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Kardaras G, Christodorescu R, Boariu M, Rusu D, Belova A, Chinnici S, Vela O, Radulescu V, Boia S, Stratul SI. A Low-Cost Protocol Using the Adjunctive Action of Povidone-Iodine Irrigations and Sodium Hypochlorite Rinsing Solution in Step 2 of Periodontal Therapy for Patients with Stage III-IV Periodontitis: A Single-Blind, Randomized Controlled Trial. Dent J (Basel) 2024; 12:144. [PMID: 38786542 PMCID: PMC11119210 DOI: 10.3390/dj12050144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/18/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
In severe stages of periodontitis, conventional periodontal therapy and maintenance care are usually insufficient due to the viral and bacterial etiology; thus, a mechanical approach alone may not be sufficient to eliminate a substantial portion of subgingival pathogens, especially in deep periodontal sites. Background and Objectives: This single-blind, randomized clinical trial aimed to compare the clinical and microbiological efficacy of a low-cost protocol using povidone-iodine and sodium hypochlorite formulations as adjuncts to non-surgical therapy for patients with stage IV periodontitis when compared with chlorhexidine, the most commonly employed substance to date for antimicrobial regimens in periodontal therapy. Materials and Methods: Forty-five patients were randomly divided into two groups: control (subgingival instrumentation, chlorhexidine-assisted) and test (antiviral medication, subgingival instrumentation with povidone-iodine, sodium hypochlorite rinsing solution, and antibiotics). Clinical measurements and microbiological analyses were performed at baseline and after three months. Results: After three months, notable differences were found in the bacterial detection scores for Porphyromonas gingivalis (a significant reduction in detection frequency was observed in the test compared to the control (p = 0.021)), and there were significant reductions in detection in the test group for Tannerella forsythia and Treponema denticola, showing undetectable levels (p < 0.0001 for both). In the test group, the pocket probing depth median value was reduced significantly (p = 0.0005); similarly, bleeding on probing showed a marked decrease (p < 0.0001). However, changes in clinical attachment loss and full-mouth plaque score were not statistically significant. Conclusions: Using the proposed protocol, substantial improvements in clinical and microbiological parameters were obtained when compared with the current antimicrobial recommendations.
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Affiliation(s)
- Georgios Kardaras
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (G.K.); (D.R.); (A.B.); (S.C.); (O.V.); (V.R.); (S.B.); (S.-I.S.)
| | - Ruxandra Christodorescu
- Department V Internal Medicine, Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Marius Boariu
- Department of Endodontics, Faculty of Dental Medicine, TADERP Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Darian Rusu
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (G.K.); (D.R.); (A.B.); (S.C.); (O.V.); (V.R.); (S.B.); (S.-I.S.)
| | - Alla Belova
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (G.K.); (D.R.); (A.B.); (S.C.); (O.V.); (V.R.); (S.B.); (S.-I.S.)
| | - Salvatore Chinnici
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (G.K.); (D.R.); (A.B.); (S.C.); (O.V.); (V.R.); (S.B.); (S.-I.S.)
| | - Octavia Vela
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (G.K.); (D.R.); (A.B.); (S.C.); (O.V.); (V.R.); (S.B.); (S.-I.S.)
| | - Viorelia Radulescu
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (G.K.); (D.R.); (A.B.); (S.C.); (O.V.); (V.R.); (S.B.); (S.-I.S.)
| | - Simina Boia
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (G.K.); (D.R.); (A.B.); (S.C.); (O.V.); (V.R.); (S.B.); (S.-I.S.)
| | - Stefan-Ioan Stratul
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (G.K.); (D.R.); (A.B.); (S.C.); (O.V.); (V.R.); (S.B.); (S.-I.S.)
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Maulani C, Auerkari EI, C. Masulili SL, Soeroso Y, Djoko Santoso W, S. Kusdhany L. Association between Epstein-Barr virus and periodontitis: A meta-analysis. PLoS One 2021; 16:e0258109. [PMID: 34618843 PMCID: PMC8496828 DOI: 10.1371/journal.pone.0258109] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 09/18/2021] [Indexed: 12/19/2022] Open
Abstract
Purpose Previous studies have found that Epstein-Barr virus (EBV) is associated with periodontitis, though some controversy remains. This meta-analysis aimed to clarify and update the relationship between EBV and periodontitis as well as clinical parameters. Methods A comprehensive search was conducted in the PubMed and Scopus databases in December 2020. Original data were extracted according to defined inclusion and exclusion criteria. Outcomes were analyzed, including overall odds ratios (ORs) and 95% confidence intervals (CIs). A random-effects model was used, and publication bias was assessed by Egger’s and Begg’s tests. Sensitivity analysis was used to evaluate the stability of the outcome. Results Twenty-six studies were included in the present meta-analysis, involving 1354 periodontitis patients and 819 healthy controls. The included studies mostly showed high quality. The overall quantitative synthesis for the association between EBV and periodontitis was an increased odds ratio when subgingival EBV was detected OR = 7.069, 95% CI = 4.197–11.905, P<0.001). The results of subgroup analysis suggested that the association of EBV with periodontitis was significant in Asian, European, and American populations (P<0.001; P = 0.04; P = 0.003, respectively) but not in African populations (P = 0.29). Subgroup analysis by sample type showed that subgingival plaque (SgP), tissue and gingival crevicular fluid GCF were useful for EBV detection (P<0.001). EBV detection amplification methods included nested PCR, multiplex PCR and PCR (P<0.001; P = 0.05, P<0.001, respectively), but EBV detection by real-time PCR and loop-mediated isothermal amplification presented no significant result (P = 0.06; P = 0.3, respectively). For the clinical parameters of periodontitis, pocket depth (PD) and bleeding of probing (BOP) percentages were higher in the EBV-positive sites than in the EBV-negative sites (MD 0.47 [0.08, 0.85], P = 0.02; MD 19.45 [4.47, 34.43], P = 0.01). Conclusions A high frequency of EBV detection is associated with an increased risk of periodontitis. The EBV association was particularly significant in all populations except in African populations. Subgigival plaque (SgP), tissue and GCF were not significantly different useful material for detecting EBV in periodontitis. Nested PCR and multiplex PCR are reliable methods for this purpose. In the presence of EBV, PD and BOP are reliable clinical parameters for gingival inflammation. However, some caution in such interpretation is justified due to heterogeneity among studies. A suggested extension could assess the parallel influence of other human herpesviruses.
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Affiliation(s)
- Chaerita Maulani
- Faculty of Dentistry, Doctoral Program, Universitas Indonesia, Jakarta, Indonesia
| | - Elza Ibrahim Auerkari
- Faculty of Dentistry, Department of Oral Biology, Universitas Indonesia, Jakarta, Indonesia
- * E-mail:
| | - Sri Lelyati C. Masulili
- Faculty of Dentistry, Department of Periodontology, Universitas Indonesia, Jakarta, Indonesia
| | - Yuniarti Soeroso
- Faculty of Dentistry, Department of Periodontology, Universitas Indonesia, Jakarta, Indonesia
| | - Widayat Djoko Santoso
- Faculty of Medicine, Department of Internal Medicine in Tropical Infection, Universitas Indonesia, Jakarta, Indonesia
| | - Lindawati S. Kusdhany
- Faculty of Dentistry, Department of Prosthodontics, Universitas Indonesia, Jakarta, Indonesia
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Emecen-Huja P, Danaher RJ, Dawson DR, Wang C, Kryscio RJ, Ebersole JL, Miller CS. Relationship between herpesviruses and periodontal disease progression. J Clin Periodontol 2020; 47:442-450. [PMID: 31860742 PMCID: PMC7096277 DOI: 10.1111/jcpe.13239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/14/2022]
Abstract
AIM To investigate the role of Epstein-Barr virus (EBV), cytomegalovirus (CMV), and anaerobic bacteria in the progression of periodontitis. METHODS Eighty-one adults with generalized moderate to severe periodontitis were randomly assigned to: oral hygiene or scaling and root planning ± placebo or polyunsaturated fatty acids fish oil. Subgingival plaque samples collected from three healthy and three disease sites at weeks 0, 16, and 28 and from sites demonstrating disease progression were analysed for EBV, CMV, P. gingivalis (Pg), T. forsythia (Tf), and T. denticola (Td) DNA using quantitative polymerase chain reaction. RESULTS Cytomegalovirus was detected in 0.3% (4/1454) sites. EBV was present in 12.2% of healthy sites (89/728) and 27.6% disease sites (201/726; p < .0001), but was in low copy number. Disease progression occurred in 28.4% of participants (23/81) and developed predominantly at sites identified as diseased (75/78; 96.2%). CMV and EBV were not associated with disease progression (p = .13) regardless of treatment. In contrast, disease sites were associated with higher levels of Pg, Td, Tf, and total bacteria, and sites that exhibited disease progression were associated with an abundance of Td and Tf (p < .04). CONCLUSION Disease progression was associated with Gram-negative anaerobic bacteria; not EBV or CMV.
