The use of biologic response modifiers in human clinical trials

Efficacy of FGF-2 in Periodontal Regeneration in a Case of Severe Intrabony Defect and Furcation Involvement With 15-Month Follow-Up

INTRODUCTION

Several studies have demonstrated that basic fibroblast growth factor (FGF-2) is one of the most effective growth factors for periodontal regeneration. The Ministry of Health, Labor and Welfare in Japan have approved 0.3% human recombinant FGF-2 for periodontal regeneration, and it has been commercially available since 2016. In this case report, a patient was treated with this periodontal regenerative medicine and demonstrated success at 15-month follow-up, as confirmed by dental X-ray and on cone-beam computed tomography (CBCT).

CASE PRESENTATION

A 42-year-old woman with a one by two walled intrabony defect and Class III furcation involvement in tooth #19, and Class II furcation involvement in tooth #18 (lingual) underwent periodontal regenerative surgery with FGF-2 without any bone graft materials. Favorable clinical and radiographic outcomes were noted 15 months after the procedure. The vertical bone defect in tooth #19 showed a clinical attachment level gain of 8 mm. Moreover, CBCT analysis revealed considerable new bone formation in the Class II furcation involvement in tooth #18 and limited bone formation in the Class III furcation involvement in tooth #19.

CONCLUSIONS

This case report indicates that FGF-2 showed a positive outcome in terms of periodontal regeneration in a case of one by two wall intrabony defects with Class III furcation involvement. A complete recovery of Class II furcation involvement was observed without artificial bone graft materials.

New composite endpoints to assess efficacy in periodontal therapy clinical trials

BACKGROUND

Clinical attachment level (CAL) and bone height (radiographic or clinical) are two well-accepted endpoint measures for periodontal clinical trials; however, neither one has been shown to be more predictive of long-term success than the other. We propose using a composite endpoint analysis combining clinical and radiological parameters to assess the beneficial effects on both hard and soft tissues following periodontal therapy using a single statistical test. To address this need, two composite endpoint alternatives are offered as a yardstick for clinical success; each includes the improvement in CAL and either improvement in linear bone growth or percent bone fill.

METHODS

The data for composite endpoint analyses were derived from a clinical trial evaluating two concentrations of recombinant human platelet-derived growth factor-BB (rhPDGF-BB) with beta-tricalcium phosphate (beta-TCP) compared to beta-TCP plus buffer as follows: group I, beta-TCP + 0.3 mg/ml rhPDGF-BB; group II, beta-TCP + 1.0 mg/ml rhPDGF-BB; and group III, beta-TCP + buffer. The construction of composite endpoints was based on the greatest values for change, accepted by the U.S. Food and Drug Administration (FDA), for clinical attachment level (DeltaCAL), mean change in radiographic linear bone gain (LBG), and mean radiographic percent bone fill (%BF), with the following dual standards defining a successful clinical result: CAL gain > or =2.67 mm and radiographic LBG > or =1.1 mm at 6 months and CAL gain > or =2.67 mm and radiographic %BF > or =14.1% at 6 months.

RESULTS

Group I (beta-TCP + 0.3 mg/ml rhPDGF-BB) demonstrated statistically significant differences from group III (active control) for both composite endpoints. For the CAL/LBG composite endpoint, 61.7% of sites in group I versus 30.4% of sites in group III met the composite endpoint benchmarks (P <0.001). For the CAL/%BF composite endpoint, 70% of sites in group I versus 44.6% of sites in group III met the composite endpoint benchmarks (P = 0.003). A non-significant trend was observed for group II versus group III with 37.9% (P = 0.20) and 55.2% (P = 0.13) of sites meeting the CAL/LBG and CAL/%BF composite endpoints, respectively. These results are further emphasized by findings demonstrating a low correlation between the individual efficacy endpoints (DeltaCAL and %BF; DeltaCAL and LBG) for each of the three treatment groups.

CONCLUSIONS

Composite endpoints are advantageous in periodontal clinical trials where no single efficacy endpoint has been established as the most important. A composite endpoint, combining outcome measures of both hard and soft tissue components of the periodontium, may be preferable for assessing efficacy of periodontal regenerative therapies. Two composite endpoints are offered to meet this need.

