Efficacy of Er:YAG Laser in Decontamination of Dental Implants: An In-Vitro Study
Phase: NA
Conditions: Peri-Implantitis
Sponsor: Tufts University

Confidential 
 
 
 
 
 
 
 
 
 
Efficacy of Er:YAG Laser in Decontamination of 
Dental Implants: An In-Vitro Study 
___________________________________________________________ 
 
 
 
Principal Investigator:  
  
Robert Gyurko, D.M.D., Ph.D. 
 
MS Student Co-Investigator: 
Hani AlMoharib, B.D.S. 
 
Co-Investigators: 
Driss Zoukhri, Ph.D. 
Bjorn Steffensen, D.D.S., M.S., Ph.D. 
Matthew Finkelman, Ph.D. 
 
Study Location: 
Tufts University School of Dental Medicine 
One Kneeland Street  
Boston, MA 02111 
 
NCT number: NCT03100435 
 
Protocol Version Date:  
 
 
Aug 10, 2017 
 

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I. 
Introduction 
 
Key Question 
Is Er:YAG laser a more effective method in decontamination of titanium surfaces 
compared to carbon fiber curettes? 
Hypothesis 
Er:YAG removes biofilm more effectively from titanium surfaces than carbon fiber 
curettes.  
Aim 
The aim of this study is to compare the amount of residual biofilm on titanium discs 
after decontamination with Er:YAG laser and carbon fiber curette.  
Background and Rationale 
Dental Implants 
The American Association of Oral and Maxillofacial Surgeons estimated that 69% of 
adults ages 35 to 44 have lost at least one permanent tooth. The advent of oral 
implants has revolutionized dental practice and industry as a whole.1 Implants 
provide a solution for tooth loss that is predictable with long-term success.1 A success 
rate of 90% has been reported for both fully or partially edentulous restorations.2-5 
Different implant systems have been developed with various sizes, shapes, surfaces, 
and prosthetic components.6 The success of dental implants depends on 
osseointegration, a concept defined as a direct structural connection at light 
microscopic level between the bone and surface of the implant.7 The dental implant 
and prosthetic market in the U.S is projected to reach $6.4 billion by 2018.  
 
Peri-Implantitis 
As well as teeth, dental implants are not immune to inflammatory lesions. The first 
European Workshop on Periodontology8 identified two disease entities surrounding 
implants. They have been recognized as peri-implant mucositis and peri-implantitis.8 
Peri-implant mucositis is defined as a reversible inflammation in the soft tissues 
surrounding the implant, while peri-implantitis is designated as inflammation 
associated with loss of supporting bone around an implant.8 Heitz-Mayfield9 identified 
several diagnostic criteria for peri-implant diseases such as probing depth, 
attachment level changes, bleeding on probing, suppuration, mobility, and 
radiographic bone changes. The article9 also presented oral hygiene, history of 
periodontitis, diabetes, smoking, and alcohol consumption as risk factors in 
developing peri-implantitis. In their recent meta-analysis, Derks et al.10 estimated 
the prevalence of peri-implant mucositis and peri-implantitis to be 43% and 22% 
respectively.10 These high prevalence rates led to development of different methods 
for implant surface decontamination.11 
Treatment of Peri-Implant Diseases 
Bacterial colonization on the implant surface is the main causative factor in 
development of peri-implant diseases.12-16 Formation of adherent bacterial biofilm on 

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titanium surface is critical for disease development and altering the biocompatibility 
of the surface.17 The literature provides evidence of peri-implantitis’ microbial 
etiology that is very similar to advanced periodontitis, with high levels of spirochetes 
and 
non-motile 
anaerobic 
Gram-negative 
bacterium 
(Aggregatibacter 
Actinomycetemcomitans, 
Porphyromonas 
gingivalis, 
Prevotella 
intermedia, 
Tannerella forsythia, Treponema denticola).18 Furthermore, the presence of multiple 
components in a single dental implant, i.e. fixture, abutment, and crown, accumulate 
more plaque than natural dentition.19, 20 A study by Pontoriero et al.21 demonstrated 
a cause and effect relationship between plaque accumulation and peri-implant 
mucositis. Surface debridement constitutes the basis of treatment of peri-implant 
disease.17 However, complete debridement is not a simple task.  
 
