Hyaluronic Acid for the Treatment of Gingival Recession: Comparison
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In periodontal surgery, HAhyaluronic acid exhibited better results in complete root coverage and mean root coverage when compared to the control group. Gingival recession reduction, clinical attachment level, and keratinized tissue gain were significantly increased compared to the control groups.

  • gingival recession
  • Miller class I and II
  • hyaluronic acid

1. Introduction

Tooth root exposure due to the apical movement of the gingival margin, compared to the cement-enamel junction, is termed a gingival recession [1][2]. Persistent trauma or periodontal disease, anatomic factors of soft tissue (e.g., narrow band of keratinized mucosa), or areas of biofilm development (e.g., inadequately suited dental restorations/crowding) are causes to one or more teeth can be affected by the gingival recession, thus, resulting in tooth sensitivity, hygiene issues, root cavities, and other issues [2][3][4]. As a result, for patients with good dental hygiene, surgical treatment of gingival recession was necessary to reduce these problems. Sub-epithelial connective tissue grafts (SCTG), coronally advanced flaps (CAF), semilunar coronally advanced flaps, laterally positioned flaps, and free gingival grafts have all been used to address gingival recessions [5][6][7][8][9]. The primary downside of the SCTG procedure is the need for donor tissue. In cases with multiple recessions, it necessitates a substantial tissue volume, which causes post-operative pain [10]. Therefore, as a result, biomaterials and alternative grafts have been proposed, including acellular dermal matrix (ADM), enamel matrix derivatives (EMDs), and autologous plasma [11][12][13]. Recently, the role of hyaluronic acid (HA) as a chemotherapeutic agent has been a boon to the advancement in dentistry. HA is a major natural carbohydrate component of the extracellular matrix in many tissues, including the periodontium. The biological effects of HA depend heavily on molecular weight. Hyaluronic acid with molecular weights from 0.4 to 4.0 kDa acts as an inducer of inflammation and has a non-apoptotic property. HA, with a molecular weight of 20–200 kDa, takes part in biological processes such as embryonic development and wound healing. By contrast, high molecular weight hyaluronic acid (>500 kDa) has anti-angiogenic activity and can function as a space filler and a natural immunologic depressant [14]. It has unique physiochemical and biological properties such as viscoelastic, anti-inflammatory, hygroscopic, bacteriostatic, osteoinductive, and anti-edematous properties [15][16][17]. Moreover, numerous trials proved that HA enhances clot formation, induces angiogenesis, promotes osteogenesis, and plays important roles in cell differentiation, adhesion, and migration. HA-binding proteins mediate these to cell surface receptors. Thus, it has been proposed that HA might be a suitable material for both periodontal wound healing and regeneration in periodontal defects. With its application in intra-bony defects, HA has shown promising effects like clinical attachment level (CAL) gain, probing depth reduction, and complete root coverage (CRC) [15][16][18][19][20][21][22]. However, there is no qualitative or quantitative analysis of its efficacy with respect to gingival recession.

2. Concentration of HA Application

The method of applying HA and the time interval differed among the trials, but in all three, HA was at least applied once during the therapy procedure. Kumar et al. used Hyaluron gel (0.2% HA, Gengigel, Ricerfarma Pharmacheuticals, Milan, Italy). Nandanwar et al. chose Hyaloss matrix gel (HA, Hyaloss matrix, Meta, Italy), while a cross-linked high-concentrated HA gel (2 mg/mL HA, hyaDENT BG, Bioscience, Germany) was used by Pilloni et al. [17][21][22]. The follow-up period in two studies was 6 months, while the other presented 18 months [17][21][22].

3. Complete and Mean Root Coverage

CRC and mean root coverage (MRC) have shown a significant difference in the included studies [17][22]. According to Kumar et al., when analyzed by Student’s t-test after six months of surgery, MRC was presented 68.3% in the study group and 61.7% in thecontrol group [21]. However, complete root coverage was not measured in this aforementioned study. By using Student’s unpaired t-test, Nandanwar et al. found a significant increase in CRC (77.7%) for the study group, six months post-operatively, compared to (65.25%) in the control group [22]. Mean root coverage in Nandanwar et al. study was measured 92.8% in the test group and 84% in the control group. Pilloni et al. also concluded that there is a significant increase in complete root coverage, with 80% in the test group and 33.3% in the control group 18 months postoperatively [17].

4. Gingival Recession Reduction

Gingival recession reduction was found statistically significant in the included studies [17][22]. After six months, increased mean reduction was seen in the gingival recession for the test group (1.0 and 2.55 mm) than in the control group (1.1 and 2.11 mm) [21][22]. Similarly, Pilloni et al. discovered a significant difference between the groups, with the test group experiencing a 2.7 mm reduction in recession compared to 1.9 mm in the control group [17].

5. Evaluation of CAL

CAL has shown significant improvement for all the trials included in this study. Pilloni et al. reported a statistically significant difference in CAL gain in the test group (p = 0.023) and (p = 0.011) for the control group [17]. By analyzing through Student’s unpaired t-test, Nandanwar et al. concluded that there is a significantly higher CAL gain in the test group (3.03 mm) compared to the control group (2.34 mm) [22]. Kumar et al. [21] observed significant gain in the CAL after 24 weeks post-operatively.

6. Keratinized Tissue Gain

Heterogeneity was noted among the studies when comparing keratinized tissue gain. Pilloni et al. found no difference in keratinized tissue gain between the two groups (p = 0.116) [17]. Using Student’s unpaired t-test, Nandanwar et al. noted an increase in keratinized tissue gain of 2.53 mm in the test group compared to 1.96 mm for the control group [22].

7. Synthesis of Result

Despite the fact that data were extracted in a systematic manner for this review, a meta-analysis was not possible owing to study heterogeneity and inconsistent data.

8. Quality Assessment

Two studies were marked as “low risk,” while one study by Kumar et al. [21] was of “high risk”, the summary of which is described in Figure 1.
Figure 1. Summary of risk of bias.

References

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