Functional Gene Polymorphisms in Aggressive and Chronic Periodontitis

There is strong evidence that genetic as well as environmental factors affect the development of periodontitis, and some suggestion that aggressive and chronic forms of the disease share the same genetic predisposition. This study addresses the hypothesis that there are both shared and unique genetic associations in these forms of periodontitis. A sample of 51 patients with aggressive disease, 57 patients with chronic disease, and 100 healthy controls was recruited for this study. Ten functional polymorphisms in 7 candidate genes were genotyped. The results show statistically significant (p ≤ 0.05) differences between genotype frequencies in aggressive and controls (IL-1B +3954 & IL-6 −174); chronic and controls (IL-6 −174 & VDR −1056); chronic and aggressive periodontitis (IL-1A −889); and periodontitis as a whole and controls (VDR −1056, TLR-4 399 & IL-6 −174). These results suggest that there are in fact both shared and unique genetic associations in aggressive and chronic periodontitis.

Manpower planning in periodontology--how many specialists do we need?

Given that one of the major focus points within this issue of the journal is 'practical periodontal medicine' and the relationship between periodontal disease and systemic chronic diseases, it is surprising that we have no indication of the manpower required to secure better oral and general health in this field. Despite many of the heralded improvements in dental health reported in the Adult Dental Health Survey 2009, as monitored by the falling rates of edentulous subjects and decayed, missing and filled teeth (DMF), the overall increase between 1998 and 2009 in the number of subjects with deep pockets from 6% to 8% has largely gone unnoticed! This is a major concern given that most other indicators of oral health have improved over this time period. Furthermore, the tissue damage associated with periodontitis is largely irreversible, and has consequences not only for oral function and quality of life, but also may adversely impact on aspects of general health. This article aims to highlight why we need specialists in periodontics, which patients should be referred to them, how big a problem periodontal disease is and how many specialists in periodontics would be required to meet this treatment need. Estimates are made using the information gained from the Adult Dental Health Survey 2009 and the Office for National Statistics 2011 census, along with estimates of the average patient pool managed within specialist periodontal practices. However, the paper emphasises that these are estimates based on incomplete information which would be necessary to allow more complete models of manpower planning to be used.

R-Ras interacts with filamin a to maintain endothelial barrier function

The molecular mechanisms regulating vascular barrier integrity remain incompletely elucidated. We have previously reported an association between the GTPase R-Ras and repeat 3 of Filamin A (FLNa). Loss of FLNa has been linked to increased vascular permeability. We sought to determine whether FLNa's association with R-Ras affects endothelial barrier function. We report that in endothelial cells endogenous R-Ras interacts with endogenous FLNa as determined by co-immunoprecipitations and pulldowns with the FLNa-GST fusion protein repeats 1-10. Deletion of FLNa repeat 3 (FLNaΔ3) abrogated this interaction. In these cells FLNa and R-Ras co-localize at the plasma membrane. Knockdown of R-Ras and/or FLNa by siRNA promotes vascular permeability, as determined by TransEndothelial Electrical Resistance and FITC-dextran transwell assays. Re-expression of FLNa restored endothelial barrier function in cells lacking FLNa whereas re-expression of FLNaΔ3 did not. Immunostaining for VE-Cadherin in cells with knocked down R-Ras and FLNa demonstrated a disorganization of VE-Cadherin at adherens junctions. Loss of R-Ras and FLNa or blocking R-Ras function via GGTI-2133, a selective R-Ras inhibitor, induced vascular permeability and increased phosphorylation of VE-Cadherin (Y731) and Src (Y416). Expression of dominant negative R-Ras promoted vascular permeability that was blocked by the Src inhibitor PP2. These findings demonstrate that maintaining endothelial barrier function is dependent upon active R-Ras and association between R-Ras and FLNa and that loss of this interaction promotes VE-Cadherin phosphorylation and changes in downstream effectors that lead to endothelial leakiness.

Gene polymorphisms and the prevalence of key periodontal pathogens

Growing evidence suggests that individual genetic susceptibility may influence the host's response to infections. The aim of this project was to study whether gene polymorphisms of inflammatory markers are associated with the presence of viable periodontopathogenic bacteria. We extracted genomic DNA from 45 young adults diagnosed with generalized aggressive periodontitis to study Fc receptors, formyl peptide receptor, Interleukin-6, tumor necrosis factor-alpha, and vitamin D receptor polymorphisms. The presence and viable numbers of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Tannerella forsythensis were determined by culture, and their identities confirmed by PCR. Multiple logistic regressions revealed that both Fcgamma receptor and IL-6 -174 polymorphisms were associated with increased odds of detecting A. actinomycetemcomitans, P. gingivalis, and T. forsythensis after adjustment for age, ethnicity, smoking, and periodontitis extent. These findings support the hypothesis that complex interactions between the microbiota and host genome may be at the basis of susceptibility to aggressive periodontitis.

NADPH oxidase (CYBA) and FcgammaR polymorphisms as risk factors for aggressive periodontitis: a case-control association study

INTRODUCTION

Neutrophils (PMN) in aggressive periodontitis (AgP) patients have been reported to be hyperactive especially with regards to superoxide production. Polymorphisms in genes influencing PMN function have been proposed as candidate risk factors for AgP. The aim of this study was to test the association of specific gene polymorphisms affecting PMN functions with AgP.

MATERIALS AND METHODS

Two hundred and twenty-four patients with confirmed diagnosis of AgP and 231 subjects with healthy periodontium took part in the study. A blood sample was collected from subjects and genotypes for p22phox (CYBA) NADPH oxidase, FP, Fcalpha and Fcgamma receptors were analysed in a blind fashion.

RESULTS

The C242T p22phox NADPH oxidase T allele was significantly associated with AgP in a multiple logistic regression model adjusting for confounders, and this was observed for all subjects [p = 0.002, odds ratio (OR) = 1.87, 95% confidence interval (CI) = 1.27-2.83] and Caucasians (p = 0.009, OR=2.07, 95% CI = 1.20-3.59). Concomitant presence of C242T p22phox NADPH oxidase T allele and FcgammaRIIIb NA1 homozygosity was associated with the generalized AgP phenotype in Caucasians (p = 0.001, OR = 30.35, 95% CI = 3.81-241.97).

