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2. disease
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Research
Article
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J Res Adv Dent 2013; 2:1:20-30
Evaluation of Association Between Periodontitis and Prostate
Specific Antigen Levels in Chronic Prostatitis Patients
Chakrapani Swarna1 Vijay Prasad Koganti2* Ramanarayana Boyapati3 Kishore K. Katuri4 DN.
Swamy5 D. Ravindranath6
ABSTRACT
Back ground: Prostate specific antigen (PSA) is the most important of all tumor markers in men with prostatic
disease. In the presence of inflammation or malignancy, PSA levels are raised to ≥4 ng/ml. This study was
conducted to evaluate an association between periodontitis and PSA levels in chronic prostatitis patients.
Materials and methods: A total of 47 chronic prostatitis patients with periodontal disease were divided into
four groups based on the type of prostatitis and clinical attachment level. The four groups were group 1A (CAL <
2.7 mm and mild prostatitis), group 2A (CAL ≥ 2.7 mm and mild prostatitis), group 1B (CAL < 2.7 mm and
moderate/severe prostatitis), group 2B (CAL ≥ 2.7 mm and moderate/severe prostatitis). PSA values were
calculated and correlation with periodontal parameters was done.
Results: The mean gingival and plaque index scores in group 1B and group 2B were significantly higher than
group 1A and group 2A (p< 0.05). Pocket depth, clinical attachment level and the mean PSA values in group 2B
were higher when compared with other groups. Subjects with CAL≥2.7 mm had higher mean PSA values
(16.27±25.96 ng/ml) than those with CAL≤2.7 mm (2.24± 1.51mm), which is significant (p< 0.05) suggesting a
positive correlation between PSA and CAL.
Conclusion: In cases where CAL≥2.7 mm and moderate/severe prostatitis there are higher PSA values than
those with either condition alone.
Keywords: Periodontitis, Prostatitis, Prostate specific antigen levels.
INTRODUCTION
Prostatitis is a condition that involves
inflammation of the prostate gland, which is
especially seen among men younger than 50 years,
with a variety of complaints referring to the lower
urogenital tract and perineum.1,2
Symptoms of
Prostatitis include pain during urination, difficulty
in emptying the bladder completely, urinary
frequency and pain in penis, testicles, pelvic area
and during or after ejaculation.3 Prostate specific
antigen is a 33kDa serine protease enzyme, which is
a biological marker or a tumor marker, synthesized
primarily by the epithelial cells that line the acini
and ducts of the prostate gland.4 The major function
of PSA is to liquefy the gel proteins (seminogelin I
and II and fibronectin) in the semen and help in the
lyses of seminal clots for the release of motile sperm
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eISSN 3898-6473
needed for fertilization.5 A normal level of PSA in
the circulation is 4ng/ml, but the disruption of the
prostatic architecture, by inflammation or
malignancy, causes the increased serum PSA levels.6
Gram- negative bacteria like Escherichia
coli and Klebsiella spp, have been implicated in the
etiology of prostatic infection.7 There is
substantiating evidence to support the role of the
immune system in the pathogenesis of prostatitis,
which is likely to be mediated through proinflammatory cytokines, such as interleukin -1β (IL1β) and tumor necrosis factor- (TNF – ). 8, 9
Study was approved by Institutional ethical
committee. A total of 47 prostatitis patients with
periodontal disease were included in the study
based on the above criteria. After obtaining the
patients consent, periodontal examination was
performed.
The periodontal parameters assessed are:
Gram-negative
bacteria
have
been
suggested as etiologic agents for periodontitis and
category I and II prostatitis.10 Cytokine imbalance
towards increased pro-inflammatory and decreased
anti-inflammatory cytokines has been implicated in
the pathogenesis of both periodontitis and
prostatitis.11
Given
the
similarity
in
etiopathogenesis of prostatitis and periodontitis, it
is possible that an association between the two
conditions exists which may manifest elevated PSA
levels in the circulating blood7. The prostatespecific antigen (PSA) test is routinely used as a
screening tool in the diagnosis of prostate cancer.
The purpose of this study is to evaluate any
association between periodontitis and PSA levels in
chronic prostatitis patients.
1) Probing depth (PD) and clinical attachment level
(CAL) at six sites per tooth using UNC-15 Probe.
