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

Antimicrobial Activity of Antibacterial Sutures in Oral Surgery: A Scoping Review

OBJECTIVE

The aim of this scoping review was to explore and synthesise the current evidence on the antimicrobial activity of antibacterial suture materials used in oral surgery.

METHODS

The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. A bibliographic search was carried out in the PubMed and Scopus databases to retrieve all human clinical studies that investigated the antimicrobial efficacy of antibacterial-coated sutures used in oral surgery. Included studies were screened and extracted independently by 2 examiners. Data were tabulated and qualitatively described.

RESULTS

The search initially returned 150 articles and resulted in 5 included studies after the duplicates' removal and the full-text screening. Selected studies were published from 2014 to 2019. Three studies (60%) were randomised clinical trials, whilst the remaining studies did not report information on randomisation. The antimicrobial agents for coated sutures included triclosan and chlorhexidine. In almost all the studies, antibacterial-coated sutures exhibited lower bacterial retention compared to those without coating.

CONCLUSIONS

Within limitations, the antimicrobial-coated sutures employed in oral surgery exhibited good results in terms of their microbicidal activity when compared with sutures that were not coated. Considering the high variability and confounding factors identified in the included studies, more high-quality research is needed to confirm these results. Antimicrobial-coated sutures could represent a promising and clinically valid strategy to reduce microbial colonisation in oral surgery. The reduced bacterial adherence is likely to improve the clinical success of the surgical procedures. Yet, the cost-benefit ratio of antimicrobial-coated sutures should be assessed in larger clinical trials to confirm their efficacy over conventional noncoated sutures.

How to avoid pitfalls when referring patients to otolaryngology

ABSTRACT

Delayed, faulty, incomplete, or misdiagnosed referrals to otolaryngology (also called ear, nose, and throat, or ENT) can result in physical and monetary harm to the patient and time spent by clinicians in reordering the appropriate diagnostic tests. This article describes how to refer patients to ENT in the most time- and cost-effective ways, and addresses initial management in primary care.

Comparison of the postoperative anti-inflammatory efficacy of chlorhexidine, saline rinses and herbal mouthwashes after mechanical debridement in patients with peri-implant mucositis: A randomized controlled trial

AIM

The null hypothesis is that there is no difference in the post-operative anti-inflammatory efficacy of chlorhexidine (CHX), 2% saline rinses (SR) and a herbal mouthwash (MW) after non-surgical mechanical debridement (MD) for treatment of peri-implant mucositis (PiM). The aim was to compare the post-operative anti-inflammatory efficacy of CHX, 2% SR and a herbal oral rinse after non-surgical MD of PiM.

MATERIALS AND METHODS

The present randomized controlled trial had a single-blinded parallel arm design. Patients diagnosed with PiM were enrolled. Demographic information was recorded. All patients underwent MD and were randomly divided into 4 groups: CHX-group: 0.12% non-alcoholic CHX; Sodium chloride (NaCl) group: 2% NaCl rinses; Herbal MW group: Herbal-based MW and H₂ O group: distilled water with peppermint flavour. After MD, all the participants were advised to rinse twice daily (every 12 hrs) for 2 weeks with their respective MWs. In all groups, peri-implant modified plaque index (mPI), modified gingival index (mGI) and probing depth (PD) were measured at baseline and at 12 weeks of follow-up. Sample size was estimated using data from a pilot investigation; and group-comparisons were performed. Statistical significance was confirmed when P-values were below 0.01.

RESULTS

Sixty individuals (15 patients/group) were included. At baseline, mPI, mGI and PD were comparable in all groups. At baseline, there was no significant difference in peri-implant mPI, mGI and PD in all groups. At 12-weeks' follow-up, there was a statistically significant reduction in peri-implant mPI (p < 0.01), mGI (p < 0.01) and PD (p < 0.01) in CHX, NaCl and herbal MW groups compared with H₂ O group. There was no significant relation between implant location, duration for which, implants were functional, gender and peri-implant clinical parameters in all groups.

