Effectiveness of Antibiotic Prophylaxis in Third Molar Surgery: A Meta-Analysis of Randomized Controlled Clinical Trials

doi:10.1016/j.joms.2007.03.004

Journal of Oral and Maxillofacial Surgery

Volume 65, Issue 10, October 2007, Pages 1909-1921

https://doi.org/10.1016/j.joms.2007.03.004 Get rights and content

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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

Section snippets

Search Strategy

An initial search was conducted using Ovid Medline, PubMed, and the Cochrane Central Register of Controlled Trials (CENTRAL) with a combination of Medical Subject Headings (MeSH) of “anti-bacterial agents” or “antimicrobial agents,” and “third molar.” Both English and non-English articles were included in the literature search. All abstracts were reviewed and the articles described as a clinical trial were selected. The reference lists of the selected articles were searched and any relevant

Results

Ovid Medline, PubMed, and CENTRAL search resulted in 96 titles that potentially meet the inclusion criteria. After reviewing all the abstracts, 23 clinical trials involving systemic antibiotics were identified. Further search of reference lists of published clinical trials and review articles identified 14 more publications. Searching the NLM Gateway located 1 abstract presented at an international conference. The primary author in Barcelona, Spain was contacted and a manuscript accepted for

Discussion

The results of this meta-analysis of randomized controlled trials indicated that systemic antibiotics were effective in reducing the frequencies of AO and wound infection after surgical removal of impacted mandibular third molars. On average, patients receiving systemic antibiotics were 2.2 times less likely to develop AO and 1.8 times less likely to develop wound infection after third molar surgery. The wide spectrum antibiotics, represented by various penicillin derivatives, and the narrow

Acknowledgments

The authors thank Drs Michael Yunker and Thomas DeRosa for their critical review and constructive comments during the preparation of this article.

References (66)

W.G. Flick
The third molar controversy: Framing the controversy as a public health policy issue
J Oral Maxillofac Surg
(1999)
I.R. Blum
Contemporary views on dry socket (alveolar osteitis): A clinical appraisal of standardization, etiopathogenesis and management: A critical review
Int J Oral Maxillofac Surg
(2002)
N. Gersel-Pedersen
Fibrinolytic activity of blood and saliva before and after oral surgery
Int J Oral Surg
(1981)
H. Birn
Fibrinolytic activity of alveolar bone in “dry socket
” Acta Odont Scand
(1972)
M. Chiapasco et al.
Side effects and complications associated with third molar surgery
Oral Surg Oral Med Oral Pathol
(1993)
M.H. Goldberg et al.
Complications after mandibular third molar surgery: A statistical analysis of 500 consecutive procedures in private practice
J Am Dent Assoc
(1985)
R.P. Happonen et al.
Prophylactic use of phenoxymethylpenicillin and tinidazole in mandibular third molar surgery, a comparative placebo controlled clinical trial
Br J Oral Maxillofac Surg
(1990)
T.P. Osborn et al.
A prospective study of complications related to mandibular third molar surgery
J Oral Maxillofac Surg
(1985)
T. Yoshii et al.
Incidence of deep fascial space infection after surgical removal of the mandibular third molars
J Infect Chemother
(2001)
M. Kunkel et al.
Third molar complications requiring hospitalization
Oral Surg Oral Med Oral Pathol Oral Radiol Endodont
(2006)

J.F. Piecuch et al.

Prophylactic antibiotics for third molar surgery: A supportive opinion

J Oral Maxillofac Surg

(1995)

D.L. Zeitler

Prophylactic antibiotics for third molar surgery: A dissenting opinion

J Oral Maxillofac Surg

(1995)

L.W. Kay

Investigations into the nature of pericoronitis—II

Br J Oral Surg

(1966)

J.K. Barclay

Metronidazole and dry socket: Prophylactic use in mandibular third molar removal complicated by non-acute pericoronitis

N Z Dent J

(1987)

J.B. Curran et al.

An assessment of the use of prophylactic antibiotics in third molar surgery

Int J Oral Surg

(1974)

G. Monaco et al.

Antibiotic therapy in impacted third molar surgery

Eur J Oral Sci

(1999)

M. Ritzau et al.

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

Int J Oral Maxillofac Surg

(1992)

L. Krekmanov

Alveolitis after operative removal of third molars in the mandible

Int J Oral Surg

(1981)

L. Krekmanov et al.

Relationship between bacterial contamination and alveolitis after third molar surgery

Int J Oral Surg

(1980)

J.B. Lyall

Third molar surgery: The effect of primary closure, wound dressing and metronidazole on postoperative recovery

J Royal Army Med Corps

(1991)

D.A. Mitchell et al.

