Does Intra-Alveolar Application of Chlorhexidine Gel in Combination With Platelet-Rich Fibrin Have an Advantage Over Application of Platelet-Rich Fibrin in Decreasing Alveolar Osteitis After Mandibular Third Molar Surgery? A Double-Blinded Randomized Clinical Trial

Effectiveness of Advanced Platelet-Rich Fibrin on Postoperative Sequelae for Impacted Mandibular Third Molar Surgery: A Prospective Study

Introduction Impacted third molar extraction is frequently removed surgically by maxillofacial surgeons, which is mostly associated with postoperative sequelae like pain and swelling. It is essential to minimize the complications and enhance wound healing in the extracted socket of the third molar. Hence, this study aimed to assess the efficiency of advanced platelet-rich fibrin (A-PRF) in wound healing and reducing pain after surgical extraction of the impacted mandibular third molar (IMTM). Materials and methods Thirty healthy patients who have been diagnosed with Pell and Gregory class II IMTM were included in this study. In the study group, which comprises 15 patients, extraction sockets were filled with A-PRF extract. In the control group, no material was placed in the extraction sockets. The pain was assessed preoperative and on the third and seventh postoperative days using a visual analog scale (VAS). Wound healing was assessed on the third and seventh postoperative days using a modified laundry scale. SPSS for Windows was used for data analysis. Categorical data was compared between the groups using the Chi-square test. P-value less than 0.05 was considered as statistically significant. Results The study population's mean age was 25.67 ± 2.4 years. Nineteen patients were male, and 11 patients were female. Differences in mean pain scores between the groups were not statistically significant both on the third postoperative day (p=0.59) and the seventh postoperative day (p=0.33). During the seventh day postoperative day, the study group exhibited better wound healing compared to the control group and the results were statistically significant (p=0.01). Conclusion A-PRF is a simple and effective method of reducing postoperative sequela by promoting wound healing after surgical extraction of IMTM. It has the advantage of less chance of allergic and anaphylactic reactions, unlike their predecessor platelet concentrates.

Investigation of the clinical efficacy of CGF and ozone in the management of alveolar osteitis: a randomized controlled trial

OBJECTIVES

To investigate the efficacy of concentrated growth factors (CGF) and ozone in the treatment of alveolar osteitis (AO).

MATERIALS AND METHODS

Patients admitted for the treatment of AO and eligible for the study were included and divided into control, ozone, and CGF + ozone groups. For the treatment of AO alveogyl, ozone, and CGF + ozone were applied to control, ozone, and CGF + ozone groups, respectively, and repeated on 3rd day. Demographic data and oral hygiene were recorded at the initial visit. Pain with visual analog scale (VAS) and analgesic consumption were evaluated at the 6th and 24th h, and on 2nd-7th days. Granulation tissue health and inflammation severity were evaluated on the 1st, 3rd, and 7th days. Quality of life was evaluated with the postoperative symptom severity scale (Posse) on the 7th day.

RESULTS

A total of 60 patients (43 females/17 males; mean age 42.7 ± 13.76 years), 20 patients per group were included. Among the groups, pain scores on the 7th day (p = 0.042), granulation tissue health on the 3rd (p = 0.003) and 7th (p = 0.015) days showed a significant difference while analgesic consumption, Posse scores, and inflammation severity showed no significant differences (p > 0.05). Between genders analgesic consumption at 6 h (p = 0.027), 24 h (p = 0.033), and on the 2nd day (p = 0.034) and inflammation severity on the 7th day (p = 0.012) showed significant differences while Posse scores and granulation tissue health showed no significant differences (p > 0.05).

CONCLUSIONS

This study demonstrates that regenerative treatment which modulates angiogenesis, and tissue regeneration by stimulating stem cells, growth factors, and cytokines with CGF + ozone are more effective than conventional treatment regarding AO.

CLINICAL RELEVANCE

Usage of CGF and ozone together provides faster and more satisfactory management of AO.

Does the Choice of Preparation Protocol for Platelet-Rich Fibrin Have Consequences for Healing and Alveolar Ridge Preservation After Tooth Extraction? A Meta-Analysis

PURPOSE

Multiple preparation protocols for platelet-rich fibrin (PRF) are in use today, and clinical results are often heterogeneous. This study analyzes the impact of the chosen PRF preparation protocol on 1) wound healing and 2) alveolar ridge preservation.

