THE SILENT KILLER:
Understanding and Addressing the Inflammatory Pathway
Goal Setting:
1.
Presented by: Jo-Anne Jones, RDH
2.
President, RDH Connection Inc.
www.jo-annejones.com
[email protected]
3.
Synopsis:
Why another course on the oral-systemic link?
Are we still treating periodontal disease as an infection
when leading authorities have redefined periodontitis
as an inflammatory disease? Is our practice compliant
with the newly published 2015 JADA guidelines?
The link between periodontal disease and systemic
health is becoming increasingly clear and is the
benchmark of innovative healthcare delivery. Long
running, ongoing chronic disease such as periodontal
disease tips the body’s balance towards chronic
inflammation.
Inflammation often being referred to as the ‘silent
killer’ is one of the hottest topics of research. The
latest research surrounding the oral systemic link is
both startling and compelling. What if we now could
slow down the destruction caused by chronic
inflammation and impact not only oral health but
systemic health? We have the ability to change lives
through the power of our message and the science of
our treatment.
Learning Outcomes:
FACT: The information has been redefining our understanding of
how inflammation is at the very core of today’s complex, prevalent
and deadly diseases
FACT: Moderate to severe chronic periodontitis has significant
systemic implications
FACT: The AAP has redefined periodontal disease as an
inflammatory disease with far reaching effects.
FACT: We need to reconsider our therapeutic endpoints to ensure
that the impact of oral disease does not continue to threaten
overall health
FACT: We need to meet the needs of today’s population
SCIENCE MEETS THE DEMOGRAPHIC
We OWN This:
Defining of a healthcare professional:
“An occupation whose core element is work based upon the mastery
of a complex body of knowledge and skills….to be used in the service
of others. Professions and their members are accountable to those
served and to society. Society rewards health professionals…this
status, however, comes with professional obligations.”
1. Recognize the role of the inflammatory pathway in
initiating disease states within the body
2. Elevate understanding and treatment of periodontal
disease as an inflammatory rather than an infectious
disease
3. Incorporate new therapeutic modalities and
communication strategies to enhance treatment
outcomes
References:
Vujicic M, Israelson H, Antoon J, Kiesling R, Paumier T,
Zust M. A profession in transition. J Am Dent Assoc.
2014 Feb;145(2):118-21.
Economic Report to the Dental Profession. November
2013. Prepared by R. K. House & Associates.
Offenbacher S, Beck JD. Changing Paradigms in the
Oral Disease-Systemic Disease Relationship. J
Periodontol June 2014;761-764.
Jones, JD. Summary of the 2015 JADA Evidence-based
Guidelines on the Non-surgical Treatment of Chronic
Periodontitis. Oral Health. Dec 2015.
Self-Evaluation: Rate Your Present Periodontal Therapy Program
1. How satisfied are you with your present periodontal therapy
program?
2. Are you receiving predictable outcomes?
3. What do you feel would elevate your periodontal program to the
next level?
4. How are you addressing the inflammatory component of
periodontal disease?
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Notes:
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5. Do you have an evidence based risk assessment program in
place?
6. Do you feel your medical history update is uncovering sufficient
information to fully address the needs of your dental hygiene client?
7. Do you have adequate resources to educate your client about the
oral-systemic link?
8. What treatment modalities have you incorporated into your
periodontal therapy program in order to reduce the bacterial
burden?
9. What treatment modalities have you incorporated into your
periodontal therapy program in order to address the host response?
10. What are your determinants and criteria for referring to a
periodontist?
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1. Understand the Most Current and Compelling Research Related
to the Oral Systemic Link: Cardiovascular Disease:
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Two pathways:
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References & Resources:
Jones JD, Golub LM, Gu Y, et al. Is periodontitis an
infectious or inflammatory disease? Oral Hyg May
2015.
Donley T, Golub LM, Jones JD, et al. Addressing the
inflammatory response in periodontal and related
systemic disease. Oral Health Periodontics Fall 2015.
https://www.cdha.ca/pdfs/Profession/Resources/Dis
ease_Link_Article.pdf
Roifman I, Beck PL, Anderson TJ et al. Chronic
inflammatory disease and cardiovascular risk: a
systematic review. Can J Cardiol 2011 MarApr;27(2):174-82.
https://www.cdha.ca/pdfs/Profession/Resources/Dis
ease_Link_Article.pdf
Danesh J, Whincup P, Walker M et al. Low grade
inflammation and coronary heart disease: prospective
study and updated meta-analyses. BMJ.
2000;32(7255):199-204.
Hansson GK. Inflammation, atherosclerosis, and
coronary artery disease. N Eng J Med.
2005;352(16):1685-95.
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Notes:
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Cardiovascular Disease: Clinical Considerations for Dental Hygiene
Practice
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References & Resources:
Jones JD, Golub LM, Gu Y, et al. Is periodontitis an
infectious or inflammatory disease? Oral Hyg May
2015.
