Evaluation of 0.12% chlorhexidine rinse on the prevention of alveolar osteitis

Early periodontal wound healing after chlorhexidine rinsing: a randomized clinical trial

OBJECTIVES

This single-center randomized, parallel design, clinical trial with a 2-week follow-up involved patients affected by periodontitis undergoing periodontal surgery. The aim was to evaluate periodontal surgical wound healing with the use of chlorhexidine-based mouth rinses versus an untreated control group.

MATERIALS AND METHODS

Periodontal surgery was performed following a standardized protocol. Patients were randomly prescribed i) chlorhexidine (CHX) + anti-discoloration system (ADS) + hyaluronic acid (HA), ii) CHX + ADS or iii) no treatment (control group). Plaque score, gingival inflammation, and Early Healing Index (EHI), assessing the degree of wound closure and the presence of fibrin and necrosis, were evaluated at 3, 7 and 14 days after surgery.

RESULTS

In total, 33 patients were enrolled. Patients were comparable at baseline for all measured clinical parameters. At 3-days wound healing was significantly improved in all patients treated with CHX + ADS-based mouth rinses with a lower EHI score at the interdental papillae compared with control group (p < 0.01). CHX + ADS + HA group presented improved healing across all time points in terms of EHI, plaque containment, and gingival inflammation when compared to control group (p < 0.01).

CONCLUSIONS

The usage of CHX-ADS following periodontal surgery improved early wound healing, reduced plaque accumulation and gingival inflammation. During the early post-operative period the adjunct of HA further improved soft tissue closure.

CLINICAL RELEVANCE

This study aims at evaluating the response of gingival tissues to mouth rinsing with chlorhexidine and anti-discoloration system (CHX + ADS) or CHX + ADS + hyaluronic acid (CHX + ADS + HA) versus no rinse in terms of healing of the periodontal surgical wound. CHX + ADS mouth rinses enhanced early soft tissue closure after periodontal surgery and contributed to the reduction in plaque accumulation and gingival inflammation. The adjunct of HA may be beneficial especially in the early post-operative period. CHX + ADS administration following periodontal surgery may improve soft tissue healing in the first two post-operative weeks.

Efficacy of Oxytetracycline Hydrocortisone-Soaked Gauze Pack on Postoperative Sequelae in Lower Third Molar Surgery: A Prospective Study

Background Though various advancements came into the field of surgery to do the atraumatic procedure, post-operative pain, and swelling are unavoidable complications. Hence, various medicaments are packed in the extracted third molar sockets to prevent these post-operative complications. Aim The study aimed to evaluate the efficacy of oxytetracycline hydrocortisone-soaked gauze in reducing post-operative pain and swelling compared to conventional surgical procedures without any packing in patients undergoing surgical extraction of the impacted mandibular third molars. Materials and methods The study was conducted in the Department of Oral and Maxillofacial Surgery at Saveetha Dental College and Hospitals, Chennai. In this study, 50 patients were randomly included in two groups of 25 participants each. In group A, oxytetracycline hydrocortisone-soaked gauze was placed, and in group B, conventional closure was done without any pack after surgical removal of impacted mandibular third molars. Post-operative pain was assessed on days one, three, and five using a 10-point visual analog scale. Post-operative swelling was assessed on the third and seventh days using a four-point swelling measurement. Data analysis was done using SPSS (IBM Corp. Armonk, NY). A p-value less than 0.05 was considered statistically significant. Independent sample t-test was done to compare the outcomes between the two groups. Results The results demonstrated that group A (Oxytetracycline Hydrocortisone-soaked gauze) showed superior pain reduction compared to group B (conventional closure) at all post-operative intervals (P=0.001). Moreover, group A exhibited reduced swelling, resulting in higher patient satisfaction levels compared to group B on the third post-operative day (P=0.001). Conclusion It can be concluded from the study that there was a significant reduction in post-operative pain and swelling with the use of oxytetracycline hydrocortisone-soaked gauze, as it acts like a local drug delivery system in patients undergoing impacted mandibular third molar surgeries.

Efficacy of Chlorhexidine after Oral Surgery Procedures on Wound Healing: Systematic Review and Meta-Analysis

Our objective was to evaluate qualitatively and quantitatively, through a systematic review and meta-analysis, available evidence on the efficacy of chlorhexidine (CHX) when applied after oral surgery on wound healing and related clinical parameters. MEDLINE/PubMed, Embase, CENTRAL, Web of Science, and Scopus were searched for studies published before January 2023. The quality of the methodology used in primary-level studies was assessed using the RoB2 tool; meta-analyses were performed jointly with heterogeneity and small-study effect analyses. Thirty-three studies and 4766 cases were included. The results point out that the application of CHX was significantly more effective, compared to controls where CHX was not employed, providing better wound healing after oral surgery (RR = 0.66, 95% CI = 0.55-0.80, p < 0.001). Stratified meta-analyses confirmed the higher efficacy of 0.20% CHX gel vs. other vehicles and concentrations (p < 0.001, respectively). Likewise, the addition of chitosan to CHX significantly increased the efficacy of surgical wound healing (p < 0.001). The use of CHX has also been significantly beneficial in the prevention of alveolar osteitis after any type of dental extraction (RR = 0.46, 95% CI = 0.39-0.53, p < 0.001) and has also been effective when applied as a gel for a reduction in pain after the surgical extraction of third molars (MD = -0.97, 95% CI = -1.26 to -0.68, p < 0.001). In conclusion, this systematic review and meta-analysis demonstrate on the basis of evidence that the application of CHX exerts a beneficial effect on wound healing after oral surgical procedures, significantly decreasing the patient's risk of developing surgical complications and/or poor wound healing. This benefit was greater when CHX was used at 0.20% in gel form with the addition of chitosan.

Oral Contraceptive Use and Alveolar Osteitis Following Third Molar Extraction: A Systematic Review and Meta-Analysis

PURPOSE

Alveolar osteitis (AO) is a common postoperative complication of third molar extractions that is thought to be associated with the intake of oral contraceptives (OCPs). This meta-analysis sought to evaluate the risk of AO associated with OCP use and sex independently and whether this risk was affected by the use of postoperative analgesics or antibiotics.

METHODS

PubMed/Medline, EMBASE, and Cochrane databases were searched for articles pertaining to OCP use and the incidence of AO using MESH terms. The measured outcome was the development of AO following a third molar extraction. Additional variables such as sex, analgesic, and antibiotic use were documented and included in the analysis. The data were analyzed in R using the Mantel-Haenszel method.

RESULTS

Fifteen studies with a total of 1366 female participants who were OCP users and 2919 nonuser female participants were included in this meta-analysis. OCP users were approximately twice (pooled-RR: 1.98, 95% CI: 1.42-2.76) as likely to develop AO following a third molar extraction when compared to nonuser females. The increased incidence of AO in the OCP group was statistically significant (p < 0.01). The pooled-RR of AO in females not taking OCPs was not significantly different from males (p=0.45).

