♦ What is periodontitis ?

Periodontitis is the irreversible loss of attachment to the connective tissue supporting the alveolar bone. It is an inflammatory desease characterized by the distruction of alveolar bone, root cement, periodontal ligament as a response to elicited by microbial accumulance on tooth surface. (1)

♦ Periodontal desease

Periodontitis is the main cause of tooth losing .The aim of periodontal therapy , is to eliminate the inflammatory process, to stop the progression of periodontal desease and to regenerate the lost periodontal tissues. (2)                                                                                                                                    Earlier attemps to archive regeneration , included denator of the interdental bone to treat intrabony defect and the use of autografts to fill the surgical site. Good results have been taken in treatment of periodontitis using a combination of graft material and collagen membrane (3).

But recently , the focus is in the use of ‘growth factors’.The periodontal wound healing , needs the colaburation of epithelial cells , gingival fibroblasts , periodontal ligament cells and osteoblasts.                                                             There is evidence that the presence of growth factors , cytokinins in platelets , play an important role in the wound healing.Platelets also secrete fibrin , fibronectin and vitronectin which are a matrix for the connective tissue .These leads to the use of platelets in periodontal desease (4)

♦ Role of platelets in periodontal wound healing

Platelets play a key role in wound healing and hence wound healing after periodontal treatment can be accelerated by the use of platelet concentrates.The wound healing process initiated by the formation of blood clot and after tissues injury in periodontal surgery ,causes adherence and aggregation of platelets favoring the formation of thrombin andfibrin.In addision ,there is release of certan substances from platelets that promote tissue repair ,angiogenesis ,inflammation and immune response (5).   Platelets also contain biologicially active proteins and the binding of these secreted proteins within a developing fibrin mesh or to the extracellular matrix can create chemotactic gradients, favoring the recruitment of the stem cells ,stimulating cell migration ,differentiation,and promoting repair.


♦ PRP (Platelet Rich Plasma )
Prp was the first use alone or in combination with grafting materials or membrane in periodontal desease , but the latest generation,prf is the most effective and the latest procedure .(6)

♦ PRF (Platelet Rich Fibrin)
Prf is an autologous growth factor reserve which accumulate platelets and cytokinins in a physiologic fibrin clot. It was developed in France in 2001 by the Choukrown et al .It consists of 97 % of platels and a > 50% of leukocytes in a specific 3 dimensional distributor.
Prf constist of intimate assembly of cytokinins , glycanic chains and a structural glycoproteis enmeshed within a slowly polimerised fibin network.It has shown successfully results in a periodontal intrabony defects. (7)

Picture Source – botiss.com

♦ The preparation of PRF
Platelet rich fibrin (PRF) preparation protocol was developed by Choukrown et al . Just prior to surgery , approximately 5 mm of intavenose blood was drown from the cubital fossa of the patient and collected in 10 ml sterile glass tube without anticoagulant and immediately centrifuged at 3000 rpm for 10 minutes .

Blood centrifugation results in a separation of blood into a structured fibrin clot in the middle of the tube , just between the red corpuleses at the bottom and a acellular plasma at the top(Platels poor plasma).

After removal of PPP,PRF can be easely separated from the red corpuscles base using tweezers and scissors.
The mechanism consists in that ,fibrinogen which is in the hights part of the tube ,combines with the circulation thrombin due to centrifugation to form fibrin.The fibrin clot is then obtained in the middle of the tube .Platels are trapped in the fibrin meshes. (8)

The literature contains animal and human studies at the experimental use of PRF. PRF is considered as a healing biomaterial commonly used in implant and plastic periodontal surgery for bone regeneration and soft tissue wound healing.It can develop the healing by this mechanism.

According to Chong et al ,PRF promotes the expression of phosphorylat extracellular signal-regulated protein kinase and stimulates the production of osteogenics differentiation of the human dental cell.

Prf releases growth factors during 3 days culture. Sharm et al conducted randomized controlled clinical trial, for the treatment of three-wall intrabony defects in chronic periodontitis.Patients with platels rich fibrin, reported significant improvement in pocket depth reduction and bone fill in test group.

◊ The various advantages of PRF include (Dohan et al) {9,10,11,12}

1.Completely autogenous
2.Extended growth factor release for 7 days
3.Simple and fast technique
4.Non expensive
5.No requirement of any additive constituent such as bovine thrombin
6.No biochemical handling involved
7.No associated immune reactions
8.No associated infections
9.Acts as an ‘immune regulation node’
10.Has anti-inflammatory effects

◊ The vast benefits of PRF has led to its applications in different fields of medicine and dentistry:

1.Ear ,nose,throat and plastic surgery{13]
2.Oral and maxilla-facial surgery{14}
3.Pre-implant and implant surgery{15}

♦ Drownbacks of PRF
The main shortcoming of PRF is its preparation and storage .The clinical benefit of PRF depends on time interval between speed of handling between blood collection and centrifugation as PRF is prepared without any addition anticoagulants .

Another main disadvantages of PRF is its storage after preparation as it will shrink resulting in dehydration alerting the structural integrity of PRF.

Dehydration also results in the decreased growth factor content in PRF 17 and leukocyte viability will be adversely affected altering its biologic properties.

PRF when stored in refrigerator can result in risk of bacterial contamination of the membranes.

These limitations with te use of PRF can be circumvented by sticking on to a standart protocol for preparation and preservation.

♦ Conclusion

Platelet-rich firbrin has studies through clinical and histological studies.

The role it has in enhancing periodontal regeneration, is being elucidaded .

However the mechanism of PRF in mediating the inflammatory and healing processes are yet to be studied on cell based models .

Also the effect of regeneration and its stability has not been researched through long term studies.

1. Gotlow J., Nyman S., Karring T. New attachment formation in human periodontium by guided tissue regeneration. J. Clin. Periodontol. 1984;11:494–503. doi: 10.1111/j.1600-051X.1984.tb00901.x. [PubMed][Cross Ref]
2. Reynolds M.A., Aichelmann-Reidy M.E., Branch-Mays G.L., Gunsolley J.C. The efficacy of bone replacement grafts in the treatment of periodontal osseous defects. A systematic review. Ann. Periodontol. 2003;8(1):227–265. doi: 10.1902/annals.2003.8.1.227. [PubMed] [Cross Ref]
3. Chen F.M., Shelton R.M., Jin Y., Chapple I.L. Localized delivery of growth factors for periodontal tissue regeneration: role, strategies, and perspectives. Med. Res. Rev. 2009;29(3):472–513. doi: 10.1002/med.20144. [PubMed] [Cross Ref]
4. Anitua E., Andia I., Ardanza B., Nurden P., Nurden A.T. Autologous platelets as a source of proteins for healing and
tissue regeneration. Thromb. Haemost. 2004;91(1):4–15. [PubMed]
5. Del Fabbro M., Bortolin M., Taschieri S., Weinstein R. Is platelet concentrate advantageous for the surgical treatment of periodontal diseases? A systematic review and meta-analysis. J. Periodontol. 2011;82(8):1100–1111. doi: 10.1902/jop.2010.100605. [PubMed] [Cross Ref]
6. Marx R.E., Carlson E.R., Eichstaedt R.M., Schimmele S.R., Strauss J.E., Georgeff K.R. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 1998;85(6):638–646. doi: 10.1016/S1079-2104(98)90029-4. [PubMed] [Cross Ref]
7.  Sunitha Raja V., Munirathnam Naidu E. Platelet-rich fibrin: evolution of a second-generation platelet concentrate. Indian J. Dent. Res. 2008;19(1):42–46. doi: 10.4103/0970-9290.38931. [PubMed] [Cross Ref]
8. H. Greenwell Commitee on research, science and therapy, American Academy of Periodontology. Position paper: guidelines for periodontal therapyJ Periodontol, 72 (2001), pp. 1624-1628
9. Dohan D.M., Choukroun J., Diss A., Dohan S.L., Dohan A.J., 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 b;101(3):e45–e50. doi: 10.1016/j.tripleo.2005.07.009.[PubMed] [Cross Ref]
10. Dohan D.M., Choukroun J., Diss A., Dohan S.L., Dohan A.J., 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 b;101(3):e45–e50. doi: 10.1016/j.tripleo.2005.07.009.[PubMed] [Cross Ref]
11. Dohan D.M., Choukroun J., Diss A., Dohan S.L., Dohan A.J., Mouhyi J., Gogly B. 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 c;101(3):e51–e55. doi: 10.1016/j.tripleo.2005.07.010. [PubMed] [Cross Ref]
12. Dohan D.M., Choukroun J., Diss A., Dohan S.L., Dohan A.J., Mouhyi J., Gogly B. 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 a;101(3):e37–e44. doi: 10.1016/j.tripleo.2005.07.008.[PubMed] [Cross Ref]
13. Sclafani A.P. Applications of platelet-rich fibrin matrix in facial plastic surgery. Facial Plast. Surg. 2009;25(4):270–276. doi: 10.1055/s-0029-1242033. [PubMed] [Cross Ref]
14. 21. Choukroun J., Diss A., Simonpieri A., Girard M.O., Schoeffler C., Dohan S.L., Dohan A.J., Mouhyi J., Dohan D.M. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2006;101(3):e56–e60. doi: 10.1016/j.tripleo.2005.07.011. [PubMed] [Cross Ref]
15. Mazor Z., Horowitz R.A., Del Corso M., Prasad H.S., Rohrer M.D., Dohan E.D.M. Sinus floor augmentation with simultaneous implant placement using Choukroun’s platelet-rich fibrin as the sole grafting material: a radiologic and histologic study at 6 months. J. Periodontol. 2009;80(12):2056–2064. doi: 10.1902/jop.2009.090252. [PubMed] [Cross Ref]
16. Su C.Y., Kuo Y.P., Tseng Y.H., Su C.H., Burnouf T. In vitro release of growth factors

20 June 2017
Author Dr.Xhensila Halitaj  for http://www.universaldentists.com

Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)






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