|Year : 2019 | Volume
| Issue : 4 | Page : 311-317
A Study to Evaluate the Efficacy of Platelet Rich Fibrin with Nanocrystalline Beta-Tricalcium Phosphate in the Treatment of Periodontal Intrabony Defects
Nimmi Singh1, Sneha Mayuri2, Anindita Banerjee2, Nitubroto Biswas2, Prabhat Kumar Singh2, Rajat Sehgal2
1 Department of Dentistry, Oral Medicine and Radiology, IGIMS, Patna, Bihar, India
2 Department of Periodontics, Buddha Institute of Dental Sciences and Hospital, Patna, Bihar, India
|Date of Submission||07-Dec-2019|
|Date of Acceptance||28-Dec-2019|
|Date of Web Publication||03-Mar-2020|
Dr. Sneha Mayuri
Department of Periodontics, Buddha Institute of Dental Sciences and Hospital, Patna, Bihar; C/O Dr. Naresh Prasad, Ayodhya Niwas, 85-A Block, Road No-2B, Rajendra Nagar, Patna - 800 016, Bihar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Presently, there is no gold-standard regenerative material for the treatment of periodontal intrabony defects. The use of bone grafts in combination with guided tissue regeneration membrane is a predictable treatment option but is expensive. Platelet concentrates are increasingly being used due to their ease of use and cost-effectiveness. Aims: The objective of the present study is to compare clinically and also by Cone Beam Computed Tomography (CBCT), the effect of platelet-rich fibrin combined with synthetic beta-tricalcium phosphate to synthetic beta-tricalcium phosphate alone in the treatment of periodontal intrabony defects. Materials and Methods: 10 patients possessing 2 almost identical interproximal intrabony defects in either side of mandible were selected and the defects were further divided into 2 groups randomly: Control Group A (Beta-tricalcium phosphate placed) and Test Group B (Beta-tricalcium phosphate with platelet-rich fibrin placed). Regeneration of soft tissue and hard tissue (using CBCT) were evaluated after 6 months from baseline in both groups. Statistical Analysis Used: The intragroup and intergroup comparisons were done using Paired and student t-test. Results: Intragroup showed significant improvement in both soft tissue and hard tissue parameters. Mean of all parameters was better in the test group; however, the intergroup difference was not statistically significant. Conclusions: Within the limitations of the present study, the use of beta-tricalcium phosphate bone graft combined with platelet-rich fibrin and beta-tricalcium phosphate bone graft alone are both equally effective for the treatment of periodontal intrabony defects.
Keywords: Beta-tricalcium phosphate, periodontal tissue regeneration, platelet concentrates
|How to cite this article:|
Singh N, Mayuri S, Banerjee A, Biswas N, Singh PK, Sehgal R. A Study to Evaluate the Efficacy of Platelet Rich Fibrin with Nanocrystalline Beta-Tricalcium Phosphate in the Treatment of Periodontal Intrabony Defects. J Indian Acad Oral Med Radiol 2019;31:311-7
|How to cite this URL:|
Singh N, Mayuri S, Banerjee A, Biswas N, Singh PK, Sehgal R. A Study to Evaluate the Efficacy of Platelet Rich Fibrin with Nanocrystalline Beta-Tricalcium Phosphate in the Treatment of Periodontal Intrabony Defects. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2020 Apr 4];31:311-7. Available from: http://www.jiaomr.in/text.asp?2019/31/4/311/279863
| Introduction|| |
The optimal periodontal treatment should aim not only for the arrest of disease but also for the regeneration of structures lost due to disease. Bone grafting is one of the most common forms of regenerative therapy and is usually essential for restoring periodontal supporting tissues. In the present study, beta-tricalcium phosphate, which is a bioceramic material, with Ca/PO4 ratio similar to natural bone, has been used as a bone graft.
Growth factors have recently emerged as an important factor in periodontal regeneration and have shown promising results. Growth factors are a class of natural biologic mediators that regulate key cellular events in tissue regeneration including cell proliferation, chemotaxis, differentiation, and matrix synthesis via binding to specific cell surface receptors.
Platelet-rich fibrin is a second-generation platelet-rich concentrate introduced by Choukroun et al. in 2001 which is an autologous platelet-rich fibrin (PRF) gel with growth factors and has several advantages.