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Affiliation(s)
| | | | | | - Chunmei Wang
- Center for Oral Health Research, College of Dentistry, University of Kentucky
| | - Richard J. Kryscio
- Department of Statistics, College of Arts & Sciences, University of Kentucky
| | - Jeffrey L. Ebersole
- Center for Oral Health Research, College of Dentistry, University of Kentucky
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Botero JE, Rodríguez‐Medina C, Jaramillo‐Echeverry A, Contreras A. Association between human cytomegalovirus and periodontitis: A systematic review and meta‐analysis. J Periodontal Res 2020; 55:551-558. [DOI: 10.1111/jre.12742] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 02/05/2020] [Accepted: 02/10/2020] [Indexed: 12/18/2022]
Affiliation(s)
| | - Carolina Rodríguez‐Medina
- Facultad de Odontología Universidad de Antioquia Medellín Colombia
- Facultad de Odontología Universidad Cooperativa de Colombia Medellín Colombia
| | - Adriana Jaramillo‐Echeverry
- UNICOC, Colegio Odontológico Colombiano Cali Colombia
- Escuela de Odontología Universidad del Valle Cali Colombia
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Abstract
Four billion individuals worldwide have a history of periodontitis, with the poorest people in society most affected. Periodontitis can lead to unsightly drifting of teeth and tooth loss that may interfere with the wellbeing of daily living and has also been linked to at least 57 medical diseases and disabilities. The etiology of severe periodontitis includes active herpesviruses, specific bacterial pathogens, and destructive immune responses, but herpesviruses seem to be the major pathogenic determinant. Periodontal herpesviruses that disseminate via the systemic circulation to nonoral sites may represent a major link between periodontitis and systemic diseases. Current treatment of periodontitis focuses almost exclusively on bacterial biofilm and will require revision. Periodontal therapy that targets both herpesviruses and bacterial pathogens can provide long-term clinical improvement and potentially reduces the risk of systemic diseases. Molecular diagnostic tests for periodontal pathogens may enable early microbial identification and preemptive therapy. This review details an efficient and reliable anti-infective treatment of severe periodontitis that can be carried out in minimal time with minimal cost.
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Affiliation(s)
- Jørgen Slots
- School of Dentistry, University of Southern California, Los Angeles, California
| | - Henrik Slots
- University of Nevada at Reno School of Medicine, Reno, Nevada.,St. George's School of Medicine, St. George, Grenada.,Renown Medical Center, Reno, Nevada
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Bilichodmath S, Nair SK, Bilichodmath R, Mangalekar SB. mRNA expression of IFN-λs in the gingival tissue of patients with chronic or aggressive periodontitis: A polymerase chain reaction study. J Periodontol 2019; 89:867-874. [PMID: 29717481 DOI: 10.1002/jper.17-0349] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 12/06/2017] [Accepted: 12/29/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Several studies have proven the existence of herpesviruses in periodontal pockets of patients with chronic or aggressive periodontitis. Recently discovered interferon lambda (IFN-λ) has antiviral properties and is induced by herpesviruses. The present study was a quantitative analysis of messenger RNA (mRNA) expression of IFN-λs (IFN-λ1, IFN-λ2, IFN-λ3) in the gingival tissues of patients with chronic or aggressive periodontitis. METHODS A total of 90 participants (50 men and 40 women; age range 19-50 years, mean age 31.50 ± 7.8) were categorized into three groups: healthy participants, patients with chronic periodontitis, and patients with aggressive periodontitis. mRNA expression of IFN-λs in gingival tissues was estimated using reverse transcriptase polymerase chain reaction and was correlated with clinical parameters such as gingival index (GI), probing pocket depth (PPD), and clinical attachment level (CAL). RESULTS mRNA of IFN-λ1, IFN-λ2, and IFN-λ3 was expressed in gingival tissues of healthy participants and in patients with chronic or aggressive periodontitis. The highest level of IFN-λ1 was observed in patients with aggressive periodontitis (3.049 ± 9.793), whereas IFN-λ2 (4.322 ± 11.310) and IFN-λ3 (11.932 ± 27.479) were highest in patients with chronic periodontitis. The difference in mRNA expression of IFN-λ1 (P = 0.008) and IFN-λ3 (P = 0.043) among three groups was statistically significant CONCLUSION: Increased quantity of IFN-λs in patients with chronic and patients with aggressive periodontitis suggests a role in periodontitis. Variation in the expression of IFN-λ1 and IFN-λ3 in patients with periodontitis needs to be further evaluated. The mRNA expression of antiviral IFN-λs in gingival tissues might enhance our understanding related to viral pathogenesis of periodontal diseases.
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Affiliation(s)
| | - Sruthi K Nair
- Department of Periodontology, Rajarajeswari Dental College and Hospital, Bangalore, India
| | - Rekha Bilichodmath
- Department of Periodontology, Rajarajeswari Dental College and Hospital, Bangalore, India
| | - Sachin B Mangalekar
- Deparment of Periodontology, Bharti Vidyapeeth Dental College, Wanlesswadi, Sangali, Maharashtra, India
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Abstract
Purpose of Review Research suggests that periodontal tissue might serve as a reservoir for oral human papillomavirus (HPV) infection, while another hypothesis is that chronic inflammation of the tissue might perpetuate an infection with oral HPV infection. In this narrative review, we summarize the evidence related to a potential association between oral HPV infection and periodontitis. Recent Findings Twelve articles were identified, and their key findings summarized. Studies vary in sample size, study population, study design, and methods for assessment of oral HPV and periodontitis. Although results are conflicting and still inconclusive, various studies have found an association between oral HPV infection and periodontitis, which is supported by biological plausibility. Summary Future longitudinal studies should further evaluate this association, using clinical definitions of oral HPV infection and periodontitis, and focusing on high-risk populations for oral HPV infection. Studying this association is important since periodontitis might help identify at-risk individuals for oral HPV infection and potentially HPV-related oropharyngeal cancers.
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Ivanovska-Stojanoska M, Popovska M, Anastasovska V, Kocova M, Zendeli-Bedzeti L, Dimova C, Taseva A. Detection of Virus Herpes Simplex Type 1 in Patients with Chronic Periodontal Disease. Open Access Maced J Med Sci 2018; 6:1737-1741. [PMID: 30338001 PMCID: PMC6182537 DOI: 10.3889/oamjms.2018.307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 07/23/2018] [Accepted: 08/25/2018] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Periodontal disease is an inflammatory-destructive condition of the supporting tissues of the teeth. Microorganisms found in the dental plaque were considered to be the primary local etiologic factor responsible for the periodontal destruction. It is also evident that herpes simplex viruses may have an impact in the etiopathogenesis of periodontal disease. AIM This study has been made with the aim to analyse the prevalence of herpes simplex virus type 1 (HSV-1) in the dental plaque (supra- and subgingival) of patients with the chronic periodontal disease. MATERIAL AND METHODS The study comprised a total of 89 patients with chronic periodontal disease divided into two groups (patients with moderate and severe periodontitis). Supragingival dental plaque samples were taken with sterile cotton (supragingival), and subgingival dental plaque samples were taken with paper absorbents. Samples were subjected to extraction of DNA and further analysis with multiplex PCR for the presence of herpes viral DNA. RESULTS HSV-1 virus was detected In 24.7% of all patients included in the study. HSV-1 was detected in 22.2% of patients with the moderate stage of the disease, of which in all (100%) in the supragingival plaque samples and only 16.7% in subgingival plaque samples. In two patients HSV-1 was concomitantly detected in supra and subgingival plaque samples. In patients with advanced stage of the disease, the HSV-1 virus was detected in 28.6% patients. In two of the patients, HSV-1 was concomitantly detected in supra and subgingival plaque samples. Statistically, a significant difference was found in HSV-1 positive patients with a moderate stage of disease, between the presence of the virus in subgingival (100%) and subgingival (16.7%) dental plaque samples, p < 0.05. CONCLUSION Herpes simplex viruses type 1 are present in supragingival and subgingival dental plaque.
