Joseph Matthews DDS
One year after treatment, areas treated with enamel matrix derivative (EMD) showed improved periodontal attachment levels (PAL) and periodontal probing depth (PPD) compared to either no treatment or guided tissue regeneration (GTR), but these results warrant cautious interpretation.
In adult patients with intrabony periodontal defects, how does treatment with EMD compare to no treatment, GTR or bone grafting procedures when assessing PAL and PPD?
The authors searched four databases up to February 2009 without restrictions on publication status or language. Only randomized controlled trials (RCTs) treating intrabony defects greater than three millimeters with follow-up of at least one year were considered. The authors assessed PAL, PPD and recession (REC) as the primary outcomes, along with notes regarding any post-operative complications.
A total of 13 trials were included in the final review. A meta-analysis (9 trials) showed that EMD treated sites displayed statistically significant PAL improvements (mean difference 1.1mm, 95 percent confidence interval [CI] 0.61 to 1.55) and PPD reduction (0.9mm, CI 0.44 to 1.31) at one year after treatment when compared to placebo or control treated sites, though a high degree of heterogeneity was found. Significantly more sites had
These results should be interpreted with great caution due to the heterogeneity found among trials and because trials judged to be at a lower risk of bias showed less benefit from the use of EMD. The review found that application of EMD regenerates about 1mm more tissue than surgical cleaning alone. EMD showed similar clinical results to GTR. Because GTR is technique sensitive and leads to significantly more post-op complications such as wound dehiscence and suppuration, EMD was found to be much simpler to use. However, because RCTs included in this review only assessed 1-year follow-up, it cannot be concluded that more compromised teeth can be saved using EMD. Future trials should evaluate long-term follow-up for possible recurrence of these intrabony defects and their aesthetic results as well as EMD in combination with other treatments.
Source of Funding:
Institutional support through School of Dentistry, University of Manchester, UK.
Importance and Context:
Approximately 7% of adults in the US suffer from moderate to severe periodontal disease [Prevalence of Periodontal Disease in the United States: NHANES 1999-2004]. Without treatment, further destruction of the periodontium is likely with resulting tooth loss, diminution of function and compromised aesthetics. When possible the usual path of treatment is improving patient care and eliminating periodontal infection followed by soft tissue and bone reconstruction. Deciding if treatment will improve the prognosis as well as which treatment is the most appropriate one are important and challenging decisions. Therefore, providing practitioners and patients with current information about available treatments and their likely outcomes is an ongoing effort for research and review. Although studies have investigated the use of EMD in treating intrabony defects, the results of those studies should be synthesized for review and evaluation.
Strengths and Weaknesses of the Systematic Review:
The authors conducted a thorough systematic review. Their appraisal method compares favorably with the measurement tool AMSTAR, assessment of multiple systematic reviews. The authors searched published and unpublished English and non-English RCTs and applied clear inclusion and exclusion criteria. A transparent process of study selection and quality assessment was reported and meta-analyses were undertaken when combination of trial results was appropriate. The review considered at least three clinical questions instead of a single question which can complicate interpretation.
Strengths and Weaknesses of the Evidence:
The use of multiple RCTs is a strong experimental design for answering the clinical questions. However, four of five RCTs were rated as high risk for bias when comparing EMD to GTR. This weakens the authors' conclusion that no difference exists between treatment results of EMD and GTR. Also, the authors' comparison of EMD with bone substitute included only one high quality RCT which weakens their finding that bone substitute is associated with less recession. Significantly, these studies generally included patients in good health who do not smoke. In addition, a strict follow-up regimen (such as weekly supragingival prophylaxis) was required for their participation. Such conditions may not reflect actual practice. No evaluation of tooth loss was possible due to a limited follow-up period. No estimation of cost to benefit was discussed.
Implications for Dental Practice:
Intrabony defects must be addressed early in the disease process to maximize treatment benefits. There is limited evidence that new treatments such as EMD show improved results when compared to flap surgery alone. However, this improvement may be small and not necessarily clinically evident . In addition to the results of this systematic review, the clinician’s decision to use EBD, GTR or bone grafting should consider their skill and familiarity with the procedures, as well as careful patient selection and the patient's aesthetic expectations. Patient motivation and follow-up must be maintained to achieve a favorable long-term prognosis.