Download Periodontal status and pathogenic bacteria after gastric bypass: a

J Clin Periodontol 2015; 42: 530–536 doi: 10.1111/jcpe.12410
Periodontal status and
pathogenic bacteria after gastric
bypass: a cohort study
Sılvia Helena de Carvalho
Sales-Peres1, Patrıcia Garcia de
Moura-Grec1, Joselene Martinelli
Yamashita1, Elza Araujo Torres1,
Dionısio2, Celso Vieira
Thiago Jose
de Souza Leite3, Arsenio
Sales-Peres1 and Reginaldo
Ceneviva4
1
Sales-Peres SHdC, Moura-Grec PGd, Yamashita JM, Torres EA, Dionısio TJ,
Leite CVdS, Sales-Peres A, Ceneviva R. Periodontal status and pathogenic
bacteria after gastric bypass: a cohort study. J Clin Periodontol 2015; 42: 530–
536. doi: 10.1111/jcpe.12410
Abstract
Aim: The aim this study was to evaluate the influence of gastric bypass surgery
(GBS) on periodontal disease and quantify the periodontopathogenic bacteria in
patients undergoing this surgery.
Material and Methods: This prospective study was composed of 50 patients who
underwent bariatric surgery and the data collection was performed in three periods pre-operative, 6 (6M) and 12 months (12M) postoperative. The oral clinical
examination to assess periodontal disease; gingival fluid sample collection for
quantification of the periodontopathogenic bacteria Porphyromonas gingivalis,
Tannerella forsythia, Treponema denticola, and Prevotella intermedia using q-PCR;
body mass index (BMI) and for collection of the individual’s health-related data
from medical files.
Results: There was a significant reduction in serum C-reactive protein (CRP) and
glucose levels after surgery. The mean probing pocket depth (PPD) and clinical
attachment level (CAL) increased significantly in the postoperative period of
6 months (p = 0.001). In the same period, the amount of P. gingivalis increased
(p = 0.028) and the other bacteria decreased slightly (p > 0.050). In the presence
of P. gingivalis, T. forsythia, T. denticola and P. intermedia, a poor periodontal
condition was observed.
Conclusion: The periodontal disease increased in severity and P. gingivalis
increased after GBS. A systemic inflammation resolution due to bariatric surgery
in obese subjects does not seem to affect the course of periodontal disease.
Obesity has grown in epidemic proportions and is the fastest health
problem in the world. Obesity has
Conflict of interest and source of
funding statement
The authors declare that they have
no conflict of interest.
This research was funded entirely
and partially by CNPq (Proc. 70/2009
and 301146/2010-1) and FAPESP
(Proc. 08/00240-3 and 08/05798-2).
530
been associated with increased
comorbidities, such as coronary
artery disease, diabetes, and destructive periodontal disease. Periodontal
disease is known as a chronic infection of the hard and soft tissue supporting the teeth (Page & Kornman
1997, Ekuni et al. 2008) and, is a
leading cause of tooth loss in older
adults (Thornton-Evans et al. 2013).
Periodontitis is a multifactorial
inflammatory disease, that is, characterized by the progressive destruction
Department of Pediatric Dentistry,
Orthodontics and Public Health, Bauru
~o Paulo,
School of Dentistry, University of Sa
Bauru, Brazil, 2Department Biological
Science, Bauru School of Dentistry,
~o Paulo, Bauru, Brazil;
University of Sa
3
Botucatu School of Medicine, Botucatu,
~o Preto School of Medicine,
Brazil; 4Ribeira
~o Paulo, Ribeira
~o Preto,
University of Sa
Brazil
Key words: bariatric surgery; obesity;
periodontal diseases; polymerase chain
reaction; Porphyromonas gingivalis
Accepted for publication 19 April 2015
of the tooth-supporting tissues. The
main goal of periodontal therapy is
to arrest the inflammatory and tissue-destructive processes by reducing
or eliminating the pathogenic microorganisms in the periodontal pockets
(Heitz-Mayfield 2005).