Mechanical hand instrumentation using curettes to remove biofim and calculus is still 
the basis for any periodontal therapy. Based on the extensive evidence supporting 
hand instrumentation in treatment of periodontitis, hand instruments were proposed 
for the treatment of peri-implant diseases. Scalers of different materials were made 
specifically for implant surfaces. These scalers were made with similar or lower 
external hardness, in order not to produce scratches on the implant surface and not 
to make the implant surface more plaque retentive. Furthermore, a damaged surface 
impairs adhesion of fibroblasts and lowers biocompatibility of the implant.22, 23 Fox et 
al.23 studied the effect of stainless steel, titanium, and plastic curettes on implant 
surface roughness by scanning electron microscopy (SEM). Surprisingly, the roughest 
surface was produced by the titanium curettes followed by stainless steel and plastic. 
The plastic surface alteration was determined to be insignificant. Homiak et al.24 in 
their SEM study on implant abutments confirmed that stainless steel instrument 
produced a rougher surface. Whereas, plastic scalers rounded off sharp edges and 
smoothened the surface but changes were not extremely dramatic. Carbon fiber 
curettes are another alternative to plastic curettes, which do not significantly damage 
the implant surface.25 Strooker et al.26 reported decrease in Gingival Index and 
number of bacterial colonies in patients treated by mechanical instrumentation using 
carbon fiber curettes. 
 
Karring et al. showed that mechanical non-surgical therapy alone is not sufficient to 
treat peri-implantitis.27 Persson et al.28 compared using curettes with ultrasonic 
devices, and reported failure of both measures to resolve the disease. Renvert et al. 
observed mechanical non-surgical therapy could only be effective in peri-implant 
mucositis cases only, and results could be enhanced by the adjunctive use of 
antimicrobial rinses.17 No treatment protocols have received full consensus as a 
standard of care, as most treatments were unable to achieve complete inflammation 
resolution or surface decontamination.17, 29, 30 Therefore, different modalities of 
treatment have been developed to overcome inadequacies such as sustained 
antibiotics release, antiseptics, air abrasion, and laser therapy.17 
 
Er:YAG Laser 
 
Laser therapy has been advocated for implant surface decontamination.31, 32 Several 
types of lasers have been evaluated for this purpose such as erbium-doped yttrium–
aluminum–garnet (Er: YAG), carbon dioxide (CO2), gallium–aluminum– arsenide 

