PRP and BMP: Should These Become Standard of Care for Implant Placement?

You have got to be careful when you say "standard of care" ... When you use that term you are saying that if you do not follow a certain protocol, the results can be compromised and that the patient is getting lass than ideal care. These are types of statements malpractice lawers just love to hear. To give you my humble opinion on the subject: No, not necessarily. The evidence that PRP makes bone grow better in all situations is not supported by research. Many that use PRP use it because it works well in their hands and has not failed them yet. I know many practioners that range from OS, to perio to GPs that were drawn into the use of PRP by its claims and then were dissapointed. Only to use their centrifuges as doorstops. I also know many who would not practice without it. PRP makes the use of particulate grafting material easier because it binds it together in a manageable mass, it is absolutely outstanding in its effects on soft tissue healing, but does it really make a huge difference in the growth of bone- I do not think that is conclusive in clinical settings. BMP- yes it works, but is it worth the huge expense to use it? It also creates a tremendous amount of inflammation in the area where it is used. Should a GP use these adjuncts- definately; if they are properly versed in their use, and they graft as routine. To think that adding these materials will make up for poor surgical skill and a lack of knowlege of grafting biology, is setting up the practioner for failure. PRP only requires the ability to draw blood. After that, it is following a recipe to create it. BMP requires the ability to open a package. These adjuncts, just like all of the tools we have available to us are useful but not panacea. As more research is done and evolve, we will get better products which are more predictable. Hope this helps. Charles Schlesinger, DDS

I agree, plus the jury is still out about the downside of BMP.

Thank you Dr. Schlesinger. I have used PRP and not used PRP. I find soft tissue healing a little faster with PRP. As far as bone grafting, I believe the initial angiogenesis is speed up with PRP and particulate graft material is held together better with PRP as its biological glue than the initial blood clot with all its RBCs. This does not mean that the use of PRP is the standard of care. I find the patient's cooperation and adherence to instructions to make the biggest different, whether PRP is used or not. Please be careful with the statement, "Standard of care". If you see someone else's patient, you may not know everything that was done to help the patient, and a poor result is not necessarily the result of poor surgical practices or skills. There are very skilled implant surgeons that are GPs and there are poor surgeons that have more formal graduate training. The history and development of Implant Dentistry has a rich heritage of wonderful, talented, and dedicated GPs. Only recently, has graduate programs formalized training in implant surgery. The American Academy of Implant Dentistry is working very hard to raise the standard of care. It was founded by GPs.

Charles: i don't know if we've met but we sure speak the same language. everyone take the time to read and reread his post. and i will ad to the fire. there is published literature that has shown NO difference whatsoever between bilaterally grafted sinuses where prp was used and where it was not. so how can a procedure that does not have a consensus in the lit be considered a standard of care (btw, that is a legal term and has nothing whatsover to due with clinical practice). gary

Standard of care means something that has been well documented and has been predictable for a number of years ,there 's enough follow up on numerous clinical cases and last but not the list is not so technique sensitive especially on BMP 2 .Hialuronic acid or collagen were the carriers of choice so far and collagen seemed to offer more support.Still we dont have enough cases and enaough clinical follow up to see covering with a titanium mesh is the best way to do it or not .Still theres the down side stated by the fact bone grows into the mesh holes and is very hard to remove at the time of the second stage ,if theres connective tissue ,worst case ,procedure looks more like a disection and there no bone grown into the site .Because there's atitanium mesh involved ,risk of complication for instance exposure is very likely to happen if the suture is not tension free by high flap release.Not to mention large edema post op at most of the cases. And finally MEDTRONIC company that produces BMP 2 has a very high price for the product that is beeing used in hospitals in orthopedic clinics and some universitys dental departments . Maybe after gathering more data ,in a few years we could hope that this could became a standard of care and trained dental practitioners could use the product in their office in a predictable way .

I am glad you mentioned patient compliance. This can be the missing link with success or failure. Also, the AAID is a fantastic organization with great training programs ie. MAXI Courses, bone grafting, perioplasctic surgery, pharmacology for implant dentistry. The AAID welcomes all commers that are serious about this field.

PRP does help to reduce infection and as per the lateral sinus lift PRP helps to keep the graft in one place and facilitate closing a perf.

The use of PRP in conjunction with bone grafting has largely been discredited. In fact it has been banned by most of the orthopedic training programs as it has caused the disappearance of bone graft material which has been harvested from the hip and other sources of vital bone - tibia, rib etc. There is anecdotal reportage of its use in soft tissue healing with improved results as compared with not using PRP. There is no substantiation of this reportage in any peer reviewed journal that I know of that has any value. We have a centrifuge that is gathering dust in our storage area and the same issue exists in 3 of the hospitals where I work. The first author is correct. We must be careful before jumping on the band wagon about new and improved technologies before they are proven. BMP i believe has promise. The kinks and the price have not yet been worked out. Dobs

Dobs OMFS, You are 100% correct, very good response!!

Estoy utilizando la técnica del PRGF del Dr.Anitua desde hace mes de 10 años. Lo importante para mí es poder cerrar la herida sin tensión. Me gusta la técnica y utilizo regularmente. Sigo con interés sus comentarios desde Barcelona (Spain).

I too agree with Dobs OMS and Dr. Don Callan.

PRP by itself is not a solution and does replace a good graft. Screening the literature in this matter, there is no benefit to use alone or in combimnation with a graft.

If one concentrated growth factor is good, then more is better? BMP is one of the only legitimate additives to grafts used today. But for the proponents of PRP and, for that matter, PDGF, these concentrated growth factors work on tissue in the earlier phases of growth. This past year at AO, Dr. Jack Ricci showed that growth factors such as platelet derived growth factor actually delay final maturation of bone as it stays in a more immature state longer. BMP's upregulate osteoblastic activity as it does during osteoclastic resorption of bone when natural BMP' are released. However, adding PRP or other cocktails of concentrated growth factors actually makes the bone so metabolically active that it causes excessive bone resorption before bone has a chance to mature. Until, and unless, the cost of BMP's comes down, it will be relegated to use in orthopedics and OMFS in the hospital setting where medical insurance picks up the cost. RJM

BMP results in a HUGE amount of swelling with 8x cost. I just did a case for a 18yo on #7 and #10. I told her she might look like planet of the apes and I was right, unfortunately. The swelling is underestimated and MUST BE DEALT with PARQ. We need studies like this with graft on #7 and BMP on #10 with good conebeam followup. Don -- make it happen!!!

BMP is osteoconductive and works very well and it seems to be an excellent alternative to AICBG, PRP has no osteoconductive properties, it aids in stabilization or matrix of graft material for those who are still using Bio-Oss or other bottle bone, if you have read the literature, PRP initially aids in healing especially soft tissue, but does not promote new bone formation. In 2000 we thought PRP was going to be our magic solution and aid in bone grafting procedures, about 2003 we pretty much stopped using it at the Implant Center at Loma Linda University. At Loma Linda University the BMP studies which we performed we were able to grow bone in places where bone should not have grown, i.e. soft tissues, Dr. Philip Boyne, Marshall Urist read some of their research and you will see the great benefits of BMP, a side from the cost. The last sinus I placed implants into in which I used BMP as my only graft material, with the exception of salt and pepper with Puros, I had to tap the bone in a severely pneumatized sinus (preoperatively).

I just had a meeting with the local Medtronic rep about Infuse (BMP). The cost for the Infuse XX small is $876.00. The is the smallest amount of BMP they sell and is enough for a single area/one socket site for grafting. Obviously, there is no coverage by dental insurance and is all out of pocket for the patient. Therefore it is difficult for us in private practice to buffer up the cost to make some profit on the biomaterials when it is already so expensive. She said that the oral surgeons will use BMP in the hospitals because they can then bill it to the patients medical insurance and it is then more likely to be covered. The hospital also buys the Infuse (BMP), therefore the OS does not have to buy it...therefore lower overhead fot the case. The largest dosage of Infuse (BMP) is large II (there are a total of 6 sizes available) cost $5408 to the hospitals. This is used for long bone fracture regeneration. The hospitals are charging the patient between $15,000 and $20,000 for this dosage and the medical insurance companies are paying for it. This is a sign that the cost of Infuse (BMP) to us the dentists will not likely come down unless more of us use it to drive the cost down. The rep also said that Wyeth manufactures Infuse and Medtronic distributes it. They share 50%-50% of the profits and that it why it is so expensive. They have a distribution agreement until 2017. Wyeth has also been bought by Pfizer so let's also see what happens. I thought this was important to bring up.

That's news - Wyeth manufactures Infuse. Big Pharma does not play nice when it comes to their products and prices. Just take a look at how many M.D.'s are kicking pharma reps out of their office. I would not hold your breath if big pharma is involved.

PRP ususally has good results but no on its own. Patient compliance is a major factor. Without patient compliance, failure will result.

Interesting discussion. I believe one needs to exercise caution in reviewing the body of literature to date on PRP. Commercial preparation of PRP differs tremendously in the concentration of growth factors, the concentration of WBC's , and ratio of GF's. PRP is far from the "standard of care" in orthopedics, dental surgery or sports medicine. We do know that the science behind PRP is solid. Studies have shown PRP promotes differentiation of osteoblasts, tenocytes and myocytes. Most of the literature has been done using a PRP concentration of 2-3x baseline. It also appears that the concentration of GF's should be delivered in an autologous ratio. The IGF suspended in the plasma appears to be an important component of PRP's efficacy. I do not know what all the fuss is about the BMP products available on the market today. Soul it bot be much more cost effective to use a DBM product (hydroxyapatite scaffold) to promote osteoconductive scaffold and bathe the product in PRP during the procedure? We have to remember that BMP 2 to BMP 7 are part of the TGF beta subfamily. I understand this would mean one extra step but it may be worth dusting off the centrifuge and trying. Ensure the PRP product you are using is conditioned not to contain degratory WBC's and contains all the plasma (or you loose the benefits of the IGF).