Effects of omega-3 supplementation as an adjunct to non-surgical periodontal therapy on periodontal parameters in chronic periodontitis patients: A randomized clinical trial

doi:10.21203/rs.3.rs-1861758/v1

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Effects of omega-3 supplementation as an adjunct to non-surgical periodontal therapy on periodontal parameters in chronic periodontitis patients: A randomized clinical trial

https://doi.org/10.21203/rs.3.rs-1861758/v1

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Objectives: This study aimed to assess the effects of omega-3 fatty acid supplementation as an adjunct to non-surgical periodontal therapy on periodontal parameters in patients with chronic periodontitis (CP).

Materials and Methods: This randomized clinical trial was conducted on 30 patients with moderate to severe generalized CP. All patients received standard non-surgical periodontal therapy, and were randomly divided into two groups of intervention and control (n=15). The intervention group was asked to use 1000 mg omega-3 soft-gels daily while the control group used placebo soft-gels for 3 months. Clinical attachment loss (CAL), probing depth (PD), and bleeding index (BI) were recorded at baseline (before the intervention) and after 3 months. The two groups were compared regarding the clinical parameters by t-test (alpha=0.05).

Results: All three clinical parameters significantly decreased in both groups at 3 months compared with baseline (P=0.001). The improvement in PD and CAL in the intervention group was significantly greater than that in the control group (P=0.001); however, the difference in BI was not significant between the two groups (P=0.283).

Conclusion: Omega-3 supplementation for 3 months as an adjunct to non-surgical periodontal therapy significantly improved the clinical parameters in CP patients.

Fatty Acids

Omega-3

Periodontal Diseases

Chronic Periodontitis

Periodontitis is a multifactorial inflammatory disease, which can cause periodontal tissue destruction and eventual tooth loss. Several factors can affect the susceptibility to periodontal disease and its progression, such as genetics, systemic diseases, and lifestyle including oral hygiene, smoking, stress, and nutrition [1]. Although presence of bacterial biofilm is an important prerequisite for development of periodontitis, the host immune response is a key factor in disease progression [2].

Professional subgingival scaling along with elimination of supragingival plaque by patients can significantly improve probing depth (PD), clinical attachment loss (CAL), and bleeding on probing [3]. Scaling and root planing (SRP) is the gold-standard treatment for most patients with chronic periodontitis (CP). Nonetheless, different therapeutic strategies have been proposed over the past years to improve the results of SRP and decrease the need for surgical periodontal interventions in patients with advanced periodontitis [4]. For example, various types of mouthwashes have been proposed as an adjunct to periodontal therapy and many of them have caused a significant reduction in gingival and periodontal parameters [5]. Of the available chemical mouthwashes, chlorhexidine is the gold-standard antimicrobial mouthwash [6]. Ginger [7], thyme [8], Trachypermum ammi [9], and cinnamon [10] have also been used in the form of herbal mouthwashes as an adjunct to SRP.

Host modulation treatments have been recently suggested as an adjunct to SRP, aiming to decrease tissue destruction caused by inflammation. These treatments include topical, local or systemic use of medications as a supplemental method during periodontal therapy [11]. Theoretically, different medications may be suitable for host modulation such as non-steroidal anti-inflammatory drugs, tetracyclines, or bisphosphonates; however, they can only be used for a limited period of time since they have adverse side effects [12].

Some previous studies reported further improvement of periodontal status by the consumption of dietary supplements such as vitamin D [13], vitamin C [14], hyaluronic acid [15], and probiotics [16] as an adjunct to SRP. Unsaturated omega-3 fatty acids can also be used as a supplement in many chronic inflammatory diseases with fewer side effects. Their optimal efficacy for reduction of inflammation in periodontal disease has been previously reported [17]. Intake of omega-3 fatty acids is necessary since they are not synthesized in the human body. The ratio of omega 3/omega 6 in the body highly depends on their intake through diet [18]. Omega-3 fatty acids include α-linolenic acid, eicosapentaenoic acid, and docosahexaenoic acid, which are found in abundance in fish oil and walnut oil [19].

