Platelet Concentrates Review

Volume 2 Issue 1 February 2011

Platelet Concentrates: A Promising Innovation In Dentistry

Senior Lecturer, 2Reader, 3Professor and Head of the Department, Department of

Pedodontics and Preventive Dentistry, Sri Siddhartha Dental College and Hospital, Tumkur, Karnataka.

Abstract: A recent Innovation in dentistry is the preparation and use of Platelet Concentrates (PRP, PRF), a concentrated suspension of growth factors found in platelets. These growth factors are involved in wound healing and are postulated as promoters of tissue regeneration. This article describes the methods of preparation, clinical application and safety concerns of PRP and also the evolution of second generation platelet concentrate, referred to as PRF. Key Words: Platelet rich plasma, growth factors, Platelets.
Journal of Dental Sciences & Research 2:1: Pages 50-61

Introduction : One of the last achievements in dentistry is the use of platelet concentrates for the improvement of reparation and regeneration of the soft and hard tissues after different surgical procedures. Post surgically, blood clots initiate the healing and regeneration of hard and soft tissues. Using platelet concentrates, is a way to

accelerate and enhance the bodys natural wound healing

mechanisms. A natural blood clot contains mainly red blood cells, approximately 5% platelets and less than 1% white blood cells1. It is now well known that platelets have many functions beyond that of simple hemostasis. Platelets

contain important growth factors

50 Journal of Dental Sciences and Research

Platelet Concentrates that initiate and support wound healing. Platelet Evolution: In concentrates general, are blood platelet derived Concentrates:

Volume 2 Issue 1 February 2011 plasma, the stability and quality of fibrin glue were low 2. It is now well known that platelets have many functions

beyond that of simple hemostasis. Platelets contain important growth factors that, when secreted, are responsible mitosis, for increasing cell

products used for the prevention and treatment of hemorrhages due to serious thrombopenia of the central origin. The development of platelet concentrates as bioactive surgical additives that are applied locally to promote wound healing stems from the use 1990, of fibrin

increasing

collagen

production, recruiting other cells to the site of injury, initiating vascular in-growth, and inducing cell differentiation3. The study of these growth factors discovery platelets combined of their with extrusion to the by the

adhesives. science

Since

medical several

has

recognized

components in blood, which are a part of the natural healing process; when added to wounded tissues or surgical potential sites, to they have the

has of

led an

development

autologus

platelet gel PRP to be used in various surgical fields. Whitman et al have called PRP an autologus alternative to fibrin glue. Fibrin glue obtained through blood bank donations has been used for years as hemostatic agent and surgical adhesive. The important difference in composition between PRP and Fibrin Glue is the presence of a high concentration of platelets and

accelerate

healing.

Fibrin glue was originally described in 1970 and is formed by with It was donor

polymerizing thrombin originally and

fibrinogen calcium. using

prepared

plasma; however, because of the low concentration of fibrinogen in

51 Journal of Dental Sciences and Research

Platelet Concentrates native concentration of fibrinogen in PRP4. The present paper describes the preparation and uses of two commonly used platelet

Volume 2 Issue 1 February 2011 Preparation of PRP: PRP can be prepared by two

techniques. 1. General-purpose separators 2. Platelet-concentrating separators 1. General-purpose cell cell cell

concentrates: Platelet-rich plasma (PRP) and Platelet rich Fibrin (PRF). Platelet Rich Plasma: Platelet rich plasma (PRP) is an autologus concentrate of human platelets in a small volume of

separators: It requires large quantities of blood (450 to ml) be and generally in a

plasma. Therefore, the term PRP is preferred to autologus platelet gel, plasma-rich growth factors (PRGFs) or a mere
5

requires

operated

hospital setting. Blood is drawn into a collection bag containing citrate-phosphate-dextrose anticoagulant. It is first centrifuged

autologus

platelet

concentrate . Platelet rich plasma was

at 5,600 rpm to separate RBCs from platelet-poor plasma (PPP) and PRP. The centrifugation speed is then reduced to 2,400 rpm to get a final separation of about 30 ml of PRP from the RBCs. With this technique, the remaining PPP and RBCs can be returned or to can the be

developed in the early 1970s as a byproduct pheresis . equipment improved

of

multi-component Techniques and

have through

dramatically the 1990s.

