Evaluation of the Clinical and Radiographic Success of Platelet-Rich Fibrin, Chitosan, and Blood Clot as Scaffolds in Regenerative Endodontic Treatment of Molars
Phase: NA
Conditions: Regenerative Endodontics
Sponsor: Inonu University

Evaluation of the Clinical and Radiographic Success of Platelet-Rich Fibrin, Chitosan, 
and Blood Clot as Scaffolds in Regenerative Endodontic Treatment of Molars 
 
NCT ID not yet assigned 
 
Document Date: 10.01.2022 
 

RESEARCH PROTOCOL     
  
 
 
 
 
 
 
 
 
 
 
 
 
 
NAME OF THE 
RESEARCH: 
Evaluation of Clinical and Radiological Success of the 
Platelet-Rich Fibrin, Chitosan and Blood Clot as a Scaffold 
in the Regenerative Endodontic Treatment of Molar Teeth 
 
 
 
CENTER/CENTERS 
WHERE THE STUDY 
WILL BE DONE 
 
Inonu University Faculty of Dentistry Department of 
Pedodontics 
 
 
 
BASIS AND 
JUSTIFICATION OF THE 
RESEARCH: 
Young permanent teeth may become necrotic due to 
caries or trauma. Root development stops in necrotic 
teeth, resulting in thin root dentin walls and an open 
apex. Therefore, appropriate mechanical preparation 
and subsequent hermetic filling during endodontic 
treatment becomes difficult, and root canal treatment 
cannot be performed. Calcium hydroxide 
apexification and single-session apexification 
techniques are frequently used, but they cannot 
ensure continued root development. Teeth with these 
techniques are prone to fracture due to thin root canal 
walls. Thus, regenerative endodontic treatments, 
which provide pulp regeneration, dentin formation, 
and continued root development after treatment, have 
become widespread. The terms regenerative 
endodontics, revascularization, and revitalization 
have been adopted in the literature. Regenerative 
endodontics aims to promote continued root 
maturation by restoring the pulp-dentin complex. (1) 
A fundamental component of regenerative 
endodontic treatment is the presence of a scaffold 
that allows for the adhesion, proliferation, and 
differentiation of stem cells from the apical papilla. 
Many studies in the literature have examined various 
scaffold materials used in regenerative endodontic 
treatment and compared their success. These studies 
support the idea that an ideal scaffold material should 
support the survival and proliferation of apical 
papilla stem cells, be biocompatible, allow cell 
migration and vascularization, be biodegradable, and 
be nontoxic. Several studies have determined that, in 
the absence of a scaffold, apical papilla stem cells do 
not adhere to the root canal system and therefore fail 
to regenerate the pulp-dentin complex (2, 3, 4). 

Although PRF and blood clots are widely used and 
will be used in this study, chitosan is an important 
alternative regenerative endodontic treatment 
material that has achieved successful results in recent 
years (2). Although there are studies evaluating these 
three materials together and separately, there are no 
studies evaluating their clinical and radiological 
success in molar teeth. Controlled clinical studies are 
needed, particularly for molar teeth. 
 
1. 
Lin, Louis M, and Bill Kahler. “A review of regenerative endodontics: 
current protocols and future directions.” Journal of Istanbul University 
Faculty of Dentistry vol. 51,3 Suppl 1 S41-S51. 2 Dec. 2017, 
doi:10.17096/jiufd.53911 
2. 
Raddall, Gavin et al. “Biomaterials and Scaffold Design Strategies for 
Regenerative Endodontic Therapy.” Frontiers in bioengineering and 
biotechnology vol. 7 317. 15 Nov. 2019, doi:10.3389/fbioe.2019.00317 
3. 
Trevino, Ernesto G et al. “Effect of irrigants on the survival of human 
stem cells of the apical papilla in a platelet-rich plasma scaffold in 
human root tips.” Journal of endodontics vol. 37,8 (2011): 1109-15. 
doi:10.1016/j.joen.2011.05.013. 
4. 
Jadhav, Ganesh et al. “Revascularization with and without platelet-rich 
plasma in nonvital, immature, anterior teeth: a pilot clinical 
study.” Journal of endodontics vol. 38,12 (2012): 1581-7. 
doi:10.1016/j.joen.2012.09.010 
 
