Association of Chronic Periodontitis with Reduced Haemoglobin Level

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INTRODUCTION
Chronic periodontitis is an infectious disease of supporting tissues of tooth.However, the microorganisms/their byproducts can invade periodontal tissues and gain access to systemic circulation producing proinflammatory cytokines. 1,2search has revealed that periodontitis increases the risk of various systemic problems and this long-standing Dr. Rebicca Ranjit, 1 Dr. Pujan Acharya, 2 Dr. Bikash Kumar Baniya, 3 Dr.Khushbu Adhikari 2
Hence, the participants were divided into controls: 30 periodontally healthy subjects and cases: 30 patients with chronic periodontitis.For inclusion in the study, participants had to be systemically healthy with following characteristics: (i) aged 30 to 60 years, (ii) probing depth ≤3 mm (controls) (iii) probing depth ≥5 mm in at least two teeth per quadrant and (iv) clinical attachment loss ≥2 mm at >30% sites (cases). 9

RESULTS
The patients with age 30-60 years were included in the study where mean age of control group and case group were 38.5 years and 40.2 years respectively.Similarly, control group included females 17 (56.7%)more than males 13 (43.3%)while cases had higher proportion of males 16 (53.3%)than females 14 (46.7%).
On comparing Hb concentration in the study population, cases showed lower Hb level as compared to controls which was statistically significant (P <0.05,Table 1  Comparison of Hb concentration among various CAL groups in cases was done in order to assess if the level of Hb varies with the severity of periodontitis (Table 3).The P value, corresponding to F-statistic of one-way ANOVA was applied among various CAL groups, and was found to be >0.05suggesting that the values of Hb does not differ among the different severity of periodontitis.
The correlation matrix of various demographic, haematological, and periodontal parameters among cases showed statistically significant moderate negative correlation of Hb concentration with probing pocket depth (r=-0.424)and statistically significant weak negative correlation of Hb concentration with clinical attachment level (r=-0.307).The analysis also showed weak negative correlation between Hb concentration and GI score (r=-0.149)which was statistically insignificant (Table 4).
On applying Yates corrected Chi-square test to assess the association between chronic periodontitis and the anaemic condition in male patients, it was observed that male patients who were anaemic have 26.4 times more chances to have chronic periodontitis in comparison to the males who were not suffering from anaemia (Table 5).The association was statistically significant (P <0.05).Similarly, the female patients who were anaemic have 5.24 times more chance to have chronic periodontitis in comparison to those females who were not suffering from anaemia.However, this association was not statistically significant (P=0.083)

