participants (A). A single analyte showed a peak value in 11 patients, two peaks were found in 7 patients. In the remaining 12 patients between 3 and 10 analytes showed peak values. For individuals with 2 or more peaks, the mean values of PD and BOP were within the range of the other patients (PD: 4.41; BOP: 86.6).
The second bar graph in Figure 26 (B) shows the number of analytes with peak values per subject after therapy. Therapy did not significantly reduce the number of subjects having at least one peak (BL: 30 subjects, M3: 27 subjects, p=0.62). The number of subjects with 4 or more peaks, however, was greatly reduced (BL: 11 subjects, M3: 1 subject, p=0.003). With regards to the reduction of peaks, no specific benefit of adjunctive antibiotics could be seen. A single patient still showed 8 peaks after treatment. This particular subject had 8 peaks at BL also, was treated with antibiotics and responded well to therapy as far as clinical parameters are concerned (mean PD at BL: 6.26 mm, BOP at BL: 100%, PD after therapy: 3.07 mm, BOP after therapy:
39.9%).
Table 4 shows the mean serum biomarker levels in periodontitis patients per treatment group at baseline and M3 of those 13 analytes with a frequency of detection >75%. The levels were significantly lower at M3 than at baseline for most of these markers. Differences between groups were not significant.
Levels of 13 serum biomarkers with a detection frequency of >75% in periodontitis patients per treatment group, at BL and M3. Data are means (standard deviation), n=40 participants.
Parameters Baseline Month 3 p
Placebo Test Placebo Test BL-M3
Participants, n 21 19 21 19
IL-1ra, pg/ml 12.6 (29.3) 5.8 (8.5) 0.5 (1.2) 2.0 (7.3) <0.001
IL-8, pg/ml 5.7 (8.6) 6.7 (6.3) 5.6 (9.5) 6.1 (7.3) n.s.
IL-12-p70, pg/ml 25.8 (20.9) 30.0 (30.6) 5.8 (4.6) 8.4 (6.1) <0.001 MIP-1β, pg/ml 189.4 (157.9) 157.0 (74.4) 97.0 (50.1) 99.0 (52.6) <0.001 VEGF, pg/ml 237.6 (244.3) 354.3 (544.8) 148.7 (130.0) 499.0 (1253.4) 0.002 α2M, mg/ml 1.3 (0.6) 1.6 (0.5) 1.7 (0.3) 1.6 (0.3) 0.04
CRP, µg/ml 5.7 (8.1) 6.4 (11.7) 4.6 (4.4) 5.1 (7.6) n.s.
Hp, mg/ml 1.0 (1.5) 2.3 (2.5) 2.8 (2.7) 3.2 (3.0) 0.004
SAP, µg/ml 56.2 (20.0) 56.5 (13.9) 67.1 (25.7) 58.2 (13.5) 0.02
Ferritin, ng/ml 117.0 (166.9) 109.4 (122.6) 99.0 (128.4) 97.0 (107.0) 0.002
Fibrinogen, µg/ml 2.6 (0.9) 2.3 (1.0) 1.9 (0.6) 1.8 (0.6) 0.001
PCT, ng/ml 2.5 (2.1) 2.3 (1.8) 0.5 (0.6) 0.5 (0.8) <0.001
SAA, µg/ml 8.9 (7.0) 6.5 (5.2) 3.6 (3.5) 3.7 (6.7) <0.001
We measured a range of 24 analytes in serum of periodontally diseased patients before and standard for measuring inflammatory mediators, MBBA offers a number of advantages, notably the possibility to simultaneously measure up to 100 different analytes in a single sample across patients. Among 40 patients with untreated periodontitis, 11 exhibited levels above threshold of four and up to ten inflammatory markers at the same time. After treatment, the number of subjects with four or more peaks was significantly reduced. Only a single patient remained with multiple peaks (8 analytes above threshold). The fact that this person was the only one having also 8 peaks at BL and responding well to therapy suggests that the reason for this unusual pattern was not periodontal disease. The number of subjects with peaks increased significantly after treatment for only one analyte (Hp, p=0.01). This was probably due to random variability. biomarkers were highly heterogeneous following periodontal therapy in a trial of another group where a large number of analytes was assessed simultaneously 13. 1/3 of the patients showed a
change in systemic inflammation. inflammatory markers and changes in the clinical periodontal status after therapy, reduction of periodontal pathogens and reduction of serum IgG antibody levels to periodontal microbiota 5 13
17. It seems that serum levels of specific cytokines or acute phase proteins do not reflect the clinical periodontal health status independently; pre-‐existing susceptibility for systemic inflammation may influence the individual response. However, the reduction of most of the peak values, defined as >mean+2SD in periodontally healthy subjects, can be attributed to periodontal therapy. A marked increase of CRP has been reported 24 h after instrumentation 12, indicating that patients undergoing periodontal treatment experience short-‐term perturbations of systemic inflammation. Due to the timing of our trial we could not corroborate the existence of short termed peaks of some of the acute phase proteins. But even if they exist it seems that they are short-‐lived, as they were undetectable at M3 in our study.
Systemic amoxicillin plus metronidazole significantly improved clinical outcomes of periodontal therapy, similar to previous studies 18. No significant difference on the biologic response to therapy was however found between the two groups. We assume that the mechanical removal of pathogenic bacteria by SRP was sufficient to suppress peak values of inflammatory biomarkers.
The current analysis is part of a large randomized clinical trial on the adjunctive effects of antibiotics given at different time points during periodontal therapy, i.e. surgical phase and maintenance phase. For the present analysis we focused on the outcomes at the 3-‐month re-‐
evaluation after initial therapy.
There is ongoing debate on the clinical usefulness of the current periodontal disease classification that discriminates aggressive and chronic periodontitis 19. Given this controversy, in our study we did not differentiate between chronic and aggressive type of periodontitis from our sample selection criteria. Periodontal treatment may have stronger effect on serum proteins in aggressive periodontitis patient as has been shown recently 20. However, in this study adjunctive antibiotics yielded better clinical results in both groups than in nonsurgical therapy alone.
In the current study, single rooted teeth and molar flat surfaces were measured. For practical reasons, furcation involvement and intrabony defects were not included in the current analysis.
It is still unknown the degree of response of these specific periodontal lesions to the current therapeutic regime as far as the clinical parameters are concerned. It was shown that these sites represent a challenge for the nonsurgical mechanical therapy alone due to arduous accessibility
21 22.
Finally, few questions will need further investigation in the future. For example, how long does the effects of periodontal therapy on systemic inflammation persist? Which factors may influence long-‐term effects? Longitudinal studies should address these questions.
The following can be concluded from our work:
1. Subjects with untreated periodontitis may show isolated high peaks for one or several inflammatory markers in serum.
2. Non-‐surgical periodontal treatment with or without antibiotics reduced most peak levels of serum markers.
3. Non-‐surgical periodontal therapy with adjunctive systemic antibiotics showed better clinical outcomes than the mechanical therapy alone.
4. No serious adverse events were associated with the treatment regime.
5. MBAA is an efficient method for the quantitative analysis of multiple cytokines.
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This work was supported by the Swiss National Science Foundation, Grant No. 320030-‐122089
for all of you before, during and at this final step. Mom, Dad, my sister Basma, my brothers Ibrahim and Zaher you have given me the warmest love that helped me to drive this road with strength and motivation, Thank you forever. My great uncle Murshed and aunt Najat I am grateful for you and I acknowledge you for your kind emotional support.
Few words I have to say it to my wife Amal: you kept my heart beating and the enthusiasm for this stage was quit intellectual between us. I couldn't have hoped for a better partner to share these events of progress while watching our children grow. You're an incredible woman, and I'm so grateful to have been blessed with your continuous warm feelings and support throughout this period and for the future to build a wonderful life.
Finally, thank you very much my country; kingdom of Saudi Arabia for giving me this very precious opportunity to advance my level of education and knowledge from the land of real science, piece, civilization, democracy, ethics, respect, fairness and precision; Switzerland.