Original Article

Evaluation of Periodontal Wound Healing with Human Placental Extract

as an Adjunct to Scaling and Root Planing – A Randomized Controlled
Clinico‑Histological Trial

Abstract Sahithi Garapati,

Aim: The present study is aimed to assess the clinical and histological evaluation of human placental Suryakanth
extract (Placentrex®) as an adjunct to scaling and root planing in Stage III Grade A periodontitis. Malgikar,
Methods: Forty sites in twelve, stage III Grade A periodontitis patients, were randomly assigned into
Group I (Test) and Group II (Control). Plaque index (PI), gingival index (GI), probing pocket depth Raja Babu
(PPD), and clinical attachment level (CAL) were recorded, and curettage samples were collected Palaparthy,
in both groups for histological evaluation of collagen density (pixels) at baseline and one month. Vidya Sagar Sistny,
Results: Significant reduction in PI and GI was observed within the groups at baseline and one Jagadish Reddy
month. Probing pocket depth at the end of one month was 3.55 ± 0.83 in Group I and 2.50 ± 0.83 Gooty,
in Group II. The gain in clinical attachment level was 2.55 ± 0.83 in Group I and 1.65 ± 0.59
in Group II. PPD and CAL are better in Group I but could not reach statistical significance. Vikram Reddy
Collagen density (pixels) at the end of one month histologically was 2884.9 ± 1386 in Group I Guntakandla
and 447.9 ± 244.6 in Group II which were statistically significant (P < 0.05*). Conclusions: Local Department of Periodontology,
drug delivery of human placental extract played a significant role in managing Stage III Grade A Kamineni Institute of Dental
periodontitis, especially as an adjunct to scaling and root planing. Sciences, Narketpally, Nalgonda,
Telangana, India
Keywords: Collagen density, histological assessment, human placental extract, periodontitis, wound
healing

Introduction or epithelialization leading to the closure of

the wound. There is a lacuna of medications
Periodontal disease is one of the most
that directly brings about wound healing.
prevailing global chronic disorders.
But recently, human placental extract
Pathology affecting the structure
(HPE) has shown promising healing in
surrounding teeth results in inflammation
surgical wounds. It is obtained from fresh
initiated by bacterial aggregation and
term healthy human placentae tissues
alteration in their profile.[1] Despite the
and contains fibronectin type III ‑ like
host’s protective mechanisms, these
peptide; fragments of nucleotides PDRN
microorganisms are responsible for
(polydeoxyribonucleotide), NADPH Address for correspondence:
connective tissue breakdown; alveolar bone
(nicotinamide adenine dinucleotide), etc.; Dr. Suryakanth Malgikar,
loss, and tooth loss are the disease’s basic Department of Periodontology,
amino acids—glutamate; and a water‑soluble
characteristics. The composition of bacteria Kamineni Institute of Dental
peptide with CRF (corticotropin‑releasing Sciences, Narketpally,
in subgingival biofilm is mostly anaerobic.
factor) like activity.[3] Nalgonda, Telangana, India.
Conventional periodontal therapeutics have E‑mail: drmalgikarsuryakanth@
focused on the control of etiologic agents HPE claims to directly facilitate the process gmail.com
thus promoting the healing and repair of of wound healing through these active
tissues.[2] Delivery of therapeutic agents into biomolecules. It has been reported earlier
Received : 19‑02‑2023
the local environment acts as drug reservoirs that human fibronectin type III peptide Revised : 21‑03‑2024
which could vary pathogenic flora and also has high efficacy in stimulating cell Accepted : 15‑06‑2024
promote its repair and wound healing. Over migration and wound repair.[4] Based on Published : 24-12-2024
the years, the mainstay of wound therapy fluorescent screening, ‘HPE’ has a content
Access this article online
has been antimicrobials that exert control of biologically active NADPH facilitating
Website:
over the infection but have no direct role in nitric oxide‑mediated wound healing. https://journals.lww.com/ijdr
tissue regeneration, new vessel formation, Nitrous oxide helps in debriding necrotic
DOI: 10.4103/ijdr.ijdr_135_23
tissues, killing bacteria and promoting Quick Response Code:
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
How to cite this article: Garapati S, Malgikar S,
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
Palaparthy RB, Sistny VS, Gooty JR, Guntakandla VR.
others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are Evaluation of periodontal wound healing with human
licensed under the identical terms. placental extract as an adjunct to scaling and root
planing – A randomized controlled clinico‑histological
For reprints contact: [email protected]
trial. Indian J Dent Res 2024;35:290-4.

