Using ginger supplement in adjunct with non-surgical periodontal therapy improves metabolic and periodontal parameters in patients with type 2 diabetes mellitus and chronic periodontitis: A double-blind, placebo-controlled trial

Journal Pre-proof Using Ginger Supplement in Adjunct with Non-surgical Periodontal Therapy Improves Metabolic and Periodontal Parameters in Patients with Type 2 Diabetes Mellitus (DM) and Chronic Periodontitis. A Double-Blind, Placebo-Controlled Trial Hasan Gholinezhad, Hadi Bazyar, Homeira Rashidi, Parvin Salehi, Mohammad Hosein Haghighi-zadeh, Ahmad Zare Javid

PII:

S2210-8033(19)30062-4

DOI:

https://doi.org/10.1016/j.hermed.2019.100315

Reference:

HERMED 100315

To appear in:

Journal of Herbal Medicine

Received Date:

5 December 2018

Revised Date:

28 April 2019

Accepted Date:

5 November 2019

Please cite this article as: Gholinezhad H, Bazyar H, Rashidi H, Salehi P, Haghighi-zadeh MH, Javid AZ, Using Ginger Supplement in Adjunct with Non-surgical Periodontal Therapy Improves Metabolic and Periodontal Parameters in Patients with Type 2 Diabetes Mellitus (DM) and Chronic Periodontitis. A Double-Blind, Placebo-Controlled Trial, Journal of Herbal Medicine (2019), doi: https://doi.org/10.1016/j.hermed.2019.100315

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Using Ginger Supplement in Adjunct with Non-surgical Periodontal Therapy Improves Metabolic and Periodontal Parameters in Patients with Type 2 Diabetes Mellitus (DM) and Chronic Periodontitis. A Double-Blind, Placebo-Controlled Trial

Running Title: Ginger and Diabetes Mellitus with Chronic Periodontitis

Health research institute, Diabetes research center, Ahvaz Jundishapur University of

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a.

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Haghighi-zadehe, and Ahmad Zare Javidc,f* [email protected]

Medical Sciences, Ahvaz, Iran. b.

Student Research Committee, Ahvaz Jundishapur University of Medical Sciences,

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Ahvaz, Iran.

Department of Nutrition, School of Allied Medical Sciences, Ahvaz Jundishapur

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c.

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Hasan Gholinezhada,b, Hadi Bazyarb,c, Homeira Rashidia, Parvin Salehid, Mohammad Hosein

University of Medical Sciences, Ahvaz, Iran d.

Dept.of Periodontology, School of Dentistry, Ahvaz Jundishapur University of Medical

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Sciences, Ahvaz, Iran.

Department of Biostatistics, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

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Nutrition and Metabolic Diseases Research Center, Ahvaz Jundishapur University of

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Medical Sciences, Ahvaz, Iran *

Correspondence to: Ahmad Zare Javid, Professional Assistant, Member of Nutrition and

Metabolic diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran :, Tel: +98 914 317 6237

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Abstract Background: The objective of this study was to investigate the effects of ginger supplementation in adjunct with non-surgical periodontal therapy (NSPT) on metabolic and

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periodontal parameters in patients with type 2 DM (T2DM) and chronic periodontitis (CP).

Material and methods: In this double-blind clinical trial study, 50 T2DM patients with CP were

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randomly allocated to intervention and control groups and received either 2g ginger or placebo (4 tablets) twice a day for 8 weeks. All subjects underwent NSPT during the intervention period.

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Fasting blood glucose (FBG), glycosylated hemoglobin levels (HbA1c), triglyceride (TG), total cholesterol (CHOL), high-density (HDL-c) and low-density lipoprotein (LDL-c) cholesterol, very

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low-density lipoprotein (VLDL-c), Total antioxidant capacity (TAC), Malondialdehyde (MDA), clinical attachment loss (CAL), Pocket depth (PD), plaque index and bleeding on probing (BOP)

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were measured in all subjects at baseline and post-intervention Results: A significant reduction (p < 0.05) was observed in the mean levels of HbA1c, FBG, MDA, CAL and PD in the intervention group post-intervention. There were no significant

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differences found in the mean levels of TG, CHOL, LDL-C, VLDL, TAC, plaque and BOP in intervention group post-intervention. The mean serum levels of HDL was significantly increased in the intervention group post-intervention (p < 0.05). There were significant differences observed in the mean changes of HbA1c (-0.75 ± 1.17 and -0.16 ± 0.44; P = 0.04), HDL (3.95 ± 8.54 vs -0.76 ± 5.04; P = 0.03), CAL (-0.57 ± 0.50 vs -0.14 ± 0.35; P = 0.003) and PD (-0.52 ±

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0.51 vs - 0.19 ± 0.51; P = 0.04) between intervention and control groups after the intervention. Conclusion: It is recommended that ginger supplementation together with NSPT may be effective in control of the glycemic, lipid, antioxidant and periodontal status in T2DM with CP.

Abbreviations:

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Type 2 Diabetes mellitus (T2DM) Chronic periodontitis (CP) Non-surgical periodontal therapy (NSPT) Fasting blood glucose (FBG) Glycosylated hemoglobin levels (HbA1c)

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Triglyceride )TG) Total cholesterol (CHOL)

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High-density lipoprotein (HDL)

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Low-density lipoprotein (LDL) cholesterol Very low-density lipoprotein (VLDL)

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Total antioxidant capacity (TAC)

Clinical attachment loss (CAL) Bleeding on probing (BOP)

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Pocket depth (PD)

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Malondialdehyde (MDA)

Keywords: Type 2 diabetes mellitus; Periodontal disease; Ginger; Lipid profile; Glycemic control; Antioxidant status.

