Can concentrated growth factor prevent postoperative complications of impacted third molar surgery? A split-mouth randomized double-blind trial

OBJECTIVES

The purpose of the present study was to evaluate the effect of concentrated growth factor (CGF) on prevention of postoperative complications in the impacted third molar extraction.

MATERIALS AND METHODS

A total of 25 healthy patients with symmetrical bilaterally impacted third molars (50 extraction sites) were enrolled in this split-mouth, randomized, double-blind clinical trial. Third molar extractions were performed in both sites of the mandible at the same appointment. Randomization was performed using a coin toss to choose the test and control sites. CGF was placed in the extraction socket and the socket was sutured (test group), while the contralateral socket was only sutured (control group). Each patient acted as their own control. The primary outcome were pain assessed by visual analog scale (VAS) and facial swelling on the1st, 3rd and 7th postoperative days. The secondary outcomes were bone healing in extraction sockets through alveolar bone height (ABH) and alveolar bone density (ABD) evaluated by cone beam computed tomography (CBCT) immediately after extraction and in the 3rd and 6th months.

RESULTS

Twenty-five patients (12 female, 13 male; mean age 29.17) with bilateral impacted third molars participated in the study. A statistically significant reduction in pain was determined on the 3rd and 7th postoperative days in the CGF sites compared to the control sites while no statistically significant difference was found between the groups on the 1st postoperative day (3rd day, p = 0.009; 7th day, p = 0.039). There were no statistically significant differences in facial swelling and bone healing between the test and control groups at different time intervals, although the data obtained were slightly favoring the CGF group (p > 0.05). There were no serious adverse effects such as infection, alveolitis, paraesthesia, fracture through the follow-up period in all of the cases.

CONCLUSION

The study has demonstrated the effect of CGF on relieving the severity of pain after the third molar extraction.

CLINICAL RELEVANCE

Placement of CGF in the extraction socket could relieve postoperative pain and reduce patient discomfort after the third molar extraction. CGF is recommended during the third molar extraction due to its good biological effects, low cost and simple preparation procedures.

TRIAL REGISTRATION NUMBER

ChiCTR2300077819.

Platelet-Rich Fibrin in Oral Surgery and Implantology: A Narrative Review

Background

The application of blood concentrates has gained popularity in dentistry in recent years. Platelet-rich fibrin (PRF) has been discussed frequently due to a high content of growth factors and the option of chair-side manufacturing in a simple centrifugation process. PRF is free from adjuvants and inexpensive to produce. The number of studies reporting beneficial effects of PRF in various clinical applications such as alveolar ridge preservation, sinus floor elevation, management and prevention of medical-related osteonecrosis of the jaw, third molar extractions, and guided bone regeneration in dentistry has increased recently. However, to date, neither clinical recommendations nor guidelines are available. The present narrative review aims to summarize the level of evidence on the clinical application of PRF within the field of oral surgery and implantology.

Summary

A literature search in Pubmed and Medline has identified 34 articles as a basis for this narrative review. The effectiveness of the clinical application of PRF has been analyzed for five indications within dentistry: medical-related osteonecrosis of the jaw, wisdom tooth extraction, guided bone regeneration, sinus floor elevation, and alveolar ridge preservation. The amount of data for third molar extractions, socket preservation, and guided bone regeneration is extensive. Less data were available for the use of PRF in combination with sinus floor elevations. There is a lack of studies with scientific evidence on PRF and medical-related osteonecrosis of the jaw; however, studies positively impact patient-related outcome measures. Most studies report on beneficial effects when PRF is additionally applied in intrabony defects. There is no evidence of the positive effects of PRF combined with bone graft materials during sinus floor elevation. However, some benefits are reported with PRF as a sole filling material.

Key Messages

Many recently published studies show the positive clinical impact of PRF. Yet, further research is needed to ensure the validity of the evidence.

