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| Year : 2011 | Volume
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| Issue : 1 | Page : 107-115 |
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| Evaluation of the relative efficacy of autologous platelet-rich plasma in combination with β-tricalcium phosphate alloplast versus an alloplast alone in the treatment of human periodontal infrabony defects: A clinical and radiological study |
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Nalini Saini1, Poonam Sikri2, Harinder Gupta3
1 Department of Periodontics, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India
2 Department of Periodontics, Seema Dental College and Hospital, Rishikesh, Uttaranchal, India
3 Department of Periodontics, Punjab Government Dental College and Hospital, Amritsar, Punjab, India
Click here for correspondence address and email
| Date of Submission | 20-Nov-2009 |
| Date of Decision | 31-Aug-2010 |
| Date of Acceptance | 10-Nov-2010 |
| Date of Web Publication | 25-Apr-2011 |
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 Abstract | | |
Background: Platelet-rich plasma (PRP) contains high levels of polypeptide growth factors that may enhance periodontal regeneration when combined with graft materials.
Aim: The purpose of this study was to compare the efficacy of autologous PRP in combination with β-tricalcium phosphate (β-TCP) versus β-TCP alone in the treatment of human infrabony defects.
Materials and Methods: Using a split-mouth design, 20 patients showing clinical evidence of almost identical bilateral infrabony defects were randomly selected. The right infrabony defects of the patient were designated as Group A and treated by the placement of β-TCP alone. The left infrabony defects of the same patient were designated as Group B and treated by the placement of PRP mixed with β-TCP. Clinical assessment of probing pocket depth and attachment level and radiographic evaluation of the defect depth were done preoperatively and at 12, 24 and 36 weeks postoperatively. The relative efficacy of two treatment modalities was evaluated using paired Student's t-test and the comparative evaluation between the two groups was done using independent Student's t-test.
Results: Both the groups exhibited a highly significant reduction in probing pocket depth, gain in clinical attachment level and linear bone fill at the end of 36 weeks postoperatively. Comparative evaluation between the two study groups revealed a significant reduction in probing pocket depth (P = 0.036*), mean gain in clinical attachment level (P = 0.042*) and linear bone fill (P = 0.014*) in Group B as compared to Group A.
Conclusions: Combination of PRP and β-TCP led to a significantly more favorable clinical and radiographic improvement in infrabony periodontal defects. Keywords: Alloplast, platelet-rich plasma, periodontal regeneration, tissue engineering
How to cite this article:
Saini N, Sikri P, Gupta H. Evaluation of the relative efficacy of autologous platelet-rich plasma in combination with β-tricalcium phosphate alloplast versus an alloplast alone in the treatment of human periodontal infrabony defects: A clinical and radiological study. Indian J Dent Res 2011;22:107-15 |
How to cite this URL:
Saini N, Sikri P, Gupta H. Evaluation of the relative efficacy of autologous platelet-rich plasma in combination with β-tricalcium phosphate alloplast versus an alloplast alone in the treatment of human periodontal infrabony defects: A clinical and radiological study. Indian J Dent Res [serial online] 2011 [cited 2023 Mar 24];22:107-15. Available from: https://www.ijdr.in/text.asp?2011/22/1/107/80008 |
The ultimate goal of periodontal therapy is to regenerate the loss of tooth supporting tissues, caused by the infectious disease process, including alveolar bone, periodontal ligament, and cementum. [1],[2],[3]
Bone grafting is the most common form of regenerative therapy available today and is usually essential for restoring all types of periodontal supporting tissues. [4] Amongst bone grafts, alloplasts hold a great promise as a bone graft material. β-tricalcium phosphate (β-TCP) is a biocompatible alloplast and is of the highest purity. β-TCP has a crystalline structure and its porosity provides optimal biologic properties, i.e., osteoconductivity and total resorbability. It has calcium to phosphate ratio of 1:1.5, with particle size ranging from 0.5 to 1.0 mm and resorbs progressively, releasing calcium and phosphate ions, which promote new bone formation within 3-6 months. [5]
Recently bone grafts have added biologic modifiers, i.e., the substances which influence the activity of the cells responsible for new attachment apparatus formation. Classic examples of biologic modifiers are growth factors.Human platelets are a rich source of various growth factors.