In a favourable environment
deprived of oxygen, the proliferation
of anaerobium and Gram negative of
orange complex occurs (Fusobacterium nucleatum, Prevotella intermedia,
Prevotella nigrescens), which in turn,
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Periodontopathogenic bacteria
precedes the appearance of red
complex (P. gingivalis, T. forsythia e
T. denticola), destroying the periodontal tissues (Socransky et al. 1998).
A prominent periodontal pathogen is
P. gingivalis and has potent effects on
host cells. Gingival epithelial respond
to bacteria in a number of different
ways and the response in part
depends upon the specific bacteria
present (Li et al. 2013).
The anatomical alterations of the
gastrointestinal tract seem to spark
relevant systemic consequences that
may be repercussions in the microbiota of the mouth. Obesity is associated with a higher risk of
periodontitis (Jagannathachary &
Kamaraj 2010). However, the literature does not offer published reports
regarding the effects of bariatric
surgery on periodontophatogenic
bacteria, such as Porphyromonas
gingivalis,
Tannerella
forsythia,
Treponema denticola, e Prevotella interm
edia, which in turn triggers the
periodontitis.
Bariatric surgery permits weight
loss and decreases overall mortality,
as well as the development of new
health conditions in morbid obese
patients. Considering that gastric
bypass surgery reduces the inflammatory response in the body, it
was hypothesized that there are
changes in periodontal disease and
periodontopathogenic bacteria after
12 months of surgery. Therefore, the
aim of the present prospective
cohort study was to investigate
whether significant weight loss by
Roux-en-Y gastric bypass would
decrease the presence of periodontophatogenic bacteria and periodontal
diseases in morbid obese patients in
a 12-month follow up.
Methods
The STROBE guidelines were used
to ensure the reporting of this prospective cohort study.
Study population
The sample size was calculated considering the difference between two
mean adopted by the software
GPower version 3.1 (Heinrich-HeineUniversity, D€
usseldorf, Germany),
significant level of 5%. Percentage of
sites with 4–5 mm pockets by using
2% as the minimum difference to be
detected (corresponding to an incidence of three sites), obtained in a
pilot study, and the power of the
test = 0.80. The sample size calculation and the values ranged from 8 to
36. Therefore, we decided to evaluate 64 morbid obese patients for the
pre-operative sample (baseline), considering the possible loss during the
prospective study.
In this study, the eligibility criteria sample consisted of a morbid
obese patient indicated for bariatric
surgery and treated at the Public
Health System of Brazil. The exclusion criteria were patients with fewer
than six teeth, smokers, pregnant,
carriers of infectious diseases, as well
as patients who had received antiinflammatory or antibiotic treatments 3 months prior to the study.
The patients (n = 64) were recruited
from April 2010 to March 2012,
attended to at three hospitals in the
State of S~
ao Paulo, Brazil. However,
a cohort of 50 randomly selected
male (n = 8) and female (n = 42)
morbid obese patients who underwent Roux-en-Y gastric bypass were
selected to participate in this longitudinal study. The study was approved
by the Research Ethical Committees
of the three Medical School hospitals. All patients were informed of
the purpose of the investigation and
signed a written consent form to
participate.
Data of patient’s medical records
Limited information regarding general health, such as BMI, C-reactive
protein (CRP) and glucose levels
and other predisposing factors to
periodontal disease were obtained
from the patients’ medical records.
The outcomes of this information
were collected in pre-operative, 6
and 12 months after surgery.
Oral clinical evaluation
A single calibrated dentist performed
all examinations at three periods;
pre-operative, 6 and 12 months after
gastric bypass surgery (Kappa
>0.82), which indicated intra-examiner concordance.
A North Carolina periodontal
probe was used for the clinical exam.