Effect of manuka honey socket dressing on postoperative sequelae and complications following third molar extraction: A randomized controlled study

To evaluate the effect of manuka honey on the healing of mandibular third molar extraction sockets. This was a prospective randomized study at a tertiary health institution in Lagos, Nigeria. All extractions were transalveolar, using the distobuccal bone guttering technique. Participants were randomized into two study groups. Group A underwent intrasocket application of manuka honey, after which sockets were completely closed using the mucosal flap, while participants in group B underwent mucosal flap closure of the socket without application of manuka honey. The primary outcome was healing of the extraction socket at 7 days postoperatively. The secondary outcomes measured were postoperative sequelae, namely pain, swelling, and trismus on postoperative days 1, 3, and 7, and socket healing complications - specifically inflamed socket, infected socket, and alveolar osteitis. In total, 112 participants completed the study, with 56 participants per group. There were no significant differences in demographic variables between both groups. On the 7th day postoperatively, 26.8% of participants in group B had an unhealed extraction site, compared with 10.3% of participants in group A (p = 0.029). A significant difference was observed between pre- and postoperative pain scores in both study groups (p = 0.001). A comparison of postoperative mean facial swelling between the two groups showed no statistically significant differences on all the review days (p = 0.66). The difference in postoperative socket healing complication rate between both groups was statistically significant (χ² = 4.747, p = 0.029). Within the limitations of the study it seems that the application of manuka honey appears to aid earlier healing of the third molar extraction socket, with a significantly lower frequency of complications. Therefore, the application of manuka honey is recommended whenever appropriate.

A longitudinal assessment of sex differences in the growth of the mandibular retromolar space

OBJECTIVE

To assess longitudinal variation in patterns of retromolar space growth, with regard to sex and cervical vertebrae maturation.

DESIGN

We utilized serial lateral cephalograms from three craniofacial growth studies (Denver, Iowa, Oregon), measuring retromolar space and cervical vertebrae maturation in 99 subjects (56% male) from 8 to 18 years of age for each subject. Repeated measures ANOVA and a linear mixed effects model were used to assess retromolar space growth through time.

RESULTS

Our analyses revealed an average increase in retromolar space of 8.73 mm from 8 to 18 years. While t-tests failed to find differences in retromolar space growth between males and females at the measured age points, repeated measures ANOVA and linear mixed effects models revealed modest differences in growth trends between sexes, with females having more growth earlier but a younger age of deceleration of growth (between 12 and 14 years of age).

CONCLUSIONS

Our results confirm large increases in retromolar space through growth, reaching an average of 1.38 mm/year around puberty. Importantly, we add to the conversation regarding sex differences, showing differences in timing of growth. This highlights the importance of using longitudinal data and analytical approaches to address questions of this nature.

Low-level laser therapy is effective in controlling postoperative pain in lower third molar extractions: a systematic review and meta-analysis

This systematic review aimed to evaluate the effectiveness of low-level laser therapy in controlling postoperative pain in lower third molar extractions. A search was carried out in MEDLINE/PubMed, Web of Science and Cochrane Library (CENTRAL) databases, using the "low-level laser therapy", "photobiomodulation therapy", "impacted mandibular third molar", "mandibular third molar", "third molar extraction" descriptors and 2625 studies were found, including only randomized clinical trials published until July 2020, with no restrictions on language and country of study. Selected studies were submitted to initial screening based on the reading of titles, abstracts and full article, and duplicate studies were excluded. Overall, 2562 articles were found, of which only 15 randomized clinical trials were included in this review. A total of 648 patients (16-44 years) who received low-level laser therapy as an intervention and placebo in their control group were evaluated. The pain evaluation criterion was the Visual Analog Scale (VAS) on the second and seventh days after surgery. Photobiomodulation with low-level laser showed statistically significant reduction in postoperative pain in lower third molar extractions, both on the second (MD: - 0.59; CI: - 0.92, - 0.27) and seventh day after surgery (MD: - 0.76; CI: - 1.21, - 0.32).

