July 15, 2020 by riverteam
This article was originally published in the Academy of General Dentistry. The original article can be found here.
Christopher H. Hughes, DMD, FAGD, DABOI, FAAID, uses leukocyte- and platelet-rich fibrin (L-PRF) for surgical procedures in his Herrin, Illinois-based practice, including socket grafting, soft tissue grafting, bone grafting and most implant placement procedures. He said L-PRF is “like a miracle drug.”
“One week after surgery, it’s common for a surgical site where L-PRF was used to appear as if it has been healing for three or four weeks,” Hughes said. “It dramatically speeds up the healing cascade.”
Platelet-rich fibrin (PRF) and its predecessor, platelet-rich plasma (PRP), are categorized as autologous blood concentrates, which are blood products made using the patient’s own blood. The clinician draws a blood sample from the patient then concentrates it using a centrifuge machine to separate the different blood components into individual, concentrated layers that the clinician can use. Although several variations of this technology exist today that prioritize different blood components, the overarching concept in dentistry is the same — they use the patient’s own blood to enhance healing after oral surgery.
And speedy healing is just one benefit, Hughes said. Speaking specifically about the L-PRF variation, he noted a laundry list of benefits for patients and dentists: It decreases bleeding intraoperatively and reduces inflammation. It enhances primary closure where surgical flaps are re-approximated. L-PRF is “rich” in leukocytes, so there’s a decreased risk of postoperative infection. And because it’s made from the patient’s own blood, risk of allergic or immunologic rejection is eliminated. Lastly, Hughes said it’s inexpensive and simple to make.
“In my 30 years of clinical practice, there has been no other medication, device or technique that does all of these things to the extent that L-PRF does,” Hughes said.
Autologous blood concentrates may help patients during and after oral surgery, but general dentists often face challenges when adding PRP/PRF to their practices. Challenges specific to adding the use of autologous blood concentrates include navigating the growing market for equipment, understanding the different variations and how to use them, and interpreting research on their use in dental applications.
PRP and PRF are not the same product, although both practitioners and researchers have used the terms interchangeably, said Richard J. Miron, DDS, BMSc, MSc, PhD, Dr med dent, co-editor of “Next-Generation Biomaterials for Bone & Periodontal Regeneration” and “Platelet Rich Fibrin in Regenerative Dentistry: Biological Background and Clinical Indications.” PRP was first used in oral surgical procedures in 1997, and it refers to a platelet-rich concentrate mixed with anticoagulants, Miron said. PRF was introduced in 2001 as a secondgeneration platelet concentrate without the use of anticoagulants.1
“Data from many fields of medicine have clearly demonstrated superior outcomes of PRF when compared with PRP, since clotting is an important event during wound healing,” Miron said.
He says the benefits of using PRP and PRF lie in their ability to contribute to tissue regeneration at relatively low costs. “The use of PRP is generally no longer recommended for clinical use since it has two main drawbacks,” Miron said. “First, it contains anticoagulants and, therefore, prevents clotting once re-implanted into patients. Second, the disposable blood collection kits generally cost more per patient.”
However, the argument that PRP “always” uses an anticoagulant is one that Arun K. Garg, DMD, the co-discoverer of PRP, disputes.
“In the early days of using PRP, we sometimes omitted an anticoagulant based on how quickly we needed to use the material,” Garg said. “For longer surgeries, we added an anticoagulant to preserve the platelet-derived growth factors until we were ready to use the material, and then we would induce clotting at the time of use.”
Hughes, who exclusively uses PRF in his practice, added that the need to improve upon PRP was in part because the original PRP equipment was expensive, and the technique was more intricate and time-consuming — PRP requires two spins in the centrifuge plus the addition of thrombin, while PRF requires only one spin with no additions.
“PRP was initially most commonly used in hospitals for large oral or plastic surgery cases,” Hughes said. “For use in a typical dental office, PRP proved to be impractical.”
Both PRF and PRP are collected and produced in a similar fashion, explained Ellen Paulisick, DDS, FAGD, Rebeca Zechmann, DDS, and Alex Kusek, DDS, who use PRF in their practice in Daniel Island, South Carolina.
They explained that blood is taken from the patient and placed in a vial. The vial is then spun in a centrifuge at a predetermined speed and duration, a process wherein PRF is isolated from the blood. The resulting PRF is a yellow, gel-like membrane that is then typically compressed into a flatter membrane.
“These membranes can then be adapted over the top of the bone graft material, combined with the bone graft material, and/or positioned around or on top of the dental implant to provide a biological membrane that will encourage bone maturation and improve the health of the keratinized gingival tissue,” Kusek said. “PRF can also be used in periodontal surgery as the sole graft material. Additionally, this material is extremely helpful in repairing perforations during sinus augmentation, preventing infection and improving clinical outcomes.”
“Typical uses for PRP include combining it with PRF and bone particulate to create a ‘sticky’ bone that is easy to adapt and manipulate within the mouth during grafting procedures,” Kusek continued. “The PRP material can also be syringed onto the graft area for increased stabilization and injected into surrounding tissue to improve healing.”
Cliff E. Rogge, DDS, FAGD, also uses both PRP and PRF in his practice in Longmont, Colorado.
“I use them in my practice for bone grafting by mixing PRP with bone grafting material and placing it in the socket, followed by a PRF membrane on top and then a polytetrafluoroethylene membrane over that,” Rogge said. “I also use PRF as a clot after any extractions — including wisdom teeth — to help reduce dry sockets and promote healing. Honestly, I have not had a dry socket since implementing PRF.” Eliminating dry sockets isn’t the only benefit Rogge has seen.
