Effect of chlorhexidine rinse on the incidence of dry socket in impacted mandibular third molar extraction sites

Comparison of Different Techniques in Post-Extractive Socket Regeneration Using Autologous Tooth Graft: Histological and Clinical Outcomes

OBJECTIVE

 Post-extractive socket grafting techniques reduce alveolar ridge dimensional changes. Numerous graft materials have been suggested and a growing interest in tooth material has been observed as a valuable alternative to synthetic biomaterials or xenografts. Furthermore, different clinical procedures have been proposed for the wound closure of the post-extractive site. This study aims to compare histological and clinical outcomes of two different surgical techniques to seal the post-extractive site with the use of autologous demineralized extracted tooth as graft material.

MATERIALS AND METHODS

 Sixteen post-extractive socket without buccal and/or palatal bone walls, in sixteen healthy patients, were grafted with the autologous tooth material treated by the new Tooth Transformer device (Tooth Transformer, Milan, Italy). Alveolar socket preservation procedures were performed without flap elevation. Patients were randomly subdivided into two equal groups according to the site closure technique. In group A, the pedunculate tissue was used, while in group B ice cone technique. A bone samples were collected in each site after 4 months for histological analysis.

RESULTS

 No significant clinical differences among the different sealing techniques were observed. In both groups, the site was filled by new bone formation after 4 months of healing. The histological analysis revealed 46.1 ± 8.07% of bone volume, 9.2 ± 9.46% of residual graft, and 35.2 ± 12.36% of vital bone in group A, while group B shows 41.22 ± 5.88% of bone volume, 7.94 ± 7.54% of residual graft, and 31.7 ± 7.52% new bone. No statistical differences were detected (p > 0.05).

CONCLUSION

 Further studies with a large number of patients, and different observation periods will be needed to confirm the results of this pilot study; however, the interesting data obtained have shown how these techniques, mixed with the autologous dentin derived graft material, seem to promote bone regeneration and reduce physiological bone resorption during alveolar socket preservation treatments.

Oral Contraceptive Use and Alveolar Osteitis Following Third Molar Extraction: A Systematic Review and Meta-Analysis

PURPOSE

Alveolar osteitis (AO) is a common postoperative complication of third molar extractions that is thought to be associated with the intake of oral contraceptives (OCPs). This meta-analysis sought to evaluate the risk of AO associated with OCP use and sex independently and whether this risk was affected by the use of postoperative analgesics or antibiotics.

METHODS

PubMed/Medline, EMBASE, and Cochrane databases were searched for articles pertaining to OCP use and the incidence of AO using MESH terms. The measured outcome was the development of AO following a third molar extraction. Additional variables such as sex, analgesic, and antibiotic use were documented and included in the analysis. The data were analyzed in R using the Mantel-Haenszel method.

RESULTS

Fifteen studies with a total of 1366 female participants who were OCP users and 2919 nonuser female participants were included in this meta-analysis. OCP users were approximately twice (pooled-RR: 1.98, 95% CI: 1.42-2.76) as likely to develop AO following a third molar extraction when compared to nonuser females. The increased incidence of AO in the OCP group was statistically significant (p < 0.01). The pooled-RR of AO in females not taking OCPs was not significantly different from males (p=0.45).

CONCLUSIONS

OCP use significantly elevated the risk of AO in females. Females who did not take OCPs had a similar risk of developing AO compared to males, suggesting that OCP use is a potential effect modifier. Neither postoperative antibiotics use nor the type of postoperative analgesic significantly affected AO incidence in those taking OCPs.

An Analysis of Different Techniques Used to Seal Post-Extractive Sites—A Preliminary Report

Background: Bone grafting in post-extractive site improves tissue regeneration. Soft tissue sealing of the grafted post-extractive alveolus is supposed to limit microbiological contamination from the oral cavity and to stabilize the coagulum. Several techniques are presented in the literature to reach this goal using different heterologous matrices or autogenous grafts. In addition, recently, a technique based on the use of granulation tissue in the post-extractive alveolus has been proposed. Aim: To compare the effect of different graft sealing approaches in post-extractive sites by qualitatively evaluating their healing process. Materials and Methods: This retrospective investigation included 30 patients requiring post-extractive site regeneration in the aesthetic area. Post-extractive sites were regenerated using a bovine bone matrix and patients were divided into three groups (10 patients in each group) according to the material used to seal the alveolar socket. In the UD group, the granulation tissue was used to seal the defect; in the PC group, epithelial-connective soft tissue graft was used, and in the COLL group, a collagen-based membrane was employed. Images of the post-extractive sites at different follow-up periods (2 and 12 weeks) were taken and the healing process was blindly evaluated by two independent practitioners. The Healing Index (HI) by Landry, Turnbull and Howley was used to assess the quality of the healing process. The combination of presence/absence of five clinical criteria defines an HI ranging from 1 (very poor) to 5 (excellent). Patients’ clinical-pathological variables were recorded. One-way ANOVA was used to explore the dependence of HI on the different socket preservation protocols. Results: Based on clinical-pathological characteristics of the included patients, there were no statistically significant differences among the different sealing techniques. At the 2-week follow-up appointment, HI did not differ among the socket preservation protocols evaluated. Moreover, smoking status and reason for extraction did not influence the HI among the three groups (two-way ANOVA p-value = 0.686, p-value = 0.248 respectively). At the 2-week follow-up appointment, HI was significantly different among the socket preservation protocols investigated. Specifically, the group undergoing collagen-based socket preservation procedure reported the highest HI, compared to the other two techniques (COLL mean 4.60 ± 0.5; PC mean 3.5 ± 1.2; UD mean 3.4 ± 0.5, one-way ANOVA p-value 0.006). Conclusions: The use of collagen porcine membranes may represent a suitable option to improve the patient healing process in grafted post-extractive sites together with reducing the surgical intervention time compared to alternative sealing techniques.

