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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 77-82

Evaluation of serum albumin concentration in generalized chronic periodontitis patients after surgical periodontal therapy


Department of Periodontics, Nair Hospital Dental College, Mumbai, Maharashtra, India

Date of Submission01-May-2019
Date of Acceptance08-Jan-2020
Date of Web Publication3-Feb-2020

Correspondence Address:
Dr. Manish Arun Ashtankar
233 New Balaji Nagar Manewada Road, Nagpur - 440 027, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmd.ijmd_29_19

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  Abstract 


Introduction: Chronic periodontitis is one of the most prevalent diseases which affect patient's mastication and nutrition. Chronic inflammation of the gingiva also causes loss of serum albumin. Serum albumin is considered as a marker for general health as it has many functions in human body. Protein deficiency also accentuates the destructive effects of local irritants and occlusal trauma.
Aims: The aim is to study the effect of surgical periodontal therapy (flap surgery) on serum albumin in chronic periodontitis patients.
Subjects and Methods: Fifty participants of generalized chronic periodontitis were selected from the outpatient department. Clinical parameters were recorded at baseline, after 1 month, and 3 months. Venous blood was collected at baseline and 3 months after surgery from the participants to measure serum albumin by the bromocresol green albumin method.
Statistical Analysis Used: Effect of surgical periodontal therapy on clinical parameters analyzed using one-way ANOVA (repeated-measures one-way ANOVA) followed by Tukey's multiple comparison tests for intragroup and intergroup comparison. A paired t-test was applied for serum albumin analysis.
Results: Serum albumin level increased from baseline to follow-up period after surgical periodontal treatment, i.e., 3 months. This effect was found to be statistically significant (<0.001) in both groups as per the paired t-test.
Conclusion: Surgical periodontal treatment (open flap debridement) has a positive effect on serum albumin level.

Keywords: Clinical attachment loss; gingival index; plaque index; probing pocket depth; serum albumin


How to cite this article:
Ashtankar MA, Dixit MB, Pimpale SK. Evaluation of serum albumin concentration in generalized chronic periodontitis patients after surgical periodontal therapy. Indian J Multidiscip Dent 2019;9:77-82

How to cite this URL:
Ashtankar MA, Dixit MB, Pimpale SK. Evaluation of serum albumin concentration in generalized chronic periodontitis patients after surgical periodontal therapy. Indian J Multidiscip Dent [serial online] 2019 [cited 2020 Dec 1];9:77-82. Available from: https://www.ijmdent.com/text.asp?2019/9/2/77/277450




  Introduction Top


Periodontitis is defined as an inflammatory disease of the supporting tissue of teeth caused by specific microorganisms or group of microorganisms, resulting in progressive destruction of periodontal ligament and alveolar bone with pocket formation, recession, or both.[1] The prevalence of periodontal diseases increases with age because of the cumulative effects of diseases over a lifetime.[2] Poor oral health contributes to tooth loss, edentulism, and potential inflammation and affects nutrition and causing chronic systemic inflammation. Poor nutrition and excessive inflammation have been linked to frailty.[3] Serum albumin is the most abundant plasma protein in humans and is produced in the liver. Albumin is essential for maintaining the osmotic pressure needed for proper distribution of body fluids between intravascular compartments and body tissues. The range of albumin concentration in blood is 30–50 g/l.[4]

Genco et al. (1994) investigated and reported that hypoalbuminemia was associated with an increased mortality rate. It is apparent that oral disease might be indicated and monitored by the level of serum albumin. Serum albumin levels might be the marker of general health status as they described the severity of an underlying disease and mortality in the elderly.[5] A periodontal infection has been implicated as a risk factor for systemic diseases such as coronary heart diseases and diabetes (Genco et al. 2001, Taylor 2001, Nishimura et al. 2003). Protein deficiency also accentuates the destructive effects of local irritants and occlusal trauma.[6] Studies have shown that there might be an inverse relationship between periodontal disease and serum albumin concentration in elderly patients.[5] Hence, the purpose of this study is to determine the effect of surgical periodontal therapy on serum albumin in chronic periodontitis patients.


  Subjects and Methods Top


Source of data

A total of fifty participants with chronic periodontitis were selected from the outpatient department of Periodontology department, after taking approval by the Institutional Ethical Committee Nair Hospital Dental College, Mumbai.

