1. What data in particular will be shared?
   Response - All of the individual participant data collected during the trial, after de-identification.
   


2. What additional supporting information will be shared?
   Response -  Study Protocol
   Response -  Statistical Analysis Plan
   Response - Informed Consent Form
   
   
3. Who will be able to view these files?
   Response - Anyone
   


4. For what types of analyses will this data be available?
   Response - For individual participant data meta-analysis.
   


5. By what mechanism will data be made available?
   Response - Proposals should be directed to [drchandrubr@yahoo.com].
   


6. For how long will this data be available start date provided 17-12-2021 and end date provided 30-12-2024?
   Response - Beginning 9 months and ending 36 months following article publication.
   


7. Any URL or additional information regarding plan/policy for sharing IPD? 
   Additional Information - NIL

Title of the proposed research project: Melatonin, as a locally delivered drug in the treatment of periodontal infra bony defects - A randomized controlled trial. 

Public Title: Evaluating the effectiveness of locally applied melatonin gel in the treatment of advanced gum disease. 

Background: Periodontal diseases are among the most common oral diseases affecting about 20-50% of global population with rising evidence. Periodontal diseases are associated with systemic diseases such as cardiovascular disease, diabetes, adverse pregnancy outcomes and many more.^[1-2]

Global burden of periodontal disease: Periodontal disease is one of the most common oral diseases affecting human population.^[3]  The Global Burden of Disease Study (GBD, 1990–2010) indicates that: (i) severe periodontitis is the 6th most prevalent disease worldwide, with an overall prevalence of 11.2% and around 743 million people affected, and (ii) the global burden of periodontal disease increased by 57.3% from 1990 to 2010. Periodontitis is also one of the major causes of tooth loss in adult population worldwide, leading to edentulism and masticatory dysfunction. This affects their nutrition, quality of life and self-esteem besides having adverse socio-economic impacts by increasing healthcare costs.^[4]

National statistics: The prevalence of periodontal disease was 57%, 67.7%, 89.6% and 79.9% in the age groups 12, 15, 35-44 and 65-74 years, respectively (periodontal disease is not evaluated in 5 year olds). The lower prevalence in older age could be due to loss of teeth in the elderly. Moderate periodontitis was seen in 17.5% of the 35-44 years group; and 21.4%, in the 65-74 years group; whereas severe disease, defined as at least one tooth with ≥6 mm probing depth, was seen in 7.8% in the 35-44 years group and 18.1% in the 65-74 years group.^[5] 

Impact on systemic health: Periodontal disease can cause 19% increase in the risk for cardiovascular disease, and this increase in relative risk reaches to 44% among individuals aged 65 years and over. Type 2 diabetic individuals with severe form of periodontal disease have 3.2 times greater mortality risk compared with individuals with no or mild periodontitis. Literature indicate that periodontal therapy improves glycemic control in type 2 diabetic subjects. Periodontitis is also associated with maternal infection, preterm low birth weight, and preeclampsia.^[3]

Social and economic burden: The global burden of periodontal diseases is increasing. The socio-economic burden of periodontitis is responsible for 3.5 million years lived with disability, 54 billion USD/year in lost productivity and a major portion of the 442 billion USD/year cost for oral diseases.^[3]

Current concepts of treating advance destructive periodontal diseases and their shortcomings: Most often periodontal diseases are treated with scaling and root planning besides other surgical interventions. Most often treatment for severe destructive periodontitis with alveolar bone loss or furcation involvement will involve surgical intervention along with use of systemic antibiotics. The inadvertent use of antimicrobial drugs has escalated the risk of antimicrobial drug resistance which is also a major public health concern today. Antibiotic resistance is dangerously rising in all parts of the world with emergence of new resistance mechanisms threatening our ability to treat common infectious diseases According to the WHO, around 7,00,000 people die every year which is attributable to antibiotic resistance.^[3,6]

Chlorhexidine gluconate is the most commonly used antiplaque agent in the treatment of periodontal diseases. However, some potential drawbacks like altered taste sensation, staining of teeth and development of resistant microorganisms incapacitate its long term use.^[7]In this background, discovery and development of newer drugs which are less affected by resistant mechanisms are currently the only realistic therapy that can ensure a remedial approach.