Effects of intraoperative placement of tetracycline, tetracycline + gelatin sponge, and placebo on postoperative pain after mandibular molar extraction: A comparative prospective study

BACKGROUND

Painless postoperative period is a major requisite following routine dental extractions. Reduction in the postextraction complication is beneficial to both clinician and patients. Hence, emphasis should be given to the techniques and agents that help reduce the complications for better postoperative recovery.

MATERIALS AND METHODS

Three groups of 30 patients each requiring mandibular molar extractions were randomly selected with intrasocket placement of tetracycline, tetracycline plus gelatin sponge, and placebo control after extraction. A small piece of collagen membrane was used on the superior surface of the socket after the placement of the medicament in Group A and Group B. The postoperative pain scores were evaluated at 24 h, 48 h, and 7 days postoperatively.

RESULTS

Ninety patients requiring mandibular molar teeth extraction were enrolled as the study participants. Forty-two patients (55.26%) were male and 34 (44.73%) were female. Tetracycline alone and tetracycline + gelatin sponge group shows no statistical significant difference in reducing postoperative pain after 7 days, but the pain score values were less in Tetracycline + gelatin sponge group. The comparison between tetracycline alone and control group showed no significant difference observed between the groups at 24 h but showed statistically significant difference between the groups after 48 h and 7 days, whereas comparison between tetracycline + gelatin sponge and control group showed statistically significant difference between the groups after 24 h, 48 h, and 7 days (P = 0.009, 0.001, and 0.017, respectively).

CONCLUSION

Tetracycline and gelatin sponge intrasocket placement provides a good substitute to the prolong use of analgesics and as a good adjuvant in reducing pain in the first few days after routine dental extraction.

The efficacy of chlorhexidine gel in the prevention of alveolar osteitis after mandibular third molar extraction: a systematic review and meta-analysis

BACKGROUND

Alveolar osteitis is a very painful and distressing condition for a patient who has recently undergone a tooth extraction and has led dental professionals to search for preventive measures. The aim of this meta-analysis to determine the effect of chlorhexidine (CHX) gel on the incidence of alveolar osteitis after mandibular third molar extraction.

METHODS

Studies were searched for on electronic search engines using Medline (PubMed), Cochrane central, Scopus and advanced Google Scholar from May 2015 to December 2015. Randomized controlled trial studies with a history of mandibular third molar extraction, along with the administration of topical chlorhexidine gel were included. The risk of bias of the selected articles was assessed using the Cochrane risk of bias assessment tool. RevMan 5.3 Software was used to analyze the pooled effect. I2 was calculated to determine heterogeneity and a funnel plot was used to check the risk of bias. Subgroup analysis was also done based on the presence of confounding factors (smoking, oral contraceptive etc.) and on split mouth design.

RESULTS

Out of 52 articles, ten met the inclusion criteria. 862 participants were involved in the selected studies with a mean age range from 24.15 ± 5.02 to 36.65 ± 11. The overall RR was 0.43 (95% CI: 0.32, 0.58, p < 0.00001). Three studies used a split-mouth design to check the effect of chlorhexidine gel in the prevention of alveolar osteitis incidence. There was a pooled effect of 0.29 (95% CI: 0.16, 0.50) for the intervention group in the split mouth design studies. A stratified analysis was done to check the effect of CHX gel in patients with confounding factors and a significant reduction of AO incidence was found; 0.60 (95% CI: 0.41, 0.87; p = 0.05) in the intervention. There was no reported adverse reaction. The heterogeneity (I2) was 40%. The funnel plot showed that there was no significant publication bias.

CONCLUSION

This meta-analysis suggests that CHX gel is superior to a placebo in reducing the incidence of alveolar osteitis after mandibular third molar extraction.

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).

Effect of oral contraceptive use on the incidence of dry socket in females following impacted mandibular third molar extraction: a meta-analysis

The aim of this comprehensive meta-analysis was to provide evidence-based data to test whether oral contraceptive (OC) use can promote the incidence of dry socket (DS) in females following impacted mandibular third molar extraction. PubMed, the Cochrane Library, and Elsevier Science Direct databases were searched. The pooled risk ratio (RR) with 95% confidence interval (CI) was calculated using fixed-effects or random-effects model analysis. Heterogeneity among studies was evaluated with the Cochran test and I(2) statistic. Study quality was assessed with the Newcastle-Ottawa scale. Of 70 articles identified in the search, 12 reporting 16 clinical controlled trials were included in this study. The incidence of DS was significantly greater in the OC groups than in the control groups (RR 1.80, 95% CI 1.33-2.43). Subgroup analyses showed that the unit assessed (tooth or patient), the region in which the study was conducted, and the intervention were not related to the incidence of DS in females taking OC after impacted mandibular third molar extraction. The sensitivity analysis showed no significant change when any one study was excluded. Publication bias was also not detected. This study suggests that OC use may promote the incidence of DS in females following impacted mandibular third molar extraction.

