Effects of citric acid and fibronectin and laminin application in treating periodontitis

A New Approach for Root Surface Biomodification Using Injectable Platelet-Rich Fibrin (I-PRF)

Background

This study investigated the potential effects of Injectable Platelet-Rich Fibrin (I-PRF) on root coverage of free gingival graft surgery.

Material/Method

A total of 40 patients with Miller class I or II gingival recession were included. The patients who participated in this study were randomly divided into 2 groups, including the control and experiment groups. The patients in the control group were treated only with free gingival graft (FGG). The patients in the experiment group were treated with free gingival graft and injected with I-PRF as a root surface biomodification agent (FGG+I-PRF). The patients were called back after 3 months, and the amount of exposed root surface was determined and compared to the preoperative findings.

Results

The mean initial exposed root surface was 4.7±1.49 mm for the FGG+I-PRF group, 4.1±1.07 mm for the FGG group, and 4.4±1.31 mm for all subjects. Three months after the operation, the mean root surface coverage values of the 2 groups were 3.5±1.05 and 3.9±0.78 mm in the control and experiment groups, respectively.

Conclusions

The findings showed that the injection of Injectable Platelet-Rich Fibrin (I-PRF) had a positive effect on root coverage in free gingival graft surgery.

Enamel matrix-derived protein stimulates attachment of periodontal ligament fibroblasts and enhances alkaline phosphatase activity and transforming growth factor beta1 release of periodontal ligament and gingival fibroblasts

BACKGROUND

Although it is claimed that enamel matrix-derived proteins (EMP) can be used to promote new attachment formation around periodontally involved teeth, the underlying biological mechanism is not understood. It was the aim of the present study to investigate the effects of EMP on the behavior of human periodontal ligament (HPLF) and gingival fibroblasts (HGF) in vitro, with special focus on their attachment properties, the expression of alkaline phosphatase (ALP) activity, the release of transforming growth factor (TGF)beta1, and their proliferative rate.

METHODS

Fibroblast populations were obtained from 10 individuals with a healthy periodontium and cultured in chemically defined medium on culture plates coated with EMP, purified collagen type I, or their respective vehicles. Experiments were performed in the absence of serum for periods up to 48 hours.

RESULTS

It was shown that HGF barely attached and spread on EMP-coated substrata, whereas HPLF attached and spread within 24 hours. However, when cultured on purified collagen type I, both cell types showed rapid attachment and spreading. Furthermore, the expression of ALP activity was significantly enhanced under the influence of EMP, especially in HPLF. HPLF and HGF both released significantly higher levels of TGFbeta1 in the presence of EMP. EMP did not influence 3H-thymidine incorporation by HPLF and HGF.

CONCLUSIONS

Our results indicate that HPLF and HGF respond differently to EMP. A more rapid attachment of HPLF to this substratum might contribute, during the initial stages of periodontal healing, to selective outgrowth and colonization of exposed root surfaces in vivo.

Guided tissue regeneration with dentin biomodification

This study was undertaken to provide histologic observations on the effectiveness of citric acid and tetracycline HCl root surface demineralization when used in conjunction with guided tissue regeneration (GTR) procedures. Eight beagle dogs with naturally-occurring periodontitis were initially treated with scaling and root planing. Four weeks later, 12 mandibular quadrants were treated surgically with modified Widman flap and expanded polytetrafluoroethylene (ePTFE). The teeth in 4 of the quadrants were randomly root conditioned with tetracycline HCl, while those in 4 additional quadrants were randomly treated with citric acid. ePTFE membranes were sutured in place. The beagles received prophylaxis (chlorhexidine and toothbrushing) 3 times a week. After 6 weeks, the membranes were removed; prophylaxes continued for 4 months. Histological evaluation revealed new cementum on the root surfaces. A new periodontal ligament with fibers inserting into the new cementum was noted. Statistical evaluation of the buccolingual measurements demonstrated membranes alone resulted in significantly more new connective tissue and new bone formation than membranes with root conditioning agents. Within the furcation, no significant differences were found. However, there was a trend for more bone formation with membranes alone. Within the limits of this study it may be concluded that GTR utilizing an ePTFE membrane results in new connective tissue attachment and bone regeneration in the beagle dog. Root surface demineralization with citric acid or tetracycline HCl does not enhance the results achieved with GTR when used alone.