The periodontal evaluation included
the gingival index (GI) (Loe & Silness 1963), calculus index (CI)
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
531
(Ainamo & Bay 1975), probing
pocket depth (PPD), and clinical
attachment loss (CAL) as previously
described (Devanoorkar et al. 2012).
We elected to assess a full mouth
examination (Devanoorkar et al.
2012) instead of the Community
Periodontal Index of Treatment
Needs (CPITN) recommended by
the World Health Organization for
epidemiological
surveys
(WHO,
1997).
The gingival and calculus index
were used to measure the presence of
bleeding or calculus respectively. The
PPD was measured as the distance
between the gingival margin and the
bottom of the gingival crevice. The
CAL was determined by measuring
the distance between the cementenamel junction and the bottom of
the gingival crevice. Sites with PPD
equal to or greater than 4 mm and
with CAL equal to or greater than
3 mm constituted the presence of
periodontitis. Bleeding on probing
indicates the presence of gingivitis.
Collection of crevicular gingival fluid
Samples were collected from 9 to
11 h in the morning, considered the
circadian rhythm period, from the
deepest site per sextant at baseline
and the same sites were measured
after surgery. The crevicular fluid
was collected from the groups (pre,
6 months and 12 months) with standardized absorbent paper strips
(PerioPaper, IDE Interstate, Amityville-NY, USA) for detection of the
following bacteria; Porphyromonas
gingivalis, Tannerella forsythia, Treponema denticola, and Prevotella intermedia. The location of collection was
dried with gauze. Sterile filter strip
paper was inserted into the gingival
pocket until a minimum of resistance
was felt for 45 s (Rai et al. 2008)
and the samples were then stored in
little sterile tubes, which were identified for posterior analyses. The tubes
were shaken thoroughly and stored
at 200°C up to the analysis.
Detection and quantification of
periodontopathogenic bacteria
For the detection of Porphyromonas
gingivalis, Tannerella forsythia, Treponema
denticola
e
Prevotella
interm
edia in the samples, the quantitative or real-time polymerase
532
Sales-Peres et al.
chain reaction – q-PCR was used.
Before the DNA was isolated from
the subgingival samples, they were
warmed to 37°C for 10 min and
mixed well on a Vortex mixer and
0.2 ml of the microbial suspension
was washed three times with distilled
water. The bacterial pellets were
resuspended in 0.1 ml of distilled
water, boiled for 10 min and placed
on ice. After centrifugation to
remove cell debris, the supernatant
was used for the PCR analysis
(Ashimoto et al. 1996).
DNA extraction
Total bacterial DNA were extracted
from the samples using the InstaGene Matrix DNA extraction (BioRad Laboratories. Inc., Hercules,
CA, USA) according to the InstaGene Matrix (Bio-Rad Laboratories.
Inc.). Next, the quantities and purity
of the DNA samples were analysed
by optical density in a spectropho1000;
tometer
(NanoDropTM
Thermo Fisher Scientific, Wilmington, Delaware, USA). The readings
were repeated in the samples when
the results were doubtful and were
excluded when the results were not
satisfactory.
Nine samples with different DNA
concentrations were selected and the
acceptable range from 260 to 280
established the reaction value limits
(pilot of laboratory phase). The minimal concentration of DNA was
3 ng/ll. Thus, all samples were
diluted in 6 ng/ll with the addition
of Milli-Q water, to standardize the
concentration of DNA before the
amplification to allow for the comparison among the periods. Forty
samples were analysed per period
(pre-operative, 6M and 12M), in
total 120 samples.
q-PCR analysis
The DNAs were amplified and
marked with the SYBRÒ Green
Master Mix reagent (Applied Biosystems, Foster City, CA, USA) for the
q-PCR. Specific primers were used
for each proposed bacteria in this
study and a universal primer (16S)
for the standard bacteria to verify
the presence of bacteria DNA and
allow for the relative quantification.