Donley T, Golub LM, Jones JD, et al. Addressing the
inflammatory response in periodontal and related
systemic disease. Oral Health Periodontics Fall 2015.
Danesh J, Whincup P, Walker M et al. Low grade
inflammation and coronary heart disease: prospective
study and updated meta-analyses. BMJ.
2000;32(7255):199-204.
Hansson GK. Inflammation, atherosclerosis, and
coronary artery disease. N Eng J Med.
2005;352(16):1685-95.
http://www.surgicalrestorative.com/articles/2013/02
/the-link-between-periodontitis-and-cardiovasculardisease-a-brie.html
www.hypertension.ca/en/
Guidelines: Hypertension Canada – 135/85 (Normal
blood pressure)
http://www.cdho.org/Advisories/CDHO_Advisory_Hy
pertension.pdf
(p. 21, 22)
https://www.diabetes.ca/CDA/media/documents/pu
blications-and-newsletters/advocacy-reports/canadaat-the-tipping-point-policy-backgrounder-english.pdf
Diabetes in Canada: Facts and figures from a public
health perspective. Public Health Agency of Canada.
www.publichealth.gc.ca
Boyd LD, Giblin L, Chadbourne D. Bidirectional
relationship between diabetes mellitus and
periodontal disease: State of the evidence.
Can J Dent Hygiene 2012;46, no.2:93-102.
Is it mandatory to take my client’s blood pressure?
Definition of Hypertension:
 A condition where blood pressure persistently exceed specified
limits
 One of the leading health problems in Canada preceding stroke,
heart attack, kidney failure, dementia and sexual dysfunction
 More than 1 in 5 Canadians currently suffer from hypertension
with a lifetime risk of 90%
 Often asymptomatic; referred to ‘silent killer’
Responsibility of Today’s Dental Hygienist:
 Important to have a baseline as part of initial assessment
 Requirement of blood pressure to be taken when medical
history indicates a need
 Ensure client is not being placed at risk before initiating dental
hygiene treatment
 If client’s history is clear, a registrant is encouraged to take a
baseline assessment; prudent and proactive to periodically
monitor as often asymptomatic
Diabetes in Canada:
The Facts on Diabetes:
FACT: Approximately 3 million Canadians with diabetes; increase of
over 70% in the last decade; Estimated by 2020 1 in 3 Canadians will
be living with diabetes or prediabetes
FACT: Periodontal disease is listed as the 6th complication
FACT: 82% of diabetic patients with severe periodontitis
experienced the onset of one or more major cardiovascular,
cerebrovascular or peripheral vascular events compared to only 21%
of diabetics without periodontitis.
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Understanding the Oral-Systemic Link: Diabetes
Research supports that infectious and inflammatory processes
increase insulin resistance resulting in hyperglycemia.
Hyperglycemia (elevated blood glucose) diminishes the ability of
WBC, neutrophils in particular to track, adhere and kill bacteria
Diabetes increases risk through an amplified inflammatory response
and depressed wound healing; elevated blood glucose leads to
elevated glucose levels in GCF hindering wound healing capacity of
fibroblasts.
GCF contains elevated concentrations of cytokines producing higher
levels of MMPs that promote tissue destruction and disease severity
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Diabetes: Clinical Considerations for Dental Hygiene Practice
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A diabetes management program should involve on-going
comprehensive periodontal assessments
Independent association between moderate to severe periodontitis
and increased risk for development or progression of diabetes
AAP and EFP Consensus Report…”periodontal interventions may
provide beneficial effects on diabetes outcomes in some patients, so
regular comprehensive periodontal evaluations should be part of an
ongoing diabetes management program”
Solicit feedback regarding diabetic status;
• Type 1, 2 or pre-diabetic or familial history? What is their blood
glucose target? What were the results of their last A1c test?
• What was their blood glucose level the morning of the
appointment? What times of the day are best for scheduled
appointments?
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References & Resources:
Fowler MJ. Microvascular and Macrovascular
Complications of Diabetes. Clinical Diabetes.
2008;26(2):77-82
Manuchehf-Pour M, et al. Comparison of neutrophil
chemotactic response in diabetic patients with mild
and severe periodontal disease. J Periodontol.
1981;52:410-415.
McMullen JA, et al. Neutrophil chemotaxis in
individuals with advanced periodontal disease and a
genetic predisposition to diabetes mellitus. J
Periodontol. 1981;52:167-173.
Tunes RS, Foss-Freitas MC, Nogueira-Filho, G et al.
