Village: http://www.familyvillage.wisc.edu/med_altn.htm

·

Google: http://directory.google.com/Top/Health/Alternative/

·

Healthnotes: http://www.thedacare.org/healthnotes/

·

Open Directory Project: http://dmoz.org/Health/Alternative/

·

TPN.com: http://www.tnp.com/

·

Yahoo.com: http://dir.yahoo.com/Health/Alternative_Medicine/

·

WebMDÒHealth: http://my.webmd.com/drugs_and_herbs

·

WellNet: http://www.wellnet.ca/herbsa-c.htm

·

WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

Researching Alternative Medicine 151

The following is a specific Web list relating to periodontitis; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation: ·

Herbs and Supplements Bloodroot Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Chamomile Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Chlorhexidine Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Coenzyme Q Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Coenzyme Q10 Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm CoQ10 Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Echinacea Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm

152 Periodontitis

Echinacea purpurea Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Flavonoids Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Glycyrrhiza1 Alternative names: Licorice; Glycyrrhiza glabra L. Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ Myrrh Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Peppermint Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Phenytoin Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Sage Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Sanguinaria Alternative names: Bloodroot; Sanguinaria canadensis L. Source: Alternative Medicine Foundation, Inc.; www.amfoundation.org Hyperlink: http://www.herbmed.org/ Sanguinaria Source: Healthnotes, Inc.; www.healthnotes.com

Researching Alternative Medicine 153

Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm ·

Related Conditions Gingivitis Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm

General References A good place to find general background information on CAM is the National Library of Medicine. It has prepared within the MEDLINEplus system an information topic page dedicated to complementary and alternative medicine. To access this page, go to the MEDLINEplus site at: www.nlm.nih.gov/medlineplus/alternativemedicine.html. This Web site provides a general overview of various topics and can lead to a number of general sources. The following additional references describe, in broad terms, alternative and complementary medicine (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · Complementary Therapies in Dental Practice by Peter Varley (Editor); Paperback, 1st edition (January 15, 1998), Butterworth-Heinemann Medical; ISBN: 0723610339; http://www.amazon.com/exec/obidos/ASIN/0723610339/icongroupinterna · Alternative Medicine for Dummies by James Dillard (Author); Audio Cassette, Abridged edition (1998), Harper Audio; ISBN: 0694520659; http://www.amazon.com/exec/obidos/ASIN/0694520659/icongroupinterna ·

Complementary and Alternative Medicine Secrets by W. Kohatsu (Editor); Hardcover (2001), Hanley & Belfus; ISBN: 1560534400; http://www.amazon.com/exec/obidos/ASIN/1560534400/icongroupinterna

·

Dictionary of Alternative Medicine by J. C. Segen; Paperback-2nd edition (2001), Appleton & Lange; ISBN: 0838516211; http://www.amazon.com/exec/obidos/ASIN/0838516211/icongroupinterna

·

Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating by Walter C. Willett, MD, et al; Hardcover - 352 pages (2001), Simon & Schuster; ISBN: 0684863375; http://www.amazon.com/exec/obidos/ASIN/0684863375/icongroupinterna

154 Periodontitis

· Encyclopedia of Natural Medicine, Revised 2nd Edition by Michael T. Murray, Joseph E. Pizzorno; Paperback - 960 pages, 2nd Rev edition (1997), Prima Publishing; ISBN: 0761511571; http://www.amazon.com/exec/obidos/ASIN/0761511571/icongroupinterna ·

Integrative Medicine: An Introduction to the Art & Science of Healing by Andrew Weil (Author); Audio Cassette, Unabridged edition (2001), Sounds True; ISBN: 1564558541; http://www.amazon.com/exec/obidos/ASIN/1564558541/icongroupinterna

·

New Encyclopedia of Herbs & Their Uses by Deni Bown; Hardcover - 448 pages, Revised edition (2001), DK Publishing; ISBN: 078948031X; http://www.amazon.com/exec/obidos/ASIN/078948031X/icongroupinterna

· Textbook of Complementary and Alternative Medicine by Wayne B. Jonas; Hardcover (2003), Lippincott, Williams & Wilkins; ISBN: 0683044370; http://www.amazon.com/exec/obidos/ASIN/0683044370/icongroupinterna For additional information on complementary and alternative medicine, ask your healthcare provider or write to: National Institutes of Health National Center for Complementary and Alternative Medicine Clearinghouse P. O. Box 8218 Silver Spring, MD 20907-8218

Researching Nutrition 155

APPENDIX C. RESEARCHING NUTRITION Overview Since the time of Hippocrates, healthcare providers have understood the importance of diet and nutrition to patients’ health and well-being. Since then, they have accumulated an impressive archive of studies and knowledge dedicated to this subject. Based on their experience, dentists and healthcare providers may recommend particular dietary supplements to patients with periodontitis. Any dietary recommendation is based on a patient's age, body mass, gender, lifestyle, eating habits, food preferences, and health condition. It is therefore likely that different patients with periodontitis may be given different recommendations. Some recommendations may be directly related to periodontitis, while others may be more related to the patient's general health. These recommendations, themselves, may differ from what official sources recommend for the average person. In this chapter we will begin by briefly reviewing the essentials of diet and nutrition that will broadly frame more detailed discussions of periodontitis. We will then show you how to find studies dedicated specifically to nutrition and periodontitis.

Food and Nutrition: General Principles What Are Essential Foods? Food is generally viewed by official sources as consisting of six basic elements: (1) fluids, (2) carbohydrates, (3) protein, (4) fats, (5) vitamins, and

156 Periodontitis

(6) minerals. Consuming a combination of these elements is considered to be a healthy diet: ·

Fluids are essential to human life as 80-percent of the body is composed of water. Water is lost via urination, sweating, diarrhea, vomiting, diuretics (drugs that increase urination), caffeine, and physical exertion.

·

Carbohydrates are the main source for human energy (thermoregulation) and the bulk of typical diets. They are mostly classified as being either simple or complex. Simple carbohydrates include sugars which are often consumed in the form of cookies, candies, or cakes. Complex carbohydrates consist of starches and dietary fibers. Starches are consumed in the form of pastas, breads, potatoes, rice, and other foods. Soluble fibers can be eaten in the form of certain vegetables, fruits, oats, and legumes. Insoluble fibers include brown rice, whole grains, certain fruits, wheat bran and legumes.

·

Proteins are eaten to build and repair human tissues. Some foods that are high in protein are also high in fat and calories. Food sources for protein include nuts, meat, fish, cheese, and other dairy products.

·

Fats are consumed for both energy and the absorption of certain vitamins. There are many types of fats, with many general publications recommending the intake of unsaturated fats or those low in cholesterol.

Vitamins and minerals are fundamental to human health, growth, and, in some cases, disease prevention. Most are consumed in your diet (exceptions being vitamins K and D which are produced by intestinal bacteria and sunlight on the skin, respectively). Each vitamin and mineral plays a different role in health. The following outlines essential vitamins: ·

Vitamin A is important to the health of your eyes, hair, bones, and skin; sources of vitamin A include foods such as eggs, carrots, and cantaloupe.

·

Vitamin B1, also known as thiamine, is important for your nervous system and energy production; food sources for thiamine include meat, peas, fortified cereals, bread, and whole grains.

·

Vitamin B2, also known as riboflavin, is important for your nervous system and muscles, but is also involved in the release of proteins from nutrients; food sources for riboflavin include dairy products, leafy vegetables, meat, and eggs.

·

Vitamin B3, also known as niacin, is important for healthy skin and helps the body use energy; food sources for niacin include peas, peanuts, fish, and whole grains

Researching Nutrition 157

·

Vitamin B6, also known as pyridoxine, is important for the regulation of cells in the nervous system and is vital for blood formation; food sources for pyridoxine include bananas, whole grains, meat, and fish.

·

Vitamin B12 is vital for a healthy nervous system and for the growth of red blood cells in bone marrow; food sources for vitamin B12 include yeast, milk, fish, eggs, and meat.

·

Vitamin C allows the body's immune system to fight various diseases, strengthens body tissue, and improves the body's use of iron; food sources for vitamin C include a wide variety of fruits and vegetables.

·

Vitamin D helps the body absorb calcium which strengthens bones and teeth; food sources for vitamin D include oily fish and dairy products.

·

Vitamin E can help protect certain organs and tissues from various degenerative diseases; food sources for vitamin E include margarine, vegetables, eggs, and fish.

·

Vitamin K is essential for bone formation and blood clotting; common food sources for vitamin K include leafy green vegetables.

·

Folic Acid maintains healthy cells and blood and, when taken by a pregnant woman, can prevent her fetus from developing neural tube defects; food sources for folic acid include nuts, fortified breads, leafy green vegetables, and whole grains.

It should be noted that one can overdose on certain vitamins which become toxic if consumed in excess (e.g. vitamin A, D, E and K). Like vitamins, minerals are chemicals that are required by the body to remain in good health. Because the human body does not manufacture these chemicals internally, we obtain them from food and other dietary sources. The more important minerals include: ·

Calcium is needed for healthy bones, teeth, and muscles, but also helps the nervous system function; food sources for calcium include dry beans, peas, eggs, and dairy products.

·

Chromium is helpful in regulating sugar levels in blood; food sources for chromium include egg yolks, raw sugar, cheese, nuts, beets, whole grains, and meat.

·

Fluoride is used by the body to help prevent tooth decay and to reinforce bone strength; sources of fluoride include drinking water and certain brands of toothpaste.

158 Periodontitis

·

Iodine helps regulate the body's use of energy by synthesizing into the hormone thyroxine; food sources include leafy green vegetables, nuts, egg yolks, and red meat.

·

Iron helps maintain muscles and the formation of red blood cells and certain proteins; food sources for iron include meat, dairy products, eggs, and leafy green vegetables.

·

Magnesium is important for the production of DNA, as well as for healthy teeth, bones, muscles, and nerves; food sources for magnesium include dried fruit, dark green vegetables, nuts, and seafood.

·

Phosphorous is used by the body to work with calcium to form bones and teeth; food sources for phosphorous include eggs, meat, cereals, and dairy products.

·

Selenium primarily helps maintain normal heart and liver functions; food sources for selenium include wholegrain cereals, fish, meat, and dairy products.

·

Zinc helps wounds heal, the formation of sperm, and encourage rapid growth and energy; food sources include dried beans, shellfish, eggs, and nuts.

The United States government periodically publishes recommended diets and consumption levels of the various elements of food. Again, your healthcare provider may encourage deviations from the average official recommendation based on your specific condition. To learn more about basic dietary guidelines, visit the Web site: http://www.health.gov/dietaryguidelines/. Based on these guidelines, many foods are required to list the nutrition levels on the food’s packaging. Labeling Requirements are listed at the following site maintained by the Food and Drug Administration: http://www.cfsan.fda.gov/~dms/labcons.html. When interpreting these requirements, the government recommends that consumers become familiar with the following abbreviations before reading FDA literature:40 ·

DVs (Daily Values): A new dietary reference term that will appear on the food label. It is made up of two sets of references, DRVs and RDIs.

·

DRVs (Daily Reference Values): A set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium.

·

RDIs (Reference Daily Intakes): A set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals

40

Adapted from the FDA: http://www.fda.gov/fdac/special/foodlabel/dvs.html.