The sequence of these primers
and the annealing temperature were
obtained from the scientific literature, showed in Table 1.
These steps were followed up for
the q-PCR analysis and the primers
were diluted in a 50 lM concentration. An aliquot of 200 ll to 25 lM
was obtained from 100 ll of primer
F (Forward) and 100 ll of R
(Reverse). Next, a rate 200 ll of
concentration of 10 lM and 80 ll of
the aliquot diluted in 25 lM in
120 ll of Milli-Q water were used
for the reaction. To assemble the
q-PCR plate, each well was filled in
duplicate with 5 ll of the DNA sample, 7.5 ll of the SYBRÒ Green
Mater Mix, which corresponds to
half of the total volume (manufacturer’s recommendations), 0.6 ll of
primer to 10 lM and supplemented
with 1.9 ll of Milli-Q water.
The plate was centrifuged to
obtain a spinning action in order
for the liquid to settle at the bottom of the wells, to avoid any trace
in the well walls. The plate was
then sealed and brought to the 7500
Real-Time PCR System thermocycler (Applied Biosystems), previously calibrated with the ROX
passive reference pigment (Applied
Biosystems).
The thermocycling process consisted of 45 cycles, each one composed of 95°C for 30 s denaturation.
Table 1. Primer sequences and references of authors
Target
P. intermedia
P. gingivalis
T. denticola
T. forsythia
Universal 16S
References
Sense/antisense sequences
Ta
F- GTGGCGCGTATTTTATGTATGTG
R- ATCCGCCATACGCCCTTAG
F- AGGCAGCTTGCCATACTGCG
R- ACTGTTAGCAACTACCGATGT
F- AGAGCAAGCTCTCCCTTACCGT
R- TAAGGGCGGCTTGAAATAATGA
F- GGGTGAGTAACGCGTATGTAACCT
R- ACCCATCCGCAACCAATAAA
F- CCATGAAGTCGGAATCGCTAG
R- GCTTGACGGGCGGTGT
60°C
Price et al. (2007)
56°C
Estrela et al. (2010)
59°C
Ferreira et al. (2008)
59°C
Ferreira et al. (2008)
60°C
Ramseier et al. (2009)
The annealing adopted the temperature recommended for each bacteria
(Table 1) for 1 minute and an extension of 72°C for 1 min.
The readings were obtained with
the 7500 Real-Time PCR System
software (Applied Biosystems). The
relative quantification (RQ) of bacteria was conducted. The higher the
RQ, the greater the number of bacteria. The RQ was calculated using
the formula (Schmittgen and Livak,
2008): RQ = 2 DCt, DCt = Ct of
target – Ct of universal.
Statistical analysis
Participants’ individual characteristics were described using frequency
distribution for categorical variables,
as well as a mean and standard deviation for continuous variables. The
Kolmogorov–Smirnov test was performed to analyse the normality of
the variables. Data were analyzed
using the Statistica Version 7 software (Statsoft Inc., Tulsa, OK,
USA). The analysis included ANOVA
for repeated measures to verify the
difference between the three periods
(pre-operative and 6 and 12 months
postoperative) and the Pearson correlation with verify the relationship
between quantitative variables in
each period. The significance level of
p < 0.05 was adopted.
Results
Preoperative evaluation
The initial sample was composed of
64 morbid obese patients; however,
only 50 of them were followed up in
the three periods because they
underwent gastric bypass surgery in
the Public Health System. This was
comprised 42 females (84%) and
eight males (16%). Thus, in 50 morbid obese patients the mean BMI
and ages were 49.69 9.97 kg/m2
and 38.90 10.13 years old, respectively. The values of CRP were
1.73 2.63 mg/dl and glucose levels
were 103.57 36.49 mg/dl.
