Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects

Abstract

Background: Periodontitis is a chronic infective disease of the gums caused by bacteria present in dental plaque. This condition induces the breakdown of the tooth supporting apparatus until teeth are lost. Surgery may be indicated to arrest disease progression and regenerate lost tissues. Several surgical techniques have been developed to regenerate periodontal tissues including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). EMD is an extract of enamel matrix and contains amelogenins of various molecular weights. There is evidence to show that amelogenins are involved not only in enamel formation, but also in the formation of the periodontal attachment during tooth formation.

Objectives: To test the efficacy of EMD in comparison with open flap debridement, GTR and various BG procedures for the treatment of intrabony defects.

Search strategy: We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Several journals were handsearched. No language restrictions were applied. Authors of randomised controlled trials (RCTs) identified, personal contacts and the manufacturer were contacted to identify unpublished trials. Most recent search: January 2003.

Selection criteria: RCTs on patients affected by periodontitis having intrabony defects treated with EMD compared with open flap debridement, GTR and various BG procedures with at least one year follow up. The outcome measures considered were: tooth loss, changes in probing attachment levels (PAL), pocket depths (PPD), gingival recessions (REC), marginal bone levels on intraoral radiographs and postoperative infections.

Data collection and analysis: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two reviewers. Results were expressed as random effect models using weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval (CI). Heterogeneity was investigated including both clinical and methodological factors.

Main results: No difference in tooth loss was observed. A meta-analysis including eight trials showed that Emdogain treated sites displayed statistically significant PAL improvements (mean difference 1.3 mm, 95%CI: 0.8 to 1.8) and PPD reduction (1 mm, 95%CI: 0.5 to 1.4) when compared to flap surgery. Comparing Emdogain with GTR (six trials), GTR showed a statistically significant reduction of PPD (0.6 mm) and increase of REC (0.5 mm). No difference in postoperative infections was observed.

Reviewer's conclusions: Emdogain is able to significantly improve PAL levels (1.3mm) and PPD reduction (1mm) when compared to flap surgery, however these results may not have a great clinical impact, since it has not been shown that more periodontally compromised teeth could be saved. There was no evidence of clinically important differences between GTR and Emdogain.