Patients' perception of recovery after third molar surgery following postoperative treatment with moxifloxacin versus amoxicillin and clavulanic acid: a randomized, double-blind, controlled study

Do antibiotics prevent infection after third molar surgery? A network meta-analysis

The aim of this systematic review was to determine whether antibiotics, compared to placebo, can prevent infection or dry socket after third molar surgery. A systematic review and network meta-analysis (NMA) was performed following registration of the protocol (CRD42021276266). Four databases and the grey literature were searched, and papers were selected based on the PICOS question. RoB 2 and GRADE were used to evaluate the risk of bias and certainty of the evidence, respectively. The NMA was performed using Stata. Of 58 randomized clinical trials identified, 34 were included in the NMA. Patients treated with amoxicillin (relative risk (RR) 0.56, 95% confidence interval (CI) 0.38-0.84; low quality of evidence) and those treated with metronidazole (RR 0.51, 95% CI 0.31-0.84; low quality of evidence) showed a lower risk of infection and dry socket when compared to patients given a placebo. Postoperative amoxicillin (750 mg) and amoxicillin plus clavulanate (500 mg + 125 mg, or 2000 mg + 125 mg), and preoperative metronidazole (800 mg) are useful to prevent infection or dry socket when compared to placebo. The low rate of infection after third molar surgery, the correct concept of antibiotic prophylaxis, and antibiotic resistance must be taken into account when choosing to treat healthy patients undergoing third molar surgery with antibiotics.

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.

Use of antibiotics after lower third molar surgery - useful or harmful procedure? A randomized, double-blind, placebo-controlled trial

Introduction/Objective. The aim of the present study was to investigate the effects of moxifloxacin and cefixime in preventing postoperative infection following mandibular third molar surgery. Methods. Double-blind study was completed by 157 patients undergoing surgical removal of mandibular third molars. Patients were randomly assigned to three groups: moxifloxacin (M), cefixime (C) and placebo (P). Patients in each group were classified into two subgroups: subgroup (a) without previous history of pericoronitis and subgroup (b) with previous history of pericoronitis. All patients were evaluated at the postoperative follow-ups on the first, second and seventh postoperative day. Results. Postoperative infections were registered only in patients with history of pericoronitis. Antibiotic prophylaxis with cefixime, and moxifloxacin, reduced the occurrence of postoperative infection. Overall incidence of postoperative infections was 6.4%. All postoperative infections were registered in placebo-group, where the incidence of postoperative infection was 19.2%. Microbiological tests verified the clinically obtained results. Isolated microflora was resistant to penicillin-derived antibiotics in 50% of cases. Conclusion. Prophylactic use of antibiotics after third molar surgery should be weighted against potential risks and benefits and could be considered in cases with previous history of pericoronitis, when complicated surgical extraction is performed.

Effect of antibiotic prophylaxis for preventing infectious complications following impacted mandibular third molar surgery. A randomized controlled trial

Background

The objective of this study was to determine the effect of antibiotic prophylaxis in preventing postoperative infections after extraction of impacted mandibular third molars.

Material and Methods

A Parallel-group, randomized, blind, placebo-controlled trial was performed. 154 patients were randomly allocated to 2 groups; experimental (n=77) receiving 2g amoxicillin 1 hour prior to surgery and control (n=77) receiving placebo. Primary outcome was postoperative infections and secondary outcome was the need for rescue analgesia.

Results

4.5% of patients developed postoperative infections, five patients of the control group (4 alveolar osteitis, 1 surgical site infection) and two of the experimental group (1 alveolar osteitis, 1 surgical site infection). Difference between groups was not statistically significant, RR=0.4 (95%CI 0.08-1.99, 𝘱=0.41) NNTB=26. Rescue analgesia intake was significantly higher in the control group (41 vs 18 patients of experimental group) RR=0.49 (95%CI 0.32-0.75, 𝘱<0.05) NNTB=3.