CONCLUSIONS

C242T p22phox NADPH oxidase and FcgammaR polymorphisms may predispose to AgP through a modulation of neutrophil superoxide production.

Periodontal status among relatives of aggressive periodontitis patients and reliability of family history report

OBJECTIVES

To assess the periodontal status of relatives of Aggressive Periodontitis (AgP) patients, and to evaluate the reliability of the family history report as provided by the proband.

MATERIAL AND METHODS

Data from 54 AgP patients were gathered along with a family history report for each of their relatives. Only 27 patients (probands) had relatives willing to be examined. This yielded a total of 61 relatives from whom the periodontal status was obtained. The family history report for each examined relative was compared with the periodontal diagnosis made at examination to assess reliability.

RESULTS

Eight percentage of the examined relatives, aged between 12-76, were diagnosed with AgP, while chronic periodontitis was present in 39%, gingivitis in 38% and 15% were healthy. If the report provided by the proband was positive, the likelihood of finding any type of periodontitis in that relative was 85.7%, whereas if the report was negative the likelihood of the absence of periodontitis was 70.6%.

CONCLUSION

The percentage of examined relatives who were affected with AgP (8%), although lower than percentages reported in other AgP family studies, was still higher than the prevalence of the condition in random populations. Reliability of periodontal family history was considered good and more reliable when it was positive.

Changes in transforming growth factor-beta1 in gingival crevicular fluid following periodontal surgery

OBJECTIVES

Growth factors play a major part in wound healing, including in the periodontium. However, the presence of growth factors in gingival crevicular fluid (GCF) in humans during periodontal wound healing has not yet been determined. Our hypothesis is that such factors are present in GCF and that changes in their levels might be of value as a prognostic marker of wound-healing activity and therapeutic progress following periodontal surgery. The aim of this study was therefore to measure transforming growth factor-beta1 (TGF-beta1) in GCF collected from sites that have undergone guided tissue regeneration (GTR) and conventional flap (CF) surgery and to compare these with GCF collected from unaffected healthy sites.

MATERIALS AND METHODS

GCF samples were collected, using filter paper strips, at baseline (pre-surgical) and then at intervals up to 26 weeks from 16 patients undergoing GTR and from 11 patients undergoing CF surgery. After elution and acid treatment, TGF-beta1 levels were measured by ELISA.

RESULTS

Treatment of periodontal defect sites significantly reduced the mean probing pocket depth (PPD) and improved the mean lifetime cumulative attachment loss (LCAL). Average GCF volumes also significantly increased at all sites at 2 weeks post-surgery and thereafter declined to baseline levels, except at the GTR test sites that were still elevated at 7 weeks. TGF-beta1 could be detected in almost all GCF samples, and 2 weeks after surgery, the average levels increased two-fold at the surgically treated but not at the control sites, which remained unchanged.

CONCLUSION

TGF-beta1 is readily detectable in GCF and increases transiently following periodontal surgery. This suggests that changes in the levels of this growth factor in GCF might be useful for monitoring the progress of periodontal repair and regeneration.

Unification of the "burst" and "linear" theories of periodontal disease progression: a multilevel manifestation of the same phenomenon

Previously, burst and linear theories for periodontal disease progression were proposed based on different but limited statistical methods of analysis. Multilevel modeling provides a new approach, yielding a more comprehensive model. Random coefficient models were used to analyze longitudinal periodontal data consisting of repeated measures (level 1), sites (level 2), teeth (level 3), and subjects (level 4). Large negative and highly significant correlations between random linear and quadratic time coefficients indicated that subjects and teeth with greater-than-average linear change experienced decelerated variation. Conversely, subjects and teeth with less-than-average linear change experienced accelerated variation. Change therefore exhibited a dynamic regression to the mean at the tooth and subject levels. Since no equilibrium was attained throughout the study, changes were cyclical. When considered as a multilevel system, the "linear" and "burst" theories of periodontal disease progression are a manifestation of the same phenomenon: Some sites improve while others progress, in a cyclical manner.

Is reduction of pocket probing depth correlated with the baseline value or is it "mathematical coupling"?

Previous studies using correlation or regression analysis have showed that treatment effects measured by the change in clinical parameters are often associated with baseline values of the same parameters. These studies, however, have a methodological weakness. Correlation/regression between baseline measures and the derived change variable invalidates the statistical procedures of testing the null hypothesis: that the coefficient of correlation/regression is zero. This is due to the phenomenon of mathematical coupling. To investigate the impact that this has on the observed correlation/regression coefficient when in reality this is zero, we used random simulations of hypothetical data to model the treatment of periodontal pockets. Results showed a strong probability of obtaining statistically significant correlation/regression coefficients. To separate this artificial effect of mathematical coupling from the true underlying biological relationship, one must apply appropriate analytical strategies to re-evaluate previous evidence within the periodontal literature.

Prevalence and extent of lifetime cumulative attachment loss (LCAL) at different thresholds and associations with clinical variables: changes in a population of young male military recruits over 3 years

AIM

The aims of this study were to monitor the prevalence and progression of lifetime cumulative attachment loss (LCAL) in a group of young British male military recruits over a 3-year period, and to determine the relationship between signs of LCAL and selected periodontal variables.

METHODS

100 subjects, aged 16-20 years (mean 17 years) at baseline, were examined at 0 (baseline), 12 and 30 months. LCAL, probing depth, plaque, bleeding on probing, gingival colour and supra- and subgingival calculus were assessed on the mesio-buccal, disto-buccal, mesio-lingual and disto-lingual surfaces of all teeth present, excluding third molars. Data were analysed cross-sectionally at each examination.

RESULTS

Over the period of the study, the prevalence of LCAL > or =1 and 2 mm ranged from 95-100%, whereas LCAL > or =3 mm ranged from 40-47%. The extent of LCAL > or =1 mm ranged from 76-86%. However, the extent of LCAL > or =2 mm was dramatically lower (10.5-12.7%), and LCAL > or =3 mm was uncommon (0.5-0.9%). Examining the number of subjects according to the number of sites affected above a threshold, showed that a small number of subjects have a large number of sites above threshold. Using Pearson's rank correlation coefficient a significant correlation (p<0.05) was found between LCAL and the periodontal variables of gingival bleeding and supra- and subgingival calculus.