Periodontal therapy aims in regenerating the lost tissue. However, the prognosis is always questionable due to the multi-factorial nature of disease, varied pathogenesis of microbiota, unpredictable drug release, patients’ compliance, host response.^[8] In the quest of finding the most suitable therapeutic mode, local delivery of drugs has also been experimented wherein, a calculated dose of drug is delivered at the local site to ensure long term release of drug excluding the systemic side effects.^[9] The “treat-to-target” strategy^[10]is widely considered the best practice in the management of periodontal defects. Surgical intervention in the treatment of bone defects in severe destructive periodontitis will be painful and may be contraindicated in some medically compromised patients.

Although local drug delivery is an established concept in the treatment of severe destructive periodontitis, the search for innovative strategies which are non-invasive, cost effective and patient friendly are always a priority in the view of increasing antimicrobial resistance against conventional drugs which are used at present.

Since decades, melatonin is being used in the field of medicine. Melatonin, an endogenous molecule released from the pineal gland has significant anti-microbial activity. It binds to copper, iron and zinc reducing its cytoplasmic pool and the unavailability of these metal ions leads to bacterial cell lysis, as micro-organisms are strongly dependant on iron for their survival. It is a versatile molecule that shows low toxicity over a wide range of doses. Hence, melatonin has been extensively used in managing sleep disorders, ocular diseases, bacterial infections, treatment of sepsis and many more conditions.^[11-18]

Literature evaluating the efficacy of melatonin as an anti-microbial, anti-resorptive and anti-inflammatory agent for the treatment of infra-bony  defects in patients with severe periodontal disease is practically non-existent. In this background, this translational research which is a combination of in-vitro and in- vivo study by a multi-speciality team will give an opportunity to formulate, characterize and clinically evaluate the efficacy of locally delivered Melatonin gel in the treatment of infra-bony defects in patients with severe periodontitis.

            These novel targeted drug delivery systems can become successful intervention strategy in the treatment of alveolar bone defects in patients with severe periodontitis where it shows great promise in terms of ease of drug administration and better patient compliance.

Literature review:

Periodontitis is one of the most common oral diseases afflicting mankind. It is one of the leading causes of premature tooth loss that has proven adverse consequences on nutritional intake. Moreover, periodontitis is positively associated with systemic diseases like diabetes and cardiovascular diseases besides predisposing to low birth weight.^[1-3] Treatment of periodontitis in advanced stages most often requires surgical intervention to facilitate bone regeneration. This makes the procedure more invasive and expensive. Besides, patient compliance and acceptance of these conventional surgical interventions are always uncertain. Antimicrobial agents used in surgical interventions pose the risk of drug resistance.^[6-7] Hence, innvoative studies related to novel drugs and their delivery systems are esential for effective treatment of alveolar bone defects in severe periodontitis.

            Melatonin is an endogenous molecule that has many favorable effects. It has strong anti-oncotic, anti-inflammatory, anti-resorptive effect and has been reported to reduce progression of bone loss which occurs by the down regulation of pro inflammatory factors.^{[11- 14]}It also exhibits anti-oxidant action on human gingival fibroblasts.^[15]Although, melatonin is used in the treatment of sleep disorders, ocular diseases, bacterial infections and sepsis management,^[18] research evaluating the efficacy of melatonin in the treatment of alveolar bone defects in severe periodontitis is practically non-existent.

Melatonin release from pineal gland and its effects is diagrammatically represented in figure 1. Clinical merits of Melatonin are diagrammatically represented in figure 2. Mechanism of action of Melatonin in bone remodeling is diagrammatically represented in figure 3.

