- Email: [email protected]
Tetracycline compound placement to prevent dry socket: a postoperative study of 200 impacted mandibular third molars
J Oral Maxillofac Surg 62:587-591, 2004
Tetracycline Compound Placement to Prevent Dry Socket: A Postoperative Study of 200 Impacted Mandibular Third Molars J.M. Sanchis, MD, PhD,* U. Sa ´ ez, DDS, PhD,† M. Pen ˜ arrocha, MD, PhD,‡ and C. Gay, MD, PhD§ Purpose:
Our objective was to study whether the placement of intra-alveolar tetracycline prevents dry sockets or improves the postoperative period. Patients and Methods: A comparative clinical study of the surgical removal of 200 impacted mandibular third molars is made, with particular reference to postextraction pain, inflammation, trismus, and the incidence of dry socket. In 50% of these cases, a pharmacologic preparation that includes tetracycline was placed in the socket after removal of the impacted molar. Results: Dry socket was diagnosed in 4 cases (2%), with no relation to intra-alveolar tetracycline placement being observed. The patients who were administered intra-alveolar tetracycline had less pain and trismus and consumed fewer analgesics than the patients who received no such treatment, although statistical significance was not reached. Conclusions: The intra-alveolar placement of tetracycline compound after the surgical removal of impacted mandibular third molars did not affect the incidence of dry socket. © 2004 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 62:587-591, 2004 socket, with or without halitosis.1 The pain is not relieved with mild analgesics.2,3 The incidence of dry socket is 1% to 3% after extractions,4 whereas recent research places the figure at between 20%4 and 30%5 after third molar surgery. With the use of chlorhexidine rinses,6-9 intra-alveolar antiseptics,10 metronidazole11 or fibrinolytic agents,12,13 tetracyclines,14-17 clindamycin,18 or other intra-alveolar pharmacologic preparations,5 this incidence has been reduced to 2% to 8%, according to a study by Bloomer in 2000.5 In the present study, we investigate whether the placement of a pharmacologic preparation that includes tetracycline in the postextraction sockets of impacted mandibular third molars modifies the incidence of dry socket and/or is able to influence the postoperative course (pain, inflammation, and trismus).
Dry socket, or alveolitis sicca, is one of the most frequent complications of impacted mandibular third molar surgery, and it manifests as an intense pain in the extraction zone commencing on the third to fifth postoperative day. Dry socket is a postoperative pain that occurs in and around the extraction site and increases in severity at any time between 1 and 3 days after the extraction accompanied by a partially or totally disintegrated blood clot within the alveolar *Associate Professor of Oral Surgery, Valencia University, Medical and Dental School, Valencia, Spain. †Dentist and Master of Oral Surgery and Implantology, Valencia University, Medical and Dental School, Valencia, Spain. ‡Assistant Professor of Oral Surgery, Director, Master of Oral Surgery and Implantology, Valencia University Medical and Dental School, Valencia, Spain. §Professor and Chairman of Oral and Maxillofacial Surgery, Director, Master of Oral Surgery and Implantology, Barcelona University Medical and Dental School, Barcelona, Spain. Address correspondence and reprint requests to Dr Pen ˜ arrocha: Clı´nicas Odontolo ´ gicas, Gasco ´ Oliag 1, 46021 Valencia, Spain; email: [email protected]
Patients and Methods A total of 200 patients with impacted mandibular third molars were studied. Our objective is to study whether the placement of intra-alveolar tetracycline prevents dry sockets or improves the postoperative period. We divided the cases into a group of 100 patients who underwent extraction of 1 third man-
© 2004 American Association of Oral and Maxillofacial Surgeons
0278-2391/04/6205-0073$30.00/0 doi:10.1016/j.joms.2003.08.035
587
588 dibular molar, in which a pharmacologic preparation was placed in the postextraction socket consisting of 9 mg of tetracycline hydrochloride (antibiotic), 12 mg of tetracaine hydrochloride (analgesic), 6 mg of antipyrine (analgesic, antipyretic), 20 units of fungal protease (proteolytic enzymes), and 200 mg of excipient (Conalgil; Lab. SPAD, Dijon Cedex, France); and a control group of 100 patients who underwent extraction of one third mandibular molar, in which no compounds were placed in the sockets. No patients served as both control and experimental subject in this study. Patients with acute infection were excluded, as were those with pericoronitis or tetracycline allergy, and subjects receiving antibiotic therapy. All extractions were performed in the same outpatient operating room, using the same material and surgical instruments, and involving a team of surgeons with similar experience (third-year students of the Master of Oral Surgery and Implantology). In all cases, the inferior alveolar, lingual, and buccal nerves were anesthetized with 2 anesthetic cartridges containing 2% lidocaine with 1:100,000 epinephrine. A doubletrajectory incision was made, involving a first incision distal from the posterior portion of the retromolar trigone to the second molar, and a second anterior and oblique incision was made in the mesial zone of the second molar. After extraction of the molar, the socket was examined, cleaned, and sutured with 00 silk sutures. Data recorded included patient age and gender, oral hygiene, tobacco smoking, and the use of oral contraceptives. Hygiene was scored with the Simplified Oral Hygiene Index (OHI-S) as follows: good, 0 to 1.2; regular, 1.3 to 3; and poor, 3.1 to 6. Smoking was in turn coded as 1) nonsmoker, 2) up to 10 cigarettes per day, 3) 11 to 20 cigarettes per day, and 4) more than 20 cigarettes per day. Oral contraceptive use was evaluated as either 1) yes or 2) no. Surgical difficulty was rated (in millimeters) by measurement of the Winter line, corresponding to the perpendicular traced from the line joining the bony septum distal to the molar and the septum between the first and second molar, to the hypothetical point of application corresponding to the cementoenamel junction of the third molar17 (Fig 1). Pain was rated individually by each patient at 2, 6, and 12 hours after extraction and then everyday for the first 6 postoperative days, based on a visual analog scale from 0 to 10. Inflammation was always in turn evaluated by the same observer (U.S.), using a subjective 4-point scale of no inflammation, mild inflammation (small degree of intraoral inflammation), moderate inflammation (significant intraoral inflammation), and severe inflammation (significant intraoral inflammation with an extraoral component). Before surgery,
TETRACYCLINE COMPOUND TO PREVENT DRY SOCKET
FIGURE 1. Measure of Winter length, A, Distance between distal bone of the third mandibular molar and intraseptal osseous between first and second molars. B, Winter length.
the active maximum interincisal oral aperture (in millimeters) was measured using a millimeter ruler from the upper incisal margin to the incisal margin of the lower incisors. Dry socket was determined by increased severity of pain and loss of the blood clot in the days following extraction. All patients received amoxicillin (500 mg/8 hours for 4 days). Forty-eight hours and 7 days after surgery, evaluations were made of oral aperture, the number of analgesic tablets (metamizole) used by each patient, and the possible complications, such as neurologic damage. The sensitivity of the mental nerve region was evaluated in a subjective way by the patient and by the same observer on clinical examination. STATISTICAL ANALYSIS
A descriptive study was made of each of the variables, and the associations between different parameters were investigated using the 2 test for qualitative variables and the Student t test for quantitative parameters, with verification of variance homogeneity in each case. In addition, calculations were made of the percentage variance associated with group assignment in those cases where the results proved to be significant. Analysis of variance was performed for the comparison of more than 2 variables.
Results We recorded the pain and inflammation in the first 7 days of the postoperative period. The greatest pain appeared after 6 hours, and maximum inflammation, 1 day after third molar extraction, respectively. The mean decrease in oral aperture after 48 hours was 18.5 mm versus 9.9 mm after 7 days. The average analgesic consumption after 48 hours and 7 days was 2.5 and 3.9 tablets of metamizole, respectively. The 2 groups were homogeneous, as a result of which the distributions of mean patient age, male/female proportion, smoking, oral hygiene, and surgical difficulty
589
SANCHIS ET AL
Table 1. DESCRIPTIVE STATISTICS SHOWING INTERGROUP HOMOGENEITY
No Tetracycline Tetracycline Mean age (yr) Gender (n) Male Female Tobacco use (n) Nonsmoker ⬍10 Cigarettes/d 10 to 20 Cigarettes/d ⬎20 Cigarettes/d Hygiene (n) Good Regular Poor Surgical difficulty (mean Winter distance)
25.84
25.33
26 74
38 62
64 19 16 1
66 19 11 4
72 27 1
60 33 6
Table 3. ANALGESIC CONSUMPTION
P .69* .09† .43†
.07†
8.32
8.55
No Tetracycline
Tetracycline
P*
48 Hours Day 7
2.71 4.42
2.38 3.56
.206 .164
*Student t test.
or oral hygiene was observed. Of these 4 women, only 1 used oral contraceptives; that is, the incidence of dry socket among the women taking oral contraceptives (14 subjects) was 7.1% (1 woman) versus 2.3% among those not using such drugs (3 of 122 patients). Dry socket was related to surgical difficulty; the mean Winter distance among the 4 affected women was 10.25 mm versus 8.39 mm in the 196 patients without dry socket.
