Volume 79 • Number 7

Gingival Crevicular Fluid Alkaline

Phosphatase Activity Reflects
Periodontal Healing/Recurrent
Inflammation Phases in Chronic
Periodontitis Patients
Giuseppe Perinetti,*† Michele Paolantonio,* Beatrice Femminella,* Emanuela Serra,*
and Giuseppe Spoto*

Background: Roles for host enzymes as diagnostic indicators of

periodontal status in gingival crevicular fluid (GCF) have been pro-
posed. One of these host enzymes is alkaline phosphatase (ALP),
the GCF activity of which has been associated with periodontal inflam-
mation. Thus, the present study aimed to improve our understanding
of how the healing of chronic periodontitis following scaling and root
planing (SRP) affects GCF ALP activity after 15 and 60 days.

G
ingival crevicular fluid
Methods: Sixteen systemically healthy subjects (aged 35 to 61 (GCF) is a transudate
years) with moderate to advanced generalized chronic periodontitis with constituents that de-
were recruited. In each subject, paired pockets with probing depths rive from a variety of sources,
(PDs) ‡4 mm that were located in two symmetric quadrants were cho- including microbial dental pla-
sen. These sites were randomized at the split-mouth level, with half re- que, host tissues, and serum (for
ceiving SRP treatment and the other half left untreated. Ninety-two review, see Uitto1); however,
pockets were included in the study. Clinical examinations were per- during inflammation, the GCF
formed at baseline (prior to SRP) and after 15 and 60 days; information becomes an exudate.2 In recent
recorded included the presence of plaque, PD, clinical attachment years, a number of GCF constit-
level (CAL), and bleeding on probing. GCF was collected from each uents have been shown to be
pocket included in the study at the three time points. diagnostic markers of active tis-
Results: A large and significant decrease in GCF ALP activity was sue destruction in periodontal
seen 15 days after SRP, concomitant with an improvement in clinical diseases.3 In particular, host en-
parameters. After 60 days, an increase in GCF ALP activity back to zymes in GCF have been pro-
baseline levels was recorded along with further improvements in clin- posed as diagnostic indicators of
ical parameters. Moreover, in the SRP pockets with initial PDs >6 mm, periodontal status.4 Among these
the CAL gains between days 15 and 60 were significantly associated host enzymes, alkaline phospha-
with changes in GCF ALP activity over the same time interval. tase (ALP) was one of the first
Conclusions: The decrease in GCF ALP activity at 15 days corre- to be identified.5 ALP is released
sponded to a decrease in clinical signs of inflammation; in contrast, from polymorphonuclear cells
the increase in GCF ALP activity at 60 days seemed to be related to (PMNs) during inflammation4
subclinical recurrent inflammation or further healing/remodeling of and from osteoblasts6 and peri-
the periodontal tissue. Therefore, GCF ALP reflects the short-term peri- odontal ligament fibroblasts7
odontal healing/recurrent inflammation phases in chronic periodonti- during bone formation and peri-
tis patients. J Periodontol 2008;79:1200-1207. odontal regeneration, respectively.
For the inflammatory process,
KEY WORDS
previous studies showed that
Alkaline phosphatase; chronic periodontitis; clinical trial; ALP is involved in gingivitis8 and
gingival crevicular fluid; therapy. periodontitis,5,9 with an increase
seen in GCF ALP activity. Like
* Department of Oral Sciences, University G. D’Annunzio, Chieti, Italy.
† Department of Cell Biology and Oncology, Consorzio Mario Negri Sud, Santa Maria Imbaro, Italy.
doi: 10.1902/jop.2008.070519

1200
J Periodontol • July 2008
other markers, this increased GCF ALP activity has
predictive value in terms of attachment loss that is sig-
nificantly more accurate than the use of clinical pa-
rameters.10,11 In this regard, a chemiluminescence
kit to measure GCF ALP activity has been devel-
oped.11 Conversely, a previous study9 questioned
the reliability of the use of such individual biochemical
markers, because they might have a limited capacity
to distinguish between active and inactive tissue
breakdown, thus recommending the simultaneous
use of multiple markers.
