Efficacy of inorganic bovine bone combined with leukocyte and platelet-rich fibrin or collagen membranes for treating unfavorable periodontal infrabony defects: Randomized non-inferiority trial

A narrative review on the use of autologous platelet concentrates during alveolar bone augmentation: Horizontal (simultaneous/staged) & vertical (simultaneous/staged)

This review aimed to answer the general question of whether autologous platelet concentrates (APCs, an autologous blood-derivative) can improve the outcome of alveolar bone augmentation. Three clinical scenarios were assessed: horizontal/vertical bone augmentation in combination with implant placement (simultaneous approach), horizontal bone augmentation in a staged approach, and vertical bone augmentation in a staged approach. An electronic literature search strategy was conducted for each review from the outset to July 1st, 2023. The titles and abstracts (when available) of all identified studies were screened and imported into a database. If articles appeared to meet the inclusion criteria or their title and abstract had insufficient data, the full text was obtained to make the final decision. All studies that met the inclusion criteria underwent data extraction. Moreover, the references of the identified papers were screened for additional studies. After title and abstract screening and selection criteria application, 14 clinical studies were included for the qualitative analysis: seven for horizontal/vertical bone augmentation in a simultaneous approach, five for horizontal bone augmentation in a staged approach, and two for vertical bone augmentation in a staged approach. There is scarce literature regarding the added value of APCs in bone augmentation, and most studies had small sample sizes, a lack of standardized protocols, and different outcome variables, which makes comparisons between studies difficult. Out of the 14 studies, four were well-designed randomized clinical trials, where we could find better results for the APCs groups. Most studies, particularly comparative and well-designed studies, demonstrated beneficial and promising results of using APCs in alveolar bone augmentation. However, before high-level evidence-based conclusions can be drawn, more randomized clinical trials must compare the benefits of adding APCs to the gold-standard approach.

Treatment of Unfavorable Intrabony Defects with Autogenous Bone Graft in Combination with Leukocyte- and Platelet-Rich Fibrin or Collagen Membranes: A Non-Inferiority Study

Background and Objectives: Unfavorable intrabony defects (IBDs) are associated with the progression of periodontal disease and tooth loss. Growing scientific evidence has demonstrated the effectiveness of platelet concentrations in periodontal treatment. The aim of our study was to demonstrate the non-inferiority of an autogenous bone graft (ABG) associated with leukocyte- and platelet-rich fibrin (L-PRF) compared to ABG + Collagen Membrane in the treatment of IBDs. Material and Methods: Sixty-four patients with at least one IBD were randomly assigned to two groups: ABG+L-PRF and CM+ABG. Clinical and radiographic evaluations were performed at baseline and 12-month follow-up. Clinical attachment level (CAL), gingival recession (GR), probing pocket depth (PPD), and radiograph defect bone level (DBL) were compared between the two treatments. To evaluate the effectiveness of ABG+L-PRF, a non-inferiority margin of =1 mm (-1 mm for GR) was chosen; a second non-inferiority margin of =0.5 mm (-0.5 mm for GR) was set for clinical relevance. Results: At 12-month follow up, both treatments showed clinical and radiographic improvements. The 90% confidence intervals of the CM+ABG-L-PRF+ABG mean difference for CAL gain (-0.0564 mm [-0.316 to 0.203]), DBL gain (-0.433 mm [-0.721 to -0.145]), and PPD reduction (0.232 mm [0.015 to 0.449]) were below the 0.5 mm non-inferiority margin; the GR increase (0.255 mm [0.0645 to 0.445]) stayed above the -0.5 mm. Conclusions: the L-PRF+ABG treatment of unfavorable IBDs is non-inferior with respect to the CM+ABG therapy for CAL gain, but with a lower GR, a slightly higher PPD, and DBL gain.

From Basic Science to Clinical Practice: A Review of Current Periodontal/Mucogingival Regenerative Biomaterials

Periodontitis is a dysbiosis-driven inflammatory disease affecting the tooth-supporting tissues, characterized by their progressive resorption, which can ultimately lead to tooth loss. A step-wise therapeutic approach is employed for periodontitis. After an initial behavioral and non-surgical phase, intra-bony or furcation defects may be amenable to regenerative procedures. This review discusses the regenerative technologies employed for periodontal regeneration, highlighting the current limitations and future research areas. The search, performed on the MEDLINE database, has identified the available biomaterials, including biologicals (autologous platelet concentrates, hydrogels), bone grafts (pure or putty), and membranes. Biologicals and bone grafts have been critically analyzed in terms of composition, mechanism of action, and clinical applications. Although a certain degree of periodontal regeneration is predictable in intra-bony and class II furcation defects, complete defect closure is hardly achieved. Moreover, treating class III furcation defects remains challenging. The key properties required for functional regeneration are discussed, and none of the commercially available biomaterials possess all the ideal characteristics. Therefore, research is needed to promote the advancement of more effective and targeted regenerative therapies for periodontitis. Lastly, improving the design and reporting of clinical studies is suggested by strictly adhering to the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement.

Platelet-rich fibrin as an autologous biomaterial for bone regeneration: mechanisms, applications, optimization

Platelet-rich fibrin, a classical autologous-derived bioactive material, consists of a fibrin scaffold and its internal loading of growth factors, platelets, and leukocytes, with the gradual degradation of the fibrin scaffold and the slow release of physiological doses of growth factors. PRF promotes vascular regeneration, promotes the proliferation and migration of osteoblast-related cells such as mesenchymal cells, osteoblasts, and osteoclasts while having certain immunomodulatory and anti-bacterial effects. PRF has excellent osteogenic potential and has been widely used in the field of bone tissue engineering and dentistry. However, there are still some limitations of PRF, and the improvement of its biological properties is one of the most important issues to be solved. Therefore, it is often combined with bone tissue engineering scaffolds to enhance its mechanical properties and delay its degradation. In this paper, we present a systematic review of the development of platelet-rich derivatives, the structure and biological properties of PRF, osteogenic mechanisms, applications, and optimization to broaden their clinical applications and provide guidance for their clinical translation.

Green tea and hyaluronic acid gel enhance fibroblast activation and improves the gingival healing post-third molar extraction

This study evaluates the effects of a green tea (Camellia sinensis) and hyaluronic acid gel on fibroblast activity and alveolar bone repair following third molar extractions. By examining the gene expression related to cell survival, proliferation, and angiogenesis, the study bridges in vitro findings with clinical outcomes in a split-mouth randomized trial. Human fibroblasts were exposed to the treatment gel, analysing gene expression through RT-qPCR. Twenty participants undergoing bilateral third molar extractions received the test gel on one side and a placebo on the other. Assessments included patient-reported outcomes, professional evaluations, and radiographic analyses at multiple postoperative intervals. The test gel significantly enhanced AKT, CDKs, and VEGF gene expressions, indicating a positive effect on angiogenesis and cell proliferation. Clinically, it resulted in reduced exudate, swelling, and secondary interventions, with radiographs showing improved alveolar bone density after 90 days. The green tea and hyaluronic acid gel significantly improves soft tissue and bone healing post-extraction, offering a promising adjunctive therapy for enhancing postoperative recovery. This gel represents a novel adjuvant treatment option for facilitating improved healing outcomes after third molar extractions, highlighting its potential utility in clinical dental practice.

Efficacy of Sub-Gingivally Delivered Propolis Nanoparticle in Non-Surgical Management of Periodontal Pocket: A Randomized Clinical Trial

Naturally sourced products like propolis are commonly employed for the non-surgical treatment of periodontal pockets. The use of nanoparticle formulations of these natural remedies has the potential to improve treatment outcomes. The aim of the present study was to evaluate the efficacy of sub-gingivally delivered propolis nanoparticles in the non-surgical management of periodontal pockets. Forty patients diagnosed with periodontitis presenting at least one periodontal pocket with a probing pocket depth between 4 and 6 mm were selected. Patients were randomly assigned into the control group (n = 20), which received scaling and root planing (SRP) and saline (SRP + Saline), and the test group (n = 20), which received SRP and sub-gingivally delivered propolis nanoparticles (PRO) into the periodontal pocket (SRP + PRO). The clinical parameters recorded were plaque index (PI), gingival index (GI), relative attachment loss (RAL), probing pocket depth (PPD), and bleeding on probing (BOP). They were assessed at baseline, one month, and three months post therapy. The results indicated that there was a significant improvement in clinical parameters (p < 0.05) in the test sites compared with the control sites at the end of the study. The gingival index at one month and three months was found to be significantly better in the SRP + PRO group than the SRP + Saline group, with a p value of <0.001. The BOP, PPD, and RAL showed significant improvement with the SRP + PRO group at the end of the 3-month follow-up with p values of 0.0001, 0.001, and 0.05, respectively. The subgingival delivery of propolis nanoparticles showed promising results as an adjunct to SRP in patients with periodontitis presenting periodontal pockets.

Evaluation of PRF and PLA-PGA Membrane Along with Hydroxyapatite Crystal Collagen Fibers Bone Graft in the Treatment of Infrabony Defects

AIM

The present study was carried out to compare the effectiveness of leukocyte platelet-rich fibrin (L-PRF) membrane and polylactic acid-polyglycolic acid (PLA-PGA) membrane along with hydroxyapatite crystal collagen fibers bone graft in the treatment of human infrabony defects using cone beam computed tomography.

MATERIALS AND METHODS

A total of 28 systemically healthy patients was chosen which were found appropriate after initial therapy. Each group comprises of 14 defects, according to randomized parallel design. The group A was managed by hydroxyapatite crystal collagen fibers bone graft in conjunction with L-PRF membrane, while group B was treated by hydroxyapatite crystal collagen fibers bone graft in conjunction with PLA-PGA membrane. Clinical and radiographic measurements were recorded at baseline and 6 months postoperatively.

RESULTS

Statically significant difference was seen in mean probing pocket depth (PPD), mean R-CAL, and DD from baseline to 6 months in group A and group B but there was no statically significant difference in mean PPD reduction (0.35 ± 1.90 mm), mean R-CAL gain (0.28 ± 1.85 mm) and DD reduction (0.12 ± 1.42 mm) seen at 6 months when compared between both the groups.

CONCLUSION

At 6 months post-surgery both treatment modalities demonstrated statistically significant improvements with regards to CAL gains, PPD reduction, and reduction in radiographic defect depth.

CLINICAL SIGNIFICANCE

Platelet-rich fibrin (PRF) membrane and PLA-PGA membrane along with hydroxyapatite crystal collagen fibers bone graft are useful in the treatment of infrabony defect. Platelet-rich fibrin membrane with hydroxyapatite crystal collagen fibers bone graft have shown to be better in regeneration of bony defect as PRF membrane has growth factors which help in bone regeneration.

Influence of Periodontal Status and Prosthetic Treatment on Survival and Success Rates in Implant Therapy: A 5-Year Retrospective Follow-Up Study

The objective of the present study was to evaluate the 5-year outcome of dental implant therapy and assess the survival, success, and biological and technical complications. A periodontal and prosthetic-oriented evaluation was conducted on the variables that can influence the long-term predictability of implant therapy. A total of 615 patients and 1427 dental implants from a private clinic (MedArtis Dent, Cluj-Napoca, Romania) were enrolled in the study. The study was a longitudinal cohort with data collected retrospectively from physical/digital dental records in combination with a cross-sectional clinical/radiological examination. Results showed that periodontal diagnosis at baseline had a significant impact on the marginal bone loss prediction. Data showed that the cylindrical implant with an internal 45° medium taper connection experienced a higher rate of bone resorption compared to the tapered implant with the 5° internal connection. Screw-retained restorations and overdentures showed a statistical decrease in the marginal bone level height when compared to the cemented restorations. Data from our study suggest that not only is there a powerful association between recall visits and the rate of complications in dental implant treatment, but a lack of professional maintenance predicts a higher bone level loss during the 5-year interval.

