DOI: 10.21276/sjds.2016.3.10.5
Scholars Journal of Dental Sciences (SJDS)
Sch. J. Dent. Sci., 2016; 3(10):290-295
ISSN 2394-496X (Online)
ISSN 2394-4951 (Print)
©Scholars Academic and Scientific Publisher
(An International Publisher for Academic and Scientific Resources)
www.saspublisher.com
Original Research Article
Effect of Scaling and Root Planing on Liver Function Test (Alanine
Aminotransferase and Aspartate Aminotransferase) in Systemically Healthy –
Chronic Periodontitis Subjects: A Clinical Trial
Pradnya Rajendra Khatavkar1, Rahul Ashok Patil2, Abhijit Ningappa Gurav3, Abhijeet Rajendra Shete2, Sumit S
Shetagar4, Sagar Prakash Kadam1
1
Post graduate student Department of Periodontology Tatyasaheb Kore Dental College & Research Centre, Kolhapur,
Maharashtra, India
2
Reader, Department of Periodontology Tatyasaheb Kore Dental College & Research Centre, Kolhapur, Maharashtra,
India
3
Head of Department and Professor Department of Periodontology Tatyasaheb Kore Dental College & Research Centre,
Kolhapur, Maharashtra, India
4
Lecturer, Department of Periodontology Tatyasaheb Kore Dental College & Research Centre, Kolhapur, Maharashtra,
India
*Corresponding author
Pradnya Rajendra Khatavkar
Email: [email protected]
Abstract: Chronic exposure to periodontal bacteria and their products thought to be responsible for the pathogenesis of
systemic diseases. The aim is to evaluate effect of non- surgical periodontal therapy on liver function in systemically
healthy chronic periodontitis (CP) subjects. The study includes 50 CP subjects with age group of 35- 60 years selected
from the OPD of department of periodontology TKDC and research center RC, Kolhapur. Subjects were equally divided
into test (TG) and control group (CG). Liver function test- AST & ALT were checked at baseline and at 1 month after
treatment. Clinical examination includes PI, GI, SBI, PD, CAL. Comparison between group I and group II for all the
measures of periodontal parameters and AST levels were analyzed by applying Student t test. A statistically significant
difference (P<0.05) between mean PI, GI PD, CAL, AST & ALT levels at baseline and after 1–months of initial therapy
was obtained, suggestive of a significant decrease in mean PI, GI, PD, CAL, AST & ALT levels in TG after therapy as
compared to that of baseline. There is a correlation between liver markers and periodontitis suggesting that AST and
ALT levels decreases when periodontal status improves.
Keywords: Chronic Periodontitis, Alanine aminotransferase, Aspartate aminotransfrase
INTRODUCTION
Periodontal
disease
is
an
immune–
inflammatory disease characterized by connective tissue
breakdown, loss of attachment and alveolar bone loss.
Chronic exposure to periodontal bacteria, bacterial
products, and cytokines is supposed to be responsible
for the pathogenesis of systemic diseases [1, 2]. During
progression of periodontitis, deep periodontal pockets
create increased subgingival space for bacterial
deposits, which causes ulcerations in the periodontal
pocket [3]. The pathologic changes permit bacteria and
their components, e.g., lipopolysaccharide (LPS), to
enter the systemic circulation [4]. These results suggest
that periodontitis can have systemic effects on other
organs, such as the liver. The liver plays an important
physiologic role in LPS detoxification. In case of septic
shock, an increase in serum LPS concentration is
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related to the release of inflammatory cytokines, such as
tumor necrosis factor- alpha (TNF-a), or reactive
oxygen species, and such a condition would incite a
vigorous pathologic response in the liver tissues [5].
Aspartate aminotransferase (AST) previously
termed as glutamic oxaloacetate transferase (GOT) has
proven to be a strong diagnostic indicator of periodontal
inflammatory lesions. It is a soluble cytosolic enzyme
which is restricted to the cell cytoplasm but is released
by dead or dying cells. Since cell death is an integral
and critical component of periodontal tissue destruction,
AST should be released during this process. AST levels
help in determining the ongoing tissue destruction and
hence aid in identifying sites undergoing active disease
process [6].
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Khatavkar PR et al., Sch. J. Dent. Sci., Vol-3, Iss-10 (Oct, 2016), pp-290-295
AST is found in serum and erythrocytes of
healthy individuals but its concentrations in active
periodontal pockets of patients with periodontitis are
higher. It is released into extracellular fluid upon cell
death. Increased AST activity in serum can thus be a
useful marker of periodontal disease activity [7].
ALT is also measured as enzyme associated
with cell injury and cell death and change in this
enzymatic activity reflects metabolic changes in the
gingiva and periodontium, in the inflammation. So there
can be a relationship between increased ALT activity in
serum and periodontal disease activity [8].
Shimada et al [9] suggested that AST levels
may be a useful adjunct in the clinical assessment of
periodontal disease sites, since AST level decreases
when periodontal status improves.
So Studies have indicated that with the
improvement in the periodontal condition after therapy
there is a significant reduction in the AST and ALT
levels. Therefore, this study was planned with an aim to
evaluate the potential of AST and ALT levels as a
diagnostic marker to assess periodontal disease activity
and to determine its relationship after non surgical
periodontal therapy in systemically healthy chronic
periodontitis (CP) subjects.
MATERIALS AND METHODS
The present clinical study was carried out from
January 2015 to march 2015 in 60 subjects between 35
to 60 years of age. They belonged to the group of
patients referred to Department of Periodontology,
TKDC and RC, New Pargaon for the treatment of CP
and they were systemically healthy. Prior approval for
study was obtained from the institutional ethical
committee. After the study was explained, including the
benefits, risk and alternative treatments, the patients
signed an informed consent form indicating their
agreement to participate in the study.
Sample size
With 95% confidence and 80% power
minimum 25 Patients from either groups, tests as well
as control group, were required to be included in the
study.
Study group
A total 50 systemically healthy patients with
CP within age group of 35 to 60 years who visited the
Department of Periodontology Tatyasaheb Kore Dental
College & Research Centre, New Pargaon were
recruited for the study. The patients in the study group
were clinically evaluated for CP according to CDC
[10]. The patients otherwise healthy, with no history of
major illness and consumption of antioxidants,
antibiotics, anti-inflammatory or any other drugs and
had not received any periodontal therapy for at least 3
months prior to the study.
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Subjects who have undergone periodontal
treatment within six months of inception of study,
Tobacco habits in any form and alcoholics, Pregnant
and lactating women were excluding from the study.
After screening through inclusion and exclusion criteria
patients were divided into two groups i.e. test group and
control group. Subjects were explained about the nature
of the study and informed consent was taken. A
thorough medical and dental history was obtained,
followed by a complete oral and clinical examination.
All subjects were explained about the nature and
duration of the study schedule and informed consents
were obtained.
Clinical study design
At 0 day (at baseline)-Baseline clinical
examination;
 Recording of clinical parameters;
 Collection of blood;
 Phase I therapy (scaling and root planing) in
test group
 At 1 months follow-up-Post-initial therapy
clinical examination;
 Recording of clinical parameters;
 Collection of blood
Blood collection
3ml of blood was collected from the
anticubital fossa by venipuncture using 20 gauge needle
with 5ml syringes. Blood samples were left to clot for
(1-2) hours, then centrifuged to obtain the serum. Serum
was collected in disposable plastic serum containing
tube, which was stored at (2-40C) until time of assay.
Biochemical estimation of AST and ALT
levels in serum was done at baseline (on 0 day) and
post-initial therapy (on 30th day). Periodontal status
was assessed by using PPD, clinical attachment level
(CAL), bleeding on probing (Papillary Bleeding Index
by Muhlemann, 1977) and gingival index (Loe and
Silness, 1963) using UNC 15 probe.
Biochemical analysis
Methodology used according to international
federation of clinical chemistry by using 2;oxaglutarate,
L-Aspartate, MDH, LDH, NADH, Tris buffer(ph=7.8,
at 25degree C.) for SGOT and L- Alanine, NADH,
LDH, 2-Oxaglutarate, Tris buffer(ph=7.5 at 25 degree
C.) for SGPT.
Statistical analysis
Descriptive and inferential statistical analysis
has been carried out in the present study. Results on
continuous measurements are presented on Mean  SD
(Min-Max) and results on categorical measurements are
presented in Number (%). Significance is assessed at 5
% level of significance. The following assumptions on
data is made, Assumptions: 1. Dependent variables
should be normally distributed, 2.Samples drawn from
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Khatavkar PR et al., Sch. J. Dent. Sci., Vol-3, Iss-10 (Oct, 2016), pp-290-295
the population should be random, Cases of the samples
should be independent.
** Strongly significant (P value: P0.01)
Student t test (two tailed, independent) has
been used to find the significance of study parameters
on continuous scale between two groups (Inter group
analysis) on metric parameters.