290 © 2024 Indian Journal of Dental Research | Published by Wolters Kluwer - Medknow
 Garapati, et al.: Periodontal wound healing with human placental extract

re‑epithelialization.[5] Based on these findings, its utilization against tissue so as to engage the inner lining of the pocket
in the periodontal milieu as a potential complement of wall. The pocket wall was supported with gentle finger
wound healing placental extracts could be a promising pressure on the external surface, and then, the tissue was
novel therapy. The present study was thus designed to excised in both groups (baseline and at the end of 1 month)
assess the clinical and histological efficacy of human followed by SRP employing both hand instruments
placental extract (Placentrex®) as an adjunct to scaling and (Hu‑Friedy, USA) and a piezoelectric ultrasonic handpiece
root planing in Stage III Grade A periodontitis subjects. (EMS, Switzerland) at baseline. After SRP, the test sites
in Group I additionally received 0.5 ml of Placentrex®
Materials and Methods gel (Albert David Ltd.,) which was injected deep into
The present double‑blinded randomized trial was carried the base of the pocket using a 2 ml syringe of 24‑gauge
out at a single center. The clinical trial was registered needle (Dispo Van®, Haryana, India). After one month of
in clinical trials—in India with registration number follow‑up, curettage samples were collected under local
CTRI/2021/07/034774. The ethical clearance was obtained anesthesia of 2% lidocaine with 1:80,000 adrenaline
from Institutional Ethical Committee - IEC/2020/302. in both groups and sent for histological evaluation.
Individuals satisfying the inclusion and exclusion criteria Connective tissue sample was obtained in the selected sites
were enrolled in the study from the outpatient department in both groups which were collected during periodontal
of periodontics. Informed written consent was obtained surgical therapy during the initial and month follow‑up of
from all the subjects before participating in the study. periodontal therapy, in a sterile sample container with 10%
Inclusion criteria were age group 25‑60 years, minimum formalin, and were transported for tissue processing. For
of 20 permanent teeth that should be present, periodontal the follow‑up sample collection, only sites with residual
pocket depth ≥5 mm and clinical attachment level ≥3 mm, PPD of greater than 5 mm were included for sample
and radiological evidence of bone loss. Exclusion criteria collection and their assessment.
were systemically compromised patients and those on Initially, after obtaining the sample from the treated site,
medications that may interfere with wound healing, grossing was done. The specimen was placed in a liquid
pregnant women and lactating mothers, active periodontal fixative of 10% formalin for 24 hrs. Following fixation,
treatment within the last 6 months, smokers, and diabetic tissue was dehydrated through a series of 70%, 80%, 90%,
individuals. The sample size was calculated using two and 100% alcohol for 1 hour each, and then, clearing was
mean hypothesis testing for two means (equal variances). done in xylene for 3 hrs. The tissue was impregnated
Twenty sites in each group would be sufficient to achieve in melting wax at 40°C ‑ 60°C where it solidifies to a
the required significance under 90% power with an alpha consistency that allows sections to be consistently cut.
error (%) value set at 5. Paraffin wax‑embedded tissue blocks were sectioned to
The following clinical parameters were recorded at baseline 4 μm thickness with a rotary microtome. Each section
and 1 month—plaque index (PI), gingival index (GI), was taken onto a glass slide, deparaffinized by placing
probing pocket depth (PPD), and clinical attachment level it in a hot air oven at 100°C for 10 minutes, and further
(CAL). The primary outcomes for the study are PPD, rehydrated by taking the tissue sections through absolute
CAL, and histological evaluation of collagen density alcohol, 80% alcohol, and 70% alcohol for 5 minutes each.
(pixels), while PI and GI were secondary outcomes. The Masson’s trichrome stain is a tricolored stain that stains
PPD and CAL were measured using UNC‑15 graduated collagen in blue, nuclei in black, and muscle, cytoplasm,
periodontal probe. Measurements were done at selected and keratin in red color. Materials used for preparation
sites. One experienced periodontal examiner performed were: Weigert’s iron hematoxylin, Biebrich scarlet–acid
all measurements. A total of 20 patients were screened, fuchsin, phosphomolybdic–phosphotungstic acid, aniline
out of which 12 individuals in the age group 25‑60 (seven blue, and 1% acetic acid solution. The staining procedure
males and five females) were enrolled in the study. These was done according to the protocol given by Foot.[6]
12 patients had 40 potential sites that were randomly
In brief, the amount of collagen in Masson’s
allocated by a simple randomization approach using
trichrome‑stained tissue sections was quantified using
computer‑generated random numbers, which was employed
Image J software.[7] Three images were taken for each
to assign patients into either group. The sequence was
section at the head, body, and tail regions. Each image
concealed until interventions were assigned. Group I (Test):
was converted into a tagged image file format (tiff) with
n = 20 sites underwent SRP + human placental extract
640 × 480 resolution. Image acquisition was done which
(Placentrex®) gel; or Group II (Control): n = 20 sites
is a prerequisite for further analysis. Area and integrated
treated with scaling and root planing (SRP) only.
density were set using the ‘analyze’ option. Separation
After anesthetizing the area with 2% lignocaine with via color deconvolution provides a means of separating
adrenaline (1:80,000) solution, curettage samples were collagen fibers from overlapping regions. During color
collected from the selected sites in Group I and Group II deconvolution, Masson’s trichrome stain image was
by inserting sharp Gracey curettes with the cutting edge separated into 3 components (red, blue, and green). The