 
 
 
 
AIM OF THE RESEARCH 
 
 
 
 
This study aimed to evaluate and compare, both clinically 
and radiographically, the treatment and long-term follow-
up results of using platelet-rich fibrin, blood clots, and 
chitosan as scaffolds in molar tooth regeneration. 
 
 
 
 
RESEARCH METHOD: 
 
The sample group for the planned study will be selected 
from among patients applying to the Inonu University 
Faculty of Dentistry Pedodontics Clinic with necrotic pulp 
and immature apexes. Block randomization will be used to 
determine the material to be applied to the teeth. According 
to the minimum sample size determined by the power 
analysis, the study will be conducted on at least 24 teeth. 
Patients who leave the study early or do not comply with the 
treatment procedure will be excluded, and new patients will 
be added in their place. Patients will not undergo additional 
procedures, appointments, or radiograph requests within the 
scope of the study. Regeneration treatment is a popular, 
routinely applied procedure in our clinic and in dentistry 
faculties. It is also successfully performed by pedodontists 
and endodontists in private clinics. The protocol stipulates 
that each study participant will be informed about the nature 
of the treatment to be administered and the research to be 

conducted. Informed consent will be obtained from the 
patient's legal guardian. In the initial session, local 
anesthesia will be administered to the teeth, a rubber dam 
will be positioned, and the caries will be meticulously 
removed. Subsequently, the pulp will be meticulously 
eradicated through the employment of a sterile barnacle. 
Each canal will undergo irrigation with 20 milliliters of a 
2.5% sodium hypochlorite solution. Subsequently, a volume 
of 20 milliliters of sterile saline will be applied to each 
canal. Calcium hydroxide paste will be placed as a 
medicament in the canals that have been dried with paper 
points and closed with a temporary filling. The patient will 
be contacted to schedule a second session between one and 
four weeks later. In the second session, local anesthesia will 
be administered without the use of a vasoconstrictor. Prior to 
this, a rubber dam will be placed, and the temporary filling 
will be removed. The calcium hydroxide paste placed in the 
canal as a medicament will be removed, and each canal will 
undergo a gentle irrigation with 20 milliliters of 17% 
ethylenediaminetetraacetic acid (EDTA). The canals will be 
dried using paper points. The induction of bleeding will be 
accomplished through the utilization of an excessive number 
of instruments, specifically a 20 number K File, which will 
be inserted 2 mm beyond the apical extent of the canal. 
Subsequently, platelet-rich fibrin or chitosan (Sigma-
Aldrich) will be placed in the canal as a scaffold. In the 
"control group," where apical bleeding will be used directly 
as a scaffold, which is mentioned as the gold standard in the 
literature because it is the most easily accessible material, 
these will not be used and only bleeding from the apex will 
be sufficient. MTA (Angelus MTA) will be applied to the 
canal orifices to prevent oral fluids from leaking into the 
canal. The MTA will be covered with glass ionomer cement. 
Dental elements that are deemed suitable for endodontic 
restoration will undergo treatment with composite fillings. 
Teeth that are not amenable to restoration with composite 
fillings due to extensive material loss can be restored with 
stainless steel crowns. The protocol stipulates that patients 
are to be contacted for medical checkups at three-month 
intervals during the first year of the study, and at six-month 
intervals during the second year. The evaluation of the data 
will be conducted with the utilization of statistical software 
and the expertise of subject matter specialists. During the 
check-ups, the teeth will be evaluated according to the 
criteria listed below. 
 
