Anticardiolipin in porphyromonas gingivalis antisera causes fetal loss in mice

Periodontal Health and Disease in the Context of Systemic Diseases

During recent years, considerable progress has been made in understanding the etiopathogenesis of periodontitis in its various forms and their interactions with the host. Furthermore, a number of reports have highlighted the importance of oral health and disease in systemic conditions, especially cardiovascular diseases and diabetes. In this regard, research has attempted to explain the role of periodontitis in promoting alteration in distant sites and organs. Recently, DNA sequencing studies have revealed how oral infections can occur in distant sites such as the colon, reproductive tissues, metabolic diseases, and atheromas. The objective of this review is to describe and update the emerging evidence and knowledge regarding the association between periodontitis and systemic disease and to analyse the evidence that has reported periodontitis as a risk factor for the development of various forms of systemic diseases in order to provide a better understanding of the possible shared etiopathogenetic pathways between periodontitis and the different forms of systemic diseases.

Exploring the Mechanisms and Association between Oral Microflora and Systemic Diseases

The scope of dentistry is ever-changing and dynamic in all fields of dentistry including periodontal health and disease. Recent studies show that oral health and systemic health are interdependent, particularly in the way that poor oral hygiene and periodontal health affect the systemic health of an individual and vice versa. Periodontal diseases are multifactorial in nature in which the role of bacterial infections is inevitable. Furthermore, high-throughput sequencing technologies have shed light on the dysregulation of the growth of oral microbial flora and their environment, including those that are associated with periodontitis and other oral and non-oral diseases. Under such circumstances, it becomes important to explore oral microbiota and understand the effects of periodontal pathogens in the pathogenesis of systemic diseases. In addition, it may strengthen our view that a better understanding of oral microbial flora and proper examination of the oral cavity may aid in the early diagnosis and possible treatment of systemic diseases and conditions. This will eventually lead to providing better care to our patients. Therefore, in this research, we attempt to outline the periodontal pathophysiology along with the role of periodontal pathogens in some commonly encountered systemic conditions.

Periodontitis and Its Inflammatory Changes Linked to Various Systemic Diseases: A Review of Its Underlying Mechanisms

Periodontitis is a chronic inflammatory disease of the gums. The incidence of periodontitis is increasing all over the world. In patients with periodontitis, there is gradual destruction of the periodontal ligament and the alveolar bone, and later, in advanced stages, there is tooth loss. Different microorganisms, the host’s immune response, and various environmental factors interact in the progression of this chronic inflammatory disease. In the present review, we discuss the epidemiology, clinical features, diagnosis, and complications of periodontitis. We also discuss the association of chronic inflammation found in periodontitis with various other systemic diseases, which include cardiovascular, respiratory, diabetes, Alzheimer’s, cancer, adverse pregnancy, and multiple myeloma, and also highlight microbial carcinogenesis and the microRNAs involved. The latest updates on the molecular mechanism, possible biomarkers, and treatment procedures may be beneficial for diagnostic and therapeutic purposes.

Purification of RgpA from external outer membrane vesicles of Porphyromonas gingivalis

INTRODUCTION

Purification of native gingipains is challenging because these proteases are frequently associated with the cell surface, which affects yield. This study aimed to purify native Arg-gingipain (RgpA) from Porphyromonas gingivalis Outer Membrane Vesicles (OMV).

METHODS

Native RgpA was purified from P. gingivalis strain ATCC33277 OMV using a strategy including ultracentrifugation, sonication, and successive anionic and cationic fast protein liquid chromatography (FPLC). The presence and purity of the protease were confirmed by SDS-PAGE and detection of protease activity using fluorogenic substrates. Rat antibodies produced against the unique adhesin hemagglutinin (H1) domain of RgpA (amino acids 719-865) were titrated by ELISA at a 1:100 dilution using whole P. gingivalis lysate as an antigen and western blotting to detect a 75 kDa band corresponding to RgpA.

RESULTS

Double anionic-cationic FLPC yielded prominent peaks with evident amidolytic gingipain activity of the appropriate molecular weight, as confirmed by western blotting. The final RgpA yield from 1 L of bacterial culture with colony forming unit (CFU) (Log₁₀) 7.4 ± 0.08/mL was of 12.6% (2 mg/mL), with 3.2 FU/μg of amidolytic activity.