Conclusions

The use of 2g amoxicillin 1 hour before surgery was not effective in significantly reducing the risk of postoperative infections from impacted mandibular third molars extraction, when compared to placebo. Nevertheless, antibiotic prophylaxis was associated with a reduced need for rescue analgesia.

Key words:Antibiotic prophylaxis, third molar, tooth extraction, impacted tooth, dry socket, surgical wound infection, oral surgery.

Antibiotics to prevent complications following tooth extractions

BACKGROUND

The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection. This is an update of a review first published in 2012.

OBJECTIVES

To determine the effect of systemic antibiotic prophylaxis on the prevention of infectious complications following tooth extractions.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 16 April 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 3), MEDLINE Ovid (1946 to 16 April 2020), Embase Ovid (1980 to 16 April 2020), and LILACS (1982 to 16 April 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised, double-blind, placebo-controlled trials of systemic antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication.

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed data extraction and 'Risk of bias' assessment for the included studies. We contacted trial authors for further details where these were unclear. For dichotomous outcomes, we calculated risk ratios (RR) and 95% confidence intervals (CI) using random-effects models. For continuous outcomes, we used mean differences (MD) with 95% CI using random-effects models. We examined potential sources of heterogeneity. We assessed the certainty of the body of evidence for key outcomes as high, moderate, low, or very low, using the GRADE approach.

MAIN RESULTS

We included 23 trials that randomised approximately 3206 participants (2583 analysed) to prophylactic antibiotics or placebo. Although general dentists perform dental extractions because of severe dental caries or periodontal infection, only one of the trials evaluated the role of antibiotic prophylaxis in groups of patients affected by those clinical conditions. We assessed 16 trials as being at high risk of bias, three at low risk, and four as unclear.  Compared to placebo, antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% (RR 0.34, 95% CI 0.19 to 0.64; 1728 participants; 12 studies; low-certainty evidence), which means that 19 people (95% CI 15 to 34) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. Antibiotics may also reduce the risk of dry socket by 34% (RR 0.66, 95% CI 0.45 to 0.97; 1882 participants; 13 studies; low-certainty evidence), which means that 46 people (95% CI 29 to 62) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. The evidence for our other outcomes is uncertain: pain, whether measured dichotomously as presence or absence (RR 0.59, 95% CI 0.31 to 1.12; 675 participants; 3 studies) or continuously using a visual analogue scale (0-to-10-centimetre scale, where 0 is no pain) (MD -0.26, 95% CI -0.59 to 0.07; 422 participants; 4 studies); fever (RR 0.66, 95% CI 0.24 to 1.79; 475 participants; 4 studies); and adverse effects, which were mild and transient (RR 1.46, 95% CI 0.81 to 2.64; 1277 participants; 8 studies) (very low-certainty evidence).  We found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important. The included studies enrolled a subset of patients undergoing dental extractions, that is healthy people who had surgical extraction of third molars. Consequently, the results of this review may not be generalisable to all people undergoing tooth extractions.

AUTHORS' CONCLUSIONS

The vast majority (21 out of 23) of the trials included in this review included only healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. None of the studies evaluated tooth extraction in immunocompromised patients. We found low-certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low-certainty evidence of no increase in the risk of adverse effects. On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection. It is unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection. Due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications. Immunocompromised patients, in particular, need an individualised approach in consultation with their treating medical specialist.

The effects of amoxicillin with or without clavulanic acid on the postoperative complaints after third molar surgery: a retrospective chart analysis

Purpose:

The aim of this chart-based retrospective study was to evaluate the effects of orally administered amoxicillin alone or amoxicillin combined with clavulanic acid on the frequency of post-operative complications and patients’ comfort after mandibular third molar surgery.

Materials and Methods:

The records of patients who had undergone lower third molar surgery between October 2014 and December 2015 were examined. A total of 62 patients who had fully impacted teeth in mesioangular position and who had been prescribed same type and dose of anti-inflammatory drug were included in this study. Among them, 32 subjects were found to have been prescribed 500 mg amoxicillin trihydrate orally every 8 h for 5 days (Group A) and 30 patients 500 mg amoxicillin trihydrate plus 125 mg potassium clavulanate orally every 8 h for 5 days postoperatively (Group AC). Post-operative pain levels, swelling, presence of trismus, frequency of alveolar osteitis and quality of life (QoL) scores were gathered from patients’ charts and were statistically compared.

