Sample Page: Augmentation- biologics and growth factors

Study Questions:

• What are biologic mediators? Which have been studied in reference to periodontal regeneration?
• What type of material is enamel matrix derivative (EMD)? Is it a graft? How is it made?
• What are the specific growth factors that it utilizes and what is the theory behind its use?
• What does Emdogain® (EMD) do at a cellular level? What are the indications for its use? What are the contraindications?
• Can EMD be used for intrabony defects?
• Is root surface treatment protocol necessary to use this material?
• How do EMD results compare to open flap debridement? How does it handle?
• How long does EMD remain on tooth surface after application?
• How does EMD heal? Are there any controversies concerning its healing?
• Are there any differences in healing of animal or human studies, or between diseased root surface vs created defects?
• Have all of these results analyzed intrabony defects?
• What is the histologic evidence for regeneration with EMD?
• How does this compare to open flap debridement? How does this compare to EMD alone?
• What results can be expected when EMD is utilized in non – surgical periodontal therapy?
  Describe what other materials have been used with EMD and what the results are.
• How does EMD compare to a more traditional GTR?
• Is EMD a justifiable expense to a patient?
• How effective is EMD when used in furcations?
• What other biologic modifiers have been studied in infrabony defects?
• What are the advantages when using biologic modifiers? What are the drawbacks?
• Define PRP, PRF, and PRGF and describe the difference in preparation.
• What is PDGF? What are the results?

References:

Biologic Mediators

1. Kao RT, Murakami S, Beirne OR. The use of biologic mediators and tissue engineering in dentistry. Periodontol 2000. 2009;50:127-53.

Reviews of enamel matrix derivative (EMD). 

1. Lyngstadaas SP, Wohlfahrt JCBrookes SJ, et al. Enamel matrix proteins; old molecules for new applications.Orthod Craniofac Res. 2009 Aug;12(3):243-53.
2. Miron RJ, Sculean A, Cochran DL, Froum S, Zucchelli G. Twenty years of enamel matrix derivative: the past, the present and the future. J Clin Periodontol. 2016 Aug; 43(8):668-83.
3. Bosshardt DD. Biological mediators and periodontal regeneration: a review of enamel matrix proteins at the cellular and molecular levels. J Clin Periodontol. 2008 Sep; 35(8 Suppl):87-105.
4. Miron RJ Dard M, Weinreb M. Enamel matrix derivative, inflammation and soft tissue wound healing. J Periodontal Res. 2015 Oct; 50(5):555-69.

Root preparation and handling of EMD

1. HeijlL, Heden G, Svardstrom G, Ostgren A. Enamel matrix derivative (EMDOGAIN®) in the treatment of intrabony periodontal defects. J Clin Perio 24:705-714, 1997.
2. Sculean A, Reich E, et al. Treatment of intrabony periodontal defects with an enamel matrix protein derivative (Emdogain): A report of 32 cases. Int J Perio Rest Dent19:157-163, 1999.
3. GiannobileWV, Somerman MJ: Growth and amelogen-like factors in periodontal wound healing. A systematic review. Ann Periodontol 2003; 8: 193-203
4. Parodi R, Santarelli GAE, Gasparetto B: Treatment of intrabony pockets with Emdogain: Results at 36 months. Int J Periodontics Restor Dent 2004; 24:57-63
5. FrancettiL, et al; Enamel matrix proteins in the treatment of intra-bony defects. J Clin Periodontol 2004; 31: 52-59

Duration of EMD on tooth surface after application.

1. Sculean A, Windisch P, Keglevic h T, Fabi B, Lundgren E, Lyngstadaas PS. Presence of an enamel matrix protein derivative on human teeth following periodontal surgery. Clin Oral Investig. 2002 Sep; 6(3):183-7

EMD healing and histology.

1. Cochran DL, King GN, et al: The effect of enamel matrix proteins on periodontal regeneration as determined by histologic analyses. J Periodontol 74: 1043-1055
2. Sculean A, Chiantella GC, Windisch P, Donos N. Clinical and histologic evaluation of human intrabony defects treated with an enamel matrix protein derivative (Emdogain). Int J Perio Rest Dent20:375-381, 2000.
3. ParodiR, Liuzzo G, Patrucco P,et al. Use of Emdogain in the treatment of deep intrabony defects: 12-month clinical results. Histologic and radiographic evaluation. Int J Periodont Rest Dent 2000; 20:585-595.
4. YuknaRA, Mellonig JT. Histologic evaluation of periodontal healing in humans following regenerative therapy with enamel matrix derivative. J Periodontol 71:752-759, 2000.
5. Hammarstrom L, Heijl L, Gestrelius S. Periodontal regeneration in a buccal dehiscence model in monkeys after application of enamel matrix proteins. J Clin Periodontol24:669-677, 1997.
6. Sculean A, Donos N, Windisch P, Brecx M, Gera I, Reich E, Karring T. Healing of human intrabony defects following treatment with enamel matrix proteins or guided tissue regeneration. J Periodontal Res. 1999 Aug; 34(6):310-22.
7. McGuire, M. K. & Cochran, D. L. (2003) Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 2: histological evaluation. Journal of Periodontology 74, 1126–1135.
8. Tonetti, M. S., Fourmousis, I., Suvan, J., Cortellini, P., Bragger, U. & Lang, N. P. (2004) Healing, post-operative morbidity and patient perception of outcomes following regenerative therapy of deep intrabony defects. Journal of Clinical Periodontology 31, 1092–1098

COMPARISON STUDIES:

EMD in non – surgical periodontal therapy

1. Mombelli, A., Brochut, P., Plagnat, D., Casagni,F. & Giannopoulou, C. (2005) Enamel matrix proteins and systemic antibiotics as adjuncts to non-surgical periodontal treatment: clinical effects. Journal of Clinical Periodontology 32,225–230

How does this compare to open flap debridement? How does this compare to emdogain alone?

1. Heijl L. Periodontal regeneration with enamel matrix derivative in one human experimental defect. A case report. J Clin Periodontol 24:693-696, 1997.
2. FroumSJ, Weinberg MA, Rosenberg E, Tarnow D. A comparative study utilizing open flap debridement with and without enamel matrix derivative in the treatment of periodontal intrabony defects: A 12-month re-entry study. J Periodontol 72:25-34, 2001.
3. TonettiMS, Lang NP, Cotellini P, et al: Enamel matrix proteins in the regenerative therapy of deep intrabony defects. A multicenter randomized controlledclinical trial. J Clin Periodontol 2002; 29: 317-325
4. Rosing, C. K., Aass, A. M., Mavropoulos, A. & Gjermo, P. (2005) Clinical and radiographic effects of enamel matrix derivative in the treatment of intrabony periodontal defects: a 12-month longitudinal placebo-controlled clinical trial in adult periodontitis patients. Journal of Periodontology 76, 129–133
5. Sculean, A., Blaes, A., Arweiler, N., Reich, E., Donos, N. & Brecx, M. (2001a). The effect of postsurgical antibiotics on the healing of intra-bony defects following treatment with enamel matrix proteins. Journal of Periodontology 72, 190–195

Emdogain is often used mixed with other materials.

Combination therapies (EMD + bone grafting materials)

1. Camargo PM, Lekovic V, Weinlaender M, et al: The effectiveness of enamel matrix proteins used in combination with bovine porous bone mineral in the treatment of intrabony defects in humans. J Clin Periodontol 2001; 28: 1016-1022
2. Sculean A, et al: Clinical evaluation of an enamel matrix protein derivative (Emdogain) combined with a bovine-derived xenograft (Bio-Oss) for the treatment of intrabony defects in humans.Int J Periodont Restor Dent 2002; 22:259-267
3. Gurinsky BS, Mills MP, Mellonig JT: Clinical evaluation of demineralized freeze-dried bone allograft and enamel matrix derivative versus enamel matrix derivative alone for the treatment of periodontal osseous defects in humans. J Periodontol 2004; 75: 1309-1318
4. Esposito M, et al. Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects. A Cochrane systematic review.Eur J Oral Implantol.2009 Winter;2(4):247-66.
5. Li W, Xiao L, Hu J. The use of enamel matrix derivative alone versus in combination with bone grafts to treat patients with periodontal intrabony defects: a meta-analysis. J Am Dent Assoc. 2012 Sep;143(9):e46-56.
6. Yilmaz, S., Cakar, G., Yildirim, B. & Sculean, A.(2010) Healing of two and three wall intrabony periodontal defects following treatment with an enamel matrix derivative combined with autogenous bone. Journal of Clinical Periodontology37, 544–550
7. Ogihara, S. & Tarnow, D. P. (2014) Efficacy of enamel matrix derivative with freeze-dried bone allograft or demineralized freeze-dried bone allograft in intrabony defects: a randomized trial. Journal of Periodontology85, 1351–1360.
8. Zucchelli, G., Amore, C., Montebugnoli, L. & De Sanctis, M. (2003) Enamel matrix proteins and bovine porous bone mineral in the treatment of intrabony defects: a comparative controlled clinical trial. Journal of Periodontology 74, 1725–1735.
9. Hoffmann, T., Al-Machot, E., Meyle, J., Jervoe-Storm, P. M. & Jepsen, S. (2015) Three-year results following regenerative periodontal surgery of advanced intrabony defects with enamel matrix derivative alone or combined with a synthetic bone graft. Clinical Oral Investigations. 20, 357–364
10. Miron, R. J., Bosshardt, D. D., Buser, D., Zhang,Y., Tugulu, S., Gemperli, A., Dard, M., Caluseru, O. M., Chandad, F. & Sculean, A.(2015a) Comparison of the capacity of enamel matrix derivative gel and enamel matrix derivative in liquid formulation to adsorb to bone grafting materials. Journal of Periodontology 86, 578–587.

Systematic Review:

1. Matarasso, M., Iorio-Siciliano, V., Blasi, A.,Ramaglia, L., Salvi, G. E. & Sculean, A. (2015) Enamel matrix derivative and bone grafts for periodontal regeneration of intrabony defects. A systematic review and meta-analysis. Clinical Oral Investigations.19, 1581–1593.

EMD compared to GTR.    

1. Silvestri, M et al: Comparison of infrabony defects treated with enamel matrix derivative versus guided tissue regeneration with a nonresorbable membrane. A multicenter controlled clinical trial. J Clin Periodontol 2003; 30: 386-393
2. Pontoriero, R., Wennstrom, J. & Lindhe, J. (1999) The use of barrier membranes and enamel matrix proteins in the treatment of angular bone defects. A prospective controlled clinical study. Journal of Clinical Periodontology 26, 833–840
3. Sculean, A., Windisch, P., Chiantella, G. C., Donos, N., Brecx, M. & Reich, E. (2001b) Treatment of intrabony defects with enamel matrix proteins and guided tissue regeneration. A prospective controlled clinical study. Journal of Clinical Periodontology 28, 397–403
4. Zucchelli, G., Bernardi, F., Montebugnoli, L. &De, S. M. (2002) Enamel matrix proteins and guided tissue regeneration with titanium-rein-forced expanded polytetrafluoroethylene mem-branes in the treatment of infrabony defects: a comparative controlled clinical trial. Journal of Periodontology 73,3–12
5. Sanz, M., Tonetti, M. S., Zabalegui, I., Sicilia, A., Blanco, J., Rebelo, H., Rasperini, G., Merli, M., Cortellini, P. & Suvan, J. E.(2004) Treatment of intrabony defects with enamel matrix proteins or barrier membranes: results from a multicenter practice-based clinical trial. Journal of Periodontology75, 726–733

EMD in furcations.

1. Hoffmann, T., Richter, S., Meyle, J., Gonzales, J.R., Heinz, B., Arjomand, M., Sculean, A.,Reich, E., Jepsen, K., Jepsen, S. & Boedeker,R. H. (2006) A randomized clinical multi-center trial comparing enamel matrix derivative and membrane treatment of buccal class II furcation involvement in mandibular molars. Part III: patient factors and treatment outcome.Journal of Clinical Periodontology33, 575–583.

What biologic modifiers have been studied in infrabony defects? Are these off-label uses or following manufacturer protocol? What are the advantages to biologic modifiers? What are the drawbacks?

Autologous platelet- / blood- derived growth factors (PRP, PRF, PRGF).

1. Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotechnol. 2009 Mar;27(3):158-67.
2. 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 Jan; 44(1):67-82.
3. Tobita M, Uysal CA, Guo X, Hyakusoku H, Mizuno H. Periodontal tissue regeneration by combined implantation of adipose tissue-derived stem cells and platelet-rich plasma in a canine model. Cytotherapy. 2013 Dec;15(12):1517-26.
4. Pradeep AR, Rao NS, et al. Comparative evaluation of autologous platelet-rich fibrin and platelet-rich plasma in the treatment of 3-wall intrabony defects in chronic periodontitis: a randomized controlled clinical trial. J Periodontol. 2012 Dec;83(12):1499-507
5. Lekovic V, Milinkovic I, et al. Platelet-rich fibrin and bovine porous bone mineral vs. platelet-rich fibrin in the treatment of intrabony periodontal defects. J Periodontal Res. 2012 Aug;47(4):409-17
6. Cohran, D, et al: Evaluation of recombinant human bone morphogenic protein-2 in oral applications including the use of endosseous implants: 3-year results of a pilot study in humans. J Periodontol 71:1241-1247, 2000
7. Choi SH, Kim CK, Cho KS, et al. Effect of recombinant human bone morphogenetic protein-2/absorbable collagen sponge (rhBMP-2/ACS) on healing in 3-wall intrabony defects in dogs. J Periodontol. 2002 Jan;73(1):63-72.
8. Chiu HC, Chiang CY, Tu HP, Wikesjö UM, Susin C, Fu E. Effects of bone morphogenetic protein-6 on periodontal wound healing/regeneration in supraalveolar periodontal defects in dogs. J Clin Periodontol. 2013 Jun;40(6):624-30

Platelet derived growth factors (PDGF) (commercially known as Gem 21S).

1. Nevins M, Camelo M, Nevins ML, Schenk RK, Lynch SE Periodontal regeneration in humans using recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and allogenic bone. J Periodontol. 2003 Sep;74(9):1282-92
2. Sarment D.,et al: Effect of rhPDGF-BB on bone turnover during periodontal repair. J Clin Peridontol 2006; 33: 135-140
3. Lynch SE, Wisner-Lynch L, Nevins M, Nevins ML. A new era in periodontal and periimplant regeneration: use of growth-factor enhanced matrices incorporating rhPDGF. Compend Contin Educ Dent. 2006 Dec;27(12):672-8;
4. Ridgway, H et al: Human Histologic and clinical evaluation of recombinant human platelet derived growth factor and beta-tricalcium phosphate for the treatment of periodontal intraosseous defects. Int J Periodontics Restorative Dent; 2008; 79: 677-683
5. Mishra A, Avula H, Pathakota KR, Avula J. Efficacy of modified minimally invasive surgical technique in the treatment of human intrabony defects with or without use of rhPDGF-BB gel: a randomized controlled trial. J Clin Periodontol. 2013 Feb;40(2):172-9.
6. Camelo M, Nevins ML, Schenk RK, Lynch SE, NevinsM. Periodontal regeneration in human Class II furcations using purified recombinant human platelet-derived growth factor-BB (rhPDGF-BB) with bone allograft. Int J Periodontics Restorative Dent 2003; 23:213-225.
7. Nevins M, Giannobile WV, McGuire MK, et al. Platelet-derived growth factor stimulates bone fill and rate of attachment level gain: Results of a large multicenter randomized controlled trial .J Periodontol2005;76:2205-2215.
8. McGuire MK, Kao RT, Nevins M, Lynch SE. rhPDGF-BB promotes healing of periodontal defects: 24-month clinical and radiographic observations. Int J Periodontics Restorative Dent 2006;26:223-23
9. Nevins M, Kao RT, McGuire MK, McClain PK, Hinrichs JE, McAllister BS, Reddy MS, Nevins ML, Genco RJ, Lynch SE, Giannobile WV. Platelet-derived growth factor promotes periodontal regeneration in localized osseous defects: 36-month extension results from a randomized, controlled, double-masked clinical trial. J Periodontol. 2013 Apr; 84(4):456-64.
10. Oates, T., et al: Mitogenic effects of growth factors on human periodotnal ligament cells in vitro. J Periodontol 64:142-148, 1993.
11. Giannobile, W et al: Platelet – derived growth factor (PDGF) gene delivery for application in periodontal tissue engineering. J Periodontol 72: 815-23, 2001
12. Inukai T, Katagiri W, Yoshimi R, et al. Novel application of stem cell-derived factors for periodontal regeneration. Biochem Biophys Res Commun. 2013 Jan 11;430(2):763-8.

Abstracts:

What are biologic mediators? Which have been studied in reference to periodontal regeneration?

Kao, 2009
P: Review the use of biologic mediators and tissue engineering in dentistry
D: In wound healing, the natural process usually results in tissue scarring or repair. Using tissue engineering, the wound healing process is manipulated so that tissue regeneration occurs. This manipulation usually involves one or more of the following three key elements: Signaling molecule, Scaffold or supporting matrices, and cells
1) Signaling molecules
– Research has focused on two main approaches: semipurified preparations (EMD, autologous PRP preparations) or recombinant growth factors (rhPDGF-BB, rhFGF, rhBMP)
1.1) PRP
– Source of growth factors in bone and periodontal regeneration
– 338% more in PRP
– Growth factors: PDGF, TGF-B, IGF, FGF-2, EGF, VEGF
– Stimulation the proliferation of fibroblasts and PDL cells. Extracellular matrix formation and neovascularization. Suppression of inflammatory cytokine release and limit inflammation.
– Contains high concentration of fibrinogen
1.2) EMD
– Harvested from porcine teeth
– Mechanism of action: EMD contains a mixture of low-molecular-weight proteins that stimulate cell growth and the differentiation of mesenchymal cells, including osteoblasts
– Contains TGF-B, BMP
– Stimulates endothelial cell proliferation and chemostaxis, and stimulates vascular endothelial cell growth factor production by PDL cells. When applied to root surfaces, the proteins are absorbed into the hydroxyapatite and collagen fibers of the root surface, where they induce cementum formation followed by periodontal regeneration
1.3) PDGF
– Potent mitogenic and chemotactic factor for mesenchymal cells in cell culture
1.4) FGF-2
– Ability to promote mesenchymal cell prolifereation and maintain the multipotent properties of these cells
– Promote proliferation of PDL cells and produce a regenerative environment that would support regeneration and angiogenesis
1.5) BMP
– A group of regulatory glycoproteins that are members of the TGF-B superfamily
– Stimulates differentiation of mesenchymal stem cells into chondroblasts and osteoblasts
– At least 7 BMPs have been isolated from bovine and human sources. In the field of periodontal regeneration, much of the research interest has focused on BMP-2, BMP-3, BMP-7
2) Scaffold or supporting matrices
– Bone allografts, synthetic and natural polymers, synthetic ceramics, bovine type I collagen, and calcium sulfate
– Provide physical support for the healing area so that there is no collapse of the surrounding tissue into the wound site
– To serve as a barrier to restrict cellular migration in a selective manner (principle of GTR)
– To serve as a scaffold for cellular migration and proliferation
– To potentially serve as a time-release mechanism for signaling molecule
3) Cell therapy
– Most common application involves a cell-expansion strategy in an ex vivo environment followed by transplantation back into the defect area
– Can combine with scaffold or supporting matrices
– Problem: Explanted material required a substantial volume of donor tissue and the advantage of this approach was not evident

Application of tissue-engineering principles: Periodontal regeneration
EMD
– Has been effective in the treatment of intrabony defects
– Histologic evidence for EMD-induced periodontal regeneration
rhPDGF
– Used in conjunction with allograft
– Histologic evidence of periodontal regeneration
– 0.3 mg/ml performed better than 1.0 mg/ml
rhFGF-2
– Histologic evidence of regeneration

What type of material is enamel matrix derivative? Is it a graft? How is it made? What are the specific growth factors that it utilizes and what is the theory behind its use? What are the indications for its use? What are the contraindications?

