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Ito H, Numabe Y, Hashimoto S, Sekino S, Murakashi E, Ishiguro H, Sasaki D, Yaegashi T, Takai H, Mezawa M, Ogata Y, Watanabe H, Izumi Y, Kido JI, Hiroshima Y, Nagata T. Utility of a haemoglobin test of gingival crevicular fluid: A multicentre, observational study. Oral Dis 2024; 30:1533-1542. [PMID: 36790046 DOI: 10.1111/odi.14536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/06/2022] [Accepted: 02/12/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE The purpose of this study was to verify the accuracy and utility of clinical parameters (plaque index, gingival crevicular fluid volume, probing depth, clinical attachment level, bleeding on probing and gingival index) and biochemical parameters (aspartate aminotransferase, protein and haemoglobin) in a longitudinal analysis during the supportive periodontal therapy period. SUBJECTS AND METHODS A total of 279 test sites of 128 patients were investigated clinically and biochemically. After the first examination of clinical and biochemical parameters, periodontal support treatments were administered immediately and performed once every three months up to the second examination. RESULTS All of the clinical and biochemical parameters were significantly lower at the second examination than at the first, except for the plaque index and bleeding on probing. Of these parameters, in particular, aspartate aminotransferase and haemoglobin in the gingival crevicular fluid were significantly reduced compared to those of the first examination in both the ≤4 and ≥5 mm probing depth groups, and they clearly suggested that periodontitis tended to recover. CONCLUSION Adding the haemoglobin test to the bleeding on probing test strongly improves the accuracy of measurement of clinical parameters after periodontal treatment.
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Affiliation(s)
- Hiroshi Ito
- Department of Periodontology, School of Life Dentistry at Tokyo, The Nippon Dental University, Chiyoda-ku, Japan
| | - Yukihiro Numabe
- Department of Periodontology, School of Life Dentistry at Tokyo, The Nippon Dental University, Chiyoda-ku, Japan
| | | | - Satoshi Sekino
- Department of Periodontology, School of Life Dentistry at Tokyo, The Nippon Dental University, Chiyoda-ku, Japan
| | - Etsuko Murakashi
- Department of Periodontology, School of Life Dentistry at Tokyo, The Nippon Dental University, Chiyoda-ku, Japan
| | - Hitomi Ishiguro
- Department of Periodontology, School of Life Dentistry at Tokyo, The Nippon Dental University, Chiyoda-ku, Japan
| | - Daisuke Sasaki
- Department of Conservative Dentistry and Oral Rehabilitation, Division of Periodontology, Iwate Medical University School of Dentistry, Morioka, Japan
| | - Takashi Yaegashi
- Department of Conservative Dentistry and Oral Rehabilitation, Division of Periodontology, Iwate Medical University School of Dentistry, Morioka, Japan
| | - Hideki Takai
- Department of Periodontology, Nihon University School of Dentistry at Matsudo, Matsudo, Japan
| | - Masaru Mezawa
- Department of Periodontology, Nihon University School of Dentistry at Matsudo, Matsudo, Japan
| | - Yorimasa Ogata
- Department of Periodontology, Nihon University School of Dentistry at Matsudo, Matsudo, Japan
| | - Hisashi Watanabe
- Section of Periodontology, Department of Hard Tissue Engineering, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Bunkyo-ku, Japan
| | - Yuichi Izumi
- Section of Periodontology, Department of Hard Tissue Engineering, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Bunkyo-ku, Japan
| | - Jun-Ichi Kido
- Department of Periodontology and Endodontology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Yuka Hiroshima
- Oral Microbiology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Toshihiko Nagata
- Department of Periodontology and Endodontology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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Shankar S, Manjunath S, Alqahtani SM, Ganji KK, Nagate RR, Ghokale ST, Nagarajappa AK, Javali MA, Tikare S, Khader MA. Variations of Serum CRP Levels in Periodontal Health and Diseases: A Clinico-Biochemical Study. Diagnostics (Basel) 2023; 13:2483. [PMID: 37568846 PMCID: PMC10417054 DOI: 10.3390/diagnostics13152483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/16/2023] [Accepted: 07/19/2023] [Indexed: 08/13/2023] Open
Abstract
