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IJCRR - 8(9), May, 2016

Pages: 59-63

Date of Publication: 12-May-2016


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EVALUATION OF SYSTEMIC MARKERS RELATED TO ANEMIA IN PERIPHERAL BLOOD OF PATIENTS WITH CHRONIC GENERALISED SEVERE PERIODONTITIS A COMPARATIVE STUDY

Author: Chakravarthy Muppalla, Ramakrishnan Theyagarajan, Geetha Ari, Jaideep Mahendra

Category: Healthcare

Abstract:Background: The purpose of this study was to evaluate systemic markers related to anemia in peripheral blood of patients with chronic generalized severe periodontitis and compare them with healthy controls.
Materials and Methods: A total of 60 systemically healthy males, aged 18 to 50 years were selected from the out patients department of periodontology, Meenakshi Ammal Dental College and Hospital. They were divided into two groups; Controls (group A) 30 male volunteers with healthy gingiva and Test Group (group B) 30 male patients with chronic generalized severe periodontitis. Periodontal clinical parameters and hematological parameters were recorded in both the groups.
Results: Blood parameters of patients with chronic generalized severe periodontitis especially Red Blood Cell (RBC) count, Haemoglobin (Hb) and Packed Cell Volume (PCV) values were reduced in group B indicating that chronic generalized severe periodontitis has a definite systemic effect.
Conclusion: RBC count, Haemoglobin (Hb) and PCV values of chronic generalized severe periodontitis patients were low compared to healthy individuals.

Keywords: Anemia of chronic disease, Chronic generalized severe periodontitis, RBC Count, Packed cell volume, Haemogloblin

Full Text:

INTRODUCTION
Periodontitis is an inflammatory disease of the periodontium which is characterized by a progressive destruction of the tissues supporting the tooth fundamentally initiated by chronic bacterial infection.(1,2) Its primary etiology is of microbial infections which may be composed of bacteria currently recognized in the oral cavity. Several reports have indicated that bacterial cells can be found in the pocket wall of periodontitis lesions. Substantial scientific data indicate that the localized infections characteristic of periodontitis can have a significant effect on the systemic health of humans.(3-6) This host response may offer illustrative mechanisms for the interactions between periodontal infection and a variety of systemic disorders,(7) infections, malignant cells, and autoimmune dysregulation all lead to the activation of the immune system and production of cytokines, most notably tumor necrosis factor- alpha and IL-1 and IL-6.(8) Such inflammatory cytokines can depress erythropoietin production leading to the development of anemia.(9-10) The anemia of chronic disease (ACD) can be defined as the anemia seen in chronic infections, inflammatory conditions, or neoplastic disorders that is not due to marrow deficiencies or other diseases and occurs despite the presence of adequate iron stores and vitamins. The aim of this study was to evaluate systemic markers related to anemia in peripheral blood of male patients with chronic generalized severe periodontitis and compare it with males having healthy periodontium.

MATERIALS AND METHODS
Materials A total of 60 systemically healthy males, aged 18 to 50 years were selected from the out patients Department of periodontology, Meenakshi Ammal Dental College and Hospital from June 2014 to July 2015. The “Institutional Ethics Committee” approved this study and written informed consent was obtained from all participants of the study. The study comprised of Group A which includes 30 male volunteers with healthy gingiva with no attachment loss and Group B which includes 30 male patients with chronic generalized severe periodontitis were recruited.

INCLUSION CRITERIA
Patients with a clinical attachment loss of ≥5 mm in >30% of sites classified as chronic generalized severe periodontitis were included.

