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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 101-110

A Comparative evaluation of platelet-rich fibrin with metronidazole and platelet-rich fibrin alone in the treatment of intrabony periodontal defects: A clinical and radiographical study


1 Department of Periodontics and Oral Implantology, Jaipur Dental College, Jaipur, Rajasthan, India
2 Department of Anatomy, Jaipur Dental College, Jaipur, Rajasthan, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Neha Taneja
563, Shanti Nagar, Gopalpura Bypass, Jaipur - 302 018, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_37_17

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   Abstract 


Aim: The study comparatively evaluated the efficacy of platelet rich fibrin (PRF) with metronidazole and PRF alone in the treatment of intrabony periodontal defects both clinically and radiographically. Methods: A total no. of 20 subjects maintaining good oral hygiene with minimum two sites having vertical bony defects were selected using CBCT. All subjects were randomly assigned to anyone of the two groups (group A PRF+MTZ ; group B PRF only) using lottery system. All subject underwent open flap debridement and placement of either of the material mentioned above and a periodic follow-up at 6 and 9 months. Results: Improvement in clinical parameters (Plaque index, gingival index, probing depth, relative attachment level) as well as in radiographic parameters (defect depth and defect volume) as compared to baseline in both the groups was observed with group A exhibiting higher statistically significant values as compared to group B. Conclusion: The combination of PRF+MTZ were proven to be better than PRF alone. Further, long term clinical trials with larger samples of various drug concentrations and longer duration should be carried out to assess a complete periodontal regeneration rather than bone regeneration.

Keywords: Chronic periodontitis, endogenous regenerative technology, intrabony defects, metronidazole, platelet-rich fibrin


How to cite this article:
Taneja N, Kudva P, Goswamy M, Bhat GK, Kudva HP. A Comparative evaluation of platelet-rich fibrin with metronidazole and platelet-rich fibrin alone in the treatment of intrabony periodontal defects: A clinical and radiographical study. J Interdiscip Dentistry 2017;7:101-10

How to cite this URL:
Taneja N, Kudva P, Goswamy M, Bhat GK, Kudva HP. A Comparative evaluation of platelet-rich fibrin with metronidazole and platelet-rich fibrin alone in the treatment of intrabony periodontal defects: A clinical and radiographical study. J Interdiscip Dentistry [serial online] 2017 [cited 2018 Jul 18];7:101-10. Available from: http://www.jidonline.com/text.asp?2017/7/3/101/221893




   Clinical Relevance to Interdisciplinary Dentistry Top


The aim of using platelet rich fibrin with metronidazole and without metronidazole is to minimize antigenicity by autologous nature of platelet rich fibrin and to overcome systemic complications arising by the use of metronidazole.


   Introduction Top


Periodontal disease is a complex disease in which disease expression involves intricate interactions of the biofilm with the host immunoinflammatory response and subsequent alterations in bone and connective tissue homeostasis.[1],[2],[3]

Chronic periodontitis is considered as the most common form of periodontitis, which is further classified as localized or generalized (more than 30% of the sites) depending on the site involvement.

Open flap debridement alone falls short of the objective of adequate regeneration hence various regenerative techniques have been advocated.[4] Various regenerative techniques have been advocated.

At present, endogenous regenerative technology (ERT) has gained attention in the field of regeneration as it can trigger latent self-repair mechanisms in patients and activate the host's innate capacity for regeneration.

The most widely used ERT is platelet-rich fibrin (PRF). PRF, a second-generation platelet concentrate,[5] is an autologous leukocyte and PRF biomaterial as described by Choukroun.[6],[7],[8] It is made up of an integrated conclave of cytokines, glycan chains, and structural glycoproteins encased within a slowly polymerized fibrin network.

Currently, drugs have also been incorporated into ERT to create a material alcove in an injured site where the progenitor/stem cells from neighboring tissues can be employed for in situ periodontal regeneration.

Metronidazole (MTZ) is a broad spectrum antimicrobial drug mainly acting against protozoal and anaerobic bacterial infections (Tracy and Webster 1996, Lamp et al. 1999).

At present, MTZ is the drug of choice in the treatment of both types of periodontitis; chronic as well as aggressive. MTZ is very effective against periodontic pathogens and is used solely or in combination with amoxicillin in the treatment of periodontal diseases (Winkelhoffvan et al. 1989, American Academy of Periodontology 1996, Elter et al. 1997, Winkelet al. 2001, Slots and Ting 2002). Hence, MTZ is a drug of interest for periodontist for treating periodontitis-induced alveolar bone loss.

The detection and accurate assessment of the location, extent, and configuration of the intrabony defect was done using cone beam computed tomography (CBCT) as it is an enhanced tool to assess endosseous defect correctly (Papapanou and Wennstrom 1991).

The present study is an effort to comparatively evaluate the efficacy of platelet-rich fibrin (PRF) with MTZ and PRF alone in the treatment of intrabony periodontal defects both clinically and radiographically.

The study was conducted at Department of Periodontology and Implantology, Jaipur Dental College, Jaipur, Rajasthan. The proposed study began after the approval from the Institutional Research Review Board, Jaipur Dental College, Jaipur. Informed consent was taken from the individuals participating in the study.

Aims and objectives

  1. To evaluate clinically the efficacy of PRF with MTZ and PRF alone in the treatment of intrabony periodontal defects [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
  2. To evaluate radiographically the efficacy of PRF with MTZ and PRF alone in the treatment of intrabony periodontal defects
  3. To compare the efficacy of PRF with MTZ and PRF alone on clinical and radiographic parameters.
Figure 1(a-d): Platelet rich fibrin preparation

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Figure 2:(a) 1% metronidazole; (b) 1% metronidazole mixed with platelet-rich fibrin

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Figure 3: Preoperative cone beam computed tomography (panoramic view)

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Figure 4: Preoperative RAL measurements

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Figure 5:Mucoperiosteal flap reflection

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Figure 6: Defect site

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Figure 7:Placement of 1% metronidazole (Group A)

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Figure 8: Placement of platelet-rich fibrin (Group B)

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Figure 9: Sutures

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Figure 10:Postoperative RAL measurement

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Figure 11: Postoperative cone beam computed tomography (panoramic view)

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   Material and Methods Top


Individuals following a maintenance phase were recalled for periodontal assessment. A total number of 20 individuals maintaining good oral hygiene with minimum two sites having vertical bony defects were selected for this split-mouth study design. All individuals were randomly assigned to anyone of the following group using lottery system.

Group A – open flap debridement followed by placement of PRF with MTZ 1% gel.

Group B – open flap debridement followed by placement of PRF alone.

Inclusion criteria:-Individuals in the age range of 35–55 years with systemically healthy status and pocket probing depth in the range of 5–7 mm, bilateral intrabony vertical defects, radiographic evidence of vertical bone loss were included in the study.

Exclusion criteria:- Individuals with medically compromised status (history of diabetes, hypertension, thyroid), pregnant females or lactating mothers, individuals allergic to any kind of medications, smokers, patient with unacceptable oral hygiene, and periodontal resurgical cases were excluded from the study.

Materials used in the study

Platelet-rich fibrin

A blood sample was taken without anticoagulant in 10-mL tubes which were immediately centrifuged at 3000 rpm (approximately 400 g according to our calculations) for 10 min. This technique required neither anticoagulant nor bovine thrombin (nor any other gelling agent).[5]

Metronidazole

A 1% MTZ bioadhesive periodontal gel was developed using carboxymethyl cellulose, methyl cellulose, hydroxylethyl cellulose, polyvinylpyrrolidone, and carbopol. Increased concentrations of the polymers decreased the drug release rate and enhanced syringe ability, yield value, and adhesiveness but decreased the spreadability. The gel containing 20% hydroxyethyl cellulose, 20% polyvinylpyrrolidone, and 1% carbopol exhibited zero order drug release kinetics and suitable physical properties.[9]

Storage and shelf life:-Both the drugs (gels) were stored in a refrigerator in a temperature of 10°C –18°C and had a shelf life up to December 15, 2017.

In vitro studies (diffusion cell)

The in vitro study part was carried out at Sree Dattha Institute of Pharmacy, Hyderabad.

Presurgical phase

All individuals received scaling and root planing followed by oral hygiene instructions. Plaque (Silness and Loe, 1964) and gingival indices (Loe and Silness, 1963) were measured at baseline. All patient underwent RVG (radiovisiography) followed by CBCT for locating bony defects.

Customized acrylic stent using cold-cure acrylic resins was prepared on the stone models by making alginate impressions of the individuals.

Clinical parameters

All clinical parameters were recorded preoperatively (baseline recordings), at 6 months, and 9 months postoperatively. A stent was used along with a calibrated probe (UNC – 15 probe) to ensure reliability and reproducibility of data collected sequentially. Clinical parameters recorded were plaque index, gingival index, probing depth, and relative attachment level.

Bone defect morphology was assessed using three-dimensional (3-D) CBCT (v3.5.7 Carestream Health, Inc New York, US software) with the following parameters: slice thickness of 0.625 mm, exposure of 68–90 KVp, and 4 mA. It is a high-resolution CT scanner equipped with a 3-D image-reconstruction software[see [graph 1],[graph 2],[graph 3],[graph 4],[graph 5],[graph 6] and [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], Carestream CS9300 imaging system (CS3D) imaging.

Table 1: Intra-group comparison of Plaque Index at various time intervals

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Table 2: Intra-group comparison of Gingival Index at various time intervals

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Table 3: Intra-group comparison of mean probing depth at various time intervals

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Table 4: Intra-group comparison of mean relative attachment level at various time intervals

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Table 5: Intra-group comparison of mean defect depth at various time intervals

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Table 6: Intra-group comparison of mean defect volume at various time intervals

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Surgical therapy included administration of local anesthesia (xylocaine 2%), open flap debridement, and placement of material as per designated group followed by suturing and postoperative instructions.

Statistical analysis

The data were coded and entered into Microsoft Excel spreadsheet. Analysis was done using SPSS version 20 (IBM SPSS Statistics Inc., Chicago, Illinois, USA) Windows software program. The variables were assessed for normality using the Kolmogorov–Smirnov test. Descriptive statistics included computation of percentages, means, and standard deviations.


   Results Top


On intragroup comparison for soft tissue parameters in Group A (PRF + MTZ), the mean value of plaque index and gingival index at 6 months from baseline and 9 months from baseline was found to be nonsignificant. Comparison of change between 6 and 9 months revealed a nonsignificant change.

The mean value of probing depth at 6 months from baseline and 9 months from baseline was found to be significant. Comparison of change between 6 and 9 months revealed a significant change.

The mean value of relative attachment level at 6 months from baseline and 9 months from baseline was found to be significant. Comparison of change between 6 and 9 months revealed a nonsignificant change.

While in Group B (PRF), the mean value of plaque index at 6 months from baseline and 9 months from baseline was found to be nonsignificant. Comparison of change between 6 and 9 months revealed a nonsignificant change.

The mean value of gingival index at 6 months from baseline and 9 months from baseline was found to be significant. Comparison of change between 6 and 9 months revealed a nonsignificant change.

The mean value of probing depth and relative attachment level at 6 months from baseline and 9 months from baseline was found to be significant. Comparison of change between 6 and 9 months revealed a nonsignificant change.

Considering hard tissue parameters in Group A (PRF + MTZ), the mean value of defect depth at 6 months from baseline and 9 months from baseline was found to be significant. Comparison of change between 6 and 9 months revealed a significant change.

The mean value of defect volume at 6 months from baseline and 9 months from baseline was found to be significant. Comparison of change between 6 and 9 months revealed a significant change.

In Group B (PRF), the mean value of defect depth at 6 months from baseline was found to be nonsignificant and 9 months from baseline was found to be significant. Comparison of change between 6 and 9 months revealed a nonsignificant change.

The mean value of defect volume at 6 months from baseline was found to be significant and 9 months from baseline was found to be significant. Comparison of change between 6 and 9 months revealed a significant change.

On intergroup comparison for mean plaque index scores, mean difference from baseline to 6 months was nonsignificant. Mean difference from baseline to 9 months was found to be nonsignificant.

Mean gingival index score from baseline to 6 months was found to be nonsignificant in Group A while in Group B, it is found to be significant (P ≤ 0.05). Mean difference from baseline to 9 months was found to be nonsignificant in Group A while in Group B, it is found to be significant (P ≤ 0.05).

Mean probing depth score from baseline to 6 months was found to be significant in all groups (P ≤ 0.05). Mean difference from baseline to 9 months was found to be significant in both the groups (P ≤ 0.05).

Mean Relative attachment level score from baseline to 6 months was found to be significant in both the groups (P ≤ 0.05). Mean difference from baseline to 9 months was found to be significant in both the groups (P ≤ 0.05).

Mean defect depth score from baseline to 6 months was found to be significant in Group A (P ≤ 0.05) while nonsignificant in Group B.

Mean difference from baseline to 9 months was found to be significant in both the groups (P ≤ 0.05).

Mean defect volume score from baseline to 6 months was found to be significant in all groups (P ≤ 0.05). Mean difference from baseline to 9 months was found to be significant in both the groups (P ≤ 0.05).


   Discussion Top


The present study was designed as a randomized controlled trial which comprised of 20 systemically healthy controls having moderate-to-severe chronic generalized periodontitis with minimum two sites having intrabony defects totaling to 40 defect sites.

A comparative assessment of PRF with MTZ and PRF alone in treatment of intrabony defects was done in the present study.

The clinical parameters assessed were plaque index (Silness and Loe, 1964); gingival index (Loe and Silness 1963), probing depth, and relative attachment level.

Plaque index and gingival index were recorded to assess the oral hygiene maintenance and inflammatory status at various time intervals.

Probing depth and relative attachment level were assessed to evaluate the outcome of various treatment modalities.

The CBCT was used for the study since it had various advantage over the conventional radiographic technique (Intra-oral peri apical radiograph, orthopantamogram) such as display of multiple panoramic and cross-sectional images followed by generation in three types of views: axial, cross-sectional, and panoramic.

The defects were randomly divided into two test groups using lottery method: Group A involved the use of PRF with MTZ and Group B involved the use of PRF only.

At present, for periodontal regeneration, various chemical agents and growth factors have been advocated. PRF has been used in different treatment modalities for root coverage and treating intrabony periodontal defects.

Drugs such as MTZ had shown to have other beneficial properties besides their main properties such as osteogenic potential. Hence, in the present study, it was incorporated in PRF to assess their regeneration potential.

MTZ is a potent antimicrobial agent and has been widely used in the field of periodontal therapy both as an antibiotic agent as well as immunomodulatory agent affecting pro-inflammatory cytokines such as interleukin-1 (IL-1) β, IL-6, IL-8, IL-12, and TNF-α cytokines in human periodontal ligament cells in various studies (Antonietta Rizzo, Rossella Paolillo, Luigi Guida, Maria Antonietta Tufano 2012).[10] MTZ has been found to be effective either with a systemic administration or with local biodegradable sustained-release agents (gels, chips, membranes) in both soft tissue healing and osseous regeneration (Kurtiş et al., 2002; Mohindra et al., 2014).[11],[12]

The results of the current study are in agreement with the study done by Tripthi et al., 2014[13] who evaluated soft tissue healing and bone regeneration in extraction sockets following application of PRF gel infused with MTZ in transalveolar extractions.

The study exhibited that PRF gel with MTZ improved wound healing during the 1st week after surgery owing to maximum growth factor concentration and antibiotic action for the first 5–7 days. It was also observed that significant improvement in bone regeneration (reduction in defect size) occurred over the entire course of healing as evident by the rapid and more complete bone growth observed in the test group patients.

The results are in accordance with Needleman IG, et al.,[14] who evaluated the regenerative potential of a MTZ-loaded biodegradable (polylactide/glycolide)-guided tissue regeneration membrane in dogs and found beneficial effects on soft tissue healing and osseous regeneration.

Results also going in hand with Vinayak KS et al.[15] in 2014, who evaluated the bone regeneration using collagen sponge with MTZ 4.5 mg in osseous defect and concluded that collagen sponge with MTZ is clinically and radiographically efficacious in the treatment of a osseous defect, thus signifying its role as a regenerative material in the treatment of osseous defects.

The results of the present study are not in agreement with the study done by Needleman et al.[14] in 2005, who tested whether local application of a slow-release antimicrobial might exert an adjunctive effect on healing following periodontal surgery and found that application of MTZ gel on exposed root surface did not provide any additional benefit in soft tissue healing.

In Group B, PRF was used for treatment of intrabony defects. PRF as described by Dohan et al.[5] allows one to obtain fibrin mesh enriched with platelets and growth factors, from an anticoagulant free blood harvest without any artificial biochemical modification. The PRF clot forms a strong natural fibrin matrix which concentrates almost all the platelets and growth factors of the blood harvest and shows complex architectures as a healing matrix, including mechanical properties, which no other platelet concentrate can offer. It also acts as an innovative growth factor delivery medium. It has been used in field of periodontology since long either as a membrane or as a vehicle.

The results of the present study are in accordance with the study by Vinayak et al., 2013[15] who focused on the properties and various applications of PRF in the clinical practice. Wound healing is a staged process which involves the activity of leukocytes and platelets. The growth factors present in platelets are important to guide the regenerating cells to the area of healing. PRF is one such material that holds onto these growth factors enmeshed in the fibrin network resulting in their sustained release over a period of time that can accelerate the wound healing process.

The results are also in agreement with the study by Shah et al., 2013[16] which stated that PRF, developed in France by Choukroun et al., is a second-generation platelet concentrate widely used to accelerate soft and hard tissue healing. It is a strictly autologous fibrin matrix containing a large quantity of platelet and leukocyte cytokines. It has also been shown to stimulate the growth of osteoblasts and periodontal ligament cells, both of which are significant for the regeneration of periodontal defects.

The results are also in accordance with Yogesh et al. in 2015[17] who stated clinical and radiographic results of an intrabony periodontal defect treated with PRF.

The results are also in accordance with Mathur, et al. in 2015,[18] who compared clinically and radiographically the efficacy of autologous PRF and autogenous bone graft obtained using bone scrapper in the treatment of intrabony periodontal defects and stated that although both gave similar results, using PRF is a safer, cheaper, less technique sensitive, and minimally invasive procedure.


   Summary and Conclusion Top


The present study was an attempt to comparatively evaluate the regenerative potential of PRF with MTZ and PRF alone in the treatment of intrabony periodontal defects.

Results showed an improvement in clinical parameters (plaque index, gingival index, probing depth, relative attachment level) as compared to baseline in all three groups. Statistically significant results were obtained in all three groups with Group A exhibiting higher statistically significant values as compared to Group B.

Radiographically, there was significant reduction in defect depth and defect volume compared to baseline in both the groups with Group A exhibiting higher statistically significant values as compared to Group B for defect depth reduction.

Both the treatment modalities (PRF + MTZ and PRF alone) were found to be effective both clinically and radiographically in the treatment of intrabony defects.

However, the combination of PRF + MTZ was proven to be better than PRF alone.

Further, long-term clinical trials with larger samples of various drug concentrations and longer duration should be carried out to assess a complete periodontal regeneration rather than bone regeneration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Samar S, Amit C, Yogesh K. Local drug delivery system a comprehensive review. Indian J Appl Res 2015;5:19-23.  Back to cited text no. 2
    
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Hoidal MJ, Grimard BA, Mills MP, Schoolfield JD, Mellonig JT, Mealey BL, et al. Clinical evaluation of demineralized freeze-dried bone allograft with and without enamel matrix derivative for the treatment of periodontal osseous defects in humans. J Periodontol 2008;79:2273-80.  Back to cited text no. 3
    
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Offenbacher S, Barros SP, Singer RE, Moss K, Williams RC, Beck JD, et al. Periodontal disease at the biofilm-gingival interface. J Periodontol 2007;78:1911-25.  Back to cited text no. 4
    
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Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e37-44.  Back to cited text no. 5
    
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Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: From pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotechnol 2009;27:158-67.  Back to cited text no. 6
    
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Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part III: Leucocyte activation: A new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e51-5.  Back to cited text no. 7
    
8.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part II: Platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e45-50.  Back to cited text no. 8
    
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Varshosaz J, Tavakoli N, Saidian S. Development and physical characterization of a periodontal bioadhesive gel of metronidazole. Drug Deliv 2002;9:127-33.  Back to cited text no. 9
    
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Rizzo A, Paolillo R, Guida L, Annunziata M, Bevilacqua N, Tufano MA, et al. Effect of metronidazole and modulation of cytokine production on human periodontal ligament cells. Int Immunopharmacol 2010;10:744-50.  Back to cited text no. 10
    
11.
Kurtiş B, Unsal B, Cetiner D, Gültekin E, Ozcan G, Celebi N, et al. Effect of polylactide/glycolide (PLGA) membranes loaded with metronidazole on periodontal regeneration following guided tissue regeneration in dogs. J Periodontol 2002;73:694-700.  Back to cited text no. 11
    
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Mohindra K, Malhotra R, Grover V, Grover D. Bone regeneration using metronidazole containing collagen sponge in periodontal horizontal bone defect. Indian J Oral Sci 2014;5:128-33.  Back to cited text no. 12
  [Full text]  
13.
Tripthi PS, Rao SG, Bhat P. Platelet-Rich Fibrin (PRF) gel as a medium for local drug delivery of metronidazole. Int J Adv Health Sci 2014;1:113-22.  Back to cited text no. 13
    
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Needleman IG, Collins AM, Moles DR. Periodontal flap surgery with 25% metronidazole gel. (1). Clinical outcomes. J Clin Periodontol 2000;27:187-92.  Back to cited text no. 14
    
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Khiste SV, Naik TR. Platelet-rich fibrin as a biofuel for tissue regeneration. Hindawi Publishing corporation. ISRN Biomaterials 2013;2013:6.  Back to cited text no. 15
    
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Shah MP, Gujjari SK, Chandrasekhar VS. Evaluation of the effect of probiotic (inersan®) alone, combination of probiotic with doxycycline and doxycycline alone on aggressive periodontitis – A clinical and microbiological study. J Clin Diagn Res 2013;7:595-600.  Back to cited text no. 16
    
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18.
Mathur A, Bains VK, Gupta V, Jhingran R, Singh GP. Evaluation of intrabony defects treated with platelet-rich fibrin or autogenous bone graft: A comparative analysis. Eur J Dent 2015;9:100-8.  Back to cited text no. 18
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