Oral Infectious Diseases Research Articles

Research progress on the relationship and mechanisms between periodontal disease and preterm birth and low-birth-weight infants

Preterm birth (PB) is defined as the birth of a baby less than 37 weeks of gestational age. Low birth weight (LBW) is defined as a newborn baby's weight of less than 2 500 g. PB is often accompanied by LBW. Preterm low birth weight (PLBW) is the leading cause of newborn deaths. Periodontal disease (PD) is a chronic oral infectious disease, and it is closely related with general health. Epidemiological data show that PD is a risk factor for PLBW and other adverse pregnancy outcomes. The possible mechanisms include the direct effects of periodontal bacteria, inflammatory reactions, and immune response; however, the exact pathogenetic mechanism involved remains controversial. This article aims to review the research progress on the relationship between PD and PLBW and their underlying mechanisms, as well as the effects of periodontal treatment on PLBW incidence.

Fabrication of Antimicrobial Peptide-Loaded PLGA/Chitosan Composite Microspheres for Long-Acting Bacterial Resistance.

An antimicrobial decapeptide, KSL-W (KKVVFWVKFK-CONH2), which could maintain stable antimicrobial activity in saliva, has therefore been widely used to inhibit biofilm formation on teeth and prevent the growth of oral microorganisms for related infectious diseases treatment. In order to control the release of KSL-W for long-term bacterial resistance, KSL-W-loaded PLGA/chitosan composite microspheres (KSL/PLGA/CS MSs) were prepared by electrospraying and combined crosslinking-emulsion methods. Different formulations of microspheres were characterized as to surface morphology, size distribution, encapsulation efficiency, in vitro drug release, and antimicrobial activity. Antibacterial experiment demonstrated the prolonged antimicrobial and inhibitory effects of KSL/PLGA/CS MSs on oral bacteria. Moreover, the cell proliferation assay proved that the released KSL-W antibacterial dosage had no cytotoxicity to the growth of osteoblast MC3T3-E1. Thus, our study suggested that the KSL-W-loaded PLGA/CS composite microspheres may have potentially therapeutic applications as an effective drug delivery system in the treatment of oral infectious diseases such as periodontitis and periodontitis, and also within bone graft substitutes for alveolar bone augmentation.

Microbiomics of Oral Biofilms: Driving The Future of Dental Research

<p>Oral infectious diseases such as dental caries, periodontal disease, endodontic infections, oral candidiasis and peri-implantitis cause major health problems worldwide. All of these infectious diseases are associated with the biofilm growth mode of the oral pathogens. In the past, researchers often attempted to examine the association of single pathogens with particular dental diseases such as in the case of <em>Streptococcus mutans</em> acting as an aetiological agent for dental caries and the so-called “red-complex” bacteria for periodontal disease. However, with the recent advent of OMICS biology techniques such as genomics, transcriptomics, proteomics, it is possible to gain new insights into the host-microbial interaction, microbial community structure and composition in the oral cavity. The new studies on oral microbiomics can unravel the facets of the aetiopathology of oral diseases as never seen before. This mini-review will provide an history and overview of some of the existing DNA sequencing platforms employed to study the microbiomics of oral biofilms and the exciting future ahead for dental research.</p>

Synergistic effect of eugenol, carvacrol, thymol, p-cymene and γ-terpinene on inhibition of drug resistance and biofilm formation of oral bacteria

Dental caries remains the most prevalent oral infectious disease worldwide. In this study, the antibacterial and the antibiofilm activities of five essential oils (EO's): eugenol (EUG), carvacrol (CAR), thymol (TYH), p-cymene (CYM) and γ-terpinene (TER) were tested (alone or in combinaison with tetracycline) against oral bacteria. In addition, their potential roles to enhance the accumulation of ethidium bromide (EtBr) in bacterial cells were tested. Our results indicated that EO's induced a selective antimicrobial activity. A synergistic effect of EO's and tetracycline (TET) was noticed with a reduction rate ranged from 2 to 8-fold. In addition, the efflux of EtBr was inhibited with a decrease in loss of EtBr from the bacteria. On the other hand a significant anti-biofilm activities of EO's (alone or combined with antibiotics) was noticed. In conclusion the tested EO's may be considered as a potential natural source with a resistance-modifying activity and may be applied to eradicate bacterial biofilm.

