We read with great interest the paper by Gülnahar et al. regarding oxidative stress (OS) after third molar surgery, as measured with heat shock protein 70 (HSP70). We would like to comment on some of the concepts outlined by the authors in their paper.

First, the piezoelectric surgery device has been in use in third molar surgery for many years and has proven utility in preserving the inferior alveolar nerve and in reducing swelling and the use of analgesics. However, for an accurate osteotomy, this technique requires more time as compared to the use of a bur; time is a critical variable that needs to be taken into consideration, particularly when using local anaesthesia and/or with anxious patients.

Prior observations from our group have focused mainly on the role of OS in third molar surgery. Gülnahar et al. report that mechanical stress may cause OS at alveolar bone and in the surrounding tissues, and they expect to find greater values of HSP70 and OS with greater mechanical stress, i.e. with the bur. However, the authors do not take into consideration that OS is generated physiologically in vivo, and levels depend greatly on individual factors, such as prior pathologies, concomitant allergies, and even pollution or hormones.

Gülnahar et al. described 13 female patients, excluding breastfeeding mothers, but did not provide information on pregnancy, menopausal women, or phases of the menstrual cycle. Individual OS values should be measured before surgery and the increase in rate should be the variable for analysis. Further, different preoperative OS levels, as measured in peri-coronal soft tissues, are related to different postoperative outcomes, thus generating a gender dimorphism.

The OS status is basically not equal in all individuals, and HSP70 is not the most common marker to measure it; isoprostanes are the most reliable markers of OS in vivo.

Therefore more studies are needed in order to investigate the preoperative status of alveolar bone and surrounding tissues, such as the gingival soft tissues, and its involvement in the postoperative outcome.