Is there an effective way to control pain perception after free gingival graft removal? A systematic review and meta-analysis

Abstract The literature describes multiple ways to stimulate wound healing to reduce the patient's perception of pain. This systematic review aimed to evaluate if methods that enhance wound healing can reduce the patient's perception of pain after free gingival graft removal from the palate region compared to natural healing. A systematic review protocol was written following the PRISMA checklist. Electronic searches of five databases were performed to identify randomized clinical trials (RCTs) that assessed the patient's perception of pain after the removal of a free gingival graft from the palate. The primary outcome was the visual analog scale (VAS) score assessing the patient's perception of pain 7 days after the free gingival graft removal from the palate region. Of the 1,622 potentially relevant articles retrieved from the electronic databases, 16 RCTs were selected for qualitative analysis, and of these, 6 RCTs were included in the meta-analysis. RCTs showed a significant VAS reduction associated with the use of methods to enhance wound healing. The pooled estimates revealed a significant overall VAS reduction of 2.20 (95% CI 2.32, 2.07) 7 days after surgery. The methods that presented the greatest reduction in the perception of pain were platelet-rich fibrin, hyaluronic acid, and autologous fibrin glue. Methods that enhance wound healing, including platelet-rich fibrin, hyaluronic acid, and autologous fibrin glue, can reduce pain perception after free gingival graft removal in the palate region. However, only 1 RCT investigated each approach, which hinders the conclusion regarding the best procedure to reduce the perception of pain.

Resumo A literatura descreve diferentes formas de estimular a cicatrização para reduzir a percepção de dor do paciente. Esta revisão sistemática teve como objetivo avaliar se métodos que melhoram o reparo de feridas podem reduzir a percepção de dor do paciente após a remoção de enxerto gengival livre da região do palato quando comparado a cicatrização natural. Um protocolo de revisão sistemática foi escrito seguindo a lista de verificação PRISMA. Pesquisas eletrônicas em cinco bancos de dados foram realizadas para identificar ensaios clínicos aleatorizados (ECA) que avaliaram a percepção de dor do paciente após a remoção do enxerto gengival livre do palato. O desfecho primário foi o escore da escala visual analógica (VAS) avaliando a percepção de dor do paciente 7 dias após a remoção do enxerto gengival livre da região do palato. Dos 1.622 artigos potencialmente relevantes recuperados das bases de dados eletrônicas, 16 ECAs foram selecionados para análise qualitativa, e destes, seis ECAs foram incluídos na meta-análise. Os estudos analisados demonstraram uma redução significativa de VAS associada ao uso de métodos para melhorar a cicatrização de feridas. As estimativas agrupadas revelaram uma redução global significativa do VAS de 2,20 (95% CI 2,32, 2,07) 7 dias após a cirurgia. Os métodos que apresentaram maior redução na percepção de dor foram fibrina rica em plaquetas, ácido hialurônico e cola de fibrina autóloga. Métodos que melhoram a cicatrização de feridas podem reduzir a percepção de dor após a remoção do enxerto gengival livre na região do palato, especialmente fibrina rica em plaquetas, ácido hialurônico e cola de fibrina autóloga. No entanto, apenas um ECA avaliou cada abordagem, o que impossibilita a conclusão sobre qual é o melhor procedimento para reduzir a percepção de dor.

Periostin and matrix stiffness combine to regulate myofibroblast differentiation and fibronectin synthesis during palatal healing.

