Evaluation of the effect of one stage versus two stage full mouth disinfection on C-reactive protein and leucocyte count in patients with chronic periodontitis.

BACKGROUND: Conventional non-surgical periodontal therapy is carried out in quadrant basis with 1-2 week interval. This time lag may result in re-infection of instrumented pocket and may impair healing. Therefore, a new approach to full-mouth non-surgical therapy to be completed within two consecutive days with full-mouth disinfection has been suggested. In periodontitis, leukocyte counts and levels of C-reactive protein (CRP) are likely to be slightly elevated, indicating the presence of infection or inflammation. The aim of this study is to compare the efficacy of one stage and two stage non-surgical therapy on clinical parameters along with CRP levels and total white blood cell (TWBC) count.
MATERIALS AND METHODS: A total of 20 patients were selected and were divided into two groups. Group 1 received one stage full mouth dis-infection and Group 2 received two stages FMD. Plaque index, sulcus bleeding index, probing depth, clinical attachment loss, serum CRP and TWBC count were evaluated for both the groups at baseline and at 1 month post-treatment.
RESULTS: The results were analyzed using the Student t-test. Both treatment modalities lead to a significant improvement of the clinical and hematological parameters; however comparison between the two groups showed no significant difference after 1 month.
CONCLUSION: The therapeutic intervention may have a systemic effect on blood count in periodontitis patients. Though one stage FMD had limited benefits over two stages FMD, the therapy can be accomplished in a shorter duration.

INTRODUCTION

Periodontitis is a complex interplay of bacterial infection and host response, modified by behavioral and systemic risk factors. There is considerable evidence to support scaling and root planning (SRP) as one of the most effective procedures for the treatment of infectious periodontal diseases.[12] Conventional nonsurgical periodontal therapy is performed on the quadrant basis with 1-2 week interval. This time lag may cause reinfection of instrumented pocket by the periodontal pathogens that are present in other sites of the oral cavity, such as the dorsal surface of the tongue, buccal mucosa, palate and tonsils, in addition to the subgingival pockets.[3456] Although the role of an extra-oral source cannot be totally ruled out.[78] In order to prevent this bacterial recolonization, Quirynen et al. in 1995 proposed one stage full mouth disinfection (OSFMD).[9] A series of clinical and microbiological studies conducted by Quirynen et al. reported that OSFMD resulted in significantly greater improvements than conventional quadrant-wise therapy.[910111213]

As the periodontal disease progresses, it is speculated that the inflamed and ulcerated subgingival pocket epithelium may facilitate bacterial entrance into the circulation causing bacteremia resulting in inflammation and infection of distant sites.[14] There are various studies, which have demonstrated the effect of periodontitis and non-surgical periodontal therapy on various inflammatory parameters in blood,[15161718] but no study has determined the effect of OSFMD on serum C-reactive protein (CRP) levels and other inflammatory parameters in blood like total white blood cell (TWBC) count. The rational to carry out this study was to evaluate two different FMD protocols as several studies comparing FMD versus quadrant wise SRP and failed to show any clinical significance and also hematologically. Thus, the present study aims to determine the effect of one stage versus two stages FMD on serum CRP levels and leucocyte count in patients with chronic periodontitis.

MATERIALS AND METHODS

A total of 20 chronic periodontitis patients aged between 30 and 55 years (8 Male and 12 Females) were recruited from the Department of Periodontics, Mamata Dental College, Khammam, India. Informed consent and ethical clearance was obtained from the ethical committee of the Mamata Dental College, Khammam. The inclusion criteria were patients with moderate to severe periodontitis who did not undergo any treatment at least 1 year before, patients with at least 20 teeth including third molars and systemically healthy individuals were included in the study. Patients under antibiotic therapy, smoking, pregnant and lactating women were excluded from the study. The selected patients were divided into two groups randomly using coin toss. Each group consisted of 10 patients. Group 1 received OSFMD following Quirynen's protocol[13] where complete supragingival scaling was performed using the ultrasonic scalers and subgingival SRP was performed using Gracey curettes in two visits within 24 h. Subgingival irrigation of all pockets was performed with 1% chorhexidine gel (3 times repeatedly within 10 min), tongue brushing was carried out with 1% chlorhexidine gel and Mouthrinsing and gargling was perfomed with 0.2% chlorhexidine solution for 2 min. This protocol helps in disinfection of all the niches in the oral cavity.

