Introduction
Periapical pathology occurs as a sequela of microbial insults from the
root canal leading into excessive osteoclastic bone resorption
circumscribing the root (1)
. Failure of nonsurgical root canal treatment
necessities surgical intervention in the form of periradicular surgery (2)
.
The periradicular surgery aims to remove the pathological and
granulation tissues in the periapical area. Removal of such tissues creates
a surgical defect in the periapical area that requires bone substitutes to fill
the defect. The type of bone substitute is a critical factor that affects the
healing of the periradicular area. The best bone substitute is autologous
bone which has osteoconductive and osteoinductive properties that
accelerate the healing of the periapical tissues(3)
. Unfortunately, such type
of bone substitute requires donor sites rather than the defective surgical
one that leads to provoking pain, stress,and delayed surgery for the patent
(4)
. As an alternative to autologous bone, synthetic bone substitutes are
used that only have osteoconductive properties that require more time for
complete healing To overcome the disadvantages of both autologous and
synthetic bone substitutes different alternatives have been developed such
as using blood derivatives. Platelet rich in fibrin (PRF) which is an
autologous leukocyte and platelet‑rich fibrin biomaterial with a specific
composition and three‑dimensional architecture.it consists of a fibrin
three‑dimensional polymerized matrix in a specific structure, with the
incorporation of almost all the platelets and more than half of the
leukocytes along with growth factors and circulating stem cells. It
supports and accelerates the healing process which introduces it as a
promising blood derivative for bone healing (5)
. Alternatively, Hyaluronic
acid (HA), which is also called hyaluronan, is a high molecular weight
(HMW) glycosaminoglycan, composed of repeated nonsulfated
2
disaccharide units of N-acetyl glucosamine and D-glucuronic acid (6,7)
. It
is one of the main components of the extracellular matrix (ECM) (8)
. It
was found that HA has an active role in cellular signaling; morphogenesis
and matrix organization in addition to regulating fibroblast and
myofibroblast proliferation (9)
. Subsequently to tissue injury, HA
concentration levels significantly increase to stimulate migration of the
ECM cells to the zone and to form a temporary structural skeleton by
forming fibrin-clot relations. Therefore, the initial phase of the healing
process is regulated by HA (10,11)
. Concomitantly with the type of bone
substitute, other factors may affect the healing of bone which is the
hormonal changes that leads to systemic diseases such as diabetes
mellitus. Diabetes mellitus is a chronic metabolic disease with high blood
glucose levels (12)
. Diabetes results from deficits in the production of
insulin or deficit insulin resistance coupled with insufficient insulin
production. Diabetes mellitus often leads to serious complications that
affect the heart, blood vessels, eyes, kidneys, and nerves. Hyperglycemia
may affect bone through enhanced expression of pro-inflammatory
cytokines such as Tumor necrosis factor(TNFα), which reduces osteoblast
differentiation, and osteoblast activity and increases osteoblast
apoptosis(13)
. Although there is an abundance in the research where PRF
and HA are used in the dental aspect, however little few studies in which
PRF and HA are used alone or in combination to induce bone
regeneration in periradicular areas.