J Periodontol • May 2014
Serum Anticardiolipin Concentrations in Patients With Chronic Periodontitis Following Scaling and Root Planing Reve Chaston,* Robert Sabatini,† Thomas E. Koertge,† Carol N. Brooks,‡ and Harvey A. Schenkein†
Background: Anticardiolipin antibodies (antiCl), present in some patients with autoimmune disease, are associated with thrombosis, fetal loss, and other conditions. A significant proportion of patients with chronic periodontitis (CP) test positive for antiCl, likely because some periodontal pathogens contain antigens homologous to the target antigen of antiCl on the serum protein b-2 glycoprotein-I (b2GPI) and thus can induce antiCl by molecular mimicry. The authors hypothesized that treatment of periodontitis by scaling and root planing (SRP) could therefore decrease serum titers of antiCl in patients with CP. Methods: Thirty patients with CP received complete periodontal examinations at baseline including assessment of probing depth, attachment loss, gingival index, and plaque index. SRP was performed in two sessions at 2-week intervals. Eight weeks later, patients were reexamined. Blood samples were taken at baseline, 2 weeks after the initial therapy appointment, and 8 weeks after the completion of treatment for assessment of immunoglobulin (Ig)G and IgM antiCl levels. Results: All periodontal parameters improved significantly. Consistent with previous observations, five (16.7%) of the 30 patients exhibited elevated levels of IgG or IgM antiCl at baseline. Following treatment, the concentrations of IgG and IgM antiCl remained unchanged for the entire cohort of 30 patients. However, in the five patients with elevated antiCl at baseline, IgM antiCl concentrations decreased significantly (P = 0.0008) owing to therapy, while IgG antiCl did not. Conclusion: The oral microflora is a likely source of antigen inducing antiCl in CP, since IgM antiCl levels can be reduced in the short term with conservative therapy. J Periodontol 2014;85:683-687. KEY WORDS Anticardiolipin antibody; chronic periodontitis; dental scaling; immunoglobulin M; molecular mimicry; root planing. * Currently, Private practice, Layton, UT; previously, Department of Periodontics, Virginia Commonwealth University School of Dentistry, Richmond, VA. † Department of Periodontics, Virginia Commonwealth University School of Dentistry. ‡ Department of General Practice, Virginia Commonwealth University School of Dentistry.
A
nticardiolipin (antiCl) autoantibodies are strongly associated with thrombosis, fetal loss, and associated conditions in individuals with the antiphospholipid syndrome and as a secondary consequence of systemic lupus erythematosis.1 In addition, a number of studies have demonstrated strong associations between antiphospholipid antibodies, especially antiCl, and cardiovascular diseases in patients without overt autoimmune disease.2 Because it has been demonstrated in animal models that microbial infections of various types can lead to production of antibodies that functionally mimic antiCl,3 it is hypothesized that some patients may acquire antiCl due to bacterial, viral, or fungal infections,4-6 although these antibodies may not all be pathogenic. The ability of some microbes to induce pathogenic antiCl is due to significant homology between some microbial antigens and the serum protein b-2 glycoprotein-I (b2GPI), the target antigen of antiCl autoantibodies. The authors of this study have previously shown that a greater proportion of patients with chronic periodontitis (CP) or aggressive periodontitis (AgP) have elevated serum antiCl levels than systemically and periodontally healthy individuals.7 This observation raised the question of the source of antigen capable of inducing antiCl. It has been observed that periodontal pathogens, including Porphyromonas gingivalis, Actinobacillus
doi: 10.1902/jop.2013.130408
683
Anticardiolipin in Chronic Periodontitis Following Treatment
actinomycetemcomitans, and Treponema denticola, have antigens bearing peptide sequences of sufficient similarity to key sequences in b2GPI to induce these antibodies.8,9 Furthermore, the antiCl found in sera of patients with periodontitis are biologically functional, as they are capable of activating endothelial cells to produce the key cytokine monocyte chemotactic protein (MCP)-1.10 Additionally, the observation that immunization of mice with P. gingivalis results in production of antibodies reactive with b2GPI, and that passive immunization of pregnant mice with these antibodies results in increased fetal loss.11 It was therefore hypothesized that the source of antiCl in periodontitis is the oral microflora. Because routine therapy for periodontitis includes reduction of the oral