Impact of Periodontitis on the Diabetes-Related
Inflammatory Status. JCDA August 2010.
https://www.diabetes.ca/CDA/media/documents/pu
blications-and-newsletters/advocacy-reports/canadaat-the-tipping-point-policy-backgrounder-english.pdf
http://www.perio.org/node/501 (Milestones July
2013)
http://www.perio.org/node/501
(Milestones July 2013)
Understanding the Oral-Systemic Link between Obesity and
Periodontal Disease:
 A pro-inflammatory state exists in obesity as a result of the
release of several cytokines and hormones from adipose tissue
into systemic circulation; similar cytokines are released into
circulation in periodontal disease
 A person with a BMI of 30 or more is generally considered obese;
research is debating whether BMI, waist circumference (WC) or
both should be used to determine disease risk
 Obesity is a major risk factor for a number of chronic diseases
including type 2 diabetes, hypertension, cardiovascular disease,
metabolic syndrome, liver disease, musculoskeletal disease,
reproductive abnormalities and cancer. Recent studies have
reported an association between obesity and periodontitis.
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References & Resources:
http://www.diabetes.ca/clinical-practiceeducation/clinical-practice-guidelines
Genco RJ, Grossi SC, Ho A, et al. A proposed model
linking inflammation to obesity, diabetes, and
periodontal infections. J Periodontol.
2005;76:11(Suppl) 2075-84.
Yoshihiro Iwamoto, Fusanori Nishimura et al. The
Effect of Antimicrobial Periodontal Treatment on
Circulating Tumor Necrosis Factor-Alpha and Glycated
Hemoglobin Level in Patients with Type 2 Diabetes. J
Periodontal.72:774-778, 2001
Pischon N, Heng N, Bernimoulin J, et al. Obesity,
Inflammation and Periodontal Disease. J Dent Res.
2007 66:400.
Twells LK, Gregory DM, Reddigan J, Midodzi WK.
Current and predicted prevalence of obesity in
Canada: a trend analysis. CMAJ Open. 2014 JanMar;2(1): E18-E26.
Genco RJ, Grossi SC, Ho A, et al. A proposed model
linking inflammation to obesity, diabetes, and
periodontal infections. J Periodontol.
2005;76:11(Suppl) 2075-84.
Saito T, Shimazaki Y, Koga T, et al. Relationship
between upper body obesity and periodontitis. J
Dent Res. 2001;80:7:1631-36.
Scannapieco FA, Bush RB, Paju S. Associations
between periodontal disease and risk for nosocomial
bacterial pneumonia and chronic obstructive
pulmonary
Disease. A systematic review. Ann Periodontol.
2003;8(1):54-69.
Azarpazhooh A, Leake JL. Systematic review of the
association between respiratory diseases and oral
health. J Periodontol. 2006;77(9):1465-82.

Studies prove that a high prevalence of PD can be expected
among obese adults
Obesity Rates in North America:
Between 1985 and 2011, the prevalence of overweight adults
increased by 21% to 33.6% and obesity increased 200% from 6.1% to
18.3%.
Respiratory Disease
Biological Link between Periodontal Disease and Respiratory
Disease:
Possible mechanisms for presence of oral bacteria in pathogenesis of
respiratory invasions include;
 Dental plaque may serve as a reservoir for pulmonary pathogens
responsible for aspiration pneumonia in high risk patients
 Enzymes associated with periodontal disease may facilitate
adherence of respiratory pathogens to the mucosal tissues in the
oral cavity and ultimate in the airways
 Hydrolytic enzymes associated with periodontal disease
pathogens may destroy salivary pellicles and reduce their host
defense capabilities
 Cytokines and other inflammatory mediators originating from
the periodontal tissues may alter respiratory epithelium
resulting in pathogen adherence and colonization.
Rheumatoid Arthritis (RA)
Understanding the Oral-Systemic Link with Rheumatoid Arthritis:
 Periodontal disease (PD) is an infection characterized by chronic
inflammation, and may ultimately lead to tooth loss
 Rheumatoid arthritis (RA) is a chronic disease, characterized by
inflammation of the synovium of the joints, and may ultimately
lead to destruction of the joint
o RA begins with inflammation of the synovial
membrane…lymphocytes, neutrophils and other
inflammatory cells migrate into the joint and release
inflammatory chemicals that destroy body tissues
 Chronic inflammatory mediators are shared by both these
diseases, and this has prompted researchers to investigate the
possibility of a relationship between RA and PD
RA: Clinical Consideration for Dental Hygiene Practice
 4.5 million, or 1 in 6 Canadians aged 15 years and older report
having arthritis. By 2031, approximately 7 million Canadians, 1
in 5 are expected to have arthritis
Pregnancy (PLBW)
Understanding the Oral Systemic Link with Pregnancy (PLBW):
•1 in 10 infants born are considered to be preterm; improvements in
neonatal intensive care medicine have improved the survival rate
however rate of premature delivery has steadily climbed since the
1950’s
•Other risk factors include race, smoking, alcohol and drug use,
lower socioeconomic status and lower education; more than ¼ of all
complicated pregnancies occur for no apparent reason
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Notes:
Periodontal disease may contribute by presenting an infectious,
inflammatory ongoing challenge to the fetus
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References & Resources:
Agado B, Bowen D. Periodontal disease and
respiratory disease: A systematic review of the
evidence. Can J Dent Hygiene 2012; 46, no; 103-114.
