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cda j ournal , vol 38 , n

4
ap ri l 201 0215
April
departments
f e at ure s
I T S PERI O- SYSTEMI C LI NK; ORAL- SYSTEMI C LI NK I S A MI SNOMER
An |n|roia.||on |o ||e |ssae.
Richard T. Kao, DDS, PhD
I NFLAMMATI ON I N CHRONI C PERI ODONTI TI S AND SI GNI FI CANT SYSTEMI C DI SEASES
Fniogenoas .|em|.c| mei|c|ors |c.e sem|nc| ro|es |n ||e |n|||c||on, ers|s|en.e, cni reso|a||on o/
|n/|cmmc||on. !n |||s cer, ||e s|gn|/|.cn.e o/ ||ese s|ai|es ser.es cs c |cs|s /or sa|seaen| i|s.ass|on
regcri|ng se.erc| |e, cse.|s o/ ||e |n/|cmmc|or, resonse |n er|oion||||s ||c| mc, |e re|c|ei |o se.erc|
s,s|em|. i|secses ||c| cre |mor|cn| |o c||en|s cni .on|emorcr, ien|c| rc.||||oners.
Michael P. Rethman, DDS, MS
AN I NTERVI EW WI TH DR. KENNETH KORNMAN
!n ||e cs| ie.cie, ||ere |cs |een c /o.as on |n/|cmmc||on |n ||e .cri|o.cs.a|cr mei|.|ne i|s.|||ne.
!n |||s |n|er.|eu u||| !r. Kenne|| Kornmcn, ||e ca||or e|ores some o/ ||ese csso.|c||ons |n c
rc.||.c| cni ||eore||.c| uc,.
David W. Richards, DDS, PhD
CLI NI CAL CHALLENGES I N DI AGNOSI NG AND MONI TORI NG PERI ODONTAL
I NFLAMMATI ON
T||s re.|eu ecm|nes some o/ ||e .||n|.c| .|c||enges csso.|c|ei u||| i|cgnos|ng cni mon||or|ng
er|oion|c| |n/|cmmc||on. G|.en ||ese i|//|.a|||es, c||en| mcncgemen| mc, |e more e//e.||.e
u|en ||ese c||en|s cre .omcncgei u||| c er|oion||s|.
Richard T. Kao, DDS, PhD; Stacey Lee; and Lisa Harpenau, DDS, MS
STRATEGI ES FOR MANAGI NG PERI ODONTAL I NFLAMMATI ON
|os| o/ ||e ||ssae ies|ra.||on |n er|oion|c| i|secse |s .casei |, ||e c||en|s |n/|cmmc|or, resonse.
Fmerg|ng cni /a|are croc.|es, |n.|aiei |n |||s cr||.|e, u||| re|, more on moi|/,|ng ||e |n/|cmmc|or,
resonse ||se|/, |, ||m|||ng ||e c.||.||, o/ ro|n/|cmmc|or, c||uc,s cni |, cm||/,|ng c||uc,s ||c|
reso|.e |n/|cmmc||on.
Steven E. Schonfeld, DDS, PhD
247
242
259
263
272
21 7
223
229
284
296
298
The Editor/Personalized Medicine
Impressions
CDA Presents
Classieds
Advertiser Index
Dr. Bob/Giggle Your Way to Good Health
223
216ap ri l 201 0
cda j ournal , vol 38 , n

4
Journal of the California
Dental Association
published by the
California Dental
Association
1201 K St., 14th Floor
Sacramento, CA 95814
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Kerry K. Carney, DDS
editor-in-chief
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associate editor
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associate editor
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CDA Journal
Volume 38, Number 4
apri l 201 0
Journal of the California Dental Association (issn
1043-2256) is published monthly by the California Dental
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cda j ournal , vol 38 , n

4
ap ri l 201 0217
Editor
nothcr good thing about CLA
mcmbcrship is thc casc with
which onc can download
cdcrally and statcrcquircd
orms and postcrs. Tc Fqual
Fmploymcnt Opportunity postcr is a good
cxamplc. In thc Lcccmbcr .cc, issuc o
C!A Jic|e, thcrc was ncws bric about
thc most rcccnt rcvision to thc FFO postcr.
Tc scction titlcd Fqual Fmploymcnt
Opportunity Is thc Iaw has bccn updatcd.
Tc ncw vcrsion includcs and dcscribcs
thc prohibition o gcnctic discrimination
as mandatcd by thc Ccnctic Inormation
Nondiscrimination Act, CINA.
Prcsidcnt Ccorgc \. Bush signcd
CINA into law on May .r, .cc8. Atcr r
ycars o dcbatc, it was passcd ovcrwhclm
ingly in both thc Scnatc and thc Housc.
It was dcsigncd to protcct Amcricans
against discrimination in thcir insurancc
and cmploymcnt bascd on thcir gcnctic
inormation. Tc intcnt o thc law is to
allow thc public to acccss pcrsonalizcd
mcdicinc without car o discrimination.
CINA prohibits cmploycrs rom collccting
gcnctic inormation rom cmployccs, and
using this inormation to makc dccisions
rcgarding cmploymcnt tcrms.
Tc issucs o privacy, gcnomics, cthics,
govcrnancc, and pcrsonalizcd mcdicinc arc
all wound up togcthcr. \c uscd to think
about gcnctic counscling in tcrms o somc
rarc gcnctic dccct. Counscling was part
o gcncticists spccialty training. It was
a scicncc and an art. It involvcd cducat
ing thc subjcct andor amily mcmbcrs
to thc mcanings o gcnctic variation in
tcrms o risk, scvcrity o cxprcssion, social
ramications, and thcir own vcry pcrsonal
contcxt. Howcvcr, now thcsc counsclors
arc somctimcs cut out o thc loop cntircly.
Now, thcrc is dirccttoconsumcr, gcnomic
proling and intcrprctation. Tcsc LTC
prolcs arc thc rcsult o an astounding
accclcration in tcchnological innovation,
cost rcduction, and a concomitant rctar
gcting o diagnostic inormation rom
physician to consumcr.
Tc Human Ccnomc Projcct bcgan
in r,,c. Tc planncd complction datc
was .cc but thc spcctacular advanccs in
scqucncing shortcncd thc timcramc by
two ycars. Ccnc scqucncing and gcnomic
proling havc bccomc insinuatcd into our
cvcryday cxpcricncc. How is thc public
cxposcd to most gcnctic tcrminology`
Rathcr than scicntic journals, courtroom
or orcnsic dramas arc morc likcly thc
sourcc. Somc common uscs o gcnctic
tcsting havc bccomc as amiliar as our
commutc to work. Ccnctic tcsting or pa
tcrnity has givcn risc to billboard advcrt
izing in Mcmphis proposing to answcr
thc qucstion. \hos your daddy`
r
Ccnctics has rcplaccd linguistics as a
markcr or migration pattcrns and intcr
marriagc in thc cthnohistory o human
populations. A gcnomic boutiquc industry
has sprung up around proling oncs an
ccstry. A Mountain Vicw, Cali., company
that providcs LTC gcnomic prolcs pro
claims in its mission statcmcnt to bc thc
worlds trustcd sourcc o pcrsonal gcnctic
inormation. On thcir \cb sitc, thc con
sumcr can choosc thc Anccstry Fdition
at s,,, thc Hcalth Fdition at s.,, or
thc Complctc Fdition at s,,. Somc
proling scrviccs portray thcmsclvcs as
gcnomic vcrsions o visa and cntry stamps
in traditional passports, thcy ocr up a
picturc o whcrc your gcnomc has bccn.
Having acccss to an individuals gc
nomc could providc a wcalth o inorma
tion and allow thc tailoring o pcrsonal
izcd mcdicinc. Tc rcal brcakthrough in
pcrsonalizcd mcdicinc will comc whcn
thc cost o wholc gcnomc scqucncing
drops low cnough that consumcrs start
to dcmand trcatmcnt bascd on thcir
own pcrsonal gcnomcs. At that point,
both rcscarch and clinical practicc will
bc transormcd.
amcs \atson and Francis Crick
dcscribcd thc doublc hclix structurc o
LNA in r,. \atson has bccomc thc rst
human to havc his pcrsonal gcnomc madc
public and availablc on thc \cb. Hc rc
ports that hc is not troublcd by thc lack o
privacy.
.
Hc dcscribcs how his hctcrozy
gous lactosc intolcrancc gcnc allows him
to ingcst thc occasional icc crcam conc
without gastric rcpcrcussion. Howcvcr,
hc gocs on to say that hc did not havc
his APOF, an Alzhcimcrs prcdisposing
gcnc, scqucncc rcvcalcd to him nor to thc
public. Hc said hc wantcd to livc as i hc
would not bc victimizcd in his ,cs, as was
onc o his grandparcnts.
.
In this instancc,
\atson chosc privacy ovcr knowlcdgc or
vcry pcrsonal rcasons.
A
Personalized Medicine
kerry k. carney, dds
Genetics has replaced linguistics as a marker
for migration patterns and intermarriage in
the ethnohistory of human populations.
218ap ri l 201 0
cda j ournal , vol 38 , n

4
\atson gocs on to dcscribc gcnomic
pharmacology. Hc is homozygous or
CYP.P (an allclc o a drug mctabolizing
gcnc) and bascd on that inormation, hc
succcssully rcduccd his blockcr rcgimcn
rom onc a day to onc a wcck. It is casy to
imaginc that thc pharmaccutical industry
will at somc point bcgin to incorporatc
gcnomcbascd warnings into thcir pack
agc inscrts.
Tc incvitablc tsunami o inorma
tion rom pcrsonal gcnomcs will impact
our undcrstanding o gcnomic variability
and thc variability o our rcsponscs to
mcdicincs.

Bascd on pcrsonal gcnomcs,

individuals may choosc to modiy thcir
licstylcs. Tcy may choosc to stay abrcast
o cxpcrimcntal thcrapics or conditions
thcy arc at risk to dcvclop in thc uturc.
Tcy may choosc unncccssary or inccc
tivc mcdical proccdurcs bascd on inaccu
ratc data or poor intcrprctations o data.
So what will bc thc rolc o thc physi
cian` Tc Amcrican Socicty o Human
Ccnctics rccommcnds, Procssional or
ganizations should cducatc thcir mcm
bcrs rcgarding thc typcs o gcnctic tcsts
ocrcd LTC, so that providcrs can coun
scl thcir paticnts about thc potcntial
valuc and limitations o LTC tcsting.

Physicians arc no longcr gatckccpcrs
to gcnomic inormation. Tcy will bc
rcsponsiblc or intcgrating that inorma
tion into a pcrsonal trcatmcnt plan and
making thc inormation undcrstandablc
in a practical, clinically rclcvant way or
thc paticnt.
Studics havc rcccntly shown that gcnc
cxprcssion and biological pathways
involvcd with hcaling arc important in
undcrstanding thc onsct and hcaling
proccss associatcd with gingivitis. Tc
idcntication o biomarkcrs or individu
als at risk or pcriodontal discasc could
makc possiblc thc dcsign o advanccd,
pcrsonalizcd trcatmcnt options and
prcvcntivc carc. In a uturc not ar away, a
paticnts gcnomic prolc will bc as
important and acccssiblc as his or hcr
blood prcssurc is today.
references
1. Ashby A, Whos your daddy? Its easier to nd out than you
think. The Daily News, May 5, 2006, htp://www.memphisdai-
lynews.com/editorial/Article.aspx?id=30197. Accessed Jan.
25, 2010.
2. Watson J, Living with my personal genome. Personalized
Med 6(6): 607, 2009.
3. Mardis ER, Lunshof JE, A focus on personal genomics.
Personalized Med 6(6):603-6, 2009.
4. Lamb NE, Myers RM, Gunter C, Education and personalized
genomics: deciphering the publics genetic health report,
Personalized Med 6(6):681-90, 2009.
a p r i l 1 0 e d i t o r
Address comments, leters, and questions
to the editor to kerry.carney@cda.org.






MICHAEL J. KHOURI
ATTORNEY AT LAW

CRIMINAL DEFENSE

PROFESSIONAL BOARD DISCIPLINE DEFENSE

MEDI-CARE AND MEDI-CAL AUDIT AND FRAUD DEFENSE

Former Deputy District Attorney
Over 25 Years Experience
Admitted in all California state and federal courts

Telephone: (949) 336-2433; Cell: (949) 680-6332
4040 BARRANCA PARKWAY, SUITE 200
IRVINE, CALIFORNIA 92604
www.khourilaw.com
LAW OFFICES OF
MICHAEL J. KHOURI
220ap ri l 201 0
cda j ournal , vol 38 , n

4
Letters
Editorial Hits Close to Home;
Formocresol Article Questioned
thought thc cditorial, Strugglc, by
Ruchi K. Sahota, LLS, CLF, (oarnc|
o/ ||e Cc||/orn|c !en|c| Asso.|c||on,
8(.).8r., Fcbruary .crc) was a
wondcrul and introspcctivc articlc.
As I was rcading, I ound myscl nodding
and laughing with all hcr strugglcs as
thcy arc minc also.
As a working mom, I strugglc with
managing my ncw occ, balancing my
associatcship at anothcr occ, voluntccring
with thc Rotary club, managing my husband
and .ycarold son, and still trying to makc
homccookcd mcals cvcry night. In thc last
two ycars, I havc lcarncd to say no. I totally
undcrstand how Lr. Sahota ccls.
wanlan xi ao, dds
!|.ermore, Cc||/.
More Kudos for Struggle Editorial
\hat a wondcrully writtcn cditorial,
Strugglc. Tosc o us who arc busy do
indccd strugglc with thc balancc o lic.
Iikc you, my wic and I nd it challcng
ing to spcnd thc timc with our our boys
as wcll as run our practicc, othcr invcst
mcnts, and our nonprot voluntccring.
Tcrc is an incrcdiblc dcntal organiza
tion that not cnough dcntists arc awarc o
that addrcsscs thcsc issucs. Our cxpo
surc to programs by Stcphcn Covcy, Rcv.
Schullcr, and othcrs havc hclpcd us stay
groundcd in what wc do. For cxamplc,
thc most powcrul mcssagc wc hcard was
rom a ormcr Nc||onc| Geogrc||. sta
photographcr. Hc taught us that no mat
tcr how you look at or scc things, thcrc
is always anothcr way to look at it. And,
otcn, thc altcrnativc way is thc bcst
Tc Amcrican Acadcmy o Lcntal
Practicc Administration (aadpa.org),
although a bit o a mislcading namc, is an
incrcdiblc group o positivc on lic and
practicc dcntists and consultants.
Iastly, I will closc with inormation
about anothcr passion o minc. Boy Scout
councils and troops nccd dcntists and
dcntal tcam mcmbcrs to support scouting
by signing up to bc a mcrit badgc coun
sclor. Tc dcntistry mcrit badgc is thc
most obvious, but most dcntists also havc
knowlcdgc and skills that apply in othcr
arcas as wcll. I am happy to providc morc
inormation about this to anyonc.
Tanks or all you do.
wm. randy jungman, dds
Fs.oni|io, Cc||/.
Assertions on Formocresol Challenged
Editors note: !n resonse |o ||e a|||.c
||on o/ !r. Frci|e, !eu|s Le C|so|es.en.e
o/ Formo.reso| (ournal o thc Caliornia
Lcntal Association, ,8(.)..o.,, Fe|racr,
.o.o), ue re.e|.ei ||ree |n.|s|.e |e||ers. !r. Anc
P|cne||s |oo| |ssae u||| ||e ca||ors .|c|m ||c|
C||n|.|cns s|oa|i |e ci.|sei ||c| as|ng /or
mo.reso| |s no| re.ommeniei |, ||e Amer|.cn
Asso.|c||on o/ Fnioion||s|s cni ||e Amer|.cn
A.ciem, o/ Pei|c|r|. !en||s|r,. !r. P|cne||s
io.amen|ei ||c|, Nou|ere |n ||e AAP!
ga|ie||nes io ||e, s|c|e ||c| /ormo.reso| |s no|
re.ommeniei. A re.|eu o/ ||e ga|ie||nes cni
os|||on cers a|||s|ei on ||e AAF we| s||e
/oani ||c| ||e AAF ioes re.ommeni against
||e ase o/ crc/ormc|ie|,ie.on|c|n|ng mc|er|
c|s u||| regcri |o |||ng mc|er|c|s cni sec|ers,
|a| ||ere |s no o.|c| os|||on .on.ern|ng /or
mo.reso|. !r. !eu|s i|i no| resoni |o reaes|s
/or e|cnc||on or .|cr|.c||on o/ ||s s|c|emen|.
Le ournal regre|s cn, .on/as|on ||c| ||e
ca||ors s|c|emen| mc, |c.e .casei.
!n/ormc||on on ||e AAF cni AAP! os|
||ons .cn |e /oani |n ||e /o||ou|ng io.amen|s.
n
Ga|ie||ne on Pa| Lerc, /or Pr|mcr,
cni !mmc|are Permcnen| Tee||. uuu.cci.
org/mei|c/Po||.|es_Ga|ie||nes/G_Pa|.i/
n
AAF Pos|||on 3|c|emen|. Con.ern|ng
Pcrc/ormc|ie|,ieCon|c|n|ng Fnioion||.
F||||ng |c|er|c|s cni 3ec|ers. uuu.cce.org/
NP/rion|,res/.F,,.F!A.!.,,,,F,
!o.o.F,oF.,/o/crc/ormc|ie|,ie|||ng
mc|er|c|s.i/
1nc ossoicsccNcc or
FEBRUARY
DcnLin Wcar
Mobilc DcnLal Clinic
Usc o Rosa Damasccna Journal
or f ne c tL i r onni t ne nftL ts s oc i tf i on
I
Le /o||ou|ng |e||er ree.|s ||e mc,or||,
o/ ||e .ommen|s re.e|.ei |, ||e ournal |n
resonse |o !r. !eu|s cr||.|e.
I rcad with intcrcst your lcad articlc
on Tc Obsolcsccncc o Formocrcsol. I
would likc to rccct on both thc structurc
and substancc o thc authors argumcnt
or doing away with thc usc o ormocrc
sol in primary tooth pulpotomics.
In his conclusion, thc author uscs
thc statcmcnt that duc to ormocrcsols
harmul cccts and lack o scicntic sup
port, its usc should bc climinatcd rom
dcntal practicc. Tis immcdiatcly rcminds
mc o thc typc o argumcnts that I havc
routincly hcard rom antiuoridationists
and antiamalgam advocatcs, i.c., cvcryonc
knows thcrcs a problcm. I would makc thc
point that i an advocatc or author bcgins
with a highly biascd point o vicw, it is my
cxpcricncc that thcy can nd any numbcr
o additional points o cvidcncc to support
that original bias. I submit that an opcn
mind is a most important attributc in nd
ing truth. By way o cxamplc, my original
training cquatcd acid ctching o thc dcntin
with tooth dcath and malpracticc, it was
only through opcnncss to possibilitics that
mainstrcam dcntistry has incorporatcd
acidctching tcchniqucs into daily practicc.
cda j ournal , vol 38 , n

4
ap ri l 201 0221
Tc author rccrcnccs Caccda in his
articlc] and notcs whilc hcshc has dc
vclopcd a pulpotomy tcchniquc using no
ormocrcsol and yct hcshc still routincly
cmploys thc old standby ormocrcsol
pulpotomy. I scnsc in thc articlcs tonc a
surprisc and incrcdulity that any lcarncd
dcntal practitioncr could still usc ormo
crcsol. Ict mc suggcst that, likc myscl,
Caccda may havc a rcscrvoir o cxpcricncc
(thousands o succcssul proccdurcs) as
a body o cvidcncc supporting ormocrc
sols continucd usagc or pulpotomics.
\hcn I considcr thc lcngth (/c to 8c
ycars`) and brcadth o clinical cxpcri
cncc (millions o succcsscs`), this dwars
thc rathcr minisculc numbcr o cascs o
clinical cxpcricnccs with MTA and makcs
mc somcwhat uncasy about thc authors
adamant ccrtainty o MTAs supcrior
pcrormancc.
\hilc my usc o MTA is admittcdly
limitcd (approximatc thrcc dozcn cascs,
all pcrmancnt tccth), I will say I am im
prcsscd with my succcsscs so ar. My con
ccrns with thcsc uscs o MTA is twoold.
r. Tc diculty o clinic tcchniqucs is
rcal and dramatic in my cxpcricncc, cspc
cially in usagc with limitcd coopcration
pcdiatric paticnts.
.. Tc rathcr outragcous cost pcr pa
ticnt. Tis in my vicw prcscnts a rcal issuc
as ar as pcdiatric paticnt acccss to carc.
I do wish to ccho thc authors lamcnt
about thc lack o standardization o carc,
i.c., why isnt a standardizcd prcparation
o ormocrcsol o a known pcrccntagc
availablc` As with cvcry mcdication, dos
agc obviously crcatcs a widcly variablc sct
o accts BOTH positivc and ncgativc.
Finally, thcsc typcs o articlcs taunting
thc obvious supcriority o a tcchniquc
tcnd to limit acccssibility to an unbiascd
asscssmcnt o availablc inormation and
rcsult in car bccoming thc primc movcr
in dccisionmaking. As an addcd cxamplc,
I havc dctcctcd an undcrcurrcnt o con
ccrn rom somc o my collcagucs about
cugcnols possiblc dclctcrious cccts, c.g.,
toxicity and gcnotoxic possibilitics, which
thc authors Tablc r sccms to ccho. \ith
both cugcnol and ormocrcsol, I ccl it
is ncccssary to look at thc wholc picturc
and not rcly solcly on cmpiric cvidcncc o
thc millions o succcssully and apparcnt
ly sac usagc o thcsc mcdicamcnts BUT
on thc othcr hand dont cavalicrly ignorc
thosc. \c nccd to look at trcatmcnts
and paticnts in a complctc way, balanc
ing sacty, ccctivcncss, timc, and cost to
dclivcr thc bcst possiblc dcntal trcatmcnt
to thc most paticnts.
At a timc o incrcasing conccrns
about acccss to carc, I would hopc that
somcthing likc MTA with its addcd
cost and tcchniquc limitations docs not
bccomc thc standard o carc. Ict us
rathcr look or improvcmcnts without
abnormally raising thc spcctcr o car as a
rcason or changc.
robert j. venn, dds
|oies|o, Cc||/.
800.733.0633 tdicsolutions.com CA Insurance Lic. #0652783
Coverage specically underwritten by The Dentists Insurance Company includes professional liability, ofce
property, and employment practices liability. Workers compensation, life, health, disability, long-term care,
business overhead expense, home and auto products are underwritten by other insurance carriers, brokered
through TDIC Insurance Solutions.
Protecting
dentists.
Its all we do.
Professional Liability
Ofce Property
Employment Practices Liability
Workers Compensation
Life/Health/Disability
Long-Term Care
Business Overhead Expense
Home & Auto
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cda j ournal , vol 38 , n

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ap ri l 201 0223
Impressions
conti nues on 225
Club Ethics
by david w. chambers, phd
\hcn grcctcd in public with thc
qucstion, How arc you, thc propcr
rcsponsc is Im nc. How arc you` To
say that you arc supcrb is prcsumptu
ous, it is an imposition to bcgin a list
o ailmcnts and complaints. Violating a
condcncc would bc tcrribly bad orm
or a ricnd and unorgivablc, and pcr
haps cvcn lcgally actionablc in a pricst,
hcalth carc providcr, or attorncy. On thc
othcr hand, in politics and thc cntcrtain
mcnt industrics, ailurc to pass on thc
wcllplaccd lcak would jcopardizc oncs
status in thc nctwork.
Club cthics rcgulatc thc way wc
bchavc in groups. Politicians can bc
clcctcd whilc in jail, scrving scntcnccs
or bribcry, whilc othcrs havc thcir
rcclcctions sabotagcd or voting thcir
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Toothbrush Time, Oral Health Education Now Included
in Massachusetts Preschool Schedule
The Bay State is the rst in the country to include toothbrushing and oral health
education to the routine of children in day care.
In late January, the regulations geared to curtail dental disease went into play
and require that children who eat at least one meal at a day care facility or atend for more
than four hours are required to brush their teeth as well as
learn about good oral health habits.
While the directive brought smiles to many dental
professionals and parents, some were not as pleased. I dont
want someones hand in my childs mouth, said one teacher
and mother of a 5-month-old baby, according to a newspaper
interview. Its a litle too much government intervention.
However, parents can opt out, said Sherri Killins,
commissioner of the Department of Early Education and
Care, the agency that watches over day care centers.
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224ap ri l 201 0
cda j ournal , vol 38 , n

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Ancient Dentition Oers Clues to
Mans Evolution
Tc dcntition o a child is hclping
rcscarchcrs illuminatc modcrn mans cvolu
tion. A tcam o intcrnational scicntists
arc using thc rcmains o a c,cccycarold
youth, cxcavatcd in r,,8r,,, in Portugal
and classicd as a modcrn human with
Ncandcrthal anccstry, to comparc thc childs
milk tccth and ncarly all o its pcrmancnt
tccth to thosc o Ncandcrthals, latcr Plcisto
ccnc humans, and modcrn humans.
Tis ncw analysis o thc Iagar Vclho
child joins a growing body o inorma
tion rom othcr carly modcrn human
ossils ound across Furopc (in Mladc in
thc Czcch Rcpublic, Pctcra cu Oasc and
Pctcra Muicrii in Romania, and Ics Rois
in Francc) that shows thcsc carly modcrn
humans wcrc modcrn without bcing ully
modcrn. Human anatomical cvolution
continucd atcr thcy livcd c,ccc to c,ccc
ycars ago, said oo Zilho, PhL, a procs
sor at thc Univcrsity o Bristol, who is on
thc intcrnational tcam, in a prcss rclcasc.
Tc childs dcntition has cvokcd qucs
tions about thc dcgrcc Ncandcrthals and
modcrn human groups o Arican dcsccnt
brcd whcn thcy camc into contact in
Furopc. \ith anatomy basically compa
rablc to todays human racc, carly modcrn
humans cmcrgcd morc than c,ccc ycars
ago. A longhcld, univcrsal opinion is that
littlc has changcd in human biology sincc
carly modcrn humans.
Using Xrays to crcatc crossscctions
o L objccts, scicntists wcrc ablc to
rcscarch thc rclativc stagcs o ormation
o thc dcvcloping tccth and proportions
o crown cnamcl, pulp in thc tccth and
dcntin, according to thc study publishcd
rcccntly in thc Pro.eei|ngs o/ ||e Nc||onc|
A.ciem, o/ 3.|en.es.
Tcir ndings wcrc that or a sct stagc
o dcvclopmcnt o thc chcck tccth, thc
ront tccth wcrc rclativcly dclaycd in
thcir dcgrcc o ormation, according to a
prcss rclcasc.
a p r i l 1 0 i m p r e s s i o n s
Virtual 3-D reconstruction
of four deciduous and
one permanent teeth
assessed for linear,
surface, and volumetric
tissue proportions.
Tighter Controls on Drugs Keeps Risk for Abuse in Check
To thwart the dental oce being used as a proverbial candy store, stricter control policies should be put in place,
according to an author in a recent issue of Anesthesia Progress.
Dentists who are too trusting of their employees are actually puting themselves at risk when it comes to controlled
substances, said Joel M. Weaver, DDS, PhD, adding, dentists who regulate drug access and distribution are protecting more
than their practice, theyre also protecting their patients, employees, and reputation. While its ofen easier to stick with the
way things have traditionally been done, making a few changes to drug access policies makes good business sense.
Although change is dicult and usually meets with resistance, the thoughtful practitioner who can step back and
observe his or her practice for potentially fatal weaknesses will be much less likely to succumb to a disaster, wrote
Weaver. Accredited hospitals already have strict rules to help prevent drug thef, but private unaccredited oces
without mandatory controls are highly vulnerable to drug thef and deception.
By taking sole responsibility for storing, lling, and handling syringes
with controlled substances, dentists reduce the chance for illegal drug use
and mistaken dosages. Its important to rely only on those licensed to handle
medications, Weaver said, singling out dentists, pharmacists, nurses, and
medical doctors. Errors with dosages and concentrations may occur by certain
employees who only have on-the-job training.
To read the entire article, Who Should Have Access to the Controlled
Substances in Your Oce? go to www2.allenpress.com/pdf/anpr-56-4fnl.pdf.
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cda j ournal , vol 38 , n

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ap ri l 201 0225
Timeline Suggested to Optimize
Treatment of Clef Lip/Palate
Tc sooncr a child rcccivcs trcat
mcnt or oroacial clct, thc bcttcr thcir
psychosocial and mcdical wcllbcing.
Tc Amcrican Clct PalatcCranioacial
Association rcccntly prcscntcd somc
guidclincs indicating thc bcst timc thc
primary surgcry should bc donc, bascd on
thc childs typc o oroacial clct.
A rctrospcctivc study was carricd out
to vcriy whcthcr childrcn with oroacial
clcts rcccivc surgcry or primary rcpair
within thc timc suggcstcd by thc guidc
lincs, according to a prcss rclcasc. Tc
study was publishcd in an issuc o Le
C|e/| Pc|c|eCrcn|o/c.|c| oarnc|.
Childrcn whosc mothcrs rcccivcd ma
tcrnity carc coordination, rcccivcd prcnatal
carc at a local hcalth dcpartmcnt, or livcd
in thc southcastcrn or northcastcrn rcgion
o thc statc wcrc morc likcly to rcccivc
timcly clct surgcry, said thc authors.
Tc study, conductcd in North Caro
lina, involvcd birth dcccts rcgistrics,
conscicncc against thc party caucus.
In cxtrcmc cascs, gang mcmbcrs must
dcmonstratc conspicuous launting
o thc public good (as in tagging), and
maioso or CIA agcnts might kill to
dcmonstratc thcir good cthical status.
\hat wc arc dcaling with is cascs whcrc
a positivc bond bctwccn mcmbcrs and
thc group dcmands bchavior that is in
dcpcndcnt o or in somc cascs antithcti
cal to cthics gcncrally.
Procssional cthicists havc ocuscd
almost cxclusivcly on thc naturc o mor
al acts. It also mattcrs who is acctcd by
moral bchavior and thc stylc in which it
is donc. I havc hcard storics o dcntists
whosc trcatmcnt o paticnts was so
alarming that thc procssion vigorously
sought to curb thcir practiccs, only to
bc blockcd or cquivocatcd by thc lcgal
systcm. But whcn thc minor rcstraints
imposcd by justicc wcrc tampcrcd with,
thc samc dcntist gcts thc contcmpt o
court book thrown at thcm. It mattcrs
which clubs rulcs arc violatcd.
Tc challcngc o club cthics cxists in
thc Amcrican Lcntal Association Codc,
most notably in Scction C. Paticnts
should bc inormcd o thcir oral hcalth
status without disparaging commcnt
about prior scrvicc. Tis standard rom
thc scction labclcd Procssional Con
duct is at odds with thc statcmcnt in thc
Fthics scction that thc bcnct o thc
paticnt (is thc dcntists) highcst goal.
Tcrc is a conict hcrc bctwccn club cth
ics and cthical rcsponsibility to thc public.
In many ycars o lcading casc discus
sions with studcnts and practitioncrs,
thcrc havc bccn a surprising numbcr who
placc thc club cthic highcr than thc gcn
cral onc. Scvcral practitioncrs who havc
bccn occrs in organizcd dcntistry havc
strongly statcd thcrc arc no circumstanc
club ethi cs, conti nued from 223
cs whatsocvcr that justiy challcnging thc
work o collcagucs. Onc told mc rcccntly,
Paticnts comc and go, I havc to livc with
my collcagucs throughout my carccr.
Tcsc samc practitioncrs nd it
troublcsomc that dcntal studcnts prctty
rigorously cnorcc thc club cthic o not
ratting on collcagucs who arc known to
chcat in dcntal school.
Tc nub.
In cthics, it mattcrs what is donc, but
also whom it is donc to and how.
Following thc norms o oncs group
is otcn casicr and morc highly rcwardcd
than bcing cthical in gcncral.
Choosc your ricnds carcully. thcy
dcnc what it mcans to bc good.
!c.|i w. C|cm|ers, P|!, |s ro/essor o/
ien|c| eia.c||on, Ar||ar A. !agon| 3.|oo| o/
!en||s|r,, 3cn Frcn.|s.o, cni ei||or o/ ||e
ournal o thc Amcrican Collcgc o Lcntists.
The American Clef
Palate-Craniofacial
Association recently
presented some
guidelines
indicating the
best time the
primary surgery
should be done,
based on the
childs type of
orofacial clef.
Mcdicaid lcs, and vital statistics o thosc
acctcd childrcn or a scvcnycar pcriod
starting in r,,. Catcgorics, according to a
prcss rclcasc, rangcd rom pcrinatal carc
rcgion to placc to rcsidcncc, and thc
charactcristics o matcrnal, child, and
systcm. Tc rcsults ound that /8 pcrccnt
in thc study obtaincd primary rcpair
surgcry by thc agc rccommcndcd in thc
associations guidclincs. Othcr pcrccntagcs
includcd ,c pcrccnt or childrcn with clct
lips, 8 pcrccnt or thosc with clct palatcs,
and ncarly 8, pcrccnt or thosc with
clct lippalatc. Additionally, blacks
and nonHispanics, as wcll as thosc
rcsiding in thc southwcstcrn arca o
thc statc, wcrc not as apt to rcccivc
surgcry, pcr thc rccommcndcd guidclincs.
Listancc to thc cranioacial ccntcr and thc
various scrviccs providcd by thc acilitics
likcly wcrc actors.
To rcad thc cntirc articlc, Timclincss
o Primary Clct IipPalatc Surgcry, go
to www..allcnprcss.compdCPC._
nl.pd.
1
2
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226ap ri l 201 0
cda j ournal , vol 38 , n

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Bring MouthPower to Your Oce
A CLROM o thc National Muscum
o Lcntistrys cvcrpopular oral hcalth
cducation program, MouthPowcr, is
now availablc to hygicnists and dcntists,
thanks to a partncrship bctwccn thc mu
scum and Unitcd Concordia Lcntal.
Tc sccrct to a hcalthy smilc is simplc
taking good carc o your tccth, said
onathan Iandcrs, cxccutivc dircctor o
thc National Muscum o Lcntistry. Tc
MouthPowcr program shows kids how to
do that in a un and cducational way.
Tc CL can bc uscd by dcntal procs
sionals to rclay thc importancc o good
oral hcalth habits to paticnts, according
to a prcss rclcasc. Onc o thc highlights is
thc charactcr Mouthic, in an intcractivc
sctting, who tcachcs childrcn to oss and
upcomi ng meeti ngs
2 0 1 0
April 1117 United States Dental Tennis Association, Amelia Island Plantation, Fla.,
dentaltennis.org.
April 2628 National Oral Health Conference, St. Louis, Mo.,
nationaloralhealthconference.com.
May 1316 CDA Presents The Art and Science of Dentistry, Anaheim, 800-CDA-SMILE
(232-7645), cda.org.
May27-29 Canadian Academy of Periodontology 55th annual general meeting,
Vancouver, BC, cap-acp.ca.
Sept. 911 CDA Presents The Art and Science of Dentistry, San Francisco, 800-CDA-SMILE
(232-7645), cda.org.
Nov. 713 United States Dental Tennis Association, Grand Wailea, Hawaii,
dentaltennis.org.
2 0 1 1
May 12-15 CDA Presents the Art and Science of Dentistry, Anaheim, 800-CDA-SMILE
(232-7645), cda.org.
Sept. 22-24 CDA Presents the Art and Science of Dentistry, San Francisco, 800-CDA-SMILE
(232-7645), cda.org.
To have an event included on this list of nonprofit association continuing education meetings, please send the information
to Upcoming Meetings, CDA Journal, 1201 K St., 16th Floor, Sacramento, CA 95814 or fax the information to 916-554-5962.
a p r i l 1 0 i m p r e s s i o n s
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The WOW Powder Oral
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WOW Powder Oral Rinse
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removes plaque, combats
gum disease, cleanses the
oral cavity and provides
brush, makc hcalthul ood dccisions, as
wcll as avoid thc usc o tobacco. Bilingual
lcssons and handy activity shccts makc it
un or kids to lcarn and put into practicc
good oral hcalth routincs.
Tc CL can bc obtaincd by making a
rcqucst through thc muscum, it also will
bc scnt to thc participating ,ccc Unitcd
Concordia dcntists across thc country.
\c arc cxcitcd to partncr with thc
National Muscum o Lcntistry to sharc this
outstanding oral hcalth cducation program
with our participating dcntists, said Karcn
A. \hitcscl, vicc prcsidcnt, Unitcd Concor
dia Lcntal Corporatc, procssional rclations.
Our hopc is that this cxciting tool will hclp
dcntists tcach thcir young paticnts liclong
habits that maintain hcalthy smilcs.
instantly fresh breath.
WOW Powder Oral Rinse
can be used once to three
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when a toothbrush is
not readily available. For
more information visit
woworalcare.com.
cda j ournal , vol 38 , n

