Evaluation of the effect of platelet rich fibrin and low level laser therapy (LLLT) on treatment of alveolar osteitis (blinded comparative clinical study)

doi:10.21203/rs.3.rs-4700705/v1

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Evaluation of the effect of platelet rich fibrin and low level laser therapy (LLLT) on treatment of alveolar osteitis (blinded comparative clinical study)

https://doi.org/10.21203/rs.3.rs-4700705/v1

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Background: A dry socket is a common complication that can occur during the healing process following a tooth extraction. Despite its frequent occurrence in otherwise healthy individuals, the exact cause of this condition remains unclear. As a result, the management of dry sockets has traditionally relied on practical experience rather than on scientific theory. The objective of this study was to compare the effectiveness of platelets-rich fibrin (PRF) and low-level laser therapy (LLLT) for the treatment of dry sockets with conventional treatments.

Material and Methods: A randomized controlled clinical trial was conducted among patients with a dry socket, who were categorized into three treatment groups. In the first group, the conventional treatment was used by performing gentle socket curettage and saline irrigation. The second group was treated with platelet-rich fibrin (PRF), whereas the third group underwent low-level laser therapy (LLLT). Initially, the dry socket patients were examined at day 0 and achieved one of three treatment options, then scheduled follow-up appointments on days 4 and 7 after therapy. The pain score, inflammation and tenderness around the socket, and quantity of granulation tissue formation were assessed, respectively.

Results

A total of eighty-seven patients with dry socket were divided into three treatment groups. The conventional therapy group took more than seven days to reach the same healing phase as group II, which received PRF treatment, and group III, which received LLLT irradiation. In the comparison of healing rates between PRF and LLLT, it was noticed that the socket treated by LLLT showed an increase in both granulation tissue production and pain management on day 4 compared to the PRF-treated group II patients.

CONCOLUSION

The sockets treated with platelet-rich fibrin (PRF) and low-level laser therapy showed a statistically significant improvement in the healing process and granulation tissue formation compared with conventional treatment.

dry socket

depth of the socke

low-level laser therapy

platelet rich fibrin

The worldwide incidence of dry socket, which has been documented to range from 1 to 4% following normal dental extractions, is a matter of concern (1). The lower teeth have a ten times increase in risk compared to the upper teeth, and the risk may potentially approach 45% for the removal of the mandibular third molar (2).

A dry socket, alveolar osteities, is a very common complication that can happen after a tooth extraction (3). It is characterized by the absence of a blood clot in the socket, exposing the underlying bone(4). The management of dry socket has historically been based on empirical methods rather than scientific ones (5). Practitioners have utilized many therapeutic techniques: In order to benefit from its antioxidant properties, hyaluronic acid (6) was used as a wound dressing. Honey (7) and Turmeric (8) could be also introduced for their ability to promote regenerative growth. Zinc oxide eugenol was used as a pain relief dressing, utilizing butamben or iodoform for their antiseptic properties. Eugenol provided both analgesic and antiseptic effects. Additionally, a biocompatible fibrous filler material, such as penghawar Djambi,(9) while topical rifampicin (10) has been utilized for its antimicrobial efficacy. including the implantation of vitamin-C dressings within the socket (11).

The practice of irrigating dry sockets has traditionally involved the use of physiological saline and chlorhexidine (10). While these treatments are recommended for alleviating symptoms and protecting the damaged wound, they do not specifically target the main problems associated with wound breakdown and the pursuit of regenerative therapy (12). The current standard approach for treating dry socket involves delicately removing debris from the socket with a gently curettage, followed by rinsing with saline solution. The socket is subsequently permitted to heal through the natural course of biological repair (12).

The cause and treatment options for dry socket are still a subject of ongoing debate. In order to develop a regenerative medicine method for treating dry socket lesions, scientists must have a comprehensive understanding of the elements that regulate wound healing mechanisms, as dry socket is a condition characterized by delayed wound healing. In dentistry, the current intraoral regenerative wound-healing technologies encompass platelet-rich plasma (PRP) (13) and concentrated growth factor (CGF)(14).

low-intensity pulsed ultrasound therapy (LIPUS)(15) and low-level laser therapy (LLLT) (16).

