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ORIGINAL ARTICLE
Year : 2018  |  Volume : 36  |  Issue : 1  |  Page : 65-70
 

A clinicoradiographic comparison of the effects of platelet-rich fibrin gel and platelet-rich fibrin membrane as scaffolds in the apexification treatment of young permanent teeth


1 Department of Pedodontics, Government Dental College, Thrissur, India
2 Department of Conservative Dentistry and Endodontics, Madha Dental College and Hospital, Chennai, Tamil Nadu, India
3 Department of Pedodontics, GDC, Kozhikode, Kerala, India

Date of Web Publication28-Mar-2018

Correspondence Address:
Dr. Madhu Santhakumar
Department of Pedodontics, Government Dental College, Thrissur, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_180_17

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   Abstract 

Aims: This triple blinded clinical trial was undertaken to check whether Platelet rich firin in its membrane form is as reliable as when it is in the gel form. Settings and Design: Triple blinded randomized clinical trial. Methods and Material: 20 patients in PRF gel group and 20 patients in PRF membrane group selected after randomization and considering inclusion and exclusion criteria were taken up for this study. The samples were clinically and radiographically evaluated for success. Results and Conclusions: Regenerative endodontics with PRF membrane is easier and less time consuming. They have similar clinical success.PRF gel gave a better radiographic success in 12 months period.


Keywords: Apical closure, platelet-rich fibrin gel, platelet-rich fibrin membrane, regenerative endodontics


How to cite this article:
Santhakumar M, Yayathi S, Retnakumari N. A clinicoradiographic comparison of the effects of platelet-rich fibrin gel and platelet-rich fibrin membrane as scaffolds in the apexification treatment of young permanent teeth. J Indian Soc Pedod Prev Dent 2018;36:65-70

How to cite this URL:
Santhakumar M, Yayathi S, Retnakumari N. A clinicoradiographic comparison of the effects of platelet-rich fibrin gel and platelet-rich fibrin membrane as scaffolds in the apexification treatment of young permanent teeth. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2019 Nov 18];36:65-70. Available from: http://www.jisppd.com/text.asp?2018/36/1/65/228739





   Introduction Top


Trauma and dental caries can cause irreversible damage to the dental pulp. In a young permanent tooth, routine endodontic treatment may not be possible due to the immature apex it possesses. Newer methods based on the principles of revascularization and regeneration have been tried and found to be much better than the traditional methods of apexification since it helps in physiological root maturation, unlike traditional methods which result in only artificial barrier formation without root lengthening.[1],[2],[3],[4],[5],[6],[7] Three integral factors for apexification based on regenerative endodontic strategies were stem cells, signaling molecules, and scaffolds.[8],[9],[10] Platelet-rich fibrin (PRF) in the form of gel [11] was found to be a suitable biological scaffold. One problem identified with this PRF gel was its flexible consistency, making it difficult to place it into the root canal.[11],[12],[13] A PRF membrane made from PRF gel after removing its excess fluids could be a suitable alternative with improved handling features.[12],[13],[14] Hence, this randomized controlled triple-blinded clinical trial was undertaken to check whether PRF membrane is as reliable as PRF gel clinically and radiographically in doing apexification with regenerative endodontics.


   Materials and Methods Top


The study design was a triple-blinded randomized clinical trial for 18 months [Table 1].
Table 1: CONSORT 2010 flow diagram

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Forty patients with nonvital, immature maxillary central incisors were randomly categorized into two treatment groups: Group A, patients were treated with PRF gel, and Group B, patients were treated with PRF membrane as scaffold. The patients, investigator, and evaluator were unaware of allocation sequence. Randomization was done with a random number table drawn from the internet. Written Informed consent from parents and patients were obtained. The study was approved by Institutional Ethics Committee and registered with clinical trial registry. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975, as revised in 2000.

Inclusion criteria

Healthy controls in the age group of 7–12 years with nonvital maxillary central incisors and with root length less than crown length with open apex and short roots were included in this study. Patients were evaluated at 6-, 12-, and 18-month-intervals. Apical foramen need to be >2 mm wide.

