The effect of tetracycline on the incidence of postextraction alveolar osteitis

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four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies.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

Antibiotics in Dentoalveolar Surgery, a Closer Look at Infection, Alveolar Osteitis and Adverse Drug Reaction

PURPOSE

To execute an evidence-based review answering the following questions: "What antibiotic type and mode of delivery are most effective at reducing inflammatory complications in third molar and dental implant surgery? What are the types and rates of antibiotic-related adverse reactions in the context of third molar surgery, infective endocarditis, medication-related osteonecrosis of the jaw (MRONJ) and osteoradionecrosis (ORN)?"

MATERIAL AND METHODS

We performed a comprehensive literature review of peer-reviewed studies using MEDLINE/PubMed, Cochrane, Scopus/Elsevier, Google Scholar, and Wiley online library databases.

RESULTS

Twenty-five studies were reviewed for third molar surgery. Although there is some evidence that systemic antibiotics reduce inflammatory complications (infection and alveolar osteitis), routine use is not recommended for third molar surgery. For at-risk cases, a single preoperative dose of amoxicillin is preferred. Clindamycin, amoxicillin-clavulanic acid and erythromycin have a high adverse risk profile. Eight studies were reviewed for dental implant surgery. Antibiotics with dental implant placement showed little reduction in post surgery infection and minimal improvement in long-term success. A comprehensive search found limited data on antibiotic-related adverse effects in the context of infective endocarditis, MRONJ and ORN.

CONCLUSIONS

A set of clinical recommendations are presented to better guide evidence-based and standardized antibiotic usage on the basis of the literature discussed in this review. This review highlights the need for further research focusing on antibiotic type and timing of delivery with adverse drug reaction as a primary outcome measure when assessing treatment outcomes and complications in dentoalveolar surgery. This will better elucidate the risks vs benefits of antibiotic in dentoalveolar surgery.

Complications of Dentoalveolar Surgery

This article explores how to prevent and manage complications of dentoalveolar surgery. Many complications are avoidable. Surgical skills and knowledge of anatomy play an important role in prevention of complications. Prevention starts with detailed history and physical examination of the patient. Key to perioperative management of patients is risk assessment. Without a proper history and physical examination, the clinician is unable to assess the risk of performing surgery and anesthesia for each patient. Some illnesses and medications increase the risk of complications. The following complications are discussed: alveolar osteitis, displacement, fracture, hemorrhage, infection, nonhealing wound, oroantral communication, swelling, and trismus.

The efficacy of 1% Betadine mouthwash on the incidence of dry socket after mandibular third molar surgery

Background

Dry socket or alveolar osteitis is a delayed healing of alveolar bone after exodontia causing moderate to severe pain 2-4 days after extraction of teeth. Antibacterial agents such as antibiotics and chlorhexidine have been previously proved to prevent or reduce the incidence of dry socket. Betadine is a mixture of iodine and povidone which has bactericidal, antifungal and antiviral effects. The aim of the present study was to evaluate the effect of preoperative povidone iodine 1% mouthwash before surgical extraction of impacted mandibular third molar, however age, gender and oral hygiene were also considered.

Material and Methods

189 patients who needed surgical extraction of Pell and Gregory class A and B mandibular third molars were included in this study. The patients who were not willing to participate in the study, took, women who took oral contraceptives or were in the first 22 days of menstrual cycle were excluded. Patients were randomly assigned to control or test group. 97 patients in the test group took preoperative povidone iodine 1% mouthwash and 92 patients in the control group didn’t take any antibiotic or mouthwash. Patients were examined in days 3 and 7 postoperatively for incidence of alveolar osteitis.

Results

Chi-square test didn’t show any significant relation between dry socket incidence and gender (p value: 0.848) and Oral hygiene (p value: 0.866). However, it revealed a significant relation between age and dry socket incidence (p value: 0.003) and patients older than 30 were reported to have higher incidence of dry socket. Independent T-Test showed a significant difference between the test and control group in incidence of dry socket (p value: 0.036).

