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Table of Contents   
ORIGINAL RESEARCH  
Year : 2013  |  Volume : 24  |  Issue : 4  |  Page : 468-473
Evaluation of micronutrient (zinc, copper and iron) levels in periodontitis patients with and without diabetes mellitus type 2: A biochemical study


1 Department of Periodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, India
2 Department of Oral and Maxillofacial Surgery, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, India
3 Department of Biochemistry, K.S. Hegde Medical Academy, Karnataka, India

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Date of Submission23-Nov-2012
Date of Decision31-Mar-2013
Date of Acceptance25-Mar-2013
Date of Web Publication19-Sep-2013
 

   Abstract 

Context: Periodontal tissue destruction is caused by an inappropriate host response to microorganisms. Diabetes is a metabolic disease and most of its complications are due to hyperglycemia. Periodontitis is considered as its sixth complication. Micronutrients such as zinc, copper and iron are essential for human health. There is accumulating evidence that the metabolism of several trace elements is altered in diabetes mellitus and that these nutrients might have specific roles in the pathogenesis and progress of this disease and its complication. An association between micronutrients and periodontitis has also been suggested by preliminary studies. However, till date there is a lack of relevant clinical data.
Aim: This study was designed to estimate and compare the serum levels of zinc, copper and iron in diabetes mellitus type 2 patients and healthy individuals with and without periodontitis.
Setting and Design: Single centre case-control study.
Subjects and Materials: This study included 150 subjects, 50 in each group. Group 1 comprised of 50 subject with diabetes mellitus type 2 and periodontitis. Group 2 comprised of 50 subjects with chronic periodontitis and Group 3 comprised of 50 control subjects. Atomic absorption spectrophotometry method was used to measure clinical level of zinc and copper in serum. Estimation of serum iron levels was done by bathophenanthroline method.
Statistical analysis: The results obtained were tabulated and subjected to statistical analysis by analysis of variance and Tukey multiple comparison tests using statistical software SPSS version 17.
Results: The results showed that the serum levels of zinc decreased and serum levels of iron and copper increased in diabetes patients with periodontitis compared to healthy individuals with and without periodontitis.
Conclusion: Imbalance of Zinc, copper and iron levels in the serum can predispose an individual to the risk of developing periodontitis.

Keywords: Copper, diabetes mellitus type 2, iron, periodontitis, zinc

How to cite this article:
Thomas B, Gautam A, Prasad B R, Kumari S. Evaluation of micronutrient (zinc, copper and iron) levels in periodontitis patients with and without diabetes mellitus type 2: A biochemical study. Indian J Dent Res 2013;24:468-73

How to cite this URL:
Thomas B, Gautam A, Prasad B R, Kumari S. Evaluation of micronutrient (zinc, copper and iron) levels in periodontitis patients with and without diabetes mellitus type 2: A biochemical study. Indian J Dent Res [serial online] 2013 [cited 2019 Nov 17];24:468-73. Available from: http://www.ijdr.in/text.asp?2013/24/4/468/118400
Periodontitis is an immuno-inflammatory disease of the periodontal tissue characterized by destruction of bone and connective tissue attachment. It is a multifactorial disease modified by numerous risk factors, which include diabetes, smoking, host response, diet. [1] It is now accepted that though periodontitis is initiated by microbes, most of the periodontal tissue destruction is caused by an inappropriate host response (inflammatory and immune response) to those microorganisms. Loss of homeostasis between protective and destructive factors determines the host response and thus, eventually the extent of periodontal damage. [2]

Diabetes mellitus is a clinically and genetically heterogeneous group of metabolic disorders manifested by abnormally high levels of glucose in the blood. The hyperglycemia is the result of a deficiency of insulin secretion caused by pancreatic β-cell dysfunction or of resistance to the action of insulin in the liver and muscle, or a combination of these. [3]

The more prevalent form of diabetes is diabetes mellitus type-2 also referred to as non-insulin dependent diabetes mellitus, a condition which often develops over a period of time, involves reduced responsiveness of tissues to circulating insulin, and is often controlled by diet or oral hypoglycemic drugs. This condition is characterized by hyperglycemia, hyperlipidemia, and associated complications. [4],[5] The American Dental Association has recognised periodontitis as its sixth complication. [6]

Nutrition has significant effects on the inflammatory processes as well as the cellular and humoral immune mechanism. The interaction between nutritional status and the immune response to the bacterial challenge can be an underlying factor in the progression of periodontal disease. [7] Nutrition also plays an important role in wound healing. [8] A periodontal lesion is essentially a wound, and adequate nutrition must be available for optimal healing to take place. [9]

The daily diet consists of both macronutrients and micronutrients. The micronutrients are required in milligram (mg) to microgram (μg) quantity and include vitamins and minerals. Recommended daily allowance of micronutrient such as iron, copper, and zinc is less than 100 μg. These micronutrients have diverse metabolic characteristics and functions and are essential for human health. They are also necessary for functioning of many enzyme systems like deoxyribonucleic acid (DNA) polymerase, ribonucleic acid (RNA) polymerase, superoxide dismutase, catalases, alkaline phosphatase. [10] However, the exact mechanism by which micronutrients modify periodontal destruction has not been precisely understood.

Several studies suggest that diabetes mellitus can disrupt the homeostasis of several trace elements. Conversely, research also suggests that imbalances of specific elements may play an important role in the pathogenesis of diabetes and its various complications. [11]

However, there are only a few studies that have evaluated the possible relationship between micronutrients and periodontitis. Hence this study was designed to estimate and compare the serum levels of zinc, copper and iron in diabetes mellitus type 2 patients and healthy individuals with and without periodontitis.


   Subjects and Methods Top


The study was a case control study comprising of 150 subjects, 50 in each group.

  • Group 1: 50 subjects with type 2 diabetes mellitus and chronic periodontitis
  • Group 2: 50 subjects who were systemically healthy with chronic periodontitis
  • Group 3: 50 subjects who were systemically healthy and without chronic periodontitis.
The subjects were selected from the Department of Periodontics, A.B. Shetty Memorial Institute of Dental Sciences and Department of Medicine, K.S. Hegde Medical Academy, Mangalore. A written informed consent was taken from each subject. The ethical clearance was obtained from ethical board of NITTE University. The study was conducted from December 2010 to June 2012.

Subjects aged from 35 years to 60 years of both sexes were included in the study.

Criteria for subject selection are as follows:

Inclusion criteria

  • Patients categorized as type 2 diabetes mellitus who are under treatment for atleast 6 months and are on oral hypoglycaemic drugs, in the age group of 35-60 years
  • Patients with clinical attachment loss ≥ 4 mm in more than 30% of the sites for Group 1 and 2
  • Subjects who have a gingival index score of less than 2 in Group 3
  • Subjects with minimum complement of 20 teeth
Exclusion criteria

  • History of any antibiotic/anti-inflammatory therapy for 3 months prior to study
  • History of any systemic diseases for Group 2 and 3
  • History of any systemic disease other than diabetes mellitus type 2 for the Group 1
  • Pregnancy/lactation
  • Subjects with a history of smoking and any form of ­tobacco consumption
  • Subjects with a history of use of mouth wash within 3 months prior to study
  • Subjects with a history of vitamins/minerals or ­antioxidant supplements intake during the last 3 months
  • Subjects who had undergone any periodontal treatment for at least 3 months prior to study.
Screening examination

  • Medical history and dental history
  • Probing depth and loss of attachment using William's periodontal probe [Figure 1]
  • Figure 1: Measurement of loss of clinical attachment level

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  • Gingival index (Loe and Silness)
  • History of use of vitamins/minerals or antioxidants.
All measurements and readings were taken before the collection of the blood sample. The samples were coded before being sent for laboratory investigations.

Evaluation of zinc, copper and iron:

5 ml of venous blood sample was drawn from the subject through a disposable syringe and transferred to a centrifuge tube [Figure 2]. The sample was centrifuged at 3000 rpm for 15 min and the supernatant serum was collected [Figure 3]. Then digestion of the serum was done. Atomic abosorption spectrophotometry method was used to measure clinical levels of zinc and copper in serum [Figure 4]. Estimation of serum iron levels was done by bathophenanthroline method.
Figure 2: Collection of venous blood

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Figure 3: Centrifuge

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Figure 4: Atomic spectrophotometer

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Statistical analysis

The results obtained were tabulated and subjected to statistical analysis by one way analysis of variance (ANOVA) using statistical software SPSS version 17. The data were expressed as mean and standard deviation. Inter group comparison was done using Tukey test for multiple comparison. P values were considered to be statistically significant (P < 0.0005).


   Results Top


The study was designed as a case control study.

