JICDRO is a UGC approved journal (Journal no. 63927)

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REVIEW ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 10-16

Adjunctive use of autologous platelet concentrates in surgical management of periodontal osseous defects: A literature review


Department of Periodontics, Mahatma Gandhi Missions Dental College and Hospital, Navi Mumbai, Maharashtra, India

Date of Submission18-Jun-2020
Date of Decision12-Oct-2020
Date of Acceptance14-Jan-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. Shrushti Mahendra Sukalkar
Mahatma Gandhi Missions Dental College and Hospital, Plot No. 1, Sector 1, Kamothe, Navi Mumbai - 410 209, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_38_20

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   Abstract 


The autologous platelet concentrates (APC) comprise of platelet rich plasma (PRP) and platelet rich fibrin (PRF). These platelet concentrates provide a rich source of growth factors and have been used alone or in combination with bone grafts (BG) during open flap debridement (OFD) to treat various periodontal osseous defects. This literature review was performed to assess the effect of adjunctive use of autologous platelet concentrates (APC) in the surgical management of periodontal osseous defects. Literature search was performed through the databases of national library of medicine and EBSCO host using PubMed and Google scholar search engines and manual searches in which 36 randomized clinical trials (RCT) meeting inclusion criteria that evaluated the healing outcomes of Probing depth (PD) reduction, gain in clinical attachment level (CAL) , radiographic bone fill and defect fill in intervention of OFD+APC / OFD+BG +APC as compared to OFD/ OFD+BG in the treatment of periodontal osseous defects published between 2001 to 2019 were assessed. Upon assessment of literature the adjunctive use of APCs appears to have an additive effect to open flap debridement alone or along with bone grafts in surgical management of periodontal osseous defects.

Keywords: Autologous platelet concentrates, furcation defects, infrabony defects, intrabony defects, platelet-rich fibrin, platelet-rich plasma


How to cite this article:
Sukalkar SM, Kini V. Adjunctive use of autologous platelet concentrates in surgical management of periodontal osseous defects: A literature review. J Int Clin Dent Res Organ 2021;13:10-6

How to cite this URL:
Sukalkar SM, Kini V. Adjunctive use of autologous platelet concentrates in surgical management of periodontal osseous defects: A literature review. J Int Clin Dent Res Organ [serial online] 2021 [cited 2021 Sep 24];13:10-6. Available from: https://www.jicdro.org/text.asp?2021/13/1/10/319523




   Introduction Top


Periodontal osseous defects result from host inflammatory response mediated adaptive remodeling of alveolar bone in response to dental plaque. Periodontal osseous defects comprise of horizontal bone loss, infrabony, and interradicular osseous defects. Infrabony defects are further comprised of one walled, two walled, three walled defects, and osseous craters; whereas interradicular osseous defects include furcation defects.[1] The surgical correction of osseous defects includes surgical treatment modalities of additive osseous surgeries including graft associated or nongraft associated regenerative techniques. Recently autologous platelet concentrates (APCs) have been used as an adjunct to open flap debridement (OFD) alone and along with graft associated regenerative techniques to enhance healing outcomes such as reduction in pocket depth (PD), gain in clinical attachment levels (CALs), radiographic bone fill and defect fill. The APCs used as adjunct to reconstructive periodontal osseous surgeries include platelet rich fibrin (PRF) used as natural guided tissue regenerative (GTR) barrier membrane biomatrix and/or as a bio-scaffold when used as PRF plugs having osteoconductive potential. APCs in the form of PRF and platelet rich plasma (PRP) also serve as a source for growth factors such as platelet derived growth factor (PDGF) I and II with osteoinductive potential. David M. Dohan Ehrenfest et al.[2] has classified platelet concentrates into leukocyte poor or pure PRP (P-PRP), leukocyte and P-PRP, leukocyte poor or pure PRF (P-PRF), and leukocyte and pure PRF. PRP is a first generation platelet concentrate[2] generated when whole blood is centrifuged with an anticoagulant producing a platelet gel which releases growth factor PDGF I and II which have osteoinductive properties thereby having potential to initiate in situ osseous regeneration.[3],[4] Second generation of platelet concentrates is generated when whole blood is centrifuged without anticoagulants yielding PRF which comprises of a fibrin matrix scaffold with enmeshed platelets which release PDGF I and II.[5] The fibrin mesh of PRF has the potential to serve as a natural barrier membrane and has been used in guided tissue regeneration (GTR) procedures as a biomatrix with GTR membrane properties with additional benefit of having embedded platelets that release PDGF I and II.

