Evaluation of the Need for Antibiotic Prophylaxis During Routine Intra-alveolar Dental Extractions in Healthy Patients: A Randomized Double-Blind Controlled Trial

Risk factors for oral infection and dry socket post-tooth extraction in medically complex patients in the absence of antibiotic prophylaxis: A case-control study

INTRODUCTION

Dry socket and infection are complications of tooth extractions. The objective was to determine risk factors for post-extraction complications in patients without antibiotic prophylaxis stratified by early- and late-complications and complication type (oral infection and dry socket).

METHODS

Retrospective, case (with complications)-control (without complications) study of patients (n = 708) who had ≥1 extraction performed at any Veterans Health Administration facility between 2015-2019 and were not prescribed an antibiotic 30 days pre-extraction.

RESULTS

Early complication cases (n = 109) were more likely to be female [odds ratio (OR) = 2.06; 95% confidence interval (CI):1.05-4.01], younger (OR = 0.29; 95% CI:0.09-0.94 patients ≥ 80 years old, reference:18-44 years), Native American/Alaska Native (OR = 21.11; 95% CI:2.33-191.41) and have fewer teeth extracted (OR = 0.53 3+ teeth extracted; 95% CI:0.31-0.88, reference:1 tooth extracted). Late complication cases (n = 67) were more likely to have a bipolar diagnosis (OR = 2.98; 95% CI:1.04-8.57), history of implant placement (OR = 8.27; 95% CI:1.63-41.82), and history of past smoking (OR = 2.23; 95% CI:1.28-3.88).

CONCLUSION

Predictors for post-extraction complications among patients who did not receive antibiotic prophylaxis were similar to prior work in cohorts who received prophylaxis. Unique factors identified in a medically complex population included being younger, Native American/Alaska Native, having mental health conditions, history of a dental implant, and fewer teeth extracted.

Use or abuse of antibiotics as prophylactic therapy in oral surgery: A systematic review

BACKGROUD

Antibiotics are a type of medication routinely prescribed by dental professionals; however, it is very common that the administration is not justified. Around 15% of dentists admit that they have administered antibiotics unnecessarily more than once a week. The objective of this project is to identify the effectiveness of the use of antibiotics as prophylactic therapy in oral surgery, and to carry out an analysis of the alternatives to pharmacological therapy.

METHODS

The search strategy was carried out in the PubMed, Scopus, and ScienceDirect databases. For study selection, a first filter was carried out by title and abstract, which mentioned the use of prophylactic antibiotics in some type of oral surgery. To establish the risk of bias, the JBI Critical Appraisal Checklist for Randomized Controlled Trials was utilized.

RESULTS

The type of antibiotics most prescribed as prophylactic therapy were beta-lactams, which were indicated in 100% of the studies. Penicillins predominated, observing amoxicillin as the most indicated drug in 54.1% of the studies (n = 13) followed by the use of amoxicillin in conjunction with clavulanic acid in 33.3% of the studies (n = 8). Of the 21 studies included, 17 mention that there is insufficient evidence to support the use of antibiotics as prophylactic therapy in patients who will undergo some type of oral surgery.

CONCLUSIONS

Without a doubt, the biggest challenge is to develop academic update strategies aimed at dentists with active clinical practice and dental students from educational and government institutions to provide updated information about the correct use of prescription drugs.

Antibiotics Efficiency in the Infection Complications Prevention after Third Molar Extraction: A Systematic Review

(1) Background: Antibiotics are used in every medical field including dentistry, where they are used for the prevention of postoperative complications in routine clinical practice during the third molar extraction. (2) Methods: This study is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The present systematic review aimed to evaluate and systematize the use of antibacterial drugs in order to prevent postoperative complications in outpatient oral surgery for wisdom teeth extraction. We conducted a systematic review using electronic databases such as Medline PubMed, Scopus, and the Cochrane Central Register of Controlled Trials. Considering inclusion and exclusion criteria, we included randomized clinical trials published up to 2021 investigating the antibiotic prescription for third molar extraction. (3) Results: We selected 10 studies after the application of inclusion and exclusion criteria. The results showed that the most widely used antibiotic was amoxicillin both with and without clavulanic acid, in different dosages and duration. There were no statistically significant differences between treatment groups for development of postoperative complications. (4) Conclusions: Based on the analysis of the included studies, penicillin is currently the most widely prescribed group of antibiotics. The widespread use of this antibiotic group can lead to antimicrobial resistance (AMR). Due to increasing prevalence of bacteria resistance to penicillins, clinicians should carefully prescribe these antibiotics and be aware that the widespread use of amoxicillin may do more harm than good for the population.

