Conditions: Osteoporosis, Postmenopausal Periodontitis
Keywords: sclerostin dickkopf-related protein-1
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 43
Healthy volunteers: yes

Brief summary:
Symptoms of periodontal disease are tissue destruction and destruction of the alveolar bone which supports the tooth. Wnt way (wingless-type MMTV integration site family) plays a role in the regulation of bone homeostasis in periodontal disease-induced bone resorption. The Wnt / β-catenin signal is controlled by physiological antagonists, including dickkopf released from osteocytes-associated protein 1 (DKK-1) and sclerostin (SOST). Thus, Wnt inhibitors SOST and DKK-1 affect bone mass changes. Bisphosphonates used in osteoporous treatment are selective inhibitors of bone resorption. In the serum of postmenopausal osteoporotic women treated with bisphosphonate, short-term and decreased DKK-1 level during the treatment, and increased SOST in the late period were reported. Increased bone formation after bisphosphonate treatment in postmenopausal osteoporotic patients has been associated with increased serum SOST level. The aim of our study is to investigate the effect of bisphosphonate in patients with post-menopausal osteoporosis on the bone demolition metabolism in periodontally healthy and periodontally diseased tooth regions and gingival health with the clinical data by investigating the SOST and DDK-1 molecules that play role in bone destruction mechanism.

Detailed description:
This study aims to reveal the effect of initial periodontal treatment together with bisphosphonate on sclerostin (SOST) and dickkopf-related protein-1 (DKK-1) in gingival crevicular fluid (GCF) of patients with osteoporosis.

Clinical recordings and GCF were obtained from postmenopausal women; with chronic periodontitis and those using bisphosphonate (Group A, n=12), with chronic periodontitis and otherwise healthy (Group B, n=10), without chronic periodontitis and those using bisphosphonate (Group C, n=11), systemically and periodontally healthy controls (Group D, n=10) at the baseline.

GCF sampling were recorded and repeated at the 6th and 12th months in Group A, B and C. SOST and DKK-1 values were measured by ELISA.

Arms:
arm 1: * Subjects with chronic periodontitis and osteoporosis.
* Phase 1 periodontal therapy and bisphosphonate therapy ( Aclasta: intravenous infusion of 5 mg of zoledronic acid once a year) were administered to the subjects. arm 2: * Subjects with chronic periodontitis and systemically healthy.
* Phase 1 periodontal theraphy was administered to the subjects. arm 3: * Subjects with periodontally healthy and osteoporosis.
* Bisphosphonate therapy ( Aclasta: intravenous infusion of 5 mg of zoledronic acid once a year) were administered to the subjects. arm 4: * Systemically and periodontally healthy controls
* No intervention has been made.

Interventions: intervention 1: Phase 1 periodontal therapy intervention 2: Bisphosphonate therapy
Intervention descriptions: intervention 1: Scaling and root planning with ultrasonic and hand instruments under local anesthesia. intervention 2: Using aclasta: intravenous infusion of 5 mg of zoledronic acid once a year

Protocol document:
Prot_SAP_003.pdf: 
 
 
 
 
 
 
Investigation of the Effects of Bisphosphonate on the 
Gingival Crevicular Fluid Levels of Sclerostin and the 
DKK-1 in Individuals with Postmenopausal 
Osteoporosis with Periodontal Changes 
 
 
 
 
 
 
Document Date: December, 2018 
Uploaded: September, 2020 
 
 
 


Study Protocol 
 
Individuals with chronic periodontitis and osteoporosis between 51 
and 66 years (mean age: 57.15 ± 4.93) (group A, n=12), 52 to 66 
years (mean age: 57.41 ± 4.94) with systemic healthy chronic 
periodontitis (group B, n=10), between the ages of 50-63 (mean 
age: 55.64 ± 3.79) periodontally healthy osteoporotic individuals 
(group C, n=11) and 52-64 years (mean age: 56.55 ± 4.06) 
periodontal and systemically healthy individuals (group D, n=10) 
were included in study. 43 postmenopausal women in total were 
included in the study. This study involved postmenopausal women 
admitted to the Ondokuz Mayıs University Faculty of Medicine, 
Department of Endocrinology and Metabolism between 2016 and 
2018. The study protocol was approved by Ethical Board of 
Ondokuz Mayis University School of Medicine (OMU KAEK 
2016/100) and was carried out in accordance with the ethical 
standards established in the 1964 Declaration of Helsinki, as 
revised in 2008. Written informed consent was obtained from each 
subject before enrollment in the study. 
Bisphosphonates were started in the patients who were diagnosed 
with osteoporosis. Individuals smokes, who had received antibiotic 
treatment in the last 3 months and/or periodontal treatment in the 
last 6 months were excluded from the study. Following medical 