Omega-3 fatty acids are merged with the cell membrane phospholipids, and serve as a precursor for lipid mediators to control cell signals, alter gene expression, and regulate inflammatory processes [19,20], resulting in anti-inflammatory effects. Moreover, the metabolism of omega-3 fatty acids results in production of pro-resolving lipid mediators with anti-inflammatory and immunoregulatory effects, inhibiting the migration of immune cells and production of pro-inflammatory cytokines [21]. Furthermore, eicosapentaenoic acid and docosahexaenoic acid have antibacterial effects and can inhibit the activity of some periopathogenic microorganisms such as Porphyromonas gingivalis, Fusobacterium nucleatum, and Prevotella intermedia [17,22]. Omega-3 supplements do not have significant complications; however, some patients may be allergic to them [23]. Also, omega-3 supplements may interfere with some anti-coagulants and cause hemorrhage [24].

As mentioned earlier, the optimal effects of omega-3 fatty acids on periodontal parameters have been previously documented [25,26]. However, some other studies refuted such effects [27-30]. A recent systematic review could not reach a final conclusion on the advantages of omega-3 supplementation for periodontal therapy due to high heterogeneity in the findings and high risk of bias [31]. Considering the existing controversy on this topic, this study aimed to assess the effects of omega-3 fatty acid supplementation on periodontal parameters in patients with CP.

This study was conducted at the Periodontics Department of School of Dentistry, Yazd University of Medical Sciences between August 2021 and March 2022. The study was approved by the ethics committee of this university (IR.SSU.REC.1400.025) and at 17/07/2021 registered in the Iranian Registry of Clinical Trials (IRCT20151013024509N5).

Trial design:

A parallel-design randomized clinical trial was conducted in which, the intervention group received omega-3 supplementation for 3 months after SRP while the control group received placebo for 3 months after SRP. The results were reported in accordance with the Consolidated Standards of Reporting Trials.

Participants, eligibility criteria, and settings:

The inclusion criteria were (I) moderate to severe CP with CAL > 3 mm [32], (II) age between 30 to 70 years, (III) no cigarette smoking or tobacco use, (IV) no history of periodontal therapy, (V) no history of antibiotic use in the past 3 months, (VI) absence of diseases or conditions that would interfere with wound healing such as diabetes mellitus or coagulation disorders, (VII) absence of oral mucosal inflammatory conditions such as aphthous ulcers or lichen planus, (VIII) no intake of medications affecting the periodontium such as anticonvulsants, calcium channel blockers, or immunosuppressants, and (IX) no pregnancy or nursing.

The exclusion criteria were (I) not showing up for the 1-month or 3-month follow-ups, and (II) no or poor adherence to the instructions regarding omega-3 supplementation, or oral hygiene instructions at the 1-month follow-up.

The sample consisted of 30 patients with CP presenting to the Periodontics Department of School of Dentistry, Yazd University of Medical Sciences for periodontal therapy.

Informed consent was obtained from the patients to participate in the study and to use the results obtained from the study by the post-graduate student.

Interventions:

Written informed consent was obtained from all patients after they were briefed about the study. The diagnosis of moderate to severe CP was made according to the criteria proposed in the International Periodontology Workshop in 1999 based on CAL ≥ 3 mm. The CAL, PD and bleeding index (BI) [32] were measured for each patient and recorded at baseline. Next, all patients received SRP with an ultrasonic scaler (Various 350; NSK, Japan) and a manual universal curette (Gracey; Hu-Friday, Chicago, USA) by a post-graduate student of periodontics. They also received prophylaxis with a prophy brush and prophy paste. The modified Bass tooth brushing technique was then instructed to patients on a model. Next, the patients were randomly assigned to two groups, and were standardized in terms of age, gender distribution, and severity of periodontal disease based on the mean baseline PD, CAL, and BI.

Omega-3 soft-gels (n=1800, 1000 mg each) and placebo soft-gels containing only the solvent oil of omega-3 were produced by Omid Kavir pharmaceuticals. The intervention group received 1000 mg omega-3 soft-gels while the control group received placebo soft-gels. Both groups were instructed to use one 1000 mg soft-gel daily for 3 months [26]. Accordingly, each group received three bottles, each containing 30 soft-gels.