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1. Introduction

Diabetes mellitus (DM) is considered as a metabolic disorder characterized by chronic

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hyperglycemia due to insulin deficiency, insulin resistance or both (Farhangi et al., 2016). About 415 million people are suffering from DM in the world, of which about 35.4 million people are

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located in the MENA (Middle East and North Africa) region, and it is expected that this will increase to 72.1 million, by 2040 (Mahjoob et al., 2017). Several physiological changes may lead

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to metabolic imbalance, hyperglycemia and chronic inflammation in diabetic conditions (Khanuja et al., 2017). Chronic hyperglycemia is linked with several acute and chronic complications influencing all organs and systems specifically the gingival and periodontal tissues

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in the human body (Salvi et al., 2008). Dyslipidemia may also develop due to uncontrolled hyperglycemia and insulin resistance in diabetic patients (Chait and Goldberg, 2017). According to the reports of some studies, the prevalence of severe periodontitis is about 39 to 59.6% with the greater amount in diabetic than in non-diabetic patients (Daniel et al., 2012). CP is considered as an inflammatory disorder characterized by gingival bleeding, periodontal pocket

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formation and destruction of the connective tissue attachment. The formation of a layer (plaque) of bacterial biofilm followed by stimulating the host defense system against bacterial pathogens are important agents in the progression of CP (Kara et al., 2013). CP may be affected by genetic and environmental factors as well as systemic diseases (Ferreira et al., 2017). According to some evidence there is a bidirectional relationship between DM and CP (Bazyar et al., 2019). DM is associated with increased incidence and progression of CP with several adverse effects on the periodontium and conversely CP may have harmful effects aggravating the condition in 4

diabetics. The potential common pathophysiologic pathways involved in both diseases include some inflammatory process, altered host responses, tissue homeostasis and insulin resistance (Karande et al., 2017). There are several studies indicating that periodontal inflammation may affect glycemic control, insulin resistance and inflammatory responses (Mammen et al., 2017). Several systematic studies with meta-analyses reported that the effective periodontal therapy (NSPT with or without adjunctive topical or systemic antibiotics) can decrease insulin resistance and serum inflammatory markers and improve periodontal status and insulin sensitivity in

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patients with T2DM (Mammen et al., 2017; Artese et al., 2015). Although mouthwash antibiotics are broadly used to control CP, the excessive use of antibiotics may cause bacterial resistance against them. Therefore, a new and complementary treatment strategy is required. Natural

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components originated from plants are widely used for the treatment of CP (Zare Javid et al., 2016). In addition, some potent oxidative species are produced in periodontal disease and

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diabetes mellitus. These reactive oxygen species (ROS) may interact with different biological components and damage host cells. Therefore, the removal and control of these ROS may be

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necessary in prevention of destruction of periodontal tissue. As antioxidants may act against harmful effects of ROS in humans, the role of dietary antioxidants in the prevention of

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periodontal disease and DM is considered to be important (Zare Javid et al., 2014). The rhizome of ginger (Zingiber officinale Roscoe) is a well-known food spice and medicinal plant in the world (Noori et al., 2018). The main bioactive compounds available in ginger are gingerol and

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shogaol (Daily et al., 2015). Some evidence shows several pharmacological effects of ginger powder, extract, or its bioactive components including anti diabetic activity, anti-inflammatory, antioxidant, anti-cancer, anti-obesity effects and lipid lowering properties (Srinivasan, 2017). In addition, it has been shown that ginger may be used for the management of several oral diseases (Rashmi and Tiwari, 2016). Ginger is generally used as a safe herbal medicine according to the

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FDA’s report (Brown, 2016). Recent studies found that supplementation with ginger reduced FBG, HbA1c, TAC and some fractions of lipid profile in T2DM patients (Shidfar et al., 2015). To our best of knowledge, there is no study evaluating the effects of oral ginger supplementation in diabetic patients with CP. Therefore, the aim of this study was to investigate the effects of ginger supplementation in adjunct with NSPT on metabolic and periodontal parameters in patients with T2DM and CP. . 5

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2. Materials and Methods 2.1. Study design and subjects

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In this double-blinded, placebo-controlled trial 96 T2DM patients with some symptoms of CP were recruited from “Outpatient Endocrinology and Metabolism Clinics of Imam Khomeini

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Hospital” in Ahvaz Jundishapur University of Medical Science, Iran (Fig 1). Subjects were referred to the Dental Clinic for further diagnosis to confirm CP. 46 patients were excluded out of 96 participants (as not meeting the inclusion criteria or not interested in participation). Fifty

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subjects were randomly allocated to intervention (n = 25) and placebo (n = 25) groups. The randomization was carried out using a random permuted block procedure based on the combined analysis. Based on the block design and using two codes including A and B, all subjects were assigned to 6 groups with 4 blocks plus 2 separate subjects in two steps (first step; AABB, BBAA, ABAB, BABA, ABBA, BABA, second step; AABB, BBAA, ABAB, BABA, ABBA,

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BABA and AB). In this study, both researchers and the subjects were not informed of the contents of the packets. The coding procedure was performed by a third person in the health care system not aware of the research. The control group received placebo (pea flour) and the intervention group received ginger supplement (zingiberene, ar–curcumene, geranial, zingiberol, and zingiber officinale) 2 g/d as four tablets (two tablets before lunch and two tablets before dinner) for 8weeks. The selective dosage in this study was based on similar studies. Most studies have shown the beneficial effects 6

of ginger in this dosage (Mahluji et al., 2013). Both the ginger and placebo tablets were purchased from the “Dineh Company, Iran”. The placebo tablets were matched with the ginger tablets in terms of shape, color and size. All subjects were monitored for any possible side effects of supplements 3 times during the study. The compliance of the subjects was assessed by counting the tablets remaining. The subjects with the consumption of less than 90 % of ginger tablets or self-reported sensitivity to or dissatisfaction with ginger consumption were excluded. All subjects were asked to follow any prescribed diabetic diet and continue with their usual

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physical activities and diet throughout the study. The inclusion criteria in this study were as follows: males and females aged between 30-60 years

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old, body mass index of 18.5-30 kg/m2, confirmed DM (more than five years since diagnosis) and mild and moderate periodontitis (PD ≥ 4 mm and CAL = 1-4 mm). Exclusion criteria

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included kidney failure, pregnancy, breastfeeding, thyroid disease, traveling more than two weeks, smoking, using immunosuppressive medications, using insulin, periodontal treatment history during the past six months, using any antioxidant supplements, anti-inflammatory agents,

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using antibiotics and use of anticoagulant medications such as warfarin and aspirin, severe periodontitis (because they received surgical treatment), considerable changes in diet over the

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past six months. By definition, subjects with FBS ≥126 mg/dl and HbA1c ≥ 6.5% or 2-hour glucose )2 hpp( ≥ 200 mg/dl were considered as diabetic (Mahan et al., 2012).

