Omega-3 Fatty Acids Plus Low-dose Aspirin Daily Supplementation in Surgical Therapy to Treat Aggressive Periodontitis
Condition: Residual Disease; Aggressive Periodontitis
MeSH terms: Periodontitis; Aggressive Periodontitis; Aggression
Study type: Interventional
Phase: Phase 2/Phase 3

Summary: 
      The aim of this randomized controlled clinical trial of superiority will be to evaluate the
      effect of 3 g of omega-3 polyunsaturated fatty acids and 100 mg of aspirin daily
      supplementation over a period of 180 days as adjunct to surgical therapy of residual pockets
      from patients with generalized aggressive periodontitis. Probing depth, clinical attachment
      level, gingival index and concentration of microorganisms and cytokines at baseline, 3, and 6
      months after the procedure will be evaluated.
    

Detailed description: 
      The study is designed as a prospective, interventional, parallel, blinded, randomized,
      controlled clinical trial clinical of superiority, with a 6 month follow-up. The methodology
      of the present study will follow the standards of CONSORT-STATEMENT 2010 (Moher et al., 2010)
      and SPIRIT 2013 (Chan et al., 2013) for randomized clinical trials.

      Source of data The population will be composed of patients diagnosed with generalized
      aggressive periodontitis (GAgP) recruited at Institute of Science and Technology - Unesp, in
      São José dos Campos / SP, who have already undergone non-surgical periodontal treatment and
      still have pockets with probing depth ≥5 mm and bleeding on probe.

      Sample size Sample size calculation was performed using Sealed EnvelopeTM software. For this
      study, a population of 34 patients will be included. Considering α = 5% and β = 5% (power of
      95%) to detect a change of at least 1 mm in clinical attachment level between groups, to a
      standard deviation of 0.8 mm, 17 patients will be required in each group

      Clinical Parameters All clinical parameters will be assessed by a single blinded, trained and
      calibrated examiner (CFA) before surgical therapy (baseline) and at 3 and 6 months after
      using a manual probe. Measurements will be done at six sites per tooth (mesiobuccal, buccal,
      disto-buccal, distolingual, lingual, and mesiolingual) in all teeth, except third molars.

      The following clinical parameters will be evaluated: 1) Full-mouth plaque index (PI); 2)
      Bleeding on probing (BoP); 3) Probing depth (PD): distance from the bottom of sulcus/pocket
      to gingival margin; 4) Gingival recession (GR): distance from the free gingival margin to
      cement-enamel junction (CEJ); 5) Clinical attachment level (CAL): distance from bottom of
      sulcus/pocket to the CEJ. The CEJ will be identified by careful probe on cervical area.

      Calibration and Randomization Initially, ten patients with GAgP will be selected. The
      designated examiner (CFA) will measure CAL and PD in all patients twice within 24 hours, with
      an interval of ≥ 1 hour between examinations. Then, the measures will be submitted to
      intraclass correlation test and the examiner will be judged calibrated if reaches 90%
      agreement.

      Patients will be allocated into two groups according to a computer-generated list. The
      allocation will be implemented by an investigator (NC) who was not directly involved in the
      examination or treatment procedures.

      Selection of sites with residual pockets

      After the reevaluation, a residual periodontal pocket with probing depth ≥5 mm and bleeding
      on probe will be selected from a site not located in furcation region, by chance, to receive
      one of the following treatments:

        -  Control group (CG): surgical access for scaling and root planing + placebo pills (n =
           17);

        -  Test group (TG): surgical access for scaling and root planing associated with daily
           supplementation of 3 g of omega-3 and 100 mg of acetylsalicylic acid for 180 days (n =
           17).

      Treatment

      One hour before surgical therapy, patients will receive a single dose of dexamethasone 4 mg.
      The packaging of the products will be delivered according to the therapy indicated in the
      randomization. The administration will begin immediately before the surgical treatment, which
      will be performed by a single operator (CA), following the sequence:

        1. 10 mL of 0.1% chlorhexidine digluconate solution (Periogard®, Colgate Palmolive Ltda -
           Osasco - SP) will be provided to be chewed by the patient for 1 minute for intraoral
           disinfection;

        2. Antisepsis of the perioral region with sterile gauze soaked in chlorhexidine digluconate
           solution 0.2%;

        3. The patient will receive local injectable anesthesia with mepivacaine 2% with
           epinephrine 1: 100,000 (Mepivacaína®, DFL - Rio de Janeiro / RJ) through an infiltrative
           technique;

        4. Surgical access will be performed by Kirkland modified surgical technique (Kirland,
           1931). With a 15c blade, intrasulcular incisions will be made to the bottom of the
           pocket / sulcus on buccal, lingual and interproximal surfaces. The incisions will extend
           into the mesial and distal directions of the affected tooth. The gingival tissue will be
           detached from the bone to allow exposure of the root surface which will be carefully
           scaled and plained with periodontal curettes after removal of all granulation tissue.
           After copious irrigation with saline solution, the flap will be repositioned and
           maintained by interproximal sutures with Ethicon ® 4-0 silk suture (Ethicon Johnsons do
           Brasil SA, São José dos Campos - SP).