Growth and morphogenetic factors in bone induction: role of osteogenin and related bone morphogenetic proteins in craniofacial and periodontal bone repair

Bone has considerable potential for repair as illustrated by the phenomenon of fracture healing. Repair and regeneration of bone recapitulate the sequential stages of development. It is well known that demineralized bone matrix has the potential to induce new bone formation locally at a heterotopic site of implantation. The sequential development of bone is reminiscent of endochondral bone differentiation during bone development. The collagenous matrix-induced bone formation is a prototype model for matrix-cell interactions in vivo. The developmental cascade includes migration of progenitor cells by chemotaxis, attachment of cells through fibronectin, proliferation of mesenchymal cells, and differentiation of bone. The bone inductive protein, osteogenin, was isolated by heparin affinity chromatography. Osteogenin initiates new bone formation and is promoted by other growth factors. Recently, the genes for osteogenin and related bone morphogenetic proteins were cloned and expressed. Recombinant osteogenin is osteogenic in vivo. The future prospects for bone induction are bright, and this is an exciting frontier with applications in oral and orthopaedic surgery.

Expression of integrins in human gingiva

The distribution of the alpha 1-alpha 6 subunits of beta 1 integrins was studied by using a panel of monoclonal antibodies in indirect immunofluorescence microscopy. The results showed that the beta 1 subunit was expressed at the cell membrane of basal cells of gingival epithelium, throughout the cells of junctional epithelium (JE), and in cells of connective tissue, including endothelial cells and, more faintly, in inflammatory cells in gingival connective tissue. The alpha 4 subunit was expressed selectively in inflammatory cells, and the alpha 5 subunit was expressed in cells throughout gingival connective tissue. An overall cell membrane immunoreactivity for the alpha 2 and alpha 3 subunits was shown in basal cells of gingival epithelium and in cells of JE, corresponding to the epithelial localization of the beta 1 subunit. The alpha 6 subunit was polarized to the basal aspects of basal epithelial cells, but was also present in an overall cell surface distribution in basal cells and in cells of JE. The beta 4 integrin subunit was mainly expressed at the basal aspects of basal cells in gingival epithelium and JE. The results indicate that the alpha 2/beta 1, alpha 3/beta 1, alpha 6/beta 1, and alpha 6/beta 4 integrins are all expressed in human gingival epithelium. Of these, the alpha 6/beta 4 integrin complex is the major candidate for mediation of the attachment of epithelial cells to the basement membrane facing the connective tissue and probably also the tooth.

The use of autologous fibronectin in the surgical repair of through-and-through furcation lesions in man. A pilot study

4 subjects with bilateral through-and-through mandibular furcation lesions were assessed for the healing response in terms of attachment gain following surgical debridement, root planing, citric acid demineralisation and topical application of autologous fibronectin. The results were compared with sham-operated and saline-treated contra-lateral sites. There was no significant difference in the attachment gain at sites treated with autologous fibronectin and citric acid compared with sites treated with citric acid alone.

Long-term assessment of periodontal surgery versus curettage or scaling and root planing

The various treatments for periodontal disease must be assessed in light of the recently articulated goals of periodontal therapy to preserve teeth for a lifetime and to enhance esthetics and comfort as well as oral health. This article examines the long-term comparisons of periodontal surgery, curettage, and scaling and root planing in improving attachment levels instead of the more traditional pocket depth.

