78th Publication- JPBS- 3rd Name.pdf

S1275
© 2021 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow
Background: Periodontitis is a chronic inflammatory disease with conglomerate
etiology making it difficult to diagnose at the early stages. Potential biomarkers
in gingival crevicular fluid (GCF) would determine the presence of the current
disease activity, predict sites vulnerable for future breakdown, and assess the
response to periodontal interventions. Merely elevated levels of inflammatory
soft‑tissue markers do not indicate bone destruction. Since there is no single
ideal biomarker established, bone‑related biomarkers such as telopeptide of
type I collagen, osteocalcin, calprotectin, osteopontin, and tartrate‑resistant
acid phosphatase (TRAP) seem to hold great promise as predictive markers to
determine bone destruction and active phases in the disease progression. The
present study is intended to explore the biologic plausibility of the levels of
TRAP in health and chronic periodontitis. Materials and Methods: The present
cross‑sectional clinico‑biochemical study comprised 30 systemically healthy
subjects with 15 periodontally healthy and 15 chronic periodontitis subjects who
were age and gender matched. GCF and blood samples were collected from all the
patients. TRAP estimation was done in both the samples using an enzyme‑linked
immunosorbent assay kit. The data were analyzed using independent t‑test
and Pearson correlation test. Results: Serum and GCF TRAP levels in chronic
periodontitis subjects were significantly higher when compared to the periodontally
healthy group. There were no significant correlations found among serum and
GCF TRAP levels with increasing age and gender in both the groups. An increase
in disease severity, i.e., increase in probing pocket depth and clinical attachment
level, did not show correlation with the GCF and serum TRAP levels in the
chronic periodontitis group. Conclusion: Based on the findings of the present
study, increased GCF TRAP levels in chronic periodontitis seem to be a potential
marker for identifying ongoing periodontal destruction.
Keywords: Gingival crevicular fluid, Periodontitis, tartrate‑resistant acid
phosphatase
Evaluation of Gingival Crevicular Fluid and Serum Tartrate‑resistant
Acid Phosphatase Levels in Subjects with Clinically Healthy
Periodontium and Chronic Periodontitis – A Clinico‑biochemical Study
Harshitha Baddam1
, Gopinath Vivekanandan2
, Kameswari Kondreddy3
, Swapna Peddi4
, Pranjal Praveen Chitnis5
, Yash Pal
Singh6
, Rahul V. C. Tiwar7
Access this article online
Quick Response Code:
Website: www.jpbsonline.org
DOI: 10.4103/jpbs.jpbs_90_21
Address for correspondence: Dr. Harshitha Baddam,
Department of Periodontics, Sri Sai College of Dental Surgery,
Vikarabad, Telangana, India.
E‑mail: baddamharshitha@gmail.com
Introduction
Periodontitis being a chronic inflammatory disease
has composite etiology which includes biofilm,
environmental, behavioral factors, and genetic attributes
of the host. In periodontitis, though bacteria are the
primary agents, the chemical mediators of inflammation
resulting from microbial thrust play a crucial role in
1
Department of Periodontics,
Sri Sai College of Dental
Surgery, Vikarabad,
Telangana, India,
2
Aditya Dental College and
Hospital, Beed, Maharashtra,
India, 3
Department of
Periodontics, Faculty
of Dentistry, AIMST
University, Bedong,
Malaysia, 4
Bachelor of
Dental Surgery, SVS Dental
College, Mahbubnagar,
Telangana, India,
5
Sri Siddhartha Dental
College, Tumkur, Karnataka,
India, 6
Department of
Restorative and Prosthetic
Dental Sciences, College
of Dentistry, Dar Al
Ulum University, Riyadh,
Saudi Arabia,
7
Department of OMFS,
Narsinbhai Patel Dental
College and Hospital,
Sankalchand Patel University,
Visnagar, Gujarat, India
Submitted: 19‑Feb‑2020
Revised: 20-Feb-2021
Accepted: 22‑Feb‑2021
Published: 10-Nov-2021
Abstract
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak,
and build upon the work non‑commercially, as long as the author is credited and the new
creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
How to cite this article: Baddam H, Vivekanandan G, Kondreddy K, Peddi S,
Chitnis PP, Singh YP, et al. Evaluation of gingival crevicular fluid and serum
tartrate‑resistant acid phosphatase levels in subjects with clinically healthy
periodontium and chronic periodontitis – A clinico‑biochemical study.
J Pharm Bioall Sci 2021;13:S1275-9.