Scannapieco FA. Role of oral bacteria in respiratory
infection. J Periodontol. 1999;70:793-802
Scannapieco F, The Relationship between Respiratory
Diseases and Periodontal Diseases. Dent Today July
2003.
Saini R, Saini S, Sharma S. Periodontitis: A Risk Factor
to Respiratory Diseases. Lung India. 2010 July – Sept;
27(3): 189.
Page RD, Offenbacher S, Schroeder HE et al.
Advances in the pathogenesis of periodontitis:
summary of developments, clinical implications and
future directions. Periodontol 2000. 1997;14:1:21648.
Marieb EN, Hoehn K. Anatomy and Physiology. 4th
Ed. San Francisco, Pearson Benjamin Cummings;
2008:289-39.
Bartold PM, Marshall RI, Haynes DR. Periodontitis
and rheumatoid arthritis: A review. J Periodontol
2006;76:11(Suppl.)2066-74.
Mecado FB, Marshall RI, Bartold PM. Interrelationships between rheumatoid arthritis and
periodontal disease. J Clin Periodontol.
2003;30:9:761-72.
Mercado FB, Marshall RI, Bartold PM. Is there a
relationship between rheumatoid arthritis and
periodontal disease? J Clin Periodontol.
2000;27(4):267-72.
www.arthritis.ca
http://www.statcan.gc.ca/pub/82-625x/2011001/article/11457-eng.htm
Feb 2015 Statement:
During normal pregnancy, the placenta invades the surrounding
uterine tissue and provides an exchange of nutrients and waste
between mother and fetus via the umbilical cord. As pregnancy
progresses, amniotic fluid levels containing prostaglandin E2 (PGE2)
and inflammatory cytokines—tumor necrosis factor (TNF-α) and
interleukin 1(IL-1β)—steadily rise to reach the threshold that induces
labor. Thus, normal labor and delivery are induced by inflammatory
signaling. One theory for the association between periodontal
diseases and preterm birth is that women with periodontitis, a
bacterial infection, exhibit an increase in fluid mediator levels and
inflammatory cytokines, which can trigger labor prematurely.
Furthermore, an increase in other markers of inflammation such as
C-reactive protein (CRP) has been associated with an elevated risk
for preeclampsia and intrauterine growth restriction.
Osteoporosis
Biological Link between Periodontal Disease and Osteoporosis:
 In periodontal disease, chronic oral inflammation results in
destruction of oral bone and periodontal ligament
 Increased production of cytokines, IL-6 stimulate osteoclast
activity and promote bone resorption
 Similar mechanism may contribute to osteoporosis
 Evidence indicates there is an association between the two
diseases
 Common risk factors; age, genetics, estrogen deficiency, calcium
and Vitamin D deficiency, alcohol intake and smoking
Alzheimer’s Disease
Understanding the Systemic Link between Alzheimer’s and
Periodontal Disease:
 Alzheimer’s disease (AD) is a degenerative disease of the brain
characterized by neurofibrillary tangles and the accumulation of
beta amyloid plaques
 A strong positive correlation was found between midlife Creactive protein levels, a marker of inflammation and the risk of
developing AD. The chronic nature of oral infections, such as
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
periodontitis, may further amplify the mechanisms that lead to
the onset or progression of AD.
It is possible that periodontal pathogens may directly invade the
central nervous system via systemic circulation; oral Treponema
may have reached the brain via the trigeminal nerve.
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Recognize the Role of the Inflammatory Pathway in Initiating
Disease States within the Body
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References & Resources:
Lopez N. Periodontal Therapy May Reduce the Risk of
Preterm Low Birth Weight in Women with
Periodontal Disease: A randomized Controlled Trial.
Journal of Periodontology August 2002, Vol. 73, No. 8,
Pages 911-924.
Offenbacher S, Beck JD, Jared HL et al. Effects of
periodontal therapy on rate of preterm delivery: a
randomized controlled trial. Obstet Gynecol. 2009
Sep;114(3):551-9.
Offenbacher S. Dillow K. Reduce the risk of adverse
pregnancy outcomes. Dimensions of Dental Hygiene
Feb 2015.
http://www.dimensionsofdentalhygiene.com/2015/0
2_February/Features/Reduce_the_Risk_of_Adverse_
Pregnancy_Outcomes.aspx
Haram K, Mortensen JH, Wollen AL. Preterm delivery:
an overview. Acta Obstet Gynecol Scand.
2003;82:687–704.
Madianos PN, Bobetsis YA, Offenbacher S. Adverse
pregnancy outcomes (APOs) and periodontal disease:
pathogenic mechanisms. J Clin Periodontol.
