Antibiotic prophylaxis in third molar surgery. Does prophylactic administration of systemic antibiotics prevent postoperative inflammatory complications after third molar surgery? Role of antimicrobials in third molar surgery: prospective, double blind,randomized, placebo-controlled clinical study. Comparison of two chlorhexidine rinse protocols on the incidence of alveolar osteitis following the surgical removal of impacted third molars. The prevention of 'dry socket' with topical metronidazole in general dental practice. Effect of azidocillin, erythromycin, clindamycin and doxycycline on postoperative complications after surgical removal of impacted mandibular third molars. Prophylactic use of phenoxymethylpenicillin and tinidazole in mandibular third molar surgery, a comparative placebo controlled clinical trial. A prospective, randomised trial of prophylactic antibiotics versus bag extraction in the prophylaxis of wound infection in laparoscopic cholecystectomy. Prophylaxis versus pre-emptive treatment for infective and inflammatory complications of surgical third molar removal: a randomized, double-blind, placebo-controlled, clinical trial with sustained release amoxicillin/clavulanic acid (1000/62.5 mg). Microbiological analysis after complete or partial removal of carious dentin in primary teeth: a randomized clinical trial. Prospective, randomised study on antibiotic prophylaxis in colorectal surgery. Is it really necessary to use oral antibiotics? Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: efficacy and risk factor analysis. Dexamethasone reduces pain and swelling following extraction of third molar teeth. Perioperative antibiotic prophylaxis for prevention of postoperative neurosurgical infections. A randomized clinical trial. A comparison of the effect of phenoxymethylpenicillin and azidocillin on postoperative complications after surgical removal of impacted mandibular third molars. The influence of platelet-rich plasma on the healing of extraction sockets: an explorative randomised clinical trial. Randomized, double-blind study on effectiveness of intra-alveolar chlorhexidine gel in reducing the incidence of alveolar osteitis in mandibular third molar surgery.
To evaluate the role of prophylactic antibiotics, if any, in the removal of mandibular impacted third molars.
                A total of 89 patients were randomly allocated in 3 groups (group 1, placebo; group 2, amoxicillin 1 g orally 1 h before surgery; and group 3, metronidazole 800 mg orally 1 h before surgery).
                Of the 89 patients, 5 had surgical wound infection (3 [10.33%] in group 1, 2 [6.45%] in group 2, and none [0%] in group 3), leading to an overall infection rate of 5.61%. There was no statistically significant difference found in surgical wound infection between the groups.
                Our study failed to show any advantage in the routine use of prophylactic antibiotics because we found no statistically significant difference between the groups. To estimate and compare the frequencies of inflammatory complications after third molar (M3) surgery in subjects receiving intravenous prophylactic antibiotics or saline placebo.
                Using a placebo-controlled, double-blind, randomized clinical trial, the investigators enrolled a sample composed of subjects who required extraction of at least 1 impacted M3 and requested intravenous sedation or general anesthesia. The predictor variable was treatment group classified as active treatment (penicillin or clindamycin for penicillin-allergic subjects) or placebo (0.9% saline). Study medications were randomly assigned. Both surgeon and subject were blinded to treatment assignment. The medication was administered intravenously prior to any incision. The outcome variable was postoperative inflammatory complication classified as present or absent and included alveolar osteitis (AO) or surgical site infection (SSI). Other variables were demographic, anatomic, or operative. Descriptive and bivariate statistics were computed. Statistical significance was set at P < or = .05, single-tailed test of hypothesis.
                The sample was composed of 118 subjects (n = 59 per study group). In the active treatment group, there were no postoperative inflammatory complications. In the placebo group, 5 subjects (8.5%) were diagnosed with SSI, (P = .03). No subject met the case definition for AO. All SSIs were associated with the removal of partial bony or full bony impacted mandibular M3s.
                In the setting of third molar removal, these results suggest that the use of intravenous antibiotics administered prophylactically decrease the frequency of SSIs. The authors cannot comment on the efficacy of intravenous antibiotics in comparison to other antibacterial treatment regimens, eg chlorhexidine mouthrinse or intrasocket antibiotics. To test the efficacy of two dosing regimens of antimicrobial prophylaxis during the removal of impacted lower third molars.