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The research protocol was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (Ref No. IR.AJUMS.REC.1395.806) and was registered in the Iranian Registry of Clinical Trials website (IRCT2017030432874N1). 2.2. Anthropometric and nutritional assessments

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Anthropometric measurements including height, body weight, BMI, waist circumference, hip circumference and waist-to-hip ratio (WHR) were measured by a professional nutritionist. A 3Day 24-hour dietary recall (including two working days and one weekend) was obtained for dietary assessment at the beginning and end of the study. The dietary assessment was analyzed by the “Nutritionist 4”. 2.3. Evaluation of periodontal status

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The periodontal parameters including presence or absence of plaque (i.e. the measurement of the state of oral hygiene based on recording both soft debris and mineralized deposits on teeth), BOP (bleeding on probing; bleeding that is induced by gentle manipulation of the tissue at the depth of the gingival sulcus, or interface between the gingiva and a tooth), CAL and PD were measured by a dentist at six sites of a tooth (mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual and distolingual). The sites were randomly selected from at least 3 quadrants (a division of mouth and teeth) out of 4 quadrants: upper right, upper left, lower right and lower left) for the

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clinical measurements after intervention. PD (the distance between gingival margin and the base of the gingival sulcus or periodontal pocket) was recorded using a UNC-15 (University of North Carolina No. 15) manual periodontal probe at 6 sites per tooth. PD ≥ 4 millimeter (mm) was

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selected for the clinical measurements after intervention. The CAL was evaluated by a full –

mouth periodontal examination and determined by measuring the distance from the cement –

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enamel junction to the bottom of the gingival crevice. Periodontal disease is considered as severe in individuals with CAL ≥ 5 mm (not on the same tooth) or moderate in individuals with CAL of

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3-4 mm (not on the same tooth) or weak in individuals with CAL of 1-2 mm (not on the same tooth). In this study individuals with weak and moderate CP were selected (Bazyar et al., 2018).

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All subjects in both groups of study underwent NSPT. The NSPT included root surface debridement and scaling. Also, some instructions regarding with dental hygiene including how to brush and use dental floss correctly, were provided for the subjects. The subjects were also asked

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to avoid using mouthwash during the study. 2.4. Biochemical measurements

A blood sample (5 ml) was collected after an overnight fasting (12h) at baseline and postintervention. All samples (except some for analyzing FBS and HbA1c) were stored at − 70 °c

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until biochemical analysis. FBS was immediately measured by the enzymatic method using laboratory kits (Pars Azmoon, Tehran, Iran) and an auto-analyzer. HbA1c was measured by enzymatic method using nycocard laboratory kits (Norway). TG, CHOL and HDL were also measured by colorimetric method using the laboratory kits of Pars Azmoon (Tehran, Iran). VLDL and LDL were calculated by the following formula (Friedewald formula) (Knopfholz et al., 2014). LDL-c (mg/dL) = TC (mg/dL) − HDL-c (mg/dL) − TG (mg/dL)/5 (VLDL) 8

VLDL =TG (mg/dl)/5 Serum levels of TAC and MDA was measured by the ZellBio GmbH assay kit. 2.5. Statistical analysis According to the study by Arablou et al (Arablou et al., 2014b) and considering HbA1C as the primary variable (-1.0 ± 1.7 and 0.4 ± 1.4, mean differences for intervention and control group, respectively), the sample size with a 95% confidence interval and 80% power of the study was

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calculated according to the following formula. The sample size was considered as 20 subjects in each group, however, considering a 25% probable withdrawing, 25 subjects were involved for 𝛼

(𝜇1 −𝜇2 )2

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each group. 𝑛 =

2

(𝑧1 − 2 + 𝑧1 −𝛽) (𝛿1 2 +𝛿2 2 )

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Statistical analysis was performed using SPSS (version 19). Data were reported as mean ± SD. A visual examination of the data and a goodness of fit test (Kolmorogov-Smirnoff) were conducted in order to determine whether the data had a normal distribution. The Independent sample t-test

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was used to compare the results between two groups. The Paired sample t-test was also used to

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as significant.

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compare the results within groups post-intervention. The p-values less than 0.05 were considered

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3. Results

3.1. General characteristics, anthropometric indices and dietary intake

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42 subjects (21 subjects in each group) completed the study. All data in this study had normal distribution. The mean age of subjects in the intervention and control groups was 52.81 ± 6.44

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and 51.62 ± 5.95 years, respectively. No significant differences were observed regarding with demographic characteristics, physical activity, medicine use between two groups at baseline (p ≥ 0.05). Furthermore, there was no significant difference seen between two groups in the mean

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levels of FBG, HbA1C, CHOL, TG, LDL-C, HDL, VLDL, TAC, MDA, CAL, PD, plaque and BOP (P ≥ 0.05) at baseline (Table 1). Also, no significant differences were obtained between two groups for dietary intake including energy, macronutrients and micronutrients such as antioxidant vitamins C, E, A, beta-carotene, α-tocopherol, and selenium at baseline and post intervention (P ≥ 0.05) (Table 2).

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3.2. Glycemic control

The mean FBG (p=0.03), HbA1C (p=0.008) was significantly reduced in the intervention group post intervention. The mean changes of HbA1C were significantly (P=0.04) lower in the intervention group compared with control group post-intervention (-0.75 ± 1.17 and -0.16 ± 0.44, respectively) (Table3). 3.3. Lipid profile 10

Although the mean serum levels of TG and VLDL decreased in the intervention group postintervention, but it was not significant (p=0.19 and p=0.15, respectively). In the intervention group, the mean serum levels of HDL was significantly increased at the end of study (p =0.04). Also, the mean changes of HDL were significantly (p=0.03) higher in the intervention group compared with control group post-intervention (3.95 ± 8.54 and -0.76 ± 5.04, respectively). There were no significant differences in the mean serum levels of TG, CHOL, LDL-C, and VLDL post-intervention (Table3).

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3.3. MDA and TAC The mean levels of MDA were significantly decreased in the intervention group (P=0.04) post

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intervention. Also there was an increase in the serum mean of TAC in the intervention group, but

comparison post-intervention (p=0.33) (Table3).

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this change was not significant as within group comparison (P=0.08) and between groups

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3.4. Periodontal parameters (PD, CAL, BOP and plaque)

The results of this study showed that in the intervention group the mean of CAL and PD was reduced significantly (P <0.001) post-intervention compared with baseline (3.04 ± 0.86 to 2.47 ±

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0.60 and 4.95 ± 1.16 to 4.42 ± 1.39, respectively). Also, at the end of the study there was a significant difference in the mean changes of CAL and PD between intervention and control

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groups (-0.57 ± 0.50 vs -0.14 ± 0.35, respectively; P=0.003) and PD (-0.52 ± 0.51 vs - 0.19 ± 0.51, respectively; P=0.04). The BOP and plaque were decreased in both control and intervention groups post-intervention compared with baseline, however the differences were not significant between two groups post-intervention (p=0.11) (Table4). After 8 weeks use of ginger no side

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effects were observed.

