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

The effects of chlorhexidine gel and tranexamic acid application after tooth extraction on the risk of alveolar osteitis formation: a double blind clinical study

BACKGROUND

Alveolar osteitis(AO), one of the most common complications occurring in 1-10% of cases following tooth extraction, occurs due to the disruption of clot formation in the extraction socket. This study aims to evaluate the effect of using absorbable gelatin sponge, chlorhexidine gel, and tranexamic acid agents on the development of AO following extraction.

METHODS

Between March and October 2023, the teeth of 98 healthy patients (average age: 38, range: 19-62) with extraction indications were extracted at Recep Tayyip Erdoğan University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery. 113 extraction sockets(85 molars and 28 premolars) were randomly treated with absorbable gelatin sponge(AGS), chlorhexidine gel with AGS, and tranexamic acid with AGS. Pain and edema levels were recorded using visual analog scale(VAS) ranging from 0 to 10 by the patients. Additionally, presence of halitosis, trismus and exposed bone was noted on forms on 3rd and 7th days (recorded as present or absent). The study prospectively aimed to prevent AO using 3 different dental agents in the extraction sockets. Statistical analyses of the study were conducted using the SPSS software package.

RESULTS

Alveolitis was observed in 12 out of 113 tooth extractions(%10.6). Pain and edema scores significantly decreased in absorbable gelatin sponge group on the 7th day (p < 0.05). Pain score on the 7th day in chlorhexidine group and age, edema score on the 7th day in tranexamic acid group, were found to be significantly higher (p < 0.05).

CONCLUSION

Incidence of AO, can be reduced by placing agents in the extraction socket, preventing post-extraction pain experienced by patients.

CLINICAL TRIALS ID

NCT06435832.

Prevalence and Factors Influencing Post-Operative Complications following Tooth Extraction: A Narrative Review

Background

Complications from dental extractions may result in multiple post-operative visits and adversely affect the patient's life. Preventing complications may decrease post-operative morbidity for the individual as well as lower societal costs, such as lost time from work and healthcare costs.

Objectives

This narrative review aims to assess the prevalence and factors influencing post-operative complications following tooth extraction, helping clinicians minimise the risk. Data Sources. Cross-sectional studies. Study Eligibility and Participants. Patients undergoing dental extractions. Our exclusion criteria included in vitro studies, animal studies, terminally ill patients, and tooth loss not due to dental extraction. Literature was collected from "PubMed" and "Web of Science" through search criteria based on the "PICO" framework. Twenty articles were used to formulate a prevalence table, and 156 articles were included for the factors influencing complications. Study Appraisal and Synthesis Methods. This narrative review was reported using the SANRA (a scale for the quality assessment of narrative review articles) checklist. Due to the scope of our narrative review and its associated objectives, the quality of cross-sectional studies (AXIS) will be conducted from the studies outlining the prevalence.

Results

Alveolar osteitis appears to be the most prevalent post-operative complication following tooth extraction. Predisposing factors can be significant in their ability to alter the risk of postoperative complications, and clinicians should provide patient-centred care to mitigate this risk. Limitations. Due to the breadth of context, a systematic review was not feasible, as it may have introduced heterogeneity.

Conclusion

This narrative review has highlighted an array of factors which can influence the prevalence of post-operative complications. Future research would benefit from individually reporting post-operative complications, reducing the heterogeneity in definitions of the complications, and including greater detail on the predisposing factors studied.

Root-shaped antibacterial alginate sponges with enhanced hemostasis and osteogenesis for the prevention of dry socket

Tooth extraction commonly causes uncontrolled bleeding, loss of blood clots, and bacterial infection, leading to the dry socket and bone resorption. Thus, it is highly attractive to design a bio-multifunctional scaffold with outstanding antimicrobial, hemostatic, and osteogenic performances for avoiding dry sockets in clinical applications. Herein, alginate (AG)/quaternized chitosan (Qch)/diatomite (Di) sponges were fabricated via electrostatic interaction, Ca²⁺ cross-linking, as well as lyophilization methods. The composite sponges are facilely made into the shape of the tooth root, which could be well integrated into the alveolar fossa. The sponge shows a highly interconnected and hierarchical porous structure at the macro/micro/nano levels. The prepared sponges also possess enhanced hemostatic and antibacterial abilities. Moreover, in vitro cellular assessment indicates that the developed sponges have favorable cytocompatibility and significantly facilitate osteogenesis by upregulating the formation of alkaline phosphatase and calcium nodules. The designed bio-multifunctional sponges display great potential for trauma treatment after tooth extraction.

