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Effect of non-surgical periodontal treatment on the subgingival microbiota of patients with chronic kidney disease.


Chronic kidney disease (CKD) is a public health problem worldwide, (1) and its prevalence has been increasing. (2) CKD is defined as glomerular filtration rate (GFR) reduction or kidney damage, reflected as abnormal urine sediment or abnormalities in the renal anatomy. (1) Periodontitis has emerged as a non-traditional risk factor and a prediction model for CKD. (3) The link between periodontal disease and CKD may be due to concomitant infection and inflammation. (4) The periodontal inflammatory state may add to the chronic inflammation present in CKD, (5) decreasing renal function. (6) Periodontal therapy reduces inflammation and improves endothelial function, (7) leading to more effective kidney microcirculation and filtration. CKD patients with periodontitis can also be effectively treated by periodontal mechanical therapy. (8,9) In a previous study, we demonstrated that non-surgical mechanical treatment led to periodontal clinical improvement, as well as an improvement in GFR levels. (8) However, limited data are available regarding the subgingival microbial profile of predialysis CKD patients and the effect of therapy on the oral microbiota. Therefore, the aim of this study was to investigate the effect of mechanical non-surgical periodontal therapy on the subgingival microbiota of CKD patients with chronic periodontitis.


The present study was a two-arm monocentric clinical trial with a 3-month follow-up period. The study was conducted according to the principles outlined in the Declaration of Helsinki on experimentation involving human individuals, and was approved by the Human Research Committee/Institute for Community Health Studies at the Federal University of Rio de Janeiro, protocol 113/2006. To be enrolled, patients were informed about the nature of the proposed treatment, its risks and benefits, and signed informed consent forms. The sample population has been described in a previous paper. (8) From January to November 2006, 16 pre-dialysis (CKD) patients were recruited from the Nephrology Division of Clementino Fraga Filho University Hospital, and 14 systemically healthy individuals (C) were recruited from the General Medicine department of the same hospital. This study used the GFR to define the groups, according to the renal function stages proposed by the National Kidney Foundation. (1) The CKD group consisted of patients with clinical diagnosis of renal failure, having GFR between 89 and 15 mL/min, and receiving conservative treatment (pre-dialysis). The C group consisted of patients seeking general medical care without signs and symptoms of renal disease and having GFR > 90 mL/min. All study participants were between 35 and 76 years of age, presented at least 15 teeth, and were diagnosed as having chronic periodontitis, i.e., the presence of [greater than or equal to] 4 sites in 3 different teeth with clinical attachment level (CAL) [greater than or equal to] 4 mm and bleeding on probing (BOP). A detailed medical history was obtained from all participants at baseline, as well as information about age, gender, ethnicity, and smoking habit. Exclusion criteria included HIV infection, pregnancy, lupus erythematosus, rheumatoid arthritis, need for antibiotic prophylaxis for periodontal procedures, periodontal treatment, and/or use of antibiotics in the preceding 6 months. A full-mouth periodontal clinical examination was performed at 6 sites per tooth (excluding third molars) by one calibrated examiner (C.O.S.) at both visits. Periodontal assessment included probing depth (PD) and CAL, measured to the nearest millimeter with a periodontal probe (UNC-15, Hu-Friedy, Chicago, USA), the presence or absence of BOP, supragingival biofilm (VP), gingival marginal bleeding (GB), and suppuration (SUP). Intra-class correlation coefficients > 0.90 were obtained for PD and CAL. The periodontal treatment was performed by a single experienced periodontist (H.P.C.A.). Both groups received non-surgical periodontal therapy consisting of oral hygiene instructions, and supra- and subgingival scaling and root planing with hand instruments (Gracey curettes; Hu-Friedy[R]) under local anaesthesia. One sextant was instrumented at each dental visit (1- to 2-hour session), and the therapy was completed within 6-8 weeks.

