[Alveolitis: review of the literature]

Alveolitis are infectious complications following the dental extraction. They appear under two forms: dry, characterized by a painful syndrome and uninhabited alveolus, and suppurative, which becomes identified by provoked pain and alveolus filled. Their etiopathogenesis remain a subject of interrogation because of the rarity of studies concerning this complication. Nevertheless, treatment is mainly favorable by a sedation of the pain and the startup of a physiological healing. From this article, we are going to review their clinical forms, their etiology as well as the followed treatment.

Does chlorhexidine prevent dry socket?

DATA SOURCES

The BBO (Bibliografia Brasileira de Odontologia), Biomed Central, Cochrane Library, Directory of Open Access Journals, LILACS, Open-J-Gate, OpenSIGLE, PubMed, Sabinet and Science-Direct databases were searched.

STUDY SELECTION

Articles were selected for review from the search results on the basis of their compliance with the broad inclusion criteria: relevant to the review question; and prospective two-arm (or more) clinical study. The primary outcome measure was the incidence of AO reported at the patient level.

DATA EXTRACTION AND SYNTHESIS

Two reviewers (VY and SM) independently extracted data and assessed the quality of the accepted articles. Individual dichotomous datasets for the control and test group were extracted from each article. Where possible, missing data were calculated from information given in the text or tables. In addition, authors were contacted in order to obtain missing information. Datasets were assessed for their clinical and methodological heterogeneity following Cochrane guidelines. Meta-analysis was conducted with homogeneous datasets. Publication bias was assessed by use of a funnel plot and Egger's regression.

RESULTS

Ten randomised trials were included; almost all involved the removal of third molars. Only two of six identified application protocols (single application of chlorhexidine 0.2% gel or multiple application of 0.12% rinse versus placebo) were found to significantly decrease the incidence of AO.

CONCLUSIONS

Within the limitations of this review, only two of six identified application protocols were found to significantly decrease the incidence of AO. The evidence for both protocols is weak and may be challenged on the grounds of high risk of selection, detection/performance and attrition bias. This systematic review could not identify sufficient evidence supporting the use of chlorhexidine for the prevention of AO. Chlorhexidine seems not to cause any significantly higher adverse reactions than placebo. Future high-quality randomised control trials are needed to provide conclusive evidence on this topic.

The management of dry socket/alveolar osteitis

Dry socket/alveolar osteitis is a very debilitating, severely painful but relatively common complication following dental extractions. Its incidence is approximately 3% for all routine extractions and can reach over 30% for impacted mandibular third molars. A number of methods have been suggested in the literature as to how this condition may be prevented and managed. Most of these suggestions are empirical and not evidence based. This paper is a review of the literature on dry socket. The results of an audit carried out in the Dublin Dental School and Hospital are also presented and a suggestion is made as to how best this painful condition may be managed. Our audit showed that a wide range of treatments are being used in the treatment of dry socket: rinsing of the socket with chlorhexidine (74%) or saline (26%); placement of a non-resorbable obtundant dressing (56%); and, instruction in home rinsing of the socket with chlorhexidine (44%). This condition is one of the most examined topics in dentistry and is currently being researched in the Dublin Dental School and Hospital. Over the years little progress has been made in establishing firm conclusions as to how best dry socket should be managed. Our recommendations are based on a review of the literature, being the best available evidence on which to base our clinical practice.

A consensus conference on management of the lower third molar. Italian Society of Odontostomatological Surgery

During the first Congress of the Italian University Schools of Oral Surgery, held in Rome on 18-20th February, 2010, a task force was convened by the Italian Society of Odontostomatological Surgery (SIdCO) to summarize the data collected from the current literature on selected aspects relating to the mandibular third molar and its removal. The task of the Conference Participants was to review and analyze the pertinent literature and to elaborate conclusive recommendations for the management of the lower third molar. The statements made and the recommendations presented represent the consensus of the Conference, which can be considered the official statement of the SIdCO.

