Enamel Matrix Derivative in PropyleneGlycol Alginate for Treatment of InfrabonyDefects With or Without SystemicDoxycycline: 12- and 24-Month ResultsPeter Eickholz,* Lasse Rollke,* Beate Schacher,* Martin Wohlfeil,* Bettina Dannewitz,*†

Jens Kaltschmitt,† Jorg K. Krieger,† Diana M. Krigar,† Peter Reitmeir,‡ and Ti-Sun Kim†

Background: This aim of this study is to compare regen-erative therapy of infrabony defects with and without ad-ministration of post-surgical systemic doxycycline (DOXY)12 and 24 months after therapy.

Methods: In each of 57 patients, one infrabony defect(depth ‡4 mm) was treated regeneratively using enamelmatrix derivative at two centers (Frankfurt am Main andHeidelberg). By random assignment, patients received ei-ther 200 mg DOXY per day or placebo (PLAC) for 7 daysafter surgery. Twelve and 24 months after surgery, clinicalparameters (probing depths [PDs] and vertical clinical at-tachment level [CAL-V]) and standardized radiographs wereobtained. Missing data were managed according to the lastobservation carried forward.

Results: Data of 57 patients (DOXY: 28; PLAC: 29) wereanalyzed (26 males and 31 females; mean age: 52 – 10.2years; 13 smokers). In both groups, significant (P <0.01) PDreduction (DOXY: 3.7 – 2.2 mm; PLAC: 3.4 – 1.7 mm),CAL-V gain (DOXY: 2.7 – 1.9 mm; PLAC: 3.0 – 1.9 mm),and bone fill (DOXY: 1.6 – 2.7 mm; PLAC: 1.8 – 3.0 mm)were observed 24 months after surgery. However, the dif-ferences between both groups failed to be statistically sig-nificant (PD: P = 0.574; CAL-V: P = 0.696; bone fill: P =0.318).

Conclusions: Systemic DOXY, 200 mg/day for 7 days,after regenerative therapy of infrabony defects did not re-sult in better PD reduction, CAL-V gain, or radiographicbone fill compared with PLAC 12 and 24 months after sur-gery, which may be attributable to low power and, thus,random chance. J Periodontol 2014;85:669-675.

KEY WORDS

Alveolar bone loss; dental enamel proteins; doxycycline;guided tissue regeneration, periodontal; periodontaldiseases; wound healing.

Regenerative therapy using barriermembranes and enamel matrixderivative (EMD) in a propylene

glycol alginate carrier for infrabony de-fects have demonstrated superior clin-ical results compared with open flapdebridement.1-10

Periopathogenic bacteria impair peri-odontal wound healing after surgicaltherapy in general11 and after regenerativeprocedures using membranes in par-ticular.12 Thus, in many clinical studies,different antibiotic regimens were usedpost- or peri-surgically of regenerativetherapy of infrabony defects using mem-branes or EMD; e.g., 250 mg tetracy-cline four times daily for 1 week,13 1.5 gamoxicillin once a day for 1 week,2

200 mg doxycycline (DOXY) once aday for 1 week,3,5,14,15 1 g amoxicillinplus clavulanic acid once a day for 8days,16 or 3 g amoxicillin once 30 to 60minutes before surgery.17 Tetracyclinederivatives are used most frequently afterregenerative periodontal therapy.3,5,13-15

However, to our knowledge, until now,only one randomized placebo (PLAC)-controlled study compared short-termeffects of EMD therapy with or withoutsystemic DOXY and it failed to find addi-tional benefits.18 Data on intermediate-term effects of systemic DOXY on useof EMD for treatment of infrabony de-fects have not been reported.

doi: 10.1902/jop.2013.130290

* Department of Periodontology, Center of Dentistry and Oral Medicine (Carolinum),Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt, Germany.

† Section of Periodontology, Department of Conservative Dentistry, Clinic for Oral, Dental,and Maxillofacial Diseases, University Hospital Heidelberg, Heidelberg, Germany.

‡ Institute of Health Economics and Health Care Management, Helmholtz ZentrumMunchen, Neuherberg, Germany.

J Periodontol • May 2014

669

Therefore, the purpose of this randomized PLAC-controlled clinical trial was to compare the clinicaloutcomes 12 and 24 months after regenerativeperiodontal therapy using EMD in infrabony defectswith or without post-surgical administration of 200 mgDOXY once a day for 7 days.

MATERIALS AND METHODS

PatientsFrom April 2007 to February 2009, all patients un-dergoing periodontal treatment at the Departmentof Periodontology, Center of Dentistry and OralMedicine (Carolinum), Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt, Germany,and the Section of Periodontology, Department ofConservative Dentistry, Clinic for Oral, Dental, andMaxillofacial Diseases, University Hospital Heidelberg,Heidelberg, Germany, were screened for this study.Patients and methods of this study have been describedin detail previously.18 Thus, only a brief description isprovided. Patient characteristics and baseline intra-surgical defect characteristics are given in Table 1.

Inclusion criteria included: 1) adults ( aged ‡18years) with moderate-to-severe periodontitis; 2) com-pletion of initial periodontal treatment consisting oforal hygiene instruction, scaling and root planingunder local anesthesia according to the concept offull-mouth disinfection and reevaluation of the tis-sue response, and the patients’ plaque control 3months later; 3) at least one radiographically de-tectable infrabony lesion;19 4) good physical healthand effective individual plaque control (full-mouthplaque control record [PCR] score £30%);20 5) fe-males of childbearing age (<45 years)21 who prac-ticed contraception from screening to at least 1week after surgery; 6) written informed consent;7) interproximal angular defects on single-rootedteeth or multirooted teeth without furcation involve-ment, radiographic infrabony component (INFRA)‡4 mm, vertical clinical attachment level (CAL-V)>6 mm, and probing depth (PD) ‡6 mm.

Exclusion criteria included the following: 1) knownallergies to tetracycline or any components of theactive drug or PLAC; 2) severe liver dysfunction;3) local or systemic antibiotic treatment during thelast 3 months before surgery; 4) kidney dysfunc-tion; 5) medicated with barbiturate, carbamazepin,diphenylhydantoin, sulfonyl-urea, methoxyflurane, cy-closporine A, theophylline, or isotretinoin; 6) reportingchronic alcohol abuse; 7) under anticoagulativetherapy; 8) requiring antibiotic endocarditis pro-phylaxis; 9) pregnant or lactating females.

The trial was approved by the Institutional ReviewBoards for Human Studies of the Medical Facultiesof the Johann Wolfgang Goethe University Frankfurtam Main (159/06) and the University of Heidelberg

(ABmu-179/2006), as well as the German FederalDrug Authority (Federal Office of Drugs and MedicineProducts). All participating individuals were informedof the risks, benefits, and the procedures of the study.This study is registered under EudraCT 2006-001367-36and under ClinicalTrials.gov NCT01030666.

Clinical MeasurementsThe following clinical parameters were assessed atsix sites per tooth (mesio-buccal, mid-buccal, disto-buccal, disto-lingual, mid-lingual, and mesio-lingual)at baseline, and 12 and 24 months after surgery;PD and CAL-V were measured to the nearest 0.5mm using a straight manual periodontal probe§:1) gingival index (GI); 22 2) plaque index (PI); 22 3)PD; and 4) CAL-V. As reference for the CAL-V mea-surements, the cemento-enamel junction (CEJ) wasused. If the CEJ was destroyed, the restoration margin(RM) served as the reference.18

Radiographic ExaminationStandardized radiographs were obtained of test teethby modified film holders.i23,24 These were done inthe clinical setting, after initial periodontic treatmentand immediately before surgery. Intraoral size 0 and2 dental films¶ were exposed using an x-ray source#

with 7 mA and 60 kVp and developed under stan-dardized conditions.**

Radiographic EvaluationAll radiographs were evaluated by one examiner(LR), masked to the clinical results and to the timeradiographs were taken.25 All radiographs were dig-italized using a computer program†† and a flatbedscanner‡‡ with 600-dpi resolution and 8-bit grayvalues. The image files were stored as TIFF files andanalyzed using the abovementioned computer pro-gram and a 19-inch flat screen.§§18

The analyzing tool of the program was used forevaluation. The image files were opened and mag-nified by using the zoom function once. Then thedistances CEJ/RM to alveolar crest (AC), CEJ/RMto bone defect (BD), and the depth of the INFRAwere measured. The definition of these radiographiclandmarks has been published in detail.25-27

Microbiologic ExaminationImmediately before and 14 – 2 days after sur-gery, subgingival plaque samples were taken fromthe test sites and analyzed by a commercially avail-able real-time polymerase chain reaction testii for

§ PCPUNC 15, Hu-Friedy, Chicago, IL.i VIP 2 Positioning, UpRad, Fort Lauderdale, FL.¶ Insight, Eastman Kodak, Rochester, NY.# Heliodent DS, Sirona, Bensheim, Germany.** XR24Pro, Durr Dental, Bietigheim-Bissingen, Germany.†† SIDEXIS neXt Generation v.1.51, Sirona.‡‡ ScanMaker 4, Microtek, Hsinchu, Taiwan.§§ Totoku CCL 192 plus, Totoku Electric, Ueda, Japan.ii Meridol Paro Diagnostik, GABA, Lorrach, Germany.

Enamel Matrix Derivative With Postoperative Doxycycline Volume 85 • Number 5

670

Aggregatibacter actinomycetemcomitans (Aa), Por-phyromonas gingivalis (Pg), Tannerella forsythia,Treponema denticola, Fusobacterium nucleatum,and Prevotella intermedia. The detection limit of thistest is 102.

Periodontal SurgeryAs previously described, the infrabony defects re-ported in this analysis were treated by applicationof EMD¶¶ before closure of the defect intrasurgicalparameters were measured.18

Post-Surgical CareAll patients took a post-surgical medication once aday for 7 days after regenerative periodontal ther-apy: 1) test: 200 mg DOXY; 2) control: 200 mgPLAC. DOXY and PLAC were packaged identicallyand stored in sealed envelopes marked with therandomization code. The patient and clinician weremasked. Block randomization by smoking status(currently smoking: smokers/former smokers andnever smoked: non-smokers) was provided by themanufacturer of the DOXY and PLAC.##18

All patients were advised to rinse with a 0.12%chlorhexidine gluconate solution*** for 2 minutestwice a day for 5 to 7 weeks after surgery. Duringthis period, all patients were instructed to refrainfrom mechanical plaque control and thus were seenevery other week for plaque control and gentleteeth cleaning. In addition, 400 mg ibuprofen dailywas prescribed if needed for pain. If soft-tissuedehiscence was noted, the patient was advised touse a 1% chlorhexidine gluconate gel††† twice daily.Sutures were retained as long as they maintainedclosure.18 Seven to 8 days after surgery, woundhealing was classified according to the early-woundhealing index (EHI).9

Statistical AnalysesSample size calculation was based on an observedstandard deviation for CAL-V gain (1.6 mm) in astudy comparing regenerative therapy with andwithout antibiotics.28 To detect a mean difference of1.0 mm with a test power of 80% and a type 1 errora <0.05, a minimal sample size of 84 patients hadto be recruited, 42 for each group. Thus, it was de-cided to recruit a total of 90 patients.

The patient was defined as the statistical unit. Bonefill at 12 months was used as primary and CAL-Vgain at 12 months as secondary outcome vari-ables. All other parameters were control variables.Baseline patient characteristics were described asmean – SD (age, PCR) or frequencies/percentages(sex, smoking). All clinical parameters were cal-culated as mean – SD (PI, GI, PD, CAL-V, INFRA).

After controlling for normal distribution, CAL-V gainand PD reduction for the two groups were compared

using an independent t test. Intragroup comparisons(baseline/12 months/24 months) were calculatedusing the paired t test. Intergroup and intragroupcomparisons for radiographic bone, PI, and GI werecalculated using Mann-Whitney U and Wilcoxon tests,respectively. To explore the impact of subgingivalmicroflora on the primary and secondary outcomevariables, bone fill (Mann-Whitney U test) and CAL-Vgain (independent t test) were compared 12 monthsafter therapy according to the presence/absence ofthe tested periodontal pathogens.

A multiple regression model was calculated for thedependent variable bone fill with the independentvariables baseline clinical parameters (CAL-V, PD, GI,PI), post-surgical medication, defect parameters(INFRA, percentage of 1-, 2-, and 3-wall component),baseline Aa, age, sex, center, smoking, and EHI. Sex,center, and smoking habits were defined by indicatorvariables. All patients recruited and treated accordingto the study protocol were considered for analysis(intent to treat). If a patient left the study before allreexaminations, the respective data of the last re-examination were entered into the analysis (last ob-servation carried forward). Statistical analysis wasperformed using a personal computer program.‡‡‡

RESULTS

PatientsBecause the DOXY shelf life expired before theestimated sample size was reached, only 61 pa-tients were included (Frankfurt: 43; Heidelberg: 18).Five patients left the study: two after 21 days; oneafter 6 months; and two after 12 months. The pro-tocol allowed for the use of EMD, barriers, and com-bination with fillers. However, the majority of defects(57) were treated exclusively with EMD. In threedefects (Frankfurt), EMD was combined with fillers.In one patient (Heidelberg), a bioabsorbable barrierwas used (missing data were handled according tothe last observation carried forward approach. Thus,drop-outs did not reduce the sample size. The fourpatients that were not treated exclusively with EMD[three combination with fillers and one barrier, all fromthe PLAC group] were excluded from analysis to avoidconfounding). All remaining patients treated exclusivelywith EMD remained in the analysis (N = 57; 26 malesand 31 females; mean age: 52 – 10.2 years).

Clinical and Radiographic ParametersPI and GI at baseline, 12 months, and 24 monthsafter surgery are given in Table 2. In both groups,statistically significant (P <0.001) PD reduction and

¶¶ Emdogain, Institut Straumann, Basel, Switzerland.## August Wolff Arzneimittel, Bielefeld, Germany.*** ParoEx, Butler, Kriftel, Germany.††† Chlorhexamed 1% Gel, GlaxoSmithKline, Buhl, Germany.‡‡‡ Systat for Windows v.10, Systat, Evanston, IL.

J Periodontol • May 2014 Eickholz, Rollke, Schacher, et al.

671

CAL-V gain (at 12 months, DOXY: 2.78 – 1.75 mm;PLAC: 2.76 – 1.76 mm; at 24 months, DOXY: 2.74 –1.89 mm; PLAC: 2.95 – 1.92 mm) (Table 3) wereobserved. Three radiographs in the DOXY group andtwo in the PLAC group were not readable. Thus, ra-diographs of only 52 patients could be evaluated.After 12 months, bone fill was significant (P = 0.008)in the PLAC group only (for 12 months, DOXY:1.09 – 2.70 mm; PLAC: 1.36 – 2.98 mm), after 24months in both groups (DOXY: 1.60 – 2.67 mm;PLAC: 1.83 – 2.95 mm) (Table 4). However, the dif-ference in CAL-V gain and bone fill between groupswas not statistically significant. Post hoc analysisrevealed a test power of 6% for bone fill 12 monthsafter therapy. Bone fill and CAL-V gain 12 monthsafter therapy were better if Aa and Pg were presentat baseline. However, the differences were not sig-nificant (data not shown). Baseline distance CEJ/RMto BD and baseline INFRA influenced bone fill posi-tively and EHI negatively (Table 5).

DISCUSSION

Systemic antibiotics are commonly used after re-generative therapy of infrabony defects with mem-branes1-5,14-17 and EMD.28-31 Until now, studies failedto observe better clinical results after use of addi-tional antibiotics.4,29 Six months after surgery, thefirst PLAC-controlled study also failed to observesignificant differences between regenerative therapyusing EMD with and without systemic DOXY.18

Since all infrabony defects in this analysis wereonly treated with EMD, conclusions can only bedrawn for this specific therapy. The present resultsare benchmarked at 12 and 24 months by com-paring them with other studies on EMD for treat-ment of infrabony defects. This clinical trial revealedsimilar CAL-V gain in infrabony defects with an INFRAof 4.8 mm (DOXY) and 5.2 mm (PLAC) 12 monthsafter therapy using EMD compared with results re-ported by others 12 months after EMD in similar ormore favorable defects: In moderately deep (5.6 mm)1- and 2-wall defects, CAL-V gains of 1.9 mm werereported27 and in deep (8.5 mm) non-contained in-frabony defects, CAL-V gains of 2.4 mm were re-ported.32 In deep (6.8 mm) 2- and 3-wall defects,CAL-V gains of 3 mm was observed.33 Further-more, 12 months after treatment, mean CAL-V gainof 3.4 mm34 and 4.7 mm was achieved in defectswith 6.1 mm INFRA.35 None of these studies usedany systemic antibiotics post-surgically.27,32-35 Otherstudies which used post-surgical antibiotics reportedCAL-V gain of 2.73 mm (2 g amoxicillin plusclavulanic acid for 6 days; INFRA: 4.55 mm),36 of 2mm (500 mg penicillin three times a day for 5 days;INFRA: 3.57 mm)37 and 3.4 mm (500 mg amoxi-cillin three times a day for 10 days; INFRA: 3.8 mm)38

12 months after EMD. Results observed 24 monthsafter EMD therapy in infrabony defects are rarelyreported: CAL-V gain of 3.76 mm, radiographicbone fill of 2.61 mm36 and CAL-V gain of 3.51 mmand radiographic bone fill of 3.18 mm 24 monthsafter EMD.10 Heijl et al.39 reported 2.2-mm CAL-V

Table 1.

