Dent Clin N Am 49 (2005) 677–694

Future Treatment and Diagnostic

Strategies for Periodontal Diseases
Howard C. Tenenbaum, DDS, PhD, FRCD(C)a,
Henri Tenenbaum, DDS, PhD, HDR(F)b,
Ron Zohar, DDS, PhD, FRCD(C)c,*
a
Discipline of Periodontology, Faculty of Dentistry, University of Toronto, 124 Edward Street,
Suite 349C, Toronto, Ontario, Canada M5G 1G6
b
Department of Periodontology, Dental Faculty, University Louis Pasteur, Strasbourg, France
c
Disciplines of Periodontology and Biomaterials, Faculty of Dentistry, University of Toronto,
124 Edward Street, Suite 464A, Toronto, Ontario, Canada M5G 1G6

Treatment of periodontal diseases has undergone a series of changesd

perhaps not quite a revolutiondover the past 20 years [1–6]. The goal of
treatment has always been to regenerate lost periodontal tissues, but
clinicians have had to ‘‘settle’’ for treatments that lead to disease cessation
and healing if not outright regeneration. That said, there are newer treatment
strategies that may become available over time that will allow clinicians to
achieve limited or more robust regeneration of the periodontium. Because of
the absence of reliable methods for regeneration, new approaches to disease
control are also being pursued that will benefit those suffering chronic
periodontal diseases [7,8]. In addition to novel therapeutics, there has been
increasing focus on the development of more sensitive and specific diagnostic
tests for periodontal diseases [9–11]. It is hoped that such tests will allow the
clinician to determine whether a patient has active disease and what sort of
attachment loss might be expected if the patient were not treated. In addition,
by developing newer diagnostic tests, it will also be possible to focus therapy
more on the disease process. Using collagenase levels as an example, if
a diagnostic test shows this to be elevated [9], in addition to treating the
microbial trigger, one might also attempt to regulate (reduce) collagenase
levels or activity to prevent further tissue degradation.

* Corresponding author.
E-mail address: ron.zohar@utoronto.ca (R. Zohar).

0011-8532/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2005.03.006 dental.theclinics.com
678 TENENBAUM et al

Periodontal disease diagnosis

Periodontal diseases are probably one of the most common bacterial
infections in humans. It has become evident that only a few of the several
hundred species of microorganisms within the gingival crevice and the
periodontal pocket play a significant role in initiation and progression of the
disease [10,12]. Thus, such pathogens at low levels should be considered as
part of the normal oral flora. The notion of a ‘‘critical mass’’ of these
periodontal pathogens has recently been introduced because of their
presence in healthy gingival sites, albeit in low numbers [13]. The
inflammatory and degradative processes associated with chronic periodon-
titis are likely induced by a critical mass of different pathogens, thereby
leading to tissue destruction, possibly by way of three different pathways:
1. Pathogens may directly release proteolytic enzymes that degrade
periodontal structures without the intervention of host cells.
2. Pathogens may elaborate products such as toxins, enzymes, and
lipopolysaccharide that may trigger host cell populations to express
degradative enzymes.
3. Pathogens may stimulate an immune response resulting in release of
proinflammatory cytokines such as interleukin (IL)-1, IL-6, and tumor
necrosis factor a [14].
The components of the periodontal tissue extracellular matrix, especially
collagens, appear to be the main target of degradation in periodontal
diseases. Among host proteases degrading the extracellular matrix, matrix
metalloproteinases (MMPs) seem to be highly associated with tissue de-
struction and remodeling events in periodontal diseases.
Regarding the balance between pathogens and host responses, reliable
diagnostic tests should focus on three main objectives:
1. Determine the presence and the proportions of pathogens in diseased
sites or in susceptible patients.
2. Identify factors that indicate the first steps of disease activity in
apparently healthy sites that may appear clinically normal.
3. Detect patients in whom the host response is unable to balance
pathogen aggressiveness or diagnose the degree of genetic predisposition
at an early age when periodontal destruction has not yet developed.
To achieve these goals, microbiologic testing, analysis of disease activity,
and genetic analyses have been proposed to identify patients at increased
risk for periodontal disease [15].

Microbiologic testing
Periodontal diseases are considered a mixed infection. It has never been
possible to prove that specific bacteria directly cause periodontal disease
 FUTURE TREATMENT AND DIAGNOSTIC STRATEGIES 679

according to Koch’s postulates. In consequence, the ideal that a single

causative agent of the disease would be identified and a rapid chairside test
would be used to assess the bacterial risk has never been reached.
To be considered true periodontal pathogens, bacteria should fulfill the
following criteria [16]:

They must occur at higher numbers in disease-active lesions compared
with healthy or disease-inactive sites.

Their elimination should lead to arrest of disease progression.

They should express virulence factors relevant to the disease process.

They should evoke a specific immune host response.

They should be able to induce similar periodontal destruction in relevant
animal models.
Several types of microbiologic tests have been developed and are
available on the market.
First, it must be noted that the information generated by microbiologic
analysis of a sample collected from a periodontal pocket is highly dependent
on sampling technique. Two methods can be used to collect subgingival
plaque samples: curettes and paper points. Both methods require careful
removal of supragingival plaque to avoid contamination.
It has been shown that it is possible to remove 60% to 90% of the
bacteria populating a diseased pocket with the use of a curette, whereas only
about 6% to 41% of bacteria are sampled with the use of a paper point
[17,18]. Moreover, with the latter method, it has been suggested that most of
the sampled bacterial mass is from the outer layers of the subgingival
biofilm; however, the inner layers may contain the more-pathogenic species
[19].
The following microbiologic tests have been proposed:

Microscopic identification
This method is limited to the determination of the relative proportion of
coccal and the more-pathogenic, filamentous-shaped bacteria [20]. This
technique cannot be used to help in selection of an antimicrobial therapeutic
agent if desired or to predict recurrence of the disease. In fact, bacteria
thought to be periodontal pathogens cannot be identified or distinguished
by microscopic assessment alone. The monitoring of plaque maturation
does not give value over conventional clinical evaluation for the assessment
of therapeutic efficacy; hence, as a chairside diagnostic system, the cost-to-
benefit ratio is essentially negative.