Researching Nutrition 159

and, in selected groups, protein. The name “RDI” replaces the term “U.S. RDA.” ·

RDAs (Recommended Dietary Allowances): A set of estimated nutrient allowances established by the National Academy of Sciences. It is updated periodically to reflect current scientific knowledge. What Are Dietary Supplements?41

Dietary supplements are widely available through many commercial sources, including health food stores, grocery stores, pharmacies, and by mail. Dietary supplements are provided in many forms including tablets, capsules, powders, gel-tabs, extracts, and liquids. Historically in the United States, the most prevalent type of dietary supplement was a multivitamin/mineral tablet or capsule that was available in pharmacies, either by prescription or “over the counter.” Supplements containing strictly herbal preparations were less widely available. Currently in the United States, a wide array of supplement products are available, including vitamin, mineral, other nutrients, and botanical supplements as well as ingredients and extracts of animal and plant origin. The Office of Dietary Supplements (ODS) of the National Institutes of Health is the official agency of the United States which has the expressed goal of acquiring “new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold.”42 According to the ODS, dietary supplements can have an important impact on the prevention and management of disease and on the maintenance of health.43 The ODS notes that considerable research on the effects of dietary supplements has been conducted in Asia and Europe where the use of plant products, in particular, has a long tradition. However, the overwhelming majority of supplements have not been studied scientifically. This discussion has been adapted from the NIH: http://ods.od.nih.gov/whatare/whatare.html. 42 Contact: The Office of Dietary Supplements, National Institutes of Health, Building 31, Room 1B29, 31 Center Drive, MSC 2086, Bethesda, Maryland 20892-2086, Tel: (301) 435-2920, Fax: (301) 480-1845, E-mail: [email protected]. 43 Adapted from http://ods.od.nih.gov/about/about.html. The Dietary Supplement Health and Education Act defines dietary supplements as “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, mineral, amino acid, herb or other botanical; or a dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above; and intended for ingestion in the form of a capsule, powder, softgel, or gelcap, and not represented as a conventional food or as a sole item of a meal or the diet.” 41

160 Periodontitis

To explore the role of dietary supplements in the improvement of health care, the ODS plans, organizes, and supports conferences, workshops, and symposia on scientific topics related to dietary supplements. The ODS often works in conjunction with other NIH Institutes and Centers, other government agencies, professional organizations, and public advocacy groups. To learn more about official information on dietary supplements, visit the ODS site at http://ods.od.nih.gov/whatare/whatare.html. Or contact: The Office of Dietary Supplements National Institutes of Health Building 31, Room 1B29 31 Center Drive, MSC 2086 Bethesda, Maryland 20892-2086 Tel: (301) 435-2920 Fax: (301) 480-1845 E-mail: [email protected]

Finding Studies on Periodontitis The NIH maintains an office dedicated to patient nutrition and diet. The National Institutes of Health’s Office of Dietary Supplements (ODS) offers a searchable bibliographic database called the IBIDS (International Bibliographic Information on Dietary Supplements). The IBIDS contains over 460,000 scientific citations and summaries about dietary supplements and nutrition as well as references to published international, scientific literature on dietary supplements such as vitamins, minerals, and botanicals.44 IBIDS is available to the public free of charge through the ODS Internet page: http://ods.od.nih.gov/databases/ibids.html. After entering the search area, you have three choices: (1) IBIDS Consumer Database, (2) Full IBIDS Database, or (3) Peer Reviewed Citations Only. We recommend that you start with the Consumer Database. While you may not find references for the topics that are of most interest to you, check back periodically as this database is frequently updated. More studies can be found by searching the Full IBIDS Database. Healthcare professionals and Adapted from http://ods.od.nih.gov. IBIDS is produced by the Office of Dietary Supplements (ODS) at the National Institutes of Health to assist the public, healthcare providers, educators, and researchers in locating credible, scientific information on dietary supplements. IBIDS was developed and will be maintained through an interagency partnership with the Food and Nutrition Information Center of the National Agricultural Library, U.S. Department of Agriculture.

44

Researching Nutrition 161

researchers generally use the third option, which lists peer-reviewed citations. In all cases, we suggest that you take advantage of the “Advanced Search” option that allows you to retrieve up to 100 fully explained references in a comprehensive format. Type “periodontitis” (or synonyms) into the search box. To narrow the search, you can also select the “Title” field. The following information is typical of that found when using the “Full IBIDS Database” when searching using “periodontitis” (or a synonym): ·

A clinical and microbiological evaluation of systemic and local metronidazole delivery in early onset periodontitis patients. Author(s): Department of Periodontology, Faculty of Dentistry, Marmara University, Istanbul, Turkiye. Source: Yilmaz, S Kuru, B Noyan, U Kadir, T Acar, O Buget, E JMarmara-Univ-Dent-Fac. 1996 September; 2(2-3): 500-9 1018-5992

·

Acute apical periodontitis: incidence of post-operative pain using two different root canal dressings. Source: Fava, L R Int-Endod-J. 1998 September; 31(5): 343-7 0143-2885

·

Biodegradable dental implants of ciprofloxacin beta-cyclodextrin inclusion complex in the treatment of periodontitis. Author(s): Visveswarapura Institute of Pharmaceutical Sciences, Bangalore, India. Source: Nagaraju, R Udupa, N Mathew, J Varma, B R Indian-J-Exp-Biol. 1999 March; 37(3): 305-7 0019-5189

·

Clinical effect of subgingival tetracycline irrigation and tetracyclineloaded fiber application in the treatment of adult periodontitis. Author(s): Department of Periodontology, University of Ferrara, School of Dentistry, Italy. Source: Trombelli, L Scabbia, A Carotta, V Scapoli, C Calura, G Quintessence-Int. 1996 January; 27(1): 19-25 0033-6572

·

Dietary shifts may explain the incidence of periodontitis in industrialized countries. Author(s): Department of Periodontology, University of Turku, Finland. Source: Sewon, L A Makinen, K K Med-Hypotheses. 1996 March; 46(3): 269-75 0306-9877

·

Dissolution of type I collagen fibrils by gingival fibroblasts isolated from patients of various periodontitis categories. Author(s): Department of Periodontology, School of Dentistry, Faculty of Health Sciences, University of Copenhagen, Denmark. [email protected]

162 Periodontitis

Source: Havemose Poulsen, A Holmstrup, P Stoltze, K Birkedal Hansen, H J-Periodontal-Res. 1998 July; 33(5): 280-91 0022-3484 ·

Double-blind evaluation of the clinical efficacy of an herbal dentifrice against gingivitis and periodontitis. Source: Emling, R C J-Clin-Dent. 1988 Summer; 1 Suppl AA27-9 08958831

·

Effect of different root canal sealers on periapical repair of teeth with chronic periradicular periodontitis. Author(s): Department of Endodontics, Araraquara School of Dentistry, University of the State of Sao Paulo, Brazil. Source: Tanomaru Filho, M Leonardo, M R Silva, L A Utrilla, L S IntEndod-J. 1998 Mar; 31(2): 85-9 0143-2885

·

Effects of destructive periodontitis, induced by diet, on the mechanical properties of the periodontal ligament of the mandibular first molar in golden hamsters. Author(s): Department of Periodontics and Endodontics, School of Dental Medicine, Tsurumi University, Yokohama, Japan. Source: Yamazaki, Y J-Periodontal-Res. 1992 March; 27(2): 149-58 00223484

·

Effects of flurbiprofen on the progression of periodontitis in Macaca mulatta. Source: Offenbacher, S Braswell, L D Loos, A S Johnson, H G Hall, C M McClure, H Orkin, J L Strobert, E A Green, M D Odle, B M J-PeriodontalRes. 1987 November; 22(6): 473-81 0022-3484

·

Ehlers-Danlos syndrome, type VIII presenting with periodontitis and prolonged bleeding time. Author(s): Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, USA. Source: Cunniff, C Williamson Kruse, L Clin-Dysmorphol. 1995 April; 4(2): 145-9 0962-8827

·

Experimental endocarditis following dental extractions in rats with periodontitis. Author(s): Department of Oral Diagnosis, Baltimore College of Dental Surgery, Dental School, University of Maryland, Baltimore 21201. Source: Overholser, C D Moreillon, P Glauser, M P J-Oral-MaxillofacSurg. 1988 October; 46(10): 857-61 0278-2391

·

Flurbiprofen treatment of human periodontitis: effect on alveolar bone height and metabolism. Source: Jeffcoat, M K Williams, R C Reddy, M S English, R Goldhaber, P J-Periodontal-Res. 1988 November; 23(6): 381-5 0022-3484

Researching Nutrition 163

·

Gingival crevicular fluid lactoferrin levels in adult periodontitis patients. Author(s): Kaohsiung Medical College, School of Dentistry, Taiwan. Source: Tsai, C C Kao, C C Chen, C C Aust-Dent-J. 1998 February; 43(1): 40-4 0045-0421

·

Improvement of gingival and alveolar bone status in periodontitisaffected hamsters treated with 15-methyl prostaglandin E1. Author(s): Laboratoire de Biologie et Biomateriaux du Milieu Buccalet Osseux, Faculty of Dental Surgery, University of Paris-V, Montrouge, France. Source: Caillon, P Saffar, J L J-Periodontal-Res. 1994 March; 29(2): 138-45 0022-3484

·

Increased numbers of black-pigmented Bacteroides in induced periodontitis in monkeys. Author(s): Karolinska Institutet, Stockholm, Sweden. Source: Sasaki, N Soder, P O Fronstell, G Zambelis, G Bull-Tokyo-DentColl. 1990 February; 31(1): 1-7 0040-8891

·

Indomethacin or flurbiprofen treatment of periodontitis in beagles: comparison of effect on bone loss. Source: Williams, R C Jeffcoat, M K Howell, T H Hall, C M Johnson, H G Wechter, W J Goldhaber, P J-Periodontal-Res. 1987 September; 22(5): 4037 0022-3484

·

Influence of irrigation and intracanal dressing on the healing process of dogs' teeth with apical periodontitis. Author(s): Department of Endodontics, UNESP, Aracatuba, Sao Paulo, Brasil. Source: Holland, R Soares, I J Soares, I M Endod-Dent-Traumatol. 1992 December; 8(6): 223-9 0109-2502

·

Inhibitory effects of YM175, a bisphosphonate, on the progression of experimental periodontitis in beagle dogs. Author(s): Pharmacology Laboratories, Yamanouchi Pharmaceutical Co. Ltd, Ibaraki, Japan. Source: O'uchi, N Nishikawa, H Yoshino, T Kanoh, H Motoie, H Nishimori, E Shimaoka, T Abe, T Shikama, H Fujikura, T Matsue, M Matsue, I J-Periodontal-Res. 1998 May; 33(4): 196-204 0022-3484

·

Irrigation with antimicrobial agents for the treatment of periodontitis-is it effective? Author(s): Navajo Area Indian Health Service at Gallup Indian Medical Center, New Mexico 87301, USA. Source: Gustke, C J Gen-Dent. 1999 Mar-April; 47(2): 164-8; quiz 169-70 0363-6771

164 Periodontitis

Federal Resources on Nutrition In addition to the IBIDS, the United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) provide many sources of information on general nutrition and health. Recommended resources include: ·

healthfinder®, HHS's gateway to health information, including diet and nutrition: http://www.healthfinder.gov/scripts/SearchContext.asp?topic=238&page=0

·

The United States Department of Agriculture's Web site dedicated to nutrition information: www.nutrition.gov

·

The Food and Drug Administration's Web site for federal food safety information: www.foodsafety.gov

·

The National Action Plan on Overweight and Obesity sponsored by the United States Surgeon General: http://www.surgeongeneral.gov/topics/obesity/

·

The Center for Food Safety and Applied Nutrition has an Internet site sponsored by the Food and Drug Administration and the Department of Health and Human Services: http://vm.cfsan.fda.gov/

·

Center for Nutrition Policy and Promotion sponsored by the United States Department of Agriculture: http://www.usda.gov/cnpp/

·

Food and Nutrition Information Center, National Agricultural Library sponsored by the United States Department of Agriculture: http://www.nal.usda.gov/fnic/

·

Food and Nutrition Service sponsored by the United States Department of Agriculture: http://www.fns.usda.gov/fns/

Additional Web Resources A number of additional Web sites offer encyclopedic information covering food and nutrition. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=174&layer=&from=subcats

·

Family Village: http://www.familyvillage.wisc.edu/med_nutrition.html

·

Google: http://directory.google.com/Top/Health/Nutrition/

·

Healthnotes: http://www.thedacare.org/healthnotes/

·

Open Directory Project: http://dmoz.org/Health/Nutrition/

Researching Nutrition 165

·

Yahoo.com: http://dir.yahoo.com/Health/Nutrition/

·

WebMDÒHealth: http://my.webmd.com/nutrition

·

WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

The following is a specific Web list relating to periodontitis; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation: ·

Vitamins Ascorbic Acid Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm

·

Minerals Calcium Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm Folate Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm

·

Food and Diet Water Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Gingivitis.htm

166 Periodontitis

Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Ciprofloxacin: A carboxyfluoroquinoline antimicrobial agent that is effective against a wide range of microorganisms. It has been successfully and safely used in the treatment of resistant respiratory, skin, bone, joint, gastrointestinal, urinary, and genital infections. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Diuretic: An agent that promotes the excretion of urine. [EU] Diuretics: Agents that promote the excretion of urine through their effects on kidney function. [NIH] Fibroblasts: Connective tissue cells which secrete an extracellular matrix rich in collagen and other macromolecules. [NIH] Flurbiprofen: An anti-inflammatory analgesic and antipyretic of the phenylalkynoic acid series. It has been shown to reduce bone resorption in periodontal disease by inhibiting carbonic anhydrase. [NIH] Irrigation: Washing by a stream of water or other fluid. [EU] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong

Researching Nutrition 167

electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH]

Finding Medical Libraries 169

APPENDIX D. FINDING MEDICAL LIBRARIES Overview At a medical library you can find medical texts and reference books, consumer health publications, specialty newspapers and magazines, as well as medical journals. In this Appendix, we show you how to quickly find a medical library in your area.

