ROOT

BIOMODIFICATION

By: Dr. Jinal Desai

MDS II
Dept of periodontics & implantology
 INTRODUCTION:
Periodontal regeneration A relentless goal of the periodontist

Challenge of regeneration is to reconstitute the lost periodonal tissue complex onto

the root surface.

Chemical modification of the root surface the oldest & most frequently

attempted

type of regeneration.
WHAT IS ROOT
BIOMODIFICATION??

Definition :

The process of making the exposed root surface biologically

compatible with healthy periodontium during periodontal surgery is

so-called as root surface conditioning/bio-modification.

 RATIONALE:
Major Requirement for regeneration of connective tissue attachment to a

denuded, periodontitis affected root is migration and attachment of connective

tissue cells to the root surface (Boyko, 1980).

Hence, root bio-modification procedure have been introduced by using a variety

of agents in order to detoxify, decontaminate, demineralize the root surface

there by removing the smear layer and exposing the collagenous matrix of

dentin and cementum. (Hanes et al,1985)

BIOLOGICAL CONCEPT:
Acid treatment

demineralization of the root planed dentin, hereby exposing collagen

fibrils of the dentin

matrix.

facilitate adhesion of the blood clot to the root surface

favour migration of fibroblasts

that the exposed collagen fibrils of the dentin matrix may inter-digitate
GOAL:

Determine the alterations in the diseased root surface that

would create an appropriate & hospitable surface for cell

attachment and eventual development of a fibre

attachment.
HISTORICAL BACKGROUND:
1833 Marshall presented a case of pocket eradication with presumable clinical

reattachment after the use of aromatic sulfuric acid.

1890s Younger and Stewart acids in conjunction with the mechanical removal of

calculus and cementum.

1965 Urist dentin following acid demineralization possessed inductive properties.

1973 - Urist demonstrated allogenic dentin matrix , following partial or total

demineralization with O.6N Hcl and transplanted in various animal models
the ability to induce the formation of new bone or cementum on the
implant surface.

1973 Register et al performed the first controlled study on the use of

acid on root surfaces. They investigated whether new attachment,
cementogenesis and osteogenesis could be induced adjacent to tooth
roots demineralized in vivo.

Register & Budick in 1975 evaluated various acids for their potential to
promote new connective tissue attachment. The acids tested were
hydrochloric, lactic, citric, phosphoric, trichloroacetic and formic. Optimal
METHODS OF
RBM
 Methods of root surface bio-
modification

Chemical
Mechanical Citric acid
Physica
By Scaling Tetracycline
hydrochloride l
and By
Root Fibronectin
Laminin Lasers
Planing
EDTA
Sodium hypochlorite
Sodium
deoxycholate
Stannous fluoride
MECHANICAL METHODS
SCALING & ROOT PLANING:
Includes

- removal of cementum,

- removal of softened dentin, or

- smoothing of surface irregularities.

Root planing removes nearly all detectable bacterial endotoxin from

periodontally involved root surfaces. (Jones & O Learey 1978).

Although, the effectiveness of scaling and root planing has been well

documented, the efficacy of mechanical removal making the root

surfaces disease free has been still questioned.

CHEMICAL
METHODS
CITRIC ACID:
First suggested by Register in 1973 for smear layer removal.

Applied at pH - 1.0 for 1 min

CA acts on dentinal hydroxyapatite in three ways: (Nyman et al,

1980)

-First, it releases H+ ions which demineralizes the crystalline structure

-It contains two or more groups in its molecules which can combine with calcium and act as
chelating agent.
 HISTOLOGICAL - ANIMAL
STUDIES:

PROCEDURE RESULTS
STUDY
Ririe et al Through & through furcations High rates of bone regeneration
(1980) were studied in dogs. & flap reattachment with topical
Nilveus et al application of CA.
+VE
Nyman et al On monkey models Both case & control showed
(1981) experimental periodontitis was healing by LGE suggestive of no
treated by flap and citric acid effect on formation of new
pH 1 for 3 minutes. cementum and CT.
-VE Dyer et al. Teeth in 12 quadrants were Root conditioning by either
(1993) treated, 4 by citric acid, 4 by agent did not enhance the
tetracycline, and 4 by amount of CT and bone; gained
membrane alone in beagle by membrane alone.
dogs.
 HISTOLOGICAL - HUMAN STUDIES:

Cole et al. Teeth treated by flap procedures & Regeneration of soft tissue abt
(1980) topical CA application for 5 1.2 - 2.6 mm coronal from the
minutes. reference notch in 4 of the 10
specimens.
+VE
Albair et al The roots of 9 teeth were treated 6 /9 CA treated teeth
(1982) with CA and remaining 9 were demonstrated evidence of CT
served as untreated controls . attachment on SEM & light
microscope.
Stahl and Root surfaces were treated with No evidence was observed of
Froum citric acid & effects on pocket accelerated cementogenesis or
-VE
(1977) closure was evaluated both functional CT attachment AFT
clinically and histologically 14 weeks.
Cogen et Comparison of root planing alone, CA treatment offered no
al. (1984) CA alone & a combination of both additional fibroblastic
on fibroblast attachment to attachment compared to root
diseased roots. planing alone.
 CLINICAL STUDIES:

Cole et al 12 patients with advanced A probing attachment

(1981) periodontitis were treated with level gain of 2.1 mm for
citric acid pH 1 for 3 -5 mins on the acid-treated teeth
+VE
the experimental side. resulted, compared to 1.5
mm for controls.
Mark et al Comparison was made with or No added clinical
(1986) without citric acid t/t for advantage of citric acid

-VE generalized effect on gingival conditioning of the roots

height, PPD & CAL. during treatment of
periodontitis.
POSSIBLE MECHANISMS:

1. Antibacterial effect (Daly, 1982)

2. Root detoxification (Aleo et al 1975)

3. Exposure of root collagen and opening of dentinal tubules (Polson et al

1984)

4. Removal of the smear layer (Polson et al 1984)

5. Initial clot stabilization (Wikesjo, 1991)

6. Demineralization prior to cementogenesis (Register, 1975, 1976)

7. Enhanced fibroblast growth and stability (Boyko et al 1980)

8. Attachment by direct linkage (Stahl and Tarnow, 1985; Stahl, 1986) or

periodontal without cementogenesis (Levine and Stahl, 1972; Masileti, 1975)

9. No adverse effects to either the pulp (Hagner and Polson, 1986) or

periodontal tissues (Polson and Haynes, 1986) have been reported.

Recently, in a series of studies comparing EDTA and CA, Blonlf (1996,

1995,2000) reported greater tissue necrosis and greater dissolution of

the exposed collagen bundles with CA than with EDTA .

TETRACYCLINE
Tetracycline hydrochloride (TTC) has recently been used for acid root
demineralization because it provides the same benefits as CA:

1. Antibacterial (Baker et al 1983)

2. Exposure of root collagen and opening of the dentinal tubules; removal of the smear

layer (Wikesjo , 1986)

3. Demineralization (Bjorvatn, 1983)

4. Detoxification of the root surface (Terranova et al 1986)

5. Permits attachment by direct linkage with or without cementogenesis (Alger et al

 It also has a number of other advantages:

1. Anticollagenase activity (Golub et al 1984)

2. Positive effects when placed in bone grafts (Al-Ali et al 1989;

Papelarsi et al 1991)

3. Substantively antibacterial for 2 to 14 days (Baker, 1983)

4. Enhances bone repair in extraction sockets (Hars and Massler,

1972)

5. Binds more fibronectin (FN) to the demineralized surface

LIMITATIONS:

A dosage dependent effect (> 100 mg) on fibroblastic cell attachment and

spreading about which they will not occur. (Somerman et al 1988),

TTC may therefore require higher concentrations (> 0.5%) &/ longer

application times(>5 mins).

Further, in comparative studies with CA, TTC has been found not to

establish new CT attachment (Haynes et al , 1991).

Finally, unlike for CA, no human histologic or clinical studies show the

positive effects of TTC root demineralization.

The most recent clinical studies have been inconclusive as to the

beneficial effects of TTC. (Alger et al 1990; Machtei et al 1993; Parashis

et al 1993; Darhous et al 1995)

pH 1.6, 100mg/ml for 2 to 3 mins -Terranova et al., 1986

ETHYLENEDIAMINETETRAACETIC
ACID(EDTA)
24% EDTA is a neutral pH (7.0) etching agent recommended for root

detoxification and demineralization of root surfaces and has been

shown to have the following advantages over low pH (1.0) etching

agents similar to CA:

1. Equally effective in smear layer removal (Blomlf et al, 1997)

2. Exposes more intact collagen bundles (Blomlf et al, 1996)

4. Does not dissolve root collagen fibers (Blomlf et al 2000)

5. Greater histologic attachment with less junctional epithelium formation

(Blomlf et al 1996)

The studies indicate that EDTA produces ; a biocompatible root surface

with greater exposure of intact collagen bundles that is more conducive

for cell repopulation and periodontal fibroblast chemotaxis. (Posthethwane

et al1978;Fernyhaugh & Page, 1983)

FIBRONECTIN
Fibronectin (FN) is a high-molecular-weight glycoprotein

that is found in the extracellular tissue and is the main

component that holds the clot together. (Seelich and Redl,

1979; Baum and Wright, 1980).

It promotes cell adhesion to both Collagen and Scaled

root surfaces
Periodontally, the application of FN to partially demineralized roots has

been shown significantly to

(1) enhance the effects of demineralization with regard to new

attachment

(Caffesse et al, 1978) and

(2) enhance cell proliferation from the periodontal ligament

and supracrestal area

(Caffesse et al , 1987).

The optimum concentration for use has been shown to be 0.38/mL saline
 STUDIE
S
Smith et al (1987) Effect of CA & FN on healing after significant increase in new
periodontal flap surgery on in dogs. connective tissue attachment
in all surgical sites where
fibronectin had been added

Caffesse et al 46 pts were evaluated aft t/t with CA & Significant gains in CAL & PD
(1990) FN reduction with FN

Exogenous application of FN only has shown to be limited use ;however

encouraging results have been obtained with CA conditioning & subsequent

FN application.
LAMININ
It is a glycoprotein of high molecular weight & capable of adhering to

various substrates.

Studies have demonstrated that Laminin promotes

1)gingival epithelial chemotaxis and

2)additional movement of gingival fibroblasts from confluent cultures

to dentin.
Terranova & Martin in (1986) have demonstrated that mineralised

surfaces attract laminin which favors epithelial down growth and this is

undesirable.

In contrast , demineralised surfaces attract FN & favour fibroblast

attachment.

Fibronectin and laminin have been implicated in the directed movement

of different cell types & this is k/a RECIPROCAL UTILIZATION of

CHLORHEXIDINE

Bogle et al,1974 studied the effect of post operative use of

chlorhexidine on regeneration of bifurcation defects in dogs.

Chlorhexidine applied to the root surface during surgical

treatment of bifurcation defects in dogs resulted in an

increase in bone height but not in the level of connective

tissue attachment.
GROWTH FACTORS
Growth factors are polypeptide molecules released by cells in the

inflamed area that regulate events in wound healing.

These growth factors help promoting proliferation of fibroblasts from the

periodontal ligament and favoring bone formation.

Combination of PDGF and IGF-1 would be effective in promoting growth

of all the components of the periodontium.

ENEMAL MATRIX PROTEIN

In recent years bio-modification of root surface with Enamel Matrix Protein

during surgery, following demineralization with EDTA has been introduced.

Biologic Concept :

application of EMP (amelogenins) may promote periodontal

regeneration as it mimics events that take place during the development of

periodontal tissues.
Heijl et al (1997) have compared the use of EMP with a

placebo in 33 patients with 34 paired test and control sites,

mostly one and two wall defects, followed for 3 years. They

found a statistically significant radiographic bone gain of 2.6

mm.

In a set of studies surgically root biomodification treated

intrabony defects with EMP were compared with open-flap

debridement alone; showed the average defect fill was greater

RBM BY
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.

The removal of root surface contaminants with these techniques allows

for the, elimination of inflammation and possible attachment to adjacent

Nd:YAG LASER
Nd: yag laser was developed by Geusic in 1964

Various in vitro studies have shown its efficacy in removing smear layer &

inactivating the endotoxin in the superficial layer of the root surfaces .(Wilder-

Smith et al 1995)

However ,there is significant rise in the intrapulpal & root surface temperature

and root surface alterations which is unfavorable for fibroblast attachment .

(Trylovich et al 1992)
In vivo study by Liu et al(1990), showed no additional benefit when

laser t/t was used secondary to traditional therapy.

Based on the results of previous in vitro & in vivo studies, the Nd:yag

laser can not

achieve root surface debridement to a satisfactory degree due to

- Insufficient ability to remove calculus &

- Distinct root surface alteration induced by heat generation

CARBON DIOXIDE LASER
Patel et al in 1964 were the first to develop CO2 laser.

Based on the various characteristics of lasers such as ablation, vaporization

and sterilization, researchers have suggested their use for scaling, root

planing and root conditioning.

However, they have the same limitations of thermal side effects such as

cracking or charring at target site and pulpal damage like the Nd:YAG laser.
Misra et al., showed that CO2 laser produced surface charring and

carbonization, and were totally ineffective in exposing the dentinal tubules.

However, a SEM study showed increased fibroblast attachment after root

conditioning in pulsed defocus mode. (Crepsi et al,2002)

In contrast to this a histological study showed in vivo inhibition of

periodontal tissue attachment by residual char layer. (Gopin et al, 1997)

Thus the CO laser, when used with

-high-energy output, especially in a continuous wave mode, is not

appropriate for root surface debridement due to major thermal side-

effects, such as carbonization.

- At relatively low energy output in a pulsed and/or defocused mode,

this laser may have root conditioning, detoxification and bactericidal

effects on contaminated root surfaces.

 Er:YAG LASER
Hibst et al in 1988 gave a first description of effects of Er: YAG laser on dental
hard tissues.

A set of studies showed the

-bactericidal potential,

-removal of lipopolysaccharide,

-reduction of endotoxin and bacteria on root surfaces .

(Yamaguchi et al 1997 ,Ando et al 1996, Folwaczny 2003)

However another study reported slight temperature rise of 1.4 C in the

pulpal wall during laser scaling under water coolant and better

conditions for the adherence of fibroblasts.

Research conducted on lasers so far has indicated the safety and

effectiveness of clinical application of the Er:YAG laser for root surface

debridement than CO2 and Nd:YAG laser.

CONTROVERSIES:
Root demineralization is recommended for use

-in cosmetic gingival reconstruction prior to placement of bone

implants (CA and

TTC), (Miller 1983, 1985; Allen and Miller, 1989)

-in infrabony defects,

-as an implant additive (TTC) (Schallhorn and McClain, 1988 & 1993),

-as a primary treatment for Class II furcations (CA) with or without

bone implants.
 According to the systemic review on Efficacy of Chemical Root
Surface Modifiers in the Treatment of Periodontitis in Annals of
Periodontology by Mariotti 2003;
Main Results
1. Thirty-four studies incorporating a total patient population of 575 were analyzed: 26
for CA ,
5 for TTC, and 3 for EDTA treatment.
2. Four of 8 human histological studies reported regeneration with the use of CA. Only 1
of 18 clinical studies reported attachment gain.
3. Of the 5 studies examined using TTC, 1 histological study and 1 clinical study
reported attachment gain.
4. No regeneration was reported in the 3 studies evaluating the use of EDTA.
5. Meta-analysis performed on 28 clinical trials did not show any significant effects of
acid root treatment on attachment level gains or probing depth.
According to the systemic review on Efficacy of Root Surface
Biomodification in Root Coverage ; none of the RSB protocols
produced any advantage to justify their use in root coverage
procedures.
( Oliveira & Muncinelli , 2012)
It is important to note that in the Annals Garrett 1996; Mariotti 2003;

AAP 2005

both the subject reviewer and the consensus report were in agreement

that :
The current use and application of citric
acid, tetracycline or EDTA to modify the root surface provides no clinical
benefit to the patient with respect to reduction of probing depths or gain
in clinical attachment.

Chemical root-surface biomodification has not been demonstrated to

CONCLUSIO
N
RBM has not been shown to have any negative effects but

does not have the potential to enhance and/or facilitate

regeneration solely and should be considered as part of any

clinical procedure requiring root detoxification.

In the future, periodontal regeneration will combine root

detoxification with a combination of synthetic biologic protein

modifiers that will artificially stimulate tissue regeneration.