Baseline Patient and DefectCharacteristics

Variable

DOXY

(n = 28)

PLAC

(n = 29) P Values

Age (years) 54.2 – 10.3 49.8 – 10.0 0.120

Females (n/%) 11/39 20/69 0.025

Current smokers (n/%) 7/25 6/17 0.698

PCR (%) 18.1 – 7.6 18.6 – 7.7 0.801

CEJ/RM to BD (mm) 10.39 – 2.42 10.48 – 2.56 0.896

INFRA (mm) 6.64 – 2.79 6.76 – 3.05 0.882

3-Wall component (mm) 3.46 – 1.73 2.97 – 2.27 0.354

2-Wall component (mm) 2.14 – 1.99 2.17 – 3.01 0.965

1-Wall component (mm) 1.11 – 1.06 1.62 – 1.88 0.209

Table 2.

Clinical Parameters: PI and GI

PI GI

Examination DOXY (n = 28) PLAC (n = 29) DOXY (n = 28) PLAC (n = 29)

Baseline 0.71 – 0.98 0.35 – 0.55 1.46 – 0.79 1.13 – 0.95

12 months 0.68 – 0.91 0.73 – 0.70 0.64 – 0.91 0.58 – 0.91Change -0.03 – 1.35 0.38 – 0.82 -0.82 – 1.02 -0.55 – 1.06

24 months 0.82 – 0.86 0.45 – 0.74 0.64 – 0.91 0.97 – 0.94Change 0.11 – 1.37 0.10 – 0.98 -0.82 – 1.02 -0.16 – 1.04

Enamel Matrix Derivative With Postoperative Doxycycline Volume 85 • Number 5

672

gain and radiographic 2.6-mm bone fill 36 monthsafter treatment. Both groups used systemic antibi-otics postoperatively.36,39 Characteristics of infrabonydefects (e.g., depth of INFRA, contained/non-containeddefect) and patients (e.g., smoking, oral hygiene) havebeen shown to influence periodontal healing after re-generative therapy.2,25 However, systemic antibioticsdo not seem to have an influence.

Only a few studies include radiographic exami-nations and, thus, report change of bone loss.18,35

Bone gain varies from 1.09 mm (PLAC) to 4.7 mm12 months after therapy.35 The most pronouncedbone fill was observed in the deepest BDs.35 Thereis a tendency to an increase of bone gain with time.

Twelve and 24 months after surgery, systemicDOXY did affect neither CAL-V gain nor bone fill. Inthe PLAC group, 0.27 mm more bone fill was ob-served 12 months after therapy than in the DOXYgroup. This small difference may be statisticallyinsignificant because of the low test power of 6%.However, the difference is clearly clinically irrele-vant. Multiple regression revealed baseline distanceCEJ/RM to BD and baseline INFRA had a positiveeffect on bone fill, whereas EHI had a negativeeffect and systemic DOXY had no effect. However,post-surgical systemic antibiotics may be beneficialfor other regenerative approaches incorporating ma-terials temporarily (membranes) or permanently (filler)into the wound/defect. The current study providesdata to calculate sample sizes for future studies onthis issue. Additional studies are needed to addressthe issue of systemic antibiotics after use of mem-branes and fillers for regenerative therapy.

Interestingly, multiple regression also revealed EHIto influence bone fill after 12 months: the better earlywound healing, the more bone fill. This result high-lights the significance of perfect defect closure forperiodontal regeneration.

CONCLUSION

Within the limits of the present study, the followingconclusion may be drawn: 12 and 24 months aftersurgery, 200 mg systemic DOXY for 7 days afterregenerative therapy of infrabony defects using EMDfailed to result in better bone fill, PD reduction, andCAL-V gain compared with PLAC, which may be at-tributable to low power and, thus, random chance.

ACKNOWLEDGMENTS

This study was funded in part by the authors andtheir institutions. Microbiologic analysis was fundedby GABA International, Munchenstein, Switzerland.Furthermore, funding was provided by the GermanSociety of Periodontology GABA Research Fund andthe Medical Faculty of the Johann Wolfgang GoetheUniversity Frankfurt. Study medication, patients’

Table 3.

Clinical Parameters: PD and CAL-V

Examination DOXY (n = 28) PLAC (n = 29) P Values

PD (mm)Baseline 8.05 – 1.79 7.86 – 1.64 0.67512 months 4.57 – 1.40 4.57 – 1.93 0.996Change -3.48 – 2.05 -3.29 – 1.59 0.699P <0.001 <0.001

24 months 4.36 – 1.57 4.46 – 1.91 0.816Change -3.69 – 2.23 -3.40 – 1.73 0.574P <0.001 <0.001

CAL-V (mm)Baseline 9.19 – 1.96 9.31 – 1.92 0.82512 months 6.41 – 1.97 6.55 – 2.06 0.793Change 2.78 – 1.75 2.76 – 1.76 0.985P <0.001 <0.001

24 months 6.45 – 1.98 6.36 – 2.11 0.877Change 2.74 – 1.89 2.95 – 1.92 0.696P <0.001 <0.001

Table 4.

Radiographic Parameters*

Examination

DOXY

(n = 25)

PLAC

(n = 27) P Values

CEJ/RM to BD (mm)Baseline 8.84 – 2.62 9.04 – 2.95 0.73512 months 7.75 – 1.66 7.68 – 1.91 0.978Change 1.09 – 2.70 1.36 – 2.98 0.318P 0.201 0.008

24 months 7.24 – 1.62 7.21 – 1.87 0.978Change 1.60 – 2.67 1.83 – 2.95 0.318P 0.007 0.001

CEJ/RM to AC (mm)Baseline 5.06 – 1.49 5.16 – 1.67 0.89812 months 5.11 – 1.49 5.45 – 1.86 0.415Change -0.05 – 1.04 -0.29 – 1.15 0.614P 0.721 0.249

24 months 5.07 – 1.39 5.38 – 1.74 0.415Change -0.01 – 1.23 -0.23 – 0.90 0.614P 0.459 0.889

Depth of INFRA (mm)Baseline 4.82 – 2.69 5.18 – 3.15 0.84012 months 3.74 – 1.49 3.65 – 2.21 0.323Change 1.09 – 2.48 1.52 – 2.90 0.260P 0.221 0.004

24 months 3.11 – 1.65 3.09 – 1.64 0.323Change 1.72 – 2.67 2.09 – 2.99 0.260P 0.006 0.001

* Three radiographs in the DOXY group and two in the PLAC group werenot readable. Thus, radiographs of only 52 patients were evaluated.

J Periodontol • May 2014 Eickholz, Rollke, Schacher, et al.

673

insurance, and monitoring were provided by AugustWolff, Bielefeld, Germany. The authors report no con-flicts of interest related to this study.

REFERENCES1. Cortellini P, Pini Prato G, Tonetti MS. Periodontal

regeneration of human intrabony defects with tita-nium reinforced membranes. A controlled clinicaltrial. J Periodontol 1995;66:797-803.

2. Cortellini P, Carnevale G, Sanz M, Tonetti MS.Treatment of deep and shallow intrabony defects.A multicenter randomized controlled clinical trial. JClin Periodontol 1998;25:981-987.

3. Cortellini P, Tonetti MS. Evaluation of the effect oftooth vitality on regenerative outcomes in infrabonydefects. J Clin Periodontol 2001;28:672-679.

4. Eickholz P, Lenhard M, Benn DK, Staehle HJ. Peri-odontal surgery of vertical bony defects with orwithout synthetic bioabsorbable barriers. 12-monthresults. J Periodontol 1998;69:1210-1217.

5. Tonetti MS, Cortellini P, Suvan JE, et al. General-izability of the added benefits of guided tissue re-generation in the treatment of deep intrabony defects.Evaluation in a multi-center randomized controlledclinical trial. J Periodontol 1998;69:1183-1192.

6. Tonetti MS, Lang NP, Cortellini P, et al. Enamel matrixproteins in the regenerative therapy of deep intrab-ony defects. J Clin Periodontol 2002;29:317-325.

