Treatment of localized aggressive periodontitis
Contents
1. Surgical procedure A flap debridement procedure was undertaken An incision through the groove was performed and was extended beyond the defect site so as to allow lifting the flap and viewing the whole defect While debridement procedure was being performed the bone allograft was hydrated with PRP root surfaces were equally scraped and planed Figure 5 Bovine thrombin mixed with calcium gluconate at 1 6 proportion was incorporated into PRP in order to initiate activation This allowed the cellular adhesion molecules to bond bone allograft and provide a working component which would be easier to manipulate Once PRP is combined with bone allograft the Surgeon can use the material in several ways In the present clinical case it was additionally used as a membrane by placing on the site several layers of clotted PRP this membrane has a duration of 5 to 7 days This allows filtration of growth factors outside of the clot and penetration into the graft Flaps were repositioned a triple zero black silk with suspensory stitches was used to suture The patient s brackets were used to avoid further tissue contraction It is worth mentioning that during this phase orthodontic treatment was maintained inactive Postoperative care Postoperative care consisted on use of 12 chlorhexidine oral rinse twice a day avoiding mechanical cleansing of the surgical areas Sutures were removed 8 days after surgery This healing phase was comp2. was decided to repair damage caused by periodontal disease with platelet rich plasma PRP combined with bone allograft We would like to mention as precedent that PRP was first reported by Dr M Ferrari in 1987 as an autologous component used in an open heart surgical event with the aim of decreasing bleeding Unfortunately in recent years PRP could only be obtained through a cell separator or plasmapheresis machine These machines were large and costly therefore use of PRP was limited to the operating theatre and mainly used for major surgical events Usage for wound healing showed possible benefits to promote growth when applied to soft tissues this technique generated great expectations and numerous publications were included in varied medical specialties Table PRP is an autogenous blood clot which contains highly concentrated amounts of platelets In this clot the minimum platelet count is one million platelets microliter This represents from 4 to 7 times over the normal count which is 200 000 platelets microliter A normal blood clot contains 94 erythrocytes 6 platelets and less than 1 leukocytes In comparison a PRP blood clot contains 94 platelets only 5 erythrocytes and 1 leukocytes Figure 1 Platelets rise from cytoplasmic fragmentation of megakaryocyte in the bone marrow They enter circulation as anuclear elements therefore they have a limited 7 to 10 day life Platelets possess many pseudopod
3. Sheridan PJ Kupp LI Is platelet rich plasma the perfect enhancement factor A current review nt J Oral Maxillofac Implants 2003 18 1 93 103 Mailing address Beatriz Raquel Yanez Ocampo E mail raquely0 O yahoo com mx
4. 004 62 489 496 9 Norma Oficial Mexicana NOM 253 SSA1 2012 Para la disposicion de sangre humana y sus componentes con fines terap uticos 10 Asociaci n Argentina de Hemoterapia Manual t cnico de la Asociaci n de Banco de Sangre 15 edici n Argentina 2008 11 Lang NP Tonetti MS Periodontal risk assessment for patients in supportive periodontal therapy Oral Health Prev Dent 2003 1 1 7 16 12 Lindhe J Clinical periodontology and implant dentistry Cap 32 4ta ed Editorial M dica Panamericana 2003 pp 816 838 13 Marx RE Carlson ER Eichstaedt RM Strauss JE Georgeff KR Platelet rich plasma growth factor enhancement for bone grafts Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998 85 638 646 14 Freymiller EG Aghaloo TL Platelet rich plasma ready or not J Oral Maxillofac Surg 2004 62 4 484 488 15 Carlson NE Roach RB Jr Platelet rich plasma clinical applications in dentistry J Am Assoc 2002 133 10 1383 1386 RECOMMENDED READINGS Linch SE Genco RJ Tissue engineering applications in maxillofacial surgery and periodontics Chicago USA Quintessence Publishing Co Inc 1999 pp 18 25 71 82 Cho MI Lin WL Genco RJ Platelet derived growth factor modulated guided tissue regenerative therapy J Periodontal 1995 66 6 522 530 Tolga F Burak D Platelet rich plasma a promising innovation in dentistry J of the Canadian Dental Association 2003 69 10 Sanchez AR