Lyngstadaas, 2009
Background: Enamel matrix derivative (EMD) purified acid extract of proteins from pig enamel matrix (Emdogain; Straumann AG, Basel, Switzerland.)
Application: Amelogenins are dissolved in aqueous, acidic solution of PGA (propylene glycol alginate). Upon application, acidity of gel is neutralized and temp is increased which allows release of amelogenins. They can self assemble into insoluble nanospheres. Over the course of days and weeks, they are processed by matrix proteases, slowly releasing biologically active components into the local environment, promoting regeneration (possibly) by triggering a release of growth factors (TGF-B increased, as well as VEGF, PDGF, and IL-6). Can stimulate growth of mesenchymal cells, including fibroblasts, cementoblasts, osteoblasts and stem cells.
PDL: The role of enamel proteins in periodontal ligament formation is supported by their presence in initial cementum formation during normal development of tooth attachment. The amelogenins are known to self-assemble into supramolecular aggregates that form an insoluble extracellular matrix, with high affinity for HA and collagens. EMD has potential to trigger regenerative response in PDL cells.
Cementum: Amelogenin deposition precedes cementum formation, then EMD treatment probably mimics odontogenesis and works by restarting dormant developmental programs in cells for (re)generation of the tooth attachment apparatus. It has been assumed that the most important mechanism of action of EMD is to initiate periodontal regeneration through recruitment of cementoblasts to the root-surface and hence to stimulate these to form root-cementum.
Growth Factors: Amelogenins are rich in proline residues (30%) that are believed to inhibit the formation of classic secondary structures such as b-sheet, a-helix, and random coil, producing an intrinsically disordered protein .The activity of EMD has been compared with that of bone morphogenic proteins (BMP) and transforming growth factor (TGF)-b-like molecules (19). Full length amelogenin molecules have been shown to stimulate autocrine production of BMP while the smaller amelogenin fragments of leucine rich amelogenin peptide (LRAP)- and tyrosine-rich amelogenin peptide (TRAP)- related molecules stimulate autocrine production of TGF-b. It has also been shown that EMD increases autocrine synthesis of TGF-b in ligament fibroblasts while TGF-b itself is undetectable in the EMD formulation
Pulp: It has been shown that amelogenin participates in the maturation and growth of dental pulp cells during tooth formation. Experiments in pigs have compared the effect of EMD with calcium hydroxide when used for direct pulp capping. The histological evaluation demonstrated a significantly more pronounced formation of secondary dentine in teeth treated with amelogenin.
Bone: In a systematic review (SR) on the efficacy of EMD to promote regeneration of osseous tissue in intrabony defects, alone or in combination with membranes, a total of 20 in vivo studies with histomorphometric analysis were evaluated. The main results that were that EMD treatment significantly improved bone regeneration when compared with open-flap debridement. However, EMD was not more effective than traditional guided tissue regeneration (GTR)
Implants: Amelogenin is one such candidate that has a potential role in stimulating peri-implant bone growth. However, no studies so far have been able to demonstrate a significant effect from EMD or amelogenins on implant performance when analyzed by biomechanical testing. As far as a PDL tissue engineering on implant surface, this route might actually hinder cell attachment to the material surface.
Avulsion: Root surface conditioning with amelogenins could prevent root resorption and ankylosis, and stimulate periodontal ligament formation after repositioning of the avulsed tooth. Results have been mixed. Possible that when used with anti-inflammatory meds, EMD can support healing if teeth have been stored for time or in medium that does not support PDL reformation.
Wound Healing: EMD is clinically reported to show exceptionally fast wound healing and minimal post op symptoms such as pain or swelling, possibly due to anti-inflammatory or anti-microbial effects. Amelogenins used in studies w/skin wound healing showed that the amount of granulation tissue in an EMD-treated wound was significantly increased, and that wound fill and re-epithelialization of full thickness wounds progressed almost twice as fast in the presence of EMD
BL: EMD appears to utilize a principle of biomimicry to stimulate growth factor expression, and acts as its own release device to ensure this stimulation occurs over time. Although its results are controversial in aspects of dentistry, it can be used in perio regeneration therapy, as well as several other aspects of dentistry.

Topic: EMD

Authors: Miron RJ, Sculean A, Cochran DL, Froum S, Zucchelli G.

Title: Twenty years of enamel matrix derivative: the past, the present and the future.

Source: J Clin Periodontol. 43(8):668-83,

DOI: 10.1111/jcpe.12546

Type: Review

Keywords:

Background: Over 20 years ago, researchers in Sweden found that enamel matrix proteins (EMPs) could be utilized as a biological agent capable of periodontal regeneration. Based on studies that certain EMPs were deposited on the surface of developing tooth roots prior to cementum formation and may play a possible role in cementogenesis. EMPs are proteins secreted by Hertwig’s epithelial root sheet capable of promoting periodontal regeneration.

The purified fraction derived from the enamel layer of developing porcine teeth was given the name enamel matrix derivative (EMD). Major components of EMD are the following substances: Amelogenins,Enamelin, and Ameloblastin

Purpose: There are 4 aims in this review article:

1. To provide a biological background in order to fully grasp the rationale for EMD utilization
2. To show studies based on animal and human histology showing periodontal regeneration
3. To provide a summary of clinical trials using EMD for numerous regenerative procedures and to provide evidence-based indications for usage of EMD in clinical practice
4. To discuss future avenues research, including the development of Osteogain

Discussion:

Biological Rationale:

Early research showed that enamel matrix proteins (EMPs), previously thought to be enamel specific proteins, are secreted from Hertwig’s Epithelial Root Sheath and contribute to differentiation of periodontal tissues particularly cementogenesis. Emdogain is enamel matrix derivative (EMD) made of purified fractions of the enamel layer of a developing porcine tooth. 90% hydrophobic amelogenin proteins. 10% other proteins: enamelin, ameloblastin, amelotin, apin and various proteinases. Carrier medium is a propylene glycol alginate (PGA) gel In vitro studies applied EMP or EMD to different cell types: epithelial cells, gingival fibroblasts, PDL fibroblasts, cementoblasts, osteoblasts, and bacterial cells. The proteins influence cell behavior through enhancement of: Cell attachment, proliferation, differentiation, and survival, Production / secretion of transcription factors, growth factors, cytokines, and other ECM proteins, Soft tissue healing and angiogenesis

Animal and Human In Vivo Research:

Animal and human models demonstrate that EMD added to a variety of surgical applications (recession, intrabony, and furcation defects) provides histological evidence of periodontal regeneration compared to debridement alone.

• Similar quantity and quality of periodontal regeneration comparing EMD to GTR.
• Key authors in this early human research: Mellonig, Yukna, and Sculean
• An important caveat – regeneration is not always achieved in either EMD or GTR protocols
• Attributed to wound stability, infection, systemic conditions and age
• The hydrophobic gel delivery of the EMD product raised questions about its ability to permit adherence to debrided root surfaces rather than leaking out of the flap.
• EMD shown to persist on root surfaces for up to 4 weeks
• Stimulate de novo cementum deposition on old native cementum
• Positive effects EMD can been at 6 months of wound maturation

Clinical Applications:

• EMD has been proven a safe adjunct to therapy – proteins contained within EMD are derived from highly conserved genes across many species i.e. porcine and human species
• This translates to EMD being a low risk of allergen – no reports of allergic reactions in 20 years of human trials
• Wound Stability – Promotion of angiogenesis through the stimulation of growth factors (i.e. vEGF) contributes to early soft tissue healing around wounds.
• Tonetti – increase in soft tissue density in the initial 6 weeks of healing compared to controls
• Non-Surgical therapy – RCTs show no clinical benefits; thus, not recommended as an adjunct to NS therapy
• OFD vs. OFD + EMD for Intrabony Regeneration
• Better defect fill, improvement of PD and CAL and soft tissue density with addition of EMD
• Various flap designs explored: traditional envelope flap, modified papilla preservation flaps, or simplified papilla preservation flaps
• EMD or GTR for Intrabony Regeneration
• Similar improvements in clinical parameters
• Complication rates higher involving membrane exposure (non-resorbable and resorbable)
• Complication rate may be reduced through use of EMD since it can be applied in minimally invasive techniques which preclude the use of membranes.
• Recent trials using a variety of minimally invasive surgical techniques (MIST) pioneered by clinicians such as Cortellini, Tonetti, and Harrell employ the use of EMD in their protocols.
• Minimally invasive nature of the flap design can improve wound stability and reduce patient morbidity.
• The additional benefit of EMD to these minimally invasive techniques vs MIST alone has yet to be proven.
• Combination EMD + GTR for Intrabony Regeneration
• Speculation that use of EMD alone does not provide enough space maintenance to prevent flap collapse, especially with non-contained defect morphology
• Many authors show no additional benefit of EMD + GTR vs either EMD or GTR alone
• Does this favor EMD usage alone due to ease of application?
• Combination EMD + BRG for Intrabony Regeneration
• Research generally points to improved outcomes but with large variability between studies.
• The improved outcomes and variability are shown with a variety of bone grafting materials.
• Appears to be no long-term benefit to combination of an alloplast with EMD.
• Soft Tissue Grafting:
• The addition of EMD to CAF has improved KT width and long-term stability of root coverage versus CAF alone.
• EMD + CAF vs CTG + CAF by McGuire demonstrates equivalent results in terms of root coverage and CAG
• Consensus papers suggest use of CTG or EMD with CAF significantly improve chances of complete root coverage.
• Histologic evaluation shows
• Enhanced regeneration with EMD + CAF
• CTG + CAF consistently heals via a long junctional epithelium and possesses a small risk of root resorption
• Furcation Defects
• Evidence in this application is not as robust.
• Some evidence points to improved horizontal probing improvements in Mandibular Cl II furcations with EMD vs GTR.
• The benefit in proximal furcations in the maxilla is unclear.

Future Direction:

• Multi-center RCTs clarifying a benefit of EMD with MISTs in the treatment of intrabony defects is warranted
• EMD in treatment of supra-alveolar defects in conjunction with OFD
• Limited research in treatment of peri-implantitis lesions by Froum and Rosen group uses a multitude of adjuncts (Chemical Decontamination, EMD, PDGF, Membranes/Connective Tissue Grafts, and different BRGs)
• Not possible to clarify the magnitude of benefit of one therapy over another.
• Combinations of EMD and PDGF within the same lesion by this group is justified by significantly better cell proliferation with the combination shown by Chong, 2006.
• Clarification of the benefit of different fractions of proteins within EMD may enable simulation and proliferation of specific cellular and tissue components (bone vs cementum vs gingival/PDL fibroblasts, etc.)
• The propylene glycol gel delivery system for the current Emdogain product has raised concerns that it reduces the adsorption of the EMPs to the bone graft material. Research into a more hydrophilic carrier, Osteogain, designed specifically for combination with bone grafts is ongoing.

Conclusion: EMD is a biologic adjunct with proven regenerative capacity in periodontal applications. Strong evidence supporting its use for the improvement of clinical parameters alone or in combination with other therapies exists. Future research is ongoing seeking to further understand EMD’s biological mechanisms and improve its clinical performance, particularly when in combination with bone grafting techniques.

EMD on a cellular level

Topic: biologic mediators

Author: Bosshardt DD.

Title: Biologic mediators and periodontal regeneration: a review of enamel matrix proteins at the cellular and molecular levels

Source: J Clin Periodontol 2008; 35(8): 87-105

DOI: 10.1111/j.1600-051X.2008.01264.x

Type: review

Keywords: cell biology, enamel matrix derivative, enamel matrix proteins, periodontal regeneration

Purpose: To assess the available data of enamel matrix proteins (EMPs) for regenerative periodontal treatment at the cellular and molecular level that support wound healing.

Methods: Literature search was performed for studies looking at epithelial cells, gingival fibroblasts, PDL cells, cementoblasts, and wound healing in relation to enamel matrix proteins. 103 papers met the inclusion criteria.

Discussion: A large amount of data was available on EMPs as the relate to different cell types and wound healing. There was significant heterogeneity in the types of EMPs used, concentrations, observation periods and cell types, therefore some results were conflicting. Overall the data suggest:

• Cell attachment, spreading and chemotaxis -EMPs caused an increase in cell attachment of epithelial cells, gingival fibroblasts and PDL fibroblasts
• Cell proliferation and survival -the most robust data available supports the concept that EMPs favor cell proliferation of PDL fibroblasts over gingival/epithelial fibroblasts
• Expression of transcription factors -EMPs specifically increase the expression of Osx, Runx2, Sox9, Zfp60 that relate to chondroblast and osteoblast/cementoblast differentiation.
• Expression of growth factors, cytokines, ECM constituents and other macromolecules -EMPs stimulate total protein synthesis. Upregulated cytokines include: TGF-B1, BMP-2, VEGF, FGF2, TNFa, IL6, IL8, OPN, collagens.
• Expression of molecules involved in the regulation of bone remodeling -EMPs may play a role in modulating the RANK-RANKL-OPG axis, favoring bone apposition.
  

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Topic: Emdogain

Authors: Miron RJ Dard M, Weinreb M.

Title: Enamel matrix derivative, inflammation and soft tissue wound healing..

Source: J Periodontal Res. 2015 Oct; 50(5):555-69.

DOI: 10.1111/jre.12245

Type: Discussion/Review

Purpose: To gather all studies that deal with the effects of EMD on tissue inflammation with particular interest in the cellular mechanisms involved in inflammation and soft tissue wound healing/resolution.

History of EMD: The actions of EMD on periodontal regeneration mimic the normal development of periodontal tissues . The histological observation that amelogenin, which until then was considered an enamel-specific protein, is deposited on to the surface of developing tooth roots before cementum formation, led to the hypothesis that amelogenin might be responsible for the differentiation of periodontal tissues.

Methods: Systematic review searching databases, including MEDLINE, PubMed, Embase and Cochrane. The initial search criteria for “enamel matrix proteins,” “enamel matrix derivative” or “emdogain.” thereafter, this search query was searched against each cell types and each inflammatory marker, including interleukin, prostaglandin, TNF-a, MMP, OPG and RANKL separately.

Results: Monocytes: EMD was able to induce osteoclast formation and function when added simultaneously with RANKL. In a study by Sato, it was found that monocytes exposed to lipopolysaccharide in the presence of EMD exhibited a decrease in TNF-a production and an increase in PGE2 production compared to control cells not treated with EMD. On the other hand, a study by Khedmat found that EMD did not alter the expression of TNF-a or IL-1b as assessed by enzyme-linked immunosorbent assay and did not modify the phagocytic activity of these cells following treatment with EMD.

Lymphocytes: It was found that EMD produced a slight increase of the proliferation of lymphocytes, restricted to the CD25 (IL-2 receptor) fraction of the CD4 positive T lymphocytes and a concomitant decrease of CD-19-positive B lymphocytes. EMD had no influence on other cell fractions, including CD8-positive T cells, B cells and NK cells.

Neutrophils: Only one study has investigated the effects of EMD on polymorphonuclear neutrophils (PMNs). The aim of this study was to determine in vitro the impact of EMD on superoxide (O2 ) genera- tion, chemotaxis and MMP-8 secretion by PMNs to understand better the role of EMD in surgical wound healing. Human PMNs responded to EMD with significantly elevated O2 generation and chemotactic activity, EMD did not induce MMP-8 expression.

Gingival Fibroblasts: Results showed that TNF-a increased the expression of MMP-1 but EMD decreased it and stimulated the expression of TIMP-3, with little effect on various other forms of MMPs and TIMPs These data suggest that EMD may affect gingival health by ways other than cell prolif- eration/survival, but by curbing MMP expression and stimulating TIMP-3 production. This process may lead to reduced periodontal breakdown caused by an inflamma- tory reaction induced by bacterial pathogens.

Wound Healing: Hagewald found that the use of EMD was able to increase significantly the formation of keratinized tissue. Cueva found that the application of EMD gel to denuded root surfaces receiving CAF + EMD significantly increased the percentage of root coverage compared to CAF without EMD. In addition, EMD application was accompanied by a significant increase in keratinized tis- sue 6 mo after surgery. Tonetti studied the effects of regenerative therapy on healing, postoperative morbidity and patient perception of outcomes in deep intrabony defects. The results from this study observed earlier gains in soft tissue density following application of EMD.

Can Emdogain be used for intrabony defects? Is root surface treatment necessary to use this material? How are the roots treated now, and does that differ from previous applications of Emdogain? How does it compare to open flap debridement? How does it handle?

Heijl 1997
Background: Prior to the formation of acellular cementum, enamel matrix proteins are secreted and temporally deposited onto the root surface providing an essential surface for the expression of cementum-forming cells. The discovery of the enamel matrix layer between the peripheral dentin and the developing cementum and its function provided the fundamental concept for enamel matrix derivatives (Emdogain-EMD)-supported tissue engineering in regenerative periodontal therapy.
P: To compare the long-term effect of EMD treatment as an adjunct to MWF with MWF w/ placebo.
M&M: A mulicenter RCT with split-mouth design involving 33 subjects with 34 paired test and control sites. The protocol required 2 interproximal sites, in the same jaw with PD ≥6 mm and an associated intrabony defect with a depth of ≥4 mm and a width of ≥2 mm measured radiographically. 1- and 2-wall defects were included. PPD, BOP, PI, CAL and radiographic bone levels were evaluated at baseline and then at 8, 16 and 36 months. The surgical areas were “etched” for 15 seconds with 37% phosphoric acid to remove the smear layer and allow enamel matrix proteins to precipitate onto a root surface. Doxycycline 200mg first day and then 100mg for 20 more days; in addition, patients were advised to rinse with CHX 0.2%/4-6 weeks post-op.
R: 1) BOP and PI were maintained throughout the study period. There were no differences between the test and control sites at any examination intervals.
2)

CAL gain	8 months	16 months	36 months
Test	2.1mm	2.3mm	2.2mm
Control	1.5mm	1.7mm	1.7mm

3) The radiographic bone level continued to increase over the 36 months at the EMD-treated sites, while it remained close to the baseline level at the control sites. The SS radiographic bone gain at 36 months of 2.6 mm at EMD-treated sites.
BL: The favorable results obtained in the present clinical trial may indicate that EMD may be used conjunction with periodontal surgery in regenerative procedures.

Sculean 1999
P: To evaluate the clinical outcome following the application of Emdogain in the treatment of intrabony periodontal defects.
M&M: 28 patients, 32-60 years old participated in the study. 32, 2- and 3-walled intrabony defects with a depth at least 6 mm were included. PD, REC and CAL were evaluated 1 week pre-sx and 8 months after treatment. CEJ was used as reference point. In case CEJ was not visible a restoration margin was used. Pre and post-op hard tissue changes were evaluated using standardized radiographs. Sx treatment: FTFs, defects degranulated, roots scaled and planed, root surfaces were etched with 37% phosphoric acid for 15s, rinsing with saline, application of Emdogain, flaps were coronally positioned to achieve primary closure. All patients received amoxicillin 500 mg tid for 1 week, 0.2% CHX mouthrinse twice a day for 6 weeks, SPT every 2 weeks by dental hygienist.
R: Post-op healing was uneventful in all cases. There were no complications such as allergic reactions, abscess formation, or infections throughout the entire study period. The mean PD was reduced from 8.7 mm at baseline to 4.3 mm after 8 months, the mean gingival recession increased from 1.8 mm to 3.3 mm, and the mean CAL changed from 10.6 mm to 7.6 mm. All investigated parameter changes were SS. New hard tissue formation was radiographically observed in 26 of the 32 defects.

AL #’s do not add up
BL: Treatment of intrabony periodontal defects with Emdogain may lead to significant improvements of all of the investigated clinical parameters. However, controlled histologic and clinical trials are needed to compare this treatment modality with other conventional and regenerative periodontal surgical methods

Giannobile 2003
Purpose: To evaluate the evidence to support the utilization of Enamel Matrix Derivative (EMD) and growth factors (GFs) for periodontal repair and regeneration associated with natural teeth.
Materials and methods: Review of literature until 2002, human and animal studies included but not in vitro studies. Meta-analyses were performed for studies that fulfilled the eligibility criteria for the following continuous variables: clinical attachment level (CAL), probing depth (PD), or bone level (radiographic, re-entry, or histologic)
Results: The animal trials revealed heterogeneous methodology and after statistical analysis it was concluded that animal data were insufficient for meta-analysis. 8 human studies were finally included (representing 511 subjects) because the majority of the rest studies had a low evidence rating. These data were about EMD, while data about GFs were insufficient to conduct a meta-analysis on their effect in periodontal repair or regeneration.
Conclusion: 1. There is evidence supporting the use of EMD for periodontal osseous defects to improve CAL and reduce PD, although long-term benefits have not been established.
2. EMD has demonstrated notable consistency among the studies investigated in terms of superiority to controls (in general compared to open flap debridement).
3. EMD appears to be safe for single and multiple administrations in terms of lack of elicitation of antibody responses or other local/systemic inflammatory events.
4. Preclinical and initial clinical data for growth factors appear promising but are insufficient to draw definitive conclusions at this time.