Preparation Before going to the library, highlight the references mentioned in this sourcebook that you find interesting. Focus on those items that are not available via the Internet, and ask the reference librarian for help with your search. He or she may know of additional resources that could be helpful to you. Most importantly, your local public library and medical libraries have Interlibrary Loan programs with the National Library of Medicine (NLM), one of the largest medical collections in the world. According to the NLM, most of the literature in the general and historical collections of the National Library of Medicine is available on interlibrary loan to any library. NLM's interlibrary loan services are only available to libraries. If you would like to access NLM medical literature, then visit a library in your area that can request the publications for you.45

45

Adapted from the NLM: http://www.nlm.nih.gov/psd/cas/interlibrary.html.

170 Periodontitis

Finding a Local Medical Library The quickest method to locate medical libraries is to use the Internet-based directory published by the National Network of Libraries of Medicine (NN/LM). This network includes 4626 members and affiliates that provide many services to librarians, health professionals, and the public. To find a library in your area, simply visit http://nnlm.gov/members/adv.html or call 1-800-338-7657.

Medical Libraries Open to the Public In addition to the NN/LM, the National Library of Medicine (NLM) lists a number of libraries that are generally open to the public and have reference facilities. The following is the NLM’s list plus hyperlinks to each library Web site. These Web pages can provide information on hours of operation and other restrictions. The list below is a small sample of libraries recommended by the National Library of Medicine (sorted alphabetically by name of the U.S. state or Canadian province where the library is located):46 ·

Alabama: Health InfoNet of Jefferson County (Jefferson County Library Cooperative, Lister Hill Library of the Health Sciences), http://www.uab.edu/infonet/

·

Alabama: Richard M. Scrushy Library (American Sports Medicine Institute), http://www.asmi.org/LIBRARY.HTM

·

Arizona: Samaritan Regional Medical Center: The Learning Center (Samaritan Health System, Phoenix, Arizona), http://www.samaritan.edu/library/bannerlibs.htm

·

California: Kris Kelly Health Information Center (St. Joseph Health System), http://www.humboldt1.com/~kkhic/index.html

·

California: Community Health Library of Los Gatos (Community Health Library of Los Gatos), http://www.healthlib.org/orgresources.html

·

California: Consumer Health Program and Services (CHIPS) (County of Los Angeles Public Library, Los Angeles County Harbor-UCLA Medical Center Library) - Carson, CA, http://www.colapublib.org/services/chips.html

·

California: Gateway Health Library (Sutter Gould Medical Foundation)

·

California: Health Library (Stanford University Medical Center), http://www-med.stanford.edu/healthlibrary/

46

Abstracted from http://www.nlm.nih.gov/medlineplus/libraries.html.

Finding Medical Libraries 171

·

California: Patient Education Resource Center - Health Information and Resources (University of California, San Francisco), http://sfghdean.ucsf.edu/barnett/PERC/default.asp

·

California: Redwood Health Library (Petaluma Health Care District), http://www.phcd.org/rdwdlib.html

·

California: San José PlaneTree Health Library, http://planetreesanjose.org/

·

California: Sutter Resource Library (Sutter Hospitals Foundation), http://go.sutterhealth.org/comm/resc-library/sac-resources.html

·

California: University of California, Davis. Health Sciences Libraries

·

California: ValleyCare Health Library & Ryan Comer Cancer Resource Center (ValleyCare Health System), http://www.valleycare.com/library.html

·

California: Washington Community Health Resource Library (Washington Community Health Resource Library), http://www.healthlibrary.org/

·

Colorado: William V. Gervasini Memorial Library (Exempla Healthcare), http://www.exempla.org/conslib.htm

·

Connecticut: Hartford Hospital Health Science Libraries (Hartford Hospital), http://www.harthosp.org/library/

·

Connecticut: Healthnet: Connecticut Consumer Health Information Center (University of Connecticut Health Center, Lyman Maynard Stowe Library), http://library.uchc.edu/departm/hnet/

·

Connecticut: Waterbury Hospital Health Center Library (Waterbury Hospital), http://www.waterburyhospital.com/library/consumer.shtml

·

Delaware: Consumer Health Library (Christiana Care Health System, Eugene du Pont Preventive Medicine & Rehabilitation Institute), http://www.christianacare.org/health_guide/health_guide_pmri_health _info.cfm

·

Delaware: Lewis B. Flinn Library (Delaware Academy of Medicine), http://www.delamed.org/chls.html

·

Georgia: Family Resource Library (Medical College of Georgia), http://cmc.mcg.edu/kids_families/fam_resources/fam_res_lib/frl.htm

·

Georgia: Health Resource Center (Medical Center of Central Georgia), http://www.mccg.org/hrc/hrchome.asp

·

Hawaii: Hawaii Medical Library: Consumer Health Information Service (Hawaii Medical Library), http://hml.org/CHIS/

172 Periodontitis

·

Idaho: DeArmond Consumer Health Library (Kootenai Medical Center), http://www.nicon.org/DeArmond/index.htm

·

Illinois: Health Learning Center of Northwestern Memorial Hospital (Northwestern Memorial Hospital, Health Learning Center), http://www.nmh.org/health_info/hlc.html

·

Illinois: Medical Library (OSF Saint Francis Medical Center), http://www.osfsaintfrancis.org/general/library/

·

Kentucky: Medical Library - Services for Patients, Families, Students & the Public (Central Baptist Hospital), http://www.centralbap.com/education/community/library.htm

·

Kentucky: University of Kentucky - Health Information Library (University of Kentucky, Chandler Medical Center, Health Information Library), http://www.mc.uky.edu/PatientEd/

·

Louisiana: Alton Ochsner Medical Foundation Library (Alton Ochsner Medical Foundation), http://www.ochsner.org/library/

·

Louisiana: Louisiana State University Health Sciences Center Medical Library-Shreveport, http://lib-sh.lsuhsc.edu/

·

Maine: Franklin Memorial Hospital Medical Library (Franklin Memorial Hospital), http://www.fchn.org/fmh/lib.htm

·

Maine: Gerrish-True Health Sciences Library (Central Maine Medical Center), http://www.cmmc.org/library/library.html

·

Maine: Hadley Parrot Health Science Library (Eastern Maine Healthcare), http://www.emh.org/hll/hpl/guide.htm

·

Maine: Maine Medical Center Library (Maine Medical Center), http://www.mmc.org/library/

·

Maine: Parkview Hospital, http://www.parkviewhospital.org/communit.htm#Library

·

Maine: Southern Maine Medical Center Health Sciences Library (Southern Maine Medical Center), http://www.smmc.org/services/service.php3?choice=10

·

Maine: Stephens Memorial Hospital Health Information Library (Western Maine Health), http://www.wmhcc.com/hil_frame.html

·

Manitoba, Canada: Consumer & Patient Health Information Service (University of Manitoba Libraries), http://www.umanitoba.ca/libraries/units/health/reference/chis.html

·

Manitoba, Canada: J.W. Crane Memorial Library (Deer Lodge Centre), http://www.deerlodge.mb.ca/library/libraryservices.shtml

Finding Medical Libraries 173

·

Maryland: Health Information Center at the Wheaton Regional Library (Montgomery County, Md., Dept. of Public Libraries, Wheaton Regional Library), http://www.mont.lib.md.us/healthinfo/hic.asp

·

Massachusetts: Baystate Medical Center Library (Baystate Health System), http://www.baystatehealth.com/1024/

·

Massachusetts: Boston University Medical Center Alumni Medical Library (Boston University Medical Center), http://medlibwww.bu.edu/library/lib.html

·

Massachusetts: Lowell General Hospital Health Sciences Library (Lowell General Hospital), http://www.lowellgeneral.org/library/HomePageLinks/WWW.htm

·

Massachusetts: Paul E. Woodard Health Sciences Library (New England Baptist Hospital), http://www.nebh.org/health_lib.asp

·

Massachusetts: St. Luke's Hospital Health Sciences Library (St. Luke's Hospital), http://www.southcoast.org/library/

·

Massachusetts: Treadwell Library Consumer Health Reference Center (Massachusetts General Hospital), http://www.mgh.harvard.edu/library/chrcindex.html

·

Massachusetts: UMass HealthNet (University of Massachusetts Medical School), http://healthnet.umassmed.edu/

·

Michigan: Botsford General Hospital Library - Consumer Health (Botsford General Hospital, Library & Internet Services), http://www.botsfordlibrary.org/consumer.htm

·

Michigan: Helen DeRoy Medical Library (Providence Hospital and Medical Centers), http://www.providence-hospital.org/library/

·

Michigan: Marquette General Hospital - Consumer Health Library (Marquette General Hospital, Health Information Center), http://www.mgh.org/center.html

·

Michigan: Patient Education Resouce Center - University of Michigan Cancer Center (University of Michigan Comprehensive Cancer Center), http://www.cancer.med.umich.edu/learn/leares.htm

·

Michigan: Sladen Library & Center for Health Information Resources Consumer Health Information, http://www.sladen.hfhs.org/library/consumer/index.html

·

Montana: Center for Health Information (St. Patrick Hospital and Health Sciences Center), http://www.saintpatrick.org/chi/librarydetail.php3?ID=41

174 Periodontitis

·

National: Consumer Health Library Directory (Medical Library Association, Consumer and Patient Health Information Section), http://caphis.mlanet.org/directory/index.html

·

National: National Network of Libraries of Medicine (National Library of Medicine) - provides library services for health professionals in the United States who do not have access to a medical library, http://nnlm.gov/

·

National: NN/LM List of Libraries Serving the Public (National Network of Libraries of Medicine), http://nnlm.gov/members/

·

Nevada: Health Science Library, West Charleston Library (Las Vegas Clark County Library District), http://www.lvccld.org/special_collections/medical/index.htm

·

New Hampshire: Dartmouth Biomedical Libraries (Dartmouth College Library), http://www.dartmouth.edu/~biomed/resources.htmld/conshealth.htmld/

·

New Jersey: Consumer Health Library (Rahway Hospital), http://www.rahwayhospital.com/library.htm

·

New Jersey: Dr. Walter Phillips Health Sciences Library (Englewood Hospital and Medical Center), http://www.englewoodhospital.com/links/index.htm

·

New Jersey: Meland Foundation (Englewood Hospital and Medical Center), http://www.geocities.com/ResearchTriangle/9360/

·

New York: Choices in Health Information (New York Public Library) NLM Consumer Pilot Project participant, http://www.nypl.org/branch/health/links.html

·

New York: Health Information Center (Upstate Medical University, State University of New York), http://www.upstate.edu/library/hic/

·

New York: Health Sciences Library (Long Island Jewish Medical Center), http://www.lij.edu/library/library.html

·

New York: ViaHealth Medical Library (Rochester General Hospital), http://www.nyam.org/library/

·

Ohio: Consumer Health Library (Akron General Medical Center, Medical & Consumer Health Library), http://www.akrongeneral.org/hwlibrary.htm

·

Oklahoma: Saint Francis Health System Patient/Family Resource Center (Saint Francis Health System), http://www.sfhtulsa.com/patientfamilycenter/default.asp

Finding Medical Libraries 175

·

Oregon: Planetree Health Resource Center (Mid-Columbia Medical Center), http://www.mcmc.net/phrc/

·

Pennsylvania: Community Health Information Library (Milton S. Hershey Medical Center), http://www.hmc.psu.edu/commhealth/

