Relationship between gingival crevicular fluid levels of aspartate aminotransferase and active tissue destruction in treated chronic periodontitis patients

Discrepancies in periodontitis classification among dental practitioners with different educational backgrounds

Background

The 2018 classification of periodontal disease characterizes the disease with a multidimensional staging and grading system. The purpose of this multicenter study was to examine variations in periodontitis classification among dental practitioners with different postgraduate educational backgrounds at the University of Maryland School of Dentistry and the Loma Linda University School of Dentistry using the 2018 classification.

Methods

This cross-sectional observational study included two cohorts: dental practitioners with periodontal backgrounds (n₁ = 31) and those with other educational backgrounds (n₂ = 33). The survey instrument contained three periodontitis cases presented with the guideline of the 2018 classification and a questionnaire including closed and open-ended questions. The participants were asked to review each case and to fill out the questionnaire independently. Fisher’s exact test was conducted to examine the differences in responses between the two cohorts. Polychoric correlations were calculated to examine the relation between the level of familiarity with the 2018 classification and the accuracy of the classification.

Results

The distribution of item responses was significantly different between the two cohorts regarding only one item, grading for Case 1 (p = 0.01). No significant differences in accuracy between the two cohorts were observed except for two items, grading in Case 1 (p = 0.03) and staging in Case 3 (p = 0.04). There were no significant differences in risk factor identification for each case among the two cohorts (p = 1.00, Case 1; p = 0.22, Case 2). Staging in Case 3

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Conclusion

A fair level of agreement in periodontitis classification was observed among dental practitioners with different educational backgrounds when the 2018 classification was used. The periodontal cohort showed better agreement levels and partially better accuracy. Risk factor identification for periodontal disease was difficult regardless of the educational background.

Hepatitis C Infection and Periodontal Disease: Is there a Common Immunological Link?

Hepatitis C virus (HCV) infections could have an important impact on the oral health status of patients, favoring conditions such as periodontal disease and oral cancer. The review of the existing scientific literature written in English was performed, searching for oral and periodontal manifestations of HCV infection and its impact on the oral fluids. HCV infection can determine direct extrahepatic manifestations at the oral and periodontal level including oral lichen planus, Sjögren-like sialadenitis, and oral cancer. The changes caused by the infection in the subjects' immune system, diet, and lifestyle can facilitate the development of oral conditions such as periodontal disease. Important changes also occur in the composition of the infected patients' saliva and gingival fluid. HCV-infected patients need to be carefully monitored in terms of oral health since the infection with the virus can result in oral complications. The cellular and molecular particularities of the gingival fluid of HCV-infected patients can answer some questions regarding its impact upon periodontium impairment and whether this refers to a possible bidirectional relationship, with hepatic biomarker adjustments being induced by the periodontal patients' inflammatory status.

Point of Care- A Novel Approach to Periodontal Diagnosis-A Review

Periodontal disease, one of the prevalent oral diseases, is characterized by gingival inflammation and periodontal tissue destruction. Diagnosing this disease is challenging to the clinicians as the disease process is discontinuous and shows periods of exacerbation and remission. Traditional diagnostic methods basically tells about the past tissue destruction so new diagnostic methods are required which is able to detect the active state of the disease, determine the future progression and also estimates the response to the therapy, thereby helping in the better clinical management of the patient. Both saliva and Gingival crevicular fluid (GCF) are believed to be reliable medium to detect the biomarkers which plays a pivotal role in measuring the disease activity. Keeping these observations in mind rapid chairside tests are developed to diagnose periodontal disease called as Point of Care (POC) diagnostics which simplifies diagnosis and helps in improving the prognosis. This review article highlights about the biomarkers used in the diagnosis and throws light on the various available point of care diagnostic devices.

Gingival crevicular fluid alkaline phosphate activity during the retention phase of maxillary expansion in prepubertal subjects: A split-mouth longitudinal study

INTRODUCTION

The aim of this study was to monitor the alveolar bone formation at the tension sites of teeth supporting the appliances for rapid maxillary expansion (RME) during the retention phase according to the local gingival crevicular fluid (GCF) alkaline phosphatase (ALP) activity.

METHODS

This split-mouth prospective study included 23 prepubertal subjects (15 girls, 8 boys; mean age, 9.0 ± 1.4 years) who had a constricted maxillary arch and were undergoing RME. Periodontal parameters, including probing depth, were recorded at 3 and 6 months after RME. Furthermore, the GCF ALP activity was measured at the tension sites of the supporting test teeth (TT) and at the antagonist control teeth (CT) sites.

RESULTS

Periodontal parameters were generally similar between the TT and CT sites during the study, with the exception that probing depth underwent a slight increase at the TT sites. At baseline, the GCF ALP activity was similar between the TT and CT sites; however, at both 3 and 6 months, significantly greater enzymatic activity was seen at the TT sites. The overall probing depth changes were not significantly correlated with the corresponding GCF ALP activity changes for either the TT or the CT sites.

CONCLUSIONS

Alveolar bone formation at the tension sites would last up to 6 months of retention after RME. These results warrant more comprehensive studies to assess whether the GCF ALP activity has potential as a diagnostic tool for bone formation during the retention phase of RME.

Association of Periodontal Diseases and Liver Fibrosis in Patients With HCV and/or HBV infection

BACKGROUND

Periodontal disease and systemic health are closely associated. However, there is no data supporting the association between periodontal disease and patients with liver diseases associated with hepatitis C virus (HCV) and/or hepatitis B virus (HBV) infection.

OBJECTIVES

The aim of this study was to evaluate the association between periodontitis and progression of liver diseases in patients with HCV and/or HBV infection.

PATIENTS AND METHODS

In this retrospective study, 351 patients with HCV- and/or HBV-related liver diseases underwent screening for periodontal disease using the Salivaster® salivary occult blood test from February 2010 to June 2014. Furthermore, we examined the prevalence of fimbrillin (fimA) genotype of Porphyromonas gingivalis (P. gingivalis) in 28 HCV-infected patients visited at our hospital between January 2013 and June 2014. P. gingivalis with fimA genotype with types I to V was further detected using a PCR method.

RESULTS

Of 351 patients, 76 patients (group 1) had a strong positive result for salivary occult blood test and 275 patients (group 2) had weak positive or negative test results. Significant factors between the groups were obesity, level of AST, ALT, LDH, ALP, Alb, D.Bil, T.cho, AFP, platelets (Plt), IRI, HOMA-IR, current interferon (IFN) treatment and the daily frequency of tooth brushing. Between-groups analysis indicated that total protein (T.pro) level and liver fibrosis were significant factors. According to multivariate analysis, five factors were associated with periodontal disease as Plt count below 80000, brushing teeth only once a day, current IFN treatment, aged 65 years or older and obesity. The adjusted odds ratios for these five factors were 5.80, 3.46, 2.87, 2.50 and 2.33, respectively, and each was statistically significant. Twenty-eight saliva specimens had positive results for P. gingivalis with fimA genotype types I to V. The prevalence of fimA genotype II was higher in 14 patients with liver cirrhosis or a history of hepatocellular carcinoma treatment (group B, 50.00%) than 14 patients with only hepatitis C (group A, 21.43%).

CONCLUSIONS

Periodontitis might be associated with progression of viral liver disease; hence, controlling oral disease is essential for the prevention and management of liver fibrosis.

Biological response at the cellular level within the periodontal ligament on application of orthodontic force - An update

Orthodontic force elicits a biological response in the tissues surrounding the teeth, resulting in remodeling of the periodontal ligament and the alveolar bone. The force-induced tissue strain result in reorganization of both cellular and extracellular matrix, besides producing changes in the local vascularity. This in turn leads to the synthesis and release of various neurotransmitters, arachidonic acid, growth factors, metabolites, cytokines, colony-stimulating factors, and enzymes like cathepsin K, matrix metalloproteinases, and aspartate aminotransferase. Despite the availability of many studies in the orthodontic and related scientific literature, a concise integration of all data is still lacking. Such a consolidation of the rapidly accumulating scientific information should help in understanding the biological processes that underlie the phenomenon of tooth movement in response to mechanical loading. Therefore, the aim of this review was to describe the biological processes taking place at the molecular level on application of orthodontic force and to provide an update of the current literature.

To estimate salivary aspartate aminotransferase levels in chronic gingivitis and chronic periodontitis patients prior to and following non-surgical periodontal therapy: A clinico-biochemical study

Context:

Saliva can be used as a diagnostic fluid in dentistry. Various enzymes have been proposed as markers for periodontal destruction. One of them is aspartate aminotransferase, for which salivary analysis can offer a cost-effective approach for monitoring the disease. Changes in enzymatic activity reflect metabolic changes in the gingiva and periodontium in inflammation.

Aims:

The purpose of this study was to assess the aspartate aminotransferase levels in saliva prior to and following scaling and root planning (SRP) at 1 month and 3 month interval and correlating it with the clinical parameters in generalized chronic gingivitis and chronic periodontitis patients.