Comparative Clinical Study Between Chlorhexidine Gel (0.2%) and Hyaluronic Gel (1%) in the Prevention of a Dry Socket After Tooth Extraction for Orthodontic Treatment

Introduction Several articles have investigated the intra-alveolar applications of bioadhesive gels containing various medicines and active chemicals, such as chlorhexidine (CHX) and hyaluronic acid (HA) to minimize the numerous postoperative sequelae, such as a dry socket. The purpose of this study was to investigate the postoperative outcomes of intra-alveolar application of 0.2% chlorhexidine or hyaluronic acid following atraumatic extraction. Methods A randomized clinical trial was conducted on a sample of 36 patients who need extraction of lower first premolar for orthodontic treatment. The patients were assigned randomly into two groups: CHX group and HA group. The signs and symptoms of the dry socket were evaluated on the third day in two groups. Results There was no statistically significant difference between the study and control groups when comparing the CHX group (P=0.2.6). In contrast, a significant difference was seen between the study and control sides in the HA group. Conclusions Within the limitation of this clinical trial, using hyaluronic gel with a gelatin sponge may be a preventive strategy for a dry socket following tooth extraction. After non-surgical tooth extraction, the topical administration of CHX with a gelatin sponge as a carrier did not seem to act as a protective substance against a dry socket.

Antimicrobial agent containing absorbable gelatin sponge to prevent dry socket: A systematic review

Background:

The use of absorbable gelatin sponges (AGSs) as a hemostatic surgical material resulted in a reduction of dry sockets occurrence. The systemic use of antibiotics and antimicrobial agents can also reduce the infection of extracted teeth, and therefore, it may show pain-relieving effects on the dry socket as well.

Objective:

Given the high prevalence of dry sockets in the extracted teeth, the main objective of this review was a brief overview of AGSs, including antimicrobial agents to prevent dry sockets.

Methods:

The electronic search of the literature was done on the Pubmed and Google Scholar databases with the MESH keywords of Antimicrobials, Gelatin sponge, Gelfoam, Dry socket, Antibiotics, Alveolar osteitis. Only papers published in English were investigated. No limitations were put on the publication date.

Results:

Of the 279 electronic papers, 79 articles were found relevant to the study. All abstracts were reviewed, and only desired articles were selected. The final electronic and manual search led to 15 articles for use in this study. Among these studies, 5 studies were related to AGSs, including antimicrobial agents to prevent dry sockets.

Conclusion:

The reviewed literature showed that the systemic/topical use of antibiotics and antimicrobial agents can reduce infection and, therefore, may show pain-relieving effects on the dry socket. Besides, antimicrobial-loaded AGSs can be helpful in curing or preventing dry sockets. There were a limited number of clinical trials that used antimicrobial loaded AGSs for dry socket. More clinical studies are needed, especially in subgroups of patients with a high risk of infectious conditions, to validate the effectiveness of antimicrobial-loaded AGSs for dry socket.

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.

Clinical Efficacy of 1% CHX Gluconate Gel and 0.12% CHX Solution: A Randomized Controlled Trial

Chlorhexidine (CHX) is an effective antibacterial agent and is used in dental treatment in several formulations. The aim of this study was to compare the effectiveness of CHX solution and CHX gel on dental plaque inhibition and gingivitis relief by a randomized clinical trial. Thirty-eight participants were randomly divided into two groups: control group (0.12% CHX solution) and test group (1% CHX gel). Participants were provided with CHX products and were instructed to use each product in the morning and evening for 1 week. Clinical results were evaluated by analyzing the collected data of Turesky et al. the modified Quigley-Hein Plaque Index (TQHPI), gingival index (GI) and the BANA test. Measurements were conducted 4 weeks and 8 weeks after using chlorhexidine products. The results were analyzed using repeated measured ANOVA and paired t-test. TQHPI and GI were significantly different after treatments in both groups (p < 0.001). The GI decreased more in the test group compared to the control group 4 weeks and 8 weeks later. In both groups, the BANA score also significantly decreased (p < 0.001) after 8 weeks, though the BANA score decreased relatively more in the CHX gel group than the CHX solution group. These results suggest that 1% CHX gel is more effective in reducing gingivitis and bacteria of periodontal disease than the 0.12% CHX solution. Therefore, the 1% CHX gel is expected to be actively used for non-surgical treatment of periodontal disease patients.

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

Background

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

Material and Methods

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

Results

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

Conclusions

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

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

Chitosan-CaP microflowers and metronidazole loaded calcium alginate sponges with enhanced antibacterial, hemostatic and osteogenic properties for the prevention of dry socket after tooth removal

