Benefits of PRP and PRGF: Does the Clinical Experience Support the Literature?

Here is my two cents. I have used PRP and PRGF both have there benefits. I think they both work well in soft tissue applications. I think both have minimal effects for bone. Although I think some of the problem with the PRP research is PRP can vary based on what technique/machine is used. A good review is in compendium on PRP is article entitle is : Surgical considerations in the use of platelet-rich plasma. Pubmed it. I think the future of platelet concentration is going to be (PRF) Platelet Rich Fibrin. I think your going to see appplications for both bone and soft tissue and it actually work for bone, the growth factors are released over time instead of right away as with PRP. There is a great review article in October's JIACD By Toffler entitled Introduction of Platelet Rich Fibrin to the Surgical Mellieu, if can be retrived online, it is a good read and tells you what you need to know. There are other research articles in OOOOE by Choukrouns and Dohan and one by Lin that show the research and some results on PRF. Bottom line PRP and PRGF good for Soft tissue, questionable bone....Future lies with PRF.

I have to say I read the Toffler article in jiacd and it was good background article that is a must read but would like to see more results. PRP, and PRGF havent really added anything to my practice. They are good for soft tissue and not much else. Will wait to see some results and lectures on PRF before I add it to my practice.

I stopped using PRP long ago. PRGF is a mainstay in my practice. BTI has alot of research out in Spain. Works well for both bone and soft tissue. Linkow PRF is looks interesting not sure if I would call it the future yet, need more research that PRGF already has behind it. I read the toffler article it was a good background article. Dr. C dont waste your time with PRP, look into PRGF.

i have been using PRP for about three years and I have a service come in and hands me the gun. I use both PRP and PPP and I am excited tolearn more about the new PRF from France.The healing with the PRP and PPP in one week looks like the pt has healed one month. I love it and suggest it for anyone. A great technique is to dip the implant in PRP before inserting. Amazing!

I have used PRP in the past and had good results in term of soft tissue healing yet the effect on bone regen is minimal.In the pat two years I have been using choukroon's PRF with graet results.There is no doubt it promotes bone healing having the growth factors from both the platelets and from the leukocytes.PRP acts short term only at the time of application while PRF has a slow release mechanism of growth factors at least for 7 days post application. An article submitted by me to J Perio was accepted for publication in the next few months showing use of PRF as sole grafting material for sinus augmentation with simultaneous implants placement.

PRP may be good for a faster wound healing in major bone graftings but it does not mean it will make your case more successful. In fact, the venipuncture will add some discomfort to patients plus additional overhead clinical time and management.

I had the same question. At the 2008 AAID meeting it was the concensus that it sped up healing,BUT there was no difference at 4-6 months later. There are some great docs on both sides of the fence as far as how usefull is it. MOST will agree if you look at a patient a year later you couldn't tell the PRP from the non PRP patient. your choice, is it worth it?

There will be more articles coming out on the clinical applications of PRF. In addition to Ziv Mazor's(who turned me on to PRF) paper on lateral windows and PRF, there will be papers demonstrating PRF benefits in extraction sites and ridge augmentation. Next week I will be submitting an article to J Perio on using PRF as the sole graft material in osteotome-mediated sinus floor elevation (same topic published by Diss et al in triple O). PRF predictably elevates the sinus floor and increases the safety of the procedure. There will be courses available on PRF prep and application in 2010. Watch online at journal Implant and Advanced clinical dentistry (jiacd.com) for the dates and description.

Mazor I have seen your research in the Sinus and it is to be respected. How can you be so sure the PRF is released 7 days out. I heard the same thing with PRP and PRGF by Antiua. Yet I only see soft tissue applications and not bony applications. Please explain.

Toffler I read your article online in the jiacd and it was well done. That being said I am vexed by how you can use PRF in a closed technique. Its not hard as bone and wont it just be squashed when you tap it in the sinus? I think bone would be a better option to hold the membrane up in a closed technique. I look forward to your next paper.

Dr Mraz I have recently completed a book chapter on osteotome sinus floor elevation for Dr Michael Sonicks upcoming book entitled Implant Site Development where I reviewed all the osteotome literature and I can assure you that graft material is not needeed for osteotome sinus floor elevation. Success rates are equivocal using graft or no graft with avg sinus floor elevation of 3 to 4 mm. I have not used graft material since incorporating PRF into the osteotome procedure. As long as the membrane is tented by the implant bone will form at the apex. PRF may help in the tenting, healing and membrane repair in case of a tear. I hope to have the new PRF protocol published soon. We will be giving couses in New York in 2010 which will include PRF application in sinus floor elevation. Look at jiacd.com for announcement.

See publication Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology Volume 108, Number 5, November 2009 p 707 for explanation PRF sustained release vs. PRP

Interesting comments and claims made on this site with very little evidence to support the claims. Anecdotal case reports and series do not constitute evidence. To see hype and marketing of "courses" based on poor evidence and hype for the sole purpose of selling courses is very disturbing to say the least.

Lindhe I disagree with you. There is plenty of evidence, Prehaps you heard of pubmed. Put platelet rich fibrin dental into the search. There is no less 20 articles. If you put platelet rich fibrin alone to include medical articles you get 500+. Granted there arent any randomized controlled clinical trials out there. But how many techniques, materials out there have those kind of studies?????? minimal.

Furthermore, alot of evidence we base our work in are case reports and case series so I dont know how you can say there is no evidence. Vercellotti's piezosurgery almost all the papers are case reports and case series yet there is a piezo unit in almost every office today. Would you say the same about piezo since its is supported by mostly case series and reports?

You should read Jung's systematic review on growth factors as well as Boyapati and Wang's systematic review on PRP. Both are well written and a high level of evidence not influenced by company funding. Also, the temporal release kinetics, even if done slowly, may not be optimum. Look at how BMP upregulates noggin and can actually inhibit bone formation around an implant. You can see this in Wikesjo's dog studies...less bone to implant contact. At this point, people are throwing pixie dust into the mix with little understanding of cytokine interplay and wound healing kinetics which aren't well known enough at this point,.

Linkow, with all due respect, your statements that there are "plenty of evidence" based on a pubmed search illustrates your lack of understanding of the critical analysis of the available evidence. You mistaken the availability of published articles with science. If your reasoning is correct, then you should go to pubmed and look up treatment for hair loss. You will have no less than 10,000 articles, yet according to available date, 99% of the available treatment marketed to day are considered ineffective. The reality is, there is currently a lack of evidence to support the use of PRP or PRF for sinus augmentation or bone augmentation. How do you justify charging patients and subjecting them to procedures and techniques where there is poor and anecdotal evidence (at best) for what you do ? Especially, when we can achieve the same results, according to good evidence, without such intervention.

Linde I understand evidence based dentistry just fine. When I said do a pubmed search, if you read the articles that you find in pub med you will find plenty of evidence to use PRF. Is it the magic bullit....No Is more research needed....absolutely....but I feel there is more promise there in PRF then in PRP and PRGF. Which go back and read my orginal statement. We base are treatment of patients on the evidence we have at hand. There is not alot of evidence to support the use of millennium laser for the treatment of periodontal disease, yet there are 100's of dentist using it. There is more evidence to support that a delay implant placement approach is more successful then doing immediates yet people place immediates all the time. So to go back to your rude and insulting comment that "a pubmed search illustrates your lack of understanding of the critical analysis of the available evidence." I actually pull the articles and read them and dont just look at the abstracts!!!!

Who is calling themselves Linkow, other than Leonard I. Linkow?

I agree that there is ample research to support use of PRF. It is currently a mainstay of my surgical approach to bone grafting. Sure, more research is needed but at this time I believe it to be a minimally invasive beneficial procedure for our patients. My results personally have been excellent regarding soft tissue healing, lack of infection and volume maintenance. I do not actually charge extra for it because it is simple, inexpensive and fast. Anecdotally, post op pain and edema seem to be less.

I totally agree with both Howard and Linkow. Using PRF doesn't involve additional expenses or machinary except for the simple centrifuge. There is plenty of research done on this specific entity. Specifically on sinuses there is an article I submitted and accepted for publication on grafting the sinus with PRF only with simultaneous implants placement with CT post op and histology. It will be coming out in the next few months.

Dr. Ziv Mazor, and what do you think would have happened if you had not placed the PRF ? Are you saying that if you had not placed PRF, there would not have been bone formation ? Did you do a split mouth or did you have a control to compare or test your intervention ? Study by Lundgren demonstrates that you don't need to place anything except for lifting of the membrane, to predictably grow bone in the sinus...every single case that he did. Numerous other studies demonstrate that you only need to place a piece of gelfoam (without BMP) to generate bone consistently underneath the sinus membrane. If the intervention made no difference, then what is the rationale for doing it...because you have the centrifuge ?

It is not a question as to whether you can grow bone in the sinus with or without a graft. Maintenance of volume is all that is required. But you are completely missing the point as to the benefits of PRF. In addition to tenting the membrane, it will slowly release cytokines over approximately 7 days. This release of VEGF, PDGF, TGF beta, and Thrombospondin 1 will speed up early angiogenesis. It will help to repair membrane perforations and has bacteriocidal properties. This ultimately results in bone with greater density which is desireable if the sinus is highly pneumatized and the implants end up almost completely in the grafted area. And, while devotees of literature always try to have their day, it still ends up being evidence-based clinical results that help shape my protocols. PRF consistently gives me superior results, supported by the literature or not. RJM

This is obviously a topic of great interest to many surgeons in the implant field. Conclusion - we are all looking for more predictability in our bone (and soft tissue) grafting. Whereas EMD has increased the predictability of periodontal regeneration, there is an alphabet city of "growth factors" and harvested enhancers for the bone regenerative field. A published, bilateral sinus graft study out of NYU has not shown an increase in bone formation after the use of PRP. This type of study should be done for PRF, BMP and yes, even calcium sulfate. The study is currently being done with BMP. I believe we need to study, with the help of the manufacturers, all products that are purported to increase bone formation. PRF is the easiest to prepare and, according to the work by Choukroun and "devotees" (of which I am one) gets outstanding results. I have seen so in a number of my and Dr. Mazor's cases and in publications by other authors including Drs Ehrenfest and Toffler. The materials, their standardized methods of being obtained and used require standardized, clinical studies before widespread use can become the standard of care. Until that point in time, as Dr. Miller has stated, we have to go by our clinical impression and the few studies that have been published and evaluated in peer-reviewed journals. SO, let's all look at our cases carefully, both from the clinical side and histologically. Let's try to get the necessary funding to do the research. We have to agree as well on standards of "success". Is it just 12% vital bone in a sinus grafted site? Implant success? Or are we going to look for true bone regeneration leaving vital bone in the treated site without the remnants of non-vital, non-resorbable materials?

Dr. Horowitz, You have made valid points!

Well said Dr Horowitz , It is why we always use fully bioresorbable materials in the sinus , you get what you see not a debatable outcome only ascertained by core sample. Peter

Wow. Linkow, Lindhe, Mazor, Grunder, Horowitz etc. etc. Would love to get Anitua, Choukroun and Marks on this forum. Very interesting statements made but in the end not "enough" peer reviewed research yet. Most of the research has been by the inventors of the protocols so far.

If you want to hear directly from the source, Dr. Choukroun will be doing an all day lecture and workshop in New York, Friday, January 29th and in Boca Raton, Florida Saturday, January 30th, 2010. He will be teaching the entire PRF process, from the biology to the clinical applications, along with a hands-on using the centrifuge and PRF box for fabrication of membranes. He will also cover the use of metronidazole in bone grafting. In a few days I will post the link for more information. RJM

Sánchez concludes after latest(experimental animal studies) that there is not enogh proof for such a claim. (Sánchez et al., 2005). Appel (2004) could not realize any kind of improvemnent or acceleration in osteoneogenesis by adding PRP. There are other oppinions regarding the utility of those factors- they can help for new bone formation- but can they help transforming "mineralized ceramics" into vital bone ? Whatever boosts new formation might boost formation of tissue nobody wants to be responsable for in the end. Keep the sinus membrane tented- and you will have all local factors provided. Why can the principles of GBR not be applied on the sinus ! Does anybody think they have lost their validity in that anatomical hight ?

TO LINKOW, I CHATTED TODAY WITH THE REAL AND LIVE DR. lEONARD I. LINKOW. I mentioned that someone is using his name in this thread/blog whatever it is called. He is a dear friend, mentor and colleague to me and he wants you to stop using his name and ASAP.

Dr. Miller, I am interested in said course.

PRP PRGF and now PRF.....Save your money, they are great for soft tissue and do nada for bone. Better off spending your money on emdogain or gem 21. Dont have to do a blood draw and patient will be happier.

If you attended this years Academy of Osseointegration meeting in San Diego, you may have seen the Oral Abstract award winning lecture by Jack Ricci, PhD (New York University). He reported that when PDGF (i.e. GEM 21)is mixed with a graft material, it actually keeps bone in an immature state LONGER than mixed cytokines in a lower dose. When PDGF is used, as long as the bone graft is turning over, the early pathway that produces angiogenesis remains predominant. Only after PDGF is metabolized do we see lamellar bone forming. Therefore, this is PRECISLEY why we use PRF where the pronounced activity of PDGF, VEGF, and TGF is gone after 7 days. This early effect kick-starts the wound healing process and then allows normal turnover of bone to occur. There is ample research and a well-rounded collection of papers on this phenomenon. I would suggest reading them and then formulating your opinion. I would be happy to email a zip folder containing some of these papers to all interested clinicians. RJM

Robert There are plent of papers by Nevins and such to demonstrate the positive effects of Gem 21 and bone formation. More positive then negative. I am sure we can find the negative in any material we use and you would probably agree we havent found the magic bullet yet. I doubt the PRP PRF PRGF or any other 3 letter manifestations we come up with is the magic bullit either. Having an winning abstract is far from evidence at this point to downgrade the positives that have been seen from Sam Lynch's research in Gem 21..... As Linde from above pointed out "The reality is, there is currently a lack of evidence to support the use of PRP or PRF for sinus augmentation or bone augmentation. How do you justify charging patients and subjecting them to procedures and techniques where there is poor and anecdotal evidence (at best) for what you do ?" "To see hype and marketing of “courses” based on poor evidence and hype for the sole purpose of selling courses is very disturbing to say the least."

If you want to attend the only US workshop on PRF, Dr. Choukroun, the inventor of PRF, will be doing a presentation in New York, Friday, January 29th and in Boca Raton, Florida Saturday, January 30th, 2010. Check out the listing on Osseonews.com under Courses. He will be teaching the entire PRF process, along with a hands-on using the centrifuge and PRF box for fabrication of membranes. He will also cover the use of metronidazole in bone grafting. This is the only presentation planned in the US by Dr. Choukroun and a great opportunity to learn from the world's leading authority on PRF. It will be a literature based presentation, sharing maxillofacial, orthopedic, and implant applications for PRF including the most current papers just published. RJM

Details of Dr. Choukroun's lecture can be found by Clicking Here

Choukroun's PRF is an autologous leukocyte and platelet rich fibrin matrix.Although the platelet concentrates seem to improve soft tissue healing, but their role on active bone formation is in doubt.PRF is being actually considered a fibrin biomaterial and it has been advocated that the fibrin mesh is slowly remodeled and replaced by a strong collagenous newly formed tissue.Accordin to this theory, the use of PRF may lead to a thick tissue around the implants. If PRF can be able to present clear effects on bone formation and maturation (which enough reliable data for that has not been provided yet), it can play a significant role on the stability of the grafted bone surfaces.Even if it is true, this bone gain can never be protected or guaranteed by the growth factors and the fibrin itself and the early re-establishment of the periosteum and other soft tissue beds certainly bring about the acceptable long-term results. I still believe that what happens in regards to PRF is due to its effects on soft tissues rather than the bone itself.

PRF has direct effects on bone cells as well as soft tissue. It is clear from the literature that PRF potentiates osteoblasts whether used alone or in combination with bone grafts to preserve volume. The controlled release of cytokines stimulates all of the important pathways of tissue regeneration in a way that PRP and PRGF cannot. The following are some examples of current peer reviewed papers. David M. Dohan, Joseph Choukroun, Antoine Diss, Steve L. Dohand, Anthony J.J. Dohane, Jaafar Mouhyi, Bruno Gogly, Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution, Oral and Maxillofacial Surgery ,Volume 101, Issue 3, Pages 37-44 (March 2006). David M. Dohan, Joseph Choukroun, Antoine Diss, Steve L. Dohand, Anthony J.J. Dohane, Jaafar Mouhyi, Bruno Gogly, Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part II: Platelet-related biologic features, Oral and Maxillofacial Surgery, January 11, 2006, pages e45-e50. (March 2006). David M. Dohan, Joseph Choukroun, Antoine Diss, Steve L. Dohand, Anthony J.J. Dohane, Jaafar Mouhyi, Bruno Gogly, Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part III: Leucocyte activation: A new feature for platelet concentrates?, Oral and Maxillofacial Surgery ,Volume 101, Issue 3, Pages e51-e55 (March 2006). Joseph Choukroun, Antoine Diss, Alain Simonpieri, Marie-Odile Girard, Christian Schoeffler, Steve L. Dohand, Anthony J.J. Dohane, Jaafar Mouhyi, David M. Dohan, Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part IV: Clinical effects on tissue healing, Oral and Maxillofacial Surgery ,Volume 101, Issue 3, Pages e56-e60 (March 2006). Joseph Choukroun, MDaAntoine Diss,Alain Simonpieri, Marie-Odile Girard, Christian Schoeffler, Steve L. Dohand, Anthony J.J. Dohane, Jaafar Mouhyi, David M. Dohan, Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation in sinus lift, Oral and Maxillofacial Surgery, Volume 101, Issue 3, Pages 299-303 (March 2006) Sunitha Raja V, Munirathnam Naidu E, Platerlet-rich-fibrin: Evolution of a second-generation platelet concentrate, Indian Journal of Dental Research, Vol 19, Issue 1, page 42-46,Jan-March 2008 Anilkumar K, Geetha A, Umasudhakar, Ramakrishnana T, Vijayalakshmi R, Pameela E., Platelet -rich-fibrin: a novel root coverage approach., Journal of Indian 'Society of Periodontoloogy, Vol 13, Issue 1, Jan-Apr 2009. Dohan Ehrenfest DM, de Peppo GM, Doglioli P, Sammartino G, Slow release of growth factors and thromboposdin-1 in Choukroun's platelet-rich-fibrin (PRF): a gold standard to achieve for all surgical platelet concentrates technologies, Growth Factors. 2009 Feb;27(1):63-9 Alain Simonpieri, Marco Del Corso, Gilberto Sammartino, David Dohan Ehrenfest, The Relevance of Choukroun's Platelet-Rich Fibrin and Metronidazole During Complex Maxillary Rehabilitations Using Bone Allograft. Part II: Implant Surgery, Prosthodontics, and Survival, Implant Dent. 2009 Jun ;18 (3):220-229. RJM

Sir, it seems that you have read a lot about this method but you have not seen the results or at least the long term results by yourself. By the way, if you look exactly at the name of the authors of the articles that you have referred to, you'll see that some names have been repeated "en suivi".Let's look forward to hearing from some independent academic research centers that do not have any financial interests in this kind of innovations.

We need few details to understand more about growth factors. All the techniques are active: PRP, PRGF, PRF but the using conditions introduce differences between the 3 techniques: The growth factors are active only on cells !! it's biologic. This is because the 3 technqiues are active in soft tissue: because cells are immediately available! Difference between PRP, PRGF and PRF? PRF can release more than 7 days the growth factors in the site (published 2009)Result: more stimulation and better results in soft tissue engineering(keratinized gingiva). In the bone engineering, the problematic is the same: can we get cells quickly ? if yes, the growth factors will stimulate the progenitor cells and osteoblasts.Obligatory, because biologic! If you have not cells in the site, you'll never get stimulation with Growth Factors techniques. Difference between the 3 techniques ? PRF liberates slowly and progressively growth factors during more than seven days. Like this, you can wait the cells arrival in the grafted site. Last detail: the cells attraction and proliferation depends of the biomaterial quality: pure mineral, mineral and organic,pure organic? This is because you can see different results with the GF techniques in bone engineering: the action of the GF techniques depends of the quantity of available cells in the site. With long presence of GF, we can hope bone faster, not more bone! I'll comment these very important details in the next US courses (29-30 january). JC