CONCLUSIONS

These data suggest that the onset and progression of chronic periodontitis can be seen in young adults, and in this group gingival bleeding and supra- and subgingival calculus are the variables most strongly associated with early periodontitis.

Utilisation of locally delivered doxycycline in non-surgical treatment of chronic periodontitis. A comparative multi-centre trial of 2 treatment approaches

AIM

In the present 6-month multicentre trial, the outcome of 2 different approaches to non-surgical treatment of chronic periodontitis, both involving the use of a locally delivered controlled-release doxycycline, was evaluated.

MATERIAL AND METHODS

105 adult patients with moderately advanced chronic periodontitis from 3 centres participated in the trial. Each patient had to present with at least 8 periodontal sites in 2 jaw quadrants with a probing pocket depth (PPD) of > or =5 mm and bleeding following pocket probing (BoP), out of which at least 2 sites had to be > or =7 mm and a further 2 sites > or =6 mm. Following a baseline examination, including assessments of plaque, PPD, clinical attachment level (CAL) and BoP, careful instruction in oral hygiene was given. The patients were then randomly assigned to one of two treatment groups: scaling/root planing (SRP) with local analgesia or debridement (supra- and subgingival ultrasonic instrumentation without analgesia). The "SRP" group received a single episode of full-mouth supra-/subgingival scaling and root planing under local analgesia. In addition, at a 3-month recall visit, a full-mouth supra-/subgingival debridement using ultrasonic instrumentation was provided. This was followed by subgingival application of an 8.5% w/w doxycycline polymer at sites with a remaining PPD of > or =5 mm. The patients of the "debridement" group were initially subjected to a 45-minute full-mouth debridement with the use of an ultrasonic instrument and without administration of local analgesia, and followed by application of doxycycline in sites with a PPD of > or =5 mm. At month 3, sites with a remaining PPD of > or =5 mm were subjected to scaling and root planing. Clinical re-examinations were performed at 3 and 6 months.

RESULTS

At 3 months, the proportion of sites showing PPD of < or =4 mm was significantly higher in the "debridement" group than in the "SRP" group (58% versus 50%; p<0.05). The CAL gain at 3 months amounted to 0.8 mm in the "debridement" group and 0.5 mm in the "SRP" group (p=0.064). The proportion of sites demonstrating a clinically significant CAL gain (> or =2 mm) was higher in the "debridement" group than in the "SRP" group (38% versus 30%; p<0.05). At the 6-month examination, no statistically significant differences in PPD or CAL were found between the two treatment groups. BoP was significantly lower for the "debridement" group than for the "SRP" group (p<0.001) both at 3- and 6 months. The mean total treatment time (baseline and 3-month) for the "SRP" patients was 3:11 h, compared to 2:00 h for the patients in the "debridement" group (p<0.001).

CONCLUSION

The results indicate that simplified subgingival instrumentation combined with local application of doxycycline in deep periodontal sites can be considered as a justified approach for non-surgical treatment of chronic periodontitis.

Flow cytometry analysis of guided tissue regeneration-associated human periodontal cells

BACKGROUND

Expanded polytetrafluoroethylene (ePTFE) barrier membranes have been widely used for guided tissue regeneration (GTR) of the human periodontal ligament (PL). However, the precise cellular and molecular events involved in the re-growth of the new tissue are still unclear.

METHODS

Retrieved membranes and the newly-regenerated soft tissue (RT) underlying the membranes were used to examine the cells associated with GTR compared with normal human PL and gingival cells. Flow cytometry (FCM) was used, for the first time, to analyze the spindle-shaped fibroblast-like cells which were adherent to these membranes and the cells which grew out of the RT.

RESULTS

The results showed that the membrane-associated (M) cells had the lowest rate of proliferation and appeared to be larger and more granular than the other types of cell. Moreover, both the M- and RT-derived cells were found to express higher levels of the extracellular matrix (ECM) proteins collagen type 1, fibronectin, tenascin, and decorin. In addition, evidence based on FCM profiles identified distinct sub-populations of GTR cells in which fibronectin expression was markedly up-regulated compared with normal PL cells and which also differed in size and granularity.

CONCLUSIONS

The results of this study show that cells associated with GTR barrier membranes and with the underlying tissue appear to have distinct phenotypic and functional activities consistent with the production of new periodontal connective tissue and periodontal regeneration.

An application of multilevel modelling to longitudinal periodontal research data

OBJECTIVE

To introduce the concepts of random coefficient multilevel models through an application to periodontal research data.

BASIC RESEARCH DESIGN

Multilevel models with random coefficients are illustrated using periodontal data that comprise four levels: repeated measurements at level-1, sites at level-2, teeth at level-3, and subjects at level-4. The study explores random coefficient models--where random variation occurs about explanatory variable coefficients. Outcomes considered are lifetime cumulative attachment loss and pocket probing depth.

PARTICIPANTS

The study data were taken from a survey of periodontal disease involving 100 white male trainee engineers aged between 16 and 20 entering the apprentice training school at the Royal Air Force-Halton, UK.

RESULTS

The application of multilevel modelling to longitudinal data provides a new way of exploring old problems. The multilevel random coefficient models provide an opportunity to examine the 'linear' and 'burst' theories of periodontal disease progression, leading to the postulation that both can be unified within the multilevel framework.

CONCLUSIONS

The multilevel methodology illustrates how advances in the understanding of oral health can be achieved with the advent of new statistical methods

The influence of partial and full-mouth recordings on estimates of prevalence and extent of lifetime cumulative attachment loss: a study in a population of young male military recruits

BACKGROUND

Previous studies have shown that the use of index teeth may underestimate the prevalence of chronic periodontitis in adults. However, there is little information on the effect of using index teeth to estimate the prevalence of early periodontitis in younger adults and the effect this may have on planning treatment needs and health care resources. The aim of this study was to compare full mouth examination with partial examination using index teeth in a group of young British males.

