Trends Biomater. Artif. Organs, 25(2), 86-90 (2011) http://www.sbaoi.

org

Platelet-Rich Plasma: A Novel Bioengineering Concept

Palwinder Kaur, Puneet, Varun Dahiya1
Department of Prosthodontics, Swami Devi Dyal Dental College & Hospital, Barwala, Distt. Panchkula. Haryana
1
Department of Periodontics, D J Dental College, Modinagar.
Corresponding author: Dr. Palwinder Kaur, e-mail: soniya.bagri@gmail.com

Received 19 August 2010; Accepted 12 January 2011; Available online 4 May 2011

A promising biologic therapy, offering various applications in dentistry is the use of platelet rich- plasma (PRP). PRP has became an
increasingly popular clinical tool as an alternative source of growth factors for several types of dental procedures. These growth
factors are described as promoters of tissue repair mechanisms and remodelling. The application of PRP in dentistry include sinus
grafting, periodontal soft and hard tissue surgical procedures, ridge augmentation, dental implant osseous-integration etc. The use
of PRP represents a relatively new concept of biotechnology that is becoming inseparable part of tissue engineering and cellular
therapy today. The purpose of this article is to update clinician’s knowledge about the preparation of PRP, its most efficacious
means of application and reviews the current literature on this emerging treatment modality.