2) Gingival Index (Silness and Loe 1963).
3) Plaque Index (Loe and Silness 1967). 12
4) Percentage of sites with bleeding on probing
(Ainamo and Bay Bleeding index 1975).
Methodology: Patients are divided into four
groups based on type of prostatitis and clinical
attachment level. The groups are: Group 1A - CAL <
2.7 with mild prostatitis, Group 2A - CAL≥ 2.7 with
mild prostatitis, Group 1B - CAL < 2.7 with
moderate or severe prostatitis and Group 2B is CAL
≥ 2.7 mm with moderate or severe prostatitis. 5 ml
of intra venous blood sample was collected from
each patient and the blood sample was sent for
estimation of serum PSA levels to the laboratory.
Prostate needle biopsy of the Prostate gland had
been taken and sent for histological sectioning. 13
Among these, 32 patients were non-malignant and
15 were malignant.
MATERIALS & METHODS
RESULTS
Study design: Patients attending the
department of Urology, Government General
Hospital, Guntur, who complained of lower urinary
tract infections and diagnosed as Prostatitis with
chronic periodontitis were examined.
Among 47 patients, 16 patients were with
mild prostatitis (34.05%) and 31 patients were with
severe prostatitis (65.95 %), 15 patients were
malignant (31%). The clinical attachment level
among these patients ≤ 2.7 was seen in 10 patients
(21.3%) and ≥2.7 was in 37 patients (78.7%) (Table
1 and Graph 1). A significant difference was
observed between mild and moderate and severe
types of prostatitis in relation to status of
malignancy (Chi square=9.2533, p<0.05) (Table 2
and Graph 2). The mean gingival index score and
plaque index scores in group 1A was 1.63±1.27 and
1.59±1.23, in group 1B was 1.40±0.50 and
1.56±0.69, in group 2A was 1.37±0.47 and
1.35±0.42 and in group 2B was 1.89±0.53 and
1.83±0.49 respectively. A significant difference
(p<0.05) was observed between the groups IA and
2B (Table 3 and Graph 3).
Inclusion criteria:
1. Patients aged 21 years or above
2. Prostate needle biopsy performed within the last
6 months or with elevated serum PSA levels ≥4
ng/ml
3. Patients with ≥12 teeth present
4. Patients who had not undergone oral prophylaxis
in the last six months were recruited into the study.
Exclusion criteria:
1. Age <21years
2. Periodontal treatment within the last 3 months
3. History of other systemic diseases
21
22
23
The mean bleeding index score in group 1A
was 0.80±0.31, in group 1B it was 1.00 and in 2A
group was 0.97±0.006 and 2B group it was 1.0
respectively. When compared with other groups,
the subjects in group 2B had significant higher
percentage of bleeding on probing (p<0.05) (Table
4 and Graph 4). Subjects in group 2B had
significantly higher (p<0.05) CAL and probing depth
scores 5.69±1.34mm and 3.76±0.96mm respectively
when compared with group 1A (1.90±0.61mm and
3.26±0.55mm) group 1B (2.28±0.03mm and
3.72±0.01mm) and group 2A (3.61±0.87mm and
3.49±0.71mm) (Table 5 and Graph 5).
24
16
18.00
15
16
16.00
Number
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0
0.00
Mild
Moderate/severe
Malignant
No malignant
25
2.25
1.9
Mean value
2.00
1.75
1.8
1.6
1.6
1.6
1.4
1.4
1.4
1.50
1.25
1.00
0.75
0.50
0.25
0.00
Group 1A
Group 1B
Group 2A
GI scores
Group 2B
PI scores
1.25
1.0
1.0
1.0
Mean value
1.00
0.8
0.75
0.50
0.3
0.25
0.1
0.0
0.0
0.00
Group 1A
Group 1B
Mean PSA
Group 2A
Group 2B
Std.Dev. PSA
26
7.00
5.7
Mean value
6.00
5.00
3.7
4.00
3.3
3.00
3.6
3.8
3.5
2.3
1.9
2.00
1.00
0.00
Group 1A
Group 1B
CAL scores
Group 2A
Group 2B
PD scores
25.00
Mean value
19.5
20.00
15.00
10.00
4.2
5.00
4.7
1.8
0.00
Group 1A
Group 1B
Group 2A
Group 2B
27
18.5
20.00
18.00
Mean value
16.00
14.00
12.00
10.00
8.00
3.2
6.00
4.00
2.00
0.00
Mild
The PSA levels were higher in subjects with CAL
≥2.7mm than those with CAL≤2.7mm. The PSA level
in group 1A was 1.75±1.24ng/ml, in group 1B it was
4.23±0.32ng/ml, in group 2A it was 4.73±1.53ng/ml
and in group 2B it was 19.46±28.60ng/ml
respectively. No statistically significant (F=1.8265,
p>0.05) difference in PSA levels was observed in
between the groups (Table 6 and Graph 6). Subjects
with moderate or severe prostatitis had
significantly higher (t=-2.1715, p<0.05) PSA levels
(18.47±27.88ng/ml) than those with none or mild
prostatitis (3.23±2.04ng/ml) (Table 7 and Graph 7).
Moderate/severe
and the extent and aggressiveness of prostate
inflammation in biopsy specimens.14,7
DISCUSSION
Hasui et al and Irani et al also supported
the same finding and attributed that increased
serum PSA is due to disruption of epithelial
integrity of the prostate gland. 6,15 Kuzner et al
found less PSA staining in inflamed areas than in
non-inflamed areas and concluded that increased
PSA levels in prostatitis patients was caused
because of inflammatory response which disrupts
glandular epithelium and causes leakage of PSA into
blood stream not because of glandular hyperactivity
or hyperplasia.16
Prostate-specific
antigen
has
been
extensively studied and widely used in monitoring
the growth of prostatic malignancies (Oesterling,
1991).
Prostate-specific
antigen
(PSA)
concentration levels have become an essential tool
in the diagnosis of early, curable prostate cancer.
Morote et al showed that serum PSA levels
were directly related to the prostate volume and not
the extent or type of inflammatory infiltrate and
stated that there might be another non-prostatitic
source of PSA such as periodontium which is
responsible in the increasing serum PSA levels.17
The higher PSA levels are found in patients
with moderate/severe compared to no/mild
prostatitis in agreement with previous study by
Kandirali et al and Joshi et al, who reported a
positive correlation between the serum PSA levels
In our study, a higher PSA values are seen
in patients with CAL≥2.7 mm compared to CAL<2.7
mm. A positive correlation was observed between
periodontal parameters with elevated PSA levels
stating that all the individual periodontal
28
parameters were significantly increased with
increase in PSA levels. This is in contrast with the
earlier study conducted by Nishant Joshi et al7.
However bleeding index scores were not significant
among the groups.
When the Probing depth and clinical
attachment level were compared, all the four study
groups showed a direct relationship with Prostate
Specific Antigen levels.
Although
the
relationship
between
periodontitis and prostatitis are yet to be proved
but there is substantial evidence that supports the
role of the immune system in the pathogenesis of
both prostatitis and periodontitis, which is mainly
mediated through pro-inflammatory cytokines such
as interleukin (IL)- 1β and tumor necrosis factor-α
(TNF-α). Current evidence suggests that periodontal
disease contributes to the increased levels of
various pro-inflammatory cytokines and other acute
phase proteins which regulate inflammatory
response. Elevated levels of IL-1, TNF-α and IL-6 in
serum of men with prostatitis is well documented.18
Therefore, it is possible that periodontitis indirectly
contributes to the inflammation of prostate gland or
disruption of epithelium with increased production
of inflammatory cytokines.
The present study was done on small
sample size and cross-sectional in nature which will
not give us cause and effect relationship. So, a large
sample size with long term evaluation with the
assessment of other risk factors will determine the
level of relationship between PSA levels and
periodontitis. Change in the PSA levels and prostate
volume were not evaluated in this study. Therefore,
PSA density (PSA value divided by prostate volume)
assessment gives more accurate values considering
the variations in the size of prostate gland
enlargement. Further studies should emphasize
more on the relationship of periodontitis with
prostatitis considering all the inflammatory
markers for further association.
CONCLUSION:
With the increasing severity of prostatitis
and periodontitis, the Prostate Specific Antigen
levels are also increasing, showing that in subjects
where there is CAL≥2.7 mm and moderate/severe
prostatitis, there are higher PSA values than those
with either condition alone.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this
article was reported.
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