Professional Documents
Culture Documents
277
278
Paraskevas et al.
Only articles in English were included (Moher et al. 2000). Papers without
abstracts whose title suggested that they
were related to the objectives of this
review were also selected so that the full
text could be screened. Data that were
published twice or more often were
selected only once. Reviews on CRP
levels were excluded after screening
for unpublished data. The search was
supplemented by reference checking.
Search strategy
CRP in periodontitiss
and/or means [ standard deviation(SD)] for hsCRP. When periodontitis patients were stratified by
severity categories, data from all severity groups were entered separately and
used in the analyses. Some studies
reported only median values (and range)
due to the non-normal data distribution.
Because meta-analysis of median values
was not possible, as a second step,
studies reporting means ( SD) were
processed for data extraction and metaanalyses. When not reported, or where it
was not clear whether data normalization had taken place it was assumed that
the means ( SD) in a given study were
rightfully used. All suitable data were
entered and analysed with RevMan 4.2.
(http://www.cc-ims.net/RevMan). Metaanalyses were conducted separately for
cross-sectional studies and longitudinal
(treatment) studies. For the latter, the
difference (D) baseline-end was calculated by means of the formula:
279
papers included
in meta-analyses (n=13)
(Tables 3C & D, figures 3A, B, 4 & 5)
Fig. 1. Flow-chart outlining the search strategy and results along the various steps.
Results
280
Paraskevas et al.
Table 1. Reviews used for screening of unpublished data and reference checking, in reversed
chronological order
Author(s)
Ioannidou et al. (2006)
Loos (2005)
Ebersole et al. (2002)
Beck & Offenbacher (2002)
Ebersole & Cappelli (2000)
Beck et al. (2000)
Greenwell (2000)
McCarty (1999)
Type of review
Systematic
Traditional
Traditional
Traditional
Traditional
Traditional
Traditional
Traditional
Results
No further new data retrieved
Provided means ( SD) for Loos et al. (2000)
No further new data retrieved
No further new data retrieved
No further new data retrieved
No further new data retrieved
No further new data retrieved
No further new data retrieved
patients and controls from the crosssectional and interventional studies, respectively. Tables 3C and D display the
included papers for the cross-sectional
and interventional studies, respectively,
reporting on mean values ( SD).
Quality assessment
Table 2. Studies (n 5 27) which were excluded from the review in reversed chronological order
and main reason(s) for rejection
Author(s)
Taylor et al. (2006)
Elter et al. (2006)
DAiuto et al. (2005a)
Bretz et al. (2005)
Persson et al. (2005)
Casecontrol
Casecontrol
Casecontrol
Casecontrol
Casecontrol
Casecontrol
(matched) Cases:
treated periodontal
patients with healthy
gingiva
Casecontrol
Casecontrol
Casecontrol
Havemose-Poulsen
et al. (2006)
Havemose-Poulsen
et al. (2006)
Salzberg et al.
(2006)
Salzberg et al.
(2006)
Yamazaki et al.
(2005)
Fredriksson et al.
(2003)
Fredriksson et al.
(1999)
40/43
53/43
2 (013)/0
(012)
1.30/0.90
1.45/0.90
1 (0.452.4)/0.6
(0.31.5)
15/15
54/43
0.317z/0.195
2.732 (0.073
14.04)/0.816
(0.03310.07)
1.115(0.024
14.13)/0.816
(0.03310.07)
3 (NR)/3 (NR)
5 (NR)/3 (NR)
CRP median
(mg/l) (range)
(P/C)
24/23
97/91
18/25
93/91
27/25
n (P/C)
Methodw
Diagnostic criterian/examiner
Given
Given
Given
Given
Given
Given
Given
Given
Medical
condition
52/51
42/42
42/42
51/53
41/44
23/31
31/31
20/25
32/25
Age
(mean)
(P/C)
NR
NR
NR
P, periodontitis; C, control; NR, not reported; LaP, localized aggressive periodontitis; GaP, generalized aggressive periodontitis; LP, localized periodontitis; GP, generalized periodontitis.
n
Diagnostics: PD, probing depth; RL, root length; AL, attachment loss.
w
Method: 1 5 nephelometric, 2 5 ELISA, 3 5 radial immunodiffusion assay, 4 5 immunoturbidimetric.
z
C-reactive protein (CRP) value for the P (periodontitis) group before periodontal treatment.
Study design
Author(s)
Table 3A. Included cross-sectional studies using median values (and range), in reversed chronological order, and study characteristics
CRP in periodontitiss
281
Given
48/46 range
3060
Diagnostics: PD, probing depth; RL, root length; AL, attachment loss.