Tooth removal, particularly for patients with severe periodontitis, can frequently cause massive bleeding, postoperative infection, and bone resorption, resulting in a dry socket. Thus, developing bio-multifunctional materials with excellent antibacterial, hemostatic, and osteogenic characteristics for the prevention of dry sockets after tooth removal is highly desirable in clinical applications. Herein, chitosan-CaP microflowers (CM) and metronidazole (MD) loaded calcium alginate (CA) sponges (CA@CM/MD) with enhanced antibacterial, hemostatic, and osteogenic properties were developed via Ca²⁺ crosslinking, lyophilization, and electrostatic interaction for the prevention of dry socket after tooth removal. The fabricated CM particles display 3-dimensional, relatively homogeneous, and flower-shaped architectures. The CA@CM/MD composite sponges were facilely shaped into the tooth root as well as exhibit interconnected porous and lamellar structures with remarkable porosity, suitable maximum swelling ratio, as well as excellent compressive and hemostatic performance. Besides, the in vitro cellular assessment demonstrates that the prepared CA@CM/MD composite sponges possess satisfactory cytocompatibility. Importantly, the designed sponges significantly suppress the growth of S. aureus and E. coli, as well as promote cellular osteogenic differentiation by upregulating the formation of alkaline phosphatase. Our findings indicate that the tooth root-shaped composite sponges hold great promise for wound management after tooth removal.

The Effectiveness of 0.2% Chlorhexidine Gel on Early Wound Healing after Tooth Extraction: A Randomized Controlled Trial

Objective  This study aimed to evaluate the effect of 0.2% chlorhexidine (CHX) gel on wound healing after tooth extraction.

Materials and Methods  A single blind, randomized controlled trial was performed recruiting 32 participants who underwent dental extractions. Patients were randomly allocated for CHX group or placebo group. The primary outcomes were wound closure measured with calipers and healings were assessed by Landry et al index after 7 days of topical application of allocated gels on extraction sites.

Results  The wound closures were greater in CHX group compared with placebo group and healing scores were correlated with the use of CHX gel ( p -value < 0.05).

Conclusion  In a population of healthy nonsmoker adults, application of 0.2% CHX gel twice a day for 7 days after tooth extraction has a beneficial effect on wound healing.

Evaluation of antimicrobial activity of chlorhexidine-containing oral gels against aspiration pneumonia-inducing bacteria: An In Vitro study

Aim

Hospitalised patients have a high risk of developing aspiration pneumonia because of poor oral care and oral microbial flora changes. Chlorhexidine (CHX) solution has been used to reduce inflammation and prevent infections in oral cavity, but it is difficult to use in inpatients. Gel-type antimicrobial agents rather than the liquid form may be effective for the oral management of hospitalised patients. Therefore, we evaluated the in vitro antimicrobial effects of CHX-containing oral gels on aspiration pneumonia-inducing bacteria compared to the CHX solution.

Materials and Methods

The experimental products of two oral gel types containing 1% and 0.1% CHX, respectively, were selected. Hexamedine, a 0.12% CHX solution, was used as a positive control. The antimicrobial activity of CHX agents against six pneumonia-causing bacteria and Streptococcus mutans, one of the most common oral bacteria, was comparatively analysed using the agar disk diffusion method.

Results

In the disk diffusion assay, the 1% CHX gels showed the highest inhibitory effect on all bacteria. All CHX agents including gels and solution had the highest antibacterial activity against Staphylococcus aureus compared with other bacteria.

Conclusions

We confirmed the significant antimicrobial effects of the 1% CHX oral gels on aspiration pneumonia-inducing bacteria. These results suggest that CHX gels may be an effective oral care method for preventing infection in inpatients who have difficulty using the solution.

Oxytetracycline-hydrocortisone ointment reduces the occurrence of both dry socket and post-extraction pain after third molar extraction: An observational study

Objectives

Dry socket and post-extraction pain are typical discomforts experienced by patients after tooth extraction. In this study, we inserted gauze coated with oxytetracycline-hydrocortisone ointment into the extraction socket immediately after lower third molar extraction and then evaluated the occurrence of dry socket and post-extraction pain compared with gauze non-insertion.

Methods

This retrospective study was carried out on patients undergoing lower third molar extraction in the Department of Oral Surgery at Shizuoka Prefectural General Hospital in Shizuoka, Japan from November 2018 to October 2019. A comparison was carried out between a gauze-insertion group and a non-insertion group. The occurrence versus non-occurrence of dry socket was determined, and degree of pain was assessed based on a visual analogue scale (VAS) and on patients reporting the number of loxoprofen sodium oral analgesic tablets (60mg/tablet) that they had taken. Dry socket was defined as patient-reported spontaneous pain that did not subside 1 to 3 days postoperatively. Spontaneous post-extraction pain was recorded four times: on the operative day, on the first postoperative day (POD1), on POD3, and during suture removal (POD7).

Results

The occurrence of dry socket was lower in the gauze-insertion group than in the non-insertion group (0.9%, 2/215 vs. 19.6%, 9/46, p<0.001). The results also showed that both VAS-defined pain level and the number of analgesic tablets taken were lower in the gauze-insertion group than in the non-insertion group on POD3 and POD7.