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.

[Assessment of the effectiveness of low level laser in the treatment of alveolar osteitis]

BACKGROUND/AIM

Alveolar osteitis (AO) is the extraction wound healing disorder with a presence of severe pain. Low level laser therapy stimulates cell metabolism and microcirculation, have has pronounced analgesic, antiedematous and anti-inflammatory effect and speeds up wound healing process. The aim of this study was to present results of clinical research that examined the effectiveness of low level laser in pain relief and healing of extraction wounds with alveolar osteitis in the lower jaw which was formed on the second day after tooth extraction.

METHODS

The study was conducted on 60 subjects divided into the study and the control group. In both groups extraction wounds were processed in similar way, except that in the study group was applied daily treatment of low level laser with a total of eight sessions of radiation, while in the control group extraction wounds were dressed with zinc oxide eugenol paste, which was changed every 48 hours up to the pain cessation. Measurement of pain intensity was done with a visual analogue scale (VAS) 10 min prior to processing of extraction wounds and daily for the next eight days. Assessment of the effectiveness of low level laser on healing of extraction wounds was performed on the day eight of the treatment.

RESULTS

On the day five after beginning of the treatment of extraction wounds with alveolar osteitis in the patients of the study group a lower average value of pain as compared to the control group was registered. This difference was increased within the following days. Extraction wounds healing in the study group was more successful and faster than in the control group.

CONCLUSION

This study suggested that the reduction of pain was more pronounced in the patients with alveolar osteitis whose extraction wounds were subjected to low level laser radiation in comparison to those in which extraction wounds were treated with zinc oxide eugenol paste.

Evaluation of the perioperative use of 0.2% chlorhexidine gluconate for the prevention of alveolar osteitis after the extraction of impacted mandibular third molars: a clinical study

PURPOSE

To clinically evaluate the perioperative use of 0.2% chlorhexidine gluconate for the prevention of alveolar osteitis, to assess the patient compliance to chlorhexidine and to prepare a comprehensive treatment plan to prevent alveolar osteitis after removal of an impacted third molar extraction.

METHODS

A prospective study was done on 50 patients with bilaterally impacted lower third molars which were indicated for extraction. Extraction of impacted mandibular third molar on one side was done without using any mouthrinse. While extracting the third molar on the other side, patients were instructed to use chlorhexidine 0.2% mouth rinse for 8 days, 1 day preceding and 7 days following the surgery. They were instructed to use chlorhexidine 0.2% (Rexidine) mouth rinse for 30 s twice a day (before breakfast and after dinner) with 15 ml of the rinse with 1:1 dilution with clean water. All the patients were evaluated for pain, presence or absence of clot and condition of the alveolar bone for the diagnosis of dry socket.

RESULTS

Incidence of dry sockets was 8%, when patients did not use 0.2% chlorhexidine gluconate perioperatively which is statistically significant.

CONCLUSIONS

It appeared that the incidence of dry socket can be reduced significantly by using 0.2% chlorhexidne gluconate mouth rinse perioperatively (twice daily, 1 day before and 7 days after surgical extraction.

Clinical concepts of dry socket

Dry socket is one of the most studied complications in dentistry, and a great number of studies have searched for an effective and safe method for its prevention and treatment. One of the great clinical challenges since the first case was reported has been the inconsistency and differences in the various definitions of dry socket and the criteria used for diagnosis. The pathophysiology, etiology, prevention, and treatment of dry socket are very important in the practice of oral surgery. The aim of the present report was to review and discuss each aspect.

Randomized, double-blind study of effectiveness of intra-alveolar application of chlorhexidine gel in reducing incidence of alveolar osteitis and bleeding complications in mandibular third molar surgery in patients with bleeding disorders

PURPOSE

Chlorhexidine (CHX) is an antimicrobial agent used in the prevention of tooth decay, periodontal disease, and postextraction alveolar osteitis (AO). Recently, a bioadhesive gel to deliver the active substance, CHX, was introduced. The intra-alveolar placement of the bioadhesive gel allows a more direct and prolonged therapeutic effect of CHX, which is useful in the prevention of AO after extraction of impacted third molars. The intra-alveolar application of the bioadhesive CHX gel in patients with bleeding disorders may increase the risk of postoperative bleeding complications. Inversely, bleeding disorders might influence the efficacy of CHX for AO prevention. The purpose of the present study was to evaluate the effectiveness of the bioadhesive 0.2% CHX gel in reducing the incidence of impacted third molar postextraction AO in patients with bleeding disorders.