Patients in Group 2 received supragingival scaling on the day of the first visit, later complete full mouth sub gingival SRP was accomplished after 1 week and disinfection of the periodontal pockets and other oral structures was carried out similar to the Group 1 on the day of the second visit [Figure 1]. Patients in both groups were prescribes ibuprofen 20 mg and were asked to take whenever they experienced pain. No antibiotics and specific oral hygiene instructions were not given to any patient as it may aid in reducing the bacteremia and may act as a confounding factor in effecting the results of the study. The clinical and hematological parameters were evaluated at baseline (on the day of the first visit before beginning the scaling) and 1 month post-treatment for both the groups [Figures 2 and 3]. As the usual period of reevaluation after phase-I therapy is 1 month and the patients were planned for further surgical procedures; all the clinical and hematological parameters in the study were monitored for only 1 month. The clinical parameters were evaluated for plaque index, bleeding index, pocket depth, clinical attachment level (CAL) using UNC 15 (Hu-Friedy Manufacturing Co., Chicago, IL, USA). The hematological parameters were estimated for TWBC count and the CRP levels. The TWBC count was not estimated immediately after initial therapy because of the lack of patient's compliance. To evaluate the hematological parameters the blood was drawn from the patients anticubital vein and was sent to the laboratory for further estimation. TWBC count was evaluated using SYSMEX automatic hematological analyzer. The serum CRP levels were analyzed using turbidimetric immunoassay (Beckman Coulter-Au 400). In this method, the latex particles were coated with an antibody directed against the CRP in the sample. The increase in turbidity, which accompanies aggregation, is proportional to the CRP concentration. As the microbiological investigations were not under the scope of the study's aim they were not evaluated.

Figure 1

Disinfection of periodontal pockets using chlorhexidine gel as a part of Quirynen's full mouth disinfection protocol

Figure 2

Evaluation of clinical parameters

Figure 3

Hematological analyzer SYSMEX

Patients were asked to estimate the degree of pain after treatment, on a visual analog scale from 0 to 10 and also to note the number of analgesics taken. The mean time taken to accomplish the FMD for both groups was also calculated in minutes [Table 1]. The average time taken to operate each quadrant was approximately 30-40 min.

Table 1

Patient perception about the treatment and total treatment time

Statistical analysis

The clinical and hematological parameters at baseline i.e., on the day of the first visit before beginning the scaling and after 1 month in each group were analyzed by using Student paired t-test and the improvement in all the parameters between the two groups were compared and analyzed using Independent t-test. The level of significance was set as P ≤ 0.05. Data was analyzed by Statistical Package for the Social Sciences (SPSS) version 12.0 software (SPSS, Chicago, IL, USA).

RESULTS

A total of 20 patients with periodontitis aged between 30 and 55 years (8 Male and 12 Females) were included in the study. Table 2 includes the demographic data where 10 individuals were included in each group. Both groups had 4:6 Male: Female ratio with the mean age was 41.75 ± 8.1 7 and 40 ± 8.6, respectively for Group 1 and Group 2.

Table 2

Demographic data

Tables 3 and 4 show the baseline clinical parameters and hematological parameters of Group 1 and Group 2, respectively. The mean plaque index in Group 1 and Group 2 is 1.57 ± 0.12 and 1.55 ± 0.21, respectively. The mean baseline sulcus bleeding index in both Group 1 and Group 2 is 1.69 ± 0.59 and 1.65 ± 0.34. Mean probing depth of Group 1 and Group 2 at baseline is 3.66 ± 0.48 and 3.68 ± 0.77 respectively. The mean CAL at baseline for patients in Group 1 and Group 2 is 4.78 ± 0.95 and 4.64 ± 0.45, respectively. When evaluated the hematological parameters at baseline showed mean CRP levels for both Group 1 and Group 2 as 2.23 ± 0.62 and 2.33 ± 0.38, respectively. The mean TWBC count at baseline for both Group 1 and Group 2 is 6610.00 ± 1090.82 and 6610.00 ± 1084.69, respectively.

Table 3

Comparision of baseline and 1 month later clinical and hematological parameters in Group 1 (intragroup comparision using paired t-test)

Table 4

Comparision of baseline and 1 month later clinical and hematological parameters in Group 2 (intragroup comparision using paired t-test)

When compared with the baseline scores, both groups have shown significant improvement in clinical and hematological parameters at the end of 1 month (P ≤ 0. 05). There is a reduction in plaque scores, bleeding index scores, probing depth and gain in attachment level is seen statistically significant with respect to both the treatment modalities. Hematological parameters evaluating serum CRP levels and TWBC count have shown significant reduction from baseline to 1 month post-treatment in both the treatment groups.

Table 5 compares the two treatment methods and shows no statistically significant difference between them (P ≥ 0. 05).

Table 5

Evaluation of the effectivety of therapy in Group 1 and Group 2 after 1 month by intergroup examination using unpaired t-test

Table 1 shows the patient perception about the treatment and total treatment time. Patients in Group 1 reported greater pain during and after the therapy when compared with patients in Group 2. Patients in either group did not take analgesics after the treatment. The time taken to accomplish the treatment was greater in Group 1 than Group 2.

DISCUSSION

The untreated periodontal pockets may represent a significant reservoir for the reinfection of adjacent sites following active periodontal therapy. In order to avoid intraoral transmission of periodontal pathogens from periodontal pockets to recently instrument and healing periodontal sites, the FMD concept was propagated. The “OSFMD” concept was introduced to improve the results of subgingival scaling in the treatment of chronic periodontitis (Quirynen et al. 1995).[9] As the bacterial load is reduced it is anticipated that a reduction of the inflammatory markers such as serum CRP levels and TWBC count may occur. The purpose of this study is to determine the effect of two different FMD protocols on systemic inflammatory markers such as serum CRP levels, leukocyte count in patients with chronic periodontitis.