Tinidazole or pivampicillin in third molar surgery

Int J Oral Maxillofac Surg

(1987)

L. Hedstrom

Effect of metronidazole on development of dry socket following removal of lower third molars

Tandlakartidningen

(1990)

I. Arteagoitia et al.

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

Oral Surg Oral Med Oral Pathol Oral Radiol Endodont

(2005)

F. Graziani et al.

Clinical evaluation of piroxicam-FDDF and azithromycin in the prevention of complications associated with impacted lower third molar extraction

Pharmacol Res

(2005)

Martinetz Lacasa J, Jimenez J, Ferras V, et al. A double blind, placebo-controlled, randomized, comparative Phase III...

M. Bergdahl et al.

Metronidazole for the prevention of dry socket after removal of partially impacted mandibular third molar: A randomized controlled trial

Br J Oral Maxillofac Surg

(2004)

P.W. Poeschl et al.

Postoperative prophylactic antibiotic treatment in third molar surgery—A necessity?

J Oral Maxillofac Surg

(2004)

C.H. Sekhar et al.

Role of antimicrobials in third molar surgery: Prospective, double blind, randomized, placebo-controlled clinical study

Br J Oral Maxillofac Surg

(2001)

S.P. Foy et al.

The impact of intravenous antibiotics on health-related quality of life outcomes and clinical recovery after third molar surgery

J Oral Maxillofac Surg

(2004)

M. Colorado-Bonnin et al.

Quality of life following lower third molar removal

Int J Oral Maxillofac Surg

(2006)

A.T. Ruvo et al.

The impact of delayed clinical healing after third molar surgery on health-related quality-of-life outcomes

J Oral Maxillofac Surg

(2005)

G.D. Slade et al.

The impact of third molar symptoms, pain, and swelling on oral health-related quality of life

J Oral Maxillofac Surg

(2004)

G. Leandro

Meta-Analysis in Medical Research—The Handbook for the Understanding and Practice of Meta-Analysis

(2004)