Conclusions

Based on the results of this study povidone iodine 1% mouthwash can decrease dry socket incidence also as the age increases, the incidence of dry socket becomes higher.

Key words:Dry socket, impaction, betadine, povidone iodine.

Alveolar Osteitis: Patients' compliance to post-extraction instructions following extraction of molar teeth

Background:

To evaluate the effect of various combination of post-extraction regimen administered to patients who had intra-alveolar molar tooth extraction.

Patients and Methods:

One year prospective study involving 76 consenting patients who came for 1-week post-extraction review. The patients were placed on warm saline mouth rinse with (verbal instruction) or without antibiotic and or analgesic therapy (written prescription), after intra-alveolar molar tooth extraction. Information was obtained from the patients through questionnaire and clinical examination.

Results:

The patients were placed on warm saline mouth rinse (n = 29, 38.2%) only, warm saline rinse, antibiotics (Amoxicillin and metronidazole) and Paracetamol (n = 31, 40.8%), Paracetamol and warm saline rinse (n = 12, 15.8%) and antibiotics (Amoxicillin and metronidazole) and Paracetamol (n = 4, 5.3%). A total of 63 (82.9%) patients complied with the post-extraction regimen, giving a significant high compliance to the post-extraction instructions (P = 0.001). There were 10 (13.2%) cases of post-extraction localised alveolar osteitis, with predilection for the lower molar teeth (n = 6, 7.9%) and a significant predilection for females (n = 8, 10.5%) [P = 0.005]. Overall, there were five (6.6%) cases each of localised alveolar osteitis in the compliant patients (n = 63, 82.9%) and non-compliant patients (n = 13, 17.1%), giving a ratio of 1:13 and 1:3, respectively. There was significant association of compliance with post-extraction instruction and the reduced incidence of localized alveolar osteitis (P = 0.015).

Conclusion:

This study showed a significant patients’ compliance with post-extraction warm saline rinse, prophylactic antibiotics and analgesic and a corresponding significant reduction in the incidence of localised alveolar osteitis following intra-alveolar molar tooth extraction. This study emphasises the need to properly educate patients on the effect of compliance to various combination of post-extraction regimen.

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.

Experimental alveolitis in rats: microbiological, acute phase response and histometric characterization of delayed alveolar healing

The pathogenesis of alveolitis is not well known and therefore experimental situations that mimic some features of this disease should be developed.

OBJECTIVE

In this study, the evolution of the experimentally induced infection in rat sockets is characterized, which leads to clinical signs of suppurative alveolitis with remarkable wound healing disturbs.

MATERIAL AND METHODS

Non-infected (Group I) and experimentally infected sockets in Rattus novergicus (Group II) were histometrically evaluated regarding the kinetics of alveolar healing. In addition, the characterization of the present bacteria in inoculation material and the serum levels of C-reactive protein (CRP) were performed. The detected species were Capnocytophaga ochracea, Fusobacterium nucleatum ss nucleatum, Prevotella melaninogenica, Streptococcus anginosus, Treponema socranskii and Streptococcus sanguis.

RESULTS

All experimentally infected rats developed suppurative alveolitis, showing higher levels of CRP in comparison to those non-infected ones. Furthermore, infected rats presented a significant delayed wound healing as measured by the histometric analysis (higher persistent polymorphonuclear infiltrate and lower density of newly formed bone).

CONCLUSION

These findings indicate that rat sockets with experimentally induced infection produced higher levels of serum CRP, showing the potential of disseminated infection and a disturb in the alveolar repair process in an interesting experimental model for alveolitis studies.

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.

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.

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.

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.

Quantifying the healing of dry socket using a clinical volumetric method

OBJECTIVES

To quantify the healing of dry sockets using a simple clinical volumetric method that measures the reduction in the volume of dry sockets and to study the effects of sex and smoking on socket healing.

