The prevention of 'dry socket' with topical metronidazole in general dental practice

In vitro studies support clinical trials showing platelet-rich fibrin-mediated local delivery of antibiotics improves outcomes in impacted mandibular third molar surgery

Our previous clinical observations showed that platelet rich fibrin (PRF) can be used to deliver antibiotics to attenuate postoperative complications after unilaterally impacted mandibular third molar surgery (IMTMS). In order to begin understanding the mechanism involved in the beneficial in vivo effects of PRF-mediated delivery of antibiotics, in vitro studies were performed, which showed that PRF preparations containing amoxicillin/clavulanic acid or clindamycin significantly inhibited the growth of S. aureus bacteria. In our previous study, comparisons were made between control and treated groups. However, since variations among individual patients could possibly affect the results, the current study included patients with bilaterally symmetric impacted mandibular third molars, allowing us to compare control and antibiotic treatment within each patient. The effects of PRF preparations containing amoxicillin/clavulanic acid or clindamycin on IMTMS was tested in 60 clinical cases. Antibiotic-injected PRF treatment after bilaterally IMTMS resulted in significantly reduced pain, less use of analgesics, and reduced swelling and trismus compared to the control group (PRF without antibiotics) confirming our previous results after unilaterally IMTMS. The in vitro results support the hypothesis that in vivo delivery of antibiotics using PRF produces therapeutic effects after IMTMS by attenuating bacterial infection and inflammation.

Development and Optimization of a Novel Lozenge Containing a Metronidazole-Peppermint Oil-Tranexamic Acid Self-Nanoemulsified Delivery System to Be Used after Dental Extraction: In Vitro Evaluation and In Vivo Appraisal

In-depth studies on essential oil-based nanoemulsions (NEs) have centered on a variety of oral health issues. NEs improve the delivery of nonpolar active agents to sites and thereby boost the dissolution and distribution of the agents. Metronidazole-peppermint oil-tranexamic acid self-nanoemulsifying drug delivery systems (MZ-PO-TX-SNEDDS) were created and loaded into novel lozenges to act as antifungal, hemostatic, antimicrobial, and analgesic dosage forms after dental extractions. The design-of-experiments approach was used in creating them. To generate the NEs, different concentrations of MZ-PO (240, 180, and 120 mg), 2% TX (600, 450, and 300 mg), and Smix1:1 (600, 400, and 200 mg) were used. The ideal formulation had serum levels of 1530 U/mL of interleukin-6, a minimal inhibitory concentration against bacteria of 1.5 µg/mL, a droplet size of 96 nm, and a blood coagulation time of 16.5 min. Moreover, the produced NE offered better MZ release. The adopted design was used to produce the ideal formulation; it contained 240 mg of MZ-PO, 600 mg of 2% TX, and 600 mg of Smix1:1. It was incorporated into lozenges with acceptable characteristics and an improved capability for drug release. These lozenges had reasonable coagulation times, IL-6 serum levels, and MIC values. All of these characteristics are desirable for managing symptoms following tooth extractions. Therefore, these lozenges loaded with MZ-PO-TX-SNEDDs might be considered a beneficial paradigm for relieving complications encountered after tooth extractions.

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

Background:

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Local interventions for the management of alveolar osteitis (dry socket)

BACKGROUND

Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012.  OBJECTIVES: To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.

SEARCH METHODS

An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence.

MAIN RESULTS

We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate-certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively.  Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate-certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low-certainty evidence).  The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket  Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low-certainty evidence).  A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) -1.40, 95% CI -1.75 to -1.04; P < 0.00001; 2 studies, 80 participants; very low-certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects.

AUTHORS' CONCLUSIONS

Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate-certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol.

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

Background

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

Material and Methods

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

Results

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

Conclusions

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

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

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

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

Evaluation of the Effects of Topical Application of Chlorhexidine, Ozone, and Metronidazole on Palatal Wound Healing: A Histopathological Study