Original Article
[Downloaded free from http://www.jpbsonline.org on Wednesday, November 10, 2021, IP: 49.204.225.73]

S1276 Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 2 ¦ August 2021
Baddam, et al.: GCF and STAP in Chronic Periodontitis
initiation and progression.[1]
If this is left untreated, there
would be continuous bone destruction causing tooth
mobility and loss.[2]
Chronic inflammation causes bone
resorption with cycles of remissions and progressions.[3]
Understanding the molecular basis of pathogenesis of
periodontitis helps in development of more efficient
diagnostic procedures by furnishing information
about the location and severity. These findings
furnish indispensable data for treatment planning,
maintenance, and prognosis.[4]
Recent advances in
research are incorporating methods to determine and
gauge periodontal risk by objective measures such as
biomarkers.[4]
Biomarkers play a prime role in diagnosis,
evaluating treatment outcome and drug discovery.
Molecules present in gingival crevicular fluid (GCF),
saliva, and in blood products like plasma or serum have
been explored in an endeavor to accord a marker both
specific and sensitive for the periodontal destruction.
Saliva and GCF are remarkably propitious as they carry
both locally and systemically derived products and can
be easily obtained from the patient.[5]
The inflammatory
stimulus/response which is triggered by the periodontal
pathogens can be evaluated in serum or plasma.[6]
The
estimation of the levels of inflammatory mediators in
the GCF is used to evaluate the “risk” for periodontal
disease.[7]
Tartrate‑resistant acid phosphatase (TRAP)
is an metallo‑phosphodiesterase which plays a part
in osteoclast‑mediated bone resorption. The TRAP
enzyme is expressed abundantly by bone‑resorbing
cells such as osteoclasts and few subpopulations of
macrophages/monocytes and dendritic cells.[8]
GCF
TRAP levels are probable indicators for the disease
activity and the progression of periodontitis. The present
study evaluates TRAP levels in serum and GCF of
healthy and chronic periodontitis subjects and explores
the biologic plausibility of considering TRAP as a
biomarker in periodontitis.
Materials and Methods
Fifty‑one patients were recruited from the Outpatient
Department of Periodontics, out of which 10 patients did
not satisfy the criteria and 11 patients dropped in between
and 30 patients finally completed the study. This is a
cross‑sectional study and patients were enrolled based
on the criteria using the convenience sampling method.
Ethical clearance was issued from the Institutional
Review Committee Board (SSCDS/2018/59).
Inclusion criteria
Group A (healthy group) consisted of 15 systemically
healthy subjects aged between 30 and 60 years
with healthy periodontium and absence of clinical
inflammation. Group B (chronic periodontitis group)
consisted of 15 systemically healthy subjects aged
between 30 and 60 years having a minimum of 14 teeth,
with severe chronic generalized periodontitis with
probing pocket depth (PPD) ≥6 mm in each quadrant.
Exclusion criteria
Exclusion criteria included subjects with known systemic
disease (diabetes, hypertension, etc.) and osteoporosis;
history of any recent infections; subjects consuming
alcohol, and smokers; pregnancy/lactation; subjects on
anti‑inflammatory medications and antibiotics in the
past 3 months; and history of any periodontal therapy
in the past 6 months prior to the study and aggressive
periodontitis. After recruitment, informed written consent
was procured from all the subjects. After a thorough
clinical examination, parameters were recorded in a
proforma which is specifically designed for the study.
Clinical parameters
Clinical parameters included plaque index (PI), bleeding
index, modified gingival index (MGI), PPD, and
clinical attachment level (CAL). Case history, clinical
parameters recording, and selection of sampling sites
were performed on the 1st
day. After 2 days, subsequent
appointments were preferred to collect the GCF and
blood samples to avoid contamination of GCF with
blood. In chronic periodontitis subjects, GCF samples
were procured from the site with the deepest PPD. In
the periodontally healthy group, pooled GCF samples
were procured due to their meager quantity in health.
Sample collection
Standardized volume of 3 µl GCF was collected with
calibrated microcapillary pipette€
by placing at the
gingival sulcus (un‑stimulated) for 5–20 min. In subjects
with healthy periodontium, pooled GCF samples were
gathered from multiple sites to attain minimum required
amount (3 µl). In chronic periodontitis, sample collection
involved less time as it could be easily obtained from the
sites with the deepest PPD. GCF samples were adulterated
with saliva or blood and air bubbles were disposed and
the other samples collected were wrapped in aluminum
foil. Serum is separated by centrifuging the blood samples
at 3000 rpm for 10 min, transferred to a vial, and both the
samples were stored at −80°C until they were processed.
GCF and serum TRAP levels were measured employing
a commercially available enzyme‑linked immunosorbent
assay (ELISA) Kit¥
. Phosphate buffer saline was used to
dilute GCF samples to a volume of 1 ml.
