Regeneration of Human Intrabony Defects With rhFGF-2/HA
Condition: Periodontitis
MeSH terms: Periodontitis
Study type: Interventional
Phase: Phase 1/Phase 2

Summary: 
      BACKGROUND: Periodontal disease is an infection that results in progressive loss of dental
      support, which may lead to tooth loss.. The goal of the present study was to evaluate if
      recombinant human Fibroblast Growth Factor type 2 (rhFGF-2) applied in periodontal intrabony
      defects in a hyaluronic acid (HA) carrier would enhance the clinical paramenters of
      regeneration of the periodontal attachment apparatus and the long-term maintenance of the
      results obtained. METHODS: Thirty adult patients were evaluated. Initial treatment consisted
      in plaque control measures executed previously to the experimental phase. Two intra-bony
      defects in each patient were ramdomly allocated for each of the treatment methods employed.
      Control group (n=30) were treated by open debridement with the papilla preservation flaps,
      while the text group (n=30) also received a topical application of rhFGF-2/HA in the
      intrabony defect. The parameters evaluated were, probing depth (PD), gingival recession
      (REC), probing attachment level (PAL) and probing bone level (PBL). Clinical measurements
      obtained at baseline and 1, 5 and 10 years after the surgical procedure were compared.
    

Detailed description: 
      Study Population and Experimental Design The study was designed as a randomized, prospective,
      split-mouth, controlled clinical trial. It was conducted in accordance with the guidelines of
      the World Medical Association Declaration of Helsinki (version VI, 2002), after approval of
      the study design and consent by the Faculty of Medicine, Ethical Committee of Medical
      Research, Federal Fluminense University (Approval protocol CEP-HUAM/CCM 21/03). Written
      informed consent was obtained from all subjects. Systemically healthy patients with moderate
      to advanced chronic periodontitis referred to the Department of Periodontology, Faculty of
      Dentistry, Federal Fluminense University for periodontal treatment of advanced periodontitis
      were recruited for and treated in the study.

      Inclusion criteria of the study were: (a) adult subjects with chronic periodontitis
      presenting (b) radiographic evidence alveolar bone loss at the proximal aspect of the tooth,
      (c) intrabony defect deeper than 4mm, (d) probing pocket depth >6 mm at the site, (e)
      unremarkable general health according to medical history and clinical judgment, (f) no
      medications taken for at least six months and no antibiotics taken for twelve months before
      the beginning of the study. Subjects who have quit the habit of smoking for at least one year
      before the beginning of the study were considered as non-smokers and, if the other included
      criteria were met, were included in the present sample. Exclusion criteria for the study
      were: (a) subjects with "early onset" or aggressive forms of periodontitis, (b) current
      smokers, (c) presence of significant systemic diseases (i.e., cancer, AIDS, diabetes), (d)
      clinical evidence of furcation defects, (e) presence of apical radioleucency and (f) previous
      lack of cooperation with the maintenance program.

      Two defects were selected from each patient, and were randomly assigned, immediately before
      each surgical appointment, by computer generated random sequence allocation to one of the two
      treatment modalities employed: (a) Control: open instrumentation of the root surfaces and
      bone defects via flap modified papilla preservation flap; (b) Test: open instrumentation of
      the root surfaces and bone defects via flap modified papilla preservation flap and
      application of a rhFGF-2/HA in the intrabony defect. Treatment allocation was registered in
      an allocation table sheet that was unavailable to the clinical examiner throughout the study.
      Both the control and test sites were treated at the same surgical appointment and no
      information on treatment allocation was provided to the patient. All surgical procedures were
      performed by a single operator, which became aware of the site allocation only after
      completed root planning and conditioning, and immediately before the application of the
      growth factor in the test sites. A strict surgical protocol emphasizing careful hard- and
      soft-tissue management, root debridement, wound stability and infection control was employed
      (Santana et al 2009; Miranda et al 2013). Nonsurgical infection control was performed in the
      context of cause- related periodontal therapy and consisted of oral hygiene instructions,
      scaling and root planing, tooth polishing and plaque control measures performed six months
      prior to regenerative surgery. Patients were re-evaluated three and six months after the
      completion of the non-surgical cause-related periodontal therapy and enrolled following the
      later evaluation appointment.

      Clinical Recordings Clinical parameters were assessed using the cemento-enamel junction (CEJ)
      or, when applicable, another defined landmark, as a fixed reference point. All measurements
      were recorded using an UNC #15 periodontal probe (PCP-UNC 15, Hu-Friedy, Chicago, IL, USA) by
      a blinded, trained and calibrated examiner (CMMS), unaware of the treatment provided at
      baseline and one year after treatment. Measurements were recorded to the nearest mm. Full
      mouth plaque score (FMPS) was recorded dichotomously as the percentage of total surfaces
      (four sites per tooth) (O'Leary et al. 1972). BOP was also assessed dichotomously at the same
      sites, and a full mouth bleeding score was calculated. Recession (REC) was measured as the
      distance from the CEJ to the gingival margin (GM). Probing depth (PD) was measured as the
      distance from the GM to the bottom of the gingival sulcus. PD and REC were used to calculate
      the vertical clinical attachment level (PAL). Under local anesthesia, transgingival probing
      was performed and the distance between the CEJ and the bottom of the defect (distance CEJ-BD)
      was also recorded. Clinical measurements obtained at baseline (immediately before surgery)
      and at twelve months are reported. After debridement of the surgical site, the bottom of the
      defect (BD) was defined as the distance between cemento-enamel junction and base of the
      defect. Bone crest level (BC) was measured as the distance between the cementoenamel junction
      and crest of the defect and the intra-bony defect depth (INTRA) was measured as the
      subtraction of BC from BD measurements (BD-BC). Moreover, the depth of the three, two and
      one-wall sub-components of the bony defect were also measured. The primary and secondary
      outcome variables of the present study were, respectively, change in PAL and bone gain
      (change in distance CEJ-BD).