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Affiliation(s)
- Marija Ivanovska-Stojanoska
- University Dental Clinical Centre St. Panteleimon, Department of Oral Pathology and Periodontology, Skopje, Republic of Macedonia
| | - Mirjana Popovska
- Ss. Cyril and Methodius University of Skopje, Faculty of Dentistry, Skopje, Republic of Macedonia
| | - Violeta Anastasovska
- University Children's Hospital, Faculty of Medicine, Ss. Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Mirjana Kocova
- University Children's Hospital, Faculty of Medicine, Ss. Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Lidita Zendeli-Bedzeti
- University Dental Clinical Centre St. Panteleimon, Department of Oral Pathology and Periodontology, Skopje, Republic of Macedonia
| | - Cena Dimova
- University "Goce Delchev", Faculty of Dentistry, Shtip, Republic of Macedonia
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Passariello C, Gigola P, Testarelli L, Puttini M, Schippa S, Petti S. Evaluation of microbiota associated with Herpesviruses in active sites of generalized aggressive periodontitis. ANNALI DI STOMATOLOGIA 2017; 8:59-70. [PMID: 29299190 DOI: 10.11138/ads/2017.8.2.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Aims The present study aimed to investigate microbial patterns associated with disease progression and coinfection by different Herpesviruses in generalized aggressive periodontitis (GAP). Methods Microbiological samples were obtained from active (AS) and non-active (n-AS) sites in 165 subjects affected by GAP and were analyzed for 40 bacterial species by the Checkerboard DNA-DNA Hybridization technique and for Herpes simplex 1 (HSV-1), Human Cytomegalovirus (CMV), and Epstein Bar virus (EBV) by PCR.Common Factor Analysis and Multiple Regression Analysis were applied to disclose specific microbial patterns associated with the three viruses. Results Herpesviruses were detected in 37.6% of subjects. Detection of each of the searched viruses was associated with specific patterns of subgingival biofilm in AS. Logistic regression analyses evidenced several virus/bacteria associations: i) EBV with Aggregatibacter actinomycetemcomitans; ii) CMV with A. actinomycetemcomitans, Veillonella parvula, Parvimonas micra and Fusobacterium nucleatum subsp. polymorphum; iii) HSV-1 with Porphyromonas gingivalis, Tannerella forsythia, Fusobacterium periodonticum and Staphylococcus aureus. Conclusions Microbiological data suggest that Herpesviruses are probably not mere spectators of disease progression and that specific patterns of subgingival plaque are correlated with the presence of different Herpesviruses.
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Affiliation(s)
- Claudio Passariello
- Department of Public Health and Infectious Diseases, " Sapienza" University of Rome, Rome, Italy
| | - Pierangelo Gigola
- Department of Medical-Surgical Specialties, Radiologic and Public Health Sciences University of Brescia, Brescia, Italy
| | - Luca Testarelli
- Department of Odontostomatologic and Maxillo-Facial Sciences, "Sapienza" University of Rome, Rome, Italy
| | | | - Serena Schippa
- Department of Public Health and Infectious Diseases, " Sapienza" University of Rome, Rome, Italy
| | - Stefano Petti
- Department of Public Health and Infectious Diseases, " Sapienza" University of Rome, Rome, Italy
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Li F, Zhu C, Deng FY, Wong MCM, Lu HX, Feng XP. Herpesviruses in etiopathogenesis of aggressive periodontitis: A meta-analysis based on case-control studies. PLoS One 2017; 12:e0186373. [PMID: 29036216 PMCID: PMC5643052 DOI: 10.1371/journal.pone.0186373] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 10/01/2017] [Indexed: 02/07/2023] Open
Abstract
Objective Previous studies have found that herpesviruses are associated with aggressive periodontitis (AgP). However, these findings are controversial. This meta-analysis was aimed at clarifying the association between herpesviruses and AgP. Methods We identified eligible case–control studies evaluating the association between herpesviruses and AgP from PubMed and Embase databases in October 2015. Original data were extracted and quality assessment was done. Overall odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. Random-effects model was determined. The stability was evaluated by sensitivity analysis. Finally, Egger’s funnel plot was used to investigate the publication bias. Results Twelve case-control studies involving 322 patients and 342 controls were included in the present meta-analysis. The included case-control studies were assessed as high quality. The quantitative synthesis results for Epstein–Barr virus (EBV) showed significance (10 studies: p = 0.0008, OR = 6.11, 95% CI = 2.13–17.51); nevertheless, evidence of publication bias for EBV was considerable (EBV: Egger’s test, p<0.001). Human cytomegalovirus (HCMV) and Herpes simplex virus type 1 (HSV-1) had significant association with AgP (12 studies for HCMV: p = 0.009, OR = 3.63, 95% CI = 2.15–6.13; 4 studies for HSV-1: p<0.001, OR = 19.19, 95% CI = 4.16–79.06). Sensitivity analyses showed the results yielded consistency, and no significant publication bias was observed for HCMV. The association between Herpes simplex virus type 2 (HSV-2) and AgP was inconclusive (2 studies: p = 0.20, OR = 3.46, 95% CI = 0.51–23.51). Conclusion This meta-analysis suggests that HCMV and HSV-1 are significantly associated with AgP. However, due to the heterogeneity among studies these conclusions should be cautiously interpreted. There is insufficient evidence to draw any conclusion between EBV, HSV-2 and AgP based on the currently limited data.
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Affiliation(s)
- Fei Li
- Department of Preventive Dentistry, Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Ce Zhu
- Department of Preventive Dentistry, Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Feng-Ying Deng
- Department of Endodontics, Shandong Province Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - May. Chun. Mei Wong
- Dental Public Health, Faculty of Dentistry, University of Hong Kong, Hong Kong, China
| | - Hai-Xia Lu
- Department of Preventive Dentistry, Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Xi-Ping Feng
- Department of Preventive Dentistry, Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Key Laboratory of Stomatology, Shanghai, China
- * E-mail:
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Gao Z, Lv J, Wang M. Epstein-Barr virus is associated with periodontal diseases: A meta-analysis based on 21 case-control studies. Medicine (Baltimore) 2017; 96:e5980. [PMID: 28178139 PMCID: PMC5312996 DOI: 10.1097/md.0000000000005980] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Some controversies still exist between the detection of Epstein-Barr virus (EBV)'s DNA and risks of periodontal diseases. Hence, a comprehensive meta-analysis on all available literatures was performed to clarify the relationship between EBV and preidontitis.A comprehensive search was conducted within the PUBMED, EMBASE, and WANFANG databases up to October 10th, 2016 according to inclusion and exclusion criteria and finally 21 case-control literatures were obtained. The outcomes including odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the strength of associations. Publication bias was determined by Begg or Egger test. Sensitivity analysis was used to investigate reliability and stability of the results.According to the data from included trials, the association between overall increased risks of periodontitis and the detection of EBV was significant (OR = 6.199, 95% CI = 3.119-12.319, P < 0.001). In the disease-type analysis, the pooled ORs for chronic periodontitis and aggressive periodontitis were 6.586 (95% CI = 3.042-14.262, P < 0.001) and 8.361 (95% CI = 2.109-33.143, P = 0.003), respectively. In the subgroup analysis of ethnicity, our results suggested that high EBV-detecting frequencies were correlated with increased risks of periodontitis in Asians, Europeans, and Americans (P < 0.001). Subgroup analysis by the sample type showed that subgingival plaque (SgP) samples and tissue samples were available for EBV detecting (P < 0.001). Detecting EBV of samples in ≥5 (6) mm sites of periodontal pockets were easier than in ≤3-mm sites (P = 0.023).This meta-analysis indicates that high frequent detection of EBV correlates with increased risk of periodontal diseases. SgP and tissue are available for detecting EBV in patients of periodontitis. At last, our results suggest that detecting EBV of samples in =5 (6) mm sites of periodontal pockets are more sensitive than in ≤3-mm sites.
