GENETICS IN

PERIODONTAL DISEASE
Part 2
 Most forms of periodontitis with postpubertal
onset are not inherited as Mendelian diseases,
that is, they are probably not caused by major
genes.
 Rather, many polymorphic genes with
relatively small but significant associations
with disease risk may interact to contribute to
overall risk.
 Genetic polymorphisms can be divided
into:
1. Genetic polymorphisms of immune system
2. Genetic polymorphisms of protease and
structure molecules.
Gene polymorphisms of immune
components
 Data from human and animal studies indicate that
genetic variance can influence the innate, inflammatory,
and immunological response to microbial infection.
 Features of host immune response contributing to
periodontal disease are:
 Epithelial, connective tissue, and fibroblast defects.
 Functional defects or a deficient number of
polymorphonuclear leukocytes
 proinflammatory cytokines has attracted much attention as
potentially crucial variants influencing the host response in
periodontitis.
 Cytokine polymorphism
 Differences in the expression of cytokines,
especially pro inflammatory cytokines, are of
great interest in periodontal research.
 IL-1 gene polymorphism
 Three IL-1 genes are arranged in a cluster on human
chromosome 2q13.
 Two of the genes, namely IL-1A and IL- 1B, encode the
cytokines IL-1a and IL- 1b, respectively, while the third
gene, known as IL-1RN, encodes the receptor antagonist
(IL-ra) protein (Nicklin et al. 1994).
 Interleukin-1 gene complex (IL-1A and IL-1B genes)
which control levels of the multifunctional cytokine IL-1.
 A specific genotype is characterized by the presence
of polymorphic gene clusters IL-1A (-889) and IL-1B
(+3953), also referred to as ‘‘genotype-positive’’, has
been associated with severe chronic periodontitis in a
non-smoking population of Caucasian Northern
European heritage (Kornman et al. 1997). (termed the
composite genotype)
 The specific genotype of the polymorphic interleukin-
1 gene cluster (periodontitis susceptibility trait, PST
or composite genotype) was only associated with
severity of periodontitis in nonsmokers, and
distinguished individuals with severe periodontitis
from those with mild disease (odds ratio 18.9 for ages
40–60 years, but wide confidence intervals of 1.04–

343.05).
 Similar results were reported by McDevitt et al. and
from smaller studies by McGuire et al. , Laine et al. ,
and Gore et al.
 Contradictory reports such as Meisel et al. stated that
the composite genotype showed a strong interaction
with smoking, an established risk factor for
periodontitis, whereas nonsmokers, even when
genotype positive, were not at any increased risk.
 Absence of periodontal therapy

 The effect of IL-1 genotype status on PPD and CAL

was assessed over 5 years in 295 Australians of
Caucasian ethnicity (Cullinan et al. 2001).
 No systematic periodontal treatment or supportive
periodontal therapy (SPT) was provided over the
entire observation period.
 Considering all age groups, IL-1 genotype-positive
subjects did not experience a statistically significantly
elevated PPD and CAL loss compared with IL-1
genotype-negative subjects.
 Hence, IL-1 genotype status alone did not yield a positive
predictive value for periodontal disease progression.
 On the other hand, IL-1 genotype status in conjunction
with age, smoking status and presence of P. gingivalis
was considered a contributory factor for periodontal
disease progression.
 Non-surgical periodontal therapy
 The prognostic utility of the interleukin-1 genotype on
chronic periodontitis progression following nonsurgical
therapy was performed by Ehmke et al.
 Of the 33 patients studied, 16 had the susceptible
composite genotype reported by Kornman et al.
 Following 2 years of periodontal maintenance care, no
differences in tooth or attachment loss were detected
between those with or without the genotype.
 IL-1 and GTR
 De Sanctis et al. demonstrated that genotype
expression did not affect guided tissue regeneration
treatment response at 1 year, but had a great impact on
long-term stability (year 4).
 In a 3-year period, patients with a positive interleukin-1
genotype lost about 50% of the clinical attachment level
gained in the first year and were about 10 times more
likely to experience >2 mm clinical attachment loss
when compared to oral hygiene-matched genotype-
negative patients.
 In a retrospective study, Weiss et al. (2004) assessed
the effect of IL-1 genotype status on the outcome of
bone grafting in the treatment of interproximal
periodontal defects.
 When applying multivariate linear regression analysis
adjusting for baseline PPD and CAL, age, gender,
smoking status, fullmouth plaque index, full-mouth
bleeding index, IL-1 genotype status failed to
influence significantly PPD reduction and CAL gain.
 IL-1 and microbiology

 Socransky et al. investigated the presence of

periodontal pathogens in genotype-positive patients.

