Emdogain

I happened to be working beside a periodontist on clinic today and had been to a lecture by another last week. The former was using Emdogain on a patient with a 3 wall defect on an upper first molar. The latter had been enthusing about the benefits of Emdogain to treat infrabony defects. Ever the one to find my own evidence I did a quick search for Emdogain in the Cochrane Library (all databases).

There was a Cochrane systematic review of Emdogain versus placebo or other bone regeneration techniques from 2010. 13 trials (parallel and split-mouth) involving 653 patients were included. There didn't appear to be any more recent clinical trials so I make the assumption that this is the most up-to-date evidence.

"periodontal attachment loss improved 
by a mean difference of 1.1 mm"

When the data from the individual studies were combined in a meta-analysis, periodontal attachment loss (PAL) improved by a mean difference of 1.1 mm (95% CI 0.61 to 1.55) and periodontal pocket depth (PPD) reduction was 0.9 mm (95% CI 0.44 to 1.31) when compared to placebo or control treated sites over 1 year. When only those studies thought to be at lower risk of bias were included the PAL gain shrank to 0.62mm (95% CI 0.28-0.96). I have copied and pasted the Forest Plot from the Cochrane study below:


Reproduced from: Esposito M, Grusovin MG, Papanikolaou N, Coulthard P, Worthington HV. Enamel matrix derivative (Emdogain®) for periodontal tissue regeneration in intrabony defects. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD003875. DOI: 10.1002/14651858.CD003875.pub3

Overall the quality of the evidence according to GRADE criteria was low. The studies seem to have been very heterogenous with some including various antibiotic regimens and chorhexidine rinsing alongside the surgical treatment. All the studies appear to have included infrabony defects of 3-4mm or greater. I guess then that 1mm attachment gain is relatively significant but I wonder if in deeper defects the benefit would be proportionally similar (i.e. 2mm gain in a 6mm defect) or just 1mm. If the latter the benefit becomes less significant as the defect deepens I suppose.

At a cost of around £350 for a pack of 3 syringes (if we were only treating one defect we would use one syringe but it may get spread between 2 or 3 defects if these existed I am guessing), that makes it potentially £117 a pop for the material. If you were the patient with one of those 6mm attachment gains one sees in presentations (for example, see the bottom of this page) I reckon it would be worth it - but for 1mm or nothing? mmm....

Questions, questions and, please, more questions

I had a discussion with a student this afternoon about a finals case. I wondered how or if he was using those EBD skills taught back in the 2nd year. There was much to discuss.

The case is a person with periodontal disease (with 30-50% bone loss) who requires composite build-ups, a couple of crowns and a partial denture. I asked the following questions, amongst others:

1. Can you give the patient an idea of how long he can expect to retain the worst-affected teeth?

2. What is the evidence that crowns are any more successful than large fillings?

3. If the composite build-ups are for posterior teeth, what are the alternatives and how do they compare?

4. Which lasts longer in posterior teeth - composite or amalgam?

Now this wasn't me trying to catch the student out - there weren't many confident answers coming back at me. What I wanted to encourage was the following:
1. to ask these questions yourselves when you are managing patients
2. to think about how you will answer it by searching for evidence. Is there a systematic review to help? If not, what trial design is the best one to answer your question?

For the prognosis question we'd want a study that followed a bunch of patients with severe periodontitis and see if / when they lost their teeth. That's a cohort study.

For all the others we want a study that compares two or more interventions, ideally in a random way. That would be a randomised controlled trial.

Please do ask these questions and let me know how you get on.