GMJ, ASM 2013;2(S1):S120-S125 GULF MEDICAL JOURNAL

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1 Evaluate clinical effectiveness of autologous platelet rich plasma (PRP) using curasan technique in treating intrabony defects using regenerative material Bone graft / GTR membrane M Sesha Reddy College of Dentistry, Gulf Medical University, Ajman, UAE ABSTRACT Objective: Ultimate aim of periodontal treatment is to ensure betterment in overall periodontal conditions that in turn suit the patient desire. In order to accomplish this objective majority of periodontal procedures intend to decrease probing pocket depth and gain in clinical attachment level that measured as surrogate endpoints. Various surgical modalities are available in order to treat intrabony defect. Remarkable attention to polypeptide growth factors (PGFs) as biological mediators in periodontal tissue regeneration has given importance to PRP. The advantage of using growth factors for periodontal regeneration is their regulatory effect on bone and periodontal ligament cells to proliferate and differentiate to form new tissue. This case report was undertaken to evaluate the clinical efficacy of PRP when used along with bone graft or GTR membrane, bone graft in the treatment of intra bony defect. Materials and Method: Three wall intra bony defects were selected from two different patients for the study. One defect each was treated using PRP with bone graft and other using PRP, bone graft and GTR membrane. Clinical parameters such as probing pocket depth, clinical attachment levels and radiographic bone fill were measured at base line and then after six months respectively. Results: By the end of six months there were considerable differences noticed in clinical parameters such as reduction in probing pocket depth 9mm to 4mm, gain in attachment loss of 4mm and radiographic bone fill was significant after six months. Conclusion: PRP which has abundant amount of growth factors has a detrimental effect on periodontal wound healing. A combination of PRP plus bone graft / PRP plus bone graft with GTR membrane was more effective in the treatment of intrabony defects. Supplementary studies are needed to confirm the results of the present study. Keywords: PRP, intrabony, GTR, bone graft INTRODUCTION Ultimate aim of periodontal treatment is to ensure betterment in overall periodontal conditions that in turn suit the patient desire. In order to accomplish this objective majority of periodontal procedures intend to decrease probing pocket depth and gain in clinical attachment level that measured as surrogate endpoints. Various surgical modalities are available in order to treat intrabony defect. However, in most cases when conventional methods were adapted, histological studies revealed healing by repair rather than regeneration 1. True regeneration is defined as reorientation of new periodontal ligament fibers into new cementum that was previously denuded by periodontal disease 2. Ever since flap surgical procedures with or without bone, grafts had partial accomplishment in-terms of true regeneration newer techniques have been tried out keeping in mind the advancement made in the field of tissue engineering 3-5. Remarkable attention to polypeptide growth factors (PGFs) as biological mediators in periodontal tissue regeneration has given importance. The advantage of using growth factors for periodontal regeneration is their regulatory effect on bone and periodontal 120

2 ligament cells to proliferate and differentiate to form new tissue. Comprehensive review on Platelet derived growth factor (PDGF) and transforming growth factor β (TGF-β) were done amid all growth factors 6. Many vitro animal studies have reveled true regeneration when PDGF and TGF-β used 7-9. When prepared platelet rich plasma serves as an autologous source of highly concentrated dose of platelets. PRP preparation can be by single or double spin of patients own blood This case report describes the intrabony defect treated by autologous PRP with GTR membrane in one tooth and PRP with bone graft in another defect. Over six month period clinical and radiographic parameter was reevaluated. PRP preparation: Curasan et al technique was followed to prepare PRP 12. CASE REPORT: 1 A 35 years old male patient reported to department of periodontics complaining of food impaction and dull pain in the lower left back tooth region since few months and also feels an urge to dig that area. Patient systemic health and medical history was normal. Intra oral assessment revealed generalized bleeding on probing without exudates. Probing pocket depth (PPD) 36 was 9mm mesiobuccal, with no signs of mobility or trauma from occlusion. Periapical radiograph revealed presence of interproximal intra bony defect in relation to 36. Comprehensive treatment planning was performed based on periodontal findings. Oral hygiene instructions (OHI) to educate and motivate the patient for better oral hygiene maintenance Scaling and Root planning was performed using standard gracey curettes. Reevaluation after 6weeks of phase I periodontal therapy to evaluate PPD and Clinical attachment loss (CAL) which was 8mm and 5mm respectively. Surgical periodontal therapy was done after reevaluation of the patient. Surgical Procedure: Case 1 Presurgical mouth rinsing was performed using 0.2% chlorhexidine digluconate. Inferior alveolar nerve block was given to anesthetize the area. Subsequent to anesthesia conventional mucoperiosteal flaps were reflected keeping in concern regarding preservation of inter-proximal soft tissue as much as possible. Later ultrasonic instruments and curettes were used for through defect debridement. PRP with bone graft (Perioglass) was placed into the defect. (Figures 1, 2) Simple interrupted sutures (4-0) were used to reposition the mucoperiosteal flap and later periodontal pack was placed to secure the raw wound surface. Pre and post-operative radiographs show difference in bone fill (Figures 3,4). Figure 1: PRP with bone graft Figure 2: Simple interrupted suturing Figure 3: Pre operative radiograph 121

3 Figure 4: Post operative radiograph CASE REPORT: 2 A 30year old male patient reported to department of periodontics complaining of bleeding gums and bad breath. Patient was systemically healthy. Intra oral examination revealed generalized bleeding on probing and deep pocket in relation to 46 without signs of mobility or trauma from occlusion. A periapical radiograph was taken which revealed presence of interproximal intra bony defect in relation to 46. (Figure 1) Based on the clinical and radiologic findings, the following periodontal treatment plan was followed: A. Oral hygiene instructions (OHI) to educate and motivate the patient for better oral hygiene maintenance B. Scaling and Root planning was performed using standard gracey curettes. C. Reevaluation after 6weeks of phase I periodontal therapy to evaluate PPD and Clinical attachment loss (CAL) which was 7mm and 6mm respectively. D. Surgical periodontal therapy was done after reevaluation of the patient. Surgical Procedure: Case 2 Presurgical mouth rinse was performed using 0.2% chlorhexidine digluconate before periodontal surgery. Inferior alveolar nerve block was performed to anesthetize 46 tooth regions. Following anesthesia conventional flap surgery was done and care was taken to preserve the interdental papilla for proper flap closure of GTR membrane. Surgical debridement of the defect was done using specific curettes. Later, after through debridement the intra bony defect was filled with PRP with bone graft (Perioglass),then GTR membrane was placed in and stabilized in position with sling sutures. Both facial and lingual flaps were approximated using intercepted sutures, followed by application periodontal dressing (Figure 4). Pre and post-operative radiographs show difference in bone fill (Figures 5,6). Postoperative care: Antibiotics and analgesics (amoxicillin 500 mg three times per day for 5 days and Ibuprofen 500 mg three times for 5 day) were prescribed, along with 0.2% chlorhexidine digluconate which was to be rinsed twice daily for 2 weeks. Two weeks post-operatively periodontal dressing and sutures were removed. Following this proper oral hygiene instructions were given to the patient. In follow up period after 6months both PPD and radiographs were taken to assess any improvement in reduction in PPD and gain in radiographic bone fill. Figure 2: Intra Bony Defect Figure 1: Pre operative PPD 122

4 Figure 3: GTR membrane placed Figure 4: GTR membrane sutured Figure 5: Pre operative radiograph Figure 6: Post operative radiograph 6months later DISCUSSION In the present scenario clinical use of PRP with bone graft as well as GTR with PRP, bone graft was evaluated clinically. Success of periodontal therapy by using PRP was assessed by means of PPD and radiographic findings. In the present report there was significant reduction in PPD from 8mm 5mm and also radiographic bone fill was observed. All of which could be attribute to the use of PRP which has enormous growth promoting factors resulting in accelerating the periodontal wound healing by its mitogenic properties 13. Literature review suggests that growth factor available to tissues is directly proportional to the concentration of platelets. Various growth factors like TGF-β1, PDGF AB, and IGF-1 within the PRP can stimulates cascade of wound healing like mitogenic, angiogenic and chemotactic activities of natural proteins and other growth factors 14,15. In the present cases report defects were IBD, so the advantage of 3wall defects is that it provides the best spatial relation for defect self-bridging by vascular and cellular elements 16. This type of defects could also help to prevent membrane collapse and provide space for periodontal tissue regeneration. Use of bone graft or bone graft with membrane are cost effective and failure to attain true periodontal regeneration will be a burden on patient 17,18. In this aspect the use of autologous PRP to promote periodontal regeneration shows promising results compared to other materials which results in long junctional epithelium formation. PRP has various bio-mimicking factors which accelerate periodontal wound healing 19,20. PRP has high concentration of platelets and fibrinogen that favors scaffold formation. This in turn enhances cellular migration which is an essential step in the regeneration of IBD. It also helps in the early stages of wound healing by attracting undifferentiated mesenchymal cells within the fibrin matrix and trigger 123

5 cell division all of which is responsible for cascade of events taking place during periodontal wound healing. CONCLUSION Information from present case reports conclude that PRP is clinically and radio graphically useful in the treatment of IBD. PRP is economical when compared to other regenerative materials. Along with this it has a regulatory effect on proliferation and differentiation of cells from bone and connective tissue which can hasten wound healing. REFERENCES 1. Sander L, Karring T. Healing of periodontal lesions in monkeys following the guided tissue regeneration procedure. A histological study. J Clin Periodontol. 1995;22: American Academy of Periodontology. Glossary of periodontal terms, 3rd edn. Chicago: American Academy of Periodontology; Siciliano VI, Andreuccetti G, Siciliano AI, et al. Clinical outcomes after treatment of non-contained intrabony defects with enamel matrix derivative or guided tissue regeneration: a 12-month randomized controlled clinical trial. J Periodontol 2011;82: Wu SY, Chen YT, Chen CW, et al. Comparison of clinical outcomes following guided tissue regeneration treatment with a polylactic acid barrier or a collagen membrane. Int J Periodontics Restorative Dent. 2010;30: Orsini M, Orsini G, Benlloch D, et al. Long-term clinical results on the use of bonereplacement grafts in the treatment of intrabony periodontal defects. Comparison of the use of autogenous bone graft plus calcium sulfate to autogenous bone graft covered with a bioabsorbable membrane. J Periodontol. 2008;79: Giannobile WV. The potential role of growth and differentiation factors in periodontal regeneration. Journal of Periodontology. 1996;67: , ISSN Lynch SE, de Castilla GR, Williams RC. et al. The effects of short-term application of the combination of the platelet-derived growth factor and insulin-like growth factor on periodontal wound healing. Journal of Periodontology. 1991;62: ISSN Rutherford RB, Niekrash CE, Kennedy JE, et al. Platelet-derived and insulin-like growth factors stimulate periodontal attachment in monkeys. Journal of Periodontal Research. 1992;27: ,.ISSN Sporn MB & Roberts AB. Transforming growth factor-β: Recent progress and new challenges. Journal of Cell Biology. 1992;119: ISSN Tamimi FM, Montalvo S, Tresguerres, et al. A comparative study of 2 methods for obtaining platelet rich plasma. Journal of Oral and Maxillofacial Surgery. 2007;65: , ISSN Marx RE. Platelet rich plasma (PRP): What is PRP and what is not PRP? Implant Dentistry 2001;10: ISSN Weibrich G, Kleis WK. Curasan PRP kit vs. PCCS PRP system. Collection efficiency and platelet counts of two different methods for the preparation of platelet-rich plasma. Clin Oral Implants Res. 2002;13(4): Dohan DM, Del Corso M, Charrier JB. Cytotoxicity analyses of Choukroun s PRF (Platelet Rich Fibrin) on a wide range of human cells: the answer to a commercial controversy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103: Eppley BL, Woodell JE, Higgins J. platelet quantification and growth factors analysis from platelet rich plasma. Implications for wound healing. Plast Reconstr Surg. 2004;114: Weibrich G, Kleis WK, Hafner G. Growth factor levels in platelet rich plasma and correlation with donar age, sex and platelet count. J Craniomaxillofac Sur. 2002;30: Blumenthal NM, Mario EAF, Salah A, et al. Defect-Determined Regenerative Options for Treating Periodontal Intrabony Defects in Baboons. J Periodontol. 2003;74:

6 17. Christgau M, Moder D, Hiller KA, et al. Growth factors and cytokines in autologous platelet concentrate and their correlation to periodontal regeneration outcomes. Journal of Clinical Periodontology. 2006;33: ISSN Christgau M, Moder D, Wagner J, et al. Influence of autologous platelet concentrate on healing in intra-bony defects following guided tissue regeneration therapy: A randomized prospective clinical split-mouth study. Journal of Clinical Periodontology. 2006;33: ISSN Garret JS. Periodontol regeneration around natural teeth. Annals of Periodontology, 1996;1: ISSN Caton JG & Zander HA. Osseous repair of an infrabony pocket without new attachment of connective tissue. Journal of Clinical Periodontology. 1976;3: ISSN