record retrieving, patients were leaded to Ondokuz Mayıs 
University Faculty of Dentistry Periodontology Department for 
periodontal examination, receipt of clinical records and gingival 
crevicular fluid (GCF) samples. Following the receipt of medical 
records; standard periodontal recordings including plaque index 
(PI) (1), gingival index (GI) (2), bleeding on probing index (BOP), 
pocket depth measurement (PD), clinical attachment loss 
measurement (CAL), dental radiographs were received from each 
patient. Clinical measurements were taken from the region under 
each tooth (mesio-vestibule, mid-vestibule, disto-vestibule, mesio-
lingual, mid-lingual, disto- lingual) using Williams probe. In the 
first 
clinical 
and 
radiographic 
evaluation, 
groups 
with 
postmenopausal osteoporosis and healthy groups were divided into 
2 subgroups as chronic periodontitis and healthy control groups. 
The diagnosis of chronic periodontitis was made clinically and 
radiographically according to the criteria determined by the “1999 
Periodontology Workshop” (3). Periodontitis patients consisted of 
patients with 4 or more probes with bleeding index (BOP) positive, 
5 mm or more deeper pocket depth (PD) and ≥6 mm attachment 
loss (CAL) and radiographically determined alveolar bone loss. 
Individuals with <3 mm PD and no radiographically determined 
alveolar bone loss were preferred to form groups with healthy 
periodontium. In the groups with chronic periodontitis gingival 


crevicular fluid (GCF) was collected with the help of periopaper 
(Periopaper®; Oraflow, New York, NY, USA) from the regions with 
the deepest pocket depth with periodontal defect, and in healthy 
groups it was collected by taking the right mandibular molar 
region as reference. Each time, the volume value of the collected 
GCF was determined by the Periotron 8000 device. GCF collected 
paper strips were placed in eppendorf tubes and stored at -80 ° C 
until biochemical analysis was performed (NUAIRE Ultra-Low 
Freezer Model no: Nu-6420E). Following the initial sample 
collection and recording of patient data (medical, periodontal and 
radiographic), patients were placed under phase 1 periodontal 
treatment (scaling and root planing), and oral hygiene habits of 
the patients were corrected and followed up for 1 year. In this 
period, periodontal treatments, controls and sample collections of 
the patients in Group A and Group B who completed phase 1 
treatment were repeated at the end of 6th month and at the end of 
the 12th month after the end of the treatment, their clinical 
changes were recorded. The clinical data and GCF SOST and 
DKK-1 levels of osteoporosis groups (Group A and C) and non-
osteoporotic 
chronic 
periodontitis 
group 
(Group 
B) 
with 
bisphosphonate were reevaluated in the determined times. 
 
 


Biochemical Analysis 
 
SOST and DKK-1 levels in gingival crevicular fluid were 
determined by ELISA (Enzyme-linked immunosorbent assay) kits 
(SunRed Human DKK1 ELISA Kit, Cat.No:201-12-063, and 
SunRedHuman SOST ELISA Kit, Cat No: 201-12 -5418) The 
SOST and DKK1 assay ratios according to the manufacturer's 
instructions are 0.2-60 ng / mL 0.5-78 ng / mL, respectively. 
Sensitivity is 0.412 ng / mL for DKK-1 and 0.17 ng / mL for SOST. 
Color intensity is measured at 450 nm and the results were 
calculated using standard curves for each kit. GCF SOST and 
DKK-1 concentrations were obtained by dividing total amount of 
SOST 
and 
DKK1 
values 
by 
GCF 
volume 
(microliter). 
Concentration values will be presented in ng / mL. 
 
Statistical Analysis 
 
Statistical analysis was performed using SPSS (version 21, SPSS 
Inc. Chicago, IL, USA) program. The Shapiro-Wilk test was used 
to show if the data were consistent with the normal distribution. 
Comparisons of biochemical data between groups were performed 
with non-parametric Kruskal-Wallis test and p <0.05 was 
considered as statistically significant. In determining the 


difference group, p value was divided by the number of comparison 
and p <0.016 was accepted as significance level (Mann- Whitney U 
test with Bonferroni correction). Friedman test was used to 
determine the time difference in groups and p<0.05 was 
considered as statistically significant. 
 
