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Title A Combination of Regenerative Therapies Provides Greater CAL Gain and Reduction in PD in Intrabony Defects than a Single Therapy Alone
Clinical Question For patients with intrabony defects, would a combination of regenerative therapies as compared to a single regenerative therapy alone provide better gain in clinical attachment (CAL) and decrease in probing depth (PD)?
Clinical Bottom Line When treating intrabony defects, a combination of regenerative therapies will provide greater CAL gain and reduction in probing depth than a single regenerative therapy alone, but more research is still needed as new therapies continue to be explored. Furthermore, all regenerative therapies evaluated were significantly more successful than open flap debridement (OFD) alone. This conclusion is supported by two large-scale systematic reviews and meta-analyses containing data from RCTs.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 31860134Nibali / 202079 RCTs / 3,042 patientsMeta-Analysis
Key resultsRegenerative procedures in this analysis included guided tissue regeneration (GTR), deproteinized bovine bone material (DBBM), demineralized freeze-dried bone allograft (DFDBA), platelet rich fibrin (PRF), and enamel matrix derivatives (EMD). When compared with OFD alone, all of the regenerative procedures provided an increase in clinical attachment level gain (1.34 mm; 0.95–1.73) and a decrease in PD (1.20 mm; 0.85–1.55). They also compared many regenerative procedures to one another. OFD+GTR+DBBM provided greater CAL gain (MD = 1.05, 95% CI: 0.09-2.01, p=.03) compared to DBBM alone, and OFD+DFBDA+PRF had significantly better CAL gain (MD = 1.12, 95% CI: 0.81-1.43, p<.00001) and PD reduction (MD = 0.55, 95% CI: 0.24-0.86, p=.0006) than PRF alone. When compared to DBBM alone, OFD+EMD+DBBM had significantly greater CAL gain (MD = 0.9, 95% CI: 0.37-1.43, p=.0009) and PD reduction (MD = 0.4, 95% CI: 0.09-0.71, p=.01). Therefore, the results suggest that combining regenerative procedures could provide greater CAL gain and probing depth reduction.
#2) 33289191Stavropoulos / 202130 RCTsMeta-Analysis
Key resultsStavropoulos’ results suggested that the majority of regenerative therapies (with the exception of GTR + BC and EMD + grafting + BC) (BC = blood-derived growth factor constructs like recombinant human platelet-derived growth factor-BB (rhPDGF-BB) + β-tricalcium phosphate) provided significantly greater CAL gain (1.26 to 2.66 mm) and shallower residual PD (−2.37 to −0.60 mm) when compared to OFD alone. All four individual therapies (OFD, EMD, GTR, and grafting alone) had the lowest SUCRA (surface under the cumulative ranking) values for CAL gain. In contrast, each of the combination therapies (except GTR + BC) had SUCRA values >50% with Grafting + BC having the greatest SUCRA value of 87% (low validity, based on two studies) for CAL gain. Overall, the data suggests that a combination of regenerative therapies provide the greatest CAL gain and probing depth reduction. Specifically, bone grafting with either EMD or GTR can yield the best results. More research is needed on blood-derived growth factor constructs to confirm their efficacy.
Evidence Search (intrabony defects) AND (regenerative surgery)
Comments on
The Evidence
Nibali’s review included searches through MEDLINE, Cochrane Database, and Scopus. Only RCTs were included in this review. However, only 10 of the studies included had a low risk of bias, and 14 had a high risk of bias. All studies included at least a 12-month follow-up with 11 reporting a 3-year follow-up. 50 RCTs were included in the meta-analysis. Thirteen separate meta-analyses were conducted, most of which had moderate heterogeneity, with some having substantial, and a few having low heterogeneity. Lastly, while many of the results were statistically significant, they may not be considered clinically significant due to the small mean differences. Stavropoulous’ review was conducted via an electronic search through MEDLINE, EMBASE, and CENTRAL. Only RCTs were included with a minimum follow up of 24 months. Thirty RCTs were included in the review; however, only one study had a low risk of bias, while 9 studies had a high risk of bias. Six studies were not included in the network meta-analysis “because they were comparing a similar type of treatment.” Stavropoulos did not report specific data on heterogeneity of studies.
Applicability Nibali and Stavropoulous evaluated multiple different modes and combinations of regenerative therapy for treatment of intrabony defects. Their findings are directly applicable to us as clinicians, because performing regenerative therapy is a daily part of our practice as periodontists. Clinical attachment gain will provide a better prognosis for teeth, and regenerative therapies can achieve this. However, using a combination of regenerative therapies can be an expensive endeavor. Therefore, patient acceptance of combination therapy could be a challenge from a financial standpoint. The main positive outcome from these reviews though, is that any regenerative therapy we do for our patients will be better than open flap debridement. So, even if a patient cannot afford to “throw the kitchen sink” at the defect, they still have treatment options that can be successful.
Specialty/Discipline (Periodontics)
Keywords intrabony defects, regeneration, periodontal surgery, enamel matrix derivatives, bone grafting
ID# 3546
Date of submission: 10/25/2023spacer
E-mail gabelk@uthscsa.edu
Author Kathryn Gabel, DDS
Co-author(s) Camille Banson, DMD
Co-author(s) e-mail banson@uthscsa.edu
Faculty mentor/Co-author Angela Palaiologou-Gallis, DDS MS
Faculty mentor/Co-author e-mail palaiologou@uthscsa.edu
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