L-PRF: Leukocytic Platelet Rich Fibrin – A New Frontier for Dentistry
Modern day alchemy has been used to describe the bone and tissue banks of the world today. You remember alchemy, trying to turn something like lead into gold? The bone/tissue banks don’t pay for their raw products, they instead get them from donors like you and me after we are dead, for free! Then they turn it into products that they sell to dentists for the price equivalent of gold. What a racket! No wonder organized crime wants a piece of the action.
Bone morphogenetic proteins (BMP2) will not be widely available to dentistry any time soon as long as corporate greed exists in the world today. One of my oral surgeons and I did one of those “Teeth in a Day” procedures to replace all of a patient’s maxillary teeth with a hybrid FPD, and just the costof the BMP2 alone was $5000 (bilateral sinus lift with facial onlay grafts and he was swollen like a toad, unable to wear his dentures for two weeks after). After all, if they can sell BMP to an orthopedic surgeon for a big bucket of dollars, why should they sell a small dab to dentistry for a reasonable price ($800+ is the smallest amount they will sell to dentists). I guess the thinking on this is that if they open up the market to the dental profession at a reasonable price, the orthopedic guys will just buy that instead of the high dollar product they currently are forced to buy.
Platelet Rich Plasma (PRP) isn’t as expensive (or versatile) as BMP2, tissue, or bone, but the disposables used in the process of PRP amount to nearly the cost of bone products. Some of the PRP kits are fairly reasonable in price, but some border on being cost prohibitive. Then there are always relatively cheap techniques like the one I was introduced to during an implant workshop out in L.A. by a periodontist named Jin Kim.
There has to be something out there that satisfies the many criteria for grafting/wound healing that modern dentistry can use without breaking the bank. The patient populations around the world cannot routinely pay for processed bone, tissue, or even PRP at these prices. Stacking the cost of these products on top of the cost of the extraction/implant/graft puts it out of reach for most people. Wouldn’t it be great if we had a material that was cheap, relatively easy to get, and completely compatible with every patient’s particular biological immunity? Also, a product that lasts up to 2 weeks in the body, super-charges the healing response, is a suturable membrane, can be placed in extraction site socket grafts, used with connective tissue grafts, and in sinus lift grafts? Well, I think there is such a product out there that comes close, and it is going to change how dentists treat their every day patients around the world.
The product is called Leukocytic-Platelet Rich Fibrin (L-PRF) or just PRF for short. At first appearance, PRF sounds like PRP. You still have to draw blood like PRP, and you still have to use a centrifuge like PRP, but that is were the similarities end. Joseph Choukroun, MD, invented and pioneered the research and development of PRF membranes.
Fibrinogen is the active form of fibrin and is found in blood plasma. It plays a role in platelet ?-granule aggregation during hemostasis. Fibrinogen transforms into the insoluble sticky fibrin in the presence of the patient’s naturally occurring thrombin and consolidates the initial platelets into a clot at the site of an injury. Not using foreign thrombin as in PRP it helps alleviate many fears over immune reactions and antigenicity problems that some fear may happen when using either bovine or human thrombin.
Trapping the platelets and leukocytes inside the fibrin clot helps in many ways:
- Transforming Growth Factor beta or TGF? is a protein that assists in cellular differentiation and proliferation.
- Platelet Derived Growth factor or PDGF helps bring in mesenchymal stem cells into the area as well as differentiate and proliferate endothelial cells.
- Insulin-like Growth factor or IGF helps healing cells from dying so fast and continue healing longer.
- Growth factors will work on type 1 collagen to form fibroblasts and osteoblasts
- Releases cytokines to attract the healing response of the body.
- Leukocytes will enhance the bodies own inflammatory process to heal quicker.
- Fibrin network increase the blood flow into the area with Vascular Endothelial Growth Factor or VEGF.
- Neutrophile degrades the site for wound remodeling and bring in the macrophages to clean up the site.
Making PRF from a patient’s blood is a very simple protocol: Blood is drawn without anticoagulant in 10-mL tubes. It is immediately centrifuged at 2700 rpm for 12 minutes (or if they are on some kind of blood thinner then 18 minutes). Waiting more than a minute or two will cause the fibrin to polymerize in a diffuse way and only a small poorly formed clot will form in the test tube. The trick is to start the process immediately after drawing the blood. Doing it quickly, before the platelets can begin to coagulate from the trauma of the test tube/centrifuge process, will produce a very large PRF clot (approximately 40-60% of the product) in the middle of the test tube between the lighter clear platelet poor plasma and the packed red blood cells. This PRF blood product is what is used to make this very resistant autologous fibrin membrane. It is then lightly pressed to extract the growth factors used to rehydrate grafting materials. It also can be used as a filler for bone grafts (sinus lifts/socket grafts) and as a healing membrane liner to accelerate the healing process up to two times faster.
The “kit” as it is sold from the Intra-Lock International company costs $3500 retail and $3000 at the meeting. It comes with a centrifuge, two test tube racks, two boxes of test tubes, a tourniquet, a box of butterfly 23 gauge needles, two stainless processing boxes, two thin stainless bowls, 2 nice scissors and pick-up forceps, a little bag of fuses and other parts that I have no idea what they are for, an instruction manual obviously translated into English by someone from France, and a little bag of Band-Aids that looks like they were repackaged from a bigger box. Unfortunately, this looks like another example of gouging the dental field. They will not sell anyone the processing boxes without first buying their centrifuge. We had one doctor there at the meeting that already secured a centrifuge over eBay for about $200, and was processing the PRF with “good” results. However, the speaker strongly discouraged this process saying that the process was so delicate that you needed to only use their centrifuge or you may have different results. That their centrifuge is weighted correctly, and is certified for this process. Please make your own decisions about that…
All in all, the lecture on L-PRF was very good. It brought up a lot of physiology I had not thought about in a long time. However, since this process is so new the speaker didn’t have a lot of definitive answers about how, and when it is to be used. He would venture to say that others have used it in a certain way, only to recant by saying he didn’t do that because the literature didn’t support it, yet.
(This isn’t actually our first case. We have done several socket grafts using the PRF membranes chopped up in the grafting material, and as a membrane for over the socket/under a cytoplast membrane. We have also used it in through the crest sinus lifts).
This case was done at another office on a centrifuge that was so old it looked like the space viper probe droid that crashed onto the ice planet Hoth. It had only one dial marked from 1 to 7 which indicated the speeds. We had absolutely no idea what those speeds were. (International Equipment Co. NeedHam, Mass)
The patient was having a lateral wall sinus lift (metronidazole) with simultaneous implant placed under IV sedation and everyone there wanted to try to make some PRF for a surgical membrane to dress over the lateral window, and implant. Two vials of blood were drawn, placed into the centrifuge, and dialed up to top speed, “7”. The patient was on a low dose of coumadin so we spun it for 18 minutes. It worked! The handling characteristics were similar to a wet paper towel laying on a table. It didn’t want to attach to anything except the tissue it was placed over. Very easy to manipulate.
This case in no way represents Dr. Choukroun’s research. I have no idea if this fibrin clot has the same composition as a PRF clot done with the “officially calibrated” centrifuge sold by Intra-Lock. If you have an old centrifuge and want to use it for the manufacturing of PRF, I suggest you experiment on a vial of your own blood first. If you get a large well formed clot then congratulations. If you cannot secure a “Box” to process a membrane, then try pressing the clot between two glass slabs. The best and easiest way to make PRF for your patient is to contact Intra-Lock International and purchase the entire kit from them.
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62. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Aug;102(2):175-9. Epub 2006 Jan 19. A comparative histologic analysis of tissue-engineered bone using platelet-rich plasma and platelet-enriched fibrin glue. Zhu SJ, Choi BH, Jung JH, Lee SH, Huh JY, You TM, Lee HJ, Li J. Department of Dentistry, Yonsei University Wonju College of Medicine, Wonju, South Korea.Tags: bone grafting, Dental blog, L-PRF, membranes, platelet rich fibrin, PRF