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Affiliation(s)
- Zilong Gao
- Department of Oral and Maxillofacial Surgery, Dongfeng Stomatology Hospital. The Genetal Hospital of Dongfeng, Hubei University of Medicine, Shiyan, China
| | - Juan Lv
- Department of Stomatology, HuaGuo Hospital of Dongfeng Auto Corporation, Shiyan, China
- Department of Stomatology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Min Wang
- Department of Oral Implantology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
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Alzahrani AA. Association between human herpes virus and aggressive periodontitis: A systematic review. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.sjdr.2016.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Jakovljevic A, Andric M, Knezevic A, Milicic B, Beljic-Ivanovic K, Perunovic N, Nikolic N, Milasin J. Herpesviral-bacterial co-infection in mandibular third molar pericoronitis. Clin Oral Investig 2016; 21:1639-1646. [PMID: 27620215 DOI: 10.1007/s00784-016-1955-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 09/05/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The aim of this study was to assess the presence of herpesviruses and periodontopathic bacteria and to establish their potential association with pericoronitis. MATERIALS AND METHODS Fifty samples obtained with paper points (30 from pericoronitis and 20 controls) were subjected to polymerase chain reaction (PCR) analysis. A single-stage and nested PCR assays were used to detect herpesviruses: human cytomegalovirus (HCMV) and Epstein-Barr virus (EBV) and six periodontopathic anaerobic bacteria: Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Parvimonas micra, Treponema denticola, and Tannarella forsythia. RESULTS Pericoronitis samples harbored HCMV and EBV at significantly higher rates than the control group (70 vs. 40 % and 46.7 vs. 15 %, P = 0.035, P = 0.021, respectively). P. micra and T. forsythia (66.7 vs. 0 %, and 40 vs. 10 %, P = 0.001, P = 0.021, respectively) were significantly more common in pericoronitis compared to the control group. Multivariate logistic regression analysis showed that the presence of T. forsythia was associated with pericoronitis development (OR 7.3, 95 % CI, 1.2-43.2, P = 0.028). CONCLUSION The occurrence of HCVM and EBV extends our previous knowledge on microbiota in pericoronitis. These PCR-based findings demonstrated that bacterial and viral DNA occurred concomitantly in pericoronitis samples. T. forsythia appeared to be significantly associated with pericoronitis development in the examined sample. CLINICAL RELEVANCE Herpesviral-bacterial co-infections might exacerbate the progression of pericoronitis.
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Affiliation(s)
- Aleksandar Jakovljevic
- Clinic of Oral Surgery and Implantology, School of Dental Medicine, University of Belgrade, dr. Subotica 4, Belgrade, 11 000, Serbia.
| | - Miroslav Andric
- Clinic of Oral Surgery and Implantology, School of Dental Medicine, University of Belgrade, dr. Subotica 4, Belgrade, 11 000, Serbia
| | - Aleksandra Knezevic
- Department of Virology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, dr. Subotica 1, Belgrade, 11 000, Serbia
| | - Biljana Milicic
- Department of Medical Statistics and Informatics, School of Dental Medicine, University of Belgrade, Dr. Subotica 1, Belgrade, 11 000, Serbia
| | - Katarina Beljic-Ivanovic
- Clinic of Restorative Dentistry and Endodontics, School of Dental Medicine, University of Belgrade, Rankeova 4, Belgrade, 11 000, Serbia
| | - Neda Perunovic
- Clinic of Periodontology and Oral Medicine, School of Dental Medicine, University of Belgrade, Dr. Subotica 4, Belgrade, 11 000, Serbia
| | - Nadja Nikolic
- Department of Biology and Human Genetics, School of Dental Medicine, University of Belgrade, Dr. Subotica 1, Belgrade, 11 000, Serbia
| | - Jelena Milasin
- Department of Biology and Human Genetics, School of Dental Medicine, University of Belgrade, Dr. Subotica 1, Belgrade, 11 000, Serbia
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Abstract
For decades, Aggregatibacter actinomycetemcomitans has been considered the most likely etiologic agent in aggressive periodontitis. Implementation of DNA-based microbiologic methodologies has considerably improved our understanding of the composition of subgingival biofilms, and advanced open-ended molecular techniques even allow for genome mapping of the whole bacterial spectrum in a sample and characterization of both the cultivable and not-yet-cultivable microbiota associated with periodontal health and disease. Currently, A. actinomycetemcomitans is regarded as a minor component of the resident oral microbiota and as an opportunistic pathogen in some individuals. Its specific JP2 clone, however, shows properties of a true exogenous pathogen and has an important role in the development of aggressive periodontitis in certain populations. Still, limited data exist on the impact of other microbes specifically in aggressive periodontitis. Despite a wide heterogeneity of bacteria, especially in subgingival samples collected from patients, bacteria of the red complex in particular, and those of the orange complex, are considered as potential pathogens in generalized aggressive periodontitis. These types of bacterial findings closely resemble those found for chronic periodontitis, representing a mixed polymicrobial infection without a clear association with any specific microorganism. In aggressive periodontitis, the role of novel and not-yet-cultivable bacteria has not yet been elucidated. There are geographic and ethnic differences in the carriage of periodontitis-associated microorganisms, and they need to be taken into account when comparing study reports on periodontal microbiology in different study populations. In the present review, we provide an overview on the colonization of potential periodontal pathogens in childhood and adolescence, and on specific microorganisms that have been suspected for their role in the initiation and progression of aggressive forms of periodontal disease.
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Rodrigues PMDS, Teixeira AL, Kustner EC, Medeiros R. Are herpes virus associated to aggressive periodontitis? A review of literature. J Oral Maxillofac Pathol 2015; 19:348-55. [PMID: 26980964 PMCID: PMC4774289 DOI: 10.4103/0973-029x.174621] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 11/23/2015] [Indexed: 12/20/2022] Open
Abstract
Periodontal Disease includes a wide variety of infectious entities with various clinical manifestations in the oral cavity and responses to treatment. The determinants of clinical manifestations of periodontal disease include the type of infectious agent, the host immune response and environmental factors. Aggressive periodontitis (AP) is defined as a type of inflammation with specific clinical and laboratory features, which distinguish it from other types of periodontitis, with high incidence rates in a sub-group of individuals. Bacteria have been frequently mentioned as the agent inciting gingival inflammation and tissue destruction that underlies the pathogenesis of periodontitis. However, recent studies, with some controversial results, have suggested that the herpes family of viruses, including CMV and EBV-1 as well as papillomaviruses, HIV, Human T-lymphotropic virus type 1, Torquetenovirus and hepatitis B and C occur with high frequency in active periodontal lesions. There is a lack of information about this disease and the role of herpesviruses in its pathophysiology. This review provides a critical analysis of the scientific evidence linking bacteria and viruses with AP and their potential impact on clinical characteristics, prognosis and therapy.
