Platelet-rich plasma and platelet-rich fibrin in periodontal regeneration: A review

Sunil Paramel Mohan¹, Nallusamy Jaishangar², Sandha Devy³, Anjhana Narayanan⁴, Deepthi Cherian⁴, Sanupa Sethu Madhavan^4
1 Department of Stem Cells and Regenerative Medicine; Department of Oral and Maxillofacial Pathology, Sree Anjaneya Institute of Dental Sciences, Calicut, Kerala, India
² Department of Oral Medicine and Radiology, Sree Anjaneya Institute of Dental Sciences, Calicut, Kerala, India
³ Department of Oral Pathology and Microbiology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth Deemed To Be University, Pillayarkuppam, Puducherry, India
⁴ Department of Periodontics, Sree Anjaneya Institute of Dental Sciences, Calicut, Kerala, India

Date of Web Publication

28-May-2019

Correspondence Address:
Dr. Sunil Paramel Mohan
Prof. and HOD, Department of Oral Pathology and Microbiology, Director of Department of Stem Cells and Regenerative Medicine, Sree Anjaneya Institute of Dental Sciences, Calicut, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/JPBS.JPBS_41_19

Abstract

Platelet concentrates (PCs; platelet-rich plasma and platelet-rich fibrin) are autologous bioactive substances that have found varied application in medical and dental fields, particularly in oral and maxillofacial surgery, plastic surgery, and sports medicine. The rationale of these technologies is to extract all the elements from patient’s own blood sample, which could be used to improve healing by promoting tissue regeneration. PCs have evolved a long way since its introduction in 1954. PCs have been used successfully in periodontics and implant dentistry. However, the preparation protocol, processing time, transfer of concentrates, centrifugation temperature, vibration, etc., being not standardized are various factors for the mixed results reported in the literature. This review intends to discuss evolution of PCs, their preparation techniques, and their clinical and technical aspects and applications.

Keywords: Fibrin glue, leukocyte and platelet-rich fibrin, platelet concentrates, platelet-derived growth factors, platelet-rich fibrin, platelet-rich plasma, sticky bone

How to cite this article: Mohan SP, Jaishangar N, Devy S, Narayanan A, Cherian D, Madhavan SS. Platelet-rich plasma and platelet-rich fibrin in periodontal regeneration: A review. J Pharm Bioall Sci 2019;11, Suppl S2:126-30

How to cite this URL: Mohan SP, Jaishangar N, Devy S, Narayanan A, Cherian D, Madhavan SS. Platelet-rich plasma and platelet-rich fibrin in periodontal regeneration: A review. J Pharm Bioall Sci [serial online] 2019 [cited 2019 May 28];11, Suppl S2:126-30. Available from: http://www.jpbsonline.org/text.asp?2019/11/6/126/258872

Introduction

Periodontitis is an inflammatory disease of the periodontal tissues, which is characterized by loss of support of the affected teeth, specifically periodontal ligament fibers and the bone into which they are inserted. Regeneration or repair is the expected healing outcome following periodontal therapy. This depends on two crucial events: availability of cell types needed and presence or absence of signals necessary to recruit and stimulate the cells. The cascade of healing of any wound is initiated by clot formation, followed by proliferative stage and maturative stage. Growth factors favor wound healing by promoting proliferation of cells (mitogenesis), migration of cells (chemotaxis), and stimulation of new blood vessel formation (angiogenesis).^[1]

The use of blood-derived products to heal wounds began in 1970 when fibrin glues or fibrin sealants, which were formed by polymerizing fibrinogen with thrombin and calcium, were introduced. Fibrin glue had clinical applications such as topical hemostasis and tissue sealing, soft tissues, and melting agents for particulate bone substitutes. As the concentration of fibrinogen in plasma is less, the stability and quality of fibrin glue were low.^[2],[3] Variation in its composition and characteristics, lower resistance to physical stresses, costly processing and associated with a risk of viral transmission are its drawbacks.

Platelets contain biologically active proteins that bind on to a developing fibrin mesh or to the extracellular matrix. The proteins thus create a chemotactic gradient for recruitment of stem cells. These stems cells undergo differentiation, and promote healing by regeneration. Hence, the use of autologous platelet concentrates opens a promising treatment option in the field of periodontal regeneration, especially in clinical situations demanding rapid healing.^[4] The regenerative potential of platelets was initially introduced in 1974 by Ross et al.^[5] It was proposed that platelet-derived growth factor (PDGF) serves as growth factor on fibroblasts, smooth muscle cells, and glial cells.

The application of platelet concentrates was initially limited to treatment and prevention of hemorrhage due to severe thrombopenia. As its scope in medical application expanded, an idea to combine the fibrin sealant properties with the growth factors in platelets was tried for wound healing and regeneration of tissues.

