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Review ArticleMatrix Metalloproteinase-8 as an Inflammatory and PreventionBiomarker in Periodontal and Peri-Implant Diseases
Ahmed Al-Majid ,1 Saeed Alassiri,2 Nilminie Rathnayake,3 Taina Tervahartiala,2
Dirk-Rolf Gieselmann,4 and Timo Sorsa 2,3
1Clinic of Preventive Dentistry, Periodontology and Cariology, Center of Dental Medicine, University of Zurich,Zurich, Switzerland2Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland3Karolinska Institutet, Department of Dental Medicine, Division of Periodontology, Stockholm, Sweden4Institute of Molecular Diagnostics, Dentognostics GmbH, Solingen and Jena, Germany
Correspondence should be addressed to Ahmed Al-Majid; [email protected]
Received 20 April 2018; Accepted 8 August 2018; Published 16 September 2018
Academic Editor: Saso Ivanovski
Copyright © 2018 Ahmed Al-Majid et al.(is is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Levels of and especially the degree of activation of matrix metalloproteinase (MMP-8) in oral fluids (i.e., saliva, mouth rinse,gingival crevicular fluid (GCF) and peri-implantitis sulcular fluid (PISF)) increase to pathologically elevated levels in theperiodontal and peri-implant diseases. (is study aimed at collecting and collating data from previously published studies anddetermining whether active MMP-8 (aMMP-8) could serve as a biomarker for the diagnosis and prevention of periodontal andperi-implant diseases. (e literature search identified a total of 284 articles. Out of 284 articles, 61 articles were found to berelevant. Data obtained from the selected studies were combined, and it indicated that aMMP-8 in oral fluids exerts the strongpotential to serve as a useful adjunctive diagnostic and preventive biotechnological tool in periodontal and peri-implant diseases.aMMP-8 can be used alone or in combination with other proinflammatory and/or microbiological biomarkers.
1. Introduction
Periodontitis and peri-implantitis, globally common infection-induced oral inflammatory disorders of teeth and dental im-plants supporting soft and hard tissue, i.e., periodontium andperi-implatium, involve destruction of both soft and hardtissues, as active periodontal and peri-implant degradation(APD). Periodontal/peri-implant tissues are mainly made upof type I collagen. (e proteolytic enzyme mainly re-sponsible for the active periodontal/peri-implant soft andhard tissue degeneration (APD) is matrix metalloproteinase(MMP-8), also known as collagenase-2 or neutrophil col-lagenase. MMP-8 is a member of the MMP family. Struc-turally related but genetically distinct MMPs are Ca2+- andZn2+-dependent endopeptidases capable of degradationof almost all extracellular matrix and basement membraneprotein components both in physiologic repair and patho-logic destruction of tissues, such as a breakdown of
extracellular matrix in embryonic development, woundhealing, and tissue remodeling [1].
(e MMP family is divided into six protease groups:collagenases (MMP-1, MMP-8, and MMP-13), gelatinases(MMP-2 and MMP-9), stromelysins (MMP-3, MMP-10, andMMP-11), matrilysins (MMP-7 and MMP-26), member-typeMMPs (MMP-14, MMP-15, MMP-16, MMP-17, and MMP-12), and other nonclassified MMPs, given their auxiliarycontrasts [2]. Among all of these groups, the collagenasegroup is of particular relevance in periodontal disease as it canefficiently cleave native collagen fibers I, II, and III. MMP-8has been categorized under the interstitial collagenase sub-group of the MMP family. Activities of MMPs are inhibitedand regulated by the endogenous or natural tissue inhibitorsof tissue inhibitors of MMP (TIMPs) and α2-macroglobulin[3].(e imbalance betweenMMPs and TIMPs often results inirreversible periodontal and peri-implant destructive pa-thology involving irreversible APD [3–5].
HindawiInternational Journal of DentistryVolume 2018, Article ID 7891323, 27 pageshttps://doi.org/10.1155/2018/7891323
Recently, an increased level of MMP-8, especially inactivated/active form (aMMP-8), in oral fluids is associatedwith and reflects periodontal and peri-implant inflammation/diseases especially in clinical active phases [3, 6–8]. Peri-odontal and peri-implant degeneration (APD) is caused byinterstitial collagenase MMP-8 and not by bacterial enzymes[9]. MMP-8 is released from neutrophils by selective de-granulation triggered by potent periodontopathogenic bac-teria and their virulence factors together with host-derivedproinflammatory mediators [3, 7]. Gingival fibroblasts, whenstimulated by proinflammatorymediators, such as interleukin(IL)-1β and tumor necrosis factor-α, can produce collage-nolytic MMPs including MMP-8 [10]. (e level of active, butnot latent or total, collagenase-2/MMP-8 reflects, predicts,and is related to progressive periodontal and peri-implantdisease activity [11]. Elevated levels of aMMP-8 in oral fluids(saliva, mouth rinse, gingival crevicular fluid (GCF), and peri-implant sulcular fluid (PISF)) were found to be associatedwith clinical periodontal parameters, i.e., probing pocketdepth (PPD), bleeding on probing (BOP), and clinical at-tachment loss (CAL) [12]. (e levels of aMMP-8 decreaseafter successful periodontal and peri-implant treatments[7, 13, 14].
A number of studies that have been performed utilizepoint-of-care (PoC)/chair-side analysis of elevated aMMP-8in saliva/oral fluids [15–17]. A study comparing a PoCimmunoflow tool with the standard gold laboratory-basedone concluded that concentration of aMMP-8 in oral fluidsis useful in distinguishing periodontal diseases from healthysubjects [15]. Lateral flow immunoassay of aMMP-8 hasbeen shown to have high sensitivity for at least two sites withBOP and two sites with deepened periodontal pockets [18].Sorsa et al. demonstrated that immunofluorometric assay(IFMA) and DentoAnalyzer-PoC-test could detect aMMP-8from GCF samples, and these methods are comparable withthe chair-side/PoC aMMP-8 dip-stick test [6]. (e Amer-sham enzyme-linked immunosorbent assay (ELISA) fortotal MMP-8 immunoactivities was not in line with thePoC/chair-side immune tests, specific for aMMP-8 [6]. Fewstudies demonstrated the associations of various periodontalpathogens in oral fluids with the levels of aMMP-8 andsuggested to use in combination with aMMP-8 with otherproinflammatory and microbiological biomarkers that maypotentially improve the diagnostic accuracy [6, 7]. (epresent review aimed at collecting and collating the datafrom published literature regarding the potential of aMMP-8in saliva/oral fluids to be used as a biomarker and predictorfor periodontal and peri-implant diseases [6, 7, 19, 20].
2. Materials and Methods
2.1. Study Identification. A literature search was performedin two electronic databases PubMed and Cochrane toidentify related studies of the past 15 years. In addition tothis, other relevant studies were identified by manualsearching. Keyword used for study identification in all da-tabases were “MMP-8 and periodontal inflammation,”“MMP-8 and peri-implantitis,” and “MMP-8 and low-dosedoxycycline.” (e synonyms such as MMP-8, collagenase-2,
and neutrophil collagenase were also searched in combi-nation with periodontitis. (e electronic search was donefrom November 11, 2016, to July 30, 2018.
2.2. StudySelection. All identified studies were screened, andthe selection process was done on the basis of inclusion andexclusion criteria.
2.2.1. Inclusion Criteria. Inclusion criteria are as follows:
(1) Randomized controlled trials(2) Observational studies(3) Review articles(4) Studies included low-dose doxycycline/sub-
antimicrobial dose doxycycline (L/SDD) as an ad-junctive drug for treatment of periodontal diseases
2.2.2. Exclusion Criteria. Exclusion criteria are as follows:
(1) Written in language other than English(2) Case reports(3) (esis(4) Animals studies(5) Diagnosis of periodontal disease was not written(6) Experimental gingivitis
3. Results
3.1. Study Selection and Data Abstraction. (e literaturesearch identified a total of 284 articles. Out of 284 articles,data of 61 articles were selected. Data obtained from selectedstudies were combined and summarized in the present study(Table 1).
3.2. Sources of MMP-8 in the Oral Cavity. A major source ofMMP-8 (neutrophil-type MMP-8) in humans are degra-nulating triggered neutrophils, but MMP-8 (mesenchymalcell-type MMP-8) is also de novo expressed and secreted insmall amounts by non-PMN-lineage cells such as epithelialcells, smooth muscle cells, fibroblasts, macrophages, andendothelial cells [74–77]. Neutrophil collagenase/polymorphonuclear leukocyte- (PMN-) derivedcollagenase-2/MMP-8 differs from interstitial collagenasessecreted by other cells in that it is synthesized only duringthe myelocyte stage of development of neutrophils in thebone marrow and stored as a latent enzyme, i.e., latent pro-MMP-8 (Mr 85 kDa) within the specific granules of PMN.Pro-MMP-8 is rapidly released from activated PMN un-dergoing selective subcellular granule degranulation and isthen activated through the cysteine switch mechanism often,but not always, associated with selective N-terminal pro-teolysis to yield the active form of the enzyme (Mr 65 kDa)and activation fragments [3, 74–77].
(e main source of oral salivary collagenase is PMNsthat enter the oral cavity through gingival sulcus [11, 75]. It isevident from the fact that collagenase was only detected in
2 International Journal of Dentistry
Tabl
e1:
Summaryof
stud
iesrelatedto
period
ontitis,
peri-im
plantitis,
andL/SD
Dandlevelo
fMMP-8in
oral
fluids.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
1
Collagenasesin
different
categories
ofperi-im
plant
vertical
bone
loss
[21]
Maet
al.(2000)
[21]
Toinvestigateiflevelo
fcollagenase-2
and
collagenase-3
inPISF
actas
mediatorsin
theprocesso
fbo
nedestructionin
peri-
implantitis
PISF
samples
N/A
aMMP-8by
IFMA
13subjects
aged
from
23to
89yearsold
Peri-im
plantitis
GingivalInd
exisno
taclinically
impo
rtant
markerforbo
neloss,b
utaM
MP-8andMMP-13
inPISF
are.(
eymight
participatein
peri-im
plant
osteolysis
2
Levelsand
molecular
form
sof
MMP-7(m
atrilysin
-1)
andMMP-8
(collagenase-2)in
diseased
human
peri-im
plant
sulcular
fluid
[22]
Kivela-
Rajamakie
tal.
(2003)
[22]
Toidentifyvariou
siso
form
sof
MMP-8in
PISF
andits
relatio
nship
with
MMP-7
PISF
samples
N/A
aMMP-8levelswere
determ
ined
bythe
western
immun
oblot
metho
dwith
polyclon
alanti-hu
man-M
MP-8
13subjects
aged
from
21to
86yearsold
Peri-im
plantitis
(eele
vatedlev
elsof
aMMP-8andMMP-7were
identifi
edin
activeform
sin
diseased
PISF,b
utMMP-7
was
lessprom
inent.MMP
inhibitors,p
otentialfuture
tissueprotectivedrugs,
seem
inglydo
notinterfere
with
thedefensive
antibacterialactionofMMP-
7butcan
inhibita
MMP-8
3
Laminin-5
gamma2-chain
and
collagenase-2
(MMP-8)
inhu
man
peri-im
plant
sulcular
fluid
[23]
Kivela-
Rajamakie
tal.
(2003)
[23]
Toinvestigatetheform
sandconcentrationof
MMP-8andlaminin-5
gamma2-chain
inPISF
and
tofin
dcorrelationof
these
twowith
clinical
parameters(i.e.,the
recorded
ging
ivalandbo
neresorptio
n)of
peri-
implantitis
PISF
samples
N/A
aMMP-8levelswere
determ
ined
bywestern
immun
oblot
13subjects
aged
from
21to
86yearsold
Peri-im
plantitis
aMMP-8isaim
portant
biom
arkerof
peri-
implantitis,
butlon
gitudinal
studiesarerequiredtoassess
theiruse,either
alon
eor
incombinatio
nas
molecular
biochemicalPISF
markers,
topredictthe
riskof
progressionof
peri-
implantitis,
aswellasto
mon
itortheim
pact
oftreatm
ento
fthe
disease
4
Gingivalc
revicular
fluid
collagenase-2
(MMP-8)
test
stick
forchair-sid
emon
itoring
ofperiod
ontitis[24]
Mantyla
etal.
(2003)
[24]
Todevelopatest
stickfor
detectionof
MMP-8in
GCF,
toevaluate
itsdiagno
stic
potentiala
spo
int-of-care/chair-sid
etest,a
ndto
mon
itorthe
respon
seto
treatm
entof
period
ontitis
GCFsamples
N/A
aMMP-8levelswere
determ
ined
byIFMA,
andchair-sid
edip-stick
was
performed
29subjects,age
nota
pplicable
Health
y,ging
ivitis,and
chronic
period
ontitis
aMMP-8GCFlevelsand
chair-sid
etest
differentiatedperiod
ontitis
from
ging
ivitis,and
healthycontrolsites.
Scalingandroot
planing
couldbe
follo
wed
successfully
bybo
thPo
C-
/chair-sideandIFMA
5
(eeffectof
adjunctiv
elow-dose
doxycyclinetherapy
onclinical
parametersand
GCFMMP-8levels
inchronic
period
ontitis[25]
Emingile
tal.
(2004)
[25]
Tocompareeffectiv
enesso
fLD
Dcombinedwith
nonsurgicalp
eriodo
ntal
therapyalon
ein
redu
cing
levelsof
MMP-8in
GCF
andim
provingclinical
parametersinpatientsw
ithchronicperiod
ontitis
GCF
12no
nsmok
ers.
none
ofthe
subjects
was
aheavysm
oker
(i.e.,n
otmorethan
10cigarette
s/day)
aMMP-8levels
determ
ined
bythe
immun
ofluo
rometric
assay
30subjects,37to
61yearsof
age
Chron
icperiod
ontitis
Rand
omized,dou
bleblind,
placebo-controlled,
parallela
rmstud
y.LD
Dim
proved
theeffects
ofno
nsurgicalp
eriodo
ntal
therapy
International Journal of Dentistry 3
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
6
Long
itudinal
analysisof
metalloproteinases,
tissueinhibitors
ofmetalloproteinases
andclinical
parametersin
GCF
from
period
ontitis-
affectedpatients
[26]
Pozo
etal.