PRF acts by releasing polypeptide growth factors, such as transforming growth factor-b1, platelet-derived growth factor, vascular endothelial growth factor (VEGF), and matrix glycoproteins into the surgical wound in a sustained fashion for at least 7 days as shown in vitro.
PRF could improve the periodontal osseous defect healing, as PRF can up regulate phosphorylated extracellular signal-regulated protein kinase expression and suppress the osteoclastogenesis by promoting secretion of osteoprotegerin (OPG) in osteoblasts cultures. Hence, the clinician can expect less post surgical discomfort, rapid soft tissue healing with less edema compared with other techniques.
Although multiple studies have been done with beta-tricalcium phosphate and platelet-rich fibrin as regenerative materials for vertical bone defects separately,,, there is a dearth of studies regarding the use of both these materials together and also regarding the interpretation of treatment outcome using cone-beam computed tomography (CBCT), by which we get more reliable data than by conventional 2D imaging techniques. This deficiency necessitated the present study.
| Aims and Objectives|| |
The objective of the present study is to compare clinically and also by cone-beam computed tomography (CBCT), a three-dimensional imaging technique, the effect of platelet-rich fibrin combined with synthetic beta-tricalcium phosphate to synthetic beta-tricalcium phosphate alone in the treatment of periodontal intrabony defects.
| Materials and Methods|| |
10 systemically healthy patients possessing almost 2 identical interproximal intrabony defects in either side of mandible reporting to the Outpatient Department (O.P.D) of Periodontology at Buddha Institute of Dental Sciences and Hospital, Postgraduate Institute and Research Center Patna, Bihar were selected. Ethical clearance and consent was taken for all patients.
- Systemically healthy subjects.
- Presence of almost 2 identical interproximal intrabony 3 walled defects on either side of mandibular arch clinically assessed and assumed by radiograph.
- Clinical probing depth of at least 5 mm at the defect site without furcation involvement.
- Subjects who had not taken antibiotics 6 months prior to initial examination.
- No periodontal surgery performed in the areas to be treated within the last 12 months.
- Patient with any systemic disease or condition that contraindicate periodontal surgery.
- Patients having low platelet count for PRF preparation, that is, less than 1,50,000 per microliter of circulating blood.
- Patient with unacceptable oral hygiene after reevaluation of phase 1 therapy.
- Patients using tobacco in any form.
- Pregnant or lactating mothers.
- Untreated acute infection at a surgical site.
- Teeth with endodontic involvement and mobility of grade III.
- Unwilling and noncompliant patients.
- Patients under medications that can affect periodontal wound healing.
For selected subjects, detailed history, clinical examination, and routine investigations were done. Sagittal cone-beam computerized tomogram (CBCT) was done for the defect parameters. Two measurements were performed for each site: the depth of the defect, measured from the CEJ to the bottom of the defect; and the width of the defect, measured from the highest point of the alveolar crest (AC) to the dental root adjacent to the defect. All subjects were treated with initial phase I–therapy and were reevaluated after 6 weeks.
The study was a split-mouth randomized controlled clinical trial where 20 sites in contralateral quadrants of 10 patients were taken. The sites were divided into 2 groups randomly [Figure 1].
Control Group A
Placement of synthetic nanocrystalline beta-tricalcium phosphate (600–700 micron) alone [Figure 2].
Test Group B
Placement of synthetic nanocrystalline beta-tricalcium phosphate (600–700 micron) with platelet-rich fibrin [Figure 3].
|Figure 3: Platelet-rich fibrin and beta-tricalcium phosphate placed in test site|
Click here to view
Probing pocket depth, gingival recession, and clinical attachment loss of selected site were recorded using acrylic occlusal stent before surgery and again was recorded 6 months postoperatively [Figure 4]. Radiographic parameters of each defect was recorded before surgery and again after 6 months post operatively [Figure 5].
Platelet-rich fibrin preparation
Following Choukroun' s method of PRF preparation, immediately before the surgical procedure, 10 ml of blood was drawn from the subject's vein. The blood-containing tube was immediately centrifuged at a rate of 3000 rpm for 10 min. The centrifuged blood mass presented with a structured fibrin clot in the middle of the tube, between the red corpuscle layer on the bottom and the acellular plasma on top. The fibrin clot could easily be removed from the tube. In the present study, PRF was compressed between the gauge and was then mixed with beta-tricalcium phosphate to a homogenous mixture to be placed at the test site.
