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International Journal of Dental

Research & Development (IJDRD)


ISSN (P): 2250-2386; ISSN (E): 2321-0117
Vol. 6, Issue 3, Jun 2016, 13-18
TJPRC Pvt. Ltd.

EFFECT OF PERIODONTAL TREATMENT ON RED BLOOD


CELL PARAMETERS IN PATIENTS WITH CHRONIC PERIODONTITIS
KAPIL JAIN1, SWARGA JYOTI DAS2, SHIVANI DWIVEDI3, RAHUL JAIN4,
BABITHA NUGALA5 & MEGHA JAIN6
1,3,5

Department of Periodontics, Peoples College of Dental Sciences & Research Centre, Bhopal, Madhya Pradesh, India
2

Department of Periodontics, Regional Dental College, Guwahati, Assam, India

Department of Medicine, Peoples College of Medical Sciences & Research Centre, Bhopal, Madhya Pradesh, India
6

Private Practice, Madhya Pradesh, India

ABSTRACT
OBJECTIVES
Anemia of chronic diseases is a cytokine mediated anemia seen in various chronic infective inflammatory
conditions. The present study was carried out to evaluate the effect of periodontal treatment on levels of red blood cell
parameters related to anemia of chronic disease in patients with chronic periodontitis.

A total number of 36 females with chronic perodontitis were included in the study. The Clinical parameters
recorded at base line were periodontal pocket depth and Clinical attachment level followed by full mouth scaling and
root planning. Red blood cell parameters recorded at baseline were hemoglobin concentration, red blood cell count,
packed cell volume, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin
concentration and erythrocyte sedimentation rate. The clinical parameters and Red blood cell parameters were again

Original Article

METHODS

recorded at nine months post treatment.


RESULTS
Post treatment there was a significant decrease in probing pocket depth, clinical attachment level and
erythrocyte sedimentation rate. While, there was a significant increase in levels of red blood cells, hemoglobin
concentration and packed cell volume. The mean corpuscular volume, mean corpuscular hemoglobin and mean
corpuscular hemoglobin concentration were comparable at both point of time.
CONCLUSIONS
The study provides evidence that periodontal therapy in patients with chronic periodontitis may lead to an
increase in levels of red blood cells, hemoglobin concentration and packed cell volume together with decrease in values
of ESR.
KEYWORDS: Anemia, Chronic Periodontitis, Hemoglobin, Red Blood Cell,Mean Corpuscular Volume

Received: Apr 12 2016; Accepted: Apr 26 2016; Published: Apr 30 2016; Paper Id.: IJDRDJUN20162

INTRODUCTION
Periodontitis comprises a group of inflammatory conditions of the supporting tissues of the teeth. They
are initiated by the microorganisms and their products and modulated by the immunological response of the

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Kapil Jain, Swarga Jyoti Das, Shivani Dwivedi, Rahul Jain, Babitha Nugala & Megha Jain

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host.1The subgingival microbiota in patients with periodontitis provides a significant and persistent gram-negative bacterial
challenge to the host.These organisms and their products, such as lipopolysaccharide and proinflammatory cytokines such
as interleukins, tumour necrosis factor- , interferon- and prostaglandinE2 have ready access to the circulation via the
sulcular epithelium, which is frequently ulcerated and discontinuous.2 It has therefore been speculated that periodontitis
results in a low grade systemic inflammation.
Recent studies suggest that periodontitis can results in cardiovascular and cerebrovascular disease, chronic
obstructive pulmonary disease, poor glycaemic control and preterm low birth weight infants.3-6 Hutter et al.7 and Taylor,8
suggested that periodontitis has chronic and systemic effects and that periodontitis patients may tend towards anemia of
systemic inflammation which is also known as Anemia of chronic disease(ACD).
ACD is a cytokine mediated anaemia occurs in patients with acute or chronic immune activation.9 and seen in
patients with chronic infection, inflammatory and/or neoplastic disorders despite the presence of an adequate iron and
vitamins stores.10 ACD is usually normocytic normochromic and is characteristically mild to moderate in nature.The
condition is characterised by a low reticulocyte count indicating the underproduction of Red blood cells (RBC).11
The present study was carried out to evaluate the effect of periodontal treatment on levels of various
hematological parameters related to ACD.