Platelet rich fibrin (PRF) is derived from the individual's blood through centrifugation, PRF is a fibrous matrix composed of fibrin that contains growth factors that serve as catalysts for tissue regeneration (17), and cells, WBC with cytokines,. These components are held within the matrix and can be released over time. PRF can function as a membrane that can be absorbed by the body (18).

Choukroun and his colleagues were among the early adopters of the PRF protocol in oral and maxillofacial surgery, aiming to enhance bone healing in implant dentistry. Autologous platelet-rich fibrin (PRF) is regarded as a regenerative biomaterial with healing properties. Currently, research has demonstrated its use in different areas of dentistry (19).

LLLT was initially identified by Endre Mester through his observation of hair regrowth in mice after the administration of laser light (20). It is essentially a photochemical process that stimulates cells on the skin (21). The photostimulatory impact enhances the proliferation of fibroblasts (22). Platelet-derived growth factor (PDGF) stimulates bone repair and collagen formation while causing minimum heat injury (23).

Both growth factor processing materials and low-level laser therapy (LLLT) are currently provided in dental and oral surgery practices.

This clinical study aims to assess the effectiveness of PRF (Platelets rich fibrin ) and LLLT (Low-Level Laser Therapy) in treating dry socket. The study will compare these treatments with the conventional technique of socket curettage and irrigation, and allowing the body to naturally heal the lesion without any assistance.

A pilot randomized controlled clinical trial was conducted among patient with a dry socket, were categorized into three treatment groups at AL-Ameed University Dental Hospital from August 2022 till December 2023. Human Ethics, approval was obtained from the Research Ethics Committee, University of Al-Ameed (Number: UAM/EC/5/2017). Patients who were diagnosed with alveolar osteitis were referred to the oral surgery department. All patients aged between 28 and 50 years, who had undergone nonsurgical tooth extraction, and diagnosed with alveolar osteitis during the period study were included. Any patient refused to take part in the study or don’t complete the follow up was excluded. Before starting therapy, a periapical radiograph of the socket was taken for each group to rule out the possibility of retained apices, bone fragments, and alveolar fractures. In these cases, the patients were also excluded. All patients were given information regarding their dry socket condition and informed consent was obtained. Following the provision of three treatment alternatives, they were randomly split into three groups. Ninety Patients divided into three groups: patients in group I received conventional treatment for dry socket. Patient in group II received PRF, and patient in group III treated with LLLT.

In group I, under local anesthesia, the dry socket was gently curetted and irrigated with saline.

In group II after socket curettage and irrigated we insert the PRF clot immediately in the socket. A 9 mL of the patient's blood were drawn into a vacuum blood collecting tube. Using a centrifuge machine from china, the blood was centrifuged at the chairside for 10 minutes at 3,000 revolutions per cycle(rpm). The thick gel layer known as PRF was eventually created. With the use of a surgical tweezer , the PRF clot was inserted straight into the socket.(24) Then sutured the socket for stabilaztion the PRF clot.

In group III, the socket was similarly curetted and irrigated under local anesthesia, and the walls were lased with LLLT, all in accordance with the required laser safety protection protocol. Using a elexxion pico (diodelaser made in Germany), the radiation was applied for 30 seconds at a delivery distance of 1 cm to the buccal, lingual, and central surface of the socket at a setting of 200 mW, 6 J, 808nm, continuous wave mode.1 as in picture 1.

The Collected data included demographic status (age, sex), visual analogue pain scale from 1 to 10, peri-socket inflammation and tenderness score (socket depth, quantity of granulation tissue formation).

With three groups, the pain score, inflammation and tenderness around the socket, and quantity of granulation tissue formation were assessed on days 0, 4 and 7 of follow-ups .