CONCLUSIONS

OCP use significantly elevated the risk of AO in females. Females who did not take OCPs had a similar risk of developing AO compared to males, suggesting that OCP use is a potential effect modifier. Neither postoperative antibiotics use nor the type of postoperative analgesic significantly affected AO incidence in those taking OCPs.

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.

Preventing Alveolar Osteitis After Molar Extraction Using Chlorhexidine Rinse and Gel: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Alveolar osteitis (AO) may occur after molar extraction. Chlorhexidine (CHX) rinse and CHX gel are widely used to prevent AO. Although previous meta-analyses support the effectiveness of both CHX rinse and CHX gel in preventing AO, important issues regarding these two formulations have not been addressed adequately in the literature.

PURPOSE

A systematic review and meta-analysis of randomized controlled trials was conducted to determine the effectiveness of CHX rinse and CHX gel in preventing AO.

METHODS

PubMed, EMBASE, SCOPUS, and Cochrane databases were searched for randomized controlled trials published before June 2018. The risk ratio (RR) was used to estimate the pooled effect of AO incidence using a random-effect model.

RESULTS

The RRs of AO in patients treated with 0.12% CHX rinse (RR = 0.54, 95% CI [0.41, 0.72]) and 0.2% CHX rinse (RR = 0.84, 95% CI [0.52, 1.35]) were significantly lower than in those treated with the control. Moreover, a significantly lower RR was identified in patients treated with 0.2% CHX gel (RR = 0.47, 95% CI [0.34, 0.64]) than in those treated with the control. When CHX products of different concentrations were grouped together, patients treated with CHX rinse showed an RR of AO of 0.61 (95% CI [0.48, 0.78]) and those treated with CHX gel showed an RR of AO of 0.44 (95% CI [0.43, 0.65]). On the other hand, a meta-analysis of three trials that compared CHX rinse and CHX gel directly showed a significantly lower RR of AO in patients treated with CHX rinse than in those treated with CHX gel (RR = 0.56, 95% CI [0.34, 0.96]).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The results support the effectiveness of both CHX rinse and gel in reducing the risk of AO after molar extraction. Each formulation provides unique benefits in terms of ease of application and cost. On the basis of the results of this study, the authors recommend that CHX gel be used immediately after molar extraction because of the convenience and cost-effectiveness of this treatment and that CHX rinse be used by the patient after discharge at home in combination with appropriate health education and case management.

Frequency of inflammatory complications following surgical tooth extraction and the efficiency of postoperative protocols for their prevention

Introduction: Surgical tooth extraction is one of the most common surgical procedures in oral surgery nowadays. The post-extraction period is usually uneventful, however, in some cases, the healing process may be affected by the extraction trauma or by the impact of bacteria at the surgical site. Aim: The aim of this paper is to establish the frequency of inflammatory complications, specifically surgical site infections and alveolar osteitis, after surgical extractions, and to explore the impact of antiseptics and antibiotics regarding the prevention of these complications. Material and methods: A number of 60 patients was included in this research, divided into three research groups according to the post-operative treatment type prescribed. The first group consisted of the patients who had been prescribed antibiotics, while the second group consisted of the patients who had been instructed to rinse their mouth with 0.12% chlorhexidine digluconate rinse postoperatively. Control group consisted of the patients who had not been prescribed any treatment. The postoperative check-ups were done on the second and the seventh day after the surgery, where it was checked if there were any clinical signs of infection or alveolar osteitis at the surgical site. Results: The study consisted of 60 patients, out of which a total of 67 teeth were extracted. Two patients were diagnosed alveolar osteitis, while four patients were diagnosed postoperative infection Conclusion: Statistically significant difference between the participant groups regarding the frequency of postoperative complications has not been noticed. There is insufficient evidence to justify the routine use of antibiotics or antiseptics after surgical tooth extractions.

The influence of intra-alveolar application of honey versus Chlorhexidine rinse on the incidence of Alveolar Osteitis following molar teeth extraction. A randomized clinical parallel trial

Background

Alveolar Osteitis (AO) is a complication occurs on the post-extraction days that includes pain and disintegrated blood clot. Chlorhexidine (CHX) rinse after extraction is an effective method for decreasing the incidence of AO. Honey has natural antibacterial properties and effectiveness when it is used as a dressing on burns and wounds. However, the effect of intraoral honey dressings on healing is still not adequately studied. This study aimed to compare pain and AO after extraction of a molar tooth in a group of patients who received the intra-alveolar application of Manuka Honey post-operatively with another group who used 0.2% CHX rinse.

Material and Methods

A randomized clinical trial of parallel groups was carried out on 100 patients who had a single molar tooth extraction. They were randomly divided into two groups. Group1 (G1) used 0.2 % CHX twice daily for 7 days. In Group2 (G2), Manuka Honey applied topically by a cotton swab into the socket directly after extraction and on Day3. Re-evaluation, including pain assessment, empty socket, and halitosis was done on day 3 and day 7.

Results

G1 included 43 patients and G2 included 57 patients. Higher grades of pain, more empty sockets, and halitosis were found in G2 than in G1 on day3 and day7 without significant differences. Four cases of AO were found in G1 (9.3%) and 7 cases in G2 (12.3%), without significant difference between the two groups according to Chi-squared tests (p=0.753).

Conclusions

The application of Manuka honey in the extraction socket directly after extraction and on day 3 has been found to be insignificantly less efficient in the prevention of AO than CHX rinse twice daily for seven days. However, honey is promising as natural dressing material and further studies are recommended. Key words:Manuka honey, Chlorhexidine, Alveolar Osteitis, extraction, dry socket.

Clinical efficacy of a chlorhexidine-based mouthrinse containing hyaluronic acid and an antidiscoloration system in patients undergoing flap surgery: A triple-blind, parallel-arm, randomized controlled trial

OBJECTIVES

To evaluate the postsurgery gingival healing as well as plaque, gingival inflammation and staining levels following the use of a 0.2% chlorhexidine (CHX) solution with or without antidiscoloration system (ADS) and 0.2% hyaluronic acid (HA).

METHODS

Patients undergoing flap surgery at sites with an intact or reduced but healthy periodontium participated in a parallel-arm RCT. After surgery, patients used the assigned mouthrinse (CHX + HA + ADS or CHX) for 21 days. At days 7 and 21, the healing process was evaluated at experimental teeth using a composite index, namely the Gingival Healing Index (GHI). GHI score was obtained as the sum of the scores related to the severity of wound dehiscence (score 1-3) and the profile of the buccal and oral aspects of the papilla (score 1-3). Therefore, GHI ranged from 2 (worst quality of healing) to 6 (optimal quality of healing). Plaque Index (PlI), Gingival Index (GI), angulated bleeding score (AngBS), and tooth and tongue staining were also assessed.

RESULTS

In both groups, GHI assumed values of 5 or 6 at both days 7 and 21 in ≥50% of patients, and low median values of PlI, GI, AngBS and staining were observed during the 21-day period. Except for a significantly lower GI in CHX group at day 7, no other significant intergroup differences were found.

CONCLUSIONS

Postsurgery plaque control based on either CHX or CHX + HA + ADS mouthrinses results in optimal plaque control and quality of early gingival healing along with limited tooth and tongue staining.

Angiogenesis and the prevention of alveolar osteitis: a review study

Angiogenesis is one of the essential processes that occur during wound healing. It is responsible for providing immunity as well as the regenerative cells, nutrition, and oxygen needed for the healing of the alveolar socket following tooth extraction. The inappropriate removal of formed blood clots causes the undesirable phenomenon of alveolar osteitis (AO) or dry socket. In this review, we aimed to investigate whether enhanced angiogenesis contributes to a more effective prevention of AO. The potential pro- or anti-angiogenic activity of different materials used for the treatment of AO were evaluated. An electronic search was performed in the PubMed, MEDLINE, and EMBASE databases via OVID from January 2000 to September 2016 using the keywords mentioned in the PubMed and MeSH (Medical Subject Headings) terms regarding the role of angiogenesis in the prevention of AO. Our initial search identified 408 articles using the keywords indicated above, with 38 of them meeting the inclusion criteria set for this review. Due to the undeniable role of angiogenesis in the socket healing process, it is beneficial if strategies for preventing AO are directed toward more proangiogenic materials and modalities.

Chlorhexidine for prevention of alveolar osteitis: a randomised clinical trial

Objective

To determine the effectiveness of chlorhexidine 0.12% mouthwash (CHX) after tooth extraction for the prevention of alveolar osteitis (AO).

Material and methods

We conducted a double-blind randomised clinical trial stratified by risk factors. We enrolled a cohort of 822 patients who underwent dental extractions, and were considered to be at risk of developing AO (previous surgical site infection, traumatic extraction, and tobacco smoking). After extraction, patients were randomly allocated for CHX group or placebo group, matched by risk factors. The primary outcome was clinical diagnosis of AO: increasing postoperative pain for 4 d within and around the socket, and total or partial breakdown of the blood clot in the socket with or without bone exposure.

Results

Follow-up was completed by 744 participants (372 chlorhexidine and 372 placebo). We detected no significant differences between the two groups at baseline. After completed follow-up, risk factors were equally distributed between the two groups. Overall incidence of OA was 4.97%, in which 27 participants treated with placebo (7.26%) and 10 participants treated with CHX (2.69%) developed AO. CHX reduced the incidence of AO by 63% [Absolute Risk Reduction: 4.57 (95% CI 1.5-7.7), Number Needed to Treat: 21.88 (95% CI 13.0-69.3), Fisher's exact test: p=0.006]. No adverse effects were reported.

Conclusion

The use of chlorhexidine 0.12% mouthwash after tooth extraction is safe and effective in reducing the incidence of AO in high-risk patients.

Effectiveness of irrigation with chlorhexidine after removal of mandibular third molars: a randomised controlled trial

To evaluate the effect of postoperative irrigation with chlorhexidine on inflammatory complications after the extraction of lower third molars under local anaesthesia, we recruited 100 patients to participate in a controlled, single-blind, randomised clinical trial. They were assigned to one of two groups: the intervention group (postoperative irrigation of the surgical site with chlorhexidine for seven days) or the control group (postoperative chlorhexidine mouth rinse for seven days). The primary outcome variables were pain, swelling, trismus, infection, and alveolar osteitis. The secondary outcome variables were wound dehiscence and food impaction. A total of 95 participants completed the study (47 in the irrigation group and 48 in the rinse group). In the irrigation group, alveolar osteitis and facial swelling had reduced significantly at seven days postoperatively (both p<0.01). Pain scores had also reduced significantly at seven days (p<0.01), but not at 48hours, and patients had lower levels of food impaction (p<0.01) and less severe symptoms (p=0.02). Routine irrigation with chlorhexidine after the extraction of third molars helps to reduce pain and lowers the incidence of alveolar osteitis.

Does Chlorhexidine Prevent Alveolar Osteitis After Third Molar Extractions? Systematic Review and Meta-Analysis

PURPOSE

The prevention of alveolar osteitis (AO) in dental extractions remains a controversial issue. Chlorhexidine is one of the most widely studied antiseptics for the prevention of AO. The purpose of this systematic review and meta-analysis was to assess the efficacy and effectiveness of chlorhexidine in the prevention of AO after third molar extractions.

MATERIALS AND METHODS

The authors searched databases and the references of each article retrieved up to December 2015. Clinical randomized controlled trials (RCTs) using only chlorhexidine were included. The predictor variable was whether chlorhexidine was used in any formulation, concentration, or regimen. The outcome measurement was the incidence of postoperative AO. The authors also recorded variables describing the characteristics of the included studies. Statistical analysis was performed using STATA 12.0. Meta-analysis of binary data was conducted using a fixed-effects model. Risk ratios and 95% confidence intervals (CIs) were estimated. Forest, l'Abbé, and funnel plots were constructed.

RESULTS

Twenty-three studies published from 1979 to 2015, corresponding to 18 trials (16 parallel-group and 2 split-mouth RCTs), that reported on 2,824 third molar extractions (1,458 in experimental group and 1,366 in control group) were included. The overall relative risk (RR) was 0.53 (95% CI, 0.45-0.62; P < .0001). There was no evidence of heterogeneity (I² = 9.3%; P = .336 by χ² test). The number needed to treat was 8 (95% CI, 7-11). There were no relevant differences between chlorhexidine rinse (RR = 0.58; 95% CI, 0.47-0.71) and gel (RR = 0.47; 95% CI, 0.37-0.60). Chlorhexidine did not cause a larger proportion of adverse reactions than placebo.

CONCLUSION

The use of chlorhexidine, in any formulation, concentration, or regimen, is efficacious and effective in preventing AO in patients who have undergone third molar extraction. Chlorhexidine gel was found to be moderately more efficacious than the rinse formulation.

Effectiveness of intra-alveolar chlorhexidine gel in reducing dry socket following surgical extraction of lower third molars. A pilot study

BACKGROUND

Dry socket is one of the most studied complications in dentistry and several studies have sought an effective and safe method for its prevention and treatment. The aim of this study was to evaluate the effectiveness of intra-alveolar gel chlorhexidine in preventing dry socket after the surgical removal of third molars.

