COMPARISON OF POST OPERATIVE HEALING OF EXTRACTION SOCKET
WITH AND WITHOUT CALCIUM CHLORIDE ACTIVATED PLATELET
RICH PLASMA- AN IN VIVO STUDY
Dissertation submitted to
The Tamil Nadu Dr. M.G.R. Medical University
In partial fulfilment of the degree of
MASTER OF DENTAL SURGERY
BRANCH III
ORAL AND MAXILLOFACIAL SURGERY
2017-2020
ACKNOWLEDGEMENT
“At times our own light goes out and is rekindled by a spark from another person.
Each of us has cause to think with deep gratitude of those who have lighted the flame
within us.”
I extend my sincere and heart felt gratitude to my teacher Dr. Mathew Jose,
Prof and HOD, under his able guidance and encouragement, I had the opportunity of
being taught and explained the surgical techniques, tips and tricks of being an
efficient surgeon. Vast experience of him has attributed in unwinding the complex
nature of many questions that took me through different but difficult situation in my
post graduate studies. I could not have asked for a better mentor or guide for my
post graduate studies.
I thank Dr. Sajesh for the able guidance and support he has provided me during
the research and also post graduate studies. He with his friendly talks, critical
questions and sometimes being strict has made sure that I am travelling in correct
path of being a good surgeon. Best part of him always approachable and ready to
share the vast knowledge and experience he has acquired in years.
I take this opportunity to thank our principal Dr. Elizabeth Koshi for her help,
support & patient guidance for finishing this work on the time bound limits.
I express my sincere gratitude to my teacher Dr. Nandagopan continually and
persuasively conveyed a spirit of adventure in regard to research and scholarships,
and an excitement in regards to teaching. He has always supported me and his
helpful nature has one of been the driving force for the fulfillment of my research
work.
I extend my deepest gratitude and thanks to Dr. Marban joe who
has always been a great teacher and for us. He has taught us to have the right kind
of attitude a fellow surgeon need to have, he has tried to mold us into a well behaved
and classy professional with etiquette and moral and ethical responsibilities.
I am indebted to my teacher Dr. Achuthan Nair who has tried to bring the
best out of me. He has motivated me to a mass knowledge and taught us how
learning process could be an enjoyable moments. He has been one of the serious
critics of my post graduate studies.
I extend my sincere thanks to Dr.Sindhuja Devi for her contributions in my thesis
work. Her humbleness and dedication to profession coupled with tremendous skill
had always been a fascination to me.
I am highly obliged Dr.Meglin for being there always to clear my doubts and
guide me through the right path.
I would like to thank Dr. Yazhini for supporting me through the hard times and
motivating me to study harder.
I would like to thank my super seniors Dr.Abirami and Dr.Harine
for teaching me the intimate skills of surgery.
I would like to thank my seniors Dr.Ruban and Dr.Subin for timely support and
guidance.
I would like to thank my juniors Dr.saravanan, Dr.Tamil, Dr.Saumya and
Dr.Venkidesh for the support and enjoyable moments we had during the post
graduate life.
Above all I thank Almighty God, My parents and my husband Mr.Aneesh for walking
with me in each and every step of my life and making this study to successful one.
SPECIAL ACKNOWLEDGEMENT
I take this opportunity to thank specially our Chairman Dr.C.K.VELAYUTHAN NAIR
MS, Sree Mookambika Institute of Dental Sciences, our Director Dr.REMA.V.NAIR
MD, Sree Mookambika Institute of Dental Sciences and our Trustees
Dr.R.V.MOOKAMBIKA MD, DM, Dr.VINU GOPINATH MS, MCH and
Mr.J.S.PRASAD, Adminstrative officer for giving me the opportunity to utilize the
facilities available in this institution for conducting this study.
CONTENTS
SI.NO INDEX PAGE
NO.
1 List of Abbreviations i
2 List of Tables ii
3 List of Graphs iii
4 List of Figures iv
5 Abstract v-vi
6 Introduction 1-
7 Aims and Objectives
8 Review of literature
9 Platelet Rich Plasma
10 Materials and Methods
11 Figures vii-
12 Results
13 Tables and Graphs
14 Discussion
15 Summary and Conclusion
16 Bibliography
17 Annexures
LISTS OF ABBREVIATIONS
PRP Platelet Rich Plasma
PRF Platelet Rich Fibrin
PPP Platelet Poor Plasma
PDGF Platelet Derived Growth Factor
TGF Transforming Growth Factor
IGF Insulin Derived Growth Factor
PDWHF Platelet Derived Wound Healing Factor
AFA Autologous Fibrin Adhesive
BMP Bone Morphogenic Protein
BFGF Basic Fibroblast Growth Factor
EGF Epidermal Growth Factor
i
LISTS OF TABLES
Table 1 Demographic data of study population
Table 2 Comparison of mean soft tissue healing values post operative
3rd day between the groups.
Table 3 Comparison of mean soft tissue healing values post operative
7th day between the groups.
Table 4 Comparison of mean soft tissue healing values post operative
14th day between the groups
Table 5 Comparison of mean soft tissue values between the groups at
different time periods
Table 6 Comparison of mean bone density values within the groups at
immediate
Table 7 Comparison of mean bone density values at 4th week
between the groups
Table 8 Comparison of mean bone density values within the groups at
3 month
Table 9 Comparison of mean values between the groups at different
time periods
ii
LISTS OF GRAPHS
Graph 1
Demographic data of study population
Graph 2
Comparison of mean soft tissue healing values between
the groups at different time periods
Graph 3
Comparison of mean bone density values between the
groups at different time periods
Graph 4
Multiple comparison of mean soft tissue healing values
within the groups at different time periods
Graph 5
Multiple comparison of mean bone density values within
the groups at different time periods
iii
LISTS OF FIGURES
Figure 1 Armamentarium
Figure 2 Medico centrifuge
Figure 3 Withdrawal of blood
Figure 4 After first centrifugation
Figure 5 After second centrifugation
Figure 6 Platelet rich plasma activated with 10% calcium
chloride
Figure 7 Calcium chloride activated PRP gel
Figure 8 Extracted socket
Figure 9 Suture done after placement of calcium chloride
activated PRP in the extraction socket
Figure 10 Post-operative clinical evaluation of extraction
socket healing
Figure 11 Grey level histogram value evaluation from
digital radiograph
Figure 12 Postoperative radiograph evaluation of bone
density of extraction socket.
iv
ABSTRACT
ABSTRACT
The study was conducted to evaluate the efficiency of calcium chloride activated platelet-
rich plasma in bone regeneration and soft tissue healing in the extraction socket.
Twenty-five patients needing bilateral similar tooth extractions were selected, and one side
is taken as a control group and another side as the case group. PRP was prepared with blood
drawn from individuals who came for extraction using standard double centrifugation
technique, and 10 % calcium chloride was added to activate PRP. The formed PRP gel was
placed in the extraction socket of the case group and secured with sutures. An immediate
digital radiograph was taken after extraction for both groups. Moreover, for soft tissue
evaluation, patients reviewed at postoperative day 3rd, seventh, and 14th day and soft tissue
healing index taken. For radiographic analysis, socket surface area and density were
performed using a computer graphics software program. The clinical follow-up
assessments were performed in the fourth week and third month, and the collected data
were assessed using ANOVA and multiple comparison tests.
RESULTS:-Patients were aged between 18 to 32 (Mean age 24 years), including 17
females and 8 males. The mean soft tissue healing for the case group were 3.46, 4.42,5 at
3rd 7th and 14th day, respectively. The soft tissue healing was significantly higher among
the test group as compared to the control group.
The mean radiographic density in the case group was 57.752, 76.458 in 4th week and 3rd
month, respectively. The mean bone density was significantly higher in the test group than
the control group at all-time intervals.
v
CONCLUSION:-The study outcomes demonstrate that 10 % calcium chloride activated
PRP is biocompatible and accelerates socket wound healing after tooth extraction and
increased bone density.
KEYWORDS:-Platelet Rich Plasma, 10 % Calcium Chloride, Soft Tissue healing, Bone
Density, Bilateral Extraction Socket.
vi
INTRODUCTION
Introduction
1 | P a g e
Platelet-rich plasma (PRP) is a modern and potentially
valuable adjunct in the area of oral and maxillofacial surgery1. Platelet-rich plasma (PRP),
an autologous concentrate of platelets in a proportionately meager quantity of plasma,
expedites the delivery of growth factors in risen amounts to surgical sites to enhance wound
healing. Platelets contain many growth factors. Some of the growth factors are, platelet-
derived growth factor (PDGF) (including αα, αβ, and ββ isomers), transforming growth
factor-β (TGF-β) (including β1 and β2 isomers), fibroblast growth factor, insulin-like
growth factor-I (IGF-I), epithelial growth factor, vascular endothelial growth factor. The
platelets also contain numerous other secretory proteins3, 4.
In their article labeled ‘‘Platelet Gel: An Autologous Alternative to Fibrin Glue with
Applications in Oral and Maxillofacial Surgery.’’ Written in 1997, Whitman et al.
proposed that platelet-rich plasma (PRP) can be used widely by the Oral Surgery society.
As per this article, it was recommended that through activation of the platelets, within the
gel, there will be a release of growth factors, and by this, there will be an enhanced wound
healing..’’ In 1998 Max et al. conducted a study that indicated that a combination of PRP
with autogenous bone in mandibular continuity deficiencies resulted in considerably faster
radiographic maturation and histo-morphometrically denser bone regeneration. After the
disclosure of this Benchmarking article, there was a significant increase in then notoriety
in the oral and maxillofacial surgery community. It certainly seemed as though a new age
in bone grafting had begun1, 2, 3. PRP can be expressed as a platelets concentrate, in which
concentrated platelets are suspended in a small volume of plasma. Cell adhesion molecules
for osteoconduction and as a mold for bone, connective tissue, and epithelial migration are
Introduction
2 | P a g e
distinguished as the three proteins in the blood involved in PRP. These cell adhesion
molecules are fibrin, fibronectin, and vitronectin5.
By activating Platelet rich plasma it will impact the availability of bioactive molecules
and consequently influences more accelerated tissue healing. The approach is preferred to
initiate PRP to influence both its physical form and discharged in terms of GF amount
and release kinetic9.
Activation of PRP gel, thus causing degranulation of α-granules present in the platelets and
releasing the growth factors. The various agents for the activation reported in the literature
include CaCl2 alone, CaCl2 plus bovine thrombin, human thrombin, autologous bone, or
whole blood that contains thrombin2. In our plan, an autologous platelet gel was prepared
in which CaCl2 alone was combined with PRP. This platelet gel was free of extracting any
antigen-antibody reaction, as it was acquired from patients’ blood. The study symbolizes a
marked enhancement in the soft tissue healing and more active reformation of bone after
third molar surgery in cases handled with PRP as corresponded to the control group
postoperatively. This advancement in wound healing, reduction in pain, and improvement
in the bone density signify and highlights the use of PRP, certainly as a proven approach
in influencing and stimulating soft and hard tissue regeneration. An added advantage of
PRP recorded in the present investigation is its capacity to compose a biologic gel that
produced clot endurance and functions as an adhesive, CaCl2 induced a gradual release of
GFs from 15 minutes and progressing up to 24 hours.
The system of PRP preparation is modest, cost-effective and has proved beneficial
outcomes. Several studies have suggested that platelet concentrates, especially PRP, may
Introduction
3 | P a g e
stimulate osseous and soft tissue regeneration while also reducing inflammation, pain and
unwanted side effects5, 6.
This prospective clinical trial was designed to compare bone density and soft tissue healing
with and without 10 % of calcium chloride activated autologous platelet rich plasma gel in
extraction socket.
AIMS AND OBJECTIVES
Aims And Objectives
4 | P a g e
The aim of the study is to evaluate clinically and radiographically, extraction socket
healing using calcium chloride activated platelet rich plasma, compared to normal healing
pattern.
REVIEW OF LITERATURE
Review Of Literature
5 | P a g e
Matras et al. 198514 was the one who first described fibrin glue used
as surgical adhesive which helpful for healing process. Fibrin glue which is derived from
blood, is used to stimulate healing and also to seal wounds. This contains concentrated
fibrinogen polymerization induced by calcium and thrombin. This is prepared using donor
plasma and used to improve skin wound healing in a rat model.
Knighton et al. 198615 examined the efficacy of platelet derived
wound healing factors (PDWHF) which applied topically prepared with 2- step
centrifugation procedures. It was applied in 41 patients and kept for 12 hours in 71 chronic
non-healing cutaneous ulcers. He explained that PDWHF stimulate chronically non-
healing human wounds by granulation tissue formation and epithelialization. There is no
evidence of over healing like keloid formation or hypertrophic scar.
Lynch et al. 198716 suggested that at the site of injury, platelet
derived growth factors (PDGF) plays a major role in the initiation of the wound healing
process.
Knighton et al. 199017 in his study chronic non-healing wounds in
32 patients were treated with platelet-derived wound healing formula (PDWHF). This
study shows a statistically highly significant effect of topically applied PDWHF for the
repair of chronic non-healing ulcers with increase in epithelialisation of the wound.
Slater et al. 199518 conducted a study to examine the efficacy of
concentrated human platelet as a basic medium in the functional and proliferative activity
of human osteoblastic like cells. The results shows that eked out platelet medium stimulates
Review Of Literature
6 | P a g e
the proliferation and maintains the activity of differentiated function of human fetal
osteoblast like cells.
Whitman et al. 199719 used “platelet gel” derived from platelet
concentrate which shown their clinical results in reconstruction of oral and maxillofacial
surgery. The ‘Platelet Gel’ was produced by a gradient density cell separator. The authors
considered the platelet gel as a fibrin glue helpful for mandibular reconstruction, alveolar
cleft procedure, and closure of oro-antral and oro-nasal communication and also show
greater effect in implant placement.
Heldin et al. 199720 presented a report on intracellular signal
transduction pathways which involves PDGF induced cell motility and growth also
discussed the fact that the inhibitory stimulatory pathways are parallelly induced. He also
reported that the PDGF exert their effect by the binding of two protein tyrosine kinase
receptor which is structurally related.
Marx et al. 199811 first introduced platelet rich plasma in dental
studies clinically. The platelet rich plasma is used to improve the graft incorporation in the
Mandibular reconstruction to the patients who have received cancellous bone marrow
grafts after the tumour removal. In their study it has been showed that, PRP contains a
concentrated platelets and growth factors. The PRP,
Which was used with grafts showed an evidence of radiographic maturation rate 1.6 to 2.16
times faster than the grafts, which was used without PRP.This data suggested strongly that
by adding PRP to bony grafts accelerates the degree and rate of bone formation.
Review Of Literature
7 | P a g e
Green et al. 199821 reported that platelet gel can be used as
wound sealant. The presence of leukocytes and platelets in the formulation of antimicrobial
and haemostatic support which bring the growth factors and cytokines to the surgical site
and induce wound healing process.
Heldin et al. 199922 reported that PDGF was the first growth
factor which shows chemotactic for migration of cells in the healing skin wound like
fibroblast, monocytes and neutrophils. He also proved that PDGF enhances not only the
proliferation of fibroblast and extracellular matrix production but also it stimulates the
fibroblast to contract collagen matrices and also induces the myofibroblast phenotype
which suggest a major role in healing of wound. He also demonstrated a series of clinical
and experimental studies about the useful effects of PGDF which can be used in wound
healing disorders.
Schuldiner et al. 200023 examined the ability of eight growth
factors such as basic fibroblast growth factor(bFGF), activin-A, bone morphogenic protein
4 ( BMP-4), ), transforming growth factor ß1 (TGF-ß1), epidermal growth factor(EGF),
hepatocyte growth factor(HGF), b nerve growth factor (bNGF) and retinoic acid(RA)
which found in PRP for wound healing.
De Obarrio et al. 200024 states that combined PRP with bone
allograft and guided tissue regeneration for the periodontal therapy of human intra bony
defects and observed significant gain in clinical attachment and bone formation, as revealed
by 2-year follow-up.
Review Of Literature
8 | P a g e
Choukroun et al. 200025 developed another form of PC in
France, which was labeled as PRF, based on the robust fibrin gel polymerization found in
this preparation. It was stamped as a “second-generation” platelet concentrate because it
was different from other PRPs. This proved an essential milestone in the evolution of
terminology.
Anitua et al. 200126 conducted various studies to see the effect
of platelet-rich in growth factors (PRGF). She proved it is a conventional method to
accelerate soft tissue and bone regeneration in post-extraction sockets.
Petrungaro 2001 27 published a case series in which collagen
membranes covered PRP, subepithelial connective tissue grafts, and gingival recessions;
the therapy was successful in all cases.
Lacoste et al. 200328 quantified that concentration of TGF-ß1,
bFGF, VEGF, and PDGF-BB from platelet concentrates and the whole blood before and
after there is an addition of various concentrations such as calcium and thrombin and also
have been assessed that physiological importance of growth factors on angiogenesis.
Weibrich et al. 200329 studied the level of growth factors in PRP.
Dispersion of cell separation method and also point of care method. It is also called a ‘buffy
coat method’. Whole blood is drawn from 115 healthy donors. The increase in
thrombocyte count was achieved in both of the methods, which result in higher TGF-ß1
levels, while an increase in the leukocyte count in curasan PRP shows more PDGF-AB
levels. Quantified that concentration of TGF-ß1, bFGF, VEGF, and PDGF-BB from
Review Of Literature
9 | P a g e
platelet concentrates and the whole blood before and after there is an increase of various
concentrations such as calcium and thrombin and also have been assessed that
physiological significance of growth factors on angiogenesis.
Anitua et al. 200430 showed that the platelets contain the
storage pools of growth factors such as VEGF, TGF-ß, and PDGF and cytokines, which
include proteins like PF4 and CD40L. He also reported that the growth factors attached to
the platelets or fibrin resulted in enhanced activity over the recombinant proteins. He also
reviewed various situations in the muscle/tendon repair, orthopaedic surgery, whole repair
in the eye surgery, the reversal of skin ulcers, and cosmetic surgery, where platelet
accelerates the healing mechanism.
Barry L. Eppley et al. 200431 suggests Platelet-rich plasma,
and the associated fibrin clot, can conceivably support in wound reconstruction and back
to complete and maintain hemostasis, or can be blended with other tissues as an adjunct to
their transplantation healing.
Hanna et al. 200432 suggested that the use of PRP in Intra-
bony defect resolution will result in an additional mean probing pocket reduction of 1.0mm.
Oyama et al. 200433 suggested the use of PRP enhances the
osteogenesis of alveolar bone grafting in cleft lip and palate patients. It may be beneficial
for succeeding in orthodontic therapy.
Dohan et al. 200634 quantified the level of cytokine within
PRF clot exudates serum and platelet-poor plasma supernatant: IL-1b, IL-4, IL-6, VEGF,
Review Of Literature
10 | P a g e
and TNF-alpha that was obtained within plasma and in serum. He proved that PRF exhibits
a complex three-dimensional architecture. It produces a real platelet and also a leukocyte
rich fibrin biomaterial.
Li et al. 200635 explained the pleiotropic function of TGF-ß
which is signalling in T cells. It shows that T cell specific deletion in mice with of TGF-ß
receptor II developed a lethal inflammation and is associated with T cell activation and
differentiation.
Thor et al. 200736 calculated the impact of platelet-rich plasma on
the early stage and late-stage bone healing after maxillary sinus grafting. There was
significantly more new bone developed at platelet-rich plasma-treated sites when compared
to the control group in 3 months of healing. He recommended that platelet-rich plasma has
a low regenerative capacity, which influenced bone healing in the early phase.
Su et al. 200837 interpreted that growth factors released from the
platelet gels from 10 volunteers where the whole blood was collected along with
anticoagulant citrate dextrose (ACD). The evaluation of growth factor from platelet gel
with the release, platelet gel, released with thrombin at 5, 60, 120, 300-minute time points.
TGF-ß1, PDGF-AB, EGF, and VEGF increase was recognized in platelet gel with the
release of the PDGF-AB of 0.6x10-16 and also the TGF-ß1 of 0.9x10-16 per PLT.
Sunitha et al. 200838 concluded that the combination of
growth factors and bone grafts contained in platelet rich fibrin and platelet rich plasma may
be suitable for the increase in bone density. In experimental study the content such as
Review Of Literature
11 | P a g e
growth factor in platelet rich fibrin and platelet rich plasma was measured by using Elisa
Kit.
Kajikawa et al. 200839 suggested that PRP can both inhibit
excess inflammation and also augment stem cell proliferation and maturation, as
demonstrated in vitro studies.
Gassling et al. 200940 generated PRF and PRP from the whole
blood samples in ten patients. Human fibroblasts, human osteoblasts and human osteoblast
derived osteosarcoma cells which were used for the cell culture and shown the growth
factors IGF-1and TGF-ß1 and ß2 ,PDGF-AB and BB found that the cytokine
concentration were higher for PRP and PRF in the osteoblasts and also in Saos-2 cultures.
Dohan Ehrenfest et al. 200941 proposed the first
classification of platelet concentrate. This classification defined four leading families
based on the separation of the products using two fundamental parameters. The cellular
content (primarily leukocytes) and fibrin architecture. The first one being Pure platelet-rich
plasma (P-PRP) - or leukocyte-poor platelet-rich plasma (LP-PRP); the second one is the
Leukocyte-and platelet-rich plasma (L-PRP); the third one being the Pure PRF (P-PRF) -
or leukocyte-poor PRF; and the last and the fourth one is Leukocyte- and platelet-rich fibrin
(L-PRF).
James L. Rutkowski et al. 20109 study suggests that the use
of a simple, cost-effective BC-PRP method to enhance the rate of bone formation and
reduce healing time in the initial two weeks following oral surgery may be advantageous.
Review Of Literature
12 | P a g e
Treatment with PRP may not induce pain, bleeding, and/or numbness, but may decrease
inflammation.
Senger et al. 201042 revealed that both bFGF and VEGF
would stimulate endothelial proliferation and also angiogenesis. However, VEGF
transcripts encode and direct active secretion of VEGF from the cell, and it is considered
to be the endothelial-specific mitogen. The VEGF stimulates nitric oxide production. It
will restrain platelet activation and proposing that the role of VEGF is to prevent
undesirable thrombosis.
Ahmed et al. 201143 described the autocrine pool between
FGF and PDGF-BB. It is shown that the FGF transcriptionally activates PDGF receptors.
It is then reinforced to the membrane. PDGF and FGF triggered expression of PDGFR and
FGFR, sequentially, and ended in a reduction in the number of receptors staying in the
plasma membrane after internalization. There is crosstalk about the proteins to switch the
expression of receptors to sensitize the cells to the respective ligands; this shows how both
these factors regulate the neoplasticity metastasis and angiogenesis.
Kiran et al. 201144 described method of how to prepare PRP
and their clinical application and also the safety concerns of PRP. The evolution of PRF,
the second-generation platelet concentrate, which is prepared by the blood, is centrifuged
in a centrifuge machine for 12 minutes at 2700 RPM. Then he reported that PRF eliminates
adding anticoagulant as well as it needs to neutralize.
Review Of Literature
13 | P a g e
Stacie G et al. 201245 suggests PRP is a useful regenerative
therapy to address many musculoskeletal injuries. It is important to understand that PRP is
more than just platelets and that it contains many bioactive factors that act in anabolic,
catabolic, proinflammatory, and anti-inflammatory pathways.
Nathan E Carlson et al. 201246 suggests the development
of an autologous PRP has been shown to be relatively easy, and to be effective as a surgical
adjunct, to retain high levels of the desired growth factors after preparation and to be
clinically useful in expediting postsurgical healing in both periodontal and oral surgery
administrations.
Dohan et al. 201247 estimated that the slow release of
growth factors PDGF-AB, TGF-ß1, VEGF, and matrix proteins from the P-PRP gel
membrane and L-PRF in a culture medium. He explained that the less than five days, P-
PRP gel membranes dissolve entirely in the culture medium. Meanwhile, the L-PRF
membranes are still intact after seven days. This implies that polymerization and the final
architecture of the fibrin matrix influence the strength and the growth factor trapping/
release potential of the membrane.
Tomasz Bielecki et al. 201248 The study grants an in-depth
understanding concerning the application of stem cells and PRP in vitro, in vivo, and their
utilization in clinical studies in the tomorrow.
Ruchi Pathak Kaul et al. 20123 This study attempted to use
autologous PRP to encourage wound healing and osseous reconstruction in human third
Review Of Literature
14 | P a g e
molar extraction sites. It designates a visible advancement in soft tissue healing and faster
reformation of bone after third molar surgery in cases handled with PRP as analyzed to
control group postoperatively
Antonino Albanese et al. 20138 this review of the literature
implies that the use of PRP in the alveolar socket after tooth removals is unquestionably
capable of improving soft tissue healing and positively impacting bone regeneration.
Nevertheless, following the outcome, as mentioned above, appears to reduce a few days
after the extraction. PRP has manifested more reliable conclusions in periodontal therapy
in comparison with distinct elements than when it is used solely, implying that the
particular preference of agents/procedures mixed with PRP could be vital.
Amable et al. 201350 investigated fluctuations in relativistic
centrifugal force (RCF), temperature, and time for optimizing circumstances for platelet
isolation and quantification of cytokines and extension factors in PRP before and
subsequent platelet activation.
Mc Lellan et al. 201451 in 12 healthy patients the PRF is
evaluated thoroughbred geldings and it is compared with the temporal release of the growth
factors to PRP. For five days, four groups were analysed for slow and immediate release
of PRP and PRF.
Kumar et al. 201552 Platelet concentrates shown to have great
scope in reconstructive and regenerative medicine as well in dentistry. And PRF being the
Review Of Literature
15 | P a g e
recent of the Platelet Derivatives which is safer and simpler when compared to previous
PRP concentrates they are used clinically.
Mourão et al. 201553 suggests that the use of PRP in the
alveolar socket subsequent tooth uprootings is unquestionably capable of enhancing soft
tissue healing. It assuredly induces bone reformation, but the following consequence seems
to reduce a few days after the extraction.
Carola Cavallo et al. 201614 Platelet-Rich Plasma (PRP) is a
low-cost method to produce high concentrations of autologous growth factors (GFs).
Platelet activation is a requisite level that forces impact the availability of bioactive
molecules and, therefore, tissue healing. Activation of PRP from ten intentional healthy
males was conducted by adding 10% of CaCl2, 10% of autologous thrombin, 10% of a
mixture of CaCl2 + thrombin, and 10% of collagen type I. CaCl2 induced a gradual release
of GFs from 15 minutes and progressing up to 24 hours. The approach is practiced to
initiate PRP impacts both its physical form and the discharge rate in terms of GF amount
and deliver kinetic.
Ahmed Abdullah Alzahrani et al. 201710 Outcomes of the study
demonstrate that the use of PRF accelerates socket wound healing after tooth extraction.
As it is noticed by increased bone fill and reduced alveolar bone width resorption using
clinical and radiographic methods10.
Kanae Niimi et al. 201754 The study, the outcomes described the
ubiquity of advanced inflammatory effects and a vibrant fibrin network in the experimental
Review Of Literature
16 | P a g e
group, which led to the creation of thick, vessel-rich granulation tissue. The conclusions of
day-5 specimens showed the remaining granulation tissue on the full area seen in the
control group. Meantime, the basement membrane regenerated in the full area in control
groups, then in the experimental groups in the study of the day-7 specimens. We revealed
that the utilization of PRP excites wound healing in tooth uprooting bone deficiencies;
however, the method of execution of the growth constituents continues unclear.
Elena Conde-Montero et al. 201755 The study describes the
fundamental postulates of PRP in wound healing. It aims to offer a renewed evaluative
appraisal of the available clinical evidence that confirms the utility of PRP for the
therapeutic challenge that chronic ulcers reproduce in our daily clinical practice.
Francesca Zotti et al. 201856 suggests arthrocentesis with
platelet-rich plasma. The platelet-rich plasma injections in temporomandibular disorders’
management were found to be effective in reducing pain and joint sound as well as in
improving mandibular motion in a maximum follow-up of 24 months.
Gisselle Escobar et al. 201857 suggests P-PRP (Pure Platelet Rich
Plasma) and S-PRP (Supernatant of Calcium Activated Platelet Rich Plasma) do not have
an equivalent biological effect on macrophages, and suggest that they could present a
different clinical tissue-repair potential. And he stated that in some cases clot formed after
PRP activation can be discarded and the S-PRP itself can be used as a platelet product for
tissue repair therapy as it contains the growth factors released by activated platelets.
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17 | P a g e
Jihua Chai et al. 201958 regeneration potential of hDPCs when
confronted with conventional PRP. Moreover, liquid PRF also attenuated the inflammatory
situation grasped by LPS and kept a supportive regenerative ability, for the stimulation of
odontoblastic differentiation and reparative dentin in hDPCs.
El-Sayed A. 201959 study aimed to compare platelet-rich plasma
(PRP) versus conventional ordinary dressing in the management of diabetic foot wounds.
On a comparative approach the highest healing rate was observed for both groups at the
fourth week, and it was better for the PRP group.
Platelet Rich Plasma
18 | P a g e
Platelet rich plasma (PRP), is the first generation autologous platelet concentrate.
The PRP is prepared by adding citrate to whole blood which binds the ionized calcium and
inhibit the clotting cascade. This is followed by two steps of centrifugation in which the
first step separates the white and red blood cells from platelets and plasma and in the
second step of centrifugation it further concentrates the platelets and ultimately produces
the PRP separate from poor plasma and platelet. But the real efficacy of PRP is debatable.
It is hypothesized that, just before the cell outgrowth from the surrounding tissue, PRP
releases growth factors quickly.
Platelets are essential in the wound healing process. They appear instantly at the
wound position and commence coagulation. They release multiple wound healing growth
factors and cytokines, including platelet-derived growth factor (PDGF), remodeling
growth factors (TGF)/β1 and β2, vascular endothelial growth factor (VEGF), platelet-
derived endothelial cell growth factor (PDGF), interleukin- 1 (IL-1), primary fibroblast
growth factor (bFGF), and platelet Activating factor-4 (PAF-4). These growth factors are
accountable for bone regeneration and progressed vascularity, vital features of a healing
bone graft1 .
The results from the previous studies demonstrated that PRP and PRF, were able to
release growth factors over time from their respective platelet formulations. Interestingly,
PRP demonstrated the ability to release significantly higher levels of growth factors at very
early time points and sudden fibrin polymerization depending on the amount of surgical
additives (thrombin and calcium chloride). Bilateral Junctions (condensed tetra molecular)
are constitute with strong thrombin concentrations and allow the thickening of fibrin
polymers leading to the Constitution of a rigid network, unfavourable to cytokine
Platelet Rich Plasma
19 | P a g e
enmeshment and cellular migration, whereas PRF had a more gradual release of growth
factors up to a 10-day period12. PRP is a platelet concentrate, but how many platelets are
enough for the properties and action of PRP is a critical question. The activity of Haynes
worth et al. explained that the increase of adult mesenchymal stem cells and their
differentiation were undeviatingly linked to the platelet concentration. They explicated a
dose-response curve, which symbolized that a sufficient cellular response to platelet
concentrations first began when a 4- to 5-fold increase over baseline platelet numbers were
accomplished. Most individuals have a baseline blood platelet count of 200,000 -
75,000/uL, a PRP platelet count of 1 million/uL as marked in the standard 6-mL aliquot
has displayed the benchmark for therapeutic PRP1.
MATERIALS AND METHODS
Materials And Method
20 | P a g e
The patients were selected for the study from the outpatient department of oral and
maxillofacial surgery, Sree Mookambika Institute of Dental Science, Kulasekharam. Total
25 patients who needed bilateral similar tooth extraction was selected for the study. Total
50 extraction (25 in case and 25 in control). Atraumatic extraction of tooth was carried out
in the right and left quadrant of the same jaw. In Study group, calcium chloride activated
Platelet-Rich plasma gel was placed in the extraction socket on one side, and the other side
taken as control group.
In Control group patients there is no intervention after extraction in
the extracted socket. Before commerencing the study we got approval from Institutional
research committee and Institutional human ethical committee, Sree Mookambika Institute
of Dental Science, Kulasekharam. All the patients who were involved in the study accepted
for the study protocol and written informed consent was tendered. All patients were
reviewed in 3rd day 7th day and 14 th day after extraction for wound healing evaluation and
suture removal in 7th day and reviewed in 1st, 3rd month postoperatively for radiographic
examination for bone formation.
