Research Article | Open Access
Salivary Levels of IL-6 and IL-17 Could Be an Indicator of Disease Severity in Patients with Calculus Associated Chronic Periodontitis
Background/Purpose. Chronic periodontitis is an inflammatory disease of gums that causes loss of supporting structures of teeth, that is, gingiva, periodontal ligament, cementum, and alveolar bone. Levels of various cytokines in the serum, gingival tissues, and gingival crevicular fluid in patients with chronic periodontitis have been studied, but limited data are available on the level of cytokines in saliva. Therefore, a study was designed to determine levels of salivary IL-6 and IL-17 in patients with calculus associated chronic periodontitis. Materials and Methods. It was a comparative, cross-sectional study that is comprised of 41 healthy controls and 41 calculus associated chronic periodontitis patients (CP patients). According to the degree of attachment loss, CP patients were subcategorized as mild (CAL 1-2 mm), moderate (CAL 3-4 mm), and severe (CAL > 5 mm) forms of periodontitis. Salivary levels of IL-6 and IL-17 were determined using enzyme-linked immunosorbent assay (ELISA) technique. Data was analyzed using SPSS 20.0. Results. Between healthy controls and CP patients (moderate and severe disease), a statistically significant difference was observed in the concentrations of IL-6 and IL-17. In CP patients, the highest mean ± SD of salivary IL-6 and IL-17 was observed in severe CP, followed by moderate and mild CP. Regarding level of IL-6, a statistically significant difference was observed between mild and severe disease and between moderate and severe subcategories of CP patients. Similarly, statistically significant difference was observed in the level of IL-17 between mild and moderate, mild and severe disease, and moderate and severe disease. Conclusion. The levels of salivary IL-6 and IL-17 were increased significantly in calculus associated CP patients as compared to healthy controls and these levels increased with the progression of CP. Clinical Significance. Salivary levels of IL-6 and IL-17 may help in the subcategorization of CP.
Periodontal diseases are progressive and destructive inflammatory conditions that involve tooth supporting structures like gingiva, periodontal ligament, cementum, and alveolar bone. There are multiple risk factors for this disorder such as bacteria, host response, and genetic predisposition. It can manifest as localized or generalized, that is, involving single tooth or many teeth, respectively .
Chronic periodontitis (CP) leads to devastation of supporting structures of teeth, alveolar bone, periodontal ligament, pocket formation, gum recession, and eventually tooth loss. It can occur at any age but is more common in adults and is associated with dental plaque and calculus. Dental fillings, artificial crown, and diseases like diabetes may lead to disease progression .
Dental plaque can be supragingival or subgingival and it contains proliferating microorganisms, epithelial cells, leukocytes, and macrophages . Subgingival plaque extends into periodontal pocket and often contains Gram-negative organisms. Therefore, it is responsible for calculus formation, root caries, and slow progressive periodontal disease, while unattached plaque is responsible for periodontal destruction. Mineralization of dental plaque results in dental calculus .
Oral cavity is colonized by more than 600 species of microorganisms, but only a few of them are pathogenic and cause disease. Most of these microorganisms are Gram negative, for example, P. gingivalis, Treponema denticola, and Tannerellaforsythia with different virulence factors such as lipopolysaccharides (LPS) that induce host immune response by activating multiple cell signaling cascades via Toll-like receptors (TLRs), which may trigger CP . The progression of periodontal inflammation is associated with an increase in microorganisms in subgingival plaque [5, 6].
In periodontitis, microbial pathogens increase inflammatory infiltrate, that is, T-cells, B-cells, macrophages, and neutrophils with concomitant increase in inflammatory cytokines like IL-1, IL-11, IL-6, TNF-β, TNF-α, TGF-β, kinins, and thrombin . In chronic inflammation, proinflammatory cytokines like IL-1, TNF-γ, IFN-α, and IL-6 play significant role in bone resorption by activating osteoclasts [8–10].
Interleukin-17 (IL-17) is a proinflammatory cytokine secreted by Th-17 cells. It is a powerful activator of neutrophils as it regulates G-CSF and its receptor and chemokine expression . It contributes in the pathogenesis of various autoimmune and inflammatory diseases [12, 13]. It regulates antimicrobial activity of molecules like calgranulins, β-defensins, and mucin . Its increased level has been documented in CP [14, 15]. Although periodontal infection (P. gingivalis) induces IL-17, the protective role of IL-17 against bone destruction has also been suggested [12, 16].
IL-6 is produced by many cells in response to LPS and it has both proinflammatory and anti-inflammatory roles. It is involved in inflammatory, regenerative, metabolic, and neural processes . In CP, increased level of IL-6 in gingival crevicular fluid  and its significant reduction in serum after nonsurgical treatment of CP has been reported . However, no significant differences in the levels of various cytokines in saliva of CP patients and healthy individuals were suggested .
In CP, most of the studies have investigated level of cytokines in serum or gingival crevicular fluid. The current study was designed to determine level of IL-6 and IL-17 in the saliva of patients with calculus associated CP.
2. Materials and Methods
This comparative, cross-sectional study was carried out in the Department of Immunology, University of Health Sciences (UHS), Lahore, after approval by Ethical Review Committee of UHS. Healthy individuals as controls and calculus associated CP patients from 18 to 55 years were recruited from Punjab Dental Hospital Lahore and Sheikh Zaid Hospital Lahore. Forty-one healthy controls and the same number of calculus associated CP patients were included. Pregnant females and patients with malignancy, autoimmunity, infectious disease, edentulous, xerostomia, or traumatic oral ulcers, having prosthesis or dentures, were excluded. Patients with periodontitis other than calculus associated CP, for example, aggressive periodontitis, periodontitis associated with systemic diseases, and necrotizing periodontitis, were excluded. After an informed consent was obtained, 3–5 ml of saliva was collected from each subject as suggested by Prakasam and Srinivasan (2014)  that was transported in ice bag to the Department of Immunology, UHS, Lahore.
Periodontal examination of each subject was performed by the consultant dental surgeon. For the selected teeth, probing depth, clinical attachment loss, and bleeding on probing were recorded. CP patients with minimum ten natural teeth, attachment loss of ≥1 mm in >30% of the sites examined, presence of abundant calculus, and radiographic confirmation of bone loss were included. Stages of CP were determined on the basis of criteria used by Wiebe and Putnins (2000) . On the basis of clinical attachment loss (CAL), CP patients were subcategorized as mild (CAL 1-2 mm) (10 patients), moderate (CAL 3-4 mm) (16 patients), and severe (CAL > 5 mm) (15 patients) . The samples were centrifuged at 1217.7 for 10 minutes and supernatant containing purified saliva was separated and kept at −80°C until cytokines were estimated by ELISA technique .
3. Statistical Analysis
The data was entered and analyzed using IBM SPSS 20.0. Mean ± SD was calculated for quantitative variables and qualitative variables were expressed as frequencies, percentages, and graphs. Kruskal-Walis test to normally distributed data and Post Hoc Tukey test to observe group means differences were applied. A value of ≤0.05 was considered as statistically significant.
Highest mean ± SD of age was observed in CP patients compared to healthy controls and on comparison, there was no statistically significant difference between healthy controls and CP patients . Demographic data of the studied subjects is presented in Table 1. Mean ± SD of IL-6 and IL-17 was high in CP patients compared to healthy controls with a statistically significant difference ( in each) (Table 2).
Statistically significant , CP = chronic periodontitis, M = male, F = female, and = number.
Statistically significant ; CP = chronic periodontitis.
Mean ± SD of IL-6 and IL-17 was highest in the severe periodontitis followed by moderate and mild CP, while the lowest concentration was in healthy controls. An increase of mean ± SD of IL-6 and IL-17 was observed with the progression of disease, that is, from mild to severe CP (Table 3).
Statistically significant , CP = chronic periodontitis, 1Healthy and mild, 2Healthy and moderate, 3Healthy and severe, 4Mild and moderate, 5Mild and severe, 6 Moderate and severe.
While comparing the levels of IL-6 in healthy subjects with the subcategories of CP patients, a statistically significant difference was observed with moderate and severe form of CP ( and <0.001, resp.) (Table 3). Regarding levels of IL-17, a statistically significant difference was observed between healthy subjects and CP patients with moderate and severe form of disease (Table 3)
CP represents long lasting inflammation of periodontal tissues where microbes are a major etiological factor and the hallmark of periodontal diseases is bone loss. Virulence factors produced by P. gingivalis such as Arg- and Lys-gingipain proteinases are key factors for host tissue invasion which leads to activation of immune-inflammatory processes. Subsequently, various molecules (proteases, MMPs, cytokines, etc.) are activated leading to destruction of connective tissue attachment and alveolar bone loss . It has been documented that, in humans, production of IL-6 and matrix metalloproteinase-1 (MMP-1) is upregulated by periodontal ligament (PDL) fibroblasts. Therefore, IL-17 induces production of MMP-1 both directly and indirectly by increasing IL-6 production, thus resulting in the destruction of collagens in the periodontal ligament .
In the current study, female predominance was observed and it is in agreement with previous studies where researchers investigated the relationship between proinflammatory cytokines in saliva and periodontal status . Mean ± SD of age of CP patients was high compared to healthy controls which is not in concordance with the Romanian study that reported high mean ± SD of age of healthy individuals compared to CP patients that could be due to the age range of the patients as they included > than 18 years of age, while in the current study adults were enrolled .
Th17 cell differentiation and expansion is directed by IL-6 and other cytokines. IL-17A, the proinflammatory cytokine secreted by the activated Th17, has been involved in a number of human autoimmune and inflammatory diseases . It also regulates molecules with direct antimicrobial activity like calgranulins, β-defensins, and mucin . It has been reported that IL-17 is involved in bone destruction by inducing of RANKL production . Many studies assessed the role of IL-17 in chronic periodontitis but still it is an open question whether IL-17 stimulates bone resorption or protects bone in chronic periodontitis although increasing evidence indicates increased IL-17 expression in both chronic and aggressive periodontitis . In the present study, mean ± SD of IL-17 in saliva was high in CP compared to healthy controls and it gradually increased with the severity of disease. Corroborating our data, previous studies have documented increased level of IL-17A in saliva, serum, and gingival crevicular fluid (GCF) in periodontitis compared to healthy subjects and also reported important role of IL-17 in gingival inflammation and bone loss [21, 29–32].
Besides the destructive role of IL-17 in chronic periodontitis, the protective role of IL-17 against pathogen associated bone destruction has also been reported. IL-17 enhances bone destruction in rheumatoid arthritis, but IL-17 signaling through IL-17 receptor exerts bone protective effect on periodontal bone loss because it provides antimicrobial defense against periodontal organisms like P. gingivalis  and decreases alveolar bone resorption due to defective neutrophil chemotaxis .
IL-6 is involved in antigen-specific immune responses and inflammatory reactions. IL-6, CXCL-8, and TNF-α may have an important role in the pathogenesis of chronic periodontitis and detection of these cytokines may be beneficial to identify periodontitis patients. IL-6 along with IL-1β and IL-23 is required for the initiation, amplification, and stabilization stages of Th17 cell differentiation .
In the current study, salivary IL-6 was high in CP compared to healthy controls. Studies have reported similar results [18, 34–36]. The integrity of bone tissue depends on the balance between bone formation by osteoblasts and bone resorption by osteoclasts. Therefore, several proinflammatory cytokines were identified as key molecules contributing to the destruction of periodontal tissues, like IL-1, TNF-, IFN-α, and IL-6. Thus, it is possible that high level of IL-6 in the patients may have acted as a osteoclastogenic factor by inducing the local osteoclast differentiation that could terminate in bone resorption. IL-6 induced by IL-17F or IL-17A may play a potential feedback loop in the pathogenesis of chronic periodontitis. However, whether it is a positive or negative feedback loop, it is still arguable .
Salivary levels of IL-6 and IL-17 were significantly higher in patients with calculus associated CP compared to healthy subjects. These cytokines increased as the disease progressed from mild to moderate and severe form. Therefore, we can conclude that the salivary level of IL-6 and IL-17 may help in the subcategorization of periodontitis.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
- M. G. Newman, H. H. Takei, and P. R. Kliokkevold, Carranza FA. Carranzas Clinical Periodontology, Elsevier, New Delhi, Indaia, 10th edition, 2007.
- R. Genco and R. C. Williams, “RC: Periodontal disease and overall health: A clinicians guide,” in Professional Audience Communication, Inc, Pa, USA, 2010.
- S. Reddy, Essentials of Clinical Periodontology and Periodontics, Jaypee Brothers Medical Publishers (P) Ltd., 2nd edition, 2011.
- Q. Li, M. S. Valerio, and K. L. Kirkwood, “MAPK Usage in Periodontal Disease Progression,” Journal of Signal Transduction, vol. 2012, pp. 1–17, 2012.
- NY. Yang, Q. Zhang, and Li. JL, “Progression of periodontal inflammation in adolescents is associated with increased number of Porphyromonasgingivalis, Prevotellaintermedia, Tannerellaforsytensis and Fusobacteriumnucleatum,” International Journal of Paediatric Dentistry, pp. 226–233, 2014.
- J. Mysak, S. Podzimek, P. Sommerova et al., “Review article., Porphyromonasgingivalis, Major Periodontopathic Pathogen Overview,” Journal of Immunology Research, 2014.
- S. A. Hienz, S. Paliwal, and S. Ivanovski, “Mechanisms of bone resorption in periodontitis,” Journal of Immunology Research, vol. 2015, Article ID 615486, 10 pages, 2015.
- D. M. Isaza-Guzmán, N. Cardona-Vélez, D. E. Gaviria-Correa, M. C. Martínez-Pabón, M. C. Castaño-Granada, and S. I. Tobón-Arroyave, “Association study between salivary levels of interferon (IFN)-gamma, interleukin (IL)-17, IL-21, and IL-22 with chronic periodontitis,” Archives of Oral Biolog, vol. 60, no. 1, pp. 91–99, 2015.
- A. Cekici, A. Kantarci, H. Hasturk, and T. E. Van Dyke, “Inflammatory and immune pathways in the pathogenesis of periodontal disease,” Periodontology 2000, vol. 64, no. 1, pp. 57–80, 2014.
- T. A. Da Costa, M. J. B. Silva, P. M. Alves et al., “Inflammation Biomarkers of Advanced Disease in Nongingival Tissues of Chronic Periodontitis Patients,” Mediators of Inflammation, vol. 2015, Article ID 983782, 2015.
- S. L. Gaffen, “An overview of IL-17 function and signaling,” Cytokine, vol. 43, no. 3, pp. 402–407, 2008.
- J. J. Yu, M. J. Ruddy, G. C. Wong et al., “An essential role for IL-17 in preventing pathogen-initiated bone destruction: recruitment of neutrophils to inflamed bone requires IL-17 receptor-dependent signals,” Blood, vol. 109, no. 9, pp. 3794–3802, 2007.
- D. Lin, L. Li, and Y. Sun, “IL-17 regulates the expressions of RANKL and OPG in human periodontal ligament cells via TRAF6/TBK1-JNK/NF-κB pathways,” The Journal of Immunology, 2014.
- A. Mitani, W. Niedbala, T. Fujimura et al., “Increased expression of interleukin (IL)-35 and IL-17, but not IL-27, in gingival tissues with chronic periodontitis,” Journal of Periodontology, vol. 86, no. 2, pp. 301–309, 2015.
- T. Oda, H. Yoshie, and K. Yamazaki, “Porphyromonas gingivalis antigen preferentially stimulates T cells to express IL-17 but not receptor activator of NF-κB ligand in vitro,” Oral microbiology and immunology, vol. 18, no. 1, pp. 30–36, 2003.
- J. Goswami, N. Hernández-Santos, L. A. Zuniga, and S. L. Gaffen, “A bone-protective role for IL-17 receptor signaling in ovariectomy-induced bone loss,” European Journal of Immunology, vol. 39, no. 10, pp. 2831–2839, 2009.
- J. Scheller, A. Chalaris, D. Schmidt-Arras, and S. Rose-John, “The pro- and anti-inflammatory properties of the cytokine interleukin-6,” Biochimica et Biophysica Acta (BBA), vol. 1813, no. 5, pp. 878–888, 2011.
- K. D. Tymkiw, D. H. Thunell, G. K. Johnson et al., “Influence of smoking on gingival crevicular fluid cytokines in severe chronic periodontitis,” Journal of Clinical Periodontology, vol. 38, no. 3, pp. 219–228, 2011.
- SY. Zhou, XQ. Duan, R. Hu, and XY. Ouyang, “Effect of non-surgical therapy on serum levels of TNF-a, IL-6 and C-reactive protein in periodontitis subjects with stable coronary heart disease,” Chin J Dent Res, vol. 16, no. 2, pp. 145–151, 2013.
- R. P. Teles, V. Likhari, S. S. Socransky, and A. D. Haffajee, “Salivary cytokine levels in subjects with chronic periodontitis and in periodontally healthy individuals: a cross-sectional study,” Journal of Periodontal Research, vol. 44, no. 3, pp. 411–417, 2009.
- S. Prakasam and M. Srinivasan, “Evaluation of salivary biomarker profiles following non-surgical management of chronic periodontitis,” Oral Diseases, vol. 20, no. 2, pp. 171–177, 2014.