A comparative analysis of the efficacy of moxifloxacin and cefixime in the reduction of postoperative inflammatory sequelae after mandibular third molar surgery

Background/Aim. There is no scientific evidence that the prophylactic use of antibiotics as a part of the mandibular third molar surgery is effective in suppressing postoperative pain, edema, trismus, and dry socket. The aim of the study was to investigate the effects of antibiotics from the fluoroquinolone (moxifloxacin) and cephalosporin (cefixime) groups in reducing postoperative inflammatory sequelae (pain, edema, and trismus), as well as in possibly reducing the incidence of dry socket after mandibular third molar surgery. Methods. This double-blind study was completed by 157 subjects, comprising two study groups (who received the aforementioned antibiotics) and a control group, who received placebo tablets. Subjects were assessed on the first, second, and seventh day following surgery. In the postoperative course, patients were monitored for the occurrence, intensity, and duration of postoperative inflammatory sequelae and dry socket. Results. Both antibiotics, especially moxifloxacin, had a pronounced effect on reducing all inflammatory sequelae (pain, edema, and trismus) as the most common postoperative complaints following mandibular third molar surgery, and also contributed to reducing the incidence of dry socket. Conclusion. Antibiotic prophylaxis with cefixime and, especially moxifloxacin, reduced the occurrence of postoperative inflammatory sequelae and alleviated discomfort. It is interesting, that both antibiotics, especially moxifloxacin, also contributed to reducing the incidence of postoperative dry socket, which is not provoked by inflammation. Therefore, further research into the underlying mechanisms behind such an effect is warranted.

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.

Antibiotics or No Antibiotics, That Is the Question: An Update on Efficient and Effective Use of Antibiotics in Dental Practice

The antimicrobial resistance (AMR) phenomenon is an emerging global problem and is induced by overuse and misuse of antibiotics in medical practice. In total, 10% of antibiotic prescriptions are from dentists, usually to manage oro-dental pains and avoid postsurgical complications. Recent research and clinical evaluations highlight new therapeutical approaches with a reduction in dosages and number of antibiotic prescriptions and recommend focusing on an accurate diagnosis and improvement of oral health before dental treatments and in patients' daily lives. In this article, the most common clinical and operative situations in dental practice, such as endodontics, management of acute alveolar abscesses, extractive oral surgery, parodontology and implantology, are recognized and summarized, suggesting possible guidelines to reduce antibiotic prescription and consumption, maintaining high success rates and low complications rates. Additionally, the categories of patients requiring antibiotic administration for pre-existing conditions are recapitulated. To reduce AMR threat, it is important to establish protocols for treatment with antibiotics, to be used only in specific situations. Recent reviews demonstrate that, in dentistry, it is possible to minimize the use of antibiotics, thoroughly assessing patient's conditions and type of intervention, thus improving their efficacy and reducing the adverse effects and enhancing the modern concept of personalized medicine.

Antibiotic prophylaxis in oral and maxillofacial surgery: a systematic review

Surgical site infections are a complication of oral and maxillofacial procedures, with the potential for significant morbidity and mortality. Use of preoperative, perioperative, and postoperative antibiotic prophylaxis to reduce the incidence of surgical site infections must be balanced with considerations of a patients' risk of antibiotic-related adverse events. This review aimed to provide evidence-based recommendations for antibiotic prophylaxis. Searches were conducted using MEDLINE, the Cochrane Library, EMBASE, and PUBMED for maxillofacial procedures including: treatment of dental abscesses, extractions, implants, trauma, temporomandibular joints, orthognathics, malignant and benign tumour removal, and bone grafting, limited to articles published since 2000. A total of 98 out of 280 retrieved papers were included in the final analysis. Systematic reviews were assessed using AMSTAR criteria. Randomised controlled trials were assessed for bias using Cochrane Collaborative tools. The overall quality of evidence was assessed using GRADE. Prophylactic antibiotic use is recommended in surgical extractions of third molars, comminuted mandibular fractures, temporomandibular joint replacements, clean-contaminated tumour removal, and complex implants. Prophylactic antibiotic use is not routinely recommended in fractures of the upper or midface facial thirds. Further research is required to provide recommendations in orthognathic, cleft lip, palate, temporomandibular joint surgery, and maxillofacial surgical procedures in medically-compromised patients.

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.

Non-impacted tooth extractions and antibiotic treatment: A RCT study

OBJECTIVES

A controlled, single-blind, randomized clinical trial was performed to evaluate usefulness of antibiotics in preventing pain and complications after tooth extractions and benefits of probiotics in reducing gastro-intestinal symptoms associated with antibiotic therapy.

MATERIALS AND METHODS

A total of 159 patients were enrolled in this trial. After tooth extractions, patients were allocated to one of the groups: group 1 received postoperatively amoxicillin + clavulanic acid; group 2 received the same antibiotic therapy with an adjunctive probiotic treatment; and group 3 received neither antibiotics nor probiotics. Follow-up visits were planned at 7, 14, and 21 days after tooth extractions (T1, T2, and T3), and parameters assessed were pain, presence of abscess, edema, fever, alveolitis, trismus, pain, difficulty in daily routine activities, and gastro-intestinal symptoms.

