Anton Sculean, Prof. Dr. med. Dent., Dr. h.c., M.S. is chairman of the Department of Periodontology at the University of Berne. He has gained experience and knowledge working in clinics and research in many European countries. His impressive work was as well honored by a large variety of prizes. His main work and research areas are the periodontal wound healing, regenerative and plastic aesthetic periodontal ltherapy, minimal invasive therapy, oral biofilm and application of laser in the periodontology. He is as well part a many editorial board including Journal of Clinical Periodontology, Clinical Oral Implants Research and PERIO. He is author and co-author of more than 160 publications in peer reviewed journals and has hold over 200 presentation in national and international congresses.
Professor Anton Sculean didn’t start out as a believer in Emdogain – in fact, he conducted a ten-year follow-up study, comparing treatment of intra-bony defects with enamel matrix proteins and/or guided tissue regeneration,1 with an aim to demonstrate the inferiority of Emdogain compared to Guided Tissue Regeneration (GTR). The study compared four treatment options (open flap debridement (OFD), Emdogain with OFD, GTR, and GTR and Emdogain) in the treatment of intrabony defects. We talked with Professor Sculean about the results of this study, why it turned him into an advocate for Emdogain and how his use of the product has changed over the last 10 years.
The entire market was quite different when we started the study. At the time when Emdogain was launched, Guided Tissue Regeneration (GTR) procedures were standard for treating periodontal defects. Having been trained on GTR and being convinced of its high efficacy, my goal was to show the inferiority of Emdogain. At that time, Emdogain was not as researched as it is today and it had yet to find its place in the market. The outcome of this study – and a full package of different studies – completely changed my mind.
In this study, it is important to point out that every treatment type showed an improvement in probing depth, both short term and long term. The first priority for any clinician should be to simply treat the patient. One of the key findings was that Emdogain worked as well as GTR alone when compared to the initial situation. This changed my mindset toward what was a rather new product at the time. The 10 year data has shown that this improvement wasn’t only an improvement for the short term – but that it can be maintained over time. Thus, the positive improvement observed when Emdogain was added to the surgical procedure for intrabony defects was shown to be predictable.
Using new technologies has its advantages and these should be taken into account when making treatment decisions. However, it’s also important to look at the results of this study in the context of a complete body of evidence. The study was part of an entire series including both histological and clinical evidence. With all of this evidence, we saw that Emdogain has its strengths and we should consider it in the treatment of periodontal diseases.
Within its limits, this study has shown remarkable improvement of patient status, which were maintained over a long time period (10 years). To get these results, patient selection was crucial. Patients had to be suitable from an indication point of view (e.g. non- smoker) and ready to collaborate (e.g. cleaning regularly, plaque control follow up). All approaches have shown a stable outcome after 10 years, but using advanced technologies like Emdogain support an improved outcome over performing the surgical procedure alone (in this case, open flap debridement).
We’ve seen in several studies that when Emdogain is added to the surgical procedure, it supports the regeneration of the periodontal ligament. This then leads to the regeneration of bone and patients are more likely to be able to keep their teeth. The results are similar to GTR, but with less pain and swelling.2 I’ve also observed in my patients an improvement in periodontal wound healing. This can, in turn, lead to higher patient satisfaction and more receptivity toward periodontal treatment. In this study, we also observed that the combination of GTR (membrane) and Emdogain did not show any improvements compared to Emdogain alone – thereby, demonstrating that there’s no need to add a membrane to the procedure.1
I use Emdogain in many indications – infrabony defects, furcations, gingival recession (Miller Class I, II & III). For larger defects, I use it in combination with bone regeneration materials and/or a Connective Tissue Graft (CTG). Clinically, I’ve observed a better treatment outcome when I mix bone graft material with Emdogain. This has become my standard for larger defects.
The more experience we had with the product, the more we could appropriately adapt our surgical technique. The product is generally easy to use, but there is a learning curve. Various factors have to be considered, including patient selection (e.g. non-smoker), analysis of the patient (e.g. bleeding plaque score), pre-surgical preparation, surgical approach and follow-up.
Patient selection is a key to success. If the patient is not ready to change his/her habits (e.g. heavy smoker), success can be jeopardized. Patient preparation is critical in the treatment – in fact, I normally do not perform the procedure with Emdogain until six months after the first cleaning and antibiotics treatment.
From a technique standpoint, we are moving to smaller flap designs as we gain experience with specific cases. The suture technique has also improved, enabling us to better stabilize the wound, which in turn also affects the outcome.
In my practice, I have observed enhanced periodontal wound healing when using Emdogain. In addition, I’ve had less post-operative complications when treating a patient with Emdogain compared to a membrane.3 It seems that Emdogain affects more than just the regeneration of the periodontal ligament.
From a clinical point, the most important data is long term data because the effectiveness of a treatment is demonstrated. Our first goal is to save the patient’s tooth and the second is to keep it for as long as possible. There is nothing better than that what nature has created. Thus, it should be our highest priority to keep the natural tooth in place and functional. If we are confident that the treatment we provide to our patients will last for a long time, our patients will also have confidence and will be more likely to choose treatment.
As we’ve discussed, there are many factors that can impact treatment. Emdogain supports us in reaching the most important part – helping patients keep their teeth in place and in function for as long as possible.
1Sculean A, Kiss A, Miliauskaite A, Schwarz F, Arweiler NB, Hannig M. Ten-year results following treatment of intra-bony defects with enamel matrix proteins and guided tissue regeneration. J Clin Periodontol. 2008 Sep;35(9):817-24.
2Jepsen S, Heinz B, Jepsen K, Arjomand M, Hoffmann T, Richter S, Reich E, Sculean A, Gonzales JR, Bödeker RH, Meyle J. A randomized clinical trial comparing enamel matrix derivative and membrane treatment of buccal Class II furcation involvement in mandibular molars. Part I: Study design and results for primary outcomes. J Periodontol. 2004 Aug;75(8):1150-60.
3Sanz M, Tonetti MS, Zabalegui I, Sicilia A, Blanco J, Rebelo H, Rasperini G, Merli M, Cortellini P, Suvan JE. Treatment of intrabony defects with enamel matrix proteins or barrier membranes: results from a multicenter practice-based clinical trial. J Periodontol. 2004 May;75(5):726-33.