A clinical study of serum alkaline phosphatase and calcium level in type 2 diabetes mellitus with periodontitis among the south Indian population

DS Pushpa Rani; S Nirmala Anandan

doi:10.4103/0976-433X.107396

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ORIGINAL ARTICLE

Year : 2012 | Volume : 3 | Issue : 3 | Page : 175-179

A clinical study of serum alkaline phosphatase and calcium level in type 2 diabetes mellitus with periodontitis among the south Indian population

DS Pushpa Rani, S Nirmala Anandan
Department of Biochemistry, SRM Dental College, Ramapuram, Chennai, India

Date of Web Publication

19-Feb-2013

Correspondence Address:
D S Pushpa Rani
Department of Biochemistry, SRM Dental College, Ramapuram, Chennai 600 089. Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0976-433X.107396

Abstract

Aim: To evaluate the association of serum alkaline phosphatase (ALP) and calcium level in type 2 diabetes mellitus with periodontitis. Materials and Methods: In this study, a total of 240 subjects, aged 34-42 years were selected and was divided into four groups as 60 healthy individuals (group A), 60 type 2 diabetes mellitus without periodontitis (group B), 60 type 2 diabetes mellitus with periodontitis (group C), and 60 non-diabetes mellitus with periodontitis (group D). Blood samples were collected after an overnight fast for the estimation of serum glucose, ALP, and calcium using glucose oxidase-peroxidase (GOD-POD), p-Nitrophenyl Phosphate (p-NPP), and o-Cresolphthalein Complexone (OCPC) methods, respectively. Results: The concentration of serum ALP and calcium showed a significant increase ( P < 0.0001) in type 2 diabetes mellitus patients with periodontitis (group C) when compared to control. Conclusion: Increased serum ALP and calcium level could be often associated with the alveolar bone loss and tooth loss in type 2 diabetes mellitus with periodontitis among the South Indian population.

Keywords: Alkaline phosphatase, alveolar bone loss, calcium, periodontitis, type 2 diabetes mellitus

How to cite this article:
Pushpa Rani D S, Anandan S N. A clinical study of serum alkaline phosphatase and calcium level in type 2 diabetes mellitus with periodontitis among the south Indian population . SRM J Res Dent Sci 2012;3:175-9

How to cite this URL:
Pushpa Rani D S, Anandan S N. A clinical study of serum alkaline phosphatase and calcium level in type 2 diabetes mellitus with periodontitis among the south Indian population . SRM J Res Dent Sci [serial online] 2012 [cited 2023 Mar 20];3:175-9. Available from: https://www.srmjrds.in/text.asp?2012/3/3/175/107396

Introduction

Periodontitis is a common, inherited disorder of the adjacent and underneath tissues of the teeth, characterized by bleeding, swollen gingival, loss of attachment, and resorption of alveolar bone. More severe or advanced form of periodontitis would lead to the cause of tooth loss in adults. Although the exact relationship between diabetes mellitus and periodontitis still remains unclear, diabetes mellitus has long been considered a risk factor for the development of periodontal disease. ^{[1],[2],[3],[4],[5],[6],[7],[8]} Diabetes mellitus is a metabolic disorder of carbohydrate, protein and lipid metabolism that contributes to the development of many chronic conditions. The most common complications associated with diabetes mellitus are retinopathy, nephropathy, neuropathy, microvascular disease, and impaired wound healing. Periodontitis is expressed to be the sixth complication of diabetes. ^[9]

Alkaline phosphatase (ALP) (EC 3.1.3.1; Orthophosphoric monoester phosphohydrolase; ALP) comprise a group of enzymes that catalyze the alkaline hydrolysis of phosphoric acid from monophosphoric esters, generating an organic radical and inorganic phosphate. ^[10] For the most part, ALP is present in all tissues and especially found to be secreted in the cells of periodontium, including osteoblasts, fibroblasts, and neutrophils. Its level is particularly seen elevated in liver, intestinal epithelium, kidney tubules, and placenta. ALP requires divalent ions like Mg ²⁺ , Co ²⁺ , and Mn ²⁺ for the activation and has Zn ²⁺ as its constituent metal ion. ALP physiologically increases during normal bone growth, while pathological increase is related to hepatobiliary disease and bone disease associated with increased osteoblastic activity. ^[11]

Calcium (Ca) is the fifth most abundant element next to oxygen, carbon, hydrogen, and nitrogen. It is an important element present in the bones and teeth, providing a structural function. ^[12] It is an intracellular "second messengers" affecting enzyme activity and secretion of many hormones including insulin, aldosterone, vasopressin, and rennin. It is crucial for the maintenance of cell metabolism, nerve transmission, and muscle contraction. ^[13] In addition, it plays many important roles in the synthesis, release, and receptor responsiveness to neurotransmitters. ^[14] In this current study, we evaluated the association of ALP and calcium levels in type 2 diabetes patients with and without periodontitis among the South Indian population.