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(GaAlAs) diode, neodymium-doped yttrium–aluminum–garnet (Nd:YAG) and erbium- 
and chromium-doped yttrium–scandium–gallium–garnet.31, 32 CO2, diode, and Er:YAG 
lasers have been implicated for irradiation of implant surfaces because they are 
poorly absorbed by the implant and do not raise surface temperature.33 The Er:YAG 
laser appears optimal for implant decontamination as the Er:YAG laser energy is 
primarily absorbed by water, resulting in vaporization of bacteria and minimal surface 
alterations on the implant surface.34, 35 
Several investigations have been carried out on the effectiveness of Er: YAG laser in 
surface decontamination. Kreisler et al.36 incubated Streptococcus sanguinis over 
titanium discs and irradiate them with power 60 and 120 mJ/pulse at 10 Hz. Their 
results reported reduction ranges from 98.3% to 99.94%. Matsuyama et al.37 
evaluated Er: YAG in six contaminated healing abutments. They showed that Er: YAG 
at 30 mJ/pulse and 30 Hz with water spray was capable of effectively removing 
plaque and calculus on the implant abutments without injuring their surfaces. 
Quaranta et al.38 explored different types of implant surfaces contaminated with 
Porphyromonas gingivalis. They observed values of 76.2% for machine tested 
implants, 90.9% for titanium plasma spray implants, and 98.3% for sandblasted and 
etched implants. A minimal residual bacterial presence was observed in all groups. 
Sennhenn-Kirchner et al.39 evaluated efficacy against Candida albicans incubation. 
They found Er:YAG laser damaged the fungal cells to a great extent wherever it was 
applied on direct contact. Decontamination efficacy was dose-dependent with values 
ranging from 59% following irradiation with 80 mJ/pulse at 5 Hz40 to 99.94% 
following irradiation with 120 mJ/pulse at 10 Hz.36 Schwarz et al.41 in a canine study 
showed Er:YAG to be more suitable to promote re-osseointegration than ultrasonics 
or plastic curettes. 
Studies evaluated efficiency of decontamination using scanning light microscopy, 
scanning electron microscopy (SEM), counting the colony forming units (CFU), 
bacterial smears, and photometric XTT–formazan evaluations.31 Molecular Probes’ 
LIVE/DEAD® BacLightTM Bacterial Viability Kits provide a novel two-color fluorescence 
assay of bacterial viability that has proven useful for a diverse array of bacterial 
genera. LIVE/DEAD BacLight allow researchers to easily, reliably and quantitatively 
distinguish live and dead bacteria in minutes, even in a mixed population containing 
a range of bacterial types. 
Since no consensus treatment for peri-implantitis has yet emerged, there is an urgent 
need for quantitative evaluation of the available treatment options.  This study is 
designed to compare the biofim removal efficiency of the Er:YAG laser with 
mechanical biofilm removal tools.  Our goal is to establish whether Er:YAG laser 
significantly improves titanium surface decontamination.  Our findings may 
contribute to the development of novel and efficient treatment of peri-implantitis. 
Standard of Care in the TUSDM Periodontal Clinic 
 
For patients who are experiencing a failing dental implant, the treatment starts with 
improving overall oral hygiene and controlling any etiological factors that prevent 
restoration of optimum oral health. The second step usually involves a surgical 

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intervention method such as open flap debridement, followed by implant 
decontamination using Er:YAG, titanium brushes, or plastic curettes. If the bony 
defect developed by the disease process is contained, bone regenerative therapy may 
be used.  
 
I) Research Plan 
 
A) Experimental Design 
 
This study is designed to investigate the efficiency of biofilm decontamination of 
Er:YAG laser compared to carbon fiber curette. The first phase is clinical wherein 
experimental subjects will be recruited. Full periodontal examination will be 
performed and alginate impressions will be taken. A custom mouth guard that holds 
multiple titanium discs will be fabricated. Experimental subjects will be instructed to 
wear this mouth guard for 72 hours, during which time a natural bacterial biofim will 
form on the disc surfaces. The second phase of the study will be performed after 
collecting the discs from the subjects and exposing them ex vivo to one of four 
treatment groups 1) Er:YAG laser, 2) carbon fiber curette, 3) titanium brush, and 4) 
no treatment (control). The biofilm will be stained with LIVE/DEAD BacLight dye and 
the residual biofilm will be visualized under fluorescence microscopy.  Quantification 
of residual biofilm will be performed using image analysis software (Image J, NIH).  
Statistical methods will be used to determine the significance of each treatment 
modality. The primary outcome of the study is the percent area of the titanium disc 
covered by biofilm.   
 
B) Power Calculation 
  
A power calculation was performed via the statistical software nQuery Advisor 
(Version 7.0). Using the results of Schwarz et al.42 for anticipated means and 
standard deviations, and assuming that the mean for the combination group is equal 
to the mean of the Er:YAG laser group, a sample of 8 subjects, allowing for ~20% 
dropout with a final projected sample size of 6 (8 discs per subject, 64 total discs) is 
sufficient for a Type I error rate of 5% and a power over 99%. Discs retrieved from 
each mouth guard will be randomized over the 4 treatment groups using the “sample” 
function of the statistical software package R (Version 3.1.2), so that each subject 
will contribute two discs to each treatment group. 
  