MATERIALS AND METHODS

We performed a double-blind, randomized, parallel-group study of 38 patients with bleeding disorders. The experimental group (n = 14) was treated with bioadhesive 0.2% CHX gel applied intraoperatively once after surgical removal of the third molar. The control group (n = 24) was treated in an identical fashion with placebo gel.

RESULTS

We observed a 57.15% reduction in the incidence of AO in the experimental group. The control group had a 17% incidence of AO and the experimental group had a 7% incidence of AO (P = .402). Bleeding complications occurred in 21% of the experimental group compared with 29% of the control group (P = .601).

CONCLUSIONS

As described in previous studies, the single intra-alveolar application of the bioadhesive 0.2% CHX gel in an intraoperative fashion seems to reduce the incidence of AO after removal of impacted third molars in patients with bleeding disorders. On the basis of the reported percentage of bleeding complications, the routine use of postoperative local hemostatic measures is recommended.

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

PURPOSE

Chlorhexidine is an antimicrobial agent used in the prevention of postextraction alveolar osteitis, tooth decay, and periodontal diseases. There are various forms of chlorhexidine application. The most extensively studied is one that uses the rinse as the form of application. Recently, a bioadhesive gel form has become available. Its main advantage is that it prolongs the bioavailability of chlorhexidine in the application area. The purpose of this study was to compare the effectiveness of chlorhexidine gel versus a chlorhexidine rinse in reducing postoperative alveolar osteitis after the extraction of mandibular third molars.

MATERIALS AND METHODS

The experimental or gel group (n = 41) applied the bioadhesive 0.2% chlorhexidine gel to the wound during the first postoperative week and a control or rinse group (n = 32) used a 0.12% chlorhexidine rinse during the first week postextraction.

RESULTS

We observed a 70% decrease in postoperative alveolar osteitis in the gel group (P = .040). The rinse group had 25% incidence postoperative alveolar osteitis, while the gel group had 7.5%.

CONCLUSIONS

It was concluded that the topical application of bioadhesive chlorhexidine gel to the surgical wound during the postoperative week may decrease the incidence of alveolar osteitis after extraction of the mandibular third molars.

Oily calcium hydroxide suspension (Osteoinductal) used as an adjunct to guided bone regeneration: an experimental study in rats

OBJECTIVES

To evaluate whether an oily calcium hydroxide suspension (OCHS) promotes bone healing when used as an adjunct to guided bone regeneration (GBR).

MATERIAL AND METHODS

Rigid, hemispherical, teflon capsules were placed with their open part facing the lateral surface of the ramus on both sides of the mandible in 10 adult Wistar rats. In each animal, one capsule was filled out with an OCHS (test) before placement, while the capsule on the other side was left empty (control). After 4 months of healing, the animals were sacrificed and histological sections containing the capsules and the neighboring soft and hard tissues were prepared. On three to four sections taken by uniformly random sampling from each specimen, the relative volumes of (1) the newly formed bone (mineralized bone and marrow), (2) the soft connective tissue, (3) the residual OCHS, and (4) the acellular (empty) space inside the capsule were estimated by a point-counting technique, and expressed as percentage of the space originally created by the capsule.

RESULTS

There was no new bone formation inside the capsules in all but one test specimen, where only a minimal amount of newly formed bone could be observed in continuation with the lateral surface of the ramus. OCHS had a homogenous appearance and occupied the major portion (79.4%) of the space created by the capsule. No signs of active resorption of the material could be observed. On the contrary, 31.5% of the space provided by the capsule was filled out with newly formed bone in the control group. The new bone had a trabecular appearance with large marrow spaces filled with hematopoietic and fatty marrow. The rest of the capsule space in the controls appeared empty.

CONCLUSION

OCHS may hamper bone healing when used as an adjunct to GBR.

In vitro comparison of chlorhexidine and povidone-iodine on the long-term proliferation and functional activity of human alveolar bone cells

This work reports the behaviour of osteoblastic human alveolar bone cells (first subculture) in the presence of chlorhexidine (CHX) and povidone-iodine (PI). Short contact (2 min) of 24-h cultures with CHX, at 0.12 and 0.2%, and PI, at 5 and 10%, caused cell death within minutes; contact with 1% PI resulted in loss of the elongated characteristic cell shape. Cell adhesion was adversely affected at concentrations higher than 5 x 10(-5)% CHX or 0.05% PI. Long-term exposure to CHX at 10(-5) and 10(-4)% or PI at 10(-4)% had little effect on cell growth and caused an induction in the synthesis of alkaline phosphatase (ALP). Concentrations of CHX and PI similar and higher than, respectively, 5 x 10(-4)% or 0.05% caused dose-dependent deleterious effects. CHX affected mainly the cell growth, whereas the effects of PI were observed mostly in ALP production and matrix mineralization. Considering the levels of CHX and PI used routinely in the oral cavity, results suggest that CHX has a higher cytotoxicity profile than PI. This observation might have some clinical relevance regarding the potential utility of PI in the prevention of alveolar osteitis.