STUDY DESIGN

Volumes of 28 mandibular dry sockets were measured under standard conditions by injecting sterile normal saline solution into them and aspirating the solution back into a calibrated syringe. Measurements were done at diagnosis (T0), at 4 days after diagnosis (T4), at 7 days after diagnosis (T7), and at 14 days after diagnosis (T14). Differences in socket volumes at different intervals were analyzed using paired samples t test and differences between males and females or between smokers and nonsmokers were analyzed using independent samples t test.

RESULTS

Average socket volume in all patients decreased by an average of 5.16% daily from 1.44 (+/- 0.36) mL at T0 to 1.08 (+/- 0.43) mL at T4, 0.74 (+/- 0.35) mL at T7, and 0.40 (+/- 0.28) mL at T14. These differences were statistically significant (P = 0.00). No statistically significant difference in the rate of socket healing was found between males and females or between smokers and nonsmokers.

CONCLUSION

Dry socket healing can be quantified using the volumetric method described in this study. Sex and smoking do not appear to affect the rate of dry socket healing.

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.

Histomorphometric evaluation of the effect of doxycycline on the healing of bone defects in experimental diabetes mellitus: a pilot study

PURPOSE

Bone healing is impaired in diabetes mellitus, particularly due to increased collagen breakdown. Recently, tetracyclines have been used to treat experimental bone defects because they have anticollagenolytic properties, and positive effects on the healing process have been obtained. The objective of this study was to develop a computer-assisted histomorphometric technique to quantitatively determine the amount of regenerating bone within experimental bone defects in a diabetic rodent model.

MATERIALS AND METHODS

This study examined the effects of systemic doxycycline administration on the healing of tibial bone defects in healthy albino rats and in experimentally induced diabetic rats. Twenty-four female albino rats were assigned to 4 groups: diabetic, diabetic plus doxycycline, control, or control plus doxycycline. The standardized bone defects were histomorphometrically examined 10 and 30 days postoperatively. Histomorphometric analysis of the amount of new bone formation was performed using the Zeiss Vision image analysis program KS 400 (Kontron Elektron GmbH, Eching, Germany).

RESULTS

At 10 days of healing, the diabetic groups exhibited inferior healing compared with the control groups in terms of the amount of new bone formation within the defects. However, the effect of doxycycline administration to the diabetic and control groups was not statistically different. At 30 days of healing, there were no statistically significant differences between the amount of newly formed bone in any of the groups.

CONCLUSIONS

This study found that doxycycline administration did not significantly alter the amount of new bone formation during the healing of bone defects in control and diabetic rats.

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.

Reduction in the incidence of alveolar osteitis in patients treated with the SaliCept patch, containing Acemannan hydrogel

PURPOSE

In the present study, we compared the incidence of alveolar osteitis (AO) in patients treated with either clindamycin-soaked Gelfoam (Pharmacia and Upjohn Co, Kalamazoo, MI) or SaliCept Patches (Carrington Laboratories, Inc, Irving, TX). The SaliCept Patch is a freeze-dried pledget that contains Acemannan Hydrogel (Carrington Laboratories) obtained from the clear inner gel of Aloe vera L.

PATIENTS AND METHODS

A retrospective evaluation was performed of the records of 587 patients (1,031 sockets) whose extraction sites had been treated with clindamycin-soaked Gelfoam. A prospective trial was conducted in which 607 patients (1,064 sockets) had 2 SaliCept Patches placed immediately after extraction. The same surgeon treated all patients.

RESULTS

Analysis restricted to mandibular third molar sites showed that 78 of 975 sites (8.0%) in the Gelfoam group developed AO, whereas only 11 of 958 sites (1.1%) in the SaliCept group developed AO (P <.0001). Further analysis of all extraction sites revealed that the incidence of AO in the Gelfoam group was 7.6% compared with 1.1% in the SaliCept-treated group (P <.0001).

