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Table of Contents   
ORIGINAL RESEARCH  
Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 500-503
Estimation of high sensitivity C-reactive protein in patients with periodontal disease and without coronary artery disease


1 Department of Periodontics, Chettinad Dental College and Research Institute, Kanchipuram, Tamil Nadu, India
2 Department of Pathology, Chettinad Health City, Kelambakkam, Kanchipuram, Tamil Nadu, India
3 Department of Oral and Maxillofacial Surgery, Chettinad Dental College and Research Institute, Kanchipuram, Tamil Nadu, India

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Date of Submission11-Aug-2014
Date of Decision26-Oct-2014
Date of Acceptance04-May-2015
Date of Web Publication17-Dec-2015
 

   Abstract 

Background: HsCRP (Highly sensitive C reactive protein) is a global indicator for future vascular events in adults detected in blood stream 48 hours before the cardiovascular event. Periodontal disease may increase blood levels of inflammatory markers like IL-6, CRP and HsCRP. Hence the aim of the present study is to evaluate the presence of elevated HsCRP levels in chronic periodontitis patients.
Material and Methods: 100 patients who reported for cardiac master health check up were enrolled in the study. The periodontal status was assessed using periodontal probing pocket depth and clinical attachment level. The decayed, missing and filled tooth was recorded using DMFT index. The venous samples of these patients were obtained for recording HsCRP levels.
Results: Pearson correlation was used to analyze the relationship between HsCRP level and probing pocket depth, clinical attachment loss and DMFT. The correlation value was 0.051, 0.025 and 0.101 respectively, the correlation is statistically significant for probing pocket depth and clinical attachment level (P>0.05). Chi- square test was performed to study the association between gender and HsCRP, Diabetes Mellitus and HsCRP and Hypertension and HsCRP; the results showed that there is no significant association between any of the above mentioned factors and HsCRP level in blood.
Conclusions: We found an increased level of HsCRP in patients with chronic periodontitis which revealed the susceptibility of these patients to cardiac diseases like myocardial infarction and stroke. Hence present day focus in the line of management of cardiac patient has changed from the periodontal perspective.

Keywords: Cardiovascular disease, diabetes mellitus, HsCRP, periodontal disease

How to cite this article:
Anitha V, Nair S, Shivakumar V, Shanmugam M, Priya B M, Rajesh P. Estimation of high sensitivity C-reactive protein in patients with periodontal disease and without coronary artery disease. Indian J Dent Res 2015;26:500-3

How to cite this URL:
Anitha V, Nair S, Shivakumar V, Shanmugam M, Priya B M, Rajesh P. Estimation of high sensitivity C-reactive protein in patients with periodontal disease and without coronary artery disease. Indian J Dent Res [serial online] 2015 [cited 2020 Sep 24];26:500-3. Available from: http://www.ijdr.in/text.asp?2015/26/5/500/172048
Periodontal disease is an encircling term relating to the destructive inflammatory disorders of the hard and soft tissues surrounding the teeth. Dental plaque accumulation induces chronic inflammation of the periodontal tissues, which leads to destruction of the periodontal ligament and bone. [1],[2] This response to bacterial toxins is elicited by the host's immuno-inflammatory mediators. These inflammatory mediators can spill over into the systemic circulation along with micro-organisms and can offer an explanation for shift in causality and directionality of oral and systemic diseases. Acute phase reaction is a systemic response which usually follows a physiological condition that takes place in the beginning of an inflammatory process. This physiological change usually lasts 1-2 days. The aim of this systemic response was to restore homeostasis. These events are accompanied by up-regulation of some proteins (positive acute phase reactants) during inflammatory reactions. [3]

C-reactive protein (CRP) is an acute-phase reactant that has long been considered a classic marker for inflammation, which can raise the serum level a hundredfold or more. [4],[5] It is now known that atherosclerosis, the process underlying cardiovascular disease (CVD), which includes coronary heart disease, myocardial infarction (MI), and ischemic stroke, as well as peripheral vascular disease, is due at least in part to a chronic, low-level inflammation of the vascular endothelium. [6],[7] Thus, CRP is an acute phase protein which acts as an intermediate substance linking periodontal and CVD. [8],[9]

High sensitive C-reactive protein (HsCRP) is a recent global indicator for future vascular events in adults without any previous history of CVD. HsCRP is detected in the blood stream 48 h before the cardiovascular event. This inflammation precipitates atherothrombosis. HsCRP stimulates the coagulation pathway by inducing the monocytes and macrophages to produce tissue factor thereby leading to increase in blood coagulability. HsCRP also stimulates the complement cascade further exacerbating the inflammation. Hence, the measurement of inflammatory markers such as HsCRP can be a predictable marker of future MI and stroke among healthy individuals. [10] Although chronic periodontitis is a low-grade inflammatory disease of the tooth supporting structures, an acute exacerbation of this inflammatory status may increase blood levels of inflammatory markers such as interleukin (IL-6), CRP, and HsCRP which could precipitate cardiac events such as MI and stroke.

The aim of the present study was to evaluate the presence of HsCRP as a predictor for future cardiovascular risk in patients with periodontal disease without the history of CVD.


   Materials and methods Top


Hundred patients who reported to the Chettinad Super Speciality Hospital for cardiac master health check-up were enrolled in the study. Ethical approval was obtained from the Institutional Ethics Committee, Chettinad Health City prior to the start of the study. Written informed consent was obtained from all the subjects who were enrolled into the study. Patients with a history of CVD were excluded as the cardiac markers are already elevated in patients with the incidence of MI and stroke. The periodontal status of these patients was assessed using a standard periodontal examination, which consists of probing pocket depth (PPD) and clinical attachment level (CAL) measurement using Williams periodontal probe. The PPD was measured as the distance between the gingival margin and the base of the pocket. The CAL is the distance from a reference point on the tooth (cementoenamel junction) to the base of the pocket. The decayed, missing, and filled tooth (DMFT) was analyzed using decay-missing-filled (DMFT) index (Henry T. Klein and Carrole E. Palmer, 1938). The venous sample of these patients was obtained for recording HsCRP levels. According to the center for disease control risk assessment guideline, the patients were categorized based on the HsCRP level mentioned below.

  • Low risk <1 mg/dl
  • Average risk 1-3 mg/dl
  • High risk >3 mg/dl.

   Results Top


Statistical analysis was done using SPSS software 16.0 (IBM corporation, Illinois, USA). Among 100 patients who reported for master health check-up in Chettinad Super Speciality Hospital 77 (77%) were males and 23 (23%) were females [Table 1]. Pearson correlation was used to analyze the relationship between HsCRP level and PPD, loss of attachment and DMFT index. The correlation was significant for PPD and loss of attachment level, the value being 0.051 and 0.025 respectively. The correlation was not significant for HsCRP and DMFT index, the value being 0.101. The medical history was also recorded which stated that 28.3% had diabetes mellitus and 26.3% had hypertension. Chi-square test was performed to study the association between gender and HsCRP, diabetes mellitus and HsCRP and hypertension and HsCRP; the results showed that there was no significant association between any of the above-mentioned factors and HsCRP level in blood [Table 2] and [Table 3].
Table 1: Chisquare test across Gender vs HsCRP


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Table 2: Chisquare test across Diabetes Mellitus vs HsCRP


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Table 3: Chisquare test across Hypertension vs HsCRP


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   Discussion Top


Numerous markers have been evaluated to determine the relationship between periodontal disease and CVD (ref). All the markers are usually elevated in subjects with CVD and periodontal disease. The current study aimed to evaluate whether HsCRP can be used as a future predictor for CVD in patients with chronic periodontitis.