A- CLINICAL 
1. Loss of Tooth 
2. Presence of pain 
 

       3. Percussion and Palpation Sensitivity 
       4. Presence of Pathological Mobility 
       5. Presence of fistula 
6. Evaluation of restoration  
 
B- RADIOGRAPHIC 
1. Pulp Obliteration 
2. Internal - External Root Resorption 
3. Apical Radiolucency 
4. Increase - Decrease in Lamina Dura Width 
5. Presence of Ankylosis 
6. Root length 
7. Root thickness 
 
 
 
 
 
POWER ANALYSIS: 
 
The number of people in the study was decided by a 
calculation called "power analysis." The G*power 3.1 
program was used to calculate the sample size. The 
sample size was determined to be 24, with 8 teeth for 
each group. The effect size was set at 0.25, the margin of 
error at 0.05, the confidence level at 0.95, and the 
universe representation power at 0.95 Cohen states that 
the sample size for which power values ranging from 
0.90 to 0.99 were calculated should be reached (5).   
5. 
Cohen, J, (1988), Statistical Power Analysis for the behavioral sciences, 2. 
Edition, Taylor & Francis INC, New York, US.)  
 

 
 
END POINT OF THE 
RESEARCH 
 
 
 
The goal of this study is to follow patients over time to 
see if regeneration treatment works for molar teeth with 
open apex. We will use three different scaffolds for the 
treatment. No clinical controlled study has been found in 
the literature on regeneration with molar teeth. The 
existing data are in the form of case reports or studies 
performed on incisors. The goal of the study is to 
successfully obtain 12-18 months of clinical and 
radiographic follow-up with at least 24 teeth. We will 
compare the success rates of the materials used based on 
the data we get. Since scientists haven't found the perfect 
material yet, this study will be a big help to researchers 
when it's finished. 
 
 
 
 
 
 
EXPECTED BENEFITS AT 
THE END OF THE 
RESEARCH 
 
The goal is to compare the long-term success of chitosan, a 
material that has been proven to work in clinical trials, with 
other materials. This will provide useful data for the scientific 
literature. Chitosan is used a lot in dentistry because it kills 
bacteria and helps tissue grow. (6). Studies have shown that 
it has some benefits. It is a good support structure for a type 
of tooth cell called apical papilla stem cells. It is also 
compatible with living tissue and is not very toxic. However, 
there is limited information about the use of chitosan in 
literature about other teeth. Since the roots are thin in molars, 
it is quite difficult to perform root canal treatment with apical 
plug. Therefore, the regenerative endodontic procedure was 
developed as an alternative, which is quite advantageous in 
molars with open apicals. Since many patients come from 
nearby provinces, the number of molars that need a 
regenerative endodontic treatment is also increasing in our 
clinic, where we see a lot of patients. This study aims to 
provide valuable data to the existing literature by evaluating 
molar teeth.  Comparison of 3 different scaffold materials will 
contribute to the determination of materials that are 
advantageous in terms of cost/benefit ratio and will provide 
support for their clinical use. 
 
6) 
Fakhri, 
Elaheh 
et 
al. 
“Chitosan 
biomaterials 
application 
in 
dentistry.” International journal of biological macromolecules vol. 162 (2020): 
956-974. doi:10.1016/j.ijbiomac.2020.06.211 
 
7) Chang, Bei et al. “Injectable scaffolds: Preparation and application in dental and 
craniofacial regeneration.” Materials science & engineering. R, Reports : a review 
journal vol. 111 (2017): 1-26. doi:10.1016/j.mser.2016.11.001 
 

 
 
PLANNED DURATION OF THE STUDY: 
 
Planned Start Date: 
 10.01.2022 
Planned Completion Date: 
01.08.2024 
 
CONTACT PERSON FOR THE PROJECT: 
 
Name and Surname of the 
Executor: 
PINAR DEMİR 
Address: 
Inonu University Faculty of Dentistry Department of 
Pedodontics Floor:1 MALATYA 
Phone number: 
+90 533 143 16 56 
Email Address: 
pinardemir101@hotmail.com 
Date:  
10.01.2022 
İmza: