Postoperative effects of intra-alveolar application of 0.2% chlorhexidine or 1% hyaluronic acid bioadhesive gels after mandibular third molar extraction: a double-blind randomized controlled clinical trial

Hyaluronic acid in tooth extraction: a systematic review and meta-analysis of preclinical and clinical trials

OBJECTIVES

To assess whether in animals or patients with ≥ 1 tooth extracted, hyaluronic acid (HyA) application results in superior healing and/or improved complication management compared to any other treatment or no treatment.

MATERIALS AND METHODS

Three databases were searched until April 2022. The most relevant eligibility criteria were (1) local application of HyA as adjunct to tooth extraction or as treatment of alveolar osteitis, and (2) reporting of clinical, radiographic, histological, or patient-reported data. New bone formation and/or quality were considered main outcome parameters in preclinical studies, while pain, swelling, and trismus were defined as main outcome parameters in clinical studies.

RESULTS

Five preclinical and 22 clinical studies (1062 patients at final evaluation) were included. In preclinical trials, HyA was applied into the extraction socket. Although a positive effect of HyA was seen in all individual studies on bone formation, this effect was not confirmed by meta-analysis. In clinical studies, HyA was applied into the extraction socket or used as spray or mouthwash. HyA application after non-surgical extraction of normally erupted teeth may have a positive effect on soft tissue healing. Based on meta-analyses, HyA application after surgical removal of lower third molars (LM3) resulted in significant reduction in pain perception 7 days postoperatively compared to either no additional wound manipulation or the application of a placebo/carrier. Early post-operative pain, trismus, and extent of swelling were unaffected.

CONCLUSIONS

HyA application may have a positive effect in pain reduction after LM3 removal, but not after extraction of normally erupted teeth.

CLINICAL RELEVANCE

HyA application may have a positive effect in pain reduction after surgical LM3 removal, but it does not seem to have any impact on other complications or after extraction of normally erupted teeth. Furthermore, it seems not to reduce post-extraction alveolar ridge modeling, even though preclinical studies show enhanced bone formation.

The effect of hyaluronic acid addition to collagen in reducing the trismus and swelling after surgical extraction of impacted lower third molars: a split-mouth, randomized controlled study

BACKGROUND

Removal of impacted third molars is associated with postoperative complications such as pain, swelling, ecchymosis, trismus, infection, and hematoma. Thus, contemporary surgery aims to reduce complications by applying collagen or hyaluronic acid in the socket after extracting the impacted mandibular third molars. This study aimed to study the efficacy of hyaluronic acid (HA) addition to collagen, compared to collagen application alone, on the magnitude of swelling and trismus following impacted mandibular third molar surgery.

METHODS AND MATERIALS

A total of 40 impacted molars of 20 participants who had completely bilateral impacted lower third molars were enrolled in this split-mouth, randomized, clinical trial. Randomization was carried out by two opaque envelops; two materials were applied topically in the socket collagen alone or with hyaluronic. The postoperative mouth-opening limitation and swelling rate were assessed on the third and seventh days after the extraction.

RESULTS

The mean age was 22.7 ± 3.079 years (75% female and 25% male). Regarding the rate of trismus, the test sides had less values than the control sides on 3rd days (44.03 ± 12.8 vs. 52.14 ± 13.7) and 7th days (19.22 ± 12.8 vs. 32.45 ± 15.3) postoperatively but the difference is only significant on the seventh day (P = 0.005). The swelling scores of the hyaluronic acid addition group were significantly lesser than those of the collagen alone group on the third and the seventh day (P < 0.05) except for the lateral canthus to the angulus mandibulae on the third day (P = 0.133).

CONCLUSION

Adding hyaluronic acid to collagen could effectively reduce the severity of facial swelling and trismus following surgical extraction of impacted lower third molars.

STATEMENT OF CLINICAL RELEVANCE

Swelling and trismus are the most sequela following impacted third molar surgical extraction. This study showed that applying hyaluronic acid with collagen can reduce the severity of facial swelling and trismus which could be useful in surgeons' daily practice. We should mention that this original article has a preprint edition (44).

Does the "Root Removal First" strategy prevent postoperative complications in the surgical removal of impacted mandibular third molars in the Pell and Gregory class C and horizontal position? - a randomized clinical trial

OBJECTIVE

To evaluate the clinical outcomes of the "Root Removal First" strategy in the surgical removal of impacted mandibular third molar (IMTM) in the class C and horizontal position.

MATERIALS AND METHODS

A total of 274 cases were finally included in the statistics. The positions of IMTM in the horizontal position were confirmed by cone-beam computed tomography (CBCT). Cases were randomly divided into two groups: the "Root Removal First" strategy was applied in the new method (NM) group, and the conventional "Crown Removal First" strategy was executed in the traditional method (TM) group. The clinical information and relevant data upon follow-up were recorded.

RESULTS

The duration of the surgical removal and the incidence rates of lower lip paresthesia in the NM group were significantly lower than those in the TM group. The degree of mobility of the adjacent mandibular second molar (M2) in the NM group was significantly lower than that in the TM group at 30 days and 3 months post-operation. The distal and buccal probing depth of the M2, as well as the exposed root length of M2 in the NM group, were significantly lower than those in the TM group 3 months post-operation.

CONCLUSIONS

The "Root Removal First" strategy can reduce the incidence rate of inferior alveolar nerve injury and periodontal complications of the M2 in the surgical removal of IMTM in class C and horizontal position with high efficiency.

TRIAL REGISTRATION

ChiCTR2000040063.

Photobiomodulation for Managing "Dry Socket": A Randomised Controlled Trial

OBJECTIVE

There are no studies that have evaluated the effect of Alveogyl with and without adjunct photobiomodulation therapy (PBMT) in reducing self-rated post-operative pain (SPP) in patients with alveolar osteitis (AO; dry socket). The aim of the present randomised controlled trial was to assess the effectiveness of Alveogyl with and without PBMT for the management of SPP in patients with AO.

METHODS

Adult nonsmokers with diagnosed AO were included. Patients were randomly divided into 4 groups. In Group 1, patients underwent mechanical curettage (MC) with copious normal saline irrigation. In Group 2, patients underwent MC + Alveogyl dressings in extraction sites which were changed every 48 hours until cessation of pain. In Group 3, patients underwent MC + Alveogyl followed by PBMT using a 660-nm indium-gallium-aluminum-phosphide diode laser. In Group 4, patients were treated solely with PBMT. The visual analogue scale was used up to 3 postoperative days to assess SPP up to 3 days at 6- (T0) and 12-hour (T1) intervals. Statistical analyses were performed using the analysis of variance and Bonferroni post hoc adjustment tests. Correlation between SPP scores and age, sex, and eruption status of teeth was assessed using logistic regression models. P values <.01 were nominated as being statistically significant.

RESULTS

In all, 14, 13, 14, and 14 individuals with AO were included in groups 1, 2, 3 and 4, respectively. All patients had undergone extraction of mandibular third molars. At baseline and on day 1, there was no difference in SPP in all groups. On days 2 and 3, mean visual analogue scale (VAS) scores at T1 (P < .01) and T2 (P < .01) intervals were significantly high in Group 2 compared with Group 3. On days 2 and 3, mean VAS scores at T1 (P < .01) and T2 (P < .01) intervals were significantly high in Group 4 compared with Group 3. There was no difference in SPP in groups 3 and 4 on day 3 at T0 and T1 intervals.

CONCLUSIONS

PBMT following MC and Alveogyl dressing is more efficient in reducing SPP compared with MC with or without Alveogyl dressing in patients with AO.

