|Year : 2021 | Volume
| Issue : 2 | Page : 59-65
Platelet-rich plasma in oral and dental surgery: A review
Ahmed Salah Al-Noaman
Department of Oral Surgery, College of Dentistry, University of Babylon, Babylon City, Iraq
|Date of Submission||19-Nov-2020|
|Date of Acceptance||20-Dec-2020|
|Date of Web Publication||26-Jun-2021|
Ahmed Salah Al-Noaman
Department of Oral Surgery, College of Dentistry, University of Babylon, Babylon City
Source of Support: None, Conflict of Interest: None
Background: Platelet-rich plasma (PRP) has been employed widely in dental and oral surgery. However, there is considerable debate about its effect on wound healing and inflammatory response. Materials and Methods: PubMed, Google Scholar, Scopus data base, and manual search were performed to find out articles on the use of PRP in dental and oral surgery using keywords such as PRP , oral surgery, dental surgery, lower wisdom teeth, periodontal pocket, dental implant, tooth socket preservation, dry socket, cystic lesion, and ridge augmentation. These articles discussed the use of PRP (after surgical removal of wisdom teeth, treatment of periodontal pocket, ridge preservation, implant stability, prevention of dry socket, treatment of bony defect after cystic removal, and ridge augmentation). Results: Twenty-seven articles were found on the usage of PRP in dental and oral surgery. Six articles on the use of PRP after surgical removal of lower wisdom teeth, five articles in the treatment of periodontal pocket and implant stability, four article in ridge preservation, three articles in prevention of dry socket and two articles on the use of PRP after cystic removal and ridge augomentation. Conclusion: PRP enhanced bone regeneration and soft-tissue healing aftery lower wisdom tooth surgery. It decreased the depth of periodontal pocket, maintained implant stability, preserved ridge height and prevented dry socket. However, PRP had no effect on pain, swelling, and bleeding. There is no justification for the impact of PRP on bone augmentation and healing of bony defect after cystic removal of the jaws. More studies should be carried out to support the usage of PRP in oral and dental surgery.
Keywords: Bone, dental, oral, platlate-rich plasma, surgery
|How to cite this article:|
Al-Noaman AS. Platelet-rich plasma in oral and dental surgery: A review. Med J Babylon 2021;18:59-65
| Introduction|| |
Scientific research in dental and oral surgery usually comprises substances and maneuvers which have the capacity to improve clinical outcomes in terms of effective wound hraling. Platelets play an important role in the initial phases of soft-tissue healing and bone formation. This is by discharging growth factors such as platelet-derived growth factor, transforming growth factor-beta and cytokines, chemokines, and other molecules which enhance cell-mediated soft-tissue healing and bone regeneration.
Platelet-rich plasma (PRP) is a derivative of blood (plasma) that is rich in platelets. It is a modern path to tissue regeneration and is becoming a beneficial auxiliary to facilitate healing in various oral surgical maneuvers. This material can be achieved by centrifugation of patient's own blood and different protocols have been suggested to prepare the final product. In general, anticoagulated blood was first subjected to soft spin to separate the plasma fraction from leukocyte. The plasma fraction then exposed to the second hard spin to split the platelets from the platelet-poor plasma (PPP). The platelet pellet containing leukocytes is hanging in a lower volume of PPP and activated by thrombin and calcium. From these two centrifugation process, platelets are within 2–5 times more than the normal blood.
PRP acts as a fibrin tissue adhesive with tissue sealing property and a direct surgical hemostatic agent that is characterized by compatiblity, safety, and efficiency. In addition to that, it speeds up endothelial and epithelial turn over, triggers angiogenesis, promotes collagen synthesis, facilitates soft-tissue recovery, encourages the hemostatic response to injury and inverses the prohibition of wound healing occurred due to exogenous steroids.
PRP is broadly employed nowadays to speed up postoperative healing process and is completely safe. Since the used blood is taken from the patient him/herself, contracting a disease is not a matter and relatively most patients were satisfied and comfort after their procedures. In addition to that, as PRP collecting is performed with only 55 cc of blood in the doctor's clinic, the patient does not need to subject to the expense of the collecting procedure in a hospital or at the blood donor center. PRP is easy to manipulate and improves the ease of application of bone substitutes and bone grafting products by converting them to a gel-like material. However, candidates indicated for treatment with PRP should undergo a pretreatment blood investigation to eliminate the risk of coagulopathies and platelet dysfunction. Anemic patients and those with thrombocytopenia may be improper candidates for treatment with PRP and this may consider a limitation of this biological material.
PRP has been utilized in several dental and oral surgical operations. These include preservation of tooth socket after extraction, dry socket, treatment of infrabony periodontal pockets and closure of the oroantral fistula, as well as operations related to the insertion of osseointegrated dental implants. In these maneuvers, the adhesive property of PRP promotes the simplest manipulating of graft material, more predictable flap adaptation, adequate hemostasis and provides effecient seal compared with suturing alone., Nowadays, the usage of PRP has also been suggested in the treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ) or avascular necrosis, which associated with other causes (e.g., radio-osteonecrosis), with the goal of improving soft-tissue healing and bone maturation.
This study aimed to evaluate the effectiveness of PRP in oral surgical procedures and to evaluate the applications of PRP in oral and dental surgery.
| Materials and Methods|| |
Articles on the use of autologous PRP in dental and oral surgery have been collected from December 15, 2019 to June 10, 2020. An electronic PubMed, Google Scholar, Scopus database and manual search were used to collect articles and other reviews relevant to this study. The keywords or the terms used for searching the articles include PRP, oral surgery, dental surgery, dry socket, dental implant, tooth socket preservation, wound healing and bone defect. The inclusion criteria include articles used PRP in oral and dental surgical procedures (after surgical extraction of impacted lower wisdom teeth, treatment of periodontal pocket, preservation of tooth socket, mantainance of implant stability and bone density, prevention of dry socket, treatment of bony defect after cystic removal and ridge augmentation), original articles, studies using adult patients, and articles published in the English language. The exclusion criteria involve articles used other platelet's derivatives such as platelete-rich fibrin (PRF), the use of PRP in bisphosphonate-related necrosis of the jaws (BRONJ), studies using <6 patients and articles published before 2010.
The articles were analyzed according to the type of study, sample size, treatment modality, study outcome, time for follow-up and patients' age. The evaluation of the outcome of each study depends on the clinical and radiographical parameters used during the study. Since the main concern of this review is to estimate the effect of PRP in certain dental and oral surgical procedures, parameters consideration of accelerating bone regeneration and soft tissue healing, decreasing inflammatory response (pain, swelling and bleeding) were taken as to estimate the effectiveness of PRP.
| Results|| |
Twenty-seven original articles were chosen to carry out a systematic review on the possible use of PRP alone or in combination with other bone substitutes in dental and oral surgery. There are six articles on the usage of PRP after surgery of impacted lower wisdom teeth, five articles on the treatment of infrabony pocket and dental implant treatment, four on the ridge preservation, three on the prevention of dry socket and two articles on the treatment of bony defect after removal of cystic lesion and ridge augmentation. All studies are randomized clinical trials and the majority were split-mouth design, while the other are parallel studies. Since the number of articles regarding the clinical use of PRP was too low and there was high variation in the surgical procedures among studies, meta-analysis was not performed. The evaluation was determined according to the outcome differences between the PRP-containing system and non PRP-containing system. Details of each study are shown in [Table 1].
|Table 1: Characteristics of randomized clinical trials on the use of platelet-rich plasma in dental and oral surgery|
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The results of these studies on the use of PRP in dental and oral surgery are described as followings:
After surgical removal of mandibular wisdom teeth
These studies include five randomized clinical trials (split mouth) and one was parallel design. The number of patients employed in these studies ranged between 6 and 150 patients. Both male and female genders were involved in these studies with age ranged from 18 to 70 years. All studies used PRP as a gel form except the study of Rutkowski et al. where PRP was used as a buffy PRP (gelfoam and PRP) coat. In most of these studies, patients were followed up from 1 day to 7 days apart from the study of Joy and Kaul et al., where patients were followed up to 1, 2, 3, and 6 months postoperatively. The outcome of these studies showed that PRP reduced probing depth distal to lower second molar, prevent wound dehiscence, and facilitate soft- and hard-tissue healing. However, the study of Rutkowski et al. and Gandevivala et al., revealed that PRP had insignificant effect on pain, swelling, bleeding, and numbness.
Treatment of infrabony periodontal pocket
These articles include four randomized clinical trials (split mouth) and one parallel trial. Both male and female genders were involved in the study with age ranged from 25 to 48 years and the number of patients ranged from 10 to 45. In these studies, PRP was used in combination with bone graft/and or open flap debridement (OFD) to treat infrabony pocket and patients were followed up from 6 months to 5 years. The outcome of the studies of Pradeep et al. and Hassan et al., showed that PRP with chips of torus mandibularis and PRP/OFD improved clinical attachment level (CAL) and probing depth. However, other studies,, indicated that PRP alone or with other bone graft or OFD had an insignificant effect on CAL and pocket depth.
Treatment of dental implants
These articles include five randomized clinical trials (split-mouth design). Both male and female genders were involved in the studies with age ranged from 18 to 44 years and the number of patients ranged from 16 to 32. In these studies, PRP was used as a gel form and patients were followed up from 1 week to 36 months. All studies revealed that PRP improved osseointegration, bone density and stability of dental implants. However, the study of Ergun et al. stated that PRP has no impact on implant stability in the maxilla after long-term follow-up.
Preservation of alveolar ridge
These articles include four randomized clinical trials. Three of these studies were split-mouth design and one parallel trial. Both male and female genders were involved in these studies with age ranged from 18 to 60 years and sample size ranged from 10 to 30 patients. In these studies, PRP was used in combination with other bone grafts such as collagen plug, calcium sulfate, demineralized freeze-dried bone (DFDB), and inorganic bovine bone (ABB) and patients were followed up to 9 months. The outcome of these studies demonstrated that PRP with other bone substitutes improved bone density and bone height but not the width of alveolar ridge.
Prevention of dry socket
There are three articles on the utilization of PRP in the prevention of dry sockets that were found during searching. Three of these articles were randomized clinical trials (split-mouth design) and one was parallel. In these studies, males and females were involved with age ranged from 18 to 40 years and the sample size ranged from 20 to 75 patients. PRP was used alone in the gel form and patients were followed up from 3 days to 3 months postoperatively. These studies stated that PRP prevented the occurrence of dry socket after extraction of permanent teeth and promote healing of soft tissue. However, these studies agreed that PRP had no impact on bone healing.
Treatment of bony defect
There are two articles on the usage of PRP in the treatment of bony defect in the maxillofacial region that were found during searching. Both of these studies were designed as split-mouth trials. Male and female were involved in the studies with the sample size ranged from 11 to 12 patients. PRP was used in the gel form to treat bony defect after removal of cystic lesion or benign tumors like cyst in the maxillofacial region. The patients in these studies were followed up to 6 months postoperatively. The results of Supriya et al. revealed that PRP enhanced bone regeneration in a bony defect; whereas the study of Ramanathan and Cariappa indicated that PRP had an insignificant impact on bone healing after 6 months.
There are two articles on the usage of PRP for ridge augmentation. Both of these studies were split-mouth design. Male and female were used in these studies with age ranged from 19 to 76 years and the sample size was within 30 patients. PRP was used in the gel form and the patients were followed up from 4 to 30 months. The findings of these studies showed that PRP increased width of the ridge after 4 and 30-month follow-up.
| Discussion|| |
There is a considerable debate on the effect of PRP in wound recovery and despite a large body of literature discussing this effect, the outcomes are conflicting and need further evaluation. This systematic review includes 27 articles aimed to evaluate the benefit of PRP in certain dental applications.
Six articles on the usage of PRP after removal of lower wisdom teeth were chosen. These articles evaluated the effect of PRP on pain, swelling, bleeding, probing depth distal to lower second molar, wound dehiscence and bone regeneration and soft-tissue healing. Some of these studies found that PRP reduced pain and swelling postoperatively, wound dehiscence and probing depth distal to lower second molar and improved bone regeneration and soft-tissue healing., However, other studies stated that PRP may improve bone regeneration and soft-tissue healing but had a negligible effect on pain, swelling and bleeding., These differences among the studies may be attributed to the type of PRP used or the methods used to measure pain, swelling and bleeding or to the sample size. The type and level of impaction of mandibular wisdom teeth were not mentioned in these articles which may be another source of diffrence among these studies.
Franchini et al., 2019 stated that periodontal tissue involves hard-tissue (bone) element and soft-tissue element. This systematic review revealed that there is a controversial effect of PRP on the CAL and pocket depth after treatment of periodontal pocket. Three of the studies,, showed that PRP alone or in combination with other bone grafts had no effect on CAL or pocket depth. However, others, reported that PRP containing grafts had significant effect on probing depth and (CAL). These differences among the studies may be attributed to the difference in the (criteria of patient's selection. the measurement of the periodontal pocket and PRP containing system and non-PRP containing system). In addition to that, most of these studies evaluated the effect of PRP up to 9 months, apart from the study of Döri et al., where patients were followed up to 5-years. In the latter study, PRP was used in conjunction with natural bone mineral and enamel matrix derivatives and the results showed that PRP did not improve (CAL).
Five articles in this systematic review discussed the impact of PRP on dental implant stability and bone density. One study included PRP with other bone graft to treat bony defect associated with implant placement; while other studies coated the implant surface with PRP before implant insertion.,, Most of these studies indicated that PRP alone or in conjuction with other bone graft improved implant stability and bone density. However, the study of Ergun et al. showed that there was no appreciable impact of PRP on implant stability. The study of Ergun et al. studied the impact of PRP on primary implant stability in the posterior region of the maxilla, whereas other studies discussed this effect in different regions of the upper and lower jaws. This may explain the differences between the study of Ergun et al. and other studies. The posterior region of the maxilla contains soft bone and lack of cortical bone and the alveolar ridge tends to resorb with age. These factors render the achievement of implant stability in the posterior maxilla is problematic and difficult.
Four articles investigating the outcome of PRP alone or in conjunction with other bone grafts to preserve ridge height, width, and bone density. Two of these articles demonstrating that the height and width of alveolar ridge were preserved when alveolar socket covered with PRP with calcium sulfate or ABB., However, PRP with collagen plug was failed to preserve ridge height and bone density. In addition to that, a comparative study between PRP and PRF with DFDB graft proved that PRP with DFDBG revealed less effect on width, height and bone density of the upper and lower alveolar ridge. These differences among these studies may be due to the sample size, criteria of patients selection and type of PRP-containing system. Notably, the effect of sample size was very clear in the studies of Orabee et al. and Isaia et al., where the sample size was ranged from 10 to 12 patients which may be not indicative of the impact of PRP on alveolar ridge preservation. This is in comparison with other studies, where 30 patients were recruited to demonstrate similar effect.
Three studies demonstrating the effect of PRP on prevention of dry socket. All these studies,, indicated that PRP reduced the incidence of dry socket and promoted soft-tissue healing. In two of these studies,, patients were followed up to 15 days and these studies stated that healing of soft tissue occurred within this time period; whereas the study of Alissa et al. demonstrated that PRP was able to prevent dry socket but not bone regeneration despite the fact that the patients were followed up to 3 months. However, these studies did not mention whether PRP was used alone or in combination with other bone substitutes.
Two studies evaluated the effect of PRP on the treatment of bony defect after surgical removal of cystic lesion or benign tumor of the jaws. In these studies,, PRP was used in the gel form to manage bony defect. The findings of these studies were controversial as the study of Supriya et al. stated that PRP enhanced bone regeneration after 6-month follow-up, whereas the study of Ramanathan and Cariappa showed that PRP had an insignificant effect on bone formation. These differences among the studies may be due to the differences in the size of the bony defect or the PRP-containing system or patient's age recruited in the studies. It has been stated that healing of bony defect depends on many factors such as anatomical site, patient's age, nature of the bony defect whether mono- or bicortical defect, hormonal secretion, periosteal integrity and blood supply. Many studies indicated that spontaneous healing of bony defect after removal of cystic lesion or benign tumors may take 2 years.,, However, other studies showed that this period was reduced to 6 months after using PRP gel.,, It is worth to mention that two articles may be not enough to justify whether PRP enhanced bone formation after cystic removal or not.
Two studies evaluated the effect of PRP on the ridge augmentation., In these studies, PRP was used with cancellous allograft and ABB and titanium mesh. The formal study showed that there was an increase in bone width apical to the crest of the ridge, while the latter revealed that PRP had no effect on ridge augmentation. It is difficult to justify whether PRP has an influence on ridge augmentation or not based on two studies. In addition to that, the PRP-containing system was different in both these studies. Therefore, the judgment on the effect of PRP on ridge augmentation needs further studies to reach the final conclusion.
| Conclusion|| |
PRP improved soft-tissue healing and bone regeneration after surgical extraction of lower wisdom tooth but had no effect on inflammatory response (pain, swelling and bleeding). PRP decreased the depth of periodontal pocket but not improved CAL. Implant stability and ridge height were maintained using PRP. PRP reduced the incidence of dry sockets in susceptible patients and there is no justification for the effect of PRP on bone regeneration in a bony defect after cystic removal or ridge augmentation. Further studies should be conducted to support the usage of PRP in dental and oral surgical procedures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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