The results of this study show that there is statistically significant reduction in plaque scores, bleeding scores and pocket depth after therapy in both groups from baseline to 1 month post-treatment. There is a significant gain in attachment level seen in both the groups from baseline to 1 month post-treatment. These findings are in accordance with several studies,[9101112] which suggest an improvement in clinical parameters after SRP. The reduction in periodontal parameters in both groups indicates that periodontal therapy was effective in reducing the bacterial load and infection, which may enhance the process of healing.

Both therapies were associated with an improvement in the clinical parameters. No statistically significant difference was observed in the clinical parameters at baseline and 1 month after non-surgical therapy between Group 1 and Group 2. This is in accordance with study performed by Savitha et al.[19] The methodology followed in that study is similar to that of the present study and have suggested that the improvement seen in the clinical parameters could be due to decreased bacteremia caused due to full mouth disinfection, which might have improved healing.

Although periodontitis is chronic in nature, acute-phase elements such as CRP are also part of the innate immunity in periodontitis and confirm that in periodontitis a systemic inflammation is present.[15] It is biologically plausible that inflammatory mediators, especially interleukin-1 and -6 and tumor necrosis factor-alpha are released under conditions of periodontitis and present the capacity to stimulate hepatocytes to produce CRP. In this manner, it can be expected that, in the presence of chronic periodontitis, higher serum CRP levels would be found.[2021] The results suggest a positive association existed between the presence of chronic periodontitis and high serum CRP levels and these levels subsequently decreased after therapy in both groups, which was statistically significant. These results are in accordance with the studies carried out by Paraskevas et al. in 2008,[22] D’Aiuto et al. (2005)[23] and Joseph et al. (2011).[24] Contrastingly Ioannidou (2006)[17] in a systematic review concluded that there is no difference in CRP levels before and after non-surgical treatment. These findings were based on the studies reviewed by them, where CRP levels before periodontal therapy were within the normal range and that is why there was no much difference found after periodontal therapy and also they suggested that none of the studies, which they reviewed have adequate data to support that CRP levels decreased after non-surgical periodontal therapy. In the present study both therapies were associated with an improvement in the serum CRP levels. No statistically significant difference was observed at baseline and 1 month after nonsurgical therapy with Group 1 when compared with Group 2. In a recent study,[25] non-surgical periodontal therapy was performed on 60 type 2 diabetic patients and were followed for 6 months. The authors concluded that the non-surgical periodontal therapy has limited effect on the levels of CRP in type 2 diabetic patients. However in a pilot study[26] of 10 patients with both types of diabetes mellitus, a significant reduction of CRP levels was observed, which is in accordance with the present study.

Comparision of the baseline and 1 month post-treatment TWBC counts, the results showed a statistically significant improvement in both the treatment groups. The TWBC count decreased after the intervention of therapy in both the groups, which is in accordance to study performed by Christgau et al. (1998) suggesting that the decreased bacterial load has significantly decreased the level of inflammation and thereby decreasing the leukocyte count.[27] In an another study, Radafshar et al. (2010)[16] has proposed that non-surgical periodontal therapy results in a significant decrease in circulating levels of CRP and WBC count.

Both therapies were associated with a reduction in leukocyte count indicating that FMD performed in either one stage or in two stages was effective in reducing the infection caused by bacteremia and consequently there was a reduction in the count of these inflammatory cells. No statistical significant difference was observed in the TWBC count at baseline and 1 month after non-surgical therapy with Group 1 when compared with Group 2, which is in accordance with the study carried out by Sambashivaiah et al. (2011).[19] As there are limited studies that followed the methodology similar to that of the present we have compared FMD with that of quadrant wise SRP.

The TWBC count was evaluated 1 month post-treatment, but not immediately after the treatment because of the decreased patient compliance. The WBC count appears to be within the expected range both at baseline and after a month with a slight decrease. These minor changes can be interpreted to be of any less clinical significance. Further studies have to be carried out to verify these findings.

In the present study, though there is no statistical significant difference seen between the two treatment modalities in the present study yet OSFMD has many advantages over Two Stage FMD such as the reduction in bacterial load and prevention of cross-contamination of the instrumented pockets is made possible,[9101112] frequency of visits is decreased, which is comfortable and economical to both patient and the clinician and may be hypothesized as an ideal treatment approach for patients with low compliance. However, clinicians should select the treatment modality based on practical considerations, related patient compliance and clinical condition.

Limitations of this study include small sample size and also the short time period. Further studies with long duration and large sample size are required in the future to overcome these limitations.

CONCLUSIONS

Both the treatment modalities showed significant improvement in both clinical and hematological parameters after therapy providing its clinical effectiveness. However comparison between the treatment modalities showed no statistical significant difference after 1 month. Though OSFMD may have a limited additional benefit over two stage FMD, in the treatment of periodontitis, it has certain advantages such as a reduction in bacterial load and prevention of cross-contamination of the instrumented pockets, frequency of visits is decreased, which is comfortable and economical to both patient and the clinician.