Current thinking in lower third molar surgery

The removal of lower third molar teeth is one of the most common surgical procedures performed worldwide, but many concepts in this surgery have been unclear and have engendered different opinions. This paper aims to review current thinking in certain pertinent aspects of this surgery to update the reader on the most current research and synthesise it to make clinical recommendations. Topics covered include preoperative imaging, timing of removal, flap design, lingual retraction, coronectomy, lingual split, closure techniques, and use of antibiotics, steroids, and drains.

Collaboration with an infection control team promoted appropriate antibiotic use for third molar extraction at a Japanese hospital

Oral antibiotic therapy is routinely administered when a third molar (M3) is extracted to prevent infectious complications after surgery. Oral third-generation cephalosporins are frequently used after M3 extraction in Japan but at the expense of an increased risk of antimicrobial resistance. Therefore, the infection control team (ICT) at our institution recommended a reduction in use of these agents after M3 extraction. In this study, we compared the types of antibiotic agents prescribed for patients undergoing M3 extraction before and after this recommendation. We investigated the relationship between type of antibiotic used and the likelihood of infectious complications as well as cost savings in patients who underwent M3 extraction in the 6 months before and after the ICT recommendation in July 2018. There was a marked reduction in use of oral third-generation cephalosporins after M3 extraction (P < 0.0001) and increased use of oral penicillins and first-generation cephalosporins after the ICT recommendation. Moreover, surgical site infection (SSIs) were significantly less common after the ICT recommendation (P = 0.0099); however, the SSI rate was higher in patients who received a third-generation cephalosporin than in those who received penicillin (8.8% vs 0.5%). There was also a significant saving in per-patient antibiotic costs after the ICT recommendation (269.5 ± 282.0 JPY vs 454.7 ± 376.6 JPY; P < 0.0001). These findings suggest that collaboration with an ICT promotes appropriate antibiotic use, decreases the risk of an SSI, and improves the cost-benefit ratio in patients undergoing M3 extraction.

Subcutaneous emphysema and vocal fold paresis as a complication of a dental procedure

Third molar extraction is a common oral surgery performed in the pediatric population. Here we report a case of extensive subcutaneous emphysema of the orbital, masticator, parapharyngeal, retropharyngeal spaces, bilateral carotid and visceral spaces, and pneumomediastinum after third molar extraction with turbine drill. This was treated with intubation for airway protection, transoral drainage, and intravenous antibiotics. After discharge the patient reported persistent dysphonia and was found to have left vocal fold paresis. This was likely related to extensive pneumomediastum causing injury to the recurrent laryngeal nerve. This is the first report of cervicofacial emphysema leading to vocal cord paresis after third molar extraction, demonstrating the importance of serial clinical monitoring in these cases.

Management of Odontogenic Fascial Space Infection in Hemophilia Patients: A Proposed Protocol

Purpose

The purpose of this study was to suggest a protocol for the management of odontogenic space infections in patients with hemophilia which is often incompletely addressed by clinicians because of the fear of excessive bleeding leading to prolonged morbidity.

Methods and Results

Six diagnosed cases of hemophilia (four cases of hemophilia A and two cases of hemophilia B) with odontogenic fascial space infection were included in the study. Apart from routine investigations, assessments were also done to identify inhibitors to factor VIII/IX. Factor VIII/IX was replaced along with infusion of factor eight inhibitor bypass activity (FEIBA) one hour before incision and drainage. All the cases were treated by incision and drainage along with removal of foci under local anesthesia. The postoperative outcome was uneventful in all cases except one in which postoperative bleeding was noted from the extraction site on the third day which was again managed following the designed protocol.

Conclusion

Maintaining good oral hygiene and seeking early dental care are of prime importance in patients with hemophilia to avoid invasive procedures. However, if odontogenic infection develops in these patients, performing timely incision and drainage using our protocol will minimize the complications and give successful outcome.

Rare and life-threatening complication after an attempted lower third molar extraction: Lemierre syndrome

Lemierre's syndrome is also known as the forgotten disease, and is a rare but life-threatening complication that can arise after surgical extractions of infected mandibular third molars. Owing to its rarity, oral and maxillofacial surgeons might not immediately recognise or can underestimate the pathological signs, and consequently do not apply the appropriate therapy to treat the syndrome. Here, we report on the occurrence and management of a case of Lemierre's syndrome, where the complications affected the right sigmoid sinus. Since the condition appear to be underreported and not properly highlighted, eventual systematic review and meta-analysis of the occurrence of the Lemierre's syndrome are highly recommended.

Pure type-1 collagen application to third molar extraction socket reduces postoperative pain score and duration and promotes socket bone healing

BACKGROUND/PURPOSE

Extraction of the third molar may cause post-operative complications. This study assessed whether application of pure type-1 collagen to the third molar extraction socket can reduce post-operative pain score and duration and promote socket bone healing.

METHODS

Fourteen patients who underwent 20 bilateral and symmetric third molar extractions were included in this study. After two tooth extractions at two different occasions in the same patient, one socket was filled with pure type-1 collagen (experimental group, n = 20) and the other socket received nothing but the blood clot (control group, n = 20). The post-operative pain score and duration, mouth-opening limitation, and the bone density at the socket site were assessed at weeks 1, 2, 4, and 8 after tooth extraction.

RESULTS

Patients in the experimental group had a significantly lower mean post-operative pain score (2.6 ± 1.2) than patients in the control group (4.7 ± 2.0), and had a significantly shorter post-operative pain duration (2.7 ± 1.4 days) than patients in the control group (3.7 ± 1.8 days). We also observed a significantly lower frequency of mouth-opening limitation in 20 experimental-group patients (45%) than in 20 control-group patients (90%, P = 0.007). Moreover, a significantly higher mineralization ratio (10.2%) was found in the experimental socket site than in the control socket site.

CONCLUSION

Application of pure type-1 collagen to the third molar extraction socket can reduce post-operative pain score and duration, decrease the frequency of mouth-opening limitation, and increase mineralization ratio at the extraction socket site.

Measurement of generic compared with disease-specific quality of life after removal of mandibular third molars: a patient-centred evaluation

Our aim was to evaluate patients' perceptions and their responsiveness to a generic quality of life (QoL) scale after removal of mandibular third molars. We asked 40 consecutive patients who met NICE guidelines for removal of third molars to rank items from the generic EuroQuol three-dimensional questionnaire (EQ 5D 3L) and the disease-specific Oral Health Impact Profile (OHIP-14) based on what they perceived to be important outcomes. Each item was then assigned a numerical value that depended on its rank, and an overall score calculated. Fifty consecutive patients were then invited to complete a paper-based EQ 5D 3L QoL questionnaire daily for seven days after removal of third molars. Most of the generic QoL items ranked more highly than disease-specific ones. The generic EQ 5D 3L questionnaire indicated an initial fall in QoL after removal of the teeth, before improving for all participants over the first seven postoperative days. The responses to questions about "overall QoL", "pain/discomfort", and "anxiety/depression" in the EQ 5D 3L tool were strongly correlated. The EQ 5D 3L is used to assess fluctuations in QoL during the early postoperative period after removal of third molars, and describes items that are perceived by patients to be more important than those recorded by the disease-specific OHIP-14 QoL questionnaire. It is therefore more relevant for counselling patients preoperatively. Development of measures of early outcomes after removal of third molars should incorporate generic items to remain useful.

Temporal Evaluation of Neurosensory Complications After Mandibular Third Molar Extraction: Current Problems for Diagnosis and Treatment

Objective:

This retrospective study aimed to report the incidence of neurosensory complications after third molar extraction and also to identify current problems and discuss appropriate management of these complications.