7. Needleman IG, Worthington HV, Giedrys-Leeper E,Tucker RJ. Guided tissue regeneration for peri-odontal infra-bony defects. Cochrane Database SystRev 2006;(2, Issue 2): CD001724.

8. Esposito M, Grusovin MG, Papanikolaou N,Coulthard P, Worthington HV. Enamel matrix de-rivative (Emdogain(R)) for periodontal tissue regen-eration in intrabony defects. Cochrane Database SystRev 2009;(4, Issue 4): CD003875.

9. Wachtel H, Schenk G, Bohm S, Weng D, Zuhr O,Hurzeler MB. Microsurgical access flap and enamelmatrix derivative for the treatment of periodontal intrab-ony defects: A controlled clinical study. J Clin Peri-odontol 2003;30:496-504.

10. Francetti L, Trombelli L, Lombardo G, et al. Eval-uation of efficacy of enamel matrix derivative in thetreatment of intrabony defects: A 24-month multi-center study. Int J Periodontics Restorative Dent2005;25:461-473.

11. Nyman S, Lindhe J, Rosling B. Periodontal surgeryin plaque-infected dentitions. J Clin Periodontol 1977;4:240-249.

12. Nowzari H, MacDonald ES, Flynn J, London RM,Morrison JL, Slots J. The dynamics of microbialcolonization of barrier membranes for guided tissueregeneration. J Periodontol 1996;67:694-702.

13. Cortellini P, Prato GP, Tonetti MS. The modifiedpapilla preservation technique. A new surgical ap-proach for interproximal regenerative procedures. JPeriodontol 1995;66:261-266.

14. Tonetti MS, Cortellini P, Lang NP, et al. Clinicaloutcomes following treatment of human intrabonydefects with GTR/bone replacement material or ac-cess flap alone. A multicenter randomized controlledclinical trial. J Clin Periodontol 2004;31:770-776.

15. Cortellini P, Tonetti MS, Lang NP, et al. The simplifiedpapilla preservation flap in the regenerative treat-ment of deep intrabony defects: Clinical outcomesand postoperative morbidity. J Periodontol 2001;72:1702-1712.

16. De Sanctis M, Zucchelli G. Interleukin-1 gene poly-morphisms and long-term stability following guidedtissue regeneration therapy. J Periodontol 2000;71:606-613.

17. Eickholz P, Kim TS, Steinbrenner H, Dorfer C, Holle R.Guided tissue regeneration with bioabsorbable barriers:Intrabony defects and class II furcations. J Periodontol2000;71:999-1008.

18. Rollke L, Schacher B, Wohlfeil M, et al. Regenera-tive therapy of infrabony defects with or withoutsystemic doxycycline. A randomized placebo-con-trolled trial. J Clin Periodontol 2012;39:448-456.

19. Weinberg MA, Eskow RN. Osseous defects: Properterminology revisited. J Periodontol 2000;71:1928.

20. O’Leary TJ, Drake RB, Naylor JE. The plaque controlrecord. J Periodontol 1972;43:38.

21. Federal Center for Political Education. Glossary: De-mographic terms (in German). Available at: http://www.bpb.de/izpb/55938/glossar-demografische-begriffe.Accessed June 26, 2013.

22. Loe H. The gingival index, the plaque index and theretention index system. J Periodontol 1967;38:610-616.

23. Duckworth JE, Judy PF, Goodson JM, SocranskySS. A method for the geometric and densitometricstandardization of intraoral radiographs. J Periodontol1983;54:435-440.

24. Eickholz P, Benn DK, Staehle HJ. Radiographic eval-uation of bone regeneration following periodontal sur-gery with or without expanded polytetrafluoroethylenebarriers. J Periodontol 1996;67:379-385.

25. Eickholz P, Horr T, Klein F, Hassfeld S, Kim TS. Ra-diographic parameters for prognosis of periodontal

Table 5.

Backward Stepwise Multiple Regression Analysis: Bone Fill 12 Months After Surgery

Variable B SE (b) T P Value

Constant -3.638 0.883 -4.117 <0.001

Baseline distance CEJ/RM to BD 0.464 0.132 3.516 0.001

Baseline radiographic INFRA 0.339 0.134 2.539 0.014

EHI -0.588 0.249 -2.366 0.022

Analysis of variance, P <0.001. Dependent variable: bone fill (mm); n = 55; R2 = 0.678; R2adjusted = 0.659; standard error of estimate = 1.626.

Enamel Matrix Derivative With Postoperative Doxycycline Volume 85 • Number 5

674

healing of infrabony defects: Two different definitionsof defect depth. J Periodontol 2004;75:399-407.

26. Pretzl B, Kim TS, Steinbrenner H, Dorfer C, HimmerK, Eickholz P. Guided tissue regeneration with bio-absorbable barriers III 10-year results in infrabonydefects. J Clin Periodontol 2009;36:349-356.

27. Meyle J, Hoffmann T, Topoll H, et al. A multi-centrerandomized controlled clinical trial on the treatmentof intra-bony defects with enamel matrix derivatives/synthetic bone graft or enamel matrix derivativesalone: Results after 12 months. J Clin Periodontol2011;38:652-660.

28. Sculean A, Donos N, Blaes A, Lauermann M, ReichE, Brecx M. Comparison of enamel matrix proteinsand bioabsorbable membranes in the treatment ofintrabony periodontal defects. A split-mouth study.J Periodontol 1999;70:255-262.

29. Sculean A, Blaes A, Arweiler N, Reich E, Donos N,Brecx M. The effect of postsurgical antibiotics onthe healing of intrabony defects following treatmentwith enamel matrix proteins. J Periodontol 2001;72:190-195.

30. Gurinsky BS, Mills MP, Mellonig JT. Clinical evalua-tion of demineralized freeze-dried bone allograft andenamel matrix derivative versus enamel matrix de-rivative alone for the treatment of periodontal osseousdefects in humans. J Periodontol 2004;75:1309-1318.

31. Cortellini P, Tonetti MS. Improved wound stabilitywith a modified minimally invasive surgical technique inthe regenerative treatment of isolated interdental intra-bony defects. J Clin Periodontol 2009;36:157-163.

32. Siciliano VI, Andreuccetti G, Siciliano AI, Blasi A,Sculean A, Salvi GE. Clinical outcomes after treat-ment of non-contained intrabony defects with enamelmatrix derivative or guided tissue regeneration: A 12-month randomized controlled clinical trial. J Periodontol2011;82:62-71.

33. Dilsiz A, Canakci V, Aydin T. The combined use ofNd:YAG laser and enamel matrix proteins in the

treatment of periodontal infrabony defects. J Peri-odontol 2010;81:1411-1418.

34. Grusovin MG, Esposito M. The efficacy of enamelmatrix derivative (Emdogain) for the treatment ofdeep infrabony periodontal defects: A placebo-controlled randomised clinical trial. Eur J OralImplantology 2009;2:43-54.

35. Cardaropoli G, Leonhardt AS. Enamel matrix pro-teins in the treatment of deep intrabony defects.J Periodontol 2002;73:501-504.

36. De Leonardis D, Paolantonio M. Enamel matrixderivative, alone or associated with a synthetic bonesubstitute, in the treatment of 1- to 2-wall peri-odontal defects. J Periodontol 2013;84:444-455.

37. Rosing CK, Aass AM, Mavropoulos A, Gjermo P.Clinical and radiographic effects of enamel matrixderivative in the treatment of intrabony periodontaldefects: A 12-month longitudinal placebo-controlledclinical trial in adult periodontitis patients. J Peri-odontol 2005;76:129-133.

38. Sculean A, Windisch P, Chiantella GC, Donos N,Brecx M, Reich E. Treatment of intrabony defectswith enamel matrix proteins and guided tissue re-generation. A prospective controlled clinical study.J Clin Periodontol 2001;28:397-403.

39. Heijl L, Heden G, Svardstrom G, Ostgren A. Enamelmatrix derivative (EMDOGAIN) in the treatment ofintrabony periodontal defects. J Clin Periodontol 1997;24:705-714.

Correspondence: Dr. Peter Eickholz, Department of Peri-odontology, Center for Dentistry and Oral Medicine(Carolinum), Johann Wolfgang Goethe-University Frankfurtam Main, Theodor-Stern-Kai 7, D-60596 Frankfurt am Main,Germany. Fax: 49-0-69-6301-3753; e-mail: eickholz@med.uni-frankfurt.de.

Submitted May 2, 2013; accepted for publication July 6,2013.

J Periodontol • May 2014 Eickholz, Rollke, Schacher, et al.

675