CONCLUSIONS

The study results suggest that the SaliCept Patch significantly reduces the incidence of AO compared with clindamycin-soaked Gelfoam.

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.

Alveolar osteitis prevention by immediate placement of medicated packing

OBJECTIVE

The purpose of this study was to evaluate whether immediate placement of medicated dry socket packing would decrease the incidence of alveolar osteitis (dry socket) with lower third molar extractions.

STUDY DESIGN

In 100 patients, 200 lower third molars were extracted. One half of the sockets were packed to the crest of the alveolar ridge with a one-quarter-inch radiograph-detectable filament gauze that contained 9% eugenol, 36% balsam of Peru, and 55% petroleum jelly. The medicated packing was removed 1 week after surgery. None of the patients were taking antibiotics. Patients were instructed to increase their oral hygiene before and after surgery and were to use 0.12% chlorhexidine gluconate 2 days before and 3 days after surgery. RESULTS; Two hundred bilateral lower third molars of varying difficulty were extracted. The overall alveolar osteitis rate was 34 (17%). The immediately packed lower third molar sites had an alveolar osteitis rate of 8 (8%). The sockets that were not packed with medicated packing the day of surgery had an alveolar osteitis rate of 26 (26%). The difference was statistically significant (P =.001).

CONCLUSION

The results of this study suggest that placement of medicated dry socket packing immediately after lower third molar extraction decreases the alveolar osteitis rate.

Dental extraction wound management: medicating postextraction sockets

The rather impressive percentage of extraction sites undergoing clot loss and deranged healing results in significant morbidity for the patient and frequent visits to the surgeon to effect relief of discomfort, most often by the use of anodyne dressings. The amount of work lost by patients needing such palliative treatment, and loss of productive time for the surgeon, translate into an unknown, but potentially large, economic loss to society. This would mandate that economical methods of ensuring normal extraction socket healing with minimal morbidity be developed. The most useful socket medicaments to prevent socket healing derangements would include broad-spectrum antibiotics, specifically clindamycin and tetracycline. Not discussed in this article, but possibly germane to the subject of clot stabilization and healing, is consideration of resorbable substances such as gelatin sponge, polylactic acid, and methylcellulose as clot-stabilizing socket implants. The record of such substances in preventing AO is mixed, but the combinations of these inexpensive materials with topical socket medicaments may yield a decreased tendency for clot lysis and greater mechanical strength to the bulk blood clot, as has been demonstrated with difficult mandibular third molar impactions in one study involving polylactic acid, tetracycline, and hydrocortisone.

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.

Evaluation of topical viscous 2% lidocaine jelly as an adjunct during the management of alveolar osteitis

PURPOSE

This study evaluated the efficacy of topical viscous 2% lidocaine jelly for the alleviation of pain experienced during the instrumentation of mandibular third molar extraction sites diagnosed with alveolar osteitis and for pain relief during the postinstrumentation period.

PATIENTS AND METHODS

Thirty adult patients with a diagnosis of alveolar osteitis in a mandibular third molar extraction site were included in this prospective, double-blind study. Each patient had their sutures removed, the socket irrigated, and 2% lidocaine jelly placed on the tip and side of the tongue to blind the patient against the test substances. The subjects were then randomly distributed into two groups. Group 1 had a nonactive jelly base placed into the socket 2 minutes prior to the placement of a standard obtundant dressing. Group 2 had viscous 2% lidocaine jelly placed into the socket in the same manner. Patients subjectively quantified their pain intensity pretreatment, during instrumentation, immediately postmanipulation, at 5-minute intervals to 30 minutes, and at 45 and 60 minutes. They also subjectively quantified their pain relief at each of the time intervals following instrumentation.