Results:

Analysis of the variables showed that there were no significant differences between the Groups A and AC regarding pain levels, swelling, trismus and QoL scores. The frequency of alveolar osteitis was found to be 1.6% in the Group A, however, no significant difference was observed among study groups.

Conclusion:

Within the limitations of this retrospective chart review, it can be stated that amoxicillin and amoxicillin with clavulanic acid might provide similar outcome in terms of patient comfort following third molar surgery.

Do systemic antibiotics prevent dry socket and infection after third molar extraction? A systematic review and meta-analysis

OBJECTIVES

The use of antibiotics to prevent dry socket and infection is a controversial but widespread practice. The aim of the study is to assess the efficacy of systemic antibiotics in reducing the frequencies of these complications after extraction.

STUDY DESIGN

A systematic review and meta-analysis, according to the PRISMA statement, based on randomized double-blind placebo-controlled trials evaluating systemic antibiotics to prevent dry socket and infection after third molar surgery. Databases were searched up to June 2015. Relative risks (RRs) were calculated with inverse variance-weighted, fixed-effect, or random-effect models.

RESULTS

We included 22 papers in the qualitative and 21 in the quantitative review (3304 extractions). Overall-RR was 0.43 (95% confidence interval [CI] 0.33-0.56; P < .0001); number needed to treat, 14 (95% CI 11-19). Penicillins-RR: 0.40 (95% CI 0.27-0.59). Nitroimidazoles-RR: 0.56 (95% CI 0.38-0.82). No serious adverse events were reported.

CONCLUSIONS

Systemic antibiotics significantly reduce the risk of dry socket and infection in third molar extraction.

Chilean patients' perception of oral health-related quality of life after third molar surgery

OBJECTIVE

To describe the perception of the quality of life in oral health based on the Health-Related Quality of Life instrument in its Spanish version (HRQOL-sp) in Chilean patients with third molar extraction surgery.

PATIENTS AND METHODS

A cross-sectional study. The HRQOL-sp was administered to dental patients at the Public Hospital in Rio Bueno in southern Chile treated for unilateral third molar extraction between March and June 2014. The instrument was applied by phone survey on the first, third, fifth, and seventh days after surgery. For the ordinal scale, the response was considered interference in the quality of life when patients selected the options "quite a bit of trouble" or "lots of trouble" for oral function and general activity; and selected complications-related signs and symptoms, a pain level score with a Verbal Rating Scale (range 0 to 7), and worst pain perceived. The patient's sociodemographic data, type of surgery, and the quality of life level were analyzed according to the domains of the HRQOL-sp instrument.

RESULTS

A total of 106 patients were selected (age: 20.4±7.39 years; 71.7% women) and a total of 127 extracted third molars. On the first day of follow-up, most patients reported interference in their quality of life. The main problems were difficulty opening the mouth (50.94%) and swelling (83.02%). The worst symptom perceived was "bad breath" (>31%) and the worst pain felt was a mean of 4.31±1.62 on the Verbal Rating Scale. All items gradually reduced until the seventh day.

CONCLUSION

The HRQOL-sp revealed substantial interference in the quality of life on the first postoperative day. It is suggested that the risk factors associated with quality of life be analyzed and the instrument in Spanish be validated.

Comparative Efficacy of Amoxicillin/Clavulanic Acid and Levofloxacin in the Reduction of Postsurgical Sequelae After Third Molar Surgery: A Randomized, Double-Blind, Clinical Trial in a Nigerian University Teaching Hospital

Background:

The most common sequelae after surgical removal of mandibular third molar are pain, trismus, swelling, and dysphagia. However, these symptoms can also signal the onset of surgical site infection and alveoli osteitis. The aim of this study was to evaluate the efficacy of prophylactic amoxicillin/clavulanic acid and levofloxacin and preemptive therapy of amoxicillin/clavulanic acid in the reduction of postinflammatory complications, surgical site infection, and alveolar osteitis following the third molar surgery.

