Regenerative treatment with platelet-rich plasma combined with a bovine-derived xenograft in smokers and non-smokers: 12-month clinical and radiographic results

Influence of Smoking on Periodontal and Implant Therapy: A Narrative Review

BACKGROUND

smoking is considered the most modifiable risk factor for periodontal disease.

OBJECTIVE

the aim of this narrative review is to emphasize the effect of smoking on periodontal and implant therapy.

METHODS

The authors reviewed the literature reporting the clinical outcomes of smoking on periodontal surgical and nonsurgical treatment. The impact of smoking on implant therapy and sinus lifting procedures were also reviewed.

RESULTS

Periodontal and implant therapy outcomes are adversely affected by smoking. Smokers respond less favorably to periodontal therapy and periodontal flap procedures as compared to nonsmokers. Clinical outcomes for smokers are 50-75% worse than for nonsmokers. Studies reveal that smokers experience a significantly lower reduction in pocket depth compared to nonsmokers as well as less bone growth after treating infra-bony defects with guided tissue regeneration. The relative risk of implant failure is significantly higher in patients who smoke 20 cigarettes or more per day compared to nonsmokers. Additionally, smoking has also been shown to increase postoperative wound dehiscence and infection rates following sinus floor elevation. Longitudinal studies on smoke cessation have shown a reduction in bone loss and probing depths for periodontitis patients after cessation compared to those who smoke.

CONCLUSION

Smoking cessation can reduce probing depths and improve clinical attachment after nonsurgical periodontal therapy. There is insufficient evidence regarding the effect of smoking on peri-implantitis, as well as the loss of implants in the long-term.

Influence of aging on periodontal regenerative therapy using enamel matrix derivative: A 3-year prospective cohort study

AIM

To investigate the influence of chronological aging on periodontal regenerative therapy (PRT) outcomes with enamel matrix derivative (EMD).

MATERIALS AND METHODS

In total, 253 intra-bony defects (151 patients) including 44 furcation involvement were prospectively investigated for 3 years after regenerative therapy with EMD by evaluating probing pocket depth (PPD), clinical attachment level (CAL), and radiographic bone defect depth (RBD). The influence of age on these outcomes was assessed using multilevel regression analyses adjusting for confounders.

RESULTS

Participants' mean age was 55.9 ± 12.3 years (range: 22-85). Baseline PPD, CAL, and RBD were 6.14 ± 1.82, 7.22 ± 2.14, and 5.08 ± 2.04 mm, respectively. Significant improvement was observed with PPD reductions of 2.84 ± 1.73 and 2.87 ± 1.87 mm, CAL gains of 2.40 ± 1.87 and 2.47 ± 1.89 mm, and RBD gains of 1.76 ± 1.98 and 2.39 ± 2.41 mm at 1- and 3-year examinations, respectively. At the 1-year examination, multivariate analysis revealed a significant negative association between age and improvement in PPD and CAL (coefficients: -0.13, -0.23 mm per 10 years). However, by the 3-year examination, no significant association was noted between age and improvement in PPD, CAL, or RBD.

CONCLUSION

Although the statistical difference was detected with age at 1-year examination, PRT with EMD significantly improved clinical outcomes on long-term observation, irrespective of the patient's age.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000039846.

The Effect of Tobacco Smoking on Musculoskeletal Health: A Systematic Review

This systematic review explored associations between smoking and health outcomes involving the musculoskeletal system. AMSTAR criteria were followed. A comprehensive search of PubMed, Web of Science, and Science Direct returned 243 articles meeting inclusion criteria. A majority of studies found smoking has negative effects on the musculoskeletal system. In research on bones, smoking was associated with lower BMD, increased fracture risk, periodontitis, alveolar bone loss, and dental implant failure. In research on joints, smoking was associated with increased joint disease activity, poor functional outcomes, and poor therapeutic response. There was also evidence of adverse effects on muscles, tendons, cartilage, and ligaments. There were few studies on the musculoskeletal health outcomes of secondhand smoke, smoking cessation, or other modes of smoking, such as waterpipes or electronic cigarettes. This review found evidence that suggests tobacco smoking has negative effects on the health outcomes of the musculoskeletal system. There is a need for further research to understand mechanisms of action for the effects of smoking on the musculoskeletal system and to increase awareness of healthcare providers and community members of the adverse effects of smoking on the musculoskeletal system.