Parodi 2000
Purpose: To verify whether differences exist in the results obtained at midterm(12months) and long term (36months) after the treatment of osseous defects with Emdogain

Materials and Methods

• • Twenty three patients mean age 53yo with one and two wall deep interproximal pockets >5mm

• All periodontal indices were measured, but only probing pocket depth (PPD), probing attachment level (PPL) and gingival recession were considered statistically
• Standarized radiographs were taken at 0, 12 and 36 months

• The surgical technique used was that recommended by the manufacturer

Results

• • In all reentry cases at 12 months the defects appeared remodeled, and the morphology differed from baseline

• A new thick, white tissue was noted; it was rubbery, difficult to probe and well adhered to the underlying surfaces.
• The gain in PAL from baseline to 36 months was significant but not between 12 and 36 moths

• No significant improvement was noted radiographically

Discussion

• At 36 months PPD and PAL showed statistically relevant gains.
• Recession showed an interesting trend, at 12 months noteworthy recession at deep 1 wall defects and at 36 they were diminished
• Radiographic bone gain was not demonstrated but stabilization and maturation was observed.

• In the authors experience Emdogain has the ability to obtain new fibrous attachment, but not new bone, except episodically. Matches our experience. Emdo alone was disappointing; however Emdo with FDB was consistently good. CR- no controls.
  

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Francetti 2004
P: To compare surgical treatment in combination with EMD to surgery alone in the treatment of intrabony periodontal defects.
M&M: 24 patients (11males/13 females), age 30-66 years, 1,2 or 3- wall defects with PPD >=6mm and IBD >=4mm. Preliminary clinical evaluation consisted of plaque index(PI), gingival index(GI), probing pocket depth(PPD) and periodontal attachment level(PAL) at the sites to be treated. IBD was evaluated radiographically. Also, full mouth plaque score (FMPs) and full mouth gingival bleeding (FMBs) were assessed. Non-surgical periodontal therapy consisted of full mouth SRP and detailed OHI. Patients of one group were treated with the simplified papilla preservation flap technique (SPP), while the patients of the second group were treated with SPP flap technique in combination with EMD after EDTA acid root conditioning ???. Radiographs were taken at baseline, at 12 and 24 months after surgery. At 12 and 24 months after surgery PPD, PAL, PI, GI, FMPs, FMBs and radiographic IBD were assessed.
R: In both groups a slight decrease in FMPs, FMBs, PI and GI was observed. No significant difference with respect to these parameters was observed between these two groups. In both groups a significant decrease of PPD, IBD and a significant improvement of PAL after 12 and 24 months were observed. The test group displayed better outcomes when compared with the control group for IBD, PPD and PAL gain of 12 months and only for PAL and IBD gain at 24 months.
BL: The adjunct of Emdogain in the treatment of intrabony periodontal defects possibly enhances periodontal tissue regeneration. Straumann^® PrefGel is a pH neutral, 24% EDTA root surface conditioner intended for topical application onto exposed root surfaces during periodontal surgery.

For how long does EMD remain on tooth surface after application?

Topic: EMD

Author: Sculean A, Windlisch P, Keglevich T, Fabi B, Lundgren E, Lyngstadaas PS

Title: Presence of an enamel matrix protein derivative on human teeth following periodontal surgery

Source: Clin Oral Investig 2002; 6(3): 183-7

DOI: DOI 10.1007/s00784-002-0171-6

Type: review

Keywords: enamel matrix derivative, enamel matrix proteins, periodontal regeneration

Purpose: To investigate the persistence of the EMD-based matrix on periodontally involved human teeth treated with EMD.

Methods: 16 patients (10F, 6M) with chronic periodontitis and 16 advanced intrabony defects at teeth scheduled for extraction were included. All patients were treated with either OFD or OFD +Emdogain. Patients defects were stratified so they could be observed at 1,2,3 and 4 weeks post-surgery. Biopsies were taken en bloc and immunohistochemical staining and analysis was performed.

Results:

Post-op healing: Generally uneventful with some minor swelling.

Histologic Findings: EMD was detected on all the root surfaces treated with EMD at all time points. No EMD was detected at any of the control teeth.

Discussion: This study confirms that in humans, EMD remains present on surgically treated root surfaces and is present at least 4 weeks. This helps us further understand the wound healing process and suggests that EMD does remain in place to aid in biologic wound healing that may lead to regeneration.

How does emdogain heal? Are there any controversies concerning its healing? Is there a difference in healing of animal or human studies, or between diseased root surface vs created defects? Have all of these results analyzed intrabony defects? Would that make a difference?

What is the histologic evidence for regeneration with EMD?

Cochran DL 2003
P: to evaluate the histologic regeneration of periodontal tissues in the baboon following the use of enamel matrix proteins.
M&M: Five baboons. Four one-walled defects; 2/3 down to the root surface and 1, 2, 4, and 6 mm wide were created bilaterally around 3 teeth in the mandibles. Plaque was allowed to accumulate around ligatures placed into the defects. After 2 months, the ligatures were removed, the teeth were scaled and root planed, and a notch was placed at the base of the defect. On one side of the mandible, EDTA and EMD were used to treat the defects. The other side served as a control, with EDTA treatment alone after SRP. Flaps were sutured and the animals were allowed to heal without OH procedures. After 5 months, the animals were sacrificed and the teeth were processed for histology.
R: Periodontal regeneration occurred in all sizes of the periodontal defects.
Qualitative findings:
– New cementum, periodontal ligament with Sharpey’s fibers, and new bone tissue were observed. In many instances, dramatic tissue formation occurred far coronal to the base of the defects
– EMD treatment resulted in greater tissue formation than controls.
Quantitative findings:
– Horizontal bone fill occurred in defects that were initially 4 or 6 mm wide. The resultant width of the PDL was similar in all defects regardless of the original defect width.
– The cementum width was slightly greater in the wider (4 and 6 mm) defects compared to the more narrow (1 and 2 mm) defects
– When evaluating the combined 1 and 2 mm defects, the height of new cementum with EMD treatment was 45% greater than the control, with 31% greater new bone height versus the control.
– In the combined wider defects (4 and 6 mm), new tissue height was more similar between enamel matrix protein-treated defects and control defects. (The results from the wider defects must be interpreted cautiously, because the interproximal bone heights were resorbed more adjacent to the wider defects during the plaque accumulation period and likely limited the potential for regeneration).
BL: The treatment of various sized periodontal defects with EMD stimulated substantial periodontal regeneration.

Sculean, 2000
P: To present the clinical and histological findings following treatment of human intrabony periodontal defects w/ Emdogain.
M&M: Case report of 2 pts (1M, 1F) 55 and 50 yrs old respectively, No Systemic dz. OHI, S/RP, 3 months prior Sx. FTF elevated, granulation tissue removed, S/RP, Notch at the most apical part of defect, and at the alveolar crest level. Root conditioning w/ 24% EDTA gel, tissues rinse w/ saline, Emdogain applied, flaps positioned coronally, and sutured. Amoxicillin 1g/day for 1week. Professional cleaning once a week for 6 weeks, and then once a month for 6 months. Tooth extracted w/ surrounding tissue, histo performed.

R/ Concl:

BL: Emdogain possesses some potential for enhancing periodontal regeneration in human intrabony defects.

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Parodi et al, 2000
P: To evaluate clinically, radiographically and histologically the results obtained of the application of an enamel matrix derivative (Emdogain) in deep 1- and 2- wall interproximal defects.
M&M: 21 patients presenting IP defects that could be treated with GTR were selected. Inclusion criteria: PDs 5mm and persistent BOP, radiographically identified osseous defect of at least 3mm depth and >2mm width. 7/21 patients smoked >10 cigarettes/day, 14/21 were non-smokers. The 1- and 2- wall intrabony defects were divided into deep (5-8 mm) and very deep (>9 mm) defects and were only located in max or mand anterior sextants. 1 week before sx clinical parameters were assessed: BOP, PI, PD, mobility index, gingival recession, CAL. Surgical bone level (CEJ-deepest osseous level) was measured during sx. Professional hygiene was performed monthly for 12 months. Surgery: FTFs, defects degranulated, roots scaled and planed, root surface was etched for smear layer removal (orthophosphoric acid 15s for first cases and EDTA for all other cases), rinsing with saline solution, application of Emdogain. All pts were put on bacampicillin (2,400 mg/day) and flurbiprofen (100 mg/day) for 2 weeks. At 12 months, cases were re-examined and clinical parameters were recorded. In 13/21 cases surgical re-entry was performed. Histological analysis was performed in 2 cases. Strange cut off #s for groups of PDs. May have change it to massage the results
R: 12 deep, 9 very deep defects grafted (EMDO only) following Emdogain protocol. The mean PD decreased from 8.1mm to 3.2 mm; CAL decreased from 10.4 mm to 7.0 mm; recession increased from 2.3 mm to 3.8 mm; and surgical bone level decreased from 9.6 mm to 7.1 mm.
NSD was noted between bone defects with 1 or 2 walls, smokers and nonsmokers, or most parameters for deep vs very deep. (SSD was found between deep and very deep defects when attachment gain was considered). Standardized and computerized radiographs at 12 months did not reveal significant improvement. Surgical reentry in only 13 cases; a rubber type hard tissue was found filling the defects. The histologic examination carried out on 2 block graft samples did not show evidence of new attachment.
BL: EMD showed good clinical results (reduction in PD) but no regeneration ability in human periodontal defects.

Yukna, 2000
B: EMD (enamel matrix proteins) that are obtained from tooth germs of pigs, then processed and sterilized, and appear to stimulate the formation of periodontal attachment tissues.
P: To evaluate histology of wound healing following EMD therapy of periodontally affected roots to see if periodontal regeneration takes place.
M+M: Multicenter study (LSU and UT-San Antonio) with a total of 8 patients with 10 defects were enrolled. Isolated moderate-severe periodontitis, teeth treatment planned for extraction were included. Splinted teeth, SRP of adjacent teeth performed. Photos, recession, CAL, PD measurements were made prior to surgery, FTF elevated and notch placed. Measurements made from the base of defect to notch and from notch to crest. Root planed coronal to notch. Citric acid placed for 1 min. Intra-marrow penetration and EMD coated root surface with slight overfill of defect. Sutures and dressing placed for 2 weeks. NSAID, doxycycline, narcotics, and CHX given post-op. Patients were seen biweekly to monthly for prophylaxis and OHI. At 6 months, tooth removed en bloc and tooth bisected longitudinally. Ridge augmentation performed. Histology performed.
R: 10 defects resulted in 3 defects with regeneration, 3 with new attachment, and 4 with long junctional epithelium. The 3 regeneration cases showed parallel and perpendicular fibers. These also showed acellular and cellular cementum. No resorption, ankylosis, or inflammation noted.
PD reduction: 1-6 mm. CAL change: +6mm to –2mm. Recession: 0-5 mm.

BL: 60% (6/10) of defects showed either true regeneration or new attachment on a previously contaminated root surface. Deeper defects did not determine the type of healing.

Hammarstrom 1997
P: To determine if application of enamel matrix on a denuded root surface could promote regeneration of all the periodontal tissue, and to try different vehicles for these proteins.
M&M: Homogenized enamel matrix was scraped from mandiblular, non-erupted, developing premolars and molars of approximately 6-month-old pigs. The homogenate was stored frozen and thawed before use. Enamel matrix derivative (EMD) was prepared by purification of acidic extract followed by lyophilization. It was applied either as a lyophilisate, and acidic aqueous solution, or in one of the following vehicles: propylene glycol alginate (PGA), hydroxyethyl cellulose (HEX), or dextran. In monkeys, flaps were raised form maxillary canine to first molar, and the buccal bone, PDL and cementum were removed with a bur to create a dehiscence. A notch was made to determine the extent of the defect. The distance of the CEJ-apical extent of the defect was roughly 6mm. Roots were conditioned with citric acid or 37% phosphoric acid and rinsed with saline prior to application of the preparations. All teeth in one quadrant received treatment and the contralateral quadrant usually served as the controls. After 8 weeks the monkeys were sacrificed and histological analysis performed.
R: In general, areas around control teeth and those only treated with EDTA showed more inflammation than the other sites. EMD in PGA gave about the same results as EMD with no vehicle. When EMD was in HEC or dextran, it had a less favorable appearance macroscopically and gave worse results than EMD alone, acidic extract, or EMD + PGA. The EMD, acidic extract, or EMD + PGA resulted in extensive regain of acellular cementum, PDL and alveolar bone (bone slightly more apical to cementum); the regeneration was between 60-80%. The other groups (HEX, dextran) displayed very little formation of new cementum and almost no bone, simply a long JE.
BL: One can expect 60-80% regeneration when EMD, acidic extract, or EMD + PGA is applied to sx-created buccal dehiscences in monkeys. Studying the best vehicle for Emdogain

Topic: Human Histology of Regeneration with EMD

Author: Sculean A, Donos N, Windisch P, Brecx M, Gera I, Reich E, Karring T.

Title: Healing of human intrabony defects following treatment with enamel matrix proteins or guided tissue regeneration.

Source: J Periodontal Res. 1999 Aug; 34(6):310-22.

DOI: 10.1111/j.1600-0765.1999.tb02259.x

Type: Clinical and Histological

Keywords: intrabony defects, enamel matrix proteins, guided tissue regeneration, bioabsorbable membranes, human histology

Purpose: Evaluate histologically in humans the healing of intrabony defects after treatment with EMD or bioabsorbable membranes and to compare the newly formed cementum on the original cementum present on intact root surfaces.

Methods:

• 14 patients with 14 advanced intrabony defects scheduled for extraction were included
• All patients received OHI, initial therapy and splinted if necessary
• Defects were assigned randomly to either treatment with EMD or GTR.
• Intrasulcular incisions, full thickness flaps buccal and lingual, defects debrided, and root surfaces scaled with hand/ultrasonics.
• Notches were placed at the apical level of calculus or bottom of the defect if no calculus was present, and again at the crest of bone
• Any periodontal tissue attachment above the notch would be de novo
• EMD groups: surfaces conditioned for 2 minutes with EDTA, defects filled with EMD gel
• GTR groups: no root surface conditioning was completed, bioabsorbable membrane was adapted over the defect and fixed to the area.
• Flaps were fully closed, sutures removed at 14 days, maintenance every 2 weeks for 6 months
• After 6 months, teeth were removed en bloc with soft/hard tissues intact

Results:

• Clinical Results:
• Baseline:
• PD: 11.3mm EMD, 11.4mm GTR
• CAL: 12.1mm EMD, 13.3mm GTR
• 6 months:
• PD: 5.6mm EMD, 5.6mm GTR
• CAL: 9.1mm EMD, 10.1mm GTR
• Mean CALgain EMD- 3.2mm
• Mean CALgain GTR- 3.6mm
• Histological Results:
• EMD:
• 6mm of new connective tissue attachment
• 9mm new bone
• New cementum was cellular and had collagen fibers inserting showing new attachment
• Bone regeneration was seen in 4/6 patients
• GTR:
• 4mm new connective tissue attachment
• 1mm new bone
• New cementum was cellular and continuous with old cementum with fibers inserting showing new attachment
• Bone regeneration was in all patients that had new attachment

Discussion:

• Intrabony defects treated with either EMD or GTR show not only clinical improvements but histologically new CT attachment and some regeneration
• The treatment with GTR seems to promote regeneration to a higher degree than treatment with EMD
  

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Topic: EMD & Regeneration

Authors: McGuire, M. K. & Cochran, D. L.

Title: Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 2: histological evaluation.

Source: Journal of Periodontology. 74, 1126–1135, 2003.

DOI: 10.1902/jop.2003.74.8.1126

Type: Histological study

Keywords: biometry, comparison studies, enamel matrix derivative, follow-up studies, gingival recession/surgery, gingival recession/therapy, grafts, connective tissue, periodontal regeneration, proteins, enamel matrix/therapeutic use, surgical flaps

Purpose: To assess the quality and nature of new tissue attachment to a previously denuded root surface (recession defect) following treatment with either coronally advanced flap with EMD or a coronally advanced flap with subepithelial connective tissue.

Methods:

• One patient (29 years old) presented with two hopeless teeth
• #7 & #9 planned to be extracted, #6 & #11 were included in the study
• #6 & #7 were randomly chosen to receive a coronally advanced flap plus EMD
• #9 & #11 were assigned a subepithelial connective tissue graft
• The surgery was done in accordance to the protocol previously described (Part 1)
• Except that a notch was placed into the root surface at the preoperative free gingival margin on the right lateral incisor (#7) and on the left central incisor (#9), and a notch was placed into the root surface at the alveolar bone crest on the left central incisor
• The right lateral incisor had no facial cortical plate and the end of the root had been removed through an apicoectomy, so the notch was placed at the most apical portion of the root
• The teeth and a small collar of tissue were removed at 6 months and underwent histological analysis

Results:

Evaluation #9 (CT graft):

• Histological evaluation of the subepithelial connective tissue graft revealed a connective tissue attachment between the tooth and graft
• No histological evidence of cementum, bone, or periodontal ligament (PDL) regeneration
• There appeared to be some resorption of the dentin adjacent to the graft

Evaluation #7 (CAF + EMD):

• Histological evaluation of the coronally advanced flap with EMD revealed new cementum, organizing PDL fibers and islands of condensing bone at a constant distance from the root surface
• Evaluation was complicated by a fenestration of the flap located in close proximity to the notch

Conclusion: The authors suggest there is no doubt that the healing mechanism following that treatment comes much closer to regeneration than did the coronally advanced flap with the subepithelial connective tissue graft. The results suggest that EMD may possess potential for enhancing periodontal regeneration of coronally advanced flaps over denuded root surfaces.

Topic: Emdogain

Authors: Tonetti, M. S., Fourmousis, I., Suvan, J., Cortellini, P., Bragger, U. & Lang, N. P.

Title: Healing, post-operative morbidity and patient perception of outcomes following regenerative therapy of deep intrabony defects.

Source: Journal of Clinical Periodontology 2004;31, 1092–1098

DOI: 10.1111/j.1600-051X.2004.00615.x

Type: Clinical

Purpose: To compare the clinical outcomes of papilla preservation flap surgery with or without the application of enamel matrix derivatives (EMD).

Methods:

• One hundred and seventy-two patients with advanced chronic periodontitis and at least one intrabony defect of X3 mm were recruited in 12 centers in seven countries.
• Test and control defects were accessed using either the simplified papilla preservation flap or the modified papilla preservation technique depending on the width of the interdental space. The exposed defects were carefully scaled and root planedto remove residual mineralized deposits, but not necessarily the root cementum. Root surfaces at both test and control sites were conditioned with EDTA gel for 2 min. In the test sites, EMD gel was applied on the root surface and to overfill the defect.
• Healing was monitored 1, 2, 3, 4, 6 and 12 weeks after surgery. During the first 12 weeks of healing, supracrestal soft-tissue density was evaluated with a computer-assisted densitometric image analysis system (CADIA) using underexposed radiographs taken on a subset of 34 patients. Patient perceptions were evaluated with a questionnaire immediately after the procedure, at suture removal 1 week later and at 1 year.

Results

• During the procedure, 35% of test subjects reported feeling moderate pain this compared with 27% of control subjects who reported similar pain intensity. No significant differences between test and control treatments were observed at any time point.
• Post-operative morbidity was limited to a minority of patients. 29.5% of test patients and 23.8% of controls reported that the procedure somehow interfered with daily activity for an average of 3.6 days in the tests and 3.2 days in the controls.

Conclusion: This study portrayed the early healing events, pain, discomfort and adverse events of papilla preservation flap surgery and the 1-year patient perceptions of the benefits and disadvantages of periodontal surgery in intrabony defects.

COMPARISONS:
EMD in non – Surgical periodontal therapy

Topic: Biologics – EMD

Authors: Mombelli, A., Brochut, P., Plagnat, D., Casagni,F. & Giannopoulou, C

Title: Enamel matrix proteins and systemic antibiotics as adjuncts to non-surgical periodontal treatment: clinical effects

Source: J Clin Periodontol. 2005 Mar;32(3):225-30

DOI: 10.1111/j.1600-051X.2005.00664.

Type: Clinical

Keywords: chronic periodontitis; enamel matrix proteins; nonsurgical treatment

Purpose: to evaluate the effect of EMD, applied during non-surgical therapy in deep periodontal pockets with or without adjunctive systemic antibiotics.

Method: Randomized controlled longitudinal clinical trial of 12 months. Split mouth design randomly treated with EMD or placebo in contralateral sites. Half of the subjects received systemic antibiotics and the other half placebo. 16 patients, systemically healthy with untreated moderate to advanced periodontitis were included. One inter-proximal periodontal intrabony defect of atleast 2mm depth associated with PPD of atleast 5mm with CAL >5mm and BOP were chosen as study sites.