Method:

Patients who underwent extraction of deeply impacted mandibular third molars under general anesthesia were included. The following epidemiological data were retrospectively gathered from medical charts: type of neurosensory complication, treatment for complication, and outcome.

Results:

A total 369 mandibular third molars were extracted in 210 patients under general anesthesia during this study period. Thirty-one of the 369 teeth (8.4%) in 31 patients had neurosensory complications during the first postoperative week resulting from inferior alveolar nerve damage. Neurosensory complications lasting from 1 to 3 months postoperatively included 17 cases of hypoesthesia and 8 of dysesthesia in 19 patients. Five cases of hypoesthesia and 4 of dysesthesia in 5 patients persisted over 1 year postoperatively. Sixteen of 369 teeth (4.3%) in 16 patients had persistent neurosensory complications after third molar extraction under general anesthesia. Stellate ganglion block was performed in 4 patients. Early initiation of stellate ganglion block (within 2 weeks postoperatively) produced better outcomes than late stellate ganglion block (over 6 months postoperatively).

Conclusion:

Refractory neurosensory complications after third molar extraction often combine both hypoesthesia and dysesthesia. Current problems in diagnosis and treatment included delayed detection of dysesthesia and the lack of uniform timing of stellate ganglion block. In the future, routinely inquiring about dysesthesia and promptly providing affected patients with information about stellate ganglion block might produce better outcomes.

Oral health-related quality of life following third molar surgery with either oral administration or submucosal injection of prednisolone

AIM

The aim of this study was to evaluate the changes in oral health-related Quality of Life (QoL) following third molar surgery with either oral administration or submucosal injection of prednisolone.

PATIENT AND METHODS

Subjects were randomly distributed into three groups of 62 subjects each: Group A consisted of subjects who received 40 mg oral prednisolone; group B received 40 mg submucosal injection of prednisolone, while group C did not receive prednisolone. Preoperative and postoperative quality of life evaluations of all subjects were done using the 14-item Oral Health Impact Profile (OHIP-14) questionnaire. Postoperatively, quality of life evaluation was done on postoperative days 1, 3, and 7. Subjects were categorized as either affected (OHIP score ≤28) or not affected (OHIP score >28). Mean OHIP scores between preoperative and postoperative periods, as well as between the three groups, were compared.

RESULTS

A significant increase in the mean total and subscale scores was found in all the groups postoperatively. This was most marked on the first postoperative day, and it gradually improved throughout the immediate postoperative period. Subjects who received prednisolone experienced a statistically significant better quality of life than those who did not. Subjects who received submucosal injection of prednisolone showed statistically significant less deterioration in QoL than those who received oral prednisolone (P = 0.001).

CONCLUSION

Administration of prednisolone was significantly associated with less deterioration in quality of life and earlier recovery when compared with subjects who did not receive prednisolone. Submucosal injection of prednisolone 40 mg (which offers a simple, safe, painless, and cost-effective therapeutic option) is an effective therapeutic strategy for improving the quality of life after surgical removal of impacted lower third molars.

Efficacy of Intranasal Dexmedetomidine for Conscious Sedation in Patients Undergoing Surgical Removal of Impacted Third Molar: A Double-Blind Split Mouth Study

BACKGROUND

This study was conducted to evaluate the utility and effectiveness of Intranasal Dexmedetomidine on Sedation status and pain experience of the patients undergoing surgical extraction of impacted third molar.

