CC BY
19
npoSAeMH eKOAorii Ta MejHUHHH
English version: LEVELS OF ALANINE- AND ASPARTATE AMINOTRANSFERASES IN PERIODONTAL POCKETS IN OUTCOMES OF CHRONIC PERIODONTITIS THERAPY WITH AZITHROMYCIN
Skrypnykov P., Nepokupna-SlobodyanyukT. *; Shynkevich V.
Higher state educational establishment of Ukraine "Ukrainian Medical Stomatological Academy", Poltava; * Dental Clinic of Company with Limited Liability "Medikol plus", Kyiv
Using of objective criteria of treatment efficiency of chronic periodontitis in ciinicai trials is an important issue. Therefore, estabiishing the relationship of ALT and AST levels with the ciinic outcomes of chronic periodontitis treatment in two modes of azithromycin use could confirm the effectiveness of treatment. After the standard periodontal treatment of chronic generaiized periodontitis (CGP) I-III severity, 60 patients were divided equally into 3 groups. In group 2 and 3 azithromycin was administered: 500 mg 1 time per day, for 3 days, and 500 mg 1 time per day for 7 days, followed by 500 mg 1 time per week for 12 weeks. Ciinicai indexes and AST, ALT concentrations were evaluated before treatment and in 1 week time and then in 2, 3, 6, 12 months. An exacerbation of CGP reported in 65% of patients in 3 months of standard treatment, the levels of AST, ALT in the group did not differ from the state before treatment. An exacerbation of CGP reported in 50% of patients in 6 months in group 2 and increased levels of AST, AL T was observed. Reduced AST and ALT levels (64.4±26.9; 76.6±22.0 U/L) confirmed the clinical benefit of therapy in the third group (20% of exacerbations CGP) in comparison with group 1 (110.7±17.5; 104.9±22.0 U/i) and2 (82.9±18.6; 95.2±27.3 U/L), but levels were higher than in previous periods of research (p<0.05). The evaluation of AL T, AST in periodontal pockets can be sensitive, suitable, convenient and simple method to determine inflammatory periodontal destruction activtty.
Key words: alanine aminotransferase, aspartate aminotransferase, chronic generalized periodontitis, azithromycin.
Persistent subgingival bacterial plaque induces host immune response causing tissue destruction by activating universal destructive mechanisms in chronic generalized periodontitis (CGP) [4, 5]. Conventionally, two related inflammation types support the CGP progression - immune and non-specific, and there are a range of metabolites to assess inflammation activity [2, 13, 14]. Alanine and aspartate aminotransferases (ALT, AST) are cytoplasmic enzymes that have importance to amino acids synthesis, and release from destroyed cells [20, 21]. ALT and AST is always present in the oral fluid, secretions of the salivary glands [17, 19], periodontal ligament, gingival crevicular fluid and enamel pellicle [12] in some concentration.
Periodontal pathogenic bacteria penetrate periodontal tissues and blood at CGH, so it is difficult to eradicate [15]. Azithromycin is semisynthetic antibiotic-macrolide of second generation which has effectiveness against microbial biofilm due appropriate antimicrobial spectrum [8] and immunomodulating properties by accumulation in neutrophils, macrophages, fibroblasts, showing antibacterial, anti-inflammatory and regenerative effects [10].
The aim of study was to establish the relationship of ALT and AST concentrations with clinical parameters of periodontal status in outcomes of CGP complex conservative treatment in two modes of azithromycin using to confirm effectiveness of treatment.
Contingents and methods.
The study was conducted at bases of Department of postgraduate dentists education, State higher educational establishment of Ukraine "Ukrainian Medical Stomatological Academy", Poltava, Dental Clinic of Company with Limited Liability "Medikol plus", Kyiv and Research Institute for Genetic and Immunological Bases
of Pathology and Pharmacogenetic of Ukrainian Medical Stomatological Academy, Poltava. The study was approved by the Bioethical Committee of Ukrainian Medical Stomatological Academy.
The trial was conducted on 60 chronic periodontitis patients, aged 23-65 years, with CGP I, II and III levels of severity. Before enrolling in the clinical trial, all patients were screened and their diagnosis were verified. The patients were examined for complete blood count, blood glucose, periodontal clinical parameters (PPD, BoP and CAL), x-ray. All patients received the same initial periodontal treatment (IPT), which included scaling and root planing, irrigation and instillation in periodontal pockets (PC) 2% chlorhexidine, periodontal dressing "Parasept" (Vladmyva, Russia), oral hygiene instructions, seals and restorations correction or replacement, occlusal adjustment when indicated, and supportive periodontal therapy (SPT) when indicated, according to the standard protocol.