Inclusion criteria

  1. Patients with generalized chronic periodontitis
  2. Age group between 35 and 70 years
  3. Patients with veg/nonveg diet group
  4. Pocket depth and clinical attachment loss of about 5 mm or more
  5. Systemically healthy individuals/no underlying medical conditions.


Exclusion criteria

  1. Patients with any systemic diseases which are known to affect any of the considered parameters in any way
  2. Patient on any protein supplements
  3. Smokers
  4. Pregnant and lactating females
  5. Any periodontal therapy in the previous 6 months
  6. Use of any antimicrobials in the previous 3 months.


Study design

Group A

Blood samples were collected for serum albumin detection from all patients before the start of periodontal therapy.

Group B

Blood samples were collected for serum albumin detection from all patients 3 months after surgical (open flap debridement) periodontal therapy.

Clinical parameters

The following parameters were recorded at baseline (before any treatment), at 1-month (after nonsurgical therapy), at the end of 3-month postsurgery (flap surgery).

  1. Plaque index (PI) (Turkey-Gilmore-Glickman Modification of Quigley Hein)[7]
  2. Gingival index (GI) (Loe and Silness, 1963)[8]
  3. Probing pocket depth (PPD)
  4. Clinical attachment level (CAL).


Presurgical procedure

Following initial examination and treatment planning, the selected participants underwent Phase I therapy (thorough scaling and root planning). Trauma from occlusion if detected was relieved. Detailed instructions regarding self-performed plaque control measures were given. After 4–6 weeks, only those patients maintaining optimum oral hygiene were subjected to the surgical procedure. The baseline PI, GI, PPD, and CAL was recorded.

Surgical procedure

Perioral preparation with povidone-iodine was followed by rinsing of the mouth with 10 ml of 0.2% chlorhexidine and all aseptic precautions, including continuous suction, was applied to keep the surgical site clean. The operative site was anesthetized with 2% lignocaine hydrochloride with adrenaline (1:100,000). After achieving adequate anesthesia indicated flap surgery was done.

Follow-up

Recall appointments were made after 1, 3 months postsurgery, and at each visit, oral hygiene instructions were reinforced, and scaling was done if necessary. Patients were evaluated clinically at 1, 3 months postoperatively. Serum albumin level was measured at 3-month follow-up.

Serum albumin measurement

Collection of blood

  1. Venous blood was collected in vacutainers at baseline and 3 months after the surgery from the participants
  2. For biochemical tests, 1 ml blood was drawn from an antecubital vein and was centrifuged at 2500 rpm for 10 min under aseptic precautions
  3. Biochemical value of serum albumin level was measured by the bromocresol green (BCG) albumin method.


Biochemical analysis

Autozyme albumin was the reagent set used for the determination of albumin in serum or plasma-based on the BCG method.[9],[10],[11]

Principle

Serum albumin in the presence of BCG under acidic conditions forms the green-colored complex. The absorbance of this complex is proportional to the albumin concentration in serum or plasma.

Reagents composition

  • Succinate buffer (ph: 3.6): 100 mmol/L
  • BCG: 0.15 mmol/L
  • Stabilizer.


Procedure

Manual assay preparation

The reagent was brought to room temperature before use. The following assay was prepared1.0 ml procedure.

Incubation

The assay mixture was incubated for 1 min at room temperature (25°C –300°C). After completion of incubation period absorbance was measured against blank at 600 nm. The final color is stable for 10 min if not exposed to direct light.

Calculation

Albumin g% = Absorbance of sample/absorbance of standard × 5

Expected value

3.5–5.0 g%.

Statistical analysis

To check the effect of surgical periodontal therapy on clinical parameter, the data were subjected to one-way ANOVA (repeated measures one-way ANOVA) followed by Tukey's multiple comparison tests for intragroup and intergroup comparison. A paired t-test was applied for serum albumin analysis.