                Double blind, prospective, placebo-controlled trial.
                Teaching hospital, India.
                151 patients aged 19-36 having impacted lower third molars removed.
                Random allocation into three groups: placebo (n= 34), metronidazole 1g orally, 1 hour preoperatively (n= 44), or metronidazole 400mg orally eight hourly for 5 days postoperatively (n= 47). Patients were recalled on the sixth postoperative day for assessment of pain scores on the second and sixth days, swelling, differences in mouth opening between preoperative and the sixth postoperative day, and the state of the wound.
                There were no significant differences in the outcome between the three groups (P= 0.09).
                Antimicrobial prophylaxis does not seem to reduce morbidity after removal of lower third molars.
                Copyright 2001 The British Association of Oral and Maxillofacial Surgeons. Alveolar osteitis (dry socket) is the most common complication following the extraction of permanent teeth. This study was undertaken to compare the effect of two chlorhexidine rinse protocols on the incidence of alveolar osteitis in patients undergoing surgical removal of impacted mandibular third molar teeth.
                A prospective randomized clinical trial was conducted among 99 subjects. Patients were randomly assigned into two groups. Subjects were instructed to rinse twice daily with 15 ml of chlorhexidine rinse 30 seconds for one week before and one week after surgery (group I) or one week after surgery (group II). Postoperatively, all patients were instructed to return in one week or sooner if bothersome pain increased or persisted. Data were collected regarding abnormal healing, presence of necrotic tissue, exposed bone, and absence of clot.
                The results indicated group I and group II were not statistically significant different in the reduction of alveolar osteitis.
                To reduce alveolar osteitis after impacted third molar surgery, it was observed use of postoperative chlorhexidine rinse was adequate. The postoperative use of chlorhexidine is more feasible than both preoperative and postoperative use. The purpose of the study was to determine if the intra-alveolar application of topical metronidazole gel could reduce the incidence of alveolar osteitis (dry socket) following routine tooth extraction in molar and premolar extraction sites.
                This was a multicentre, double blind, randomised, placebo-controlled clinical trial. A total of 302 patients took part, of which 23 returned with alveolar osteitis. Of these, eight had received the metronidazole gel and 15 the placebo.
                The study was carried out in three general dental practices by general dental practitioners working in England over the period 2000-2003.
                Following extraction of either a molar or premolar tooth, either a 25% metronidazole gel or KY Jelly was syringed gently into the socket. A painful post operative complication was recorded if either a dry socket was present or the patient returned with pain.
                The difference in the incidence of alveolar osteitis between the placebo and the active gel groups was not significant and it was concluded that 25% topical metronidazole gel was not effective in reducing the incidence of alveolar osteitis. It was found that the incidence of alveolar osteitis reduced with increasing age and was more likely to occur in a patient with a previous history of the condition. Treatment of osteitis after surgical removal of the third molar of the mandible is still a clinical problem. A total of 140 patients undergoing operations for removal of an impacted third molar of the mandible, were included in a double-blind study. Placebo or antibiotics - azidocillin, erythromycin, clindamycin and doxycycline - were given to the patients preoperatively and for the following 7 days. The concentrations in serum, alveolar serum and mandibular bone were measured and the postoperative courses - pain, trismus, swelling and wound-healing - were recorded. No correlation was obtained between the antibiotic concentration and the postoperative complaints, except in the azidocillin group on day 2, in which fewer complaints were noticed in patients with high concentrations of the drug at the time of operations. The 80 patients in the antibiotic groups responded significantly better with respect to wound-healing than the 60 patients in the placebo groups. Only 15 operations lasted more than 15 min and the three of them which subsequently resulted in alveolitis were in the placebo groups. Antibiotics significantly reduced pain on day 7 postoperatively. In general, no statistically significant differences in trismus and swelling could be demonstrated between the patient groups. However, there was a significant difference between the placebo and doxycycline groups with respect to swelling (day 2 postoperative, P < 0.01; day 5 postoperative, P < 0.05). Thus systemically administered antibiotics offered only slight advantages in routine operations of impacted third mandibular molars, but could decrease the rate of infections after traumatic operations. A clinical double-blind placebo controlled trial was carried out in 136 patients to test the value of the prophylactic use of phenoxymethylpenicillin and