RESULTS

There was no statistical difference between the pretreatment pain experienced by both groups. The use of 2% lidocaine jelly had a measurable (P = .056), but not statistically significant, effect on pain due to instrumentation. At every time interval thereafter, the use of 2% lidocaine jelly elicited a statistically significant (P < .05) decrease in pain perception, and a statistically significant increase in pain relief when compared with the inactive jelly.

CONCLUSION

Topical viscous 2% lidocaine jelly is a useful adjunct during the treatment of alveolar osteitis, especially in the early (< or = 60 minutes) postinstrumentation period.

The effect of polylactic acid granules on the incidence of alveolar osteitis after mandibular third molar surgery. A prospective randomized study

OBJECTIVE

To evaluate the effect of polylactic acid granules placed in third molar sockets on the incidence of alveolar osteitis.

STUDY DESIGN

A prospective randomized study with 161 patients (322 bilaterally impacted mandibular third molars).

RESULTS

The sockets in which the polylactic acid granules were placed had a significantly higher rate of alveolar osteitis (23.6%) than did the control sockets (13.58%). In all subgroups analyzed, the incidence of alveolar osteitis was higher in the experimental (polylactic acid) group.

CONCLUSION

On the basis of the findings of this study, polylactic acid granules do not reduce the incidence of alveolar osteitis and may actually contribute to a higher incidence of alveolar osteitis.

Experimental topical tetracycline-induced neuritis in the rat

PURPOSE

Recent studies have reported that tetracycline may induce chronic inflammatory responses in the adjacent soft tissues. The purpose of the present study was to determine if dry, powdered tetracycline evoked an inflammatory response in nerve tissue.

MATERIALS AND METHODS

Twenty male Sprague-Dawley rats were anesthetized and bilateral mental nerves were exposed. Half of the 40 nerves were intentionally injured by removing the epineurium, and the remaining nerves were uninjured. In a prospective, randomized, double-blind manner, equal volumes of color-matched, precoded tetracycline powder or Gelfoam (Upjohn, Kalamazoo, MI) powder control was placed in intimate contact with the nerves and sealed in polyethylene tubes. Forty-five days later the animals were killed and 5-micron sections of the nerves were prepared for histologic examination. The presence of epineurium, fascicular number, and fascicular area were measured. An inflammatory response in nerve tissue and the intrafascicular and epifascicular inflammatory index was measured by counting darkly stained nuclei with a Jandel Video Analysis System (Jandel Scientific, Corte Madera, CA).

RESULTS

Experimental injury (ie, epineurectomy) of nerves resulted in a statistically significant increase in fascicular number (P = .034), but not in fascicular area. For the intrafascicular inflammatory index, there was a significant main effect for drug (P = .002) and injury (P = .002). Experimental injury in both Gelfoam control and tetracycline grouped nerves resulted in an increase in intrafascicular inflammation. There was no significant increase in intrafascicular inflammation in either Gelfoam control or tetracycline grouped nerves when the epineurium was intact. The combination of both tetracycline and epineurectomy resulted in the largest increase in intrafascicular inflammation found among the groups studied. For epifascicular inflammatory index, there was a significant main effect for drug (P = .003) and injury (P = .001) that mirrored the intrafascicular inflammatory pattern.

CONCLUSION

The results of the present study suggest that dry, powdered tetracycline accentuates the inflammatory response in intrafascicular and epifascicular nerve tissue following epineurectomy. The maintenance of epineurium inhibited the inflammatory response in intrafascicular and epifascicular nerve tissues. Gel-foam was an inert material when placed against exposed nerve tissue. These findings suggest that tetracycline should not be placed in extraction sockets when injury of the inferior alveolar and/or lingual nerves are present.