The synthetic human beta-defensin-3 C15 peptide exhibits antimicrobial activity against Streptococcus mutans, both alone and in combination with dental disinfectants.

Streptococcus mutans is a major etiologic agent of human dental caries that forms biofilms on hard tissues in the human oral cavity, such as tooth and dentinal surfaces. Human β-defensin-3 (HBD3) is a 45-amino-acid natural antimicrobial peptide that has broad spectrum antimicrobial activity against bacteria and fungi. A synthetic peptide consisting of the C-terminal 15 amino acids of HBD3 (HBD3-C15) was recently shown to be sufficient for its antimicrobial activity. Thus, clinical applications of this peptide have garnered attention. In this study, we investigated whether HBD3-C15 inhibits the growth of the representative cariogenic pathogen Streptococcus mutans and its biofilm formation. HBD3-C15 inhibited bacterial growth, exhibited bactericidal activity, and attenuated bacterial biofilm formation in a dose-dependent manner. HBD3-C15 potentiated the bactericidal and anti-biofilm activity of calcium hydroxide (CH) and chlorhexidine digluconate (CHX), which are representative disinfectants used in dental clinics, against S. mutans. Moreover, HBD3-C15 showed antimicrobial activity by inhibiting biofilm formation by S. mutans and other dentinophilic bacteria such as Enterococcus faecalis and Streptococcus gordonii, which are associated with dental caries and endodontic infection, on human dentin slices. These effects were observed for HBD3-C15 alone and for HBD3-C15 in combination with CH or CHX. Therefore, we suggest that HBD3-C15 is a potential alternative or additive disinfectant that can be used for the treatment of oral infectious diseases, including dental caries and endodontic infections.

Consumption and direct costs of dental care for patients with head and neck cancer: A 16-year cohort study.

Patients with head and neck (H&N) cancer are commonly treated with surgery and/or radiotherapy, which can increase the risk of oral infection, dental caries, and periodontal disease. The present study investigated dental care consumption and costs in patient with H&N cancer before and after the cancer diagnosis. Data from Swedish regional and national registers were used to follow up dental care utilization and dental procedure costs. The analysis included 2,754 patients who had been diagnosed with H&N cancer (exposed cohort) in Stockholm County, Sweden, during 2000–2012 and 13,036 matched persons without cancer (unexposed cohort). The exposed cohort was sub-grouped into irradiated and non-irradiated patients for analysis. The exposed cohort underwent a moderately higher number of dental procedures per year than the unexposed cohort in both the year of the cancer diagnosis and the year after cancer diagnosis; in addition, these numbers were higher in the irradiated than in the non-irradiated subgroup of the exposed cohort. Dental care consumption and costs in the exposed cohort declined over time but remained at a slightly higher level than in the unexposed cohort over the long term (more than two years). Examinations and preventive procedures accounted for most of the higher consumption in the short term (2 years) and at the longer term follow-up. Swedish national insurance subsidized costs for dental treatment, which were highest in the irradiated subgroup and lowest in the unexposed cohort. Direct costs to the patient, however, were similar among the groups. Swedish national health insurance protects patients with H&N cancer from high dental expenditures. Further studies on the cost-effectiveness of preventive dental care for patients are needed.

Identification of Helicobacter and Wolinella spp. in Oral Cavity of Toy Breed Dogs With Periodontal Disease

Periodontal diseases are the most common oral cavity infectious diseases in adult dogs. We aimed in this study to identify Helicobacter and Wolinella spp. in saliva and dental plaque of dogs with periodontitis. Sixty-two small-breed pet dogs, aged more than 6 years from both sexes, were categorized into healthy and periodontitis groups. Samples from saliva and dental plaques were collected, and Helicobacter and Wolinella were identified on genus and species levels using polymerase chain reaction. Our results showed significant increase in infection rate of Wolinella spp. in periodontitis compared with healthy dogs (P = .002). Furthermore, infection rate of Helicobacter genus was significantly higher in periodontitis compared with healthy dogs (P = .007). Infection with Wolinella spp. showed higher rate than Helicobacter spp. in dogs with periodontitis. According to species-specific polymerase chain reaction results, Helicobacter felis (9.76%) was the main Helicobacter spp. in dogs with periodontitis compared with healthy dogs (P < .001). Oral cavity of pet dogs with periodontitis could be considered as an important source of Wolinella and Helicobacter spp. infections.