METHODS

One hundred subjects aged between 16 and 20 years (mean 17 years) on entry to the study were examined at baseline, 12 months later, and 30 months later. Lifetime cumulative attachment loss (LCAL) > or =1 mm was measured on the mesio-buccal, disto-buccal, mesio-lingual, and disto-lingual surfaces of all teeth, excluding third molars. All data were entered into a database. The indices used to express LCAL were prevalence, defined as the percentage of subjects with LCAL > or =1 mm, 2 mm, or 3 mm, and extent, defined as the percentage of sites with LCAL > or =1 mm, 2 mm, or 3 mm. Two sets of index teeth were chosen to compare with full mouth recordings, Ramfjord index teeth and the Periodontal Index for Treatment (PIT) teeth.

RESULTS

The prevalence of LCAL > or =1 mm was similar (approaching 100%) for the full mouth and both partial mouth recordings. However, as LCAL increased from a minimum of 1 to 3 mm, partial mouth recording resulted in an underestimation of the prevalence of disease. LCAL > or =2 mm was underestimated by up to 22% and LCAL > or =3 mm by up to 36%. The extent of LCAL was less affected by partial mouth recording, in that the percentage of sites with no sign of early attachment loss was underestimated by up to 11%. However, the percentage of sites with LCAL > or =1 mm and 2 mm were overestimated by 11% and, 7% respectively.

CONCLUSIONS

These data indicate that the use of index teeth in epidemiological studies which include young adults may result in an underestimation of the prevalence of early periodontitis and an overestimation of the extent.

The application of multilevel modelling to periodontal research data

OBJECTIVE

To explain the theory of multilevel modelling and demonstrate its application in the analysis of dental research data.

BASIC RESEARCH DESIGN

Multilevel modelling was introduced using dental data comprising four levels: repeated measurements at level-1, sites at level-2, teeth at level-3, and subjects at level-4. Variance components models (which have no explanatory variables) were evaluated for all outcome measures. Explanatory variables were added to the models with outcomes for both lifetime cumulative attachment loss and pocket probing depth. Salient features of the multilevel models were discussed.

PARTICIPANTS

Research data were obtained from a longitudinal survey of periodontal disease conducted on 100 white male trainee engineers aged between 16 and 20 years entering the apprentice training school at Royal Air Force Halton, England.

RESULTS

The statistical methods revealed that periodontal measures demonstrate considerable variation at all levels of the multilevel structure. Models for lifetime cumulative attachment loss and pocket probing depth illustrated that risk factors operated at more than one level. Supragingival calculus was a risk factor at the subject-level (subjects experiencing more sites with the condition had greater attachment loss and greater pocketing) whilst there was apparently a protective effect occurring at the site (sites with the condition had less attachment loss and less pocketing).

CONCLUSIONS

This study demonstrates that multilevel modelling is a more powerful research tool than single-level techniques for the analysis of hierarchical dental data. Researchers using these techniques are well equipped to analyse complex hierarchical data structures, such as those often found within dentistry.

Comparison of clinical outcomes following treatment of chronic adult periodontitis with subgingival scaling or subgingival scaling plus metronidazole gel

BACKGROUND, AIMS

Conventional treatment of chronic periodontitis involves mechanical debridement of periodontal pockets. Recently, subgingival antimicrobials have been used adjunctively following such debridement. This 2-centre study compared the clinical effects of subgingival scaling (SRP) with SRP plus subgingival application of 25% metronidazole gel, Elyzol (SRP+gel), in patients with chronic adult periodontitis.

METHOD

Voluntary informed written consent was obtained from 45 subjects at the Eastman (mean age 46, range 34-63) and 43 subjects at RAF Halton (mean age 47, range 34-71) who participated in this blind, randomised split-mouth design study. All had at least 2 sites in each quadrant with probing pocket depth (PPD) > or = 5 mm. PPD, bleeding on probing (BOP), and clinical probing attachment levels (CAL) measured using a stent, were recorded at baseline and at 1, 3, 6 and 9 months post-therapy. After subgingival scaling of all quadrants, 2 quadrants were randomly selected to be treated with metronidazole gel.

RESULTS

A paired t-test on baseline values showed no bias between groups. Both treatments effectively reduced the signs of periodontitis. At each follow-up visit, reduction in PPD, CAL and BOP after the combined treatment was greater than for SRP alone. Paired t-tests showed that the improvement in the SRP+gel group was statistically significantly better (p<0.001) than for SRP alone (mean 0.5 +/- 0.6 mm. 95% CI 0.4-0.6 mm.) Similarly, the % of sites which improved to a final pocket depth of < or = 3 mm and the % of sites which improved over the 9 months of the study by as much as > or = 2 mm were greater for SRP+gel than for SRP alone.

CONCLUSIONS

At the end of the study, the mean reductions for PPD were 1.0 mm (SRP) compared to 1.5 mm (SRP+gel), and for CAL they were 0.4 mm (SRP) compared to 0.8 mm (SRP+gel), with mean difference for CAL between treatments of 0.4 +/- 0.6 mm (95% confidence intervals of 0.3-0.6 mm). The combination therapy of SRP+gel was superior to the conventional treatment of SRP alone, and these differences were maintained for 9 months.

Calibration of the Periotron 8000 and 6000 by polynomial regression

This paper reports the detailed calibration of the new Periotron 8000 with different fluids and uses the method of least squares to derive polynomial regression equations up to the 6th order, to investigate the most accurate descriptor of the resulting calibration lines. The use of a 4th order polynomial regression equation (recommended by the manufacturer) provided better coefficients of determination (R2: 0.999) and root mean square errors (RMSE = 1.6) than either linear regression (R2: 0.986, RMSE = 10.9) or quadratic models (R2: 0.998, RMSE = 3.2). Data derived using the manufacturer's MLCONVERT software program lacked accuracy and incurred large errors for volumes > 0.5 microliter. Calibrations performed on one day could be used with accuracy to derive volumes > 0.1 microliter collected on subsequent days, when using the same machine (s.d. for residuals plot = 2.49 Periotron units), but this was not the case for different machines (s.d. = 9.57 Periotron units). Varying serum protein concentration by up to 500% had a negligible effect on calculated volumes above 0.1 microliter. We conclude that the Periotron 8000 is at least as reliable a machine as the Periotron 6000, and that the calibration lines for both machines are best described using 4th order polynomial regression equations and "look-up" tables, rather than quadratic (Periotron 6000) or the manufacturer's software (Periotron 8000). Serum seems to be an acceptable GCF substitute for calibrations, which can be performed 1 day, and used on subsequent days for a given machine and for volumes above 0.1 microliter.