This study aimed to quantify serum C-reactive protein (CRP) values in periodontally healthy people and explore the relationship between serum CRP levels and chronic periodontitis, and the influence of scaling as well as root planing (SRP) on serum CRP levels. The study included 100 systemically healthy adults (n = 100; 50 males and 50 females) who were separated into two groups: Group A (control) n = 50; periodontally healthy subjects and Group B (test) n = 50; subjects with chronic periodontitis. The test group (group B) was further separated randomly into two groups: B1 (n = 25) and B2 (n = 25). The clinical parameters and serum CRP levels were measured only once in Group A and before SRP in Group B1 subjects. In Group B2 subjects the clinical parameters and serum CRP levels were measured only after two months following SRP. For group A, B1, and B2 (the readings recorded after SRP) the mean gingival index scores were 0.146, 2.437, and 1.052, respectively, while the plaque index was 0.414, 2.499, and 0.954, respectively. Probing pocket depth (PPD) and clinical attachment loss (CAL) showed statistically significant differences between three groups, with higher values in patients with periodontitis before intervention (2.196 ± 0.49; 1.490 ± 0.23), respectively. Healthy controls (Group A) had a C-reactive protein level of 0.04820 mg/dL, while group B1 (test) had 1.678 mg/dL and 0.8892 mg/dL (group B2). C-reactive protein levels were observed to be greater in the test group (groups B1 and B2), and these differences were statistically significant (p < 0.001). Chronic periodontitis enhances blood levels of systemic inflammatory markers like CRP, which has been reduced by periodontal treatment with SRP.
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Affiliation(s)
| | - Shiva Manjunath
- Department of Periodontics, Institute of Dental Sciences, Bareilly 243006, India;
| | - Saad Mohammad Alqahtani
- Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (S.M.A.); (R.R.N.); (M.A.J.); (S.T.); (M.A.K.)
| | - Kiran Kumar Ganji
- Department of Preventive Dentistry, College of Dentistry, Jouf University, Sakaka 72345, Saudi Arabia
- Department of Periodontics & Implantology, Datta Meghe Institute of Higher Education & Research, Sharad Pawar Dental College, Sawangi (Meghe), Wardha 442107, India
| | - Raghavendra Reddy Nagate
- Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (S.M.A.); (R.R.N.); (M.A.J.); (S.T.); (M.A.K.)
| | - Shankar T. Ghokale
- Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (S.M.A.); (R.R.N.); (M.A.J.); (S.T.); (M.A.K.)
| | - Anil Kumar Nagarajappa
- Department of Oral & Maxillofacial Surgery & Diagnostic Sciences, College of Dentistry, Jouf University, Sakaka 72345, Saudi Arabia;
| | - Mukhatar Ahmed Javali
- Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (S.M.A.); (R.R.N.); (M.A.J.); (S.T.); (M.A.K.)
| | - Shreyas Tikare
- Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (S.M.A.); (R.R.N.); (M.A.J.); (S.T.); (M.A.K.)
| | - Mohasin Abdul Khader
- Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (S.M.A.); (R.R.N.); (M.A.J.); (S.T.); (M.A.K.)
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Kamran MA, Alnazeh AA, Almagbol M, Almoammar S, Alhaizaey AHA, Alshahrani I. Role of six cytokines and bone metabolism biomarkers in gingival crevicular fluid in patients undergoing fixed orthodontic appliance treatment in comparison with aligners: a clinical study. Angle Orthod 2023; 93:490741. [PMID: 36807401 PMCID: PMC10117209 DOI: 10.2319/091722-649.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/01/2022] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVES The objective of this study was to assess bone biomarkers and cytokines in patients with conventional labial appliances (CLAs) and aligners. MATERIALS AND METHODS Participants were recruited to undergo orthodontic treatment with CLAs and aligners according to predefined inclusion and exclusion criteria. Periodontal examination was accomplished at baseline and 4 weeks using the plaque index (PI), gingival index (GI), and bleeding on probing (BoP). Samples of gingival crevicular fluid (GCF) were collected at baseline (T0) before the start of treatment and at the 1-month follow-up (T1) to assess bone metabolic and inflammatory biomarkers. GCF from participants with CLAs and aligners was evaluated with enzyme-linked immunosorbent assay. Comparison between labial conventional orthodontic treatment and aligners were assessed using an unpaired t-test. The difference between T0 and T1 was measured using a paired t-test. RESULTS BoP, PI, and GI demonstrated no significant difference between participants treated with aligners and subjects with CLAs at baseline and at 4 weeks (P > .05). Bone markers and other biomarkers (tumor necrosis factor α, interleukin [IL]-α, IL-2, IL-6, and IL-8) showed significant differences (P < .05). Also, a significant difference between CLAs and aligners was noted among all biomarkers (P < .05) except IL-β. CONCLUSIONS Aligners and CLAs increase the level of inflammatory and bone metabolic biomarkers after 1 month.