Expression and antimicrobial character of cells transfected with human β‑defensin‑3 against periodontitis‑associated microbiota in vitro.

Periodontitis is an oral chronic inflammatory disease induced by microorganisms that can destroy tooth-supporting structures. Human β-defensin-3 (HBD-3) is a type of endogenous antimicrobial peptide that inhibits a broad spectrum of microorganisms. The objectives of the present study were to transfect human periodontal ligament cells (HPDLCs) and human bone marrow stromal cells (HBMSCs) with lentivirus containing the HBD-3 gene, determine the transfection efficiency, and investigate the antimicrobial activity of the experimental cells against periodontal pathogens. Fluorescence microscopy was used to calculated the transfection efficiency. Western blot analysis and ELISA were conducted to confirm the expression of HBD-3 at the protein level. The effect of the HBD-3 gene on the antimicrobial activity of the cells were demonstrated by antimicrobial tests. The results of the present study demonstrated that the transfected HPDLCs and HBMSCs stably expressed HBD-3. In addition, periodontal pathogens and caries-causing bacteria were susceptible to the antimicrobial activity of the cells. Both HPDLCs and HBMSCs hold potential for use as seeding cells in cell- and gene-based therapies for periodontal disease. The lentiviral vector containing HBD-3 resulted in broad-spectrum antimicrobial activity against a variety of oral organisms, and could potentially be applied in the treatment of oral infectious diseases, including periodontitis.

Microbiomics of oral biofilms: Driving the future of dental research

Oral infectious diseases such as dental caries, periodontal disease, endodontic infections, oral candidiasis and peri-implantitis cause major health problems worldwide. All of these infectious diseases are associated with the biofilm growth mode of the oral pathogens. In the past, researchers often attempted to examine the association of single pathogens with particular dental diseases such as in the case of Streptococcus mutans acting as an aetiological agent for dental caries and the so-called “red-complex” bacteria for periodontal disease. However, with the recent advent of OMICS biology techniques such as genomics, transcriptomics, proteomics, it is possible to gain new insights into the host-microbial interaction, microbial community structure and composition in the oral cavity. The new studies on oral microbiomics can unravel the facets of the aetiopathology of oral diseases as never seen before. This mini-review will provide an history and overview of some of the existing DNA sequencing platforms employed to study the microbiomics of oral biofilms and the exciting future ahead for dental research.

Dental Caries: A Microbiological Approach

Tooth decay, also known as dental caries is an epidemic, microbiological contagious disease of the teeth that ends in localized dissolution and damage of the calcified structure of the teeth. This disease occurs due to multiple factors such as interactions within the plaque community, host physiology, diet, fluoride, pH and the nature of the tooth enamel, and dominance of Streptococcus mutans . The time factor is significant for the commencement and development of caries in teeth. The main instigation and progress of dental caries involves acidogenic and aciduric Gram-positive bacteria such as Streptococcus, Lactobacillus and Actinomycetes colonizing the supragingival biofilm which impede with usual nutrition intake, verbal communication, self-worth and daily habitual behavior. Nutritional influences on craniofacial development, oral cancer and other oral infectious diseases are expensive to treat. In spite of development in science of oral diseases, dental caries extend to be a global health concern affecting human being of different age groups. With this concern, this review article highlights different microbiological perspectives of dental caries in broader sense and its update will help to upgrade the recent trends of microbiology in dental caries and also formulating various developmental programs towards oral hygiene.

Probiotics and oral health: A systematic review.

BackgroundProbiotics are microorganisms, mainly bacteria, which benefit the host’s health. Many studies support the role of probiotics as a contributor to gastrointestinal health, and nowadays many authors are trying to prove its influence in oral health maintenance. ObjectivesTo review the published literature with the purpose of knowing the importance of using probiotics as a preventive and therapeutic method for oral infectious diseases management.Material and MethodsAn electronic search in PubMed database with the keywords “oral health AND probiotics AND dentistry” was conducted. The inclusion criteria were: randomized clinical trials (RCTs) that assess the action of any probiotic strain in the treatment and / or prevention of an infectious oral disease, RCTs that assess the action of any probiotic strain on counting colony forming units (CFU) of oral pathogens, systematic reviews and meta-analysis. The Jadad scale was used to assess the high quality of RCTs.ResultsFifteen articles were considered for this review. Of which, 12 were RCTs of good / high quality (Jadad scale), two meta-analysis and one systematic review.ConclusionsThe literature reviewed suggests probiotics usage could be beneficial for the maintenance of oral health, due to its ability to decrease the colony forming units (CFU) counts of the oral pathogens. However, randomized clinical trials with long-term follow-up periods are needed to confirm their efficacy in reducing the prevalence/incidence of oral infectious diseases. Furthermore, the recognition of specific strains with probiotic activity for each infectious oral disease is required, in order to determine exact dose, treatment time and ideal vehicles. Key words:Probiotics, periodontal diseases, dental caries, oral health.