Cultures
Bacterial culture is still considered the ‘‘gold standard’’ against which
other microbiologic identification methods must be compared. It is a
quantitative method and most cultivable microorganisms can be identified.
680 TENENBAUM et al

Nevertheless, the technique has limitations such as (1) the inability to detect
noncultivable organisms such as spirochetes; (2) high cost; (3) the short time
required for transportation to the culture laboratory before cells die and
cannot be cultured (24–48 hours); and (4) a prolonged period before results
are obtained.

Enzymatic assays
Although enzymatic assays permit detection of bacteria that possess
trypsinlike enzymes, other pathogenic bacteria that do not produce such
enzymes are not detected. Two tests have been developed: the BANA test
(PerioScan; Oral B, Redwood, California) [21] and the PerioCheck test
(Sunstar, Osaka, Japan) [22].
Both of these tests can be done at chairside and are interpreted or rated
by the use of color intensity scores. For the BANA test, trypsinlike enzymes
from Tannerella forsythensis, Treponema denticola, and Porphyromonas
gingivalis hydrolyze the substrate N-benzoyl-DL-arginine-2-naphthylamide,
thereby producing a blue-black color, the intensity of which is proportional
to the total amount of the three bacteria [23,24].
The PerioCheck test differs from the BANA test in that a different
substrate is used. Neither test can be used to distinguish between the relative
proportions of the three bacteria and, of course, cannot identify the presence
of other potential pathogens that do not produce trypsinlike enzymes.
Given these issues, their utility in diagnosis is limited due to a low
reliability to predict clinical disease progression [22].

Immunoassays
Detection of immunoglobulin against bacterial antigens present in serum
by the use of immunoassays (ELISA, agglutination assays, immunofluores-
cence) requires the development of polyclonal or monoclonal antibodies
that recognize specific lymphocyte epitopes [25–28].
The advantages of immunoassays are (1) the detection of specific
virulence factors of given bacteria; (2) the investigation of the specific role of
protein (eg, cytolethal distending toxin CdT from Actinobacillus actino-
mycetemcomitans); and (3) their low cost for large-scale studies.
It is unfortunate that there are also the following disadvantages: (1) local
sampling cannot be done, so site-specific disease parameters cannot be
assessed; and (2) immunoassays cannot be used to determine bacterial
virulence.

Nucleic acid probes

DNA extracts from samples of pocket-derived bacteria can be hybridized
with so-called ‘‘anti-sense DNA probes’’ [29]. When these probes are also
labeled with an enzyme such as alkaline phosphatase, they can be detected
 FUTURE TREATMENT AND DIAGNOSTIC STRATEGIES 681

using enzyme-staining assays, thus indicating the presence of DNA from

specific bacteria. The probe sequences may be derived from (1) whole
genomic DNA; (2) randomly cloned sequences of nucleic acids from target
bacteria (greater risk of false-positive reactions than whole genomic probes);
and (3) synthetic oligonucleotides that hybridize to 16S ribosomal RNA-
DNA sequences that contain highly conserved and extreme heterogeneous
sequences that make them ideal for distinction of species [30].
Nucleic acid probes have other interesting advantages including easy
sampling and transport (viability of bacteria is not a requirement), rapid
analysis, high sensitivity and specificity, and the ability to detect a wide
spectrum of bacterial species including the detection of noncultivable
organisms. Despite these strengths, currently available molecular techniques
cannot be used to assess antibiotic sensitivity or bacterial virulence. To
address this problem, however, a variation of standard molecular
identification was suggested in 1994 by Socransky et al [31] who described
‘‘Checkerboard’’ DNA-DNA hybridization analysis that may permit some
inferences as to pathogenicity.

Polymerase chain reaction

Polymerase chain reaction is a molecular biologic method that allows for
high-yield replication of DNA. Therefore, it allows for the synthesis of
a vast number of copies of even the smallest samples of bacterial DNA [32].
A modification of the original polymerase chain reaction method, real-time
polymerase chain reaction, permits not only detection of specific bacteria
but also quantification. Polymerase chain reaction is generally considered
reliable when used in combination with synthetic 16S ribosomal RNA
probes, which are highly specific to given species.

Biosensors
Metabolites (eg, volatile sulfur compounds) from pathogenic bacteria can
be detected by various physical methods [33,34]. Various pathogenic
bacteria (Treponema denticola, Porphyromonas gingivalis, Prevotella inter-
media, and Tannerella forsythis) can reduce sulphates, thereby producing
significant levels S, HS, H2S, and CH3SH by degradation of serum proteins,
cysteine, and methionine. A sulfide sensor, Perio 2000 (Diamond General
Corp., Ann Arbor, Michigan) can measure levels of these compounds and
report them as scores ranging from 0 to 5 in increments of 0.5. A score of
0 represents undetectable S (!107 M sulfide), whereas a score of 5
represents a concentration of 102 M sulfide. This chairside technique can
be used repeatedly on the same sites and produces results rapidly. This test,
however, is nonspecific and only semiquantitative, and its usefulness is
limited by the fact that not all pathogenic bacteria produce sulfides. Because
the detectable species are highly pathogenic, however, the detection of high
sulfide levels could indicate that this site is at higher risk of disease activity
682 TENENBAUM et al

and attendant attachment loss [34]. This indication could lead to ear-
lier treatment and prevention of tissue loss. Furthermore, although it is
conceivable that sulfide levels could be used to assess efficacy of treatment,
this methodology still needs to be validated by clinical trials.
Currently, no single diagnostic approach can be used to provide enough
information for the clinician to make a diagnosis that would necessarily be
different from one derived from clinical assessment. Similarly, treatment
decisions, apart from the need for adjunctive antibacterial therapy or
perhaps MMP regulation (see later discussion), are not necessarily
influenced by currently available testing methods. In this regard, the
following questions remain unanswered:
1. Was a specific bacterial species present when the disease was initiated (is
there a causal relationship)?
2. Were the bacteria present at the site after the disease occurred (is there
an opportunistic relationship)?
Perhaps in the future, more attention should be paid to identification of
common virulence factors (especially pathogen-associated molecular pat-
terns) and how these virulence factors regulate the responses of different
host cells like keratinocytes, Langerhans cells, dendritic cells, and macro-
phages [16].

