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Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 187-193

Effect of autologous platelet aggregates on the healing outcome of periapical surgery for the management of apico-marginal defects: A systematic review

Department of Conservative Dentistry and Endodontics, Manav Rachna Dental College, Faridabad, Haryana, India

Date of Submission25-Sep-2019
Date of Decision05-Nov-2019
Date of Acceptance26-Nov-2019
Date of Web Publication27-Aug-2020

Correspondence Address:
Dr. Namrata Mehta
20/1 Second Floor, Old Rajinder Nagar, New Delhi - 110 060
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_146_19

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Introduction: An apico-marginal defect is a combined endodontic periodontal lesion that poses a challenge to the healing outcome and therefore often leads to the decreased prognosis of periapical surgery. This systematic review aims to analyze clinical studies and case reports that show evidence of the effect of autologous platelet aggregates on the healing outcome of apico-marginal defects.
Materials and Methods: Literature search strategy was performed to find relevant clinical studies and case reports according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The question was “healing outcome of apico-marginal defects treated using autologous platelet aggregates.” The review involved a search of electronic databases of Pubmed, Scopus, Ebsco host, as well as manual search.
Results: Five relevant literature published between 1990 and June 2019 were selected after thorough analysis and exclusion according to the strict criteria. The included studies were related to clinical and radiographic healing outcome of apico-marginal defects with autologous platelet aggregates.
Conclusion: The collected data suggested that autologous platelet aggregates give a favorable healing outcome for the management of apico-marginal defects.

Keywords: Apico-marginal defects, endodontic surgery, platelet aggregates, platelet-rich fibrin, platelet-rich plasma

How to cite this article:
Mehta N, Gupta A, Aggarwal V, Abraham D, Singh A. Effect of autologous platelet aggregates on the healing outcome of periapical surgery for the management of apico-marginal defects: A systematic review. Saudi Endod J 2020;10:187-93

How to cite this URL:
Mehta N, Gupta A, Aggarwal V, Abraham D, Singh A. Effect of autologous platelet aggregates on the healing outcome of periapical surgery for the management of apico-marginal defects: A systematic review. Saudi Endod J [serial online] 2020 [cited 2021 Dec 3];10:187-93. Available from: https://www.saudiendodj.com/text.asp?2020/10/3/187/293567

  Introduction Top

Periodontal and pulpal tissues share a close relationship. Pulpal infection, if persists, most often leads to secondary infection and devastation of the periodontal architecture and vice versa.[1] The major anatomical route of communication that allows the communication of inflammatory mediators to and from the tissues is through the apical foramina and lateral canals. Because of this, bone resorption often results at or around the root apex, in the periradicular area, especially in cases of apical periodontitis or apical abscess. Such lesions are termed as endodontic-periodontal lesions and classified into primary endodontic lesion, primary periodontal lesion, primary endodontic lesion with secondary periodontal involvement, primary periodontal lesion with secondary endodontic involvement, and true combined lesion.[2] An apicomarginal defect can be defined as a combined endodontic periodontal lesion with the total loss of the buccal bone plate extending from crestal bone to the apex of the tooth.[3]

These are rare, but when they do occur, they pose a big challenge to healing outcome and therefore lead to decreased prognosis of periapical surgery due to downward growth of epithelial tissues along the entire root surface and the progression of nonosteogenic tissues into the surgical site.[4] Guided tissue regeneration (GTR) therapy has been extensively used, since the 1980s, to revive lost periodontium in periodontal diseases. Its use has also been advocated in endodontic surgeries as an affiliated treatment during the management of endodontic-periodontal lesions. The method consists of placing different types of membrane barriers to cover the denuded bone and the periodontal ligament, acting as a separation between gingival epithelium and connective tissue that in turn prevents the movement of epithelial tissue into the surgical site, overall potentiating the healing of the lesion.[5] However, the use of GTR membranes could have a few demerits such as high cost, an increased likelihood of contamination, complex flap approximation, and an amplified threat of mechanical trauma to the surgical site that might lead to the development of endo-perio communications and increased probability of infectivity.[5]

Recently, there is more preference of using autologous platelet aggregates over the use of GTR membrane in the treatment of apicomarginal communications. Platelet concentrates such as platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are often used for many medical and dental surgical procedures. They release protein growth factors when activated which aid in the healing process. Other preparations such as plasma rich in growth factors and concentrated growth factors (CGF) have been used in oral surgeries. CGF is known to have more amount of growth factors. However, there is less documented literature about applying these preparations in endodontic surgeries and more studies are needed to reinforce the use of CGF in peri-radicular surgery.[6],[7],[8],[9]

Only a few studies have established the successful use of PRP and PRF in periradicular surgery to promote healing of apicomarginal defects. There is a dearth of documented data regarding the application of platelet concentrates for periapical surgeries to manage combined endo-perio lesions, especially apicomarginal defects. This systematic review aims to analyze clinical studies and case reports that show evidence of the effect of autologous platelet aggregates on the healing outcome of apicomarginal defects.

