Relationship between bacterial contamination and alveolitis after third molar 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.

Microbiota of alveolar osteitis after permanent tooth extractions: A systematic review

Alveolar osteitis (AO) or dry socket after dental extractions is a common postoperative complication characterized by the presence of severe pain associated with an empty socket. Although some authors consider AO to be related to an alteration of the blood clot, the underlying etiology remains unclear, and recent reports suggest that bacteria might play an important role. A systematic review was made, compiling relevant references from PubMed, the Cochrane Library, Scopus and the Web of Science databases to determine which bacteria have been identified in AO sockets after dental extractions. Papers published between 1980-2019, identifying the bacteria present in AO sockets after tooth extractions, were included. Data were displayed in tables, and a descriptive analysis was carried out. After the screening process, four papers were analyzed, comprising a total of 138 samples from 138 patients with AO. The most commonly detected bacteria were Prevotella, Fusobacterium, Parvimonas and Peptostreptococcus. Two studies also showed the microbiota of patients that developed AO after dental extractions to be apparently different from that of patients without postoperative complications. These results indicate that bacteria may play an important role in the pathogenesis of AO, though further studies are needed to confirm these findings.

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.

What strategies are helpful in the operative management of third molars?

PURPOSE

The purpose of this review was to investigate and report strategies that might improve patient recovery after third molar (M3) surgery.

MATERIALS AND METHODS

This was a literature review on various topics to identify the methods of improving outcomes after M3 removal. Numerous topics were reviewed, including patient age, flap design, effect of smoking, use of antibacterial rinses, pre-emptive analgesia, and the role of antibiotics and corticosteroids in recovery.

RESULTS

Increased patient age appears to be a factor in a higher complication rate, but the literature is sparse. The results of studies on flap design are contradictory, but there is no difference in long-term periodontal health. Systematic reviews clearly show that longer periods of smoking cessation decrease surgical complications, but few studies have addressed M3 surgery. Likewise, the role of pre-emptive analgesia, although beneficial in a general surgical setting, has not been studied thoroughly with regard to M3 surgery. The use of chlorhexidine rinses to prevent alveolar osteitis and surgical site infection has been studied extensively, but meta-analyses have not convincingly proved this effect. The evidence is convincing that antibiotics decrease alveolar osteitis and surgical site infection. Similarly, it is clear that corticosteroids decrease postoperative trismus and edema; however, the role of steroids in decreasing pain is not proved.

CONCLUSION

This review found various factors associated with improving recovery and minimizing complications in M3 surgery.

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.

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.

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.

Alveolar osteitis: a comprehensive review of concepts and controversies

Alveolar osteitis, "dry socket", remains amongst the most commonly encountered complications following extraction of teeth by general dentists and specialists. A great body of literature is devoted to alveolar osteitis addressing the etiology and pathophysiology of this condition. In addition numerous studies are available discussing methods and techniques to prevent this condition. To this date though great controversy still exists regarding the appropriate terminology used for this condition as well as the actual etiology, pathophysiology, and best methods of prevention and treatment. This article is a comprehensive critical review of the available literature addressing the concepts and controversies surrounding alveolar osteitis. We aim to assist the dental health care professional with patient preparation and management of this commonly encountered postoperative condition should be encountered.

Effectiveness of antibiotic prophylaxis in third molar surgery: a meta-analysis of randomized controlled clinical trials

PURPOSE

We conducted a synthetic quantitative review of the published clinical trials on the effectiveness of antibiotic prophylaxis in third molar surgery.

MATERIALS AND METHODS

Electronic databases were searched for randomized controlled trials. The primary outcome variables included alveolar osteitis (AO) and surgical wound infection. The extracted data were analyzed using a meta-analytical program with a random-effect model. Number needed to treat (NnT) was calculated.

RESULTS

A total of 2,932 patients randomized in 16 clinical trials reported AO as an outcome. AO occurred in 84 of 1,350 patients in the treatment group, a frequency of 6.2%; and in 228 of 1,582 patients in the control group, a frequency of 14.4%. Systemic antibiotic therapy was effective in reducing the risk of AO (odds ratio [OR], 2.175) with an NnT of 13. A total of 2,396 patients randomized in 12 clinical trials reported wound infection as an outcome. Wound infection occurred in 44 of 1,110 patients in the treatment group, a frequency of 4%; and in 78 of 1,286 patients in the control group, a frequency of 6.1%. Systemic antibiotic therapy was effective in reducing the risk of wound infection (OR, 1.794) with an NnT of 25. Antibiotics reduced the risk of AO and wound infection only when first dose was given before surgery.

CONCLUSIONS

Systemic antibiotics given before the surgery were effective in reducing the frequencies of AO and wound infection after third molar surgery.

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

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

Removal of impacted third molars by oral/maxillofacial surgery and general dentistry residents

The post-operative symptoms of patients who had undergone third molar extractions by Oral/Maxillofacial Surgery (OMS) residents were compared with those of patients whose extractions were performed by General Dentistry (GD) residents. The OMS group had more extractions per visit and were more likely to use intravenous sedation than the GD-treated group. No significant differences were found when the provider groups were compared by post-operative symptoms such as osteitis, infection, trismus, or paresthesia/dysthesia. The pain relief due to postoperative analgesics during the immediate 12-hour period was higher for patients treated by GD residents. Multiple regression analysis revealed that this difference was due to the number of teeth extracted and the complexity of the surgical procedure, independent of type of provider.

Does metronidazole prevent alveolitis sicca dolorosa? A double-blind, placebo-controlled clinical study

The effect of a single preoperative dose of metronidazole in the prevention of alveolitis sicca dolorosa (ASD) after surgical removal of one impacted, non-infected mandibular third molar was investigated. A patient sample of 270 were given either 1000 mg of metronidazole or placebo at least 30 min before surgery. The preoperative recordings included gender, age, tooth to be removed, experience of surgeon, time of test medication, and duration of surgery. No difference was found between the metronidazole and placebo groups in the occurrence of ASD. The duration of surgery and the experience of the operating surgeons had no effect on the occurrence of ASD. The present study failed to demonstrate any preventive effect of a single dose of metronidazole on the development of ASD.

The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars

A prospective randomized double-blind placebo-controlled study was conducted with 139 patients (278 bilaterally impacted mandibular third molars) to determine the effect of a perioperative 0.12% chlorhexidine gluconate rinse on the incidence of alveolar osteitis following surgical removal of impacted mandibular third molars. A statistically significant 60% reduction in the incidence of alveolar osteitis was obtained in the chlorhexidine group compared with the placebo group. In most subgroups analyzed, chlorhexidine was associated with at least a 50% reduction in alveolar osteitis compared with control groups.

The effect of chlorhexidine irrigation on the incidence of dry socket: a pilot study

A pilot study was conducted to measure the reported incidence of dry socket following pre-operative irrigation and mouthrinsing with either 0.2% (w/v) chlorhexidine gluconate or normal saline or with no irrigation (control). Three hundred and twenty-four patients presenting for the single extraction of a lower premolar or molar under local anaesthesia were divided into three equal groups; no irrigation, irrigation with saline and irrigation with a 0.2% (w/v) chlorhexidine gluconate solution. After administration of the local anaesthetic agent, 10 ml of the test solutions were applied to the gingival crevice using a blunted needle. The solutions were retained in the patients mouth for 2 min following irrigation. Pre-operative irrigation of the gingival crevice and mouthrinsing with 0.2% (w/v) chlorhexidine gluconate significantly reduced the number of dry sockets. There was no significant reduction in the number of dry socket cases following irrigation and rinsing with normal saline. The irrigation technique, using 0.2% (w/v) chlorhexidine gluconate is safe, inexpensive, easy to apply and can be recommended for routine use in dental practice, to reduce the incidence of dry socket.

Fibrinolytic alveolitis and its prevention

This study aimed at testing the clinical efficacy of a topical prevention of FA, the sample comprising 300 cases of extractions. A sponge was inserted in the socket of each of them, dividing the sample into 3 equal groups: group A (gelatine), group B (gelatine + Solcoseryl) and group C (gelatine + Solcoseryl + propyl-hydroxy-benzoic-acid). The global incidence of FA was a comparatively high, 7.6%, which could be related to the pool of patients included in the study as to the presence of teeth and techniques more prone to complications. No specific clinical characteristic has been isolated (distribution within sex, age, teeth, etc.) which could contradict data collected from other authors. The incidence was lower in the groups B (3%) and C (7%) as compared to group A (13%), but only sponges of group B demonstrated a clinical and statistical efficacy, according to the high number of lower third molar extractions. In contrast, the addition of Solcoseryl proves efficient and does not delay healing, according to previous histological studies. This last characteristic has to be confirmed in the experimental conditions described in our study, as has its mode of action. The ultimate mechanism of FA has still, in our opinion, to be better defined well before the restatement of a topical prevention of FA.

Complications following removal of impacted third molars: the role of the experience of the surgeon

The incidence of complications associated with the removal of impacted third molars in a group of 500 patients treated by oral surgery faculty were compared with the incidence of complications in 208 patients treated during the same period by residents of oral and maxillofacial surgery. The results show that complications were more numerous after the removal of third molars classified as partial bony or complete bony impactions, and that less-experienced surgeons had a significantly higher incidence of such complications.

Postoperative complications after surgical removal of mandibular third molars. Effects of penicillin V and chlorhexidine

A random material of 112 patients, was investigated after surgical removal of impacted lower third molars. 2 experimental groups and 1 control group were studied. Prophylactic medication with penicillin V combined with preoperative rinsing using 0.2% chlorhexidine gluconate (Hibitane) was found to reduce postoperative symptoms, when compared with preoperative rinsing alone. In both cases, patients were compared with the control group.