Periodontitis is a chronic inflammatory disease affecting the supporting structures of the teeth, leading to progressive destruction of the periodontium and eventual loss of attachment and alveolar bone (1). One of the characteristic features of advanced periodontitis is the resorption of alveolar bone, which extends apically and results in the involvement of the bifurcation or trifurcation areas of multi-rooted teeth (2). This condition, termed furcation involvement, is a pathological process caused by periodontal disease progression, leading to the breakdown of supporting tissues within the furcation region (3).

Molar furcation involvement is a frequent consequence of periodontitis, with bacterial plaque being the primary etiological factor (4). Additional predisposing factors include root trunk length, root form, interradicular dimension, and anatomical features such as enamel pearls, bifurcation ridges, and root concavities (5). The presence of furcation involvement complicates periodontal treatment and increases the risk of tooth loss, with Class II furcation defects demonstrating the highest potential for regenerative treatment (6).

Various treatment approaches have been proposed for furcation involvement, ranging from conservative scaling and root planing to surgical interventions, including open flap debridement, gingivectomy, root amputation, and tunneling procedures. Advanced treatment modalities such as bone grafting, guided tissue regeneration (GTR), and biomaterials have shown promising results in periodontal regeneration (4). Periodontal regeneration involves a complex biological process requiring cellular adhesion, migration, proliferation, and differentiation to restore lost tissues (7).

Numerous biomaterials have been explored for their regenerative potential, including autogenous, allogeneic, xenogeneic, and synthetic bone grafts, as well as platelet concentrates and biomimetic agents (8). Among these, platelet-rich fibrin (PRF) and chitosan have gained attention for their biocompatibility and regenerative properties. PRF, first introduced by Choukroun et al. (2001), is a second-generation platelet concentrate obtained without anticoagulants, resulting in a fibrin matrix enriched with platelets and growth factors (9). It facilitates cell migration and proliferation, aiding in tissue repair and regeneration through the sustained release of growth factors such as platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), and transforming growth factor-beta (TGF-β) (10).

Chitosan, a biopolymer derived from chitin, possesses notable antimicrobial, anti-inflammatory, hemostatic, and tissue regenerative properties, making it a valuable biomaterial in periodontal therapy (11). It has been used in various dental applications, including drug delivery systems, wound dressings, and periodontal membranes (12). Chitosan has demonstrated potential in reducing probing pocket depth and increasing clinical attachment levels in periodontal defects (13).

The ultimate objective of periodontal therapy is to achieve regeneration of the lost periodontium, restoring both the structural and functional integrity of the affected tissues (14). Given the regenerative potential of PRF and chitosan, their application in treating Class II furcation defects presents an emerging therapeutic approach. This study aimed to evaluate and compare the efficacy of PRF and chitosan gel in conjunction with open flap debridement for the management of Class II furcation defects.

This randomized, parallel-arm clinical study was conducted at the Department of Periodontology, RUHS College of Dental Sciences, Jaipur, India, from January 2019 to June 2020. A total of 45 patients (24 males and 21 females) with Class II furcation defects were selected based on specific inclusion and exclusion criteria. Patients with buccal Class II furcation defects in vital, asymptomatic first and second molars, with vertical probing depths (PD) ≥5 mm and horizontal PD ≥3 mm, were included. Patients with systemic conditions affecting periodontal status, those on medications altering periodontal therapy outcomes, smokers, pregnant or lactating women, and individuals with non-vital or carious teeth were excluded. The study followed the ethical guidelines of the Helsinki Declaration and was approved by the Institutional Ethical Committee. Patients were randomly allocated into three groups: Group 1 (Open Flap Debridement - OFD), Group 2 (OFD + Platelet-Rich Fibrin - PRF), and Group 3 (OFD + Chitosan Gel), with each group comprising 15 sites.

Pre-surgical procedures included oral hygiene reinforcement and full-mouth scaling and root planing (SRP) one month before surgery. Platelet-rich fibrin (PRF) was prepared using the Choukroun protocol by collecting 10 ml of intravenous blood from the antecubital vein, centrifuging it at 3000 rpm for 10 minutes, and retrieving the fibrin clot from the test tube. The surgical procedure involved extraoral and intraoral antisepsis, administration of local anesthesia, intrasulcular incisions, and full-thickness flap elevation. Thorough debridement was performed using Gracey curettes, and regenerative materials were placed according to the assigned group. The flaps were repositioned with 3-0 silk sutures, and periodontal dressing was applied. Postoperative care included antibiotics, analgesics, and chlorhexidine mouthwash, with sutures removed after one week.

Clinical parameters such as Plaque Index (PI), Gingival Index (GI), Probing Pocket Depth (PPD), Relative Vertical Clinical Attachment Level (RVCAL), and Relative Horizontal Clinical Attachment Level (RHCAL) were recorded at baseline and at 9 months. Hard tissue evaluation was performed using intraoral periapical radiographs with a grid to assess the intrabony defect (IBD) depth and its reduction. Data analysis was conducted using SPSS 20.0, with one-way ANOVA and post-hoc Tukey’s test for intergroup comparisons, while paired t-tests were used for intragroup comparisons. Statistical significance was set at p<0.05.

The present study aimed to evaluate and compare the efficacy of Chitosan Gel and Platelet-Rich Fibrin (PRF) in the treatment of Class II furcation defects. A total of 45 patients were divided into three groups:

• Group 1 (OFD): Open Flap Debridement alone (n=15)
• Group 2 (OFD + PRF): Open Flap Debridement with PRF (n=15)
• Group 3 (OFD + Chitosan): Open Flap Debridement with Chitosan Gel (n=15)

All patients completed the 9-month follow-up period with no reported complications. The primary outcome of the study was bone defect reduction, while the secondary outcomes included clinical attachment level gain, probing pocket depth reduction, and plaque and gingival index scores.

Clinical Parameters

A significant reduction in Plaque Index (PI) and Gingival Index (GI) was observed in all three groups after 9 months (p < 0.001). The mean PI score reduced from 2.15 ± 0.34 to 1.45 ± 0.62 in Group 1, from 2.31 ± 0.38 to 1.32 ± 0.54 in Group 2, and from 2.38 ± 0.37 to 1.43 ± 0.53 in Group 3. Similarly, GI scores improved from 2.33 ± 0.26 to 1.79 ± 0.63 in Group 1, from 2.40 ± 0.24 to 1.63 ± 0.57 in Group 2, and from 2.47 ± 0.25 to 1.81 ± 0.63 in Group 3 (Table 1).

Table 1: Mean Plaque Index and Gingival Index scores at baseline and 9 months

Probing Pocket Depth and Clinical Attachment Level

There was a significant reduction in Probing Pocket Depth (PPD) and a gain in Relative Vertical Clinical Attachment Level (RVCAL) and Relative Horizontal Clinical Attachment Level (RHCAL) in all three groups (p < 0.001).

• The mean PPD reduced from 7.13 ± 0.64 mm to 5.43 ± 0.46 mm in Group 1, from 7.52 ± 0.84 mm to 3.10 ± 0.51 mm in Group 2, and from 7.54 ± 0.76 mm to 3.57 ± 0.49 mm in Group 3.
• The RVCAL gain was 1.71 ± 0.49 mm in Group 1, 3.26 ± 0.69 mm in Group 2, and 2.56 ± 0.58 mm in Group 3.
• The RHCAL gain was 1.26 ± 0.39 mm in Group 1, 2.80 ± 0.56 mm in Group 2, and 2.17 ± 0.41 mm in Group 3 (Table 2).

Table 2: Changes in Probing Pocket Depth and Clinical Attachment Level

Radiographic Assessment

The Intrabony Defect (IBD) reduction was greater in the PRF and Chitosan groups compared to the OFD group.

• The mean IBD depth decreased from 3.83 ± 0.52 mm to 3.54 ± 0.51 mm in Group 1, from 4.33 ± 0.46 mm to 2.27 ± 0.46 mm in Group 2, and from 4.17 ± 0.35 mm to 2.73 ± 0.52 mm in Group 3.
• PRF (2.06 ± 0.41 mm) and Chitosan (1.44 ± 0.35 mm) showed significantly greater IBD fill than the control sites (0.29 ± 0.05 mm) (Table 3).

Table 3: Radiographic Assessment of Intrabony Defect (IBD) Reduction

Summary of Results

• Significant improvements in PI and GI were observed across all groups, with the highest reduction in the PRF group.
• PPD reduction and CAL gain were significantly greater in the PRF and Chitosan groups compared to OFD alone.
• Radiographic bone defect reduction was most evident in the PRF group, followed by Chitosan, and least in OFD alone.
• Although PRF and Chitosan both showed promising results, PRF demonstrated superior improvements in bone defect reduction and clinical parameters.

These findings suggest that both PRF and Chitosan enhance periodontal regeneration, but PRF may offer greater advantages in furcation defect management. Further long-term studies with larger sample sizes are recommended to validate these results.

The primary objective of periodontal therapy is to halt the progression of periodontitis and promote the regeneration of lost periodontal structures. Class II furcation defects present a clinical challenge due to their complex anatomy and limited accessibility for debridement. In this study, the efficacy of Chitosan Gel and Platelet-Rich Fibrin (PRF) was compared in the treatment of Class II furcation defects in terms of clinical and radiographic parameters over a period of nine months.

Periodontal regeneration involves a series of biological processes, including cell adhesion, migration, proliferation, and differentiation, which are influenced by the choice of biomaterials used for treatment (1). Several regenerative approaches, including bone grafts, guided tissue regeneration (GTR), enamel matrix derivatives, and growth factors, have been investigated in the past (2). However, both PRF and chitosan have gained significant attention due to their biocompatibility, bioactivity, and cost-effectiveness.

Effect of PRF and Chitosan on Clinical Parameters

The Plaque Index (PI) and Gingival Index (GI) significantly improved in all groups, indicating enhanced oral hygiene status post-surgically. Similar improvements in plaque control and gingival health have been reported in previous studies utilizing biomaterials in furcation defects (3,4). However, PRF-treated sites showed slightly better reductions in plaque and gingival inflammation compared to chitosan and open flap debridement (OFD) alone. This might be attributed to the anti-inflammatory cytokines released from PRF, such as IL-4 and transforming growth factor-beta (TGF-β), which modulate host response and reduce inflammation (5).

Probing Pocket Depth (PPD) reduction and Clinical Attachment Level (CAL) gain were significantly greater in PRF and Chitosan groups compared to OFD alone. PRF showed the highest PPD reduction (4.42 ± 0.73 mm), followed by Chitosan (3.97 ± 0.68 mm), while OFD alone resulted in the lowest reduction (1.70 ± 0.47 mm). These findings align with previous studies that demonstrated superior PPD reduction and attachment gain when biomaterials were used in periodontal therapy (6,7). PRF may promote a greater early-stage wound healing response, owing to its fibrin matrix structure and growth factor release, which enhances fibroblast proliferation and osteoblastic activity (8).

Radiographic Bone Defect Fill

Radiographic evaluation showed greater bone defect reduction in PRF and chitosan groups compared to OFD alone. PRF-treated sites exhibited the highest intrabony defect (IBD) fill (2.06 ± 0.41 mm), followed by Chitosan (1.44 ± 0.35 mm) and OFD alone (0.29 ± 0.05 mm). These results align with previous studies where PRF demonstrated enhanced bone fill in intrabony and furcation defects (9). The presence of platelet-derived growth factor (PDGF) and vascular endothelial growth factor (VEGF) in PRF may stimulate angiogenesis and osteogenesis, contributing to better defect resolution (10).

Chitosan also demonstrated a significant bone fill, which could be attributed to its osteoconductive properties, ability to promote mesenchymal stem cell adhesion, and antimicrobial activity (11). Previous studies have reported that chitosan-based scaffolds, when combined with growth factors, enhance bone formation and periodontal regeneration (12). However, PRF demonstrated slightly superior results in terms of bone defect reduction, possibly due to its sustained growth factor release over a longer period (13).

Comparison Between PRF and Chitosan

While both PRF and Chitosan demonstrated statistically significant improvements in clinical and radiographic parameters, PRF exhibited slightly better outcomes. This could be due to the following reasons:

• PRF releases growth factors continuously over 7-10 days, whereas chitosan primarily provides a scaffold effect without sustained bioactive molecule release (14).
• PRF enhances wound healing due to its fibrin network, promoting faster tissue repair and reducing inflammation (15).
• Chitosan has antimicrobial properties, but lacks active signaling molecules that accelerate periodontal healing when used alone.

Despite these advantages, chitosan is cost-effective and widely available, making it a promising alternative biomaterial for periodontal regeneration. However, further long-term clinical trials with a larger sample size are needed to validate its regenerative potential in furcation defects.

Limitations

• Small sample size limits the generalizability of the findings.
• Long-term studies are required to determine the stability of treatment outcomes.
• Histological analysis is needed to confirm true periodontal regeneration.

Both PRF and Chitosan significantly improved clinical and radiographic outcomes compared to OFD alone in the management of Class II furcation defects. However, PRF demonstrated slightly superior results in probing depth reduction, clinical attachment gain, and bone defect fill. Given its affordability and biocompatibility, PRF may be considered a more effective option in furcation defect management. Future research should focus on combining PRF and Chitosan to explore potential synergistic effects in periodontal regeneration.

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