EXCLUSION CRITERIA
patients, subjects with history of diabetes, kidney disease, cancer and infectious diseases, patients with a history of hospitalization or intake of medications in the last 6 months, patients with a current or past habit of tobacco smoking or chewing and with a previous history of periodontal therapy, and patients with iron deficiency were excluded. Methods Periodontal parameters such as bleeding on probing, probing depth, clinical attachment loss and plaque index and heamotological parameters like total no of erythrocytes (RBC), Haemoglobin concentration (Hb), Mean Corpuscular Haemoglobin (MCH), Mean Corpuscular Haemoglobin Concentration (MCHC), Mean Corpuscular Volume (MCV), Packed cell volume (PCV), Serum Ferritin were examined Blood parameters assessment Blood samples (5 ml) were collected by vene puncture of the cubital vein in the antecubital fossa by using a 5 ml disposable syringe. A component of the blood sample was then transferred to sterile vacuum tubes containing an anticoagulant ethylene diamine tetraaceticacid (EDTA), for whole blood analysis. The left over blood was collected in sterile vacuum tubes with no added anticoagulant this was designated for serum separation for serum ferritin The hematological parameters like RBC count, PCV, Hb, MCV, MCH and MCHC were estimated in an automated blood counting machine. Biochemical parameters like serum ferritin were analyzed by using an automated analyzer.

STATISTICAL ANALYSIS
Statistical analysis was performed with SPSS Software for means ± SD of all the parameters were calculated for both the groups. And to illustrate differences between groups, independent sample t test and mann whitney u test formula p value were used, and was considered statistically significant if p value was <0.05.

RESULTS
In group A mean Plaque index score was 0.50.08 and in group B mean plaque index score was 0.6±0.09.In group A the percentage of bleeding sites on probing was found to be 31% and for group B it was found to be 73%.In group A mean probing depth and CAL was found to be 2.8±0.23mm and in group B mean Probing depth and CAL was found to be 5.8±0.67mm and 6.0±0.7mm respectively. (Table/fig- 1) The hematological parameters RBC count, Haemoglobin, PCV, MCV, MCH, MCHC and serum ferritin were evaluated in both the groups and compared. The mean RBC count (in million/mm3) in group A was 4.7±0.44 and in group B it was 4.2±0.77 and the mean Haemoglobin (in gm%) was 14.7±0.87 and 13.5±1.20 in group A and group B respectively with p value 0.04.(Table/fig-2) The mean PCV (in gm%) was 43.8±2.38 in group A and in group B it was 40.5±3.57 and difference was found to be statistically significant with p value 0.001.(Table/fig-2) The mean values of MCH, MCHC, MCV and Serum ferritinin group A and group B difference was found to be statistically not significant. (Table/fig-2) Results showed that Mean, standard deviation and level of significance of the clinical parameters among the two groups were presented in Table /fig-1.

DISCUSSION
Anemia of chronic diseases is the second common type of anemia (next to iron deficiency anemia). It is characterized by short lifespan of RBCs, caused by disorder in iron metabolism or resistance to erythropoietin action. A characteristic finding of the disorders associated with ACD was the increased production of the cytokines that mediate the immune or inflammatory response. All the processes involved in the development of ACD can be recognized to these cytokines and these cytokines are also released by periodontal tissues in response to bacterial infection. It has been guessed that periodontitis results in a low grade systemic inflammation. By tradition, an elevation in the number of peripheral leukocytes and a variation in the levels of serum proteins identified, as acute-phase proteins are characteristic of infectious conditions. Cartwright (1966)(11) stated that the pathologic processes such as shortened erythrocyte survival, failure of the bone marrow to increase red blood cell (RBC) production to compensate for this increased demand, and impaired release of iron from the reticuloendothelial system are involved in ACD. The pro-inflammatory cytokines are thought to act as mediators in suppressing erythropoeisis from the bone marrow leading to anemia. The cytokines like interleukin (IL)-1 , IL- 6, and tumor necrosis factor–alpha (TNF α) have been related to suppression of erythropoiesis. Cartwright also suggested that the supply of erythropoietin (EPO) to the marrow might be the rate-limiting factor in the impaired marrow response to ACD. Similar changes in blood components may also be noticed in patients with periodontitis. A study done by Hutter et al (2001)(12)shown lower erythrocyte numbers and lower haemoglobin (Hb) levels were reported in periodontitis patients. Down regulation of the erythropoiesis in bone marrow by pro-inflammatory cytokines may be responsible for decreased blood count.(13) Systemic circulation of cytokines originating from local inflammation destroys erythropoiesis.

Currently, two significant theories are available to explain the relationship between severe anemia and periodontitis. Some studies have provided evidence for improved periodontal health after correction of some anemia types.(14) However, others have reported improved anemia with the control of periodontal disturbances.(15-17). To rule out anemia caused due to iron deficiency, we also evaluated serum ferritin levels and included it as one more parameter in our study. Females were excluded in our study as they more prone to anemia due to increased blood loss during menstruation, hormonal imbalance during puberty, during reproductive phase and during menopausal stage. Smokers were also excluded since various studies (18) had shown that smoking also affects erythrocytes and other blood parameters. Patients with other systemic diseases and infectious diseases were also excluded as these diseases have shown reduction in RBCs in these patients.(19) The difference in plaque index score between the groups was less, the difference in bleeding sites, probing depth and CAL is significantly higher in group B compared to that of group A. This may be due to presence of virulent subgingival microbiota in patients with chronic generalized severe periodontitis which provide a significant and persistant gram negative bacterial challenge to the host. The sulcular epithelium which is normally ulcerated and irregular in chronic periodontitis patients may be the reason for the increased bleeding sites in group B.[20] On comparing the mean values of the mean RBC count (in million/mm3) and and the mean Haemoglobin (in gm%) between group A and group B the difference was statistically significant. The reduction in RBC and haemoglobin in group B patient may be caused by periodontal inflammation upregulating the proinflammatory cytokine. In chronic diseases, bone marrow activity is less due to cytokines produced at the inflammatory site.(21) The difference of the mean PCV (in gm%) was found to be statistically significant, this may be because of reduction of RBCs in group B as PCV varies with RBC counts, increase in RBC count causes increase in PCV and with decrease in RBC count PCV also decreases.(22) In our study the MCV value of group B was within the normal range which is usually seen in anemia of chronic disease.(23) In our study group B MCH was within the normal range indicating that patients did not suffer from megaloblastic anemia or iron deficiency anemia.(23) In our study in group B MCHC value was within normal range which shows that patients were not suffering from iron deficiency anemia.(23) In our study group B had serum ferritin level within normal range and MCV, MCH, MCHC values were also within normal range indicating patients were not suffering from iron deficiency anemia. In our study blood parameters of patients with chronic generalized severe periodontitis especially RBC count, Haemoglobin and PCV values are affected indicating that chronic periodontitis has a definite systemic effect. Further longitudinal and interventional study with more number of sample size has to be done to confirm that chronic generalized severe periodontitis can also lead to haematological signs of anemia. The signs might not be as severe as seen in other systemic conditions but they definitely cannot be disregarded.

CONCLUSION
In our study we found that there is reduction of some of the hematological parameters like RBCs, Haemoglobin, PCV of patients with chronic generalised severe periodontitis comparing with periodontally healthy individuals. This is the first study where serum ferritin levels has been evaluated and the patients with iron deficiency anemia were excluded from the present investigation. Since Chronic periodontitis is an inflammatory disease, the systemic conditions such as anemia may not have a direct effect on the progression of periodontitis, but indirectly it may effect the course of the disease through the production of proinflammatory cytokines. However this relationship needs to be explored further, in order to establish the association between the two ailments.

References:

1. Listgarten MA. Pathogenesis of periodontitis. J Clin Periodontol 1986;13:418-430.

2. Jotwani R, Cutler CW. Adult periodontitis Specific bacterial infection or chronic inflammation? J Med Microbiol 1998;47:187- 188.

3. DeStefano F, Anda RF, Kahn HS, Williamson DF, Russell CM. Dental disease and risk of coronary heart disease and mortality. Bio Med Journal 1993;306:688-691.