Risk Factor Analysis of Graft Failure With Concomitant Cyst Enucleation of the Jaw Bone: A Retrospective Multicenter Study

PURPOSE

Cysts are common pathologic entities in the oral and maxillofacial region. Enucleation is commonly used for treatment and is occasionally followed by bone grafting. However, no studies have evaluated factors affecting the failure of grafts used for cystic defects in the oral and maxillofacial region. Therefore, the present study was conducted to determine the risk factors for postoperative graft failure in patients treated with cyst enucleation and simultaneous bone grafting.

MATERIALS AND METHODS

Clinical data for 305 patients who had undergone cyst enucleation with simultaneous bone grafting were retrospectively investigated in this multicenter case-and-control study. The predictor variables included host, pathologic, and treatment factors. The outcome variable was success or failure of the bone graft. Descriptive statistics were computed, and the P value was set at .05.

RESULTS

Bone graft failure was observed in 48 cases. The mean duration from surgery to failure was 38.7 days. Multivariable logistic regression analysis showed a significant association between graft failure and younger age (odds ratio [OR] = 1.033; P = .016), smoking (OR = 2.598; P = .017), preoperative infection (OR = 4.660; P = .001), large cysts (OR = 1.052; P = .010), impaction of the mandibular third molar in the cystic cavity (OR = 3.021; P = .007), perilesional osteosclerosis (OR = 4.973; P = .001), and the use of mixed non-autogenous and autogenous bone grafts (OR = 3.891; P = .007).

CONCLUSIONS

This study provides a list of important factors that should be considered by clinicians planning enucleation and simultaneous bone grafting for cysts in the oral and maxillofacial region.

The effect of platelet-rich plasma on clinical outcomes of the surgical treatment of periodontal intrabony defects: A systematic review and meta-analysis

Background

Studies investigating the use of platelet–rich plasma (PRP) in the treatment of intrabony defects have yielded mixed results. The aim of our study was to evaluate the efficacy of PRP by comparing clinical attachment level (CAL) and pocket depth (PD) for patients who received PRP as an adjunct to periodontal intrabony defect therapy with those for patients who did not. We also analyzed the influence of guided tissue regeneration (GTR) and different study designs (parallel and split–mouth studies) on the clinical outcomes of intrabony defects.

Methods

We performed a systematic review of articles published in any language up to June 7, 2015 by searching PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We included only randomized controlled clinical trials (RCTs) that compared clinical outcomes between patients who received PRP as an adjunct to periodontal intrabony defect therapy and patients who did not. We combined data from randomized trials to assess clinical outcomes using a random–effects model.

Results

Of the 307 abstracts that were initially identified, 12 RCTs related to the treatment of periodontal intrabony defects were included in the final analysis. Clinically and significantly greater CAL gains and PD reductions were observed in subjects who received PRP as an adjunct to periodontal intrabony defect therapy than in subjects who did not (CAL: WMD 0.76 mm, 95 % CI = 0.34 to 1.18 mm, P = 0.0004; PD: WMD 0.53 mm, 95 % CI = 0.21 to 0.85 mm, P = 0.001). Subgroup meta-analyses of patients who underwent GTR demonstrated that this approach did not significantly affect treatment outcomes (CAL: WMD 0.08 mm, 95 % CI = −0.30 to 0.46 mm, P = 0.67), as indicated by a comparison with patients who did not undergo GTR (CAL: WMD 1.22 mm, 95 % CI = 0.88 to 1.57 mm, P < 0.00001). Univariate meta-regression analyses revealed that the use of GTR explained the heterogeneity among the included studies (P < 0.05).

Conclusions

Within its limitations, this review suggests that PRP may be beneficial as an adjunct to graft materials for the treatment of periodontal intrabony defects, except in cases involving the use of GTR.

Platelet-rich plasma for chronic lateral epicondylitis: is one injection sufficient?

INTRODUCTION

Chronic lateral epicondylitis is generally treated using nonsurgical methods including physiotherapy and infiltrations of cortisone or platelet-rich plasma (PRP). The latter is known for its simple application as well as associated low risk of adverse events, which lend to its widespread use in treating various musculoskeletal conditions. There is limited evidence on the effectiveness of PRP injections to optimally treat chronic lateral epicondylitis. This study explored the effectiveness of single or repeated injections for patients with symptoms that spanned 6 months or more and were unresponsive to alternate conservative measures.