·

Pennsylvania: Community Health Resource Library (Geisinger Medical Center), http://www.geisinger.edu/education/commlib.shtml

·

Pennsylvania: HealthInfo Library (Moses Taylor Hospital), http://www.mth.org/healthwellness.html

·

Pennsylvania: Hopwood Library (University of Pittsburgh, Health Sciences Library System), http://www.hsls.pitt.edu/chi/hhrcinfo.html

·

Pennsylvania: Koop Community Health Information Center (College of Physicians of Philadelphia), http://www.collphyphil.org/kooppg1.shtml

·

Pennsylvania: Learning Resources Center - Medical Library (Susquehanna Health System), http://www.shscares.org/services/lrc/index.asp

·

Pennsylvania: Medical Library (UPMC Health System), http://www.upmc.edu/passavant/library.htm

·

Quebec, Canada: Medical Library (Montreal General Hospital), http://ww2.mcgill.ca/mghlib/

·

South Dakota: Rapid City Regional Hospital - Health Information Center (Rapid City Regional Hospital, Health Information Center), http://www.rcrh.org/education/LibraryResourcesConsumers.htm

·

Texas: Houston HealthWays (Houston Academy of Medicine-Texas Medical Center Library), http://hhw.library.tmc.edu/

·

Texas: Matustik Family Resource Center (Cook Children's Health Care System), http://www.cookchildrens.com/Matustik_Library.html

·

Washington: Community Health Library (Kittitas Valley Community Hospital), http://www.kvch.com/

·

Washington: Southwest Washington Medical Center Library (Southwest Washington Medical Center), http://www.swmedctr.com/Home/

Your Rights and Insurance 177

APPENDIX E. YOUR RIGHTS AND INSURANCE Overview Any patient with periodontitis faces a series of issues related more to the healthcare industry than to the medical condition itself. This appendix covers two important topics in this regard: your rights and responsibilities as a patient, and how to get the most out of your medical insurance plan.

Your Rights as a Patient The President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry has created the following summary of your rights as a patient.47 Information Disclosure Consumers have the right to receive accurate, easily understood information. Some consumers require assistance in making informed decisions about health plans, health professionals, and healthcare facilities. Such information includes: ·

Health plans. Covered benefits, cost-sharing, and procedures for resolving complaints, licensure, certification, and accreditation status, comparable measures of quality and consumer satisfaction, provider network composition, the procedures that govern access to specialists and emergency services, and care management information.

47Adapted

from Consumer Bill of Rights and Responsibilities: http://www.hcqualitycommission.gov/press/cbor.html#head1.

178 Periodontitis

·

Health professionals. Education, board certification, and recertification, years of practice, experience performing certain procedures, and comparable measures of quality and consumer satisfaction.

·

Healthcare facilities. Experience in performing certain procedures and services, accreditation status, comparable measures of quality, worker, and consumer satisfaction, and procedures for resolving complaints.

·

Consumer assistance programs. Programs must be carefully structured to promote consumer confidence and to work cooperatively with health plans, providers, payers, and regulators. Desirable characteristics of such programs are sponsorship that ensures accountability to the interests of consumers and stable, adequate funding.

Choice of Providers and Plans Consumers have the right to a choice of healthcare providers that is sufficient to ensure access to appropriate high-quality healthcare. To ensure such choice, the Commission recommends the following: ·

Provider network adequacy. All health plan networks should provide access to sufficient numbers and types of providers to assure that all covered services will be accessible without unreasonable delay -including access to emergency services 24 hours a day and 7 days a week. If a health plan has an insufficient number or type of providers to provide a covered benefit with the appropriate degree of specialization, the plan should ensure that the consumer obtains the benefit outside the network at no greater cost than if the benefit were obtained from participating providers.

·

Women's health services. Women should be able to choose a qualified provider offered by a plan -- such as gynecologists, certified nurse midwives, and other qualified healthcare providers -- for the provision of covered care necessary to provide routine and preventative women's healthcare services.

·

Access to specialists. Consumers with complex or serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within a plan's network of providers. Authorizations, when required, should be for an adequate number of direct access visits under an approved treatment plan.

·

Transitional care. Consumers who are undergoing a course of treatment for a chronic or disabling condition (or who are in the second or third trimester of a pregnancy) at the time they involuntarily change health

Your Rights and Insurance 179

plans or at a time when a provider is terminated by a plan for other than cause should be able to continue seeing their current specialty providers for up to 90 days (or through completion of postpartum care) to allow for transition of care. ·

Choice of health plans. Public and private group purchasers should, wherever feasible, offer consumers a choice of high-quality health insurance plans.

Access to Emergency Services Consumers have the right to access emergency healthcare services when and where the need arises. Health plans should provide payment when a consumer presents to an emergency department with acute symptoms of sufficient severity--including severe pain--such that a “prudent layperson” could reasonably expect the absence of medical attention to result in placing that consumer's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Participation in Treatment Decisions Consumers have the right and responsibility to fully participate in all decisions related to their healthcare. Consumers who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators. Dentists and other health professionals should: ·

Provide patients with sufficient information and opportunity to decide among treatment options consistent with the informed consent process.

·

Discuss all treatment options with a patient in a culturally competent manner, including the option of no treatment at all.

·

Ensure that persons with disabilities have effective communications with members of the health system in making such decisions.

·

Discuss all current treatments a consumer may be undergoing.

·

Discuss all risks, nontreatment.

·

Give patients the opportunity to refuse treatment and to express preferences about future treatment decisions.

benefits,

and

consequences

to

treatment

or

180 Periodontitis

·

Discuss the use of advance directives -- both living wills and durable powers of attorney for healthcare -- with patients and their designated family members.

·

Abide by the decisions made by their patients and/or their designated representatives consistent with the informed consent process.

Health plans, health providers, and healthcare facilities should: ·

Disclose to consumers factors -- such as methods of compensation, ownership of or interest in healthcare facilities, or matters of conscience -that could influence advice or treatment decisions.

·

Assure that provider contracts do not contain any so-called “gag clauses” or other contractual mechanisms that restrict healthcare providers' ability to communicate with and advise patients about medically necessary treatment options.

·

Be prohibited from penalizing or seeking retribution against healthcare professionals or other health workers for advocating on behalf of their patients.

Respect and Nondiscrimination Consumers have the right to considerate, respectful care from all members of the healthcare industry at all times and under all circumstances. An environment of mutual respect is essential to maintain a quality healthcare system. To assure that right, the Commission recommends the following: ·

Consumers must not be discriminated against in the delivery of healthcare services consistent with the benefits covered in their policy, or as required by law, based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.

·

Consumers eligible for coverage under the terms and conditions of a health plan or program, or as required by law, must not be discriminated against in marketing and enrollment practices based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment. Confidentiality of Health Information

Consumers have the right to communicate with healthcare providers in confidence and to have the confidentiality of their individually identifiable

Your Rights and Insurance 181

healthcare information protected. Consumers also have the right to review and copy their own medical records and request amendments to their records. Complaints and Appeals Consumers have the right to a fair and efficient process for resolving differences with their health plans, healthcare providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review. A free copy of the Patient's Bill of Rights is available from the American Hospital Association.48

Patient Responsibilities Treatment is a two-way street between you and your healthcare providers. To underscore the importance of finance in modern healthcare as well as your responsibility for the financial aspects of your care, the President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry has proposed that patients understand the following “Consumer Responsibilities.”49 In a healthcare system that protects consumers' rights, it is reasonable to expect and encourage consumers to assume certain responsibilities. Greater individual involvement by the consumer in his or her care increases the likelihood of achieving the best outcome and helps support a quality-oriented, cost-conscious environment. Such responsibilities include: ·

Take responsibility for maximizing healthy habits such as exercising, not smoking, and eating a healthy diet.

·

Work collaboratively with healthcare providers in developing and carrying out agreed-upon treatment plans.

·

Disclose relevant information and clearly communicate wants and needs.

·

Use your health insurance plan's internal complaint and appeal processes to address your concerns.

·

Avoid knowingly spreading disease.

48 To order your free copy of the Patient's Bill of Rights, telephone 312-422-3000 or visit the American Hospital Association’s Web site: http://www.aha.org. Click on “Resource Center,” go to “Search” at bottom of page, and then type in “Patient's Bill of Rights.” The Patient’s Bill of Rights is also available from Fax on Demand, at 312-422-2020, document number 471124. 49 Adapted from http://www.hcqualitycommission.gov/press/cbor.html#head1.

182 Periodontitis

·

Recognize the reality of risks, the limits of the medical science, and the human fallibility of the healthcare professional.

·

Be aware of a healthcare provider's obligation to be reasonably efficient and equitable in providing care to other patients and the community.

·

Become knowledgeable about your health plan’s coverage and options (when available) including all covered benefits, limitations, and exclusions, rules regarding use of network providers, coverage and referral rules, appropriate processes to secure additional information, and the process to appeal coverage decisions.

·

Show respect for other patients and health workers.

·

Make a good-faith effort to meet financial obligations.

·

Abide by administrative and operational procedures of health plans, healthcare providers, and Government health benefit programs.

Choosing an Insurance Plan There are a number of official government agencies that help consumers understand their healthcare insurance choices.50 The U.S. Department of Labor, in particular, recommends ten ways to make your health benefits choices work best for you.51 1. Your options are important. There are many different types of health benefit plans. Find out which one your employer offers, then check out the plan, or plans, offered. Your employer's human resource office, the health plan administrator, or your union can provide information to help you match your needs and preferences with the available plans. The more information you have, the better your healthcare decisions will be. 2. Reviewing the benefits available. Do the plans offered cover preventive care, well-baby care, vision or dental care? Are there deductibles? Answers to these questions can help determine the out-of-pocket expenses you may face. Matching your needs and those of your family members will result in the best possible benefits. Cheapest may not always be best. Your goal is high quality health benefits.

More information about quality across programs is provided at the following AHRQ Web site: http://www.ahrq.gov/consumer/qntascii/qnthplan.htm. 51 Adapted from the Department of Labor: http://www.dol.gov/dol/pwba/public/pubs/health/top10-text.html. 50

Your Rights and Insurance 183

3. Look for quality. The quality of healthcare services varies, but quality can be measured. You should consider the quality of healthcare in deciding among the healthcare plans or options available to you. Not all health plans, dentists, hospitals and other providers give the highest quality care. Fortunately, there is quality information you can use right now to help you compare your healthcare choices. Find out how you can measure quality. Consult the U.S. Department of Health and Human Services publication “Your Guide to Choosing Quality Health Care” on the Internet at www.ahcpr.gov/consumer. 4. Your plan's summary plan description (SPD) provides a wealth of information. Your health plan administrator can provide you with a copy of your plan’s SPD. It outlines your benefits and your legal rights under the Employee Retirement Income Security Act (ERISA), the federal law that protects your health benefits. It should contain information about the coverage of dependents, what services will require a co-pay, and the circumstances under which your employer can change or terminate a health benefits plan. Save the SPD and all other health plan brochures and documents, along with memos or correspondence from your employer relating to health benefits. 5. Assess your benefit coverage as your family status changes. Marriage, divorce, childbirth or adoption, and the death of a spouse are all life events that may signal a need to change your health benefits. You, your spouse and dependent children may be eligible for a special enrollment period under provisions of the Health Insurance Portability and Accountability Act (HIPAA). Even without life-changing events, the information provided by your employer should tell you how you can change benefits or switch plans, if more than one plan is offered. If your spouse's employer also offers a health benefits package, consider coordinating both plans for maximum coverage. 6. Changing jobs and other life events can affect your health benefits. Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), you, your covered spouse, and your dependent children may be eligible to purchase extended health coverage under your employer's plan if you lose your job, change employers, get divorced, or upon occurrence of certain other events. Coverage can range from 18 to 36 months depending on your situation. COBRA applies to most employers with 20 or more workers and requires your plan to notify you of your rights. Most plans require eligible individuals to make their COBRA election within 60 days of the plan's notice. Be sure to follow up with your plan sponsor if you don't receive notice, and make sure you respond within the allotted time.