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ap ri l 201 0227
Protein Holds Promise to Kill
Cancer Cells
A rcccntly discovcrcd protcin may
spcll RIP to canccr cclls.
Rcscarchcrs at thc Univcrsity o Michi
gan studicd a protcin, rcccptorintcracting
protcin, that acts as a togglc that scts o thc
ccll dcath proccss, which may hclp cradicatc
canccr cclls, according to a prcss rclcasc.
Yvonnc Kapila, an associatc procs
sor, Lcpartmcnt o Pcriodontics and
Oral Mcdicinc at thc univcrsitys School
o Lcntistry, said thc RIP plays a rolc
in mcdiating both thc lic and dcath o
squamous ccll carcinoma canccr cclls.
Additionally, Kapila said, thc nding is im
portant bccausc canccr cclls can dodgc thc
typical ccll dcath proccss. I that proccss
could bc activatcd articially by a targctcd
introduction o RIP into canccr paticnts,
thosc cclls could bc dcstroycd bcorc thcy
circulatc out o control in thc body.
Tc ccll must analyzc multiplc
signals and say, OK, am I going to
dic or am I going to livc, Kapila said.
\c clt thcrc must bc somc kind o
communication bctwccn pathways o
lic and dcath othcrwisc thc ccll will bc
conuscd and not know what to do.
In looking at squamous ccll carci
noma cclls rom hcad and ncck tumors,
as wcll as broblasts in micc, rcscarchcrs
discovcrcd applications to othcr typcs o
canccrs and that RIP was thc communi
cator, according to a prcss rclcasc.
Hcalthy cclls conncct to a matrix in
ordcr to survivc, i dctachcd, thc cclls dic.
Canccr cclls can dctach rom a matrix and
circulatc rccly, pcrmitting thcm to sprcad
and mctastasizc in thc body, said Kapila.
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Parents Cautioned to be Mindful When
Their Young Children Use Fluoridated
Toothpastes
\hilc a study has dctcrmincd that
uoridccontaining toothpastcs (a mini
mum conccntration o r,ccc parts pcr
million) can hclp prcvcnt tooth dccay in
childrcn, rcscarchcrs advocatc parcnts
talk to thcir dcntists about conccrns o
uorosis, which is causcd by swallowing
cxccssivc uoridc.
Cochranc Oral Hcalth Croup rcscarch
crs conductcd a study that involvcd
/,ccc childrcn around thc globc and
ncarly 8c trials. In studying thc out
comcs o various toothpastcs uscd by
thc participating childrcn, it was lcarncd
that toothpastcs containing uoridc
conccntrations lcss than r,ccc parts pcr
million wcrc only as ccctivc as non
uoridc toothpastcs at prcvcnting tooth
dccay, according to a prcss rclcasc. Tc
conccntration o uoridc toothpastcs in
thc study rangcd rom rcc ppm to r,cc
ppm. Prcvious rcscarch, also conductcd
by thc Cochranc Oral Hcalth Croup, had
shown that comparcd to nonuoridc
New Study: Tooth Enamel Growth Due to Proline Repeats
University of Illinois at Chicago researchers have discovered that a tooths structural integrity is due to a
repeat of a basic amino acid in the middle of proteins in tooth enamel.
Proline repeats are amazing, said Tom Diekwisch, DMD, PhD, professor and head of oral biology in the
UIC College of Dentistry and lead researcher on the study. They hold the key to understanding the structure
and function of many natural proteins, including mucins, antifreeze proteins, Alzheimer amyloid, and prion
proteins. We hope that our ndings will help many other important areas of scientic research, including the
treatment of neurodegenerative diseases.
Researchers looked at proline repeats in animal models and amphibians. In frogs, when the repeats are
abbreviated, teeth dont have the enamel prisms responsible for the strength of human enamel, according to
a press release. On the other hand, when the proline repeats are longer, they contract groups of molecules
that enable the growth of enamel crystals.
The ndings were published in the December 2009 online version of the Journal PLoS Biology.
Diekwisch said that when tooth enamel is grown, it is bathed in bubble-shaped groupings of proteins.
The protein bubbles size ranges in various animals; for example, in cows, its 5 nanometers; 40 in frogs; and
20 in mice. The study also revealed that the more elongated the stretch of proline repeats, the more the
protein bubbles contracted, he said. Additionally, research indicated that the smaller protein bubbles were
associated with longer enamel crystals, according to a press release.
toothpastcs, thosc with uoridc dccrcascd
dcntal dccay by . pcrccnt.
In thc rcccnt study, it was ound that
usc a uoridccontaining toothpastc on
childrcn undcr thc agc o r may boost thc
risk o mild uorosis. \hats morc, uo
rosis is still a actor in childrcn up to thc
agc o who swallow largcr amounts. Us
ing small amounts o uoridc toothpastcs
rcduccs this risk, said thc authors, adding
that atcr agc , tccth arc ully dcvclopcd
and thc risk o mottling diminishcd.
It is vcry conusing or parcnts to
know how to strikc thc right balancc,
which isnt hclpcd by thc act that dicr
cnt companics usc dicrcnt conccntra
tions o uoridc in thcir toothpastcs
aimcd at childrcn, said AnncMaric
Clcnny, PhL, onc o thc authors.
From a public hcalth point o vicw,
thc risk o tooth dccay and its consc
qucnccs such as pain and cxtractions is
grcatcr than thc small risk o uorosis.
Childrcn would havc to swallow a lot o
toothpastc ovcr a long pcriod o timc
to gct thc scvcrc brown mottling on thc
tccth, said Clcnny.
a p r i l 1 0 i m p r e s s i o n s
resents cda
P
ANA10
ANAHEIM, CA MAY 13-16, 2010
SHOW HIGHLIGHTS
World-renowned speakers
Be inspired by two of the masters in restorative surgery,
Terry Tanaka, DDS and Harald Heymann, DDS. Each is also
a featured guest at the two Exclusive Access Luncheons.
An exhibit hall brimming with possibilities
With about 600 vendors and countless new product launches,
the exhibit hall has everything your ofce needs to stay ahead
of the curve in dentistry.
Hands-on laser workshops
Lasers are quickly becoming a dentists most useful
instrument. Gain hands-on experience at the
Wonderful World of Lasers.
The sun and fun of Anaheim
Fun for the whole family, CDA Presents is a
short hop to Disneyland, Knotts Berry Farm,
the beach and more.
Register at cdapresents.com
The Art and Science of Dentistry in the
Heart and Soul of Southern California
CDAP_ANA10_Journal_Highlights_April.indd 1 3/18/10 3:12 PM
CDA PRESENTS MEETING SCHEDULE MAY 1316
Register online at cdapresents.com.
Registration/Ticket Sales/Tote Bag and Lanyard Pickup
Anaheim Convention Center Thursday, 6:30 a.m.5:30 p.m.
Friday, 6:30 a.m.5:30 p.m.
Saturday, 6:30 a.m.5:30 p.m.
Sunday, 7 a.m.2 p.m.
Bag and Lanyard Pickup
Hilton Anaheim Hotel Friday, 7 a.m.3 p.m.
Saturday, 8 a.m.noon
Programs
Anaheim Convention Center and
Hilton Anaheim Hotel
Symposia Thursday, various times
Lectures/Workshops ThursdaySunday, various times
Anaheim Convention Center Dental Assistant Student Table Clinic Viewing
Friday, noon2 p.m.
Military/Resident Table Clinic Viewing
Saturday, noon2 p.m.
Student Table Clinic Viewing
Sunday, noon2 p.m.
Exhibit Information Anaheim Convention Center
Grand Opening of the Exhibit Hall Friday, 9:30 a.m.
Exhibit Hall Hours Friday and Saturday, 9:30 a.m.5:30 p.m.
Sunday, 9:30 a.m.2 p.m.
Family Hours Daily, 9:3011:30 a.m.
Kid Zone Hours Friday and Saturday, 9:30 a.m.5:30 p.m.
Sunday, 9:30 a.m.2 p.m.
Special Events
Hilton Anaheim Hotel Child Care
Thursday and Sunday, 8 a.m.6 p.m.
Friday and Saturday, 7 a.m.6 p.m.
California Adventure Membership Party
Friday, May 14, 711 p.m.
TOP SIX TIPS FOR RECEIVING C.E.
1. Plan ahead Arrive at least 15 minutes early to all courses, and plan an alternate course in the event
that your preferred course is full. Doors close at the start of the lecture, and late arrivals will not be
admitted.
2. Scan in and out of each course Arrival and departure times are used to issue C.E. credits. You will need
to scan upon entry and exit, and must remain in the course the entire time. Partial credit cannot be
granted. Credit cannot be given for overlapping course times.
3. Write down course codes During each course, the host will give attendees a three-digit code that should
be recorded and saved until you have your complete C.E. certifcate after the convention.
4. License numbers matter When registering, include the license numbers and formal names of all licensed
attendees to ensure C.E. credits are granted.
5. Go to the C.E. Pavilion or cdapresents.com after attending class At the C.E. Pavilion, you will verify your
C.E. units as well as take a brief survey for each course attended. For your convenience, you can wait
until you have attended all of your courses to verify, or visit cdapresents.com up to fve days after the
meeting.
6. Print your certificate online To make your C.E. certifcates available in a timelier manner, certificates
will now be available online approximately three to four weeks after the meeting. At that time, you will
receive an e-mail containing a link that will take you to your C.E. certifcate. You may also access your
C.E. certifcate under the Member Profle area at cdapresents.com. Should you need a copy of your
certifcate mailed to you, please call 800.232.7645 approximately four weeks after the meeting, and we
will be happy to mail you a copy.
EXHIBITOR LIST
1-800-DENTIST 848
3M ESPE Dental Products 1360, 1460
A. Titan Instruments 1377
A.C.E.S. 866
AB Dental USA 762
Accutron 334
Acteon North America 1172, 268
AdDent DentLite 2042
A-dec Inc. 516
Aegis Communications 1277
AFP Imaging 128
Airgas/Littell Industries 1260
Air Techniques 334
ALCO Professional Supplies 1586
All County Construction 672
Alliance H. Inc. 160
Allied Systems Products 1679
AllPro 775
Almore International Inc. 1632
AlphaDent 884
Als Dental Equipment 1258
AMD LASERS 2536
American Business Card 124
American Dental Association 857
American Dental Software 216
American Eagle Instruments 853
American Express OPEN 109
American Oral Cancer Foundation 2546
AM-Touch Dental 1262
Anthem Blue Cross 572
Archer & White Sales 779
Archtek Inc. 752
Aribex Inc. 2141
Army Healthcare Professions 2545
Art 4 Your Practice 1764
Aseptico 1124
Ashtel Dental 102, 577
Aspen Dental 2447
Associated Dental Dealers 1258
Assured Dental Lab 2048
ATS Dental 1258
Aurum Ceramic Dental Laboratories 777
AXIS Dental 2235
Banc of America Practice Solutions 803
Bank of America Card Services 706
Bausch Articulating Papers Inc. 753
Beaverstate Dental Inc. 630
Bell Dental Products LLC 755
Belmont Equipment 1032
Bergman Dental Supply 747
Best Instruments USA 2263
Beutlich LP, Pharmaceuticals 1661
Bicon Dental Implants 360
Bien Air 326
Bioclear Matrix System by Dr. David Clark 1774
BioHorizons 1577
BIOLASE Technology Inc. 2230
Biotec 1240
Biotrol 431
Bisco Dental Products 1470
Bosworth Company 1234
Brandi Dental Laboratory Inc. 751
Brasseler USA 1144
Brewer Design 1325
Buffalo Dental Manufacturing 667
Burbank Dental Laboratory 1183
Burkhart Dental Supply 316
CA Association of Nurse Anesthetists 272
CA Dept. of Public Health 585
Radiologic Health Branch
Cadent iTero 766
California Academy of General Dentistry 770
California Army National Guard 264
California Bank & Trust 854
California Dental Arts 1677
California Dental Assistants Association 2446
California Dental Certifications 668
California Dental Hygienists Association 2549
California Dentists Guild 1579
California General Bank 2558
California Practice Sales 317
California Smokers Helpline 2550
CamSight Co. Inc. 460
CareCredit 710
Carestream Health Inc. 402
CariFree 670
Carl Heyer Inc. 575
Carl Zeiss Meditec 1645
CDA Endorsed Programs MBC
CDA Foundation MBC
CDA Practice Support Center MBC
CDA Publications MBC
CDA Well Being Program 860
Centrix Inc. 616
Certol International 2363
ChaseHealthAdvance 221
Chattem 2156
Chuan Fu Medical Instrument Co. 2541
Church & Dwight Company Inc. 560
CIT Small Business Lending 2362
CK Dental Industries 1663
Clinicians Choice Dental Products 1177
Cochran Dental 1258
Colgate 1316
Coltene/Whaledent Inc. 716
Columbia Dentoform 1160
Comlite Systems 2127
Common Sense Dental Products 1722
Community Medical Center - GPR Program 867
Confirm Monitoring Systems Inc. 743
Consult-Pro 578
Continental Dental Laboratory 1280
Cosmedent Inc. 721
Cowsert Dental 1258
Crescent Products Inc. 415
Crosstex International 1430
Crystal Tip/Liquid Smile 472
CRYSTALMARK Dental Systems 1780
CustomAir 1160
D & M Practice Sales and Leasing 654
D4D 2234, 2238
da Vinci Dental Studios 859
Dansereau Health Products 1278
Danville Materials/Engineering 1151
Darby Dental Supply LLC 1550
Darden Dental Supply 105
Datacon Dental Systems 1658
DCI Equipment 2231
DDS Lab Inc. 2361
DefiNet Contact LLC 785
Delta Dental 735
Delta Dental Federal Services 741
Demandforce 709
DenLine Uniforms Inc. 1186
Den-Mat Holdings LLC 416
CDA Presents features one of the largest dental tradeshows in the nation. Search for products,
services, show specials and view the interactive exhibit foor plan at cdapresents.com.
ANA10_Exhib_List_Journal_April.indd 1 3/23/10 12:01 PM
Denovo Dental Inc. 1627, 634
DentaCheques 2448
Dental Board of California 268
Dental Elite 2153
Dental Equipment Specialist 1258
Dental Health Products Inc. 570
Dental Hygiene Committee of California 270
Dental Products Report 252
Dental R.A.T. 226
Dental Technology Consultants 2038
Dental Trade Alliance 2151
Dental Tribune America 771
Dental USA Inc. 1758
DentalBanc 2437
Dentalcompare 768
DentalEZ Group 1160
DentalPro Insurance Services 878
Dentalree.com 2534
DentalXChange - EHG Inc. 1244
Dentamerica Inc. 1687
DentaPure 872
Dentatus USA Ltd. 471
Dentazon Corporation 2560
Dentech Equipment 160
Dentex House of Turbines 676
Denti-Cal 739
Denticator 761
DentiMax Practice Management 244
Dentis Co. Ltd. 784
Dentistry Today 373
Dentists Advantage 168
Dentrix - Henry Schein Practice Solutions 2334
DENTSPLY International 1306, 1406
Dent-X 128
Designs for Vision Inc. 1330, 846
DEXIS Digital X-Ray 2330
Diatech 1750, 258
Digital Doc 351
Discovery Medical Inc. 2344
Discus Dental 134, 1674
Disposabowl 113
Diversified Dental & Upholstery 1787
DMG America 310
Docs Duds 883
DOCS Education 371
Doctorbase 673
Doral Refining Corp. 1224
Dowell Dental Products Inc. 680
Dr. Fresh Inc. 2265, 880
DUX Dental 1216
Easy Dental 2018
Edge Medical Technologies Inc. 858
Efficient Dental Technologies 1760
Elavon 704
Electro Medical Systems Corporation 2253
Ellman International 1526
Endo Shopper 1524
Endo Technic 759
Engle Dental Systems 332
Essential Dental Systems 333
Estrada Dental Supply Co. 773
Evolve Dental Technologies Inc. 863
EXACTA Dental Direct 2142, 323
Excel National Bank 684
EZ 2000 Inc. 1353
E-Z Floss 1149
FDI - World Dental Federation 869
First Choice Practice Sales 148
First Pacific Corporation 1220
Fitzpatrick Dental Equipment Co. 624
Flight Dental Systems 2364
Flossaid Corporation 2249
Flow Dental Corp. 1369
Forest Dental Products 334
Fortune Management 2346
Galaxy Dental Mfg. Co 658
Garfield Refining Company 1252
Garrison Dental Solutions 2441, 729
GC America Inc. 1434
Gebauer Company 2350
Gendex Dental Systems 2118
Genuitive Inc. 1671
George Taub Products 1279
Gingi-Pak 2040
GlaxoSmithKline 1642
Glidewell Laboratories 1444
Global Surgical Corporation 723
Glove Club 832
Gold Promotions 314
GoldBurs.com 1573
Golden State Construction Inc. 2456
GoldenMisch 1345
Great Lakes Prosthodontics 1351
Greater New York Dental Meeting 2352
Group Financial Services 377
Guardian Life Insurance Co. of America 2064
H & H Company 1576
Hager Worldwide 648
Handler Mfg. Co. Inc. 1522
Hartzell & Son, G. 1321
Hayes Handpiece Company 2133
HEAD DENTAL CORPORATION 1744
HealthFirst Corporation 544
HEINE 2342
Henry Schein Dental 2234, 2338
Henry Schein Financial Services 2234, 2338
Henry Schein Professional 2340
Practice Transitions
Heraeus 722
Hexagon International 2442
High Q Dental 1724
High Speed Service 1258
Hiossen Inc 2068
Hispanic Dental Association 267
Hospira 1176
HOYA ConBio Dental Lasers 1287
Hu-Friedy Mfg. Co. Inc. 1334
ICW International 334
Imaging Sciences 2130
IMTEC, a 3M Company 1566
Imtek Direct Marketing 2360, 581
InfoStar 647
InsidersCircle.com 2145, 331
Instrumentarium/Soredex 1666
Integrated Laminate Systems 330
InTouch Practice Communications 1784
Invisalign 210
Isolite Systems 202
ITL Dental 1474
Ivoclar Vivadent Inc. 1380
J&J Instruments Inc. 571
J. Morita USA Inc. 748
J. Rouseks GiggleTime Toy Co. 1331
Jelenko Alloys 2139
Jordco Inc. 2440
JS Dental Manufacturing Inc. 1248
Kangen Water Oasis 1155
KaVo Dental 2318
Keating Dental Arts 2152
Kelkom Systems 511
Kerr Corporation 1106, 1206
Kettenbach L.P. 374
Keurig Inc. 464
KeyScan Inc. 1782
Keystone Industries 580
Kilgore International Inc. 1560
Kimberly Clark Health Care 2458
MBC = CDA Member Benefits Center
ANA10_Exhib_List_Journal_April.indd 2 3/23/10 12:01 PM
EXHIBITOR LIST
Kings Two Dental Supply 774
Kodak Dental Systems 502
Komet USA 2138, 757
Kuraray America Inc. 2252
L & R Ultrasonics 1178
L.A.K. Enterprises Inc. 1625
Ladera Ranch Implant Institute 1673
Lancer Orthodontics Inc. 1226
Lang Dental Manufacturing Co. 1355
Lares Research 1654
Latinos For Dental Careers 265
Lee Skarin and Associates, Inc. 1230
Len Bucko Photo.com 2044
Lester A. Dine Inc. 1558
Lexi-Comp Inc. 370
Liberty Global Group 2559
Life-Like Cosmetic Solutions 2135
Lighthouse Practice Management Group Inc. 1746
Live Oak Bank 2451
Loma Linda University School of Dentistry 406
LumaLite Inc. 103
M&CC Modular and Custom Cabinets 334
MacPractice Inc. 2460
Magnified Video Dentistry 108
Main Street Bank 481
MANI Inc. 222
Market Connections Inc. 2052
Marrott Dental 1258
Marus Dental 2218
Massco Dental 787
Matsco 638
Maui Amenities Inc. 2140
Maxdent Dental Supply 1258
McKenzie Management 715
Medelita 327
Medical Protective 1772
Medicom 325
MedicTalk DentForms Software 569
Medidenta.com 1733
MedikBuild 470
MegaGen Implant Co., Ltd. 782
Meisinger USA 321
Member Benefits Center 1107
CDA Endorsed Programs
CDA Foundation
CDA Practice Support Center
CDA Publications
TDIC (The Dentists Insurance Company)
TDIC Insurance Solutions 1432
Meta Biomed Inc. 478
Metalift Crown & Bridge Removal System 745
Microbrush International 2046
Microcopy 1530, 733
MicroDental, a DTI Laboratory 1385
Microtek Lab Inc. 780
Midmark Corporation 1370
Miele Inc. 664
Milestone Scientific 1641
Millennium Dental Technologies Inc. 1680
Miltex 1516
MIS Implants Technologies Inc. 2149
Mosby/Saunders/Elsevier 1728
MyRay - Cefla Dental Group 2452
Nadia International Inc. 1556
National Childrens 228
Oral Health Foundation
Network Experts Inc. 379
NevinLabs 1160
New Tom 128
Nobel Biocare 1180
Nordent Manufacturing Inc. 345
Nouvag AG 1286
Novalar Pharmaceuticals Inc. 236
NuSmile Primary Crowns 1768
Nuvora Inc. 367
Obtura Spartan 1349
OC-1 Dental Supply Corp. 1776
OCO Biomedical 871
Officite LLC 763
Onsys 21 Inc. 220
Onyx Dental Supplies 349
Op-d-op Inc. 1621
OralCDx Laboratories 240
OralDNA Labs Inc. 781
Orange County Cosmetic Dental Lab 874
OraPharma Inc. 1624
Orascoptic 1106, 1206
Ortho Classic 864
Ortho Organizers Inc. 1540
Ortho-Tain Inc. 1623
Osada Inc. 1367
OSHA Review Inc. 702, 727
Pac-Dent International Inc. 339
Pacific Dental Services Inc. 564
PacStar Inc. 875
PACT-ONE Solutions 115
Palisades Dental 1575
Palmero Health Care 380
Panadent Corporation 1659
Panoramic Corporation 1531
Parkell Inc. 756
Patient News Publishing 249
Patientdocs.com 511
Patterson Dental 434
PBHS Inc. 652
PDT Inc./Paradise Dental Technologies 2264
Pearson Dental Supply Co. 302
Pelton & Crane 2218
Pentron Clinical Technologies 1660
Perio Protect LLC 1179
PeriOptix Inc. 1562
PHB 622
Philips Sonicare 444
PhotoMed International 2034
Plak Smacker 156
Planmeca Inc. 352
Porter Royal Sales 1240
Posca Brothers Dental Lab Inc. 749
Practice Sales & Appraisals 515
Practice Transition Partners 260
Practice-Web Inc. 644
PracticeWorks 502
Premier Dental Products Company 1634
Prestige Dental Products Inc. 660
Preventech 1716
Preventive Dental Specialties 2450
PreXion Inc. 868
Print4dentist.com 107
Procter & Gamble 1350
Professional Practice Sales 1157
Professional Sales Associates Inc. 334
Profit Finder 620
Progeny - A Midmark Company 1378
Proma 1240
Prophy Perfect 2050
Prophymagic 632
ProSites Inc. 1373, 610
Pro-Tex International/Snore Guard 1284
Puche Dental Lab 881
Pulpdent Corporation 1759
PureLife Dental 1570, 579
Q-Optics & Quality Aspirators 817
Quantum Inc. 2260
Quantum Products 2453
Quicklase Quickwhite 2365
Quintessence Publishing Co. Inc. 1327
R & D Services Amalgam Separators 1720
ANA10_Exhib_List_Journal_April.indd 3 3/23/10 12:01 PM
RAMVAC 1160
Reliance Dental Mfg. Co. 1276
Replacement Parts Industries Inc. 565
RF America 1122
RF System Lab 675
RGP Dental Inc. 361
Rhode Island Novelty 1639
Ribbond Inc. 1223
Rode, Chas. W. Inc. 1232
Roque Orthodontic Laboratories Inc. 783
Rose Micro Solutions 1266
Rowpar Pharmaceuticals 1584
Royal Dental Mfg. 1240
Roydent Dental Products 873
Ruiz Dental Seminars 246
RX Honing (Sharpening) Machine 1633
Sacramento Dental 1258
Satelec 1172, 1268
Sav-A-Life Systems 369
Schultz Loupes 2144
Schumacher Dental Instruments 2161
SciCan Inc. 760
Scotts Dental Supply 230
SDI (North America) Inc. 2241
Septodont Inc. 110
SheerVision Inc. 1534
Shofu Dental Corporation 1128
Signature Resources 754
Sikka Software Corp. 384
Sirona Dental Systems 734
SmartPractice 2146
Smile Reminder 234
SolmeteX 2137
Soluna Medical LLC 882
SOTA Imaging 2461
Southland Distribution and Sales 2435
Space Maintainers Laboratory 1344
Splintek/SleepRight 2147
SS White Burs Inc. 1476
Staples Advantage 713
StarDental 1160
Star Refining London 852
Stericycle Inc. 353
Sterisil Inc. 769
Sterngold 2233
Straumann USA 1272
Sultan Healthcare 1116
Summit Dental Systems (SDS) 2165
Sun Dental Labs 116
Suni Medical Imaging Inc. 2056
Sunstar Americas 1134
SurgiTel/General Scientific Corp. 1480
Suter Dental Mfg. Co. Inc. 1538
Suvison Business Services 2547
Sybron Dental Specialties 1106, 1206
SybronEndo 1106, 1206
Symphony Metals 513
TCS Inc. 2060
TDIC MBC
TDIC Insurance Solutions MBC, 1432
Technology4Medicine 1580
Tekscan Inc. 567
TeleVox 2434
TePe Oral Health Care Inc. 1657
Tess Corporation 2129
The Afghanistan Dental Relief Project Inc. 772
The Childrens Dental Center 2544
of Greater Los Angeles
The Dentists Insurance Company MBC
The Suitcase Clinic 583
TheraSnore by Distar 608
THN Enterprises Inc. 677
Tokuyama America Inc. 341
TPC 366
TR Dental 1686
Tri County Dental Supply 217
Trident Dental Laboratories 686
Triodent Corporation 2256
Trojan Professional Services 1520
Tuttnauer USA Co. Ltd. 1740
UC Irvine, The Paul Merage School 2551
of Business
UCLA Dental Alumni Association 412
UCLA School of Dentistry 414
UCSD Student-Run Free Dental Clinic 2548
Ultradent Products Inc. 2134, 450, 550
Ultralight Optics 1381, 1631, 679
Uncommon USA Inc. 877
Unicare Biomedical Inc. 224
Uniform Management & 2164
Procurement Services Inc.
United Concordia Companies Inc. 248
United States Dental Tennis Association 266
Universal Orthodontic Lab 576
University of the Pacific, 410
Arthur A. Dugoni School of Dentistry
Upholstery Packages & Services 2131
US Navy Recruiting Command 120
USC School of Dentistry 509
Valley Dental Supply Inc. 1486
ValuMax International 2125
Vargas Dental 1258
Vatech 2356
Vector R & D Inc. 862
Velopex International Inc. 1587
VELscope - LED Dental Inc. 251
Vericom Co. Ltd. 879
Viade Products Inc. 507
VIDAR Systems Corporation 2444
Vident 428
Video Dental Concepts 665
Vista Dental Products 1725
Vivio Sites Inc. 468
VOCO America Inc. 2443, 355
Warrens Professional Service 1258
Water Pik Inc. 1616
WebVisible 876
West Coast Precious Metals 574
Western Society of Periodontology 2543
Westridge Builders/JOA Construction 278
Whip Mix Corporation 1736
White Towel Services 546
Wide Open Excursions 2462
Wiederman & Potter 2150
Premium Practice Sales
Wiltrace 250
WOW Oral Care 150
X Handpiece Systems Inc. 2160
XDR Radiology 2439
Xlear Inc./Spry 269
Yaeger Dental Supply 1258
Yates Motloid 480
YDM Corporation 856
Yodle 12542348
Young Dental 433
Zest Anchors Inc. 1181
Zila, a TOLMAR Company 602
Zimmer Dental 885
Zirc Company 259
ZOLL Medical Corporation 1472
MBC = CDA Member Benefits Center
ANA10_Exhib_List_Journal_April.indd 4 3/23/10 12:01 PM
Trswhite and Dazzling in Just 15 minutes!
Opalescence Trswhite Supreme 15% features:
15% hydrogen peroxide
15 minute wear-time
And, when you order at the show, a 15% discount!
Visit Ultradents booth 550 to learn more!
Booth 550 800.552.5512 www.ultradent.com
Present coupon to receive
$50 off a V3 Starter Pack!
The V3 Sectional Matrix System produces high-quality Class II composite restorations.
The nickel-titanium V3 Ring uses optimal separation force to achieve consistently tight
contacts with minimal fnishing. The V3 Starter Pack contains: 1 Universal V3 Ring,
1 Narrow V3 Ring, 2 Pin-Tweezers, 1 Forceps, 75 Wave-Wedges and 75 V3 Matrices.
Visit booth 2256 to redeem your voucher.
Booth 2256 800.811.3949 www.triodent.com
Selective Dentin Removal for Deep Lesion Dentistry
Buy 1 assortment pack of 25 Smartburs

II
Get (1) 10 pack of RA4, RA6, or RA8 Smartburs

II free
Smartburs

II can provide a conservative endpoint during excavation of highly infected carious dentin
while preserving underlying and potentially protective caries-affected dentin. Smartburs

II relies on dentin
hardness to provide an objective endpoint, and not staining which can be variable or absent.
Daniel W. Boston, DMD
Associate Dean for Clinical Comprehensive Care
Temple University Kornberg School of Dentistry
Booth 1476 800.535.2877 www.sswhiteburs.com
Win The New Apple iPad! Daily Drawings!
Friday & Saturday 5 p.m. - Sunday 1 p.m.
Name: __________________________________________
Address: _________________________________________
Phone: __________________________________________
Email: ___________________________________________
Booth 610 888.932.3644 www.prosites.com
Show Specials for CDA Presents in Anaheim, May 14-16, 2010
CDA Show Specials_2010.indd 1 3/23/10 11:25 AM
Show Specials
EXPAND YOUR INTERNET PRESENCE
by Tying Internet Technology Together
InfoStar offers a comprehensive search engine optimization (SEO) and social
network traffc builders that will signifcantly move your web page up in ranking.
We list you everywhere and link everything together so no matter where you are
found, your web page will beneft. We do everything for you as you experience cost
effective results. No contracts!
Booth 647 916.988.2323 www.infostardentalwebsites.com
See SIDEKICK animation in 3D
3D Patient Education without glasses
See this Amazing Product
A ONE-TIME Introductory Show Offer
Procedure animation that jumps off the screen to your patients delight. Become the talk
of the town with state-of-the-art 3D presentations. InfoStar has redeveloped its popular
SideKick program to allow a doctor to fully customize his/her own program. The SideKick
has added more exclusive features and of course, the SideKick is available in 3D.
Booth 647 916.988.2323 www.infostarproductions.com
NatureZone, Protect Your Patients Health
A growing number of studies have shown that removable dental appliances are the
perfect breeding place for bacteria and diseases. The NatureZone Purifcation Chamber
utilizes a combination of UV light and Ozone to sanitize and deodorize appliances
such as mouth guards, dentures, night guards, retainers, etc. In just one 3-minute cycle,
NatureZone kills 99.99% of pathogens including Staph, Methicillin-Resistant Staph
(MRSA), Salmonella, E.Coli, Strep and others. NatureZone uses no messy liquids,
astringents or tablets and its 8000 hour bulb life means years of reliable service.
Booth 2334 800.372.4346 www.henryscheindental.com
Now if it only came with smarty pants.
Visit CDAs Member Beneft Center and learn how to get your
Smart Dentist t-shirt. But hurry, we have a feeling they might go fast.
Booth 1107 866.232.6362 www.cdacompass.com
CDA Show Specials_2010.indd 5 3/23/10 11:25 AM
Show Specials
Stop by for a FREE Hand Sanitizer Sample!
Bring this coupon to our booth and receive a free sample of
our new Hand Sanitizer in a convenient travel-ready bottle
From the manufacturers of Septocaine

and NDurance

.
Booth 110 800.872.8305 www.septodontusa.com
Biolm Management with the Perio Protect Method
TM
The minimally invasive Perio Protect Method
TM
combines mechanical and
chemical therapies to disrupt bioflm growth. Attend a Perio Protect seminar
and learn how medications placed into periodontal pockets via a custom-formed
prescription tray help dissolve the bioflm matrix and modify the anaerobic
environment of pockets for signifcant pathogen reductions.
$100 discount on seminar or self-study tuition. Visit booth 1179.
Booth 1179 866.693.3400 www.perioprotect.com
PBHS Website Design
A better choice, for half the price! Why pay another frm twice as much for a
website that performs half as well? PBHS helps dentists promote their practice,
enhance offce productivity and better pre-educate their patients. Achieve
these goals with a Custom or Semi-Custom designed website. We will create an
affordable web presence that accommodates your premier dental practice.
Stop by booth 652 for a quick demonstration. Bring this coupon with you
for a $500 conference discount off of our regular website pricing.
Booth 652 800.840.5383 www.pbhs.com
Grow Your Practice With Invisalign

Take $200 off Introductory Training

Offer Invisalign and watch your practice grow! The frst step to becoming an
Invisalign provider is to attend Clear Essentials

I. Register for an upcoming

course near you during CDA Presents and take $200 off your registration fee.
Visit us at booth 210 today!
Booth 210 866.217.0293 www.invisalign.com
CDA Show Specials_2010.indd 3 3/23/10 11:25 AM
Show Specials
Get up to $1,000 Off a Single
DOCS Education Course!
Just for stopping by DOCS Educations booth, take advantage of the following
incredible discounts: $300 off Sedation Solutions, $400 off Oral Sedation Dentistry
or Pediatric Sedation Dentistry, and $1,000 off IV Sedation for Dentistry. Dont miss
this valuable opportunity! Come visit the DOCS Education booth 371 to fnd out
how you can expand your practice and increase proftability.
Booth 371 866.592.9619 www.docseducation.org
New, New, Nuance: It Looks Different Because It Is
Nuance is the new ultra-simple restorative system from Discus Dental. No more
complex layering since its sub-micron particles perfectly mimic opacity and
translucency and blend well with shading of the surrounding teeth. Nuance
also boasts a smooth, butter-like consistency that guarantees effortless handling
and sculpting. Not only that, the unique syringe design has a ergonomic feel for
maximum comfort, twist-and-click technology for precise measurements, and hinged
cap that conveniently keeps contents fresh for multiple applications. Visit the
Discus booth to try it for yourself.
Booth 134 800.422.9448 www.discusdental.com
Protecting dentists. Its all we do.
Visit TDIC at the Member Beneft Center to learn
how weve been protecting dentists for 30 years.
And while youre there enter to win a free iPad.
Booth 1107 800.733.0633 www.tdicsolutions.com
Free
iPad
FREE* BruxZir

Solid Zirconia Crown

Patient Presentation Sample
Finally, a tooth-colored restoration indicated for bruxing patients. Find out what the
buzz is all about when you visit booth 1444 during the 2010 CDA Convention.
Well give you a free BruxZir

patient presentation sample just for stopping by.

* Quantities limited. No rainchecks. Must present card May 13-16, 2010, during the CDA Convention
for free sample. One card per visitor.
Booth 1444 800.854.7256 www.glidewelldental.com
CDA Show Specials_2010.indd 7 3/23/10 11:25 AM
Show Specials
Protecting dentists. Its all we do.
Visit TDIC at the Member Beneft Center to get a no obligation insurance quote
and learn about the ultimate in protection.
Because we were founded by dentists, and protecting dentists is all we do, were experts
on the coverage youll need to protect your practice and everything else that matters.
Booth 1107 800.733.0633 www.tdicsolutions.com
Ashtel Dental Oral Care
FREE Gift with Purchase
Visit us at booth 577 for all of your oral care needs. Come see our Brush Buddies
talking timer toothbrushes, the fun way to get kids brushing. We offer a variety of
oral care products, including adult, teen, and pedo toothbrushes, disposable and
prepasted toothbrushes, dental foss, hygiene kits, and ortho kits.
Booth 577 866.274.8351 www.ashteldental.com/oralcare
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Thank You AD_ANA10.indd 1 3/19/10 11:12 AM
cda j ournal , vol 38 , n

4
ap ri l 201 0243
i n t r o d u c t i o n
hy arguc this distinction` Impropcrly applicd
tcrminology always contributcs to misintcr
prctation o thc litcraturc and scicntic con
usion. Sincc thc tooth is thc only structurc
that pcnctratcs thc intcgrity o thc cpithclial
barricr, it is thc point o acccss or a myriad o microbial inva
sions. It is thc pcriodontium, thc invcsting organ o thc tooth
that is thc sitc o intcractions bctwccn thc host immunc
systcm and thc microbcs. In thc past cw dccadcs, it has bc
comc incrcasingly clcar that pcriodontal discascs arc thc rcsult
o both bactcrial activitics and thc hosts immunc rcsponsc
to thc incction. It is this inammatory host rcsponsc and
rcsulting proinammatory mcdiators that arc rcsponsiblc or
thc tissuc changcs that occur in pcriodontal discascs. Fur
thcrmorc, this is thc prcdominatc sourcc o thc inammatory
load rom thc oral cnvironmcnt. In rcccnt ycars, numcrous
cpidcmiological studics havc suggcstcd thc association bc
twccn chronic pcriodontitis and scvcral systcmic discascs.
Fvidcncc now suggcsts that thc proinammatory mcdia
tors in pcriodontal discasc arc thc samc mcdiators involvcd
in pathologic proccss such as myocardial inarction, strokc,
diabctcs, rhcumatoid arthritis, and Alzhcimcrs discasc. In this
issuc, thc authors hclp dcntal practitioncrs undcrstand thc ncw
paradigm o pcriodontal discasc and its rclationship to systcmic
guest editor
Richard T. Kao, dds, phd,
is an associate clinical
professor, University of
California, San Francisco;
associate adjunct
professor at Arthur
A. Dugoni School of
Dentistry, San Francisco;
and in private practice in
Cupertino, Calif.
hcalth. Furthcrmorc, thcsc articlcs makc
it clcar that dcntal carc docs not start
and cnd in thc mouth, but rathcr propcr
clinical managcmcnt o a paticnts hcalth
rcquircs us to bc dcnitivc and vigilant
in thc managcmcnt o our paticnts
pcriodontal conditions. Cuidclincs
and rccommcndations arc discusscd.
In thc rst articlc, Lr. Michacl Rcth
man cxamincs how our undcrstanding
o inammation has changcd sincc our
dcntal school immunology courscs. Hc
updatcs us on thc currcnt undcrstand
ing o inammation and summarizcs
thc ndings rom thc Amcrican Acad
cmy o Pcriodontology concrcncc on
inammation. Utilizing this inorma
tional oundation, Lr. Rcthman discusscs
scvcral kcy aspccts o thc pcriodontal
inammatory rcsponsc that may bc
rclatcd to scvcral systcmic discascs.
In thc sccond articlc, Lr. Lavid Rich
ards intcrvicws Lr. Kcnncth Kornman, cd
itor o thc oarnc| o/ Per|oion|o|og,, on thc
During the past ve years, there has been a plethora of publications
touting the importance of how inammation in the mouth may
be linked to systemic health and disease. Some of these articles have
labeled this link as the oral-systemic link. In this issue, the case is
argued that these interactions should more appropriately be labeled
as the perio-systemic link.
its perio-systemic link;
Oral-Systemic Link Is a Misnomer
richard t. kao, dds, phd
W
244ap ri l 201 0
cda j ournal , vol 38 , n

4
association bctwccn cardiovascular discasc
and pcriodontal inammation. Tis articlc
dctails how our undcrstanding o this
association has cvolvcd, what is thc ncccs
sary cvidcncc to dcmonstratc thc rclation
ship is causativc, and cxplorc somc o thc
practical and thcorctical implications. Tis
discussion will hclp thc rcadcrship undcr
stand thc important dicrcncc bctwccn an
association vcrsus a causativc or ctiologic
rolc. Tc cost and thc study dcsign may
prohibit thc dcnitivc answcr. Ncvcrthc
lcss, it is important or clinicians to undcr
stand this issuc sincc it will bc an impor
tant convcrsation topic whcn our paticnts
approach us with thcir undcrstanding
misundcrstandings on this subjcct.
Civcn thcsc associations bctwccn
pcriodontal inammation and systcmic
discasc, why arc pcriodontal discascs
misdiagnoscd or undcrdiagnoscd` In thc
third articlc, collcagucs and I discuss somc
o thc clinical challcngcs in thc diagnosing
and monitoring o pcriodontal inam
mation. Potcntial diagnostic problcms
and possiblc rcsolutions arc discusscd.
Iastly, Lr. Stcvcn Schoncld rcvicws
ccctivc stratcgics or managing pcri
odontal inammation. Hc providcs a mas
tcr clinicians vicw o practical stratcgics
or pcriodontal thcrapy, as wcll as rcvicws
thc issuc o statistically vcrsus clinically
signicant approachcs to thcrapy. Lr.
Schoncld wraps up his discussion with
somc insights as to cmcrging tcchnol
ogy or controlling inammation.
Tcsc oarnc| articlcs mark a pivotal
timc in our procssion. Our procssional
rcsponsibilitics havc clcarly bccn cxpandcd
such that wc now morc than cvcr nccd to
work with physicians in hclping our paticnt
control thcir inammatory load. By doing
so, wc contributc to our paticnts ovcrall
hcalth. As our undcrstanding o thc
pcriosystcmic link cxpands and intcrccp
tivc thcrapy cmcrgcs, it impcrativc that as
rcsponsiblc hcalth carc providcrs wc stay
abrcast o this topic.