The Influence of the Hyaluronic Acid Gel on the Postoperative Sequelae following Surgical Removal of the Impacted Mandibular Third Molar in Comparison with the A-PRF: A Randomized Controlled Trial

One of the most common procedures in oral surgery is the removal of impacted mandibular third molars, often followed by pain, swelling, alveolitis, and trismus. Purpose. To compare the outcomes of the intrasocket application of 1% hyaluronic acid oral gel (HA) and advanced platelet-rich fibrin (A-PRF) on the expected postoperative complications, pain, swelling, and trismus follow the surgical extraction of the impacted mandibular third molar. Material and Methods. A randomized controlled trial was conducted at the Oral and Maxillofacial Surgery Unit, Dental Teaching Hospital. Healthy patients who required surgical removal of the impacted mandibular third molar were divided randomly into three groups. The extraction site of the group (A) patients remained without the addition of any material, just suturing of the wound with simple interrupted sutures, while in group (B) patients, the extraction site was filled with 1 cc of 1% hyaluronic acid gel (periokin®), and in group C patients, the extraction site was filled with A-PRF. Results. Sixty-six eligible patients participated in this study; both hyaluronic acid gel 1% (periokin®) and advanced platelet-rich fibrin showed a significant reduction in pain, swelling, and trismus on the 1st, third, and seventh postoperative days when compared to the control group, while the comparison between HA and A-PRF showed no significant differences except for the pain on the third postoperative day. There was a significant pain decrease in the A-PRF group than HA group. Conclusion. Intrasocket application of 1% hyaluronic acid gel (periokin®) or advanced platelet-rich fibrin can be an effective primary way to significantly reduce postoperative pain, trismus, and edema compared to the control group following mandibular third molar surgery.

Does surgical removal of mandibular third molar influence the periodontal status of the adjacent second molars? A systematic review

Objective: This study aimed to assess the influence of mandibular third molar surgical removal on the periodontal status of adjacent second molars and to investigate the potential impact of the flap design. Methods: A systematic review of the literature, registered in PROSPERO, has been carried out from Pubmed and Scopus databases following PRISMA guidelines from January 2010 to January 2022. PICO method was used to select the relevant articles. Studies comparing the periodontal status of the second molar before and after mandibular third molar removal were considered. Results: Twenty-three studies involving 1067 patients were included. The two main parameters studied were periodontal pocket depth and clinical attachment level. The envelope flap and the triangular flap were the most commonly used flap techniques. Periodontal health of adjacent second molar was maintained or improved in most of the included studies. The flap design did not seem to have a significant influence either. Conclusion: Avulsion of impacted third molar in healthy young adults does not impair the periodontal health of adjacent second molars. Further studies, with higher levels of evidence, are needed to confirm these results and to identify possible risk factors (such as age, impaction depth or periodontal disease) responsible for poorer healing.

Overview on Adjunct Ingredients Used in Hydroxyapatite-Based Oral Care Products

Hydroxyapatite, Ca₅(PO₄)₃(OH), is a biomimetic active ingredient, which is used in commercial oral care products such as toothpastes and mouthwashes worldwide. Clinical studies (in vivo) as well as in situ and in vitro studies have shown the preventive effects of hydroxyapatite in various field of oral care. In some products, hydroxyapatite is combined with other active ingredients, to achieve an additional antibacterial effect or to promote gum health. This review analyzes the efficacy of six selected natural and nature-inspired ingredients that are commonly used together with hydroxyapatite. These additional actives are either antibacterial (lactoferrin, xylitol, and zinc) or promote gum health (allantoin, bisabolol, and hyaluronic acid). A systematic literature search was performed, and all studies found on each ingredient were analyzed. In summary, all analyzed ingredients mentioned in this review are well described in scientific studies on their beneficial effect for oral health and can be used to expand the preventive effect of hydroxyapatite in oral care products.

Comparative Clinical Study Between Chlorhexidine Gel (0.2%) and Hyaluronic Gel (1%) in the Prevention of a Dry Socket After Tooth Extraction for Orthodontic Treatment

Introduction Several articles have investigated the intra-alveolar applications of bioadhesive gels containing various medicines and active chemicals, such as chlorhexidine (CHX) and hyaluronic acid (HA) to minimize the numerous postoperative sequelae, such as a dry socket. The purpose of this study was to investigate the postoperative outcomes of intra-alveolar application of 0.2% chlorhexidine or hyaluronic acid following atraumatic extraction. Methods A randomized clinical trial was conducted on a sample of 36 patients who need extraction of lower first premolar for orthodontic treatment. The patients were assigned randomly into two groups: CHX group and HA group. The signs and symptoms of the dry socket were evaluated on the third day in two groups. Results There was no statistically significant difference between the study and control groups when comparing the CHX group (P=0.2.6). In contrast, a significant difference was seen between the study and control sides in the HA group. Conclusions Within the limitation of this clinical trial, using hyaluronic gel with a gelatin sponge may be a preventive strategy for a dry socket following tooth extraction. After non-surgical tooth extraction, the topical administration of CHX with a gelatin sponge as a carrier did not seem to act as a protective substance against a dry socket.

A randomized controlled trial evaluating hyaluronic acid gel as wound healing agent in alveolar ridge preservation

AIM

To compare the results of administration of hyaluronic acid (HA) gel to no gel administration following alveolar ridge preservation (ARP) in terms of changes in wound dimensions over time.

MATERIALS AND METHODS

Systemically healthy patients scheduled for ARP at one or two sites in the incisor, cuspid, or premolar area with at least one neighbouring tooth and >50% buccal bone present following extraction were included. ARP consisted of socket grafting with collagen-enriched, deproteinized bovine bone mineral and socket sealing by means of a collagen matrix. Following surgical therapy, sites were randomly allocated to the control group (no gel application) or the test group (0.8% HA gel applied onto the collagen matrix three times per day for 7 days). Bucco-lingual and mesio-distal wound dimensions were registered at T0 (immediately post operation), T1 (1 week), and T2 (3 weeks). Patient-reported outcomes, clinical outcomes, and hard and soft tissue changes were recorded up to 4 months (T3).

RESULTS

In the control group, 20 patients (7 males, 13 females; mean age 53.30) with 23 sites, and in the test group 18 patients (9 males, 9 females; mean age 52.56) with 23 sites, were included. There were no significant differences between the groups in the changes in wound dimensions from T0 to T2 (bucco-lingual aspect: p = .340; mesio-distal aspect: p = .883). Three sites (13%) in the control group and six (26%) in the test group demonstrated complete wound resolution at T2 (p = .259). HA failed to show any effect on the number of analgesics taken (p = .175), patient-reported outcomes (p ≥ .263), alveolitis (p = .136), socket healing (p ≥ .424), soft tissue changes (p ≥ .064), or mucosal scarring (p = .548). However, significantly more horizontal bone loss at the coronal aspect was found in the test group (p ≤ .025).

CONCLUSION

HA failed to promote wound resolution on a collagen matrix. This study was registered in ClinicalTrials.gov (NCT04467736).

Versatile strategies for bioproduction of hyaluronic acid driven by synthetic biology

Owing to its outstanding water-retention ability, viscoelasticity, biocompatibility and non-immunogenicity, Hyaluronic acid (HA), a natural linear polymer alternating linked by d-glucuronic acid and N-acetylglucosamine, has been widely employed in cosmetic, medical and clinical applications. With the development of synthetic biology and bioprocessing optimization, HA production via microbial fermentation is an economical and sustainable alternative over traditional animal extraction methods. Indeed, recently Streptococci and other recombinant systems for HA synthesis has received increasing interests due to its technical advantages. This review summarizes the production of HA by microorganisms and demonstrates its synthesis mechanism, focusing on the current status in various production systems, as well as common synthetic biology strategies include driving more carbon flux into HA biosynthesis and regulating the molecular weight (MW), and finally discusses the major challenges and prospects.