Review of literature on clinical application of melatonin

Santos et al. evaluated the effects of melatonin on insulin resistance and signaling, proinflammatory cytokine levels, and lipid profiles in pinealectomyzed rats with periodontal disease. The results indicated that Melatonin replacement therapy efficiently prevented Insulin resistance, improved lipid profile, and increased plasma levels of insulin with increase in Tumor Necrosis factor -alpha in Periodontal disease and pinealectomized rats.^[19]

Virto studied the effectiveness of adjunctive systemic administration of melatonin to standard mechanical periodontal therapy in obese rats with experimental periodontitis. Outcomes were evaluated by the changes in clinical parameters, bone resorption and in the levels of biomarkers in plasma and in gingival tissue. It was concluded that adjunctive melatonin therapy significantly reduced alveolar bone loss and exerted a protective anti-inflammatory effect mainly in those experimental animals affected by the co-morbidity of periodontitis and obesity.^[20]

Montero et al. designed a clinical trial to evaluate the effects of topical application of melatonin on the crevicular fluid levels of interleukins and prostaglandins and to evaluate changes in clinical parameters. Patients with diabetes and periodontitis were treated with topical application of melatonin for 20 days. The rest of the patients with diabetes and periodontitis and healthy subjects were treated with a placebo of orabase cream. The periodontogram was performed with a Florida Probe. It was concluded that treatment with topical melatonin was associated with improvement in the gingival index and pocket depth. Reduction in concentrations of interleukin-1β, interleukin-6 and prostaglandin E2 in gingival crevicular fluid was also noticed.^[21] 

Local drug delivery: The key to treat infra-bony defects/alveolar bone defects in severe periodontitis is “right drug at the right dose by the right route of administration to the right patient”. Local drug delivery is a method to apply drug substances or therapeutic composites into the affected site. Local drug delivery system in the treatment of furcation defect/infra bony pockets will require that the drug will be injected into the site. The local administration is always favored because it will not only deliver the drug to the site of inflammation in high concentration but also minimize the side effects related to systemic cytotoxicity and promotes efficient utilization of drugs. Intra defect administration of the dosage form will give a site specific delivery of a drug to the infra-bony defects, because of the availability of maximum concentration of drug at the site of action. Moreover, a more important concern is how long the drug can stay at the desired place. In this background, there is a need to develop novel delivery systems fabricated using biocompatible and biodegradable polymers. With the degradation of the polymer, encapsulated drugs can release from polymer composites for their designed functions improving drug residence time and its efficacy.

Review of literature on local drug delivery system in the treatment of severe periodontitis with infra-bony defects.

Garg et al. explored the efficacy of 1.2% Rosuvastatin and 1.2% Atorvastatin gels as a local drug delivery and redelivery system adjunct to scaling and root planing (SRP) for treatment of Class II furcation defects and showed improvement in clinical and radiographic parameters. However, the results with RSV gel delivery were significantly better than ATV gel.^[22]

Reddy et al. studied the use of sub-gingivally administered chlorhexidine gelatin bioresorbable chips to enhance bone gain in conjunction with guided tissue regeneration in periodontal bone defects. It was concluded that locally delivered, controlled-release antimicrobial treatment may improve the amount of bone gain during guided tissue regeneration procedures.^[23] 

Pradeep et al. aimed to explore the efficacy of 1% ALN gel as a local drug delivery system as an adjunct to scaling and root planing (SRP) for the treatment of Class II furcation defects in comparison with placebo gel.  Clinical parameters were recorded at baseline, 3 months, 6 months, and 12 months, and radiographic parameters were recorded at baseline, 6 months, and 12 months. Defect fill at baseline, 6 months, and 12 months was calculated on standardized radiographs using image analysis software. It was concluded that local delivery of 1% ALN into a Class II furcation defect stimulates a significant PD reduction, RVCAL and RHCAL gains, and improved bone fill compared with placebo gel as an adjunct to SRP.^[24]

Current status of research and development in subject (both International and National status)*

Although melatonin is being used in the field of medicine, literature evaluating the efficacy of melatonin as an anti-microbial, anti-resorptive and anti-inflammatory agent in the treatment of infra-bony defects in patients with severe periodontal disease is practically non-existent.