pathogen load by scaling and root planing (SRP), it was further hypothesized that such therapy might, in the short term, also reduce the serum concentrations of antiCl. If so, this would be further indication that the source of antiCl in patients with periodontitis is the oral microflora. MATERIALS AND METHODS This study was approved by the Internal Review Board of Virginia Commonwealth University, Richmond, Virginia, and all patients provided written consent. Participants in the study were examined and treated between January 2006 and December 2012. Thirty patients identified with CP (16 males and 14 females, aged 35 to 55 years) were enrolled. Each patient had a minimum of five teeth per quadrant after removal of hopeless teeth and interproximal attachment loss (AL) of ‡5 mm at sites on five teeth. Exclusion criteria included a history of: 1) atherosclerosis, including coronary artery disease, cerebrovascular disease, or peripheral arterial disease; 2) diabetes mellitus; 3) any bleeding disorder, thrombotic disorder, or platelet disorder; 4) any condition requiring antibiotic prophylaxis; 5) hepatic, chronic or acute systemic inflammatory disease, or autoimmune disease; 6) uncontrolled hypertension; 7) the use of current chronic aspirin, clopidogrel, warfarin, non-steroidal anti-inflammatory drugs, antibiotics, or statins; 8) pregnancy or lactation; 9) organ transplants; 10) immunosuppressive or radiation therapy; and 11) chronic diseases including alcoholism. In addition, patients with clinical or radiographic features of AgP were excluded. Clinical Measurements Clinical periodontal status was documented with a complete examination of all teeth present and erupted, excluding third molars. This examination included plaque index (PI),12 gingival index (GI),13 probing depth (PD), AL, and the proportion of sites 684
Volume 85 • Number 5
with bleeding on probing (BOP). Measurements were made by one of four clinical examiners (RS, TK, CB, or HS), who were calibrated for all measurements. Study Design Blood samples were taken at the initial appointment during which the medical history was taken and periodontal examination was performed. After removal of hopeless teeth, patients were scheduled for full-mouth SRP, which was completed in two appointments separated by 2 weeks. At the second treatment appointment, an intermediate blood sample was acquired. Eight to 10 weeks after the completion of therapy, a third blood sample was taken and a complete periodontal examination was performed. Assessment of AntiCl Sera derived from blood samples were assayed for antiCl using commercially available immunoassay kits.§ These are enzyme-linked immunosorbent assays (ELISAs) certified for in vitro diagnostic use. These assays are calibrated such that levels of antiCl (immunoglobulin [Ig]G or IgM) >15 U/mL are considered to be positive (that is, greater than levels seen in 99% of healthy individuals as determined by the manufacturer). Samples were assessed in duplicate determinations. Statistical Analyses Repeated measures analysis of variance was used to assess changes in clinical measures and antibody levels over time. Multiple regression analyses were performed to determine effects of demographic variables, if any, on changes in clinical measures and antibody concentrations. RESULTS Patients with CP were treated by SRP, and serum levels of IgG and IgM antiCl were monitored during and 8 to 10 weeks after the completion of therapy. Table 1 illustrates the demographic characteristics of the patients. Table 1 also shows the influence of SRP on clinical periodontal measures, including PD, AL, PI, and GI, demonstrating that these parameters significantly improved following treatment. Multivariate analyses indicated that demographic variables were not significantly associated with either antiCl levels or treatment outcomes. The levels of antiCl antibody during the course of treatment are shown in Table 2. When all 30 patients are considered, there was no significant change in either IgG or IgM antiCl levels during the course of periodontal treatment or at 8 to 10 weeks after the completion of therapy. However, as expected, the majority of the patients (25) had initial serum levels § Varelisa Cardiolipin IgG and IgM kits, Thermo Fisher Scientific, Hudson, NH.
Chaston, Sabatini, Koertge, Brooks, Schenkein
J Periodontol • May 2014
of antiCl considered to be clinically normal. Five patients (16.7%) had elevated (>15 U/mL) levels of antiCl before initiation of treatment. When these patients with elevated levels of antiCl were considered as a subgroup, a significant decrease in IgM antiCl concentration following therapy (P = 0.0008) was noted, while IgG levels were unchanged. Thus, Table 1.
