Evaluation of platelet-rich plasma alone or in combination with demineralized freeze dried bone allograft in treatment of periodontal infrabony defects: A comparative clinical trial

Comparing efficacies of autologous platelet concentrate preparations as mono-therapeutic agents in intra-bony defects through systematic review and meta-analysis

Aim

This systematic review and meta-analysis aimed to assess individually the regenerative potential of PRF (Platelet-rich Fibrin), PRP (Platelet-rich Plasma), and PRGF (Plasma Rich in Growth Factors) in comparison to OFD (Open Flap Debridement) alone for treating Intrabony defects, by calculating pooled effect sizes.

Background

Relevant randomized controlled trials on humans were searched in PUBMED, COCHRANE CENTRAL, and GOOGLE SCHOLAR. Mean differences (MD) of Clinical Attachment level (CAL), Probing Pocket depth (PPD), and Defect Depth Reduction (DDR) between the Experimental and Control groups were used for calculating pooled effect sizes. Risk of bias was assessed using Cochrane's tool, and publication bias was evaluated through Funnel plots, Trim & Fill Method, and Rosenthal's Fail-Safe N Test.

Review result

A total of 23 studies were identified for qualitative and quantitative analysis. These studies were categorized into PRF, PRP, and PRGF groups based on the type of APC used. PRF showed the highest CAL gain (1.60 mm, 95% CI = 0.963-2.232 mm, P < 0.001, I2 = 93.83%) and PPD reduction (1.76 mm, 95% CI = 1.056 to 2.446, P < 0.001, I2 = 96.05%). However, PRP exhibited the greatest DDR (3.42 mm, 95% CI = -13.67 to -20.50, P = 0.011, I2 = 87.27%). PRF and PRP demonstrated large effect sizes, while PRGF showed a small effect size.

Conclusion

The use of PRF, PRP, and PRGF showed advantages in treating intrabony defects. However, caution is advised when interpreting the results due to heterogeneity and publication bias among the studies.

Actual quantitative attachment gain secondary to use of autologous platelet concentrates in the treatment of intrabony defects: A meta-analysis

Background

There are no authoritative meta-analyses and no clear quantitative assessments available estimating effects of open flap debridement (OFD) combined with platelet-rich fibrin (PRF) or platelet-rich plasma (PRP) over and above that of OFD. This study evaluated the actual quantitative mean gain for various clinical (clinical attachment level [CAL], probing pocket depth [PPD] and gingival marginal level [GML]) and radiographic (intrabony defect depth [IBD]) parameters of Platelet Concentrates- PCs (PRP/PRF) as sole grafting material along with OFD and OFD alone in the treatment of intrabony defects.

Materials and Methods

A detailed electronic search was carried out in PUBMED/MEDLINE, COCHRANE, EBSCOHOST, and Google Scholar databases by unifying related search terms with additional hand searches in select specialty journals up to May 2017. The eligibility criteria included human randomized clinical trials, either of a parallel group or a split-mouth design with follow-up period of at least 6 months. Periodontal intrabony defects with radiographic IBD ≥3 mm with corresponding CAL ≥5 mm were included. For the meta-analysis, the inverse variance method was used in fixed- or random-effect models.

Results

Actual quantitative mean gains were calculated for OFD with PRF/PRP (CAL = 1.1 mm, IBD = 1.68 mm, PPD = 0.97 mm and GML = 0.48 mm) over and above that of OFD alone.

Conclusion

Because of very high heterogeneity, the results may not be dependable. Apart from gains in radiographic bone fill, all other periodontal clinical parameters showed negligible gains. Using PRF technologies in periodontal intrabony defects may not be of great clinical significance over and above that of OFD alone, the effect sizes are also not large enough.

Does a combination of platelet-rich plasma and decalcified freeze-dried bone allograft offer advantages over decalcified freeze-dried bone allograft alone when using pocket depth and clinical attachment level as markers for periodontal healing? A literature review

The aim of the present study was to investigate whether a combination of platelet-rich plasma (PRP) and decalcified freeze-dried bone allograft (DFDBA) offers advantages over DFDBA and saline in infrabony defects. The objectives were to primarily evaluate changes in clinical attachment level (CAL) and secondarily changes in pocket depth (PD). A search was performed of electronic databases (Medline, PubMed, Embase, The Cochrane Central Register of Controlled Trials, and Web of Science), as well as hand searching and reference list searching. Only randomized, controlled trials published up until 30 March 2018 were included that had a follow-up period of at least 6 months. Four papers met the eligibility criteria and were critically appraised using the Consolidated Standards of Reporting Trials statement and put through the Cochrane Collaboration's tool for assessing risk of bias. In three of the four studies, clinically and significantly greater CAL gains and PD reductions were observed in patients who received PRP and DFDBA in comparison to those who received DFDBA and saline (P < 0.05). Methodological heterogeneity existed among the studies, especially in the preparation of PRP and the type of infrabony defect. This made it difficult to draw clear conclusions, but despite this, the studies could still be regarded, as significant as they showed a low risk of bias.