• 24% EDTA with EMD placed at test sites or only PGA gel
• Patients given systemic Metronidazole 250mg and Amoxicillin 375mg 3x/ day for 1 week or placebo pill

Patients recall schedule after 10 days, 2, 6, and 12 months where OHI given and parameters recorded and only supragingival scaling performed as needed.

Paper points were used to collect GCF and analyzed specifically for P. gingivalis.

Results: At baseline, study sites had mean PD of 7.3mm and CAL 8.12mm with BOP and 59% tested positive to P. gingivalis. The overall pocket depth reduction of all sites whether treated with EMD or not. Mean PPD at 6 months 4.9 and 12 months 5.1mm. Patients treated with systemic antibiotics had significantly better clinical results than those treated with placebo. PPD mean reduction for antibiotic use was 3.0mm at 6 mo vs. 1.6mm without antibiotics at 6 months.

Sites treated with EMD + antibiotics gained largest amount of clinical attachment, while significant clinical attachment gain was shown in sites treated with antibiotics but without EMD.

Conclusion: Benefit of adjunctive EMD and systemic antibiotics to non-surgical therapy of deep lesions in patients with chronic periodontitis was shown in this study. Effects of antibiotics visible and positive effects of EMD only seen when in combination with antibiotics. NSSD of pooled subjects comparing EMD use or not.

How does this compare to open flap debridement? How does this compare to emdogain alone? How does it compare to a more traditional GTR? Is it a justifiable expense to a patient?

Topic: Emdogain

Author:Heijl, 1997, Heden G, Svardstrom G, Ostgren A

Title: Enamel matrix derivative (EMDOGAIN®) in the treatment of intrabony periodontal defects

Source: J Clin Perio 24:705-714, 1997

DOI: N/A

Type: Randomized clinical trial

Keywords: Enamel proteins, periodontal regeneration, intrabony defects, clinical trial

Purpose: To compare the long-term effect of Emdogain (EMD, enamel matrix derivative) treatment as an adjunct to modified Widman flap (MWF) surgery with the effect of MWF surgery and placebo alone.

Methods:

• 48 patients with 2 interproximal sites separated in the same jaw, with probing pocket depths 6 mm or greater and an intrabony defect 4 mm or greater with a width of 2 mm or greater as measured on a periapical radiograph after at least 1 month of supervised oral hygiene were included in this study.
• 1- and 2-wall defects were included. Pocket probing depth (PPD), bleeding on probing (BOP), plaque index (PI), clinical attachment level (CAL) and radiographic bone levels were evaluated at baseline and then at 8, 16 and 36 months.
• The test site surgical areas were “etched” for 15 seconds with 37% phosphoric acid to remove the smear layer and allow enamel matrix proteins to precipitate onto a root surface.
• PGA was used on placebo sites.
• Doxycycline was prescribed for 20 days following surgery alone with chlorhexidine rinse for 4-6 weeks.

Results:

• There were no differences in BOP or PI at any examination time period.
• Significantly greater gains in pocket reduction, CAL and radiographic bone level were seen in the test group over the control group.
• The radiographic bone level continued to increase over the 36 months at the EMD-treated sites, while it remained close to the baseline level at the control sites.
• A significant radiographic bone gain at 36 months of 2.6 mm was seen at EMD-treated sites

Discussion: Results obtained in the present clinical trial underlines the therapeutic prospects in regenerative periodontal therapy for EMDOGAIN.

Froum, 2001
P: To compare OFD with OFD and enamel matrix derivative (EMD) at 12 month re-entry.
M+M: 23 subjects with at least 2 intrabony defects were included. 53 defects received EMD with OFD (test) and 31 defects were treated with OFD alone (control). Customized acrylic stents were fabricated to serve as fixed reference points. Surgery consisted of: FTF, root debridement, and application of citric acid for 15 seconds with cotton pledgets for both EMD+OFD or OFD alone. EMD was prepared by mixing the 30mg powder with the propylene glycol alginate vehicle. Flaps sutured and a resin dressing applied. Prescribed tetracycline HCl 1g/day for 2 weeks. OHI and 0.12% CHX for 8 weeks. Pt returned every 2 weeks for 6 weeks and then 1x/month for 10 months. Re-entries were performed at least 1 year post-surgery. GI, PI, PD, FGM, CAL, crestal bone and depth of defect recorded at baseline and prior to re-entry. Statistical analysis was performed using generalized estimating equations??? to determine changes in GI, PI, PD, CAL, % of defect fill, and crestal resorption.
R: EMD + OFD was superior to OFD in all parameters measured. NSSD in PI and GI either initially or prior to re-entry. EMD+OFD had 2.7 mm greater PD reduction, 1.5mm greater CAL gain, and 2.4mm greater osseous fill as compared to OFD alone. Defect fill was more than 3x greater for test versus control group (74% defect fill with EMD versus 23% defect fill for control sites). Resolution after 12 months was 83% for EMD+OFD sites vs. 48% for OFD sites.

BL: In intraosseous defects, EMD + OFD is clinically superior to OFD alone in every parameter evaluated. Percentage fill of osseous defects treated with EMD+OFD compares favorably with results utilizing bone grafts or membrane barriers (stats from previously published literature).

Tonetti, 2002 ARTICLE
P: To compare the results with and without the application of emdogain (EMD) for the treatment of intrabony defects in a prospective, multicenter, RCT.
M&M: 172 pt with a deep intrabony pocket (≥3mm) in the IP area in the anterior and premolar area were selected for the study. Heavy smokers (>20 cigs/day) were excluded. Intitial therapy completed and the plaque score , bleeding score, PD, REC, CAL and mobility were measured at baseline with a pressure sensitive probe. Papilla preservation technique (simplified & modified) was used. The defects were debrided and root surfaces treated with EDTA for 2min (test and control group). EMD was placed in the test sides to overfill the defects. No EMD used for the controls. Flaps were placed back and sutured with Gore-tex sutures. Prophys were done 1-6 weeks, 3, 6, 9 months. After 1 year, 166 pts were in the study (83 test/control). The same measurements were done. NSSD between groups at baseline.
R: 166 pts were available for the 1-year follow-up. Initial mean PD was 8mm for test and 7.7 for control sites. Mean initial CAL was 9.4 for test and 9.1 for control group. 1 year after the therapy the CAL gain was 3.1±1.5mm for the test group and 2.5±1.5mm for the control (SSD), the PD decreased 3.9±1.7 mm for EMD treated defects and 3.3±1.7mm for the controls (SSD). NSSD in recession (0.8mm for test, 0.7mm control). Non-smokers had 0.4mm higher CALgain than smokers. Also, markedly corticalized and very cancellous bleeding intrabony defects had SS lower CALgains than defects with a regular cribiform bony lining. 3-wall defects had a 269% greater chance than 1-wall defects to gain 3mm CAL or more.

Discussion:

• Application of EMD in conjunction with papilla preservation flaps offered a significant added benefit in terms of CALgainand PD reduction in infrabony
• Application of EMD doubled the probability of obtainjinga highly significant outcome (CALgain >4mm) and halved the probability of obtaining clinically insignficiant results (CALgain <2mm)
• Half of patients displayed CALgainsof 2-3mm in both groups
• The probability of obtaining CAL gains of 3mm of more following EMD was improved in non-smokers, in subjects treated in specific clincis, defects with normal bony architecture, and predominantly 3-walled defects.

BL: Emd can have a greater increase CAL and decreasing PD when it is used with the papilla preservation technique for treating periodontal defects in comparison to the papilla preservation flap alone.
Cr: Stents were not used to take the measurements. No % defect fill, so tough to compare to other GTR studies. On average, pts had residual 4mm PDs (8mm initial – 3.9mm PD reduction). No reentry

Topic: Emdogain

Author: Rosing, C. K., Aass, A. M., Mavropoulos, A. ; Gjermo, P

Title: Clinical and radiographic effects of enamel matrix derivative in the treatment of intrabony periodontal defects: a 12-month longitudinal placebo-controlled clinical trial in adult periodontitis patients

Source: Journal of Periodontology 76, 129–133

DOI: 10.1902/jop.2005.76.1.129

Type: Randomized clinical trail

Keywords: Bone loss/etiology; clinical trials, controlled; clinical trials, randomized; enamel matrix derivative; periodontal diseases/ complications.

Purpose: to evaluate the clinical and radiographic benefit from application of an enamel matrix protein in conjunction with surgical periodontal therapy of intrabony defects in patients with chronic periodontitis over 12 months.

Methods:

• 16 adult chronic periodontal patients
• Baseline measurements, 6 months and 12 months
  • Plaque index, gingival index, probing depths, CAL, BOP
• Radiographic evaluation
  • Periapical radiographs taken at baseline, 6 months and 12 months
  • Measurements of CEJ to bone crest, CEJ to defect depth, bone crest to defect depth
• 2 sites in each patient, papilla preservation technique flap to gain access
• Teeth debrided and treated with 24% edta for 2 mins the 1 site treated with EDM and other site with placebo

Results:

• 14 patients included at 12 month analysis
• Both groups had statistically significant pocket reduction
  • Pocket depth EDTA
    • Baseline 7.6mm
    • 12 month: 3.4mm
  • Pocket depth placebo
    • Baseline: 7.4
    • 12 month: 2.99mm
  • No statically difference between groups for any clinical/ radiographic assessments.
  • Both groups showed improvements

Discussion: Results of this study did not reveal any statistically significant differences between treatments in any of the measured parameters: PI, GI, BOP and PPD, CAL and radiographic linear measurements. More favorable results of non-smokers then smokers in both groups.

Topic: EMD vs. OFD

Authors: Sculean, A., Blaes, A., Arweiler, N., Reich, E., Donos, N. & Brecx, M.

Title: The effect of postsurgical antibiotics on the healing of intra-bony defects following treatment with enamel matrix proteins.

Source: Journal of Periodontology. 72, 190–195, 2001.

DOI: 10.1902/jop.2001.72.2.190

Type: Clinical study

Keywords: antibiotics/therapeutic use, clinical trials, controlled, clinical trials, randomized, double-blind method, periodontal pockets/drug therapy, protein, enamel matrix, amoxicillin/therapeutic use, periodontal regeneration

Purpose: To determine the effect of postsurgical administration of antibiotics on the healing of intrabony periodontal defects treated with EMD.

Methods:

• Thirty-four patients (22 females & 12 males), exhibiting one deep intrabony defect, inclusion criteria were:
• At least 1 intrabony defect measuring 6mm, No systemic disease, No history of antibiotic use (6 months), No periodontal treatment history (2 years), Good level of oral hygiene
• Patients were randomly treated with either enamel matrix proteins plus antibiotics (test: EMD + AB) or with enamel matrix proteins alone (control: EMD).
• The antibiotic regimen consisted of a combination of TID 375 mg amoxicillin and TID 250 mg metronidazole 7 days
• Plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL) were recorded at baseline and 1 year post-operatively
• Full-thickness flaps were elevated, defects were thoroughly debrided, root surfaces were conditioned with 24% EDTA (2 minutes), EMD was then applied to the root surfaces and into the defects, and sites were then closed
• There were 12 two-wall, 2 three-wall, and 3 one-wall defects treated with EMD + AB

Results: No statistically significant differences in any of the investigated parameters between the 2 groups were observed at baseline.

• The results have shown that in the EMD + AB group the PD decreased from 9.1 +/- 1.5 mm to 4.5 +/- 1.1 mm and the CAL changed from 11.0 +/- 1.6 mm to 7.5 +/- 1.4 mm
• In the EMD group the PD decreased from 9.0 +/- 1.7 mm to 4.3 +/- 1.7 mm and the CAL changed from 10.6 +/- 1.6 mm to 7.3 +/- 1.5 mm
• There were no significant differences in any of the investigated parameters between the 2 groups.
• Due to the small number of smokers in each group, statistical analysis was not performed

Conclusion: The results of the present study have shown that the treatment of intrabony defects with EMD with or without postoperative administration of antibiotics resulted in a significant reduction of probing depth and gain of clinical attachment. No statistically significant differences between the 2 treatment modalities in any of the investigated clinical parameters were found at 1 year after therapy. The results obtained in the present study should not be extrapolated to other regenerative procedures. Within the limits of the current study, it can be concluded that the present results do not support the routine administration of amoxicillin and metronidazole following regenerative treatment with EMD

Emdogain is often used mixed with other materials.

Combination therapies (EMD + bone grafting materials)

Camargo 2001 ARTICLE
Purpose: To evaluate the effectiveness of Enamel Matrix Proteins (EMPs) combined with Bovine Porous Bone Mineral (BPBM) in reducing PDs, improving CAL and promoting bone fill in intrabony defects in humans compared to results obtained by OFD alone.
Materials and Methods: 24 healthy patients, mean age 42 years old, 18 smokers and 6 non-smokers with matched pairs of interproximal defects were recruited for the study. Two similar interproximal defects of PDs 6mm or more after initial therapy should be in the same arch but not in the same interproximal area. Radiographic evidence of intrabony defects had to exist.
Exclusion criteria endodontically treated test and adjacent teeth, patients with systemic illnesses, immune – compromised or patients taking drugs known to cause gingival enlargement, patients allergic or sensitive to any medication to be used.
Initial therapy consisted of OHI, SRP, occlusal adjustment and teeth splinting if needed and re-eval was performed 6-8 weeks later. Split mouth study design: EMPs/BPBM (Emdogain + Bioss) on one defect and OFD as control on the other defect. Occlusal stents were fabricated to standardize the clinical measurements.
Full thickness flaps were elevated, complete debridement of the defect, scaling and root planing and standardized measurements of the osseous defects were made using the same stent. Control and test sites were treated with the same surgical procedure excluding the EDTA root treatment, EMPs and bone grafts. Flaps were sutured, periodontal dressing was placed, amoxicillin, CHX 0.12% and ibuprofen were prescribed.
Sutures were removed one week later, and teeth with class I mobility or more were splinted. Mechanical oral hygiene was initiated on the end of the second week.
6 months post-op clinical measurements were repeated and surgical reentries were performed.
Results: No cases of flap dehiscences or infection during healing period and all wounds were completely covered with soft tissue by day 14.
17 two-wall defects and 7 three-wall in the test group and 18 two-wall and 6 three-wall defect in the control group.
Differences in PD, AL, defect fill and alveolar crest levels:

Differences in recession, plaque and gingival sulcus index were not satistically significant.
Conclusion: Intrbony defects can successfully been treated with a combination of EMPs and BPBM, and result in significan reduction of PD, improvement of AL and promote bone fill.
Not a good study design. Should also have included bioss alone

Sculean 2000 ARTICLE
Purpose: To compare the clinical outcome following treatment of intrabony defects with a combination of Emdogain (EMD and Bovine derived xenografts BDX or Bovine derived xenografts alone

Materials and methods

• • Twenty four patients with no systemic diseases, good OH and the presence of one intrabony defect with a PD of at least 6mm and and Intrabony component of at least 4mm seen on RX. If patient smoked more than 10 cigarettes a day was considered smoker.

• PI, GI, BOP, PD, Recession and CAL assessed 1 week prior to treatment and 1 year after with same probe
• FTF, granulation tissue removed, roots SRP, Roots were conditioned with EDTA, Emdogain was applied and the remaining Emdogain was mixed with BDX, defects were filled and flaps repositioned and sutured

• The second groups received the same treatment just without the application of Emdogain

Results

• • There was no significant difference between groups at baseline and 1 year following therapy.

• Both GI and BOP significantly improved
• PD decreased significantly in both groups compared to baseline
• The increase in gingival recession was significant in both groups

• CAL improved significantly in both groups

Discussion

• No statistically or clinically significant differences were observed between the two groups
• The collapse of the mucoperiosteal flap in the present study was hindered by the use of BDX

Gurinsky 2004, ARTICLE
P: To compare the use of DFDBA+EMD to EMD alone in the treatment of human intrabony periodontal defects.
M&M: 40 patients, 67 sites, probing depth >=5mm, intrabony lesions with depth>=3mm. All baseline clinical parameters were obtained the day of the surgery and at 6-month post-surgery reentry. Soft tissue measurements: 1) CEJ-FGM, 2) FGM-base of the pocket 3) CEJ –base of the pocket. Hard tissue measurements: 1) CEJ- base of the pocket, 2) CEJ-alveolar crest 3) alveolar crest-base of the defect. All patients received SRP, OHI and occlusal adjustment. After 4-6 weeks re-eval. Each patient received either EMD alone or in combination with DFDBA. After 6 months of healing all measurements were repeated.
R: Soft tissue findings: Both groups demonstrated significant improvement from baseline. No statistical difference between the two groups. Hard tissue findings: The mean value for the bone fill in EMD+DFDBA group was 3.7mm (74.9%) while EMD alone demonstrated a bone fill of 2.6mm (55.3%). The combination of DFDBA+EMD yield statistically significant improvements in bone fill, crestal resorption and % of sites gaining greater than 50% and 90% bone fill when compared to EMD alone.
BL: The combination of DFDBA and EMD may enhance bone regeneration.

Esposito 2009 ARTICLE review
Background: 2 past systematic reviews on the efficacy of bone graft materials for perio regeneration in intrabony defects was assessed (Trombelli 2002, Reynolds 2003). Trombelli concluded that there was variability with respect to different materials but that conclusions were difficult to reach b/c there was so much heterogenicity in the studies. Reynolds concluded that there were no differences in clinical outcome measures among various graft types.
Purpose: A Cochrane systematic review to test whether EMD is effective, and to compare EMD versus GTR, as well as various BG procedures for the treatment of intrabony defects.
M&M: A The Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE and EMBASE were searched. Selection criteria was randomized controlled trials on patients affected by periodontitis having intrabony defects of at least 3 mm treated with EMD compared with open flap debridement, GTR and various BG procedures with at least 1 year of follow-up. The outcome measures considered were: tooth loss, changes in CAL, PPD, and recession, bone levels from the bottom of the defects on intraoral radiographs, aesthetics and adverse events.
Results: A total of 13 trials were included out of 35 potentially eligible trials, all w/1-year follow up.
All applications of EMD included 36% ortho-phosphoric acid etch 15 seconds (to controls as well), 24% EDTA gel for 2 minutes (some only placed in EMD not controls, others used in both). 1 study used a 17% EDTA concentration. Most studies placed patient on a wide range of antibiotics afterwards; 2 apparently used CHX only.

• Most reported having NSD b/w test and control at baseline, but this was NOT standard. Most had post op care w/supraging cleaning q 1-2 weeks for at least 4 weeks, then q 3 months for at least 1 yr. Most studies reported at 12 month, one included study had data from 16 months. Blinding and allocation concealment were not reported for every study. Trials with both high and low risk of bias are included.

• Nine of these trials compared EMD to flap control, some with a placebo gel (PGA alone). A meta-analysis of these trials showed that EMD treated sites displayed statistically significant PAL improvements (mean difference 1.1 mm, 95% CI 0.61 to 1.55) and PPD reduction (0.9 mm, 95% CI 0.44 to 1.31) when compared to placebo or control treated sites, though a high degree of heterogeneity was found. Significantly more sites had < 2 mm PAL gain in the control group, with RR 0.53 (95% CI 0.34 to 0.82). Approximately nine patients needed to be treated (NNT) to have one patient gaining 2 mm or more PAL over the control group, based on a prevalence in the control group of 25%. No differences in tooth loss or aesthetic appearance as judged by the patients were observed. When evaluating only trials at a low risk of bias in a sensitivity analysis (four trials), the effect size for PAL was 0.62 mm (95% CI 0.28 to 0.96), which was less than 1.1 mm for the overall result.
• Four trials compared EMD with GTR using a non-resorbable barrier (all trials with a resorbable barrier had defects shallower than 3 mm and therefor could not be used). GTR showed significantly more post-operative complications (three trials, RR 0.12, 95% CI 0.02 to 0.85) and more REC (0.4 mm 95% CI 0.15 to 0.66). good ref, well done

• The only trial comparing EMD with a bioactive ceramic filler found statistically significantly more REC (-1.60 mm, 95% CI -2.74 to – 0.46) at the EMD treated sites.

Conclusion: One year after its application, EMD significantly improved PAL levels (1.1 mm) and reduced PPD (0.9 mm) when compared to a placebo or control, however, the clinical significance of this improvement is debatable. For a comparison of teeth needing extraction or additional surgical intervention, longer follow up and true blinding are necessary as generally this is at the subjective discretion of the treating dentist. In addition, a sensitivity analysis indicated that the overall treatment effect might be overestimated. The actual clinical advantages of using EMD are unknown. With the exception of significantly more postoperative complications and a slight increase in recession in the GTR group, there was no evidence of clinically important differences between GTR and EMD.
BL: At this time, there is statistical but possibly not clinical improvements with EMD compared to placebo or control, no evidence that more compromised teeth could be saved using EMD, and no patient preference for esthetic reasons. All results should be interpreted cautiously as differences in the trials reviewed make it difficult to draw conclusions.