  Results Top


Mean score of PI [Table 1], GI [Table 2], PPD [Table 3], and clinical attachment loss [Table 4] at 3 months postsurgery was significantly less as compared to score at baseline and 1-month follow-up. A highly significant difference was found in mean scores Serum albumin between baseline and 3 months after the surgery (P < 0.001) as per paired t-test [Table 5]. It suggests that the mean score of serum albumin at 3 months postsurgery was significantly higher as compared to score at baseline.
Table 1: Effect of periodontal therapy on Plaque index

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Table 2: Effect of periodontal therapy on Gingival Index

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Table 3: Effect of periodontal therapy on probing pocket depth

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Table 4: Effect of periodontal therapy on clinical attachment loss

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Table 5: Effect of surgical periodontal therapy on serum albumin level

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  Discussion Top


Periodontitis is defined as an inflammatory disease of the supporting tissue of teeth caused by specific microorganism or group of microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both.[1]



Serum albumin is a negative acute-phase protein and serum albumin levels might be the practical marker of general health status (Phillips et al. 1989)[5] Many conditions such as inflammatory states, liver diseases, and renal diseases have been indicated to reduce serum albumin levels (Herrmann et al.)[14] Inflammation and malnutrition both reduce serum albumin concentration by decreasing its rate of synthesis.[13] 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.

The present study consisted of fifty patients (28 males and 22 females) having a mean age of 43.28 ± 11.78 years (35–59 years). In the present study, statistically significant improvements seen in all clinical parameters were compared such as PI and GI. Positive effect on these parameters could be because of repeated reinforcement of oral hygiene instruction and resolution of gingival inflammation after nonsurgical and surgical periodontal therapy. These findings are in accordance with that of Kaur et al. in 2015.[14]

The reduction in PPD can be attributed to soft- and hard-tissue improvements following the resolution of inflammation and regeneration of bony defects. A highly significant difference was found in mean scores clinical attachment loss between baseline and follow-up period (P < 0.001).

The mean score of serum albumin at baseline was 3.893, and 3 months after surgery was 4.703 with (P < 0.001) as per paired t-test. It suggests that the mean score of serum albumin at 3 months postsurgery was significantly higher as compared to score at baseline. In this trial, 50 patients with chronic periodontitis had a periodontal loss of attachment, which was >5 mm. The results showed a positive effect of surgical periodontal treatment on serum albumin levels by improving its level than the baseline level after periodontal treatment. However, periodontal disease susceptibility can also be increased by risk factors such as diabetes, hypertension, obesity and metabolic syndrome, stress, and genetic factors.[15] The possibility of these factors in influencing the results of this study has been reduced by including only systemically healthy patients in the study.

The number of bacteria ranges from 1 × 103 in healthy shallow crevices to >1 × 108 in periodontal pockets. These bacteria attract monocytes into the gingival crevicular space, and numerous cytokines are found within this space. Furthermore, they can invade the host. Individuals with significant periodontitis have recurrent episodes of low-level bacteremia. Porphyromonas gingival is 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 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.[16] Studies have shown that there might be an inverse relationship between periodontal disease and serum albumin concentration in elderly patients.[5]

Fleck et al.[17] showed that increased vascular permeability is an important cause of the lowered concentration of albumin commonly seen in acute and chronic diseases. In another study done by Don and Kaysen et al.,[12] they showed that inflammation and malnutrition both reduce albumin concentration by decreasing its rate of synthesis, while inflammation alone is associated with a greater fractional catabolic rate and when extreme, increased transfer of albumin out of the vascular compartment. In 2006, Yoshihara and Ogawa,[5] in their study, concluded that there might be an inverse relationship between periodontal disease and serum albumin concentration in these elderly subjects.

Other studies provide similar evidences in literature like Kshirsagar et al.[16] in group of patients on hemodialysis, Kolte et al.,[18] Maruyama et al.[19] in head-and-neck cancer patients, Mary et al.,[20] Shi et al.[21] in aggressive periodontitis patients, Saravanan et al.[22]

Shaila et al.[23] showed that a very highly significant rise in the salivary total protein and albumin concentration was noted in gingivitis and periodontitis participants of both young and elderly. Pimpale et al.[24] showed that the serum albumin levels in chronic periodontitis patients had decreased in comparison with healthy individuals of the same age group. Thus, serum albumin concentration could be a significant risk indicator for patients with chronic periodontitis. Kaur et al.[14] showed serum albumin levels have an inverse relationship between the serum albumin concentration and chronic periodontal disease.

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.[25] Serum albumin is the main protein synthesized by the liver.[17] In elderly individuals, it would seem imperative that the impaired dentition status and the possibility of compromised systemic health status would reflect the values of serum albumin concentration.[25]

Serum albumin is a negative acute-phase protein that supports the contention that serum albumin is a marker of inflammation.[17] 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).[13] Moreover, malnutrition may also be monitored by means of serum albumin concentration (Don and Kaysen. 2004).[5] Therefore, albumin concentration is associated with nutrition and inflammation. Several studies have demonstrated that serum albumin concentrations are associated with general health status among the elderly.[26] 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.