Antibiofilm and Anti‐Inflammatory Activities of Houttuynia cordata Decoction for Oral Care

Dental biofilms that form in the oral cavity play a critical role in the pathogenesis of several infectious oral diseases, including dental caries, periodontal disease, and oral candidiasis. Houttuynia cordata (HC, Saururaceae) is a widely used traditional medicine, for both internal and external application. A decoction of dried HC leaves (dHC) has long been consumed as a health-promoting herbal tea in Japan. We have recently reported that a water solution of HC poultice ethanol extract (wHCP) exerts antimicrobial and antibiofilm effects against several important oral pathogens. It also exhibits anti-inflammatory effects on human keratinocytes. In our current study, we examined the effects of dHC on infectious oral pathogens and inflammation. Our results demonstrated that dHC exerts moderate antimicrobial effects against methicillin-resistant Staphylococcus aureus (MRSA) and other oral microorganisms. dHC also exhibited antibiofilm effects against MRSA, Fusobacterium nucleatum (involved in dental plaque formation), and Candida albicans and inhibitory effects on interleukin-8, CCL20, IP-10, and GROα productions by human oral keratinocytes stimulated by Porphyromonas gingivalis lipopolysaccharide (a cause of periodontal disease), without cytotoxic effects. This suggests that dHC exhibits multiple activities in microorganisms and host cells. dHC can be easily prepared and may be effective in preventing infectious oral diseases.

Antimicrobial efficacy of probiotic-containing toothpastes: an in vitro evaluation.

Aim To evaluate, in vitro antimicrobial ability of two probiotic toothpastes (one containing Lactobacillus paracasei, other containing Lactobacillus acidophilus) and one toothpaste without probiotic separately, and in a combination with two different mouthrinses (one containing essential oils and the other containing hexitidine). Methods Antimicrobial susceptibility was checked by using the ditch method and Clinical Laboratory Standard Institute (CLSI) guidelines. Two different toothpastes with probiotic, toothpaste without probiotic and two different mouthrinses were tested against the following selected microorganisms: Candida albicans, Candida tropicalis, Enterococcus faecalis, Streptococcus salivarius and Staphylococcus aureus. Kruskal-Wallis test and MannWhitney U test were used for the statistical analysis (p≤ 0.05). Results Probiotic toothpastes had better inhibitory effect than toothpaste without probiotic in the case of Candida albicans (p=0.043) and Streptococcus salivarius (p=0.043). In all cases, toothpastes had stronger inhibition capacity than mouthrinses (p≤0.05). Conclusion Probiotic toothpastes, as a relatively new concept in the prevention of oral infectious diseases such as caries and periodontal disease, can contribute to the prevention of oral infectious diseases.

다엽의 5가지 페놀성분과 R-(-)-carvone의 치아우식균 Mutans Streptococci에 대한 항균력 상승효과

Objectives : Camellia sinensis (Theaceae) possesses a various beneficial effects such as free radical-scavenging, inactivation of urokinase in cancer cell proliferation, antibacterial, and hypotensive. Dental caries is one of the most common oral infectious disease in a human. Oral microorganisms play a significant role in the etiology of dental caries. An aberration to this ecology due to dietary habits, improper oral hygiene or systemic factors lead to an increase in cariogenic microorganisms. Cariogenic microorganisms like Streptococcus mutans and Streptococcus sobrinus encourage the accumulation and adherence of plaque biofilm by metabolizing sucrose into glucans. The purpose of this study was to investigate the antimicrobial activity of phenolic compounds of Camellia sinensis and R-carvone, monoterpenes, is can be found naturally in numerous essential oils, on Streptococcus mutans and Streptococcus sobrinus .Methods : The antimicrobial activity of these compounds was determined by the broth microdilution method and checkerboard dilution assay to investigate the potential synergistic effects of each five compounds of Camellia sinensis (C. sinensis) and R-carvone.Results : C. sinensis-isolated compounds and R-carvone were determined with MIC of more than 1,000 ㎍/mL. However, the combination test showed significant synergism against S. mutans and S. sobrinus, implicated in the lowered MICs.Conclusions : These results suggest that combinatory application of phenolic five compounds (theophyllin, l-theanine, epicatechin, epicatechin gallate, and caffeine) from C. sinensis and R-carvone has a potential synergistic effect and thus may be useful as a mouthrinse in helping control cariogenic microorganism.