      In order to ensure the reproducibility and consistency of pre- and post-intervention
      measurements, examiner calibration was performed before the beginning of the study. Fourteen
      sites, in seven patients, with probing depths >6 mm were evaluated by the examiner on two
      separate occasions, 48h apart.

      Flap Design Intracrevicular incisions were made and buccal and lingual mucoperiosteal flaps,
      including at least one tooth mesial and another distal the tooth being treated, were elevated
      by blunt dissection. Extreme care was taken to preserve the marginal gingiva and inter-dental
      tissue to achieve better closure of the treated sites. Thus, the defect-associated
      inter-dental papilla was accessed with papilla preservation ﬂap techniques (Takey 1985,
      Cortellini et al. 1995, Cortellini et al. 1999) according to indications. A vertical
      releasing incision was performed at the mesial aspect of the flap whenever necessary to
      obtain optimized, tensionless, access to the surgical area.

      Root and bone defect debridement The bone defect was meticulously debrided with surgical
      curettes and ultrasonic instruments with special effort to remove all the inflammatory
      granulation tissue, but with no intention to perforate the cortical bone walls. Thorough root
      planing was performed with hand (Hu-Friedy, IL, USA), rotary (Intensiv, Grancia, Switzerland)
      and ultrasonic instruments (Cavitron, Dentisply, USA), to remove subgingival plaque and
      calculus until all root surfaces attained a hard glassy surface. During the instrumentation,
      the ﬂaps were slightly elevated, carefully protected with periosteal elevators, and
      frequently irrigated with saline.

      Root conditioning and rhFGF-2 application After instrumentation, the root surfaces were
      washed with saline solution to remove any remaining detached fragments from the defect and
      surgical field. Then, a freshly prepared tetracycline hydrochloride paste in saline was
      applied with gentle circular movements on the instrumented and dried root surfaces of both
      test and control groups for three minutes. After that, the defect area was carefully rinsed
      with saline. Finally, on the experimental sites, 0.2ml of a gel containing 4mg/ml rhFGF-2 in
      sodium hyaluronate MW 1.3 x 106 was applied on the dried root surfaces and bone defect. The
      flaps were then repositioned and tension-free primary flap closure was obtained using
      internal mattress, and single interrupted sutures (5.0 Ethicon Sutures, Johnson & Johnson,
      NJ, USA or Gore-tex Sutures, W.L Gore, AZ, USA).

      Post-Operative Treatment The patients were prescribed systemic antibiotic therapy consisting
      of 200mg of doxycycline***** the day before surgery, followed by 100 mg daily continued until
      the 20th day after surgery. No surgical dressing was used. The patients were instructed to
      continue their regular home hygiene care, except in the operated area, which was cleaned by
      means of gentle topical applications of 0.2% chlorhexidine gluconate (Perioxidin®, Lacer,
      Barcelona, Spain) in saturated cotton swabs. Patients were instructed not to brush or ﬂoss
      the surgical area for 4 weeks, when mechanical plaque control was re-instituted. The sutures
      were removed two weeks after surgery. Hyper-mobile teeth were splinted either before or
      immediately after the surgical procedure.

      Maintenance Schedule Patients were enrolled in a stringent post-operative supportive care
      programme following surgery (Santana et al 2009). All patients were seen weekly during the
      first three months and bi-weekly for the next three months. Thereafter, the patients were
      seen once monthly for the last six-month period of the study. After 1 year, the patients were
      recalled and re-instructed on proper oral hygiene. Sites were rescaled when indicated.

      Radiographic assessments Radiographs were taken with a parallel, standardized, technique at
      baseline (Eickholz et al. 2004). Radiographs were digitized and analysed using NIH Image
      Analysis software. The anatomical landmarks for the study included cementum-enamel junction
      (CEJ), alveolar crest (AC) and base of the defect (BD) (Schei et al. 1959). Radiographic
      defect depth was measured along the root surface, parallel to the root axis, as the distance
      between CEJ and BD.

      Statistical Analyses Quantitative data were recorded as mean and standard deviations. No data
      points were missing. Sample size was determined by Power analysis, assuming a standard
      deviation of the difference of 0.5, which indicated that with a sample of 20 subjects, the
      study would have >90% power to detect a 1-mm difference in the primary outcome measures PAL
      gain and CEJ-BD reduction between the two groups. In order to verify the normality of the
      data, the kurtosis and skewness curves were used. Because all data were considered to be
      normal for the parameters analysed, Student's paired t-test was used for intra-group
      (baseline versus 12 months) and inter-group (test versus control) comparisons. The level of
      significance set at 5% was used in all statistical comparisons performed in the software
      ProStat (Poly Software International, Pearl River, NY, USA) .
    

Intervention name(s): a gel containing 4mg/ml rhFGF-2 in sodium hyaluronate; Periodontal flap surgery
Intervention type(s): Device; Procedure
Intervention description(s): 0.2ml of a gel containing 4mg/ml rhFGF-2 in sodium hyaluronate MW 1.3 x 106
Intervention MeSH terms: Hyaluronic Acid
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: alveolar bone loss; periodontal attachment loss