Li 2012
P: A meta-analysis comparing clinical outcomes of EMD used in combination with bone grafts and EMD alone
M&M: RCT’s were analyzed through 9/30/11, taken from Medlin, PubMed, Embase, and Cochrane. PD, CAL, Rec, and defect gain were the main clinical outcmes. Inclusion criterion: RCT, prospective, clinical outcomes measured at baseline and 6mo or more post-op, and data not published in another article.
R: Out of 446 articles screened for inclusion, 11 RCT’s met the inclusion criteria. At 6 to 8 mo f/u, there were 282 defects, 142 were treated with EMD plus one type of bone graft and 140 treated with EMD alone. Pooled estimates showed a 1.6mm more reduction in probing depth comparing the combination with EMD alone, which was shown to be NSSD. There was an improvement of 0.37mm in CAL when comparing the two groups, again shown to be NSSD. There was a 0.98mm more gain in bone fill with the comination graft which was shown to be SSD. 0.29mm less recession was seen in the combination cohort, which was a SSD.
In the 12mo group, data from 6 trials were available. 226 defects were treated, 113 with the combination and 113 w/ EMD alone. There was a 0.25mm more reduction in PD in the combination graft, which was NSSD. 0.34 more reduction in CAL was seen, which was NSSD. 0.75mm more bone gain was seen, which was SSD. Recession showed a 0.17 decrease in the combination, which was NSSD.
C: EMD used in combination with bone graft was statistically shown to be advantageous in bone fill and recession at 6-8mo, but no significant difference in recession was seen at 12mo. However, the clinical significance is questionable. NSSD wrt PDs and CALs

Topic: EMD + Bone Grafting

Author: Yilmaz, S., Cakar, G., Yildirim, B. &amp; Sculean, A.

Title: Healing of two and three wall intrabony periodontal defects following treatment with an enamel matrix derivative combined with autogenous bone.

Source: Journal of Clinical Periodontology: 2010; 37, 544–550

DOI: 10.1111/j.1600-051x.2010.01567.x

Type: Clinical Study

Keywords: autologous bone, enamel matrix protein derivative, grafting materials, intrabony periodontal defects, regenerative periodontal treatment

Purpose: To evaluate the healing of advanced intrabony defects treated with either a combination of EMD + AB (autogenous bone) or EMD alone.

Methods:

• 40 systemically healthy, non-smoking, patients with advanced periodontitis presenting with PPD >6mm and intrabonydefect of at least 3mm on radiographs
• Measurements:
• Pocket probing depth (PPD)
• Relative attachment level (RAL)
• Probing Bone Level (PBL)
• Gingival recession (GR)
• Surgical procedure:
• Intrasulcular incisions, full thickness flaps, degranulated defects, roots scaled
• Defects randomly assigned by flipping a coin into:
• EMD + AB (test)
• EMD alone (control)
• For both groups, root surfaces conditioned for 2 minutes with EDTA
• EMD + AB group had EMD placed into the defect along with cortico-cancellous AB from the retromolar pad, EMD alone had just EMD.
• Flaps were sutured with primary closure
• Sutures removed after 14 days, recall appointments every 2 weeks for first 2 months and 1 per month for a year

Results:

• Measurement of the intrabonydefect during surgery was 5.4mm for the test group and 5.2mm for control group
• After 1 year:
• Test sites- PD reduction 5.4mm, gain RAL of 4.2mm, gain in mean PBL of 3.9mm
• Control sites- PD reduction 4.6mm, gain RAL 3.4mm, PBL gain 2.8mm
• Test treatment resulted in SS higher PD reductions, RAL gains, PBL gains compared to control
• GR increased significantly in both groups compared to baseline, but NSSD between groups
• RAL gains >4mm were seen in 90% of test and only 55% of control groups
• PBL gains >4mm 85% of test and only 25% of control groups

Discussion:

• After 1 year, both therapies resulted in SS clinical improvements over baseline
• Combining EMD + AB may lead to SS clinical improvements in PD, gains in CAL and PB when compared to EMD alone.
  

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Topic: DFDBA and EMD

Author: Gurinsky, B. S., Mills, M. P. &amp; Mellonig, J. T

Title: Clinical evaluation of demineralized freeze-dried bone allograft and enamel matrix derivative versus enamel matrix derivative alone for the treatment of periodontal osseous defects in humans

Source: Journal of Periodontology 75, 1309–1318

DOI: 10.1902/jop.2004.75.10.1309

Type: Clinical

Keywords: bone, demineralizxed, freeze-dried, clinical trials, enamel matrix derivative, grafts, periodontal regeneration.

Purpose: To compare the treatment of intrabony defects with the use of DFDBA and EMD compared to EMD alone.

Methods:

• 40 healthy adults
  • 23 female, 17 males between ages of 19-76
• Inclusion criteria:
  • Prob depth of >5mm and a intrabony defect >3mm
• Post-op evaluations taken at 6 months.
• Soft tissue measurements
  • CEJ-FGM, FGM-base of pocket, CEJ-base of pocket
• Hard tissue measurements
  • CEJ-base of defect, CEJ to crest, crest to base of defect, number of walls, radiograph
• Treatment
  • SRP and OHI completed, re-evaluation at 4-6 weeks
  • two groups
    • Group 1- EMD Alone
    • Group 2- EMD and DFDBA
  • Initial surgery and reentry surgeries 6 months apart
  • Surgery
    • FTF raised, granulation removed, roots planed, EDTA applied to roots for 2 minutes, rinse/dried, EMD applied along with DFDBA if in experimental group
  • Post op
    • antibiotics, CHX rinse and pain medications. Appointments scheduled 7-10 days, 25-30 days, 3 and 6 months
    • 6 months soft tissue measurements and radiographs taken followed by reentry surgery for hard tissue measurements.

Results:

• 40 patients and 67 defects received surgical therapy
  • 33 sites treated with EMD and DFDBA
  • 34 sites treated with EMD alone
• No significant difference noted for any defects in terms of number of walls, maxilla or mandible, tooth position, age or gender
• Soft tissue
  • both groups had significant improvement from baseline
  • no significant difference for probing depth reduction, CAL gain or recession between groups
• Hard tissue
  • both groups had improvement in bone fill, % bone fill, % defect resolution
  • Greater crestal resorption for EMD alone group
  • greater result for EMD and DFDBA in mean bone fill
    • % of sites gaining greater than 50% bone fill were
      • 80%of sites treated with EMD+DFDBA
      • 48% of sites treated with EMD alone
    • % of sites gaining greater than 90% bone fill were
      • 26% of sites treated with EMD+DFDBA
      • 17% of sites treated with EMD alone

Discussion: No significant difference between the two groups in soft tissue measurements. Statistically significant improvement in hard tissue measurements with EMD and DFDBA over the use of EMD alone. The number of Sites that gained greater then 50% and 90% bone were greater in sites treated with EMD+ DFDBA.

Topic: Combination Therapies

Authors: Ogihara, S. & Tarnow, D. P.

Title: Efficacy of enamel matrix derivative with freeze-dried bone allograft or demineralized freeze-dried bone allograft in intrabony defects: a randomized trial.

Source: Journal of Periodontology. 85, 1351–1360, 2014.

DOI: 10.1902/jop.2014.130520

Type: Clinical trial

Keywords: allografts; bone and bones; clinical trials, randomized; enamel matrix protein; regeneration; tissues

Purpose: To determine the efficacy of EMD/FDBA versus EMD/DFDBA for intrabony defects.

Methods:

• Randomized controlled trial from 2004 to 2011 with 69 patients split into 3 groups: EMD+FDBA, EMD+DFDBA, and EMD alone, one defect treated per patient.
• Exclusion criteria consisted of systemic disease, systemic medications, pregnancy, smoking, or sensitivity to minocycline and tetracycline
• All grafting material contained added minocycline.
• All patients had CAL ≥6 mm with associated radiographic bone loss, and all had completed initial therapy (full mouth ScRP, occlusal adjustment prn, OHI) at least 2 months before enrollment.
• PD reduction and CAL gain was evaluated at baseline, 1-year follow-up and 3-year follow-up.
• Open probing attachment level (OPAL) gain was evaluated at baseline and at 6-month reentry.
• Full-thickness flaps were elevated, defects were thoroughly debrided, categorized based on morphology, minocycline was used to condition the root surface (3 minutes), EMD was applied to the surgical site, graft (FDBA or DFDBA) was mixed with minocycline and EMD and placed into the defect, and flaps were closed

Results:

• 67 total patients completed the study. EF group (23), ED group (23), and E control group (23)
• Changes in PD (mm, 95% CI)
• 1 year: EMD/FDBA (4.4 mm, 4.0 to 4.7), EMD/DFDBA (3.7 mm, 3.4 to 4.0), and EMD (3.3 mm, 3.0 to 3.6)
• 3 years: EMD/FDBA (4.4mm, 4.1 to 4.8), EMD/DFDBA (3.7mm, 3.4 to 4.0), and EMD (3.1 mm, 2.8 to 3.4)
• Changes in CAL (mm, 95% CI)
• 1 year: EMD/FDBA (4.1 mm, 3.8 to 4.5), EMD/DFDBA (3.5mm, 3.0 to 4.0), and EMD (3.0mm, 2.5 to 3.6)
• 3 years: EMD/FDBA (4.2 mm, 3.7 to 4.7), EMD/DFDBA (3.6 mm, 3.1 to 4.1), and EMD (3.0 mm, 2.5 to 3.5)
• There were significant differences for OPAL changes between the two intervention groups and the EMD group (0.9 mm difference for each), but not between the two intervention groups.

Conclusion: Both EMD/FDBA and EMD/DFDBA combinations result in greater soft and hard tissue improvements than EMD alone. Both graft materials worked well in combination with EMD.

Topic: EMD + BioOss

Author: Zuchelli G, Amore C, Montebugnoli L, DeSanctis M

Title: Enamel matrix proteins and bovine porous bone mineral in the treatment of intrabony defects: a comparative controlled clinical trial

Source: J Periodontol 2003; 74: 1725-1735

DOI: 10.1902/jop.2003.74.12.1725

Type: clinical

Keywords: enamel matrix proteins, xenograft, periodontal defects

Purpose: To perform an RCT comparing the clinical efficacy of enamel matrix proteins (EMP) and bovine porous bone mineral (BPBM, Bio-Oss) to EMP alone with the simplified papilla preservation (SPP) flap.

Methods: 60 patients (26M, 34F) with severe chronic periodontitis were enrolled. One tooth per patient had to have an angular defect >6mm PPD and >3mm radiographic intrabony component. 20 patients were smokers. Clinical measures were taken at baseline. Patients were randomly assigned to groups.

SX: Patients sites were accessed with SPP flaps, SRP and debridement was performed. EDTA placed on roots for 2min, then EMP gel was applied on the roots and left for 2min. In the test group, remaining EMP was mixed with BPBM and graft was packed into defects. In both groups complete flap closure was achieved.

SPT: Patients were seen every month for 1yr until the re-evaluation.

Results: CAL gain of 5.8 was achieved in the test group and CAL gain of 4.9 was seen in the control group. PD reduction was 6.2mm in EMP+BPBM vs 5.8 in EMP group. The difference between groups was SSD favoring the combined EMP and graft. Additionally, all sites treated with EMP+BPBM had at least 4mm gain.

Discussion: These results suggest that EMP application leads to clinically and statistically significant clinical gains and there may be a positive adjunct to using BPBM in the intrabony component.

Topic: Biologics – EMD

Authors: Hoffmann, T., Al-Machot, E., Meyle, J., Jervoe-Storm, P. M. & Jepsen, S.

Title: Three-year results following regenerative periodontal surgery of advanced intrabony defects with enamel matrix derivative alone or combined with a synthetic bone graft.

Source: Clinical Oral Investigations. 20, 357–364

DOI: 10.1007/s00784-015-1522-4

Type: Clinical

Keywords: bone replacement graft; enamel matrix derivative; intrabony defects

Purpose: to compare the clinical outcomes of EMD in combination with biphasic calcium phosphate or EMD alone in the treatment of advanced one or two-wall intrabony defects over a period of 36 months.

Method: Randomized, multi-center controlled trial design to evaluate the amount of defect fill 6 and 12 months following two different treatments for one and two-wall intrabony periodontal defects.

-Test group: EMD/ synthetic bone graft with modified papilla preservation, exposed root surface treated with 24% EDTA more 2 minutes, rinse, then application of EMD followed by placement of synthetic bone graft (60% hydroxyapatite and 40% beta-tricalcium phosphate)

-control group: same procedure with no synthetic bone graft placement.

Acrylic stent fabricated to calibrate measurements. Primary outcome was change in bone fill after 6, 12, and 36 months measured by bone sounding.

Results: 73 patients participated in the 6 and 12 month evaluation but only 30 subjects completed 36 months evaluation, 15 in each group. All defects were atleast 4mm depth and 2mm wide.

Mean depth from bone crest to depth of defect were 7.2mm (test) and 6.2 (control) and width 3.5mm (test) and 3.3mm (control).

After 36 months:

No differences between test and control groups for any variables.

Conclusion: This study showed favorable outcomes after 36 months with the use of EMD/ synthetic bone graft and EMD alone with comparable results for both treatments for intrabony periodontal defects. Concluding that results can be maintained over 3 year period and no improvement of results by adding synthetic biphasic calcium phosphate graft.

Author: Miron et al

Title: Comparison of the capacity of enamel matrix derivative gel and enamel matrix derivative in liquid formulation to adsorb to bone grafting materials

Source: J Periodontol 86, 578-587

DOI: 10.1902/jop.2015.140538

Type: in vitro

Keywords: Biphasic calcium phosphate; bone graft adsorption; bone transplantation; enamel matrix proteins; osseoinduction; osseoinductive

Purpose: to investigate the adsorption properties of enamel matrix proteins to bone grafts after surface coating with either EMD (as a liquid formulation) or EMD (as a gel formulation).

Methods:

• Three different types of grafting materials: natural bone mineral (NBM), DFDBA, or calcium phosphate (CaP) were coated with either EMD liquid or EMD gel
• 30 mg EMD were dissolved in 3 mL cold, sterile 0.1% acetic acid solution. Stock EMD solution was diluted 100x in 0.1 M carbonate buffer at 4°C to give a working solution of 100 mg/mL.
• One milliliter EMD solution was poured onto 100 mg grafting material in 24-well culture plates and incubated overnight at 4°C to form EMD liquid.
• EMD gel was dissolved to a concentration of 100 mg/mL and coated overnight onto bone grafting materials at 4°C
• Samples were analyzed by scanning electron microscopy (SEM), or transmission electron microscopy (TEM), using an immunostaining assay with gold-conjugated anti-EMD antibody
• Total protein adsorption to bone grafting material was quantified using an enzyme-linked immunosorbent assay (ELISA) kit for amelogenin
  

Results:

• Adsorption to amelogenin to the surface of grafting material varied significantly based on the carrier system used
• EMD gel adsorbed less protein to the surface of grafting particles, which easily dissociated from the graft surface after phosphate buffered saline rinsing
• TEM analyses revealed that adsorption of amelogenin proteins were significantly farther from the grafting material surface, likely a result of the thick polyglycolic acid gel carrier.
• ELISA protein quantification assay demonstrated that the combination of EMD liquid+ NBM and EMD liquid + DFDBA adsorbed higher amounts of amelogenin than all other treatment modalities
• Amelogenin proteins delivered by EMD liquid were able to penetrate the porous surface structure of NBM and DFDBA and adsorb to the interior of bone grafting particles.
• Grafting materials coated with EMD gel adsorbed more frequently to the exterior of grafting particles with little interior penetration
  

Discussion:

• Surface coatings with enamel matrix proteins vary depending on the coating of bone grafting materials with either EMD liquid or EMD gel.
• Differences in amelogenin adsorption were observed among NBM, DFDBA, and biphasic CaP particles
• The liquid formulation of EMD allows for increased and more complete surface loading or porous graft materials, as well as tighter and more stable surface coating with enamel matrix proteins
• Thus, the potential for a liquid carrier system for EMD, used to coat EMD, may be advantageous for better surface coating

Systematic Review:

Topic: Enamel matrix derivative

Author: Matarasso M, et al

Title: Enamel matrix derivative and bone grafts for periodontal regeneration of intrabony defects. A systematic review and meta-analysis

Source: Clin Oral Investig. 2015 Sep;19(7):1581-93.

DOI: 10.1007/s00784-015-1491-7

Type: Review

Keywords: Intrabony defect, Periodontal disease, Enamel matrix derivative, Bone graft, Periodontal pocket, Periodontal regeneration

Purpose: to assess the clinical efficacy of regenerative periodontal surgery in intrabony defects using a combination of EMD and bone grafts compared with the application of EMD alone.

Inclusion criteria:

• RCT comparing EMD + bone graft with EMD alone
• Controlled Clinical Trials (CCT) comparing EMD + bone graft with EMD alone
• Studies with a mean follow-up period between 6 and 24 months
• Defect sites with PD ≥5 mm
• Intrabonydefect depth ≥3 mm

Results:

• 12 studies included
• Six different types of intervention were tested:
• 4 studies: a combination of EMD and DBBM
• 2 studies: combination of EMD and autologous bone graft
• 2 studies: combination of EMD and Bioglass
• 2 studies: combination of hydroxyapatite and β-tricalcium phosphate (HA + β-TCP)
• 2 studies: combination of EMD and DFDBA
• 1 study: combination of EMD and β-TCP
• Follow-up varied from 6 months to 24 months
• Morphology of intrabonydefects:
• 4 studies: one-, two-, and three-wall intrabonydefects were treated
• 3 studies: two- and three-wall defects were selected
• 4 studies: one- to two-wall defects
• The percentage of sites with BOP was collected in three studies
• Mean PD reduction was 4.22mm at sites treated with EMD and bone graft and 4.12mm at sites treated with EMD alone.
• Mean difference of 0.05 mm was calculated.
• Mean CAL gain was 3.76mm for the intrabonydefects treated with combination of EMD and bone graft and 3.32mm for the defects treated with EMD alone.
• Mean difference of 0.37 mm was noted.
• At sites treated with EMD and bone graft, a mean recession increaseof 0.76mm was recorded, while at sites treated with EMD alone, the mean recession increase was 0.91mm
• Mean difference measured 0.35 mm

Conclusion:

• significantly better CAL gain and PD reduction in the defects treated with EMD and bone grafts when compared with the healing of the defects treated using EMD alone.
• statistically significantly better outcome in terms of recession increase following treatment with EMD alone.

Limitations:

• Despite the fact that tooth survival rate was 100 % using both regenerative approaches, none of the studies reported on the outcomes in terms of residual pockets ≥5 mm. Furthermore, in most studies, no data on sites with attachment loss following regenerative surgery were recorded

How does it compare to a more traditional GTR? Is it a justifiable expense to a patient?

Silvestri 2003
P: To compare the efficacy of GTR with non-resorbable membranes to Emdogain in infrabony defects.
M&M: 100 pt (50 EMD and 50 GTR) that had infrabony defect component of > 4mm were grafted at 6 centers (one university; five private practices). Pts were either nonsmokers or smoked less than 10 cigarettes/day (light smokers). Each pt received initial therapy and was randomly assigned to one group. In both groups, the roots were treated with EDTA 24% for 2 minutes. In the GTR group, the Gore membranes were removed 6 weeks after surgery, and tissues were coronally displaced to obtain complete coverage of newly formed tissues. Intrasurgically, the measurements recorded were CEJ-bottom alveolar crest and CEJ-bottom of bone defect. Pt received prophylaxis weekly for the first two months, and then every 3 months until one year after surgery. No probing or deep scaling was performed before the one-year follow-up. The treatments were then compared based on the percentage of their PAL gain and PD reduction.
R: Only 2 pts did not come to the one-year post-op visit. The percentage of smokers was 38% for GTR and 36% for EMD. Baseline parameters and outcomes were similar between groups (no significant difference). Membrane exposure occurred in 48% of the GTR group. The mean PAL expressed as a percent was 41% for EMD, while it was 48% for the GTR group (not statistically significant). When PAL > 8mm, GTR provided a statistically better outcome when compared to Emdogain by 0.3 mm. There was also a significant difference between the 3-wall group and the 1 and 2-wall groups. There was no significant difference between the 1 and 2-wall groups.
BL: There is no statistical difference between EMD and GTR with ePTFE membranes in defects with PAL < 8mm. If the PAL > 8mm, GTR provided better outcome. Results make sense. Gtr maintains the space better.