 
1. Silness J, Loe H. Periodontal disease in pregnancy. II. 
Correlation between oral hygiene and periodontal condition. 
Acta Odontol Scand 22:121-35, 1964. 
2. Loe H, Silness J. Periodontal disease in pregnancy. I. 
prevalence and severity. Acta Odontol Scand 21:533-51, 
1963. 
3. Armitage GC. Development of a classification system for 
periodontal diseases and conditions. Ann Periodontol 4,1:1-
6, 1999. 

ICF_002.pdf: 
PATIENT INFORMED VOLUNTEER WILL FORM EXAMPLE * 
 
 
Investigation of the Effects of Bisphosphonate on 
the Gingival Crevicular Fluid Levels of Sclerostin 
and the DKK-1 in Individuals with 
Postmenopausal Osteoporosis with Periodontal 
Changes 
 
 
 
Document Date: June, 2016  
Uploaded: September, 2020  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


PATIENT INFORMED VOLUNTEER WILL FORM EXAMPLE * 
 
NAME OF THE RESEARCH (OPEN NAME OF THE STUDY): 
Investigation of the effect of bisphosphonate use on levels of sclerostin and DKK-1 levels in 
gingival crevicular fluid of patients with postmenopausal osteoporosis with periodontal 
changes 
 
Initials of the volunteer's name and surname << >> 
 
 
You are asked to participate in a research study. Before deciding whether you want to 
participate, it is important that you understand why the research was conducted, how your 
information was used, what the study involved, and the possible benefits, risks, and discomfort. 
If you are involved in another study, you cannot take part in this study. 
 
DO I HAVE TO PARTICIPATE IN THIS STUDY? 
 
The decision whether or not to participate is entirely up to you. If you decide to participate in 
the study, you will be given this Informed Volunteer Consent Form to sign. If you decide to 
participate, you are free to leave the work at any time. This will not affect the standard of 
treatment you receive. If you wish, your doctor / family doctor will be informed of your 
participation in this clinical trial. In addition, if the supporting company decides to terminate 
the work, you will also be excluded. 
 
WHAT IS THE SUBJECT AND PURPOSE OF THE STUDY? 
 
The subject of our “Investigation of the effect of bisphosphonate use on levels of sclerostin and 
DKK-1 levels in gingival crevicular fluid of patients with postmenopausal osteoporosis with 
periodontal changes” study: The effect of bisphosphonate used for bone resorption on bone 
metabolism and oral tissues. 
The aim of this study was to investigate the effect of bisphosphonate on the jawbone and gingival 
health. For this purpose, we found it appropriate to investigate two molecules called sclerostin 
and DKK-1 which show bone resorption. 
 
WORKING PROCEDURES: 
 
Records will be taken from the vicinity of the teeth, which allow us to measure dental calculus, 
gingival bleeding and health. These procedures are routinely performed in our clinic using a 
special probe to determine the gingival disease status for each patient. After these records are 
taken, painless and non-anesthetic paper strips will be examined using the liquid collection 
process will be done around the teeth. Routine radiographic x-rays will be taken for 
radiographic diagnosis. Following the collection of samples and recording of patient data, 
routine dental calculus cleaning for routine periodontal treatment, tooth brushing and interface 
cleaning will be explained and oral hygiene habits will be improved. The collection of the 
molecules to be examined (sclerostin and DKK-1) in the gingival gut fluid and recording of the 
clinical values will be continued and recorded at the end of the 4th week, the 6th month and 
the 12th month. Samples and data of the control group will be taken only on the day they apply 
to the clinic. 
 
 


WHAT DO I NEED TO DO? 
 
You should be willing to follow your doctor's instructions, participate in appointments and visits, 
and follow all procedures related to the work described above. You must come to visit your 
labor doctor on designated days and your next visit should be planned before you leave. It is 
also important that you tell the physician of any other medical treatment you have received 
before or during the study. 
 
WHAT ARE THE POSSIBLE SIDE EFFECTS, RISKS AND DISABILITY OF MY 
PARTICIPATION? 
 
There is no side effect, risk or discomfort to your participation. 
 