The patients were recalled at 1 month to ensure their adherence to oral hygiene instructions. The patients were requested to continue using the supplement. The patients were recalled again at 3 months, and their PD, CAL, and BI were measured again.

Outcomes (primary and secondary):

The main objective of this study was to assess the effect of omega-3 supplementation following SRP on clinical periodontal parameters in patients with CP.

Sample size calculation:

The sample size was calculated to be at least 15 in each group according to a study by Kruse et al, [25] considering alpha=5%, study power of 80%, standard deviation of CAL to be 0.7, and a minimum significant difference of 0.6 unit in CAL between the two groups.

Interim analyses and stopping guidelines:

No interim analyses were performed, and no stopping guidelines were established.

Randomization:

The patients were randomly assigned to the intervention and control groups by a table of random numbers generated by the Random Allocation software.

Blinding:

The study had a double-blind design. Both omega-3 and placebo soft-gels had the same shape and color and similar packaging. A pharmacist not involved in the study coded the soft-gels A and B based on their content and administered them among the patients. The dental clinician who measured the clinical periodontal parameters and the patients were not aware of the group allocation of soft-gels. The statistician who analyzed the data was also blinded to the group allocation of data.

Statistical analysis:

Data were analyzed by SPSS version 25 (SPSS Inc., IL, USA). Normal distribution of data was evaluated by the Kolmogorov-Smirnov test. Comparisons were made by paired t-test and t-test at 0.05 level of significance.

Participant flow:

A total of 30 patients in 2 groups of 15 were evaluated in this study. Figure 1 shows the flow-diagram of patient selection. The two groups were standardized in terms of age, gender, and baseline clinical periodontal parameters as shown in Table 1. There were 7 females (46.7%) and 8 males (53.3%) in the intervention group, and 9 females (60%) and 6 males (40%) in the control group. The two groups were not significantly different regarding gender distribution (P=0.358).

Harms:

No patients were harmed during the study and no side effect was reported.

Subgroup analysis:

The Kolmogorov-Smirnov test confirmed normal distribution of data (P>0.05). Table 2 presents the mean PD, CAL and BI in the two groups at baseline and at 3 months after the intervention. As shown, all parameters significantly decreased at 3 months compared with baseline in both groups (P<0.05).

The improvement in PD and CAL in the intervention group was significantly greater than that in the control group (P=0.001); however, the difference in BI was not significant between the two groups (P=0.283). The difference in PD and CAL between the two groups was clinically significant as well since the difference was > 1 mm.

This study assessed the effects of omega-3 fatty acid supplementation on periodontal parameters in patients with CP. The sample size of this study was similar to that in a study by Keskiner et al, [29] higher than that in studies by Martinez et al, [28] and Rampally et al, [33] and smaller than that in studies by Stańdo et al, [34] and Shalaby and Morsy [35]. The dosage of omega-3 administered in the present study was similar to some previous studies [33,36,37]. No side effect was reported by patients in the present study; however, Stańdo et al. [34] reported that patients complained of nausea and mouth malodor (fish smell) as side effects. Selection of 1- and 3-month follow-ups was also in line with previous studies [33,34,38].

The present results showed that all three clinical parameters significantly decreased in both groups at 3 months compared with baseline (P=0.001). The improvement in PD and CAL in the intervention group was significantly greater than that in the control group (P=0.001); however, the difference in BI was not significant between the two groups (P=0.283). Bleeding on probing has a strong correlation with inflammatory processes due to the presence of dental plaque. Usually, if dental plaque is not removed after one week, the primary clinical signs and symptoms of inflammation appear, which include gingival redness and bleeding. However, CAL and increase in PD take longer to occur [39]. Since the final assessment was done at 2 months after the first follow-up session, it is possible that patients did not perfectly adhere to oral hygiene instructions for complete plaque removal, resulting in an increase in their BI. Also, it should be noted that patients who willingly participate in a study related to oral hygiene status often take better care of their teeth and better adhere to oral hygiene instructions. This phenomenon is referred to as the Hawthorne effect [40]. Of limited studies that assessed BI, the present results were in agreement with those of El-Sharkawy et al, [41] and Martinez et al [28]. However, Stańdo et al. [34] reported a significant reduction in bleeding on probing in the intervention group, compared with the control group. They also evaluated patients at 3 weeks and 3 months. Thus, different between their results and the present findings may be due to the higher dose of omega-3 used in their study (3000 mg), or better adherence of patients to plaque control measures, or the fact that patients also received instructions to use inter-dental brush (which was not used in the present study), in addition to toothbrush and dental floss. Of clinical parameters, CAL and PD were evaluated in almost all similar previous studies. Stańdo et al, [34] and many others [36,38,41] reported results similar to the present findings regarding the improvement in clinical parameters as the result of omega-3 supplementation. Martinez et al, [28] and Keskiner et al. [29] reported a reduction in CAL and PD in both the intervention and control groups but the difference between the two groups was not significant. In the present study, the difference in CAL and PD between the two groups was > 1 mm, and therefore, it was clinically significant.

