Maintenance of periodontal health or transition to a periodontal lesion reflects the continuous and ongoing battle between the vast microbial ecology in the oral cavity and the array of resident and emigrating inflammatory/immune cells in the periodontium. This war clearly signifies many 'battlefronts' representing the interface of the mucosal-surface cells with the dynamic biofilms composed of commensal and potential pathogenic species, as well as more recent knowledge demonstrating active invasion of cells and tissues of the periodontium leading to skirmishes in connective tissue, the locality of bone and even in the local vasculature. Research in the discipline has uncovered a concerted effort of the microbiome, using an array of survival strategies, to interact with other bacteria and host cells. These strategies aid in colonization by 'ambushing, infiltrating and outflanking' host cells and molecules, responding to local environmental changes (including booby traps for host biomolecules), communicating within and between genera and species that provide MASINT (Measurement and Signature Intelligence) to enhance sustained survival, sabotage the host inflammatory and immune responses and by potentially adopting a 'Fabian strategy' with a war of attrition and resulting disease manifestations. Additionally, much has been learned regarding the ever-increasing complexity of the host-response armamentarium at both cellular and molecular levels that is addressed in this review. Knowledge regarding how these systems fully interact requires both new laboratory and clinical tools, as well as sophisticated modeling of the networks that help maintain homeostasis and are dysregulated in disease. Finally, the triggers resulting in a 'coup de main' by the microbiome (exacerbation of disease) and the characteristics of susceptible hosts that can result in 'pyrrhic victories' with collateral damage to host tissues, the hallmark of periodontitis, remains unclear. While much has been learned, substantial gaps in our understanding of the 'parameters of this war' remain elusive toward fulfilling the Sun Tzu adage: 'If you know the enemy and know yourself, you need not fear the result of a hundred battles.'

Aim Peri-implant gingival healing following one-stage implant placement was investigated and compared to periodontal healing. Methods Healing at surgical sites (implant (I) and adjacent teeth (T+)) was compared to non-operated tooth (T-) in non-smokers receiving one-stage implant. Periodontal Indices (PI, GI) were recorded at surgery and up to 12 weeks postoperatively. Peri-implant (PICF) and gingival crevicular (GCF) fluids were analyzed for cytokines, collagenases and inhibitors. Data was analyzed by linear mixed model regression analysis and repeated measures ANOVA. Results 40 patients (22 female; 21-74 yrs old) completed the study. Surgical site GI, increased at week 1, decreased significantly during early healing (weeks 1-3; p=0.0003) and continually decreased during late healing (weeks 6-12) for I (p<0.01). PICF volume decreased 3-fold by week 12 (p=0.0003). IL-6, IL-8, MIP-1β, and TIMP-1 levels significantly increased at surgical sites at week one, significantly decreasing thereafter (P<0.016). Week one IL-6, IL-8 and MIP-1β levels were ~3-fold higher, and TIMP-1 levels 63% higher, at I compared to T+ (p=0.001). Conclusion Peri-implant gingival healing, as determined by crevicular fluid molecular composition, differs from periodontal healing. The observed differences suggest that peri-implant tissues, compared to periodontal tissues, represent a higher pro-inflammatory state.

Periodontitis is a chronic inflammation that destroys periodontal tissues caused by the accumulation of bacterial biofilms that can be affected by environmental factors. This report describes an association study to evaluate the relationship of environmental factors to the expression of periodontitis using the National Health and Nutrition Examination Study (NHANES) from 1999–2004. A wide range of environmental variables (156) were assessed in patients categorized for periodontitis (n = 8884). Multiple statistical approaches were used to explore this dataset and identify environmental variable patterns that enhanced or lowered the prevalence of periodontitis. Our findings indicate an array of environmental variables were different in periodontitis in smokers, former smokers, or non-smokers, with a subset of specific environmental variables identified in each population subset. Discriminating environmental factors included blood levels of lead, phthalates, selected nutrients, and PCBs. Importantly, these factors were found to be coupled with more classical risk factors (i.e. age, gender, race/ethnicity) to create a model that indicated an increased disease prevalence of 2–4 fold across the sample population. Targeted environmental factors are statistically associated with the prevalence of periodontitis. Existing evidence suggests that these may contribute to altered gene expression and biologic processes that enhance inflammatory tissue destruction.