5. Revista Odontol gica Mexicana Vol 19 No 2 e April June 2015 pp 106 113 Facultad de Odontolog a CASE REPORT Treatment of localized aggressive periodontitis with platelet rich plasma and bone allograft Clinical case report Tratamiento de periodontitis agresiva localizada con plasma rico en plaquetas y aloinjerto seo Un caso cl nico Beatriz Raquel Y ez Ocampo Mar a Guadalupe Mar n Gonz lez ABSTRACT Introduction Platelet rich plasma PRP has emerged as an alter native in periodontal therapy Presently there is an evidence based learning curve showing a first stage when it was used as cementing biomaterial as well as bone tissue regeneration stimulant In a se cond current stage based and substantiated on biological evidence it is applied for soft tissue wounds healing This has elicited great expectations in several medical specialties including dentistry Method The case here presented is of a healthy non smoker 29 year old female patient who attended the Graduate and Research School National School of Dentistry National University of Mexico UNAM Diagnosis emitted was localized aggressive periodontitis After phase I the patient was subjected to flap surgery with PRP and bone allograft Results The patient was assessed 6 and 12 months after treatment Based on the six maintenance parameters established by Drs Lang and Tonetti she was classified as pre senting low risk of periodontal disease re
6. ational School of Dentistry National University of Mexico UNAM This article can be read in its full version in the following page http www medigraphic com facultadodontologiaunam Revista Odontol gica Mexicana 2015 19 2 106 113 the repair or regeneration of damage caused They purported the aim of improving periodontal circumstances as well as preserving esthetics and function This does not mean that one technique might be better than the next it means that each technique has a precise indication In the present clinical case it Table I Medical specialties which have published PRP use Dentistry e Mandibular reconstruction e Bone grafts e Dental implants Traumatology Arthroplasty prostheses and implants Bone implants Spinal fusion Fractures and bone defects treatment Intra articular infiltrations Chondro articular regeneration Ophthalmology e Incision closure e Reparation of ulcers abrasions and burns Neurosurgery e Duramater reparation e Craniotomy in general e Pituitary tumor surgery Cardiovascular surgery e Vascular grafts and prostheses e Aortic abdominal thoracic or thoracic abdominal aneurysms e Carotid surgery e Venous ulcers Dermatology Dermis and epidermis regeneration Skin grafts Burns Bulbar implants and mesotherapy Body and facial mesotherapy for esthetic and reparation purpose Normal clot E Erythrocytes E Platelets E Leukocytes PRP clot 107
7. currence Conclusions Today s clinical operator increasingly understands the need of ma king decisions based upon scientific evidence To the present date we recognize that it is biologically possible for a higher platelet con centration to foster healing Key words Periodontitis platelet rich plasma bone allograft Palabras clave Periodontitis plasma rico en plaquetas aloinjerto seo INTRODUCTION Periodontal diseases are mixed endogenous infections caused by microorganisms which colonize and cause periodontal pockets recession or both These diseases were Classified in 1999 at the International Meeting for Classification of Periodontal Conditions and Diseases At said meeting aggressive periodontitis as such was characterized and named for the first time Aggressive periodontitis mainly appears in young systemically healthy patients It is characterized by rapid loss of attachment and bone destruction irrespective of the amount of present microbial deposits In these cases flora is specific with high RESUMEN Introducci n El plasma rico en plaquetas ha emergido como una alternativa en la terapia periodontal Hoy tenemos una curva de aprendizaje basada en la evidencia que nos muestra una primera etapa donde se utiliz como biomaterial cementante y como esti mulante de la regeneraci n de tejido seo En una segunda etapa actual se aplica para la curaci n de heridas en tejidos blandos ba sado y fundamentado en