Introdcution

Enhancement of the regenerative process of human body
by utilizing the patient’s own blood, is a unique concept
to dentistry. Platelet- rich plasma (PRP) is coming up as
a biological revolution in dental field. PRP represents a
similarity to the natural healing process, with the
application of multiple growth factors. Growth factors are
the biologically active substances that are involved in
tissue-repair mechanism such as chemotaxis, cell
proliferation, angiogenesis, extracellular matrix
deposition, and remodelling. Platelet- rich plasma (PRP)
has been traditionally used as a vehicle of growth factors.
A concentrated source of autologous platelets, PRP
contains and releases (through degranulation) at least
seven different growth factors (cytokines) that stimulate
bone and soft tissue healing. Each growth factor has the
capability to induce a unique response in the
enhancement of healing. Alpha granules are storage units
within platelets, which contain pre-packaged growth
factors in an inactive form. The main growth factors
contained in these granules are: PDGF (platelet derived
growth factor), TGF-â1 (transforming growth factor
beta1), TGF-â2 (transforming growth factor beta2), ILGF
(insulin like growth factor). PDGF is involved in the wound
healing procedures for its effects on mitosis,
angiogenesis, releasing of other growth factors. TGF-â1
and TGF-â2 stimulate chemotaxis and mitogenesis of
the osteoblasts ŠŠ(‘þ¨Šprecursors and inhibition of
osteoclasts ŠŠ(‘þ¨Š activity. ILGF has a role in the
activation of the osteoblasts ŠŠ(‘þ¨Š precursors and the
activation of the osteoblasts responsible for the deposition
of bone in the initial phases of bone regeneration. PRP
is more that just a platelet concentrate; it also contains
the 3 proteins in blood known to act as cell adhesion
molecules for osteoconduction and as a matrix for bone,
connective tissue, and epithelial migration. These cell
adhesion molecules are fibrin itself, fibronectin, and
vitronectin.
The autologous nature of PRP differ it from recombinant
human growth factors like rhPDGF, which are purely
human but are foreign growth factors to that person. [1]
The use of PRP in place of recombinant growth factors
has several advantages, in that growth factors obtained
from platelets not only have their own specific action on
tissues but also interact with other growth factors,
resulting in activation of gene expression and protein
production. As an autologous preparation, PRP requires
no considerations like antibody formation, effectively
preventing the risk of graft vs. host disease and leading
to better acceptance by patients. The short shelf life and
inefficient delivery to target cells are other major concerns
associated with local administration of recombinant
human growth factors.
Until now, the use of PRP use has been restricted to the
hospital setting. This was mainly due to the cost of
separating the platelets from the blood (thousands) and
the large amount of blood needed (one unit) to produce
a suitable quantity of platelets. . An easy, cost-effective
way to obtain high concentrations of growth factors for
tissue healing and regeneration is autologous platelet
storage via PRP. This new technology permits to safely
harvest and produce a sufficient quantity of platelets from
only 8-10 ml of blood drawn from patients in dental office.
 Platelet-Rich Plasma: A Novel Bioengineering Concept
Ease of procurement along with application of PRP in the
surgical dental practice, and its beneficial outcomes has
popularized it among the clinicians.
PRP preparation
Platelet rich plasma (PRP), is essentially an increased
concentration of autologous platelets suspended in a small
amount of plasma after centrifugation. Centrifugation
process accelerates the sedimentation of the heavier cells
such as white blood cells and red blood cells, while
platelets (which sediment to a lower rate) remain floating
within the plasma fraction at the top side of the tubes.
PRP can be prepared in a laboratory or surgical/dental
clinic from blood collected in the immediate preoperative
period. [2,3,4]
Basically, patient’s blood is collected ( approx. 50 cc)
and centrifuged at varying speeds until it separates into 3
layers: platelet poor plasma (PPP) on topmost layer, PRP
in middle, and red blood cells at the bottom. Usually 2
spins are used. The first spin (ŠHard spinŠ) separates the
platelet poor plasma (PPP) from the red fraction and
platelet rich plasma (PRP). The second spin (ŠSoft spinŠ)
separates the red fraction from the PRP. This is achieved
by simple bench centrifugation at high gravitational force.
After centrifugation, material with the highest specific
gravity (PRP) will be deposited at the bottom of the tube.
Immediately prior to application, a platelet activator/agonist
(topical bovine thrombin and 10% calcium chloride) is
added to activate the clotting cascade, producing a platelet
gel. The whole process takes approximately 12 minutes
and produces a platelet concentration of 3Š5x that of
native plasma. [5] Although the concentration of platelets
can vary depending on the method of extraction and
equipment, studies have shown that clinical benefit can
be obtained if the PRP used has an increased platelet
concentration of 4x greater than normal blood.
Recent studies have demonstrated that PRP prepared
from 8 to 10 ml of whole blood is sufficient for periodontal
regenerative therapies. [6,7,8] However, in oral and
maxillofacial reconstruction, 8 to 500ml of whole blood
should be drawn , so as to obtain the larger amounts of
PRP needed for larger surgical defects. The preparation
and processing of PRP is similar in most of commercial
systems available, except anticoagulant used, speed and
duration of centrifugation may vary with different systems.
Risk with PRP use
As the gel formation after isolation of PRP involve the
use of bovine thrombin, which may be associated with
antibodies to the factors 5, 9 and thrombin, resulting in
life threatening coagulopathies. Bovine thrombin
preparations has factor 5, which can stimulate immune
system if challenged by a foreign protein. Safer options
include the use of recombinant human thrombin or
autologous thrombin. Contraindications to the use of PRP
usage are rare and may include platelet dysfunction
syndrome, septicemia, anemia (Hg < 10 g/dL), critical
thrombocytopenia, hemodynamically unstable patients
and pregnancy. Therefore, the sequence of procedures,
healing periods and possible risk and complications should
be clearly explained to patients prior to treatment.
87
Mechanism of action of PRP
It is essential for understanding the biologic rationale of
PRP to know the role of platelets in wound healing. PRP
initiate wound repair by releasing locally acting growth
factors. These growth factors aid healing by attracting un-
differentiated cells in the newly formed matrix and
triggering cell division. PRP works via the degranulation
of the granules in platelets, which contain the synthesized
and prepackaged growth factors. The active secretion of
these growth factors is initiated by the clotting process of
blood and begins within 10 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. PRP
enhances the early wound-healing cascade by the
interactions of activated platelet-released growth factors
with the extra cellular matrix with potential potent anabolic
affects. Platelets in PRP also play a role in host defence
mechanism at the wound site by producing signalling
proteins that attract macrophages. [9]
Clinical application in dentistry
Utilizing the methods of enhancement of bone and soft
tissues regeneration with the use of PRP is becoming
more evident in many areas of dentistry such as
periodontics, oral implantology and oral and maxillofacial
surgery. These procedures are applicable for improving
the contour of alveolar ridge in relation to ideal pontic,
papilla esthetics for fixed partial prosthesis, healthy dento-
alveolar complex for periodontal attachment and bone for
dental implant placement. New bone formation is a
prerequisite for the regeneration of tissues lost through
periodontal disease and for the osseointegration of
implants used in restorative dentistry. [10]
Periodontal regeneration is a complex process of body.
The aim of regenerative periodontal procedures is to
induce regeneration at the alveolar bone and cementum
and to develop a new functional periodontal ligament. All
the mineralized and non mineralized components must
be restored to their original position and architecture for
regeneration of the periodontium to occur. Growth factors
exert regulatory effects on the homeostasis of the
periodontal tissues and they also have the ability of
modifying the response of periodontal soft and hard
tissues during the healing processes after their exogenous
application. [11] In periodontal surgery it has been used
in gingival grafting, crown lengthening and periodontal
regeneration.
In the field of implant dentistry, the most frequently
encountered hinderences at the implantation site are lack
of adequate bone available and proximity to anatomic
structures, such as the maxillary sinus and the inferior
alveolar nerve canal. Advanced surgical procedures that
act as an adjunct in dental implants consist of sinus
grafting and guided bone regeneration. With the
application of PRP in addition to autogenous grafts used
for these procedures like sinus lifts, ridge augmentations,
etc will promote and accelerate osseointegration process.
It is specially benefitted in maxilla , in cases of previous
implant failures, in type 4 bone, in osteoporotic women,
etc. [12] The ability to predictably augment the alveolar
88 P. Kaur, Puneet, V. Dahiya
ridge with deficient bone volume has greatly benefited
patients with such challenging situations. Block grafts offer
the advantage of slow resorption and easy fixation in the
site of compromised bone quantity. So the use of
autogenous bone has been recommended as the
preferred bone graft, with its osteogenic, osteoinductive
and osteoconductive properties.
In the field of oral and maxillofacial surgery, PRP has
proven to improve the surgical results in a variety of
procedures . Surgical sites enhanced with PRP have been
shown to heal at rates two to three times that of normal
surgical sites. Because PRP also enhance soft tissue
mucosal and skin healing, it is used in onlay grafts,
particulate grafts, alveolar cleft palate repair, oral/nasal
fistula repair, mucosal flaps for root coverage, post-
operative hemostasis of bone graft donor sites, continuity
defects of the mandible and hemophiliacs undergoing
surgery. Block grafts with PRP may be successfully used
in healthy patients with deficient alveolar ridges, restoring
the original bony architecture to accommodate a dental
implant. [13] Calcium sulfate-Platelet rich plasma is a novel
biomaterial able to induce osteogenesis in bone defects
created by removal of teeth, small cysts, and in various
clinical situations. [14] Promoting soft tissue healing and
rapid epithelialisation of skin also play a crucial role in
cosmetic dentistry. So the goal of accelerating healing
that we now gain with PRP by activating natural healing
process hold a promising future in advancing years of
dentistry.
Advantages
PRP offers many advantages in clinical use: it decreases
the chances of intraoperative and postoperative bleeding
at the donor and the recipient sites, also facilitates more
rapid soft-tissue wound healing, aids in the initial stability
of the grafted tissue at the recipient sites (as a result of its
cohesive and adhesive nature), may promote faster
vascularisation of the healing tissue by delivering growth
factors and, in combination with bone replacement
materials, that induces regeneration.
Benefits of PRP
PRP acting as a vehicle for growth factors offer several
advantages like ;(1) PRP is a by-product of the patient’s
own blood; therefore, chances of infectious disease
transmission is rare,(2) PRP can be easily generated in
the dental office while the patient is undergoing an
outpatient surgical procedure, like placement of dental
implants, extraction defects, variety of grafting and soft
tissue procedures,oral surgery etc.,(3) as there is super
saturation of the wound with PRP, and thus growth factors,
fasten tissue regeneration,(4) since PRP harvesting is
done with only 8-10 ml of blood, the patient need not bear
the expense of the harvesting procedure in hospital or at
the blood bank,(5) it is easy to handle and actually
improves the ease of application of bone substitute
materials by making them more gel-like,(6) preparation
time is relatively short and concentrate can be obtained
within 12 min.
Discussion
According to what has been found in literature, P.R.P has
got an important role in stimulation and acceleration of
bone and soft tissue healing. The first clinical dental results
with PRP were reported by Marx and others in 1998, who
used PRP to improve graft incorporation in mandibular
reconstructions in patients who had received cancellous
bone marrow grafts after tumor removal. Their data
strongly suggested that adding PRP to bone grafts
accelerated the rate and degree of bone formation.
Mineralization of collagen matrix is speeden up due to
PDGF that is present in the graft material , instead of being
released from collagen. The rate of bone formation also
has improved from 1.62 to 2.18 times that of the controls.
[15]
Improvement in trabecular bone density has been
reported in literature with the use of platelet rich plasma
in conjunction with graft. The patients undergoing implant
placement after extraction, who received a mixture of
autologous bone and PRP, much better epithelization and
compact mature bone with well-organized trabeculae was
demonstrated compared to the control group. Another
major benefit of PRP is Šjump startŠ osteogenesis by
releasing growth factors at the local site and early
consolidation of graft. This allows placement of implant
into the grafted site at an early time. Bone defects around
titanium implants could be treated successfully with bone
powder and PRP that improve bone formation. If a tooth
is extracted and the extraction site has poor healing, it
may delay the use of dental prosthetics or implants. In
such case use of PRP may aid in speeding up healing
and bone formation. PRP also allow earlier implant loading
and improved osseointegration when used in
compromised bone such as osteoporotic bone and bone
after radiotherapy. [16] In the field of periodontics, growth
factors have regulatory effects on homeostasis of the
periodontal soft and hard tissues upon their application.
In a recent in vitro study, significant mitogenic effect of
growth factors on human osteoblast-like and periodontal
ligament cells was demonstrated. In this study it was also
evaluated that gender and sex of the donor have no
influence in platelet-count or growth factor concentrations
in PRP. [17] Researchers are studying PDGF for its use
as an adjunct to regenerative therapy. Studies have found
that PDGF was the only growth factor that effectively
stimulated periodontal ligament fibroblast migration and
proliferation without the added risk of the patient
experiencing ankylosis of the teeth. When used in clinical
trials on beagles, PDGF-modulated guided tissue
regeneration, or GTR, therapy was shown to effectively
aid in the regeneration of periodontal furcation defects. It
was also shown in another study that PDGF-BB and TGF-
â1 exert mitogenic effect on human periodontal ligament
cells and human fibroblasts by promoting DNA synthesis.
[18] In addition, PRP was used in the treatment of severe
form of chronic periodontitis, with an improvement in the
depth reduction of gingival recession and clinical
attachment level. [19] Moreover, PRP has also shown
encouraging results when used in periodontal defects
combined with bone allograft and guided tissue
regeneration (GTR). Marx and coworkers also performed
a monoclonal antibody study on the platelets sequestered
by the centrifugation process and on the harvested bone
graft material. The data indicated that PDGF and TGF
from the platelets had been absorbed by the graft, and
receptors for PDGF and TGF were present within the
autogenous grafts They concluded that the addition of
 Platelet-Rich Plasma: A Novel Bioengineering Concept 89

PRP accelerated the rate and degree of bone formation
and that bone autografts contained platelets and thus were
positive for receptors for the growth factors. Furthermore,
it was noted that the PRP was an autologous preparation
obtained at the time of the surgery, thus eliminating
concerns about disease transmission, immunogenic
reactions, and mislabelling of the sample. [20, 21] Park
and colleagues conducted similar studies on beagles,
comparing the treatment of Class III furcation defects with
PDGF and GTR vs. with GTR alone. The study indicated
a statistically greater amount of bone and periodontal
ligament in sites treated with PDGF and GTR together
than in sites treated with GTR alone The newly formed
bone filled 80 percent of the lesion at eight weeks and 87
percent of the lesion at 11 weeks in the sites treated with
PDGF and GTR, compared with 14 percent of the lesion
at eight weeks and 60 percent at 11 weeks in sites treated
with GTR alone. Additionally, the sites treated with PDGF
and GTR seemed to have increased ratios of wanted to
unwanted tissue types filling the wounds as compared with
sites treated with GTR alone. [22]
Garg and coworkers proposed that resorbable barrier
membrane materials be infused with PRP. They have
proposed that this PRP-based membrane could serve as
a short-acting biologic barrier, since all platelets contained
in PRP will degranulate within 3 to 5 days, and their initial
growth activity expires within 10 days. So PRP infused
into resorbable barrier membranes tend to retard epithelial
migration and also provide localized growth factors to
accelerate hard and soft tissue maturation. Placement of
platelet rich fibrin membrane in recession defects can be
used to restore the functional properties of the labial
gingiva of mandibular anterior teeth by repairing gingival
defects and re-establishing the continuity and integrity of
the zone of keratinized gingiva. [23] PRP also enhances
soft tissue mucosal and skin healing, it is therefore used
in connective tissue grafts, palatal grafts, gingival grafts,
mucosal flaps together for root coverage, skin graft donor
etc. PRP has been a valuable adjunct in several oral
surgerical procedures ; they include ablative surgical
procedures, associated oroantral or oronasal fistulas,
mandibular reconstruction and surgical repair of alveolar
cleft. In these surgical procedures, the adhesive nature
of PRP allows easier handling of graft material, more
predictable flap adaptation and seal than with primary
closure alone. Along with this is the resultant release of
the previously mentioned growth factors.
In an attempt to enhance the bone grafting procedures,
clinicians have used different kinds of growth factors as
part of this innovative tissue-engineering concept. Platelet-
rich plasma has been proposed as potential stimulant of
bone and soft tissue healing. Kassolis and colleagues
reported that the successful use of PRP-augmented
demineralized freeze-dried bone allografts for alveolar
augmentation or sinus lift procedures before implant
placement. [24] More recently Forum and associates
concluded that when FDBA was used with PRP for
subantral sinus augmentation, results showed that the
application of PRP will only result in accelerated new bone
formation if target cells such as osteoblasts and osteocytes
are present. It was also reported that, PRP when combined
with inorganic bovine bone grafts, had no effect on defect
mineralization at any time point. This can be one of the
reasons that several studies using non vital grafting
material have failed to show any promoting effect. [25,
26] The incorporation of PRP into the sinus graft has been
proposed as a method to shorten healing time, enhance
wound healing, and improve bone quality. [27]
As the growth factors stimulate cellular proliferation, some
have shown concern that PRP might stimulate cancers.
Actually no growth factor can provoke a cancer. All growth
factors act on cell membranes, not the cell nucleus.
Growth factors activate an internal cytoplasmic signal
protein, to promotes a normal gene expression, rather
an abnormal gene expression. Growth factors are not
mutagens , but are normal body proteins. The specific
relation of PRP and cancer is nothing more than the same
blood clot that would be in any normal wound, except that
it contains a greater number of platelets. [12] So far most
of published researches showed it is safe to use the
product, however, future study in this area is certainly
needed.
Conclusion
The emerging science of transfusion medicine, as it
applies to regenerative therapy and the formation of an
autogenous platelet gel, still is a growing field in which
many studies are yet to be made. Although the growth
factors, ideal ratios of the components and exact
mechanisms, still are being investigated, and more clinical
research with long-term results is needed. With the
reduction in cost, the ease of applying PRP in dental clinic
provides a promising adjunct to dental surgical procedures
by promoting safe and natural healing. PRP with its
beneficial outcomes will definitely revolutionize the surgical
dentistry in the near future. It is the responsibility of the
clinician to gain a thorough understanding of this
biotechnology and to use it correctly and wisely for the
benefit and well being of our patients, who trust our
judgment.

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