Materials and Methods:

Thirty patients with generalized chronic gingivitis and 30 with generalized chronic periodontitis were selected. The activity of aspartate aminotransferase levels in saliva were assessed biochemically before and after SRP at 1 month and 3 months. The aspartate aminotransferase levels were correlated with clinical parameters (gingival index and probing depth).

Statistical Analysis Used:

A paired t test was done.

Results:

A decrease in gingival index, probing depth, and aspartate aminotransferase levels were seen in both the groups at 1 and 3 months which was found to be statistically highly significant (P value 0.00). Aspartate aminotransferase levels were statistically significantly correlated with the clinical parameters at baseline (P < 0.05) but at 3 months, a positive correlation was seen in both the groups which was statistically insignificant (P > 0.05).

Conclusions:

Elevated salivary aspartate aminotransferase levels were seen in generalized chronic gingivitis and chronic periodontitis patients, with higher values recorded in generalized chronic periodontitis correlating to the tissue destruction taking place in these conditions.

Periodontal proteomics: wonders never cease!

Proteins are vital parts of living organisms, as they are integral components of the physiological metabolic pathways of cells. Periodontal tissues comprise multicompartmental groups of interacting cells and matrices that provide continuous support, attachment, proprioception, and physical protection for the teeth. The proteome map, that is, complete catalogue of the matrix and cellular proteins expressed in alveolar bone, cementum, periodontal ligament, and gingiva, is to be explored for more in-depth understanding of periodontium. The ongoing research to understand the signalling pathways that allow cells to divide, differentiate, and die in controlled manner has brought us to the era of proteomics. Proteomics is defined as the study of all proteins including their relative abundance, distribution, posttranslational modifications, functions, and interactions with other macromolecules, in a given cell or organism within a given environment and at a specific stage in the cell cycle. Its application to periodontal science can be used to monitor health status, disease onset, treatment response, and outcome. Proteomics can offer answers to critical, unresolved questions such as the biological basis for the heterogeneity in gingival, alveolar bone, and cemental cell populations.

Enzymatic evaluation of gingival crevicular fluid in cleft palate patients during orthodontic treatment: A clinico-biochemical study

Background:

Therapeutic goal in patients with cleft lip and palate is esthetics and long-term health of the stomatognathic system. Patients with cleft lip and palate routinely require extensive and prolonged orthodontic treatment. The osseous structures are absent or poorly developed in the osseous clefts and may be traumatized in the course of orthodontic therapy; hence require constant monitoring during orthodontic treatment. The aim of the study was to evaluate the tissue response of cleft palate patients by quantitative analysis of enzyme activity during orthodontic treatment and assess any difference in the tissue response with that of noncleft patients undergoing orthodontic treatment.

Materials and Methods:

20 patients requiring orthodontic treatment agedbetween 15 to 25 years were included to participate in the studyof which ten were cleft palate patients (group I) and ten noncleft patients (group II). The GCF samples were collected at incisor and molar sites during orthodontic treatment on days as per the study design in both the groups. The GCF enzymatic levels were estimated and compared.

Results:

Both groups showed significant increased enzyme activity at the incisor site compared to molar site corresponding to the phases of tooth movement.

Conclusion:

There was significant difference in enzyme activity between the incisor adjacent to the cleft site and molar site. There was no difference in the tissue response between cleft palate patients and noncleft patients during orthodontic treatment.

Presence of Aspartate Aminotransferase in Peri-Implant Crevicular Fluid With and Without Mucositis

The aim of this study was to assess the presence of aspartate aminotransferase (AST) in peri-implant crevicular fluid, with or without clinical signs of mucositis, to determine its predictive diagnostic value, sensitivity, and specificity. The AST levels were determined (at a threshold of 1200 µIU/mL) for 60 clinically successful implants in 25 patients with or without peri-implant mucositis. Samples were taken prior (AST1) to peri-implant probing with a manual constant-pressure probe (0.2 N) and 15 minutes after probing (AST2). Clinical assessments included radiographic determination of preexisting bone loss, probing, and the evaluation of mucositis, plaque, and bleeding upon probing. Analysis was performed at both the level of the implant and the patient as a unit. We detected a significant difference between AST1 and AST2 at both levels. A significant difference was observed at AST1 between implants that bled upon probing and those that did not. However, when we considered the patient as a unit, there were no significant differences. The plaque index was not significant at either level. AST1 had high specificity and positive predictive diagnostic value (80%) for bleeding upon probing. Probing induces a greater release of AST from inflamed tissues compared with healthy tissues in situ but not at the systemic level. At the implant level, the implant position could be responsible for this difference. Aspartate aminotransferase was a reliable predictor of patients with mucositis.

Rheumatoid arthritis and periodontitis - inflammatory and infectious connections. Review of the literature

An association between oral disease/periodontitis and rheumatoid arthritis (RA) has been considered since the early 1820s. The early treatment was tooth eradication. Epidemiological studies suggest that the prevalence of RA and periodontitis may be similar and about 5% of the population are aged 50 years or older. RA is considered as an autoimmune disease whereas periodontitis has an infectious etiology with a complex inflammatory response. Both diseases are chronic and may present with bursts of disease activity. Association studies have suggested odds ratios of having RA and periodontitis varying from 1.8:1 (95% CI: 1.0–3.2, NS) to 8:1 (95% CI: 2.9–22.1, p<0.001). Genetic factors are driving the host responses in both RA and periodontitis. Tumor necrosis factor-α, a proinflammatory cytokine, regulates a cascade of inflammatory events in both RA and periodontitis. Porphyromonas gingivalis is a common pathogen in periodontal infection. P. gingivalis has also been identified in synovial fluid. The specific abilities of P. gingivalis to citrullinate host peptides by proteolytic cleavage at Arg-X peptide bonds by arginine gingipains can induce autoimmune responses in RA through development of anticyclic citrullinated peptide antibodies. In addition, P. gingivalis carries heat shock proteins (HSPs) that may also trigger autoimmune responses in subjects with RA. Data suggest that periodontal therapies combined with routine RA treatments further improve RA status.

Diagnosis and classification of periodontal disease

Periodontal diseases have been recognized and treated for at least 5000 years. Clinicians have recognized for many years that there are apparent differences in the presentation of periodontal diseases and have attempted to classify these diseases. Systems of classifications of disease have arisen allowing clinicians to develop structures which can be used to identify diseases in relation to aetiology, pathogenesis and treatment. It allows us to organize effective treatment of our patients' diseases. Once a disease has been diagnosed and classified, the aetiology of the condition and appropriate evidence-based treatment is suggested to the clinician. Common systems of classification also allow effective communication between health care professionals using a common language. Early attempts at classification were made on the basis of the clinical characteristics of the diseases or on theories of their aetiology. These attempts were unsupported by any evidence base. As scientific knowledge expanded, conventional pathology formed the basis of classification. More recently, this has been followed by systems of classification based upon our knowledge of the various periodontal infections and the host response to them. Classification of periodontal diseases has, however, proved problematic. Over much of the last century clinicians and researchers have grappled with the problem and have assembled periodically to review or develop the classification of the various forms of periodontal disease as research has expanded our knowledge of these diseases. This has resulted in frequent revisions and changes. A classification, however, should not be regarded as a permanent structure. It must be adaptable to change and evolve with the development of new knowledge. It is expected that systems of classification will change over time. This review examines the past and present classifications of the periodontal diseases.

Current developments in salivary diagnostics

Salivary diagnostics is an emerging field that has progressed through several important developments in the past decade, including the publication of the human salivary proteome and the infusion of federal funds to integrate nanotechnologies and microfluidic engineering concepts into developing compact point-of-care devices for rapid analysis of this secretion. In this article, we discuss some of these developments and their relevance to the prognosis, diagnosis and management of periodontitis, as an oral target, and cardiovascular disease, as a systemic example for the potential of these biodiagnostics. Our findings suggest that several biomarkers are associated with distinct biological stages of these diseases and demonstrate promise as practical biomarkers in identifying and managing periodontal disease, and acute myocardial infarction. The majority of these studies have progressed through biomarker discovery, with the identified molecules requiring more robust clinical studies to enable substantive validation for disease diagnosis. It is predicted that with continued advances in this field the use of a combination of biomarkers in multiplex panels is likely to yield accurate screening tools for these diagnoses in the near future.

The impact of the stone age diet on gingival conditions in the absence of oral hygiene

BACKGROUND

The objective of this study was to assess the oral microbiota and clinical data in subjects without access to traditional oral hygiene methods and who ate a diet available in the Stone Age.

METHODS

Ten subjects living in an environment replicating the Stone Age for 4 weeks were enrolled in this study. Bleeding on probing (BOP), gingival and plaque indices, and probing depth (PD) were assessed at baseline and at 4 weeks. Microbiologic samples were collected at the mesio-buccal subgingival aspects of all teeth and from the dorsum of the tongue and were processed by checkerboard DNA-DNA hybridization methods.