 Higher levels of the ‘‘red’’ and ‘‘orange’’ complexes

were detected in genotype-positive subjects more

frequently than genotype-negative patients.

 Association of these IL-1 polymorphisms with
periodontitis has been demonstrated in a northern
European population, yet these polymorphisms were
found not be of use in assessing risk in a Chinese
population due to their rare occurrence in this
population.
 IL-1 polymorphism and AgP
 Hodge et al. examined interleukin-1a and
interleukin- 1b genetic polymorphisms in unrelated
European white Caucasian patients with generalized
early onset periodontitis and found no significant
differences between patients and controls
 It was concluded that there was a lack of association
between the interleukin-1 polymorphisms and
aggressive periodontitis.
 Other studies on the composite genotype and
aggressive periodontitis have had similarly mixed
results.
 Furthermore, Parkhill et al. investigated the
frequency of polymorphisms in the genes encoding
interleukin-1b in Caucasians with aggressive
periodontitis compared to controls and failed to
show an association.
 IL-1 and smoking
 Smokers bearing the genotype-positive IL-1 allele
combination may be at an increased risk of developing
periodontitis.
 Meisel et al. concluded that the IL-1 gene cluster
combined with smoking was associated with an
increased risk of attachment loss.
 In this population, non-smoking subjects were not at
increased risk, even if they are genotype-positive.
 IL-1 genotype & Mucogingival
surgery
 In hispanic population, periodontally healthy subjects
treated with mucogingival surgery for Types I and II
recession defects using connective tissue grafts.
 The mean response to mucogingival surgery to cover
localized gingival recessions is similar irrespective of
the IL-1 genotype, however, full coverage is
achieved more frequently in genotype negative
subjects after.
Caffesse et al., 2002
 GCF studies related to IL-1 genotype
polymorphism
 Shirodaria et al. assessed the functional effect of the
composite genotype in terms of the quantity of
interleukin-1a protein in gingival crevice fluid of severe
chronic periodontitis patients.
 These researchers found that allele 2 at position -889 of
interleukin-1a gene was associated with a fourfold
increase interleukin-1a as determined by enzyme linked
immunoassay.
 This is a useful study given that it addresses the in vivo
effects of the polymorphism on interleukin-1 protein
quantities.
 IL-1 and implants
 The effects of the IL-1 genotype, smoking status, and patient’s
age on failed or failing implants was recently compared to
successfully integrated implants .
 Although smoking increased the risk of implant failures by
approximately 2.5 times, statistical testing failed to indicate a
relationship between implant failure, age, or IL-1 genotype status.
 This was further validated by another study that failed to
demonstrate a relationship between implant failure and the IL-1A
(-899), IL-1B (+3953) composite genotype in Caucasian patients .
 However, it was suggested that the absence of these alleles may
not indicate a reduced risk of periodontitis or peri-implantitis.
 Conclusion
 The composite polymorphisms may be part of several
factors involved in the genetic risk for chronic
periodontitis;
 The polymorphism is only a useful marker in defined
populations
 confirmation of the functional significance of this gene
polymorphism remains to be confirmed;
 clinical utilization of the composite polymorphisms for
risk assessment and prognostic determination is
premature.
 Interleukin-2
 Interleukin-2 is a pro-inflammatory cytokine produced by
T-helper 1 cells, participates in B lymphocyte activation
and macrophage stimulation, as well as in natural killer
and T lymphocyte proliferation
 The interleukin-2 gene is located in chromosome 4q26
Polymorphism at positions (+330) and (+166), relative to
the transcription start site, were identified by John et al.
 The (+330) polymorphism has two common alleles T
and G.
 In a periodontal study in Caucasian subjects, the T-
allele carriers seem to be approximately half as likely to
develop severe periodontal disease (OR ¼ 1.99; 95% CI
¼ 1.07–3.7).
 Moreover, individuals with the TT genotype seem to be
2.5-times less likely to develop severe periodontitis
than individuals who are heterozygous or GG
homozygous (OR ¼ 2.57; 95% CI ¼ 1.15–5.73) (208).
 Interleukin-4
 The gene for interleukin- 4 is found in chromosome
5q31.1.
 Promoter single nucleotide polymorphism at position
(+590) and a 70-bp variable numbers of tandem repeat
polymorphism at intron 2 have been identified.
 Case–control reports relating to aggressive periodontitis
and chronic periodontitis susceptibility and severity
across several populations have failed to establish a
connection between these loci and periodontal disease.
 Interleukin-6
 The interleukin-6 gene was demonstrated to be
localized in chromosome 7p21.
 In periodontitis, the G–C single nucleotide
polymorphism at the (+174) position correlated with
chronic periodontitis susceptibility in Brazilian
Caucasians (OR ¼ 3.0), but not in Czech Caucasians.
 A recent report revealed that the (-174) G/C,
(+190)C/T and (-597) G/A loci were non-polymorphic
in a Japanese population (133).
 In another study, periodontitis patients carrying one or
two copies of the rare allele in the interleukin-6 (-174)
polymorphism displayed significantly higher serum
interleukin-6 and C-reactive protein concentrations.
 It appears that interleukin-6 gene polymorphisms affect
the serum levels of circulating interleukin-6, and
consequently modify the patient’s response to
periodontal treatment.
 Interleukin-10
 Interleukin-10 stimulates the production of protective
antibodies and down-regulates pro-inflammatory
cytokines produced by monocytes.
 The gene encoding interleukin-10 was mapped to
chromosome 1q31–32. Three promoter single
nucleotide polymorphisms have been described in
this gene: (-1087) G/A; (-819) C/T; and (-592) C/A.
 The (-1087) G/A locus was not associated with chronic
periodontitis susceptibility in Japanese and Brazilian
subjects, but was linked to chronic periodontitis
severity in Swedish Caucasians (OR ¼ 2.58).
 The (-819) C/T and (-592) C/A loci correlated with
chronic periodontitis susceptibility in Brazilians (OR ¼
3.04; CI ¼ 1.31– 6.91 and OR ¼ 3.38; 95% CI ¼
1.29–8.82, respectively) but not in Japanese and
German Caucasian subjects.
 The (-1087) single nucleotide polymorphism was
associated with high in vitro interleukin-10 production.
Other interleukins
 Fc receptor polymorphisms