Patients and Methods:

A total of 135 patients were randomized into three equal groups: Group A (preemptive therapy of amoxicillin/clavulanic acid) with preoperative dose of 875/125 mg amoxicillin/clavulanic acid followed by 500/125 mg amoxicillin/clavulanic acid 12 hourly for 5 days, Group B (amoxicillin/clavulanic acid prophylaxis) with a single preoperative dose of amoxicillin/clavulanic acid 875/125 mg tablets, and Group C (levofloxacin prophylaxis) with a single preoperative dose of levofloxacin 1000 mg tablets. All patients had ostectomy using surgical handpiece and burs and received same analgesics (tabs ibuprofen 400 mg 8 hourly for 3 days).

Results:

No case of surgical site infection or alveoli osteitis was recorded in the study groups. There were no statistically significant differences between the treatment groups with regard to pain, mouth opening, postoperative facial dimension, and body temperature.

Conclusion:

Amoxicillin/clavulanic acid as a single preoperative bolus should be adequate for the prevention of postoperative wound infection and alveoli osteitis following the third molar extraction as there is no need for an extension of the antibiotic. Moreover, levofloxacin can be utilized as prophylaxis in patients undergoing mandibular third molar extraction if such patients are allergic to penicillins.

Risk of wound infection and safety profile of amoxicillin in healthy patients which required third molar surgery: a systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to assess the risk of surgical wound infection and the adverse effects of amoxicillin in healthy patients who required excision of third molars. We identified eligible reports from searches of PubMed, Medline®, the Cochrane Library, Imbiomed, LILACS, and Google Scholar. Studies that met our minimum requirements were evaluated using inclusion and exclusion criteria and the Oxford Quality Scale. Those with a score of 3 or more on this Scale were included and their data were extracted and analysed. For evaluation of the risk of infection the absolute risk reduction, number needed to treat, and 95% CI were calculated. For evaluation of the risk of an adverse effect the absolute risk increase, number needed to harm, and 95% CI were calculated using the Risk Reduction Calculator. Each meta-analysis was made with the help of the Mantel-Haenszel random effects model, and estimates of risk (OR) and 95% CI were calculated using the Review Manager 5.3, from the Cochrane Library. A significant risk was assumed when the lower limit of the 95% CI was greater than 1. Probabilities of less than 0.05 were accepted as significant. The results showed that there was no reduction in the risk of infection when amoxicillin was given before or after operation compared with an untreated group or placebo. In conclusion, this study suggests that amoxicillin given prophylactically or postoperatively does not reduce the risk of infection in healthy patients having their third molars extracted.

Antibiotics in third molar extraction; are they really necessary: A non-inferiority randomized controlled trial

INTRODUCTION

Antibiotic resistance is now a serious problem, although it was not so only a few years ago. The need of the hour is to give clear evidence of the efficacy of antibiotic use, or lack thereof, to the surgeon for a procedure as common as mandibular third molar surgery.

AIM

This study aimed to evaluate whether postoperative combined amoxicillin and clavulanic acid in mandibular third molar extraction is effective in preventing inflammatory complications.

STUDY AND DESIGN

The study was structured as a prospective randomized double-blind placebo-controlled clinical trial.

MATERIALS AND METHODS

A study was designed wherein the 96 units (two bilaterally similar impacted mandibular third molars per head in 48 patients) were randomly assigned to two treatment groups (Group I and Group II). Each patient served as his/her own control. Each patient received 625 mg of combined amoxicillin and clavulanic acid 1 h before surgery. In the case of third molars belonging to Group I, 625 mg of combined amoxicillin and clavulanic acid TDS was continued for 3 days; in Group II, placebo in similar-looking packs was continued for 3 days. The patients were evaluated on the third and seventh postoperative days for signs of clinical infection and for microbial load evaluation.