Postoperative evaluation
Table 2 shows the main mean variables in the three periods evaluated
(pre-operative, 6 and 12 months
follow up after surgery) and the different letters showed that there were
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Periodontopathogenic bacteria
Table 2. Mean of variables evaluated in the three periods. (n = 50)
Variables
BMI (kg/m2)
Calcium (mg/dl)
CRP (mg/dl)
Glucose level (mg/dl)
Teeth present
PPD (mm)
CAL (mm)
GI (% of sites)
Pocket 4–5 mm (% of sites)
Pocket ≥6 mm (% of sites)
Pre-operative
Mean SD
49.69
9.37
1.73
103.57
25.67
1.84A
1.96A
24.67
3.32
0.72
8.97 A
0.56
2.63A
36.49A
6.14
0.47
0.61
17.49
4.07
2.20
6M
Mean SD
36.16
9.46
0.42
81.86
25.47
2.14B
2.24B
26.56
5.18
0.93
.05B
0.52
0.41B
14.77B
6.55
0.40
0.58
19.41
7.97
2.12
12M
Mean SD
32.26
9.43
0.19
83.32
25.45
2.07B
2.15B
22.25
4.67
075
5.78C
0.51
0.24B
15.06B
6.39
0.43
0.52
18.08
8.97
1.79
CRP, C-reactive protein; PPD, probing pocket depth; CAL, clinical attachment loss;
BI, bleeding index; CI, calculus index.
Different letters in the same line indicate statistical significance among the periods
(p < 0.05).
significant differences between them
(p < 0.050). The BMI value decreased
to class I obesity in 6M and the overweight in 12M (p < 0.05). After 12M,
the BMI decreased significantly
(p = 0.001), classified as degree I
obesity (mean = 32.26 kg/m2) in 36%
of the patients. Normal BMI was
found in 6% of the patients and overweight in 30%. The excess weight loss
was 55% and 71% after 6M and
12M, respectively. The values of Creactive protein were 0.42 0.41 and
0.19 0.24 mg/dl and the glucose
levels were 81.86 14.77 and
83.32 15.06 mg/dl after 6M and
12M respectively.
In relation to periodontal disease,
there was a major occurrence of calculus index in the obese pre-operative and in 6M and 12M
postoperative, the higher prevalence
was the probing pocket depth (4–
5 mm) (Table 2). The difference
between before and after bariatric
surgery was statistically significant
(p = 0.029). Almost all periodontal
conditions (PPD, CAL and BI)
worsened in 6M, except for the
calculus.
Porphyromonas gingivalis, T. forsythia, T. denticola, and P. intermedia were found in 71%, 80%, 72%,
and 85% of the patients before
surgery respectively. After 6M, it
changed to 80%, 85%, 75%, and
86% and after 12M, 75%, 90%,
81%, and 81% for P.gingivalis,
T. forsythia, T. denticola, and P. intermedia.
With regard to the Relative quantitative (RQ) of bacteria, there was a
sharp increase in P. gingivalis
(p = 0.004) in 6M (from 0.06 to
0.26). From 6M to 12M, the RQ
decreased significantly (p = 0.026).
The quantity of T. Forsythia
increased from 0.005 to 0.014 after
6M (p = 0.032) and decreased to
0.011 between 6M and 12M, however, there was no significant difference found in the last period.
Treponema denticola and P. intermedia showed a slight increase after
6M and decreased again after 12M
of surgery, and there were no significant differences among the three
periods (p > 0.05). The RQ values of
bacteria are presented in Fig. 1,
according to the period analysed.
q-PCR quantification
Discussion
The mean DNA concentration
obtained was 21.57 ng/ranging from
5.8 to 127.9 ng/and the ratio of 260/
280 varied from 1.1 to 1.9 were only
used in the acceptable range from
1.5 to 1.9. After dilution to near
6 ng values, the concentrations ranged from 4.60 to 9.10 ng/, with a
mean of 6.97 ng. In Table 3, Q-PCR
for 120 samples and 40 were analysed in the evaluation period.