Analysis of disease activity

Salivary and gingival crevicular fluid enzymes and other proteins have the
potential to be useful markers of disease progression. Presently, more than
65 gingival crevicular fluid components have been examined and identified
as potential markers of disease progression. These components fall into
three general categories:
1. Host-derived enzymes such as MMPs and their inhibitors
2. Inflammatory mediators and host response modifiers such as cytokines
3. Tissue breakdown products such as glycosaminoglycans, osteonectin,
osteopontin, and laminin
A major problem with measurement of enzymes is that it is often difficult
to distinguish those associated with gingivitis and periodontitis sites from
active and inactive disease sites. Enzymes like the collagenases (MMP-1,
MMP-3, MMP-8, and MMP-13), elastase, and gelatinases (MMP-2 and
MMP-9) may be significantly elevated in the presence of existing disease, but
measurement of their levels to predict future destruction remains unclear
(such as the test for aspartate aminotransferase [AST]) [35,36]. Hence,
virtually all enzyme tests evaluated to date have demonstrated fairly high
rates of false-positive findings (ie, although a test is ‘‘positive,’’ there may
still not be any disease activity and therefore no disease progression). The
same can be said about assays for inflammatory mediators.
 FUTURE TREATMENT AND DIAGNOSTIC STRATEGIES 683

The most promising gingival crevicular fluid markers of disease

progression are probably host breakdown products (as opposed to the
enzymes that breakdown host tissues). Among these products, chondroitin-
4-sulfate (a cartilage- and bone-specific glycosaminoglycan) [37,38],
pyridinoline cross-links of the carboxyterminal telopeptide of type I
collagen, and RankL (receptor activator for NF-xB ligand) are potential
markers of bone and connective tissue destruction [39,40].

Genetic analyses
The etiology of periodontal disease is multifactorial and thus influenced
by genetics (ie, the host) and the environment [41]. With regard to genetics,
studies have revealed that most forms of periodontal disease are likely
associated with multiple modifying genes (the disease is said to be
polygenic). For example, in Papillon-Lefèvre syndrome and in generalized
forms of prepubertal periodontitis, Hart et al [42] identified and localized
a modified gene on chromosome 11 that caused a decrease in cathepsin C
activity. The same decrease in cathepsin C activity has been demonstrated in
severe chronic periodontitis [43]. Other studies have focused on IL-1 gene
polymorphism leading to the development of the periodontitis susceptibility
trait test [44]. The periodontitis susceptibility trait test is the only genetic
susceptibility test for severe periodontitis that is commercially available. The
periodontitis susceptibility trait test evaluates the simultaneous occurrence
of allele 2 at the IL-1A þ4845 and IL-1B þ3954 loci. A patient with allele 2
at both these loci is considered genotype positive and therefore more
susceptible to develop severe periodontitis.
Although genetic tests might be used to identify a predisposition to
disease (even before disease development) [45], treatment approaches and
outcomes will still be influenced by environmental and behavioral factors
whether or not the individual is genetically susceptible to periodontal
disease. Moreover, genetic testing gives no information on disease activity
or susceptibility.
Although great strides are being made with respect to the development of
diagnostic tests, there remains a great need for well-designed long-term
longitudinal investigations and controlled clinical treatment studies.

Periodontal diseasesdnovel therapeutics

Regenerative treatment
From a historical perspective, regeneration of periodontal tissues lost as
a result of periodontitis has been an elusive goal despite the development of
widely available regenerative surgical techniques. Such approaches have
involved the use of bone grafts to replace lost bone; however, bone is but
684 TENENBAUM et al

one component of the connective tissues composing the periodontium.

Inasmuch as bone loss has been considered one of the major sequelae of
periodontitis and is the most striking radiographic feature of periodontally
diseased tissues, the use of bone grafting treatments has been popular.
Critical analyses of clinical, histologic, and radiographic data, however,
suggest that although correction of bone defects can be demonstrated
[46,47], the regeneration of a new attachment apparatus following bone
grafting including new bone, cementum, and a functionally oriented
periodontal ligament does not generally occur except at the very base of
the periodontal defect. Because bone grafting has been shown to have
limited effectiveness with respect to regeneration of lost periodontium, other
approaches have been developed that ostensibly would exploit the biologic
principles that describe cellular domains [48]. If specific cell types occupy
specific domains to the exclusion of other cell types, then the creation of an
environment that would preferentially select for cells that might regenerate
the periodontal ligament would provide for reliable regenerative treatment
outcomes. To accomplish this, investigators have developed an array of
membrane technologies. These treatments require the insertion of a mem-
brane over a periodontal defect to, in effect, ‘‘exclude’’ epithelial cells from
the previously diseased root surface, thereby permitting upward migration
of periodontal ligament cells or their precursors. A variety of membrane
materials has been developed, including some that had to be removed from
the surgically treated site weeks or months later and some that were
resorbable and could be left in place. Initial reports regarding the use of
these membranes (a technique called guided tissue regeneration) were
positive, but over the longer-term, it became apparent that apart from the
use of guided tissue regeneration to regenerate bone (called guided bone
regeneration) about implants or in other osseous sites requiring augmen-
tation, periodontal regeneration could still not be expected to occur reliably
[47] (Zohar and Tenenbaum, submitted for publication, 2005).

Enamel matrix derivatives

Taking advantage of developmental biologic studies of the periodontal
attachment apparatus, it was noted that before development of cementum
and new periodontal ligament, enamel matrix proteins are deposited directly
onto dentine surfaces [49,50]. This observation led investigators to
hypothesize that enamel matrix proteins might play an important role in
the signaling for and recruitment of cells required for production of
a normal tooth attachment apparatus. This observation further led to the
notion that if such proteins could be purified or otherwise harvested, then
they might prove useful in regenerative therapy. In this regard, it was
thought that by adding such proteins to a previously diseased or exposed
tooth root surface, they might signal a recapitulation of the embryologic
developmental sequence, leading to the creation of a new gomphosis. As
 FUTURE TREATMENT AND DIAGNOSTIC STRATEGIES 685

a result, there is now a growing body of evidence based on randomized

controlled trials [4,51] that enamel matrix proteins can be used for limited
regeneration of the periodontium. In addition, further studies have dem-
onstrated that these proteins may prove useful in periodontal plastics and
root coverage procedures, thereby reducing or eliminating the need for the
harvesting of connective tissue [51,52]. As the mechanisms underlying
enamel matrix derivative effects are understood more precisely, it is likely
that other related extracts or even purified proteins will become a part of the
routine armamentarium of periodontists in the future when regenerative
therapy is required.