In the bone-formation process, ALP has been dem-
onstrated within matrix vesicles that are deposited as
buds that derive from the cell membrane; these de-
posits have an essential role in bone formation be-
cause ALP hydrolyzes non-organic pyrophosphate,
a potent inhibitor of the mineralization process.12
ALP is produced in extremely high amounts during
the formation phase of the bone cycle; therefore, it
is an excellent indicator of bone-formation activity.6
ALP activity was shown to increase in regenerating
human periodontal cells shortly after the surgical
placement of membranes,13 although in vivo studies
investigating GCF ALP activity during periodontal re-
generation are still lacking. Moreover, the potential of
GCF ALP activity to be used as a diagnostic tool for
monitoring periodontal remodeling during orthodon-
tic tooth movement14 and in peri-implant crevices15
was also proposed recently.
In a previous study16 on GCF ALP activity after
phase I periodontal treatment, a significant decrease
in ALP activity (compared to the baseline values)
was shown after 1 year of treatment. However, this
study was performed on postmenopausal women
with/without estrogen supplements and with only
a 1-year time point analysis after the treatment.
Therefore, little has been reported in favor of the use
of GCF ALP levels as an indicator of periodontal heal-
ing in systemically healthy patients after surgery or
scaling and root planing (SRP).
Considering the dual involvement of ALP in the dis-
tinct processes of periodontal inflammation and heal-
ing/ regeneration, the monitoring of GCF ALP activity
over shorter periods after periodontal treatment
seems reasonable. Thus, the present study was de-
signed to understand how the clinical healing of
chronic periodontitis following SRP affects GCF ALP
activity after 15 and 60 days.
MATERIALS AND METHODS
Subjects and Study Design
This was a randomized, single-masked, controlled,
split-mouth, clinical trial that was conducted in the
Department of Oral Sciences, University of Chieti,
from August 2005 to December 2006. The experi-
mental protocol was approved by the Institutional
Perinetti, Paolantonio, Femminella, Serra, Spoto
Ethical Committee of the G. D’Annunzio University
Faculty of Medicine, and voluntary informed consent
was obtained from the subjects after providing them
with detailed information about the clinical trial. Six-
teen subjects, 10 females and six males (aged 35 to
61 years; mean age, 49.6 – 7.9 years), affected by
moderate to severe generalized chronic periodontitis
were enrolled in this study. The exclusion criteria were
smoking, pregnancy, systemic antimicrobial and
anti-inflammatory drug therapy within 3 months prior
to the study, periodontal treatment undertaken <12
months prior to the preliminary visit, or the presence
of a removable prosthesis.
A preliminary visit took place a week before the
baseline visit. During this preliminary visit, full-mouth
supragingival scaling was carried out, and oral hy-
giene instructions were given to all of the subjects.
At the baseline visit, the following clinical parameters
were recorded: full-mouth plaque score (FMPS), full-
mouth bleeding score (FMBS), probing depth (PD),
clinical attachment level (CAL), and bleeding on
probing (BOP); full-mouth periapical radiographs
were also taken. During the same clinical session,
the subjects underwent SRP following a split-mouth
design: two quadrants were treated, and the corre-
sponding two opposite and contralateral quadrants
were left untreated throughout the study period. No
additional therapies were administered during the
study period. Each subject provided two-to-four
SRP and control pockets (Fig. 1). In particular, nine
subjects provided pockets with initial PDs of 4 to 6
mm, and the other seven subjects provided pockets
with initial PDs >6 mm. Furcation sites and teeth with
a fixed prosthesis were excluded. According to these
criteria, 92 pockets (46 SRP and 46 control) were in-
cluded in the study.
SRP was performed under local anesthesia, with
a second session performed within 48 hours of the
first. Each appointment lasted 1 hour, and SRP was
performed carefully with Gracey curets for 5 minutes
Figure 1.
Flowchart of the SRP and control groups.
1201
SRP and GCF ALP Activity
for each experimental site.17 Normal oral hygiene
procedures were allowed, except for the use of che-
motherapeutic mouthrinses and oral irrigation de-
vices. The treated sites constituted the SRP group,
whereas the untreated sites constituted the control
group. Clinical parameters were recorded, and GCF
was collected from each included site at baseline (be-
fore the SRP sessions) and 15 and 60 days later.
Clinical Measurements
The following clinical parameters were recorded at
each time point (baseline and 15 and 60 days). FMPS
and FMBS were scored as the percentage of tooth sur-
faces positive for the presence of supragingival plaque
(PL+) or positive for bleeding within 15 seconds after
probing (BOP+) with a 20-g controlled-force probe.‡
At the corresponding tooth of each pocket, the clinical
examination consisted of recording the presence of
plaque (PL+), assessed dichotomously by visual crite-
ria; PD, measured from the gingival margin to the base
of the pocket; CAL, measured from the cemento-
enamel junction or restoration margin to the base of
the pocket; and BOP+. The same operator (BF) al-
ways collected the clinical data.
