Abstract
Objective: To determine whether the administration
of postoperative antibiotics following extraction of a asymptomatic soft tissue
impacted lower wisdom teeth is necessary to reduce the incidence of dry socket,
and post operative morbidity such as pain, swelling and trismus.
Method: This study including 441 patients (208
males, 233 females) who required surgical extraction of lower wisdom teeth. Patients
were divided into three groups; (G1) patients received Metronidazole, (G2) patients
received Amoxicillin, and (G3) patients did not receive antibiotics at all. All
patients received the same analgesic regimen. The incidence of dry socket,
swelling, and the intensity of pain was recorded. The chi-squared test was
employed to compare the results in the three treated groups
Results: No significant difference was found
between the three groups regarding the evaluated parameters in the
postoperative sequelae, i.e. pain, swelling and alveolar osteitis (dry socket).
Conclusion: This study showed that prescribing postoperative
oral prophylactic antibiotic treatment following the removal of soft tissue
impacted lower third molars does not contribute to less pain, less swelling,
increased mouth opening or a lower incidence of dry socket, therefore it is not recommended for routine
use.
Key
words: Antibiotics, Dry
socket, Pain, Swelling, Third molar.
JRMS
September 2011; 18(3): 47-51
Introduction
The
routine use of postoperative prophylactic antibiotic therapy in patients
undergoing surgical extraction of the lower third molars as an essential
measure against infection and postoperative complications such as swelling,
limitation of mouth opening and alveolar osteitis is still a widespread
practice and a very controversial issue.(1,2)
It
is believed now by many surgeons that the advantages of using such prophylaxis
seem to be marginal, as shown in the audit undertaken at the University Dental
Hospital National Health Service Trust in Cardiff (UK) about the usage of
antibiotic prophylaxis practices in case of dental extraction and demonstrated
the ''potential for saving large sums of money while apparently incurring no
clinical disadvantage''.(3) Also, Monaco G et al,
found no difference in patients undergoing surgical third molar extractions
between those receiving postoperative amoxicillin and the control group who did
not receive antibiotics in terms of prevention of postoperative complications
i.e. fever, pain, swelling and alveolar osteitis.(4)
Iciar
Arteagoitia et al, demonstrated clearly in their study that studied the
efficacy of amoxicillin/clavulanic acid in preventing infectious and
inflammatory complications following extraction of soft tissue vertically
impacted mandibular third molar teeth, they found out that antibiotics are probably inefficacious, and they stated that
antibiotics might be of value in cases where
third molars are partially covered by bone and those in a horizontal
position, they concluded this based on the fact that the frequency of
postoperative complication without antibiotics was 12.9%, which in all cases
was resolved using the rescue antibiotic.(5)
Also,
Leslie R et al in their question whether prophylactic administration of
systemic antibiotics prevent postoperative inflammatory complications after
third molar surgery, they hypothesized
that only mandibular third molars requiring bone removal are at higher risk for
post operative complications and antibiotics are better limited to this group
and so limiting the exposure of patients to antibiotics and their associated
risks and costs, also they recommended that more multicenter research need to
be done in this field to determine the necessity for antibiotics and what type
of antibiotics to be administered.(6)
T. Kaczmarzyk et
al evaluated the significance of administration of clindamycin applied in a
single preoperative dose of 600 mg with or without subsequent 5-day
therapy in prevention of postoperative complications after third molar surgery;
again they could not demonstrate any significance for antibiotic prophylaxis
that should affect the post operative sequalae in lower third molar surgery.(7)
In
another study, two different types of antibiotics were tested in patients
undergoing surgical removal of third molar teeth, two groups of patients given
amoxicillin (with calvulanic acid) and clindamycin respectively compared to
another group of patients given
placebo, no significant
difference was found between the three different groups in the potoperative
sequel, as no specific postoperative oral prophylactic antibiotic treatment
after the removal of lower third molars could prevent the cases of inflammatory
problems after surgery, as it did not contribute to a better wound
healing, less pain,
or increased mouth opening, and therefore a conclusion made that routine use of antibiotics in these cases is
not recommended.(8)
From
the literature review in the recent years, it is well noted that surgeons tend to
avoid using prophylactic antibiotics following the surgical removal of the non
infected third molars, and to start focusing on more important local factors
that may play an important role in avoiding postoperative complications. The
aim of this paper is to evaluate the actual need for the administration of postoperative
oral antibiotics following the removal of asymptomatic soft tissue impacted
lower third molars, and the efficacy of antibiotic therapy in preventing
postoperative complications.
Methods
This
study was conducted to assess the clinical efficacy of two antibiotics regimens
(amoxicillin 500 mg tds and Metronidazol 250 mg tds) in two groups of patients
compared with a third group of patients who were not given antibiotics in the setting of surgical extraction of a soft tissue
impaction of third mandibular molar teeth. The study was conducted in
accordance with Good Clinical Practice as approved by the ethical committee of
the Royal Medical Services in Jordan.
A written, dated informed consent was obtained from all patients prior to study
entry. The study was carried out in the period between July 2008 till March
2009 at Prince Ali Hospital
in Karak, see Table I showing demographic, objective and subjective measurement
data.
Four
hundred forty one patients, 208 males (47.2%), 233 females (52.8%) requiring surgical
extraction of a soft tissue impacted lower wisdom teeth were enrolled in this
study. All patients were adults above 18 years old with mean age of 24.6 (age
range 19-29 years). All patients were referred to our department by their
treating dentists. No patient showed any sign of pain, inflammation, or
swelling at the time of surgery. Clinical and radiologic factors were recorded
for each case; all patients were medically free, as patients with any chronic
illness such as diabetes mellitus or any other medical problem were excluded
from the trial. The rationale for assigning the patients to the groups was
strictly random and was done after surgery by using prepared randomizations in
sealed envelopes. The standard surgical procedure was the
same
in all cases and only one lower third molar was removed at a time. A mouth rinse of 0.2% chlorhexidine solution for 1 minute was used before surgery.
Table
I. Demographic, objective and subjective
measurement data
|
|
G (1) patients on Metronidazol
|
G (2) patients on Amoxicillin
|
G (3) placebo patients
|
|
Number
of patients
|
143 (33.4%)
|
140 (32.7%)
|
145 (33.8%)
|
|
Age
(mean)
|
24.5
|
24.9
|
24.1
|
|
Gender
|
65 M 78 F
|
66 M 74 F
|
67 M 78 F
|
|
Mean
duration of surgery (mint)
|
15.4
|
14.7
|
15.9
|
Table
II. Postoperative pain scoring in the three
groups of patients
|
Pain score
|
Group 1 (143)
|
Group 2 (140)
|
Group 3 (145)
|
|
Mild
|
78 (54%)
|
66 (47%)
|
73 (50%)
|
|
Moderate
|
45 (31%)
|
56 (40%)
|
51 (35%)
|
|
Sever
|
20 (14%)
|
18 (12%)
|
21 (14%)
|
Table
III.
Postoperative swelling
|
Group
|
Group 1
|
Group 2
|
Group 3
|
|
Number
of patients
|
43 (30%)
|
38 (27%)
|
41 (28%)
|
Table
IV. Incidence of dry socket
|
Group
|
Group 1
|
Group 2
|
Group 3
|
|
Number
of patients
|
12 (8%)
|
14 (10%)
|
13(8.9%)
|
Patients
were divided into three groups, group one (G1) received Metronidazole as 250 mg
tds, group two (G2) received Amoxicillin 500 mg tds, and the third group (G3
did not receive antibiotics at all. The first and second groups had their
antibiotics for 5 days postoperatively.
All
patients in the three groups had the same regimen of analgesia that consisted
of 50 mgs tablet of diclofenac sodium taken one hour preoperatively, followed
by diclofenac 50 mg of sodium tds orally for five days postoperatively. Also
patients were asked to review the oral surgery clinic or in case of any
emergency regarding pain or any other postoperative complication. Patients were
asked not to take any other drugs during the trial and not to seek any other
medical help except from our oral surgery clinic.
The
incidence of dry socket (alveolar osteitis), swelling, and the intensity of
pain was recorded for all patients. The occurrence of dry socket was judged by
both the signs and symptoms, and clinical examination. Dry socket was defined
as absence of clot with necrotic remains present in the alveolus accompanied by
severe persisting mandibular pain or increasing 48 h after surgery accompanied
by intraoral inflammation and erythema.
Swelling
was subjectively measured, as patients had
just been asked if a significant swelling occurred or not and for how many days
it lasted.
The
assessment of the intensity of post operative pain was done by employing a 100
mm visual analogue scale, and then results were classified into three
categories, i.e. mild, moderate and severe.
All patients
were operated by the same surgeon (the main author) and the same surgical
technique was employed in all cases, i.e. envelope mucopereosteail flap with minimal
buccal bone removal if needed. All cases were done in the oral surgery
outpatient clinics in our department at the Prince Ali Hospital in Karak (South of Jordan). All
cases were performed under local anesthesia (zylocaine with adrenaline). The
follow-up period was for two weeks, patients were reviewed on the second
postoperative day, on day seven after the surgery and finally on day 14
postoperatively. Statistical analysis was performed by using 1-way analysis of
variance, Student’s t test, and chi-square test. A value of P <
0.05 was considered statistically significant.
Results
Among
the 441 patients who entered the trial, 13 did not check in for the follow-up
examination and complete data sets were obtained only from 428 patients, for
whom statistical analysis was performed. The three main parameters i.e. pain,
swelling and alveolar osteitis (dry socket) had been evaluated and analyzed
independently in the three groups of patients (G1, G2, G3).
For
the evaluation of post operative pain, see Table II that illustrates the
numbers of patients who experienced mild, moderate or sever pain in the three
groups of patients. The chi-squared test was employed to compare the results in
the three treated groups, no statistically significant difference was found
between the three groups (P > 0.05).
Regarding
the postoperative reactionary swelling, the number of patients who experienced
a significant swelling that was associated with limitation of mouth opening and
lasted more than 48 hours was as follows: in Group one (43 patients 30%), in
Group two (38 patients 27%) and in Group 3 (41 patients 28%), see Table III.
Again no statistically significant difference was found between the data in the
three tested groups (P > 0.05).
The
incidence of alveolar osteitis (dry socket) in the three groups was as follows:
in Group one (12 patients 8%), in Group two (14 patients 10%) and in Group 3
(13 patients 8.9%), see Table IV. Again no statistically significant difference
was found between the three tested groups (P > 0.05).
Among
the patients who experienced dry socket, 68% of the cases were males, and 32%
were females. Another significant finding was that 85% of the patients who
experienced dry socket were heavy smokers; they even smoked at the day of
surgery.
Discussion
We
conducted this study in view of the growing concerns about the
over-prescription of antibiotics, considering the implications regarding
adverse effects in individual patients and increasing antimicrobial resistance
within the community, a very high price to pay, this becomes very true when
patients get exposed to a life threatening infections and antibiotics fail to
play their expected role, also a significant financial implications should be
considered when considering the high price spent on unjustified prescription of
antibiotics, and the need for more expensive antibiotics when serious infections
happen.
Piecuch J et
al, in their clinical trial to answer the question "should antibiotics
be used for third molar surgery?" They found that the practice of oral
surgeons of giving antibiotics to patients is usually led by one or more of the
following reasons: 1) Presence of infection; 2) the patient is medically
compromised and requires antibiotic prophylaxis against metastatic infection;
3) the patient or the patient's family demands antibiotics; 4) the standard of
care in the oral surgery community is to use antibiotics, and hence not to use
them violates this standard; and when 5) the risk of postoperative infection is
high and, consequently, prophylaxis is needed. But in their analysis of these
reasons and their results, they found that in case of erupted mandibular or
partially erupted third molars antibiotics are not justified unless an active
infection is present, or when prophylaxis is needed in certain cases of medical
compromise, including cardiac and immunosuppressive disorders. Also they stated
that antibiotics are not justified for wound prophylaxis for maxillary third
molar extractions regardless of the level of impaction because the overall
infection rate is so low (0.27%). So, they recommended complying with these
standards regardless of the patient’s desires, or even if it was the standard
of care in the oral surgery community is to use antibiotics, as usually that
standard implicates using antibiotics after surgery and that violates the basic
principles of prophylaxis.(9) Also, many supportive opinions
are in the literature recommending not to give antibiotics in third molar
extraction as shown in the multi center
study that involved patients with all four third molars below the occlusal
plane, who were divided into two groups, the first group were given intravenous
antibiotics just before third molar surgery, the second group (control group)
did not receive intravenous antibiotics, and no statistically significant
difference found between the two groups in term of the postoperative outcome.(10-13)
Also, we should not underestimate the
value of some local measures like the application of 0.2% chlorhexidine gluconate mouth rinsing
preoperatively for 30 seconds and postoperatively for seven days. It was found to improve the outcome of
surgery in terms of patients’ quality of life and postoperative complication.(14)
Another valuable local measure after
third molar surgery is local cold compression for 45 minutes postoperatively, as
it causes vasoconstriction leading to reduced reactionary oedma and hence decreases
the excitability of free nerve endings and peripheral nerve fibers,
consequently increasing the pain threshold.(15) Also, the
administration of IV corticosteroid with third molar surgery does have a
positive impact in improving recovery after third molar surgery.(16)
Dentists
for decades are used to prescribing antibiotics
routinely after extraction. It is about time to reconsider this, and carry out
a more thorough evaluation for the patients, especially those who are asymptomatic
prior to extraction. Also, if antibiotics are to be given, they should be given
preoperatively, as systemic antibiotic should be present in the tissues before
the procedure is begun, and the use of antibiotics only after surgery has no
benefit or justification.(17)
Patients
following surgery usually will suffer pain, and what we really should care
about is a very good regimen of analgesics, best started preoperatively, the
best undoubtedly are the nonsteroidal anti-inflammatory drugs (NSAID), given on
regular basis, and toped up by a more potent analgesics when needed, as
basically what the patients go through following extraction is an inflammatory
state that is best treated by an anti-inflammatory drugs and good analgesics
rather than treating it with antibiotics.
Conclusion
The
results of our study showed that specific postoperative oral prophylactic
antibiotic treatment after the removal of partially erupted or soft tissue
impacted lower third molars does not contribute to less pain, less swelling, or
decreased incidence of dry socket. And therefore, it is not recommended for
routine usage.
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