By Richard Nagelberg, DDS, and Kim Miller, RDH, BSDH, RDHMP
Source: J Periodontal Res. 2009 Jul 8. [Epub ahead of print]
Title: A multiplex immunoassay demonstrates reductions in gingival crevicular fluid cytokines following initial periodontal therapy.
Authors: Thunell DH, Tymkiw KD, Johnson GK, Joly S, Burnell KK, et al.
Overview:
The generally accepted model of periodontal disease development and progression is bacterial infection by perio pathogens in oral biofilms, followed by the body's inflammatory response causing the majority of periodontal tissue destruction. This study compared the levels of cytokines in the gingival crevicular fluid (GCF) before and after periodontal therapy. Cytokines are regulatory proteins that are released as part of the inflammatory response. They play an important role in the pathogenesis of periodontal disease.
The relevance of this research is that in the near future, successful treatment outcomes will be measured not only by clinical improvement, but also by measuring the reduction of inflammatory mediators and bacterial levels as well.
Summary of research:
• The quantities of cytokines in GCF before and after initial periodontal therapy (IP) were measured.
• Following clinical exam of study subjects, GCF samples were obtained from diseased and healthy sites in the same individuals.
• The quantity of 22 inflammatory mediators measured prior to IP and at re-evaluation 6-8 weeks post-op
Results and conclusions:
• Only 2 cytokines differed before treatment (Il-1 alpha and Il-1 beta) in initially diseased vs. initially healthy sites.
• Following IP, 13 of 16 detectable cytokines decreased significantly in diseased sites. 3 of 16 mediators decreased in healthy sites following treatment.
• Results confirm that periodontal therapy effectively reduces the pro-inflammatory cytokines, which are important in the initiation and progression of perio disease.
Key take-aways:
• This study affirms that periodontal therapy results in the reduction of inflammatory mediators, which in turn ceases the tissue destructive pathways, allowing the patient's healing to begin.
• The therapeutic endpoint of treatment occurs when the factors that denote the end of a therapeutic process have been achieved. When applied to periodontal disease, the therapeutic endpoint has been universally accepted as clinical resolution
• When clinical resolution is achieved without a significant reduction in the inflammatory mediators and/or the periodontal pathogens, we could logically and scientifically conclude that the patient is at considerable risk for disease recurrence. Clinical measurements alone would not have revealed this critical information on our patient's response to therapy.
• We should expect and even be on the lookout for other parameters to be included in the therapeutic endpoint such as the reduction in inflammatory mediators, as demonstrated in this study, as well as the reduction in the periodontal pathogens.
Implementation Strategies:
As science unfolds, we have a greater understanding of the host immune response to the periodontal pathogens, but before we can individualize therapy for a patient, there are still some questions that beg to be asked.
• Which pathogens are causing my patient's perio disease?
• Are any of them tissue invasive?
• Are the pathogens high risk or low risk?
• Is my patient genetically susceptible to perio disease?
• What other risk factors does my patient have?
The above information will directly affect our treatment planning strategies. As clinicians we should be taking advantage of diagnostic testing that take the guesswork out of the diagnosis.
While there are currently no commercially available tests to measure inflammatory mediators in the GCF there are tests available to determine type, concentration and risk level of periodontal pathogens. There is also a simple cheek swab test available to determine if a patient is genetically susceptible to periodontal disease (PST test).
Samples for microbial and PST testing would be appropriately collected during the Comprehensive Periodontal Examination (CPE, ADA diagnostic code 0180). According to the American Academy of Periodontology, microbial and other biologic assessments may be needed during a CPE. (1)
As clinicians we should be anticipating additions to the therapeutic endpoint of periodontal treatment. Our prediction is that one of the criteria to denote the end point of perio therapy will be GCF and salivary tests for levels of periodontal pathogens and inflammatory mediators.
(1) AAP, Parameter on Comprehensive Periodontal Examination J Periodontol 2000;71:847-848
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