Six weeks after the completion of the initial therapy, all the patients were undertaken for periodontal surgery.
Area subjected to surgery was anesthetized by nerve block-infiltration depending on the surgical site. 2% lignocaine hydrochloride was used as the local anesthetic.
Sulcular incision was made using Bard-Parker scalpel with surgical blade no. 15 to the level of alveolar bone. The incision was extended one tooth mesially and one tooth distally to the involved tooth.
Flap reflection and debridement
A full-thickness mucoperiosteal flap was raised using periosteal elevator on both facial and lingual sides until the bony defect was exposed. The granulation tissue was removed from the bony walls and the associated root surfaces using area-specific Gracey curettes to expose the root surface and the alveolar bone. The inner surface of the flap was carefully curetted to remove the lining pocket epithelium and granulation tissue. Then, the defect area was confirmed clinically.
In Group A or control group, beta-tricalcium phosphate (600–700 μg) was packed into the defect [Figure 2].
In Group B or test group, PRF was prepared and mixed with beta-tricalcium phosphate (600–700 μg) to get a homogeneous mass. The prepared mixture was properly condensed in the defect to the level of surrounding bony walls [Figure 3].
The flap was adapted back to its original position and suturing was done using nonresorbable silk thread (3-0). Periodontal dressing was placed.
The patients were prescribed 500 mg amoxicillin and 400 mg ibuprofen to be taken thrice daily for 5 days. The subjects were instructed not to brush the operated area until sutures removed and to use 0.2% Chlorhexidine rinses twice daily for ten days. Periodontal dressing and sutures were removed after 10 days postoperatively.
Clinical parameters including probing pocket depth, gingival recession, and clinical attachment loss were evaluated at 6 months postoperatively [Figure 4].
Radiological parameters for the defect site were evaluated with the help of sagittal cone beam computerized tomography after 6 months postoperatively [Figure 5]. The clinical and radiographical parameters were recorded in data collection sheet and the data was subjected to statistical analysis.
| Results|| |
Data was entered in Microsoft excel and Paired and student t-test applied for comparison between two groups using statistical analysis software Graph pad Prism (Version 5). “P” value of less than 0.05 was accepted as indicating significance.
[Table 1], [Graph 1] denote intragroup comparison of PPD, GR, and CAL measurements in Control Group A at baseline and 6 months. It reveals significant decrease in probing pocket depth (PPD) after 6 months with respect to the baseline (P-value < 0.001), a nonsignificant increase in gingival recession after 6 months (P-value = 0.1039), and a significant decrease in clinical attachment loss (CAL) after 6 months (P-value <.001).
[Table 2], [Graph 2] show comparison of radiographic measurement (CBCT) at baseline and after 6 months in Control Group A. It reveals a significant decrease of defect height after 6 months, (P-value < 0.001) and a significant decrease of defect width after 6 months, (P-value < 0.001).
[Table 3], [Graph 3] show a comparison of PPD, GR, and CAL in Test Group B at baseline and 6 months. It reveals significant decrease in probing pocket depth (PPD) after 6 months with respect to baseline (P-value < 0.001), a nonsignificant increase in gingival recession (GR) after 6 months (P-value =0.3434), and a significant decrease in clinical attachment loss (CAL) after 6 months (P-value < 0.001).
[Table 4], [Graph 4] show comparison of radiographic measurement (CBCT) at baseline and after 6 months in Test Group B. It reveals a significant decrease of defect height after 6 months (P-value < 0.001) and a significant decrease of defect width after 6 months (P-value < 0.001).
[Table 5], [Graph 5] show comparison of difference after 6 months follow-up for PPD, GR, and CAL measurements between Control Group A and Test Group B. It reveals more probing pocket depth reduction and clinical attachment loss reduction in Group B than Group A and more gingival recession in Group A than Group B after 6 months. However, the values were not statistically significant.
|Table 5 : Comparison of difference after sixth month follow up for the PPD, GR and CAL between Group A and Group B|
Click here to view
[Table 6], [Graph 6] show comparison of difference after 6-month follow-up for the radiographic measurement (CBCT) between Group A and Group B. It reveals decrease in defect height more in Group B as compared to Group A and greater decrease in defect width in Group B as compared to Group A, but the values were not statistically significant.
|Table 6 : Comparison of difference after sixth month follow up for the radiographic measurement (CBCT) between Group A and Group B|
Click here to view
| Discussion|| |
Regeneration of soft tissue and hard tissue (using CBCT) was evaluated after 6 months from baseline in both Control Group A and Test Group B which showed significant improvement in both soft tissue and hard tissue parameters. Mean of all parameters was better in the test group; however, the intergroup difference was not statistically significant.