2013;40:S170–S180.
Herrera JA, Parra B, Herrera E, et al. Periodontal
disease severity is related to high levels of C-reactive
protein in pre-eclampsia. J Hypertens. 2007;25:1459–
1464.
www.dimensionsofdentalhygiene.com/2015/02_Febr
uary/Features/Reduce_the_Risk_of_Adverse_Pregna
ncy_Outcomes.aspx
Wactawski-Wende J. Periodontal diseases and
osteoporosis: Association and mechanisms. Ann
Periodontol 2001;6(1):197-208.
Chesnut CH, III. The relationship between skeletal and
oral bone mineral density: An overview. Ann
Periodontol 2001;6(1):193-196.
www.elsevier.com/about/press-releases/researchand-journals/amyloid-formation-may-link-alzheimerdisease-and-type-2-diabetes
Schmidt R, Schmidt H, Curb JD et al. Early
inflammation and dementia: a 25-year follow-up
study of the Honolulu-Asia Aging Study. Ann Neurol.
2002;52(2):168-74.
Rivere GR, Riviere KH, Smith KS. Molecular and
immunological evidence of oral Treponema in the
human brain and their association with Alzheimer’s
disease. Oral Microbiol Immunol. 2002;17(2):113-18.
FACT: The Common Link – Inflammation:
 Today’s diseases of influence are linked by the inflammatory
pathway

Periodontal disease is the most common chronic inflammatory
disease known to mankind

Living longer, consequences of Western lifestyle adding to
today’s inflamed body
Elevate Understanding and Treatment of Periodontal Disease as an
Inflammatory Disease
We’ve Lost the Battle…when we focus on reducing the bacterial
component only, we do not achieve the reduction of the host
response. Inflammation and destruction continues placing healing,
repair and systemic health in jeopardy.
FACT: American Academy of Periodontology Statement:
Today’s Periodontal Therapy Program Objective:
 Traditional clinical periodontal examination includes assessment
of already existing damage to periodontal tissues as well as
measure of periodontal inflammation
 Cost effective, simple method in determining the location and
severity of diseased periodontal tissues
 However, in predicting future periodontal breakdown or even
just quantifying current disease activity…especially inflammation,
these methods are far from ideal
 Oral inflammatory load (OIL) not pocket depths or periodontal
pathogenic bacteria explains the linkages with systemic disease
FACT: Call to Action for Dental Hygienists
“If we, in dentistry, are indeed healers, it is imperative for us to take
a different approach... the goal is to help patients become and
remain inflammation-free.”
Dr. Tim Donley
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Understand and Apply the 2015 JADA Guidelines into Clinical
Practice and Treatment Delivery
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References & Resources:
Doering H, Tenenbaum HC, Glogauer M. Oral
inflammatory load – a new concept for the
understanding of oral Disease. Oral Health October
2014;64-68.
http://www.dentalproductsreport.com/dental/article
/5-things-consider-regarding-connection-betweenstroke-and-inflammation
T Van Dyke, C Serhan, A Novel Approach to Resolving
Inflammation, Oral and the Whole Body
Health;2006:42-45
D Graves, Cytokines That Promote Periodontal Tissue
Destruction, J Periodontol (Suppl.), 2008;1585-1591
Goldstep F. Periodontal Inflammation: Simplified.
Oral Health: Dec 2013;8 – 17.
TIME Magazine article:
http://www.inflammationresearchfoundation.org/infl
ammation-science/inflammation-details/timecellular-inflammation-article/
1. Adequate Management of Risk Factors:
 Oral Science Risk Questionnaire
 Philips Oral Healthcare CARE tool (Customized Assessment and
Risk Evaluator) web-based client interview and integration of risk
management program into dental hygiene clinical practice:
https://www.philipcare.com
2. Adequate Bacterial Reduction:
 Biofilm leads to bacteremia
 Onset of bacteremia initiates inflammatory response
 Systemic involvement
Solutions for Effective Client Self-Care
www.oralscience.com
www.oralhealthboutique.com
3. Address Host Response
Periodontal Inflammation and Destruction:
 Cytokines are an intermediate mechanism between bacterial
stimulation and tissue destruction; may also be produced by
fibroblasts and osteoblasts
 The host response is the major contributing factor for chronic
maladaptive periodontal disease. A deficient host response
initiates the chronic condition and response that leads to further
tissue breakdown
 Bacteria initiate periodontitis. They are essential but insufficient.
What is required is a susceptible host.
 Primary etiologic basis for periodontal disease is bacterial
however the excessive host inflammatory response or
inadequate resolution of inflammation is critical to the
pathogenesis of periodontitis.