(2005)
[26]
Assessm
entof
period
ontal
diseaseperformed
through
measuremento
fextracellularMMP-8,
MMP-9,andtheirTIMP-1
andTIMP-2in
GCF
GCFsamples
N/A
aMMP-8levelswere
determ
ined
byim
mun
e-western
blottin
g(C
at.
MAB3316,C
hemicon
International,Temecula,
CA,U
SA),MMP-9by
zymograph
y,anddo
tblot
ofTIMP-1and
TIMP-2(C
at.sc-6832
andsc-6835,respectiv
ely,
SantaCruz
Biotechn
ology,
Santa
Cruz,CA,U
SA)
24subjects,30to
35yearsold
Health
y,and
chronic
period
ontitis
Adifferent
patte
rnof
aMMP-8in
controla
ndpatient
sitewas
foun
d.(
estud
yhasestablish
edthe
significantcorrelation
betweentheseverity
ofperiod
ontaldise
asea
ndthe
actual
aMMP-8.
aMMP-8
andthelow
levelo
fboth
TIMP-1andTIMP-2were
foun
d
7
Istheexcessive
inhibitio
nof
matrix
metalloproteinases
(MMPs)by
potent
synthetic
MMP
inhibitors
(MMPIs)
desir
able
inperiod
ontitisand
otherinflammatory
diseases?(
atis:
“Leaky”MMPIsvs
excessivelyeffi
cient
drugs[27]
Sorsaand
Golub
(2005)
[27]
Com
parisonbetweenSD
Dandtetracyclin
e(non
-antib
acterial
compo
sition)
with
morepo
tent
MMP
inhibitors
N/A
N/A
N/A
N/A
N/A
Lette
rto
edito
r:beneficial
clinical
efficiency
observed
only
with
LDD
8
Mon
itoring
period
ontald
isease
status
insm
okers
andno
nsmok
ers
usingaging
ival
crevicular
fluid
matrix
metalloproteinase-
8-specificchair-sid
etest
[28]
Mantyla
etal.
(2006)
[28]
Toevaluate
theeffi
cacy
oftheaM
MP-8-specific
chair-sid
edip-sticktest
inlong
itudinally
mon
itoring
theperiod
ontalstatusof
smok
ingandno
nsmok
ing
patientswith
chronic
period
ontitis,
using
aMMP-8concentrationin
GCF
GCFsamples
11sm
okersand5
nonsmok
erswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
bychair-sid
elateral-fl
owim
mun
otests
andIFMA
16subjects,age
nota
pplicable
chronic
period
ontitis
Persistently
elevated
GCF
aMMP-8concentration
wereidentifi
ed,and
they
indicatedsites
atenhanced
risk;p
atientswith
inadequate
respon
seto
conv
entio
naltreatment
wereidentifi
edby
PoC/chair-sidetest
and
IFMA
9
Matrix
metalloproteinases:
contribu
tionto
pathogenesis,
diagno
sisand
treatm
entof
period
ontal
inflammation[3]
Sorsaet
al.
(2006)
[3]
Toun
derstand
therole
ofMMPs
andtheirinhibitors
inpathogenesis,
diagno
sis,
andtreatm
entof
period
ontalinfl
ammation
N/A
N/A
N/A
N/A
N/A
Review
:beneficial
LDD
adjunctiv
emedical
canbe
mon
itored/follo
wed
byaM
MP-8Po
C/chair-side
test
4 International Journal of Dentistry
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
10
Salivarybiom
arkers
ofexisting
period
ontald
isease:
across-sectional
stud
y[29]
Miller
etal.
(2006)
[29]
Todeterm
inethe
correlationbetween
salivarybiom
arkers
specificforperiod
ontal
tissueinflammation,
collagendegradation,
bone
turnover,and
clinical
features
ofperiod
ontitis
Unstim
ulated
who
leexpectorated
salivasamples
33.3
case
subjects
and27.6
control
subjectsm
okers
wereinclud
edin
thestud
y
TotalM
MP-8levelswere
determ
ined
bytheEL
ISA
kit(Quantikine,R&
DSystem
s,minneapolis,
MN,U
SA)
57subjects,28to
61yearsof
age
Health
y,and
chronic
period
ontitis
Asalivarylevelo
fMMP-8
appearsto
serveas
biom
arkerof
period
ontitis
11
Characteristicsof
collagenase-2
from
ging
ival
crevicular
fluid
andperi-
implantsulcular
fluidin
period
ontitis
andperi-im
plantitis
patients:pilots
tudy
[30]
Xuet
al.(2008)
[30]
Toidentifythedifference
incollageno
lytic
activ
itybetweenhealthysubjects
andsubjects
with
peri-
implantitisandto
findthe
correlationbetween
severity
ofperi-im
plantitis
andcollagenase
activ
ity
GCFandPISF
samples
Non
smok
erswere
includ
edin
the
stud
y
Both
aMMP-8andtotal
MMP-8levelswere
determ
ined
bywestern
blot
andDNP-
octapeptideassay
29subjects,4
healthy,
5ging
ivitis
patients,10
chronic
period
ontitis
patients,5
implants
patients,5peri-
implantitis
patients,theage
rang
e23
to72
yearsold
Health
y,ging
ivitis,chronic
period
ontitisand
peri-im
plantitis
Peri-im
plantitisPISF
containedhigh
eractiv
eaM
MP-8levelsandactiv
itythan
GCFfrom
similar
deep
chronicperiod
ontitis
sites.G
CFandPISF
from
severe
chronic
period
ontitisandperi-
implantitisexhibitedthe
high
esta
MMP-8from
PMNsandfib
roblasts
12
Host-respon
setherapeuticsfor
period
ontald
iseases
[31]
Giann
obile
(2008)
[31]
Tostud
yfactorsaffectin
ghard
andsofttissue
degradationarou
ndthe
teethanddental
implants.
N/A
N/A
N/A
N/A
N/A
Review
:SSD
isauseful/beneficial
adjunctiv
emedicationin
period
ontitis
13Hostrespon
semod
ulationin
period
ontics[32]
Preshaw
(2008)
[32]
Tostud
ytheroleof
SDDin
mod
ulationof
host
respon
sein
period
ontal
diseasemanagem
ent
N/A
N/A
N/A
N/A
N/A
Review
:MMP-8is
apo
tentialb
iomarkerat
period
ontitisandLD
Dis
auseful
adjunctiv
emedication
14
Matrix
metalloproteinase
levelsin
child
ren
with
aggressiv
eperiod
ontitis[33]
Alfant
etal.
(2008)
[33]
Tofig
ureou
tthe
MMP-1,
-2,-3,
-8,-9,
-12,
and-13
levelsin
acoh
orto
fAfrican
American
child
renwith
andwith
outa
ggressive
period
ontitis
GCFsamples
17no
nsmok
ers
wereinclud
edin
thestud
y
TotalM
MP-1,
-2,-3,
-8,
-9,-12,a
nd-13levels
weredeterm
ined
bythe
ELISA
kit(SenzoL
yte
520,
AnaSpec,S
anJose,
CA,U
SA)
44subjects
with
AgP
,7to
19yearsof
age,and
12healthy
controls.
17adults
with
chronic
period
ontitis35
to65
yearso
fage
Health
y,chronic
period
ontitis,
and
aggressiv
eperiod
ontitis
MMP-8levelswere
elevated
inAgP
sites
relativ
eto
nond
iseased
sites
inthesamesubjects,
insib
lings
andcontrols
andsubjects
with
chronic
period
ontitis.
MMPs
associated
with
theAgP
sites
inchild
renwere
generally
elevated
comparedto
anadult
coho
rtwith
ahistoryof
chronicperiod
ontitis
International Journal of Dentistry 5
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
15
Matrix
metalloproteinase-8
concentrationin
shallow
crevices
associated
with
the
extent
ofperiod
ontald
isease
[34]
Passojaet
al.
(2008)
[34]
Tostud
yassociation
betweenMMP-8levelsin
shallow,g
ingivalc
revices
andtheextent
ofperiod
ontald
isease
GCFsamples
20no
nsmok
ers
and28
smok
ers
wereinclud
edin
thestud
y
TotalM
MP-8levelswere
determ
ined
bytheEL
ISA
kit(Quantikine,R&
DSystem
s,Minneapolis,
MN,U
SA)
48subjects,22to
75yearsold
Chron
icperiod
ontitis
Statistically
significant
associationbetweenMMP-8
concentrationfro
mshallow
crevices
andtheextent
ofattachmentlevel(AL)
≥4m
m(p
�0.028)
and
AL≥6m
m(p
�0.001),in
subjectswith
mod
erateto
high
plaque
scores
16
Identifi
catio
nof
pathogen
andho
st-
respon
semarkers
correlated
with
period
ontald
isease
[35]
Ramseieret
al.
(2009)
[35]
Tofin
dou
tthe
ability
ofpu
tativ
eho
stand
microbially
derived
biom
arkers
toidentify
period
ontald
iseasestatus
from
who
lesalivaand
plaque
biofi
lm
Unstim
ulated
who
lesaliva
samples
0%healthy,
19%
ging
ivitis,36%
mild
chronic
period
ontitis,
and
81%
severe
chronic
period
ontitis
smok
erswere
includ
edin
the
stud
y
TotalM
MP-8and-9,
calprotectin,and
OPG
levels
weredeterm
ined
bytheE
LISA
kit(Quantikine,
R&D
Syste
ms,
Minneapolis,
MN,U
SA).
A.actin
omycetem
comitans,
C.rectu
s,F.
nucleatum
,P.
interm
edia,P.gingivalis,T
.forsythia,andT.
dentico
lawith
aquantitativePC
Rassay,IL-1β,
-2,-4,-5,-6,
-10,and-13,TN
F-α,
(FN-
cby
proteinmicroarray
(Whatm
an,Florham
Park,
NJ),
andICTP
byradioimmun
oassay
(Immun
odiagnostic
Syste
ms,Foun
tain
Hills,
AZ)
100subjects,
aged≥18
years
old
Health
y,ging
ivitis,and
chronic
period
ontitis
Multip
lecombinatio
nsof
biom
arkers
especially
MMP-8,
9,and
osteop
rotegerincombined
with
redcomplex
bacteria
provided
high
lyaccurate
predictio
nsof
period
ontal
diseases.
17
Associatio
nof
GCF
biom
arkers
during
period
ontal
maintenance
with
subsequent
progressive
period
ontitis[36]
Reinhardte
tal.
(2009)
[36]
Tofin
dcorrelation
betweenGCFbiom
arkers
ofinflammationandbo
neresorptio
nandloss
ofperiod
ontala
ttachment
andbo
ne
GCF
N/A
TotalM
MP-8levelw
asdeterm
ined
bytheEL
ISA
kit(Biosource,
Cam
arillo,
CA)
128osteop
enic
postmenop
ausal
females
(not
taking
estrogen)
45to
70yearsof
age
Goodgeneral
health,fro
mhealthy
andchronic
perio
dontitis
patients’
Placebo-controlledclinical
trial:SD
Dtargetselevated
aMMP-8with
beneficial
clinical
outcom
e
18
OralsalivaryMMP-
8,TIMP-1,
and
ICTP
asmarkers
ofadvanced
period
ontitis[37]
Gursoyet
al.
(2010)
[37]
Todetectpo
tentialm
arkers
ofadvanced
period
ontitis
insaliva.
Inadditio
n,we
comparedtwoMMP-8
detectionmetho
dsusing
IFMA
andEL
ISA
todifferentiate
period
ontitis
subjects
from
controls
Stim
ulated
who
lesalivasamples
17.2%
healthyand
52.3%
chronic
period
ontitis
smok
erswere
includ
edin
the
stud
y
aMMP-8lev
elswere
determ
ined
byIFMA,total
MMP-8,MMP-14,and
TIMP-1lev
elswere
determ
ined
bytheEL
ISA
kit(Amersham
,GE
Health
care,
Buckingamshire,U
K)and
ICTP
levels
werem
easured
byenzymeim
mun
oassay
(Orio
nDiagnosticaOy,
Espoo,
Finland)
165subjects,
aged≥30
years
old
Health
yand
chronic
period
ontitis
SalivaryaM
MP-8,
when
used
incombinatio
nwith
TIMP-1andIC
TPis
apo
tentialb
iomarkerin
thedetectionof
advanced
period
ontitis.
(e
detectionof
totalM
MP-8
bythetradition
alEL
ISA
metho
dtechniqu
eisless
accurate
than
theaM
MP-8
IFMA
techniqu
e
6 International Journal of Dentistry
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
19
Associatio
nsbetweenmatrix
metalloproteinase-8
and-14and
myeloperoxidase
inging
ival
crevicular
fluid
from
subjects
with
progressive
chronic
period
ontitis:
along
itudinalstudy
[13]
Hernand
ezetal.(2010)[13]
Toassociatethelevels,
molecular
form
s,iso
enzymedistribu
tion,
anddegree
ofactiv
ationof
MMP-8andMMP-14,
MPO
,and
TIMP-1in
GCF
from
patientswith
progressivep
eriodo
ntitisa
tthebaselin
eandafter
period
ontaltherapy
GCFsamples
N/A
aMMP-8levelswere
determ
ined
bywestern
blot
andIFMA.M
POlevelsweredeterm
ined
bytheEL
ISA
kit
(Immun
diagno
stik,
Bensheim
,Germany).