Although the matricellular protein periostin is prominently upregulated in skin and gingival healing, it plays contrasting roles in myofibroblast differentiation and matrix synthesis respectively. Palatal healing is associated with scarring that can alter or restrict maxilla growth, but the expression pattern and contribution of periostin in palatal healing is unknown. Using periostin-knockout (Postn-/-) and wild-type (WT) mice, the contribution of periostin to palatal healing was investigated through 1.5 mm full-thickness excisional wounds in the hard palate. In WT mice, periostin was upregulated 6 days post-wounding, with mRNA levels peaking at day 12. Genetic deletion of periostin significantly reduced wound closure rates compared to WT mice. Absence of periostin reduced mRNA levels of pivotal genes in wound repair, including α-SMA/acta2, fibronectin and ßigh3. Recruitment of fibroblasts and inflammatory cells, as visualized by immunofluorescent staining for fibroblast specific factor-1, vimentin, and macrophages markers Arginase-1 and iNOS was also impaired in Postn-/-, but not WT mice. Palatal fibroblasts isolated from the hard palate of mice were cultured on collagen gels and prefabricated silicon substrates with varying stiffness. Postn-/- fibroblasts showed a significantly reduced ability to contract a collagen gel, which was rescued by the exogenous addition of recombinant periostin. As the stiffness increased, Postn-/- fibroblasts increasingly differentiated into myofibroblasts, but not to the same degree as the WT. Pharmacological inhibition of Rac rescued the deficient myofibroblastic phenotype of Postn-/- cells. Low stiffness substrates (0.2 kPa) resulted in upregulation of fibronectin in WT cells, an effect which was significantly reduced in Postn-/- cells. Quantification of immunostaining for vinculin and integrinß1 adhesions revealed that Periostin is required for the formation of focal and fibrillar adhesions in mPFBs. Our results suggest that periostin modulates myofibroblast differentiation and contraction via integrinß1/RhoA pathway, and fibronectin synthesis in an ECM stiffness dependent manner in palatal healing.

Diode laser for harvesting de-epithelialized palatal graft in the treatment of gingival recession defects: a randomized clinical trial.

AIMS: The aim of present randomized controlled clinical study was to evaluate the effects of the use of diode laser for graft harvesting and palatal wound irradiation on post-operative morbidity and root coverage outcomes after a coronally advanced flap (CAF) with de-epithelialized gingival grafts (DGG). METHODS: Fifty-two patients with isolated recessions were treated. The CTG resulted from the de-epithelialization of a free gingival graft (FGG) with blade (control group:DGG-B) or diode laser (DL) (test group:DGG-L). The DL was used to de-epithelialize the outer part of the FGG and photo-biostimulate the palatal wound area. Post-operative morbidity was evaluated by using Oral Health-related Quality of Life (OHQoL) and Visual Analogue Scale-discomfort (VAS). Root coverage outcomes were also evaluated 6 months after operation. RESULTS: Statistically significant differences were found for OHQoL (p = 0.0001) and VAS (p = 0.0001) at the 7th day post-operatively favouring test sites. Root coverage results did not show a statistically significant difference. CONCLUSIONS: While both techniques were effective with regard to root coverage at 6 months, the DGG-L technique decreased post-operative morbidity associated with palatal donor-site surgery.

Evaluation of palatal donor site haemostasis and wound healing after free gingival graft surgery.

AIM: Evaluating effectiveness of a medicinal plant extract (MPE) in achieving haemostasis and early wound healing at free gingival graft (FGG) donor site in a randomized controlled fashion. METHODS: Forty patients requiring FGG at lower anterior area were randomly assigned into two groups. FGG was performed to all patients and following graft procurement; wet gauze (WG) was applied alone (control: WG group) or with MPE (test: MPE + WG group) for haemostasis. Donor site working time, bleeding (BLE), colour match (CM), pain, epithelization (EP) and sensation loss (SL) were evaluated. RESULTS: Thirty-three participants completed a 6-month period study. In the test group, primary BLE was shorter (p < 0.001) and fewer individuals showed secondary BLE during 3 days (p < 0.001). During the 6 days, pain scores were higher in WG patients (p < 0.05). Later on, no inter-group difference was observed. EP was relatively faster (p < 0.001) and CM was slightly better (p < 0.05) in MPE + WG group. CONCLUSION: MPE provided faster and continuous haemostasis that made a positive contribution to the early soft tissue healing to some extent but due to limitations; further trials are needed to demonstrate the efficiency of this material.