Indian Journal of Dental Research | Volume 35 | Issue 3 | July-September 2024  291

 Garapati, et al.: Periodontal wound healing with human placental extract

green component’s threshold value, which represents respectively (P = 0.0001). The intra‑group comparison
collagen fibers, was adjusted and measured. Quantification showed a statistically significant gain in CAL in both
of collagen fibers was obtained as a numeric value. groups. Inter‑group comparison of CAL showed a gain
of 2.55 ± 0.83 mm in Group I and 1.65 ± 0.59 mm in
The data were analyzed using the SPSS‑software 20.00
Group II, respectively, which were statistically significant
program (SPSS Inc., Chicago, IL, USA). The intra‑group
at the end of one month (P = 0.0001). A significant
comparison of all clinical parameters and histological
increase in collagen density (pixels) was seen in both
assessment was done using the Wilcoxon‑matched paired
groups. Inter‑group comparison [Table 2] of collagen
test. The inter‑group comparison of all clinical parameters
density (pixels) showed a mean increase of 2884.9 ± 1386
and histological assessment was done using the Mann–
in Group I [Figure 1a-d] and 447.9 ± 244.6 in Group II
Whitney U test. Differences were considered statistically
[Figure 2a-d] which were statistically significant at the end
significant at P < 0.05.
of one month (P = 0.0001).
Results
Discussion
Forty sites were assessed in 12 patients (Group I—4 males
The goals of today’s treatment of periodontitis are to
and 3 females, and Group II—3 males and 2 females). All
reduce infection, resolve inflammation, and create a clinical
12 patients completed one month study, with none reporting
condition compatible with periodontal health.[8] Non‑surgical
any postoperative pain, discomfort, or complications at any
periodontal therapy consists of scaling and root planing
of the follow‑up appointments. The intra‑group comparison
(SRP) combined with oral hygiene instructions. Typically,
of PI and GI scores showed a significant statistical
these results gain in attachment and recession of the
mean reduction between Groups I and II (P < 0.05).
gingival margin due to the resolution of the inflammation.
The inter‑group comparison of PI and GI scores was not
Now and then, even though the expected effect has been
statistically significant but better results are seen in the test
achieved, some residual pockets remain after therapy.[9]
group.
Additional periodontal surgery is needed to resolve these
The intra‑group comparison [Table 1] showed a residual pockets. When the expected effect of non‑surgical
statistically significant reduction in PPD scores in both periodontal therapy is not achieved, the treatment needs
groups. Inter‑group comparison of PPD showed a mean to be adjusted and thereby local drug delivery could be a
reduction of 3.55 mm and 2.50 mm in Groups I and II, good alternative. The present study was the second of its

Table 1: Intragroup comparison of clinical parameters and Histological assessment of Collagen Density (Pixels) in
Group I (Test) and Group II (Control)
Parameters Group I (Test) Mean±SD P Group II (Control) Mean±SD P
Baseline One Month Baseline One Month
Plaque Index (PI) 1.11±0.08 0.68±0.24 0.0003* 1.08±0.13 0.69±0.11 0.0001*
Gingival Index (GI) 1.29±0.26 0.85±0.34 0.0003* 1.13±0.30 0.71±0.06 0.0001*
Probing Pocket Depth (PPD) (mm) 8.90±1.07 5.35±1.09 0.0001* 8.50±1.61 6.00±1.21 0.0001*
Clinical Attachment Level (CAL) (mm) 6.65±1.04 4.10±0.85 0.0001* 6.10±1.02 4.45±0.83 0.0001*
Collagen Density (Pixels) 3080.6±763.8 5965.4±1634.36 0.0001* 2879.00±524.54 3326.90±674.31 0.0001*
P<0.005* ‑ Statistically Significant