Statistical analysis
The data analysis was done using statistical analysis
software¶. Intergroup analysis for age, gender, MGI, PI,
PPD, CAL, serum, and GCF TRAP was done using the
Student’s independent t‑test. Correlation of serum and

S1277
Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 2 ¦ August 2021
GCF TRAP levels with age and gender was evaluated
in both Groups A and B and with clinical parameters,
namely MGI, PI, PPD, and CAL in Group B using
Pearson’s correlation coefficient test. P < 0.01 are noted
as statistically significant.
Results
The mean age of the subjects in Group A and in
Group B was 43.40 ± 6.54 and 43.13 ± 7.84 years,
respectively [Table 1]. There were 8 males (53.3%) and
7 females (46.7%) in both the groups [Table 1].
Clinical parameters
Gingival inflammation
Gingival status as assessed by MGI was 0.0 in the
Group A and 1.68 ± 0.41 in the Group B [Table 1].
Probing pocket depth
The mean PPD was 1.76 ± 0.59 mm in Group A and
6.72 ± 0.39 mm in Group B, respectively.
Clinical attachment level
Mean CAL was 0.00 mm in the Group A and 6.93 ± 0.35
mm in Group B respectively.
Tartrate‑resistant acid phosphatase concentration
In serum
The maximum TRAP levels in Group A subjects were
188.51 ng/ml and 566.29 ng/ml in Group B subjects.
The mean serum concentration was 107.714 ± 44.65
ng/ml in Group A and 430.48 ± 135.49 ng/ml in
Group B [Figure 1].
In gingival crevicular fluid
The mean concentration in Group A subjects was
2531.94 ± 344.84 ng/ml and 3483.46 ± 884.52 ng/ml in
Group B, while the maximum TRAP levels in healthy
subjects were 3096.05 ng/ml and 5481.5 ng/ml in the
diseased group [Figure 2]. Evaluation of the correlation
between GCF and serum TRAP concentration with age
and gender along with clinical parameters, i.e., mean
PPD, mean CAL, MGI, and PI, was done by Pearson
correlation coefficient test. No significant correlation
was found among serum and GCF TRAP levels with
gender and increasing age in both the groups [Table 2]
and with the overall mean PPD and CAL in the chronic
periodontitis group [Table 3].
Discussion
In periodontitis, there is documented evidence stating
that inflammation also affects the immune system besides
causing resorption of alveolar bone.[9]
Since GCF is
closely approximated with periodontal tissues where the
disease process initiates, it seems to provide a hot tip
than other biological fluids. Several components of GCF
such as inflammatory mediators, enzymes, inhibitors,
modifiers, and disintegrating products reflect the course
and predictability of the disease progression and their
qualitative changes could have diagnostic and therapeutic
significance. Since there is no single nonpareil biomarker
established, bone biomarkers such as telopeptide of type
I collagen (ICTP), calprotectin, osteocalcin, osteopontin,
and TRAP seem to hold great promise as predictive
markers to determine bone destruction and active phases
in the disease progression. TRAP is induced by osteoclasts
in ample amounts.[8]
Studies reported a positive association
between TRAP in rheumatoid arthritis and osteodystrophy
in primary hyperparathyroidism patients.[10]
In dentistry,
numerous immunohistochemical and assay studies have
been done to evaluate the correlation of TRAP with bone
resorption and were concluded that TRAP enzyme can
be a useful biomarker of bone resorption in endodontic
lesions[11]
and bone remodeling in orthodontic tooth
Table 1: Intergroup comparison of clinical parameters
and tartrate‑resistant acid phosphatase concentration in
gingival crevicular fluid and serum
Group (mean±SD) P
A B
Age (years) 43.40±6.54 43.13±7.84 0.92 (NS)
Sex (%)
Female 46.7 46.7 ‑
Male 53.3 53.3 ‑
Overall PPD (mm) 1.76±0.59 6.72±0.39 <0.001 (S)
Overall CAL (mm) 0.00±0.00 6.93±0.35 ‑
MGI 0.00±0.00 1.68±0.41 ‑
PI 0.22±0.08 2.07±0.26 <0.001 (S)
Serum TRAP (ng/ml) 107.71±44.65 430.48±135.49
Minimum 35.92 148.1 <0.001 (S)
Maximum 188.51 566.29
GCF TRAP (ng/ml) 2531.94±344.84 3483.46±884.52
Minimum 2040.6 2251.5 0.001 (S)
Maximum 3096.05 5481.5
NS: Nonsignificant, S: Significant P≤0.05, SD: Standard
deviation, PPD: Probing pocket depth, CAL: Clinical attachment
level, MGI: Modified gingival index, PI: Plaque index, TRAP:
Tartrate‑resistant acid phosphatase, GCF: Gingival crevicular fluid
Figure 1: Intergroup comparison of subject‑wise tartrate‑resistant acid
phosphatase concentration in serum

S1278 Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 2 ¦ August 2021
is presumed to be the first to evaluate the values of
TRAP both in GCF and serum in healthy subjects and