MMP-14
andTIMP-1
levelsweredeterm
ined
bytheE
LISA
kit(Biotrak,
GEhealthcare,
amersham
,Slough,
UK)
25subjects,35to
62yearsold
Chron
icperiod
ontitis
HighaM
MP-8andMPO
levelsandahigh
MPO
/MMP-8po
sitive
correlationwerefoun
din
activ
eandinactiv
esites
atbaselin
e.Afte
rtreatm
ent,
decreasesin
MPO
and
aMMP-8wereseen,except
foractiv
esites
inwhich
MMP-8differences
were
nots
ignificant
20
Smok
ingaffects
diagno
stic
oral
salivaryperiod
ontal
diseasebiom
arker
levelsin
adolescents
[38]
Heikkinen
etal.
(2010)
[38]
Toinvestigatethe
associationbetween
salivaryaM
MP-8and
PMN
elastase
with
common
lyused
period
ontalh
ealth
indices
inabirthcoho
rtof
adolescentsaccoun
tingfor
theirsm
okinghabits
Stim
ulated
who
lesalivasamples
61bo
ysand66
girls
were
smok
ers.197bo
ysand177girls
were
nonsmok
ers
ActiveMMP-8levels
weredeterm
ined
byIFMA
501subjects,1
5to
16yearsold
Mosts
ubjects
werechronic
period
ontitis
Smok
ingsig
nificantly
decreasedbo
thbiom
arkers,including
aMMP-8stud
ied
21
Detectio
nof
ging
ival
crevicular
fluid
MMP-8levels
with
different
labo
ratory
and
chair-sid
emetho
ds[6]
Sorsaet
al.
(2010)
[6]
Tocompare
four
metho
dsfordetectionof
MMP-8in
GCF
GCFsamples
Smok
erswere
includ
edin
the
stud
y,bu
texact
numberof
smok
ersisno
tmentio
ned
aMMP-8levelswere
determ
ined
byDentoAnalyzer
(Dentogn
osticsGmbH
,Jena,G
ermany),IFM
A,
andchair-sid
elateral-
flow
immun
otests
(Medix
BiochemicaLtd,
Espo
o,Finland).Total
MMP-8levelswere
determ
ined
bytheEL
ISA
kit(Amersham
,GE
healthcare,
Buckingamshire,UK)
10subjects,age
nota
pplicable
Health
y,ging
ivitis
andchronic
period
ontitis
IFMA
(aMMP-8)
and
DentoAnalyzer(aMMP-8)
results
candetect
MMP-8
from
GCFsamples,a
ndthesemetho
dsare
comparable.(
echair-sid
edip-sticktest
(aMMP-8)
results
werewellinlin
ewith
theseassays.(
eAmersham
ELISA
(total
MMP-8)
results
wereno
tin
linewith
tests.
22
Gingivalc
revicular
fluid
levelsof
MMP-
8,MMP-9,
TIMP-2,
andMPO
decrease
afterperiod
ontal
therapy[39]
Marcaccini
etal.(2010)[39]
Tocompare
thelevelsof
MMP-8,
MMP-9,
TIMP-1,
TIMP-2,andMPO
inGCF
ofchronicperiod
ontitis
patientsa
ndcontrolsatthe
baselin
eandthreemon
ths
afterno
nsurgicaltherapy
GCFsamples
N/A
TotalM
MP-8,
MMP-9,
TIMP-1,
andTIMP-2
levelsweredeterm
ined
bytheEL
ISAkit(Duo
Set
R&D
System
s,Inc.,
Minneapolis,
MN,U
SA),
andMPO
levelswere
determ
ined
(Sigma
chem
ical,C
o.,S
t.Lo
uis,
MO,U
SA)
42subjects,35to
55yearsold
Health
y,and
chronic
period
ontitis
Levelo
fallthemarkers
except
TIMP-1was
foun
dto
behigh
erin
GCFof
patientscomparedwith
controls.
(eelevated
level
decreasedthreemon
ths
afterperiod
ontaltherapy
International Journal of Dentistry 7
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
23
Use
ofho
st-and
bacteria-derived
salivarymarkers
indetectionof
period
ontitis:
acumulative
approach
[40]
Gursoyet
al.
(2011)
[40]
(esalivaryconcentration
ofthreedifferent
salivary
markers
P.gingivalis,
IL-
1β,and
MMP-8were
calculated
together
toob
tain
thecumulativerisk
scorefordetectionof
period
ontitis
Stim
ulated
who
lesalivasamples
N/A
P.gingivaliswith
aqu
antitativereal-tim
ePC
Rassay,
IL-1βlevels
weredeterm
ined
bythe
ELISA
kit(Amersham
),andaM
MP-8levelswere
determ
ined
byIFMA
165subjects,
aged≥30
years
old
Health
y,and
chronic
period
ontitis
(eresults
pointtothat
acumulativeriskscore,
calculated
from
thethree
salivarybiom
arkers,d
etects
perio
dontalstatus
more
accurately
than
anyof
the
markers
individu
ally.
How
ever,itisstillsuffi
cient
todistinguish
the
perio
dontitispatient
from
thehealthygrou
p.How
ever,aMMP-8is
reliablewhenused
alon
e
24
Smok
ingandmatrix
metalloproteinases,
neutroph
ilelastase
and
myeloperoxidase
inchronic
period
ontitis[41]
Ozçakaet
al.
(2011)
[41]
Toinvestigatethepo
ssible
relatio
nshipbetween
smok
ingandserum
concentrationof
aMMP-8,
MMP-9,
TIMP-1,
MPO
,andneutroph
illactasein
chronicperiod
ontitis
patientsrelativ
eto
period
ontally
healthy
subjects
Serum
samples
Health
ysubjects
(17sm
okers)
and
chronic
period
ontitis
patients(16
smok
ers)
were
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
byIFMA;
MMP-9levelswere
determ
ined
byBiotrak
ELISA
System
s,Amersham
Biosciences
Ltd,
Buckingh
amshire,
UK;T
IMP-1levelswere
measuredby
Duo
ste
ELISA
Develop
ment
System
s,R&
Dsystem
s,MN,U
SA;M
POlevels
weremeasuredby
Immun
odiagn
ostic
AG,
Bensheim
,Germany;and
neutroph
ilelastase
byBe
nder
MedSystem
sGmbH
,Vienn
a,Austria
111subjects,3
3to
65years
Health
y,and
chronic
period
ontitis
aMMP-8concentration
andaM
MP-8/TIMP-1
molar
ratio
sin
chronic
period
ontitisgrou
pwere
notfou
ndto
besig
nificantly
different
from
thosein
theperiod
ontally
healthygrou
p
25
Oralrinse
MMP-8
point-of-care
immun
otest
identifi
espatients
with
strong
period
ontal
inflammatory
burden
[42]
Lepp
ilahtie
tal.
(2011)
[42]
Todeterm
ineifMMP-8
(measuredby
three
different
metho
ds),TIMP-
1,andelastase
activ
itydifferentiate
subjects
with
thedifferent
period
ontal
cond
ition
s,andsecond
,to
findou
tifM
MP-8levels
werecomparableam
ong
themetho
dsused
Oral-rinse
samples
Smok
erswere
includ
edin
stud
y,bu
ttheexact
numberof
smok
ersisno
tmentio
ned
aMMP-8levelswere
determ
ined
byDentoEL
ISA
(Dentogn
osticsGmbH
,Jena,G
ermany)
and
IFMA;total
MMP-8
levelsweremeasuredby
theEL
ISA
kit
(Amersham
,GE
Health
care,
Buckingamshire,UK);
TIMP-1levelswere
determ
ined
bytheEL
ISA
kit(Amersham
);and
elastase
activ
ityby
Sigm
aCo.,S
tLou
is,MO,U
SA
214subjects,4
4to
78yearsold
Chron
icperiod
ontitis
aMMP-8testingof
oral-
rinsesamples
may
bebeneficialinperiod
ontal
diagno
stics.To
talM
MP-8
levelswereno
tusefulin
diagno
sis
8 International Journal of Dentistry
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
26
Salivarybiom
arkers
ofperiod
ontal
diseasein
respon
seto
treatm
ent[43]
Sexton
etal.
(2011)
[43]
Tocheckutility
ofsalivary
biom
arkers
inthe
mon
itoring
ofperiod
ontal
diseaseover
timein
subjects
who
received
localized
period
ontal
therapy
Unstim
ulated
who
lesaliva
samples
23%
oftheSR
Pgrou
p,and33%
oftheOHIgrou
psm
okerswere
includ
edin
the
stud
y
TotalM
MP-8andOPG
levelsweredeterm
ined
bytheEL
ISA
kit
(Quantikine,R&
DSystem
s,Minneapolis,
MN,U
SA)a
ndIL-1β,IL-
8,MIP-1α,
andTN
F-α
levelsweremeasuredby
Luminex
human
cytokine/chemok
ine
multip
lexkits(M
illipore,
St.C
harle
s,MO,U
SA)
68subjects,
aged≥18
years
old
Chron
icperiod
ontitis
Salivarylevelsof
biom
arkers,i.e.,IL-1β
MMP-8,OPG
,and
MIP-1α
reflected
diseaseseverity
andrespon
seto
therapy
suggestin
gtheirpo
tential
utility
formon
itoring
period
ontald
iseasestatus
27
Full-mou
thprofi
leof
activ
eMMP-8in
period
ontitis
patients[44]
Kraft-
Neumarker
etal.(2011)[44]
Toinvestigatewhether
therewas
arelatio
nship
betweenclinicaldiagno
stic
parametersandthe
concentrationof
aMMP-8
inGCFin
thesite
levelfull-
mou
thanalysis
GCFsamples
Non
smok
erswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
byIFMA
9subjects,3
5to
66yearsold
Chron
icperiod
ontitis
Astatistically
significant
relatio
nshipfoun
dbetweenlevelo
faMMP-8
andpo
cket
depth
28
Matrix
metalloproteinase-8
isthemajor
potential
collagenase
inactiv
eperi-im
plantitis[45]
Arakawaet
al.
(2012)
[45]
Tocompare
levelsof
MMP-1,
-8,a
nd-13in
PISF
ofbo
thhealthyand
diseased
sites
andto
find
correlationbetweenthese
MMPs
with
bone
loss
PISF
samples
N/A
TotalM
MP-8,
MMP-1,
andMMP-13
levelswere
determ
ined
byFu
jiChemical
Indu
stry,
Takaok
a,Japan
64subjects,the
aged
rang
e59
to78
yearsold
Peri-im
plantitis
(isstud
yalso
show
edMMP-8as
apo
ssible
markerforprogressive
bone
loss
inperi-
implantitis
29
Matrix
metalloproteinases
andinflammatory
cytokinesin
oral
fluidof
patientsw
ithchronicgeneralized
period
ontitisand
variou
scon
struction
materials[46]
Kushlinskii
etal.(2012)[46]
Tocompare
oral
fluid
ofpractically
healthysubjects
with
intact
period
ontiu
mandpatient
with
chronic
generalized
period
ontitis
with
variou
sstructural
materialsof
dental
restorations
Oralfl
uidsamples
N/A
TotalM
MP-8levelswere
determ
ined
bytheEL
ISA
kit(Quantikine,R&
DSystem
s,Minneapolis,
MN,U
SA)
105subjects,1
8to
52yearsold
Chron
icperiod
ontitis
(eMMP-8levelinoral
fluid
was
foun
dto
behigh
erthan
theno
rmal
only
inpatientswith
chronicgeneralized
period
ontitiswith
metal
restorations.N
osig
nificant
differencewas
foun
din
the
levelo
fMMP-8in
patients
ofchronicgeneralized
period
ontitiswith
out
metal
restoration
30
Effecto
fscalin
gand
root
planingon
interle
ukin-1β,
interle
ukin-8
and
MMP-8levelsin
ging
ival
crevicular
fluid
from
chronic
period
ontitis
patients[47]
Kon
opka
etal.
(2012)
[47]
Todeterm
ineam
ountsof
MMP-8,IL-8,and
IL-1βin
GCFfrom
patientswith
chronicperiod
ontitisin
relatio
nto
clinical
parameters
GCFsamples
Non
smok
erswere
includ
edin
the
stud
y
TotalM
MP-8andIL-8
andIL-1βlevelswere
determ
ined
bytheEL
ISA
kit(Quantikine,R&
DSystem
s,Minneapolis,
MN,U
SA)
51subjects,3
0patients(m
ean
age48.7±9.1
yearsold),and
21healthy
subjects
(mean
age33.7±8.2
years)
Health
y,and
chronic
period
ontitis
Short-term
nonsurgical
therapyresultedin
significantimprovem
entin
period
ontalind
ices
and
amarkeddecrease
ofMMP-8,IL-8,and
IL-1βin
GCF.
How
ever,the
levelo
fhu
moral
factorswas
still
high
erthan
thosein
controlg
roup
International Journal of Dentistry 9
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
31
Associatio
nsof
period
ontal
microorganism
swith
oral
salivary
proteins
andMMP-
8in
ging
ival
crevicular
fluid
[19]
Yako
bet
al.
(2012)
[19]
Toinvestigatein
subjects
with
andwith
out
period
ontitis,
thelevelsof
salivaryproteins
and
aMMP-8in
GCFin
relatio
nto
thepresence
ofspecificperiod
ontal
pathogens
Unstim
ulated
and
stim
ulated
who
lesaliva,
andGCF
samples
15healthy,and30
chronic
period
ontitis
smok
erswere
includ
edin
the
stud
y
aMMP-8lev
elswere
determ
ined
byIFMA,A
.actin
omycetem
comitans,P.
interm
edia,P
.gingivalis
T.forsythia,andT.
dentico
lawith
aquantitativePC
Rassay;Album
inwas
analyzed
usingan
immun
oturbidometric
Tina-Q
uant®k
it(Roche,
Basel,Sw
itzerland
);the
salivaryim
mun
oglobulin
concentra
tions
werethen
analyzed
byEL
ISA[87];
andsalivarytotalp
rotein
was
measuredusingthe
colorim
etric
Lowry
method[49]
101subjects,
meanage59.2±
SD2.9
Health
y,and
chronic
period
ontitis
Salivaryalbu
min
and
proteinconcentrationwere
significantly
high
erin
subjects
with
T.denticola.
