The healing touch of PRF-a case report

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1 Case Report: The healing touch of PRF-a case report Prof. (Dr.) Utpal Kumar Das¹, Prof. (Dr.) Aditya Mitra 2, Dr. Nabanita Bose 3 ¹HOD, Department of Conservative Dentistry & Endodontics, Guru Nanak institute of Dental Science and Research, India 2Professor, Department of Conservative Dentistry & Endodontics, Guru Nanak institute of Dental Science and Research, India 3PG, Department of Conservative Dentistry & Endodontics, Guru Nanak institute of Dental Science and Research, India Corresponding author : Dr Nabanita Bose Abstract: Ever since dentistry has dealt with tooth decay, it has been searching for a medicament which, when placed in direct contact with exposed pulp, would result in a reparative dentin bridge and pulp healing. Tissue engineering has been presently defined as the relatively new, highly promising field of reconstructive biology.developments in the field of tissue engineering have made the generation of artificial substitutes in several areas of medicine.this leads to the development of platelet concentrate as bioactive surgical additives that are applied locally to promote wound healing stems from the use of fibrin adhesive. PRF is a matrix of autologous fibrin, in which are embedded a large quantity of platelet and leukocyte cytokines during centrifugation.the case report emphasis the innovative technique of regeneration using platelet- rich fibrin. Key words: Platelet-Rich Fibrin (PRF),Pulpotomy,Mineral Trioxide Aggregate I INTRODUCTION Since 1990, medical science has recognized several components in blood, which are a part of the natural healing process; when added to wounded tissues or surgical sites, they have the potential to accelerate healing. Platelet-rich fibrin (PRF) described by Choukroun et al.[1]is a secondgeneration platelet concentrate which allows one to obtain fibrin membranes enriched with platelets and growth factors, after starting from an anticoagulant-free blood harvest without any artificial biochemical modification. The PRF clot forms a strong natural fibrin matrix,which concentrates almost all the platelets and growth factors of the blood harvest[2,3]and shows a complex architecture as a healing matrix, including mechanical properties no other platelet concentrate offers. PRF can be considered as a natural fibrin-based biomaterial favorable to the development of a microvascularization and able to guide cell migration into wound area. Its chief advantages include ease of preparation and lack of biochemical handling of blood, which makes this preparation strictly autologous. II.CASE REPORT A 21-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with pain in the lower right posterior region. 37

2 ii.i. CLINICAL AND RADIOGRAPHIC EXAMINATION On clinical examination, occlusal caries was seen on the right mandibular first molar.(fig.no.1 ) An intra-oral periapical radiograph revealed deep occlusal caries invading the pulp with slight periapical rarefaction. (Fig.no.2 ) ii.ii. DIAGNOSIS The diagnosis of pulpitis was determined on the basis of clinical assessment, including history of spontaneous pain and intense,lingering pain to cold stimulus. III. PROCEDURE After obtaining written consent from the patient, PRF was prepared by drawing the required amount of blood into a 10-mL test tube without an anticoagulant and centrifuged immediately using a table top centrifuge. The resultant product consisted of the following three layers (Fig.no.3 ) Caries excavation done with pin point pulp exposure. Pulpotomy was performed with a round bur in a high-speed handpiece with copious irrigation; coronal pulp tissue was removed to the level of pulp chamber floor. Haemostasis was achieved by irrigating the cavity with sterile saline and cotton pellets. The blood clot-free pulpal wound was covered with a small piece of PRF. (Fig.no.4) An approximately 2 mm thick layer of MTA was placed over the PRF and a final restoration of glass ionomer cement was placed. (Fig.no.5,6) The patient had no pain or discomfort at 1and 6 months recall, and radiographic examination revealed normal periodontal ligament space and trabecular bone pattern approaching normal.(fig.no.7,8) III.DISCUSSION Pulpotomy is a vital pulp therapy in which a portion of coronal pulp tissue is remove surgically, and the remaining radicular tissue is covered with a suitable material that protects the pulp from further injury and permits and promotes healing (Bakland 2002). Platelet-Rich Fibrin (PRF) was first described by Choukroun et al., (2001).It has been referred to as a second-generation platelet concentratewhich has been shown to have several advantages over traditionally prepared platelet-rich plasma. PRF eliminates theredundant process of adding anticoagulant as well as theneed to neutralize it. The addition of bovine-derivedthrombin to promote conversion of fibrinogen to fibrinin PRP is also eliminated. The elimination of these stepsconsiderably reduces biochemical handling of blood as wellas risks associated with the use of bovine-derived thrombin. The conversion of fibrinogen into fibrin takes place slowlywith small quantities of physiologically available thrombinpresent in the blood sample itself. Thus, a physiologicarchitecture that is very favorable to the healing process isobtained due to this slow polymerization process. Directly over the PRF clot the MTA was packed and condensed to obtain a tight coronal seal as it is hydrophilic and needs moisture to set, which is a favorable property when there is potential for moisture contamination in the clinical setting, and also MTA by itself provides signaling molecules for the growth of the stem cells [4]. Historically, vital pulp therapy was first considered by performing pulp amputationat the root orifices and placing calcium hydroxide. The aim was to form dentin over thesurface of the cut wound and wall off the pulp from the cavity. It was reported in an initialstudy of vital pulp therapy that 71% of