Effect of placement of occlusive membranes on root resorption and bone regeneration during healing of circumferential periodontal defects in dogs

Previous studies indicate that root resorption is a frequent sequela to significant amounts of periodontal repair in animal models. A model was developed in labrador dogs to study periodontal wound healing in large circumferential defects in the absence of influence from the oral environment. A polytetrafluorethylene membrane of 1 micron pore size (GORE-TEX) was used to occlude cells from specific tissues from populating the healing dentin-connective tissue wound. 3 modalities were studied: (1) control, in which no membrane and therefore no cell occlusion was used, (2) flap occlusion, in which the internal surface of the flap was lined with the membrane preventing contribution of cells from the flap, (3) bone occlusion, in which the reduced alveolar bone was lined with the membrane preventing contribution from bone cells. Wound closure included total submergence of teeth and membranes. The membranes remained incorporated and no exposure of membranes or teeth occurred during the 3 months healing period. Histology revealed bone regrowth in all 3 treatment modalities. It is suggested that inductive elements in the connective tissue or dentin, or bone cells from periosteum were responsible for bone regrowth in the bone membrane treatment modality. No significant difference was seen for root resorption between the 3 treatment modalities. This study found that physical occlusion of cells from the inside of the surgical flap, or from the pre-existing bone, is not sufficient to prevent root resorption in periodontal wound healing.

Periodontal ligament cells and gingival fibroblasts respond differently to attachment factors in vitro

One of the initial events required for regeneration of periodontal tissues lost due to disease is the establishment of connective tissue attachment to root surfaces. Thus, considerable research efforts have focused on developing reliable procedures to gain new connective tissue attachment. Our studies focus on evaluating agents for their ability to promote cell attachment and spreading using an in vitro assay. For these studies human gingival fibroblasts (GF) and human periodontal ligament (PDL) cells, after exposure to fibronectin; 44 kilodalton bone phosphoprotein (44K BPP-osteopontin) or guanidine EDTA extracts of bone, cementum, or dentin, were compared as to degree of cell attachment and spreading. Fibronectin equally enhanced attachment and spreading PDL cells and GF. In contrast, 44K BPP, as well as guanidine EDTA extracts of bone and cementum, preferentially promoted attachment of GF when compared with attachment of PDL cells. For both PDL cells and GF the attached cells exhibited spreading. The guanidine EDTA extract of dentin did not promote attachment of either cell type. These results suggest that PDL cells and GF have different attachment properties which need to be considered for investigations directed at developing regenerative periodontal treatments.

Collagen linkage in periodontal connective tissue reattachment. An ultrastructural study in beagle dogs

Early stages of connective tissue reattachment to surgically denuded cementum and root dentin following citric acid application were studied in fenestration wounds. Block specimens were obtained after seven, 14, and 21 days. Continuity between newly deposited collagen fibrils in the granulation tissue and unmasked dental matrix collagen had been established within seven days by interdigitation of fibrils in an up to 0.5 micron-wide zone at the cementum or dentin surface. Splicing of collagen at the fibrillar level by direct attachment to the severed end of matrix fibrils or by juxtapositioning of new and old fibrils was seen in rare instances only. At 14 and 21 days, distinct bundles of collagen fibrils inserted deeply into the orifice of dentinal tubules. Arrested and reversed surface resorption was encountered at all time points. At these sites as well, new collagen fibrils interdigitated with denuded matrix collagen, while some resorbed surfaces were characterized by absence of collagen continuity. The results lend continued support to the concept of reattachment based on interdigitation of collagen fibrils. However, since attachment is established even in the absence of this feature, a significant role for specific attachment substances not shown can also be postulated.

Comments on the clinical application of fibronectin in dentistry

Several studies have demonstrated that citric acid demineralization of the root surface promotes tissue attachment. Since demineralization exposes collagen to which fibronectin binds, the role of fibronectin in the attachment of cells to the tooth surface has been of considerable interest. It is clear that fibronectin and other cell adhesion proteins can promote cell attachment to the tooth surface; therefore, attempts have been made to utilize these findings in a clinical setting. Using a quantitative ELISA procedure to measure the binding of fibronectin to demineralized bone and tooth, we have found that 1 microgram fibronectin can saturate approximately 1 mg of either demineralized bone or demineralized tooth powder. Since serum contains 300 micrograms fibronectin per mL, the bleeding that occurs during oral surgery should saturate exposed tooth surfaces with amounts of fibronectin adequate for cell adhesion. Thus, exogenous fibronectin would appear to be of little clinical benefit.