Conclusions and clinical relevance

Inserting gauze coated with oxytetracycline-hydrocortisone ointment into the extraction socket immediately after third molar extraction reduces the occurrence of both dry socket and post-extraction pain.

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.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

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

Alveolar iodine tampon packing after impacted third molar surgery improves oral health-related quality of life and postoperative sequela: a randomized study

Objective

The aim of this study was to evaluate the effect of an iodine tampon on postoperative discomfort after surgical removal of a mandibular third molar.

Material and methods

Patients were randomly assigned to two groups: one group received an alveolar iodine-containing tampon in the extraction socket (N = 44), and the other group used a disposable syringe (Monoject®) to rinse the wound (N = 43). Postoperative discomfort was assessed with the Oral Health Impact Profile-14 (OHIP-14) questionnaire, Pain Intensity Numerical Rating Scale (PI-NRS), and questions about self-care and discomfort.

Results

This study included 87 patients (52 women and 35 men) with an average age of 26.47 years (SD, 6.36). The mean OHIP-14 sum scores were significantly lower in the iodine tampon group compared with the Monoject® syringe group. Mean PI-NRS scores significantly differed between the iodine tampon group (3.33; SE, 0.27) and Monoject® syringe group (4.46; SE, 0.27) (F (1, 85) = 8.16, p < 0.01), with no interaction effect between time and PI-NRS (F (6, 510) = 1.26, p = 0.28). Patients in the iodine tampon group reported less postoperative discomfort.

Conclusions

Insertion of an iodine-containing tampon in the postoperative socket reduced the pain and impact on oral health-related quality of life during the first postoperative week and positively influenced postoperative sequelae.

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

Background

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

Material and Methods

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

Results

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

Conclusions

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

Postoperative effects on lower third molars of using mouthwashes with super-oxidized solution versus 0.2% chlorhexidine gel: A randomized double-blind trial

BACKGROUND

The main objective of the present study is to evaluate the effects and possible benefits with regard to the postoperative period of lower third molar extractions, comparing the intraalveolar application of a bioadhesive gel of 0.2% chlorhexidine (CHX) to the use of a mouthwash with a super-oxidized solution, (SOS) Dermacyn® Wound Care (Oculus Innovative Sciences lnc., California, USA).

MATERIAL AND METHODS

A randomized double-blind study was carried out in 20 patients with a split-mouth design, with a total of 40 extractions of symmetrically impacted bilateral lower third molars. Patients were divided into two groups, a control group (C = 20) and an experimental group (D = 20). Any infectious complications, wound healing, plaque accumulation in the stitches, and presence of trismus and inflammation were evaluated using the distance between different facial points, at three, eight, and fifteen days after extraction. Pain, swelling, and amount of analgesics taken were evaluated using the VAS scale throughout the 15 days following extraction. Tolerance to treatment was evaluated using a verbal scale. Results were statistically compared using the Student's t- and chi-squared tests.

RESULTS

No statistically significant differences were found between the two groups with regard to infectious complications, swelling, or wound healing. Use of analgesics and self-reported pain levels were slightly lower in the experimental group than in the control group during days 6 and 7 of the study (p < 0.05). The global treatment tolerance was satisfactory and similar in both groups.

CONCLUSIONS

Both CHX and SOS are effective at improving the postoperative period after extraction of lower third molars.

Evaluation of wound healing and postoperative pain after oral mucosa laser biopsy with the aid of compound with chlorhexidine and sodium hyaluronate: a randomized double blind clinical trial

OBJECTIVES

The aim of this study is to evaluate secondary intention healing process and postoperative pain of oral soft tissues after laser surgery with the use of a compound containing chlorhexidine and sodium hyaluronate.

MATERIALS AND METHODS

This double-blind, randomized clinical study included 56 patients affected by benign oral lesions and subjected to excisional biopsy with diode laser and randomly divided into three groups. Study group (SG) received 0.2% chlorhexidine digluconate and 0.2% sodium hyaluronate treatment; control group (CG) received 0.2% chlorhexidine digluconate; and placebo group (PG) followed the same protocol, taking a neutral solution having the same organoleptic characteristics. Wound healing was evaluated using percentage healing index (PHI). Numeric rating scale (NRS) was used to evaluate postoperative pain.

RESULTS

PHI (T1 = 7 days) was 67.25% for SG, 58.67% for CG, and 54.55% for PG. PHI (T2 = 14 days) was 94.35% for SG, 77.79% for CG, and 78.98% for PG. A statistically significant difference was between the groups for PHI at T2 p = 0.001. No difference was detectable for pain index.

CONCLUSIONS

A solution containing sodium hyaluronate and chlorhexidine is a good support to increase wound healing by secondary intention after laser biopsy, but no differences were in postoperative perception of pain.

CLINICAL RELEVANCE

The use of the tested solution can be recommended after laser oral biopsies, to achieve a healing without suture. About the postoperative pain, the compound has not showed the same results and did not have measurable effects.