Comparative evaluation of growth factors from platelet concentrates: An in vitro study

Aim

The aim of the study was to compare and evaluate the various growth factors released for a period of 23 days from platelet rich fibrin (PRF) and platelet rich fibrin matrix (PRFM).

Materials and Methods

A total of 15 systemically healthy controls were recruited and 10 ml of blood sample was withdrawn from the individual. Following the standard centrifugation protocol, PRF and PRFM were prepared. The platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), fibroblast growth factor (FGF), transforming growth factor (TGF), and insulin growth factor (IGF) were evaluated for 23 days.

Results

The PDGF released from PRFM was statistically significant from PRF till the 15^th day of release. The VEGF too had an increased release up till the 15^th day from PRFM group as compared to PRF, but no statistically significant difference could be obtained. EGF from the 15^th day to 23^rd day had a greater release from PRFM group as compared to PRF group. FGF from 7^th day to 23^rd day had statistically significant difference in the PRFM group as compared to PRF group. TGF and IGF had statistically significant difference in PRFM group as compared to PRF group from 11^th day to 23^rd day and 1^st to 17^th day, respectively.

Conclusion

The initial and robust release of GFs was seen in PRFM group at earlier days, whereas a steady and constant release of six GFs could be appreciated from PRF group upto 23^rd day. Therefore, for a rapid and early healing and regeneration, both the platelet concentrates can be utilized in periodontal therapy.

Autologous platelet concentrates for treating periodontal infrabony defects

BACKGROUND

Periodontal disease is a condition affecting tooth-supporting tissues (gingiva, alveolar bone, periodontal ligament, and cementum), with the potential of introducing severe adverse effects on oral health. It has a complex pathogenesis which involves the combination of specific micro-organisms and a predisposing host response. Infrabony defects are one of the morphological types of alveolar bone defects that can be observed during periodontitis. Recent approaches for the treatment of infrabony defects, combine advanced surgical techniques with platelet-derived growth factors. These are naturally synthesized polypeptides, acting as mediators for various cellular activities during wound healing. It is believed that the adjunctive use of autologous platelet concentrates to periodontal surgical procedures produces a better and more predictable outcome for the treatment of infrabony defects.

OBJECTIVES

To assess the effects of autologous platelet concentrates (APC) used as an adjunct to periodontal surgical therapies (open flap debridement (OFD), OFD combined with bone grafting (BG), guided tissue regeneration (GTR), OFD combined with enamel matrix derivative (EMD)) for the treatment of infrabony defects.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 27 February 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1) in the Cochrane Library (searched 27 February 2018); MEDLINE Ovid (1946 to 27 February 2018); Embase Ovid (1980 to 27 February 2018); and LILACS BIREME Virtual Health Library (from 1982 to 27 February 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials on 27 February 2018. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of both parallel and split-mouth design, involving patients with infrabony defects requiring surgical treatment. Studies had to compare treatment outcomes of a specific surgical technique combined with APC, with the same technique when used alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and risk of bias assessment, and analysed data following Cochrane methods. The primary outcomes assessed were: change in probing pocket depth (PD), change in clinical attachment level (CAL), and change in radiographic bone defect filling (RBF). We organised all data in four groups, each comparing a specific surgical technique when applied with the adjunct of APC or alone: 1. APC + OFD versus OFD, 2. APC + OFD + BG versus OFD + BG, 3. APC + GTR versus GTR, and 4. APC + EMD versus EMD.