Autologous platelet-rich plasma (PRP) is a concentrated suspension of growth factors found in platelets. [6] Human platelets contain platelet derived growth factor (PDGF) and transforming growth factor-β (TGF-β) in their alpha granules. PRP contains a high concentration of platelets and therefore is a good source of growth factors, specifically PDGF and TGF-β.[7],[8] PDGF, a biologic modifier, has been shown to play an important role in the healing of bone and the periodontium by regulating key cellular processes such as mitogenesis, chemotaxis, cell differentiation and cell metabolism. [9] The growth factors are critical for the stimulation and regulation of wound healing and are postulated as promoters of tissue regeneration. [6] Soft tissue healing is also substantially improved by the application of PRP as it increases collagen content, promotes angiogenesis, and increases early wound strength. [9]
The possibility of using autologous PRP along with bone grafting procedures was first explored by Marx et al. who showed that the bone maturation increased by 1.62-2.16 times when compared to bone grafts alone at 6 months postoperatively, as measured by histomorphometry. [7] Use of PRP in conjunction with different graft materials, viz., freeze-dried bone allograft (FDBA), β-TCP, have shown to promote bone formation and also enhance soft tissue healing. [10],[11] Autologous PRP has been successfully used with graft materials like porous hydroxyapatite, [12] bovine porous bone mineral (BPBM), [13] natural bone mineral with collagen membrane, [14] anorganic bovine bone mineral and expanded polytetrafluoroethylene membranes, [15] demineralized freeze-dried bone allograft (DFDBA), [16] and recently with peptide-enhanced bone graft [17] in the treatment of human infrabony defects. Also, there are several studies on the use of autologous PRP combined with β-TCP alloplast, with or without guided tissue regeneration (GTR), in the treatment of human periodontal infrabony defects.[18],[19],[20],[21] In the present study, an attempt has been made to evaluate clinically and radiographically the relative efficacy of autologous PRP in combination with β-TCP versus β-TCP alone in the treatment of human periodontal infrabony defects.
| Materials and Methods | |  |
Clinical trial
Twenty systemically healthy patients (12 females and 8 males; age range: 22-50 years; mean age: 40.30 years) showing clinical evidence of almost identical bilateral infrabony defects, as determined by clinical and radiographic evaluation, were selected from amongst those reporting at the Department of Periodontics, Punjab Government Dental College and Hospital, Amritsar, Punjab, India.
The patients selected were non-smokers, non-alcoholics, with no history of allergy or any other systemic debilitating disease. Patients who were co-operative and agreed to act as subjects were included in this study after they signed an informed consent. All patients meeting the selection criteria were consecutively enrolled from March 2007 to February 2008.
These patients were subjected to oral prophylactic procedures, occlusal equilibration, if required, and routine laboratory investigations prior to surgery. Patient oral hygiene status was evaluated by the O'Leary plaque index [22] and considered satisfactory when the plaque score of <10% was present.