Total duration of the study: 6 months
Number of groups: Two groups
Description of groups:
25 patients were taken for dental extraction. Total 50 extraction (25 in case and 25 in
control) one is case group and other is control group. Atraumatic extraction Carried in the
right and left quadrant of the same jaw and same teeth. One side taken as case and other
side as control.
Materials And Method
21 | P a g e
Group A- Calcium chloride activated platelet rich plasma
Group B- No intervention
Sample size of each group:
According to this formula the sample size of each group may be 25.
Inclusion criteria
• Patient of age group 18 to 50 years will be select.
• Patients who needs bilateral similar tooth extraction
Exclusion Criteria:
• Allergic to local anaesthesia.
• Chain smoker
• Uncontrolled systemic illness.[on h/o]
• Immunodeficiency pathology [on h/o]
• Bone disorders
• Patient with psychiatric problem
• Patients who were not willing for post-operative follow-up
• Platelet disorders
• Haematological disorders.
• Chemotherapy and radiotherapy
• Who needs surgical removal of tooth.
Materials And Method
22 | P a g e
The subjects were informed of the study after the screening procedure. They were
explained that their selection was made since they met the inclusion and exclusion criteria.
The subjects were ensured that their participation is voluntary and that they have the right
to withdraw at any time during the course of the study without giving reasons. Informed
consent was obtained from the volunteers.
ARMAMENTARIUM
• Medical centrifuges
• Tourniquet
• 5ml disposable syringe with 24 gauge needle
• Surgical gloves
• Cotton gauze
• Spirit swabs
• Blood collecting tubes
• Curette
• Lignocaine 2% [LA]
• 3ml syringe with 24 / 26 gauge needle.
• Periosteal elevator
• Extraction forceps
• Bone file/bone rounger
• Needle holder
Materials And Method
23 | P a g e
• Scissors
• 3.0 silk suture material
• Stop watch
PROCEDURE IN DETAIL:
Patient prepared for the extraction. One side is taken as case and other side
is taken as control in same patient with bilateral similar tooth extraction. Under aseptic
condition, Intraoral inferior alveolar nerve, long buccal nerve block, lingual nerve block
will be given for mandibular extractions and posterior superior alveolar nerve block,
middle superior nerve block, greater palatine nerve block and nasopalatine nerve block will
be given for maxillary extractions, by injecting 2% solution of lignocaine hydrochloride
along with 1:80000 adrenaline. (LIGNOX 2 %) [3ml Syringe with 24-gauge needle]
SURGICAL TECHNIQUE:
Full thickness mucoperiosteal flap reflected to achieve adequate
exposure of the surgical site by periosteal elevator. Then the Tooth removed using
appropriate forceps. After extraction, bony spicules removed.
Sharp and rough edges of extracted socket trimmed and smoothened with bone file and
bone rounger. The haemostasis achieved by compression. After this procedure, the
prepared autologous calcium chloride activated Platelet rich plasma gel placed in the
extracted socket for the side of case group. With 3-0 silk suture
Materials And Method
24 | P a g e
Material figure of eight suture placed on the extraction socket. Post-operative instructions
had given to patients followed by antibiotic and analgesic (Cap.Amoxicillin 500mg tid,
T.Zerodol-P bd) for 3 days. Post-operative follow-up done in case group after 24 hours to
check the stability of Platelet rich plasma gel in socket. The opposite side extraction carried
out after 1 week and taken as control.
After 7 days suture removal had done for case groups and succeeding follow-up had done
at 3rd day, 7th day and 14th day for the clinical evaluation of wound healing and 1st month
and 3rd month postoperatively for the radiographic evaluation of the bone fill in socket.
PREPARATION OF PLATELET RICH PLASMA GEL:
1st STEP: Under all aseptic conditions 5 ml of venous blood was collected from the
antecubital region.
2nd STEP: Preparation of PRP
1. The tube was put in a centrifuge machine and counterbalanced. The first centrifuge cycle
was done at 2,000 rpm for 15 min. The proceeds was the separation of the whole blood
into the following three layers.
Topmost layer was consisted of straw-coloured plasma (This plasma contains
relatively low concentration of platelets (platelet poor plasma)
The Middle layer was enriched with Platelet rich fibrin clot (This higher
concentration of platelets and WBC in the boundary layer is often called as ‘Buffy coat’).
Bottom layer is Red blood corpuscles
Materials And Method
25 | P a g e
2. The upper layer with poor platelet rich plasma was discarded and the middle and bottom
layer again centrifuged at 3,000 rpm for 10 min. After the second centrifuge, the upper half
was discarded and the lower half was used as PRP.
3rd STEP: PRP GEL Preparation
The PRP will be activated with CaCl2 10% to form a PRP gel in a ratio 10:1
ROUTINE POST OPERATIVE CARE:
• The post-operative instructions were given to the patients which includes a 30 minutes firm
pressure with a sterile gauze pack and to take semisolid or cold liquid diet for first 24 hours
and to avoid rinsing.
• After every meals patients were advised to rinse with warm saline rinse and 0.2%
chlorhexidine rinses twice daily after 24 days for 1 week.
• Postoperatively antibiotics and analgesics were prescribed for 5 days.
• On 7th postoperative day the suture was removed.
FOLLOW-UP:
• Post-operative follow up to be done after 24 hours in case group to check the stability of
platelet rich Plasma gel in socket.
• Post-operative follow to be done in case group and control group on post-operative 3rd day
,7th day and 14th day for extraction socket healing.
Materials And Method
26 | P a g e
• After 7 days suture removal was done for case group. Succeeding follow-up was done at
4th week, 3rd month postoperatively for the evaluation of radiographic parameters.
PARAMETERS EVALUATED
Evaluation of Soft Tissue Healing by healing index by Landry, Turnbull and howley1
Healing Index 1: Very poor (has 2 or more of the following)
• Tissue colour: C50 % of gingiva red
• Response to palpation: bleeding
• Granulation tissue: present
• Incision margin: not epithelialized, with loss of epithelium beyond incision margin
• Suppuration present
Healing Index 2: Poor
• Tissue colour: C50 % of gingiva red
• Response to palpation: bleeding
• Granulation tissue: present
• Incision margin: not epithelialized, with connective tissue exposed
Materials And Method
27 | P a g e
Healing Index 3: Good
• Tissue colour: C25 and 50 % of gingiva red
• Response to palpation: no bleeding
• Granulation tissue: none
• Incision margin: no connective tissue exposed
Healing Index 4: Very good
• Tissue colour: 25 % of gingiva red
• Response to palpation: no bleeding
• Granulation tissue: none
• Incision margin: no connective tissue exposed
Healing Index 5: Excellent
• Tissue colour: all tissues pink
• Response to palpation: no bleeding
• Granulation tissue: none
• Incision margin: no connective tissue exposed
Materials And Method
28 | P a g e
RADIOGRAPHIC ANALYSIS
Digital Subtraction Radiography for assessment of bone density. Intra oral radiograph,
RVG will be taken before extraction, immediately after extraction, post- op after 1 month
and 3months. An x-ray unit 70Kvp,80Ma using focal long cone paralleling technique with
focal spot film distance 16inch with an exposure time of 0.08sec and Ren HXCP film
holding device will be used for placing x-ray sensor, and vertical angulation of x-ray beam
is also recorded for each patient every time.(max canines +50, incisors +45, premolars +35,
molars +25. Mandible canines-25, incisors-20, premolars-10, molar-5).and evaluate by
means of DSR, with in subtraction images, a window (experimental region) is defines
covering the visible density changes in the defect area. Background noise measured by
using a similarly sized window (control region) located in an area without calcium chloride
activated platelet rich plasma. By comparing radiographs .Bone density changes was
quantitatively evaluate by calculation of the mean, standard deviation and maximum and
minimum values of the grey level histogram with in these window. Protection measures
was taken for patients to reduce x-ray exposure by using thyroid collor and lead apron.
RVG x-ray exposure is 8.6 times narrower than intra oral periapical radiograph.
BONE DENSITY ANALYSIS
The grey level histogram value was measured in immediate postoperative radiograph and
the graph was marked. This interpretation of bone density appears white for dense bone
and it appears black on empty defect in radiograph. The bone density analysis was done
and compared postoperatively by using software measured by grey level histogram value
in 1st month, 3rd month and 6th month postoperative period and the value were compared.
Materials And Method
29 | P a g e
STATISTICAL TOOLS EMPLOYED:
The study was analysed by Software(s) to be used for statistical analysis:
Microsoft Excel 2016 and statistical package for social sciences SPSS version 20.0.
Statistical tests used for data analysis are Mean, Standard Deviation, ANOVA, Student‘t’
test. . P value less than 0.05(p<0.05) considered statistically significant at 95%
confidence interval.
Materials And Method
30 | P a g e
SREE MOOKAMBIKA INSTITUTE OF DENTAL SCIENCE,
KULASEKHARAM
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
CASE RECORD
DATE: OP NO.
PERSONAL DATA:
Name:
Age:
Sex:
Address:
History:
Cheif complaints:
History of present illness.