Platelets

Platelets are enucleated hematologic component derived from bone marrow precursor cells: megakaryocytes. It measures 2–3 µm in diameter, and the cell organelles constitute granules, few mitochondria, and prominent membrane structures. It has a surface-connected canalicular system and a well-stacked tubular system, which help in expulsion of growth factors especially PDGF, upon activation of platelets [Figure 1].^[6]

Figure 1: Structure of platelet (Courtesy: postgradmedj-2001-October-77-912-e6-F1.large) Click here to view

The α granules are spherical or oval membrane-enclosed units with the cytoplasm. Diameter of the granules range from 200 to 500nm each. These macromolecules constitute 15% of the total platelet volume^[7] while being the storage pool of proteins important in various stages of wound healing: PDGF, transforming growth factor (TGF-β), and insulin-like growth factor (IGF-I).^[8] PDGF promotes protein synthesis in osseous tissues and proliferative stage in wound healing along with TGF-β. TGF-β has chemotactic effect on osteoblastic cells and endothelial cells, inhibitory effects on osteoclasts, and initiates woven bone formation. IGF-1 stimulates proliferation of osteoblasts and increases expression of osteocalcin for matrix synthesis. A combination of IGF-1 and PDGF checks the rate and quality of wound healing [Figure 2].^[9]

Figure 2: Growth factors released from α granules and their function (Courtesy: researchgate.net). BMP = bone morphogenic protein, VEGF = vascular endothelial growth factor, PGDF = platelet-derived growth factor, TGF-β = transforming growth factor Click here to view

The α granules after activation fuse with the cell membrane. Upon activation, the proteins are secreted, bind to transmembrane receptors of the target cells, trigger the intracellular signal proteins, and influence the expression of a gene sequence, thus promoting healing.

Classification of platelet concentrates [Figure 3]:

Figure 3: Platelet concentrates (Courtesy: researchgate.net) Click here to view

1. Platelet-rich plasma (PRP), the first-generation platelet concentrates, showed positive results; however, its limitations included complexpreparation protocol and the risk of cross infection from bovine thrombin.
2. Platelet-rich fibrin (PRF) also called as Choukroun’s platelet-rich fibrin named after its inventor.

Platelet-Rich Plasma

PRP is a first-generation platelet concentrate containing high concentration of platelet but minimal amount of natural fibrinogen. The α granules release growth factors within 3–5 days of platelet activation, which sustain their stimulation of proliferative phase for 10 days after release.

Platelet-rich plasma procurement

PRP is processed from autologous blood. The cell separator withdraws 400–450mL of autologous blood through a central vein catheter. Before the blood is placed in the centrifuge, sodium citrate dextrose is added to the blood at a ratio of 1:5 for the purpose of anticoagulation through calcium binding followed by a two spin centrifugation. The tube is centrifuged at 1300rpm for 10 minutes (soft spin). A second centrifugation is performed at 2000rpm for 10 minutes (hard spin). After 10 minutes of centrifugation, three layers are obtained. The least dense layer, which is platelet-poor plasma, is about 45% of the sample; middle layer consists of RBCs and is about 40% of the sample; and lower layer is the PRP, which makes up around 15% of the sample. It is also called the buffy coat because of its white or buffy appearance.

Each mix draws 7mL PRP + 1mL CaCl₂ +1000 units of topical bovine thrombin + 1mL air respectively (the CaCl₂ and thrombin initiate the coagulation process and easy handling). It is then agitated for 6–10 seconds to initiate clotting and is immediately used onto the graft site or added to particulate graft. It can also be gelled into a membrane that can be placed into a surgical site.

The architecture of PRP constitutes bilateral junctions (condensed tetra molecular) constituted with strong thrombin concentrations; thickening of fibrin polymers forming a rigid network, unfavorable to cytokine enmeshment; and cellular migration.^[10] Periodontal applications of PRP are periodontal defect treatment, root coverage procedures, ridge augmentation grafting, guided bone regeneration, sinus lift grafting, and implant surgery. The clinical application of PRP also extends to mandibular and maxillary reconstruction (tumor and trauma related defects), blepharoplasty, dermal fat grafts, and orthopedic surgery.

Advantages of using PRP are the following: brings cytokines and growth factors to the site, which helps in rapid regeneration in a manner that would not occur with fibrin glue because of the presence of platelets; free from concerns over transmissible disease; and convenient for patient. However, its limitations are lack of standardization in PRP preparation protocol, variation in storage time of different platelet concentration, and life-threatening coagulopathies (bovine thrombin can trigger antibodies to clotting factors).

In a recent systemic review, Plachokova et al.^[11] found evidence for beneficial effects of PRP in the treatment of periodontal defects. Evidence for beneficial effects of PRP in sinus elevation appeared weak and no conclusions could be drawn about its other applications in dentistry. Meanwhile, Kotsovilis et al.^[12] obtained diverse outcomes for the efficacy of PRP with various therapeutic bioactive agents/procedures, possibly suggesting that the specific selection of agents/procedures combined with PRP could be important. A meta-analysis by Bae et al.^[13] suggested that there was sufficient evidence to support the use of PRP for bone formation on a sinus bone graft, whereas its effect on the implant survival was less significant.

Platelet-Rich Fibrin

An autogenous living biomaterial, developed in France by Choukroun et al.^[14] (2001), is a second-generation platelet concentrate. It has gained popularity as it accelerates soft- and hard-tissue healing. Its advantages over PRP are ease of preparation/application, minimal expense, and lack of biochemical modification (no bovine thrombin or anticoagulant is required).^[14] A major advantage of PRF is that it has a simple preparation protocol. The difference between natural blood clot and PRF is that the latter is more homogeneous and stable and easy to handle and place.^[15]

Protocol for platelet-rich fibrin preparation

The protocol tries to accumulate platelets and the released cytokines in a fibrin clot.^[16] For preparation of PRF, only centrifuged blood without any addition of anticoagulant and bovine thrombin is required. Blood sample is taken without anticoagulant in 10-mL tubes in a glass or glass-coated plastic tube and immediately centrifuged at 3000rpm for 10 minutes.^[17] The resultant product consists of the following three layers: top-most layer consisting of an acellular plasma, PRF clot in the middle, and a red corpuscle base at the bottom [Figure 4].^[18]

Figure 4: Layers obtained after centrifugation (Courtesy: www.naturaldentistassociates.com) Click here to view

Mazor et al.^[8] suggested that on compression between two sterile gauzes or in a specific PRF tool, clot could be transformed into a membrane. The contact of blood with a silica surface activates the clot polymerization process; this activation reduces the risk of cytotoxicity compared with the use bovine thrombin used for PRP preparation.^[19] Compared to PRP, structurally it has equilateral junctions (connected trimolecular), fine and flexible fibrin network that support cytokines enmeshment and cellular migration. This three-dimensional organization provides elasticity, flexibility, and strength to PRF membrane.^[20] Advantages of PRF as a bioactive substitute include less technical skills, minimal biochemical modification, cost effectiveness, increased incorporation of the circulating cytokines in the fibrin meshes, and slow polymerization, thus accelerating healing, better structural integrity.^[21] Reported limitations of PRF are low quantity and requires immediate use after preparation because it can lose the structural integrity by shrinkage due to dehydration.^[19] Leukocytes present adversely alter its biologic properties, and bacterial contamination occurs on storage.^[22] Being a promising line of treatment in the direction of tissue regeneration, various authors have suggested different clinical application of PRF. The concept of “natural bone regeneration” was suggested by Simonpieri et al.,^[15] which indicates reshaping the whole alveolar bone and the restoration of gingival volume and peri-implant bone. Chang and Zhao^[23] suggested favorable clinical results with PRF in the treatment of periodontal infrabony defects. Clinical studies achieved promising results in maxillary sinus floor augmentation and sealing sinus membrane perforation.^[24] Combination of PRF and bone graft reduces the volume of bone substitute and improves revascularization by its property of angiogenesis. Simonpieri et al.^[15] noted good clinical results when several layers of PRF was used with immediate implants.

The literature reports that some other possible applications of osteitis reduction were found in surgical sites of the third molars^[25] adjunct to wound healing of donor site of free gingival graft^[26] in pulp revascularization procedures of immature permanent tooth, reconstruction after cancer surgery.^[27] High quantities of L-PRF can be produced in large quantities using specific multiple centrifuge tubes for larger surgeries.^[28]The new advanced PRF releases higher amount of growth factor that leads to the accumulation of significant amount of proteins for a long time.^[29]Gassling et al.^[28] reported that PRF appears to be superior to collagen as a scaffold for cell proliferation, and in vitro cultivation of periosteal cells for bone tissue engineering can be procured with PRF membranes.^[30]

Conclusion

PRF, a new generation of platelet concentrate, is a novel step in regenerative periodontal treatment with simplified processing and without biochemical modification. Apart from its application in dentistry, PRF is also been used in various medical fields: orthopedic and plastic surgery. Although merits and demerits of PRF have been confirmed by various systematic reviews and meta-analysis, numerous prospective studies have yet to be explored. Clinical studies in cooperating PRF for various treatments are quite encouraging; however, further studies are necessary to support its common use in routine dental practice with high clinical efficacy and long-term stability.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

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