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Table of Contents   
TECHNICAL NOTE  
Year : 2013  |  Volume : 24  |  Issue : 5  |  Page : 627-630
Platelet rich fibrin: A new hope for regeneration in aggressive periodontitis patients: Report of two cases


1 Post Graduate Student, Tatyasaheb Kore Dental College and Research Centre, New Pargaon, Kolhapur, Maharashtra, India
2 Department of Periodontology, Tatyasaheb Kore Dental College and Research Centre, New Pargaon, Kolhapur, Maharashtra, India

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Date of Submission15-Mar-2013
Date of Decision19-Apr-2013
Date of Acceptance04-May-2013
Date of Web Publication21-Dec-2013
 

   Abstract 

The purpose of this study was to evaluate the effectiveness of platelet rich fibrin (PRF) in periodontal regeneration in generalized aggressive periodontitis (GAgP) patients. Two patients diagnosed with GAgP were selected for this study. Baseline clinical and radiographic examination was performed and patients were treated by surgical periodontal therapy along with PRF. Post-surgical re-evaluation was carried out at regular intervals to evaluate clinical and radiographic changes. Surgical periodontal therapy accompanying the placement of PRF in angular defects of GAgP patients showed decreased probing pocket depth, increased attachment level and radiographic bone fill when baseline and 9 month follow-up data was compared. Surgical reconstructive therapy with placement of PRF in angular defects of GAgP patients can be an effective approach to enhance the periodontal regeneration.

Keywords: Periodontitis, platelet derived growth factors, regeneration

How to cite this article:
Desarda HM, Gurav AN, Gaikwad SP, Inamdar SP. Platelet rich fibrin: A new hope for regeneration in aggressive periodontitis patients: Report of two cases. Indian J Dent Res 2013;24:627-30

How to cite this URL:
Desarda HM, Gurav AN, Gaikwad SP, Inamdar SP. Platelet rich fibrin: A new hope for regeneration in aggressive periodontitis patients: Report of two cases. Indian J Dent Res [serial online] 2013 [cited 2019 Nov 22];24:627-30. Available from: http://www.ijdr.in/text.asp?2013/24/5/627/123411
Generalized aggressive periodontitis (GAgP) essentially is "interproximal attachment loss affecting at least three permanent teeth other than the first molars and incisors." [1] Aggressive periodontitis has been defined following the criteria, which includes age of onset, distribution of lesions, severity of destruction, rate of progression and response to therapy. A positive family history has also been associated with aggressive periodontitis patients. Successful treatment of GAgP is dependent on early diagnosis, directing the therapy (non-surgical/surgical) toward elimination or suppression of the pathogenic microorganisms and providing an environment conducive to health. Treatment alternatives include scaling and root planning alone or in conjunction with systemic antibiotics as well as surgical approach. [2] Time honored non-surgical periodontal therapy has proved to be of limited value in regeneration of the lost tissues. [2] Periodontists have been experimenting various modalities for regeneration in GAgP with varying degree of success. Periodontal surgery combined with platelet rich fibrin (PRF) has been introduced as a method to promote regeneration of the lost periodontium. However, very few studies report the use of PRF in GAgP and hence the regenerative potential of PRF in GAgP is vastly unexplored.

Therefore, purpose of this study was to evaluate the improvement in periodontal health of patients when treated with surgical periodontal therapy along with the use of PRF in angular defects of aggressive periodontitis patients.

PRF preparation

The protocol developed by Choukroun et al. [3] was used as a guide for PRF preparation.

Just prior to surgery, intravenous blood (by venepuncture of the antecubital vein) was collected in 10-ml sterile tubes without anticoagulant and immediately centrifuged in centrifugation machine at 3,000 revolutions for 10 min. Blood centrifugation immediately, after collection leads to the formation of a structured fibrin clot in the middle of the tube, red corpuscles at the bottom and platelet-poor plasma (PPP) at the top. PRF was easily separated from red corpuscles base preserving a small red blood cell layer using a Sterile tweezer and scissor after removal of PPP and then transferred onto a sterile container.


   Case Report Top


Case 1

A healthy 18-year-old female patient reported to the Department of Periodontics, with the chief complaint of bleeding gums since 6-7 months and spacing in maxillary anterior teeth. Initial examination revealed good oral hygiene status, but deep periodontal pockets ranging from 6 mm to 11 mm. Periodontal examination included probing depth, clinical attachment loss, tooth mobility and degree of inflammation. Pathologic migration was evident with 11 and 21 and grade I mobility was evident with 12, 31, 41 and 42. Grade II furcation involvement was noticed with 36, 46. Details of periodontal charting are shown in [Figure 1]. History of familial aggregation was not relevant. Routine hematological investigations, full mouth intraoral periapical radiographs and orthopantomogram (OPG) were obtained. OPG displayed typical arch shaped bone loss, which extended from distal surface of 35 to mesial surface of 37 and the same pattern in 45-47 region [Figure 2]. It also presented the advanced vertical bony defects in relation to 14, 15, 16, 26 and 31 to 33. Radiolucency was seen in furcation site, which is suggestive of involvement of furcation in 36 and 46 region. Baseline periapical radiograph with 26 shows advanced angular defect with the loss of lamina dura [Figure 3]. Based on the history, age, clinical and radiographic examinations, a diagnosis of GAgP was confirmed.