MATERIALS AND METHODS

In this double-blind, split mouth study, in 15 patients, evaluations pertaining to classes of third molar impaction was done. Each patient was randomly assigned to receive either intranasal normal saline (placebo group) or intranasal 1.5 µg/kg atomized Dexmedetomidine during the first session. The other regimen was used during the second session. Study was conducted for over a period of 120 min and data for sedation and pain was collected at an interval of 30 min. The collected data was then compared between the two groups within the same patient. Sedation status was assessed by a blinded observer with a modified Observer's Assessment of Alertness/Sedation (OAA/S) 13 scale (Annexure- B). Pain experience was evaluated by Visual Analog Scale (VAS) (Annexure-B). Clinical evaluation for sedation and pain was done by a blinded observer at 30, 60, 90, and 120 min after administration of the intranasal solution. The values were then tabulated, and compared between two visits.

RESULTS

The mean values of OAA score of Dexmedetomidine group were significantly higher as compared to Placebo group with a 'p' value of 0.000. And the mean values of Pain score of Dexmedetomidine group were significantly lower as compared to Placebo group with a 'p' value 0.009.

CONCLUSION

The results of this study clearly indicated that: Intranasally administered Dexmedetomidine was significantly useful and effective to achieve optimal sedation and analgesia during third molar surgery.

The antioxidant and anti-inflammatory efficiency of hyaluronic acid after third molar extraction

PURPOSE

Hyaluronic acid (HA) has a number of clinical applications in current practice. Therefore, correlation of HA with free radicals and inflammatory cells is clinically important. The purpose of this study is to measure the efficacy of high molecular weight HA on the oxidative stress of oral wounds (glutathione (GSH) and lipid peroxidation (LPO) levels), the inflammatory reaction (leucocytes, collagen and angiogenesis content), pain (visual analogue scale (VAS) records) and trismus (maximum interincisal opening (MIO) records) after third molar (M3) extraction.

PATIENTS AND METHODS

40 patients were included in this study. 0.2 ml 0.8% HA was applied immediately after surgery within the HA group (n = 20). Nothing was applied to the control group (n = 20). The primary outcome variables were the changes in the inflammatory reaction (leucocyte, angiogenesis and collagen content), oxidative stress (GSH, LPO) and clinical parameters (VAS, MIO). Results were compared immediately after extraction (T0) and 1 week after surgery (T1). Bivariate analyses were used to assess the differences between the HA and control groups for each study variable.

RESULTS

There was a statistically significant difference of leucocyte infiltration and angiogenesis between the groups at T1. The HA group showed less leucocyte infiltration and more angiogenesis than the control group. There was no statistically significant difference in oxidative stress, VAS or MIO levels between the groups.

CONCLUSION

Our results confirm the hypothesis that HA has an anti-inflammatory effect following M3 extraction. However, the oxidative stress levels and clinical outcomes were similar after one week. Further studies examining these parameters at different times are necessary.

Role of platelet rich fibrin and platelet rich plasma in wound healing of extracted third molar sockets: a comparative study

AIMS AND OBJECTIVES

This prospective study was done to evaluate and compare the utility and effectiveness of platelet rich fibrin (PRF) with that of platelet rich plasma (PRP) on soft tissue healing and bone tissue healing of extracted third molar sockets.

MATERIALS AND METHODS

This study included split mouths of 20 patients who underwent bilateral extraction of impacted third molars. During the same appointment, following which PRF and PRP were prepared from patients' autologous blood and placed in right and left extracted sockets, respectively. The data for soft tissue healing were recorded at end of 1 week, using healing index of Landry et al. and the data for bone tissue healing were recorded at the end of 4 months using digitalized orthopantomogram images on Adobe Photoshop CS; which was then compared between the two sites of the same patient.

RESULTS

The mean values of soft tissue healing collected at 1 week post-operative, for PRF group were significantly higher as compared to PRP group. And the mean values of bone density collected at the end of fourth month post-operative, for PRF group were also significantly higher as compared to PRP group. Both tests showed p value of 0.00.

CONCLUSION

PRF is significantly better in promoting soft tissue healing and also faster regeneration of bone after third molar extraction, in comparison with PRP. This could be attributed to simpler preparation protocols of PRF over PRP and the ability of PRF to release growth factors in a controlled way.