Injectable platelet-rich fibrin with demineralized freeze-dried bone allograft compared to demineralized freeze-dried bone allograft in intrabony defects of patients with stage-III periodontitis: a randomized controlled clinical trial

Mashaal Mohammed Alshoiby, Karim Mohamed Fawzy El-Sayed, Weam Elbattawy, Manal Mohamed Hosny, Mashaal Mohammed Alshoiby, Karim Mohamed Fawzy El-Sayed, Weam Elbattawy, Manal Mohamed Hosny

Abstract

Aim: The current randomized controlled clinical trial assessed the effect of injectable platelet-rich fibrin (I-PRF) combined with demineralized freeze-dried bone allograft (DFDBA) compared to DFDBA alone in the management of intrabony defects of stage-III periodontitis patients.

Methodology: Following sample size calculation, twenty stage-III periodontitis patients with ≥ 5 mm clinical attachment level (CAL)-loss and ≥ 3 mm intrabony defects were randomized into test (I-PRF + DFDBA; n = 10) and control (DFDBA; n = 10) groups. CAL (primary outcome), periodontal probing depth (PPD), gingival recession depth (GRD), full-mouth plaque scores (FMPS), full-mouth bleeding scores (FMBS), radiographic linear defect depth (RLDD), and bone fill (secondary outcomes) were examined at baseline, 3, 6, and 9 months post-surgically.

Results: I-PRF + DFDBA and DFDBA independently demonstrated significant intragroup CAL-gain, PPD-, and RLDD-reduction at 3, 6, and 9 months (p < 0.05), with no significant intergroup differences observed (p > 0.05). CAL-gain (mean ± SD) of 2.40 ± 0.70 mm and 2.50 ± 0.85 mm and PPD-reduction of 3.50 ± 1.18 mm and 2.80 ± 0.42 mm were demonstrated for I-PRF + DFDBA and DFDBA at 9 months respectively. Both groups showed significant intragroup RLDD improvement, with a RLDD of 3.58 ± 0.66 mm and 3.89 ± 1.57 mm for I-PRF + DFDBA and DFDBA at 9 months respectively. Stepwise linear regression analysis revealed that baseline RLDD and bone fill at 9 months were significant predictors of CAL (p < 0.05).

Conclusion: Within the present study's limitations, DFDBA with or without I-PRF resulted in significant improvement in clinical and radiographic periodontal parameters in the surgical treatment of periodontal intrabony defects of stage-III periodontitis patients. Addition of I-PRF to DFDBA does not appear to significantly enhance the DFDBA's reparative/regenerative outcomes.

Clinical relevance: Within the current study's limitations, routinely adding I-PRF to DFDBA cannot be recommended to significantly improve DFDBA's treatment outcomes in intrabony defects.

Keywords: Allograft; Intrabony; Periodontal; Periodontitis; Platelet rich-fibrin; Regeneration.

Conflict of interest statement

The authors declare no competing interests.

© 2023. The Author(s).

Figures

Fig. 1
Fig. 1
Flow diagram of patient recruitment and inclusion
Fig. 2
Fig. 2
Intrabony defect radiographic measurements. a Reference point identification: cemento-enamel junction (CEJ), alveolar crest (AC), and defect base (DB). b Reference line identification (in red): vertical line corresponding to long axis and horizontal perpendicular line passing through AC and identifying radiographic linear defect depth (RLDD) in blue. c Radiographic angle connecting CEJ, DB, and AC
Fig. 3
Fig. 3
Clinical steps in representative cases of the control (a–d) and test (e–j) groups. Control group using DFDBA alone and test group using I-PRF/DFDBA. Control group: a 7 mm probing pocket depth using a prefabricated stent at baseline, b intrabony defect with vertical component of 4 mm at the mesial site of lower left first molar, c application of DFDBA in the defect, and d 3 mm proping pocket depth 9 months post-operatively. Test group: e 6 mm probing pocket depth at the mesial site of lower left first molar, f intrabony defect with vertical component of mm, g injectable-PRF, h combination of I-PRF with DFDBA, i application of combined I-PRF/DFDBA in the defect, and j 2 mm proping pocket depth 9 months post-operatively