Materials and Methods

Informed consent and ethical approval

The Institutional Scientific Ethical Committee approval was obtained before study set up from Medical and Health Sciences of SRM University, Kattankulathur, and an informed consent was taken from all the participants.

Recruitment of participants

The study group consisted of a total of 240 subjects which included 60 healthy individuals as control (group A), 60 type 2 diabetes mellitus without periodontitis (group B), 60 type 2 diabetes mellitus with periodontitis (group C), and non-diabetes mellitus with periodontitis (group D). Patients were randomly selected from a large group of persons attending diabetes outpatient clinics of SRM specialty hospital. The classification and diagnosis of diabetes ^{[15],[16],[17]} used in this study were made based on the guidelines with recommendations made by expert committee. Type 2 diabetes patients with periodontitis and non-diabetic patients with periodontitis were selected from the outpatients attending Department of Periodontology and Oral Implantology, SRM Dental College, Ramapuram, India. The study included both male and female patients of type 2 diabetes mellitus with or without periodontitis. The mean age of diabetic patients without periodontitis and with periodontitis were 40.81 ± 6.95 and 40.45 ± 6.64, respectively. The average duration of diabetes was found to be 6.9 years. Sixty healthy subjects, non-diabetics, sex and age matched to patients were integrated as the control group. These control subjects were selected from the same geographical zone. The health status of controls was confirmed particularly by primary ascertainment of clinical condition. Type 2 diabetes mellitus patients were all on oral hypoglycemic therapy and without any infections for at least 3 months before the study. Smokers, alcoholics, and drug-abused patients who had periodontal therapy 6 months prior to the study, patients under antibiotics and having systemic disease other than diabetics were excluded from the study. The healthy controls were not on any kind of prescribed medication or dietary restrictions.

Clinical assessment of subjects

All participants completed a questionnaire approved for the study. Each participant, after granting his or her informed consent, was given a full physical examination by a physician. The clinical history of each patient disease condition and treatment history as well as demographic data were also recorded.

Clinical assessment of periodontitis

The clinical assessment included examination of gingiva, intraoral examination- number of teeth present and missing, pathological migration, Debris index, Calculus index, Russels periodontal index, and plaque index. The mean probing depth of ≥4 mm and clinical attachment loss of ≥3 mm were included in the periodontitis group. The periodontal status was examined by a trained Periodontist of SRM Dental College, Department of Periodontology, Chennai, India.

Biochemical analysis

Two milliliters of fasting venous whole blood sample was collected and centrifuged at 1500 rpm for 10 minutes. The serum obtained was used for the estimation of calcium (Ca) and ALP. Ca was measured in a photo digital colorimeter using the reagent kits from Crest Biosystems, India. ALP was determined in a UV spectrophotometer (ELICO) with PNPP (p-nitro phenyl phosphate) kinetic method using the commercial assay kits purchased from Beacon Diagnostics Pvt. Ltd, Navsari, India.

Statistics

The data are presented as mean ± SD (standard deviation) and Pearson's correlation was used to test the relationship between variables. Analysis of variance (ANOVA) was used to compare multiple means. Data analysis was performed with the statistical package and the level of significance was considered to be statistically significant at P value <0.05.

Results

Alkaline phosphatase and calcium levels in diabetes mellitus with and without periodontitis

The findings in this study were based on the South Indian population. [Table 1] shows that the mean ALP was significantly higher in type 2 diabetes mellitus without periodontitis (group B) and type 2 diabetes mellitus with periodontitis (group C), P < 0.0001 when compared to control. The ALP level of non-diabetic patients with periodontitis (group D), showed no significant difference when compared with the control. As regards calcium, there were significant increases in serum Ca level among the type 2 diabetes mellitus with periodontitis and non-diabetes mellitus with periodontitis patients (P < 0.0001). However, in the case of type 2 diabetes mellitus without periodontitis, the serum Ca levels were decreased non-significantly.

Table 1: Serum concentration of alkaline phosphatase and calcium in the control healthy individuals (group A); Type 2 diabetes mellitus without periodontitis (group B); Type 2 diabetes mellitus with periodontitis (group C) and non-diabetic periodontitis patients (group D)

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Pearson correlation for serum calcium and ALP

[Table 2], represents the Pearson Correlation data between serum calcium and ALP level for all four groups. Calcium of control group A subjects correlates negatively with serum ALP of group A, group C, and group D and shows positive correlation with group B. However, calcium of type 2 diabetes without periodontitis (group B) shows positive correlation with serum ALP of group A, group C, and group D and negative correlation with group B. In patients of type 2 diabetes with periodontitis (group C), serum calcium was found to have negative correlation with serum ALP of group A and group C and positive correlation with group B and group D. Pearson Correlation of serum calcium with ALP for non-diabetic patients with periodontitis (group D) is similar to that observed in group C.

Table 2: Pearson correlation data for serum calcium with alkaline phosphatase in all the 4 groups

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[Figure 1] represents the mean fasting serum sugar level in all the 4 groups. Type 2 diabetes patients with periodontitis and without periodontitis showed a significant increased serum glucose levels, whereas in non-diabetes mellitus with periodontitis patients, no significant differences was found when compared to control.