Criteria for inclusion in the study: 1) signing the informed consent, 2) a patient suffers from CGP I, II, III severity. Criteria for exclusion: 1) heavy non-control internal diseases, or neuropsychiatric disorders, 2) the presence of other conditions as determined by the patient's inability to understand the nature and possible consequences of the study.
Patients were randomly assigned into three groups of 20 people after initial periodontal treatment and sanation measures. The patients of the 1st group received initial periodontal treatment and supportive periodontal therapy when indicated, according to the standard protocol. In group 2 and 3 azithromycin ("Azymed", "Kievmedpreparat", Ukraine) was administered: by mode short-term prescribing 500 mg 1 time per day, 3 days; and by long-term prescribing 500 mg 1 time per day, 7 days, followed by 500 mg 1 time per week for 12 weeks.
To cite this English version: Skrypnykov P., Nepokupna-SlobodyanyukT*.; Shynkevich V. Levels of alanine- and aspartate aminotransferases in periodontal pockets in outcomes of chronic periodontitis therapy with azithromycin / / Problemy ekologii ta medytsyny. - 2013. - Vol 17, № 5-6. - P. 51 -55.
Clinical indexes and AST, ALT concentrations were evaluated before treatment and in 14±3, 30±5, 90±5, 180±5 and 360±5 days.
Clinical dental examination included the determination of subjective well-being of patients using a visual analog scale, assessment of hygiene index (HI) Fedorova-Volodkinoi, HI and index of dental calculus Green Vermillion (OHI-S = DI+CI), probing Shyllera-Pisareva (PS-P), PMA, periodontal index Russell's (PI), probing pocket depth (PPD), gingival recession (GR), index of teeth pathological mobility (TM), bleeding on probing (BoP), signs of traumatic occlusion.
The material for the study of ALT and AST were samples of periodontal pockets content received with paper pins. Sample obtained from one or two PCs of the same teeth, which was determined as active inflammation: area was isolated from oral fluid, supragingival plaque was removed, tooth was dried, pins gently submerged into periodontal pocket edge 1-2 mm and heated for 30 seconds. Pins with samples were put into sterile dry ependorfes, and delivered to the laboratory within 12 hours. They were stored at -80°C
prior evaluation. And they were transported from Kiev in a thermos with freezing elements. Determination of ALT, AST was performed by kinetic photometric (dinitrofenilhidrazyn) method using a kit "Bio-La-Test" (Czech Republic) as previously described [3].
The results were assessed statistically using the method of t-test for independent or dependent variables, chi-square test (x2) with Yates's correction. Complete blood count and blood glucose in patients were spent in certified clinical laboratories of Kyiv and Poltava, according to standard methods.
Results.
Periodontitis patients were recruited and randomized into three groups of clinical research, balanced for age, sex, CGP severity, clinical features and comorbidities that were compensated.
Average baseline data of clinical indexes for three groups did not differ clinically significantly (shown in Table 1). Results of X-rays researches showed irregular type of interalveolar bone destruction, the destruction level confirmed the CGP severity.
Table 1
Average clinical indexes befor initial periodontal treatment
Groups HI F.-V., scores OHI-S DI, scores OHI-S CI, scores PMA, % BoP, scores TM, scores PPD, mm GR levels, mm PI Rassel's, scores
1 2.75±0.33 2.00±0.33 1.44±0.67 67.60± 15.97 2,11±0.62 0.61 ±0.65 1.60±0.89 1.47±0.76 3.80±1.25
2 3.46±2.22 2.41±0.21 * 1.42±0.77 66.05± 19.29 2.0±0.62 0.73±0.52 1.29±0.72 1.72±0.83 3.75±1.28
3 3.30±0.61* 2.56±0.68 1.27±0.74 68.75± 17.88 1.95±0.43 0.52±0.54** 1.64±0.85** 1.23±0.71 ** 3.80±1.05
Note. Statistical analysis by t-test for independent variables deviation (SD, 5); * - p <0.05 when compared to 1
ALT and AST levels had significant individual deviations before treatment, but the overall pattern was quite high in average: 102.4±13.7 U/l; 89.0 ±11.7 - in group 1, 95.0±23.6; 83.7±10.1 - in the 2nd, 111.0±34.8 and 95.3±18.2 - in the 3rd, which did not differ significantly.
