Journal of Oral Research and Review

REVIEW ARTICLE
Year
: 2021  |  Volume : 13  |  Issue : 2  |  Page : 143--148

Autologous platelet concentrates in periodontal regenerative therapy: A brief overview


Dhiraj B Dufare 
 Department of Periodontia, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India

Correspondence Address:
Dhiraj B Dufare
Department of Periodontia, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal
India

Abstract

Autologous platelet concentrates (platelet-rich plasma and platelet-rich fibrin) enriched with various growth factors play an important role in periodontal regeneration. This review includes biological principle, efficacy, and effectiveness of autologous platelet concentrates. Based on the result obtained from the systematic review and meta-analysis it can be concluded that complimentary effects of autologous platelet concentrates may be used as lucrative adjunct to regenerative periodontal therapy. However, postoperative plaque control is one of the key factors influencing periodontal healing following regenerative periodontal therapy.



How to cite this article:
Dufare DB. Autologous platelet concentrates in periodontal regenerative therapy: A brief overview.J Oral Res Rev 2021;13:143-148


How to cite this URL:
Dufare DB. Autologous platelet concentrates in periodontal regenerative therapy: A brief overview. J Oral Res Rev [serial online] 2021 [cited 2022 Jan 19 ];13:143-148
Available from: https://www.jorr.org/text.asp?2021/13/2/143/319007


Full Text



 Introduction



Periodontal regeneration is the reconstitution of the lost periodontium as a result of trauma or diseases to restore the original architecture and function of the periodontium.[1] The objective of periodontal regenerative therapy was to augment the periodontal attachment and bone level of periodontally compromised tooth, decrease pocket depth along with limited/or minimal soft tissue recession. According to the world workshop in Periodontics of AAP (1996) a periodontal treatment is considered as regenerative when it fulfills the following criteria: Human histological evidence signifying new cementum, periodontal ligament and alveolar bone, Controlled human clinical trials signifying superior clinical attachment level gain and bone level gain and Controlled animal histological studies acknowledging new cementum, periodontal ligament, and bone. Autologous platelet concentrates enriched with several autologous growth factors are used for periodontal regeneration. Among different types of platelet concentrates the most well-known are platelet-rich plasma (PRP) and platelet-rich fibrin (PRF). Platelet concentrates have the benefits of contributing numerous collaborative growth factors at the wound sites and that are physiologically and biologically more significant. Platelet granules are enriched with several growth factors that are released upon their activation. The growth factors released from platelet are the followings: platelet-derived growth factor (PDGF), transforming growth factor-β (TGF-β), vascular endothelial growth factor (VEGF), epidermal growth factor, insulin-like growth factor-1, and fibroblast growth factor. These growth factors function as powerful biological accelerators that stimulate various cellular activities during wound healing, like cell proliferation, differentiation, matrix synthesis, and thereby encouraging periodontal regeneration.

 Types of Autologous Platelet Concentrates



Dohan Ehrenfest et al.[2] was the first to propose the type of autologous platelet concentrates. Defined four main families based on two key parameters the cellular content (primarily leukocytes) and fibrin architecture which are:

Pure-PRPLeukocyte and PRPPure-PRFLeukocyte-PRF (L-PRF).

 Platelet-Rich Plasma



PRP is a first generation of platelet concentrates. It is defined as “autologous concentration of platelets in small volume of plasma.”[3] and is considered as rich source of growth factors.

 Biological Rationale For Use of Platelet-Rich Plasma in Periodontal Regeneration



PRP enriched with several growth factors, such as PDGF and TGF-b may strongly modulate the regeneration process.[4],[5] In vitro study[6] showed the proliferation and differentiation of periodontal ligament and osteoblast cells; whereas the proliferation and differentiation of epithelial cells were inhibited. PRP was capable of enhancing collagen synthesis in the extracellular matrix and provides a constructive scaffold for cellular migration and adhesion.[7] PRP shortens the healing period by accelerating wound healing and in combination with bone graft augments the rate of bone deposition and bone volume.[8],[9]

 Preaperation Protocol For Platelet-Rich Plasma Using Two Step Centrifugation Procedures



