CASE REPORT

Use of Platelet-Rich Plasma Combined With Hydroxyapatite in theManagement of a Periodontal Endosseous Defect Associated With a

Palato-Radicular Groove: A Case ReportC.N. Guruprasad,* A.R. Pradeep,* and Esha Agarwal*

Introduction: Various root developmental anomalies, such as palato-radicular groove, have been associated withworsening the periodontal condition. Platelet-rich plasma (PRP), an autologous concentration of platelets, has been reportedto significantly enhance bone and soft-tissue healing and the combination of PRP and a hydroxyapatite (HA) osseous grafthas been demonstrated to be efficacious in the treatment of periodontal endosseous defects. Here, we present a 1-year fol-low-up report of such a clinical case, treated by the combined use of PRP and HA osseous graft for periodontal regenerationand, finally, restorative therapy.

Case Presentation:A36-year-old Indian female reportedwith pain in the uppermaxillary incisor region. On clinical andradiologic examination, a deep 3-wall periodontal endosseous defect was found mesial to the maxillary left lateral incisor thatwas etiologically associated with the presence of a palato-radicular groove, leading to the development of a periapical lesion.Endodontic therapy, non-surgical periodontal therapy, and surgical periodontal therapywith amixture of PRP gel andHAwereperformed. One-year examination showed uneventful healing and complete elimination of the periodontal pocket.

Conclusions: A palato-radicular groove may serve as a pathway for the development of a periodontal endosseousdefect and for pulpal involvement. The combination of PRP andHAmay be efficacious in the treatment of such a periodontalendosseous defect. Additional research should be performed to evaluate the efficacy of PRP andHA in the treatment of peri-odontal endosseous defects. Clin Adv Periodontics 2012;2:28-33.

Key Words: Bone regeneration; endodontics; fibrin; graft; pain; platelet-rich plasma.

BackgroundVarious root developmental anomalies, such as palato-radicular groove, have been associated with the developmentof localized periodontitis.1 Various treatment modalitiesfor such defects with periodontal and/or endodontic in-volvement have been reported in the literature, such as gin-givectomy or apically repositioned flap,2 surgical exposure,and flattening of the groove (odontoplasty) with or withoutapplication of guided tissue regeneration techniques3,4 and/or

placing amalgam or glass ionomer cement (GIC) restorationin the groove.2

The efficacy of platelet-rich plasma (PRP) in periodontalregeneration procedures has been evaluated.5-7 The combi-nation of PRP and a hydroxyapatite (HA) osseous graft hasbeen demonstrated to be efficacious in the treatment of peri-odontal endosseous defects.8 To our knowledge, there havebeen no previous reports describing a clinical case in whichPRP and HA were used to treat a periodontal endosseousdefect etiologically associated with a palato-radiculargroove and leading to pulpal necrosis.

Clinical PresentationA36-year-old Indian female reportedwith the chief complaintof pain in the upper maxillary incisor region. On intraoral

* Department of Periodontics, Government Dental College and ResearchInstitute Fort, Bangalore, Karnataka, India.

Submitted March 18, 2011; accepted for publication May 5, 2011

doi: 10.1902/cap.2011.110028

28 Clinical Advances in Periodontics, Vol. 2, No. 1, February 2012

examination, the probing depth (PD) on the mesiopalataland mesiolabial aspect of tooth #10 was 7 mm, clinical at-tachment level (CAL)was 9mmmesiolabially andmesiopa-latally, gingival recessionwas 2mm interproximally, and nomobility was detected (Fig. 1a).

On thepalatal aspect of tooth#10, therewas adeeppalato-radicular groove initiating fromthe cingulumof the toothandextending apically (Fig. 1b). The patient complained of painon the vertical and horizontal percussion of tooth #10. Thepatient did not report a history of past or current smokingor any relevant medical history.

Case ManagementThe periapical radiograph taken after the placement of guttapercha point revealed a loss of continuity of lamina dura atthe apical third of the root and the concomitant presence ofaperiapical radiolucency andan intrabonydefect locatedme-sial to tooth #10 (Fig. 1c), strongly suggesting an etiologicalassociation between the presence of the palato-radiculargroove and the development of the periodontal endosseousdefect. We diagnosed the presence of two lesions: an endo-sseous defectmesial to tooth #10 of purely periodontal originand a periapical lesion.