Effect of gelatin sponge with colloid silver on bone healing in infected cranial defects

Oral infectious diseases may lead to bone loss, which makes it difficult to achieve satisfactory restoration. The rise of multidrug resistant bacteria has put forward severe challenges to the use of antibiotics. Silver (Ag) has long been known as a strong antibacterial agent. In clinic, gelatin sponge with colloid silver is used to reduce tooth extraction complication. To investigate how this material affect infected bone defects, methicillin-resistant Staphylococcus aureus (MRSA) infected 3-mm-diameter cranial defects were created in adult female Sprague-Dawley rats. One week after infection, the defects were debrided of all nonviable tissue and then implanted with gelatin sponge with colloid silver (gelatin/Ag group) or gelatin alone (gelatin group). At 2 and 3days after debridement, significantly lower mRNA expression levels of IL-6 and TNF-α and lower plate colony count value were detected in gelatin/Ag group than control. Micro-CT analysis showed a significant increase of newly formed bone volume fraction (BV/TV) in gelatin/Ag treated defects. The HE stained cranium sections also showed a faster rate of defect closure in gelatin/Ag group than control. These findings demonstrated that gelatin sponge with colloid silver can effectively reduce the infection caused by MRSA in cranial defects and accelerate bone healing process.

Cationic Lipid Content in Liposome-Encapsulated Nisin Improves Sustainable Bactericidal Activity against Streptococcus mutans.

An oral infectious disease, dental caries, is caused by the cariogenic streptococci Streptococcus mutans. The expected preventive efficiency for prophylactics against dental caries is not yet completely observed. Nisin, a bacteriocin, has been demonstrated to be microbicidal against S. mutans, and liposome-encapsulated nisin improves preventive features that may be exploited for human oral health. Here we examined the bactericidal effect of charged lipids on nisin-loaded liposomes against S. mutans and inhibitory efficiency for insoluble glucan synthesis by the streptococci for prevention of dental caries. Cationic liposome, nisin-loaded dipalmitoylphosphatidylcholine/phytosphingosine, exhibited higher bactericidal activities than those of electroneutral liposome and anionic liposome. Bactericidal efficiency of the cationic liposome revealed that the vesicles exhibited sustained inhibition of glucan synthesis and the lowest rate of release of nisin from the vesicles. The optimizing ability of cationic liposome-encapsulated nisin that exploit the sustained preventive features of an anti-streptococcal strategy may improve prevention of dental caries.

Morphological and physiological changes induced by contact-dependent interaction between Candida albicans and Fusobacterium nucleatum.

Candida albicans and Fusobacterium nucleatum are well-studied oral commensal microbes with pathogenic potential that are involved in various oral polymicrobial infectious diseases. Recently, we demonstrated that F. nucleatum ATCC 23726 coaggregates with C. albicans SN152, a process mainly mediated by fusobacterial membrane protein RadD and Candida cell wall protein Flo9. The aim of this study was to investigate the potential biological impact of this inter-kingdom interaction. We found that F. nucleatum ATCC 23726 inhibits growth and hyphal morphogenesis of C. albicans SN152 in a contact-dependent manner. Further analysis revealed that the inhibition of Candida hyphal morphogenesis is mediated via RadD and Flo9 protein pair. Using a murine macrophage cell line, we showed that the F. nucleatum-induced inhibition of Candida hyphal morphogenesis promotes C. albicans survival and negatively impacts the macrophage-killing capability of C. albicans. Furthermore, the yeast form of C. albicans repressed F. nucleatum-induced MCP-1 and TNFα production in macrophages. Our study suggests that the interaction between C. albicans and F. nucleatum leads to a mutual attenuation of virulence, which may function to promote a long-term commensal lifestyle within the oral cavity. This finding has significant implications for our understanding of inter-kingdom interaction and may impact clinical treatment strategies.