The pain score was assessed the by numeric rating scales which typically consist of a series of numbers ranging from 0 to 10 with endpoints intended to represent the extremes of the possible pain experience and labeled “no pain” and” worst possible pain,” respectively. Patients choose the number that best corresponds to the intensity of their pain.(25). The perisocket inflammation and tenderness assessed recording in table 1

Table 1 assessment of perisocket inflammation and tenderness

Perisocket inflammation	Score
Normal pink perisocket gingiva	0
Mild redness at perisocket gingiva	1
Moderate redness with increase vascularity at perisocket gingiva	2
Severe redness with increase vascularity at perisocket gingiva extending to vestibule	3
Perisocket tenderness	Score
No perisocket tenderness on palpation	0
Perisocket tenderness on palpation	1
Perisocket tenderness on slight touch	2
Perisocket tenderness on slight touch extending to vestibule and cheek	3

For the socket depth used the WHO probe, the distance from the bottom of socket to the level cemento enamel junction of the adjacent tooth was measured, during each visit as show in Fig2 and picture 3 .

the level of cement- enamel junction of the adjacent tooth consider reference point because it more reliable and fixed point

Statistical Analysis

Data analysis was performed using the SPSS statistical package (version 25.0, SPSS Inc, Chicago, IL, USA). Continuous variables were described as means ± standard deviations, when normally distributed and as medians with their 25^th and 75^th percentile, when not. Categorical variables were summarized with absolute and relative frequencies. The compression of categorical variables using chi-square and Fisher’s exact tests. The compression of continuous variables using Anova test, Kruskal-Wallis test, Students t tests and Mann-Whitney U-test. The statistical significance at p-value < 0.05.

In total, eighty-seven patients with a dry socket, were included into three treatment groups. Twenty-eight patients participated in group I, 30 patients in group II, and 29 patients in group III. Four patients were excluded because they were lost to follow-up.

The difference between the age and number in these groups was non-significant as show in diagram 1. Sex ratio was 1.45 in group I, 0.7 in group II and 2.8 in group III.

Results of pain index, presocket inflammation index (PSI) preresocket tendereness index (PST) and depth of socket in day 0 had shown non-significant difference between these groups except the depth of socket which show significant difference (p=0.003) (table 2).

Table 2: The differences in Pain, PSI, PST, and depth of socket between groups on day 0

DAY 0		CONTROL	PRF	LLLT	P VALUE
PIAN, medium (Q25%-Q75 %)		9(8-10)	9(9-10)	9(8-10)	0.130
PSI, medium (Q25%-Q75 %)		2(2-3)	2(2-3)	2(2-3)	0.380
PST, medium (Q25%-Q75 %)		3(2-3)	3(2-3)	3(2-3)	0.550
DEPTH OF SOKET ,medium (Q25%-Q75 %)	11.5(11-12)		12.5(11.75-13)	11.5(11-13)	0.003

Forth day results showed statistically significant difference between three groups as showed in the table 3. The degree of pain(p=0.000), tenderness(p=0.000), inflammation (p=0.000) and depth of pocket(p=0.000) was decreased significantly in PRF and LLLT groups compared with control.

Table 3: Shows the difference in pain, PSI, PST, and depth of socket among groups on day 4

DAY 4	CONTROL	PRF		LLLT	P VALUE
PIAN, medium (Q25%-Q75 %)	5(5-6)	1(0-4)		1(1-2)	0.000
PSI, medium (Q25%-Q75 %)	2(2-2)	0(0-31)		1(0-1)	0.000
PST, medium (Q25%-Q75 %)	2(2-2)	0(0-1)		1(0-1)	0.000
Depth of socket medium (Q25%-Q75 %)	9.5(8-10)		5(4-6)	4(1-5)	0.000

Result in day 7 showed statistically significant difference between these groups, as showed in this table 4. The degree of pain (p=0.000) ,tenderness(p=0.000) , inflammation(p=0.000) , depth of pocket (p=0.000) was decreased significantly in PRF and LLLT groups compared with control group.

Table 4 shows the difference in pain, PSI, PST, and depth of socket among groups on day 7

DAY 7		CONTROL	PRF	LLLT	P VALUE
PIAN, medium (Q25%-Q75 %)		3(2-4)	0(0-0)	0(0-0)	0.000
PSI, medium (Q25%-Q75 %)		2(1-2)	0(0-0)	0(0-0)	0.000
PST, medium (Q25%-Q75 %)		2(1-2)	0(0-0)	0(0-0)	0.000
Depth of socket , medium (Q25%-Q75 %)	4(3.5-6)		1(1-2)	1(1-1)	0.000

Only Result of depth of socket in day 4 was statistically significant between the PRF 5(4-6) and LLLT 4(1-5) groups as show in table 5 and diagram 2. This mean the granulation tissue formed in the socket treated with LLLT was larger than the PRF but at 7 day the difference was non-significant (p=0105).

Table 5 shows the difference in socket depth between PRF and LLLT groups on days 0,4 and 7 of the follow-up

Day	LLLT	PRF	P VALUE
Day 0	11.5[11-13]	12.5[11.75-13]	0.063

Day 4	4[1-5]	5[4-6]	0.001*
Day 7	1[1-1]	1[1-2]	0.105

* significant when p value ≥0.05

The worldwide incidence of dry socket, which has been documented to range from 1 to 4% following normal dental extractions, is a matter of concern (1). The lower teeth have a 10 times increase in risk compared to the upper teeth, and the risk may potentially approach 45% for the removal of the mandibular third molar.(2). Dental practitioners frequently underestimate the level of pain intensity experienced by individuals with dry socket and sometimes fail to provide sufficient care to these individuals. the inflammation in the per socket sometimes extended to the buccal vestibule and sometimes towards the cheek. However, there was no increase in body temperature. This phenomenon has verified that the classical dry socket is a localized pathological condition that only affects the maxillary or mandibular alveolar process, without causing any systemic disturbance(4) .

Regardless of the kind and extent of the injury, wound healing is a complex biological process made up of interconnected steps that are classified as inflammation, angiogenesis, granulation tissue development, and tissue remodeling and regeneration. These stages are part of a biological chain reaction that results in tissue repair and healing (26).

Therefore, the inflammation score and granulation tissue formation used as parameters for healing the dry socket beside to compare the pain score and tenderness around the socket between the groups .

Socket curettage in this study caused bleeding and clotting in a damaged tooth socket that did not heal successfully after the initial attempt. Gentle socket curettage and saline irrigation aid in removing necrotic hard and soft tissue that cannot be cleared by natural physiological processes. As all the patients were healthy, their healing ability was not affected, despite an estimated delay after the formation of the new clot.

Group II is expected to benefit from the insertion of PRF clot into the socket to aid healing in the impaired socket. After curettage and saline irrigation, the PRF clot was easily inserted into the socket and stabilization carefully.

Sutures may be necessary for stabilization, especially in maxilla. It is commonly seen that dry sockets take longer to heal after receiving appropriate therapy compared to recovering sockets without complications (27). The concept of enhancing healing by the application of PRF is based on observations in the field of general surgical wound healing.

Scientifically, the application of growth factors in oral surgery generates a mixture that boosts healing in a dry socket by modulating the immune system (28) to decrease inflammation and stimulate the growth of cells needed for regeneration. Pain and sensitivity decrease, allowing for the restoration of early oral functions.

Platelet-Rich Fibrin (PRF) contains a concentrated cocktail of various growth factors trapped within its fibrin matrix. These growth factors play a crucial role in stimulating healing and tissue regeneration following tooth extraction. Here are some of the key growth factors found in PRF:

Platelet-derived growth factor (PDGF), this group of growth factors plays a vital role in promoting cell proliferation and attracting other cells involved in wound healing, including fibroblasts responsible for building granulation tissue (29).