DISCUSSION
Earlier paradigms have maintained that periodontitis is an oral disease and that the tissue destruction remains localised within the periodontium, limiting its effects to oral tissues supporting the teeth only.However, recent studies have proved that periodontitis also affects the systemic health.Periodontal deterioration increases the risk of various systemic problems and this long-standing chronic inflammation can also lead to anaemia. 5,6,11,12e present study showed that patients with periodontitis showed lower Hb level as compared to controls.In correspondence to the results of current study, several    14 found an increase in Hb and red blood cell (RBC) levels after scaling and root planing in the patients with severe periodontitis.Similarly, several studies 15,16 also showed a significant improvement in Hb value and erythrocyte counts after non-surgical periodontal therapy.This supports the hypothesis that periodontitis may be a contributing factor for the reduced erythrocyte counts. 9,17On contrary to this, few studies [18][19][20]  in study groups demonstrated that cases had lower Hb level as compared to controls in both males and females, which was statistically significant.This finding was in accordance with the result obtained in previous studies. 22,23en the haematological variables between the two study groups were compared separately in men and women, it was observed that, irrespective of gender, the patients with periodontitis had significantly lower Hb concentrations and lower erythrocyte counts. 23inical attachment loss provides a reliable indicator of the degree of periodontal tissue destruction.Therefore, in the present study, Hb concentration was compared amongst various CAL groups (mild periodontitis, moderate periodontitis and severe periodontitis).This was done to assess if Hb concentration varies with the severity of periodontitis.However, it was found that the level of Hb does not differ among the different severity of periodontitis.
This result was in accordance with previous studies [24][25][26] where haematological and biochemical parameters were not affected by the severity of periodontitis.On contrary to the present study, the study by Khan et al. 11 showed a substantial decrease in red blood cell parameters with increase in the severity of periodontal destruction.
Pearson correlation analysis showed weak negative correlation between Hb concentration and GI score which was statistically insignificant.This result was in accordance to a study carried out by Ali 12 which showed a weak negative but statistically insignificant correlation between Hb level and GI.The result of present study was also in correspondence to an interventional study performed by Patel et al. 27 where the GI score in anaemic patients dropped after periodontal treatment.It strongly suggested that gingivitis is closely linked with the severity of anaemia and the oxygen content in the blood.This is also in accordance with the study by Nair et al. 5 and it can be interpreted that in the presence of gingivitis, the Hb% and the RBC count tends to decrease.
The analysis from present study also showed statistically moderate negative correlation of Hb concentration with probing pocket depth and statistically weak negative correlation of Hb concentration with clinical attachment level.This significant relationship may indicate the beginning of subclinical or clinically evident anaemic status.This result was in correspondence with the study conducted by Nair et al. 5 which showed negative correlation between the CAL and Hb%.In accordance to the current study, a weak negative but insignificant correlation were found between Hb level and PPD in the previous studies 4,12 This negative correlation suggests that anaemic status may be considered a risk factor for the periodontal diseases.
This may be caused by the impaired oxygen supply to the periodontal tissues as a result of the reduced oxygencarrying capacity of blood in anaemic patients leading to a persistent sub-gingival gram-negative anaerobic bacterial challenge to the host. 3nversely, some authors 1,2 reported that depression in the number of erythrocytes is apparently secondary to the presence of periodontal disease.The inflamed and ulcerated epithelium, in periodontitis, acts as an easy portal of entry for the oral microorganisms to enter the connective tissue and thus into the systemic circulation producing proinflammatory cytokines.The elevated levels of proinflammatory cytokines from local chronic disease process, may downregulate erythropoiesis in bone marrow leading to low erythrocyte count and ultimately low Hb level. 28" The same inflammatory cytokines have been found to play a central role in the pathogenesis of anaemia of chronic disease (ACD). 29,30Hence, periodontitis, being a chronic disease, may lead to decreased erythrocyte count consequently lowering the Hb levels in a substantial number of patients.There have been conflicting findings as far as the Hb levels are concerned in periodontitis patients.On contrary to the present study, Wakai et al. 20 did not observe any relationship between increased Community Periodontal Index of Treatment Needs scores and Hb levels.Accordingly, the study by Havemose-Poulsen et al. 19 did not show any association between Hb levels and periodontal status.
The changes in Hb and RBC values were not as high as observed in anaemia due to other inflammatory conditions like rheumatoid arthritis and multiple myeloma.This may be due to the reason that other diseases are more severe Ranjit et al: Association of Chronic Periodontitis with Reduced Haemoglobin Level inflammatory conditions than periodontitis.Therefore, anaemia resulting from periodontitis (low-grade chronic infection) is relatively mild.[20] It was observed that male patients who were anaemic were 26.4 times more likely to have chronic periodontitis in comparison to the males who were not suffering from anaemia.The association was statistically significant.In correspondence to the results of the present study, several studies 1,2,11,27 also showed that male patients with chronic periodontitis have lower Hb level along with other red cell parameters when compared to healthy controls.Similarly, female patients who were anaemic have 5.24 times more chance of developing chronic periodontitis than the females who were not suffering from anaemia.However, the association was not statistically significant.Females are prone to hormonal imbalance during puberty, during the reproductive phase, and toward menopausal age.The microbial flora and the host immune response are altered leading to exaggerated response of the periodontal tissues to local factors.Therefore, to eliminate the bias, comparison of Hb concentration between the two study groups was performed separately between males and females. 22 would be prudent that longitudinal studies with greater sample size, and determining the effect of interventional therapeutics on the haematological parameters would have helped to arrive at a definitive conclusion.Within the limitations of the present study, it can be stated that chronic periodontal diseases are associated with alterations in the Hb concentration.

CONCLUSIONS
Like any other chronic condition, chronic periodontitis can also lead to signs of anaemia.Being a low-grade infection, the signs may not be as severe as seen in other systemic conditions, but they definitely cannot be ignored.As these chronic conditions reinforce each other, meticulous management of either may assist treatment of other.The present study has paved the path for future studies in order to further validate the association between periodontal disease and anaemia.
. The study included 60 systemically healthy subjects visiting the Department of Periodontology and Oral Implantology, Universal College of Medical Sciences (UCMS), College of Dental Surgery, Siddharthanagar, Rupandehi, Nepal.The protocol of this study was approved by the Institutional Review Committee, UCMS (Ref.UCMS/ IRC/016/15).The purpose of this research project was explained to the patients and informed consent forms were due signed.
Similarly, patients with history of known systemic diseases, severe trauma, or renal transplant, history of hospitalisation or who had taken systemic medications within previous six months, smokers, obese individuals, pregnant or lactating females were excluded in the study.Under strict aseptic condition, periodontal examinations of the participants were done using mouth mirror and University of North Carolina-15 (UNC-15) probe.The clinical parameters including gingival index (GI), 10 probing pocket depth (PPD), and clinical attachment level (CAL) were recorded at the same visit.Based on their periodontal findings, they were categorised into case group and control group.A tourniquet and 3 ml syringe were used to withdraw venous blood from the cubital fossa.The collected blood was transferred into ethylenediaminetetraacetic acid (EDTA) containing vials.The sample was then sent to the Department of General Pathology for estimation of serum Hb level (cyanmethaemoglobin method).Data obtained by clinical examinations and laboratory tests were entered into Microsoft Excel Sheet 2013 and analysed using SPSS Statistics for Windows, version 16.0 (SPSS Inc., Chicago, Ill., USA).The student's unpaired t-test, one-way analysis of variance (ANOVA) test, Pearson's correlation and Odd's ratio were applied.

comparison of Hb concentration in study groups demonstrated that cases had lower Hb level as compared to controls in both males and females which was statistically significant (P <0.05).
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Table 1 :
Comparison of Hb concentration in study groups.

Table 2 :
Agewise and genderwise comparison of Hb concentration in study groups.
*Statistically significant (p <0.05) Ranjit et al: Association of Chronic Periodontitis with Reduced Haemoglobin Level

Table 4 :
Pearson's correlation among various study parameters in Cases group.

Table 5 :
Association between chronic periodontitis and Hb level in males and females.