 Leukocyte receptors for the constant (or Fc-) part of

immunoglobulin (FcR) link cellular and humoral
branches of the immune system, which are considered
essential for the host defense against bacteria.
 FcR for immunoglobulin G (FcγR) play a crucial role in
the host defense against these bacteria.
RECEPTOR LIGAND
 FcR IgA
 FcR IgG
 FcR IgD
 FcR IgE
 FcR IgM
 Fc/R IgA & IgM
 FCR TYPES

TYPES Affinity
FCRI (A B & C) CD64 IgG1>G3>G4>G2

FCRII (A B & C) CD32 IgG1+G3>IgG2=G4

FCRIII (A & B ) CD16 IgG1+G3>IgG2=G4

 The genes for FCR are found on long arm of
chromosome 1 and encode for FCRI , FCRII,
FCRIII.
 Functional bi-allelic polymorphisms have been
identified for three FcγR subclasses:
1. FcγRIIA,
2. FcγRIIIA, and
3. FcγRIIIB.
 This polymorphism affects the function of
polymorphonuclear neutrophils and influences their
ability to utilize antibodies efficiently as opsonins.
 Thus, this polymorphism could play a role in the patients
ability to deal with bacterial infections.
 fMLP receptor polymorphism
 N--formyl-l-methionyl-l-leucyl-l-phenylalanine
fMLP) peptides are thought to be structural analogs
of bacterial products involved in chemotaxis of
neutrophils to areas of bacterial infection.
 Depressed chemotactic response to fMLPs in
localized juvenile periodontitis (LJP) patients has
been confirmed by several investigators .
 The fMLP receptor genes are localized in
chromosome 19.
 Gwinn et al. examined the fMLP receptor gene, and
found that two single nucleotide base alterations (329
T/C and 378 C/G) were associated with aggressive
periodontitis.
 Zhang et al. found no association of these fMLP
receptor polymorphisms (329 T/C and 378 C/G) with
susceptibility to aggressive periodontitis.
 HLA genetics
 Human leukocyte antigens (HLA) are involved in
genetically predetermined humoral immune
response via recognition of foreign antigens.
 In humans, the ‘‘classical’’ major histocompatibility
complex (MHC)
 Class I molecules (HLA-A, -B, and -C) are expressed on
most nucleated cells
 Class II molecules (HLA -DP, -DQ, -DR) are expressed
on cells that immuno survey host cells including B and T
cells, macrophages and accessory cells for the presence of
foreign peptides.
 The MHC genes are the most polymorphic genes
present in the genome of every species analyzed .
Complex HLA
MHC
II III I
Class
Region DP DQ DR C4, C2, BF B C A