RESULTS

No subject had periodontitis. Mean BOP decreased from 34.8% to 12.6% (P <0.001). Mean gingival index scores changed from 0.38 to 0.43 (not statistically significant) and mean plaque scores increased from 0.68 to 1.47 (P <0.001). PD at sites of subgingival sampling decreased (mean difference: 0.2 mm; P <0.001). At week 4, the total bacterial count was higher (P <0.001) for 24 of 74 species, including Bacteroides ureolyticus, Eikenella corrodens, Lactobacillus acidophilus, Capnocytophaga ochracea, Escherichia coli, Fusobacterium nucleatum naviforme, Haemophilus influenzae, Helicobacter pylori, Porphyromonas endodontalis, Staphylococcus aureus (two strains), Streptococcus agalactiae, Streptococcus anginosis, and Streptococcus mitis. Bacterial counts from tongue samples were higher at baseline (P <0.001) for 20 species, including Tannerella forsythia (previously T. forsythensis), Aggregatibacter actinomycetemcomitans (previously Actinobacillus actinomycetemcomitans; serotype a), and Streptococcus spp.

CONCLUSIONS

The experimental gingivitis protocol is not applicable if the diet (e.g., Stone Age) does not include refined sugars. Although plaque levels increased, BOP and PD decreased. Subgingival bacterial counts increased for several species not linked to periodontitis, whereas tongue bacterial samples decreased during the study period.

Analysis of gingival crevicular fluid as applied to the diagnosis of oral and systemic diseases

Gingival crevicular fluid (GCF), a serum transudate or inflammatory exudate, can be collected from the gingival crevice surrounding the teeth. As such, the fluid reflects the constituents of serum, the cellular response in the periodontium, and contributions from the gingival crevice. The study of GCF has focused on defining the pathophysiology of periodontal disease, and identification of a potential diagnostic test for active periodontitis. The majority of markers that have been identified as potential candidates for such a test are measures of inflammation (i.e., prostaglandin E2 (PGE2), neutrophil elastase, and the lysosomal enzyme beta-glucuronidase). Further, analysis of inflammatory markers in GCF may assist in defining how certain systemic disorders (e.g., diabetes mellitus) can modify periodontal disease, and how periodontal disease/periodontal inflammation can influence certain systemic disorders (i.e., cardiovascular/cerebrovascular diseases). Methodological concerns related to the collection and analysis of GCF are important factors that need to be considered when studying GCF. Practical concerns argue against the widespread clinical application of GCF as an adjunct to periodontal diagnosis. Rather, analysis of GCF-derived mediators in saliva may serve as a means of rapid screening for periodontal disease.

Effect of Follow‐Up Intervention of Toothbrushing on Periodontal Health in Workplace Dental Examination

This study examined the effect of follow-up intervention on periodontal health of workers on the basis of clinical assessment and a laboratory test. Toothbrushing instruction was given to 26 workers (41.4 +/- 7.8 yr of age). In the experimental group (EG), 13 workers received re-instruction and reminder messages after the initial intervention. The remaining 13 workers, who served as a control group (CG), underwent no follow-up. Brushing skill was assessed on the basis of plaque scores for the whole mouth (Plaque Control Record, PCR) and for eight representative teeth (Plaque Index, PLI). Periodontal health was evaluated with the Community Periodontal Index (CPI). Assessment of gingival inflammation (Modified Gingival Index, MGI), measurements of pocket depth (PD) and attachment level (AL), and collection of gingival crevicular fluid (GCF) were performed at the representative sites. Aspartate aminotransferase (AST) in GCF was determined. Periodontal assessments were conducted prior to and three months after the first examination. Data were analyzed on site- and subject-bases. Both groups exhibited a significant reduction in PLI and MGI. PCR and PD significantly decreased exclusively in the EG. No significant change was observed in the CPI or AL. A significant reduction in PD in shallow pockets (PD<=3 mm) and declines in AL and AST in deeper pockets (PD>=4 mm) were detected in EG. A reduction in PD in deeper pockets was significant in the CG. These results indicate that intervention with follow-up is more effective with respect to periodontal health of workers than is a single intervention; moreover, the laboratory GCF test could be employed to ascertain the outcome of behavioral change.

Association of gingival crevicular fluid and serum intracytoplasmic enzyme levels in periodontally healthy homozygous (major) beta-thalassemia patients

OBJECTIVE

To assess tissue necrosis in beta-thalassemia major patients, as in other areas of medicine, lactate dehydrogenase (LDH), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) have been widely used. These markers of tissue degradation have also been studied in the gingival crevicular fluid (GCF) in relation to periodontal disease status. The purpose of this study was to investigate whether periodontal diagnostic tests based on these markers of tissue degradation are influenced from the enzymes' levels in serum and, therefore, could be used in the assessment of the patient's periodontal status.

MATERIAL AND METHODS

Forty-four periodontally healthy, homozygous beta-thalassemia patients were enrolled in the study. GCF and serum samples were obtained and the levels of AST, ALT and LDH were determined; the measurements took place in an automated analyzer (Hitachi 777) using the kits of Roche Company.

RESULTS

Lack of correlations between serum and GCF enzyme levels was demonstrated. Serum LDH and serum AST, serum AST and serum ALT are significantly positively correlated. Concerning the GCF, AST and ALT were proved to be significantly positively correlated.

CONCLUSIONS

Elevated values of LDH, ALT and AST in serum do not constitute a confounding factor in GCF measurements of the respective enzymes.

Longitudinal monitoring of subgingival colonization by Actinobacillus actinomycetemcomitans, and crevicular alkaline phosphatase and aspartate aminotransferase activities around orthodontically treated teeth

OBJECTIVES

During orthodontic treatment, changes in subgingival plaque colonization and tissue inflammation and remodelling have been described. This study uses a longitudinal design to examine subgingival colonization of Actinobacillus actinomycetemcomitans (Aa) and alkaline phosphatase (ALP) and aspartate aminotransferase (AST) activities in gingival crevicular fluid (GCF) in order to assess whether these parameters have potential as biomarkers of tissue responses to orthodontic tooth movement in humans.

MATERIALS & METHODS

Twenty-one patients (ages: 11.2-22.5; mean 17.1 +/- 3.3 years) participated in the study. An upper canine from each patient undergoing treatment for distal movement served as the test tooth (DC), and its contralateral (CC) and antagonist (AC) canines were used as controls. The CC was included in the orthodontic appliance, but was not subjected to the orthodontic force; the AC was free from any orthodontic appliance. The subgingival plaque and GCF around the experimental teeth was harvested from both mesial and distal tooth sites immediately before appliance activation and on day 28. Clinical gingival condition was evaluated at the baseline and at the end of the experimental period. Aa colonization was determined by culture methods, while ALP and AST activities were evaluated spectrophotometrically.

RESULTS

Throughout the study, the clinical conditions worsened in both the DCs and the CCs as compared with the baseline, whereas no significant differences were found between the DCs and the CCs, or between mesial and distal sites of each of these teeth on day 28. In the ACs, clinical parameters remained at baseline levels throughout the study. Similar results were found for Aa colonization, which increased significantly on day 28 in the DC and CC groups. On day 28, ALP and AST activities were significantly elevated in all sites from the DC and CC groups as compared with the ACs, where, conversely, enzymatic activities remained at the baseline levels. However, ALP activity in the DC group was significantly greater than in the CCs at mesial (tension) sites on day 28, while AST activity in the DCs was significantly elevated as compared with the CC group at the distal (compression) sites. Greater ALP activity in the DC group was observed at the tension sites compared with the compression sites on day 28.

CONCLUSIONS

Our results suggest that Aa subgingival colonization, and ALP and AST activities in GCF reflect the tissue responses that occur in the periodontium during orthodontic treatment.

Gingival crevicular fluid levels of aspartate amino transferase, sulfide ions and N-benzoyl-DL-arginine-2-naphthylamide in diabetic patients with chronic periodontitis

BACKGROUND

The aim of this study is to analyze the correlations between plaque index (PlI), gingival index (GI), probable pocket depth (PPD), clinical attachment level (CAL), aspartate aminotransferase (AST), N-benzoyl-DL-arginine-2-naphthylamide (BANA) and sulfide ion activity (SIA) of diabetic patients with chronic periodontitis with regard to disease activity detected by AST levels.

MATERIAL AND METHODS

A total of 95 sites from eight diabetic patients with chronic periodontitis and 74 sites from eight systemically healthy patients with chronic periodontitis were enrolled in the study. The patients had no history of periodontal treatment or any antibiotic therapy during the last 6 months and were nonsmokers. All the sites selected for the study had a CAL of at least 2 mm. Gingival crevicular fluid volumes (GCFV) were measured in all sites.