4. Kweider M, Lowe GD, Murray GD, Kinane DF, McGowan DA. Dental disease, fibrinogen and white cell count; Links with myocardial infarction? Scott Med J 1993; 38:73-74. 5. Syrjnen J, Peltola J, Valtonen V, Iivanainen M, Kaste M, Huttunen JK. Dental infections in association with cerebral infarction in young and middle-aged men. J Intern Med 1989;225:179- 184. 6. Collins JG, Smith MA, Arnold RR, Offenbacher S. Effects of Escherichia coli and Porphyromonas gingivalis lipopolysaccharide on pregnancy outcome in the golden hamster. Infect Immun journal 1994;62:4652-4655.

7. Mealey BL, Klokkevold PR. Periodontal medicine. In: Newman MG, Takei HH, Carranza FA, eds. Carranza’s Clinical Periodontology, 9th ed. Philadelphia: Saunders; 2002:229-244.

8. Weiss G, Goodnough LT. Anemia of chronic disease. Engl J Med 2005;352:1011-1023.

9. Faquin WC, Schneider TJ, Goldberg MA. Effect of inflammatory cytokines on hypoxia-induced erythropoietin production. Blood 1992;79:1987-1994.

10. Raja KB, O Latunde-Dada G, Peters TJ, McKie AT, Simpson RJ. Role of interleukin-6 in hypoxic regulation of intestinal iron absorption. Br J Haematol 2005; 131:656-662.

11. Cartwright GE. The anemia of chronic disorders. Semin Hematol 1966;3(4):351-75.

12. Hutter JW, Van der Velden U, Varoufaki A, Huffels RA, Hoek FJ, Loos BG. Lower numbers of erythrocytes and lower levels of hemoglobin in periodontitis patients compared to control subjects. J Clin Periodontol 2001;28:930-936.

13. Jongen-Lavrencic M, Peeters HR, Vreugdenhil G, Swaak AJ. Interaction of inflammatory cytokines and erythropoeitin in iron metabolism and erythropoiesis in anemia of chronic disease. Clin Rheumatol 1995;14:519-525.

14. Salvi GE, Lawrence HP, Offenbacher S, Beck JD. Influence of risk factors on the pathogenesis of periodontitis. Perio 2000 1997;14:173-201.

15. Pradeep AR, Sharma A, Arjun Raju P. Anemia of Chronic Disease and Chronic Periodontitis: Does Periodontal Therapy Have Effect on Anemic Status. J Periodontol 2011;82:388-394.

16. Agarwal N, Kumar VS, Gujjari SA. Effect of periodontal therapy on hemoglobin and erythrocyte levels in chronic generalized periodontitis patients: An interventional study. J Indian Soc Periodontol 2009;13:6-11.

17. Lu S-Yu, Eng HL. Dramatic recovery from severe anemia by resolution of severe periodontitis. J Dent Sci 2010;5:41−46

18. Ernst E. Haemorheological consequences of chronic cigarette smoking. J Cardiovasc Risk 1995;2:435-439.

19. Sneha R. Gokhale,,Shivaswamy Sumanth, and Ashvini M. Padhye. Evaluation of Blood Parameters in Patients With Chronic Periodontitisfor Signs of Anemia. J Periodontol. August 2010;vol 81(8);1202-1205.

20. Page RC. The pathobiology of periodontal diseases may affect systemic diseases: inversion of a paradigm, ann periodontal 1998; 3:108-109.

21. Prakasam Reddy. Erythropoises. Fundamentals of Medical Physiology 5th edition:PARAS:268.

22. Prakasam Reddy. Packed cell volume or Haematocrit, blood indices and Erythrocyte Sedimentation Rate. Fundamentals of Medical Physiology 5th edition 279-280.

23. Ravi Sharma Text book of Clinical Methods, The history, physical and Laboratory Examinations: Third edition: Butterworths publications. Red blood indices 720-723.

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Awards, Research and Publication incentive Schemes by IJCRR

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

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‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

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A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
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A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
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A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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