Demographic and Clinical Characteristics (mean [SEM]) of the Patient Population (N = 30) Characteristic Mean age (years) – SE
Value
P*
46.6 (1.4)
Race (black/white)
10/20
Sex (M/F)
16/14
Serum Anticardiolipin Concentrations in Patients With Chronic Periodontitis Following Scaling and Root Planing Reve Chaston,* Robert Sabatini,† Thomas E. Koertge,† Carol N. Brooks,‡ and Harvey A. Schenkein†
Background: Anticardiolipin antibodies (antiCl), present in some patients with autoimmune disease, are associated with thrombosis, fetal loss, and other conditions. A significant proportion of patients with chronic periodontitis (CP) test positive for antiCl, likely because some periodontal pathogens contain antigens homologous to the target antigen of antiCl on the serum protein b-2 glycoprotein-I (b2GPI) and thus can induce antiCl by molecular mimicry. The authors hypothesized that treatment of periodontitis by scaling and root planing (SRP) could therefore decrease serum titers of antiCl in patients with CP. Methods: Thirty patients with CP received complete periodontal examinations at baseline including assessment of probing depth, attachment loss, gingival index, and plaque index. SRP was performed in two sessions at 2-week intervals. Eight weeks later, patients were reexamined. Blood samples were taken at baseline, 2 weeks after the initial therapy appointment, and 8 weeks after the completion of treatment for assessment of immunoglobulin (Ig)G and IgM antiCl levels. Results: All periodontal parameters improved significantly. Consistent with previous observations, five (16.7%) of the 30 patients exhibited elevated levels of IgG or IgM antiCl at baseline. Following treatment, the concentrations of IgG and IgM antiCl remained unchanged for the entire cohort of 30 patients. However, in the five patients with elevated antiCl at baseline, IgM antiCl concentrations decreased significantly (P = 0.0008) owing to therapy, while IgG antiCl did not. Conclusion: The oral microflora is a likely source of antigen inducing antiCl in CP, since IgM antiCl levels can be reduced in the short term with conservative therapy. J Periodontol 2014;85:683-687. KEY WORDS Anticardiolipin antibody; chronic periodontitis; dental scaling; immunoglobulin M; molecular mimicry; root planing. * Currently, Private practice, Layton, UT; previously, Department of Periodontics, Virginia Commonwealth University School of Dentistry, Richmond, VA. † Department of Periodontics, Virginia Commonwealth University School of Dentistry. ‡ Department of General Practice, Virginia Commonwealth University School of Dentistry.
A
nticardiolipin (antiCl) autoantibodies are strongly associated with thrombosis, fetal loss, and associated conditions in individuals with the antiphospholipid syndrome and as a secondary consequence of systemic lupus erythematosis.1 In addition, a number of studies have demonstrated strong associations between antiphospholipid antibodies, especially antiCl, and cardiovascular diseases in patients without overt autoimmune disease.2 Because it has been demonstrated in animal models that microbial infections of various types can lead to production of antibodies that functionally mimic antiCl,3 it is hypothesized that some patients may acquire antiCl due to bacterial, viral, or fungal infections,4-6 although these antibodies may not all be pathogenic. The ability of some microbes to induce pathogenic antiCl is due to significant homology between some microbial antigens and the serum protein b-2 glycoprotein-I (b2GPI), the target antigen of antiCl autoantibodies. The authors of this study have previously shown that a greater proportion of patients with chronic periodontitis (CP) or aggressive periodontitis (AgP) have elevated serum antiCl levels than systemically and periodontally healthy individuals.7 This observation raised the question of the source of antigen capable of inducing antiCl. It has been observed that periodontal pathogens, including Porphyromonas gingivalis, Actinobacillus
doi: 10.1902/jop.2013.130408
683
Anticardiolipin in Chronic Periodontitis Following Treatment
actinomycetemcomitans, and Treponema denticola, have antigens bearing peptide sequences of sufficient similarity to key sequences in b2GPI to induce these antibodies.8,9 Furthermore, the antiCl found in sera of patients with periodontitis are biologically functional, as they are capable of activating endothelial cells to produce the key cytokine monocyte chemotactic protein (MCP)-1.10 Additionally, the observation that immunization of mice with P. gingivalis results in production of antibodies reactive with b2GPI, and that passive immunization of pregnant mice with these antibodies results in increased fetal loss.11 It was therefore hypothesized that the source of antiCl in periodontitis is the oral microflora. Because routine therapy for periodontitis includes reduction of the oral pathogen load