J Periodontol • June 2009

A Surgical Reentry Study on the

Influence of Platelet-Rich Plasma in
Enhancing the Regenerative Effects of
Bovine Porous Bone Mineral and Guided
Tissue Regeneration in the Treatment of
Intrabony Defects in Humans
Paulo M. Camargo,* Vojislav Lekovic,*† Michael Weinlaender,‡ Tihana Divnic-Resnik,†
Marija Pavlovic,† and E. Barrie Kenney*

Background: The purpose of this study was to evaluate the ad-

ditional benefits provided by the incorporation of platelet-rich
plasma (PRP) into a regenerative protocol consisting of bovine
porous bone mineral (BPBM) and guided tissue regeneration
(GTR) in the treatment of intrabony defects in humans.
Methods: Twenty-three paired intrabony defects were surgi-
cally treated using a split-mouth design. Defects were treated

P
eriodontal regeneration involves
with BPBM/GTR/PRP (experimental group) or with BPBM/GTR the formation of alveolar bone,
(control group). The clinical parameters evaluated included cementum, and a new func-
changes in probing depth, clinical attachment level, and defect tional periodontal ligament.1 For peri-
fill as revealed by reentry surgeries at 6 months. odontal regeneration to occur, a
Results: Preoperative probing depths, attachment levels, and number of biologic events, including
transoperative bone measurements were similar for the two cell migration, adherence, multiplica-
groups. Post-surgical measurements taken at 6 months revealed tion, and differentiation, need to oc-
that both treatment modalities resulted in a significant decrease cur in a well-orchestrated sequence.
in probing depth, gain in clinical attachment, and bone fill of Therefore, therapeutic modalities that
the defects compared to baseline. Postoperative differences ob- aim at facilitating periodontal tissue
served between the two groups were 0.72 – 0.36 mm at buccal cells to behave in a way that is
sites and 0.90 – 0.32 mm at lingual sites for probing depth, conducive to regenerate the peri-
0.82 – 0.41 mm at buccal sites and 0.78 – 0.38 at lingual sites odontium have potential application
for gain in clinical attachment, and 0.85 – 0.36 mm at buccal in patient care.
sites and 0.94 – 0.42 mm at lingual sites for defect fill, all favoring Polypeptide growth factors (PGFs)
the experimental sites. However, none of the differences were sta- are biologic mediators that have the
tistically significant. ability to regulate cell multiplication,
Conclusion: Within the limitations related to using a small sam- migration, and differentiation. There-
ple size, PRP did not significantly augment the effects of BPBM fore, PGFs have potential applications
and GTR in promoting the clinical resolution of intrabony defects. in periodontal regeneration. Several
J Periodontol 2009;80:915-923. PGFs have been identified in human
periodontal tissues by immunohisto-
KEY WORDS
chemistry and in situ hybridization.2
Guided tissue regeneration; periodontal regeneration; Moreover, these PGFs were shown to
platelet-rich plasma. promote cell growth and differentia-
tion in vitro and periodontal regenera-
tion in animals.3-12 Human studies on
* Division of Associated Clinical Specialties, Section of Periodontics, University of California,
Los Angeles School of Dentistry, Los Angeles, CA. the effects of PGFs on periodontal
† Faculty of Stomatology, Department of Periodontics, University of Belgrade, Belgrade,
Republic of Serbia.
‡ Private practice, Vienna, Austria.
doi: 10.1902/jop.2009.080600

