YIJOM-2808; No of Pages 5
Int. J. Oral Maxillofac. Surg. 2013; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2013.09.016, available online at http://www.sciencedirect.com
Clinical Paper Oral Surgery
Comparative study of the effect of warm saline mouth rinse on complications after dental extractions
O. D. Osunde1,2, R. A. Adebola2, J. B. Adeoye2, G. O. Bassey1 1
Department of Oral and Maxillofacial Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria; 2Department of Dental and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
O.D. Osunde, R.A. Adebola, J.B. Adeoye, G.O. Bassey: Comparative study of the effect of warm saline mouth rinse on complications after dental extractions. Int. J. Oral Maxillofac. Surg. 2013; xxx: xxx–xxx. # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The aim of the present study was to determine the effect of saline mouth rinse on postoperative complications following routine dental extractions. Patients aged 16 years, who were referred to the oral surgery clinic with an indication for non-surgical extraction of pathologic teeth, were prospectively and uniformly randomized into three groups. Group A (n = 40) were instructed to gargle six times daily with warm saline and group B (n = 40) twice daily; group C (n = 40) were not instructed to gargle with warm saline and served as controls. Information on demographic characteristics, indications for extraction, and the development of complications, such as alveolar osteitis, acute inflamed socket, and acute infected socket, was obtained and analyzed. There were no significant differences between patients who gargled six times daily with warm saline and those who gargled twice daily with reference to either alveolar osteitis or acute inflamed socket (P > 0.05). However saline mouth rinses at either frequency were beneficial in the prevention of alveolar osteitis in comparison with those who did not rinse. A twice-daily saline mouth rinse regimen is more convenient, and patient compliance may be better than with a six times daily rinse regimen.
The use of warm saline rinse is commonly included in the instructions given to the patient by the dentist post-extraction, and this is also the case in Nigeria. Patients are usually instructed to gargle six to eight times daily for about a week. The warm saline rinse is prepared by dissolving one level teaspoon of salt in a glass of warm water (300–350 ml), thus producing a hypertonic solution that is believed to be bacteriostatic.1 The 0901-5027/000001+05 $36.00/0
warm saline rinse is also thought to promote uncomplicated healing via vasodilatation, thereby bringing phagocytes to the extraction site. However, an objective assessment of the efficacy of this agent is lacking, as revealed by a literature search. In fact, several electronic searches were done using the search terms ‘warm saline mouth rinse’, ‘warm saline gargle’, and ‘post-extraction instructions’ in PubMed,
Key words: warm saline rinse; complications; dental extractions. Accepted for publication 18 September 2013
Medline, Cochrane Library, and HINARI. A manual search of textbooks including lecture notes was also performed. The search yielded very little or no information on warm saline mouth wash and oral surgical procedures. In addition, the few publications that did mention the use of warm saline rinsing after dental extractions did not state the optimum number of gargles/day or the optimum duration of treatment for maximum benefit.2–5
# 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Osunde OD, et al. Comparative study of the effect of warm saline mouth rinse on complications after dental extractions, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.09.016
YIJOM-2808; No of Pages 5
2
Osunde et al.
The use of warm saline rinse, even with all its acclaimed benefits, is not evidencebased. Anecdotal evidence has revealed that patients who have defaulted in terms of outright disregard for the instruction, in the number of gargles/day, or in the duration of use, have not suffered any complication, such as delayed healing, severe pain, or alveolar osteitis. Anecdotal evidence has also revealed that this practice is not promoted by dentists in some parts of the world. In addition, strict adherence to the instruction to use warm saline rinse may not be feasible for some, as patients are expected to gargle before and after every meal; no consideration is given to the patient’s social activities or the patient’s occupation. The aim of this study was to determine the beneficial effect of different warm saline rinse regimens on the development of alveolar osteitis, acute inflamed socket, and acute infected socket following routine dental extraction.
Materials and methods
This was a randomized prospective singleblind study conducted in a dental and maxillofacial surgery department. Patients referred to the department with an indication for the non-surgical extraction of their pathologic teeth were selected and consecutively randomized into three treatment groups. The study protocol was approved by the institutional ethics committee. Details of the study, including the possible complications, were adequately explained to the selected patients who gave written informed consent for study participation. Our inclusion criteria were: healthy patients, aged 16 years and above, who presented consecutively to the dental and maxillofacial surgery department with a clear indication for dental extraction within the study period. Patients with a history of an underlying systemic abnormality, such as uncontrolled diabetes mellitus, sickle cell disease, renal disease, or another immunosuppressive condition, as well as smokers and women on oral contraceptives, were excluded. Also excluded were patients on steroid medications, immunosuppressive therapy, those with previous radiotherapy to the head and neck region, and patients with a dentoalveolar abscess or facial cellulitis. Patients who had undergone a previous dental extraction and so may have been familiar with the warm saline rinse instructions were also excluded.