RESULTS

According to the result of AST analysis, 45 sites were AST positive and 50 were AST negative in the diabetic group and 36 sites were AST positive and 38 were AST negative in the control group. There was a significant correlation between BANA hydrolysis and PPD in both diabetic and control groups, but no correlation between PPD and AST levels. A significant correlation was observed between AST-positive sites and GI, but not between GI and BANA hydrolysis. In both groups, the correlation between SIA and BANA hydrolysis was significant, but no correlation was revealed between SIA and AST levels in either diabetic or control groups.

CONCLUSION

The GCF metabolites had significant correlations with periodontally diseased sites in patients with chronic periodontitis, whether diabetic or systemically healthy, and may help to confirm clinical findings.

Aspartate aminotransferase activity in pulp of orthodontically treated teeth

This study examines the aspartate aminotransferase activity in the pulp of orthodontically treated teeth. Seventeen healthy male and female subjects (ages: 14.5-19.6; mean 16.8 +/- 1.6 years) who needed extraction of the maxillary first premolars for orthodontic reasons were enrolled in the study. One randomly chosen maxillary first premolar, included in a straight-wire fixed orthodontic appliance and supporting orthodontic force, was considered as the test tooth. The contralateral first premolar, included in the orthodontic appliance but not subjected to mechanical stress, was used as the control tooth. After a week of treatment, the dental pulp tissues were extracted from both experimental teeth. Aspartate aminotransferase activity was significantly elevated in the test teeth as compared with the control teeth. These results demonstrate that in the early phases of treatment, orthodontic force application to the teeth can lead to significant metabolic changes in the pulp of these teeth.

Position Paper: Diagnosis of Periodontal Diseases

At the present time, the diagnosis and classification of periodontal diseases are almost entirely based on traditional clinical assessments. Supplemental quantitative and qualitative assessments of the gingival crevicular fluid and subgingival microflora can potentially provide useful information about the patient's periodontal disease. In certain situations, these supplemental risk-assessment tests may be particularly valuable in establishing the endpoint of therapy prior to placing patients on a periodontal maintenance program. Although the clinical utility of none of these tests has been validated, their further development is warranted. A genetic test for susceptibility to periodontitis has become commercially available. How best to use this and future host-based tests in clinical practice remains to be determined. Probing depth and clinical attachment loss measurements obtained with periodontal probes are practical and valid methods for assessing periodontal status. Computer-linked, controlled-force electronic periodontal probes are commercially available and are currently in use by some practitioners. Many of the logistical problems associated with subtraction radiography are being overcome and this powerful diagnostic tool may soon come into widespread use. Future developments in this and other imaging techniques are likely to have a profound effect on our approach to the diagnosis of periodontal diseases.

Levels of aspartate aminotransferase (AST) in saliva of patients with different periodontal conditions

OBJECTIVES

The purpose of this study was to evaluate the relationship between aspartate aminotransferase (AST) levels in saliva measured by Reflotron trade mark System of Diagnosis and periodontal condition indicated by Community Periodontal Index of Treatment Needs (CPITN).

MATERIAL AND METHODS

Fifteen patients were assigned to one of four groups C0, C1, C3 and C4, based on their largest CPITN code among the examined sites, totaling 60 participants. About 1.0 ml of non-stimulated saliva was collected from the individuals after a mouth rinse with water. Biochemical analyses of saliva samples were carried out using the proposed system in order to quantify their AST concentration.

RESULTS

There were no significant differences between levels (U/ml) of AST (median; interquartile range) from groups C0 (30.9; 14.7-41.7), C1 (30.3; 19.5-39.4) and C3 (35.1; 27.0-63.5). However, group C4 (106.2; 84.4-129.7) differed statistically from the others (p<0.001) and presented AST levels as high as 284.2 U/ml. Gingival bleeding and suppuration were observed in three individuals with concentrations higher than 125.0 U/ml.

CONCLUSION

Levels of AST in saliva from patients presenting CPITN code 4 were higher than from patients coded lower and could be detected by the evaluated diagnostic system. Periodontal destruction such as periodontal pockets, gingival bleeding and suppuration seems to be related to higher AST levels in saliva.

Aspartate aminotransferase activity in gingival crevicular fluid during orthodontic treatment. A controlled short-term longitudinal study

BACKGROUND

During orthodontic tooth movement, the early response of periodontal tissues to mechanical stress involves an acute inflammatory response, with a sequence characterized by periods of activation, resorption, reversal, and formation in both tension and compression sites. This study used a longitudinal design to examine aspartate aminotransferase (AST) activity in gingival crevicular fluid (GCF) in order to assess whether AST in GCF has potential as a possible diagnostic aid to monitor tooth movement and tissue response during orthodontic treatment.

METHODS

Eighteen patients (mean age, 16.1 years) participated in the study. An upper first molar from each patient undergoing treatment for distal movement served as the test tooth (TT), with its contralateral (CC) and antagonist (AC) first molars used as controls. The CC was included in the orthodontic appliance, but was not subjected to the orthodontic force; the AC was free from any orthodontic appliance. The GCF around the experimental teeth was collected from both mesial and distal tooth sites immediately before appliance activation, 1 hour after, and weekly over the following 4 weeks. Clinical gingival condition was evaluated at baseline and at the end of the experimental period. AST activity was determined spectrophotometrically at 30 degrees C, and the results were expressed as total AST activity (mU/sample).

RESULTS

Throughout the experiment, AST levels were significantly elevated in all sites from the TT and CC groups compared to the AC group where, conversely, AST activity remained at the baseline level. However, enzyme levels in the TT group were significantly greater than in the CCs at tension sites on day 14, and in compression sites on days 7 and 14. Moreover, AST activity from the TT group was significantly greater in compression sites than in tension sites on day 7; this was not observed for the CCs.

CONCLUSIONS

Our results suggest that AST levels in GCF reflect the biological activity which occurs in the periodontium during controlled occlusal trauma and, therefore, should be further evaluated as a diagnostic tool for monitoring correct orthodontic tooth movement in clinical practice.

Association of early onset periodontitis microbiota with aspartate aminotransferase activity in gingival crevicular fluid

OBJECTIVES

The objective of this study was to determine the relationship between the activity of the enzyme aspartate aminotransferase (AST) in gingival crevicular fluid (GCF) using the colorimetric PerioGard (PTM) test and the subgingival microflora in early onset periodontitis lesions.

MATERIAL AND METHODS

The study population consisted of 25 otherwise healthy individuals exhibiting early onset periodontitis (EOP). In each patient four experimental sites were identified comprising one deep periodontal pocket (PD >5 mm) randomly chosen in each quadrant. Bacterial samples were obtained from the experimental sites, consecutively cultured anaerobically and in 10% CO(2) using selective and nonselective media. Isolates were characterized to species level by conventional biochemical tests and various identification kits. Clinical measurements as well as AST activity, assessed either as positive or negative using the PTM, were recorded at the same sites.

RESULTS

Sixty-two sites exhibited AST positive and 38 AST negative activity. Analysis of bacterial counts using the ANOVA (Mann Whitney U-test) showed that Streptococcus intermedius, Peptostreptococcus micros, Campylobacter concisus, Bacteroides forsythus, Camplobacter gracilis, Campylobacter rectus and Selenomonas sputigena were significantly higher in sites with AST-positive activity. The odds ratio of having high prevalence of S. intermedius, P. micros, C. concisus, B. forsythus, C. gracilis, C. rectus and S. sputigena in the presence of a positive AST site was very high (range: 3.5-17.0). Streptococcus sanguis, Actinomyces naeslundii, Gemella morbillorum, Capnocytophaga gingivalis, Veillonella parvula, Fusobacterium varium, Eubacterium lentum and Prevotella oralis were detected in significantly higher proportions in sites with AST negative activity and manifested a negative odds ratio in the presence of AST positive sites. The logistic regression analysis revealed that smoking and bleeding upon probing showed a significant association with AST activity, while plaque and suppuration were not found to be significant predictors of AST activity. The co-infection of Porphyromonas gingivalis, B. forsythus and P. micros, or P. gingivalis, B. forsythus and C. rectus were found to be significantly associated with the AST activity (p<0.001). AST positive sites revealed significantly higher occurrence of co-infections by P. gingivalis, B. forsythus, S. sputigena or by P. gingivalis, B. forsythus, S. intermedius than AST negative sites (p<0.001). P. gingivalis, B. forsythus, A. naeslundii co-infection was found significantly higher in the AST negative sites (p<0.001).

CONCLUSIONS

The present study found a high level of agreement between the presence of putative periodontal pathogens and positive AST scores at periodontal sites that clinically were considered to be potentially disease active. Prospective studies should be performed to confirm the findings.

Relationship between crevicular aspartate aminotransferase levels and periodontal disease progression

BACKGROUND

Aspartate aminotransferase (AST), an enzyme released from necrotic cells, has been identified in gingival crevicular fluid (GCF), and elevated levels are associated with periodontal tissue destruction. The aim of this study was to examine the relationship between elevated GCF levels of AST and periodontal disease progression.

METHODS

Over a 12-month period, 8 to 10 interproximal sites in 41 periodontitis subjects (PS) and 15 healthy subjects (HS) were monitored. Clinical measurements included relative attachment level (RAL), probing depth, and bleeding on probing (BOP). Semiquantitative levels of GCF AST (< 800 microIU, > or = 800 microIU, and > or = 1,200 microIU) were determined using a chairside assay. At the 6- and 12-month visits, scaling and root planing and prophylaxis were performed in the PS and HS, respectively. Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) were calculated for 2 diagnostic criteria (AST > or = 800 microIU, AST > or = 1,200 microIU) utilizing 4 thresholds of disease progression as determined by 2 methods (absolute change in relative attachment level and cumulative sum [CUSUM]).

RESULTS

The percentage of sites exhibiting AST > or = 800 microIU, AST > or = 1,200 microIU, and BOP in the PS was significantly (P<0.02) lower at 6 and 12 months compared to baseline. The use of crevicular AST activity to monitor periodontal disease progression was associated with many false-positive results. Overall, low specificities, PPV, and odds ratios were demonstrated by the assay when using 2 diagnostic criteria and 4 thresholds of disease progression. The high NPV suggest that a negative AST test result was indicative of a periodontally stable site.

CONCLUSIONS

These results demonstrate that elevated levels of AST were present at sites that did not subsequently exhibit disease progression. The high prevalence of AST-positive sites due to gingival inflammation diminished the test's ability to discriminate between progressive and stable, but inflamed, sites.

Aspartate aminotransferase activity in crevicular fluid from dental implants

BACKGROUND

Aspartate aminotransferase (AST) is an enzyme normally confined to the cytoplasm of cells, but released to the extracellular environment upon cell death. Its levels are associated with the severity of experimental gingivitis and the loss of periodontal attachment. The aim of the present study was to investigate the presence and activity levels of AST in peri-implant crevicular fluid (PCF) from healthy and diseased endosseous implants in order to assess if AST in PCF can be further studied as a possible objective diagnostic aid in oral implantology.

METHODS

Eighty-one fixtures from 81 systemically healthy subjects were divided into 3 groups, 27 healthy implants (HI), 27 implants with mucositis (MI) and 27 implants affected by peri-implantitis (PI) according to well-defined clinical and radiographic criteria. PCF was collected by the insertion of a #40 standardized endodontic paper point to the base of the crevice or pocket for 30 seconds. AST activity was determined spectrophotometrically at 25 degrees C. The results were expressed as AST Units/ml in PCF.

RESULTS

An AST activity was detected in each sample from HI, MI and PI. The mean AST activity in HI was 0.26 +/- 0.16 U/ml; in MI, 0.38 +/- 0.27 U/ml; in PI, 0.62 +/- 0.29 U/ml. ANOVA showed that the difference among HI, MI, and PI was statistically significant at P <0.01 level. Post-hoc tests demonstrated that a significant difference in AST activity existed between HI/PI (t = 5.14; P<0.01) and MI/PI (t = 3.09; P<0.01). No statistically significant difference was found between HI/MI (t = 1.07; P >0.1) AST activity was significantly (P <0.01) associated with probing depth (r = 0.55), the amount of bone loss (r = 0.60) and bleeding on probing (r = 0.67). When the threshold for a positive AST test was set > or =0.4 U/ml, a sensitivity = 0.81 and a specificity = 0.74 were found in the detection of peri-implantitis; the positive predictive value was 61% and the negative predictive value was 88%.

CONCLUSIONS

Within the limits of this study, our results may suggest that PCF analysis could be further investigated in longitudinal studies as a suitable diagnostic strategy in the evaluation of dental implants.

The association of calprotectin level in gingival crevicular fluid with gingival index and the activities of collagenase and aspartate aminotransferase in adult periodontitis patients

BACKGROUND

Calprotectin, a major cytosol protein of leukocytes, exists in plasma and other body fluids of healthy human subjects. Since the calprotectin concentration rises markedly in some inflammatory diseases including rheumatoid arthritis, this protein has been thought to be a marker of inflammatory disease. Recently, we identified calprotectin in human dental calculus and gingival crevicular fluid (GCF), and found that the calprotectin concentration in GCF from patients with periodontitis was significantly higher than that in GCF from healthy subjects. In the present study, the association of GCF calprotectin level with GCF volume, gingival index (GI), and levels of biochemical markers including collagenase and aspartate aminotransferase (AST) in GCF was investigated to clarify the relationship between GCF calprotectin level and periodontal inflammation.

METHODS

Ninety GCF samples collected from periodontal pockets with a probing depth of more than 4 mm in 54 patients with adult periodontitis were used for these assays. The GCF volume was measured, and GI in each site was recorded. The calprotectin content in GCF samples was determined by ELISA using a specific antibody. The activity of collagenase or AST was measured by a respective assay kit.

RESULTS

The total amount of calprotectin and GCF volume showed a highly significant correlation (r = 0.64, P <0.0001), whereas the calprotectin concentration had no correlation with the GCF volume (r = 0.01, P= 0.924). The mean calprotectin concentration in GCF increased with the degree of GI, and the concentration in individual samples was significantly correlated with the GI score (r = 0.56, P<0.0001). Significant positive correlations were observed in GCF calprotectin versus collagenase (r = 0.57, P <0.0001) and GCF calprotectin versus AST levels (r = 0.40, P <0.005).

CONCLUSIONS

From the present results and our previous findings, it is shown that the GCF calprotectin level significantly correlates not only with clinical indicators but also with current biochemical marker levels and that calprotectin may be a useful marker for periodontal inflammation.

Changes in gingival crevicular fluid levels of immunoglobulin A following therapy: association with attachment loss

BACKGROUND

In previous studies, we demonstrated that increased levels of immunoglobulin A (IgA) in gingival crevicular fluid (GCF) may be "protective", while increased levels of the polymorphonuclear lysosomal enzyme, beta-glucuronidase, in GCF were associated with increased risk of disease activity. In this study, we examined the effect of scaling and root planing (SRP) on the levels of beta-glucuronidase, IgG, and IgA in GCF over a 24-week period and compared these to clinical attachment loss (CAL).

METHODS

Twenty-nine patients with periodontal disease were examined for attachment level, probing depth, plaque, and bleeding on probing at 6 sites per tooth. GCF was collected from the mesial aspect of all teeth excluding third molars and analyzed for beta-glucuronidase, IgG, and IgA. After baseline data were collected, each patient received SRP, and GCF was collected again at 2, 4, 6, 8, 12, and 24 weeks post-SRP while clinical data were obtained at 4, 8, 12, and 24 weeks. In addition, we analyzed whether the magnitude of the IgA response to SRP would affect the rate of periodontal disease progression by examining GCF IgA levels at 2 time intervals: 2 to 4 weeks post-SRP and 6 to 12 weeks post-SRP.

RESULTS

Seventeen patients (58.6%) exhibited at least 1 site losing > or =2.5 mm of CAL during the 24-week study. Beta-glucuronidase in GCF was significantly decreased at 2 weeks following SRP and then demonstrated a gradual increase throughout the study period. Levels of IgA in GCF significantly increased following SRP, reaching a peak at 6 weeks and then gradually decreasing throughout the study. Furthermore, we found an inverse relationship between GCF IgA levels at 6 to 12 weeks post-SRP and the occurrence of CAL.

CONCLUSIONS

These results support the hypothesis that maintenance of high levels of IgA in GCF may be "protective" against periodontal attachment loss. Furthermore, levels of beta-glucuronidase appear to be a more sensitive indicator of gingival inflammation than clinical measures.

Microbiological response of localized sites with recurrent periodontitis in maintenance patients treated with tetracycline fibers

BACKGROUND

Whether adjunctive tetracycline fibers can provide an additive effect to scaling and root planing in treating non-responsive sites in maintenance subjects is still controversial. Recolonization of the bacteria from untreated sites or from the extracrevicular region may explain the insignificant response to local therapy. The purpose of the present study was to evaluate the microbiological response of sites treated with tetracycline fibers combined with scaling and root planing.

METHODS

The study was conducted in a split-mouth design. Thirty patients on maintenance therapy having at least 2 non-adjacent sites in separate quadrants with probing depths between 4 to 8 mm with bleeding on probing, or aspartate aminotransferase enzyme levels > 800 microIU in the gingival crevicular fluid, were treated with scaling and root planing plus tetracycline fibers or with scaling and root planing only. Subgingival plaque samples were collected at baseline, and 1, 3, and 6 months following treatment. A. actino-mycetemcomitans, C. rectus, B. forsythus, E. corrodens, F. nucleatum, P. gingivalis, and P. intermedia were detected by culture, immunofluorescence, or PCR technique.

RESULTS

There was a reduction of total bacterial cell count, as well as of certain periodontal pathogens, following treatment. The prevalence of A. actinomycetemcomitans, B. forsythus, and P. gingivalis and the mean proportions of C. rectus, P. intermedia, F. nucleatum, and P. gingivalis decreased after therapy, but there was no statistically significant difference between the 2 treatment groups with respect to bacterial proportions or the number of positive sites. Besides, the pathogens could not be eliminated from the periodontal pocket, and recolonization of the pocket was noted at 3 months post-treatment.

CONCLUSIONS

Bacteria located within the cheek, tongue mucosa, saliva, or untreated sites may contribute to reinfection of the pockets and explain the insignificant response to local tetracycline therapy.

Relationship of the subgingival microbiota to a chairside test for aspartate aminotransferase in gingival crevicular fluid

BACKGROUND

The aim of the present study was to evaluate the association between the occurrence of certain specific periodontal pathogens and aspartate aminotransferase (AST) levels in gingival crevicular fluid (GCF).

METHODS

Thirty systemically healthy subjects with moderate to advanced periodontitis were selected. Within each subject, the AST contents of GCF from sites with probing depth between 5 mm and 7 mm were measured using a chairside colorimetric test. AST-positive site refers to one that had an AST level > or = 800 microIU. Subgingival plaque samples from one AST-positive and one negative site were collected for microbiological examination. One site with probing depth < or = 3 mm and no gingival inflammation was selected as a healthy control. Clinical parameters of the chosen sites, including the plaque index and gingival index scores, probing depth, and clinical attachment level were measured. Culture and immunofluorescence (IF) were used for detecting common periodontal pathogens, including Actinobacillus actinomycetemcomitans, Peptostreptococcus micros, Campylobacter rectus, Eikenella corrodens, Fusobacterium nucleatum, Capnocytophaga species, Prevotella intermedia, Prevotella melaninogenica, and Porphyromonas gingivalis. Logistic regression was used to analyze the correlation between the AST test and certain specific pathogens.

RESULTS

The GCF scores and total cultivable bacterial counts were higher in AST-positive sites than either AST-negative or healthy sites. The prevalence and proportions of specific periodontal pathogens such as C rectus, E. corrodens, F. nucleatum, Capnocytophaga species, P. intermedia, and P. gingivalis were significantly higher in positive than in negative sites. In analyzing the correlation of the proportion of 6 pathogens with the AST test by logistic regression, only P. gingivalis showed a significant positive correlation. The odds ratio of having a high proportion of P. gingivalis in the presence of a positive AST test was 1.21.

CONCLUSIONS

The present study showed that at AST-positive sites, there is a higher prevalence and higher proportion of certain periodontal pathogens. Although only the correlation of P. gingivalis and AST values was statistically significant, the results imply that certain periodontal pathogens may be associated with elevation of AST levels in GCF.

Analysis of gingival crevicular fluid intracytoplasmic enzyme activity in patients with adult periodontitis and rapidly progressive periodontitis. A longitudinal study model with periodontal treatment

In the present study, the activity of 3 functionally related enzymes, creatine kinase (CK), lactate dehydrogenase (LDH), and aspartate aminotransferase (AST) levels in the rest and flow gingival crevicular fluid (rGCF, fGCF) from patients with rapidly progressive periodontitis (RPP) and adult periodontitis (AP) were determined before and after periodontal treatment, including maintenance. When rGCF and fGCF mean enzyme levels were compared, rGCF was found to contain approximately twice as much enzyme levels than fGCF throughout the study. The findings of the present study revealed that both the rGCF and fGCF samples also contained higher CK, LDH, and AST levels than serum samples. Baseline clinical parameters and GCF enzyme levels presented a significant decline throughout the non-surgical and surgical treatment phases in both patient groups, with surgical treatment being more effective. Despite clinical stability, in the AP group levels of LDH and AST showed a tendency to increase in the third month, while enzyme levels still continued to decrease in the RPP group, who received additional antibiotics during the surgical phase. These findings suggest that GCF intracytoplasmic enzyme profile is related with periodontal status and successful periodontal treatment, in addition to clinical improvement, has a significant effect on this profile. Analysis of biochemical events, more specifically intracytoplasmic enzyme levels in GCF, are likely to offer a sensitive measure of periodontal pathology which may help in overcoming the existing limitations of clinical parameters. For this purpose, analysis of rGCF intracytoplasmic enzymes seems to be more beneficial.

Microbial factors and gingival crevicular fluid aspartate aminotransferase levels. A cross-sectional study

The aim of this cross-sectional study was to investigate the clinical application of chairside tests for gingival crevicular fluid (GCF) aspartate aminotransferase (AST) levels and plaque BANA hydrolysis activity with the presence of the periodontal pathogens Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans. The study comprised 100 periodontitis sites (pocket depths > or =4 mm, GI=3) from 10 patients with chronic adult periodontitis and 100 control sites (pocket depths <4 mm, GI<3) from 10 periodontally healthy patients comprising 55 healthy sites (pocket depths <4 mm, GI=0) and 45 gingivitis sites (pocket depths <4 mm, GI=1 or 2). The values for both BANA hydrolysis and AST levels were significantly higher in samples from periodontitis compared with gingivitis and healthy sites (p<0.001). A. actinomycetemcomitans was identified in 45% and P. gingivalis in 17% of periodontitis sites but neither pathogen was recovered from control sites and there was no significant correlation with the clinical parameters measured. There was no significant relationship between the presence of P. gingivalis and/or A. actinomycetemcomitans with BANA hydrolysis or AST levels. A significant correlation (p=0.0017) was observed between BANA hydrolysis and pocket depth and between AST hydrolysis and the GI (p=0.01). This study failed to demonstrate a positive association between chairside analysis of GCF metabolites for AST levels and/or BANA hydrolysis with P. gingivalis and A. actinomycetemcomitans. However, the GCF metabolites had a significant correlation with periodontally diseased sites in patients with chronic adult periodontitis and may help confirm clinical observations.

Evaluation of components of gingival crevicular fluid as diagnostic tests

Gingival crevicular fluid (GCF) is an inflammatory exudate that can be collected at the gingival margin or within the gingival crevice. The biochemical analysis of the fluid offers a noninvasive means of assessing the host response in periodontal disease. In recent years, the relationship of measures of the inflammatory response in GCF to risk for development of active periodontal disease (defined as clinical attachment loss or radiographic bone loss) has been studied in longitudinal trials. The greatest interest has focused on prostaglandin E2, an arachidonic acid metabolite; beta-glucuronidase and neutrophil elastase, markers of lysosomal enzyme release from neutrophils; and aspartate aminotransferase, a cytoplasmic enzyme indicative of cellular necrosis. Analysis of the data allows a number of conclusions to be drawn concerning the potential diagnostic significance of GCF: 1) an exuberant host inflammatory response is associated with progressive disease in patients with periodontitis; 2) collection of GCF using small precut strips is a reproducible and reliable collection technique; 3) the total amount of the mediator and not concentration of the mediator in the GCF sample can be reported when timed samples are collected; and 4) technology exists for GCF-based diagnostic tests to be performed in the dental office. Nevertheless, many questions remain. Still to be determined are: 1) the relationship of test results to the development of periodontitis in patients with gingivitis; 2) the level of test accuracy needed to justify use of these tests; 3) the unit of observation (patient, site) that is being evaluated by the test; and 4) the need for such tests as perceived by clinicians. While these questions are formidable, introduction of GCF-based diagnostic tests will provide clinicians with an improved, quantitative means of evaluating patients and offer specific criteria to assess the effectiveness of treatment.

Detection of neutral protease (Periocheck) and BANA hydrolase (Perioscan) compared with traditional clinical methods of diagnosis and monitoring of chronic inflammatory periodontal disease

Perioscan requires a plaque sample to detect the presence of enzymes capable of degrading N-benzoyl-DL-arginine-2-naphthylamide (BANA) from relatively few anaerobic periodontal pathogens. Periocheck assays the presence of neutral proteases in crevicular fluid. The aim of this study was to compare these test kits with traditional clinical methods of detecting periodontal disease and to monitor the ability of the kits to reflect the response to initial therapy. 19 patients with moderately severe chronic periodontitis were seen before and after a course of oral hygiene and root instrumentation consisting of 4 appointments. Clinical measurements and test assays were collected at 5 diseased sites and 2 healthy sites in each subject. Complete data from 125 sites were available for statistical analysis. At baseline Periocheck had a sensitivity of 88% and a specificity of 61% whereas Perioscan had a sensitivity of 99% and a specificity of 55%, when related to the clinical diagnosis. A composite clinical assessment, based on improvement or deterioration of one whole unit change of the subjective clinical indices and 2 mm changes or greater in probing depth or probing attachment level, revealed 75 sites which improved following treatment, whereas 45 sites did not change and 5 sites deteriorated. The probability that the tests agreed with the clinical outcome after treatment, was calculated as 50.4% for Periocheck and 52% for Perioscan. The diagnostic kits did not reliably reflect the clinical assessment of periodontal disease in the cross sectional study, or the outcome following treatment.

