KVG DENTAL COLLEGE

SULLIA, KARNATAKA

ANNEXURE-II

PROFORMA FOR THE REGISTRATION OF SUBJECTS FOR DISSERTATION.

1. / NAME OF THE CANDIDATE AND ADDRESS
( IN BLOCK LETTERS) / DR. JITENDRA KUMAR
POST GRADUATE STUDENT
DEPT OF PERIODONTOLOGY
KVG DENTAL COLLEGE,SULLIA
KARNATAKA
2. / NAME OF THE INSTITUTION / KVG DENTAL COLLEGE AND HOSPITALS
SULLIA,
KARNATAKA.
3. / COURSE OF STUDY AND SUBJECT / MASTER OF DENTAL SURGERY (M.D.S) IN
PERIODONTOLOGY
4. / DATE OF ADMISSION TO COURSE / 3rd AUGUST 2013
5. / TITLE OF THE TOPIC / EFFECT OF SCALING AND ROOT PLANING ON THELEVELS OF C-REACTIVE PROTEIN(CRP) AND ERYTHROCYTE SEDIMENTATION RATE(ESR) IN CHRONIC PERIODONTITIS PATIENTS -A CASE CONTROL STUDY
6 / BRIEF RESUME OF THE INTENDED WORK:
6.1 / Need for the Study:
Periodontitis is an inflammatory disease of the supporting tissues of teeth caused by specific micro-organisms in a susceptible host. The sulcular epithelium acts as a protective barrier and prevents entry of micro-organisms and other irritants into systemic circulation. Ulcerated epithelium acts as a portal of entry for the bacteria to enter the connective tissue and thus into the systemic circulation.1
Periodontal bacterial products are characterized by infiltration of periodontal tissue by inflammatory cells including polymorphonuclear neutrophils and macrophages. Activated macrophages release cytokines and some individuals respond to microbial challenge with an abnormally high delivery of inflammatory mediators such as Interlukin-1(IL-1) and tissue necrotic factor-alpha (TNF-alpha).2
These cytokines are involved in destruction of both periodontal connective tissue and alveolar bone. They can also initiate a systemic acute phase response. Recent studies have shown that C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) serum levels in patients with periodontal disease are elevated.3,4
The erythrocyte sedimentation rate is a strong predictor of coronary heart disease mortality, and appears to be a marker of aggressive forms of coronary heart disease. The erythrocyte sedimentation rate probably gives substantial information in addition to that given by fibrinogen on the risk of coronary heart disease death.5
C-reactive protein (CRP) may increase in cardiovascular disease in response to infectious agents inducing inflammatory reactions in the (coronary) vessels.Chronic infections elsewhere in body are also associated with increase risk of cardiovascular disease. Periodontal infections may contribute to atherosclerosis by repeatedly challenging the vascular endothelium with bacterial lipopolysachrides and proinflammatory cytokines. Cardiovascular diseases are recognized as having a major systemic inflammatory component ,further emphasizing possible similiarties with periodontal inflammatory diseases.6,7
The present study will be carried out in above background with the aim of evaluating the difference in the level of CRP and ESR in patients with and without periodontitis and effect of scaling and root planning on the level of CRP and ESR in chronic periodontits patients.
6.2 Review of Literature:
The belief that oral disease causes systemic illness is attributed to Miller and Hunter. Miller proposed a role for oral bacteria in the causation of numerous diseases in organs that are distant from the oral cavity.8
A study was done to evaluate the association between rheumatoid arthritis, periodontal disease and coronary artery disease and the influence of systemic inflammatory factors. A total of 100 active rheumatoid arthritis patient of which 50 had established coronary artery disease and 50 had no coronary artery disease were assessed for periodontal disease. Blood sample were obtained and the level of high sensitivity CRP, ESR and tissue necrotic factor alpha were assessed. The inflammatory markers hsCRP, ESR and TNF-alpha were raised in all patient but were significantly higher in rheumatoid arthritis patients with coronary artery disease who also had periodontal disease. The implication is that inflammation may be the central link between the chronic inflammatory disease, autoimmune disorder and atherosclerosis.9
A study was done to invastigate systemic levels of inflammatory markers of cardiovascular disease like CRP and Interlukin-6(IL-6) in patients with chronic periodontitis patients in comparison to periodontally healthy patients .A total of 42 individuals both male & female above age of 30 years were included in the study. Peripheral blood samples were taken, CRP and IL-6 were estimated .The results shows higher systemic level of CRP and IL-6.10
A study done in Brajil ,22 patients were examined and randomly divided into two groups. The test group was composed of 11 patients (mean age, 48.9 ± 3.9 years) who received periodontal treatment, whereas the control group had 11 patients (mean age, 49.7 ± 6.0 years) whose treatment was delayed for 3 months. Demographic and clinical periodontal data were collected, and blood tests were performed to measure the levels of IL-6, CRP, and fibrinogen at baseline and 3 months later. Results shows non-surgical periodontal therapy was effective in improving periodontal clinical data and in reducing the plasma levels of IL-6, CRP, and fibrinogen in hypertensive patients with severe periodontitis.11
A study was done to evaluate the effect of periodontal therapy on markers of systemic inflammation in patients with coronary heart disease risk .73 patients with chronic periodontitis , dyslipidemia and other CHD risk factors were subjected to periodontal therapy .Periodontal parameters ,serum CRP ,fibrinogen and ESR were assessed before and after 6 weeks of therapy . The results shows that CRP levels significantly increased while no chnages were observed in fibrinogen and ESR levels.12
A study was done in Netherland to evaluate the elevation of systemic markers related to Cardiovascular disease in peripheral blood of periodontitis patients .Patients with generalized periodontitis and localized periodontitis had higher median CRP levels and interlukin-6 than controls.13 .
An observational prospective cohort study done in Turkey aimed to evaluate the effects of non-surgical periodontal treatment on clinical periodontal measurements and systemic inflammatory mediator levels in low or moderate to highly active rheumatoid arthritis (RA) patients with chronic periodontitis.Thirty patients with RA with moderate to high disease activity and chronic periodontitis and thirty patients with RA with low disease activity and chronic periodontitis were enrolled in the study. The patients were monitored at the beginning and 3 months after undergoing periodontal therapy. The results shows erythrocyte sedimentation rate (ESR),C-Reactive Protein(CRP), TNF-alpha levels in serum and periodontal parameters exhibited similar and significant reduction 3 months after the non-surgical periodontal treatment.14
6.3 Aims and Objectives of the Study:
Aim
Assessment of C-Reactive Protein(CRP) and Erythrocyte Sedimentation Rate (ESR) values in chronic periodontitis patients and healthy control and to evaluate the effect of scaling and root planing on thelevels of C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) in chronic periodontitis patients.
Objectives:
  1. Estimation of ESR and CRP levels in chronic periodontitis patients & healthy controls before scaling and root planing.
  2. Estimation of ESR and CRP levels in chronic periodontitis patients with altered ESR and CRP after 6weeks of scaling and root planing.
  3. Comparison of ESR and CRP levels in chronic periodontitis patients & healthy controls before scaling and root planning.
  4. Comparison of ESR and CRP levels in chronic periodontitis patients with altered ESR and CRP before and after scaling and root planning.