MAIN RESULTS

We included 38 RCTs. Twenty-two had a split-mouth design, and 16 had a parallel design. The overall evaluated data included 1402 defects. Two studies were at unclear overall risk of bias, while the remaining 36 studies had a high overall risk of bias.1. APC + OFD versus OFD alone Twelve studies were included in this comparison, with a total of 510 infrabony defects. There is evidence of an advantage in using APC globally from split-mouth and parallel studies for all three primary outcomes: PD (mean difference (MD) 1.29 mm, 95% confidence interval (CI) 1.00 to 1.58 mm; P < 0.001; 12 studies; 510 defects; very low-quality evidence); CAL (MD 1.47 mm, 95% CI 1.11 to 1.82 mm; P < 0.001; 12 studies; 510 defects; very low-quality evidence); and RBF (MD 34.26%, 95% CI 30.07% to 38.46%; P < 0.001; 9 studies; 401 defects; very low-quality evidence).2. APC + OFD + BG versus OFD + BG Seventeen studies were included in this comparison, with a total of 569 infrabony defects. Considering all follow-ups, as well as 3 to 6 months and 9 to 12 months, there is evidence of an advantage in using APC from both split-mouth and parallel studies for all three primary outcomes: PD (MD 0.54 mm, 95% CI 0.33 to 0.75 mm; P < 0.001; 17 studies; 569 defects; very low-quality evidence); CAL (MD 0.72 mm, 95% CI 0.43 to 1.00 mm; P < 0.001; 17 studies; 569 defects; very low-quality evidence); and RBF (MD 8.10%, 95% CI 5.26% to 10.94%; P < 0.001; 11 studies; 420 defects; very low-quality evidence).3. APC + GTR versus GTR alone Seven studies were included in this comparison, with a total of 248 infrabony defects. Considering all follow-ups, there is probably a benefit for APC for both PD (MD 0.92 mm, 95% CI -0.02 to 1.86 mm; P = 0.05; very low-quality evidence) and CAL (MD 0.42 mm, 95% CI -0.02 to 0.86 mm; P = 0.06; very low-quality evidence). However, given the wide confidence intervals, there might be a possibility of a slight benefit for the control. When considering a 3 to 6 months and a 9 to 12 months follow-up there were no benefits evidenced, except for CAL at 3 to 6 months (MD 0.54 mm, 95% CI 0.18 to 0.89 mm; P = 0.003; 3 studies; 134 defects). No RBF data were available.4. APC + EMD versus EMDTwo studies were included in this comparison, with a total of 75 infrabony defects. There is insufficient evidence of an overall advantage of using APC for all three primary outcomes: PD (MD 0.13 mm, 95% CI -0.05 to 0.30 mm; P = 0.16; 2 studies; 75 defects; very low-quality evidence), CAL (MD 0.10 mm, 95% CI -0.13 to 0.32 mm; P = 0.40; 2 studies; 75 defects; very low-quality evidence), and RBF (MD -0.60%, 95% CI -6.21% to 5.01%; P = 0.83; 1 study; 49 defects; very low-quality evidence).All studies in all groups reported a survival rate of 100% for the treated teeth. No complete pocket closure was reported. No quantitative analysis regarding patients' quality of life was possible.

AUTHORS' CONCLUSIONS

There is very low-quality evidence that the adjunct of APC to OFD or OFD + BG when treating infrabony defects may improve probing pocket depth, clinical attachment level, and radiographic bone defect filling. For GTR or EMD, insufficient evidence of an advantage in using APC was observed.

Treatment of horizontal defect with and without platelet-rich fibrin matrix: A randomized comparative clinical study

AIM

The aim of the present study was to assess the clinical and radiographical parameters in horizontal bone defects in patients with chronic periodontitis.

MATERIALS AND METHODS

In this randomized, controlled clinical trial study, nine individuals with 94 sites having moderate to deep periodontitis were selected and distributed to Group A - open flap debridement (OFD), Group B - open flap debridement and intra marrow penetration (OFD + IMP) and Group C - Open flap debridement + Intramarrow penetration + platelet rich fibrin matrix (OFD + IMP + PRFM). Plaque index (PI) and gingival index (GI) were evaluated at baseline, 6 months, and 9 months after surgery. Probing pocket depth (PPD) and clinical attachment level (CAL) were recorded at baseline and 9 months after surgery. Radiographic assessment was carried out to measure the periodontal defect depth and defect fill percentage (DF%) at baseline and 9 months after the surgery using radiovisiography.

RESULTS

The statistical evaluation obtained after 9 months showed no significant difference between PI and GI at 9 months interval. Intergroup comparison of PPD and CAL has shown significant difference in Group C as compared to Group A and B with P < 0.05. The defect depth was statistically significant at 9 months in all the groups, and DF percentage (DF%) has shown statistically significant results in Group C as compared to A and B with P = of 0.001.

CONCLUSION

The addition of PRFM to horizontal type of periodontal defects has shown promising results over a 9-month follow-up period.

[Decalcified freeze-dried bone allograft combined with rich platelet derivatives for the treatment of human periodontal intrabony defects: a Meta-analysis]

OBJECTIVE

This review aims to systematically evaluate the effect of decalcified freeze-dried bone allograft (DFDBA) combined with rich platelet derivatives on the treatment of human periodontal intrabony defects.

METHODS

A search in PubMed, Web of Science, Embase, Cochrane Library, CNKI, and other electronic databases was conducted to identify randomized controlled trials (RCT) of the use of DFDBA combined with rich platelet derivatives in the treatment of human periodontal intrabony defects, performed before May 2016. The quality of the RCTs was assessed. RevMan 5.3 software was applied for Meta-analysis.

