DISSERTATION – SYNOPSIS
DR. VIDYA JAYASHEELA
POST GRADUATE STUDENT
DEPARTMENT OF PERIODONTICS
A.B. SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES
DERALAKATTE,
MANGALORE - 575018
KARNATAKA
Guided by: Prof.(Dr.)Amitha Ramesh
Department of Periodontics
A.B.Shetty Memorial Institute of Dental Sciences
Deralakatte, Mangalore
Karnataka
Co-guided by: Prof.(Dr.) Sucheta Kumari
Department of Biochemistry
K.S.Hegde Medical Academy
Deralakatte, Mangalore
Karnataka
Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. /Name of the Candidate and
Address(In block letters) / DR. VIDYA JAYASHEELA
POST GRADUATE STUDENT,
DEPARTMENT OF PERIODONTICS,A.B. SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES,
NITYANANDA NAGAR P.O.,
DERALAKATTE,
MANGALORE. – 575 018
2. / Name of the Institution / A.B. SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES,
DERALAKATTE,
MANGALORE. – 575 018
3. / Course of study and subject / MASTER OF DENTAL SURGERY.
PERIODONTICS
4. / Date of admission of course / 31st MAY 2008
5. / Title of the topic
A COMPARATIVE EVALUATION OF ALKALINE PHOSPHATASE LEVELS IN GCF AND SALIVA IN PREMENOPAUSAL AND POST MENOPAUSAL WOMEN WITH PERIODONTITIS.
6.
7.
8. / Brief resume of the intended work:
6.1 NEED FOR THE STUDY:
The interaction of microbial plaque and host defense mechanism is considered an important factor in the pathogenesis and onset of periodontal disease. On the other hand, numerous studies have demonstrated an increase in gingival inflammation during puberty, menstrual cycle and pregnancy concomitant with increased secretion of sex steroid hormones. The deficiency of estrogen in women at menopause is contributing factor to osteoporosis and considered one of the risk factors for periodontal disease. It has been hypothesized that osteoporosis decreases alveolar bone density and in turn increases its susceptibility to resorption due to periodontal inflammation. Accelerated bone loss in menopause is related to increased bone turnover. This is accompanied by increased levels of biochemical markers such as Alkaline phosphatase (ALP), which is associated with bone metabolism and is produced by various cells such as polymorphoneuclear leukocytes (PMNLs), osteoblasts, macrophages, and fibroblasts within the area of periodontium and GCF. Alteration in GCF and Salivary Alkaline phosphatase levels might be expected as an indication of periodontal disease activity. Purpose of this study is to assess the effect of menopause on GCF and salivary Alkaline phosphatase levels in periodontitis.
6.2 REVIEW OF LITERATURE:
GCF is an exudate that can be harvested non invasively from the gingival sulcus or periodontal pocket. As GCF traverses the inflamed tissue it carries molecules involved in the periodontal destructive process. Bone resorption is prominent feature of periodontal disease. Alkaline phosphatase (ALP) plays a role in bone metabolism and has been used as a marker of osteoblastic activity. ALP level in GCF is higher than in serum. In serum the enzyme is associated with systemic bone disease and its elevation in GCF reflects the changes of alveolar bone in localized areas. Increased levels of ALP have been noted in experimental gingivitis and at periodontitis site and may serve as a predictor for future or current disease activity1.
A study by conducted Totah A et al (2006) estimated salivary Aspartate amino transferase (AST) and Alkaline phosphatase (ALP) of patients presenting with probing depth ≥ 5mm, bleeding on probing and alveolar bone loss ≥ 40%. Results revealed that there was significant increase in salivary AST and ALP activity in patients with periodontal disease compared to control. Study concluded that the salivary AST could be a useful marker for monitoring periodontal disease. The increase in salivary ALP activity in periodontitis could be associated with alveolar bone loss. Salivary analysis for biochemical markers of periodontal disease can offer a cost effective approach for monitoring the disease2.
A study conducted by Ozlem Daltaban et al (2006) on 36 postmenopausal women on estrogen supplement (ES) and 37 estrogen deficient postmenopausal women (ED), were divided in to two sub groups - chronic periodontitis and clinically healthy controls after clinical and radiographic examination. Results revealed that, periodontitis groups demonstrated significant increase in GCF ALP levels compared to control groups. GCF total ALP levels of ED periodontitis group were significantly higher than ES periodontitis group. These data suggested that the presence of ALP in GCF is not simply a reflection of local inflammation state but the estrogen status of the patient may possibly influence local ALP levels in GCF3.
A study conducted by Cao et al (2007), evaluated the effects of estrogen deficiency on alveolar bone in ovariectomized rats by histometric measurement of attachment level in vivo. Using RT-PCR and Western-blot procedure, mRNA and protien products of Estrogen receptors (ERs) are detected. The effects of estrogen on bone forming capability is estimated by monitoring ALP activity and osteocalcin production in cultured human periodontal ligament cells(PDLcs). Results demonstrated that both ER-alpha and beta were expressed in PDLcs. When exposed to 17-ß estradiol, PDLcs exhibited positive modulation on ALP activity and osteocalcin production. Study suggested that estrogen and ERs may play an important role in periodontal diseases4.
A study conducted by Kang-Moon Kim et al (2002) on 43 postmenopausal patients with no systemic disease, were grouped in to 3 groups by their periodontal conditions; 12 mild periodontitis, 11 moderate periodontitis, 20 advanced periodontitis. Blood ALP and osteocalcin were measured. Results revealed that the blood ALP and OC levels were similar among the groups with different periodontal condition5.