PREGNANCY AND BIRTH CONTROL 
 
If the subject / patient is a breastfeeding woman, she will be excluded. 
 
WHAT ARE THE POSSIBLE BENEFITS OF PARTICIPATION? 
 
In this study, with the regular follow-up of the patients, the possible side effects of osteoporous 
disease and bisphosphanate treatment on the oral tissues will be determined and prevented from 
the side effects. In addition, regular dental and gingival checks and treatments will ensure that 
your oral and dental health is fully ensured and your regular records and treatments will 
continue in the future. 
 
VOLUNTEER PARTICIPATION 
 
I decide to participate in this research completely voluntarily. I am aware of the fact that I can 
refuse to participate in this study, or that I can leave at any time, without being affected and 
without any responsibility. If I leave the study at any time, I will discuss with my doctor the 
reasons for my separation, the consequences of my separation and the treatments I will receive 
in the following period. 
 
WHAT IS THE COST OF MY PARTICIPATION? 
 
Labor doctor visits and all laboratory tests related to the study will be covered by the study 
sponsor and will not be paid to you or your private insurance or official social security 
institution. If any side effects or physical damage develop, immediately inform your work 
physician so that the necessary medical treatment can be performed. 
 
HOW WILL MY PERSONAL INFORMATION BE USED? 
 
By signing this form, you consent to your doctor and his / her staff collecting and using your 
personal information (“Study Data onun) for the study. This is your date of birth, your gender, 
your ethnicity, and your consent to the use of your study data does not have a designated unit 
date, but you can discontinue your consent at any time by informing your doctor. 
 
The study data shared with the sponsor will be protected using a code number (olan Code ”), 
which is a unique number for you. The code key required to access your study data is under the 


supervision of your doctor. Persons appointed by the study sponsor firm regulatory authority or 
other supervisory bodies may review your study data held by your doctor. 
 
Your doctor will use your study data for the study. Supporting firm; use your study data to 
conduct the study, diagnostics and develop medical aid. Both the institution where your doctor 
is working and the supporting company are responsible for managing your work data in 
accordance with applicable data protection laws. 
 
The work sponsor may share your work data with other companies, service providers, 
contracted companies and other research organizations in its own group that will use it only for 
the purposes mentioned above. The results of the study may be published in medical 
publications, but your identity will not be disclosed in these publications. 
 
You have the right to request information from your doctor or study sponsor about your 
collected study data. You also have the right to request that any errors in this data be corrected. 
If you have a request, please contact your doctor who may be able to help you contact your 
study sponsor. 
 
If you give up your consent, your doctor will no longer be able to use or share your study data 
with others. The work sponsor may continue to use your previous work data without giving up 
your consent. 
 
By signing this form, I consent to the use of your study data as described in this form. 
 
PERSONS THAT CAN BE REACHED IN 24 HOURS DURING THE RESEARCH: 
Name, Surname and telephone numbers 
 
 
 
 
 
 
 
 
CONDITIONS REQUIRED TO LEAVE FROM THE WORK 
 
During work, 
 
1- The emergence of other systemic diseases other than bone resorption and diseases that are 
known to increase the risk of periodontal disease and which are thought to affect the results of 
the study (such as diabetes, leukemia, neutropenia, agranulocytosis, obesity, renal failure, 
immunosuppression for any reason) 
2- Corticosteroid, estrogen, phenytoin, cyclosporine, nifedipine use 
3- Smoking 
4- Being treated in another center 
5- Failure to comply with regular follow-up and scheduled treatment dates 
 
 
 
 


HOW NEW INFORMATION CAN IMPACT THE ROLE IN THE WORK 
 
All new information that has emerged while the work is in progress will be communicated to 
me immediately. 
 
Confirmation of Participation 
 
I have read all the explanations on the Informed Volunteer Consent Form. The written and 
oral explanation of the above-mentioned subject and purpose of the research was given to me 
by the physician named below. I know that I voluntarily participate in the research, that I can 
leave the research at any time, with or without justification, and that I can be excluded from 
the research by the researcher regardless of my own will. 
I agree to participate voluntarily without any pressure or coercion. My doctor gave me a copy 
of this document for me to keep, including the points I will pay attention to during the study. 
 
Name / Surname / Signature / Date of the Disclosure 
 
Name / Surname / Signature / Date of Person Witnessing Consent if necessary 
 
Name / Surname / Signature / Date of Legal Representative if necessary