METHODS

For this systematic review and meta-analysis, eligible studies were identified in PubMed and Cochrane databases. Included were randomized controlled and controlled clinical trials with healthy patients treated with PRF after atraumatic tooth extraction compared to untreated socket(s), reporting at least one of the following outcome variables: pain, swelling, soft tissue healing, alveolar osteitis risk, horizontal and vertical bone loss, socket fill, and new bone formation. Main predictor variable was relative centrifugal force (RCF) comparing high RCF (high PRF), intermediate RCF (standard [S-PRF]), low RCF (advanced PRF), and various RCF settings (concentrated growth factor preparation [CGF]). The type of centrifugation tubes (silica-coated plastic and glass) was a secondary predictor. Weighted or standardized mean differences, risk ratio and corresponding 95% confidence intervals were calculated.

RESULTS

Forty studies published between 2012 and 2022 were selected. The pooled effects of all outcomes were significant against untreated sockets. Within the subgroups high PRF or advanced PRF had the lowest efficacy for many outcome parameters. Pain reduction (in visual analog scale units) was highest for S-PRF (-1.18 [-1.48, -0.88], P < .00001) and CGF (-1.03 [-1.16, -0.90], P < .001). The risk ratio of alveolar osteitis (0.09 [0.01, 0.69], P < .02) and soft tissue healing (standardized mean difference = 2.55 [2.06, 3.03], P < .001) were best for CGF. No subgroup differences were found for bone-related outcomes. No meaningful analysis of the tube material effect was possible.

CONCLUSION

This study confirms that PRF is associated with reduced postoperative complications but indicates that preparation protocol influences clinical outcomes. S-PRF and CGF protocols appear to be superior for several outcome parameters.

Local interventions for the management of alveolar osteitis (dry socket)

BACKGROUND

Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012.  OBJECTIVES: To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.

SEARCH METHODS

An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence.

MAIN RESULTS

We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate-certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively.  Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate-certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low-certainty evidence).  The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket  Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low-certainty evidence).  A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) -1.40, 95% CI -1.75 to -1.04; P < 0.00001; 2 studies, 80 participants; very low-certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects.

AUTHORS' CONCLUSIONS

Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate-certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol.

Aetiology, Prevention and Management of Alveolar Osteitis-A Scoping Review

BACKGROUND

Alveolar osteitis (AO) is a poorly understood, common, painful complication following exodontia. It is sometimes managed by inappropriate prescription of antibiotics which contributes to the global threat of antimicrobial resistance. Use of intra-alveolar chlorhexidine also presents a serious risk of anaphylaxis to the patient.

OBJECTIVE

This scoping review aims to investigate the aetiology, prevention and management of AO and highlight the extent of inappropriate prescribing and intra-alveolar chlorhexidine use.

DESIGN

A scoping review was undertaken using the PRISMA guidelines. Medline, Ovid and Pubmed were searched between 2010 and 2020, from which 63 studies were selected for review that related to the aetiology, prevention or management of AO. Data were analysed for frequency of studies reporting information on risk factors for aetiology, prevention strategies and management including inappropriate management using antibiotic prescribing and intra-alveolar chlorhexidine.

RESULTS

Impaired immune response, surgical technique and age were identified as significant factors in the development of AO, while there is conflicting evidence regarding the effects of smoking and gender. With regard to prevention, the use of prophylactic antibiotics is not supported within the literature. Saline irrigation and eugenol pastes used preventively have been shown to be cheap and effective alternatives to chlorhexidine with no adverse effects. Hyaluronic acid and low-level laser therapies showed a significant reduction in pain and soft-tissue inflammation in the management of AO compared to Alveogyl.

CONCLUSIONS

Further understanding of the pathophysiology of AO is needed, in addition to large high-quality RCTs or long-term observational studies into the aetiology, prevention, and management of AO to produce up-to-date evidence-based clinical guidelines. Clinicians should also be mindful of their contribution to growing antimicrobial resistance and avoid inappropriate prescribing of antibiotics. Saline should replace chlorhexidine as the intra-alveolar irrigant of choice.

Application of platelet-rich fibrin on mandibular third molar extraction: systematic review and Meta-analysis

OBJECTIVES

This study aims to analyze the effectiveness of platelet-rich fibrin (PRF) in mandibular third molar extraction and provide suggestions for alleviating postoperative complications.

METHODS

Pubmed, EMBASE, Web of Science, and SinoMed were searched electronically on February 2020. Randomized controlled trials focusing on PRF usage in mandibular third molar extraction were included. Reviewers assessed the risk of bias in the included literature and extracted data independently using the criteria recommended by the Cochrane Collaboration. Meta-analysis was performed using RevMan 5.3 and STATA 13.0.