P R E S E N T S
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well as more functionality. With searchable
exhibitor specials, available class schedules, photo
galleries, and travel accommodations, planning for
the nations premier dental conventions
in Anaheim, or San Francisco,
has become a virtual snap.
We, the Members of the California Society of Periodontists, seek to achieve optimal dental
health for our patients. We work with our dental colleagues in an atmosphere of mutual respect, cooperation,
trust and good will. When your patients require a periodontal specialist, we ask you to select one of the follow-
ing CSP Members to care for their periodontal needs. For more information on our Members including oce
location, phone numbers, website and email , please visit our website: www.calperio.org. Tank you. We are:
California Society of Periodontists

P.O. Box 7875

Norco

CA 92860

951-371-4321

FAX 951-371-7055
Te California Society of Periodontists is registered as a referral agency with the State Board of Dental Examiners
and makes referrals for periodontal care exclusively to members of this organization.
Abe, Kenneth, DDS
Abelson, Michael, DDS, MS
Abulhasan, Marwa, DMD
Adamich, Thomas, DDS
Ahmad, Dean, DDS, FICOA, DABP
Ahn, Brand, DDS
Aldredge, Wayne, DMD
Allen, Marshall, DDS
Alpagot, Tamer, DDS, PhD
Amaya, Ana, DDS, MS
Amid, David, DDS
Anderson, Jed, DDS
Angel, Leo, DDS
Angha, Sarvenaz, DDS
Anson, David, DDS
Arndt, Dennis, DMD
Arzouman, Michael, DDS
Aslam, Sheryar, DDS
Avera, Sean, DDS
Bahat, Oded, BDS, MSD
Bains, Rena, DDS
Baker, Thomas, DDS
Barkordar, Rahmat, DMD
Beck, Tina, DDS
Beckstead, Mark, DDS
Benia, Todd, DMD, MScD
Benveniste, Richard, DDS, MSD
Berrin, Robin, DDS
Borchers, Steven, DDS
Bounds, Steven, DDS, MS
Bourcy, Bradley, DDS
Boyle, Donald, DDS
Brown, Donald, DDS
Browning, Richard, DDS, MS
Caballero, Mario, DDS
Calvert, Dennis, DDS
Camargo, Paulo, DDS, MS
Caplanis, Nicholas, DMD, MS
Cargasacchi, John, DDS
Carlton, Dana, DDS, MS
Carson, John, DDS, MS
Chang, Huei-Ling, DMD
Charles, Allan, DDS
Chen, P Kevin, DMD, MS
Chen, Carol Tzu-Ling, DDS
Chertok, Keith, DDS
Chiu, Ching-Hsu Ketty, DDS
Choi, Myung Soo, DDS
Choi, Jae, DDS
Chrispens, John, DDS
Clark, Jennifer, DDS
Clem, Donald, DDS
Cole, Byron, DDS
Consani, Kevin, DDS, MS
Conte, Gregory, DMD
Corradi, David, DDS
Criveanu, Beatrice, DDS
Dang, Calvin, DDS
Dault, Scott, DDS
deSanz, Sarah, DDS
Detsch, Steven, DDS
Dianati, Mehrnoosh, DDS
Dienstein, Benjamin, DDS, MS
Dornan, Donald, DDS, MS
Dougherty, Mark, DDS
Douglass, Gordon, DDS
Drury, Gerald, DDS, MS
Ducar, John, DDS
Dunlap, Robert, DDS
Elkhoury, Jad, DDS, MS
Elliott, John, DDS
Ellis, Ryan, DDS, MS
Engdahl, Karl, DDS
Erickson, Graig, DDS
Evans, Corwin, DDS
Fagan, Mark, DDS, MS
Fakheri, Pedram, DMD
Farahmand, Arta, DDS
Filippi, Clarke, DDS
Finney, Debra, DDS
Fleming, Jeffrey, DDS, MS
Flores, Jun, DDS
Ford, Christine, DDS
Freed, Harvey, DDS
Frostad, Kenneth, DDS
Fuentes, J Paul, DDS
Gabany, Joseph, DMD
Gaffaney, Thomas, DDS
Gara, George, DDS
Gilani, Sam, DMD, MS
Godfrey, Valerie, DDS, MS
Golden, Tracy, DMD
Gonzalez, Veronica, DDS
Gordon, Jonathan, DDS
Gordon, Randall, DDS, MS
Goroski, Patrick, DDS
Grasu, Rodica, DDS, MS
Green, Martyn, DDS
Greenberg, Lionel, DDS
Grippo, William, DDS
Gross, Marc, DDS
Guglielmoni, Paolo, DDS, MS
Gurrola, Randy, DDS
Habekost, Charles, DDS
Hakimi, Nicky, DDS
Hame, Ewa, DDS
Hame, Homayoon Marcus, DDS
Han, Thomas, DDS, MS
Haney, J Marc, DDS, MS
Harandi, Kourosh, DDS, MS
Harmeson, Raynor, DDS
Hart, Rebecca, DDS
Hartman, Philip, DDS
Hassan, Mohamed, DDS
Hayashi, Christine, DDS, MS
Hayashi, Ellen, DDS
Heitman, Mercedes, DDS
Henkin, Jeffrey, DDS, MS
Henriod, Joel, DDS
Herrera, Casey, DDS
Hirst, Robert, DDS, MS
Ho, Humphrey, DDS
Hoang, Taylor, DDS
Hoang, Tram, DDS, MS
Hollander, Brian, DDS, MS
Holpuch, Russell, DDS
Hsu, Anna, DDS
Hu, Qizhi, DDS
Huaman, Evelyn, DDS
Hunt, Brad, DDS
Hunter, Ronald, DDS
Huston, Patrick, DDS
Huynh, Quang, DDS
Hymes, Robert, DDS
Im, Terry, DDS
Imberman, Michael, DMD
Inouye, Allen, DDS
Iskandar, Irma, DMD
Javadi, Hamed, DDS
Javadi, Elham, DDS
Johansen, Niels, DDS, MSD
John, Stephen, DDS
Johnson, Bruce, DMD
Johnstone, Dale, DDS
Jolkovsky, David, DMD, MS
Jones, Jr., James, DDS, MS
Kallaos, Stephen, DDS
Kaminsky, Steven, DMD
Kanemura, Gary, DDS
Kania, Ann, DDS, DMedSc
Kao, Richard, DDS, PhD
Kao, David, DDS
Kar, Kian, DDS
Keeley, Patrick, DMD
Kelk, Pichak, DDS
Kenney, E. Barry, DDS
Kepic, Thomas, DDS, MSD
Kheirkhahi, Ellie, DDS, MSD
Kim, Luis, DDS, MS
Kim, Alexander, DDS
Kim, Clara, DMD
Kim, Andrew, DDS
Kinder-Haake, Susan, DMD, PhD
King, Sanford, DDS
Kitazawa, Gary, DDS
Klokkevold, Perry, DDS, MS
Korchek, David, DMD
Krivitsky, Alina, DDS
Kunihira, Daniel, DDS
Kwan, John, DDS
Lagos, Rodrigo, DDS, MS
Laksmana, Theresa, DMD
Lamb, Robert, DDS, MSD
Lampley, Jana, DDS
Lane, Judith, DDS
Lang, Kenneth, DDS
Lara-Cordoba, Monica, DMedSc
Lascoe, Ronald, DMD
Lee, Leland, DDS
Lee, Nancy, DDS
Lee, Victor, DDS
Levine, Stephen, DDS
Levy, Ori, DDS
Lewis, John, DMD, MS
Lewis, Brenda, DDS
Lim, Barney, DDS
Lim, Semi, DMD
Lipson, David, DDS
Litch, Joyce, DDS
Lofthus, John, DDS
Loomer, Peter, DDS, PhD
Lott, Wallace, DD
Low, Howard, DDS
Lyford, Robert, DDS
Ma, Wenge, DDS
Malekzadeh, Reza, DDS
Manesh, Al, DMD
Marsden, J Philip, BDS, MSD
Martin, Eric, DDS, MS
Martin, Dwyane, DDS, MS
Martinez, Frank, DDS
Mata, James, DDS
Matoska, William, DDS
Mazza, John, DDS
McCallion, Russell, DDS
McGregor, Adriana, DDS
Melnick, Philip, DMD
Mendieta, Carlene, DDS
Merin, Robert, DDS, MS
Mihram, William, DDS, MSD
Millard, Garry, DDS
Miller, Ronald, DDS
Miller, Todd, DDS
Milliken, Scott, DDS, MS
Mintzer, Roy, DDS
Minutello, James, DDS
Moffson, Allen, DMD
Moloyern, Shervin, DDS
Moncada, F. Ray, DDS
Moran, Alice, DMD
Morishita, Wilson, DDS
Mukai, Craig, DDS
Mullin, David, DDS
Murray, Patricia, DMD
Nagy, Richard, DDS
Nalley, Todd, DDS, MS
Nattkemper, Lloyd, DDS
Naval, Francie, DDS
Neacy, Kit, DDS
Nelson, Daniel, DDS
Newhouse, Nancy, DDS, MS
Nguyen, Susan, DDS, MSD
Nishimine, Dee, DDS
Nishimine, Dennis, DDS, MSD
Niver, Franklin, DMD, MS
Niver, Eric, DDS
Nowzari, Hessam, DDS, PhD
Okui, Matthew, DDS
Onea, Dorel, DDS, MS
Oren, Menachem, DMD
Otomo-Corgel, Joan, DDS, MPH
Owyoung, Jeremy, DDS
Partovi, Farangis, DDS
Pattison, Gordon, DDS
Pechak, Jochen, DDS, MS
Penhaskashi, Alfred, DDS
Peterson, Jon, DDS
Phillips, Michelle, DDS
Pickering, Stephen, DDS, MSD
Piehl, Joel, DDS
Pieroni, Gerald, DDS
Pope, Bryan, DMD, MS
Poulos, Louis, DDS
Pretel, Robert, DDS
Pucher, Jeffery, DDS
Raee, Ra, DDS
Rathbun, W. Eugene, DDS
Rayant, Garry, DDS, MS
Razi, Saghi, DDS, MS
Rees, William, DDS
Reid, Stephen, DDS
Rezvan, Ehsan, DDS, MS
Rhee, Hyon, DDS
Riccoboni, Frank, DDS, MS
Rice, Denine, DDS, MS
Richards, David, DDS, PhD
Roberts, Daniel, DDS
Roberts, Judson, DDS
Roitman, Igor, DMD
Roman, Karla, DMD
Roncone, Tinou, DDS, MS
Ronderos, Mauricio, DDS, MS
Rosenblatt, Ari, DDS, DMD
Ross, Stanley, DDS
Rubinoff, Craig, DDS, MS
Russo, Peter, DDS
Rustamzadeh, David, DDS, MSD
Ryder, Mark, DMD
Saghizadeh, Mahasti, DDS
Sahl, Erik, DDS
Salha, Wesam, DDS
Salzman, Jay, DDS
Samsani, Elaheh, DDS
Sanders, Richard, DDS, MScD
Schiller, Lary, DDS
Schonfeld, Steven, DDS, PhD
Schultz, Allen, DDS
Setya, Ajay, DDS, MSD
Sha, Sahar, DDS
Shanelec, Dennis, DDS
Shellow, Roy, DDS
Shepard, Wayne, DDS
Shepherd, Stephen, DDS
Shirazi, Hamid, DDS
Silliman, Cathleen, DDS
Silverstein, Irvin, DDS, MS
Simonds, James, DMD
Sims, Thomas, DDS
Sin, Elisa, DMD
Sinks, James, DDS
Smith, Scott, DDS
Smith, Stephen, DDS
Smith, Neetal, DDS
Sobel, Robert, DDS
Soleiman, Bobby, DDS
Sottosanti, John, DDS
Spector, Sidney, DDS
Speert, Paul, DDS
State, Caton, DDS
Synowski, Blake, DMD
Szymanowski, Jonathan, DMD, MMSc
Szymanowski, Casimir, DDS
Tagge, David, DDS, MSD
Takei, Henry, DDS
Tam, Yvonne, DDS
Tandy, Robert, DDS, MS
Temlock, Alec, DMD
Tom, Alex, DDS
Towghi, Pedram, DDS, MS
Townsend, Bradley, DDS, MS
Trujilo, Israel, DDS
Uemura, Jay, DDS
Ueno, Jeremy, DMD
Vahey, Edward, DMD, MS
Valenzuela, Oscar, DDS
Vanderheyden, Paul, DDS
Vandersloot, Ralph, DDS, MS
VanVolkinburg, James, DDS
Verdi, Sahar, DDS
Wakabayashi, Robin, DDS, MS
Wardlaw, David, DDS
Warshawsky, Peter, DDS
Wasemiller, Michael, DDS
Wasserstein, Jack, DDS
Waterman, Jeffrey, DDS
Weaver, Russell, DDS
Wedner, Irwin, DDS
Weinstock, Alfred, DDS
Wells, Richard, DDS
Westbrook, Perry, DMD
Westbury, Lawrence, DDS
Wetzel, Matthew, DDS
Wilgus, Jeremy, DDS
Wootton, Barry, DDS
Workman, Parker, DMD, MS
Wright, E. Clark, DDS, MSBD
Wright, Peter, DDS
Wu, Rosemary, DMD, MS
Yen, Nelson, DDS
Yonemura, Craig, DDS
Zinman, Edwin, DDS
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cda j ournal , vol 38 , n

4
ap ri l 2 01 0247
Inflammation in
Chronic Periodontitis
and Significant
Systemic Diseases
michael p. rethman, dds, ms
abstractEndogenous chemical mediators play seminal roles in the initiation,
persistence, and resolution of inammation. Recent studies have revealed parallels
between inammatory mediators and mechanisms common to oral and systemic
diseases. These relationships imply that novel therapeutics that profoundly modulate
inammatory mediators may improve clinical outcomes. Key source for this article
is a 2008 conference reported in a Journal of Periodontology supplement titled
Proceedings of the 2008 Workshop on Inammation; Inammation and Periodontal
Diseases: A Reappraisal.
The Immune System
1-3
nammation consists o biochcmi
cal and ccllular proccsscs initiatcd by
tissuc irritation, injury, or incction.
Ncarby capillarics, solublc protcins
and inammatory cclls rcspond to
chcmical signaling and cdcma rcsults.
Inammatory cclls arc attractcd rom
ncarby tissucs and blood. Complcx cas
cadcs bcgin that arc aimcd at acilitating
thc dcstruction and rcmoval o orcign
organisms, rcmoval and rcplaccmcnt o
nccrotic cclls and damagcd structural
componcnts, all aimcd at thc cvcntual rcs
toration o tissuc homcostasis and hcalth.
Inammation also activatcs othcr
componcnts o thc immunc systcm and
may providc unctional capabilitics or
thcsc systcms. Indccd, many o thc morc
primitivc mcchanisms o thc inammatory
rcsponsc, such as lytic protcins collcctivcly
namcd complcmcnt, arc tools that arc uscd
i n f l a mmat i o n
by morc targctcd immunc mcchanisms
that dcvclopcd latcr in cvolution. Unortu
natcly, somc o thcsc tools, although usu
ally adcquatc to thc task at hand, arc otcn
not idcal. Many aspccts o inammation
arc nonspccic in thcir actions and can
damagc or dcstroy important host tissucs
whilc attcmpting to rcstorc homcostasis.
Fxamplcs includc thc pcriodontal ligamcnt
in pcriodontitis, and joint componcnts
in rhcumatic arthritis. Furthcrmorc,
inammation may ncvcr ully succccd
at rcstoring tissuc hcalthhomcostasis
and chronic inammation may rcsult.
To bcttcr undcrstand thc contcxt
or inammation as part o thc immunc
systcm, its important to rccall a basic
undcrstanding o cntirc immunc systcm
itscl. Tcrcorc, two gcncral divisions
o thc immunc systcm will bc dcscribcd,
namcly thc innatc, or nonspccic, and
adaptivc, or spccic, componcnts.
author
Michael P. Rethman,
dds, ms, is a periodontist
in Kaneohe, Hawaii; a
diplomate, American
Board of Periodontology;
and an adjunct assistant
professor at both the
College of Dentistry, The
Ohio State University, and
at Baltimore College of
Dental Surgery, University
of Maryland.
I
248ap ri l 201 0
cda j ournal , vol 38 , n

4
tcs and scvcral typcs o skin disordcrs.)
Tcclls arc morc typically activatcd by thc
prcscntation o a proccsscd antigcn.
Although many ccll typcs can prcscnt
antigcns, dcrmal dcndritic cclls, ccrtain
Bcclls, and macrophagcs play kcy rolcs.
Lcndritic cclls arc commonly ound in thc
cpithclium, including thc oral mucosa.
Prcscntation cclls proccss antigcnic
protcins and prcscnt pcptidcs to Tcclls
rcsiding in ncarby lymph nodcs. \hcn a
propcr match is madc, Tcclls prolicratc
and attack invadcrs that display thc spc
cic antigcnic pcptidcs on thcir ccll mcm
brancs. Unortunatcly, this cxquisitc sys
tcm is not always pcrcct. Tis is bccausc
proccsscd antigcns similar to protcins
displaycd by a hosts cclls arc thought
rcsponsiblc or many autoimmunc
discascs (c.g., rhcumatic hcart discasc).
Genes, Epigenetics and
Gene-Environment Interactions
in Inammation and Disease
Ccncs, also known as allclcs, unc
tion as thc primary blucprints or
protcins rcsponsiblc or thc anatomy
and unctionality o cach organism.
Tc c,ccc human gcncs consist o
dcoxyribonuclcic acid (LNA) polymcrs.
LNA molcculcs contain thrccunit
nuclcotidc scqucnccs that codc or
thc .c amino acids uscd to producc all
human protcins. Only a small raction
o cach LNA molcculc is known to
contain gcncs, thc rcmaindcr appcars
to havc othcr physiological unctions
that arc as yct not wcll undcrstood.
Human LNAs iconic doublc hclix
is usually coilcd around protcin com
plcxcs callcd histoncs. LNAhistonc
complcxcs orm chromatin packagcd
into . pairs o chromosomcs. Tc gcncs
thcmsclvcs, cpigcnctic actors, and
gcnccnvironmcnt intcractions all havc
rolcs in inammation and discasc.
Bcclls producc antibodics and rcmain
quicsccnt until bccoming ully activatcd
by a spccic antigcn whosc molccular
structurc docks with a uniquc antigcn
rcccptor complcx on thc Bccll suracc.
Oncc a Bccll cncountcrs its match
ing antigcn and rcccivcs an additional
signal rom a Thclpcr ccll, it can urthcr
dicrcntiatc into a plasma Bccll or a
mcmory Bccll. Tc ormcr produccs
prodigious amounts o antibodics that
quickly bind to invading cclls that display
a matching antigcn and thcrcby acilitatc
Tc innatc immunc systcm consists
o cvolutionary oldcr mcchanisms that
rcspond locally and immcdiatcly to
incction or trauma. A kcy caturc o thc
innatc immunc systcm caturc is complc
mcnt. Tc solublc protcin componcnts o
complcmcnt circulatc in thc scrum and
may bc activatcd by numcrous pathways.
Bactcria thcmsclvcs can dircctly activatc
thc complcmcnt. \hcn activatcd, complc
mcnt protcins sclasscmblc into porclikc
tubular structurcs that can pcnctratc bac
tcrial mcmbrancs causing thcm to pcrish.
Although bactcria thcmsclvcs can activatc
thc complcmcnt, thc complcmcnt is also
an important cxamplc o an innatc capa
bility that can bc activatcd or amplicd
by othcr immunc systcm componcnts.
Using chcmical signals callcd cytokincs,
thc innatc systcm rccruits immunc cclls, ac
tivatcs complcmcnt, acilitatcs thc rcmoval
o orcign substanccs, and activatcs thc
adaptivc immunc systcm. Phagocytic im
munc cclls such as ncutrophils, monocytcs,
and macrophagcs rclcasc cytokincs tcrmcd
intcrlcukins that in turn play othcr rolcs in
cluding thc clcaring o pathogcns or mark
ing thcm or dcstruction by othcr cclls.
Tc adaptivc immunc systcm ampli
cs thc capabilitics o thc innatc immunc
systcm bccausc it is ablc to distinguish
bctwccn host and orcign substanccs. Tis
systcm is highly adaptablc bccausc o an
cxquisitcly rcncd gcnctic mcchanism that
pcrmits a small numbcr o gcncs to gcncr
atc a vast numbcr o dicrcnt antigcn
rcccptors, cach o which is uniqucly cx
prcsscd on individual lymphocytcs. \hcn
challcngcd by a spccic antigcn, such
lymphocytcs arc activatcd. Howcvcr, thcrc
arc unctionally and anatomically distinct
Tlymphocytc (Tccll) and Blymphocytc
(Bccll) systcms. Bcclls originatc in bonc
marrow, inhabit thc splccn, and circu
latc in thc blood. Tcclls originatc in thc
thymus and rcsidc in thc lymph nodcs.
thcir climination via a numbcr o mccha
nisms, including acilitatcd phagocytosis
and complcmcntmcdiatcd lysis. Mcmory
Bcclls arc longlivcd and unction as
promptrcspondcrs to assurc a quick
and ovcrwhclming antibody rcsponsc
should thc samc antigcn bc dctcctcd
again. Most vaccincs takc advantagc
o this aspcct o Blymphocytcs.
Unlikc Bcclls, Tcclls ail to rccognizc
antigcn in thc abscncc o a ormalizcd
antigcn prcscntation, with thc important
cxccption o supcrantigcns that can trig
gcr a Tccll rcsponsc much morc dircctly.
(Many bactcria producc supcrantigcns,
including thc normally nonoral 3|c|,|o
.o..as careas and 3|re|o.o..as ,ogenes.
Supcrantigcns may causc scrious acutc
and chronic discascs including toxic shock
syndromc, rhcumatoid arthritis, diabc
when activated,
complement proteins
self-assemble into
pore-like tubular structures
that can penetrate bacterial
membranes causing
them to perish.
i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 201 0249
thc two X chromosomcs in cmalcs and
thc monoallcic cxprcssion o ccrtain rcgu
latory gcncs (c.g., insulin growth actor.
cxprcsscd rom thc patcrnal gcnc only).
Fpigcnctic changcs arc likcly causcs
o thc incrcascd rcqucncy o autoim
munc and ncoplastic with incrcasing
agc. Indccd, studics in aging monozy
gotic twins rcvcal incrcasing cpigcnctic
dicrcnccs apparcntly rcsulting rom
cnvironmcntal inucnccs (figure 1).
Acctylation o histonc protcins and
mcthylation o LNA arc two ccntral
cpigcnctic mcchanisms. Tc ormcr
rclaxcs histonc structurcs thcrcby
cncouraging gcnc cxprcssion by mak
ing thc LNA morc acccssiblc or gcnc
transcription. On thc othcr hand, LNA
mcthylation inhibits transcription.
Although cpigcnctics is an cmcrging
cld o study in inammation rcscarch,
somc activitics havc bccn idcnticd.
Fxpcrimcnts cxamincd thc gcnc
spccic control o lipopolysaccharidc
(IPS) induccd tolcrancc by chromatin.
8

(Many bactcrial spccics associatcd with
to how gcncs arc activatcd.

\hat this
mcans is that cvcry human ccll has thc
samc instruction manual, but dicrcnt
ccll typcs arc using dicrcnt chaptcrs.
For cxamplc, thc sccrctory cclls in thc pa
rotid gland contain thc LNA instructions
ncccssary to makc bonc, but or thcsc
cclls and most othcrs, thc bonc gcncs
arc turncd o. Fpigcnctic changcs arc prc
scrvcd whcn cclls dividc but most cpigc
nctic changcs only occur within thc coursc
o an individual organisms lictimc.
/
Ncw cvidcncc suggcsts kcy rolcs
or cpigcnctics in human pathologics,
including inammatory and ncoplastic
disordcrs. Tc cpigcnomc is inucnccd
by cnvironmcntal actors throughout lic.
Nutritional actors can havc proound cpi
gcnctic cccts on thc cxprcssion o spc
cic gcncs and thcsc traits can bc passcd
on to subscqucnt gcncrations o cclls.
Somc canccrs arc associatcd with altcrcd
cpigcnctic prolcs that lcad to altcrcd cx
prcssion o gcncs involvcd in ccll growth
or dicrcntiation. Fpigcnctic changcs arc
ncccssary or thc inactivation o onc o
Gene-Caused Diseases
Tcrc arc dozcns o gcnccauscd
disordcrs such as hcmophilia A and sicklc
ccll ancmia. Tc lattcr is a gcnccauscd
discasc that rcsults rom a singlc nuclc
otidc variation that appcars in ccrtain
individuals in whom thc amino acid valinc
rcplaccs glutamatc in a componcnt o
hcmoglobin. Individuals who inhcrit this
gcnctic variation rom both parcnts lcad
shortcr livcs and arc pronc to scrious
vascular problcms whcn thcir rcd blood
cclls assumc sicklc shapcs. Howcvcr,
consistcnt with cvolutionary prcssurcs
that acct human gcncs, childrcn who
inhcrit thc variant allclc rom only onc
parcnt arc substantially lcss likcly to incur
licthrcatcning malarial incctions.

Epigenetics and Disease

5
Fvcry ccll with a nuclcus contains all
o an organisms gcncs. Howcvcr, or cclls
to spccializc as ncrvc cclls, cpithclial cclls,
musclc cclls, ctc., gcnc activity must bc
rcgulatcd. Fpigcnctics considcrcd ccrtain
typcs o chcmical modications rclcvant
epi genotype
(birth)
geneti cs
epi genotype
(adult)
Maternal Factors Diet Toxins Aging
In Utero Nutrition Toxins/Drugs Illness
Diseases
Including Cancer
fi gure 1. The epigenome changes in response to various environmental stimuli. Smoking, illnesses, drugs, diet, age, and in utero nutrition may aect the epigenetic signature to
varying degrees at dierent points in development. Induced epigenetic modications may be passed on to subsequent cell generations with potentially detrimental eects. Reprinted
with permission from the American Academy of Periodontology 79:1517, 2008.
Environmental Changes Aecting the Epigenome
250ap ri l 201 0
cda j ournal , vol 38 , n

4
rcvcalcd that a dict high in plant oods,
olivc oil, and modcratc winc intakc
(but low in mcat and dairy products)
was cardioprotcctivc cvcn in individu
als with high CPS scorcs (figure 2).
MctS is a constcllation o abnor
malitics, gcncrally considcrcd to includc
abdominal obcsity, high blood glucosc
impaircd glucosc tolcrancc, dyslipidcmia,
and high blood prcssurc. Togcthcr thcsc
incrcasc thc risk or typc . diabctcs
and cardiovascular discasc. A growing
body o cvidcncc rom cxpcrimcntal
and cpidcmiologic studics suggcsts that
a ncxus o all thcsc abnormalitics is a
proinammatory statc. Tc hypothcsis
that chronic lowlcvcl inammation
undcrlics thc pathophysology o MctS
is supportcd by thc nding that as thc
charactcristics o MctS risc in a popu
lation, plasma conccntrations o pro
inammatory markcrs, high scnsitivity
Crcactivc protcin (CRP) and II, also
incrcasc, as thc conccntration o adi
poncctin (an adipocytcdcrivcd protcin
important in glucosc rcgulation and
atty acid (FA) catabolism) dccrcascs.
individuals rcspond dicrcntly to drugs
and dict. Lcspitc tightly controllcd condi
tions, dictary intcrvcntions to rcducc
scrum cholcstcrol dcmonstratc widc
ranging yct modcst avcragc cccts. Tc
widc rangc o cccts is cncouraging, cs
pccially or thosc with a gcnotypc that is
highly rcsponsivc. Howcvcr, thc middling
avcragc rcsponsc suggcsts signicant
gcnctic complcxity undcrlying common
clinical phcnotypcs such as thosc with
high cholcstcrol. In rcccnt ycars, thc
complcxity o gcnctic bascs or typc . dia
bctcs has suggcstcd that many gcncs play
rolcs making it ncarly impossiblc to study
thc cccts o any singlc gcnc bccausc
o cach gcncs rclativcly small ccct.
A rcccnt study scorcd and rankcd
individuals by gcnctic prcdisposition
scorcs (CPS) bascd on ccrtain candidatc
gcncs, somc o which producc cytokincs
involvcd in inammation (c.g., IIr
II and TNF).
rc
Tc incidcncc o myo
cardial inarction was asscsscd. Tcsc
rcsults suggcst a gcnctic thrcshold or
prcdisposition to myocardial inarction.
Tis study was also important bccausc it
pcriodontitis producc IPS.) Although
macrophagcs rcspondcd to IPS stimula
tion, thcy bccomc hyporcsponsivc upon
rcpcat IPS stimulation. Two distinct
pattcrns o chromosomal modications
occurrcd during this hyporcsponsivc
statc. A group o gcncs rcsponsiblc or
inammatory molcculc production
(c.g., TNF and II) was transicntly
silcnccd (i.c., tolcrizcd). A sccond
group o gcncs that includcs various
antimicrobial capabilitics rcmaincd
nontolcrizcd. O notc is that tolcriza
tion sccms to limit additional pathology
associatcd with cxccssivc inammation,
whcrcas nontolcrizcd gcncs continuc
to producc antimicrobial cnzymcs
that can do morc harm than good.
Gene-Environmental Interactions
9
Tis scction will discuss thc c
ccts o thc cnvironmcnt on gcnctic
cxprcssion rclcvant to maladics linkcd
to oral inammation, namcly typc
. diabctcs, cardiovascular discascs,
and mctabolic syndromc, MctS.
Numcrous studics havc shown that
01.5 2 2.5 3 3.5 4 4.511.0
GPS
P
e
r
c
e
n
t
a
g
e

W
i
t
h
i
n

C
a
s
e
s

o
f

C
o
n
t
r
o
l
s
30
25
15
5
20
10
0
fi gure 2. Distribution of cases with coronary infarct and control subjects by GPS. The subjects with coronary infarct (red line) had a GPS distribution that skewed toward the higher
values, whereas the distribution of the control subjects (green line) was skewed toward lower values. Data from Trichopoulou et al.
10
Reprinted with permission from the American Academy
of Periodontology 79:1510, 2008.
Coronary Infarct Control
i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 201 0251
A numbcr o gcnccnvironmcntal
intcractions havc bccn surmiscd rom
an ongoing study that cxamincs how
gcnccnvironmcntal intcractions inu
cncc susccptibility to MctS. Known as
thc Ccnctics o Iipid Iowcring Lrugs
and Lict Nctwork (COILN) study, it
aims to charactcrizc thc gcnctic bascs
or thc variablc rcsponsc o triglyccr
idcs (TC) lcvcls ollowing two dictary
challcngcs, onc that acutcly raiscs TC
via a atladcn dict vcrsus lowcrcd
TC rcsulting rom cnobratc admin
istration.
rr
Twclvc hundrcd gcncti
cally homogcncous subjccts with and
without MctS wcrc comparcd.
n
\aist circumcrcncc, saturatcd
atty acid lcvcls in crythrocytc ccll
mcmbrancs, lcvcls o CRP, II and
TNF wcrc all highcr in subjccts with
MctS. Icvcls o polyunsaturatcd atty
acids (PUFA) wcrc lowcr.
n
Not only was MctS associatcd
with highcr lcvcls o IIr, but thc risk
or MctS was also associatcd with scvcral
gcnctic variants o thc gcncs that cncodc
IIr.
n
In light o thc abovc, invcstigators
wondcrcd i dict could countcr incrcascd
risks among thosc with dicring allclcs.
Lata indicatcd that dicts high in ccrtain
orms o PUFA could do just that.
r.
Othcr rcports dcrivcd rom thc
COILN data invcstigatcd thc cccts o
TClowcring cnobratc trcatmcnt on
risk actors or cardiovascular discascs.
Fcnobratc (cg., brandnamc pharmaccu
ticals Antara, Fcnoglidc, Iipocn, Io
bra, TriCor, Triglidc) lowcrs scrum lipid
lcvcls and targcts thc athcrogcnic lipid
triad (high scrum TCs, low highdcnsity
lipoprotcin lcvcls with small and dcnsc
lowdcnsity lipoprotcin particlcs) and
inammation. Bccausc both phcnotypcs
arc important componcnts o diabctcs
and MctS that potcntially link thcsc
mctabolic disordcrs to cardiovascular
discasc, bratcs wcrc hypothcsizcd to
bc thcrapics that might rcducc cardio
vascular discasc risk in thcsc paticnts.
Unortunatcly, thc study rcsults wcrc
mixcd. Somc individuals with ccrtain
CRP allclcs rcspondcd wcll. (CRPs rolc in
athcrogcncsis, indcpcndcnt o lipidbascd
risk actors has bccn associatcd with mul
tiplc risk actors or cardiovascular discasc
including obcsity, insulin rcsistancc, and
high blood prcssurc, and is a prcdictor o
MctS.
r
) Tcsc data suggcst that rcsistancc
Cytokines in Periodontal Tissue
Destruction
15,16
Bctwccn thc initial incction and thc
tissuc dcstruction charactcrizing pcrio
dontitis is thc production o numcrous
cytokincs that mcdiatc inammatory
mcchanisms. Cytokincs arc unction
ally subdividcd into chcmokincs, innatc
immunc cytokincs, and acquircd immunc
cytokincs. Animal cxpcrimcnts havc
suggcstcd rolcs or all in pcriodontitis.
Chcmokincs arc chcmotactic cytokincs,
such as intcrlcukin8, monocytc chcmo
attractant protcinr, and macrophagc
inammatory protcinr. Chcmokincs
arc produccd by cclls normally prcscnt
noninamcd tissuc and rccruit lcuko
cytcs and modulatc ostcoclast ormation.
Numcrous ccll typcs in thc pcriodontium
producc chcmokincs, including broblasts,
cndothclial cclls, macrophagcs, ostcoclasts,
cpithclial cclls, ncutrophils, monocytcs,
lymphocytcs, and mast cclls. Somc stimu
latc ostcoclast ormation and survival.
Ncutrophils, monocytcs, and othcr
cclls producc innatc immunc cytok
incs such as IIr, II, IIrr and TNF
atcr bcing summoncd to thc sitc o
injury or incction by thc chcmokincs.
Fxpcrimcntal supprcssion o IIr ap
pcars to slow pcriodontal dcstruction, II
appcars prodcstructivc, IIrr appcars pro
tcctivc. TNF spurs ostcoclast ormation
and accclcratcs pcriodontal brcakdown as
cxpcrimcnts in a murinc modcl incctcd
with pcriodontal pathogcn Aggregc|||c.|er
c.||om,.e|em.om||cns (Aa) havc shown.
Indccd, grcatcr numbcrs o Aa wcrc
obscrvcd in tcst micc gcnctically modicd
to dccrcasc TNF rcactivity. Howcvcr,
dcspitc highcr bactcrial lcvcls, lowcr lcvcls
o boncrcsorptioninducing cytokincs
wcrc dctcctcd comparcd with control micc.
Acquircd immunc cytokincs arc pro
duccd by antigcnactivatcd T and Bcclls
as dcscribcd abovc. Tcy includc IIr,
to thc antiinammatory drug cnobratc
dcpcnds on variablc CRP gcnctic cxprcs
sion among MctS subjccts. Similar to CRP
cxprcssion, dicrcnccs in allclcs associ
atcd with proinammatory II gcnc
appcar rcsponsiblc or modulating scrum
lcvcls o II and also modulatc various
scrum lipid lcvcls associatcd with MctS.
Anothcr aspcct o lipid mctabolism
is that thc pcrilipin protcins coating
intraccllular lipid droplcts in at cclls
havc numcrous allclic variants that ap
pcar to play rolcs in lipid mctabolism.
Tcsc havc bccn linkcd to postprandial
TC lcvcls, body wcight, obcsity, risk or
MctS, and scrum inammatory lcvcls.
Although incomplctc, rcscarch cncour
agingly indicatcs that gcnctic prcdisposition
to MctS and othcr disordcrs can bc substan
tially dccrcascd via dictary changcs.
r
although incomplete,
research encouragingly
indicates that genetic
predisposition to MetS
and other disorders can be
substantially decreased
via dietary changes.
252ap ri l 201 0
cda j ournal , vol 38 , n

4
II and TNF in addition to IIr/ and
nuclcar actorkappa B ligand (RANKI).
IIr and II play rolcs in bonc rcsorp
tion via stimulation o RANKI, although
lymphocytcs also sccrctc numcrous
ostcoclastormation inhibitors such as
ostcoprotcgcrin (OPC), II, IIrc, IIr
and intcrcron. RANKI, which binds to
RANK, is onc o thc most potcnt induc
crs o ostcoclast ormation and activ
ity. OPC binds to RANKI and inhibits
ostcoclast activitics. It sccms clcar that
various immunc cytokincs can inhibit
or cnhancc pcriodontal dcstruction.
Cytokincs, such as IIr, arc also
involvcd in a phcnomcnon tcrmcd bonc
dccoupling. Bonc dccoupling is thc unbal
ancing o ostcoblastic bonc ormation with
ostcoclastic bonc dcstruction as is sccn in
thc bonc loss that charactcrizcs pcriodon
titis. Fxpcrimcnts in diabctic micc havc
suggcstcd that TNF plays a rolc in induc
ing an incrcascd morbidity among ostco
blasts that may lcad to dccoupling.
r/
Similar
cvidcncc in primatcs has bccn rcportcd.
r8
Multiplc lincs o cvidcncc clcarly
indicatc that incrcascs in RANKI produc
tion raisc thc RANKIOPC ratio and
stimulatc thc dicrcntiation maturation
and longcvity o ostcoclasts lcading to nct
bonc loss. On thc othcr hand, lowcring
o thc ratio by cithcr rcducing RANKI
or incrcasing OPC rcsults in ostcoclast
apoptosis and is thcrcby ostcoprotcctivc.
Historically, pcriodontal practitioncrs
havc ocuscd almost cntircly on mitigating
thc bactcrial ctiologics o pcriodontitis.
Although such tactics rcmain rcasonablc,
it sccms that rcduction o inammation
and attcnuation o thc hosts immunc
rcaction to thc microbial plaquc, lcading
to a dccrcasc in thc ratio o RANKI to
OPC rcsulting in a dccrcasc in bonc loss
would bc clinically uscul as wcll. Futurc
pcriodontal thcrapcutic tactics may di
rcctly targct thc RANKRANKIOPC axis.
The Relationship of Inammation to
Important Systemic Diseases That may
be Associated With Chronic Periodontitis
Diabetes
19
Liabctcs is a scrious hcalth carc con
ccrn. Its worldwidc incidcncc is prcdictcd
to incrcasc in conccrt with incrcascd prcv
alcncc o obcsity. Liabctcs is a major indi
vidual and public hcalth burdcn bccausc
o its scrious microvascular scquclac.
Tcsc includc ncphropathy, rctinopathy,
ncuropathy, cardiovascular discasc, and
to insulin (known as insulin rcsistancc)
that ovcrwhclms thc ability o pancrcatic
bcta cclls to sccrctc sucicnt insulin.
Although thcrc is controvcrsy sur
rounding thc prccisc rolc o inammatory
proccsscs in typc r diabctcs, intriguing
ndings havc cmcrgcd rom studics o thc
inammatory biomarkcr, CRP. Although
CRP conccntrations in individuals with
thc ncw onsct (within days o diagnosis)
o typc r diabctcs wcrc similar to thosc
obscrvcd in hcalthy controls, lcvcls in
individuals with longtcrm typc r diabctcs
wcrc signicantly highcr (Pc.c).
Tcsc ndings suggcst that inam
matory proccsscs may play a grcatcr rolc
in thc longtcrm progrcssion o typc r
diabctcs than in its onsct. To wit, incrcascs
in inammatory markcrs arc obscrvcd in
conjunction with thc complications o typc
r diabctcs. For cxamplc, incrcascs in circu
lating lcvcls o CRP, solublc vascular ccll ad
hcsion molcculcr, and nitrotyrosinc wcrc
sccn in paticnts with microvascular discasc
comparcd to thosc without diabctcs.
.c
In
crcascs in monocytc rclcasc o intcrlcukin
(II)r and supcroxidc anions wcrc also
rcportcd in paticnts with typc r diabctcs.
Type 2 Diabetes
Incrcascs in inammatory markcrs havc
appcarcd in apparcntly hcalthy individu
als who latcr dcvclopcd typc . diabctcs.
.r.