In 14±3 days after IPT, all patients in groups showed self-esteem improvement, that was reflected in a significant increase in visual scale scores (from 43.60±20.39 to 80.70±11.30* in group 1, from 45.80±18.87 to 77.70±16.75* in the 2nd and from 45.60±18.61 to 75.1±20.90* - in the 3rd). Average AST concentration decreased significantly among patients of the 3rd group as compared with 1st, and 2nd. Periodontal pockets ALT level increased at the term in patients of group 3 (Fig. 1, 2).
■ the data are presented as the sample mean (M) ± standard st group; ** - p <0.05 to 2nd.
□ 1 group
□ 2 group
□ 3 group
14 days 30 days 90 days
Fig. 1. Comparative average AST concentrations dynamics in periodontal pockets in patients groups
□ 1 ffoup
□ 2 a-oup
□ 3 a-oup
Betor treatment
Fig. 2. Comparative average ALT concentrations dynamics in periodontal pockets in patients groups
In 30±5 days after treatment, all clinical indexes in groups improved significantly and did not differ between groups, but the average level of gingival recession was lower in the 3rd groups (1.53±0.89), compared to the 1st (1.97±0.99), p<0,05. It was interesting a dramatic decrease of average BoP in 2nd (0.54±0.33) and 3rd group (0.44±0.33) compared with baseline values (p<0.05). That can be explained by azithromycin clinical efficacy compared to only standard local IPT. The average AST concentrations in the 2nd and 3rd groups were significantly lower than in the 1st (Fig. 1). The average ALT concentration was significantly decrease in 3rd group versus 1st group (Fig. 2), which may reflect the additional benefice in the 3rd group within 1 month after IPT.
In 90 ± 5 days visual analogue scale values remained significantly elevated in all groups. The average HIs were significantly lower in the 3rd group, compared to the 1st. indexes Average indexes of dental calculus, PMA, BoP,
30 —
50 —
40 —
20
14
30 day
90
80
360
120
100
80
60
40
20
180
360
npoSAeMH eKOAoriï Ta MejHUHHH
PI, PPD were exceeded those in group 1 versus other groups. In the 3rd group, the lowest value of GR was observed (data not shown). So, clinical IPT effects were not enough in the 1st group after 3 months: CGP exacerbations were registered in 13 of 20 patients (65%) (they had received SPT). Thus, clinically, the effect of treatment in group 1 lasted up to 3 months in 35 % of patients. The lowest concentrations of ALT and AST were registered in the 3rd group, compared with others (Fig. 1, 2). In 2nd group ALT and AST levels were lower
compared to the 1st, indicating the lowest therapy effect in group 1, that consistent and complement clinical data.
In 180±5 days of observation the best self-esteem recorded in the 3rd patients group according to visual scale data. The best hygienic condition, the lowest level of clinical inflammation was observed in the 3rd group. The highest indexes of dental calculus and PI Rassel's were in group 1 (Table 2). CGP exacerbations were registered in 9 patients in 1st and 10 - in 2nd group at this stage of researches.
Table 2
Clinical parameters comparison between 1, 2 and 3 groups after 180±5 days of observation
Indices Groups
1 2 3
Visual scale values, mm 70.20±24.92 68.05±26.05 84.65±20.86* **
HI F.-V., scores 2.34±0.4 2.29±0.43 1.99±0.49* **
OHI-S DI, scores 1.40±0.58 1.48±0.35 1.21±0.54 **
OHI-S CI, scores 0.57±0.53 0.24±0.28* 0.09±0.15 *
PMA, % 57.85±14.71 53.45±14.56 49.50±14.12 *
BoP, scores 1.40±0.95 1.17±0.92 0.05±0.07* **
TM, scores 0.48±0.49 0.52±0.40 0.22±0.30 * **
PPD, mm 1.20±0.52 1.11 ±0.57 1.10±0.61
GR, mm 2.27±1.08 2.01±1.03 1.52±0.88 * **
PI Rassel's, scores 4.08±1.41 3.75±1.03 3.56±1.18*
In about six months after IPT average AST and ALT concentrations in patients of 3rd group observed pattern as for the previous stage - its were the lowest. In group 2, there are signs of gradual increase in inflammation in the form of an increase in the mean concentration of
ALT, which now does not differ significantly from the 1st group (see Fig. 2).