Angiogenesis and the prevention of alveolar osteitis: a review study

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

Chlorhexidine for prevention of alveolar osteitis: a randomised clinical trial

Objective

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

Material and methods

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

Results

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

Conclusion

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

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

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

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.

Repercussions of intraalveolar placement of combination of 0.2% chlorhexidine & 10 Mg metronidazole gel on the occurrence of dry sockets- A randomized control trial

Background

To evaluate the effects of intraalveolar placement of gel containing 0.2% chlorhexidine and 10gm of metronidazole on the incidence of alveolar osteitis.

Material and Methods

A total of 300 impacted third molars were extracted in 150 patients enrolled in this trial. In each subject a socket was randomly selected and packed to the crest of alveolar ridge with the gel. The contralateral socket was packed with placebo dressing. The occurrence of dry socket was assessed during 3rd and 5th postoperative days .The data was analysed using a meta analytical program.

Study Design

Double blind, prospective, placebo controlled trial.

Results

The combination of metronidazole + chlorhexidine gel significantly reduced dry socket incidence from 22.6% to 6.6% (P ≤ 0.001) [McNemar and chi-square tests].

Conclusions

The decrease in incidence of adverse reactions and complications related to local application of metronidazole and chlorhexidine gel explains its clinical use, specifically in mandibular molar extractions where the chances of dry sockets are high.

Key words:Chlorhexidine, dry socket, intra-alveolar, metronidazole, placebo.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The efficacy of intra-alveolar 0.2% chlorhexidine gel on alveolar osteitis: a meta-analysis

OBJECTIVES

The objective of this meta-analysis was to assess the effect of 0.2% chlorhexidine gel in preventing alveolar osteitis following mandibular third molar extraction(s).

METHODS

PubMed, Cochrane Library, Embase, Web of Science, Science Direct and the references of identified articles were searched for relevant studies that met our eligibility criteria. Treatment effects were combined by meta-analysis using RevMan 5.3 and Stata 12.0 software.

RESULTS

We included 11 trials in this meta-analysis. Compared to the control, 0.2% chlorhexidine gel reduced the risk of alveolar osteitis by 62% (RR = 0.38, 95% CI = 0.28-0.53, P < 0.00001) following mandibular third molar extraction(s). The subgroup analysis results indicated that 0.2% chlorhexidine gel reduced the risk of alveolar osteitis after mandibular third molar extraction(s) by 75% (RR = 0.25, 95% CI = 0.11-0.58) and 56% (RR = 0.44, 95% CI = 0.30-0.63) compared to no treatment and placebo, respectively. However, the occurrence of alveolar osteitis following mandibular third molar extraction(s) was not significantly different between 0.2% chlorhexidine gel and 0.12% chlorhexidine mouthwash (RR = 0.24, 95% CI = 0.06-1.00).

CONCLUSION

The results showed that 0.2% chlorhexidine gel was effective in preventing alveolar osteitis after lower third molar extraction(s).

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY WORDS

Third molar surgery, dry socket, chorhexidine gel.

Novel incision design and primary flap closure reduces the incidence of alveolar osteitis and infection in impacted mandibular third molar surgery

OBJECTIVE

To measure the influence of flap design on alveolar osteitis (AO) and postoperative complications following mandibular third molar surgery.

STUDY DESIGN

This study was designed as a randomized single-blind, split-mouth clinical trial. The predictor variable was flap type. Envelope flap, modified triangular flap (MTF), and two related experimental flaps (second molar mesial papilla-sparing marginal incision with distobuccal release with double-pass single-layered primary closure [MPMI-2 X] and single-pass single-layered primary closure [MPMI-1 X]) were used. The primary outcome variable was AO. The secondary outcome variables were wound dehiscence and infection. Bivariate and logistic analyses were computed. P value < .05 was considered to be statistically significant.

RESULTS

One hundred ninety-six patients with symmetric bilateral partial bony or full bony impacted mandibular third molars participated. No sites (0 of 196) treated with MPMI-2 X developed AO, and only two sites (2 of 196) treated with MPMI-2 X developed postoperative infection. Both MPMI-1 X and MPMI-2 X were associated with decreased odds of complications compared with MTF and envelope flap. MPMI-2 X sites were significantly less likely than MTF sites to experience complications for both sides.

CONCLUSIONS

MPMI-2 X is a reliable technique to reduce complications, such as AO, wound dehiscence, and infection in mandibular third molar surgery.

Effect of Diode Laser on Healing of Tooth Extraction Socket: An Experimental Study in Rabbits

OBJECTIVES

To evaluate the effect of low-level laser therapy on healing of extracted tooth socket of healthy rabbits.