METHODS AND MATERIALS

Patients with chronic lateral epicondylitis received PRP injections in 4-week intervals that were complemented with standardized physical therapy. Patient-reported outcomes based on the patient-rated elbow evaluation (PREE), quick disabilities of the arm, shoulder and hand (qDASH), and EuroQol (five dimensions) 3-level version (EQ5D3L) questionnaires were documented at each visit including 6 months after the first injection. These outcomes were compared between patients receiving 1 vs. 2 or 3 PRP injections.

RESULTS

Sixty-two patients received one (n = 36) or more (n = 26) PRP injections. The mean baseline to 6-month follow-up scores of the PREE and qDASH questionnaires improved significantly from 54.0 to 23.0 and 50.3 to 20.7, respectively. The mean baseline EQ5D3L-visual analogue scale score improved from 62.5 to 82.9 by 6 months post-injection. These outcomes did not significantly differ between the patients who received varying numbers of injections.

CONCLUSIONS

Patients with chronic lateral epicondylitis reported significant pain relief and gain in function as well as quality of life 6 months after localized PRP treatment. A single PRP injection may be sufficient.

Impact of smoking on guided tissue regeneration using a biocomposite poly (lactic-co-glycolic) acid/sub-micron size hydroxyapatite with a rubber dam as an alternative barrier

The purpose of our study was to critically evaluate the results obtained from a guided tissue regeneration technique after 12 months using a bocomposite poly (lactic-co-glycolic) acid/sub-micron size hydroxyapatite (PLGA/HA) with a rubber dam as a barrier in smoking and non-smoking patients. We selected 36 patients (18 current smokers and 18 non-smokers) diagnosed with chronic advanced periodontitis with a periodontal site (probing depth [PD] >5) amenable to regenerative surgery. Twelve months after surgery, the periodontal parameters were found to have statistically improved, when non-smokers were compared with smokers, in: PD reduction (6.3 ± 2.1 mm vs. 3.6 ± 1.9 mm); CAL gain (4.4 ± 1.1 vs. 2.8 ± 2.2 mm); recession (1.8 ± 1.4 mm vs. 0.8 ± 0.9 mm); and hard tissue fill (4.7 ± 0.8 mm vs. 2.8 ± 2.1 mm). Furthermore, since we found PD baseline differences between groups, smoking seemed not to influence the outcomes achieved (CAL gain and ΔREC) 12 months post surgery with respect to PD baseline. The use of PLGA/HA with a rubber dam significantly improved the periodontal parameters in both smoking and non-smoking subjects. This improvement was nevertheless lower in smokers than the non-smokers, confirming the negative impact of smoking on periodontal regeneration.

Current perspective of the impact of smoking on the progression and treatment of periodontitis

This literature review provides an overview of the current scenario regarding the impact of smoking on the progression and treatment of periodontitis; clinical, microbiological and immunological data from studies from our and other groups are presented. In general, preclinical and clinical data are unanimous in demonstrating that smokers present increased susceptibility, greater severity and faster progression of periodontal disease compared with nonsmokers. The evidence further demonstrates that smokers lose more teeth and have a less favorable response to therapy than do nonsmokers. Although it is well established that smoking significantly impacts on the onset, progression and outcome of periodontal disease, the mechanisms involved remain unclear. More importantly, some of the reported deleterious effects of smoking on periodontal tissues have been reported to be reversible upon participation in smoking-cessation programs. Therefore, clinicians should strongly advise smokers to enroll in cessation strategies, even temporarily, in order to improve the overall outcome.

Periodontal Regeneration - Intrabony Defects: Practical Applications From the AAP Regeneration Workshop

Focused Clinical Question: What are important considerations for selecting a predictable regenerative surgical approach for intrabony defects? Summary: The predictable regeneration of intrabony defects remains an important goal in the management of periodontitis. Clinical and histologic evidence of periodontal regeneration has been shown for multiple regenerative therapies, including bone replacement grafts, guided tissue regeneration, and biologics, when used alone or in combination. Regenerative therapies improve periodontal health, as evidenced by gains in clinical attachment level, reductions in probing depth, and gains in radiographic bone fill. Important patient-related factors (e.g., smoking) and defect/site-related factors (e.g., defect morphology and gingival biotype) can influence the potential to achieve periodontal regeneration. The regeneration of intrabony defects generally becomes more challenging with increasing loss of height, proximity, and number of bony walls. Therefore, combination therapies may be necessary to achieve predictable regeneration. Clinical improvements after regenerative therapy can be maintained over extended periods (≥10 years) with professional maintenance at appropriate intervals and adequate home care. Conclusions: Periodontal regeneration of intrabony defects is possible using a variety of regenerative strategies. Management should be coupled with an effective oral hygiene and supportive periodontal maintenance program for long-term success.