  • Group 1: 50 subjects with type 2 diabetes mellitus and chronic periodontitis
  • Group 2: 50 subjects who were systemically healthy with chronic periodontitis
  • Group 3: 50 subjects who were systemically healthy and without chronic periodontitis
[Table 1] and [Figure 5] shows and compares the mean and standard deviation of serum zinc levels in the three groups. The serum levels of zinc in Group 1 Shows a mean and standard deviation of 38.75 ± 8.482 when compared to Group 2 and 3, which shows a mean and standard deviation of 68.96 ± 7.267 and 74.71 ± 8.280 respectively. The result of one way ANOVA showed high statistical significance (P < 0.0005) between Group 1 and Group 2, between Group 2 and Group 3 and between Group 1 and Group 3.
Figure 5: Zinc -Group 1: Diabetic patients with chronic periodontitis. Group 2: Systemically healthy individuals with chronic periodontitis. Group 3: Systemically healthy individuals without chronic periodontitis

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Table 1: Mean and standard deviation of serum zinc levels in the three groups

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The Tukey test of significance showed highly statistically significant difference (P < 0.0005) between Group 1 and Group 3, between Group 1 and Group 2 and statistically significant difference (P < 0.018) between Group 2 and Group 3 as depicted by [Table 2].
Table 2: Comparison of serum zinc levels in three groups

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[Table 3] and [Figure 6] shows and compares the mean and standard deviation of serum Copper levels in the three group. The serum levels of Copper in Group 1 shows a mean and standard deviation of 128.94 ± 6.458 when compared to Group 2 and 3 which shows a mean and standard deviation of 88.64 ± 18.408 and 76.68 ± 4.893 respectively. The result of one way ANOVA showed high statistical significance (P < 0.0005) between Group 1 and Group 2, between Group 2 and Group 3 and between Group 1 and Group 3.
Figure 6: Copper -Group 1: Diabetic patients with chronic periodontitis. Group 2: Systemically healthy individuals with chronic periodontitis. Group 3: Systemically healthy individuals without chronic periodontitis

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Table 3: Mean and standard deviation of serum copper levels in the three groups

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Tukey test of significance showed highly statistically significant difference (P < 0.0005) between Group 1 and Group 3, between Group 1 and Group 2 and between Group 2 and Group 3 as depicted in [Table 4].
Table 4: Comparison of serum copper levels in three group

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[Table 5] and [Figure 7] shows and compares the mean and standard deviation of serum Iron levels. The serum levels of Iron in Group 1 shows a mean of 165.45 ± 14.612 when compared to Group 2 and 3 which shows a mean of 141.69 ± 24.412 and 130.67 ± 21.863 respectively. The result of one way ANOVA showed high statistical significance (P < 0.0005) between Group 1 and Group 2, between Group 2 and Group 3 and between Group 1 and Group 3.
Figure 7: Iron -Group 1: Diabetic patients with chronic periodontitis. Group 2: Systemically healthy individuals with chronic periodontitis. Group 3: Systemically healthy individuals without chronic periodontitis

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Table 5: Mean and standard deviation of serum iron levels in the three groups

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Tukey test of significance showed highly statistically significant difference (P < 0.0005) between Group 1 and Group 2 and between Group 1 and Group 3. The difference between Group 2 and Group 3 was not significant as depicted in [Table 6].
Table 6: Comparison of serum iron levels in three groups

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   Discussion Top


Micronutrients like zinc, copper and iron play an essential role in regeneration, for coping with oxidative stress and for an adequate immune response. Hence, these elements are essential for maintaining health throughout life. Micronutrients can cause diseases through deficiency, imbalance, or toxicity. Studies have shown that elevated copper and iron levels and decreased zinc levels may be a contributing factor in many inflammatory conditions. [12]

The results of the study demonstrated lower levels of zinc and higher levels of copper and iron in the serum of individuals with periodontitis compared to the control group without periodontitis. The difference is found to be statistically significant for serum zinc and copper levels.

Frithiof et al. and Tulin et al. in separate studies found decreased serum zinc levels in individuals with periodontitis when compared to healthy controls. [13],[14] In contrast, Freeland et al. found no difference. [15] Frinthof et al. also showed an inverse relation between serum zinc levels and alveolar bone loss. This could be explained on the basis that zinc is an essential cofactor in enzymes like DNA polymerase and RNA polymerase and thus essential for DNA synthesis, protein synthesis, and cellular proliferation. Zinc deficiency has been shown to reduce osteoblastic activity, collagen and proteoglycan synthesis as well as alkaline phosphatase activity. [16] Hence, deficiency in zinc could impair regenerative capacity. Along with this, zinc deficiency also impairs both innate and acquired immunity (e.g., downregulation of phagocytosis by macrophages and neutrophils, natural killer cell activity, generation of oxidative burst, antibody responses, and the numbers of cytotoxic T cells). [17] Zinc deficiency also leads to altered metabolism of androgens, oestrogens and progesterone which impairs immunity indirectly. [18]

Zinc has antioxidant properties as it stabilizes the cell membrane structure, contributing, to the structure of the superoxide dismutase and maintaining the metallothionein tissue concentrations. Hence long term deficiency of zinc can promote tissue injury due to oxidative stress. [18]

Thus, it can be suggested that inadequate intake of zinc may lead to suppressed immunity along with increased oxidative stress and poor regenerative capacity in an individual, which can predispose to periodontitis.

The present study showed an increase in serum copper levels in individuals with periodontitis when compared with healthy individuals. A study by Freeland et al. also showed increased serum copper levels in individuals with periodontitis. [15] Turnlund and associates reported that increased serum Copper can modulate immune function and antioxidant status. Studies on animal models have shown that increased serum copper levels reduce several aspects of immune response, including neutrophil numbers, lymphocyte proliferation, and antigen-specific antibody production. [19] It has also been reported that elevated serum copper levels alter collagen metabolism and hence can promote periodontitis. [20]

On the other hand, inflammation is also believed to increase the copper levels. Pekarek et al. have suggested that hepatic copper primarily as ceruloplasmin can get mobilized as a feedback signal by leukocyte endogenous mediators. [21] However, it is beyond the scope of the present study to suggest whether, elevated levels of copper can be a risk factor for periodontitis or that the elevated levels of copper is caused by inflammatory conditions like periodontitis.

The results of the present study showed an increase in iron levels in an individual with periodontitis compared to control group without periodontitis, but the difference is not statistically significant. A recent study by Prakash et al. also found no significant difference between periodontitis patients and healthy controls. [22]

The other objective of the present study was to evaluate the serum zinc, copper and iron levels in diabetes mellitus type 2 patients with periodontitis. The result of the study demonstrated lower levels of zinc and increased levels of copper and iron in diabetes mellitus type 2 patients with periodontitis when compared to healthy individuals with and without periodontitis and the difference is statistically significant. The result correlates with a recent study by Thomas et al. [23]

Both animal and human studies have suggested a possible role of altered micronutrient status in the pathogenesis of diabetes mellitus type 2 and its complication.

Chung et al. in their study have suggested that diabetes mellitus is associated with increased urinary excretion of zinc leading to its lower levels in serum. Intestinal absorption of zinc is also decreased in this condition. [24] Lowered serum levels in turn can depress immune response and promote free-radical activity.

Excessive copper and iron in serum may promote development and progression of oxidative stress, altered immunity and altered insulin secretion or its action. [11]

An abundance of information accumulated from studies on the complication of diabetes and periodontal disease have revealed that altered immune response may be antecedent of both diseases, which may have a synergistic effect when they coexist in the host. Zinc deficiencies and elevated levels of copper and iron are associated with an increased oxidative stress along with an altered immune response which could lead to various diabetes complications including periodontitis.

The present study may have important therapeutic implications in terms of the use of micronutrient supplements in periodontal therapy to prevent tissue destruction. An interventional study on rat has shown that a topical administration of zinc ion containing compound either as a mouthwash or toothpaste can reduce loss of alveolar bone. [25] However, interventional trials done on humans are required to determine the exact therapeutic success.

This study is limited primarily by its cross sectional design, which prevents the establishment of a temporal relationship between micronutrients and periodontitis. Another limitation is that serum concentrations are perhaps not the best index of micronutrient levels in periodontal tissues.

More longitudinal studies with a larger sample size should be carried out to have a better understanding of the inter-relationship between micronutrient imbalance and chronic disease processes like periodontitis and diabetes. Further studies should also be carried out to evaluate the serum levels of micronutrients before and after periodontal therapy to arrive to a more conclusive result.


   Conclusion Top


In the last decades, the impact of micronutrients on human physiology has begun to be elucidated. Imbalance of zinc, copper and iron levels in the serum can predispose an individual to the risk of developing periodontitis due to decreased regenerative capacity and impaired immune function along with development of excessive oxidative stress.

 
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Correspondence Address:
Anshuman Gautam
Department of Periodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.118400

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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