Immune Response After Periodontal Treatment
Phase: NA
Conditions: Periodontal Diseases
Sponsor: University of Glasgow

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                     The Systemic Response to Periodontal Treatment              
 
The Immune Response after ultrasonic scaling versus hand scaling Periodontal 
Treatment: A randomised controlled trial 
: A randomised controlled trial 
 
 
 
 
 
Running title: The Immune Response after Periodontal Treatment (IRaPT)            
 
Protocol Version: 
 
 
Version 1.1 
Date:  
 
 
 
9th February 2018 
REC Reference Number: 
 
TBC 
ISRCTN/Clinical trial.gov:  
Sponsor’s Protocol Number: 
 
 
Sponsor: 
 
Funder: 
 University of Glasgow/Dentsply Sirona 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
This study will be performed according to the Research Governance Framework for 
Health and Community Care (Second edition, 2006) and WORLD MEDICAL 
ASSOCIATION DECLARATION OF HELSINKI  Ethical Principles for Medical 
Research Involving Human Subjects 1964 (as amended). 

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CONTACTS 
Chief Investigator 
 
Dr Shauna Culshaw 
Senior Clinical Research Fellow, Honorary Consultant in Periodontics 
Oral Sciences, Level 9, Room L14, University of Glasgow Dental School, 378 
Sauchiehall Street, Glasgow. G2 3JZ 
0141 211 9733 
E-mail: shauna.culshaw@glasgow.ac.uk 
 
Co-investigator  
 
Mrs Debbie McKenzie 
Clinical Research Hygienist 
Level 7, Clinical Research Facility, 378 Sauchiehall Street, Glasgow. G2 3JZ 
0141 211 9875 
E-mail: deborah.mckenzie@ggc.scot.nhs.uk 
 
Study Statistician 
 
Dr Andrea Sherriff 
Senior Lecturer in Statistics 
Level 9, University of Glasgow Dental School, 378 Sauchiehall Street, Glasgow. G2 
3JZ 
Tel: 0141 211 9733 
E-mail: andrea.sherriff@glasgow.ac.uk 
 
 
Sponsor  -  
 
Sponsor’s representative – 
 
Mary McAuley 
NRS   Performance Research Portfolio Manager 
West Node Health Boards  
Clinical Research & Development Unit  
West Glasgow Ambulatory Care Hospital (formerly Yorkhill) Dalnair Street 
Glasgow G3 8SW 
Telephone: 0141 232 1824   
 
Funding Body –  
University of Glasgow  

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PROTOCOL APPROVAL 
 
The Systemic Response in Periodontal Disease  
 
Chief Investigator 
Dr Shauna Culshaw 
Senior Clinical Research Fellow, Honorary Consultant 
in Periodontics 
Infection and Immunity, Level 9, Room L14,  
University of Glasgow Dental School 
378 Sauchiehall Street 
Glasgow  
G2 3JZ 
 
  
 
Signature: 
 
 
 
 
 
 
Date:  
 
 
 
 
 
Sponsor’s representative  
 
Signature:  
 
 
 
Date:  
 
 
 
 
 

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TABLE OF CONTENTS 
Once protocol draft complete, left click on this section press F9 and update entire 
table 
 
