White Blood Cell Signaling and Defense Mechanisms in Patients With Diabetes Mellitus Type 2 and Periodontitis (DMS)

Human Polymorphonuclear Neutrophil (PMN) Cytosolic Signaling and Effector Functions in Patients With Diabetes Mellitus Type 2 and Periodontitis

White blood cell membrane and surface structures are affected by the metabolic disorders and complications found in diabetes mellitus. Therefore, cellular activation, signal propagation, intracellular signaling as well as bactericidal effector functions are altered.

When diabetic symptoms are corrected by the systemic intervention and treatment of the patients (Anti-diabetic Therapy/ADT, i.e. anti-diabetic medication, diet and dietetic supervision, physiotherapy and physical exercises), white blood cell functions will then normalize and reach the functionality comparable to those cells derived from healthy subjects.

Gum diseases like periodontitis have long been associated with and termed complications of uncontrolled diabetes mellitus. Vice versa, after diabetic conditions are corrected, periodontitis treatment will be proven effective, when oral hygiene regimen, full mouth decontamination (FD, i.e. the oral use of topical antiseptics prior and after professional mechanical tooth cleaning, tooth as well as root surface planing, polishing as well as gum and soft tissue decontamination in combination with systemic antibiotics) are performed. To reinforce gum healing, reinfection prevention (RP) as well as supportive periodontal therapy (SPT) will be administered by dental professionals on an individual basis and a detailed schedule.

If periodontal pockets critical for participant's self care are not eliminated by FD including RP and SPT, and niches >5mm after 6 month persist, patients are informed and offered surgical intervention as indicated for gum disease elimination.

Dental follow up exams will be offered to all participants.

Study Overview

• Status: Unknown
• Conditions: Diabetes Mellitus, Type 2; Chronic Periodontitis
• Intervention / Treatment: Procedure: ADT+FD; Procedure: FD

Detailed Description

Specific Aims

1. To investigate if cytosolic Ca2+- ( delta[Ca2+]i) and pH (delta_pHi) signaling responses and bactericidal effector functions of PMN dependent upon the status of diabetic control and are reduced or increased when compared to age and gender matched controls
2. To determine the biochemical basis for diabetic PMN alteration of motility as well as bactericidal functions: production of superoxide and release of elastase, respectively
3. To characterize the molecular basis of the observed alterations in the regulation of cytosolic calcium (delta[Ca2+]i) and pH (delta_pHi) exhibited by diabetic PMN
4. To investigate if the pre-activated state and altered bactericidal functionality of diabetic PMN are reversed when the patients' glycemic control is normalized, blood glucose levels as well as periodontal disease are corrected
5. To evaluate, if systemic and periodontal intervention can lead to clinical attachment gain in patients with diabetes mellitus type 2

• Study Type: Interventional
• Enrollment (Anticipated): 45
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Germany
  • Giessen, Germany, 35392
    • Department of Periodontontology, ZentrumZMK

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 70 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Diabetes Mellitus, Type II
• Glycated Hemoglobin ≥8.5%
• Chronic Periodontitis
• Patients and controls should have at least 12 natural teeth (without subgingival fillings, crowns or caries)

Exclusion Criteria:

• Pregnancy
• Smoking
• Low Body Mass Index (BMI <18.5kg/m*m)
• Severe cardiovascular disease including coronary artery disease, cerebral vascular disease, peripheral vascular disease, valvular heart disease, and congestive heart failure
• Other major illnesses including cancer, liver disease, pulmonary disease, chronic infectious disease other than periodontitis (HIV, hepatitis, etc.), rheumatological disease, hematological disease, or any condition requiring hospitalization or chronic medical therapy other than diabetes.
• Major psychiatric illness requiring treatment, or that might interfere with the ability to understand or cooperate with the protocol
• Ongoing alcohol or drug abuse; all forms of medication or illegal substance abuse
• Systemic enteral or parenteral medication, in part daily vitamin or anti-oxidative supplementation and certain calcium channel blockers (i.e. Nifedipine); but anti diabetic drugs or insulin substitution
• Allergies to antibiotics or adjuvant medication / antiseptics as well as dental materials in use (including gloves) in particular those against topical antiseptic solutions i.e. chlorhexidine / N',N'''''-hexane-1,6-diylbis[N-(4-chlorophenyl)(imidodicarbonimidic diamide)] or povidone iodine / 2-Pyrrolidinone, 1-ethenyl-, homopolymer, compound with iodine
• Severe dental disease defined as severe dental caries, and/or severe pulpal disease requiring surgical correction, or any other mucosal or dental condition not readily treated, or requiring extensive dental, oral surgical or prosthetic treatment, or any other oral treatment which could affect the outcome of periodontal therapy or diseases or syndromes that require systemic medication.
• Systemic, topical or inhaled steroid treatment for more than 30 consecutive days within 6 weeks of baseline.
• Any periodontal treatment within 6 months prior to baseline
• For controls: a periodontal screening index (PSI) > 1

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Antidiabetic Therapy(ADT)+Full Mouth Decontamination(FD); ADT: (Par-)enteral, anti-diabetic medication, diet and dietetic supervision, physiotherapy and physical exercises FD: The oral use of topical antiseptics prior and after mechanical tooth debridement, tooth as well as root surface planing and soft tissue decontamination in combination with systemic antibiotics (a combination of amoxicillin and metronidazole - if no microbial resistances were detected)	Procedure: ADT+FD; Other Names: Anti-diabetic Treatment and Full Mouth Decontamination
Active Comparator: Full Mouth Deconatamination(FD); FD: The oral use of topical antiseptics prior and after mechanical tooth debridement, tooth as well as root surface planing and soft tissue decontamination in combination with systemic antibiotics (a combination of amoxicillin and metronidazole - if no microbial resistances were detected)	Procedure: FD; Other Names: Full Mouth Decontamination
No Intervention: No Treatment; Healthy individuals to be monitored cross-sectional