Alkaline phosphatase activity is upregulated in regenerating human periodontal cells

The activity of alkaline phosphatase (ALP) is considered to indicate the presence of osteoblast cells and the formation of new bone. In the present study this enzyme was investigated in cells obtained from retrieved polytetrafluoroethylene membranes (M cells) of periodontal disease patients treated by guided tissue regeneration (GTR) and from the regenerated tissue underlying the membrane (RT cells). Normal periodontal ligament (PL) and gingival cells were also grown from the corresponding healthy tissues of human subjects. ALP activity was measured colourimetrically, using paranitrophenyl phosphate as the substrate, after 4 and 7 d of culture in the absence and presence of dexamethasone (DEX), a synthetic glucocorticoid which induces osteoblast differentiation. The results showed that basal levels of ALP activity were expressed by all the cells and that DEX upregulated ALP levels in the M, RT and PL cells but not in the gingival cells. Moreover, both the basal and DEX-induced ALP activities were statistically significantly higher in the RT cells than in any of the other cells. Our results suggest that both the GTR-associated and normal PL cells express osteoblast-like characteristics and, furthermore, that the RT cultures in particular contain a high proportion of osteoprogenitor cells.

Evaluation of osteocalcin and pyridinium crosslinks of bone collagen as markers of bone turnover in gingival crevicular fluid during different stages of orthodontic treatment

Osteocalcin (Oc) and the collagen cross-links pyridinoline (Pyr) and deoxypyridinoline (dPyr) are used as markers of bone turnover in metabolic bone diseases. The aims of this study were: 1) to establish if Oc, Pyr and dPyr can be detected in GCF and 2) using the orthodontic tooth movement model of alveolar bone resorption to evaluate GCF levels of osteocalcin and these collagen cross-links as markers of bone breakdown. Plaque, colour and bleeding indices, probing measurements and GCF samples were collected at two sites in each of 20 adolescents, during 4 stages of fixed appliance therapy: (1) prior to appliance fit, (2) post appliance fit, (3) during active retraction of the maxillary canines, (4) during retention. GCF was collected onto filter paper strips and the volume determined by weighing. An ELISA kit was used for the detection of osteocalcin, whereas Pyr and dPyr were assayed using high performance liquid chromotography (HPLC). Wilcoxon signed ranks test and Bonferroni correction revealed statistically significant increases in plaque (p= 0.012), GCF volume (p=0.024) and osteocalcin concentration (p=0.012), between stages 1 and 2. There were no statistically significant differences between the other variables at this stage or between any of the variables at stages 2 and 3, or between stages 3 and 4. All but 3 of the GCF samples yielded detectable osteocalcin, with large site and subject variation. The median values of osteocalcin and osteocalcin concentration of all the samples were 87.5 pg and 66 pg/microl, with a range of 0-1,248 pg, 0-1,572 pg/microl. The detection of osteocalcin in GCF during every stage, the wide variation between subjects, and the lack of a consistent pattern related to stages of orthodontic treatment, suggests that osteocalcin may merely be a constituent of GCF associated with the developing dentition, which would reduce its potential as a marker of bone turnover in this group. None of the 16 GCF samples analysed for Pyr and dPyr gave a positive result. This study confirms that fitting an orthodontic appliance results in plaque accumulation and increased gingival inflammation, and that GCF volume is the most sensitive indicator of that inflammation. Osteocalcin was detected in GCF collected from adolescents, whereas Pyr and dPyr could not be detected. Further work is required to establish whether GCF osteocalcin levels can be used as a marker of bone turnover, and whether improvements in the sensitivity of detecting Pyr & dPyr make further study of these promising bone markers worthwhile.

Flow cytometry analysis of gingival and periodontal ligament cells

Gingival and periodontal ligament (PDL) fibroblasts are the major cellular components of periodontal soft connective tissues, but the precise differences between these cells are not yet known. In the present study, we have therefore examined the phenotypic and functional features of the cells obtained from gingival and PDL biopsy samples. Spindle-shaped cells characteristic of fibroblasts were the main cell type observed in vitro, although epithelial cells were also present in primary gingival cell cultures. Flow cytometry was used to measure the size and granularity of the cultured cells, and showed that the gingival fibroblasts were smaller and less granular compared with the PDL cells. The expression of certain key extracellular matrix (ECM) proteins, fibronectin, collagen type I, and tenascin was measured by flow cytometry. Analysis of the fluorescence profiles of these cultures showed that the majority of cells expressed fibronectin and that the average fluorescence intensity of this antigen in the PDL cells was higher than that in the gingival fibroblasts. Moreover, the fibronectin-positive PDL cells apparently comprised two subpopulations which expressed fibronectin at different levels, suggesting that the cells in the PDL cultures were functionally heterogeneous. The level of collagen type I was also found to be up-regulated in the PDL compared with the gingival cells and, as with fibronectin, was expressed at two different levels by subsets of the PDL cells. In contrast, tenascin was expressed at very similar levels by both the gingival fibroblasts and PDL cells. In addition, measurement of alkaline phosphatase, a marker enzyme for mineralized tissue-forming cells, showed that the PDL cells had higher activity than the gingival fibroblasts and that the alkaline phosphatase activity in the PDL cells was far more markedly up-regulated by dexamethasone. Our findings demonstrate that, despite their similar spindle-shaped appearance, fibroblasts derived from gingival and PDL tissues appear to display distinct functional activities which are likely to play a vital part in the maintenance of tissue integrity and regenerative processes.