Friedewald et al. described the mechanism for an association between periodontal disease and atherosclerotic CVD. They stated that moderate to severe periodontitis increases the level of systemic inflammation as measured by the levels of HsCRP. In untreated periodontitis 10 8 -10 12 Gram-negative bacteria was found in the atheroma of the diseased coronary artery. In our study, chronic periodontitis increased systemic inflammation which is characterized by the presence of elevated HsCRP in these patients. [11] Shanies discusses the significance of infections such as periodontal disease in increasing the systemic inflammation and precipitating atherosclerosis thereby increasing the risk of CVD. [12] They also emphasized the testing of HsCRP in dental diseases and detection of periodontal diseases in cardiovascular patients. The findings in our study revealed the presence of elevated HsCRP levels in chronic periodontitis patients without CVD.

Miyashita compared 49 patients with moderate to advanced periodontitis and 40 healthy controls. In periodontally healthy patients, HsCRP levels were measured at baseline. In periodontitis patients, the HsCRP levels and antibody titers to Porphyromonas gingivalis were measured at baseline and reassessment was done 3-4 months after periodontal therapy. HsCRP levels and antibody titers decreased after treatment. [13] Malhotra studied the association between periodontal disease and coronary artery disease in sixty patients aged between 40 and 60 years. They were divided into two groups of 30 patients each based on their periodontal status. The two groups were compared for periodontal parameters and HsCRP levels. The periodontally diseased group showed higher levels of HsCRP, which was consistent with our study. [3] Rastogi et al. evaluated the effect of nonsurgical periodontal therapy on the levels of serum inflammatory markers in patients with chronic periodontitis and known coronary artery disease. They showed a significant decrease in serum inflammatory markers in patients with coronary artery disease after periodontal treatment. [14] Marcaccini et al. compared the level of inflammatory markers such as IL-6, HsCRP, and CRP in patients with and without periodontal disease and stated that the circulating concentration of HsCRP, CRP, and IL-6 decreased 3 months after periodontal therapy. [15] Nakajima et al. studied the concentration of serum HsCRP, IL-6 and tumor necrosis factor-α (TNF-α) in 78 periodontitis patients at baseline and in reassessment. The concentrations of HsCRP, IL-6, and TNF-α in the serum of periodontitis patients were significantly higher than those in control subjects which was consistent with our study. [16] Thomopoulos C revealed the presence of chronic periodontitis enhanced subclinical inflammation and eventually contributed to endothelial and vascular dysfunction. There was some evidence suggesting that periodontal pathogens could modulate the initiation and perpetuation of atherosclerosis. In this study, chronic periodontitis enhanced HsCRP levels. [17]

Koppolu et al. studied whether the presence of periodontitis and periodontal therapy could influence the serum levels of CRP and TNF-α in CVD patients. Forty patients were classified into two groups of control and a test group of 20 each. The test group underwent scaling and root planing. Periodontal clinical parameters such as simplified oral hygiene index, PPD, were evaluated along with serum CRP, TNF-α, at baseline and these parameters were reassessed after 8 weeks for both the groups. The results of the study were that the clinical parameters and inflammatory biomarkers decreased after periodontal therapy. [18] Marcaccini et al. stated that periodontal disease is associated with increased concentrations of IL-6 and HsCRP, which decreased 3 months after scaling. [15]


   Conclusion Top


We found an increased level of HsCRP in patients with chronic periodontitis which revealed the susceptibility of these patients to cardiac diseases such as MI and stroke. Hence, present day focus in the line of management of cardiac patient has changed from the periodontal perspective. Further studies needs to be carried out to prove the correlation between periodontal disease and CVD.

 
   References Top

1.
Grossi SG. Dental plaque attack: The connection between periodontal disease, heart disease and diabetes mellitus. Compend Contin Educ Dent 2001;22:13.  Back to cited text no. 1
    
2.
Ross R. Atherosclerosis - An inflammatory disease. N Engl J Med 1999;340:115-26.  Back to cited text no. 2
    
3.
Malhotra S, Bakash H. Coronary artery disease and periodontitis - A prospective study. JIMSA 2013;26:93-7.  Back to cited text no. 3
    
4.
Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH. Plasma concentration of C-reactive protein and risk of developing peripheral vascular disease. Circulation 1998;97:425-8.  Back to cited text no. 4
    