MATERIALS AND METHODS


A total number of 36 females, with chronic generalised periodontitis were selected from outpatient department,
Department of Periodontics, Regional Dental College, Guwahati, the study protocol was approved by institutional ethical
committee. Informed consent was obtained from the patients. Inclusion criteria were, systemically healthy subjects with the
presence of at least 20 teeth having mean probing pocket depth (PPD) 4 mm with no history of mechanical periodontal
therapy within last one year before initiation of this study. Exclusion criteria were females with gynaecological problems,
present and past smokers and subjects who have been on long term medication for at least 6 months preceding the study.
The clinical parameters recorded were PPD and clinical attachment level (CAL). All teeth except third molars
were probed using a UNC-15 periodontal probe on distobuccal/distolabial, buccal/labial, mesiobuccal /mesiolabial and
lingual/palatal position. The clinical parameter were recorded at base line, followed by full mouth scaling and root
planing(SRP).All subjects were put on the maintenance phase. The clinical parameters were again recorded after 9 month
post SRP.

BLOOD SAMPLE COLLECTION AND HEMATOLOGICAL INVESTIGATIONS


5ml of venous blood samples were collected by venepuncture under aseptic conditions in the antecubital
fossa.The blood sample was then pushed immediately in sodium citrate vial and EDTA vial separately, shaked well and
labelled .
The hematological investigations that were carried out were hemoglobin (Hb) (in gm% by sahlis method), RBC
count (in millions/mm3 using neubauer counting chamber).erythrocyte sedimentation rate (ESR ) (in mm at the end of first
hour by Westergren tube) ,Packed Cell volume (PCV)(in % by wintrobes tube centrifuge method),mean corpuscular
volume (MCV) (in cubic microns),mean corpuscular hemoglobin (MCH) (in Pico gm) and mean corpuscular hemoglobin
concentration (MCHC)(in g/dl).
Impact Factor (JCC): 1.9876

Index Copernicus Value(ICV) : 6.1

Effect of Periodontal Treatment on Red Blood Cell


Parameters in Patients with Chronic Periodontitis

15

The haematological investigations were carried out at base line and after 9 month post SRP.
The data obtained were entered in excel sheet and analyzed by using SPSS 17 software. The students paired t test
was applied to analyze the data. The results and values were expressed as mean and standard deviation. The significance
was fixed at 0.05 (P< 0.05).

RESULTS
A total of 36 females with mean age of 42 6.10 were included in the study. The PPD and CAL recorded at the
base line and at the end of nine months are shown in table1. The mean PPD in subjects at baseline and at the end of 9
month were 4.65 0.44 mm and 3.60 0.40 respectively. The mean CAL recorded at base line and at the end of 9 month
were 4.88 0.52 mm and 3.98 0.42 mm respectively. The difference in PPD and CAL at the two point of time was found
to be statistically highly significant (p < 0.001).
RBC parameters at the base line and at the end of nine months are shown in table2. The RBC parameters recorded
at both the point of time were within normal physiological range.
The mean RBC count at base line was 4.42 0.34 millions while the same at the end of nine months was 4.51 0.32
millions. The difference in RBC count was found to be statistically significant (p < 0.05).
The hemoglobin concentration recorded at base line was 12.21 0.97 gm/100ml while the same at the end of nine
months was 12.45 0.97 gm/100ml.The difference in haemoglobin concentration was found to be statistically significant
(p < 0.05).
The PCV recorded at base line and at the end of 9 month were 37.97 3.17 mm and 38.63 3.00 mm
respectively. The difference in PCV was found to be statistically significant (p < 0.05).
The calculated MCV at base line and at the end of 9 month were 85.68 3.04 mm and 85.57 2.76 respectively.
The calculated MCH at base line and at the end of 9 month were 27.68 0.73 mm and 27.68 0.64 respectively. The
calculated MCHC at base line and at the end of 9 month were 32.24 0.91 mm and 32.17 0.80 respectively. The
difference in values of MCV, MCH and MCHC was not found to be statistically significant (p > 0.05).
The ESR recorded at base line and at the end of 9 month were 11.88 4.71 mm and 11.33 4.50 mm
respectively. The difference in ESR was found to be statistically significant (p < 0.05).

DISCUSSIONS
Various studies suggest that periodontitis patients are at an increased risk for systemic diseases like cardiovascular
and cerebrovascular disease, chronic obstructive pulmonary disease, poor glycaemic control and preterm low birth weight
infants.3-6 Moreover, a reduced level of hemoglobin and red blood cell count has been observed in patients with chronic
periodontitis by various investigators.7, 8. These indicate that periodontitis has some effects on systemic health, which may
be brought out by the raised plasma levels of inflammatory markers such as interleukin-1 and 6, tumor necrosis factor-,
fibrinogen, acute phase proteins including C-reactive proteins, soluble cellular adhesion molecule and cytokines accounted
in case of periodontitis.12-14

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Kapil Jain, Swarga Jyoti Das, Shivani Dwivedi, Rahul Jain, Babitha Nugala & Megha Jain