Bisphosphonates to inhibit bone loss

The bisphosphonates are a class of drugs related to pyrophosphate [53].
Unlike pyrophosphate, which can be degraded by alkaline phosphatase [54]
and pyrophosphatase, the bisphosphonates are resistant to degradation and
have a high affinity for mineralized tissue [55]. One of the most important
uses of bisphosphonates relates to their ability to inhibit bone resorption,
presumably by direct or indirect inhibition of osteoclast cell activity [53].
This property could prove useful in the development of future therapeutic
approaches to the prevention of periodontal bone loss [53,56] and possibly
bone-supported implants [57,58]. In addition, it has been shown that local
application of bisphosphonates reduces the bone loss that occurs following
periodontal flap surgery [59]. In addition, given their affinity for mineralized
tissues such as bone, the bisphosphonates, when tagged with a radionuclide
such as technetium 99m, can also be used for diagnostic purposes. In this
regard, the bisphosphonates would ‘‘home’’ to areas of bone that are
undergoing active remodeling. Hence, the bisphosphonates would target or
be concentrated in areas in which periodontal bone loss is about to occur or
in other areas with increased remodeling in which bone loss may occur.
Radioactively tagged bisphosphonates can be detected using various
radiologic imaging methods and can be localized to sites where bone loss
may occur. In fact, in using these methods, it is possible to identify sites
within the periodontium in which bone loss will occur even before
radiographic changes have occurred. Thus, although not discussed in detail
previously, it is possible that these drugs could prove useful in the future not
only for prevention of bone loss but also (from a diagnostic perspective) to
identify areas where bone loss may occur much earlier than might be
possible radiographically [60].

Bisphosphonates may stimulate bone formation

In addition to their ability to inhibit bone formation, it is also known that
at certain concentrations, bisphosphonates inhibit mineralization [61]. This
particular effect was thought to be essentially deleterious, and in fact,
686 TENENBAUM et al

second- and third-generation bisphosphonates were developed to increase

their ability to inhibit bone resorption so that they could be used in lower
doses and not interfere with mineralization [62]. This approach has proved
to be effective, particularly for management of osteoporosis [62]; however,
recent studies have suggested that inhibition of mineralization might be
useful so long as it is a transitory phenomenon. In relation to this, it has
been demonstrated that bone matrix (osteoid) formation is inversely
proportional to mineralization [63]. When mineralization is inhibited using
the first-generation bisphosphonate etidronate (HEBP), osteoid formation
has been shown to double in vivo and in vitro [56,61,64]. When the HEBP is
continually present, more osteoid forms but is poorly mineralized.
Alternatively, when HEBP treatment (in culture or in vivo) is stopped, the
newly formed ‘‘excess’’ osteoid mineralizes and, as demonstrated in cell
culture, the mineral is even more dense than control. This property of HEBP
could be exploited to stimulate new bone formation in the periodontium and
elsewhere. It could prove useful for acceleration of osseointegration about
implants; however, the dosage regime in this model has not been clearly
worked out. HEBP treatment has also been shown to induce the periodontal
ligament to produce high levels of the bone protein bone sialoprotein and to
induce the ligament to produce bone tissue. Thus, it is possible that
judicious local application or systemic administration of HEBP or similar
agents could prove useful for regeneration of lost bone in implant or other
sites and for the acceleration of endosseous implant integration in the
future.

Antimicrobial therapy
Local delivery systems
It has been well established that most forms of periodontitis are related to
chronic infection with periodontal pathogens [15] (usually gram-negative
anaerobic species [34]). As a result, there has been an extensive amount of
investigation related to the development of effective antimicrobial regimes
for treatment of chronic, refractory, or other forms or periodontitis. Indeed,
double-blind placebo-controlled randomized trials have demonstrated that
antimicrobial treatment is an extremely useful adjunct for treatment of
periodontitis [10,65]. Before the advent of antimicrobial therapy, so-called
‘‘refractory periodontitis’’ (eg, periodontitis demonstrating a downhill or
extreme downhill course [65a]) might constitute about 20% of all cases. This
figure, however, is now in the 5% range because it has been shown that the
previously difficult-to-treat cases, or cases that do not respond well to
conventional periodontal treatments, can be managed or improved with the
use of antimicrobials [57,66]. That said, the use of systemic antimicrobial
medications to treat a local infection has drawbacks including, for example,
gastrointestinal side effects such as pseudomembranous colitis, allergic
reaction [67], superinfection with commensal organisms, or development of
 FUTURE TREATMENT AND DIAGNOSTIC STRATEGIES 687

resistant organisms. Therefore, there have been a number of attempts to

develop locally delivered antimicrobials to infected periodontal pockets [57].
The antimicrobials have included metronidazole in an ointment form
(Elyzol), chlorohexidine (Periochip), and doxycycline in a fiber form
(Actisite) or in a polymeric delivery system (Atridox) [66]. These locally
delivered antimicrobials, and in particular Atridox, have been demonstrated
to be efficacious in the treatment of localized periodontal pockets. On
average, Atridox, for example, seems to be equally as effective as scaling and
root planing but is more difficult to administer for generalized disease than
for treatment of localized defects. This type of drug delivery system should
definitely be considered for treatment of refractory periodontal pockets,
infected implant sites, and possibly even in surgical sites. This approach may
be particularly useful in the future for treatment of recall patients who
present with localized sites showing recurrent disease.