Host Modulation: Low-dose doxycycline (LDD)
Medical and Dental Benefits
About 30 years ago, Golub et al discovered that doxycycline had the
unexpected ability to inhibit host-derived tissue-destructive enzymes
known as MMPs by mechanisms unrelated to the
antibacterial/antibiotic properties of these drugs
These enzymes when present in pathologically-excessive levels are
largely responsible for degrading collagen fibers and mediating bone
resorption related to various medical and dental diseases
Over the past decade this novel non-antimicrobial LDD has been
tested in patients with medical disorders which excessive MMPs and
inflammatory mediators play a role
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Therapeutic Benefit of Inhibiting Collagen Breakdown:
 Inhibit breakdown of collagen in diseased joint (synovial) tissues
reducing severity of symptoms in ARTHRITIS
 Inhibit breakdown of collagen in connective tissues around
CANCER cells: reduced local invasiveness and metastasis
 Protect collagen “cap” stabilizing cholesterol-rich arterial
plaques: reduced risk for MYOCARDIAL INFARCTION & STROKE
 Reduce diagnostic biomarkers of skeletal bone resorption for
POST MENOPAUSAL OSTEOPOROSIS with no effect on
biomarkers of bone formation
 Reduce blood levels of Hemoglobin A1C after SDD + SRP for
DIABETICS
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References & Resources:
Stoner JA, Golub LM, Payne JB. Probing depth: a poor
predictor of clinical attachment level changes. J Dent
Res 2015 (94 Spec. Is.):Abstract 1670.
Smiley CJ, Tracy SL, Abt E, et al. Systematic review and
meta-analysis on the nonsurgical treatment of chronic
periodontitis by means of scaling and root planing
with or without adjuncts. JADA 2015;146(7):508-524.
Proceedings of the 1996 World Workshop in
Periodontics, Lansdowne, Virginia, July 13-17, 1996,
Ann Periodontol 1996;1:1-947
Goldstep F. Periodontal Inflammation: Simplified.
Oral Health: Dec 2013;8 – 17.
T Van Dyke, C Serhan, A Novel Approach to Resolving
Inflammation, Oral and the Whole Body
Health;2006:42-45.
Smiley CJ, Tracy SL, Abt E, et al. Evidence-based
clinical practice guideline on the nonsurgical
treatment of chronic periodontitis by means of scaling
and root planing with or without adjuncts. JADA
2015;146(7):525-535.
Golub LM, Lee HM, Lehrer G et al. Minocycline
reduces gingival collagenolytic activity during
diabetes: preliminary observations and a proposed
new mechanism of action. J Periodontol Res., 1983,
18:516-526.
Walker SG, Golub LM. Host modulation therapy for
periodontal disease: Subantimicrobial-dose
doxycycline, medical as well as dental benefits. Oral
Health. October 2012.
Sub-antimicrobial Dose Doxycycline (SDD) Study
Listing at end of handout
Periostat: Mechanism of Action
Periostat will help to reduce the over-production of collagenase
(enzymes responsible for the destruction of collagen) and osteoclasts
(bone cell responsible for the resorption of bone) that are present in
overabundance during a chronic, prolonged & destructive
inflammatory response.
This exaggerated inflammatory response is common among
inflammatory diseases such as periodontitis, cardiovascular disease
and rheumatoid arthritis.
Therefore, Periostat, when used (BID) for 6 to 9 months, will help to
modulate the chronic, prolonged & destructive inflammatory
response into a normal & healthy inflammatory response process.
9
“My client doesn’t want to take any more medications”
KEY TALKING POINTS:
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“I’m concerned with my client experiencing side effects from taking an antibiotic for so long”
KEY TALKING POINTS:
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“My client doesn’t have any real medical concerns at this time”
KEY TALKING POINTS:
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“My client comes in regularly, has effective self-care measures. Insurance covers a 3 month maintenance interval.
There is still inflammation present however I don’t feel he needs Periostat.”
KEY TALKING POINTS:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Empower the Client through the Provision of Resources to Understand the Oral Systemic Connection
CDHA; http://www.cdha.ca/pdfs/OralCare/Educational_Resources_6.pdf
http://www.cdha.ca/pdfs/profession/resources/FactSheet_WholeBody_C.pdf
Colgate Professional;
www.colgateprofessional.com/professional-education/oral-systemic-health
www.colgateprofessional.com/Professional/v1/en/us/locale-assets/docs/OSH-CardiovascularHealth-Healthy-Mouth-Healthy-Body.pdf
CDHO Knowledge Network;
http://www.cdho.org/knowledge+network.asp
American Academy of Periodontology Consumer Site;
http://www.perio.org/consumer/other-diseases
What’s Your Real Age?
www.realage.com
Oral Systemic Link Professional and Public Information; www.oralsystemiclink.pro www.oralsystemiclink.net
Product References:
For the complete monography: http://www.oralscience.ca/en/products/periostat.html
Clinical Resources:
Oral Science Products; Curaprox, Perio Patch, Plaque Finder, Gengigel
1-888-442-7070
www.oralsicence.com
www.oralhealthboutique.com (product purchase online)
Certain products available in London Drugs, Shoppers Drug Mart
Thank you for your time and participation. If there is anything further that I may assist you with in regards to today’s
presentation please do not hesitate to contact me.