Gastric bypass surgery induces substantial weight loss in the majority
of morbid obese patients (de MouraGrec et al. 2014) and reduces the
inflammatory response. However,
the risk factors of periodontitis progression are related to the reduction
in obesity (Wood et al. 2003). In this
study, the periodontal conditions did
not improve, even after significant
weight loss.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
533
It is known that the most tissue
destruction observed in periodontal
diseases results from indirect damage,
mediated by the immunoinflammatory
response. The inflammation is the
main mechanism of destruction of
the periodontal tissues (Kayal 2013)
and after bariatric surgery, the
inflammation in the body is reduced.
Further researches are necessary to
elucidate the periodontitis progression in patients underwent to bariatric surgery.
In this study, there were a few
limitations due to the fact that the
data were prospectively collected and
part of the sample was not followed.
These limitations are inherent to any
longitudinal
prospective
cohort
study. The consequence of bypass
surgery must be measured in morbid
obese patients after the surgery and
not compared with a control group.
All clinical variables for the periodontal conditions assessed showed
that there was a worse condition
between pre-operative and 6M and
there was a slight improvement
between 6M and 12M. The severity
of periodontal disease increased during the study period and these
results are in accordance with the
findings of (Marsicano et al. 2011),
since the prevalence and severity of
periodontal pocket depth increased
three times after bariatric surgery.
This occurrence may be related to
the feeding habit changes after surgery, such as eating more times per
day, even in less quantity. Thus, the
oral conditions remain favourable to
increase the bacterial amounts
(Hague & Baechle 2008).
Another explanation could be the
nutritional deficiency, such as a lack
of vitamin D, which is observed in
the postoperative of bariatric surgery
(Elder & Wolfe 2007), which in turn
may lead to metabolic bone disease
(de Prisco & Levine 2005).
Osteoporosis is considered a risk
factor for periodontal disease, since
it may influence the alveolar bone
loss rate in chronic periodontitis,
causing tooth loss (NicopoulouKarayianni et al. 2009). The alveolar
bone loss was assessed by cone beam
computerized tomography in a
patient who underwent bariatric surgery and showed that the periodontal pocket depth worsened after the
second year of surgery (de MouraGrec et al. 2012). With this in mind,
534
Sales-Peres et al.
Table 3. ANOVA to compare the three periods, according to the periodontophatogenic bacteria (P. gingivalis, T. forsythia, T. denticola, and
P. intermedia)
Variables
P. gingivalis
BMI (kg/m2)
PPD (mm)
CAL (mm)
GI (% of sites)
CI (% of teeth)
Pocket 4–5 mm (% of sites)
Pocket ≥6 mm (% of sites)
T. forsythia
BMI (kg/m2)
PPD (mm)
CAL (mm)
GI (% of sites)
CI (% of teeth)
Pocket 4–5 mm (% of sites)
Pocket ≥6 mm (% of sites)
T. denticola
BMI(kg/m2)
PPD (mm)
CAL (mm)
GI (% of sites)
CI (% of teeth)
Pocket 4–5 mm (% of sites)
Pocket ≥6 mm (% of sites)
P. intermedia
BMI (kg/m2)
PPD (mm)
CAL (mm)
GI (% of sites)
CI (% of teeth)
Pocket 4–5 mm (% of sites)
Pocket ≥6 mm (% of sites)
Pre-operative
6M
12M
Y
N
p
Y
N
p
Y
N
p
49.02
1.90
2.01
26.83
21.09
3.68
0.65
50.97
1.67
1.82
18.81
31.68
2.10
0.89
0.506
0.139
0.333
0.148