Figure 1: Fasting serum sugar levels in type 2 diabetes mellitus without periodontitis (Group B), type 2 diabetes mellitus with periodontitis (Group C), non - diabetic periodontitis (Group D) vs. healthy controls (Group A), *** P<0.0001 Extremely significant; NS, nonsignificant

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[Figure 2] and [Figure 3] show the comparison of serum calcium and ALP levels in all the 4 groups.

Figure 2: Comparison of serum calcium levels in all 4 groups, Group A: Control healthy individuals; Group B: Type 2 diabetes mellitus without periodontitis; Group C: Type 2 diabetes mellitus with periodontitis; Group D: Non - diabetic periodontitis patients

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Figure 3: Comparison of serum alkaline phosphatase levels in all 4 groups, Group A: Control healthy individuals; Group B: Type 2 diabetic patients without periodontitis; Group C: Type 2 diabetics patients with periodontitis; Group D: Non - diabetic periodontitis patients

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Discussion

It is well established that inadequate management and or control of hyperglycemia predisposes diabetic patients to a number of complications. The aim of our study is to compare the serum ALP and calcium levels among the type 2 diabetes patients with and without periodontitis. The duration of diabetes is known to be related to the development of complications. ^[18] However, in this study, no such association was found. Although periodontitis is a potential complication of diabetes, emerging evidence suggests that treatment of periodontal infections in diabetics could improve glycemic control. Patients with controlled diabetes had no more periodontal destruction than healthy controls and increased periodontal destruction was found in diabetic patients. ^[19],[20] Our results are in agreement with the earlier reports showing no significant differences in the periodontal health status between serum ALP level of diabetic group without periodontitis and the control group [Table 1]. Simultaneously, with the worsening of the diabetes with periodontitis, serum ALP, calcium and frequency of pockets seem to increase. On the contrary, some investigators have found increased periodontal destruction in diabetic patients. In some cases, drastic deterioration of periodontal conditions has even led to the diagnosis of diabetes mellitus. ^{[21],[22],[23],[24]} The results of this study show that increased serum Ca and ALP in type 2 diabetes mellitus with periodontitis may be linked to alveolar bone loss. We observed a clear progressive increase in serum Ca and ALP level among type 2 diabetes mellitus with periodontitis (group C) compared to type 2 diabetes mellitus without periodontitis (group B) and nondiabetes with periodontitis patients (group D). However, serum ALP level was found to be nonsignificant among non-diabetic patients with periodontitis. This implies to the fact that type 2 diabetes mellitus with periodontitis (group C) are severely affected with alveolar bone loss and tooth loss when compared to patients having type 2 diabetes without periodontitis (group B) and nondiabetes mellitus with periodontitis (group D). Finally, it is of interest to note that very high serum Ca concentration in type 2 diabetes mellitus with periodontitis indicates a strong correlation found between the pocket depth and alveolar bone loss. Ca and insulin are important for the formation of bone collagen ^[25],[26] and depletion of Ca bone mineral content leads to alveolar bone loss, bone fractures, and tooth loss in periodontitis patients with and without diabetes.

The finding that human serum has more significant ALP activity among the type 2 diabetes mellitus with periodontitis indicates the probable origin of this enzyme from periodontal bone. ^[27] The increased ALP enzyme activity causes the release of phosphate ions, which in turn leads to more calculus formation and may worsen the condition of periodontitis in type 2 diabetes mellitus. This, in turn, results in increased alveolar bone loss, raising the serum Ca level. The most significant evidence revealed from this study is the involvement of bone metabolism in type 2 diabetes mellitus with periodontitis. There are many needs for additional research in periodontology, including the development of biomarkers of current and future disease activity.

Conclusions

Many theories have been advanced to explain the pathogenesis of diabetic complications, but, as until now, no one has provided a complete and satisfactory answer to this problem. The observation that a significant increased level of serum ALP and calcium in patients having type 2 diabetes mellitus with periodontitis could possibly explain more credible mechanistic justification on the role of diabetes in the pathogenesis of periodontal disease. The suggestion of the relationship between ALP and calcium in patients with type 2 diabetes mellitus and periodontitis provides a testable hypothesis that may offer novel insights into the pathogenesis of diabetic complications. We conclude that the significantly elevated level of serum ALP and calcium can serve as a biomarker to the rapid development of periodontitis in type 2 diabetes patients.

Acknowledgments

The authors are indebted to the Management, Dr. K. Ravi, M.D.S. (Dean), Dr. K. Rajkumar M.D.S., (Vice-Principal) of SRM Dental College, Chennai, India, for providing us the laboratory facilities to carry out the experimental work. The authors like to thank Dr. P. Theagarayan M.D.S., Professor, Department of Periodontology and Oral Implantology, SRM Dental College, for his help and valuable comments in assessing the periodontal status of the patients.

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