The treatment plan consisted of full mouth scaling and root planning along with systemic administration of amoxicillin 500 mg + metronidazole 400 mg 3 times daily for 7 days. After full mouth scaling and root planning, patient was advised to rinse with 0.2% chlorhexidine solution twice daily. Oral hygiene instructions were advised to the patient. Patient was recalled 6 weeks after phase-I therapy. On re-evaluation probing pocket depth was found to be persistent with a maximum of 11 mm at 26. Therefore, surgical intervention was deemed necessary and thus open flap debridement with regeneration using of PRF with 26 and demineralized freeze dried bone allograft (DFDBA) at remaining sites were planned.
Figure 1: Baseline periodontal charting of Case 1 patient

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Figure 2: Orthopantomogram (a) Case 1 patient; (b) Case 2 patient

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Figure 3: Baseline radiograph Case 1 (a) angular defect with 25, 26; (b) post-operative radiograph showing bone fill Case 2 (c) defect with 35, 36, 37; (d) post-operative radiograph showing bone fill

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Surgical procedure consisted of: (a) Modified flap operation (b) preparation of PRF (c) placement of PRF (d) suturing.

Modified flap operation was performed from 21 to 27 and thorough debridement was carried out. Simultaneous with the process of debridement, PRF was prepared by well-trained assistant to avoid the overexposure of surgical field. Prepared PRF was then placed in the bony defect with 26. Following placement of the PRF, defect was closed with interrupted sutures and a periodontal dressing was placed [Figure 4]. Other areas with vertical defects (46 and 36) were treated with DFDBA and guided tissue regeneration membrane.
Figure 4: Surgical procedure (a) defect; (b) placement of platelet rich fibrin in defect; (c) suturing

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Following the surgery, patient was recalled once a month for 9 months and routine supportive periodontal therapy was performed. Full-mouth clinical measurements were recorded with a manual periodontal probe at 4 month recall visit. Probing pocket depth at 26 was reduced to 6 mm from the preoperative depth of 11 mm [Figure 5]. Radiographically, just 4 months after the surgical therapy, a bone fill of approximately 60-75% was attained when compared with preoperative radiograph. Subsequently, radiograph obtained 9 months after the therapy displayed approximately 85-90% bone fill of the defect and continuity of lamina dura [Figure 3]. Postoperative healing was satisfactory with sharp contours of the tissues.
Figure 5: Post-operative charting of Case 1 patient

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Case 2

Another case of healthy 18 year old male patient reported to the Department of Periodontics, with the chief complaint of sensitivity in mandibular left posterior teeth region since 1 year. On clinical examination, the oral hygiene status of the patient was found to be good. Periodontal examination revealed the presence of generalized deep periodontal pockets with the maximum depth of 10 mm in maxillary and mandibular anterior region and 7-8 mm in posterior molar areas. Grade I mobility was observed with 11, 21, 22 and 42 and grade II mobility was observed with 31 and 41. Pathologic migration was present with 11-22 and 32-42 [Figure 6]. Routine hematological investigations and full mouth intra-oral periapical radiographs were obtained. OPG revealed generalized horizontal bone loss, and advanced angular bone loss and loss of lamina dura in relation to 26, 35, 36, 37 and 45, 46, 47 [Figure 2]. Based on the history, clinical and radiographic examination, a diagnosis of GAgP was confirmed. The treatment plan and the surgical procedure performed was the same as described for the case 1. The surgical regenerative therapy with PRF was performed with 35, 36, 37 and remaining areas with angular defects were treated using DFDBA.
Figure 6: Baseline periodontal charting of Case 2 patient

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Routine supportive periodontal therapy was performed every month. Full-mouth clinical measurements were recorded with a manual periodontal probe at 4 months after the therapy. Measurements demonstrated distinct clinical improvement. Probing depth of the 35, 36, 37 had decreased to 3 mm [Figure 7].
Figure 7: Post-operative charting of Case 2 patient

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Radiographs obtained 4 months after the therapy displayed approximately 70-80% bone fill of the defect and continuity of lamina dura [Figure 3].


   Discussion Top


The use of polypeptide growth factors (PGFs) to regenerate the periodontium and to accelerate the healing has recently attracted the attention of researchers. [4] Vast studies and research has been carried out on transforming growth factor-α (TGF-α) and platelet derived growth factor (PDGF), among all the PGFs. PDGF and TGF-α have been shown to promote periodontal regeneration by cell growth and differentiation. [4] PDGF are abundant in the alpha granules of platelets. [4] These platelets are a natural source of PGFs and are involved in the wound-healing process. [4] A simplest method to obtain autologous PDGF and TGF-α is the use of PRF that can be easily prepared from patient's own blood by centrifugation. [5] It was assumed that by increasing local concentrations of PGFs with the application of PRF, the periodontal healing outcome would be enhanced and accelerate the regeneration of periodontium.