In 360 ± 5 days of observation the best self-esteem was in patients of the 3rd group. This group was characterized by significantly better performance for almost all indexes (Table 3).
Table 3
Clinical parameters comparison between 1, 2 and 3 groups after 360±5 days of observation
Indices Groups
1 2 3
Visual scale values, mm 62.0±22.94 57.75±23.91 82.98±17.72 * **
HI F.-V., scores 2.46±0.35 2.35±0.29 2.12±0.47 * **
OHI-S DI, scores 1.37±0.59 1.55±0.39 1.39±0.41
OHI-S CI, scores 0.67±0.54 0.28±0.25* 0.18±0.19*
PMA, % 64.35±17.08 55.70±14.04* 49.80±13.96*
BoP, scores 1.75±0.76 1.46±1.01 0.06±0.09* **
TM, scores 0.58±0.54 0.54±0.43 0.23±0.80* **
PPD, mm 1.47±0.66 1.21±0.57 1.12±0.65*
GR, mm 2.47±1.05 2.24±1.0 1.55±0.90* **
PI Rassel's, scores 4.25±1.36 3.87±1.32 3.53±1.20*
This group remains stable previous trend for AST and ALT levels. Reduced AST and ALT concentration (64.4±26.9; 76.6±22.0 U/L) confirmed the clinical benefit of therapy in the 3rd group (20% CGP exacerbations) compared to the 1st (110.7±17.5; 104.9±22.0 U/L) and 2nd (82.9±18.6; 95.2±27.3 U/L), at higher concentrations than in the previous study periods (p<0.05). Average concentration of ALT was not significantly different in group 2 and 1st at the end of the study.
Thus, in the 2nd and 3rd groups recorded the best clinical therapeutic effect confirmed by biochemical indices of AST and ALT levels compared with controls (1st group), which received only the standard treatment without adjuvant antibiotic therapy.
Discussion
AST and ALT are cytoplasmic enzymes released during cell death or lesion, and increased levels of enzymatic activity is clearly associated with sites of active periodontal inflammation. Sites with severe gingivitis and
progressive loss of attachment are characterized by a significant AST increasing in crevicular fluid [11].
In studies in patients with periodontitis, the activity of AST in saliva was significantly increased (5 times) compared with control, and ALT activity changes in saliva not reaching significance [17]. Saliva AST level was significantly increased in patients who had more severe periodontitis. Bleeding gums and suppuration was observed in 20% of those in which the concentration of AST in saliva was increased three times compared to the control. Among the larger cohort of patients AST level was dependent on the severity of periodontitis, and ALT level was increased also [9].
Research shows AST and ALT levels decreasing in saliva of patients with CGP after scaling [18].
AST and ALT concentrations in periodontitis are associated with the type of tissue necrosis [9, 16, 22]. Periodontal ligament fibroblasts produce significantly lower levels of aminotransferases than gingival epithelial cells [7], which confirms the close relationship of ALT and
AST activity in periodontal pockets and its periodontal destruction.
We determined AST and ALT concentrations in the most active clinically sites of periodontitis, directly to the periodontal pockets, which would more accurately reflect the total activity of periodontal ligament destruction, which is, in fact, substrate of chronic periodontitis. AST and ALT concentrations were interpreted as indicators of nonspecific inflammation activity in periodontal pockets [17, 19].
When comparative changes in AST, ALT concentrations and clinical parameters dynamics were measured it was suggested clinical indexes and AST, ALT levels returned to baseline values in group 1 at day 90th±5 (Fig. 1, 2). Thence, clinical and biochemical dynamics in group 1 matched at time.
In group 2 AST and ALT levels began to grow at 90th±5 day, while remaining significantly below baseline data and below average values of the 1st group. But after six months observation AST levels did not differ from the baseline once. And mean ALT concentration was even higher than before treatment. Thus, according to these findings, treatment effect was lost after six months. At the same time, the value of clinical indexes of hygiene, plaque, PMA, BoP, teeth mobility and an average PPD were significantly decreased than before treatment. GR increased in that group along. Therefore, there is an advancing tendency for the biochemical nonspecific inflammation parameters in comparing with clinical impairment at short-term adjuvant therapy with azithromycin.
