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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.
NAME OF THE CANDIDATE
AND ADDRESS ( IN BLOCK
LETTERS)
Dr. VAZHAKKAT POOJA
RAJACHANDRAN
POST GRADUATE STUDENT
DEPARTMENT OF PERIODONTICS,
THE OXFORD DENTAL COLLEGE AND
HOSPITAL, HOSUR ROAD,
BOMMANAHALLI,
BANGALORE – 560068
2.
NAME OF THE INSTITUTION
THE OXFORD DENTAL COLLEGE AND
HOSPITAL, BANGALORE
3.
COURSE OF STUDY AND
SUBJECT
MASTER OF DENTAL SURGERY,
PERIODONTICS
4.
DATE OF ADMISSION OF
COURSE
03 /06/2013
5.
TITLE OF THE TOPIC
COMPARATIVE EVALUATION OF THE
EFFECT
OF
PERIODONTAL
GINGIVAL
NON-SURGICAL
THERAPY
CREVICULAR
ADRENOMEDULLIN
ON
FLUID
LEVELS
IN
CHRONIC PERIODONTITIS PATIENTS
WHO
ARE
SMOKERS
AND
NON-
SMOKERS – A CLINICOBIOCHEMICAL
STUDY.
6.
BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY
Human gingival epithelium is constantly exposed to multiple assaults by microbes that
live harmoniously in the oral niche1. Periodontal diseases are initiated by breakdown of
the bacteria - host equilibrium that results in inflammatory destruction of tooth
supporting tissues1.
Gingival epithelium is the first line of host defence, represented by its barrier function
and antimicrobial properties1. Oral keratinocyte innate immune effector molecules
include the antimicrobial peptides like defensin, cathelicidin, adrenomedullin and
calprotectin2.
Adrenomedullin, a 52 amino acid peptide has antimicrobial properties against both
Gram positive and Gram negative bacteria, local bactericidal effect, potent microvascular vasodilatory properties, supply inflammatory cells and mediators to inflamed
periodontal tissues3. Production of adrenomedullin is up-regulated by oxidative stress
(particularly in smokers), pro-inflammatory cytokines, angiotensin II, hypoxia,
hyperglycemia, natriuretic peptide, aldosterone, etc4
Therefore, the aim of the present study is to determine the effect of non-surgical
periodontal therapy on gingival crevicular fluid adrenomedullin levels in chronic
periodontitis patients who are smokers and non-smokers.
6.2 REVIEW OF LITERATURE
1. A study was conducted to investigate the levels of gingival crevicular fluid
adrenomedullin and human neutrophil peptides1-3 (HNP1-3) in patients with
different periodontal diseases. This study demonstrated that periodontitis groups had
a significantly higher total amount of GCF adrenomedullin compared to the
gingivitis and healthy control groups after adjusting for age and gender.
Additionally, GCF adrenomedullin levels were positively correlated with clinical
periodontal parameters of sampling sites. The total amount of gingival crevicular
fluid HNP1-3 level was not different among the study groups, and there was no
correlation between the total amount of gingival crevicular fluid HNP1-3 level and
clinical periodontal parameters5.
2. The aim of the study was to compare GCF adrenomedullin levels of periodontally
healthy individuals (GROUP I), individuals with chronic periodontitis (GROUP II),
periodontally healthy individuals with diabetes mellitus type 2(GROUP III) and
individuals with chronic periodontitis and diabetes mellitus type 2(GROUP IV).
This study concluded that groups with diabetes mellitus type 2(GROUP I and
GROUP II) had significantly higher periodontal clinical indices than nondiabetes
mellitus groups (GROUP I and GROUP II). The group of individuals with chronic
periodontitis and diabetes mellitus type 2 had a significantly higher total GCF
adrenomedullin level compared with other groups. A higher total GCF
adrenomedullin level was found in diabetes mellitus type 2 groups (GROUP I and
GROUP II) compared with nondiabetes mellitus groups (GROUP I and GROUP
II)6.
3. A study was carried out to investigate whether adrenomedullin (ADM), a
multifunctional peptide with key roles in host antimicrobial defence and
inflammation, was present and quantifiable in human gingival crevicular fluid
(GCF) and to study its relationship with periodontal health and disease. This study
concluded that measurable adrenomedullin-like immunoreactivity (ADM-LI) was
present in all the GCF samples collected and ADM-LI was significantly higher in
