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Emdogain's Place in Periodontal Regeneration

    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 true regeneration.

    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, bioactive glass.

    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 include:

Emdogain has no known antigenicity.

After Emdogain application, the enamel matrix proteins precipitate onto the root surface.

The protein precipitate stimulates chemotaxis of periodontal ligament and marrow cells to the healing site.

The precipitate provides an anchorage for cells to cling to and begin the regenerative process.

These cells differentiate into cementoblasts and form acellular cementum.

After the cementum is formed, the new periodontal ligament and alveolar bone are formed.

Emdogain stimulates 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 patient.

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.

Author Year Type Results
      Probing Depth Attachment Level Change Percent

Bone Fill

Yukna 1989 DEBHA 1.42.8 0.51.1 ----------
Kenney 1,988 DEB

PHA

0.6

2.1

0.0

1.8

-----

-----

Bowen 1,989 DFBA

PHA

2.9

2.9

2.1

1.6

61%

53%

Yukna 1,990 DEB

HTR

2.3

3.2

1.0

1.9

32%

61%

Blumenthal 1,990 DEB

DFBA

DFBA+CM

1.5

2.0

2.7

0.7

1.4

2.0

-----

-----

-----

Mellonig 1,984 DEB

DFBA

2.9

3.1

1.5

2.9

38%

65%

Becker 1,988 PTFE 6.4 4.5 ----
Pontoriero 1,988 DEB

PTFE

2.1

3.5

0.6

2.9

-----

-----

Lekovic 1,989 DEB

PTFE

1.1

4.1

0.1

2.9

-----

-----

Heijl 1,997 DEB

EMDG

2.3

3.1

1.7

2.2

0.0%

66%

Mellonig 1,999 EMDG 5 4 -----

Key DEB= 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 defects.

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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