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Focal Infection and Periodontitis: a Narrative Report and New Possible Approaches Hindawi International Journal of Microbiology Volume 2020, Article ID 8875612, 9 pages https://doi.org/10.1155/2020/8875612 Review Article Focal Infection and Periodontitis: A Narrative Report and New Possible Approaches Jean-Paul Rocca,1,2 Carlo Fornaini ,1,2 Zuomin Wang,3 Lixin Tan,4 and Elisabetta Merigo1,2 1Shijiazhuang 2nd Hospital, Department of Stomatology (South), Gonguong Road 425, Quoxi District, Shijiazhuang, China 2UFRO dontologie, UPR Micoralis, University Coˆte d’Azur, 24 Avenue des Diables Bleus, 06354 Nice Cedex, France 3Beijing Chaoyang Hospital, Department of Stomatology, Capital Medical University, Beijing, China 4Shijiazhuang 2nd Hospital, Department of Diabetes, Gonguong Road 425, Quoxi District, Shijiazhuang, China Correspondence should be addressed to Carlo Fornaini; [email protected] Received 3 July 2020; Revised 29 September 2020; Accepted 17 October 2020; Published 29 October 2020 Academic Editor: Carlo Genovese Copyright © 2020 Jean-Paul Rocca et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. +e “focal infection theory” is a historical concept based on the assumption that some infections may cause chronic and acute diseases in different districts of the body. Its great popularity spanned from 1930 to 1950 when, with the aim to remove all the foci of infection, drastic surgical interventions were performed. Periodontitis, a common oral pathology mainly of bacterial origin, is the most evident example of this phenomenon today: in fact, bacteria are able to migrate, develop and cause health problems such as cardiovascular and respiratory diseases, diabetes, and osteoporosis. +e aim of this narrative report is to verify the hypothesis of the association between oral infections and systemic diseases by different ways of approach and, at the same time, to propose new kinds of treatment today made possible by technological progress. +e analysis of the literature demonstrated a strong relationship between these conditions, which might be explained on the basis of the recent studies on microbiota movement inside the body. Prevention of the oral infections, as well as of the possible systemic implications, may be successfully performed with the help of new technologies, such as probiotics and laser. 1. Introduction In January 1940, Reimann and Havens published a re- view and a “critical appraisal” [5] which represent the most +e “focal infection theory” is a historical concept theorizing influential criticism of the focal infection theory; here, they that focal infections may be the cause of many chronic diseases, summarized that “the removal of infectious dental focal including systemic and common ones, [1] thus explaining infections in the hope of influencing remote or general virtually all diseases, including arthritis, atherosclerosis, cancer, symptoms of disease must still be regarded as an experi- and mental illnesses [2, 3]. mental procedure not devoid of hazard”. Focal infection was considered, more than one century ago, A 1952 editorial [6] in the Journal of the American as an infection at a specific location able to spread to different Medical Association marked the end of the theory era by districts of the body; in 1931, Graham wrote “by the term “focal stating that “many patients with diseases presumably caused infection,” one means a chronic, usually low-grade, infection by foci of infection have not been relieved of their symptoms that develops insidiously and progresses slowly producing local by removal of the foci, many patients with these same and systemic symptoms”. It is a common primary cause of systemic diseases have no evidence focus of infection, and chronic ill-health, but more often, it acts as a contributing foci of infection are as common in apparently healthy factor in disease conditions primarily due to other causes” [4]. persons as in those with disease”. 2 International Journal of Microbiology Today, moreover, based on progresses in the under- hand, the normal microflora is able to colonize permanently standing of pathogenic mechanisms also with the help of and to install a permanent commensal relationship with the molecular biology, the “focal theory” finds new interest in host “eating at the same table” (from Latin words cum = with medicine, as demonstrated by the important number of and mensa = table). +is microflora participates in multiple publications appeared in the literature. beneficial relationships protecting, for instance, from ex- +e aim of this narrative report is to give a contribution ogenous invasion and infections, by excluding other mi- to understand whether this new interest has to be regarded croorganisms [16]. But, qualitative and