periodontitis sites than in control healthy sites3.
4. A study was performed to elucidate the significance of oxidative stress in the
modulation of endothelial functions. They examined the effects of H2O2 on the
expression of two endothelium-derived vasoactive peptides, endothelin(ET) and
adrenomedullin(AM), and their interaction. It was concluded that hydrogen peroxide
decreased ET secretion and suppressed ET-1 mRNA expression. Antioxidants
prevented hydrogen peroxide induced decrease of ET secretion. Hydrogen peroxide
increased AM secretion and AM mRNA expression with augmentation of cAMP
production. Neutralizing AM monoclonal antibody attenuated H2O2 - induced
suppression of ET secretion and exogenously administered AM and cAMP
suppressed ET secretion7.
5. A study was conducted to assess the effect of non-surgical periodontal therapy on
the expression frequencies of human beta-defensin (HBD)-1, 2, and 3 in the gingival
crevicular fluid (GCF) of patients affected by localized aggressive periodontitis. In
the patient group ,the expression frequencies of HBD-1,-2,and-3 mRNA at baseline
were 30% ,85% ,and 35%, respectively ,which changed after periodontal therapy to
80%,45%,and 85%, respectively. In the healthy control subjects, the expression
frequencies were 95%, 40%, and 95% for HBD-1, 2, and3, respectively, which were
different from those of diseased patients at baseline. This study concluded that the
appropriate expression of HBD peptides in health and disease may contribute to the
maintenance of periodontal homeostasis, possibly through its antimicrobial effects
and the promotion of adaptive immune responses8.
6. A study was carried out to determine whether Adrenomedullin (AM) exerts its
inflammatory role in keratinocytes through the activation of NF-κB and IL-6
secretion. This study concluded that AM induces degradation of inhibitor IκB and as
a result, NF-κB is translocated to the nucleus of HaCaT cells (skin epithelial cells)
where it will induce expression of genes such as IL-69.
6.3 AIMS AND OBJECTIVES OF THE STUDY
1. To evaluate GCF adrenomedullin level before and after non-surgical periodontal
therapy in chronic periodontitis patients.
2. To compare GCF adrenomedullin level before and after non-surgical periodontal
therapy in chronic periodontitis patients.
3. To evaluate GCF adrenomedullin level before and after non-surgical periodontal
therapy in chronic periodontitis patients who are smokers.
4. To compare GCF adrenomedullin level before and after non-surgical periodontal
therapy in chronic periodontitis patients who are smokers.
7.
MATERIAL AND METHODS
7.1 SOURCE OF DATA
A total of 40 patients reporting to the Outpatient Department of Periodontics, The
Oxford Dental College and Hospital, Bangalore will be selected.
7.2 METHOD OF COLLECTION OF DATA
A total of 40 patients will be selected for the study based on inclusion and exclusion
criteria.
Patients will be explained in detail about the study procedure, and a written consent
will be obtained from the patient before including him or her in the study.
INCLUSION CRITERIA
GROUP I ( CHRONIC PERIODONTITIS PATIENTS)
1. Patients with probing pocket depth of ≥ 5mm
2. Clinical attachment loss of ≥ 3 mm
3. Radiographic evidence of bone loss ≤ 50%
GROUP II ( CHRONIC PERIODONTITIS PATIENTS WHO ARE SMOKERS)
1. Patients with probing pocket depth of ≥ 5mm
2. Clinical attachment loss of ≥ 3 mm
3. Radiographic evidence of bone loss ≤ 50%
4. Current smokers will be selected i.e. persons who have ever smoked 100 cigarettes
and who currently smoke every day or some days. (National Health Interview Survey,
NHIS, 2011, Centres for Disease Control and Prevention, U.S. Department of Health
and Human Services)10
EXCLUSION CRITERIA
1. Patients with any systemic disorders or medically compromised patients
2. Pregnant or lactating mothers
3. Patients who have received medications that would alter the level of adrenomedullin
in the last 6 months. (Anti-inflammatory drugs, Antibiotics, Corticosteroids)
4. Patients who have undergone any form of periodontal therapy within last 6 months
STUDY DESIGN
The patients will be divided into following groups based on inclusion and exclusion
criteria:

GROUP I : 20 samples : Chronic Periodontitis patients

GROUP II : 20 samples :

GROUP III: 20samples :

GROUP IV : 20 samples :
Chronic Periodontitis patients who are smokers
GROUP I after non-surgical periodontal therapy
(3 months recall)
GROUP II after non-surgical periodontal therapy
(3 months recall)
The following clinical parameters will be recorded at baseline (at first visit) and 3
months after non- surgical periodontal therapy :

Gingival index: (Loe and Silness,1963)11.

Plaque index: (Silness and Loe,1964)12.

Bleeding on probing (Ainamo and Bay, 1975)13.

Probing pocket depth

Clinical attachment level

Radiographic assessment using OPG
Probing pocket depth and clinical attachment measurements will be measured using
FLORIDA PROBE and standardized using acrylic stent.
Non- surgical periodontal therapy which includes scaling and root planing will be
performed.
Patients will be put on oral hygiene maintenance which includes oral hygiene
instructions and recall every month for 3 months. At recall visits, reinforcement of oral
hygiene instructions and if required scaling will be carried out.
Patients requiring periodontal surgical therapy will be refrained from treatment for 3
months after non-surgical periodontal therapy as per Helsinki declaration for the
purpose of the study.
METHOD OF COLLECTION OF SAMPLE
Collection of gingival crevicular fluid
GCF sample collection will be done one day after recording clinical parameters to
avoid stimulation of the sample and its contamination with blood. The tooth to be
sampled will then be dried with warm air for 10 seconds. Each site selected for GCF
sampling will be isolated with cotton rolls and a saliva ejector will be used to decrease
the risk of salivary contamination. GCF sample collection (4µl) will be done by extrasulcular method using calibrated microcapillary pipettes of length 125mm and bore
size of 0.01mm.
GCF samples will be collected from sites with deepest probing pocket depth before
non-surgical periodontal therapy in group I and II and after non-surgical periodontal
therapy in group III and IV .The collected GCF samples will be stored in a freezer
(temperature maintained at - 80°C) till the assay procedure is carried out.
The collected GCF samples will be subjected to ELISA (CUSABIO) for estimating the
levels of ADRENOMEDULLIN.
STUDY DURATION: 1 year.
STATISTICAL ANALYSIS: Analysis of variance, Paired t test.
7.3 DOES THIS STUDY REQUIRE ANY INVESTIGATION OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER
BEINGS?
Yes, GCF samples will be collected from patients for quantitative analysis of
adrenomedullin level which will later be subjected to statistical analysis.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION?
Yes, The ethical clearance certificate has been attached.
8.
LIST OF REFERENCES :
1. Lu Q, Samaranayake LP, Darveau RP, Jin L. Expression of human beta- defensin-3
in gingival epithelia. J Periodont Res 2005;40:474-81.
2. Hiroshima Y, Bando M, Kataoka M, Inagaki Y, Herzberg CM, Ross FK et al.
Regulation of antimicrobial peptide expression in human gingival keratinocytes by
interleukin-1α. Arch Oral Biol 2011;56(8):761-7.
3. Lundy FT, O’Hare MMT, McKibben BM, Fulton CR, Briggs JE, Linden GJ.
Radioimmunoassay quantification of adrenomedullin in human gingival crevicular
fluid. Arch Oral Biol 2006;51(4):334-8.
4. Ali SM, Mohammed SMH. Adrenomedullin as a novel promising therapeutic
approach. International Journal of Science and Technology (IJST) 2013
Oct;2(10):747-53.
5. Turkoglu O, Emingil G, Kutukculer N, Atilla G. Evaluation of gingival crevicular
fluid adrenomedullin and human neutrophils peptide 1-3 levels of patients with
different periodontal diseases. J Periodontol 2010 Feb;81(2):284-91.
6. Ertugrul AS, Dilkilitas A, Sahin H, Alpaslan NZ, Bozoglan A. Gingival crevicular
fluid adrenomedullin level in individuals with and without diabetes mellitus type 2.
J Periodont Res 2013;48:342-9.
7. Saito T, Itoh H, Chun T, Fukunaga Y, Yamashita J, Doi K et al. Coordinate
regulation of endothelin and adrenomedullin secretion by oxidative stress in
endothelial cells. Am J Physiol Heart Circ Physiol 2001;281:H1364-H1371.
8. Ebrahem MA, Expression of human beta defensins (HBDs) 1,2 and 3 in gingival
crevicular fluid of patients affected by aggressive periodontitis. Saudi Dent J
2013;25(2):75-82.
9. Pleguezuelos O, Pavli EN, Crowther G, Kapas S. Adrenomedullin signals through
NF-κB in epithelial cells. FEBS Letters 2004;577(1-2):249-54.
10. CDC. 2011 National Health Interview Survey (NHIS) public use data release.
Hyattsville, MD: US Department of Health and Human Services, CDC, National
Center for Health Statistics; 2011.
11. Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta
Odontol Scand 1963;21:533-51.
12. Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral
hygiene and periodontal conditions. Acta Odontol Scand 1964;22:121-35.
13. Ainamo J, Bay I. Problems and proposal for recording gingivitis and plaque. Int
Dent Journal 1975;25:229-35.
9.
SIGNATURE OF THE CANDIDATE
10.
REMARKS OF THE GUIDE
11.
NAME AND DESIGNATION
11.1
GUIDE
Dr. SHOBHA K.S
READER
DEPARTMENT OF PERIODONTICS
THE OXFORD DENTAL COLLEGE
AND HOSPITAL,
BANGALORE 560068.
SIGNATURE
11.2 HEAD OF THE DEPARTMENT
SIGNATURE
12.
REMARKS OF THE PRINCIPAL
SIGNATURE
Dr. ANIRBAN CHATTERJEE
DEPARTMENT OF PERIODONTICS
THE OXFORD DENTAL COLLEGE
AND HOSPITAL,
BANGALORE 560068.