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Affiliation(s)
| | | | | | - Rui Medeiros
- Department of Virology, Portuguese Institute of Oncology of Oporto, Portugal
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Khosropanah H, Karandish M, Ziaeyan M, Jamalidoust M. Quantification of Epstein-Barr Virus and Human Cytomegalovirus in Chronic Periodontal Patients. Jundishapur J Microbiol 2015; 8:e18691. [PMID: 26322203 PMCID: PMC4548403 DOI: 10.5812/jjm.8(5)2015.18691] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 06/15/2014] [Accepted: 11/18/2014] [Indexed: 11/20/2022] Open
Abstract
Background: Although studies focused mainly on the identification of periopathogenic bacteria, recent reports have suggested that various herpes viruses may also be involved in the occurrence and progression of different forms of periodontal diseases. Objectives: This study aimed to compare the prevalence and load of Epstein-Barr Virus (EBV) and Human Cytomegalovirus (HCMV) in subgingival tissue specimens between chronic periodontitis and healthy sites. Patients and Methods: A total of 60 samples from the systematically healthy patients with chronic periodontitis participated in this study (mean age, 35 ± 7). Clinical periodontal evaluation included the plaque index (PI) (Loe and Silness), bleeding on probing (BOP) (O’Leary), bleeding index, periodontal pocket depth (PPD) and clinical attachment level measurement. Tissue specimens harvested from > 6 mm periodontal pockets and from ≤ 3 mm sulcus depth in a quadrant of the same patient using periodontal curettes. Moreover, the unstimulated whole saliva was gathered as a shedding medium. A Taq-man Real-Time Polymerase Chain Reaction assay was used to identify genomic copies of periodontal HCMV and EBV. Data were analyzed by the Wilcoxon-signed ranks and Friedman tests using the SPSS 16 software. Results: Out of 60 samples of subgingival tissues taken from the patients with chronic periodontitis, EBV count was the highest in saliva and the least in the tissue sample with PD < 3 mm (P < 0.05). The highest HCMV count was in saliva and tissue samples with PD > 6 mm (P < 0.05). Conclusions: According to the results of this study, quantification of HCMV and EBV observed in this study is high in periodontal tissue samples of severe chronic periodontitis.
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Affiliation(s)
- Hengameh Khosropanah
- Periodontology Department, Dental School, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Maryam Karandish
- Orthodontic Department, Dental School, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding author: Maryam Karandish, Orthodontic Department, Dental School, Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel: +98-9173376586, E-mail:
| | - Mazyar Ziaeyan
- Professor Alborzi Clinical Microbiology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Marzieh Jamalidoust
- Professor Alborzi Clinical Microbiology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, IR Iran
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Abstract
Periodontal diseases (gingivitis and periodontitis) are chronic bacterial infections with a remarkably high prevalence and morbidity. Periodontitis, in contrast to gingivitis, is not reversible, is associated with certain bacterial species and affects all of the soft tissue and bone that support teeth. Among the periodontal pathogens, species, such as Aggregatibacter (Actinobacillus) actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythensis, and several forms of uncultivable spirochetes play the major role in the pathogenesis. In severe chronic, recurrent and especially aggressive forms of periodontitis, diagnosis of the species involved and, whenever possible, an optimized evidence-based antimicrobial treatment is indicated. In order to monitor alarming bacterial changes in the periodontal pocket, several techniques, namely microscopy, culture, immunoassays, enzyme tests and DNA-based techniques, have been established and the methods are described in the first part of this review. In the second part, the selection and use of locally delivered (topical) and systemic antibiotics used adjunctively in periodontal therapy are discussed.
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Affiliation(s)
- Hans-Peter Horz
- Division of Oral Microbiology and Immunology, Department of Operative and Preventive Dentistry and Periodontology, University Hospital RWTH Aachen, Aachen, Germany.
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Stein JM, Said Yekta S, Kleines M, Ok D, Kasaj A, Reichert S, Schulz S, Scheithauer S. Failure to detect an association between aggressive periodontitis and the prevalence of herpesviruses. J Clin Periodontol 2012; 40:1-7. [PMID: 23163882 DOI: 10.1111/jcpe.12021] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Revised: 08/01/2012] [Accepted: 09/09/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Herpes simplex virus type 1 (HSV-1), human cytomegalovirus (HCMV) and Epstein-Barr virus (EBV) have been suspected to play a causal role in periodontitis pathogenesis. The aim of this study was to determine the prevalence of these viruses in subgingival plaque samples of Caucasian patients with generalized aggressive periodontitis compared to periodontally healthy controls. METHODS A total of 65 patients with aggressive periodontitis and 65 unmatched controls from Germany were investigated in the study. Subgingival plaque samples were analysed for the presence of HSV-1, EBV and HCMV by quantitative real-time polymerase chain reaction assays. Viral antibody titres were determined quantitatively by immunosorbent assays. RESULTS DNA of HSV-1 and HCMV were detected in 1.5% of the patients and controls, whereas EBV DNA was present in 10.8% and 13.9% respectively. Detection rates of serum IgG against HSV-1 (76.1% versus 73.9%), EBV (98.5% versus 96.9%), HCMV (47.7% versus 46.2%) and IgM levels against HSV-1 (6.2% versus 1.5%), EBV (0% versus 0%), HCMV (0% versus 1.5%) did not significantly differ between patients and controls. CONCLUSION The data of our study do not suggest any contribution of HSV-1, EBV or HCMV to aggressive periodontitis in a German population. Ethnic and methodological aspects might have caused conflicting results of previous studies.
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Affiliation(s)
- Jamal M Stein
- Department of Operative Dentistry, Periodontology and Preventive Dentistry, University Hospital, Aachen, Germany.
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Das S, Krithiga GSP, Gopalakrishnan S. Detection of human herpes viruses in patients with chronic and aggressive periodontitis and relationship between viruses and clinical parameters. J Oral Maxillofac Pathol 2012; 16:203-9. [PMID: 22923891 PMCID: PMC3424935 DOI: 10.4103/0973-029x.98502] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS Recent microbiological researches have revealed the possible role of human cytomegalovirus (HCMV), Epstein barr virus (EBV), and herpes simplex virus (HSV-1 and HSV-2) in the etiopathogenesis of periodontal diseases. The present pilot study has been undertaken to detect the presence of these viruses in chronic periodontitis, aggressive periodontitis, and healthy individuals and to determine the relationship between these viruses and the clinical parameters. MATERIALS AND METHODS A total of 10 patients belonging to the age group of 18 to 55 years were included. The patients were randomly assigned into periodontally healthy (sulcus depth ≤ 3 mm), chronic periodontitis, and aggressive periodontitis with pockets measuring ≥6 mm. Seventy-five subgingival plaque samples (25 samples from each group) were collected and subjected to multiplex polymerase chain reaction for the detection of presence of HCMV, EBV, HSV-1, and HSV-2. The results were analyzed using one-way ANOVA for multiple group comparisons followed by Student's t-test for pair-wise comparisons. Categorical data was analyzed by Fisher's exact test. RESULTS HSV-1 was detected in 76% (P<0.001) of sites with chronic periodontitis and 80% (P<0.001) sites with aggressive periodontitis. EBV was detected in 32% (P<0.05) of sites with chronic periodontitis and aggressive periodontitis. The probing pocket depth and clinical attachment level was statistically significant in HSV-1 detected sites compared with undetected sites in aggressive periodontitis patients CONCLUSION Among these viruses HSV-1 and EBV were found to be significantly associated with destructive periodontal disease, including chronic and aggressive periodontitis. Further, HSV-1 was found to be associated with severity and progression of destructive periodontal disease.