CONTACTS ............................................................................................................................ 2 
PROTOCOL APPROVAL ......................................................................................................... 3 
TABLE OF CONTENTS ........................................................................................................... 4 
ABBREVIATIONS ................................................................................................................... 5 
STUDY SYNOPSIS .................................................................................................................. 6 
STUDY FLOW CHART ............................................................................................................ 8 
SCHEDULE OF ASSESSMENTS .............................................................................................. 9 
1. 
INTRODUCTION ............................................................................................... 9 
1.1 
Background ....................................................................................................... 9 
1.2 
Rationale ......................................................................................................... 10 
1.3 
Prior experience of periodontal research ........................................................... 10 
1.4 
Study hypothesis ............................................................................................. 10 
2. 
STUDY OBJECTIVES ...................................................................................... 11 
3. 
STUDY DESIGN .............................................................................................. 12 
3.1 
Study Population ............................................................................................. 12 
3.2 
Inclusion criteria .............................................................................................. 12 
3.3 
Exclusion criteria.............................................................................................. 12 
3.4 
Identification of participants and consent .......................................................... 13 
3.5 
Withdrawal of subjects ..................................................................................... 13 
4 
Trial procedures .............................................................................................. 13 
4.1 
Study schedule ................................................................................................ 13 
4.2 
Study Outcome Measures ................................................................................. 15 
4.2.1 
Primary Outcome Measure ........................................................................ 15 
4.2.2 
Secondary Outcome Measure .................................................................... 15 
4.3 
Laboratory Tests .............................................................................................. 15 
5. 
STATISTICS AND DATA ANALYSIS ................................................................. 16 
5.1 
Statistical analysis plan .................................................................................... 16 
5.2 
Primary efficacy analysis .................................................................................. 16 
5.3 
Secondary efficacy analysis .............................................................................. 18 
5.4 
Safety analysis ................................................................................................ 18 
5.5 
Software for statistical analysis ......................................................................... 19 
5.6 
Sample size ........................................................ Error! Bookmark not defined. 
5.7 
Management and delivery ................................................................................ 19 
6. 
STUDY CLOSURE / DEFINITION OF END OF TRIAL ......................................... 19 
7.  
DATA HANDLING .......................................................................................... 20 
7.1 Case Report Forms ............................................................................................. 20 
7.2 Record Retention ................................................................................................ 20 
8. 
TRIAL MANAGEMENT .................................................................................... 21 
8.1 
Routine management of trial: Trial Management Group ..................................... 21 
9. 
STUDY AUDIT ................................................................................................ 22 
10. 
PROTOCOL AMENDMENTS .......................................................................... 23 
11. 
ETHICAL CONSIDERATIONS ........................................................................ 24 
11.1 
Ethical conduct of the study ........................................................................... 24 
11.2 
Informed consent .......................................................................................... 24 
12. 
INSURANCE AND INDEMNITY ....................................................................... 25 
13. 
FUNDING ...................................................................................................... 26 
14. 
ANNUAL REPORTS ...................................................................................... 27 
15. 
DISSEMINATION OF FINDINGS ..................................................................... 28 
16. 
REFERENCES .............................................................................................. 29 
The Systemic Response in Periodontal Disease – Case Report FormError! Bookmark not defined. 
 

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ABBREVIATIONS 
 
 
CI 
Chief Investigator 
CO 
Co-Investigator 
CRF 
Case Report Form 
GDHCRF 
Glasgow Dental Hospital Clinical Research Facility 
PD 
Periodontal Disease 
PIL 
Participant Information Leaflet 
R&D 
Research and Development 
REC 
Research Ethics Committee 
SD 
Standard Deviation 
FM 
FULL MOUTH 
HS 
HAND SCALE 
USS 
ULTRASONIC SCALER 
 

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STUDY SYNOPSIS 
 
Title of 
Study: 
The Immune Response after Periodontal Treatment 
Study 
Centre: 
Glasgow Dental Hospital 
Duration of 
Study: 
36 MONTHS 
Primary 
Objective: 
To identify changes in systemic markers of inflammation 
following periodontal treatment, comparing two standard 
treatment modalities (hands scaling and ultrasonic scaling) 
 
 
Secondary 
Objectives: 
To investigate bacteraemia, composition and function of oral 
bacteria, treatment outcomes following periodontal treatment, 
patient and operator preferences, and treatment time 
comparing hand scaling and ultrasonic scaling.  
 
Primary 
Endpoint: 
C-reactive protein in the circulation following treatment. 
Rationale: 
To determine whether hand scaling or ultrasonic scaling are 
different at inducing a systemic inflammatory response.  
Methodology
: 
RCT  
Sample Size: 42 patients  (TBC)  
Screening: 
Patients referred to Glasgow Dental Hospital Unit of 
Periodontics requiring periodontal treatment at Glasgow 
Dental Hospital.  
Registration/
Randomisati
on: 
Patients and their samples will be assigned a study code. 
There will be (stratified) randomisation to treatment with 
either hand scaling or ultrasonic scaling 
Main 
Inclusion 
Criteria: 
• Provision of signed, written, informed consent to 
participate 
• Men or women aged 18 years to 70 years inclusive 
• Periodontal disease requiring treatment at Glasgow 
Dental Hospital 
Main 
Exclusion 
Criteria: 
• Known or suspected high risk for tuberculosis, hepatitis 
B or HIV infections 
• Require interpreter/non English language written 
material to understand and provide, or any other 
reason for being unable to provide written, informed 
consent 
• History of bleeding diathesis  
• Females using contraceptive methods. 
• Pregnant or lactacting females. 
• Reported diagnosis of any systemic illnesses including 
cardiovascular, renal, and liver diseases. 

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• Any pharmacological treatment within 3 months before 
the beginning of periodontal treatment. 
• Specialist Periodontal treatment in the previous 6 
months. 
• Patients who will not tolerate Ultrasonic instrumentation 
even with local anaesthesia.  
Statistical 
Analysis:  
Different types of data will be generated from the study, e.g.  
- 
Serum CRP pre and post treatment.  
- 
Serum cytokine levels pre and post treatment 
- 
Bacteraemia pre and post treatment 
- 
Composition and function of oral bacteria pre and post 
treatment.  
- 
Clinical data to provide a measure of severity and extent 
of periodontal disease pre and post treatment.  
- 
Patient centred outcomes of each treatment modality.  
- 
See statistical analysis plan (SAP) for further details.  
 