This study had several strengths. At the onset of study, the patients were evaluated to ensure absence of confounders such as cardiovascular diseases and diabetes mellitus, history of antibiotic therapy in the past 3 months, and pregnancy to ensure no effect of confounders on the results. Martinez et al. [28] did not exclude smokers and Rampally et al. [33] evaluated type II diabetes mellitus patients. Also, the two groups were standardized in terms of the mean age, gender distribution, and severity of periodontal disease in the present study. Both groups received SRP and oral hygiene instructions. Also, the placebo soft-gels were identical to the omega-3 soft-gels.

This study had some limitations as well. Due to the COVID-19 pandemic, a larger sample size could not be recruited. Also, patients were not willing to show-up for the follow-ups due to COVID-19 pandemic. Thus, longer follow-ups could not be scheduled.

Future studies are required with a larger sample size and longer follow-up periods. Also, the efficacy of omega-3 supplementation along with antibiotic therapy or periodontal surgery should be evaluated in further investigations.

Omega-3 supplementation for 3 months as an adjunct to non-surgical periodontal therapy significantly improved the clinical parameters in CP patients.

CAL: Clinical attachment loss, PD: Probing depth, BI: Bleeding index

Acknowledgements
Thanks to all the patients who participated in this clinical study.
Author contributions
F.RM designed and directed the project and developed the theoretical framework. M.F performed the interventions and measurements. F.T performed simulations and blinded the study. Both F.RM and F.M contributed to writing the final version of the manuscript.
Funding
This study was supported by Shahid Sadoughi university of medical sciences.
Availability of data and materials
The datasets generated and/or analyzed during the current study are not publicly available due to privacy and ethical concerns but are available from the corresponding author on reasonable request.
Ethics approval and consent to participate
This study was approved by the ethics committee of this university (IR.SSU.REC.1400.025) and at 17/07/2021 registered in the Iranian Registry of Clinical Trials (IRCT20151013024509N5) and written informed consent was obtained from all patients. All methods were performed in accordance with the 1964 Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1.Department of Periodontics, Faculty of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. 2. Department of Periodontics, Faculty of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. 3. Department of Toxicology and Pharmacology, School of Pharmacy, Shahid Sadoughi University of Medical Sciences,Yazd,Iran.

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Table 1. Standardization of the two groups at baseline using t-test (n=15)

Table 2. Mean PD, CAL and BI in the two groups at baseline and at 3 months after the intervention

Group	Variable	Time	Mean	Std. deviation	*P-value
Intervention	PD	Baseline	5.067	0.982	0.000
	PD	3 months	2.653	0.843
	CAL	Baseline	5.24	1.04	0.000
	CAL	3 months	3.07	0.61
	BI	Baseline	78.53	9.86	0.000
	BI	3 months	49.80	16.06
Control	PD	Baseline	4.507	1.018	0.000
	PD	3 months	3.340	0.940
	CAL	Baseline	4.66	1.01	0.000
	CAL	3 months	3.57	0.92
	BI	Baseline	79.53	10.43	0.000
	BI	3 months	56.26	15.09

*Paired t-test at 0.05 level of significance

No competing interests reported.

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You are reading this latest preprint version

Effects of omega-3 supplementation as an adjunct to non-surgical periodontal therapy on periodontal parameters in chronic periodontitis patients: A randomized clinical trial

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