periodontitis. A sensitive sandwich ELISA commercially
available kit is used to quantify and detect TRAP in the
samples. The mean GCF concentration of TRAP levels
was significantly elevated in chronic periodontitis subjects
in comparison to the periodontally healthy group and did
not correlate with the disease severity, measured by PPD
and CAL, both in serum and GCF and this is in accordance
with other studies that estimated different bone markers
such as TRAP, ICTP, and osteopontin.[14,15]
The increase
in TRAP levels can be attributed to the increase in
osteoclast activity which indicates the active periodontal
destruction. Contrary to this, Sharma and Pradeep
reported that the levels of osteopontin, a noncollagenous
protein, were proportionately higher in periodontitis and
correlated with an increase in PPD and CAL.[16]
The mean
serum concentration of TRAP was remarkably increased
in chronic periodontitis subjects in comparison to the
periodontally healthy group and no significant correlation
with age and gender was found in serum and GCF in both
the groups and this is in harmony with the findings of
Cheung et al. in an immunoassay study.[17]
Several studies
published the elevated levels of inflammatory mediators,
connective tissue breakdown products, and host‑derived
enzymes such as MMP 8 ,9 , and 13, etc., in serum of
chronic periodontitis subjects.[18,19]
Existing paradigms
have supported the elevated levels of these markers and
suggested their possible role in a periosystemic link
and thereby substantiate the element of evaluating these
markers in serum.[20,21]
Conclusion
Serum and GCF TRAP levels were markedly elevated
in the periodontitis group in comparison to the healthy
group. No significant correlations were found among
GCF and serum TRAP levels with gender and increase
in age in both the groups. The GCF and serum TRAP
levels did not correlate with the disease severity,
measured by an increase in PPD and CAL in the chronic
periodontitis group.
Table 2: Correlations between serum and gingival
crevicular fluid tartrate‑resistant acid phosphatase
concentration with age and gender in the Groups A and
B using Pearson correlation
With age
Group (age) Serum TRAP GCF TRAP
A
Pearson correlation −0.220 −0.046
P 0.431 (NS) 0.870 (NS)
B
Pearson correlation −0.184 0.065
P 0.512 (NS) 0.819 (NS)
With gender
Group Sex (mean±SD) P
Female Male
A
Serum TRAP 102.75±53.17 112.06±38.96 0.702 (NS)
GCF TRAP 2517.91±329.46 2544.22±380.02 0.889 (NS)
B
Serum TRAP 410.78±142.17 447.72±136.60 0.617 (NS)
GCF TRAP 3563.99±871.43 3412.99±949.57 0.755 (NS)
NS: Nonsignificant, SD: Standard deviation, TRAP:
Tartrate‑resistant acid phosphatase, GCF: Gingival crevicular fluid
movement.[12]
Increased activity of TRAP was evident
in ligature‑induced periodontitis through histochemical
studies.[13]
Gursoy et al. inferred the increased TRAP
levels in saliva of periodontitis patients.[14]
This study
Figure 2: Intergroup comparison of subject‑wise tartrate‑resistant acid
phosphatase concentration in gingival crevicular fluid
Table 3: Correlation between serum and gingival crevicular fluid tartrate‑resistant acid phosphatase concentration
with clinical parameters of Group B using Pearson correlation
Mean PPD Mean CAL MGI PI
Serum TRAP
Pearson correlation −0.065 −0.110 0.084 −0.289
P 0.819 (NS) 0.696 (NS) 0.765 (NS) 0.296 (NS)
GCF TRAP
Pearson correlation −0.052 0.455 −0.240 −0.136
P 0.854 (NS) 0.089 (NS) 0.390 (NS) 0.629 (NS)
NS: Nonsignificant, TRAP: Tartrate‑resistant acid phosphatase, GCF: Gingival crevicular fluid, PPD: Probing pocket depth, CAL: Clinical
attachment level, MGI: Modified gingival index, PI: Plaque index

S1279
Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 2 ¦ August 2021
As it is difficult to diagnose a case of early periodontitis
in advanced gingivitis patients, potential biomarkers
would ascertain the status of disease activity, anticipate
sites pregnable for breakdown, and evaluate the
prognosis.[22]
On the basis of the present study, estimation
of GCF TRAP levels in chronic periodontitis seems to
be a plausible indicator of ongoing periodontal disease
progression. Further longitudinal studies are required
to assess the TRAP levels pre‑ and posttreatment
and correlate the levels with bleeding on probing to
ascertain both active and inactive sites and also estimate
the disease progression rate and also to gauge it as a
probable marker for periodontitis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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