Medical history:
Materials And Method
31 | P a g e
Dental history:
Personal history:
Family history
EXAMINATIONS:
Extra oral examination:
Face:
Tmj:
Lymphnodes:
Materials And Method
32 | P a g e
Intraoral examination:
Soft tissue examination:
Buccal/labial mucosa:
Tongue:
Alveolar mucosa:
Floor of the mouth:
Hard tissue examination:
Teeth present:
Materials And Method
33 | P a g e
PROVISIONAL DIAGNOSIS:
TREATMENT PLAN:
POSTOPERATIVE EVALUATION:
EVALUATION OF SOFT TISSUE HEALING INDEX
Review Case group Control group
3rd post -op day
Date:
7th post -op day
Date:
14th post -op day
Date:
Materials And Method
34 | P a g e
RADIOGRAPHIC EVALUATION
Findings
Grey level histogram values
Immediate post-op
Date:
4th week post-op
Date:
3rd month post-op
Date:
Guide/ Co-guide signature
Review
FIGURES
Figures
vii | P a g e
FIG: 1 ARMAMENTARIUM
FIG:2 MEDICO CENTRIFUGE
Figures
viii | P a g e
FIG:3 WITHDRAWAL OF BLOOD
FIG:4 AFTER FIRST CENTRIFUGATION
Figures
ix | P a g e
FIG:5 PRP AFTER SECOND CENTRIFUGATION
FIG:6 PRP ACTIVATED WITH 10 % CALCIUM CHLORIDE
Figures
x | P a g e
FIG:7 CALCIUM CHLORIDE ACTIVATED PLATELET RICH PLASMA GEL
CASE: 1
FIG:8 POST OP CLINICAL EVALUATION OF EXTRACTION SOCKET HEALING
IMMEDIATELY AFTER EXTRACTION
CASE CONTROL
Figures
xi | P a g e
3 DAYS AFTER EXTRACTION
CASE CONTROL
7 DAYS AFTER EXTRACTION
CASE CONTROL
Figures
xii | P a g e
14 DAYS AFTER EXTRACTION
CASE CONTROL
FIG: 9 RADIOGRAPHS OF POSTOPERATIVE PERIODS
IMMEDIATE POSTOPERATIVE DAY
CASE CONTROL
POST OP AFTER 4 WEEKS
CASE CONTROL
Figures
xiii | P a g e
POST OP AFTER THREE MONTHS
CASE CONTROL
CASE:2
FIG: 10 POST OP CLINICAL EVALUATION OF EXTRACTION SOCKET
HEALING
3 DAYS AFTER EXTRACTION
CASE CONTROL
Figures
xiv | P a g e
7 DAYS AFTER EXTRACTION
CASE CONTROL
14 DAYS AFTER EXTRACTION
CASE CONTROL
Figures
xv | P a g e
FIG: 11 RADIOGRAPHS OF POSTOPERATIVE PERIODS
IMMEDIATE POSTOPERATIVE DAY
CASE CONTROL
4 WEEKS POSTOPERATIVE PERIOD
CASE CONTROL
3 MONTH POSTOPERATIVE PERIOD
CASE CONTROL
Figures
xvi | P a g e
CASE:3
FIG: 12 POST OP CLINICAL EVALUATION OF EXTRACTION SOCKET
HEALING
3 DAYS AFTER EXTRACTION
CASE CONTROL
7 DAYS AFTER EXTRACTION
CASE CONTROL
Figures
xvii | P a g e
14 DAYS AFTER EXTRACTION
CASE CONTROL
FIG: 13 RADIOGRAPHS OF POSTOPERATIVE PERIODS
IMMEDIATE POSTOPERATIVE DAY
CASE CONTROL
4 WEEKS POSTOPERATIVE PERIOD
CASE CONTROL
Figures
xviii | P a g e
3 MONTH POSTOPERATIVE PERIOD
CASE CONTROL
CASE:4
FIG: 14 POST OP CLINICAL EVALUATION OF EXTRACTION SOCKET
HEALING
3 DAYS AFTER EXTRACTION
CONTROL CASE
Figures
xix | P a g e
7 DAYS AFTER EXTRACTION
CONTROL CASE
14 DAYS AFTER EXTRACTION
CONTROL CASE
Figures
xx | P a g e
FIG: 15 RADIOGRAPHS OF POSTOPERATIVE PERIODS
IMMEDIATE POSTOPERATIVE DAY
CONTROL CASE
4 WEEKS POSTOPERATIVE PERIOD
CONTROL CASE
3 MONTH POSTOPERATIVE PERIOD
CONTROL CASE
RESULT
Results
35 | P a g e
The present study was intended to assess the efficiency of 10 % calcium chloride
activated platelet-rich plasma gel in bone regeneration and soft tissue healing after
extraction. The study was undertaken on 25 patients (age range of 18-32 years) with
bilateral extraction which includes 17 (68 %) females and 8(32 %) males in the ratio
1:2.2(Table: 1, Graph: 1). the age, sex and date of procedure were recorded.
An analysis was done regarding the soft tissue healing on the third day for the two
categories. The case group showed a mean score of 3.46 and for control group
2.46(P<0.05), and after 7 days it was 4.42 and 3.42 for case and control and on 14th day it
was 5 for both case and control groups (P<0.05).
The Comparison of mean soft tissue healing value between the groups at post-
operative day 3rd become significant. (Table: 2)
The Comparison of mean soft tissue healing value between the groups at post-
operative day 7th day become significant. (Table: 3)
The Comparison of mean soft tissue healing value between the groups at post-
operative day 14th day become significant. (Table: 4)
Comparison of mean soft tissue value between the groups at different time periods
become significant. (Table: 5, Graph: 2)
Grey level histogram value recorded from radiograph RVG in immediately after
extraction, 1 month and 3 month postoperatively of all patients of the case and
control groups has been tabulated.
The bone healing overall density values become 47.3342 and 47.3354 of control
and case of immediate postoperative (P= 0.1), During the 4th week the overall bone
Results
36 | P a g e
healing density for case group showed a means score of 57.752 and 55.394 for
control group.(P=0.2)and in 3rd month of postoperative period the values for control
and case group were 73.7181 and 76.4585 respectively(P=0.3).
The Comparison of mean soft tissue value between the groups at 3rd post-operative
day become significant. (Table: 6)
The Comparison of mean soft tissue value between the groups at 7th post-operative
day become significant. (Table: 7)
The Comparison of mean soft tissue value between the groups at 14th post-operative
day become significant. (Table: 8)
The Comparison of mean soft tissue value between the groups at different time
periods become significant. (Table: 9, Graph: 3)
The multiple comparison of mean soft tissue values within the groups at different
time periods is significant when compared with post-operative value at 3rd day, 7th
day and 14th day. (Graph 4)
The multiple comparison of mean bone density values within the groups at different
time periods is significant compared immediate with other time periods, 4th week
with other time periods and 3rd month with other time periods.( Graph 5).
Extracted socket enhanced with 10 % calcium chloride activated PRP gel shown to
heal at 1.5 times faster than of normal healing of extraction socket. The bone density value
and soft tissue healing in extraction socket is higher in case treated with 10% calcium
chloride activated Autologous Platelet Rich Plasma gel compared with control group which
has been not treated with Calcium chloride Activated Autologous Platelet Rich Plasma gel.
TABLES
Tables
37 | P a g e
Table-1: Demographic data of study population
Demographic
data
Age
MEAN
Gender
Male Female
Number Percentage
(%)
Number Percentage
(%)
Groups
2
4
8
32.00
17
68.00
Table-2: Comparison of mean soft tissue values post-operative 3rd day between the
groups
Groups
3rd Day
(MEAN)
p value
Control
2.46
<0.05
Case 3.46
Tables
38 | P a g e
Table-3: Comparison of mean soft tissue values post-operative 7th day between the
groups
Groups
7th DAY
(MEAN)
p value
Control
3.42
<0.05
Case 4.42
Table-4: Comparison of mean soft tissue values post-operative 14th day between the
groups
Groups
14TH
DAY
(MEAN)
p value
Control
5.0
0.00
Case 5.0
Tables
39 | P a g e
Table-5: Mean Soft tissue healing values of different groups at different post-
operative periods
GROUP
Mea
n
Std.
Deviati
on
Std.
Error
Mean
EVALUATION OF SOFT
TISSIUE HEALING - 3rd
Day
CASE 3.46 .508 .100
CONTRO
L
2.46 .508 .100
EVALUATION OF SOFT
TISSIUE HEALING - 7th
Day
CASE 4.42 .504 .099
CONTRO
L
3.42 .504 .099
EVALUATION OF SOFT
TISSIUE HEALING - 14th
Day
CASE 5.00 .000a .000
CONTRO
L
5.00 .000a .000
Table-6: Comparison of mean bone density values immediately after extraction
between the groups
Groups
Immediately
(MEAN)
+/-SD
p value
Control
47.3354+/-
O.58
<0.05
Case 47.3342+/-
0.58
Tables
40 | P a g e
Table-7: Comparison of mean bone density values post-operative 4th week between
the groups
Groups
4th week
(MEAN)
p value
Control
55.39+/-
1.17
<0.05
Case 57.75+/-
1.15
Table-8: Comparison of mean bone density values post-operative 3rd Month between
the groups
Groups
4th week
(MEAN)
p value
Control
73.71+/-
1.66
<0.05
Case 76.45+/-
1.61
Tables
41 | P a g e
Table-9: Mean Bone density values of different groups at different post-operative
periods
Group Mean
Std.
Deviati
on
Std.
Error
Mean
Evaluation of bone
density - immediately
after extraction
Case 47.3342 .58579 .11488
Control 47.3354 .58512 .11475
Evaluation of bone
density - 1 month
Case 57.752 1.3563 .2660
Control 55.397 1.1798 .2314
Evaluation of bone
density - 3rd month
Case 76.4588 1.6179
4
.31730
Control 73.7181 1.6673
7
.32700
GRAPHS
Graphs
xxi | P a g e
GRAPH:1 Demographic Data of Study population
GRAPH:2 Mean soft tissue healing values of different groups at different post-
operative periods
3.46
4.425
2.46
3.42
5
0
1
2
3
4
5
6
3rd Day 7th Day 14th Day
ME
AN
±SD
CASE CONTROL
Male32%
Female68%
Graphs
xxii | P a g e
GRAPH:3 Mean bone density values of different groups at different post-operative
periods
GRAPH 4:Multiple Comparison of mean soft tissue healing values within the group
at different time periods
47.3342
57.752
76.4588
47.335455.397
73.7181
0
20
40
60
80
100
immediately after extraction 1 month - 3rd month
ME
AN
±SD
Case Control
0
1
2
3
4
5
6
3rd Day 7th Day 14th Day
Chart Title
Control Case
Graphs
xxiii | P a g e
GRAPH 5:Multiple Comparison of Mean bone density values within the group at
different time periods
0
10
20
30
40
50
60
70
80
90
Immediate 4 Weeks 3rd Month
Control Case
DISCUSSION
Discussion
42 | P a g e
Immediately following tooth removal, a healing process commences that affects the
final alveolar bone volume and architecture of the alveolar ridge. Satisfactory and timely
healing is crucial to obtain ideal functional reconstruction. Traumatic removal of a tooth,
or inadequate healing response, may lead to excessive bone loss delaying tooth
replacement11. Bone tissue repair is a convoluted process helpful for cellular functions and
mineralization of defects to remodelling the surgical defect to regain the original structure.
In the future, protecting the wound and regain the bone will become standard care for all
extractions. Platelet-rich plasma is a new step in the platelet therapeutic concept helpful for
artificial biochemical modification. PRP progress via centrifugation has significantly been
explained so that it can be done in the office environment as well as in the operating room9.
Nevertheless, the centrifugation process must be sterile and precisely suited to
platelet separation from red blood cells and their sequestration in high concentrations
without dropping the platelets or damaging them so that they no longer can actively secrete
their growth factors11.
The platelet rich plasma is first generation platelet concentrate factor obtained from
freshly drawn venous blood, centrifuged twice without anticoagulants which contain
diverse growth factors such as platelet derived growth factor, vascular endothelial growth
factor and transforming growth. Fibrin, fibronectin and vitronectin are the three proteins
present which is helpful for epithelial migration and osteo-conduction1.
During the last decade, there have been numerous in vivo animal studies, which
have adopted biological mediators such as polypeptide growth factors to expedite soft
tissue and bony healing. It is, therefore, a reasonable hypothesis that raising the
concentration of platelets in bone defects may lead to improved, faster healing and
Discussion
43 | P a g e
stimulate new bone formation. May lead to advanced, faster healing and spur new bone
formation 13. Surgical sites improved with PRP have been bestowed to heal at two to three
times that of regular surgical sites. PRP can be a great supplement to many surgical
procedures14, and PRP accelerates wound maturity and epithelialization, hence decreased
scar formation. PDGF and epidermal growth factor (EGF) are the primary growth factors
associated with fibroblast migration, proliferation, and collagen synthesis. Raised
congregations of these growth factors is a likely cause for the accelerated soft tissue wound
healing1.
Wound healing involves a sequence of physiological events that restore and
replace damaged tissue functions. After extraction has been done, the healing is revealed
in the coagulative phase, proliferative phase, and osteogenic remodelling phase. The
coagulative phase starts immediately after the extraction and lasts until 3days, which
involves filling the socket with clot and inflammatory process initiation. In this phase,
platelets, endothelium, and fibroblast start to release numerous growth factors. After this,
the proliferative phase starts and lasts until 20 days to 2 months following the postoperative
period. After this, the blood clot becomes dissolved, and the connective tissue matrix is
formed. There is a supply of blood to the wound the osteoblastic activity and osteoclastic
activity is initiated, the last and the most extended phase is an osteogenic-remodeling
phase. The healing of the extracted socket lasts from 8weeks to months. This phase
involves mineralization of the matrix, secretion of osteoid, and bone remodeling.
The platelets are helpful for blood clotting by hemostatic plug formation. By using
platelet concentrate, it is helpful for natural clot formation, which induces wound healing
and bone regenerative process21. The PRP creates a gel-like substance that contains
Discussion
44 | P a g e
functional, activated, intact platelets present in the plasma matrix, which immediately starts
to release growth factors. It is mainly used as a protective layer for the Schneiderman
membrane in the sinus lift procedure to fill the material6.
Bone morphogenic was first identified in the year 1965. The bone formation is
induced when demineralised bone matrix is placed. There is a wide evidence which
supports there role as bone induction regulators repair and maintenance also being critical
determinants of embryological development of mammalian organisms. In differentiation,
growth inhibition, proliferation and arrest of wide variety of maturation cells BMP plays a
major role depending on cellular microenvironment and interaction with other regulatory
factors. Some of the demerits of BMP are poor distribution, large dose requirement, high
cost and short half-life. In order to overcome these demerits alternative methods like
promoting bone regeneration and formation76.
The initial coagulative phase contains a series of physiological process, they are
proliferation, cellular migration and differentiation, initiation of vascular in-growth and
increased collagen production. In order to bring efficient and timely prepare of wounds
many type of cell, other proteins and growth factors interact with one another. The active
secretion of these growth factors is initiated by the clotting process of blood and begins
within 10 minutes after clotting. More than 95% of the presynthesized growth factors are
secreted within 1 hour2 . Therefore, PRP must be developed in an anticoagulated state and
should be used on the graft, flap, or wound, within 10 minutes of clot initiation. Studies
that have not used anticoagulated whole blood, which is then clotted to activate the PRP14.
The discharged growth factors instantly bind to the outer surface of cell membranes of cells
in the graft, flap, or wound through transmembrane receptors. After the beginning blast of
Discussion
45 | P a g e
PRP-related growth factors, the platelets synthesize and secrete additional growth factors
for the prevailing seven days of their life span. Once the platelet is drained and dies off the
macrophage, it has reached in the region through the vascular in-growth stimulated by the
platelets, considers the function of wound healing management by secreting some of the
same growth factors as well as others. Therefore, the number of platelets in the blood clot
within the graft, wound, or adherent to a flap fastens the pace of wound healing. PRP
slightly rises this number. Researches have revealed that adult mesenchymal stem cells,
osteoblasts, fibroblasts, endothelial cells, and epidermal cells signify the cell membrane
receptors to growth factors in PRP. These transmembrane receptors, in turn, persuade
activation of an endogenous internal signal protein, which causes the expression of
(unlocks) a typical gene sequence of the cell, such as cellular proliferation, matrix
formation, osteoid production, collagen synthesis, etc. The significance of this knowledge
is that the PRP growth factors never access the cell or its nucleus, they are not mutagenic,
and they act through the stimulation of natural healing, just much faster. Therefore, PRP
cannot persuade tumor formation and has never done so9.
Several studies made in last 10 years in animal and in vivo conclude polypeptide
growth factors helpful for soft tissue and bony healing. Transforming growth factor (TGF)
ß1 and ß2 helpful to inhibit bone resorption. It is helpful for faster maturation of collagen
in wounds. Platelet derived growth factor (PDGF) is helpful to increase the wound healing
cells which helpful for increase wound healing properties21.
Moreover, the increase in soft tissue healing was found to occur at earlier time
points than non-PRP treated control sites. Of note was the immediate increase in healing
index readings which indicates enhanced early re epithelisation.. Accelerate tissue healing
Discussion
46 | P a g e
is in contrast to the drop in wound healing seen at the control site before wound healing
began to take place. It took approximately 1weeks for the control sites to reach the same
bone density that the PRP-treated site had reached by 3 days Further examination of the
soft tissue healing changes shows that the finding of parallel increases in bone density in
later weeks most likely represents normal healing taking place at both sites, subsequent
changes in soft tissue healing with the PRP-treated and control sites are parallel, with no
significant differences, except for the 3rd day and 7th day time points.
Intra-oral digital radiographs taken of the individual surgical sites revealed that the
effects of PRP were significantly beneficial (P<.05) for increasing bone density following
extraction. The increase in bone density suggests a greater volume of new bone formation
with PRP treatment. Moreover, the increase in bone density (presume as increased volume
of new bone formation) was found to occur at earlier time points than non-PRP treated
control sites. Of note was the immediate increase in grayscale readings which indicates
enhanced early bone formation. This corresponds with results from the Lucarelli molecular
study that demonstrated PRP treatment of human mesenchymal stem cells induced early
proliferation of these cells and possibly differentiation into osteoblasts. Accelerate bone
formation is in contrast to the drop in bone density (representing bone loss) seen at the
control site before bone formation began to take place. It took approximately 6 weeks for
the Control sites to reach the same bone density that the PRP-treated site had reached by 4
week. The PRP-induced acceleration in bone formation may be due to the presence of bone
morphogenetic proteins (BMPs)-2 and -6 in PRP that stimulates mesenchymal stem cells
to begin osteoblast differentiation and subsequent calcification. Healing at control sites
would be dependent upon initial osteoclast activity to break down existing bone thereby
Discussion
47 | P a g e
releasing BMPs9. The findings of this study correspond with the known, accepted bone
repair timeline. The immediate start of bone formation seen with PRP treatment is of
clinical relevance because it is the initial 2 weeks following bone manipulation oral surgery
that are crucial in countering infection, loss of the blood clot and/or AO (dry socket)
formation. with greater bone density for the PRP-treated sites due to earlier, more rapid
bone formation. The significant differences seen at 4th week and 3rd month may be due to
bone remodeling or inherent variations in the radiographic evaluation.In this study we used
calcium chloride activated platelet rich plasma to regenerate the bony defects in the
extraction sockets and a faster soft tissue healing.
The use of PRP is a recently proposed technique for the regeneration of periodontal
defects. Limited studies have assessed the effect of activated and non-activated PRP
(Graziani et al. 2006; Creeper and Ivanovski 2012; Slapnicka et al. 2008) and their different
concentrations (Graziani et al. 2006; Slapnicka et al. 2008; Ogino et al. 2006; Choi et al.
2005; Kanno et al. 2005) on proliferation of HGF and MG-63 cell lines.
Graziani et al. reported the highest proliferation rate of fibroblasts in the low
concentration PRP group at 24 h. In their study, in contrast to ours, the 10% activate PRP
group caused the highest proliferation rate of HGFs at 72 h after culture; however, the FBS-
rich DMEM group showed the highest proliferation rate among other groups. The 10%
activated PRP had the most significant effect on the proliferation of HGFs among PRP
groups at 24, 48, and 72 h10. PRP enhances osteoprogenitor cells in the host bone. It has
found clinical applications in fully autogenous bone grafts and composites of autogenous
bone grafts with a variety of bone substitutes with as little as 20% autogenous bone. PRP
has shown improved results in continuity defects, sinus lift augmentation grafting,
Discussion
48 | P a g e
horizontal and vertical ridge augmentations ridge preservation grafting, and
periodontal/peri-implant defects and had also recognized PRP allows first implant filling
and improved Osseointegration when used in compromised bone such as osteoporotic bone
after radiotherapy. Because PRP also improves soft tissue mucosal and skin healing, it is
utilized in connective tissue grafts, palatal grafts, gingival grafts, mucosal flaps13.
PRP gel is formed from PRP for the degranulation of a-granules which are present
in the platelets and are responsible for releasing the growth factors.
Platelet activation is a crucial step that might influence the availability of bioactive
molecules and, therefore, tissue healing. The most commonly used activation methods in
the current clinical practice were directly compared. CaCl2, autologous thrombin, their
combination, and collagen type I were used to mimicking the clinical situations where their
proximity in the administered connective tissues should provoke an “in situ” platelet
activation. The latter is currently taken for several PRP applications since it was considered
as a more convenient and more robust strategy to deliver platelet bioactive molecules.
Carola Cavallo et al. 2016 study shows CaCl2, thrombin, CaCL2/thrombin, and collagen
type I induced different platelet aggregation. In particular, PRP activated with CaCl2,
thrombin, and CaCL2/thrombin formed clots recognized in the 15-minute evaluation and
continuing up to 24 hours (thrombin and CaCL2/thrombin already macroscopically stable
at 15 minutes, CaCl2 starting at 15 and visually stabilized at 30 minutes).
In contrast, in collagen-type-I-activated samples, no clot formation was noticed for
any of the time points evaluated. At 15 and 30 minutes, thrombin and CaCl2/thrombin
produced a significantly higher amount of PDGF concerning that of CaCl2The release
pattern of PRP activated with CaCl2 was similar for all the GFs evaluated, with a
Discussion
49 | P a g e
significant and progressive release of GFs starting from 15 minutes and increasing up to
24 hours. CaCl2/thrombin induced a significantly higher VEGF release. At 15 minutes,
thrombin and CaCl2/thrombin showed a more significant amount of TGF-𝛽 concerning
that of CaCl2 and collagen type I (𝑝 < 0.05), whereas no significant difference was noted
between CaCl2 and collagen type I14.
In our technique CaCl2 alone was mixed with PRP to form an autologous platelet
gel. This platelet gel was free of eliciting any antigen–antibody reaction as it was prepared
from patients’ own blood.
The present study to evaluate soft tissue healing and bone regeneration in
the extraction socket by using calcium chloride activated platelet rich plasma. Bilateral
extraction of same tooth in a patients is chosen for this study one side taken as control and
another it was taken as case. When comparing the case with control the bone regeneration
is higher in case than control. So the patients were treated with 10% calcium chloride
activated Platelet rich plasma gel shows1.5 times more bone regeneration and faster
extraction socket healing without any complications than the patients not treated with
calcium chloride activated PRP gel. And the rate of soft tissue healing was much faster and
case group attained a healing of socket in 3 days which the control group attained on 7th
day. And on the 7th day the socket was almost closed by secondary intension.
The limitations of study were listed below,
Bone width and bone height were not assessed
Longer follow up is needed for better results
Platelets quality, quantity and its growth factor were not assessed.
SUMMARY AND CONCLUSION
Summary And Conclusion
50 | P a g e
The procedure for the preparation of 10% calcium chloride activated platelet-rich
plasma is a simple chairside procedure, patients own blood, no allergic reactions, little cost,
time-consuming is very less, no side effects, and shows good results. In this study, soft
tissue healing and bone generation in the extraction socket is analyzed in different time
intervals. There are significant changes seen in the extracted socket treated with 10%
Calcium chloride activated platelet-rich plasma when compared to the socket alloyed to
heal naturally.
Study Concluded that the 10%calcium chloride activated platelet-rich plasma
shows a significant role in soft tissue healing and bone regeneration process in the extracted
socket when compared to the non-treated socket.
This advancement in wound healing, reduction in pain, and improvement in the
bone density imply and highlights the use of PRP, certainly as a proven method in
producing and accelerating soft and hard tissue regeneration.
It was also helpful for osseous regeneration in other post-surgical defects, implant
placement, mandibular reconstruction, ridge augmentation, graft for bone substance, etc.
An appended advantage of PRP noted in the present study is its capacity to develop
a biologic gel that provided clot stability and functions as an adhesive and enhances wound
healing much faster.
The limitations of the study were bone width, and bone height was not assessed
Platelets quality, quantity, and its growth factor was not assessed. The present study was
Summary And Conclusion
51 | P a g e
done with a follow up of 3 months. Further clinical trials with longer duration follow up
with a larger sample size should be done to get a more affirmative and conclusive result.
BIBLIOGRAPHY
Biblography
xxiv | P a g e
1. Shubha Ranjan Dutta;Mandibular Third Molar Extraction Wound Healing
With and Without Platelet Rich Plasma: A Comparative Prospective Study.
J. Maxillofac. Oral Surg. 2015; 14:808–815.
2. Robert E. Marx;Platelet-Rich Plasma: Evidence to Support Its Use. J Oral
Maxillofac Surg.2004;62:489-496.
3. Ruchi Pathak Kaul ;Autologous Platelet Rich Plasma After Third Molar Surgery:
4. A Comparative Study. J. Maxillofac. Oral Surg.2012;119(2):200–5
5. Vivek GK; Potential for osseous regeneration of platelet rich plasma: a comparative
Study in mandibular third molar sockets.J Maxillofac Oral Surg.2009;,8(4):308–
311
6. Ozgur Baslarli; Evaluation of osteoblastic activity in extraction sockets treated with
platelet- rich fibrin Med Oral Patol Oral Cir Bucal. 2015; 20 (1):e111-6.
7. Bahadır Gürbüzer; Scintigraphic Evaluation of Osteoblastic Activity in Extraction
Sockets Treated With Platelet-Rich Fibrin. J Oral Maxillofac Surg .2010;68:980-8.
8. Aron Gonshor;Technique for Producing Platelet-Rich Plasma and Platelet
Concentrate: Background and Process. The International Journal of Periodontics &
Restorative Dentistry.2002; 22: 547-556.
9. Antonino Albanese; Platelet-rich plasma (PRP) in dental and oral surgery: from the
wound healing to bone regeneration. Immunity & Ageing .2013;10:23.
10. James L. Rutkowski;Platelet Rich Plasma to Facilitate Wound Healing Following
11. Tooth Extraction. Journal of Oral Implantology.2010;36: 11-23.
12. Ahmed Abdullah Alzahrani;Influence of platelet rich fibrin on post-extraction
Biblography
xxv | P a g e
13. Socket healing: A clinical and radiographic study. Saudi Dental Journal.2017;29,
149–155.
14. Robert E. Marx; Platelet-rich plasma Growth factor enhancement for bone grafts.
15. Oral Surg Oral Meal Oral Pathol Oral Radiol Endod.1998; 85:638-646.
16. Eizaburo Kobayashi;Comparative release of growth factors from PRP, PRF, and
advanced-PRF. Clin Oral Invest.2016; 1719-1.
17. Joseph Choukroun; Platelet-rich fibrin (PRF): A second-generation platelet
18. concentrate.Part IV: Clinical effects on tissue healing.Oral Surg Oral Med Oral
Pathol Oral Radiol Endod.2006;101:56-60.
19. Matras H. Fibrin seal: the state of the art. J Oral Maxillofac Surg. 1985;43(8):605-
11
20. Knighton DR, Ciresi KF, Fiegel VD, Austin LL, Butler EL.Classification and
treatment of chronic nonhealing wounds. Successful treatment with autologous
platelet-derived wound healing factors (PDWHF). Ann Surg 1986; 204(3): 322-30
21. Lynch SE, Nixon JC, Culvin RB, Antoniades HN. Role of platelet-derived growth
factor in wound healing. Synergistic effects with other growth factors.
Proc.Natl.Acad.Sci.USA 1987;84:7696-7700
22. Kington DR, Ciresi K, Fiegel VD, Schumerth S, Butler E, Cerra F. Stimulation of
repair in chronic, nonhealing, cutaneous ulcers using platelet-derived wound
healing formula. Surg. Gynecol. Obstet 1990; 170(1):56-60.
23. Slater M, Patava J, Kingham K. Involvement of platelets in stimulating osteogenic
activity. J Ortho Res 1995;13: 655-663
Biblography
xxvi | P a g e
24. Whitman DH, Berry RL, Green DM. Platelet gel: An autologous alteration in oral
and maxillofacial surgery. J Oral Maxillofac Surg 1997;55:1294
25. Heldin CH. Simultaneous induction of stimulatory and inhibitory signals by PDGF.
FEBS Lett 1997;410:17-21.
26. Green, David M, Klink B. Platelet gel as an intraoperatively procured plateletbased
alternative to fibrin glue. Plast Recon Surg 1998;61:101
27. Heldin CH, Westermark B. Mechanism of action and in vivo role of plateletderived
growth factor. Physiol Rev 1999;79:1283-316.
28. Schuldiner M, Yanuka O, Eldor JI, Melton DA, Benvenisty N. Effects of eight
growth factors on the differentiation of cells derived from human embryonic stem
cells. PNAS2000;21:11307-12.
29. Obarrio, J & Araúz-Dutari, J & Chamberlain, T & Croston, A. (2000). The Use of
Autologous Growth Factors in Periodontal Surgical Therapy: Platelet Gel
Biotechnology - Case Reports. The International journal of periodontics &
restorative dentistry. 20. 486-97.
30. H Choukroun J, Adda F, Schoeffer C, Vervelle A. PRF: An opportunity in perio
implantology. Implantodontie 2000; 42: 55-62
31. Anitua E. The use of platelet rich growth factors(PRGF) in oral surgery.
PracProcedAesthet Dentistry 2001;13:487-93.
32. Petrungaro, P. (2001). Using platelet-rich plasma to accelerate soft tissue
maturation in esthetic periodontal surgery. Compendium of continuing education
in dentistry (Jamesburg, N.J. : 1995). 22. 729-32, 734, 736 passim; quiz 746.
Biblography
xxvii | P a g e
33. Lacoste E, Martineau I, Gagnon G, Platelet concentrates: Effects of calcium and
thrombin on endothelial cell proliferation and growth factor release. J Periodontal
2003;74:1498-507
34. Weibrich G, Kleis WK, Hafner G, Hitzler WE, Wagner W. Comparision of platelet,
leukocyte and growth factor levels in point of care platelet enriched plasma,
prepared using a modified cursan kit, with preparations received from a local blood
bank. Clin Oral Implants Res 2003;14:357-62.
35. Anitua E, Andia I, Ardanza B, Nurden P, Nurden AT. Autologous platelet as a
source of proteins for healing and tissue regeneration. Thromb haemost 2004;91:4-
15
36. Barry L. Eppley et al. Platelet Quantification and Growth Factor Analysis from
Platelet-Rich Plasma:Implications for Wound Healing. 200:,6:1502-1508.
37. Hanna, Raouf & Trejo, Pedro & Weltman, Robin. (2005). Treatment of Intrabony
Defects With Bovine-Derived Xenograft Alone and in Combination With Platelet-
Rich Plasma: A Randomized Clinical Trial. Journal of periodontology. 75. 1668-
77. 10.1902/jop.2004.75.12.1668.
38. Oyama, Tomoki & Nishimoto, Soh & Tsugawa, Tomoe & Shimizu, Fumiaki.
(2004). Efficacy of Platelet-Rich Plasma in Alveolar Bone Grafting. Journal of oral
and maxillofacial surgery : official journal of the American Association of Oral and
Maxillofacial Surgeons. 62. 555-8. 10.1016/j.joms.2003.08.023.
39. Dohan DM, Choukroun J, Diss A, Dohan AJ, Mouhyi J et al. Platelet rich
fibrin(PRF): a second generation platelet concentrate. Part III: leucocyte activation:
a new feature for platelet concentrate? Oral Surg Oral Med Oral
Biblography
xxviii | P a g e
Pathol Oral Radiol Endod 2006;101(3):51-55.
40. Li MO, Sanjabi S, Flavell RA. Transforming growth factor-beta controls
development, homeostasis and tolerance of T cells by regulatory T cell dependent
and independent mechanisms. Immunity 2006;25:455-71.
41. Thor AV, Stenport F, Johanson CB, Rasmusson L. Early bone formation in human
bone grafts treatment with platelet-rich plasma; preliminary
histomorphometic result. Int J Oral Maxillofac Surg 2007;36:1164-1171.
42. Su CY,Kuo YP, Nieh HL, Tseng YH, Burnoff T. Quantitative assessment of the
kinetics of growth factors release from platelet gel. Transfusion 2008;48: 2414-20.
43. Sunitha RV, Munirathnam NE. Platelet rich fibrin. Evolution of a second generation
platelet concentrate. Ind J Of Dent Res 2008;19(1):42-46.
44. Kajikawa Y, Morihara T, Sakamoto H, et al. 2008. Plateletrich plasma enhances
the initial mobilization of circulationderived cells for tendon healing. J Cell Physiol
215:837– 845.
45. Gassling VL, Acil Y, Springer IN et al (2009) Platelet-rich plasma and plateletrich
fibrin in human cell culture. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
108:48–55
46. Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet
concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich
fibrin (L-PRF). Trends Biotechnol 2009;27: 158-167 [PMID: 19187989 DOI:
10.1016/j.tibtech.2008.11.009]
47. Senger DR. Vascular endothelial growth factor: much more than an angiogenesis
factor. Mol Biol Cell 2010;21:377-9.
Biblography
xxix | P a g e
48. Ahmed SS et al. Investigating the potential role of platelet derived growth factor
(PDGF). Biotechnology and Molecular Biology Review 2011:6(6):133-41
49. Kiran NK, Mukunda KS, Tilak Raj TN. Platelet concentrates: A promising
innovation in dentistry. Journal of dental sciences and research 2011; 2(1):50-61.