References

    1. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: framework and proposal of a new classification and case definition. J Periodontol. 2018;89(Suppl 1):S159–s172. doi: 10.1002/jper.18-0006.
    1. Nibali L, Sultan D, Arena C, Pelekos G, Lin GH, Tonetti M. Periodontal infrabony defects: systematic review of healing by defect morphology following regenerative surgery. J Clin Periodontol. 2021;48(1):100–113. doi: 10.1111/jcpe.13381.
    1. Liang Y, Luan X, Liu X. Recent advances in periodontal regeneration: a biomaterial perspective. Bioact Mater. 2020;5(2):297–308. doi: 10.1016/j.bioactmat.2020.02.012.
    1. Zhou S, Sun C, Huang S, Wu X, Zhao Y, Pan C, Wang H, Liu J, Li Q, Kou Y. Efficacy of adjunctive bioactive materials in the treatment of periodontal intrabony defects: a systematic review and meta-analysis. Biomed Res Int. 2018;2018:8670832. doi: 10.1155/2018/8670832.
    1. Choukroun J, Ghanaati S. Reduction of relative centrifugation force within injectable platelet-rich-fibrin (PRF) concentrates advances patients’ own inflammatory cells, platelets and growth factors: the first introduction to the low speed centrifugation concept. Eur J Trauma Emerg Surg. 2018;44(1):87–95. doi: 10.1007/s00068-017-0767-9.
    1. Miron RJ, Chai J, Zheng S, Feng M, Sculean A, Zhang Y. A novel method for evaluating and quantifying cell types in platelet rich fibrin and an introduction to horizontal centrifugation. J Biomed Mater Res A. 2019;107(10):2257–2271. doi: 10.1002/jbm.a.36734.
    1. Wend S, Kubesch A, Orlowska A, Al-Maawi S, Zender N, Dias A, Miron RJ, Sader R, Booms P, Kirkpatrick CJ, Choukroun J, Ghanaati S. Reduction of the relative centrifugal force influences cell number and growth factor release within injectable PRF-based matrices. J Mater Sci Mater Med. 2017;28(12):188. doi: 10.1007/s10856-017-5992-6.
    1. Fujioka-Kobayashi M, Kono M, Katagiri H, Schaller B, Zhang Y, Sculean A, Miron RJ. Histological comparison of platelet rich fibrin clots prepared by fixed-angle versus horizontal centrifugation. Platelets. 2021;32(3):413–419. doi: 10.1080/09537104.2020.1754382.
    1. Zhao R, Yang R, Cooper PR, Khurshid Z, Shavandi A, Ratnayake J. Bone grafts and substitutes in dentistry: a review of current trends and developments. Molecules. 2021;26(10):3007. doi: 10.3390/molecules26103007.
    1. Kyyak S, Blatt S, Pabst A, Thiem D, Al-Nawas B, Kämmerer PW. Combination of an allogenic and a xenogenic bone substitute material with injectable platelet-rich fibrin - a comparative in vitro study. J Biomater Appl. 2020;35(1):83–96. doi: 10.1177/0885328220914407.
    1. Sohn D-S, Huang B, Kim J, Park WE, Park CC. Utilization of autologous concentrated growth factors (CGF) enriched bone graft matrix (sticky bone) and CGF-enriched fibrin membrane in implant dentistry. J Implant Adv Clin Dent. 2015;7(10):11–18.
    1. Dsa E, Chatterjee A, Shetty DN, Pradeep A. Clinical evaluation and comparison of platelet-rich fibrin and injectable platelet-rich fibrin (sticky bone) in the treatment of intrabony defects. Niger J Exp Clin Biosci. 2020;8(2):78. doi: 10.4103/njecp.njecp_24_20.
    1. Ding ZY, Tan Y, Peng Q, Zuo J, Li N. Novel applications of platelet concentrates in tissue regeneration (Review) Exp Ther Med. 2021;21(3):226. doi: 10.3892/etm.2021.9657.
    1. Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: decision-making algorithms for clinical practice and education. J Clin Periodontol. 2019;46(4):398–405. doi: 10.1111/jcpe.13104.
    1. Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Beglundh T, Sculean A, Tonetti MS. Treatment of stage I-III periodontitis-the EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47(Suppl 22):4–60. doi: 10.1111/jcpe.13290.