STATISTICAL ANALYSIS

The data between the two groups were statistically analyzed by the two-tailed Fisher's exact test, with a 95% confidence interval.

RESULTS

The difference was not statistically significant between the test group and the control group with regard to erythema, dehiscence, swelling, pain, trismus, and infection based on microbial load. The data were statistically significant for alveolar osteitis, with the occurrence of alveolar osteitis (14.58%) in the placebo group.

CONCLUSION

Postoperative antibiotics are recommended only for patients undergoing contaminated, long-duration surgery.

Oral health-related quality of life following non-surgical (routine) tooth extraction: A pilot study

Aim:

The study was designed to explore the changes in oral health-related quality of life (QoL) in the immediate postoperative period following routine (non-surgical) dental extraction.

Setting and Design:

A prospective study carried out at the Oral and Maxillofacial Surgery clinic of the Lagos University Teaching Hospital, Nigeria.

Materials and Methods:

Subjects attending who required non-surgical removal of one or two teeth under local anesthesia were included in the study. A baseline QoL questionnaire (oral health impact profile-14 [OHIP-14]) was filled by each patient just before surgery, and only those who were considered to have their QoL “not affected” (total score 14 or less) were included in the study. After the extraction, each subject was given a modified form of “health related QoL” [OHIP-14]-instrument to be completed by the 3^rd day-after surgery, and were given the opportunity to review the questionnaire on the 7^th day postoperative review.

Results:

Total OHIP-14 scores ranged between 14 and 48 (mean ± SD, 26.2 ± 8.3). Majority of the subjects (60%) reported, “a little affected.” Only few subjects (5.8%) reported, “not at all affected,” and about 32% reported, “quite a lot.” Summation of OHIP-14 scores revealed that QoL was “affected” in 41 subjects (34.2%) and “not affected” in 79 subjects (65.8%). More than 30% of subjects reported that their ability to chew, ability to open the mouth and enjoyment of food were affected following tooth extraction. Few subjects (14-34%) reported deterioration in their speech and less than 20% of subjects reported that change in their appearance was “affected.” Only few subjects (12.5-15.1%) reported sleep and duty impairment. Thirty-percent of subjects reported their inability to keep social activities, and 41% were not able to continue with their favorite sports and hobbies. Multiple regression analysis revealed no significant association between age, sex, indications for extraction, duration of extraction, intra-operative complications, and deterioration in QoL (P < 0.05). Consumption of analgesics beyond postoperative day 1 (POD1) was more common in subjects with socket healing complications than those without (P = 0.000). About 33% of subjects reported, “inability to work” (1-3 days).

Conclusion:

About a third of subjects experienced significant deterioration in QoL. The most affected domains were eating/diet variation and speech variation. Therefore, patients should be informed of possible deterioration in their QoL following non-surgical tooth extraction.

A single dose of amoxicillin and dexamethasone for prevention of postoperative complications in third molar surgery: a randomized, double-blind, placebo controlled clinical trial

Background

The aim of this study was to assess the efficacy of a single prophylactic dose of amoxicillin and/or dexamethasone in preventing postoperative complications (PC) after a surgical removal of a single mandibular third molar (M3).

Methods

This study is a randomized, placebo controlled clinical trial. Four groups were included: Group 1 (G1) included a prophylactic dose of 2 g of amoxicillin and 8 mg of dexamethasone; Group 2 (G2) included a prophylactic dose of 2 g of amoxicillin and 8 mg of placebo; Group 3 (G3) included a prophylactic dose of 8 mg of dexamethasone and 2 g of placebo and; Group 4 (G4) placebo.

Results

Fifty patients were included. It was observed one case of alveolar infection (2%) and two of alveolar osteitis (4%) resulting in three PC (6%). No statistical differences were observed between therapeutic groups for development of PC, trismus, pain and edema. The use of antibiotics showed an absolute risk reduction (ARR) for PC development of 3.52% and the number needed to treat (NNT) was 29.

Conclusion

Prophylactic antibiotics and corticoid in a single dose regimen did not bring any benefit on M3 surgeries.

