Okada et al.

Asian Pac J Dent 2015; 15: 25-31

Predication of the prognosis after initial periodontal treatment bysalivary biomarkers
Ayako Okada, DDS, PhD,a Yoshiaki Nomura, DDS, PhD,a Kentaro Matsumoto, DDS,bKazuaki Yamane, DDS, PhD,b Tatsuhiko Yoshida, DDS,b Megumi Hatano, DDS,b
Shinya Miyamatsu, DDS,b Naomi Fukaishi, DDS,b Tomoya Amagasaki, DDS,b KumikoNagamatsu, DDS, PhD,b Hiroo Yoshikawa, DDS, PhD,b Takahide Gunji, DDS, PhD,bSeiji Kajiura, DDS,c and Nobuhiro Hanada, DDS, PhDaaDepartment of Translational Research, Tsurumi University School of Dental Medicine, Yokohama,c
Shimane Dental Association, Matsue, and Department of Health and Welfare, Shimane PrefecturalGovernment, Matsue, JapanbPurpose: The aim of this study was to predict the necessity of periodontal pocket curettage by the salivary levelsof hemoglobin and lactose dehydrogenase at baseline.
Materials and Methods: The study population was selected from the subjects with chronic periodontitis who
attended eight private dental offices. The study population consisted of 14 men and 32 women, and their meanage was 53.9+/-15.4. Patients with periodontal pockets deeper than 4 mm after initial treatment were diagnosed
as necessity pocket curettage (Group II: n=31). Other patients were once finished periodontal therapy andrecommended to visit for the supportive periodontal therapy (SPT) (Group I: n=15). Salivary levels of lactose
dehydrogenase and hemoglobin were measured using commercially available kits, according to themanufacturer’s instructions.
Results: For predict the prognosis of the initial treatment, statistically significant differences were not observedin clinical markers. In contrast both hemoglobin and lactose dehydrogenase, mean values were significantly
higher in Group II patients. In addition, 94.4% patients were necessary of the periodontal curettage if thelactose dehydrogenase value was more than 333.3 IU/L at baseline.
Conclusion: Salivary levels of lactose dehydrogenase at baseline may be useful markers for the prediction of thenecessity of pocket curettage after initial periodontal therapy.
(Asian Pac J Dent 2015; 15: 25-31.)
Key Words: initial periodontal therapy, lactose dehydrogenase, prognosis, saliva

Introduction
Periodontal disease is one of the most prevalent oral diseases among the middle-aged and elderly
population.

Diagnosis, assessment, and evaluation of periodontal disease are based on the visual examinationand manipulation.

This method check the morphologically changed periodontium caused by the inflammation

originated from bacterial infection.

It is obstacle to detect initial stage of periodontal disease, to check thesubtle changes of the inflammation and cost effective screening of periodontal disease.
teeth for the examination make the problem more conflicting.
still conflicting.

1,2

Additionally, plural

Even the definition of the periodontal disease isTherefore, more simple, useful and objective markers should be developed.

Saliva has been used as a diagnostic fluid in medicine and dentistry.3-5

Salivary level of lactate
6-18

Our previous study and19-21

diagnosis, prognosis anddehydrogenase (LD) has been suggested to be co-related with several oral diseases.
other studies demonstrated the usefulness of the levels of LD, in the screening,
evaluation of therapy in periodontal disease.

22-25

LD activity in saliva could constitute a specific indicator oforal mucosal lesions with tissue breakdown including periodontal disease.20,23,24
hemoglobin (Hb) as a potential biomarker.

19-21,24,25

co-relations with the probing pocket depth (PD)20,25

Previous studies considered

Salivary levels of Hb and LD had statistically significantand CPI.21

levels were significantly decreased after dental scaling.24

Moreover, we also showed that salivary LD

These biomarkers are thought to reflect the levels ofinflammation and destruction of periodontal tissues, thus indicating that they are clinically useful biomarkers for25

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Asian Pac J Dent 2015; 15: 25-31

patient follow-up after periodontal therapy.
Periodontal therapy is consisted of the initial preparation and subsequent pocket curettage and surgicaltreatment.

At the initial stage if the revaluation can predict, more effective therapy can be carried out andpatient satisfaction will go up.

The aim of this study was to predict the periodontal conditions at therevaluation by the conventional clinical markers and salivary biomarkers and set the cut-off point of these tests.

Materials and Methods
Study population
The study population was selected from the subjects with chronic periodontitis who attended eight private
dental offices under the administration of members of the Shimane Dental Association in Japan.
included if older than 20 and had more than 20 remaining teeth.
life-related diseases were excluded.
checked by interview.

Subjects wereCurrent smokers, subject with affected

Smoking status, medication and with or without life related diseases were

The study population consisted of 14 men and 32 women, and their mean age was53.9+/-15.4.
Clinical examination
Oral examination was carried out by the dentists.

The number of remaining teeth, presence or absence ofcalculus, bleeding on probing (BOP), and pocket depth (PD) were recorded.