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4. Discussion

According to the findings of this study 8 weeks consumption of ginger had a significant

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reduction impact on FBG and HbA1C. Therefore, it is suggested that ginger may improve glycemic control in diabetic patients. The authors findings are consistent with the results of some previous studies (Daily et al., 2015). There are several clinical trials and animal model studies

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indicating that ginger and its main constituents have an efficient role in the glycemic control of T2DM (Rahmani, 2014). Similarly, Mozaffari-Khosravi et al (2014) found that glycemic indices

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involving FBG and HbA1c were reduced after 8 weeks of consumption of ginger powder. They also reported an improvement in indices of insulin resistance such as fasting insulin level, homeostasis model assessment insulin resistance index (HOMA-IR), and insulin sensitivity in diabetic patients (Mozaffari-Khosravi et al., 2014). In another study, Makhdoomi et al (2017) showed that 10 weeks consumption of ginger significantly reduced serum levels of FBG and

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HbA1c in patients with T2DM (Arzati et al., 2017). In an animal study by Chakraborty et al (2012), after 12 weeks consumption of [6]-gingerol (75 mg/kg), the plasma insulin and hepatic GLUT4 concentrations were significantly increased, where blood glucose was also reduced (Chakraborty et al., 2012). It is presumed that some beneficial effects of ginger such as reducing blood glucose results from its components including polyphenols and several phytochemicals (Ahmad et al., 2015). [6]-Gingerol may enhance glucose-stimulated insulin secretion by activating GLP-1 mediated insulin secretion pathway (GLP-1/cAMP/PKA pathway) and by regulating insulin granule exocytosis. It also may increase glucose uptake in skeletal muscle via 12

increasing GLUT4 membrane mRNA and protein expression (Samad et al., 2017). On the other hand, [6]-Gingerol regulate glucose metabolism through AMPK mediated pathways such as the AS160–Rab5 pathway (Lee et al., 2015). Furthermore, insulin producing effects of ginger may be linked, at least partially, to the helpful effects exerted on hepatic factors involved in glucose metabolism. For example, increasing liver expression of signaling molecules such as PPARα, PPARγ and GLUT-2 and an enhancement of plasma adiponectin levels may play key roles in the glycemic control (de las Heras et al., 2016).

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The findings of this study indicated that HDL cholesterol was increased after ginger consumption, but no significant changes were seen in the levels of other lipid profiles. These

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results are partially in accordance with the observations reported by Makhdoomi Arzati et al

(2017) who found that consumption of 2000 mg per day of ginger supplements for 10 weeks had

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no significant effects on TG, CHOL, LDL, and HDL levels; however, in that study ginger reduced the ratio of LDL-C/HDL-C (Arzati et al., 2017). In another study, Arablou et al (2014) found that using 1600 mg ginger for 12 weeks reduced TG and CHOL, but there were no

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significant differences in the levels of HDL and LDL (Arablou et al., 2014a). Nonetheless, in a study on diabetic rats, ginger improved all lipid profiles (Al-Noory et al., 2013). Such

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discrepancies in the results may be linked to some factors such as dosage and duration of ginger supplementation, subject selection, clinical setting, and illness severity. In the present study, selecting subjects with no dyslipidemia may be the reason behind not finding any beneficial

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effects of ginger on lipid profile. It seems that ginger may be considered as an important component to modify blood lipids, especially in diabetic patients. This potential efficacy may be due to the following reasons; increasing intestinal peristalsis and reduced fat absorption by inhibiting the lipase enzyme in the pancreas and intestine, increasing expression and activity of the lipoprotein lipase enzyme in the vessels breaking down triglycerides in blood vessels and

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reduces blood levels of triglycerides. The possible effect of ginger on reducing serum total cholesterol may be due to the effect of this plant on increasing the activity of cholesterol 7-αhydroxylase enzyme in the liver. It also inhibits the biosynthesis of cholesterol in the liver by down-regulation of HMG-COA reductase protein expression. Ginger may increase the LDL-c particle size and improve hypercholesterolemia through modifying lipoprotein metabolism and enhancing uptake of LDL-c by increasing LDL-c receptors (Arablou and Aryaeian, 2017). It is

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also proposed that niacin in ginger may reduce the catabolic rate of HDL and increase its levels in the blood (Al-Noory et al., 2013, Kamanna et al., 2013). There is some growing evidence to support a two-way relationship between DM and CP and the role of oxidative stress in both diseases. It has been shown that the anti-oxidant defense system in the human body is partially interrupted due to excessive production of free radicals, a condition exacerbated during the coincidence of these two diseases (Trivedi et al., 2014). It was reported that plant antioxidants may have reducing effects on oxidative stress and ROS in

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diabetic patients (Kooti et al., 2016). Moreover, NSPT may further improve oxidative stress and inflammatory status of patients with CP (Torumtay et al., 2016). The present study showed that

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ginger consumption along with NSPT significantly reduced MDA in diabetic patients with

periodontitis. TAC was also increased post ginger consumption, although these increases were

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not significant. Similarly, Khandouzi et al (2013) in a double-blind clinical trial reported a decreased level of MDA in diabetic patients who received 2 g/day of ginger powder for 12 weeks (Khandouzi et al., 2015). Moreover, Shidfar et al (2015) showed that receiving 3g ginger by

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diabetic patients for 3 months not only resulted in a significant increase in the levels of TAC, but also decreased the levels of MDA (Shidfar et al., 2015). In an animal study, it was found that the

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activity of anti-oxidant enzymes in diabetic rats were augmented by oral administration of ginger. Moreover, in that study, ginger administration reduced MDA level (Shanmugam et al., 2011). Evidence indicates that ginger has strong in vitro and in vivo antioxidant properties

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(Boozari and Hosseinzadeh, 2017). It seems that the potent antioxidant properties of ginger may be attributed to the presence of antioxidant components such as vitamin C, flavonoids, β carotene, tannins, polyphenols and phenolic substances like gingerol and shogaol, which act through scavenging superoxide anion, hydroxyl free radicals and hydroperoxide. They also prevent lipid peroxidation (LPO) and inhibits NO synthesis (Rahmani, 2014). Previous studies