Hence, we aim to use a locally delivered Melotonin gel to treat infra-bony defects in patients with severe periodontitis.   

            In present study, an attempt for the direct delivery of melatonin gel by formulating as a biocompatible, biodegradable injectable system is investigated. The proposed system will be designed to provide a faster onset yet effectively control the drug release by tailoring the system as necessitated by the clinical conditions incorporating technological parameters. The proposed delivery system may address the current requirements and can be potential alternate for effective treatment of infra-bony defects in severe periodontitis.

The optimized locally delivered melatonin gel can be commercialized after the technology transfer, to the interested pharmaceutical companies.

Hypothesis:

v  Locally delivered melatonin gel is effective in improving various clinical parameters like gingival index, probing pocket depth, clinical attachment loss, bleeding index and bone loss in comparison with chlorhexidine based system as control among patients with severe periodontitis.

v  Locally delivered melatonin gel is effective in improving bone fill and density (type of bone formed) in the treatment of infra-bony defects in comparison with chlorhexidine based system as control among patients with severe periodontitis.

This will be the first of its kind study to clinically evaluate the effectiveness of locally delivered melatonin gel in the treatment of infra-bony defects in patients with severe periodontitis. The local drug delivery system will be an alternate to chlorhexidine and conventional surgical intervention.

Novelty of the work

1.         Development of a biocompatible, biodegradable locally delivered melatonin gel to be injected into infra-bony defects in severe periodontitis as a smart gel (site specific drug delivery)

2.         Smart gelling system, transforms from sol to gel at the site of injection (easy to deliver solution; retains at the site of injection)

3.         The composite system will be retained for prolonged period delivering melatonin in controlled/ sustained manner (longer dosing frequency).

4.         The drug entrapped will be concealed till its release (reduces drug metabolism & related side effects).

5.         The formulation will have low cost of therapy and better patient compliance (lesser economic burden).

The aim of this research is to develop a drug delivery system that gives provision for drug localization. Less frequent dosing with increased drug efficacy helps in minimizing toxicity and produces sustained or persistent effects of drugs. This approach ensures that the drug is confined within the periodontal defect, where its effects on periodontal tissue inflammation are enhanced and the drug leakage possibility is minimized.

Objectives:

1.      To evaluate efficacy of locally delivered Melatonin gel in the treatment of infra-bony defects in patients with severe periodontitis using a double-blind randomized control trial. 

2.      To evaluate the feasibility of using melatonin gel as an alternate to chlorhexidine.   

Methodology

This human randomized control trial will be undertaken among eligible study participants with severe periodontitis after obtaining informed consent from participants in accordance with declaration of Helsinki for undertaking human trials. This will be a double blind parallel arm randomized control trial on patients with severe periodontitis.

Sample size: Estimation of sample size will be done based on the results of pilot study at an effect size of 0.6 and 80% power at 5% level of significance.

Participant recruitment: This will be done at the department of Periodontics and rural health training center attached to JSS Dental College and Hospital, Mysore after obtaining informed consent. Informed consent will be obtained from each participant after explaining them about rationale, procedures, risks and benefits of participating in the study by principal investigator. Participants will be given information sheet in local language along with informed consent form. They will be requested to return the signed consent form after one week. This will give them sufficient time to make an informed decision to voluntarily participate in the study.

Inclusion criteria:

v  Aged above 18 years

v  Willing to offer informed consent

v  Having severe periodontitis

Exclusion criteria

v  With known history of allergy or hypersensitivity to the drugs in trial

v  Systemic diseases that compromise periodontal host defense mechanism

v  History of use of antimicrobial drugs in the last three months

Baseline examination: Pre intervention evaluation of all clinical and radiological parameters will be done. Clinical parameters like gingival index, probing pocket depth, clinical attachment loss, bleeding index and bone loss in test and control group will be assessed. Clinical parameters will be evaluated using sterile mouth mirrors and graduated probe by a trained and calibrated investigator. A pre-designed, structured and validated data collection proforma will be used for collecting all relevant information from the study participants. Training and calibration of investigator will be carried out in the department of Public Health Dentistry before the investigator is assigned to collect data on clinical parameters. The bone loss will be evaluated using either Cone Beam Computed Tomography (CBCT)/IOPA radiographs.