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Affiliation(s)
- Sushma Das
- Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India
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Bertoldi C, Pellacani C, Lalla M, Consolo U, Pinti M, Cortellini P, Cossarizza A. Herpes Simplex I virus impairs regenerative outcomes of periodontal regenerative therapy in intrabony defects. A pilot study. J Clin Periodontol 2012; 39:385-92. [DOI: 10.1111/j.1600-051x.2012.01850.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2011] [Indexed: 11/27/2022]
Affiliation(s)
- Carlo Bertoldi
- Department of Specialistic Surgeries Head-Neck; University of Modena and Reggio Emilia; Modena; Italy
| | - Chiara Pellacani
- Department of Specialistic Surgeries Head-Neck; University of Modena and Reggio Emilia; Modena; Italy
| | - Michele Lalla
- Chair of Statistics; Department of Political Economy; University of Modena and Reggio Emilia; Modena; Italy
| | - Ugo Consolo
- Department of Specialistic Surgeries Head-Neck; University of Modena and Reggio Emilia; Modena; Italy
| | - Marcello Pinti
- Department of Biomedical Sciences; University of Modena and Reggio Emilia; Modena; Italy
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Gutiérrez-Venegas G, Rodríguez-Pérez CE. Toll-like receptor 3 activation promotes desensitization of histamine response in human gingival fibroblasts: Poly (I:C) induces histamine receptor desensitization in human gingival fibroblasts. Cell Immunol 2012; 273:150-7. [PMID: 22285102 DOI: 10.1016/j.cellimm.2011.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 09/09/2011] [Accepted: 12/12/2011] [Indexed: 02/08/2023]
Abstract
Viruses are associated with the development of periodontal disease, particularly during periods of suppressed cellular immunity. For this reason, we evaluated the hypothesis that viral components regulate the actions of histamine, an important mediator of immune responses. We assessed the effect of Poly (I:C) on histamine-mediated intracellular calcium mobilization in human gingival fibroblasts. Our results show that histamine induces an increase in intracellular calcium concentrations in a dose-dependent manner. This response was blocked when cells were incubated in the presence of Poly (I:C). In addition, phorbol esters, a diacylglycerol analog, mimics the inhibitory actions of Poly (I:C) in response to histamine. The effect of Poly (I:C) was reversed by Stuarosporine (1 μM), GÖ6983 (7 μM), Bisindolylmaleimide (1 μM) [a protein inhibitor (PKC)], and SB 203580 (3 μM) (a p38-MAPK inhibitor). These findings suggest that Poly (I:C) regulates histamine-induced calcium mobilization through activation of PKC and p38.
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Affiliation(s)
- Gloria Gutiérrez-Venegas
- Laboratorio de Bioquímica División de Estudios de Posgrado e Investigación, Facultad de Odontología, Universidad Nacional Autónoma de México, Mexico.
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Ereş G, Altıok E, Özkul A, Açıkel CH. Subgingival Epstein-Barr and Cytomegalovirus Occurrence in Pregnancy Gingivitis. J Periodontol 2011; 82:1676-84. [DOI: 10.1902/jop.2011.100587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Thomasini RL, Bonon SH, Durante P, Costa SCB. Correlation of cytomegalovirus and human herpesvirus 7 with CD3+ and CD3+ CD4+ cells in chronic periodontitis patients. J Periodontal Res 2011; 47:114-20. [PMID: 21895663 DOI: 10.1111/j.1600-0765.2011.01413.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Human chronic periodontitis is an inflammatory process characterized by dense accumulation of immune cells in the periodontal tissue. The periodontitis can lead to loss of teeth in the patient and the pathogenesis of this disease is not completely known. This study tested the hypothesis that chronic periodontitis-affected sites can harbor betaherpesviruses and that viruses are linked to a profile of the inflammatory infiltrate. MATERIAL AND METHODS Biopsies of periodontal tissue were taken from periodontitis-affected patients and from healthy subjects. Immunohistochemistry was performed to count CD19(+) B cells, CD3(+) total T cells, T-CD4(+) and T-CD8(+) cell subsets, and PCR was performed to detect cytomegalovirus and human herpesvirus 6 and 7 in the samples. One slide of each sample was stained with Giemsa for histopathological examination and to evaluate the quality of the cellular infiltrate. RESULTS As expected, tissues collected from healthy subjects presented no significant level of inflammatory infiltration and were therefore excluded from immunostaining procedures. Results showed that CD19(+) B cells were in higher number than CD3(+) T cells in the periodontitis-affected tissue, but this was not statistically significant. The T-CD4(+) lymphocyte subset was significantly higher than the T-CD8(+) lymphocyte subset (p = 0.004) in the samples. Cytomegalovirus and human herpesvirus 7 were found at periodontitis-affected sites, but not in tissue collected from healthy subjects (p = 0.04 and p = 0.04, respectively). Human herpesvirus 6 was rarely detected. We found a correlation between cytomegalovirus and lower CD19(+) /CD3(+) ratios (ratio < 0.9, p = 0.003) and between human herpesvirus 7 and lower CD19(+) /CD3(+) ratios (ratio < 0.9, p = 0.003) and higher CD4(+) /CD8(+) ratios (ratio > 1.1, p = 0.002). CONCLUSION This study shows that cytomegalovirus and human herpesvirus 7 can be present at periodontitis-affected sites but are uncommon at healthy periodontal sites. Moreover, our data suggest that cytomegalovirus can be related to an inflammatory infiltrate with predominance of CD3(+) T cells, whereas human herpesvirus 7 can be associated with an infiltrate with predominance of T-CD4(+) cells. However, further studies are necessary to support this hypothesis. Herpesviruses could play a role in human chronic periodontitis by modulation of the T cell response.
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Affiliation(s)
- R L Thomasini
- Department of Clinical Medicine, State University of Campinas, UNICAMP, Campinas, São Paulo, Brazil.
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Mahanonda R, Sa-Ard-Iam N, Rerkyen P, Champaiboon C, Vanavit N, Pichyangkul S. Innate antiviral immunity of periodontal tissue. Periodontol 2000 2011; 56:143-53. [DOI: 10.1111/j.1600-0757.2010.00378.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Horewicz VV, Feres M, Rapp GE, Yasuda V, Cury PR. Human papillomavirus-16 prevalence in gingival tissue and its association with periodontal destruction: a case-control study. J Periodontol 2010; 81:562-8. [PMID: 20367098 DOI: 10.1902/jop.2009.090571] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Human papillomavirus (HPV)-16 is detected in normal oral mucosa and several oral lesions, including squamous cell carcinoma, condyloma acuminatum, verruca vulgaris, focal epithelial hyperplasia, and periodontal diseases. It was hypothesized that HPV may be involved in periodontal breakdown and that periodontal tissue acts as a reservoir for the virus. Therefore, in this study, the prevalence of HPV-16 in the gingival tissue of Brazilians with periodontal health or disease is investigated. METHODS Fifty-six gingival samples from subjects with chronic periodontitis, 26 samples from subjects with gingivitis, and 22 samples from subjects with healthy peridontium were analyzed. Total DNA was extracted, and the presence of HPV-16 was assessed using a real-time polymerase chain reaction. Positive and negative controls were included in the reactions. RESULTS HPV-16 was not detected in any of the 104 gingival samples evaluated; therefore, this virus showed no association with periodontal disease in this study. CONCLUSION In the population studied, HPV-16 may not have participated in the pathogenesis of chronic periodontitis, and the gingival tissue did not act as a reservoir for this virus.
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Affiliation(s)
- Verônica V Horewicz
- Research Group on Periodontal Disease, Department of Periodontics, School of Dentistry, Federal University of Bahia, Salvador, BA, Brazil
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Nibali L, Atkinson C, Griffiths P, Darbar U, Rakmanee T, Suvan J, Donos N. Low prevalence of subgingival viruses in periodontitis patients. J Clin Periodontol 2009; 36:928-32. [PMID: 19811582 DOI: 10.1111/j.1600-051x.2009.01476.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Viruses such as Human Cytomegalovirus (HCMV) and Epstein-Barr virus (EBV) have been proposed to be periodontal pathogens. The aim of this study was to analyse the presence of herpesvirus DNA in subgingival plaque samples of patients with different forms of periodontitis and in healthy periodontia. MATERIALS AND METHODS A total of 140 ethnically mixed (prevalently Caucasian) subjects took part in the study. Sixteen were affected by localized aggressive periodontitis (LAgP), 64 by generalized aggressive periodontitis (GAgP), 20 by chronic periodontitis (CP) and 40 were periodontally healthy. Polymerase chain reaction (PCR) analyses were performed to detect HCMV and EBV. Sera were tested for anti-HCMV and EBV IgG antibodies. PCRs for herpes simplex (HSV) and varicella zoster virus (VZV) were performed in subgingival samples from a subset of 20 AgP subjects. RESULTS HCMV DNA was not detected in any plaque samples. EBV DNA was detected in four LAgP (25%), two GAgP (3%) subjects and four healthy individuals (10%). HSV DNA and VZV DNA were not detected in the subset of studied individuals. CONCLUSIONS This study challenges the previously reported high prevalence of herpesvirus DNA in subgingival samples from periodontitis patients and so questions whether they act as pathogens in such patients.
