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 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 4  |  Page : 240-249

Subgingival temperature: A forgotten cardinal sign of gingival inflammation

1 Department of Periodontology, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha, India
2 Department of Public Health Dentistry, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha, India

Date of Submission25-Oct-2020
Date of Acceptance16-Jan-2021
Date of Web Publication24-Dec-2021

Correspondence Address:
Dr. Dhirendra Kumar Singh
Department of Periodontology, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar - 751 024, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_147_20

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The first information since the 2nd century Anno Domini (AD) – when Celsius proposes “calor” (temperature) as one of the cardinal sign of inflammation, Cornelius Celsius, a nonmedico Roman from the first century, who was the first to describe the features of inflammation-redness, swelling, heat, and pain. Of all the cardinal signs of inflammation, the temperature is the only one that can be measured quantitatively and objectively. Furthermore, periodontitis is a chronic inflammatory disease and should manifest an increase in temperature in the diseased periodontium. The most challenging task in doing the diagnosis and treatment planning periodontal diseases is to predict which periodontal site the disease activity will increase. The routine clinical diagnostic parameters used for predicting and assessing periodontal disease activity are less reliable in predicting disease activity at particular sites. Periodontal pocket depth measurement is inherently inadequate because it fails to distinguish between active and inactive gingival and periodontal disease. Subgingival temperature is a more reproducible method for diagnosing periodontal disease activity, which has been forgotten by clinicians and has formed the concept for this scientific review.
The following core competencies are addressed in this article: Medical knowledge, Patient care.

Keywords: Diagnosis, gingivitis, inflammation, periodontitis, subgingival temperature

How to cite this article:
Singh DK, Kumar G. Subgingival temperature: A forgotten cardinal sign of gingival inflammation. Int J Acad Med 2021;7:240-9

How to cite this URL:
Singh DK, Kumar G. Subgingival temperature: A forgotten cardinal sign of gingival inflammation. Int J Acad Med [serial online] 2021 [cited 2023 Jun 5];7:240-9. Available from: https://www.ijam-web.org/text.asp?2021/7/4/240/333404

  Introduction Top

Gingivitis is the inflammation of gingival soft tissues. Various forms of gingivitis have been described in various pieces of literature. Although the clinical signs of gingivitis are easy to detect, it is not clear how much inflammation a person must have to be considered a gingivitis case.

The four cardinal signs of inflammation – redness (Latin rubor), heat (calor), swelling (tumor), and pain (dolor)—were described in the 1st century AD by the Roman medical writer Aulus Cornelius Celsus. Redness is caused by the dilation of small blood vessels in the area of injury. Heat results from increased blood flow through the area and are experienced only in peripheral parts of the body such as the skin. Fever is brought about by chemical mediators of inflammation and contributes to the rise in temperature at the injury. Swelling, called edema, is caused primarily by the accumulation of fluid outside the blood vessels. The pain associated with inflammation results in part from the distortion of tissues caused by edema, and it also is induced by certain chemical mediators of inflammation, such as bradykinin, serotonin, and prostaglandins.[1] During the chairside diagnosis of periodontal patients, we regularly screen three cardinal signs of gingival inflammation i. e. Redness, Swelling, and Pain but we give very least importance to the 4th very much important cardinal sign of gingival inflammation, i.e., sub-gingival temperature.

One of the most challenging tasks in diagnosing and treating periodontal disease is predicting in which sites the activity of disease will be elevated. Clinical parameters that are used for assessing periodontal disease activity are gingival color, contour, consistency, bleeding on probing, probing depth, attachment loss, and radiographic evidence of bone loss. Changes in these clinical parameters however have been found to be less reliable in predicting disease activity at individual sites.[2],[3]

Measurement of periodontal pocket depth at present is the principal clinical method in periodontal diagnosis. This measurement indicates the severity of the disease process, which again is an indication of past pathological events in the Periodontium. It is inherently inadequate as a diagnostic tool because it fails to distinguish between active and inactive disease; as it is well known that destruction of periodontal tissues around teeth in periodontal disease fluctuates i.e., periods of disease activity succeed periods of inactivity.[4]

Elevation of temperature has been acknowledged as an indicator of inflammation since the second century AD; when Celsius proposed “Calor” (temperature) as one of the cardinal signs of inflammation.[5] To measure the body temperature, the usually rectal or oral temperature is recorded. Average normal temperature is generally considered to be 36.7°C–37°C when measured orally and approximately 0.6°C higher when measured rectally. However, body temperature varies to a certain extent with body exercise and surrounding environmental temperature. In few situations rise or fall in temperature occurs locally in diseased areas of the body. Such conditions usually result in localized inflammation, degeneration, circulatory disturbances, and increased physiologic activity of an organ or a part of the body.[6]