A study conducted by Morishta M, et al (1999), investigated the effects of estradiol on mineralized nodule formation by human periodontal ligament (PDL) cells. The formation of mineralized nodules was assessed by staining the PDL cells with alizarin red and counting the number of mineralized nodule. Estradiol 20 ng/ml significantly enhanced the ALP activity and the mineralized nodule formation, compared to the control. These results suggested that estrogen status may modify the regenerative activity of periodontal tissue.6
6.3 AIMS AND OBJECTIVES:
· Estimation of ALP levels in GCF and Saliva in Premenopausal women with periodontitis.
· Estimation of ALP levels in GCF and Saliva in Postmenopausal women with periodontitis.
· To compare the ALP levels in GCF and Saliva between Premenopausal and Postmenopausal women with periodontitis.
· To assess ALP levels in GCF and saliva as a predictor for increased alveolar bone loss in Postmenopausal women.
Materials and methods
7.1 SOURCE OF DATA:
Subjects reporting to the Dept of Periodontics of A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore are selected for the study.
7.2 METHOD OF COLLECTION OF DATA:
Sample size: Total 60 subjects are included in the study.
Subjects are divided into two groups:
· Group A: 30 Premenopausal women with chronic periodontitis, in the age group of 30 to 40 years.
· Group B: 30 Postmenopausal women with chronic periodontitis, in the age group of 45 to 55 years.
INCLUSION CRITERIA:
· Subjects within 5years of menopause and not on hormonal replacement therapy.
· Subjects who have not attained menopause and not on any OCP or hormonal therapy.
· Subjects with chronic periodontitis with ≥4mm of clinical attachment loss and ≥30% of alveolar bone loss, involving at least 6 teeth in each arch.
· Subjects with good systemic health and not received any periodontal therapy in the past 6months.
EXCLUSION CRITERIA:
· Subjects with any systemic disorders.
· Subjects currently on antibiotics, steroids, or hormonal therapy.
· Pregnant women, lactating women and women in their menstrual phase.
CLINICAL AND RADIOGRAPHIC EXAMINATION:
· Medical and Dental history are taken.
· Subjects are screened for periodontal status by measuring clinical attachment loss.
· Intraoral periapical radiographs are taken to determine the alveolar bone loss.
METHOD OF COLLECTION OF SAMPLE:
· Informed consent will be taken from the patient before the collection of samples.
· GCF samples are collected from the areas with ≥4mm of clinical attachment loss and ≥30% of alveolar bone loss.
· The test site is cleaned of all debris with air-water jet spray. Site is isolated with cotton roll.
· GCF is collected using micropipette and transferred to a glass vial.
· Pipettes contaminated with saliva, debris and blood are excluded from the study.
· Unstimulated saliva sample is also collected at the same time in a glass vial.
· Collected samples are immediately sent for biochemical analysis.
BIOCHEMICAL ANALYSIS:
Alkaline phosphatase (ALP) levels are measured using an ALP kit, which contains following reagents:
Reagent 1(R1) – Diethanolamine Buffer, (pH 10.2)
Magnesium Chloride
Reagent 2(R2) – p- Nitrophenyl Phosphate
Kinetic determination of Alkaline Phosphatase (ALP) based upon the following reaction.
ALP
p- Nitrophenyl phosphate + H2O p- Nitrophenol + Inorganic phosphate
The amount of Nitrophenol liberated in unit time, determines the measure of Alkaline phosphatase activity.
STATISTICAL ANALYSIS:
Obtained data will be statistically analyzed using unpaired student‘t’ test.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals?
Yes, GCF & Saliva samples need to be collected and sent for biochemical assessment of GCF and Salivary Alkaline phosphatase levels after obtaining a written consent.
7.4 Has the ethical clearance been obtained from your institution in case of 7.3?
Yes, Ethical clearance letter is enclosed.
LIST OF REFERENCES
1. Laurie K Mc Cauley and Rahime M. Nohutcu: Mediators of periodontal osseous destruction and remodeling: Principles and implications for Diagnosis and therapy: J periodontal 2002; 73:1377-1391.
2. Totah A, Greabu M, Totac, Sinu T: Salivary aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase: Clinical chemistry and laboratory medicine 2006, vol44 (5):612-5.
3. Ozlem Daltaban, Sayagun, Belgin Bal, Kokasal Balos, and Muhittin Serdar: Gingival crevicular fluid, alkaline phosphatase levels in postmenopausal women: Effect of phase I periodontal treatment: J periodontal 2006; 77: 67-72.
4. Cao, M., Shu, L., Li, J., Su, J., Zhang, W., Wang, Q., Guo, T., Ding, Y: The expression of estrogen receptors and the effects of estrogen on human periodontal ligament cells: Methods of Find Exp Clin Pharmacol 2007, 29(5):329.
5. Kang-Moon Kim, Faculty of Dental Sciences, Graduate School, Chonnam National University: Osteoporotic condition in postmenopausal patients with periodontitis.2002.
6. Morishta M, Yamamura T, Shimzu A, Bachchu AH, Iwamoto Y: Estradiol enhances the production mineralized nodules by human periodontal ligament cells.J Clin Periodontol 1999; 26: 748-751.
9. /
Signature of the candidate
10. / Remarks of the guide11. / Name & designation of:
11.1 Guide
(In block letters) / PROF. (DR.) AMITHA RAMESH
PROFESSOR
DEPT. OF PERIODONTICS
11.2 Signature
11.3 Co-guide (If any)
11.4 Signature / PROF. (DR.) SUCHETA KUMARI
PROFESSOR
DEPT. OF BIOCHEMISTRY
K S HEGDE MEDICAL ACADEMY OF MEDICAL SCIENCES
DERALAKATTE,
MANGALORE. – 575 018
11.5 Head of the department
11.6 Signature
/ PROF. (DR.) BIJU THOMAS
PROFESSOR
DEPT.OF PERIODONTICS
12 / 12.1 Remarks of the principal:
12.2 Signature