Phase I periodontal therapy, endodontic therapy of tooth#10, and surgical periodontal therapywas done. Endodontictherapy of tooth #10 resulted in the reduction of the peri-apical lesion (Fig. 2). For esthetic purposes, a modified pa-pilla preservation technique9 was used (Figs. 3a and 3b),a full-thickness flap was raised, and thorough debridementand root planing was performed. The palato-radiculargroove was restored with GIC

†(Fig. 3c).

PRP Gel PreparationTwenty milliliters of blood were drawn from the antecubi-tal vein and collected in sterile plastic test tubes containingcitrate–phosphate–dextrose–adenine solution (CPD-A)‡ asan anticoagulant in the ratio of 2.8 mL CPD-A/20 mLblood. Test tubes were shaken gently and retained at roomtemperature for a minimum of 45 minutes to minimize thecomplement activity. Subsequently, the citrated blood so-lution was centrifuged, using a refrigerated centrifuge at3,000 rpm for 10 minutes, resulting in separation of threefractions: erythrocytes at the bottom layer, PRP in the mid-dle layer, and platelet-poor plasma (PPP) at the top layer(Fig. 4a). PPP was aspirated with a pipette (Fig. 4b) andwas used as source of the autologous thrombin.7 ThePRP was collected in conjunction with the top 1 to 2 mmof the red blood cell fraction, because the latter is also richin newly synthesized platelets.10 PRP gel was prepared ac-cording to themethod described by Su et al.10 At the time ofapplication, coagulation of autologous PRP was achievedby using autologous thrombin. Approximately 3mLof PPPwas taken in a sterile test tube, and freshly prepared cal-cium chloride solution of 10% in the ratio of 33 mL/mLPPP was added and left until coagulated. The clot formedwas rung out and the membranous skin remaining was dis-posed. The remaining fluid was autologous thrombin-richplasma. This autologous thrombin-rich plasma was mixedwith PRP in the ratio of 0.16 mL/mL PRP, on a sterile flat-surfacedcontainerandallowed tocoagulate for3 to5minutes.The coagulated material was placed onto several sterile drylint-free gauze pads, which absorbed the excess serum, leavingwell-formed PRP gel.

The 3-walled intrabony defect was filled with a mixtureof the autologous PRP gel and the HA bone graftx (Fig. 5a).

FIGURE 1a Baseline facial clinical view, showing a PD measurement of 7 mm mesial to tooth #10. 1b Baseline palatal clinical view demonstrating thepresence of a palato-radicular groove (arrow) on the palatal aspect of tooth #10. 1c Baseline periapical radiograph of tooth #10, showing a gutta percha pointplaced along the bone defect.

FIGURE 2 Periapical radiograph taken 1 month after endodontic therapyof tooth #10.

† GC Fuji II, GC Corporation, Tokyo, Japan.‡ HL Haemopack, HLL Lifecare, Thiruvanathapuram, Kerala, India.x PerioBone G, Top-Notch Health Care Products, Aluva, Kerala, India.

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The PRP preparation procedure is described above. Flapswere approximated with interrupted sutures of 3-0 blacksilk,k andperiodontal dressing{wasplaced (Fig. 5b). Sutureswere removed after 1week. The 6-month postoperative pic-ture shows uneventful healing (Fig. 6).

Full ceramic crown on tooth #10 and construction of thedistal surface of tooth #9with a light-cured composite resinrestoration was done (Fig. 7a).

Clinical OutcomesReexamination after 12 months revealed reduction in PD(from 7 to 2 mm) and CAL (from 9 to 4 mm) (Fig. 7b)and also significant radiographic bone formation in theperiodontal endosseous defect (Fig. 7c).

DiscussionThe combination of PRP and anHA osseous graft has beendemonstrated clinically and radiographically efficacious inthe treatment of periodontal endosseous defects.8 To ourknowledge, this is the first report describing a clinical casein which PRP and HAwas used to treat a periodontal endo-sseous defect, etiologically associatedwith apalato-radiculargroove.