915
Xenograft and GTR With or Without PRP in Intrabony Defects
regeneration in vivo are limited. Of all known PGFs,
platelet-derived growth factor (PDGF) was shown to
exert a favorable effect on periodontal regeneration
as measured by gain in clinical attachment and radio-
graphic defect fill in humans.13,14
The combination of graft materials with guided tis-
sue regeneration (GTR) is a proven modality of ther-
apy for the treatment of intrabony defects15-18 and
Class 2 furcation invasions.19,20 Results from the
above-mentioned studies showed that the outcomes
achieved with the combination of the two agents are
at least as effective as, and in some cases superior
to, those achieved with bone grafts alone. Bovine po-
rous bone mineral (BPBM) is a graft material prepared
by protein extraction of bovine bone that results in a
trabecular structure of hydroxyapatite similar to hu-
man cancellous bone, and it has the ability to enhance
bone formation.21 Therefore, it has been widely used
in periodontal regenerative procedures alone or in
combination with GTR. In a controlled clinical trial,
Camargo et al.22 examined the effects of BPBM and
a collagen membrane of porcine origin for GTR on
the treatment of intrabony defects and showed a mean
clinical attachment gain >3 mm and mean defect fill
>3.5 mm; both values were significantly better than
those observed in controls treated with open flap de-
bridement. Camelo et al.23 reported on two cases of
intrabony defects treated with BPBM and GTR; they
demonstrated that clinical attachment levels can be
improved and histologic regeneration of the attach-
ment apparatus can be achieved using this combined
technique.
The PGFs PDGF and transforming growth factor-
beta (TGF-b) are abundant in the alpha granules of
platelets.24 Therefore, the use of platelet-rich plasma
(PRP) is a convenient approach to obtain autologous
PDGF and TGF-b. The technique to obtain such a
platelet preparation was reported elsewhere;25-27 it
basically involves the sequestration and concentra-
tion of platelets in plasma with the subsequent appli-
cation of that preparation to the wound-healing site. It
was shown that the application of PRP to the wound-
healing site can increase the local concentration of
platelets substantially because PRP contains ;338%
more platelets than peripheral blood.26
In a case report series,28 de Obarrio et al. incorpo-
rated PRP into a bone allograft/GTR combination
technique as periodontal therapy for intrabony de-
fects in humans. This initial investigation showed a
significant gain in clinical attachment and defect fill
in the treated defects as revealed by 2-year reentry
surgeries. Camargo et al.29 subsequently compared
the effectiveness of BPBM/PRP/GTR to that of an open
flap debridement procedure in the treatment of intra-
bony defects. The results of that study confirmed the
effectiveness of the triple therapy as anecdotally
916
Volume 80 • Number 6
reported by de Obarrio et al.28 and showed that the
positive outcome observed could not be attributed
to the flap surgical procedure alone. The design of
those studies did not allow for the identification of
which component(s) of the triple therapy contributed
to the positive results obtained.
Döri et al.30,31 examined the role played by PRP in
augmenting the effects of BPBM/GTR. They reported
that PRP did not provide an additional benefit to that of
the BPBM/GTR combination, either when a collagen
membrane30 or an expanded polytetrafluoroethylene
(ePTFE) membrane was used as a barrier.31 In yet an-
other study, Döri et al.32 showed that PRP did not en-
hance the regenerative capabilities of beta tricalcium
phosphate used in combination with ePTFE mem-
branes in the treatment of intrabony defects. The pri-
mary outcomes of the three studies listed above were
gain in clinical attachment and probing depth resolu-
tion. No reentry of the treated areas was conducted;
therefore, it is still unknown if PRP exerts an additional
positive effect on the formation of hard tissue in de-
fects treated with a bone graft and GTR.
The purpose of this study was to compare the clin-
ical effectiveness of two regenerative techniques in
treating intrabony defects in humans: a combination
of PRP/BPBM/GTR versus a combination of BPBM/
GTR. Specifically, this study was designed to examine
the role played by PRP in augmenting the effects of
BPBM/GTR in promoting probing depth reduction,
clinical attachment gain, and intrabony defect fill.
MATERIALS AND METHODS
Patients
The study was conducted at the School of Dentistry,
University of Belgrade, from May 15, 1999 to March
20, 2000. Twenty-three systemically healthy patients
(14 females and nine males; age range: 34 to 67 years;
mean age: 47 – 10 years; 11 smokers and 12 non-
smokers) with matched pairs of interproximal defects
were recruited for the study. Inclusion criteria consisted
of patients having two similar interproximal defects with
probing depths ‡6 mm after initial therapy. Radio-
graphic evidence of intrabony defects had to exist.
Upon surgical exposure, defects needed to have a min-
imum depth of 3 mm (as measured from the most cor-
onal point of the bony walls surrounding the defect to
the deepest point in the defect) and present with two
or three bony walls as a final criterion for patients to
be included in the study. The exclusion criteria were
systemic illnesses, compromised immune system,
pregnant and/or lactating women, and patients taking
any drug known to cause gingival enlargement. Pa-
tients allergic or sensitive to any of the medications to
be used in the study were not included. Teeth non-re-
sponsive to cold or endodontically treated were also ex-
cluded from the study. The two defects to be treated
J Periodontol • June 2009
could not be present in the same interproximal space.
Patients were informed as to the character and purpose
of the study and were required to sign informed consent.
The University Institutional Review Board approved the
study design and consent form.
Presurgical Therapy
Therapy consisted of oral hygiene instructions, which
was repeated until patients achieved a modified
O’Leary plaque score33 £25%. Scaling and root plan-
ing of the quadrant(s) involving the teeth to be treated
were performed with hand curets§ under local anes-
thesia. Occlusal adjustment was performed if trauma
from occlusion was diagnosed. Trauma from occlu-
sion was evaluated by examining the presence of
fremitus in centric occlusion or in working or balanc-
ing excursions.
Six to 8 weeks after phase I therapy, a periodontal
reevaluation was performed to confirm the suitability
of the sites for this periodontal surgical study, and a
preoperative periapical radiograph was taken that
provided baseline data. The study used a split-mouth
design, and two interproximal sites were randomly
(toss of a coin) assigned to the control and experimen-
tal groups.
The experimental therapy consisted of surgical ex-
posure of the defects and treatment with BPBM, GTR,
and PRP (experimental group) and BPBM and GTR
(control group).
PRP Preparation
PRP was prepared using the Curasan method.34-36
Ten milliliters of blood was drawn from each patient
by venipuncture of the antecubital vein. Blood was
collected into glass tubes,i which contained 10% triso-
dium citrate solution as an anticoagulant. The blood-
containing glass tubes were centrifuged at 5,600
revolutions per minute for 6 minutes, which resulted
in the separation of three basic fractions: platelet-poor
plasma (PPP) at the top of the preparation, PRP in the
middle, and the red blood cell (RBC) fraction at the
bottom. Two milliliters of the top layer corresponding
to PPP was aspirated with a Pasteur pipette and dis-
carded. The PRP was collected in conjunction with
the top 1 to 2 mm of the RBC fraction because the lat-
ter is also rich in newly synthesized platelets. This
preparation typically yields a platelet concentration
that is 1.7 to 3.5 times greater than in blood.
Calibration of Surgeons and Examiner
All surgeries were performed by two periodontists.
An examiner other than the surgeons performed all
clinical measurements without knowledge of the
treatment groups. Intraexaminer calibration was
achieved by examining three patients twice, 48 hours
apart, prior to beginning the study. Calibration was
accepted if measurements at baseline and at
Camargo, Lekovic, Weinlaender, Divnic-Resnik, Pavlovic, Kenney
48 hours were similar to the nearest whole millimeter
at ‡90% level.
Presurgical Clinical Measurements
Occlusal stents for positioning measuring probes
were fabricated with cold-cured acrylic resin on a cast
model obtained from an alginate impression. The oc-
clusal stents were made to cover the occlusal surface
of the tooth being treated and the occlusal surfaces of
at least one tooth in the mesial and distal directions.
Stents were also extended apically on the buccal
and lingual surfaces to cover the coronal third of the
teeth involved. Grooves were placed so that measure-
ments made post-surgery were at the same position
and angulation as those made prior to surgery. All
steps described above were developed to obtain an
occlusal stent that was stable when in position and
easily removed by the therapist.
Prior to surgery, the plaque index37 and gingival
sulcus bleeding index38 were measured. With the
acrylic stent in position, the periodontal probe was in-
serted at the angle necessary to reach the deepest
portion of the interproximal pocket. Angulation varied
between 10 and 20. A pencil mark was made where
the probe made contact with the acrylic stent, and a
groove was made on the pencil-marked area with a
cylindric low-speed burr. Using the groove as a guide,
the periodontal probe was reinserted into the pocket,
and probing depth (using the gingival margin as refer-
ence) and relative attachment level (using the most
apical end of the stent as reference) were recorded.
Measurements were performed with a Marquis peri-
odontal probe¶ and recorded to the nearest millimeter.
The same measurements were repeated on the buccal
and lingual surfaces of each interproximal defect.
Surgical Procedures and
Intrasurgical Measurements
Surgical procedures were performed after local infil-
tration of 2% lidocaine containing epinephrine at a
concentration of 1:100,000. Buccal and lingual sulc-
ular incisions were performed, and mucoperiosteal
flaps were elevated. Care was exercised to preserve
as much interproximal soft tissue as possible. Com-
plete debridement of the defects as well as scaling
and root planing were achieved with an ultrasonic de-
vice# and hand curets. Measurements of the osseous
defects were made using the grooves previously used
to record probing depth and attachment levels. The
distance between the most apical end of the stent
and the point at which the groove-adapted probe
made contact with the bottom of the defect was re-