Randomization
Statistical analysis
The patients were selected consecutively as they presented and were randomized to one of three groups, A, B, and C. Patients in group A were instructed to gargle with warm saline six times daily and group B to gargle twice daily; group C were not instructed to use warm saline rinse and served as controls.
The data collected were analyzed using SPSS version 13 (SPSS Inc., Chicago, IL, USA). Analysis included mean, standard deviation, frequency distribution, and cross-tabulation. Comparative statistics was done using the Chi-square test, nonparametric Kruskal–Wallis test, or Mann– Whitney U-test, as appropriate. A P-value of less than 0.05 was considered significant.
Surgical protocol
Dental extractions were performed by general dental practice and dental surgery residents in their second year of training. It was assumed that these groups of residents would have the same level of surgical experience. All extractions were carried out within the duration of 15 min, and patients whose procedures lasted over 20 min were excluded. All patients received the same oral antibiotics (amoxicillin 500 mg 8-hourly and metronidazole 200 mg 8-hourly for 5 days) and analgesics, and similar postoperative instructions, except that the warm saline rinses varied depending on the treatment group, as outlined above. The control group did not receive any instruction on the use of warm saline rinse. The warm saline groups were instructed to commence rinsing 24 h from the time of completion of the procedure. Patients were advised to adhere strictly to the instructions and to return to the clinic 72 h post-extraction for evaluation. Patients were also advised to report to the clinic on any other day in the case of other untoward events or perceived discomfort related to the surgical procedure. Post-extraction evaluation
The patients were evaluated 72 h postoperatively for the presence of alveolar osteitis, acute inflamed socket, and acute infected socket, by an independent observer who was blinded to the treatment group. Using the assessment parameters reported by Chuang et al.6 for postsurgical complications following tooth extraction, acute inflamed socket was diagnosed as a painful socket, red and swollen, without pus or systemic fever, presenting within 48–72 h after surgery; acute infected socket was diagnosed when there was redness, swelling, and discharging pus or systemic fever presenting within the same duration as above. Alveolar osteitis was diagnosed on the basis of persistent throbbing pain and exposure of bare alveolar bone, usually presenting within 48– 72 h post dental extraction.
Results
A total number of 120 patients equally distributed among the study groups participated in the study. Fifty-two were males (43.3%) and 68 were females (56.7%), and they ranged in age from 17 to 45 years (mean 29.13 5.23 years). Caries-related sequelae (n = 99; 82.5%) were the most common indications for extraction. Other indications were chronic periodontitis (n = 5; 4.2%), failed restoration (n = 3; 2.5%), fractured tooth (n = 8; 6.7%), and prosthetic (n = 3; 2.5%) and orthodontic reasons (n = 2; 1.7%) (Table 1). The demographic and baseline parameters, such as indication for extraction, were comparable among the study groups (P > 0.05) (Table 1). The overall prevalence of alveolar osteitis was 10.0% and that of acute inflamed socket was 25.0%. No case of acute infected socket was observed across the different study groups. There were no significant differences between the maxilla and mandible (x2 = 0.19, df = 1, P = 0.49), or between the anterior and posterior teeth (x2 = 0.21, df = 1, P = 0.54) with respect to the occurrence of alveolar osteitis. There was a statistically significant difference among the study groups with respect to the development of alveolar osteitis (x2 = 15.43, df = 2, P = 0.001), but not for acute inflamed socket (x2 = 3.44; df = 2; P = 0.179) (Table 2). The development of alveolar osteitis among the three study groups is represented graphically in Fig. 1. While the development of alveolar osteitis was remarkable in the control group, less alveolar osteitis was recorded in the warm saline groups (P < 0.001) (Table 3). This shows some beneficial effect of warm saline mouth gargle in preventing the development of alveolar osteitis. In contrast, warm saline rinse did not play any significant role in preventing the development of acute inflamed socket (Table 3). There were no significant differences between patients who gargled six times daily with warm saline and those who
Please cite this article in press as: Osunde OD, et al. Comparative study of the effect of warm saline mouth rinse on complications after dental extractions, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.09.016
YIJOM-2808; No of Pages 5
Warm saline mouth rinse after dental extractions
