A metagenomic study of patients with alveolar osteitis after tooth extraction. A preliminary case-control study

Limosilactobacillus reuteri DSM 17938 Inhibition of Biofilm Formation by Prevotella intermedia and Fusobacterium nucleatum Across Salivary pH: An In Vitro Study

OBJECTIVES

 This study aims to investigate Limosilactobacillus reuteri DSM 17938's antibiofilm effects on Prevotella intermedia and Fusobacterium nucleatum, common causes of alveolar osteitis. It seeks topical alternatives to prevent this condition posttooth extraction. The secondary objective is to assess these effects under different pH conditions (pH 4.5 and pH 7), mimicking oral cavity saliva pH dynamics.

MATERIALS AND METHODS

 Ethical approval was secured for the saliva collection process involving five healthy adult participants who had undergone wisdom tooth extraction. Saliva samples were diligently collected on the 7th day post-surgery. The unstimulated saliva underwent a series of treatments, including the addition of phenylmethylsulfonyl fluoride (PMSF), pH adjustments, centrifugation, and filtration. The pH levels were re-measured, and subsequent adjustments were made to achieve pH values of 4.5 or 7. Limosilactobacillus reuteri DSM 17938, with a concentration of 1×108 colony-forming units (CFU) per 5 drops, was utilized in the study. Biofilm testing involved incubating saliva samples with varying pH (4.5 or 7) alongside bacterial suspensions (Prevotella intermedia, Fusobacterium nucleatum, or a mixed species). The Interlac suspension was introduced, and plates were anaerobically incubated for 24 hours. Biofilm results were obtained using a spectrometer. The test is conducted in triplicate.

STATISTICAL ANALYSIS

 To scrutinize the impact of pH on biofilm development, the acquired data underwent a two-way ANOVA test in SPSS as part of the statistical analysis. A significance level of p<0.05 was used to determine statistical significance.

RESULTS

 Limosilactobacillus reuteri DSM 17938 significantly reduced biofilm formation across bacterial strains (p = 0.000). Statistical analysis indicated a significant impact of pH on biofilm development (p = 0.000) compared to no saliva samples, with higher formation observed under acidic conditions (pH 4.5). However, the pH levels of 4.5 and 7 did not result in significantly different bacterial biofilm formation (p = 0.529).

CONCLUSION

 This research highlights Limosilactobacillus reuteri DSM 17938's potency in inhibiting biofilm formation of Prevotella intermedia and Fusobacterium nucleatum. Salivary pH variations significantly influence biofilm development, emphasizing the need to consider pH when assessing probiotic effectiveness. Despite limitations in saliva sample sterilization, this study provides valuable insights into alternative approaches for preventing alveolar osteitis. Further research should explore clinical applications and refine sterilization methods for more accurate results.

Antibiotic prophylaxis in the prevention of dry socket and surgical site infection after lower third molar extraction: a network meta-analysis

Clinicians frequently prescribe systemic antibiotics after lower third molar extractions to prevent complications such as surgical site infections and dry socket. A systematic review of randomised clinical trials was conducted to compare the risk of dry socket and surgical site infection after the removal of lower third molars with different prophylactic antibiotics. The occurrence of any antibiotic-related adverse event was also analysed. A pairwise and network meta-analysis was performed to establish direct and indirect comparisons of each outcome variable. Sixteen articles involving 2158 patients (2428 lower third molars) were included, and the following antibiotics were analysed: amoxicillin (with and without clavulanic acid), metronidazole, azithromycin, and clindamycin. Pooled results favoured the use of antibiotics to reduce dry socket and surgical site infection after the removal of a lower third molar, with a number needed to treat of 25 and 18, respectively. Although antibiotic prophylaxis was found to significantly reduce the risk of dry socket and surgical site infection in patients undergoing lower third molar extraction, the number of patients needed to treat was high. Thus, clinicians should evaluate the need to prescribe antibiotics taking into consideration the patient's systemic status and the individual risk of developing a postoperative infection.

Local interventions for the management of alveolar osteitis (dry socket)

BACKGROUND

Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012.  OBJECTIVES: To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.

SEARCH METHODS

An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence.