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Affiliation(s)
- Luigi Nibali
- Periodontology Unit, Eastman Dental Institute, London WC1X 8LD, UK
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28
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Passariello C, Palamara A, Garaci E, Pasquantonio G. Herpesviruses and periodontal disease: a cautionary tale. Int J Immunopathol Pharmacol 2009; 22:263-8. [PMID: 19505379 DOI: 10.1177/039463200902200202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Periodontitis is an inflammatory disease of bacterial origin, characterized by an inconstant progression of lesions affecting the tooth supporting tissues. In spite of more than half a century of research efforts, the clinician still lacks any specific molecular or microbial diagnostic tool to predict the progression of periodontal lesions. Recently, several reports have proposed a role for some herpesviruses in the etiology of destructive phases of periodontitis. This paper critically analyzes these data in the light of consolidated knowledge that was developed in the characterization of virus-bacteria cooperative interactions, and proposes new topics of investigation to clarify the role of herpesviral infections in periodontitis and their potential predictive role as markers of progression.
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Rotola A, Cassai E, Farina R, Caselli E, Gentili V, Lazzarotto T, Trombelli L. Human herpesvirus 7, Epstein-Barr virus and human cytomegalovirus in periodontal tissues of periodontally diseased and healthy subjects. J Clin Periodontol 2008; 35:831-7. [PMID: 18691217 DOI: 10.1111/j.1600-051x.2008.01301.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIMS To evaluate (i) the presence of human herpesvirus 7 (HHV-7), Epstein-Barr virus (EBV) and human cytomegalovirus (HCMV), and (ii) the transcription pattern of HHV-7 in gingival biopsies from patients affected by periodontitis (P) and periodontally healthy subjects (H). MATERIAL AND METHODS Thirty-seven subjects (P: n=24; H: n=13) were included. Each P patient contributed two gingival biopsies (representative of a clinically affected and non-affected site) and each H subject contributed one gingival biopsy. After DNA extraction, nested polymerase chain reaction was used to identify the viruses. RESULTS HHV-7 was detected in 91.7% of P patients and in 61.5% of H subjects (p=0.02), EBV in 50.0% samples of P patients and 7.7% of H subjects (p=0.005) and HCMV only in one sample from H group. EBV was more frequently detected in biopsies from affected sites (50.0%) than from non-affected sites (16.7%) (p=0.008). HHV-7 transcription was detected in 15.4% of affected and 15.4% of non-affected sites. CONCLUSIONS The results indicate that (i) gingival tissues can be considered a potential reservoir for HHV-7; (ii) when present, HHV-7 persists in a latent state in the majority of cases; (iii) the presence of EBV seems to be associated with the diseased state of the patient and site.
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Affiliation(s)
- Antonella Rotola
- Section of Microbiology, Department of Experimental and Diagnostic Medicine, University of Ferrara, Ferrara, Italy
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Imbronito AV, Grande SR, Freitas NMD, Okuda O, Lotufo RFM, Nunes FD. Detection of Epstein-Barr virus and human cytomegalovirus in blood and oral samples: comparison of three sampling methods. J Oral Sci 2008; 50:25-31. [DOI: 10.2334/josnusd.50.25] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Ana V. Imbronito
- Departments of Periodontology, Dental School, University of São Paulo
| | - Sabrina R. Grande
- Departments of Periodontology, Dental School, University of São Paulo
- Department of Oral Pathology, Dental School, University of São Paulo
| | | | - Osmar Okuda
- Departments of Periodontology, Dental School, University of São Paulo
| | | | - Fabio D. Nunes
- Department of Oral Pathology, Dental School, University of São Paulo
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Meng H, Xu L, Li Q, Han J, Zhao Y. Determinants of host susceptibility in aggressive periodontitis. Periodontol 2000 2007; 43:133-59. [PMID: 17214839 DOI: 10.1111/j.1600-0757.2006.00204.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Huanxin Meng
- Department of Periodontology, Peking University, School and Hospital of Stomatology, Beijing, China
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Yildirim S, Yapar M, Kubar A. Detection and quantification of herpesviruses in Kostmann syndrome periodontitis using real-time polymerase chain reaction: a case report. ACTA ACUST UNITED AC 2006; 21:73-8. [PMID: 16476015 DOI: 10.1111/j.1399-302x.2006.00250.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/AIMS Kostmann syndrome, or severe congenital neutropenia, is an autosomal recessive disease of neutrophil production and is associated with severe periodontal pathology. The aim of this study was to determine whether human cytomegalovirus (HCMV) and Epstein-Barr virus (EBV) contribute to the pathogenesis of Kostmann syndrome periodontitis. METHODS Supragingival plaque and saliva samples were taken from a 6-year-old boy and his 3-year-old sister suffering from Kostmann syndrome, and from two age- and gender-matched healthy children serving as controls. The samples were taken before and 24 months after periodontal treatment. Real-time polymerase chain reaction (TaqMan Real-Time PCR) assay was used to quantify HCMV and EBV DNA. RESULTS EBV was detected in baseline samples from the Kostmann syndrome patients but not in samples from the healthy control subjects. HCMV was only detected in the saliva of the boy with Kostman syndrome at baseline. Herpesviruses numbers decreased dramatically in the post-treatment samples. CONCLUSION EBV and HCMV were detected in the two subjects with Kostmann syndrome periodontitis. The results of the study indicate that nonsurgical treatment of Kostmann syndrome periodontitis can reduce supragingival and salivary herpes viral loads.
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Affiliation(s)
- S Yildirim
- Selçuk University, Faculty of Dentistry, Department of Pediatric Dentistry, Konya, Turkey.
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Yildirim S, Yapar M, Kubar A, Slots J. Human cytomegalovirus, Epstein-Barr virus and bone resorption-inducing cytokines in periapical lesions of deciduous teeth. ACTA ACUST UNITED AC 2006; 21:107-11. [PMID: 16476020 DOI: 10.1111/j.1399-302x.2006.00268.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND A connection of herpesvirus periapical infection with symptomatic and large-size periapical lesions has been recognized in adult patients, but no data exist about a possible involvement of herpesviruses in severe periapical pathosis in children. Herpesviruses have the potential to elicit potent bone resorption-inducing cytokines in mammalian cells. AIM This study aimed to determine the occurrence of human cytomegalovirus and Epstein-Barr virus DNA, and mRNA transcripts of receptor activator of nuclear kappa B ligand (RANKL), osteoprotegerin, core binding factor alpha-1, colony stimulating factor-1, transforming growth factor-beta, and monocyte chemoattractant protein-1 in periapical symptomatic pathosis of deciduous teeth. MATERIAL AND METHODS Twelve deciduous molar teeth from patients aged 2-8 years were extracted due to severe periapical infection, and granulomatous tissue adherent to the root tip of the extracted teeth was collected using a surgical knife. Non-diseased pulpal tissue, obtained from 12 teeth extracted for orthodontic reasons, served as negative control. Polymerase chain reaction assays were employed to identify herpesvirus DNA and cytokine gene expression, using established polymerase chain reaction primers and procedures. RESULTS Seven (58%) of the periapical lesions yielded human cytomegalovirus and eight (67%) Epstein-Barr virus. Only one (8%) periapical lesion showed neither human cytomegalovirus nor Epstein-Barr virus. In healthy pulpal tissue, one (8%) specimen demonstrated human cytomegalovirus and another (8%) specimen revealed Epstein-Barr virus. Of the cytokines examined, RANKL expression showed significantly higher occurrence in periapical pathosis than in healthy pulpal tissue (P < 0.040). No relationship was identified between the type of herpesvirus and cytokine expression in the periapical lesions studied. CONCLUSIONS The present findings provide evidence of a putative role of human cytomegalovirus and Epstein-Barr virus in the pathogenesis of symptomatic periapical pathosis in deciduous teeth. Increased RANKL expression in periapical lesions may be of pathogenetic significance.