Levelo
faMMP-8was
significantly
high
erin
subjects
with
T.denticola
andT.
forsythia
32
Trepon
ema
denticolaassociates
with
increasedlevels
ofMMP-8and
MMP-9in
ging
ival
crevicular
fluid
[50]
Yako
bet
al.
(2013)
[50]
Toassess
theassociation
betweenthepresence
ofsite-specificsubgingival
microorganism
sandthe
levelo
faMMP-8and
MMP-9in
GCF
GCFsamples
15healthyand30
chronic
period
ontitiswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
byIFMA,A
.actin
omycetem
comita
ns,
P.interm
edia,P
.gingivalis,
T.forsythia,
andT.
denticolawith
aqu
antitativePC
Rassay;
MMP-9levelswere
determ
ined
bytheEL
ISA
kit(Amersham
,BiosciencesUK
Ltd,
Buckingh
amshire,UK)
99subjects,
meanage59.2±
2.9
Health
y,and
chronic
period
ontitis
(epresence
ofT.
forsythiaandT.
denticola
was
associated
with
increasedlevelsof
aMMP-
8in
thetest
sites
33
Cytok
inea
ndmatrix
metalloproteinase
expressio
nin
fibroblasts
from
peri-im
plantitis
lesio
nsin
respon
seto
viable
porphyromon
asging
ivalis[51]
Irshad
etal.
(2013)
[51]
Toanalyzeinflammatory
reactio
nsof
fibroblasts
afterinvitrochalleng
ewith
P.gingivalis
Fibrob
lasts
Allsubjects’
nonsmok
erswere
includ
edin
the
stud
y
TotalM
MP-8,
-1levels
weredeterm
ined
bythe
ELISA
kit(Quantikine
Hum
an,P
harm
acia
Biotech,
Buckingh
amshire,UK),
TIMP-1im
mun
oassay
(R&D
System
s,Minneapolis,
MN,U
SA),
andP.
gingivaliswith
aqu
antitativereal-tim
ePC
Rassay
Five
patients
period
ontally
healthy54.4±
(±18.7)years
old,
nine
patients(II)5
7.8
(±12.4)years
old,
sevenperi-
implantitis
patients54.4
(±9.2)
yearsold
Peri-im
plantitis
Fibroblasts
from
peri-
implantitisandperio
dontitis
lesions
gave
amore
pron
ounced
inflammatory
respon
seto
theP.
gingivalis
challen
gethan
fibroblasts
from
healthydono
rs.(
eymay
thereforeb
einvolvedin
thedevelopm
ento
finflammationin
peri-
implantitisand
perio
dontitis.Moreover,the
susta
ined
upregulatio
nof
inflammatorymediators
andMMP-1in
peri-
implantitisfibroblastsmay
play
arolein
the
pathogenesisof
peri-
implantitis
10 International Journal of Dentistry
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
34
Salivarybiom
arkers
oforal
health:
across-sectional
stud
y[52]
Rathnayake
etal.(2013)[52]
Aim
edto
investigatingif
know
nsalivarybiom
arkers
couldbe
used
for
epidem
iologicalstudies
for
detectionof
period
ontitis
Stim
ulated
who
lesalivasamples
75sm
okerswere
includ
edin
the
stud
y
ActiveMMP-8levels
weredeterm
ined
byIFMA;T
IMP-1levels
weremeasuredby
the
ELISA
kit;(A
mersham
);TN
F-α,
IL-1β,
IL-6,a
ndIL-8
weremeasuredby
Luminex
Chemok
ine
multip
lex);lysozym
elevelsweremeasuredthe
ELISA
kit(Quantikine,
R&D
System
s,Minneapolis,
MN,U
SA)
966subjects,2
0to
89yearsold
Chron
icperiod
ontitis
aMMP-8couldbe
used
asmarkerof
period
ontal
diseasein
moresig
nificant
patient
popu
latio
ns
35
Oralsalivarytype
Icollagen
degradationend-
prod
uctsandrelated
matrix
metalloproteinases
inperiod
ontitis[53]
Gursoyet
al.
(2013)
[53]
Type
Icollagen
degradationendprod
ucts
andrelatedMMPs
were
exam
ined
aimingat
detectingpo
tential
markers
ofperiod
ontitisin
salivawith
high
sensitivity
andspecificity
Stim
ulated
who
lesalivasamples
86sm
okerswere
includ
edin
the
stud
y
ActiveMMP-8levels
weredeterm
ined
byIFMA;M
MP-9and
MMP-13
levelswere
measuredby
theEL
ISA
kit(Amersham
,GE
Health
care,
Buckingh
amshire,UK);
TRACP-5b
levelswere
measuredby
BoneTR
AP ®
assay,
Immun
odiagn
ostic
System
sLtd,
Boldon
,UK);IC
TPlevelswere
measuredby
enzyme
immun
oassay;(Orion
Diagn
osticaUniQ
ICTP
,EIA;O
rion
Diagn
ostica,
Espo
o,Finland);C
Txlevelsweremeasuredby
Serum
CrossLaps®
ELISA
assay
(Immun
odiagn
ostic,
System
sLtd,
Boldon
,UK);andNTx
levelswere
measuredby
OST
EOMARK®N
Tx;
serum
levelswere
measuredby
Wam
pole
Labo
ratories
(Princeton
,NJ,USA
)
230subjects
of≥3
0yearsold
Chron
icperiod
ontitis
aMMP-8isareliable
biom
arkercand
idatefor
detectingalveolar
bone
destruction
International Journal of Dentistry 11
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
36
Period
ontal
treatm
entredu
ces
matrix
metalloproteinase
levelsin
localized
aggressiv
eperiod
ontitis[54]
Gon
çalves
etal.
(2013)
[54]
ToevaluateMMP-1,-2,-3,
-8,-9,-12and-13levelsin
theGCFaftertreatm
ento
fLA
gPandto
correlatethese
levelswith
clinical
respon
se
GCFsamples
Non
smok
erswere
includ
edin
the
stud
y
TotalM
MPs
levelswere
determ
ined
bytheEL
ISA
kit(SensoL
yte520,
AnaSpec,F
remon
t,CA)
29subjects
of5
to21
yearsold
Aggressive
period
ontitis
Treatm
ento
fLAgP
with
Con
ventionalm
echanical
treatm
entandsystem
icantib
ioticsreduced
specific
MMPs
levelseffectiv
ely.
(esig
nificantassociation
was
observed
between
MMP-1,
-2,-3,
-8,-9,
-12
and-13andpercentage
ofsites
with
PD>4mm
37
Patte
rnsof
salivary
analytes
provide
diagno
stic
capacity
fordistinguish
ing
chronicadult
period
ontitisfrom
health
[55]
Ebersole
etal.
(2013)
[55]
Todeterm
ineto
analyze
expressio
nlevelsin
unstim
ulated
who
lesaliva
samples
collected
from
multip
leoccasio
nsfrom
30healthyadults
and50
chronicadultp
eriodo
ntitis
patients
Unstim
ulated
who
lesaliva
samples
Onlyno
nsmok
ers
wereinclud
edin
stud
y
TotalM
MP-8levelswere
determ
ined
bytheEL
ISA
kit(Quantikine,R&
DSystem
s,minneapolis,
MN,U
SA)
80subjectsof
18to
45yearsold
Health
yand
chronic
period
ontitis
Salivarylevelsof
MMP-8
weresig
nificantly
elevated
inperiod
ontitispatients
comparedwith
thedaily
variationob
served
inhealthyadults
38
Clin
icalcorrelates
ofalateral-fl
owim
mun
oassay
oral
risk
indicator[18]
Nwhatoret
al.
(2014)
[18]
Toinvestigatetheclinical
correlates
ofalateral-fl
owim
mun
oassay
with
BOP,
oral
hygiene,and
period
ontalp
robing
depth
onthefirst
time
Oral-rinse
samples
5sm
okersand71
nonsmok
erswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
bychair-sid
elateral-fl
owim
mun
otests
(Dentogn
osticsGmbH
,Jena,G
ermany)
76subjects,age
nota
pplicable
Health
y,and
chronic
period
ontitis
(echair-sid
eaM
MP-8
immun
oassay
show
edah
igh(82.6%
)sensitivity
for
atleasttwosites
with
BOP
andperio
dontalpockets.It
show
edalower
relatio
nship
with
single-siteperio
dontal
pocketsandBO
P
39
Crevicularflu
idbiom
arkers
and
period
ontald
isease
progression[56]
Kinneyet
al.
(2014)
[56]
Assessthe
abilityof
apanel
ofGCFbiom
arkers
aspredictors
ofperiod
ontal
diseaseprogression
Unstim
ulated
who
lesaliva
samples
0%was
healthy,
19%
were
ging
ivitis,36%
weremild
chronic
period
ontitis,
and
81%
weresevere
chronic
period
ontitis
smok
erswere
includ
edin
the
stud
y
TotalM
MP-8levelswere
determ
ined
bytheEL
ISA
kit(Quantibod
yhu
man
cytokine
arrayby
RayB
iotech,Inc.,
Norcross,GA,U
SA)
100subjects,
aged≥18
years
old
Health
y,ging
ivitis,and
chronic
period
ontitis
MMP-8was
significantly
high
erin
period
ontal
diseaseprogressiongrou
pcomparedto
stablepatients
40
Salivarybiom
arkers
associated
with
ging
ivitisand
respon
seto
therapy
[57]
Synd
ergaard
etal.(2014)[57]
(eprim
aryaim
was
tocompare
the
concentrations
ofIL-1β,
IL-6,P
GE 2,M
MP-8,
and
MIP-1αin
thewho
lesaliva
from
patientswith
ging
ivitiswith
concentrations
ofthese
substrates
inthesalivaof
patientswith
aclinically
healthyperiod
ontiu
m
Unstim
ulated
who
lesaliva
samples
N/A
TotalM
MP-8,
IL-1β,
IL-
6,PG
E 2,a
ndMIP-1α
levelsweredeterm
ined
byEL
ISA
kit,assay
desig
n,Ann
Arbor,M
I&EM
D,m
illipore,
Billerica,M
A
80subjectsof
23to
38yearsold
Health
yand
ging
ivitis
Con
centratio
nsof
IL-1β,
IL-6,a
ndMMP-8cann
otdistinguish
ging
ivitisfrom
health
12 International Journal of Dentistry
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
41
Oralsalivary
biom
arkers
ofbacterialb
urden,
inflammatory
respon
se,a
ndtissue
destructionin
period
ontitis[58]
Salm
inen
etal.
(2014)
[58]
Toinvestigatethe
associationof
selected
salivarybiom
arkers
with
period
ontalp
aram
eters
andvalid
atetheuseof
ano
velsalivarydiagno
stic
approach,the
cumulative
risk
score(C
RS),in
detectionof
period
ontitis
insubjects
with
angiograph
ically
verified
coronary
artery
disease
diagno
sis
Stim
ulated
who
lesalivasamples
58werecurrent
smok
ersand202
form
ersm
okers
wereinclud
edin
thestud
y
aMMP-8levelswere
determ
ined
byIFMA,IL-
1βwas
measuredby
flow
cytometry-based
Luminex
kits,M
illiplex,
Map
Kit;
MPX
HCYT
O-
60k,
Millipore,Billerica,
MA,U
SA,and
P.gingivaliswith
aqu
antitativePC
Rassay
was
performed
493subjects,age
nonapp
licable
Chron
icperiod
ontitis
(ehigh
salivary
concentrationof
aMMP-8,
IL-1β,andP.
gingivaliswas
associated
with
deepened
period
ontalp
ockets
and
alveolar
bone
loss.aMMP-
8performed
bette
rcomparedto
BOP%
42
Matrix
metalloproteinases
and
myeloperoxidase
inGCFprovidesite-
specificdiagno
stic
valueforchronic
period
ontitis[59]
Lepp
ilahtie
tal.
(2014)
[59]
Toidentifythediagno
stic
accuracy
ofGCFcand
idate
biom
arkersto
discriminate
period
ontitisfrom
inflamed
andhealthysites
andto
compare
the
performance
oftwo
independ
entMMP-8
immun
oassays
GCFsamples
5subjects
healthy
(non
smok
ers),3
nonsmok
erswith
ging
ivitis,and3
nonsmok
erswith
chronic
period
ontitiswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
byIFMA,
andtotalM
MP-8was
measuredby
ELISA
kits,
GEHealth
care,
Amersham
25subjects,
healthy(m
ean
age,48.2±11.2
years)
ging
ivitis
(meanage,
35.7±15.4
years)
and
period
ontitis
patients(m
ean
age,46.0±5.0
years)
Health
y,ging
ivitis,and
chronic
period
ontitis
MMPs
arehigh
lydiscriminatorybiom
arkers
forsite-specificdiagno
sisof
period
ontitis.
(e
comparisonof
two
quantitativeMMP-8
metho
dsdemon
strated
IFMAto
bemoreaccurate
than
ELISA
43
Gingivalc
revicular
fluid
matrix
metalloproteinase-8
levelspredict
treatm
entou
tcom
eam
ongsm
okers
with
chronic
period
ontitis[60]
Lepp
ilahtie
tal.