Particulate bioglass as a grafting material in the treatment of periodontal intrabony defects

The present clinical trial was designed to evaluate the effects of a bioactive glass, Perioglas, in the treatment of periodontal intrabony defects. 20 patients, 23-55 years of age (44 sites), with intrabony defects completed the 1-year study. Teeth with furcation involvement were excluded. After completion of initial therapy, defects were randomly assigned to either a test or control procedure. Following flap reflection, root planing and removal of chronic inflammatory tissue in both groups, the test defects were restored with the bioactive glass particulate material. Mucoperiosteal flaps were replaced, sutured and a periodontal dressing was used. All the patients received postoperative antibiotics and analgesics and were seen at 1 week for suture removal. Follow-up was then carried out weekly and at 3 months, 6 months, 9 months and 1 year post-surgery. Plaque score, bleeding score, probing pocket depth (PPD), probing attachment level (PAL) and gingival recession were recorded at baseline, 3 months and 1 year. Standardised radiographs for computer-assisted densitometric image analysis (CADIA) were taken at baseline, immediately post-operatively and at 1 year. The CADIA data showed a significant increase (F-ratio: 15.67, p < 0.001) in radiographic density and volume between the defects treated with the Perioglas when compared to those treated with surgical debridement only. PPD and PAL showed significant improvements in both experimental and control sites, with a greater trend to improvement in the experimental sites. It was concluded that this bioactive glass is effective as an adjunct to conventional surgery in the treatment of intrabony defects.

In vitro accuracy and reproducibility of automated and conventional periodontal probes

The aim of this study was to investigate the accuracy and reproducibility of experienced and inexperienced examiners using 3 automated periodontal probes (Florida Pocket Probe, Florida Disk Probe, Peri Probe) in comparison with 3 conventional periodontal probes (Marquis, Williams and EN-15 probes). Test blocks of aluminium had 30 holes of diameter 1.10 mm and depths ranging from 2.75 to 10.0 mm. machined with a tolerance of +/- 0.01 mm. 8 experienced examiners and 8 inexperienced examiners were selected to perform duplicate measurements on the blocks over 6 visits using each of the 6 probes. 1 automated and 1 conventional probe were used at each examination. The % accuracy and reproducibility for each of the duplicate measurements was calculated and analysed using Friedman 2-way analysis of variance and the Wilcoxon matched pairs test. On average, all probes showed high reproducibility, with the Florida Disk Probe, the Florida Pocket Probe and the Williams probe ranked best and the other 3 probes were less reproducible. On average, all probes showed a high degree of accuracy, automated probes were ranked best and were significantly better than conventional probes. Experience had little effect on reproducibility, with only the Peri Probe showing significant differences at the 5% level between the groups. Experience appeared to be more important for accuracy, as experienced examiners were more accurate than inexperienced examiners, with significant differences at the 5% level for the EN-15, Florida Disk Probe and Peri Probe. However, inexperienced examiners were significantly more accurate using the Williams probe. This in vitro study has shown that automated probes offer increased accuracy over conventional probes and the Florida Pocket and disk probes compare well with conventional probes for reproducibility.

Permeability of the gingival tissues to IgM during an experimental gingivitis study in man

Changes in the permeability of the underlying vasculature of the gingival crevice region may occur either as part of an inflammatory response during gingivitis or as a response to trauma during collection of gingival crevicular fluid IgM was selected as a marker of permeability and the concentration in gingival crevicular fluid was determined immunochemically by dot blotting, using rabbit antihuman IgM specific for mu chain. Gingival crevicular fluid samples were derived from experimental (non-cleaning) and control (cleaning) sites in six individuals participating in a 28-day experimental gingivitis study using a split-mouth protocol. The fluid was collected by a filter-paper method. At each site, four gingival crevicular fluid samples were collected for 5 s each over a 3-min period and a fifth sample was collected after a further 6 min. IgM was detected in 7/30 experimental strips at baseline (after intensive professional prophylaxis) and this increased to 21/30 by 24 days: control values were 13/30 and 12/30, respectively. The data indicate that IgM was detected with greater frequency as gingivitis becomes evident, suggesting increased permeability in response to plaque accumulation. IgM was detected in 17/120 of the first strip samples, collected over the 66-day study period, whereas in the fifth strip samples IgM was detected in 68/120, and the concentration of IgM in gingival crevicular fluid also increased, indicating that sequential collection induced permeability. It is concluded that the permeability of the gingiva changes in response to both an inflammatory stimulus and trauma due to collection.

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

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

Use of an internal standard in subtraction radiography to assess initial periodontal bone changes

OBJECTIVE

To assess the use of an internal reference when performing histogram analyses in digital subtraction images and to determine the ability of the method to detect initial bone lesions.

METHODS

Fifty-one Royal Air Force recruits had standardized vertical bitewing radiographs and clinical assessment of attachment level recorded annually over three years. Subtraction analyses of crestal bone changes at the mesial surface of the upper right first molar were compared with changes at the mesial surface of the same tooth. Changes over the periods from age 17 to 18 years and age 18 to 20 years were monitored using two subtraction procedures.

RESULTS

Reproducibility studies revealed that Pearson correlations between duplicate measurements of the test site alone (16 crest; r = 0.74) were lower than those between duplicate measurements of changes where misalignment was controlled for, either as a difference (16 crest-16 tooth; r = 0.93) or ratio (16 crest/16 tooth; r = 0.93). We used the differences between the mean subtraction density for 16 crest and 16 tooth as our measure of change in bone density. For the duplicate measurements, the standard deviation of these differences was 3.9: a difference of +/- 7.8 was therefore taken as a threshold value for evidence of real change. Bone gain was noted between the ages of 17 and 18 years (16/21 subjects), but some early bone loss was seen between 18 and 20 years (12/21 subjects), with four subjects showing changes significantly greater than the method error. There were no associations between the clinical and radiographic observations.

CONCLUSION

Use of a control site in subtraction radiography improves the reproducibility; such systems can detect small changes in alveolar bone which may assist in early diagnosis of the initial periodontal lesion which may precede observable clinical changes.