Statistical software
The Statistical software namely SAS 9.2, SPSS
15.0, Stata 10.1, MedCalc 9.0.1 ,Systat 12.0 and R
environment ver.2.11.1 were used for the analysis of the
data and Microsoft word and Excel have been used to
generate graphs, tables etc.
Chi-square/ Fisher Exact test has been used to
find the significance of study parameters on categorical
scale between two or more groups.
Significant figures
+ Suggestive significance (P value: 0.05<P<0.10)
* Moderately significant (P value: 0.01<P  0.05)
RESULTS
The distribution of age & sex in the control
and test groups was similar. There was also no
significant difference in age, as the means and standard
deviations were 45.68±2.94 yrs. and 45.84±4.19 yrs. for
the respective groups. [Table No. 1]
Table 1: Age wise distribution among Test and Control Group
Test Group
Control Group
Age in years
No
%
No
%
40-50
21
84.0
24
96.0
51-60
4
16.0
1
4.0
Total
25
100.0
25
100.0
Mean ± SD
45.84±4.19
45.68±2.94
Test Group
Control Group
Gender
No
%
No
%
Female
13
52.0
12
48.0
Male
12
48.0
13
52.0
Total
25
100.0
25
100.0
It can be seen that CG & TG differed with
respect to PI, GI, PD, CAL , ALT , and AST at the
baseline. [Table No. 2] At baseline there was no
P value
0.876
0.777
statistical difference in the Plaque Index (p=0.112) but
one month after intervention it shows statistically
significant difference between CG & TG (p=< 0.001).
Table 2: Comparing two groups (test group and control group) at baseline as well as after 1 month for various
parameters
Sr. No.
Criteria
CG vs TG
P values
1
Baseline
0.112
PI
1 Month
< 0.001
2
Baseline
0.051
GI
1 month
< 0.001
3
Baseline
0.581
PD
1 month
< 0.001
4
Baseline
0.088
CAL
1 month
< 0.001
5
Baseline
0.264
AST
1 month
< 0.001
6
Baseline
0.646
ALT
1 month
< 0.078
On comparing the GI at baseline there was no
significant difference between TG & CG (p=0.051) but
evaluating the value after 1 month shows statistically
significant difference between CG & TG. (p=< 0.001).
Likewise, on evaluation of the Probing depth at baseline
there was no significant difference in CG & TG
(p=<0.581), after 1 month also there was significant
difference between CG & TG (p= 0.001). No significant
difference is also seen in case of CAL evaluation at
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baseline (p=<0.088) but significant difference seen after
1 month (p=<0.001)
Comparison of serum examination it shows
that, there was no significant difference in serum AST
at the baseline (p=0.264) & after intervention, 1 month
evaluation it show significant difference between CG &
TG. (p=<0.001), likewise on evaluation of serum ALT
level there was no significant difference between CG &
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Khatavkar PR et al., Sch. J. Dent. Sci., Vol-3, Iss-10 (Oct, 2016), pp-290-295
TG at baseline (p=0.646) but suggestive significant
difference after 1 month. (p=<0.078).
After intergroup evaluation of all periodontal
parameters & serum parameters of CG at baseline and
at 1 month shows that there is no statistical significant
difference [Table No. 3] but TG shows statistical
significant difference between at baseline & 1months in
periodontal & serum parameters. [Table no. 4]
Table 3: Intragroup Comparison of Parameters in Control Group (CG)
Sr. No.
Criteria
Control Group
P values
1
Baseline vs 1 Month
0.103
PI
2
Baseline vs 1 Month
0.754
GI
3
Baseline vs 1 Month
0.327
PD
4
Baseline vs 1 Month
0.215
CAL
5
Baseline vs 1 Month
0.264
AST
6
Baseline vs 1 Month
0.646
ALT
Table 4: Intragroup Comparison of Parameters in Test Group (TG)
Sr. No.
Criteria
Test Group
P values
1
Baseline vs 1 Month
<0.001
PI
2
Baseline vs 1 Month
<0.001
GI
3
Baseline vs 1 Month
<0.001
PD
4
Baseline vs 1 Month
<0.001
CAL
5
Baseline vs 1 Month
<0.001
AST
6
Baseline vs 1 Month
<0.078
ALT
DISCUSSION
Biochemical tests are used extensively in
medicine both in relation to diseases that have an
understandable metabolic basis and those in which
biochemical changes are a result of the disease. In
dentistry, these tests are gaining importance in the
diagnosis, prognosis, monitoring, and screening of
periodontal diseases in which changes in enzymatic
activity reflect metabolic changes in gingiva and
periodontium in inflammation. These tests have been
anticipated to assess periodontal disease activity in
addition to clinical assessments [11].