The clinical parameters assessed were probing pocket depth and clinical attachment level (to ascertain the clinical attachment loss). Occlusal stents for positioning the measuring probes were fabricated with cold cure acrylic resin on a cast model obtained from an alginate impression [23] [Figure 1]. Radiographically, the infrabony defect depth was ascertained by using a standardized radiographic technique and measuring from a fixed reference point (the adjacent cuspal tip) to the most apical point of the base of the defect. For this purpose, a grid was used as an adjunct to the X-ray film for the accuracy in the measurements. [24]  | Figure 1: Probing pocket depth measurement by William's calibrated periodontal probe using customized acrylic stent
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The infrabony defects in the 20 patients were divided into two groups, viz., Group A and Group B. The right infrabony defects of the patient were designated as Group A and the left infrabony defects of the same patient were designated as Group B. Group A was control side where defects were treated by the placement of β-TCP graft alone. β-TCP was hydrated with sterile saline first and then placed into the control defects. Group B was test side where defects were treated by the placement of PRP mixed with β-TCP. Only one surgeon/operator performed all the surgeries. The treatment order followed was random and blinding of observer/examiner as well as statistician was done. There was single observer other than the operator who performed all clinical measurements, preoperatively as well as postoperatively, in the whole study without the knowledge of the treatment groups. The patients were also not aware of the case or control side.
Preparation of autologous platelet-rich plasma
One day prior to surgery, PRP was prepared in the laboratory. Exactly 8.5 ml of whole blood was drawn from each subject by venipuncture of the antecubital vein. Blood was collected in two 5 ml sterile glass tubes coated with acid-citrate-dextrose (an anticoagulant). Whole blood was initially centrifuged (2400 rpm for 10 minutes) to separate PRP and platelet-poor plasma (PPP) portions from the red blood cell (RBC) fraction. PRP and PPP portions were again centrifuged (3600 rpm for 15 minutes) to separate the PRP (0.6 ml) from the PPP. The PRP was stored at -20°C until used. [12]
Fifteen minutes prior to the use of the PRP in the periodontal surgical procedures, the PRP was rapidly thawed, and a coagulated preparation of 0.3 ml of PRP was obtained by its combination with 0.1 g of sodium alginate. Within a few minutes, the PRP preparation assumed a sticky gel consistency. Then β-TCP was mixed with the coagulated PRP preparation.
Surgical procedure
The patients were premedicated using 10 mg/2 ml diazepam and 0.3 mg/1 ml glycopyrrolate injection intramuscularly, 45 minutes before the procedure.
The area to undergo surgery was anesthetized with lignocaine hydrochloride 2% with adrenaline 1:200,000. Envelope flaps were reflected [Figure 2] so as to debride the infrabony defects prior to the placement of β-TCP graft, either alone or in combination with PRP [Figure 3]. Flaps were re-positioned and approximated by pressing with moist cotton, placed on both labial/buccal and lingual/palatal sides for 5 minutes and interrupted interdental sutures were given with 3-0 black braided silk [Figure 4].
Antibiotic therapy (amoxycillin 250 mg + cloxacillin 250 mg + 60 million lactobacillus spores, three times a day) for 1 week along with an anti-inflammatory agent for 3 days was prescribed postoperatively. The patients were asked to follow diet instructions strictly and perform adequate plaque control by rinsing with 15 ml of 0.12% chlorhexidine gluconate for 30 seconds twice daily for 2 weeks postoperatively. Sutures were removed 1 week after surgery. Supragingival professional tooth cleaning was performed weekly for the first 6 weeks post-surgery. Thereafter, postoperative care included reinforcement of oral hygiene and mechanical plaque control, whenever necessary. The postoperative assessments for the clinical and radiographic parameters [Figure 5], [Figure 6], [Figure 7] and [Figure 8] were done at 12, 24, and 36 weeks. The observations recorded were subjected to statistical analysis. | Figure 5: Infrabony defect depth of group B, radiographically (preoperative)
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 | Figure 6: Infrabony defect depth of group B, radiographically (12 weeks postoperative)
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 | Figure 7: Infrabony defect depth of group B, radiographically (24 weeks postoperative)
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 | Figure 8: Infrabony defect depth of group B, radiographically (36 weeks postoperative)
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Statistical analysis
The mean values (mean ± SE m ) of probing pocket depth [Table 1], clinical attachment level [Table 2] and infrabony defect depth [Table 3] at the four points in time were evaluated. The efficacy of the two treatment modalities at 12, 24, and 36 weeks postoperatively were evaluated using the paired Student's t-test. The two groups, A and B, were then comparatively evaluated over the three time intervals using the independent Student's t-test for equal sample sizes.  | Table 1: Probing pocket depth of Group A (β -TCP alone) and Group B (β -TCP mixed with PRP) (in mm)
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 | Table 2: Clinical attachment level of Group A (β -TCP alone) and Group B (β -TCP mixed with PRP) (in mm)
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 | Table 3: Radiographically ascertained infrabony defect depth of Group A (β -TCP alone) and Group B (β -TCP mixed with PRP) (in mm)
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| Results | | |
It was observed that β-TCP as well as prepared PRP possessed excellent handling characteristics, were easy to manipulate and were well tolerated by all the patients; with no adverse tissue reaction, infection or delayed healing reported during the course of the study.