Evaluation of the healing response following placement of Coe-pak and an experimental pack after periodontal flap surgery

2 periodontal dressings, Coe-pak and RD8 (a product under development), were assessed following periodontal surgery, using a double-blind study of randomised split-mouth design, with each patient acting as their own control. Matched sites were selected for periodontal flap surgery under local analgesia. Sites were randomly allocated to each group. The dressings were applied by a single operator and both patients and clinical assessors were blind as to the dressing employed. The dressings were assessed as to their handling properties, in addition to a 7-day post-operative assessment of the surgical sites and a subjective patient report. Maximum pain levels were relatively low (4 in a scale 0-10); subjects reported more pain and analgesics required with RD8 than with Coe-pak. This was reflected in the results of the patient assessment which indicated that 50% preferred Coe-pak, compared to 25% who preferred the RD8 dressing. The results showed RD8 to be an acceptable periodontal dressing when compared to Coe-pak. There were no statistically significant differences between treated sites in both groups with regard to post-operative plaque scores, bleeding scores or tissue healing.

Associations between volume and flow rate of gingival crevicular fluid and clinical assessments of gingival inflammation in a population of British male adolescents

Gingival crevicular fluid (GCF) sampling was performed on 2 occasions separated by 1 year, at 2 sites in the mouths of 102 male adolescents, mean age 17.85 years. Samples were collected onto 5 filter paper strips which were sequentially applied to the mouth of the crevice over a 9-min collection period. Volume and flow rates of GCF were determined for each site and were compared with clinical measurements of plaque, gingival colour, bleeding, gingival index (GI) and pocket depth, using a general linear models (GLM) procedure. While the initial volume of GCF showed no association with any clinical measurement, there was an association between flow rate of GCF and gingival colour. The volume of GCF collected in the final, 5th sample was associated with the GI. The sample site strongly influenced all measures of GCF volume. It is proposed that the flow rate of GCF may be a better indicator of gingival inflammation than the more imprecise clinical assessments of inflammation, since GCF flow rates more precisely reflect changes in tissue permeability. The association between the final sample, collected after 9 min, and clinical measurements, was probably a reflection of the association between clinically-detectable inflammation and the susceptibility of the site to mild irritation.

Contamination of human gingival crevicular fluid by plaque and saliva

Dental plaque and saliva are both possible contaminants of gingival crevicular fluid (GCF). Plaque samples from 12 sites in four subjects who had allowed plaque to accumulate for 24-48 h were quantified using the Plaque Index and then transferred to filter paper strips for fluid volume determination using the Periotron 6000. The mean volume of fluid for plaque scores of 0 was 0.02 (+/- 0.01) microliter, whereas for plaque scores of 3 the mean volume was 0.15 (+/- 0.07) microliters. In a clinical study, GCF samples, from 19/184 subjects (10.4%) were assessed as contaminated or suspected to be contaminated with saliva, but only 28/1740 strips (1.6%) were placed in these categories of contamination. An assay to confirm salivary contamination was established, using an immunochemical, double-antibody method with sheep anti-human salivary alpha-amylase followed by peroxidase-conjugated rabbit anti-sheep immunoglobulin. The detection threshold of the assay was 7.5 ng of alpha-amylase, which represents approx. 15-25 nl of saliva. The assay was evaluated on 90 GCF samples categorized as 'known' (n = 16), 'suspected' (n = 16), or 'not' contaminated (n = 58) with saliva; 81.25, 50-61.5 and 5.2-8.6%, respectively, were positive for salivary alpha-amylase. In some GCF samples salivary contamination was in excess of 50%. It was concluded that GCF samples seen to be contaminated with saliva should be discarded, whereas samples considered free from contamination may be used with confidence. Samples suspected of contamination may require an alpha-amylase assay before further analysis.

Interleukin-1 beta (IL-1 beta) levels in gingival crevicular fluid from adults with previous evidence of destructive periodontitis. A cross sectional study

We have estimated the levels of Interleukin-1 beta (IL-1 beta) by ELISA in gingival crevicular fluid (GCF) at 58 sites from 37 patients with adult periodontitis. GCF was collected for 5 s on filter papers and a 2nd sample was collected for 30 s 1 min later. 68/116 strips yielded detectable levels of IL-1 beta. IL-1 beta was present in both the 1st and 2nd samples at 28 sites, in the 1st only at 4 sites and in the 2nd only at 8 sites; 18 sites were below the level of detection for the assay. When the concentrations of IL-1 beta were calculated in the original volume of GCF on each strip, the mean value for positive strips was 34.16 +/- 29.45 (SD) pg/microliters with a range from 1.75 to 97.13 pg/microliters. There were no statistically significant correlations with the plaque index, bleeding index or probable crevice depth (pocket depth). The results indicate that IL-1 is present in the GCF from a proportion of sites with evidence of previous periodontal destruction.

Specific antibody responses to subgingival plaque bacteria as aids to the diagnosis and prognosis of destructive periodontitis

We have reviewed the recent literature on the humoral immune responses to a variety of subgingival plaque bacterial species in patients with destructive periodontal diseases. We do not feel that the information presently available on the specific antibody responses to proposed pathogens such as Bacteroides gingivalis and Actinobacillus actinomycetemcomitans allows antibody responses to be diagnostic. All control subjects without periodontal destruction have antibodies to candidate pathogens but the generally higher levels in patients are not sufficiently elevated to be diagnostic. Nor can they be used to predict the initiation of disease or the onset of new episodes of destruction where disease had previously occurred. Successful treatment of patients may lead to lower levels of antibodies to some organisms, including possible pathogens, and thus support a given species in the aetiopathogenesis of disease. It appears that unsuccessful treatment may be accompanied by continuing high antibody levels to some organisms and further studies may enable this observation to be used to monitor therapy. There is some evidence from serological studies that each destructive episode may be induced by a different bacterial species or consortium. The start of studies using single antigens and the techniques of molecular biology will provide not only antibody-based diagnostic methods but also allow us to determine which bacterial antigens are virulence factors and thus the role of the antibody responses, whether protective or damaging, in the periodontal diseases.

