Nilminie Rathnayake

Periodontitis Increases the Risk of a First Myocardial Infarction: A Report From the PAROKRANK Study

Background— The relationship between periodontitis (PD) and cardiovascular disease is debated. PD is common in patients with cardiovascular disease. It has been postulated that PD could be causally related to the risk for cardiovascular disease, a hypothesis tested in the Periodontitis and Its Relation to Coronary Artery Disease (PAROKRANK) study. Methods and Results— Eight hundred five patients (<75 years of age) with a first myocardial infarction (MI) and 805 age- (mean 62±8), sex- (male 81%), and area-matched controls without MI underwent standardized dental examination including panoramic x-ray. The periodontal status was defined as healthy (≥80% remaining bone) or as mild-moderate (from 79% to 66%) or severe PD (<66%). Great efforts were made to collect information on possibly related confounders (≈100 variables). Statistical comparisons included the Student pairwise t test and the McNemar test in 2×2 contingency tables. Contingency tables exceeding 2×2 with ranked alternatives were tested by Wilcoxon signed rank test. Odds ratios (95% confidence intervals) were calculated by conditional logistic regression. PD was more common (43%) in patients than in controls (33%; P<0.001). There was an increased risk for MI among those with PD (odds ratio, 1.49; 95% confidence interval, 1.21–1.83), which remained significant (odds ratio, 1.28; 95% confidence interval, 1.03–1.60) after adjusting for variables that differed between patients and controls (smoking habits, diabetes mellitus, years of education, and marital status). Conclusions— In this large case–control study of PD, verified by radiographic bone loss and with a careful consideration of potential confounders, the risk of a first MI was significantly increased in patients with PD even after adjustment for confounding factors. These findings strengthen the possibility of an independent relationship between PD and MI.Background— The relationship between periodontitis (PD) and cardiovascular disease is debated. PD is common in patients with cardiovascular disease. It has been postulated that PD could be causally related to the risk for cardiovascular disease, a hypothesis tested in the Periodontitis and Its Relation to Coronary Artery Disease (PAROKRANK) study. Methods and Results— Eight hundred five patients (<75 years of age) with a first myocardial infarction (MI) and 805 age- (mean 62±8), sex- (male 81%), and area-matched controls without MI underwent standardized dental examination including panoramic x-ray. The periodontal status was defined as healthy (≥80% remaining bone) or as mild-moderate (from 79% to 66%) or severe PD (<66%). Great efforts were made to collect information on possibly related confounders (≈100 variables). Statistical comparisons included the Student pairwise t test and the McNemar test in 2×2 contingency tables. Contingency tables exceeding 2×2 with ranked alternatives were tested by Wilcoxon signed rank test. Odds ratios (95% confidence intervals) were calculated by conditional logistic regression. PD was more common (43%) in patients than in controls (33%; P <0.001). There was an increased risk for MI among those with PD (odds ratio, 1.49; 95% confidence interval, 1.21–1.83), which remained significant (odds ratio, 1.28; 95% confidence interval, 1.03–1.60) after adjusting for variables that differed between patients and controls (smoking habits, diabetes mellitus, years of education, and marital status). Conclusions— In this large case–control study of PD, verified by radiographic bone loss and with a careful consideration of potential confounders, the risk of a first MI was significantly increased in patients with PD even after adjustment for confounding factors. These findings strengthen the possibility of an independent relationship between PD and MI. # CLINICAL PERSPECTIVE {#article-title-44}

Salivary Biomarkers for Detection of Systemic Diseases

Background and Objective Analysis of inflammatory biomarkers in saliva could offer an attractive opportunity for the diagnosis of different systemic conditions specifically in epidemiological surveys. The aim of this study was to investigate if certain salivary biomarkers could be used for detection of common systemic diseases. Materials and Methods A randomly selected sample of 1000 adults living in Skåne, a county in the southern part of Sweden, was invited to participate in a clinical study of oral health. 451 individuals were enrolled in this investigation, 51% women. All participants were asked to fill out a questionnaire, history was taken, a clinical examination was made and stimulated saliva samples were collected. Salivary concentrations of IL-1β, -6, -8, TNF-α, lysozyme, MMP-8 and TIMP-1 were determined using ELISA, IFMA or Luminex assays. Results Salivary IL-8 concentration was found to be twice as high in subjects who had experience of tumour diseases. In addition, IL-8 levels were also elevated in patients with bowel disease. MMP-8 levels were elevated in saliva from patients after cardiac surgery or suffering from diabetes, and muscle and joint diseases. The levels of IL-1β, IL-8 and MMP-8, as well as the MMP-8/TIMP-1 ratio were higher in subjects with muscle and joint diseases. Conclusion Biomarkers in saliva have the potential to be used for screening purposes in epidemiological studies. The relatively unspecific inflammatory markers used in this study can not be used for diagnosis of specific diseases but can be seen as markers for increased systemic inflammation.