GCF Collection
Each periodontal site included in the study was iso-
lated with cotton rolls. Before GCF collection, any
supragingival plaque was removed with cotton pel-
lets,18 and a gentle air stream was directed toward
the tooth surface for 5 seconds to dry the area. The
GCF was collected using #30 standardized sterile pa-
per strips§19 inserted 1 mm into the gingival crevice
and left in situ for 30 seconds. Care was taken to avoid
mechanical injury, and samples with blood were dis-
carded. Contamination of GCF samples was mini-
mized by recording PL+ before carefully cleaning
the tooth with cotton pellets, collecting GCF from
the isolated area, and then recording PD, CAL, and
BOP+, as described previously.18 Immediately after
collection, the paper points were transferred to plastic
vials and stored at -20C until they were analyzed.
Enzymatic Activity Determinations
ALP activity was assayed spectrophotometrically.i14
The GCF samples were incubated at 30C (–
<0.05C fluctuations) in 1 ml substrate for 20 minutes.
This substrate consisted of 10 mM p-nitrophenyl
phosphate in carbonate buffer (pH, 10.2 – 0.1 at
30C) with 200 mM mannitol and 3 mM MgCl2. ALP
hydrolyzes p-nitrophenyl phosphate to p-nitrophenol
and inorganic phosphate. The reactions were stopped
by adding 50 ml 1 M NaOH. After centrifugation at
13,400 · g for 5 minutes at 4C, the supernatants were
collected and transferred to a 1-cm-path-length cu-
vette for spectrophotometric recording. Following
subtraction of the background absorbance (substrate
1202
Volume 79 • Number 7
without GCF sample), the absorbance at 405 nm was
recorded as the measure of p-nitrophenol formed.
Using 18.45/(cm · mmol) for the specific absorption
of p-nitrophenol, the absorbance was converted into
enzyme activity units (1 Unit = 1 mmol of p-nitrophe-
nol released per minute at 30C). The final results are
expressed as total ALP activity (mUnits/sample).
Data Processing
A subject-based statistical analysis was performed for
each variable; therefore, within each subject and
treatment, PL+ and BOP+ were considered the mean
number of experimental sites positive for the presence
of supragingival plaque and BOP, respectively; PD,
CAL, and GCF ALP activity were similarly considered
the mean values obtained for the SRP/control pockets
within the same subject. These mean values were the
statistical units of each dataset considered in the anal-
ysis. Each dataset was treated as ordinal data by non-
parametric tests because of the failure to meet the
required assumption for using parametric analyses.
Nevertheless, the mean – SD for the clinical parame-
ters are reported for descriptive purposes. Within
each PD group (with initial PDs of 4 to 6 or >6 mm),
a Wilcoxon test was used to assess the significance
of differences for each variable between the treat-
ments, whereas the significance of changes over time
within the treatments was assessed using a Friedman
test followed by a Bonferroni-corrected Wilcoxon
paired sign-rank test, as appropriate.
The significance of the correlation between PD and
ALP activity at baseline was tested using the Spear-
man r correlation coefficient. In particular, within
each subject, a single mean score was derived from
all data from the control and SRP sites. Moreover,
within each treatment, further Spearman r correlation
coefficients were calculated for the relationship be-
tween changes in ALP activity and CAL gain, from
day 15 to day 60.
A P value <0.05 was used for rejection of the null
hypothesis.
RESULTS
Clinical Parameters
FMPS and FMBS were <20% at baseline and remained
at this level throughout the study, without any statis-
tically significant differences between the groups or
among the time points (data not shown). All other
clinical outcomes for SRP and control groups are sum-
marized in Table 1 for initial PDs of 4 to 6 and >6 mm.
At baseline, all clinical parameters were similar be-
tween the groups across both initial PD subsets, with
no statistically significant differences.
‡ Vivacare TPS Probe, Vivadent, Schaan, Lichtenstein.
§ Inline, Turin, Italy.
i Model 8453, Hewlett Packard, Waldgrohn, Germany.
J Periodontol • July 2008 Perinetti, Paolantonio, Femminella, Serra, Spoto

Table 1.
Clinical Parameter Scoring (mean – SD) for PDs of 4 to 6 mm (n = 9) and >6 mm (n = 7)

Initial PD (mm) Parameter Group Baseline 15 Days 60 Days Difference With Time

4 to 6 PL+ Control 0.5 – 0.3 0.5 – 0.3 0.6 – 0.3 NS

SRP 0.7 – 0.4 0.6 – 0.4 0.5 – 0.4 P = 0.024
Diff. NS NS NS
PD (mm) Control 4.5 – 0.4 4.2 – 0.5 4.2 – 0.5 P = 0.023
SRP 4.3 – 0.3 3.8 – 0.2* 3.5 – 0.4* P = 0.001
Diff. NS NS P = 0.011
CAL (mm) Control 5.9 – 1.8 5.7 – 1.5 5.7 – 1.4 NS
SRP 5.9 – 1.1 5.4 – 1.0* 5.3 – 1.0* P = 0.001
Diff. NS NS NS
BOP+ Control 0.5 – 0.4 0.2 – 0.3 0.5 – 0.4 NS
SRP 0.3 – 0.3 0.2 – 0.2 0.1 – 0.1 P = 0.037
Diff. NS NS NS
>6 PL+ Control 0.8 – 0.1 0.7 – 0.4 0.9 – 0.2 NS
SRP 0.7 – 0.4 0.4 – 0.4 0.5 – 0.4 NS
Diff. NS P = 0.041 P = 0.046
PD (mm) Control 7.9 – 0.9 7.7 – 0.7 7.7 – 0.7 NS
SRP 7.6 – 1.7 6.9 – 1.2 6.3 – 1.3 P = 0.002
Diff. NS NS P = 0.039
CAL (mm) Control 9.7 – 0.6 9.5 – 0.9 9.7 – 1.1 NS
SRP 9.1 – 0.5 8.5 – 0.7 8.1 – 0.9 P = 0.008
Diff. NS NS P = 0.018
BOP+ Control 0.6 – 0.3 0.7 – 0.2 0.7 – 0.2 NS
SRP 0.9 – 0.1 0.5 – 0.3 0.4 – 0.3 P = 0.011
Diff. NS P = 0.041 P = 0.041
NS = not statistically significant; Diff. = significance of the differences between the groups within each time point; results of the pairwise comparisons.
* Statistically significant difference compared to corresponding baseline value (P <0.05).

For the pockets with initial PDs of 4 to 6 mm in the
control group, PL+, BOP+, and CAL did not show sig-
nificant changes over time; in contrast, PD decreased
slightly but significantly over time by up to 0.3 mm. In
the SRP group, all clinical parameters decreased signifi-
cantly over time; in particular, PD and CAL recorded
at days 15 and 60 were significantly lower compared
to their corresponding baseline values in the pairwise
comparisons. PD, CAL, and BOP+ also showed further
decreases at 60 days compared to 15 days; however,
these differences were not statistically significant in
the pairwise comparisons. In cross-sectional compari-
sons of the SRP group, only PD recorded at 60 days
was significantly lower than that of the control group.
For the pockets with initial PDs >6 mm in the control
group, none of the clinical parameters changed signif-
icantly over time. The opposite was seen for the SRP
group, in which all clinical parameters decreased over
time and reached statistical significance in all cases,
with the exception of PL+. Again, in the SRP group,
PD, CAL, and BOP+ further decreased at 60 days
compared to 15 days; however, these differences
did not reach statistical significance. The cross-sec-
tional comparisons showed that the SRP group had
significantly lower PL+ and BOP+ at days 15 and 60
and significantly lower PD and CAL after 60 days com-
pared to the control group.
GCF ALP Activity
The changes in GCF ALP with time are shown in Fig-
ure 2. At baseline, no differences were seen between
SRP and control groups for the pockets with initial PDs
of 4 to 6 and >6 mm.
In the pockets with initial PDs of 4 to 6 mm (Fig.
2A), GCF ALP activity in the control group decreased
at 15 and 60 days compared to baseline, although
these differences did not reach statistical significance.
In contrast, in the SRP group, GCF ALP activity was
decreased at 15 days and had returned to around
the initial levels at day 60. The differences among
the time points were statistically significant (P =
0.032). In particular, the pairwise comparison be-
tween baseline and day 15 was statistically significant
(P = 0.022). In the cross-sectional comparisons be-
tween the groups and within each time point, a signif-
icantly higher GCF ALP activity was seen after 60
days in the SRP group (P = 0.007).
In the deeper pockets with initial PDs >6 mm (Fig.
2B), GCF ALP activity in the control group also de-
creased over time, although this was not statistically

1203
SRP and GCF ALP Activity
Figure 2.
Total GCF ALP activity in the 4- to 6-mm (A) (n = 9) and >6-mm (B)
(n = 7) pockets for the SRP and control groups. Data are presented as
median values (bars represent 25th and 75th percentiles). Time points
of the SRP and control groups are slightly mismatched for clarity. The
differences with time were statistically significant only within the SRP
group (PDs of 4 to 6 and >6 mm) (P = 0.032 and P = 0.028,
respectively). Results in the pairwise comparisons are shown by lines
and P values.
significant. In the SRP group, GCF ALP activity de-
creased from baseline to 15 days and then increased
back to around the initial level after 60 days. The dif-
ferences among the time points were statistically
significant (P = 0.028). In particular, the pairwise
comparison between baseline and day 15 was statis-
tically significant (P = 0.036). In the cross-sectional
comparisons between the groups and within each
time point, a significantly lower GCF ALP activity
was seen after 15 days in the SRP group (P = 0.043).
Correlations Between GCF ALP Activity and
Clinical Parameters
The GCF ALP activity correlations with the clinical pa-
rameters are shown in Figures 3 and 4. At baseline,
with pooling of all of the pockets (with all initial PDs
and SRP and control groups together), GCF ALP ac-
tivity showed a significant positive correlation with
PD (Spearman r = 0.59; P = 0.017; Fig. 3). Moreover,
when the GCF ALP activity changes from day 15 to
day 60 were compared to the corresponding CAL
changes (pooling all of the pockets with all initial
1204
Volume 79 • Number 7
Figure 3.
Scatter plot of total GCF ALP activity and PD at baseline (pockets with
all initial PDs and SRP and control groups pooled). Spearman r = 0.59;
P = 0.017; N = 16.
Figure 4.
Scatter plot of increases in GCF ALP activity and CAL gain between
days 15 and 60 in the SRP group (pockets with all initial PDs pooled).
Spearman r = 0.74; P = 0.001; N = 16.
PDs), a positive correlation was seen in the SRP group
between GCF ALP increase and CAL gain (Spearman
r = 0.74; P = 0.001; Fig. 4). In contrast, this association
was not significant in the control group.
DISCUSSION
In the present study, we tested the potential use of
GCF ALP activity as an inflammatory and periodontal
ligament cell/osteoblast activity marker after SRP in
systemically healthy subjects affected by chronic peri-
odontitis. Taking into account that these enzyme var-
iations occur earlier than tissue modifications,11 the
15- and 60-day time points were used to differentiate
between the ALP derived from these different cellular
sources. The results showed a large and significant de-
crease in GCF ALP activity 15 days after SRP, concom-
itant with an improvement in clinical parameters, and
then a return of GCF ALP activity to baseline levels
60 days after treatment, accompanied by further
decreases in PD, CAL, and BOP+. Moreover, a split-
mouth design was used to control in full for the
J Periodontol • July 2008
individual subject responses and particularly for the di-
rect comparison of SRP to untreated control sites.
Generally, the clinical parameters did not show any
significant changes in the control group over time,
with the exception of a slight reduction in PD that
was seen in the control pockets with initial PDs of 4
to 6 mm (Table 1). This was probably due to the gen-
eral improvement in oral hygiene that the subjects un-
derwent after the beginning of the study, because they
received supragingival scaling and oral hygiene in-
structions 2 to 3 weeks before the beginning of the
study. It was shown that just the control of supragin-
gival plaque can alter the composition of subgingival
plaque, with moderate improvements in clinical con-
ditions also being seen.20,21 However, this was true
only for the control pockets with initial PDs of 4 to 6
mm; the control pockets with initial PDs >6 mm did
not show any significant improvements (Table 1).
The latter outcome was expected considering that
the effects of the control of supragingival plaque are
likely to be less on the subgingival plaque composi-
tion of the deeper pockets. This reduction in PD in
the 4- to 6-mm pocket control group seemed to be re-
lated to a moderate reduction in gingival enlargement,
because a concomitant CAL gain was not seen for the
same group. Moreover, its limited extent might not be
clinically relevant.
The use of GCF host enzyme activities to monitor
periodontal status was proposed several years ago.4
ALP has the peculiarity of being involved in inflam-
mation4,5 and regeneration.7 GCF ALP activity is
presented here as total activity/sample,14,16,22 rather
than as final concentrations, to avoid the small errors in
volume determination that can lead to large errors in
estimates of final concentrations when the total vol-
umes collected are small.23 Moreover, the amounts
of GCF increase with inflammation and capillary per-
meability,24,25 and an increase in GCF volume can sig-
nificantly dilute its contents.26 Nevertheless, further
insights may be carried out when evaluating GCF en-
zyme activities normalized by the total GCF volume/
total protein content.
In the present study, GCF ALP activity (Fig. 2) in the
control group showed slight but not significant de-
creases over time. The reason why GCF ALP activity
was slightly decreased here should arise from the pos-
itive effects that supragingival plaque control can have
on subgingival plaque composition.20,21 Similarly,
GCF ALP activity in the SRP and control groups was
more similar in the shallower pockets (initial PDs of
4 to 6 mm) than in the deeper ones (initial PDs >6
mm) (compare Figs. 2A and 2B). Thus, as for the
PD reduction seen in the control group with initial
PDs of 4 to 6 mm, this could be due to supragingival
plaque control being less effective on subgingival pla-
que in deeper pockets.
Perinetti, Paolantonio, Femminella, Serra, Spoto
For the SRP group, GCF ALP activity was de-
creased significantly at 15 days and then returned
to baseline values at 60 days; however, this behavior
was more pronounced in the deeper pockets. Indeed,
deeper sites have a greater potential for clinical im-
provement.27 This could explain the more striking
clinical and enzymatic modifications noted following
SRP in pockets with initial PDs >6 mm compared to
those with initial PDs of 4 to 6 mm.
The decrease in GCF ALP activity seen at day 15 in
the SRP group (with all initial PDs) was expected, be-
cause ALP is released by PMNs4 during inflammation,
and increased GCF ALP activity was shown in in-
flamed periodontal tissues compared to healthy peri-
odontium.5,8,9 However, to the best of our knowledge,
the present study provides the first evidence for initial
short-term (day 15) decreases in GCF ALP activity af-
ter SRP in chronic periodontitis patients. Based on
this, GCF ALP activity can be proposed as a marker
for successful SRP in chronic periodontitis.
The return of GCF ALP activity toward baseline
values at 60 days is more difficult to explain. This might
be due to recurrent inflammation (although remaining
clinically undetectable) or periodontal tissue-healing
processes that follow the SRP. Regarding the former,
it was shown that clinical parameters are not sensitive
to initial increases in inflammation;28 therefore, al-
though the clinical parameters (PD, CAL, and BOP+)
were continuing to improve in the present study at
60 days, this does not specifically exclude a second,
recurrent round of tissue inflammation taking place
at this time point. The major source of ALP in GCF
was proposed to be of PMN origin.28 In such a case,
measuring GCF ALP activity after SRP would be useful
to monitor recurrent inflammation of the tissue after
SRP treatment. Regarding the latter hypothesis, in an
in vivo study,13 ALP levels were significantly increased
in regenerating human periodontal cells 5 to 7 weeks
after the surgical placement of membranes. Moreover,
a longitudinal study29 showed that when combined
with supportive therapy, SRP can result in significant
PD reductions and CAL gains, even in pockets ‡7
mm in depth. Although a study30 showed that the
CAL gain after SRP is mainly due to the formation of
an epithelial attachment, a limited amount of tissue re-
generation has also been seen;31 it is hypothesized
here that minimal and clinically subdetectable tissue
regeneration takes place, including bone and even
periodontal ligament and cement tissues. Moreover,
although it also was reported that SRP can fail to com-
pletely remove debris from root surfaces depending on
the experience of the operator32 and the involvement
of furcation sites,33 in the present study, SRP was per-
formed carefully for 5 minutes for each experimental
site by an expert operator, and furcation sites were
excluded.
1205
SRP and GCF ALP Activity
However, to fully elucidate the biologic meaning of
the increase in GCF ALP activity seen at 60 days, fur-
ther investigations should combine the monitoring of
GCF ALP activity with a second GCF component,
which is exclusively sensitive to tissue inflammation,
or with the subgingival microflora.
Daltaban et al.16 only saw a reduction in GCF ALP
activity, although this could be related to the timing
they used, i.e., 1 year. They also reported that estro-
gen levels can affect total GCF ALP levels and PD, al-
though postmenopausal women (three of 10) were
enrolled in the present study.
The results relating to the correlation of GCF ALP
activity changes and CAL gain between the consecu-
tive time points are of particular interest in the present
study. A non-significant association was seen be-
tween the decrease in GCF ALP activity and CAL gain
from baseline to day 15 (Spearman r = -0.16; P =
0.540); in contrast, a positive, significant association
was seen between the increase in GCF ALP and CAL
gain from day 15 to day 60 (Fig. 4). This implies that
the sites with more improved CAL from day 15 to day
60 also had greater increases in GCF ALP activity,
which reinforces the potential for GCF ALP activity
to be used as a tissue-monitoring parameter.10,11
Efforts have been made to provide an easy-to-use
and non-invasive chairside kit that measures GCF
ALP activity, aimed at monitoring periodontal sta-
tus.11 Thus, ALP activities are valuable to clinicians
because they provide the possibility of monitoring
the periodontal status with a chairside kit that is al-
ready available.11 This is particularly important
because detectable enzymatic modifications occur
at the GCF level earlier than clinically evident modifi-
cations.
CONCLUSION
The changes in GCF ALP activity reflect the short-term
periodontal healing/recurrent inflammation phases in
chronic periodontitis patients, and this is more evident
in the deepest pockets.
ACKNOWLEDGMENTS
The authors are grateful to Dr. Domenico D’Archivio,
Department of Oral Sciences, University G. D’Annunzio,
for clinical assistance, and Dr. Christopher Paul Berrie,
Department of Cell Biology and Oncology, Consorzio
Mario Negri Sud, for his critical appraisal of the text.
The authors report no conflicts of interest related to
this study.
REFERENCES
1. Uitto VJ. Gingival crevice fluid – An introduction.
Periodontol 2000 2003;31:9-11.
2. Griffiths GS. Formation, collection and significance
of gingival crevice fluid. Periodontol 2000 2003;31:
32-42.
1206
Volume 79 • Number 7
3. Lamster IB. The host response in gingival crevicular
fluid: Potential applications in periodontitis clinical
trials. J Periodontol 1992;63:1117-1123.
4. McCulloch CA. Host enzymes in gingival crevicular
fluid as diagnostic indicators of periodontitis. J Clin
Periodontol 1994;21:497-506.
5. Ishikawa I, Cimasoni G. Alkaline phosphatase in hu-
man gingival fluid and its relation to periodontitis. Arch
Oral Biol 1970;15:1401-1404.
6. Christenson RH. Biochemical markers of bone metab-
olism: An overview. Clin Biochem 1997;30:573-593.
7. Groeneveld MC, Van den Bos T, Everts V, Beertsen W.
Cell-bound and extracellular matrix-associated alka-
line phosphatase activity in rat periodontal ligament.
Experimental Oral Biology Group. J Periodontal Res
1996;31:73-79.
8. Chapple IL, Glenwright HD, Matthews JB, Thorpe GHG,
Lumley PJ. Site-specific alkaline phosphatase levels in
gingival crevicular fluid in health and gingivitis: Cross-
sectional studies. J Clin Periodontol 1994;21:409-414.
9. Nakashima K, Giannopoulou C, Andersen E, et al. A
longitudinal study of various crevicular fluid compo-
nents as markers of periodontal disease activity. J Clin
Periodontol 1996;23:832-838.
10. Binder TA, Goodson JM, Socransky SS. Gingival fluid
levels of acid and alkaline phosphatase. J Periodontal
Res 1987;22:14-19.
11. Chapple IL, Garner I, Saxby MS, Moscrop H, Matthews
JB. Prediction and diagnosis of attachment loss by
enhanced chemiluminescent assay of crevicular fluid
alkaline phosphatase levels. J Clin Periodontol 1999;
26:190-198.
12. Coleman JE. Structure and mechanism of alkaline
phosphatase. Annu Rev Biophys Biomol Struct 1992;
21:441-483.
13. Kuru L, Griffiths GS, Petrie A, Olsen I. Alkaline phos-
phatase activity is upregulated in regenerating human
periodontal cells. J Periodontal Res 1999;34:123-127.
14. Perinetti G, Paolantonio M, D’Attilio M, et al. Alkaline
phosphatase activity in gingival crevicular fluid during
human orthodontic tooth movement. Am J Orthod
Dentofacial Orthop 2002;122:548-556.
15. Paknejad M, Emtiaz S, Khoobyari MM, Gharb MT,
Yazdi MT. Analysis of aspartate aminotransferase and
alkaline phosphatase in crevicular fluid from implants
with and without peri-implantitis. Implant Dent 2006;
15:62-69.
16. Daltaban Ö, Saygun I, Bal B, Balos K, Serdar M.
Gingival crevicular fluid alkaline phosphatase levels in
postmenopausal women: Effects of phase I periodon-
tal treatment. J Periodontol 2006;77:67-72.
17. Paolantonio M, D’Angelo M, Grassi RF, et al. Clinical
and microbiological effects of subgingival controlled-
release delivery of chlorhexidine chip in the treatment
of periodontitis: A multicenter study. J Periodontol
2008;79:271-282.
18. Perinetti G, Paolantonio M, D’Attilio M, et al. Aspartate
aminotransferase activity in gingival crevicular fluid
during orthodontic treatment. A controlled short-term
longitudinal study. J Periodontol 2003;74:145-152.
19. Perinetti G, Spoto G. The use of ISO endodontic paper
points in determining small fluid volumes. J Appl Sci
Clin Dent 2004;1:7-11.
20. McNabb H, Mombelli A, Lang NP. Supragingival clean-
ing 3 times a week. J Clin Periodontol 1992;19:348-356.
21. Sato K, Yoneyama T, Okamoto H, Dahlén G, Lindhe J.
The effect of subgingival debridement on periodontal
J Periodontol • July 2008
disease parameters and the subgingival microbiota.
J Clin Periodontol 1993;20:359-365.
22. Plagnat D, Giannopoulou C, Carrel A, Bernard JP,
Mombelli A, Belser UC. Elastase, alpha2-macroglob-
ulin and alkaline phosphatase in crevicular fluid from
implants with and without periimplantitis. Clin Oral
Implants Res 2002;13:227-233.
23. Lamster IB, Hartley RL, Oshrain RL, Gordon JM. Evalua-
tion and modification of spectrophotometric procedures
for analysis of lactate dehydrogenase, beta-glucuronidase
and aryl sulfatase in human gingival crevicular fluid
collected with filter paper strips. Arch Oral Biol 1985;30:
235-242.
24. Egelberg J. Permeability of the dento-gingival blood
vessels. II: Clinically healthy gingivae. J Periodontal
Res 1966;1:276-286.
25. Egelberg J. Permeability of the dento-gingival blood
vessels. 3: Chronically inflamed gingivae. J Periodon-
tal Res 1966;1:287-295.
26. Griffiths GS, Moulson AM, Petrie A, James IT. Evalu-
ation of osteocalcin and pyridinium crosslinks of bone
collagen as markers of bone turnover in gingival
crevicular fluid during different stages of orthodontic
treatment. J Clin Periodontol 1998;25:492-498.
27. Adriaens PA, Adriaens LM. Effects of non-surgical
periodontal therapy on hard and soft tissues. Peri-
odontol 2000 2004;36:121-145.
28. Chapple IL, Socransky SS, Dibart S, Glenwright HD,
Matthews JB. Chemiluminescent assay of alkaline
Perinetti, Paolantonio, Femminella, Serra, Spoto
phosphatase in human gingival crevicular fluid: Inves-
tigations with an experimental gingivitis model and
studies on the source of the enzyme within crevicular
fluid. J Clin Periodontol 1996;23:587-594.
29. Ramfjord SP. Surgical periodontal pocket elimination:
Still a justifiable objective? J Am Dent Assoc 1987;
114:37-40.
30. Bowers GM, Chadroff B, Carnevale R, et al. Histologic
evaluation of new attachment apparatus formation in
humans. Part I. J Periodontol 1989;60:664-674.
31. Caton J, Nyman S. Histometric evaluation of peri-
odontal surgery. I. The modified Widman flap proce-
dure. J Clin Periodontol 1980;7:212-223.
32. Brayer WK, Mellonig JT, Dunlap RM, Marinak KW,
Carson RE. Scaling and root planing effectiveness:
The effect of root surface access and operator expe-
rience. J Periodontol 1989;60:67-72.
33. Loos B, Nylund K, Claffey N, Egelberg J. Clinical
effects of root debridement in molar and non-molar
teeth. A 2-year follow-up. J Clin Periodontol 1989;16:
498-504.
Correspondence: Dr. Giuseppe Perinetti, Department of
Cell Biology and Oncology, Consorzio Mario Negri Sud, Via
Nazionale 8/A, 66030 Santa Maria Imbaro, CH, Italy.
E-mail: perinetti@negrisud.it.
Submitted September 24, 2007; accepted for publication
January 7, 2008.
1207