Randomization: After baseline evaluation, participants will be divided into two groups using computer generated random allocation sequence by the coordinator.

Intervention: Phase I periodontal therapy will be given as part of intervention along with local delivery of injectable gels by a periodontist.

Group I: Test group will receive locally delivered melatonin gel

Group II: Control group will receive Chlorhexidine based gel.

Participants will be requested to inform the principal investigator if they are taking any medications during the follow up period.

Blinding: The group allocation information will be concealed from investigator involved in clinical data collection and microbiological evaluation to ensure blinding. 

Post intervention evaluation: This will be done by the same investigator who undertook baseline examination using all the parameters used at baseline. The negative outcomes in the form of any adverse reactions will be noted during the study period. The post intervention evaluation will be done at intervals specified beneath following intervention.

v  Clinical parameters will be evaluated at baseline followed by 6 weeks and six months following intervention.

v  Radiological parameters using CBCT/IOPA will be evaluated at baseline and six months following intervention.

Statistical analysis: This will be done using SPSS version 24. Quantitative data will be presented as mean and standard deviation while qualitative data will be presented as frequencies and percentages. Clinical and radiological parameters between the test and control groups at baseline and post intervention will be compared using independent sample t-test while the change in parameters between baseline and post intervention in each group will be compared using either paired t-test or repeated measures analysis of variance. Statistical significance will be fixed at 0.05.

RCT will be coordinated by the Principal investigator in the department of Public Health Dentistry, and co-investigator from the department of Periodontia, JSS Dental College and Hospital.

v  Specialist from Public Health Dentistry will coordinate patient recruitment, randomization, blinding, data collection and distribution of oral hygiene kits.

v  Specialist from Periodontics will complete the intervention besides collecting GCF and sub gingival plaque samples at specific intervals.

v  Formulation and development of drugs will be done by Principal Investigator in the department of Pharmaceutics, JSS College of Pharmacy, Mysore.

References

1.      Manjunath BC, Praveen K, Chandra Shekar BR, Rani RM, Bhalla A. Periodontal infections: a risk factor for various systemic diseases. Natl Med J India 2011; 24(4):214-9.

2.      Chandra Shekar BR, Reddy CVK. Oral health status in relation to socio-economic factors among the Municipal employees of Mysore city. Indian J Dent Res 2011; 22(3): 410-18.

3.      Nazir MA. Prevalence of periodontal disease, its association with systemic diseases and prevention. International journal of health sciences. 2017 Apr;11(2):72 – 80.

4.      Tonetti MS, Jepsen S, Jin L, Otomo‐Corgel J. Impact of the global burden of periodontal diseases on health, nutrition and wellbeing of mankind: A call for global action. Journal of clinical periodontology. 2017 May;44(5):456-62.

5.      Shaju JP, Zade RM, Das M. Prevalence of periodontitis in the Indian population: A literature review. Journal of Indian Society of Periodontology. 2011 Jan;15(1):29 – 34.

6.      Manjunath BC, Chandra Shekar BR, Vatchala RRM, Babaji P, Singh I, Arora K et.al. Addressing antimicrobial resistance in dentistry. J Oral health Comm Dent 2013; 7(2): 102-8.

7.      Eley BM. Antibacterial agents in the control of supragingival plaque — A review. Br Dent J1999; 186 (6): 286-96.

8.      Bartold PM, Van Dyke TE. Periodontitis: a host‐mediated disruption of microbial homeostasis. Unlearning learned concepts. Periodontology 2000. 2013 Jun;62(1):203-17.

9.      Prakash AP. Local Drug Delivery in periodontal diseases.…… A Review. Nitte University Journal of Health Sciences. 2016;1:74-9.