ABSTRACT

This study aimed to evaluate the effects of chlorhexidine, metronidazole, and ozone application on the healing of palatal wounds in diabetic rats. A defect in the form of a 4 mm-diameter wound was created on the palatal mucosa of 84 adult female Wistar albino rats, which were randomly divided into 4 groups: control, chlorhexidine, metronidazole, and ozone groups. The animals were euthanized after 3, 6, and 10 days, and wound closure was histologically assessed. On day 3, polymorphonuclear leukocytes were significantly higher in the control group than in the chlorhexidine and ozone groups (P < 0.05). Fibrosis was higher in the ozone group than in the control and chlorhexidine groups (P < 0.05). Vascular endothelial growth factor was higher in the metronidazole and ozone groups than in the control group (P < 0.05). On day 6, the quantity of polymorphonuclear leukocytes was higher in the control, metronidazole, and chlorhexidine groups than in the ozone group (P < 0.05). Vascular endothelial growth factor was higher in the ozone group than in the control, chlorhexidine, and metronidazole groups (P < 0.05). On day 10, Vascular endothelial growth factor was higher in the control, chlorhexidine, and metronidazole groups than in the ozone group (P < 0.05). The authors concluded that the use of chlorhexidine, ozone, and metronidazole pastes resulted in enhanced wound healing, as determined histologically. The authors suggest that ozone supplementation can be an alternative therapy to chlorhexidine in impaired wound healing in diabetes mellitus.

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.

Protection of an intraoral surgical wound with a new dressing: a randomised controlled clinical trial

Operations that involve the maxillofacial region often require intraoral incisions, and contamination of these wounds is common as a result of the presence of saliva, plaque, and food debris. Postoperative infection is therefore common. The aim of the study was to evaluate the clinical efficacy of an intraoral dressing material, Reso-Pac®, in improving postoperative comfort for patients and its effect on wound healing. One hundred patients who required removal of impacted mandibular third molars were recruited, and were randomised into two groups (50 in each). A standardised surgical technique was used for removal of the impacted teeth, and wounds were closed with sutures. Postoperatively, the study group was given Reso-Pac® dressing while the control group was not. Postoperative pain was measured using a visual analogue scale (VAS). Wound healing was assessed with the help of Landry's scale, and we also measured thermal sensitivity. Data were analysed using the paired t test. The results in the study group were significantly better than those in the control group (p<0.001). Reso-Pac® promoted wound healing and improved patients' comfort during the postoperative phase.

Angiogenesis and the prevention of alveolar osteitis: a review study

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

Dry Socket Etiology, Diagnosis, and Clinical Treatment Techniques

Dry socket, also termed fibrinolytic osteitis or alveolar osteitis, is a complication of tooth exodontia. A dry socket lesion is a post-extraction socket that exhibits exposed bone that is not covered by a blood clot or healing epithelium and exists inside or around the perimeter of the socket or alveolus for days after the extraction procedure. This article describes dry socket lesions; reviews the basic clinical techniques of treating different manifestations of dry socket lesions; and shows how microscope level loupe magnification of 6× to 8× or greater, combined with co-axial illumination or a dental operating microscope, facilitate more precise treatment of dry socket lesions. The author examines the scientific validity of the proposed causes of dry socket lesions (such as bacteria, inflammation, fibrinolysis, or traumatic extractions) and the scientific validity of different terminologies used to describe dry socket lesions. This article also presents an alternative model of what causes dry socket lesions, based on evidence from dental literature. Although the clinical techniques for treating dry socket lesions seem empirically correct, more evidence is required to determine the causes of dry socket lesions.

Efficacy of different methods used for dry socket prevention and risk factor analysis: A systematic review

BACKGROUND

Dry socket is one of the most common complications that develops after the extraction of a permanent tooth, and its prevention is more effective than its treatment.

OBJECTIVES

Analyze the efficacy of different methods used in preventing dry socket in order to decrease its incidence after tooth extraction.

MATERIAL AND METHODS

A Cochrane and PubMed-MEDLINE database search was conducted with the search terms "dry socket", "prevention", "risk factors", "alveolar osteitis" and "fibrynolitic alveolitis", both individually and using the Boolean operator "AND". The inclusion criteria were: clinical studies including at least 30 patients, articles published from 2005 to 2015 and written in English. The exclusion criteria were case reports and nonhuman studies.

RESULTS

30 publications were selected from a total of 250. Six of the 30 were excluded after reading the full text. The final review included 24 articles: 9 prospective studies, 2 retrospective studies and 13 clinical trials. They were stratified according to their level of scientific evidence using SIGN criteria (Scottish Intercollegiate Guidelines Network).

CONCLUSIONS

All treatments included in the review were aimed at decreasing the incidence of dry socket. Locally administering chlorhexidine or applying platelet-rich plasma reduces the likelihood of developing this complication. Antibiotic prescription does not avoid postoperative complications after lower third molar surgery. With regard to risk factors, all of the articles selected suggest that patient age, history of previous infection and the difficulty of the extraction are the most common predisposing factors for developing dry socket. There is no consensus that smoking, gender or menstrual cycles are risk factors. Taking the scientific quality of the articles evaluated into account, a level B recommendation has been given for the proposed-procedures in the prevention of dry socket.