Photodynamic therapy
Although local delivery of an agent such as doxycycline can be useful, the
use of self-polymerizing gels can be difficult when considering treatment of
generalized periodontitis. Moreover, it has been demonstrated that full-
mouth ‘‘decontamination’’ may lead to better short-term and possibly
longer-term outcomes when managing periodontal diseases compared with
staged decontamination approaches [68]. Agents delivered in gel or fiber
form, however, cannot readily be delivered to periodontal pockets within
the whole mouth and certainly cannot be used in the eradication of
periodontal pathogens from nondental oral surfaces (eg, cheeks, tongue,
and tonsil bed in addition to periodontal pockets). In addition, although the
antimicrobials mentioned previously are delivered in high concentrations to
minimize bacterial resistance, this does not preclude the possibility that
resistant bacteria will be selected following treatment.
To address these problems, other approaches for antimicrobial therapy
for periodontitis have been investigated, including an approach known as
photodynamic therapy. Photodynamic therapy essentially involves the use
of light-activated drugs to kill periodontal pathogens. This therapeutic tool
was initially investigated for treatment of malignancy because chemother-
apeutic drugs could be given to patients systemically in an essentially inert
form and then activated by administering light (usually laser) at the site of
a tumor, thereby killing tumor cells without making a patient ill from
chemotherapy [69]. Photodynamic therapy has also been used successfully
for the management of macular degeneration [70]. Recently, it has been
demonstrated that toluidine blue, when activated by laser light, can be used
to kill periodontal pathogens [71]. Hence, it was postulated that toluidine
blue or other photoactivated drugs could be used to treat periodontitis,
presumably by laser activating such chemicals after they have been instilled
within periodontal pockets. The problem with this approach, however, is
that it would be necessary to irradiate every single pocket following lavage
688 TENENBAUM et al

with the photoreactive agent, and full-mouth decontamination would be

equally as difficult as suggested earlier for locally delivered antimicrobials
[72].
Clinical trials focusing on the use of laser-activated drugs are underway
for treatment of periodontitis. Future trials will likely take advantage of
broad-spectrum light, thereby permitting more effective elimination of
periodontal pathogenic bacteria that are resident in the oral cavity as
a whole. This approach could lead to more robust treatment responses
and would serve as a useful adjunct for management of periodontal in-
fection in conjunction with conventional therapy. This treatment would
also prove useful for periodontal maintenance, during periodontal surgery,
and in periodontal management of infected endosseous implant surfaces.

Inhibition of matrix degradation

As discussed previously with respect to diagnostic tests, matrix
degradation is a major hallmark and even a predictor of bone and
periodontal attachment loss. Hence, there have been major efforts devoted
to the development of treatment approaches that interfere with or
completely block matrix degradation. The bisphosphonates, previously
addressed in relation to their ability to inhibit bone resorption, do not
inhibit destruction of connective tissue matrices, although the authors’
laboratory has some evidence suggesting that HEBP might interfere with
MMP activity [72a]. Most investigation in this area has focused on the use
of tetracycline and its derivatives for prevention of connective tissue (even
hard connective tissue) destruction mediated by MMPs. To this end, it has
been suggested that given that MMPs are elevated in the presence of
periodontitis, particularly in persons with diabetes mellitus, a major goal of
therapy would be to reduce MMP activity. In addition to tetracycline’s
antimicrobial actions, it has the ability to inhibit MMP activity [57,73,74].
This nonantimicrobial action of MMP inhibition has also been demon-
strated with the tetracycline derivative doxycycline [66]. When administered
in doses that are nonantibacterial, doxycycline has been shown to prevent
periodontal breakdown due to its ability to inhibit MMP enzyme activity
[57]. Tetracycline’s anti-colagenolytic activity has given rise to the de-
velopment and use of Periostat (CollaGenex Pharmaceuticals, Inc., New-
town, Pennsylvania), a form of low-dose doxycycline for management of
periodontitis. Low-dose doxycycline may prove useful in the management of
refractory periodontal diseases or other forms of chronic periodontitis that
for various reasons cannot be managed with conventional therapy. For
instance, patients who are medically compromised and who cannot tolerate
conventional in-office treatment could benefit from low-dose doxycycline. In
the authors’ experience, low-dose doxycycline has proved to be very helpful
in management of periodontitis in a large hospital-based population of
young and old patients. Despite its effectiveness, it does not appear that low-
dose doxycycline would be a first-line choice of conventional periodontal
 FUTURE TREATMENT AND DIAGNOSTIC STRATEGIES 689

therapy, but it definitely shows promise in management of difficult-to-treat

patients or difficult-to-manage forms of periodontitis. Furthermore, it is
probable that drugs designed to inhibit MMP or other proteinase activity
will be developed further to be more specific in targeting proteinases of
interest (eg, MMP-8 in the case of periodontitis). It is possible that certain
proteins or peptides related to decorin [75] will become therapeutic adjuncts.
Decorin binds to collagen and may prevent its degradation, which could be
an interesting approach to management of periodontal breakdown because
in this case, MMP activity would not be inhibited, but the drug’s effects
would be through alteration of the substrates.

Management of periodontal diseases in smokers

It clearly has been demonstrated that individuals who smoke cigarettes
are at greater risk for the development of periodontitis, have more severe
periodontitis, and do not respond to treatment of periodontitis as well as
those who do not smoke [8,10,76]. This finding was thought to be a lifestyle
issue (eg, poor oral hygiene), but a number of studies have shown that
compared with nonsmokers, smokers do not necessarily have more bacterial
plaque and their plaque is not populated by more periodontal pathogens.
Therefore, there must be constituents of cigarette smoke that trigger or act
as cofactors to initiation and progression of periodontitis. For obvious
reasons, nicotine has received much attention in the literature and, indeed, it
has the ability to cause a number of changes in the immune system and in
the vasculature that could lead to exacerbation of periodontal disease risk
and severity [77–79]. In addition, there are hundreds of other potentially
toxic compounds in cigarette smoke that likely damage periodontal tissues.
The authors’ research group has focused on a particular class of agents
found in high levels in cigarette smoke and in the environment: aryl
hydrocarbons [80]. The most prevalent aryl hydrocarbons in cigarette smoke
are benzo-a-pyrene and dimethyl benzanthracene [81]. Benzo-a-pyrene in
particular has been shown to directly inhibit osteoblast differentiation [80].
To carry out further studies, the authors used a prototypical aryl
hydrocarbon (dioxin) to study the effects of these agents on bone tissues
and bone cells. These studies confirmed that aryl hydrocarbons inhibit
osteoblast differentiation and bone production. Moreover, they interfere
with osteoclast cell formation (Tenenbaum et al, unpublished data), an
action that leads to overall reductions in bone remodeling, which could
exacerbate periodontal diseases. Moreover, the authors’ laboratory dem-
onstrated that the aryl hydrocarbon benzo-a-pyrene acts in a synergistic
manner with lipopolysaccharide from one of the periodontal pathogens
described earlier (Porphyromonas gingivalis) in blocking bone cell differen-
tiation and function [80]. These deleterious effects were shown to be
mediated through the aryl hydrocarbon receptor (a cytosolic receptor). Of
importance, the authors identified an agent commonly found in red wine,
690 TENENBAUM et al