ALT concentration significantly increased in 3rd group on day 14th, when antibiotic treatment was lasting. But the concentration decreased in other two groups, which requires discussion. It is known azithromycin causes degranulation of neutrophils, evidence of which is lysosomal enzymes increasing in plasma and decreasing in macrophages after the first dose of azithromycin. After a standard course of antibiotic therapy (500 mg of azithromycin daily, for 3 days) the level of enzymes in the blood remained high for some time, and at the same time granules accumulates in neutrophils by feedback mechanism, thus provides prolonged anti-infective protection. Chemotaxis of macrophages into inflammatory focus is induced at the same time with lysosomal enzymes levels increasing. Thus, significant anti-infective barrier increasing occurs through attracting new pools of leukocytes and their function activation [1]. Also, azithromycin promotes "oxidative burst" in macrophages. This effect is very long and provides activation of phagocytes [6]. Obviously, these processes can explain some transient ALT increasing in locus morbid.
In the 3rd group AST concentrations decreased, as in group 2, at day 14th ± 3 after IPT, ALT - at day 30th±5, but more significantly, they fell down at third month, when the antibiotic has just ended. On the period of about six months, ALT, AST values increased slowly, remaining significantly below the baseline (ie, before treatment) at the end of the study (see Fig. 1, 2). A similar trend was noted for clinical indicators of 3rd group, although biochemical parameters increased with some advance, as in group 2. Laboratory nonspecific inflammation parameters increased prior to clinical impairment at long therapy with azithromycin.
Importance of diagnostic AST, ALT concentrations determination in periodontal pockets at different forms of
chronic periodontitis is difficult to overestimate. Standard methods of clinical monitoring have several disadvantages. So pockets depth measurement should be carried out in six points around each tooth. Attachment level depends on the level of gingival recession, which increases after inflammation reduction, thus does not reflect active inflammation at the time of measurement and for further calculations. Further, the level of interalveolar bone destruction, which is a central objective measure to establish the severity of periodontitis, reflects mainly the cumulative destruction, but no active inflammation at the moment, so has clinical implications for orthopedic treatment or tooth extraction better than as indications for anti-inflammatory periodontal therapy. In addition, due to smaller thickness interradicular bone at the frontal, the level of destruction happened greater and faster. Instrumental determination of bone pockets, number of its walls, etc., still guided in lateral dental regions, and it is also quite time consuming rather then removal of dental plaque.
In contrast to ALT, AST determination in oral fluid, its measuring in periodontal pockets more accurately reflects local status, since the composition of oral fluid dependents on salivary glands condition and oral mucous first of all [9, 17]. Thus, diagnostic of AST, ALT determination in periodontal pockets should take a prominent place among the standard screening methods to determine periodontal treatment outcomes due its simplicity, speed and inexpensive cost.
Conclusions
1. ALT, AST levels determination in the periodontal pockets can be sensitive, reasonable, convenient and easy method to determine the activity of inflammatory periodontal destruction at a certain periodontal site.
2. Biochemical AST and ALT levels reflected nonspecific inflammation activity in periodontal pockets may increase prior for at least one month to clinical impairment measured by standard periodontal indexes.
3. Biochemical AST, ALT monitoring in periodontal pockets confirmed the best effect of long adjuvant course of azithromycin.
References
1. Karpov O.I. Macrolides: a new paradigm -pharmacodynamics / immunomodulation [electronic resource] / O. Karpov // Clinical Pharmacology and terapiya.-2005.-T. 14, № 5.- access to journal.: Http://medi.ru/DOC/1475187.htm.
2. Clinical and metabolic database of chronic generalized periodontitis / E.M. Gilmiyarov, V.P. Gentle, I.E. Gilmiyarova, V.P. Tlustenko // Stomatologiya. 2008. - № 5.-P.23-26.
3. Methods for clinical and experimental research in medicine [Berkalo L.V. Bobovich A.V., Bobrova N.A. and others.], ed. by Kaydashev I.P. - Poltava: Polimet, 2003.-319p.
4. Essays of immunobiology of the oral mucosa / [Kaydashev I.P., Shinkevich V.I., Korol D.M.et al.], ed. by I.P. Kaydashev.-Poltava: Polimet, 2008.-310p.
5. Shynkevych V.I. Characterization of immune cells from gingiva mucous at chronic generalized periodontitis according to severity / V.I. Shynkevych, I.P. Kaydashev // Immunologiya and Alerholohiya.-2004. - № 4.-P.15-19.
