Level of C-reactive Protein in Periodontal Patients Before and After Treatment in a Teaching Hospital Selected Population

Level of C-reactive Protein in Periodontal Patients Before and After Treatment in a Teaching Hospital Selected Population
Farzeen Shafiq* , Mozaffer Rahim Hingorjo** , MasoodA.Qureshi***


To determine the change in C-reactive protein (CRP) levels in subjects after treatment of chronic periodontitis.

100 patients, aged 30 to 50 years, having chronic periodontitis with a periodontal index (PI) of 6 and 8 were selected from low socioeconomic class. The patients completed a structured questionnaire that included data regarding oral and general health habits. They received treatment for chronic periodontitis and PI was reassessed after 3months.CRPlevelswere similarlymeasured at baseline and 3months after treatment.


The mean PI of all subjects was 7.3 ± 0.96 and 4.53 ± 1.93 before and after treatment, respectively. Similarly, the mean CRP level (in mg/L) was 6.34 ± 2.29 and 5.62 ± 2.01 before and after treatment, respectively. CRP levels were higher in males as compared to females, at baseline than after treatment. However, both groups responded equally to treatment (P < 0.0005). CRP levels were also higher in older age groups (> 40 years), both at baseline and after treatment.


The CRP levels accompanied the severity of periodontal infection, and decreased significantly after improvement of periodontal health following the treatment.


C- reactive protein, Periodontal Index,Chronic Periodontitis


Periodontal diseases are a diverse group of clinical entities in which induction of inflammation results in destruction of the attachment apparatus of the teeth resulting in loss of tooth, if left untreated. It is the most common infection of the oral cavity, affecting the adult population worldwide. According to world health organization (WHO) reports 2003, more than 93% of Pakistani population is affected by periodontal problems. Currently, there has been increasing interest in the study of the relationship between periodontal health and ischemic heart disease.This is supported by the detection ofDNAof periodontal bacteria in the coronary arteries .The rationale behind this association is an increase in levels of inflammatorymediators like C-reactive proteins (CRP) as a result of chronic periodontal infections that may stimulate major vascular responses and as a result contribute to atherogenesis . Several studies have demonstrated in different populations, that even mild increase of plasma CRP in the normal range, observed in apparently healthy individuals, strongly predicts future vascular events.

CRPis an acute phase reactant protein, synthesized in liver and is normally present as a trace constituent of plasma or serum. Its level may rise within 4-8 hours after the onset of an acute event resulting in tissue injury, inflammation, or infection. The plasma levels can double at least every 8 hours, reaching a peak after about 50 hours, falling rapidly after effective treatment or removal of the inflammatory stimulus, due to the short plasma half-life of 5-7 hours. CRP levels could be used as an adjunct for risk assessment in primary and secondary prevention of cardiovascular disease and is of prognostic value.

The aim of the present study was to determine whether the presence of chronic periodontitis and subsequent periodontal treatment could influence the serumlevels of CRP, in otherwise healthy individuals.


Hundred patients were selected from the periodontology department of Fatima Jinnah Dental College Hospital, Karachi, between Dec 2006 and Mar 2007. All the patients selected belonged to low socio economic class. The socio economic class was defined on the basis of three parameters: education, income and the occupation of subjects. Patients included were otherwise healthy, with no known systemic disease andwith chronic periodontitis. The evaluation of periodontal status included four measures of periodontal status i.e. Periodontal pocket depth (PD) using a periodontal probe, Gingival Index (GI), Gingival bleeding on probing (GB) and periodontal attachment level (AL). All four measurements were carried out in all teeth and theirmean values were determined for each patient, respectively. Chronic generalized periodontitis was diagnosed in all patients on the basis of criteria for periodontal index which was recorded on 1st molars and central incisors of the patients (as given under annex_1part 10). Patientswith chronic periodontitis,with a periodontal index of ‘6’ and ‘8’ were selected, as this level of periodontitis indicates subjects having chronic periodontitis with destruction of periodontium.

The subjects belonged to age groups 30 50years, as during this span of life there is a higher risk of development of periodontal and cardiovascular disease. The subjects were then categorized into four groups in accordancewith their ages and sex as follows: Group M1: males ≤ 40 years; Group M2: males > 40 years Group F1: females ≤ 40 years; Group F2: females > 40 years.

The patients were required to fill a structured questionnaire that included data regarding oral and general health habits. This included questions regarding brushing habits, use of floss, mouthwash, use of toothpick, smoking and panchewing. Depending on the degree of Periodontal Index they were given treatment forchronic periodontitis that included mechanical debridement of the plaque and calculi by hand, scaling, deep curettage of gingival and periodontal tissues, and an antibiotic course for 5-7 days consisting mainly of Metronidizole was given as needed. In order to maintain oral hygiene, proper brushing and flossing techniques were demonstrated to the patients and they were prescribed a suitable mouthwash containing Chlorohexidine and toothpaste specific for gum diseases. PIwas reassessed 3month after treatments.

The CRP levels were measured were measured on the chair side of patient by using NycoCard CRP single test kit. The NycoCard CRP Test is a solid phase, sandwich format, immunometric assay. A sample diluted with borate buffer (pH 9.0)was applied to the test device. In the presence of pathological levels of CRP the membrane appeared red brown with color intensity proportional to the concentration of the sample. The color intensity was measuredwith the Nyco Card Reader TheNycoCardCRPsingle testwas calibrated against ERM-DA470 (CRM 470), IFCC/BCR/CAP reference preparation.With ameasuring range of 8-250mg/L, while usingwhole blood.

CRP levels were measured at baseline and 3 months after treatment. CRP levels were measured at baseline and 3months after treatment.


Of the 100 patients enrolled in the study, 52% were males and 48% were females. . Brushing frequency once dailywas observed more in males(78.8%) as compared to females(54.95%), while twice daily brushing was higher in females (45.05%) as compared to males(19.9%).Only 5% of the total subjects were using the dental floss regularly. Thirty Eight percent subjects were smokers and 37% were the pan chewers. Table 1 shows the baseline data of subjects according to their age and sex distribution.

The results at baseline suggest a poor periodontal health in the older age group (> 40 years) as compared to the younger group (< 40 years) and in females in comparison tomales.Themean PI of all subjectswas 7.3 ± 0.96 and 4.53 ± 1.93 before and after treatment, respectively. Similarly, themean CRP level (inmg/L)was 6.34 ± 2.29 and 5.62 ± 2.01 before and after treatment, respectively. CRP levels were higher in the older age groups and in males as compared to females, at baseline and after treatment. However, both groups responded equally to treatment {(P< 0.0005) (Table 2&figure1)}.


Periodontal infection is a well known inflammaton of periodontium, caused by specific microorganism or groups of specific microorganisms that results in the progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession or both.6 The involvement of periodontal infection in etiology of a variety of medical illness, most importantly ischemic heart disease, has been proved recently by many researchers The reason of this connection can be the oral bacteria themselves which have been found in blood circulation following many dental procedures. The bacterial endotoxins (lipopolysacharrides) can influence the inflammatory cytokines, causing a disturbance in lipid metabolismand promoting atherosclerosis.

In this context, inflammatory cytokines, released during acute phase reaction, like CRP have been recognized as a link between chronic infection like periodontitis and atherosclerosis. In 2003, theAmerican Heart Association (AHA) and the Centers for Disease Control and Prevention published a joint statement advising measurements of CRP for patients at intermediate risk for heart disease (having 10 20%risk of developing the disease over ten year).

The role of CRP as a predictor for future coronary events in healthy populations is now being seriously considered. Cardiovascular disease accounted for 78% deaths in 1999 and is the leading cause of death throughout theworld but specifically in developing countries. Due to the presence of chronic marginal gingivitis / periodontitis throughout the lives ofmajority of world’s population, it is necessary to understand the relation between dental health and systemic illness.

We measured C-reactive protein levels in all selected subjects at baseline and 3 months after the treatment (Table 2).CRPlevelswere higher inmales, as compared to females at baseline in the present study, similar to other studies thus requiring specified threshold of CRP according to age and gender so as to accurately assess the risk of atherosclerosis. The results from our study demonstrate a significant decrease in CRP levels in all patientswho responded to delivered periodontal treatment as given inTable2

The results at base line suggest that the periodontal health was poor in the older age group (> 40 years) as compared to younger age (<40 years) (Table 1 and figure 1) The periodontal index showed that females had a poor periodontal status in comparison to males (Table 1) .The reason may be hormonal fluctuations during a female's lifetime such asmenstruation, pregnancy, and the use of oral contraceptives. The resulting exaggerated inflammatory response to dental plaque leads to periodontitis. However, menopause in this age group may be a more prominent factor leading to bone loss and contributing to periodontitis Several studies have reported the direct link between highCRPs levelswithmiddle age, cardiovascular diseases and mortality. A study in China, investigated the relationship between CRP, lipid profile and periodontitis in ethnic Han population and found a significant association between them thereby promoting coronary heart disease. InThailand researchers evaluated the associations of chronic periodontitis and Porphyromonas gingivalis, the main causative organism of periodontal infection. Periodontitis and subgingival P. gingivalis were associatedwith increased CRP levels inThai population. These findings suggest that periodontal infection may contribute to systemic inflammatory burden in otherwise healthy individuals. In India, Balwant Rai studied the relation between peripheral blood components and CRP and has suggested an important role of CRP in the development of periodontitis. In Iran Kazemi-Bajestani SM suggested CRP as an independent risk factor / predictor among patients suspected ofCAD. In our study, the given treatment improved the periodontal health of all subjects as is evident inTable 1.It was observed that C-reactive protein levelswere higher in patientswhowere >40 years (Table2&Figure1)

At baseline which draws a parallel with the poor periodontal condition, as the periodontal health was improved, theCRPlevelswere reduced. Significantly, CRP Level best describes the inflammatory status of the individual. As indicated, this study was designed to detect changes in CRP concentrations mainly and to relate the inflammatory burden exclusively with the chronic periodontitis and the effect of treatment.


1: The periodontal status was very poor among the study subjects. Their CRP levels accompanied the severity of the periodontal infection.
2: The CRP levels significantly decreased after the improvement of periodontal health following the treatment suggesting that chronic periodontitis may indeed contribute to elevatedCRPlevels.
3: Further studies are needed to answer ifmeasurement of CRP may be used as a routine prognostic test for assessment of risk of CAD, along with lipid profile, specifically in patientswith chronic periodontitis.


1. Petersen PE. The World Oral Health Report 2003: Continuous improvement of oral health in the 21st
century – The approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31(Suppl. 1):3-24.
2. Oliveira FJ, Vieira RW, Coelho OR, Petrucci O, Oliveira PP, Antunes N, Oliveira IP, Antunes E.
Systemic inflammation caused by chronic periodontitis in patients victims of acute ischemic
heart attack. Rev Bras Cir Cardiovasc 2010;25:51-58.
3. Joshipura KJ, Hung HC, Rimm EB, Willett WC, Ascherio A. Periodontal disease, tooth loss, and
incidence of ischemic stroke. Stroke 2003;34:47- 52.
4. Kushner I, Rzewnicki DL. The acute phase response: general aspects. Baillieres Clin Rheumatol 1994;
5. Rai B, Kharb S, Jain R, Anand SC. Biomarkers of periodontitis in oral fluids. JOral Sci 2008;50:53-56.
6. Niedzielska I, Janic T, Cierpka S, Swietochowska E. The effect of chronic periodontitis on the development of atherosclerosis: review of the literature. Med Sci Monit. 2008 ;14:103-106.
7. Genco R, Offenbacher S, Beck J. Periodontal disease and cardiovascular disease: epidemiology and
poss ible mechanisms . J Am Dent Assoc 2002;133(Suppl):14S-22S.
8. Bahrani-Mougeot FK, Paster BJ, Coleman S,Ashar J, Barbuto S, Lockhart PB. Diverse and novel oral
bacterial species in blood following dental procedures. J ClinMicrobiol. 2008 Jun;46:2129-2132.
9. Khovidhunkit W, Kim MS, Memon RA, Shigenaga JK, Moser AH, Feingold KR, Grunfeld C. Thematic
review series: The pathogenesis of atherosclerosis. Effects of infection and inflammation on lipid and
lipoprotei n metabolism mechanisms and consequences to the host. J Lipid Res 2004; 45:1169-1196.
10. Ridker PM, Silvertown JD. Inflammation, C-reactive protein, and atherothrombosis. J Periodontol 2008; 79(8 Suppl):1544-1551.
11. Noack B,Genco RJ, TrevisanM,Grossi S, Zambon JJ, De Nardin E. Periodontal infections contribute to
elevated systemic C-reactive protein level. JPeriodontol 2001;72:1221-1227.
12. World Health Organization. TheWorld Health Report 2003. Neglected global epidemics: three growing
threats Shaping the Future. Geneva: World Health Organization, 2003; pp. 83-101.
13. Pihlstrom B, Michalowicz B, Johnson N. Periodontal diseases.TheLancet 2005;366(9499):1809-1820.
14. Burta O, Qadri SM, Burta OL. Clinical significance of the biomarker C-reactive protein Acute myocardial Infarction:Apreliminary Laboratory evaluation. Res J Biol Sci 2007;2:718-721.
15. Dotsenko O, Chackathayil J, Lip GY. Measurement of C-reactive protein and natriuretic peptides for
cardiovascular risk assessment: the need for age and gender-specific thresholds. J Hypertens 2008;
16. Becerik S, Ozcaka O, NalbantsoyA,Atilla G, Celec P, Behuliak M, Emingil G. Effects of menstrual cycle on periodontal health and gingival crevicular fluid markers. JPeriodontol 2010;81:673-81.
17. Machtei EE,Mahler D, SanduriH, PeledM. The effect ofmenstrual cycle on periodontal health. J Periodontol2004;75:408-412.