Pilot Study on Oral Health Status as Assessed by an Active Matrix Metalloproteinase-8 Chairside Mouthrinse Test in Adolescents

BACKGROUND Matrix metalloproteinase (MMP)-8 is a major destructive collagenase involved in periodontitis and can be regarded as a periodontitis biomarker. A neutrophil collagenase 2 (active MMP-8 [aMMP-8]) oral fluid immunoassay has recently been demonstrated to be a periodontitis risk indicator among adults. The aim of this study is to investigate whether a point-of-care mouthrinse test based on an aMMP-8 immunoassay could identify patients with oral inflammatory burden (periodontitis and caries) among adolescents with early pathologic findings. METHODS This cross-sectional study was carried out at the Kotka Health Center, Finland. First, the aMMP-8 chairside mouthrinse test was performed on enrolled individuals (adolescents aged 15 to 17 years, n = 47), and the results were read based on a color change within 5 minutes. Then, full-mouth clinical parameters of oral health were assessed, including periodontal, oral mucosal, and caries status. RESULTS The sensitivity and specificity of the test for bleeding on probing were 71.8% and 77.5%, respectively (P = 0.05); for ≥1 site with probing depth (PD) ≥4 mm, 48.3% and 100% (P <0.001); for ≥2 sites with PD ≥4 mm, 63.6% and 100% (P <0.001); and for >2 sites with PD ≥4 mm, 76.5% and 96.7% (P <0.01). Regarding periodontitis (≥1 site with PD ≥4 mm), hardly any false-positive results were identified. The sensitivity of the immunoassay for ≥1 caries lesions was 76.5%, and the specificity was 96.7% (P <0.01). CONCLUSIONS In 5 minutes, the aMMP-8 chairside test showed promising results, recognizing oral inflammatory burden in adolescents with early initial signs of periodontitis. Caries lesions could also be detected, but less efficiently.

Salivary Matrix Metalloproteinase-8 and-9 and Myeloperoxidase in Relation to Coronary Heart and Periodontal Diseases : A Subgroup Report from the PAROKRANK Study (Periodontitis and Its Relation to Coronary Artery Disease)

Background and Objective Matrix metalloproteinase (MMP) -8, -9 and myeloperoxidase (MPO) are inflammatory mediators. The potential associations between MMP-8, -9, MPO and their abilities to reflect cardiovascular risk remains to be evaluated in saliva. The objective of this study was to investigate the levels and associations of salivary MMP-8, -9, MPO and tissue inhibitors of metalloproteinase (TIMP)-1 in myocardial infarction (MI) patients and controls with or without periodontitis. Materials and Methods 200 patients with a first MI admitted to coronary care units in Sweden from May 2010 to December 2011 and 200 controls matched for age, gender, residential area and without previous MI were included. Dental examination and saliva sample collection was performed 6-10 weeks after the MI in patients and at baseline in controls. The biomarkers MMP -8, -9, MPO and TIMP-1 were analyzed by time-resolved immunofluorescence assay (IFMA), Western blot and Enzyme-Linked ImmunoSorbent Assay (ELISA). Results After compensation for gingivitis, gingival pockets and smoking, the mean salivary levels of MMP-8 (543 vs 440 ng/mL, p = 0.003) and MPO (1899 vs 1637 ng/mL, p = 0.02) were higher in non-MI subjects compared to MI patients. MMP-8, -9 and MPO correlated positively with clinical signs of gingival/periodontal inflammation while TIMP-1 correlated mainly negatively with these signs. The levels of latent and active forms of MMP-8 did not differ between the MI and non-MI groups. Additionally, MMP-8, MPO levels and MMP-8/TIMP-1 ratio were significantly higher in men compared to women with MI. Conclusions This study shows that salivary levels of the analyzed biomarkers are associated with periodontal status. However, these biomarkers could not differentiate between patients with or without a MI. These findings illustrate the importance to consider the influence of oral conditions when analyzing levels of inflammatory salivary biomarkers.

Salivary Diagnostics—Point-of-Care diagnostics of MMP-8 in dentistry and medicine

Human saliva is an easily accessible biological fluid and contains a variety of disease-related biomarkers, which makes it a potential diagnostic medium. The clinical use of salivary/oral fluid biomarkers to identify oral and systemic conditions requires the development of non-invasive screening and diagnostic technologies, and is among the main goals of oral fluid researchers. The analysis of the disease-specific oral and systemic biomarkers in saliva and oral fluids (i.e., mouth-rinse, gingival crevicular fluid (GCF) and peri-implantitis sulcular fluid (PISF)) is demanding. Several factors influence their expression and release; these factors include the intracellular location, the molecular size and the flow characteristics of the biological fluid. The type of saliva/oral fluid utilized for the diagnostics affects the analysis. High sensitivity together with sophisticated methods and techniques are essential to get a useful outcome. We describe here a recently developed mouth-rinse that is practical, convenient and inexpensive, as well as PISF chair-side/point of care (PoC) lateral-flow active matrix metalloproteinase (aMMP-8) immunoassays to detect, predict and monitor the course and treatment of periodontitis and peri-implantitis.

Pilot Study on the Genetic Background of an Active Matrix Metalloproteinase-8 Test in Finnish Adolescents

BACKGROUND In periodontitis, genetics and smoking play important roles in host immune system response. The aim of this study is to determine whether the genetic background of initial periodontitis and caries could be detected using an active matrix metalloproteinase (aMMP)-8 chairside test in Finnish adolescents. METHODS Forty-seven participants gave approval for analysis of both oral fluid collection and DNA. An aMMP-8 chairside test was performed on participants (adolescents aged 15 to 17 years), and full-mouth clinical parameters of oral health were assessed including periodontal, oral mucosal, and caries status in Eastern Finland from 2014 to 2015. DNA was extracted from oral fluid samples and genotyped for 71 polymorphisms in 29 candidate genes for periodontitis. Results were analyzed using a logistic regression model. P values were corrected for multiple testing using false discovery rate (<0.05). RESULTS aMMP-8 chairside test positivity and three or more ≥4 mm pockets were associated with vitamin D receptor (VDR) (rs2228570, P = 0.002, q = 0.04) and MMP3 (rs520540, rs639752, rs679620, P = 0.0009, 0.003, 0.003, q = 0.04, respectively). None of the other single-nucleotide polymorphisms studied showed a significant association with the aMMP-8 chairside test and at least one caries lesion positivity. CONCLUSION Genetic polymorphisms of MMP3 and VDR are linked to initial periodontitis in Finnish adolescents, and the aMMP-8 chairside test can eventually detect initial periodontitis in young patients with predisposing genetic background.

Dental caries, prevalence and risk factors in patients with Crohn's disease.

Objective The present study tested the hypothesis that patients with Crohn’s disease (CD) have a higher prevalence and risk for caries compared to people without CD. Material and Methods Patients with CD were divided into groups; 71 patients (50.7±13.9 years) who had gone through resective intestinal surgery and 79 patients (42.0±14.4 years) who had not. The patients were compared to 75 controls (48.6±13.4 years) regarding DMF-T and DMF-S, Lactobacilli (LB), Streptococcus mutans (SM), salivary flow and dental plaque. Statistical methods including ANOVA or Chi-square test for calculation of demographic differences between groups, analysis of covariance (ANCOVA) to compare the clinical variable and Post hoc analyses were done with Fischers Least Significant Difference test or Chi-square. Non-parametric Spearman’s correlation matrix coefficient was estimated between clinical variables and disease duration. Results CD patients who had been subjected to resective surgery had a higher DMF-S score (50.7 versus 36.5; p = 0.01) compared to the control group after adjusting for age, gender and smoking. These patients had higher counts of SM (1.5 versus 0.9; p = 0.04) and LB (10000.0 versus 1000.0; p = 0.01), and more dental plaque (53.7 versus 22.6; p = 0.001). CD patients reported a more frequent consumption of sweetened drinks between meals compared to controls (p = 0.001). Conclusions The present study shows that patients with CD who had undergone resective surgery had a higher DMFs score, and higher salivary counts of Lactobacilli and Streptococcus mutans compared to the control group.