DESIGN

The sample of this study was 20 male rabbits of 2-2.5 kg weight with age range of 8-12 months. Right and left lower first premolar teeth were extracted. The extraction sockets of lower right first premolar were irradiated with 0.9 W gallium-aluminum-arsenide (GaAlAs) diode laser for 5 min, immediately after extraction and then every 72 h for the next 12 days. The extraction socket of left side were not exposed to laser and served as a control. The animals were sacrificed after 7, 14, 30 and 45 days and the experimental and control sockets were removed from the harvested mandibles and prepared for haematoxylin and eosin staining and Masson's stain. The prepared slides were examined under light microscope for histological and histomorphometric examination.

RESULTS

The histological examination showed that diode laser-treated sockets demonstrated early formed new bone with faster maturation of primary bone to secondary bone as compared to non-treated control sockets. Histomorphometric analysis revealed a statistically significant increase in the density and volume of trabecular bone in laser-treated sockets than control sockets.

CONCLUSION

Diode laser application to tooth extraction socket has a positive effect on bone formation.

Efficacy of different methods used for dry socket management: A systematic review

BACKGROUND

Dry socket is one of the most common complications occurring after the extraction of a permanent tooth, but in spite of its high incidence there is not an established treatment for this condition.

OBJECTIVES

Analyze the efficacy of different methods used in the management of dry socket regarding results of pain's relief and alveolar mucosa healing compared to conventional surgical treatment of curettage and saline irrigation.

MATERIAL AND METHODS

A Cochrane and PubMed-MEDLINE database search was conducted with the search terms "dry socket", "post-extraction complications", "alvogyl", "alveolar osteitis" and "fibrynolitic alveolitis", individually and next, using the Boolean operator "AND". The inclusion criteria were: clinical studies including at least 10 patients, articles published from 2004 to 2014 written in English. The exclusion criteria were case reports and nonhuman studies.

RESULTS

11 publications were selected from a total of 627. Three of the 11 were excluded after reading the full text. The final review included 8 articles: 3 prospective studies, 2 retrospective studies and 3 clinical trials. They were stratified according to their level of scientific evidence using the SORT criteria (Strenght of Recommendation Taxonomy).

CONCLUSIONS

All treatments included in the review have the aim to relief patient's pain and promote alveolar mucosa healing in dry socket. Given the heterogeneity of interventions and the type of measurement scale, the results are difficult to compare. Curettage and irrigation should be carried out in dry socket, as well as another therapy such as LLLT, zinc oxide eugenol or plasma rich in growth factors, which are the ones that show better results in pain remission and alveolar mucosa healing. Assessment alveolar bone esposure must be a factor to consider in future research. Taking into account the scientific quality of the articles evaluated, a level B recommendation is given for therapeutic interventions proposed for the treatment of dry socket.

Double-blind, randomized pilot study of bioadhesive chlorhexidine gel in the prevention and treatment of mucositis induced by chemoradiotherapy of head and neck cancer

Background

To evaluate, in an initial way, the effectiveness of bioadhesive chlorhexidine gel 0.2% versus placebo as a preventive and therapeutic intervention of oral mucositis induced by radiation therapy and chemotherapy in patients diagnosed with head and neck cancer treated with chemoradiotherapy.

Material and Methods

In this pilot study, 7 patients (range of age: 18- 65), having histological documented diagnosis of squamous carcinoma on the head and neck region in stage III and IV, and receiving combined radiation treatment and chemotherapy (cisplatin 100 mg/m2 IV on days 1, 22, and 43 of irradiation) were studied. Simultaneously, a topical application was performed with bioadhesive chlorhexidine gel 0.2% in the study group, and the placebo gel for the control group in 5 applications per day, from the time of initiation of cancer treatment to 2 weeks after completion of chemo-radiotherapy treatment (11 weeks of follow-up). The gradation of mucositis, pain, analgesic consumption, infectious complications, and treatment tolerance was measured.

Results

After 7 patients completed the protocol, any differences were observed between groups in an interval analysis. Mucositis, pain, and tolerance was similar in both groups.

Conclusions

Our results must be interpreted with caution due to the reduced sample size, but the use of bioadhesive chlorhexidine gel 0.2% didn’t contribute clinical improvement to the oral mucositis induced by radiation therapy and chemotherapy.

Key words: Chlorhexidine, mucositis, head and neck cancer.