This current literature review was performed with the aim to assess the influence of APCs upon the healing outcomes following the adjunctive use of APCs in the form of bio-scaffolds/GTR barrier membranes/source for growth factors with OFD alone and along with bone grafts (OFD + APC/OFD + BG + APC) as compared to OFD alone or along with bone grafts (OFD/OFD + BG) in the treatment of periodontal osseous defects resulting from plaque-induced periodontitis.


   Search Strategy Top


The research question for this literature review was to assess whether there was any difference observed in the healing outcomes of reduction in PD, gain in clinical attachment, defect fill and radiographic bone fill following the adjunctive use of APCs with OFD alone or along with bone grafting (BG) (OFD + APC/OFD + BG + APC) as compared to OFD alone and along with bone grafting (BG) (OFD/OFD + BG) in treatment of periodontal osseous defects.

The pertinent literature search was performed using search engines such as PubMed and Google scholar exploring the databases of national library of medicine and EBSCO host. Manual searches were also performed of the journals specific to dentistry accessible in institutional library to identify scientific papers published between 2001 and 2019 relevant to the research question. The search strategy included the use of controlled terms (MeSH) and keywords and their combinations thereof in free to access full text articles in the English language. The MeSH terms used for search strategy included “Periodontal osseous defects,” ”Intrabony defects,” ”Infrabony defects,” ”Furcation defects,” ”Open flap debridement,” ”Platelet concentrates,” ”Platelet rich fibrin,” ”Platelet rich plasma,” ”Platelet plug,” ”PRF membrane,” ”Pocket depth,” ”Clinical attachment level,” ”Bone fill,” ”Defect fill,” ”Sounding depth,” ”Bone grafts” and ”Bone substitute.”

This review included articles in which participants were systemically healthy and where APCs have been used as adjunct to OFD alone or along with bone grafting (BG) (OFD + APC/OFD + BG + APC) as compared to OFD alone and along with bone grafting (BG) (OFD/OFD + BG) in treatment of periodontal osseous defects with a minimum follow-up period of 6 months in patients having infrabony and furcation osseous defects resulting from a chronic periodontitis experience. Randomized controlled trials, controlled clinical trials, clinical trials, parallel arm studies and split mouth studies were included in this literature review. Literature in foreign language and in form in vitro studies, case reports, animal model studies, case series, unpublished articles, and abstracts were excluded.

A total of 74 articles were shortlisted from the mentioned electronic databases and manually searched literature. Following scrutiny of shortlisted literature, 38 articles were excluded based on relevance of title or abstract to research question (10), duplicate articles (11), articles not meeting inclusion criteria (13), and articles in foreign languages (4) resulting in 40 articles being deemed eligible for this literature review.

Objectives

Comparative evaluation of the healing outcomes of reduction in PD, gain in CALs, defect fill and radiographic bone fill upon adjunctive use of APCs to OFD alone or along with bone grafts (OFD + APC/OFD + BG + APC) compared to OFD alone or along with bone grafts (OFD/OFD + BG) in the treatment of periodontal osseous defects resulting from plaque-induced periodontitis.


   Discussion Top


Osteoinductive potential of platelet-rich plasma and platelet-rich fibrin

The influence of adjunctive use of PRP in gel form in clinical studies with OFD alone or in combination with bone grafts led to the following observations from which derivative inferences were made:

Raouf Hanna et al. in 2004[6] and AR Pradeep in 2009[7] demonstrated significant (P < 0.05) results in PD reduction, gain in CAL, defect fill in treatment of 26 and 28 intrabony defects, respectively, when treated with PRP and bovine derived xenograft and PRP and bovine derived xenograft/peptide 15 as compared to of xenograft alone or a combination of xenograft and peptide 15.

However, Dori in 2009[8] demonstrated comparable results with regards to PD reductions and CAL gains when PRP was used along with anorganic bovine bone mineral (PRP + ABBM) as compared to anorganic bovine mineral alone (ABBM) in the treatment of 30 intrabony defects.

Matteo Piemontese et al. in 2008[9] found that OFD with a combination of PRP and demineralized freeze-dried allograft (DFDBA) demonstrated greater gain in CAL, reduction in PD (P < 0.001) compared OFD + DFDBA alone in the treatment 60 intrabony defect.

Bharadwaj et al. in 2011[10] demonstrated greater (P < 0.05) reduction in PD, gain in CAL and greater defect fill with OFD with PRP along with alloplast (OFD + PRP + hydroxyapatite and beta tricalcium phosphate) as compared to OFD with alloplast in the treatment 20 intrabony defects.

Pradeep et al. in 2012[11] demonstrated grater reduction in PD, gain in CAL and bone fill (P < 0.05) in treatment of 90 intrabony when treated with OFD and PRP as compared to OFD alone.

Agarwal et al. in 2015[12] compared the effect of OFD + PRP to OFD + PRP + DFDBA and OFD alone in the treatment of 30 intrabony defects over 12 months' follow-up and found significant (P < 0.05) greater reduction in PD, gain in CAL and greater defect fill at sites treated with OFD + PRP and OFD + PRP + DFDBA as compared to OFD alone.

However, Demir et al. 2007[13] demonstrated no statistically significant difference (P > 0.05) in regards to reduction in PD, gain in CAL, defect fill in treatment of 29 intrabony defects between OFD + PRP + bioactive glass as compared to OFD + bioactive glass. Similarly, Markou et al. in 2009[14] concluded that no significant (P > 0.05) difference was observed for reduction in PD, gain in CAL, defect fill when OFD + PRP + DFDBA was compared to OFD + PRP in treating 24 intrabony defects.

Ozdemir et al. in 2012[15] compared OFD + PRP + beta tricalcium phosphate and OFD + beta tricalcium phosphate in treatment of 29 intrabony defect and found no significant (P > 0.001) reduction with PD, gain in CAL or defect fill.

Shukla et al. in 2016[16] evaluated OFD with PRP along with calcium phosphosilicate putty (CPS) to OFD and CPS putty alone in the treatment of 20 intrabony defects and demonstrated comparable results with respect to reduction in PD and gain in CAL for both groups.

Jalaluddin et al.[17] in 2017 evaluated the role of adjunctive use PRP gel to OFD as compared to OFD alone in the treatment of 20 intrabony defects over a period of 6 months' follow-up and concluded that there was no statistically significant difference (P > 0.05) in PD reduction or gain in CAL between both groups.

Pradeep et al. in 2009,[18] Bajaj et al. in 2013[19] evaluated the adjunctive use of PRP gel to OFD compared to OFD alone and demonstrated statistically significant (P > 0.05) results in regards to vertical and horizontal defect fill, gain in CAL and reduction in PD on 40 and 72 furcation defects, respectively.

Patel et al. in 2017[20] evaluated the effect of PRF coagulum combination with OFD as compared to OFD alone in the treatment of 26 intrabony defects and concluded that OFD with PRF group showed significant (P < 0.05) reduction in PD, gain in CAL and percentage bone fill following radiography over OFD alone.

Agarwal et al. in 2017[21] studied the effect of OFD with PRF along with calcium phosphosilicate putty (OFD + PRF + CPS putty) as compared to (OFD + CPS putty) in the treatment of 45 intrabony defect and demonstrated greater reduction in PD, gain in CAL, defect fill, and defect resolution (P < 0.05) in the OFD + PRF gel + CPS-putty group compared to the OFD + CPS putty group.

Saravanan D, Rethinam S, Muthu K, Thangapandian A et al.[22] in 2019 evaluated PRF + bioactive glass compared to OFD + bioactive glass in the treatment of 30 intrabony defects and demonstrated greater reduction in probing depth and gain in CALs (P < 0.001) in PRF + bioactive glass group compared to when bioactive glass was used alone.

Ghonima JK, El Rashidy ME, Kotry GS, Abdelrahman HH et al.[23] in 2020 evaluated advanced PRF + BCP compared to BCP (biphasic calcium phosphate) in 22 intrabony defects. PRF + BCP group demonstrated greater reduction in probing PD and gain in CAL s (P < 0.05) compared to BCP (biphasic calcium phosphate) alone.

Atchuta A, Gooty JR, Guntakandla VR, Palakuru SK, Durvasula S, Palaparthy R et al.[24] 2020 evaluated PRF + DFDBA compared to DFDBA alone in 39 intrabony defects and demonstrated that there was marked reduction in probing depth and gain in CAL s in PRF + DFDBA group compared to DFDBA alone.

Based on these studies it may be permissible to derive that APC, i.e., PRP/PRF when used as a gel in the treatment of periodontal osseous defects has shown beneficial effect on the treatment outcomes of reduction in PD, Gain in clinical attachment and defect fill. These observed clinically benefits could be attributed to the growth factors (PDGF I and II) present within the APCs (PRP and PRF( and possible osteoconductive bioscaffold effect of the fibrin plug of the PRF.