Tis suggcsts that inammation ramps up
carly in thc discasc proccss. For cxamplc,
in adult Pima Indians (cpigcnctically pronc
to typc . diabctcs), individuals with highcr
whitc blood ccll (\BC) counts (an indicator
o grcatcr inammation), wcrc morc likcly
to dcvclop typc . diabctcs ovcr a .cycar
pcriod comparcd with thosc who had lowcr
\BC counts. Similarly, in a prospcctivc
study o apparcntly hcalthy, middlcagcd
womcn, inammatory markcrs II and
CRP wcrc associatcd with an incrcascd
risk or dcvcloping typc . diabctcs ovcr a
pcriodontitis. Total annual costs cxcccd
sr. billion in thc Unitcd Statcs alonc.
Many actors, such as gcnctics, dict,
scdcntary licstylc, thc pcrinatal cnviron
mcnt, agc, and obcsity arc associatcd with
diabctcs. Ncvcrthclcss, an inammatory
basis or diabctcs and its complications is
gaining traction. Inammation is associ
atcd with both typc r and typc . diabctcs.
Typc r diabctcs is typically ound in
adolcsccnts and young adults and ariscs
rom thc autoimmunc dcstruction o
pancrcatic islct cclls that producc insulin.
Tc incrcasingly common typc . diabc
tcs occurs mainly in adults, although
its prcvalcncc among young pcoplc is
incrcasing in conccrt with childhood obc
sity ratcs. Typc . diabctcs is charactcrizcd
by incrcascd ccllular nonrcsponsivcncss
these findings
suggest that inammatory
processes may play
a greater role in the
long-term progression
of type 1 diabetes than
in its onset.
i n f l a mmat i o n
cda j ournal , vol 38 , n

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ap ri l 201 0253
ship rcmains unclcar or pcriodontitis.
As notcd in figure 3, altcrcd gcnc cx
prcssion and altcrcd protcin unction arc
thought to play rolcs at local lcvcls whcrc
diabctic complications arc manicstcd.
Among numcrous othcr cytokincs, kinasc
bcta (PKC) is thought to play a kcy rolc
in microvascular complications. Tc prom
ising drug ruboxistaurin may inhibit this
pathway and is in human clinical trials.
Although thc most widcly studicd dia
bctic complications sharc a microvascular
componcnt advcrscly acctcd by hypcr
glyccmia, pcriodontitis may bc dicrcnt.
Indircct cvidcncc linking pcriodontitis
to obcsity among individuals who arc
nondiabctic supports this distinction.
Ncvcrthclcss, its not unlikcly that obc
sity and insulin rcsistancc cnhancc pcrio
dontitis risk and that hypcrglyccmia o
diabctcs worscns pcriodontitis. Additional
ourycar pcriod. Tcsc ndings arc similar
thosc sccn in hcalthy, middlcagcd mcn.
Typc . diabctcs is linkcd to obcsity.
Obcsity and MctS havc bccn linkcd to
highcr lcvcls o inammatory mark
crs as discusscd carlicr. Howcvcr, othcr
data indicatc that typc . diabctcs may
dcvclop in somc indcpcndcnt o such
associations. Ncvcrthclcss, cvidcncc rom
both animal and human studics suggcst
possiblc rolcs or TNF, othcr inam
matory mcdiators, circulating markcrs
o obcsity (rcc atty acids), bactcrial
lipopolysaccharidcs, protcin kinascs and
or oxidants in thc dcvclopmcnt o insulin
rcsistancc in obcsity and typc . diabctcs.
In this modcl, nuclcar actorkappa B
is activatcd by thcsc mcdiators and rcsults
in thc transcription o gcncs that promotc
insulin rcsistancc and thc production o
cvcn morc inammatory markcrs. Fur
thcrmorc, both animal and human trials
havc shown that pharmacological disrup
tion o this pathway improvcs insulin scn
sitivity and lowcrs inammatory load.
.
Tc hypcrglyccmia that charactcrizcs
poorly controllcd diabctcs is considcrcd a
major risk actor or thc dcvclopmcnt o
diabctic complications including cardio
vascular discasc. figure 1 schcmatically
rcprcscnts pathways and mcchanisms.
Tc actions o inammatory pathways
at thc local tissuc lcvcl arc kcy to undcr
standing thcir contribution to thc patho
gcncsis o diabctic complications. Fvi
dcncc suggcsts that incrcascs in systcmic
markcrs o inammation, such as CRP and
II, arc associatcd with complications
such as diabctic ncphropathy. Howcvcr,
systcmic inammatory actors arc only
wcakly associatcd with thc dcvclopmcnt
o diabctic rctinopathy, and thc rclation
Cellular Dysfunction and Damage
Aldose Reductase
Pathway
Advanced Glycation
Endproduct
Pathway
Reactive Oxygen
Intermediate
Pathway
Protein Kinase C
Pathway
Reactive Glucose Metabolites
Activation of Cell Signaling Molecules
(e.g., protein kinase C, mitogen-activated protein kinase, and nuclear factor-B
Altered Protein Function Altered Gene Expression
Abnormal Angiogenesis
Abnormal Cell Growth
and Survival
Hypermeablilty
Basement Matrix
Thickening
Abnormal Blood Flow
Increased Leukocyte
Adhesion
Contractility
Cardiomyopathy
Thrombosis
Hyperglycemia
fi gure 3. Major pathways initiated by hyperglycemia that contribute to complications of diabetes. Reprinted with permission from Blackwell Publishing.
254ap ri l 201 0
cda j ournal , vol 38 , n

4
studics that tcasc out thc rclativc contribu
tions o thc proinammatory cccts o obc
sity alonc vcrsus thc cccts o insulin rcsis
tancc and hypcrglyccmia would bc hclpul
to bcttcr undcrstand thcsc rclationships.
Inammation and Alzheimers Disease
25
Alzhcimcrs discasc is thc most com
mon causc o progrcssivc intcllcctual
ailurc and a major causc o dcmcntia. As
dcmographics in thc dcvclopcd world shit
toward morc agcd populations, Alzhcim
crs may bccomc cvcn morc prcvalcnt. Tc
classic pathologic hallmarks o Alzhcimcrs
arc two. amyloid plaqucs and thc ncu
robrillary tanglcs. In an Alzhcimcrs pa
ticnt, thcsc arc prouscly distributcd in thc
rontal ncocortcx and limbic systcm. Tcsc
brain rcgions arc associatcd with thc high
cr mcntal unctions that Alzhcimcrs im
pairs. Furthcrmorc, a rcccntly rccognizcd
aspcct o Alzhcimcrs pathology is inam
mation, spccically, an innatc inamma
tory rcsponsc that may rccct attcmpts to
rcmovc amyloid dcposits rom thc brain.
In rcccnt ycars, numcrous innatc in
ammatory mcdiators havc bccn rcportcd
to bc uprcgulatcd in pathologically vulncr
ablc rcgions o thc brain in Alzhcimcrs
discasc. Tcsc data lcd to a rccxamination
o thc dogma o brain immunologic privi
lcgc and ncw studics that cxamincd thc
rolcs o thc innatc inammatory rcsponsc
in a numbcr o othcr ncurologic disordcrs,
particularly Parkinsons discasc and hu
man immunodccicncy virus dcmcntia.
Liscovcrics about ncuroinam
mation arc bcginning to movc to thc
clinic. Morc than .c cpidcmiologic
survcys havc dcmonstratcd that com
mon nonstcroidal antiinammatory
drugs (NSAILS) may protcct against thc
dcvclopmcnt o Alzhcimcrs. By contrast,
antiinammatory trcatmcnt trials or
cxisting Alzhcimcrs havc typically shown
littlc to no ccct on halting or rcvcrsing
thc disordcr, although thc drugs tcstcd
havc otcn not bccn thosc suggcstcd by
cpidcmiological or othcr scicntic rcsults.
Tc cxtcnsivc litcraturc on innatc in
ammation and ncurologic discasc asidc,
kcy qucstions rcmain. First, arc innatc
inammatory rcsponscs a causc o ncuro
logic discasc or mcrcly an ccct` Sccond,
can antiinammatory agcnts ccctivcly
trcat cxisting ncurologic discasc, or is a
protcctivc stratcgy in highrisk paticnts
thc only rcasonablc option` Tird, whcth
cr or protcction or trcatmcnt, what is thc
bcst choicc o antiinammatory agcnt`
bctcs, alcohol intakc, obcsity, and blood
prcssurc, subjccts with pcriodontitis
had a r.r to r.,old grcatcr risk or
dcvcloping coronary hcart discasc com
parcd to thosc without pcriodontitis.
Although thc mcchanisms undcr
lying this association arc not clcarly
undcrstood, it was rcportcd that ccr
tain colonizcrs o pcriodontal pockcts
(Aggregc|||c.|er c.||nom,.e|em.om||cns
and Por|,romoncs g|ng|.c||s) havc bccn
dctcctcd in athcrosclcrotic plaqucs.
.8,.,

Tcsc pathogcns producc lipopolysac
charidcs, that, in turn, inducc mac
rophagcs to sccrctc cytokincs (intcrlcukin
II]r and r and tumor nccrosis
actor TNF]) that can play important
rolcs in athcrothrombogcncsis.
Flcvatcd ccll and cytokincmcdiatcd
markcrs o inammation, including
CRP, brinogcn, and various cytokincs,
arc associatcd with pcriodontitis.
c
Tc
samc clcvatcd proinammatory ac
tors in pcriodontitis havc also bccn
linkcd with athcrothrombogcncsis.
Tc conncction bctwccn vascular
cvcnts and pcriodontitis is also sup
portcd by cvidcncc that oral bactcria
cnhancc thc cxprcssion o platclct
aggrcgationassociatcd protcin.
Athcrosclcrosis appcars to bc a
chronic inammatory disordcr, suggcst
ing that plasma markcrs o inamma
tion would bc uscul or vascular discasc
risk asscssmcnt. For cxamplc, in a largc
prospcctivc study involving hcalthy mcn,
II lcvcls wcrc clcvatcd among mcn who
subscqucntly cxpcricnccd a myocardial
inarction comparcd with agcmatchcd
controls.
r
In anothcr largc prospcctivc
study, hcalthy middlcagcd womcn who
subscqucntly dcvclopcd cardiovascu
lar cvcnts cxhibitcd incrcascd lcvcls
o solublc Psclcctin, solublc CLcI,
or macrophagcinhibitory cytokinc
comparcd with matchcd controls.
.
O intcrcst to dcntal practitioncrs,
Alzhcimcrs discasc has not bccn associatcd
with scrum lcvcls o proinammatory
mcdiators or with chronic pcriodontitis.
Inammation, C-reactive Protein, and
Atherosclerosis
26
Cardiovascular cvcnts, such as myo
cardial inarction and strokc, rcmain
lcading causcs o morbidity and dcath
in thc Unitcd Statcs. Fvidcncc sug
gcsting ctiologic links bctwccn chronic
pcriodontitis and cardiovascular discasc
cxists. Lata dcrivcd rom a mctaanal
ysis o vc prospcctivc cohort studics,
vc casccontrol studics, and vc cross
scctional studics suggcstcd a positivc
corrclation bctwccn pcriodontitis and
coronary hcart discasc.
./
Atcr adjusting
or risk actors, such as smoking, dia
alzheimers disease
has not been associated
with serum levels
of proinammatory
mediators or with
chronic periodontitis.
i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 201 0255
Stroke and Ischemic Events
Inammatory proccsscs also ap
pcar to hcightcn thc risk or strokc and
ccrcbral smallvcsscl discasc. In a samplc
o cldcrly pcoplc, agcs c to ,c, hsCRP
lcvcls wcrc associatcd with thc prcscncc
and progrcssion o whitc mattcr lcsions
in thc brain prcsumcd to bc thc rcsult
o ischcmia.
,
In anothcr study, CRP
lcvcls wcrc comparcd to thc likclihood
o ischcmic strokcs or transicnt ischcmic
attacks.
c,r
Atcr adjusting or othcr risk
actors, thosc in thc highcst quartilcs o
CRP lcvcls had a two to thrccold grcatcr
risk or strokc. Ovcrall, thcsc data sup
port thc hypothcsis that CRP, as a markcr
o lowlcvcl inammation, prcdicts an
incrcascd risk or cardiovascular cvcnts
in apparcntly hcalthy individuals.
Inammation Appears to be a Risk
Factor for Diabetes
As notcd carlicr, cvidcncc supports
rolcs or inammation in thc pathogcncsis
o diabctcs. Similar to cardiovascular dis
casc, incrcascd hsCRP is a prcdictor o risk
Framingham risk scorc, including agc,
smoking status, blood prcssurc, prcs
cncc or abscncc o diabctcs mcllitus, and
HLI and ILI lcvcls, quintilcs o CRP
rcmaincd an indcpcndcnt prognostic
actor or risk. Morcovcr, incrcasing lcvcls
o CRP wcrc associatcd with an incrcascd
risk or cardiovascular cvcnts at all lcvcls
o cstimatcd rcycar risks (figure 4).
Sincc thcsc rcports, studics bascd on
at lcast a dozcn morc population cohorts
around thc world havc corroboratcd thc
usculncss o hsCRP as a prcdictor o
myocardial inarction, ischcmic strokc,
and cardiovascular dcath. A rcccnt,
largc, prospcctivc, randomizcd, doublc
blind, placcbocontrollcd multiccntcr
trial (thc UPITFR trial) comparcd thc
cccts o an oral statin drug vcrsus a
placcbo in apparcntly hcalthy paticnts
with clcvatcd hsCRP lcvcls and noncl
cvatcd lcvcls o ILI cholcstcrol. Tis
study was tcrminatcd carly bccausc o
thc bcnccial cccts o thc statin drug
rosuvastatin in rcducing in rcducing thc
ratc o scrious cardiovascular cvcnts.
8
TNF is anothcr actor associatcd
with cardiovascular disordcrs. Plasma
conccntrations o TNF wcrc mcasurcd
rom ./. paticnts who dcvclopcd rccur
rcnt nonatal myocardial inarcation or
anothcr cardiovascular cvcnt.

TNF
lcvcls wcrc pcrsistcntly clcvatcd among
postmyocardial inarction paticnts at
incrcascd risk or rccurrcnt coronary
cvcnts. Tcsc data indicatc that changcs
in basclinc lcvcls o thc inammatory
biomarkcrs discusscd abovc may bc
potcntial biomarkcrs indicativc o uturc
risk or cardiovascular cvcnts, and may
cvcn bc thcrapcutic targcts aimcd at
cardiovascular discasc prcvcntion.
Tc highscnsitivity CRP (hsCRP)
assay morc accuratcly mcasurcs CRP than
oldcr asscssmcnt tcchniqucs. Incrcascd
hsCRP appcars to bc indcpcndcnt
prcdictor or cardiovascular cvcnts. Tc
rclativc risk or a rst myocardial inarca
tion and ischcmic strokc incrcascs as
basclinc conccntrations o hsCRP risc
(suggcsting strongly that athcrothrom
bosis a typical prccursor to myocardial
inarcation and strokc is, at lcast in
part, an inammatory disordcr).

Flcvations o othcr biomarkcrs sig

nicantly associatcd with vascular cvcnts
includc Ip(a) lipoprotcin, homocystcinc,
II, total cholcstcrol, scrum amyloid A,
apolipoprotcin Brcc, lowdcnsity lipo
protcin (ILI) cholcstcrol, highdcnsity
lipoprotcin (HLI) cholcstcrol, and thc ra
tio o total cholcstcrolHLI cholcstcrol.

In .cc., data dcrivcd rom a longitudinal
study o ncarly c,ccc hcalthy womcn
also supports CRP as a cardiovascular
risk indicator.
/
CRP is also a strongcr
prcdictor or cardiovascular cvcnts and
dcath than arc mcasurcs o ILI. Indccd,
womcn in thc high CRPlow ILI sub
group wcrc at highcr absolutc risk than
thosc in thc low CRPhigh ILI subgroup.
Atcr adjusting or componcnts o thc
01 24 59 1020
Framingham Estimate of 10-Year Risk (%)
R
e
l
a
t
i
v
e

R
i
s
k
25
15
5
20
10
0
CRP (mg/l)
n
<1.0
n
1.03.0
n
>3.0
fi gure 4. CRP levels are a stronger predictor of cardiovascular events than are LDL levels and add to prognostic
information supported by the Framingham risk score. A) Event-free survival among women (N=27,939) with CRP and LDL
levels above or below the median for the study population.
14
B) Multivariable-adjusted relative risks for cardiovascular
disease according to CRP levels and the estimated 10-year risk based on the Framingham risk score, currently dened
by the National Cholesterol Education Program and according to CRP levels and categories of LDL.
19
Copyright 2002
Massachusets Medical Society. All rights reserved. Ridker PM, Rifai N, et al, Comparison of C-reactive protein and low-density
lipoprotein cholesterol levels in the prediction of rst cardiovascular events. N Engl J Med 347(20):1557-65, Nov. 14, 2002.
256ap ri l 201 0
cda j ournal , vol 38 , n

4
Genetics and CRP
A numbcr o studics havc linkcd
varianccs in hsCRP to gcnctic dicr
cnccs. Morcovcr, a rcccnt gcnomcwidc
asscssmcnt o .,cc womcn, data
suggcstcd closc gcnctic links among CRP,
diabctcs, and carly athcrothrombosis.
8

Howcvcr, analysis o thcsc studics has
suggcstcd that only bctwccn .c pcr
ccnt and c pcrccnt o thc population
variancc in CRP has a gcnctic basis.
Terapeutic Implications
Tus ar, it is unprovcn that inhib
iting inammation in gcncral or CRP
in particular will dccrcasc thc ratc o
vascular cvcnts. Howcvcr, carly rcscarch
is promising. For cxamplc, a CRP in
hibitor rcsultcd in smallcr inarcts and
lcss cardiac damagc (in rats doscd with
rhCRP). Othcr approachcs includc thc
usc o novcl II or TNF inhibitors.
Altcrnatcly, lowdosc mcthotrcxatc,
otcn uscd to trcat rhcumatic arthritis,
is known to dccrcasc paramctcrs linkcd
with systcmic inammation in humans,
including crythrocytc scdimcntation ratc,
CRP conccntrations, and signs o clinical
inammation. An carly study was prom
ising.
,
In light o thc similaritics bctwccn
rhcumatic arthritis and athcrosclcrosis
(such as thc involvcmcnt o cytokincs
and clcvatcd lcvcls o CRP), conducting
a trial comparing lowdosc mcthotrcxatc
to placcbo in thc sccondary prcvcntion o
cardiovascular discasc would contributc
signicant undcrstanding in this arcna.
Conclusion
Tc human immunc systcm, thc
cpigcnomc, thc cnvironmcnt and
cytokincs play complcx and intcrwovcn
rolcs in thc myriad proccsscs o inam
mation. Inammation is now known to
bc a common caturc o many discascs
associatcd with aging such as chronic
wcrc prcdictcd to bc at highcr or lowcr
risk than anticipatcd whcn thc Rcynolds
risk scorc was uscd, and in almost all
cascs, this rcclassication was corrcct.

Sincc thc anuary .cc8 AAP workshop
(that is thc scminal basis or this articlc),
additional cvidcncc has bccn publishcd
validating thc Rcynolds risk scorc as an
improvcd riskprcdiction systcm in mcn.

Trcatmcnt guidclincs rccommcnd statins
or paticnts at highcr risk. Tc Rcynolds
risk scorc should acilitatc morc ccc
tivc and ccicnt usc o thcsc drugs.
or typc . diabctcs. In a largc prospcctivc
cohort study in womcn initially rcc o di
agnoscd diabctcs, basclinc lcvcls o hsCRP
and II wcrc signicantly highcr among
cascs than controls.
.
Iatcr studics invcsti
gating a dircct association bctwccn hsCRP
lcvcls and diabctcs uscd cxogcnous injcc
tions o rccombinant human CRP (rhCRP).
Following injcctions o rhCRP, numcrous
cytokinc markcrs o inammation bccamc
signicantly clcvatcd comparcd with con
trols.

In a ollowup study by thc samc

group, rhCRP injcctions administcrcd
to hcalthy malcs rcsultcd in incrcascd
plasma glucosc lcvcls and dccrcascd
insulin production. Additional cvidcncc
implicatcd CRP as a prognostic markcr
or MctS. Collcctivcly, this cvidcncc
suggcstcd thc nccd to dcvclop stratcgics
aimcd at dccrcasing vascular risk among
individuals with clcvatcd lcvcls o CRP.
Reynolds Risk Score Improves on
Framingham Risk Score
\hcthcr to add hsCRP asscssmcnt to
traditional riskprcdiction modcls, such
as thc Framingham risk scorc, rcmains a
topic o currcnt rcscarch. To addrcss this
issuc, a scrics o risk actors wcrc cvalu
atcd at basclinc among .,8 initially
hcalthy womcn ovcr agc who wcrc
ollowcd or uturc cardiovascular cvcnts
ovcr a rcycar pcriod. Using thcsc data, a
ncw riskprcdiction algorithm, thc Rcyn
olds risk scorc, was dcvclopcd and validat
cd. In bric, o thc ncw biomarkcrs o risk,
thc most important additions wcrc hsCRP
and parcntal history o myocardial inarc
tion bcorc agc c. \hcn thcsc two ac
tors wcrc addcd to thc usual risk markcrs,
thc Rcynolds risk scorc provcd to bc morc
accuratc than thc Framingham risk scorc,
particularly or thosc at intcrmcdiatc
risk whcrc /c pcrccnt o all cvcnts occur.
Furthcrmorc, among thosc at intcrmc
diatc risk, almost hal o all participants
Statins
Statins posscss potcnt lipid lowcr
ing and antiinlammatory propcrtics.
\hcn ,/ paticnts with acutc coro
nary syndromc (an umbrclla tcrm uscd
to covcr clinical symptoms compatiblc
with acutc myocardial ischcmia) wcrc
trcatcd with statins, thc lcvcls o ILI
cholcstcrol and hsCRP wcrc dccrcascd.

Trcatcd subjccts who achicvcd a targct
lcvcl o hsCRP . mgl had a signii
cant improvcmcnt in cvcntrcc sur
vival, indcpcndcnt o lcvcls o ILI
cholcstcrol. Subjccts who achicvcd
ILI cholcstcrol lcvcls /c mgdl and
hsCRP lcvcls . mgl did cvcn bcttcr.
Thcsc indings wcrc corroboratcd in a
sccond multinational trial that rcin
orccd thc signiicancc o hsCRP as an
indicator o risk and inlammation.
/
following
injections of rhCRP,
numerous cytokine markers
of inammation became
signicantly elevated
compared with controls.
i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 201 0257
the risk of cardiovascular disease in apparently healthy men. N
Engl J Med 336:973-9, 1997.
37. Ridker PM, Rifai N, et al, Comparison of C-reactive protein
and low-density lipoprotein cholesterol levels in the prediction
of rst cardiovascular events. N Engl J Med 347:1557-65, 2002.
38. Ridker PM, Danielson E, et al, Rosuvastatin to prevent
vascular events in men and women with elevated C-reactive
protein. N Engl J Med 359:2195-207, 2008.
39. van Dijk EJ, Prins ND, et al, C-reactive protein and cerebral
small-vessel disease: the Roterdam scan study. Circulation
112:900-5, 2005.
40. Rost NS, Wolf PA, et al, Plasma concentration of C-reactive
protein and risk of ischemic stroke and transient ischemic
atack: the Framingham study. Stroke 32:2575-9, 2001.
41. Pradhan AD, Manson JE, et al, C-reactive protein, interleu-
kin 6, and risk of developing type 2 diabetes mellitus. JAMA
286:327-34, 2001.
42. Bisoendial RJ, Kastelein JJ, et al, Activation of inammation
and coagulation afer infusion of C-reactive protein in humans.
Circ Res 96:714-6, 2005.
43. Ridker PM, Buring JE, et al, Development and valida-
tion of improved algorithms for the assessment of global
cardiovascular risk in women: the Reynolds risk score. JAMA
297:611-9, 2007.
44. Ridker PM, Paynter NP, et al, C-reactive protein and paren-
tal history improve global cardiovascular risk prediction: the
Reynolds risk score for men. Circulation 118:2243-51, 2008.
45. Ridker PM, Cannon CP, et al. C-reactive protein levels and
outcomes afer statin therapy. N Engl J Med 352:20-8, 2005.
46. Morrow DA, de Lemos JA, et al, Clinical relevance of
C-reactive protein during follow-up of patients with acute
coronary syndromes in the Aggrastat-to-Zocor trial. Circula-
tion 114:281-8, 2006.
47. Ridker PM, Pare G, et al, Loci related to metabolic-syn-
drome pathways including LEPR, HNF1A, IL6R, and GCKR as-
sociate with plasma C-reactive protein: the womens genome
health study. Am J Hum Genet 82:1185-92, 2008.
48. Choi HK, Hernan MA, et al, Methotrexate and mortality in
patients with rheumatoid arthritis: a prospective study. Lancet
359:1173-7, 2002.
49. Pradhan AD, Manson JE, et al, C-reactive protein, interleu-
kin 6, and risk of developing type 2 diabetes mellitus. JAMA
286:327-34, 2001.
to request a printed copy of this article, please
contact Michael P. Rethman, DDS, MS, 47-140 Heno Place,
Kaneohe, Hawaii, 96744-5608.
16. Cochran DL, Inammation and bone loss in periodontal
disease. J Periodontol 79:1569-76, 2008.
17. Liu R, Bal HS, et al. Diabetes enhances periodontal bone
loss through enhanced resorption and diminished bone forma-
tion. J Dent Res 85:510-4, 2006.
18. Assuma R, Oates T, et al, IL-1 and TNF antagonists inhibit
the inammatory response and bone loss in experimental
periodontitis. J Immunol 160:403-9, 1998.
19. King GL, The role of inammatory cytokines in diabetes and
its complications. J Periodontol 79:1527-34, 2008.
20. Devaraj S, Cheung AT, et al, Evidence of increased inam-
mation and microcirculatory abnormalities in patients with
type 1 diabetes and their role in microvascular complications.
Diabetes 56:2790-6, 2007.
21. Pradhan AD, Manson JE, et al, C-reactive protein, interleukin
6, and risk of developing type 2 diabetes mellitus. JAMA
286:327-34, 2001.
22. Vozarova B, Weyer C, et al, High white blood cell count is
associated with a worsening of insulin sensitivity and predicts
the development of type 2 diabetes. Diabetes 51:455-61, 2002.
23. Thorand B, Lwel H, et al, C-reactive protein as a predictor
for incident diabetes mellitus among middle-aged men:
Results from the MONICA Augsburg cohort study, 1984-1998.
Arch Intern Med 163:93-9, 2003.
24. Fleischman A, Shoelson SE, et al, Salsalate improves
glycemia and inammatory parameters in obese young adults.
Diabetes Care 31:289-94, 2008.
25. Rogers J, The inammatory response in Alzheimers
disease. J Periodontol 79:1535-43, 2008.
26. Ridker PM, Silvertown JD, Inammation, C-reactive protein
and atherothrombosis. J Periodontol 79:1544-51, 2008.
27. Bahekar AA, Singh S, et al, The prevalence and incidence of
coronary heart disease is signicantly increased in periodonti-
tis: a meta-analysis. Am Heart J 154:830-7, 2007.
28. Schenkein HA, Barbour SE, et al, Invasion of human vascu-
lar endothelial cells by actinobacillus actinomycetemcomitans
via the receptor for platelet-activating factor. Infect Immun
68:5416-9, 2000.
29. Spahr A, Klein E, et al, Periodontal infections and coronary
heart disease: role of periodontal bacteria and importance of
total pathogen burden in the coronary event and periodontal
disease (CORODONT) study. Arch Intern Med 166:554-9, 2006.
30. Graves DT, Cochran D, The contribution of interleukin-1
and tumor necrosis factor to periodontal tissue destruction. J
Periodontol 74:391-401, 2003.
31. Ridker PM, Rifai N, et al, Elevation of tumor necrosis factor-
alpha and increased risk of recurrent coronary events afer
myocardial infarction. Circulation 101:2149-53, 2000.
32. Ridker PM, Buring JE, Rifai N, Soluble P-selectin and the
risk of future cardiovascular events. Circulation 103:491-5,
2001.
33. Schonbeck U, Varo N, et al, Soluble CD40L and cardiovas-
cular risk in women. Circulation 104:2266-8, 2001.
34. Brown DA, Breit SN, et al, Concentration in plasma of mac-
rophage inhibitory cytokine-1 and risk of cardiovascular events
in women: A nested case-control study. Lancet 359:2159-63,
2002.
35. Ridker PM, Hennekens CH, et al, C-reactive protein and oth-
er markers of inammation in the prediction of cardiovascular
disease in women. N Engl J Med 342:836-43, 2000.
36. Ridker PM, Cushman M, et al, Inammation, aspirin, and
pcriodontitis, typc . diabctcs, cardiovas
cular discasc, and Alzhcimcrs discasc.
Furthcrmorc, thcrc is incrcasing cvidcncc
that chronic oral inammation and thc
rcsulting systcmic incrcascs in inamma
tory mcdiators may cnhancc thc morbid
ity o ccrtain systcmic discascs common
ly associatcd with advancing agc.
Tcrcorc, it will bchoovc dcntal practi
tioncrs to rcmain alcrt in coming ycars
or thc advcnt o improvcd prcdictivc,
prcvcntivc, and mitigativc tactics that
will cmcrgc rom this cxciting and
dynamic cld o study. As o now, thcrc
rcmains much to bc lcarncd, but thc
bcncts will likcly bc proound.
references
1. Van Dyke TE, Inammation and periodontal diseases: a reap-
praisal. J Periodontol 79:1501-2, 2008.
2. Van Dyke TE, Kornman KS, Inammation and factors that
may regulate inammatory response. J Periodontol 79:1503-8,
2008.
3. Goldsby R, Kindt TJ, et al, Immunology, sixth ed., New York:
WH Freeman pages 1-574, 2006.
4. Pennisi E, DNA study forces rethink of what it means to be a
gene. Science 316:1556-7, 2007.
5. Wilson AG, Epigenetic regulation of gene expression in the
inammatory response and relevance to common diseases. J
Periodontol 79:1511-9, 2008.
6. Mutskov V, Raaka BM, et al, The human insulin gene displays
transcriptionally active epigenetic marks in islet-derived mes-
enchymal precursor cells in the absence of insulin expression.
Stem Cells 25:3223-33, 2007.
7. Graves D, Cytokines that promote periodontal tissue
destruction. J Periodontol 79:1585-91, 2008.
8. Foster SL, Hargreaves DC, Medzhitov R, Gene-specic con-
trol of inammation by TLR-induced chromatin modications.
Nature 447:972-8, 2007.
9. Ordovas JM, Shen J, Gene-environment interactions and sus-
ceptibility to metabolic syndrome and other chronic diseases.
J Periodontol 79:1508-10, 2008.
10. Trichopoulou A, Yiannakouris N, et al, Genetic predisposi-
tion, nongenetic risk factors and coronary infarct. Arch Intern
Med 168:891-6, 2008.
11. GOLDN, Genetics of lipid lowering drugs and diet network.
htp://www.biostat.wustl.edu/goldn/. Accessed Feb. 1, 2010.
12. Shen J, Arnet DK, et al. Interleukin1beta genetic polymor-
phisms interact with polyunsaturated faty acids to modulate
risk of the metabolic syndrome. J Nutr 137:1846-51, 2007.
13. Verma S, Szmitko PE, Ridker PM, C-reactive protein comes
of age. Nat Clin Pract Cardiovasc Med 2:29-36, 2005.
14. DeBusk RM, Fogarty CP, et al, Nutritional genomics in prac-
tice: where do we begin? J Am Diet Assoc 105:589-98, 2005.
15. Graves D, Cytokines that promote periodontal tissue
destruction. J Periodontol 79:1585-91, 2008.
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cda j ournal , vol 38 , n

4
ap ri l 201 0259
An Interview With
Dr. Kenneth Kornman
david w. richards, dds, phd
abstractInammation is recognized as the major underlying contributor to a
number of chronic diseases, amongst them periodontitis and cardiovascular diseases.
The relationship between these diseases is explored and commented on in this
question-and-answer session between Ken Kornman, DDS, PhD, the editor of the Journal
of Periodontology and David Richards, DDS, PhD, a former student of Dr. Kornmans.
Practical suggestions and guidelines for the dentist are also examined.
n thc past dccadc, thcrc has bccn a
ocus on inammation in thc cardio
vascular mcdicinc disciplinc. Tis has
rcsultcd in a bcginning to undcrstand
what may bc an association bctwccn
cardiovascular discasc and inammation
duc to pcriodontitis. In this intcrvicw with
Kcnncth Kornman, LLS, PhL, wc havc cx
plorcd somc o thcsc associations in a prac
tical and thcorctical way. Kornman wrotc
in a dcdication to his r,,, tcxtbook, To
thosc who will providc most pcriodontal
carc in thc uturc. thc gcncral dcntists and
hygicnists. Hc is vcry intcrcstcd in gcncral
dcntistry undcrstanding this discasc.
Kcnncth Kornman, LLS, PhL, is
oundcr and chic scicntic occr o Intcr
lcukin Ccnctics, a biotcchnology company
ocuscd on gcnctic variations that inu
cncc immunoinammatory and mctabolic
mcchanisms involvcd in chronic discascs.
Hc holds morc than .c U.S. patcnts on gcnc
variations that rcgulatc chronic discascs
and on sotwarc mcthods or modcling
i n t e r v i e w
complcx biological mcchanisms, and cur
rcntly rctains an acadcmic appointmcnt at
Harvard Univcrsity. Kornman has publishcd
morc than rcc pccrrcvicwcd manuscripts,
authorcd thrcc tcxtbooks on trcatmcnt
o pcriodontal discascs, and is cditorin
chic o thc oarnc| o/ Per|oion|o|og,.
Q: Please give us a give us a brief
history of the association between
cardiovascular disease and inammation
due to periodontitis.
A: In thc carly to midr,,cs scv
cral cpidcmiologic studics cmcrgcd rom
throughout thc world suggcsting an
association bctwccn pcriodontal discasc
and cardiovascular discasc. Although thcsc
obscrvations initially rcccivcd limitcd
attcntion, a cw pcriodontal rcscarchcrs
pursucd dctails o thcsc associations in
adcquatcly sizcd databascs. In addition,
studics o biological mcchanisms that
might cxplain thc obscrvcd associations
wcrc rcportcd and wcrc intriguing.
author
David W. Richards, dds,
phd, has been in private
practice in San Diego
since 1997 when he lef the
University of California,
San Francisco, School of
Dentistry, as an associate
professor.
I
260ap ri l 201 0
cda j ournal , vol 38 , n

4
Tcsc studics involvcd thrcc potcntial cxplanations or thc
cpidcmiological associations. Tc rst suggcstcd that bactcria
migrating through thc blood rom thc pcriodontal arca attachcd
to injurcd vascular cndothclium and uninitiatcd or accclcratcd
athcrosclcrotic proccsscs. Tis thcory was supportcd by thc
dcmonstration o pcriodontal pathogcns in athcromas takcn
rom coronary and carotid artcrics. A sccond linc o invcstiga
tion linkcd inammatory mcdiators rom pcriodontal discasc to
thc incrcascd risk or cardiovascular discasc. And nally, othcrs
suggcstcd that risk actors common bctwccn thc two discascs
may bc acting as a conoundcr in thc analysis o association.
In thc past cw ycars, sucicnt studics wcrc nally avail
ablc to pcrorm a mctaanalysis, which is
basically an analysis to dctcrminc whcthcr
thc prcpondcrancc o cvidcncc supports
or dcnics an association bctwccn thc two
discascs. Tc mctaanalyscs concludcd
that pcriodontitis is a signicant and
indcpcndcnt risk actor or athcrosclcrotic
cardiovascular discasc. At thc samc timc,
imprcssivc cvidcncc cmcrgcd rom thc
cardiovascular cld to suggcst that thc most
rcasonablc cxplanation or this association
with any chronic inammatory discasc,
such as pcriodontitis, appcars to involvc thc
rolc o systcmic inammatory mcdiators that havc bccn strongly
implicatcd in athcrosclcrotic cardiovascular discasc cvcnts.
O coursc thc dcnitivc tcst o this association is a prospcc
tivc intcrvcntion study in which paticnts with pcriodontitis arc
trcatcd and monitorcd or scvcral ycars to scc i that trcatmcnt
rcduccs thc incidcncc o cardiovascular cvcnts as comparcd to
individuals who do not havc pcriodontal trcatmcnt. Although
such prospcctivc trcatmcnt studics havc not bccn donc with
cardiovascular cvcnts as thc cnd point, intcrvcntion studics
havc dcmonstratcd a signicant ccct o pcriodontal trcatmcnt
o modcratc to scvcrc pcriodontitis on rcducing intcrmcdiatc
biomarkcrs such as cndothclial dysunction as an outcomc.
Q: Last summer there appeared in the American Journal of
Cardiology and simultaneously in the Journal of Periodontol-
ogy a consensus paper on clinical recommendations for manag-
ing patients with cardiovascular disease and periodontitis.