8. e first to conduct a formal study and transmit to the scientific dental community the potential presented by platelet rich plasma From that moment onwards many clinicians and researchers started to publish countless articles related to PRP Unfortunately along this way a terminology confusion was established with respect to the systems used to obtain this platelet rich plasma and many studies were conducted with platelet poor plasma PPP Figure 5 Surgical procedure Techniques used to obtain PRP in several studies might influence their success since some isolation techniques might contribute to early and premature platelet degranulation We presently have an evidence based learning curve which overcomes aforementioned problems Within PRP s clinical use evolution there is a first stage where it was used as cementing biomaterial and as bone tissue regeneration stimulant In a second and more recent stage based on and supported by biological evidence it was applied to heal soft tissue wounds This fact has given rise to great expectations in several medical specialties the field of dentistry among them Revista Odontol gica Mexicana 2015 19 2 106 113 Bleeding when probing Environmental factors Systemic disease Bone loss age Figure 7 Maintenance diagram after one year CONCLUSIONS Today s clinician is every day more aware of the need to make decisions based on scientific evidence and not bas
9. ed on recommendations and treatment alternatives presented by the dental commercial industry PRP seems to increase the healing process speed since it is biologically possible that a higher platelet concentration might help wound healing This would be due to the greater platelet concentration and faster onset of cellular response when compared to normal blood clots REFERENCES 1 Armitage GC Development of a classification system for periodontal diseases and conditions Ann Periodontol 1999 4 1 6 2 Marx RE Garg AK Dental and craniofacial applications of platelet rich plasma Chicago Ed Quintessence 2005 3 Arcuri A Plasma rico en plaquetas Recuperacion de tejidos con factores estimulantes de crecimiento autologos Argentina Editorial AMOLCA 2013 113 Figure 6 Pre surgical and post surgical X rays One year after treatment 4 Steven R Thomas M Platelets Encyclopedia of life sciences amp 2001 Nature Publishing Group www els net 5 Guyton H Tratado de fisiolog a m dica 12a edici n M xico editorial Elsevier 2011 6 Anitua E Un nuevo enfoque en la regeneracion periodontal Plasma rico en factores de crecimiento Vitoria Espana Editorial Puesta al Dia Publicaciones 2000 7 The potential role of growth and differentiation factors in periodontal regeneration J Periodontol 1996 67 5 545 553 8 Marx RE Platelet rich plasma evidence to support its use J Oral Maxillofac Surg 2
10. ese active principles at the right moment and place to thus initiate a sequence of events which has the aim of restoring normal architecture of the tissue where they are found Figure 3 Interaction of PRP with bone allograft Due to its higher platelet concentration PRP initiates a faster cellular response in the bone graft than that observed with a normal blood clot Healing of bone graft takes place during the first three weeks and it is characterized by capillary growth proliferation and cell activity Table Il Function of growth factors Growth factor Action Stimulated cells PDGFaa Mitogens 1 Mesenchymal stem PDGFbb 2 Osteoblasts to create PDGFab 3 Endothelial cells for replication so they secrete basal lamina for new blood vessels 4 Fibroblasts for replication and collagen production TGFPp1 Morphogenic mitogens 1 Stimulate cell replication TGFB2 2 Stimulate matrix production 3 Direct differentiation towards cartilage or bone VEGE Their effect is limited to epithelial cells 1 They stimulate them so that they synthesize basal lamina 2 Recruitment of pericytes to support development of new blood vessels EGF Their effect is limited to mucous membrane and skin basal cells 1 Induce replication and migration on biological surface 2 Stimulate these cells so they produce specific components of basal membrane Revista Odontol gica Mexicana 2015 19 2 106 113 e omy oe E Receptor Mono
11. f growth factors and other cytokines in the alpha granules of these cellular elements PRP interaction mechanism Alpha granules contained in platelets be it in a normal blood clot or in a PRP clot begin to de granulize in a 10 minute period They secrete over 90 of their pre packed growth factors in less than one hour Secreted growth factors join the external surface of the cellular membrane in the graft flap or wound by means of the trans membrane receptors Studies have reported that adult mesenchymal stem cells osteoblasts fibroblasts endothelial cells and epidermal cells express receptors for factors in their cellular membrane These transmembrane receptors in turn induce activation of an internal signaling protein