Effect of chlorhexidine rinse on the incidence of dry socket in impacted mandibular third molar extraction sites

This nonrandomized prospective study was conducted in a private practice setting to determine the effect of a 0.12% chlorhexidine gluconate rinse (Peridex, Proctor and Gamble, Cincinnati, Ohio) on the incidence of dry socket after removal of impacted mandibular third molars. Over a 3-year period, 371 patients (total of 654 impacted mandibular third molars) received either no treatment (group 1), 2 weeks of twice daily Peridex rinse postsurgery (group 2), or one rinse presurgery (group 3). The group that used Peridex twice daily for 2 weeks after surgery (group 2) showed a significant reduction (56%) in the incidence of dry socket when compared with either the group that did not rinse (group 1) or the group that rinsed only once just before surgery (group 3). The incidence of dry socket was higher in smokers and in females who used oral contraceptives. Twice daily use of Peridex for 2 weeks also yielded significant reductions in dry socket in smokers, nonsmokers, and in females who did not use oral contraceptives. Results from this study demonstrate that the use of Peridex for 2 weeks after surgery is effective in prevention of dry socket after surgical extraction of impacted molars.

Prophylactic application of an intra-alveolar socket medicament to reduce postextraction complications in HIV-seropositive patients

A prospective, controlled trial was performed to investigate the effect of a prophylactic socket medicament containing chlortetracycline, aspirin, and local anesthetics, in reducing the incidence of postextraction pain and infection in patients who are HIV-seropositive. Fifty patients were in the study; 25 received the experimental dressing and 25 had no dressing. Patients were asked to complete a questionnaire rating the pain at 24 hours and 48 hours after surgery. Seven days after extraction, socket healing was scored, and sockets with delayed healing sampled for culture. Four of 25 (16%) patients who received the experimental dressing and 8 of 25 (32%) controls experienced pain during the 48 hours after extraction (p = not significant). None of the group who received the experimental dressing and 7 of 25 (28%) in the control group had delayed healing, of these 4 had alveolar osteitis and three had infected sockets (p = 0.0096). We conclude that the experimental agent is useful as a prophylactic agent to reduce delayed healing in HIV-positive patients who undergo exodontia.

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

A double-blind study evaluated the ability of 0.12% chlorhexidine rinse to decrease the incidence of localized alveolar osteitis after the removal of mandibular third molar teeth. One hundred sixty extraction sites in 80 patients were evaluated. A statistically significant decrease in the incidence of dry socket was seen in patients using the chlorhexidine rinse with no significant adverse reactions. Thus a 0.12% chlorhexidine rinse is shown to be an effective means of decreasing alveolar osteitis that may follow removal of third molar teeth.

Prevention of dry socket: an overview

Dentists, exodontists, oral surgeons, and now oral and maxillofacial surgeons have been plagued with a postextraction complication, commonly known as "dry socket," since the inception of our profession. Other designations that have been attached to this malady over the years include alveolar osteitis, postextraction osteitis, osteomyelitic syndrome, alveolar sicca dolorosa, and, latterly, fibrinolytic alveolitis. Myriad attempts to eliminate this painful condition have been made, to no avail. Nonetheless, significant progress has been made in an endeavor to reduce its incidence. Perhaps it is time to take an inventory of the proven methods that will assist the practitioner in reducing the incidence of this complication in his/her practice. This article presents a review of past investigations that appear to have merit in this regard, with a summary of recommendations at the conclusion of the article.

A double-blind study on the effectiveness of tetracycline in reducing the incidence of fibrinolytic alveolitis

This study presents the results of a double-blind study evaluating the effectiveness of topical tetracycline used as a suspension in a square of gelatin sponge and placed in the sockets of extracted mandibular third molars for the prevention of dry socket. An assessment of the relationship between the amount of bone relief (trauma) incidental to the surgery and the occurrence of dry socket also is made. Dry socket occurred in 20.4% of the placebo-treated sockets, whereas the incidence in the tetracycline-treated sockets was 3.9%. No correlation was observed between the amount of bone relief attendant to the surgery and the incidence of dry socket. It is concluded that tetracycline is an effective prophylaxis for fibrinolytic alveolitis.