    1. Ellis P. The impact of smoking on wound healing: the role of the nurse. Br J Nurs. 2018;27(6):S10–s14. doi: 10.12968/bjon.2018.27.6.S10.
    1. Naji A, Edman K, Holmlund A. Influence of smoking on periodontal healing one year after active treatment. J Clin Periodontol. 2020;47(3):343–350. doi: 10.1111/jcpe.13228.
    1. Patel S, Srivastava S, Singh MR, Singh D. Mechanistic insight into diabetic wounds: pathogenesis, molecular targets and treatment strategies to pace wound healing. Biomed Pharmacother. 2019;112:108615. doi: 10.1016/j.biopha.2019.108615.
    1. Kshirsagar JT, Balamurugan A. Role of sex hormones in periodontium during pregnancy: a review. IJADS. 2018;4(4):168–173.
    1. Pilloni A, Rojas MA, Marini L, Russo P, Shirakata Y, Sculean A, Iacono R. Healing of intrabony defects following regenerative surgery by means of single-flap approach in conjunction with either hyaluronic acid or an enamel matrix derivative: a 24-month randomized controlled clinical trial. Clin Oral Investig. 2021;25(8):5095–5107. doi: 10.1007/s00784-021-03822-x.
    1. Agarwal A, Gupta ND, Jain A. Platelet rich fibrin combined with decalcified freeze-dried bone allograft for the treatment of human intrabony periodontal defects: a randomized split mouth clinical trail. Acta Odontol Scand. 2016;74(1):36–43. doi: 10.3109/00016357.2015.1035672.
    1. O'Leary TJ. The impact of research on scaling and root planing. J Periodontol. 1986;57(2):69–75. doi: 10.1902/jop.1986.57.2.69.
    1. Tonetti MS, Pini-Prato G, Cortellini P. Periodontal regeneration of human intrabony defects. IV. Determinants of healing response. J Periodontol. 1993;64(10):934–940. doi: 10.1902/jop.1993.64.10.934.
    1. Ramfjord SP. The periodontal disease index (PDI) J Periodontol. 1967;38:602. doi: 10.1902/jop.1967.38.6_part2.602.
    1. Francetti L, Del Fabbro M, Basso M, Testori T, Weinstein R. Enamel matrix proteins in the treatment of intra-bony defects. A prospective 24-month clinical trial. J Clin Periodontol. 2004;31(1):52–59. doi: 10.1111/j.0303-6979.2004.00437.x.
    1. AydemirTurkal H, Demirer S, Dolgun A, Keceli HG. Evaluation of the adjunctive effect of platelet-rich fibrin to enamel matrix derivative in the treatment of intrabony defects. Six-month results of a randomized, split-mouth, controlled clinical study. J Clin Periodontol. 2016;43(11):955–964. doi: 10.1111/jcpe.12598.
    1. Elbehwashy MT, Hosny MM, Elfana A, Nawar A, Fawzy El-Sayed K. Clinical and radiographic effects of ascorbic acid-augmented platelet-rich fibrin versus platelet-rich fibrin alone in intra-osseous defects of stage-III periodontitis patients: a randomized controlled clinical trial. Clin Oral Investig. 2021;25(11):6309–6319. doi: 10.1007/s00784-021-03929-1.
    1. Abdulrahman YA, Hosny MM, Elfana A, Fawzy El-Sayed KM. Clinical and radiographic evaluation of low-speed platelet-rich fibrin (PRF) for the treatment of intra-osseous defects of stage-III periodontitis patients: a randomized controlled clinical trial. Clin Oral Investig. 2022 doi: 10.1007/s00784-022-04627-2.
    1. Graziani F, Karapetsa D, Mardas N, Leow N, Donos N. Surgical treatment of the residual periodontal pocket. Periodontol 2000. 2018;76(1):150–163. doi: 10.1111/prd.12156.
    1. Cortellini P, Tonetti MS. Clinical performance of a regenerative strategy for intrabony defects: scientific evidence and clinical experience. J Periodontol. 2005;76(3):341–350. doi: 10.1902/jop.2005.76.3.341.
    1. Miron RJ, Fujioka-Kobayashi M, Hernandez M, Kandalam U, Zhang Y, Ghanaati S, Choukroun J. Injectable platelet rich fibrin (i-PRF): opportunities in regenerative dentistry? Clin Oral Investig. 2017;21(8):2619–2627. doi: 10.1007/s00784-017-2063-9.