Exclusion criteria

Patients allergic to drugs and with systemic diseases, patients with teeth with draining sinus, periodontally weak mobile teeth, internal or external root resorption etc., were excluded from the study

Treatment methods and assessment of success

Tooth was isolated with rubber dam and access opening done with around bur. Nonvital pulp tissue was removed with a barbed broach and irrigation of canal done with 3% sodium hypochlorite and saline. Canal was dried with paper points. Triple antibiotic paste,[15],[16] a mixture of metronidazole 400 mg, ciprofloxacin 200 mg, and minocycline 100 mg in 1:1:1 by weight was prepared and mixed with macrogol in 1:1 ratio and placed into the canal. Access was closed with cotton pellet and Intermediate restorative material (IRM). In the second sitting after 21 days, IRM and cotton were removed and antibiotic paste was removed with saline irrigation all under rubber dam isolation. Canal was dried with paper points. According to random allocation, using random number table, in 20 patients, PRF gel was used as scaffold and in the other 20 patients PRF membrane was used. The access was triple sealed with mineral trioxide aggregate (Pro root MTA), type II glass ionomer (Fugi 2) cement, and composite material (3M ESPE). The patient was reassessed for clinical and radiographic success in 6, 12, and 18 months.

Preparation of platelet-rich fibrin gel

A volume of 5 ml of blood sample was taken from patients' anticubital vein. The blood was centrifuged without anticoagulant at 3000 rpm for 10 min, and PRF gel [11] was obtained at the bottom of the test tube and was removed with a sterile tweezer [Figure 1] and [Figure 2].
Figure 1: Blood being drawn

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Figure 2: Platelet-rich fibrin gel

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Preparation of platelet-rich fibrin membrane

After obtaining PRF gel, it was squeezed using especially designed PRF compression device [13] [Figure 3] to remove the excess fluid. The rubber stopper in the PRF compression device ensured uniformity in the pressure applied [12],[13],[14]. The membrane obtained was cut linearly in the shape of root canal space for ease of placement [Figure 4].
Figure 3: Platelet-rich fibrin compression device

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Figure 4: Platelet-rich fibrin membrane

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Assessment of success

Patient was reviewed at 6, 12, and 18 months. Success was assessed using clinical and radiographic criteria. A treatment was clinically considered successful if the tooth is found to be without pain, mobility, abscess, and tenderness to percussion. For a radiographic success, two criteria were to be met, namely, attainment of minimum crown-to-root ratio [17] for crown placement (1:1) and apical closure. The increase in root length and root-end closure were assessed using a Shei's ruler [Figure 5].[18] Increase in root length was assessed by superimposing Schei's ruler over the radiographic image in such a way that the long axis of the tooth and the ruler was parallel to each other. The changes in the root length were determined by comparing the number of segments of Schei's ruler from the incisal edge to the root apex at the beginning of treatment and at 6, 12, and 18 months. The treatment was considered to be successful when both clinical and radiographic success were obtained.
Figure 5: Schei's ruler

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   Results Top


Assessment of treatment time

Total treatment time of second sitting when PRF gel or membrane was used was evaluated to know whether there was a significant difference in the treatment time using PRF gel and membrane. It was found that the total average treatment time was 43.42 min with PRF gel and 32.94 min with PRF membrane [Table 2]. The difference in time was found to be significant at 5% significance level (independent sample t-test).
Table 2: Treatment time with platelet-rich fibrin gel and platelet-rich fibrin membrane

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Independent operator who performed the procedures was interviewed after all the procedures, and he was of the opinion that PRF membrane was easier to manipulate compared to PRF gel.

Assessment of clinical success

Clinical success was defined by the absence of pain, swelling and mobility, and lack of tenderness to percussion. Patients were examined at 6-, 12-, and 18-month period. Out of 19 patients who could follow-up for PRF group, all the 19 were found to be successful clinically after 6 and 12 months. In the PRF membrane group also, of the 19 patients who completed the study, 19 were found to be clinically asymptomatic after 6 and 12 months. At the end of 18 months, both the groups showed 1 failed case with mobility and pain [Table 3]. Hence, clinical success was similar in both the groups [Table 3]. There is no significance difference between the two groups (P = 0.757 [Fisher's exact test]).
Table 3: Clinical success with platelet-rich fibrin gel and membrane

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Assessment of radiographic success

Root lengthening to achieve sufficient crown-to-root ratio and apical root-end closure was considered as criteria for radiographic success.

