Electro-surgery versus Conventional Surgery for Excision of Pericoronal flaps

Headnote

Abstract

Aim: The purpose of this study was to compare and evaluate the efficacy of electro-surgery as an alternative to conventional surgery for the treatment of pericoronal flaps.

Material and methods: This split mouth randomized, single blind, clinical study was carried out on 10 patients who needed bilateral operculectomy. Pericoronal flap was removed in the test group using the electrosurgical technique, and in the control group conventional surgery was used. Clinical parameters such as time needed to remove the pericoronal flap, patient comfort, pain, edema/inflammation, mouth opening and wound healing were assessed and compared between the 2 groups.

Results: The results of this study indicate that there was a significant difference between conventional surgery and electro- surgical techniques in terms of time, hemostasis, patient comfort, pain, edema and wound healing. The test group showed signi- ficantly better results than the control group.

Conclusion: When used correctly, electro-surgery offers a safe, effective, acceptable, and impressive alternative for excision of pericoronal flaps.

Keywords: Pericoronal flap; electro-surgery; conventional surgery.

Introduction

Pericoronitis is a common problem in young adults with partial tooth impactions. It usually occurs within 17 to 24 years of age, as it is when the third molars start erupting.1 It was first reported by Gunnel in 1844 as "painful affection. " The term pericoronitis was first introduced to dental liter- ature by Bloch in 1921.2 It results from a bacterial infection caused either by staphylococcal or streptococcal bacteria, or both.3 This condition is often brought on when there is accumulation of plaque and calculus or food particles trap- ped in surrounding gingival tissues. Poor oral hygiene and mechanical trauma from the opposing tooth can exacerbate the inflammation. It can be impossible to effectively brash the necessary area and prevent this from occurring due to a partially erupted tooth.

Pericoronitis has an average of 8% incidence associated with wisdom teeth.4 Pericoronitis classically presents with a history of acute pain along with swelling of the perico- ronal tissues, and quite often tenderness on closing because of the occlusion of the swollen tissue with the opposing tooth. Occasionally there is facial swelling, Ludwig's angi- na, along with some maxillary and cervical lymph gland involvement. Quite often the area may be the site of super- imposed acute necrotising ulcerative gingivitis. Acute per- icoronitis is treated by local antiseptic lavage and gentle curettage under the flap, with or without systemic antibio- tics. Once the acute phase is controlled, the offending mo- lar is extracted or a wedge of hyperplastic pad tissue is rem- oved surgically.5

3 established methods of cutting oral soft tissue in dentistry are conventional surgery, electro-surgery and use of lasers. Each of these methods works well; however, they are diff- erent from the standpoints of hemostasis, healing time, wi- dth of the cut, anesthetic required and disagreeable charac- teristics, such as smoke production, odor of burning flesh and undesirable taste.6

Since 1914, electro-surgery has been used routinely in var- ious aspects of medicine, including dentistry. Electrosurg- ery involves the intentional passage of high frequency waveforms or currents, through the tissues of the body to achieve a controllable surgical effect. By varying the mode of application of this type of current, the clinician can use electro-surgery for cutting or coagulating soft tissues. The electro-surgery equipment, if used for such procedures, minimizes bleeding and most patients experience very litt- le post-operative pain after the procedure.6

Currents used in oral electro-surgery are fully rectified filt- ered (usually called "cut" or "filtered" on the devices), fully rectified (usually called "coagulate," "coagulate/cut," "co- agulate/hemostasis" or "unfiltered" on the devices) or part- ially rectified (usually called "coagulate" or "fulgurate" de- vices).7

Cutting mode involves the generator producing a continu- ous output, while coagulation mode involves a pulsed out- put. The blend facility only functions when in cutting mode and allows a combination of cutting and coagulation to inc- rease the degree of hemostasis during cutting. While using the cutting mode, the passage of current into tissue cause cellular fluid to turn into steam, bursting cell wall and disr- upting the structure.8 Excision of soft tissue with a scalpel results in excessive bleeding which obscures the operative field and increases the fear of surgery.9

In this study we employed electro-surgery, with the objec- tive of comparing and evaluating the efficacy of electro- surgery as an alternative to conventional surgery in the tre- atment of pericoronal flaps.

