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Emdogain's Place in Periodontal
During the last three decades
periodontics has concentrated on developing predictable methods to regenerate lost
periodontal support. For years, it was heatedly debated what constitutes
"regeneration." Currently, regeneration is defined as the creation of new bone,
new acellular cementum and a periodontal ligament around a previously
bacteria-contaminated root surface. The definition is an important one because it
clarifies the difference between a less than ideal "repair" type of healing and
Initially, the focus centered on placing
various implanted particulates into alveolar bone defects following debridement in an
effort to regenerate the periodontium. The results from "grafting" as it is
often called, ranged disappointments to success. Successful sites showed bone fill
radiographically, and reduced probing depths clinically. However, most studies to date
demonstrated periodontal repair, rather than regeneration occurred when grafting was used
alone. Most experts agree that usually a thin layer of epithelium separates the newly
formed bone from the root. This type of healing is suspected to be more prone to recurrent
pocketing. There have been isolated reports demonstrating partial regeneration. These
results were good, but they were clearly not as predictable or maintainable as they could
be. The grafted materials included many different substances, but focused mostly on
autogenous bone, human allograft bone, and synthetics like hydroxyapatite and resorbable,
The next main breakthrough in
regenerative technology came in the mid 1980's and was called "guided tissue
regeneration." The concept of utilizing "barrier membranes" to control the
cellular repopulation of periodontal defects following debridement expanded treatment
options for periodontal defects. Studies have demonstrated that this type of treatment can
result in regeneration when viewed histologically, however cellular cementum is usually
produced. The same technology was later applied to implant placement or repairs of
alveolar ridge deficiencies. The non resorbable Goretex periodontal membrane was the first
commercially available here in the United States. Guidor, Biomend and Atrisorb soon
followed Goretex. Now there are many others to choose from. Many specialists are combining
membrane placement with grafting in an attempt to boost the degree of regeneration.
With Emdogain, next generation in
periodontal regeneration is here. It represents a breakthrough in the utilization of
chemical mediators, which turn on the cellular mechanisms responsible for producing
tissue. Emdogain is derived from porcine tooth buds. Comprised of enamel matrix proteins
Emdogain contains approximately ninety percent amelogenin and ten percent of other related
proteins, which are important to the regeneration process. Some of the properties of
¨Emdogain has no known
application, the enamel matrix proteins precipitate onto the root surface.
precipitate stimulates chemotaxis of periodontal ligament and marrow cells to the healing
provides an anchorage for cells to cling to and begin the regenerative process.
differentiate into cementoblasts and form acellular cementum.
¨After the cementum is
formed, the new periodontal ligament and alveolar bone are formed.
the production of tissue growth factor-1B and osteocalcin. These two compounds aid the
production of the new periodontal ligament and alveolar bone.
¨Initial healing rates
are increased and usually less post operative pain and swelling are experienced by the
An Emdogain kit comes with two vials, one syringe and two
needles. One vial contains a propylene glycol vehicle while the other contains a wafer
comprised of enamel matrix proteins. Approximately 15 minutes prior to use, the vehicle is
syringed into the vial containing the wafer. The wafer is allowed to dissolve. After the
clinician has thoroughly prepared the root and defect in the regeneration site, the
Emdogain is generously syringed onto the root and into the defect. The gingival flaps are
sutured over the regeneration site and the patient is followed with postoperative care
identical to that of other regeneration procedures.
To compare the results from an Emdogain clinical study with
other treatment modalities, the following table has been prepared.
debridement,DFBA=decalcified freeze dried allograft bone, EMDG= Emdogain,
HA= hydroxyapatite, HTR= "HTR"
copolymer, PHA= porous hydroxyapatite, PTFE= polytetrafluoroethylene
Probing depths= mm reductions in pockets,
Attachment Level Change= mm gains in attachment levels
It is important to understand that there are
limitations in our ability to make direct comparisons due to variations in study designs
and techniques for regeneration. What should be very clear from this table is that
debridement alone consistently performs worse than all other regenerative modalities. In
other words it is by far, more advantageous to attempt some form of regeneration than to
simply debride a defect.
The next conclusion that we can make is that all
regenerative techniques can be expected to provide between approximately 60 to 70% bone
fill in most defects, excluding furcation sites. The regenerative gains are related to
defect morphology, thoroughness of the debridement, adequacy of flap closure and patient
factors like overall health and oral hygiene status. Defect responses for different
morphologic patterns can be classed from best to worst as follows: deep three wall
defects, shallow three wall defects, two wall defects, 1 wall defects, and furcation
Finally, Emdogain performs as well as guided
tissue regeneration in early studies. The fact that the probing depth reduction and gains
in clinical attachment appear nearly equivalent to guided tissue regeneration is very
significant in that this is the first commercially available product using the new
technology of biologic mediation. As more work is done in this field, we can expect the
development of new mediators to work alone or in conjunction with Emdogain to provide even
better results. Furthermore, the anecdotal reports of combinational approaches using
Emdogain with guided tissue regeneration or with decalcified freeze dried allograft bone
and the results we see in our practice seem very promising, though controlled studies have
yet to be reported. Perhaps the most significant finding from several authors using
Emdogain has been the reports of the consistent histologic finding of true regeneration.
This is, after all, what Periodontology has been seeking for decades.
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