.64†
Discussion
*Student t test. †2 Test.
were similar in both the tetracycline and control groups (Table 1). The incidence of dry socket was 3% among the patients administered tetracycline (3 cases) and 1% among those who received no such treatment. The comparative analysis showed the former to have comparatively less pain (Table 2), with a lesser consumption of analgesic (Table 3), although the differences between groups were not significant. The patients treated with topical tetracycline also showed less trismus than the controls (although not significant) (Table 4). The placement of tetracycline did not influence the course of inflammation. In no case was neurologic damage in the mental nerve region found. There were 4 cases of dry socket (2%) in patients aged an average of 38.2 years, significantly older than the remainder of the series (25.4 years); all 4 patients were women. No relation to either tobacco smoking
Table 2. COURSE OF PAIN IN THE FIRST POSTOPERATIVE WEEK
Time
No Tetracycline
Tetracycline
P*
6 Hours 12 Hours Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
4.18 3.85 3.35 2.94 2.29 1.69 1.21 0.9 0.5
3.96 3.76 3.22 2.7 2.05 1.46 1.14 0.8 0.1
.513 .794 .711 .424 .229 .216 .778 .620 .363
*Student t test.
Time
The results of the present study show a trend that tetracycline compound placement after the surgical extraction of impacted mandibular third molars yielded less pain and inflammation than in the controls who received no such treatment, although the differences were not statistically significant. In a study of human immunodeficiency virus infection–positive patients, Pankhurst et al19 found that the injection of a chlortetracycline solution into the sockets after extraction led to a reduction in pain and improved healing. According to Verbic20 and Olech,21 antibiotic use (penicillin and tetracycline) in postextraction sockets may reduce swelling and trismus, although this postulate has not been confirmed in recent years. According to Vezeau,22 the most useful medications to prevent socket healing derangements include broad-spectrum antibiotics, specifically clindamycin and tetracycline, but possibly germane to the subject of clot stabilization and healing, is consideration of resorbable substances such as gelatin sponge, polylactic acid, and methylcellulose as clot-stabilizing socket implants. We observed no direct relation between tetracycline placement in the postextraction sockets and inflammation, and recorded only a slightly greater incidence of trismus in the control group. The incidence of dry socket was 2% in the present study. This figure coincides with the best results of
Table 4. DECREASE IN ORAL APERTURE
Time
No Tetracycline
Tetracycline
P*
48 Hours Day 7
19.74 10.79
17.36 9.15
.062 .161
*Student t test.
590
TETRACYCLINE COMPOUND TO PREVENT DRY SOCKET
some of the studies in the literature, with values of 2% to 8%.4,5 All of our cases corresponded to women, although it should be taken into account that females clearly predominated in the global series (68%). According to Castellani et al,23 the incidence of dry socket after mandibular third molar surgery is greater among women taking oral contraceptives, particularly when surgery is performed between days 1 and 22 of the menstrual cycle, because a relationship exists between estrogen levels and dry socket. In our series, the incidence was higher among the women taking oral contraceptives (7.1%) than in those who did not use such drugs (2.4%)—the degree of surgical difficulty and mean patient age being similar in both groups—though it should be taken into account that the limited number of cases of dry socket recorded (4) precludes the drawing of firm conclusions. In accord with the literature,24,25 the patients with dry socket were significantly older than the subjects in whom this complication did not develop. Likewise, dry socket was more common in situations of increased surgical difficulty. Bloomer5 reported a greater incidence of dry socket in relation to increased depths of the extracted molar. In this context, it is well established that that the risk of dry socket increases with the degree of surgical trauma involved.26,27 Different authors14-17 have associated tetracycline placement in postextraction sockets with a reduction in the incidence of alveolitis sicca. However, in our series, such topical treatment did not influence the appearance of dry socket, possibly because only 4 cases were recorded in the global series. On the other hand, the placement of an antiseptic pharmacologic preparation (basically comprising eugenol and Peru balsam) in postextraction sockets has recently been reported to reduce the incidence of dry socket from 26% to 8%.5 Because of these controversial results concerning the placement of intra-alveolar drugs, their use does not seem to be indicated at the present time.28 On the other hand, our patients had no problems associated with the use of intra-alveolar tetracycline, although cases of local sensitization,29,30 foreign body reactions,31,32 delayed healing,33 and neurosensory alterations34,35 have been described after the placement of different intra-alveolar preparations, particularly tetracycline; however, according to our results, we believe that intra-alveolar tetracycline placement is not indicated to prevent dry socket, nor the pain and inflammation of the postoperative course.