Chlorhexidine-loaded hydroxyapatite microspheres as an antimicrobial delivery system and its effect on in vivo osteo-conductive properties

Hydroxyapatite (HA) has been investigated as a delivery system for antimicrobial and antibacterial agents to simultaneously stimulate bone regeneration and prevent infection. Despite evidence supporting the bactericidal efficiency of these HA carriers, few studies have focused on the effect of this association on bone regeneration. In this work, we evaluated the physico-chemical properties of hydroxyapatite microspheres loaded with chlorhexidine (CHX) at two different concentrations, 0.9 and 9.1 μgCHX/cm2 HA, and characterized their effects on in vitro osteoblast viability and bone regeneration. Ultraviolet-visible spectroscopy, scanning and transmission electron microscopy associated with energy-dispersive X-ray spectroscopy and electron energy loss spectroscopy were used to characterize the association of CHX and HA nanoparticles. The high CHX loading dose induced formation of organic CHX plate-like aggregates on the HA surface, whereas a Langmuir film was formed at the low CHX surface concentration. Quantitative evaluation of murine osteoblast viability parameters, including adhesion, mitochondrial activity and membrane integrity of cells exposed to HA/CHX extracts, revealed a cytotoxic effect for both loading concentrations. Histomorphological analysis upon implantation into the dorsal connective tissues and calvaria of rats for 7 and 42 days showed that the high CHX concentration induced the infiltration of inflammatory cells, resulting in retarded bone growth. Despite a strong decrease in in vitro cell viability, the low CHX loading dose did not impair the biocompatibility and osteoconductivity of HA during bone repair. These results indicate that high antimicrobial doses may activate a strong local inflammatory response and disrupt the long-term osteoconductive properties of CHX-HA delivery systems.

Systemic review of dry socket: aetiology, treatment, and prevention

Our systemic review is to make a comprehensive review about the aetiology, treatment and the prevention of dry socket, the inclusion criteria were all the studies that discuss the dry socket and its etiology, treatment and prevention and exclusion criteria were all the studies that discuss the other complications of tooth extraction, the materials and methods used for this systemic review was to search in the Pub Medline database between 2008 to 2013, using specific words "dry socket, aetiology, treatment and prevention" and published in the English language, the articles were screened by abstract for relevance to aetiology, treatment and prevention of dry socket, 82 papers were identified in pub med but a total of 36 out of Publications were included in the final systemic review according to the specific keywords and materials mentioned above. The occurrence of dry socket in an everyday oral surgery or dental practice is unavoidable. The risk factors are smoking, surgical trauma, single extractions, age, sex, medical history, systemic disorder, extraction site, amount of anaesthesia, operator experience, antibiotics use prior to surgery, difficulty of the surgery and the previous surgical site infection in addition to oral Contraceptives, menstrual cycle and immediate postextraction socket irrigation with normal saline. The traditional options of treatment are directed toward palliative care, such as the irrigation of the surgical site, avoiding curetting the extraction socket, Packing with a zinc oxide- eugenol paste on iodoform gauze can be considered to relieve acute pain episodes, there is also new agents in the market can accelerate the healing of the socket such as PRGF and GECB. The prevention methods include avoiding smoking before and after surgery and a traumatic surgery, the use of antibiotics, such as, azithromycin, can be considered, the other preventive measures such as chlorhecidine rinse or gel can be effective in the reduction of dry socket incidence.

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

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

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

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

A practical approach to evidence-based dentistry: III: how to appraise and use an article about therapy

BACKGROUND AND OVERVIEW

Dental practitioners spend most of their time administering treatments. To ensure that their clinical decisions are informed by the best available evidence, dental practitioners need to be skilled in critically appraising studies addressing therapy issues. Randomized controlled trials offer the optimal study design to inform decisions regarding therapy. The critical appraisal of randomized controlled trials involves assessing the risk of bias, results, and applicability. In this article, the authors present these concepts and provide guidance for this type of appraisal.

PRACTICAL IMPLICATIONS

Dentists who wish to inform their clinical decisions regarding therapy and prevention questions can use these guidelines to decide what type of studies to search, define the specific question of interest to search efficiently for these studies, and critically appraise an article about therapy or prevention.

Effectiveness of 1% versus 0.2% chlorhexidine gels in reducing alveolar osteitis from mandibular third molar surgery: a randomized, double-blind clinical trial

Purpose: Alveolar osteitis (AO) is the most common postoperative complication of dental extractions. The purpose of this study was to compare the effectiveness of 1% versus 0.2% chlorhexidine (CHX) gel in reducing postoperative AO after surgical extraction of mandibular third molars, and assess the impact of treatment on the Oral HealthRelated Quality of Life (OHRQoL). Material and Methods: This clinical study was a randomized, double-blind clinical trial. Eighty eight patients underwent surgical extraction of one retained mandibular third molar with the intra-alveolar application of 0.2% CHX gel. Afterwards, they were assigned to one of two groups: 1% CHX gel (n=42) or 0.2% CHX gel (n=46). The patients applied the gel twice a day to the wound for one week. All patients were evaluated for AO. Results: In the 0.2% CHX gel group, 13% of AO incidence was found, while in the 1% CHX gel group, AO incidence was 7%, a difference that was not statistically significant. Variables such as sensation of pain and inflammation at baseline and during one week, as well as OHRQoL of the patients at 24 hours and 7 days post-extraction, gave no statistically significant differences. Conclusions: There are no significant differences in AO after surgical extraction of mandibular third molars, when comparing applying 1% CHX gel twice a day for 7 days with 0.2% CHX gel.