resveratrol, which is an aryl hydrocarbon receptor antagonist that inhibits

the effects of aryl hydrocarbons. Hence, it may be possible in the future to
use agents such as resveratrol or synthetic and more powerful analogs to
ameliorate some of the effects of smoking on the periodontium and other
tissues. Certainly, smoking cessation is the ultimate goal, but this has not
proved to be as effective as its proponents would like. Thus, other
approaches such as the inhibition of aryl hydrocarbon effects should be
considered, especially because these agents are found in high levels within
the environment, not only in cigarette smoke. It is with this in mind that
a clinical trial focusing on the use of resveratrol to manage periodontitis in
smokers is now underway.

Summary
It can be inferred from the foregoing that new technologies have been
developed or are in development that could be used to enhance the ability to
predict, diagnose, and treat periodontitis. Not all of these technologies will
bear fruit; however, those that do will provide clinicians of the twenty-first
century with more effective means of detection, prevention, and treatment of
periodontitis than are currently available. Hence, periodontists and dentists
will take on the role of physicians dedicated to the prevention and treatment
of oral diseases and rely less on mechanical or nonbiologically based
treatment modalities.

References
[1] Nyman S, Lindhe J, Karring T, et al. New attachment following surgical treatment of
human periodontal disease. J Clin Periodontol 1982;9(4):290–6.
[2] Sanders JJ, Sepe WW, Bowers GM, et al. Clinical evaluation of freeze-dried bone
allografts in periodontal osseous defects. Part III. Composite freeze-dried bone allografts
with and without autogenous bone grafts. J Periodontol 1983;54(1):1–8.
[3] Axelsson P, Nystrom B, Lindhe J. The long-term effect of a plaque control program on
tooth mortality, caries and periodontal disease in adults. Results after 30 years of
maintenance. J Clin Periodontol 2004;31(9):749–57.
[4] Kalpidis CD, Ruben M. Treatment of intrabony periodontal defects with enamel matrix
derivative: a literature review. J Periodontol 2002;73(11):1360–76.
[5] Nakashima M, Reddi AH. The application of bone morphogenetic proteins to dental
tissue engineering. Nat Biotechnol 2003;21(9):1025–32.
[6] Nevins M, Camelo M, Nevins ML, et al. Periodontal regeneration in humans using
recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and allogenic bone.
J Periodontol 2003;74(9):1282–92.
[7] Cobb CM. Clinical significance of non-surgical periodontal therapy: an evidence-based
perspective of scaling and root planing. J Clin Periodontol 2002;29(Suppl 2):6–16.
[8] Albandar JM. Global risk factors and risk indicators for periodontal diseases. Periodontol
2000 2000;29:177–206.
 FUTURE TREATMENT AND DIAGNOSTIC STRATEGIES 691

[9] Mancini S, Romanelli R, Laschinger CA, et al. Assessment of a novel screening test for
neutrophil collagenase activity in the diagnosis of periodontal diseases. J Periodontol
1999;70(11):1292–302.
[10] Maupome G, Pretty IA, Hannigan E, et al. A closer look at diagnosis in clinical dental
practice: part 4. Effectiveness of nonradiographic diagnostic procedures and devices in
dental practice. J Can Dent Assoc 2004;70(7):470–4.
[11] Moseley R, Stewart JE, Stephens RJ, et al. Extracellular matrix metabolites as potential
biomarkers of disease activity in wound fluid: lessons learned from other inflammatory
diseases? Br J Dermatol 2004;150(3):401–13.
[12] Dahan M, Nawrocki B, Elkaim R, et al. Expression of matrix metalloproteinases in
healthy and diseased human gingiva. J Clin Periodontol 2001;28(2):128–36.
[13] Li J, Helmerhorst EJ, Leone CW, et al. Identification of early microbial colonizers in
human dental biofilm. J Appl Microbiol 2004;97(6):1311–8.
[14] Seymour GJ, Gemmell E. Cytokines in periodontal disease: where to from here? Acta
Odontol Scand 2001;59(3):167–73.
[15] Michalek SM, Katz J, Childers NK, et al. Microbial/host interactions: mechanisms
involved in host responses to microbial antigens. Immunol Res 2002;26(1–3):223–34.
[16] Ezzo J, Cutler CW. Microorganisms as risk indicators for periodontal disease.
Periodontol 2000 2000;32:24–35.
[17] Socransky SS, Haffajee AD. Dental biofilms: difficult therapeutic targets. Periodontol
2000 2000;28:12–55.
[18] Van Winkelhoff AJ, Loos BG, Van Der Reijden WA, et al. Porphyromonas gingivalis,
Bacteroides forsythus and other putative periodontal pathogens in subjects with and
without periodontal destruction. J Clin Periodontol 2002;29(11):1023–8.
[19] Tanner AC, Goodson JM. Sampling of microorganisms associated with periodontal
disease. Oral Microbiol Immunol 1986;1(1):15–22.
[20] Offenbacher S, Odle B, van Dyke T. The microbial morphotypes associated with
periodontal health and adult periodontitis: composition and distribution. J Clin
Periodontol 1985;12(9):736–49.
[21] Loesche WJ, Giordano J, Hujoel PP. The utility of the BANA test for monitoring
anaerobic infections due to spirochetes (Treponema denticola) in periodontal disease.
J Dent Res 1990;69(10):1696–702.
[22] Hemmings KW, Griffiths GS, Bulman JS. Detection of neutral protease (Periocheck) and
BANA hydrolase (Perioscan) compared with traditional clinical methods of diagnosis and
monitoring of chronic inflammatory periodontal disease. J Clin Periodontol 1997;24(2):
110–4.
[23] Bretz WA, Lopatin DE, Loesche WJ. Benzoyl-arginine naphthylamide (BANA)
hydrolysis by Treponema denticola and/or Bacteroides gingivalis in periodontal plaques.
Oral Microbiol Immunol 1990;5(5):275–9.
[24] Lopez NJ, Socransky SS, Da Silva I, et al. Subgingival microbiota of Chilean patients with
chronic periodontitis. J Periodontol 2004;75(5):717–25.
[25] Snyder B, Ryerson CC, Corona H, et al. Analytical performance of an immunologic-based
periodontal bacterial test for simultaneous detection and differentiation of Actinobacillus
actinomycetemcomitans, Porphyromonas gingivalis, and Prevotella intermedia. J Peri-
odontol 1996;67(5):497–505.
[26] Papapanou N, Neiderud AM, Sandros J, et al. Checkerboard assessments of serum
antibodies to oral microbiota as surrogate markers of clinical periodontal status. J Clin
Periodontol 2001;28(1):103–6.
[27] Pussinen J, Vilkuna-Rautiainen T, Alfthan G, et al. Multiserotype enzyme-linked
immunosorbent assay as a diagnostic aid for periodontitis in large-scale studies. J Clin
Microbiol 2002;40(2):512–8.
[28] O’Brien-Simpson NM, Veith D, Dashper SG, et al. Antigens of bacteria associated with
periodontitis. Periodontol 2000 2000;35:101–34.
692 TENENBAUM et al

