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Volume 76 • Number 5

Evaluation of Demineralized Bone Matrix

Paste and Putty in Periodontal
Intraosseous Defects
Sara A. Bender,* Joanna B. Rogalski,† Michael P. Mills,‡ Ralph M. Arnold,‡ David L. Cochran,‡
and James T. Mellonig‡

Background: Demineralized bone matrix (DBX) paste and

putty are particulate demineralized bone matrices in a 2% or
4% hyaluronate carrier, respectively. The purpose of this study
was to determine the effectiveness of DBX paste and putty com-
pared to demineralized freeze-dried bone allograft (DFDBA) in
the treatment of human intraosseous periodontal defects.
Methods: Sixty systemically healthy individuals between the

R
egeneration of lost structures has
ages of 31 and 71 years with at least one intraosseous periodontal become the primary therapeutic goal
defect of ≥3 mm in depth and radiographic evidence of at least in periodontics over the past several
40% to 50% vertical bone loss were accrued. Following initial decades.1,2 The objectives of periodontal
non-surgical periodontal therapy, sites were randomly selected regenerative therapy are to reconstitute the
to receive either DBX paste, DBX putty, or DFDBA (control). bone, cementum, and periodontal ligament
Baseline and 6-month reentry soft and hard tissue parameter on a previously diseased root surface.3
measurements were made by calibrated examiners. Data were True regeneration can only be confirmed
analyzed within and between groups utilizing analysis of variance through histological analysis.4 Currently,
(ANOVA) and paired and unpaired Student t tests. autogenous grafts,5-7 demineralized freeze-
Results: Probing depth reductions were significantly improved dried bone allografts,8,9 biologic mediators
in all treatment groups with DFDBA, DBX paste, and putty alone10 or with demineralized freeze-dried
patients demonstrating 2.8 mm, 3.6 mm, and 2.3 mm, respec- bone allografts,11-13 citric acid,4 and bovine
tively. Attachment level gains were significantly improved from bone xenografts14,15 have demonstrated
baseline for all treatment groups with DFDBA, DBX paste, and regenerative potential. Demineralized
putty, respectively, demonstrating 2.4 mm, 2.9 mm, and 1.6 mm. freeze-dried bone allografts have repeat-
Bone fill was similar between all groups with DBX paste, putty, edly demonstrated significant improve-
and DFDBA control groups demonstrating 2.0 mm, 2.4 mm, and ments in both soft and hard clinical tissue
2.2 mm, respectively. All groups yielded significant improve- parameters the treatment of intraosseous
ments in percent bone fill with DFDBA, DBX paste and putty, periodontal defects.16-18
respectively, achieving 37%, 42.1%, and 50% with no significant Factors present in the demineralized
differences between the groups. bone graft material, bone morphogenic
Conclusion: In summary, demineralized bone matrix paste, proteins, stimulate local cell cycles to make
demineralized bone matrix putty, and demineralized freeze-dried new bone.19,20 The freeze-drying process
bone allograft all demonstrated similar favorable improvements destroys cells while maintaining cellular
in soft and hard tissue parameters in the treatment of human morphology and chemical integrity.21,22
intraosseous defects. J Periodontol 2005;76:768-777. These two factors have allowed clinicians
KEY WORDS to have access to a seemingly limitless
supply of graft material, and with new
Bone, demineralized; bone, freeze-dried; grafts, bone;
technologies emerging, to utilize it in con-
periodontal diseases/surgery; periodontal diseases/therapy.
junction with other materials to enhance
periodontal regeneration and/or bone
* Private practice, Frisco, TX; previously, Department of Periodontics, The University of fill.23
Texas Health Science Center at San Antonio, TX.
† Private practice, Houston, TX; previously, Department of Periodontics, The University of While particulate bone grafting mater-
Texas Health Science Center at San Antonio, TX. ials have traditionally been used in treat-
‡ Department of Periodontics, The University of Texas Health Science Center at San
Antonio, TX. ing intraosseous periodontal defects,
carriers have been investigated to aid
in the intraoperative manipulation and

