Interaction Between Hypertension and Periodontitis
Condition: Hypertension; Periodontitis
MeSH terms: Periodontitis; Hypertension
Study type: Interventional

Summary: 
      Objective:The possible association between hypertension and periodontitis and the effect of
      hypertension on periodontal treatment were investigated by evaluating salivary and gingival
      crevicular fluid (GCF) interleukin (IL)-6 and C reactive protein (CRP) levels. Methods:Forty
      two healthy individuals without any previously diagnosed systemic disease [10 periodontally
      healthy (control) and 10 periodontitis (CP)] and subjects with hypertension [13 periodontally
      healthy (HP) and 9 with periodontitis (CP + HP)] participated in the study. GCF and saliva
      samples were obtained at baseline and four weeks after Phase I periodontal treatment.
      Biochemical parameters were analyzed using ELISA. Results:Before the periodontal treatment,
      significantly higher GCF IL-6 and CRP levels were detected in CP+HP and CP groups compared to
      HP and control groups (p<0.01). Salivary CRP level in CP+HP group was found to be higher than
      the control group (p<0.05). Statistically significant gingival and plaque index measurements
      (p<0.01) might suggest a possible effect of hypertension on periodontal status. Periodontal
      treatment significantly improved the clinical indices, however biochemical parameters did not
      change after the treatment. Conclusion:the association of hypertension with periodontitis
      through local salivary and GCF mediators might be possible in disease process.
    

Detailed description: 
      Forty-two participants were included in the study. The study groups consisted of 20 healthy
      individuals without any previously diagnosed systemic disease (10 periodontally healthy and
      10 with periodontitis) and 22 patients with hypertension (13 periodontally healthy and 9 with
      periodontitis). The patient population was randomly selected among the patients who referred
      to Periodontology Clinic. Hypertensive patients with at least 5 years of follow up were
      included in the hypertension group. Hypertension patients treated with antihypertensive drugs
      known to cause gingival overgrowth were excluded from the study.

      Other exclusion criteria were diabetes mellitus, high cholesterol levels, CVD and drugs usage
      other than antihypertensive drugs. A calibrated examiner performed a comprehensive
      periodontal examination included plaque index (Silness & Loe, 1964) (PI), gingival index (Loe
      & Silness, 1963) (GI), probing depth (PD), clinical attachment level (CAL) and bleeding on
      probing (BOP). The measurements were made at six sites per tooth (mesio-buccal, mid-buccal,
      disto-buccal, mesio-lingual, mid-lingual and disto-lingual) using a periodontal probe
      (Williams periodontal probe, Nordent Manufacturing, Elk Grove Village, IL., USA) To perform
      the intra-examiner calibration, PD and CAL were measured twice at six sites of each tooth
      within 24 hours. Intra-examiner agreement was at least 90% for both PD and CAL within 1 mm.
      Examiner who recorded the clinical indexes was blinded to the systemical status of the
      patients and the periodontologists who were responsible for patients periodontal treatment
      were not blinded because of the anesthesia applied to hypertension patients and the
      precautions needed to be taken.

      During the study period, patients were instructed not to use any local/systemic antibiotics
      and antimicrobial agents.Patients diagnosed with periodontitis had Stage II periodontitis in
      a generalized pattern with probing depths of 3-4mm. The diagnosis was performed based on
      criteria that maximum probing depth ≤5 mm, mostly horizontal loss and >30% of teeth involved.
      Healthy periodontium was identified as the presence of BOP≤10% and PD≤3 mm.The deepest four
      pockets of non-adjacent single rooted teeth were selected for GCF sampling. The participants
      were distributed into four groups; healthy subjects with healthy periodontal condition
      (control), healthy subjects with periodontitis (CP), hypertension patients with periodontitis
      (CP + HP) and hypertension patients with healthy periodontal condition (HP). The study was
      approved by the local ethics committee (291208/11) and all patients signed an informed
      consent form. Exclusion criteria were smoking, pregnancy, established secondary hypertension
      diagnosis, other systemic diseases and previous periodontal and/or antibiotic treatment
      within the last six months. All patients with periodontitis received phase I periodontal
      therapy including oral hygiene instruction (OHI) and scaling/root planning (SRP) without any
      antimicrobial therapy. GCF and saliva samples were obtained and clinical measurements were
      performed at baseline (before treatment (BT) and four weeks after the phase I periodontal
      therapy (AT). The timeline for the phase I therapy (within 2 weeks of baseline examination 4
      days). Primary biochemical outcome measures included salivary and GCF IL-6 and CRP, and
      primary periodontal outcome measures were PI, GI, PD, CAL and BOP. Secondary outcome measure
      was GCF volume.

      GCF and saliva sampling and processing The GCF sampling site was gently air dried and
      supragingival plaque was removed.

      The area was carefully isolated with cotton rolls in order to prevent contamination.

      Standardized paper strips (Periopaper, Pro Flow, Amityville, NY, USA) were inserted into the
      sulcus until slight resistance was felt and left in place for 30 seconds. Strips contaminated
      by bleeding or exudates were discarded. GCF volumes were determined as described previously.
      To determine the amount of GCF, an electronic balance was used to weigh the paper strips
      before and immediately after collection. The mass (mg) of the fluid on each strip was
      converted to a volume in millimeters by assuming that the density of GCF was 1. Strips were
      placed into coded micro centrifuge tubes and stored at -800C until processing. Before
      biochemical analysis, paper strips were placed in 0,1 % bovine serum albumin/phosphate
      buffered saline solution in Eppendorf tubes, and the fluid from the paper strip was eluted by
      centrifugation for 6 minutes at 5,000 · g at 4 C. Following centrifugation, the strips were
      removed.The participants were asked to stop eating and drinking 2 hours before each sampling.
      They were instructed to rinse their mouth for 30 seconds with 10 mL of water and to rest for
      2 minutes before unstimulated saliva was collected by spitting. Approximately 1 mL of
      unstimulated whole saliva was collected into Eppendorf tubes. Samples were centrifuged for 10
      minutes at 15.000 × g at 4°C to remove any particulate matter. The supernatants were stored
      at -20°C until analysed.

      GCF and saliva enzyme-linked immunosorbent assay (ELISA) analysis for IL-6 and CRPThe levels
      of IL-6 and CRP in GCF and saliva were measured using a sandwich ELISA kit (Biosource,
      Invitrogen Corporation, Carlsbad, California 92008). The ELISA procedures were carried out
      according to the manufacturer's instructions. Results were expressed as pg/mL. Total amounts
      were also calculated by multiplying concentrations and CRP volumes.
    

Intervention name(s): Scaling and root planing
Intervention type(s): Procedure
Intervention description(s): Each tooth with inflammation symptoms was cleaned with scalers, curettes and ultrasonic devices routinely.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Diagnostic
Keywords: IL-6; CRP; Periodontitis; Hypertension; Phase I therapy