|Year : 2022 | Volume
| Issue : 1 | Page : 1-8
The use of titanium platelet-rich fibrin to enhance the treatment outcome of intrabony defect in the chronic periodontitis patients – A systematic review and meta-analysis
Swapna Arunkumar Mahale1, Ankita Katkurwar1, Jui Vilas Bhandare1, Arunkumar Mahale2
1 Department of Periodontology, MGV's KBH Dental College and Hospital, Nashik, Maharashtra, India
2 Department of Gen Medicine, SMBT Dental College, Sangamner, Maharashtra, India
|Date of Submission||19-Aug-2021|
|Date of Decision||18-Sep-2021|
|Date of Acceptance||29-Oct-2021|
|Date of Web Publication||06-Apr-2022|
Swapna Arunkumar Mahale
Professor and HOD, Dept Of Periodontology, MGV's KBH Dental College, Nashik, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim and Objective: The aim and objective of the study are to ascertain the use of titanium platelet-rich fibrin (T-PRF) to enhance the treatment outcome of intrabony defect in the chronic periodontitis patients. Methodology: Data resources: Four databases MEDLINE (by PubMed), Cochrane database, EBSCO, and Google Scholar were explored to identify the studies in English from 2015 up to March 2021. An additional hand search of relevant journals was also done. All the reviewers screened the retrieved articles using the particular inclusion criteria. Randomized control trials evaluating the use of T-PRF to enhance the treatment outcome of intrabony defect in chronic periodontitis patients were included in the study. Outcome variables examined were probing pocket depth (PPD) reduction, relative attachment level (RAL) gain, change in gingival index (GI) and plaque index (PI), radiographic depth reduction. Statistical Analysis: Data were analyzed using Revman 5.3 software. The mean differences and 95% confidence interval were used to illustrate the estimate of effect size. Study Selection: five relevant articles were recognized for data procurement. A total of 138 patients had been appraised with confirmation of intrabony defects. In the included studies, age span of participants was between 20 and 59 years. Results: It displayed that the use of T-PRF induced a reduction in PPD, gain in RAL along with open flap debridement (OFD) in the management of intrabony defects. The use of T-PRF along with OFD and OFD only has equal effect on GI and PI. Conclusion: Thus, within the constraints of the study, it implies that T-PRF can be adapted contentedly in conjunction with OFD to deal with the intrabony defect.
Keywords: Chronic periodontitis, intrabony defects, titanium platelet-rich fibrin
|How to cite this article:|
Mahale SA, Katkurwar A, Bhandare JV, Mahale A. The use of titanium platelet-rich fibrin to enhance the treatment outcome of intrabony defect in the chronic periodontitis patients – A systematic review and meta-analysis. J Dent Res Rev 2022;9:1-8
|How to cite this URL:|
Mahale SA, Katkurwar A, Bhandare JV, Mahale A. The use of titanium platelet-rich fibrin to enhance the treatment outcome of intrabony defect in the chronic periodontitis patients – A systematic review and meta-analysis. J Dent Res Rev [serial online] 2022 [cited 2022 Dec 2];9:1-8. Available from: https://www.jdrr.org/text.asp?2022/9/1/1/342698
| Introduction|| |
Periodontal regeneration is a multifactorial and complex procedure which is related to the reconstruction of cementum, periodontal ligament, and alveolar bone. The reconstruction of the periodontal tissues to maintain a clinically healthful state is the eventual purpose of the treatment. Periodontitis is a longstanding disease of the periodontium caused by periodontopathic bacteria, differentiated by the irreparable loss of periodontal apparatus as well as surrounding alveolar bone. Loss of supporting alveolar bone is the remarkable sign in the identification of periodontal disease. It triggers to horizontal and/or vertical bone defects, imparts loosening of teeth which step up the chance of teeth loss. Horizontal bone defects make restoration difficult. Whereas angular bone defects, particularly intrabony defects had proven superior regeneration potential.
In the last few decades, different treatment modalities involving nonsurgical techniques, as well as conservative, resective and regenerative surgical techniques, have been procured and have attained variable success. Platelet-rich fibrin (PRF) has been proposed by Choukroun et al. in 2001 as a second genesis platelet concentrate. It is a fibrin membrane endowed with growth factors and platelets after commencing from no coagulant blood without any biochemical agent. Due to constant extrication of growth factor from PRF, there is a spurring of neighboring progenitor cells leading to periodontal renewal as well as tissue reconciling. They also possess fibronectin, leukocytes, cytokines, and bone morphogenetic proteins that boost the wound healing process.
