Estimation and Comparison of Serum and Salivary IgA Levels in Controlled, Uncontrolled Diabetics and Normal Individuals

Transcription

1 /jp-journals Sanat Kumar Bhuyan et al RESEARCH ARTICLE Estimation and Comparison of Serum and Salivary IgA Levels in Controlled, Uncontrolled Diabetics and Normal Individuals 1 Sanat Kumar Bhuyan, 2 RN Mody, 3 Ruchi Bhuyan 1 Professor, Department of Oral Medicine and Radiology, Institute of Dental Science, Sum Hospital, Bhubaneswar, Odisha, India 2 Professor and Head, Department of Oral Medicine and Radiology, Hitkarani Dental College, Jabalpur, Madhya Pradesh, India 3 Professor and Head, Department of Oral Pathology and Microbiology, Institute of Dental Science, Sum Hospital, Bhubaneswar, Odisha, India Correspondence: Sanat Kumar Bhuyan, Professor, Department of Oral Medicine and Radiology, Institute of Dental Science, Sum Hospital, Bhubaneswar, Odisha, India, drsanatkumar@rediffmail.com ABSTRACT Diabetes mellitus is a disease of absolute or relative insulin deficiency characterized by insufficient secretion of insulin by the pancreatic beta cells. In diabetes there is proliferation and swelling of endothelial cells, frequently obliterating the vessel lumen which leads to reduced blood flow and decrease in oxygen diffusion leads to good environment for growth of microorganism. The present study was carried out with the aim of getting information on humoral immune status of individuals having diabetes by measuring the serum and salivary IgA levels. With intense review of literature and observation we concluded with there was statistically significant increase in the salivary IgA level in controlled and uncontrolled diabetics compared to normal individuals and serum IgA level was higher in controlled and uncontrolled diabetics compared to normal individuals. Keywords: Diabetes, Serum and saliva, IgA level INTRODUCTION Diabetes mellitus is a disease of absolute or relative insulin deficiency characterized by insufficient secretion of insulin by the pancreatic beta cells (insulin-dependent diabetes mellitus type I) or subresponsiveness of tissue to circulating insulin (noninsulin-dependent diabetes type II). 1 Both the types share a common metabolic dysfunction that involves abnormal regulation of both glucose and fat metabolism leading to hyperglycemia. Clinically, this often leads to retinal and renal damage and also cardiovascular complications, immune impairment, etc. It also affects neutrophil chemotaxis, phagocytosis and adhesion. In diabetes, there is proliferation and swelling of endothelial cells, frequently obliterating the vessel lumen which leads to reduced blood flow and decrease in oxygen diffusion. Lowered oxygen content produces better environment for growth of anaerobes and thus increased susceptibility to infection. 2 There was higher level of immunoglobulins in gingival tissue which might be protective mechanism against the inceased bacterial infection in diabetics. 3 There are no specific or pathognomic oral manifestations associated with diabetes, however, various oral conditions exacerbated in the diabetic patient are median rhomboid glossitis, gingival and periodontal diseases, oral candidiasis, localized osteitis after exodontias and burning tongue. The altered immune response might be the principal causative factor for the various oral manifestations of diabetes mellitus. The fully responsive immunologic system is essential to encounter various infections and toxic agents. Determination of salivary constituents is useful in description and manegment of oral findings in diabetic patients. 4 AIMS AND OBJECTIVES The present study was undertaken with the aim of studying humoral immune status of individuals having diabetes by measuring the serum and salivary IgA levels. To achieve the above aim the following objectives were sought: 1. To estimate the serum and salivary IgA levels in controlled and uncontrolled diabetics and to compare the same with that of the normal individuals. 2. To establish a relationship between IgA levels in serum and saliva of controlled diabetics, uncontrolled diabetics and the normal individuals. REVIEW OF LITERATURE The systemic condition of diabetes mellitus has several secondary oral manifestations, such as xerostomia and periodontal disease, etc. It seems likely that the thirst and dry mouth, characteristic of diabetes are related to the poor metabolic control of the disease with increased diuresis and fluid loss and that normal salivary flow rate is restored when the disease is well-controlled. 5 Diabetes mellitus has also been reported to affect the flow rate and composition of saliva. Several authors have reported decreased salivary function in diabetic populations while other investigators have reported the opposite effect JAYPEE