MATERIAL AND METHODS

The sample involved the treatment of 40 patients who required extraction of third molars impacted, which were randomly assigned to research groups: experimental group (chlorhexidine gel 0.12%) and control group (placebo gel). Performed the extraction was administered 1 mL of chlorhexidine gel or 1 mL of placebo gel within the socket. The removal of suture was on the fifth postoperative day in which the presence or absence of dry socket was evaluated.

RESULTS

No relationship between the appearance of dry socket after application of chlorhexidine gel or placebo gel (X2 test, p = 0.311) was found. However, significant differences (U Mann-Whitney test, p = 0.036) in the pain presented on the fifth postoperative day were evident (VAS).

CONCLUSIONS

The administration of intra-alveolar chlorhexidine gel 0.12% could generate a better response to postoperative pain after the removal of third molars.

KEY WORDS

Third molar surgery, dry socket, chorhexidine gel.

Effectiveness of 0.2% chlorhexidine gel and a eugenol-based paste on postoperative alveolar osteitis in patients having third molars extracted: a randomised controlled clinical trial

The aim of this study was to compare the effect of application of 0.2% chlorhexidine gel, a eugenol-based paste, together with a control group on the postoperative incidence of alveolar osteitis in patients having third molars extracted. A total of 270 patients who had this procedure at the Dept of Oral and Maxillofacial Surgery, Saveetha Dental College and who met the inclusion criteria were enrolled in the study and divided into 3 groups: the first had a 0.2% chlorhexidine-based gel applied to the alveolar socket once after extraction; the second had a eugenol-based paste applied to the alveolar socket once after extraction; and the third group acted as controls, with no treatment. The incidence of alveolar osteitis was recorded for 7 days. We also recorded postoperative pain, inflammation, infection, and wound healing. Nine of the control group (10%) and 2 (2%) of the chlorhexidine group developed alveolar osteitis on the seventh postoperative day. The overall incidence (11/270) was 4%, which is less than reported elsewhere. The distribution of alveolar osteitis among the 3 groups was significant (p=0.002), with the eugenol group having no cases. The chlorhexidine group showed less incidence of alveolar osteitis than other reported studies and also less pain, inflammation, infection, and better wound healing than the control group. We conclude that eugenol was the better of the 2 interventions.

A practical approach to evidence-based dentistry: VI: How to use a systematic review

BACKGROUND AND OVERVIEW

Dental practitioners face new clinical challenges on a daily basis. New treatment options and diagnostic tools are disseminated quickly, and the volume of articles and new evidence is overwhelming. Systematic reviews summarize and synthesize the available evidence related to diagnosis, therapy, prognosis, and harm for clinicians, patients, and decision makers. Such reviews represent one of the most powerful tools to translate knowledge into action.

PRACTICAL IMPLICATIONS

The critical appraisal of this type of study involves assessing the risk of bias, results, and applicability of such study. The authors provide guidance for clinicians to critically appraise systematic reviews and apply the findings in clinical practice.

Effect of intra-alveolar placement of 0.2% chlorhexidine bioadhesive gel on the incidence of alveolar osteitis following the extraction of mandibular third molars. A double-blind randomized clinical trial

Alveolar osteitis (AO) is a common complication after third molar surgery. One of the most studied agents in its prevention is chlorhexidine (CHX), which has proved to be effective. Objectives: The aim of this randomized double-blind clinical trial was to evaluate the efficacy of 0.2% bioadhesive chlorhexidine gel placed intra-alveolar in the prevention of AO after the extraction of mandibular third molars and to analyze the impact of risk factors such as smoking and oral contraceptives in the development of AO. Study Design: The study was a randomized, double-blind, clinical trial performed in the Ambulatory Surgery Unit of Hospital Vall d’Hebron and was approved by the Ethics Committee. A total of 160 patients randomly received 0.2% bioadhesive gel (80 patients) or bioadhesive placebo (80 patients). Results: 0.2% bioadhesive chlorhexidine gel applied in the alveolus after third molar extraction reduced the incidence of dry socket by 22% compared to placebo with differences that were not statistically significant. Smoking and the use of oral contraceptives were not related to higher incidence of dry socket. Female patients and the difficulty of the surgery were associated with a higher incidence of AO with statistically significant differences. 0.2% bioadhesive chlorhexidine gel did not produce any of the side effects related to chlorhexidine rinses. Conclusions: A 22% reduction of the incidence of alveolar osteitis with the application of 0.2% bioadhesive chlorhexidine gel compared to placebo with differences that were not statistically significant was found in this clinical trial. The lack of adverse reactions and complications related to chlorhexidine gel supports its clinical use specially in simple extractions and adds some advantages compared to the rinses in terms of duration of the treatment and reduction of staining and taste disturbance.

Key words:Alveolar osteitis, dry socket, chlorhexidine bioadhesive gel, mandibular third molar surgery.

A randomized clinical trial compared the effect of intra-alveolar 0.2 % Chlorohexidine bio-adhesive gel versus 0.12% Chlorohexidine rinse in reducing alveolar osteitis following molar teeth extractions

OBJECTIVES

To evaluate socket healing, incidence of acute alveolar ostieitis (AO) and associated pain following single molar tooth extraction in patients who receive intra-alveolar 0.2% chlorhexidine (CHX) gel, and those who rinsed with 0.12 % CHX rinse.

STUDY DESIGN

A prospective randomized clinical trial was conducted on two parallel groups of patients. Group 1 (141 patients): Rinsed with 0.12 % CHX rinse from the second postoperative day, two times daily for a week. Group2 (160 patients): Who had direct intra-alveolar application of 0.2% CHX gel and day 3 post-operatively. The socket was evaluated 3 and 7 day postoperatively for the presence of AO by checking probing tenderness in the socket, empty socket, food debris, halitosis and pain assessment by VAS.

RESULTS

Forty-eight AO cases were diagnosed out of 301 extractions (15.9%). In Group 1, 25 cases were found (17.7%) while 23 cases were found in Group 2 (14.4%). The difference was not statistically significant (p=0.428). Presence of empty socket and food debris in Group 1 were higher than in Group 2 but the difference was not statistically significant (p= 0.390 & p = 0.415). Occurrence of halitosis in Group 2 was more than Group 1, but the difference was not significant (p= 0.440). Statistical significance was found between AO in extraction done by root separation (29%) and those routinely extracted (12.3 %) (p=0.001).

CONCLUSION

Postoperative evaluation of molar extraction sockets that received direct intra-alveolar application of 0.2% CHX gel showed insignificant less occurrence of AO when compared with 0.12 % CHX rinse.