Productive clinical outcomes have been described with PRF for the treatment of intrabony defect but some physicians are bothered for wellbeing threat of glass tubes coated with silica used for pooling of blood in preparing PRF. The coating of silica in the tube is abundant to settle down with red corpuscles at bottom and adequately tiny for the section to swing in the buffy coat, fibrin along with poor layered blood plasma. Consequently, when the product is utilized for treatment, these molecules may extent to the patient. Hence, Tunalı et al., in 2013 harnessed titanium biomedical tubes for the construction of titanium coated titanium platelet-rich fibrin (T-PRF).
Titanium was stabilized as an oxide layer which has been more useful in stimulating platelets compared to glass tubes and forms a thicker fibrin clot which exhibits longer resorption span. Even histopathological studies by Tunalı et al. and Chatterjee et al. displayed that T-PRF boasted profuse fibrin meshwork as well as excessive cellular strangulation provoking increase cellularity at the prescribed loci thereby induced periodontal genesis.
Therefore, the objective of this systematic review is to ascertain the use of T-PRF to enhance the treatment outcome of intrabony defect in the patients with chronic periodontitis.
| Methodology|| |
Protocol and registration
PROSPERO is prospectively registered an international database for systematic reviews. The enrolment of the review protocol has been accomplished at PROSPERO (CRD42021225248) so as to elude any inadvertent imitation of the review on this topic. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines have been stringently abided., Our review question was “to evaluate the use of T-PRF to enhance the treatment outcome of intrabony defect in the chronic periodontitis patients.” PRISMA statement and Cochrane handbook for systematic review of interventions have been cited in describing this study.
Focused PICOS question
The following Population ,Intervention, Comparator, Outcome studies (PICOS) model was enrolled for this review:
The participants (P) included are systemically healthy adults with a clinical diagnosis of Chronic Periodontitis with intrabony defects.
I-types of interventions or test
The intervention (I) has been open flap debridement (OFD) with the use of T-PRF.
The control (C) has been OFD alone without the use of T-PRF or autologous PRF or leukocyte PRF.
Outcome (O) measures
- Primary outcome – probing pocket depth (PPD), relative attachment level (RAL), radiographic bone fill (defect depth)
- Secondary outcomes – plaque index (PI), gingival index (GI), histologic analysis.
All these outcomes were estimated up to a minimal recall visit of 9 months.
We ascertained for randomized controlled clinical trials, printed only in the English language. Limits exploited were “humans.” Further studies were obtained from manual seeking of journals, grey literature and related scientific papers.
A complete literature search was mounted from 2015 to March 2021. All randomized controlled clinical trials completed on the human gingival tissues were surveyed in four databases PubMed, EBSCO, Cochrane Database, and Google Scholar.
The search approach was achieved by compounding (Mesh Terms OR Key Words) and by means of the subsequent words: “T-PRF” OR “Titanium PRF” OR “T-PRF” AND “chronic periodontitis” OR “periodontitis” “AND “clinical attachment level” AND “intrabony defect” AND “OFD” OR “OFD” AND “Randomized Controlled Trial” OR “randomized control trial (RCT)” AND “PPD” OR “PPD” AND “Radiographic bone fill.”
Patients included were above18 years of age without any systemic illness possessing PPD ≥5 mm interproximally. They even had ability to maintain good oral hygiene. Both males and female patients willing to participate in the study and available for follow-up were included
Patients having habit of smoking, pregnant, lactating patients, or suffering from systemic illness which will influence periodontal tissues or inability to maintain oral hygiene were excluded.
Screening along with data extraction
The titles and abstracts of associated studies were solely isolated by all the appraisers to prevent any duplication of write up that do not match the involved norms. We acquired transcripts of the full text for all suitable write up and review, examiners judged them separately to choose whether they match the involved norms. Any disagreement was settled with open discussion and talking with auxillary authors. Articles that do not match the involved norms were eliminated and causes for removal were entered. Data were extracted from the eventually involved studies in an excel sheet independently by all the investigators and finally ascertained.
Risk of bias
The features of collected randomized clinical trials were appraised by all the investigators discretely applying the risk of the bias assessment tool (The Cochrane collaboration's tool) Seven quality norms were substantiated: (1) Random sequence generation (2) allocation concealment (selection bias), (3) blinding of participants and personnel (performance bias), (4) blinding of outcome assessment (detection bias), (5) incomplete outcome data (attrition bias), (6) selective outcome reporting (reporting bias), and (7) other bias. If any conflicts over a review then settled with consultation. The studies were coded as having a high, low, or unclear risk of bias by using the risk of the bias valuation tool. After the quality computation, the studies were grouped into (1) low risk: when entire norms are matched or even single norm is unclear/not met; (2) moderate risk: when two criteria are unclear/not matched; (3) high risk: when more than two criteria are not matched. As per the Cochrane handbook, Chi-square and Higgins index (I2) has been exercised to find out if there was discrepancy.