Method: 1 5 nephelometric, 2 5 ELISA, 3 5 radial immunodiffusion assay, 4 5 immunoturbidimetric.
z
Values referring to the delayed treatment group.
For abbreviations see Table 3A.
IQR, inter-quartile range.
w
Prospective RCT
2 groups of
periodontitis
patients
Immediate versus
delayed treatment
Ide et al. (2003)
24/15
1
At least five sites with
PPD45 mm and radiographic
evidence of AL
unknown examiner
41/44
Given
0.397/0.195 (NR)
24/23
1
Casecontrol
Yamazaki et al.
(2005)
Non-surgical
periodontal
therapy,
periodontal
surgery
(antibiotics for 4
days)
Non-surgical
periodontal
therapy
0.317/0.261
(periodontitis
patients) (NR)
Medical
condition
n (P/C)
Methodw
Study design
Author(s)
Intervention
Diagnostics criterian/examiner
CRP median
(range) (mg/l)
before/after
treatment
Baseline CRP
median (mg/l)
P/C
Paraskevas et al.
Table 3B. Included treatment studies using median values and range in the presentation of results in reversed chronological order and study characteristics
282
Study design
Diagnosticsn/examiner, criteria
Bizzarro
Casecontrol Subgroup severe periodontitis radiographs
et al. (2007)
Severe Periodontitis (SeP): Patients with X7 teeth with X50%
bone loss
Periodontist
Bizzarro
Casecontrol Subgroup moderate periodontitis radiographs
et al. (2007)
Moderate periodontitis (MoP): patients with o7 teeth with
o50% bone loss
Periodontist
Havemose- Casecontrol GaP: interproximal attachment loss on at X3 permanent teeth
other than first molars and incisors and X10 of the sites showing
Poulsen et al.
(2006)
bleeding/suppuration on probing
Periodontist
HavemoseLaP: interproximal ALX2 permanent teeth, one of which was a
Poulsen et al.
first molar, and involving no more than two teeth other than first
(2006)
molars and incisors; confirmed circumpubertal disease onset and
at least one of the sites showing bleeding/suppuration on probing
Periodontist
Salzberg
Casecontrol Subgroup GaP: X5 mm on X8 teeth, X3 of which are not first
et al. (2006)
molars and Incisors; age of onset was under 35 years
Unknown examiner
Salzberg
Casecontrol Subgroup LaP: localized pattern of clinical AL limited to first
et al. (2006)
molar or incisor teeth and up to two additional teeth; age of onset
was under 30 years
Unknown examiner
Joshipura
Casecontrol Self-report
et al. (2004)
Author(s)
53/39
27/25
18/25
93/91
97/91
50/46
26/29
44/25
50/65
107/43
1
1
3
1
91/377 all
men 2.20 (2.25)/1.80 (3.00)
38/39
n (P/C)
Methodw
Given
Given
Given
Given
Given
Given
Given
Given
Given
Given
Given
Given
Medical
condition
Table 3C. Included cross-sectional studies reporting means ( SD), study characteristics and quality assessment, in reversed chronological order
NR
NR
NR
NR
41/42
68/54
39/30
42/41
NR
23/31
31/31
20/25
32/25
44/40
46/40
Age
(mean)
(P/C)
CRP in periodontitiss
283
Study design
Diagnosticsn/examiner, criteria
n (P/C)
17/17
Methodw
1
2.62 (2.90)/0.87 (1.73)
Study design/
duration.
Diagnosticsn/examiner, criteria
1.80/1.10
1.70/1.10
2.00/1.60
30/31
20/24
Given
Given
Given
Given
20/20
61/59
n (P/C)
51/48
40/41
48
48/48
Age
(mean)
(P/C)
Methodw
Given
Medical
condition
1, 2
1, 2
1, 2
1, 2
Treatmentz
53/52
Age
(mean)
(P/C)
1, 2, 3
1, 2
1, 2
1, 2
Quality assessment
NR
Diagnostics: PD, probing depth; RL, root length; AL, Attachment loss.
Method: 1 5 nephelometric, 2 5 RID/ELISA, 3 5 radial immunodiffusion assay, 4 5 immunoturbidimetric.
z
Treatment: 1 5 root planning, 2 5 antibiotics.
Quality assessment: RAND: randomization ALLOC, allocation concealment; BLIND, blindness; FOL, Follow-up.