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STUDY FLOW CHART 
 
Legend for study flow chart. 
 
Text in BOLD indicates a patient visit. Grey shaded boxes indicate stages of the 
study which fit into the patient journey. All of these would be part of the usual patient 
journey in the unit of Periodontics.  
 

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SCHEDULE OF ASSESSMENTS 
 
Study Procedure  
Screening  
initial 
consultant 
appointmen
t  
Base 
line 
 
TREATMENT 
VISITS 
DAY 1 
WITHI
N 
24HR 
Day 7 
+/- 
24HR 
Day 90 
+/-
10DAY 
Study information given  
Y 
 
 
 
 
 
Review 
Inclusion/Exclusion 
Criteria 
Y 
Y 
Y 
Y 
Y 
Y 
Obtain initial indication if 
patient will consider 
study and appoint for 
combined study/first 
treatment visit 
Y 
 
 
 
 
 
Obtain written consent  
 
Y 
 
 
 
 
Randomisation 
 
Y 
 
 
 
 
FMPS & FMBS & 
Periodontal charting 
* 
Y 
 
 
 
 
Blood Collection ( 8- 
10am ) 
 
y 
 
 
 
 
blood pressure and BMI 
record 
 
y 
 
 
 
 
Medical History 
Y 
Y 
Y 
Y 
Y 
Y 
OHI 
 
y 
Y 
 
Y 
Y 
Sample collection 
(blood, plaque, GCF, 
saliva) 
 
√ 
 
Y  
Y  
Y  
Obtain^/Review consent  
 
 
Y 
Y 
Y 
Y 
Complete CRF 
 
Y 
Y 
Y 
Y 
Y 
*deepest site on each tooth recorded only 
1. INTRODUCTION 
1.1 
Background 
Effective root surface debridement (RSD) is essential for successful periodontal 
treatment. Myriad studies demonstrate that RSD may be carried out using hand or 
ulstrasonic instruments with equal efficacy (1). Locally, effective debridement results 
in reduced inflammation in the gingival tissues, ultimately preserving the dentition. 
Systemically, RSD results in an immediate inflammatory response with elevated C-
reactive protein (CRP), and cytokines (e.g. interleukin-6 and Tumor Necrosis Factor) 
detectable in the serum (2). This systemic inflammation may relate to systemic 
dissemination of bacteria from the periodontal pockets into the circulation, during 
instrumentation. Bacteria are detectable in serum immediately after instrumentation 
(3). The incidence of the bacteraemia varies considerably between different studies, 

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ranging from 13% of patients (4) to 43% (5) to 55% (6). These studies used different 
methods of instrumentation; Kinane et al used full mouth ultrasonic scale, Zhang et al 
used a mixture of hand and ultrasonic instruments, and Heimdahl et al used curettes 
only. Whilst tempting to speculate that ultrasonic instrumentation induces less 
bacteraemia than hand instrumentation, there is no direct comparison of the effect of 
ultrasonic instrumentation with hand instrumentation on post treatment systemic 
inflammation. 
1.2 
Rationale 
. We propose that ultrasonic and hand instruments may cause different 
immediate systemic effects on patients. The long-term consequences of post-
RSD systemic inflammation and bacteraemia are not known. In healthy individuals it 
could be speculated that the systemic effects of RSD are short lived, resolve, and do 
not harm the patient. However, in medically compromised patients, for example with 
vascular disease, such perturbation to systemic homeostasis could be speculated to 
carry a greater potential risk to health. With an aging population and increased tooth 
retention, more medically compromised patients receive periodontal treatment.  
We propose a study to investigate the systemic impact of different debridement 
methods, outlined in the diagram below.  
 
1.3 
Prior experience of periodontal research 
The Chief Investigator (CI) is a specialist periodontist treating patients with advanced 
and aggressive forms of periodontal disease. The CI has a developing track record in 
periodontal research, with current research funding in the region of £1.3 million and a 
number of peer reviewed publications as detailed on attached CV. The CI works in 
close collaboration with world-renowned immunologists and microbiologists and 
several consultant periodontist colleagues at the Glasgow Dental Hospital.  
DMcK is an extremely experienced Dental Hygienist who also has experience of 
dental research, including commercial and non-commercial studies, which have 
included treatment of periodontitis.  
 
 
1.4 
Study hypothesis 
There is a difference in the systemic response to periodontal treatment using either 
hand instruments, as compared with periodontal treatment using ultrasonic 
instruments.  
 

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2. STUDY OBJECTIVES 
 
1. To investigate systemic markers of inflammation following periodontal treatment, 
comparing two standard treatment modalities (hands scaling and ultrasonic scaling). 
 