“Not only do I see faster healing and increased bone growth, but I’ve also noticed a decrease in reported postoperative pain when using PRP and PRF.”
Paulisick, Zechman and Kusek said PRP/PRF technology is relatively simple to add to a dental practice. In most cases, other than the purchase of a centrifuge, only additional phlebotomy training is required.
“Dentists are permitted to perform blood draws in most states with no formal certification needed,” Kusek said. “There are numerous weekend courses that can teach phlebotomy basics as well as the principles and applications of PRF/PRP use.”
After taking a phlebotomy course in 2014, Carl D. Werts, DDS, FAGD, FICOI, said drawing blood for PRP/PRF has been an integral part of his Glendale, California-based practice for extractions, bone grafting, and other implant and periodontal surgeries.
“Will the patients heal if you don’t use PRP/PRF? Absolutely,” Werts said. “But, if you can get them to the end result easier, quicker and with fewer complications, why wouldn’t you?”
Costs for adding PRP/ PRF into a general dentistry practice vary, driven in large part by the booming business of autologous blood concentrates. These products have spawned a multi-billion-dollar industry, with various manufacturers creating subtle — sometimes proprietary — variations of centrifuges and vials.
“Centrifuges with different speed settings have been introduced to the market, and the variations in centrifugation can affect the vitality and effectiveness of the cells within,” Werts said. “Is it clinically significant? I’m not sure how someone could measure that.”
Outside of the centrifuge investment and phlebotomy training, Werts said other costs involved with using PRP/PRF in the practice, such as vacuum-sealed collection tubes, butterfly needles and draw tubes, are “minimal.”
“Using resorbable membranes for your graft procedures can run $50 to $100 each,” Werts said. “Comparatively, using the patient’s own PRF as membranes is pennies in outside cost plus your time, which is something that can be billed. There is an insurance code for autologous blood products, but insurance coverage rarely pays for this. I frequently charge for the procedure then credit it off as a gift to the patient.”
Paulisick, Zechman and Kusek estimated that the initial cost of adding a centrifuge and PRF membrane compressor to their practice was between $2,000 and $4,000, and the only additional cost is the disposable blood collection kits, which typically cost less than $10 per case. Due to the industry competition and the large number of centrifuges available on the market, dentists should be able to find equipment at a wide range of price points. Research suggests there may not be significant differences in the quality of PRF produced using different centrifuges as long as the protocol is consistent.2
“After an initial investment, this technology can promote better outcomes, fewer failures and happier patients,” Kusek said.
Although a wide array of uses are possible for autologous blood concentrates in general dental offices, Miron said dentists should consult the available research when applying it to their practice.
“Our research group recently published a systematic review in which we found that PRF significantly improved the clinical outcomes for periodontal and soft tissue repair,” Miron said. “Despite this, we also concluded that there remains a lack of well-conducted studies convincingly demonstrating the role of PRF in inducing bone formation (osteoinduction). Therefore, clinicians should be informed that PRF has greater regenerative capabilities for soft tissue than hard tissue.”3
Most scientific studies seem to support Miron’s claim. Evidence suggests that PRP/PRF do aid in the healing process, even in instances where the level of improvement is not statistically significant. Even though plenty of anecdotal evidence exists, researchers suggest the need for more conclusive evidence.
Since PRF was first used in oral surgical procedures in 2001, several variations have emerged — L-PRF, A-PRF (advanced platelet-rich fibrin) and i-PRF (injectable platelet-rich fibrin). As Werts put it, it’s “all enough to make your head spin trying to learn and remember them all.”
“In essence, it all goes back to the initial concepts of PRP/PRF,” he said. “Yes, the advantages of each of these new ‘improvements’ can be scientifically demonstrated, but, clinically, it all works the same — it all enhances healing dramatically.”
Hughes agreed, noting that L-PRF, A-PRF and i-PRF are all “minor” variations of PRF. The varieties don’t require special equipment but rather adjustments to the centrifugation protocol (time and spin forces).
“To create the different varieties of PRF involves changing the amount of time the blood is spun or changing the rotations-per-minute (RPM) during the centrifugation,” Hughes explained.
The first variation of PRF was L-PRF, and then came A-PRF. A third variety, i-PRF, is a liquid, injectable form of PRF that offered an alternative to PRP.
“It is important to understand that PRF is usually in a clot form,” Hughes said. “If you need the PRF to be injectable, you simply vary the centrifuge time and RPM to make a liquid form — that’s i-PRF.”
Without an anticoagulant, i-PRF does not remain liquid for long. If not injected quickly, it turns into a sticky glue-like gel, but that product can be useful, too, said Hughes.
“It makes for a great adjunct for particulate or block bone grafting to help stabilize and immobilize the graft,” he said. “I’ve seen great results using it in this capacity.”
If the varieties, acronyms and nomenclature are confusing to those in the industry, how should the general dentist explain the concept of autologous blood concentrates to patients?
“I say it’s a way to reduce complications and enhance and speed up healing times, making them heal like a teenager,” Werts said. “It’s lighter fluid for the healing process.”
The industry still has a way to go toward clarifying confusion around applications, establishing the terminology and promoting better understanding of the variations, but autologous blood concentrates offer solid benefits for patients and general dentists alike.
“Incorporating PRP/PRF into your practice tells your patients that you are up on current trends, using techniques that are in their best interests and putting in the effort to ensure the best possible results,” Werts said.
Kelly Rehan is a freelance journalist based in Omaha, Nebraska.