Material and methods

This split mouth randomized, single blind, clinical study was carried out in the Department of Periodontology and Oral Implantology, I.T.S-CDSR, Muradnagar, Ghaziabad, U.R The study protocol had been reviewed and approved by the Ethical committee. A single examiner performed all the clinical measurements to reduce inter examiner bias.

Individuals with radiographically fully erupted third mola- rs (confirmed on an IOPAradiograph), which were proper- ly aligned in the arch, having opposite tooth present, and showing signs and symptoms of pericoronitis were recrui- ted. Exclusion criteria included impacted teeth, buccally erupted teeth, caries, subjects who had taken any antibiotic treatment in the last 2 months, and pregnant and lactating mothers. All subjects were required to provide a written informed consent for participation in the study.

15 subj ects were randomly selected. 5 patients opted out of the study for personal reasons. Remaining 10 subjects who needed bilateral operculectomy were enrolled. In each sub- ject, the sites were randomly assigned into control and test groups of 10 each by the toss of a coin. One side ofthe man- dible served as control: pericoronal flap treated with conv- entional surgery and the opposite side as test: pericoronal flap treated with electro-surgery.

Prior to excision of pericoronal flap, occlusal analysis was performed in the patients and on patient casts to determine if the opposing tooth was occluding with the flap. Curett- age under the flap was done and the area was flushed with warm water to remove the debris and exudate. Antibiotics were prescribed. Patients were reviewed after a period of 1 week. Pericoronal flap excision was performed after the acute symptoms had subsided.

Clinical characteristics

The parameters assessed at the time of surgery were :

1 ) Time needed to remove the pericoronal flap, measured in minutes as the time taken for performing operculectomy, after achieving anesthesia.

2) Patient comfort: All subjects were asked about the pres- ence of discomfort with both the procedures, which was recorded as present and absent after the surgery.

3 ) Pain was recorded on 0-10 numerical rating scale- VAS.

4) Edema/inflammation was observed as per by the 3 point general observation scale used by an oral surgeon to assess swelling associated with gingivitis.10

5) Submandibular nodes were palpated by pulling or rolli- ng the tissues under the chin up and over the inferior border of the mandible and were recorded as palpable or non pal- pable.

6) Mouth opening: Graduated scale in millimeters and 3 fi- nger insertion technique was used to measure the inter inc- isal distance between the upper and lower central incisors. Pain, edema/inflammation, sub-mandibular lymph nodes and mouth opening were also assessed at 3rd, 701 and 2131 day post operatively. Lobene's Wound healing score was recor- ded to reflect the extent of healing at the surgical site at 3 rd, 7th and 2131 day post-operatively.11

In the test group, the site was anesthetized and the resection of pericoronal flap was performed employing needle and loop electrodes. The electrodes were used in light brushing strokes and the tip was kept in motion all the time. A cutting and coagulating current in the range of 1.5 to 7.5 megahertz was used and a repeated or prolonged application of curr- ent and entry into deep tissue was avoided to prevent unde- sired tissue destruction. The incision edges were sealed by the current. Suction was used to remove the unpleasant od- our. Burnt tissue was removed with moist gauze.

In the control group following local anesthesia, the resec- tion of pericoronal flap was performed with a No. 15 blade. Any remaining tissue tags were removed with the Castro- viejo scissors. Hemostasis was obtained with sterile gauze and by applying direct pressure.

Post-surgical instructions: Subjects were advised to take Paracetamol if they had discomfort after the effects of ane- sthesia wore off. They were instructed to avoid hot food for 24 hours and smoking. All subjects were advised to rinse twice a day with a 0.2% Chlorhexidine gluconate solution for 2 weeks.

Results

The results were analysed using a Mann Whitney U test and student t-test. Table 1 shows that the mean time taken to remove the flap was significantly higher in control group as compared to the test group (p < 0.001). In both groups, time needed for achieving anesthesia was not included. Pa- tient discomfort associated with electro-surgery and conv- entional surgery was observed in 20% of test group and 90 % of control group subjects, thus showing a significant dif- ference (p = 0.009).

In Table 2, at baseline, no significant difference between 2 groups was observed. At the examination 3rd and 7th days post-operatively, the mean pain score in test group was sig- nificantly lower (p = 0.001) and mean edema score on day 7, was significantly lower (p= 0.028) as compared to that in control groups. A gradual decrease was observed from bas- eline till day 7, whereas in control group no change was observed between baselines to day 7 in case of lymph no- des palpation. Clinical re-examination of the subjects on day 21 post-operatively did not reveal any meaningful diff- erences between test and control groups. The mean pain, edema and wound healing scores were 0 and all the lymph nodes were non-palpable. In both the groups, all the subje- cts had adequate mouth opening at all time intervals. At 3rd day, the difference between the 2 groups was not signific- ant but at day 7, the mean wound healing score of test group was significantly lower as compared to control group, thus showing better healing (p=0.029) (Table 2,3).

Discussion

Pericoronitis is an inflammatory and infective condition of the soft tissue contiguous to and overlying a tooth crown, most frequently encountered in the mandibular third mola- rs. Females are significantly more affected than males, par- ticularly in the younger age groups because pericoronitis attacks coincide with the pre-menstrual and immediate post-menstrual periods. Greater number of pregnant wom- en develop pericoronitis during the second trimester. Emo- tional or physical stress are important factors in the patho- genesis of pericoronitis. Stress has been found to lessen salivary flow, which in turn reduces the mechanical or che- mical debridement by saliva and normal lubrication of sali- va. This may result in increased susceptibility to plaque accumulation and eventual inflammation.12

The peak levels ofpericoronitis were reported in the month of January to March.13 The higher frequency of pericoro- nitis in these seasons (spring/autumn) may be related to a higher frequency of upper respiratory tract infections, whi- ch weaken the general conditions of patients, thus increas- ing the risk of pericoronitis.14

Electo-cautery is the least frequently used technique in the contemporary dental armamentarium because of the misc- onceptions caused by fear and inadequate knowledge. Ele- ctrosurgery provides homeostasis by coagulation, seals the capillary and lymphatic vessels and permits an adequate contouring of the soft tissues.15 Chau et ah, demostrated that steel scalpel yields greater incision-related blood loss when compared with the electro-surgery blade.16

The speed at which the electrode is passed through tissue could influence histologic and clinical changes. If the elec- trode is repeatedly passed through the tissue, more tissue damage may occur.17 Studies ofwound healing after electr- osurgery excision of gingival tissue compared with conve- ntional periodontal scalpels have yielded conflicting resul- ts. Some investigators reported no significant differences in gingival healing after electro-surgery and conventional surgery.18 Eisenmann et ah, studied the healing process at the cellular level under electron microscope. They showed no differences between steel scalpel and electro-surgery scalpel.19 In a comparative study of electrosurgical and sca- lpel wounds, Nixon et ah, showed delayed healing of elec- trosurgical wounds. But in the present study, clinical wou- nd healing response is better on the 7th day post operatively in case of electro-surgery as compared to scalpel.20Electro- surgical wound had more inflammatory response and more tissue destruction. But in both the wounds the viability of osteoblasts was the same, and there was no increase in the osteoclasts which would indicate that no bone resorption had occurred. This variability between reports of electro- surgery healing can be attributed to differences in the curr- ent wave form, shape, and size, and in the speed of the elec- trode through the tissue.21

Rossein showed that in electro-surgery the wound healing is painless. The current study also demonstrated that pati- ent experiences less post-operative pain in electro-surgery group as compared to the control group.22 Kearns et ah, have indicated that the electro-surgery has significant adv- antages over steel scalpel based on incision time, blood loss, early post-operative pain and analgesia. The results are similar to those seen in the present study.23

When evaluating electro-surgery against conventional sur- gery, sufficient tissue shaping ability and lack of haemorrhage in the operation field with electro-surgery may be considered advantageous. An inherent problem with elect- rosurgery is the foul odour that is produced. However, the use of a high-speed evacuator close to the operation area reduces the odour.

The split-mouth design was an excellent method to deter- mine the clinical relevance of comparison of the 2 techni- ques to remove pericoronal flaps. By comparing the techni- ques within a subject, it minimizes the influence of numer- ous inter-subject factors, such as age, sex, anatomic fact- ors, and bone metabolism, on any differences that may be present.

Conclusion

This study indicated that there was a significant difference between conventional surgery and electro-surgery techniq- ues in terms of time, patient comfort, pain, edema and wou- nd healing, the electro-surgery group showed significantly better results than the control group. The findings of this study support the use of electro-surgery.

References

References

1. Bartzokas CA, Smith GW (eds). Managing Infections: Dec- ision making Options in Clinical Practice. Informa Health Care. 1998;157. ISBN 1859961711.

2. Sangal NC. Pericoronitis: A study of nature and aetiology. J Indian Dent Assoc 1984;56:103-09.

3. Laskaris G. Color Atlas of Oral Diseases. Tíñeme. 2003;176. ISBN 1588901386.

4. Friedman JW. The prophylactic extraction of third molars: a public health hazard. Am J Public Health 2007;97:1554-59.

5. Kieser JB. Periodontics: a practical approach. Chapter 25. Acute periodontal problems. London; Wright Publishing, 1990;393-406.

6. Bashetty K, Nadig G, Kapoor S. Electrosurgery in aesthetic and restorative dentistry: A literature review and case reports. JConserv Dent 2009;12:139-44.

7. Christensen GJ. Soft-Tissue Cutting With Laser versus Elect- rosurgery. J Am Dent Assoc 2008;139:981-84.

8. Sheikh B. Safety and efficacy of electrocautery scalpel utiliz- ation for skin opening in neurosurgery. Br J Neurosirrg 2004; 18:268-72.

9. Awooda EM, Osman B, Yahia AA. Use of Diode Laser (810 nm) inFrenectorny. Sudan JMS 2007;2:45-47.

10. Babbush CA, Kagan D, Madhavi D, Rubido A. The efficacy of Perfect Smile Toothpaste containing Coenzyme QlObeta- Cyclodextrin Inclusion Complex in reducing mild to moder- ate gingivitis. Nat Med J 2010;2:16-20.

11. Lobene RR, Weatherford T, Ross NM, Larnrn RA, Menaker L. A modified gingival index for use in clinical trials. Clin Prev Dent 1986;8:3-6.

12. Ayanbadejo PO, Urnesi-Koleoso DC. A retrospective study of some socio-demograhic factors associated with pericoro- nitis inNigerians.WestAfr J Med2007;26:302-05.

13. Kay LW. Investigations into the nature of pericoronitis. Br J Oral Surg 1966;3:188-205.

14. Owotade F J, Adebiyi KE, Aboderin OA, Fatusi OA, Ogunbo- dede EO, Akuerne O. Is malaria a predisposing factor for third molar Pericoronitis in the tropics? J Infect 2006;53:56-59.

15. Osman FS. Dental electrosurgery: General precautions. Can DentAsso J 1982;48:642.

16. Chau JK, Dzigielewski P, Mlynarek A, Cote DW, Allen H, Harris JR, et al. Steel scalpel versus electrocautery blade: comparison of cosmetic and patient satisfaction outcomes of different incision methods. J Otolaryngol Head Neck Surg 2009;38:427-33.

17. Noble WH, McClatchey KD, Douglass GD. A histologic comparison of effects of electrosurgical resection using diff- erent electrodes. JProsthet Dent 1976;35:575-79.

18. Glickman I, Imber I. Comparison of gingival resection with electro surgery and periodontal knives: A biometric and histo- logical evaluation. J Periodontol 1970;41:142-48.

19. Eisenmann D, Malone WF, Kusek J. Electron microscopic evaluation of electrosurgery. Oral Surg 1970;29:660-65.

20. Nixon KC, Adkins KF, Keys DW. Histological evaluation of effects produced in alveolar bone following gingival incision with an electrosurgery scalpel. J Periodontol 1975;46:40-44.

21. Williams VD. Electrosurgery and wound healing: Areview of the literature. J Am Dent Assoc 1984;108:220-22.

22. Rossein K. Predictable soft tissue management with radio- surgery. Dent Today 2003;22:80-83.

23. Kearns SR, Connolly EM, McNally S, McNamara DA, Dea- sy J. Randomized clinical trial of diathermy versus scalpel incision in elective midline laparotomy. Br J Surg 2001 ;88: 41-44.