Randomization: 1 5 adequate, 2 5 inadequate, 3 5 unclear;
Allocation: 1 5 adequate, 2 5 inadequate, 3 5 unclear;
Blindness: 1 5 single blind, 2 5 double blind, 3 5 not blind/unclear;
Follow-up: 1 5 The number of patients at baseline and at completion of the follow-up interval reported, 2 5 all the patients who entered the trial properly accounted for at completion, 3 5 The analysis take into
account the drop-outs/losses to follow-up or the excluded patients.
z
PICO; P, periodontal patients; I, intensive (with local antibiotics) periodontal Tx and supragingival scaling/polishing; C, supragingival scaling/polishing versus standard periodontal Tx; O, levels of biomarkers
(CRP).
k
Standard error of the mean.
nn
PICO: P, periodontal patients; I, intensive (with local antibiotics) periodontal Tx and standard periodontal Tx; C, intensive versus standard periodontal Tx; O, levels of biomarkers such as CRP.
ww
PICO: P, periodontal patients; I, periodontal Tx (with syst. antibiotics) and standard periodontal Tx; C, intensive versus standard periodontal Tx or Control; O, levels of biomarkers such as CRP.
zz
PICO: P, periodontal patients, I, intensive periodontal Tx (with local antibiotic), C: diameter brachial artery before and after periodontal Tx versus control subjects; O, levels of biomarkers and diameter of
brachial artery.
For abbreviations see Table 3A.
Author(s)
Table 3D. Included treatment studies reporting means ( SD), study characteristics and quality assessment, in reversed chronological order
Diagnostics: PD, probing depth; RL, root length; AL, attachment loss.
Method: 1 5 nephelometric, 2 5 ELISA, 3 5 radial immunodiffusion assay, 4 5 immunoturbidimetric.
z
Data reported by Loos (2005).
For abbreviations see Table 3A.
BMI, body mass index, HDL, high-density lipoproteins; LDL, low-density liporoteins; TG, triglycerides.
Fredriksson Casecontrol At least six sites with marked attachment loss (clinical
et al. (1998) (matched)
attachment level 45 mm)
Unknown examiner
Author(s)
284
Paraskevas et al.
CRP in periodontitiss
Medians periodontitis
Medians control
285
Meta-analyses
The main outcome measure was the
WMD of plasma/serum CRP levels in
the cross-sectional studies for periodontitis
patients and controls, and in longitudinal
treatment studies (RCTs and CCTs) the
WMD of the differences in CRP levels
between before and after treatment for
patients and untreated subjects (controls).
In the first meta-analysis, only the
cross-sectional studies were included
(Fig. 3a) (Fredriksson et al. 1998, Loos
et al. 2000, Noack et al. 2001, Amar et
al. 2003, Buhlin et al. 2003, Craig et al.
2003, Joshipura et al. 2004, HavemosePoulsen et al. 2006, Salzberg et al. 2006,
Bizzarro et al. 2007). The mean ( SD)
levels for CRP in the Loos et al. (2000)
study were provided in the Loos (2005)
paper. Consistently, all studies showed
higher CRP levels in periodontitis
patients than in controls. There was a
statistically significant WMD (1.65 mg/
l; 95% CI 1.052.24; po0.00001) in
CRP levels between the periodontitis
patients and controls. However, there
was considerable heterogeneity among
the studies (I2 5 76.7%, Fig. 3a). Further
investigation of heterogeneity (controlling for gender and SES as the most
important factors) revealed two studies
that contributed considerably to heterogeneity: the Craig et al. (2003) study,
where there was a remarkable contribution of subjects with low SES, which is a
Discussion
38
53
93
97
27
18
91
50
17
44
50
107
17
N
3.10(4.40)
3.10(3.30)
3.72(2.88)
2.57(2.95)
5.00(2.70)
5.00(5.40)
2.20(2.25)
3.28(4.64)
2.30(2.30)
5.78(1.07)
4.06(5.55)
2.64(3.48)
2.62(2.90)
periodontitis CRP
Mean (SD)
38
53
93
97
27
18
50
17
50
107
17
N
3.10(4.40)
3.10(3.30)
3.72(2.88)
2.57(2.95)
5.00(2.70)
5.00(5.40)
3.28(4.64)
2.30(2.30)
4.06(5.55)
2.64(3.48)
2.62(2.90)
periodontitis CRP
Mean (SD)
502
39
39
91
91
25
25
46
21
65
43
17
904
39
39
91
91
25
25
377
46
21
25
65
43
17
1.90(2.00)
1.90(2.00)
1.54(2.95)
1.54(2.95)
3.00(2.00)
3.00(2.00)
1.74(1.68)
1.00(1.00)
1.70(1.91)
1.21(1.34)
0.87(1.73)
control CRP
Mean (SD)
1.90(2.00)
1.90(2.00)
1.54(2.95)
1.54(2.95)
3.00(2.00)
3.00(2.00)
1.80(3.00)
1.74(1.68)
1.00(1.00)
2.46(1.44)
1.70(1.91)
1.21(1.34)
0.87(1.73)
control CRP
Mean (SD)
WMD (random)
95% CI
WMD (random)
95% CI
100.00
4.98
9.89
16.48
16.44
7.08
1.71
6.19
8.49
4.53
19.66
4.54
Weight
%
100.00
6.40
8.11
9.10
9.10
7.33
3.53
10.16
6.98
7.77
9.84
6.14
9.38
6.15
Weight
%
[ 0.33, 2.73]
[0.11, 2.29]
[1.34, 3.02]
[0.19, 1.87]
[0.71, 3.29]
[ 0.61, 4.61]
[ 0.15, 0.95]
[0.17, 2.91]
[0.13, 2.47]
[2.67, 3.97]
[0.75, 3.97]
[0.66, 2.20]
[0.14, 3.36]
[ 0.33, 2.73]
[0.11, 2.29]
[1.34, 3.02]
[0.19, 1.87]
[0.71, 3.29]
[ 0.61, 4.61]
[0.17, 2.91]
[0.13, 2.47]
[0.75, 3.97]
[0.66, 2.20]
[0.14, 3.36]
1.56 [1.21, 1.90]
1.20
1.20
2.18
1.03
2.00
2.00
1.54
1.30
2.36
1.43
1.75
WMD (random)
95% CI
1.20
1.20
2.18
1.03
2.00
2.00
0.40
1.54
1.30
3.32
2.36
1.43
1.75
WMD (random)
95% CI
Fig. 3. Forest plots presenting the weighted mean difference (WMD) of CRP levels in mg/l between periodontitis patients and control subjects in cross-sectional studies, heterogeneity and overall
effect for the initial analysis (a) and after controlling for heterogeneity (b). The studies are displayed in reverse chronological order. nMeans and standard deviations were published in a review by
Loos (2005). CRP, C-reactive protein.
567
Total (95% CI)
Test for heterogeneity: Chi = 6.09, df = 10 (P = 0.81), I = 0%
Test for overall effect: Z = 8.92 (P < 0.00001)
Study
or sub-category
702
Total (95% CI)
Test for heterogeneity: Chi = 51.41, df = 12 (P < 0.00001), I = 76.7%
Test for overall effect: Z = 5.42 (P < 0.00001)
Study
or sub-category
286
Paraskevas et al.
4
2
Favours intensive
0
Favours standard
2
4
40
Total (95% CI)
Test for heterogeneity: Chi = 0.44, df = 1 (P = 0.51), I = 0%
Test for overall effect: Z = 1.77 (P = 0.08)
41
0.00(2.25)
0.30(1.92)
21
20
0.40(1.10)
0.60(1.27)
20
20
D'Aiuto 2005b ITx
D'Aiuto 2006 ITx
Fig. 5. Forest plots presenting the weighted mean difference (WMD) of Dbaseline end CRP levels in mg/l between intensive and standard periodontal treatment in periodontitis patients,
heterogeneity and overall effect for treatment studies. diff, difference; B, baseline; E, end; ITx, intensive treatment; STx, standard treatment.
WMD (random)
95% CI
Weight
%
WMD (random)
95% CI
diff B-E STx
Mean (SD)
N
diff B-E ITx
Mean (SD)
N
Study
or sub-category
4
Favours treatment
2
2
4
72
Total (95% CI)
Test for heterogeneity: Chi = 0.57, df = 2 (P = 0.75), I = 0%
Test for overall effect: Z = 2.32 (P = 0.02)
79
0.10(1.65)
0.10(1.65)
0.00(0.80)
24
24
31
0.40(1.01)
0.00(2.25)
0.60(1.38)
20
21
31
D'Aiuto 2005b ITx
D'Aiuto 2005b STx
Seinost 2005
Favours control
WMD (random)
95% CI
diff B-E C
Mean (SD)
N
diff B-E Tx
Mean (SD)
N
Study
or sub-category
Fig. 4. Forest plots presenting the weighted mean difference (WMD) of Dbaselineend CRP levels in mg/l between the treatment groups and control groups, heterogeneity and overall effect for
treatment studies. diff, difference; B, baseline; E, end; C, control (group); Tx, treatment (group); STx, standard treatment; ITx, intensive treatment; CRP, C-reactive protein.
Weight
%
WMD (random)
95% CI
CRP in periodontitiss
287
288
Paraskevas et al.
Acknowledgements
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Clinical Relevance
Address:
Spiros Paraskevas
Department of Periodontology
Academic Centre for Dentistry Amsterdam
(ACTA)
University of Amsterdam and Vrije University
Louwesweg 1
1066 EA Amsterdam
The Netherlands
E-mail: s.paraskevas@acta.nl