tinidazole in mandibular third molar surgery. The three patient groups were uniform with regard to the background data such as age and weight of the patients and the clinical status of the operated tooth, as well as to the observations made at surgery. No statistically significant differences were found between the study groups in the parameters used for evaluation. The results indicate that neither penicillin nor tinidazole have more effect on postoperative complications following operative extraction of wisdom teeth, than placebo tablets. Septic complications are rare following laparoscopic cholecystectomy if prophylactic antibiotics are given, as demonstrated in previous studies. Antibiotic treatment may be unnecessary and, therefore, undesirable, so we compared two forms of prophylaxis: a cephalosporin antibiotic and bag extraction of the dissected gallbladder. A total of 76 patients undergoing laparoscopic cholecystectomy were randomised to either receive an antibiotic or to have their gallbladder removed from the abdomen in a plastic bag. Complicated cases were excluded. There was a total of 6 wound infections (7.9%), 3 in each of the study groups. All these were associated with skin commensals. There were no other septic complications. Bacteriological studies grouped the organisms isolated from the bile and the wound as potential pathogens and likely commensals. A total of 10 potential pathogens were isolated, 9 of which were found in the group receiving antibiotics. We conclude that septic sequelae of uncomplicated laparoscopic cholecystectomy are uncommon, but clearly not entirely prevented by antibiotic or mechanical prophylaxis. Prophylactic antibiotics may not be required in uncomplicated laparoscopic cholecystectomy. Further study is warranted. The most common complications after surgical extraction of the third mandibular molar are trismus, oedema or swelling, local pain, dysphagia and infection. The aim of this comparative, double-blind, randomized clinical trial was to evaluate the efficacy of two sustained release amoxicillin/clavulanate regimens in the reduction of infection after third molar extractive surgery. A total of 225 patients were randomized into three equal groups: placebo, prophylaxis with single pre-surgical dose of two tablets amoxicillin/clavulanate 1000/62.5 mg, and pre-emptive post-surgery therapy with two tablets amoxicillin/clavulanate 1000/62.5 mg BID for 5 days. A higher rate of infection (P=0.006) was found among patients receiving placebo (16%) than those receiving single-dose prophylaxis (5.3%) or 5-day pre-emptive therapy (2.7%). A relationship between both the duration (13.8% for long versus 7.4% for medium versus 1.6% for short) and difficulty (12.7% with ostectomy versus 3.5% without ostectomy; P=0.011) of surgical procedure and incidence of subsequent infection was also observed. Both prophylactic and therapeutic regimens versus placebo achieved greater reduction of pain after surgery on day 3 (P=0.001). Logistic regression analysis revealed a risk of infection of 24%, 9% and 4% for ostectomy with placebo, prophylaxis and pre-emptive treatment, respectively, whereas it was 7%, 2% and 1% if ostectomy was not performed. Pre-emptive therapy with the oral sustained release amoxicillin/clavulanate formulation reduced the rate of subsequent infection in patients undergoing ostectomy. Prophylaxis was beneficial in simpler procedures and may be indicated in cases where ostectomy is not performed. Since viable bacteria can persist in tooth cavities regardless of the technique used for caries removal, the objective of the present randomized clinical trial was to examine the microflora of primary teeth treated by complete or partial removal of carious dentin. Deciduous molars with acute carious lesions in the inner half of dentin and vital pulp were randomly divided into two groups of 16: complete removal, in which the carious dentin was completely removed with the help of a caries detector dye, and partial removal, in which the carious dentin was completely removed from the dentinoenamel junction and lateral walls, while the necrotic carious dentin from the cavity floor was only removed superficially. Dentin samples were obtained with a sterile No. 3 bur after caries removal and 3-6 months after protection with calcium hydroxide cement and restoration of the cavities with resin composite. The samples were stored in thioglycolate. Decimal dilutions were then prepared and seeded for the enumeration of Streptococcus spp., mutans streptococci, Lactobacillus spp. and total microorganisms. Before sealing, a larger number of microorganisms was detected in teeth submitted to partial caries removal compared to the complete removal group. However, after sealing the level of colonization was similar in the two groups for all microorganisms studied. The results suggest that persistence of bacteria does not seem to be a reason for reopening of cavities in deciduous teeth after partial caries removal. The use of prophylactic antibiotics in addition to mechanical cleansing is the current standard of care prior to colonic surgery. The question of whether the antibiotics should be administered intravenously or orally, or by both routes, remains controversial. Our aim was to compare three methods of prophylactic antibiotic administration in elective colorectal surgery.