Table 2: Intergroup comparison of clinical parameters and Histological assessment of Collagen Density (Pixels) in
Group I (Test) and Group II (Control)
Parameters Group I (Test) Mean±SD Group II (Control) Mean±SD Difference
Baseline One Month Baseline One Month Group I Group II
Plaque Index (PI) 1.11±0.08 0.68±0.24 1.08±0.13 0.69±0.11 0.44 0.39
0.0003* 0.0003*
Gingival Index (GI) 1.29±0.26 0.85±0.34 1.13±0.30 0.71±0.06 0.45 0.42
0.0003* 0.0001*
Probing Pocket 8.90±1.07 5.35±1.09 8.50±1.61 6.00±1.21 3.55 2.50
Depth (PPD) (mm) 0.0001* 0.0001*
Clinical Attachment 6.65±1.04 4.10±0.85 6.10±1.02 4.45±0.83 2.55 1.65
Level (CAL) (mm) 0.0001* 0.0001*
Collagen Density (Pixels) 3080.6±763.8 5965.4±1634.36 2879.00±524.54 3326.90±674.31 ‑2884.8 ‑447.90
0.0001* 0.0001*
P<0.005* ‑ Statistically Significant

292 Indian Journal of Dental Research | Volume 35 | Issue 3 | July-September 2024

 Garapati, et al.: Periodontal wound healing with human placental extract

a
c

b d
Figure 1: (a) Masson trichome stain at baseline in group I (b) Masson trichome stain at one month in group I (c) Collagen density at baseline in group I
(d) Collagen density at one month in group I

a c

b d
Figure 2: (a) Masson trichome stain at baseline in group II (b) Masson trichome stain at one month in group II (c) Collagen density at baseline in group II
(d) Collagen density at one month in group II. Measurement: Pixels

kind similar to Sharma et al.,[10] where the effect of human Shukla and Adil[14] found that 52% of patients had 75‑100%
placental extract (Placentrex®) gel application as an adjunct epithelization of wounds in 4‑8 weeks dressed with HPE gel,
to scaling and root planing was assessed clinically (like without any adverse reaction. They found that it is extremely
PI, GI, PPD, and CAL) and also the wound healing using effective in healing wounds as it increases the blood supply
collagen density (pixels) through histological analysis in in tissues and enhances regeneration and recovery of the
moderate‑to‑severe periodontitis. The mechanism of action tissue, which can be correlated with the present study in
of human placental extract (Placentrex®) was described terms of wound healing. An animal study by Hong et al.,[15]
by Gupta et al.[11] In a case report by Sharma et al.,[10] evaluated the effect of HPE in a wound healing model with
Placentrex gel was used as a surgical wound healing agent local administration of it directly onto wound margins. They
in a gingival enlargement condition. The end of a 1‑month advocated better wound healing, due to an increase in the
follow‑up resulted in uneventful wound healing. In the amount of TGF‑β in the early phase of wound healing and
present study, it is correlated with the collagen formed after vascular endothelial growth factor (VEGF) in the late phase.
one month of the follow‑up period, which corroborated Different staining techniques that are used to stain collagen
similar results to their study. Subramanian et al.,[12] are hematoxylin and eosin, Masson’s trichrome, Gomori’s,
observed that in indolent ulcers, Placentrex gel dressing Verhoeff–van Gieson’s elastic, Mallory, Gomori’s reticulin
seems to free the lesion from infection, producing adequate fiber, and Movat Pentachrome stain. By using conventional
granulation tissue formation and facilitating healing. Pote[13] staining methods such as hematoxylin and eosin, the study
compared povidone iodine ointment and HPE gel as topical of wound healing becomes more challenging as the stain is
agents in superficial burns. In patients treated with HPE not able to differentiate important histopathological changes
gel, wounds healed significantly earlier than those with in the wound healing process.[16] To overcome these deficits,
povidone‑iodine ointment. HPE gel was found to be more an alternative stain such as Masson’s trichrome was used in
acceptable than povidone iodine ointment. the study.
Indian Journal of Dental Research | Volume 35 | Issue 3 | July-September 2024  293
 Garapati, et al.: Periodontal wound healing with human placental extract

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Financial support and sponsorship
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There are no conflicts of interest.
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