The software Revman 5.3 (Review Manager Version 5.3; The Cochrane Collaboration, Copenhagen, Denmark) was used for the meta-analysis of the included studies. The continuous data have been disclosed as mean difference and 95% confidence interval, with P < 0.05 being statistically significant. When the inconsistencies among the studies are low (P ≥ 0.10, I2 ≤ 50%), the model of fixed effect is adopted and when inconsistencies are high (P < 0.10, I2 >50%), the model of random effect is appropriate for meta-analysis. The outcome of meta-analysis has been captured in the forest plot.
| Results|| |
In all 217 studies, PubMed – 73, Google scholar – 43, Cochrane database – 85, and EBSCO – 16 were coupled after the initial electronic search. No studies were picked out by the hand searching. After inspecting the headings and abstracts, 5 articles,,,, have been reanalyzed for complete content, and the rest documents were omitted since either they were alike or they do not match the inclusion criteria. After studying the full content, no papers were precluded. All 5 studies were entered for record removal. The PRISMA flow plan of the selection method is condensed in [Figure 1].
One hundred and thirty-eight patients had been assessed with approval of intrabony defects. A. Chatterjee et al. incorporated the maximum number of 38 patients with 90 periodontal intrabony defects whereas Mitra et al. study comprised minimum of 10 patients. In the included studies, age span of participants was between 20 and 59 years. Only two studies, described gender distribution. One out of five studies were carried out in Turkey, rest all in India. There was an extreme follow-up of 9 months in all the studies. In two studies, valuation was done at baseline, 3 months, 6 months, and 9 months., In the study of Ustaoğlu et al., evaluation was done at baseline and 9 months. Monitoring was achieved at baseline, 6 months, and 9 months by Ashish Patel et al. whereas by Mitra et al. at baseline, 3 months, and 9 months. Only one study was a split mouth study. In three studies,,,, they have embraced three wall defects. In the study by Ashish Patel et al. have not specified the type of defect. In the study done by Ustaoğlu both 2 and 3 wall defects were included. Mitra et al. completed a study in which clinical, radiographic, and histological parameters were also estimated. The features of the involved studies have been compiled in [Table 1] and the extracted facts in [Table 2].
Quality of studies
All the articles described sequence generation, three articles exercised a coin toss method,,, one employed digital software, and the remaining one article did not clarify the method of random generation. Except one all other studies did not provide allocation concealment. Since it is a surgical procedure, it was impossible to be unsighted to the patient. One article was unsighted to the patient only regarding the group of procedure and not regarding the procedure, one article was blocked to the assessors while the remaining four,,,, articles were unclear regarding the assessor. Recall reports were finalized for entire papers excluding one where it is indistinct. Selective reporting was there only in one study. Other bias was not spotted in any study. After the appraisal, one article was ranked as low risk (when one criterion was not met or unclear). One article was listed as moderate risk (when two norms were not met or unclear) and three,, as high risk (when three or four norms are not met or unclear). The distinct computation of the specific studies has been presented in [Figure 2].
Probing pocket depth reduction
The meta-analysis was executed in 4 studies.,, A random-effect model was employed (I2 = 91%). The outcomes displayed the usage of T-PRF-induced reduction in PPD along with OFD in the management of intrabony defects [Figure 3]a. Subgroup analysis revealed that no significant difference was reported.
|Figure 3: (a) Forest plot for probing pocket depth reduction. (b) Forest plot for relative attachment level gain. (c) Forest plot for change in gingival index. (d) Forest plot for change in plaque index|
Click here to view
Relative attachment level gain
The meta-analysis was performed for 2 studies., A random-effects model has been applied (I2 = 97%). The outcomes demonstrated the T-PRF adoption induced a gain in attachment level along with OFD in the dealing of intrabony defects [Figure 3]b. Subgroup analysis revealed that no significant difference was constituted.
Change in gingival index
The meta-analysis was performed for 2 studies., A fixed-effect model was applied (I2 = 97%). The outcomes exhibited the usage of T-PRF along with OFD and OFD only have equal effect on GI. Although the outcomes for L PRF and T PRF were similar, T PRF was found to be more effective in the treatment of intrabony defects [Figure 3]c. Subgroup analysis revealed that the significant difference was noticed (P = 0.19).