RESULTS

A total of nine RCTs were included. A total of 194 patients and 303 defects were involved. Short-term (6 months) and long-term (12 to 18 months) groups were included. Meta-analysis results revealed that DFDBA combined with rich platelet derivatives was superior to DFDBA or rich platelet derivatives alone for probing depth reduction in the short-term [MD=0.75 mm, 95% confidence intervals (CI) (0.31 mm, 1.20 mm), P=0.001 0] and longterm groups [MD=0.87 mm, 95%CI (0.02 mm, 1.72 mm), P=0.04], clinical attachment level gain in the short-term [MD=
0.65 mm, 95%CI (0.08 mm, 1.22 mm), P=0.03] and long-term groups [MD=1.31 mm, 95%CI (0.60 mm, 2.01 mm), P<0.000 3], gingival recession reduction in the long-term group [MD=-0.58 mm, 95%CI (-0.78 mm, -0.38mm), P<0.000 01], bone fill gain in the short-term [MD=0.52 mm, 95%CI (0.03 mm, 1.00 mm), P=0.04] and long-term groups [MD=1.26 mm, 95%CI (0.65 mm, 1.86 mm), P<0.000 1].

CONCLUSIONS

DFDBA combined with platelet rich derivatives is probably effective in the treatment of human periodontal intrabony defects. It is probably superior to DFDBA or platelet rich derivatives alone. Considering the limitation of the included studies, high-quality and large-sample RCTs are required to evaluate the effect.

Evaluation of 3D-Printed Polycaprolactone Scaffolds Coated with Freeze-Dried Platelet-Rich Plasma for Bone Regeneration

Three-dimensional printing is one of the most promising techniques for the manufacturing of scaffolds for bone tissue engineering. However, a pure scaffold is limited by its biological properties. Platelet-rich plasma (PRP) has been shown to have the potential to improve the osteogenic effect. In this study, we improved the biological properties of scaffolds by coating 3D-printed polycaprolactone (PCL) scaffolds with freeze-dried and traditionally prepared PRP, and we evaluated these scaffolds through in vitro and in vivo experiments. In vitro, we evaluated the interaction between dental pulp stem cells (DPSCs) and the scaffolds by measuring cell proliferation, alkaline phosphatase (ALP) activity, and osteogenic differentiation. The results showed that freeze-dried PRP significantly enhanced ALP activity and the mRNA expression levels of osteogenic genes (ALP, RUNX2 (runt-related gene-2), OCN (osteocalcin), OPN (osteopontin)) of DPSCs (p < 0.05). In vivo, 5 mm calvarial defects were created, and the PRP-PCL scaffolds were implanted. The data showed that compared with traditional PRP-PCL scaffolds or bare PCL scaffolds, the freeze-dried PRP-PCL scaffolds induced significantly greater bone formation (p < 0.05). All these data suggest that coating 3D-printed PCL scaffolds with freeze-dried PRP can promote greater osteogenic differentiation of DPSCs and induce more bone formation, which may have great potential in future clinical applications.

Use of Platelet Rich Plasma in the Management of Periodontal Intra-Osseous Defects: A Clinical Study

Background:

Periodontal disease is characterized by the presence of gingival inflammation, periodontal pocket formation, loss of connective tissue attachment, and alveolar bone around the affected tooth. Alveolar bone support and attachment apparatus regeneration has been achieved through various processes and have given elusive results. An expedient and cost-effective approach to obtain autologous platelet-derived growth factor (PDGF) and transforming growth factor (TGF)-β is the use of platelet-rich plasma (PRP). PRP is obtained by sequestrating and concentrating platelets by gradient density centrifugation.

Aims:

The current study was aimed at evaluating the regenerative potential of platelet-rich plasma in comparison with open flap debridement.

Settings and Designs:

This study was a randomized controlled clinical trial conducted in the Department of Periodontics and Oral Implantology, KIDS, Bhubaneswar, Odisha.

Materials and Methods:

Twenty periodontal infrabony defects in 10 patients; 6 males and 4 females of age between 25–45 years were included in this study and were followed up for a period of 6 months.

Statistical Analysis:

Both the groups showed a mean plaque index of 2.10 and 2.50 at baseline, 1.75 and 2.05 at 3 months, and 1.28 and 1.53 at the end of 6 months. The mean reduction of 0.35 and 0.45 at three months and 0.82 and 0.97 at six months was achieved, which was statistically significant. (P < 0.001). When comparison was done between the two groups it was not found to be statistically significant (P < 0.05). In each of the group there was definitive reduction in plaque score over a period of time.

Results and Conclusion:

There was no statistically significant difference in the treatment outcome between open flap debridement and PRP alone. Platelet-rich plasma application holds promise and needs further exploration.