2 JIAOMR Estimation and Comparison of Serum and Salivary IgA Levels in Controlled, Uncontrolled Diabetics and Normal Individuals Many studies on the composition of saliva in diabetics have indicated increased levels of glucose, calcium and potassium. Significantly increased buffer capacity of saliva has also been reported. 6 Examination of salivary glands reveals lymphocytes, specifically adapted for secretory immunity with 95% containing IgA. A bulk of it is dimeric and capable of binding to secretory components. Though the major contribution of IgA comes from major salivary glands, about 30 to 35% is contributed by the minor salivary glands. The concentration of salivary IgA in these secretions nearly double after meal. Very few studies have been carried out to analyze the immunologic status (IgA, IgM, IgG) of saliva in diabetics. 7 Bruno A, Innocenti M, Pasquino M, Pugliese F and Zola P (1976) studied IgG, IgM and IgA values in 45 diabetic patients of various ages and both sexes under treatment (30 being treated with oral hypoglycemic drugs and 15 with insulin). They found marked departure of serum IgA values from normal. 8 Gill EW, Bush WS, Burleigh WH and Cooke-Gomes D (1981) studied serum immunoglobulins (IgA, IgM, IgG) levels in 66 noninsulin-dependent diabetics and found it to be significantly higher in the diabetic group when compared with that of the control group. 9 Cheta D, Michalache N, Santu E and Mincu I (1981) studied IgG, IgA and IgM in 100 diabetics and compared it with that of 26 healthy subjects. Significant increase was found with IgA levels, which increased with the duration of the disease. 10 Cheta D (1982) studied serum immunoglobulins in four different groups of diabetics, representing more than 400 subjects. He noticed that the mean values of IgA was almost constantly raised in diabetics that the heathy individuals. 11 Cheta D, Mihaescu S and Mihalache N (1982) studied serum immunoglobulins (IgA, IgG and IgM) by radial immunodiffusion in a group of 217 diabetics (152 were insulin dependent and 65 noninsulin dependent). They observed higher values of IgA as compared with IgG and IgM, whatever the criteria of clinical analysis used. The highest IgA values were found in diabetics aged over 65 at the onset of disease and in those with renal complications. 12 Hammes Hp, Kiefel V, Laube H and Federlin K (1990) studied nonenzymatic glycation of circulating immunoglobulin (IgG, IgA and IgM) by boronic acid affinity chromatography and found it to be significantly increased in diabetics group than in controls {IgG 21.6% (± 3.4%) vs 14.1% (± 2.9%; p < 0.01); IgA 14.7% (± 4.9%) vs 7.7% (± 1.3%); p < 0.01}. 13 Streckfus CF, Marcus S, Welsh S, Brown KH and Cherrypeppeas G (1994) studied composition of parotid saliva in three groups of diabetics (insulin dependent, taking oral hypoglycemic agent, diet controlled) in African-Americans above the age of 65 years. They found no significant difference in IgA concentrations between the diabetic and healthy individuals. 4 In a study of parotid and submandibular salivary gland function or IgA secretion in adult onset diabetics and normal individuals in age and sex matched controls. Marder MZ, Abelson DC and Mandel ID (1975) reported no statistical differences in salivary A levels. 14 Ben-Arych H and Cohen M (1988) reported diminuation of whole salivary flow, but no reduction in salivary IgA level in insulin-dependent diabetics. 15 Claman et al and Gave (1972) have reported the IgA content of normal saliva to be 2 to 5 mg% accounting for 1 to 3% of total salivary proteins. They also reported that 50 mg of it is excreated daily in the oral cavity. 16 Marder MZ et al (1982) found that the levels of secretory IgA were generally within their normal range in diabetes mellitus. 17 Brandtzaeg (1972) and Tenovuo J (1986) found that there was significantly elevated IgA level in whole saliva of diabetic patients. 18,19 MATERIALS AND METHODS This study was carried out in the Department of Oral Medicine and Radiology, Government Dental College and Hospital, Nagpur and in the Diabetic Clinic of Government Medical College and Hospital, Nagpur. In all, 90 patients were selected for this study after thorough medical and dental examination. Patients with history of present or past major illness other than diabetes were excluded from the study. Particular attention was paid to exclude patient with any chronic diseases. Patients were divided into three groups: Group I: Thirty normal healthy patients (having fasting blood sugar between 80 to 120 mg% and postmeal blood sugar up to 180 mg%) (Table 1). Group II: Thirty patients with controlled diabetes (patients undertreatment having fastening blood sugar less than 120 mg% and postmeal blood sugar less than 10 mg%) (Table 2). Group III: Thirty patients with uncontrolled diabetes patients undertreatments with uncontrolled diabetes (patients undertreatment having fastening blood sugar more than 120 mg% and postmeal blood sugar more than 180 mg%) (Table 3). In standard proforma details, such as name, age, sex, registration number, address, the type and known duration of diabetes, duration of specific antidiabetic treatment and other medication taken, etc. for each individual were recorded. Collection of Blood Sample Under aseptic condition 2 cc of venous blood was drawn by using a sterile disposable 22 gauge needle and sterile 5 cc. syringe and collected in a sterile bottle containing fluoride and oxalate, to prevent glycolysis and clotting of blood samples. Subjects were instructed not to take anything by mouth since previous midnight for the fasting samples. Postmeal samples were taken approximately 1 hour after a full meal in the afternoon. Collection of Saliva Sample After thorough mouth rinse the subjects were asked to chew paraffin for 1 minute and the salvia samples were collected in a clean bottle. Journal of Indian Academy of Oral Medicine and Radiology, October-December 2011;23(4):