On analyzing the clinical criteria of reduction in probing pocket depth of individual groups, it was seen that the use of β-TCP alone as well as β-TCP mixed with PRP exhibited a highly significant reduction in probing pocket depth after 12, 24, and 36 weeks postoperatively [Table 4]. | Table 4: Reduction in probing pocket depth of Group A (β -TCP alone) and Group B (β -TCP mixed with PRP) (in mm)
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Evaluating the parameter of clinical attachment level, both the groups exhibited a significant gain in clinical attachment level at all the three points in time [Table 5]. | Table 5: Gain in clinical attachment level of Group A (β -TCP alone) and Group B (β -TCP mixed with PRP) (in mm)
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The linear bone fill for both the groups was statistically highly significant for all the three points in time [Table 6]. | Table 6: Linear bone fill (ascertained radiographically) of Group A (β -TCP alone) and Group B (β - TCP mixed with PRP) (in mm)
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On comparative evaluation of the two groups, the use of β-TCP mixed with PRP exhibited a greater reduction in probing pocket depth than graft alone and this difference over the entire span of the study, i.e., between preoperative and 36 weeks postoperative was statistically significant (P = 0.036*) [Table 7]. | Table 7: Comparative reduction in probing pocket depth between Group A (β -TCP alone) and Group B (β -TCP mixed with PRP)
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The mean gain in clinical attachment level of β-TCP mixed with PRP was also greater than that of graft alone and this difference over the entire span of the study, i.e., between preoperative and 36 weeks postoperative was found to be statistically significant (P = 0.042*) [Table 8]. | Table 8: Comparative gain in clinical attachment level between Group A (β -TCP alone) and Group B (β -TCP mixed with PRP)
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Graft mixed with PRP also exhibited a statistically significant linear bone fill as compared to graft alone over the entire span of the study from preoperative to 36 weeks postoperative (P = 0.014*) [Table 9]. | Table 9: Comparative linear bone fill (ascertained radiographically) between Group A (β -TCP alone) and Group B (β -TCP mixed with PRP)
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| Discussion | | |
Periodontitis is a chronic inflammatory disease that targets tooth supporting structures through complex microbial plaque harboring multitude of pathogens. It produces changes in all the tissues of the periodontium, but the changes that occur in the alveolar bone are critical because the destruction of the alveolar bone is ultimately responsible for tooth loss. [25]
Historically, autogenous and allogenic bone grafts have been used with some success. [26],[27] Although the use of intraoral autogenous bone graft is a well-accepted treatment option in periodontal community, limited availability of donor sites, requirement for an additional surgery to obtain the graft material, and extra chair time are the limitations of this technique. On the other hand, the use of an allograft such as freeze-dried bone has the risk of disease transmission and this led to the development of alloplasts. [28]
Over the years, β-TCP, an alloplast, has been successfully used in the treatment of periodontal osseous defects. [29],[30],[31],[32]
Recent advances in our understanding of cell regulation by growth factors present new options and provide additional treatment methods for regenerating lost periodontal support. The use of autologous PRP is a recent and promising innovation in periodontal regenerative therapy.