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J Periodontol • May 2005
performance of the allograft material.24 A carrier must
be biocompatible, to eliminate the possibility of invok-
ing an immunogenic reaction, and biodegradable, with
a known period of degradation. In the instance of bone
grafting with the goal of regenerating lost tissues, it is
imperative that a carrier allow migration, adhesion,
and proliferation of osteoblastic progenitor cells and
allow or even potentiate the effects of local growth
factors.25
Sodium hyaluronate, one such carrier substance, is
an extracellular polysaccharide formed by plasma mem-
brane proteins and composed of N-acetylglucosamine
and glucuronic acid. Found in abundance throughout the
extracellular matrices, sodium hyaluronate provides a
structural role and, when located on cell surfaces, it
may influence cellular behavior. These cellular interac-
tions make sodium hyaluronate essential to cellular
proliferation, migration and adhesion in its respective
tissue.26,27
Sodium hyaluronate has proven to be extremely
safe when experimentally implanted into tissues.
Immunologically, hyaluronate demonstrates no adverse
reactions on cell viability or to cellular aggregation and
clumping. There is some evidence to show that the
inflammatory response, namely the phagocytic ability
of macrophages, may be marginally inhibited with
increasing concentrations or viscosity of hyaluronate.28
One study demonstrated hyaluronate to increase
migration and proliferation of endothelial cells and ulti-
mately angiogenesis.29 As such, hyaluronate may be
an ideal substrate to carry and initially stabilize de-
mineralized bone material at recipient sites.
DBX paste§ and putty
are, respectively, a 2% and
4% sodium hyaluronate mixture with human deminer-
alized bone matrix. The belief is that the 2% and 4%
sodium hyaluronate is biocompatible30 and can effec-
tively carry and stabilize allogenic bone matrix in the
recipient site, in this case, a periodontal intraosseous
defect. It is believed that the increased concentration
of the sodium hyaluronate solution will increase the vis-
cosity of the DBX paste and putty, consequently allow-
ing for a more manageable product for the clinician to
work with intraoperatively and a more stable graft in its
recipient site. The objective of this study is to evaluate
the effectiveness of DBX paste and putty compared to
demineralized freeze-dried bone allograft (DFDBA)¶ in
the treatment of human intraosseous periodontal defects.
MATERIALS AND METHODS
Patient Population
Sixty subjects between the ages of 31 and 71 years
with at least one site with chronic periodontitis were
chosen for this single-masked, randomized, controlled
clinical study. More than one site was averaged for an
N of one per patient. Each site demonstrated a radi-
ographic vertical defect with an associated probing
Bender, Rogalski, Mills, Arnold, Cochran, Mellonig
depth of ≥5 mm following initial non-surgical perio-
dontal therapy. Patients were systemically healthy with
no contraindications to periodontal surgical therapy.
Subjects were given oral and written explanations of
the study including the risks, benefits, expected time
requirements, and alternative therapies for a given site.
Prior to the surgical phase, each patient signed an
approved informed consent by The University of Texas
Health Science Center at San Antonio Institutional
Review Board.
All patients received initial therapy including oral
hygiene instruction, scaling and root planing utilizing
2% xylocaine with 1:100,000 epinephrine, and occlusal
adjustment when indicated. Re-evaluation examina-
tions were accomplished 4 to 6 weeks after initial ther-
apy to determine periodontal changes.31 Surgical
therapy was initiated on patients when adequate plaque
control, judged by a ≤20% O’Leary plaque index, was
demonstrated by each individual.32
Eligible sites were categorized as either 1-, 2-, or
3-wall or circumferential-type defects. Furcation defects
or intraosseous defects associated with furcation inva-
sions were not included as part of the study. All eligi-
ble teeth in the quadrant randomly received the same
treatment of either DBX paste, putty, or DFDBA.
Affected teeth in other quadrants were further ran-
domized to receive either DBX paste, putty, or DFDBA.
Sites were randomized by a coin toss between DBX
paste, DBX putty, and the positive control (DFDBA).
Clinical Data
Preoperative clinical measurements were recorded for
each patient the same day of the surgery. All soft and
hard tissue measurements were recorded with a 15 mm
University of North Carolina (UNC-15) periodontal
probe to the nearest millimeter by calibrated examin-
ers. Soft tissue measurements included: 1) probing
depth, measured from the free gingival margin (FGM)
to the base of the pocket (BP); 2) recession, measured
from the cemento-enamel junction (CEJ) to the FGM;
and 3) clinical attachment level, measured from the
CEJ to the BP. Hard tissue measurements included: 1)
CEJ to the base of the defect (BD) as a measure of
defect fill; 2) alveolar crest (AC) to the BD for defect
depth; and 3) CEJ-AC to determine crestal resorption.
If the CEJ was not available, measurements were made
from another identifiable fixed reference point (eg.,
restorative margin). Surgical findings and impressions
were recorded for future reference.
Surgical Protocol
Surgical sites were anesthetized with 2% xylocaine with
1:100,000 epinephrine. Intrasulcular incisions were made
§ DBX Paste, Musculoskeletal Transplant Foundation, Edison, NJ.

DBX Putty, Musculoskeletal Transplant Foundation.
¶ Musculoskeletal Transplant Foundation.
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Demineralized Bone Matrix in Periodontal Defects
and full-thickness flaps were reflected. Intraosseous
defects were debrided of granulation tissue and roots
planed with hand and ultrasonic instruments. Only sites
with a defect depth ≥3 mm were included in the study.
Hard tissue measurements were recorded to the nearest
millimeter.
Following hard tissue measurements, root surfaces
were treated with 50 mg/ml tetracycline-soaked cot-
ton pellets for 5 minutes to remove the smear layer,
detoxify the root surface, and expose dentinal tubules
and collagen.33,34 Intra-marrow penetrations were per-
formed at sites with thick cortical bone to increase
vascular supply to the area for healing.35 Copious 0.9%
NaCl irrigation was accomplished prior to defect fill
with graft material. Patients randomly received, deter-
mined by a toss of a coin, either DBX paste, DBX
putty, or DFDBA. Bone graft material was condensed
with sterile gauze. Flaps were reapproximated with 4-0
chromic gut suture and damp gauze pressure was
applied for 5 minutes. A periodontal dressing was then
placed on the buccal and lingual of the surgical site.
Patients were given verbal and written postopera-
tive instructions. Subjects were instructed to rinse
twice daily with 0.12% chlorhexidine# and avoid
brushing and flossing of the area for 7 to 10 days
postoperatively. Analgesics were prescribed for post-
operative discomfort and doxycycline 100 mg two
times daily for 10 days for prevention of infection.
Postoperative visits were made at 7 to 10 days, when
the periodontal dressing and sutures were removed,
at 25 to 30 days, and at three and six months. Oral
hygiene was reinforced at each postoperative visit
and supragingival debridement accomplished as
needed.
At the 6-month postoperative visit, soft tissue para-
meters, including probing depth, recession, and clinical
attachment level, were recorded and a non-standardized
periapical radiograph was taken. Surgical reentry was
accomplished on previously grafted sites to re-record
hard tissue measurements. Residual intraosseous defects
of at least 2 mm were re-grafted with DFDBA. Other-
wise, osseous recontouring was accomplished as
deemed appropriate to improve tissue adaptation and
healing. Patients were postoperatively evaluated at 7 to
10 days and subsequently placed on a 3-month perio-
dontal maintenance protocol.
Statistical Analysis
Paired Student t tests were performed to determine if
pre- and post-treatment soft and hard tissue measures
were significantly different from baseline within each
group. One-way ANOVAs were performed to deter-
mine if significant differences were observed among
treatment groups with respect to pre- and post-treat-
ment means for probing measures. In addition, one-
way ANOVAs were performed to determine if the
770
Volume 76 • Number 5
means for treatment outcome measures including
recession, probing depth reduction, attachment level
gain, crestal resorption, bone fill (mm), % bone fill,
and % defect resolution were significantly different
between treatment groups. If the F test for the ANOVA
was significant (P <0.05), then Sidak-adjusted pair-
wise comparisons were performed to identify group
differences, with P <0.05 considered significant.
Two-way ANOVAs were used to compare the experi-
mental and control data sets for the maxilla and
mandible. This was followed by unpaired Student t tests
for the maxilla and mandible within each treatment
group. Only unpaired Student t tests were performed
to compare anterior and posterior teeth for the control
and experimental groups together since too few ante-
rior teeth were treated to utilize a two-way ANOVA
analysis.
The data were examined statistically to detect gross
errors that may have occurred during data entry.
Means, ranges, and standard deviations were calcu-
lated for all recorded parameters and calculations.
Probabilities <0.05 were considered statistically
significant.
RESULTS
A total of 60 sites, 20 in the DFDBA control group, 20
in the DBX paste and 20 in the DBX putty test group,
were enrolled in the study. Number of sites based on
arch, tooth type, number of osseous walls and smok-
ing status are reported in Table 1. Three control and
no paste or putty sites were lost between baseline mea-
surements and 6-month reentry surgery, leaving 17
control sites and 40 test sites for statistical analysis. One
DFDBA, 11 DBX paste, and four DBX putty sites were
in smokers. No adverse effects or complications were
reported for either the paste, putty, or the DFDBA post-
operative healing. All sites were reentered at 6 months
or later from the initial surgery. Similar plaque levels
were found at the reentry surgery as were found at
baseline surgery. Analysis confirmed 93.3% agreement
within 1 mm for soft and hard tissue measurements
between calibrated examiners. Figures 1 through 3
demonstrate radiographs, and presurgical, surgical, and
reentry clinical photographs for DFDBA, DBX paste,
and putty.
Of the 57 grafted sites, 25 were maxillary and 32
were mandibular teeth. Of these, five were incisors, 11
canines, 21 premolars, and 20 molars. Forty-two of the
grafted sites were 2-wall defects with nine 3-wall defects,
one 1-wall defect, and five circumferential defects
(Table 1). While no significant differences existed in the
outcome measures with respect to the number of
osseous walls per defect, only a single 1-wall defect (a
maxillary first molar with furcation involvement and
# Peridex, Zila Pharmaceuticals, Phoenix, AZ.
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J Periodontol • May 2005 Bender, Rogalski, Mills, Arnold, Cochran, Mellonig

Table 1. recession, post-surgical probing depth, PDR, and ALG

(F test, P >0.05). It was determined that the dispropor-
Number of Sites by Arch, Tooth Type,
tionate number of smokers (11 subjects) in the DBX
Number of Osseous Walls, and Smoking paste group confounded the results when comparing
Status parameters between groups. These differences were
attributed to DBX paste baseline soft tissue measure-
DFDBA Paste Putty ments, specifically the baseline recession in these indi-
Category (N = 17) (N = 20) (N = 20) viduals, 1.5 ± 1.4 mm compared to 0.3 ± 0.7 mm and
Maxilla 7 7 11
0.4 ± 0.8 mm in DFDBA and DBX putty groups, respec-
tively (Table 2). This difference was translated into the
Mandible 10 13 9 post-surgical measurements, confounding the overall
Incisor 0 2 3
mean results and statistical comparisons. When DBX
paste parameters were analyzed independent of the
Canine 0 9 2 other two groups, it was concluded that DBX paste
Premolar 8 6 7
demonstrated a positive and significantly improved
response to the treatment and differences between
Molar 9 3 8 groups were attributed to the disparity in baseline para-
3 osseous walls 2 1 6
meters (t test, P <0.001) (Table 4).

2 osseous walls 13 19 10 Hard Tissue Results (Table 3)