3 Sanat Kumar Bhuyan et al Quantization of Serum Immunoglobulin Blood and saliva samples were stored at 4 C until assayed by immunodiffusion for immunoglobulin A. Sodium azide was used as preservative during the storage immunoglobulin A was measured by modified single radial immunodiffusion technique (SRID) of Mancini et al. 20 Principle: Following the radial diffusion of the soluble antigen it was transferred from the cylindrical wells into the antibody incorporated gel, a circular precipitate develop provided the antibody is evenly distributed in uniformly thick gel. If well size and volume of the antigen is kept constant, then the diameter of the precipitate (D) is directly proportional to the antigenic concentration (Marcini et al). 20 Salivary IgA The value of salivary IgA in normal individuals ranged from 4.3 to 4.7 (mg/dl) with the mean value of 5.8 ± (mg/dl), while in controlled diabetics, the range of salivary IgA was from 0.6 ± 6.0 (mg/dl) with the mean value of 3.4 ± 1.25 (mg/ dl) and in uncontrolled diabetics, the value of salivary IgA ranged from 0.5 to 5.6 (mg/dl) with the mean value of 2.89 ± 1.23 (mg/dl) (Table 4). It was observed that the value of salivary IgA decreased gradually from normal individuals (5.8 mg/dl) to controlled diabetics (3.41 mg/dl) and further to 2.8 mg /dl in uncontrolled diabetics. On application of student t-test, it was observed that there was significant difference in salivary IgA levels between the normal individuals and the controlled and uncontrolled diabetics (Table 5). In 1994, Streckfuls CF et al 5 studied salivary IgA in three groups of differently treated diabetics (control group, insulin dependent, noninsulin dependent). They found that there was no significant difference in salivary IgA levels between these three groups. In the present study it was found that the salivary IgA level decreased in controlled (3.41 mg/dl) as well as uncontrolled (2.89 mg /dl) diabetics as compared to normal individuals (5.8 mg/dl). The decreases were more marked in uncontrolled diabetics. The decrease in salivary IgA level in diabetics may be due to the decrease in the local immune response in the form of secretory IgA. This could be one of the predisposing factors which makes the diabetics more susceptible to oral infections. It was also observed that the salivary IgA level further decreased in patients with uncontrolled diabetics compared to controlled diabetics, making the uncontrolled diabetics more susceptible to infections. Therefore, the effective control of diabetes is essential to minimize the infections of the oral cavity. The salivary IgA levels should be evaluated in these patients from time to time. Thereby controlling the diabetes and ultimately the infective episodes. Serum IgA The value of serum IgA in normal individuals ranged from 180 to 340 (mg/dl) with the mean value of ± (mg/dl), while in controlled diabetics the range was from 135 to 450 (mg /dl) with the mean value of ± 81.4 (mg /dl) and in the uncontrolled diabetics it ranged from 90 to 450 (mg/dl) with the mean value of ± (mg/dl) (Table 4). It was observed that in both controlled and uncontrolled diabetics the serum IgA value increased as compared to the normal individuals but this increase was higher in case of controlled diabetics than the uncontrolled diabetics. On application of student t-test, it was observed that there was significant difference in serum IgA levels between group II with I (3.75) and III with 1 (1.15) but there was no significant correlation observed between controlled and uncontrolled diabetics. Similar finding was observed by Gill CW et al 9 (1981) and Cheta D et al 12 (1982) who studied serum IgA levels in diabetics and normal individuals. They found that serum IgA levels were significantly higher in diabetic group as compared to normal individuals. In the present study, it was also found that serum IgA level was significantly higher in diabetic group as compared to the normal individuals. This indicates the presence of some amount of systemic infection in the diabetics. That is why the natural immune system of the body tries to synthesize more amount of immunoglobulins in order to overcome or minimize the systemic infections. Hence, increase in serum immunoglobulins can be used as one of parameters of judging presence of systemic infections. OBSERVATION, FINDINGS AND DISCUSSION Table 1: Distribution of age, sex, fasting blood sugar, postmeal blood sugar, salivary IgA, serum IgA in normal individuals 1. 43/M /M /F /M /M /M /M Contd. 550 JAYPEE

4 JIAOMR Estimation and Comparison of Serum and Salivary IgA Levels in Controlled, Uncontrolled Diabetics and Normal Individuals Contd /M /M /M /M /F /M /M /M /M /M /M /M /M /F /M /F /F /M /F /M /F /F /F Table 2: Distribution of age, sex, fasting blood sugar, postmeal blood sugar, salivary IgA, serum IgA in controlled diabetics 1. 60/F /M /F /M /M /F /M /F /M /M /F /M /F /M /M /M /M /M /M /M /M /M /M /M /M /M /M /M /F /M Journal of Indian Academy of Oral Medicine and Radiology, October-December 2011;23(4):