Periodontal regeneration - intrabony defects: a systematic review from the AAP Regeneration Workshop

BACKGROUND

Previous systematic reviews of periodontal regeneration with bone replacement grafts and guided tissue regeneration (GTR) were defined as state of the art for clinical periodontal regeneration as of 2002.

METHODS

The purpose of this systematic review is to update those consensus reports by reviewing periodontal regeneration approaches developed for the correction of intrabony defects with the focus on patient-, tooth-, and site-centered factors, surgical approaches, surgical determinants, and biologics. This review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systematic reviews. A computerized search of the PubMed and Cochrane databases was performed to evaluate the clinically available regenerative approaches for intrabony defects. The search included screening of original reports, review articles, and reference lists of retrieved articles and hand searches of selected journals. All searches were focused on clinically available regenerative approaches with histologic evidence of periodontal regeneration in humans published in English. For topics in which the literature is lacking, non-randomized observational and experimental animal model studies were used. Therapeutic endpoints examined included changes in clinical attachment level, changes in bone level/fill, and probing depth. For purposes of analysis, change in bone fill was used as the primary outcome measure, except in cases in which this information was not available. The SORT (Strength of Recommendation Taxonomy) grading scale was used in evaluating the body of knowledge.

RESULTS

1) Fifty-eight studies provided data on patient, tooth, and surgical-site considerations in the treatment of intrabony defects. 2) Forty-five controlled studies provided outcome analysis on the use of biologics for the treatment of intrabony defects.

CONCLUSIONS

1) Biologics (enamel matrix derivative and recombinant human platelet-derived growth factor-BB plus β-tricalcium phosphate) are generally comparable with demineralized freeze-dried bone allograft and GTR and superior to open flap debridement procedures in improving clinical parameters in the treatment of intrabony defects. 2) Histologic evidence of regeneration has been demonstrated with laser therapy; however, data are limited on clinical predictability and effectiveness. 3) Clinical outcomes appear most appreciably influenced by patient behaviors and surgical approach rather than by tooth and defect characteristics. 4) Long-term studies indicate that improvements in clinical parameters are maintainable up to 10 years, even in severely compromised teeth, consistent with a favorable/good long-term prognosis.

Additive effect of autologous platelet concentrates in treatment of intrabony defects: a systematic review and meta-analysis

The aim of the present review is to systematically evaluate the additive effect of autologous platelet concentrates (APCs) in treatment of intrabony defects when used along with other regenerative procedures and when used alone in terms of clinical and radiological outcomes. A search was performed in electronic databases (i.e., MEDLINE and the Cochrane Central Register of Controlled Trials) in order to identify randomized clinical trials (RCTs) assessing the additive efficacy of APCs for healing and regeneration of hard and soft tissues in patients undergoing regenerative surgical procedures for the treatment of intrabony defects, having a follow-up of at least 9 months. Included studies underwent risk of bias assessment and data extraction. The main variables evaluated for efficacy were: pocket depth (PD), clinical attachment level (CAL), radiographic bone filling, and postoperative pain. The effect of APCs adjunct was evaluated for the following procedures: open flap debridement (OFD) alone, OFD plus grafting of the defect with autogenous bone or bone substitutes, and grafting in combination with a covering membrane for guided tissue regeneration (GTR). Platelet-rich fibrin (PRF) has a significant additive effect when used along with OFD. Platelet-rich plasma (PRP) has a significant additive effect when used along with bone grafts. Conversely, PRP was found to be ineffective when used in combination with GTR procedures. No study evaluated the effect of APCs on postoperative pain. Platelet-rich plasma may be used advantageously as an adjunct to grafting materials, but not in combination with GTR, for treatment of intrabony defects. Moreover, PRF can be effective as a sole regenerative material, in combination with OFD. There is still a lack of evidence regarding the effect of PRF in combination with grafting materials and GTR, the effect of other types of APCs such as plasma rich in growth factors, and the effect of APCs on postoperative pain.