Change in plaque index
Three studies,, were included in the meta-analysis. A fixed-effect model has been exercised (I2 = 24%). The outcomes revealed that there is appreciably equivalent shift in PI with T-PRF in contrast with OFD or L-PRF in the treatment of intrabony defects [Figure 3]d. Subgroup analysis affirmed that there was a significant difference constructed.
| Discussion|| |
The strive of periodontal surgical procedures allows to regulate and halt the periodontal infection and finally toward recreation of disoriented periodontal attachment apparatus. Success of periodontal regeneration rest on the restructuring of an epithelial closure, the impeachment of new acellular extrinsic fiber cementum, and the incorporation of functionally adapted to connective tissue fibers hooked on the root surface and reinstate alveolar bone level. A task in attaining this goal is with the managing of deep intra-osseous defect display, as it rises the hazard for disease progression and burst after systemic traditional remedy.
For the treatment of intrabony defects, there has not been any biomaterial which is regarded as gold standard. Thus, the quest for an ideal biomaterial is still there. The application of growth factors in periodontal regeneration plays a significant role, as they are endowed to be the responsible agents to stimulate the cells which are requisites for regeneration. These growth factors are the biologically active materials which initiate and govern the process of regeneration and thus they are being extensively research. In 2001, PRF had been invented by Choukroun et al. at France, which constitutes a novel phase in the platelet gel healing perception with simple dealing out with any other natural biological agent.
The tubes for the PRF preparation are treated with dense silica particles which sediment along with the erythrocytes, a tiny part of it gets laid off in buffy coat, fibrin, and platelet poor plasma sheets, and thereby extent to the patient. Many investigators have delineated the bioabsorbable as well as thrombogenicity of titanium. Tunali et al. in the research investigated that the constitution of PRF and T-PRF was identical histopathologically.
An in vivo estimation of T-PRF on a rabbit prototype confirmed that the initiation of bone and original connective tissue portion within the next 30 days when T-PRF has been employed. A histomorphometry examination represented that the T-PRF fibrin system encloses a greater extent than the white blood cell and PRF network, and the fibrin appears copious in the T-PRF models. Consequently, platelet activation by titanium assumes to exhibit some higher distinctive features. Even so, the interval between the release of growth factors with T PRF is quite long as compared to PRF.
Hence, with the preset attentive question, only RCTs were studied for this systematic review so as to evade honest procedural flaws and to get robust proof for the systematic review. Only two and three-walled inflammatory bowel disease (IBDs) were preserved as the number of bony walls demonstrates the usefulness of stabilizing a biomaterial, blood clots, as well as emergence of renewed blood vessels uniting the periodontal ligament and bony walls.
Four studies,,, have evaluated the IBD change. IBD is considered as distance from cementoenamel junction to the base of the defect. In studies of G Ustaoglu et al. and Gummaluri et al., long-cone parallel procedure with film stabilizer is analyzed along with J image software. Mitra et al. prepared occlusal stents of acrylic, ligature wire with a round metal ball. It furnished a fixed orientation tip and static angulations for the clinical extents of the intrabody defects whereas Ashish Patel et al. employed parallel cone technique. In all the studies, decrease in IBD depth was acquired in both experimental and control group and the alterations amid the groups were statistically significant. Two studies, evaluated defect depth resolution that is the distance between alveolar crest (AC) to base of defect. In the study by Gummaluri et al., percentage defect resolution was marked as a nonsignificant change (P = 0.096) among T-PRF and L-PRF groups following 9 months. Whereas Anirban Chatterjee et al. found statistically significant change in bone fill percentage among Group I (OFD alone) and II (OFD + PRF) and among Group I (OFD) and III (OFD = TRF), nonetheless no significant alterations were detected between Group II (OFD + PRF) and III (OFD + TPRF). One study was eliminated from meta-analysis because mean changes data could not be procured.
Regarding the outcome estimated that the use of T-PRF along with OFD and OFD only has equal effect on GI. Although the outcomes for L PRF and T PRF were similar, T PRF was found to be more effective in the reduction of GI. While there is almost equal change in PI with T-PRF in comparison with OFD alone or L-PRF in the treatment of intrabony defects. The utilization of T-PRF causes a decrease in PPD, improvement in RAL along with OFD when related to OFD alone or OFD + PRF or OFD + LPRF in the therapy of intrabony defect. Heterogeneity of PPD appears to be because of different probe harnessed for measurement.
It is important to keep in mind that the results may be significantly afflicted by other factors such as tooth morphology (one or more roots), defect structure, flap designs, and skill of the operator.
| Conclusion|| |
Thus, within the constraints of the study, it implies that T-PRF can be adapted contentedly in conjunction with OFD to deal with the intrabony defect. However, only provisional decision can be drawn from this study since there are restricted number of studies with lean data, having relatively high risk of bias and little follow-up span. To validate the adequacy of T-PRF, further high quality RCTs with a large sample size and long follow-up, as well as histologic confirmation for the nature of regeneration, are required to show a definitive outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]