A study of the reliability of a no disease progression conclusion

Concluding that the clinical attachment level at a periodontal site is stable, while in reality it is progressing at a clinically relevant rate, is an example of a false-negative conclusion. No guidelines are currently available to evaluate the likelihood for false-negative conclusions in periodontal clinical trials that monitor disease progression by means of clinical attachment levels. The goal of this study was to estimate the amount of linear disease progression in clinical attachment levels that cannot reliably be detected, when it is truly present. This rate is called the critical linear rate; rates equal to or below this critical linear rate cannot reliably be detected. An equation for determining the critical linear rates for various clinical situations is presented and may provide a rule-of-thumb guideline for the interpretation of negative conclusions. If the critical linear rate for a study is larger than what is considered a clinically relevant disease progression rate, negative conclusions should be interpreted with caution; clinically relevant disease progression might be present, but the diagnostic tools used were too insensitive to detect it. False-negative conclusions may be important in diagnostic trials where low sensitivity can translate into lack of clinical utility.

Periodontal disease diagnosis: current status and future developments

OBJECTIVES

This manuscript attempts to critically review traditional and currently employed methods of periodontal diagnosis, in the light of current knowledge about individual patients and sites at risk of progressive periodontal attachment loss.

DATA SOURCES

Articles published over the last decade from international research journals, have demonstrated that existing methods of periodontal disease diagnosis are seriously deficient with respect to accuracy, their ability to predict ongoing or future disease activity and their ability to determine the current activity status of historically diseased sites.

STUDY SELECTION

Longitudinal studies have questioned the rationale behind traditional treatment regimes and underlined the importance of site-directed therapy to avoid potentially damaging instrumentation of quiescent or healthy sites. The recent explosion in local, less invasive chemotherapies for periodontal disease management has aimed at addressing the site-specific nature of this group of diseases, but the true benefits of such novel therapies cannot be realised until more accurate and specific diagnostic techniques become available.

CONCLUSIONS

The manuscript concludes that the range of clinical information collected by experienced periodontists using currently available technology is probably sufficient to manage mild-to-moderate chronic adult periodontitis. However, those patients at risk from more aggressive attachment loss, and those individuals that appear refractory to traditional therapies, require the development of more accurate diagnostic tests to compliment the revolution in site-specific therapies. A diagnostic model is presented, which attempts to draw together current and future diagnostic methods for managing the majority of periodontal disease types, and it is suggested that current diagnoses should include some assessment of "risk'.

The relationship between gingival crevicular fluid cathepsin B activity and periodontal attachment loss in chronic periodontitis patients: a 2-year longitudinal study

This study aims to determine whether gingival crevicular fluid (GCF) cathepsin B levels, total activity (TA) and concentration (EC) predict progressive attachment loss (AL). Seventy-five previously untreated patients with moderate periodontitis were recruited. GCF was collected from 16 molar and premolar mesiobuccal sites and probing attachment level (PAL) and probing depth (PPD) were measured with an electronic probe. Gingival, gingival bleeding and plaque indices were then scored. Prior to baseline patients were given basic periodontal treatment after which the above procedures were repeated. Carefully localized radiographs were taken of the test teeth and repeated annually. Patients were seen 3-monthly for 2 yr and the procedures were repeated. One hundred and twenty-one AL sites, 90 rapid AL (RAL) and 31 gradual AL (GAL), in 49 patients were detected. Cathepsin B levels (TA & EC) at RAL sites were significantly higher (p < 0.0001) than paired control sites at the attachment loss time (ALT) and prediction time (PT). Mean levels (TA & EC) over the study period at GAL sites were significantly higher (p < 0.0001) than paired control sites. Using a critical value (CV) of 7.5 microU/30 s (TA) and 30 microU/microL (EC) showed a sensitivity of 100% and specificity of 99.83% (TA) and 100% and 99.75%(EC) at both ALT & PT. Mean cathepsin B levels (TA & EC) were significantly higher (p < 0.0001) at RAL and GAL sites than non-attachment loss (NAL) sites in AL patients in intrapatient comparisons and mean patient levels were significantly higher (p < 0.0001) in AL patients than NAL patients in interpatient comparisons. These results indicate that GCF cathepsin B may serve as a predictor of attachment loss.

Short-term responses to periodontal therapy in insulin-dependent diabetic patients

This investigation studied relative changes in periodontal conditions of 18 insulin-dependent diabetic patients. Measures of gingival inflammation, crevicular fluid aspartate aminotransferase (AST) levels, probing depth and attachment levels, the presence of three periodontal pathogens (Porphyromonas gingivalis, Bacteroides forsythus, and Actinobacillus actinomycetemcomitans) and serum antibody titers to these bacteria, and blood sugar levels (glycosylated hemoglobin, HbAlc) were studied before and 2 months after non-surgical debridement. Antibody titers to the same bacteria were also studied in sera from 18 sex- and age-matched periodontally healthy and non-diabetic subjects. Periodontal conditions showed significant improvement. The mean probing depth at 4 of the worst sites selected in each patient decreased from 5.7 mm to 4.8 mm (p < 0.0001). The mean full width probing depth changed from 2.9 mm (s.d. +/- 0.2) to 2.5 mm (s.d. +/- 0.3). A mean gain of 0.4 mm attachment level was recorded (P < 0.0001). The mean AST value decreased from 1009 microIU to 518 microIU (P < 0.006). Minimal differences in mean glycosylated hemoglobin values (HbAlc) were noticed before and after treatment. A. actinomycetemcomitans was never detected. P. gingivalis was present at 7% of the sites both before and after treatment. B. forsythus was found at 29% of sites (50% of patients) before and at 36% of sites (61% of patients) after treatment. Positive associations were found between the presence of B. forsythus and AST values, gingival index, probing depth, and attachment level (P < 0.05). Baseline serum IgG titers to P. gingivalis were significantly lower in the patients with diabetes (9.5 ELISA units vs. 28.5 ELISA units in the healthy controls). IgG titers to B. forsythus did not differ between diabetic and non-diabetic subjects. No changes in IgG titers occurred after treatment. Clinical improvements after mechanical non-surgical therapy in patients with insulin-dependent diabetes mellitus were modest after 2 months. Treatment did not eliminate B. forsythus and P. gingivalis and did not affect IgG titer responses. More intense therapy, and longer follow-up times, may be necessary to see more pronounced clinical and systemic effects.

Correlation between gingivain/gingipain and bacterial dipeptidyl peptidase activity in gingival crevicular fluid and periodontal attachment loss in chronic periodontitis patients. A 2-year longitudinal study

The aim of this study is to determine whether either gingival crevicular fluid (GCF) bacterial gingivain/gingipain or dipeptidyl peptidase (DPP) levels, total activity (TA) and concentration (EC), predict progressive attachment loss (AL) in 75 patients with moderate periodontitis. GCF was collected from 16 molar and premolar mesiobuccal sites and then clinical attachment level (CAL) and probing depth (PD) were measured with an electronic constant pressure probe. Lastly, gingival, gingival bleeding, and plaque indices were scored. Prior to the baseline visit, patients were given basic periodontal treatment after which the above procedures were repeated. In addition, carefully localized radiographs were taken of the test teeth and repeated annually. Patients were then seen every 3 months for 2 years and the clinical measurements repeated at each visit. In 48 patients, 124 AL sites, 91 rapid AL (RAL), and 33 gradual AL (GAL) were detected. Gingivain/gingipain and bacterial DPP levels (TA and EC) at RAL sites were significantly higher (P < or = 0.0001) than at paired control sites at the attachment loss time (ALT) and prediction time (PT). Mean levels over the study period of both proteases (TA and EC) at GAL sites were significantly higher (P < or = 0.0001) than those at paired control sites. The GCF levels of gingivain/gingipain were always higher than those of DPP. Critical values (CV) of 5 microU/30 seconds (TA) and 30 microU/microL (EC) for both proteases showed high sensitivity and specificity values for TA and EC, which were the same at both ALT and PT. The positive predictive values were higher for gingivain/ gingipain. Mean site levels, over the course of the study, of both proteases (TA and EC) were significantly higher (P < or = 0.0001) at AL, RAL, and GAL sites than non-attachment loss (NAL) sites in AL patients and mean patient levels were significantly higher (P < or = 0.0001) in AL, RAL, and GAL patients than NAL patients. These results indicate that both of these bacterial proteases in GCF may be predictors of periodontal attachment loss.