                Three hundred consecutive elective colorectal resections were studied. All patients had preoperative mechanical colon cleansing with oral sodium phosphate and intravenous antibiotic prophylaxis with cefoxitin (one dose before skin incision and two postoperative doses). Patients were randomised to one of the following three groups: group A: three doses of oral antibiotic (neomycin and metronidazole) at the time of mechanical colon cleansing; group B: one dose of oral antibiotic; group C: no oral antibiotics. All patients were followed during their hospital stay and at 7, 14 and 30 days post-surgery.
                Vomiting occurred in 31%, 11% and 9% of the studied patients (groups A, B and C, respectively) (p<0.001). Nausea was present in 44%, 18% and 13% of patients (p<0.001). Abdominal pain was recorded in 13%, 10% and 4% of patients (p: 0.077). Wound infection was present in 7%, 8% and 6% and suture dehiscence occurred in 2%, 2% and 3% of the patients in the three groups (no differences among them). Neither were differences found among the three groups in terms of urinary infections, pneumonia, postoperative ileus or intra-abdominal abscess.
                The addition of three doses of oral antibiotics to intravenous antibiotic prophylaxis is associated with lower patient tolerance in terms of increased nausea, vomiting and abdominal pain, and has shown no advantages in the prevention of postoperative septic complications. Therefore, we recommend that oral antibiotics should not be used prior to colorectal surgery. 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.
                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.
                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).
                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. Extraction of multiple third molar teeth can cause significant postoperative pain, swelling and trismus, which may result in delayed hospital discharge. We have examined the effect of a single prophylactic dose of oral dexamethasone 8 mg on these complications, in a randomised double-blind study of 50 adult patients. The number of extractions performed and the operative approach were standardised. Dexamethasone resulted in a significant reduction in pain 4 h postoperatively, and eliminated the need for opioid analgesia in the postoperative period. The incidence of severe swelling was also reduced significantly, but there was no effect on trismus. Postoperative nausea and vomiting were significantly lower in the dexamethasone group. We conclude that the use of prophylactic oral dexamethasone is useful in reducing postoperative analgesia requirements in this group of patients, and may facilitate surgery performed on a day case basis. The authors report the results of a randomized, prospective study to assess the effectiveness of perioperative antibiotic prophylaxis in preventing postoperative infections following clean neurosurgical operations. The study group comprised 846 patients treated between October, 1979, and June, 1984. Antibiotics, including cefazolin and gentamicin, were administered only in the immediate preoperative and intraoperative periods. Sixteen patients, none of whom developed infections, were excluded from final statistical analysis because they had inadvertently been entered into the study while failing to meet entry criteria. Fifteen wound infections (3.64%) developed in the group of 412 patients who did not receive antibiotics, whereas only four infections (0.96%) were identified among the 418 patients who received antibiotics. The difference is statistically significant (p = 0.008) and represents a 74% reduction in infection rate with antibiotics. An analysis of subgroups of surgical procedures revealed a dramatic decrease in craniotomy infections from 6.77% to 0% (p = 0.003). Of the four infections that occurred among the antibiotic-treated patients, three were in cases where foreign bodies had been implanted. No complications of antibiotic usage were identified. The rates of infection in areas of the body other than the surgical wound were no different in the antibiotic-treated and nontreated groups. All wound infections in both antibiotic-treated and nontreated patients involved similar types of Gram-positive organisms, suggesting that antibiotic prophylaxis did not produce infections with resistant or unusual organisms. This study, combined with other recently published analyses, suggests that routine perioperative antibiotic prophylaxis can significantly reduce the incidence of postoperative neurosurgical infections. Postoperative complications after surgical removal of mandibular third molars are still a clinical problem. Sixty patients undergoing operations for removal of an impacted third mandibular molar, were included in a double blind study. Phenoxymethylpenicillin 800 mg, azidocillin 750 mg, or placebo were given to the patients pre-operatively and then twice per day for the following seven days. The concentrations of phenoxymethylpenicillin and azidocillin in serum and alveolar serum were measured and the postoperative courses - pain, trismus, swelling and wound-healing - were recorded. The 40 patients in the antibiotic groups responded significantly better with respect to wound-healing than the 20 patients in the placebo group, and there were no differences between phenoxymethylpenicillin and azidocillin. Antibiotics significantly reduced pain on day 7 postoperatively. There were no differences between antibiotic groups and placebo with respect to trismus and swelling. When the dental alveolar serum concentrations of phenoxymethylpenicillin 3.0 microgram/ml and azidocillin 7.9 microgram/ml were related to their range of inhibitory concentrations for microorganisms isolated from orofacial infections, it was noticed that the two drugs achieved levels sufficient to inhibit most strains. The effect of phenoxymethylpenicillin and azidocillin on postoperative infections can be of value after traumatic oral surgery or after operations on patients especially susceptible to infections. To investigate the effect of platelet-rich plasma (PRP) on the healing of hard and soft tissues of extraction sockets with a pilot study.
                Patients undergoing tooth extraction under intravenous sedation were asked to participate in the trial. Autologous platelet concentrates were prepared from the patients' blood and autologous thrombin was produced. Outcome measures were: pain level, analgesic consumption, oral function (ability to eat food, swallowing, mouth opening and speech), general activity, swelling, bruising, bleeding, bad taste or halitosis, food stagnation, patient satisfaction, healing complications, soft tissue healing, trabecular pattern of newly formed bone in extraction sockets, trabecular bone volume, trabecular separation, trabecular length, trabecular width, and trabecular number. Patients were followed up to 3 months post-extraction.
                Twelve patients (15 sockets) were randomly allocated to the PRP group and 11 patients (14 sockets) to the control group. Two patients from the control group did not attend any of the scheduled appointments following tooth extraction, and were considered dropouts. Additionally, one more patient from the control group and four patients from the PRP group did not attend their 3-month radiographic assessment appointments. Statistically significantly more pain was recorded in the control group for the first (P=0.02), second (P=0.02) and third (P=0.04) post-operative days for Visual Analogue Scale scores, whereas no differences were observed for the fourth (P=0.17), fifth (P=0.38), sixth (P=0.75) and seventh (P=0.75) post-operative days. There was a statistically significantly higher analgesic consumption for the first (P=0.03) and second (P=0.02) post-operative days in the control group and no differences thereafter. Differences in patients' responses in the health-related quality of life questionnaire were statistically significant in favour of PRP treatment only for the presence of bad taste or bad smell in the mouth (P=0.03), and food stagnation in the operation area (P=0.03). The difference between groups was not statistically significant for patient satisfaction with the treatment (P=0.31). Regarding complications, two dry sockets and one acutely inflamed alveolus occurred in patients of the control group, which determined a borderline statistically significant difference in favour of the PRP group (P=0.06). Soft tissue healing was significantly better in patients treated with PRP (P=0.03). Radiographic evaluation carried out by the two blinded examiners revealed a statistically significant difference (P=0.01) for sockets with dense homogeneous trabecular pattern, a borderline statistically significant difference in the trabecular pattern for bone volume (P=0.06) favouring PRP use, and no significant differences for trabecular separation (P=0.66), trabecular length (P=0.16), trabecular width (P=0.16) and trabecular number (P=0.38).
                PRP may have some benefits in reducing complications such as alveolar osteitis and improving healing of soft tissue of extraction sockets. There were insufficient data to support the use of PRP to promote bone healing or to enhance the quality of life of patients following tooth extraction, although the sample size was too small to detect statistically significant differences. 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.
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.