Blood needs to be collected in the glass test tube with anticoagulant. The first rotation is carried out at 2400 rpm for 10 min. These separate the blood into three basic components: Red blood cell (RBC) layer, PRP and platelet-poor plasma (PPP). The RBCs present at the bottom, PRP in the middle, and the PPP layer at the top. PRP and PPP were collected in another glass tube. Then second rotation needs to be performed at 3600 rpm for 15 min. The PRP is concentrated at the bottom of the tube, whereas PPP is collected on the top. The PPP was removed so only PRP remained in the tube. PRP prepared with this procedure contain an average platelet count of 2520 ± 834 × 103/μL and an average concentration of growth factors (295 ng/μL PDGF-AB and 500 ng/μL TGF-B).[10]

 Factors Affecting Biological Properties of Platelet-Rich Plasma



Centrifugation speed and time

from technical perspective, the first centrifugation should be performed at the shortest speed and time this would separate the RBCs and platelet clearly. The second centrifugation should be performed at sufficiently high speed and time, which allows more platelet to precipitate without damaging.[11]

Types of anticoagulant

from the preparation perspective, the selection of an anticoagulant is the vital variable for conserving the platelet biology, reliability, and morphology. do Amaral et al.,[12] concluded that ethylenediaminetetraacetic acid increased the mean platelet volume following the blood centrifugation. The authors demonstrated that the use of citrate dextrose and sodium citrate significantly encourage the proliferation of mesenchymal stem cells. PRP obtained with sodium citrate has superior platelet resurgence and also had a negligible change in mesenchymal stem cell gene expression.

Nature of polymerization

from biological perspective, due to a quick and imperfect fibrin polymerization, growth factors and other proteins are not trapped in the fibrin network, since growth factors were mainly liberated during the first few hours.[13]

Human clinical studies on periodontal regeneration with PRP [Table 1].{Table 1}

 Efficacy and Effectiveness of Platelet-Rich Plasma



Evidence for clinical efficacy of PRP in periodontal regenerative therapy were assessed in the systematic review and meta-analysis.[15],[16],[17] They reported that PRP augments clinical and radiological outcomes as an adjunct to bone graft materials. However, the addition of PRP to guided tissue regeneration membrane failed to promote a significant reconstruction of periodontal tissue.

 Platelet-Rich Fibrin



PRF is a second-generation platelet concentrates, enriched with high concentration of several growth factors. The solid structural design of the fibrin matrix and its better mechanical properties differentiate it from other platelet concentrates.[18]

 Biological Rationale For Use of Platelet-Rich Fibrin in Periodontal Regeneration



PRF can foster differentiation and proliferation of progenitor and stem cells involved in periodontal reconstruction, such as cementoblast, periodontal ligament, and osteoblast revitalizing efficient reconstruction of lost tissue.[19] Dense fibrin matrix triggers the expression of integrin αvβ3, which acquiesce cells to bind to fibrin, fibronectin, and vitronectin. This significantly commences the process of angiogenesis and thus tissue wound healing.[20] Immune-inflammatory regulation at surgical sites is the result of cytokines (interleukin [IL]-1β, tumor necrosis factor-α, IL-6, and IL-4) significantly enmeshed in the fibrin network and released during the remodeling of the fibrin matrix.[21]

 Preaperation Protocol for Platelet-Rich Fibrin Using One Step Centrifugation Procedures



Blood needs to be collected in dry glass tube without anticoagulant or chemical additive and centrifuge immediately.

Two centrifugation protocol for PRF preparation:

2700 rpm for 12 min3000 rpm for 10 min.

After centrifugation, three layers were formed: Bottom-RBC layer, middle-PRF clot, and TOP-PPP. The PRF forms a strong fibrin matrix in which most of the platelets and leukocytes harvested from the blood are concentrated. PRF clot was removed from the tube using sterilized tweezers, separated from the RBC base using scissors and placed in the metal cup.

 Factors Affecting Biological Properties of Platelet-Rich Fibrin



Centrifuge characteristics

from mechanical perspective, centrifuge used for PRF production, the most pertinent variables to be evaluated are the shaking of centrifuge during centrifugation process, the vibration shocks, and the ultimate character of shaking. When vibration increases, there is a risk of resonance in the tube, which might produce considerable destruction to the blood cell content of the tube.[22]

Centrifugation speed

low speed (1300 rpm) lesson the shaking, but it does not permit a good quality of detachment of blood components and the restoration of the leukocytes. Therefore, centrifugation speed pertinent for PRF would around 2700 rpm, for adequate separation of blood elements, no shaking or resonance to preserve the blood cell content, and sufficient restoration of leukocytes.[22]

Blood collection and transport to centrifuge

speed of blood collection and transport to centrifuge is the significant parameter which determines the success of this technique. Without anticoagulant blood samples commence to coagulate without delay on contact with glass tubes. Rapid manipulation is the only mode to obtain a clinically functional PRF clot. If the duration required for blood collection and transport to centrifuge is too extended failure will occur.[13]

Nature of polymerization

from biological perspective, due to natural and progressive polymerization, it forms a solid structural design of fibrin network with well defines organization, even more, comprehensible than natural fibrin clot. Slow polymerization augments integration of the circulating growth factors in the fibrin meshes and acquiesces profound slow release.[19]

Human clinical studies on periodontal regeneration with PRF [Table 2].{Table 2}

 Efficacy and Effectiveness of Platelet-Rich Fibrin



Evidence for clinical efficacy of PRF in periodontal regenerative therapy were assessed in the systematic review and meta-analysis.[23],[24],[25] they reported, PRF augment clinical and radiological outcomes in periodontal regenerative therapy. PRF reinforces the reconstructive effects of bone substitute. It also accelerates wound healing.

 Advances in Traditional Leukocyte-Platelet-Rich Fibrin



Concentrated growth factors

was introduced in 2006 by Sacco.[26] Concentrated growth factor (CGF) utilizes altered centrifugation from 2400 to 2700 rpm for 12 min. CGF is much larger, denser, and richer growth factor fibrin matrix.

Sticky bone

growth factors-enriched bone graft matrix also known as “sticky bone” using autologous fibrin glue was introduced in 2010 by Sohn.[27] Sticky bone provides stabilization of bone graft in the defect, and therefore, accelerates tissue healing and minimizes bone loss during the healing period. The centrifugation time for AFG (Autologous Fibrin Glue) varies from 2 to 12 min. To get higher growth factors, the centrifuge is stopped after 2 min centrifugation and takes the AFG tube out of the centrifuge first.

Advanced-platelet rich fibrin

obtained by using centrifugation at 1500 rpm for 14 min. Changes in the centrifugation protocol enhanced the number of neutrophils entrapment in the fibrin-rich clot.[28] Advanced-platelet-rich fibrin releases significantly greater amounts of growth factors TGF-β, PDGF, VEGF, and chemotactic molecules CCL-5 (Chemokine ligand 5) and eotaxin, when compared with traditional PRF.[29]

Titanium prepared-platelet rich fibrin

Tunalı et al. 2014[30] proposed a new product called titanium prepared-PRF (T-PRF). The rationale behind the use of titanium tubes for collection and centrifugation despite glass tubes was that titanium might be a more effective platelet activator than silica, for preparing L-PRF. Based on light, scanning electron and fluorescence microscopy analysis, the author concluded that T-PRF has well-organized fibrin meshwork which was thicker and also it covered larger area.[30]

Injectables-platelet rich fibrin

obtained by using centrifugation at 700 rpm for 3 min.[31] The advantages of the liquid form of injectables-PRF were more efficient incorporation with particulate bone allograft or autograft materials.

All the above-mentioned advances of traditional PRF are the second generation and prepared without any anticoagulant or chemical additives unlike first-generation platelet concentrates such as PRP or plasma rich in growth factors. The detailed description on this topic was beyond the scope of this review.

 Conclusion



Based on the result obtained from the present systematic review and meta-analysis it can be concluded that the evidence on the additional beneficial effects of autologous platelet concentrates may be advantageously used as adjunct to regenerative periodontal therapy. Further, large-scale human multicenter clinical trial on autologous platelet concentrates (PRP and PRF) has to be carried out for applicability of these treatment strategies in evidence-based clinical practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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