|Year : 2015 | Volume
| Issue : 1 | Page : 69-73
Management of an endo-perio lesion in an immature tooth using autologous platelet-rich fibrin: A case report
NB Nagaveni1, K Nandini Kumari1, P Poornima1, VV Subba Reddy2
1 Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka, India
2 Department of Oral Pathology, College of Dental Sciences, Davangere, Karnataka, India
|Date of Web Publication||9-Jan-2015|
Dr. N B Nagaveni
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere - 577 004, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Treatment of an endo-perio lesion involving a non-vital young permanent tooth is a highly challenging task to Pediatric Dentists. There is a quest for the newer biological approach to management of these lesions as traditional methods have various disadvantages. Recently, platelet-rich fibrin (PRF), a second-generation platelet concentrate, is rich in growth factors have been used in the periodontal regeneration procedure. The purpose of this paper is to describe the efficacy of PRF in the treatment of a deep intra bony defect associated with an endo-perio lesion in an immature right mandibular first premolar of 12-year-old female patient. A freshly prepared autologous PRF membrane was placed in the bony defect following debridement. Clinical and radiographic follow-up were performed at regular intervals that revealed absence of pain, gain in clinical attachment level, reduction in probing depth, and excellent bone regeneration indicating successful outcome.
Keywords: Growth factors, platelet-rich fibrin, regeneration
|How to cite this article:|
Nagaveni N B, Kumari K N, Poornima P, Reddy VS. Management of an endo-perio lesion in an immature tooth using autologous platelet-rich fibrin: A case report. J Indian Soc Pedod Prev Dent 2015;33:69-73
|How to cite this URL:|
Nagaveni N B, Kumari K N, Poornima P, Reddy VS. Management of an endo-perio lesion in an immature tooth using autologous platelet-rich fibrin: A case report. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2020 Jan 25];33:69-73. Available from: http://www.jisppd.com/text.asp?2015/33/1/69/149013
| Introduction|| |
Pulpal inflammation and necrosis are caused by various agents like dental caries, restorative procedures, trauma, chemical irritation, and severe thermal stimulation. The inter-relationship between periodontal and endodontic disease has aroused much speculation, confusion, and controversy over the years. Simring and Goldberg  were the first authors who described the relationship between periodontal and pulpal diseases in 1964. Since then, the term endo-perio lesion has been used more frequently to describe lesions arising from inflammatory products found in varying degrees in both pulpal and periodontal tissues. According to Simon et al.,  an endo-perio lesion can be classified into five types:
- Primary endodontic lesion,
- Primary periodontal lesion,
- Primary endodontic lesion with secondary periodontal involvement,
- Primary periodontal lesion with secondary endodontic involvement, and
- True combined lesion.
Among these, the management of a true combined lesion is very difficult, especially when there is an extensive periodontal destruction.
The goal of periodontal therapy includes not only the arrest of periodontal disease progression, but also the regeneration of vital structures lost due to disease. Several treatment modalities have been investigated for the management of bony defect like open flap debridement,  bio-modification of the root surface, and various regenerative procedures, including guided tissue regeneration  and bone grafts.  However, to overcome the prevailing healing limitation in the endo-Perio lesion, the principles of tissue engineering have been started using a purified growth factor to stimulate the patient's own cells toward a regenerative response.
Recently platelet-rich plasma (PRP), a first-generation platelet concentrate has been used widely to accelerate soft tissue and hard tissue healing with promising results.  However, there are potential health related risks associated with the use of PRP.
PRF a second-generation platelet concentrate was first described by Choukroun et al., in 2001  has caught the interest of the various specialties of Dentistry. Its advantages over the better known PRP include ease of preparation or application, minimal expense, and lack of biochemical modification (no bovine thrombin or anticoagulant is required). It is strictly an autologous fibrin matrix containing a large quantity of platelet and leukocyte cytokines. Therefore, the purpose of this case report is to discuss the clinical andradiological outcome using PRF in the regeneration of a true combinedendo-perio lesion resulting in severe bone loss of an immature mandibular premolar.