which is directed to the nucleus Figure 2 Within the nucleus transducing protein unblocks a specific genetic sequence for a regulated cellular function such as mitosis collagen synthesis osteoid production etc After the initial release of PRP related growth factors platelets synthesize and secrete additional growth factors during the remaining 7 days of life Once the platelet is depleted and dies the macrophage upon continuing to secrete growth factors assumes the function of wound healing regulation PRP involvement in healing process Intervention of growth factors Growth factors are in charge of sorting out tissue reparation and regeneration This action depends on the release of th
12. la evidencia biol gica lo que ha generado grandes expectativas en varias especialidades m dicas entre las que se encuentra la odontolog a M todo Se presenta un caso cl nico de una paciente de 29 a os de edad no fumadora y sin enfer medad sist mica la cual fue captada en la DEPel de la UNAM El diagn stico fue una periodontitis agresiva localizada Despu s de la fase se le realiz una cirug a por colgajo con PRP y aloinjerto seo Resultados Se valor a la paciente a los 6 y 12 meses des pu s del tratamiento y se clasific como paciente de bajo riesgo a la recurrencia de enfermedad periodontal durante el mantenimiento con base en los seis par metros del Dr Lang y Tonetti Conclusio nes El cl nico de hoy entiende cada vez m s la necesidad de tomar decisiones basadas en la evidencia cient fica Hasta este momen to sabemos que biol gicamente es posible que una concentraci n m s alta de plaquetas pueda ayudar en la cicatrizaci n proportions of Aggregatibacter as well as P gingivalis In this situation phagocytes can be affected Moreover other family members might be afflicted with the same condition In cases when first molars and central incisors are involved aggressive periodontitis is sub classified into localized Along the time different techniques have been used to treat this disease These techniques targeted Professor Implantology and Periodontics Department Gradua te and Research School N
13. leted with personal plaque control every two weeks during the first two months After that period the patient was included in a bi yearly maintenance program Revista Odontol gica Mexicana 2015 19 2 106 113 111 Figure 4 Initial circumstances RESULTS Clinical assessment results after 6 months showed health compatible circumstances with respect to color shape consistency texture and bleeding upon probing These results were maintained along 12 months During maintenance stage the patient s risk status was assessed taking into account 6 parameters after a year 12 1 Bleeding upon probing the distal aspect of tooth number 15 2 5 mm deep periodontal pocket at the distal aspect of tooth number 15 3 Absence of tooth loss during this period 4 Absence of bone loss Contrary to this radiographic assessment revealed bony filling in all sites with vertical defects Figure 6 5 General health status of patient was suitable 6 Environmental factors such as tobacco use and restorations were assessed in order to avoid compromising the achieved periodontal stability Based on the aforementioned six parameters we could conclude that the patient was under low risk of Y ez OBR et al Treatment of localized aggressive periodontitis with platelet rich plasma and bone allograft 112 periodontal disease recurrence one year after initial treatment Figure 7 DISCUSSION In 1998 Dr Marx et al were th
14. meric aosphorylation sphorylates to PIP2 109 Figure 2 Growth factors action mechanisms Injured tissue gt Patt Clotting cascade Healed tissue Epithelialization lt EGF VEGF Tissue granulation liquid Collagen synthesis Wound contraction After 3 to 6 weeks osteoprogenitor cells have proliferated and differentiated enough to produce osteoid In the third phase the osteoid weak and elastic undergoes resorption by osteoclasts which liberate BMPs IL and IL interleukin one and two and these in turn induce adjacent osteoclasts and mesenchymal stem cells to differentiate and produce a more mature substitution bone with lamellar architecture and non present Haversian systems in the osteoid PDGF Remodeling TGF gt and neutrophils Inflammation Macrophages activation EGF TaF preoer gt Fibroblast activit gt Figure 3 Healing process Intervention of growth factors This bone regeneration continues during the whole life of the graft with a normal rhythm of remodeling resorption replacement similar to the rest of the skeleton approximately 0 7 per day Platelets and PRP act in the initial biochemical first stage of a three phase bone regeneration sequence Recent PRP studies have revealed its efficiency when combined with bone substitute materials Bone substitutes produce new bone by way of osteoconduction of adjacent osteop
