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   Table of Contents    
ORIGINAL ARTICLE
Year : 2018  |  Volume : 22  |  Issue : 6  |  Page : 487-491  

Evaluation of serum and salivary alkaline phosphatase levels in chronic periodontitis patients before and after nonsurgical periodontal therapy


1 Department of Periodontics, Rajas Dental College and Hospital, Tirunelveli, India
2 Department of Periodontics, APDCH, Melmaruvathur, Tamil Nadu, India
3 Department of Orthodontics, Penang International Dental College, Penang, Malaysia

Date of Submission22-Feb-2018
Date of Acceptance29-Jun-2018
Date of Web Publication1-Nov-2018

Correspondence Address:
Dr. Renganath Murugan Jeyasree
Department of Periodontics, Rajas Dental College and Hospital, Kavalkinaru - 627 105, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_133_18

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   Abstract 


Background: The traditional method of diagnosing periodontitis includes the assessment of clinical parameters and radiographic aids to evaluate the periodontal tissue destruction. Saliva has the potential to be used as the diagnostic fluid for oral disease. This study aimed at comparing the quantitative levels of alkaline phosphatase (ALP) in saliva and serum before and after scaling and root planing in patients with chronic generalized periodontitis. Materials and Methods: A total number of 50 participants (40 with chronic generalized periodontitis and 10 periodontally healthy volunteers) of 30–50 years were included in the study. Clinical parameters such as simplified oral hygiene index (OHI-S), gingival index, probing depth, and clinical attachment loss (CAL) were measured, and then, saliva and blood sample collection was done and analyzed for ALP levels by spectrometry. The clinical parameters along with saliva and serum ALP levels were reevaluated after 30 days following Phase I periodontal therapy. The results were statistically analyzed using paired t-test and one-way ANOVA. Results: The saliva and serum ALP levels were significantly increased in patients with chronic generalized periodontitis with an increase in clinical parameters such as OHI-S, gingival index, probing depth, and CAL when compared with periodontally healthy individuals. The saliva and serum ALP levels were significantly decreased following Phase I periodontal, therapy along with improvement in clinical parameters. Conclusion: With the limitations of the present study, it could be concluded that ALP levels in saliva can be used for the diagnosis of active phase of periodontal disease and also for evaluation of the treatment outcomes following Phase I periodontal therapy.

Keywords: Alkaline phosphatase, biomarkers, chronic periodontitis, saliva, serum


How to cite this article:
Jeyasree RM, Theyagarajan R, Sekhar V, Navakumar M, Mani E, Santhamurthy C. Evaluation of serum and salivary alkaline phosphatase levels in chronic periodontitis patients before and after nonsurgical periodontal therapy. J Indian Soc Periodontol 2018;22:487-91

How to cite this URL:
Jeyasree RM, Theyagarajan R, Sekhar V, Navakumar M, Mani E, Santhamurthy C. Evaluation of serum and salivary alkaline phosphatase levels in chronic periodontitis patients before and after nonsurgical periodontal therapy. J Indian Soc Periodontol [serial online] 2018 [cited 2018 Dec 19];22:487-91. Available from: http://www.jisponline.com/text.asp?2018/22/6/487/244556




   Introduction Top


Of the various illnesses that affect teeth, periodontitis is a common disease results in the destruction of supporting structures of the teeth, ultimately which cause tooth loss.[1] Although periodontitis is an infectious disease of gingival tissue origin, changes that occur in the bone are crucial as the alveolar bone destruction is responsible for tooth loss. The most common cause of alveolar bone destruction in periodontitis is the extension of inflammation from the marginal gingiva to the underlying periodontal tissues.[2]

Salivary constituents for diagnosing periodontal disease include enzymes and immunoglobulins, hormones of host origin, bacteria and bacterial products, ions, and volatile compounds.[3]

Intracellular enzymes are released progressively into the gingival crevicular fluid (GCF) and saliva from the damaged cells of periodontal tissues. Several enzymes that are evaluated for the early diagnosis of periodontal disease include lactate dehydrogenase, aspartate and alanine aminotransferase, creatine kinase, alkaline and acid phosphatase (ALP), and gamma-glutamyltransferase.

ALP is a hydrolase enzyme responsible for removing phosphate groups from many types of molecules and is a marker of bone metabolism. It is a membrane-bound glycoprotein produced by a various number of cells, such as polymorphonuclear leukocytes, macrophages, fibroblasts, and osteoblasts, within the area of the periodontium and gingival crevice.[4]

Various studies have assessed the levels of salivary ALP with respect to gingivitis, chronic periodontitis, and correlation of the same with clinical parameters.[5],[6] However, there was lagging evidence regarding the comparative effects of ALP in serum and saliva following periodontal treatment.

ALP levels in saliva can be detected similarly to serum ALP estimation by using ultraviolet spectrometry. So far, ALP has not been supported by research findings as a predictive indicator for future periodontal tissue breakdown. The purpose of this study was to compare the serum and salivary ALP levels in chronic periodontitis patients before and after Phase I periodontal therapy which served to hold to the hypothesis that saliva can be used as an alternative to serum for evaluating ALP as a biomarker in periodontal disease progression.


   Materials and Methods Top


A clinical study was conducted at the Department of Periodontology as a total number of 50 participants with the age range of 30–50 years; of which, control group consisted of 10 individuals (periodontally healthy individuals) and study group consisted of 40 patients (chronic generalized periodontitis) were selected from the outpatient division of periodontics. Ethical clearance for the study was obtained from the Institutional Review Board (ethical clearance No: 2014-MD-BrII-SAS-05). All the participants participated in the study were informed about the nature of the study and all the participants signed an informed consent form.

Inclusion criteria for control group were the participants with at least 20 natural teeth and probing pocket depth of 2–3 mm with no attachment loss and bleeding on probing with <20% sites. Moreover, for the study group, the participants had to have five qualifying sites in two quadrants with a minimum of two affected teeth in each quadrant with each site having probing depth ≥5 mm, clinical attachment loss (CAL) ≥3 mm, and bleeding on probing. Patients with systemic diseases, smokers, pregnant women, and patients who were not maintaining their oral hygiene were excluded from the study.

Informed consent was obtained from all the individuals who participated in the study. All the participants were subjected to measurement of clinical indices including simplified oral hygiene index (OHI-S) and gingival index and clinical parameters including probing depth [Figure 1] and CAL at baseline for the study group followed by saliva and blood sample collection for both the study and control groups, which were then analyzed for ALP estimation. Following sample collection, complete ultrasonic scaling was performed at day 1 for patients with chronic periodontitis. Complete root planing was done within 15 days from the baseline in two subsequent visits. On the 30th day, after the completion of Phase I periodontal therapy, patients were reviewed [Figure 2] where saliva and blood samples were collected and analyzed again for ALP activity.
Figure 1: Probing depth >5 mm at baseline

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Figure 2: Probing depth after Phase 1 periodontal therapy

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All the patients in the study were asked to rinse their mouth with normal water (to wash out exfoliated cells). After 5 min, 5 ml of unstimulated saliva and 5 ml of intravenous blood were collected from each patients from 9.00 to 11.00 am as method given by Navazesh 1993.[7] Unstimulated saliva was collected by the spit method in a sterile sample collection container [Figure 3]. The saliva and serum samples were sent to the laboratory immediately where it was centrifuged at 3000 rpm for 5 min, and then, the ALP enzyme activity in saliva and serum was determined spectrophotometrically with the help of a semi-autoanalyzer [Figure 4] (BTS 350, BIOSYS®) using ALP enzyme kit (Diasys®) [Figure 5] with the International Federation of Clinical Chemistry and Laboratory Medicine recommendations and the results were expressed in international units.
Figure 3: Collection of saliva

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Figure 4: Semi auto analyzer for alkaline phosphatase estimation

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Figure 5: Alkaline phosphatase kit (Diasys®)

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Following the sample collections, complete ultrasonic scaling was performed to all the patients in the study group. All the patients were instructed to maintain their oral hygiene with modified bass brushing technique and to use chlorhexidine mouthwash twice daily. Root planing, wherever required, was done after 15 days from baseline within two subsequent visits. All the patients were recalled on the 30th day following completion of Phase I periodontal therapy for review and postoperative sample collection (both blood and saliva).


   Results Top


This clinical study was conducted to evaluate the levels of serum and salivary ALP in patients with generalized chronic periodontitis before and after nonsurgical periodontal therapy and to compare the outcomes with healthy participants. All clinical parameters were measured at baseline with saliva and blood samples collected on the same day and then 30 days after Phase I periodontal therapy. The collected samples were spectrometrically analyzed for ALP levels. The obtained results were tabulated, and the data collected were participant to statistical analysis through SPSS (SPSS V:24.0, Softonic International S.A. © 1997-2018).

The paired-t test was used to assess the baseline and postoperative values of clinical parameters and one-way ANOVA was used to compare the enzyme levels in saliva and serum between the study group at baseline and postoperatively along with control group.

On comparing the clinical parameters that includes OHI-S, gingival index, probing depth, and CAL [Table 1] in study group, there was improvement in OHI-S and gingival index scores along with reduction in the probing depth and gain in CAL postoperatively, which was found to be statistically significant.
Table 1: Clinical parameters at baseline and 1 month following Phase I periodontal therapy in patients with chronic periodontitis

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On comparing the mean values of salivary and serum ALP levels of control group with baseline values of the study group, the difference in salivary and serum ALP levels between control group (23.00 ± 6.67 and 72.70 ± 2.19) and study group (79.55 ± 6.40 and 97.62 ± 4.17) was found to be statistically significant with P = 0.000** and 0.009** (**indicates statistically highly significant) for saliva and serum, respectively. On comparing the mean baseline salivary and serum ALP values with postoperative values in study group, the difference in salivary and serum ALP levels from baseline (79.55 ± 6.40 and 97.62 ± 4.17) to postoperative (49.47 ± 5.11 and 85.40 ± 4.10) was found to be statistically significant with P = 0.000 and 0.009 for saliva and serum, respectively.