CONCLUSIONS

This protocol allows purification of native RgpA from OMV that retains protease activity.

aMMP-8 Oral Fluid PoC Test in Relation to Oral and Systemic Diseases

The manuscript uses the previously published literature and highlights the benefits of active-matrix metalloproteinase (aMMP)-8 chairside/point-of-care (PoC) diagnostic tools as adjunctive measures in oral and systemic diseases. Previous studies suggest that as a biomarker, aMMP-8 is more precise than total MMP-8, MMP-9, MMP-2, MMP-3, MMP-13, MMP-7, MMP-1, calprotectin, myeloperoxidase (MPO), human neutrophil elastase (HNE), tissue inhibitor of matrix metalloproteinase (TIMP)-1, and bleeding of probing (BOP). Therefore, aMMP-8 could be implemented as the needed key biomarker for the new disease classification for both periodontitis and peri-implantitis. With a sensitivity to the tune of 75–85% and specificity in the range of 80–90%, lateral flow aMMP-8 PoC testing is comparable to catalytic protease activity assays for aMMP-8. The test can be further applied to estimate the glycemic status of an individual, to ascertain whether a person is at risk for COVID-19, in managing the oral side effects of radiotherapy carried in head and neck cancers, and in selected cases pertaining to reproductive health. In the future, aMMP-8 could find application as a potential systemic biomarker in diseases affecting the cardiovascular system, cancers, bacteremia, sepsis, diabetes, obesity, meningitis, as well as pancreatitis. The aMMP-8 PoCT is the first practical test in the emerging new dental clinical field, that is, oral clinical chemistry representing oral medicine, clinical chemistry, peri-implantology, and periodontology.

Influence of probiotics on the periodontium, the oral microbiota and the immune response during orthodontic treatment in adolescent and adult patients (ProMB Trial): study protocol for a prospective, double-blind, controlled, randomized clinical trial

Background

Orthodontic treatment with fixed appliances is often necessary to correct malocclusions in adolescence or adulthood. However, oral hygiene is complicated by appliances, and prior studies indicate that they may trigger oral inflammation and dysbiosis of the oral microbiota, especially during the first 3 months after insertion, and, thus, may present a risk for inflammatory oral diseases. In recent periodontal therapeutic studies, probiotics have been applied to improve clinical parameters and reduce local inflammation. However, limited knowledge exists concerning the effects of probiotics in orthodontics. Therefore, the aim of our study is to evaluate the impact of probiotics during orthodontic treatment.

Methods

This study is a monocentric, randomized, double blind, controlled clinical study to investigate the effectiveness of daily adjuvant use of Limosilactobacillus reuteri (Prodentis®-lozenges, DSM 17938, ATCC PTA 5289) versus control lozenges during the first three months of orthodontic treatment with fixed appliances. Following power analysis, a total of 34 adolescent patients (age 12–17) and 34 adult patients (18 years and older) undergoing orthodontic treatment at the University Hospital Erlangen will be assigned into 2 parallel groups using a randomization plan for each age group. The primary outcome measure is the change of the gingival index after 4 weeks. Secondary outcomes include the probing pocket depth, the modified plaque index, the composition of the oral microbiota, the local cytokine expression and—only for adults—serum cytokine levels and the frequencies of cells of the innate and adaptive immune system in peripheral blood.

Discussion

Preventive strategies in everyday orthodontic practice include oral hygiene instructions and regular dental cleaning. Innovative methods, like adjuvant use of oral probiotics, are missing. The aim of this study is to analyse, whether probiotics can improve clinical parameters, reduce inflammation and prevent dysbiosis of the oral microbiota during orthodontic treatment. If successful, this study will provide the basis for a new strategy of prophylaxis of oral dysbiosis-related diseases during treatment with fixed appliances.

Trial registration

This trial is registered at ClinicalTrials.gov in two parts under the number NCT04598633 (Adolescents, registration date 10/22/2020), and NCT04606186 (Adults, registration date 10/28/2020).