Randomized, double-blind study on effectiveness of intra-alveolar chlorhexidine gel in reducing the incidence of alveolar osteitis in mandibular third molar surgery

Chlorhexidine (CHX) mouthwash is a good prophylactic agent for postextraction alveolar osteitis (AO), a very common complication. Recently, a bio-adhesive gel to deliver the active substance, CHX, has been introduced. The intra-alveolar positioning of the bio-adhesive gel allows more direct and prolonged action of CHX, which could be useful in the prevention of AO following extraction of impacted third molars. Presented here is a double-blind, randomised and parallel-group study evaluating the efficacy of the bio-adhesive 0.2% CHX gel (n=53) applied once within the alveolus during third molar surgery, compared to placebo gel only (n=50), in reducing the incidence of impacted third-molar postextraction AO. A 63.33% reduction in the occurrence of AO (P=0.019) was observed in the experimental group. In the control group, the occurrence of AO was 30% compared to 11% in the experimental group. Bio-adhesive 0.2% CHX gel, applied only once within the alveolus site at the time of surgery, may reduce the incidence of AO following removal of impacted third molars.

Efficacy of amoxicillin/clavulanic acid in preventing infectious and inflammatory complications following impacted mandibular third molar extraction

OBJECTIVE

To find out whether the frequency of postoperative infectious and inflammatory complications (IC) in subjects treated with placebo (Pl) is greater than those treated with antibiotic (Ab) after extraction of an impacted mandibular third molar (M3). Our hypothesis is there are more IC in Pl than in Ab, with a maximum ratio difference of 0.067.

STUDY DESIGN

A double-blind placebo-controlled randomized clinical trial. The sample was derived from the population of subjects attending Cruces Hospital for evaluation and extraction of 1 M3 under local anesthesia. Patients were treated with postoperative placebo or amoxicillin/clavulanic acid 500/125 mg 3 times a day during 4 days. The outcome variable was infectious and inflammatory complications. Sex, age, smoking, molar depth, angulation, need for sectioning, ostectomy, and operation time were recorded. Analysis was by intention to treat, risk measures, and logistic regression.

RESULTS

In 490 subjects (259 Ab and 231 Pl), the frequency of IC was 1.9% in the Ab and 12.9% in the Pl group (OR 7.6, 95%CI 2.9-19.9; P < .001). The number needed to treat was 10 (7-16). Unadjusted relative risk was 0.15 (0.06-0.38) (P < .001). Absolute reduction risk was 0.11(0.066-0.155)]. Therefore, the hypothesis cannot be rejected. Multivariate analysis shows treatment with antibiotic (OR = 8.66 (3.17-23.67); P < .001) and age (OR = 1.08 (1.00-1.16); P = .029) are the only variables to be included in the logistic regression model.

CONCLUSION

Amoxicillin/clavulanic acid is efficacious in reducing the incidence of IC following third molar extraction but should not be prescribed in all cases.

Prevention of alveolar osteitis with chlorhexidine: A meta-analytic review

OBJECTIVE

The objective of this study was to assess if chlorhexidine (CHX) rinse decreases the occurrence of alveolar osteitis (AO) following third molar removal.

STUDY DESIGN

A literature search identified 7 randomized prospective clinical trials reporting incidence of AO following removal of mandibular third molars. Studies were combined into 2 groups and summary relative risks were calculated for each group. One group of studies evaluated rinsing on the day of surgery only and the second group of studies rinsed at least on the day of surgery and several days after surgery.

RESULTS

The relative risk for the single rinse group was 1.36 (95% confidence interval [CI] 0.80, 2.33), P>.05, whereas for the multiple rinse group, the relative risk was 1.90 (95% CI 1.46, 2.47), P<.05.

CONCLUSION

Rinsing with CHX on the day of surgery and several days after may reduce the incidence of AO.

Die antimikrobielle photodynamische Therapie zur Pr�vention der alveol�ren Ostitis und des Dolor post extractionem

AIM

Alveolar ostitis occurs with an incidence of 3-25% after tooth extraction. Antimicrobial photodynamic therapy (aPDT) with HELBO Blue and TheraLite laser enables local decontamination of the extraction socket. The aim of the study was to evaluate the possibility of aPDT with HELBO Blue and diode soft laser to reduce the prevalence of alveolar ostitis.

MATERIAL AND METHODS

In an intraindividual study with 100 patients in 130 jaws, one or multiple contralateral teeth were removed at 1-week intervals. Randomly each side was treated with or without aPDT with a standardized protocol. At recall the evaluation of the extraction socket was performed by the investigator and the postoperative pain sensation was judged by the patient on an analog pain scale (0-100).

RESULTS

In the group with aPDT alveolar ostitis occurred at one extraction site and in the control group without aPDT in 13 cases. The subjective pain assessment on the day after tooth removal was scored with 11.2+/-9.8 in the aPDT-group and with 19.0+/-12.2 in the control group. One week after extraction the pain sensation in the aPDT group was scored with 2.4+/-9.2 and in the control group with 13.1+/-25.2. The difference was significantly lower with p=0.000 for the 1st and 8th post-surgical days in the aPDTgroup.

CONCLUSIONS

The significantly lower incidence of alveolar ostitis after antimicrobial photodynamic therapy seems to be a new and promising possibility for the prevention of alveolar ostitis.