The cyclooxygenase-2 inhibitor celecoxib and alveolar osteitis

PURPOSE OF THE STUDY

The purpose of this study was to report our clinical experience, in a pilot study, of the use of the selective cyclooxygenase-2 (COX-2) inhibitor celecoxib, pre-emptively, to control pain in patients after surgical extraction of a mandibular molar tooth.

PATIENT AND METHODS

This randomised, double-blind, placebo-controlled, prospective clinical trial was conducted over an eight-month period. Participants were randomly allocated to receive a standard oral dose of 200 mg celecoxib, 400 mg ibuprofen, or a placebo containing lactose, pre-emptively, one hour before surgery. Each patient was prescribed amoxycillin 500 mg three times per day postoperatively for seven days. The participants were given standardised participant information sheets, and written informed consent was subsequently obtained from the participants prior to the commencement of the study.

RESULTS

The results showed that 13% of the patients who had ibuprofen had severe pain two to three days postoperatively. This was diagnosed as alveolar osteitis, which is in line with the universally accepted outcome for the surgical extraction of mandibular molar teeth. Statistical analysis (Chi-square test) confirmed that the ibuprufen group had a significantly higher alveolar osteitis incidence than the celecoxib group (p < or = 0.05) and the placebo group (p < or = 0.05).

CONCLUSION

This is the first reported study to demonstrate that the use of celecoxib resulted in a significant decrease in the occurrence of alveolar osteitis.

Can flap design influence the incidence of alveolar osteitis following removal of impacted mandibular third molars?

This study sought to evaluate the influence of flap design (that is, modified triangular flap or buccal envelope flap) on alveolar osteitis (AO) and on healing following the surgical removal of an impacted mandibular third molar. A double-blind split-mouth clinical trial examined 17 patients who were candidates for extraction of a bilaterally impacted mandibular third molar with the same difficulty index; a modified triangular flap was placed on one side and a buccal envelope flap (control) was placed on the other side. AO and healing were assessed at three and seven days after surgery. Data were analyzed with the McNemar and Wilcoxon signed-rank tests. The modified triangular flap decreased the incidence of AO and expedited healing at seven days postsurgery. In addition, statistically significant differences were observed in terms of both AO and postoperative healing.

Chlorhexidine in the prevention of dry socket: effectiveness of different dosage forms and regimens

Dry socket (DS) is a potential postoperative complication of dental extractions. It is clinically diagnosed by the presence of a denuded socket secondary to premature loss of the blood clot, and manifests as slight discomfort for the patient, followed by sudden worsening with intense or lancing pain. Since the underlying etiology is not clear, the best treatment is prevention. Chlorhexidine (CHX) is an antiseptic that acts upon the bacteria of the oral cavity, and is widely used in dental practice.

OBJECTIVES

A metaanalysis is made of the different CHX treatment regimens used for the prevention of DS, with the proposal of a management protocol designed to maximize the efficacy of such treatment.

MATERIAL AND METHODS

Literature searches were made in the PubMed Medline, Cochrane and ISI Web of Knowledge databases, crossing the terms: alveolar osteitis, dry socket and chlorhexidine. The search was limited to randomized or nonrandomized clinical trials.

RESULTS

Twelve clinical trials using CHX in rinse or gel form at doses of 0.12% or 0.2% with different administration regimens for the prevention of DS were identified.

CONCLUSION

After reviewing the existing medical literature, it can be concluded that 0.2% CHX gel, applied every 12 hours for 7 days after extraction is the best available option for the prevention of DS. However, this is also the most expensive option, and since CHX is not subsidized by the Spanish public healthcare system, it occasionally may be more advisable to use the 0.12% rinse with the same dosing regimen.

[Lincomycin applied to the alveolus on TCP carrier and its effect on wound healing after surgical extraction of a third molar]

INTRODUCTION

The dental surgeon is often confronted by complications particularly after extraction ofunerupted lower third molars. The most common complication is alveolar periostitis. The healing process after extraction is accompanied by physiologic atrophy of the alveolus involving on the average 30% of bone tissue. Beta-tricalcium phosphate (TCP) is a synthetic material used in medicine to fill up bone defects caused by pathologic processes. The properties of TCP are appropriate for the material to be used as a carrier for drugs, in particular antibiotics. This study was undertaken to determine whether lincomycin applied to the alveolus on TCP carrier can be used to accelerate wound healing and reduce inflammation after surgical extraction of a third molar.

MATERIALS AND METHODS

We enrolled 80 patients (males and females between the age of 18 and 50 years) who underwent extraction of a third molar at the Department of Dental Surgery, Pomeranian Medical University in Szczecin. Surgical difficulty in the patients according to the Pederson scale corresponded to grade 2 or 3 (medium or high difficulty). The study group consisted of 40 patients who received lincomycin on TCP. Beta-tricalcium phosphate (300-700 microm pores) obtained from the Department of Technology of Ceramics and Refractories, AGH University of Science and Technology in Cracow, was soaked with 500 mg of lincomycin in solution and applied to the dental alveolus after tooth extraction. The alveolus was tightly sutured. The control group comprised 40 patients not treated with lincomycin. The patients reappeared for examination on the first, third, and seventh day after surgery. Attention during follow-up was directed to alveolar periostitis, pain, and trismus. Pain intensity was assessed with the 10-degree Visual Analog Scale (VAS).

RESULTS

We analyzed the subjective pain intensity reported during follow-up by the patients. In the study group, 20 patients reported no pain 24 hours after extraction. On the third day after surgery, alveolar periostitis was present in 15% of patients in the study group and 75% of patients in the control group. On the last day of follow-up, periostitis was present in only 2.5% of patients in the study group as opposed to 45% of patients in the control group. The differences were statistically significant (chi-square 36.05, p < 0.0001).

CONCLUSIONS

(1) Lincomycin on TCP can be used to prevent alveolar periostitis. (2) Lincomycin on TCP reduces complications in the form of pain and trismus. (3) Beta-tricalcium phosphate prevents atrophy of the alveolar process.

Effectiveness of antibiotic prophylaxis in third molar surgery: a meta-analysis of randomized controlled clinical trials

PURPOSE

We conducted a synthetic quantitative review of the published clinical trials on the effectiveness of antibiotic prophylaxis in third molar surgery.

MATERIALS AND METHODS

Electronic databases were searched for randomized controlled trials. The primary outcome variables included alveolar osteitis (AO) and surgical wound infection. The extracted data were analyzed using a meta-analytical program with a random-effect model. Number needed to treat (NnT) was calculated.

RESULTS

A total of 2,932 patients randomized in 16 clinical trials reported AO as an outcome. AO occurred in 84 of 1,350 patients in the treatment group, a frequency of 6.2%; and in 228 of 1,582 patients in the control group, a frequency of 14.4%. Systemic antibiotic therapy was effective in reducing the risk of AO (odds ratio [OR], 2.175) with an NnT of 13. A total of 2,396 patients randomized in 12 clinical trials reported wound infection as an outcome. Wound infection occurred in 44 of 1,110 patients in the treatment group, a frequency of 4%; and in 78 of 1,286 patients in the control group, a frequency of 6.1%. Systemic antibiotic therapy was effective in reducing the risk of wound infection (OR, 1.794) with an NnT of 25. Antibiotics reduced the risk of AO and wound infection only when first dose was given before surgery.

CONCLUSIONS

Systemic antibiotics given before the surgery were effective in reducing the frequencies of AO and wound infection after third molar surgery.