Comparative study of the effect of warm saline mouth rinse on complications after dental extractions

The aim of the present study was to determine the effect of saline mouth rinse on postoperative complications following routine dental extractions. Patients aged ≥16 years, who were referred to the oral surgery clinic with an indication for non-surgical extraction of pathologic teeth, were prospectively and uniformly randomized into three groups. Group A (n=40) were instructed to gargle six times daily with warm saline and group B (n=40) twice daily; group C (n=40) were not instructed to gargle with warm saline and served as controls. Information on demographic characteristics, indications for extraction, and the development of complications, such as alveolar osteitis, acute inflamed socket, and acute infected socket, was obtained and analyzed. There were no significant differences between patients who gargled six times daily with warm saline and those who gargled twice daily with reference to either alveolar osteitis or acute inflamed socket (P>0.05). However saline mouth rinses at either frequency were beneficial in the prevention of alveolar osteitis in comparison with those who did not rinse. A twice-daily saline mouth rinse regimen is more convenient, and patient compliance may be better than with a six times daily rinse regimen.

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

BACKGROUND

Alveolar osteitis (dry socket) is a complication of dental extractions and occurs more commonly in extractions involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively, a socket that may be partially or totally devoid of blood clot and in some patients there may be a complaint of halitosis. It can result in an increase in postoperative visits.

OBJECTIVES

To assess the effects of local interventions for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 29 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10), MEDLINE via OVID (1946 to 29 October 2012) and EMBASE via OVID (1980 to 29 October 2012). There were no restrictions regarding language or date of publication. We also searched the reference lists of articles and contacted experts and organisations to identify any further 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 post-extraction. 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 for the management of dry socket because these interventions are evaluated in separate Cochrane reviews.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook risk of bias assessment and data extraction in duplicate for included studies using pre-designed proformas. Any reports of adverse events were recorded and summarised into a table when these were available. We contacted trial authors for further details where these were unclear. We followed The Cochrane Collaboration 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 instead. We used the GRADE tool to assess the quality of the body of evidence.

MAIN RESULTS

Twenty-one trials with 2570 participants met the inclusion criteria; 18 trials with 2376 participants for the prevention of dry socket and three studies with 194 participants for the treatment of dry socket. The risk of bias assessment identified six studies at high risk of bias, 14 studies at unclear risk of bias and one studies at low risk of bias. When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and after extraction(s) prevented approximately 42% of dry socket(s) with a RR of 0.58 (95% CI 0.43 to 0.78; P < 0.001) (four trials, 750 participants, moderate quality of evidence). The prevalence of dry socket varied 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 with (0.12% and 0.2%) chlorhexidine rinse to prevent one patient having dry socket (NNT) was 232 (95% CI 176 to 417), 47 (95% CI 35 to 84) and 8 (95% CI 6 to 14) for control prevalences of dry socket of 1%, 5% and 30% respectively.Compared to placebo, placing chlorhexidine gel (0.2%) after extractions prevented approximately 58% of dry socket(s) with a RR of 0.42 (95% CI 0.21 to 0.87; P = 0.02) (two trials, in 133 participants, moderate quality of evidence). The number of patients needed to be treated with chlorhexidine gel to prevent one patient having dry socket (NNT) was 173 (95% CI 127 to 770), 35 (95% CI 25 to 154) and 6 (95% CI 5 to 26) for control prevalences of dry socket of 1%, 5% and 30% respectively.A further 10 intrasocket interventions to prevent dry socket were each evaluated in single studies, and therefore there is insufficient evidence to determine their effects. Five interventions for the treatment of dry socket were evaluated in a total of three studies providing insufficient evidence to determine their effects.

AUTHORS' CONCLUSIONS

Most tooth extractions are undertaken by dentists for a variety of reasons, however, all but three studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is some evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, provides a benefit in preventing dry socket. There was insufficient evidence to determine the effects of the other 10 preventative interventions each evaluated in single studies. There was insufficient evidence to determine the effects of any of the interventions to treat dry socket. The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% and 2% chlorhexidine mouthrinses, though most studies were not designed 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 (though previous allergy to chlorhexidine was an exclusion criterion in these trials). In view of recent reports in the UK of two cases of serious adverse events associated with irrigation of dry socket with chlorhexidine mouthrinse, it is recommended that all members of the dental team prescribing chlorhexidine products are aware of the potential for both minor and serious adverse side effects.

Primary and secondary closure of the surgical wound after removal of impacted mandibular third molars

AIM

The present study attempted the evaluation of Primary and secondary closure techniques after removal of impacted third molars in terms of healing, post-operative pain and swelling.

MATERIAL AND METHODS

60 patients with impacted mandibular third molars were randomly divided into two groups of 30. Panoramic radiographs were taken to assess degree of eruption and to asses 3rd molar angulations to the long axis of 2nd molar. Teeth were extracted, and in Group 1 the socket was closed by hermetically suturing the flap. In group II a 5-6 mm wedge of mucosa distal to the second molar was removed & the flap was repositioned. Interrupted sutures were given, so as to form a triangular opening distal to second molar measuring about 5 × 5 mm. Swelling and pain were evaluated for 7 days after surgery with the VAS scale.

RESULTS

Study results showed that post operative Sequale were comparatively less in secondary closure group than the primary closure group. Pain showed statistically significant difference between two groups. Pain was less in secondary closure group from day 1 to day 7. Swelling & trismus was also significantly less in secondary closure group. Evaluation of the complications of these two techniques showed that delayed wound healing occurred in 66.6% of cases (20 cases out of 30) in secondary closure group where as dehiscence of suture line occurred in 33.33% of cases (10 out of 30) in primary closure group.

CONCLUSIONS

The results obtained in the present study enable us to conclude that, in cases of equal intra-operative difficulty, open healing of the surgical wound after removal of impacted third molars produces less post-operative swelling and pain than occurs with closed healing, by hermetically suturing the socket.

The Effectiveness of GECB Pastille in Reducing Complications of Dry Socket Syndrome

Background and Purpose. Dry socket syndrome is one of the most irritating complications after tooth extraction. This study aims to investigate the efficacy of pastille GECB compared to ZOE. Materials and Methods. 30 patients with dry socket syndrome were selected and divided into two groups. GECB pastille was produced with 3% Guaiacol, 3% Eugenol 1.6% Chlorobutanol, sized 3 × 7 × 10 mm. GECB was applied in one group, and ZOE was used for the other group. Duration of pain after treatment and painkiller intake values were recorded within 20 days. The data were analyzed with independent samples t-test, Mann-Whitney, and Chi-Square tests. Results. Pain persisted for 45.53 ± 33.34 minutes in patients treated with ZOE and 19.87 ± 21.80 minutes in those treated with GECB (P = 0.19). Patients in the ZOE group reported more painkiller intake within 20 days (P = 0.031). Conclusion. GECB showed more significant efficacy in reducing complications after tooth extraction.

Dry socket: frequency, clinical picture, and risk factors in a palestinian dental teaching center

Aims:

The objectives of this study were to find out the frequency, clinical picture, and risk factors of dry socket at the Dental Teaching Center of Al-Quds University in Palestine.

Methods and Materials:

Two previously used questionnaires were accomplished in this study over a one year period. The first questionnaire was completed for every patient who had one or more permanent teeth extracted in the Dental Surgery Clinic. The other one was completed for every patient suffered a postoperative pain and was diagnosed with dry socket.

Results:

There were 1305 dental extractions performed in 805 patients. The overall frequency of dry socket was 3.2%. The incidence of dry socket following non-surgical extractions was 1.7% while it was 15% following surgical extractions (P< 0.005). The incidence of dry socket was significantly higher in smokers (12%) than in non-smokers (4%) (P < 0.005), however, there is a strong association between the amount of smoking and the incidence of dry socket (P < 0.002). The incidence of dry socket was significantly higher in the single extraction cases (13%) than in the multiple extraction cases (5%) (P = 0.005). Age, sex, medical history, extraction site, amount of local anesthesia and experience of operator play no role in the occurrence of dry socket.

Conclusion:

Smoking, surgical trauma and single extractions are considered predisposing factors in the occurrence of dry socket. On the other hand, factors like: age, sex, medical history, extraction site, amount of anesthesia, and operator experience have no effect on the observation of dry socket.

Alveolar osteitis: a comprehensive review of concepts and controversies

Alveolar osteitis, "dry socket", remains amongst the most commonly encountered complications following extraction of teeth by general dentists and specialists. A great body of literature is devoted to alveolar osteitis addressing the etiology and pathophysiology of this condition. In addition numerous studies are available discussing methods and techniques to prevent this condition. To this date though great controversy still exists regarding the appropriate terminology used for this condition as well as the actual etiology, pathophysiology, and best methods of prevention and treatment. This article is a comprehensive critical review of the available literature addressing the concepts and controversies surrounding alveolar osteitis. We aim to assist the dental health care professional with patient preparation and management of this commonly encountered postoperative condition should be encountered.

Clinical concepts of dry socket

Dry socket is one of the most studied complications in dentistry, and a great number of studies have searched for an effective and safe method for its prevention and treatment. One of the great clinical challenges since the first case was reported has been the inconsistency and differences in the various definitions of dry socket and the criteria used for diagnosis. The pathophysiology, etiology, prevention, and treatment of dry socket are very important in the practice of oral surgery. The aim of the present report was to review and discuss each aspect.

Randomized, double-blind study of effectiveness of intra-alveolar application of chlorhexidine gel in reducing incidence of alveolar osteitis and bleeding complications in mandibular third molar surgery in patients with bleeding disorders

PURPOSE

Chlorhexidine (CHX) is an antimicrobial agent used in the prevention of tooth decay, periodontal disease, and postextraction alveolar osteitis (AO). Recently, a bioadhesive gel to deliver the active substance, CHX, was introduced. The intra-alveolar placement of the bioadhesive gel allows a more direct and prolonged therapeutic effect of CHX, which is useful in the prevention of AO after extraction of impacted third molars. The intra-alveolar application of the bioadhesive CHX gel in patients with bleeding disorders may increase the risk of postoperative bleeding complications. Inversely, bleeding disorders might influence the efficacy of CHX for AO prevention. The purpose of the present study was to evaluate the effectiveness of the bioadhesive 0.2% CHX gel in reducing the incidence of impacted third molar postextraction AO in patients with bleeding disorders.

MATERIALS AND METHODS

We performed a double-blind, randomized, parallel-group study of 38 patients with bleeding disorders. The experimental group (n = 14) was treated with bioadhesive 0.2% CHX gel applied intraoperatively once after surgical removal of the third molar. The control group (n = 24) was treated in an identical fashion with placebo gel.

RESULTS

We observed a 57.15% reduction in the incidence of AO in the experimental group. The control group had a 17% incidence of AO and the experimental group had a 7% incidence of AO (P = .402). Bleeding complications occurred in 21% of the experimental group compared with 29% of the control group (P = .601).

CONCLUSIONS

As described in previous studies, the single intra-alveolar application of the bioadhesive 0.2% CHX gel in an intraoperative fashion seems to reduce the incidence of AO after removal of impacted third molars in patients with bleeding disorders. On the basis of the reported percentage of bleeding complications, the routine use of postoperative local hemostatic measures is recommended.

Dry socket: a prospective study of prevalent risk factors in a Nigerian population

PURPOSE

To identify major risk factors for developing dry socket in some Nigerians, and to formulate a nonpharmacologic protocol for its effective prevention.

PATIENTS AND METHODS

Patients presenting with dry socket at the Oral Surgery Clinic of the Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria, over an 18-month period were studied. Biographic data, preoperative diagnoses, teeth extracted, oral hygiene status, and history relevant to the extractions and presentations of dry socket were documented. Procedures were classified as traumatic or atraumatic. Data were analyzed using SPSS version 11.0 (SPSS Inc, Chicago, IL) with simple descriptive statistics and the chi(2) test, as appropriate. P <or= .05 was considered significant.

RESULTS

Sixty-eight extraction sockets in 65 patients (46 females and 19 males) with a mean age of 33.48 (+/-SD 13.5) years were studied. All extracted teeth were posterior (17 maxillary, and 51 mandibular). Preoperative diagnoses were mainly of acute apical periodontitis secondary to carious lesion (30/68), chronic apical periodontitis (18/68), and chronic pulpitis (15/68). The use of an oral contraceptive was elicited in 25% of the females, and extractions were performed between days 1 and 22 of their menstrual cycle. Extraction was traumatic in 66.2% of cases. A ranking of the elicited risk factors suggests that a previously infected posterior tooth involves an equal risk in both genders. Poor oral hygiene and traumatic extraction in a mandibular tooth were prominent in males, whereas extractions performed between days 1 and 22 of the menstrual cycle were significant in females.

CONCLUSION

Control of preoperative infection, insistence on good oral hygiene, avoidance of trauma, and avoidance of surgery on days 1 to 22 of the menstrual cycle in nonmenopausal women may reduce the incidence of dry socket in the study population.

Effectiveness of chlorhexidine gel versus chlorhexidine rinse in reducing alveolar osteitis in mandibular third molar surgery

PURPOSE

Chlorhexidine is an antimicrobial agent used in the prevention of postextraction alveolar osteitis, tooth decay, and periodontal diseases. There are various forms of chlorhexidine application. The most extensively studied is one that uses the rinse as the form of application. Recently, a bioadhesive gel form has become available. Its main advantage is that it prolongs the bioavailability of chlorhexidine in the application area. The purpose of this study was to compare the effectiveness of chlorhexidine gel versus a chlorhexidine rinse in reducing postoperative alveolar osteitis after the extraction of mandibular third molars.

MATERIALS AND METHODS

The experimental or gel group (n = 41) applied the bioadhesive 0.2% chlorhexidine gel to the wound during the first postoperative week and a control or rinse group (n = 32) used a 0.12% chlorhexidine rinse during the first week postextraction.