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Abstract
The purpose of this review was to evaluate the evidence supporting the hypothesis that viral infection plays a role in the development of periodontitis. An involvement in periodontal diseases has been suspected specifically for human immunodeficiency virus (HIV) and herpes viruses. An association has been demonstrated between HIV infection and some distinct forms of periodontal infection, i.e. necrotizing lesions. Furthermore, reports of increased prevalence and severity of chronic periodontitis in HIV-positive subjects suggests that HIV infection predispose to chronic periodontitis. Several studies, most of them from the same research group, have demonstrated an association of herpesviruses with periodontal disease. Viral DNA have been detected in gingival tissue, gingival cervicular fluid (GCF) and subgingival plaque from periodontaly diseased sites. In addition markers of herpesviral activation have been demonstrated in the GCF from periodontal lesions. Active human cytomegalovirus (HCMV) replication in periodontal sites may suggest that HCMV re-activation triggers periodontal disease activity. Concerns regarding sampling, methods and interpretation cast doubts on the role of viruses as causes of periodontal disease.
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Affiliation(s)
- I Cappuyns
- School of Dental Medicine, University of Geneva, Geneva, Switzerland.
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Hormia M, Willberg J, Ruokonen H, Syrjänen S. Marginal periodontium as a potential reservoir of human papillomavirus in oral mucosa. J Periodontol 2005; 76:358-63. [PMID: 15857068 DOI: 10.1902/jop.2005.76.3.358] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although human papillomaviruses (HPVs) are associated with a number of proliferative epithelial lesions including squamous cell malignancies, they can also be detected in the normal oral mucosa in 10% to 20% of the adult population. However, the point of entry and the site of replication of HPV in the oral cavity are not known. Since the gingival pocket is the only site in the oral mucosa where basal cells, known to be targets of HPV at other mucosal sites, are normally exposed to the environment, we hypothesized that this could be the site of latent HPV. METHODS Gingival biopsies taken from 38 individuals with clinically diagnosed periodontal disease were examined. The presence of HPV DNA was studied by using nested PCR (polymerase chain reaction with MY09/MY11 and GP05+/GP06+ primers targeting the L1 region of HPV), followed by subsequent hybridization with a cocktail of 12 high-risk HPV oligoprobes and in situ hybridization (ISH) with probes for HPV screening and the HPV subtype 16. RESULTS In the present study, high-risk HPV types were detected in 26% (8/31) of the gingival biopsies with PCR. By using in situ hybridization, the viral DNA was localized to the coronal part of the junctional epithelium in the gingival pocket. CONCLUSIONS The results suggest that the periodontal pocket might serve as a reservoir of HPVs in oral mucosa. While having important implications in understanding the HPV transmission, this observation does not rule out the possibility that HPV may be involved in the initiation of periodontal disease.
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Affiliation(s)
- Marketta Hormia
- Department of Anatomy, Institute of Biomedicine, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Affiliation(s)
- Jørgen Slots
- School of Dentistry, University of Southern California, Los Angeles, CA, USA
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Saygun I, Kubar A, Ozdemir A, Slots J. Periodontitis lesions are a source of salivary cytomegalovirus and Epstein-Barr virus. J Periodontal Res 2005; 40:187-91. [PMID: 15733155 DOI: 10.1111/j.1600-0765.2005.00790.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Several herpesvirus species can be detected in periodontal pockets and saliva. This study compared human cytomegalovirus (HCMV) and Epstein-Barr virus (EBV) DNA copy counts in periodontitis sites and in whole saliva, and evaluated the potential of periodontal therapy to reduce the salivary level of the two viruses. MATERIAL AND METHODS A total of 20 systemically healthy periodontitis patients, 21-56 years of age, participated in the study. All 20 patients were examined at baseline, and seven patients also at 3 months after periodontal therapy. Treatment included oral hygiene instruction, scaling and root planing, and surgery. Clinical parameters were evaluated using established methods. In each patient, virological samples were collected from one periodontal pocket of 6-10 mm probing depth, from the adjacent inflamed periodontal pocket wall, and from unstimulated whole saliva. Relationships between subgingival, gingival tissue and salivary herpesvirus counts were evaluated using Spearman's and Kendall's rank correlation coefficient tests. The 5'-nuclease (TaqMan) real-time polymerase chain reaction (PCR) assay was employed to quantify genomic copies of periodontal HCMV and EBV. RESULTS At baseline, the 20 periodontitis patients showed significant positive correlations between gingival tissue and salivary counts of HCMV DNA (p=0.003) and EBV DNA (p=0.045). Periodontal pocket depth was positively correlated with salivary EBV DNA counts (p=0.002). Periodontal therapy reduced average full-mouth periodontal pocket depth from 4.6 mm to 1.4 mm, plaque index from 2.1 to 0.9, and gingival index from 2.1 to 0.4. Following treatment, HCMV DNA counts decreased 37.5 fold in subgingival sites and 64.6 fold in saliva, and EBV DNA counts decreased 5.7 fold in subgingival sites and 12.9 fold in saliva. CONCLUSIONS The present study provides compelling evidence of a periodontitis source for salivary HCMV and EBV. The potential of periodontal therapy to decrease herpesvirus salivary counts may help diminish herpesvirus transmission from person to person and herpesvirus-related diseases in exposed individuals. Further research is warranted to determine the relationship between periodontal herpesvirus counts and the risk of viral transmission to close acquaintances.
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Affiliation(s)
- Işil Saygun
- Department of Periodontology, Gülhane Military Medical Academy, Ankara, Turkey.
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Abstract
AIM Human cytomegalovirus (HCMV), a herpesvirus, is discussed in this review as it relates to destructive periodontal disease in humans. RESULTS HCMV genomic sequences, detected by polymerase chain reaction identification, occur with elevated frequency in severe adult periodontitis, localized and generalized aggressive (juvenile) periodontitis, Papillon-Lefèvre syndrome periodontitis, acute necrotizing ulcerative gingivitis, and periodontal abscesses. DISCUSSION Herpesviruses establish lifelong persistent infections. HCMV infection involves an asymptomatic latent phase interrupted by periods of recrudescence where viral replication and possibly clinical disease become manifest. HCMV reactivation is triggered by a number of immunosuppressive factors, some of which have been shown also to be risk factors/indicators of periodontitis. HCMV periodontal infection may cause release of tissue-destructive cytokines, overgrowth of pathogenic periodontal bacteria, and initiation of cytotoxic or immunopathologic events. CONCLUSIONS A growing body of data supports the concept that HCMV contributes to severe types of periodontal disease. HCMV infection of the periodontium may alter the immune control of resident microorganisms and be important in a multistage pathogenesis of periodontitis involving viral activation, periodontopathic bacteria, and host immune responses. Understanding the significance of HCMV and other herpesviruses in the development of periodontal disease may have important therapeutic implications. Vaccines against HCMV, which are in various stages of development, need to be evaluated for their ability to decrease the incidence of destructive periodontal disease.
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Affiliation(s)
- J Slots
- University of Southern California, School of Dentistry, Los Angeles, CA 90089-0641, USA.
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Allen EP, Bayne SC, Cronin RJ, Donovan TE, Kois JC, Summitt JB. Annual review of selected dental literature: report of the committee on scientific investigation of the American academy of restorative dentistry. J Prosthet Dent 2004; 92:39-71. [PMID: 15232563 DOI: 10.1016/j.prosdent.2004.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Edward P Allen
- Department of Periodontics, Baylor College of Dentistry, Dallas, Tex 75231, USA.
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