184 Periodontitis

7. HIPAA can also help if you are changing jobs, particularly if you have a medical condition. HIPAA generally limits pre-existing condition exclusions to a maximum of 12 months (18 months for late enrollees). HIPAA also requires this maximum period to be reduced by the length of time you had prior “creditable coverage.” You should receive a certificate documenting your prior creditable coverage from your old plan when coverage ends. 8. Plan for retirement. Before you retire, find out what health benefits, if any, extend to you and your spouse during your retirement years. Consult with your employer's human resources office, your union, the plan administrator, and check your SPD. Make sure there is no conflicting information among these sources about the benefits you will receive or the circumstances under which they can change or be eliminated. With this information in hand, you can make other important choices, like finding out if you are eligible for Medicare and Medigap insurance coverage. 9. Know how to file an appeal if your health benefits claim is denied. Understand how your plan handles grievances and where to make appeals of the plan's decisions. Keep records and copies of correspondence. Check your health benefits package and your SPD to determine who is responsible for handling problems with benefit claims. Contact PWBA for customer service assistance if you are unable to obtain a response to your complaint. 10. You can take steps to improve the quality of the healthcare and the health benefits you receive. Look for and use things like Quality Reports and Accreditation Reports whenever you can. Quality reports may contain consumer ratings -- how satisfied consumers are with the dentists in their plan, for instance-- and clinical performance measures -- how well a healthcare organization prevents and treats illness. Accreditation reports provide information on how accredited organizations meet national standards, and often include clinical performance measures. Look for these quality measures whenever possible. Consult “Your Guide to Choosing Quality Health Care” on the Internet at www.ahcpr.gov/consumer.

Medicare and Medicaid Illness strikes both rich and poor families. For low-income families, Medicaid is available to defer the costs of treatment. The Health Care Financing Administration (HCFA) administers Medicare, the nation's largest health insurance program, which covers 39 million Americans. In the following pages, you will learn the basics about Medicare insurance as well as useful

Your Rights and Insurance 185

contact information on how to find more in-depth information about Medicaid.52

Who is Eligible for Medicare? Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. You might also qualify for coverage if you are under age 65 but have a disability or EndStage Renal disease (permanent kidney failure requiring dialysis or transplant). Here are some simple guidelines: You can get Part A at age 65 without having to pay premiums if: ·

You are already receiving retirement benefits from Social Security or the Railroad Retirement Board.

·

You are eligible to receive Social Security or Railroad benefits but have not yet filed for them.

·

You or your spouse had Medicare-covered government employment.

If you are under 65, you can get Part A without having to pay premiums if: ·

You have received Social Security or Railroad Retirement Board disability benefit for 24 months.

·

You are a kidney dialysis or kidney transplant patient.

Medicare has two parts: ·

Part A (Hospital Insurance). Most people do not have to pay for Part A.

·

Part B (Medical Insurance). Most people pay monthly for Part B. Part A (Hospital Insurance)

Helps Pay For: Inpatient hospital care, care in critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas) and skilled nursing facilities, hospice care, and some home healthcare.

This section has been adapted from the Official U.S. Site for Medicare Information: http://www.medicare.gov/Basics/Overview.asp.

52

186 Periodontitis

Cost: Most people get Part A automatically when they turn age 65. You do not have to pay a monthly payment called a premium for Part A because you or a spouse paid Medicare taxes while you were working. If you (or your spouse) did not pay Medicare taxes while you were working and you are age 65 or older, you still may be able to buy Part A. If you are not sure you have Part A, look on your red, white, and blue Medicare card. It will show “Hospital Part A” on the lower left corner of the card. You can also call the Social Security Administration toll free at 1-800-772-1213 or call your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772. For more information, call your Fiscal Intermediary about Part A bills and services. The phone number for the Fiscal Intermediary office in your area can be obtained from the following Web site: http://www.medicare.gov/Contacts/home.asp. Part B (Medical Insurance) Helps Pay For: Healthcare providers, services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home healthcare. Part B helps pay for covered services and supplies when they are medically necessary. Cost: As of 2001, you pay the Medicare Part B premium of $50.00 per month. In some cases this amount may be higher if you did not choose Part B when you first became eligible at age 65. The cost of Part B may go up 10% for each 12-month period that you were eligible for Part B but declined coverage, except in special cases. You will have to pay the extra 10% cost for the rest of your life. Enrolling in Part B is your choice. You can sign up for Part B anytime during a 7-month period that begins 3 months before you turn 65. Visit your local Social Security office, or call the Social Security Administration at 1-800-7721213 to sign up. If you choose to enroll in Part B, the premium is usually taken out of your monthly Social Security, Railroad Retirement, or Civil Service Retirement payment. If you do not receive any of the above payments, Medicare sends you a bill for your part B premium every 3 months. You should receive your Medicare premium bill in the mail by the 10th of the month. If you do not, call the Social Security Administration at 1800-772-1213, or your local Social Security office. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772. For

Your Rights and Insurance 187

more information, call your Medicare carrier about bills and services. The phone number for the Medicare carrier in your area can be found at the following Web site: http://www.medicare.gov/Contacts/home.asp. You may have choices in how you get your healthcare including the Original Medicare Plan, Medicare Managed Care Plans (like HMOs), and Medicare Private Fee-for-Service Plans.

Medicaid Medicaid is a joint federal and state program that helps pay medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state. People on Medicaid may also get coverage for nursing home care and outpatient prescription drugs which are not covered by Medicare. You can find more information about Medicaid on the HCFA.gov Web site at http://www.hcfa.gov/medicaid/medicaid.htm. States also have programs that pay some or all of Medicare's premiums and may also pay Medicare deductibles and coinsurance for certain people who have Medicare and a low income. To qualify, you must have: ·

Part A (Hospital Insurance),

·

Assets, such as bank accounts, stocks, and bonds that are not more than $4,000 for a single person, or $6,000 for a couple, and

·

A monthly income that is below certain limits.

For more information on these programs, look at the Medicare Savings Programs brochure, http://www.medicare.gov/Library/PDFNavigation/PDFInterim.asp?Langua ge=English&Type=Pub&PubID=10126. There are also Prescription Drug Assistance Programs available. Find information on these programs which offer discounts or free medications to individuals in need at http://www.medicare.gov/Prescription/Home.asp.

NORD’s Medication Assistance Programs Finally, the National Organization for Rare Disorders, Inc. (NORD) administers medication programs sponsored by humanitarian-minded pharmaceutical and biotechnology companies to help uninsured or under-

188 Periodontitis

insured individuals secure life-saving or life-sustaining drugs.53 NORD programs ensure that certain vital drugs are available “to those individuals whose income is too high to qualify for Medicaid but too low to pay for their prescribed medications.” The program has standards for fairness, equity, and unbiased eligibility. It currently covers some 14 programs for nine pharmaceutical companies. NORD also offers early access programs for investigational new drugs (IND) under the approved “Treatment INDs” programs of the Food and Drug Administration (FDA). In these programs, a limited number of individuals can receive investigational drugs that have yet to be approved by the FDA. These programs are generally designed for rare diseases or disorders. For more information, visit www.rarediseases.org.

Additional Resources In addition to the references already listed in this chapter, you may need more information on health insurance, hospitals, or the healthcare system in general. The NIH has set up an excellent guidance Web site that addresses these and other issues. Topics include:54 ·

Health Insurance: http://www.nlm.nih.gov/medlineplus/healthinsurance.html

·

Health Statistics: http://www.nlm.nih.gov/medlineplus/healthstatistics.html

·

HMO and Managed Care: http://www.nlm.nih.gov/medlineplus/managedcare.html

·

Hospice Care: http://www.nlm.nih.gov/medlineplus/hospicecare.html

·

Medicaid: http://www.nlm.nih.gov/medlineplus/medicaid.html

·

Medicare: http://www.nlm.nih.gov/medlineplus/medicare.html

·

Nursing Homes and Long-term Care: http://www.nlm.nih.gov/medlineplus/nursinghomes.html

Adapted from NORD: http://www.rarediseases.org/cgibin/nord/progserv#patient?id=rPIzL9oD&mv_pc=30. 54 You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html. 53

Your Rights and Insurance 189

·

Patient's Rights, Confidentiality, Informed Consent, Ombudsman Programs, Privacy and Patient Issues: http://www.nlm.nih.gov/medlineplus/patientissues.html

·

Veteran's Health, Persian Gulf War, Gulf War Syndrome, Agent Orange: http://www.nlm.nih.gov/medlineplus/veteranshealth.html

Online Glossaries 191

ONLINE GLOSSARIES The Internet provides access to a number of free-to-use medical dictionaries and glossaries. The National Library of Medicine has compiled the following list of online dictionaries: ·

ADAM Medical Encyclopedia (A.D.A.M., Inc.), comprehensive medical reference: http://www.nlm.nih.gov/medlineplus/encyclopedia.html

·

MedicineNet.com Medical Dictionary (MedicineNet, Inc.): http://www.medterms.com/Script/Main/hp.asp

·

Merriam-Webster Medical Dictionary (Inteli-Health, Inc.): http://www.intelihealth.com/IH/

·

Multilingual Glossary of Technical and Popular Medical Terms in Eight European Languages (European Commission) - Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish: http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html

·

On-line Medical Dictionary (CancerWEB): http://www.graylab.ac.uk/omd/

·

Technology Glossary (National Library of Medicine) - Health Care Technology: http://www.nlm.nih.gov/nichsr/ta101/ta10108.htm

·

Terms and Definitions (Office of Rare Diseases): http://rarediseases.info.nih.gov/ord/glossary_a-e.html

Beyond these, MEDLINEplus contains a very user-friendly encyclopedia covering every aspect of medicine (licensed from A.D.A.M., Inc.). The ADAM Medical Encyclopedia Web site address is http://www.nlm.nih.gov/medlineplus/encyclopedia.html. ADAM is also available on commercial Web sites such as Web MD (http://my.webmd.com/adam/asset/adam_disease_articles/a_to_z/a) and drkoop.com (http://www.drkoop.com/). Topics of interest can be researched by using keywords before continuing elsewhere, as these basic definitions and concepts will be useful in more advanced areas of research. You may choose to print various pages specifically relating to periodontitis and keep them on file. The NIH, in particular, suggests that patients with periodontitis visit the following Web sites in the ADAM Medical Encyclopedia:

192 Periodontitis

·

Basic Guidelines for Periodontitis Periodontitis Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001059.htm

·

Signs & Symptoms for Periodontitis Breath odor Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003058.htm Gums bleed easily Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003062.htm Swelling Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003103.htm Swollen gums Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003066.htm

·

Diagnostics and Tests for Periodontitis Dental X-rays Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003801.htm X-ray Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003337.htm

·

Background Topics for Periodontitis Bleeding Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000045.htm

Online Glossaries 193

Oral hygiene Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001957.htm Systemic Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002294.htm

Online Dictionary Directories The following are additional online directories compiled by the National Library of Medicine, including a number of specialized medical dictionaries and glossaries: ·

Medical Dictionaries: Medical & Biological (World Health Organization): http://www.who.int/hlt/virtuallibrary/English/diction.htm#Medical

·

MEL-Michigan Electronic Library List of Online Health and Medical Dictionaries (Michigan Electronic Library): http://mel.lib.mi.us/health/health-dictionaries.html

·

Patient Education: Glossaries (DMOZ Open Directory Project): http://dmoz.org/Health/Education/Patient_Education/Glossaries/

·

Web of Online Dictionaries (Bucknell University): http://www.yourdictionary.com/diction5.html#medicine