The Ability of Quantitative, Specific, and Sensitive Point-of-Care/Chair-Side Oral Fluid Immunotests for aMMP-8 to Detect Periodontal and Peri-Implant Diseases

The analysis of the disease-specific oral and systemic biomarkers in saliva and oral fluids (i.e., mouth rinse, gingival crevicular fluid (GCF), and peri-implantitis fluid (PISF)) is demanding. Several hosts and microbial factors may influence their expression, release, and levels. The type of saliva/oral fluids utilized for the diagnostics affects the analysis. High sensitivity and specificities together with sophisticated methods and techniques are essential for valuable outcome. We describe here recently developed practical, convenient, inexpensive, noninvasive, and quantitative mouth rinse and PISF/GCF/chair-side/point-of-care (PoC) lateral-flow aMMP-8 immunoassays (PerioSafe and ImplantSafe/ORALyser) to detect, predict, and monitor successfully the course, treatment, and prevention of periodontitis and peri-implantitis, respectively. The tests have been independently and successfully validated to differentiate periodontal and peri-implant health and disease in Finland, Germany, Netherland, Sweden, Turkey, Nigeria, Malawi, and USA. The clinical use of salivary/oral fluid biomarkers to identify oral and systemic conditions requires additional studies utilizing these noninvasive screening, diagnostic, and preventive aMMP-8 PoC/chair-side technologies.

Mucin 4 and matrix metalloproteinase 7 as novel salivary biomarkers for periodontitis.

Abstract Aim Periodontitis is a chronic inflammatory disease, characterized by irreversible destruction of tooth‐supporting tissue including alveolar bone. We recently reported mucin 4 (MUC4) and matrix metalloproteinase 7 (MMP7) as highly associated with periodontitis in gingival tissue biopsies. The aim of this study was to further investigate the levels of MUC4 and MMP7 in saliva and gingival crevicular fluid (GCF) samples of patients with periodontitis. Materials and Methods Saliva and GCF samples were collected from periodontitis patients and healthy controls. The levels of MUC4, MMP7, and total protein concentrations were analysed using ELISA or Bradford assay. Results MUC4 levels were significantly lower in saliva and GCF from periodontitis patients relative to healthy controls. MMP7 levels were significantly higher in saliva and GCF from periodontitis patients. Multivariate analysis revealed that MUC4 was significantly associated with periodontitis after adjusting for age and smoking habits and, moreover, that the combination of MUC4 and MMP7 accurately discriminated periodontitis from healthy controls. Conclusions MUC4 and MMP7 may be utilized as possible novel biomarkers for periodontitis.

Active Matrix Metalloproteinase-8: Contributor to Periodontitis and a Missing Link Between Genetics, Dentistry, and Medicine

Periodontitis is one of the most common infection-induced inflammatory tissue destructive diseases globally. According to the epidemiological studies in Western countries, about 30% of populations are affected by periodontitis [1]. The pathogenesis of periodontitis can be briefly described and summarized as follows: the dental plaque, a bacterial biofilm, induces an inflammatory and immune responses in the adjacent gingival and periodontal or peri-implant tissues. The cells of the immune and inflammatory system are together with resident gingival cells (including fibroblasts, cementoblasts, and epithelial cells, bone cells) triggered to express and release pro-inflammatory cytokines, reactive oxygen species, and matrix metalloproteinases (MMPs) [2–5]. MMPs are genetically distinct but structurally related proteinases that can degrade not only almost all extracellular matrix proteins but also non-matrix bioactive molecules such as growth factors, serpins, insulin receptor, apolipoprotein-1, complement components, and pro- and anti-inflammatory cytokines and chemokines [2–5]. Thus, MMPs can modify immune responses [2–5]. The active form of catalytically competent matrix metalloproteinase-8 (aMMP-8; neutrophil collagenase or collagenase-2) is the predominant MMP in periodontitis-affected gingiva, gingival crevicular fluid (GCF), peri-implant sulcular fluid (PISF), saliva, and mouthrinse [2–5]. MMP-8 cleaves preferably and efficiently the interstitial collagens, mainly type I fibers of the gingival and periodontal tissues, leading to irreversible soft and hard tissue destruction, i.e., the development of periodontal pockets and attachment loss, and eventually leading to tooth loss [2–5]. Physiological levels of MMP-8 in periodontal tissue also participate to protective and anti-inflammatory resolution of infection-induced tissue destruction [6, 7].