Key words:Alveolar osteitis, chlorhexidine gel, third molar.

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.

Topical 1% oxytetracycline hydrochloride versus placebo in oral mucosa biopsy

BACKGROUND

Oral surgical procedures produce side effects such as pain and inflammation, the magnitude of which depends on the degree of tissue damage produced.

OBJECTIVE

To explore the effectiveness and safety of the topical application of 1% oxytetracycline hydrochloride after biopsy of the oral mucosa.

METHODS

A randomized, double-blind, placebo- and no treatment-controlled study was conducted in 90 patients with lesions needing histopathologic analysis. The patients were divided into three groups. Group I (control) received no treatment; in group II, the site of surgical intervention was treated topically with 1% oxytetracycline hydrochloride three times a day for 1 week; and in group III, the patients were treated in the same way but with placebo. Using a visual analog scale, we determined the time of maximum postoperative pain.

RESULTS

Maximum pain intensity was recorded in the placebo group, with peak pain occurring 24 hours after surgery. The pain subsequently tended to decrease gradually over the 1-week period of the study. The maximum level of pain was significantly lower in group II than in the controls. No adverse effects were recorded.

CONCLUSIONS

Topical 1% oxytetracycline hydrochloride decreases pain symptoms after oral mucosa biopsy.

Formulation and Characterization of Oral Mucoadhesive Chlorhexidine Tablets Using Cordia myxa Mucilage

BACKGROUND

The dilution and rapid elimination of topically applied drugs due to the flushing action of saliva is a major difficulty in the effort to eradicate infections of oral cavity. Utilization a proper delivery system for incorporation of drugs has a major impact on drug delivery and such a system should be formulated for prolonged drug retention in oral cavity.

OBJECTIVES

The aim of the present study was the use of mucilage of Cordia myxa as a mucoadhesive material in production of chlorhexidine buccal tablets and its substitution for synthetic polymers such as HPMC.

MATERIALS AND METHODS

The influence of mucilage concentration on the physicochemical responses (hardness, friability, disintegration time, dissolution, swelling, and muco-adhesiveness strength) was studied and swelling of mucilage and HPMC were compared. The evaluated responses included pharmacopoeial characteristics of tablets, the force needed to separate tablets from mucosa, and the amount of water absorbed by tablets.

RESULTS

In comparison to HPMC, the rise of mucilage concentration in the formulations increased disintegration time, drug dissolution rate, and reduced MDT. Also, compared to 30% HPMC, muco-adhesiveness strength of buccal tablets containing 20% mucilage was significantly higher.

CONCLUSIONS

It can be concluded that the presence of Cordia myxa powdered mucilage may significantly affect the tablet characteristics, and increasing in muco-adhesiveness may be achieved by using 20% w/w mucilage.

Diagnosis and management of common postextraction complications

Extraction of impacted teeth is one of the most common surgical procedures performed by oral and maxillofacial surgeons. Every surgical procedure results in some degree of postoperative bleeding and inflammation, typically manifesting as pain and edema. Although the complex physiology of the human body is beyond the scope of this article, the educated clinician should have an understanding of the time line associated with these processes so as to determine whether a patient's complaint of postoperative bleeding, pain, or swelling represents a normal response to surgical trauma or an aberrant reaction.

Fabrication and anti-microbial evaluation of drug loaded polylactide space filler intended for ridge preservation following tooth extraction

Background:

The preservation or reduction of alveolar ridge resorption following tooth extraction is important in patients especially for those intended for implants at a later stage. One way to achieve this is by using membranes, graft materials, and biodegradable space fillers to prevent alveolar bone resorption and promote regeneration. A major attraction for using biodegradable and biocompatible polymers as space fillers for ridge preservation is their safety profile in comparison to xenograft materials like lyophilized bone and collagen.

Materials and Methods:

Biocompatible polylactide space fillers were fabricated by fusing porous polylactide particles. The sponges were loaded with drugs by placing them in the respective solutions. Pseudomonas aeruginosa was isolated from a chronic periodontitis patient and in vitro anti-microbial evaluation was done with the drug loaded sponges.

Results:

Chlorhexidine loaded space filler showed significant anti microbial effect against multiple drug resistant Pseudomonas aeruginosa isolated from a patient with chronic periodontitis.

Conclusion:

The results of this study indicate that biodegradable drug releasing polylactide space fillers has the potential to be used for ridge preservation following tooth extraction. Release of drugs in the socket may prove useful in preventing development of alveolar osteitis post extraction which can interfere with normal healing of the socket. Synthetic biodegradable polymers also exhibit a controlled degradation rate to achieve complete resorption within the intended time.