Tell us how this was accomplished?
A: A conscnsus papcr rclativc to thc association bc
twccn cardiovascular discasc and pcriodontitis cvolvcd
rom a collcction o activitics initiatcd rom various dircc
tions. In somc ways it rcprcscnts a vcry good cxamplc o
how orwardlooking individuals and organizations may
inucncc thc cnvironmcnt, but it ccrtainly docs not hap
pcn until lots o picccs arc in placc. Tc Amcrican Acad
cmy o Pcriodontology hcld a concrcncc on inammation
that includcd numcrous cxpcrts in pcriodontal discasc,
mcdicinc and inammation, a vcnuc or discussions across
scvcral disciplincs that may bc unitcd by inammation.
Shortly atcr that concrcncc, thc cditors o thc Amer|.cn
oarnc| o/ Ccri|o|og, hcld a conscnsus mccting on psoriasis
and cardiovascular discasc. Bascd upon thc cnthusiasm ol
lowing that mccting, somc o thc participants, who had also
attcndcd thc AAP inammation con
crcncc, suggcstcd pcriodontitis as a
possiblc arca or considcration rclativc
to a conscnsus mccting on inamma
tion and cardiovascular discasc. Tis
suggcstion was rapidly ollowcd up by
thc cditors o thc Amer|.cn oarnc| o/
Ccri|o|og, who contactcd thc AAP.
Q: Could you summarize dentistrys
role as outlined by these recommendations?
A: Tc conscnsus rcport rccom
mcnds somc vcry spccic actions by
both dcntists and cardiologists. First o all, paticnts with
modcratc to scvcrc pcriodontitis should bc inormcd that
thcrc may bc an incrcascd risk o cardiovascular discasc.
Sccondly, paticnts with modcratc to scvcrc pcriodontitis
who havc known cardiovascular risk actors should bc ad
viscd to considcr a mcdical cxam on a rcgular basis to cvalu
atc thcir cardiovascular status and risk managcmcnt.
Paticnts with both pcriodontitis and a history o car
diovascular discasc should bc inormcd that pcriodon
titis may raisc inlammatory markcrs in thc blood that
havc bccn associatcd with a signiicant incrcascd risk or
cardiovascular cvcnts. Lcntists should also cncouragc
paticnts with pcriodontitis to asscss thc risk or uturc
cardiovascular discasc cvcnts using onc o thc onlinc risk
algorithms, such as thc onc dcvclopcd by thc National
Cholcstcrol Fducation Program or thc Rcynolds Risk
Scorc. Morc cort to control standard risk actors that
acct both discascs is cncouragcd. For cxamplc, all pa
ticnts with pcriodontitis who smokc should discontinuc.
\c should also cncouragc dcntists and physicians who
arc managing paticnts with pcriodontitis and cardiovascular
patients with moderate
to severe periodontitis
should be informed that there
may be an increased risk of
cardiovascular disease.
i n t e r v i e w
cda j ournal , vol 38 , n

4
ap ri l 201 0261
discasc to closcly collaboratc on thc trcatmcnt to optimizc risk
rcduction and pcriodontal carc. It is important to cmphasizc
that pcriodontal trcatmcnt to assist in rcducing cardiovas
cular risk should bc ocuscd on rcducing and controlling thc
bactcrial accumulations and climinating inammation.
I inammation has not bccn climinatcd, it should bc as
sumcd that thc potcntial addcd risk or cardiovascular discasc
may rcmain. It is important to cmphasizc as notcd abovc that
thcrc is currcntly no dircct cvidcncc that trcating pcriodontitis
prcvcnts cithcr primary or sccondary cardiovascular cvcnts.
Howcvcr, as clinical dccisions must bc madc daily in practicc
whilc waiting or morc dcnitivc cvidcncc, it is, in thc judg
mcnt o thc conscnsus tcam, appropriatc
or dcntists and cardiologists to act on
thc currcntly availablc inormation.
Q: Could you summarize the current
understanding of inammation in
periodontitis with special regard to the
conversion of gingival inammation to
attachment loss? Could you indicate
which risk factors and diagnostic tests are
the most useful in detecting this shift?
A: Most inammation is primarily
protcctivc. Acutc inammation usually
rcsolvcs niccly i thc stimulant is rcmovcd and i thc rcsolu
tion is not intcrruptcd. Cingivitis is a pcrcct cxamplc o this
proccss. Tc inammatory rcsponsc howcvcr may bc quitc
dcstructivc undcr ccrtain circumstanccs. I thc stimulant is
chronic, such as continucd bactcrial prcscncc or continucd
sun cxposurc on thc skin, thc inammatory rcsponsc may
not bc allowcd to rcsolvc and complctc thc rcpair phasc.
Tc samc outcomc may rcsult in somc pcoplc i thc in
ammatory rcsponsc is cxaggcratcd whcn its activatcd.
Such cxaggcratcd inammatory rcsponscs may rcsult rom
gcnctic dicrcnccs among individuals or may rcsult rom
othcr inammatory discascs throughout thc body. Inam
mation may also bc dcstructivc i thc normal rcpair proccsscs
arc disruptcd, or cxamplc as a rcsult o smoking. Tcrc
arc currcntly no good indicators o thc transition rom thc
simplc rcvcrsiblc phasc o gingivitis to thc carlicst stagcs
o morc irrcvcrsiblc dcstruction. \c can, howcvcr, usc risk
actors to hclp idcntiy paticnts who arc morc likcly to havc
uturc dcstructivc pcriodontal discasc. Tc most wclldocu
mcntcd risk actors or uturc progrcssion o pcriodontitis
arc smoking, diabctcs, and ccrtain gcnctic variations.
Q: What we have seen in the literature reviews about the
association of periodontal inammation and other systemic
diseases are generalities about the inammatory burden
placed on the body by periodontitis. Are there more specic
hypotheses developed explaining linkages or causality of
systemic diseases thought to be aected by periodontitis?
A: I agrcc that using thc tcrm inammatory burdcn is thc
rcsult o not having a dcnitivc cxplanation or what is caus
ativc. I am also guilty o using that nonspccic tcrminology. Tc
cvidcncc docs support howcvcr an incrcasc in systcmic inam
mation associatcd with modcratc to scvcrc pcriodontitis. Sincc
trcatmcnt o pcriodontitis lowcrs systcmic inammation, it is
rcasonablc, in my opinion, to start with
thc statcmcnt that inammation con
nccts pcriodontitis and othcr conditions
that arc inammatory. Today, wc know
that complcx proccsscs, such as inamma
tion, cannot bc attributcd to onc causativc
chcmical cntity, but arc bcst dcncd by
pathways. I wc arc ortunatc to dctcrminc
thc critical pathways involvcd in discasc,
this may ultimatcly lcad to a bcttcr undcr
standing o causation, but at this stagc wc
rcally arc spcaking in nonspccic tcrms.
Q: As periodontists we have all been aware of the role of
inammation and disease. Now the focus seems to be largely
on inammation alone and seems to be dumbing down our
outlook and simplifying what we know to be a very complicated
disease. What about the role of bacteria and genetic misadven-
tures such as PMN adhesion defects?
A: For morc than .c ycars, many o us havc dcncd pcri
odontal discasc as a bactcrially induccd chronic inammatory
discasc. Morc than rc ycars ago, Roy Pagc and I discusscd how
gcnctic and cnvironmcntal actors may modiy this inam
matory rcsponsc to thc bactcria and attcmptcd to providc
somc contcxt to somc o thc spccic biologic mcchanisms. \c
ccrtainly should not discount thc critical rolc playcd by bactcrial
complcxcs in initiating this discasc and in discasc progrcssion.
\c also should not losc sight o various mcchanisms that arc
in thc critical paths lcading to tissuc dcstruction, such as poly
morphonuclcar lcukocytcs, macrophagcs, and antibodics. Mul
tiplc ccll typcs arc involvcd and somc dcstructivc mcchanisms
arc wcllstudicd, such as matrixmctalloprotcinascs. Tc addcd
cmphasis in thc past rc ycars on inammation is primarily thc
rcsult o thc trcmcndous cvidcncc on inammation in discascs
the most well-documented
risk factors for future
progression of periodontitis
are smoking, diabetes, and
certain genetic variations.
262ap ri l 201 0
cda j ournal , vol 38 , n

4
such as cardiovascular discasc. Tosc ndings shapc our knowl
cdgc and rcscarch in thc pcriodontal arca, but inammation
is just part o that broadcr discussions on risk actors, patho
gcnic mcchanisms, and intcractions among multiplc discascs.
Q: Could you give us some guidance on the few recent clinical
intervention studies that have not resulted in an apparent
eect of periodontal treatment on pregnancy outcomes and
cardiovascular disease events?
A: In rcccnt ycars, somc clinical trials dcsigncd to cvaluatc
thc ccct o pcriodontal trcatmcnt on systcmic conditions, such
as prctcrm dclivcry, havc bccn cithcr disappointing or unimprcs
sivc. \c, o coursc, must start by considcr
ing thc possibility that pcriodontal discasc
has no or minimal ccct on prctcrm dcliv
cry, or that thc trcatmcnt was inadcquatc
to havc a clinically mcaningul ccct. Tc
gcncral conccrns that I havc with somc
studics is that thc trcatmcnt has bccn
protocol drivcn rathcr than cndpoint
drivcn. Tis mcans that or cxamplc thc
protocol may dcnc trcatmcnt as scaling
and root planing or c minutcs pcr quad
rant. All paticnts would thcn bc trcatcd
as spccicd by that protocol. Tis is vcry
dicrcnt thcn spcciying that all paticnts should bc trcatcd by
whatcvcr proccdurcs arc ncccssary to climinatc all inammation.
My sccond conccrn is that pcriodontal trcatmcnt stud
ics continuc to bc modcst in sizc and may wcll bc too small
to cvaluatc trcatmcnt cccts in such complcx conditions.
Q: Is it possible that the associations between these systemic
diseases and periodontitis are due to the same or similar abnor-
malities in the immune systems of individuals with each disease
that results in the inammatory mediation of the diseases and
that is where the association ends not involving direct causality?
A: Onc o thc plausiblc cxplanations or associations
bctwccn pcriodontal discasc and othcr conditions is that
thcrc arc common undcrlying dcccts that lcad to dicr
cnt discascs in dicrcnt tissucs. Undcrlying dcccts may bc
gcnctic or cnvironmcntal, such as smoking. As indicatcd,
this would mcan that thc causality arrow may not go rom
pcriodontitis to cardiovascular discasc, but thc arrow may
go rom somc spccic mcchanism to both discascs. I am
comortablc with that possiblc cxplanation. So ar thcrc
has bccn limitcd cvidcncc to support that conccpt.
Q: What are some of the population eects of this informa-
tion? What should dentistry be doing to promote better overall
health? Do you have recommendations for strategies that
dentists can use when dealing with our medical colleagues?
A: As wc indicatcd carlicr, shorttcrm inammation is good
and protcctivc. It is chronic inammation that is not hcalthy and
has bccn implicatcd in most discascs o aging. As thc individu
als rcsponsiblc or managing onc o thc most common chronic
inammatory discascs, it is rcasonablc or us to assist our paticnts
in controlling thcir inammation. In my opinion, this involvcs
cducating thcm about inammation and guiding bcttcr control
o chronic inammation on a systcmic basis. In my opinion, thc
discussion with our mcdical collcagucs may
bc wcllscrvcd at this timc by ocusing on
coopcration to control inammation in
our sharcd paticnts. Tis is a vcry dicrcnt
discussion than arguing that pcriodontal
trcatmcnt will rcducc hcart attacks.
Q: What do you see to be the future
of this information and its practical
application?
A: Mcdical spccialtics or many
ycars havc bccn organizcd by organs
and tissucs bascd on anatomic obscrva
tions. Such distinctions havc lcss and lcss rclcvancc as wc
bcttcr undcrstand thc broad mcchanisms such as inamma
tion that may acct multiplc tissucs. Tc uturc application
o this knowlcdgc rcquircs prospcctivc trcatmcnt studics
that dcnc whcthcr or not pcriodontal trcatmcnt makcs a
substantial dicrcncc in thc cxprcssion o ccrtain discascs.
I it docs, thc world changcs bccausc pcriodontal trcatmcnt
thcn bccomcs a ccntral part o ovcrall hcalth maintcnancc.
As wc wait or such studics it sccms vcry rcasonablc or
us to cducatc paticnts about what is known and to hclp thcm
managc thcir own hcalth by assisting in thc rcduction o
inammation.
to request a printed copy of this article, please contact David W. Richards, DDS, PhD,
4060 Fourth Ave., Suite 303, San Diego, Calif., 92103-2120.
references
1. Friedewald VE, Kornman KS, et al, The American Journal of Cardiology and Journal of
Periodontology editors consensus: periodontitis and atherosclerotic cardiovascular disease. J
Periodontol 80(7):1021:32, 2009.
addi ti onal i nformati on
National Cholesterol Education Program, americanheart.org/presenter.jhtml?identier=4638.
Reynolds Risk Score, www.reynoldsriskscore.org. Accessed Feb. 8, 2010.
in my opinion,
the discussion with our
medical colleagues may be
well-served at this time by
focusing on cooperation to
control inammation in our
shared patients.
i n t e r v i e w
cda j ournal , vol 38 , n

4
ap ri l 201 0263
Clinical Challenges
in Diagnosing
and Monitoring
Periodontal Inflammation
richard t. kao, dds, phd; stacey lee; and lisa harpenau, dds, ms
abstractAn understanding of the new paradigm that periodontal disease may
have a relationship to various systemic inammatory conditions of aging reinforces
the importance of monitoring oral inammation. As oral health care providers, it is
important to accurately assess, monitor, and manage our patients inammatory load.
This review examines some of the clinical challenges associated with diagnosing and
monitoring periodontal inammation. Given these diculties, patient management may
be more eective when these patients are co-managed with a periodontist.
uring thc opcning ccrcmony
at thc .cc, Annual Mccting
o thc Amcrican Acadcmy
o Pcriodontology, kcynotc
spcakcr and rcnowncd car
diologist Paul Ridkcr, ML, MPH, chal
lcngcd dcntal procssionals to considcr
thcir potcntial rolc in prcvcnting many
o todays systcmic discascs. Ridkcr
dcscribcd a paradigm shit that is occur
ring in mcdicinc. Rcccnt cvidcncc sug
gcsts that chronic inammation plays an
important rolc in mctabolic discascs, such
as athcrosclcrosis, typc . diabctcs, strokc
ischcmic cvcnts, and Alzhcimcrs discasc.
Tc incidcncc and amount o inamma
tion that paticnts cxpcricncc, or thcir
inammatory load, may bc critical to thc
onsct and progrcssion o thcsc discascs.
Rcccntly, considcrablc rcscarch has
ocuscd on thc immunomodulatory cccts
p e r i o d o n ta l i n f l a mmat i o n
o scvcral nutricnts, such as atty acids,
antioxidants, carbohydratcs, amino acids,
micronutricnts, and alcohol, which play
a crucial rolc in maintaining an opti
mal immunc rcsponsc.
r
Ncw cvidcncc
now suggcsts that i thc inammatory
load an individual cxpcricnccs can bc
minimizcd, thc onsct o thcsc discascs
may bc rctardcd.
.
In his prcscntation,
Ridkcr suggcstcd that dcntists havc a
rolc in contributing toward thc gcncral
hcalth o paticnts by monitoring and
managing oral inammation, thcrcby
dccrcasing thcir inammatory load.
Are We Measuring the Correct
Parameters?
Inammation in thc oral cavity is com
mon duc to thc cvcrprcscnt microbial o
ra inhabiting this part o thc body and thc
act that tccth rcgularly comc in contact
authors
Richard T. Kao, dds, phd,
is an associate clinical
professor, University of
California, San Francisco;
associate adjunct
professor at Arthur
A. Dugoni School of
Dentistry, San Francisco;
and in private practice in
Cupertino, Calif.
D
Stacey Lee is a research
associate.
Lisa Harpenau, dds, ms,
is an associate professor,
Arthur A. Dugoni School of
Dentistry, San Francisco.
264ap ri l 201 0
cda j ournal , vol 38 , n

4
tooth is dividcd into our scgmcnts, and
cach scgmcnt is scorcd as cithcr positivc
or ncgativc or blccding on probing. Tc
pcrccntagc o sitcs with blccding can thcn
bc calculatcd (table 1). In an adaptation
o thc CIS, this TiMF charting o thc
uppcr right quadrant rccords a possiblc o
six possiblc blccding points pcr tooth. In
this casc, thcrc arc r/ blccding sitcs out
o a total o . sitcs. Tis givcs a blccd
ing indcx o c pcrccnt. Tc goal ovcr
cach maintcnancc visit is to dccrcasc
thc pcrccntagc blccding indcx. Tough
collccting thcsc data takcs timc, this can
ccctivcly bc accomplishcd at thc rccall
appointmcnts. Tcsc indiccs arc advanta
gcous bccausc thcy providc paticnts with
a quantiablc scorc that cnablcs thcm
to dctcrminc how wcll thcy arc doing in
controlling pcriodontal inammation.
\hcn intcracting with paticnts,
clinicians should cxplain that blccd
ing is simply a rccction o thc lcvcl o
inammation that cxists at thc dcntal
cpithclialconncctivc tissuc intcracc and
it can bc rcvcrsiblc. Blccding on probing
docs not ncccssarily prcdict uturc discasc
activitics. Iang ct al. studicd blccding on
probing as a prcdictor or thc progrcssion
o pcriodontal discasc and ound that
it had low positivc prcdictivc valuc or
thc progrcssion o pcriodontitis.
/
In act,
thcy ound that thc consistcnt abscncc o
blccding ovcr scvcral visits was an cxccl
lcnt prcdictor o pcriodontal stability.
Tcrcorc, paticnts nccd to undcr
stand that blccding is a uscul indicator
o thc prcscncc o pcriodontal inam
mation at a particular point in timc.
Sccond, thcy should bc counsclcd
that it is rcvcrsiblc with improvcd oral
hygicnc and thcrapy. Iastly, i dcntists
arc conscicntious about gathcring thcsc
data and sharing rcsults with paticnts,
this can bc an ccctivc way to improvc a
paticnts oral inammatory load status.
with thc cxtcrnal cnvironmcnt. Tc pcrio
dontium providcs a barricr that prcvcnts
microbial inux into thc body. Consc
qucntly, thc immunc systcm is vcry activc
in thc pcriodontium. Not surprisingly
thcn, pcriodontal inammation rcprcscnts
thc prcdominant orm o oral inamma
tion. \hcthcr onc bclicvcs in Ridkcrs thc
sis or arc simply trying to maintain thcir
paticnts oral hcalth, it is important to
rccognizc that clinical monitoring and con
trol o pcriodontal inammation should
bc kcy tasks o all oral hcalth providcrs.
But arc dcntists doing a good job
monitoring and idcntiying pcriodontal
inammation` Most mcmbcrs o thc
dcntal tcam havc a gcncral apprccia
tion o hcalthy gingiva (figure 1a). Oral
changcs associatcd with inammation
includc altcrcd gingival appcarancc (c.g.,
cdcma, cnlargcmcnt, color changcs, lack
o a kniccdgcd and scallopcd shapc)
(figure 1b), gingival blccding, discomort
pain, unplcasant tastc, and halitosis. Onc
problcmatic issuc is that or many pa
ticnts, thcsc arc common occurrcnccs so
complaints arc inrcqucnt. For clinicians,
thcsc clinical paramctcrs arc dicult
to documcnt or quantiy. As a rcsult,
thcsc inammatory signals arc scldom
rccordcd at and bctwccn dcntal visits.
Tis commcntary will rcvicw various
ways in which clinicians asscss inam
mation. Somc o thc actors compli
cating thc accuratc mcasurcmcnt o
inammation also will bc discusscd.
Finally, somc possiblc solutions to
thcsc problcms will bc ocrcd.
Factors That Compromise the
Accurate Discrimination of
Periodontal Inammation
Gingival Inammation and Bleeding
Tough gingival blccding is an obvi
ous manicstation o inammation,
monitoring o this clinical symptom is
inconsistcnt. Slight gingival blccding oc
curs so rcqucntly that it is scldom ully
apprcciatcd by both paticnts and dcntal
hcalth carc providcrs. Unlcss it ollows
an acutc traumatic cpisodc, blccding
should always bc rccognizcd as a sign
o pathosis. Unortunatcly, howcvcr,
most clinicians mcrcly commcnt on this
obscrvation, lcaving paticnts with littlc
mcans to comparc how wcll thcy arc
controlling thcir inammatory load.
Scvcral indiccs arc uscd to clinically
asscss gingival inammation. Tc two
most rcqucntly uscd mcasurcmcnts arc
thc gingival indcx, CI, and thc papilla
blccding indcx, PBI.
,
Tc CI can bc uscd
to accuratcly comparc gingival inam
matory status at rccall visits and activc
maintcnancc thcrapy scssions. Tc PBI
is an casily rcproduciblc asscssmcnt o
thc gingival status that can bc uscd to
cnhancc paticnts apprcciation or plaquc
control. Unortunatcly, thcsc two tcsts
arc rclcgatcd to clinical rcscarch and
arc not otcn uscd in clinical practicc.
Somc practiccs, howcvcr, arc morc
diligcnt, incorporating thc gingival indcx
simplicd, CIS, or gingival blccding
indcx, CBI, into thcir cxaminations.
,

Both mcthods arc similar in that cach
fi gure 1a. The clinical presentation
of a healthy periodontium with no signs of
inammation.
fi gure 1b. In this presentation of chronic
periodontitis, marginal redness, gingival
enlargement, and some localized bleeding on
probing are present in response to localized plaque.
p e r i o d o n ta l i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 201 0265
havc bccn dcvclopcd or rcscarch pur
poscs, only thc Florida clcctronic probc
is clinically availablc.
r.
Tc rcproducibility
o thc Florida probc is supcrior to manual
probing, but its incorporation into clini
cal practicc is not prcvalcnt. Fvcn morc
critical than probing orcc is thc altcrcd
position o thc probing dcpth in thc prcs
cncc o inammation. At an inamcd sitc,
thc riability o thc tissuc otcn rcsults in
casy pcnctration, cvcn with a rclativcly
light probing orcc. In somc instanccs, thc
probc may pcnctratc to thc bonc margin.
Tis rcsults in an ovcrcstimation o thc
truc pockct dcpth.
r,r
Luc to thcsc actors
that acct thc accuracy o pcriodontal
probing, it can takc somc timc bcorc pcri
odontal brcakdown can bc asccrtaincd.
Tough much o thc clinicians ocus
is on pcriodontal pockct dcpth, onc
should bc attcntivc to thc mcasurcmcnt
o clinical attachmcnt lcvcl, thc prcscncc
and prcvalcncc o gingival inammation,
and radiographic cvidcncc o alvcolar
bonc loss. I a clinician subscribcs to thc
conccpt that dccrcasing oral inamma
tory load promotcs oral and systcmic
hcalth, thcy must also rccognizc that
it may takc considcrablc timc to dc
tcct changcs, and thc proccss may bc
raught with tcchnical dicultics.
Periodontal Biotypes
Historically, Ochscnbcin and Millcr
havc discusscd thc importancc o thick
vcrsus thin gingival biotypcs and how
this distinction can inucncc rcstorativc
trcatmcnt.
r
Morc rcccntly, this conccpt
has bccn cxpandcd. Tc gingival biotypc
is a dcscription o thc sot and bony tis
suc surrounding a tooth. Tick and thin
gingival biotypcs rcspond dicrcntly to
inammation, rcstorativc trauma, and
paraunctional habits, and thc rcsult
ing dcccts dictatc dicrcnt typcs o
trcatmcnt modalitics.
r/
For cxamplc,
Periodontal Pocketing and its
Measurements
Probing dcpth has bccomc thc stan
dard by which most practitioncrs monitor
pcriodontal discasc. Unortunatcly, this is
not rcally a good indicator or pcriodontal
inammation. Attachmcnt loss, rccctcd
by incrcascd probing dcpth and changcs
in gingival crcstal lcvcls, dcmonstratcs
pcriodontal brcakdown. Howcvcr, it
only yiclds thc amount o pcriodontal
brcakdown at that point. It cannot bc
dctcrmincd whcthcr thc discasc occurrcd
in thc past and has bccn managcd, or
whcthcr thcrc is currcnt discasc activ
ity simply by looking at onc sct o data.
Tis is akin to looking at a singlc ramc
o a cartoon strip and trying to gurc out
what camc bcorc or will comc atcrward.
It is dicult to ollow thc storylinc.
Only with multiplc chartings o
attachmcnt lcvcl (probing dcpth and
gingival crcstal changc in rclationship
to thc ccmcntocnamcl junction) can thc
practitioncr dctcct pcriodontal brcak
down ovcr timc. Unortunatcly, most
clinical practiccs mcasurc only thc probing
dcpths, paying littlc or no attcntion to
gingival rcccssion and cnlargcmcnt. \hilc
monitoring attachmcnt lcvcl is an csscn
tial part o pcriodontal diagnosis, it must
bc intcrprctcd togcthcr with gingival
inammation and swclling, and radio
graphic cvidcncc o alvcolar bonc loss.
Fvcn in rarc situations whcrc both
probing dcpths and gingival rcccssion arc
monitorcd ovcr timc, intcr and intra
cxamincr variability may account or a ..
to mm dicrcncc in probing dcpth mca
surcmcnts, and it may takc onc to two
ycars bcorc pcriodontal dcstruction can
bc accuratcly dctcrmincd.
8,,
Tis is not a
vcry ccctivc stratcgy or monitoring and
managing pcriodontal inammatory load.
A numbcr o actors can acct thc
accuracy o pcriodontal probing. Tcsc
includc probc sizc, probing angulation,
tooth anatomy, probing orcc, and thc in
ammatory status o thc pcriodontal tis
suc. Scvcral studics havc shown that pcri
odontal probing otcn ails to rccord thc
truc pockct dcpth.
rc,rr
Tough probc sizc
and angulation can bc controllcd, crrors
arc morc rcqucnt duc to probing orcc
and thc scvcrity o inammation in thc
tissuc. Probing orccs o . g havc bccn
suggcstcd as appropriatc, howcvcr, intcr
and intracxamincr probing orccs havc
bccn shown to vary rom to rc g.
r.,r
Although scvcral clcctronic probcs
TABLE 1
TIME for Periodontics - [Joe Perio Session - 10/22/2009]
Furcation Classification --- --- --- --
Bleeding - Suppuration B B B -B - --B B - B B--
Gingival Width --- 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
Attachment Loss --- 7 4 4 2 > 6 5 3 4 4 3 4 4 3 2 --- ---
Recession/Enlargement - 7-4 -4 - 2-5 -3 - 4-3 -3 - 3-3 -4 - 3-3 -2 ---
Buccal Pocket Depths --- 3 2 3 3 7 6 4 2 4 4 2 3 4 2 3 3 2 3 3 2 3
Maxillary Arch 1 2 3 4 5 6 7 8
Palatal Pocket Depths --- > 7 > 6 2 9 4 2 6 7 2 6 6 2 3 3 2 3 3 2 3
Recession/Enlargement - 3-3 -4 --- - 3-3 -3 - 3-3 -3 --- ---
Attachment Loss --- > 8 > 3 3 4 3 6 7 3 6 3-- --- ---
Bleeding - Suppuration B B B B - B --B B - B B
Tooth Mobility - II+ I+ - - - - -
Prognosis - Hpls Poor Guard Poor Guard Fair Fair

266ap ri l 2 01 0
cda j ournal , vol 38 , n

4
tion sprcads around thc gingival margin.
In thin biotypc, thc hcalthy appcarancc
o a kniccdgcd gingival margins and
scallopcd papillac. \ith inammation,
thc papillac bccomc slightly cnlargcd
and cdcmatous, with bluntcd margins
(figures 3a). Two hallmark rcsponscs
to chronic inammation arc gingival
rcccssion and loss o intcrproximal tis
suc, rcsulting in a visiblc spacc at thc
apcx o thc intcrproximal cmbrasurc.
As prcviously notcd, paticnts with this
gingival biotypc will usually havc vcry
shallow pockct dcpth. \ith chronic pcri
odontal discasc, attachmcnt loss is otcn
cvidcnccd not by incrcasing pockct dcpth,
but by incrcasing gingival rcccssion. Ols
son and Iindhc ound that approximatcly
r pcrccnt o thc Scandinavian popula
tion has thin gingival biotypcs.
r,
It is not
cnough to monitor only probing dcpths
in thcsc paticnts sincc this may givc thc
illusion that thcrc is no changc. In thcsc
cnlargcd cdcmatous appcarancc, and
blccding on probing. In thc prcscncc o
longstanding chronic inammation,
thc gingival tissuc will bccomc morc
brous. It may rcmain rm and pink,
but thc tissuc appcars thickcr with
incrcascd pockct dcpth. Blccding on
probing may bc lcss obvious. In paticnts
with poorly controllcd diabctcs, thcrc
may also bc chronic subclinical absccss
ormation whcrc thc gingival margin is
highly thickcncd and rollcd. \hcrcas
carly inammatory changcs arc casy to
rcvcrsc, chronic inammation usually
rcsults in pockct ormation and changcs
in thc osscous architccturc that otcn
will rcquirc surgical intcrvcntion.
It is morc challcnging to monitor
inammation in thc thin gingival biotypc.
Farly signs arc otcn rccctcd in subtlc
marginal rcdncss. Sincc thc intcrdcntal
cmbrasurc is thc sitc o grcatcst plaquc
accumulation and morc dicult to main
tain, inammation tcnds to initiatc in thc
papilla arca. Subscqucntly, thc inamma
whcn tccth arc cxtractcd, thcsc tissuc
biotypcs rcact with dicrcnt hcaling
bonc rcmodcling rcsponscs, ncccssitat
ing variablc approachcs in implant sitc
prcparation.
r8
Tis scction will prcscnt
inammatory changcs associatcd with
thcsc pcriodontal biotypcs and thc di
cultics in monitoring thcsc changcs.
Tick gingival tissuc is probably thc
imagc most associatcd with pcriodontal
hcalth (figures 2a-b, table 2). Tc tissuc
appcars dcnsc with a rclativcly largc zonc
o attachcd gingiva and a thickcr undcr
lying bony architccturc. Tin gingival
tissuc tcnds to bc dclicatc and almost
transluccnt in appcarancc (figures 3a-b,
table 3). It appcars riablc with a minimal
zonc o attachcd gingiva. Tc sottissuc
topography is highly acccntuatcd with
thin or minimal bonc ovcr thc labial
roots. Fach o thcsc gingival biotypcs
rcsponds dicrcntly to inammation.
Farly in thc inammatory proccss,
thick pcriodontal biotypcs otcn cxhibit
marginal inammation, cyanosis, an
fi gure 2a. The clinical presentation of thick
gingiva. Note that with chronic inammation,
the tissue becomes brotic and pocket
formation occurs.
fi gure 3a. The clinical presentation of thin
gingival biotype. Note the gingival recession and
in areas of advanced periodontal breakdown,
there is loss of interproximal papilla.
fi gure 2b. The type of osseous
architecture associated with this
gingival tissue type.
fi gure 3b. The osseous architecture
associated with thin gingival biotype.
TABLE 2
Characteristics of Thick
Gingival Biotype
n
Relatively flat soft tissue and bony
architecture
n
Dense fibrotic soft tissue
n
Relatively large amount of attached

gingiva
n
Thick underlying osseous form
n
Relatively resistant to acute trauma
n
Reacts to disease with pocket formation

and infrabony defect formation

TABLE 3
Characteristics of Thin
Gingival Biotype
n
Highly scalloped soft tissue and bony

architecture
n
Delicate friable soft tissue
n
Minimal amount of attached gingiva
n
Thin underlying bone characterized by

bony dehiscence and fenestration

n
Reacts to insults and disease with

gingival recession
p e r i o d o n ta l i n f l a mmat i o n
cda j ournal , vol 38 , n

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ap ri l 2 01 0267
Aggressive Periodontal Disease
An altcrcd immunc systcm, as notcd
in thc prcvious scction, can rcsult in an
unusual inammatory rcsponsc. Simi
larly, altcrcd immunc ccll unction can
rcsult in rapid pcriodontal dcstruction
as dcmonstratcd in paticnts with ag
grcssivc pcriodontitis who arc othcrwisc
hcalthy. Tc most common orms o
thcsc aggrcssivc discascs arc localizcd
aggrcssivc pcriodontitis (prcviously
callcd localizcd juvcnilc pcriodontitis or
prcpubcrtal pcriodontitis) and gcncral
izcd aggrcssivc pcriodontitis (prcviously
callcd rapidly progrcssivc pcriodontitis).
Unlikc pcriodontitis that is a manics
tation o systcmic discasc or nccrotizing
pcriodontal discasc whcrc thc inam
mation is vcry dramatic and visiblc,
aggrcssivc pcriodontitis can bc clinically
on an altcrnativc calcium channcl blockcr
showcd rcgrcssion in thcir nicdipinc
induccd gingival cnlargcmcnt.
.c
Tcrcorc,
sincc gingival cnlargcmcnt is associatcd
with calcium channcl blockcrs, it may
bc rcasonablc or paticnts to inorm thc
supcrvising cardiologist about thcir oral
situation and rcqucst a switch to anothcr
calcium channcl blockcr i ncccssary.
Cingival cnlargcmcnt can crcatc clcts
and morc arcas or plaquc accumulation,
making it morc dicult or paticnts to
maintain good oral hygicnc. Tis cvcntual
ly can rcquirc that a gingivcctomy bc pcr
ormcd to rcmovc thc hypcrplastic tissuc.
Paticnts should always bc inormcd that
thc rcqucncy o surgical rctrcatmcnt is
highly dcpcndcnt on thc ratc o rcgrowth.
Tcrcorc, propcr oral homc carc and pcri
odontal rccall appointmcnts arc csscntial.
cascs, thc inammatory rcsponsc is rc
cctcd in thc continucd brcakdown o thc
thin buccal bonc, clinically visualizcd as
gingival rcccssion. In thcsc paticnts, it is
ncccssary to documcnt at lcast oncc a ycar
thc attachmcnt loss that has occurrcd.
Drug-Inuenced Gingival Overgrowth
A numbcr o mcdications havc
bccn ound to altcr thc gingivas im
munc rcsponsc to plaquc biolm. Tcsc
includc anticonvulsants (phcnytoin),
immunosupprcssivc mcdications (cy
closporin), and calcium channcl blockcrs
(nicdipinc, amlodipinc, and diltiazcm).
Tcsc mcdications modulatc thc immunc
systcm such that, whcn combincd with
poor plaquc control, gingival cnlargc
mcnt occurs. Tc gingiva on thc labial
aspcct o thc antcrior tccth is usually
morc scvcrcly acctcd than thc gingiva
o postcrior tccth. Tc swclling is mainly
brous tissuc and may appcar lobu
latcdmultilobulatcd (figures 4a-b).
Tis gingival cnlargcmcnt is mostly
duc to incrcascd dcposition o cxtraccl
luar matrix matcrial. \ith good oral
hygicnc, thc cnlargcmcnt is lcss prolicra
tivc or abscnt altogcthcr. Intcrcstingly,
thc amount o cnlargcmcnt docs not
corrclatc to thc mcdication dosagc. Tc
thrcshold dosagc that clicits this clini
cal rcsponsc is vcry individualistic. Tis,
couplcd with thc obscrvation that good
oral hygicnc tcnds to minimizc gingival
cnlargcmcnt, suggcsts that cach paticnts
immunc systcm has its own thrcshold.
Otcntimcs changing mcdications is
not possiblc, as in thc casc o cpilcptic
paticnts who arc taking anticonvulsants
and organ transplant paticnts taking
immunosupprcssivc mcdications. It is
known that calcium channcl blockcrs
arc critical in thc managcmcnt o cardiac
angina, arrhythmias, and hypcrtcnsion.
Howcvcr, c pcrccnt o paticnts placcd
fi gure 4a. Dilantin-induced gingival
enlargement is multilobulated with deep
clefs such that maintaining good oral hygiene
is dicult. (Case treated and contributed by
Dr. G. Pieroni.)
fi gure 4b. Even afer gingivectomy, marginal
inammation is still present despite improved
oral hygiene. (Case treated and contributed by
Dr. G. Pieroni.)
fi gures 5a- b. A case of localized aggressive periodontitis where there is rapid localized bone loss primarily
associated with anterior teeth. The patient had minimal level of dental care during adolescence. With the rst
comprehensive dental examination during the patients mid-20s, advanced bone loss was a new revelation. Radiographs
of the patients anterior dentition are provided (figure 5a) and clinical presentation of lower anterior (figure 5b), which
the patient had no sense that there was a problem. Dental history revealed prior dental visits did not include anterior
periapical radiographs and the rapid periodontal atachment loss was not diagnosed in a timely fashion.
fi gure 5a.
fi gure 5b.
268ap ri l 201 0
cda j ournal , vol 38 , n

4
papcr has argucd this is a dicult task
that will rcquirc somc ncw approachcs.
First, clinicians must bc morc ccctivc
in monitoring gingival inammation, incor
porating ccctivc mcchanisms such as thc
CIS or CBI into thc pcriodontal maintc
nancc programs. By rccording blccding sitcs
and dctcrmining thc pcrccntagc o total
sitcs that blccd on probing, inammation
can bc mcasurcd ovcr timc and clinicians
can ocr thcir paticnts quantiablc data
that illustratc how ccctivc thcir corts at
homc arc in climinating inammation.
Sccond, it must rccognizc that prob
ing dcpth inormation whcn mcasurcd
singularly is usclcss. It is important to
mcasurc both thc probing dcpth as wcll
as thc gingival rcccssion on a rcgular
basis or this is thc only way to monitor
changcs in attachmcnt lcvcl. I onc simply
mcasurcs thc probing dcpth, paticnts with
thin biotypc may havc a stablc probing
dcpth but thc rcccssion may progrcss. For
pcriodontal risk managcmcnt, pcriodon
tal dcstruction can bc only bc ollowcd
by intcrprcting changcs in attachmcnt
lcvcl and not just probing dcpth.
Tird, givcn all thc dicultics in accu
ratcly monitoring and managing pcriodon
tal inammation, it is crucial thc dcntal
tcam work togcthcr. Tc hygicnists ccc
tivcncss in cducating and motivating pa
ticnts can bc incrcascd considcrably whcn
blccding sitcs arc mcasurcd via thc CIS
or CBI. Cathcring this inormation also
pcrmits thc dcntist to asscss changcs in a
paticnts pcriodontal inammatory load.
Finally, considcring all thc actors such
as gingival tissuc biotypcs, drug intcrac
tion, aggrcssivc pcriodontitis, and
smoking that can compromisc thc
accuratc asscssmcnt o pcriodontal
inammation, it would bc grcatly
bcnccial or thc dcntal tcam to involvc a
pcriodontist to hclp comanagc cascs that
arc not stablc.
studics cstablishcd that cigarcttc smoking
incrcascs thc ovcrall risk or scvcrc
pcriodontal discasc by ..8 timcs indcpcn
dcnt o conounding actors o dcntal
plaquc and calculus.
../
Additionally, thc
scvcrity o attachmcnt loss is dircctly
rclation to both thc amount (packs) and
thc lcngth o history or smoking.
.,.

Today, this is discusscd in tcrms o ci
thcr packycars or numbcr o cigarcttcs pcr
day. Tough thc rst and orcmost ccct
o smoking is immunosupprcssivc ccct
on thc host, thcrc is incrcascd bactcrial
subtlc. Tis is cspccially truc o localizcd
aggrcssivc pcriodontitis whcrc thc discasc
occurs during adolcsccncc (figures 5a-b).
Tcrc arc two orms. localizcd aggrcssivc
pcriodontitis, in which bonc dcstruction
is limitcd to thc rst molars and incisors,
and a gcncralizcd orm whcrc dcstruc
tion is not limitcd. Tc prcvalcncc o this
discasc is approximatcly c.. pcrccnt in
whitcs and Asians and c.8 to .., pcrccnt
in blacks in thc Unitcd Kingdom.
.r
Similar
ndings wcrc ound in thc Unitcd Statcs.
..
Lcspitc thc rapid and aggrcssivc naturc
o bonc dcstruction associatcd with thcsc
discascs, thc gingiva usually shows cw,
i any, signs o inammation. Also, thcrc
is scldom any notablc amount o gingival
blccding, plaquc, or calculus. Tus thc con
dition otcn cscapcs dctcction until adult
hood. By that timc, bonc dcstruction has
ccascd, but thc dccp pcriodontal dcccts
lcad to thc dcvclopmcnt o pcriodontal ab
sccsscs with associatcd pain and swclling.
Unlikc druginucnccd gingival
ovcrgrowth whcrc thc immunc systcm
is modulatcd to producc an cxaccrbatcd
rcsponsc, thc gcnctically transmittcd
ncutrophil dysunction associatcd with
aggrcssivc pcriodontitis suggcsts that
thc immunc systcm can bc modulatcd to
rcsult in vcry rapid bonc dcstruction with
lcss obvious gingival inammation. Pcri
odic pcriapical radiographs and pcriodon
tal probing arc csscntial or carly dctcc
tion o this orm o pcriodontal discasc.
Smoking
Smoking has bccn long rccognizcd as a
risk actor or cardiovascular and pulmo
nary discasc. Tough carly studics o
smoking and incrcascd pcriodontal discasc
discountcd its ctiologic contribution as thc
rcsult o poor oral hygicnc and accumula
tion o local actors, studics in thc r,ccs
clcarly indicatc that tobacco usc incrcasc
thc risk or pcriodontal discasc.
../
Tcsc
adhcsion, highcr lcvcls o putativc pcri
odontal discasc associatcd microora, and
inammatory cytokincs.
.8r
Sincc smok
ing is proinammatory, clinicians should
considcr cithcr providing or rccrring
paticnts to smoking ccssation programs.
Conclusions: Possible Solutions
A paradigm shit has occurrcd in our
undcrstanding o pcriodontal discasc.
As wc lcarn morc about pcriosystcmic
links, it bccomcs clcar that our ormcr
rcliancc on monitoring probing dcpths
and attachmcnt loss is no longcr cnough.
I pcriodontal inammation rcsults in an
incrcascd inammatory load that is intcr
rclatcd to scrious and widcsprcad systcmic
discascs, attcntion should bc paid on
thc accuratc dctcction, monitoring, and
rcvcrsal o gingival inammation. Tis
it is important to
measure both the probing
depth as well as the gingival
recession on a regular
basis for this is the only
way to monitor changes in
atachment level.
p e r i o d o n ta l i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 201 0269
16. Ochsenbein C, Ross A, A re-evaluation of osseous surgery.
Dent Clin North Am 13:87-103, 1969.
17. Kao RT, Pasquinelli K, Thick vs. thin gingival tissue: a key
determinant in tissue response to disease and restorative
treatment. J Calif Dent Assoc 30(7):521-26, July 2002.
18. Kao RT, Fagan MC, Conte GJ, Thick vs. thin gingival biotypes:
a key determinant in treatment planning for dental implants. J
Calif Dent Assoc 36(3):193-8, March 2008.
19. Olesson M, Lindhe J, Periodontal characteristics in individu-
als with varying forms of the upper central incisors. J Clin
Periodontol 18:78-82, 1991.
20. Westbrook P, Bednarczyk EM, et al, Regression of
nifedipine-induced gingival hyperplasia following switch to
same class calcium channel blocker, Isradipine. J Periodontol
68:645-50, 1997.
21. Saxby M, Juvenile periodontitis. An epidemiological study
in the West Midlands of the United Kingdom. J Clin Periodontol
14:594-8, 1987.
22. Melvin WL, Sandifer JB, Grey JL, The prevalence and the sex
ratio of juvenile periodontitis in a young racially mixed popula-
9. Haajee AD, Socransky SS, Atachment level changes in de-
structive periodontal disease. J Clin Periodontol 13:461-72, 1986.
10. Van Velden U, Probing force and the relationship of the
probe tip to the periodontal tissue. J Clin Periodontol 6:106-14,
1979.
11. Listgarten MA, Periodontal probing: what does it mean? J
Clin Periodontol 7:165-76, 1980.
12. Magnusson I, Clark WB, et al, Atachment level measure-
ments with a constant force electronic probe. J Clin Periodon-
tol 15:185-8, 1988.
13. Hassell TM, Germann MA, Saxer UP, Periodontal probing:
investigator discrepancies and correlations between probing
force and probing depth. Helv Odontol Acta 17:38-42, 1973.
14. Armitage GC, Svanberg GK, Loe H, Microscopic evaluation
of clinical measurements of connective tissue atachment
level. J Clin Periodontol 4:173-90, 1977.
15. Polson AM, Caton JG, et al, Histological determination of
probe tip penetration into gingival sulcus of humans using
an electronic pressure-sensitive probe. J Clin Periodontol
7:479-88, 1980.
references
1. Kontogianni MD, Zampelas A, Tsigos C, Nutrition and inam-
matory load. Ann NYAcad Sci 1083:214-38, 2006.
2. Ridker PM, Danielson E, et al, Rosuvastatin to prevent vascu-
lar events in men and women with elevated C-reactive protein.
N Engl J Med 359:2195-207, 2008.
3. Loe H, Silness J, Periodontal disease in pregnancy, preva-
lence and severity. Acta Odontol Scand 21:532-51, 1963.
4. Muhlemann HR, Son S, Gingival sulcus bleeding A leading
symptom in initial gingivitis. Helv Odontol Acta 15:107-13, 1971.
5. Lindhe J, Textbook of Clinical Periodontology, Copenhagen,
Munksgaard, 1983.
6. Ainamo J, Bay I, Problems and proposals for recording
gingivitis and plaque. Int Dent J 25:229-35, 1975.
7. Lang NP, Joss A, et al, Bleeding on probing. A predictor for
the progression of periodontal disease. J Clin Periodontol
13:590-6, 1986.
8. Haajee AD, Socransky SS, Goodson JM, Comparsion of
dierent data analysis for detecting changes in atachment
level. J Clin Periodontol 10:298-310, 1983.
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270ap ri l 201 0
cda j ournal , vol 38 , n

4
tion. J Periodontal 62:330-34, 1991.
23. Haber J, Watles J, Crowley M, et al, Evidence for cigarete
smoking as a major risk factor for periodontitis. J Periodontol
64:16-23, 1993.
24. Grossi SG, Zambon JJ, Ho AW, et al, Assessment of risk for
periodontal disease. I. Risk indicators for atachment loss. J
Periodontol 65:260-267, 1994.
25. Dolan T, Gilbert G, Ringelberg M, et al, Behavioral risk indi-
cators of atachment loss in adult Floridians. J Clin Periodontol
24:223-232, 1997.
26. Tomar S, Asma, Smoking-atributable periodontitis in the
United States: ndings from the NHANES III. J Periodontol
71:743-751, 2000.
27. Beck J, Koch G, Rozier R, Tudor G, Prevalence and risk
indicators for periodontal atachment loss in a population of
older community-dwelling blacks and whites. J Periodontol
61:521-528, 1990.
28. Kenny EB, Kraal JH, Saxe SR, Jones J, The eect of ciga-
rete smoke on human oral polymorophonuclear leukocytes. J
Periodont Res 12:223-224, 1977.
29. Haajee A, Socransky S, Relationship of cigarete smoking
to atachment level proles. J Clin Periodontol 28:283-295, 2001.
30. Bostrom L, Linder LE, Bergstrom J, Smoking and crevicular
uid levels of IL-6 and TNF-alpha in periodontal disease. J Clin
Periodontol 26:352-357, 1999.
31. Soder B, Neutrophil elastase activity, levels of prosta-
glandin E2, and matrix metalloproteinase-8 in refractory
periodontitis sites in smokers and nonsmokers. Acta Odont
Scand 557:77-82, 1999.
to request a printed copy of this article, please
contact Richard T. Kao, DDS, PhD, 10440 S. DeAnza Blvd.,
Suite D-1, Cupertino, Calif., 95014.
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272ap ri l 201 0
cda j ournal , vol 38 , n

4
Strategies for Managing
Periodontal Inflammation
steven e. schonfeld, dds, phd
abstractMost of the tissue destruction in periodontal disease is caused by the
patients inammatory response. Classical approaches to controlling inammation rely
on atempts to eliminate pathogenic bacteria that incite the inammatory response
through mechanical or chemical means. This approach still has a place in treating
periodontal inammation today. Emerging and future approaches will rely more on
modifying the inammatory response itself, by limiting the activity of proinammatory
pathways and by amplifying pathways that resolve inammation.
any dcntists, cspccially o
my gcncration, will probably
rcmcmbcr thc thrccring
Vcnn diagram (figure 1)
uscd to cxplain thc nccd or
a susccptiblc host (paticnt), pathogcnic
bactcria and pcrmissivc cnvironmcntal
actors (in this casc, thc prcscncc o sugars
in thc dict) to bc prcscnt simultancously
in ordcr or dcntal carics to dcvclop. Carics
can bc prcvcntcd i any o thc thrcc actors
can bc climinatcd or sucicntly modicd.
r
Tis diagram can scrvc as a simplistic
paradigm or many incctious discascs
by rcplacing carics with thc namc o
anothcr incctious discasc (c.g., pcrio
dontitis) and bactcria with thc namc
o thc associatcd incctious agcnt(s). O
coursc, thc chic drawback o this modcl
is its lack o spccicity in dcning cxactly
what makcs a paticnt susccptiblc to a
particular discasc or how cnvironmcntal
actors can inucncc thc outcomc o thc
intcraction bctwccn thc incctious agcnt
and host. Fortunatcly, in thc ncarly vc
dccadcs sincc thc modcl was suggcstcd,
biomcdical scicncc has advanccd considcr
ably and thcrc is a bcttcr undcrstanding o
c o n t r o l l i n g i n f l a mmat i o n
somc o thc actors that can inucncc thc
outcomc o hostparasitc intcractions. A
morc complcx, but still simplicd, schcmc
or pcriodontal discasc that rcccts our
dccpcr undcrstanding o thc situation
is shown in figure 2 and this gurc will
orm thc basis or this discussion.
Tc accumulation o pathogcnic
bactcria in thc pcriodontal spaccs is clcarly
thc initiating actor in thc dcvclopmcnt o
inammatory pcriodontal discascs (IPL).
.

It should bc strcsscd that whilc a numbcr
o dicrcnt bactcria can apparcntly causc
gingivitis, a smallcr numbcr o bactcria
sccm to bc capablc o causing thc chronic
inammation that lcads to pcriodontitis.
.
A scminal conccpt that has bccn cvolv
ing sincc thc r,/cs is that whilc pathogcnic
bactcria arc thc inciting actors or IPL,
most o thc tissuc dcstruction sccn in
this discasc appcars to bc rclatcd to thc
inammatory rcsponsc o thc host rathcr
than bcing causcd dircctly by bactcrial
actors.
8
Hcncc, control o inammation
is paramount in thc ability to succcssully
trcat IPL. In a .cc8 statcmcnt in its clinical
rcsourccs or pcriodontal practitioncrs
scrics, thc Amcrican Acadcmy o Pcriodon
M
author
Steven E. Schonfeld, dds,
PhD, is a periodontist in
private practice in Eureka,
Calif.
cda j ournal , vol 38 , n

4
ap ri l 201 0273
to bclicvc that adcquatc oral hygicnc can
prcvcnt gingival inammation in most
pcoplc by prcvcnting thc accumulation
o bactcria on and around thc tccth, and
that plaquc rcmoval can rcsolvc gingivitis.
To rcturn to thc rclativcly simplc
carics modcl, carics can bc prcvcntcd i
onc o thc ncccssary actors rcquircd or
its dcvclopmcnt is climinatcd or modi
cd. Iikcwisc, thc intcrruption, rcvcrsal,
or sucicnt modication o any cvcnts
lcading rom Hcalthy Tissuc through
Pathogcnic Bactcria and Inamma
tion as dcpictcd in figure 2, IPL and
pcriodontal tissuc dcstruction can bc
prcvcntcd. In act, all currcnt and cmcrg
ing stratcgics or managing pcriodontal
inammation rcly on this basic principlc.
Tc uppcr lct (Oral HygicncRoot
PlaningSurgcryAntimicrobials) box
in figure 2 lists most o thc cxisting
approachcs to managing pcriodontal
incctions and inammation. Tc mccha
nism involvcd in all o thcsc approachcs is
to cithcr prcvcnt thc colonization o thc
pcriodontal spaccs and tissucs by patho
gcnic bactcria, or to rcmovc thcm i thcy
havc gaincd a oothold. Tis has bccn thc
undcrlying principlc bchind thc trcatmcnt
o IPL sincc thc rccognition o pcriodontal
discascs by ancicnt pcoplcs and rcmains an
important approach, although cxccutcd in
a somcwhat morc sophisticatcd manncr,
to this day. O coursc, bcorc thc advcnt
o modcrn microbiology and immunology,
clinicians did not undcrstand thc basis or
any succcss that thcir trcatmcnts may havc
had. Although still incomplctc, thc undcr
standing o thcsc proccsscs has incrcascd
dramatically in thc past .c ycars and con
tinucs to incrcasc with currcnt rcscarch.
Not cvcryonc practiccs pcrcct, or
cvcn adcquatc, oral hygicnc on a consis
tcnt basis, and thc act is that plaquc and
calculus accumulatcs on and around thc
tccth o most pcoplc at onc timc or anoth
thc initial inammatory rcsponsc rcsolvcs
and thc gingival tissuc is rcstorcd to
a statc o homcostasis (bottom arrow
labclcd Rcsolution rom thc Inamma
tion box in figure 2), or whcthcr it con
vcrts to a statc o chronic inammation
lcading to tissuc dcstruction (righthand
arrow rom thc Inammation box).
rr

Tc potcntial to modulatc somc aspccts
o thc inammatory rcsponsc, mainly c
cctor pathways, orm thc basis or somc
cmcrging trcatmcnts, and, morc impor
tantly, suggcst avcnucs or thc dcvclop
mcnt o ncw approachcs to trcating IPL.
Classical and Contemporary
Approaches to Managing Periodontal
Inammation
Pcriodontal discasc has bccn rccog
nizcd as a human aiction in various
culturcs or morc than .,ccc ycars, and
thc ancicnts advocatcd various oral hy
gicnc mcasurcs to prcvcnt it.
r
Tc rolc o
bactcrial plaquc in initiating gingivitis and
thc ccacy o plaquc rcmoval in rcsolving
it was conrmcd in pionccring, wcll
controllcd clinical studics morc than c
ycars ago.
r,r
Hcncc, thcrc is good rcason
tology obscrvcd that pcriodontal thcrapy
is primarily about climination (o) or con
trolling inammation through rcmoval o
local irritants and bchavior modication.
It also is important to notc that not
cvcry paticnt who harbors pathogcnic spc
cics will go on to dcvclop pcriodontitis.
,,rc

Paticnts whosc immunc systcms can
ccctivcly managc colonization o thc
pcriodontal spaccs and tissucs by mount
ing an acutc inammatory rcaction that
rcsolvcs rclativcly quickly (rccctcd by
thc bottom arrow labclcd Rcsolution
rom thc Inammation box in figure
2) sccm to bc at rclativcly low risk o
dcvcloping IPL, whilc thosc paticnts who
dcvclop a chronic inammatory rcsponsc
(rightpointing arrow rom thc Inamma
tion box) will bc at much grcatcr risk.
rr
As indicatcd in thc uppcr righthand
box (CcncticsFpigcncticsLrugs
Fnvironmcnt) in figure 2, gcnctic and
cpigcnctic actors, along with cnviron
mcntal actors such as smoking (scc thc
contribution by Lr. Rcthman in this issuc
or morc dctails) can inucncc thc naturc
o an individual paticnts inammatory
rcsponsc.
r.,r
Tis will dctcrminc whcthcr
fi gure 1. For caries to occur, a susceptible host (patient), pathogenic bacteria and permissive environmental factors
(in this case, the presence of sugar in the diet) all need to be present simultaneously. If only two of the factors are
present, caries does not occur (-).
Environment
Host
()
Caries
()
Bacteria
()
274ap ri l 201 0
cda j ournal , vol 38 , n

4
ous studics havc shown that surgcry rc
sults in a grcatcr dccrcasc in pockct dcpth
comparcd with nonsurgical root planing,
although thc dicrcncc appcars to bccomc
lcss signicant with timc.
..8
Noncthc
lcss, by incrcasing thc chanccs o adcquatc
root dcbridcmcnt, and thus dccrcasing
thc load o potcntial pathogcnic bactcria
that can lcad to pcrsistcnt inammation,
ap surgcry still rcmains a part o thc
clinical armamcntarium in trcating IPL.
Tc history o topical mcdicamcnts
and mouthwashcs rccommcndcd to trcat
pcriodontal discasc gocs back to thc an
cicnt Babylonians and Assyrians.
r
In morc
contcmporary timcs, thcrc has bccn a
widc varicty o topical and systcmic agcnts
advocatcd to trcat pcriodontal discascs.
Antiincctivc thcrapy can bc uscd
locally by dclivcry into thc mouth, c.g., via
dcntiriccs and mouthrinscs, or applicd
dircctly into thc pcriodontal pockct. Al
tcrnativcly, thcy can bc uscd systcmically,
i.c., ingcstcd. Tc local dclivcry agcnts
initiatcd by bactcrial plaquc. Howcvcr,
thcrc arc limits to thc ccctivcncss o
SRP without surgical acccss, cspccially
in pockcts dccpcr than mm.
.r,..
I clinical signs o inammation arc
not rcsolvcd ollowing SRP, c.g., thcrc is
continucd blccding on probing, clinically
inamcd gingival tissucs or inammatory
markcrs continuc to bc prcscnt, othcr mo
dalitics o trcatmcnt should bc considcrcd.
Blccding on probing, or cxamplc, has
bccn shown to bc corrclatcd with thc prcs
cncc o putativc pcriodontal pathogcns
and, hcncc, whcn prcscnt, suggcsts that
thc bactcrial burdcn which incitcs inam
mation has not bccn adcquatcly rcduccd.
.
Tc rolc o ap surgcry in controlling
pcriodontal inammation is, likc SRP,
dcpcndcnt on physical rcmoval o bactcria
and thcir products that incitc a chronic
inammatory rcsponsc. Flap surgcry has
rcpcatcdly bccn shown to incrcasc thc c
cacy o root dcbridcmcnt irrcspcctivc o
any othcr possiblc bcncts.
..,.,.
Numcr
cr. Tcrapists havc bccn rcmoving thcsc
accumulations or at lcast r,ccc ycars.
r
Nonsurgical mcchanical dcbridcmcnt,
scaling andor root planing (SRP), physi
cally rcmovcs bactcria and thcir products.
It can thus intcrrupt thc progrcssion rom
hcalthy tissuc through inammation
to a discascd statc that is initiatcd and
maintaincd by thc prcscncc o bactcria,
as symbolizcd by thc downwardpointing
arrow rom thc uppcr lct (Oral Hygicnc
Root PlaningSurgcryAntimicrobials)
box in figure 2. Indccd, root planing has
bccn shown to improvc thc clinical hcalth
o tissucs, as wcll as rcducing thc num
bcrs o potcntial pcriodontal pathogcns
and somc inammatory markcrs.
rr,
SRP
appcars to bc cqually ccctivc whcn donc
using hand instrumcnts or mcchanically
drivcn dcviccs, such as ultrasonic scalcrs.
.c

It rcmains as a mainstay o pcriodontal
thcrapy today and should gcncrally bc
thc rst typc o trcatmcnt providcd or
paticnts with pcriodontal inammation
fi gure 2. A simplied schematic showing various pathways leading to periodontal disease and bone loss by inammatory events incited by the accumulation of pathogenic
bacteria (horizontal arrows). Areas that oer opportunities for preventing or reversing these events are also represented (vertical arrows). See text for details.
Diseased Tissue
Bone Loss
Pathogenic Bacteria Inammation
Resolution
(+)
(-)
c o n t r o l l i n g i n f l a mmat i o n
Oral Hygiene
Root Planing
Surgery
Anti-microbials
Genetics
Epigenetics
Drugs
Environment
Healthy Tissue
Drugs/Biologics
Diet?
cda j ournal , vol 38 , n

4
ap ri l 201 0275
suggested by the data in table 1, repro-
duced from the report Eectiveness of
Anti-microbial Adjuncts to Scaling and
Root Planing Terapy for Periodontitis
from the Agency for Healthcare Research
and Quality.

Tis report is a systematic

review and meta-analysis of the litera-
ture related to use of anti-microbials and
antibiotics in the adjunctive treatment of
periodontal disease published in .
Tere are various types of scientic
evidence one can consider when trying to
decide on the ecacy of a clinical inter-
vention. Not all of these types of evidence
have equal weight, though. In fact, there
is a hierarchy of the quality of clinical
evidence that can be used to support evi-
dence-based decision-making in the health
disciplines.

A typical hierarchy is as
of them exhibit some anti-bacterial activity
against a variety of bacterial species in vitro
when used at appropriate concentrations.
While the anti-microbials are gener-
ally only delivered locally, antibiotics can
either be taken systemically or applied
directly into the periodontal pocket, usu-
ally in some type of carrier.

Anti-micro-
bials and antibiotics are usually used as
adjuncts to conventional SRP, and, as with
mechanical treatment, the mechanism of
action is to reduce or eliminate the bac-
teria that incite inammatory reactions.
Some studies have shown that a vari-
ety of antibiotics and anti-microbials have
statistically signicant positive eects
when used adjunctively in this fashion.
However, the clinical ecacy of most of
these substances is hard to determine, as
can be further divided into those that
are capable of sustained release, either
through inherent substantivity or by
means of carriers providing for controlled
release over time, and those that are not.
Anti-infective substances can also be
classied either as antibiotics or as sub-
stances with anti-microbial properties such
as chlorhexidine, citric acid, essential oils,
hydrogen peroxide (both as a single agent
and in combination with sodium bicarbon-
ate and sodium chloride), iodine, quaterna-
ry ammonium compounds, sanguinarine,
sodium hypochlorite, stannous uoride and
triclosan, all of which will be referred to as
anti-microbials.

All of these substances

have been suggested as remedies for gin-
givitis or periodontitis, and are frequently
used as adjuncts to mechanical therapy.

All
Intervention Pocket Depths Clinical Attachment Levels
#/+
Studies*
Effect sizes (mm): Range
and Meta-analysis (MA)
#/+
Studies*
Effect sizes (mm): Range
and Meta-analysis (MA)
Tetracycline, systemic 5/0 Range: NA MA : 0.15 (-0.29 - 0.58) 5/1 Range: 0.31 MA: none done
Tetracycline, local 16/5 Range: 0.40-0.93 MA: 0.47 (0.22 - 0.72) 16/2 Range: 0.15 - 0.48 MA: 0.24 (0.07 - 0.42 )
Minocycline, systemic 2/0 Range: NA MA: none done 0/0 Range: NA MA: none done
Minocycline, local 8/4 Range: 0.30 1.10 MA: 0.49 (0.40 - 0.58) 8/3 Range: 0.39 0.80 MA: 0.46 (0.32 - 0.60)
Metronidazole, systemic 8/3** Range: 0.47 1.645 MA: none done 6/2 Range: 0.47 1.19# MA: none done
Metronidazole, local 11/4** Range: 0.18 0.80 MA: 0.32 (0.20 - 0.44) 8/2 Range: 0.40 0.66 MA: 0.12 (0.01 0.24)
Metronidazole with
amoxicillin, systemic
4/2** Range: 0.7 MA: none done 4/1** Range: NR MA: none done
Chlorhexidine, local 17/2 Range: 0.26 0.33 MA: 0.24 (0.13 - 0.35) 13/3 Range: 0.16 0.28 MA: 0.16 (0.04 0.28)
Other antibiotics, systemic 7/3** Range: 0.47 0.87 MA: none done 6/2** Range: 1.30 MA: none done
Other antibiotics, local 1/1 Range: 0.44 MA: none done 1/1 Range: 0.37 MA: none done
Other antimicrobials, local 5/1 Range: 0.8 MA: none done 4/0 Range: NA MA: none done
(Adapted from Bonito A, Lohr K, et al Effectiveness of Anti-microbial Adjuncts to Scaling and Root Planing Therapy for Periodontitis, vol. 1, Evidence Report and Appendixes.
Evidence Report/Technology Assessment No. 88; AHRQ Publication No. 04-E014-2. Rockville, Md., Agency for Healthcare Research and Quality, March 2004.)
TABLE 1
Effects of Adjunctive Antibiotics or Anti-microbials on Pocket Depth and Clinical Attachment Levels When Used
as Adjuncts to Scaling and Root Planing.
* Number of studies/Positive studies. Positive studies are defined as those showing statistically significant effects in favor of the adjunctive therapy as contrasted
with scaling and root planing alone.
CI, confidence interval; MA, meta-analysis; mm, millimeters; NA, not applicable; NR, not reported.
0.30 mm PD reduction for baseline PD of 5 mm or greater.
1.10 mm PD reduction for baseline PD of 7 mm or greater.
0.47 mm PD reduction and CAL gain for baseline PD of 4 mm to 6 mm.
1.64 mm PD reduction for baseline PD of more than 6 mm.
# 1.19 mm CAL gain for baseline PD of more than 6 mm.
** One of these studies did not report any specific data, only a significant difference.
0.87 mm PD reduction for baseline PD of 6 mm or greater.
276ap ri l 2 01 0
cda j ournal , vol 38 , n

4
wcllcxccutcd. Tcsc situations may includc
paticnts with rcractory pcriodontitis or
who havc dccp pockcts, dcccts or urcation
involvcmcnt, or circumstanccs in which thc
modicd \idman ap surgcry is not donc,
which would cnablc propcr dcbridcmcnt o
othcrwisc hardtorcach arcas. Routinc usc
o appropriatc, i.c., ccacious, adjunctivc
thcrapics might arguably bc rcscrvcd or
paticnts such as thcsc.
n
Tc improvcmcnts produccd by
adjunctivc antimicrobials bcyond thosc
lcvcls, produccd by SRP alonc ... (arc)
approximatcly oncquartcr to oncthird o
thc impact o SRP alonc.
Tc rcsults o thc systcmatic rcvicw
suggcst that whilc thcrc arc somc studics
showing ccacy with thc ajdunctivc usc
o antimicrobials and antibiotics, thc
prcpondcrancc o thc cvidcncc docs not
support widcsprcad usc o thcsc agcnts as
adjuncts to mcchanical thcrapy at this
timc.
c
Noncthclcss, thcrc may bc ccrtain
situations in which paticnts would bcnct
rom thcir usc, cspccially in paticnts who
prcscnt with morc scvcrc discasc. Anothcr
rclativcly rcccnt systcmatic rcvicw
concludcd that although bcncts o
adjunctivc usc wcrc minimal, in somc
populations, antiincctivc agcnts in a
sustaincdrclcasc vchiclc alonc can rcducc
PL and blccding on probing (BOP) cquiva
lcnt to that achicvcd by SRP alonc.
.

Intcrcstingly, ccrtain antibiotics may
bc uscul in thc trcatmcnt o IPL, but
work by mcchanisms distinct rom rcduc
ing or climinating pathogcnic bactcria.
Tis will bc discusscd in thc ncxt scction.
Emerging Approaches to Managing
Periodontal Inammation
Tc classical and contcmporary intcr
vcntions discusscd abovc all dcpcnd on in
tcrrupting thc chain o cvcnts lcading rom
hcalthy to discascd tissuc by rcmoving accu
mulations o pathogcnic bactcria and thcir
i.c., thc amount o improvcmcnt makcs a
substantial dicrcncc in thc clinical
outcomc. Tc authors includc thc ollowing
salicnt points in thcir conclusions.
c
n
Adjunctivc local antibiotics ap
pcarcd to havc morc impact than adjunc
tivc systcmic antibiotics,
n
Tc major probing dcpth (PL)
rcductions wcrc in thc rangc o about onc
quartcr to onchal millimctcr, and thc
major clinical attachmcnt lcvcl (CAI)
gains in thc rangc o about onctcnth to
onchal millimctcr,
ollows, listcd rom most rcliablc cvidcncc
at thc top to lcast rcliablc at thc bottom.
n
Systcmatic rcvicwmctaanalysis o
many randomizcd, controllcd clinical trials
n
Randomizcd controllcd clinical trial
n
Cohort study
n
Casc control study
n
Casc rcports
n
Fxpcrt opinions, cditorials
A systcmatic rcvicw sccks to idcntiy all
studics addrcssing a spccic clinical qucs
tion. Tc rcvicwcrs thcn asscss thc quality
o thc studics and cxcludc thosc that ail
to mcct prcdctcrmincd quality standards
in tcrms o cxpcrimcntal dcsign, powcr o
thc study, data analysis, and othcr actors.
\hcn trying to dccidc on whcthcr to in
corporatc a ncw matcrial or tcchniquc into
oncs practicc, it is clcarly wisc to usc thc
highcst quality cvidcncc availablc, according
to thc principlcs o cvidcnccbascd practicc.
Tus, a mctaanalysis, an analysis that com
bincs data rom a numbcr o dicrcnt stud
ics to givc a singlc mctaanalytic cstimatc o
thc actual trcatmcnt ccct, or systcmatic rc
vicw o many studics is much morc powcr
ul than anccdotc, casc rcports, or individual
studics, no mattcr how good thc cxpcrimcn
tal dcsign o thc individual study may bc.
Tc data in table 1 show how wcll anti
microbials or antibiotics work whcn uscd
adjunctivcly with mcchanical trcatmcnt. It
comcs rom a rcvicw o /c papcrs that mct
thc inclusion critcria, i.c., thcy addrcsscd
thc spccic qucstions bcing askcd and wcrc
dccmcd to bc o sucicnt quality to bc in
cludcd.
c
As thc tablc shows, thcrc is a high
dcgrcc o variability in thc study outcomcs.
Tc majority o thc studics did not
show statistically signicant positivc
outcomcs. Morcovcr, cvcn in thosc cascs
whcrc thcrc was statistically signicant
improvcmcnt with adjunctivc antimicrobi
al or antibiotic trcatmcnt, it is not clcar
whcthcr thc incrcmcntal improvcmcnt ovcr
root planing alonc was clinically signicant,
n
Combining PL and CAI rcsults
suggcsts that local minocyclinc might bc
thc most promising adjunctivc thcrapy,
mctaanalysis cstimatcs o c., mm or
PL rcduction and c. mm or CAI gain,
ollowcd by local tctracyclinc, cstimatcs
o c./ mm or PL rcduction and c..
mm or CAI gain. Iocal mctronidazolc
and chlorhcxidinc rcsults arc wcll bclow
thcsc lcvcls,
n
By and largc, harms rom thcsc
adjunctivc thcrapics arc rclativcly minor.
\c takc notc, howcvcr, o conccrns about
bactcrial rcsistancc rom ovcrusc o
systcmic antibiotics, and
n
Somc rcsults o trials that wc did
rcvicw suggcstcd that addcd ccctivcncss
o adjunctivc trcatmcnt was grcatcr in
circumstanccs o morc scvcrc pcriodontitis
whcrc supportivc or sclcarc may bc lcss
there is a hierarchy
of the quality of
clinical evidence that
can be used to support
evidence-based
decision-making in
the health disciplines.
c o n t r o l l i n g i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 2 01 0277
rom gramncgativc pcriodontal bactcria.
In addition to thcir dircct ccct on
conncctivc tissuc and bonc, MMPs arc
also involvcd in thc rcgulation o thc
inammatory rcsponsc by clcaving and
activating somc cytokincs.

Tcsc arc
molcculcs that carry signals bctwccn cclls
and havc a varicty o unctions including
rccruiting inammatory cclls, rcgulat
ing thcir unctions, and stimulating thc
ormation o ostcoclasts.
8
Hcncc, thc inhi
bition o MMPs by lowdosc tctracyclincs
appcars to rcsult in both dircct inhibition
o tissucdcstroying cnzymcs and intcrcr
cncc with proinammatory pathways and
ccctor cclls such as ostcoclasts, signicd
doscs too low to havc an antimicrobial
ccct and which havc not bccn rcportcd to
causc antibiotic rcsistancc in bactcria.
,
Collagcnascs arc cnzymcs that dc
gradc nativc collagcn (thc major struc
tural protcin o conncctivc tissuc and
bonc), and arc mcmbcrs o thc class o
cnzymcs callcd matrix mctalloprotcinascs
(MMPs). MMPs arc intimatcly involvcd
in dcgradation o tissuc and bonc, bonc
rcmodcling, wound hcaling, and othcr
important biologic unctions.

In thc
gingivac, MMPs arc sccrctcd by poly
morphonuclcar lcukocytcs (PMNs) and
broblasts in rcsponsc to thc prcscncc o
bactcrial lipopolysaccharidcs (cndotoxins)
products or prcvcnting thcir accumulation
in thc rst placc. Fmcrging approachcs scck
to limit tissuc dcstruction by dircctly block
ing proinammatory pathways without
accting bactcrial accumulations, although
cvcry attcmpt should still bc madc to rcducc
thc bactcrial burdcn. Tis is rcprcscntcd
by thc right arrow rom thc lowcr box
labclcd LrugsBiologicsLict in figure 2.
In thc mid r,8cs, Colub and col
lcagucs discovcrcd that tctracyclinc
dcrivativcs could inhibit mammalian
collagcnascs.

Tcy subscqucntly ound

that thcsc drugs could bc uscd to limit
inammation and bonc dcstruction in
pcriodontal discascs, cvcn whcn givcn at
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278ap ri l 201 0
cda j ournal , vol 38 , n

4
cally signicant bcncts or NSAIL trcat
mcnt. Intcrcstingly, scvcn o cight studics
also ailcd to nd a dccrcasc in gingival
inammation, mcasurcd by gingival
indcx, in thc NSAILtrcatcd groups.
/
\hcn alvcolar bonc lcvcls wcrc mca
surcd, thcrc did appcar to bc a bcnct to
NSAIL usc. Six o thc studics mcasurcd
alvcolar bonc loss and thcsc studics
consistcntly showcd statistically signi
cant dccrcascs in bonc loss.
/
Howcvcr,
this bcnct must bc wcighcd against thc
potcntial hazards o modcratc to longtcrm
NSAIL usc, including scrious advcrsc CI
cvcnts blccding, ulccration and stomach
or intcstinc pcroration as wcll as
incrcascd risk or scrious and potcntially
atal cardiovascular thrombotic cvcnts
(myocardial inarction and strokc), as
outlincd in thc black box warnings thc
Food and Lrug Administration rcquircs or
all NSAILs. Tcrc also is rcason to bclicvc
that most o thc NSAILs may intcrcrc
with homcostatic mcchanisms involvcd in
thc rcsolution o inammation (scc bclow).
In summary, most NSAILs probably
do not havc much o a rolc in control
ling pcriodontal inammation, although
thcrc is clcarly thc potcntial or thc usc
o ncw antiinammatory agcnts that
may bccomc availablc in thc uturc.
Bccausc bonc loss is a gcncrally ir
rcvcrsiblc conscqucncc o IPL, invcstiga
tors also havc lookcd at boncsparing
agcnts, such as thc bisphosphonatcs in
trcating thc discasc. Tc bisphospho
natcs, such as Arcdia (pamidronatc, No
vartis), Fosamax (alcndronatc, Mcrck),
or RcclastZomcta (zolcdronic acid, No
vartis), arc a class o drugs that dccrcasc
ostcoclastic bonc rcsorption and consc
qucntly bonc turnovcr. Tcy arc com
monly prcscribcd to trcat ostcoporosis,
ostcopcnia, and Pagcts discasc o bonc.

\hilc thcrc havc not bccn a lot

o studics on thc usc o thc bisphos
\hilc it is sac and apparcntly docs not
lcad to thc cmcrgcncc o doxycyclinc
rcsistant bactcria, clinicians should
considcr whcthcr thc rclativcly small
gains in clinical attachmcnt arc important
cnough to warrant its widcsprcad usc.
Sincc, as statcd prcviously, pcriodontal
thcrapy is primarily about climination (o)
or controlling inammation, it is prob
ably not surprising that antiinammatory
drugs havc bccn considcrcd or adjunctivc
usc in thc trcatmcnt o IPL. Tc primary
class o drugs that havc bccn invcstigatcd
by thc righthand arrow rom thc lowcr
box (LrugsBiologicsLict`) in figure 2.
In r,,8, thc Food and Lrug Adminis
tration approvcd a ormulation consisting
o .c mg o doxycyclinc hyclatc (Pcriostat,
CollaCcncx Pharmaccuticals) to bc takcn
twicc daily as an adjunct to mcchanical
trcatmcnt or pcriodontitis. Tc drug is
also availablc as a gcncric. Bccausc this is
a dosc that is lowcr than that nccdcd to
inhibit bactcrial growth, it is rccrrcd to as
subantimicrobialdosc doxycyclinc (SLL).
A .cc systcmatic rcvicw o scvcn
randomizcd clinical trials concludcd thcrc
was a statistically signicant bcnccial ccct
whcn SLL was uscd adjunctivcly to SRP.
/

Unlikc thc situation with locally applicd
antiincctivc agcnts, howcvcr, thc majority
o thcsc studics showcd positivc rcsults with
SLL. Noncthclcss, thc magnitudc o thcsc
changcs was still modcst, with additional
clinical attachmcnt lcvcl gains bcing gcncr
ally lcss than r mm ovcr what was sccn with
SRP alonc. As with thc antiincctivc agcnts,
thc bcnccial cccts wcrc morc pronounccd
in sitcs with dccpcr initial pockct dcpths.
Tc rcvicw also considcrcd six studics
that lookcd at thc sacty o SLL, with
most o thc studics looking at six to r.
months o usc. No changcs to thc oral and
subgingival ora wcrc ound (as would bc
cxpcctcd i thc dosc o doxycyclinc was
truly subantimicrobial). Advcrsc cccts
in thc tcst groups wcrc not dicrcnt rom
thosc in thc control groups, so SLL ap
pcars to bc a sac trcatmcnt modality.
A morc rcccnt proo o principlc
study lookcd at SLL uscd adjunctivcly to
ap surgcry.
8
Tc rcsults, which should
bc considcrcd prcliminary in naturc,
indicatcd that SLL may also bc uscul
whcn uscd as an adjunct to ap surgcry.
To summarizc, it appcars that SLL
may bc a uscul adjunct to convcntional
mcchanical thcrapy, cspccially in paticnts
with morc scvcrc or rcractory discasc.
or this purposc arc thc nonstcroidal
antiinammatory drugs (NSAILs).
NSAILs arc a class o drugs that in
cludcs aspirin, diclocnac, diunisal, ur
biprocn, ibuprocn, kctoprocn, kctoro
lac, mcclocnamatc, mcloxicam, naproxcn,
and piroxicam. Tcy act by inhibiting
cyclooxygcnascs, which arc cnzymcs in
thc pathway that gcncratcs proinamma
tory mcdiators such as ccrtain prostaglan
dins, thromboxancs, and prostacyclins.
,
A systcmatic rcvicw o ninc studics
on thc cccts o NSAIL thcrapy cithcr
alonc or as an adjunct to mcchanical
thcrapy gcncrally indicatcd no statisti
cally signicant dccrcasc in thc loss o
clinical attachmcnt whcn NSAILs wcrc
uscd.
/
Tcn studics lookcd at pockct dcpth
mcasurcmcnts, and thc vast majority
(cight out o rc) could not nd statisti
interestingly,
seven of eight studies
also failed to nd a
decrease in gingival
inammation, measured
by gingival index, in the
NSAID-treated groups.
c o n t r o l l i n g i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 2 01 0279
bisphosphonatcs or thc trcatmcnt o
ostcoporosis, thc rclativc prcvalcncc
o BRON in thcsc paticnts was low
according to a .cc/ systcmatic rcvicw.
.
To summarizc, trcatmcnt with
boncsparing mcdications may ocr
an approach to trcating thc inam
matory bonc loss associatcd with IPL.
Howcvcr, whilc thc cxisting data arc
promising, thcrc is probably not yct
cnough cvidcncc to rccommcnd that
thcsc drugs bc widcly uscd or thc
trcatmcnt o IPL. Clinicians should
also considcr thc risk o BRON, which
although rarc, can bc a scvcrc complica
tion bcorc prcscribing thcsc agcnts.
(BRON). Tis condition can occur whcn
alvcolar bonc is cxposcd, usually during a
dcntal cxtraction.
r
It is most rcqucntly
sccn in canccr paticnts who arc tak
ing rclativcly high intravcnous doscs o
bisphosphonatcs or palliativc trcatmcnt
o bonc mctastascs or to trcat hypcrcal
ccmia associatcd with ccrtain malignan
cics, but paticnts taking oral bispho
sphonatcs or ostcoporosis havc also
dcvclopcd BRON. \hilc thc incidcncc
o BRON in paticnts taking oral bispho
sphonatcs is hard to dctcrminc, somc
cstimatcs rangc bctwccn r.rc,ccc and
r.rcc,ccc.
r
Howcvcr, considcring that
millions o paticnts havc bccn prcscribcd
phonatcs or trcating IPL, thosc that
wcrc includcd in thc .cc systcmatic
rcvicw mcntioncd abovc showcd posi
tivc cccts.
/
In onc study, cwcr sitcs
lost bonc as comparcd with thc pla
ccbo (.c pcrccnt vcrsus c pcrccnt).
In anothcr study, thcrc was a dccrcasc
in thc absolutc amount o bonc loss in
thc trcatmcnt arm comparcd with thc
placcbo. Morc rcccntly, a longcr and
largcr study showcd bcncts in tcrms
o CAI, pockct dcpths, and blccding
on probing with bisphosphonatcs.
c
A rarc but scvcrc sidc ccct o
bisphosphonatc thcrapy is bisphospho
natcrclatcd ostconccrosis o thc jaw
280ap ri l 201 0
cda j ournal , vol 38 , n

4
incs involvcd in thc activation cascadc, so
inhibition o MMPs by SLL may acct this
carly stagc in thc inammatory pathway by
supprcssing activation o ccrtain cytokincs.
A potcntial ncw intcrvcntion may
comc in thc orm o a ncw drug callcd
Protclos (strontium ranclatc, Scrvicr
Iaboratorics), which has bccn shown to
stimulatc ostcoblasts to sccrctc OPC, thus
prcvcnting thc activation o ostcoclasts.

It has also bccn shown to uprcgulatc
thc dicrcntiation o ostcoblasts rom
stromal cclls in bonc, so it sccms to bc
ablc to both prcvcnt bonc rcsorption and
cnhancc bonc dcposition.

Strontium
ranclatc is availablc as a trcatmcnt or
ostcopcnia and ostcoporosis in Furopc,
but it has not bccn clcarcd by thc FLA or
usc in thc Unitcd Statcs as o this writing.
\hilc this rcvicw has ocuscd primar
ily on thc dclctcrious cccts o chronic
inammation in IPL, thc inammatory
rcsponsc clcarly has protcctivc unctions
as wcll. Tcrc is no doubt that a compc
tcnt immunc systcm and wcllrcgulatcd
inammatory rcsponsc arc ncccssary to
prcvcnt scvcrc pcriodontitis. For cxamplc,
paticnts with dcccts in PMN numbcrs
or unction rcqucntly cxhibit aggrcssivc
pcriodontitis, as do paticnts with acquircd
immunodccicncy syndromc.
/,8
Hcncc,
any intcrvcntion that altcrs proinam
matory rcsponscs at a basic lcvcl nccds
to bc cxamincd carcully or unintcndcd
conscqucnccs that could lcad to morc
dcstruction instcad o lcss, or which could
acct othcr systcms in thc body that
rcly on intact inammatory pathways.
Tc intcrvcntions discusscd so
ar ccntcr on intcrrupting proinam
matory pathways or ccctor cclls and
molcculcs, but this may not bc thc only
approach to controlling inammation.
Anothcr potcntially important avcnuc
or managing IPL in thc uturc may bc by
cnhancing thc mcchanisms that rcsolvc
ostcoclast dicrcntiation actor by bind
ing to and activating thc rcccptor activa
tor o nuclcar actorkappa B (RANK)
on ostcoclast prccursor cclls. RANK,
as thc namc implics, is an activator o
nuclcar actor kappa o B cclls (NFB),
which was originally ound in activatcd
Blymphocytcs but is ound in othcr ccll
typcs as wcll. \hcn activatcd, NFB
turns on gcnc transcription and protcin
synthcsis in rcspondcr cclls, allowing
thcm to pcrorm ccctor unctions in thc
inammatory and immunc rcsponscs.

Future Approaches to Managing

Periodontal Inammation
As has bccn sccn, contcmporary
approachcs to managing pcriodontal
inammation largcly ccntcr on rcduc
ing thc burdcn o bactcria that incitc thc
inammatory rcsponsc. Somc cmcrging
tcchnology, c.g., SLL, inhibits inamma
tory ccctor molcculcs or cclls such as thc
MMPs and ostcoclasts. Futurc approachcs
may work by modulating thc inam
matory rcsponsc carlicr in thc proccss,
intcrrupting thc initial cascadc o mcdia
tors that incrcasc inammation and bonc
rcsorption, or by cnhancing thc rcsolution
o inammation.
8,,,,
Tcsc pathways
arc rcprcscntcd by thc uppcr and lowcr
vcrtical arrows rom thc lowcr righthand
box (LrugsBiologicsLict`) in figure 2.
Initial cvcnts in thc inamma
tory rcsponsc to thc prcscncc o bactcria
includc binding o bactcrial products
such as cndotoxins by molcculcs callcd
tolllikc rcccptors that arc ound on thc
suracc o dcndritic cclls, monocytcs
macrophagcs, mast cclls, and somc
lymphocytcs. Tis binding causcs thc cclls
to makc and sccrctc a varicty o inam
matory mcdiators, c.g., bradykinin, and
cytokincs such as intcrlcukinr (IIr) and
tumor nccrosis actoralpha (TNF).
8,,,

Cytokincs, as cxplaincd prcviously, arc a
class o molccular mcsscngcrs that among
othcr things, rccruit and rcgulatc inam
matory cclls, and can also stimulatc or
block , dcpcnding on which cytokinc,
thc ormation o ostcoclasts that arc thc
cclls rcsponsiblc or bonc rcsorption.
IIr and TNF acct ostcoclast
unction by inducing thc production o
othcr cytokincs by ostcoblasts or stromal
cclls in bonc.

Onc o thcsc, thc rcccp

tor activator o nuclcar actorkappa B
ligand(RANKI), stimulatcs thc dicr
cntiation and activation o ostcoclasts,
which is why it also is somctimcs callcd
Othcr intcrlcukins, c.g., II, and
somc intcrcrons can inducc thc pro
duction o ostcoprotcgrin (OPC), which
is a compctitivc inhibitor o RANKI,
and thcrcby rcduccs ostcoclast activa
tion. Tus, ostcoclast activity sccms to
bc rcgulatcd by thc OPC.RANKI ratio,
whcn morc OPC is availablc, it binds
to RANK (without activating it) and
thus prcvcnts binding o RANKI and
subscqucnt ostcoclast activation. Tis
has thc ccct o inhibiting bonc loss.

Clcarly, thcsc complcx proinamma

tory pathways ocr a numbcr o points
at which potcntially thcrapcutic intcrvcn
tions could occur, by cithcr inactivating
ccctor cclls or molcculcs thcmsclvcs, or
by limiting thcir activation or production.
As discusscd carlicr, MMPs arc involvcd in
clcaving and activating somc o thc cytok
there is no doubt
that a competent
immune system and
well-regulated
inammatory response
are necessary to prevent
severe periodontitis.
c o n t r o l l i n g i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 201 0281
cholinc. AA is thc substratc or a vari
cty o biosynthctic pathways involvcd
in thc synthcsis o proinammatory
lipid mcdiators such as thc prostanoids
(prostacyclincs, prostaglandins and
thromboxancs) via thc cyclooxygcnasc
pathways (COXr and COX.), or lcu
kotricncs via thc lipoxygcnasc (IO)
pathway, thc prostanoids and lcukot
ricncs participatc along with proinam
matory cytokincs in inammatory ccll
rccruitmcnt, cdcma, pain, and dcstruc
tion o conncctivc tissuc and bonc.
,,.
Apparcntly, whcn thc conccntration o
proinammatory substanccs rcachcs a criti
cal point, thcy can causc a changc in PMNs
many proinammatory ccctors, c.g.,
somc prostaglandins, thromboxancs, and
lcukotricncs. Somc antiinammatory
lipids arc madc rom omcga polyun
saturatcd atty acids ( PUFAs) in
addition to thosc madc rom omcga
atty acids such as arachidonic acid
(AA), which is also thc prccursor o
somc proinammatory lipids.
,,,r
Farly gingival cvcnts in thc inam
matory rcsponsc to pathogcnic bactcria
includc thc binding o inammatory
agonist molcculcs, c.g., bradykinin, by
ccll suracc rcccptors that activatc thc
cnzymc phospholipasc A
.
. Tis cnzymc,
in turn, libcratcs AA rom phosphatidyl
inammation and rcturn thc tissucs to a
statc o homcostasis.
rr,,
Tis is possiblc
bccausc rcccnt rcscarch indicatcs that
thc rcsolution o inammation rclics
not mcrcly on thc abscncc or diminu
tion o proinammatory pathways, but
is an activc proccss mcdiatcd by spccic
rcsolution pathways.
,
Tc tissuc dc
struction sccn in IPL may bc thc rcsult
o thc inordinatc pcrsistcncc o inam
mation in rcsponsc to bactcrial chal
lcngcs causcd by thc ailurc o rcsolution
pathways to rcstorc homcostasis.
,
Molcculcs that appcar to bc impor
tant in thc rcsolution o inammation
arc lipids madc rom atty acids, as arc
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282ap ri l 201 0
cda j ournal , vol 38 , n

4
o intcrvcntion is rcprcscntcd by thc down
wardpointing arrow rom thc lowcr box
labclcd LrugsBiologicsLict` in figure 2.
Tcrc is anothcr group o cndogcnous
antiinammatory lipid mcdiators that
arc synthcsizcd rom scvcral PUFAs,
spccically cicosapcntanoic acid (FPA) and
docosahcxanoic acid (LHA) rathcr than
rom AA.
c,.
Tcsc mctabolitcs arc callcd
rcsolvins (ormcd rom both FPA and
LHA) or protcctins (rom LHA).
c
As with
thc lipoxins, ASA sccms to incrcasc thc
stability and duration o action o thcsc
that induccs othcr biosynthctic pathways
or AA (a classswitch) that cvcntually
rcsult in thc production o lipid mcdiators
callcd lipoxins.

Iipoxins arc capablc o pro

moting thc rcsolution o inammation by
limiting thc migration o additional PMNs
into thc sitc o inammation, activating
noninammatory monocytcs, and stimulat
ing thc rcmoval o dcad (apoptotic) PMNs
by macrophagcs.
,,.
Tis pathway is rcprc
scntcd by thc lowcr arrow labclcd Rcsolu
tion rom thc Inammation box which
lcads back to Hcalthy Tissuc in figure 2.
A conscqucncc o this ccdback loop
may bc that thc usc o NSAILs othcr than
aspirin can actually dclay thc rcsolution o
inammation by inhibiting thc gcncration
o thc critical conccntration o proinam
matory mcdiators nccdcd or thc class
switch to occur.
,,c
Aspirin (ASA) may also
inducc a switch rom proinammatory to
prorcsolving AA mctabolitcs.
r
Iikc othcr
NSAILs, ASA inhibits thc production
o thc proinammatory prostanoids by
COXr and COX.. Howcvcr, ASA is thc
only NSAIL that also induccs thc synthc
sis o rRhydroxy(p)cicosatctracnoic
acid, that is urthcr modicd by IO to
orm rcpilipoxins. Tcsc arc known
as aspirintriggcrcd lipoxins (ATIs).
ATIs arc morc bioactivc orms o lipox
ins and hcncc havc grcatcr prorcsolving
activity than thc unmodicd orms.
,,r
Tus, thc usc o ASA to inducc cndog
cnous ATIs is a possiblc intcrvcntion to
rcsolvc chronic inammation in IPL. O
coursc, thc usc o ASA nccds to bc balanccd
by potcntially scrious sidc cccts such as CI
blccds. Anothcr approach on thc horizon
may bc to usc cxogcnous synthctic lipoxin
analogs, as it has bccomc possiblc to chcmi
cally synthcsizc lipoxin analogs, which arc
morc stablc than thc nativc molcculcs. Tcsc
lipoxin analogs havc bccn shown to havc in
hibitory cccts on acutc inammation by ac
tivating prorcsolving pathways.
,
Tis typc
pointing arrow rom thc lowcr box labclcd
LrugsBiologicsLict` in figure 2.
Finally, it has bccn shown that a chcmi
cally synthcsizcd rcsolvin (RvFr) was c
cctivc in limiting or rcvcrsing pcriodontal
discasc in rabbits incctcd with P. g|ng|
.c||s.
/
Tis opcns thc possibility o using
cxogcnous prorcsolving mcdiators o in
ammation such as lipoxins, rcsolvins, and
protcctins in thc clinical trcatmcnt o pcri
odontal discasc at somc timc in thc uturc.
Take-Home Lessons
Classical approachcs to controlling
inammation rcly cxclusivcly on attcmpts
to supprcss pathogcnic bactcria that
incitc thc inammatory rcsponsc through
mcchanical (SRP, ap surgcry) or chcmical
(antimicrobials and antibiotics) mcans.
\hilc this approach has roots going back
at lcast r,ccc ycars, it still has a placc in
trcating pcriodontal inammation today.
Fmcrging and uturc approachcs
will rcly morc on modiying thc in
ammatory rcsponsc itscl, by limit
ing thc activity o proinammatory
pathways, ccctor cclls and mcdiators,
as wcll as by ampliying pathways
that rcsolvc inammation. Trcatmcnt
with SLL is a start in this dircction,
but thc uturc holds thc promisc o
cvcn morc ccctivc intcrvcntions.
Clinicians should always usc thc bcst
availablc cvidcncc whcn dcciding whcn or
whcthcr to adopt ncw trcatmcnt modali
tics. Tis is bcst achicvcd by scarching thc
clinical scicntic litcraturc or systcm
atic rcvicws and mctaanalyscs that givc
a much bcttcr scnsc o thc statc o thc
art than individual articlcs or tcstimoni
als, cspccially rom partics who stand
to gain i you adopt thcir products.
references:
1. KeyesP, JordanV, Factorsinuencingtheinitiation, transmission
andinhibitionof dental caries. In: Mechanismsof hardtissuede-
struction, ed., SognnaesR, Washington: AAAS, pages261-84, 1962.
molcculcs.
c
Tc rcsolvins and protcctins
act by diminishing thc attraction o in
ammatory cclls, incrcasing phagocytosis
o apoptotic PMNs and blocking thc pro
duction o proinammatory mcdiators.
Tcrc is somc cvidcncc that incrcascd
dictary intakc o PUFAs can havc
bcnccial cccts in rcducing morbidity
rom athcrsclcrosis, asthma, cardiovas
cular discasc, and canccr.
r,
Tcrc is an
inammatory componcnt in all o thcsc
discascs and it has bccn postulatcd
that incrcascd dictary s can lcad to
incrcascd synthcsis o rcsolvins and
protcctins.
c,r
Tis lcads to thc pos
sibility that incrcasing dictary intakc o
s, cspccially whcn takcn with ASA,
can bc an ccctivc stratcgy in control
ling inammation in IPL. Tis pathway
is also rcprcscntcd by thc downward
asa is the only nsaid
that also induces the
synthesis of 15-R-hydroxy-
(p)-eicosatetraenoic acid,
that is further modied by
5-LO to form 15-epi-lipoxins.
c o n t r o l l i n g i n f l a mmat i o n
cda j ournal , vol 38 , n

4
ap ri l 201 0283
41. Assael L, Oral bisphosphonates as a cause of bisphospho-
nate-related osteonecrosis of the jaws: clinical ndings, as-
sessment of risks, and preventive strategies. J Oral Maxillofac
Surg 67:35-43, 2009.
42. Pazianas M, Miller P, et al, A review of the literature on
osteonecrosis of the jaw in patients with osteoporosis treated
with oral bisphosphonates: prevalence, risk factors, and clini-
cal characteristics. Clin Ther 29:1548-58, 2007.
43. Cochran D, Inammation and bone loss in periodontal
disease. J Periodontol 79 (Proceedings of the 2008 workshop
on inammation):1569-76, 2008.
44. Genco R, Clinical innovations in managing inammation
and periodontal diseases: the workshop on inammation and
periodontal diseases. J Periodontol 79 (Proceedings of the
2008 workshop on inammation):1609-11, 2008.
45. Gilmore T, Introduction to NF-kB: players, pathways,
perspectives. Oncogene 25:6680-84, 2006.
46. Marie P, Strontium ranelate: new insights into its dual
mode of action. Bone 40:S5-8 2007.
47. Daniel M, Van Dyke T, Alterations in phagocyte function and
periodontal infection. J Periodontol 67:1070-5, 1996.
48. Grassi M, Williams C, et al, Management of HIV-associated
periodontal diseases. In: perspectives on oral manifestations
of AIDS, Robertson P, Greenspan J, eds., Litleton, Mass. PSG
Publishing Co., pages 119-30, 1988.
49. Van Dyke T, Serhan C, Resolution of inammation: a new
paradigm for the pathogenesis of periodontal diseases. J Dent
Res 82:82-90, 2003.
50. Serhan C, Controlling the resolution of acute inammation:
a genus of dual anti-inammatory and proresolving media-
tors. J Periodontol 79 (Proceedings of the 2008 workshop on
inammation):1520-6, 2008.
51. Serhan C, Hong S, et al, Resolvins: a family of bioactive
products of omega-3 faty acid transformation circuits
initiated by aspirin treatment that counter proinammation
signals. J Exp Med 196:1025-37, 2002.
52. Tilley S, Coman T, Koller B, Mixed messages: modulation
of inammation and immune responses by prostaglandins and
thromboxanes. J Clin Invest 108:15-23, 2001.
53. Levy B, Clish C, et al, Lipid mediator class switching dur-
ing acute inammation: signals in resolution. Nat Immunol
2:612-9, 2001.
54. Takano T, Clish C, et al, Neutrophil-mediated changes in
vascular permeability are inhibited by topical application of
aspirin-triggered 15-epi-lipoxin A4 and novel lipoxin B4 stable
analogues. J Clin Invest 15:819-26, 1998.
55. Serhan C, Takano T, Madox J, Aspirin-triggered 15-epi-
lipoxin and stable analogs of lipoxin A4 are potent inhibitors
of acute inammation. Receptors and pathways. Adv Exp Med
Biol 447:133-49, 1999.
56. Ordovas J, Shen J, Gene-environment interactions and
susceptibility to metabolic syndrome and other chronic
diseases. J Periodontol 79 (Proceedings of the 2008 workshop
on inammation):1509-13, 2008.
57. Hasturk H, Kantarci A, et al, RvE1 protects from local
inammation and osteoclast-mediated bone destruction in
periodontitis. FASEB J 20:401-3, 2006.
to request a printed copy of this article, please
contact Steven E. Schonfeld, DDS, PhD, 2773 Harris St., Suite
B, Eureka, Calif., 95503-4866.
with and without periodontal ap surgery. J Clin Periodontol
13:205-10, 1986.
23. Demmer R, Papapanou P, et al, Bleeding on probing dieren-
tially relates to bacterial proles: the oral infections and vascular
disease epidemiology study. J Clin Periodontol 35:479-86, 2008.
24. Brayer W, Mellonig J, et al, Scaling and root planing ef-
fectiveness: the eect of root surface access and operator
experience. J Periodontol 60:67-72, 1989.
25. Wylam J, Mealey B, et al, Eectiveness of open versus
closed scaling and root planing. J Periodontol 64:1023-8, 1993.
26. Heitz-Mayeld L, Trombelli L, et al, A systematic review
of the eect of surgical debridement versus nonsurgical
debridement for the treatment of chronic periodontitis. J Clin
Periodontol 29 (Suppl. 3):92-102 and 160-2, 2002.
27. Becker W, Becker B, et al, A longitudinal study comparing
scaling, osseous surgery and modied Widman procedures:
results afer ve years. J Periodontol 72:1675-84, 2001.
28. Philstrom B, McHugh R, et al, Comparison of surgical and
nonsurgical treatment of periodontal disease. A review of
current studies and additional results afer 6 years. J Clin
Periodontol 10:524-41, 1983.
29. Hill M, Moore R, Locally acting oral chemotherapeutic agents.
In: Periodontics. Medicine, surgery, and implants, ed., by Rose L,
Mealey B, et al, St. Louis: Elsevier Mosby, pages 276-87, 2004.
30. Bonito A, Lohr K, et al, Eectiveness of anti-microbial
adjuncts to scaling and root planing therapy for periodontitis,
vol. 1, evidence report and appendixes. Evidence report/tech-
nology assessment No. 88; AHRQ Publication No. 04-E014-2.
Rockville, Md., Agency for Healthcare Research and Quality,
March 2004.
31. Newman M, Caton J, Gunsolley J, The use of the evidence-
based approach in a periodontal therapy contemporary
science workshop. Ann Periodontol 8:1-11, 2003.
32. Hanes P, Purvis J, Local anti-infective therapy: pharmacologi-
cal agents. A systematic review. Ann Periodontol 8:79-98, 2003.
33. Golub L, Lee H, et al, Minicycline reduces gingival col-
lagenolytic activity during diabetes. Preliminary observations
and a proposed new mechanism of action. J Periodontol Res
18:515-26, 1983.
34. Golub L, Suomalainen K, Sorsa T, Host modulation with
tetracyclines and their chemically modied analogues. Curr
Opin Dent 2:80-90, 1992.
35. Thomas J, Walker C, Bradshaw M, Long-term use of
subanti-microbial dose doxycycline does not lead to changes
in anti-microbial susceptibility. J Periodontol 71:1472-83, 2000.
36. Giannobile W, Host-response therapeutics for periodontal
diseases. J Periodontol 79 (Proceedings of the 2008 workshop
on inammation):1592-1600, 2008.
37. Reddy M, Geurs N, Gunsolley J, Periodontal host modula-
tion with anti-proteinase, anti-inammatory, and bone-sparing
agents. A systematic review. Ann Periodontol 8:12-37, 2003.
38. Gapski R, Barr J, et al, Eect of systemic matrix metal-
loproteinase inhibition on periodontal wound repair: a proof of
concept trial. J Periodontol 75:441-52, 2004.
39. Van Dyke T, The management of inammation in peri-
odontal disease. J Periodontol 79 (Proceedings of the 2008
workshop on inammation):1601-8, 2008.
40. Lane N, Armigate G, et al, Bisphosphonate therapy
improves the outcome of conventional periodontal treatment:
results of a 12-month, randomized, placebo-controlled study. J
Periodontol 76:1113-22, 2005.
2. Socransky S, Microbiology of periodontal disease present
status and future considerations. J Periodontol 48:497-504, 1977.
3. Moore L, Moore W, et al, Bacteriology of human gingivitis. J
Dent Res 66:989-95, 1987.
4. Haajee A Socransky S, Microbial etiological agents of de-
structive periodontal diseases. Periodontol 2000 5:78-111, 1994.
5. Ivanyi L, Lehner T, Stimulation of lymphocyte transformation
by bacterial antigens in patients with periodontal disease.
Arch Oral Biol 15:1089-96, 1970.
6. Horton S, Raisz L, et al, Bone resorbing activity in superna-
tant uid from cultured human peripheral blood leukocytes.
Science 177:793-5, 1972.
7. Birkedal-Hansen H, Role of matrix metalloproteinases in
human periodontal diseases. J Periodontol 65:474-84, 1993.
8. Graves D, Cytokines that promote periodontal tissue de-
struction. J Periodontol 79 (proceedings of the 2008 workshop
on inammation):1585-91, 2008.
9. Loe H, Anerud A, et al, The natural history of periodontal
disease in man. Rapid, moderate and no loss of atachment in
Sri Lankan laborers 14 to 46 years of age. J Clin Periodontol
13:431-45, 1986.
10. Loe H, Anerud A, et al, The natural history of periodontal
disease in man. The rate of periodontal destruction before 40
years of age. J Periodontol 49:607-20, 1978.
11. Kornman K, Mapping the pathogenesis of periodontitis: a
new look. J Periodontol 79 (Proceedings of the 2008 workshop
on inammation):1560-8, 2008.
12. Ordovas J, Shen J, Gene-environment interactions and
susceptibility to metabolic syndrome and other chronic
diseases. J Periodontol 79 (Proceedings of the 2008 Workshop
on Inammation):1508-1513, 2008.
13. Wilson A, Epigenetic regulation of gene expression in the
inammatory response and relevance to common diseases.
J Periodontol 79 (Proceedings of the 2008 workshop on
inammation):1514-9, 2008.
14. Guerini V, A history of dentistry from the most ancient
times until the end of the 18th century. Philadelphia, Lea &
Febiger, pages 129-30, 1909. htp://tinyurl.com/dental-history.
Accessed Jan. 29, 2010.
15. Loe H, Theilade E, Jensen S, Experimental gingivitis in man. J
Periodontol 36:177-87, 1965.
16. Theilade E, Wright W, et al, Experimental gingivitis in man.
II. A longitudinal clinical and bacteriological investigation. J
Periodontol Res 29:168-73, 1966.
17. Sato K, Yoneyama T, et al, The eect of subgingival debride-
ment on periodontal disease parameters and the subgingival
microbiota. J Clin Periodontol 20:359-65, 1993.
18. Cugini M, Haajee A, et al, The eect of scaling and root
planing on the clinical and microbiological parameters of
periodontal diseases: 12-month results. J Clin Periodontol
27:30-6, 2000.
19. Tuter G, Kurtis, B, et al, Eects of phase I periodontal treat-
ment on gingival crevicular uid levels of matrix metallopro-
teinase-3 and tissue inhibitor of metalloproteinase-1. J Clin
Periodontol 9:1011-5, 2005.
20. HallmonW, ReesT, Local anti-infectivetherapy: mechanical
approaches. Asystematicreview. AnnPeriodontol 8:99-114, 2003.
21. Rabbani G, Ash M, Caesse R, The eectiveness of subgin-
gival scaling and root planing in calculus removal. J Periodontol
52:119-23, 1981.
22. Caesse R, Sweeney P, Smith B, Scaling and root planing
Specializing in the Selling and Appraising of Dental Practices
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LOS ANGELES COUNTY
BEVERLY HILLS PATIENT CHARTS ONLY! - Approx. 676 pat. charts w/ approx. 525 active charts. Coll approx. $30K/mo. ID#3061.
ENCINO GP - 3 eq. ops., 1,200 sq. ft. suite, 7 story professional building. Collected approx. $514,348 for 2009. ID#2631. Price Reduced!
GLENDALE - Turn Key practice, 3 eq. ops., 5 plumbed not eq., 2,000 sq. ft. suite, two story Med/Dent bldg. ID#2591. Price Reduced!
*LANCASTER GP - 3 eq. ops., 1,200 sq. ft. suite, one story shopping center. BUYERS NET OF $123,769. ID#2691.
*LAWNDALE GP & Bldg - Excellent practice w/8 eq. ops., 3,000 sq. ft., free standing bldg. NET OF $237K. ID#2901.
*LAWNDALE GP (New) - Store front office w/parking behind bldg., 4 eq. ops., 2 plumbed not eq. NET OF $63,234. ID#1331.
LOS ANGELES GP - 4 eq. ops., 1,700 sq. ft. office, strip shopping center. Collected approx. $345,882 for 2009. ID#2621.
LOS ANGELES GP - Turn Key, 3 eq. ops., multi story Med/Dent bldg. Coll. approx. $197,238 in 2009. Great views. ID#2831.
MARINA DEL REY- Great starter location - LSHLD - 2 eq. ops., 1 plmbd, Only dental practice in bldg. ID#2791.
MONTEBELLO - Long established practice - Equip. & Charts Only! 2 eq. ops., in single story busy shopping center. ID#2701.
*REDONDO BEACH GP - 3 eq. ops., in large remodeled shopping center. Collected approx. $276,831 in 2009. NET $85,477. ID#2821.
*ROLLING HILLS GP - Long established practice w/5 eq. ops., 1,760 sq. ft. suite in a 2 story Med/Prof. bldg. NET $109K. ID#2981.
*SAN PEDRO GP - 2 eq. ops., 1 plmbd., 1,400 sq. ft. office located on 2nd fl of strip center; visible location. ID#2851. Price Reduced!
SHERMAN OAKS GP - Excellent street visibility. 3 eq. ops., Med/Dent bldg. Collected approx. $404,565 for 2009. ID#2491.
*WILMINGTON GP - A must see practice! 3 eq. ops., 1,400 sq. ft. office located in a 1 story free standing bldg. NET OF $387K. ID#2841.
ORANGE COUNTY
*GARDEN GROVE GP - 7 eq. ops., 2,200 sq. ft. suite. 16+yrs of Goodwill. Collected $1,061,802 in 2009. NET $329K. ID#2891. SOLD
IRVINE GP/SPEC - Leasehold Improv. & Equip. Only! 3 ops., 1 plmbd not eq., suite in 2 story Med/Dent Bldg. ID#2661. Price Reduced!
SAN JUAN CAPISTRANO GP (New) - Well design & modern office w/4 eq. ops., 3 plmbd not eq., in a 2 story prof. bldg. ID#3021.
*TUSTIN GP - Turn Key, state of the art office. 5 eq. ops., 3 chairs in open bay. Ready for multi specialty office. ID#2861. SOLD
WESTMINSTER GP - 2 eq. ops., 850 sq. ft. suite, single story strip mall. BUYERS NET OF $44,326. ID#2711.
RIVERSIDE / SAN BERNARDINO COUNTIES
*INDIAN WELLS GP - Long established practice, 5 eq. ops., 1,400 sq. ft. suite, 2 story prof. bldg. NET $151,585. ID#2801.
LA QUINTA (New) - Leasehold & Equip. Only! 3 eq. ops., 1,000 sq. ft. suite in a strip shopping center. Established in 1995. ID#3011.
ONTARIO GP (New) - Excellent growth potential office w/4 eq. ops. in a single strip plaza in major intersection. ID#2791.
SAN DIEGO COUNTY
EL CAJON (New) - Solo Practice, 3 eq. ops., 1 plmd not eq. 2,200 sq. ft. office, free standing bldg. Seller owns bldg. NET $123K. ID#3031.
OCEANSIDE - 4 eq. ops., 1,500 sq. ft. office, one story Med/Dent bldg. Collected approx. $345,049. ID#1641. Great Location!
VENTURA / SANTA BARBARA / SAN LUIS OBISPO COUNTIES
*SANTA BARBARA COUNTY GP (New) - Long Establised Practice, 3 eq. ops.,1,010 sq.ft, 2 story strip mall. NET OF $219K. ID#2881.
SPECIALTY PRACTICES
RIVERSIDE ORTHO - 4 chairs in open bay, 1,480 sq. ft. suite. Collected approx. $363,385. NET OF $164,506. ID#2751.
WHITTIER ORTHO - Leasehold Improvements & Equip. Only! 6 chairs in open bay, seller offering 2 months free rent. ID #2781
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cda j ournal , vol 38 , n

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ap ri l 201 0285
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bakersfield pediatric dental
office for rent Iong cstablishcd
pcdiatric dcntal occ. Four plumbcd
opcratorics. Ncwly rcmodclcd. Quict room.
r,ccc sq. t. occ. Across thc strcct rom
Bakcrscld Collcgc. Major oot trac.
sr,rc a month. Plcasc call r8/rc/8c.
dental suites for lease
silicon valley Rcnovatcd ortho,
pcdo, gcncral occ spacc with vicws in
Ios Catos, an aucnt community. Closc
to schools, downtown and rccways.
Contact c8/8r,,, cmail
.oakmcadow,sbcglobal.nct.
How to Place a
Classied Ad
CDA and ADA members are charged $50 for
up to 20 words and $10 for each additional
10 words or less. Condential CDA box
numbers are available for an additional
$10 per month. Rates for non-CDA/ADA
members are $75 for up to 20 words
and $15 for each additional 10 words or
less. Condential CDA box numbers are
available for an additional $15 per month.
All advertisements must be prepaid either
by check, VISA, MasterCard or American
Express. Ads are not accepted over the
phone. All ads will be placed on the CDA
Web site on the 15th of the month prior to
the month of publication and will remain
online for 45 days at no extra fee.
The deadline for classied advertising is the
rst day of the month, prior to the month
of publication. Example: Jan. 1 at 5 p.m. is
the deadline for the February issue of the
Journal. If the rst falls on a weekend or
holiday, then the deadline will be 5 p.m. the
following workday. Afer the deadline closes,
ads will not be accepted, altered or canceled.
Deadlines are rm.
To receive a classied ad request form,
please contact Jena Gruchow at
916-554-5332 or Jenae.Gruchow@cda.org.
Reply to ads with CDA box numbers as follows:
Classied Box Replies
CDA Box_________
California Dental Association
P.O. Box 13749
Sacramento, CA 95853
Classied advertisements available are:
Equipment for Sale, Equipment Wanted,
Oces for Sale, Oces for Rent or Lease,
Opportunities Available, Opportunities
Wanted, Practices for Sale and Practices
Wanted.
Licensed agents and brokers may not place
classied ads. For information on display
advertising, please contact Corey Gerhard at
916-554-5304 or Corey.Gerhard@cda.org.
CDA reserves the right to edit copy and
does not assume liability for contents of
classied advertising.
conti nues on 286
offi ces for rent or lease
286ap ri l 201 0
cda j ournal , vol 38 , n

4
conti nues on 290
operatory for rent or lease
Lcntist with . ycars cxpcricncc
wants to rcnt or sublcasc an opcratory on
Saturdays in thc Sacramcnto or Roscvillc
arca. Fmail drprcddis,gmail.com or call
,rr/,,c.
share office space Ncw occ
with thc latcst in tcchnology and cquip
mcnt. Iargc lab, cxccllcnt location.
Torrancc, CA. ../.c/.
vallejo office for lease
Occ or lcasc at Vallcjos Ccntral Hub at
Tcnncsscc Strcct and Admiral Callaghan
Ianc with casy acccss to Intcrstatc 8c.
Spacc is .,ccc sq. t. with vc opcratorics.
Tcrc arc two othcr gcncral practiccs in
thc cxisting complcx. Tc prcscnt tcnant
is an oral surgcon lcaving to practicc in his
own building. Tc spacc will bc vacant
bcginning May .crc. Call /c/8r,.
california practice opportunity
turlock Family Lcntistry in
pcaccul, Ccntral Caliornia location.
Succcssul, ncwly dccoratcd, six ops,
amily practicc scrving thc community or
c ycars is sccking somconc to join thc
tcam with thc intcntion o transitioning
to owncr. Turlock is a growing commu
nity, ocring a pcaccul licstylc with casy
acccss to Sacramcnto, San Francisco,
Sicrras and Montcrcy. Our tcnurcd tcam
is looking orward to supporting your
succcss. Plcasc cmail jcswcarin,att.nct or
visit www.TurlockLcntalTcam.com.
classi fi eds, conti nued from 285
opportuni ti es avai lable
SINCE 1987
Nor Cal GOLDEN STATE PRACTICE SALES sm
Specializing In Northern & Central California Practice Sales & Consulting
James M. Rodriguez, MA, DDS
44 Holiday Drive, P.O. Box 1057, Alamo, CA 94507
DRE Licensed Broker # 957227
v MARIN COUNTY - Coll. $207K part time. Good starter or satellite for
existing Marin practice. Only dental office in area. CLOSED
v PERIODONTAL - S.F. East Bay - Established 30 plus years. Well known
and respected in dental community. Seller will stay on contractually for
introduction to established referral base.
v CENTRAL CONTRA COSTA - Danville established family practice.
Priv/ins UCR. $1.2M collections. 4 operatories. SALE PENDING
v SOUTH LAKE TAHOE - For lease. 5 ops. Not equipped. State of the art
offce. No upgrades or additions needed. Very special stunning location.
Call for details.
Practice Sales - Presale Complimentary Consultations and Valuation Estimates-
Practice Appraisals and Forensic Services - Independent Practitioner Programs
Each Transaction Handled Personally From Start to Finish
Buyer Consultant Service Available
STRICT CONFIDENTIALITY OBSERVED
925-743-9682
Integrity-Experience-Knowledge-Reputation
e-mail gspsjimrod@sbcglobal.net
GoldenStatePS0310.indd 1 3/10/10 10:56 AM
Buyers and Sellers:
Trust the winning team
Professional Practice Sales, Inc.
Thomas Fitterer
Dean George
Ray Irving and Edna Irving
over 100 years experience in selling Dental practices
PPS excels at explaining Options to enhance your bottom line.
This is the Hottest Sellers market in history.
Consider cashing in and doing it again in a rapid growth area!
BUYERS AND SELLERS
Register for HOT LISTINGS & IMMEDIATE NOTIFICATION
Free Appraisal for Sellers:
Professional Practice Sales, Inc.
Serving the Dental Professions since 1966
For Personal Service, mail or fax back. Inquiries will be kept in confdence.
PPS, Inc., 18410 Irvine Blvd., Suite A, Tustin, CA 92780 Ph: 714-832-0230, 800-695-2732 Fax: 714-832-7858
I want immediate attention on a Practice to buy.
Location_____________________________________________________Grossing $______________________
I want to sell my practice.
Name______________________________________________________________________________________
Address______________________________________City____________________State______Zip__________
E-mail___________________________Phone________________Mobile____________Home_______________
Northern California:
4 Harris Hill Drive, Novato, CA 94947-2904
415-899-8580 530-894-0700
Fax: 415-899-8588
www.PPSsellsDDS.com
Southern California:
18410 Irvine Blvd., Suite A, Tustin, CA 92780
714-832-0230 800-695-2732
Fax: 714-832-7858
www.PPSdental.com
Making your transition a reality.
DENTAL PRACTICE BROKERAGE
FFCFESSlCN/L FF/CIlCE IF/NSlIlCNS
More inIormation is available
on our website regarding practices
listed in other states, articles,
upcoming seminars and more.
Practice Sales Mergers
Partnerships Appraisals
Patient Record Sales
HENRY SCHEIN PPT INC.
CaliIornia Regional Coporate OIIice
DR. DENNIS HOOVER, Broker
OIIice:(800) 519-3458 OIIice (209) 545-2491
Fax (209) 545-0824 Email: dennis.hooverhenryschein.com
5831 Stoddard Road, Ste.808 Modesto, CA 95356
Henry Schein PPT Inc., Real Estate Agents
and Transitions Consultants
Dr. Tom Wagner (916) 812-3255 N. CaliI.
Hallie Johnson-Nelson (209) 545-2491 N. CaliI.
Mario Molina (323) 974-4592 S. CaliI.
Thinh Tran (949) 533-8308
For more inIormation regarding the listings below:
VISIT OUR WEBSITE AT:
WWW.PPTSALES.COM
(Practice Opportunities)
CALIFORNIA / NEVADA REGIONAL OFFICE
APTOS: For Sale - FF General Dentistry Practice. Highly
desirable location. 2008 Gross Receipts ov oo er $1Mil.
w/adjusted ov oo erhead at 51%. 3-operatories in 1,000 sq ft.
Pano & Modi computerized software. 9-hygiene da hh ys per aa
week. Practice operated for past 33 years in same location.
Open 5 days a w aa eek. Owner willing to work back for new
owner 2 days/wk. aa
ATW AA A WW TER: AA For Sale - FF General Dentistry Practice. Gross
receipts $177K with adjusted net income of $67,495. Practice
has been in its present location for the past 30 years. 1,080 sq
ft. 2-equipped operatories. Owner to retire.
CITRUS HEIGHTS: RR For Sale- FF General Dentistry Practice.
Well-designed 6 operatories with 1,500 sq. ft. of WW f ff ice in ff
professional building. Desirable location. 2-3 days h aa ygiene. hh
Owner is retiring.
DIXON: For Sale- FF General Dentistry Practice. 08 collections
were $122,894. 3 op 1,100 sq. ft. off ff ice. Owner has relocated ff
out of state and is motiv ted. Good opportunity to build a
practice in a growing community near Davis, CA. #14265 aa
EL SOBRANTE: For Sale- FF General Dentistry Practice: Ideal
for recent grad or DDS looking for satellite practice. 3 ops.
w/potential of 5. 08 receipts $350K, adj. net income $124K.
3 days of h aa ygiene, P hh ano, Easy Dental software. 1,300 sq. ft.
Seller is retiring after 35years in same location. #14302
FRESNOAREA: For Sale- FF Exceptional General Dentistry
Practice. This outstanding practice has annualized collections
of $1,921,467, $798K adj. net income. The off ff ice has ff
Dentrix, Laser, Intra-oral camera, digital x-ray and P aa ano.
Bldg. may be a aa v aa ail. for sale. Owner is retiring. #14283
FRESNO: For Sale FF -General Dentistry IV Sedation Practice.
Collections $1,064,500. Seller looking for either an outright
sale or a buyer to purchase 1/2 of the practice. Buyer will
need IV sedation skills or hav aa e been trained to provide IV oo
sedation. Facility 1,500 sq. ft. w/5 equipped operatories & 7
days of h aa ygiene. #14250 hh
FRESNO: For Sale- FF General Dentistry Practice. Owner has
practiced in same location 24 years. 3 TX rooms, 1,000 sq ft.
Located in a Medical/Dental Bldg. Owner to retire. 2008
collections were $86K. Ideal for a new grad or satellite
off ff ice. ff
FRESNO: For Sale- FF Office Space Onl ff y in North Fresno
Area. New fully equipped 3-op dental space av aa ail. asking
$115K. Equip. approx. 2 years old. Space av aa ail. for 4th op.
Off ff ice design contemporar ff y & tastefully done. Asking price
includes all leasehold improv oo ements.
GRASS VALLEY VV : For Sale- FF This Periodontal Practice is
located in a very desirable growing community. Practice yy
has been in its present location for the past 28 years.
Off ff ice consists of 1500 sq ft 3 ops, Intral-oral camera. ff
Practice has 5 days of h aa ygiene. hh
GREATER AA AUB AA URN AREA: For Sale- FF General
Dentistry Practice 7 Dental Building, Outstanding
opportunity to purchase well established, v dd ery successful,
4 op Fee for Service practice. 1,800 sq. ft. dental bldg. in
the Sierra Foothills. No PPO or HMO. 08 Collections
$763K on 3.5 days with 5.5 da aa ys of h aa ygiene. Owner is hh
retiring. #14304
LAKE FORREST: For Sale FF - General Dentistry
Practice. This 4 operatory, 1,200 sq. ft. of yy f ff ice had g ff ross
receipts of 1.2 million in 2009. There are 5 days of aa
hygiene and appro hh x. 2,000 collective patients. Approx.
10% of receipts are from two HMO plans. Seller has
practiced in the same location for approx. 30 years.
Owner is retiring.
MODESTO: For Sale FF - General Dentistry Practice. 5
operatories, 32-years in practice. Gross Receipts $884K
w/adjusted net income of $346. Dentrix, Cerec, and
Intra-oral camera. Owner to retire.
MODESTO: For Sale- FF General Dentistry Practice. 12
Treatment rooms, P TT ano, Laser, Intra Oral Camera,10-years
in same location. Three days of h aa ygiene. Owner hh -32 years
in practice willing to work a couple days of w aa eek to help
transition the practice or as Role-Reversal.
MURRIETA/TEMECULA: TT For Sale FF - 2009 receipts
were $648,000. This 4 op, 1,500 sq. ft. off ff ice space with ff
4.5 days of h aa ygiene. hh Av AA erage age of Dental Equip is 7
years.
NO. CAWINE COUNTRY RR : ENDO PRACTICE AA For
Sale-GR 958K adj net $673K 4 Ops, 1,500 sq ft.
Overhead 29% Owner to retire #14296
ORO RR VILLE: OO For Sale FF - General Dentistry Practice.
Owner dentist recently deceased. 2009 collections $770K.
Ver VV y nice stand alone dental building with basement. 7 ops
digital x-ray 5 da aa ys of h aa ygiene. Bldg 3,000 sq ft Basement hh
540 sq ft. Temporar TT y Dentist in place.
PALM SPRINGS: PP For Immediate Sale FF - General Dentistry
Practice. 2008 Gross Receipts $906K with adj. net income
of $346K. Highly desire able location with 4 ops. Laser,
and Intra-oral camera. 5 days of h aa ygiene. Owner recentl hh y
deceased.
PORTER RR VILLE: RR For Sale FF -One of two partners is retiring in
this highly successful General Dentistry Practice. Receipts
$2Mil. adj. net $1,257,000. 2,000 sq ft 6 ops. Intra-Oral
camera, Pano, Dentrix.10 days of h aa ygiene. #14291 hh
RANCHO SANTA MARGARIT TT A: TT For Sale FF - General
Dentistry: Off ff ice Space Full ff y Equipped ll : Owner would like to
sell existing dental equipment and hav aa e buyer take ov oo er lease
in the 1,200 sq. ft. treatment room, off ff ice. Built b ff y Henry
Schein in 2005 with Pelton and Crane cabinetry and
sterilization center. Excellent opportunityfor a low cost start
up or satellite practice.
RED BLUFF: For Sale FF -General Dental Practice
"REDUCED PRICE" Facility ov oo erlooks the Sacramento
River, 3,500 sq ft, has 8 ops, 10 hygiene da hh ys. Reduced aa
price/Or Best Offer due to retiring doctor ff s health. Historically
Gross Receipts hav aa e been ov oo er $1 Mil per year. 100%
financing a ff v aa ailable. Sale of Building (optional) #14252
REDDING: For Sale FF -Owner looking for Assoc. trans. into
Partnership w/Buy-Out. GR $1 Million dollars income
$436K. 5.5 days h aa ygiene, 2,200 sq. ft. #14293 hh
RENO: FOR IMMEDIATE SALE AA DECEASED DENTIST
- General Dentistry Practice. 2 ops, 17yrs. present location 07
GR $763K with adj. net of $263K w/65% ov oo erhead. Bldg.
also for sale. Owner deceased.
ROSEVILLE: RR For Sale- FF General Dentistry Practice. 2008
Receipts $834K with adjusted net income of $297,218.
64.4% ov oo erhead. Practice has been in this present location for
the past 7 years. 13-15 N w Patients a month. 6-treatment
rooms in 2,100 sq ft. Laser, Intra-oral camera, and digital
radiography hh . Owner relocating out of of yy f ff ice. ff
SAN FRANCISCO: Financial District 4 ops, 1,500 sq. ft.
MERGER - Buyer needs to bring in Pt. base #14288
SAN FRANCISCO: For Sale-P FF atient Base f PP or Sale ff -Owner
passed aw aa ay last June and the practice has continued on 4 aa
days a w aa eek with an associate. Lease cant be renewed. There
are approx. 1,000 acive patients in the practice. The patient
base can be purchased at no risk to buyer since the purchase
price is paid according to the receipts collected on the patients
that transfer.
SOUTH LAKETAHOE: TT For Sale- FF General Dentistry
Practice. Off ff ice is 647 sq ft w/3 ops. Practice has been in its ff
present location for the past 26 years. Owner to retire. #14277
YUBA CITY/ MARYSVILLE RR : For Sale- FF General Dentistry
Practice w/Bldg av aa ail. Practice located in present (great)
location ov oo er 30 years.1,800 sq ft 5 ops 4 hygiene da hh ys. aa
Owner to retire.#14273
S
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290ap ri l 201 0
cda j ournal , vol 38 , n

4
classi fi eds, conti nued from 286
opportunities available I
yourc looking or a longtcrm commit
mcnt and dcsirc to bc productivc, thc
opportunity is yours Sccking FT manag
ing dcntists to join largc group practicc in
Iancastcr, Ios Angclcs, Orangc County,
Inland Fmpirc, San Licgo and any doctors
looking to rclocatc to Arizona. Stcady
paticnt ow in high volumc HMO
cnvironmcnt. Must havc ycars
cxpcricncc and bc procicnt in molar
cndo RCT. A comprchcnsivc bcncts
packagc is ocrcd including malpracticc
covcragc. Compctitivc pay For availablc
positions plcasc call. /r.8rc,
submit your rcsumc to. kristin.armcnta,
brightnow.com or ax to. /rc8.
opportunity available Lcntal
Assisting Program Lircctor wantcd to
dcvclop curriculumtcach at ncw ccntcr in
Tarzana, Caliornia. Fxpcricncc rcquircd.
Call Iaura 8r8/8/.
opportunity available north-
western washington Sccking
cxpcricnccd dcntist or busy, cstablishcd,
rapidly growing, ccorscrvicc group
dcntal practicc. Fxccllcnt immcdiatc
incomc opportunity (sr8c,ccc to
s/,ccc + pcr ycar) dcpcnding on
productivc ability and hours workcd.
Sccurc longtcrm position. You can
conccntratc on optimum paticnt trcat
mcnt without practicc managcmcnt
dutics. Ncwly cquippcd, modcrn occ
with cxccllcnt sta and lab scrviccs
providcd. I you arc bright, cncrgctic with
a dcsirc to bc productivc, vcry pcrsonablc,
pcoplc oricntcd and havc grcat gcncral
and spccialty clinical skills, ax rcsumc to
Otto . Hansscn at .8.rrc.
a p r i l 1 0 c l a s s i f i e d s
conti nues on 294
VISIT US @ THE CDA IN ANAHEIM MAY 14-16, 2010 BOOTH # 654
ANAHEIM (3) op computerized G.P. Low overhead offce. Cash/Ins/PPO/Denti-Cal patient base.
Annual Gross Collect. $260K+ p.t. Will do more f.t. Seller motivated.
ARCADIA (4) op computerized G.P. Cash/Ins/PPO only. Gross Collect $315K+/yr on a (4) day
week. In a well known, easily accessible medical/dental bldg on a main blvd. SOLD
BAKERSFIELD #22 (5) op G.P. (4) eqtd. Strip Ctr. Gross Collect ~ $200K/yr p.t. NEW
BAKERSFIELD #23 Partner Wanted! 50% Ownership! (12) op comp. G.P. in a retail ctr.
Cash/Ins/PPO. Digital x-rays & Pano. Paperless offce. Annual Gross Collect. $2M+. NEW
CALABASAS - Build to Suit Dental space avail for long term lease. 1,200 3,600 sq ft NEW
FRESNO (3) op G.P. (4) yr old eqt. Mixed patients. 2009 Collections $220K+ p.t. NEW
FRESNO SUBURB (3) op G.P. Gross Collect. $375K/yr. No competition. REDUCED!
GLENDALE Extremely motivated Seller wishes to sell their (4) op (2 eqtd/2 plumbed) G.P.
located in a free stand. bldg. Gross Collect. ~ $120K/yr p.t. Excellent starter or buy & combine.
HIGHLAND #2 (3) op compt. G.P. in a shop ctr. Mixed Pt. Base. 09 Collect. $447K. NEW
LODI (4) op/(3) eqtd G.P. Cash/Ins/PPO/HMO. Cap Ck ~ $6K/mos. 09 Collections ~ $500K.
LOS ANGELES (KOREA TOWN) 7 op computerized State of the Art G.P. with an Annual Gross
Collection of $1.4M+ and an Annual Net Income of ~ $450K. Cash/Ins/PPO only. Cerec 3, digital
x-rays, Dentrix s/w, ICAT Imaging System, (2) lasers, & a PRP System.
PETALUMA (2) op G.P. Cash/Ins/PPO/HMO. Cap Ck ~ $3K/mos. 09 Collections ~ $480K.
SAN JACINTO (HEMET AREA) (4) op Computerized G.P. Absentee owned HMO pract. w
$6K/mos Cap Checks. No Denti-Cal. 2009. Gross Collect. ~ $400K on a (3) day wk. PENDING
SANTA CLARITA VALLEY (11) op comput. G.P. (10) ops eqtd 11
th
op plmb. Cap Cks.
$14K-$16K/mos. Cash/Ins/PPO/HMO/min Denti-Cal. Annual Gross ~ $1.6M. Back on Market
STOCKTON WOW! ~ $18K/mos CAP Checks! (7) op comp G.P. Cash/Ins/PPO/HMO pts.
No Denti-Cal! Cap Ck ~ $18K/mos. 09 Collections ~ $1.15M. Absentee Owner.
TARZANA (3) op G.P. in a shop ctr. 08 Gross $551K+ on a 2-3 day wk. Mixed pts. SOLD
WESTLAKE VILLAGE (4) op compt. G.P. in a highly desirable area. (3) ops eqtd.
Digital x-rays. Drop Dead Gorgeous! Cash/Ins/PPO only! 09 Gross Collections ~ $629K. NEW
VALLEY VILLAGE (SHERMAN OAKS) (4) op computerized G.P. 2009 Collect. $477K. Cash/
Ins/PPO pts. Seller is a 1-800-DENTIST. In a free stand. bldg. w visibility. PENDING
VENTURA Multi-Specialty 5 op comput paperless offce, digital x-rays/Pano. Newer Eqt. 2 days/
wk Pedo, 3 days/mos O.S., 2 days/wk Endo, 1 day/mos Perio. Gross $540K+. REDUCED!
WOODLAND HILLS (3) op comput. G..P. Dentrix s/w. Located in a strip ctr. Cash/Ins/PPO only.
2009 Gross Collect. ~ $570K. Newer eqt., digital x-rays/intra oral camera. PENDING

UPCOMING PRACTICES: Canoga Park, Covina, L.A., Montebello, Oxnard, & Simi Valley.
DENTAL CONDOS FOR SALE: L.A. Cty, San Diego Cty, Orange Cty & Riverside Cty.
D & M SERVICES:
Practice Sales & Appraisals Practice Search & Matching Services
Practice & Equipment Financing Locate & Negotiate Dental Lease Space
Expert Witness Court Testimony Medical/Dental Bldg. Sales & Leasing
Pre - Death and Disability Planning Pre - Sale Planning
P.O. Box #6681, WOODLAND HILLS, CA. 91365
Toll Free 866.425.1877 Outside So. CA or 818.591.1401 Fax: 818.591.1998
www.dmpractice.com CA DRE Broker License # 01172430
Paul Maimone Broker/Owner

D&Mad0410.indd 1 3/15/10 11:53 AM
3017 SOUTH BAY
Est. Cosmetic and Restorative Practice in
desirable area. Seller retiring and able to help
for a smooth transition. 1,530 sq. ft. ofce
with 4 fully equipped ops. 2009 GR $829K+.
Asking Price $658K
3011 MID-PENINSULA GP
Located in a single story retail shopping
centre. 2,000 sq. ft. ofce with 7 fully-equip.
ops. Seller leaving area. 2008 GR 1.1M+
Asking $716K.
2999 NO. CA COAST
Flourishing Pediatric Dental Practice. Well
est. with seasoned staff. 4,000+ active pts.,
avg. 50-80 new pts./mo. Avg. over 2.2M in
Gross Receipts. Fully equip. 1,600 sq. ft. ofce
with open bay and 2 quiet areas Asking
$1,542,000.
2976 NORTH BAY SANTA ROSA GP
Beautiful, contemporary & pristine, state of
the art ofce in a strip shopping ctr. with
anchor retailers: Safeway, Starbucks, Baja
Fresh, etc. Averaging 40+ new patients a
month with 1,200+ active patients (all fee-for-
service). 4 ops (3-fully-equipped) in 1,350 sq.
foot facility. Located on a well-traveled
intersection with incredible street signage and
visibility. 2009 gross receipts $626K+ with an
adj. net of $202K+. Owner willing to assist
Buyer for a smooth transition. Asking only
$498,500.00.
3006 MONTEREY COUNTY ORTHO
Est. Ortho practice in 2,668 sq. ft. ofce with
5 open bay chairs in a professional dental
complex. Panorex and Cephlometric X-ray
machines. Stable and loyal referral base. GR
for 2008 were $340K+. Annualized GR as of
Oct 2009 are $335K+. Owner retiring and
willing to help for a smooth transition. Asking
227K.
2986 SAN JOSE FACILITY & EQUIP
A 1 1/2 year-old stunning facility with small
pt. base that has all the bells and whistles.
2,000 sq. ft., state-of-the-art dream ofce.
Located in desirable comm./residential
neighborhood close to O'Connor Hospital &
Valley Fair Mall. 6 ops and new equip. For the
est. GP who is looking to move into a larger
facility or for the assoc. GP who is ready to
start out on their own. Asking $475K.
3022 MODESTO GP
Owner retiring from well est. friendly, family
practice w/3 ops. in 1,150 sq. ft. ofce +
spacious storage area. Avg. GR for past 5
years $379K w/44% overhead & great upside
potential. Quality staff. Owner willing to help
w/smooth transition. Partnership in building
available. Asking $278K for practice.
3016 CONTRA COSTA COUNTY
PERIO
Est. 1990 in desirable bedroom community 20
miles from SF. 1,068 sq. ft. beautifully
remodeled ofce w/4 fully-equipped ops., &
excellent staff. Assignable 5 year lease w/5
year option. Seller willing to help in the
transition of the practice. 2008 GR $441K+,
2009 GR projected to $460K+ as of Oct.
Terric upside potential. Asking $275K.
COMING SOON:
NORTH BAY GP
3 OPs, 2,000 sq. ft. ofce. Avg. GR $438K+
WINE COUNTRY GP
5 OPs Avg. 1,500 sq. ft. ofce Avg. GR $751K+
MATCHING THE RIGHT DENTIST
TO THE RIGHT PRACTICE
Our New Address:
Carroll & Company
2055 Woodside Road, Ste 160
Redwood City, CA 94061
Phone:
650.403.1010
Email:
dental@carrollandco.info
Website:
www.carrollandco.info
CA DRE #00777682
Serving you: Mike Carroll & Pamela Gardiner
Complete Evaluation of Dental Practices & All Aspects of Buying and Selling
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BAY AREA CONTINUED

NEW! D-857 MOUNTAIN VIEW- Qual-
ity practice. Busy traffic flow. Significant
walk-in patients-continuous growth. Free-
standing bldg w/ ample exclusive patient
parking. 3,400sf - 11 ops $620k

NORTHERN CALIFORNIA

E-729 AUBURN - Busy retail shp ctr w/
excellent signage & good traffic flow. Well
maintained FFS practice. 1750sf, 4ops.
Plumbed for 2 addl ops $300k
E-7121 SACRAMENTO AREA
Largely FFS. 1800sf, 4ops (+2 addl
plumbed). Highly visible,2-story Prof bldg.
$695k
E-818 SACRAMENTO-Increase the part-
time, relaxed workweek and watch the
practice grow! Loyal Patient Base. Collec-
tions over $350k in 2007. 1,200sf & 4 ops.
Building previously appraised @ $260k in
2004. $315k for Practice AND Building
E-821 Facility SACRAMENTO-Attractive
officetraditional dcor. Well-maintained,
highly visible, single-story bldg. Great
area. 1,400sf, 3ops. Plumbed 4th op $60k
NEW! E-849 SACRAMENTO-
Established community in distinct area.
FFS Quality practice. Free-standing build-
ing. 3 fully equipped ops $205k
F-7651 COASTAL EUREKA AREA-
Near Thriving University. Vibrant student/
staff population. Seller retiring. 2700sf, 6
ops. $480k
G-751 RED BLUFF/CHICO- Known for
special sense of community & small town
living. Complete remodel ~5 yrs ago. FFS
GP. 2350sf / 4 ops equipped. Plumbed for
2 addl. Current Lender Willing to
Carry Qualified Buyer. Practice Offered
at $175k / Real Estate $250k

BAY AREA

A-6781 SAN FRANCISCO - New equip-
ment-hardly used. VIRTUALLY NEW
practice! 1,000 sf/3 ops. $65k
A-7751 SAN FRANCISCO- Space Shar-
ing. GP seeks DDS to share office in re-
nowned 450 Sutter St bldg. Call Now!
NEW! A-807 SAN FRANCISCO - Well-
known Medical/Dental Prof bldg in heart
of downtown financial district. Quality,
state-of-the-art practice. 800sf w/2 fully
equipped ops. Plumbed for 1 addl $250k
A-817 BELMONT- Surrounded by dental
specialties in a 2-story Prof. Bldg w/easy
access to public transportation. 860sf w/ 2
ops & plumbed for 1 addl. $210k
A-829 SAN FRANCISCO Facility At-
tractive Office w/traditional dcor. 1600sf
& 2 fully equipped ops. ONLY $49k
B-7881 TRI VALLEY, CA - Facility
Only - Location, Location, Location! 1070
sf, 4ops, ADEC chairs and equipment.
Fully networked Dentrix computers. $325k
NEW! B-846 OAKLAND- Long-
establ ished, fee-for-service prac-
tice.Excellent reputation. Dental Prof Bldg.
2,100sf w/ 3 fully equipped ops $325k
NEW! B-8531 W. Contra Costa - Just
blocks off I-80 commuter corridor. Multi-
story Dental Prof Bldg. 1,212sf w/3 fully
equipped ops. $475k
C-690 SANTA ROSA -1050 sf with 3 ops.
One of the most prestigious areas in Santa
Rosa. Very mature landscape & beautiful
office. Emphasis on Crown & Bridge, es-
thetics dentistry & prosthetics $345k
C-787 SANTA ROSA - GP in very desir-
able area. 1700 sf , 4 fully equipped ops.
Gross over $300k last year! Write your
own success story here. $150k
C-7811 SOLANO CO - 2,997 sf w/6 fully
equipped ops + 2 Hyg ops + 1 addl op!
Buy the whole practice for $1.3m or only
50% for $650k. Call for Full Details!
BAY AREA CONTINUED

NEW! D-842 PLEASANTON General
Dentistry. 1,488sf w/ 2 ops $295k
D-790 MORGAN HILL FACILITY -
SPECTACULAR! Dental Prof Plaza on
busy intersection. 1,730 sf/5ops, 3 of which
are fully equipped. This is an Ideal Satel-
lite Office for Specialty Practice! $75k
D-779 SUNNYVALE - Well established
GP in heart of Silicon Valley! 4 ops,
1050sf. Call for more information! $225k
D-824 SANTA CLARA- GP - 35+ new
pats/mo by word-of-mouth referrals. Retail
Shp Ctr in heart of Silicon Valley. Just 6
years old w/ 1,500 sf & 3 fully equipped
ops. Plumbed for 1 addl op $485k
D-8301 SAN JOSE- FFS - One Stop
Shop w/multiple Specialists under one roof.
Exc Pt Base. Amazing opportunity in a
highly desirable, family-oriented commu-
nity. 2,400 sf & 8 ops, $1.2m
NEW! D-845 SAN JOSE - Facility -
Attractive office. Traditional dcor. Retail
Plaza. 2,240 sf & 5 ops. $150k
NEW! D-8521 SAN MATEO-Facililty -
SPECTACULAR office -Quality dental
care - Modern facility. Just blocks off of
Hwy. 92 and I-280. 2-Story Shp Plza.
2,076 sf & 4 ops + 3 addl $150k
NEW! D-8541 SANTA CRUZ-Relaxed
atmosphere. Well-established, modern
practice. Free standing single story build-
ing. Affluent, desirable location. 1,650sf &
4 ops. Plumbed for 1 addl. $430k
NEW! D-8601 PALO ALTO
FACILITY-Ideally Suited for a Specialist.
Highly desirable upscale community. Sig-
nificant leasehold improvements! 1100sf
w/3 fully equipped ops $390k
NEW! D-863 SAN JOSE-Excellent loca-
tion & Stellar Reputation! Professionally
Decorated in Popular Retail Shopping Ctr.
1500sf & 3 fully equipped ops $495k


WESTERN PRACTICE SALES
John M. Cahill Associates
8 0 0 . 6 4 1 . 4 1 7 9
W E S T E R N P R A C T I C E S A L E S . C O M
NEVADA CONTINUED

LV-800 LAS VEGAS-Well Established
FFS practice. Emphasis on prevention. Sea-
soned Staff. 3350 sf & 6 ops. $785k
NEW! LV-850 LAS VEGAS- Med Prof
complex. 2,603 sf & 6 fully equipped ops,
$652,200
NEW! LV-861 LAS VEGAS FFS Quality
PracticeStable Patient Base & Seasoned
Staff. Professionally Remodeled 1750sf,
5 op office. Call for Info! $180k
R-810 DAYTON-Gross Rcpts over $1mil in
08! Amazing, quality, well-estab w/loyal,
stable patient base & seasoned staff. Excel-
lent signage, easy freeway accessibility, am-
ple parking. 1,500sf & 5 ops. $595k
R-841 RENO Long-established, quality
practice committed to patient education,
technology & self improvement. Wonder-
ful, stable patient base. Excellent signage,
Centrally located in desirable, upscale
neighborhood. 1,750 sf & 5 ops. $350k

SPECIALTY PRACTICES

K-653 GARDEN GROVEORTHO -
Desirable area. 2200 sf 4 chairs in open
bay. 2 private ops. $285k
C-6821 SOLANO CO. PROSTHO- Per-
sonalized treatment in warm caring envi-
ronment. 1040 sf with 3 fully equipped
ops. $325k
I-7861 CTRL VLY ORTHO- 2,000sf,
open bay w/8 chairs. Garden View. An-
tique Exam Room. 45 years of goodwill.
FFS practice sees 60-70 patients daily. Prof
Plaza. $370k
E-811 SIERRA FOOTHILLS ORTHO-
Fast growing area. Patient Oriented, Well
respected Ortho practice. Avg 30 pats/day.
1200 sf & 3 chairs in open bay. $175k
NEW! I-8481 TWO Perio Practices
CENTRAL VALLEY -Office
1
: 1,100sf &
2 ops. Office
2:
1,660sf & 2 ops
REDUCED TO ONLY $90k
NO. CALIFORNIA CONTINUED

H-634 WEST OF RENOOn the Feather
River in Plumas Co. 1500 sf/ 4 ops, excel-
lent location. Lease below market value.
$250k
H-668 NORTHEASTERN CA GP with
over 30 yrs goodwill. 4 ops 1600sf office.
2007 gr rcpts exceed $650k $395k
H-831 SUTTER CREEK -Buy-in op-
portunity during Sellers eventual retire-
ment plans. Dental Prof Bldg w/ ample
parking on a busy scenic highway in desir-
able neighborhood. 4 ops. $160k
NEW! H-856 SOUTH LAKE TAHOE
Live and Practice in the Beautiful and
Unique Tahoe Area! This GP accepts over
50 new patients each month! Respected and
Growing! 1568 sf & 4 fully equipped ops
$425k

CENTRAL VALLEY

I-685 TURLOCK - 1700sf, 7 ops. Avgs
14 patients & 11 Hyg Pats/day! Practice
recently remodeled. Highly attractive free
standing building. Mostly Adec Eqpmt.
$350k
I-772 Facility STOCKTON-Desirable,
affluent health care area. 2,140sf/4 ops
$250k
I-802 MODESTO - Facility. ~ 1500sf
w/4 ops & room for 1 more. State of the art
facility directly in front of Vintage Faire
Mall $445k
I-838 MODESTO- Retail Shopping Center
adjacent to a popular Supermarket, draw-
ing walk-in patients from traffic flow &
word-of-mouth referrals. 1,200 sf & 4 fully
equipped ops $350k
NEW! I-840 TRACY- Must See to Appre-
ciate! Major thoroughfare / desirable area.
2,165 sf & 6 ops. Plumbed for 1 addl op.
REDUCED!! $345k
J-801 FRESNO Facility. ~ 1300sf and 4
ops. Traditional Dcor. ONLY $70k
SOUTHERN CALIFORNIA

K-735 ALISO VIEJO FACILITY - Up-
scale 2 story Prof Bldg. 1,800sf/4 ops. $4k
sublet income at this location too! $225k
K-762 INDIAN WELLS Well Respected
practice w/loyal patient base. Newly re-
modeled, 1400+ sf, 5 ops REDUCED!
NOW ONLY $475k
K-793 SAN DIEGO-2500sf & 4 fully
equipped ops w/ plumbing for an addl 2
ops. Highly Desirable Neighborhood
$475k
K-827 STUDIO CITY-Highly esteemed,
4 op fee-for-service practice setting the bar
for excellence! Near Beverly Hills, W.
Hlywood ,Westwood $515k
K-816 MISSION VIEJO-Reputation as
one of the best dentists in this vibrant OC
Comm. Top-notch office in popular Rtl
Shp Ctr. Close proximity to Gov. amenities
& schools. 1,300 sf & 2 ops. $325k
NEW! K-847 SANTA MARIA- Spacious
ops & picturesque windows capturing sce-
nic views. 1,200+ sf/3 ops + 1 addl $425k
NEW! K-858 CHATSWORTH Seasoned
Staff supported by Excellent Specialists.
Stable Loyal Patient Base. 2150 sf & 4 +
fully equipped ops $295k

NEVADA

LV-756 LAS VEGAS-Brand new 1,600sf/
3 op office (Plumbed for 1 addl op) Attrac-
tive & well-equipped in Rtl Shpng Ctr.
$150k
LV-796 HENDERSON - Master-planned
community! Excellent location & easy
freeway accessibility. Spacious, like-new
office. 2,080 sf w/3 fully equipped ops &
plumbed for 3 addl ops $295k
LV-694 LAS VEGAS - Well established,
large GP. 2200 sf & 6 ops. Gross Receipts
over $900k. Equipment less than 5 years old.
Office was recently painted and carpeted.
$545k

Timothy G. Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD
294ap ri l 201 0
cda j ournal , vol 38 , n

4
classi fi eds, conti nued from 290
seeking associate for san luis
obispo office Arc you looking or
an occ whcrc you can usc all o your
skills in a caring and upbcat cnviron
mcnt` \c arc a astpaccd, rapidly
cxpanding occ looking or an associatc
to join our dcntal tcam and wc nccd two
ull days right now, lcading into to
days a wcck. \crc locatcd in bcautiul
San Iuis Obispo, CA. Call 8c,88.
in house periodontist/implant
surgeon available for your
practice In thc Crcatcr San
Francisco Bay Arca. Implant Surgcon
Bonc Crating Pcrio Surgcryrd Molar
opportuni ti es wanted
Fxtractions. Fmail bayarcapcrio,gmail.
com or call r/8,r..
architecturally outstanding
2,600 sq. ft. dental office Statc
o thc art cquipmcnt. Six opcratorics.
Amazing opportunity brought upon by
suddcn changc in owncrs amily situa
tion. Fantastic dcmographics to grow thc
practicc. For morc inormation visit
www.dcntaloccorlcasc.com or call
Mark at /c/.,cc.
practice for sale Iand, building
and dcntal practicc or salc in \oodburn,
Orcgon. Call c/.cr/r.
practi ces for sale
1-800-992-9392
3100 Walnut Grove Road, Suite 603
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296ap ri l 2 01 0
cda j ournal , vol 38 , n

4
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cda j ournal , vol 38 , n

4
ap ri l 2 01 0297
happy, bubblingwithlaughtcr pcoplc who
visit our occ ncvcr havc anything wrong
with thcir tccth. Admittcdly, most o
thcsc pcoplc arc cithcr salcsmcn or UPS
dclivcrymcn, not that thcrc is anything
wrong with that. Tosc actual paticnts
with multiplc oral problcms arc dcprcss
ingly glum, tcnding to cast a pall ovcr thc
wholc occ.
So thcrc is much work to bc donc i
wc arc to succcssully promotc laughtcr
as thc bcst mcdicinc. Somctimcs littlc
rcmarks likc Your tccth arc OK, but your

a p r i l 1 0 d r . b o b
dr. bob, conti nued from 298
gums will havc to go will snap thcm
out o thcir bluc unk into paroxysms o
hilarity, but you can tcll thcir hcarts arcnt
rcally in it dcspitc thc tcars rolling down
thcir chccks.
\c want Peciers !|ges| and thc
Ccntcr or Prcvcntivc Cardiology to
undcrstand wcrc doing our bcst. Furthcr
rcscarch is nccdcd to nd out what thosc
pcoplc who arc said to bc laughing all thc
way to thc bank arc doing. And by thc
way, what do you hcar rom thc morti
cians o Amcrica`
should bc dclibcratcly incorporatcd into
daily activitics just likc cxcrcisc and vigor
ous consumption o Sarah Icc products.
To bc ccctivc, laughtcr should bc
indulgcd in conccrt with at lcast onc
othcr pcrson, or pcrhaps a small ani
mal. Pcoplc who rcqucntly laugh all by
thcmsclvcs arc rcgardcd with suspicion.
Tis has somctimcs rcsultcd in thcir
bcing summarily ttcd with jackcts ca
turing multiplc straps or bcing shot. In
cithcr casc, thc spontancity is ccctivcly
squclchcd and in thc lattcr instancc, thc
hcalth bcncts arc dubious.
\hat wc arc looking or arc ways to
apply this rcscarch to thc dcntal icld
whcrc laughtcr is conccdcd to bc in
short supply. Obviously, no mcntion
must bc madc o pcriodontal discasc
in thc paticnts prcscncc. Nothing will
kill an cnjoyablc scssion at thc dcn
tists likc a dctailcd dcscription o his
gum dcicicncics. Iikcwisc, words likc
cxtraction, dccay, drill, root canal, and
scc should bc avoidcd. Iaughtcr is a
dclicatc thing, casily qucnchcd by somc
thoughtlcss rcmark rom thc dcntist or
a sta mcmbcr.
\c havc dccidcd to incorporatc a laugh
track in our spcakcr systcm similar to thosc
that arc a ncccssary part o cvcry sitcom.
On thc thcory that laughtcr is con
tagious likc yawning, an occ suuscd
in giggling and guaws could bc sccond
only to Lisncyland as Tc Happicst Placc
on Farth. It gocs without saying that
trcatmcnt plans involving anything othcr
than prophylaxis should bc writtcn out
and givcn thc paticnt in a scalcd cnvclopc
to bc opcncd latcr at homc whilc hc is sit
ting, or bcttcr yct, laying down.
\c arc ablc to conrm thc validity o
thc laughtcr rcscarchcrs hypothcsis. It
has bccn our obscrvation that thc rcally
298ap ri l 201 0
cda j ournal , vol 38 , n

4
Dr. Bob
Iaughtcr is thc bcst mcdicinc Peciers
!|ges| has bccn proclaiming or thc past
c ycars or so in onc o its caturc dcpart
mcnts. Tis small ormat pcriodical that
is so handy or poking in a hip pockct and
that lcnds itscl so casily to pinching rom
doctors waiting rooms without bcing
dctcctcd, has always tricd to bc all things
to all pcoplc.
Pathos, inspiration, tcarul concs
sions, and spiritual convcrsions arc all
grist or thc pagcs o thc !|ges|. Intcr
spcrscd arc thc Mamor |n Jn|/orm, Co||ege
Mamor, Mamoroas Pemcr|s o/ 3mc|| C|||
iren, and Fann, L|ngs |, Pe| !|i ! wcn|
|o Te|| Yoa A|oa| scctions.
You may rcmcmbcr a cw ycars ago
whcn an undcrcovcr paticnt commis
sioncd by thc magazinc visitcd dcntal
occs around thc country and camc up
with trcatmcnt plans that varicd wildly
in complcxity and cost, all or thc samc
mouth. Although this cxposc cvokcd much
mcrrimcnt among paticnts and dcntists,
thc Mamor |n !en||s|r, scction ncvcr madc
it big and has sincc bccn droppcd.
Tc !cag||er !s ||e Fes| |ei|.|ne
dcpartmcnt, howcvcr, is still going strong
and rcccntly rcccivcd a sort o blcssing
rom nonc othcr than thc dircctor o
thc Ccntcr or Prcvcntivc Cardiology at
thc Univcrsity o Maryland. Lr. Michacl
Millcr says rcscarch has provcd having an
activc scnsc o humor inucnccs hcart
and artcry discasc. Hc ccls that laughtcr
Robert E.
Horseman,
DDS
illustration
by dan hubig
,
conti nues on 297
To be eective, laughter
should be indulged in
concert with at least one
other person, or perhaps
a small animal.
Giggle Your Way
to Good Health
Giggle Your Way
to Good Health
www.ultradent.com | 800.552.5512
2010 Ultradent Products, Inc. All rights reserved.
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