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Deng K, Pelekos G, Jin L, Tonetti MS. Gingival bleeding on brushing as a sentinel sign of gingival inflammation: A diagnostic accuracy trial for the discrimination of periodontal health and disease. J Clin Periodontol 2021; 48:1537-1548. [PMID: 34494292 PMCID: PMC9293219 DOI: 10.1111/jcpe.13545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 12/30/2022]
Abstract
AIM To assess the accuracy of self-reported gingival bleeding on brushing (GBoB) for differentiating between periodontal health and disease and explore the optimal haemoglobin concentration that enables visual detection of GBoB. MATERIALS AND METHODS Self-assessment of GBoB was conducted in supervised sessions for 408 consecutive adults. The haemoglobin levels in saliva/toothpaste slurry (TPS) were analysed, followed by a full-mouth periodontal examination. Periodontal diagnoses were made based on the 2017 classification of periodontal diseases. Gingival inflammation was defined as presence of at least 10% of sites with bleeding on probing (BOP). Logistic regression and area under the receiver operating characteristic curve (AUROC) analyses were applied to assess the accuracy of GBoB. RESULTS Overall, 37.1% of the subjects claimed self-reported GBoB, and they had higher values of BOP (median: 25.0%; interquartile range (IQR): 16.0%-37.5%) than those without GBoB (median: 13.5%; IQR: 8.0%-24.8%, p < .001). The concentration/total amount of haemoglobin in TPS was positively correlated with the number of bleeding sites (r = .409/r = .520, p < .001). Haemoglobin concentration of 90.58 μg/ml or 0.51 μl blood volume enabled visual detection of GBoB with an AUROC of 0.848. Self-reported GBoB exhibited significantly increased values of diagnostic odds ratios (3-8) for varying degrees of gingival inflammation and periodontal disease (gingivitis and periodontitis). It showed low to moderate accuracy for discriminating periodontitis and gingivitis from periodontal health, with a sensitivity of 37.1% and 61.3% and a specificity of 84.8% and 84.4%, respectively. Absence of self-reported GBoB and low levels of haemoglobin had 93%-98% predictive values for periodontal health. CONCLUSIONS Despite its low sensitivity for the discrimination of periodontitis, self-reported GBoB is a promising sentinel sign for periodontal health and disease, and gingival inflammation in particular. It is visually detectable after minor blood loss. After validation in an independent population, identification of GBoB may promote earlier detection and better prevention and treatment of periodontal disease, thereby eventually reducing the global burden of the disease.
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Affiliation(s)
- Ke Deng
- Division of Periodontology and Implant Dentistry, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China.,Shanghai PerioImplant Innovation Center, Department of Oral and Maxillofacial Implantology, National Clinical Research Center of Stomatology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - George Pelekos
- Division of Periodontology and Implant Dentistry, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Lijian Jin
- Division of Periodontology and Implant Dentistry, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Maurizio S Tonetti
- Division of Periodontology and Implant Dentistry, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China.,Shanghai PerioImplant Innovation Center, Department of Oral and Maxillofacial Implantology, National Clinical Research Center of Stomatology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,European Research Group on Periodontology, Genoa, Italy
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Predictive Periodontitis: The Most Promising Salivary Biomarkers for Early Diagnosis of Periodontitis. J Clin Med 2021; 10:jcm10071488. [PMID: 33916672 PMCID: PMC8038382 DOI: 10.3390/jcm10071488] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/22/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
The primary cause of tooth loss in the industrialized world is periodontitis, a bacterial anaerobic infection whose pathogenesis is characterized by composite immune response. At present, the diagnose of periodontitis is made by a complete status check of the patient’s periodontal health; full-mouth plaque score, full-mouth bleeding score, probing depth, clinical attachment level, bleeding on probing, recessions, mobility, and migration are evaluated in order to provides a clear picture of the periodontal conditions of a single patient. Chair-side diagnostic tests based on whole saliva could be routinely used by periodontists for a very early diagnosis of periodontitis, monitoring, prognosis, and management of periodontal patients by biomarker detection, whose diagnostic validity is related to sensitivity and specificity. Recent paper reviews and meta-analyses have focused on five promising host derived biomarkers as candidate for early diagnosis of periodontitis: MMP-8 (Metalloproteinase-8), MIP-1α (Macrophage inflammatory protein-1 alpha), IL-1 β (Interleukin-1 beta), IL-6 (Interleukin-6), and HB (Hemoglobin), and their combinations. Chair-side Lab-on-a-chip (LOC) technology may soon become an important part of efforts to detect such biomarkers in saliva medium to improve worldwide periodontal health in developed nations as well as in underserved communities and poor countries. Their applications in preventive and predictive medicine is now fundamental, and is aimed at the early detection of risk factors or the presence or evolution of the disease, and in personalized medicine, which aims to identify tailor-made treatments for individual patients. The aim of the present paper is to be informative about host derived periodontal biomarkers and, in particular, we intend to report information about the most important immune response derived biomarkers and Hemoglobin as candidates to be routinely utilized in order to obtain a chair-side early diagnosis of periodontal disease.