RESULTS

The number of patients reporting pain at T1 was significantly higher in the control group when compared to group 2 (p = .016), while no difference for pain intensity was observed between groups. No surgical site infection was observed in any of the groups. Intestinal symptoms seemed to be tackled by probiotic administration.

CONCLUSIONS

Pain was the most important symptom in the control group. Antibiotics were not necessary after non-impacted tooth extractions, and probiotics can reduce gastro-intestinal symptoms associated with antibiotics.

Biocidal and bioresorbable chitosan/triclosan/collagen matrixes

Biomedical application of biomaterials has increased in recent years. Some preferred characteristics of these materials are biocompatibility, biodegradability and antimicrobial effect. We are facing a constant search for antimicrobial materials to be used instead of antibiotics therapy to reduce the possibility of dental surgery contamination. In this study, biocidal, bioresorbable and non-toxic matrixes were synthesized from chitosan, triclosan and collagen. Three experimental groups received different chitosan/collagen combinations, (0.5:1, 0.75:1 and 1:1), all with the same dose of triclosan (0.1%). Antimicrobial effect was measured by the inhibition of S. aureus growth. Moreover, matrixes were placed in a PBS-collagenase solution to measure degradation over time; matrix residues were evaluated at 1, 4, and 7 days. Finally, cell toxicity of each matrix was analyzed on NIH-3T3 fibroblast cells. As a result, inhibition of S. aureus growth was similar in the three established experimental groups of matrixes vs vancomycin antibiotic as control. These data suggest potent antimicrobial effect of chitosan/triclosan/collagen matrixes. Degradation over time showed that 80% of the matrix was degraded after 4 days, thus suggesting that chitosan/triclosan/collagen matrixes are bioresorbable material. On the other hand, viability of NIH-3T3 cells was between 60% to 74% after 24 h and prior to matrix exposition to culture cells. These data indicate light toxicity in the 0.5:1 and 0.75:1 matrix groups and non-toxic effect in the 1:1 matrix group. By taking together these data, we propose the application of chitosan/triclosan/collagen matrixes to prevent bacterial contamination after dental surgery.

Factors Influencing the Onset of Intra- and Post- Operative Complications Following Tooth Exodontia: Retrospective Survey on 1701 Patients

Complications after tooth extraction may occur because of several factors correlated to the patient's medical history, surgical site or type of intervention. The aim of this retrospective cohort study was to evaluate type and frequency of complications after exodontic surgery, its correlation with antibiotic administration and between patient's related systemic factors. From June 2015 until February 2016 1701 exodontic interventions, for a total of 2322 extracted teeth, were carried out at the Unit of Oral Surgery in Trieste. Descriptive statistic, and backward multiple logistic regressions were performed to identify the variables associated with the presence of post-operative alveolitis or any other post-operative complication. The presence of coagulopathy and smoking habit were related to high risk of post-operative alveolitis (OR = 5.51, p = 0.035 and OR = 2.5, p = 0.029, respectively). Tooth fracture was found to be correlated with higher probability of post-operative alveolitis (p = 0.001) and concomitant chemotherapy put at a higher risk post-operative complications, including alveolitis (OR = 29.5, p = 0.018). According to the present results, antibiotic consumption did not seem to reduce the incidence of post-operative infective complications (alveolitis). A careful analysis of medical history, the adequate surgical technique, and the correct instructions in post-surgical behavior, prevent the insurgence of intra and post-operative complications.

Assessment of the bioavailability of an antibiotic prophylactic protocol in patients undergoing third molar surgery

The aim of this prospective study was to determine the antibiotic bioavailability of a prophylactic protocol in patients undergoing third molar surgery. Samples from 25 patients were analysed (average age 21 ± 3.89 years, range 18-33 years; 14 female). The patients received single-dose prophylaxis of 2 g amoxicillin orally 1 hour prior to third molar surgery. Venous blood (1.5 ml) and blood from the third molar socket (1.50 ml) were obtained. The amoxicillin plasma concentration was determined in both samples by high performance liquid chromatography with a diode-array detector (HPLC/DAD). Their associations with demographic variables (age, height, weight, body mass index (BMI), sex) and antibiotic exposure time were analyzed using linear regression models. The mean amoxicillin plasma level detected in the venous blood was 1.21 ± 1.17 μg/ml (range 0.49-6.34 μg/ml) and in the third molar socket was 4.14 ± 2.24 μg/ml (range 0.86-7.46 μg/ml) (P <  0.001). No relationship was observed between the bioavailability of the drug and the patient biometric indices evaluated. The prophylactic administration of 2 g amoxicillin in third molar surgery showed greater bioavailability in the molar socket than the concentrations established as necessary to inhibit the growth of microorganisms that cause oral infections. The results show the need to review the current infection control protocols in oral surgery in light of the overestimated doses observed.