CONCLUSION

After non-surgical MD, post-operative use of CHX and herbal and NaCl MWs is useful for the management of PiM in the short-term.

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.

Is it worth applying self-irrigation after third molar extraction? A randomised controlled trial

In this study, we aimed to examine the effectiveness of self-irrigation following the extraction of mandibular third molars. A randomised controlled clinical trial was conducted with 155 patients who had undergone extraction of a mandibular third molar. The irrigation group was instructed to self-irrigate the extraction socket with tap water using a syringe three times a day, starting seven days after the tooth extraction. The incidence of complications and mouth opening, halitosis, plaque/gingival index, and oral health-related quality of life (OHRQoL) were measured. The irrigation group showed a lower incidence of complications than the non-irrigation group. The halitosis, plaque, and gingival scores were lower by mean (SD) 19.66 (5.19), 0.58 (0.06), and 0.62 (0.08), respectively, in the irrigation group than in the non-irrigation group (p = 0.0001). A greater amount of food packing was associated with higher halitosis, plaque, and gingival scores and poorer OHRQoL (p < 0.05). Further, more frequent irrigation was associated with lower halitosis, plaque, and gingival scores and better OHRQoL (p ≤ 0.016). Self-irrigation of the extraction socket using a syringe containing tap water is a very effective method for keeping the extraction socket clean. This technique reduced halitosis, improved plaque and gingival indices, and increased OHRQoL.

Wound Healing Following Palatoplasty Using Either Honey or Warm Saline Mouth Bath for Postoperative Wound Care: A Randomized-Controlled Study

OBJECTIVE

To evaluate and compare the effect of honey or saline mouth bath for wound care on the rate of re-epithelisation of the lateral palatal defects and occurrence of early postoperative complications following palatoplasty.

METHODOLOGY

This was a prospective randomized study on participants with non-syndromic cleft palate conducted at a tertiary health institution in Lagos, Nigeria. The test group received oral honey drops for post-operative care for an initial period of two weeks post-surgery, while the control group had regular oral toileting using a warm saline solution. The primary outcome was epithelisation of lateral palatal defect at 2- and 4-weeks post repair. Descriptive and comparative statistics were computed, and the p-value was set at <0.05.

RESULTS

Fifty participants were recruited into the study, 24 in the Test group and 26 in the Control group. The frequency of occurrence of oronasal fistula in the Test group was 4.0% while in the Control group was 10.0%, however, this was not statistically significant. Complete epithelisation of the lateral palatal defect was clinically observed in 66.7% of the participants in the Test group at 2 weeks post-operation, while only 38.5% of participants in the Control group had clinically observed complete epithelisation at the same time point (β = 1.70, p = .035, 95% CI 1.122-26.533). At four weeks, all wounds had epithelised irrespective of the study group.

CONCLUSION

The application of honey appears to aid earlier epithelization of palatal surgical wounds following cleft palate repair and reduced the incidence of palatal fistula.

Is saltwater mouth rinse as effective as chlorhexidine following periodontal surgery?

Design Randomised prospective double-blind study.Case selection Thirty-seven chronic periodontitis patients were randomly prescribed either saltwater (n = 17) or chlorhexidine (n = 20) mouth rinse following open flap debridement. Gingival Index (GI), post-operative pain, mouth rinse satisfaction, matrix metalloproteinase activity and tasting were assessed at baseline, one week and 12 weeks.Data analysis Inter-group and intra-group comparisons were done for all the parameters recorded at different time intervals using Friedman, Wilcoxon signed-rank and Mann-Whitney U tests. P value less than 0.05 was considered statistically significant.Results There was a statistically significant decrease in GI from baseline to week 1/week 12 following surgery in both the groups. However, there was no significant difference between the groups at any time point.Conclusions Saltwater rinses are as efficient as 0.12% chlorhexidine in reducing inflammation following minimal invasive periodontal surgery. Being an inexpensive and easily accessible option, it might be considered the mouth rinse of choice during the early stages of wound healing.