(2014)
[60]
Toexploredifferent
GCF
aMMP-8patte
rnsin
smok
ersandno
nsmok
ers
with
chronicperiod
ontitis
andtest
theutility
ofbaselin
eGCFaM
MP-8
levelsin
predictin
gcategorically
assessed
treatm
entou
tcom
es
GCFsamples
10sm
okersand5
nonsmok
erswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
byIFMA
15subjects,aged
28to
64years
Chron
icperiod
ontitis
Baselin
eaM
MP-8levelin
GCFstrong
lypredictsho
waM
MP-8levelsbehave
during
themaintenance
period
.Inthisregard,
aMMP-8analysiscanbe
considered
moreuseful
than
BOP.
Insm
okers’
sites,h
ighbaselin
eaM
MP-
8levelsindicate
and
predictw
eaktreatm
ent
respon
se
44
Targeted
salivary
biom
arkers
for
discriminationof
period
ontalh
ealth
anddisease(s)
[61]
Ebersole
etal.
(2015)
[61]
Saliva-baseddiagno
stic
approach
forperio
dontal
health
anddiseasebased
upon
theabun
danceof
salivaryanalyses
coincidencewith
thed
isease
Unstim
ulated
who
lesaliva
samples
28current
smok
erswere
includ
edin
the
stud
y
TotalM
MP-8levelswere
determ
ined
byEL
ISAkit,
theMILLIPL
EXMAP
Kit,
EMD
millipore,
Billerica,M
A,U
SA
209subjects,
aged≥18
years
Health
y,ging
ivitis,and
chronic
period
ontitis
Dem
onstratedtheutilityof
MMP-8in
differentiatin
gperiod
ontitisfrom
health
45
Activated
matrix
metalloproteinase-8
insalivaa
sdiagnostic
testforperio
dontal
disease?
acase-
controlstudy
[62]
IzadiB
orujeni
etal.(2015)[62]
Toevaluate
sensitivity
and
specificity
ofachair-sid
etest
foraM
MP-8to
detect
period
ontitis
Oral-rinse
samples
25sm
okerswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
bychair-sid
elateral-fl
owim
mun
otests,
Dentogn
osticsGmbH
,Jena,G
ermany
60subjects,
aged≥18
years
Health
yand
chronic
period
ontitis
Positiveresults
ofthe
aMMP-8test
significantly
correlatewith
generalized
chronicperiod
ontitis.
(e
test
show
s87%
sensitivity
and60%
specificity
inthe
diagno
sisof
chronic
period
ontitis
International Journal of Dentistry 13
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
46
(eutility
ofging
ival
crevicular
fluid
matrix
metalloproteinase-8
respon
sepatte
rnsin
predictio
nof
site-
levelc
linical
treatm
entou
tcom
e[63]
Lepp
ilahtie
tal.
(2015)
[63]
Tostud
ydifferent
respon
sepatte
rnsof
MMP-8am
ong
smok
erandno
nsmok
ersubjectswith
CPandGAgP
totest
itsutility
inpredictin
gsitelevel
treatm
ento
utcome
GCFsamples
86sm
okerswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
byIFMA
158subjects,
aged
27to
49years
Chron
icperiod
ontitisand
aggresive
period
ontitis
Distinct
typesof
MMP-8
respon
sepatte
rnswere
obtained
forsm
okersand
nonsmok
ers.Optim
alcutofflevelsof
aMMP-8
defin
edforsm
okersand
nonsmok
ers,which
indicate
risk
for
comprom
isedtreatm
ent
outcom
eat
baselin
eand
during
maintenance
47
Pilotstudy
onoral
health
status
asassessed
byan
activ
ematrix
metalloproteinase-8
chair-sid
emou
thrinsetest
inadolescents[64]
Heikkinen
etal.
(2016)
[64]
Toinvestigatewhether
aPo
Cmou
thrinsetest
basedon
aMMP-8
immun
oassay
could
identifypatientswith
oral
inflammatorybu
rden
amon
gadolescentswith
early
pathologic
finding
s
Mou
thrinse
samples
5sm
okers,and42
nonsmok
erswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
bychair-sid
elateral-fl
owim
mun
otests
(Dentogn
osticsGmbH
,Jena,G
ermany)
47subjects,aged
15to
17years
Chron
icperiod
ontitis
PoC/chairsidewas
foun
dto
beuseful
intheon
line
detection/diagno
sisof
oral
inflammatorybu
rden,i.e.,
perio
dontitisin
adolescents
with
early
,initialsigns
ofperio
dontitis.Detectio
nof
carie
sisalso
possiblebu
twith
lesseffi
ciency.(
etest
show
s76.5%
sensitivityand
96.7%
specificity
inthe
diagno
sisof
initial
chronic
perio
dontitis
48
Host-derived
biom
arkers
atteeth
andim
plants
inpartially
edentulous
patients.A
10-year
retrospectivestud
y[65]
Ramseieret
al.
(2016)
[65]
Tocompare
host-derived
biom
arkers
inPISF
andin
GCFfrom
adjacent
teeth
andto
analyzetheirlevelin
both
period
ontald
isease
andhealthycond
ition
PISF
andGCF
samples
Smok
erswere
includ
edin
stud
ybu
texactn
umber
ofsm
okersisno
tmentio
ned
IL-1β,
MMP-3,
MMP-8,
MMP-1,
andMMP-
1/TIMP-1levelswere
determ
ined
byEL
ISA
kits,R
&D
system
s,Eu
rope
Ltd,
Abing
don,
UK
Total9
97samples
were
evaluated
chronic
period
ontitisand
peri-im
plantitis
Increasedlev
elsof
MMP-8
andIL-1βin
PISF
orGCF
may
beassocia
tedwith
inflammationaround
teeth
andim
plantswhilelower
levels
ofMMP-8/TIMP-1
may
bean
indicatorof
diseaseprogressionaround
implantsandeasedlev
elsof
MMP-8a
ndIL-1βinPISF
orGCF
may
beassocia
tedwith
inflammationaround
teeth
andim
plantswhilelower
levels
ofMMP-1/TIMP-1
may
bean
indicatorof
diseaseprogressionaround
implants
49
Non
-antibacterial
tetracyclin
eform
ulations:h
ost-
mod
ulatorsin
the
treatm
entof
period
ontitisand
relevant
system
icdiseases
[66]
Golub
etal.
(2016)
[66]
Toaddresstheevidences
supp
ortin
gadjunctiv
euse
ofho
stmod
ulationtherapy
with
scalingandroot
planning
inthelong
-term
managem
ento
fperiod
ontald
isease
N/A
N/A
N/A
N/A
N/A
Review
:aMMP-8Po
Ctest
issuita
bleto
mon
itorthe
adjunctiv
ebeneficialS
DD
inperiod
ontitis
14 International Journal of Dentistry
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
50
Analysis
ofmatrix
metalloproteinases,
especially
MMP-8,
inGCF,
mou
thrinse,andsalivafor
mon
itoring
period
ontald
iseases
[7]
Sorsaet
al.
(2016)
[7]
Toreview
recent
stud
ies
relatedto
mon
itoring
ofperiod
ontala
ndperi-
implantd
iseases
byanalyzingsystem
icand
oral
fluid
biom
arkers
N/A
N/A
N/A
N/A
N/A
Review
:SDD
targets
increasedaM
MP-8
beneficialc
linical
outcom
eandno
developm
ent
bacterialresistance
51
Proteinbiom
arkers
andmicrobial
profi
lesin
peri-
implantitis[67]
Wanget
al.
(2016)
[67]
Toassess
diagno
sticability
ofbiom
arkers
when
combinedwith
microbial
profi
les
PICFsamples
4currentsm
okers
and21
past
smok
erswere
includ
edin
the
stud
y
TotalM
MP-8,OPG
,IL-
1β,T
IMP-2,andvascular
endothelialgrow
thfactor
levels
weredeterm
ined
byEL
ISAkits,
custo
mhu
man
Quantibody,arrays,
RayBiotech,Inc.,
Norcross,GA,U
SA,and
A.actin
omycetem
comitans,
P.interm
edia,P.gingivalis,
T.forsythia,
andT.
dentico
lawith
aquantitativePC
Rassay
68subjects,age
rang
e:37
to83
years
Peri-im
plantitis
(epresentd
atasuggest
that
theincreasedlevelsof
theselected
PICF-deriv
edbiom
arkers
ofperio
dontal
tissueinflammation,
matrix
degradation/regulatio
n,and
alveolar
bone
turnover/resorption
combinedwith
site-specific
microbial
profi
lesmay
beassociated
with
peri-
implantitisandcouldhave
potentiala
spredictors
ofperi-im
plantd
iseases
52
Peri-im
plants
ulcus
fluid
(PISF)
matrix
metalloproteinase
(MMP)
-8Levelsin
peri-im
plantitis[14]
(ierbachet
al.
(2016)
[14]
Toassess
MMP-8levelsin
PISF
from
diseased
sites
inbo
thsm
okersand
nonsmok
ers
PISF
samples
17sm
okerswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
byDentoEL
ISA
immun
oassay
(Dentogn
ostics,Jena,
Germany)
29subjects,8
healthypatients,
3ging
ivitis,and
18chronic
period
ontitis
Peri-im
plantitis
aMMP-8levelsincrease
inperi-im
plantitisaffected
implantsboth
inno
nperiodo
ntitisand
perio
dontitispatients,bu
tlevelsstillaftertreatm
ento
fthecond
ition
reflect
intensified
hostrespon
searou
ndim
plantsand
indicate
challenges
ofcontrolling
peri-im
plantitis
with
anytreatmentm
odality
53
Correlatio
nbetween
peri-im
plant
sulcular
fluid
rate
andexpressio
nof
collagenase2
(MMP8
)[68]
Janska
etal.
(2016)
[68]
Toidentifycorrelation
betweenPISF
and
collagenase-2
levelin
superficialandfund
usarea
ofPI
sulcus
PISF
samples
N/A
aMMP-8levelswere
determ
ined
byDentoEL
ISA
immun
oassay
(Dentogn
ostics,Jena,
Germany)
15subjects,the
agerang
e43
to75
years
Peri-im
plantitis
Exam
inationof
aMMP-8is
asensitive
metho
dwhen
exam
iningearly
inflammatorychangesbu
tdepend
sfrom
thedepthof
thesam
plec
ollectionin
the
ging
ival
54
Rapidassessmento
foralsalivaryMMP-8
andperiod
ontal
diseaseusinglateral
flow
immun
oassay
[15]
John
sonet
al.
(2016)
[15]
Todeterm
inetheeffi
cacy
ofano
velP
OCID
for
detectingMMP-8
concentrationin
oralflu
ids
incomparisonwith
agold
standard
labo
ratory-based
immun
oassay
Unstim
ulated
who
lesaliva
samples
10sm
okerswere
includ
edin
the
stud
y
TotalM
MP-8levelswere
determ
ined
byrapidassays,ApS,
Cop
enhagen-S,
Denmark,
EMD
Millipore,Billerica,M
Aandluminex,A
ustin
,TX,
USA
41subjects,aged
18yearso
rolder
Health
yand
chronic
period
ontitis
MMP-8canbe
detected
byPO
CID
andconcentra
tion
correla
teswith
luminex
for
both
salivaandrin
seflu
ids.
(isstu
dyconfi
rmed
and
furth
erextend
edtheo
riginal
studiesofNwhatoretal.[18]
andHeikkinen
etal.[64]
International Journal of Dentistry 15
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
55
Diagn
ostic
accuracy
forapical
and
chronic
period
ontitis
biom
arkers
inging
ival
crevicular
fluid:A
nexploratorystud
y[69]
Baezaet
al.
(2016)
[69]
Assessm
entof
levela
nddiagno
stic
accuracy
ofan
asseto
fpotentia
lbiom
arkers
inGCFfrom
patientswith
chronic
period
ontitisandAAP
GCFsamples
19sm
okerswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
byIFMA,
MPO
levelswere
determ
ined
byEL
ISAkit,
immun
odiagnostik
,AG,
Bensheim
,Germany.IL-
1β,IL-6,
TNF-α,
Dkk-1,
ON,P
TN,T
RAP-5,
and
OPG
levelswere
determ
ined
byMultip
lex
detectionpanelsMillipore,
St.C
harles,MO,U
SA,
Magpix,Millipore,St.
Charles,MO,U
SA,and
MMP-2and-9
levelswere
determ
ined
bygelatin
zymograph
y.
106subjects,
aged
44to
52years
Chron
icperiod
ontitis
aMMP-8show
sdiagno
stic
potentialfor
both
chronic
period
ontitisandAAP.
aMMP-8was
foun
dto
behigh
erin
chronic
period
ontitis,
follo
wed
byAAP
56
Pilotstud
yon
the
genetic
backgrou
ndof
anactiv
ematrix
metalloproteinase-8
test
infin
nish
adolescents[70]
Heikkinen
etal.
(2017)
[70]
Todeterm
inewhether
aMMP-8chair-sid
etest
candetect
initial
period
ontitisandcaries
with
genetic
backgrou
ndin
adolescents
Oralfl
uidand
DNA
samples
5sm
okersand42
nonsmok
erswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
bychair-sid
elateral-fl
owim
mun
otests
(Dentogn
osticsGmbH
,Jena,G
ermany)
47subjects
aged
15to
17years
Chron
icperiod
ontitis
(ea
MMP-8chair-sid
etest
hasp
otentialtodetectinitial
perio
dontitisin
adolescents
with
predisp
osinggenetic
backgrou
nd.aMMP-8
PoC/chair-sid
etestactsas
agene
test
57
Associatio
nof
oral
fluid
MMP-8with
perio
dontitisinsw
issadultsub
jects[12]
Mauramoet
al.