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Clinicians frequently prescribe systemic antibiotics after lower third molar extractions to prevent complications such as surgical site infections and dry socket. A systematic review of randomised clinical trials was conducted to compare the risk of dry socket and surgical site infection after the removal of lower third molars with different prophylactic antibiotics. The occurrence of any antibiotic-related adverse event was also analysed. A pairwise and network meta-analysis was performed to establish direct and indirect comparisons of each outcome variable. Sixteen articles involving 2158 patients (2428 lower third molars) were included, and the following antibiotics were analysed: amoxicillin (with and without clavulanic acid), metronidazole, azithromycin, and clindamycin. Pooled results favoured the use of antibiotics to reduce dry socket and surgical site infection after the removal of a lower third molar, with a number needed to treat of 25 and 18, respectively. Although antibiotic prophylaxis was found to significantly reduce the risk of dry socket and surgical site infection in patients undergoing lower third molar extraction, the number of patients needed to treat was high. Thus, clinicians should evaluate the need to prescribe antibiotics taking into consideration the patient’s systemic status and the individual risk of developing a postoperative infection.
Dentists’ perception of third molar surgery in the Kingdom of Saudi Arabia: A cross sectional pilot study
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Concerns about the indications for the surgical removal of third molars have not yet reached a decisive agreement. The aim of the study was to evaluate the perception and practice of Saudi’ dentists when encountering third molars clinical situations including diagnosis, treatment, and postsurgical care.
A cross-sectional survey was conducted and approved by the ethics research committee at Prince Sattam Bin Abdulaziz (PSAU). The survey comprised of four sets of questions with multiple-choice answers including the participants’ details and type of practice (private or government), clinical awareness and attitude regarding lower third molars surgery, and the confidence level of dentists when performing third molars extraction. The survey was published online with a timeframe of three months to respond.
196 participants responded to the designated survey (55 dental interns and 141 general dental practitioners (GPs)). Most responses (80.1%) were from Riyadh province (central region). There was a significant difference between GPs and interns in terms of impacted third molars with associated cystic lesions, bony impactions, and diffuse pain (P < 0.05). Male dentists tend to prescribe antibiotics more than female dentists (P = 0.001) and GPs more than interns (P = 0.027). The results also indicated that male dentists were more confident than females when performing third molar extraction. Generally, female dentists preferred to have further training on such surgery (P < 0.05).
Continuing professional development programs both during dental internship and general practice are recommended to improve the required skills of third molar extraction.
Effect of manuka honey socket dressing on postoperative sequelae and complications following third molar extraction: A randomized controlled study
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To evaluate the effect of manuka honey on the healing of mandibular third molar extraction sockets.
This was a prospective randomized study at a tertiary health institution in Lagos, Nigeria. All extractions were transalveolar, using the distobuccal bone guttering technique. Participants were randomized into two study groups. Group A underwent intrasocket application of manuka honey, after which sockets were completely closed using the mucosal flap, while participants in group B underwent mucosal flap closure of the socket without application of manuka honey. The primary outcome was healing of the extraction socket at 7 days postoperatively. The secondary outcomes measured were postoperative sequelae, namely pain, swelling, and trismus on postoperative days 1, 3, and 7, and socket healing complications — specifically inflamed socket, infected socket, and alveolar osteitis.
In total, 112 participants completed the study, with 56 participants per group. There were no significant differences in demographic variables between both groups. On the 7th day postoperatively, 26.8% of participants in group B had an unhealed extraction site, compared with 10.3% of participants in group A (p = 0.029).
A significant difference was observed between pre- and postoperative pain scores in both study groups (p = 0.001). A comparison of postoperative mean facial swelling between the two groups showed no statistically significant differences on all the review days (p = 0.66). The difference in postoperative socket healing complication rate between both groups was statistically significant (χ² = 4.747, p = 0.029).
Within the limitations of the study it seems that the application of manuka honey appears to aid earlier healing of the third molar extraction socket, with a significantly lower frequency of complications. Therefore, the application of manuka honey is recommended whenever appropriate.
Antibiotic prophylaxis in oral and maxillofacial surgery: a systematic review
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Surgical site infections are a complication of oral and maxillofacial procedures, with the potential for significant morbidity and mortality. Use of preoperative, perioperative, and postoperative antibiotic prophylaxis to reduce the incidence of surgical site infections must be balanced with considerations of a patients’ risk of antibiotic-related adverse events. This review aimed to provide evidence-based recommendations for antibiotic prophylaxis. Searches were conducted using MEDLINE, the Cochrane Library, EMBASE, and PUBMED for maxillofacial procedures including: treatment of dental abscesses, extractions, implants, trauma, temporomandibular joints, orthognathics, malignant and benign tumour removal, and bone grafting, limited to articles published since 2000. A total of 98 out of 280 retrieved papers were included in the final analysis. Systematic reviews were assessed using AMSTAR criteria. Randomised controlled trials were assessed for bias using Cochrane Collaborative tools. The overall quality of evidence was assessed using GRADE. Prophylactic antibiotic use is recommended in surgical extractions of third molars, comminuted mandibular fractures, temporomandibular joint replacements, clean-contaminated tumour removal, and complex implants. Prophylactic antibiotic use is not routinely recommended in fractures of the upper or midface facial thirds. Further research is required to provide recommendations in orthognathic, cleft lip, palate, temporomandibular joint surgery, and maxillofacial surgical procedures in medically-compromised patients.
Comparison between the prophylactic effects of amoxicillin 24 and 48 hours pre-operatively on surgical site infections in Japanese patients with impacted mandibular third molars: A prospective cohort study
2021, Journal of Infection and Chemotherapy
Citation Excerpt :
Specifically, there are no reports about prospective studies on the proper use of antimicrobials targeted in the Japanese population. While the Japanese guidelines were prepared with reference to past reports [1,2,5,19,27]. It has been reported that Japanese people are small in physical size compared to other races [21], so when applying overseas guidelines, it is necessary to consider the populations physical size.
According to the guidelines, the dosage for mandibular wisdom tooth extraction (MWTE) varies within the administration period. There is a 24-fold difference between the minimum and maximum doses. If an appropriate antimicrobial can be administered without increasing incidence of surgical site infection (SSI), it may lead to a global action plan on antimicrobial resistance (AMR). Therefore, we prospectively surveyed incidence of SSI post-operatively and use of oral antibiotics (OA) for MWTE.
Subjects were patients who underwent MWTE in our dental outpatient clinic from May 2019 to April 2020. Two groups were formed depending on type of administration period they received: 24 h and 48 h after surgery. The following information was collected: (1) patient factors (age, gender, body mass index, presence/absence of preoperative medication, diagnosis, impacted wisdom tooth status; (2) surgical factors (operative time, presence/absence of closure, presence/absence of hemostat, doctor career, type and frequency of painkiller); (3) relationship between administration period of OA and SSI occurrence; and (4) details of SSI.
Three hundred forty subjects were analyzed, all of which used amoxicillin. There were 106 cases in 24 h group and 234 cases in 48 h group. The total incidence of SSI was 1.1% (4/340 cases), with 0.9% (1/106 cases) in 24 h group and 1.3% (3/234 cases) in 48 h group; there was no difference between the two groups.
Our study suggests that amoxicillin (250 mg/dose every 8 h x 3 doses beginning 1 h before surgery) might be sufficient in preventing SSI in Japanese dental patients without SSI risk factors.