7.MATERIALS AND METHODS :
7.1 Source of Data:
The patients to be studied will be selected from the outpatient section, Dept. of Periodontology, KVG Dental College and Hospital, Sullia. 40 subjects will be included in the study based on inclusion and exclusion criteria.
It will be made clear to the potential subjects that participation will be voluntary and written informed consent will be obtained from those who agree to participate.
7.2 Methods of Collection of Data:
1. American Academy of Periodontology (1999) classification for chronic periodontitis will be used for selection of chronic periodontitis patients.
2. Age group between 30 yrs and 50 yrs.
3. The subjects will be categorized under two groups – Test group consisting 20 chronic periodontitis patients and control group consisting 20 subjects with healthy periodontium.
4. 2 ml venous blood from antecubital fossa will be collected and stored in sterile vial one with black cap vacutainer containing 3.8% sodium citrate for ESR estimation and other one with red cap vacutainer for estimation of CRP. Both estimation will be done in KVG Medical college central lab by high sensitivity CRP nephelometry for CRP estimation and by wintrobe method for ESR estimation.
5. For assessment of periodontal status probing pocket depth (PPD), clinical attachment level (CAL), Oral hygiene index simplified(OHI-S) and plaque index will be recorded.
Armamentarium:
 Cotton rolls
 Mouth mirror
 Explorer
 Williams graduated periodontal probe
 Kidney tray
 Gloves
 Mouthmask
 Tweezer
 Red cap vacutainer
 5cc Syringe and Sprit Swab
 Torniquet
 Black cap vacutainer containing 3.8% sodium citrate
Evaluation:
To avoid inter examiner variation a single examiner will perform all the evaluations. Evaluation of the data will be based on the results obtained.
INCLUSION CRITERIA:
  • Age from 30 years to 50 years
  • Systemically healthy
  • Probing Pocket depth >/ 5 mm in >/ 10 teeth
  • Minimum 16 naturally existing teeth present
EXCLUSION CRITERIA:
•Patients who have received periodontal treatment 6 months before sampling.
•Rheumatoid arthritis
•History of any disease known to severely compromise systemic health
•Current pregnancy or lactation
 Chronic use of anti-inflammatory drugs
Follow up period:
Patients with altered level of CRP and ESR will be recalled 6 weeks after scaling and root planing for estimation of CRP and ESR levels and for assessment of periodontal status by measuring probing pocket depth (PPD), clinical attachment level (CAL), Oral hygiene index simplified (OHI-S) and plaque index.
Statistical Analysis:
The results will be statistically evaluated using student paired t test and repeated measure ANOVA.
7.3 Does the study require any investigation or intervention to be conducted onpatients or other human or animal? If so, please describe briefly.
Yes, 2 ml of peripheral venous blood will be drawn by venous puncture for measurement of CRP and ESR values in patients.
Has ethical clearance been obtained in case of above?
Yes.
8 References:
  1. Sneha R. Gokhale, Shivaswamy S, Ashwani M.Padhye.Evaluation of blood parameters in patients with chronic periodontitis for sign of anemia. J Periodontol 2010;81:1202-1206.
  2. BNoack,R.J.Genco,M.Trevisan,S.Grossi,J.J.Zambon, E.D.Nardin,.Periodontalinfectionscontributes to elevated systemic C-reactive protein level.J Periodontol 2001;72:1221-1227.
  3. Page RC.The role of inflammatory mediators in the pathogenesis of periodontal disease. J Periodont Res 1991;26;230-242.
  4. Hutter JW, Van der Velden U, Varoufaki A, Huffels RA, Hoek FJ, Loos BG. Lower number of haemoglobinin periodontitis patients compared to control subjects.J Clin Periodontol 2001;28:930-936.
  5. Tarik M.Husain, David HKim. C-reactive protein and erythrocte sedimentation rate in orthopaedics.The University of pennsylvania Orthopaedic Journal2002; 15:13-16.
  6. Mendall MA, Patel P,Ballam L,Strachan D,Northland TC.C-reactive protein and its relation to cardiovascular risk factors :a population based cross sectional study.BMJ.1996;312:1061-1065.
  7. Ross R.L.Atherosclerosis –An inflammatory disease .N Engl J Med 1999;340:115-26.
  8. Hunter W.Oral sepsis as a cause of disease .Br Med J 1900;1:215-6.
  9. Abou-Raya S,Abou-Raya A ,Naim A, Abuelkheir H .Rheumatoid arthritis,coronary artery disease and periodontal disease .ClinRheumatol.2008;27:421-7.
  10. Dhruva Kumar Gani, Deepa Lakshmi ,Rama Krishnan,Pamela Emmadi. Evaluation of C-reactive protein and interleukin-6 in the peripheral blood of patients with chronic periodontitis.J Indian Soc Periodontol 2009;13:69-74.
  11. Fábio Vidal, Carlos Marcelo S. Figueredo, Ivan Cordovil, Ricardo G.Fischer .Periodontal therapy reduces plasma levels of interlukin-6,C-reactive protein,and fibrinogen in patients with severe periodontitis and refractory arterial hypertension. J Periodontol 2009;80:1315-22.
  12. López NJ,Quintero A,Llancaqueo M, Jara L.Effect of Periodontal therapy on markers of systemic inflammation in patients with coronary heart disease. RenMedChil2009;137:1315-22.