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Bibi T, Khurshid Z, Rehman A, Imran E, Srivastava KC, Shrivastava D. Gingival Crevicular Fluid (GCF): A Diagnostic Tool for the Detection of Periodontal Health and Diseases. Molecules 2021; 26:molecules26051208. [PMID: 33668185 PMCID: PMC7956529 DOI: 10.3390/molecules26051208] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
The methodologies applicable for the evaluation of periodontal associated diseases are constantly evolving to provide quick, realistic, and scientifically proven results. Trends in the past followed a clinical evaluation of periodontal tissues and radiographic-based reports that formed the foundation for detection of diseases involving the structures supporting the teeth. As the confines and limitations of conventional strategies became obvious over the passage of time, hand in hand variety of techniques have evolved and experimentally justified. These improvisations are based on an improved understanding of the periodontal-pathogenic cascade. Periodontal pathogenesis and a paradigm shift from disease understanding to disease prevention and treatment entail few prerequisites that demand the objectivity of diagnostics procedure that includes sensitivity and specificity along with an explanation of the intensity of the disease, Gingival crevicular fluid an oral bio-fluid resides in the close proximity with gingival tissues have been widely used to understand and differentiate the periodontal health and diseased status. The biomarkers present in the GCF can be a reliable tool to detect the minute changes seen in the disease processes. The GCF consists of various host and bacterial-derived products as well as biomarkers which in turn can be evaluated for the diagnosis, prognosis as well as management of the periodontal disease. Thus, the review aims at describing GCF as a potential oral biofluid helpful in differentiating periodontal health and disease status.
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Affiliation(s)
- Tauqeer Bibi
- Department of Orthodontics, Bahria University Medical and Dental College, Karachi 75260, Pakistan;
| | - Zohaib Khurshid
- Department of Prosthodontics and Dental Implantology, College of Dentistry, King Faisal University, Al-Ahsa 31982, Saudi Arabia
- Correspondence: (Z.K.); (D.S.); Tel.: +966-558420410 (Z.K.); +966-500782498 (D.S.)
| | - Ambreen Rehman
- Centre for Oral Immunobiology and Regenerative Medicine, Institute of Dentistry, Barts and The London, School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK;
| | - Eisha Imran
- Department of Dental Materials, HITEC Dental College, Institute of Medical Sciences, Taxilla 751010, Pakistan;
| | - Kumar Chandan Srivastava
- Oral Medicine and Radiology, Department of Oral Maxillofacial Surgery & Diagnostic Sciences, College of Dentistry, Jouf University, Sakaka 72345, Saudi Arabia;
| | - Deepti Shrivastava
- Periodontics, Department of Preventive Dentistry, College of Dentistry, Jouf University, Sakaka 72345, Saudi Arabia
- Correspondence: (Z.K.); (D.S.); Tel.: +966-558420410 (Z.K.); +966-500782498 (D.S.)