Glossary 195

PERIODONTITIS GLOSSARY The following is a complete glossary of terms used in this sourcebook. The definitions are derived from official public sources including the National Institutes of Health [NIH] and the European Union [EU]. After this glossary, we list a number of additional hardbound and electronic glossaries and dictionaries that you may wish to consult. Abdominal: Pertaining to the abdomen. [EU] Abscess: A localized collection of pus caused by suppuration buried in tissues, organs, or confined spaces. [EU] Actinobacillus: A genus of pasteurellaceae described as gram-negative, nonsporeforming, nonmotile, facultative anaerobes. Most members are found both as pathogens and commensal organisms in the respiratory, alimentary, and genital tracts of animals. [NIH] Anaerobic: 1. lacking molecular oxygen. 2. growing, living, or occurring in the absence of molecular oxygen; pertaining to an anaerobe. [EU] Antibiotic: A chemical substance produced by a microorganism which has the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Antibody: An immunoglobulin molecule that has a specific amino acid sequence by virtue of which it interacts only with the antigen that induced its synthesis in cells of the lymphoid series (especially plasma cells), or with antigen closely related to it. Antibodies are classified according to their ode of action as agglutinins, bacteriolysins, haemolysins, opsonins, precipitins, etc. [EU] Antidepressant: An agent that stimulates the mood of a depressed patient, including tricyclic antidepressants and monoamine oxidase inhibitors. [EU] Antigens: Substances that are recognized by the immune system and induce an immune reaction. [NIH] Antimicrobial: Killing microorganisms, or suppressing their multiplication or growth. [EU] Antiseptic: A substance that inhibits the growth and development of microorganisms without necessarily killing them. [EU] Anxiety: The unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict. Physiological concomitants include

196 Periodontitis

increased heart rate, altered respiration rate, sweating, trembling, weakness, and fatigue; psychological concomitants include feelings of impending danger, powerlessness, apprehension, and tension. [EU] Aspiration: The act of inhaling. [EU] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Atypical: Irregular; not conformable to the type; in microbiology, applied specifically to strains of unusual type. [EU] Bacteremia: The presence of viable bacteria circulating in the blood. Fever, chills, tachycardia, and tachypnea are common acute manifestations of bacteremia. The majority of cases are seen in already hospitalized patients, most of whom have underlying diseases or procedures which render their bloodstreams susceptible to invasion. [NIH] Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Bacteroides: A genus of gram-negative, anaerobic, rod-shaped bacteria. Its organisms are normal inhabitants of the oral, respiratory, intestinal, and urogenital cavities of humans, animals, and insects. Some species may be pathogenic. [NIH] Benign: Not malignant; not recurrent; favourable for recovery. [EU] Bethanechol: A slowly hydrolyzed muscarinic agonist with no nicotinic effects. Bethanechol is generally used to increase smooth muscle tone, as in the GI tract following abdominal surgery or in urinary retention in the absence of obstruction. It may cause hypotension, cardiac rate changes, and bronchial spasms. [NIH] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Biopsy: The removal and examination, usually microscopic, of tissue from the living body, performed to establish precise diagnosis. [EU] Boron: Boron. A trace element with the atomic symbol B, atomic number 5, and atomic weight 10.81. Boron-10, an isotope of boron, is used as a neutron absorber in boron neutron capture therapy. [NIH] Bruxism: A disorder characterized by grinding and clenching of the teeth. [NIH]

Buccal: Pertaining to or directed toward the cheek. In dental anatomy, used to refer to the buccal surface of a tooth. [EU] Campylobacter: A genus of bacteria found in the reproductive organs, intestinal tract, and oral cavity of animals and man. Some species are pathogenic. [NIH]

Glossary 197

Candidiasis: Infection with a fungus of the genus Candida. It is usually a superficial infection of the moist cutaneous areas of the body, and is generally caused by C. albicans; it most commonly involves the skin (dermatocandidiasis), oral mucous membranes (thrush, def. 1), respiratory tract (bronchocandidiasis), and vagina (vaginitis). Rarely there is a systemic infection or endocarditis. Called also moniliasis, candidosis, oidiomycosis, and formerly blastodendriosis. [EU] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cataract: An opacity, partial or complete, of one or both eyes, on or in the lens or capsule, especially an opacity impairing vision or causing blindness. The many kinds of cataract are classified by their morphology (size, shape, location) or etiology (cause and time of occurrence). [EU] Causality: The relating of causes to the effects they produce. Causes are termed necessary when they must always precede an effect and sufficient when they initiate or produce an effect. Any of several factors may be associated with the potential disease causation or outcome, including predisposing factors, enabling factors, precipitating factors, reinforcing factors, and risk factors. [NIH] Cerebrovascular: Pertaining to the blood vessels of the cerebrum, or brain. [EU]

Cheilitis: Inflammation of the lips. It is of various etiologies and degrees of pathology. [NIH] Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Chlamydia: A genus of the family chlamydiaceae whose species cause a variety of diseases in vertebrates including humans, mice, and swine. Chlamydia species are gram-negative and produce glycogen. The type species is chlamydia trachomatis. [NIH] Chlorhexidine: Disinfectant and topical anti-infective agent used also as mouthwash to prevent oral plaque. [NIH] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH]

198 Periodontitis

Ciprofloxacin: A carboxyfluoroquinoline antimicrobial agent that is effective against a wide range of microorganisms. It has been successfully and safely used in the treatment of resistant respiratory, skin, bone, joint, gastrointestinal, urinary, and genital infections. [NIH] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Cognition: Intellectual or mental process whereby an organism becomes aware of or obtains knowledge. [NIH] Collagenases: Enzymes that catalyze the degradation of collagen by acting on the peptide bonds. EC 3.4.24. [NIH] Concomitant: Accompanying; accessory; joined with another. [EU] Condyloma: C. acuminatum; a papilloma with a central core of connective tissue in a treelike structure covered with epithelium, usually occurring on the mucous membrane or skin of the external genitals or in the perianal region. [EU] Contraceptive: conception. [EU]

An agent that diminishes the likelihood of or prevents

Coronary: Encircling in the manner of a crown; a term applied to vessels; nerves, ligaments, etc. The term usually denotes the arteries that supply the heart muscle and, by extension, a pathologic involvement of them. [EU] Cranial: Pertaining to the cranium, or to the anterior (in animals) or superior (in humans) end of the body. [EU] Cyst: Any closed cavity or sac; normal or abnormal, lined by epithelium, and especially one that contains a liquid or semisolid material. [EU] Cytokines: Non-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner. [NIH] Cytomegalovirus: A genus of the family herpesviridae, subfamily betaherpesvirinae, infecting the salivary glands, liver, spleen, lungs, eyes, and other organs, in which they produce characteristically enlarged cells with intranuclear inclusions. Infection with Cytomegalovirus is also seen as an opportunistic infection in AIDS. [NIH] Decontamination: The removal of contaminating material, such as radioactive materials, biological materials, or chemical warfare agents, from

Glossary 199

a person or object. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Dentists: Individuals licensed to practice dentistry. [NIH] Dentition: The teeth in the dental arch; ordinarily used to designate the natural teeth in position in their alveoli. [EU] Dentures: An appliance used as an artificial or prosthetic replacement for missing teeth and adjacent tissues. It does not include crowns, dental abutments, nor tooth, artificial. [NIH] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Digestion: The process of breakdown of food for metabolism and use by the body. [NIH] Doxycycline: A synthetic tetracycline derivative with a range of antimicrobial activity and mode of action similar to that of tetracycline, but more effective against many species. Animal studies suggest that it may cause less tooth staining than other tetracyclines. [NIH] Eikenella: A genus of gram-negative, facultatively anaerobic, rod-shaped bacteria that occurs in the human mouth and intestine. Organisms of this genus can be opportunistic pathogens. [NIH] Endocarditis: Exudative and proliferative inflammatory alterations of the endocardium, characterized by the presence of vegetations on the surface of the endocardium or in the endocardium itself, and most commonly involving a heart valve, but sometimes affecting the inner lining of the cardiac chambers or the endocardium elsewhere. It may occur as a primary disorder or as a complication of or in association with another disease. [EU] Endotoxemia: A condition characterized by the presence of endotoxins in the blood. If endotoxemia is the result of gram-negative rod-shaped bacteria, shock may occur. [NIH] Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU] Epidermal: Pertaining to or resembling epidermis. Called also epidermic or epidermoid. [EU] Epithelium: The covering of internal and external surfaces of the body,

200 Periodontitis

including the lining of vessels and other small cavities. It consists of cells joined by small amounts of cementing substances. Epithelium is classified into types on the basis of the number of layers deep and the shape of the superficial cells. [EU] Erythema: A name applied to redness of the skin produced by congestion of the capillaries, which may result from a variety of causes, the etiology or a specific type of lesion often being indicated by a modifying term. [EU] Exfoliation: A falling off in scales or layers. [EU] Exogenous: Developed or originating outside the organism, as exogenous disease. [EU] Extraction: The process or act of pulling or drawing out. [EU] Femur: The longest and largest bone of the skeleton, it is situated between the hip and the knee. [NIH] Fibrinolysis: The natural enzymatic dissolution of fibrin. [NIH] Fibroblasts: Connective tissue cells which secrete an extracellular matrix rich in collagen and other macromolecules. [NIH] Flurbiprofen: An anti-inflammatory analgesic and antipyretic of the phenylalkynoic acid series. It has been shown to reduce bone resorption in periodontal disease by inhibiting carbonic anhydrase. [NIH] Fructosamine: An amino sugar formed when glucose non-enzymatically reacts with the N-terminal amino group of proteins. The fructose moiety is dervied from glucose by the "classical" Amadori rearrangement. [NIH] Fusobacterium: A genus of gram-negative, anaerobic, rod-shaped bacteria found in cavities of humans and other animals. No endospores are formed. Some species are pathogenic and occur in various purulent or gangrenous infections. [NIH] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Gelatin: A product formed from skin, white connective tissue, or bone collagen. It is used as a protein food adjuvant, plasma substitute, hemostatic, suspending agent in pharmaceutical preparations, and in the manufacturing of capsules and suppositories. [NIH] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Gestation: The period of development of the young in viviparous animals, from the time of fertilization of the ovum until birth. [EU] Gingivitis: Inflammation of the gingivae. Gingivitis associated with bony changes is referred to as periodontitis. Called also oulitis and ulitis. [EU] Ginseng:

An araliaceous genus of plants that contains a number of

Glossary 201

pharmacologically active agents used as stimulants, sedatives, and tonics, especially in traditional medicine. [NIH] Glossitis: Inflammation of the tongue. [EU] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Glutamine: A non-essential amino acid present abundantly throught the body and is involved in many metabolic processes. It is synthesized from glutamic acid and ammonia. It is the principal carrier of nitrogen in the body and is an important energy source for many cells. [NIH] Halitosis: An offensive, foul breath odor resulting from a variety of causes such as poor oral hygiene, dental or oral infections, or the ingestion of certain foods. [NIH] Heartburn: Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. [NIH] Helicobacter: A genus of gram-negative, spiral-shaped bacteria that is pathogenic and has been isolated from the intestinal tract of mammals, including humans. [NIH] Hemagglutinins: Agents that cause agglutination of red blood cells. They include antibodies, blood group antigens, lectins, autoimmune factors, bacterial, viral, or parasitic blood agglutinins, etc. [NIH] Hematology: A subspecialty of internal medicine concerned with morphology, physiology, and pathology of the blood and blood-forming tissues. [NIH] Heredity: 1. the genetic transmission of a particular quality or trait from parent to offspring. 2. the genetic constitution of an individual. [EU] Herpes: Any inflammatory skin disease caused by a herpesvirus and characterized by the formation of clusters of small vesicles. When used alone, the term may refer to herpes simplex or to herpes zoster. [EU] Hormonal: Pertaining to or of the nature of a hormone. [EU] Hybridization: The genetic process of crossbreeding to produce a hybrid. Hybrid nucleic acids can be formed by nucleic acid hybridization of DNA and RNA molecules. Protein hybridization allows for hybrid proteins to be formed from polypeptide chains. [NIH]

202 Periodontitis

Hyperpigmentation: Excessive pigmentation of the skin, usually as a result of increased melanization of the epidermis rather than as a result of an increased number of melanocytes. Etiology is varied and the condition may arise from exposure to light, chemicals or other substances, or from a primary metabolic imbalance. [NIH] Hyperplasia: The abnormal multiplication or increase in the number of normal cells in normal arrangement in a tissue. [EU] Hypersensitivity: A state of altered reactivity in which the body reacts with an exaggerated immune response to a foreign substance. Hypersensitivity reactions are classified as immediate or delayed, types I and IV, respectively, in the Gell and Coombs classification (q.v.) of immune responses. [EU] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Hypothalamic: Of or involving the hypothalamus. [EU] Immunity: The condition of being immune; the protection against infectious disease conferred either by the immune response generated by immunization or previous infection or by other nonimmunologic factors (innate i.). [EU] Immunization: The induction of immunity. [EU] Impetigo: A common superficial bacterial infection caused by staphylococcus aureus or group A beta-hemolytic streptococci. Characteristics include pustular lesions that rupture and discharge a thin, amber-colored fluid that dries and forms a crust. This condition is commonly located on the face, especially about the mouth and nose. [NIH] Implantation: The insertion or grafting into the body of biological, living, inert, or radioactive material. [EU] Inflammation: A pathological process characterized by injury or destruction of tissues caused by a variety of cytologic and chemical reactions. It is usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Intestines: The section of the alimentary canal from the stomach to the anus. It includes the large intestine and small intestine. [NIH]

Glossary 203

Invasive: 1. having the quality of invasiveness. 2. involving puncture or incision of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Irritants: Drugs that act locally on cutaneous or mucosal surfaces to produce inflammation; those that cause redness due to hyperemia are rubefacients; those that raise blisters are vesicants and those that penetrate sebaceous glands and cause abscesses are pustulants; tear gases and mustard gases are also irritants. [NIH] Isoproterenol: Isopropyl analog of epinephrine; beta-sympathomimetic that acts on the heart, bronchi, skeletal muscle, alimentary tract, etc. It is used mainly as bronchodilator and heart stimulant. [NIH] Klebsiella: A genus of gram-negative, facultatively anaerobic, rod-shaped bacteria whose organisms arrange singly, in pairs, or short chains. This genus is commonly found in the intestinal tract and is an opportunistic pathogen that can give rise to bacteremia, pneumonia, urinary tract and several other types of human infection. [NIH] Laminin: Large, noncollagenous glycoprotein with antigenic properties. It is localized in the basement membrane lamina lucida and functions to bind epithelial cells to the basement membrane. Evidence suggests that the protein plays a role in tumor invasion. [NIH] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Ligament: A band of fibrous tissue that connects bones or cartilages, serving to support and strengthen joints. [EU] Lipid: Any of a heterogeneous group of flats and fatlike substances characterized by being water-insoluble and being extractable by nonpolar (or fat) solvents such as alcohol, ether, chloroform, benzene, etc. All contain as a major constituent aliphatic hydrocarbons. The lipids, which are easily stored in the body, serve as a source of fuel, are an important constituent of cell structure, and serve other biological functions. Lipids may be considered to include fatty acids, neutral fats, waxes, and steroids. Compound lipids comprise the glycolipids, lipoproteins, and phospholipids. [EU] Lumbar: Pertaining to the loins, the part of the back between the thorax and the pelvis. [EU] Lymphoma: Any neoplastic disorder of the lymphoid tissue, the term lymphoma often is used alone to denote malignant lymphoma. [EU]

204 Periodontitis

Malabsorption: Impaired intestinal absorption of nutrients. [EU] Mandible: The largest and strongest bone of the face constituting the lower jaw. It supports the lower teeth. [NIH] Maxillary: Pertaining to the maxilla : the irregularly shaped bone that with its fellow forms the upper jaw. [EU] Mediator: An object or substance by which something is mediated, such as (1) a structure of the nervous system that transmits impulses eliciting a specific response; (2) a chemical substance (transmitter substance) that induces activity in an excitable tissue, such as nerve or muscle; or (3) a substance released from cells as the result of the interaction of antigen with antibody or by the action of antigen with a sensitized lymphocyte. [EU] Melanosis: A disorder caused by a disturbance in melanin pigmentation; melanism. [EU] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Microbiological: Pertaining to microbiology : the science that deals with microorganisms, including algae, bacteria, fungi, protozoa and viruses. [EU] Microbiology: The study of microorganisms such as fungi, bacteria, algae, archaea, and viruses. [NIH] Microorganism: A microscopic organism; those of medical interest include bacteria, viruses, fungi and protozoa. [EU] Microspheres: Small uniformly-sized spherical particles frequently labeled with radioisotopes or various reagents acting as tags or markers. [NIH] Minocycline: A semisynthetic antibiotic effective against tetracyclineresistant staphylococcus infections. [NIH] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Mucus: The free slime of the mucous membranes, composed of secretion of the glands, along with various inorganic salts, desquamated cells, and leucocytes. [EU] Nausea: An unpleasant sensation, vaguely referred to the epigastrium and abdomen, and often culminating in vomiting. [EU] Necrolysis: Separation or exfoliation of tissue due to necrosis. [EU] Neoplasms: New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. [NIH] Nephropathy: Disease of the kidneys. [EU] Neuralgia: Paroxysmal pain which extends along the course of one or more

Glossary 205

nerves. Many varieties of neuralgia are distinguished according to the part affected or to the cause, as brachial, facial, occipital, supraorbital, etc., or anaemic, diabetic, gouty, malarial, syphilitic, etc. [EU] Neuropathy: A general term denoting functional disturbances and/or pathological changes in the peripheral nervous system. The etiology may be known e.g. arsenical n., diabetic n., ischemic n., traumatic n.) or unknown. Encephalopathy and myelopathy are corresponding terms relating to involvement of the brain and spinal cord, respectively. The term is also used to designate noninflammatory lesions in the peripheral nervous system, in contrast to inflammatory lesions (neuritis). [EU] Neutrophil: Having an affinity for neutral dyes. [EU] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Nicotine: Nicotine is highly toxic alkaloid. It is the prototypical agonist at nicotinic cholinergic receptors where it dramatically stimulates neurons and ultimately blocks synaptic transmission. Nicotine is also important medically because of its presence in tobacco smoke. [NIH] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Osteoporosis: Reduction in the amount of bone mass, leading to fractures after minimal trauma. [EU] Paralysis: Loss or impairment of motor function in a part due to lesion of the neural or muscular mechanism; also by analogy, impairment of sensory function (sensory paralysis). In addition to the types named below, paralysis is further distinguished as traumatic, syphilitic, toxic, etc., according to its cause; or as obturator, ulnar, etc., according to the nerve part, or muscle specially affected. [EU] Parasympathomimetic: 1. producing effects resembling those of stimulation of the parasympathetic nerve supply to a part. 2. an agent that produces effects similar to those produced by stimulation of the parasympathetic nerves. Called also cholinergic. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Peptostreptococcus: A genus of gram-positive, anaerobic, coccoid bacteria that is part of the normal flora of humans. Its organisms are opportunistic pathogens causing bacteremias and soft tissue infections. [NIH] Periodontics: A dental specialty concerned with the histology, physiology, and pathology of the tissues that support, attach, and surround the teeth,

206 Periodontitis

and of the treatment and prevention of disease affecting these tissues. [NIH] Perioral: Situated or occurring around the mouth. [EU] Pharmacists: Those persons legally qualified by education and training to engage in the practice of pharmacy. [NIH] Phenytoin: An anticonvulsant that is used in a wide variety of seizures. It is also an anti-arrhythmic and a muscle relaxant. The mechanism of therapeutic action is not clear, although several cellular actions have been described including effects on ion channels, active transport, and general membrane stabilization. The mechanism of its muscle relaxant effect appears to involve a reduction in the sensitivity of muscle spindles to stretch. Phenytoin has been proposed for several other therapeutic uses, but its use has been limited by its many adverse effects and interactions with other drugs. [NIH] Pilocarpine: A slowly hydrolyzed muscarinic agonist with no nicotinic effects. Pilocarpine is used as a miotic and in the treatment of glaucoma. [NIH] Plasminogen: The inactive precursor of plasmin (=enzyme that catalyses the hydrolysis of peptide bonds at the carbonyl end of lysine or arginine residues). [EU] Porphyromonas: A genus of gram-negative, anaerobic, nonsporeforming, nonmotile rods or coccobacilli. Organisms in this genus had originally been classified as members of the bacteroides genus but overwhelming biochemical and chemical findings indicated the need to separate them from other Bacteroides species, and hence, this new genus was created. [NIH] Posterior: Situated in back of, or in the back part of, or affecting the back or dorsal surface of the body. In lower animals, it refers to the caudal end of the body. [EU] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Povidone: A polyvinyl polymer of variable molecular weight; used as suspending and dispersing agent and vehicle for pharmaceuticals; also used as blood volume expander. [NIH] Prevotella: A genus of gram-negative, anaerobic, nonsporeforming, nonmotile rods. Organisms of this genus had originally been classified as members of the bacteroides genus but overwhelming biochemical and chemical findings in 1990 indicated the need to separate them from other Bacteroides species, and hence, this new genus was established. [NIH] Progressive:

Advancing; going forward; going from bad to worse;

Glossary 207

increasing in scope or severity. [EU] Proportional: Being in proportion : corresponding in size, degree, or intensity, having the same or a constant ratio; of, relating to, or used in determining proportions. [EU] Prosthesis: An artificial substitute for a missing body part, such as an arm or leg, eye or tooth, used for functional or cosmetic reasons, or both. [EU] Proteins: Polymers of amino acids linked by peptide bonds. The specific sequence of amino acids determines the shape and function of the protein. [NIH]

Puberty: The period during which the secondary sex characteristics begin to develop and the capability of sexual reproduction is attained. [EU] Radiography: The making of film records (radiographs) of internal structures of the body by passage of x-rays or gamma rays through the body to act on specially sensitized film. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Recombinant: 1. a cell or an individual with a new combination of genes not found together in either parent; usually applied to linked genes. [EU] Regeneration: The natural renewal of a structure, as of a lost tissue or part. [EU]

Resection: Excision of a portion or all of an organ or other structure. [EU] Resorption: The loss of substance through physiologic or pathologic means, such as loss of dentin and cementum of a tooth, or of the alveolar process of the mandible or maxilla. [EU] Retinopathy: 1. retinitis (= inflammation of the retina). 2. retinosis (= degenerative, noninflammatory condition of the retina). [EU] Rheumatology: A subspecialty of internal medicine concerned with the study of inflammatory or degenerative processes and metabolic derangement of connective tissue structures which pertain to a variety of musculoskeletal disorders, such as arthritis. [NIH] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Saliva: The clear, viscous fluid secreted by the salivary glands and mucous

208 Periodontitis

glands of the mouth. It contains mucins, water, organic salts, and ptylin. [NIH] Sarcoma: A tumour made up of a substance like the embryonic connective tissue; tissue composed of closely packed cells embedded in a fibrillar or homogeneous substance. Sarcomas are often highly malignant. [EU] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Sedimentation: The act of causing the deposit of sediment, especially by the use of a centrifugal machine. [EU] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Silicon: Silicon. A trace element that constitutes about 27.6% of the earth's crust in the form of silicon dioxide. It does not occur free in nature. Silicon has the atomic symbol Si, atomic number 14, and atomic weight 28.09. [NIH] Sinusitis: Inflammation of a sinus. The condition may be purulent or nonpurulent, acute or chronic. Depending on the site of involvement it is known as ethmoid, frontal, maxillary, or sphenoid sinusitis. [EU] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Stomach: An organ of digestion situated in the left upper quadrant of the abdomen between the termination of the esophagus and the beginning of the duodenum. [NIH] Stomatitis: Inflammation of the oral mucosa, due to local or systemic factors which may involve the buccal and labial mucosa, palate, tongue, floor of the mouth, and the gingivae. [EU] Substrate: A substance upon which an enzyme acts. [EU] Suppuration: The formation of pus; the act of becoming converted into and discharging pus. [EU]

Glossary 209

Tetracycline: An antibiotic originally produced by Streptomyces viridifaciens, but used mostly in synthetic form. It is an inhibitor of aminoacyl-tRNA binding during protein synthesis. [NIH] Thrombocytopenia: Decrease in the number of blood platelets. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Toxic: Pertaining to, due to, or of the nature of a poison or toxin; manifesting the symptoms of severe infection. [EU] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Transplantation: The grafting of tissues taken from the patient's own body or from another. [EU] Treponema: A genus of microorganisms of the order spirochaetales, many of which are pathogenic and parasitic for man. [NIH] Tuberculosis: Any of the infectious diseases of man and other animals caused by species of mycobacterium. [NIH] Ulcer: A local defect, or excavation, of the surface of an organ or tissue; which is produced by the sloughing of inflammatory necrotic tissue. [EU] Ulceration: 1. the formation or development of an ulcer. 2. an ulcer. [EU] Vaccine: A suspension of attenuated or killed microorganisms (bacteria, viruses, or rickettsiae), administered for the prevention, amelioration or treatment of infectious diseases. [EU] Varicella: Chicken pox. [EU] Viral: Pertaining to, caused by, or of the nature of virus. [EU] Virulence: The degree of pathogenicity within a group or species of microorganisms or viruses as indicated by case fatality rates and/or the ability of the organism to invade the tissues of the host. [NIH] Warts: Benign epidermal proliferations or tumors; some are viral in origin. [NIH]