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claimed that ginger may be beneficial in the management of several oral diseases and may improve oral health with its antimicrobial, antibacterial, antifungal, antioxidant and antiinflammatory properties (Rashmi and Tiwari, 2016). Our study confirms the beneficial effects of ginger supplementation on periodontal indices such as plaque, BOP, PD and CAL. CP is initiated by bacterial pathogens producing products which may suppress host defense mechanisms and destroy periodontal support tissues, leading to the breakdown of the epithelia and other structures of the gum and loss of alveolar bones and teeth. In a study it was shown that gingerol-related 14

components inhibit the growth of oral bacteria associated with periodontitis in the human oral cavity (Park et al., 2008). Probably, ginger may inhibit growth of bacteria involved in CP and prevent the development of disease. In addition, CP is associated with reduced salivary antioxidant status and increased chronic inflammatory process and oxidative damage within the oral cavity (Podzimek et al., 2016). Ginger with its systemic effects may also prevent the production of ROS and down-regulate pro inflammatory markers leading to enhanced host defense system and prevent local damages to the periodontal tissue. Furthermore, ginger extract

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can increase saliva secretion and play an important role in the maintenance of oral health and contributes to the stability of tooth enamel, and oral immunity (Chamani et al., 2011). The

combined use of ginger supplementation with NSPT may be considered as an advantage of this

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study. However, lack of greater number of study groups may be considered as a limitation of this study. It is suggested to do further studies with 4 study groups in future (involving group1;

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Diabetes + no periodontal treatment + placebo, group2; Diabetes + no periodontal treatment + ginger, group3; Diabetes + NSPT + placebo, group4; Diabetes + NSPT + ginger). Financial

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limitations precluded using a greater number of study groups. It is also suggested that other

5. CONCLUSION

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inflammatory factors be measured in future studies, which is another limitation of the study.

The adjunct using ginger supplementation and NSPT may improve glycemic control, lipid

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profile, antioxidant status and promote periodontal treatment in type 2 diabetes mellitus with CP.

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Acknowledgements

This study was part of M.Sc thesis of MR Gholinezhad. This work was financially supported by Vice-Chancellor for Research Affairs of Ahvaz Jundishapur University of Medical Sciences (NRC-9514). Authors express thanks for the Nutrition and Metabolic Disorders Research Center, and Research Center for Diabetes, Endocrinology and Metabolism clinic employees of Ahvaz

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Imam Khomeini Hospital and Dental Clinic of Ahvaz Jundishapur University of Medical

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Sciences.

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. International Diabetes Federation/. diabetes in iran.2015(https://www.idf.org/ournetwork/regions-members/middle-east-and-north-africa/members/35-iran.html). AHMAD, B., REHMAN, M. U., AMIN, I., ARIF, A., RASOOL, S., BHAT, S. A., AFZAL, I., HUSSAIN, I. & BILAL, S. 2015. A review on pharmacological properties of zingerone (4-(4-Hydroxy-3-methoxyphenyl)-2butanone). The Scientific World Journal, 2015, 6. AL-NOORY, A. S., AMREEN, A.-N. & HYMOOR, S. 2013. Antihyperlipidemic effects of ginger extracts in alloxan-induced diabetes and propylthiouracil-induced hypothyroidism in (rats). Pharmacognosy research, 5, 157. ARABLOU, T. & ARYAEIAN, N. 2017. The effect of Ginger (Zingiber Officinale) as an ancient medicinal plant on improving blood lipids. Journal of Herbal Medicine, 12, 11-15. ARABLOU, T., ARYAEIAN, N., VALIZADEH, M., SHARIFI, F., HOSSEINI, A. & DJALALI, M. 2014a. The effect of ginger consumption on glycemic status, lipid profile and some inflammatory markers in patients with type 2 diabetes mellitus. International journal of food sciences and nutrition, 65, 515-520. ARTESE, H. P. C., FOZ, A. M., DE SOUSA RABELO, M., GOMES, G. H., ORLANDI, M., SUVAN, J., D’AIUTO, F. & ROMITO, G. A. 2015. Periodontal therapy and systemic inflammation in type 2 diabetes mellitus: a meta-analysis. PLoS One, 10, e0128344. ARZATI, M. M., HONARVAR, N. M., SAEDISOMEOLIA, A., ANVARI, S., EFFATPANAH, M., ARZATI, R. M., YEKANINEJAD, M. S., HASHEMI, R. & DJALALI, M. 2017. The Effects of Ginger on Fasting Blood Sugar, Hemoglobin A1c, and Lipid Profiles in Patients with Type 2 Diabetes. International Journal of Endocrinology and Metabolism, 15, e57927. BAZYAR, H., ADIBMANESH, A., JAVID, A. Z., MAGHSOUMI-NOROUZABAD, L., GRAVAND, E., ALIPOUR, M. & SADEGHI, N. J. O. M. 2019. The Relationship between Metabolic Factors and Anthropometric Indices with Periodontal Status in Type 2 Diabetes Mellitus Patients with chronic periodontitis. 100138. BAZYAR, H., GHOLINEZHAD, H., MORADI, L., SALEHI, P., ABADI, F., RAVANBAKHSH, M. & JAVID, A. Z. 2018. The effects of melatonin supplementation in adjunct with non-surgical periodontal therapy on periodontal status, serum melatonin and inflammatory markers in type 2 diabetes mellitus patients with chronic periodontitis: a double-blind, placebo-controlled trial. Inflammopharmacology, 27, 67–76. BOOZARI, M. & HOSSEINZADEH, H. 2017. Natural medicines for acute renal failure: A review. Phytotherapy Research, 31, 1824-35. BROWN, A. C. 2016. An overview of herb and dietary supplement efficacy, safety and government regulations in the United States with suggested improvements. Part 1 of 5 series. Food and Chemical Toxicology107, 449-71. CHAIT, A. & GOLDBERG, I. 2017. Treatment of Dyslipidemia in Diabetes: Recent Advances and Remaining Questions. Current diabetes reports, 17, 112.

