CORRELATION BETWEEN GCF HEMOGLOBIN CONTENT AND

PERIODONTAL CLINICAL PARAMETERS

Hiroshi Ito DDS PhD, Yukihiro Numabe DDS PhD, Shuichi Hashimoto DDS PhD, Satoshi Sekino DDS PhD, Etsuko Murakashi DDS PhD, Hitomi Ishguro DDS PhD, Daisuke Sasaki DDS PhD, Takashi Yaegashi DDS PhD, Hideki DDS PhD, Masaru

Mezawa DDS PhD, Yorimasa Ogata DDS PhD, Hisashi Watanabe DDS PhD, Satsuki Hagiwara DDS PhD, Yuichi Izumi DDS PhD, Yuka Hiroshima DDS PhD,

Jun-Ichi Kido DDS PhD, Toshihiko Nagata DDS PhD, Kazushi Kunimatsu DDS PhD.

Journal of PeriodontologyNovember 2016, Vol. 87, No. 11, Pages 1314-

1319https://doi.org/10.1902/jop.2016.160092

INTRODUCTION

Probing depth(PD) and bleeding on probing(BOP) are essential clinical parameters used for periodontal diagnosis. This study investigated whether detection of hemoglobin(Hb) in gingival crevicular fluid(GCF) along with PD and BOP would improve diagnostic accuracy.

Periodontitis is inflammation of the gingiva with attachment loss, and is clinically diagnosed with bleeding on probing(BOP). Examination of BOP is an important clinical parameter which points to the success or failure of periodontal therapy, reveals the presence of inflammation in the bottom of pocket and aids in planning and change of treatment.

AIM/PURPOSE OF STUDYThe purpose of the present study was to determine whether detection of Hb in GCF along with PD and BOP would more accurately detect periodontal disease activity. The associations between Hb and BOP evaluations of less than and more than cutoff value were analyzed statiscally and accuracy of both evaluations was compared to the clinical diagnosis.

MATERIALS AND METHODSA cross-sectional study design was employed to analyze Hb in GCF and its association with clinical parameter, especially BOP.

1)SAMPLE:A total of 184 non-smokers (mean age: 63.0 +/- 11.3 years, 73 males: 63.2 +/- 14.4 years, Females: 62.8 +/- 8.8 years) who were receiving regular periodontal maintenance therapy were examined.All participants were healthy and were not receiving and medication at the time of study.

2)EXCLUSION CRITERIA:1)Pateints with systemic diseases such as Diabetes, Immunological disorders, Hepatitis, Cardiac disease,2)Pregnant and lactating women and women taking oral contraceptice drugs,3)Patients who had received antimicrobial therapy for past 3 months, and4)Individuals whoe self reported the use of tobbaco products.

MATERIALS AND METHODS

3)MEASUREMENTS OF CLINICAL PARAMETERS:

A)Following clinical parameters were recorded for 401 sites of anterior teeth without restorations in maxilla/mandible of 184 patients: PI, GCF amount, GI, PD, CAL and BOP.

B)After PI measurement, GCF was collected from 401 pockets using paper strips, and was expressed as microliters. Samples of GCF contaminated with whole blood were excluded.

C)After GCF sampling, GI was recorded in 401 sites, and PD and CAL were measured using a pocket probe.

D)Finally BOP was recorded.

MATERIALS AND METHODS

4)HB INSPECTION IN GCF:The amount of Hb in GCF was measured with an Hb-detection kit using immunochromatography.When 1ng/pocket or more Hb was present, the pocket site was denoted as positive for detection of Hb.The means amount of Hb in GCF samples from all 401 sites was 48.6 +/- 85.4 ng/pocket.

5)STATISTICAL ANALYSIS:A)The statistical anaylsis was performed by 2 authors (HI, YN). The correlation between clinical

parameters and Hb detection was anaylzed using Spearman's correlation coefficient. The Mann-Whitney U test was used for between group comparisions.

B)The Receiver operating characterstis (ROC) curve, Youden index, and cut off values of the clinicalparameters were created based on PD and GCF.

C)A clinically healthy site was defined a having a PD less than or equal to 4mm and GCF less than 0.2microliter, a periodontitis progression risk site was defined as having PD greater or equal to 5mm andGCF more than 1.0 microliter.

D)Statisical analysis was considerd at the probability level, p<0.05 .

RESULTS1)CORRELATION BETWEEN THE CLINICAL PARAMETERS AND HB CONTENT IN GCF:

All Hb inspections in GCF were carried out prior to the examinations of clinical parameters( GI,PD,CAL,BOP,PI)Significant correlation were observed between every clinical parameter and Hb content in GCF. However, thecorrelation coefficient between BOP(+) and HB content was 0.172, which was the lowest coefficient in comparision to other parameters.

PI 0.5 ± 0.6

GCF (μl) 1.54 ± 2.04

PD (mm) 3.7 ± 1.7

GI 0.8 ± 0.7

CAL (mm) 4.6 ± 2.3

BOP 0.2 ± 0.4

CC 0.244

SP **0.000

CC 0.431

SP **0.000

CC 0.350

SP **0.000

CC 0.299

SP **0.000

CC 0.313

SP **0.000

CC 0.172

SP **0.001

1)CLINICAL PARAMETERS: Mean +/- SD2)Hb values: 48.6 +/- 85.4 ng/pocket.3)CC (Coefficient of correlation)4)SP (significant probability)5) ** P<0.016)n= 401 sites

2)COMPARISION BETWEEN THE GROUPS THAT WERE CLASSIFIED AS PERIODONTAL DISEASE BASED ON PDAND GCF:

On examination of sites, the clinical parameters(PI,GI,CAL) in periodontitis progression risk sites(123 sites; PD ≥ 5mm and more than 1.0 µl of GCF)were siginifcantly higher than those of clinicallyhealthy sites (45 sites; PD ≤ 4mm and less than 0.2 µl of GCF)

The clinically healthy sites: PD ≤4mm & GCF < 0.2µl; n=45 sitesThe periodontitis progression risk site: PD ≥ 5mm & GCF ≥ 1.0 µl; n= 123 sites** p value < 0.01 (≤4mm & <0.2 µl vs ≥5mm & ≥ 1.0 µl)

PI

GI

CAL

PD.GCF MEAN SD

≤4mm & <0.2 µl 0.2 0.4

≥5mm & ≥ 1.0 µl 0.7 0.6

≤4mm & <0.2 µl 0.4 0.7

≥5mm & ≥ 1.0 µl 1.3 0.5

≤4mm & <0.2 µl 2.8 1.5

≥5mm & ≥ 1.0 µl 6.6 1.6

P-value Siginificant difference

0.000 **

0.000 **

0.000 **

3)SETTING OF CUT OFF VALUES FOR PD AND GCF:The cutoff values for PI,GI, and CAL calculated by clinically healthy sites and periodontitis progression risksites were 0.500, 0.500, 4.500 mm. And likelihood ratios were 3.375, 2.937, 7.871. These values wereused to create the ROC curves and Youden indexes. A total of 107 sites with values less than cutoff valueswere classified in periodontically stable group, and 123 sites had values more than cutoof values and wereclassified as periodontal management required group.

PI GI CAL

Cut off values 0.500 0.500 4.500

Area under the curve

0.745 0.829 0.953

sensitivity 0.675 0.978 0.976

specificity 0.800 0.667 0.876

+ predictive value 0.902 0.889 0.952

- predictive value 0.474 0.909 0.929

Proper diagnosis rate

0.708 0.893 0.946

Likelihood ratio 3.375 2.937 7.871

4)DETECTION RATE OF HB IN BOP(-) AND BOP(+) SITES OF PERIODONTICALLY STABLE GROUP OR IN THEPERIODONTICALLY MANAGEMENT REQUIRED GROUP:

1) In the periodontically stable group consisting of 107 sites, 98.1% (105 sites) were BOP (-) and 1.9%(2 sites) were BOP(+). Hb was detected in 64.8% (68 sites) from 105 BOP(-) sites and in 50.0%(1 GCF site) from 2 BOP(+) sites.

2)In the periodontal management required group consisting of 122 sites, 58.2% (71 sites) were BOP(-)and 41.8% (51 sites) were BOP(+). Hb was detected in 88.7% (63 sites) from 71 BOP(-) sites and 90.2%(46 sites) from the 51 BOP(+) sites.

1)68 sites BOP(-) -->Hb was 14.8 +/- 41.6 ng/pocket ; 1 site of BOP(+) --> was 31.8ng/pocket2)63 sites of BOP(-) --> Hb was 73.0 +/- 98.1 ng/pocket ; 46 sites of BOP(+) --> Hb was 110.1 +/- 122.0 ng/pocket.

PERIODONTALLY STABLE GROUPS PERIODONTAL MANAGEMENt REQUIRED GROUP

Detection sites of Hb (107) Detection sites of Hb (122 sites)

total Hb(+) Hb(-) Total Hb(+) Hb(-)

BOP(-) 105 sites 68 37 71 sites 63 8

BOP(+) 2 sites 1 1 51 sites 46 5

DISCUSSION

1)The BOP(+) considered to be one clinical sign of relapse during periodontal maintanence therapy, thereforerecording BOP in daily clinical practice has been recognized as most effective diagnostic tool.

2)Lang et al. Reported that when all results of examinations were conducted 4 times per year were BOP(-)with attachment loss not more than 2mm in 98% sites. However inspite of BOP(-) attachment loss may stilloccur in small number of sites. Therefore this study aimed to improve diagnostic accuracy by implementing Hb examination before recording BOP.

3)Hb measurment in GCF was added as an inspection item because:a)In previous study diagnosis based on BOP was inadequate because both (BOP- and BOP+ were found.b)BOP indicates presence of bleeding after probing based on visual judgement and minute bleeding can beoverlooked.

c)it is not possible to know the presence or absence of occult bleeding caused by periodontitis with BOP inspection

DISCUSSION

4)Hb was detected in 90.2% of GCF samples in pockets judged as BOP(+), but was observed also in 88.7%

GCF of BOP(-) pockets. There results suggest that the periodontal disease activity cannot be predicted only by BOP inspection.

5)In this study, these Hb(+) group in BOP(-) sites means that the Hb is detected in periodontal pockets ofBOP(-) by Hb inspection prior to the BOP inspection. The result of these examinations indicate that the initial periodontal tissue damage that cannot be detected by the BOP test had already occurred.

6)The present result is in agreement with previous reports that significant activities of inflammatory parameters such as neutrophil elastase andor AST activity are detected in many GCF samples judged as

BOP(-)

DISCUSSION7)Page at el. Observed that clinical discrimination between healthy and periodontically diseased conditions

in the early stage is difficult. Therefore we believe that implementation of Hb examination may improve thevalidity of periodontal disease diagnosis and serve as a diagnostic strategy before the onset of periodontitis

CONCLUSION

1)In this study Hb was obeserved in more than 60% GCF samples in BOP(-) sulci in periodontalstable group and in more than 85% GCF samples in BOP(-) sulci in periodontal managementrequired group.

2)These results suggest that simple and easy examination of Hb derived from micro bleeding in the gingival sulci along conventional parameters of PD and BOP may serve as an index for accurateperiodontal diagnosis

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