2. Adeyemo WL: Critical review on dry socket. Int J Oral Maxillofac Surg 32:111, 2003 3. Cohen ME, Simecek JW: Effects of gender-related factors on the incidence of localized alveolar osteitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 79:416, 1995 4. Larsen PE: Alveolar osteitis after surgical removal of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol 73: 393, 1992 5. Bloomer CR: Alveolar osteitis prevention by immediate placement of medicated packing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90:282, 2000 6. Field EA, Nind D, Varga E, et al: The effect of chlorhexidine irrigation on the incidence of dry socket: A pilot study. Br J Oral Maxillofac Surg 26:395, 1988 7. Bonnie FL: Effect of chlorhexidine rinse on the incidence of dry socket in impacted mandibular third molar extraction sites. Oral Surg Oral Med Oral Pathol 79:154, 1995 8. Larsen PE: The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg 49: 932, 1991 9. Rango JR, Szkutnik AJ: Evaluation of 0.12% chlorhexidine rinse on the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol 72:524, 1991 10. Fotos P, Koorbusch GF, Sarasin D, et al: Evaluation of intraalveolar chlorhexidine dressing after removal of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol 73:383, 1992 11. Ritzau M, Hillerup S, Branebjerg PE, et al: Does metronidazole prevent alveolitis sicca dolorosa? Int J Oral Maxillofac Surg 21:299, 1992 12. Swanson AE: Prevention of dry socket: An overview. Oral Surg Oral Med Oral Pathol 70:131, 1990 13. Hooley JR, Golden DP: The effect of polylactic acid granules on the incidence of alveolar osteitis after mandibular third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80:279, 1995 14. Hall HD, Bildman BS, Hand CD: Prevention of dry socket with local application of tetracycline. J Oral Surg 29:35, 1971 15. Davis WM Jr, Buchs AU, Davis WM: The use of granular gelatintetracycline compound after third molar removal. J Oral Surg 39:466, 1981 16. Swanson AE: A double-blind study on the effectiveness of tetracycline in reducing the incidence of fibrinolytic alveolitis. J Oral Maxillofac Surg 47:165, 1989 17. Sorensen DC, Preisch J: The effect of tetracycline on the incidence of postextraction alveolar osteitis. J Oral Maxillofac Surg 45:1029, 1987 18. Trieger N, Schlagel GD: Preventing dry socket. A simple procedure. J Am Dent Assoc 122:67, 1991 19. Pankhurst C, Lewis DA, Clark DT, et al: Prophylactic application of an intra-alveolar socket medicament to reduce postextraction complications in HIV-seropositive patients. Oral Surg Oral Med Oral Pathol 77:331, 1994 20. Verbic RL: Local implantation of aureomycin in extraction wounds: A preliminary study. J Am Dent Assoc 46:160, 1953 21. Olech E: Value of implantation of certain chemotherapeutic agents in sockets of impacted lower third molars. J Am Dent Assoc 46:154, 1953 22. Vezeau PJ: Dental extraction wound management: Medicating postextraction sockets. J Oral Maxillofac Surg 58:531, 2000 23. Castellani JE, Harvey S, Erickson SH, et al: Effect of oral contraceptive cycle on dry socket (localized alveolar osteitis). J Am Dent Assoc 101:777, 1980 24. Osborn TP, Frederickson G, Small Y, et al: A prospective study of complications related to mandibular third molar surgery. J Oral Maxillofac Surg 43:767, 1985 25. Chiapasco M, De Cicco L, Marrone G: Side effects and complications associated with molar surgery. Oral Surg Oral Med Oral Pathol 76:412, 1993 26. Meechan JG, Macgregor IDM, Rogers SN, et al: The effect of smoking on immediate post-extraction socket. Br J Oral Maxillofac Surg 26:402, 1988
References 1. Blum IR: Contemporary views on dry socket (alveolar osteitis): A clinical appraisal of standardization, aetiopathogenesis and management: A critical review. Int J Oral Maxillofac Surg 31: 309, 2002
591
SANCHIS ET AL 27. Johnson WS, Blanton EE: An evaluation of 9-aminoacridine/ gelfoam to reduce dry socket formation. Oral Surg Oral Med Oral Pathol 66:167, 1988 28. Alexander-Roger E: Dental extraction wound management: A case against medicating postextraction sockets. J Oral Maxillofac Surg 58:538, 2000 29. Knighton HT: Consideration of topical antibiotic therapy in dentistry. Dent Clin North Am 2:101, 1958 30. Quiley JF, Royer RQ, Gores RJ: “Dry socket” after mandibular odontectomy and use of soluble tetracycline hydrochloride. Oral Surg Oral Med Oral Pathol 13:38, 1960 31. Moore JW, Brekke J: Foreign body giant cell reaction related to
32.