The present study was based upon establishing
the correlation between a biochemical cell deathmarker, i.e. AST & ALT, in serum and the status of
periodontal disease activity.
AST and ALT are the enzymes that are most
commonly associated with tissue damage. AST is
particularly important in the transport of reducing
equivalents across the mitochondrial membrane via
malate aspartate shuttle and is a sensitive indicator of
necrosis in a number of tissues. Measurement of AST
levels provides a suggestion of progression of
periodontal destruction, and AST is therefore a potential
marker for distinguishing between active and inactive
disease sites [12].
Shimada et al [9] suggested that AST levels
may be a useful adjunct in the clinical assessment of
periodontal disease sites, since AST level decreases
when periodontal status improves. Persson et al. [6]
demonstrated that AST levels can be used to assess the
presence and extent of periodontal inflammation.
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The present study was based upon establishing
the correlation between a biochemical cell deathmarker, i.e. AST & ALT in serum and the status of
periodontal disease activity at baseline & 1month after
SRP.
In this study AST & ALT levels were found to
be reduced significantly (P<0.001) after treatment when
compared by applying paired t test. This reflects that the
AST & ALT release is associated with inflammation /
necrosis.
To measure the effect of SRP, the paired t test was
applied to find the reduction in the periodontal
parameter before and after treatment and a statistically
significant reduction (p<0.001) was found suggesting
that SRP and motivation for oral hygiene measures
helped in improving the periodontal health of subjects.
Wong et al. [13], analyzed the association of
plaque and gingival indices with AST in sites with a
probing depth of 4 mm and did not find any significant
difference between positive and negative sites,
particularly in relation to the gingival index.
Smith et al. [14] reported no significant
correlation between AST positive sites and probing
depth, probably due to the sensitivity (60%) and
specificity (57%) of AST values for differentiating sites
with periodontitis and gingivitis. Such results are not
consistent with this study.
Vipin et al. [15] in his study analyzed the level
of AST in GCF at baseline and 3 months after nonsurgical therapy in patients with chronic periodontitis
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Khatavkar PR et al., Sch. J. Dent. Sci., Vol-3, Iss-10 (Oct, 2016), pp-290-295
and observed improvement in clinical parameters and
there was a corresponding reduction in AST levels.
Vipin K et al [14] concluded that AST level
may be a useful adjunct as a biomarker in the
assessment of periodontal disease as evident by its
reduction in GCF levels. The findings of this study were
similar to these results.
2.
3.
4.
A few studies analyzed the levels of AST in
GCF and saliva before and after periodontal treatment
in periodontitis patients. Improvements in clinical status
were noted following periodontal therapy and there was
a corresponding decrease in AST levels. They
concluded that AST levels may be a useful adjunct in
the clinical assessment of periodontal disease, since
AST level decreases when periodontal status improves.
Totan A et al [16] studied the influence
of periodontal disease
on
the
level
of salivary AST, alanine aminotransferase (ALT)
&
ALP & revealed that periodontal destruction such
as periodontal pockets,
gingival
bleeding
and
suppuration are related to higher ALP and AST levels
in saliva. Salivary AST could be used as a useful
marker for monitoring periodontal disease. The increase
in salivary ALP activity in periodontitis demonstrated
could be associated with alveolar bone loss, a key
feature of periodontal disease.
5.
6.
7.
8.
So, studies have indicated that with the
improvement in the periodontal condition after therapy,
there is a significant reduction in AST & ALT levels.
9.
CONCLUSION
From this study, it could be concluded that
serum AST & ALT enzyme levels were decreased in
patients with periodontitis who had under gone SRP.
Further studies in this direction with larger
study sample and particularly longitudinal clinical
studies involving the post periodontal therapy
assessment of serum enzymes in comparison to the pre
treatment activity levels could prove of enormous help
in the management of periodontal diseases in the near
future.
ACKNOWLEDGEMENT
The authors sincerely thank the staff ,Post
Graduate students- Dr.Sumit Shetgar, Dr.Sapan Doshi,
Dr.Nilima Kadam,Dr.Sagar Kadam.(Department of
Periodontology), Dr.K.K.Mane (Department of
Biochemistry, TKDC & RC) and Anant Laboratory in
charge Mr. Desai.
10.
11.
12.
13.
14.
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