New data on biological effects of chlorhexidine: Fe2+ induced lipid peroxidation and mitochondrial permeability transition

Chlorhexidine (CHX) is a bis-bis-guanide with anphipatic and antiseptic properties and is largely used in dentistry, mainly for management of periodontal problems and in oral pre-operatory procedures. The present study concerns the effect of CHX on lipid peroxidation, mitochondrial permeability transition (MPT), and the interaction of CHX with ferritin (HoSF). CHX (100 microM) increased iron release from HoSF by approximately 13-fold when compared to control values. CHX also increased iron-dependent lipid peroxidation. MPT induced by CHX was protected by ethylene glycol-bis(beta-aminoethyl-ether)-N,N,N',N'-tetraacetic acid (EGTA), dithiothreitol (DTT), and cyclosporin A (CsA), showing a Ca2+-dependent effect, in which oxidation of thiol groups is involved, as well as the involvement of the transmembrane proteinaceous pore. BHT, catalase or o-phenanthroline did not protect MPT induced by CHX. This suggests that a ROS-independent mechanism is involved in the induction of MPT.

Tetracycline compound placement to prevent dry socket: a postoperative study of 200 impacted mandibular third molars

PURPOSE

Our objective was to study whether the placement of intra-alveolar tetracycline prevents dry sockets or improves the postoperative period.

PATIENTS AND METHODS

A comparative clinical study of the surgical removal of 200 impacted mandibular third molars is made, with particular reference to postextraction pain, inflammation, trismus, and the incidence of dry socket. In 50% of these cases, a pharmacologic preparation that includes tetracycline was placed in the socket after removal of the impacted molar.

RESULTS

Dry socket was diagnosed in 4 cases (2%), with no relation to intra-alveolar tetracycline placement being observed. The patients who were administered intra-alveolar tetracycline had less pain and trismus and consumed fewer analgesics than the patients who received no such treatment, although statistical significance was not reached.

CONCLUSIONS

The intra-alveolar placement of tetracycline compound after the surgical removal of impacted mandibular third molars did not affect the incidence of dry socket.

The relationship of “shisha” (water pipe) smoking to postextraction dry socket

PURPOSE

This study was undertaken to determine whether "shisha" (water pipe) smokers (SS) were at a different risk of developing dry socket (DS) than were cigarette smokers (CS) or nonsmokers (NS) and to assess the effect of preoperative and postoperative smoking habits on the incidence of DS.

MATERIALS AND METHODS

One hundred NS, 100 CS, and 100 SS were enrolled. Surgery for removal of mandibular third molars was performed under local anesthesia with no incision or bone removal. At 1, 4, and 7 days after surgery, postoperative evaluation and postoperative smoking were recorded by the same examiner. The chi(2) test was used for statistical analysis of results. Statistical significance was defined as a value of P <.05.

RESULTS

Smokers had 2 to 3 times the risk of NS for developing DS. Although SS had a greater incidence of DS than did CS, the difference was not significant (P =.083). The incidence of DS was not age dependent. Smokers who smoked the day of surgery had a significantly higher incidence of DS than did smokers who smoked the second day after surgery. Compared with NS, CS who smoked the day of surgery and SS who smoked the day of surgery or the first day after surgery had a significantly increased incidence of DS (CS/NS, day 0, P =.001; SS/NS, day 0, P =.001; day 1, P =.005).

CONCLUSION

SS had 3 times the risk of NS for developing DS, but there was no statistically significant difference between SS and CS. Increased frequency of smoking and smoking during the day of surgery significantly increased the incidence of DS.

A clinical evaluation of dry socket in a Nigerian teaching hospital

PURPOSE

We sought to determine the incidence of dry socket in a Nigerian teaching hospital and to evaluate the patients' demographic pattern, predisposing factors, the treatment given, and treatment outcome.

PATIENTS AND METHODS

A retrospective review of records of dental extractions complicated by dry socket in Obafemi Awolowo University Teaching Hospital, Ile-Ife, between January 1996 and December 2000 was undertaken. Information retrieved included patient sociodemographic data, indications for extraction, tooth extracted, status of attending surgeon, onset of symptoms, relevant findings of the examining clinician, interval before presentation, treatment given, and its outcome.

RESULTS

Of the 3,319 dental extractions performed in 3,008 patients, 136 (4.1%) were complicated by dry socket. The patients' mean age was 33.4 (15.4) years and a peak age incidence of 21 to 30 years was found. A slight female preponderance (1.4:1) was observed. The majority of patients were in the low-income group, and presentation in the hospital was prompt in the high-income group. Mandibular teeth were affected 3 times more than maxillary teeth (P =.00080). Most cases of dry socket resulted from extractions performed by undergraduates and house officers. Various underlying systemic conditions were found in 11.0% of cases, none of which included use of oral contraceptives. Treatment was usually the use of zinc oxide eugenol dressing in an irrigated socket, combined with antibiotic therapy in 45.3% of cases. No adverse reaction to zinc oxide eugenol was observed.

CONCLUSION

The incidence of dry socket in our hospital is 4.1%. The mandible was involved 3 times more than the maxilla. With the use of zinc oxide eugenol dressing, 70.6% of patients completed treatment satisfactorily and 29.2% were lost to follow-up.

