|Year : 2016 | Volume
| Issue : 2 | Page : 106-109
Autologous platelet concentrate as a potential regenerative biomaterial in the treatment of endo-perio lesion
Pratibha Shashikumar, Swet Nisha
Department of Periodontology and Oral Implantology, JSS Dental College and Hospital, JSS University, Mysore, Karnataka, India
|Date of Web Publication||19-Dec-2016|
Department of Periodontology, Room No. 9, JSS Dental College and Hospital, S.S. Nagar, Bannimantap, Mysore - 570 015, Karnataka
Source of Support: None, Conflict of Interest: None
Endo-perio lesions are common clinical finding in the day-to-day dentistry. The treatment approach with respect to periodontal regeneration still remains point at issue. Endodontic treatment not always leads to complete healing of periapical and periodontal tissue. In literature, surgical periodontal intervention along with the use of bone grafts, guided tissue regeneration has been attempted for regeneration. Recently, use of platelet concentrates such as platelet-rich fibrin (PRF) releasing growth factors is extensively used in dentistry for periodontal regeneration. This case report aims at evaluating the efficacy of PRF as regenerative biomaterial in the treatment of Endo-perio lesion.
Keywords: Endo-perio lesions, growth factors, periodontal regeneration, platelet-rich fibrin
|How to cite this article:|
Shashikumar P, Nisha S. Autologous platelet concentrate as a potential regenerative biomaterial in the treatment of endo-perio lesion. Indian J Oral Health Res 2016;2:106-9
|How to cite this URL:|
Shashikumar P, Nisha S. Autologous platelet concentrate as a potential regenerative biomaterial in the treatment of endo-perio lesion. Indian J Oral Health Res [serial online] 2016 [cited 2020 Jul 14];2:106-9. Available from: http://www.ijohr.org/text.asp?2016/2/2/106/196148
| Introduction|| |
Dental pulp and the periodontium are related in health as well as in disease process. Although both are ectomesenchymal in origin, the pulp originates from the dental papilla and the periodontal ligament from the dental follicle. As the tooth matures, a communication between the pulp and periodontium exists via dentinal tubules, lateral and accessory canals, and apical foramen. In disease state, it can communicate through deep periodontal pockets, developmental grooves, and dentinal tubules. This connections can serve as portal of communication in disease state.
The physiological state transforms into pathology in case any infectious source invades the pulpal or periodontal territory. As with any inflammatory process, the host immune - infectious agent interaction begins and inflammation sets in. The pulpal chamber is closed, and therefore, the spread of infection occurs only through the portal of communications and continues beyond the pulp into the periodontium and results in endo-perio lesions.
Etiologic factors, such as microorganisms, and other contributing factors, such as trauma, root resorption, perforation, and dental malformations, play an important role in the development and progression of endodontic-periodontal lesions.
| Case report|| |
A 52-year-old female reported to the Department of Periodontology and Oral Implantology with a chief complaint of recurrent pain and pus discharge in lower front tooth. The pain was moderate in nature, localized, and aggravated on chewing food. The patient was systemically healthy with no relevant medical history. The patient presented with the previous history of trauma to the tooth 18 years back following which patient had noticed mobility of tooth.
On clinical examination, periodontal abscess with sinus track opening with respect to mandibular left central incisors was noted [Figure 1]. No extraoral swelling was seen. Generalized debris and calculus were present. Pocket depth of 8 mm was seen on distolabial aspect of tooth, and Grade II mobility was noted. The tooth was tender on palpation and percussion, and draining sinus was present on the labial aspect of the tooth.
|Figure 1: Preoperative labial view showing sinus tract in relation to 31|
Click here to view
On evaluation of the intraoral periapical radiograph of the mandibular left central incisor, both crestal and periapical bone loss were evident [Figure 2]. Electric pulp testing elicited a negative response. Therefore, considering the dental history, clinical tests and radiographs, the diagnosis of this case was "true combined endo-perio lesion." 
|Figure 2: Intraoral periapical radiograph showing crestal and periapical bone loss|
Click here to view
The initial phase of treatment comprised drainage of abscess. Scaling and root planning were completed, and the tooth was splinted with fiber mesh reinforced composite. Root canal therapy was done, and the patient was followed up for 3 months. At the end of 3 months, satisfactory obturation was noted, but periodontal pocket depth of 8 mm still persisted, and periodontal surgery was planned.
The surgical area was anesthetized using lignocaine with adrenaline 1:200,000. A mucoperiosteal flap was raised in relation to 31, 32, 33, 41, and 42. After reflection, open flap debridement was done at the defect area. Dehiscence extending up to apical third of the root was noted with periapical defect on labial and lingual aspect of 31 [Figure 3]. The defect area was covered with platelet-rich fibrin (PRF) coagulam.
Platelet-rich fibrin preparation
PRF was produced by taking 10 ml of patient's whole blood drawn intravenously. The tube was centrifuged immediately at 3000 revolutions per minute for 10 min. After centrifugation, the PRF coagulam was removed from the tube using sterile tweezers, separated from the red blood cell base using scissors, and placed in the defect area [Figure 4].
The primary soft tissue closure of the flap was done with nonresorbable black silk (3-0) suture using continuous sling suture. Periodontal dressing was given.
The patient was instructed rinsing with 0.12% chlorhexidine mouthwash twice daily and proper oral hygiene maintenance. Medication prescribed were, capsule amoxicillin -500 mg thrice daily for 5 days, and tablet aceclofenac 100 mg, paracetamol 650 mg twice daily for 3 days. The sutures were removed 10 days after surgery, and the patient was advised to brush at the surgical site using a postsurgical brush for 2 weeks. The patient was put on regular recall at 1, 3, 6 and 9, 12 months. After 3 months of periodontal flap surgery, the temporary splint was removed, and mobility was assessed. The mobility was reduced to Grade I. After 12 months; the probing depth was found to be reduced by 4 mm, and the sinus tract had healed completely [Figure 5]. The postoperative radiograph showed a substantial bone fill in the crestal and periapical area [Figure 6].
|Figure 5: Postoperative labial view 12 months follow-up after periodontal surgical therapy|
Click here to view
|Figure 6: Intraoral periapical radiograph showing substantial bone fill in periapical and crestal area|
Click here to view
| Discussion|| |
A definite interrelation exists between the presence of periodontal lesions and the pulpal tissue status. The pulpal periodontal syndrome as described by Seltzer et al.  still continues to be controversial issue in relation to its definition, classification, etiology, or sequence of treatment planning. The main goal of endodontic or periodontal therapy is the eradication of infectious source from the root canal and periodontium, respectively. The role of an endodontic infection as a local modifying risk factor of periodontal disease has been studied in retrospective clinical studies on periodontitis-prone patients. Single-rooted teeth with an endodontic infection evident as a periapical radiolucency are significantly correlated to deeper periodontal pockets. 
Healing phase depends not only on the removal of infective agents but also host immune response. Addition of regenerative material such as PRF may enhance the healing phase and act as a scaffold to hold the blood clot in initial stages and later in bone formation.
When a tooth is having combined endo-perio lesion, the initial phase of treatment would be periodontal Phase I therapy - scaling and root planning, to reduce the microbial load. Endodontic therapy should precede any further periodontal treatment. When the toxic material from the root canal is removed, reattachment of the soft tissue after periodontal surgery is improved.  If the pulpal content is removed before periodontal surgery, the problem of sensitivity sometimes observed after periodontal treatment can be avoided.  The same treatment protocol was followed in this case with additional regenerative approach; that is use of PRF.
Various materials have been developed as an aid in regenerative therapy still autologous origin remains the gold standard. There is reduced risk of cross-contamination; it is cost-effective, and success rate is high when autologous material is used as regenerative material as compared to others alloplastic, synthetic materials. In quest of autologous materials, Choukren et al. developed PRF in 2000 at France.
PRF belongs to a new generation of platelet concentrates, containing all constituents of a blood sample favorable to healing and immunity. The slow polymerization mode confers to the PRF membrane a particularly favorable physiologic architecture to support the healing process. 
It is of high interest to note that the PRF matrix enmeshes glycosaminoglycans (heparin, hyaluronic acid) from blood and platelets which helps in cell migration in healing process. Platelet cytokines play a fundamental role in initial healing mechanisms owing to their capacity to stimulate cell migration and proliferation and induce fibrin matrix remodeling as well as secretion of cicatricial collagen matrix.  These properties of PRF make it a novel biomaterial for periodontal regenerative therapy.
Several studies have combined the regenerative potential of PRF and different bone grafts in the treatment of endo-perio lesions. A case report by Yu-Chao et al. on clinical application of platelet-rich fibrin as the sole grafting material in periodontal intrabony defects showed to be an effective modality of regenerative treatment for periodontal intrabony defects.  In the present case report, only PRF without any bone graft was used, and substantial bone fill was seen after 12 months.
The successful outcome of surgical periodontal therapy aims at regeneration of lost periodontal tissues. Alloplastic materials act as osteoconductive material and in developing countries like India cost is a major issue while providing treatment to the patients in day today basis. Use of PRF eliminates the cost issue and provides affordable treatment and is an autologous biomaterial having favorable regenerative potential. Hence, it can be successfully used in the treatment of periodontal defects associated with endo-perio lesions.
| Conclusion|| |
Sequential planning is critical to successful treatment of endo-perio lesions PRF can be considered as cost-effective, promising regenerative biomaterial in the treatment of endo-perio lesions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rotstein I, Simon JH. Diagnosis, prognosis and decision-making in the treatment of combined periodontal-endodontic lesions. Periodontol 2000 2004;34:165-203.
Seltzer S, Bender IB, Ziontz M. The interrelationship of pulp and periodontal disease. Oral Surg Oral Med Oral Pathol 1963;16:1474-90.
Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Relationship between periapical and periodontal status. A clinical retrospective study. J Clin Periodontol 1993;20:117-23.
Perlmutter S, Tagger M, Tagger E, Abram M. Effect of the endodontic status of the tooth on experimental periodontal reattachment in baboons: A preliminary investigation. Oral Surg Oral Med Oral Pathol 1987;63:232-6.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al.
Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e37-44.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, 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:e45-50.
Yu-Chao C, Kuo-Chin W, Jiing-Huei Z. Clinical application of platelet-rich fibrin as the sole grafting material in periodontal intrabony defects. J Dent Sci 2011;6:181-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]