Conditions: Aggressive Periodontitis
Keywords: Full-mouth ultrasonic debridement Aspirin Omega-3 polyunsaturated fatty acids Non-surgical therapy
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 38
Healthy volunteers: yes

Brief 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 non-surgical therapY of patients with generalized aggressive periodontitis. Probing depth, clinical attachment level, gingival index and concentration of microorganisms and cytokines at baseline, 3, and 6 12 months after the procedure will be evaluated.

Detailed description:
The study methodology is according to CONSORT-STATEMENT 2010 for randomized controlled clinical trials.

Study Design The study is designed as a prospective, interventional, parallel, blinded, randomized, controlled clinical trial of superiority.

Source of data The population of this study will be recruited among patients referred to the Science and Technology Institute - ICT- São José dos Campos, College of Dentistry. Patients will fill a healthy history questionnaire to ensure that they are medically qualified for participate in this study. Based on the power calculation for this study, a population of 38 patients will be included. Considering α of 5% and 10% β-type error (90% power) to detect a difference of at least 1 mm in probing depth reduction of pockets ≥ 5 mm between groups, for a standard deviation of 0.94 from a previous study evaluating different antimicrobials in the treatment of GAgP (Xajigeorgiou et al., 2006), 19 patients will be needed in each group.

Clinical Parameters All clinical parameters will be assessed by a single blinded, trained and calibrated examiner (CFA) before periodontal 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 (FMPI); 2) Bleeding on probing (BoP); 3) Probing depth (PD): distance from the bottom of sulcus/pocket to gingival margin; 4) Gingival recession (GM): 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, a total of ten patients presenting 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.

Treatment Protocols

All patients will be treated with periodontal therapy through of the one-stage, full mouth, ultrasonic debridement (FMUD). In a single session, patients will receive local anesthesia and periodontal debridement with ultrasound equipment (Cavitron - Dentsply EUA) and subgingival tips (UI25KSF10S, Hu-Friedy). All diseased sites will be instrumented in this one session. The debridement session will be performed by a single experienced and trained periodontist (NA), different from the examiner. Immediately before the mechanical therapy, patients will be allocated in one of the two treatment protocols:

Test group (n = 19): FMUD + 3 g of omega-3 polyunsaturated fatty acids and 100 mg of aspirin daily supplementation over a period of 180 days; Control group (n = 19): FMUD + placebo pills.

All patients will start taking the pills immediately before of the FMUD session.

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.

Arms:
arm 1: In this group (n = 19), patients will take placebo pills and full-mouth ultrasonic debridement will be performed to treat diseased sites. arm 2: In this group (n = 19), patients will take 3 g of omega-3 polyunsaturated fatty acids and 100 mg of aspirin daily over a period of 180 days and full-mouth ultrasonic debridement will be performed to treat diseased sites.

Interventions: intervention 1: Omega-3 polyunsaturated fatty acids intervention 2: Aspirin intervention 3: Placebo intervention 4: Full-mouth ultrasonic debridement
Intervention descriptions: intervention 1: 3 g of omega-3 polyunsaturated fatty acids daily supplementation over a period of 180 days intervention 2: 100 mg of aspirin daily supplementation over a period of 180 days intervention 3: Placebo pills over a period of 180 days intervention 4: Full-mouth ultrasonic debridement will be performed in order to treat diseased sites

Protocol document:
Prot_SAP_000.pdf: 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluation of Omega-3 Polyunsaturated Fatty Acids Plus Low-dose 
Aspirin Daily Supplementation in Non-Surgical Therapy to Treat 
Generalized Aggressive Periodontitis: Randomized Controlled Clinical 
Trial 
 
 
NCT03093246 
 
March 22, 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 


Abstract 
 
Background: Periodontal destruction results mainly from the exacerbated host 
inflammatory response to the bacterial challenge. For this reason, research 
involving the modulation of host response has been developed aiming to facilitate 
the resolution of inflammation, as well as to promote tissue repair and periodontal 
stability. Recently, the use of omega-3 polyunsaturated fatty acids (Ω-3 PUFA) 
and low-dose acetylsalicylic acid (ASA) was related to the production of 
enhanced lipidic mediators and to better clinical outcomes in the treatment of 
chronic periodontitis.  
Objective: The aim of the present randomized controlled clinical trial was to 
evaluate the use of 900 mg Ω-3PUFA and 100 mg ASA for 180 days as adjuvants 
to the non-surgical treatment (NST) of generalized aggressive periodontitis 
(GAgP).  
Methods: Thirty-eight GAgP patients were submitted to subgingival debridement 
associated with Ω-3 PUFA and ASA (n=19) or placebo (n=19).  
Results: Both groups showed a statistically significant decrease (p<0.05) in all 
clinical parameters, as well as a decrease in IL-1β, with no difference between 
treatments (p>0.05). The TIMP-2 level significantly decreased in the control 
group and remained stable in the test group.  
Conclusion: The proposed new therapy did not bring clinical benefits in the non-
surgical treatment (NST) of GAgP. 
 
 
 
 
 
 
 
 
 
 
 
 


Study Protocol 
 
 
This double-blind, placebo-controlled, randomized clinical trial was 
designed to evaluate the superiority of PUFA ω-3 + ASA vs. control. The study 
followed the CONSORT 2010 and the SPIRIT 2013 Statements. The trial was 
approved 
by 
the 
human 
subjects 
ethics 
board 
of 
Unesp 
(CAAE 
66096817.3.0000.0077) and was conducted under the principles of the Helsinki 
Declaration of 1975, as revised in 2013. The study protocol was registered in 
ClinicalTrials.gov (NCT03093246). 
 
Subjects with generalized grade C periodontitis were selected at the 
Division of Periodontics, Institute of Science and Technology, São Paulo State 
University (Unesp), Brazil. A complete dental exam was carried out and medical 
records were obtained. Subjects who fulfilled the inclusion criteria were invited to 
participate in the study. Each subject provided informed consent after a thorough 
explanation of the nature, risks, and benefits of the clinical investigations. The 
inclusion criteria were: 1) diagnosis of stages III/IV generalized grade C 
periodontitis (Papapanou et al, 2018); 2) presence of ≥20 teeth, excluding third 
molars and teeth indicated for extraction; 3) presence of ≥6 sites presenting PD 
≥5 mm with bleeding on probing (BoP) and ≥2 sites with PD ≥7 mm (including 
incisors and first molars, in addition to three other non-contiguous teeth between 
them); 4) good general health; 5) at least 18 years old; and 6) agree to participate 
in the study and sign a written consent. Patients who 1) were pregnant or nursing; 
2) were suffering from any other systemic disease (e.g., cardiovascular, diabetes, 
blood dyscrasias, immunodeficiency, etc.); 3) received antimicrobials or anti-
inflammatory drugs in the previous 6 months; 4) received a course of periodontal 
treatment within the last 12 months; 5) smoked ≥10 cigarettes/day; 6) reported 
an allergy to ASA or seafood; 7) required antibiotic prophylaxis; 8) were currently 
using medication that could interfere with periodontal response; or 9) reported 
gastritis and/or gastric ulcers were excluded. 
 
The randomization was done as follows: a researcher (NCCS) generated 
a random computer sequence to determine the order in which the treatments 
would occur (test/control) according to the stablished sample. This sequence was 
kept in a brown/opaque envelope and was followed as the subgingival 
debridement were performed . The treatment was revealed only after the 


debridement session, when the patient received the pills. The professional 
responsible for patient recruitment (MPS), treatment (CFA), and the clinical 
measures (NMRBA) were distinct. 
 
The sample size of the study was calculated based on the results obtained 
by a previous study that evaluated the effect of daily supplementation of Ω-3 
PUFA and low-dose ASA in the treatment of chronic periodontitis (El-Sharkawy 
et al., 2010). Considering α = 5% and β = 20% (80% power) to detect an 
intergroup difference of at least 1.2 mm in the PD of pockets > 5 mm, with a 
standard deviation of 0.8 mm, 16 patients would be needed in each group. To 
compensate possible attritions, 19 patients per group were included, obtaining a 
power > 80%. 
 
All diseased sites were instrumented in a single session by a trained 
operator (CFA). The patients received local anesthesia and one-stage full-mouth 
ultrasonic debridement (FMUD) (Wennström et al., 2005) by an ultrasonic device 
with specific tips for subgingival scaling. The patients were assigned to the 
following groups according to the randomization:  
• Test Group (TG) (n=19): FMUD associated with 900 mg PUFA Ω-3 
+ 100 mg ASA daily for 180 days; 
• Control Group (CG) (n=19): FMUD and placebo. 
 
All clinical measures were performed by one calibrated and blinded 
researcher (NMRBA). Clinical measures were performed at baseline, 3 and 6 
months after the treatment, in all teeth, except third molars. The following clinical 
parameters were evaluated: 1) Probing depth (PD): distance from the bottom of 
sulcus/pocket to gingival margin; 2) Clinical attachment level (CAL): distance from 
the bottom of sulcus/pocket to cement–enamel junction (CEJ); 3) gingival 
recession (GR): distance from gingival margin to CEJ; 4) full-mouth plaque index 
(FMPI); and 5) full-mouth bleeding on probing (BoP). The clinical measures were 
assessed using a manual probe (North Carolina, Hu-Friedy). In addition, PD, CAL 
and GR measurements were done at six sites per tooth (mesiobuccal, buccal, 
disto-buccal, distolingual, lingual, and mesiolingual). 
 
 
 
 


Statistical Analysis Plan 
 
Mean and standard deviation were calculated for each parameter. The normal 
distribution was analyzed using the Shapiro-Wilk test. Demographic data were 
analyzed using the t-test for independent variables. The differences between the 
full-mouth variables were analyzed using a Generalized Estimated Equations 
Model and the reductions were evaluated by Generalized Linear Models, 
adjusted to baseline when indicated. The post-hoc test applied for each peer 
comparison was Bonferroni. The data were analyzed using the concepts of per-
protocol and intention-to-treat. The statistical analysis was performed using 
significance level of 5%, using IBM SPSS.