corded at buccal and lingual sites. Other grooves,
§ Hu-Friedy, Chicago, IL.
i Vacutainer, Becton Dickinson, Franklin Lakes, NJ.
¶ Hu-Friedy.
# Cavitron, Dentsply, York, PA.
917
Xenograft and GTR With or Without PRP in Intrabony Defects
one buccal and one lingual, were fabricated as de-
scribed earlier to measure the distance between the
most apical end of the stent and the interproximal al-
veolar crest that formed the superficial border of the
defect.
Experimental sites were treated as follows. At the
time of the surgery, coagulation of PRP was achieved
by its combination with an equal volume of a sterile
saline solution containing 10% calcium chloride and
100 U/ml sterile bovine thrombin.** Within a few sec-
onds it assumed a sticky gel consistency. Cancellous
BPBM granules, with a particle size of 0.25 to 1.0
mm,†† were mixed with the coagulated PRP prepara-
tion at a proportion of 1:1. Prior to grafting, PRP and
the coagulating solution were applied to the defect
walls and root surfaces. The BPBM/coagulated PRP
mixture was tightly packed into the experimental de-
fects using amalgam condensers to the level of the
surrounding bony walls. Care was taken not to overfill
defects. A porcine-derived collagen membrane‡‡ was
adapted over the grafted defect. Membranes were ex-
tended over the periphery of the defect in the buccal
and lingual directions and secured in place using
5-0 gut sutures anchored to the adjacent teeth.
Defects in the control group were treated in the
same manner as in the experimental group, but they
did not receive PRP. In brief, defects were filled with
BPBM granules over which a collagen membrane
was adapted and sutured.
Flaps in both groups were sutured at the original
levels using 4-0 silk with a continuous sling technique.
Periodontal dressing was placed over the area, and
antibiotics (penicillin vk, 500 mg, every 6 hours for
14 days) and 0.12% chlorhexidine gluconate rinses
(every 12 hours for 14 days) were prescribed. Oral an-
algesics (ibuprofen, 800 mg, every 8 hours as neces-
sary) were also dispensed.
Postoperative Care
Dressing and silk sutures were removed 1 week
postoperatively. Patients initiated mechanical oral
hygiene, consisting of brushing and flossing or inter-
proximal brushing, at the end of the second postop-
erative week. Patients were examined weekly up to
1 month after surgery and then at 3 and 6 months.
Postoperative care included reinforcement of oral
hygiene and mechanical plaque removal whenever
necessary.
Reentry Procedures
Six months after the initial surgery, all clinical mea-
surements were repeated, and surgical reentries were
performed. Surgical reentries consisted of buccal and
lingual full-thickness flaps to access the interproximal
bone. All measurements described for the first surgi-
cal procedure were repeated during reentries using
the acrylic stent as described earlier. The criteria used
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Volume 80 • Number 6
for hard tissue measurements were to remove all
granules of the graft material that were surrounded
by soft tissue and that were clearly loose and not in-
corporated into a hard tissue matrix that was judged
to be bone upon clinical inspection. Granules of the
graft material that were visible within the regenerated
tissues but surrounded by hard tissue that was judged
to be bone upon clinical inspection were left undis-
turbed. If the tip of the periodontal probe touched
any of the incorporated graft particles during any of
the measurements, it was regarded as a legitimate
landmark.
Statistical Analysis
This clinical trial was conducted to test the potential
superiority of the experimental protocol compared
to controls.
Results were averaged (mean – SE) for probing
depth, clinical attachment level, defect fill, and alveo-
lar crest resorption. The net difference between each
pair of measurements (pre- and postoperative) was
calculated, followed by computation of the difference
between treatment groups. The Student paired t test
was used to compare the differences between the
two groups.
For the plaque index and the gingival sulcus bleed-
ing index, the frequency with which each score oc-
curred was recorded for the experimental and
control groups. Intra- and intergroup comparisons
were conducted using the x2 test.
P values £0.05 were regarded as statistically
significant.
RESULTS
All 23 patients completed the study. Defects in the ex-
perimental and control groups healed uneventfully.
No cases of flap dehiscence or infection were de-
tected.
At baseline, no statistically significant differences
were detected between experimental and control sites
with respect to probing depth, clinical attachment
level, and depth of the intrabony defects.
An individual description of defect location and an-
atomic characteristics are shown in Table 1. The
experimental group had 19 2-wall defects and four
3-wall defects, whereas the control group had 17
2-wall defects and six 3-wall defects.
The majority of the experimental and control sites
presented with granules of BPBM that could be iden-
tified within the regenerated tissues at reentry surger-
ies. These granules appeared to be incorporated into
the newly developed hard tissue and could not be re-
moved easily with a periodontal curet.
** Tissucol, Immuno, Vienna, Austria.
†† Bio-Oss, Geistlich, Wolhusen, Switzerland.
‡‡ Bio-Gide, Geistlich.
J Periodontol • June 2009 Camargo, Lekovic, Weinlaender, Divnic-Resnik, Pavlovic, Kenney

Table 1. Table 1. (continued)

Individual Defect Location and Individual Defect Location and
Anatomic Characteristics Anatomic Characteristics

Tooth Tooth
Number Treatment Defect Bony Walls Number Treatment Defect Bony Walls
Patient and Surface Group Type Present Patient and Surface Group Type Present

1 22 D PRP/BPBM/GTR 3-wall DBL 16 2D BPBM/GTR 2-wall DL

1 27 D BPBM/GTR 2-wall DL 17 19 D PRP/BPBM/GTR 2-wall DL

2 15 M PRP/BPBM/GTR 2-wall ML 17 30 D BPBM/GTR 2-wall DL
2 2M BPBM/GTR 2-wall ML 18 2M PRP/BPBM/GTR 2-wall MB

3 13 D PRP/BPBM/GTR 3-wall DBL 18 15 M BPBM/GTR 2-wall MB

3 4M BPBM/GTR 2-wall ML 19 28 M PRP/BPBM/GTR 2-wall ML
4 20 D PRP/BPBM/GTR 2-wall DL 19 22 D BPBM/GTR 3-wall DBL

4 29 D BPBM/GTR 2-wall DB 20 21 M PRP/BPBM/GTR 2-wall ML

5 14 M PRP/BPBM/GTR 2-wall ML 20 28 M BPBM/GTR 3-wall MBL
5 3M BPBM/GTR 2-wall ML 21 14 M PRP/BPBM/GTR 2-wall MB
6 5D PRP/BPBM/GTR 3-wall DBL 21 3M BPBM/GTR 2-wall ML

6 12 D BPBM/GTR 3-wall DBL 22 27 M PRP/BPBM/GTR 2-wall MB

7 13 D PRP/BPBM/GTR 2-wall DL 22 28 D BPBM/GTR 2-wall DL
7 18 M BPBM/GTR 2-wall ML 23 21 D PRP/BPBM/GTR 2-wall DL

8 3M PRP/BPBM/GTR 2-wall ML 23 28 D BPBM/GTR 2-wall DL

D = distal; B = buccal; L = lingual; M = mesial.
8 2M BPBM/GTR 2-wall ML
9 20 D PRP/BPBM/GTR 2-wall DL
Changes in probing depth are reported in Table 2.
9 29 D BPBM/GTR 2-wall DL The experimental and control groups showed a signif-
10 27 M PRP/BPBM/GTR 3-wall MBL icant probing depth reduction at 6 months. The postop-
erative differences in probing depth between the two
10 22 M BPBM/GTR 3-wall MBL groups were 0.72 – 0.36 mm at buccal sites and
11 20 M PRP/BPBM/GTR 2-wall ML 0.90 – 0.32 mm at lingual sites in favor of the experi-
mental sites, but they were not statistically significant.
11 29 M BPBM/GTR 3-wall MBL Clinical attachment level changes are shown in Ta-
12 21 M PRP/BPBM/GTR 2-wall ML ble 3. Experimental sites presented with greater clin-
ical attachment gain of 0.82 – 0.41 mm at buccal sites
12 29 M BPBM/GTR 3-wall MBL and 0.78 – 0.38 at lingual sites, but these differences
13 31 M PRP/BPBM/GTR 2-wall ML were not statistically significant.
Table 4 reports changes in defect hard tissue fill for
13 18 M BPBM/GTR 2-wall ML the experimental and control groups. Both treatments
14 2M PRP/BPBM/GTR 2-wall MB resulted in significant defect fill with hard tissue. The
postoperative differences observed between the two
14 15 M BPBM/GTR 2-wall MB groups were 0.85 – 0.36 mm at buccal sites and
15 14 M PRP/BPBM/GTR 2-wall ML 0.94 – 0.42 mm at lingual sites, both favoring the ex-
perimental sites, but these differences were not statis-
15 3M BPBM/GTR 2-wall ML tically significant. Resorption of the alveolar crest was
16 15 D PRP/BPBM/GTR 2-wall DL similar for both groups (Table 4).
Plaque measurements and the gingival sulcus
bleeding index were not significantly different

919
Xenograft and GTR With or Without PRP in Intrabony Defects Volume 80 • Number 6

Table 2. versely, the data pre-

sented in this study are
Probing Depth (mm; mean – SE) Measured From the Gingival
the first to suggest that
Margin (N = 23 paired defects) PRP does not exert a
positive effect on the
Mean Difference fill of intrabony defects
Site PRP/BPBM/GTR BPBM/GTR P Value Between Groups treated with BPBM/GTR
Initial Buccal 8.19 – 1.56 8.11 – 1.48 >0.05 NS as revealed by reentry
Lingual 8.21 – 1.62 8.23 – 1.52 >0.05 NS surgeries.
In addition to clinical
6 months Buccal 3.31 – 1.38 3.95 – 1.46 >0.05 NS attachment gain and
Lingual 3.49 – 1.46 4.41 – 1.49 >0.05 NS
probing depth reduc-
Mean reduction Buccal 4.88 – 1.08 4.16 – 1.11 >0.05 NS 0.72 – 0.36 tion, defect fill is a
Lingual 4.72 – 1.12 3.82 – 0.98 >0.05 NS 0.90 – 0.32 desirable outcome of
NS = not statistically significant. periodontal regenera-
tive procedures because
Table 3. alveolar bone is an inte-
gral component of the
Changes in Clinical Attachment Levels (mm; mean – SE) Measured periodontium. One of
From the Acrylic Stent (N = 23 paired defects) the reasons why we hy-
pothesized that greater
Mean Difference defect fill would occur
Site PRP/BPBM/GTR BPBM/GTR P Value Between Groups with BPBM/GTR/PRP
than with BPBM/GTR
Mean gain (initial to 6 months) Buccal 4.38 – 1.22 3.56 – 1.21 >0.05 NS 0.82 – 0.41
was because PRP was
Lingual 4.12 – 1.18 3.34 – 1.18 >0.05 NS 0.78 – 0.38 shown to have an ana-
NS = not statistically significant.
bolic effect on bone
healing.26 Because peri-
odontal regeneration in-
Table 4.
cludes the formation of
Defect Fill and Alveolar Crest Resorption (mm; mean – SE) new bone, it was be-
Measured From the Acrylic Stent (N = 23 paired defects) lieved that PRP could
influence the regenera-
Mean Difference tion of the bony compo-
Site PRP/BPBM/GTR BPBM/GTR P Value Between Groups nent of the periodontal
unit. A possible expla-
Mean defect fill Buccal 4.81 – 1.26 3.96 – 0.91 >0.05 NS 0.85 – 0.36 nation for PRP not hav-
(initial to 6 months) Lingual 4.72 – 1.24 3.78 – 0.88 >0.05 NS 0.94 – 0.42
ing an added positive
Mean resorption Buccal 0.69 – 0.66 0.88 – 0.72 >0.05 NS 0.19 – 0.21 effect on bone forma-
(initial to 6 months) Lingual 0.72 – 0.71 0.79 – 0.76 >0.05 NS 0.07 – 0.11 tion in the defects trea-
NS = not statistically significant. ted in this study may lie
in the fact that BPBM is
between the experimental and control groups at base- a very powerful osteoconductive agent in the process
line or at 6 months postoperatively (Table 5). of bone formation and that GTR also has the ability to
enhance osteogenesis in the periodontal regenerative
DISCUSSION process. Therefore, the BPBM/GTR combination may
The results of this clinical study suggest that PRP did have optimized the regenerative potential of the de-
not significantly augment the effects of BPBM com- fects and, therefore, obfuscated any additional posi-
bined with GTR in terms of decreasing probing depth, tive osteogenic effect exerted by PRP. It was reported
promoting clinical attachment gain, and enhancing hard that fill of intrabony defects treated with BPBM/GTR
tissue fill of intrabony defects. These results confirm data can be substantial, leaving little room for further im-
from studies30-32 in which an osseous graft or a hard tis- provement.22
sue substitute graft combined with a non-absorbable or Lekovic et al.39 compared BPBM/GTR/PRP to
bioabsorbable membrane for GTR did not benefit from BPBM/PRP as regenerative treatment modalities for in-
the addition of PRP with regard to promoting probing trabony defects that were similar in severity to the ones
depth resolution or increasing clinical attachment. Con- examined in this study. Data from that study showed

920
J Periodontol • June 2009 Camargo, Lekovic, Weinlaender, Divnic-Resnik, Pavlovic, Kenney

Table 5. cells from the flap.42 If membranes and PRP work by

controlling the dynamics of periodontal defect cell re-
Plaque Index and Gingival Sulcus Bleeding
population, this might explain why PRP failed to aug-
Index (N = 23 paired defects) ment the effects of BPBM and GTR in the present
study. Further supporting this theory are the facts that
BPBM/GTR PRP/BPBM/GTR P Value PRP significantly increased the effects of BPBM com-
Plaque index pared to BPBM used alone in the treatment of intrabony
Initial 0 (70.6%) 0 (72.8%) ‡0.05 NS defects43 and that autologous platelet concentration (a
1 (14.1%) 1 (10.9%) preparation similar to PRP) failed to augment the effect
2 (9.8%) 2 (9.8%) of GTR in regenerating periodontal defects.44,45
3 (5.4%) 3 (6.5%) This clinical trial was conducted to examine the
6 months 0 (71.7%) 0 (76.1%) ‡0.05 NS working hypothesis that adding PRP to BPBM/GTR
1 (13.0%) 1 (7.6%) would result in superior results in the clinical param-
2 (8.7%) 2 (6.5%)
eters evaluated compared to BPBM/GTR without
3 (6.5%) 3 (9.8%)
PRP. The sample size used in this study was relatively
P value ‡0.05 NS ‡0.05 NS
small, but it was within the range of most periodontal
Sulcus bleeding index regenerative studies.46 This sample size was adopted
Initial 0 (30.4%) 0 (30.4%) ‡0.05 NS because it was within the range used in other peri-
1 (23.9%) 1 (22.8%) odontal regenerative studies conducted by the authors’
2 (19.6%) 2 (21.7%) research group in which a statistically significant dif-
3 (17.4%) 3 (16.3%)
ference was reached between various control and ex-
4 (8.7%) 4 (8.7%)
perimental protocols with respect to the parameters
6 months 0 (32.61%) 0 (36.96%) ‡0.05 NS
1 (33.70%) 1 (26.09%) evaluated.47,48 That does not mean that this study
2 (15.22%) 2 (17.39%) had the power to demonstrate superiority or equiva-
3 (13.04%) 3 (14.13%) lency.49 In conducting a post hoc power analysis of
4 (5.43%) 4 (5.43%) the data reported in this study, all differences in the
P value ‡0.05 NS ‡0.05 NS magnitude observed between the control and experi-
NS = not statistically significant. mental groups would have been statistically signifi-
cant if 61 paired defects had been used instead of
23. This post hoc power analysis was based on the pa-
that GTR did not have an additional benefit to BPBM/ rameter that presented with the smallest difference
PRP for any of the parameters evaluated, i.e., decrease between control and experimental sites, i.e., probing
in probing depth, gain in clinical attachment, and de- depth on the buccal aspect (95% power at alpha =
fect fill. Although comparisons between independent 0.05). Therefore, if the current study were conducted
studies should be conducted with care, and definitive with 61 paired defects, all differences between treat-
conclusions cannot be drawn from such comparisons, ment groups would have reached statistical signifi-
when the data sets from the current study and the one cance. Within the subject of statistical significance,
by Lekovic et al.39 are compared, it could be specu- the lack of statistical significance between the two
lated that GTR and PRP exert a similar effect in aug- treatment groups should not be interpreted as the
menting the regenerative effects of BPBM in treating two treatment modalities being equivalent. In general,
intrabony defects. Although the mechanism by which for two treatment modalities to be statistically equiv-
GTR promotes periodontal regeneration is believed to alent, a larger sample size is required than the one in
be well understood,40 the exact role played by PRP in a study to demonstrate superiority.
the regenerative process is less clear. It is possible that Hypothesizing that the differences observed be-
the PGFs present in PRP promote the growth and differ- tween experimental and control sites in the current
entiation of the periodontal ligament and alveolar bone study were statistically significant, one should also
cells, and that effect would result in the fast regenera- evaluate the results in terms of the clinical significance
tion of the periodontal unit. Another possible mecha- of combining PRP with BPBM/GTR in the treatment of
nism of action for PRP may be related to the physical intrabony defects. Clinical significance is a more sub-
characteristics of its fibrin component. Once the PRP jective issue than statistical significance, and, there-
preparation is coagulated, it assumes a sticky consis- fore, it may be a matter of interpretation. One way
tency because of its high fibrin content. The fibrin com- to frame clinical significance in light of the data pre-
ponent of PRP works as a hemostatic agent aiding in sented in this article is for the therapist to decide
stabilizing the graft material and the blood clot;41,42 it whether the time and cost involved in preparing PRP
may also adhere to the root surface and impede the ap- is justifiable by achieving greater probing depth reso-
ical migration of epithelial cells and connective tissue lution, clinical attachment gain, and defect fill that is

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Xenograft and GTR With or Without PRP in Intrabony Defects
not >1 mm compared to not using PRP. Preparation of
the PRP adds another step to the periodontal surgery
appointment and increases the time of the entire pro-
cedure by 20 to 30 minutes. Under the supervision of a
dental surgeon, a properly trained surgical assistant
can prepare PRP. In addition to time, there are costs
associated with disposable items and equipment ac-
quisition and maintenance. Although assigning a pre-
cise monetary value to the preparation of PRP in a
periodontal practice scenario is a complex exercise
that is outside the scope of this study, it is fair to state
that such a cost is not insignificant. Given the fact that
PDGF for periodontal applications can be obtained
from other sources, such as those generated via ge-
netic engineering,14 a comparison between PRP and
PDGF with regard to its effectiveness and the cost/
benefit ratio would be of interest. Taken together, it
could be argued that the cost/benefit ratio of adding
PRP to BPBM/GTR is high and difficult to justify.
CONCLUSIONS
The data reported herein suggest that PRP does not
augment the effects of BPBM/GTR in the regenerative
treatment of intrabony defects in humans. It also sug-
gests that PRP does not enhance defect fill in intrabony
defects treated with the BPBM/GTR combination. It
must be emphasized that this study used a relatively
small sample size. Hypothetically, if similar studies
with a larger sample size (‡61 paired defects) were
performed and the results were the same as in the cur-
rent clinical trial, the differences between the experi-
mental and control groups would be statistically
significant. However, even in that hypothetical sce-
nario, the clinical benefits of adding PRP to BPBM
and GTR would be marginal at best.
ACKNOWLEDGMENT
The authors report no conflicts of interest related to
this study.
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Correspondence: Dr. Paulo M. Camargo, University of
California, Los Angeles School of Dentistry, Periodontics
CHS 63048, 10833 Le Conte Ave., Los Angeles, CA 90095.
Fax: 310/206-3282; e-mail: pcamargo@dentistry.ucla.edu.
Submitted November 20, 2008; accepted for publication
February 20, 2009.
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