Does oral contraceptive use affect the incidence of complications after extraction of a mandibular third molar?

OBJECTIVE

This study investigated whether oral contraceptive use affects the incidence of complications (pain, trismus, dry socket) in women undergoing removal of impacted mandibular third molars.

PATIENTS AND METHOD

Two hundred and sixty seven women, aged 17 - 45 years, underwent removal of an impacted mandibular third molar. Eighty seven of the women were regular users of oral contraceptives. All patients were evaluated for postoperative pain, trismus and dry socket (localized alveolar osteitis).

RESULTS

Mean trismus values (measured as maximum interincisal distance) were similar in the two groups of patients. Postoperative pain was significantly more frequent among women taking contraceptives, both on day 1 (30% of women taking contraceptives used analgesics, versus 11% of women not taking contraceptives, p < 0.001) and on day 5 (14% versus 5%, p = 0.024). Similarly, dry socket occurred more frequently among women taking contraceptives than among women not taking contraceptives (11% versus 4%, p = 0.017).

CONCLUSIONS

The results of this study support the view that oral contraceptive use favours the appearance of dry socket and postoperative pain after extraction, but has no effect on trismus.

Effects of 0.2% chlorhexidine gluconate and amoxicillin plus clavulanic acid on the prevention of alveolar osteitis following mandibular third molar extractions

OBJECTIVE

The purpose of this study was to evaluate the use of a 0.2% chlorhexidine gluconate and amoxicillin plus clavulanic acid combination as a prophylactic therapy for the prevention of alveolar osteitis after mandibular third molar extractions and to investigate adverse reactions to chlorhexidine.

STUDY DESIGN

This randomized, placebo-controlled, parallel group study was conducted in a group of 177 subjects, from which 3 groups were formed. The first group (n = 62) received 0.2% chlorhexidine gluconate, the second group (n = 56) received a 0.2% chlorhexidine gluconate and amoxicillin plus clavulanic acid combination, and the third group (n = 59) received 0.09% sterile saline solution. All patients were recalled for the diagnosis of alveolar osteitis on the third and seventh postoperative days.

RESULTS

When patients in the antibiotic group were compared with those in the other 2 groups, a significant reduction in alveolar osteitis was noted (P <.05). An alteration in taste, the bad taste of the solution, and staining of dentures and oral tissues were the major complaints about chlorhexidine.

CONCLUSION

It would be more beneficial to use chlorhexidine solution with a beta-lactamase inhibitor-containing antibiotic to enhance its effectiveness for the prevention of alveolar osteitis.

Reduction in the incidence of alveolar osteitis in patients treated with the SaliCept patch, containing Acemannan hydrogel

PURPOSE

In the present study, we compared the incidence of alveolar osteitis (AO) in patients treated with either clindamycin-soaked Gelfoam (Pharmacia and Upjohn Co, Kalamazoo, MI) or SaliCept Patches (Carrington Laboratories, Inc, Irving, TX). The SaliCept Patch is a freeze-dried pledget that contains Acemannan Hydrogel (Carrington Laboratories) obtained from the clear inner gel of Aloe vera L.

PATIENTS AND METHODS

A retrospective evaluation was performed of the records of 587 patients (1,031 sockets) whose extraction sites had been treated with clindamycin-soaked Gelfoam. A prospective trial was conducted in which 607 patients (1,064 sockets) had 2 SaliCept Patches placed immediately after extraction. The same surgeon treated all patients.

RESULTS

Analysis restricted to mandibular third molar sites showed that 78 of 975 sites (8.0%) in the Gelfoam group developed AO, whereas only 11 of 958 sites (1.1%) in the SaliCept group developed AO (P <.0001). Further analysis of all extraction sites revealed that the incidence of AO in the Gelfoam group was 7.6% compared with 1.1% in the SaliCept-treated group (P <.0001).

CONCLUSIONS

The study results suggest that the SaliCept Patch significantly reduces the incidence of AO compared with clindamycin-soaked Gelfoam.

Oral hygiene and postoperative pain after mandibular third molar surgery

OBJECTIVE

The purpose of this study was to evaluate the association between oral hygiene before surgery and pain, inflammation, and trismus after the surgical removal of 190 impacted lower third molars.

STUDY DESIGN

Patient hygiene was assessed by the simplified oral hygiene index. The maximum active interincisal oral opening was determined before surgery by using a millimeter scale, from the upper incisive edge to the lower incisive edge. Pain and inflammation were in turn recorded in written form by each patient 2, 6, and 12 hours after the operation and every day thereafter for 7 days.

RESULTS

Maximum postoperative pain was recorded 6 hours after extraction, with peak inflammation after 24 hours. The patients with the poorest oral hygiene reported higher pain levels throughout the postoperative period and more analgesic consumption in the first 48 hours. In contrast, oral hygiene appeared to exert no influence on either trismus or inflammation.

CONCLUSIONS

Poor oral hygiene before the surgical removal of 190 impacted lower third molars is correlated with greater postoperative pain.

Alveolar osteitis prevention by immediate placement of medicated packing

OBJECTIVE

The purpose of this study was to evaluate whether immediate placement of medicated dry socket packing would decrease the incidence of alveolar osteitis (dry socket) with lower third molar extractions.