3
Table 1. Demographic characteristics and indications for extraction in the three study groups. Warm saline mouth rinse
Variables None
Total
Two times daily
Six times daily
Percentage (%)
Gender Male Female Total x2 = 0.27; df = 2; P = 0.87
18 22 40
16 24 40
18 22 40
52 68 120
43.3 56.7 100.0
Age group, years 16–25 26–35 36–45 Total x2 = 3.96; df = 4; P = 0.41
5 32 3 40
12 25 3 40
9 27 4 40
26 84 10 120
21.7 70.0 8.3 100.0
Indications Apical periodontitis Unrestorable caries Irreversible pulpitis Chronic periodontitis Failed restoration Fractured tooth Prosthetic reason Orthodontic reason Total 2 x = 5.15; df = 10; P = 0.88
26 2 4 2 1 3 1 1 40
29 0 3 2 1 2 2 1 40
30 1 4 1 1 3 0 0 40
85 3 11 5 3 8 3 2 120
70.8 2.5 9.2 4.2 2.5 6.7 2.5 1.7 100.1
Table 2. Comparative statistics for the development of complications among the three study groups. Acute inflamed socket
Alveolar osteitis
Acute infected socket
*
Mean rank
x2
df
P-value
None Six times daily Two times daily
65.00 54.50 62.00
3.44
2
0.179
None Six times daily Two times daily
69.50 54.50 57.50
15.43
2
0.001*
None Six times daily Two times daily
60.50 60.50 60.50
2
1.000
Warm saline group
Complication
0.000
Significant.
gargled twice daily with reference to either alveolar osteitis or acute inflamed socket (P > 0.05) (Table 4). Discussion
This study evaluated the efficacy of different warm saline mouth rinse regimens on the prevention of alveolar osteitis after
routine extractions. A null hypothesis that warm saline mouth rinse is not beneficial in preventing alveolar osteitis, acute inflamed socket, and acute infected socket was formulated. Alveolar osteitis is a very common postextraction complication, its incidence following routine extraction of any teeth being around 1–70%, and following
Table 3. Comparative statistics for the development of complications in the warm saline group (n = 80) versus the control group (n = 40). Complication
Warm saline
Control
x2
P-value
Alveolar osteitis Yes No
2 78
10 30
15.00
0.001*
Acute inflamed socket Yes No
13 67
17 23
1.80
0.1800
*
Significant.
surgical extraction of impacted third molars, between 20% and 30%.2,7–9 The overall prevalence of 10% observed in this study is consistent with published reports, but was found to occur predominantly in the group not instructed to rinse with warm saline; alveolar osteitis was recorded less in the warm saline groups. This difference was statistically significant (P < 0.001) and thus shows some beneficial effect of warm saline mouth rinse on the prevention of the development of alveolar osteitis. In contrast, the difference between the scores for acute inflamed socket was not significant between patients instructed to use warm saline rinse and controls. Acute inflamed socket is a normal sequelae of inflammatory changes following the trauma associated with exodontia and it resolves on its own without any intervention.
Please cite this article in press as: Osunde OD, et al. Comparative study of the effect of warm saline mouth rinse on complications after dental extractions, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.09.016
YIJOM-2808; No of Pages 5
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Osunde et al.
Table 4. Comparative statistics for the development of complications with the six-times and twice-daily warm saline rinse regimens. Complication
Warm saline group
Mean rank
Mann–Whitney U-test
Z
P-value
Acute inflamed socket
Six times daily Two times daily
38.0 43.0
700.000
1.358
0.174
Alveolar osteitis
Six times daily Two times daily
39.50 41.50
760.000
1.423
0.155
Acute infected socket
Six times daily Two times daily
40.50 40.50
800.000
0.000
1.000
In an extensive review of the concepts and controversies of alveolar osteitis, Kolokythas et al. did not include warm saline mouth rinse as one of the measures to prevent this complication.10 Some authors, however, have recommended warm saline oral rinse as one of the ways to prevent the development of alveolar osteitis and to promote a smooth recovery after dental extraction.2–5 There is no agreement in the standard post-extraction instructions on the warm saline rinse regime that provides the optimum benefit, with the frequency ranging from 6 to 10 times daily.1,3 This study compared a twice-daily regimen and the conventional six times daily warm saline mouth rinse regimen and found essentially no difference with respect to the development of alveolar osteitis and acute inflamed socket among the study participants (P > 0.05). Gargling before and after every meal is burdensome for the patient and strict adherence to this instruction may not be feasible for some patients because of their social activities and the nature of their work. Twice-daily saline mouth rinsing is a more convenient regimen and patient compliance may be better than with the six times daily rinse routine.
The literature is replete with other methods for minimizing the incidence of alveolar osteitis, including chlorhexidine mouth rinse,4,9,11 systemic and topiantibiotics,12–14 fibrinolytic cal agents,15,16 local antiseptic packs,17,18 and others.19 Although the present study did not compare the efficacy of warm saline rinse with other described modalities, in particular 0.12% chlorhexidine solution, which appears most popular, Delilbasi et al.11 found similar percentages of alveolar osteitis using mouthwashes of warm saline and 0.2% chlorhexidine (23.7% vs. 20.9%). The use of warm saline mouth rinse is a viable option, especially in a resource-limited setting like Nigeria and other parts of Africa, because it is cheap, readily available, and is easy to prepare. The instruction to use warm saline mouth rinse is beneficial in the prevention of alveolar osteitis after dental extractions. There is no significant difference in the efficacy of the twice-daily warm saline mouth rinse regimen compared to the six times daily regimen. The twice-daily saline mouth rinse regimen is more convenient, and patient compliance may be better than with the six times daily rinse routine.
Fig. 1. Box-plot showing the development of alveolar osteitis among the study groups. Note the similarity between the two times daily and six times daily warm saline rinse groups.
Funding
No external sources of funding. Competing interests
None. Ethical approval
Ethical approval given: AKTH/MAC/ SUB/12/P3/IV/689. References 1. Alling CC, Helfrick JF, Alling RD. Impacted teeth. Philadelphia: WB Saunders; 1993 : 193. 2. Benediktsdottir IE, Wenzel A, Petersen JK, Hintze H. Mandibular third molar removal: risk indicators for extended operation time, post operative pain and complications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;79:434–46. 3. Alling CC, Catone GA. Management of impacted teeth. J Oral Maxillofac Surg 1993;51(Suppl. 1):3–6. 4. Caso A, Hung LK, Bierne OR. Prevention of alveolar osteitis with chlorhexidine: a metaanalytic review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:155–9. 5. Jerjes W, El-Maaytah M, Swinson B, Banu B, Upile T, D’Sa S, Al-Khawalde M, Chaib B, Hopper C. Experience versus complication rate in third molar surgery. Head Face Med 2006;2:14. 6. Chuang S, Perrott DH, Susarla SM, Dodson TB. Age as a risk factor for third molar complications. J Oral Maxillofac Surg 2007;65:1685–92. 7. Berwick JE, Lessin ME. Effects of chlorhexidine gluconate oral rinse on the incidence of alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg 1990;48: 444–8. 8. Larsen PE. Alveolar osteitis after surgical removal of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol 93–7. 1992;73: 9. Ragno Jr JR, Szkutnik AJ. Evaluation of 0.12% chlorhexidine rinse on the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol 1991;72:524–6. 10. Kolokythas A, Olech E, Miloro M. Alveolar osteitis: a comprehensive review of concepts
Please cite this article in press as: Osunde OD, et al. Comparative study of the effect of warm saline mouth rinse on complications after dental extractions, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.09.016
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Warm saline mouth rinse after dental extractions and controversies. Int J Dent 2010; 2010:2490–573. 11. Delilbasi C, Saracoglu U, Keskin A. Effects of 0.2% chlorhexidine gluconate and amoxicillin plus clavulanic acid on the prevention of alveolar osteitis following mandibular third molar extractions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:301–4. 12. Ritzau M, Hillerup S, Branebjerg PE, Ersbol BK. Does metronidazole prevent alveolitis sicca dolorosa?. A double-blind placebocontrolled clinical study. Int J Oral Maxillofac Surg 1992;21:299–302. 13. Sorenson DC, Preisch J. The effect of tetracycline on the incidence of postextraction alveolar osteitis. J Oral Maxillofac Surg 1987;45:1029–33.
14. Trieger N, Schlagel GD. Preventing dry socket. A simple procedure that works. J Am Dent Assoc 1991;122:67–8. 15. Schatz JP, Fiore-Donno G, Henning G. Fibrinolytic alveolitis and its prevention. Int J Oral Maxillofac Surg 1987;16:175–83. 16. Gersel-Pedersen N. Tranexamic acid in alveolar sockets in the prevention of alveolitis sicca dolorosa. Int J Oral Surg 1979;8:421–9. 17. Fotos P, Koorbusch GF, Sarasin DS, Kist RJ. Evaluation of intra-alveolar chlorhexidine dressing after removal of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol 1992;73:383–8. 18. Torres-Lagares D, Guttierez-Perez JL, Infante-Cossio P, Garcia-Calderon M, Romero-Ruiz MM, Serrera-Figallo MA. Randomized, double-blind study on effectiveness
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of intra-alveolar chlorhexidine gel in reducing the incidence of alveolar osteitis in mandibular third molar surgery. Int J Oral Maxillofac Surg 2006;35:348–51. 19. Poor MR, Hall JE, Poor AS. Reduction in the incidence of alveolar osteitis in patients treated with Salicept patch. J Oral Maxillofac Surg 2002;60:373–9.
Address: Otasowie D. Osunde Department of Oral and Maxillofacial Surgery University of Calabar Teaching Hospital Calabar Nigeria Tel: +234 8034529092 E-mail: [email protected]
Please cite this article in press as: Osunde OD, et al. Comparative study of the effect of warm saline mouth rinse on complications after dental extractions, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.09.016
Int. J. Oral Maxillofac. Surg. 2013; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2013.09.016, available online at http://www.sciencedirect.com
Clinical Paper Oral Surgery
Comparative study of the effect of warm saline mouth rinse on complications after dental extractions
O. D. Osunde1,2, R. A. Adebola2, J. B. Adeoye2, G. O. Bassey1 1
Department of Oral and Maxillofacial Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria; 2Department of Dental and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
O.D. Osunde, R.A. Adebola, J.B. Adeoye, G.O. Bassey: Comparative study of the effect of warm saline mouth rinse on complications after dental extractions. Int. J. Oral Maxillofac. Surg. 2013; xxx: xxx–xxx. # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The aim of the present study was to determine the effect of saline mouth rinse on postoperative complications following routine dental extractions. Patients aged 16 years, who were referred to the oral surgery clinic with an indication for non-surgical extraction of pathologic teeth, were prospectively and uniformly randomized into three groups. Group A (n = 40) were instructed to gargle six times daily with warm saline and group B (n = 40) twice daily; group C (n = 40) were not instructed to gargle with warm saline and served as controls. Information on demographic characteristics, indications for extraction, and the development of complications, such as alveolar osteitis, acute inflamed socket, and acute infected socket, was obtained and analyzed. There were no significant differences between patients who gargled six times daily with warm saline and those who gargled twice daily with reference to either alveolar osteitis or acute inflamed socket (P > 0.05). However saline mouth rinses at either frequency were beneficial in the prevention of alveolar osteitis in comparison with those who did not rinse. A twice-daily saline mouth rinse regimen is more convenient, and patient compliance may be better than with a six times daily rinse regimen.
The use of warm saline rinse is commonly included in the instructions given to the patient by the dentist post-extraction, and this is also the case in Nigeria. Patients are usually instructed to gargle six to eight times daily for about a week. The warm saline rinse is prepared by dissolving one level teaspoon of salt in a glass of warm water (300–350 ml), thus producing a hypertonic solution that is believed to be bacteriostatic.1 The 0901-5027/000001+05 $36.00/0
warm saline rinse is also thought to promote uncomplicated healing via vasodilatation, thereby bringing phagocytes to the extraction site. However, an objective assessment of the efficacy of this agent is lacking, as revealed by a literature search. In fact, several electronic searches were done using the search terms ‘warm saline mouth rinse’, ‘warm saline gargle’, and ‘post-extraction instructions’ in PubMed,
Key words: warm saline rinse; complications; dental extractions. Accepted for publication 18 September 2013
Medline, Cochrane Library, and HINARI. A manual search of textbooks including lecture notes was also performed. The search yielded very little or no information on warm saline mouth wash and oral surgical procedures. In addition, the few publications that did mention the use of warm saline rinsing after dental extractions did not state the optimum number of gargles/day or the optimum duration of treatment for maximum benefit.2–5
# 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Osunde OD, et al. Comparative study of the effect of warm saline mouth rinse on complications after dental extractions, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.09.016
YIJOM-2808; No of Pages 5
2
Osunde et al.
The use of warm saline rinse, even with all its acclaimed benefits, is not evidencebased. Anecdotal evidence has revealed that patients who have defaulted in terms of outright disregard for the instruction, in the number of gargles/day, or in the duration of use, have not suffered any complication, such as delayed healing, severe pain, or alveolar osteitis. Anecdotal evidence has also revealed that this practice is not promoted by dentists in some parts of the world. In addition, strict adherence to the instruction to use warm saline rinse may not be feasible for some, as patients are expected to gargle before and after every meal; no consideration is given to the patient’s social activities or the patient’s occupation. The aim of this study was to determine the beneficial effect of different warm saline rinse regimens on the development of alveolar osteitis, acute inflamed socket, and acute infected socket following routine dental extraction.
Materials and methods
This was a randomized prospective singleblind study conducted in a dental and maxillofacial surgery department. Patients referred to the department with an indication for the non-surgical extraction of their pathologic teeth were selected and consecutively randomized into three treatment groups. The study protocol was approved by the institutional ethics committee. Details of the study, including the possible complications, were adequately explained to the selected patients who gave written informed consent for study participation. Our inclusion criteria were: healthy patients, aged 16 years and above, who presented consecutively to the dental and maxillofacial surgery department with a clear indication for dental extraction within the study period. Patients with a history of an underlying systemic abnormality, such as uncontrolled diabetes mellitus, sickle cell disease, renal disease, or another immunosuppressive condition, as well as smokers and women on oral contraceptives, were excluded. Also excluded were patients on steroid medications, immunosuppressive therapy, those with previous radiotherapy to the head and neck region, and patients with a dentoalveolar abscess or facial cellulitis. Patients who had undergone a previous dental extraction and so may have been familiar with the warm saline rinse instructions were also excluded.
Randomization
Statistical analysis
The patients were selected consecutively as they presented and were randomized to one of three groups, A, B, and C. Patients in group A were instructed to gargle with warm saline six times daily and group B to gargle twice daily; group C were not instructed to use warm saline rinse and served as controls.
The data collected were analyzed using SPSS version 13 (SPSS Inc., Chicago, IL, USA). Analysis included mean, standard deviation, frequency distribution, and cross-tabulation. Comparative statistics was done using the Chi-square test, nonparametric Kruskal–Wallis test, or Mann– Whitney U-test, as appropriate. A P-value of less than 0.05 was considered significant.
Surgical protocol
Dental extractions were performed by general dental practice and dental surgery residents in their second year of training. It was assumed that these groups of residents would have the same level of surgical experience. All extractions were carried out within the duration of 15 min, and patients whose procedures lasted over 20 min were excluded. All patients received the same oral antibiotics (amoxicillin 500 mg 8-hourly and metronidazole 200 mg 8-hourly for 5 days) and analgesics, and similar postoperative instructions, except that the warm saline rinses varied depending on the treatment group, as outlined above. The control group did not receive any instruction on the use of warm saline rinse. The warm saline groups were instructed to commence rinsing 24 h from the time of completion of the procedure. Patients were advised to adhere strictly to the instructions and to return to the clinic 72 h post-extraction for evaluation. Patients were also advised to report to the clinic on any other day in the case of other untoward events or perceived discomfort related to the surgical procedure. Post-extraction evaluation
The patients were evaluated 72 h postoperatively for the presence of alveolar osteitis, acute inflamed socket, and acute infected socket, by an independent observer who was blinded to the treatment group. Using the assessment parameters reported by Chuang et al.6 for postsurgical complications following tooth extraction, acute inflamed socket was diagnosed as a painful socket, red and swollen, without pus or systemic fever, presenting within 48–72 h after surgery; acute infected socket was diagnosed when there was redness, swelling, and discharging pus or systemic fever presenting within the same duration as above. Alveolar osteitis was diagnosed on the basis of persistent throbbing pain and exposure of bare alveolar bone, usually presenting within 48– 72 h post dental extraction.
Results
A total number of 120 patients equally distributed among the study groups participated in the study. Fifty-two were males (43.3%) and 68 were females (56.7%), and they ranged in age from 17 to 45 years (mean 29.13 5.23 years). Caries-related sequelae (n = 99; 82.5%) were the most common indications for extraction. Other indications were chronic periodontitis (n = 5; 4.2%), failed restoration (n = 3; 2.5%), fractured tooth (n = 8; 6.7%), and prosthetic (n = 3; 2.5%) and orthodontic reasons (n = 2; 1.7%) (Table 1). The demographic and baseline parameters, such as indication for extraction, were comparable among the study groups (P > 0.05) (Table 1). The overall prevalence of alveolar osteitis was 10.0% and that of acute inflamed socket was 25.0%. No case of acute infected socket was observed across the different study groups. There were no significant differences between the maxilla and mandible (x2 = 0.19, df = 1, P = 0.49), or between the anterior and posterior teeth (x2 = 0.21, df = 1, P = 0.54) with respect to the occurrence of alveolar osteitis. There was a statistically significant difference among the study groups with respect to the development of alveolar osteitis (x2 = 15.43, df = 2, P = 0.001), but not for acute inflamed socket (x2 = 3.44; df = 2; P = 0.179) (Table 2). The development of alveolar osteitis among the three study groups is represented graphically in Fig. 1. While the development of alveolar osteitis was remarkable in the control group, less alveolar osteitis was recorded in the warm saline groups (P < 0.001) (Table 3). This shows some beneficial effect of warm saline mouth gargle in preventing the development of alveolar osteitis. In contrast, warm saline rinse did not play any significant role in preventing the development of acute inflamed socket (Table 3). There were no significant differences between patients who gargled six times daily with warm saline and those who
Please cite this article in press as: Osunde OD, et al. Comparative study of the effect of warm saline mouth rinse on complications after dental extractions, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.09.016
YIJOM-2808; No of Pages 5
Warm saline mouth rinse after dental extractions
3
Table 1. Demographic characteristics and indications for extraction in the three study groups. Warm saline mouth rinse
Variables None
Total
Two times daily
Six times daily
Percentage (%)
Gender Male Female Total x2 = 0.27; df = 2; P = 0.87
18 22 40
16 24 40
18 22 40
52 68 120
43.3 56.7 100.0
Age group, years 16–25 26–35 36–45 Total x2 = 3.96; df = 4; P = 0.41
5 32 3 40
12 25 3 40
9 27 4 40
26 84 10 120
21.7 70.0 8.3 100.0
Indications Apical periodontitis Unrestorable caries Irreversible pulpitis Chronic periodontitis Failed restoration Fractured tooth Prosthetic reason Orthodontic reason Total 2 x = 5.15; df = 10; P = 0.88
26 2 4 2 1 3 1 1 40
29 0 3 2 1 2 2 1 40
30 1 4 1 1 3 0 0 40
85 3 11 5 3 8 3 2 120
70.8 2.5 9.2 4.2 2.5 6.7 2.5 1.7 100.1
Table 2. Comparative statistics for the development of complications among the three study groups. Acute inflamed socket
Alveolar osteitis
Acute infected socket
*
Mean rank
x2
df
P-value
None Six times daily Two times daily
65.00 54.50 62.00
3.44
2
0.179
None Six times daily Two times daily
69.50 54.50 57.50
15.43
2
0.001*
None Six times daily Two times daily
60.50 60.50 60.50
2
1.000
Warm saline group
Complication
0.000
Significant.
gargled twice daily with reference to either alveolar osteitis or acute inflamed socket (P > 0.05) (Table 4). Discussion
This study evaluated the efficacy of different warm saline mouth rinse regimens on the prevention of alveolar osteitis after
routine extractions. A null hypothesis that warm saline mouth rinse is not beneficial in preventing alveolar osteitis, acute inflamed socket, and acute infected socket was formulated. Alveolar osteitis is a very common postextraction complication, its incidence following routine extraction of any teeth being around 1–70%, and following
Table 3. Comparative statistics for the development of complications in the warm saline group (n = 80) versus the control group (n = 40). Complication
Warm saline
Control
x2
P-value
Alveolar osteitis Yes No
2 78
10 30
15.00
0.001*
Acute inflamed socket Yes No
13 67
17 23
1.80
0.1800
*
Significant.
surgical extraction of impacted third molars, between 20% and 30%.2,7–9 The overall prevalence of 10% observed in this study is consistent with published reports, but was found to occur predominantly in the group not instructed to rinse with warm saline; alveolar osteitis was recorded less in the warm saline groups. This difference was statistically significant (P < 0.001) and thus shows some beneficial effect of warm saline mouth rinse on the prevention of the development of alveolar osteitis. In contrast, the difference between the scores for acute inflamed socket was not significant between patients instructed to use warm saline rinse and controls. Acute inflamed socket is a normal sequelae of inflammatory changes following the trauma associated with exodontia and it resolves on its own without any intervention.
Please cite this article in press as: Osunde OD, et al. Comparative study of the effect of warm saline mouth rinse on complications after dental extractions, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.09.016
YIJOM-2808; No of Pages 5
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Osunde et al.
Table 4. Comparative statistics for the development of complications with the six-times and twice-daily warm saline rinse regimens. Complication
Warm saline group
Mean rank
Mann–Whitney U-test
Z
P-value
Acute inflamed socket
Six times daily Two times daily
38.0 43.0
700.000
1.358
0.174
Alveolar osteitis
Six times daily Two times daily
39.50 41.50
760.000
1.423
0.155
Acute infected socket
Six times daily Two times daily
40.50 40.50
800.000
0.000
1.000
In an extensive review of the concepts and controversies of alveolar osteitis, Kolokythas et al. did not include warm saline mouth rinse as one of the measures to prevent this complication.10 Some authors, however, have recommended warm saline oral rinse as one of the ways to prevent the development of alveolar osteitis and to promote a smooth recovery after dental extraction.2–5 There is no agreement in the standard post-extraction instructions on the warm saline rinse regime that provides the optimum benefit, with the frequency ranging from 6 to 10 times daily.1,3 This study compared a twice-daily regimen and the conventional six times daily warm saline mouth rinse regimen and found essentially no difference with respect to the development of alveolar osteitis and acute inflamed socket among the study participants (P > 0.05). Gargling before and after every meal is burdensome for the patient and strict adherence to this instruction may not be feasible for some patients because of their social activities and the nature of their work. Twice-daily saline mouth rinsing is a more convenient regimen and patient compliance may be better than with the six times daily rinse routine.
The literature is replete with other methods for minimizing the incidence of alveolar osteitis, including chlorhexidine mouth rinse,4,9,11 systemic and topiantibiotics,12–14 fibrinolytic cal agents,15,16 local antiseptic packs,17,18 and others.19 Although the present study did not compare the efficacy of warm saline rinse with other described modalities, in particular 0.12% chlorhexidine solution, which appears most popular, Delilbasi et al.11 found similar percentages of alveolar osteitis using mouthwashes of warm saline and 0.2% chlorhexidine (23.7% vs. 20.9%). The use of warm saline mouth rinse is a viable option, especially in a resource-limited setting like Nigeria and other parts of Africa, because it is cheap, readily available, and is easy to prepare. The instruction to use warm saline mouth rinse is beneficial in the prevention of alveolar osteitis after dental extractions. There is no significant difference in the efficacy of the twice-daily warm saline mouth rinse regimen compared to the six times daily regimen. The twice-daily saline mouth rinse regimen is more convenient, and patient compliance may be better than with the six times daily rinse routine.
Fig. 1. Box-plot showing the development of alveolar osteitis among the study groups. Note the similarity between the two times daily and six times daily warm saline rinse groups.
Funding
No external sources of funding. Competing interests
None. Ethical approval
Ethical approval given: AKTH/MAC/ SUB/12/P3/IV/689. References 1. Alling CC, Helfrick JF, Alling RD. Impacted teeth. Philadelphia: WB Saunders; 1993 : 193. 2. Benediktsdottir IE, Wenzel A, Petersen JK, Hintze H. Mandibular third molar removal: risk indicators for extended operation time, post operative pain and complications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;79:434–46. 3. Alling CC, Catone GA. Management of impacted teeth. J Oral Maxillofac Surg 1993;51(Suppl. 1):3–6. 4. Caso A, Hung LK, Bierne OR. Prevention of alveolar osteitis with chlorhexidine: a metaanalytic review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:155–9. 5. Jerjes W, El-Maaytah M, Swinson B, Banu B, Upile T, D’Sa S, Al-Khawalde M, Chaib B, Hopper C. Experience versus complication rate in third molar surgery. Head Face Med 2006;2:14. 6. Chuang S, Perrott DH, Susarla SM, Dodson TB. Age as a risk factor for third molar complications. J Oral Maxillofac Surg 2007;65:1685–92. 7. Berwick JE, Lessin ME. Effects of chlorhexidine gluconate oral rinse on the incidence of alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg 1990;48: 444–8. 8. Larsen PE. Alveolar osteitis after surgical removal of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol 93–7. 1992;73: 9. Ragno Jr JR, Szkutnik AJ. Evaluation of 0.12% chlorhexidine rinse on the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol 1991;72:524–6. 10. Kolokythas A, Olech E, Miloro M. Alveolar osteitis: a comprehensive review of concepts
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Address: Otasowie D. Osunde Department of Oral and Maxillofacial Surgery University of Calabar Teaching Hospital Calabar Nigeria Tel: +234 8034529092 E-mail: [email protected]
Please cite this article in press as: Osunde OD, et al. Comparative study of the effect of warm saline mouth rinse on complications after dental extractions, Int J Oral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.ijom.2013.09.016