Topic: EMD

Author: Pontoriero R, Wennstrom J, Lindhe J

Title: The use of barrier membranes and enamel matrix proteins in the treatment of angular bone defects: a prospective controlled clinical study

Source: J Clin Periodontol 1999; 26: 833-840

DOI: 10.1034/j.1600-051x.1997.00833.x

Type: clinical

Keywords: barrier membranes, emdogain, open flap curettage

Purpose: To perform an RCT comparing the effect of barrier membranes or enamel matrix proteins with OFD and evaluate clinical outcomes.

Methods: 40 subjects (15M, 25F, 32-61yrs) were included. All had generalized advanced periodontal disease with 2 similar contralateral bony defects with PPD at least 6mm and a radiographic bony component of at least 3mm. Baseline measures were taken. Subjects were divided into 4 groups (20 per group): 1) Guidor, 2) Resolut 3) ePTFE 4) Emdogain, each subject had one site in the test and one site served as a control. All sites received OFD, then rinsed with saline. For the membrane groups, they were placed and primary closure was acheived, ePTFE membranes were removed at 4weeks. Emdogain sites were treated with EDTA gel for 2min, then the EMD was administered and the sites were sutured. Patients were recalled 2x/month for SPT. Re-examination was performed after 12 months.

Results: Plaque scores for the 4 groups at baseline were 14-15%. At 12 months follow-up <10% of treated sites had bleeding on probing, the improvement in BOP was similar for all test and control sites. In all test groups there was a statistically significant reduction of PPD of about 3.2-4.8mm and was as significant recession of 1.1-1.9mm.

Comparing the barrier membrane groups to Emdogain treatment there was no significant difference for clinical measures or bone fill. All regenerative techniques performed better than the control for bone fill.

Discussion: These findings show that regenerative procedures with either GTR or Emdogain are successful in reducing probing attachment loss, and obtaining defect fill especially when compared to control of OFD.

Topic: Emdogain

Authors: Sculean, A., Windisch, P., Chiantella, G. C., Donos, N., Brecx, M. & Reich, E

Title: Treatment of intrabony defects with enamel matrix proteins and guided tissue regeneration. A prospective controlled clinical study.

Source: Journal of Clinical Periodontology 2001;28, 397–403

DOI: 10.1034/j.1600-051x.2001.028005397.x

Type: Clinical

Purpose: To evaluate clinically the treatment effect of EMD, GTR, combination of EMD and GTR, and flap surgery (control) on intrabony defects.

Methods:

• 56 patients each of whom displaying one intrabony defect of a depth of at least 6 mm were randomly treated with one of the treatment modalities. Each patient had no systemic diseases which could interfere with periodontal healing; no use of antibiotics the last 6 months prior to treatment; good level of oral hygiene.
• The following clinical measurements were made one week prior to and at one year after surgery by the same blinded and previously calibrated examiner: plaque index (PlI), gingival index (GI), bleeding on probing (BOP), probing pocket depth (PD), gingival recession (GR), and clinical attachment level (CAL).
• The defects were randomly assigned to one of 4 treatment groups: 1. EMD alone 2. GTR with goretexmembrane 3. Combination GTR and EMD 4. Control.
• All patients received antibiotics for ten days (3×500 mg amoxicillin). The post-operative care consisted of 0.2% chlorhexidine digluconatesolution rinses twice a day for 6 weeks.

Results:

• At one year the PPD decreased significantly in all four groups. However, between the groups no statistically significant difference was found. In all four groups the GR increased significantly compared to the baseline, but the difference between the groups was not significant. The CAL improved significantly in all four groups when compared to the baseline. No statistically significant differences were observed between the EMD, GTR and EMD&GTR groups.

Conclusion: It may be concluded that all 3 regenerative treatment modalities may lead to higher CAL gain than the control one, and the combined treatment does not seem to improve the outcome of the regenerative procedure.

Topic: Biologics -EMD

Authors: Zucchelli, G., Bernardi, F., Montebugnoli, L. &De, S. M.

Title: Enamel matrix proteins and guided tissue regeneration with titanium-rein-forced expanded polytetrafluoroethylene mem-branes in the treatment of infrabony defects: a comparative controlled clinical trial.

Source: Journal of Periodontology 2002 73,3–12

DOI: 10.1902/jop.2002.73.1.3

Type: Clinical

Keywords: enamel matrix proteins; periodontal therapy; regeneration

Purpose: randomized controlled trial to compare the clinical efficacy of EMD and simplified papilla preservation flap of intrabony defects with same flap design combined with ePTFE ti-reinforced non resorbable membrane or access flap alone.

Method: 90 subjects participated in the study. Initial treatment consisted of OHI and SRP. Patients that smoked >20 cigarettes/ day received antibiotics 6 months before surgical treatment. One intrabony defects treated for each patient and was atleast 3mm deep and CAL >7mm. 40 incisors, 28 cuspids, 12 bicuspids, and 10 molars were treated. Clinical parameters recorded 1 week before surgery and 1 year after consisted of CAL, PD, and REC. Depth of defect measured at time of surgery.

3 different approaches to treat deep intrabony defects.

• Simplified papilla preservation (SPP) + EMD: SRP, 24% EDTA root conditioned 2 minutes and EMD powder combined with propylene glycol alginate (PGA) gel applied twice. First immediately after root conditioned and then right before last suture placed.
• SPP + Ti- ePTFE (GTR) group: SRP, 24% EDTA root conditioned for 2minutes, ePTFE membrane placed to overlap defects atleast 3mm.
• SPP alone: SRP and 24% EDTA root conditioning

Patients given Augmentin 1g/day beginning 1 day before procedure and post-operatively 6 days. CHX .12% CHX 2x/day for 11 weeks. Recall interval once a week for 11 weeks, then once a month for the duration of the follow-up of 1 year. Membrane removal after 6 weeks

Results: All sites healed uneventfully. Membrane exposure occurred in 10/30 cases but never exceeded 2mm of exposure. NSSD between the 3 groups found for plaque or bleeding scores at 1 year.

CAL: All groups showed significant differences in CAL, residual PD, and gingival recession. EMD and GTR groups showed less CAL after 1 year compared to flap control group. NSSD in CAL between EMD and GTR groups.

PD: EMD and flap groups showed significantly deeper PD at 1 year than GTR group.

• EMD group: mean reduction 5.1mm
• GTR group: mean reduction 6.5mm
• Flap: mean reduction 4.5mm

REC: SSD more recession at 1 year in GTR and flap control group than EMD group.

• EMD: mean 1mm
• GTR: mean 1.6mm
• Flap: mean 1.9mm

Conclusion: Both regenerative techniques (GTR and EMD) resulted in clinically and statistically significant improvements in CAL compared to flap procedure alone. Statistically significant greater amount of CAL gain was shown in GTR sites compared to EMD. EMD technique more simple and less invasive by not needing 2^nd surgery to remove the membrane. The use of EMD was helpful in favoring resolution of deep infrabony defects especially in esthetic zone and reduced patient morbidity.

Topic: EMD

Author: Sanz et al

Title: Treatment of intrabony defects with enamel matrix proteins or barrier membranes: results from a multicenter practice-based clinical trial

Source: J Periodontol 2004;75:726-733

DOI: 10.1902/jop.2004.75.5.726

Type: Clinical

Keywords: guided tissue regeneration, membranes, bioabsorable, enamel matrix proteins

Purpose: compare the clinical outcomes of enamel matrix proteins (EMD) versus placement of a bioabsorable membrane in conjunction with guided tissue regeneration (GTR).

Methods:

• Parallel group, randomized, multicenter, controlled clinical trial at 7 perio practices
• Test group: access of defect with papilla preservation flaps, surgical debridement, root conditioning with EDTA, application of EMD
• Control group: the same procedure except root condition and EMD application. A bioabsorable membrane was placed instead.
• 67 patients were included. A single defect was treated in each patient.
• Inclusion criteria: one intrabony defect ≥3mm in interproximal area of anterior and premolar teeth, presence of 2-3mm band of KT
• Exclusion criteria: <21 yo, uncontrolled/poorly controlled diabetes, unstable or life threatening conditions, requiring antibiotic prophylaxis, heavy smokers (>20 cigarettes/day), defects extending into furcation
• Recorded parameters recorded at baseline and 1 year post-op: full mouth plaque scores (FMPS), BOP, REC, PD, CEJ to bottom of defect (CEJ-BD), CEJ to bone crest (CEJ-BC). The intrabony component of the defect (INFRA) was calculated as INFRA = (CEJ- BD) − (CEJ-BC)
• Suture removal at 1 week post op, supragingival prophylaxis at 1,2,3,4,6 weeks. Pts were put on maintenance at 3, 6 and 9 months.

Results:

• EMD defects:
• CAL gain: 3.1 ±8mm
• PD reduction: 3.8 ± 1.5mm
• REC: 0.6 ± 0.9mm
• GTR group:
• CAL gain: 2.5 ± 1.9mm
• PD reduction: 3.3 ± 1.5mm
• REC: 0.7 ± 0.9mm
• Multivariate analysis indicated NSSD between EMD and GTR
• NSSD in terms of frequency distribution of the outcomes (obtaining <2mm CAL gain, 2-3mm CAL gain, and >3mm CAL gain).
• 100% GTR cases presents ≤1 surgical complication, with membrane exposure occurred in 35% of cases at 1 week, 62% at 3 weeks, and 29% at 6 weeks.
• Only 6% EMD sites displayed complications

Discussion:

• This trial did not demonstrate superiority of one treatment modality over the other
• Both EMD and GTR in conjunction with papilla preservations flaps resulted in significant improvements of CAL gains and PD reductions
• GTR outcomes were lower than anticipated, which was attributed to high prevalence of post-op complications
  

  ---

EMD in furcations.

Topic: Biologics – EMD

Authors: Hoffmann, T., Al-Machot, E., Meyle, J., Jervoe-Storm, P. M. & Jepsen, S.

Title: Three-year results following regenerative periodontal surgery of advanced intrabony defects with enamel matrix derivative alone or combined with a synthetic bone graft.

Source: Clinical Oral Investigations. 20, 357–364

DOI: 10.1007/s00784-015-1522-4

Type: Clinical

Keywords: bone replacement graft; enamel matrix derivative; intrabony defects

Purpose: to compare the clinical outcomes of EMD in combination with biphasic calcium phosphate or EMD alone in the treatment of advanced one or two-wall intrabony defects over a period of 36 months.

Method: Randomized, multi-center controlled trial design to evaluate the amount of defect fill 6 and 12 months following two different treatments for one and two-wall intrabony periodontal defects.

-Test group: EMD/ synthetic bone graft with modified papilla preservation, exposed root surface treated with 24% EDTA more 2 minutes, rinse, then application of EMD followed by placement of synthetic bone graft (60% hydroxyapatite and 40% beta-tricalcium phosphate)

-control group: same procedure with no synthetic bone graft placement.

Acrylic stent fabricated to calibrate measurements. Primary outcome was change in bone fill after 6, 12, and 36 months measured by bone sounding.

Results: 73 patients participated in the 6 and 12 month evaluation but only 30 subjects completed 36 months evaluation, 15 in each group. All defects were atleast 4mm depth and 2mm wide.

Mean depth from bone crest to depth of defect were 7.2mm (test) and 6.2 (control) and width 3.5mm (test) and 3.3mm (control).

After 36 months:

No differences between test and control groups for any variables.

Conclusion: This study showed favorable outcomes after 36 months with the use of EMD/ synthetic bone graft and EMD alone with comparable results for both treatments for intrabony periodontal defects. Concluding that results can be maintained over 3 year period and no improvement of results by adding synthetic biphasic calcium phosphate graft.

Topic: EMD in Furcations

Author: Hoffmann, T., Richter, S., Meyle, J., Gonzales, J.R., Heinz, B., Arjomand, M., Sculean, A.,Reich, E., Jepsen, K., Jepsen, S. &amp; Boedeker,R. H.

Title: A randomized clinical multi-center trial comparing enamel matrix derivative and membrane treatment of buccal class II furcation involvement in mandibular molars. Part III: patient factors and treatment outcome.

Source: Journal of Clinical Periodontology 2006; 33, 575–583.

DOI: 10.1111/j.1600-051X.2006.00947.x

Type: Randomized Clinical Trial

Keywords: enamel matrix derivative, guided tissue regeneration, mandibular class 2 furcation defects, patient factors, periodontal regeneration, treatment outcomes

Purpose: To evaluate, based on the reported data, some possible effects of patient factors on the outcomes following regenerative treatment of mandibular class 2 furcations.

Methods:

• Study protocols were followed as described by Jepsen et a. 2004
• 48 Patients were randomly allocated to the two sequences
• 21 patients for left EMD and right Resolut
• 27 patients for right EMD and left Resolut
• After surgery on both sides of the mouth, re-entry was completed at 14 months
• Measured Patient parameters:
• Smoking
• Age
• Gender
• Hypertension
• Oral Hygiene status
• Measured Clinical parameters:
• Change in horizontal depth
• Change of distance from fornix of furcation to bone crest of defect
• Change of distance stent to the bottom of defect
• Change of pocket depth at the middle of furcation
• Change of attachment level at the middle of furcation

Results:

• For all patient factors in all sequences combined with clinical parameters there was no difference in findings
• Smoking:
• For non-smokers, EMD treated sites had a higher median reduction of horizontal depth compared to the membrane treated sites (2.75mm vs 1.75mm) indicating aSSD of EMD over GTR in non-smokers
• Smokers were too small of a sample size to draw any conclusions
• Age:
• >54yo had a higher reduction in pocket depth at the middle of the furcation following treatment wit EMD versus membrane (0.37mm)
• This tendency was not found in <54yo
• Gender:
• Male patients with EMD had a higher reduction in the fornix of furcation to the bone crest than patients treated with membrane.
• This tendency was not found in females
• Oral Hygiene:
• Poor OH had a SS reduction in parameters: distance from fornix of furcation to bone crest of defect, horizontal depth of defect at the deepest point, when patients were treated with EMD compared to membrane
• This was not evident in patients with good OH

Discussion: A slight superiority was found when regenerating furcations using EMD compared to membranes for non-smokers, male patients, and those with poor OH.

What biologic modifiers have been studied in infrabony defects? Are these off-label uses or following manufacturer protocol? What are the advantages to biologic modifiers? What are the drawbacks?

Autologous platelet- / blood- derived growth factors (PRP, PRF, PRGF).

Dohan 2009 PRP, PRF and PDGF

Topic: Autologous Platelet/Blood Derived Growth Factors

Title: Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF).

Source: Trends

Biotechnol. 2009 Mar; 27(3):158-67.

DOI: 10.1016/j.tibtech.2008.11.009

Type: Discussion

Keywords: PRP, PRGF, PRF

Discussion:  A classification of the different platelet concentrates, and an overview of the available systems are presented. The use of platelet concentrates to improve healing has been explored during the last decade. Platelets contain high quantities of key growth factors, such as PDGF-AB (platelet derived growth factor- AB), TGF, 𝛽 -1 (transforming growth factor , 𝛽 -1) and VEGF (vascular endothelial growth factor), which can stimulate cell proliferation, matrix remodeling and angiogenesis. All available PRP (platelet rich plasma) techniques have some points in common: blood is collected with anticoagulant just before or during the surgery and is immediately processed with centrifugation. The time for platelet concentrates preparation is variable but it is always completed within an hour.

• Step 1: Softspin short centrifugation. This stepis designed to separate the blood into 3 layers, red blood cells (RBCs) are found at the bottom, acellular plasma (PPP-platelet poor plasma) is the supernatant and a “buffy coat” (BC) layer appears in between, in which platelets are concentrated. The “buffy coat” layer is typically of whitish color and contains the major proportion of the platelets and leukocytes.
• Step 2a: For production of pure PRP, PPP and superficial BC are transferred to another tube. After hardspin centrifugation, most of the PPP layer is discarded. The final P-PRP concentrate consists of an undetermined fraction of BC (containing a large number of platelets) suspended in some fibrin-rich plasma. Most leukocytes are not collected. 
• Step2b: For production of leukocyte-rich PRP (L-PRP), PPP the entire BC layer and some residual RBCs are transferred to another tube. After hardspin centrifugation, the PPP is discarded. The final L-PRP consists of the entire BC, which contains most of the platelets and leukocytes, and residual RBCs suspended in some fibrin-rich plasma. Because the manual PRP process is not clearly defined, this protocol might randomly lead to P-PRP or L-PRP.
• Different protocols exist for step 2.

3 Main sets of parameters are necessary for a clear classification of platelet concentrates.

1. Relates to the preparation kits and centrifuges used.
2. Relates to the content of the concentrate (platelets/leukocytes).
3. Relatesto the fibrin network that supports the platelet and leukocyte concentration during its application.

Actual available methods can be classified into 4 main categories depending on the characteristics of the obtained product:

1) pure PRP (P-PRP)

2) leukocyte rich PRP (L-PRP)

3) pure PRF (P-PRF)

4) leukocyte-rich PRF (L-PRF).

In each category, the concentrate can be produced by different processes, either in fully automatized set-up or by manual protocols.

• P-PRP
• Automated protocols: 1) plasmapheresis with a laboratory cell separator 2) Vivostat PRF.
• Manual protocols: 1) Anitua’s PRGF 2) Nahita PRP

Anitua’s PRGF: Venus blood is collected and centrifuged in several small tubes to obtain the three typical layers: RBCs, “buffy coat” and acellular plasma. The upper part of acellular plasma is called plasma poor in growth factors (PPGF)(1ml) and is discarded from each tube by careful pipetting. The remaining plasma is called PRGF (plasma rich in growth factors) and is collected with a pipette. The PRGF fraction (1ml) is collected and fibrin polymerization is induced by a 10% calcium chloride solution. After 15 to 20 min, an unstable PRGF gel is formed that will need to be used immediately.

L-PRP

• Automated protocols: SmartPReP, PCCS, GPS and Magellian.
• Manual protocols: Curasan, Friadent-Schutze, Regen and Plateltex

P-PRF

• Only method available is the Fibrinet PRFM.

L-PRF

• Choukroun’s PRF protocol. Blood is softly centrifuged immediately after collection without anticoagulants and coagulation starts quickly. Blood is separated into 3 components with the formation of a strong fibrin clot in the middle of the tube. This clot acts as a plug that traps most light blood components, such as platelet, leukocytes, growth factors and fibronectin. This method leads to the natural production of a dense leukocyte rich PRF clot. After compression of L-PRF clot, it can be easily used as a membrane.

The first published in vitro studies demonstrated a general tendency to stimulate the proliferation of several cell types, including osteoblasts, fibroblasts, tendon cells, chondrocytes, periodontal ligament cells and bone mesenchymal stem cells. However, contrasting results have also been reported. Clinical studies have indicated that platelet gels can shorten recovery time, reduce surgery-related swelling and pain, accelerate the repair of soft tissues and increase bone regeneration in the short term.

Topic: Regeneration

Author: Castro AB, Meschi N, Temmerman A, Pinto N, Lambrechts P, Teughels W, Quirynen M

Title: 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

Source: J Clin Periodontol. 2017 Jan; 44(1):67-82.

DOI: 10.1111/jcpe.12643

Type: Systematic review

Keywords: bone regeneration, gingival recession, intrabony defect, leucoctye-platelet rich fibrin, open flap debridement, tissue regeneration

Purpose: To study the beneficial effect of L-PRF used as sole filling material and as adjunct to conventional techniques in periodontal surgery.

Methods:

PICO

• Does L-PRF promote periodontal wound healing in systemically healthy patients (ASA I) during periodontal surgery compared to traditional techniques?
  • Population (P) = systemically healthy humans (ASA I) with loss of periodontal tissues.
  • Intervention (I) = use of L-PRF (protocol 2700 r.p.m./12 min. or 3000 r.p.m./10 min.) as sole biomaterial or in combination to other biomaterials in periodontal surgery.
  • Comparison (C) = traditional techniques: open flap debridement with or without grafting, periodontal plastic surgery via coronally advanced flap, with or without connective tissue graft.
  • Outcome (O) = alveolar bone and/or periodontal wound healing. A PICO question was created to

Results:

• 24 randomized control trails included
• 3 sub groups
  • Intra-bony defect fill
    • PD reduction, CAL gain and bone fill were shown when L-PRF was used alone or in combination with other biomaterials
  • Furcation defects
    • Only 2 articles were included for furcation defects
    • comparing OFD to OFD + L-PRF, Statistical significant differences could be found for PD reduction
  • Periodontal plastic surgery
    • The type of centrifuge and setting also differed from one study to another. More standardized protocols are necessary in order to better compare and standardize outcomes
    • Statistically significant PD reduction, CAL gain and Bone defect fill with the use of L-PRF
    • L-PRF and coronally placed flap may be an alternate to CTG
      • Mean root coverage of 86% at 6 months
    • Articles included may show signs of bias

Conclusion: Standardization of the protocol is needed to obtain an optimal effect of L-PRF in regenerative procedures. Favorable effects on hard and soft tissue healing and postoperative discomfort reduction were often reported when L-PRF was used.