Gene
DP DQ DR C` TNF-α
Product αβ αβ αβ Proteins TNF-β
HLA-B HLA-C HLA-A
 Shapira et al. - antigen-A9 and -B15 - aggressive
periodontitis.
 Takashiba et al. - antigen-DQa gene – aggressive
periodontitis - Japanese.
 Ohyama et al - DQB1 molecule- aggressive periodontitis.
 Hodge et al. - no association - antigen-DQa gene -
aggressive periodontitis - Caucasians.
 Bonfil et al. - antigen-DR4 (0401, 0404, 0405, 0408) –
aggressive periodontitis, in which subtypes can be a risk
factor for the disease.
 Machulla et al – human leukocyte antigen-A, -B, -Cw, -
DRB1, -DRB3/4/5, -DQB1 - aggressive periodontitis and
chronic periodontitis.
 TNF-alpha
 In addition, a polymorphism of tumor necrosis factor-a
(TNF-a), a cytokine with biological activities similar to
those of IL-1 has been reported to be associated with
severe periodontitis.
 Tumor necrosis factor has the potential to stimulate the
production of secondary mediators, including
chemokines or cyclooxygenase products, which
consequently amplifies the degree of inflammation
 The tumor necrosis factor gene (TNF) is located in
chromosome 6 within the major histocompatibility
complex, in the 6p21.3, Class III human leukocyte
antigen zone.
 Eight single nucleotide polymorphisms in the promoter
region of this gene have been described at positions –
 -1031T/C, -863C/A, -857C/T, -575G/A, -376G/A, -
308G/A, -244G/A, and -238G/A.
 Tumor necrosis factor gene polymorphisms and
periodontitis studies display conflicting results.
 It is not clear why these studies gave conflicting results.
 However, performing another approach, such as meta-
analysis, which pools all the data to extract a common
conclusion, would be helpful.
 NAT 2 polymorphism

 A polymorphism in the N-acetyltransferase gene

(NAT2) has been demonstrated.
 This polymorphism codes for the ‘slowacetylator’
phenotype, which is known to be a risk factor for
other smoking-related diseases, in particular, cancer
susceptibility.
 VDR gene polymorphism in AP
 Polymorphisms present in the vitamin D receptor (VDR)
gene, which have been correlated with both bone
mineral density and bone turnover rate, were reported to
be associated with localized aggressive periodontitis (but
not generalized aggressive periodontitis)
 The human vitamin D receptor gene is localized in
chromosome 12q12–q14.
 E T-1 polymorphism
 ET-1 is a vasoactive, mitogenic peptide detected in
increased quantities in patients with chronic
periodontitis .
 It acts synergistically with growth factors to stimulate
mitogenesis in fibroblasts and osteoblasts and may
contribute to cellular infiltration in chronically
diseased sites.
 Significant differences were reported with regard to
the three locus combination of genotypes between
diseased and healthy subjects.
 Polymorphism in chromosome 4 q
 In 1986, Boughman et al. reported that a major gene
located on chromosome 4q was responsible for
autosomal dominant transmission of localized
aggressive periodontitis in an extended family that also
exhibited dentinogenesis imperfecta .
 This observation is thought to be specific to the unique
population studied, as similar analyses of an additional
population by Hart et al. failed to reproduce this
finding .
Genes involved in CP
Genetic polymorphism associated
with aggressive periodontitis
 Genetic polymorphisms in
Periodontal health