16

The present study was carried to evaluate the influence of periodontal treatment on RBC pameters related to
ACD. In the study, we have observed a significant increase in levels of RBC, Hb% and PCV at nine months post
SRP,while there was a significant decrease in ESR. The MCV,MCH and MCHC were comparable at both the point of
time.
Increase in Hb concentration post SRP indicates that chronic periodontitis patients shows a tendency towards
anemia.The increase in Hb concentration may be related to increase in number of RBC, indicating that the anemic
tendency in periodontitis is normocytic as MCV is comparable at both point of time, similarly, MCH and MCHC were also
comparable at both point of time indicating that anemic tendency in periodontitis is of normochromic type. The normocytic
normochromic anaemia is seen in ACD 9. While microcytic hypochromic and macrocytic normochromic anemia is seen in
iron deficiency and vitamin deficiency anemia respectively

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.The increase in PCV may also be related to increase in

number RBC as the MCV are comparable. The decrease in ESR over a period of nine months post SRP may be contributed
two factors, firstly because of increased number of RBC the greater repulsive forces acting on the negatively charged
cells(RBC) decreases the sedimentation rate

16

,secondly due to decreased levels of systemic inflammatory

markers,particularly fibrinogen post scaling, as have observed by many authors

4,14

. It has been shown that fibrinogen

encourages rouleaux formation by facilitating the adhesion among RBCs, which further increases the sedimentation rate 16.
Mild to moderate anaemia has been reported as a frequent manifestation of several chronic diseases, such as
rheumatoid arthritis, parasitic diseases, bacterial and fungal infections and neoplastic illnesses 15, referred to as ACD. ACD
may be contributed to shortened erythrocyte survival, failure of bone marrow to increase RBC production to compensate
increased demand and impaired release of iron from reticuloendothelial system. Though, the cause of ACD is multifactorial, the current concept indicates that pro-inflammatory cytokines, particularly IL-1, IL-6 and tumour necrosis factor may down-regulate the erythropoiesis in bone marrow
18

17

. Since periodontitis is associated with increased levels of

inflammatory cytokines , this may lead to chronic low grade systemic inflammation,

4, 7, 19

which further may down-

regulates the erythropoiesis in bone marrow. This may be the reason of lower RBC count and hemoglobin levels. observed
in our study at base line. It has also been shown by many observers that SRP / full mouth extraction decreases the levels of
various markers of systemic inflammation in periodontitis8,12 and this effect of periodontal therapy on systemic markers
may be responsible for changes in levels of various haematological parameters as have observed in our study.
Our findings that the periodontitis patients shows a change in levels of various RBC parameters post SRP are
similar to those observed by Pradeep et.al

20

and Agarwal et.al21. The findings of Hutter et al7. and Thomas et al.22. that

periodontitis patients have a lower PCV, lower numbers of erythrocytes, lower hemoglobin levels and higher erythrocyte
sedimentation rates as compared to healthy controls also supports that subjects with periodontitis shows a tendency
towards anemia. Though Wakai et al.23 and Lainson24 did not find any positive correlation of the periodontal disease with
RBC count and hemoglobin levels.
We can speculate that the findings of low RBCs and haemoglobin in the subjects with periodontitis may be
similar to that of being reported in rheumatoid arthritis though,to a lesser extent. As periodontitis may lead to chronic low
grade systemic inflammation2,

4, 19,

that further causes depression in the bone marrow function and results in decreased

formation of RBCs.

Impact Factor (JCC): 1.9876

Index Copernicus Value(ICV) : 6.1

Effect of Periodontal Treatment on Red Blood Cell


Parameters in Patients with Chronic Periodontitis

17

CONCLUSIONS
From the present study carried out by us, we have observed a significant increase in the levels of RBC, Hb and
PCV post SRP, while there was a significant decrease in ESR .The MCV, MCH and MCHC were comparable at two point
of time. These observations provide the evidence that chronic periodontitis patients shows a tendency towards normocytic
normochromic anaemia and also that the periodontal treatment may lead to improvement in this condition.
REFERENCES
1.

Hafajee AD, SocranskySS: Microbial and Etiological agents of destructive periodontal disease:periodontology 2000
1994;5:78-111

2.

Page RC. Periodontal diseases: a new paradigm. J Dent Edu 1998;2:812821

3.

Scannapieco FA: Position paper periodontal disease as a potential risk factor for systemic diseases. Journal of
Periodontology1998; 69: 841- 850.

4.

Beck JD, Garcia R, Heiss G, Vokonas P. & Offenbacher S: Periodontal disease and cardiovascular disease. Journalof
Periodontology1996; 67: 1123-1137.

5.

Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M,Knowler WC & Pettit DJ. Severe periodontitis and risk for poor
glycemic control in patients with non-insulin dependent diabetes mellitus. Journal of Periodontology 1996; 67: 1085-1093.

6.

Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, McKaig R, Beck J. Periodontal infection as a possible risk
factor for preterm low birth weight. J Periodontal. 1996 Oct; 67(10 Suppl):1103-13

7.

Hutter JW, Van der Velden U, Varoufaki AR, Huffels AM,. Hoek FJ, Loos BG: Lower numbers of erythrocytes and lower levels
of hemoglobin in periodontitis patients compared to control subjects. Journal of Clinical Periodontology2001; 28 (10):930
936.

8.

Taylor BA, Tofler GH, Carey HMR, Morel-Kopp MC, Philcox S, Carte T.R, Elliott M.J, Kull A.D, Ward C and Schenck K
:Full-mouth Tooth Extraction Lowers Systemic Inflammatory and Thrombotic Markers of Cardiovascular Risk. Research
report Clinical: J Dent Res 2006; 85:74-78.

9.

Weiss G and Goodnough LT: Anemia of Chronic Disease(reviewarticle). N Engl J Med 2005; 352:1011-23.

10. Means, RT & Krantz SB: Progress in understanding the pathogenesis of the anemia of chronic disease. The Journal of the
American Society of Hematology1992; 80: 1639- 1647.
11. Means RT Jr. Recent developments in the anemia of chronic disease. Curr Hematol Rep 2003;2:116-21
12. Loos BG:Systemic markers of inflammation in periodontitis JPeriodontol2005; 76:2106-21.
13. Offenbacher S,Madianos PN, Champagne CM, SoutherlandJ, Paquette DW, Williams RC, Slade G & Beck J:Periodontitisatherosclerosis syndrome: An expanded model of pathogenesis. Journal of Periodontal Research1999; 34: 346-352.
14. Ebersole, J., Machen, R. L., Steffen, M., Willman, D. Systemic acute-phase reactants, C-reactive protein and haptoglobin, in
adult periodontitis. Clinical Experimental Immunology1997; 107:347 -352
15. Firkin F, Cheseterman C,Penington D, Rush B: de Gruchys text bookclinical haematology in medical practice 1989; 5Th Ed.
16. Miller A, Green M, Robinson D "Simple rule for calculating normal erythrocyte sedimentation rate". Br Med J (Clin Res
Ed)1983; 286 : 266. cited in wikipedia the free encyclopedia
17. Greer JP,Foerster J, Lukens JN,Rodgers GM,Paraskevas F, Glader B, Wintrobes text book clinical hematology11thEd. 2004;
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Kapil Jain, Swarga Jyoti Das, Shivani Dwivedi, Rahul Jain, Babitha Nugala & Megha Jain

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1:1445-1465.

18. Scannapieco FA: Position paper periodontal disease as a potential risk factor for systemic diseases. Journal of
Periodontology1998; 69: 841- 850
19. Loesche WJ : Periodontal disease as a risk factor for heart disease. Compendium of Continuing Education in Dentistry 15
1994; 976-991
20. Pradeep A.R, Sharma Anuj, and Arjun Raju P. Anemia of Chronic Disease and Chronic Periodontitis: Does Periodontal
Therapy Have an Effect on Anemic Status? Journal of Periodontology 2011, Vol. 82, No. 3, Pages 388-394
21. 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.
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23. Wakai K, Kawamura T, Umemura O, Hara Y, Machida J, Anno T, et al . Associations of medical status and physical fitness
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APPENDICES
Table 1: Comparison of Clinical Parameters at Baseline and 9 Months Post SRP
Parameter
PPD(mm)
CAL(mm)

Baseline
Mean (SD)
4.65 0.44
4.88 0.52

9 Months
Mean (SD)
3.60 0.40
3.98 0.42

T-Value

P-Value*

12.88
11.96

0.00
0.00

*P < 0.05 denotes statistical significance.


SD, standard deviation
Table 2: Comparison of RBC Parameters at Baseline and 9 Months Post SRP
Parameter

Baseline
Mean (SD)

9months
Mean (SD)

TValue

P-Value*

RBC count
(millions/mm3)

4.42 0.34

4.51 0.32

3.08

0.004

Hb(gm %)

12.21 0.97

12.45 0.97

2.88

0.007

PCV(%)

37.97 3.17

38.63 3.00

2.75

0.009

MCV (cubic
microns)

85.68 3.04

85.57 2.76

0.873

0.389

MCH (pico
gm)

27.68 0.73

27.68 0.64

0.144

0.886

MCHC (gm/dl)

32.24 0.91

32.17 0.80

0.729

ESR (mm at
the end of first
hour)

11.88 4.71

11.33 4.50

2.16

0.471

0.037

*P 0.05 denotes statistical significance.


SD, standard deviation.
Impact Factor (JCC): 1.9876

Index Copernicus Value(ICV) : 6.1

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