What is Emdogain made from?

It is a gel containing enamel matrix proteins, mainly amelogenins, extracted from the developing teeth of pigs. These proteins are involved in forming the tooth's attachment during development. Patients who avoid pork products for religious or personal reasons should mention it at the consult, since other regenerative materials are available.

Is Emdogain better than a bone graft?

Not clearly. The 2009 Cochrane review found no clinically important difference between Emdogain and membrane-based regeneration, apart from more complications with membranes, and found that bone substitutes may leave less gum recession than Emdogain. The 2020 European guideline recommends a membrane or Emdogain, either with or without a bone graft, at the same grade. The combination of Emdogain with a bone graft performed better than Emdogain alone in the largest review.

The safety record is good. In a 1997 trial of 107 patients each treated twice, Zetterström and colleagues found no rise in antibody levels, even in allergy-prone patients, and the same kind and frequency of after-surgery effects as in patients who had surgery without it.

Does insurance cover Emdogain?

Sometimes, in part. Many dental plans list biologic materials such as Emdogain as a separate item, and coverage varies from plan to plan. A pre-authorization, the plan's written statement of what it expects to pay, settles the question before treatment. The practice is out of network: it files the claim for you, and the plan reimburses you directly.

Why doesn't every periodontist use Emdogain?

Because the evidence supports more than one way to regrow bone. Membranes with bone grafts have a similar record, the benefit of Emdogain is about a millimeter on average rather than a different kind of result, and one well-known trial found it added nothing measurable when the surgery used a very small, stable flap. Periodontists choose among these based on the defect, their technique and the patient's preferences.

Is Emdogain Worth It? The Evidence, for Patients

In the Austin area? Dr. Verrett provides this care in North Austin. See Gum Disease Treatment, or request a consult.

Some patients facing gum surgery are offered Emdogain as an add-on, or read about it online and ask for it. It costs extra, and it is described as a way to regrow bone. Those two facts together raise a fair question: what does it actually add? Researchers have been testing it for nearly thirty years, so there is a real answer. This article sets it out, including the parts the brochures leave out.

What Emdogain Is

Emdogain is a gel made of enamel matrix proteins, mostly a family called amelogenins, extracted from developing pig teeth. The Cochrane review of the material describes amelogenins as involved in forming enamel and the tooth’s attachment while teeth develop. The idea behind Emdogain is to recreate that signal on a root that has lost its attachment to gum disease.

During surgery, the gum is folded back, the root is cleaned, and the gel is painted onto the root surface before the gum is closed. It is not a filler. It does not hold space the way a bone graft does, which is one reason it is often combined with one.

It is used in regenerative surgery, which tries to grow back bone and attachment rather than reshape what is left. That only works where the bone loss has a suitable shape:

A narrow crater beside the root, at least 3 millimeters deep, called an intrabony defect.
Bone loss between the roots of a lower molar, called a Class II furcation.
Gum grafting to cover exposed roots, where it is one of several accepted options.

It does not help where bone has been lost evenly across several teeth (horizontal bone loss). There, nothing is left to regrow into, whatever material is used. Periodontitis stages and grades explains how bone loss is described.

Two pairs of teeth. On the left the bone has dropped evenly below the original level along both teeth. On the right the bone is at its original level except for a V-shaped trench beside one root, an angular defect whose remaining bone walls can sometimes support regeneration.

What the Trials Show

The first major trial. In 1997, Heijl and colleagues treated paired defects in 33 patients, with Emdogain on one side and a placebo on the other. At three years, the Emdogain sites had gained 2.2 millimeters of attachment against 1.7 at the placebo sites. They also showed 2.6 millimeters of new bone on X-rays, while the placebo sites stayed close to where they started.

The largest trial. In 2002, Tonetti and colleagues randomized 172 patients across 12 centers in 7 countries. All had defects of at least 3 millimeters, treated with a careful flap design, with or without Emdogain. Emdogain sites gained 3.1 millimeters of attachment against 2.5 without it. The more useful finding was about odds: Emdogain made large gains of 4 millimeters or more more common, and poor results of under 2 millimeters less common. The same trial found that smoking, the depth of the pocket and the shape of the defect also shaped the result. So did which center did the surgery.

The Cochrane review. In 2009, Esposito and colleagues pooled the trials for the Cochrane Collaboration. Emdogain added 1.1 millimeters of attachment and 0.9 millimeters of pocket reduction at one year over surgery without it. They estimated that about nine patients would need it for one extra patient to gain 2 millimeters or more. The review also raised three cautions:

The trials varied a lot in their results.
In the four trials at low risk of bias, the benefit was smaller, 0.62 millimeters.
There was no difference in tooth loss.

The authors concluded that “the actual clinical advantages of using EMD are unknown.”

The most recent large review. In 2020, Nibali and colleagues reviewed 79 randomized trials of regeneration for the European Federation of Periodontology. Emdogain added about 1.3 millimeters of attachment over flap surgery alone, and adding a bovine bone graft improved its results further. The certainty of that evidence was rated low to moderate. On this evidence, the European Federation of Periodontology’s 2020 guideline recommends regenerating deep defects of 3 millimeters or more. For the material, it recommends either a barrier membrane or Emdogain, with or without a bone graft.

