|Year : 2019 | Volume
| Issue : 1 | Page : 4-7
Comparison of hematological parameters for signs of anemia among participants with and without chronic periodontitis: A cross-sectional study
Sarita Parihar1, NK Sharma2, Atul Bhatnagar3, Dhiraj Kishore4, Ajit V Parihar5, Faizia Rahman1
1 Department of Periodontics, Faculty of Dental Science, IMS, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Oral Surgery, Faculty of Dental Science, IMS, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Prosthodontics, Faculty of Dental Science, IMS, Banaras Hindu University, Varanasi, Uttar Pradesh, India
4 Department of Medicine, Faculty of Modern Medicine, IMS, Banaras Hindu University, Varanasi, Uttar Pradesh, India
5 Department of Orthodontics, Faculty of Dental Science, IMS, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Submission||16-Feb-2018|
|Date of Acceptance||11-Feb-2019|
|Date of Web Publication||15-Mar-2019|
Dr. Faizia Rahman
Department of Periodontics, Faculty of Dental Science, IMS, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Chronic infection has a known effect on the cytokine levels of the body which adversely affects erythropoiesis. Aim: The aim of this study is to compare hematological parameters among participants with and without chronic periodontitis which also is a known infectious inflammatory disease of the gums. Materials and Methods: Forty patients with severe chronic periodontitis (Group A) and forty periodontally healthy participants (Group B) in the age group of 30–55 years presenting to the Outpatient Department of the Faculty of Dental Sciences, Banaras Hindu University, were recruited in the study and were assessed for various hematological and periodontal parameters. SPSS 17.0 version was used. Student's t-test (unpaired) was used. P < 0.05 was considered statistically significant. Results: Group A showed lower hemoglobin (Hb, 13.47 ± 1.05, P = 0.019), erythrocyte count (4.63 ± 0.40, P = 0.002), and mean corpuscular Hb concentration (32.58 ± 0.90, P = 0.003) values compared to Group B (13.95 ± 0.70, 4.90 ± 0.33, and 33.18 ± 0.81, respectively). Conclusion: Within the limitations of the study, it can be safely deduced that a positive relationship exists between the hematological parameters and severity of chronic periodontal disease, suggesting that long-standing chronic periodontitis may lead to the development of signs of anemia.
Keywords: Chronic periodontitis, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration
|How to cite this article:|
Parihar S, Sharma N K, Bhatnagar A, Kishore D, Parihar AV, Rahman F. Comparison of hematological parameters for signs of anemia among participants with and without chronic periodontitis: A cross-sectional study. J Indian Assoc Public Health Dent 2019;17:4-7
|How to cite this URL:|
Parihar S, Sharma N K, Bhatnagar A, Kishore D, Parihar AV, Rahman F. Comparison of hematological parameters for signs of anemia among participants with and without chronic periodontitis: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2019 Jul 22];17:4-7. Available from: http://www.jiaphd.org/text.asp?2019/17/1/4/254332
| Introduction|| |
Chronic periodontitis is an inflammatory disease of the supporting structures of the teeth caused by specific microorganisms in a susceptible host. The plethora of bacterial challenges that are typical of chronic periodontitis disease poses a threat to the integrity of the sulcular epithelium which acts as a protective barrier. This breach of the sulcular epithelium acts as a gateway to the bacterial irritants to enter the connective tissue and thus into the systemic circulation. The host response in turn activates C-reactive proteins, interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) all of which can depress erythropoietin production leading to the development of anemia. Gayatri et al. reported no correlation between periodontal disease and anemia; however, Lowe and Patel et al. reported a definite correlation between anemia and chronic periodontitis. Thus, these conflicting results of previous studies led us to further our knowledge on the present topic, and thus, this study was conducted so as to know the correlation between anemia and chronic periodontitis.
The most commonly observed form of anemia in clinical medicine is anemia of chronic disease., It is defined as anemia occurring in chronic infections, inflammatory conditions, or a neoplastic disorder, which is not caused by marrow deficiencies or other diseases, and occurring despite the presence of adequate iron stores and vitamins.,
Recent years have seen a growing interest in periodontal medicine which focuses on the relationship between periodontal and systemic health. This means a two-way relationship exists in which the periodontal disease in an individual may have an effect on his/her systemic health and vice versa. However, debate still exists on the nature and degree to which this association exists.
The present study was attempted to evaluate and compare hematological parameters for signs of anemia among systemically healthy male participants with or without chronic periodontitis.
| Materials and Methods|| |
The present study was a hospital-based study. Ethical approval for the study was obtained from the Institute Ethical Committee (Ref no.: ECR/526/Inst/UP/2014 Dt 31.1.14). The entire study was carried out in the Unit of Periodontics, Faculty of Dental Sciences in collaboration with CCI Laboratory, Institute of Medical Sciences (IMS), Banaras Hindu University (BHU). The study period was from July 2017 to September 2017. Detailed verbal instructions were given to each participant of the study, and a written informed consent was obtained.
The study population consisted of 80 systemically healthy males aged 30–55 years attending the Outpatient Department of the Unit of Periodontics, Faculty of Dental Science, IMS, BHU. The sample size was determined statistically by putting the values obtained in previous studies to the following formula:
N = z2.δ2/(x1−x2)2 where Z = 1.96, δ = pooled standard deviation, X 1 = mean of Group 1, X 2 = mean of Group 2.
The participants were divided into two groups – Group A (cases) and Group B (controls). Group A comprised participants suffering from clinically visible signs of chronic periodontitis and Group B consisted of participants with clinically healthy gingiva with no signs of gingivitis or periodontitis. Age matching was done. Gender matching was not required as only males were included in the study.
A thorough systemic and family history of each participant was recorded. Participants were excluded from the study if they were found (1) suffering from diabetes mellitus, hypertension, malignancy, or any other chronic diseases except chronic periodontitis, (2) having a history of hospitalization or intake of medications in the last 6 months and having history of blood loss, (3) past or present tobacco user, (4) having any history of periodontal therapy at any time, and (5) having <16 teeth in the oral cavity.
Full-mouth examination was conducted for each participant, and detailed gingival and periodontal findings were recorded by a single independent trained dental professional (kappa value: 0.91). Group B included participants with clinically healthy gingiva with a periodontal probing depth ≤3 mm at all sites whereas Group A had participants who fulfilled the inclusion criteria of having probing pocket depth (PPD) ≥5 mm at minimum 30% of sites and clinical attachment levels (CALs) ≥2 mm at minimum 30% of sites. PPDs, CALs, gingival index, and plaque index were all recorded using a marked periodontal probe UNC-15 (HU-Friedy, Chicago, IL, USA). Tooth mobility, furcation involvement, and number of missing teeth were also recorded.
After complete recording of gingival findings, venous blood samples were obtained from each participant by a nursing assistant. Two milliliters of blood was obtained by venipuncture from the antecubital fossa under complete aseptic measures and immediately transported to the Laboratory of IMS, BHU, to which our faculty is attached for hematological analysis. Hemoglobin (Hb), number of erythrocytes (red blood cell [RBC]), mean corpuscular volume (MCV), mean corpuscular Hb (MCH), MCH concentration (MCHC) were analyzed on a fully automated hematologic analyzer. The erythrocyte sedimentation rate (ESR) was measured according to the Wintrobe's method.
Statistical analyses were performed with SPSS software. Mean and standard deviation of all the parameters were calculated for both case and control groups. Descriptive statistics analysis was done to know the differences between groups; a Student's t-test (unpaired) was used and was considered statistically significant if P < 0.05.
| Results|| |
The mean Hb values were 13.95 ± 0.70 and 13.47 ± 1.05 g% in the control and case groups, respectively. The difference was statistically significant. The mean number of erythrocytes was 4.90 ± 0.33 million/mm3 for the control group whereas it was 4.63 ± 0.40 million/mm3 for the case group. The difference was statistically significant (P < 0.05). The MCH for the case group was 29.08 ± 2.62 pg and for the control group was 30.43 ± 2.23 pg. The MCHC for the control group was again higher (33.18 ± 0.81 pg/dl) than for the test group (32.58 ± 0.90 pg/dl). The differences were statistically significant for both (P = 0.016 and 0.03, respectively). The values of MCV were found to be not statistically significant. The percentage of patients who were anemic in terms of Hb was 22.5% in the case group compared to 5% in the control group [Table 1].
| Discussion|| |
Anemia is defined as a decrease in the human Hb concentrations below the normally acceptable levels and is one of the most commonly encountered health problems around the globe, especially in the developing countries. Iron deficiency, nutritional deficiency, heavy blood loss, bone marrow dyscrasias, hemoglobinopathies, and acute and chronic infections play an etiologic role in the causation of anemia. Many chronic infectious diseases such as rheumatoid arthritis and bacterial, viral, or fungal infections have been proven to be causing anemia. This kind of anemia, seen in chronic infectious diseases, is better known as anemia of chronic diseases. Chronic periodontitis, the most prevalent form of disease of the oral cavity, is also an infectious disease of mixed bacterial origin. Keeping all this in mind, it was hypothesized that this insidious chronic disease may have a role in the causation of anemia in the participants.
The subject of association of anemia with chronic periodontitis has been discussed in literature many a times as early as the 20th century. Anemia has been thought to be a cause of chronic periodontitis, and not been implicated as an effect of it. Hutter et al. was the first to evaluate the hemodynamic profile of participants suffering from chronic periodontitis and found that these participants showed signs of anemia. The present study was thus taken up to evaluate the effect of chronic periodontitis on the hemodynamic profile of an individual, especially anemia.
Females are more commonly affected by anemia than males because of the increased menstrual loss, poor nutrition, high incidence of tropical and intestinal infections, and various other ill-defined factors. Female participants are also more prone to hormonal imbalances, leading to an alteration of the microbial flora and consequently the host response. Thus, an exaggerated response of the periodontal tissues toward the local factors may be found. This may lead to a bias in the present study. To overcome this limitation, our study involved only male participants.
The present or past use of tobacco has also been proven to have a profound effect on the periodontal tissues leading to a greater than acceptable normal breakdown of the gingival structures. Tobacco affects both the local microflora as well as the host response of the individual, especially altering the effects of neutrophils, cytokines, phagocytosis, protease inhibitor production, etc. Thus, to prevent the confounding effect of tobacco, smokers were also excluded from the present study.
In a strict sense, all the values are within the normal acceptable range, but there still exists a difference between the test and the control groups. The test group is consistently seen to be having decreased levels than the control group. MCV is the main parameter for defining anemia. A decreased value of MCV suggests microcytosis whereas an increased value of MCV is an indicator of macrocytosis mostly caused by vitamin deficiency. However, MCV was within the normal range for both the groups and showed no statistically significant difference. Similarly, the mean Hb value was found to be low in the test group although the MCH and MCHC values were within the normal range. This can be attributed to low MCH and MCHC values in the test group as compared to the control group.
Hutter et al. and Thomas et al. proved that participants suffering from chronic periodontitis show a definite lower count of all blood parameters when compared to healthy controls. The present study shows a positive association between chronic periodontitis and signs of anemia. In the test group, all the hematological parameters showed a definite lower range when compared to healthy controls. Kolte et al. 2014 conducted a study to assess and explore the hemodynamic parameters in healthy participants and those suffering from chronic periodontitis. The results showed a decreased RBC parameters and increased white blood cell parameters, effectively demonstrating the presence of inflammation and a tendency toward anemic state. Kaur investigated the effects of clinically inflamed periodontium in male and female patients on their Hb levels with their healthy counterparts. They found a significantly lower level of RBC parameters in the test group than the control group.
Rai and Kharb in their study and Agarwal et al. in their separate study demonstrated an increase in blood Hb levels after scaling and root planing in participants suffering from chronic periodontitis. Few studies have shown conflicting results which failed to show any correlation between Hb and chronic periodontitis. Similarly, Prakash et al. conducted a study to investigate the relationship of anemia with chronic periodontitis using RBC parameters and serum ferritin values as tools. Their results showed hematological parameters to be not significantly different in participants with periodontitis than in the control group.
Cytokines, TNF-α, and IL-6 have been positively related with suppression of erythropoietin production. Alvarez-Hernández et al. further proved the role of recombinant TNF-α by exposing healthy mice to its intravenous doses which induced anemia and hypoferremia. The hypoferremia was associated with abnormalities of iron release from Reticulo endothelial system (RES) and incorporation into RBCs.
ESR suggests chronic infection. ESR is a nonspecific test to diagnose the presence or absence of inflammation because of the accumulation of several inflammation-related proteins which affect rouleaux formation subsequently precipitating sedimentation of erythrocytes. However, this parameter of inflammation is of limited use as a tool of diagnosis in periodontitis to measure the systemic involvement.,
Periodontitis is also a chronic insidious infectious disease of mixed bacterial origin and does impact the general health of the individual. It leads to increased cytokine release which suppresses erythropoietin production, the degree of which depends on the time duration and the severity of the disease. Thus clinical signs of anemia develop in participants suffering from chronic periodontitis, but this effect is mild as compared to other chronic infectious diseases such as rheumatoid arthritis. This can be justified by the fact that chronic periodontitis, in itself, is a mild disease when compared to other inflammatory conditions.
| Conclusion|| |
Although within the normal range but all the blood parameters were found to be toward the lower range in participants suffering from chronic periodontitis. A definite association between periodontal disease and hematological parameters in terms of reduced Hb concentration was noted in the present study. It can, thus, be safely concluded that though mild but chronic periodontitis does show its effect on the systemic health of the participant. The effects observed are, however, not as aggressive as compared to other diseases since chronic periodontitis disease in itself is a very mild insidious inflammatory condition. Nonetheless, the after effects of this chronic insidious disease cannot be overlooked and treatment should be started as soon as possible. Within the limitations of this study, though the results suggest a relationship between anemia and chronic periodontitis, future studies with a larger sample size and over a longer time span are encouraged.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Newman M, Takei H, Klokkevold P, Carranza F. Clinical Periodontology. 10th
ed. St. Louis, Missouri: W. B. Saunders; 2006.
Lindhe J, Lang NP, Karring T. Clinical Periodontology and Implant Dentistry. 6th
ed. United States: Wiley-Blackwell; 2015. p. 403.
Gayatri, Ishwary MR, Chaterjee A, Hussain MA, Praveen J, Deepika J. Relationship between periodontitis and anemia – Does it exist? Indian J Dent Sci 2015;7.
Lowe GD. The relationship between infection, inflammation, and cardiovascular disease: An overview. Ann Periodontol 2001;6:1-8.
Patel MD, Shakir QJ, Shetty A. Interrelationship between chronic periodontitis and anemia: A 6-month follow-up study. J Indian Soc Periodontol 2014;18:19-25.
] [Full text]
Lee GR. The anemia of chronic disease. Semin Hematol 1983;20:61-80.
Beutler E. The common anemias. JAMA 1988;259:2433-7.
Means RT Jr., Krantz SB. Progress in understanding the pathogenesis of the anemia of chronic disease. Blood 1992;80:1639-47.
Weiss G, Goodnough LT. Anemia of chronic disease. N Engl J Med 2005;352:1011-23.
McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anaemia, WHO vitamin and mineral nutrition information system, 1993-2005. Public Health Nutr 2009;12:444-54.
Lindhe J, Ranney R, Lamster I, Charles A, Chung CP, Flemmig T, et al
. Consensus report. Chronic periodontitis. Ann Periodontol 1999;4:389.
Lainson PA, Brady PP, Fraleigh CM. Anemia, a systemic cause of periodontal disease? J Periodontol 1968;39:35-8.
Chawla TN, Kapoor KK, Teotia SP, Singh NK. Anaemia and periodontal disease – A correlative study. J Indian Dent Assoc 1971;43:67-78.
Hutter JW, van der Velden U, Varoufaki A, Huffels RA, Hoek FJ, Loos BG, et al.
Lower numbers of erythrocytes and lower levels of hemoglobin in periodontitis patients compared to control subjects. J Clin Periodontol 2001;28:930-6.
Medappa N. Iron absorption and its implications on strategies to control iron deficiency anaemia. Indian Council Med Res Bull 2000;30:1-7.
Amar S, Chung KM. Influence of hormonal variation on the periodontium in women. Periodontol 2000 1994;6:79-87.
MacFarlane GD, Herzberg MC, Wolff LF, Hardie NA. Refractory periodontitis associated with abnormal polymorphonuclear leukocyte phagocytosis and cigarette smoking. J Periodontol 1992;63:908-13.
Wakai K, Kawamura T, Umemura O, Hara Y, Machida J, Anno T, et al.
Associations of medical status and physical fitness with periodontal disease. J Clin Periodontol 1999;26:664-72.
Samson D. The anaemia of chronic disorders. Postgrad Med J 1983;59:543-50.
Thomas B, Ramesh A, Ritesh K. Relationship between periodontitis and erythrocyte count. J Indian Soc Periodontol 2006;10:288-91.
Kolte RA, Kolte AP, Deshpande NM. Assessment and comparison of anemia of chronic disease in healthy subjects and chronic periodontitis patients: A clinical and hematological study. J Indian Soc Periodontol 2014;18:183-6.
] [Full text]
Kaur VH. Hematological parameters – A diagnostic mirror for periodontitis. Indian J Dent Sci 2013;5:45-8.
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.
] [Full text]
Prakash S, Dhingra K, Priya S. Similar hematological and biochemical parameters among periodontitis and control group subjects. Eur J Dent 2012;6:287-94.
Cartwright GE. The anemia of chronic disorders. Semin Hematol 1966;3:351-75.
Alvarez-Hernández X, Licéaga J, McKay IC, Brock JH. Induction of hypoferremia and modulation of macrophage iron metabolism by tumor necrosis factor. Lab Invest 1989;61:319-22.
Witte DL, Angstadt DS, Davis SH, Schrantz RD. Predicting bone marrow iron stores in anemic patients in a community hospital using ferritin and erythrocyte sedimentation rate. Am J Clin Pathol 1988;90:85-7.