  Materials and Methods Top

Literature search strategy was performed, and the protocol of the systematic review was prepared using the established Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. The framed protocol was registered on the International Prospective Register of Systematic Reviews with reference no. 139959. The review question was formulated using the patient problem (or population), intervention, comparison, or control (PICO) framework of systematic review. The formulated PICO was “healing outcome in terms of bone regeneration using autologous platelet concentrates in periapical surgery of apico-marginal communications.”

Literature search strategy

The literature search was based on the following databases: Medline/Pubmed, Ebsco host, Scopus, as well as manual reverse search performed using suitable Medical Subject Headings (MeSH) terms or keywords as shown in [Table 1]. MeSH (https://www.ncbi.nml.nih.gov/mesh) terms were used together with the Boolean operators “AND” and “OR” to build a search strategy of keywords. The collected data were manually searched as well as reverse searched for the identification and exclusion of duplication, and the final number of studies was selected after applying and framing using the PRISMA checklist [Table 1].[10]
Table 1: Lists of combination of Medical Subject Heading terms and keywords for electronic database search strategy

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Inclusion and exclusion criteria

The titles and abstracts of all the articles were screened and identified in the electronic and manual searches. Articles not meeting the inclusion criteria were filtered out. All the remaining articles were thoroughly screened independently.

The inclusion criteria were framed as follows:

  1. All studies published from 1990 to June 2019
  2. Clinical trials and case–control studies
  3. Adult human patients
  4. Studies published in English language only
  5. Studies including patients with endodontic lesions leading to apicomarginal communication
  6. Studies in which final healing outcome was assessed.

Exclusion criteria were framed as:

  1. Nature of the study: cultured lab and animal studies
  2. Studies without application of autologous platelet aggregates in periapical surgery for apico-marginal defects
  3. Studies without final radiographic assessment of bone loss
  4. Studies on pediatric patients.

From the total database search, the relevant articles were hand searched. The bibliography of relevant papers and review articles was also screened to calculate the exact relevant data. Finally, the data were framed in the form of PRISMA flowchart [Figure 1].
Figure 1:Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart

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Quality assessment and data extraction

The extracted data were analyzed. Each individual study was analyzed by the following parameters such as author (year)/country, journal, language, design of the study, diagnostic criteria, material used, and procedure applied determined according to the guidelines given by the National Services Scotland.[11] Risk of bias was applied to relevant studies using Joanna Briggs Institute Critical Appraisal Checklist.[12]

  Results Top

The search strategy is depicted in [Figure 1]. The total number of relevant articles identified via the search of electronic databases and manual search was 140 items. Duplicate articles were excluded. After exclusion of duplicates, 67 articles were screened for abstract evaluation. Considering the strict inclusion and exclusion criteria, only five articles were included in the systematic review.

Risk of bias

The risk-of-bias assessment was done only on two studies (Dhiman et al.[5] and Goyal et al.[13]) using the checklist given by Joanna Briggs Institute Critical Appraisal Checklist.[12] For applying risk of bias, seven criteria were used for randomized controlled trials and ten criteria were used for nonrandomized clinical studies. For both studies, evidence level was determined by following the guidelines given by the National Services Scotland.[11] Risk of bias could only be applied to two studies by Dhiman et al.[5] and Goyal et al.[13] as the other studies were case reports. The randomized controlled trial by Dhiman et al.[5] showed very low risk of bias with evidence level 1++ and the clinical study by Goyal et al.[13] showed low-to-moderate risk of bias with evidence level of 2++ [Figure 2] and [Figure 3].
Figure 2: Risk of bias in clinical study by Meenu Dhiman et al. (2015)

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Figure 3: Risk of bias in clinical study by Bhawna Goyal et al. (2011)

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Interpretation of individual studies