- C. Wiebe and E. Putnins, “The periodontal disease classification system of the American Academy of Periodontology- an update,” Journal of the Canadian Dental Association, vol. 66, no. 11, pp. 594–597, 2000.
- M. Shibata, Y. Shintaku, K. Matsuzaki, and S. Uematsu, “The effect of IL-17 on the production of proinflammatory cytokines and matrix metalloproteinase-1 by human periodontal ligament fibroblasts,” Orthodontics & Craniofacial Research, vol. 17, no. 1, pp. 60–68, 2014.
- K. Shyu, C. Choy, D. C. Wang et al., “Change of scaling-induced proinflammatory cytokine on the clinical efficacy of periodontitis treatment,” The Scientific World Journal, vol. 2015, pp. 1–7, 2015.
- A. Monea, R. Gruber, and N. Elod, “Salivary and serum levels of TNF-a and IL-6 in a sample of Romanian adult subjects with type 2 diabetes mellitus and periodontal disease,” European Scientific Journal, vol. ESJ10, no. 9, pp. 350–359, 2014.
- Z. Luo, H. Wang, J. Chen, J. Kang, Z. Sun, and Y. Wu, “Overexpression and Potential Regulatory Role of IL-17F in Pathogenesis of Chronic Periodontitis,” Inflammation, vol. 38, no. 3, pp. 978–986, 2015.
- G. P. Garlet, “Destructive and protective roles of cytokines in periodontitis: a re-appraisal from host defense and tissue destruction viewpoints,” Journal of Dental Research, vol. 89, no. 12, pp. 1349–1363, 2010.
- Y. Lee, “The role of interleukin-17 in bone metabolism and inflammatory skeletal diseases,” BMB Reports, vol. 46, no. 10, pp. 479–483, 2013.
- R. A. Awang, D. F. Lappin, A. MacPherson et al., “Clinical associations between IL-17 family cytokines and periodontitis and potential differential roles for IL-17A and IL-17E in periodontal immunity,” Inflammation Research, vol. 63, no. 12, pp. 1001–1012, 2014.
- C. R. Cardoso, G. P. Garlet, and G. E. Crippa, “Evidence of the presence of T helper type 17 cells in chronic lesions of human periodontal disease,” Oral microbiology and immunology, vol. 24, no. 1, pp. 1–6, 2009.
- T. A. Da Costa, M. J. B. Silva, P. M. Alves et al., “Inflammation biomarkers of advanced disease in nongingival tissues of chronic periodontitis patients,” Mediators of Inflammation, vol. 2015, Article ID 983782, 2015.
- W.-C. Cheng, F. J. Hughes, and L. S. Taams, “The presence, function and regulation of IL-17 and Th17 cells in periodontitis,” Journal of Clinical Periodontology, vol. 41, no. 6, pp. 541–549, 2014.
- E. AlShwaimi, E. Berggreen, H. Furusho et al., “IL-17 receptor a signaling is protective in infection-stimulated periapical bone destruction,” The Journal of Immunology, vol. 191, no. 4, pp. 1785–1791, 2013.
- F. Javed, H. B. Ahmed, A. Saeed, A. Mehmood, and C. Bain, “Whole salivary interleukin-6 and matrix metalloproteinase-8 levels in patients with chronic periodontitis with and without prediabetes,” Journal of Periodontology, vol. 85, no. 5, pp. e130–e135, 2014.
- P. P. Costa, G. L. Trevisan, G. O. Macedo et al., “Salivary interleukin-6, matrix metalloproteinase-8, and osteoprotegerin in patients with periodontitis and diabetes,” Journal of Periodontology, vol. 81, no. 3, pp. 384–391, 2010.
- A. Cutando, J. Montero, R. G.-D. Diego, M.-J. Ferrera, and A. Lopez-Valverde, “Effect of topical application of melatonin on serum levels of C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) in patients with type 1 or type 2 diabetes and periodontal disease,” Journal of Clinical and Experimental Dentistry, vol. 7, no. 5, pp. e628–e633, 2015.
- J. Wang, R. J. Homer, Q. Chen, and J. A. Elias, “Endogenous and exogenous IL-6 Inhibit aeroallergen-induced Th2 inflammation,” The Journal of Immunology, vol. 165, no. 7, pp. 4051–4061, 2000.
Copyright © 2018 Husniah Batool et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.