Only very low quality evidence available on the use of platelets for jawbone defects

Teeth are maintained in their position by soft and hard tissues (gums and surrounding bone). Gum disease or periodontitis, is an inflammatory condition of all these tissues caused by the bacteria present in the dental plaque. If left untreated, gum disease can cause teeth to loosen and eventually lead to tooth loss. The destruction of jaw bone around teeth (called the alveolar bone) during gum disease, can be horizontal (where the whole level of bone around the root is reduced) or vertical, forming a bone defect within the bone (infrabony defect). There are several available surgical treatments for infrabony defects, including: 1. open flap debridement in which the gum is lifted back surgically in order to clean the deep tartar; 2. bone graft in which a portion of natural or synthetic bone is placed in the area of bone loss; 3. guided tissue regeneration in which a small piece of membrane-like material is placed between the bone and gum tissue in order to keep the gum tissue from growing into the area where the bone should be; and 4. the use of enamel matrix derivative, a gel-like material which is placed in the area where bone loss has occurred and promotes its regeneration. In order to accelerate the healing process, autologous platelet concentrates have been recently used. They are concentrates of the platelets of patient’s own blood containing growth factors that are thought to promote tissue regeneration. The aim of this review was to assess if the addition of APC brings any benefits in the treatment of infrabony defects when combined with different surgical treatments.

What was the research?

A systematic review of the evidence to find out whether the addition of autologous platelet concentrates (APC) improves surgical treatment outcomes of bone defects in gum disease.

Who conducted the research?

The research was conducted by a team led by Massimo Del Fabbro from IRCCS Orthopedic Institute Galeazzi in Milan, Italy, on behalf of Cochrane Oral Health. Lorena Karanxha, Saurav Panda, Cristina Bucchi, Jayakumar Nadathur Doraiswarmy, Malaiappan Sankari, Surendar Ramamoorthi, Sheeja Varghese and Silvio Taschieri were also on the team.

What evidence was included in the review?

Data was extracted from 38 randomised controlled trials. A total of 1,042 infrabony defects were included in the trials. We considered four different types of surgical treatments and compared each technique with the same one when APC was added. Overall we considered these comparisons: open flap debridement with APC versus without APC; open flap debridement and bone graft with APC versus without APC; guided tissue regeneration with APC versus without APC; and enamel matrix derivative with APC versus without APC.

What did the evidence say?

There is very low-quality evidence that the addition of APC to two types of treatment: open flap debridement and open flap debridement with bone graft, may bring some advantages in the treatment of infrabony defects. However, for the other two types of treatment, guided tissue regeneration and enamel matrix derivative, there is insufficient evidence of a benefit.

How good was the evidence?

We judged the quality of the evidence to be very low due to problems with the design of the studies, which means we cannot be certain of the results.

What are the implications for dentists and the general public?

This review found very low-quality evidence that the adjunct of autologous platelet concentrates (APC) to specific surgical techniques such as open flap debridement (OFD) and OFD + bone graft (BG) when treating infrabony defects, may improve probing pocket depth, clinical attachment level, and radiographic bone defect filling outcomes. For guided tissue regeneration (GTR) and enamel matrix derivative (EMD) interventions, insufficient evidence of an advantage in using APC was observed. The number of studies concerning these techniques was very limited (only two studies for EMD) and their quality was assessed as very low. Consequently, these assessments cannot be conclusive.

 What should researchers look at in the future?

The main problem we encountered while performing this review, was the high risk of bias for almost all included studies. Therefore, we encourage investigators to further investigate this argument and to increase the quality of the evidence with attention paid to allocation concealment and blinding of the personnel which were not correctly performed in the majority of studies. Additionally, we advise authors of future studies to follow the CONSORT Statement, to clearly detail baseline and follow-up data for the clinical outcomes and to always perform a sample size calculation.

Lastly, because of very few data available, we could not include in this review a comparison among different types of APC. Therefore, we encourage authors of future studies, to compare in the same study, different types of APC in combination with different surgical interventions in order to assess if one type of APC is more beneficial than another one.

 Link

Del Fabbro  M, Karanxha  L, Panda  S, Bucchi  C, Nadathur Doraiswamy  J, Sankari  M, Ramamoorthi  S, Varghese  S, Taschieri  S. Autologous platelet concentrates for treating periodontal infrabony defects. Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No.: CD011423. DOI: 10.1002/14651858.CD011423.pub2.