1 osseous wall 1 0 0
Circumferential 1 0 4 defect resolution (%DR) in all treatment groups com-
Smoker 1 11 4
treated with DFDBA) was available for analysis and
consequently not available for comparison.
Statistically significant improvements were demon-
strated in all soft and hard tissue parameters in all
treatment groups from baseline to reentry (t test
P <0.001). Baseline PD, CAL, and surgical defect depth
(AC-BD) for DFDBA control sites were 7.6 ± 2.1 mm,
7.9 ± 2.5 mm, and 5.5 ± 2.5 mm, respectively. Like-
wise, baseline PD, CAL, and AC-BD for DBX paste
were 6.7 ± 1.4 mm, 8.2 ± 1.7 mm, and 4.8 ± 1.6 mm
and for DBX putty, 7.1 ± 1.2 mm, 7.5 ± 1.3 mm, and
5.1 ± 1.2 mm, respectively (Tables 2 and 3).
Soft Tissue Results (Table 2)
There were statistically significant improvements in
both the postoperative probing depth reductions (PDR)
and clinical attachment level gains (ALG) when com-
pared to preoperative values for all treatment groups
(P <0.001). No significant differences were found in
mean recession between the control group, 0.4 ± 0.8 mm,
and the paste, 1.0 ± 1.1 mm, and putty groups, 0.8 ±
1.2 mm. The PDR in the DFDBA group was 2.8 ±
1.8 mm and for the paste and putty groups, 3.6 ±
1.5 mm and 2.3 ± 1.3 mm, respectively. Likewise, the
ALG was significantly improved for the DFDBA control
group by 2.4 ± 1.8 mm and the paste and putty groups
by 2.9 ± 1.9 mm and 1.6 ± 1.1 mm, respectively. There
were statistically significant differences between the
three groups with respect to pre- and post-surgical
There were statistically significant improvements in
the bone fill (BF), percent bone fill (%BF), and percent
pared to baseline values (t test, P <0.001) with no sta-
tistically significant differences between the three
treatment groups (F test, P <0.05). The amount of cre-
stal resorption was not significantly different between
the three groups with the DFDBA group exhibiting a
mean 0.4 ± 1.2 mm and the paste and putty groups
exhibiting 0.8 ± 1.0 mm and 0.4 ± 0.7 mm, respec-
tively (F test, P >0.30). Six-month reentry data showed
a mean bone fill of 2.2 ± 1.8 mm, 2.0 ± 1.6 mm, and
2.4 ± 1.0 mm, respectively for DFDBA, paste, and
putty groups (F test, P >0.60). This correlates with a
mean percent bone fill between the DFDBA, paste and
putty groups of 37.0% ± 18.7%, 42.1% ± 34.4%, and
50.0% ± 25.0%, respectively. Statistically significant
differences did not exist between the three treatment
groups (F test, P >0.30). The control group exhibited
a percent defect resolution of 47.2% ± 25.3% and the
paste and putty groups showed a 59.1% ± 33.8% and
57.2% ± 21.1% defect resolution, respectively, with no
significant differences existing between treatment
groups (F test, P >0.30). Statistically significant dif-
ferences did not exist between the DFDBA and paste
and putty groups with respect to bone fill, percent bone
fill, and percent defect resolution (Table 3).
DISCUSSION
In this study, DBX paste and putty were investigated to
evaluate their ability to resolve periodontal intraosseous
defects, intraoperative handling characteristics, and to
report any adverse effects that may ensue from their
use. DBX paste and putty were compared to DFDBA
with respect to the magnitude of defect resolution. The
results indicate no statistically significant differences in

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Demineralized Bone Matrix in Periodontal Defects Volume 76 • Number 5

Figure 1.
Sample DFDBA site. A) Periapical radiograph demonstrating vertical defect mesial to #13. B) Exposure of a 3-wall defect measuring 3 mm in depth.
C) DFDBA in place prior to suturing. D) Reentry surgery demonstrating 1 mm residual defect. E) Six-month periapical radiograph consistent with
positive results.

probing depth reductions, attachment level gain, reces-
sion, bone fill, percent bone fill or percent defect reso-
lution between DFDBA and DBX paste and putty. With
respect to probing depth reduction, all materials exhib-
ited significant improvements from baseline with mean
2.8 ± 1.8 mm, 3.6 ± 1.5 mm, and 2.3 ± 1.3 mm, respec-
tively. Likewise, favorable attachment level gains were
seen in all three groups with DFDBA exhibiting 2.4 ± 1.8
mm and DBX paste and putty exhibiting 2.9 ± 1.9 mm
and 1.6 ± 1.1 mm, respectively.

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J Periodontol • May 2005 Bender, Rogalski, Mills, Arnold, Cochran, Mellonig

Figure 2.
Sample DBX paste site. A) Vertical bitewing radiograph demonstrating vertical defect mesial to #19. B) Exposure of a 2-wall defect measuring 8 mm
in depth. C) Reentry surgery demonstrating 4 mm residual defect. D) Six-month periapical radiograph consistent with positive results.

There was a disproportionately greater number of
smokers in the DBX paste group (11 subjects) com-
pared to DFDBA (one subject) and DBX putty (four
subjects). Previous studies have shown increased prob-
ing depths, bone loss, and attachment loss in smok-
ers.36-38 The DBX paste group presented with shallower
probing depths, less attachment loss, and significantly
greater recession than the other two treatment groups
at baseline. Treatment resulted in probing depth values
significantly lower for DBX paste than the DFDBA con-
trol and DBX putty groups but similar post-treatment
attachment levels. The unequivocal presurgical and

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Demineralized Bone Matrix in Periodontal Defects Volume 76 • Number 5

Figure 3.
Sample DBX putty site. A) Periapical radiograph demonstrating vertical defect distal to #13. B) Exposure of the circumferential-type defect measuring
3 mm in depth. C) DBX putty in place prior to suturing. D) Reentry surgery demonstrating 1 mm residual defect. E) Six-month periapical radiograph
consistent with positive results.

post-surgical recession exhibited in the DBX paste group
confounded the comparisons between groups. However,
similar to previous studies, the DBX paste group with
its disproportionately greater number of smokers,
demonstrated a positive response to therapy.39,40
All materials demonstrated similar bone fill of 2.2 ±
1.8 mm, 2.0 ± 1.6 mm, and 2.4 ± 1.0 mm for DFDBA,
DBX paste, and putty, respectively. These results were
statistically significant with respect to baseline mea-
surements with no statistically significant differences

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Table 2. Table 4.
Soft Tissue Responses (mm) DBX Paste Baseline and Reentry
Means (mm)
DFDBA F Test
Parameter (Control) Paste Putty P Value Parameter Outcome Paired t Test P Value
Pre-surgical PD 7.6 ± 2.1 6.7 ± 1.4 7.1 ± 1.2 >0.20 Probing depth reduction 3.6 ± 1.5 <0.001*
Post-surgical PD 4.8 ± 1.3* 3.1 ± 0.8* 4.9 ± 1.2* <0.001† Recession 1.0 ± 1.1 <0.005*
Pre-surgical 7.9 ± 2.5 8.2 ± 1.7 7.5 ± 1.3 >0.40 Attachment level gain 2.9 ± 1.9 <0.001*
attachment level
Crestal resorption 0.8 ± 1.0 <0.005*
Post-surgical 5.5 ± 1.7 5.3 ± 1.6 6.0 ± 1.3 >0.40
attachment level Bone fill 2.0 ± 1.6 <0.001*

Pre-surgical recession 0.3 ± 0.7 1.5 ± 1.4 0.4 ± 0.8 <0.01† Bone fill (%) 42.1 ± 34.4 <0.001*

Post-surgical recession 0.7 ± 1.0 2.2 ± 1.4 1.1 ± 1.4 <0.005† Defect resolution (%) 59.1 ± 33.8 <0.001*
* Statistically significant differences from preoperative measurements
Probing depth 2.8 ± 1.8 3.6 ± 1.5 2.3 ± 1.3 <0.035† (P <0.05).
reduction

Mean treatment 0.4 ± 0.8 1.0 ± 1.1 0.8 ± 1.2 >0.25

recession When comparing defect resolution, all groups had sim-
ilar significant improvements with DFDBA, DBX paste,
Attachment 2.4 ± 1.8 2.9 ± 1.9 1.6 ± 1.1 <0.40† and putty exhibiting 47.2% ± 25.3%, 59.1% ± 33.8%,
level gain and 57.2% ± 21.1% resolution, respectively.
* Statistically significant differences from pre-operative measurements While there were no statistically significant differ-
(P <0.001).
† Statistically significant difference between treatment groups (P <0.05). ences between the three groups with respect to per-
cent defect fill, a mean 38.5% defect fill for DFDBA is
somewhat lower than results found in previous studies,
Table 3. which resulted in a mean 60% defect fill.16-18 In larger
multicenter studies using FDBA to treat intraosseous
Hard Tissue Responses (mm)
defects, approximately 60% of sites had >50% defect
fill with 23% of these exhibiting complete defect fill.41,42
DFDBA F Test
In this study, only 30% (5/17) of subjects treated with
Parameter (Control) Paste Putty P Value
DFDBA exhibited >50% defect fill, and 12% (2/17)
Original 5.5 ± 2.5 4.8 ± 1.6 5.1 ± 1.2 >0.50 exhibited no fill. Of those exhibiting no fill, one was the
defect depth mesial of a first maxillary molar with a 1-wall defect.
The other defect was of the mesial of a mandibular
Residual 2.9 ± 1.8* 2.0 ± 1.7* 2.3 ± 1.3* >0.20
defect depth
first molar with significant crestal resorption. In both
instances, root morphology with associated grooves
Amount bone fill 2.2 ± 1.8 2.0 ± 1.6 2.4 ± 1.0 >0.60 and concavities could have played a role in the rela-
Bone fill (%) 37.0 ± 18.7 42.1 ± 34.4 50.0 ± 25.0 >0.30
tive inability to properly debride and prepare the tooth
for the graft material.43,44
Crestal resorption 0.4 ± 1.2 0.8 ± 1.0 0.4 ± 0.7 >0.30 DBX paste and putty were relatively simple to use
Defect 47.2 ± 25.3 59.1 ± 33.8 57.2 ± 21.0 >0.35
with respect to their intraoperative handling charac-
resolution (%) teristics. The materials were condensed into the defect
sites with damp sterile gauze similar to the manner in
* Statistically significant differences from preoperative measurements
(P <0.001). which DFDBA is condensed into a site. However, heav-
ier pressure caused extrusion of the paste and putty
material out of the defect site. It was also observed
between the treatment groups. These finding are also that the DBX paste and putty tended to lose their
similar to results in previous studies utilizing DFDBA or respective paste or putty consistencies in sites with
FDBA with a range of 1.7 to 2.6 mm mean defect poor hemorrhage control. While not reflected in the
fill.16-18 All materials had significant percent bone fill at data or outcome, DFDBA sites exhibited more dense
37.0% ± 18.7% for DFDBA, 42.1% ± 34.4%, and 50.0% ± bone fill with respect to resistance to a periodontal
25.0% for DBX paste and putty, respectively, with no sig- probe during the reentry surgery. During the reentry
nificant differences existing between the three groups. procedure, the paste and putty sites tended to exhibit

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Demineralized Bone Matrix in Periodontal Defects
a more fibrous-like consistency than DFDBA and had
portions of the graft material that appeared to be
encapsulated and subsequently enucleated from the
defect site leaving a residual defect.
A potential confounder to this study is the 6-month
healing period before reentry surgeries. It is feasible
that debridement of the successfully grafted sites at
the reentry surgery may have inadvertently removed
immature bone. For this reason, one year reentry surg-
eries may be preferred to allow more time for bone
maturation and mineralization. Further investigation
into this subject is warranted to determine the magni-
tude of difference in bone fill results from reentry pro-
cedures attempted at various time points.
Subject variation is also an inherent drawback to
clinical studies, with the inability to control daily oral
hygiene efforts, subject health including the use of
medications, and habits such as smoking. Moreover,
each site is unique with respect to its defect and root
morphology in addition to local variations, for exam-
ple, restorative margins, interproximal, and occlusal
contacts, malalignment of teeth, and access for oral
hygiene measures.
This study demonstrated that DFDBA, DBX paste
and putty were all equally effective in achieving bone
fill in a grafted periodontal intraosseous defect. How-
ever, no conclusions may be made regarding the
regenerative ability of DBX paste and putty. Histolog-
ical evaluation with proof of new bone, cementum, and
periodontal ligament formation on a previously dis-
eased root surface would have to be established to
make such conclusions. DFDBA has the potential to
stimulate regeneration, and it is likely that DBX paste
and putty would have a similar histological outcome.
It can be concluded that the amount of defect fill
in millimeters, percent defect fill, and percent defect
resolution were significantly improved at 6-month reen-
try compared to baseline in the DFDBA, DBX paste,
and DBX putty-treated sites, with no statistically sig-
nificant differences between the three groups. Like-
wise, soft tissue measurements including probing depth
reduction and clinical attachment level gain at 6-month
reentry demonstrated statistically significant improve-
ments in all treatment groups compared to baseline.
However, no statistically significant differences between
the DBX paste, putty, and DFDBA-treated groups were
observed. Additionally, no statistically significant dif-
ferences existed in crestal resorption experienced by
any treatment group at the 6-month reentry. Finally,
no sites in any group exhibited adverse reactions to
either DBX paste, putty, or DFDBA.
ACKNOWLEDGMENTS
The authors thank The Musculoskeletal Transplant
Foundation, Edison, New Jersey for providing the
materials used in this study. We would also like to
776
Volume 76 • Number 5
thank Mr. John Schoolfield at The University of Texas
Health Science Center at San Antonio in the Center for
Academic Information for his statistical support in
analyzing the data. Thank you to Judy Doerr at The
University of Texas Health Science Center at San Antonio
Department of Periodontics for her assistance and
support.
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Correspondence: Dr. James T. Mellonig, Department of
Periodontics, MSC 7894, The University of Texas Health Sci-
ence Center at San Antonio, 7703 Floyd Curl Dr., San Antonio,
TX 78229-3900. Fax: 210/567-6858.
Accepted for publication September 20, 2004.
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