Aetiology, Prevention and Management of Alveolar Osteitis-A Scoping Review

BACKGROUND

Alveolar osteitis (AO) is a poorly understood, common, painful complication following exodontia. It is sometimes managed by inappropriate prescription of antibiotics which contributes to the global threat of antimicrobial resistance. Use of intra-alveolar chlorhexidine also presents a serious risk of anaphylaxis to the patient.

OBJECTIVE

This scoping review aims to investigate the aetiology, prevention and management of AO and highlight the extent of inappropriate prescribing and intra-alveolar chlorhexidine use.

DESIGN

A scoping review was undertaken using the PRISMA guidelines. Medline, Ovid and Pubmed were searched between 2010 and 2020, from which 63 studies were selected for review that related to the aetiology, prevention or management of AO. Data were analysed for frequency of studies reporting information on risk factors for aetiology, prevention strategies and management including inappropriate management using antibiotic prescribing and intra-alveolar chlorhexidine.

RESULTS

Impaired immune response, surgical technique and age were identified as significant factors in the development of AO, while there is conflicting evidence regarding the effects of smoking and gender. With regard to prevention, the use of prophylactic antibiotics is not supported within the literature. Saline irrigation and eugenol pastes used preventively have been shown to be cheap and effective alternatives to chlorhexidine with no adverse effects. Hyaluronic acid and low-level laser therapies showed a significant reduction in pain and soft-tissue inflammation in the management of AO compared to Alveogyl.

CONCLUSIONS

Further understanding of the pathophysiology of AO is needed, in addition to large high-quality RCTs or long-term observational studies into the aetiology, prevention, and management of AO to produce up-to-date evidence-based clinical guidelines. Clinicians should also be mindful of their contribution to growing antimicrobial resistance and avoid inappropriate prescribing of antibiotics. Saline should replace chlorhexidine as the intra-alveolar irrigant of choice.

Effectiveness of warm saline mouth bath in preventing alveolar osteitis: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to assess the effectiveness of a warm saline mouth bath (WSMB) in preventing dry socket after tooth extractions. A systematic search for randomized controlled trials published until August 30, 2020, in seven databases was conducted: Cochrane, PubMed, Ovid Medline, Google Scholar, and OpenGrey databases, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry. The inclusion criteria were studies investigating the use of a warm saline mouth bath postoperatively in a population of participants who had a tooth extraction, compared to no mouth rinse at all/any other mouth rinse. The primary outcome assessed in the studies was the incidence of alveolar osteitis. Only eight randomized studies met all inclusion criteria and were selected for qualitative analysis. Six of the studies compared WSMB with antimicrobial rinses, and two studies compared WSMB with no-rinse. This review found no significant difference (P > 0.05) in the incidence of alveolar osteitis between WSMB and other antimicrobial rinses. Based on the results of this review, WSMB has potential in reducing post-operative complications such as alveolar osteitis following a routine or surgical extraction of teeth. However, more studies are needed to validate these findings, as most of the studies reviewed had a high level of bias.

Anti-inflammatory effect of salt water and chlorhexidine 0.12% mouthrinse after periodontal surgery: a randomized prospective clinical study

OBJECTIVES

The purpose of this study was to compare the anti-inflammatory efficacy of sodium chloride- and a 0.12% chlorhexidine mouth rinses in patients undergoing minimal invasive periodontal surgery.

MATERIALS AND METHODS

Forty-seven patients with a diagnosis of periodontitis and indication for access flap procedure were randomly selected. Group A: a sodium chloride (salt)water-based mouth rinse (test group) or group B: a 0.12% chlorhexidine mouth rinse (control group) administered after surgery. Gingival Index (GI) were evaluated in the whole mouth and in the surgical site at baseline (T1), a week later (T2), and 12 weeks (T3) after the treatment. Total MMP activity was measured in GCF using a commercial kit and plate reader. Medians of total MMP activity and GI were compared for time intervals T1 vs. T2, T1 vs. T3, and T2 vs T3 using Friedman tests and Wilcoxon signed rank tests, and were also compared between test and control using Mann-WhitneyU tests at each timepoint.

RESULTS

The average GI values showed significant differences between baseline and T2 (p = 0.0005) and baseline and T3 (p = 0.003) in the test group.

CONCLUSION

The sodium chloride-mouth rinse use after periodontal surgery seems to have similar anti-inflammatory properties as CHX mouth rinse and can be used regularly postoperatively after periodontal surgical procedures.

CLINICAL RELEVANCE

The use of salt water mouthwash showed an anti-inflammatory effect similar to CHX 0.12% after minimal invasive periodontal surgery. Salt water mouthwash is accessible to the world population and can contribute on the healing process after periodontal surgery.

Effect of St. John's wort oil and olive oil on the postoperative complications after third molar surgery: randomized, double-blind clinical trial

OBJECTIVES

This multicenter study aimed to evaluate the effects of St. John's wort oil and virgin olive oil on the postoperative complications and compare this with chlorhexidine gluconate plus benzydamine hydrochloride mouthwash after the removal of impacted third molar.

METHODS

A total of 90 patients in need of impacted third molar surgery were included in this study. All included patients were randomly divided into 3 groups. The patients in group 1 received St. John's wort oil; the patients in group 2 received virgin olive oil, and those in group 3 received mouthwash containing chlorhexidine gluconate plus benzydamine hydrochloride. The self-reported pain and difficulty during jaw function, trismus, facial swelling, number of analgesics used during first postoperative week, and postoperative periodontal condition including plaque accumulation, bleeding on probing, and periodontal pocket depth were compared between the groups.

RESULTS

No significant differences were found regarding the study variables.

CONCLUSIONS

The data of the present study supports that the use of essential oils provides efficient alternative to the gold standard chlorhexidine gluconate mouthwash in reducing postoperative complications and improving healing process without adverse effects after surgical removal of impacted third molars.

CLINICAL RELEVANCE

The use of essential oils showed similar results as the chlorhexidine gluconate mouthwash regarding swelling, mouth opening, pain, need for rescue medication, infectious complications (i.e., alveolar osteitis), and periodontal healing. Therefore, essential oils can be an alternative to routine mouthwashes to ensure oral hygiene after impacted third molar surgery.

Efficacy of a Rinse Containing Sea Salt and Lysozyme on Biofilm and Gingival Health in a Group of Young Adults: A Pilot Study

Objectives

To evaluate new mouth rinse containing sea salt, xylitol, and lysozyme on biofilm formation and gingival health in a group of young adults.

Methods

The subjects were divided into two groups of 15 subjects each: control (A) and experimental group (B). The Turesky modification of Quigley-Hein plaque index was used to evaluate plaque scores while the presence or absence of gingival bleeding was used to determine gingival health. Measurements were done at baseline and at the end of the one-month trial period by one blinded examiner on six representative teeth. Group (A) maintained standardized oral health practices for the duration of the experiment. In addition, group (B) rinsed with a tablespoon of the provided sea salt mouth rinse for 30 seconds once in the morning and at night. After the 30-day trial period, subjects in both groups were reassessed as per baseline. Results. There were no statistically significant differences in the overall reduction from baseline in the mean plaque and gingivitis scores on all surfaces or on individual surfaces.

Conclusion

Within the limitations of the study, rinsing with sea salt for thirty days did not affect the gingival and plaque scores in a group of young adults.

Efficacy of different methods used for dry socket prevention and risk factor analysis: A systematic review

BACKGROUND

Dry socket is one of the most common complications that develops after the extraction of a permanent tooth, and its prevention is more effective than its treatment.

OBJECTIVES

Analyze the efficacy of different methods used in preventing dry socket in order to decrease its incidence after tooth extraction.

