Genetic Factors Associated with Periodontal Disease

Presented by : Dr Krishna Das 2nd year PG Student Department of Periodontology and Oral Implantology

CONTENTS
Introduction An insight to genetics Genetic basis of disease Methods of genetic analysis Evidence for the role of genetic variants in

Periodontitis Genetic and Inherited Disorders associated with Aggressive Periodontitis Genetic polymorphism Gene Therapy Gene therapy in Periodontics A futuristic approach to the application of genetic

INTRODUCTION
Microbial plaque induces gingivitis which may progress to chronic destructive inflammatory condition termed periodontitis in susceptible individuals.

Pathogenesis of periodontal disease

 Putative pathogens are essential to develop

periodontitis, however, their mere presence is insufficient to initiate periodontitis. (Haffajee and Socransky, 1994)
The primary etiology for periodontitis is bacteria,

however the extent and severity of periodontal lesions can be influenced by environmental factors, acquired factors, and genetic predisposition. (Kornman et al., 1997 and Salvi et al., 1997)
While microbial and other environmental factors

are believed to initiate and modulate periodontal disease progression, there now exists strong supporting evidence that genes play a role in the predisposition to and progression of periodontal diseases. (Sofaer, 1990; Hart, 1994; Michalowicz, 1994; Hassel and Harris, 1995;

PERIODONTITIS IS A MULTIFACTORIAL DISEASE

EOP: early-onset periodontitis; LAD: leukocyte adhesion deficiency; PMNs: polymorphonuclear lymphocytes; PGHS prostaglandin endoperoxide synthase (also referred to as cyclooxygenase)
Periodontology 2000. Vol. 14. 1997,202-215

 Genetic

factors influence inflammatory and immune responses in general. Individuals may respond differently to common environmental challenges due to their genetic profile. Specifically different forms of genes(allelic variants), can produce variations in tissue structure (innate immunity), and inflammatory mediators (non-specific inflammation). Allelic variants at multiple gene loci probably influence periodontitis susceptibility. (Kinane 2003).

AN INSIGHT TO GENETICS

Basic Terminologies
Genome refers to all the genes carried by an

individual or cell. The human genome consists of more than 3 billion pairs of bases contained in 22 pairs of chromosomes, termed autosomes, and a pair of sex chromosomes.
Chromosome a nuclear structure carrying genetic

information arranged in a linear sequence.

Gene a functional and physical unit of inheritance

that occupies a specific position (locus) within chromosome. In other words, it is a sequence of nucleotides located at a particular position on a particular chromosome carrying a set of instructions usually directing the synthesis of proteins.

 Allele one of several possible

alternative forms of a given gene at a particular locus of a chromosome differing in DNA sequence.
Different alleles are responsible for
Homozygous

variation in inherited characteristics such as hair color or blood type.

In an individual, the dominant form of an

the presence of identical alleles of one or more specific genes (e.g. A/A). the presence of differing alleles of one or more specific genes (e.g. A/B).

Heterozygous

allele is expressed.

 Genotype the genetic makeup of an organism or

cell distinct from its expressed features or phenotype.

Phenotype the observable characteristics displayed

by an organism as influenced by environmental factors and independent of the genotype of the organism. (Phenotype = genotype x environment)
Gene expression the process involving use of the

information in a gene via transcription and translation leading to production of a protein affecting the phenotype of the organism determined by that gene.
Autosomal dominant the dominant effect of one

gene located on an autosome regardless of the presence of the other normal copy.
Autosomal recessive A gene on an autosome that

is required in two copies to be active in an individual. An individual who carries two such copies of the same abnormal gene will be subjected to effects from that gene.

Genetic Variance
That portion of the phenotypic variance of a trait in a population which can be attributed to genetic difference amongst individual. Variance : Mutation or Polymorphism
Mutation : a permanent transmissible change in the

genetic material that occur during DNA replication or meiosis. (<1% of population)
Polymorphism: a region on the genome that varies

between individual members of a population present in a significant number of individuals. (>1% of population)

Single Nucleotide Polymorphism

Polymorphism

caused by the change in a single nucleotide believed to be the most common genetic variation between individual humans.

Gene Expression

Environmental Exposures
Differences

in physiologic functioning of proteins due to polymorphisms can be enhanced by certain environmental factors(eg. smoking, diabetes, microbes). process then certain polymorphisms can increase or decrease risk for disease phenotype.

If the protein functions in the inflammatory

Genetic Basis of Disease

Genetic

variance and environmental exposures are the key determinants to phenotypic differences. Mendelian Diseases follow predictable & simple patterns of transmission. In most cases a single gene locus is the major determinant of disease.

Simple

Complex

genetic disease are more prevalent, do not follow simple pattern of familial distribution, and are the result of interaction of multiple different gene loci as well as environmental factors.

Simple Mendelian Diseases

Complex Genetic Diseases

No correlation between presence of allele and

occurrence of disease.
Associated polymorphisms not directly linked. Each polymorphism contributes to a small part

of the disease process, sometimes requiring multiple genes to develop disease phenotype.
Environmental

factors are also critical to

etiology.

Methods of Genetic Analysis

Familial Aggregation Twin Studies Segregation Analysis Linkage Studies Association Studies/ Candidate gene approach Genome wide analysis

Familial Aggregation
Many

diseases run in families, and the degree of clustering within the family can be estimated by comparing the number of disease cases in relatives of patients to the risk of disease in the general population . to having many genes in common, family members also share many aspects of a common environment (e.g., diet, nutrition, smoking, infectious organisms and shared socioeconomic factors).

Difficulties : in addition

Twin Studies
Comparisons of

traits, including diseases in monozygotic, dizygotic, or usually both types of twins aimed at determining whether variation in the trait among members of a population is caused by genetic variation in inherited DNA sequences, environmental exposures in the subjects previous lives, or some combination of both of these processes. studies often measure the concordance rates of twins with a particular trait or disease of interest .

Twin

 Disadvantage : A genetic mutation

may

not

have

complete penetrance. Environmental conditions may contribute to the development of the disease (e.g., one twin may smoke and the other may not). Furthermore, many diseases are polygenic (i.e., caused by alterations in multiple genes).

Segregation Analysis
Statistical

analyses of the patterns of transmission of a disease in families in an attempt to determine the relative likelihood that the disease is caused by a single gene with dominant or recessive inheritance, by multiple genes, or entirely by variation in exposure to risk factors.

The observed proportions of offspring who have

the trait or disease being evaluated (i.e., the phenotype) are compared with the proportions that are expected in the general population .

Linkage analysis
A technique used

to map a gene responsible for a trait to a specific location on a chromosome. It is based on the fact that genes that are located close to each other on the chromosome tend to be inherited together as a unit. As such, these genes are said to be linked. Very expensive DNA markers are required.

Crossover between A and B much more likely than between B and D

A difficulty with linkage analyses is that many diseases are not caused by a single gene of major effect but rather by multiple genes of minor effect. In the latter situation, multiple genes each contribute a small amount to the phenotype/disease/ trait, and the linkage study approach has little power for detection. In those cases association analysis methods may be used.

Association Studies
A gene mapping approach

that tests whether one allele of a gene occurs more often in patients with the disease than in subjects without the disease.

Aim : to

identify which genes are associated with the disease.

the basis of their known or presumed function (i.e., they have some plausible role in the disease process such as producing a protein that is important in the disease pathogenesis). Conceptually, this makes sense but requires

Candidate genes are chosen on

Genome Wide Association Study (GWAS)

A GWAS investigates genetic variation across the entire genome simultaneously, with the aim of identifying genetic associations related to a trait or disease of interest. The completion of the Human Genome Project in 2003 and the development of microarray technologies capable of assaying SNPs have made GWAS possible. This method has the potential to identify the genetic contributions to common diseases. An important advantage of this approach is, because the entire genome is analyzed, the technique permits the genetics of a disease to be investigated in a nonhypothesis-driven way. It is not necessary to

 A GWAS

requires that well -characterized cases and controls be identified. large clinical sample sizes are required to reduce the likelihood of differences between cases and controls being observed simply by chance as a result of the hundreds of thousands of multiple statistical tests required to search the entire human genome.

A disadvantage of GWAS is that

Evidence for the Role of Genetic Variants in Periodontitis

Familial Aggregation: German studies of familial nature in the early 20th century have shown aggregation of chronic forms of periodontitis in families. This strongly suggested genetic predisposition. (Revd by Hassell &
Harris ,1995)

Twin study
Michalowicz et al. (1991) studied dizygous

twins reared together and apart and monozygous twins reared together and apart.
Mean probing depth and attachment level

varied less for monozygous dizygous twins.

twins than

Twin groups had similar oral hygiene

and

smoking history.
Concluded

genetics

plays

role

in

Segregation analysis
Segregation analysis in North American families

performed by Marazita et al. (1994).

Studied >100 families, segregating aggressive

forms of periodontitis, and found support for autosomal dominant transmission. Concluded autosomal dominant inheritance with ~70% penetrance occurred in Blacks and non-Blacks.
While others

Beaty et al. (1987), Long et al. (1987),Saxen et al. (1980) have found support for autosomal recessive transmision of aggressive periodontitis.

Linkage analysis
Boughman et al. (1986).Gene for Dentinogenesis

imperfecta-III (DGI-III) had been previously localized to chromosome 4. They performed linkage analysis and showed close linkage of gene for Aggressive periodontitis( AgP) to this DGI-III gene in the families of Southern Maryland. Hart et al. (1993) evaluated support for linkage of AgP near chromosome 4 in different population of families (14 African American and 4 Caucasian). Results showed that in these populations no linkage existed . Recently, Li and coworkers (2004) reported evidence of a gene responsible for localized aggressive periodontitis located on chromosome 1q25. To date, a

Genetic and Inherited Disorders associated with Aggressive Periodontitis

Severe periodontitis presents as part of the

clinical manifestations of several monogenetic syndromes. Significance of these conditions is that they clearly demonstrate that a genetic mutation at a single locus can impart susceptibility to periodontitis.

Genetic Polymorphism
In humans, studies of inherited variations in the immune system are necessarily complex, and the observed phenotype is usually the result of multiple genetic and environmental influences. It is likely that genetic polymorphisms exist for many of these immunological factors, eg.
- Immunoglobulin G2 production - FcRII receptor heterogeneity - Mediators of inflammation -Prostaglandin E2 (PgE2)

Immunoglobulin G2 production
Serum

IgG2 levels in localized aggressive periodontitis(LAP) cases are higher than serum levels of generalized aggressive periodontitis(GAP) cases (Lu et al. 1994)

IgG2 in LAP associated with protection in LAP

(Gunsolley et al.1987)

The IgG molecules contain :

- gamma heavy chains (Gm allotypes) - kappa light chains (Km allotypes) Currently the only allotype identified for IgG2 is

 The Gm allotype genes, or genes in linkage

equilibrium with them, appear expression of the IgG2 molecule.

to influence

This response appears to be race specific, and

young Caucasians of the low-responder phenotype G2m(null) [G2m("), G2m(-n) and G2m(-23)]are predisposed to specific bacterial infections.
Choi

et al. (1996) : The rapidly progressive

periodontitis patients who were positive for the G2m(23) allotype had elevated antibody to Porphyromonas gingivalis .
In addition to host factors, environmental factors

FcRII receptor heterogeneity

 Polymorphisms in Fc receptors expressed on the

surface of phagocytic cells have been shown to be important determinants of susceptibility to infections.
The immunoglobulin Fc receptor II genes have

been mapped to chromosome 1.

FcyRII

gene has two expressed alleles, which differ significantly in their ability to bind human IgG2.

The two alleles differ by the amino acid, at

position 131. - arginine (R131) - histidine (H131), recognizes IgG2,

Wilson et al. (1996) : IgG2 was significantly more effective in mediating phagocytosis of A. actinomycetemcomitans, when used with human neutrophils that were homozygous for the H131 receptor as compared to neutrophils from individuals homozygous for the R131 receptor. The genetic polymorphism that defines the FcyRII receptor, therefore, appears to be a promising marker for

Mediators of inflammation
PROSTAGLANDIN E2(PGE2) - Potent biological mediators - Diverse physiological effects - Has also been implicated in a variety of pathological conditions including periodontitis. Wang et al. (1996) : identified linkage of the chromosome 9q32-33 region with early-onset periodontitis. This physical region includes the gene for prostaglandin endoperoxide synthase 1, and this observation encourages further studies associating genetic markers of prostaglandin E with clinical

INTERLEUKIN 1 (IL-1) Elevated tissue and gingival fluid levels of interleukin 1 (IL) in particular have been repeatedly associated with periodontitis. A family of three IL-1 genes cluster on chromosome 2q13. At times the overproduction of immuno-regulatory mediators may actually prove harmful to the host.

Genetic control of IL-1: Genes and Locus of SNPs associated with controlling IL-1 biological activity
Genes Polymorphism Locus
IL-1 IL-1 IL-1RN Allele2 -889 Allele 2 +3953

Current Locus accessed with test

Allele 2 IL-1 +4845* Allele 2IL-1 +3954**

Controlled product
IL-1 IL-1 Protein receptors antagonist (impedes IL-1 & )

Genetic Susceptibility Test for periodontitis: tests for the presence of at least one copy of allele 2 at the IL-1A +4845 loci and at least one copy of allele 2 at the IL-1B +3954 locus.

*IL-1A +4845 is being used because it is easier to identify than IL-1A -889
and it is essentially concordant with it. ** IL-1B +3953 has been now renumbered as IL-1B +3954 because the current convention indicates that the numbering of the transcription should begin at +1 instead of zero.

In 1997, Kornman et al., found an association between polymorphisms in the genes encoding for interleukin1(+889) and interleukin-1(+ 3953) (termed the composite genotype) and an increased severity of periodontitis.
One of these genotypic polymorphisms IL-1 at (+3953) is associated with a fourfold increase in IL- l production.

Gene Therapy
Gene therapy uses purified preparations of a

gene or a fraction of a gene, to treat diseases.

There are four approaches:

1. A normal gene inserted to compensate for

a nonfunctional gene. 2. An abnormal gene swapped for a normal gene. 3. An abnormal gene repaired through selective reverse mutation. 4. Change the regulation of gene pairs.

Gene therapy in Periodontics

1. Protein based approach: trials have been conducted using Transforming growth factor-, Bone morphogenetic ptoteins-2,6,7,12, Vascular endothelial growth factor and Platelet derived growth factor. 2.Cell based approach: skeletal muscle derived cells can be used for delivery of BMP-2. 3.Gene- delivery approach:
-In vivo gene delivery: The genetic material is transferred directly into the body of the patient. - Ex vivo gene delivery: The genetic material is first transferred into the cells grown in vitro and then to the patients body.

A futuristic approach to the application of genetic profiles in the management of aggressive periodontitis.

Periodontology 2000, Vol. 30, 2002, 7990