Presentation delivered @ International Dental research conference, Chettinad University, Chennai in January, 2011

1. Bio-materials EFFECTIVE IN PERIODONTAL SURGERY OR NOT ?????

2. By, Dr.P.R.Ganesh MDS (Perio) Asst.Prof, GDC,Chennai

3. Age Of Google- Patients are AS informed as we are…

4. Our thinking should now be Evidence-Based….

5. So we will see the evidences available for various bio-materials… Critical Appraisal of Publications…

6. Fast Introduction of Basics…

7. PERIODONTITIS ? ? ? Deep intra-osseous defect

9. Pathogenesis-Multifactorial.

10. DIAGNOSIS- PROBING

12. Non-Surgical Therapy Surgical Therapy Perio Treatment

13. We Are Here To Discuss The Surgical Option For Periodontitis Today

14. GOALS OF SURGICAL RX Maintain Results Regenerate the Lost Tissue Remove Biofilm

16. Optimal Outcome Of Treatment- Regenerate The Periodontium To Its Pre-disease State Proven by Histological Evidence of Regeneration – both architecture and function…

17. To be considered a regenerative modality, a material or technique must HISTOLOGICALLY DEMONSTRATE that bone, cementum and a functional periodontal ligament ( A New Attachment Apparatus ) can be formed on a previously diseased root surface.

21. Bio-Materials Vs. Perio Regeneration

24. Guided Periodontal Regeneration- Many Options available…to confuse us.

25. Guided Tissue Regeneration Generation 1 – of periodontal Regeneration…. Nyman, Karring et al… Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982: 9 : 290–296.

28. Gingival Epithelium Connective Tissue Alveolar Bone Periodontal Ligament GTR- Concepts Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976: 47: 256–260.

32. GTR- Tough, Technique-Sensitive Procedure…

36. Or do GTR and Pray it works out well…

37. Generation 2 Biomaterial for - Periodontal Regeneration….

38. What are Bio-Materials? Biologic Mediators - used for Periodontal And Maxillofacial Regeneration

39. What are Bio-Materials? Partially Purified Protein Mixture From Developing Teeth. Or – Morphogens (Growth Factors) – From Recombinant Technology.

40. Biomaterials- EMD/BMP/PRP/PRF…..

42. Bio-materials - for Periodontal Regeneration Enamel Matrix Derivatives Bone morphogenetic Proteins Platelet Rich Plasma/Fibrin..

43. EMD- Enamel Matrix Derivative

47. EMD-EMDOGAIN GEL (Straumann)

53. Evidence-Based Dentistry (2003) 4, Vibeke Baelum and Rodrigo Lopez Where patients have intrabony defects, is surgery with enamel matrix derivative more effective than other treatments?

54. Evidence-Based Dentistry (2003) 4, Vibeke Baelum and Rodrigo Lopez Currently, the evidence for a possible benefit of EMD in the treatment of intrabony defects IS RATHER WEAK.

55. No.2 Biomaterial- BMP

56. Bone morphogenetic proteins recombinant human BMP-2 (rhBMP-2) -introduced by Sigurdsson etal in 1997

57. BONE MORPHOGENETIC PROTEIN TYPE I COLLAGEN SPONGE (INFUSE; Medtronic Sonfamore Danek, Memphis, TN, USA) Commercial Name….

62. I ask for Regeneration and I get ANKYLOSIS????

63. PLATELET-RICH PLASMA Source Of Growth Factors

67. Not every Patient is ready for Harvesting their Own Blood…

68. Discussion Of Periodontal Regeneration..

70. Vast difference between animal and Human studies

74. Time –out for a review….

76. Are the regenerated tissues sustainable? For Regenerated Periodontium, The Confirmatory Evidence Would Be Long-term Studies Of The Treated Defects.

77. Otherwise we would be left with mixed results..

78. EVIDENCE…….IN/OUT? Enamel Matrix Derivatives Bone Morphogenetic Proteins Platelet Rich Plasma Do they result in Regeneration? Or not?

79. Is grafting biomaterials or biological agents more effective than open-flap debridement in treating deep intraosseous defects? Trombelli L, Heitz-Mayfield L, Needleman I, Moles D, Scabbia A. A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol 2002; 29(Suppl. 3):S117–S135

81. Bio-materials/OFD Because of the significant heterogeneity in results between studies in most treatment groups, general conclusions about the clinical benefit of graft biomaterials/biologicals - Need To Be Interpreted With Caution. Trombelli L, Heitz-Mayfield L, Needleman I, Moles D, Scabbia A. A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol 2002; 29(Suppl. 3):S117–S135

82. That evidence seems to be a bit of no-brainer, right?

83. Currently there is NO EVIDENCE to support the use of these graft materials and biological agents for periodontal intra-osseous defects . Trombelli L, Heitz-Mayfield L, Needleman I, Moles D, Scabbia A. A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol 2002; 29(Suppl. 3):S117–S135

84. Does Statistical Significance Equate To Clinical Significance ??? We very much rely on statistical significance rather than clinical significance.

85. Expert Advice is In-Valuable….

86. Conclusions…

88. Periodontal Regeneration- ARE WE THERE YET? Clinicians increasingly demand predictable and faster treatment modalities

89. Results should focus on Patient-centred outcomes and evaluation of cost/benefit ratio.

90. Conclusions… Differences In CAL Gain And PPD Reduction Vary Greatly With Respect To Different Biomaterial/Biological Agents. Residual defects still remain.

91. Results These findings question the evidence for a CONSISTENT AND CLINICALLY WORTHWHILE BENEFIT .

93. Decision Making.. BENEFITS OUTCOMES Vs.

94. No evidence for use of Biomaterials…Though I am not Einstein…

95. Future Directions… Future research should focus on developing a clearer understanding of the variability of clinical outcomes

96. We are on the way to Periodontal Regeneration..

97. Though there are many difficulties ahead…

98. Coming in the Future…Wait for it

99. THIS FIGHT IS JUST BEGINNING

100. Thank you…. By, Dr.P.R.Ganesh