| Case Report|| |
A 12-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry complaining of pain and pus discharge from the right lower back tooth region since 1 month. On intra-oral examination, inflammation of the attached gingiva with gingival abscess with respect to mandibular right first premolar (MRFP) was evident. Clinically, the tooth was normal with no evidence of dental caries or trauma, but it was tender on palpation and percussion and extrusion of pus from the gingival sulcus was noticed. The presence of deep periodontal pocket measuring 13 mm mesially was observed. Electric pulp testing was done to assess for tooth vitality, which confirmed that the tooth was non-vital. An intra-oral periapical radiograph was taken which showed deep intrabony defect on the mesial aspect of the tooth extending to the apical region of the root of MRFP. The tooth had an immature root, thin dentinal walls with wide open apex. On careful radiographic examination, the presence of occult dentinal caries beneath the intact enamel and approaching pulp was noticed [Figure 1]. Based on the above findings, a diagnosis of true combined lesion was made. Treatment planning was done taking into consideration that the tooth is non-vital with an immature root, thin dentinal walls, wide open apex and associated periodontal defect as well. Endodontic treatment was planned first and as the tooth was immature and non-vital, a conventional revascularization procedure initiating a blood clot was carried out. The discussion of revascularization procedure performed is not a part of this case report and will not be explained on further. Periodontal regenerative therapy using autologous PRF was planned for the treatment of deep intrabony defect. After a thorough explanation of the treatment plan, written informed consent was obtained from the patient's parents.
|Figure 1: Preoperative periapical radiograph showing mandibular first premolar with occult dentinal caries (arrows), open apex and deep intrabony defect|
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In this phase, periodontal parameters such as pocket probing depth, mobility and radiographic evidence of bone level were assessed.
For preparation of PRF, 5 ml of whole blood was drawn intravenously from the forearm (antecubital vein) of patient using an 18-gauge needle and collected in sterile plastic vaccutube without adding any anticoagulants. Immediately, the tube was centrifuged (Remi Model, Mumbai, Maharashtra, India) under 3000 revolutions per minute (RPM) for 15 minutes. This resulted in separation of whole blood into three layers [[Figure 2]a]:
|Figure 2: (a) 3 layers formed after centrifugation. (b) Retrieval of fibrin clot from the test tube using sterile tweezers|
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- Top-most layer consisting of a cellular straw-colored fluid - Platelet Poor Plasma (PPP),
- A middle layer containing PRF clot, and
- A lower layer rich in Red Blood Cells.
A sterile tweezer was inserted into the test tube to remove the PRF clot which is jelly like consistency [[Figure 2]b]. The PRF gel was pressed between the sterile dry gauze [[Figure 3]a] to squeeze out fluid which resulted in a membrane [[Figure 3]b].
|Figure 3: (a) Platelet rich fibrin clot after retrieval (b) Platelet-rich fibrin membrane|
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The surgical site was anesthetized using 2% lidocaine with 1:1,00000 epinephrine. A full thickness muco-periosteal flap was reflected at the buccal aspect following intra-crevicular incision and vertical releasing incision using periosteal elevator [Figure 4]. After reflection, the defect was thoroughly debrided and also deep scaling was carried out. This was followed byirrigation with Betadine (Nanz Med Science Pharma Ltd., Sirmour, India) and sterile saline solution. After debridement, PRF membrane was placed into the bony defect to the level of surrounding bony walls, taking care not to overfill [Figure 5]. The mucoperiosteal flap was replaced and primary soft tissue closure of the flap was achieved by means of non-resorbable black silk (3-0) suture.
|Figure 4: (a) Full thickness mucoperiosteal flap reflection in 44. (b) Complete penetration of the probe into the intrabony defect at mesial side of 44|
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|Figure 5: (a) Placement of PRF membrane into the defect (b) condensation of membrane (c) PRF membrane in place at the defect|
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Following surgery, the patient was instructed to avoid chewing in the operated site during the first post-operative day. She was advised to maintain proper oral hygiene, with instructions to rinse the mouth daily with a solution of 0.2% of chlorhexidine mouthwash (Indoco Remedies Ltd., Aurangabad, India) for 7 days. The sutures were removed 10 days after surgery and the patient was also advised to continue the mouthwash for another 3 weeks. Recall appointments were scheduled every 10 days for the first month, and then after 3 and 6 months. At every recall appointment, the oral hygiene of the patient was checked and reinforced.
Clinical and radiographic outcome
Ten days after the suture removal healing was found to be adequate. There was no history of pain or discomfort. The clinical appearance of the tooth had improved considerably at the time of evaluation 3 and 6 months following treatment. The periodontal probing pocket depth was found to reduce to 2 mm. Radiographic examination showed a significant bony fill in the defect [[Figure 6]b]. At 6-month follow-up, the radiograph showed complete bone fill similar to adjacent normal teeth [[Figure 6]c].
|Figure 6: (a) Pre operative intraoral periapical radiograph showing the mandibular first premolar with deep intrabony defect extending to open root apex. (b) At 3 month follow-up, favorable bone regeneration is evident. (c) At 6 month recall, radiograph showing excellent bone regeneration with normal trabecular architecture|
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| Discussion|| |
The management of an immature non-vital tooth in association with periodontal lesion including severe destruction of periodontal ligaments and the formation of intrabony defects, has always been a difficult challenge. Although the role of pulpal pathology in the etiology of periodontal destruction is still unclear, the high incidence of premolar teeth with occult caries  and accessory canals supports such an association.
Regeneration has emerged as one of the goals of therapy and has become a major area of research. Bone regeneration is a multi-factorial process and requires an orchestrated sequence of biological events including cell adhesion, migration, multiplication, and differentiation.  The invention of various regenerative biological agents and techniques has recently attracted the interest of researchers in the various fields of reconstructive surgeries.
Numerous studies , have shown that bone regeneration can be enhanced by the addition of specific growth factors. PRP was proposed as a method of introducing concentrated growth factors like platelet derived growth factor (PDGF), transforming growth factor beta 1 (TGF-B1), and Intrinsic growth factor 1 (IGF-1) to the surgical site, enriching the natural blood clot in order to expedite wound healing and stimulate bone regeneration. The effects of PRP have been examined in vitro and in vivo and proved to be successful in the management of intrabony defects and cystic lesions. ,,,, However, the use of bovine thrombin in its preparation may be associated with the development of antibodies to the factors V, XI, and thrombin. Antibody development may enhance the risk of life threatening coagulopathies. 
PRF, a second generation platelet concentrate, has been developed by Choukroun et al.,  to overcome the limitations associated with the use of PRP. PRF represents a new step in the platelet gel therapeutic concept with simplified processing minus artificial biochemical modification. It can be considered as an autologous healing biomaterial incorporating leukocyte, platelets and wide range of key healing proteins in a dense fibrin matrix. Use of PRF in the treatment of endo-perio lesion is a novel approach in Contemporary Pediatric Dentistry.
In contrast to PRP, PRF differs in many aspects. The classic PRP production requires blood collection with an anticoagulant, two step centrifugation followed by artificial polymerization of the platelet concentrate using calcium chloride and bovine thrombin. Whereas, PRF preparation requires neither anticoagulants nor bovine thrombin (nor any other jellifying agent), making it no more than centrifuged natural blood without additives. Furthermore, it serves as a reservoir for slow continuous release of growth factors over a period of 7-14 days.  In contrast, PRP exhibits sudden release of growth factors in approximately 7-14 hours.  After that, the release of growth factors dramatically decreases. Moreover, PRF enhances the proliferation of various cell types, stimulates cellular differentiation and enhances the angiogenesis.  The presence of leukocytes andcytokines along with small amounts of lymphocytes in PRF can play a significant role in the self regulation of inflammatory and infectious phenomenon.
The only disadvantages associated with PRF are the invasive procedure of drawing blood in children and the requirement of specialized equipment for its processing. However, these are minor drawbacks when compared with improved healing and the regenerative responses that were obtained by its use as documented from the previous published studies ,,,, and present case.
In the present case, a freshly prepared PRF membrane was placed into the periodontal defect without adding any other bone grafts. We achieved better results in probing pocket depth reduction and clinical attachment level gain. The radiographic examination revealed significant healing in the form of an excellent bone formation with normal trabecular architecture. This result may be attributedto the beneficial effects of PRF. PRF consists of a fibrin matrixpolymerized in a tetramolecular structure, including platelets, leukocytes, and cytokines and circulating stemcells. Slow fibrin polymerization during PRF processing leads to the intrinsic incorporation of platelet cytokines and the glycan chains in the fibrin meshes. In addition to this, PRF organizes as a dense fibrin scaffold with ahigh number of leukocytes concentrated in one part of theclot thereby causing growthfactor release, immune regulation, anti-infectious activity, and matrix remodeling and angiogenesis during wound healing.  Thus, by acting as a repository of tissue healing factors, PRF improved the regeneration of hard and soft tissues in the defect area.
The radiographic examination of the treated tooth in this case report suggests that PRF in form of membrane resulted in a significant amount of bone fill (bone regeneration) and reduction in pocket probing depth. This was in accordance with other case reports and studies like Bansal and Bharti,  and Pradeep et al. Also, studies by Sharma and Pradeep  and Singh,  and Lekovic et al.,  using PRF showed significant improvement in the clinical parameters when used in intrabony defects. However, more histological studies are needed to establish the exact nature of the clinical attachment gain following periodontal regeneration using the PRF.
| Conclusion|| |
On the basis of the results achieved from this case report, we conclude that periodontal regeneration is possible using PRF and is an ideal biomaterial for routine clinical use in the regeneration of the bony defects in children. However, controlled clinical trials are highly essential to evaluate if the addition of PRF alone or in combination with bone grafts significantly enhances bone formation and maturation.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]