(2017)
[12]
Tofin
dassociation
betweenperiod
ontitisand
levelsof
aMMP-8in
saliva
andGCF
Stim
ulated
who
lesalivaandGCF
Never
smok
ers
were150(58.1%
).Fo
rmer
smok
ers
were70
(27.1%
).Current
smok
ers
were38
(14.7%
)
aMMP-8levelswere
determ
ined
byIFMA
258subjects,
meanage43.5
(21–58)years
Health
yand
chronic
period
ontitis
Elevated
levelsof
aMMP-8
insalivaandGCFare
significantly
associated
with
period
ontitisin
asystem
icallyhealthyadult
58
Associatio
nbetween
serum
andoral
matrix
metalloproteinase-8
levelsand
period
ontalh
ealth
status
association
betweenserum
and
oral
matrix
metalloproteinase-8
levelsand
period
ontalh
ealth
status
association
betweenserum
and
oral
matrix
metalloproteinase-8
levelsand
period
ontalh
ealth
status
[71]
Noack
etal.
(2017)
[71]
Toidentifytheassociation
betweenextent
ofcirculatingaM
MP-8and
status
ofperiod
ontal
diseaseandaM
MP-8levels
inoral
fluids
Unstim
ulated
who
lesaliva,
stim
ulated
who
lesaliva,
GCF,
and
serum
samples
Smok
erswere
includ
edin
stud
ybu
texactn
umber
ofsm
okersisno
tmentio
ned
aMMP-8levelswere
determ
ined
byIFMA,
PerioSafeplus,
(Dentogn
osticsGmbH
,Jena,G
ermany),and
A.
actin
omycetem
comita
ns,
P.interm
edia,P
.gingivalis,
T.forsythia,
andT.
denticolawith
asemiquantita
tivePC
Rassay
59subjects,aged
23to
58years
Health
y,ging
ivitis,and
chronic
period
ontitis
(eserum
levelscorrelated
significantly
with
oral
aMMP-8as
wella
swith
clinical
period
ontal
parametersin
ado
se-
depend
entmannerin
system
atically
healthy
subjects
16 International Journal of Dentistry
Tabl
e1:
Con
tinued.
Stud
ytitle
and
reference
Reference
(year)
Objectiv
eSamplesource
Smok
erFo
rmof
detected
MMP-8
andothermarkers
Stud
ypo
pulatio
nDiagn
osis
Result
59
Influ
ence
ofdifferent
form
sandmaterials
(zircon
iaor
titanium)
ofabutmentsin
peri-
implantsoft-tissue
healingusingmatrix
metalloproteinase-8:
arand
omized
pilot
study
[72]
Kum
aret
al.
(2017)
[72]
Tocompare
peri-im
plant
conn
ectiv
etissuerespon
searou
ndtitanium
and
zircon
iaabutments
PISF
samples
Non
smok
erswere
includ
edin
the
stud
y
TotalM
MP-8levelswere
determ
ined
byEL
ISA,
Boster
Biological
Techno
logy
CoLtd
12subjects,the
agerang
e20
to45
years
Health
y
(isstud
ysuggeststhe
presence
ofmore
remod
elingand/or
inflammatoryph
enom
ena
arou
ndtitanium
implant
abutmentsthan
arou
ndzircon
iaabutmentsof
adifferentdesigndu
ringthe
early
stagesbu
tnotat1year
60
Microbiological
and
aMMP-8fin
ding
sdepend
ingon
peri-
implantd
iseasein
patientsun
dergoing
supp
ortiv
eim
plant
therapy[73]
Ziebolzet
al.
(2017)
[73]
Tostud
yrelatio
nof
microbiological
finding
sandaM
MP-8levelw
ithperi-im
plantm
ucositisa
ndperi-im
plantitisin
subjects
receivingperiod
ontalo
rim
planttherapy
PISF
samples
17sm
okerswith
43im
plantsites
aMMP-8levelswere
determ
ined
byDentoEL
ISA
(Dentogn
osticsGmbH
,Jena,G
ermany)
89subjects
with
171im
plants.
Meanage:52±
years,116
dental
implants
werehealthy,
39dental
implants
hadmucositis,
and16
dental
implanthad
peri-im
plantitis
Peri-im
plantitis,
peri-m
ucositis
arou
ndim
plants,
andchronic
period
ontitis
With
inthelim
itatio
nsof
thisstu
dy,m
icrobiological
findingsa
ndaM
MP-8levels
areno
tsuitablefor
adifferentiatio
nbetween
healthy,peri-mucositis,and
peri-im
plantitisin
patients
allu
ndergoingSIT/SPT.
No
healthyanddiseasepatients
with
outS
IT/SPT
were
involved.O
nlysm
okingand
thepresence
ofPi
appear
tobe
potentialp
aram
eters
associated
with
peri-im
plant
diseasein
SIT/SPTpatients.
SIT/SPTinterventio
ndo
wnregulated
aMMP-8
durin
gmaintenance
61
Diagn
osingperi-
implantd
isease
usingthetong
ueas
a24/7
detector
[49]
Ritzer
etal.
(2017)
[49]
Any
one,anyw
here,and
anytim
ediagno
sticswere
developedforperi-im
plant
disease.(
esensors
respon
dedto
MMPs
and
provided
proo
fofc
oncept
instatistically
differentiatin
gpatients
with
peri-im
plantdisease
from
healthyvolunteers
Oralfl
uid
No-sm
okerswere
includ
edin
the
stud
y
aMMP-8levelswere
determ
ined
byDentoEL
ISA
(Dentogn
osticsGmbH
,Jena,G
ermany)
and
MMP-8analyzed
by24/7
chew
inggum
33subjectssaliva
orsulcus
fluid
collected
from
patientswith
peri-im
plant
disease(defined
asmucositisor
peri-im
plantitis;
n�19)and
healthycontrol
(n�14)
Peri-im
plantitis
Elevated
MMP-8couldbe
detected
inperi-
implantitis,
oral
fluid
vs.
healthyoral
fluid
International Journal of Dentistry 17
whole oral saliva of subjects and not in secretions of majororal salivary glands. Furthermore, whole oral saliva collectedfrom edentulous subjects did not show a significant amountof collagenase [75].
Oral fluid (GCF, PISF, mouth rinse, and saliva) colla-genases exert similarity with PMN- or neutrophil-typecollagenase-2 (MMP-8). It degrades type I and II colla-gens significantly faster than the type III collagen. Its mo-lecular weight is 65–70 kDa, same as collagenase of thePMNs/neutrophils/MMP-8 and gingival sulcus [3, 7]. It isactivated by gold thioglucose, which only activatesPMN/neutrophil collagenase [3, 7, 75, 77].
3.3. Active and Latent Forms. Most of the oral salivarycollagenase found in a healthy mouth is in the latent form,whereas in case of periodontal or/and peri-implant diseasepatient(s), it is in active or activated (aMMP-8) form to-gether with activation fragments [3, 43, 75, 77]. Studies doneby Gangbar et al. and Lee et al. [11, 76] demonstrated thatoral fluid active collagenase, but not latent, is related andreflects to progressive clinical periodontal disease activity,i.e., loss attachment or APD. aMMP-8 in oral fluids pre-cedes, predicts, is associated with, and reflects on on-goingor future/developing progressive, often hidden and sub-clinical, periodontal and peri-implant disease activity, i.e., CAL,APD, and active peri-implant degeneration [3, 6, 7, 17, 76, 77].Significant correlations have been found between aMMP-8and progressing severity of periodontal and peri-implantdiseases [3, 4, 6, 7, 26]. Successful periodontal and peri-implant treatment significantly reduces aMMP-8 levels inoral fluids [3, 6, 7, 17, 78, 79].
3.4.MMP-8andCorrelationwithPeriodontalDiseases. It hasbeen documented in several studies that salivary and oralfluids at aMMP-8 levels are higher in subjects with localizedand generalized periodontitis than in healthy controls butthe levels reduced after nonsurgical periodontal therapy,i.e., scaling and root planning (SRP) [12, 39, 41, 43, 53].Furthermore, aMMP-8, but not latent/total MMP-8, levelscould differentiate between periodontitis and gingivitis aswell [59]. A slight increase inMMP-8 levels could be observedin case of gingivitis, which shows a decrease after dentalprophylaxis or secondary preventive interventions [57].
Nwhator et al. demonstrated that aMMP-8, measured bylateral flow chair-side/PoC immunoassay (PerioSafe®), isdirectly proportional to the oral hygiene status [18]. It showsa positive correlation with chronic periodontitis and BOP butonly in the presence of two or more sites having the deepenedPPD of not less than 5mm; these aMMP-8 PoC findingsindicate that such deepened sites are APD affected. (esensitivity of immunoassay for a single site affected by chronicperiodontitis was found to be less [18]. Levels of aMMP-8 inoral fluids have been demonstrated to correlate with clinicalperiodontal parameters in particularly PPD, and it also re-flects the effect of treatment [12, 18, 44, 47, 54, 62]. Levels ofaMMP-8 are not only associated with clinical periodontalparameters status but also showed significant association withradiological parameters. aMMP-8 levels have been shown to
differentiate subjects with a severe bone loss with those witha slight bone loss [53, 58]. Izadi Boroujeni et al. demonstrateda sensitivity of 87% and specificity of 60% of aMMP-8 ina PoC detection of generalized chronic periodontitis [62].
In children, sites with aggressive periodontitis showhigher levels of MMP than adults with chronic periodontitis[33]. Baeza et al. reported in their study that aMMP-8 levelsin chronic periodontitis were elevated [69]. When aMMP-8levels were measured by ELISA, the cutoff point wasidentified as 13 ng/ml chronic periodontitis case [69].
In number of previous investigations, aMMP-8 levelshave been reported to predict periodontal disease pro-gression [3, 7, 76, 77]. aMMP-8 levels differentiate betweensubjects with stable and progressing periodontitis; theseconfirmatory findings have been repeatedly recorded byindependent immune and catalytic activity assays specific foraMMP-8 [6, 8, 80, 81]. While predicting periodontal diseaseprogression, highest sensitivity was noted with salivary/oralfluid aMMP-8, whereas GCF aMMP-8 showed high speci-ficity [56, 59, 63, 71].
Leppilahti et al. established cutoff levels for smoking andnonsmoking periodontal patients to predict site-specificlevels of treatment outcomes [56, 57, 59, 63]. (e mostoptimal cutoff value among smokers was 0.045, whereas fornonsmokers, the calculated value was 0.085.(ese values canbe helpful in longitudinal monitoring of the disease statusduring the maintenance period [56, 57, 59, 63].
3.5. Study Specimens. Oral fluids, such as mouth rinse, GCF,PISF, and saliva, have been used as specimens [3, 6, 7].Mouth-rinse samples can be collected quickly, non-invasively, and the collection process is less time-consumingas compared to a collection of GCF and PISF. Mouth-rinseassay is useful for screening purposes mainly, but it does notprovide exact information or identification/localizationabout the sites of clinically active disease. Whole saliva,variation in the salivary flow rate, use of antimicrobialmedication, and smoking habits may have an impact on theresults. GCF and PISF provide site-specific information,therefore useful in the personalized treatment plan of anindividual [53]. Johnson et al. reported that when measuredwith lateral flow immunoassay, saliva showed 4.1 timeshigher concentration of MMP-8 in periodontal patients thanperiodontal healthy controls [15].
Correlation between aMMP-8 levels in serum and oralfluids have been tested in few studies [34, 41, 56, 71]. Noacket al. reported a significant correlation between aMMP-8concentration in the serum and severity of periodontaldisease. In addition, serum MMP-8 concentration was alsofound to show a positive correlation with a subgingivalbacterial load [71]. Differing from findings of Noack et al.[71], others on serum concentration of MMP-8 failed to findany correlation with periodontal disease [34, 41]. (esevarying associations can also be affected by differences inthe use of clinical indices utilized to assess periodontalhealth and disease as well as systemic assessments of patientsand healthy controls. Additionally, various mediations mayaffect systemic and serum aMMP-8. [34, 41, 56, 71] Only one
18 International Journal of Dentistry
study reported that fibroblasts were used as a study specimento evaluate its role in the pathophysiology of peri-implantitis.[34] When proinflammatory and matrix degrading responsesof gingival and granulation tissue fibroblasts to an in vitrochallenge to Porphyromonas gingivalis (P. gingivalis) werecompared between subjects with healthy periodontium andpatients with periodontitis and peri-implantitis lesion, MMP-8 expression was found higher in nonchallenged peri-implantitis fibroblasts than in fibroblasts from healthyperiodontium. (is indicates that the inflammatory responsewas more pronounced in fibroblasts from periodontitis andperi-implantitis than in fibroblasts from periodontally healthyindividuals. (ese findings suggest that the exposure ofprolonged inflammation, i.e., periodontal/peri-implant dis-ease experience and burden, can affect and promote cells’ability to express MMP-8 [34].
Passoja et al. did not find any correlation between peri-odontal disease and serum MMP-8 levels [34]. A studyperformed by Ozçaka et al. showed that the levels of MMP-8in the serum of patients with chronic periodontitis did notsignificantly differ from periodontal healthy subjects [41].Kinney et al. showed that serum levels of biomarkers did notplay any significant role in the diagnosis of periodontitis [56].
3.6. Immunoassays Used to Detect aMMP-8 (IFMA, Den-toAnalyzer, DentoELISA, ELISA as Neutrophil Collagenase-2Immunoassays). MMP-8 detected by the IFMA techniquecorrelates more strongly with the periodontal and peri-implant status, and better diagnostic accuracy is foundhigher than that of ELISA [58, 59]. A possible reason is thatELISAmostly detects all forms of MMP-8 (total/latent MMP-8), whereas IFMA selectively identifies activated neutrophiland fibroblast-type isoforms of MMP-8, then particularly inthe active form (aMMP-8) [6]. A study done by Leppilahtiet al. shows that results of IFMA were comparable withDentoELISA but not with commercial Amersham ELISA;IFMA and DentoELISA utilize the same aMMP-8 antibody[6–8, 18, 24, 28, 42, 64, 70, 82] Total MMP-8 levels measuredby the Amersham ELISA test did not correlate with values ofperiodontal parameters [6–8, 42, 83].