2. To investigate bacteremia, composition and function of oral bacteria, treatment 
outcomes following periodontal treatment, patient and operator preferences, and 
treatment time comparing hand scaling and ultrasonic scaling.  
 

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3. 
STUDY DESIGN 
This Randomized Controlled Trial will be performed according to the Research 
Governance Framework for Health and Community Care (Second edition, February 
2006). 
3.1 
Study Population 
The study will aim to recruit 42 eligible patients requiring periodontal treatment within 
a recruitment period of 18-24 Months.  
3.2 
Inclusion criteria 
• 
Written informed consent 
• 
Male or female 18 years to 70 years inclusive 
• 
Periodontal treatment required at Glasgow Dental Hospital or General Dental 
Practice  
• 
Patients able to travel and attend all study visits. 
• 
Probing pocket depths >5mm on 2 or more teeth at non-adjacent sites with 
cumulative probing pocket depths of greater than or equal to 40mm 
(Cumulative probing depth is calculated by evaluating all sites on each tooth. 
The deepest site on each tooth is recorded and if this value is greater than 
4mm this is ‘counted’ and the sum of all the teeth assessed in this way 
calculated.)    
3.3 
Exclusion criteria 
• 
Known or suspected high risk for tuberculosis, hepatitis B or HIV infections  
• 
Require interpreter/non English language written material to understand and 
provide, or any other reason for being unable to provide written, informed 
consent 
• 
History of bleeding diathesis 
• Pregnant or lactacting females. 
• Reported diagnosis of any systemic illnesses including cardiovascular, renal, 
and liver diseases, and/or regular use of medication to control systemic 
illness.  
• Any pharmacological treatment within 1 month before the beginning of the 
study, including routine use of any over the counter medications.  
• Specialist Periodontal treatment in the previous 6 months. 
 
Randomisation: patients will be stratified according to smoking status then 
randomized to one of two groups (hand vs ultrasonic) according to the randomization 
schedule (permuted blocks of size 4 and 6). The randomization schedule will be 
computer generated and allocation will be concealed up until the point of treatment.  
Masking: it will not be possible to mask the clinicians providing the treatment; 
however the researcher collecting the samples and undertaking the analysis will be 
masked to group allocation, through the use of anonymised coded samples.  All other 
study personnel will not have access to identifiable data. 

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3.4 
Identification of participants and consent 
 
Patients will be identified by the CI or other clinician responsible for the patient. 
Patients will be screened at this time to establish eligibility. The inclusion/exclusion 
criteria will be evident from the information taken as part of the normal clinical 
procedure (eg history, examination and treatment plan). Eligible patients will be 
initially informed of the existence of the study and approached by the consultant or 
his/her representative who is treating the patient (E.g. specialist trainee/house 
officer/GDP/DCP). This initial contact will be to provide the patient with the 
Participant Information Leaflet (PIL) and establish whether they would consider 
taking part. At the subsequent visit, (Screening visit), the CI/CO/Registrar/consultant 
or research nurse will ask whether the patient would like to take part and obtain 
consent. At each stage, it will be made clear to the patient that that participation is 
voluntary and they can leave the study at any time without their care being affected.  
3.5 
Withdrawal of subjects 
Patients will be withdrawn for the study if they are no longer eligible (e.g. due to a 
change in general health) or if the patient withdraws their consent to participate, or if 
for any other reason the CI or patient’s consultant deems it detrimental to the patient 
to continue to participate.  Withdrawal will be immediate. The CI will be informed and 
will confirm whether the patient wishes any previously obtained samples and 
associated data withdrawn from the study. The reason for withdrawal and the 
subsequent action taken will be documented on a case-by-case basis as an addition 
to the case report form (CRF).  
 
4 
Trial procedures 
4.1 
Study schedule 
Patients will attend Glasgow Dental Hospital for screening, baseline, treatment, then 
Day 1 after treatment, Day 7 after treatment, and review (day 90 after treatment). 
Screening visits may be undertaken by GDP. The visits are labelled as per the flow 
chart/table with the purpose of the visit. 
 
Screening visit: New patient assessment  
Patients are referred then appointed on a new patient consultant clinic at which a 
clinical history and clinical examination are completed by the consultant or his/her 
staff. A treatment plan is then agreed with the patient. If this treatment plan includes 
periodontal treatment at Glasgow Dental Hospital and the patient is eligible to take 
part, then the patient will be provided with written and verbal information about the 
study. The patient will be asked to give an initial indication as to whether they would 
consider taking part – with emphasis that they should take time to consider the PIL 
and will have the opportunity to ask further questions, and that their treatment 
remains unaltered irrespective of their participation. If the patient indicates they would 
consider participation in the study, they will be appointed jointly to the GDHCRF and 
the hygienist / registrar (baseline visit).  
 
Baseline visit:  

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If the patients initially said YES to participating in the study at the screening visit, at 
this visit, prior to the start of treatment the patient will be asked if they have further 
considered participation in the study. If yes, consent for sample collection will be 
sought and samples will be collected by the GDHCRF research nurse and/or 
dentist/hygienist (the hygienist or dentist will generally only collect plaque samples as 
s/he will be removing the plaque anyway). This visit includes FMPS & FMBS & 
Periodontal charting, blood pressure recording, BMI recording and sample collection 
of GCF, plaque & blood). This visit is also for initial periodontal charting and initial 
treatment. This visit includes detailed tooth and gum home care instructions and a 
superficial scaling of the teeth. This is usually carried out by a staff or research 
hygienist, but may also be undertaken by training grade staff under the supervision of 
a consultant. 
gingival indices will be taken. The patient will then be randomised to full mouth non-
surgical periodontal treatment using either hand scalers or ultrasonic instrumentation. 
Appointments will be make for patient to attend for treatment visits, Day1, Day 7 and 
Day 90 visits with time in the GDHCRF for sample collection / blood pressure, BMI 
and periodontal charting where applicable. 
 
Treatment visits - full mouth non-surgical periodontal treatment will be carried out 
within a 24hr period (+/- 18hr) either using hand instrumentation or ultrasonic 
instrumentation as per randomization. At the last treatment visit the clinician will 
verbally enquire whether the patient is happy to continue participation in the study. If 
yes - then the patient should attend Day 1 (24hrs later (+/- 18hrs) with time in the 
GDHCRF for sample collection / blood pressure recording.                     
 
Day 1 - 24 hours (+/-18hrs) after treatment completed, further samples 
(GCF/Plaque/blood) and blood pressure recording will be performed. At this visit the 
clinician will verbally enquire whether the patient is happy to continue participation in 
the study. If yes - then the patient should attend Day 7 (+/- 1 day) with time in the 
GDHCRF for sample collection / blood pressure recording, & review of ohi 
 
Day 7 – 7 days after treatment completed, further samples (GCF/Plaque/blood) and 
tests (blood pressure recording and medical history update) will be performed. At the 
last treatment visit the hygienist will verbally enquire whether the patient is happy to 
continue participation in the study. If yes - then the patient should attend the Day 90 
visit (+/- 10days) with time in the GDHCRF for sample collection / blood pressure 
recording, plaque index  & review of oral hygiene.  
 
 
Day 90 - 90 days after treatment (+/- 10 days) Patient appointed jointly to the 
GDHCRF and for review with consultant or training grade staff / hygienist under 
consultant supervision. FMPS & FMBS & periodontal charting, medical history, blood 
pressure recording, BMI & sample collection of GCF/ Plaque / blood will be taken as 
at baseline, day 1 and day 7 visits.  
  

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4.2 
Study Outcome Measures 
4.2.1 Primary Outcome Measure 
 
Changes in serum CRP pre compared with post treatment.  
4.2.2 Secondary Outcome Measure 
To investigate: Secondary Outcomes: 
Microbiome (continuous and discrete data)  
o Microbiome analysis of plaque 
o Species diversity  
o Collected pre intervention (at baseline visit) 
o Collected post intervention (at day 1) 
Bacteraemia analysis (continuous data) 
o Collected simultaneously with serum CRP 
o  Day 1, day 7 and day 90 post intervention 
 
Inflammation and immune analysis (continuous data) 
o GCF – cytokine measurements 
o Serum cytokine measurement  
o Serum antibody (anti-bacterial/auto antibody) 
o Collected simultaneously with serum CRP 
o 
Day 1, day 7 and day 90 post intervention 
 
Clinical outcomes (discrete data) 
o Periodontal Probing Depths (at day 90 post intervention) 
o Loss of attachment (at day 90 post intervention) 
o Plaque/gingival indexes 
o Blood pressure recording 
o Treatment time (time spent on debridement) 
 
Patient centered outcomes (Questionnaire data - qualitative/qu)antitative) 
o Patient satisfaction and experience 
Clinician centered outcomes – (Interview data - qualitative/quantitative) 
o Experience with each instrumentation technique 
4.3 
Laboratory Tests 
The laboratory analysis will be carried out in University research labs using 
appropriate methodology. The laboratory research group has significant experience 
in these techniques and works within a large group of research scientists within the 
University of Glasgow Dental School and Institute for Infection, Immunity and 
Inflammation – thereby granting access to substantial expertise.  