      Postoperative Patients will receive the following postoperative recommendations: do not drink
      alcoholic beverages; do not touch the surgical wound; Do not brush and floss area for 7 days;
      Ingest only cold liquid (ice cream, yogurt, juices and gelatin) in the first 24 hours;
      Mouthwash with 0.12% chlorhexidine digluconate (Periogard®) every 12 hours for 14 days.
      Dipyrone sodium 500 mg every 4 hours will be prescribed in case of pain. The sutures will be
      removed after 7 days of surgery.

      Microbiological evaluation Subgingival microbiological samples will be collected at the
      baseline, 3 and 6 months after therapy. The site will be isolated with a sterile cotton
      roller and supragingival biofilm will be carefully removed with periodontal curettes and a
      sterile paper will be inserted into the periodontal pocket for 30 s (Hartoth et al., 1999).
      The sample will be stored in sterile microtubes. The samples will then be lyophilized and
      sent to the Department of Periodontology at the University of Florida, where the samples will
      be analyzed.

      Evaluation of cytokines For the analysis of immunological changes, crevicular gingival fluid
      (CGF) will be collected at baseline, 3 and 6 months after treatment. Each site will be
      isolated with a sterile cotton roller and the supragingival biofilm will be removed. After
      this, the CGF will be collected with Periopaper strips (Periopaper, Oraflow, Plainview, NY,
      USA), inserted in the pocket for 15 seconds. The volume of collected fluid will be measured
      (Periotron 8000, Oraflow). The Periopaper strips will be stored in a sterile tube containing
      300μl of phosphate saline (PBS) with 5% Tween-20 and stored in a freezer at -20 ° C until the
      multiplex test. The level of the following cytokines will be measured in the CGF: interferon
      (IFN) -γ, interleukins (IL) -10, -1β, -4, -6, -8, tumor necrosis factor (TNF) -α, macrophage
      inflammatory protein 1α (MIP1α), 1α monocyte chemotactic protein (MCP-1α). The 10-plex high
      sensitivity kit (Millipore Corporation, Billerica, MA, USA) will be used according to the
      manufacturer's instruction and analyzed using the MAGpixTM platform (MiraiBio, Alameda, CA,
      USA). Samples will be analyzed individually (each pocket separately) and the concentrations
      will be calculated using a standard 5-parameter curve in the Xponet program (Millipore
      Corporation). The concentration of each marker will be given in pg / ml. All analysis of
      cytokine concentrations will be done in duplicate.

      Statistical analysis Two analyzes will be performed: Per Protocol and Intention-to-treat
      (Moher, 2010; Gupta, 2011; Day, 2008). For each of them, mean and standard deviation will be
      calculated in each of the parameters. Full-mouth PI, GI, PD, CAL, and GR will be submitted to
      the Shapiro-Wilk test to evaluate the distribution of these data, and then subjected to the
      variance test for both intra- and intra-group comparison. In addition, the number of pockets
      ≥ 5mm, the frequency of closure of these pockets, the mean reduction in PS and the gain in
      CAL of these pockets will be assessed before and after the therapy by performing intra- and
      inter-group analyzes.

      The concentration of each cytokine will be analyzed by test of variance for intra and
      intergroup comparison.
    

Intervention name(s): Open flap debridement; Placebo; Omega-3 polyunsaturated fatty acids; Aspirin
Intervention type(s): Procedure; Other; Dietary Supplement; Drug
Intervention description(s): Open flap debridement will be performed to decontaminate root surface; Placebo pills over a period of 180 days; 3 g of omega-3 polyunsaturated fatty acids daily supplementation over a period of 180 days; 100 mg of aspirin daily supplementation over a period of 180 days
Other intervention name(s): Surgical therapy; Fish oil; acetylsalicylic acid
Intervention MeSH terms: Aspirin
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Aggressive periodontitis; Aspirin; Omega-3 polyunsaturated fatty acids; Surgical therapy