A 2-year longitudinal study of elastase in human gingival crevicular fluid and periodontal attachment loss

The purpose of this study is to determine whether gingival crevicular fluid (GCF) elastase total activity (TA) and concentration (EC) correlate with and predict progressive attachment loss (AL). 75 previously untreated patients with moderate periodontitis were recruited. GCF was collected from 16 molar and premolar mesiobuccal sites and probing attachment loss (PAL), probing depth (PPD), gingival index (GI), gingival bleeding index (GBI) and plaque index (Pl.I) were measured. PAL and PPD were measured with an electronic, constant pressure probe. Patients were given basic periodontal treatment prior to baseline when the above procedures were repeated. In addition, carefully localised radiographs were taken of the test teeth and repeated annually. Patients were seen at 3 months intervals to 2 years and the procedures were repeated. 119 AL sites were detected and 89 of these were rapid AL sites (RAL) and 30 were gradual AL sites (GAL). Elastase levels (TA & EC) at RAL sites were significantly higher (p < or = 0.0001) than paired control sites in the same patient at both the attachment loss time (ALT) and the prediction time (PT). The mean levels (TA & EC) over the study period at GAL sites were significantly higher (p < or = 0.0001) than paired control sites in the same patient. Using a critical value (CV) of 125 micronsU/30 s (TA) and 400 micronsU/micronsL (EC) in 2 x 2 contingency tables showed a sensitivity of 100% and specificity of 99.95% (TA) and a sensitivity of 100% and specificity of 99.91% (EC) at the PT with very similar values at the ALT. Patient level comparisons showed that the mean elastase levels (TA & EC) were significantly higher (p < or = 0.0001) at RAL and GAL sites than non-attachment loss (NAL) sites in AL patients and that the mean levels were significantly higher (p < or = 0.0001) in AL patients than NAL patients. All these results indicate that these CVs for GCF elastase activity may serve as a predictors of future attachment loss.

Human gingival crevicular fluid keratin at healthy, chronic gingivitis and chronic adult periodontitis sites

The present study was designed to determine, in a cross-sectional study, whether there was any relationship between the keratin-positive material in gingival crevicular fluid and the clinical periodontal status. Keratins were selected as putative indicators of degradation of epithelial cells cytoskeletal proteins. Keratin positive material was determined by enzyme-linked immunosorbent assay in 42 subjects exhibiting clinical sites of health, chronic gingivitis and chronic periodontitis. The concentration of keratin in parotid saliva was also measured for each subject. Keratin concentration in gingival crevicular fluid samples was significantly greater at sites exhibiting signs of gingivitis and periodontitis compared with healthy sites. No differences were detected between sites exhibiting gingivitis and periodontitis. No differences were found between the 3 groups for the saliva keratin-positive material which was significantly less than that detected in gingival crevicular fluid. These results suggest that gingival crevicular fluid keratin concentration may serve as a marker of gingival damage.

Effects of treatment on gingival crevicular collagenase, stromelysin and tissue inhibitor of metalloproteinases and their ability to predict response to treatment

Fibroblast collagenase (FIB-CL) and stromelysin (SL) are members of a family of enzymes which are capable of degrading most of the extracellular matrix macromolecules. Extracellular control of these enzymes is performed by tissue inhibitor of metalloproteinases (TIMP). During healing, inflammation and normal tissue turnover, levels of MMPs and TIMP will change. The effect of treatment on the levels of FIB-CL, SL and TIMP as well as their ability, at baseline, to predict the outcome of therapy was investigated. 21 patients each provided 8 gingival crevicular fluid (GCF) samples from sites with probing depths > or = 4 mm. Clinical recordings and GCF sampling were performed at 3 time points. Assays for SL, FIB-CL and TIMP were performed by a sandwich ELISA. Attachment level changes were detected by the "tolerance method". The ability of the GCF constituents to predict the response to treatment was assessed by comparing pre-treatment levels between sites which did or did not show attachment gain after therapy. Although no GCF constituents could reliably predict the response to treatment, SL reduced significantly (p = 0.029) after the hygiene phase of therapy. In addition, both SL and TIMP levels showed a highly significant reduction at follow-up visit (p = 0.003 and p = 0.005 respectively). Thus, SL and TIMP levels are reduced by treatment, but these GCF proteins do not appear to have an ability to predict treatment outcome from baseline.

Correlation between gingival crevicular fluid dipeptidyl peptidase II and IV activity and periodontal attachment loss. A 2-year longitudinal study in chronic periodontitis patients

OBJECTIVE

The aim of this study is to determine whether gingival crevicular fluid (GCF) dipeptidyl peptidase (DPP) II or IV levels, total activity (TA) and concentration (EC), predict progressive attachment loss (AL).

SUBJECTS AND METHODS

Seventy five patients with moderate periodontitis were recruited. GCF was first collected from 16 molar and premolar mesiobuccal sites and then probing attachment level (PAL) and probing pocket depth (PPD) were measured with an electronic probe. Finally, gingival index, gingival bleeding and plaque indices were scored. Patients were given basic periodontal treatment prior to baseline after which the above procedures were repeated. Patients were seen 3 monthly for 2 years and the procedures were repeated. Carefully localised radiographs were taken of the test teeth annually.

RESULTS

One hundred and twenty AL sites, 88 rapid AL (RAL) and 32 gradual AL (GrAL), in 48 patients were detected. DPP II and IV levels (TA and EC) at RAL sites were significantly higher (P < or = 0.0001) than paired control sites at the attachment loss time (ALT) and prediction time (PT). Mean levels over the study period of both proteases (TA and EC) at GrAL sites were significantly higher (P < or = 0.0001) than other paired control sites. The GCF levels of DPP IV were always slightly higher than those of DPP II. Critical values (CV) of 5 microU per 30 s (TA) and 25 microU microL(-1) (EC) for both proteases showed high sensitivity and specificity values for TA and EC and these were the same at both ALT and PT. The positive predictive values were slightly higher for DPP II. Mean site DPP II and IV levels (TA and EC) in intra-patient comparisons were significantly higher (P < or = 0.0001) at RAL and GrAL sites than non-attachment loss (NAL) sites in AL patients and mean patient levels were significantly higher (P < or = 0.0001) in AL patients than NAL patients in inter-patient comparisons.

CONCLUSIONS

These results indicate that both GCF DPP II and IV may be predictors of periodontal attachment loss.

Neutrophil elastase in crevicular fluid: comparison of a middle-aged general population with healthy and periodontitis groups

Neutrophil elastase (NE) was measured in crevicular fluid (GCF) collected from 3 subject groups. GCF was harvested at a single visit of subjects with periodontal health (n = 21) and with periodontitis (n = 28). Samples were obtained from 132 middle-aged, middle-class health conscious patients of a health maintenance organization (HMO) at baseline and 1 year later. GCF NE was higher in periodontitis than in health. Mean GCF NE of HMO subjects was much closer to health than to periodontitis. Few members of the HMO population had enzyme levels typical of periodontitis. Subjects and sites of the HMO population were segregated into 3 categories based on enzyme levels of the healthy and periodontitis subjects. Most HMO subjects and sites were in the activity category corresponding to healthy subjects. Only a small portion were in the activity category common in periodontitis. Enzyme levels in the highest activity category at both samplings were infrequent. High enzyme levels in the HMO population were not associated with attachment loss. Thus, assay of GCF NE provided little evidence of disease in a middle-aged, middle-class health conscious general population. This finding confirms an analysis of epidemiological surveys which concluded that a population such as studied here would not benefit from periodontal diagnostic testing.

A multicenter clinical trial of PerioGard in distinguishing between diseased and healthy periodontal sites. (I). Study design, methodology and therapeutic outcome

We designed and performed a multicenter clinical trial to determine the relationship between measurements of the level of the enzyme aspartate aminotransferase (AST) in gingival crevicular fluid (GCF) to other measures used to detect periodontal disease and monitor outcome of treatment, including pocket depth and gingival inflammation. 32 periodontitis patients were enrolled at the University of Washington, Seattle, 30 at the University of Florida, Gainesville, and 34 at the University of Illinois, Chicago. 10 periodontally normal control subjects were enrolled at each location. 8 diseased and 4 healthy sites were designated for study in each patient and 8 healthy sites designated in each control subject. Measures of disease included pocket depth, severity of gingival inflammation, and GCF volume. AST levels were measured using the PerioGard test kit. Clinical measurements were made and GCF samples harvested and tested 2x before and 2x after therapy consisting of scaling and root planing under local anesthetic. Specific design and other issues are discussed, including selection of patients and control subjects, sample size, selection of experimental test sites, methods for assessment of diseased and therapeutic improvement, harvesting of GCF and selection of appropriate biostatistical methods for data analysis. Demographics of the patient populations at the 3 locations are reported. As expected, therapy induced only negligible changes in the measures of disease at healthy sites in control subjects, and relatively minor improvement in healthy sites in patients. In contrast, statistically significant improvement relative to pretreatment baseline status in all 3 measures of disease was observed for diseased sites at all 3 study locations with all p-values less than 0.0002. The magnitude of improvement was comparable to that reported previously by others. The % of PerioGard-positive sites decreased significantly between the screening baseline and both post-treatment visits for patients at all 3 locations, with p values of 0.0001 to <0.0008.