Tobita, 2013 mesenchymal stromal cells
B: The implantation of mesenchymal stromal cells (MSCs) that can differentiate into osteoblasts, cementoblasts or PDL cells has been viewed as a promising approach for periodontal tissue regeneration. Although bone marrow is most abundant source for MSCs, other tissues like periosteum, muscle and adipose tissue also contain MSCs. Adipose tissue is attractive because of its abundance and accessibility. Adipose derived stem cells (ASCs) are isolated from fat tissue and can differentiate into cartilage, bone, and skeletal muscle.
P: To examine the combined implantation of autologous adipose tissue-derived stem cells (ASCs) and autologous platelet-rich plasma (PRP) in periodontal tissue engineering in a canine periodontal tissue defect model.
M+M: 8 beagle dogs (9-10 months old) anesthetized. Inguinal fat pads harvested, washed, minced and enzymatically digested, cells centrifuged for 5 min to obtain high density ASC, cells were resuspended and plated. Perio defects penetrating to furcation were generated in all dogs. Bilateral second, third, and fourth mandibular premolars were selected as experimental teeth. The height from top of bifurcation to reduced alveolar crest of the defect was 5mm; the apical extent of defect was marked with a notch. Root surfaces had all PDL and cementum removed. Prior to implantation of ASCs, blood was drawn and centrifuged for 10 mins from all dogsharvest plasma supernatant and buffy coat (consisting of platelets and leukocytes) into neutral tubeneutral tubes centrifuged for 15 mins to concentrate plateletsfinal PRP. ASCs were mixed with 1 mL PRP. The ASC/PRP mixture and PRP alone were activated with 2%CaCl2 and then 500microL of ASC/PRP gel or PRP gel alone were implanted into perio defect in each dog bilaterally. Non-implant sites also prepared. Animals sacrificed at 1 or 2 months post-implantation. Radiographs were taken. Histo and immunohisto analysis performed.
R:
At 1 month: Newly formed bone was detected at lower extent of perio defect in all 3 groups after implantation, in control group ingrowth of epithelium into upper part of defect was observed. ASC/PRP group cell arrangements observed on surface of dentin and newly formed cementum-like structures evident. PDL-like structures vertically integrated with newly formed cementum-like structures.

At 2 months : ASC/PRP group showed newly formed bone, but granular tissue was seen in upper and middle regions of defect in PRP only and control groups. ASC/PRP clearly exhibited newly formed cementum-like structures. PRP only and control groups had some newly formed cementum-like structures but no PDL-like structures were observed.

Percent areas of newly formed bone:
1 month: ASC/PRP- 35.1%; PRP only- 33.6%; control-37%
2 months: ASC/PRP- 63.9%; PRP only- 53.7%; control-40.3%
Percent areas of newly formed cementum:
1 month: ASC/PRP- 36.4%; PRP only- 37.7%; control-38.7%
2 months: ASC/PRP- 84.7%; PRP only- 62.5%; control-61.7%

ASC/PRP group showed newly formed bone and cementum-like structures significantly increased in defect region between 1 month and 2 months post implantation. NSSD between ASC/PRP group and PRP only a
nd control groups.

BL: The combined implantation of ASCs and PRP has potential to induce periodontal tissue regeneration in a canine model.

Pradeep 2012
P: To investigate the additional efficacy of autologous PRF or PRP with OFD in the tx of 3-wall intrabony defects (IBD) compared with OFD alone.
M&M: This is a randomized, double-masked, controlled clinical trial with a 9-month follow-up. 54 healthy pts were included with at least a 3mm IBD as well as a 5mm PD after phase I therapy. Pts with aggressive perio and smokers were excluded. Pts received either OFD alone or OFD + PRP or OFD + PRF. Clinical measurements were taken with customized stents at baseline and 9 months. Standardized PAs were taken as well. Pts were seen weekly for 1-month POT, and again at 3 and 9 months.
R: 38 sites were from single rooted teeth, and 52 sites were from multi-rooted teeth. Both PRF (3.77 +/- 1.19mm) and PRP (3.77 +/- 1.07mm) sites presented with significantly greater PD reduction at 9 months. CALgain was also greater in the PRF (3.17 +/- 1.3mm) and PRP (2.93 +/- 1.1mm) groups, but this was not SS compared with the control. Also, SS greater rx bone fill was found in PRF (55% +/- 11.4%) and PRP (57% +/- 14%) compared with the control (2% +/- 15%).
BL: PRF or PRP are beneficial in the treatment of intrabony defects when compared to OFD alone.

Lekovic 2012
Purpose: To evaluate the effectiveness of platelet-rich fibrin (PRF) in promoting clinical signs of periodontal regeneration in human intrabony defects and further assess the ability of bovine bone porous mineral (BPBM) to augment the regenerative effects of PRF in similar defects.
(PRF is believed to release polypeptide GFs such as TGF-β1, PDGF, vascular endothelial growth factor and matrix glycoproteins into the surgical wound for at least 7 days).
Materials and methods: 17 systemically healthy patients, 11 women and six men 44 years mean age, with matched pairs of interproximal intrabony defects. Inclusion criteria: two similar interproximal defects of PD 6mm or more 6 weeks after initial therapy., 2- or 3-wall defects (not craters), vital teeth, PI and GI less 1 or less and radiographic evidence of intrabony defects. Exclusion criteria: systemic illnesses, immune-compromised patients, pregnant women, pts taking drugs known to cause gingival enlargement.
Initial therapy included SRP, OHI, occlusal adjustment if needed and re-eval in 6-8 weeks. Split-mouth design, and two interproximal sites were assigned to the PRF or PRF-BPBM group. Stents were fabricated to measure PD, AL, and recession. GI and PI were also calculated.
In the surgery buccal and lingual FTF were elevated, debridement of the defects and SRP were performed and measurements of the bony defects were performed with the use of the stent. Defects were filled with Bio-Oss and PRF or with PRF alone and covered with a membrane of compressed PRF. Flaps were sutured with 4-0 silk and dressing was placed. Amoxicillin 500mg every 8h for 7 days and 0.12%Chx every 12 hours for 14 days were prescribed. Sutures were removed in one week, patients were examined weekly up to one month and then at 2,3 and 6 months post-op. During the first four visits sites were evaluated using the healing index (HI: 1 for poor healing up to 5 for excellent healing).
In six months clinical measurements were performed, radiographs were taken and surgical re-entry was done.
Results: The differences in PD, AL and defect fill were statistically significant in 6 months in favor of the PRF-BPBM group.

Plaque measurements, healing index and bleeding index were not significantly different between the two groups at baseline or at 6 months.
Conclusion: 1) PRF results in significant improvements of PD, CAL and defect fill compared with baseline and
2) BPBM significantly increases the regenerative effects observed with PRF in the treatment of human intrabony defects.

Cochran 2000 Bone Morphogenic protein (BMP)
Purpose: to monitor the long-term safety of patients treated with rhBMP-2 loaded in an absorbable collagen sponge ACS and to evaluate the dental implants placed in sites treated with this bone differentiation factor.
Materials and Methods

• 12 patients requiring either alveolar ridge preservation or augmentation. 6 patients received endosseous implants.
• Patients were monitored for 32 months at 6,12,18,24 and 36 months after rhBMP-2 placement
• Safety was assessed by monitoring oral examinations, PA xrays and occurrence of adverse experiences.
• Bone width was measured with a Boley gauge or a periodontal probe from buccal to palatal
• Bone height was measured with the help of a stent, from the inferior border of the stent to the lowest point of the alveolar crest.
• Bone length was measured from the mesial to distal aspect of the area to be augmented.

• Core biopsies were obtained when possible from rhBMP-2 areas prior to implant placement.

ResultsThe mean concentration of rhBMP-2 used was 0.43mg/ml. Twenty one adverse experiences were recorded over 36 months.The mean change from pre- to post-implantation in the alveolar ridge surrounding the tooth extraction site indicated a decrease in bone width (−3.6 mm) and height (−0.8 mm). In the alveolar ridge augmentation, the mean increase of 0.4 mm in bone width (range 0 to 2 mm), a mean increase of 1.2 mm in bone length (range –1 to 2 mm), and a reduction of –0.8 mm in bone height. All extraction sockets demonstrated some degree of fill.The alveolar ridge augmentation there was a mean increase of 0.4mm in bone width and 1.2mm in length, -0.8mm in height

Conclusion- Placement of rhBMP-2/ACS into an extraction site prior to dental implant placement does not appear to interfere with bone healing and subsequent osseointegration of an endosseous one- part, non-submerged dental implant with a titanium plasma-sprayed surface.That treatment with rhBMP-2/ACS (at 0.43 mg/ml) is safe, and that dental implants can be placed successfully in bony areas treated with rhBMP- 2/ACS.Normal alveolar bone formation in the treated sites. These findings support further studies on the use of rhBMP-2/ACS in oral applications.

Choi 2002
P: To evaluate regeneration of alveolar bone and cementum, and associated root resorption and ankylosis following surgical implantation of rhBMP-2/ACS (recombinant human bone morphogenetic protein-2 with an absorabable collagen plug).
M&M: 8 Mongrel dogs, bilateral 3-wall intrabony defects were surgically induced in the premolar region in the maxilla and mandible, root planning performed, reference notch made at base of defect. Defects received rhBMP-2/ACS, buffer/ACS (surgical control) or nothing (control). Primary closure obtained, post op Abx, CHX. Evaluated daily gingival health, maintenance of suture line closure, edema, evidence of tissue necrosis or infx prior to suture removal and then 2x/week after suture removal. Photos and radiographs taken at time of surgery, post surgery, and 8,16,24 wks after. Animals sacrificed at 24 weeks and histo analysis performed.
R: Surgical implantation of rhBMP-2/ACS resulted in accelerated enhanced bone formation in the 3-wall intrabony periodontal defects but no apparent enhancement of cementum regeneration. rhBMP-2/ACS did not appear to be associated with aberrant healing events such as root resorption and ankylosis.
BL: Surgical implantation of rhBMP-2/ACS may be used safely to support regeneration of alveolar bone in intrabony periodontal defects in dogs without adverse events such as root resorption or ankylosis complicating the regenerative procedure.

Chiu, 2013
BG: BMP-6 acts as an osteoinductive factor during endochondral bone formation in vivo and osteoblastic mesenchymal cell differentiation in vitro. Thus, BMP-6 has been suspected of fulfilling an important and unique role during the early stage of osteoprogenitor cell differentiation. Moreover, BMP-6 induces formation of more and larger bone nodules as well as increased osteocalcin secretion and is a 2-fold greater potent inducer of osteoblast differentiation than BMP-2 in vitro.
P: To evaluate periodontal wound healing/regeneration following application of a synthetic BMP-6 polypeptide to surgically created supra-alveolar periodontal defects in dogs
M&M: Eleven female Beagle dogs, 18-24 months old. Oral prophylaxis was performed 2 weeks prior to experimental surgeries. Bilateral supra-alveolar periodontal defects were created at the mandibular 2^nd and 3^rd premolars. Defect was approximated 4-5 mm from the CEJ to surgically reduced alveolar crest. Synthetic BMP-6 at 0.25, 1.0, 2.0 mg/ml on absorbable collagen sponge (ACS) was used. ACS was soak-loaded in BMP-6 solution to get dose/defect of 0.1, 0.4, 0.8 mg of BMP-6 for experiment sites and in sterile water for control site. Each treatment was randomly applied to each defect in 4 quadrants. The mucogingival flaps were advanced and adapted to submerge the crowns of the teeth and sutured. Animals were sacrificed at 8 weeks. Histology performed.
R: Healing was generally uneventful. Found cementum formation (mainly acellular), new bone, PDL. Ankylosis was not observed. The higher the concentration of BMP-6, the higher the frequency of membrane exposure (did you mean the ACS was exposed?) and the less new tissue formation. All concentrations performed better than control.
BL: Application of BMP-6/ACS onto surgically created supra-alveolar defects enhanced periodontal wound healing/regeneration. The low BMP-6 0.25 mg/ml concentration provided the most effective dose.

Platelet derived growth factors (PDGF) (commercially known as Gem 21S).

Nevins et al; 2003
Background: Purified recombinant human platelet-derived growth factor BB (rhPDGF-BB) is a potent wound healing growth factor and stimulator of the proliferation and recruitment of both periodontal ligament (PDL) and bone cells. This is the first report of periodontal regeneration demonstrated histologically in human Class II furcation defects.
Purpose: Hypothesis Application of rhPDGF-BB mixed in bone allograft would induce regeneration of a complete new attachment apparatus, including bone, PDL and cementum in human interproximal intrabony defects and molar Class II furcation lesions.
Methods: 9 non-smokers patients (15 sites) with advanced periodontitis, at least one tooth requiring extraction due to an extensive interproximal intrabony (7mm vertical defect) and/or molar Class II furcation defect (5x7mm) were entered into the study. 11 defects were randomly selected to receive rhPDGF-BB. Following FTF reflection and initial debridement, the tooth roots were notched at the apical extent of the calculus, the osseous defects were thoroughly debrided, and the tooth root(s) were planed/prepared. The osseous defects were then filled with demineralized freeze-dried bone allograft (DFDBA) saturated with one of three concentrations of rhPDGF-BB (0.5 mg/ml, 1.0 mg/ml, or 5.0 mg/ml). 4 IP defects were treated anorganic bovine bone in collagen (ABB-C) and a bilayer Bio-gide membrane. Radiographs, clinical probing depths, and attachment levels were obtained preoperatively (at baseline) and 9 months later. At 9 months postoperatively, the study tooth and surrounding tissues were removed en bloc. Clinical and radiographic data were analyzed for change from baseline by defect type and PDGF concentration. The histology was performed
Results: The post-surgical wound rapidly healed and was characterized by firm, pink gingivae within 7 to 10 days of surgery. There were no unfavorable tissue reactions or other safety concerns associated with the treatments throughout the course of the study.

• In rhPDGF/allograft sites, the vertical probing depth (vPD) reduction for interproximal defects was 6.42 ± 1.69 mm (mean ± SD) and clinical attachment level (CAL) gain was 6.17 ± 1.94 mm (both P <0.01).
• Radiographic fill was 2.14 ± 0.85 mm. Sites filled with ABBC had a PD reduction and CAL gain of 5.75 ± 0.5 and 5.25 ± 1.71, respectively.
• Furcation defects treated with rhPDGF/allograft exhibited a mean horizontal and vertical PD reduction of 3.40 ± 0.55 mm (P <0.001) and 4.00 ± 1.58 mm (P <0.005), respectively. The CAL gain for furcation defects was 3.2 ± 2.17 mm (P <0.030).
• Histologic evaluation revealed regeneration of a complete periodontal attachment apparatus, including new cementum, PDL, and bone coronal to the root notch in four of the six interproximal defects and all evaluable (four of four) furcation defects treated with PDGF.
• Two of the four interproximal intrabony defects treated with ABB-C and membrane exhibited regeneration.

Conclusions: Use of purified rhPDGF-BB mixed with bone allograft results in robust periodontal regeneration in both Class II furcations and interproximal intrabony defects.

Sarment, 2006 PDGF
Background: cell-surface receptors on periodontal and alveolar bone cells are stimulated by PDGF causing a positive effect on the DNA replication and chemotaxis of these cells. Pyridinoline cross-linked carboxyterminal telopeptide of Type I collagen (ICTP) has been shown as a biomarker for bone turnover.
P: To examine the quantity of ICTP released into periodontal wound fluid during tissue repair after periodontal reconstruction with PDGF-BB.
MM: 5 centers, 47 patients, PD >7 mm with at least 4 mm bony defect, were divided into 3 groups: b-TCP, b-TCP + 0.3 mg rhPDGF, and b-TCP w/ 1 mg rhPDGF. GCF (wound fluid) collected by strips at baseline, weeks 3, 6, 12, 18 and 24 after surgery. Radioimmunoassay was utilized to examine ICTP volume.
R: The b-TCP carrier alone group shows a decrease in the amount of ICTP released in the wound fluid up to week 24. The 0.3 and 1.0 mg/ml PDGF-BB groups had an increase in the amount of ICTP released up to 6 weeks. There were statistically significant differences at the week 6 time point between b-TCP carrier alone group versus 0.3 mg/ml PDGF-BB group (p<0.05) and between b-TCP alone versus the 1.0 mg/ml PDGF-BB-treated lesions (p<0.03). No difference was seen b/t the two PDGF-BB groups at either time frame.
C: rhPDGF increase ICTP in gingival wound fluid after surgery
`and at 6 months group 1 CAL gain continued to be greater than group 3. % bone fill was SS increased at 6 months for group 1 compared with both groups 2 and 3.
BL: Combining rhPDGF with bone graft or synthetic bone substitute for perio defects has potential to result in regeneration of bone and soft tissue. rhPDGF-BB has the promise to accelerate healing an formation of more abundant and higher quality of bone without needing to harvest autogenous bone. “rhPDGF-BB in combo with osteoconductive matrices has potential to become standard of care.”
CR: Samuel Lynch is president of BioMimetic and GEM 21S is a registered trademark of BioMimetic Therapeutics, Inc.

Topic: Biologics – PDGF ( Gem 21 )

Authors: Ridgway, H et al

Title: Human Histologic and clinical evaluation of recombinant human platelet derived growth factor and beta-tricalcium phosphate for the treatment of periodontal intraosseous defects.

Source: Int J Periodontics Restorative Dent 2008; 79: 677-683

DOI:

Type: Clinical

Keywords: rhPDGF, periodontal regeneration; clinical study

Purpose: To evaluate and compare histologic healing of intraosseous periodontal defects in humans treated with 0.3mg/ml and 1.0mg/ml rhPDGF-BB + β-TCP.

Method: 8 medically healthy patients (5M/3F), 36-68 years old, with advanced periodontitis were included. 2 teeth/patient were selected, 1 tooth was treated with 0.3 mg/ml rhPDGF-BB + β-TCP and the other tooth with 1mg/ml rhPDGF-BB + β-TCP.

Pre-surgical treatment: supra-g scaling/root planing, occlusal adjustment as needed. PD, CAL, REC were assessed before surgery and prior to block section.

Surgical therapy: FTFs, root notch placed along the apical extent of calculus, defects were degranulated, roots were scaled and planed, 2 defects/patient randomly selected to receive either 0.3 mg/ml rhPDGF-BB + β-TCP or 1mg/ml rhPDGF-BB + β-TCP, flaps positioned coronally to achieve primary closure. Dressing was applied. Pain medication and antibiotics were given (doxy 100mg 2xday).

Biopsy specimens were taken after a minimum of 180 days post-op to evaluate wound healing. Immediately prior to removal of biopsy specimens, soft tissue measurements were repeated. Histologic analysis was performed.

Results: 16 teeth were treated and analyzed.

• PD reduction was 4.6mm and CAL gain was 3.1mm for 0.3 mg/ml rhPDGF-BB + β-TCP.
• PD reduction was 4.3mm and CAL gain was 3.2mm for 1mg/ml rhPDGF-BB + β-TCP.
• NSSD between the two groups.
• Histologic evaluation demonstrated new bone, cementum and PDL coronal to the reference notch in 13/16 teeth.
• 2/16 defects healed with new attachment coronal to the notch and 1/16 defects healed with LJE.
• In sites that healed with regeneration there was not SSD between the two concentrations.
• New cementum formed on dentin and on old cementum.
• The majority of connective tissue fibers aligned parallel to root surface. Variable amounts of β-TCP particles could be seen encapsulated in the connective tissue without associated inflammatory infiltrate.

Conclusion: 0.3mg/ml and 1.0mg/ml rhPDGF-BB + β-TCP can promote regeneration in human intraosseous periodontal defects. Previous papers have found that 0.3mg/ml performs better for regeneration that 1.0mg/ml, this study detected no difference; however, it was not powered high enough to draw definitive conclusions.