Radiographic and histologic evaluation of platelet-rich plasma and bovine-derived xenograft combination in bilateral sinus augmentation procedure

There is currently a great interest regarding the use of platelet-rich plasma (PRP) in combination with various bone graft materials in sinus lift procedures. The purpose of this study was to assess and compare the radiographic and histological results of sinus augmentation procedures following treatment with PRP/bovine-derived xenograft (BDX) vs. BDX/collagen membrane. Using a split mouth design, 10 patients, with ≤5 mm of residual alveolar bone in the vertical direction, were treated with PRP/BDX or BDX/collagen membrane. At 8 months after surgery, both graft materials led to a satisfactory increase in vertical dimensions of bone. Bone biopsies were taken from the augmented sites during the implant placement. Histological analysis demonstrated that majority of the trabecula contained orderly layered lamellar bone in the PRP/BDX group, whereas mainly woven bone with a haphazard arrangement of collagen fibers were noticed in the BDX /collagen membrane group. It can be concluded that both combinations resulted with a satisfactory bone height, but more prominent and mature bone formation was observed at sites treated with PRP/BDX.

Whole cigarette smoke promotes human gingival epithelial cell apoptosis and inhibits cell repair processes

BACKGROUND AND OBJECTIVE

Smoking cigarettes increases the risk of developing various types of human diseases, including cancers and periodontitis. As gingival epithelial cells are known to play an active role in innate immunity via the secretion of a wide variety of mediators, and as these cells are the first ones exposed to environmental stimuli such as cigarette smoke, we sought to investigate the effects of whole cigarette smoke on normal human gingival epithelial cells and tissue.

MATERIAL AND METHODS

Human gingival epithelial cells were extracted from healthy nonsmokers and used either as a monolayer or as an engineered human oral mucosa to investigate the effect of whole cigarette smoke on cell growth, apoptosis and wound repair/migration.

RESULTS

Our findings show that when gingival epithelial cells were exposed once to whole cigarette smoke, this resulted in a significant inhibition of cell growth through an apoptotic pathway, as confirmed by an increase of Bax and a decrease of Bcl-xL and caspase-3 activity. Cigarette smoke also inhibited epithelial cell migration. These effects may explain the disorganization of the engineered human oral mucosa tissue when exposed to whole cigarette smoke.

CONCLUSION

Exposure to whole cigarette smoke markedly inhibits epithelial cell growth through an apoptosis/necrosis pathway that involves Bax and Bcl-xL proteins and caspase-3 activity. Cigarette smoke also disrupts epithelial cell migration, which may negatively affect periodontal wound healing.

Treatment of intrabony periodontal defects with platelet-rich plasma versus platelet-poor plasma combined with a bovine-derived xenograft: a controlled clinical trial

BACKGROUND

The purpose of this study is to assess the healing outcomes of intrabony defects after treatment with platelet-rich plasma (PRP) versus platelet-poor plasma (PPP) combined with bovine-derived xenograft (BDX).

METHODS

Using a split-mouth design, a total of 79 intrabony defects with an intrabony component of ≥3 mm in 20 patients were treated either with PRP/BDX (group 1) or PPP/BDX (group 2). At baseline and 12 months after surgery, plaque and sulcus bleeding indices, probing depth (PD), relative attachment level, recession, and probing and radiographic bone levels were recorded.

RESULTS

After 12 months, groups 1 and 2 presented a mean PD reduction of 3.87 ± 0.86 and 3.76 ± 0.80 mm, recession of 1.35 ± 0.68 and 1.58 ± 0.54 mm, attachment gain of 2.51 ± 0.97 and 2.18 ± 0.87 mm, clinical bone gain of 2.18 ± 0.86 and 2.09 ± 0.89 mm, and radiographic bone gain of 2.11 ± 0.87 and 2.19 ± 0.96 mm, respectively. Intergroup differences were found to be insignificant.

CONCLUSIONS

Within its limits, these results suggest that the outcomes of the treatment after PRP/BDX and PPP/BDX applications in intrabony defects are similar. When the platelet counts are taken into consideration, PPP seems to demonstrate similar clinical efficacy as the PRP.