  1. Goyal et al.[13] in their prospective clinical study compared the healing responses of PRP, PRP + a collagen sponge, and a collagen membrane following the principle of GTR membranes for the treatment of apicomarginal communications. Thirty patients diagnosed with suppurative chronic apical periodontitis and endo-perio communication were distributed randomly into three groups according to the physical barrier to be applied during surgery namely Group 1 of collagen membrane, Group 2 with the use of just PRP, and Group 3 with the combination of PRP with collagen sponge. The surgery was carried out, and root-end preparations were made and filled with mineral trioxide aggregate (MTA). In Group 1, the collagen membrane was placed over the defect, whereas in Group 2, PRP was prepared during the surgery. In Group 3, the combination of PRP and collagen sponge, two layers of the sponge were used as a carrier membrane for PRP and placed on the defect. Follow-up assessment was done at 3, 6, 9, and 12 months. At the 12th-month follow-up, the overall healing rate was 80.76%, greater but not significant rate of 83.33% for Group 2 of just PRP, 88.89% for Group 3 of combined PRP + collagen sponge, and 80% for Group 1 with just collagen membrane
  2. Dhiman et al.[5] carried out a randomized controlled clinical trial to study the healing outcome of PRF in periapical surgeries for apicomarginal defects and compared these results with surgeries without GTR application. Thirty patients diagnosed with suppurative chronic apical periodontitis and apicomarginal defects were randomly assigned to two groups: the PRF group and a control group. Surgery was performed, and root-end preparations were restored using MTA. This procedure was common to all the patients of both the groups. After this, for the patients assigned to the PRF group, the PRF membrane was immediately placed over the denuded root surface before flap repositioning. In the control group, similar surgery was performed but without the placement of the PRF membrane. Baseline immediate radiograph was taken, and the patients were recalled every 3, 6, 9, and 12 months. Periodontal parameters were measured only during the 12th-month follow-up assessment. In each treatment group, periodontal parameters reduced significantly during the 12-month follow-up period. The overall success rate was 83.33%, and the individual success rates in the PRF and the control groups were 86.66% and 80%, respectively, but the difference was statistically insignificant
  3. Wadhwa et al.[14] presented a clinical case report which studied the healing by applying PRF membrane in the surgical management of periapical pathology in a mandibular first molar of a 25-year-old male patient associated with an apicomarginal communication. The patient reported with a chief complaint of pain and pus discharge in lower right posterior tooth region. Clinically deep occlusal caries with a sinus opening was observed buccally in relation to #46. Radiographic examination confirmed occlusal caries approaching the pulp with a periapical radiolucency under the mesial and distal roots of the molar. The sinus tracing was carried out with gutta percha point. Probing depth (PD) >10 mm on the mid-buccal side was found via periodontal Williams O probe. It was diagnosed as suppurative chronic apical periodontitis with an endo-perio communication till the root apex. During the surgery, a full-thickness mucoperiosteal flap was elevated followed by osteotomy to give a view of the already-exposed distal root till the apex. Surgical procedure was carried out, and root-end preparations were filled with MTA. Before repositioning and suturing the flap, PRF was placed on the surgical site. Patients only reported for follow-up at 3 and 18 months. All the parameters were recorded again and healing was reported as successful
  4. Meharwade et al.[2] described the clinical treatment of an apicomarginal defect in relation with the extended destruction around the apex of a maxillary lateral incisor with a palatogingival groove (PRG). The PRG depth and extension along the surface of the root can damage the health of the periodontal and pulp tissue and could be responsible for the apicomarginal communication. A 21-year-old male reported with the complaint of mild pain, pus discharge, and bleeding gums associated with upper right front tooth region since 6 months. Clinically tooth #11 was Grade 1 mobile with a sinus opening on the labial aspect. No relevant trauma history was given by the patient. Periodontally the tooth was stable; however, the PD of tooth #12 was 15 mm on the distolingual side with PRG. Intraoral periapical radiograph presented with an indentation on disto-cervical area along with a straight radiolucency parallel to the entire length of the canal. Ill-defined radiolucency around the middle and apical thirds of the root could be seen. Angular bone loss was present with dilacerations of the root. Diagnosis was finalized as combined endo-perio lesions. A cone beam computed tomography evaluation revealed localized bone loss on the facial aspect and marginal bone loss on the labial and disto-lingual sides with nonembedded pulp stones. On the basis of these findings, it was diagnosed as an apicomarginal bone defect. Root canal was started, and intracanal medicament was placed. Root planing was performed along with curettage. Composite and wire splinting was done. The surgery included GTR principle using demineralized freeze-dried bone graft with PRF. Surgery was carried out and apically restored using MTA. The site of the defect was filled till interdental bone crest with a mix of freeze-dried bone and PRF. The entire area was then covered by a PRF membrane and sutured. Follow-up evaluation was planned at 3, 6, 9, and 12 months. Radiographic assessment at the 12th month recall confirmed successful healing of the radiolucency and the lesion
  5. Gupta et al.[15] reported a case of a 15-year–old patient who reported with a dilacerated #21 and a sinus opening in the labial vestibule with top positive in #22. He had a history of trauma to the tooth when he was 5 years of age. Clinically periodontal PD of 9 mm was seen at the distal aspect of the left lateral incisor. Radiographically a large radiolucency with an open apex and a tooth-like structure was related to #21. In addition, extra canals with respect to #21 could be observed. Root canal treatment was initiated, but even after a month of consistent intracanal medication therapy, there was no improvement in the healing or the symptoms, so it was decided to go ahead with a surgical procedure. After reflecting the full-thickness flap, an absolute loss of bony plate with a lesion around the apex indicating an apicomarginal defect with a fragment related to #22 could be seen. Retrograde restorations were completed using MTA. PRP was prepared and placed over the site. At the 12th-month recall visit, no signs and symptoms were reported with clinical closure of the sinus tract and radiographically successful bony healing of the radiolucency.