In vitro clonogenic capacity of periodontal ligament fibroblasts cultured with Emdogain

The aim of the present study was to evaluate the efficiency of Emdogain (EMD) in preserving the size of the periodontal ligament progenitor pool (clonogenic capacity) and in promoting their proliferation. Periodontal ligament fibroblasts (PDLF) were obtained from explants of young permanent healthy tooth. After initial outgrowth (10 days to 2 weeks following explantation), the culture medium of experimental flasks was replaced with medium supplemented with 100 microg ml(-1) EMD, whereas the other served as controls and were fed with regular medium. Following 5 weeks, the cells were washed (3x), harvested (trypsin + EDTA), and evaluated for their viability. Viable cells from each group were inoculated into six 96-well plates at a concentration of one viable cell per two wells and were allowed to grow for 5 weeks. The percentage of cells with clonogenic capacity was determined as the number of colonies formed/number of cells seeded x 100 in the experimental and control groups. Three degrees of dish area coverage were utilized: up to 25%, between 25% and 75% and higher than 75%. This experiment was repeated four times from four different donors. A total of 2328 cells were evaluated, half of which, were cultured with EMD. The mean percentage of cells (from all donors) who exhibited any clonogenic capacity in the presence of EMD was comparable with that of cells cultured in the absence of EMD: 26.6 +/- 14.3% when compared with 34.6 +/- 20.6% respectively (P = 0.186). Similarly, the percentage of clones that proliferated to cover up to 25% of the well area was comparable in the two groups 7.5 +/- 8.6 for EMD-treated clones and 7.1 +/- 7.8 for untreated clones (P = 0.674). The percentage of clones that proliferated to cover 25% up to 75% of the well area was greater EMD-treated clones as compared with the untreated cells: 8.1 +/- 6.7% vs 3.8 +/- 3%. However this difference was not statistically significant (P = 0.277). In contrast, the percentage of clones that covered more than 75% of the well area was significantly lower in the EMD-treated clones when compared with the untreated clones (10.9 +/- 11.1 vs 23.8 +/- 14.7; P = 0.022) . In conclusion, EMD decreased the percentage of PDLF with capabilities of arising colonies with 75-100% confluency probably by increasing their differentiation.

In vitro wound healing responses to enamel matrix derivative

BACKGROUND

Enamel matrix derivative (EMD) contains a variety of hydrophobic enamel matrix proteins and is extracted from developing embryonal enamel of porcine origin. EMD has been associated with the formation of acellular cementum and it has been found to stimulate periodontal regeneration. The present study was established to investigate the influence of EMD on human periodontal ligament (PDL) cells, gingival fibroblasts (GF), and osteosarcoma (MG-63) cells on wound-fill rates using an in vitro wound model.

METHODS

Wounds were created by making 3 mm incisions in cell monolayers across the length of tissue culture plates. The wounded PDL, GF, and MG-63 cell monolayers were treated with media containing EMD over a concentration range of 5 to 100 microg/ml, platelet-derived growth factor (PDGF-BB) at 20 ng/ml as a positive control and insulin-like growth factor (IGF-I) at 100 ng/ml as a negative control. PDL cell wounded monolayers also were treated in EMD coated tissue culture plates. After an incubation period (up to 9 days), the cells were fixed and stained and cellular fill was measured across the width of the wound by computer-assisted histomorphometry.

RESULTS

When PDL, GF, and MG-63 cells were exposed to EMD in culture medium, an enhanced wound-fill was observed for all cells compared to untreated conditions. At early time points, PDL wound-fill rates in the presence of EMD were statistically greater than the rates of GF and MG-63 treated with EMD (P<0.001). There were no significant differences in wound-fill rates of PDL cells treated with EMD in medium versus EMD coated on culture plates. At days 3 and 6 post-wounding, PDL cells showed a significantly greater response to EMD than to PDGF-BB (P <0.001). EMD also had a greater effect on GF wound-fill rates than PDGF-BB at days 6 and 9. MG-63 cells were less responsive to PDGF-BB and EMD than PDL cells and GF. All 3 cell types treated with IGF-I showed no significant increase of wound-fill rates.

CONCLUSION

The present data support the concept that clinical application of enamel matrix derivative may enhance periodontal wound regeneration by specifically modifying periodontal ligament cell proliferation and migration.

Brain damage in preterm newborns: biological response modification as a strategy to reduce disabilities

Substances that promote the growth and maturation of oligodendrocytes and their precursors might protect against white matter injury. We suggest that neuroprotection can also be provided by such modulators of fetal and neonatal inflammatory responses as antiinflammatory cytokines, cytokine-binding proteins, and cytokine-receptor blockers. We briefly describe inflammatory responses in the fetus and newborn and show how they might contribute to brain damage. We conclude with the possibility that so-called biological response modifiers, which are drugs that modulate these inflammatory responses, might reduce the risk of brain damage and disabilities.

Acceptance Program Guidelines. Products designed to regenerate periodontal tissues. Council on Scientific Affairs. American Dental Association

SCOPE

These Guidelines apply to products used to promote the regeneration of periodontal tissues lost due to periodontal diseases or other causes. Periodontal regeneration is defined histologically as regeneration of the tooth's supporting tissues, including alveolar bone, periodontal ligament, and cementum over a previously diseased root surface. Regenerative procedures must enhance the formation of a new attachment apparatus demonstrated by randomized controlled histological studies in animals, verified by human histologic evidence, and supported by beneficial results in human randomized controlled clinical trials.