PD were assessed using a probe atsix sites around each tooth; mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual, and distolingual.
Measurements were recorded to the nearest millimeter, and every observation close to 0.5 mm was rounded to
the lower whole number.
Clinical treatment
After tooth brushing instruction, whole-mouth scaling and root planing were performed under local
anesthesia.

Clinical parameters were measured and saliva was collected two weeks after final scaling.

Patients with periodontal pockets deeper than 4 mm after initial treatment were diagnosed as necessity pocket
curettage.

Other patients were once finished periodontal therapy and recommended to visit for the supportive

periodontal therapy (SPT) (Group I).
the initial treatment.

These patients (Group II) were treated with subgingival curettage after

After two-week final curettage, clinical parameters were measured and saliva wascollected again.
Measuring salivary Hb and LDSaliva was collected after informed written consent prior to the oral clinical examination.

Stimulated

whole saliva was collected by chewing on a gum base containing neither fragrant nor taste ingredients for 5minutes.

For the examination of salivary levels of LD and Hb, collected saliva was kept at 4°C.

Salivarylevels of LD and Hb were measured using commercially available kits; L type Wako LDH J (Wako ChemicalIndustry, Osaka, Japan) and OC-HEMODIA AUTO S (Eiken Kagaku, Tokyo, Japan) according to themanufacturer’s instructions.19
Statistical analysis
The changes in clinical parameters and salivary biomarkers were expressed as means ± standard deviation,and Wilcoxon signed-rank test or Friedman’s tests were used to calculate p-values.

The Mann-Whitney U test

was used for comparison between with or without necessity of subsequent treatment of initial preparation.

To

set the cut-off points to distinguish these two groups, receiver operating characteristic curves (ROC curves) were26

Okada et al.

Asian Pac J Dent 2015; 15: 25-31

constructed and the points showing minimum difference between sensitivity and specificity were selected.

TheFisher’s exact tests were carried out to confirm the statistical significance, and positive or negative predictive
values were also calculated.
Logistic regression analysis and Classification and Regression Trees analysis (CART) were carried out tofind out the effective markers for the prediction of necessity of subsequent treatment of initial preparation.

The

analyses were carried out using the statistical software package SPSS ver 19.0 software (SPSS Inc., Tokyo,Japan).
Ethics
The study was approved by the Ethics Committee of Tsurumi University School of Dental Medicine(approval number: 430) and was conducted in accordance with the Declaration of Helsinki.

Results
At baseline examination, patients were not diagnosed for the necessity of periodontal curettage.

Patients

were divided into two groups by revaluation after initial treatment of the periodontal disease with (Group II:n=31) or without (Group I: n=15) periodontal pocket more than 4 mm.

For both groups, statistically significant

reductions of clinical markers and salivary biomarkers were observed (Fig. 1).

Fig. 1 Changes of clinical markers and salivary biomarkers after initial treatment and subsequent pocket curettage
Patients without probing depth more than 4 mm were finished periodontal therapy (Group I: n=15).
Patients with probing depth more than 4 mm were diagnosed as the necessity of pocket curettage (Group II: n=31).
All change was statistically significant (p<0.05).

To predict the prognosis of the initial treatment of the periodontal disease, baseline clinical markers andsalivary biomarkers were compared.
observed.

For the clinical markers, statistically significant differences were not

In contrast both Hb and LD, mean values were significantly higher in patients with the necessity of

periodontal curettage (Fig. 2).

27

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Asian Pac J Dent 2015; 15: 25-31

Fig. 2 Comparison clinical markers and salivary biomarkers between the groups with or without
periodontal pocket after scaling and root planing
Salivary eves of Hb and LD had statistically significant differences in Groups I and II.

Table 1. Cut off point to predict the necessity of pocket curettage at baseline
Positive
Negative
predictive
predicitive
p-value
AUR
value
value
BOP
26.3
0.67
0.67
0.8
0.5
0.056
0.64
PD
2.8
0.67
0.67
0.80.5
0.056
0.68
Hb
1.4
0.68
0.67
0.81
0.5
0.055
0.69
LD
248.5
0.74
0.73
0.85
0.58
0.004
0.77
Only LD had statistically significant correlation with the necessity of pocket curettage at baseline and its AUR was highest.
Cut off

Sensitivity

Specificity

Table 2. Crude and multivariate adjusted odds ratios for the prediction of necessity of pocket curettage at baseline
Crude
Multivariate
odds
95% CI
p-valueadjusted
95% CI
ratio
odds ratio
BOP %4
1.07
14.9
0.039
1.92
0.32
11.4
PD4
1.07
14.9
0.0392.94
0.52
16.58
Hb
4.2
1.13
15.59
0.032
0.97
0.16
5.81
LD
7.91
1.95
32.02
0.004
7.13
1.45
35.15
Crude
Multivariate
odds
95% CI
p-valueadjusted
95% CIratio
odds ratio
BOP %
4
1.07
14.9
0.039
1.92
0.32
11.4
PD
4
1.07
14.9
0.039
2.94
0.52
16.58
Hb
4.2
1.13
15.59
0.032
0.97
0.16
5.81
LD
7.91
1.95
32.02
0.004
7.13
1.45
35.15
Odds ratios were calculated by logistic regression analysis.
Among the multivariate adjusted odds ratios, only LD was statistically significant and its odds were highest.

p-value
0.475
0.221
0.971
0.016
p-value
0.475
0.221
0.971
0.016

To set the cut off point for the prediction of necessity of periodontal curettage, ROC curves were28

Okada et al.

Asian Pac J Dent 2015; 15: 25-31

constructed (Fig. 3).

By the cross tabulations only LD were statistically significant.

Additionally, to checkthe importance of the LD (Table 1), logistic regression analysis was carried out by using the positive or negative
for these markers as independent variables.

By the multivariate adjusted odds ratios, only LD was statisticallysignificant and its odds ratio was highest (Table 2).

Fig. 3 ROC curves of the clinical markers and salivary
biomarkers at baseline to predict the necessity of
pocket curettage

Fig. 4 Diagnostic chart to predict the necessity of pocket
curettage at baseline

Finally, diagnostic chart was constructed by the decision analysis.

The 94.4% patients were necessary of

the periodontal curettage if the LD value was more than 333.3 IU/L at baseline.

If the LD value was less than

333.3 IU/L, mean pocket depth was more than 2.5 mm, 72.2% patients were necessary of the periodontal pocket
curettage (Fig. 4).

Discussion
Scaling and root planing is traditional periodontal therapy and its effect was reported by many researchers.
According to the meta analysis reported by Hung et al.,26 range of mean reduction of the probing depth byscaling and root planing was -0.15 mm to 0.62 mm for shallow initial pocket, 0.40 mm to 1.70 mm for medium
initial pocket and 0.99 mm to 2.80 mm for deep initial pocket.

Our results showed that mean reductions were0.37 mm for group I and 0.33 mm for group II on average.

However changes were very slight.

was not suitable for the evaluation of the treatment effects.

Mean reductions of BOP % were 13.04% for group

I and 12.31% for group II.
clinical marker.

Therefore, PD

BOP % is more suitable for the evaluation of treatment effects as a conventional

In contrast, reduction of LD were 121.9 IU/L for group I and 160.9 IU/L for group II and thoseof Hb were 4.2 µg/mL for group I and 4.0 µg/mL.

The reductions of biomarkers were also cleared.

Our previous reports have shown that salivary levels of LD and Hb had co-relation with periodontal
conditions.19,21,24,25

For the screening, LD value 345 IU/L is suggested to be the cut-off point for subjects withpocket depth more than 4 mm.19

The cut-off point to diagnose progressive or no progressive patients afterconventional periodontal therapy was 262 IU/L.25
detection and only free hemoglobin was measured.

At that time, hemoglobin was measured by colorimetric
19,24,25

By this method, the contaminated bloods of otherspecies derived from food such as meat or fish were included.

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Therefore, the diagnostic precision ofOkada et al.

Asian Pac J Dent 2015; 15: 25-31

hemoglobin was inadequate.

Since then, the method of measuring hemoglobin has been improved.

reagents used for the stool occult blood test are commercially available.

Now, two

These reagents can apply for thesalivary Hb and they use polyclonal antibody and the reactions were measured by colloidal gold-label or latex
With this method, detection of Hb in saliva has become more sensitive.21

However, data for screening

level or cut-off point to diagnose progressive or no progressive patients is missing.

Then, we compared the CPIbeads.

value and Hb and LD.

Hb value 3.86 µg/mL and LD value 217 IU/mL corresponded to CPI 4.21

In this study, baseline Hb values for the patients with was 6.66 µg/mL and patients with was 16.13 µg/mL.
These values were higher than CPI 4 of our previous study.
were higher.

LD values were also 225 IU/mL and 466 IU/mL

After scaling and root planing, values of the subjects without necessity of pocket curettage weredecreased to 1.9 µg/mL for Hb and 184 IU/mL for LD.
In contrast, the patients with necessity of pocket curettage were decreased to 12.2 µg/mL for Hb value and305 µg/mL for LD value.

When compared with our previous report, LD values were higher than that ofpatients with progressive after conventional periodontal therapy.

The cut-off point of 248.5 IU/mL for LD

were lower than that of the no progressive CP patinents.25
In this study, salivary level of LD is useful marker for the prediction of the prognosis after conventional
periodontal therapy.
cost effective.

Additionally, LD measurement is one of conventional routine bold tests; therefore, test is

Our results suggested that routine use of salivary levels of LD can be the diagnostic aids,especially for the prediction of the prognosis.

And diagnostic chart shown in Fig. 4 may facilitate thediagnosis.

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Correspondence to:
Dr. Nobuhiro Hanada
Department of Translational Research, Tsurumi University School of Dental Medicine
2-1-3 Tsurumi, Tsurumi-ku, Yokohama 230-8501, Japan
Fax: +81-45-573-2473 E-mail: hanada-n@tsurumi-u.ac.jp
Accepted December 14, 2015.
Copyright ©2015 by the Asian Pacific Journal of Dentistry.
Online ISSN 2185-3487, Print ISSN 2185-3479

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