Mishra 2013 ARTICLE
P: To evaluate modified minimally invasive surgical technique (M-MIST) with PDGF vs without PDGF in the treatment of intrabony defects.
M&M: 24 systemically healthy pts without a history of perio tx in the past 3 months were selected for the study. Smokers were excluded. A tooth with at least 5mm CAL and a 5mm PD with an intrabony defect depth of 3mm was selected. Defects with a buccal or lingual extension were excluded. OHI and initial therapy was performed on all pts and perio sx was performed wherever necessary prior to regenerative therapy. Pts wre randomly assigned to test (PDGF)or control group (no PDGF). The study was double-blind. All clinical parameters wre recorded at enrollment, baseline, 3 months and 6 moths-POT. Pas were taken (not standardized).
R: 22 pts completed the 6-month follow-up. Baseline clinical and rx defect characteristics between the groups were NSSD. CALgain and linear bone growth was 3.0 and 1.9 in test group and 2.6 and 1.9 in the control group. These differences were NSSD. All subjects had a CALgain of 2mm and above, with most pts showing a gain of 2-3mm.
BL: PDGF did not have a significant impact on the outcome of sx when the M-MIST technique is utilized for intrabony defects.

Topic: PDGF (Gem 21S)

Authors: Camelo, M., Nevins, ML., Schenk, RK., Lynch, SE. & Nevins, M.

Title: Periodontal regeneration in human Class II furcations using purified recombinant human platelet-derived growth factor-BB (rhPDGFBB) with bone allograft.

Source: Int J Periodontics Restorative Dent; 23:213-225, 2003.

DOI:

Type: Human clinical trial

Keywords: platelet-derived growth factor, bone allograft, furcation, human study, clinical trial

Purpose: There are 2 objectives in this study:

1. To determine if it is possible to achieve regeneration in advanced Class II furcation defects in humans following placement of a tissue-engineering product that combines purified rhPDGF-BB with allogeneic bone matrix.
2. To determine the safety and biocompatibility of the materials evaluated and the osteogenic potential of the product in advanced human furcation defects.

Methods:

• 4 molars with Class II furcations defects were selected for this study
• Three mandibular and one maxillary molar furcation defects were treated
• Pre-surgical preparation consisted of SRP (except for the selected tooth), OHI, and occlusal adjustment when indicated
• Examination at baseline was also completed:
• Depth of furcation, pocket depth, CAL, FGM, radiographs, medical and social history
• Full-thickness flaps were elevated, defects were thoroughly debrided, root surfaced was notched at the apical extent of the calculus, and calibrated probe was used to measure the furcation area
• Root surfaces were conditioned using tetracycline paste (4 minutes)
• Two defects received 0.5 mg/mL and two defects received 1.0 mg/mL rhPDGF-BB, in all cases mixed with DFDBA
• rhPDGF-BB/allograft mixture was packed into the osseous defect and the site was then closed
• Clinical probing depths and attachment levels were obtained pre-surgically and 9 months postsurgical, after which the teeth and surrounding tissues were removed via block extraction.

Results: After analysis of the 4 cases the following was observed:

• Both concentrations of rhPDGF-BB resulted in substantially improved horizontal (mean 3.5 mm) and vertical (mean 4.25 mm) probing depths and attachment levels (mean 3.75 mm).
• Histologic evaluation revealed periodontal regeneration, including new bone, cementum, and periodontal ligament coronal to the reference notch.
• Regeneration was also present coronal to the original osseous crest.
• In Case #2, an enamel projection extended into the fornix of the furcation, new calcified tissue with new inserting connective tissue fibers was observed over the enamel.

Conclusion: The study demonstrated that:

1. At both the clinical and microscopic levels, there was a favorable tissue response to the rhPDGF-BB–enhanced allograft
2. New calcified tissue with inserting collagen fibers can occur over enamel projections within furcations
3. For the first time, complete periodontal regeneration, documented histologically, was achieved in advanced Class II furcation defects.
   

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Topic: Gem-21

Author: Nevins M, Giannobile WB, McGuir MK, et al.

Title: Platelet-derived growth factor stimulates boen fill and rate of attachment level gain: results of a large multicenter randomized controlled trial.

Source: J Periodontol 2005l 76: 2205-2215

DOI: 10.1902/jop.2005.76.12.2205

Type: clinical

Keywords: platelet-derived growth factors, periodontal defects, regeneration

Purpose: To perform an RCT evaluated the safety and efficacy of rhPDGF-bb delivered in B-TCP for intrabony defects.

Methods: Patients were enrolled who had an interproximal periodontal defect requiring surgical treatment. A multi-center, triple-blind, prospective study was designed with 60 subjects per group (3 groups, 180 patients).

Group 1: B-TCP with 0.3mg/ml rhPDGF-bb

Group 2: B-TCP with 1mg/ml rhPDGF-bb

Group 3: B-TCP with buffer (control)

Standard OFD was performed and B-TCP was mixed with the appropriate buffer with or without PDGF-bb and placed in the osseous defects. The flaps were then sutured.

Clinical measures were assessed at baseline and 6 months post treatment.

Results: CAL gain was significantly greater at 3 months for Group 1 compared to Group 3 but was similar at 6 months. Group 1 also had greater bone fill and % defect fill (57% v. 18%) at 6 months. No serious adverse events were seen in any group.

Discussion: This RCT showed that rhPDGF-bb with B-TCP was safe and effective for reducing intrabony defects. The significant gain in CAL as early as 3 months demonstrates improved healing potential with the use of rh-PDGF-bb. Also the 0.3mg/ml is the effective level for rhPDGF-bb.

Topic: PDGF

Authors: McGuire MK, Kao RT, Nevins M, Lynch SE

Title: rhPDGF-BB promotes healing of periodontal defects: 24-month clinical and radiographic observations

Source: Int J Periodontics Restorative Dent 2006;26:223-23

DOI: 10.11607/prd.00.0690

Purpose: To present representative cases from the clinical trial for this new therapeu- tic system, for the period of enrollment through 24 months posttreatment.

Methods:

• Patients/cases were pulled from a previous study in which periodontal defects of more than 4mm were treated and palcedin on of 3 treatment groups. (1) B-TCP + 0.3 mg/mL rhPDGF-BB in buffer; (2) B-TCP + 1.0 mg/mL rhPDGF-BB in buffer; and (3) B- TCP + buffer (active control).
• Measurements included CAL and gingival recession (GR), measured clinically, as well as LBG(linear bone gain) and % BF( bone fill), as assessed radiographically by an independent centralized radiology review center.

Results:

Case1: 61-year-old nonsmoking Hispanic woman, presented with radio- graphic evidence of bone loss on the distal surface, as well as in the area of the furcation, of the mandibular left first molar. Clinical probing depth (PD) and attachment levels of 8 and 11 mm, respectively, were observed at baseline. The associated bone defect measured 5 mm deep distobuccally, 8 mm deep on the direct distal side, and 3 mm mesiodistally. This specific case received 0.3 mg/ml rhPDGF-BB, At 6 months postsurgery, PD and CAL measurements were 3 and 6 mm, respectively, representing a 5-mm improvement from baseline measurements. %BF on the distal surface of the tooth was calculated to be 81%, with an LBG of 5.11 mm. At 1 year the %BF was 94.3%, with an LBG of 5.97 mm. At 2 years The %BF was 94.3%, with an LBG of 5.97 mm.

Case 2: The patient, a 55-year-old Caucasian woman and smoker for 40 years, presented with radiographic evidence of bone loss on the mesial surface of the mandibular right first molar. A clinical PD of 9mm and CAL of 11 mm were observed at baseline. This case received 0.3 mg/mL rhPDGF-BB, . At 6 months, PD and CAL were 3 and 5 mm, respectively %BF on the mesial was calculated to be 65%, with an LBG of 4.11 mm. At 12 months, PD and CAL remained unchanged from 6 months 75% BF with an LBG of 4.79 mm. At 24 months, PD and CAL remained unchanged. The 6-mm improvement in CAL from baseline measurements was further supported by radiographic findings %BF of 99% and an LBG of 6.29 mm.

Case 3: The patient, a 38-year-old nonsmoking Caucasian man, presented with radiographic evidence of bone loss on the distal root surface of the mandibular right first molar that extended into the furcation. Baseline PD and CAL of 13 mm were observed. This patient received 1.0 mg/ml rhPDGF-BB, At 6 months postsurgery, PD and CAL were 4 mm, representing a 9-mm gain in CAL from baseline. %BF was calculated to be 46.2%, with an LBG of 4.98 mm. At 12 months, progression and maturation of bone fill continued in both the furcation and the distal defect %BF on the distal surface of the tooth was calculated to be 64.2% with an LBG of 7.0 mm. At 24 months, radiographic evidence of bone fill continued to increase from observations made at 12 months %BF of 77% and the LBG of 8.44 mm.

Case 4: The patient, a 31-year-old nonsmoking African American man, presented with radiographic evidence of bone loss on the mesial surface of the mandibular right first molar, with incipient bone loss in the area of the furcation. PD and CAL of 11 mm were observed at baseline. At 6 months postsurgery, PD and CAL were 4 mm, a 7-mm improvement from baseline %BF in the area of the original mesial defect was calculated to be 93%, with an LBG of 5.36 mm. At 18 months, PD and CAL measured 3 and 6 mm, respectively, representing 8- and 5-mm improvements from baseline measurements. Radiographic LBG was 5.43 mm, for a calculated %BF of 88%.

Conclusion: The current case series illustrates that gains in CAL following treatment with rhPDGF-BB + B-TCP are stable, and radiographic %BF and LBG may be expected to increase substantially following the initial 6-month postsurgical observation.

Topic: Biologics – PDGF ( Gem 21 )

Authors: Ridgway, H et al

Title: Human Histologic and clinical evaluation of recombinant human platelet derived growth factor and beta-tricalcium phosphate for the treatment of periodontal intraosseous defects.

Source: Int J Periodontics Restorative Dent 2008; 79: 677-683

DOI:

Type: Clinical

Keywords: rhPDGF, periodontal regeneration; clinical study

Purpose: To evaluate and compare histologic healing of intraosseous periodontal defects in humans treated with 0.3mg/ml and 1.0mg/ml rhPDGF-BB + β-TCP.

Method: 8 medically healthy patients (5M/3F), 36-68 years old, with advanced periodontitis were included. 2 teeth/patient were selected, 1 tooth was treated with 0.3 mg/ml rhPDGF-BB + β-TCP and the other tooth with 1mg/ml rhPDGF-BB + β-TCP.

Pre-surgical treatment: supra-g scaling/root planing, occlusal adjustment as needed. PD, CAL, REC were assessed before surgery and prior to block section.

Surgical therapy: FTFs, root notch placed along the apical extent of calculus, defects were degranulated, roots were scaled and planed, 2 defects/patient randomly selected to receive either 0.3 mg/ml rhPDGF-BB + β-TCP or 1mg/ml rhPDGF-BB + β-TCP, flaps positioned coronally to achieve primary closure. Dressing was applied. Pain medication and antibiotics were given (doxy 100mg 2xday).

Biopsy specimens were taken after a minimum of 180 days post-op to evaluate wound healing. Immediately prior to removal of biopsy specimens, soft tissue measurements were repeated. Histologic analysis was performed.

Results: 16 teeth were treated and analyzed.

PD reduction was 4.6mm and CAL gain was 3.1mm for 0.3 mg/ml rhPDGF-BB + β-TCP.

PD reduction was 4.3mm and CAL gain was 3.2mm for 1mg/ml rhPDGF-BB + β-TCP.

NSSD between the two groups.

Histologic evaluation demonstrated new bone, cementum and PDL coronal to the reference notch in 13/16 teeth.

2/16 defects healed with new attachment coronal to the notch and 1/16 defects healed with LJE.

In sites that healed with regeneration there was not SSD between the two concentrations.

New cementum formed on dentin and on old cementum.

The majority of connective tissue fibers aligned parallel to root surface. Variable amounts of β-TCP particles could be seen encapsulated in the connective tissue without associated inflammatory infiltrate.

Conclusion: 0.3mg/ml and 1.0mg/ml rhPDGF-BB + β-TCP can promote regeneration in human intraosseous periodontal defects. Previous papers have found that 0.3mg/ml performs better for regeneration that 1.0mg/ml, this study detected no difference; however, it was not powered high enough to draw definitive conclusions.

Topic: PDGF

Author: Nevins et al

Title: Platelet-derived growth factor promotes periodontal regeneration in localized osseous defects 36-month extension results from a randomized, controlled, double-masked clinical trial

Source: J Periodontol 2013;84:456-464.

DOI: 10.1902/jop.2012.120141

Type: clinical trial

Keywords: bone regeneration, platelet-derived growth factor, tissue engineering

Purpose: to provide results from a 36-month study evaluating the effect and long-term stability of PDGF-BB treatment in patients with localized severe periodontal osseous defects

Methods:

• 135 patients enrolled from 6 clinical centers, 85 patients completed the study at 36 months. Each pt had one localized periodontal osseous defected that was treated.
• Test groups:
  • b-tricalcium phosphate (b-TCP) scaffold with 0.3mg/ml PDGF
  • b-tricalcium phosphate (b-TCP) scaffold with 1.0 mg/ml PDGF
• Control group: b-scaffold matrix without PDGF
• The effectiveness measures consisted of CAL gain, PD reduction (PDR), gingival recession (GR), radio graphic LBG, and radiographic % bone fill (BF)
• Composite analysis for clinical and radiographic evidence of treatment success was defined as % of cases with CAL ≥2.7mm and linear bone growth (LBG) ≥1.1mm
  

Results:

• Participants exceeding this composite outcome benchmark in the 0.3mg/ml rhPDGF-BB were 62.2% at 12 months, 75.9% at 24 months, and 87% at 36 months
• 0mg/ml PDGF-BB values are 60.5% at 12 months, 48.3% at 24 months,
• Control group: 39.5% at 12 months, 48.3% at 24 months, 53.8% at 36 months.
• In both this study and the initial report at 6 months, 0.3 mg/mL PDGF is favored over the 1.0- mg/mL dose.
• rhPDGF-BB at 0.3 mg/mL was shown to result in significantly greater composite clinical and radiographic improvements, from baseline throughout the 36-month observation period, in moderate-to-severe 2- and 3-wall periodontal infrabony defects.
• NSSD increases in CAL and LBG at 36 months among all groups, but there were continued increases in CAL gain, LBG and % bone fill over time, suggesting overall stability of the regenerative response

Discussion:

• PDGF-BB at 0.3mg/ml in a synthetic scaffold matrix promotes long-term stable clinical and radiographic improvements as measure by CAL gain and LBG for patients possessing localized periodontal defects
  

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Oates 1993
Background: PDGF is a potent mitogen for cells of mesenchymal origin. Active PDGF protein dimers can be produced by the combination of PDGF A-chian and B-chain polypeptides into 3 identified isoforms, AA, BB, AB, each of which has unique binding affinities for the PDGF receptors α or β on the cell membrane. IL-1 is synthesized by a wide variety of cells including periosteal fibroblasts, macrophages and gingival fibroblasts. TGF-β is released at wound sites by platelets and macrophages. Osseous tissue provides one of the largest storage sites for TGF-β.
Purpose: To characterize the individual and interactive effects of PDGF-AA and PDGF-BB, IL-1β and TGF-β1 on the mitogenesis of fibroblast – like cells derived from human periodontal ligament.
Materials and methods: Cells were obtained from PDL explants from 4 premolars which were extracted for non-periodontal reasons. Cells cultured had a fibroblast-like morphology and a comparable rate of proliferation. Cells were cultured in different plates, GFs were added and cells were labeled and then tested for functional activity.
Results: PDGF-AA and –BB were found to be potent mitogens for human PDL cells enhancing the mitogenic activity 10- and 12- fold respectively. This response was dose dependent and fro PDGF –AA time dependent too, with the 24-hour response greater than the 48-hour.
Addition of IL-1β produced no mitogenic enhancement. High concentrations of IL-1β produced significant inhibition of the mitogenic response, no time dependence was shown.
TGF-β produced increase in mitogenic response. Greatest response was after 48 hours. Concentration rate examined was 0.01 ng/ml to 2.0 ng/ml with 1.0 ng/ml producing the greatest response. This response was weak comparing to the one induced by PDGF isoforms.
Pre-incubation with TGF-β ffro 8-24 hours prior to IL-1β showed increased mitogenic activity comparing to no or 1-hour of TGF-β pre-incubation.
Conclusion: All three PDGF isoforms may play critical role in modulating oral fibroblast cell proliferation.
TGF-β1 was found to be a weak mitogen for the human PDL cells, but modulates the cellular response to both PDGF isoforms.
IL-1β is not mitogenic, it inhibits PDL cell mitogenesis at higher concentration.
Effect of GFs and their interaction in human PFL cell mitogenesis are complex and may involve regulation t both the protein and receptor level.

Giannobile 2001
Purpose: to determine the ability of a recombinant adenovirus encoding PDGF-A to transduce and modulate the activity of cementoblasts.
Materials and method

• • Murine PDGF-A cDNA was sub-cloned into a shuttle plasmid under the control of the cytomegalovirus promoter. The Viral backbone DNA

• The linearized shuttle plasmid were co-transferred into 293 packaging cells using calcium phosphate transfection.
• Cementoblasts cells were cultured.
• Flow cytometry, Norther blotting, Immunohistochemestry, alkaline phosphatase activity DNA synthesis assay were performed.

Results: This study demonstrates the effective transduction of cementoblasts by Ad2/GFP and Ad2/PDGF-A recombinant adenoviruses with strong effects on the stimulation DNA synthesis, cell proliferation and gene expression. Flow cytometry achieved nearly 100% transduction of cementoblasts.PDGF gene expression Strong expression of the PDGF-A gene was noted following gene transfer of Ad2/PDGF-A to cementoblasts.

Discussion

• Findings show that PDGF-A gene transfer is stable in vitro and that genes known to be modulated by PDGF are induced by Ad2/PDGF-A, and in a prolonged fashion.
• Data suggest that gene transfer to a putative cell type that participates in periodontal regeneration (i.e., the cementoblasts) can be effectively transduced at high levels (>90% of cells) for extended periods of time in vitro

Conclusio- The present study demonstrates effective gene transfer of PDGF-A to cementoblasts in vitro. The transduction of cementoblasts by PDGF-A results in stimulation of mitogenesis, proliferation, and expression of PDGF-inducible genes.

Inukai 2013
BG- Mesenchymal stem cells (MSC) are well known to secrete a variety of growth factors and cytokines. Recent in vitro studies have indicated that the paracrine effects of growth factors and cytokines secreted from implanted MSC’s may promote tissue regeneration. Previous reports have shown that bone marrow derived MSC-CM (conditioned medium from cultured mesenchymal stem cells) have a very high potential for bone regeneration that is mediated by the cooperative effects of cytokines such as insulin-like growth factor-1 (IGF-1), vascular endothelial growth factor (VEGF), and transforming growth factor- β1 (TGF-β1), which regulate several events of osteogenesis, including angiogenesis, cell migration, proliferation, and osteoblast differentiation.
P: To evaluate the effect of MSC-CM on periodontal regeneration.
M&M: 5 hybrid dogs, that had prior mand 1^st, 3^rd, or 4^th PMs extracted and allowed to heal for 8 weeks. dMSC-CM and dPDLC (PDL cells) were obtained from the dogs prior to surgery. FTF elevated, box-type 1-wall infrabony defects (4mm x 5mm) were created at the distal aspect of the 2^nd and mesial aspect of the 4^th PM’s in the R and L quads. Root planning performed, reference notch made at apical extent (5mm from CEJ). Defects were randomly divided into 3 groups: MSC-CM plus scaffold (TERUPLUG), PBS (phosphate buffered saline) plus scaffold, or no implant. Standardized radiographs obtained initially and at 4 weeks. Post op abx, CHX rinse, 4 weeks dogs sacrificed and histo eval. Parameters analyzed included: cementum regeneration height, bone regeneration height, bone regeneration area. Migration assays performed and ELISA used for cytokine evaluation.
R: MSC-CM stimulated migration and proliferation of dMSC’s and dPDLC’s. Cytokines such as insulin-like growth factor-1 (IGF-1), vascular endothelial growth factor (VEGF), transforming growth factor- β1 (TGF-β1), and hepatocyte growth factor were detected in MSC-CM. MSC-CM group showed cementum regeneration height of 3.01m, bone regeneration height of 3.19mm, and bone regeneration area of 4.89mm. A large amount of new lamellar and woven bone formation was observed. Thick layered and cellular cementum was also frequently observed in the MSC-SM group.
BL: These findings suggest that MSC-CM enhanced regeneration due to multiple cytokines contained in the MSC-CM.

Steven Spindler, DDS LLC