  Discussion Top

When periapical pathology occurs along with the breakdown of the periodontium, it poses a challenge to the successful prognosis of the surgical procedure. The consequential destruction of the bone can have a negative effect on the regenerative potential of the diseased tissues.[16],[17] Using a physical barrier is known to prevent downward migration of the epithelial tissue over the bony defect. Whether the loss of bone is natural or pathological in nature plays a significant role in the decision to apply a physical barrier on the surgical site. If it is naturally occurring, no physical barrier is required because a fibrous connective tissue is already present between the root and mucosa. However, in pathological bone loss, a membrane barrier placement prevents the movement of epithelial tissue apically.[2],[18]

Marin-Boteroet al.[19] and Dietrich et al.[20] introduced the use of GTR membrane barriers and concluded improved healing in such cases as compared to conventional flap repositioning. This was confirmed by Varghese[21] that placement of a barrier membrane enhances the new attachment. Various types of biomaterials have been reported in the documented literature, to be used as membrane barriers in the application of GTR principles in surgery. These materials can be resorbable or nonresorable membranes. It can be some type of periosteal graft or bone grafts. These materials have proven successful, but still show certain disadvantages such as increased probability of infection on exposure to oral environment, a second surgery might be required in cases of nonresorable membranes only, and increased risk of mechanical trauma from the gingival sulcus as the marginal bone is resorbed. These demerits should be overcome for favorable prognosis.[2]

However, with better understanding about biological healing mechanisms, the techniques are now moving toward more regenerative and reconstructive approaches.[22],[23] Autologous platelet concentrates act as fibrin gluing the flap in a stable position.[24] The platelet granules contain protein growth factors that are important for healing and repair of any lesion. The healing mechanism utilizes the natural processes of chemotaxis, differentiation, and cellular proliferation for better regeneration.[25] The methodology for the current systematic review included search strategy using specific keywords describing “autologous platelet aggregates” which was used exclusively in the surgical management of endodontic lesions leading to buccal bone loss.

Papli and Chen in their case series reported better periodontal healing of infrabony defects when the principle of GTR was applied using a bioresorbable barrier membrane along with platelet concentrates.[26] The results in this study were in consistent with the result of the clinical study by Goyal et al.[13] that included the management of apicomarginal defects by following GTR membrane protocol through PRP and PRP + collagen sponge.

Singh[27] and Raja et al.[28] showcased the positive influence of PRP and grafts for the treatment of endo-perio lesions with significant successful radiographic and clinical results, through their case reports. Dhiman et al.[5] incorporated PRF instead of PRP due to the fact that it acts not only as a membrane barrier but also as an interpositional matrix that promotes the formation of new blood vessels that prevent necrosis of the flap. Dhiman et al.[5] reported a highly success rate in the group treating apicomarginal defects without membrane barrier techniques (80%), with improved periodontal and endodontic healing. These results are in contrast to previous studies reporting lower success rate of 27%–37%.[29],[30]

Periodontal breakdown combined with the occurrence of periapical pathosis constitutes a complex problem in periradicular surgery with less favorable and unpredictable prognosis.

Completely successful management of such rare lesions is a true challenge.[29] Platelet concentrates promote hemostasis by aiding in blood clot formation because of its high fibrin content. This blood clot in turn promotes regeneration of periodontal and periapical tissues.[31]

One of the lacunae in the current review included the fact that meta-analysis could not be applied because of the heterogeneous nature and the confounding variables in the involved studies. Risk of bias could only be applied to two of the included studies by Dhiman et al.[5] and Goyal et al.[13] This is a limitation of this review. It is due to the dearth of documented literature available in this field and more randomized and nonrandomized experimental studies are encouraged to promote more use of autologous platelet aggregates in endodontic-periodontal lesions.

  Conclusion Top

The cumulative data in the current review suggest that autologous platelet aggregates can be used for better healing outcomes after surgical procedure in apico-marginal defects. However, more documented clinical studies for the management of apico-marginal defects are encouraged to reinforce the idea to use more autologous platelet aggregates for their surgical management in future.

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Conflicts of interest

There are no conflicts of interest.

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