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Introduction New attachment is the embedding of new periodontal ligament fibres on to new cementum previously denuded by the periodontal disease1, it is essential for periodontal regeneration. Many factors for example, formation of a smear layer after root planing, interfere with new attachment.2 Hence, modification of the root surface by various means, known as biomodification procedures, has been introduced by using a variety of agents, in order to detoxify, decontaminate, and demineralise root surfaces.3 A number of physical, chemical and miscellaneous agents have been proposed for demineralisation procedure which include EDTA (Ethylene diamine tetra acetic acid)4, citric acid5, tetracycline6, fibronectin7, PDGF (Platelet derived growth factor)8, Er YAG (erbium-doped yttrium aluminium garnet) laser9, Nd YAG (neodymium-doped yttrium aluminum garnet) laser10, carbon dioxide laser11,sodium deoxycholate and human plasma fraction Cohn IV12 etc. There have been controversial evidences of new attachment following root surface modification by these agents.13 So, there is a need to evaluate various root biomodifying agents.Materials And MethodsEBSCO HOST was searched for entries since 1966 - 2014, which included these journals :- Journal of Periodontology, Annals of Periodontology, Periodontology 2000, Journal of

Clinical Periodontology, International Journal of Periodontics and Restorative dentistry, Journal of Indian Society of Periodontology and Journal of Periodontal Research.To identify studies not found in the databases search, certain issues of the following journals were searched manually: Journal of Periodontology, Journal of Clinical Periodontology, Journal of Indian Society of Periodontology and Journal of Periodontal Research, Chronicles of Dentistry, Indian Journal of Oral Sciences, text books. 2.1 Inclusion criteria:- Randomized controlled trials in systemically healthy human subjects; comparative, histologic and animal studies, narrative reviews published in English; presenting any modality of root surface biomodification. 2.2 Exclusion criteria:-Studies lacking baseline-outcome comparisons; with insufficient data; with more than one variable in addition to root surface biomodification ; and case reports, because of their weaker clinical evidence. Reading of relevant studies and quality evaluation were carried out to assess their suitability for this review.Results The result of various experiments, studies and observations have been presented in tables from number 1 to 6.

CURRENT STATUS OF ROOT BIOMODIFICATIONAGENTS IN REGENERATION

1 2 3 Kratee Sharma , Krishna Kumar Chaubey , Sunil Sharma , Mridula Trehan4

1. Second year Post graduate student, 2. Professor and Head, Department of Periodontics, Kothiwal Dental College and Research Centre, Mora Mustaqueem, Kanth Road, Moradabad, Uttar Pradesh, India, kkchaubey@rediffmail.com3. Principal, Department of Oral and Maxillofacial surgery, 4 . Professor and Head, Department of Orthodontics and Dentofacial Orthopaedics, Mahatma Gandhi Dental College and Hospital, Sitapura, Tonk road, Jaipur, India,

Abstract Background:- The smear layer formation during root planing is a barrier for new attachment. Hence, various biomodification procedures, have been introduced to detoxify, decontaminate, and demineralise root surfaces, thereby, aiding in new attachment. So, there is a need to evaluate various root biomodifying agents. Materials and methods:- EBSCO HOST was searched for entries since 1966 - 2014, which included:- Journal of Periodontology, Annals of Periodontology, Periodontology 2000, Journal of Clinical Periodontology, International Journal of Periodontics and Restorative dentistry, Journal of Indian Society of Periodontology and Journal of Periodontal Research.Results:- Out of 63 studies, only 20 reported evidence of regeneration, for citric acid, tetracycline, fibronectin, EDTA, lasers. Growth factors, sodium deoxycholate and human plasma fraction COHN IV hardly showed any role in regeneration.Conclusion:- The role of root biomodification agents in regeneration is still unpredictable and questionable.is

Key words:-

Root biomodification,

regeneration, growth factors

Source of support : None

Conflict of interest: None

Journal of Dental Science

University

TissueRegeneration

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TABLE 3.1: EVALUATION OF EFFICACY OF CITRIC ACID IN ROOT BIOMODIFICATION

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TABLE 3.2: ANALYSIS OF EFFICACY OF TETRACYCLINE IN ROOT BIOMODIFICATION

TABLE 3.3: ANALYSIS OF EFFICACY OF EDTA IN ROOT BIOMODIFICATION

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TABLE 3.4: EVALUATION OF EFFICACY OF FIBRONECTIN IN ROOT BIOMODIFICATION