13 Loos BG, Craandijk J, Hoek FJ, Wertheim-van Dillen PME, van der Velden U. Elevation of systemic markers related to cardiovascular diseases in the peripheral blood of periodontitis patients. J Periodontol 2000;71:1528-1534.

14.Erciyas K, Sezer U, Ustün K, Pehlivan Y, Kisacik B, Senyurt SZ et al. Effects of periodontal therapy on disease activity and systemic inflammation in rheumatoid arthritis patients. Oral Dis. 2013;19:394-400.

9 /
Signature of the Candidate
10 / Remarks of the guide
11. / 11.1 Name and designation of Guide
(in block letters) / Dr. M.M.DAYAKAR
PROFESSOR & HOD,
DEPARTMENT OF PERIODONTOLOGY.
KVG DENTAL COLLEGE.
11.2 Signature of the Guide
11.3Name and designation of
Co-Guide
(in block letters)
11.4Signature of the Co-guide
11.5 Head of Department / Dr. M.M.DAYAKAR
PROFESSOR & HOD,
DEPARTMENT OF PERIODONTOLOGY,
KVG DENTAL COLLEGE AND HOSPITAL.
SULLIA
11.6 Signature of Head of the department
12. / 12.1 Remarks of the Chairman and Principal
12.2 Signature of the Chairman and Principal / Dr.MOKSHA NAYAK MDS
PRINICIPAL,
KVG DENTAL COLLEGE AND HOSPITAL,
SULLIA.