In both cases, combination of non-surgical periodontal therapy with adjunctive antimicrobials followed by surgical therapy with PRF provided a good clinical and radiographic result in patients with severe and progressing GAgP. In both patients, post-operative healing was excellent. Four months after the therapy, distinct clinical improvements were observed. Probing pocket depth reduction ranged from 3 mm to 6 mm and no gingival inflammation signs were observed. The periapical radiographs showed fill of the bony defects as early as 4 months after the therapy and this fill becomes more and more radiopaque in subsequent re-evaluation. The intra-bony defects associated with the rest of the teeth that were treated with DFDBA and GTR also demonstrated improvements in clinical and radiographic parameters, but the improvement in radiographic and clinical parameters in PRF treated teeth out-measures the improvement in rest the teeth by a long way.

Previous studies have shown that use of PRF results in greater reduction in pocket depth, gain in clinical attachment level and greater intra-bony defect fill in chronic periodontitis as compared to open flap debridement; thus, proving the regenerative potential of PRF in chronic periodontitis. [6],[7],[8] Similarly, research has also shown the effectiveness of PRF combined with bone grafts in treatment of angular defect. [9] The present study focuses on the regenerative potential of PRF in GAgP cases since it differs from chronic periodontitis in the rate of disease progression, severity of disease, age of onset and the genetic and healing factors involved. GAgP was selected for the PRF therapy because of the inherent complexities involved in the regenerative treatment of the aggressive periodontitis cases. The result of these two cases therefore adds to the significance of the regenerative capacities of PRF in evidence based treatment of GAgP.


   Conclusion Top


As the initial clinical and radiographic data appear promising, it is now possible to draw a definitive conclusion that PRF can be used as a definite regenerative material in aggressive periodontitis patients.

 
   References Top

1.American Academy of Periodontology. Parameter on aggressive periodontitis. American Academy of Periodontology. J Periodontol 2000;71 Suppl 5:867-9.  Back to cited text no. 1
    
2.Sigusch B, Beier M, Klinger G, Pfister W, Glockmann E. A 2-step non-surgical procedure and systemic antibiotics in the treatment of rapidly progressive periodontitis. J Periodontol 2001;72:275-83.  Back to cited text no. 2
[PUBMED]    
3.Choukroun J, Adda F, Schoeffler C, Vervelle A. An apportunity inparo-implantology: The PRF. Implantodontie 2000;42:55-62.  Back to cited text no. 3
    
4.Giannobile WV, Somerman MJ. Growth and amelogenin-like factors in periodontal wound healing. A systematic review. Ann Periodontol 2003;8:193-204.  Back to cited text no. 4
[PUBMED]    
5.Okuda K, Kawase T, Momose M, Murata M, Saito Y, Suzuki H, et al. Platelet-rich plasma contains high levels of platelet-derived growth factor and transforming growth factor-beta and modulates the proliferation of periodontally related cells in vitro. J Periodontol 2003;74:849-57.  Back to cited text no. 5
[PUBMED]    
6.Bajaj P, Pradeep AR, Agarwal E, Rao NS, Naik SB, Priyanka N, et al. Comparative evaluation of autologous platelet-rich fibrin and platelet-rich plasma in the treatment of mandibular degree II furcation defects: A randomized controlled clinical trial. J Periodontal Res 2013 48:573-81.  Back to cited text no. 6
[PUBMED]    
7.Thorat M, Pradeep AR, Pallavi B. Clinical effect of autologous platelet-rich fibrin in the treatment of intra-bony defects: A controlled clinical trial. J Clin Periodontol 2011;38:925-32.  Back to cited text no. 7
[PUBMED]    
8.Pradeep AR, Rao NS, Agarwal E, Bajaj P, Kumari M, Naik SB. Comparative evaluation of autologous platelet-rich fibrin and platelet-rich plasma in the treatment of 3-wall intrabony defects in chronic periodontitis: A randomized controlled clinical trial. J Periodontol 2012;83:1499-507.  Back to cited text no. 8
[PUBMED]    
9.Pradeep AR, Bajaj P, Rao NS, Agarwal E, Naik SB. Platelet-rich fibrin combined With a porous hydroxyapatite graft for the treatment of three-wall intrabony defects in chronic periodontitis: A randomized controlled clinical trial. J Periodontol 2012 [In Press].  Back to cited text no. 9
    

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Correspondence Address:
Hitesh Megharaj Desarda
Post Graduate Student, Tatyasaheb Kore Dental College and Research Centre, New Pargaon, Kolhapur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.123411

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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