quantitative changes as a realistic moment in medical science or has to go back to are observed during the installation of a biofilm, depending silence; moreover, new possible approaches to the man- mainly on nutrients (inside a periodontal pocket for in- agement of these kinds of disease are described. stance) and oxygen conditions (anaerobic vs. aerobic or aeroanaerobic or microaerophylic bacteria). It is easy to 2. Brief History of the Focal Theory understand that deeply, in a periodontal pocket, the in- stallation and development of strict anaerobes are favoured. +e first report of a possible relationship between oral in- Examples are Porphyromonas gingivalis and Aggregatibacter fections and systemic diseases may be attributed to Hip- actinomycetemcommitans: both these bacteria are able to pocrates who described « a patient suffering of rheumatism bypass the epithelial barrier modulating fibroblastic in- appearing after a tooth extraction » [7]. flammatory response [17]. Porphyromonas gingivalis, a +e main problem related to this kind of investigation, as Gram-negative strict anaerobe bacterium, is able, for in- focused by Gundrum [8] in 1921, “is the inability to tell stance, to adhere to the surfaces and may dysregulate the whether a given focus is related in a causal way with the immunologic response at the gingival-epithelial interface. Its symptoms complained of”; moreover, the death and the virulence factors help to penetrate into the subepithelial subsequent revival of the focal theory may be, respectively, interface and represent a key factor that helps the devel- related to the antibiotics discovery and to their lower ef- opment of periodontal pockets. +e connective tissues of the fectiveness due to the evolution of resistance among mi- gingiva interact with P. gingivalis and its products and ac- crobes [9]. tivate host inflammatory response [18]. P. gingivalis, again, An example may be represented by dental focal infec- may be considered as a prominent actor in the pathogenesis tions, which are extraoral manifestations caused by oral of periodontitis due to its ability to colonize the oral epi- pathogens. Pathological oral conditions, such as periapical thelium and to act as an opportunistic pathogen in the oral inflammation and periodontitis, can cause bacteremia, and environment. dissemination of oral pathogens to non-oral sites can sub- Some questions remain: mayP. gingivalis have any in- sequently cause infections in extraoral tissues and organs. fluence on systemic diseases? What could be the relationship Cardiovascular infections and brain abscesses are the most between P. gingivalis and other bacterial pathogens of the common of these. +e course of such infections can be lethal. oral cavity? Is P. gingivalis the main species involved in the In order to improve patient care, a closer collaboration pathogenicity of periodontitis? May it also play a unique role between dental and medical caregivers is necessary [10]. in focal disease? [19]. +e characteristics of a biofilm are the perpetual mod- 3. Commensalism versus Pathogenicity of the ifications of the bacteria and the role of each bacterium, Oral Flora including pathogenesis and possible distal problems. Two other examples are needed to try to answer the previous Around 1014 bacterial microorganisms are present in the full questions. body (teeth and respiratory, intestinal, and urinary tracts) Fusobacterium nucleatum is one of the most common and around half of them are commensal bacteria. Equilib- anaerobic Gram-negative bacteria in the oral environment, rium is observed until, for multiple reasons, some species but it also plays a role in numerous diseases including multiplicate while others disappear [11]. +e biofilm, for different forms of periodontitis, endodontic infections and/ instance, which adheres strongly to the tooth hard surface, is or respiratory tract infections, rheumatoid arthritis, ath- a perfect and accessible model to be studied. +is biofilm is erosclerosis, and gastrointestinal problems. It is a good embedded in a self-generated extracellular matrix of poly- example for the comprehension of focal infection [20]. Its saccharides, and this matrix takes around 85% of the volume opportunistic “comportment” is observed when linked with of the dental plaque [12]. prevalence that increases with the severity of the disease Moreover, this matrix acts as a diffusion barrier and (oral or non-oral). Fusobacterium (there are 5 subspecies) inhibits binding of some antibiotics. +us, bacteria orga- has been, for a long period, considered as a commensal nized in biofilms might escape host immune systems [13] bacterium implicated in the oral biofilm and more specifi- and are protected from ecological competition
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