C) Statistical analysis 
  
Descriptive statistics (means, standard deviations, medians, and inter-quartile 
ranges) will be computed by group. Statistical significance will be assessed via 
repeated-measures ANOVA if the data are normally distributed, and Friedman’s test 
if the data are not normally distributed. P<0.05 will be considered statistically 
significant. The analysis will be conducted using SPSS Version 22. 
 
D) Products 
 
Titanium discs will be supplied by Straumann USA (Andover, MA). 

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E) Subject Characteristics 
 
Inclusion criteria: 
- 
Adults (18 years or older). 
- 
Presence of enough teeth to support the mouth guard. 
- 
English proficiency. 
- 
Subjects diagnosed with clinical health, gingivitis, or slight chronic 
periodontitis defined as periodontal inflammation with slight (1-2mm) 
attachment loss.  Subjects will not be stratified based on oral health. 
 
Exclusion criteria: 
- 
Subjects with insufficient dental support for the mouth guard 
- 
Subjects diagnosed with moderate or severe chronic periodontitis. 
- 
Subjects with known allergy to acrylic or titanium. 
- 
Subjects who smoke cigarettes, cigars, snuff tobacco, or any other form of 
smoking. 
- 
Subjects with a history of antibiotic treatment within the last six months. 
- 
Subjects with contraindications to wearing a mouth guard, such as chronic 
obstructive pulmonary disease or severe sleep apnea. 
- 
Subjects with uncontrolled or debilitating medical conditions, including but 
not limited to subjects with uncontrolled diabetes, hematologic disorders, 
cancers, 
immunosuppression, 
severe 
cardiovascular 
disease, 
or 
uncontrolled thyroid disease  
- 
Subjects that are currently pregnant according to self-report as hormonal 
changes may affect the outcomes of the study. 
- 
Subjects who are unable or unwilling to sign the informed consent form 
(ICF). 
- 
 Subjects may not participate in this study if they concurrently participate 
in another research study. 
 
Subject withdrawal and termination criteria: 
- 
Subject may withdraw from the study at any time.  Subjects may remain 
patients of TUSDM if they decide to withdraw from the study.   
- 
Investigators may terminate subjects if they no longer fulfill inclusion 
criteria, if an exclusion criterion is met, or if they do not show up for 
scheduled study visits.  Subjects may remain patients of TUSDM if they are 
withdrawn from the study. If a subject withdraws from the study early and 
returns the mouth guard, the mouth guard and the titanium discs will not 
be analyzed and will be disposed of.  Subjects withdrawing from the study 
early will not be eligible for the $25 gift card. 
- 
Unanticipated Adverse Device Event 
 
 
The Principal Investigator will determine whether subjects (either withdrawn 
subjects or subjects completing the study) are in need of additional treatment 
and/or follow-up observation.  Potential unforeseen adverse events may include 
allergic reaction to acrylic or titanium, or irritation of the gum by the mouth guard.  

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Subjects and/or their insurance will be responsible for the cost of any standard of 
care follow-up visits or additional treatment that is not part of this study. 
 
 
F) Assessment 
1) Risk 
 
Risks associated with standard of care periodontal examination for periodontal 
patients include sensitivity, discomfort, pain and bleeding during examination. 
Swelling is not expected. 
 
Risks associated with the mouth guard include speech alteration and esthetic 
concerns. Abstaining from the use of toothpaste and mouthwash for 3 days 
poses minimal health risk as the principal factor in oral hygiene is the 
mechanical plaque removal by the toothbrush bristles.  The risk associated 
with brushing without toothpaste or not using mouthwash for 3 days is 
halithosis (bad breath). Also, disc de-attachment presents another risk of 
swallowing or aspiring. That risk will be minimized by close adaptation of the 
mouth guard to the disc and the use of adhesive (PeriAcryl). 
 
Potential unforeseen adverse events may include allergic reaction to acrylic or 
titanium, or irritation of the gum by the occlusal mouth guard.   
 
Loss of confidentiality is also a risk of participation. This risk will be minimized 
by following the procedures outlined in the confidentiality section. 
 
2) Benefits 
 
There are no specific benefits to study participants in this study.  Potential 
benefits to society might include improved treatment protocols for peri-
implantitis. Potential benefits to science might include increased understanding 
of methods used to decontaminate implant surfaces. 
 
3) Alternatives 
 
The alternative is to not participate in the study and receive standard of care 
periodontal treatment at the TUSDM clinic at standard clinic costs. 
 
G) Study Procedures 
 
Visit 1: Screening and consent (Approximately 90 minutes) 
 
Subjects will be asked to read the informed consent form (ICF). Subjects will be given 
ample time to have any questions answered. If a subject decides to participate, he 
or she will be asked to sign the ICF. A copy of the ICF will be given to the subject. 
 
Medical history and demographic information will be collected. To determine eligibility 
periodontal examination will be performed according to standard of care, including 

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measuring pocket depth, recession, attachment level, and bleeding on probing. If full 
periodontal examination was performed at TUSDM no more than 6 months ago, then 
existing records may be used to determine eligibility. As periodontal measurements 
are not a primary outcome, existing periodontal measurements collected by other 
TUSDM dentists may be used.    
 
Inclusion and exclusion criteria will be considered and eligibility for the study will be 
determined.  
 
Alginate impression for the maxillary teeth will be taken using stock plastic trays 
according to subject’s arch size in conformance with standard of care practice. 
 
After Visit 1 (In the Laboratory): Impression pouring, cast, and mouth guard 
fabrication 
 
After the visit, alginate impressions will be disinfected and poured in the dental 
laboratory using dental stone. Subjects are not required to stay for the length of time 
of laboratory procedures.  Dental stone will be allowed to set for 45 minutes before 
cast retrieval. After retrieval, casts will be trimmed according to laboratory standards. 
Titanium discs (5mm diameter, 1 mm thick, 4 discs each on the left and right 
premolar/molar areas, a total of 8 discs per subject, supplied by Straumann USA) 
will be fixed on the buccal surfaces of posterior teeth of the casts. A computerized 
positive pressure thermal-molding machine (Biostar, Great Lakes Orthodontics, 
Tonawanda, NY) will be used to fabricate a 1mm thick mouth guard on top of the 
cast, covering the attached titanium discs. The mouth guard will be removed from 
cast and trimmed to proper size. New titanium discs of the same size and count will 
be secured in mouth guard compartments with surgical adhesive (PeriAcryl, Salvin 
Dental Specialties, Charlotte, NC, Figure 1). The final shape of the appliance will 
resemble an occlusal mouth guard. The mouth guard will be disinfected in 0.12% 
chlorhexidine.  
 
 
Figure 1: Gosau et al. 43 
Visit 2: Within 2 months of Visit 1- Mouth guard delivery (approximately 60 
minutes)  
 

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Medical history will be reviewed. Eligibility criteria will be re-evaluated. The mouth 
guard will be inserted into subject’s mouth and adjusted for complete fitting and 
comfort. Intra-oral photograph will be taken in frontal view of the subject’s teeth and 
gums while wearing the mouth guard. 
 
Subject will be asked to use the mouth guard for 72 hours continuously except during 
eating. Patient will be instructed to brush their teeth twice daily without the use of 
toothpaste and to floss once daily. Mouth rinses will be prohibited. These instructions 
will be given verbally with demonstration facing a mirror.  The same instructions will 
be provided to study subjects in writing as well. 
 
Visit 3: 3 days after Visit 2- Mouth guard retrieval (approximately 30 minutes)  
 
Medical history will be reviewed. Eligibility criteria will be evaluated. Mouth guard will 
be retrieved from patient and stored until analysis.  
 
After Visit 3(In the laboratory): Group Assigning, Experimental Treatments, and 
Measurements 
 
After the visit, titanium discs will be separated from the mouth guard. Subjects are 
not required to stay for the length of time of laboratory procedures.  Care will be 
taken not to disturb the surface biofilm.  The back side of each disc will be numbered 
1-64 and the subject and intraoral location will be recorded. Discs retrieved from 
each occlusal mouth guard will be randomized over the 4 treatment groups using the 
“sample” function of the statistical software package R (Version 3.1.2), so that each 
subject will contribute two discs to each treatment group. 
 
After treatment, discs will be placed individually in a 24-well tissue culture plate, 
rinsed with saline and stained using the LIVE/DEAD BacLight dye Kit (Thermo Fisher 
Scientific, Waltham, MA). Equal volumes of Component A and Component B will be 
combined in a microfuge tube. The dye mixture will be added to the discs and 
incubated at room temperature in the dark for 15 minutes. The discs will be observed 
in a fluorescence microscope equipped with FITC/TRITC filter sets (Zeiss Axiovert 
200, Carl Zeiss AG, Oberkochen, Germany).  Percent biofilm covered area will be 
calculated with digital image analysis software (ImageJ, NIH). 
                  Appointment 
 
 
Procedures 
Visit 1 
Screening/ 
Baseline 
 
Visit 2 
Baseline 
(Treatment 
Day 0) 
Visit 3 
Retrieval 
(Treatment 
Day 3) 
Consent Form 
X 
 
 
Demographics 
X 
 
 
Medical/Dental History 
X 
X 
X 
Inclusion/Exclusion Criteria 
X 
X 
X 
Oral Examination 
X 
 
 
Digital Photography 
 
X 
 
Alginate Impressions 
X 
 
 
Compensation 
 
 
X 

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Mouth guard Delivery 
 
X 
 
Mouth guard Instructions 
 
X 
 
Mouth guard Retrieval 
 
 
X 
 
H) Subject Safety  
 
1) Adverse Event Reporting 
 
Adverse Events 
 
An adverse event is any untoward or unfavorable medical occurrence in a human 
subject, including any abnormal physical exam or laboratory finding, symptom, or 
disease, temporally associated with a subject’s participation in the research. An 
adverse event in this study may be the loss of the mouth guard or the loss of a 
titanium disc. 
 
Adverse events will be recorded in source documents and on case report forms. All 
adverse events and non-serious situations will be recorded, monitored, and reported 
to the IRB at time of continuing review or at the study’s termination if this occurs 
before the study’s next continuing review. 
 
Adverse events will be recorded in source documents and on case report forms. All 
adverse events and non-serious situations will be recorded, monitored, and reported 
to the IRB at time of continuing review. 
 
Serious Adverse Events  
 
A serious adverse event is one that results in death, or is life-threatening, or results 
in hospitalization or prolongation of existing hospitalization, or results in a persistent 
or significant disability/incapacitation, or results in a congenital anomaly/birth defect, 
or may jeopardize the subject’s health and may require medical or surgical 
intervention to prevent one of the other outcomes listed above.  Based on clinical 
experience with mouth guards it is unlikely that study subjects will experience any 
serious adverse event.  Should a serious adverse events occur, will be recorded in 
source documents and on case report forms. Serious Adverse Events that meet the 
criteria of an unanticipated problem will be reported to the IRB within 5 business days 
following the Reportable New Information Policy. Serious adverse events that do not 
meet the criteria for an unanticipated problem will be recorded in source documents 
and on case report forms, and included in the summary reporting form at the 
continuing review or at the study’s termination if this occurs before the study’s next 
continuing review. 
 
Unanticipated Problems 
 
An unanticipated problem is an incident, experience, or outcome that meets all of the 
following criteria: 1) The nature, severity, or frequency is unexpected for the subject 
population or research activities as described in the current IRB approved protocol, 
supporting documents, and the ICF(s); 2) it is related or possibly related to 

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participation in the research; 3) it suggests the research may place the subject or 
others at a greater risk of harm then was previously recognized. 
 
Unanticipated problems will be recorded in source documents and on case report 
forms. Unanticipated problems will be reported to the IRB within 5 business days 
after the PI/study team becomes aware of the problem. A Reportable New 
Information Form will be submitted to the IRB no later than 5 business days after the 
PI/study team becomes aware of the problem. 
 
Subject Participation 
 
2) Screening 
 
 
Dr. AlMoharib will conduct screening as outlined in Visit 1. 
 
3) Informed Consent 
 
Dr. AlMoharib will introduce the study.   
 
Written consent will be obtained following “SOP: Written Documentation of 
Consent (HRP-091).” Consenting will take place in a private clinic bay area 
and the patient will be given as much time as he/she needs to consider 
participation. The participant will be invited to include or exclude any 
associates (e.g., loved ones) in the consent process.  
 
Patients will be asked to read the consent form and given ample opportunity 
to have their questions answered.  To avoid coercion, the consenting 
investigator will read through the copy of the consent form with the 
participant section by section, making sure the participant understands 
each section and has an opportunity to ask questions.  If at any time the 
participant indicates s/he is not interested in participation, the meeting will 
end.   
 
If after going through the consent form, the participant indicates s/he would 
like to discuss the study with associates or think about participating, then 
the meeting will be ended and the participant will be asked to contact the 
study when s/he makes her decision. If the participant contacts the study 
in the future for participation, s/he will be invited back to the clinic, and if 
informed consent is given at that time, study activities will begin then. 
 
If the participant indicates s/he may be interested in participating after 
going through the consent form with the investigator, and the investigator 
determines the participant has the capacity to provide informed consent, 
the participant will be asked to provide informed consent at that time. 
Patients will certify their willingness to participate in the study by signing 
and dating the IRB approved informed consent document.  The subject will 
be given a copy of the consent form.    
 

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If any new finding requires any change to the informed consent form, the 
subject will be re-consented. 
 
Non-English speaking subjects will not be enrolled in the study because 
study staff at this time are not certified, prepared, or trained to translate 
or communicate in any language other than English. The study budget does 
not allow for the payment of translation services at this time. There are no 
benefits to the subject by participating in this study. 
 
4) Study Location 
Tufts University School of Dental Medicine 
 
5) Personnel 
- Robert Gyurko, PI: supervision of the study, contact with IRB, 
data analysis 
- Hani AlMoharib, Co-investigator, Resident: obtaining informed 
consent, performing study visits, recording data 
- Bjorn Steffensen, Co-Investigator, advisor 
- Driss Zoukhri, Co-Investigator, advisor 
- Matthew Finkelman, statistician, data analysis 
 
6) Payment for Participation 
(a) Compensation 
- Amazon gift card ($25, given at the completion of Visit 3) 
- Subjects will not be able to keep the mouth guard fabricated for 
the study. If they wish to have a mouth guard, they will be 
referred to TUSDM for the fabrication of a new mouth guard. 
Subjects will be responsible for payment of a new mouth guard. 
(b) Transportation 
- No reimbursement for travel. 
(c) Payment and Insurance 
- Subjects and their insurance will not be billed for any study 
procedures. 
 
7) Study Results 
 
If interested, study results will be presented to a subject upon their request, either 
in person or via mail according to their preference, upon completion of the study. An 
internal log will be kept of the participants who have requested to receive study 
results. 
 
8) Confidentiality 
 
To ensure confidentiality of subject information, each subject enrolled in the study 
will be assigned a unique alphanumeric code. Subjects’ files will be kept in a secure, 
locked cabinet in a secure room (PI’s office) when the files are not being reviewed. 
The information will only be shared between the researchers. All HIPAA requirements 

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will be followed. All information collected in this study will be stored in a secure 
location TUSDM and kept strictly confidential except as may be required by law.  All 
electronic files will be kept on a password protected computer in a secure, locked 
office. If any publication results from this study, subjects will not be identified by 
name without prior consent.   
 
(a) Coding 
 
Once eligibility has been determined by the inclusion and exclusion criteria, subject 
identification number and treatment group will be assigned.  Identification numbers 
will be assigned sequentially.  The full subject identification number will consist of the 
three letters from the subject’s initials and their enrollment number.  
 