3 cases showed no radiographic changes atcheckup [5].Today, vital pulp therapy is still considered a successful treatment option[6]. Calcium hydroxide has been considered the standard of care because of beneficialproperties such as induction of mineralization, high ph, and low cytotoxicity [7 9].However, some of the limitations reported include dissolution over time,mechanically weak, and presence of tunnels in the dentin barrier [10 12]. In addition, the handling properties are less than ideal [13]. MTA is a bioactive silicate cement that hasbeen shown to be an effective pulp-cappingmaterial in canine models and in nonhuman primates.[14-16]. The material is successful because ofits small particle size, sealing ability, alkaline phwhen set and slow release of calcium ions.[17]. Investigatorshave reported that MTA induces pulpalcell proliferation[18,19] cytokine release,[20] hardtissue formation and the synthesis of an interfacewith dentin that resembles hydroxyapatite incomposition.the material is nonabsorbable, setsin the presence of moisture, has a relatively highcompressive strength and has a sustained high alkaline ph.[21]. IV.CONCLUSION The slow polymerizing potential of PRF and the fibrin technology accounts for a favourable physiologic structure to support healing. Growth factors can help in providing a blue print for tissue regeneration within tooth, thus creating new opportunities for biological approaches to dental tissue repair

4 REFERENCES [1].Choukroun J, Adda F, Schoeffer C, Vervelle A. PRF: an opportunity in perio-implantology. Implantodontie 2000;42:55-62 [in French]. [2]. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part II: platelet related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:E [3]. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part III: leucocyte activation: a new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101: E51-5. [4]. Torabinejad M, Parirokh M. Mineral trioxide aggregate: A comprehensive literature review--part II: Leakage and biocompatibility investigations. J Endod. 2010;36: [5]. 1. Zander HA. Reaction of the pulp to calcium hydroxide. J Dent Res 1939;18: [6]. Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariouslyexposed pulp: a systematic review. J Endod 2011;37: [7]. Kitasako Y, Shibata S, Pereira PN, Tagami J. Short-termdentin bridging ofmechanicallyexposedpulps capped with adhesive resin systems. Oper Dent 2000;25: [8]. Pereira JC, Segala AD, Costa CAS. Human pulpal response to direct pulp capping with an adhesive system. Am J Dent 2000;13:

5 [9]. Shuurs AH, Gruythuysen RJ, Wesselink PR. Pulp capping with adhesives resin-basedcomposite vs calcium hydroxide: a review. Dent Traumatol 2000;16: [10]. Cox CF, Suzuki S. Re-evaluating pulp protection: calcium hydroxide liners vs cohesivehybridization. J Am Dent Assoc 1994;125: [11]. Cox CF, Subay RK, Ostro E, Suzuki SH. Tunnel defects in dentin bridges: their formationfollowing direct pulp capping. Oper Dent 1996;21:4 11. [12]. Kitasako Y, Murray PE, Tagami J, Smith AJ. Histomorphometric analysis of dentinebridge formation and pulpal inflammation. Quintessence Int 2002;33: [13]. Nair PNR, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural andquantitative investigations on the response of healthy human pulps to experimentalcapping with mineral trioxide aggregate: a randomized controlled trial. Int Endod J2008;41: [14]. Camilleri J, Pitt Ford TR. Mineral trioxide aggregate: a review of the constituents and biological properties of the material. Int Endod J 2006;39(10): [15]. Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate as a pulp-capping material. JADA 1996;127(10): [16]. Junn DJ. Quantitative assessment of dentin bridge formation following pulp-capping with mineral trioxide aggregate (master s thesis). Loma Linda, Calif.: Loma Linda University; [17]. Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physiochemical basis of the biologic properties of mineral trioxide aggregate. J Endod 2005;31(2): [18]. Moghaddame-Jafari S, Mantellini MG, Botero TM, McDonald NJ, Nör JE. Effect of ProRoot MTA on pulp cell apoptosis and proliferation in vitro. J Endod 2005;31(5): [19]. Takita T, Hayashi M, Takeichi O, et al. Effect of mineral trioxide aggregate on proliferation of cultured human dental pulp cells. Int Endod J 2006;39(5): [20]. Koh ET, Pitt Ford TR, Torabinejad M, McDonald F. Mineral trioxide aggregate stimulates a biological response in human osteoblasts. J Biomed Mater Res 1997;37(3): [21].. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root-end filling material. J. Endod 1995;21(7): Date of submission: 19 January 2014, Date of provisional acceptance: 12 Feb 2013 Date of Final acceptance: 22 March 2014 Date of Publication: 08 April 2014 Source of support: Nil; Conflict of interest: Nil 39 41

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