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change from Baseline in Clinical Attachment Level (CAL) at 6 and 12 Months	CAL: Clinically and quantitatively, level of attachment is defined as the distance in mm from the cemento-enamel junction (CEJ) of the teeth to the bases of the periodontal pockets. Attachment gain may be found during healing or periodontal treatment procedures.	0, 6 and 12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Probing Pocket Depth (PPD)	PPD: also called periodontal probing depth is defined as the distance in millimeters from the gingival margin to the base of the sulcus or periodontal pocket. It is measured on six surfaces/tooth (disto-buccal, mid-buccal, mesio-buccal, disto-lingual, mid-lingual, and mesio-lingual) of all teeth present using the pressure calibrated Florida probe.	0, 6 and 12 months
Bleeding on Probing (BOP)	BOP: will be determined by recording the presence or absence of bleeding following probing to determine pocket depth (PPD). This parameter will be expressed as % bleeding sites out of all examined sites in the dentition and will be documented with the Florida probe software.	0, 6 and 12 months
Body Mass Index (BMI)	The body mass index will be assessed as the participants' body mass divided by the square of their height	-3 weeks; 0, 6 and 12 months
Glycated Hemoglobin (HbA1c)	Physiological levels of blood glucose result in a normal amount of glycated hemoglobin. Treatment procedures may help to reduce plasma glucose in individuals with diabetes mellitus type 2, thus, in a timely extended fashion the fraction of glycated hemoglobin.	-3 weeks; 0, 6 and 12 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Neutrophil Cytoplasmic Calcium Concentration ([Ca2+]i)	[Ca2+]i: ex vivo 2nd messenger cytoplasmic calcium concentration resembles a key parameter for chemoattractive or phagocytic PMN-receptor activation.	-3, 0 and 2 weeks; 6 and 12 months
Neutrophil Cytoplasmic pH (pHi)	pHi: ex vivo liganded neutrophil receptors initiate a series of signals, resulting in phagocytosis of an entity and release of the phagocyte granules' contents as well as oxidative products. The specific mechanisms by which these effector functions occur depend upon the receptor involved among [Ca2+]i is changes of pHi.	-3, 0 and 2 weeks; 6 and 12 months
Release of Reactive Oxygen Species (ROS)	ROS: these NADPH products are predominantly found within phagolysosomal compartments of the neutrophils. During phagocytosis, neutrophils may release ROS resulting in collateral tissue damage. The reactivity of ROS release will be assessed ex vivo after activation of chemoattractant as well as phagocytic receptors of the cells.	-3, 0 and 2 weeks; 6 and 12 months
Release of Neutrophil Elastase (EA)	EA: residing in the azurophilic granules of the neutrophils, elastase is activated after phagolysosomal fusion; thence, in proximity to the engulfed entities it unfolds bactericidal activity by degrading valine-rich proteins. The elastolytic activity will be assessed ex vivo after chemoattractant as well as phagocytic activation of the neutrophils' receptors.	-3, 0 and 2 weeks; 6 and 12 months
Gingival Crevicular Fluid (GCF)	GCF: a quantitative and qualitative assessment of the serum like exudate in the gingival crevice will be performed.	-3 and 0 weeks
Global Luminol Dependent Chemiluminescence of Stimulated Neutrophils (CLt)	The detection of total ROS will be performed ex vivo with a kinetic chemiluminescence assay after receptor activation of neutrophils.	0 weeks
Extracellular Luminol Dependent Chemiluminescence of Stimulated Neutrophils (CLex)	The detection of extracellular ROS will be performed ex vivo with a kinetic chemiluminescence assay after receptor activation of neutrophils.	0 weeks
Cellular Immune responses	Analyses of leukocyte subsets, i.e. T-lymphocytes from the peripheral venous blood samples	0, 6 and 12 months

Collaborators and Investigators

• Sponsor: Zentrum fuer Zahn-, Mund- und Kieferheilkunde
• Investigators: Principal Investigator: Jens Martin Herrmann, Dr., Department of Periodontology, ZentrumZMK

Publications and helpful links

General Publications

• Herrmann JM, Sonnenschein SK, Groeger SE, Ewald N, Arneth B, Meyle J. Refractory neutrophil activation in type 2 diabetics with chronic periodontitis. J Periodontal Res. 2020 Apr;55(2):315-323. doi: 10.1111/jre.12717. Epub 2020 Jan 8.

Study record dates

Study Major Dates

• Study Start: January 1, 2012
• Primary Completion (Anticipated): December 1, 2017
• Study Completion (Anticipated): December 1, 2017

Study Registration Dates

• First Submitted: April 29, 2013
• First Submitted That Met QC Criteria: May 2, 2013
• First Posted (Estimate): May 7, 2013

Study Record Updates

• Last Update Posted (Actual): July 2, 2017
• Last Update Submitted That Met QC Criteria: June 30, 2017
• Last Verified: June 1, 2017

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Glucose Metabolism Disorders; Metabolic Diseases; Endocrine System Diseases; Stomatognathic Diseases; Periodontal Diseases; Mouth Diseases; Diabetes Mellitus; Diabetes Mellitus, Type 2; Periodontitis; Chronic Periodontitis; Physiological Effects of Drugs; Hypoglycemic Agents
• Other Study ID Numbers: DMS017507GI

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No