Baeza et al. reported aMMP-8, measured by IFMA, to beless accurate in differentiating periodontitis from healthysites. Differing from the other studies, the performance ofDentoELISA was comparable to IFMA [69]. In chronicperiodontitis patients, a positive correlation was observedbetween PPD and aMMP-8, measured by IFMA. CALshowed a positive correlation with aMMP-8, measured byIFMA and DentoELISA.[69]. Lateral-flow chair-side/PoC-PerioSafe® and ImplantSafe® immunotests (Figure 1), withand without the quantitative reader ORALyzer®, utilized thesame aMMP-8 antibody as IFMA andDentoELISA, and theyall correlate well with each other [13, 17, 61, 65, 78, 84, 85].
3.7. aMMP-8 Level in Oral Fluids of Smokers. According toMantyla et al., the mean aMMP-8 levels in smokers werefound to be lower compared to non-smokers, but sites withthe progressive disease show similar or higher levels ofaMMP-8 in both smokers and nonsmokers [28]. Heikkinen
et al. found similar results when comparing levels of aMMP-8 levels between smokers and nonsmokers, but the differencefound was not statistically significant. Levels of aMMP-8reduced after SRP but sites with exceptionally elevatedaMMP-8 concentrations clustered in smokers did not showa significant decrease in aMMP-8 after SRP. (ese sites witha poor response may indicate sites at elevated risk and wereeasily identified by the chair-side/PoC aMMP-8 test. [28, 38]Baseline GCF aMMP-8 levels have been shown to predictaMMP-8 levels during maintenance of periodontitis. Par-ticularly in smokers, high levels of aMMP-8 at the baselineindicated a poor response to periodontal treatment [60].
According to Heikkinen et al., smoking affects the bio-marker values in a dose-dependent manner. Formersmokers were found to have a similar level of aMMP-8 ascompared to nonsmokers. Furthermore, obesity was foundto be a confounder. Values of aMMP-8 among nonsmokersdid not remain statistically significant when bodymass indexvalues were taken into account during analysis. However, thevalues were not affected in case of male smokers [38].
In contrast to these studies, Passoja et al. and Miller et al.did not find any significant correlation of smoking with anelevated aMMP-8 level in their independent studies done on
3 4
1 2 1 2 3 4
(a) (b)
Figure 1: Periodontitis (a) results based on PerioSafe®-mouth-rinse test: two chronic periodontitis patients (1) and (3) before and(2) and (4) after nonsurgical periodontal treatment, scaling, androot planning (SRP). (e appearance of two lines (>20 ng/ml)pointed by arrows in the figure is a considered positive test whichindicates elevated risk for periodontitis.(e appearance of only oneline indicates successful test performance and no risk for peri-odontitis (aMMP-8< 20 ng/ml) after SRP treatment. Peri-implantitis (b) results based on ImplantSafe®-PISF-strip-test; twoperi-implantitis patients (1) and (3) before and (2) and (4) afterperi-implantitis treatment (plastic scaling, oral hygiene in-structions, and use of chlorhexidine). Two lines in the resultwindow indicate elevated aMMP-8 in PISF and increased risk forperi-implantitis.(e appearance of a single line indicates successfultest performance, low aMMP-8 in PISF, and no risk for peri-implantitis after treatment [78, 84].
International Journal of Dentistry 19
saliva and GCF, respectively [29, 34]. Results of a study byGursoy et al. showed that aMMP-8 was higher in non-smoking periodontitis patients than controls, and insmokers’, only statistically significant parameter was TIMP-1 level that could differentiate between periodontitis patientsand control. (e ratio of aMMP-8, measured by the IFMAmethod, and TIMP-1 could successfully differentiate be-tween periodontitis and healthy smoking subjects as well. Apossible explanation for this finding, according to the au-thors, is that MMP-8 is less effective in mediating tissuedegradation in the smoker subjects. It also indicates thatsmoking eventually can affect the detection of the potentialbiomarkers of periodontal disease [37].
3.8. MMP-8 Levels before and after Nonsurgical =erapy.Gonçalves et al. demonstrated that SRP and use of systemicantibiotics effectively reduced local levels of specific MMPsin case of localized aggressive periodontitis. [54] Leppilahtiet al. showed in their study that in patients who underwentazithromycin antibiotic treatment, the MMP-8 levels in GCFspecifically are more stable and remain lower than a pre-defined cutoff level [63].
A study done by Konopka et al. showed that SRP im-proves all examined clinical periodontal parameters, apartfrom CAL. However, the GCF levels of MMP-8 after therapyin the periodontitis patient was still found to be higher thana control group [47]. In contrast to this finding, Gonçalveset al., found that level of MMP-8 in GCF was comparable tohealthy sites. Most marked reduction in MMP-8 levels wasnoticed in a short period, i.e., 3–6 months after receivingtreatment [54].
Nonsurgical therapy with and without antibiotics canreduce the level of active and total collagenase/MMP-8 [11]At the beginning of the treatment, the total collagenaseactivity was found similar to that of active collagenasedemonstrating that most of the collagenase present at thisstage was in an active form [11]. However, Konopka et al.could not find any correlation between clinical parametersand amount of humoral factors after the therapy, while theyshowed a correlation at the baseline with PPD and a prox-imal plaque index (PI) [47]. Baseline GCF MMP-8 levelsstrongly predict the change in level during a maintenanceperiod [59, 63]. Elevated baseline levels of GCF MMP-8 insmokers indicate a weak response to therapy [59, 60, 63].
3.9. Host Response Modulation. (is term is recently in-troduced in dentistry andmeansmodifying destructive aspectsof inflammatory host response that develops in periodontaland peri-implant tissues as a result of inflammatory outcometo chronic subgingival bacterial plaque. (e purpose of thistherapy was to restore a balance between proinflammatorymediators and anti-inflammatorymediators. Host modulationby low-dose-doxycycline/sub-antimicrobial-dose-doxycycline(L/SDD) medication also efficiently inhibits and reducesgingival tissue and oral fluid aMMP-8 and at the same timeceases the progression of periodontal/peri-implant tissuedestruction (APD) [3, 7, 66]. Only L/SDD has been licensedand accepted by FDA as a host responsemodulator andMMP-
inhibitory drug in humans for the treatment of periodontaldisease until now [66]. In L/SDD, doxycycline 20mg is givenorally twice a day or 40mg once a day to produce serum levelsof doxycycline, which is too low to produce any antimicrobialeffects but enough effective to inhibit/downregulate aMMP-8[7]. In contrast to traditional dose (100mg, once, or twicedaily), L/SDD does not cause any bacterial resistance todoxycycline and does not alter normal flora, a composition ofbacterial biofilm and their susceptibility to doxycycline andother antibiotics, even after long-term (up to 24 months) dailyadministration [66]. Furthermore, L/SDD causes a significantreduction in the levels of inflammatory mediators, mediatorsof collagenolysis (� aMMP-8), collagen degradation products,proinflammatory cytokines, and periodontal connective tissuedestruction. [32] It has been shown to inhibit alveolar boneloss during periodontitis due to its ability to reduce gingivaloxidative stress and aMMP-8 [32].
Evidence suggests that L/SDD has a strong potential formodulation of host response in beneficially aiding diseasemanagement when used as an adjunct medication to con-ventional mechanical therapy, SRP [27]. L/SDD reducespostsurgical BOP, PPD, and periodontal bone resorption[66]. L/SDD has been shown to support periodontal treat-ment like SRP as well as reduce the related systemic low-grade inflammation [31].
Emingil et al. concluded in their study that use of L/SDDtogether with SRP in the chronic periodontitis patientshowed better clinical results/treatment outcomes as com-pared to SRP alone. A significant decrease in gingival in-flammation scores at 3 months, and PPD reduction at 9months was observed in the L/SDD group compared toa placebo group and was maintained until the end of 12months [25]. In a study, L/SDD caused 36% reduction ofbone height loss, when added to periodontal maintenance[36]. Sorsa et al. concluded that L/SDD, when coupled withSRP, could inhibit the activity or decrease expression of hostMMPs, especially aMMP-8, by a mechanism that is un-related to its antimicrobial property [3, 6, 7].
3.10. Effect ofMetal Restorations. According to a study doneby Khuslinski et al. on practically healthy subjects with intactperiodontium and patients with chronic generalized peri-odontitis with various structural materials of dental resto-rations [46], the level of MMP-8 surpassed the normal onlyin oral fluids of patients with chronic generalized peri-odontitis with metal restorations. In patients with chronicgeneralized periodontitis with or without metal dentalrestorations, obtained correlation coefficients indicate trig-gered biochemical cascade accompanied by the activation ofcytokine production in response to etiological factors. (egroup of patients with periodontitis and metal restorationsdemonstrated a reaction that is more marked.
3.11. Association of Periodontal Microorganism withMMP-8.(e presence of subgingival microorganisms, mainly Trep-onema denticola (T. denticola), seemed to increase the levelsof salivary albumin, the total protein contain in saliva, andlevels of MMP-8 in GCF. (ere is a possibility that both T.
20 International Journal of Dentistry
denticola and Tannerella forsythia (T. forsythia) have in-duced a cascade-type host response with increased releaseand activation of MMP-8 in GCF [35, 50, 86]. T. denticolaand P. gingivalis-derived proteases (dentosilin and gingi-pain, respectively) can proteolytically and efficiently activateand convert latent pro-MMP-8 to aMMP-8 [45, 86, 88].
3.12. MMP-8 and Genetic Background. According to Heik-kinen et al., genetic polymorphism of MMP-3 and vitamin Dreceptor found to be linked to initial periodontitis in Finnishadolescents, and aMMP-8 PoC/chair-side immunoassayPerioSafe® mouth-rinse test can be used for on-line PoCdetection of initial periodontitis or preperiodontitis in ado-lescent patients with such type of genetic predisposition.(is indicates the preventive potential of the PerioSafe®ORALyzer®-aMMP-8 chair-side/PoC test [70].(us, aMMP-8 mouth-rinse chair-side/PoC test positivity and 3 or more>4mm pockets associated with the vitamin-D receptor andMMP-3 single-nucleotide polymorphisms. No associationwas found between single nucleotide polymorphism studiedwith the positivity of aMMP-8 [70].
3.13. MMP-8 in Dental Peri-implantitis. An inflammatoryreaction associated with loss of supporting bone beyondinitial biological bone remodeling around a dental implant,called peri-implantitis, is commonly reported as one of thesignificant contributors to dental implant failure [88–91].(e etiopathogenesis in case of peri-implantitis showsconsiderable similarity to periodontitis and shows compa-rable bacterial colonization and exudate of immune cells[88]. Similar to the periodontitis, aMMP-8 levels were re-peatedly found to be pathologically elevated in diseased PISFas well [21–23, 30, 35, 45, 68, 82]. Both PMN- and non-PMN-type MMP-8 isoforms particularly in active formshave been observed in PISF of peri-implantitis patients[21–23, 30, 82]. However, Wang et al. reported that MMP-8alone was not able to differentiate peri-implantitis patientsfrom healthy patients [67]. T. denticola and Prevotellaintermedia were reported to show diagnostic ability in caseof peri-implantitis [67, 72, 73]. Gingival inflammationshowed correlation to aMMP-8 levels in PISF [22, 23]. Maet al. found that aMMP-8 in PISF, assessed by IFMA, as-sociated with enhanced bone loss indicating that aMMP-8participated in peri-implant bone loss and osteolysis [21].Ritzer et al. [49] demonstrated by the 24/7-chewing-gumMMP-8 assay that elevated levels of MMP-8 could be de-tected in peri-implantitis oral fluids confirming and furtherextending the findings of Teronon et al., Kivela-Rajamakiet al., Xu et al., and Kivela-Rajamaki et al. [21–23, 30, 82].
Ramseier et al. reported a positive correlation betweenMMP-8, PI, and BOP in both GCF and PISF [65]. Ziebolzet al. have demonstrated that PISF aMMP-8 levels can bekept successfully low during maintenance in patients un-dergoing successfully supportive implant therapy indicatingthat successful professional maintenance intervention isassociated with low (<20 ng/ml) PISF aMMP-8 levels similarto the healthy peri-implant status [73, 78, 79]. Similarclinical parameters and MMP-8 levels were obtained with
both zirconium and titanium abutments at the end of 1 year.However, initially, titanium abutment was reported to showhigher PISF MMP-8 levels and probing depth [72].
(us, elevated levels of aMMP-8 in PISF associate sig-nificantly and repeatedly with peri-implant inflammationand bone loss/osteolysis [21–23, 30, 78]. Low (<20 ng/ml) inaMMP-8 levels in PISF reflects and indicates healthy and/orsuccessfully treated status peri-implantium (Figure 1)[73, 78, 79]. Pathologically elevated levels of aMMP-8(>20 ng/ml) can be conveniently detected by a quantita-tive lateral flow aMMP-8 dip-stick test, i.e., ImplantSafe®(Figure 1) [17, 78].
3.14. Combining Other Biomarkers to Increase DiagnosticAccuracy. Simultaneous measurement of more than oneoral fluid marker may allow more accurate prediction ofperiodontal inflammatory burden [53]. Combinations of theMMP-8 biomarker and pathogens that correspond with it(such as T. denticola) may give a more accurate prediction ofperiodontitis as compared to a single biomarker alone [35].