   Discussion Top


The term biomarker refers to biologic substances that can be measured and evaluated to serve as indicators of biological health, pathogenic processes, environmental exposure, and pharmacologic responses to a therapeutic intervention.[8]

Among several biomarkers of periodontal disease activity, ALP, being a phenotype marker of bone turnover rate has been found to be elevated in a variety of bone disorders with the highest elevations occur in Paget's disease (osteitis deformans). Other bone disorders including osteomalacia, rickets, hyperparathyroidism, and osteogenic sarcoma have also shown elevated levels of ALP. In addition, increased levels were also seen in the case of healing bone fractures and during periods of physiologic bone growth.

In the past few years, various cross-sectional clinical studies in humans have been conducted and proved the robust relationship between the periodontitis and elevated ALP levels in serum and in GCF.[9],[10]

Although predictable, the sampling of blood by intravenous method is invasive and causes discomfort to the patients; its use for periodontal disease is of less patient compliance. Although reliable, sampling from GCF is technique sensitive and takes longer time compared with the sample collection time for saliva.

Various studies in the past few years have revealed the potential to identify and measure numerous biomarkers in saliva for the diagnosis of periodontal diseases and monitoring its progression and health.[11],[12]

The study conducted by Miglani et al., in 1974[13] revealed the relationship between periodontal disease and ALP levels in saliva was the first study in the Indian population, correlating the periodontal disease status with salivary ALP levels. Later, various studies that include Todorovic et al., in 2006,[14] Desai et al., in 2008,[15] Dabra and Singh in 2012,[16] Trivedi and Trivedi in 2012,[17] Ramesh et al., in 2013,[18] and Luke et al., in 2015[19] have correlated the relationship between the enzyme ALP levels in saliva with that of clinical parameters in healthy controls, gingivitis patients, and patients with chronic periodontitis and the significant outcomes of the ALP levels after Phase I periodontal therapy.

All the studies conducted so far has aimed to rationalize the use of ALP from either saliva or serum or even GCF solely in patients with chronic periodontitis and even comparison of the same with periodontally healthy individuals.[20],[21] However, none of the studies have compared the serum and salivary ALP levels in chronic periodontitis patients before and after periodontal treatment and correlating the same with periodontally healthy individuals.

This was the first study to compare and evaluate the ALP levels in saliva and serum in patients with chronic generalized periodontitis and to correlate the ALP levels with that of the healthy individuals.

The results of present study showed that ALP levels were increased in both saliva and serum in patients with chronic generalized periodontitis which was in accordance with the study conducted by Malhotra et al., in 2010.[22] The study also showed that the following Phase I periodontal treatment, there was a significant decrease [Table 2] in the salivary and serum ALP levels in patients with chronic generalized periodontitis in accordance with the results obtained from the study conducted by Dabra and Singh in 2012[16] along with an added improvement in the clinical parameters [Table 1] following Phase I periodontal therapy.
Table 2: Salivary and serum alkaline phosphatase levels in periodontally healthy individuals and in chronic periodontitis group at baseline and 1 month following Phase I periodontal therapy

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   Conclusion Top


With the limitations of the present study, it could be concluded that ALP levels in saliva could be evaluated for the diagnosis of the active phase of the periodontal disease and also a prognostic indicator for the evaluation of treatment outcomes following Phase I periodontal therapy. Further study with large sample size and with different duration of ALP estimation in saliva should be done to support the evidence of the present study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Miglani DC, Raghupathy E, Rajasekher A, Shyamala S. Studies on salivary phosphatases III. On the possible relation between salivary alkaline phosphatase activity and gingival inflammation. J Periodontol 1974;45:511-3.  Back to cited text no. 13
    
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Todorovic T, Dozic I, Vicente-Barrero M, Ljuskovic B, Pejovic J, Marjanovic M, et al. Salivary enzymes and periodontal disease. Med Oral Patol Oral Cir Bucal 2006;11:E115-9.  Back to cited text no. 14
    
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Desai S, Shinde H, Mudda J, Patil V. Levels of alkaline phosphatase (ALP) in saliva of patients with chronic periodontitis; A clinical and biochemical study. Internet J Dent Sci 2009;8:1-9.  Back to cited text no. 15
    
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Dabra S, Singh P. Evaluating the levels of salivary alkaline and acid phosphatase activities as biochemical markers for periodontal disease: A case series. Dent Res J (Isfahan) 2012;9:41-5.  Back to cited text no. 16
    
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