33. 34. 35.
placement of tetracycline-treated polylactic acid: Report of 18 cases. J Oral Maxillofac Surg 48:808, 1990 Eslami A, Van Swol R, Sadeghi EM: Connective tissue reactions to 3% tetracycline ointment in rat skin. J Oral Maxillofac Surg 45:866, 1987 Boyne PJ, Kruger GO: Topical implantation of oxytetracycline cones in extraction sockets. J Am Dent Assoc 64:224, 1962 Zuniga JR, Leist J: Topical tetracycline-induced neuritis: A case report. J Oral Maxillofac Surg 53:196, 1995 Leist JC, Zuniga JR, Gollehons S: Experimental topical tetracycline-induced neuritis in the rat. J Oral Maxillofac Surg 53:427, 1995
Tetracycline Compound Placement to Prevent Dry Socket: A Postoperative Study of 200 Impacted Mandibular Third Molars J.M. Sanchis, MD, PhD,* U. Sa ´ ez, DDS, PhD,† M. Pen ˜ arrocha, MD, PhD,‡ and C. Gay, MD, PhD§ Purpose:
Our objective was to study whether the placement of intra-alveolar tetracycline prevents dry sockets or improves the postoperative period. Patients and Methods: A comparative clinical study of the surgical removal of 200 impacted mandibular third molars is made, with particular reference to postextraction pain, inflammation, trismus, and the incidence of dry socket. In 50% of these cases, a pharmacologic preparation that includes tetracycline was placed in the socket after removal of the impacted molar. Results: Dry socket was diagnosed in 4 cases (2%), with no relation to intra-alveolar tetracycline placement being observed. The patients who were administered intra-alveolar tetracycline had less pain and trismus and consumed fewer analgesics than the patients who received no such treatment, although statistical significance was not reached. Conclusions: The intra-alveolar placement of tetracycline compound after the surgical removal of impacted mandibular third molars did not affect the incidence of dry socket. © 2004 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 62:587-591, 2004 socket, with or without halitosis.1 The pain is not relieved with mild analgesics.2,3 The incidence of dry socket is 1% to 3% after extractions,4 whereas recent research places the figure at between 20%4 and 30%5 after third molar surgery. With the use of chlorhexidine rinses,6-9 intra-alveolar antiseptics,10 metronidazole11 or fibrinolytic agents,12,13 tetracyclines,14-17 clindamycin,18 or other intra-alveolar pharmacologic preparations,5 this incidence has been reduced to 2% to 8%, according to a study by Bloomer in 2000.5 In the present study, we investigate whether the placement of a pharmacologic preparation that includes tetracycline in the postextraction sockets of impacted mandibular third molars modifies the incidence of dry socket and/or is able to influence the postoperative course (pain, inflammation, and trismus).
Dry socket, or alveolitis sicca, is one of the most frequent complications of impacted mandibular third molar surgery, and it manifests as an intense pain in the extraction zone commencing on the third to fifth postoperative day. Dry socket is a postoperative pain that occurs in and around the extraction site and increases in severity at any time between 1 and 3 days after the extraction accompanied by a partially or totally disintegrated blood clot within the alveolar *Associate Professor of Oral Surgery, Valencia University, Medical and Dental School, Valencia, Spain. †Dentist and Master of Oral Surgery and Implantology, Valencia University, Medical and Dental School, Valencia, Spain. ‡Assistant Professor of Oral Surgery, Director, Master of Oral Surgery and Implantology, Valencia University Medical and Dental School, Valencia, Spain. §Professor and Chairman of Oral and Maxillofacial Surgery, Director, Master of Oral Surgery and Implantology, Barcelona University Medical and Dental School, Barcelona, Spain. Address correspondence and reprint requests to Dr Pen ˜ arrocha: Clı´nicas Odontolo ´ gicas, Gasco ´ Oliag 1, 46021 Valencia, Spain; email: [email protected]
Patients and Methods A total of 200 patients with impacted mandibular third molars were studied. Our objective is to study whether the placement of intra-alveolar tetracycline prevents dry sockets or improves the postoperative period. We divided the cases into a group of 100 patients who underwent extraction of 1 third man-
© 2004 American Association of Oral and Maxillofacial Surgeons
0278-2391/04/6205-0073$30.00/0 doi:10.1016/j.joms.2003.08.035
587