(b) Access 
 
Only study personnel will have access to data.  Investigators will permit monitoring, 
audits, and regulatory inspections and will provide direct access to study related 
documentation. 
 
9) New Findings 
 
The subject will be informed of any significant new findings discovered during the 
course of this study that might influence the subject’s continuation and participation 
in the study.  Subjects will be told at a study appointment or via telephone of new 
findings during the study. Costs of treatment for any new findings will not be covered 
by the study. If new findings require revisions to the ICF, the subject will be re-
consented. 
 
10)  Data Safety Monitoring Plan 
 
Study personnel will monitor this trial for all safety related issues to determine 
whether an unreasonable risk to subjects develops. Quality control measures include 
routine inspection of case report forms, source documents, data tabulations, and 
tracking of adverse events. 
  
 
I) Record Retention 
1) Study Records 
 
The Principal Investigator will maintain all study records and documents during 
the study period.  All paper files and documents will be kept in a locked file cabinet, 
within a locked room.  Electronic records will be kept on a password protected 
computer and only be accessible to study personnel. 
  
2) Long Term Retention 
 

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The investigator will maintain all study records following completion or termination 
of this study in accordance to state law and institutional policy (a minimum of 7 
years). 
 
J) Reporting 
 
Unanticipated problems and adverse events will be reported per the Tufts MC/TUHS 
IRB Reportable New Information Policy.  
The IRB will be notified of any deviations from the protocol in cases of medical 
emergencies when the change is necessary to eliminate an apparent immediate 
hazard to the subject  
Progress reports on the investigation shall be submitted to the IRB at regular 
intervals, but in no event less often than yearly, e.g., at continuing review. 
 
K) Protocol Deviations 
No protocol changes or deviations will be made without prior agreement by the IRB 
unless implemented to protect the health, safety or welfare of subjects. Protocol 
changes or deviations that affect the scientific soundness of the study or the rights, 
safety or welfare of human subjects will be made by a formal amendment subject to 
IRB approval. All such changes or deviations will be included in the final study report. 
 
L) Study Termination 
This study may be terminated for the following reasons:  
Discovery of unforeseen risk that could jeopardize the dental/physical 
well-being of subjects. 
Enrollment or recall rates that are not likely to produce sufficient data 
for evaluation of safety and efficacy 
Non-compliance with the clinical investigational plan, the Investigator 
Agreement, applicable FDA regulations or conditions of approval 
imposed by the reviewing IRB 
Withdrawal of IRB approval  
In the event of study termination, the Principal Investigator will determine 
whether subjects are in need of additional treatment and/or follow-up 
observation as a result of participation in this trial. 
M) Subject Recruitment/Advertising 
Flyers will be posted in TUSDM by the elevators, in the Periodontology clinic waiting 
room and on the pre-doctoral clinic floors next to the huddle boards.  Permission is 
not required for these posting locations. Flyers will remain posted until enrollment 
goals are met. The same flyer will be emailed to TUSDM pre-doctoral and postdoctoral 
students and dental school faculty (see attached flyer). Subjects will be recruited 
through responding to posted study advertisements.  These posted advertisements 
will be visible to faculty, staff, students, and patients.  

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Investigators may also inform clinic patients about the study. Investigators may send 
messages to colleagues via axiUm or inform colleagues verbally, asking for their help 
in recruiting eligible subjects. In addition subjects will be recruited from TUSDM pre-
doctoral clinics through verbal requests to Practice Coordinators. All of the forms of 
recruitment will be submitted for IRB approval prior to use.  
A screening interview/questionnaire or screening script will be used for recruitment 
in response to potential subjects who answer advertisements. Subject name, contact 
information and screening criteria (specified in phone script) will be collected and 
recorded during the calls so that the study team can follow-up with the interested 
people for an in-person screening.  
Screen failure data will be retained by PI. Confidentiality of subjects that screen fail 
will be maintained following procedures outlined in the confidentiality section. 
Screening ID number and demographic information will be recorded.  Identifiable 
information will not be recorded in the screening log.  
 
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O)