All patients enrolled for this study completed the study uneventfully, validating the fact that the usage of the alloplastic regenerative material beta-tricalcium phosphate and growth factor containing platelet-rich fibrin had been well accepted in the treatment of intraosseous defects in periodontal disease.
Platelets can play a crucial role in periodontal regeneration as they are reservoirs of growth factors and cytokines which are key factors for regeneration of the bone and maturation of the soft tissue. PRF is an autologous platelet concentrate prepared from patient's own blood. Recent studies are being focused on the development of therapeutic materials which are easy to prepare, biocompatible to living tissues, and economically cheap that might result in the local release of growth factors accelerating hard and soft tissue healing. PRF seems to be an ideal material which might fulfill all the above criteria. Thus, presently there is a surge in studies regarding the role of PRF in periodontal regeneration. Numerous in vitro studies have shown a beneficial effect of PRF on bone healing, like its effect on proliferation and differentiation on osteoblasts.,
A study conducted by Bansal and Bharti in 2013 using PRF and DFDBA in test sites and DFDBA alone in control sites has been found to have identical results with the present study.
A study by Ashawan and Zade in 2016 using bioactive glass and PRF as the test site and bioactive glass alone in the control site revealed exactly similar results. Other studies by Demir et al. (2007) and Lucarelli et al. (2010) had also come up with comparable results. In all the above studies, there was statistically significant soft tissue and hard tissue changes in both the test and control groups at 6 months, but the intergroup comparison was not statistically significant.
On the other hand, a study by Agarwal in 2017 using calcium phospho silicate putty alone and in combination with PRF in the treatment of intrabony defects gave significantly better soft tissue and hard tissue parameters at the end of 6 months in sites where the putty and PRF were put together. Comparable results were obtained by Naqvi et al. using bioactive glass putty and PRF at the end of 9 months.
However, a study by Pinipe et al. in 2014, with β-tri calcium phosphate alone and in combination with platelet-rich plasma (PRP) for treatment of intrabony defects in chronic periodontitis patients yielded results similar to the present study.
The safety and efficacy of β-TCP for the treatment of periodontal intraosseous defects have been demonstrated by a number of studies.,, It has been shown by examining biopsy material after implantation of TCP in human intrabony pockets that this material is actively resorbed before promoting bone formation and degraded slowly at a later stage. β-TCP has been shown to have osteogenic potential. Therefore, it has been used as an active control in this study as well as in the test site along with PRF.
In the present study, the radiographic assessment was carried out using CBCT technique. Thus, the findings of the present study can be assumed to have greater accuracy since two-dimensional techniques significantly underestimate treatment outcomes. It has been postulated that CBCT is an equivalent substitution for direct surgical measurement of bony changes occurring after bone replacement graft procedures.
The present study suffers from a number of limitations. It does not provide surgical reentry data and histological evaluation of the treated periodontal intrabony defect sites was also not done. The biodegradation of β-TCP has been shown to be an extremely slow process in humans. Thus, long-term studies would be more favorable for demonstrating bone formation and integration of the material after grafting in contrast to the present study, which had a postoperative follow-up of 6 months. The small sample size of the study was another limiting factor for it.
Thus, further studies need to be designed with larger sample size and longer postoperative follow-up periods. The studies should also be designed with options for reentry surgery and histological evaluation.
| Conclusion|| |
The present study showed significant improvements in clinical and the radiographic parameters in both test (β-TCP + PRF) and control (β-TCP) groups. All the soft tissue and hard tissue parameters were better in the test group; however, no statistically significant difference was found between the test and control groups. Thus, it can be concluded that the use of beta-tricalcium phosphate bone graft combined with platelet-rich fibrin and beta-tricalcium phosphate bone graft alone are both equally effective for the treatment of periodontal intrabony defects in humans. The findings of the present study will be useful in decision making during regenerative procedures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]