Expression of Salivary and Serum Malondialdehyde and Lipid Profile of Patients with Periodontitis and Coronary Heart Disease PDF

International Journal of Molecular Sciences Article Expression of Salivary and Serum Malondialdehyde and Lipid Profile of Patients with Periodontitis and Coronary Heart Disease Gaetano Isola 1, * , Alessandro Polizzi 1 , Simona Santonocito 1 , Angela Alibrandi 2 and Sebastia...

International Journal of Molecular Sciences Article Expression of Salivary and Serum Malondialdehyde and Lipid Profile of Patients with Periodontitis and Coronary Heart Disease Gaetano Isola 1, * , Alessandro Polizzi 1 , Simona Santonocito 1 , Angela Alibrandi 2 and Sebastiano Ferlito 1 1 Department of General Surgery and Surgical-Medical Specialties, School of Dentistry, University of Catania, 95124 Catania, Italy; [email protected] (A.P.); [email protected] (S.S.); [email protected] (S.F.) 2 Department of Economical, Business and Environmental Sciences and Quantitative Methods, University of Messina, 98122 Messina, Italy; [email protected] * Correspondence: [email protected]; Tel./Fax: +39-095-743-5360


Received: 28 October 2019; Accepted: 29 November 2019; Published: 1 December 2019
 Abstract: Malondialdehyde (MAA) within a lipid pathway has been demonstrated to possess an important role in endothelial function that undergoes periodontitis and coronary heart disease (CHD) development. This study evaluated the impact of periodontitis, CHD, or a combination of both diseases (periodontitis + CHD) on salivary and serum MAA levels. The periodontal and clinical characteristics, serum, and saliva samples were collected from 32 healthy subjects, 34 patients with periodontitis, 33 patients with CHD, and 34 patients with periodontitis and CHD. Lipid profile and levels of MDA and C-reactive protein (CRP) were assessed. Patients in the periodontitis group (serum: 3.92 (3.7–4.4) µmol/L; salivary 1.81 (1–2.1) µmol/g protein, p < 0.01) and in the periodontitis + CHD (serum: 4.34 (3.7–4.8) µmol/L; salivary 1.96 (1.7–2.3) µmol/g protein, p < 0.001) group presented higher median concentrations of salivary and serum MAA compared to patients in the CHD (serum: 3.72 (3.5–4.1) µmol/L; salivary 1.59 (0.9–1.8) µmol/g protein, p < 0.01) and control group (serum: 3.14 (2.8–3.7) µmol/L; salivary 1.41 (0.8–1.6) µmol/g protein, p < 0.01). In univariate models, periodontitis (p = 0.034), CHD (p < 0.001), and CRP (p < 0.001) were significantly associated with MAA. In the multivariate model, only CRP remained a significant predictor of serum and salivary MAA (p < 0.001) MAA levels. Patients with periodontitis and with periodontitis + CHD presented higher levels of salivary and serum MAA compared to healthy subjects and CHD patients. CRP has been found to be a significant predictor of increased salivary and serum MAA levels. Keywords: periodontitis; coronary heart disease; malondialdehyde; C-reactive protein; endothelium 1. Introduction Periodontitis is an inflammatory and chronic multifactorial disease caused by a dysbiotic microflora of periodontal bacteria, which causes the destruction of the tooth-supporting tissues and which can finally determine tooth loss in the long-term. In the USA, recent reports have been shown in which about 50% of adults aged >30 years have periodontitis and almost 10% of the world population has a severe form of periodontitis [2,3]. During the last few decades, several studies have demonstrated a strong association between periodontitis and coronary heart disease (CHD), including several conditions such as stroke, myocardial infarction, and peripheral vascular disease [4,5]. More specifically, recent systematic reviews and large cohort studies have highlighted a graded association between periodontitis, tooth loss, and increased risk of CHD [6,7]. Int. J. Mol. Sci. 2019, 20, 6061; doi:10.3390/ijms20236061 www.mdpi.com/journal/ijms Int. J. Mol. Sci. 2019, 20, 6061 2 of 12 The etiology of periodontitis comprises immunological and inflammatory processes that cause dysregulation in the host response due to the superinfection of periodontal bacteria. Furthermore, periodontitis has been associated with higher serum levels of different inflammatory biomarkers, such as interleukin 6, prostaglandin, and C-reactive protein (CRP). Oxidative stress, through nitric oxide (NO), has been determined to be one of the main features in the pathogenesis of both periodontitis and CHD. Previous studies have evidenced that during active phases of periodontitis and CHD, polymorphonuclear neutrophils produce several reactive oxygen species, which can lead to further damage to periodontal and endothelial tissues. NO is one of the important mediators that regulates function and vasodilatation of the endothelium because it regulates the level of inflammation in the vessels, the vascular tone, the cell proliferation, and it modulates the release of different growth factors. Moreover, the augmented oxidation during periodontitis and CHD alternates some low-density lipoprotein (LDL), which can lead to the formation of lipid-laden foam cells and cholesterol in the endothelial lumen which, finally, establishes the endothelial dysfunction and atherogenesis. Augmented oxidations of LDLs are also present in oral tissues ; more recently, several authors described increased levels of malondialdehyde acetaldehyde (MAA) adducts during periodontitis and CHD. MAA is a natural molecule that occurring as a lipid peroxidation product and has been shown to be strongly reactive with several lipids and proteins to form a wide range of adducts. Several authors have proposed that MAA adducts contribute to aetiological mechanisms of several diseases such as CHD, hyperlipidemia, and diabetes through endothelial damage. During CHD, Anderson et al. have shown higher levels of IgA and IgG antibodies to MAA-LDL, while Karvonen et al. have shown that IgM antibodies to MAA-LDL present an inverse association with endothelial atherosclerosis. During the last few decades, some authors have shown high levels of serum IgG antibodies to connect to P. gingivalis in atherosclerotic vascular damage and some animals infected by P. gingivalis in a periodontitis model. It has also been demonstrated that mice heat-killed with P. gingivalis presented increased plasma IgM to MAA-LDL and IgM antibodies to MAA-LDL virulence factor gingipain (Rgp44). Moreover, some antibodies to a virulence factor of A. actinomycetemcomitans heat shock protein 60 (Aa-HSP60) have been shown to react with MAA-LDL, a well-known heat shock protein molecule demonstrated as a key factor in the development of atherosclerosis. Few reports have associated periodontitis and CHD with endothelial dysfunction [22–24]. The reduced production of NO negatively impacts the vascular endothelial cells whose impairment determines, finally, endothelial dysfunction and vasodilatation [25,26]. Hence, this has aroused interest in assessing possible oral factors that influence and regulate endothelial changes, such as subclinical signs of CHD. In this regard, previous studies have demonstrated a strict association between NO, high serum MAA and CRP levels, and endothelial damage. The local production of NO has an important role in the development and progression of periodontitis and CHD. Both increment and decrement in the production of salivary NO metabolites in gingival tissue of periodontitis patients against periodontal bacteria and periodontal tissues have been reported to be associated with impaired endothelium-dependent vasodilatation [28,29]. However, to date, the role of MAA is not well understood, as subclinical stimulus of endothelial dysfunctions in patients with periodontitis and CHD. In light of these findings, the aims of this study were to further evaluate a possible impact of periodontitis, CHD, or a combination of both periodontitis and CHD on saliva and serum MAA levels. Moreover, the association between both saliva and serum MAA levels in patients with periodontitis and with CHD was assessed, and if the salivary or serum MAA levels are mediated by serum CRP. Int. J. Mol. Sci. 2019, 20, 6061 3 of 12 2. Results Study Participant The demographic and biochemical characteristics of the recruited subjects are represented in Table 1. Patients and controls were matched for age and gender, and there were no significant differences between the distribution of education levels or median values (25%; 75% percentiles) of BMI between the groups (Table 1). Patients with CHD and periodontitis + CHD had a higher proportion of previous CVD events (stroke, atrial fibrillation, angina pectoris, and heart failure) and took more CVD drugs (statins, low-dose aspirin, antihypertensive, and beta-blockers) compared to periodontitis and healthy subjects. Increased values of hs-CRP were observed among patients with periodontitis, CHD, and periodontitis + CHD in comparison with healthy subjects (p < 0.001). Table 1. Individual characteristics and biochemical parameters of recruited subjects. Data are expressed as median (25th; 75th percentiles) or number with percentage. * p < 0.001 and ** p < 0.001 significant differences vs healthy subjects calculated by the Mann–Whitney test. §§ p < 0.001 significant differences vs periodontitis patients calculated by the Mann–Whitney test. p < 0.007 significant differences vs CHD patients calculated by the Mann–Whitney test. CHD, coronary heart disease; CVD, cardiovascular disease. Periodontitis (n Periodontitis + Clinical Features Controls (n = 32) CHD (n = 33) = 34) CHD (n = 34) Age (years) 58 (54; 60) 57 (52; 59) 55 (49; 58) 56 (50; 59) Gender (male/female) 16/16 16/18 17/15 17/17 Education level Primary school, n (%) 11 (34.3) 12 (35.3) 11 (33.3) 13 (38.3) High school, n (%) 13 (40.6) 14 (41.2) 15 (45.5) 13 (38.3) College/university, n (%) 8 (25) 8 (23.5) 7 (21.2) 8 (23.5) Body mass index (kg/m2 ) 27.2 (25.6; 28.7) 24.5 (23.4; 28.4) 26.4 (23.2; 27.8) 22.8 (20.6; 26.3) Fasting glucose (mg/dL) 89.1 (86.9; 91.8) 89.6 (81.8; 129.3) 89.1 (86.9; 132.4) 91.3 (87.8; 128.6) Current smokers, n (%) 2 (6.2) 3 (8.8) 3 (9) 7 (8.8) Comorbidities Diabetes, n (%) - 4 (11.8) ** 5 (15.1) ** 4 (11.8) ** Previous CVD Atrial fibrillation, n (%) - - 6 (18.1)**,§§ 10 (29.4) **,§§ Angina pectoris, n (%) - - 17 (51.5)**,§§ 18 (53) **,§§ Stroke, n (%) - - 9 (27.3) **,§§ 11 (32.3) **,§§ Heart failure, n (%) - - 10 (30.3) **,§§ 11 (32.3) **,§§ Drug treatment of CVD Antihypertensive, n (%) - - 14 (42.4) **,§§ 15 (44.1) **,§§ Statins, n (%) - - 13 (39.4) **,§§ 13 (38.2) **,§§ Low-dose aspirin, n (%) - - 12 (36.4) **,§§ 12 (35.3) **,§§ Beta blockers, n (%) - - 13 (39.4) **,§§ 14 (41.2) **,§§ hs-CRP (mg/L) 2.7 (2.3; 3.0) 3.5 (3.1; 4.1) * 6.1 (5.4; 6.3) ** 6.8 (6.1; 8) **,§§,# Total cholesterol (mg/dL) 161 (125; 186) 171 (144; 197) 177 (153; 198) 174 (155; 201) Triglycerids (mg/dL) 137 (107; 145) 114 (59; 122) 141 (112; 168) 143 (111; 159) Table 2 shows dental and periodontal variables in patients with periodontitis, CHD, periodontitis + CHD, and controls. The median values of periodontal parameters (CAL, PD, BOP, and PI) Int. J. Mol. Sci. 2019, 20, 6061 4 of 12 were significantly higher, and the number of present teeth was significantly lower in patients with periodontitis and periodontitis + CHD compared with CHD and with healthy subjects (p < 0.001) (Table 2). Table 2. Clinical dental variables of recruited subjects. Data are expressed as median (25th; 75th Int. J. Mol. Sci. 2019, 20, x FOR PEER REVIEW percentile). CAL, clinical attachment level; PD, probing pocket depth; BOP, bleeding on probing; PI,4 of 11 Plaque index. ** p < 0.001 significant differences vs control subjects calculated by the Mann–Whitney Table 2. Clinical dental variables of recruited subjects. Data are expressed as median (25th; 75th test. §§ p < 0.001 significant differences vs periodontitis patients calculated by the Mann–Whitney test. ##percentile). CAL, clinical attachment level; PD, probing pocket depth; BOP, bleeding on probing; PI, p < 0.001 significant differences vs. CHD patients calculated by the Mann–Whitney test. Plaque index. ** p < 0.001 significant differences vs control subjects calculated by the Mann–Whitney Periodontitis + CHD Periodontal pParameters test. < 0.001 significant differences (n = 32) vsPeriodontitis periodontitis(n patients calculated CHD (n =by 33)the Mann–Whitney test. §§ Controls = 34) ## p < 0.001 significant differences vs. CHD patients calculated by the Mann–Whitney test.(n = 34) N of teeth 25 (24; 27) 17 (15; 19) ** 22 (21; 24) **,§§ 18 (15; 19) **,## ,§§ Periodontitis+CHD Periodontal CAL (mm)Parameters Controls (n = 32) 1.2 (1; 1.3) Periodontitis 3.8 (3.2; 4.2)(n **= 34) 2.3CHD (n =** (2.2; 2.6) 33) 3.8 (3.7;(n4.6) **,## = 34) CAL 4–5Nmm (% sites) of teeth 25 -(24; 27) 39.117(37.3; (15; 41.8) 19) **** 22 (21;- 24) **,§§ 42.2 18 (37.4; 19) ****,##,## (15;49.1) CAL (mm) CAL ≥6 mm (% sites) 1.2-(1; 1.3) 3.8 (3.2; 4.2) **** 18.2 (18.7; 21.4) 2.3 (2.2; - 2.6) ** ,§§ 18.83.8 (3.7;24.5) (16.4; 4.6) ** **,## ,## CAL 4–5 mm (% sites) - 39.1 (37.3; 41.8) ** - 42.2 (37.4; 49.1) **,## PD (mm) 1.6 (1.2; 2.1) 4.3 (4.1; 4.8) ** 2.1 (1.7; 2.3) **,§§ 4.1 (4.0; 4.8) **,## ,## CAL ≥6 mm (% sites) - 18.2 (18.7; 21.4) ** - 18.8 (16.4; 24.5) ** PD 4–5 mm (% sites) - 41.84.3 (40.7; ,## PD (mm) 1.6 (1.2; 2.1) (4.1;44.6) 4.8) **** - 2.3) **,§§ 2.1 (1.7; 43.84.1 (40.4; (4.0;55.7) **,## 4.8) ** PD PD ≥64–5 mm mm(%(% sites) sites) - - 41.8(18.9; 21.5 (40.7;23.6) 44.6)**** -- 25.343.8 (40.4; (21.4; 55.7) 27.5) **,## **,§§,## PD ≥6 mm (% sites) - 21.5 (18.9; 23.6) ** - 25.3 (21.4; 27.5) **,§§,## BOP (%) 9.9 (8.8; 11.4) 45.9 (45.7; 51.8) ** 11.5 (14.5; 18.6) **,§§ 47.5 (45.6; 55.2) **,§§,## BOP (%) 9.9 (8.8; 11.4) 45.9 (45.7; 51.8) ** 11.5 (14.5; 18.6) **,§§ 47.5 (45.6; 55.2) **,§§,## PIPI (%) 10.1 (9.6; 11.2) 35.6 ,§§ ,## (%) 10.1 (9.6; 11.2) 35.6(33.5; (33.5;36.2) 36.2)**** 15.2 15.2(14.5; (14.5;16.7) 16.7)****,§§ 33.5 (32.5; 33.5 32.9) (32.5; 32.9)****,## Median(25th; Median (25th; 75th 75th percentile) percentile) serum serum and and salivary salivary MAAMAA levels levels areare presented presented in Figure in Figure 1. Patients 1. Patients in in periodontitis the the periodontitis group group (serum: (serum: 3.923.92 (3.7–4.4) (3.7–4.4) µmol/L; µmol/L; salivary salivary 1.811.81 (1–2.1) (1–2.1) µmol/g µmol/g protein, protein, p