PRP has been successfully used in many recent studies, and favorable clinical outcomes have been reported following the incorporation of PRP gel in the surgical procedures of the maxillofacial region, sinus augmentation, mandibular reconstruction and implant placement. [7],[10],[11],[33],[34] The positive impact of PRP on bone healing could be attributed to the angiogenetic, proliferative and differentiating effects on osteoblasts of TGF-β and PDGF that are present in PRP in high concentrations.[35]
PRP has also been successfully used with different graft materials, with and without GTR, in the treatment of human periodontal infrabony defects. [12],[13],[14],[15],[16],[17] Studies done by Yassibag-Berkman, [18] Dφri, [19] Harnack, [20] and Attia [21] on PRP and β-TCP graft material have shown significantly favorable clinical improvement in periodontal infrabony defects.
On analyzing the results, the mean reduction in probing pocket depth of Group A as well as Group B after 12, 24 and 36 weeks postoperatively were found to be statistically highly significant. These results concur with those of Hanna et al, [36] Okuda et al, [12] and Ouyang and Qiao, [13] who observed similar clinical changes following the use of PRP in conjunction with bone graft materials.
Comparative evaluation of the two groups revealed that at the end of 36 weeks, the mean reduction in probing pocket depth of Group B was higher than that of Group A and the difference was statistically significant.
Similarly, the mean gain in clinical attachment level for individual groups showed statistically highly significant results over the entire span of the study. On comparative evaluation between Groups A and B, the mean value of Group B was higher than that of Group A and the difference was found to be statistically significant between preoperative and 36 weeks postoperative.
The mean linear bone fill for both the groups also showed an increase which was statistically highly significant over the entire study period and the comparative evaluation revealed a greater radiographic evidence of bone fill for Group B over Group A at the end of 36 weeks, with the difference being statistically significant.
The results of this study are consistent with those of Howell et al., [37] Marx et al., [7] Okuda et al., [12] and Ouyang and Qiao, [13] who have demonstrated the beneficial effects of adjunctive use of PRP in achieving bone regeneration.
PRP stimulates the proliferation of periodontal ligament (PDL) and osteoblastic cells while, at the same time, inhibiting epithelial cell proliferation. [38]
The adjunctive clinical benefit of the PRP preparation can be explained on the basis of tissue engineering, i.e., tissue engineering generally combines three key elements for regeneration: 1) scaffolds or matrices, 2) signaling molecules or growth factors, and 3) cells. By combining these elements under the appropriate biologic and environmental conditions, as well as enough time, tissue regeneration will become more predictable. [39] When this tissue engineering concept becomes applicable to the present method, β-TCP and PRP could become suitable scaffolds and growth factors, respectively.
In addition, PRP has been shown to form a gel like material in several cell cultures of either PDL or osteoblastic cells. [40] This gel like material is fibrin clot which is capable of up-regulating collagen synthesis in the extracellular matrix. Fibrinogen, converted to fibrin, in combination with growth factors present in PRP, effectively promote wound healing at sites of injury in periodontal tissue. [12] Once PRP preparation is coagulated, it assumes a "sticky consistency" due to its high fibrin content. The sticky characteristic of PRP preparation works as a hemostatic agent and stabilizes the graft material and the blood clot in the defect area. [35],[41],[42] The "sticky consistency" also improves the clinical handling properties of the combination of PRP and the graft material. [8],[12],[33],[42],[43],[44]
Moreover, autologous PRP is non-toxic, non- immunoreactive [45] and inherently safe and free from concerns over transmissible diseases. In addition, the preparation of PRP is simple and rapid. [8],[12]
In conclusion, within the constraints of this study, autologous PRP in combination with β-TCP led to significant improvements clinically as well as radiographically and, hence, can be successfully used in the treatment of periodontal infrabony defects.
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Correspondence Address:
Nalini Saini
Department of Periodontics, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.80008
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9] |
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Degradable polymers may improve dental practice |
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