Prediction of postoperative facial swelling, pain and trismus following third molar surgery based on preoperative variables

Objective: This paper investigates the relationship between preoperative findings and short-term outcome in third molar surgery. Study design: A prospective study was carried out involving 80 patients who required 160 surgical extractions of impacted mandibular third molars between January 2009 and December 2010. All extractions were performed under local anesthesia by the same dental surgeon. Swelling and maximal inter-incisor distance were measured at 48 h and on the 7th day postoperatively. Mean visual analogue pain scores were determined at four different time periods. Results: One-hundred eight (67.5%) of the 160 extractions were performed on male subjects and 52 (32.5%) were performed on female subjects. Median age was 22.46 years. The amount of facial swelling varied depending on gender and operating time. Trismus varied depending on gender, operating time and tooth sectioning. The influence of age, gender and operating time varied depending on the pain evaluation period (p < 0.05). Conclusions: Short-term outcomes of third molar operations (swelling, trismus and pain) differ depending on the patients’ characteristics (age, gender and body mass index). Moreover, surgery characteristics such as operating time and tooth sectioning were also associated with postoperative variables.

Key words:Third molar extraction, pain, swelling, trismus, postoperative findings, prediction.

Antibiotics to prevent complications following tooth extractions

BACKGROUND

The most frequent indications for tooth extractions are dental caries and periodontal infections, and these extractions are generally done by general dental practitioners. Antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection.

OBJECTIVES

To determine the effect of antibiotic prophylaxis on the development of infectious complications following tooth extractions.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 25 January 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE via OVID (1948 to 25 January 2012), EMBASE via OVID (1980 to 25 January 2012) and LILACS via BIREME (1982 to 25 January 2012). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

We included randomised double-blind placebo-controlled trials of antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias for the included studies and extracted data. We contacted trial authors for further details where these were unclear. For dichotomous outcomes we calculated risk ratios (RR) and 95% confidence intervals (CI) using random-effects models. For continuous outcomes we used mean differences (MD) with 95% CI using random-effects models. We examined potential sources of heterogeneity. The quality of the body of evidence has been assessed using the GRADE tool.

MAIN RESULTS

This review included 18 double-blind placebo-controlled trials with a total of 2456 participants. Five trials were assessed at unclear risk of bias, thirteen at high risk, and none at low risk of bias. Compared to placebo, antibiotics probably reduce the risk of infection in patients undergoing third molar extraction(s) by approximately 70% (RR 0.29 (95% CI 0.16 to 0.50) P < 0.0001, 1523 participants, moderate quality evidence) which means that 12 people (range 10-17) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. There is evidence that antibiotics may reduce the risk of dry socket by 38% (RR 0.62 (95% CI 0.41 to 0.95) P = 0.03, 1429 participants, moderate quality evidence) which means that 38 people (range 24-250) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. There is also some evidence that patients who have prophylactic antibiotics may have less pain (MD -8.17 (95% CI -11.90 to -4.45) P < 0.0001, 372 participants, moderate quality evidence ) overall 7 days after the extraction compared to those receiving placebo, which may be a direct result of the lower risk of infection. There is no evidence of a difference between antibiotics and placebo in the outcomes of fever (RR 0.34, 95% CI 0.06 to 1.99), swelling (RR 0.92, 95% CI 0.65 to 1.30) or trismus (RR 0.84, 95% CI 0.42 to 1.71) 7 days after tooth extraction.Antibiotics are associated with an increase in generally mild and transient adverse effects compared to placebo (RR 1.98 (95% CI 1.10 to 3.59) P = 0.02) which means that for every 21 people (range 8-200) who receive antibiotics, an adverse effect is likely.

