Combined endodontic-periodontal (endo-perio) lesions represent a complex clinical condition involving the simultaneous deterioration of the pulp and periodontal tissues, often leading to diagnostic dilemmas and treatment challenges (1). The etiology of such lesions is multifactorial, including microbial infection, trauma, or iatrogenic factors, which contribute to both pulpal necrosis and periodontal breakdown (2). Proper diagnosis and a multidisciplinary therapeutic approach are essential to ensure predictable healing and regeneration.

Traditional treatment for these lesions involves sequential endodontic therapy followed by periodontal management. However, outcomes may vary due to the intricate communication pathways between the pulp and periodontium through lateral canals, apical foramina, and dentinal tubules (3,4). In recent years, regenerative strategies have gained prominence in periodontology, aiming not just for repair but true regeneration of the periodontal apparatus, including alveolar bone, periodontal ligament, and cementum (5).

Advanced platelet-rich fibrin (A-PRF), an autologous blood derivative prepared by low-speed centrifugation, has emerged as a promising biomaterial in regenerative periodontal therapy. A-PRF contains a high concentration of platelets, leukocytes, and growth factors such as transforming growth factor-beta (TGF-β), platelet-derived growth factor (PDGF), and vascular endothelial growth factor (VEGF), which play crucial roles in angiogenesis, cell migration, and tissue regeneration (6,7). Its soft, fibrin-rich matrix provides a scaffold conducive for cellular infiltration and proliferation, enhancing wound healing and bone regeneration (8).

On the other hand, guided tissue regeneration (GTR) employs barrier membranes, such as resorbable collagen, to exclude epithelial and gingival connective tissue cells, thereby promoting selective repopulation by periodontal ligament and bone cells (9). While GTR has shown considerable success in treating periodontal defects, it presents limitations, including higher cost, technique sensitivity, and potential for membrane exposure and infection (10,11).

Thirty systemically healthy individuals (aged 25–55 years) diagnosed with combined endodontic-periodontal lesions in single-rooted teeth were selected based on clinical and radiographic criteria. All participants provided written informed consent prior to inclusion in the study.

Inclusion Criteria:

• Patients with primary endodontic lesions exhibiting secondary periodontal involvement.
• Single-rooted teeth with probing depth ≥6 mm and radiographic evidence of bone loss.
• Absence of systemic diseases that could affect periodontal healing.

Exclusion Criteria:

• Pregnant or lactating women.
• Smokers and individuals with a history of periodontal therapy within the last 6 months.
• Teeth with vertical root fractures or non-restorable caries.

Study Design and Group Allocation:

The participants were randomly divided into two groups (n=15 each) using a computer-generated randomization chart:

• Group A: Received standard root canal treatment followed by placement of Advanced Platelet-Rich Fibrin (A-PRF) into the periodontal defect.
• Group B: Underwent root canal therapy followed by guided tissue regeneration (GTR) using a resorbable collagen membrane over the defect.

Endodontic Procedure:

All patients underwent standardized endodontic treatment under rubber dam isolation. Access cavity preparation was done using rotary instruments, and biomechanical preparation was performed using the crown-down technique. Irrigation was carried out with 3% sodium hypochlorite and saline. Obturation was done using gutta-percha and resin-based sealer. The coronal restoration was completed with a composite filling.

Surgical Procedure:

After two weeks of completion of endodontic therapy, periodontal surgery was performed under local anesthesia. A full-thickness mucoperiosteal flap was elevated to access the defect. Thorough debridement and root planing were performed using hand and ultrasonic instruments.

• In Group A, A-PRF was prepared by centrifuging 10 ml of venous blood at 1300 rpm for 14 minutes without anticoagulant. The fibrin clot was separated and placed directly into the osseous defect.
• In Group B, a commercially available resorbable collagen membrane was trimmed and adapted to cover the defect following debridement.

Flaps were repositioned and sutured using 4-0 silk sutures, and periodontal dressing was applied. Postoperative instructions were given, and patients were prescribed antibiotics and analgesics for five days. Sutures were removed after 7–10 days.

Clinical and Radiographic Assessment:

Clinical parameters recorded at baseline and 6 months included:

• Probing depth (PD)
• Clinical attachment level (CAL)

Radiographic evaluation of bone fill was performed using standardized intraoral periapical radiographs with a paralleling technique. Images were analyzed using digital software to calculate the percentage of bone fill.

Statistical Analysis:

All data were compiled and analyzed using SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize the data. Intragroup comparisons were made using paired t-tests, and intergroup comparisons were performed using independent sample t-tests. A p-value of <0.05 was considered statistically significant.

The present randomized clinical trial evaluated and compared the clinical efficacy of Advanced Platelet-Rich Fibrin (A-PRF) and Guided Tissue Regeneration (GTR) in the management of combined endo-periodontal lesions. A total of 30 patients were included, with 15 participants in each group. All patients completed the study with no reported postoperative complications.

Baseline Comparison

At baseline, both groups demonstrated comparable values for probing depth (PD), clinical attachment level (CAL), and radiographic bone loss, with no statistically significant differences between them (p > 0.05), indicating homogeneity between groups prior to intervention (Table 1).

Table 1. Baseline Clinical and Radiographic Parameters

Postoperative Clinical Outcomes

After 6 months of treatment, both groups demonstrated significant improvements in all measured clinical parameters. However, Group A (A-PRF) exhibited greater mean reductions in PD and greater gains in CAL compared to Group B (GTR), with these differences being statistically significant (p < 0.05) (Table 2).

Table 2. Intragroup and Intergroup Comparison of Clinical Outcomes at 6 Months

Radiographic Bone Fill

Radiographic analysis at 6 months showed substantial bone regeneration in both groups. Group A achieved a mean bone fill of 68.2 ± 5.3%, whereas Group B demonstrated a bone fill of 56.7 ± 4.9%. The difference between the two groups was statistically significant (p = 0.004), as shown in Table 3.

 Table 3. Radiographic Bone Fill Percentage at 6 Months

The present randomized clinical trial aimed to evaluate and compare the effectiveness of Advanced Platelet-Rich Fibrin (A-PRF) and Guided Tissue Regeneration (GTR) in the management of combined endodontic-periodontal lesions. The results indicated that both treatment modalities led to significant clinical and radiographic improvements over a 6-month period; however, A-PRF demonstrated superior outcomes in terms of probing depth reduction, clinical attachment gain, and radiographic bone fill.

Endo-perio lesions are complex in nature due to the interrelationship between the pulp and periodontal tissues, often resulting in the progression of disease through anatomical communications such as lateral canals and dentinal tubules (1,2). Successful management requires elimination of infection and stimulation of tissue regeneration. Endodontic therapy alone may not suffice in cases with extensive periodontal involvement, which underscores the need for adjunctive regenerative strategies (3,4).

In the current study, Group A, which received A-PRF, showed statistically greater improvement in clinical parameters compared to Group B treated with GTR. These findings can be attributed to the biological properties of A-PRF, which contains a dense fibrin matrix rich in platelets and leukocytes that continuously release growth factors such as PDGF, VEGF, and TGF-β over several days, promoting angiogenesis and tissue regeneration (5,6). Additionally, A-PRF has been shown to modulate inflammatory responses and enhance the recruitment of progenitor cells essential for healing (7,8).

GTR, on the other hand, facilitates selective repopulation of periodontal tissues by acting as a physical barrier against epithelial downgrowth, allowing periodontal ligament and bone cells to repopulate the defect (9). Although GTR has been a standard in regenerative periodontal therapy, its effectiveness may be compromised by membrane exposure, infection, or technique sensitivity (10,11). In this study, GTR led to significant clinical improvement, but the gains were less pronounced than those observed with A-PRF.

Several previous studies support the superiority of platelet concentrates in regenerative therapy. Fujioka-Kobayashi et al. observed that A-PRF resulted in increased expression of growth factors and higher cell migration when compared to traditional PRF and other membranes (12). Similarly, studies by Miron et al. and Ghanaati et al. reported enhanced regenerative outcomes using A-PRF in periodontal defects (13,14).

The radiographic assessment in this trial also demonstrated greater bone fill in the A-PRF group, aligning with earlier findings that suggest the osteoconductive and osteoinductive potential of A-PRF matrices (15). This is of particular importance in endo-perio lesions where bone loss is often severe and regenerative demands are high.

In conclusion, the use of A-PRF in conjunction with endodontic therapy appears to be a more effective approach for managing combined endo-periodontal lesions when compared to traditional GTR using collagen membranes. Given its autologous nature, ease of preparation, cost-effectiveness, and biological advantages, A-PRF offers a valuable alternative in regenerative periodontal therapy.

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