RESULTS

Twenty-one studies were included, comprising 991 patients who had mandibular third molar extraction. The topical application of PRF effectively reduced pain after extraction [MD=-12.06, 95%CI (-21.42, -2.71), P=0.01], attenuated post-extraction swelling [MD=-1.42, 95%CI (-2.41, -0.44), P=0.005], and promoted soft tissue hea-ling [MD=0.66, 95%CI (0.34, 0.99), P<0.000 1]. PRF significantly reduced trismus and alveolar osteitis (P<0.05). However, data could not prove whether PRF has any significant positive effect on bone healing compared with the control group (P>0.05).

CONCLUSIONS

Limited clinical evidence indicates that applying PRF after mandibular third molar extraction could reduce pain, swelling, trismus and the occurrence of dry socket and promote soft tissue healing. However, the effect of PRF on bone healing requires further large-scale randomized controlled trials and unified measurement criteria.

Variations in reporting of clinician-reported outcome measures in third molar surgery: A focused review

Clinician-reported outcome measures (ClinRO measures) play a fundamental role in quality assurance throughout healthcare systems. With commissioners turning ever more frequently to ClinRO data to evaluate and compare individual hospital performance and casemix, and funding decisions increasingly relying on these data, agreed core outcome sets (COS) are essential for the collection of standardised specialty-specific outcomes. Beyond their role in service commissioning, COS enable standardisation of outcomes in clinical studies, allowing comparisons to be drawn between similar trials as well as pooling of data for systematic reviews and metaanalyses. This review explores those ClinRO measures most commonly reported in the third molar literature, highlighting inconsistencies in ClinRO selection, measurement and reporting among researchers. We recognise here a prime opportunity for the specialty to address this lag in COS relative to other surgical specialties. With the Quality Outcomes in Maxillofacial Surgery (QOMS) overseeing the institution of many subspecialty-specific national databases in recent years, OMFS is well placed to develop a series of COS for each subspecialty domain for the benefit of researchers, clinicians and ultimately, patients.

Effect of platelet-rich fibrin on the control of alveolar osteitis, pain, trismus, soft tissue healing, and swelling following mandibular third molar surgery: an updated systematic review and meta-analysis

The purpose of this study was to estimate the effect of platelet-rich fibrin (PRF) on the control of alveolar osteitis (AO), pain, trismus, soft tissue healing, and swelling following mandibular third molar surgery. A comprehensive search of the literature was conducted through PubMed, Embase, Web of Science, and Cochrane Library up to May 2019. Randomized controlled studies conforming to the inclusion criteria were included. The record screening and data extraction were conducted by two authors independently. The risk of bias assessment was performed according to the guidelines recommended by the Cochrane Collaboration. The quantitative analysis was performed using RevMan version 5.3. Nineteen studies were included in the systematic review and 17 studies were eligible for the meta-analysis. The use of PRF significantly reduced the incidence of AO and postoperative pain when compared to the controls (AO: relative risk 0.43, 95% confidence interval (CI) 0.28 to 0.65, Z=3.90, P<0.0001 (I²=0%); pain: day 1, standardized mean difference (SMD) -1.12, 95% CI -1.87 to -0.37, Z=2.93, P=0.003 (I²=95%); day 3, SMD -0.93, 95% CI -1.48 to -0.38, Z=3.30, P=0.001 (I²=92%); day 7, SMD -1.84, 95% CI -2.98 to -0.71, Z=3.19, P=0.001 (I²=97%)). Additionally, the result showed a better soft tissue healing when PRF was used (mean difference -0.63, 95% CI -1.08 to -0.18, Z=2.76, P=0.006 (I²=90%)). The use of PRF reduced the incidence of AO and postoperative pain following third molar surgery. Furthermore, PRF may also improve the postoperative soft tissue healing.

Efficacy of a topical gel containing chitosan, chlorhexidine, allantoin and dexpanthenol for pain and inflammation control after third molar surgery: A randomized and placebo-controlled clinical trial

BACKGROUND

The aim of this study was to evaluate and compare the postoperative effect of a topic gel containing chlorhexidine, chitosan, allantoine and dexpanthenol versus a placebo for pain and inflammation control after third molar surgery.