Jo-Anne Jones, RDH
[email protected]
www.jo-annejones.com
© 2016 All rights reserved RDH Connection Inc. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including
photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author.
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Medical History Update
Client Name: _________________________________________________ Date: ______________________________
Recent research indicates a strong relationship between the mouth and the body. Since we now know how closely they are
related, we are going to be asking you some questions about your family history and your overall health that we may not
have asked you about before. This additional information will assist us in providing the best possible care to maintain your
oral health and overall wellness.
Any changes in your health since your last dental visit? Yes
No If yes, please list:
__________________________________________________________________________________________________
What medications are you taking? _____________________________________________________________________
__________________________________________________________________________________________________
Any changes in medication dosage or medications?
Yes
No
If yes, please list:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What over the counter or ‘herbal/natural’ supplements are you taking on a regular basis? Please list:
__________________________________________________________________________________________________
Are you taking any bisphosphonates in the past or presently?
Yes
No If yes, please provide details:
__________________________________________________________________________________________
Do you have a persistent sore throat, hoarseness, ear ache or feeling of something being caught in your throat?
Yes
No If yes, please provide details:
Have you had any surgery or been hospitalized since your last visit?
Yes
No
If yes, please explain: ________________________________________________________________________________
Are you being treated for any medical problem presently?
Yes
No
If yes, please explain: _______________________________________________________________________________
Have you ever taken antibiotics prior to having your teeth cleaned or before dental work?
Yes
No
If yes, please explain: _______________________________________________________________________________
Any allergies to drugs, food, metal or latex?
Yes
No
If yes, please list: __________________________________________________________________________________
History of illness or disease in family?
If yes, please explain: _______________________________________________________________________________
Have you been diagnosed with diabetes?
Type I
Diet-controlled
Medication controlled
Type II
Pre-diabetes
Under control:
Yes
No
Have you had any heart problems or a knee, hip or prosthetic joint replacement?
Yes
No
If yes, provide details: _____________________________________________________________________________
Have you had a bone mineral density test?
Yes
No Results: ____________________________________
Female clients; Are you pregnant?
Yes
No
On a scale of 1 to 10 (10 being highest), how would you rate your general health at this time? __________________
How would you rate your level of stress presently?
Low
Moderate
High
On a scale of 1 to 10 (10 being highest), how closely related is the health of your mouth to your overall health in your
opinion? ________________
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References: Subantimicrobial Dose Doxycycline (SDD) *
1. Caton J, Ryan ME. Clinical studies on the management of periodontal diseases utilizing subantimicrobial dose doxycycline (SDD).
Pharmacol Res. 2011 Feb;63(2):114-20.
2. Ashley RA. Clinical trials of a matrix metalloproteinase inhibitor in human periodontal disease. SDD Clinical Research Team. Ann N Y
Acad Sci. 1999 Jun 30;878:335-46.
3. Lee JY, Lee YM, Shin SY, Seol YJ, Ku Y, Rhyu IC, Chung CP, Han SB. Effect of subantimicrobial dose doxycycline as an effective adjunct to
scaling and root planing. J Periodontol. 2004 Nov;75(11):1500-8.
4. Preshaw PM. Host response modulation in periodontics. Periodontol 2000. 2008;48:92-110.
5. Caton JG, Ciancio SG, Blieden TM, et al. Treatment with subantimicrobial dose doxycycline improves the efficacy of scaling and root
planing in patients with adult periodontitis. J Periodontol 2000:71:521-32.
6. Caton JG, Ciancio SG, Blieden TM, Bradshaw M, Crout RJ, Hefti AF, Massaro JM, Polson AM, Thomas J, Walker C.
Subantimicrobial dose doxycycline as an adjunct to scaling and root planing: post-treatment effects. J Clin Periodontol. 2001
Aug;28(8):782-9.
7. Preshaw PM, Hefti AF, Bradshaw MH. Adjunctive subantimicrobial dose doxycycline in smokers and non-smokers with chronic
periodontitis. J Clin Periodontol. 2005 Jun;32(6):610-6
8. Novak MJ, Johns LP, Miller RC, et al. Adjunctive benefits of subantimicrobial dose doxycycline in the management of severe,
generalized, chronic periodontitis. J Periodontol 2002:72:762-9.
9. Mohammad AR, Preshaw PM, Bradshaw MH, Hefti AF, Powala CV, Romanowicz M.Adjunctive subantimicrobial dose doxycycline in the
management of institutionalized geriatric patients with chronic periodontitis. Gerodontology. 2005 Mar;22(1):37-43
10. Gu Y, Walker C, Ryan ME, PayneJB, Golub LM. Non-antibacterial tetracycline formulations: clinical applications in dentistry
and medicine. J Oral Microbiol. 2012;4: doi: 10.3402/jom.v4i0.19227.