View all citing articles on Scopus

: This study is supported in part by NIDCR (DE16917).

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Basic and patient-oriented researchEffectiveness of Antibiotic Prophylaxis in Third Molar Surgery: A Meta-Analysis of Randomized Controlled Clinical Trials

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Search Strategy

Results

Discussion

Acknowledgments

The third molar controversy: Framing the controversy as a public health policy issue

J Oral Maxillofac Surg

Contemporary views on dry socket (alveolar osteitis): A clinical appraisal of standardization, etiopathogenesis and management: A critical review

Int J Oral Maxillofac Surg

Fibrinolytic activity of blood and saliva before and after oral surgery

Int J Oral Surg

Fibrinolytic activity of alveolar bone in “dry socket

” Acta Odont Scand

Side effects and complications associated with third molar surgery

Oral Surg Oral Med Oral Pathol

Complications after mandibular third molar surgery: A statistical analysis of 500 consecutive procedures in private practice

J Am Dent Assoc

Prophylactic use of phenoxymethylpenicillin and tinidazole in mandibular third molar surgery, a comparative placebo controlled clinical trial

Br J Oral Maxillofac Surg

A prospective study of complications related to mandibular third molar surgery

J Oral Maxillofac Surg

Incidence of deep fascial space infection after surgical removal of the mandibular third molars

J Infect Chemother

Third molar complications requiring hospitalization

Oral Surg Oral Med Oral Pathol Oral Radiol Endodont

Prophylactic antibiotics for third molar surgery: A supportive opinion

J Oral Maxillofac Surg

Prophylactic antibiotics for third molar surgery: A dissenting opinion

J Oral Maxillofac Surg

Investigations into the nature of pericoronitis—II

Br J Oral Surg

Metronidazole and dry socket: Prophylactic use in mandibular third molar removal complicated by non-acute pericoronitis

N Z Dent J

An assessment of the use of prophylactic antibiotics in third molar surgery

Int J Oral Surg

Antibiotic therapy in impacted third molar surgery

Eur J Oral Sci

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

Int J Oral Maxillofac Surg

Alveolitis after operative removal of third molars in the mandible

Int J Oral Surg

Relationship between bacterial contamination and alveolitis after third molar surgery

Int J Oral Surg

Third molar surgery: The effect of primary closure, wound dressing and metronidazole on postoperative recovery

J Royal Army Med Corps

Tinidazole or pivampicillin in third molar surgery

Int J Oral Maxillofac Surg

Effect of metronidazole on development of dry socket following removal of lower third molars

Tandlakartidningen

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

Oral Surg Oral Med Oral Pathol Oral Radiol Endodont

Clinical evaluation of piroxicam-FDDF and azithromycin in the prevention of complications associated with impacted lower third molar extraction

Pharmacol Res

Metronidazole for the prevention of dry socket after removal of partially impacted mandibular third molar: A randomized controlled trial

Br J Oral Maxillofac Surg

Postoperative prophylactic antibiotic treatment in third molar surgery—A necessity?

J Oral Maxillofac Surg

Role of antimicrobials in third molar surgery: Prospective, double blind, randomized, placebo-controlled clinical study

Br J Oral Maxillofac Surg

The impact of intravenous antibiotics on health-related quality of life outcomes and clinical recovery after third molar surgery

J Oral Maxillofac Surg

Quality of life following lower third molar removal

Int J Oral Maxillofac Surg

The impact of delayed clinical healing after third molar surgery on health-related quality-of-life outcomes

J Oral Maxillofac Surg

The impact of third molar symptoms, pain, and swelling on oral health-related quality of life

J Oral Maxillofac Surg

Meta-Analysis in Medical Research—The Handbook for the Understanding and Practice of Meta-Analysis

Basic and patient-oriented research
Effectiveness of Antibiotic Prophylaxis in Third Molar Surgery: A Meta-Analysis of Randomized Controlled Clinical Trials