MATERIAL AND METHODS

A gel combining 0.2% chlorhexdine, 0.5% chitosan, 5% dexpanthenol, 0.15% allantoin and 0.01% sodium saccharin was selected for this split mouth randomized controlled and double-blind trial including 36 patients with bilaterally and symmetrically impacted lower third molars. The teeth (n=72) were randomly divided into two groups before surgical removal: control group (CG; in which a placebo was given) and experimental group (EG). Swelling, trismus, postoperative pain, wound healing and complications were measured and recorded in order to evaluate differences between the placebo and experimental product.

RESULTS

Five patients suffered from an alveolitis in the CG (13.9%), and none in the study group (0%), but no statistically significant difference was found (p=0.063). From day 0 to day 7, trismus and swelling were significantly less pronounced in the EG, and wound healing was considered 'good' in 22.2% for the CG and 97.2% for the EG (p<0.001). Mean VAS scores during the seven postoperative days were statistically lower in the study (2.56±1,19) compared to the placebo group (3.25±1.6) (p=0.002). The mean consumption of analgesic pills during the first 92 hours was also statistically lower in the EG (0.26±0.51) in comparison to the CG (0.56±0.67) (p=0.003).

CONCLUSIONS

The use of an experimental gel containing chlorhexidine, chitosan, allantoine and dexpanthenol seems to significantly reduce postoperative pain, trismus and signs of inflammation. Future studies should further evaluate, if the gel is effective in dry socket preventing after third molar removal.

Effect of concentrated growth factors on frequency of alveolar Osteitis following partially-erupted mandibular third molar surgery: a randomized controlled clinical study

Background

The aim of this prospective study was to assess the effectiveness of concentrated growth factors (CGF) in preventing the development of alveolar osteitis (AO) after the extraction of partially-erupted mandibular third molars.

Methods

Seventy patients (26 men and 44 women) 18 years or older (mean age 25.86; range 18–35) underwent 140 third molar extractions. All the patients presented with bilateral, partially-erupted mandibular third molars and underwent surgical extractions. In each case, one socket received CGF and the other served as a control. The predictor variable was the CGF application and the sides were categorized as ‘CGF’ and ‘non-CGF’. The outcome variable was the development of AO during the first postoperative week. Other study variables included age and gender. Data were analyzed using Cochran’s Q test with the significance level set at a P value less than 0.05.

Results

The overall frequency of AO was 11.4% for the control group. The frequency of AO in the CGF group was significantly lower than in the non-CGF group (p < 0.001).

Conclusions

Based on the results of this study, application of CGF fibrin gel may decrease the risk of AO development after mandibular third molar surgery.

Trial registration

This study was registered in ClinicalTrials.gov database on November 1, 2019 (ID: NCT04151147, retrospectively registered).

Surgical techniques for the removal of mandibular wisdom teeth

BACKGROUND

Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short-term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity.

OBJECTIVES

To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth.

DATA COLLECTION AND ANALYSIS

Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel-group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross-over or split-mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split-mouth studies in our analyses, and combined parallel-group and split-mouth studies using the generic inverse-variance method. We used the fixed-effect model for three studies or fewer, and random-effects model for more than three studies.

MAIN RESULTS

We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low-certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low-certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low-certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low-certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand-piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low-certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low-certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low-certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low-certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low-certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported.

AUTHORS' CONCLUSIONS

In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future.

Usefulness of platelet-rich fibrin as a hemostatic agent after dental extractions in patients receiving anticoagulant therapy with factor Xa inhibitors: a case series

PURPOSE

To evaluate the clinical outcomes of platelet-rich fibrin (PRF) application for hemostasis after dental extraction in patients receiving anticoagulant therapy with factor Xa inhibitors.

METHODS

In total, 25 patients receiving anticoagulant therapy with rivaroxaban or apixaban who required routine dental extraction were evaluated. In all patients, PRF was used for hemostasis in addition to adapting sutures. Bleeding was subjectively assessed using a sterilize gauze pad at 24, 48, and 72 h after the procedure.

RESULTS

All invited participants (n = 25) consented to participate. The PRF clots successfully arrested bleeding after extraction in all patients, with no complications at any time point after the procedure. Favorable soft tissue healing was observed during suture removal at 10 days after the procedure in all patients, with no signs of infection or late healing.

CONCLUSIONS

The results of this case series indicate that PRF is a promising natural hemostatic agent for the management of bleeding after dental extraction in patients receiving factor Xa inhibitor therapy. Further controlled clinical studies with larger patient samples are necessary to clarify the findings of this case series.