0.118
0.225
0.741
35.86
2.20
2.31
27.84
21.61
5.84
1.13
35.04
1.95
2.06
23.76
13.90
3.24
0.30
0.734
0.084
0.225
0.582
0.261
0.396
0.309
31.84
2.14
2.24
25.08
22.56
5.79
0.95
33.88
1.83
1.91
9.27
12.77
0.74
0.06
0.298
0.030*
0.065
0.004*
0.116
0.093
0.140
49.85
1.93
2.05
26.96
20.39
3.88
0.90
45.94
1.74
1.94
20.83
25.23
2.76
0.80
0.250
0.324
0.681
0.342
0.546
0.500
0.914
35.73
2.19
2.28
28.76
16.72
5.81
1.12
43.69
2.01
2.02
12.40
44.07
0.83
0.00
0.134
0.537
0.472
0.273
0.023*
0.431
0.519
31.29
2.15
2.26
26.04
19.92
6.24
1.08
34.56
1.85
1.86
8.69
8.89
0.56
0.09
0.220
0.136
0.103
0.028*
0.125
0.200
0.268
50.30
1.93
2.05
26.33
22.48
3.97
0.74
45.82
1.79
1.95
24.15
18.41
2.83
1.25
0.139
0.426
0.674
0.705
0.570
0.443
0.563
37.23
2.22
2.32
31.21
20.58
6.19
1.03
33.03
2.06
2.11
17.81
11.24
3.58
1.12
0.135
0.301
0.273
0.085
0.152
0.436
0.928
30.85
2.12
2.20
23.95
19.73
5.30
0.88
35.35
1.98
2.11
19.10
11.36
3.27
0.38
0.085
0.409
0.698
0.536
0.211
0.603
0.486
48.38
1.98
2.13
25.78
22.14
4.29
1.04
52.96
1.39
1.41
25.50
16.97
0.09
0.00
0.228
0.005*
0.009*
0.969
0.564
0.020*
0.339
36.67
2.17
2.27
27.74
18.83
5.50
0.86
33.11
2.21
2.22
28.55
14.59
5.78
2.26
0.315
0.839
0.815
0.935
0.609
0.947
0.220
31.40
2.09
2.18
23.13
20.01
4.73
0.82
33.37
2.06
2.16
20.17
11.05
4.83
0.42
0.423
0.849
0.939
0.692
0.166
0.979
0.553
PPD, probing pocket depth; CAL, clinical attachment loss; GI, gingival index; CI, calculus index.
*Statistically significant difference (p < 0.05). The italic values show the significant difference between presence and absence of bacteria
per period.
Fig. 1. Relative quantification (RQ) of bacteria P. gingivalis, T. forsythia, T. denticola
e P. intermedia in the three periods evaluated.
this study showed that the severity
of the periodontal examination worsened from calculus to periodontal
pocket.
The relation between periodontitis and cardiovascular disease is
known. This disease is triggered by
pathogens present in the infection,
including disturbances of the lipid
metabolism and consequently, elevation of pro-inflammatory cytokines.
This fact causes most of all cardiovascular complications (Wu et al.
2000), further bacteraemic condi-
tions, whereas the periodontopathogenic bacteria have been found in
the ateroma plaques (Haraszthy
et al. 2000).
Four relevant periodontophatogens
(P. gingivalis,
T. forsythia,
T. denticola e P. intermedia) in the
gingival fluid by DNA quantification
(q-PCR) were evaluated, because
they are among the higher aetiological agents of periodontitis (Brennan
et al. 2007), with high levels of periodontal tissue destruction and lead
to expression of pro-inflammatory
cytokines (Trombone et al. 2009).
At baseline, P gingivalis was not
identified in 29% of the patients. Of
these, two showed this bacterium
after surgery, probably due to the
harshest of periodontal conditions.
These findings were reinforced by
increasing the amount of this bacterium, which was six times higher
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Periodontopathogenic bacteria
after 6M. Pataro (2010) also
observed high quantities of Pg in the
postoperative group and claimed that
there are no tangible mechanisms to
explain this finding, since weight
reduction decreases the inflammatory
response (Pataro 2010).
The presence of P gingivalis
increased during the follow up and
was associated with the probing
pocket depth and gingival bleeding
index after 12M of bariatric surgery.
