Received: 16 September 2019 | Revised: 23 May 2020 | Accepted: 8 June 2020 DOI: 10.1111/jcpe.13330 CLINICAL PERIODONTOLOGY Differences in the periodontal microbiome of successfully treated and persistent aggressive periodontitis Luigi Nibali1,2 | Vanessa Sousa2 | Mehmet Davrandi3 | David Spratt3 | Qumasha Alyahya4 | Jose Dopico5 | Nikos Donos2 1Periodontology Unit, Centre for Host Microbiome Interactions, Faculty of Abstract Dentistry, Oral & Craniofacial Sciences, Aims: The primary aim of this investigation was to analyse the periodontal microbi- King’s College London, London, UK ome in patients with aggressive periodontitis (AgP) following treatment. 2Centre for Oral Immunobiology & Regenerative Medicine & Centre for Oral Methods: Sixty-six AgP patients were recalled on average 7 years after completion Clinical Research, Institute of Dentistry, of active periodontal treatment and had subgingival plaque samples collected and Barts and The London School of Medicine and Dentistry, Queen Mary University processed for 16S rRNA gene sequencing analyses. London, London, UK Results: Of 66 participants, 52 showed persistent periodontal disease, while 13 3Microbial Diseases Department, University College London Eastman Dental Institute, participants were considered as “successfully treated AgP” (no probing pocket London, UK depths >4 mm) and 1 was fully edentulous. Genera associated with persistent gen- 4 Periodontology Unit, University College eralized disease included Actinomyces, Alloprevotella, Capnocytophaga, Filifactor, London Eastman Dental Institute, London, UK Fretibacterium, Fusobacterium, Leptotrichia, Mogibacterium, Saccharibacteria [G-1], 5Periodontics Department, Universidad Selenomonas and Treponema. “Successfully treated” patients harboured higher pro- de Santiago de Compostela, Santiago de portions of Haemophilus, Rothia, and Lautropia and of Corynebacterium, Streptococcus Compostela, Spain and Peptidiphaga genera. Overall, patients with persistent generalized AgP (GAgP) Correspondence revealed higher alpha diversity compared to persistent localized AgP (LAgP) and sta- Luigi Nibali, Centre for Host Microbiome Interactions, King’s College London, London, ble patients (p < .001). Beta diversity analyses revealed significant differences only UK. between stable and persistent GAgP groups (p = .004). Email: [email protected] Conclusion: Patients with persistent AgP showed a more dysbiotic subgingival bi- Funding information ofilm than those who have been successfully treated. It remains to be established No specific funding was obtained for this study. whether such differences were predisposing to disease activity or were a result of a dysbiotic change associated with disease recurrence in the presence of sub-standard supportive periodontal therapy or other patient-related factors. KEYWORDS aggressive periodontitis, dysbiosis, microbiome, supportive periodontal therapy 1 | INTRODUCTION define a specific condition characterized by rapid disease progres- sion in otherwise systemically healthy patients with a positive Aggressive periodontitis (AgP) was introduced as a disease entity family history of periodontal disease. Among secondary fea- by the 1999 World Workshop classification (Lang et al., 1999) to tures, elevated proportions of bacteria such as Aggregatibacter This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2020 The Authors. Journal of Clinical Periodontology published by John Wiley & Sons Ltd J Clin Periodontol. 2020;00:1–11. wileyonlinelibrary.com/journal/jcpe | 1 2 | NIBALI ET al. actinomycetemcomitans and Porphyromonas gingivalis were con- sidered typical in some populations. In particular, an association Clinical Relevance between A. actinomycetemcomitans and AgP had been suggested Scientific rationale for the study: The level of dysbiosis as- in a large study in the United States using culture and immuno- sociated with aggressive periodontitis disease recurrence fluorescence serotyping (Zambon, Christersson, & Slots, 1983) is currently unknown. and confirmed by studies observing treatment response (Mandell, Principle findings: Higher microbial diversity was detected Ebersole, & Socransky, 1987) and antibody response (Albandar, in active versus stable aggressive periodontitis cases. DeNardin, Adesanya, Diehl, & Winn, 2001; Ebersole & Cappelli, Elevated differences at both genus and species levels were 1994). The JP2 clone of A. actinomycetemcomitans has been con- detected, mainly between persistent GAgP and success- sistently associated with onset and progression of periodontal fully treated group. Overweight and irregular interdental attachment loss in children and adolescents in North and West brushing are associated with dysbiosis. Africa (Haubek et al., 2008; Höglund et al., 2014) as well as in Practical implications: Increased dysbiosis, oral hygiene and the United States (Fine et al., 2007). However, the great major- obesity should be controlled to avoid dysbiosis-associated ity of comparative studies suggest that the microbial differences periodontal disease recurrence. between AgP and Chronic Periodontitis are so limited (Lafaurie et al., 2007; Nibali et al., 2012; Riep et al., 2009) that they are no longer considered different disease entities (Tonetti, Greenwell, & Kornman, 2018); a conclusion supported also by evidence from Inclusion criteria were (a) previous diagnosis of AgP—in the ded- other pathogenicity aspects (Tonetti et al., 2018). icated AgP clinic at the EDH between 1997 and 2011, and (b) age The introduction of molecular techniques suggested a role between 16 and 65 at recruitment. Exclusion criteria were (a) known for non-cultivable microbes as Filifactor alocis, Centipeda genus, infectious diseases such as Tuberculosis, HIV or hepatitis C, (b) co- Mitsuokella sp., Selenomonas genus, Actinobacter baumannii in the morbidities that would make it unsafe for the patient to travel or to pathogenesis of periodontitis (Goncalves et al., 2012; Schlafer undergo periodontal assessment and (c) pregnancy. Following initial et al., 2010; Schulz et al., 2019) depicting a more variegated picture diagnosis, patients had received active periodontal therapy (APT) than previously thought, in line with the concept of polymicrobial consisting of oral hygiene instructions, non-surgical treatment, ad- synergy and dysbiosis (Hajishengallis & Lamont, 2014). However, the junctive antibiotics and/or surgical treatment according to clinical role of these putative periodontopathogenic bacteria has not been needs (Table 1). Following completion of APT, patients had a full fully elucidated yet, and little is known about their potential to in- periodontal assessment and were then discharged to their general stigate periodontal disease recurrence during maintenance therapy. dental practitioner for SPT. The primary aim of this investigation was to analyse the peri- At the study visit, following consent, patients were interviewed odontal microbiome in previously treated patients with AgP and to to obtain self-reported medical, dental and smoking histories. associate it with the presence of active periodontal disease or health. Participants’ height and weight were measured, and body mass We also investigated the relationship between the AgP microbiome index (BMI) calculated. Patients were classified as “normal weight” if composition and association between regular supportive periodon- their BMI was <25 kg/m2, “overweight” if their BMI was 25–29 kg/ tal therapy (SPT), tooth loss and patient-related factors, such as oral m2 and “obese” if their BMI was ≥30 kg/m2. Clinical data were col- hygiene, smoking and body mass index. lected at 6 sites per tooth by one calibrated examiner (JD) including full-mouth dichotomous plaque score (FMPS) (Guerrero et al., 2005), gingival index (Löe, 1967), tooth mobility (Laster, Laudenbach, & 2 | MATERIALS AND METHODS Stoller, 1975), tooth loss, furcation involvement (Hamp, Nyman, & Lindhe, 1975), probing pocket depth (PPD), gingival recession (dis- 2.1 | Patient population tance from the cemento-enamel junction to the free gingival mar- gin) and full-mouth dichotomous bleeding on probing score (FMBS, The study design and population have been previously described percentage of bleeding surfaces upon probing). Clinical attachment (Dopico, Nibali, & Donos, 2016). Briefly, patients seen in a dedi- level (CAL) was measured as PPD plus recession. cated AgP clinic were contacted and asked to participate in the study. Eighty-two patients were contactable of the original 330 with AgP, and 66 agreed to participate, gave informed consent and 2.2 | Clinical diagnosis completed the study visit to the Eastman Dental Hospital (EDH), in London. The study was conducted in line with the principles outlined At the study visit, the following diagnoses could be assigned: in the Declaration of Helsinki (2008) on experimentation involving human participants. Ethics approval for the conduct of the study was • Persistent AgP: in case of interproximal PPD and CAL ≥5 mm granted by the NRES Committee London—Queen Square (ref 13/ on at least two permanent teeth. Subdivided into either LAgP LO/0874). (at least one affected first molar or incisor, and no more than NIBALI ET al. | 3 TABLE 1 Study population characteristics* 2.3 | Subgingival plaque sampling Frequency Percentages