Simultaneous Detection of Oral Pathogens in Subgingival Plaque and ...

J Periodontol • September 2017

Simultaneous Detection of Oral Pathogens in Subgingival Plaque and Prostatic Fluid of Men With Periodontal and Prostatic Diseases John Estemalik,* Catherine Demko,† Nabil F. Bissada,* Nishant Joshi,* Donald Bodner,‡§ Eswar Shankar,‡§ and Sanjay Gupta‡§

Background: Chronic prostatitis (CPr) and benign prostatic hyperplasia (BPH) are complex inflammatory conditions for which etiologic determinants are still poorly defined. Periodontitis is caused by subgingival colonizing bacteria in the oral cavity. The causal effect of periodontal disease on prostatic inflammation has not been established. The purpose of this study is to isolate oral pathogens from expressed prostatic secretions of patients with periodontal disease and CPr or BPH. Methods: Twenty-four men diagnosed with CPr/BPH participated in the study. A complete periodontal examination consisting of probing depth, bleeding on probing, tooth mobility, gingival index, and plaque index was performed on the men, and prostatic secretion was collected for the study. Dental plaque and prostatic secretion samples were used for analysis of bacterial DNA for Porphyromonas gingivalis (Pg), Prevotella intermedia (Pi), Treponema denticola (Td), and Escherichia coli using reverse transcription-polymerase chain reaction. Results: Six patients were diagnosed with severe, seven with moderate, and four with mild chronic periodontitis. Seventeen of 24 (70.8%) of the prostatic secretion samples showed one or more of the studied oral pathogens. Nine of 10 BPH and eight of 14 patients with CPr had at least one oral pathogen in their prostatic secretions. Pg was found in both prostatic secretion and plaque samples in six of 17 (35.3%) patients, Td was found in both samples in seven of 15 (46.7%) patients, and E. coli was found in both samples in three of 15 (20%) patients. Pi was detected in all dental plaque samples but not in the prostatic secretion. Conclusion: An association between chronic inflammatory prostate and periodontal diseases has been demonstrated by the presence of similar bacterial DNA in both prostatic secretion and subgingival dental plaque from the same individual. J Periodontol 2017;88:823-829. KEY WORDS Genetics, microbial; periodontics; periodontitis; systemic disease. * † ‡ §

Department of Periodontics, Case Western Reserve University, Cleveland, OH. Department of Community Dentistry, Case Western Reserve University. Department of Urology, Case Western Reserve University. Urology Center, University Hospitals Cleveland Medical Center, Cleveland, OH.

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hronic prostatitis (CPr) and benign prostatic hyperplasia (BPH) are complex inflammatory conditions with histologic coexistence of hyperplastic nodules and chronic inflammatory infiltrates in a high proportion of prostate tissue.1 Prevalence of BPH is high in aging males; more than 70% of men experience enlargement of their prostate during the ages of 60 to 70 years, whereas histologic appearance of CPr, as defined by the invasion of leukocytes, especially polymorphonuclear leukocytes, into prostatic ducts and periprostatic tissue is observed in 8% of men in the United States.1-3 Both CPr and BPH coexist and have been shown to be involved in the inflammatory process for which etiologic determinants are still poorly defined. Dental plaque is defined as an organized mass, consisting mainly of micro-organisms, that adheres to teeth, prostheses, and oral surfaces and is found in the gingival crevice and periodontal pocket.4 Such plaques, present in the healthy oral cavity, remain the primary direct cause of periodontal disease,5 affecting nearly 90% of the world population. 6 Periodontal disease is further classified into two stages: gingivitis and periodontitis. Periodontitis is a chronic inflammatory disease initiated by Gramnegative bacteria found in dental plaque.4 Approximately 50% of the United States doi: 10.1902/jop.2017.160477

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Detection of Periodontal Pathogens in the Prostate

population have chronic periodontitis (CP) as manifested by resorption of the alveolar bone.7 Depending on the clinical attachment loss (AL), CP is classified as mild (1 to 2 mm AL), moderate (3 to 4 mm AL), and severe (>5 mm AL).8 Several systemic diseases including cardiovascular disease, diabetes mellitus, hematologic disorders, and low bone mineral density have been linked to periodontitis.9,10 Possible association between periodontitis and systemic disease may be through metastatic infections, dissemination of bacterial toxins, and/ or immune dysfunction.9 It is clear that the relationship between two or more systemic diseases does exist.9 Atherosclerosis is an example where oral pathogens invade cells other than those in the oral cavity. It was shown that chronic periodontal infection could induce endothelial dysfunction through a state of systemic inflammation, as evidenced by elevated plasma proteins, interleukin (IL)-6, and fibrinogen.10,11 It also is possible for oral pathogens such as Porphyromonas gingivalis (Pg) to release their products as vesicles12 or gingipains13 found in atherosclerosis. Aggregatibacter actinomycetemcomitans (Aa), which is associated with aggressive periodontitis, may also release soluble bacterial components.14 Oral bacteria can directly invade endothelial cells without the aid of their byproducts.15 Pg, which is a red-complex bacteria and one of the main periodontal pathogens,16 is able to invade the aorta via the lipid raft in human aortic cells17 and can also move from one cell to another in cardiovascular endothelial and smooth muscle cells.18 Oral pathogens associated with atherosclerosis are Aa, Prevotella intermedia (Pi), Tannerella forsythia, and Fusobacterium nucleatum (Fn). Oral bacterial pathogens are also related to other conditions, such as adverse pregnancy outcomes.19-21 Similar levels of antibodies against oral pathogens are found in women with or without preterm birth or low birth weight.19 Elevated serum levels against Fn were detected in women who experienced fetal loss.20 Pg was detected in amniotic fluid threatening premature labor.21 Pg and Aa were present in the placenta in women with preterm birth or pre-eclampsia.22-24 Fn was isolated from amniotic fluid of patients with preterm low birth weight and intact fetal membranes.25-27 Fn was also isolated from the lungs, placenta, and stomach of women who have had stillbirth infants.28 Oral pathogens were found in the synovial fluid of patients who have rheumatoid arthritis. Bacterial DNA was detected in the synovial fluid of about 14% of patients with native and failed prosthetic joints.29 These observations lead to examination of the prostate for oral bacterial DNA product. Studies by the current group of authors have evaluated the association between periodontitis and prostate-specific antigen (PSA) levels in patients with 824

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CPr.30,31 Individuals having higher AL and moderate/ severe prostatitis had higher PSA levels compared with those with either condition alone.30 A significant reduction of PSA level in blood serum was noted after periodontal treatment of patients having both periodontitis and prostatitis.31 However, an association between periodontal disease and CPr/BPH has yet to be established. The purpose of this study is to determine if oral bacterial DNA is found in prostatic secretions of men with both periodontal and prostate disease. MATERIALS AND METHODS Study Design This pilot study is a collaborative effort between the School of Dental Medicine Department of Periodontics and the Departments of Urology at Case Western Reserve University, Cleveland, Ohio, and University Hospitals Cleveland Medical Center (UHCMC), Cleveland, Ohio. Protocol for the study was approved by the University Hospitals Institutional Review Board, Cleveland, Ohio (no. 07 to 11-10). Patients who were diagnosed with CPr or benign prostatic hyperplasia (BPH) in the Urology Institute, UHCMC, Cleveland, Ohio, and showed signs of any voiding disease were asked to participate in the study. The diagnosis was then confirmed with digital rectal examination (DRE). A total of 25 male patients (aged 35 to 86 years; mean age: 61.2 – 14.3 years) was enrolled in the study from December 2014 to May 2015. Inclusion criteria for participation in the study were: 1) aged ‡21 years; 2) present condition or history of prostatitis; 3) no administration of antibiotics within the last 6 months; 4) no dental prophylaxis within the last 3 months; 5) at least 12 teeth present; and 6) able and willing to provide consent and to participate in the study. Exclusion criteria were: 1) aged