Perioperative effects of leukocyte- and platelet-rich fibrin in third molar surgery

I read with great interest the study by Ritto et al.1 on the efficacy of leukocyte and platelet-rich fibrin (L-PRF) for bone healing after the surgical removal of impacted third molars. I thank and congratulate the authors who pointed out in their concise and well-detailed report the many issues with this adjuvant aimed at accelerating the healing process. As the topic analysed in their study is of importance, I would like to add some comments about certain missing points in their detailed analysis. As mentioned by Ritto et al.1, the surgical removal of third molars is one of the most common routine surgeries in dental practice. A number of postsurgical sequelae, including pain, swelling, reduced mouth opening, and postsurgical bleeding, are the main issues following the surgical removal of a third molar2,3, and the management of these symptomatic sequelae, inflammatory mediators, and pain represents the basis of successful postoperative care. As suggested by Ritto et al.1, the most remarkable finding of their study is that treatment with L-PRF improved bone density following third molar surgery, while there was no statistically significant difference related to pain or the soft tissue compared to the control group. These conclusions are very important and could help clinicians in their clinical practice. Regarding soft and hard tissue postsurgical healing, did the authors also evaluate postoperative adverse events such as infections or abscesses during follow-up? More specifically, did the authors evaluate the risk of postsurgical bleeding and alveolar osteitis at each follow-up session? Was the ‘subjective’ Landry index evaluated by different clinicians and at longer follow-ups of much more than 7 days? In this regard, it has previously been shown that L-PRF is a rich source of growth factors, such as platelet-derived growth factor and vascular endothelial growth factor4, with important properties for healing such as angiogenesis, immune control, and wound protection, which are most important in patients, particularly those with bleeding disorders5. The slow release of these biochemical components may have a synergistic effect on the healing process in the long term6. Alveolar osteitis and associated postsurgical bleeding have been reported, such as ‘‘post-operative pain severely increasing after the extraction, accompanied by a disintegrated blood clot in the alveolar socket’’7. I believe that when selecting L-PRF after dental surgery, all effects should be considered, especially in the long term, and these should be evaluated objectively using an appropriate index. Therefore, in my opinion, further multicentre investigations with larger samples are needed to better understand the role of L-PRF in order to provide m