However, the credit of introducing platelet-rich plasma into

contemporary oral surgery goes to Whitman et al who first advocated its use for oral surgical procedures in 1997 4.

patient's discarded. (Medtronic

circulation The

ELMD-500 Auto

Electromedic,

Transfusion System, Parker, CO,

52 Journal of Dental Sciences and Research

Platelet Concentrates USA) cell separator is widely used for 2. this technique. cell

Volume 2 Issue 1 February 2011 used and the speed and duration of centrifugation may differ with

Platelet-concentrating

different systems. 1. Venous blood is drawn into a tube containing an

separators: It requires small quantity of blood and can be prepared by using certain equipments in a

anticoagulant to avoid platelet activation and degranulation. 2. The first centrifugation is called "soft spin", which allows blood separation into three layers,

dental clinic set up. Currently, two such systems are approved by FDA and commercially available: Smart PreP (Harvest MA, Technologies, USA) and the

namely bottom-most RBC layer (55% of total volume), topmost acellular plasma layer called PPP (40% of total volume), and an intermediate PRP layer (5% of total volume) called the "buffy coat". 3. Using a sterile syringe, the

Plymouth, Platelet System

Concentrate (PCCS; 3i

Collection Implant

Innovations, Inc, West Palm Beach, FL, USA). Several studies have been performed to compare the efficacy of these systems
(7-9)

. A

study conducted by Marx et al10 indicated that of all of the devices tested these 2 FDA cleared PRP devices produced greatest platelet concentrates and most important, release of therapeutic level of bioactive growth factors. The preparation and

operator transfers PPP, PRP and some RBCs into another tube without an anticoagulant. 4. This tube will now undergo a second centrifugation, which is longer and faster than the first, called "hard spin". This allows the platelets (PRP) to settle at the bottom of the tube with a very few RBCs, which explains the red tinge of the final PRP

processing of PRP is quite similar in most of the platelet-concentrating systems although the anticoagulant

53 Journal of Dental Sciences and Research

Platelet Concentrates preparation. plasma, PPP The (80% acellular of the

Volume 2 Issue 1 February 2011 2. Transforming growth factors beta 1 and beta 2 (TGF 1 & 2) 3. Vascular Endothelial Growth Factor (VEGF) 4. Platelet derived endothelial

volume), is found at the top. 5. Most of the PPP is removed with a syringe and discarded, and the remaining PRP is shaken well. 6. This PRP is then mixed with bovine thrombin and calcium chloride at the This the Calcium time results of in

cell growth factor 5. Interleukin 1 (IL-1) 6. Basic fibroblast growth factor (bFGF) 7. Platelet activating factor -4 (PAF-4) The active secretion of these growth factors is initiated by the clotting begins process within 10 of blood and

application. gelling of

platelet chloride

concentrate.

nullifies the effect of the citrate anticoagulant used, and

thrombin helps in activating the fibrinogen, which is converted to fibrin and cross-linked11. Mechanism of action of PRP: PRP works via the

minutes after

clotting. More than 95% of the presynthesized growth factors are secreted within 1 hour. Therefore, PRP must be developed in an

anticoagulated state and should be used on the graft, flap, or wound, within 10 minutes of clot initiation
(12, 13)

degranulation of the granules in platelets, which contain the

synthesized and pre-packed growth factors. The growth factors which are released from activated

The secreted growth factors immediately bind to the external surface of cell membranes of cells in the graft, flap, or wound via transmembrane receptors. These

platelets were: 1. Platelet derived growth factor (PDGF)

54 Journal of Dental Sciences and Research

Platelet Concentrates transmembrane receptors in turn induce an activation of an

Volume 2 Issue 1 February 2011 7. Healing of Extraction wounds 8. Endodontic surgeries and

endogenous internal signal protein, which causes the expression of (unlocks) a normal gene sequence of the cell such matrix as cellular

Retrograde procedures 9. Ablative surgeries of the

Maxillo-Facial region 10. Blepharoplasty

proliferation, osteoid

formation, collagen Safety concerns of PRP: Because it is an autogenous preparation, PRP is inherently safe and therefore free from concerns over transmissible diseases such as HIV, Hepatitis, West Nile fever, and

production,

synthesis etc. thus PRP growth factors act through the stimulation of normal healing, just much faster(14,15). Clinical applications of PRP: Because PRP enhances

Cruetzfeld-jacob

disease
10

(CJD)
22

(mad vow disease)

osteoprogenitor cells in the host bone and in bone grafts12, it has found clinical applications in. 1. Continuity defects12,16 2. sinus lift augmentation grafting(17,18) 3. Horizontal and vertical ridge augmentations19 4. Ridge Graftings20 5. Periodontal/peridefects21 6. Cyst enucleations/Periapical implant preservation

However, Sanchez et al

have elaborated on the potential risks associated with the use of PRP. The preparation of PRP

involves the isolation of PRP after which gel formation is accelerated using calcium chloride and bovine thrombin. It has been discovered that the use of bovine thrombin may be associated with the

development of antibodies to the factors resulting V, in XI the and risk thrombin, of life-

surgeries

threatening coagulopathies. Bovine

55 Journal of Dental Sciences and Research

Platelet Concentrates thrombin preparations have been shown to contain factor V, which could result in the stimulation of the immune system when