Role of Biomaterials Used for Periodontal Tissue Regeneration-A Concise Evidence-Based Review

Periodontal infections are noncommunicable chronic inflammatory diseases of multifactorial origin that can induce destruction of both soft and hard tissues of the periodontium. The standard remedial modalities for periodontal regeneration include nonsurgical followed by surgical therapy with the adjunctive use of various biomaterials to achieve restoration of the lost tissues. Lately, there has been substantial development in the field of biomaterial, which includes the sole or combined use of osseous grafts, barrier membranes, growth factors and autogenic substitutes to achieve tissue and bone regeneration. Of these, bone replacement grafts have been widely explored for their osteogenic potential with varied outcomes. Osseous grafts are derived from either human, bovine or synthetic sources. Though the biologic response from autogenic biomaterials may be better, the use of bone replacement synthetic substitutes could be practical for clinical practice. This comprehensive review focuses initially on bone graft replacement substitutes, namely ceramic-based (calcium phosphate derivatives, bioactive glass) and autologous platelet concentrates, which assist in alveolar bone regeneration. Further literature compilations emphasize the innovations of biomaterials used as bone substitutes, barrier membranes and complex scaffold fabrication techniques that can mimic the histologically vital tissues required for the regeneration of periodontal apparatus.

The Influence of Periodontal Disease on Oral Health Quality of Life in Patients with Cardiovascular Disease: A Cross-Sectional Observational Single-Center Study

Background and Objectives: Cardiovascular disease is a leading cause of global death with a rising prevalence and a heavy economic burden. Periodontal disease has been associated with cardiovascular diseases—including incident coronary heart disease, peripheral artery disease and ischemic stroke. The study evaluates the quality of life of patients with cardiovascular and periodontal disease from the point of view of oral health by using the short version of the Oral Health Impact Profile (OHIP-14) questionnaire. Materials and Methods: This study included a total of 221 patients (61.86 ± 15.03 years old) selected from the Emergency Hospital of Sibiu, Romania. The participants self-completed the OHIP-14 questionnaire and they benefited from an oral health examination conducted to assess the presence and the severity of periodontal disease. Results: Out of the 147 patients with cardiovascular disease, 77.5% had periodontal disease (32.6% stage I, 29.2% stage II, and 15.6% stage III and IV). The presence of periodontal disease was associated with a lower oral-health-related quality of life (p < 0.001, ANOVA) and with a higher OHIP-14 score in patients with cardiovascular disease (18.67 ± 8.17, p < 0.001 ANOVA). No significant difference was observed concerning patient sex and background; however, age, body mass index and the lack of an appropriate oral hygiene routine had a strong association with the individual quality of life. The general OHIP-14 score was higher in patients with periodontal disease and associated cardiovascular disease, the presence of both cardiovascular and periodontal disease being associated with a lower quality of life. Conclusions: By increasing the patients’ awareness to oral healthcare measures, better outcomes and improved oral-health-related quality of life could be observed.

Impact of Magnetic Stimulation on Periodontal Ligament Stem Cells

The aim of this study was to evaluate the effect of a time-dependent magnetic field on the biological performance of periodontal ligament stem cells (PDLSCs). A Western blot analysis and Alamar Blue assay were performed to investigate the proliferative capacity of magnetically stimulated PDLSCs (PDLSCs MAG) through the study of the MAPK cascade (p-ERK1/2). The observation of ALP levels allowed the evaluation of the effect of the magnetic field on osteogenic differentiation. Metabolomics data, such as oxygen consumption rate (OCR), extracellular acidification rate (ECAR) and ATP production provided an overview of the PDLSCs MAG metabolic state. Moreover, the mitochondrial state was investigated through confocal laser scanning microscopy. Results showed a good viability for PDLSCs MAG. Magnetic stimulation can activate the ERK phosphorylation more than the FGF factor alone by promoting a better cell proliferation. Osteogenic differentiation was more effectively induced by magnetic stimulation. The metabolic panel indicated significant changes in the mitochondrial cellular respiration of PDLSCs MAG. The results suggested that periodontal ligament stem cells (PDLSCs) can respond to biophysical stimuli such as a time-dependent magnetic field, which is able to induce changes in cell proliferation and differentiation. Moreover, the magnetic stimulation also produced an effect on the cell metabolic profile. Therefore, the current study demonstrated that a time-dependent magnetic stimulation may improve the regenerative properties of PDLSCs.

Polymer-Based Bone Substitutes in Periodontal Infrabony Defects: A Systematic Evaluation of Clinical Studies

Background and Objectives: The aim was to systematically review the available literature regarding the use of polymers as a bone substitute for the treatment of periodontal infrabony defect. Materials and methods: Three databases (PubMed, Scopus and Web of Science) were searched to find all relevant studies published in English from inception until September 2021 using a combination of keywords. The inclusion criteria consisted of human clinical studies which reported the use of a polymer-based bone substitute in the treatment of infrabony defects. Results: 164 studies were provided from the databases. Of these, five articles were eligible and reported favorable outcome in terms of probing depth, clinical attachment gain and defect fill at the follow-up (3 months and 6 months). Conclusions: Polymer based-bone substitutes may represent a useful alternative in treating infrabony defects. Due to the limited number of studies, more research is needed to sustain the advantages of these products.

From Blood to Bone-The Osteogenic Activity of L-PRF Membranes on the Ex Vivo Embryonic Chick Femur Development Model

(1) Background: To evaluate the effects of the direct and indirect contact of leukocyte and platelet-rich fibrin (L-PRF) on bone development, in an ex vivo embryonic chick femur model. (2) Methods: Both sections of L-PRF membranes (red and yellow portions) were evaluated with scanning electron microscopy and histochemical staining. The in vivo angiogenic activity was evaluated using a chorioallantoic membrane model. The osteogenic activity was assessed with an organotypic culture of embryonic chick femora through direct and indirect contact, and assessment was conducted by microtomographic and histological analysis. Descriptive statistics, One-Way ANOVA and Tukey’s multiple comparisons tests were performed for datasets that presented a normal distribution, and Kruskal-Wallis tests were performed for non-parametric datasets. A significance level of 0.05 was considered. (3) Results: The L-PRF induced angiogenesis reflected by a higher number and a larger and more complex gauge in the vessels that invaded the membrane. The physical presence of the membrane over the bone (direct contact) unleashes the full potential of the L-PRF effects on bone growth enhancement. The greatest increase in mineral content was observed in the diaphysis region. (4) Conclusion: The L-PRF direct contact group presented higher values on mineral content for bone volume, bone surface and bone mineral density than the indirect contact and control groups.

Periodontal Bifunctional Biomaterials: Progress and Perspectives

Periodontitis is a chronic infectious disease that destroys periodontal supportive tissues and eventually causes tooth loss. It is attributed to microbial and immune factors. The goal of periodontal therapy is to achieve complete alveolar bone regeneration while keeping inflammation well-controlled. To reach this goal, many single or composite biomaterials that produce antibacterial and osteogenic effects on periodontal tissues have been developed, which are called bifunctional biomaterials. In this review, we summarize recent progress in periodontal bifunctional biomaterials including bioactive agents, guided tissue regeneration/guided bone regeneration (GTR/GBR) membranes, tissue engineering scaffolds and drug delivery systems and provide novel perspectives. In conclusion, composite biomaterials have been greatly developed and they should be chosen with care due to the risk of selection bias and the lack of evaluation of the validity of the included studies.

Vitamin D Enhanced the Osteogenic Differentiation of Cell Spheroids Composed of Bone Marrow Stem Cells

Background and Objectives: Vitamin D is a bone modulator widely used in regenerative medicine. This study aimed to analyze the effects of vitamin D on the osteogenic differentiation and mineralization of human mesenchymal stem cells. Materials and Methods: Spheroids were fabricated using human bone marrow-derived stem cells, and were cultured in the presence of vitamin D at concentrations of 0, 0.1, 1, 10, and 100 nM. Stem cell spheroids were fabricated and the morphological evaluation was conducted on days 1, 3, 7 and 14. Determination of qualitative cellular viability was performed with Live/Dead Kit assay on days 1 and 7. Quantitative cellular viability was evaluated with Cell Counting Kit-8 on days 1, 3, 7, and 14. To analyze the osteogenic differentiation of cell spheroids, alkaline phosphatase activity assays were performed with commercially available kit on days 7 and 14. Real-time polymerase chain reaction was used to determine the expression levels of RUNX2, BSP, OCN, and COL1A1 on days 7 and 14. Results: The stem cells produced well-formed spheroids, and addition of vitamin D did not result in any noticeable changes in the shape. The addition of vitamin D did not significantly change the diameter of the spheroids at 0, 0.1, 1, 10, or 100 nM concentrations. Quantitative cell viability results from days 1, 3, 7 and 14 showed no significant difference between groups (p > 0.05). There was significantly higher alkaline phosphatase activity in the 0.1 nM group when compared with the control group on day 14 (p < 0.05). Real-time polymerase chain reaction results demonstrated that the mRNA expression levels of RUNX2, OCN, and COL1A1 were significantly increased when vitamin D was added to the culture. Conclusions: Based on these findings, we concluded that vitamin D could be applied to the increased osteogenicity of stem cell spheroids.

The Outcomes of Enamel Matrix Derivative on Periodontal Regeneration under Diabetic Conditions

Background and Objectives: Enamel matrix derivative (EMD) is a biomaterial used for periodontal regenerative therapy due to its properties of stimulating cementum development and bone synthesis. Diabetes is a chronic condition that affects healing and predisposes to infection. The aim of this review was to evaluate the current studies available on the application and results of EMD for periodontal regenerative therapy under diabetic conditions. Materials and Methods: Five databases (PubMed, ResearchGate, Scopus, Web of Science and Google Scholar) were searched for relevant articles, using specific keywords in different combinations. The inclusion criteria were clinical trials, case reports, case studies, and animal studies published in English, where periodontal treatment for bone defects includes EMD, and it is performed under diabetic conditions. Results: Of the 310 articles resulted in search, five studies published between 2012 and 2020 met the inclusion criteria and were selected for the current review. In human studies, the use of EMD in infrabony defects showed favorable results at follow-up. In animal studies, periodontal regeneration was reduced in diabetic rats. Conclusions: EMD might promote bone healing when used under diabetic conditions for the regenerative periodontal therapy. Due to limited number of studies, more data are required to sustain the effects of EMD therapy in diabetic settings.

Long-term Interactions of Circulating Neutrophils with Titanium Implants, the Role of Platelets in Regulation of Leukocyte Function

Despite the fact that different biomaterials are widely used in many biomedical applications, they can still cause side effects. Therefore, our aim was to assess neutrophil activity during the inflammatory phase of the repair process and long-term interactions between circulating neutrophils and Titanium (Ti) implants. Additionally, neutrophil in vitro response after stimulation by the extract of antimicrobial peptides (AMP extract), pentoxifylline (PTX) and some platelet-rich (L-PRP and PURE PRP) and platelet-poor (PPP) concentrates were tested. The study was conducted on eight sheep after Ti implant insertion into the tibia and revealed that the Ti implant did not cause any side effects during the course of experiment. After addition of L-PRP into neutrophils, culture activity of these cells significantly increased (p < 0.01), whereas treatment with AMP extract, PURE PRP, PPP or PTX caused decrease in neutrophil enzymatic response (on the basis of elastase, myeloperoxidase and alkaline phosphatase release) and free radical generation. These effects were observed in neutrophils isolated during the inflammatory phase as well as 4 and 10 months after implantation. Obtained results will be useful in regulation of inflammatory response during implantation of biomaterial and create possibility to modulate the cells response towards pro- or anti-inflammatory to reduce host tissue damage.

Peri-Implant Mucosa Augmentation with an Acellular Collagen Matrix

Peri-implant keratinized mucosa (PI-KM) may support implant survival. Acellular collagen matrices (aCMs) have been widely used to facilitate soft tissue regeneration. The aim of this study was to investigate clinical outcomes obtained with the use of an aCM (mucoderm^®) to enhance PI-KM. In this retrospective non-randomized case series, 27 restored implants in 14 patients (eight males and six females, mean age = 56 years) with a PI-KM width ≤ 1 mm were followed for 6 months. It was demonstrated that aCM grafts augmented PI-KM effectively (mean increase of 5.4 mm; >533%) without a significant change in bleeding on probing (BOP) from baseline. The mean aCM shrinkage was 3.9 mm (42%). Gender, area, arch, and BOP did not influence PI-KM augmentation or aCM shrinkage significantly. The present results demonstrated that the examined aCM was effective and predictable for attaining a band of keratinized tissue, while avoiding graft donor site harversting.