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Comparative Evaluation of Serum High Sensitivity C
Comparative Evaluation of Serum High Sensitivity C
KEY WORDS
From the *Post Graduate Institute of Apical periodontitis; hemogram; high-sensitivity C-reactive protein; neutrophil-lymphocyte
Dental Sciences, Rohtak, Haryana, India; ratio; periapical healing; root canal treatment
and †Post Graduate Institute of Medical
Sciences, Rohtak, Haryana, India
Apical periodontitis (AP) is localized inflammation of periradicular tissue around the tooth1, which is usually
Address requests for reprints to Dr Sanjay
Tewari, Post Graduate Institute of Dental caused by a microbial infection of the dental pulp2. Contrary to its localized nature, there is a growing
Sciences, Rohtak, Haryana, India body of evidence suggesting that AP may contribute to the total inflammatory burden of the body3. The
124001. association of AP with altered metabolic control in diabetic patients4; endothelial dysfunction5;
E-mail address: tewarisanjayrohtak@ unfavorable pregnancy outcomes6; and increased levels of numerous systemic markers, including high-
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sensitivity C-reactive protein (hsCRP)7,8, interleukin (IL)-69, and tumor necrosis factor a10 has been
reported. However, there is a paucity of prospective studies on the topic. Root canal treatment is the
Copyright © 2022 American Association
of Endodontists.
treatment of choice for AP. It involves the elimination of the microbial community within the confines of the
https://doi.org/10.1016/ root canal and filling it with an inert material. The effect of root canal treatment on the systemic
j.joen.2022.05.003 inflammatory burden also remains unexplored so far, with very few studies reporting the effect of
JOE Volume 48, Number 8, August 2022 Serum hsCRP and CH Indices in Subjects with and without AP 1021
FIGURE 1 – The study flowchart.
the microplate. The standard and sample were enzyme-linked polyclonal antibody specific for incubation period, amplifier solution was
pipetted into wells, and the immobilized hsCRP was added to the wells after washing added to the wells, and the color developed in
antibody bound any marker present. An away any unbound substances. After an proportion to the amount of hsCRP bound in
JOE Volume 48, Number 8, August 2022 Serum hsCRP and CH Indices in Subjects with and without AP 1023
FIGURE 2 – (A and B ) Preoperative and (C and D ) 6-month follow-up radiographs showing periapical healing.
3.88 at baseline to 2.32 at follow-up, which the intermediate-risk category after an increase the change in PAI score and the change in
was statistically significant (P , .05). in hsCRP. hsCRP level in the AP group (P . .05) was
The risk factors for developing future None of the factors (age, sex, WBC observed.
cardiovascular events were categorized into count, platelet count, NLR, PLR, MPV, hsCRP,
no (,1 mg/L), intermediate (1–3 mg/L), and and PAI score at baseline) analyzed in the
high (.3 mg/L) risk based on the levels of binary logistic regression analysis had a
DISCUSSION
hsCRP (Table 4). In the control group, the significant effect on success. The linear The immune response in AP is mediated by
proportions of subjects categorized as no, regression results were nonsignificant with inflammatory markers that may also add to the
intermediate, and high risk were 56%, 24%, respect to independent variables on the levels overall inflammatory burden of the body,
and 20%, respectively. In the AP group, there of hsCRP at baseline and at follow-up in the AP leading to the development or progression of
were more patients in the high-risk (44%) group. A significant correlation between AP systemic conditions22. However, this
category than intermediate and no (28% each) and baseline hsCRP was observed (P , .05), association is observed mainly in a cross-
risk (Table 4). However, this difference was whereas a nonsignificant correlation was sectional study, which is limited by its nature in
nonsignificant (P . .05). At the 6-month follow- observed with the severity of AP (PAI score) establishing a cause-effect relation16 and
up after root canal treatment, 50% of patients and hsCRP as well as with NLR (P . .05). At temporality23. A prospective study in which
from both the high- (n 5 5) and intermediate- the 6-month follow-up in the AP group, the patients are followed before and after the
risk (n 5 3) categories lowered their correlation between hsCRP and PAI score/ endodontic intervention is required to satisfy
cardiovascular disease risk status. One patient healing was nonsignificant (P . .05). In Hill’s criteria of causation33. Therefore, this
from the low-risk category was reassigned to addition, a nonsignificant correlation between study was designed to assess the effect of AP
JOE Volume 48, Number 8, August 2022 Serum hsCRP and CH Indices in Subjects with and without AP 1025
reduction was more apparent in the high-risk numbers and severity of AP, except for the hsCRP were evaluated, leaving some other
group after root canal treatment. For the NLR value, which was significantly higher important markers of systemic inflammation
majority of patients, the risk status remains (2.46 6 1.34) in patients with at least 1 tooth such as oxidative stress unanalyzed. Also,
unchanged. The previous study also reported with a PAI score of 5 compared with controls because only a single tooth with AP was
an unchanged risk status after root canal without AP (1.85 6 0.80)8. Although NLR was included, the cumulative effect of multiple teeth
treatment in about one third of the total higher in patients with AP in the present study, with AP may be studied in future studies.
patients. However, root canal treatment led to it was within the reference range of 339. The Future research should also focus on the
the lowering of the hsCRP level in most different results of the present study can also assessment of the levels of different
patients (87%) to some extent in the present be explained by the inclusion of only 1 tooth inflammatory markers in patients with varied
study, highlighting the possible causal role of with varying severity of AP. systemic conditions and AP. Well-planned
endodontic infection in the overall inflammatory Although strict criteria for enrollment intervention studies are also required to
burden. A large-scale study may be required in minimized the chances of confounding results, establish a temporal relation between systemic
the future to corroborate these findings. values of hsCRP can be affected by a range of disease and AP. Furthermore, these findings
The CH indices were within the factors, such as insomnia, depression, suggest the inclusion of endodontic diagnosis
reference range in both groups. This is in nutritional deficiencies, and chronic parasitic and a treatment protocol for the management
contrast to the findings of previous studies that infections40, that are very difficult to control. of AP in cardiac patients to minimize the
have reported a significant difference in some However, an attempt was made to mitigate systemic inflammatory burden.
parameters. For example, in animal studies, a these effects by following strict eligibility criteria
significant difference in the leukocyte, for patient recruitment, meticulous selection of
neutrophil, and lymphocyte counts was matched controls, and limited methodological
ACKNOWLEDGMENTS
observed between rats with and without variations. The small sample size and relatively
AP24,28. However, in 1 study, the difference smaller follow-up period may be some of the The authors acknowledge the support of the
was only significant with rats having multiple drawbacks of this study. Also, the inclusion of Multi-disciplinary Research Unit, Post
teeth with AP and not with rats having a single hospital-based controls may be a source of Graduate Institute of Medical Sciences,
AP28. In a case-control study, all blood selection bias because they may have Rohtak. Haryana, India.
parameters were similar across groups, underlying diseases or conditions unrelated to The authors deny any conflicts of
including controls and patients with varied AP. Furthermore, only CH parameters and interest related to this study.
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