STUDY DESIGN

In 100 patients, 200 lower third molars were extracted. One half of the sockets were packed to the crest of the alveolar ridge with a one-quarter-inch radiograph-detectable filament gauze that contained 9% eugenol, 36% balsam of Peru, and 55% petroleum jelly. The medicated packing was removed 1 week after surgery. None of the patients were taking antibiotics. Patients were instructed to increase their oral hygiene before and after surgery and were to use 0.12% chlorhexidine gluconate 2 days before and 3 days after surgery. RESULTS; Two hundred bilateral lower third molars of varying difficulty were extracted. The overall alveolar osteitis rate was 34 (17%). The immediately packed lower third molar sites had an alveolar osteitis rate of 8 (8%). The sockets that were not packed with medicated packing the day of surgery had an alveolar osteitis rate of 26 (26%). The difference was statistically significant (P =.001).

CONCLUSION

The results of this study suggest that placement of medicated dry socket packing immediately after lower third molar extraction decreases the alveolar osteitis rate.

Dental extraction wound management: medicating postextraction sockets

The rather impressive percentage of extraction sites undergoing clot loss and deranged healing results in significant morbidity for the patient and frequent visits to the surgeon to effect relief of discomfort, most often by the use of anodyne dressings. The amount of work lost by patients needing such palliative treatment, and loss of productive time for the surgeon, translate into an unknown, but potentially large, economic loss to society. This would mandate that economical methods of ensuring normal extraction socket healing with minimal morbidity be developed. The most useful socket medicaments to prevent socket healing derangements would include broad-spectrum antibiotics, specifically clindamycin and tetracycline. Not discussed in this article, but possibly germane to the subject of clot stabilization and healing, is consideration of resorbable substances such as gelatin sponge, polylactic acid, and methylcellulose as clot-stabilizing socket implants. The record of such substances in preventing AO is mixed, but the combinations of these inexpensive materials with topical socket medicaments may yield a decreased tendency for clot lysis and greater mechanical strength to the bulk blood clot, as has been demonstrated with difficult mandibular third molar impactions in one study involving polylactic acid, tetracycline, and hydrocortisone.

Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: efficacy and risk factor analysis

OBJECTIVES

The purposes of this study were to evaluate the use of 0.12% chlorhexidine gluconate as a prophylactic therapy for the prevention of alveolar osteitis and to further examine subject-based risk factors associated with alveolar osteitis.

STUDY DESIGN

The trial was a randomized, double-blind, placebo-controlled, parallel-group study conducted among 279 subjects, each of whom required oral surgery for the removal of a minimum of one impacted mandibular third molar. Subjects were instructed to rinse twice daily with 15 ml of chlorhexidine or placebo mouthrinse for 30 seconds for 1 week before and 1 week after the surgical extractions. This regimen included a supervised presurgical rinse. Alveolar osteitis diagnosis was based on the subjective finding of increasing postoperative pain at the surgical site that was not relieved with mild analgesics, supported by clinical evidence of one or more of the following: loss of blood clot, necrosis of blood clot, and exposed alveolar bone.

RESULTS

In comparison with use of the placebo mouthrinse, prophylactic use of the chlorhexidine mouthrinse resulted in statistically significant (p < 0.05) reductions in the incidence of alveolar osteitis. With chlorhexidine therapy, the subject- and extraction-based incidences of alveolar osteitis in the evaluable subset (271 subjects) were reduced, relative to placebo, by 38% and 44%, respectively. The corresponding odds ratios that describe the increased odds of experiencing alveolar osteitis in the placebo group were 1.87 and 2.05 for subject- and extraction-based analyses, respectively. In comparison with nonuse of oral contraceptives, the use of oral contraceptives in female subjects was related to a statistically significant increase in the incidence of alveolar osteitis (odds ratio = 1.92, p = 0.035). Relative to male subjects, the observed incidence of alveolar osteitis for female subjects not using oral contraceptives was not statistically significant (odds ratio = 1.18, p = 0.64). Smoking did not increase the incidence of alveolar osteitis relative to not smoking (odds ratio = 1.20, p = 0.33).

CONCLUSIONS

These data confirm that the prophylactic use of 0.12% chlorhexidine gluconate mouthrinse results in a significant reduction in the incidence of alveolar osteitis after the extraction of impacted mandibular third molars. In addition, oral contraceptive use in females was confirmed to be a risk factor for the development of alveolar osteitis.

The influence of 0.12% chlorhexidine digluconate rinses on the incidence of infectious complications and implant success

The effect of perioperative chlorhexidine on the frequency of infectious complications through stage II was examined. Chlorhexidine was used perioperatively in 54.6% of patients (52.5% of implants) in a Dental Implant Clinical Research Group study with a database of 2,641 implants (595 patients). With chlorhexidine, there was a significant reduction in the number of infectious complications (4.1% vs 8.7%). Two percent of implants failed in the absence of an infectious complication, whereas 12% with infectious complications failed. This sixfold difference is highly significant. Chlorhexidine may reduce microbial complications when used in the immediate perioperative period.