It has been shown that PRP stimulates the proliferation ofperiodontal ligament and osteoblastic cells, while at thesame time, epithelial cell proliferation is inhibited.11 It hasbeen also speculated that, because of its fibrinogen content,PRP reactswith thrombin and induces fibrin clot formation,which in turn is capable of upregulating collagen synthesis inthe extracellular matrix and provides a favorable scaffoldfor cellularmigration and adhesion.12 The fibrin componentof PRP gel not onlyworks as a hemostatic agent aiding in thestabilization of the graft material and the blood clot,13 butalso adheres to the root surface and may impede the apicalmigration of epithelial cells and connective tissue cells fromthe flap.14 Therefore, PRP may exert a guided tissue regen-eration–like effect in the treated defects. PRP also can stim-ulate monocyte chemotaxis in a dose-dependent manner,and RANTES (regulated on activation normal T-cell ex-pressed and secreted), in part, was found to be responsiblefor PRP-mediated monocyte migration.15 Lipoxin A4 wasfound to be increased in PRP, suggesting that PRP may pos-sess the potential for cytokine release, limit inflammation,and thereby promote tissue regeneration.15 This suggeststhat PRP facilitates healing by controlling the local inflam-matory response.

ConclusionsFrom the presented case, it can be concluded that a palato-radicular groovemay serve as apathway for thedevelopmentof a periodontal endosseous defect. A combined treatmentstrategy, including non-surgical and surgical periodontal,endodontic, and restorative procedures, could be requiredfor the management of such complex clinical cases. n

FIGURE 3a Facial clinical view of tooth #10 after the elevation ofa modified papilla preservation flap. 3b Palatal clinical view of tooth #10after flap elevation, showing the palato-radicular groove before restorationwith GIC. 3c Palatal clinical view of tooth #10 after flap elevation, showingthe palato-radicular groove restored with GIC.

k Ethiprime, Mersilk, Ethicon, Johnson & Johnson, Somerville, NJ.{ COE-PAK, GC America, Alsip, IL.

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30 Clinical Advances in Periodontics, Vol. 2, No. 1, February 2012 Periodontal Defect Treatment Using Platelet-Rich Plasma and Hydroxyapatite

FIGURE 4a Three basic fractions because of their differential densities: red bloodcells at the bottom layer, PRP in the middle layer, and PPP at the top layer. 4bSeparation of PPP (left test tube), PRP (middle test tube), and erythrocyte (righttest tube) fractions.

FIGURE 5a Clinical view of the periodontalendosseous defect completely filled with themixture of PRP and HA osseous graft. 5b Palatalclinical view of the surgical area immediatelyafter suturing.

FIGURE 6 Palatal clinical view of the same area 6 months after periodontal surgery, showinguneventful healing.

FIGURE 7a Final facial clinical view of the maxillary anterior area 12 months after periodontal surgery. 7b Final clinical photograph depicting a periodontalprobe measurement of the final (1 year after treatment) PD of 2 mm. 7c Final periapical radiograph of tooth #10 12 months after periodontal surgery, showingradiographic fill of the periodontal endosseous defect mesial to tooth #10.

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Summary

Why is this case new information? j PRP and HA have been used to treat a periodontal endosseousdefect, etiologically associated with a palato-radicular groove.

What are the keys to successfulmanagement of this case?

j A combined treatment strategy, including non-surgical and surgicalperiodontal, endodontic, and restorative procedures is the key tomanagement of such cases.

What are the primary limitations tosuccess in this case?

j The success of such a case depends on the precise formation of thePRP gel, as well as on the success of endodontic therapy, non-surgical therapy, and surgical periodontal therapy.

AcknowledgmentThe authors report no conflict of interest related to this casereport.

CORRESPONDENCE:C.N. Guruprasad, Department of Periodontics, Government Dental Col-lege and Research Institute Fort, Bangalore 560002, Karnataka, India.E-mail: periodontics_gdcri@gmail.com.

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