Inflammation is generally accompanied by the release of mediators at the inflammation site. These mediators such as histamine, prostaglandin, and interleukin-1 increase microvascular permeability and cause capillary vasodilation. This increased fluid transport is expected to increase the heat at the local inflammatory region.[7] One of the major risk factors that have been identified for destructive periodontal diseases is smoking. Smokers in particular have more loss of attachment and more severe bone loss compared to nonsmokers. However, gingival redness and bleeding on probing are suppressed in smokers.[8]

Trusting and depending on current methods of evaluating disease activity may lead to errors in diagnosis and treatment, primarily because bleeding on probing and periodontal probing pocket depth measurements are not accurate enough to evaluate the disease activity process especially in smokers because bleeding on probing is suppressed in them due to vasoconstrictive action of nicotine.[9] Attempts have been made to develop other measures to evaluate disease activity that may be useful when the usual clinical signs are unreliable. One such measure is subgingival temperature. These subgingival temperature measurements were able to differentiate between diseased and healthy periodontal sites in the majority of cases. Temperature changes can be expected to accompany the inflammatory process and therefore diagnostic and prognostic information can be obtained by recording the temperature of the affected area.[8]

A temperature-sensitive probe has been developed and available in the market to measure periodontal pocket temperature, which is known as periotemp. It is a commercially available device used to measure subgingival temperature, which is not available in India. Studies with this instrument have suggested that the measurement of subgingival temperature provides a simple and sensitive means of detecting disease activity.[3]

The present review article will describe the importance of the understanding of subgingival temperature and its role in the screening and diagnosis of gingival and periodontal disease activity.

  Importance and Understanding of Body Temperature Top

One of the most important developments in the higher animal is the evolution of mechanism; whereby a constant environment is maintained for its constituent cells. Thermal regulation is one of the most fundamental physiological regulations in our body.[10] Although fever has been recognized since ancient times, actual measurements of body temperature were not made till comparatively recently. Reliable clinical thermometers became available in the 17th century, but it was not until the 19th century that they were used to any extent. Body temperature is usually measured with a thermometer placed under the tongue, or else in the axilla, groin, or rectum. Of these, readings obtained from the axilla and groin are generally regarded as being least reliable. This is because the surface skin temperature fluctuates widely and may approximate to that of an external environment. Measuring urine temperature also has been advocated, and it approximates the rectal temperature. The sublingual temperature taken with the lips closed is considered to be the most reliable guide to the arterial temperature and in addition, the mouth is near the hypothalamus.

As long as skin temperature is greater than the temperature of the surroundings, heat can be lost by radiation and conduction. But when the temperature of the surroundings is greater than that of the skin, the body gains heat by both radiation and conduction. This usually occurs in human beings who are born with a congenital absence of sweat glands.[11]

Man and other animals are homoeothermic animals i.e., whatever may be the environmental temperature their own body temperature does not vary. By contrast poikilothermic animals like in reptiles, the body temperature changes as environmental temperature changes. The ability to keep body temperature within normal ranges is possible because of the thermoregulatory mechanism which is present in homoeothermic animals and weaker in poikilothermic animals. The thermal regulatory mechanism is mediated through the hypothalamus.[10]

The human body is considered to have core and shell temperature. Skin and subcutaneous tissue constitute the shell, whereas all other internal structures (covered by a shell) are called core. When one speaks about body temperature it is core temperature that remains constant. On the other hand, shell temperature may fall in cold temperatures as low as 15°C even then it is not harmful as core temperature remains constant.[10] The normal body temperature at rest is 37°C (about 98.6°F). If the temperature rises too much it causes deterioration of enzymatic function and cold, on the other hand, inhibits enzymatic activity. Therefore to remain alive internal temperature must be within a narrow range [Table 1].[10]
Table 1: Important causes of elevation of body temperature

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The normal body temperature can be measured by oral and rectal routes. The normal oral (mouth) temperature at rest is about 37°c at 8.00 am and the range in healthy adults is in between 35.8°C and 37°C (96.5°F–100°F). Body temperature shows a circadian rhythm. It is highest in the afternoon and evening and is least at around 5.00 am. The difference is about 0.5°C.[10]

The rectal temperature is about 0.5°C more than the oral temperature. It is presumed to be nearest to the core temperature. Flaws in rectal temperature occur often, such as rectum loaded with fasces may cause a considerable generation of heat and give falsely high value. In a cold environment where legs are exposed, the blood in long saphenous veins may become cold and this cold reaches the pelvis and gives falsely low value.[12]

In children as the regulatory mechanism is not satisfactory the body temperature will be high in summer and low in winter. Their body temperature is 0.5°C higher than adults.[10]

Nonpregnant women show 0.5°C more temperature in the luteal phase and menstrual cycle due to endogenous progesterone.[10]

Body temperature is affected by some severe bouts of exercises and it can be as high as 40°C (104°F).[10]

Increased temperature causes increased heart rate, sometimes to as great as double the normal. Decreased temperature causes greatly decreased heart rate, falling to as low as a few beats per minute.[11]

  Authors Supporting the Thermometer; A Most Reliable Instrument For Temperature Recording Top

Conheim in 1889[14] found that temperatures vary in different parts of the body and may be affected significantly by changing internal and external conditions, since part of the transfer of the body heat is by convection via the blood, the local changes in vascular morphology and blood flow as described in inflammation in general.