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5. 
STATISTICS AND DATA ANALYSIS 
5.1 
Statistical analysis plan  
Randomized controlled trial to investigate the difference in systemic response to 
periodontal therapy, using two different treatment modalities – hand instrumentation 
and ultrasonic instrumentation. Patients will receive one of two interventions – hand 
instrumentation or ultrasonic instrumentation, as treatment for their periodontal 
disease. These two interventions will be compared through the following outcomes. 
The primary outcome is that of systemic inflammatory response, measured through 
serum CRP. A variety of secondary outcomes will also be investigated, including 
clinical outcomes related to periodontal disease; microbiome analysis; inflammation 
and immune response analysis. 
 
Stratification and Randomization Methods 
Our target population is that of patients suffering from periodontal disease.  
Randomization 
to 
either 
intervention 
(hand 
instrumentation 
or 
ultrasonic 
instrumentation) will be performed using a computerised random number generator 
(using permuted blocks of size 4 and 6). Patients will be stratified according to 
smoking status prior to randomization.  
Allocation Concealment 
Patients will be allocated to each arm of the study by a member of the research team 
not involved with the clinical delivery of the experimental interventions. Upon 
attending their treatment appointment, an opaque envelope will contain the allocated 
intervention arm for the patient. This will be opened immediately before treatment is 
commenced. 
Blinding 
Both the patients and clinicians will remain blinded to the intervention until the 
intervention is carried out. Research personnel will remain blinded to specific patient 
allocation throughout the process through the means of patient barcodes. The key 
linking the barcodes to the patients will be available to the Chief Investigator.  The 
intervention codes will only be available once the key analyses have taken place. 
Sample Size 
The sample size calculation is based on data from previous published studies that 
measured changes in CRP following periodontal treatment.  From these studies a 
difference of 3.5 mg/l (SD=3 mg/l) in CRP was detected between the two groups 
receiving different schedules of periodontal treatment (quadrant vs full mouth 
debrimdement) at primary endpoint. Therefore at 80% power and a 5% significance 
level, a sample size of n=34 (17 in each group) is required to detect a minimum 
difference of at least 1 standard deviation (3 mg/l) between the change in CRP levels 
from baseline to primary endpoint between the two groups (hand vs ultrasonic). To 
account for potential drop out of 20% we aim to recruit 42 eligible patients to the 
study. 
 
Study Population 
The study will aim to recruit a minimum of 17 patients per group, up to 21 patients 
per group (to account for drop out) requiring periodontal treatment within a 

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recruitment period of 18 – 24 Months. The patients will be recruited from new patient 
clinics in the periodontal department of Glasgow Dental Hospital, Scotland 
 
Statistical Analysis Plan (SAP) 
Objectives 
To determine if there is a difference in the systemic response to periodontal 
treatment using either hand instruments, compared to ultrasonic instrumentation. 
General Principals 
Data will be summarised for patients in both groups. Categorical variables will be 
summarised with the number of observations and missing values, and number and 
percentages of patients falling into each category. Continuous variables will be 
summarised using the number of observations and number missing, mean, standard 
deviation (SD), median, 25th and 75th quartiles (Q1 and Q3 respectively), minimum 
and maximum values.  Formal comparisons will be made between the treatment 
groups using appropriate tests depending on the nature of the data, this may include 
Chi-Squared tests, Fisher Exact Tests, two sample t-tests and Mann Whitney tests. 
Analysis: the effect of treatment group (Manual vs ultrasonic) on changes in CRP 
levels (and other secondary outcomes): 
• 
Appropriate generalised linear models  
• 
Binary logistic models (for dichotomous outcomes) 
Models may be adjusted for age, gender, deprivation levels, operator, smoking, 
baseline disease levels.  
 
Endpoints 
Day 1 post intervention – GCF/plaque/blood samples, blood pressure 
Day 7 post intervention – GCF/plaque/blood samples, blood presure 
Day 90 post intervention – Full mouth pocket and bleeding scores & 
periodontal 
charting, 
blood 
pressure, 
BMI 
and 
sample 
collection 
(GCF/plaque/blood) 
 
Primary Outcome: 
Changes in serum CRP. This will be measured: 
• 
Pre-intervention, at baseline visit (as per flowchart) 
• 
Day 1, day 7 and day 90 post-intervention 
Secondary Outcomes: 
Microbiome (continuous and discrete data)  
o Microbiome analysis of plaque 
o Species diversity  
o Collected pre intervention (at baseline visit) 
o Collected post intervention (at day 1) 
Bacteraemia analysis (continuous data) 
o Collected simultaneously with serum CRP 
o  Day 1, day 7 and day 90 post intervention 
 
Inflammation and immune analysis (continuous data) 

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o GCF – cytokine measurements 
o Serum cytokine measurement  
o Serum antibody (anti-bacterial/auto antibody) 
o Collected simultaneously with serum CRP 
o 
Day 1, day 7 and day 90 post intervention 
 