50. Stacie G et al. Platelet-Rich Plasma: A Milieu of Bioactive Factors. The Journal of
Arthroscopic and Related Surgery, Vol 28, No 3 (March), 2012: pp 429-439.
51. NATHAN E et al. Platelet-rich plasma Clinical applications in dentistry. JADA,
Vol. 133, October 2002 1383-1386.
52. Dohan Ehrenfest DM, Bielecki T, Jimbo R, Barbe G, Del Corso M, Inchingolo F et
al. Do the fibrin architecture and leukocyte content influence the growth factor
release of platelet concentrates. An evidence based answer comparing a pure
platelet rich plasma(P-PRP) gel and a leukocyte and platelet rich fibrin(L-PRF).
Curr Pharm Biotechnlol 2012;13:1145-52.
53. Tomasz Bielecki et al. The Role of Leukocytes from L-PRP/L-PRF in Wound
Healing and Immune Defense: New Perspectives. Current Pharmaceutical
Biotechnology, 2012, 13, 1153-1162
54. Antonino Albanese et al. Platelet-rich plasma (PRP) in dental and oral surgery:
from the wound healing to bone regeneration. Immunity & Ageing 2013, 10:23.
55. Amable PR, Carias RB, Teixeira MV, da Cruz Pacheco I, Corrêa do Amaral RJ,
Granjeiro JM, et al. Platelet-rich plasma preparation for regenerative medicine:
Optimization and quantification of cytokines and growth factors. Stem Cell Res
Ther 2013;4:67.
Biblography
xxx | P a g e
56. McLellan J, Sarah Plevin. Temporal release of growth factors from platelet rich
fibrin(PRF) and platelet rich plasma(PRP) in the horse: A comparative in vitro
Analysis. Intern J Appl Res Vet Med 2014;12(1)
57. Kumar VR, Gangadharan G. Platelet rich fibrin in dentistry: A review of literature.
Int J Of Med 2015;3(2):72-76
58. Mourão CF, Valiense H, Melo ER, Mourão NB, Maia MD. Obtention of injectable
platelets rich-fibrin (i-PRF) and its polymerization with bone graft: technical note.
Rev Col Bras Cir 2015; 42: 421-423 [PMID:26814997 DOI: 10.1590/0100-
69912015006013]
59. Carola Cavallo ;Platelet-Rich Plasma: The Choice of Activation Method Affects
the release of Bioactive Molecules BioMed Research International.2016;1-7.
60. James L. Rutkowski;Platelet Rich Plasma to Facilitate Wound Healing Following
Tooth Extraction. Journal of Oral Implantology.2010;36: 11-23.
61. Elena Conde-Montero et al. Platelet-rich plasma for the treatment of chronic
wounds: evidence to date. Chronic Wound Care Management and Research 2017:4
107–120.
62. Francesca Zotti et al. Platelet-Rich Plasma in Treatment of Temporomandibular
Joint Dysfunctions:Narrative Review. Int. J. Mol. Sci. 2019, 20, 277
63. Gisselle Escobar et al. Pure platelet-rich plasma and supernatant of calcium-
activated P-PRP induce different phenotypes of human macrophages. Regen.Med.
(2018) 13(4), 427–441.
Biblography
xxxi | P a g e
64. Jihua Chai, Runze Jin,, et al.Effect of Liquid Platelet-rich Fibrin and Platelet-rich
Plasma on the Regenerative Potential of Dental Pulp Cells Cultured under
Inflammatory Conditions: A Comparative Analysis. J Endod 2019;40:1375–81
65. El-Sayed et al. Platelet-rich plasma versus conventional dressing: does this really
affect diabetic foot wound-healing outcomes?. Egyptian J Surgery.2019: 37:16–26.
ANNEXURE
CONSENT FORM
PART 1 OF 2 INFORMATION FOR PARTICIPANTS OF THE STUDY
1. Name of the Principal Investigator: Dr.Aneesha.S
. Post Graduate student
Dept. of Oral and Maxillofacial
surgery
SMIDS, Kulasekharam, pin 629161
2. Name of the Guide: Dr. Mathew Jose
Professor & H.O.D
Dept. of Oral and Maxillofacial
surgery
SMIDS, Kulasekharam, pin 629161
Dear Volunteers,
We welcome you and thank you for your keen interest in participation in this research project.
Before you participate in this study, it is important for you to understand why this research is
being carried out. This form will provide you all the relevant details of this research. It will
explain the nature, the purpose, the benefits, the risks, the discomforts, the precautions and the
information about how this project will be carried out. It is important that you read and
understand the contents of the form carefully. This form may contain certain scientific terms
and hence, if you have any doubts or if you want more information, you are free to ask the study
personnel or the contact person mentioned below before you give your consent and also at any
time during the entire course of the project.
3. Name of the Co-Guide: Dr Sajesh
Professor
Dept. of Oral and Maxillofacial
surgery
SMIDS, Kulasekharam, pin 629161
4. Institue: Sree Mookambika Institute of Dental
Sciences
V.P.M Hospital complex,
Padanilam,
Kulasekharam, pin: 629161
TamilNadu
5. Title of the study:
“COMPARISON OF POST OPERATIVE HEALING OF EXTRACTION
SOCKET WITH AND WITHOUT CALCIUM CHLORIDE ACTIVATED
PLATELET RICH PLASMA”
6. Background information:
Platelet concentrates for surgical use are tools of regenerative medicine
designed for the local Release of platelet growth factors into a surgical or wounded
site, in order to stimulate tissue
Healing or regeneration. PRP preparation is very simple. For this 5 ml blood
will be taken from patient and immediately centrifuged at 2,000 rpm for 15 minutes.
the separated PPP and buffy coat layer including 1mm below is collected in sterile
tube and centrifuge at 3000 rpm for 10 min. separated PRP will be activated with
10% calcium chloride to form a PRP gel.
It accelerates wound maturity and epithelialization, hence decreased scar
formation. PDGF and epidermal growth factor (EGF) are the main growth factors
responsible for this.
Activated PRP gel causing degranulation of αgranules present in the
platelets and releasing the growth factor which is capable of initiating the
proliferation of cells that are in a quiescent
State by stimulating deoxyribose nucleic acid synthesis and progression of
the cell cycle. They are a class of multifunctional biologic mediators, which
regulate connective tissue cell migration, proliferation, synthesis of proteins and
capable of affecting all growth, differentiation, angiogenesis, inflammation, tissue
repair and immune response.
7. Aim and objectives:
To compare the healing and bone formation of molar extraction socket
with and without autologous PRP gel
8. Scientific justification of the study:
Platelets are very important in the wound healing process. They arrive
quickly at the wound site and begin coagulation. They release multiple wound
healing growth factors and cytokines, including platelet derived growth factor
(PDGF), transforming growth factors (TGF)/b1 and b2, vascular endothelial growth
factor (VEGF), platelet derived endothelial cell growth factor (PDEGF),
interleukin- 1 (IL-1), basic fibroblast growth factor (bFGF), and platelet Activating
factor-4 (PAF-4). These growth factors are consider to be contributing to bone
regeneration and increased vascularity, vital features of a healing bone graft [1]
[Journal of oral and maxilla facial surgery (july-sept2015) 14 (3) : 808 – 815
9. Procedure for the study:
• Under aseptic condition, local anaesthesia will be given.
• Atraumatic extraction will be done with appropriate forceps
• Prepared calcium chloride activated PRP gel will be place in extraction socket and
sutured Prp is prepared from patients own blood for that,
• 5ml venous blood drawn from patient
• PRP will be prepare by double centrifugation of patient’s blood
• Separated PRP mixed with 10% calcium chloride and formed into gel form.
• Post-op record will be maintain to measure the bone regeneration and tissue
healing.
10. Expected risks for the participants:
The needle stick for drawing the blood might cause pain, bleeding and
thrombophlebitis at Injecting site.
11. Expected benefits of research for the participants:
The placement of autologous calcium chloride activated PRP gel in the
extraction site will improve the healing property of tissue and help for bone
formation, which will benefit for prosthetic rehabilitation
12. Maintenance of confidentiality:
• You have the right to confidentiality regarding the privacy of your medical
information (Personal details, results of physical examinations, investigations, and
your medical history).
• By signing this document, you will be allowing the research team investigators,
other study Personnel, sponsors, institutional ethics committee and any person or
agency required by law to view your data, if required.
• The results of clinical tests and therapy performed as part of this research may be
included in your medical record.
• The information from this study, if publish in scientific journals or presented at
scientific meetings, will not reveal your identity.
13. Why have I been chosen to be in this study?
a. Chosen because of grouping under the inclusion and exclusion criteria
b. Need of good sampling size
14. How many people will be in the study? 25 individuals
15. Agreement of compensation to the participants (In case of a study related
injury):
Patient will be taken care in case of complication and medical treatment will be
provide in the institution at the expense of the principal investigator.
16. Anticipated prorated payment, if any, to the participant(s) of the study:
For your cooperation to the study, the expenses for the routine blood investigations
for which You originally visited the clinic will be settled by the principal
investigator.
17. Can I withdraw from the study at any time during the study period?
The participation in this research is purely voluntary and have the right to withdraw
From this study at any time during the course of the study without giving any
reasons.
18. If there is any new findings/information, would I be informed? Yes
19. Expected duration of the participant’s participation in the study: 3 month
20. Any other pertinent information: No other information
21. Whom do I contact for further information?
Place: signature of principal investigator
Date:
Signature of the participant
For any study related queries, you are free to contact: Dr.ANEESHA.S
Post Graduate student.
Department of Oral & Maxillofacial Surgery,
SreeMookambika Institute of Dental Sciences,
Kulasekharam, Kanyakumari District-629161.
Mobile No: 8547148230
Place: signature of principal investigator
Date:
Signature of the participant
CONSENT FORM
PART 2 OF 2
PARTICIPANTS CONSENT FORM
The details of the study have been explain to me in writing and the details have been
Fully explained to me. I am aware that the results of the study may not be directly
beneficial to Me but will help in the advancement or medical sciences. I confirm
that I have understood the Study and had the opportunity to ask questions. I
understand that my participation in the study is voluntary and that I am free to
withdraw at any time, without giving any reason, without the
Medical care that will normally be provided by the hospital being affected. I agree
not to restrict the use of any data or results that arise from this study provided such
a use is only for scientific purpose(s). I have been given an information sheet giving
details of the study. I fully consent to participate in the study title.
“COMPARISON OF POST OPERATIVE HEALING OF EXTRACTION
SOCKET WITH AND WITHOUT CALCIUM CHLORIDE ACTIVATED
PLATELET RICH PLASMA”
Serial no / Reference no:
Name of the participant:
Address of the participant:
Contact number of the participant:
Signature / thumb impression of the participant / Legal guardian
Witnesses:
1.
2.
Date:
Place: Signature of principal
Investigator
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