11. Novak MJ, Dawson DR 3rd, Magnusson I, Karpinia K, Polson A, Polson A, Ryan ME, Ciancio S, Drisko CH, Kinane D, Powala C, Bradshaw
M. Combining host modulation and topical antimicrobial therapy in the management of moderate to severe periodontitis: a randomized
multicenter trial. J Periodontol. 2008 Jan;79(1):33-41
12. Preshaw PM, Hefti AF, Novak MJ, Michalowicz BS, Pihlstrom BL, Schoor R, Trummel CL, Dean J, Van Dyke TE, Walker CB, Bradshaw
MH. Subantimicrobial dose doxycycline enhances the efficacy of scaling and root planing in chronic periodontitis: a multicenter trial. J
Periodontol. 2004 Aug;75(8):1068-76.
13. O'Dell JR, Elliot JR, Mallek JA, Mikuls TR, Weaver CA, Glickstein S, et al. Treatment of early seropositive rheumatoid arthritis:
doxycycline plus methotrexate alone. Arthritis Rheum. 2006;54:621-7
14. Brown DL, Desai KK, Vakili BA, Nouneh C, Lee HM, Golub LM. Clinical and biochemical results of the metalloproteinase inhibition with
subantimicrobial doses of doxycycline to prevent acute coronary syndromes (MIDAS) pilot trial. Arterioscler Thromb Vasc Biol. 2004
Apr;24(4):733-8
15. Tüter G, Kurtiş B, Serdar M, Aykan T, Okyay K, Yücel A, Toyman U, Pinar S, Cemri M, Cengel A, Walker SG, Golub LM.
Effects of scaling and root planing and sub-antimicrobial dose doxycycline on oral and systemic biomarkers of disease in patients with
both chronic periodontitis and coronary artery disease. J Clin Periodontol. 2007 Aug;34(8):673-81
16. Bench TJ1, Jeremias A, Brown DL. Matrix metalloproteinase inhibition with tetracyclines for the treatment of coronary artery disease.
Pharmacol Res. 2011 Dec;64(6):561-6.
17. Payne JB, Golub LM, Stoner JA, Lee HM, Reinhardt RA, Sorsa T, Slepian MJ. The effect of subantimicrobial-dose-doxycycline
periodontal therapy on serum biomarkers of systemic inflammation: a randomized, double-masked, placebo-controlled clinical trial. J Am
Dent Assoc. 2011 Mar;142(3):262-73.
18. Reinhardt RA, Stoner JA, Golub LM, et al. Efficacy of subantimicrobial dose doxycycline in postmenopausal women: clinical outcomes.
J Clin Periodontol 2007:34:768-75.
19. Golub LM, Lee HM, Stoner JA, et al. Subantimicrobial dose doxycycline modulates gingival crevicular fluid biomarkers of periodontitis
in postmenopausal osteopenic women. J Periodontol 2008:79:1409-18.
20. Walker C, Puumala S, Golub LM, et al. Subantimicrobial dose doxycycline effects on osteopenic bone loss: microbiologic results. J
Periodontol 2007:78:1590-601.
21. Payne JB, Stoner JA, Nummikoski PV, Reinhardt RA, Goren AD, Wolff MS, Lee HM, Lynch JC, Valente R, Golub LM.
Subantimicrobial dose doxycycline effects on alveolar bone loss in post-menopausal women. J Clin Periodontol. 2007 Sep;34(9):776-87.
22. Engebretson SP, Hey-Hadavi J. Sub-antimicrobial doxycycline for periodontitis reduces hemoglobin A1c in subjects with type 2
diabetes: a pilot study. Pharmacol Res. 2011 Dec;64(6):624-9
23. Engebretson SP, Hyman LG, Michalowicz BS, Schoenfeld ER, Gelato MC, Hou W, Seaquist ER, Reddy MS, Lewis CE, Oates TW, Tripathy
D, Katancik JA, Orlander PR, Paquette DW, Hanson NQ, Tsai MY. The effect of nonsurgical periodontal therapy on hemoglobin A1c levels
in persons with type 2 diabetes and chronic periodontitis: a randomized clinical trial. JAMA. 2013 Dec 18;310(23):2523-32
24. Golub LM, Lee HM, Stoner JA, Reinhardt RA, Sorsa T, Goren AD, Payne JB. Doxycycline effects on serum bone biomarkers in postmenopausal women. J Dent Res. 2010 Jun;89(6):644-9.
25. Ryan ME, Lee HM, Bookbinder MIC et al. Treatment of genetically susceptible patients with a subanmicrobial dose of doxycycline.
Dent Res 2000:79:608 (abstract #3719)
*Note: This does not comprise a complete listing of studies related to LDD.
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