Clinical outcomes (discrete data) 
o Periodontal Probing Depths (at day 90 post intervention) 
o Loss of attachment (at day 90 post intervention) 
o Plaque/gingival indexes 
o Blood Pressure 
o Treatment time (time spent on debridement) 
Current proposal 
There is a difference in the systemic response to periodontal treatment using hand 
instruments, compared to ultrasonic instrumentation. 
1.1.1. ADDITIONAL ANALYSES TO THOSE SPECIFIED IN THE STUDY PROPOSAL 
Nil 
Research questions 
 
Is there a difference in the systemic response to periodontal treatment using either 
hand instruments, as compared with periodontal treatment using ultrasonic 
instruments.  
Software 
All statistical analyses will be carried out with Stata v 16 (or PRISM) or higher 
versions of these programs. 
 
5.2 
Primary efficacy analysis 
There is no test intervention therefore no efficacy analysis.  
5.3 
Secondary efficacy analysis 
n/a 
5.4 
Safety analysis 
The safety data (adverse events) – both numbers of subjects and events – will be 
summarised.  
 
Adverse Event (AE) – any unfavourable and unintended sign, symptom or disease 
temporally associated with participation in the research project. 
  
Serious Adverse Event (SAE) - An untoward occurrence that: 
a.            results in death 
b.            is life threatening 
c.            requires hospitalisation or prolongation of existing hospitalisation 

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d.            results in persistent or significant disability or incapacity 
e.            consists of a congenital anomaly or birth defect 
f.             is otherwise considered medically significant by the investigator 
  
 
Any SAE occurring to a research participant will be reported to the main REC) where 
in the opinion of the Chief Investigator (CI), the event was: 
• “Related” – that is, it resulted from administration of any of the research procedures, 
and 
• “Unexpected” – that is, the type of event is not listed in the protocol as an expected 
occurrence. 
  
Reports of related and unexpected SAEs will be submitted to the REC within 15 days 
of CI becoming aware of the event, using the ‘report of serious adverse event form’ 
for non-CTIMPs published on the National Research Ethics Service (NRES) website. 
  
5.5 
Software for statistical analysis  
All statistical analyses will be carried out with Stata v 16 (or PRISM) or higher 
versions of these programs 
 
5.6 
Management and delivery 
S Culshaw and colleagues will manage and analyse study data.  
 
6. 
STUDY CLOSURE / DEFINITION OF END OF TRIAL 
The study will end when the CI deems that one or more of the following situations 
applies: 
OR 
i. 
The planned sample size has been achieved; 
ii. 
There is insufficient funding to support further recruitment, and no reasonable 
prospect of additional support being obtained; 
iii. 
Recruitment is so poor that completion of the study cannot reasonably be 
anticipated. 

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7.  
DATA HANDLING 
7.1 Case Report Forms  
Patient data will be collected at the time of sample collection and recorded on the 
CRF. At the time of sample collection, each sample will be assigned a code, 
recorded on the CRF. All data associated with analysis of the samples will be 
collected and stored linked only to the code. The data linking the patient code with 
the patient data will be stored securely on University of Glasgow Computers, using 
password protected file encryption. Hard copies will be stored in a locked file at the 
University of Glasgow Dental School. The data recording sample analysis will include 
only the patient code and will also be stored on University of Glasgow Computers but 
will NOT be encrypted. Hard copies of this data will be stored in laboratory record 
books, kept at the University of Glasgow Dental School. Samples will be stored 
appropriate to the type of sample, within facilities at the University of Glasgow, with a 
detailed description of the sample location, use(s) and ultimately disposal, 
documented in a sample log record. Any data changes will be recorded in order to 
maintain a complete audit trail (reason for change, date change made, who made 
change).  
7.2 Record Retention 
To enable evaluations and/or audits from regulatory authorities, the investigator 
agrees to keep records, including the identity of all participating subjects (sufficient 
information to link records), all original signed informed consent forms, serious 
adverse event reports, source documents, and detailed records of treatment 
disposition in accordance with ICH GCP, local regulations, or as specified in the 
Clinical Study Agreement, whichever is longer.  Data will be retained by the research 
team for 15 years. 

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8. 
TRIAL MANAGEMENT 
8.1 
Routine management of trial: Trial Management Group 
The study will be coordinated from The University of Glasgow Dental Hospital, by the 
Trial Management Group. The Trial Management Group will include the CI, 
statistician, research nurse, and laboratory investigators involved in use of clinical 
samples. The group will monitor all aspects of the conduct and progress of the study, 
ensure that the protocol is adhered to and take appropriate action to safeguard 
participants and the quality of the study itself.  
See Data Security Protocol.  