Xerostomia: Dryness of the mouth from salivary gland dysfunction, as in Sjögren's syndrome. [EU]

General Dictionaries and Glossaries While the above glossary is essentially complete, the dictionaries listed here cover virtually all aspects of medicine, from basic words and phrases to

210 Periodontitis

more advanced terms (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Dictionary of Medical Acronymns & Abbreviations by Stanley Jablonski (Editor), Paperback, 4th edition (2001), Lippincott Williams & Wilkins Publishers, ISBN: 1560534605, http://www.amazon.com/exec/obidos/ASIN/1560534605/icongroupinterna

·

Dictionary of Medical Terms : For the Nonmedical Person (Dictionary of Medical Terms for the Nonmedical Person, Ed 4) by Mikel A. Rothenberg, M.D, et al, Paperback - 544 pages, 4th edition (2000), Barrons Educational Series, ISBN: 0764112015, http://www.amazon.com/exec/obidos/ASIN/0764112015/icongroupinterna

·

A Dictionary of the History of Medicine by A. Sebastian, CD-Rom edition (2001), CRC Press-Parthenon Publishers, ISBN: 185070368X, http://www.amazon.com/exec/obidos/ASIN/185070368X/icongroupinterna

·

Dorland's Illustrated Medical Dictionary (Standard Version) by Dorland, et al, Hardcover - 2088 pages, 29th edition (2000), W B Saunders Co, ISBN: 0721662544, http://www.amazon.com/exec/obidos/ASIN/0721662544/icongroupinterna

·

Dorland's Electronic Medical Dictionary by Dorland, et al, Software, 29th Book & CD-Rom edition (2000), Harcourt Health Sciences, ISBN: 0721694934, http://www.amazon.com/exec/obidos/ASIN/0721694934/icongroupinterna

·

Dorland's Pocket Medical Dictionary (Dorland's Pocket Medical Dictionary, 26th Ed) Hardcover - 912 pages, 26th edition (2001), W B Saunders Co, ISBN: 0721682812, http://www.amazon.com/exec/obidos/ASIN/0721682812/icongroupinterna /103-4193558-7304618

·

Melloni's Illustrated Medical Dictionary (Melloni's Illustrated Medical Dictionary, 4th Ed) by Melloni, Hardcover, 4th edition (2001), CRC PressParthenon Publishers, ISBN: 85070094X, http://www.amazon.com/exec/obidos/ASIN/85070094X/icongroupinterna

·

Stedman's Electronic Medical Dictionary Version 5.0 (CD-ROM for Windows and Macintosh, Individual) by Stedmans, CD-ROM edition (2000), Lippincott Williams & Wilkins Publishers, ISBN: 0781726328, http://www.amazon.com/exec/obidos/ASIN/0781726328/icongroupinterna

·

Stedman's Medical Dictionary by Thomas Lathrop Stedman, Hardcover 2098 pages, 27th edition (2000), Lippincott, Williams & Wilkins, ISBN: 068340007X, http://www.amazon.com/exec/obidos/ASIN/068340007X/icongroupinterna

Glossary 211

·

Tabers Cyclopedic Medical Dictionary (Thumb Index) by Donald Venes (Editor), et al, Hardcover - 2439 pages, 19th edition (2001), F A Davis Co, ISBN: 0803606540, http://www.amazon.com/exec/obidos/ASIN/0803606540/icongroupinterna

212 Periodontitis

INDEX A Abdominal..............................19, 112, 196 Abscess .................................................64 Adverse .....................63, 73, 99, 110, 206 Anaerobic ...58, 73, 83, 84, 85, 86, 87, 98, 196, 199, 200, 203, 205, 206 Antibiotic ......15, 31, 32, 59, 111, 204, 209 Antibody.....................52, 72, 84, 198, 204 Antigens...................71, 85, 131, 201, 207 Antimicrobial ...14, 25, 30, 46, 70, 72, 163, 166, 198, 199 Anxiety...................................................91 Aspiration...............................................19 Assay...................................74, 77, 79, 81 Atypical ..................................................92 B Bacteremia ................80, 83, 98, 196, 203 Benign ...................................93, 128, 204 Bethanechol.........................................111 Biochemical .................66, 70, 73, 87, 206 Biopsy....................................................64 Boron .......................................45, 51, 196 Bruxism..................................................93 Buccal ..................68, 83, 92, 99, 196, 208 C Candidiasis ..........25, 92, 93, 95, 111, 119 Capsules................................30, 159, 200 Carbohydrate.........................30, 158, 201 Cardiac ....................65, 97, 112, 196, 199 Cardiovascular.............21, 57, 64, 78, 109 Cataract .........................................29, 197 Causality................................................78 Cerebrovascular ....................................65 Cheilitis ..................................................92 Chemotherapy .......................................64 Chlorhexidine...................................14, 95 Chronic ...4, 27, 64, 65, 70, 74, 75, 76, 80, 95, 99, 124, 162, 178, 208 Ciprofloxacin........................................161 Coagulation ...........................................80 Cognition ...............................................65 Collagenases.........................................72 Concomitant ..........................................63 Condyloma ............................................92 Constipation...........................................19 Coronary........................................71, 106 Cranial ...................................................68 Cytokines .........................................70, 80 Cytomegalovirus....................................92 D Degenerative ...................31, 88, 157, 207

Dentists .. 2, 4, 35, 36, 37, 38, 57, 74, 120, 135, 139, 155, 183, 184 Dentition.............................. 58, 60, 63, 95 Dentures ............................................... 19 Diarrhea ........................................ 19, 156 Digestion ................................. 19, 32, 208 Doxycycline................. 15, 16, 70, 72, 104 E Endocarditis .................... 29, 91, 162, 197 Endotoxemia ........................... 80, 85, 199 Enzyme ...... 16, 30, 67, 87, 88, 109, 199, 206, 208 Epidermal................................ 32, 92, 209 Epithelium ............................... 45, 97, 198 Erythema............................................... 92 Exfoliation ............................... 60, 98, 204 Exogenous .............................. 67, 85, 200 Extracellular .................... 69, 79, 166, 200 Extraction .............................................. 64 F Femoral................................................. 73 Femur.................................................... 56 Fibrinolysis ............................................ 79 Flurbiprofen................................. 162, 163 Fructosamine ........................................ 71 G Gastrointestinal ....... 18, 30, 166, 198, 200 Gelatin................................................... 14 Genotype .............................................. 59 Gestation............................................... 73 Gingivitis .... 11, 12, 14, 20, 21, 22, 23, 24, 25, 59, 63, 75, 91, 92, 93, 95, 109, 110, 111, 118, 119, 149, 162 Ginseng................................................. 45 Glossitis ................................................ 93 Glucose..... 20, 21, 22, 30, 46, 52, 61, 71, 85, 200, 201, 202 Glutamine.............................................. 45 H Halitosis .......................................... 91, 93 Heartburn .............................................. 19 Hemagglutinins ..................................... 69 Hematology........................................... 91 Hepatitis ................................................ 91 Heredity................................................. 65 Herpes ........................ 25, 30, 92, 95, 201 Hybridization ................................. 75, 148 Hyperpigmentation................................ 92 Hyperplasia ........................................... 92 Hypersensitivity..................................... 91 Hypertension................................... 65, 91

Index 213

Hypothalamic.........................................45 I Immunity ......................................111, 202 Immunization .........52, 112, 118, 202, 208 Impetigo.................................................92 Indicative ...............................................70 Inflammation .....10, 11, 13, 14, 16, 31, 45, 65, 76, 93, 95, 96, 109, 110, 203, 207 Insulin ........................30, 52, 70, 201, 202 Intestines ...............................................19 Invasive .........................................68, 118 Irritants.....................................24, 31, 203 Isoproterenol........................................111 L Laminin ..................................................79 Lesion ..................64, 92, 97, 98, 200, 205 Ligament..............................................162 Lipid ...............................................52, 202 Lumbar ..................................................72 Lymphoma.................64, 86, 92, 124, 203 M Malabsorption ........................................19 Mandible ........................................88, 207 Maxillary ..................................64, 99, 208 Melanosis ..............................................93 Membrane ....45, 86, 97, 98, 99, 198, 203, 206 Microbiological.........................66, 77, 161 Microbiology ...... 59, 86, 90, 97, 118, 196, 204 Microorganism .........................29, 77, 195 Microspheres .........................................15 Minocycline............................................15 Mobility ..................................................60 Molecular ..32, 69, 74, 75, 77, 81, 83, 116, 121, 123, 131, 195, 206, 207, 209 Mucosa ........................91, 92, 98, 99, 208 Mucus ....................................................11 N Nausea ..................................................19 Necrolysis ..............................................92 Neoplasms...........................119, 128, 204 Nephropathy ....................................21, 70 Neuralgia .................................93, 98, 205 Neuropathy ......................................21, 70 Neutrophil ..............................................61 Niacin...................................................156 Nicotine..................................................91 O Orofacial ........................................69, 118 Overdose .............................................157 P Paralysis ..................................92, 98, 205 Parasympathomimetic .........................111 Periodontics...........................90, 101, 102 Perioral ..................................................92

Pharmacists ........................................ 111 Phenytoin .............................................. 95 Pilocarpine .......................................... 111 Plasminogen ......................................... 79 Posterior................................................ 64 Postmenopausal ............................. 56, 72 Potassium ........................................... 158 Prenatal................................................. 74 Prevalence ................................ 58, 59, 77 Progressive ................................... 63, 149 Proportional........................................... 67 Prosthesis ............................................. 60 Proteins.. 32, 69, 79, 80, 84, 85, 156, 158, 198, 200, 201 Puberty.................................... 20, 95, 119 R Radiography ......................................... 68 Recombinant......................................... 69 Recurrence ........................................... 64 Refractory ....................................... 26, 59 Regeneration .................. 16, 22, 103, 118 Resection ...................................... 66, 103 Resorption............................. 72, 166, 200 Respiratory....... 21, 29, 83, 166, 195, 196, 197, 198 Retinopathy............................... 21, 70, 79 Rheumatoid................................... 60, 106 Rheumatology....................................... 60 S Saliva ...................... 12, 45, 109, 111, 118 Sarcoma.......................... 25, 92, 119, 149 Secretion............... 31, 111, 113, 204, 208 Sedimentation ....................................... 61 Selenium ............................................. 158 Serum ................... 46, 52, 71, 73, 80, 208 Silicon ................................................... 45 Sinusitis................................... 91, 99, 208 Skeletal ................................. 56, 113, 203 Species .... 30, 59, 67, 74, 75, 77, 81, 83, 84, 85, 87, 88, 99, 196, 197, 199, 200, 206, 208, 209 Stomach.................................. 18, 30, 200 Stomatitis ................................ 92, 93, 119 Substrate............................................... 69 Suppuration............................. 58, 83, 195 Surgical ................. 22, 61, 66, 71, 91, 118 Syphilis.................................................. 92 Systemic .... 20, 24, 25, 27, 29, 44, 46, 56, 57, 62, 63, 65, 70, 72, 73, 75, 76, 78, 80, 90, 99, 110, 161, 197, 208 T Tetracycline....... 15, 30, 31, 161, 199, 204 Thermoregulation................................ 156 Thrombocytopenia ................................ 92 Thyroxine ............................................ 158

214 Periodontitis

Toxic .....32, 84, 92, 98, 99, 157, 167, 197, 205, 208, 209 Toxin..............................................99, 209 Transplantation..............................64, 107 Tuberculosis ..........................................92 U Ulcer ........................................95, 99, 209 Ulceration ..............................................92

V Varicella ................................................ 92 Viral......................... 32, 85, 119, 201, 209 Virulence ......................................... 67, 69 W Warts............................................. 25, 119 X Xerostomia............................ 91, 110, 111

Index 215

216 Periodontitis

Index 217

218 Periodontitis