5 Sanat Kumar Bhuyan et al Table 3: Distribution of age, sex, fasting blood sugar, postmeal blood sugar, salivary IgA, serum IgA in uncontrolled diabetics 1. 40/M /M /M /M /F /M /M /F /F /F /F /F /F /F /F /F /M /M /F /M /F /F /M /M /M /M /F /F /M /M Table 4: Distribution of mean and standard deviation of fasting blood sugar, postmeal blood sugar, serum IgA, salivary IgA Group Fasting blood sugar (mg/dl) Postmeal blood sugar (mg/dl) Serum IgA (ml/dl) Salivary IgA (ml/dl) Mean SD Mean SD Mean SD Mean SD I II III Group I normal individuals; Group II controlled diabetics; Group III uncontrolled diabetics Table 5: Calculated values of t Group Fasting blood sugar Post meal blood sugar Serum IgA Salivary IgA I II III Group I normal individuals Group II controlled diabetics Group II uncontrolled diabetics Table value of t p < Significant p < Highly significant SUMMARY AND CONCLUSION From the present study, it was concluded that: 1. The mean salivary IgA level progressively decreased from normal individuals to controlled diabetics and further in uncontrolled diabetics. 2. There was statistically significant increase in the salivary IgA level in controlled and uncontrolled diabetics compared to normal individuals The mean serum IgA level was higher in controlled and uncontrolled diabetics compared to normal individuals. 4. The difference in the serum IgA level in uncontrolled diabetics and normal individuals was statistically insignificant. 5. The increase in serum IgA level in controlled diabetics was statistically significant compared to normal individuals as well as uncontrolled diabetics. JAYPEE

6 JIAOMR Estimation and Comparison of Serum and Salivary IgA Levels in Controlled, Uncontrolled Diabetics and Normal Individuals REFERENCES 1. Tepperman J. Metabolic and endocrine physiology. Chicago: Year Book Medicine Publishers 1987; Yalda B, et al. Diabetes as a modifier of periodontal disease expressions. Periodontology 2000;6: Sukumaran Anil, et al. Immunoglobulin concentration in gingival tissue of type II diabetic patient with periodotitis 2006;17(4) Int J of diabetics in developing contries. 4. Bakianianian P, et al. Evaluation of salivary glucose IgA and flow rate in diabetic patients. J of Dentistry Tehran 2010;7(1). 5. Streckfus CF, et al. Parotid function and composition of parotid saliva among elderly edentulous African-American diabetics, J Oral Pathol Med 1994;23: Tenovuo J, et al. Oral health of patients with insulin-dependent diabetes mellitus, Scand J Dent Res Lehner T. Immunological aspects of oral disease in Lachmann s clinical aspects of immunology (4th ed). Blackwell Scientific Publicatons II: Bruno A, et al. Prelimenary observations on the behaviour of immunoglobulins in diabetics treated by different methods. Minerva Med Oct 20, 1976;67(50): Gill CW, et al. Elevation of IgA levels in the noninsulindependent (type-ii) diabetes patient. Diabetes Care 1981;4(6): Cheta D, et al. Study of some serum protein fractions in various clinical forms of diabetes mellitus. Med Interne 1981;19(1): Cheta D. A higher level of serum Iga in diabetes mellitus. Med Interne 1982;20(4): Cheta D, et al. Immunoglobulin A in diabetics. Med Interne 1982;20(1): Hammes HP, et al. Impaired agglutination of IgM resulting from nonenzymatic glycation in diabetes mellitus. Diabetes Res Clin Pract 1990;9(1): Marder MZ, et al. Salivary alternation in diabetes mellitus. J Periodontal 1975;46: Ben-Arych H, Cohen M. Salivary composition in diabetic patients. J Diab Complic 1988;2: Kulkarni JG. Immunoglobulins and complement 3 levels in serum and saliva in relation to dental caries in man. Dental Dialogue 1984;182: Marder MZ, et al. Salivary alternation in diabetes mellitus. Acta Odontol Scand 1982; Branditz P. Local formation and transport of immunoglobulins related to the oral cavity: Hast resistance to commensal bacteria, Churchill Lovingstone 1972; Tenovuo J, et al. Immunoglobulins and innate antimicrobial factors in whole saliva of patients with insulin-dependent diabetes mellitus. J Dent Res 1986;65(1): Mancini T, et al. Immunochemical quantitations of antigens by single immunodiffusion. Immunochemi 1965;2:235. Journal of Indian Academy of Oral Medicine and Radiology, October-December 2011;23(4):