15. rogenitor cells Yanez OBR et al Treatment of localized aggressive periodontitis with platelet rich plasma and bone allograft 110 whilst autogenous graft produces new bone by way of the transplant of osteoprogenitor cells from a distant location The purpose of presenting this clinical case was to provide an alternative treatment for localized aggressive periodontitis with PRP and bone allograft and showing obtained results at 6 and 12 months Assessment of periodontitis recurrence risk in this patient was determined based upon the individualized risk assessment model To this effect the diagram proposed in 2003 by Drs Lang and Tonetti was used Said diagram included the following aspects Percentage of bleeding upon probing Prevalence of residual pockets larger than 4 mm Tooth loss Periodontal support loss with respect to patient s age General state of patient and genetic circumstances Environmental factors such as smoking RON o Ol METHODS The present article presents the case of a 29 year old female patient who sought treatment at the Graduate and Research School of the National School of Dentistry National University of Mexico UNAM The patient reported as dental history having initiated two years before orthodontic treatment nevertheless no diagnosis of periodontal disease was established at that time At the Graduate School s Periodontics Clinic diagnosis of localized aggres
16. s invaginations of cell membrane and internal vesicles storage granules Vesicles are composed by three granule types lysosomal dense and alpha Alpha granules are growth factors storing granules Growth factors are signaling proteins which regulate key events in a process of tissue reparation such as cell differentiation and proliferation as well as their maintenance E Erythrocytes E Platelets m Leukocytes Figure 1 Platelet percentages comparison in a normal clot and a PRP clot Yanez OBR et al Treatment of localized aggressive periodontitis with platelet rich plasma and bone allograft 108 Growth factors contained in these granules are 1 Growth factor derived from platelet PDGF aa isomer PDGF bb isomer and PDGF ab isomer 2 Beta transforming growth factor 1 and 2 TGFP 1 and TGFB 2 3 Endothelial vascular growth factor VEGF 4 Epithelial growth factor EGF Table II Studies report that platelets additionally contain abundant cytokines This term is used to describe a group of molecules which regulate cellular communication such as interleukins which were grouped as IL1 to IL15 interferons three tumor necrosis factors three colony stimulating factors and a diverse group of cytosines such as osteopontin oncostatin and lymphotactin among others Platelets do not contain insulin growth factor IGF or IGF or bone morphogenetic protein BMP The basis for PRP is the existence o
17. sive periodontitis was established Treatment was undertaken after the patient signed informed consent form Figure 4 Initially periodontal phase was undertaken PRESURGICAL PROCEDURE PRP was obtained before surgery at a blood bank Official Norm 003 of the Secretaria de Salud Mexican Health Ministry protocol was adhered to The procedure consisted on taking a 10 mL sample which was then subjected to preliminary exams of hepatitis and HIV among others Once the aforementioned studies were completed a 450 mL blood sample was extracted from the patient in order to obtain PRP Bearing in mind the fact that blood clots immediately the bag should contain an anti clotting agent Sodium citrate in order to prevent clotting Two centrifugations are required to separate and concentrate platelets In the first centrifugation plasma and formed elements are separated at 1 800 rom and temperature of 18 22 Celsius for 10 minutes Once the first centrifugation is completed two bags are obtained one with formed elements and the other with platelet poor plasma This last bag is taken to a machine called Optipress in order to separate by concentration gradients plasma and cellular elements The second centrifugation is conducted at 3 500 rpm 18 22 degrees Celsius for 10 minutes Once this is completed approximately 60 mL of platelet rich plasma is obtained PRP will remain in liquid form until activation during surgery
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