Clinical, Anti-Inflammatory And Anti-Infective Properties Of Amniotic Membranes Used For Guided Tissue Regeneration
Condition: Chronic Periodontitis
MeSH terms: Periodontitis; Chronic Periodontitis
Study type: Interventional
Phase: Phase 3

Summary: 
      The objective of this study is to evaluate the anti-inflammatory and anti-infective
      properties of amniotic membrane (AM) when used for guided tissue regeneration (GTR) in
      periodontal bone defects.
    

Detailed description: 
      Study design including Randomization and Blinding The study was designed as a split-mouth,
      double-blind, randomized controlled clinical trial. Randomization and blinding included
      computerized generation of the allocation sequence in random permuted blocks (block
      randomization) and blinded disbursement of medication. Allocation was performed by assigning
      the block of sites to study groups according to the specified sequence. Based on the
      sequence, the first operator selected two sites for each of the following experimental sites;
      the test site, in which amniotic membrane with the graft was placed and the control site
      which was treated by graft placement only. All the surgeries were performed by a designated
      operator for the sake of uniformity whereas the relevant readings were recorded by the first
      operator who was blinded to the nature of the site. The blind was not broken until this
      clinical trial was completely finished.

      After the prospective interdental areas were probed buccally and lingually/palatally, the
      site was considered for the study if the average probing pocket depth (PPD) was ≥5 mm. All
      baseline (on the day of surgery) values were recorded before the surgical procedure. Gingival
      crevicular fluid (GCF) samples for IL-1β were taken at baseline and 1 week and for hBD-2 were
      taken at baseline, 1 week and 4 weeks. Non-invasive site-specific measures of the plaque
      index (PI) and modified gingival index (MGI) at the baseline, 1 week, 12 weeks and 24 weeks.
      The PPD, CAL and bone fill were recorded at the baseline (on the day of surgery) and at the
      end of 12 and 24 weeks. PPD and CAL were recorded at the baseline and at the end of 12 and 24
      weeks using a UNC-15 color-coded periodontal probe. A custom acrylic stent limited to the
      occlusal 2/3rds of the clinical crown was prepared from a cast obtained from an alginate
      impression. A groove was prepared in the stent to standardize the probing angulation
      throughout the procedure and also during the follow up visits.

      Radiograph Standardization Standard digital radiographs were taken at baseline, 12 and 24
      weeks by the paralleling/long-cone technique at pre-set parameters using a commercially
      available RVG system. After the imaging plate was placed in the film holder for paralleling
      technique, addition silicon impression material was added around the biting surface and
      allowed to set. This arrangement ensured standardized alignment of the aiming device and the
      holder ensuring correct positioning of the collimator in subsequent radiographs.

      Collection of GCF Samples:

      After isolation, 6 mm diameter filter paper circles were used for collecting the samples by
      the intra-crevicular method. The fluid seeping out of the sulcus was collected and any paper
      contaminated with blood or saliva was discarded, and the collection was repeated after 30
      minutes. GCF samples were eluted from the strips by placing them in Eppendorf tubes that
      contained 500 µL of buffer and stored at -80ºC. GCF Samples were collected at baseline, at
      the end of 1 and 4 weeks.

      Enzyme Linked Immunosorbent Assay (ELISA) for IL-1ß and hBD-2 Commercially available ELISA
      kits were used to quantify GCF levels of IL-1ß and hBD-2. All assay procedures were conducted
      according to the manufacturer's instructions and in both the tests, 100μl of the samples or
      standards were added into the respective wells in duplicate. Color development was stopped
      using 1% H2SO4 and absorbance of the entire plate was measured within 30 minutes by an ELISA
      reader at 450nm. The amounts of IL-1ß and hBD-2 were calculated based on the dilutions, and
      the results were expressed as pico-gram/30 second and pico- gram/site in the 30-second GCF
      sample.

      Amniotic membrane Lyophilized and irradiated AM (3×3 sq.cm) was obtained from a commercial
      tissue bank. The tissue was dispatched for clinical use from the tissue bank. The tissue
      conforms to the International Atomic Energy Agency (IAEA) recommendations and the Asia
      Pacific Association of Surgical Tissue Banks (APASTB) standards. AM is stable and can be
      stored at room temperature.

      Surgical phase:

      All surgical procedures were performed by one clinician. After recording relevant parameters,
      and following routine local anesthesia, sulcular incisions were given and full thickness
      mucoperiosteal flap was elevated for defect access. Thorough degranulation of the bone defect
      was done and root planing was done by using appropriate site-specific curettes.

      The test site was treated as follows; After placement and proper condensation of natural
      Hydroxyapatite graft in the defect, AM was cut based on defect anatomy of surgical site and
      then adapted over the bone graft and alveolar bone extending from base of the flap reflection
      to the tooth surface. Flap was approximated and stabilized by placing direct loop sutures.
      Periodontal dressing was placed subsequently. For the control site, the procedure was
      identical except that the membrane was not placed. Patients received post-operative
      instructions and were prescribed medication. The sutures were removed at 1 week post-surgery
      and subsequent measures were recorded.

      Radiographic assessment The evaluation of bone fill was performed by using digital
      subtraction technique and morphometric area analysis by using specific tools in two image
      processing softwares.
    

Intervention name(s): Amniotic Membrane; Control group (Hydroxyapatite only)
Intervention type(s): Device; Device
Intervention description(s): AM strongly resembles the oral mucosal basement membrane and possesses several types of laminins, which can promote regeneration, accelerate tissue adhesion, and preserve tissues, all of which play a key role in improved healing of periodontal lesions and might result in reduction in probing pocket depth (PPD) and decrease in clinical attachment loss (CAL); The placebo group was treated with Hydroxyapatite graft placement only.
Other intervention name(s): TMH Tissue Bank, Mumbai, India
Allocation: Randomized
Intervention model: Single Group Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Treatment
Keywords: Periodontitis; Periodontal Regeneration; Amniotic membrane; Guided tissue regeneration; Anti-inflammatory; Periodontal Therapy.