    1. Fujioka-Kobayashi M, Katagiri H, Kono M, Schaller B, Zhang Y, Sculean A, Miron RJ. Improved growth factor delivery and cellular activity using concentrated platelet-rich fibrin (C-PRF) when compared with traditional injectable (i-PRF) protocols. Clin Oral Investig. 2020;24(12):4373–4383. doi: 10.1007/s00784-020-03303-7.
    1. Wang X, Zhang Y, Choukroun J, Ghanaati S, Miron RJ. Effects of an injectable platelet-rich fibrin on osteoblast behavior and bone tissue formation in comparison to platelet-rich plasma. Platelets. 2018;29(1):48–55. doi: 10.1080/09537104.2017.1293807.
    1. Aimetti M, Ferrarotti F, Mariani GM, Romano F. A novel flapless approach versus minimally invasive surgery in periodontal regeneration with enamel matrix derivative proteins: a 24-month randomized controlled clinical trial. Clin Oral Investig. 2017;21(1):327–337. doi: 10.1007/s00784-016-1795-2.
    1. Ferrarotti F, Romano F, Gamba MN, Quirico A, Giraudi M, Audagna M, Aimetti M. Human intrabony defect regeneration with micrografts containing dental pulp stem cells: a randomized controlled clinical trial. J Clin Periodontol. 2018;45(7):841–850. doi: 10.1111/jcpe.12931.
    1. Aslan S, Buduneli N, Cortellini P. Clinical outcomes of the entire papilla preservation technique with and without biomaterials in the treatment of isolated intrabony defects: a randomized controlled clinical trial. J Clin Periodontol. 2020;47(4):470–478. doi: 10.1111/jcpe.13255.
    1. Sculean A, Nikolidakis D, Nikou G, Ivanovic A, Chapple IL, Stavropoulos A. Biomaterials for promoting periodontal regeneration in human intrabony defects: a systematic review. Periodontol 2000. 2015;68(1):182–216. doi: 10.1111/prd.12086.
    1. Castro AB, Meschi N, Temmerman A, Pinto N, Lambrechts P, Teughels W, Quirynen M. Regenerative potential of leucocyte- and platelet-rich fibrin. Part A: intra-bony defects, furcation defects and periodontal plastic surgery. A systematic review and meta-analysis. J Clin Periodontol. 2017;44(1):67–82. doi: 10.1111/jcpe.12643.
    1. Miron RJ, Moraschini V, Fujioka-Kobayashi M, Zhang Y, Kawase T, Cosgarea R, Jepsen S, Bishara M, Canullo L, Shirakata Y, Gruber R, Ferenc D, Calasans-Maia MD, Wang HL, Sculean A. Use of platelet-rich fibrin for the treatment of periodontal intrabony defects: a systematic review and meta-analysis. Clin Oral Investig. 2021;25(5):2461–2478. doi: 10.1007/s00784-021-03825-8.
    1. Chen L, Ding Y, Cheng G, Meng S. Use of platelet-rich fibrin in the treatment of periodontal intrabony defects: a systematic review and meta-analysis. Biomed Res Int. 2021;2021:6669168. doi: 10.1155/2021/6669168.
    1. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, Gogly B. 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(3):e45–50. doi: 10.1016/j.tripleo.2005.07.009.
    1. Dohan Ehrenfest DM, Del Corso M, Inchingolo F, Sammartino G, Charrier JB. Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) in human cell cultures: growth factor release and contradictory results. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110(4):418–421. doi: 10.1016/j.tripleo.2010.05.059.
    1. El Bagdadi K, Kubesch A, Yu X, Al-Maawi S, Orlowska A, Dias A, Booms P, Dohle E, Sader R, Kirkpatrick CJ, Choukroun J, Ghanaati S. Reduction of relative centrifugal forces increases growth factor release within solid platelet-rich-fibrin (PRF)-based matrices: a proof of concept of LSCC (low speed centrifugation concept) Eur J Trauma Emerg Surg. 2019;45(3):467–479. doi: 10.1007/s00068-017-0785-7.
    1. Agrawal D, Jaiswal P. Injectable platelet rich fibrin (i-PRF): a gem in dentistry. Int J Curr Res Rev. 2020;12:25–30. doi: 10.31782/IJCRR.2020.122116.
    1. Mourão CF, Valiense H, Melo ER, Mourão NB, Maia MD. Obtention of injectable platelets rich-fibrin (i-PRF) and its polymerization with bone graft: technical note. Rev Col Bras Cir. 2015;42(6):421–423. doi: 10.1590/0100-69912015006013.
    1. Khosropanah H, Shahidi S, Basri A, Houshyar M. Treatment of Intrabony defects by DFDBA alone or in combination with PRP: a split-mouth randomized clinical and three-dimensional radiographic trial. J Dent (Tehran) 2015;12(10):764–773.
    1. Bansal C, Bharti V. Evaluation of efficacy of autologous platelet-rich fibrin with demineralized-freeze dried bone allograft in the treatment of periodontal intrabony defects. J Indian Soc Periodontol. 2013;17(3):361–366. doi: 10.4103/0972-124x.115663.
    1. Sezgin Y, Uraz A, Taner IL, Çulhaoğlu R. Effects of platelet-rich fibrin on healing of intra-bony defects treated with anorganic bovine bone mineral. Braz Oral Res. 2017;31:e15. doi: 10.1590/1807-3107BOR-2017.vol31.0015.
    1. Naqvi A, Gopalakrishnan D, Bhasin MT, Sharma N, Haider K, Martande S. Comparative evaluation of bioactive glass putty and platelet rich fibrin in the treatment of human periodontal intrabony defects: a randomized control trial. J Clin Diagn Res. 2017;11(7):Zc09–zc13. doi: 10.7860/jcdr/2017/23831.10149.
    1. Bodhare GH, Kolte AP, Kolte RA, Shirke PY. Clinical and radiographic evaluation and comparison of bioactive bone alloplast morsels when used alone and in combination with platelet-rich fibrin in the treatment of periodontal intrabony defects-a randomized controlled trial. J Periodontol. 2019;90(6):584–594. doi: 10.1002/jper.18-0416.
    1. Sharma A, Pradeep AR. Treatment of 3-wall intrabony defects in patients with chronic periodontitis with autologous platelet-rich fibrin: a randomized controlled clinical trial. J Periodontol. 2011;82(12):1705–1712. doi: 10.1902/jop.2011.110075.
    1. Del Corso M, Sammartino G, Dohan Ehrenfest DM. Re: “Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: a 6-month study”. J Periodontol. 2009;80(11):1694–1697. doi: 10.1902/jop.2009.090253.
    1. Kobayashi E, Flückiger L, Fujioka-Kobayashi M, Sawada K, Sculean A, Schaller B, Miron RJ. Comparative release of growth factors from PRP, PRF, and advanced-PRF. Clin Oral Investig. 2016;20(9):2353–2360. doi: 10.1007/s00784-016-1719-1.
    1. Gadkari N, Bawane S, Chopra R, Bhate K, Waknis P, Kakodkar P, Kulkarni D, Kale P. Demineralized freeze-dried bone allograft vs biphasic calcium phosphate: a comparison of two graft materials in sinus augmentation procedures - a pilot study. Adv Oral Maxillofac Surg. 2021;4:100177. doi: 10.1016/j.adoms.2021.100177.
    1. Vaid T, Kumar S, Mehta R, Shah S, Joshi S, Bhakkand S, Hirani T. Clinical and radiographic evaluation of demineralized freeze-dried bone allograft with concentrated growth factor versus concentrated growth factor alone in the treatment of intrabony defects. Med Pharm Rep. 2021;94(2):220–228. doi: 10.15386/mpr-1718.
    1. Zhou S, Mizuno S, Glowacki J. Wnt pathway regulation by demineralized bone is approximated by both BMP-2 and TGF-β1 signaling. J Orthop Res. 2013;31(4):554–560. doi: 10.1002/jor.22244.
    1. Nibali L, Koidou VP, Nieri M, Barbato L, Pagliaro U, Cairo F. Regenerative surgery versus access flap for the treatment of intra-bony periodontal defects: a systematic review and meta-analysis. J Clin Periodontol. 2020;47(Suppl 22):320–351. doi: 10.1111/jcpe.13237.
    1. Cortellini P, Tonetti MS. Clinical concepts for regenerative therapy in intrabony defects. Periodontol 2000. 2015;68(1):282–307. doi: 10.1111/prd.12048.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe