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10 mCME Dental Tribune Middle East & Africa Edition | 1/2018 PRF brings new challenges to the dental offi ce mCME articles in Dental Tribune have been approved by: HAAD as having educational content for 1 CME Credit Hour DHA awarded this program for 1 CPD Credit Point CAPP designates this activity for 1 CE Credit By Dr Alvaro Betancur, USA Platelet-rich fi brin can play an im- portant role in oral and maxillofacial surgery, implant dentistry, perio- dontal regeneration and post-extrac- tion site preservation. The fi brin is a reservoir of platelets that will slowly release growth fac- tors and cytokines, which are the key factors for regeneration of the bone and maturation of the soft tissue. Platelet-rich fi brin (PRF) is an autolo- gous platelet concentrate prepared from the patient’s own blood at the dentist’s offi ce just before the oral/ dental procedure. Recent studies are focused on the de- velopment of natural therapeutic al- ternatives, which are easy to prepare, non-toxic or biocompatible to living tissues and economically inexpen- sive. The goal is the local release of growth factors, in turn accelerating hardand soft-tissue healing. PRF is a natural fi brin-based bioma- terial prepared without anticoagu- lants or artifi cial additives (biomedi- cal modifi ers) that allow us to obtain autologous fi brin membranes and plugs with a high concentration of platelets and white cells, releasing growth factors at the surgical site for seven to 14 days and accelerating the natural healing process. Evidence from literature suggests the potential role PRF provides in most oral-surgery procedures is key for regeneration and tissue engineer- ing. The slow polymerization dur- ing centrifugation and fi brin-based structure could make PRF a better healing biomaterial than PRP and other fi brin adhesives, but literature is also controversial, with many pub- lications demonstrating excellent results with PRP as well as with PRF. There is evidence that the presence of growth factors and cytokines in platelets play key roles in infl amma- tion and wound healing. Platelets also secrete fi brin, fi bronectin and vitronectin, which act as a matrix for the connective tissue and as adhe- sion molecules for more effi cient cell migration. This has led to the idea of using platelets as therapeutic tools to improve tissue repair during wound healing. Because of the benefi ts to soft tissue, PRP is now being used all over the word for facial rejuvena- tion, joint regeneration, hair growth stimulation and ED treatment. And, because of the easier and less expen- sive alternative, PRF liquid is starting to be used instead of PRP (PRP $450 vs. PRF $8 per patient). Advantages of PRF compared with PRP A look at the advantages of PRF as compared with PRP: • No anticoagulants that affect the release of growth factors • No drugs (calcium chloride) that could affect fi brin polymerization • No animal products (Bovine throm- bin) that could affect the coagulation process and immune system activa- tion • PRF has the presence of natural fi brin network, which protects the growth factors from proteolysis. • PRF favors the development of mi- cro vascularization leading to a more effi cient cell migration • PRF has the presence of monocytes, leukocytes and other white cells that have an important role during the infl ammatory phase of healing • PRF manufacturing requires mini- mum time from the doctor Fig. 3: BPRF clots in the PRF box. Fig. 4: PRF plugs. Fig. 5: PRF sticky bone. Fig.6: PRF steaky bone. Fig. 1: Boca Dental Supply blood collection tubes steri-pack are single-use, medical-grade packages for blood collection and manufactur- ing of PRF. Discard any unused tubes. Fig. 2: Doctor usually expends less than two minutes drawing patient’s blood. (Photos/Provided by Dr. Alvaro Betancur) The manufacturing of all blood concentrates at the patient’s site of treatment brings new challenges to the dentists and staff members: Infection-control protocols, staff training, education and research of the products used during PRF manu- facturing. Handling patient’s blood and manu- facturing blood products transforms the dental offi ce into a blood bank facility where stricter crosscontami- nation control protocols should be followed in order to avoid doctor’s liability risks and to comply with federal regulations of the Center for Disease Control (CDC), OSHA and to perform at the standard of care pro- tocols for surgery. PRF is used in invasive osseous sur- gery close to the eyes, ear, brain and in direct contact with bone, maxil- lary sinus, veins, arteries and nerves that could be adversely affected, if proper contamination control pro- tocols are not followed. All instruments used for the manu- facturing of PRF should be sealed sterile and dropped into a sterile fi eld separate from the instruments used for the removal of contaminated tis- sues, debridement of bone and teeth extraction. Two fi elds protocol will eliminate the risk of contamination of the PRF membranes, PRF sticky and PRF steaky bone that is going to be used for bone augmentation, as well as the PRF exudate that can be used as a sealant of the surgical site. Tourniquets, bandages, gauze, nee- dles and blood collection tubes should be single-patient-use packs only. I use the blood collection tubes steri-pack (BCTSP) from Boca Dental Supply, LLC. BCTSP tubes are the only single-use, medicalgrade packages for blood col- lection and manufacture of PRF ex- isting in the market globally. After a tubes pack is open, any unused tubes should be discarded. The manufacturing of PRF mem- branes and plugs is a simple, four- step protocol 1) Venipuncture for blood collection using needles and glass tubes from single-use packs only (medicalgrade packs). 2) Use the centrifuge to obtain sepa- ration and clot of the blood compo- nents. 3) Obtain the PRF clot from the tube and process it in the PRF box to pro- duce membranes or plugs. 4) Use membranes and plugs to mix with bone. The doctor usually expends less than two minutes drawing blood, and the rest of the procedure to manufacture PRF can be performed by a properly trained staff member. How is PRF clot formed? After the blood is collected into the glass tubes and during the eight- minute centrifugation, the contact of blood coagulation factors with the natural hydrophilic glass surfaces activates the clotting cascade leading to the conversion of fi brinogen to fi - brin forming a natural PRF clot. If plastic tubes were going to be used for PRF clot, PRF membranes and PRF plugs, such tubes would likely have additives like silica and other danger- ous chemical products to simulate the clothing characteristics of the natural glass, and the fi nal product would be a chemically induced arti- fi cial PRF clot that will produce artifi - cial PRF membranes and plugs. The use of plastic tubes with silica coating and other chemicals to sim- ulate the natural characteristics of the glass brings the challenge of not knowing what kind of damage the dentist would be causing to the pa- tient’s health. The literature and re- search evidence has shown that silica and other coating with chemicals or additives used in laboratory blood- collection tubes increase the risk of cancer and damage the DNA. The use of plastic tubes silica and other hid- den additives could be detrimental and contradictory to the basic phi- losophy of PRF when it was adapted from cardiovascular and general sur- gery to dentistry: “No anticoagulants and no additives.” More research is needed to deter- mine the fi nal damage of silica and other additives in the plastic blood- collection tubes to the grafted area and grafted bone at post-extraction sites, maxillary sinus, periodontal defects and all other boneaugmenta- tion procedures. There is currently not available publication or research to evaluate possible cancer and sys- temic effects of silica and all other chemicals used to simulate the natu- ral glass in plastic laboratory tubes when used for PRF manufacturing. When plastic blood collection tubes without any additives are used for blood collection and centrifugation, we obtain liquid PRF that is used to apply to the sticky bone and trans- form it into PRF steaky bone. This improves the handling character- istics of the bone and aids in keep- ing the bone-graft material in solid form and preventing small particles of bone from migrating between the patient’s bone and periosteum. Migration of small particles of bone could be a cause of increased infl am- matory response and swelling after surgery. Because the time in the centrifuge is reduced to process blood in the plastic tubes to manufacture PRF liq- uid, less heat will be generated thus allowing a greater number of live white cells without degradation. This will accelerate the healing process; and it is also possible that when the blood is processed at 700 RPM or less, some stem cells could also be concentrated in the PRF liquid. PRF is the newest and most popular technique to accelerate healing in dentistry. During most large implant dental conventions and meetings ÿPage 11