Holthius and Chebib[7] conducted a study to estimate the measurement error by comparing repeated measures of the same site in 6 dental hygiene students using a thermocouple thermometer. Subgingival, sublingual temperatures as well as pocket depth, and sulcular bleeding were examined in 6 students. All measurements were recorded twice. The maximum error associated with 95% of the temperature data and the average error was calculated as 1.3°C and 0.65°C respectively. It was concluded that the thermocouple thermometer used in this study is a stable instrument for measuring the gingival temperature.

Burkets[12] studied the comparison of cigarette, cigar, and pipe smoking and his study indicated that cigar smoking is associated with fewer oral lesions than is either with cigarette or pipe smoking possibly because of the increased temperature of the combustion of the tobacco with the later 2 methods.

Kung and Goodson[15] conducted a study in 11 healthy and 13 diseased subjects to assess the potential of using pocket temperature as a parameter for monitoring periodontal health. The temperature in 6 sites around each tooth was measured and referenced to sublingual temperature. Observations have suggested that with a sensitive temperature sensing device periodontal pocket temperature could provide an instant, simple and sensitive means of monitoring periodontal health. The degree of temperature elevation relative to the normal would reflect the severity of disease activity.

Granick et al.[16] conducted a study to determine the effect of gingival inflammation and probing pressure on probe tip placement in relation to the base of the gingival crevice and the most coronal connective tissue attachments fibers. The study concluded that inflammation was not a factor in probe tip position relative either to the base of the crevice or to the most coronal connective attachment.

Davies et al.[17] presented in their study the development of a thermoelectric device that is Biomat Thermal Probe (BTP) for the measurement of the temperatures. In vitro consistency tests with BTP consisted of a series of five readings at set temperatures from 0°C to 59°C. The results demonstrated that the BTP is accurate for in vitro measurement of the temperatures.

Niderman and Kent[18] conducted a study to evaluate the accuracy and reliability of the perio-temp system and described the potential application of subgingival temperature in periodontal clinical trials. Results have reported that the perio-temp system can accurately and reliably report temperature and temperature differences between 33°C and 37° C. Results also showed that the subgingival temperature has a modest correlation with other indicators of periodontal disease indicating that subgingival temperature is unique among the other commonly used indicators [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8].
Table 2: Sublingual temperature

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Table 3: Subgingival temperature

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Table 4: Subgingival temperature in normal and inflamed gingiva Normal gingiva

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Table 5: inflamed gingiva

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Table 6: Subgingival temperature and subgingival microbiota

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Table 7: Subgingival temperature and periodontal disease

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Table 8: Subgingival temperature in smokers and nonsmokers

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  Periodontal Disease and SARS COV-19 Top

Based on various studies it seems evident that periodontal health status has an indirect effect on SARS COV-19. Good oral health of an individual helps to reduce the possibility of getting systemic diseases, which are having a chance of COVID 19 morbidity[27].

COVID-19. Coronavirus has been announced pandemic along with the globe by the WHO, which have severely affected every countries healthcare framework and health care professionals globally. Due to this pandemic every individual facing severe problems both economically and emotionally. The similarity seen in the inflammatory response pathway shows there is a potential relationship between COVID-19 and Periodontal diseases. There is also a chance of feasibility that periodontal disease can be susceptible to an individual's COVID-19 unfavorable outcomes. This relationship shows the interrelation between periodontal disease and COVID-19 and between the cytokine relationships which advise in improving hygiene in the oral cavity during this COVID pandemic situation. And it is found individuals with periodontal disease have a high risk of getting COVID associated unfavorable consequences.

Even though some of the reported risk factors have not been strongly associated with periodontal disease or their causal relationships are not completely established, it is convincing to propose an association between periodontal diseases and COVID-19, subgingival temperature measurements will definitely play a reliable assessment mode for periodontal disease diagnosis[28].

  Conclusion Top

Subgingival temperature is a reliable assessment method of periodontal inflammation and disease activity when other usual clinical signs are unreliable. Measuring subgingival temperatures can serve as a fast screening process for the assessment of periodontal disease activity. Subgingival Temperature measurements have been found to reflect clinically defined conditions, suggesting that subgingival temperature measurements may have unexplored potentials in diagnosing and monitoring the periodontal condition.

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Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network (http://www.equator-network.org). The authors also attest that because there was no clinical investigation carried out, the Institutional Review Board/Ethics Committee approval was not required.

  References Top

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Singh DK, Kumar G. Comparison of the subgingival temperature of smokers and nonsmokers in healthy and diseased sites of gingiva in association with sublingual body temperature. J Family Med Prim Care 2019;8:3166-72.  Back to cited text no. 2
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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