INTRODUCTION:

Regenerative therapy in dentistry has been gaining importance in recent years within the field of dentistry. Regenerative dentistry is a very effective method for accelerating the regeneration of damaged oral tissue through biological elements¹. Regenerative dentistry is recognized as a field of dentistry that focuses on restoring damaged or lost teeth and tissues in the oral cavity using regenerative methods. This involves using biological or stem cell-based approaches to stimulate the affected tissues to repair themselves or to grow new tissues, such as bone, cartilage, or enamel². The aim of regenerative therapy in dentistry is to restore full function and structure to the teeth and surrounding tissues, rather than merely repairing those³.

Regenerative endodontics is known as an emerging field in regenerative therapy in dentistry. Regenerative endodontics is defined as a restorative method to regenerate dentin, root structures and pulp–dentin complex. The ultimate goal of regenerative endodontics is to restore normal pulp function and preserve the natural tooth structure of immature or mature teeth that have suffered trauma, decay, infection or other types of damage⁴. Reconstructive endodontics is based on the use of biological components for tooth reconstruction due to the restoration approach of living tissues found in dentin and root structure including connective tissue, blood vessels and nerves⁵. Recent developments in regenerative therapy have shown that stem cells, growth factors, and biological or natural and artificial scaffolds are the most widely used biological components in regenerative endodontics⁶. There are several pieces of evidence about the beneficial role of platelet rich plasma (PRP) and platelet rich fibrin (PRF) as the most important biological scaffolds in regenerative endodontics⁷. PRP is a concentrated platelet solution with a high concentration of platelets which is involved in clotting, wound healing, and tissue repair. PRP also contains a variety of growth factors that promote tissue regeneration and healing. PRP is often used in medical treatments for conditions such as osteoarthritis, tendonitis, and muscle injuries, among others⁸. Quite recently, considerable attention has been paid to the use of PRP in regenerative endodontics. In fact, PRP, in addition to stimulating the wound healing process, provides a suitable platform for the placement of minerals in the tooth and permanent restoration⁹. Hence, we undertook this systematic review study to evaluate the effect of PRP in regenerative endodontic treatment.

METHODS:

The present systematic review was carried out according to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statements.

Search Strategy:

A systematic search was made on electronic databases, including Scopus, PubMed/Medline, Web of Science, and Google Scholar via keywords selected from Medical Subject Headings (MeSH). Selection of keywords was performed based on the PICO style (Participants, Intervention, Comparison, and Outcome). The following keywords: “Platelet Rich Plasma”, “Plasma, Platelet-Rich”, “Regenerative Endodontic”, “Endodontic, Regenerative”, and “Endodontics, Regenerative” were used for searching from databases. The search was done based on English language. The process of search was carried out by two researchers, independently. In the current systematic review, the documents including dissertations, expert opinion and conference presentations was ignored due to imprecise results.

Eligibility Criteria:

All relevant studies published until April 2023 were eligible in the current study. The present systematic review included all articles that evaluated the role of PRP in regenerative endodontic treatment. Articles with insufficient information including case reports, observational studies, reviews, and letters to the editor, conferences, and qualitative studies were not included in this study.

Data Extraction:

The literature was screened for extraction of required data by two authors independently. The following data were extracted: study design, sample size, number of male patients, range of patient’s age, groups, and first author’s last name, country of origin and year of publication.

Quality Assessment:

To assess the methodological quality of randomized controlled trials (RCTs), the Jadad scale was used. According to this scale, the score of each study range from 0 to 5. The Jadad scale evaluate various items including randomization (Maximum points=2), blinding (Maximum points=2) and an account of all patients (Maximum points=1). The RCTs with maximum scores less than or equal to 2 was considered as low quality. On the other hand, the RCTs with minimum scores greater than or equal to 3 was considered as high quality ¹⁰.

Figure 1: Flowchart of study selection based on PRISMA statements.

RESULTS:

Study Characteristics:

The process of study selection has been indicated in detail in Figure-1. After searching through mentioned databases, 186 studies were initially identified. There were 71 studies remaining after the removal of duplicates. Of these, 48 studies that did not meet the inclusion criteria of the study were excluded. Then, 23 studies were chosen based on the research topic. Finally, 5 articles were included in the current systematic review after critical analysis. There were 5 RCTs included in final analyses. The sample size in RCTs varied between 13 and 67. The range of subject’s age was from 8 to 14, representing that all patients were child. All included publications were done after 2000. The included studies were performed in Egypt with three studies, Turkey with one study and Qatar with one study. Table-1 summarizes the characteristics of the studies included in the current systematic review.

Quality Assessment:

Based on the Jadad scale for reporting the quality of RCTs, four studies had high quality (Maximum points ≤2) and only one study had low quality (Maximum points ≥3) (Table-2).

Table 1: Summary of available literature on the effect of PRP in regenerative endodontic treatment.

Authors and publication year (Ref)	Country	Study Design	Size Included	Groups (Size)	Treatment	Follow up	Key Findings
Ulusoy AT et al. 2019 ¹¹	Turkey	Prospective randomized clinical trial	Sixty-seven healthy children (aged 8–11 years) with 88 immature necrotic incisors (33 girls and 44 boys)	a total of 88 teeth 18 teeth in PRP group	PRP	Every 3 months for the first year and, thereafter, every 6 months	Treatment with PRP increases periapical healing and root development.
Rizk H.M. et al. 2019 ¹²	Egypt	Split Mouth Double-blinded Randomized Controlled Trial	13 patients aged 8–14 years with bilateral maxillary immature permanent central incisors with necrotic pulp	the control (BC scaffold) group I or examined (PRP scaffold) group II	PRP was soaked on a 2 × 2 mL of sterile collagen sponge	3, 6, 9, and 12 months	PRP-treated teeth showed a statistically significant increase in radiographic root length, width, periapical bone density, and a decrease in apical diameter when compared with BC.
Rizk H.M. et al. 2020 ¹³	Egypt	Double blinded randomized controlled trial	26 patients with maxillary necrotic permanent immature central incisors	Group I was treated with PRP and Group II with PRF scaffolds	PRP was soaked on 2 × 2 ml of sterile collagen sponge	Every 3 months for one year	PRP showed marginal increase in radiographic root length and width, periapical bone density and a decrease in apical diameter.
ElSheshtawy et al. 2020 ¹⁴	Qatar	Randomized controlled trial	Twenty-six healthy patients with mean age of 12.66 ± 4.47, and immature permanent anterior teeth with necrotic pulps	platelet-rich plasma (PRP, test group) and blood clot (BLC, control group)	PRP	12 months	A successful and comparable clinical and radio-graphic outcomes of regenerative/revitalization endodontic technique using PRP and BLC as scaffolds in immature traumatized permanent teeth with necrotic pulps over a period of 12 months.
AHMED et al. 2022 ¹⁵	Egypt	Randomized clinical trial	Twenty-eight patients	Group1: Revascularization Group Group 2: Endodontic group	PRP	6, 12 h and daily for 5 days	PRP revascularization could be an alternative treatment to root canal treatment through decreasing postoperative pain and increasing healing

Table-2: Jadad scale for reporting randomized, controlled trials included in the systematic review.

Studies	Jadad Scale Item			Total	Quality
Studies	Randomization	Blinding	An account of all patients	Total	Quality
Ulusoy AT et al. 2019	2	1	1	4	High
Rizk H.M. et al. 2019	2	2	1	5	High
Rizk H.M. et al. 2020	1	0	1	2	Low
ElSheshtawy et al. 2020	2	2	1	5	High
Ahmed et al. 2022	2	1	1	4	High

DISCUSSION:

Several studies have evaluated the effect of PRP in regenerative endodontic treatment^16,17. In the present systematic review, we attempted to study the efficacy of PRP in regenerative endodontic treatment. The findings of this systematic review revealed that the use of PRP is effective in regenerative endodontic treatment. PRP is a defined as a concentrate of platelets in a small volume of plasma. It is well known that PRP protein content includes cytokines and various types of growth factors such as platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), insulin-like growth factors (IGFs), and other pro-angiogenic factors. These factors believed to be the most important reasons for justifying regenerative properties of PRP in body tissues ¹⁸. The use of PRP is a useful alternative to autogenous, allogeneic, and exogenous materials in implant and bone reconstruction surgeries, and with success in jawbone, face, and spine graft surgeries, management of thrombocytopenia, cardiovascular surgery, bone metabolic disease and intra-articular treatments for osteoarthritis¹⁹. In general, treatment with PRP is a prelude to achieving an autologous product and result that can be effective in limiting the inflammatory response and increasing healing over a long period²⁰. In the light of recent events in regenerative medicine, there is now considerable reports about the capacity of PRP in collagen production, angiogenesis, and cell differentiation²¹. Furthermore, there are a growing body of evidence about the beneficial biological properties of PRP such as anti-inflammatory and antibacterial properties²². In the literature there are a surprising number of studies about the therapeutic role of PRP in regenerative dentistry^23,24. In fact, PRP causes the accumulation of growth factors in the tooth area and the regeneration and repair of all types of soft and hard tissues in the mouth by creating a network and a suitable bed²⁵. In a Prospective Randomized Trial, Ulusoy et al. examined the therapeutic effect of PRP as scaffold in regenerative endodontic treatment. The results of this study highlighted that treatment of teeth with PRP could increase periapical healing and radiographic root development. The authors also found that PRP treatment led to complete apical closure, increase in root length and width¹¹. Furthermore, H.M. Rizk and colleagues in a double blinded randomized controlled trial assessed the effect of PRP scaffold in regenerative endodontic treatment of immature necrotic permanent maxillary central incisors. They noted that PRP treatment showed marginal increase in radiographic root length and width, periapical bone density and a decrease in apical diameter ²⁵. In another similar study, ElSheshtawy et al. evaluated therapeutic effect of PRP scaffold in regenerative endodontic treatment of immature necrotic permanent maxillary central incisors. The results of this randomized controlled trial exhibited that PRP was valuable as a scaffold in revascularization/revitalization of teeth²⁵. A Researcher evaluated postoperative pain and healing following regenerative endodontics using PRP treatment in necrotic mature mandibular molars with chronic periapical periodontitis in a randomized clinical trial. Their results indicated that administration of PRP significantly decrease postoperative pain and also increase the rate of healing through revascularization²⁶. Other compounds such as medicinal plants can be used to reduce post-operative pain and increase the speed of recovery through revascularization ^26-33. It is plausible that a number of limitations may influenced the results obtained. Our systematic review had some limitations such as the quality of included study, different patient populations, and therapeutic assessment methods as any other similar studies.

CONCLUION:

Our research has highlighted the importance of PRP treatment in in regenerative endodontic. These findings add substantially to our understanding of therapeutic role of PRP in regenerative endodontic. In conclusion, the present systematic review indicated that PRP can be administrate for healing of teeth with endodontic complications. Further RCTs are needed for demonstration of the efficacy of PRP in regenerative endodontic.

CONFLICT OF INTEREST:

There are no conflicts of interest to declare.

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Received on 28.05.2023 Modified on 17.06.2023

Research J. Pharm. and Tech 2023; 16(11):5562-5566.

DOI: 10.52711/0974-360X.2023.00899