RESULTS

We observed a 70% decrease in postoperative alveolar osteitis in the gel group (P = .040). The rinse group had 25% incidence postoperative alveolar osteitis, while the gel group had 7.5%.

CONCLUSIONS

It was concluded that the topical application of bioadhesive chlorhexidine gel to the surgical wound during the postoperative week may decrease the incidence of alveolar osteitis after extraction of the mandibular third molars.

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.

Patients presenting to the general practitioner with pain of dental origin

Dentofacial pain is a common presentation in general practice, and more than 50% of cases arise from dentally related pathology. In a carious tooth, pain that is site-specific, severe and spontaneous usually denotes extension of caries into the tooth pulp. Caries does not always appear as a cavity in the tooth, but may lie beneath intact enamel or on surfaces between teeth. Examination of tooth pain should include firm percussion (eg, with a tongue depressor). Tenderness on percussion denotes progression of infection into the subdental tissue. Pain occurring 24-48 hours after a tooth extraction is commonly caused by superficial osteitis in the exposed alveolar bone. Examination will reveal the absence of a blood clot in the extraction socket and severe tenderness on local palpation. Severe pain related to impacted wisdom teeth is frequently caused by pericoronitis, an infection in the gingival tissues surrounding the tooth. The surrounding gingiva is erythematous and tender to palpation. Localised facial swellings of dental origin require immediate referral to a dentist. Progressive facial swelling requires aggressive antibiotic therapy and referral to hospital for definitive management.

Experience versus complication rate in third molar surgery

Objectives

The records of 1087 patients who underwent surgical removal of third molar teeth were prospectively examined to analyse the possible relationship between postoperative complications and the surgeon's experience parameter.

Method and materials

Seven surgeons (three specialists in surgical dentistry [specialists SD] and four oral and maxillofacial Senior House Officers [OMFS residents]) carried out the surgical procedures. For each patient, several variables were recorded including age, gender, radiographic position of extracted teeth, treating surgeon, duration of surgery and postoperative complications.

Results

Analysis of the data revealed some differences in the incidence of complications produced by the specialists SD and OMFS residents. The main statistically relevant differences were increase the incidences of trismus, nerve paraesthesia, alveolar osteitis and infection in the resident-treated group, while the specialist-treated group showed higher rates of post-operative bleeding.

Conclusion

The higher rate of postoperative complications in the resident-treated group suggests that at least some of the complications might be related to surgical experience.

Further work needs to compare specialists of training programmes with different years of experience, using large cross – sectional studies.

Randomized, double-blind study on effectiveness of intra-alveolar chlorhexidine gel in reducing the incidence of alveolar osteitis in mandibular third molar surgery

Chlorhexidine (CHX) mouthwash is a good prophylactic agent for postextraction alveolar osteitis (AO), a very common complication. Recently, a bio-adhesive gel to deliver the active substance, CHX, has been introduced. The intra-alveolar positioning of the bio-adhesive gel allows more direct and prolonged action of CHX, which could be useful in the prevention of AO following extraction of impacted third molars. Presented here is a double-blind, randomised and parallel-group study evaluating the efficacy of the bio-adhesive 0.2% CHX gel (n=53) applied once within the alveolus during third molar surgery, compared to placebo gel only (n=50), in reducing the incidence of impacted third-molar postextraction AO. A 63.33% reduction in the occurrence of AO (P=0.019) was observed in the experimental group. In the control group, the occurrence of AO was 30% compared to 11% in the experimental group. Bio-adhesive 0.2% CHX gel, applied only once within the alveolus site at the time of surgery, may reduce the incidence of AO following removal of impacted third molars.

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.

Tetracycline compound placement to prevent dry socket: a postoperative study of 200 impacted mandibular third molars

PURPOSE

Our objective was to study whether the placement of intra-alveolar tetracycline prevents dry sockets or improves the postoperative period.

PATIENTS AND METHODS

A comparative clinical study of the surgical removal of 200 impacted mandibular third molars is made, with particular reference to postextraction pain, inflammation, trismus, and the incidence of dry socket. In 50% of these cases, a pharmacologic preparation that includes tetracycline was placed in the socket after removal of the impacted molar.

RESULTS

Dry socket was diagnosed in 4 cases (2%), with no relation to intra-alveolar tetracycline placement being observed. The patients who were administered intra-alveolar tetracycline had less pain and trismus and consumed fewer analgesics than the patients who received no such treatment, although statistical significance was not reached.

CONCLUSIONS

The intra-alveolar placement of tetracycline compound after the surgical removal of impacted mandibular third molars did not affect the incidence of dry socket.

A clinical evaluation of dry socket in a Nigerian teaching hospital

PURPOSE

We sought to determine the incidence of dry socket in a Nigerian teaching hospital and to evaluate the patients' demographic pattern, predisposing factors, the treatment given, and treatment outcome.

PATIENTS AND METHODS

A retrospective review of records of dental extractions complicated by dry socket in Obafemi Awolowo University Teaching Hospital, Ile-Ife, between January 1996 and December 2000 was undertaken. Information retrieved included patient sociodemographic data, indications for extraction, tooth extracted, status of attending surgeon, onset of symptoms, relevant findings of the examining clinician, interval before presentation, treatment given, and its outcome.

RESULTS

Of the 3,319 dental extractions performed in 3,008 patients, 136 (4.1%) were complicated by dry socket. The patients' mean age was 33.4 (15.4) years and a peak age incidence of 21 to 30 years was found. A slight female preponderance (1.4:1) was observed. The majority of patients were in the low-income group, and presentation in the hospital was prompt in the high-income group. Mandibular teeth were affected 3 times more than maxillary teeth (P =.00080). Most cases of dry socket resulted from extractions performed by undergraduates and house officers. Various underlying systemic conditions were found in 11.0% of cases, none of which included use of oral contraceptives. Treatment was usually the use of zinc oxide eugenol dressing in an irrigated socket, combined with antibiotic therapy in 45.3% of cases. No adverse reaction to zinc oxide eugenol was observed.

CONCLUSION

The incidence of dry socket in our hospital is 4.1%. The mandible was involved 3 times more than the maxilla. With the use of zinc oxide eugenol dressing, 70.6% of patients completed treatment satisfactorily and 29.2% were lost to follow-up.

Effects of 0.2% chlorhexidine gluconate and amoxicillin plus clavulanic acid on the prevention of alveolar osteitis following mandibular third molar extractions

OBJECTIVE

The purpose of this study was to evaluate the use of a 0.2% chlorhexidine gluconate and amoxicillin plus clavulanic acid combination as a prophylactic therapy for the prevention of alveolar osteitis after mandibular third molar extractions and to investigate adverse reactions to chlorhexidine.