588 dibular molar, in which a pharmacologic preparation was placed in the postextraction socket consisting of 9 mg of tetracycline hydrochloride (antibiotic), 12 mg of tetracaine hydrochloride (analgesic), 6 mg of antipyrine (analgesic, antipyretic), 20 units of fungal protease (proteolytic enzymes), and 200 mg of excipient (Conalgil; Lab. SPAD, Dijon Cedex, France); and a control group of 100 patients who underwent extraction of one third mandibular molar, in which no compounds were placed in the sockets. No patients served as both control and experimental subject in this study. Patients with acute infection were excluded, as were those with pericoronitis or tetracycline allergy, and subjects receiving antibiotic therapy. All extractions were performed in the same outpatient operating room, using the same material and surgical instruments, and involving a team of surgeons with similar experience (third-year students of the Master of Oral Surgery and Implantology). In all cases, the inferior alveolar, lingual, and buccal nerves were anesthetized with 2 anesthetic cartridges containing 2% lidocaine with 1:100,000 epinephrine. A doubletrajectory incision was made, involving a first incision distal from the posterior portion of the retromolar trigone to the second molar, and a second anterior and oblique incision was made in the mesial zone of the second molar. After extraction of the molar, the socket was examined, cleaned, and sutured with 00 silk sutures. Data recorded included patient age and gender, oral hygiene, tobacco smoking, and the use of oral contraceptives. Hygiene was scored with the Simplified Oral Hygiene Index (OHI-S) as follows: good, 0 to 1.2; regular, 1.3 to 3; and poor, 3.1 to 6. Smoking was in turn coded as 1) nonsmoker, 2) up to 10 cigarettes per day, 3) 11 to 20 cigarettes per day, and 4) more than 20 cigarettes per day. Oral contraceptive use was evaluated as either 1) yes or 2) no. Surgical difficulty was rated (in millimeters) by measurement of the Winter line, corresponding to the perpendicular traced from the line joining the bony septum distal to the molar and the septum between the first and second molar, to the hypothetical point of application corresponding to the cementoenamel junction of the third molar17 (Fig 1). Pain was rated individually by each patient at 2, 6, and 12 hours after extraction and then everyday for the first 6 postoperative days, based on a visual analog scale from 0 to 10. Inflammation was always in turn evaluated by the same observer (U.S.), using a subjective 4-point scale of no inflammation, mild inflammation (small degree of intraoral inflammation), moderate inflammation (significant intraoral inflammation), and severe inflammation (significant intraoral inflammation with an extraoral component). Before surgery,
TETRACYCLINE COMPOUND TO PREVENT DRY SOCKET
FIGURE 1. Measure of Winter length, A, Distance between distal bone of the third mandibular molar and intraseptal osseous between first and second molars. B, Winter length.
the active maximum interincisal oral aperture (in millimeters) was measured using a millimeter ruler from the upper incisal margin to the incisal margin of the lower incisors. Dry socket was determined by increased severity of pain and loss of the blood clot in the days following extraction. All patients received amoxicillin (500 mg/8 hours for 4 days). Forty-eight hours and 7 days after surgery, evaluations were made of oral aperture, the number of analgesic tablets (metamizole) used by each patient, and the possible complications, such as neurologic damage. The sensitivity of the mental nerve region was evaluated in a subjective way by the patient and by the same observer on clinical examination. STATISTICAL ANALYSIS
A descriptive study was made of each of the variables, and the associations between different parameters were investigated using the 2 test for qualitative variables and the Student t test for quantitative parameters, with verification of variance homogeneity in each case. In addition, calculations were made of the percentage variance associated with group assignment in those cases where the results proved to be significant. Analysis of variance was performed for the comparison of more than 2 variables.
Results We recorded the pain and inflammation in the first 7 days of the postoperative period. The greatest pain appeared after 6 hours, and maximum inflammation, 1 day after third molar extraction, respectively. The mean decrease in oral aperture after 48 hours was 18.5 mm versus 9.9 mm after 7 days. The average analgesic consumption after 48 hours and 7 days was 2.5 and 3.9 tablets of metamizole, respectively. The 2 groups were homogeneous, as a result of which the distributions of mean patient age, male/female proportion, smoking, oral hygiene, and surgical difficulty
589
SANCHIS ET AL
Table 1. DESCRIPTIVE STATISTICS SHOWING INTERGROUP HOMOGENEITY
No Tetracycline Tetracycline Mean age (yr) Gender (n) Male Female Tobacco use (n) Nonsmoker ⬍10 Cigarettes/d 10 to 20 Cigarettes/d ⬎20 Cigarettes/d Hygiene (n) Good Regular Poor Surgical difficulty (mean Winter distance)
25.84
25.33
26 74
38 62
64 19 16 1
66 19 11 4
72 27 1
60 33 6
Table 3. ANALGESIC CONSUMPTION
P .69* .09† .43†
.07†
8.32
8.55
No Tetracycline
Tetracycline
P*
48 Hours Day 7
2.71 4.42
2.38 3.56
.206 .164
*Student t test.
or oral hygiene was observed. Of these 4 women, only 1 used oral contraceptives; that is, the incidence of dry socket among the women taking oral contraceptives (14 subjects) was 7.1% (1 woman) versus 2.3% among those not using such drugs (3 of 122 patients). Dry socket was related to surgical difficulty; the mean Winter distance among the 4 affected women was 10.25 mm versus 8.39 mm in the 196 patients without dry socket.