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9. 
STUDY AUDIT 
Study site-set up visit and site file will be provided once the study has received R & D 
approval. Study audit visits will be conducted according to NHS Greater Glasgow and 
Clyde audit processes. Additional visits may be undertaken if required.  Investigators 
and site staff will be notified in advance of any audit visits. 

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10. 
PROTOCOL AMENDMENTS 
Any change in the study protocol will require an amendment.  Any proposed protocol 
amendments will be initiated by the CI following discussion with the Sponsor and 
amendment forms will be submitted to the REC and R&D.  The CI will liaise with 
Sponsor to determine whether an amendment is non-substantial or substantial.  All 
amended versions of the protocol will be signed by the CI and Sponsor 
representative.  Before the amended protocol can be implemented favourable 
opinion/approval must be sought from the original reviewing REC and R&D office. 

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11. 
ETHICAL CONSIDERATIONS 
11.1 
Ethical conduct of the study 
The study will be carried out in accordance with the World Medical Association 
Declaration of Helsinki (1964) and its revisions (Tokyo [1975], Venice [1983], Hong 
Kong [1989], South Africa [1996] and Edinburgh [2000]). 
 
Favourable ethical opinion will be sought from an appropriate REC before patients 
are entered into this research study.  Patients will only be allowed to enter the study 
once either they have provided written informed consent. 
 
The CI will be responsible for updating the REC of any new information related to the 
study. 
11.2 
Informed consent 
Written informed consent should be obtained from each trial participant. Only patients 
able to consent for themselves will be included in the study. The Consultant or 
his/her representative, or the Research Nurse will explain the exact nature of the 
study in writing, provision of patient information sheet, and verbally.  This will include 
the known side-effects that may be experienced, and the risks of participating in this 
clinical trial.  Trial participants will be informed that they are free to withdraw their 
consent from the study or study treatment at any time, and it will be emphasised to 
participants that their decision to participate in the study does NOT influence the 
treatment they will receive in any way.  

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12. 
INSURANCE AND INDEMNITY 
The sponsor will be liable for negligent harm caused by the design of the trial.  NHS 
indemnity is provided under the Clinical Negligence and Other Risks Indemnity 
Scheme (CNORIS).? 
 
The NHS has a duty of care to patients treated, whether or not the patient is taking 
part in a clinical trial, and the NHS remains liable for clinical negligence and other 
negligent harm to patients under its duty of care. 

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13. 
FUNDING 
University of Glasgow Studentship 

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14. 
ANNUAL REPORTS 
Reports to the sponsor will be coordinated by the university. Annual reports will be 
submitted to the REC and sponsor with the first submitted one year after the date 
that all trial related approvals are in place. 

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15. 
DISSEMINATION OF FINDINGS 
Findings will be presented locally at group meetings, seminars at Glasgow 
Dental School and at the Institute of Infection, Immunity and Inflammation. In 
addition, findings will be presented at national and international meetings and 
submitted to peer review journals. Public engagement in research is important to the 
investigators and funders. Therefore, outreach activities such as ‘meet the expert’ at 
Glasgow Science Centre will include findings from these studies and significant 
findings of broader interest will be promoted with advice and support from the 
University of Glasgow press office to publicise any key developments and to engage 
with a wider audience.  

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16. 
REFERENCES 
 
  
1. 
Ioannou I, Dimitriadis N, Papadimitriou K, Sakellari D, Vouros I, Konstantinidis A. Hand instrumentation versus 
ultrasonic debridement in the treatment of chronic periodontitis: a randomized clinical and microbiological trial. J Clin 
Periodontol. 2009;36(2):132-41. 
2. 
Graziani F, Cei S, Orlandi M, Gennai S, Gabriele M, Filice N, et al. Acute-phase response following full-mouth 
versus quadrant non-surgical periodontal treatment: A randomized clinical trial. J Clin Periodontol. 2015;42(9):843-52. 
3. 
Horliana AC, Chambrone L, Foz AM, Artese HP, Rabelo Mde S, Pannuti CM, et al. Dissemination of periodontal 
pathogens in the bloodstream after periodontal procedures: a systematic review. PLoS One. 2014;9(5):e98271. 
4. 
Denis F. Kinane MPR, Katie F. Walker, Duncan MacKenzie, Barbara Shearer,. Bacteraemia following periodontal 
procedures. Journal Of Clinical Periodontology. 2005;32(7):708-13. 
5. 
Zhang W, Daly CG, Mitchell D, Curtis B. Incidence and magnitude of bacteraemia caused by flossing and by scaling 
and root planing. J Clin Periodontol. 2013;40(1):41-52. 
6. 
Heimdahl A, Hall G, Hedberg M, Sandberg H, Söder PO, Tunér K, et al. Detection and quantitation by lysis-filtration 
of bacteremia after different oral surgical procedures. Journal of Clinical Microbiology. 1990;28(10):2205-9.