AAP best evidence consensus on biologics (2022): safe, worth it with a scaffold, and thin evidence at the extraction site

What it says#

A biologic, in this document, is a therapeutic agent with biological activity that is administered to achieve an enhanced regenerative or reparative effect. The AAP convened a panel of experts, commissioned three systematic reviews in advance, and asked three focused clinical questions about four agents: autologous blood-derived products (ABPs, the family that includes platelet-rich fibrin and platelet-rich plasma), enamel matrix derivative (EMD), recombinant human platelet-derived growth factor BB (rhPDGF-BB) and recombinant human bone morphogenetic protein 2 (rhBMP-2). The statement is open access and free to read in full.

Question one, periodontal plastic surgery. The review screened 1393 articles published between January 1, 2000 and September 30, 2021, assessed 85 in full text and included 48 trials reported in 55 articles, with 24 articles supplying data for network meta-analyses. Every included article was about root coverage; none addressed gingival augmentation. Biologics used with a coronally advanced flap produced statistically and clinically significant improvements in recession depth, attachment level and keratinized tissue width, with the tissue width gains more evident with ABPs or rhPDGF-BB. Two limits came with it. When baseline keratinized tissue width is greater than 2 mm, adding ABPs or EMD does not substantially improve on the flap alone. And both PRF plus flap and EMD plus flap gave inferior mean root coverage, complete root coverage, recession reduction and tissue width gain compared with a subepithelial connective tissue graft plus flap, which the review says should still be considered the gold standard.

Question two, infrabony defects. The review screened 385 articles through December 31, 2021, assessed 182 in full text, included 153 and pooled 150 in network meta-analyses. Biologics may significantly enhance the clinical and radiographic outcomes of surgical treatment. rhPDGF-BB and PRF were associated with superior outcomes compared with EMD and platelet-rich plasma. Combination therapy, a bone graft with either a biologic or a barrier membrane, was the most effective strategy, but the review adds a caution that matters at the chair: membranes with biologics should be avoided when graft containment is feasible, because the combination may block some of the benefit of the biologic. Allogeneic and xenogeneic grafts were associated with greater clinical benefit than autogenous and synthetic grafts, and a xenogeneic graft with rhPDGF-BB or PRF was the best combination for keeping the gingival margin stable.

Question three, ridge preservation and reconstruction and implant site development. This review screened 3044 articles through November 1, 2021, assessed 90 in full text and included 39 (18 on ridge preservation or reconstruction, 9 on ridge augmentation, 8 on sinus floor augmentation). Heterogeneity was severe enough that no meta-analysis could be completed, and some included studies reported off-label use of biologics. The conclusion is deliberately flat: there is limited evidence that ABPs, EMD, rhPDGF-BB or rhBMP-2 render superior clinical and radiographic outcomes compared with conventional interventions, although the adjunctive use of these biologics seems to translate into favorable histomorphometric outcomes in bone core biopsies, and patient-reported outcomes seem only minimally improved.

The overarching statements are where an owner should look. On safety, the panel found no known reported risks for any of the four agents in these applications, with one exception: a robust, dose-dependent local inflammatory reaction may occur after rhBMP-2, which has been associated with localized swelling and requires careful presurgical assessment. On limitations, results vary with case selection, technique and graft material; the cost-benefit ratio must be considered, particularly in less challenging clinical scenarios; and ABPs specifically require venipuncture, trained auxiliary personnel, specific equipment and disposables, and additional preparation and surgical time. The panel also recommends where to use them: in patients with compromised wound healing such as uncontrolled diabetes or smokers and vapers, in defects with features associated with lower predictability, where ideal soft tissue healing is crucial or surgical access is limited, where a shortened healing timeframe helps, and in patients with a history of failure after conventional treatment.

Who it applies to#

Periodontists and the general practices that refer to them, in the three surgical arenas the questions name. The clinical recommendations are written for case selection, so they reach any owner deciding whether a biologic is a standing line item or a case-by-case decision.

It does not reach agents outside the four studied, and it is not a guideline. The panel states that the available evidence is, in its judgment, insufficient to support broad conclusions or clinical practice guidelines, and that each periodontist should make an independent decision based on the needs of the patient in question. Gingival augmentation is named in the first question but no included study addressed it, so the panel's statements there rest on expert opinion, not on trial data.

What changed#

This is the fourth AAP best evidence consensus, after cone beam computed tomography (2017), laser therapy (2018) and phenotype modification (2020). Compared with the laser consensus, the tone is notably warmer: the panel concludes that appropriate use of biologics is generally safe and provides added benefits to conventional treatment approaches, which is a stronger statement than anything the laser proceedings supported. What it does not do is turn biologics into a default. The gold standard for root coverage stays the connective tissue graft. The cost-benefit ratio is named as a limitation. And for the extraction socket and the implant site, the evidence is called limited in plain words.

Where the source is#

The document is Avila-Ortiz and colleagues, American Academy of Periodontology best evidence consensus statement on the use of biologics in clinical practice, Journal of Periodontology 2022, volume 93, issue 12, pages 1763 to 1770. The link under the title resolves through the DOI to the publisher; the full text is free and open access in PubMed Central under a CC BY-NC-ND 4.0 license, and that is the copy this entry was written from, read in full. The three commissioned systematic reviews are in the same issue at pages 1771 to 1802 (root coverage and gingival augmentation), 1803 to 1826 (infrabony defects) and 1827 to 1847 (ridge preservation and implant site development); their PubMed records are linked above and their full texts sit behind the publisher's paywall, so the numbers quoted here are the ones the consensus statement itself reports. The consensus meeting was sponsored by BioHorizons, Geistlich Biomaterials, Lynch Biologics and Straumann USA, and the statement carries a conflict of interest disclosure naming advisor fees and lecture compensation from those companies and others; read it with that on the table.