nonsurgical periodontal therapy in chronic … and immunological evaluation of Coenzyme Q10 as an...

Attia A M, Edrees M F, Alghriany A. Clinical and immunological evaluation of Coenzyme Q10 as an adjunct to

nonsurgical periodontal therapy in chronic periodontitis patients. J Periodontal Med Clin Prac 2016;03: 128- 140

1 2 3Dr. Alaa Moustafa Attia , Dr. Mohamed Fouad Edrees , Dr. Alzahraa Alghriany

Clinical and immunological evaluation of Coenzyme Q10 as an adjunct to nonsurgical periodontal

therapy in chronic periodontitis patients

Original Research

Affiliation

1. Dr. Alaa Moustafa Attia- Associate Professor Oral Medicine and Periodontology, Faculty of

Dentistry, Al-Azhar University (Assiut Branch), Egypt and Umm Alqura University, KSA.

2. Dr. Mohamed Fouad Edrees- Lecturer Oral Medicine and Periodontology, Faculty of Dentistry, Al-

Azhar University (Assiut Branch).

3. Dr. Alzahraa Alghriany- Assistant Lecturer Oral Medicine and Periodontology, Faculty of Dentistry,

Assuit University.

Corresponding Author:

Name: Dr Alaa Moustafa Attia

Address: College of Dentistry, Umm Alqura University, Makah, Saudia Arabia

Email Address: [email protected]

128

Abstract:

Background:Periodontal pathogens can induce

overproduction of free radicals and reactive

oxygen species (ROS)that may increase

periodontal tissue breakdown. Coenzyme Q10

(CoQ10) serves as potent endogenous antioxidant

that act as a scavenger to ROS and may be suppress

the periodontal inflammation.

Aim:The present study was aimed to evaluate the

clinical and immunologic effects of intrapocket

application of CoQ10 as an adjunct to nonsurgical

periodontal therapy.

Materials and methods:Twenty eight mild to

moderate chronic periodontitis patients with age

ranged from 29 to 46 years. All individuals were

carried out to scaling and root planning (SRP) and

classified into group 1 (G1, treated by SRP only)

and group 2 (G2, treated by COQ10 gel plus SRP).

Clinical parameters; plaque index (PI), gingival

index (GI), pocket depth (PD) and clinical

attachment loss (CAL), in addition to gingival

crevicularfluid (GCF) samples were obtained at

baseline and 30days after treatment. Tumor

necrosis factor- (TNF-) levels were evaluated by

ELISA technique at both time intervals of

periodontal therapy.

Results: Clinical evaluation of both groups

revealed a high significant improvement in all

parameters at baseline and 30 days of treatment

(P≤0.01). Whereas, more clinical improvement in

G2 at 30 days compared to G1, but the difference

was non-significant (P≥0.05). TNF- levels were

significantly high reduced at 30 days versus to

baseline in both groups (P≤0.01), in comparison

between groups at 30 days TNF- levels reduced in

G2 compared to G1, but there is no significant

difference (P≥0.05).

Conclusions:Topical application of CoQ10 as an

Vol-III, Issue - III, Sep-Dec 2016

Clinical and immunological evaluation of Coenzyme Q10 as an adjunct to nonsurgical periodontal therapy in chronic periodontitis patients

adjunct to non-surgical periodontal therapy

improve the clinical and immunologic findings, but

it not considered a significantadjunct modality for

periodontal therapy. Further studies needed to

clarify clinical and immunological outcomes.

Keywords: chronic periodontitis, non surgical

therapy, host response

Introduction:

Chronic Periodontitis is a term used to describe an

inflammatory process, initiated by the plaque

biofilm, that leads to loss of periodontal attachment

to the root surface and adjacent alveolar bone and

which ultimately results in tooth loss. It can be

defined as a chronic infectionthat results from the

interaction of periodontopathogenic bacteria and 1host inflammatory immune responses.

Coenzyme Q10 (CoQ10) belongs to a homologous

series of compounds that share a common

benzoquinone ring structure but differ in the length

of the isoprenoid side chain. In humans and a few

other mammalian species, the side chain is

comprised of 10 isoprene units. Also, CoQ10 is 2similar to vitamin K in its chemical structure.

CoQ10 is considered as an antioxidant, so that it is

essential for the health of virtually all human tissue 3 and organs. Itis also known to play a crucial role in

the generation of adenosine triphosphate (ATP)

and cellular respiration, and act as a primary

scavenger of free radicals (FRs) and reactive 4oxygen species (ROS).

Healing and repair of periodontal tissues requires

efficient energy production, which depends in part

on an adequate supply of CoQ10. Gingival biopsies

revealed subnormal tissue levels of CoQ10 in 60%

to 96 % patients with periodontal disease and low

levels of CoQ10 in leukocytes in 86% of cases.

These findings indicate that periodontal disease is 5frequently associated with CoQ10 deficiency.

Many clinical trials with oral administration of

CoQ10 to patients with periodontal disease have

been conducted. The results have shown that oral

administration of CoQ10 increases the

concentration of CoQ10 in the diseased gingiva

and effectively suppresses advanced periodontal 6,7,8inflammation and periodontal microorganisms.

Topical application of CoQ to the periodontal 10

pocket was evaluated with and without subgingival

mechanical debridement. In the first three-week

period, significant reduction in gingival crevicular

fluid flow, probing depth and attachment loss were

found and significant improvements in modified

gingival index, bleeding on probing and peptidase

activity derived from periodontopathic bacteria

were observed only at experimental sites which

treated CoQ10 with subgingival mechanical 9debridement.

A study on clinical evaluation of topical application

of the Perio-Q gel (Coenzyme Q10) in chronic

periodontitis patients.The results represented that

intra-pocket gel application in combination with

scaling and root planning (SRP) showed

significant reduction (P<0.05) for plaque index

(PI), gingival index (GI), gingival bleeding index

(GBI), and clinical attachment loss (CAL) in

comparison to intra-pocket gel alone. On the other

hand, sub-gingival mechanical debridement only

and with CoQ10 (Perio-Q gel)showed almost

similar clinical results without any statistically 10 significant differences. Moreover, coenzyme Q10

can be said to have a beneficial effect clinically on

gingivitis and slight periodontitis when used as 11adjunct to scaling and root planning.


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Raut and Sethi 2016 performed a comparative

study on the efficacy of Coenzyme Q10 and tea tree

oil gel as an adjunct to scaling and root planing in

the treatment of chronic periodontitis. They

concluded that Coenzyme Q10 and tea tree oil gel

proved to be effective in the treatment of chronic 12periodontitis.

TNF-α is an proinflammatory cytokine that plays a

role in the development and maintenance of

inflammatory diseases, its mediating effects on the

development, progress, and maintenance of 13periodontal diseases would be expected to occur.

The effect of oral administration of coenzyme Q10

on the levels of tumor necrosis factor-α(TNF-α)

and interleukin-10 (IL-10) in gingival tissue of

experimental periodontitis in rats was studied by.

They reported that Coenzyme Q10 inhibits the

expression of TNF-α and promotes the expression

of IL-10 in periodontal tissues of experimental

periodontitis rats. Coenzyme Q10 may play a role 14in treating periodontitis.

Hence, the aim of the present study was to evaluate

the intrapocket application of Coenzyme Q10 in

nonsurgical periodontally treated chronic

periodontitis patient to assess of clinical outcomes

and the changes in gingival crevicular fluid (GCF)–

TNF- levels.

Materials and methods:

Patients:Twenty eight patients of both sex (18

females and10 males) ranged in age from 29-46

years with a mean of 38 ± 60 years with mild to

moderate chronic periodontitis. All subjects were

selected from patients attending at the out-patient

clinic, Oral Medicine and Periodontology

Department, Faculty of Dental Medicine, Al-Azhar

University, Assiut Branch. A clinical examination

was done to all patients participate in the study, and

patients gave their agreement.

All patients were categorized into two groups:

Group I: It includes 14 chronic periodontitis

patients were treated by conventional periodontal

therapy alone (scaling and root planning).

Group II: It includes 14 chronic periodontitis

patients were treated by conventional periodontal

therapy with intrapocket and topical application of

coenzyme Q 10.

Selection of patients: The inclusion criteria

include the following:

1- All subjects were free from any systemic

diseases according to the criteria of Modified 15 Cornell Medical Index.

2- All subjects were not receiving antibiotics and

non-steroidal anti-inflammatory for at least three

months prior to sample collection.

3- All subjects were non-smokers and cooperative.

4-All subjects were suffering from chronic

periodontitis with pocket depth not more than 6

mm and clinical attachment level (CAL) not more

than 4 mm.

5- All subjects were not subjected to previous

periodontal therapy during at least 6 months.

6- All subjects were not receiving vitamin

supplements. 7- All Subjects were not regularly

using mouth washes.

Periodontal examination: The periodontal

conditions were evaluated for all subjects for

baseline and 30 days using following parameters:

Plaque Index (PI), Gingival index (BI), Pocket 16-19depth (PD) and Clinical attachment loss (CAL).

Periodontal therapy:All individuals were carried

out to nonsurgical periodontal treatment include;

scaling and root planning (SRP) that done through

3 visits and the patient became maintained on

plaque control measures. Fig (1,3)


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GCF samples co1llection:GCF samples were

obtained from all patients. The site which showed

the highest probing depth and CAL (range 4-6 mm)

score was selected for GCF sampling. The teeth

selected for sampling was isolated with cotton roll,

and supragingival plaque was removed without

touching the marginal gingiva. The crevicular site

was then dried gently with an air syringe. Samples

of GCF were obtained before probing into the site

by placing paper point. Sterilized paper point size #

30was carefully inserted to the maximum depth of

the periodontal pocket and held in position for 30 20second. The site that did not express any volume

of GCF, and paper point which were contaminated

with blood and saliva, were excluded from the

study. The collected GCF was immediately

transferred into plastic vials containing phosphate

buffer saline (PBS) and the samples were frozen at -

70° C till they were assayed for TNF-α.

Application of Coenzyme Q10:In patients of the

Group 2 after treatment with conventional

periodontal therapy the teeth isolated by cotton

rolls for intrapocket and topical application of ®Perio-Qgel (PERIOQ INC, Manchester, USA). It

is a mixture of CoQ10 in a vegetable oil base in a

ratio of 1:9. It is supplied as a pack of gel and was

stored at a temperature between 4°C and 8°C for

maintaining its shelf-life.

The periodontal pocket was dried with paper points

before subgingival administration of Perio- Q gel.

Intrapocketapplication of gel with bunted needle

tip, eating, spitting and drinking was restricted for 1

hour after application, teeth brushing and flossing

for 4 hours after application. Patients were

instructed for plaque control regimen, and the oral

hygiene instructions were provided at each

appointment. Topical application was repeated

after7 &15 days. (Fig 2)

TNF-α ELISA Assay:The samples were assayed

for TNF-α levels using commercially available

enzyme-linked immunosorbent assay (ELISA).

The assay was conducted according to the

manufacturer's instructions. Highly sensitive

ELISA kit (Shanghai Sunred Biological

Technology Co., Ltd) was used to detect the TNF-α

level in the sample of Human serum, blood plasma,

GCF and other related tissue liquid.

Statistical analysis:The results were recorded and

statistically analyzed using Statistical Package for

Social Science (SPSS Version 22, IBM Inc,

Chicago, IL, USA). P < 0.05 was defined as

statistically significant. The tables and figures were

done by Microsoft word 10.


131


Fig (1): Group 2 female 41 aged patient before treatment.

Fig (2): Intrapocket application of CoQ10 gel

Fig (3): Patient at 30 days after treatment


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Results:

Twenty eight patients suffering from mild to

moderate chronic periodontitis with probing

pocket depth 4-6 mm and CAL not more than 4

mm. The patients were divided into two groups:

Group 1 (G1) treated by scaling and root planning

(SRP) only, and group 2 (G2) treated by SRP plus

topical and intrapocket application of Coenzyme

Q10 gel. The clinical outcomes of periodontal

parameters and levels of GCF-TNF- were assessed

at baseline and 30 days after treatment.

Clinical findings:The results of mean values of PI,

GI, PD and CAL among both groups at baseline

and 30 days showed high statistically significant

differences (P<0.01). (Table 1, Fig 4,5)

Table 2 showed independent t-test for comparing

Means, Standard deviations, t values and p-values

among the two groups at baseline and 30 days

representing an improvement in G2 versus G1. The

statistical comparison revealed that no statistical

significant difference in G2 compared with

G1(P≥0.5).

TNF-alpha assaying: The mean values, Standard

deviations, t values and p-values records were

expressed in (Table 3, Fig 6).The statistical

comparisons between the baseline and 30 days for

both groups, the differences were highly

significant (P<0.01).

The statistical comparisons between both groups at

baseline and 30 days were revealed in (Table 3), the

statistical results were represented a reduction of

TNF- levels at 30 days in both groups. The levels of

TNF-more decreased in G2 than G1 at day 30,

while, the statistical differences were non-

significant (P≥0.5).


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Table (1): Demonstrate the statistical comparisons of clinical parameters at baseline

compared to 30 days in both groups.

G1= Treated by SRP only G2= Treated by SRP and CoQ10 application

PI= Plaque index GI= Gingival index

PD= Pocket depth CAL= Clinical attachment loss

** = High significant (P= 0.01)

Table (2): Show the statistical comparisons of clinical parameters at 30 days in both

studied groups.

G1 = Treated by SRP only G2= Treated by SRP and CoQ10 application

PI= Plaque index GI= Gingival index

PD= Pocket depth CAL- Clinical attachment loss

Baseline 30 Days T Value P Value

G1 PI 2.69±0.480 1.23±0.43 6.789 ٠.٠٠٠**

G I 2.36±0.275 0.85±0.16 23.739 0.000**

PD 4.27±0.436 3.55±0.39 5.269 0.000**

CAL 2.33±0.473 1.83±0.36 6.059 0.000**

G2 PI 2.68±0.470 1.15±0.37 10.690 0.000**

G I 2.32±0.249 0.80±0.32 13.056 0.000**

PD 4.22±0.364 3.32±0.30 7.831 0.000**

CAL 2.35±0.962 1.70±0.39 6.150 0.000**

Comparison Mean ± Sd T V alue P Value

PI G1 Vs G2

At 30 days

G1 (1.23±0.43)

G2 (1.15±0.37)

0.480 0.635

G I G1 Vs G2 G1 (0.85±0.16 )

G2 (0.80±0.32)

0.530 0.601

PD G1 Vs G2 G1 (3.55±0.39)

G2 (3.32±0.30)

1.696 0.103

CAL G1 Vs G2 G1 (1.83±0.36)

G2 (1.70±0.39)

1.032 0.312


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Table (3): Revealed the statistical comparisons of GCF - TNF-c � (Pg1k j' � jct cjq� gl �

both studied groups.

G1 = Treated by SRP only G2= Treated by SRP and CoQ10 application

** = High significant (P= 0.01)

Comparisons Mean±Sd T Value P Value

G1 Baseline 319.90±30.699 3.941 ٠.٠٠٢**

30 days 281.67±46.089

G2 Baseline 322.48±49.223 12.710 0.003**

30 days 278.85± 52.329

G2 Vs G1 Baseline 322.48±49.223 1.179 0.249

Baseline 319.9±30.699

G2 Vs G1 30 days 278.85± 52.329 - 2.702 0.062

30 days 281.67±46.089

Discussion:

Chronic Periodontitis is an inflammatory process,

initiated by the plaque biofilm, which leads to loss

of periodontal attachment to the root surface and

adjacent alveolar bone that result from the

interaction of perio-pathogens and host

inflammatory immune responses. It is considered

as one of the most common bacterial infection

worldwide with prevalence in mild to moderate

forms ranging from 13% to 57% in different

populations depending on oral hygiene and socio-21

economic status.

Periodontal pathogens can induce reactive oxygen

species (ROS) overproduction and thus may cause

collagen and periodontal cell breakdown. When

ROS are scavenged by antioxidants, there can be a

reduction of collagen degradation. Ubiquinol

(reduced form coenzyme Q10) serves as an

endogenous antioxidant which increases the

concentration of CoQ10 in the diseased gingiva and

effectively suppresses advanced periodontal 22inflammation.

A deficiency of CoQ10 at its enzyme sites in

gingival tissue may exist independently of and/or

because of periodontal disease. If a deficiency of

CoQ10 expressed in gingival tissue for nutritional

causes and independently of periodontal disease,

then the advent of periodontal disease could

enhance the gingival deficiency of CoQ10. In such

patients, oral dental treatment and oral hygiene

could correct the plaque and calculus, but not that

part of the deficiency of CoQ10 due to systemic

cause; therapy with CoQ10 can be included with

the oral hygiene for an improved treatment of this 23type of periodontal disease.

On exogenous CoQ10 administration, an increase

in the specific activity of this mitochondrial

enzyme was found in deficient patients. The

periodontal scores were also decreased concluding


136


that CoQ10 should be considered as an adjunct for

the treatment of periodontitis in current dental 6

practice.

The purpose of this study was to evaluate the

clinical and immunologic efficacy of topically

applied CoQ10 as an adjunct to basic conventional

therapy in treatment of mild to moderate chronic

per iodont i t i s .The local appl ica t ion of

chemotherapeutic agents into periodontal pocket

could be beneficial, both in terms of rising drug

concentration directly in the active site, and in 24

preventing systemic side effects.

About 20%–30% of all chronic periodontitis cases

do not respond favorably to conventional

periodontal treatment. Many factors may

contribute to that response, such as improper

removal of bacterial deposits and calculus, poor

plaque control, systemic conditions leading to an

impaired immune response, defective restorations,

occlusal dysfunction, periodontal-endodontic

involvement and others. In these cases, other 23

treatment approaches.

The present study aimed to use a new modality in

the periodontal therapy by topical application of

antioxidant as adjunctive to basic conventional

therapy to overcome the unresponsive cases

treated by conventional periodontal therapy alone.

In the resent study, there is a highly significant

reduction of clinical parameters in patients treated

by CoQ10 plus SRP and patient treated by SRP

only. These findings were in accordance to several 6,9,10,12

studies. On the other hand, when comparing

the mean values of clinical parameters after

treatment at 30 days between both groups more

reduction was seen in patients treated by CoQ10

but the statistical differences was non-significant.

This results in consistent with Sale et al. 26

2014 whereas our results in contrary with findings 10

of Hans et al. 2012 , they reported that intra-

pocket gel application in combination with SRP

showed significant reduction (P<0.05) for PI, GI,

GBI, and CAL in comparisons to sites treated by

SRP only.

Therefore, the effect of CoQ10 locally may be not

enough to provide a significant effect than SRP

only due to deficiency of CoQ10 in the periodontal

tissues, this concept is supported by some 6,23

studies.

The mean values of GCF- TNF-α levels compared

among both groups at baseline, and 30 days

showed marked decrease in level of TNF-α (highly

significant difference) in both groups at 30 days

when compared to the baseline this is in agreement 28

with the finding of Heralgi et al. 2011 who found

that the severity of inflammation increases, there is

a significant increase in the TNF-α level

suggesting that there is a direct relationship

between TNF-α level in GCF and periodontal

destruction proved thatTNF-α may be used as a

potential biochemical marker for assessment of

periodontal disease activity in chronic generalized

periodontitis.

29In a study done by Aditietet al.2013 determined

uric acid level as anantioxidant in patients with

chronic periodontitis treated with topical

antioxidants predicting that with the improvement

of the periodontal tissue inflammation the

antioxidants level will raise so uric acid level will

increase. This direct indicator may give a false

diagnosis with many factors as any food,drink or


137


any other supplement contains antioxidants that

may raise the GCF uric acid level. TNF-α was

chosen in this study as an indirect indicator to the

response of the periodontal tissue to CoQ10

antioxidant in treatment of chronic periodontitis.

TNF-α level was high at baseline before the

treatment with SRP and CoQ10gel this level was

decreased in further session with a significant

improvement in periodontal tissue and significant

difference in periodontal parameters confirmed that

there was increase in antioxidant level and its

balance with ROS was regain, these could be 30attributed to Chapple et al.2007 who mentioned

that loss of balance between ROS and antioxidant

defense has been implicated as an etiological factor

for periodontal diseases that may manifested as an

increase in oxidative stress or decrease in individual

antioxidant level.

For elucidation, why the levels of TNF- not

significantly reduced at 30 days of treatment in G2

(SRP plus CoQ10) versus G1 (SRP only), this may

be related to the deficiency of endogenous CoQ10

that reduce ROS which induce periodontal

inflammation. This explanation supported by an

experimental study on the effect of oral

administration of CoQ10 on the expression of

tumor necrosis factor-α and interleukin-10 in

gingival tissue of experimental periodontitis in 14rats. They concluded that the CoQ10 inhibits the

expression of TNF-α and promotes the expression

of IL-10 in periodontal tissues of experimental

periodontitis rats. Regarding to that result, the

CoQ10 may play a role in treating periodontitis.

Periodontal condition after oral applications of

CoQ10 with vitamin E was studied by Brzozowska 27et al. 2007 , they concluded that CoQ10 with

vitamin E had a beneficial effect on the periodontal

tissue.

Based on suggestion of previous studies, the oral

administration plus topical application of CoQ10

gel may be more beneficial to diseased periodontal

tissues through reducing the Levels of TNF- and

improvement the clinical outcomes of periodontal

therapy. So that, the systemic and local

adminstrition of CoQ10 may be may an interest

scientific point of research.

In conclusions, the topical application of CoQ10 as

an adjunct to non-surgical periodontal therapy

improve the clinical and immunologic outcomes,

but it not considered a strong modality for

periodontal therapy. Tumor Necrosis Factor- α

could be considered as strong laboratorymarker for

periodontal disease activity. In addition,

conventional periodontal therapy remains the

cornerstone as basicand initial periodontal therapy.

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Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript.Source of support: NIL

Copyright © 2014 JPMCP. 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.


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