STUDY DESIGN

This randomized, placebo-controlled, parallel group study was conducted in a group of 177 subjects, from which 3 groups were formed. The first group (n = 62) received 0.2% chlorhexidine gluconate, the second group (n = 56) received a 0.2% chlorhexidine gluconate and amoxicillin plus clavulanic acid combination, and the third group (n = 59) received 0.09% sterile saline solution. All patients were recalled for the diagnosis of alveolar osteitis on the third and seventh postoperative days.

RESULTS

When patients in the antibiotic group were compared with those in the other 2 groups, a significant reduction in alveolar osteitis was noted (P <.05). An alteration in taste, the bad taste of the solution, and staining of dentures and oral tissues were the major complaints about chlorhexidine.

CONCLUSION

It would be more beneficial to use chlorhexidine solution with a beta-lactamase inhibitor-containing antibiotic to enhance its effectiveness for the prevention of alveolar osteitis.

Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review

The objective of this article is to harmonize descriptive definitions for the condition known as alveolar osteitis and to critically review and discuss the aetiology and pathogenesis of alveolar osteitis. In addition, the need for the identification and elimination of risk factors as well as the preventive and symptomatic management of the condition are discussed. The aim of this critical review is to provide a better basis for clinical management of the condition. A meta-analysis of data was not done.

Oral hygiene and postoperative pain after mandibular third molar surgery

OBJECTIVE

The purpose of this study was to evaluate the association between oral hygiene before surgery and pain, inflammation, and trismus after the surgical removal of 190 impacted lower third molars.

STUDY DESIGN

Patient hygiene was assessed by the simplified oral hygiene index. The maximum active interincisal oral opening was determined before surgery by using a millimeter scale, from the upper incisive edge to the lower incisive edge. Pain and inflammation were in turn recorded in written form by each patient 2, 6, and 12 hours after the operation and every day thereafter for 7 days.

RESULTS

Maximum postoperative pain was recorded 6 hours after extraction, with peak inflammation after 24 hours. The patients with the poorest oral hygiene reported higher pain levels throughout the postoperative period and more analgesic consumption in the first 48 hours. In contrast, oral hygiene appeared to exert no influence on either trismus or inflammation.

CONCLUSIONS

Poor oral hygiene before the surgical removal of 190 impacted lower third molars is correlated with greater postoperative pain.

Bacteremia and intraoral suture removal: can an antimicrobial rinse help?

Recent studies have shown that bacteremia can result from the removal of intraoral sutures. The authors found that preprocedural use of an antimicrobial oral rinse (0.12 percent chlorhexidine) did not significantly reduce the incidence of bacteremia when compared with no rinse at all. Similarly, a significant relationship between bleeding and bacteremia was not apparent. Most of the positive cultures yielded low colony counts. The results support the rationale for the American Heart Association's 1997 recommendations for use of antibiotic prophylaxis to prevent bacteremia, as well as the importance of good oral hygiene in prevention efforts.

Alveolar osteitis (dry socket) in a dog: a case report

Following extraction of a maxillary left first molar tooth in an eight year-old retriever, the dog re-presented five days later because of oral pain, which did not respond to analgesic therapy. The extraction site contained a foul-smelling fluid, but did not contain a clot or granulation tissue. Alveolar osteitis (dry socket) was diagnosed. The alveolus was curetted and flushed, and the dog was given cefalexine and prednisolone. The alveolus was filling with healthy granulation tissue one week later and the dog was no longer in pain.

Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: efficacy and risk factor analysis

OBJECTIVES

The purposes of this study were to evaluate the use of 0.12% chlorhexidine gluconate as a prophylactic therapy for the prevention of alveolar osteitis and to further examine subject-based risk factors associated with alveolar osteitis.

STUDY DESIGN

The trial was a randomized, double-blind, placebo-controlled, parallel-group study conducted among 279 subjects, each of whom required oral surgery for the removal of a minimum of one impacted mandibular third molar. Subjects were instructed to rinse twice daily with 15 ml of chlorhexidine or placebo mouthrinse for 30 seconds for 1 week before and 1 week after the surgical extractions. This regimen included a supervised presurgical rinse. Alveolar osteitis diagnosis was based on the subjective finding of increasing postoperative pain at the surgical site that was not relieved with mild analgesics, supported by clinical evidence of one or more of the following: loss of blood clot, necrosis of blood clot, and exposed alveolar bone.

RESULTS

In comparison with use of the placebo mouthrinse, prophylactic use of the chlorhexidine mouthrinse resulted in statistically significant (p < 0.05) reductions in the incidence of alveolar osteitis. With chlorhexidine therapy, the subject- and extraction-based incidences of alveolar osteitis in the evaluable subset (271 subjects) were reduced, relative to placebo, by 38% and 44%, respectively. The corresponding odds ratios that describe the increased odds of experiencing alveolar osteitis in the placebo group were 1.87 and 2.05 for subject- and extraction-based analyses, respectively. In comparison with nonuse of oral contraceptives, the use of oral contraceptives in female subjects was related to a statistically significant increase in the incidence of alveolar osteitis (odds ratio = 1.92, p = 0.035). Relative to male subjects, the observed incidence of alveolar osteitis for female subjects not using oral contraceptives was not statistically significant (odds ratio = 1.18, p = 0.64). Smoking did not increase the incidence of alveolar osteitis relative to not smoking (odds ratio = 1.20, p = 0.33).

CONCLUSIONS

These data confirm that the prophylactic use of 0.12% chlorhexidine gluconate mouthrinse results in a significant reduction in the incidence of alveolar osteitis after the extraction of impacted mandibular third molars. In addition, oral contraceptive use in females was confirmed to be a risk factor for the development of alveolar osteitis.

The effect of locally applied gauze drain impregnated with chlortetracycline ointment in mandibular third-molar surgery

A prospective randomized crossover, within-patient, controlled study was performed in 26 healthy patients to test the effect of the prophylactic local use of gauze drain impregnated with chlortetracycline (Aureomycin 3%, Lederle) ointment on postoperative alveolitis formation after surgical removal of 52 bilaterally impacted mandibular third molars. The teeth were removed on two separate occasions; on one side drain was inserted in the socket, and on the other side no drain treatment was used for control. The influence on postoperative pain, swelling, and mouth opening ability was investigated. The results indicated a statistically significant reduction (P = 0.02) in the incidence of postoperative inflammatory complications, defined as postoperative alveolitis, from 35% in the no-drain group to 4% in the drain group. No statistically significant difference was found between the two treatment methods with regard to pain and mouth opening reduction. There was a significant difference between the drain and no-drain treatment with regard to swelling on the 1st postoperative day in favor of the no-drain method. It is concluded that insertion of a chlortetracycline-impregnated drain may be an effective method for reducing postoperative alveolitis formation but has no beneficial effect on pain, swelling, and mouth opening reduction after impacted mandibular third-molar surgery.