Volume 2 Issue 1 February 2011 been referred to as a secondgeneration platelet concentrate,

which has been shown to have several advantages over

challenged with a foreign protein. Marx et al10 in their article stated that the second set of bleeding episodes in the patients who

traditionally prepared PRP. Its chief advantages include ease of

preparation and lack of biochemical handling of blood, which makes this preparation strictly autologus24.

developed coagulopathies were not due to antibodies against bovine thrombin or human thrombin but instead due to antibodies that

Preparation The preparation of PRF is very simple. Since, bovine thrombin is not used for the preparation; PRF is free from associated risks. The

developed to bovine factor Va that was a contaminant thrombin in certain

bovine

commercial

preparations. Other preparation methods of PRP for include safer the

required quantity of blood is drawn into 10-ml test tubes without an anticoagulant and centrifuged

utilization of recombinant human thrombin, autologous thrombin or perhaps extra-purified

immediately. Blood is centrifuged using a tabletop centrifuge for 12 min at 2,700 rpm.

thrombin.

Landesberg et al that

have suggested methods of

alternative

The resultant product consists of the following three layers:

activating PRP need to be studied and made available to the dental community. Platelet rich Fibrin (PRF):

Topmost layer consisting of acellular PPP

PRF clot in the middle RBCs at the bottom

PRF was first developed in France by Choukroun et al. It has

56 Journal of Dental Sciences and Research

Platelet Concentrates Because of the absence of an anticoagulant, blood begins to

Volume 2 Issue 1 February 2011 factor content in PRP and PRF aliquots was measured using Elisa kits. The results suggest that the growth factor content (PDGF and TGF-) was comparable in both. Another experimental study used osteoblast cell cultures to

coagulate as soon as it comes in contact with the for glass surface. successful

Therefore,

preparation of PRF, speedy blood collection and immediate

centrifugation, before the clotting cascade is initiated, is absolutely essential24. PRF can be obtained in the form of a membrane by

investigate the influence of PRP and PRF on proliferation and

differentiation of osteoblasts. In this study, the affinity of

squeezing out the fluids in the fibrin clot. PRF is in the form of a platelet gel and can be used in conjunction with bone grafts, which offers

osteoblasts to the PRF membrane appeared PRF over to has It be many superior22. advantages the

PRP.

eliminates of

redundant

process

adding

several promoting growth

advantages wound

including bone graft

anticoagulant as well as the need to neutralize it. The addition of bovine-derived thrombin to

healing,

and

maturation,

stabilization, wound sealing and hemostasis, handling and improving of the graft

promote conversion of fibrinogen to fibrin in PRP is also eliminated. The elimination of these steps

properties

materials. PRF can also be used as a membrane. Clinical trials suggest that the combination of bone grafts and growth factors contained in PRP and PRF may be suitable to enhance bone density. the In an

considerably reduces biochemical handling of blood as well as risks associated with the use of bovinederived thrombin. The conversion of fibrinogen into fibrin takes place slowly with small quantities of

experimental

trial,

growth

physiologically available thrombin

57 Journal of Dental Sciences and Research

Platelet Concentrates present in the blood sample itself. Thus, that a is physiologic very architecture to the

Volume 2 Issue 1 February 2011 platelet concentrate. Indian J Dent Res 2008; 19:42-6. 3. Freymiller EG, Aghaloo TL.

favorable

healing process is obtained due to this slow polymerization process. Literature pertaining to PRF is found in French, and the material is being used widely in France. The popularity of this material should increase considering The
25

Platelet-Rich Plasma: Ready or Not? J Oral Maxillofac Surg

2004; 62:484-88. 4. Whitmann DH, Berry RL, Green DM. Platelet gel: an alternative to fibrin glue with applications in oral and maxillofacial surgery. J Oral Maxillofac Surg 1997;

its

many of

advantages. Wiltfang et al

findings

from a series of

55:1294-9. 5. Marx RE. Platelet-rich Plasma. Evidence to support its use. J Oral Maxillofac Surg 2004;

clinical trials are encouraging, in that they show improved

properties of PRF as compared with PRP. In future, more histologic evaluations from other parts of the world are required to understand the benefits of this second-

62:489-96. 6. Autologus Platelet Rich Plasma (Platelet Gel). Available at : http://www.platelet-gel.net accessed 2010. 7. Appel TR, Potzsch B, Muller J, von Linden JJ, Berge SJ, Reich RH. Comparison of three on September 25,

generation platelet concentrate. References: 1. University of Miami School of medicine, Division of Oral and Maxillofacial Central. Surgery. Available PRP at:

different preparations of platelet concentrates for growth factor enrichment. Clin Oral Implants Res 2002; 13:522-8.

www.plateletrich.net. 2. Sunitha Raja V, Munirathnam Naidu E. platelet-rich fibrin:

Evolution of a second generation 58 Journal of Dental Sciences and Research

Platelet Concentrates 8. Weibrich G, Kleis WK. Curasan PRP kit vs. PCCS PRP system: Collection efficiency and platelet counts of two different methods for the preparation of plateletrich plasma. Clin Oral Implants Res 2002; 13:437-43. 9. Weibrich G, Kleis WK, Buch R, Hitzler Harvest versus platelet-rich Oral WE, Hafner PreP G. The Oral

Volume 2 Issue 1 February 2011 Radiol Endod 1998;

85:638. 13. Kevy S, Jacobson M.

Preparation of growth factors enriched autologus platelet gel. Proceedings of the 27th Annual meeting of Service Biomaterials, April 2001. 14. Schmitz JP, Hollinger JO. The

Smart

system

biology of platelet-rich plasma (letter to the editor). J Oral Maxillofac Surg 2001; 59:1120. 15. Marx RE. The Biology of

Friadent-Schutze plasma Res kit. Clin

Implants

2003;

14:233-9. 10. Marx RE. J Oral Maxillofac

platelet-rich plasma (letter to the editor). J Oral Maxillofac Surg 2001; 59:1119. P, 16. Fennis JPM, Stoelinga PJW, JA. Mandibular and

Surg 2004; 62:489-96. 11. Sonnleitner DY. for D, A Huemer

Sullivan technique

simplified producing

Jansen

reconstruction: A clinical

platelet-rich plasma and platelet concentrates for intraoral bone grafting techniques: A Technical note. Int J Oral Maxillofac

radiographic animal study on the use of autogenous scaffolds and platelet rich plasma. Int J Oral Maxillofac Surg 2002;

Implants 200; 15:879-82. 12. Marx RE, Carlson ER,

31:281. 17. Kassolis JD, Rosen PS,

Eichstaedt R, et al. PlateletRich Plasma: Growth factor

Reynolds MA. Alveolar ridge and sinus platelet augmentation rich utilizing in

enhancement for bone grafts. Oral Surg Oral Med Oral Pathol

plasma

combination with freeze dried

59 Journal of Dental Sciences and Research

Platelet Concentrates bone allograft. Case series. J Periodont 2000; 71:1654. 18. Lozada JL, Caplanis N, Maxillofac

Volume 2 Issue 1 February 2011 Implants 2003;

18:93-103. 23. Landsberg M. R, Risk Moses of M, using

Proussaefs P et al. Platelet rich plasma application in sinus graft surgery: Part I, back ground and processing techniques. J

Karpatkin

platelet rich plasma gel. J Oral Maxillofac Surg 1998; 56:11167. 24. Choukroun A, J, Diss A, MO,

Oral Implantol 2001; 27:38. 19. Garg AK. The use of platelet plasma to enhance the

Simonpieri

Girard

rich

Schoefler C, Dohan SL, et al. Platelet second rich Fibrin (PRF): A

success of bone grafts around dental implants. Dent Implantol Update 2000; 11:17. 20. Carlson NE, Roach RB Jr. rich plasma: Clinical

generation Part

platelet I: and

concentrate: Technological

Concepts

Platelet

evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101:E37-44. 25. Par Wiltfang J, Terheyden H,

Applications in Dentistry. J Am Dent Assoc 2002; 133:1383. 21. Kim SG, Chung CH, Kim YK,

et al. Use of Particulate Dentin plaster of paris combination rich

Gassling V, Acyl A. Platelet rich plasma vs platelet rich fibrin: Comparison content of and growth factor

with/without

platelet

plasma in the treatment of bone defects around implants. Int J Oral Maxillofac Implant 2002; 17:86. 22. Sanchez AR, Sheridan PJ,

osteoblast

proliferation and differentiation in the cell culture. In Report of the 2nd International

Symposium on growth factors (SyFac 2005).

Kupp LI. Is platelet rich plasma the perfect enhancement factor? A current Review. Int J Oral

60 Journal of Dental Sciences and Research

Platelet Concentrates Address For Correspondance: Dr.Kiran N K Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Sri Siddhartha Dental College and Hospital,

Volume 2 Issue 1 February 2011 Agalakote, Tumkur-502107, Karnataka, India Ph No. 9916373505 Fax no:08162-275536 E mail : [email protected]

61 Journal of Dental Sciences and Research