Platelet rich fibrin in the management of established dry socket

OBJECTIVES

Dry socket may occur secondary to the removal of any tooth. However, most dry socket cases develop in the third molar region. Dry socket is multifactorial in nature and has been treated using various modalities with varying success rates. This study assessed the efficacy of platelet rich fibrin (PRF) in established dry socket.

MATERIALS AND METHODS

Ten patients of either sex aged from 41 to 64 years with established dry socket according to established criteria were treated using PRF. Evaluation was performed by observing the reduction of pain using visual analogue scale, analgesic tablet use over the follow-up period, and healing parameters.

RESULTS

Pain was reduced on the first day in all patients with decreased analgesic use. Pain was drastically reduced during follow-up on the first, second, third, and seventh days with a fall in pain score of 0 to 1 after the first day alone. The pain scores of all patients decreased to 1 by the first day except in one patient, and the scores decreased to 0 in all patients after 48 hours. Total analgesic intake ranged from 2 to 6 tablets (aceclofenac 100 mg per tablet) over the follow-up period of 7 days. Healing was satisfactory in all patients by the end of the seventh day.

CONCLUSION

PRF showed early pain reduction in established dry socket with minimal analgesic intake. No patients had allergic reactions to PRF as it is derived from the patient's own blood. PRF showed good wound healing. Our study suggests that PRF should be considered as a treatment modality for established dry socket.

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

Background

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

Material and Methods

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

Study Design

Double blind, prospective, placebo controlled trial.

Results

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

Conclusions

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

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

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).

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.

Local interventions for the management of alveolar osteitis (dry socket)

BACKGROUND

Alveolar osteitis (dry socket) is a complication of dental extractions and occurs more commonly in extractions involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively, a socket that may be partially or totally devoid of blood clot and in some patients there may be a complaint of halitosis. It can result in an increase in postoperative visits.

OBJECTIVES

To assess the effects of local interventions for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 29 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10), MEDLINE via OVID (1946 to 29 October 2012) and EMBASE via OVID (1980 to 29 October 2012). There were no restrictions regarding language or date of publication. We also searched the reference lists of articles and contacted experts and organisations to identify any further studies.

SELECTION CRITERIA

We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket post-extraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques for the management of dry socket because these interventions are evaluated in separate Cochrane reviews.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook risk of bias assessment and data extraction in duplicate for included studies using pre-designed proformas. Any reports of adverse events were recorded and summarised into a table when these were available. We contacted trial authors for further details where these were unclear. We followed The Cochrane Collaboration statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data it was not possible to calculate RR so we calculated the exact odds ratio instead. We used the GRADE tool to assess the quality of the body of evidence.

MAIN RESULTS

Twenty-one trials with 2570 participants met the inclusion criteria; 18 trials with 2376 participants for the prevention of dry socket and three studies with 194 participants for the treatment of dry socket. The risk of bias assessment identified six studies at high risk of bias, 14 studies at unclear risk of bias and one studies at low risk of bias. When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and after extraction(s) prevented approximately 42% of dry socket(s) with a RR of 0.58 (95% CI 0.43 to 0.78; P < 0.001) (four trials, 750 participants, moderate quality of evidence). The prevalence of dry socket varied from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated with (0.12% and 0.2%) chlorhexidine rinse to prevent one patient having dry socket (NNT) was 232 (95% CI 176 to 417), 47 (95% CI 35 to 84) and 8 (95% CI 6 to 14) for control prevalences of dry socket of 1%, 5% and 30% respectively.Compared to placebo, placing chlorhexidine gel (0.2%) after extractions prevented approximately 58% of dry socket(s) with a RR of 0.42 (95% CI 0.21 to 0.87; P = 0.02) (two trials, in 133 participants, moderate quality of evidence). The number of patients needed to be treated with chlorhexidine gel to prevent one patient having dry socket (NNT) was 173 (95% CI 127 to 770), 35 (95% CI 25 to 154) and 6 (95% CI 5 to 26) for control prevalences of dry socket of 1%, 5% and 30% respectively.A further 10 intrasocket interventions to prevent dry socket were each evaluated in single studies, and therefore there is insufficient evidence to determine their effects. Five interventions for the treatment of dry socket were evaluated in a total of three studies providing insufficient evidence to determine their effects.

AUTHORS' CONCLUSIONS

Most tooth extractions are undertaken by dentists for a variety of reasons, however, all but three studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is some evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, provides a benefit in preventing dry socket. There was insufficient evidence to determine the effects of the other 10 preventative interventions each evaluated in single studies. There was insufficient evidence to determine the effects of any of the interventions to treat dry socket. The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% and 2% chlorhexidine mouthrinses, though most studies were not designed to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket (though previous allergy to chlorhexidine was an exclusion criterion in these trials). In view of recent reports in the UK of two cases of serious adverse events associated with irrigation of dry socket with chlorhexidine mouthrinse, it is recommended that all members of the dental team prescribing chlorhexidine products are aware of the potential for both minor and serious adverse side effects.

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.

Initial study on facilitating wound healing after tooth extraction by using microbial fiber membrane-flagyl

PURPOSE

The aim of the present study was to investigate the efficacy of microbial fiber membrane-Flagyl (MF-FLA) on facilitating hemostasis and wound healing and its anti-inflammatory ability after tooth extraction.

MATERIALS AND METHODS

For the animal experiment, 60 healthy male rabbits were randomly divided into control and treatment groups. Each group included 5 subgroups corresponding to different experimental periods (1, 2, 4, 8, and 12 weeks) and each subgroup had 6 rabbits. After the different experimental periods, the rabbits were killed, and the mandible was removed for histologic examination and analysis. For the human trial, 80 patients (32 males and 48 females; age range, 13 to 32 years), who were undergoing orthodontic treatment and who had undergone bilateral extraction of teeth were included. For every patient, the left tooth socket was treated with biting gauze for 30 to 60 minutes as the control group. The right fossa was covered with MF-FLA as the treatment group. The wound was inspected visually, its depth was measured, and radiographs were taken at the different experimental periods (1, 2, 4, 8, and 12 weeks) to evaluate the wound healing effect.

RESULTS

In the animal experiment, the results of the histologic examination indicated MF-FLA could facilitate the growth of fibroblasts and osteoblasts and inhibit inflammatory cells. In the human trial, the clinical observation indicated that the MF-FLA treatment showed better hemostatic ability than the biting gauze. After 4 weeks, the wound depth of the control and treatment groups was 3.08 ± 0.05 mm and 1.26 ± 1.06 mm (P < .01), respectively. The radiographs showed that the treatment group was superior to control group in the degree and rate of wound healing.

CONCLUSION

The results of our study have shown that the MF-FLA can promote early wound healing and reduce the incidence of postextraction complications because of its biocompatibility, isolating and anti-inflammatory ability, and supporting the formation of blood clot in the tooth socket.

Antibiotic prophylaxis in third molar surgery: A randomized double-blind placebo-controlled clinical trial using split-mouth technique

The use of prophylactic antibiotics to reduce postoperative complications in third molar surgery remains controversial. The study was a prospective, randomized, double blind, placebo-controlled clinical trial. 100 patients were randomly assigned to two groups. Each patient acted as their own control using the split-mouth technique. Two unilateral impacted third molars were removed under antibiotic cover and the other two were removed without antibiotic cover. The first group received antibiotics on the first surgical visit. On the second surgical visit (after 3 weeks), placebo capsules were given or vice versa. The second group received antibiotics with continued therapy for 2 days on the first surgical visit and on the second surgical visit (after 3 weeks) placebo capsules were given or vice versa. Pain, swelling, infection, trismus and temperature were recorded on days 3, 7 and 14 after surgery. Of 380 impactions, 6 sockets (2%) became infected. There was no statistically significant difference in the infection rate, pain, swelling, trismus, and temperature between the two groups (p>0.05). Results of the study showed that prophylactic antibiotics did not have a statistically significant effect on postoperative infections in third molar surgery and should not be routinely administered when third molars are removed in non-immunocompromised patients.

An audit of 600 referrals to a primary care based oral surgery service

AIM

To identify potential problems in the quality of care when oral surgery is provided in the primary health care setting.

METHOD

Retrospective analysis of referral patterns, waiting times, treatment with clinical and histological diagnosis, including complications of 600 patients referred to a practice-based oral surgical referral service.

RESULTS

Fifty-three patients were not treated. Seventy-nine percent of patients were treated within four weeks of referral. The most common procedure performed was surgical removal of impacted third molar teeth. The most frequently observed complications were dry socket (n = 31/703), pain and inflammation associated with resorbable sutures (n = 11/453), and post-operative infection (n = 9/547). One patient with post-operative infection required care in the acute hospital setting.

CONCLUSION

Acknowledging the small sample, it was safe and effective to diagnose and treat a broad spectrum of patients and oral surgical problems in the primary health care setting.