Transforming growth factor-beta (TGF-β), this growth factor has diverse functions in wound healing. It can stimulate collagen production, which is a key component of granulation tissue, and also plays a role in regulating inflammation and cell differentiation.

Vascular endothelial growth factor (VEGF), this growth factor promotes the formation of new blood vessels, which is crucial for delivering essential nutrients and oxygen to the healing socket.

Epidermal growth factor (EGF), this growth factor stimulates the proliferation of epithelial cells, which are important for re-epithelialization, the process of forming a new surface layer over the healing socket.

Insulin-like growth factor (IGF), this growth factor has various functions in wound healing, including promoting cell proliferation, differentiation, and tissue repair.

Fibroblast growth factor (FGF), this group of growth factors plays a role in stimulating the proliferation and migration of fibroblasts, further promoting granulation tissue formation.

In addition to these major growth factors, PRF may also contain other beneficial molecules like cytokines and interleukins that modulate the inflammatory response and support the healing process. Our results showed the Patients in group II, which decreased to 1 at range [0–4] on day 4. Clinical observations showed rapid remission of perisocket inflammation and reduction in discomfort by day 4 in all sockets. Granulation tissue rapidly filled the socket by day 4, and by day 7, all four sockets were fully covered by granulation tissue. By day 4, tenderness around the infected socket decreased as the granulation tissue invaded the socket, resulting in a reduction of pain symptoms and lowering the visual analogue scale (VAS) pain score to zero. for every socket by the seventh day. the results of our study agree to many previous study such as Pavlovic et al. 2021. Which stated that PRF release the growth factor along time which have significant effect on wound healing and regeneration of tissue. Benzaquén et al 2020 which provided a comprehensive overview of PRF, including a table summarizing the various growth factors found within it, such as PDGF, TGF-β, VEGF, EGF, and IGF.

Chenchev et. al. 2017 worked on alveolar osteitis using platelet rich fibrin (PRF). They claimed that PRF can successfully treat dry socket by reducing pain symptoms and expedite wound closure and epithelialization. King et al. worked on PRP as plasma rich in growth factors, to treat alveolar osteitis in 2018. They claimed that plasma rich in growth factors indeed has considerable advantages. Choukroun et al.2019 who highlight the potential applications of PRF in dentistry and mentions the presence of growth factors like PDGF, TGF-β, VEGF, and IGF within PRF that contribute to its wound healing properties. By Chou et al. [4] This review discusses the use of PRF in oral and maxillofacial surgery and emphasizes the role of its concentrated growth factors, including PDGF, TGF-β, VEGF, and EGF, in promoting tissue regeneration.

According to Simonpieri et al 2016 study that explores the scientific evidence for PRF's effectiveness in various clinical applications. It mentions the presence of growth factors like PDGF, TGF-β, VEGF, and IGF-1 within PRF and their potential impact on wound healing processes (31). Barrientos et al. [2] founded the role of various growth factors in wound healing, including those found in PRF like PDGF, TGF-β, VEGF, and FGF. It explores how these growth factors influence cellular processes crucial for repair and regeneration.

Granulation tissue is young connective tissue possessing microscopic blood vessels which is formed on the surface of a wound during the healing process, forming a protective layer, and resistant to microbial invasion. It is friable and may be easily damaged, but PRF seems to promote the formation and protection of granulation tissue in a compromised wound. This could be the main reason for the dry socket healing expedition and reduction of pain.

Autologous platelet concentrates, is easy to prepare, is of low cost, and has minimal risk for the patient [49].

In a group III, the use of LLLT because of there are many benefits that based on its photo-biostimulation effects including promoting wound healing, anti-inflammatory effects, and reduction of pain by stimulating tissues without producing any irreversible changes (32). These mechanisms are achieved by stimulation of natural biological processes, dose-dependent reduction of tumor necrosis factor-alpha concentration in acute phase of inflammation, change in size and permeability of vessel lumen, and alteration of neurotransmitter activity (33). These efficacies of LLLT have been proven to accelerate dermal wound healing in the medical fields by numerous studies(34) .

Low-level laser therapy (LLLT) is thought to improve granulation tissue formation in the socket through several potential mechanisms:

Cellular proliferation, LLLT might stimulate fibroblasts, the cells responsible for building granulation tissue, to reproduce more rapidly. This can lead to a quicker formation of the granulation tissue that fills the socket after a tooth extraction (35).

Increased blood flow, LLLT may improve blood circulation in the treated area. This increased blood flow can deliver essential nutrients and oxygen to the healing socket, promoting the growth of granulation tissue (35).

Anti-inflammatory effects, as mentioned earlier, LLLT might reduce inflammation. This is crucial because excessive inflammation can hinder tissue healing. By reducing inflammation, LLLT creates a more favorable environment for granulation tissue formation (36).

Growth factor production, LLLT may stimulate the production of growth factors, which are signaling molecules that play a vital role in tissue repair and regeneration. Increased growth factors can further enhance the formation of granulation tissue (37).

Dry sockets that had a new clot developed after curettage were treated with low-level laser therapy on their whole buccal, occlusal, and lingual surfaces. The median perisocket inflammation decreased to 1 at range [0–1] on day 4, and perisocket pain decreased to 1 at range [1–2] on day 4. The socket depth decreased to 4 at range [1–5] by the seventh day. By day 7, all sockets, with the exception of two, have fully healed, discomfort and tenderness have decreased, and patients have returned to their regular diet.

Pain and sensitivity decrease, allowing for the restoration of early oral functions. Low-level laser therapy (LLLT) has been implemented in dental surgery within the past 20 years. Initially, it was used in the orofacial area for cosmetic purposes, as low intensity laser light could penetrate the skin and stimulate fibroblast, collagen synthesis, and hyaluronic acid production to rejuvenate the face. Oral wound healing mechanisms are enhanced through biostimulation at the cellular and molecular levels, promoting the activity of growth factors such as platelet-derived growth factor and insulin-like growth factor on fibroblast proliferation and collagen formation. LLLT stimulates the growth and movement of human gingival fibroblast cells, along with inducing various biological effects such protein synthesis and growth factor release (36)(38).

Identifying treatment solutions for dry socket is challenging due to the unclear understanding of its pathophysiology. The study indicates that traditional treatment for dry socket, which depends on the body's natural healing mechanism, is less effective than treatments including regeneration molecular or light stimulation. PRF and LLLT have shown improved results in improving dry socket wound healing compared to conventional techniques by lowering inflammation, promoting tissue growth, and alleviating pain.

Angiogenesis is a crucial stage in the mechanism of wound healing. The current research demonstrated a beneficial effect of Low-Level Laser Therapy (LLLT) at 660 and 808 nm on the angiogenesis of extracted sockets (39). Angiogenesis is an essential step in tissue regeneration that includes artery sprouting, endothelial cell proliferation, and tube creation. This process supplies oxygen and nutrients to the developing tissue, promoting cell growth, movement, and protein production. Prior research has also shown the reliable effectiveness of LLLT in promoting the development of new blood vessels (36).

The power dose needs and setting parameters are simply understood, and the operation is sterile and painless, unlike PRF, which requires at least 9 mL of blood to be taken to create the growth factor-rich gel. Yet, the high cost of laser technology and the requirement to follow Laser Protection Protocol may hinder its widespread use in surgical settings. Furthermore, there is a need to determine the optimal LLLT irradiation parameters for oral surgical operations to effectively stimulate cell regeneration (40). The variation in parameter settings has resulted in different assertions regarding the clinical results of low-level laser therapy (LLLT) in wound healing approaches PRF and LLLT both expedite the production of granulation tissue in dry socket. The study demonstrates that the level of discomfort experienced in the healing dry socket is inversely related to the quantity of granulation tissue production. Granulation tissue is a fresh reddish connective tissue along with microscopic blood vessels that develops at the bottom of the dry socket as part of the healing process. It is the primary clinical indicator used to evaluate the body's response to the damage. Hyper granulation may arise due to excessive granulation tissue production, the existence of endogenous growth factor inhibitors at the PRF implantation site could hinder the binding of growth factors to their receptors, therefore obstructing cell proliferation and perhaps slowing down the production of granulation tissue during wound healing (41).

As observed in day 4 that LLLT groups overcome the PRF groups by granulation tissue formation. These include of epidermal growth factor receptor inhibitor (EGFR-I), PDGF-I, and VEGF-I. Novel exogenous growth factor delivery systems are currently under development to transport, deliver, and regulate the precise timing and location of growth factors needed for the efficient and safe utilization of growth factors in regenerative therapies in medical settings, as well as to counteract the impact of natural growth factor inhibitors(42).

This may emphasis our results why the LLLT exceed the PRF Group in day fourth in granulation tissue formed this result was in different with result show by Kemal et al 2020 that show the growth factor exceed the LLLT in GT formation.

The conventional therapy group I required more than 7 days to reach the healing phase of group II PRF treated socket and group III LLLT-exposed socket, as shown by the comparison of healing rates in this study (p < 0.05). When comparing the healing rates of Platelet-Rich Fibrin (PRF) and Low-Level Laser Therapy (LLLT). The PRF treated socket outperformed LLLT in achieving a 75% greater granulation tissue and full pain elimination by day 7 (p = 0.001).

there are many limitation of the study such as small sample size, no finding of histological study to recorded precisely the amount and number of cells formed, also we need further study on effect of LLLT according type, dose, power. Also the followed up of the study was more difficult especially after 7 days. but from another hand the PRF was less expensive and easy to prepare.

A dry socket can result in considerable pain and discomfort for normally healthy patients after a routine tooth extraction. The standard treatment, which includes thorough scraping and rinsing, often leads to slow healing. However, platelet-rich fibrin (PRF) and low-level laser therapy (LLLT) have been discovered to speed up the production of granulation tissue and offer pain relief.

The recommendation for future studies is to include a larger sample size and histological study to determine the quality and quantity of granulation tissue formed in the socket, and to detect the effect of platelet-rich fibrin (PRF) and low-level laser therapy (LLLT) on the new bone density formed in the socket

Author contributions

Author Contributions: Conceptualization, K.M. and E.M.; methodology, K.M. and E.M; software, K.M.; validation, K.M, E.M.,M.M.A and A.C.; formal analysis, A.C.; investigation, A.C.; resources, M.M.A.; data curation, E.M.; writing—original draft preparation, K.M.; writing—review and editing, E.M.; visualization, K.M; supervision, E.M.; project administration, K.M. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data availability

The data from the present study can be obtained upon reasonable request from the corresponding author.

Ethics approval and consent to participate

Human Ethics, approval was obtained from the Research Ethics Committee, University of Al-Ameed (number: UAM/EC/5/2017 ). The Universal Trial Number (UTN) is U1111-1310-8832

Consent for publication

Not applicable.

Informed consent

Not applicable.

Competing interests

The authors declare no competing interests.

Conflict of interest

The authors declare no conflicts of interest.

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Picture 1 and 2 are available in the Supplementary Files section.

Diagram 1 and 2 are available in the Supplementary Files section.

No competing interests reported.

supplementRecovered.docx
1.png
Picture 1 . A. Elexxion laser (diode ,808nm); B. during irradiated the socket.
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Picture 2 shows the measurement of socket depth Fig 2.WHO Periodontal probe
3.png
Diagram 1: The age differences between the groups (ns) represent the non-significant.
4.png
Diagram 2. The socket depth differences between the groups in 4 day
Tabels.docx

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Evaluation of the effect of platelet rich fibrin and low level laser therapy (LLLT) on treatment of alveolar osteitis (blinded comparative clinical study)

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