5.
Ridker PM, Glynn RJ, Hennekens CH. C-reactive protein adds to the predictive value of total and HDL cholesterol in determining risk of first myocardial infarction. Circulation 1998;97:2007-11.  Back to cited text no. 5
    
6.
Kuller LH, Tracy RP, Shaten J, Meilahn EN. Relation of C-reactive protein and coronary heart disease in the MRFIT nested case-control study. Multiple Risk Factor Intervention Trial. Am J Epidemiol 1996;144:537-47.  Back to cited text no. 6
    
7.
Ridker PM, Buring JE, Shih J, Matias M, Hennekens CH. Prospective study of C-reactive protein and the risk of future cardiovascular events among apparently healthy women. Circulation 1998;98:731-3.  Back to cited text no. 7
    
8.
Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med 2000;342:836-43.  Back to cited text no. 8
    
9.
Tracy RP, Lemaitre RN, Psaty BM, Ives DG, Evans RW, Cushman M, et al. Relationship of C-reactive protein to risk of cardiovascular disease in the elderly. Results from the Cardiovascular Health Study and the Rural Health Promotion Project. Arterioscler Thromb Vasc Biol 1997;17:1121-7.  Back to cited text no. 9
    
10.
Ridker PM. High-sensitivity C-reactive protein potential adjunct for global risk assessment in the primary prevention of cardiovascular disease, MD, MPH cardiovascular disease. Circulation 2001;103:1813-8.  Back to cited text no. 10
    
11.
Friedewald VE, Kornman KS, Beck JD, Genco R, Goldfine A, Libby P, et al. The American Journal of Cardiology and Journal of Periodontology editors' consensus: Periodontitis and atherosclerotic cardiovascular disease. J Periodontol 2009;80:1021-32.  Back to cited text no. 11
    
12.
Shanies SH. The significance of periodontal infection in cariodology. Oral Syst Med 2006;1:24-33.  Back to cited text no. 12
    
13.
Miyashita H, Honda T, Maekawa T, Takahashi N, Aoki Y, Nakajima T, et al. Relationship between serum antibody titres to Porphyromonas gingivalis and hs-CRP levels as inflammatory markers of periodontitis. Arch Oral Biol 2012;57:820-9.  Back to cited text no. 13
    
14.
Rastogi P, Singhal R, Sethi A, Agarwal A, Singh VK, Sethi R. Assessment of the effect of periodontal treatment in patients with coronary artery disease: A pilot survey. J Cardiovasc Dis Res 2012;3:124-7.  Back to cited text no. 14
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15.
Marcaccini AM, Meschiari CA, Sorgi CA, Saraiva MC, de Souza AM, Faccioli LH, et al. Circulating interleukin-6 and high-sensitivity C-reactive protein decrease after periodontal therapy in otherwise healthy subjects. J Periodontol 2009;80:594-602.  Back to cited text no. 15
    
16.
Nakajima T, Honda T, Domon H, Okui T, Kajita K, Ito H, et al. Periodontitis-associated up-regulation of systemic inflammatory mediator level may increase the risk of coronary heart disease. J Periodontal Res 2010;45:116-22.  Back to cited text no. 16
    
17.
Thomopoulus C, Tsioufis C, Soldatos N, Giamarelos G, Dendranos C, Selima M, et al. Chronic periodontal disease and systemic inflammation on endothelial disfunction in untreated hypertensive patients. Am J Cardiovasc Dis 2011;1:76-83.  Back to cited text no. 17
    
18.
Koppolu P, Durvasula S, Palaparthy R, Rao M, Sagar V, Reddy SK, et al. Estimate of CRP and TNF-alpha level before and after periodontal therapy in cardiovascular disease patients. Pan Afr Med J 2013;15:92.  Back to cited text no. 18
    

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Correspondence Address:
V Anitha
Department of Periodontics, Chettinad Dental College and Research Institute, Kanchipuram, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.172048

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    Tables

  [Table 1], [Table 2], [Table 3]

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