Aim To investigate the role of Epstein–Barr virus (EBV), cytomegalovirus (CMV), and anaerobic bacteria in the progression of periodontitis. Methods Eighty‐one adults with generalized moderate to severe periodontitis were randomly assigned to: oral hygiene or scaling and root planning ± placebo or polyunsaturated fatty acids fish oil. Subgingival plaque samples collected from three healthy and three disease sites at weeks 0, 16, and 28 and from sites demonstrating disease progression were analysed for EBV, CMV, P. gingivalis (Pg), T. forsythia (Tf), and T. denticola (Td) DNA using quantitative polymerase chain reaction. Results Cytomegalovirus was detected in 0.3% (4/1454) sites. EBV was present in 12.2% of healthy sites (89/728) and 27.6% disease sites (201/726; p < .0001), but was in low copy number. Disease progression occurred in 28.4% of participants (23/81) and developed predominantly at sites identified as diseased (75/78; 96.2%). CMV and EBV were not associated with disease progression (p = .13) regardless of treatment. In contrast, disease sites were associated with higher levels of Pg, Td, Tf, and total bacteria, and sites that exhibited disease progression were associated with an abundance of Td and Tf (p < .04). Conclusion Disease progression was associated with Gram‐negative anaerobic bacteria; not EBV or CMV.

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The results provided new information on a portfolio of genes expressed by oral epithelial cells, targeted substantial increases in an array of immune-related genes post-biofilm challenge, and a focused impact of environmental lead on these induced responses.

Periodontal disease (PD) is a chronic inflammatory disorder characterized by the destruction of connective tissue, tooth loss and systemic infections. Numerous virulence factors derived from chronic opportunistic pathogens such as Porphyromonas gingivalis are responsible for enhanced microbial colonization, stimulation of inflammatory responses, and suppression of host defense response. Individuals with PD present with a complex array of inflammatory mediators, and cellular infiltration by neutrophils, lymphocytes and monocytes/macrophages. Although macrophages comprise 5–30% of cells in the cellular infiltrate of human periodontal lesions, how macrophage skewing contributes to PD, and more specifically in the downstream development of a macrophage immune response to oral bacteria are unclear. We, including others have investigated the activation of monocytes/macrophages, and discovered the means of type I vs. type II inflammatory activation vs. deactivation of macrophages both in vitro and in vivo. We have shown previously that P. gingivalis infection induces M1 macrophage formation, whereas opsonized‐P. gingivalis challenge was able to switch to M2‐like phenotype demonstrating macrophage plasticity. However, the mechanism of modulation and kinetics of macrophage inflammatory reactions during the process is unclear. Prior research in the field has failed to appreciate that it is the same monocyte/macrophage cell population which is initially polarized towards an effector “inflammatory” program and subsequently re‐polarized to the deactivation program not just in PD but in any inflammation. The overarching goal of our research is to understand how macrophage skewing contributes to PD, and the downstream development of immune response to PD‐associated bacteria towards development of new macrophage‐based therapeutics. Since macrophage polarization dynamics cannot be studied in an animal model, a reliable in vitro system is needed to provide fundamental insights into macrophage biology. We have developed an in vitro model that recapitulates different phases of the inflammatory response (recruitment, initiation, development and resolution), based on purified human peripheral blood monocytes exposed to a battery of microenvironmental cues mimicking macrophage polarization/depolarization in vivo and we have created a kinetic profile of polarization by RNA analysis. Further we have applied our model to macrophage/gingival fibroblast coculture system to study kinetics of polarization. And by comparing gene clusters that are differentially expressed in M1 and M2, we have successfully recapitulated the macrophage polarization kinetics of acute inflammatory and resolution phases during periodontal inflammation and validated the key inflammatory and transcriptional factors using RT‐PCR at different phases. In conclusion, we developed an in vitro model which can be further employed to test novel macrophage‐based therapeutics to treat periodontal disease.