by scaling and root planing (SRP), it was further hypothesized that such therapy might, in the short term, also reduce the serum concentrations of antiCl. If so, this would be further indication that the source of antiCl in patients with periodontitis is the oral microflora. MATERIALS AND METHODS This study was approved by the Internal Review Board of Virginia Commonwealth University, Richmond, Virginia, and all patients provided written consent. Participants in the study were examined and treated between January 2006 and December 2012. Thirty patients identified with CP (16 males and 14 females, aged 35 to 55 years) were enrolled. Each patient had a minimum of five teeth per quadrant after removal of hopeless teeth and interproximal attachment loss (AL) of ‡5 mm at sites on five teeth. Exclusion criteria included a history of: 1) atherosclerosis, including coronary artery disease, cerebrovascular disease, or peripheral arterial disease; 2) diabetes mellitus; 3) any bleeding disorder, thrombotic disorder, or platelet disorder; 4) any condition requiring antibiotic prophylaxis; 5) hepatic, chronic or acute systemic inflammatory disease, or autoimmune disease; 6) uncontrolled hypertension; 7) the use of current chronic aspirin, clopidogrel, warfarin, non-steroidal anti-inflammatory drugs, antibiotics, or statins; 8) pregnancy or lactation; 9) organ transplants; 10) immunosuppressive or radiation therapy; and 11) chronic diseases including alcoholism. In addition, patients with clinical or radiographic features of AgP were excluded. Clinical Measurements Clinical periodontal status was documented with a complete examination of all teeth present and erupted, excluding third molars. This examination included plaque index (PI),12 gingival index (GI),13 probing depth (PD), AL, and the proportion of sites 684
Volume 85 • Number 5
with bleeding on probing (BOP). Measurements were made by one of four clinical examiners (RS, TK, CB, or HS), who were calibrated for all measurements. Study Design Blood samples were taken at the initial appointment during which the medical history was taken and periodontal examination was performed. After removal of hopeless teeth, patients were scheduled for full-mouth SRP, which was completed in two appointments separated by 2 weeks. At the second treatment appointment, an intermediate blood sample was acquired. Eight to 10 weeks after the completion of therapy, a third blood sample was taken and a complete periodontal examination was performed. Assessment of AntiCl Sera derived from blood samples were assayed for antiCl using commercially available immunoassay kits.§ These are enzyme-linked immunosorbent assays (ELISAs) certified for in vitro diagnostic use. These assays are calibrated such that levels of antiCl (immunoglobulin [Ig]G or IgM) >15 U/mL are considered to be positive (that is, greater than levels seen in 99% of healthy individuals as determined by the manufacturer). Samples were assessed in duplicate determinations. Statistical Analyses Repeated measures analysis of variance was used to assess changes in clinical measures and antibody levels over time. Multiple regression analyses were performed to determine effects of demographic variables, if any, on changes in clinical measures and antibody concentrations. RESULTS Patients with CP were treated by SRP, and serum levels of IgG and IgM antiCl were monitored during and 8 to 10 weeks after the completion of therapy. Table 1 illustrates the demographic characteristics of the patients. Table 1 also shows the influence of SRP on clinical periodontal measures, including PD, AL, PI, and GI, demonstrating that these parameters significantly improved following treatment. Multivariate analyses indicated that demographic variables were not significantly associated with either antiCl levels or treatment outcomes. The levels of antiCl antibody during the course of treatment are shown in Table 2. When all 30 patients are considered, there was no significant change in either IgG or IgM antiCl levels during the course of periodontal treatment or at 8 to 10 weeks after the completion of therapy. However, as expected, the majority of the patients (25) had initial serum levels § Varelisa Cardiolipin IgG and IgM kits, Thermo Fisher Scientific, Hudson, NH.
Chaston, Sabatini, Koertge, Brooks, Schenkein
J Periodontol • May 2014
of antiCl considered to be clinically normal. Five patients (16.7%) had elevated (>15 U/mL) levels of antiCl before initiation of treatment. When these patients with elevated levels of antiCl were considered as a subgroup, a significant decrease in IgM antiCl concentration following therapy (P = 0.0008) was noted, while IgG levels were unchanged. Thus, Table 1.
Demographic and Clinical Characteristics (mean [SEM]) of the Patient Population (N = 30) Characteristic Mean age (years) – SE
Value
P*
46.6 (1.4)
Race (black/white)
10/20
Sex (M/F)
16/14
