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Root Surface biomodifiers in periodontal
therapy
A comprehensive review

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TABLE OF CONTENTS
INTRODUCTION
EVO LU TIO N O F
R O O T BIO M O D IFIER S
C LIN IC A L EV ID E N C E
A N D EFF IC A C Y
A PP LIC ATIO N IN
GE N ER A L D EN T ISTRY

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IN TR O D U C TI O N
TIM ELIN E H IS TO RY
O F R O O T BIO M O D IF IER S
C LA SS IF IC ATIO N
M E C H A N IS M O F AC T IO N
Periodontal disease is caused by specific gram
negative pathogens which results in inflammation of
the tooth-supporting structures and subsequently
causes the continued breakdown of Periodontal
ligament, its structures and alveolar bone.

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Goals of Periodontal Therapy:
•Prevent disease progression.
•Restore structural and functional integrity of the
periodontium.
•Achieve new attachment and regeneration of tissues​
.
Challenges in conventional approach:
Smear layers that inhibit cell attachment
IN TR O D U C TI O N
C LA SS IF IC ATIO N
M E C H A N IS M O F AC T IO N
TIM ELIN E H IS TO RY
O F R O O T BIO M O D IF IER S

5. 1833 1900 1950 1975 1990 2015
Stewart et al
(1890)
Mechanical removal
of calculus and
cementum
with acid
application.
1965-Urist et al
suggested acid
demineralizatio
n,dentin
possessed
inductive
property
to form new
bone or
cementum
1975- Register et
al
Rubbing
technique
1982- Miller
used brushing
technique for
root
biomodification
during root
coverage
1986-
Terranova et
al.
Tetracycline,
Laminin
1987-Caffesse
RG et al.
Fibronectin
Rubins RP et al.
2013
Rh (PDGF)
(Growth Factor)
1991-Raul G et
al.
EDTA
Marshal et
al (1833)
‘Presumable
clinical
attachment’
Timeline history of Root
biomodifiers development
1973- Register et
al
Citric acid
1997-
Yamaguchi et al
Er:YAG
R Fekrazad et
al. 2015
Er, Cr: YSGG
A Dilsiz et al.
2010
ND:YAG

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IN TR O D U C TI O N
C LA SS IF IC ATIO N
M E C H A N IS M O F AC T IO N
EVO LU T IO N O F R O O T
BIO M O D IE R S
Root surface
conditioners
Citric acid
Tetracycline HCI
EDTA
Fibronectin
Laminin
Doxycycline
Minocycline
Polyacrylic acid
Phosphoric acid
Formalin
Chlorhexidine
Hydrogen peroxide
Cetyl pyridinium chloride and
sodium-n-lauroyl sarcosine
Cohen's factor
Bile salts and plasma fractions
Dentin bonding conditioners
Enamel matrix proteins
Platelet-rich plasma
Recombinant human
growth
Lasers

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IN TR O D U C TI O N
C LA SS IF IC ATIO N
M EC H A N ISM O F
A C T IO N
EVOLU TIO N O F R O O T
BIO M O D IFIE R S
Mechanism of Action
Smear Layer Removal: Clears
barriers that prevent cellular
attachment
Exposure of Collagen Fibers:
Enhances fibroblast attachment
Decontamination: Eliminates
bacterial endotoxins and toxic
products.
Facilitating Regeneration:
Creates a biocompatible
surface for cementum and bone
formation

8. 2020
2015
2010
2005
2000
1990
(1800s – Mid-1900s)
Acids were used as an adjunct to mechanical
scaling and calculus removal.
The rationale: Acid demineralization could
counter the hypermineralized and
contaminated root surfaces caused by
periodontal disease​
For pocket eradication
and reattachment.
Induce the
regeneration of
cementum and bone.

9. 2020
2015
2010
2005
2000
1970-1990
1980
Modern Advancements in Acid-Based Agents
• Citric Acid- exposed collagen fibers, and opened
dentinal tubules to facilitate fibroblast attachment
 Tetracycline Hydrochloride- inhibiting collagenase
activity, and promoting fibroblast attachment
 EDTA (Ethylenediaminetetraacetic Acid)-Chelates
calcium ions to demineralize surfaces without
damaging surrounding tissues, improving
fibroblast attachment
17% EDTA IN
ENDODONTICS/
24% IN
PERIODONTICS

10. 2020
2015
2010
2005
1990-2000
1990
1980
Shift to Biological Agents (1990s – 2000s)
Enamel Matrix Derivatives (EMD)
Inspired by natural tooth development, EMD (e.g., Emdogain) became a
revolutionary biomodifier.Inspired by natural tooth development, EMD
(e.g., Emdogain) became a revolutionary biomodifier.
Application: Mimics enamel proteins to stimulate cementum and
periodontal ligament regeneration.
Growth Factors
Growth factors such as platelet-derived growth factor (PDGF) and bone
morphogenetic proteins (BMPs) were introduced.
Function: Stimulate fibroblast proliferation, angiogenesis, and bone
formation.

11. 2020
2015
2010
2000 – PRESENT
2000
1990
1980
Technological Innovations (2000s – Present)
Injectable Platelet-Rich Fibrin (I-PRF):
A second-generation platelet concentrate used to
deliver growth factors directly to root surfaces.
Laser-Assisted Root Biomodification:
CO2, Nd:YAG, and Er:YAG lasers are now
used for smear layer removal, root
decontamination, and improving fibroblast
attachment.

12. Positive Outcomes:
Numerous in vitro and animal studies have shown that root surfaces
conditioned with EDTA gel (24%, pH 7) resulted in a smear-free root
surface. Besides, the exposed collagen fibrins provides a bio-compatible
surface for wound healing.
Studies show improved connective tissue attachment and cementum
regeneration with agents like citric acid and EMD.
EMD
PGA
As vehicle
EDTA

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EDTA
EMD

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LASERS IN ROOT
BIOMODIFICATION

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Enhanced Periodontal Procedures:
o Root biomodification as an adjunct to scaling and root planing.
o Better outcomes in flap surgeries and guided tissue regeneration.
Improved Patient Outcomes:
o Faster healing, reduced post-surgical complications, and better
long-term prognosis.

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 Periodontally diseased root surfaces hinder regeneration due to
unfavorable characteristics.
 Demineralization improves cell and fiber attachment, aiding
wound healing. Proper root conditioning enhances protein
adsorption, clot adhesion, and collagen deposition.
 While lasers and root canal irrigants show promise, more
randomized clinical trials are needed to confirm their efficacy in
regeneration.
Conclusion

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