Inhibition of Alveolar Osteitis in Mandibular Tooth Extraction Sites Using Platelet-Rich Plasma

Alveolar osteitis (AO), also known as dry socket, continues to be a complication of tooth removal. Platelet-rich plasma (PRP) can be used to accelerate both soft and hard tissue healing. This paper is a retrospective review of the benefits of PRP in AO prevention. PRP was obtained from patients for use in the postremoval alveolar sockets of mandibular molar extraction sites. Statistical analysis of 904 extraction sites with and without PRP use was examined. PRP significantly reduced the incidence of AO by 62.1%, from 9.57% in patients not receiving PRP to 3.63% in patients who received PRP (P = .00043). PRP use had benefits in all subpopulations. The odds of AO occurring in patients not receiving PRP treatment following tooth extraction was 2.81 times greater than in patients receiving PRP treatment immediately following tooth extraction. Four statistically significant risk factors for AO were identified: complete impaction, oral contraceptive use, bruxism, and failure to administer PRP. The application of PRP can significantly reduce the incidence of AO even in patients with risk factors for AO, such as removal of impacted teeth, bruxism, and oral contraceptive use. PRP may be of benefit because it helps initiate clot formation, provides growth factors to facilitate the healing process, and contains concentrated white blood cells to inhibit infection. The use of PRP following tooth extraction is a simple, cost-effective technique that can be used to decrease the incidence of AO and therefore decrease postoperative pain.

Single-dose and multi-dose clindamycin therapy fails to demonstrate efficacy in preventing infectious and inflammatory complications in third molar surgery

The goal of this study was to evaluate the efficacy of single- and multi-dose (5-day) clindamycin therapy for the prevention of inflammatory complications in patients undergoing lower third molar surgical extraction with bone removal. Patients who qualified for the prospective, randomized, double-masked, placebo-controlled trial were randomly divided into three groups: (1) single dose of oral clindamycin administered preoperatively (single-dose group); (2) clindamycin administered preoperatively with continued therapy for 5 days (5-day group); and (3) a placebo group. The following parameters were evaluated on the first, second and seventh days postsurgery: trismus, facial swelling, body temperature, lymphadenopathy, alveolar osteitis and subjective pain sensations. There were 86 patients (31 in the single-dose group, 28 in the 5-day group and 27 in the placebo group) enrolled in the study. There were no statistically significant differences in postoperative inflammatory complications in patients during the first and second days postsurgery. A statistically significant variation in body temperature was reported on the seventh day. Analysis of the postoperative analgesic intake did not show statistically significant differences between examined groups. Clindamycin applied in a single preoperative dose of 600 mg with or without subsequent 5-day therapy does not demonstrate efficacy in prophylaxis for postoperative inflammatory complications after third molar surgery.

Prevention of alveolar osteitis with azithromycin in women according to use of tobacco and oral contraceptives

OBJECTIVE

To evaluate the efficacy and tolerance of azithromycin in the prevention of post-extraction alveolar osteitis (dry socket) in women according to their use of tobacco and oral contraceptives.

METHOD AND MATERIALS

A clinical trial was conducted in 400 women who underwent tooth extraction, stratified into 4 risk groups according to their use of tobacco (yes/no) and oral contraceptives (yes/no). Each stratum (n = 100) was randomly divided into 2 groups: a study group that received azithromycin 500 mg once daily for 3 days after extraction and a control group that received physiologic saline 3 times daily from 24 hours after extraction for 7 days.

RESULTS

Azithromycin was significantly superior to conventional postextraction treatment with physiologic saline. There were no significant interactions with the use of either tobacco or oral contraceptives, and these variables had no confounding effects.

CONCLUSION

Azithromycin is a safe and efficacious treatment for the prevention of dry socket in women.

Does prophylactic administration of systemic antibiotics prevent postoperative inflammatory complications after third molar surgery?

PURPOSE

To estimate and compare the frequencies of inflammatory complications after third molar (M3) surgery in subjects receiving intravenous prophylactic antibiotics or saline placebo.

MATERIALS AND METHODS

Using a placebo-controlled, double-blind, randomized clinical trial, the investigators enrolled a sample composed of subjects who required extraction of at least 1 impacted M3 and requested intravenous sedation or general anesthesia. The predictor variable was treatment group classified as active treatment (penicillin or clindamycin for penicillin-allergic subjects) or placebo (0.9% saline). Study medications were randomly assigned. Both surgeon and subject were blinded to treatment assignment. The medication was administered intravenously prior to any incision. The outcome variable was postoperative inflammatory complication classified as present or absent and included alveolar osteitis (AO) or surgical site infection (SSI). Other variables were demographic, anatomic, or operative. Descriptive and bivariate statistics were computed. Statistical significance was set at P < or = .05, single-tailed test of hypothesis.