TABLE 3.5: EVALUATION OF EFFICACY OF CO LASER IN ROOT BIOMODIFICATION2

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3.6 COMPARATIVE EVALUATION OF MULTIPLE ROOT BIOMODIFICATION AGENTS

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4. DiscussionThe nature of the periodontally exposed roots has been identified as one of the major factor influencing periodontal regeneration. These diseased root surfaces are unfavourable for new attachment .38 Traditional treatment of pathologically altered root surfaces has relied on mechanical therapy alone. 39 Nevertheless, this procedure leads to smear layer formation that impairs and hinders the periodontal healing and regeneration. Thus, emphasis has been given to root surface modification through various agents, which promote root decontamination and exposure of the collagen matrix aiming at new attachment formation and, therefore, periodontal regeneration.Strict inclusion criteria were imposed to enable an unbiased analysis and a conclusion regarding its impact on treatment results. A total of 63 studies were reviewed, out of these 20, 11, 12, 6, 11 studies, only 6, 4, 6, 2, 2 reported evidence of regeneration, for citric acid, tetracycline, fibronectin, EDTA, lasers, respectively. Growth factors, sodium deoxycholate and human plasma fraction COHN IV hardly showed any role in regeneration. In most of the studies on citric acid, no stastistically significant differences were seen, indicating unpredictable role of citric acid in regeneration. 24, 25, 26 ,Some authors attributed it to the presence of exposed cementum in all specimens in which clinician attempted complete removal, which hindered regeneration and found that connective tissue attachment and cementogenesis were not enhanced by citric acid.14,15Most studies focused on histologic observations, so clinical results could not be discussed.16,17,19 The samples were too limited to make meaningful judgements, and it was found that citric acid treatment prior to free gingival grafts and laterally positioned pedicle flap, was not justifiable.5Macheti et al 30 found that the treatment of human roots with tetracycline-HCl during periodontal surgery did not result in new attachment and has no additional effect of tetracycline root preparation on guided tissue regeneration in the treatment of Class II furcation defects.The additional application of fibronectin to tetracycline- treated roots did not improve or partially negated the results observed with tetracycline treatment alone.28 Root conditioning with tetracycline enhances the binding of fibronectin to dentin. The increased binding is thought to increase movement and proliferation of periodontal ligament cells to and on dentin surfaces.32 Thus, the contradictory results indicate that further studies are needed to fully evaluate tetracycline root preparation in conjunction with regenerative therapy. In most of the studies on root surface conditioning with EDTA in regenerative procedures seemed preferable to citric or phosphoric acids because EDTA selectively removed hydroxyapatite, leaving most of the collagenous matrix intact. It was observed that cleaning with EDTA was not dependent on a low pH, and did not presented any toxicologic problems. This observation favours the use of EDTA and thus, eliminates the necrotizing effects on surrounding periodontal

tissues of an etching agent operating at a low pH such as citric or phosphoric acids.28However, some authors suggested that EDTA application in combination with nonsurgical periodontal therapy failed to add to the improvement in clinical parameters. Thus, EDTA etching of root surfaces did not contribute to the elimination of periodontal pockets or increase clinical attachment when combined with conventional nonsurgical periodontal therapy.27In another study by Alger et al., it was reported that the addition of fibronectin to tetracycline treated teeth did not enhance connective tissue attachment, and appeared to inhibit it. There was a trend for less reattachment when fibronectin was applied to the tetracycline-treated tooth.28 In studies involving lasers, it was found that laser irradication of 1 second at 3 Watt completely removed the smear layer with minimal change in the diameter of dentinal tubules. 11 In another study by Crespi et al 36, it was found that CO2 laser treatment combined with mechanical instrumentation constituted a useful tool to condition the root surface and increased fibroblast attachment to root surfaces, due to bactericidal effect of CO2 laser and ability to detoxify the root surfaces.In studies involving comparative evaluation of multiple root biomodification agents, in a study by Shetty Bhavya et al, tetracycline was found to be the best current tetracycline form for root surface conditioning as measured by its ability to affect both dentin smear layer removal and tubule exposure.13Minocha Tanuj et al reported that the application of a combination of citric acid and tetracycline showed a better effect as a root conditioning agent, enhancing the adhesion of the fibrin clot. The authors attributed to the synergistic effect of root conditioning and the antimicrobial property of citric acid and tetracycline, which would make the root surface more biocompatible for blood clot adhesion, an earlier event in periodontal healing.37

5. ConclusionWithin the limitations of this review, it is possible to conclude that the application of root biomodification agents such as citric acid, ethylenediaminetetraacetic acid, tetracycline hydrochloride, fibronectin, laminin, EDTA, sodium deoxycholate, enzyme lysozyme, growth factors, lasers provide no or minimal clinical benefit with respect to gain in attachment levels or reduction in probing pocket depths. Thus, their role in regeneration is still unpredictable and questionable. Therefore further studies are needed to ascertain the positive effect of root biomodification agents on regeneration in larger sample size.

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conditioning -A review. J Ind Soc Periodontol 2003; 6(2):88-93.

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therapy for the treatment of intraosseous periodontal defects. J Clin Periodontol 1998; 25:707-714.

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35. Caffesse RG, Kerry GJ, Chaves ES. Clinical evaluation of the use of citric acid and autologous fibronectin in periodontal surgery. J Periodontol 1988; 59:565-569.

36. Crespi R, Barone A, Covani U, Ciaglia RN, Romanos GE. Effects of CO2 laser treatment on fibroblast attachment to root surfaces. A scanning electron microscopy analysis. J Periodontol 2002; 73:1308-1312.

37. Minocha T, Rahul A. Comparison of fibrin clot adhesion to dentin conditioned with citric acid, tetracycline, ethylene diamine tetraacetic acid: An in vitro scanning electron microscopic study. J Ind Soc Periodontol 2012; 16(3):333-341.

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Correspondance:Dr. Kratee SharmaDepartment of Periodontics, Kothiwal Dental College and Research Centre, Mora Mustaqueem, Kanth Road, Moradabad, 244001,India.

E-mail id : drkratee@gmail.com

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