At the end of 6 months, there was no radiographic success in either group. At the end of 12 months, PRF gel group showed success in 10 cases whereas it was 6 in PRF membrane group which showed that gel group was probably faster in achieving radiographic success. However, there was no statistical significance between the groups (P = 0.89). Root lengthening and achievement of adequate crown-to-root ratio were achieved in 18 cases in PRF gel group but 17 in PRF membrane group [Table 4]. There is no significance difference between the two groups (P = 1.00 [Fishers' exact test]).
Table 4: Radiological success at 18 months

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Overall success rate considering both clinical and radiographic criteria was 18 out of 19 cases of PRF gel and 17 out of 19 in PRF membrane group [Table 5].
Table 5: Clinical and radiological success at 18 months

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   Discussion Top


Survival and reactivation of stem cells of apical papilla (SCAP) is the key behind the success of revascularization procedures for apexification.[4],[5] Different scaffolds have been tried for the migration and attachment of stem cells and biologically based scaffolds have been found to be most successful. Platelet-rich plasma and PRF have found to be suitable biological scaffolds.[6],[7] They had also the advantage that they are a rich source of growth factors and signaling molecules for the migration and proliferation of SCAP. Different studies have shown that PRF is easier to make, require less time for preparation, and requires no additives compared to PRP. One problem associated with PRF is its gelly consistency which makes it difficult to place it into root canals.[12],[13],[14] This study aims at nullifying this problem using a PRF membrane which could be easily made from PRF gel. It needed to be explored if PRF membrane has similar success compared to PRF gel.

To assess the ease of placement, treatment time was taken as criteria. The operator at the end of all the cases was asked was asked which material they preferred at the end of the study. Treatment time was 10.48 min higher with PRF gel group clearly indicating that PRF membrane was much less time-consuming. This was found to a statistically significant difference in treatment time. The independent evaluator preferred to use PRF membrane since it was easier to place it into the root canal.

Clinical and radiographical success was tested to assess if PRF membrane's success rate compared to PRF gel when used as scaffold. A treatment was considered successful when both clinical and radiographical success was met. Clinical success was identified with lack of symptoms such as pain, swelling, absence of tenderness to percussion, and mobility. In the present study, out of 19 patients who could follow-up for PRF group, all the 19 were found to be successful clinically. In the PRF membrane group also, of the 19 patients who completed the study, 19 were found to be clinically asymptomatic after 6 and 12 months. At the end of 18 months, both the groups showed 1 failed case with mobility and pain. Hence, clinical success was similar in both the groups.

For the radiographic success, two criteria were to be met namely achievement of minimum crown-to-root ratio for placement of crown and apical closure. Crown-to-root ratio was selected as criteria because these cases mostly required to undergo a crown treatment once the endodontic treatment was completed. Moreover, for a successful crown placement, it is absolutely necessary to have a minimum root length. Only maxillary central incisors were taken up for the study. Ideal crown-to-root ratio was 1:1.3 and a minimum was 1:1.[17] No study could find in the literature assessing crown-to-root ratio as the criteria for success. As the second criteria, the apical closure was selected because apex needs to be closed prior doing a root canal treatment later. Only when both the criteria were met, it was counted as radiographically successful.

In the present study, at the end of 6 months, none of the cases in the PRF gel or PRF membrane group showed radiogaraphic success. At the end of 12 months, PRF gel group showed success in 10 cases whereas it was six in PRF membrane group which showed that gel group was probably faster in achieving radiographic success. However, at the end of 18 months, 18 cases in PRF gel and 17 cases in PRF membrane group achieved apical closure and root lengthening. One case in each group showed internal resorption and irregular globules in the apical region which correspond to clinical failure too. One case in PRF membrane group could not achieve sufficient root lengthening.

Analyzing these factors, it was found that treatment time and ease of placement were better with PRF membrane group compared to gel group. Clinical success was similar in both the groups. Successful apical closure and root lengthening were achieved faster in 10 cases of PRF gel to PRF membrane. Loss of some amount of growth factors from gel while making it into a membrane could be a reason for this.

For making PRF membrane, a locally made PRF compression device as proposed by Kobayashi et al. was employed.[13] This helped to standardize the thickness and the physical properties of PRF membrane. This helped in avoiding the use of expensive PRF box in preparing PRF membrane.

This study may have the disadvantage that the sample size is only 20 in each group. A larger group may be required to have a final conclusion that PRF membrane is as reliable as PRF gels scaffold in regenerative endodontic procedures. In addition, a comparison with platelet-rich plasma was not done which are commonly used for endodontic purpose.


   Conclusion Top


  1. Treatment time with PRF membrane as scaffold was less compared to PRF gel
  2. The ease of manipulation and placement of PRF membrane was better
  3. PRF membrane has a comparable success rate statistically with PRF gel
  4. PRF membrane could be used as a scaffold alternative to PRF gel in cases of apexification with regenerative endodontics.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Chen MY, Chen KL, Chen CA, Tayebaty F, Rosenberg PA, Lin LM, et al. Responses of immature permanent teeth with infected necrotic pulp tissue and apical periodontitis/abscess to revascularization procedures. Int Endod J 2012;45:294-305.  Back to cited text no. 1
    
2.
Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: New treatment protocol? J Endod 2004;30:196-200.  Back to cited text no. 2
    
3.
Torabinejad M, Turman M. Revitalization of tooth with necrotic pulp and open apex by using platelet-rich plasma: A case report. J Endod 2011;37:265-8.  Back to cited text no. 3
    
4.
Hargreaves KM, Geisler T, Henry M, Wang Y. Regeneration potential of the young permanent tooth: What does the future hold? Pediatr Dent 2008;30:253-60.  Back to cited text no. 4
    
5.
Huang FM, Yang SF, Zhao JH, Chang YC. Platelet-rich fibrin increases proliferation and differentiation of human dental pulp cells. J Endod 2010;36:1628-32.  Back to cited text no. 5
    
6.
Trope M. Treatment of the immature tooth with a non-vital pulp and apical periodontitis. Dent Clin North Am 2010;54:313-24.  Back to cited text no. 6
    
7.
Jadhav G, Shah N, Logani A. Revascularization with and without platelet-rich plasma in nonvital, immature, anterior teeth: A pilot clinical study. J Endod 2012;38:1581-7.  Back to cited text no. 7
    
8.
Torabinejad M, Faras H. A clinical and histological report of a tooth with an open apex treated with regenerative endodontics using platelet-rich plasma. J Endod 2012;38:864-8.  Back to cited text no. 8
    
9.
Shah N, Logani A, Bhaskar U, Aggarwal V. Efficacy of revascularization to induce apexification/apexogensis in infected, nonvital, immature teeth: A pilot clinical study. J Endod 2008;34:919-25.  Back to cited text no. 9
    
10.
Ding RY, Cheung GS, Chen J, Yin XZ, Wang QQ, Zhang CF. Pulp revascularization of immature teeth with apical periodontitis: A clinical study. J Endod 2009;35:745-9.  Back to cited text no. 10
    
11.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part III: Leucocyte activation: A new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e51-5.  Back to cited text no. 11
    
12.
Shivashankar VY, Johns DA, Vidyanath S, Kumar MR. Platelet rich fibrin in the revitalization of tooth with necrotic pulp and open apex. J Conserv Dent 2012;15:395-8.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Kobayashi M, Kawase T, Horimizu M, Okuda K, Wolff LF, Yoshie H, et al. Aproposed protocol for the standardized preparation of PRF membranes for clinical use. Biologicals 2012;40:323-9.  Back to cited text no. 13
    
14.
Shivashankar VY, Johns DA, Vidyanath S, Sam G. Combination of platelet rich fibrin, hydroxyapatite and PRF membrane in the management of large inflammatory periapical lesion. J Conserv Dent 2013;16:261-4.  Back to cited text no. 14
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15.
Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J 1996;29:125-30.  Back to cited text no. 15
    
16.
Johns DA, Varughese JM, Thomas K, Abraham A, James EP, Maroli RK, et al. Clinical and radiographical evaluation of the healing of large periapical lesions using triple antibiotic paste, photo activated disinfection and calcium hydroxide when used as root canal disinfectant. J Clin Exp Dent 2014;6:e230-6.  Back to cited text no. 16
    
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Grossmann Y, Sadan A. The prosthodontic concept of crown-to-root ratio: A review of the literature. J Prosthet Dent 2005;93:559-62.  Back to cited text no. 17
    
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Bassiouny MA, Grant AA. The accuracy of the schei ruler: A laboratory investigation. J Periodontol 1975;46:748-52.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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