Does the Benefit Last?

The long-term studies are reassuring. In a ten-year follow-up, Sculean and colleagues found that Emdogain sites had kept a mean attachment gain of 2.9 millimeters. Sites treated with flap surgery alone had kept 1.8 millimeters. A membrane, and a membrane with Emdogain, did about as well as Emdogain alone. In a group of 41 patients followed for about ten years, De Ry and colleagues found 90.7 percent of Emdogain-treated teeth still in place. Smokers lost significantly more teeth.

Compared With Other Ways to Regrow Bone

Emdogain is one of several regenerative materials, and the comparisons matter more to a patient than the comparison with no material at all.

Membranes. The Cochrane review found no clinically important difference between Emdogain and membrane-based regeneration, except that membranes caused more complications. It also found bone substitutes may leave less gum recession than Emdogain.
Furcations in lower molars. A 2004 trial by Jepsen and colleagues treated 45 patients with matching defects on both sides, one with Emdogain and one with a membrane. Emdogain closed more of the furcation, by 2.8 millimeters against 1.8. At one week, 62 percent of Emdogain sites caused no pain against 12 percent of membrane sites, and 44 percent caused no swelling against 6 percent.
PRF, the patient’s own platelet concentrate. In an umbrella review of systematic reviews, Ardila and colleagues found that platelet concentrates used in intrabony defects gave more attachment gain and bone fill than surgery alone. For covering exposed roots, the same review found Emdogain or a connective tissue graft did better than PRF. Technology describes how PRF is used in this office.

When It May Add Little

The most important counterpoint comes from two of the researchers behind the large 2002 trial. Using a very small flap that leaves the gum between the teeth undisturbed, Cortellini and Tonetti treated 45 isolated defects three ways: surgery alone, with Emdogain, or with Emdogain and a bone graft. All three gained about 4 millimeters of attachment, with no meaningful difference between them. At ten years, the results were still the same, and surgery alone had cost the least. The trial was small and done by highly specialized surgeons, so it does not settle the question. It does suggest that much of what Emdogain adds comes from keeping the healing wound stable. A surgical approach that does that well may get most of the benefit without it.

Is It Worth the Extra Cost?

What a patient buys with Emdogain is better odds, not a different kind of result. On average, the gain is about one more millimeter of attachment. Large gains become more likely and poor results less likely. No trial has shown that it, on its own, keeps more teeth in the mouth.

A 2010 analysis by Listl and colleagues put numbers to the trade-off, using German costs. Emdogain was cost-effective only if the payer placed enough value on each extra millimeter gained. Emdogain combined with a bone substitute gave more benefit for the money than Emdogain alone.

The wider economic argument favors regeneration in general. In a ten-year trial, Cortellini and colleagues took 50 patients with a severely compromised tooth and randomly assigned them to have it regenerated or extracted and replaced with an implant or bridge. Eighty-eight percent of the regenerated teeth were still in place at ten years. Regeneration cost significantly less than extraction and replacement over the whole period. That trial tested regeneration as a whole rather than Emdogain specifically. But it shows why keeping a tooth through regeneration is often worth the effort.

Emdogain is more likely to be worth considering when:

the tooth matters, to the bite, the smile or the rest of the treatment plan
the defect is deep (3 millimeters or more) and narrow, or is a Class II furcation in a lower molar
the patient does not smoke, keeps the area clean, and will keep up maintenance every three to four months

It is less likely to add much when:

the bone loss is horizontal, so there is nothing to regrow
the patient smokes heavily, or home care is inconsistent
the defect is small and well contained, and the surgery uses a minimal flap
the tooth has other problems, such as a large cavity or a poor ratio of crown to root, that limit its future anyway

Questions Worth Asking

Is my bone loss the kind that can regrow, a narrow defect at least 3 millimeters deep, or is it horizontal?
If I don’t choose Emdogain, what will you use instead, and how does that compare?
What do you expect to gain on this tooth, and what would change the tooth’s long-term outlook?
Does my smoking, or anything else about my health, change the expected result?
How does my plan cover biologic materials, and is a pre-authorization worth getting?

A second opinion is reasonable before any regenerative surgery, particularly when the choice of material is a large part of the cost.

How This Office Approaches It

Dr. Andrew Verrett is a Diplomate of the American Board of Periodontology and the only doctor at Austin Periodontal Associates in North Austin. His usual regenerative surgery uses bone graft material, generally under a membrane, often with PRF made from the patient’s own blood at the start of the visit. He does not use Emdogain routinely. He will use it when a patient asks for it, after reviewing whether the defect is the kind where it is likely to help. Whichever material is chosen, the decision rests on the shape of the bone loss, which is measured before surgery and confirmed during it. Gum disease treatment describes the whole sequence, from deep cleaning to maintenance. Request a consult or call (512) 346-6097.

Is Emdogain Worth It? What the Evidence Shows