MAIN RESULTS

We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate-certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively.  Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate-certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low-certainty evidence).  The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket  Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low-certainty evidence).  A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) -1.40, 95% CI -1.75 to -1.04; P < 0.00001; 2 studies, 80 participants; very low-certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects.

AUTHORS' CONCLUSIONS

Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate-certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol.

Previous dry socket as a risk factor for alveolar osteitis: A nested case-control study in primary healthcare services

Background

Dry socket is one of the most common complications following tooth extraction, though no studies have been made on its main risk factors in the primary healthcare services of Barcelona (Spain). Objectives: To analyze the influence of different factors upon the appearance of dry socket in patients attended in the primary care setting, and to determine the possible presence of risk factors in patients who have suffered a previous episode of dry socket.

Material and Methods

During 24 months, questionnaires were filled with data on the patients seen in different public primary healthcare services in the area of Barcelona (Spain). A case-control study was conducted to identify the main risk factors for developing complications in the form of dry socket.

Results

A mandibular location of the extracted tooth, poor oral hygiene, difficult extraction, and previous dry socket increased the risk of developing this complication. In patients with dry socket in the past, the risk of developing the same complication again, adjusted for difficulty of extraction, was seen to increase 11.45-fold (OR: 11.45; 95%CI: 1.06 to 123.74; p = 0.045).

Conclusions

The risk factors for dry socket are a mandibular location of the extracted tooth, poor oral hygiene, difficult extraction, and particularly a history of dry socket in the past. The identification of these factors the prevention of dry socket in each patient could be improved.

Key words:Dry socket, risk factors, extraction, complications.

Potential Roles of the Free Salivary Microbiome Dysbiosis in Periodontal Diseases

Saliva is a vital mediator in the oral cavity. The dysbiosis of free bacteria in saliva might be related to the onset, development, prognosis, and recurrence of periodontal diseases, but this potential relationship is still unclear. The objective of this study was to investigate the potential roles of the free salivary microbiome in different periodontal statuses, their reaction to nonsurgical periodontal therapy, and differences between diseased individuals after treatment and healthy persons. We recruited 15 healthy individuals, 15 individuals with gingivitis, and 15 individuals with stage I/II generalized periodontitis. A total of 90 unstimulated whole saliva samples were collected and sequenced using full-length bacterial 16S rRNA gene sequencing. We found that as the severity of disease increased, from healthy to gingivitis and periodontitis, the degree of dysbiosis also increased. A higher abundance of Prevotella intermedia and Catonella morbi and a lower abundance of Porphyromonas pasteri, Prevotella nanceiensis, and Haemophilus parainfluenzae might be biomarkers of periodontitis, with an area under curve (AUC) reaching 0.9733. When patients received supragingival scaling, there were more pathogens related to recolonization in the saliva of periodontitis patients than in healthy persons. Even after effective nonsurgical periodontal therapy, individuals with periodontitis displayed a more dysbiotic and pathogenic microbial community in their saliva than healthy individuals. Therefore, the gradual transition in the entire salivary microbial community from healthy to diseased includes a gradual shift to dysbiosis. Free salivary pathogens might play an important role in the recolonization of bacteria as well as the prognosis and recurrence of periodontal diseases.

Microbiota of alveolar osteitis after permanent tooth extractions: A systematic review

Alveolar osteitis (AO) or dry socket after dental extractions is a common postoperative complication characterized by the presence of severe pain associated with an empty socket. Although some authors consider AO to be related to an alteration of the blood clot, the underlying etiology remains unclear, and recent reports suggest that bacteria might play an important role. A systematic review was made, compiling relevant references from PubMed, the Cochrane Library, Scopus and the Web of Science databases to determine which bacteria have been identified in AO sockets after dental extractions. Papers published between 1980-2019, identifying the bacteria present in AO sockets after tooth extractions, were included. Data were displayed in tables, and a descriptive analysis was carried out. After the screening process, four papers were analyzed, comprising a total of 138 samples from 138 patients with AO. The most commonly detected bacteria were Prevotella, Fusobacterium, Parvimonas and Peptostreptococcus. Two studies also showed the microbiota of patients that developed AO after dental extractions to be apparently different from that of patients without postoperative complications. These results indicate that bacteria may play an important role in the pathogenesis of AO, though further studies are needed to confirm these findings.