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CHAKRABORTY, D., MUKHERJEE, A., SIKDAR, S., PAUL, A., GHOSH, S. & KHUDA-BUKHSH, A. R. 2012. [6]Gingerol isolated from ginger attenuates sodium arsenite induced oxidative stress and plays a corrective role in improving insulin signaling in mice. Toxicology letters, 210, 34-43. CHAMANI, G., ZAREI, M. R., MEHRABANI, M. & TAGHIABADI, Y. 2011. Evaluation of effects of Zingiber officinale on salivation in rats. Acta Medica Iranica, 49, 336. DAILY, J. W., YANG, M., KIM, D. S. & PARK, S. 2015. Efficacy of ginger for treating Type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. Journal of Ethnic Foods, 2, 3643. DANIEL, R., GOKULANATHAN, S., SHANMUGASUNDARAM, N., LAKSHMIGANDHAN, M. & KAVIN, T. 2012. Diabetes and periodontal disease. Journal of pharmacy & bioallied sciences, 4, S280. DE LAS HERAS, N., VALERO-MUñOZ, M., MARTíN-FERNáNDEZ, B., BALLESTEROS, S., LóPEZ-FARRE, A., RUIZ-ROSO, B. & LAHERA, V. 2016. Molecular factors involved in the hypolipidemic-and insulinsensitizing effects of a ginger (Zingiber officinale Roscoe) extract in rats fed a high-fat diet. Applied Physiology, Nutrition, and Metabolism, 42, 209-215. FARHANGI, M. A., JAVID, A. Z. & DEHGHAN, P. 2016. The effect of enriched chicory inulin on liver enzymes, calcium homeostasis and hematological parameters in patients with type 2 diabetes mellitus: A randomized placebo-controlled trial. Primary care diabetes, 10, 265-271. FERREIRA, M., DIAS‐PEREIRA, A., BRANCO‐DE‐ALMEIDA, L., MARTINS, C. & PAIVA, S. 2017. Impact of periodontal disease on quality of life: A systematic review. Journal of Periodontal Research. KAMANNA, V. S., GANJI, S. H. & KASHYAP, M. L. 2013. Recent advances in niacin and lipid metabolism. Current opinion in lipidology, 24, 239-245. KARA, A., AKMAN, S., OZKANLAR, S., TOZOGLU, U., KALKAN, Y., CANAKCI, C. F. & TOZOGLU, S. 2013. Immune modulatory and antioxidant effects of melatonin in experimental periodontitis in rats. Free Radical Biology and Medicine, 55, 21-26. KARANDE, A. M., KHANDEPARKAR, R. & VERGEESE, C. S. 2017. INTER-RELATIONSHIP BETWEEN DIABETES MELLITUS AND PERIODONTAL DISEASE BASED ON THEIR MOLECULAR MECHANISMS. Journal of Advanced Medical and Dental Sciences Research, 5, 24. KHANDOUZI, N., SHIDFAR, F., RAJAB, A., RAHIDEH, T., HOSSEINI, P. & TAHERI, M. M. 2015. The effects of ginger on fasting blood sugar, hemoglobin A1c, apolipoprotein B, apolipoprotein AI and malondialdehyde in type 2 diabetic patients. Iranian journal of pharmaceutical research: IJPR, 14, 131. KHANUJA, P. K., NARULA, S. C., RAJPUT, R., SHARMA, R. K. & TEWARI, S. 2017. Association of periodontal disease with glycemic control in patients with type 2 diabetes in Indian population. Frontiers of medicine, 11, 110-119. KNOPFHOLZ, J., DISSEROL, C. C. D., PIERIN, A. J., SCHIRR, F. L., STREISKY, L., TAKITO, L. L., MASSUCHETO LEDESMA, P., FARIA-NETO, J. R., OLANDOSKI, M. & DA CUNHA, C. L. P. 2014. Validation of the friedewald formula in patients with metabolic syndrome. Cholesterol, 2014. KOOTI, W., FAROKHIPOUR, M., ASADZADEH, Z., ASHTARY-LARKY, D. & ASADI-SAMANI, M. 2016. The role of medicinal plants in the treatment of diabetes: a systematic review. Electronic physician, 8, 1832. LEE, J. O., KIM, N., LEE, H. J., MOON, J. W., LEE, S. K., KIM, S. J., KIM, J. K., PARK, S. H. & KIM, H. S. 2015. [6]‐Gingerol Affects Glucose Metabolism by Dual Regulation via the AMPKα2‐Mediated AS160– Rab5 Pathway and AMPK‐Mediated Insulin Sensitizing Effects. Journal of cellular biochemistry, 116, 1401-1410. MAHAN, L., ESCOTT STUMP, S. & RAYMOND, J. 2012. Krause's Food & the Nutrition Care Process,(Krause's Food & Nutrition Therapy). Philadelphia: WB Saunders. Elsevier.

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MAHJOOB, B. & KAZEMI, S. S. 2017. Mobile Learning Impact on Blood Glucose Control among People at Risk of Type 2 Diabetes Referring to Ahvaz Diabetes Consultation Center. Health Education & Health Promotion, 5, 57-67. MAHJOOB, B., KAZEMI, S. S. J. H. E. & PROMOTION, H. 2017. Mobile Learning Impact on Blood Glucose Control among People at Risk of Type 2 Diabetes Referring to Ahvaz Diabetes Consultation Center. 5, 57-67. MAHLUJI, S., OSTADRAHIMI, A., MOBASSERI, M., ATTARI, V. E. & PAYAHOO, L. J. A. P. B. 2013. Antiinflammatory effects of Zingiber officinale in type 2 diabetic patients. 3, 273. MAMMEN, J., VADAKKEKUTTICAL, R. J., GEORGE, J. M., KAZIYARAKATH, J. A. & RADHAKRISHNAN, C. 2017. Effect of non‐surgical periodontal therapy on insulin resistance in patients with type Ii diabetes mellitus and chronic periodontitis, as assessed by C‐peptide and the Homeostasis Assessment Index. Journal of investigative and clinical dentistry, 8, e12221. MOZAFFARI-KHOSRAVI, H., TALAEI, B., JALALI, B.-A., NAJARZADEH, A. & MOZAYAN, M. R. 2014. The effect of ginger powder supplementation on insulin resistance and glycemic indices in patients with type 2 diabetes: a randomized, double-blind, placebo-controlled trial. Complementary therapies in medicine, 22, 9-16. NOORI, S., ZEYNALI, F. & ALMASI, H. 2018. Antimicrobial and antioxidant efficiency of nanoemulsionbased edible coating containing ginger (Zingiber officinale) essential oil and its effect on safety and quality attributes of chicken breast fillets. Food Control, 84, 312-320. PARK, M., BAE, J. & LEE, D. S. 2008. Antibacterial activity of [10]‐gingerol and [12]‐gingerol isolated from ginger rhizome against periodontal bacteria. Phytotherapy Research, 22, 1446-1449. PODZIMEK, S., VONDRACKOVA, L., DUSKOVA, J., JANATOVA, T. & BROUKAL, Z. 2016. Salivary markers for periodontal and general diseases. Disease markers, 2016. RAHMANI, A. H. 2014. Active ingredients of ginger as potential candidates in the prevention and treatment of diseases via modulation of biological activities. International journal of physiology, pathophysiology and pharmacology, 6, 125. RASHMI, K. & TIWARI, R. 2016. Pharmacotherapeutic Properties of Ginger and its use in Diseases of the Oral Cavity: A Narrative Review. Journal of Advanced Oral Research/May-Aug, 7, 1-6. SALVI, G. E., CAROLLO‐BITTEL, B. & LANG, N. P. 2008. Effects of diabetes mellitus on periodontal and peri‐implant conditions: update on associations and risks. Journal of clinical periodontology, 35, 398-409. SAMAD, M. B., MOHSIN, M. N. A. B., RAZU, B. A., HOSSAIN, M. T., MAHZABEEN, S., UNNOOR, N., MUNA, I. A., AKHTER, F., KABIR, A. U. & HANNAN, J. 2017. [6]-Gingerol, from Zingiber officinale, potentiates GLP-1 mediated glucose-stimulated insulin secretion pathway in pancreatic β-cells and increases RAB8/RAB10-regulated membrane presentation of GLUT4 transporters in skeletal muscle to improve hyperglycemia in Lepr db/db type 2 diabetic mice. BMC complementary and alternative medicine, 17, 395. SHANMUGAM, K. R., MALLIKARJUNA, K., KESIREDDY, N. & REDDY, K. S. 2011. Neuroprotective effect of ginger on anti-oxidant enzymes in streptozotocin-induced diabetic rats. Food and chemical toxicology, 49, 893-897. SHIDFAR, F., RAJAB, A., RAHIDEH, T., KHANDOUZI, N., HOSSEINI, S. & SHIDFAR, S. 2015. The effect of ginger (Zingiber officinale) on glycemic markers in patients with type 2 diabetes. Journal of complementary and integrative medicine, 12, 165-170. SRINIVASAN, K. 2017. Ginger rhizomes (Zingiber officinale): A spice with multiple health beneficial potentials. PharmaNutrition. 5, 18-28. TORUMTAY, G., KıRZıOĞLU, F., ÖZTURK TONGUC, M., KALE, B., CALAPOĞLU, M. & ORHAN, H. 2016. Effects of periodontal treatment on inflammation and oxidative stress markers in patients with metabolic syndrome. Journal of periodontal research, 51, 489-498. 19

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TRIVEDI, S., LAL, N., MAHDI, A. A., MITTAL, M., SINGH, B. & PANDEY, S. 2014. Evaluation of antioxidant enzymes activity and malondialdehyde levels in patients with chronic periodontitis and diabetes mellitus. Journal of periodontology, 85, 713-720. ZARE JAVID, A., HORMOZNEJAD, R., ZAKERKISH, M., HAGHIGHI-ZADEH, M. H., BARZEGAR, A. & NIKNEJAD, N. 2016. The Effect of Resveratrol Supplementation in Adjunct with Non-surgical Periodontal Treatment on Blood Glucose, Triglyceride, Periodontal Status and Some Inflammatory Markers in Type 2 Diabetic Patients with Periodontal Disease. Nutrition and Food Sciences Research, 3, 17-26. ZARE JAVID, A., SEAL, C., HEASMAN, P. & MOYNIHAN, P. 2014. Impact of a customised dietary intervention on antioxidant status, dietary intakes and periodontal indices in patients with adult periodontitis. Journal of human nutrition and dietetics, 27, 523-532.

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Fig.1 Stages of clinical trial progress

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Table 1: The characteristics of subjects at baseline Intervention group (n=21) 52.81 ± 6.44

*P-value

Age (years)

Control group (n=21) 51.62 ± 5.95

Gender Female (N) (%) Male (N) (%)

12 (57.14) 9 (42.86)

11 (52.38) 10 (47.62)

0.75**

Weight (kg)

73.28 ± 6.48

72.14 ± 10.09

0.66

Height (m)

164.38 ± 9.58

166.33 ± 7.20

0.46

BMI (kg/m2)

27.18 ± 2.15

26.06 ± 3.33

0.20

WC(cm)

97.28 ± 4.14

95.23 ± 8.96

0.35

HC (cm)

102.76 ± 3.54

102.33 ± 8.24

0.82

WHR

0.94 ± 0.02

0.93 ± 0.05

0.25

Physical Activity (met-min/week)

285.85 ± 162.06

311.76 ± 170.99

0.61

FBG )mg/dl(

174.85 ± 34.10

185.23 ± 46.43

0.41

HbA1C %

8.35 ± 1.01

8.60 ± 1.37

0.50

137.33 ± 33.98

157.80 ± 39.49

0.07

147.80 ± 39.14

147.23 ± 76.19

0.97

92.85 ± 44.84

77.14 ± 29.44

0.18

46.47 ± 11.81

50.14 ± 10.29

0.29

VLDL )mg/dl(

28.26 ± 8.33

29.69 ± 15.62

0.71

TAC (mM)

0.427 ± 0.085

0.390 ± 0.067

0.12

18.248 ± 7.182

19.511 ± 7.125

0.57

3 ± 0.77

3.04 ± 0.86

0.85

4.85 ± 1.01

4.95 ± 1.16

0.77

CHOL )mg/dl( TG )mg/dl(

HDL )mg/dl(

MDA (µM)

Jo

CAL (mm)

ur na

LDL-C )mg/dl(

PD (mm)

lP

Values are expressed as means ± SD. P <0.05 was considered as significant. *P <0.05 was considered as significant using Independent T-test between the two groups at baseline. **P <0.05 was considered as significant using Chi-square test.

22

0.53

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ro

-p

re

Variable

post-intervention 1879.58 ± 143.56 1864.64 ± 151.19 0.74

**P-value 0.4 0.21

Carbohydrate (g/d)

Control group Intervention group *P-value

259.67 ± 18.20 258.49 ± 21.31 0.84

254.44 ± 17.86 252.49 ± 19.47 0.73

0.16 0.2

Protein (g/d)

Control group Intervention group *P-value

70.77 ± 5.42 71.38 ± 6.12 0.73

72.99 ± 6.80 72.71 ± 6.54 0.89

0.21 0.42

Fat (g/d)

Control group Intervention group *P-value

64.17 ± 6.08 63.01 ± 5.71 0.53

Cholesterol (g/d)

Control group Intervention group *P-value

134.68 ± 35.57 137.11 ± 34.55 0.82

142.68 ± 38.63 142.54 ± 42.61 0.99

0.15 0.47

Saturated fat (g/d)

Control group Intervention group *P-value

19.43 ± 3.84 19.52 ± 4.07 0.94

18.48 ± 2.61 18.43 ± 2.54 0.95

0.06 0.34

Vitamin A (mcg/d)

Control group Intervention group *P-value

363.36 ± 95.97 385.53 ± 121.25 0.51

370.42 ± 99.13 380.50 ± 125.81 0.77

0.77 0.88

Beta-Carotene (mcg/d)

Control group Intervention group *P-value

4390.40 ± 1559.94 4445.26 ± 1784.20 0.91

0.86 0.25

Selenium (mcg /d)

Control group Intervention group *P-value

51.03 ± 13.47 55.91 ± 13.35 0.24

4318.85 ± 1420.45 4018.04 ± 1061.34 0.44 54.95 ± 10.49 53.90 ± 8.30 0.72

Vitamin C (mg/d)

Control group Intervention group *P-value

100.67 ± 46.21 98.35 ± 34.31 0.85

103.26 ± 41.94 102.19 ± 36.71 0.93

0.79 0.67

α-tocopherol (mg/d)

Control group Intervention group *P-value

7.67 ± 1.78 7.39 ± 2.13 0.64

7.72 ± 2.03 7.90 ± 2.22 0.77

0.88 0.08

Vitamin E (mg/d)

Control group Intervention group *P-value

2.29 ± 0.71 2.18 ± 0.72 0.63

2.19 ± 0.55 2.02 ± 0.61 0.37

0.51 0.25

Jo

ro -p

62.98 ± 5.57 61.88 ± 5.12 0.5

lP

ur na

Variable Energy (kcal/d)

of

Control group Intervention group *P-value

Baseline 1910.98 ± 174.28 1898.68 ± 157.76 0.81

re

Table 2: Mean ± SD of energy, macronutrients and micronutrients intake at baseline and post-intervention

Values are expressed as means ± SD.

23

0.43 0.21

0.13 0.50

*P <0.05 was considered as significant at baseline and post-intervention using Independent T-test between two groups. **P <0.05 was considered as significant using Paired T-test.

Table 3: Glycemic status, lipid profile and inflammatory markers at baseline and post-intervention. P-value

Intervention group (n=21) Baseline After 8 weeks

P-value

FBG (mg/dl(

174.85±34.10

0.66

185.23±46.43

0.03

Changes

-2.57 ± 27.05

HbA1C %

8.35±1.01

Changes

-0.16 ± 0.44

LDL-C )mg/dl(

73.80±33.37

Changes

0.9 ± 28.30

TG )mg/dl(

147.80±39.14

Changes

0.04 ± 25.65

CHOL )mg/dl(

136.19±42.94

Changes

1.14 ± 47.99

HDL )mg/dl(

46.47±11.81

Changes

-0.76 ± 5.04

VLDL (mg/dl(

28.26±8.33

Changes

0.02 ± 4.86

TAC (mM)

0.427±0.085

Changes

-0.006 ± 0.09

172.28±48.28

*P-value

166.19±56.83

0.10

8.60±1.37 -0.75 ± 1.17

0.88

77.14±29.44

79.52±30.02

re

74.71±35.31

7.84±1.48

-p

8.18±1.02

0.71

0.12

ro

-19.04 ± 39.49

0.008

0.74

0.39 0.04 0.63

2.38 ± 33.59 0.99

147.23±76.19

lP

147.85±43.42

132.66±67.90

0.87 0.19

0.39

-14.57 ± 49.76

0.91

ur na

137.33±33.98

45.71±12.04

28.29±9.01

0.49

0.97

158.47±41.48

0.24 157.80±39.49

0.94

0.07

-0.66 ± 45.63 50.14±10.29

0.9 54.09±9.68

0.04

0.01

3.95 ± 8.54 29.69±15.62

0.03 26.56±13.74

0.15

0.63

-3.12 ± 9.59 0.420±0.108

0.7

0.390±0.067

0.014 ± 0.03

24

**P-value

of

Control group (n=21) Baseline After 8 weeks

Jo

Variable

0.18 0.405±0.063

0.08

0.57

0.33

MDA (µM)

18.248±7.182

Changes

-0.13 ± 8.66

18.108±8.283

0.94

19.511±7.125

16.135±5.842

0.04

0.37

-3.37 ± 7.16

0.19

Values are expressed as means ± SD. P <0.05 was considered as significant using Paired T-test. *P <0.05 was considered as significant using Independent T-test between the two groups post-intervention **P <0.05 was considered as significant changes using Independent T-test between the two groups post-intervention Table 4. Periodontal Status at baseline and post intervention. Δ

Baseline

After 8 weeks

Control group (n=21)

4.85 ± 1.01

4.66 ± 0.91

-0.19 ± 0.51

0.1

Intervention group (n=21)

4.95 ± 1.16

4.42 ± 1.39

-0.52 ± 0.51

<0.001

Control group (n=21)

3.00 ± 0.77

2.85 ± 0.72

-0.14 ± 0.35

Intervention group (n=21)

3.04 ± 0.86

2.47 ± 0.60

-0.57 ± 0.50

21 (100)

18 (85.7)

-p

Variable

P-value

21 (100)

14 (66.7)

7 (33.3)

P-value*

P-value**

plaque (+)

(n=21)

Bop (+)

21 (100)

19 (90.47)

0.04

0.003

<0.001

0.14***

2 (9.53)

ur na

Control group (N) (%) (n=21)

0.07

3 (14.3)

lP

(n=21) Intervention group (N) (%)

0.08

re

Control group (N) (%)

0.51

ro

CAL (mm)

of

PD (mm)

0.11***

Intervention group (N) (%) 21 (100) 15 (71.42) 6 (28.58) (n=21) Values are expressed as means ± SD. P <0.05 was considered as significant using Paired T-test. *P <0.05 was considered as significant using Independent T-test between the two groups post-intervention. **P <0.05 was considered as significant changes using Independent T-test between the two groups post-intervention

Jo

*** P <0.05 was considered as significant using Chi-square test. Δ: Difference between PD (mm) and CAL (mm) at baseline and After 8 weeks.

25