A specific hygiene hypothesis

Allergic diseases have reached epidemic proportions in Western populations in the last several decades. The hygiene hypothesis proposed more than twenty years ago has helped us to understand the epidemic and has been verified with numerous studies. However, translational measures deduced from these studies to prevent allergic diseases have not proven effective. Recent studies on immigrants’ allergies and any potential association between oral infection and allergic diseases prompt me to propose a specific hygiene hypothesis to explain how oral hygiene practices might have contributed to the uprising of hay fever, the most common allergic disease. The historic oral hygiene level in US is closely associated with the emerging allergic epidemic. Future studies to test the hypothesis are needed and verification of the hypothesis can potentially yield highly effective measures to prevent allergic diseases.

Preventive Effects ofHouttuynia cordataExtract for Oral Infectious Diseases

Houttuynia cordata (HC) (Saururaceae) has been used internally and externally as a traditional medicine and as an herbal tea for healthcare in Japan. Our recent survey showed that HC poultice (HCP) prepared from smothering fresh leaves of HC had been frequently used for the treatment of purulent skin diseases with high effectiveness. Our experimental study also demonstrated that ethanol extract of HCP (eHCP) has antibacterial, antibiofilm, and anti-inflammatory effects against S. aureus which caused purulent skin diseases. In this study, we focused on novel effects of HCP against oral infectious diseases, such as periodontal disease and dental caries. We determined the antimicrobial and antibiofilm effects of water solution of HCP ethanol extract (wHCP) against important oral pathogens and investigated its cytotoxicity and anti-inflammatory effects on human oral epithelial cells. wHCP had moderate antimicrobial effects against some oral microorganisms and profound antibiofilm effects against Fusobacterium nucleatum, Streptococcus mutans, and Candida albicans. In addition, wHCP had no cytotoxic effects and could inhibit interleukin-8 and CCL20 productions by Porphyromonas gingivalis lipopolysaccharide-stimulated human oral keratinocytes. Our findings suggested that wHCP may be clinically useful for preventing oral infectious diseases as a mouthwash for oral care.

An intriguing relation between periodontal and cardiovascular diseases

Periodontitis is a chronic inflammatory condition promoted by bacterial colonization of the gingiva that causes alveolar bone and tooth loss. Under these conditions, bacteria, as well as bacterial products and inflammatory mediators can move from the gingival pocket to the well vascularised periodontal tissues and into the circulation. In fact, recently a possible connection between oral infection and cardiovascular disease was suggested (1). One of the major pathogens involved in the progression of periodontal disease is the Porphyromonas gingivalis (LPS-G). The aim of the study was to induce endothelial differentiation in human periodontal ligaments stem cells (hPDLSCs) (2) on decellularized pig heart valve as scaffold and evaluate the role of LPS-G on cell cultures in terms of reactive oxygen species (ROS) production and NFKB pathway. Many studies have shown that ROS provoked oxidative stress plays a critical role in the development of cardiovascular disease. Excessive generation of ROS can cause cellular dysfunction and injury by directly oxidizing and damaging proteins, DNA and lipids, which ultimately result in cell death. To induce endothelial differentiation, human periodontal ligament stem cells (hPDLSCs) were cultured with endothelial growth medium (EGM-2MV) supplemented with vascular endothelial growth factor (VEGF) and seeded on decellularized pig heart valve. Valve leaflets were incubated for 30 min with 10 μM DCFH-DA at 37°C in humidified incubator. At the end of loading, the valve leaflets were observed using multiphoton microscope. Results of time lapse experiments revealed that after treatment, with 2,5 mg/ml LPS-G, a rapid sustained increase in ROS generation was observed mainly in differentiated hPDLSCs. Comparing the average response of undifferentiated and differentiated hPDLSCs is clearly evident that the latter showed an six fold increase in ROS production after LPS-G exposure, while on undifferentiated appeared to be negligible. Moreover, in endothelial differentiated cells the NFKB nuclear translocation in presence of LPS-G was evident. A reasonable conclusion could be that the treatment of periodontal disease not only improve dental but presumably also cardiovascular health.