The increase in P gingivalis
amount 12M after surgery, could
increase the risk of cardiovascular
disease, although, the risk is
expected to decrease after the treatment for obesity. Furthermore, the
clearance of inflammatory cytokines
is triggered by the periodontal pathogen and involves the atherogenesis
process (Haraszthy et al. 2000).
Thus, the prevention and treatment
of periodontal infection may contribute to the reduction in mortality and
morbidity risk in these patients.
The number of patients with the
T. forsythia and T. denticola bacterias increased slightly during the
three periods studied, however, their
relative
quantity
decreased
(p > 0.050; Table 3). The clinical
findings are in contrast with this
result, since the progression of periodontal disease increases the quantities of red complex bacteria
(Socransky et al. 1998, Brennan
et al. 2007, Ferreira et al. 2008).
A study showed that T. forsythia
presents a correlation with alveolar
bone loss in overweight females
(Brennan et al. 2007). The results of
this study are in this direction,
whereas after bariatric surgery the
mean of the BMI was minor in
patients where this bacteria was
detected, nevertheless there are no
statistical significances (Table 3).
After 12M of surgery, the number of individuals with P. intermedia
decreased, as well as the relative
quantities, however, not significantly
(p > 0.05; Table 3). The increase in
the severity of periodontal diseases
may be contributed to the red complex bacteria, which stood out more
than the P. intermedia of the orange
complex (Socransky et al. 1998).
Prevotella intermedia and T. forsythia were identified in severe levels
of bone loss (Brennan et al. 2007). In
this study, these bacteria were found
in the severe periodontal conditions,
or in other words, were related to the
probing pocket depth, especially at
the pre-operative.
The bacteria evaluated reduced
slightly instead of increasing during
the follow up periods. This fact
highlights the negative systemic consequences of bariatric surgery, such
as deficiency in calcium absorption,
which in turn may be influenced in
the most severe periodontal conditions and in the presence of bacteria.
Other studies to assess the systemic
and oral conditions in patients
undergoing bariatric surgery may be
conducted to clarify the differences
between the microbiological and
clinical evaluations.
Oral health care has an important
role in the nutritional status (Marcenes et al. 2003), thus adequate
chewing and healthy nutritional habits are essential for maintaining the
systemic benefits achieved by bariatric surgery.
In addition, bariatric patients
must be monitored by dental professionals from the pre-operative up to
the entire postoperative to contribute
to the treatment and prevention of
oral lesions, which offer benefits to
the general oral conditions of these
patients in order to reduce the risk
of
cardiovascular
complications
related to bacteraemic conditions.
Conclusion
The periodontal disease seems to
have increased in severity after gastric bypass surgery, which may
increase the risk of cardiovascular
disease. The periodontopathogenic
bacteria
quantification
revealed
alterations during three periods
(pre-operative, 6M and 12M) and
P. gingivalis was the bacteria that
influenced the severity increase in
periodontal disease.
Acknowledgement
The authors thank CNPq and
FAPESP for the concession of a
grant to the first author and a scholarship to the second author.
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are necessary, especially among morbid obese patients before and after
gastric bypass surgery.
Principal findings: After gastric
bypass surgery, the periodontal diseases increased in severity and the
P gingivalis increased in amount.
Practical implications: Highlighting
the period of the highest risk factor
for periodontal diseases to facilitate
monitoring by the dental professionals who attend the morbid
obese patient before and after gastric bypass surgery. In addition,
the periodontal diseases increased
after surgery, which may increase
the risk of cardiovascular diseases.
Address:
Sılvia Helena de Carvalho Sales-Peres
Department of Pediatric Dentistry
Orthodontics and Public Health
Bauru School of Dentistry
University of S~
ao Paulo
Avenue Oct
avio Pinheiro Brisolla
9-75. Bauru-SP
Brazil
E-mail: [email protected]
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd