| Abstract|| |
Context: Periodontitis is a chronic inflammatory disease caused by bacterial infection of the supporting tissues around the teeth. Serum albumin levels might be the practical marker of general health status. Albumin concentration is associated with nutrition and inflammation.
Aims: The aim of this study was to evaluate the relationship between periodontal health status and serum albumin levels.
Subjects and Methods: A total of 60 subjects of both genders with age range of 40-70 years were included in the study. Patients were divided into two groups viz. Group I; clinically healthy subjects and Group II; patients with chronic periodontitis, that is, loss of attachment ≥5 mm. Serum albumin concentration was estimated by bromocresol green albumin method.
Statistical Analysis Used: Student's unpaired t-test.
Results: The mean value of serum albumin levels for Group I was 4.815 g/dL with standard deviation (SD) of 0.127 and for Group II, the mean value of serum albumin levels was 4.219 g/dL (SD 0.174). The difference between serum albumin levels in Group I and Group II were found to be statistically significant ( P ≤ 0.001).
Conclusions: The findings of this clinical trial suggest an inverse relationship between the serum albumin concentration and chronic periodontal disease.
Keywords: Body mass index, chronic periodontitis, general health status, serum albumin
|How to cite this article:|
Kaur N, Kaur N, Sarangal V. A study to evaluate the correlation of serum albumin levels with chronic periodontitis. Indian J Dent Res 2015;26:11-4
Periodontitis is a chronic inﬂammatory disease caused by bacterial infection of the supporting tissues around the teeth.  Serum albumin is a negative acute phase protein and serum albumin levels might be the practical marker of general health status (Phillips et al.).  Many conditions such as inflammatory states, liver diseases, and renal diseases have been indicated to reduce serum albumin levels (Herrmann et al.).  Inflammation and malnutrition both reduce serum albumin concentration by decreasing its rate of synthesis.  This suggests that periodontal disease severity might be indicated and monitored by the levels of serum albumin. Therefore, serum albumin can be used as a risk predictor for periodontal disease.
|How to cite this URL:|
Kaur N, Kaur N, Sarangal V. A study to evaluate the correlation of serum albumin levels with chronic periodontitis. Indian J Dent Res [serial online] 2015 [cited 2019 Nov 13];26:11-4. Available from: http://www.ijdr.in/text.asp?2015/26/1/11/156788
Hence, the aim of this study was to evaluate the relationship between periodontal health status and serum albumin levels.
| Subjects and methods|| |
The present study was conducted on 60 patients of both genders with age range of 40-70 years visiting the Outpatient Department of Periodontology and Oral Implantology.
Inclusion criteria for this study were:
Exclusion criteria for this study were:
- Group I (subjects with clinically healthy gingiva)
- Group II (subjects with periodontitis, i.e., loss of attachment ≥5mm)
- Mean dentate percentage of 28 teeth per subject.
Prior to the study, an informed consent was signed by the subjects and approved by Institutional Ethical Committee and all the procedures followed were in accordance with the Helsinki Declaration of 1975 and as revised in 2000.
- Hospitalized or institutionalized patients
- Patients with a history of systemic disease.
A personal interview was conducted to obtain the information regarding gender and smoking habit.
Dental examination was carried out for the following:
- Number of teeth present
- Gingival index (GI) (Loe and Sillness, 1963) 
- Plaque index (PI) (Sillness and Loe, 1964) 
- Pocket probing depth
- Loss of clinical attachment.
Anthropometric evaluation included:
For biochemical tests
- Measurement of weight (in kg)
- Measurement of height (in meters)
- Calculation of body mass index (BMI), which is the ratio of body weight to body height squared. 
A volume of 1 ml of blood was drawn from the antecubital vein was centrifuged at 2,500 rpm for 10 min using a centrifugal machine [Figure 1]. Biochemical value of serum albumin level was measured by bromocresol green albumin method [Figure 2]. Analysis was done using fully automated biochemical analyzer [Figure 3]. The recorded data were collected and compiled. Student's unpaired t-test was used for analysis between clinically healthy subjects and chronic periodontitis patients for GI, PI, BMI index and serum albumin level. A correlation was found in BMI and serum albumin levels in both groups.
| Results|| |
The mean serum albumin level for Group I was 4.815 with a standard deviation (SD) of 0.127 and ranged between 4.60 and 5.02 g/dL. Similarly, the mean serum albumin level for Group II was 4.219 (SD 0.174), which ranged from 3.81 to 4.46 g/dL. On comparison of both the values using Student's unpaired t-test, the differences between the serum albumin levels in Group I and Group II were found to be statistically highly significant (P < 0.001) [Table 1].
|Table 1: Comparison of clinical, biochemical, and anthropometric parameters in Group I (clinically healthy gingiva) and Group II (chronic periodontitis) subjects |
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The GI and PI which are important indicators as far as periodontal health and chronic periodontitis are concerned showed values which were grossly different between the two groups. The GI values in Group I was 0.741 (SD 0.257) and in Group II was 1.976 (SD 0.624).For PI, values for Group I were 0.913 (SD 0.255) and in Group II was 1.842 (SD 0.662). On comparison, the differences between the plaque and GI values in Group I and II were found to be statistically highly significant (P < 0.001) [Table 1]. The mean BMI values for Group I were 21.50 (SD 0.78) whereas the same for Group II were 21.69 (SD 0.50). On comparison, these were found to be nonsignificant (P = 0.289) [Table 1].
On comparison within Group II, a statistically significant association was found between serum albumin and age of the patients (P < 0.039). Whereas, the relationship between serum albumin and BMI was found out to be nonsignificant (P = 0.541) [Table 2]. In case of periodontal health indicators, that is, PI and GI, a statistically significant association between serum albumin and GI has been observed (P = 0.002) whereas, with PI there is a statistically highly significant association (P < 0.001) [Table 2].
|Table 2: Relationship between serum albumin and other parameters within Group II (chronic periodontitis) subjects |
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| Discussion|| |
In this clinical trial, a statistically significant association was observed between the serum albumin levels of clinically healthy subjects and chronic periodontitis patients. In this trial, 30 patients of chronic periodontitis had a periodontal loss of attachment which was >5 mm; the results showed an inverse independent relationship between periodontal disease and serum albumin concentrations. Similar findings have been reported in the study conducted by Ogawa et al.  However, periodontal disease susceptibility can also be increased by risk factors such as diabetes, hypertension, obesity and metabolic syndrome, stress, and genetic factors.  The possibility of these factors in influencing the results of this study has been reduced by including only systemically healthy patients in the study.
Periodontitis is a painless destructive chronic infection of the gums, ligaments, and bone that supports the teeth. The primary clinical features of periodontitis include clinical attachment loss, alveolar bone loss, periodontal pocketing, and gingival inﬂammation.  In light of the extensive microbial plaques associated with periodontal infections, the chronic nature of these diseases, and the exuberant local and systemic host response to microbial assault, it is reasonable to hypothesize that these infections may influence overall health and the course of some systemic diseases. 
The number of bacteria ranges from 1 × 10 3 in healthy shallow crevices to >1 × 10 8 in periodontal pockets. These bacteria attract monocytes into the gingival crevicular space, and numerous cytokines are found within this space. Furthermore, they are able to invade the host. Individuals with significant periodontitis have recurrent episodes of low-level bacteremia. Porphyromonas gingivalis, one of the major periodontal pathogens, has been demonstrated to invade coronary and aortic endothelial cells. Hepatic acute phase reactants respond both to the secretion of local cytokines and to systemic bacteremia. Acute phase proteins, defined as those whose plasma concentrations increase (positive acute phase proteins) or decrease (negative acute phase proteins, i.e., serum albumin) by at least 25% during an episode of inflammation, are measurable indicators of active inflammation. 
Increasingly, it is accepted that there are interrelationships between oral health and general health, particularly the chronic diseases of ageing.  Among older patients, diet also plays a key role in disease prevention, as poor diets have been linked to illness such as osteoporosis, atherosclerosis, and bowel disease. Although nutritional status is influenced by factors such as age, socioeconomic status, and general health, it would appear that dental status is also significant. There is evidence from previous studies to suggest that eating ability and masticatory efficiency are affected by oral health and specifically by the number and distribution of natural teeth. 
The presence of dentures and number of teeth are associated with masticatory efficiency and ability (Bates et al., 1976), and being without natural teeth is related to being underweight (Fischer and Johnson, 1990; Keller, 1993; Strauss and Hunt, 1993; Gilmore et al.; 1995; Sullivan, 1995). One of the most likely mechanisms by which impaired oral health may affect diet is that difficulty in chewing causes dietary restrictions (Yurkstas and Emerson, 1964; Health, 1972; Osterberg and Steen, 1982; Chauncey et al., 1984; Geissler and Bates, 1984; Papas et al., 1989; Hollister and Weintraub, 1993; Sheiham et al., 1999).  The evidence generally available for elderly populations suggests that tooth loss may alter food choice, resulting in lower intakes for key nutrients such as iron and fiber. As a result, the American Dental Association recently stated that oral health and nutrition have a synergistic bidirectional relationship. 
Serum albumin is the main protein synthesized by the liver.  In elderly individuals, it would seem imperative that the impaired dentition status and a lean lifestyle along with the possibility of compromised systemic health status would reflect within the values of serum albumin concentration.  According to Hermann et al. (1992), many conditions, such as inflammatory states, liver diseases, and renal diseases, have been indicated to reduce serum albumin levels. 
Serum albumin is a negative acute phase protein supports the contention that serum albumin is a marker of inflammation.  Chronic diseases are associated with inflammation and the release of inflammatory cytokines such as interleukin-1, interleukin-6, and tumor necrosis factor-α, which cause a decrease in serum albumin (Schalk et al. 2004).  Moreover, malnutrition may also be monitored by means of serum albumin concentration (Don and Kaysen 2004).  Therefore, albumin concentration is associated with nutrition and inflammation (Kaysen et al. 2002). 
Several studies have demonstrated that serum albumin concentrations are associated with general health status among elderly.  Therefore, it becomes difficult to infer whether serum albumin concentrations are affected by an inflammatory component of chronic periodontitis or the compromised nutritional status, owing to the general health status of the individual. This possibility of general health/nutritional status in any way affecting the serum albumin concentrations was somewhat eliminated in this clinical trial, as the subjects included in this clinical trial were physically fit without any systemic diseases with the mean dentate percentage being 28 teeth per subject. Thus, it would be legitimate to infer that the lower serum albumin concentrations (4.219 g/dL) were solely affected by an inflammatory component of chronic periodontitis.
The results are similar to those reported by Yoshihara et al.  and substantiate the association between oral health status, in particular periodontal disease and serum albumin concentrations.
There has also been a linkage of serum albumin level and mortality rate. Investigations by Corti et al.  have reported graded increase in mortality rate with decreasing serum albumin levels. However, it seems more evident that serum albumin levels below 4 g/dL have higher mortality rate. Shibata et al. reported significantly different 10-year survival rate with a quartile of serum albumin levels. Therefore, the periodontal disease status has a substantial influence not only on the subject's serum albumin levels but also on general health aspects.  The mean serum albumin levels in this trial in chronic periodontitis patients was 4.219 g/dL, which would lead to an assumption that the survival rate would be better for the subjects included in the trial.
In a longitudinal study by Iwasaki, et al. a significant association was found between the number of periodontal disease events over 4 years and serum albumin levels.  Though in this study, a correlation between periodontal disease events and serum albumin levels could not be established, the subjects in Group II, that is, chronic periodontitis, exhibited an average of 17% of teeth exhibiting LA >5 mm. Hence, this group of patients does reflect the severity and extent of periodontal destruction, which at many sites within the oral cavity would represent periodontal disease events.
| Conclusion|| |
The findings of this clinical trial suggest a statistically significant inverse association between serum albumin concentration and chronic periodontal disease. There was a significant reduction in serum albumin concentration and an increase in loss of attachment. Therefore, serum albumin levels can be used to monitor the severity of periodontal disease. In order to explore the actual cause to effect relationship between periodontal disease and serum albumin concentration, longitudinal evaluations with a larger population would be necessary.
| References|| |
Eke PI, Page RC, Wei L, Thornton-Evans G, Genco RJ. Update of the case definitions for population-based surveillance of periodontitis. J Periodontol 2012;83:1449-54.
Ogawa H, Yoshihara A, Amarasena N, Hirotomi T, Miyazaki H. Association between serum albumin and periodontal disease in community-dwelling elderly. J Clin Periodontol 2006;33:312-6.
Don BR, Kaysen G. Serum albumin: Relationship to inflammation and nutrition. Semin Dial 2004;17:432-7.
Iwasaki M, Yoshihara A, Hirotomi T, Ogawa H, Hanada N, Miyazaki H. Longitudinal study on the relationship between serum albumin and periodontal disease. J Clin Periodontol 2008;35:291-6.
Löe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38 Suppl: 610-6.
Mathur LK, Manohar B, Shankarapillai R, Pandya D. Obesity and periodontitis: A clinical study. J Indian Soc Periodontol 2011;15:240-4.
Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontol 2000 2013;62:59-94.
Flemmig TF. Periodontitis. Ann Periodontol 1999;4:32-8.
Bhusari BM, Sanadi RM, Pol KG. Periodontal medicine-oral systemic interrelation. Indian J Dent Sci 2011;3:35-9.
Kshirsagar AV, Craig RG, Beck JD, Moss K, Offenbacher S, Kotanko P, et al.
Severe periodontitis is associated with low serum albumin among patients on maintenance hemodialysis therapy. Clin J Am Soc Nephrol 2007;2:239-44.
McKenna G, Allen PF, Flynn A, O'Mahony D, DaMata C, Cronin M, et al.
Impact of tooth replacement strategies on the nutritional status of partially-dentate elders. Gerodontology 2012;29:e883-90.
Sheiham A, Steele JG, Marcenes W, Lowe C, Finch S, Bates CJ, et al.
The relationship among dental status, nutrient intake, and nutritional status in older people. J Dent Res 2001;80:408-13.
Sergi G, Coin A, Enzi G, Volpato S, Inelmen EM, Buttarello M, et al.
Role of visceral proteins in detecting malnutrition in the elderly. Eur J Clin Nutr 2006;60:203-9.
Yoshihara A, Hanada N, Miyazaki H. Association between serum albumin and root caries in community-dwelling older adults. J Dent Res 2003;82:218-22.
Corti MC, Guralnik JM, Salive ME, Sorkin JD. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA 1994;272:1036-42.
Shibata H, Haga H, Ueno M, Nagai H, Yasumura S, Koyano W. Longitudinal changes of serum albumin in elderly people living in the community. Age Ageing 1991;20:417-20.
Department of Periodontology and Oral Implantology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]