Gursoy et al. concluded in their study that proportional orcombined use of oral salivary biomarkers increases diagnosticaccuracy, particularly in smoker subjects [37]. It was foundthat the MMP-8/TIMP molar ratio and the combination oftwo biomarkers, MMP-8 and pyridinoline cross-linked car-boxyterminal telopeptide of type I collagen (ICTP), weresignificantly higher in detecting periodontitis compared toMMP-8 test alone [37]. A study testing accuracy of the cu-mulative risk score calculated (CRS) from three salivarybiomarkers (i.e., P. gingivalis, IL-1β, and MMP-8) was moreaccurate in the diagnosis of advanced periodontitis than anyof the markers alone [40]. Leppilahti et al. suggested mea-surement of MMP-8 and TIMP-1 to obtain higher diagnosticaccuracy [42]. A study performed by Rathnayake et al.proposed use of MMP-8/TIMP-1 molar ratio as markers ofperiodontal disease in a larger patient population [52]. Sal-minen et al. proposed combination of three biomarkers,i.e., MMP-8, IL-1β, and P. gingivalis (CRS) for diagnosis ofperiodontitis [54] (e median concentration of these threewas significantly higher in the moderate to severe peri-odontitis group as compared to controls. In addition, Ebersoleet al. reported also that salivary levels of IL-1β, IL-6, andMMP-8 provide high diagnostic accuracy for periodontitiswith high sensitivity and specificity [55]. Furthermore, MMP-8 levels were higher in patients diagnosed with chronicperiodontitis and diabetic, but P. gingivalis did not affectmuch. Unlike MMP-8, P. gingivalis values remain unaffectedin edentulous subjects. P. gingivalis successfully differentiatedcurrent smokers from former smokers and however, did notshow correlation with BOP [54].
(erefore, using biomarkers and various pathogens incombination may improve accuracy in diagnosis; however,the complexity and costs to perform such tests routinely willincrease considerably. (erefore, simpler, inexpensive, andreadily available tests that have been shown to be sufficientalone to detect and quantify aMMP-8, such as PerioSafe®and ImplantSafe®/ORALyzer®, might be more desirable(Figure 1) [78].
International Journal of Dentistry 21
3.15. PoC Tests. Chair-side and point-of-care (PoC) lateralflow immunotests for the detection of aMMP-8 in oral fluidsare commercially available (i.e., PerioSafe® andImplantSafe®) with the detection limit of 20 ng/ml (Fig-ure 1). (e tests resemble the pregnancy home test (Fig-ure 1).(e quantitative reader-equipped ORALyzer® PoCtest of oral fluids that measure aMMP-8 is found usefulin differentiating active and inactive periodontal andperi-implant sites and patients, predicting disease pro-gression in future, and monitoring the responses totherapy during the maintenance phase [17, 78]. (ebenefits of using these aMMP-8 tests are that these can beused in clinical settings, are easy to use, are inexpensive,and give prompt quick results with high sensitivity andspecificity (i.e., the sensitivity of 90% and specificity of70–85%) [6, 7, 16, 17, 24, 28, 42, 44, 51, 62, 64, 70, 78].
Alassiri et al. demonstrated that quantitative, PerioSafe®and ImplantSafe® ORALyzer®, PoC/chair-side assays couldconveniently diagnose and follow the treatment of peri-odontitis and peri-implantitis [17, 78]. (us, these tests candetect subclinical, developing periodontitis and peri-implantitis and related collage degradation even beforethe appearance of clinical and radiographical signs[14, 16, 17, 73, 82]. (ese test alarm preperiodontitis andpre-peri-implantitis and identity preventively future peri-odontal and peri-implantitis breakdown. (ey thus makeinvisible destruction or onset of periodontal/peri-implantcollagenolysis to be visible and detectable in an enough earlyand predictive manner allowing the identification andtiming of the preventive interactions/treatment such assecondary prevention and/or supportive periodontal/peri-implant treatment [17, 61, 65, 73, 84, 85].
PerioSafe® and ImplantSafe® with digital readers aremodern in vitro fast immunological diagnostic and pre-vention professional technologies/tests for examination ofthe oral/periodontal/peri-implant status of teeth and dentalimplants at different time intervals (at least once annually) todetect risk of silent or hidden periodontal, peri-implanttissue degeneration and alveolar bone loss even beforethey can be detected clinically or radiographically [16, 17].(e PoC tests also help in time preventive treatment which isnecessary for long-term success of implants, periodontaltissues, and patients. Another aspect of it is that this is alsohealthy and economical for the patients and society.
Regarding the chair-side/PoC-aMMP-8 lateral flowimmune tests (Figure 1), the appearance of only one lineindicates the negative result that reveals normal condition/ahealthy status (<20 ng aMMP-8 per ml), and appearance oftwo lines indicates increased risk (>20 ng aMMP-8 per ml)(Figure 1) for periodontitis and/or peri-implantitis, eitheralready existing or developing periodontitis and peri-implantitis, identified by PerioSafe and ImplantSafe, re-spectively (Figure 1). (ese PoC tests can be used with thereader for quantitative analysis [17, 78].
For quantitative analysis, dip-stick tests should be placedin the corresponding compartment of the reader. (en, flapis closed, the compartment is pushed into ORALyzer®, andcheck mark is pressed. (e ORALyzer® is designed in sucha way that it automatically starts and measures the aMMP-8
levels after 5min. (us, the qualitative “eye”-estimatedplus/minus test results are quantitatively expressed in ng/mlaMMP-8 PoC/chairside [17, 78].
4. Summary
(e current review analyzed the potential of aMMP-8 asa potential diagnostic, predictive, and preventive adjunctivebiomarker/biotechnological tool for periodontal and peri-implant diseases. (e available evidence suggests that espe-cially aMMP-8 in oral fluids reflect, associate, and predict wellwith the clinical periodontal parameters and outcomes as wellas clinical disease activity of periodontitis and peri-implantitistogether with evaluation of treatment outcomes [18, 44, 47, 54].Only few studies failed to find the correlation between clinicalCAL [47], and few others reported that MMP-8 levels are notcorrelated with BOP [62]. In addition, aMMP-8 levels werereported to be associated with radiological parameters too [53].Importantly when evaluating these studies, it should be kept inmind that active/activated MMP-8, not MMP-8 or total latentMMP-8, is a biomarker of active and progressive periodontaland peri-implant disease [3, 4, 6–9, 11, 17, 76, 77, 80, 81].
(us, pathologically and repeatedly elevated of aMMP-8levels in saliva show the highest sensitivity and in GCF/PISF,the highest specificity [56]. aMMP-8 levels of mouth rinse andoral saliva can be useful for screening, whereas GCF/PISFlevels could predict at site-specific level treatment outcomesand may be a useful adjunct in an individual/personalizedtreatment and monitoring plans. (us, the aMMP-8 testsrepresent tools for personalizedmedicine [56]. aMMP-8 levelsreduce after nonsurgical therapy, such as SRP. Most of thestudies confirmed the effect of smoking on MMP-8 level,except few [29, 34]. Combination of other biomarkers (TIMP-1, IL-6, and IL-1β) and periodontal pathogens (such as T.denticola and P. gingivalis) with aMMP-8 in the detection ofperiodontal inflammationmay increase accuracy, but aMMP-8 alone functions quantitatively very well [6, 7, 16, 17, 78].Both IFMA and DentoELISA were found to be able to dif-ferentiate periodontitis from healthy subjects, but in general,IFMA was more accurate [6, 7, 16, 17]. Results obtained fromAmersham ELISA were not in line with IFMA and Den-toELISA. Lateral flow chair-side/PoC aMMP-8 immunoassaycorrelated well with clinical parameters of periodontitis butwith at least two sites and extended better accuracy than BOP[18, 78]. Notably, invasive aMMP-8 PoC-tests cause alwaysbacteremia, but noninvasive aMMP-8 PoC-tests never [78].
Despite their high sensitivity and specificity, aMMP-8PoC-assays should be mainly used as adjunct tools to theclinical examination; mouth-rinse/salivary assays are usefulfor screening and dip-stick for site-specific personlizedmedical approaches. High levels of oral fluid MMP-8 insubjects with clinically “appearing” healthy periodontium/peri-implantium indicate silent “hidden,” developing futurepreperiodontitis and pre-peri-implantitis indicating earlypreventive supportive periodontal and peri-implant treat-ment [16]. In the case, oral fluid aMMP-8 is not treated tobe <20 ng/ml, and these preperiodontitis and pre-peri-implantitis phases will often develop to be periodontitisand peri-implantitis with on-going collagenolytic APD.
22 International Journal of Dentistry
Elevated oral fluid aMMP-8 thus predicts, reflects, andprecedes future APD, i.e., CAL of the teeth and dentalimplants [3, 7, 17, 76]. (us, aMMP-8 PoC/chair-side testsmake invisible hidden inflammation visible [17, 78].
Our literature review results are in line with previousstudies. A review done by Sorsa et al. concluded that MMP-8is a promising candidate for diagnosis and determination ofprogressive periodontitis and peri-implantitis andmonitoringresponse to therapy and further extend them also to peri-implantitis and provides diagnostic tests to monitor followtreatment and adjunctive medication such as L/SDD [7].
A systematic review and a recent study were done by deMorais et al. and Alassiri et al. and they concluded the sameand recommended use of MMP-8 as a quantitative bio-marker of periodontal and peri-implant diseases adjunctiveto clinical examination [17, 78, 92].
4.1.Clinical Implications. Repeatedly pathologically elevatedlevels of aMMP-8, but not total/latent MMP-8, in oral fluids(mouth rinse, saliva, GCF, and PISF) show the positivecorrelation with the clinical and radiological parameters ofperiodontitis and peri-implantitis. Oral fluid aMMP-8 levelsreduce after periodontal therapy, i.e., SRP combined withhost modulation and/or antimicrobial medication [7, 93].Continuously and sustainably pathologically elevated oralfluid MMP-8 levels indicate and predict sites and patientswith compromised disease outcomes regarding course,treatment, and maintenance. Importantly, the oral fluidPoC/chair-side tests can be utilized to predict time pre-ventive interventions before the development of irreversibletissue destruction (APD) in periodontium and peri-implantium by indentifying and alarming the preper-iodontitis and pre-peri-implantitis [17, 70].
4.2. Limitations of the Study
(1) Only the articles written in English language wereselected.
(2) A literature search was performed in two databases,and additional articles have been chosen by manualsearching, but it is possible that some relevant dataare left behind.
4.3. Recommendations for Future Research. Further studies,especially longitudinal and perspective ones, should beconducted to explore the relationship between aMMP-8with other biomarkers. Some factors such as obesity andgender reported as confounding factors should also beaddressed more in detail. (e relationship between serumconcentration of aMMP-8 and periodontitis and peri-implantitis is still not clear and needs further investigations.
Abbreviations
PI: Plaque indexPPD: Probing pocket depthBOP: Bleeding on probing
CAL: Clinical attachment lossSRP: Scaling and root planningPISF: Peri-Implant sulcus fluidPICF: Peri-implant crevicular fluidMMP: Matrix metalloproteinaseMMP-8, etc.: Matrix metalloproteinase-8aMMP-8: Active form of matrix
metalloproteinase-8AAP: Asymptomatic apical
periodontitis(IL) IL-6, 8, etc.: Interleukins(IL)-1β: Interleukin-1 betaOPG: OsteoprotegerinDkk-1: Dickkopf-related protein 1PTN: PeriostinTRAP-5: Tartrate-resistant acid
phosphatase-5ON: OsteonectinTNF-α: Tumor necrosis factor-alphaIFN-c: Interferon gammaTRACP-5b: Tartrate-resistant acid
phosphatase serum type-5bCTx: C-terminal cross-linked
telopeptide of type I collagenNTx: N-terminal cross-linked
telopeptide of type I collagenPMN: Polymorphonuclear leukocyteP. gingivalis: Porphyromonas gingivalisA. actinomycetemcomitans: Aggregatibacter
actinomycetemcomitans(previously Actinobacillusactinomycetemcomitans)
C. rectus: Campylobacter rectusF. nucleatum: Fusobacterium nucleatumP. intermedia: Prevotella intermediaT. forsythia: Tannerella forsythia
(previously Tannerellaforsythensis)
T. denticola: Treponema denticolaPCR: polymerase chain reactionGCF: Gingival crevicular fluidIFMA: Immunofluorometric assayELISA: Enzyme-linked
immunosorbent assayTIMP-1: Tissue inhibitor of matrix
metalloproteinaseICTP: Pyridinoline cross-linked
carboxy-terminal telopeptideof type I collagen
AgP: Aggressive periodontitisCRS: Cumulative risk scoreMIP-1α: Macrophage inflammatory
proteinPGE2: Prostaglandin E2PI: Peri-implantitisCP: Chronic periodontitisG: GingivitisGAgP:
International Journal of Dentistry 23
Generalized aggressiveperiodontitis
PoC: Point-of-carePOCID: Point-of-care immunoflow
deviceAPD periodontal: Peri-implant degenerationL/SDD: Low-dose doxycycline/sub-
antimicrobial-dosedoxycycline
AUC: Area under the curveCRS: Cumulative risk score.
Disclosure
Periodontal diagnoses and classification of periodontal dis-ease have been performed during the international workshopfor classification of periodontal diseases and conditions fromOctober 30 to November 2, 1999 (Periodontol 1999) (type I:gingivitis, type II: chronic periodontitis, and type III: ag-gressive periodontitis) [85].
Conflicts of Interest
Prof. Dr. Timo Sorsa is an inventor of US-Patents 5652227,5866432, and 6143476 on diagnostic use and method ofanalysis of MMP-8 and its inhibitors in oral fluids. (eauthors declare that there are no conflicts of interest.
Acknowledgments
Prof. Dr. Timo Sorsa has been supported by grants from theHelsinki University Hospital Research Foundation (TYH2016251, TYH 2017251, TYH2018229, Y101I4SLO17, andY1014SLOI8), Helsinki, Finland, and Karolinska Institutet,Stockholm, Sweden.
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