The role of histopathology in the diagnosis and prognosis of periodontal diseases

The histological evaluation of surgical biopsies from affected tissues is a standard way of assessing pathological change and determining treatment in many diseases. In most forms of periodontal disease, however, this approach finds limited application. Here, we review what uses the histopathological approach has in the study and evaluation of the periodontal diseases. Current understanding of the changes in epithelial anatomy during pocket formation, the cellular composition and dynamics of the inflammatory infiltrate and the mechanisms of bone resorption and repair are reviewed from the perspective of the information available from microscopical investigation, including the uses and potential application of modern immunocytochemical methods to these questions. The usefulness of histological study of biopsy material is reassessed in the light of advances made in immunohistochemical techniques and their application to gingival inflammatory infiltrates and epithelia. Such techniques offer immediately valuable research opportunities with potential for diagnostic applications, noteably the recognition of phases of destructive activity and their differentiation from periods of effective host defence.

Statistical models for data from periodontal research

Many factors have been hypothesised either to characterise groups and individuals at risk for periodontal disease or to be markers of periodontal breakdown. In order to identify these as associated either with disease status or progression, a statistical association between the factor and a measure of disease will have to be demonstrated. The statistical modelling of data arising from periodontal research presents special problems. These include the large number of measurements made in each subject, the large magnitude of measurement error compared to the changes in attachment level, the analysis of longitudinal studies, the lack of a measure of instantaneous rate of attachment loss and controversies over the nature of the progression of the disease. We consider statistical methods currently available in the light of these difficulties and identify areas in which further research is necessary.

Detection of high-risk groups and individuals for periodontal diseases: laboratory markers based on the microbiological analysis of subgingival plaque

Periodontal microbiology is reviewed with regard to the potential of certain characteristics to serve as markers of high risk groups or individuals for periodontal diseases. The generally accepted associations between particular organisms and the various periodontal diseases are discussed. The usefulness of various clinical study designs is reviewed. The ecology of the subgingival plaque microflora is discussed and a number of suggestions for future research are made. We have concluded that there is no monospecific aetiology to any of the various periodontal conditions. Nevertheless, we give particular attention to the role of the black-pigmented bacteroides based upon our belief that they, and Bacteroides gingivalis in particular, are fundamental to our understanding of the biology of periodontal diseases in humans and other animals. Consequently, the contribution of its various virulence factors and their potential as markers of disease susceptibility and activity is addressed.

The protein composition of gingival crevicular fluid sampled from male adolescents with no destructive periodontitis: baseline data of a longitudinal study

Gingival crevicular fluid (GCF) is a promising source for markers of destructive periodontal diseases activity. As the initial stage of a longitudinal study into the characterization of disease markers, GCF sampled from 104 sites in 74 adolescents was examined via sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS/PAGE). In this population, which had varying degrees of gingivitis but little evidence of destructive periodontitis, there was a highly homologous GCF protein profile. The plasma components, albumin, transferrin and IgG, were major constituents of all samples. In addition, a second group of non-plasma derived proteins, with molecular weights 37 kDa, 47 kDa, 57 kDa and 59 kDa, was also commonly detected. The high frequency of occurrence of these components suggests that they may represent products of normal turnover of the periodontal tissues. Analysis of GCF sampled from patients with progressing destructive disease revealed a different SDS/PAGE profile particularly with respect to proteins of non-plasma origin. It is anticipated that the major metabolic changes which accompany the destruction of the tissues during future disease episodes in the adolescent study population will be discernible as alterations to the GCF protein profile.

Detection of high-risk groups and individuals for periodontal diseases: laboratory markers from analysis of saliva

The use of saliva as a source of components that may identify subjects at risk of developing destructive periodontitis, or provide markers of disease potential or activity, has been reviewed. It was concluded that bacteria, their constituents or products are unlikely to be rewarding and that host-derived salivary factors such as enzymes cannot identify risk, as deficiency states for these do not exist. Secretory IgA, plasma IgA and IgG isotype levels and specific antibodies may be associated with risk, but probably only if levels fall below those which are protective or a specific antibody response is absent. More work is needed to distinguish between monomeric and dimeric IgA antibodies and to identify IgG antibodies in longitudinal clinical studies. In general, although saliva may prove to be useful as a source of indicators of current disease activity or as a means of assessing responses to treatment, it is unlikely to provide evidence for the existence of risk factors.

Detection of high-risk groups and individuals for periodontal diseases: laboratory markers from analysis of gingival crevicular fluid

Gingival crevicular fluid is regarded as a promising medium for the detection of markers of periodontal diseases activity. The collection protocols are straight forward and non-invasive and can be performed at specific sites of interest in the periodontium. Because the fluid accumulates at the gingival margin, it will contain potential markers derived not only from the host tissues and serum but also the subgingival microbial plaque, and thus an extremely broad range of candidate molecules may be investigated. However, the ability to successfully describe indicators of current disease activity and predictors of future disease is dependent not only upon the choice of the biochemical marker but also on the accurate description of the health status of the sample sites using currently available clinical and radiographic methods. Areas of study which currently show the most promise involve the analysis of host enzyme activities directed against components of the extracellular matrix, the nature of the glycosaminoglycans released into the sulcus and the concentration in gingival crevicular fluid of certain mediators of the inflammatory process, most notably prostaglandin E2.

The total protein concentration of gingival crevicular fluid. Variation with sampling time and gingival inflammation

The total protein concentration of gingival crevicular fluid (GCF), sampled repeatedly over a 10-min period with the minimum of physical irritation to the sulcus, was evaluated in a group of 32 healthy adolescents. The mean concentration of the 1st sample was comparable to that of normal tissue fluids and lymph, irrespective of the state of inflammation of the sample site. However, during repeated sampling, the values rose to resemble serum protein levels, except at those sites with no clinically detectable inflammation. Gel electrophoretic analysis confirmed the increasing proportion of serum-derived molecules in the more proteinaceous GCF samples. The results demonstrate the extreme sensitivity of the gingival vasculature to GCF sampling and consequently the need for accurate standardisation of GCF collection protocols. This will apply particularly when compositional data is to be normalised with respect to the total protein content or when the levels of a serum constituent are being examined.