Hence, it is important to improve both an inflammatory component of chronic periodontitis and the compromised nutritional status, which was considered in this study by treating patients with chronic periodontitis by nonsurgical periodontal treatment followed by surgical periodontal treatment wherever required to reduced inflammatory component and to improve alveolar bone support which has been shown by improvement in GI, PI, PPD, and CAL.

Limitations of the present study

At the end of the study, it has been observed that there have been certain aspects, which demand more detailed observation and elucidation of data and facts

  1. Large sample size would have been preferable with a longer follow-up
  2. There was a lack of negative control group with chronic periodontitis having no treatment which is not ethical
  3. Variation in a diet in a patient with different age group and religion
  4. Evaluation of the masticatory ability of patients before and after treatment can provide a better picture of nutrition components affecting serum albumin levels.



  Conclusion Top


Treatment of chronic periodontitis with nonsurgical and surgical periodontal therapy not only helps to eliminate the inflammatory component completely but also helps to decrease PPD and increase in clinical attachment loss. Reduced inflammatory component, as well as improved periodontal support, helps patients in better mastication, thus improving their nutrition status. Hence within its limitation, the conclusion of this study is that surgical periodontal treatment has a positive effect on serum albumin levels.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Newman M, Carranza F. Carranza's Clinical Periodontology. 10th ed. Philadelphia, London, New York, St. Louis, Sydney, Toronto: W.B. Saunders Co., Lindo; 2006. p. 679.  Back to cited text no. 1
    
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Jepsen R, Kuchel GA. Nutrition and inflammation: The missing link between periodontal disease and systemic health in the frail elderly? J Clin Periodontol 2006;33:309-11.  Back to cited text no. 3
    
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Craig RG, Yip JK, So MK, Boylan RJ, Socransky SS, Haffajee AD. Relationship of destructive periodontal disease to the acute-phase response. J Periodontol 2003;74:1007-16.  Back to cited text no. 6
    
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Johnson AM, Rohlfs EM, Silverman LM. Proteins. In. Burtis CA, Ashwood ER, editors. Teitz Textbook of Clinical Chemistry. Vol. 3. Philadelphia: W.B Saunders Company; 1999. p. 477-540.  Back to cited text no. 9
    
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Webster D, Bignell AH, Attwood EC. An assessment of the suitability of bromocresol green for the determination of serum albumin. Clin Chim Acta 1974;53:101-8.  Back to cited text no. 11
    
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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.  Back to cited text no. 13
    
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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.  Back to cited text no. 14
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Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontol 2000 2013;62:59-94.  Back to cited text no. 15
    
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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.  Back to cited text no. 16
    
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Fleck A, Raines G, Hawker F, Trotter J, Wallace PI, Ledingham IM, et al. Increased vascular permeability: A major cause of hypoalbuminaemia in disease and injury. Lancet 1985;1:781-4.  Back to cited text no. 17
    
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Kolte RA, Kolte AP, Kohad RR. Quantitative estimation and correlation of serum albumin levels in clinically healthy subjects and chronic periodontitis patients. J Indian Soc Periodontol 2010;14:227-30.  Back to cited text no. 18
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Maruyama T, Yamanaka R, Yokoi A, Ekuni D, Tomofuji T, Mizukawa N, et al. Relationship between serum albumin concentration and periodontal condition in patients with head and neck cancer. J Periodontol 2012;83:1110-5.  Back to cited text no. 19
    
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Saravanan AV, Swaminathan MR, Panishankar KH, Kumar P. Estimation of serum albumin levels associated with chronic periodontitis in elderly subjects – A cross sectional study. SRM Univ J Dent Sci 2012;3:120-5.  Back to cited text no. 22
    
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Shaila M, Pai GP, Shetty P. Salivary protein concentration, flow rate, buffer capacity and pH estimation: A comparative study among young and elderly subjects, both normal and with gingivitis and periodontitis. J Indian Soc Periodontol 2013;17:42-6.  Back to cited text no. 23
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Pimpale S, Parmar VN, Baburaj MD. Evaluation of the relationship between periodontal disease and general health status in chronic periodontitis patients using serum albumin concentration. Int J Dent Health Sci 2014;1:468-74.  Back to cited text no. 24
    
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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.  Back to cited text no. 26
    



 
 
    Tables

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



 

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