Microbiological assessment

Microbial analyses were performed at baseline and 3 months after therapy. The presence and levels of 49 bacterial species were determined in the subgingival biofilm samples by genomic DNA probes and the checkerboard DNA-DNA hybridization method. (10) The species Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans) serotypes a, b, and c, and Propionibacterium acnes 1 and 2 were pooled into two DNA probes for the two species, respectively. Eight enteric species (Enterobacter aerogenes, Enterobacter cloacae, Enterobacter gergoviae, Enterobacter sakazakii, Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, and Pantoea agglomerans, formerly Enterobacter agglomerans) were pooled into one enteric probe. After removal of supragingival biofilm, subgingival biofilm samples were taken from 6 sites with the deepest PD per individual by means of individual sterile Gracey curettes (Hu-Friedy[R]), and were placed in individual tubes. Bacterial cells underwent lysis, and denatured DNA was fixed on a nylon membrane (GE Healthcare Life Science, Sao Paulo, Brazil) using the checkerboard slot blot device (Minislot 30, Immunetics, Cambridge, USA). Digoxigenin-labeled (Roche Applied Science, Sao Paulo, Brazil) whole-genomic DNA probes were hybridized at 90[degrees] to the lanes of the plaque samples in the slot blot device (Miniblotter 45, Immunetics). After hybridization, the membranes were washed at high stringency, bound probes were detected using phosphatase-conjugated antibody to digoxigenin (Roche Applied Science), and fluorescence was captured by an imaging system (Storm[TM] 860, GE Healthcare Life Science). Signals were evaluated visually by comparison with the standards at 105 and 106 bacterial cells for the test species on the same membrane. They were recorded as:

* 0, not detected;

* 1, < [10.sup.5] cells;

* 2, approximately [10.sup.5] cells;

* 3, [10.sup.5] to [10.sup.6] cells;

* 4, approximately [10.sup.6] cells; and

* 5, > [10.sup.6] cells.

The sensitivity of the assay was adjusted to permit the detection of [10.sup.4] cells of a given species by adjustment of the concentration of each DNA probe. The microbiological test was read by a single calibrated examiner (C.M.S.B.).

Statistical analysis

Statistical analyses were performed with SPSS software (SPSS, release 17.0, Chicago, USA). Microbial data were presented as mean levels (x [10.sup.5] bacterial cells). The levels (scores 0 to 5) of each species in a sample were converted to absolute numbers, and the mean counts were computed for each patient and averaged within the groups. Moreover, the mean counts of bacteria in sites that did not improve or presented disease progression, i.e., PD increase and/or attachment loss at 3 months post-therapy, were compared to sites that improved (PD reduction and CAL gain) after treatment. Significant differences in demographic, clinical, and microbiological parameters between groups were determined by the Mann-Whitney and [chi square] tests. Differences in clinical and microbiological changes between groups over time were evaluated by the Wilcoxon Signed-Rank test. The level of significance for all analysis was 5%.