.64†
Discussion
*Student t test. †2 Test.
were similar in both the tetracycline and control groups (Table 1). The incidence of dry socket was 3% among the patients administered tetracycline (3 cases) and 1% among those who received no such treatment. The comparative analysis showed the former to have comparatively less pain (Table 2), with a lesser consumption of analgesic (Table 3), although the differences between groups were not significant. The patients treated with topical tetracycline also showed less trismus than the controls (although not significant) (Table 4). The placement of tetracycline did not influence the course of inflammation. In no case was neurologic damage in the mental nerve region found. There were 4 cases of dry socket (2%) in patients aged an average of 38.2 years, significantly older than the remainder of the series (25.4 years); all 4 patients were women. No relation to either tobacco smoking
Table 2. COURSE OF PAIN IN THE FIRST POSTOPERATIVE WEEK
Time
No Tetracycline
Tetracycline
P*
6 Hours 12 Hours Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
4.18 3.85 3.35 2.94 2.29 1.69 1.21 0.9 0.5
3.96 3.76 3.22 2.7 2.05 1.46 1.14 0.8 0.1
.513 .794 .711 .424 .229 .216 .778 .620 .363
*Student t test.
Time
The results of the present study show a trend that tetracycline compound placement after the surgical extraction of impacted mandibular third molars yielded less pain and inflammation than in the controls who received no such treatment, although the differences were not statistically significant. In a study of human immunodeficiency virus infection–positive patients, Pankhurst et al19 found that the injection of a chlortetracycline solution into the sockets after extraction led to a reduction in pain and improved healing. According to Verbic20 and Olech,21 antibiotic use (penicillin and tetracycline) in postextraction sockets may reduce swelling and trismus, although this postulate has not been confirmed in recent years. According to Vezeau,22 the most useful medications to prevent socket healing derangements include broad-spectrum antibiotics, specifically clindamycin and tetracycline, but possibly germane to the subject of clot stabilization and healing, is consideration of resorbable substances such as gelatin sponge, polylactic acid, and methylcellulose as clot-stabilizing socket implants. We observed no direct relation between tetracycline placement in the postextraction sockets and inflammation, and recorded only a slightly greater incidence of trismus in the control group. The incidence of dry socket was 2% in the present study. This figure coincides with the best results of
Table 4. DECREASE IN ORAL APERTURE
Time
No Tetracycline
Tetracycline
P*
48 Hours Day 7
19.74 10.79
17.36 9.15
.062 .161
*Student t test.
590
TETRACYCLINE COMPOUND TO PREVENT DRY SOCKET
some of the studies in the literature, with values of 2% to 8%.4,5 All of our cases corresponded to women, although it should be taken into account that females clearly predominated in the global series (68%). According to Castellani et al,23 the incidence of dry socket after mandibular third molar surgery is greater among women taking oral contraceptives, particularly when surgery is performed between days 1 and 22 of the menstrual cycle, because a relationship exists between estrogen levels and dry socket. In our series, the incidence was higher among the women taking oral contraceptives (7.1%) than in those who did not use such drugs (2.4%)—the degree of surgical difficulty and mean patient age being similar in both groups—though it should be taken into account that the limited number of cases of dry socket recorded (4) precludes the drawing of firm conclusions. In accord with the literature,24,25 the patients with dry socket were significantly older than the subjects in whom this complication did not develop. Likewise, dry socket was more common in situations of increased surgical difficulty. Bloomer5 reported a greater incidence of dry socket in relation to increased depths of the extracted molar. In this context, it is well established that that the risk of dry socket increases with the degree of surgical trauma involved.26,27 Different authors14-17 have associated tetracycline placement in postextraction sockets with a reduction in the incidence of alveolitis sicca. However, in our series, such topical treatment did not influence the appearance of dry socket, possibly because only 4 cases were recorded in the global series. On the other hand, the placement of an antiseptic pharmacologic preparation (basically comprising eugenol and Peru balsam) in postextraction sockets has recently been reported to reduce the incidence of dry socket from 26% to 8%.5 Because of these controversial results concerning the placement of intra-alveolar drugs, their use does not seem to be indicated at the present time.28 On the other hand, our patients had no problems associated with the use of intra-alveolar tetracycline, although cases of local sensitization,29,30 foreign body reactions,31,32 delayed healing,33 and neurosensory alterations34,35 have been described after the placement of different intra-alveolar preparations, particularly tetracycline; however, according to our results, we believe that intra-alveolar tetracycline placement is not indicated to prevent dry socket, nor the pain and inflammation of the postoperative course.
2. Adeyemo WL: Critical review on dry socket. Int J Oral Maxillofac Surg 32:111, 2003 3. Cohen ME, Simecek JW: Effects of gender-related factors on the incidence of localized alveolar osteitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 79:416, 1995 4. Larsen PE: Alveolar osteitis after surgical removal of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol 73: 393, 1992 5. Bloomer CR: Alveolar osteitis prevention by immediate placement of medicated packing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90:282, 2000 6. Field EA, Nind D, Varga E, et al: The effect of chlorhexidine irrigation on the incidence of dry socket: A pilot study. Br J Oral Maxillofac Surg 26:395, 1988 7. Bonnie FL: Effect of chlorhexidine rinse on the incidence of dry socket in impacted mandibular third molar extraction sites. Oral Surg Oral Med Oral Pathol 79:154, 1995 8. Larsen PE: The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg 49: 932, 1991 9. Rango JR, Szkutnik AJ: Evaluation of 0.12% chlorhexidine rinse on the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol 72:524, 1991 10. Fotos P, Koorbusch GF, Sarasin D, et al: Evaluation of intraalveolar chlorhexidine dressing after removal of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol 73:383, 1992 11. Ritzau M, Hillerup S, Branebjerg PE, et al: Does metronidazole prevent alveolitis sicca dolorosa? Int J Oral Maxillofac Surg 21:299, 1992 12. Swanson AE: Prevention of dry socket: An overview. Oral Surg Oral Med Oral Pathol 70:131, 1990 13. Hooley JR, Golden DP: The effect of polylactic acid granules on the incidence of alveolar osteitis after mandibular third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80:279, 1995 14. Hall HD, Bildman BS, Hand CD: Prevention of dry socket with local application of tetracycline. J Oral Surg 29:35, 1971 15. Davis WM Jr, Buchs AU, Davis WM: The use of granular gelatintetracycline compound after third molar removal. J Oral Surg 39:466, 1981 16. Swanson AE: A double-blind study on the effectiveness of tetracycline in reducing the incidence of fibrinolytic alveolitis. J Oral Maxillofac Surg 47:165, 1989 17. Sorensen DC, Preisch J: The effect of tetracycline on the incidence of postextraction alveolar osteitis. J Oral Maxillofac Surg 45:1029, 1987 18. Trieger N, Schlagel GD: Preventing dry socket. A simple procedure. J Am Dent Assoc 122:67, 1991 19. Pankhurst C, Lewis DA, Clark DT, et al: Prophylactic application of an intra-alveolar socket medicament to reduce postextraction complications in HIV-seropositive patients. Oral Surg Oral Med Oral Pathol 77:331, 1994 20. Verbic RL: Local implantation of aureomycin in extraction wounds: A preliminary study. J Am Dent Assoc 46:160, 1953 21. Olech E: Value of implantation of certain chemotherapeutic agents in sockets of impacted lower third molars. J Am Dent Assoc 46:154, 1953 22. Vezeau PJ: Dental extraction wound management: Medicating postextraction sockets. J Oral Maxillofac Surg 58:531, 2000 23. Castellani JE, Harvey S, Erickson SH, et al: Effect of oral contraceptive cycle on dry socket (localized alveolar osteitis). J Am Dent Assoc 101:777, 1980 24. Osborn TP, Frederickson G, Small Y, et al: A prospective study of complications related to mandibular third molar surgery. J Oral Maxillofac Surg 43:767, 1985 25. Chiapasco M, De Cicco L, Marrone G: Side effects and complications associated with molar surgery. Oral Surg Oral Med Oral Pathol 76:412, 1993 26. Meechan JG, Macgregor IDM, Rogers SN, et al: The effect of smoking on immediate post-extraction socket. Br J Oral Maxillofac Surg 26:402, 1988
References 1. Blum IR: Contemporary views on dry socket (alveolar osteitis): A clinical appraisal of standardization, aetiopathogenesis and management: A critical review. Int J Oral Maxillofac Surg 31: 309, 2002
591
SANCHIS ET AL 27. Johnson WS, Blanton EE: An evaluation of 9-aminoacridine/ gelfoam to reduce dry socket formation. Oral Surg Oral Med Oral Pathol 66:167, 1988 28. Alexander-Roger E: Dental extraction wound management: A case against medicating postextraction sockets. J Oral Maxillofac Surg 58:538, 2000 29. Knighton HT: Consideration of topical antibiotic therapy in dentistry. Dent Clin North Am 2:101, 1958 30. Quiley JF, Royer RQ, Gores RJ: “Dry socket” after mandibular odontectomy and use of soluble tetracycline hydrochloride. Oral Surg Oral Med Oral Pathol 13:38, 1960 31. Moore JW, Brekke J: Foreign body giant cell reaction related to
32.
33. 34. 35.
placement of tetracycline-treated polylactic acid: Report of 18 cases. J Oral Maxillofac Surg 48:808, 1990 Eslami A, Van Swol R, Sadeghi EM: Connective tissue reactions to 3% tetracycline ointment in rat skin. J Oral Maxillofac Surg 45:866, 1987 Boyne PJ, Kruger GO: Topical implantation of oxytetracycline cones in extraction sockets. J Am Dent Assoc 64:224, 1962 Zuniga JR, Leist J: Topical tetracycline-induced neuritis: A case report. J Oral Maxillofac Surg 53:196, 1995 Leist JC, Zuniga JR, Gollehons S: Experimental topical tetracycline-induced neuritis in the rat. J Oral Maxillofac Surg 53:427, 1995