 A limited number of studies, have reported

genes found to be associated with periodontal
health.
 They include two HLA antigens and a
genotype of the FcγRIIIb polymorphism.
 Matrix metalloproteinase

 Matrix metalloproteinases are one of the most

important groups of enzymes involved in periodontal
connective tissue destruction .
 Despite this, there are very few reports concerning
polymorphisms of genes for matrix
metalloproteinases and periodontitis.
 Increased levels MMP-1 (interstitial collagenase) and
MMP-3 (stromelysin-1, activator of collagenase) -
periodontitis lesions- polymorphisms in the promoter
region of MMP-1 and 3 genes.
 de Souza et al – showed MMP-1 (-1607 2G/2G) -
severe chronic periodontitis – Brazilian.
 Holla´ et al. - indicated that three MMP-1
polymorphisms (-1607 1G/2G,-519 A/G, and -422
A/T) - small effect on chronic periodontitis - Czech
population.
 Itagaki et al. reported that matrix metalloproteinase-1
and or matrix metalloproteinase- 3 single nucleotide
polymorphisms were not associated with susceptibility
to periodontitis in a Japanese population.
 More recently, polymorphisms in the gene for matrix
metalloproteinase-2 were studied and no definitive
correlation with periodontitis could be found .
 Due to the limited number of studies carried out to date,
it is difficult to relate single nucleotide polymorphisms
of matrix metalloproteinase genes with periodontitis.
 Cathepsin C
 Papillon–Lefe`vre syndrome is associated with
mutations in the cathepsin C gene.
 Cathepsin C is a lysosomal protease that plays an
essential role in immune and inflammatory
processes and may also play a role in the
development of periodontitis.
 Most mutations in the cathepsin C gene have been
shown to result in a loss of enzyme function.
 Additional work has demonstrated that
Papillon–Lefe`vre syndrome and Haim– Munk
syndrome (a slightly different clinical variant
within the Papillon–Lefe`vre syndrome group
of disorders) are allelic variants of cathepsin C
gene mutations, as predicted by Gorlin et al.
 Whether the pathogenetic role of cathepsin C
gene variants also relates to types of
periodontitis other than syndrome-associated
periodontitis remains to be confirmed.

 Interestingly, Hewitt et al. have recently

reported a decreased cathepsin C activity
associated with the development of chronic
periodontitis in patients who do not suffer
from any syndrome such as Papillon–Lefe`vre
syndrome.
 Syndromic form of periodontits
 Severe periodontitis presents as part of the clinical
manifestations of a number of monogenic syndromes
and the gene many of these conditions.
 A commonality of these conditions is that they are
inherited as simple Mendelian traits due to genetic
alterations of a single gene locus.
 Significance of these conditions is that they clearly
demonstrate that a genetic mutation at a single locus
can impart susceptibility to periodontitis.
 Neutrophil functional disorders
 Molecular biology has highlighted the
important role of several receptors on the
polymorphonuclear leukocyte surface in
adhesion, and emphasized that defects in the
number of these receptors may lead to
increased susceptibility to infectious disease.
 Leukocyte adhesion deficiency
syndrome
 Page et al. proposed that the generalized form of
prepubertal periodontitis ??? is a localized oral
manifestation of the leukocyte adhesion deficiency
syndromes.
 Leukocyte adhesion deficiency occurs in two forms
both of which are autosomal recessive traits.
 leukocyte adhesion deficiency syndrome type 1
 leukocyte adhesion deficiency syndrome type 2
 Leukocyte adhesion deficiency syndromes
indicate that although the blood vessels are full
of neutrophils, the disease sites lack sufficient
leukocytes to combat the microbial challenge
and thus infections ensue rapidly in these
patients.
 Affected homozygotes suffer from acute
recurrent infections that are commonly fatal in
infancy.
 Those surviving will develop severe
periodontitis, which will begin as the primary
dentition erupts.
 Chediak–Higashi syndrome
 Chediak–Higashi syndrome is a rare disease
transmitted as an autosomal recessive trait.
 The polymorphonuclear leukocyte chemotactic
and bactericidal functions are thought to be
abnormal in these patients.
 Clinical features include generalized, severe
gingivitis and extensive loss of alveolar bone
and premature loss of teeth.
 Infantile
genetic agranulocytosis
 Rare autosomal recessive disease where
polymorphonuclear leukocyte numbers are very low
and which has been associated with aggressive
periodontitis.
 Cohen’s syndrome
 Cohen’s syndrome is another autosomal
recessive syndrome and is characterized by
mental retardation, obesity, dysmorphia, and
neutropenia.
 Individuals with Cohen’s syndrome show
more frequent and extensive alveolar bone loss
than do age-, sex-, and mental ability-matched
controls .
 Not all neutropenias result in periodontal
disease.
 Familial benign chronic neutropenia has
variable expressivity and although several
individuals within a family may be
neutropenic, not all are affected by recurrent
infections or periodontal disease.
Other conditions
Gingival Overgrowth
 CYP2C polymorphisms
 Cytochrome P450 2C (CYP2C) plays an
important role in phenytoin metabolism
 Phenytoin metabolism and gingival overgrowth in
epileptic subjects.
 CYP 2C9*3 carriers exhibited significantly higher
serum drug concentration to drug dose
Soga et al., 2004
 TGF-β1 & DIGO