[29] Conrads G. DNA probes and primers in dental practice. Clin Infect Dis 2002;35(Suppl 1):
S72–7.
[30] Tenenbaum H, Elkaim R, Cuisinier F, et al. Prevalence of six periodontal pathogens
detected by DNA probe method in HIV vs non-HIV periodontitis. Oral Dis 1997;
3(Suppl 1):S153–5.
[31] Socransky SS, Smith C, Martin L, et al. ‘‘Checkerboard’’ DNA-DNA hybridization.
Biotechniques 1994;17(4):788–92.
[32] Asai Y, Jinno T, Igarashi H, et al. Detection and quantification of oral treponemes in
subgingival plaque by real-time PCR. J Clin Microbiol 2002;40(9):3334–40.
[33] Boopathy R, Robichaux M, LaFont D, et al. Activity of sulfate-reducing bacteria in
human periodontal pocket. Can J Microbiol 2002;48(12):1099–103.
[34] Torresyap G, Haffajee AD, Uzel NG, et al. Relationship between periodontal pocket
sulfide levels and subgingival species. J Clin Periodontol 2003;30(11):1003–10.
[35] Atici K, Yamalik N, Eratalay K, et al. Analysis of gingival crevicular fluid intra-
cytoplasmic enzyme activity in patients with adult periodontitis and rapidly progressive
periodontitis. A longitudinal study model with periodontal treatment. J Periodontol 1998;
69(10):1155–63.
[36] Yucekal-Tuncer B, Uygur C, Firatli E. Gingival crevicular fluid levels of aspartate amino
transferase, sulfide ions and N-benzoyl-DL-arginine-2-naphthylamide in diabetic patients
with chronic periodontitis. J Clin Periodontol 2003;30(12):1053–60.
[37] Smith AJ, Wade W, Addy M, et al. The relationship between microbial factors and
gingival crevicular fluid glycosaminoglycans in human adult periodontitis. Arch Oral Biol
1997;42(1):89–92.
[38] Waddington RJ, Langley MS, Guida L, et al. Relationship of sulphated glycosamino-
glycans in human gingival crevicular fluid with active periodontal disease. J Periodontal
Res 1996;31(3):168–70.
[39] Al-Shammari KF, Giannobile WV, Aldredge WA, et al. Effect of non-surgical periodon-
tal therapy on C-telopeptide pyridinoline cross-links (ICTP) and interleukin-1 levels.
J Periodontol 2001;72(8):1045–51.
[40] Mogi M, Otogoto J, Ota N, et al. Differential expression of RANKL and osteoprotegerin
in gingival crevicular fluid of patients with periodontitis. J Dent Res 2004;83(2):166–9.
[41] Genco RJ. Current view of risk factors for periodontal diseases. J Periodontol 1996;
67(Suppl 10):1041–9.
[42] Hart TC, Hart S, Bowden DW, et al. Mutations of the cathepsin C gene are responsible for
Papillon-Lefevre syndrome. J Med Genet 1999;36(12):881–7.
[43] Soell M, Elkaim R, Tenenbaum H. Cathepsin C, matrix metalloproteinases, and their
tissue inhibitors in gingiva and gingival crevicular fluid from periodontitis-affected
patients. J Dent Res 2002;81(3):174–8.
[44] Mark LL, Haffajee AD, Socransky SS, et al. Effect of the interleukin-1 genotype on
monocyte IL-1beta expression in subjects with adult periodontitis. J Periodontal Res 2000;
35(3):172–7.
[45] Papapanou N, Abron A, Verbitsky M, et al. Gene expression signatures in chronic and
aggressive periodontitis: a pilot study. Eur J Oral Sci 2004;112(3):216–23.
[46] Bowers GM, Chadroff B, Carnevale R, et al. Histologic evaluation of new attachment
apparatus formation in humans. Part III. J Periodontol 1989;60(12):683–93.
[47] Froum SJ, Gomez C, Breault MR. Current concepts of periodontal regeneration. A review
of the literature. N Y State Dent J 2002;68(9):14–22.
[48] Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976;47(5):
256–60.
[49] Esposito M, Coulthard P, Worthington HV. Enamel matrix derivative (Emdogain) for
periodontal tissue regeneration in intrabony defects. Cochrane Database Syst Rev 2003;2
CD003875.
 FUTURE TREATMENT AND DIAGNOSTIC STRATEGIES 693

[50] Wennstrom JL, Lindhe J. Some effects of enamel matrix proteins on wound healing in the
dento-gingival region. J Clin Periodontol 2002;29(1):9–14.
[51] Caffesse RG, de la Rosa M, Mota LF. Regeneration of soft and hard tissue periodontal
defects. Am J Dent 2002;15(5):339–45.
[52] Karring T. Regenerative periodontal therapy. J Int Acad Periodontol 2000;2(4):
101–9.
[53] Tenenbaum HC, Shelemay A, Girard B, et al. Bisphosphonates and periodontics:
potential applications for regulation of bone mass in the periodontium and other
therapeutic/diagnostic uses. J Periodontol 2002;73(7):813–22.
[54] Ryan LM. The ank gene story. Arthritis Res 2001;3(2):77–9 [Epub 2000 Dec 19].
[55] Shinozaki T, Pritzker K. Regulation of alkaline phosphatase: implications for calcium
pyrophosphate dihydrate crystal dissolution and other alkaline phosphatase functions.
J Rheumatol 1996;23(4):677–83.
[56] Lekic I, Rubbino F, Krasnoshtein S, et al. Bisphosphonate modulates proliferation and
differentiation of rat periodontal ligament cells during wound healing. Anat Rec 1997;
247(3):329–40.
[57] Reddy MS, Geurs NC, Gunsolley JC. Periodontal host modulation with antiproteinase,
anti-inflammatory, and bone-sparing agents. A systematic review. Ann Periodontol 2003;
8(1):12–37.
[58] Sela J, Gross UM, Kohavi D, et al. Primary mineralization at the surfaces of implants. Crit
Rev Oral Biol Med 2000;11(4):423–36.
[59] Yaffe A, Fine N, Alt I, et al. The effect of bisphosphonate on alveolar bone resorption
following mucoperiosteal flap surgery in the mandible of rats. J Periodontol 1995;66(11):
999–1003.
[60] Armitage GC. Diagnosis of periodontal diseases. J Periodontol 2003;74(8):1237–47.
[61] D’Aoust P, McCulloch CA, Tenenbaum HC, et al. Etidronate (HEBP) promotes
osteoblast differentiation and wound closure in rat calvaria. Cell Tissue Res 2000;302(3):
353–63.
[62] Rodan GA. Mechanisms of action of bisphosphonates. Annu Rev Pharmacol Toxicol
1998;38:375–88.
[63] Lian JB, Stein GS. Concepts of osteoblast growth and differentiation: basis for
modulation of bone cell development and tissue formation. Crit Rev Oral Biol Med
1992;3(3):269–305.
[64] Yaffe A, Golomb G, Breuer E, et al. The effect of topical delivery of novel
bisacylphosphonates in reducing alveolar bone loss in the rat model. J Periodontol
2000;71(10):1607–12.
[65] Tenovuo J. Antimicrobial function of human salivadhow important is it for oral health?
Acta Odontol Scand 1998;56(5):250–6.
[65a] Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal
patients. J Periodontol 1978;49(5):225–37.
[66] Niederman R, Abdelshehid G, Goodson JM. Periodontal therapy using local delivery of
antimicrobial agents. Dent Clin N Am 2002;46(4):665–77 viii.
[67] Karlowsky J, Ferguson J, Zhanel G. A review of commonly prescribed oral antibiotics in
general dentistry. J Can Dent Assoc 1993;59(3):292–300.
[68] De Soete M, Mongardini C, Peuwels M, et al. One-stage full-mouth disinfection. Long-
term microbiological results analyzed by checkerboard DNA-DNA hybridization.
J Periodontol 2001;72(3):374–82.
[69] Xue LY, Chiu SM, Oleinick NL. Staurosporine-induced death of MCF-7 human breast
cancer cells: a distinction between caspase-3-dependent steps of apoptosis and the critical
lethal lesions. Exp Cell Res 2003;283(2):135–45.
[70] Beck RW. Photodynamic therapy for age-related macular degeneration. Am J
Ophthalmol 2004;138(3):513 [author reply: 513–4].
694 TENENBAUM et al

[71] Wilson M. Lethal photosensitisation of oral bacteria and its potential application in the
photodynamic therapy of oral infections. Photochem Photobiol Sci 2004;3(5):412–8
[Epub 2004 Feb 05].
[72] Koshy G, Corbet EF, Ishikawa I. A full-mouth disinfection approach to nonsurgical
periodontal therapydprevention of reinfection from bacterial reservoirs. Periodontol
2000 2000;36:166–78.
[72a] Goziotis A, Sukhu B, Torontali M, et al. Effects of bisphosphonates APD and HEBP on
bone metabolism in vitro. Bone 1995;16:17S–27S.
[73] Golub LM, Lee HM, Ryan ME, et al. Tetracyclines inhibit connective tissue breakdown
by multiple non-antimicrobial mechanisms. Adv Dent Res 1998;12(2):12–26.
[74] Zohar R, Nemcovsky CE, Kebudi E, et al. Tetracycline impregnation delays collagen
membrane degradation in vivo. J Periodontol 2004;75(8):1096–101.
[75] Bhide VM, Smith L, Overall CM, et al. Use of a fluorogenic septapeptide matrix
metalloproteinase assay to assess responses to periodontal treatment. J Periodontol 2000;
71(5):690–700.
[76] Quirynen M, De Soete M, van Steenberghe D. Infectious risks for oral implants: a review
of the literature. Clin Oral Implants Res 2002;13(1):1–19.
[77] Genco RJ, Loe H. The role of systemic conditions and disorders in periodontal disease.
Periodontol 2000 2000;2:98–116.
[78] Grossi S. Smoking and stress: common denominators for periodontal disease, heart
disease, and diabetes mellitus. Compend Contin Educ Dent 2000;30(Suppl):31–9 [quiz:
66].
[79] Kinane DF, Chestnutt IG. Smoking and periodontal disease. Crit Rev Oral Biol Med
2000;11(3):356–65.
[80] Andreou V, D’Addario M, Zohar R, et al. Inhibition of osteogenesis in vitro by a cigarette
smoke-associated hydrocarbon combined with Porphyromonas gingivalis lipopolysaccha-
ride: reversal by resveratrol. J Periodontol 2004;75(7):939–48.
[81] Singh SU, Casper RF, Fritz C, et al. Inhibition of dioxin effects on bone formation in vitro
by a newly described aryl hydrocarbon receptor antagonist, resveratrol. J Endocrinol
2000;167(1):183–95.