RESULTS

The sample was composed of 118 subjects (n = 59 per study group). In the active treatment group, there were no postoperative inflammatory complications. In the placebo group, 5 subjects (8.5%) were diagnosed with SSI, (P = .03). No subject met the case definition for AO. All SSIs were associated with the removal of partial bony or full bony impacted mandibular M3s.

CONCLUSION

In the setting of third molar removal, these results suggest that the use of intravenous antibiotics administered prophylactically decrease the frequency of SSIs. The authors cannot comment on the efficacy of intravenous antibiotics in comparison to other antibacterial treatment regimens, eg chlorhexidine mouthrinse or intrasocket antibiotics.

Effect estimates and methodological quality of randomized controlled trials about prevention of alveolar osteitis following tooth extraction: a systematic review

OBJECTIVE

To systematically review the scientific evidence derived from randomized controlled trials (RCT) about prevention of alveolar osteitis (AO).

STUDY DESIGN

Literature searches were conducted to locate RCTs about prevention of AO. The RCTs were scrutinized for methodological details and categorized according to the preventive intervention studied. Data were analyzed in relation to the frequency of AO. Absolute risk reductions (ARR), and numbers needed to treat were calculated with 95% confidence limits.

RESULTS

There was a wide variation in the design and quality of the RCTs (N = 32). The greatest risk reduction for AO was seen for local treatment with tetracycline (ARR, 12%-31%). For a majority of the preventive interventions, the evidence was absent or inconclusive.

CONCLUSIONS

Local treatment with tetracycline, and also 0.12% chlorhexidine rinsing preoperatively and 7 days postoperatively, seem to have significant and clinically relevant preventive effect on AO following surgical removal of lower third molars.

Comparison of two chlorhexidine rinse protocols on the incidence of alveolar osteitis following the surgical removal of impacted third molars

PRINCIPLES

Alveolar osteitis (dry socket) is the most common complication following the extraction of permanent teeth. This study was undertaken to compare the effect of two chlorhexidine rinse protocols on the incidence of alveolar osteitis in patients undergoing surgical removal of impacted mandibular third molar teeth.

METHODS

A prospective randomized clinical trial was conducted among 99 subjects. Patients were randomly assigned into two groups. Subjects were instructed to rinse twice daily with 15 ml of chlorhexidine rinse 30 seconds for one week before and one week after surgery (group I) or one week after surgery (group II). Postoperatively, all patients were instructed to return in one week or sooner if bothersome pain increased or persisted. Data were collected regarding abnormal healing, presence of necrotic tissue, exposed bone, and absence of clot.

RESULTS

The results indicated group I and group II were not statistically significant different in the reduction of alveolar osteitis.

CONCLUSIONS

To reduce alveolar osteitis after impacted third molar surgery, it was observed use of postoperative chlorhexidine rinse was adequate. The postoperative use of chlorhexidine is more feasible than both preoperative and postoperative use.

Influence of Surgicel gauze on the incidence of dry socket after wisdom tooth extraction

At a hospital in Damman, Saudi Arabia, it was noticed that many patients had developed dry socket after surgical removal of wisdom teeth. To enhance haemostasis, Surgicel (oxidized cellulose) gauze was sometimes used in the tooth socket in patients who were operated under general anaesthesia. An analysis was made of the records of 104 lower wisdom teeth removed surgically from 86 patients. The incidence of dry socket in the 20 Surgicel-treated teeth was 25.0%, compared with 6.0% among the 84 non-Surgicel-treated teeth. The use of Surgicel in wisdom tooth extraction seems to be associated with an increased incidence of dry socket.

Post-operative sequelae of lower third molar removal: a literature review and pilot study on the effect of Covomycin D

Pain, swelling and dry socket formation commonly follow third molar surgery. The objective was to investigate the effect of intrasocket Covomycin D, an antibiotic/anti-inflammatory medication, on pain, swelling and dry socket following lower third molar removal. Nineteen subjects had bilateral lower third molars removed. The patients were blinded to the side of medication; the opposite side acted as the control; post-operatively a pain visual analogue scale was completed, the side of the worst swelling and the incidence of dry socket noted. The data was analysed using the Wilcoxons matched pairs signed ranks test. Results showed that the pain score was lower for the medicated side in 11 patients on day one and in 16 patients over the six day post-operative period (p < 0.6). The swelling was less on the medicated side in fourteen patients. Three dry sockets developed in non-medicated sockets. In conclusion this study shows that the use of intra-socket Covomycin D favourably influences post-operative sequelae following lower third molar removal.

The prevention of 'dry socket' with topical metronidazole in general dental practice

OBJECTIVE

The purpose of the study was to determine if the intra-alveolar application of topical metronidazole gel could reduce the incidence of alveolar osteitis (dry socket) following routine tooth extraction in molar and premolar extraction sites.

DESIGN

This was a multicentre, double blind, randomised, placebo-controlled clinical trial. A total of 302 patients took part, of which 23 returned with alveolar osteitis. Of these, eight had received the metronidazole gel and 15 the placebo.

SETTING

The study was carried out in three general dental practices by general dental practitioners working in England over the period 2000-2003.

MAIN OUTCOME MEASURES

Following extraction of either a molar or premolar tooth, either a 25% metronidazole gel or KY Jelly was syringed gently into the socket. A painful post operative complication was recorded if either a dry socket was present or the patient returned with pain.

RESULTS AND CONCLUSIONS

The difference in the incidence of alveolar osteitis between the placebo and the active gel groups was not significant and it was concluded that 25% topical metronidazole gel was not effective in reducing the incidence of alveolar osteitis. It was found that the incidence of alveolar osteitis reduced with increasing age and was more likely to occur in a patient with a previous history of the condition.

Intra-alveolar chlorhexidine gel for the prevention of dry socket in mandibular third molar surgery. A pilot study

PURPOSE

Chlorhexidine is a good prophylactic agent for post-extraction dry socket alveolitis. The bio-adhesive 0.2% chlorhexidine gel could improve this action since its intra-alveolar positioning would allow a more direct action on the alveolus and more prolonged action of the medication.

MATERIALS AND METHOD

We present a single blind, randomised study on 30 patients to evaluate the efficacy of the bio-adhesive 0.2% chlorhexidine gel, placed only once within the alveolus, on the reduction of the incidence of impacted third molar post-extraction dry socket alveolitis and its post-operative effects on patients.

RESULTS

A reduction of 42.65% in the occurrence of alveolitis and a more favourable post-operative period in the experimental group was observed. In the control group, the appearance of alveolitis was 30.76% opposite to 17.64 % in the experimental group.

CONCLUSIONS

The bio-adhesive 0.2% chlorhexidine gel, applied only once after the extraction of impacted third molars, seems to be an appropriate option for the reduction of alveolitis. It improves the buccal aperture and oedema in the post-operative period, although further double blind studies with larger samples are necessary.

Prevention of alveolar osteitis with chlorhexidine: A meta-analytic review

OBJECTIVE

The objective of this study was to assess if chlorhexidine (CHX) rinse decreases the occurrence of alveolar osteitis (AO) following third molar removal.

STUDY DESIGN

A literature search identified 7 randomized prospective clinical trials reporting incidence of AO following removal of mandibular third molars. Studies were combined into 2 groups and summary relative risks were calculated for each group. One group of studies evaluated rinsing on the day of surgery only and the second group of studies rinsed at least on the day of surgery and several days after surgery.

RESULTS

The relative risk for the single rinse group was 1.36 (95% confidence interval [CI] 0.80, 2.33), P>.05, whereas for the multiple rinse group, the relative risk was 1.90 (95% CI 1.46, 2.47), P<.05.

CONCLUSION

Rinsing with CHX on the day of surgery and several days after may reduce the incidence of AO.