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Chathoth K, Martin B, Cornelis P, Yvenou S, Bonnaure-Mallet M, Baysse C. The events that may contribute to subgingival dysbiosis: a focus on the interplay between iron, sulfide and oxygen. FEMS Microbiol Lett 2020; 367:5860280. [DOI: 10.1093/femsle/fnaa100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/19/2020] [Indexed: 12/21/2022] Open
Abstract
ABSTRACT
This minireview considers the disruption of the host–microbiota harmless symbiosis in the subgingival niche. The establishment of a chronic infection by subversion of a commensal microbiota results from a complex and multiparametric sequence of events. This review narrows down to the interplay between oxygen, iron and sulfide that can result in a vicious cycle that would favor peroxygenic and glutathione producing streptococci as well as sulfidogenic anaerobic pathogens in the subgingival niche. We propose hypothesis and discuss strategies for the therapeutic modulation of the microbiota to prevent periodontitis and promote oral health.
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Affiliation(s)
- Kanchana Chathoth
- NuMeCan INSERM U1241, CIMIAD, Université de Rennes 1, F-35043 Rennes, France
| | - Bénédicte Martin
- NuMeCan INSERM U1241, CIMIAD, Université de Rennes 1, F-35043 Rennes, France
| | - Pierre Cornelis
- Department of Bioengineering Sciences, Laboratory of Microbiology, Vrije Universiteit Brussel, B-1050 Brussels, Belgium
- Laboratoire de Microbiologie Signaux et Microenvironnement, LMSM EA4312, Université de Rouen Normandie, Normandie Université, F-27000 Évreux, France
| | - Stéven Yvenou
- NuMeCan INSERM U1241, CIMIAD, Université de Rennes 1, F-35043 Rennes, France
| | - Martine Bonnaure-Mallet
- NuMeCan INSERM U1241, CIMIAD, Université de Rennes 1, F-35043 Rennes, France
- CHU Pontchaillou Rennes, 35000 Rennes, France
| | - Christine Baysse
- NuMeCan INSERM U1241, CIMIAD, Université de Rennes 1, F-35043 Rennes, France
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Ito H, Numabe Y, Hashimoto S, Uehara S, Wu YH, Ogawa T. Usefulness of hemoglobin examination in gingival crevicular fluid during supportive periodontal therapy to diagnose the pre-symptomatic state in periodontal disease. Clin Oral Investig 2020; 25:487-495. [PMID: 32556661 PMCID: PMC7819911 DOI: 10.1007/s00784-020-03396-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/05/2020] [Indexed: 12/24/2022]
Abstract
Objectives The absence of bleeding on probing (BOP) is a good predictor of disease stability. This study investigated whether detection of hemoglobin (Hb) in gingival crevicular fluid (GCF) indicates minute signs of periodontal disease, even in BOP (−) cases. Materials and methods GCF was collected from gingival sulci of 152 sound maxillary and mandibular teeth from 76 patients who had entered supportive periodontal therapy (SPT) using the split-mouth design. As clinical parameters, plaque index, GCF amount, gingival index, probing depth (PD), clinical attachment level, BOP, and alveolar bone resorption ratio were then recorded. As biochemical parameters, Hb amount, alkaline phosphatase (ALP) activity, and protein amount in GCF were measured. Periodontal conditions of diseased sites (PD ≥ 4 mm, BOP (+)) and healthy sites (PD ≤ 4 mm, BOP (−)) were further classified into two groups using the Hb cutoff value determined by PD and BOP and analyzed. Results Despite being healthy, ALP activity and protein amount in sulci of the group with Hb level greater than the cutoff value were significantly higher than those in the group with Hb level less than the cutoff value (P < 0.01). Conclusions This study indicates that Hb examination is a promising candidate marker of pre-symptomatic periodontal disease because Hb presence in GCF suggests slight tissue damage, even in healthy sites defined as BOP (−). Clinical relevance Hb examination of GCF is a powerful diagnostic tool for pre-symptomatic diagnosis of periodontal disease.
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Affiliation(s)
- Hiroshi Ito
- Department of Periodontology, School of Life Dentistry at Tokyo, The Nippon Dental University, Tokyo, Japan.
| | - Yukihiro Numabe
- Department of Periodontology, School of Life Dentistry at Tokyo, The Nippon Dental University, Tokyo, Japan
| | | | - Sunao Uehara
- Department of Periodontology, School of Life Dentistry at Tokyo, The Nippon Dental University, Tokyo, Japan
| | - Ya-Hsin Wu
- Department of Periodontology, School of Life Dentistry at Tokyo, The Nippon Dental University, Tokyo, Japan
| | - Tomohisa Ogawa
- General Dentistry, The Nippon Dental University Hospital, Tokyo, Japan
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