10.  Smolen JS. Treat-to-target: rationale and strategies. Clin Exp Rheumatol. 2012 Jul 1;30(4 Suppl 73):S2-6.

11.  Ya Li, Sha Li, Yue Zhou, Xiao Meng, Jiao-Jiao Zhang, Dong-Ping Xu and HuaBinLi. Melatonin for the prevention and treatment of cancer . Oncotarget, 2017, Vol. 8, (No. 24), pp: 39896-39921.

12.  Naza M, Kasim M and Saad A. Dose-Dependent Anti-Inflammatory Activity of Melatonin in Experimental Animal Model of Chronic Inflammation. Global Journal of Pharmacology 4 (2): 66-70, 2010.

13.  TanerArabaci, EdaKermen, SeçkinÖzkanlar. Therapeutic Effects of Melatonin on Alveolar Bone Resorption After Experimental Periodontitis in Rats. A Biochemical and Immunohistochemical Study. J Periodontol 86(7):1-13.

14.  Murakami Y, Machino M, Fujisawa S. Porphyromonasgingivalis Fimbria-Induced Expression of Inflammatory Cytokines and Cyclooxygenase-2 in Mouse Macrophages and Its Inhibition by the Bioactive Compounds Fibronectin and Melatonin. ISRN Dent. 2012;2012:350859. doi: 10.5402/2012/350859. Epub 2012 Apr 1.

15.  Gómez-Florit M, Ramis JM, Monjo M Anti-fibrotic and anti-inflammatory properties of melatonin on human gingival fibroblasts in vitro.BiochemPharmacol. 2013 Dec 15;86(12):1784-90. doi: 10.1016/j.bcp.2013.10.009. Epub 2013 Oct 19.

16.  Tekbas OF, Ogur R, Korkmaz A, Kilic A, Reiter RJ. Melatonin as an antibiotic: new insights into the actions of this ubiquitous molecule. J Pineal Res. 2008 Mar;44(2):222-6.

17.  Amaral FGD, Cipolla-Neto J A brief review about melatonin, a pineal hormone. Arch Endocrinol Metab. 2018 Aug;62(4):472-479. doi: 10.20945/2359-3997000000066

18.  Sánchez-Barceló EJ1, Mediavilla MD, Tan DX, Reiter RJ.) Clinical uses of melatonin: evaluation of human trials. Curr Med Chem. 2010;17(19):2070 95.

19.  Santos RMD, Marani F, Chiba FY, Mattera MSLC, Tsosura TVS, Tessarin GWL,et al. Melatonin promotes reduction in TNF levels and improves the lipid profile and insulin sensitivity in pinealectomized rats with periodontal disease. Life Sci. 2018 Nov 15;213:32-39. 

20.  Virto L, Cano P Jiménez-Ortega V, Fernández-Mateos P, González J, Haugen HJ, Esquifino AI, Sanz M. Melatonin as adjunctive therapy in the treatment of periodontitis associated with obesity. J Clin Periodontol. 2018 Nov;45(11):1336-1346.

21.  Montero J, López-Valverde N, Ferrera MJ, López-Valverde A^.Changes in crevicular cytokines after application of melatonin in patients with periodontal disease. J Clin Exp Dent. 2017 Sep 1;9(9):e1081-e1087.

22.  Garg S, Pradeep AR. 1.2% Rosuvastatin and 1.2% Atorvastatin Gel Local Drug Delivery and Redelivery in the Treatment of Class II Furcation Defects: A Randomized Controlled Clinical Trial. J Periodontol. 2017 Mar;88(3):259-265.

23.  Reddy MS, Jeffcoat MK, Geurs NC, Palcanis KG, Weatherford TW, Traxler BM, Finkelman RD. Efficacy of controlled-release subgingival chlorhexidine to enhance periodontal regeneration. J Periodontol. 2003 Apr;74(4):411

24.  Pradeep AR, Kumari M, Rao NS, Naik SB .1% alendronate gel as local drug delivery in the treatment of Class II furcation defects: a randomized controlled clinical trial. J Periodontol. 2013 Mar;84(3):307-15.