Total Salivary Immunoglobulin A Determination Before and After Non-Surgical Periodontal Treatment in Patients with Aggressive Periodontitis

Introduction Aggressive periodontitis (AP) is an inflammatory disease with rapid periodontal attachment and bone loss in healthy individuals. It exists as Localized aggressive periodontitis (LAP) and Generalized aggressive periodontitis (GAP). They raise total salivary immunoglobulin A(IgA) levels. This study aimed at determining IgA in AP patients compared with controls before and after non-surgical debridement. Materials and Methods Consented 37 Ghanaians aged 20-50 years (19 cases and 18 controls), were recruited. Questionnaire was used and periodontal examination was done with Orthopantomogram taken. Unstimulated saliva was collected before and after non-surgical periodontal therapy (NSPT). Centrifuged Samples were stored at 800C. Human IgA ELISA kits were used to determine J Surg Res 2022; 5 (2): 322-331 DOI: 10.26502/jsr.10020225 Journal of Surgery and Research Vol. 5 No. 2 June 2022. [ISSN 2640-1002] 323 levels. Results The mean concentration of total salivary IgA before treatment for the cases was 90.3 ± 33.1 (μg/ml) and controls was 92.0±29.4 (μg/ml). After treatment, the concentration of IgA among the cases was 90.5±31.7 (μg/ml) and controls was 84.6±31.7 (μg/ml). There was no significant difference in the mean IgA values between cases and controls as well as before and after treatment (P>0.05). Conclusion There was no significant difference in the total salivary IgA levels in participants with AP and the control group before and after treatment. But there was a significant drop in the total IgA levels for the LAP participants after treatment.


Introduction
Aggressive periodontitis is an inflammatory disease characterized by rapid periodontal attachment loss and bone destruction in otherwise systemically healthy individuals [1]. Individuals with this disease have a rapid rate of disease onset and progression. These patients can be clinically differentiated by the extent of destruction and by age [2]. There are two clinical varieties of Aggressive periodontitis (AP), the Localized aggressive periodontitis (LAP) and the Generalized aggressive periodontitis (GAP). The LAP disease usually has an age onset at about puberty and is clinically characterized by interproximal attachment loss on at least two permanent teeth, one of which is a first molar, and involving no more than two other teeth, aside from the first molars and incisors [2,3].
The GAP disease usually affects individuals under the age of thirty, even though older patients may be affected [2]. Clinically, GAP is characterized by generalized interproximal attachment loss affecting at least three permanent teeth other than first molars and incisors [2]. Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis bacteria have been associated with both the localized and generalized aggressive forms of periodontitis in teenagers and young African adults [3,4]. It has been suggested that effective treatment of patients with AP requires nonsurgical, surgical or both treatments with or without antibiotics. A study has shown that mechanical treatment combined with antibiotic treatment, provides better clinical outcomes in this group [5]. Arowojolu and Nwokorie [6] recorded an AP prevalence of 0.8-1.6% in Nigerian teenagers and young adults. Harley and Floyd [7] also reported a prevalence of 0.8% among Nigerian teenagers with AP. In the United States, a national survey of adolescents aged 14 to 17 years reported that 0.53% had LAP and 0.13% had GAP [8]. The report also revealed that blacks were at much higher risk than whites for both forms of the disease, and that male teenagers were more likely to have GAP than female adolescents.
Saliva, an intraoral fluid, is secreted by the three pairs of major salivary glands, the parotid, submandibular and sublingual and by numerous minor salivary glands situated under the tongue, buccal mucosa and the palate except the anterior part of the hard palate and gingivae. These minor glands are said to number between 450 and 750 [9]. Saliva has been used in the past few decades as a diagnostic fluid in the following; hereditary diseases, oral diseases including periodontal disease, autoimmune diseases, malignancies and in infections, as well as in monitoring levels of hormones and drugs, bone turnover, biologic markers and in providing forensic evidence [10]. Saliva contains locally produced microbial and host response mediators, as well as systemic serum markers that could aid the diagnosis of periodontal and other diseases [11]. The pathogenesis of periodontitis is reasonably well established at the clinical and microscopic levels, but the details of the specific mechanisms are still being defined [12]. Bacterial plaque is essentially what triggers periodontitis and the clinical signs that follow are a result of the activated inflammatory and immune responses rather than from the direct effect of the bacteria themselves [12]. The relationship between saliva and the pathogenesis of periodontal disease is, therefore, indirect. Salivary markers that have been studied as potential diagnostic tests for periodontal disease include proteins of host origin such as enzymes and immunoglobulins, phenotypic markers, host cells, hormones (especially cortisol), bacteria and bacterial products, ions and volatile compounds [11]. Host-derived enzymes and other inflammatory mediators originating from gingival crevices appear to hold promise as salivary diagnostic aids in periodontal disease [11]. The use of proteomic biomarkers, especially IgA, have been considered to have good diagnostic promise through the determination of their levels in saliva especially in the presence of oral infections, when compared to other genomic and microbiological markers [5]. The various biomarkers which exist in saliva can be classified into: Proteomic, Genomic and Microbiological markers [13]. This study focuses on the use of the salivary biomarker, IgA to determine the presence or absence of LAP or GAP.

Aim and Objectives
The aim of this study was to determine the level of IgA, a salivary proteomic biomarker, in participants with AP and in a group of individuals without the disease, before and after non-surgical periodontal therapy. The following specific objectives were set for the study; to determine the level of IgA in participants with aggressive periodontitis as well as a control group, to determine the level of IgA in participants with AP before and after non-surgical periodontal therapy (NSPT) and finally to determine the level of this biomarker in the localized and generalized forms of aggressive periodontitis before and after treatment.

Methods
The study was an interventional prospective design.

Results
The demographic characteristics of participants and the various subgroups are presented in table 1 below. The mean age of the GAP was 33.80 ± 8.93, LAP was 32.11 ± 8.07 and controls was 31.39 ± 8.96 years.
There were no significant differences in the demographic characteristics between cases and controls.      [17].

Participant category Demographics GAP n (%) LAP n (%) Controls n (%) Total N (%) P-Value Gender
The second source of IgA in saliva is the plasma IgA entering the oral cavity by gingival crevicular fluid [17]. Total saliva is suitable for evaluating the overall humoral immune response in the oral cavity in patients with chronic diseases such as AP especially the generalized disease type pattern [17]. The method developed for quantification of IgA was sensitive enough to measure IgA antibodies in the saliva samples. The concentration of IgA before treatment for the cases was slightly increased after treatment. For the controls there was a slight drop of IgA after treatment but in both groups the changes were not significant ( The initial concentration of total IgA among the cases in my study was lower than that recorded in the controls. In the periodontal pocket, there are numerous antigens from oral microorganisms which can modulate the humoral host defense by many mediators [26,27]. These data pose a strong point to explain contradictory reports on the relationship periodontal disease and IgA antibodies in saliva [18,28].
Differences in antigen load might also help to explain immune tolerance [28,29] and failure of induction of significant levels of salivary antibodies after oral ingestion of an antigen [30], or after recolonization of the periodontal region [26]. To solicit immune response, a certain antigen load must be detected. The immune responses may differ due to the antigen load that may lead to the production of the IgA.

Recommendations
The study showed a significant drop in IgA among LAP as a response to treatment. Prompt intervention is recommended after LAP is detected to improve the overall outcome and better prognosis of treatment.
Numerous markers in saliva have been used as prognostic, diagnostic and therapeutic monitoring indicators for periodontal disease with high specificity and sensitivity. Innovative techniques such as the labon-a chip microfluidic devices have the potential to determine the periodontal disease risk profile of patients, predict disease activity and response to therapeutic intervention. Although challenges remain, the use of saliva as a diagnostic prognostic fluid appears promising for future application to diagnose periodontal disease.

Conclusion
There was no significant difference in the total salivary IgA levels in participants with AP and the control group before and after treatment however, there was a significant drop in the total IgA levels for the LAP