The majority of individuals in both groups were females (9 in the CKD and 10 in the C group), white, and non-smokers; however, no significant differences for these parameters were observed between groups. In contrast, those in the CKD group were significantly older (58.8 [+ or -] 10.8 years) than those in the C group (52.0 [+ or -] 3.3 years; p = 0.014, Mann-Whitney test). Regarding the clinical features of the sampled sites (Table 1), there were no significant differences between groups for all periodontal parameters at baseline and at 3 months post-therapy (p > 0.05, Mann-Whitney test). Both groups showed significant clinical improvement in those sites for PD, CAL, and VP after treatment (p < 0.05, Wil coxon test). The CKD group also showed significant improvement in BOP. The subgingival microbial profiles of both groups at baseline and 3 months after therapy are depicted in Figure 1. In general, the C group showed absolute higher levels of many tested species, especially members of the green and orange complexes. However, only the species Enterococcus faecalis was detected in significantly higher mean counts in C compared to CKD individuals at baseline (p = 0.025; Mann-Whitney test). Levels of most species decreased significantly after treatment in the C group, whereas, in the CKD group, significant reductions were observed only for the species Actinomyces gerencseriae, Actinomyces oris, A. actinomycetemcomitans, Fusobacterium nucleatum polymorphum, Streptococcus constellatus, Leptotrichia buccalis, Dialister pneumosintes, Enterics, and Staphylococcus aureus. Moreover, a significant increase in mean counts was observed for Prevotella nigrescens in the CKD group (p < 0.05, Wilcoxon test). At 3 months post-therapy, significantly higher levels of Actinomyces israelii, Campylobacter rectus, Fusobacterium periodonticum, Parvimonas micra, Prevotella nigrescens, Tannerella forsythia, Neisseria mucosa, and Streptococcus anginosus were found in the CKD group compared with the C group (p < 0.05, Mann-Whitney test). The subgingival microbiota of sites that did or did not show clinical improvement after treatment were also analyzed. A total of 42 sites (35.6%) from 13 members of the CKD group and 31 sites (28.2%) from 12 members of the C group presented increases in PD and/or loss of clinical attachment in spite of treatment. The number of non-respondent sites did not differ between groups (p > 0.05, [chi square] test; data not shown). Figure 2 shows the microbial composition of successfully treated and non-responsive sites in both groups at 3 months post-therapy. Those in the CKD group had significantly higher levels of several species in sites that did not respond to therapy compared with sites that did, particularly the pathogenic species T. forsythia, Porphyromonas gingivalis, Treponema denticola, Fusobacterium spp., and non-oral species including D. pneumosintes, E. faecalis, and S. aureus (p < 0.05, Wilcoxon test). Conversely, no significant differences regarding the levels of all tested species between sites that did or did not respond to therapy were observed in the C group (Figure 2). Comparisons of non-responsive sites between groups demonstrated significantly lower levels of Veillonella parvula, Streptococcus intermedius, Capnocytophaga sputigena, Eikenella corrodens, Campylobacter showae, F. periodonticum, P. micra, T. forsythia, Eubacterium saburreum, L. buccalis, Prevotella melaninogenica, and Selenomonas noxia in individuals in the C group than in those in the CKD group (p < 0.05, Mann-Whitney test).




Limited data are available regarding the composition of the periodontal microbiota of individuals with CKD, as well as the impact of mechanical periodontal therapy on their microbiota. In this investigation, we showed that the periodontal microbiota of persons with chronic periodontitis and CKD and that of systemically healthy individuals was similar in composition, except that E. faecalis was found in higher counts in the C group. Although not considered a periodontal pathogen, E. faecalis produces various virulence factors that may be related to periodontal inflammation, tissue destruction, and neutrophil impairment. (11) Moreover, this species is a biofilm-forming bacterium, capable of adhering and invading soft tissues, which enables this organism to co-aggregate with many oral species. (12,13) E. faecalis may also enhance pathogenicity in mixed infections with anaerobic bacteria. (14) Previous studies by our group have shown an association between E. faecalis and chronic periodontitis. (15,16) However, it is difficult to explain why this species was detected in higher levels in the periodontitis biofilm of systemically healthy individuals compared with those with CKD. Due to the immunosuppression usually present in CKD patients, (17) as well as the common association of E. faecalis and kidney infections, one would expect to find this species in higher levels in the CKD group. Changes in the bacterial levels from baseline to 3 months after therapy showed that a larger number of species diminished significantly in the C compared with the CKD group. In addition, one species of the orange complex, P. nigrescens, showed a significant increase in the CKD group after treatment. However, few species differed between groups at 3 months, including species of the red and orange complexes, which were found in higher levels in the CKD group. Further analyses comparing responsive and non-responsive sites showed that individuals with CKD presented higher levels of many species, such as T. forsythia, P. gingivalis, T. denticola, Fusobacterium sp., D. pneumosintes, E. faecalis, and S. aureus, in sites with PD increase and attachment loss after therapy, whereas no differences between those sites were observed for those in the C group. Moreover, non-responsive sites in the CKD group presented higher counts of V. parvula, S. intermedius, C. sputigena, E. corrodens, C. showae, F. periodonticum, P. micra, T. forsythia, E. saburreum, L. buccalis, P. melaninogenica, and S. noxia than nonresponsive sites in the C group. Species of the red complex and D. pneumosintes have been recently associated with treatment failure or periodontal attachment loss, as well as non-responsive sites in generalized aggressive periodontitis. (18,19) The persistence of high levels of many pathogenic species in CKD patients compared with systemically healthy individuals after treatment could be related to the immunocompromised state associated with uremia in CKD patients. (20) Conceivably, the uremia can cause an indirect effect on the microbiota by modifying the host inflammatory or immune response, and by changing the host-parasite balance, favoring a rapid re-colonization by pathogenic species after mechanical therapy. One should consider, however, that this was a short-term post-therapy study consisting of a small sample population. Further longitudinal investigations are needed to evaluate how the persistence of high levels of periodontal pathogens will affect the efficacy of mechanical periodontal treatment of individuals with both CKD and chronic periodontitis.


The microbial composition of the periodontitis-associated subgingival biofilm of individuals with CKD was very similar to that of systemically healthy individuals. Nevertheless, fewer bacterial species were affected by mechanical periodontal therapy in the CKD than in the C group. In addition, pathogenic species persisted in high levels in non-responsive sites of CKD individuals compared with C patients.


This study was supported in part by the National Council for Scientific and Technological Development (CNPq), the Coordination of Improvement of Higher Education Personnel (CAPES), Brasilia, Brazil; and by the Foundation for Research Financial Support in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil.


(1.) National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, classification, and stratification. Am J Kidney Dis. 2002 Feb;39(2 Suppl 1):S1-S266.

(2.) Centers for Disease Control and Prevention (CDC). Prevalence of Chronic Kidney Disease and associated risk factors--United States, 1999-2004. MMWR: Morb Mortal Wkly Rep. 2007 Mar;56(8):161-5.

(3.) Fisher MA, Taylor GW. A prediction model for chronic kidney disease includes periodontal disease. J Periodontol. 2009 Jan;80(1):16-23.

(4.) Kshirsagar AV, Craig RG, Beck JD, Moss K, Offenbacher S, Kotanko P, et al. Severe periodontitis is associated with low serum albumin among patients on maintenance hemodialysis therapy. Clin J Am Soc Nephrol. 2007 Mar;2(2):239-44.

(5.) D'Aiuto F, Nibali L, Parkar M, Patel K, Suvan J, Donos N. Oxidative stress, systemic inflammation, and severe periodontitis. J Dent Res. 2010 Nov;89(11):1241-6.

(6.) Fried L, Solomon C, Shlipak M, Seliger S, Stehman-Breen C, Bleyer AJ, et al. Inflammatory and prothrombotic markers and the progression of renal disease in elderly individuals. J Am Soc Nephrol. 2004 Dec;15(12):3184-91.

(7.) Seinost G, Wimmer G, Skerget M, Thaller E, Brodmann M, Gasser R, et al. Periodontal treatment improves endothelial dysfunction in patients with severe periodontitis. Am Heart J. 2005 Jun;149(6):1050-4.

(8.) Artese HP, Sousa CO, Luiz RR, Sansone C, Torres MC. Effect of non-surgical periodontal treatment on chronic kidney disease patients. Braz Oral Res. 2010 Oct-Dec;24(4):449-54.

(9.) Graziani F, Cei S, La Ferla F, Vano M, Gabriele M, Tonetti M. Effects of non-surgical periodontal therapy on the glomerular filtration rate of the kidney: an exploratory trial. J Clin Periodontol. 2010 Jul;37(7):638-43.

(10.) Socransky SS, Smith C, Martin L, Paster BJ, Dewhirst FE, Levin AE. "Checkerboard" DNA-DNA hybridization. Biotechniques. 1994 Oct;17(4):788-92.

(11.) Jett BD, Huycke MM, Gilmore MS. Virulence of enterococci. Clin Microbiol Rev. 1994 Oct;7(4):462-78.

(12.) Al-Ahmad A, Muller N, Wiedmann-Al-Ahmad M, Sava I, Hubner J, Follo M, et al. Endodontic and salivary isolates of Enterococcus faecalis integrate into biofilm from human salivary bacteria cultivated in vitro. J Endod. 2009 Jul;35(7):986-91.

(13.) Johnson EM, Flannagan SE, Sedgley CM. Coaggregation interactions between oral and endodontic Enterococcus faecalis and bacterial species isolated from persistent apical periodon titis. J Endod. 2006 Oct;32(10):946-50.

(14.) Brook I. Effect of Streptococcus faecalis on the growth of Bacteroides species and anaerobic cocci in mixed infections. Surgery. 1988 Jan;103(1):107-10.