6. Amsden G. Anti-inflammatory effects of macrolides - an underappreciated benefit in the treatment of community-acquired respiratory tract unfections and chronic inflammatory pulmonary conditions? / G. Amsden // J. Antimicrob. Chemother.-2005.-Vol. 55, N 1.-P.10-21.
7. Analysis of aspartate aminotransferase in gingival crevicular fluid assessed by using PocketWatch: a longitudinal study with initial therapy / K. Shimada, T. Mizuno, K. Ohshio et al. // J. Clin. Periodontol.-2000.-Vol.27, N 11.-P.819-823.
Проблеми екологц та медицини
8. Clinical and microbiological effects of azithromycin in the 16 treatment of generalized chronic periodontitis: a randomized placebo-controlled clinical trial / E. Sampaio,
M. Rocha, L.C. Figueiredo et al. // J Clin Periodontal.-2011.-Vol. 38, N 9.-P.838-846.
9. Current developments in salivary diagnostics / C.S. Miller, 17 J.D. Foley, A.L. Bailey et al. // Tex Dent J.-2010.-Vol.127,
N 7.-P.651 -661.
10. Effects of periodontal non-surgical therapy plus azithromycin on glycemic control in patients with diabetes:
a randomized clinical trial [Електронний ресурс] / J.E. 18 Botero, F.L. Yepes, S.P. Ochoa et al. // J Periodontal Res.-2013.-Vol. 27.-Doi: 10.1111/jre.12058.
11. Gupta G. Gingival crevicular fluid as a periodontal diagnostic indicator- I: Host derived enzymes and tissue 19 breakdown products / G. Gupta // J Med Life.-2012.-Vol. 5,
N 4.-P.390-397.
12. Hannig C. Transaminases in the acquired pellicle / C. 20 Hannig, B. Spitzmuller, M. Hannig // Arch. Oral Biol.-2009.-Vol.54, N 5.-P.445-448.
13. Identification of pathogen and host-response markers 21. correlated with periodontal disease / C.A. Ramseier, J.S. Kinney, A.E. Herr et al. // J Periodontol.-2009.-Vol.80, N 3.-P.436-446. 22
14. Kinney J.S. Oral fluid-based biomarkers of alveolar bone loss in periodontitis / J.S. Kinney, C.A. Ramseier, W.V. Giannobile // Ann N Y Acad Sci.-2007.-Vol.1098.-P.230-251.
15. Mouth: A portal to the body / D. Gude, R.R. Koduganti, S.J. Prasanna, L.R. Pothini // Dent Res J (Isfahan).-2012.-Vol. 9, N 6.-P.659-664.
Relationship between levels of aspartate aminotransferase in gingival crevicular fluid and conventional measures of periodontal status assessed using PocketWatch: a cross-sectional study / K. Shimada, T. Mizuno, T. Uchida et al. // J. Oral Sci.-1999.-Vol.41, N 1.-P.35-40. Salivary aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase: possible markers in periodontal diseases? / A. Totan, M. Greabu, C. Totan, T. Spinu // Clin. Chem. Lab. Med.-2006.-Vol.44, N 5.-P.612-615.
Salivary enzyme levels after scaling and interleukin-1 genotypes in Japanese patients with chronic periodontitis / H. Yoshie, H. Tai, T. Kobayashi et al. // J. Periodontal.-2007.-Vol.78, N 3.-P.498-503.
Screening of periodontitis with salivary enzyme tests / Y. Nomura, Y. Tamaki, T. Tanaka et al. // J. Oral Sci.-2006.-Vol.48, N 4.-P.177-183.
Sherman K.E. Alanine aminotransferase in clinical practice. A review. / K.E. Sherman // Arch. Intern. Med.-1991.-Vol.151, N 2.-P.260-265.
The current state of serum biomarkers of hepatotoxicity / J. Ozer, M. Ratner, M. Shaw, W. Bailey, S. Schomaker // Toxicology.-2008.-Vol.245, N 3.-P.194-205. Yucekal-Tuncer B. Gingival crevicular fluid levels of aspartate amino transferase, sulfide ions and W-benzoyl-dl-arginine-2-naphthylamide in diabetic patients with chronic periodontitis / B. Yucekal-Tuncer, C. Uygur, E. Firatli // J. Clin. Periodontol.-2003.-Vol.30, N 12.-P.1053-1060.
Mamepian Hadiuwoe do pedaKuj'i 21.11.2013