MATERIAL AND METHODS

A Cochrane and PubMed-MEDLINE database search was conducted with the search terms "dry socket", "prevention", "risk factors", "alveolar osteitis" and "fibrynolitic alveolitis", both individually and using the Boolean operator "AND". The inclusion criteria were: clinical studies including at least 30 patients, articles published from 2005 to 2015 and written in English. The exclusion criteria were case reports and nonhuman studies.

RESULTS

30 publications were selected from a total of 250. Six of the 30 were excluded after reading the full text. The final review included 24 articles: 9 prospective studies, 2 retrospective studies and 13 clinical trials. They were stratified according to their level of scientific evidence using SIGN criteria (Scottish Intercollegiate Guidelines Network).

CONCLUSIONS

All treatments included in the review were aimed at decreasing the incidence of dry socket. Locally administering chlorhexidine or applying platelet-rich plasma reduces the likelihood of developing this complication. Antibiotic prescription does not avoid postoperative complications after lower third molar surgery. With regard to risk factors, all of the articles selected suggest that patient age, history of previous infection and the difficulty of the extraction are the most common predisposing factors for developing dry socket. There is no consensus that smoking, gender or menstrual cycles are risk factors. Taking the scientific quality of the articles evaluated into account, a level B recommendation has been given for the proposed-procedures in the prevention of dry socket.

Are systemic antibiotics necessary in the prevention of wound healing complications after intra-alveolar dental extraction?

This double-blind, randomized controlled study was done to assess the necessity of systemic antibiotics in the prevention of wound healing complications after intra-alveolar dental extraction. A consecutive recruitment method was used to allocate participants to two treatment groups. Subjects in group A (antibiotics group, n=75) received amoxicillin and metronidazole for 5 days postoperatively, while those in group B (placebo group, n=75) were given identical-looking placebo drugs in place of the antibiotics. Postoperative socket healing complications, pain, and compliance with postoperative instructions were assessed postoperatively. Healing was uneventful in 129 patients (86%). Twenty-one patients (14%) developed wound healing complications. Dry socket was the most common complication in the antibiotics group (six subjects), while acutely inflamed sockets was the most common in the placebo group (five subjects). Non-adherence to postoperative instructions and postoperative pain were found to be significantly associated with the development of wound healing complications. The prescription of antibiotics after routine intra-alveolar dental extraction in healthy patients may not play any significant role in preventing wound healing complications. However, non-compliance with postoperative instructions might be associated with increased wound healing complications.

Postoperative socket irrigation with drinking tap water reduces the risk of inflammatory complications following surgical removal of third molars: a multicenter randomized trial

Objectives

The primary aim of the present study was to evaluate the effectiveness of postoperative irrigation of the socket with drinking tap water on inflammatory complications following lower third molar removal.

Material and methods

A multicenter randomized controlled trial was carried out from June 2013 to June 2014. In one arm of the study, patients were instructed to irrigate the tooth socket and surgical site with a Monoject® Curved 412 Tip Syringe (Tyco/healthcare-Kendall, Mansfield, MA, USA) with tap water. In a second arm of the study, the standard postoperative instructions did not include irrigation instructions. The incidences of alveolar osteitis and wound infection were recorded for each group and analyzed by the Fisher’s exact test.

Results

A total of 280 patients with 333 mandibular third molars were analyzed. According to the intention-to-treat (ITT) analysis, inflammatory complications occurred in 18 cases in the Monoject® group (11.4 %) compared to 34 cases (19.1 %) in the control group (p = 0.04). These complications were associated with significant worse outcomes regarding quality of life, pain, and trismus and caused significantly more missed days of work or study. Female gender, age >26, bone removal, deep impacted third molars, less experienced surgeons, and a high amount of debris at the surgical site were also identified as risk factors for developing inflammatory complications following lower third molar removal.

Conclusion

Irrigation of the surgical site with drinking tap water using a curved syringe following removal of third molars is effective in reducing the risk of inflammatory complications.

Clinical relevance

Water is a very accessible, cost-effective irrigant without side effects and the results from this study have proven that it can be used to reduce the risk of inflammatory complications and associated morbidity following lower third molar removal.