Understanding the pathways leading to gut dysbiosis and enteric environmental dysfunction in infants: the influence of maternal dysbiosis and other microbiota determinants during early life

Maternal environmental enteric dysfunction (EED) encompasses undernutrition with an inflammatory gut profile, a variable degree of dysbiosis and increased translocation of pathogens in the gut mucosa. Even though recent research findings have shed light on the pathological pathways underlying the establishment of the infant gut dysbiosis, evidence on how maternal EED influences the development of gut dysbiosis and EED in the offspring remains elusive. This review summarizes the current knowledge on the effect of maternal dysbiosis and EED on infant health, and explores recent progress in unraveling the mechanisms of acquisition of a dysbiotic gut microbiota in the offspring. In Western communities, maternal inoculum, delivery mode, perinatal antibiotics, feeding practices, and infections are the major drivers of the infant gut microbiota during the first two years of life. In other latitudes, the infectious burden and maternal malnutrition might introduce further risk factors for infant gut dysbiosis. Novel tools, such as transcriptomics and metabolomics, have become indispensable to analyze the metabolic environment of the infant in utero and post-partum. Human-milk oligosaccharides have essential prebiotic, antimicrobial, and anti-biofilm properties that might offer additional therapeutic opportunities.

Anticardiolipin from Periodontitis Patients Impact Fetal Loss and Annexin V

Anticardiolipin antibodies, found at elevated serum concentrations in 15% to 20% of individuals with periodontitis, are associated with adverse pregnancy outcomes, thrombotic conditions, and accelerated atherosclerosis in autoimmune disease such as the antiphospholipid syndrome. Our previous studies demonstrated that antibodies raised in mice against Porphyromonas gingivalis caused fetal loss in a mouse pregnancy model due to anticardiolipin antibodies. Such antibodies are induced via molecular mimicry with the serum protein β2-glycoprotein 1 (β2GP1), the target antigen of anticardiolipin. Furthermore, human anticardiolipin IgG is associated with increased serum markers of vascular inflammation, and IgG purified from periodontitis subjects with elevated anticardiolipin stimulates inflammatory cytokine production by endothelial cells and a trophoblastic cell line. Activation of the trophoblastic cells by anticardiolipin occurs through Toll-like receptor 4. In the present study, we observed that IgG anticardiolipin from periodontitis subjects also causes fetal loss in mice. Displacement of the protective 2-dimensional lattice formed by annexin V on trophoblast surfaces by anticardiolipin, via its interaction with its target antigen β2GP1, leading to fibrin clot formation due to exposure of anionic phospholipids to plasma, is a plausible pathogenic mechanism explaining adverse obstetrical outcomes in antiphospholipid syndrome. Therefore, we assessed such interactions in periodontitis. We observed that anticardiolipin from periodontitis subjects competes for annexin V on an artificial phosphatidylserine monolayer, replicating a key activity of autoantibodies found in patients with antiphospholipid syndrome. In addition, we found that anticardiolipin from periodontitis subjects increases annexin V levels on the BeWo choriocarcinoma cell line, consistent with mobilization of annexin V to the cell surface to facilitate repair following membrane damage. The data indicate that sera and IgG from periodontitis subjects with elevated anticardiolipin levels may influence pregnancy outcomes due to interactions with annexin V.

Quantitative analysis of key periodontopathic bacteria in gestational diabetic and non-diabetic women

Purpose

The aim of this study is to compare the periodontal status and quantify Porphyromonas gingivalis (Pg) and Prevotella intermedia (Pi) from plaque samples of both gestational diabetic mellitus (GDM) and non diabetic pregnant women.

Materials and methods

Sixty first time pregnant women were selected after adjusting for age, duration of pregnancy and educational status. They were then categorized into gestational diabetic women (GDM) (Group A) and healthy pregnant women (non GDM) (Group B). Periodontal examination was done by assessing gingival index, periodontal disease index and probing depth. Microbial analysis on sub-gingival plaque was performed using polymerase chain reaction (PCR). Statistical analysis was done by student t test, chi square test and Fischer exact test.

Results

Group A showed higher gingival index, probing depth and periodontal disease index scores than group B at p < 0.001. Pg was detected in 80% of group A and 40% of group B. Amongst these; it was measured over 2.0 × 10⁴ in 33% of group A, while in the group B it never scored more than 1.0 × 10⁴. While Pi were also detected in 73% of group A women and 40% Group B women but quantification showed Pi > 2.0 × 10⁴ in more number of group A women.

