Root Surface Biomodification in periodontal therapy

1. Root Surface
Biomodification
Guided By-
Dr. Srinivasa T. S
MDS
Guide, Professor &HOD
Department of periodontology
Presented By –
Dr. Mangesh Andhare
PG Student
Department of periodontology

2. Contents
 Introduction
 History
 Classification of root surface biomodification agents
 Root surface conditioners
 Dentin bonding conditioners
 Enamel matrix proteins
 Platelet-rich plasma
 Recombinant human growth factors
 lasers
 Conclusion

3. Introduction
 Terminology
Regeneration:
“Reproduction / reconstruction of a lost or injured part in such a
way that the architecture and function of the lost or injured tissues
are completely restored” – GPT 1992
New attachment (in periodontics):
“The embedding of new periodontal ligament fibers into new
cementum and attachment of the gingival epithelium to a tooth
surface previously denuded by disease”- carranza 9th edi.

4. Reattachment :
“ Regeneration of fibrous attachment to a root surface surgically or
mechanically deprived of its periodontal ligament tissue.”
Repair :
“Describes healing of a wound in response to injury in an attempt to
restore normal structure and function.”

5. Introduction:
 The traditional treatment of periodontally compromised roots have
relied on mechanical instrumentation that is not able to fully
eliminate the infection due the formation of a smear layer of organic
and mineralized debris .
 As a compensation for these limitations of mechanical therapy;
chemical root conditioning has been introduced.
 Chemical therapy may favor clot stabilization in the earlier stages of
periodontal healing by increasing the adhesion of blood cells and
fibrin to the root surface .

6.  Root conditioning is intended to detoxify the root surface by
removing the smear layer and Demineralized by exposing the
collagen matrix that supports migration, proliferation, adhesion and
matrix synthesis of the cells involved in periodontal healing.
 This is important for periodontal tissue repair and regeneration .
 The exposed dentinal collagens are supposed to acts as a chemo
attractant for periodontal fibroblast.
 Citric acid and tetracycline hydrochloride have been
extensively researched and used clinically because of higher
tissue tolerance and easy storage.

7. History:
 History of root surface biomodification can be traced back to
“Marshall (1833)” who presented a case of pocket eradication with
“presumable clinical reattachment” after the use of Aromatic
sulfuric acid.
 In the 1890s, Younger and Stewart described the use of acids in
conjunction with the mechanical removal of calculus and cementum.
 The potential of acid demineralization of root surfaces as an adjunct
to new attachment procedures gained popularity following studies
by Urist.

8.  Urist (1965): suggested that dentin following acid demineralization
possessed inductive properties.
 Demonstrated in a series of experiments that allogenic dentin
matrix, following partial or total demineralization with O.6N HCL
possessed the ability to induce the formation of new bone or
cementum on the implant surface.
 It was suggested that the dentin matrix contained a protein or a
series of proteins that possessed the ability to induce differentiation
of cells.

9.  Results of the study suggesting that the inorganic component of
dentin may obscure potential inductive proteins associated with the
organic component.
 Register (1973): Performed a systemically designed controlled
study where the potential of demineralization to induce
cementogenesis , osteogenesis, and new attachment was assessed.

10. classification
 The Root surface bio modification agents are broadly classified as-
1.Root surface conditioners:
o Citric acid
o Tetracycline HCL Poly acrylic acid
o Phosphoric acid Formalin
o Chlorhexidine EDTA
o Fibronectin Lamanin
o Doxycycline Hydrogen peroxide
Bile salts and Plasma fractions

11. 2.Dentin bonding agents
3. Enamel matrix proteins
4. Platelet-rich plasma
5. Recombinant human growth factors
6. lasers

12. CITRIC ACID
Citric acid was initially suggested as root bio-modification agent
By Register (1973)
 Studies by Urist showed formation of
new bone or cementum on partially or totally
Demineralized dentin matrix or allogenic
bone.
pH-1.0-1.4
Application time-2 or
3 min.

14. MODE OF ACTION
Removal of smear layer formed after root planing
This creates a mat like collagen surface with exposed dentinal tubules
PDL cells and gingival FIBROBLASTS adhere
better to Demineralized root surface.

15. Citric acid mechanism for Gaining root coverage
Exposed root surface
Citric acid ph 1.0
4 microns Demineralized surface
Exposed collagen fibrils +exposed
Collagen fibrils of flap or graft.
Plasma Fibronectin factor, factor 13
Fibrin covalent linkage

16. Collagen fibrils of root
Newly synthesized collagen fibers
Collagen fibrils of graft
Fibrin covalent linkage

17. ACTIONS
 Accelerated healing and new cementum formation.
 No significant action on non-root planed surface.
 Roots, after root planing-4mm deep demineralized zone is created.
 Prevents migration of epithelium .
 Enhanced fibroblast growth and stability.
 Attachment by direct linkage.

18. Rationale for use of citric acid
 Antibacterial effect. (Daly et al. 1982)
 Root détoxification. (Aleo et al. 1974)
 Exposure of root collagen and opening of dentinal tubules (Polson et
al. 1984)
 Removal of smear layer (Polson et al.1984)
 Initial clot stabilization (Wikesjo et al.1991)
 Demineralization prior to cementogenesis (Register, 1975)
 Enhanced fibroblast growth and stability (Boyko et al. 1980)
 Prevention of epithelial migration along the denuded roots (Polson
et al. 1983)

19. TECHNIQUE OF APPLICATION

20. Rubbing technique
 Suggested by Register (1975), Miller (1982,1985)
 It has been demonstrated that application of citric acid(PH=1) for 3
min. using rubbing pressure on the surface results in the complete
removal of smear layer and the exposure of smoother root dentine
surface with relatively wide dentinal tubular opening( 8.88 20μM).

21. Drawbacks of citric acid
 Formation of extremely acidic environment in the surrounding
tissues which may results unfavorable wound healing responses.
 Low PH also shown to induce cytotoxic effects when in direct
contact with periodontal cells.

22. TETRACYCLINE HCL
 They are broad-spectrum antibiotics which are
effective in controlling periodontal pathogens.
 They are the derivatives of the polycyclic naphthalene carboxamide.
 Tetracycline hydrochloride, Doxycycline hydrochloride and
Minocyclines have been used as root conditioning agents to
demineralize the root surface as it binds strongly to the root surface
and can be released in an active form over extended periods of time.
 Tetracyclines have a low pH in concentrated solution and this can act
as a calcium chelator resulting in demineralization.

23.  tetracycline hydrochloride used for at least 30 seconds, has proven
most effective in removing smear layer and opening dentinal
tubules.
 They are generally used as a 0.5% solution at a PH of 3.2 and is
applied for 5 minutes .
 The solution is prepared by adding 1 standard ml of sterile water to
the contents of each capsule, then thoroughly mixing the two.
 The material is applied with lateral pressure using passive
burnishing technique using a sterile cotton pledget .
Wikesjo (1986)- demonstrated that 10n or 100mg/ml solution of
tetracycline hydrochloride were sufficiently concentrated to remove
the smear layer and expose the dentinal tubules.

24. Rationale for use of Tetracycline
hydrochloride (VP Terranova et al. 1986)
 Increases fibronectin binding which stimulates fibroblast attachment
and growth.
 Smear layer removal, exposure of dentin tubules / collagen fibers.
 Endothelial cell growth factor binding to dentin, stimulating
periodontal ligament cell proliferation / migration.
 Adsorbs to enamel and dentin.
 acts as antimicrobial local delivery system.
 Collagenolytic enzyme inhibition preventing bone resorption.

25. Fibronectin
 It is a glycoprotein that fibroblasts require to attach to root surfaces.
 Addition of fibronectin-promotes new attachment.
 Fibronectin-fibrin sealing system helps in healing of Periodontal
surgical wounds.
 It has chemo attractant effects on fibroblast and mesenchymal cells
and it also promotes cell adhesion to both collagen and scaled root
surfaces.
 Fibronection is acts as a non-specific opsonin.it binds to actin and
DNA thus promoting cellular and tissue debrise removal by
macrophages.
 Commercially available in Europe as ‘’TISSUCOL’’.

26. ACTIONS
 Enhances the effect of demineralization
with regard to new attachment
 Enhances cell proliferation from PDL
and SUPRACRESTAL area
 Optimum Concentration -0.38 mg/ml
saline.
Terranova and martin(1982)-
Demonstrated that after application of
exogenous Fibronectin, the fibroblasts
Attachment to the root surface was improved
Significantly.

27. EDTA (Ethylenediamine Tetracetic Acid)
 Exerts demineralization effects through chelating divalent cations at
neutral PH.
 Studies shown that 18% EDTA on the root surface improves
fibroblast attachment and migration on the root surface and also
facilitates the development of an oriented fiber attachment system
between the Demineralized surfaces.
 Various concentrations of EDTA has been used in studies ranging
from 12%-24%, neutral pH for 30 s to 3 min aiming at removing
smear layer and widening dentin tubules without damaging
biological structures. However, initial fibrin clot adhesion is limited
with its use.

28. Laminin
 It is a glycoprotein of high molecular weight.
 It is capable of adhering to various substrates .
 Fibronectin and laminin have been implicated in the directed
movement of different cell types.
 Studies have demonstrated that Laminin promotes gingival
epithelial Chemotaxis and in addition, movement of gingival
fibroblasts from confluent cultures to dentin has been observed.

29.  Terranova et al. have demonstrated that laminin promotes
epithelial cell adhesion and growth to tetracycline and glycoprotein
conditioned surfaces.

30. Polyacrylic Acid
 Wiland et al. in a comparative study on the healing of the
periodontium using Polyacrylic acid for 20 seconds and citric acid
for 3 minutes to condition root surface during periodontal therapy,
 observed that Polyacrylic acid treated teeth have shown more apical
migration.
 They also observed a greater connective tissue adhesion to root
surfaces compared to citric acid treated root surfaces.

31. Enamel matrix proteins
 The enamel matrix proteins are involved in early tooth development
and play a vital role during formation of cementum, PDL, and
alveolar bone.
 Application of enamel matrix proteins on root surface creates a
biological environment similar to that during tooth development,
favoring periodontal regeneration.

32. Emdogain
 It is commercially available formulation of EMDs.
 The main biologically active component of Emdogain are freeze
dried enamel proteins, amelogenine.
 Polygycolic acid (PGA) acts as a vehicle to carry these biologically
active proteins.
 The enamel matrix proteins are obtained and purified from tooth
buds of porcine origin.
 The two components of the material i.e. enamel matrix protein and
PGA vehicle are mixed immediately prior to application to make a
syringeable gel.

33.  The solubility of amelogenins is dependent on PH and temperature.
 At physiological PH, they insoluble but they become soluble at low
or high PH.
 Similarly, their solubility increases with a decreased temperature.
 The PH of PGA below 4.5 which makes it suitable carrier for
enamel matrix proteins.
 Before use, the vials are refrigerated so that amelogenins are easily
mixed with its vehicle.

34.  The technique using enamel protein derivatives, as described by
Mellonig is as follows :
1. Raise a flap for reconstructive purposes .
2. Remove all granulation tissue and tissue tags, exposing the
underlying bone, and remove all root deposits by hand, ultrasonic
scaling, or both.
3. Completely control bleeding within the defect.
4. Demineralize the root surface with citric acid (pH of 1.0), or
preferably with 24% ethylenediamine tetraacetic acid (EDTA Biora)
(pH of 6.7) for 15 seconds. This removes the smear layer and
facilitates adherence of the Emdogain.

35. 5. Rinse the wound with saline, and apply the gel to cover the exposed
root surface completely. Avoid contamination with blood or saliva.
6. Close the wound with sutures. Perfect abutment of the flaps is
necessary; if this cannot be obtained, correct the scalloping of the
gingival margin or perform a slight osteoplasty.
 Although placement of the dressing is optional, it may protect the
wound.
 Systemic antibiotic coverage for 10 to 21 days is recommended
(doxycycline, 100 mg daily).

36. A, Deep vertical bone loss distal to lower left central incisor.
B, Area flapped, root prepared, and defect filled with enamel
matrix protein (Emdogain).
C, Postoperative photo 6 months later.
D, Reentry surgery showing extensive bone fill.

37. Platelet rich plasma
 Platelets are important components of blood coagulation cascade.
 Major components of platelet structures are secretary granules,
which contains – Growth factors, coagulation proteins, adhesion
molecules, cytokines, integrins and inflammatory molecules, which
are synthesized by megakaryocytes and packaged into the granules.
*Platelet derived growth factor (PDGF) is major mitogen for
fibroblast ,smooth muscle cells and other cells.
* It has been shown that PDGF-AB is a potent stimulator of DNA
synthesis in fibroblast.

38. Recombinant human growth
factors
 The various growth factors which are believed to contribute to
periodontal regeneration includes-
 Platelet-derived growth factor(PDGF),
 insulin like growth factor(IGF),
 transforming growth factor(TGF),
 epidermal growth factor(EGF),
 fibroblast growth factor(FGF)and
 bone morphogenic proteins(BMP). These factors promotes
proliferation of fibroblast from PDL and favour bone formation.

39. lasers
 Recently, lasers have been recommended as an alternative or
adjunctive therapy in the control and treatment of periodontally
diseased root surface.
 Lasers are capable of sterilizing the diseased root surface and thus
ultimately promoting cell reattachment.
 Hess and Myers said that the removal of root surface contaminants
with these techniques allows for the, elimination of inflammation
and possible attachment to adjacent hard tissue.

40. ND: YAG laser
 It was developed by Geusic in 1964 and it has been proposed as an
instrument with great potential for effective root preparation.
 Use of Nd:YG lasers as an adjunct to hand instruments and
ultrasonics may have a role in both surgical and non-surgical
periodontal therapy.
 However, there are certain limitations with use of ND: YAG for the
treatment of dental hard tissues.
 They cause thermal side effects such as cracking or charring at the
target site and also pulpal damage unlike Er: YAG laser.

41. Application of the Nd: YAG laser to root surfaces results in
 Alterations in root surface protein to mineral ratio,
 Affects the ability of fibroblasts to attach
 Alters the nature of the smear layer following conventional scaling
and root planing.

42. conclusion
 It is well established that the periodontally diseased root surface
does not favour regeneration of the periodontium due to its surface
characteristics.
 Demineralization has been shown to alter the diseased root surface,
creating a more acceptable surface that can influence events in
wound healing.
 Root surface modification is usually combined with other
procedures such as guided tissue regeneration and bone grafting to
achieve best results.

43. References :
1. Carranza 10th edi.
2. Shewale Akhilesh, Gattani Deepti. A novel root biomodifier
containing chlorhexidine and EDTA – An ESEM analysis. Int J
Curr Res. 2015;7(8):19143-19146.
3. Terranova VP, Franzetti LC, Hic S, DiFlorio RM, Lyall RM,
Wikesjö UM et al. A biochemical approach to periodontal
regeneration: tetracycline treatment of dentin promotes
fibroblast adhesion and growth. J Periodontal Res 1986;
21:330-337.

44. Root biomodification
 The process of making the exposed root surface
biologically compatible with healthy periodontium during
periodontal surgery is so called as root surface conditioning
/biomodication.


45. Smear layer

46. In periodontics:
 The mechanical instrumentation of the root surface that is performed
during periodontal treatment is of paramount relevance as it is
intended to remove bacterial deposits and dental calculus.
 However, the root instrumentation creates an amorphous layer of
inorganic and organic debris called the smear layer, which may
interfere with periodontal healing. (Polson 1984)
 This layer of organic and mineralized debris has been suggested to
have a negative effect on the periodontal tissue cells, thereby
inhibiting new attachment. (Boyko et al. 1980, Polson et al. 1984).

47. composition
 Microscopic analyses have shown that the smear layer
contains residual calculus, cementum, bacteria, and
bacterial-derived products.
 For this reason, the smear layer can act as a physical
barrier between periodontal tissues/blood clots and the
root surface, and it inhibits or hinders the formation of
new insertions and possibly harbors bacterial growth.

48. Role of smear layer in periodontics:
Periodontists produce a Smear Layer on root dentin during deep
scaling or root planning.
•Register1973 found, empirically, that etching radicular dentin
with saturated citric acid facilitated reattachment following
periodontal flap surgery.
• Register (1973), register and Burdick (1975, 1976), Ririe,
Crigger and Selvig (1980) and Nalbandian and Cote (1982) have
shown that etching with citric acid stimulates cementogenesis
and the subsequent intertwining of collagenous fibres of the
matrix of dentin or cementum.

49. •They also demonstrated that cementum did not form as readily on
dentin covered with a Smear Layer.
•Apparently, cementoblasts do not find the Smear Layer a very
hospitable environment.
•Further, epithelial cells migrate rapidly across planed (Smeared)
radicular dentin etched with acid
•Careful examination of published Transmission electron
micrographs taken of mineralized sections of roots that were planed
but not etched with acid reveals the presence of a finely granular
organic layer interposed between root dentin and developing
cementum.

50. • Its presence clearly modified local reactions of tissue in
that it apparently inhibited attachment of firm new
connective tissue while permitting migration of the
epithelium over its surface.
• Etching effectively removes the Smear Layer in addition
to exposing collagen fibers in the matrix of radicualr
dentin.

51.  Even after removal of the mineral phase of the Smear Layer,
which may interfere with subsequent inter digitation of
collagen fibers of periodontal ligament and dentin matrix.
 The organic Smear Layer was easily rubbed off with a cotton
pellet.
 standardize technique of etching, specifying concentration of
acid, time of exposure, time or rinsing, dabbing or rubbing is
important in removing smear layer.

52. ROOT SURFACE CHANGES – CEMENTAL
CHANGES
A. Structural Changes:
 Formation of pathologic granules due to lysis of collagen.
 Demineralization due to proteolysis of Sharpey’s fibres &
softening & cavitation of cementum
 Remineralization in areas exposed to saliva.
 The following minerals are increased in diseased root surfaces:
Calcium, Magnesium, Phosphorus and Fluoride.

53. B. Chemical Changes
 Cementum has the property of absorbing minerals or
cytotoxins it comes in contact with, when exposed to
saliva.
C. Cytotoxic Changes
 Cementum absorbs the endotoxins produced by
periodontal pocket pathogens forming altered cementum.
This altered cementum when placed in cell culture
inhibits cell proliferation.

54. Methods of root biomodification
 MECHANICAL BIOMODIFICATION:
 in its simplest form involves scaling and root planning.
 This may include removal of cementum, removal of softened
dentin, or the smoothing of surface irregularities.
 In more involved cases, mechanical biomodification may
involve the use of rotary instruments to remove deep grooves
caused by abrasion or the removal of restorations.
 CHEMICAL BIOMODIFICATION:

55. Fibronectin –fibrin sealing system
 A fibrin – fibronectin sealing system (FFSS) has been commercially
available (Tissucol – Tisseel) in Europe since 1975.
 It is a human plasma cryoprecipitate, which consists of highly
concentrated fibrinogen, fibronectin, factor XIII, platelet – derived
growth factor (PDGF), antiplasmins and plasminogen.
 Aprotinin (bovine antiplasmin), thrombin and calcium chloride are
added at the moment of use.

56.  Fibronectin is found in plasma on the cell surface, in the
extracellular matrix and in the basement membrane of epithelium.
 Fibronectin promotes cell to cell adhesion and cell mobility.
 Thus, fibronectin promotes migration, adhesion, attachment and
synthetic activity of fibroblasts.
 Factor XIII is a transglutaminase, an enzyme that mediates the links
between the clot and the collagen and glycosamino-glycans of the
connective tissue.
 Plasminogen is a glycoprotein (90 kda) that is transformed into
plasmin under effect of active thrombin.

57.  The protease activity of plasmin causes the lysis of fibrin. The
plasminogen – fibrinogen ratio in Tissucol is reduced upto 30 times
less than in human plasma.
 This reduced proportion is more favorable to clot stability
 Anti-plasmin are macro-globulin that modulates the rate of
coagulum lysis inhibiting plasmin activity.
 Thrombin is a serinoprotease (40 kda) that activates fibrinogen and
factor XIII in the presence of Ca+2, which is provided by calcium
chloride(CaCl2) in Tissucol.

58.  Thrombin stimulates the growth of fibroblasts and synthesis of
fibronectin and collagen.
 Aprotinin is a polypeptide extracted from bovine lungs and it
inhibits plasmin activity.
 PDGF is a major human serum polypeptide growth factor.
 It is stored in granules of circulating platelets and is released
into serum during blood clotting.
 It is a potent mitogen and chemoattractant for fibroblasts.

59. Laser as root conditioning agent
 Er:YAG laser has great effect on tubular occlusion and less
thermal changes thus, it may acts as a useful conditioning tool.
 Laser application on root surfaces as significant role on fibroblast
attachment.
 In an vitro study, the effect of Nd:YAG laser was evaluated on
fibroblast attachment to non diseased root surface. (energy 75 mJ
at 20 pulse/sec using 320μm contact fiber for1min.)
 The study concluded that laser exposure denatures surface
proteins which inhibits fibroblasts attachment.( Tomas D et
al1994).

60. Amelogenin
 Amelogenin is the name for a series of closely related proteins involved
in amelogenesis the development of enamel.
 They are a type of extracellular matrix (ECM) protein, which together
with ameloblastins ,enamelins, and tuftelins direct the mineralization of
enamel to form a highly organized matrix of rods, interrod crystal, and protein.
 Although the precise role of amelogenin in regulating the mineralization
process is unknown, it is known that amelogenins are abundant during
amelogenesis.
 Developing human enamel contains about 70% protein, 90% of which are
amelogenins.


61.  these proteins regulate the initiation and growth
of hydroxyapatite crystals during the mineralization of enamel.
 In addition, amelogenins appear to aid in the development
of cementum by directing cementoblasts to the tooth's root
surface

62. Thank you !