Guided tissue regenerative barrier membrane/biomatrix potential of platelet-rich fibrin

PRF can be compressed to form a fibrin mesh membrane having a lattice framework with enmeshed platelets which has been used a biodegradable natural growth factor releasing GTR barrier membrane alone or as combination therapy with bone grafts in the treatment of periodontal osseous defects.

Sharma et al. in 2011[25] and Siddiqui et al. in 2016[26] in study on 36 and 45 furcation defects respectively evaluated the effect of OFD with PRF membrane to OFD alone and demonstrated statistically significant results (P < 0.05) in regards to vertical and horizontal defect fill, gain in CAL and reduction in PD in the group where PRF membrane was used.

Throat et al. in 2011[27] in 32 intrabony defects, Sharma et al. in 2011[28] in 56 intrabony defects, Pradeep et al. in 2012[9] in 90 intrabony defects, Ajwani et al. in 2015[29] in 40 intrabony defects evaluated the effects of OFD with PRF membrane compared to OFD alone and demonstrated significant results (P < 0.05) in regards to gain in CAL, reduction in PD, bone fill and defect fill in group treated with (OFD + PRF membrane).

Galav et al. in 2016[30] evaluated the effects of OFD with PRF membrane (OFD + PRF) compared to OFD with autogenous bone graft (OFD + ABG) on 20 intrabony defects and demonstrated comparable results (P < 0.05) in regards to gain in CAL and reduction in PD. However, OFD + ABG has shown greater amount of bone fill (P < 0.05) compared to (OFD + PRF).

Agarwal et al. in 2015[31] evaluated OFD and PRF membrane along with DFDBA compared to OFD and DFDBA and observed statistically significantly (P < 0.05) greater changes in reduction in PD, gain in CAL, defect resolution, bone fill for OFD + PRF + DFDBA group compared to OFD + DFDBA in treatment of 60 intrabony defects.

Elgendy et al. in 2015[32] evaluated the role of PRF membrane with hydroxyapatite (PRF + HA) compared to (OFD + HA) alone. PRF + HA demonstrated significant (P < 0.05) reduction in PD, gain in CAL, defect fill, bone fill when used in treatment of 40 intrabony defects.

Pradeep et al. in 2017[33] evaluated the role of PRF membrane with hydroxyapatite (PRF + HA) compared to (OFD) alone. PRF + HA demonstrated significant (P < 0.05) reduction in PD, gain in CAL, defect fill, bone fill when used in treatment of 90 intrabony defects.

Naqvi et al. in 2017[34] and Bodhare et al. in 2019[35] evaluated the effect PRF membrane along with bioactive glass compared to OFD with bioactive glass alone in treatment of 20 and 40 intrabony defects, respectively. In both studies, PRF membrane with bioactive glass demonstrated statistically significant (P < 0.001) reduction in PD, gain in CAL and bone fill compared to bioactive glass alone.

Lohi et al. in 2017[36] evaluated the effect of PRF membrane along with bioactive composite ceramic granules (OFD + PRF + BCCG) compared to OFD and bioactive composite ceramic granules (OFD + BCCG) on 20 furcation defects and demonstrated significant (P < 0.05) greater reduction in PD, gain in vertical and horizontal CAL, defect depth). In (OFD + PRF + BCCG) group, conversion in the number of class II furcation defects to class I furcation defects was observed.

From these studies, it may be permissible to derive that when PRF was used as a barrier membrane there were beneficial effects observed in reduction of PD, Gain in CAL and defect fill in the treatment of periodontal osseous defects. This is in support of the fibrin mesh lattice of PRF has potential as a barrier membrane in terms of cellular occlusion. PRF membranes are used in combination therapy with bone grafts have also demonstrated similar observations in reduction of PD, Gain in CAL and defect fill in the treatment of periodontal osseous defects thereby supporting the use of PRF membranes in graft confinement and cellular occlusion effect of the PRF membranes.

Osteoconductive potential of platelet-rich fibrin

The PRF when used as a plug has a fibrin meshwork which can also serve as a biodegradable scaffold with possible osteoconductive properties and has been used as a bone replacement graft. Following studies made observations with this particular use of PRF:

Joseph et al. in 2012[37] compared OFD with PRF plugs compared to OFD alone in the treatment of 30 infrabony defects and concluded that OFD + PRF plugs resulted in a significant decrease in PD, gain in clinical attachment and radiographic bone fill (P < 0.001) compared to OFD alone.

Shah et al. in 2014,[38] Chadwick et al. in 2016[39] evaluated the effect of (OFD + PRF) plugs compared (OFD + DFDBA) and demonstrated comparable results between (OFD + PRF) when compared (OFD + DFDBA) in terms of reduction in PD and gain in CAL in 40 and 36 intrabony defects, respectively.

Raghav et al. in 2016[40] compared the treatment modalities OFD + PRF plugs to OFD + bioactive glass and demonstrated comparable results with respect to reduction in pocket depth, gain in CAL, radiographic defect fill and defect resolution between both the groups in the treatment of 90 intrabony defects.

Mathur et al. in 2015[41] evaluated OFD with PRF plugs compared to OFD with autogenous bone graft (OFD + ABG) and demonstrated comparable results in pocket reduction, clinical attachment gain, defect fill, defect resolution in both groups in the treatment of 38 intrabony defects. However, radiographic assessment revealed significant (P < 0.05) greater defect fill in sites treated with OFD and APCs (OFD + PRF) compared to OFD + ABG.

Biswas et al. in 2016[42] evaluated OFD + PRF plugs compared to OFD + bioactive glass and demonstrated comparable results for gain in CAL, reduction in horizontal and vertical probing depth in both groups in the treatment of 20 furcation defects.

Chatterjee A, Pradeep AR, Garg V, Yajamanya S, Ali MM, Priya VS et al. in 2017[43] evaluated OFD + PRF plugs compared to OFD + T-PRF plugs or OFD alone and demonstrated marked improvement in pocket reduction, defect depth reduction, and CAL gains in both OFD + PRF and OFD + T-PRF groups compared to OFD alone.

From these studies, it may be permissible to derive that when PRF plugs were used as bone replacement grafts with OFD and compared to OFD with bone grafts, both groups demonstrated similar reduction in PD, gain in CAL, defect fill, and percentage bone fill. This supports the osteoconductive potential of PRF plugs as a bio-scaffold demonstrating comparable results to when particulate bone replacement grafts in the treatment of periodontal osseous defects.


   Discussion Top


The aim and objective of this literature review was to comparatively evaluate the healing outcomes following the adjunctive use of APCs of PRP and PRF when used as adjunct to OFD alone or along with bone grafts as compared to OFD alone or along with bone grafts in the treatment of periodontal osseous defect resulting from plaque induced periodontitis.

The limitations of this literature review were that none of the included studies had quantitatively or qualitatively assessed the growth factors within APCs in the respective studies. The role of PRF as a barrier membrane was not supported with histologic investigation or evaluation on time necessary for biodegradation to determine whether time span would be sufficient for healing in nongraft associated regenerative technique of GTR. The ability of PRF membrane to maintain space and form in terms of tensile strength was not assessed in the included studies. Similarly, the biodegradation time to assess whether PRF plugs would adequately serve as an osteoconductive scaffold was not demonstrated with histologic investigations. Most of the included studies did not include osseous craters, one wall infrabony defects and class III furcation involvements. Furthermore, defect fill with regards to tissue type was not supported by histologic investigations in any of the included literature. Limited access to databases providing access to free full text articles owing to budgetary constraints were another limitation for this literature review.

The platelets and the leukocytes present in the PRF/PRP release various cytokine releasing growth factors transforming growth factor (TGF-β1), vascular endothelial growth factor, PDGFs, insulin-like growth factors (IGFs), and bone morphogenetic protein-1.[44] TGF-β1, PDGFs, and IGFs are found to enhance the proliferation and differentiation of osteoblast and initiate in situ osseous regeneration.[45] In vitro study done by Li et al. in 2013[46] suggest that PRF significantly improved periodontal progenitor cell proliferation and migration also that the effects of PRF were tissue-specific, and they favored alveolar bone osteoblasts. However, these assessments were beyond the scope of the literature included in this review.

From this literature review, it was derived that the fibrin mesh lattice of PRF has potential as a barrier membrane in terms of cellular occlusion and demonstrated graft confinement and cellular occlusion effect of GTR membranes in combination therapy with bone replacement grafts in surgical management of periodontal osseous defects.[47],[48],[49]

PRF plugs demonstrated osteoconductive potential as a bio-scaffold demonstrating comparable results to particulate bone replacement grafts when used with OFD in the treatment of periodontal osseous defects.


   Conclusion Top


Within the limitations of this literature review, it was derived that when APCs were used as adjunct to OFD/OFD + BG in the treatment of periodontal osseous defects it had an additive effect on the treatment outcomes as compared to OFD/OFD + BG. This was attributed to the possible osteoinductive effect of PDGF I and II when used as a PRP gel/PRF plug or mesh. The ability of PRF to be used as a GTR barrier membrane biomatrix and as an osteoconductive bioscaffold plug has been supported in the literature included in this review.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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