Conclusion

This study showed that there is significant association between the severity of periodontal disease and increased levels of Pg and Pi in gestational diabetic women.

Distal Consequences of Oral Inflammation

Periodontitis is an incredibly prevalent chronic inflammatory disease, which results in the destruction of tooth supporting structures. However, in addition to causing tooth and alveolar bone loss, this oral inflammatory disease has been shown to contribute to disease states and inflammatory pathology at sites distant from the oral cavity. Epidemiological and experimental studies have linked periodontitis to the development and/or exacerbation of a plethora of other chronic diseases ranging from rheumatoid arthritis to Alzheimer's disease. Such studies highlight how the inflammatory status of the oral cavity can have a profound impact on systemic health. In this review we discuss the disease states impacted by periodontitis and explore potential mechanisms whereby oral inflammation could promote loss of homeostasis at distant sites.

Association between periodontal pathogens and systemic disease

A growing body of literature suggests that there is a link between periodontitis and systemic diseases. These diseases include cardiovascular disease, gastrointestinal and colorectal cancer, diabetes and insulin resistance, and Alzheimer's disease, as well as respiratory tract infection and adverse pregnancy outcomes. The presence of periodontal pathogens and their metabolic by-products in the mouth may in fact modulate the immune response beyond the oral cavity, thus promoting the development of systemic conditions. A cause-and-effect relationship has not been established yet for most of the diseases, and the mediators of the association are still being identified. A better understanding of the systemic effects of oral microorganisms will contribute to the goal of using the oral cavity to diagnose and possibly treat non-oral systemic disease.

Anticardiolipin (aCL) in sera from periodontitis subjects activate Toll-like receptor 4 (TLR4)

Anticardiolipin antibodies (aCL) have been reported to be present in 15–20% of sera from subjects with periodontitis at concentrations exceeding those found in 95% of the healthy adult population. These antibodies, albeit at concentrations exceeding those generally found in periodontitis subjects, are typically present in patients with the antiphospholipid syndrome (APS), an autoimmune disease characterized by thrombosis and recurrent pregnancy loss. aCL from APS patients are proinflammatory and can activate trophoblasts, macrophages, and platelets via cell-surface interactions with their target antigen beta-2-glycoprotein-I (β2GPI). β2GPI is an anionic phospholipid-binding serum protein that can associate with toll-like receptors (TLR’s) on the cell-surface, leading to cell activation following interaction with autoimmune aCL. We examined an expanded series of 629 sera from clinically characterized subjects for aCL content, and observed that 14–19% of these sera contained elevated (>95^th %-tile) levels of aCL. We purified IgG from 16 subjects with elevated or normal levels of aCL and examined their ability to activate TLR2- or TLR4-transfected human embryonic kidney (HEK) cells, and observed that IgG from periodontitis patients with elevated aCL activated HEK-TLR4 cells, but not HEK-TLR2 cells. Prior removal of aCL by immunoabsorption significantly reduced the ability of IgG preparations from these sera to activate TLR4. Further experiments using a human first trimester trophoblastic cell line (HTR8 sv/neo) revealed that aCL from periodontitis patients stimulated IL-8 production, which was profoundly decreased if aCL was removed by immunoabsorption or if HTR8 sv/neo were pretreated with blocking anti-TLR4 antibodies. Thus, it appears that aCL from periodontitis patients can be proinflammatory, activating cells via TLR4. Since these antibodies are likely produced via molecular mimicry due to similarities between oral bacterial antigens and β2GPI, the data indicate that circulating serum aCL may induce or influence inflammatory responses at sites distant from the oral cavity.