 TGF-β1 gene polymorphisms are associated

with severity of cyclosporin-A induced gingival
overgrowth
 TGF- β1 +869, codon 10 (leucine to proline
substitution), and +915, codon 25 (arginine to
proline substitution).
Linden et al., 2001
 Homozygosity for proline at codon 10 had significantly
higher overgrowth scores than those who were
heterozygous or homozygous for leucine.
 Heterozygous (arginine/proline) at codon 25 had a
significantly higher gingival overgrowth score than those
who were homozygous for arginine.
 The polymorphism in the TGF-β1 gene at codon 25
represented an independent genetic determinant of severe
gingival overgrowth in the susceptible subjects studied.
Hereditary gingival
fibromatosis
 Inheritance of HGF
 Large Brazilian family
 An autosomal dominant form of hereditary
gingival fibromatosis was mapped to
chromosome 2p21
 There was an earlier report of GF in a boy with
a cytogenetic duplication involving 2p13--p21.

Shashi et al., 1999

A gene locus for HGF1 has been localized to
genetic interval on chromosome 2p21-p22 Hart
et al., 2000
A new locus (HGF2) : On chromosome 5q13-
q22 at D5S1721.
Identified a four-generation Chinese HGF
family in which the disease manifested
within 1 year after birth. Xiao et al., 2001
 Son of Sevenless gene 1
 In HGF1 family members, a mutation in the Son
of sevenless-1 (SOS1) gene in affected
individuals was isolated.
 Insertion of a cytosine between nucleotides
126,142 and 126,143 in codon 1083 of the
SOS1 gene is responsible for HGF1.
Hart et al., 2002
 Few recent studies
 Glas J et al, july 2008 : surfactant protein D in chronic
periodontitis : no significant associations of SFTPD
gene polymorphisms could be detected in chronic
periodontitis.
 Cullinan MP, june, 2008 : Progression of periodontal
disease and interleukin-10 gene polymorphism in
Australian population individuals - having either the
ATA/ACC or the ACC/ACC genotype experiencing
around 20% fewer probing depths of >or= 4 mm
 Nibali L, april, 2008 : Interleukin-6 polymorphisms
are associated with pathogenic bacteria in subjects
with periodontitis : Multiple logistic regression
analysis revealed that the IL-6 -6106 polymorphism
was associated with the detection of A.
actinomycetemcomitans and the concomitant
detection of A. a and P. gingivalis.
 Nibali L, july 2008 Vitamin D receptor polymorphism
(-1056 Taq-I) interacts with smoking for the presence
and progression of periodontitis : found positive
association in smokers and no ass. In non smokers.
 Takeuchi-Hatanaka K , april 2008:
Polymorphisms in the 5' flanking region of IL-
12RB2 in the Japanese population which is a
crucial regulatory factor in the T-helper type (Th) 1
differentiation of T cells and found +ve asso. of
periodontal diseases with its low levels.
 Hooshmand B feb.2008 : Interleukin-4 (C-590T) and
interferon-gamma (G5644A) gene polymorphisms in
Iranian has no ass. with periodontitis.
 Gürkan A, april, 2008: Gene polymorphisms of
matrix metalloproteinase-2, -9 and -12 in periodontal
health and severe chronic periodontitis.
 Data suggest that MMP-2 -735C/T, MMP-9 -1562C/T
and MMP-12 357Asn/Ser polymorphisms are not
associated with susceptibility to severe CP in Turkish
population. However, T allele of MMP-9 -1562 gene
might be associated with decreased susceptibility to
severe CP.
 Ho YP Jan. 2008 : Cyclooxygenase-2 Gene-765 single
nucleotide polymorphism as a protective factor
against periodontitis in Taiwanese especially in AgP.
 EPIGENETICS Anthony G wilson Aug. 2008
 Epigenetics is defined as all mitotically and
meiotically changes in gene expression that are not
encoded in DNA sequence itself.
 Epigenetic modification of chromatin and DNA may
enhance or suppress the gene expression.
 Two major epigenetic mechanisms are : post
transitional modification of histone proteins in
chromatin and methylation of DNA.
 Emerging evidence suggests a key role in human
pathologies including inflammatory and neoplastic
disorders.
 Prognostic tests
 The conceptually simplest application of genetic
information would be the development of prognostic
tests to answer the question, what is the likelihood
that a patient will develop disease or experience
disease progression?
 Discovery of the association between polymorphisms
in IL-1 genes and severity of periodontitis has been
described as a major breakthrough.
 Clinical test for such genetic risk has been proposed
as a component of the risk assessment profile for
chronic periodontitis that can be used to provide a
rationale for explaining individual patient
susceptibility, providing early preventive or
therapeutic intervention, and allowing superior
prognostic capabilities.
 The practical clinical utility must be
questioned for a number of reasons.

 Associations between particular genes and disease

may only (thus far) be apparent in certain populations
and not in others. Thus, genetic tests may not apply
to all patients.
 Associations between disease and genes may be
indirect, that is, genetic factors may be associated
with environmental risk factors for periodontitis (e.g.
smoking) and thereby influence disease only in those
patients with the relevant biological exposure.
 The test, applied on an individual basis, has limited
sensitivity and specificity, that is, a significant
percentage of individuals who demonstrate the at-risk
genotype do not have periodontitis and a significant
percentage of individuals with periodontitis (who do not
smoke) do not demonstrate the genotype. There are
chances of false negative and false positive results
 The genes in questions determine a relatively small, but
significant, component of the overall risk for disease.
 Other polymorphisms also appear to contribute a small
but significant amount of risk for disease (e.g. Fc gRIIIb
polymorphisms) so that the IL-1 polymorphisms alone
are inadequate to provide a sufficient risk profile.
 Models do not provide the necessary prospective
data required to demonstrate that predetermination of
the genotype leads to disease or, more importantly to
the clinician, that knowledge of the genotype gives
the therapist the ability to modify the course of the
disease or its treatment.
 These points could be of great importance when
interpreting the results of genetic testing or evaluating
clinical approaches based upon genetic tests.
 PST GENETIC SUSCEPTIBILITY
TEST

 The PST Genetic Test detects specific variations in

the Interleukin-1α and Interleukin-1β genes.
 The presence of these variations (a PST-positive result)
increases the risk for periodontal disease 3 to 7-fold
and for tooth loss 3-fold.
Kornman et al Non- smokers