AUTHORS' CONCLUSIONS

Although general dentists perform dental extractions because of severe dental caries or periodontal infection, there were no trials identified which evaluated the role of antibiotic prophylaxis in this group of patients in this setting. All of the trials included in this review included healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. There is evidence that prophylactic antibiotics reduce the risk of infection, dry socket and pain following third molar extraction and result in an increase in mild and transient adverse effects. It is unclear whether the evidence in this review is generalisable to those with concomitant illnesses or immunodeficiency, or those undergoing the extraction of teeth due to severe caries or periodontitis. However, patients at a higher risk of infection are more likely to benefit from prophylactic antibiotics, because infections in this group are likely to be more frequent, associated with complications and be more difficult to treat. Due to the increasing prevalence of bacteria which are resistant to treatment by currently available antibiotics, clinicians should consider carefully whether treating 12 healthy patients with antibiotics to prevent one infection is likely to do more harm than good.

Amoxicillin and Clavulanic Acid Vs Ceftazidime in the Surgical Extraction of Impacted Third Molar: A Comparative Study

The objective of this work is to compare the effectiveness and the side effects of two different drugs, amoxicillin and clavulanic acid vs ceftazidime, used as antibiotic prophylaxis in the surgical extraction of third molars and to demonstrate that the use of second choice antibiotic has no significant advantages in comparison with a first choice antibiotic. One hundred and seven patients with impacted third molar were selected and divided into two groups: amoxicillin and clavulanic acid were administered to group 1 and ceftazidime to group 2 for five days after surgery and we observed the postoperative period. The statistical analysis showed no differences between the two groups which lead to the conclusion that there is no indication to routinely administrate intramuscular second-choice antibiotic prophylactic therapy (ceftazidime) in case of surgical extraction of the third molar.

Antibiotic prophylaxis in third molar surgery: a review

OBJECTIVE

Controversy exists about the efficacy of antibiotic prophylaxis in preventing complications after lower third molar surgery. For evidence-based recommendation, a review was performed on clinical trials reporting the use of antibiotic prophylaxis compared with no treatment or placebo with "infection" as outcome.

STUDY DESIGN

Useful studies were identified using Embase, Cochrane, and Ovid Medline (1966-January 2011) and references in retrieved reports and review articles. Twenty-three eligible studies were identified and reviewed by independent investigators using 2 quality assessment scales.

RESULTS

The review procedure revealed 15 "low-quality" and 8 "high-quality" articles, with major differences in treatment modalities and heterogeneity of design.

CONCLUSIONS

There is limited evidence supporting the efficacy of commonly used antibiotics in preventing complications after lower third molar removal. Well designed and well reported high-quality randomized trials considering known risk factors and taking clinical outcomes into account are needed to reach final consensus on the efficacy of antibiotic prophylaxis to allow evidence-based recommendations.

Efficacy of amoxicillin treatment in preventing postoperative complications in patients undergoing third molar surgery: a prospective, randomized, double-blind controlled study

PURPOSE

The aim of the present study was to evaluate and compare the occurrence of postoperative complications in patients receiving either pre- or postoperative amoxicillin versus placebo after third molar surgery.

PATIENTS AND METHODS

A randomized, double-blind, placebo-controlled clinical trial was performed in 123 patients undergoing third molar surgery. The patients were randomized to 3 groups, according to the treatment regimen: preoperative amoxicillin, postoperative amoxicillin, and placebo. Both surgeon and patients were unaware of the treatment assignment. The clinical outcomes, including pain, wound infection, trismus, temperature, intra- and extraoral swelling, dysphagia, side effects, and postoperative complications, were assessed.

RESULTS

Statistically significant differences were found in the incidence of pain, wound infection, temperature, trismus, and dysphagia between the groups receiving amoxicillin versus placebo. Suture dehiscence and infection of 5 sockets were only found in the placebo group. No cases of alveolitis were observed in the 3 groups studied. No significant differences in swelling were found among the different groups. No statistically significant differences in side effects were found between the groups. The efficacy was greatest in the group receiving postoperative amoxicillin compared with the group receiving a prophylactic preoperative dose.

CONCLUSION

Amoxicillin administered pre- or postoperatively demonstrated greater efficacy than placebo in preventing postoperative complications in patients undergoing third molar surgery. The best results were obtained using the postoperative protocol.