Porphyromonas gingivalis may interfere with conception in women

In this observational and prospective study, we investigated if microbiological and serological markers of periodontitis associated with conception in 256 non-pregnant women (Mage = 29.2 years; range 19-42 years). Clinical oral and gynecological examinations were performed, major periodontal pathogens in the saliva were detected, and serum and saliva antibodies against major periodontal pathogens were analyzed. The follow-up period for becoming pregnant was 12 months. Porphyromonas gingivalis was significantly (p = 0.032) more frequently detected in the saliva among those who did not become pregnant (8.3%) than among those who became pregnant (2.1%). The median levels of salivary P. gingivalis immunoglobulin A (IgA; p = 0.006) and IgG (p = 0.007) antibodies were higher among those who did not become pregnant compared to those who became pregnant. Hazard ratios (HR) for not becoming pregnant were HR = 3.75 (95% confidence interval [CI] 1.01-13.9; p = 0.048) if the subject was polymerase chain reaction-positive for P. gingivalis with high salivary antibodies against it, and HR = 1.62 (95% CI 1.03-2.54; p = 0.035) if she had high levels of serum P. gingivalis IgA and signs of periodontal infection. P. gingivalis associated with no success in getting pregnant.

Increased infection with key periodontal pathogens during gestational diabetes mellitus

AIM

Gestational diabetes mellitus (GDM), gingivitis, infection with specific periodontal pathogens and systemic inflammation each increase the risk for poor pregnancy outcome. We set out to monitor the interactions of gingivitis and GDM with respect to oral infection and the systemic inflammatory burden.

MATERIALS AND METHODS

Four case-control groups (n = 117) were recruited, (1) No gingivitis, No GDM (n = 27); (2) Gingivitis, No GDM (n = 31); (3) No gingivitis, GDM (n = 21); and (4) Gingivitis, GDM (n = 38). Oral infection with three key periodontal pathogens was determined by PCR. Systemic inflammation was determined by quantification of CRP by EIA.

RESULTS

Gingivitis during pregnancy was associated with oral infection with Porphyromonas gingivalis, Filifactor alocis and Treponema denticola and combinations thereof (all p < 0.01). GDM was also associated with increased infection with individual and multiple oral pathogens (all p < 0.05). Gingivitis during pregnancy led to a 325% increase in systemic CRP (mean, 2495 versus 8116 ng/ml, p < 0.01).

CONCLUSIONS

Diabetes and gingivitis act in concert to increase risk biomarkers for poor pregnancy outcome.

Periodontitis: from microbial immune subversion to systemic inflammation

Periodontitis is a dysbiotic inflammatory disease with an adverse impact on systemic health. Recent studies have provided insights into the emergence and persistence of dysbiotic oral microbial communities that can mediate inflammatory pathology at local as well as distant sites. This Review discusses the mechanisms of microbial immune subversion that tip the balance from homeostasis to disease in oral or extra-oral sites.

Periodontal disease, atherosclerosis, adverse pregnancy outcomes, and head-and-neck cancer

Interrelationships between periodontal infection and systemic conditions such as cardiovascular disease, adverse pregnancy outcomes, and head-and-neck cancer have become increasingly appreciated in recent years. Periodontitis is associated with cardiovascular disease (CVD) and, experimentally, with measures of atherosclerosis and endothelial dysfunction. Periodontal therapy may reduce atherosclerotic changes and improve endothelial function. Preliminary findings suggest a role for the genetic locus ANRIL in the pathobiology of both CVD and periodontitis. Periodontal pathogens induce anticardiolipin in periodontitis patients by molecular mimicry of the serum protein β-2 glycoprotein I. These antibodies have biological and pathological activities consistent with those reported for other infection-induced antiphospholipid antibodies. Anticardiolipin may explain some of the observed associations between periodontitis and systemic conditions such as CVD and adverse pregnancy outcomes. The oral commensal Fusobacterium nucleatum (Fn) becomes pathogenic on migration to extra-oral sites. Fn infection of the fetal-placental unit has been linked to pregnancy complications, including preterm birth, stillbirth, and early-onset neonatal sepsis. Reagents aimed at inhibiting or resolving inflammatory responses may be used to treat or prevent pregnancy complications due to bacterial infection. Chronic periodontitis may be independently associated with head-and-neck squamous cell carcinoma (HNSCC) through direct toxic effects of bacteria and their products, and/or through indirect effects of inflammation. Additionally, chronic periodontitis may facilitate the acquisition and persistence of oral HPV infection, a recently emerged risk factor for HNSCC.

Serum anticardiolipin concentrations in patients with chronic periodontitis following scaling and root planing

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 β-2 glycoprotein-I (β2GPI) 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.