Senstivity 74%

Specificity 66%

False positive 45%

False negative 15%

 Indications for Testing
 Overall risk assessment for all patients
 Early clinical signs of periodontitis
 Chronic or progressive periodontitis
 Prior to advanced surgical or complex restorative
procedures (including implant placement)
 Family history of PST-positive individual(s)
 Family history of periodontal disease
 Adult orthodontic treatment
 Procedure
 It requires the clinician to perform a finger prick on the
patient and place 3 drops of blood on a sampling card.
 A more recent version allows for saliva samples to be
used.
 The card is sent to a commercial laboratory in
Flagstaff, Arizona where the genetic makeup of the
Interleukin 1β gene site is determined.
 Currently the test costs $210.00.
 What does a positive test mean in
terms of care? 
 A positive test would first advise the clinician that
supportive therapy at shortened intervals is essential. 
 Perhaps these patients may need professional deplaquing
at four to six week intervals. 
 It might also indicate a benefit to be gained with the use of
connective tissue stabilizing medications, inflammatory
reaction suppressants and/or periodic antibiotics as well as
organism susceptibility testing. 
 Initial preparation procedures with closer monitoring may
be completed first, but where pockets persist surgical care
followed by stringent maintenance may be the most
effective treatment because it will produce the greatest reduction
in Interleukin 1B production.
 Mitchell K. Higashi, 2002 tested clinical scenario
required for cost effectiveness of IL-1 testing for
periodontal disease.
 Saving: $830,140 and 52.8 fewer cases of severe
CP
 Increased cost: $300,430 and 3.6 more cases.
 Three important clinical parameters: 1.
compliance rate for SPT in +ve vs. non-tested
patients. 2. Effectiveness of NSPT 3. RR for
disease progression in test +ve patients.
 MICROARRAY
 A microarray is composed of a series of DNA,
usually corresponding to segments of gene placed in a
pre-specified arrangement typically on a glass slide or
silicon chip.
 Complementary sequences will bind to each other
under right conditions.
 Contains minimum of 25 bp/ DNA

Two types
 cDNA array contains long DNA

(100 to thousands of bp)

 Oligonucleotide array contains short DNA (25 bp)
OLIGONUCLEOTIDE ARRAY
cDNA ARRAY
 Applications
 Can be used to detect SNPs.
 Quick way to genotype thousands of different loci
on a single run.
 Useful in linkage and association studies
 Can locate chromosomal aberrations like
amplifications and deletions.
 The currently immutable genetic susceptibility profile
for an individual can be used to develop assays of the
patient’s variable gene expression profile at any given
time.
 This would require identification of the baseline
‘activity’ of susceptibility genes in subjects with no
disease and the change in activity that occurs during
and as a result of initiation or progression of disease.
 should such tests be administered at an opportune
time, subclinical disease could be detected and
appropriate environmental or genetic therapies could
be administered.
 Therapy
 An approach to therapy based upon a combination of
prior knowledge of overall genetic risk and specific
genetic risk factors, existing information regarding the
patients’ pharmacogenetic profile, current assessment
of expression of genes imparting risk, and analyses of
the patient’s environmental factors that are likely to
lead to gene expression is possible.
 Should immunization protocols be available, or gene
therapy approaches exist, such preventive measures
could be targeted at those individuals at risk.
 In addition, in cases where a high genetic likelihood
of disease onset exists, aggressive steps could be
taken at a time prior to typical disease onset to remove
those environmental factors that cause the disease.
 This would be performed in an attempt to avoid
expression or overexpression of the polymorphic
genes that can initiate pathology.
 The ability to predict those at risk would certainly be
advantageous because initiation of disease might be
avoided.
 One might imagine that a pharmacogenetic approach
for choosing therapies might enhance individual
responses to treatment or ensure that the most
effective treatment is the one that is tried first.
 Such an individualized approach to therapy is simply
not available now, and the variable responses of
patients to therapy might be minimized by this
approach.
 Basic Principles and Approaches in
Gene Therapy
 Researchers may use one of several approaches
for correcting faulty genes:
 Inserting a normal gene to replace a nonfunctional
gene.
 An abnormal gene could be swapped for a normal
gene through homologous recombination; this
approach is the most common.
 The abnormal gene could be repaired through
selective reverse mutation, which returns the gene to
its normal function.
 The regulation (the degree to which a gene is turned
on or off) of a particular gene could be altered.
Gene delivery systems
 However, in the field of periodontics gene
therapy has not been applied with success
primarily because
 the technology of gene therapy is still far from
perfect
 periodontal disease is multifactorial in origin
 the involvement of multiple genes,
 no particular gene has been universally accepted
as a causative factor for periodontal disease.
 Future strategies in preventing
periodontal disease
 Gene Therapeutics-Periodontal Vaccination
 Genetic Approach to Biofilm Antibiotic
Resistance
 Antimicrobial Gene Therapy to Control
Disease Progression: One way to enhance host defense
mechanism against infection is by transfecting host
cells with an antimicrobial peptide/protein-encoding
gene. Researchers have shown when host cells were
infected in vivo with βdefensin-2 (HBD-2) gene via
retroviral vector, there was a potent antimicrobial
activity which enhanced host antimicrobial defense.
THANK