(15.) Souto R, Colombo AP. Prevalence of Enterococcus faecalis in subgingival biofilm and saliva of subjects with chronic periodontal infection. Arch Oral Biol. 2008 Feb;53(2):155-60.

(16.) Da Silva-Boghossian CM, Souto RM, Luiz RR, Colombo AP. Association of red complex, A. actinomycetemcomitans and non-oral bacteria with periodontal diseases. Arch Oral Biol. 2011 Sep;56(9):899-906.

(17.) Kaysen GA. The microinflammatory state in uremia: causes and potential consequences. J Am Soc Nephro. 2001 Jul;12(7):1549-57.

(18.) Colombo AP, Boches SK, Cotton SL, Goodson JM, Kent R, Haffajee AD, et al. Comparisons of subgingival microbial profiles of refractory periodontitis, severe periodontitis, and periodontal health using the human oral microbe identification microarray. J Periodontol. 2009 Sep;80(9):1421-32.

(19.) Heller D, Varela VM, Silva-Senem MX, Torres MC, FeresFilho EJ, Colombo AP. Impact of systemic antimicrobials combined with anti-infective mechanical debridement on the microbiota of generalized aggressive periodontitis: a 6-month RCT. J Clin Periodontol. 2011 Apr;38(4):355-64.

(20.) Vanholder R, De Smet R, Glorieux G, Argiles A, Baurmeister U, Brunet P, et al. Review on uremic toxins: classification, concentration, and interindividual variability. Kidney Int. 2003 May;63(5):1934-43.

Hilana Paula Carillo Artese (a)

Celso Oliveira de Sousa (a)

Maria Cynesia Medeiros de Barros Torres (a)

Carina Maciel Silva-Boghossian (b)

Ana Paula Vieira Colombo (b)

(a) Department of Dental Clinic, Division of Graduate Periodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

(b) Department of Medical Microbiology, Institute of Microbiology, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

Declaration of Interests: The authors certify that they have no commercial or associative interest that represents a conflict of interest in connection with the manuscript.

Corresponding author:

Hilana Paula Carillo Artese


Received for publication on Jan 31, 2012

Accepted for publication on May 08, 2012
Table 1--Periodontal clinical parameters (mean [+ or -] SEM) of
the sites sampled for microbiological analysis in the two clinical
groups, at baseline and 3 months after therapy.

Clinical parameters                  CKD (n = 16)

                            Baseline             3 months

Pocket depth (mm)       4.5 [+ or -] 0.2    1.8 [+ or -] 0.2 *
Clinical attachment     5.3 [+ or -] 0.4    4.3 [+ or -] 0.4 *
  level (mm)

% of sites with

Supragingival biofilm   78.7 [+ or -] 4.5   55.2 [+ or -] 7.7 *
Gingival bleeding       33.6 [+ or -] 7.2    25.0 [+ or -] 6.4
Bleeding on probing     77.8 [+ or -] 5.2   58.3 [+ or -] 6.6 *
Suppuration             12.7 [+ or -] 3.6    8.3 [+ or -] 4.3

Clinical parameters                  C (n = 14)

                            Baseline             3 months

Pocket depth (mm)       4.5 [+ or -] 0.4    1.7 [+ or -] 0.2 *
Clinical attachment     5.3 [+ or -] 0.4    4.1 [+ or -] 0.3 *
  level (mm)

% of sites with

Supragingival biofilm   69.2 [+ or -] 7.8   46.4 [+ or -] 7.4 *
Gingival bleeding       26.9 [+ or -] 6.0    20.2 [+ or -] 4.3
Bleeding on probing     67.4 [+ or -] 6.3    53.5 [+ or -] 4.9
Suppuration             9.3 [+ or -] 4.4     2.4 [+ or -] 1.6

CKD: chronic kidney disease pre-dialysis individuals; C: systemically
healthy individuals; * Refers to significant differences between
baseline and 3 months post-therapy within the groups (p < 0.05,
Wilcoxon test).
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Title Annotation:Periodontics
Author:Artese, Hilana Paula Carillo; de Sousa, Celso Oliveira; Torres, Maria Cynesia Medeiros de Barros; Si
Publication:Brazilian Oral Research
Date:Jul 1, 2012
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