J Oral Maxillofac
Surg
45:444-441990
Effects of a Chlorhexidine Gluconate Oral Rinse on the incidence of Alveolar Osteitis in Mandibular Third Molar Surgery MAJ JAMES E. BERWICK, DDS,* AND COL MICHAEL
E. LESSIN, DDSt
Alveolar osteitis (dry socket) continues to be a frequent sequela of third molar surgery. Chlorhexidine 0.12% used as an oral rinse has been reported to reduce the incidence of dry socket. This study compares the effectiveness of 0.12% chlorhexidine used as a preoperative rinse and immediate postextraction irrigant with 1) similarly used 0.05% cetylpyridium, preoperative chlorhexidine rinse and postextraction saline irrigation, and 2) only postextraction irrigation with normal saline in the reduction of alveolar osteitis in mandibular third molar extractions. The results indicate that chlorhexidine and cetylpyridium were no more effective in the reduction of alveolar osteitis than postextraction irrigation with normal saline.
Alveolar osteitis (dry socket), as first described by Crawford’ in 1896 continues to be a common complication of the extraction of teeth. The clinical presentation is classic but subjective. The patient complains of throbbing pain not relieved by analgesics which develops or persists several days following surgery. The patient typically has fetid breath. Inspection of the surgical site reveals a partially or completely denuded alveolus. The alveolus may be covered by necrotic debris, but the presence of an organizing blood clot is conspicuously absent. The etiology and pathogenesis of alveolar osteitis
have been the subject of much study and debate since the condition was first recognized. Despite this, no model of pathogenesis or etiologic factor is accepted universally as the basis for generation of alveolar osteitis. Birn’s studies,* which attribute alveolar osteitis or fibrinolytic alveolitis to increased fibrinolytic activity within the alveolus and clot are the most widely accepted. The etiology of alveolar osteitis has variously been attributed to inadequacy of blood supply to the alveolus3 trauma to the alveolus,4 infection,5,6 fibrinolytic activity,2 and a variety of other less likely initiating factors including seasonal variation, nutrition, excessive bleeding, and choice of anesthetic. Studies on the incidence and distribution of alveolar osteitis show that it occurs in from O.5%7 to 68.4%’ of all extractions, with an average of about 3%.279*10 Alveolar osteitis occurs much more frequently after the extraction of mandibular teeth and most frequently with mandibular third molars.5,9-‘1 The peak age of occurrence is from 20 to 40 years, alveolar osteitis being relatively rare in the young and the old. Numerous agents and methods have been used to prevent alveolar osteitis and its attendant morbidity. Antibiotics have been used with some effec-
* Chief, Oral and Maxillofacial Surgery Service, Gorgas Army Hospital, Panama. t Formerly, Chief, Oral and Maxillofacial Surgery Service and Director of Residency Training, Brooke Army Medical Center, Fort Sam Houston, TX; currently, Associate in Oral and Maxillofacial Surgery at Geisinger Medical Center, Danville, PA. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Address correspondence and reprint requests to MAJ Berwick: PSC 3001, APO Miami, FL 34092. 0 1990 American
Association
of Oral
and Maxillofacial
Sur-
geons 0278-2391/90/4805-0002$3.00/O
444
BERWICK
AND LESSIN
tiveness,i2.13 the rationale being that infection is the etiologic factor in the genesis of alveolar osteitis. Antifibrinolytics2,i4 and anti-inflammatory agents13 have been used with mixed results in an effort to stabilize the clot. Other studies have shown that improving hygiene and the use of antimicrobial rinses have been effective in reducing the incidence of alveolar osteitis in some cases.15-20 If infection of the surgical wound and subsequent fibrinolysis due to bacterial initiation is important in the generation of alveolar osteitis, then an antimicrobial rinse and lavage agent should be effective in the reduction of the incidence of alveolar osteitis. Lilly et al” demonstrated a reduction of alveolar osteitis incidence using an antiseptic mouthwash (Chloraseptic, Proctor and Gamble, Cincinnati, OH) and irrigation. Chlorhexidine gluconate as a mouthwash has been demonstrated to significantly reduce the bacterial population of both anaerobic and aerobic bacteria.16 Several previous studies have shown chlorhexidine gluconate 0.2% mouthwashes alone, or in combination with dental prophylaxis, to be effective in the reduction of alveolar osteitis.“j-*’ A study by MacGregor and Hart,*l however, found chlorhexidine 0.5% used locally over the surgical site to be ineffective in preventing third molar surgery complications. The purpose of this investigation was to study the prophylactic value of a commercially available 0.12% chlorhexidine mouthwash (Peridex, Proctor and Gamble) used as a preoperative rinse and as an immediate postextraction irrigation agent. The chlorhexidine was compared with another antiseptic agent cetylpyridium (Cepacol, Lakeside Pharmaceuticals/ Division of Merrill Dow, Cincinnati, OH), and normal saline used for postextraction irrigation only. Materials and Methods The study included 80 patients. Patients were enrolled in the study if they had mandibular third molars requiring extraction and were in good health. Patients who had pericoronitis or were taking antibiotics for other infections were excluded. Women were not excluded if they were taking oral contraceptives, despite evidence that this predisposes to alveolar osteitis.” No pregnant females were ineluded . In most cases, the patient’s maxillary third molars were removed concomitantly. The surgery was performed under intravenous sedation or outpatient general anesthesia. Local anesthesia consisting of lidocaine 2% with l:lOO,OOO epinephrine and Marcaine (bupivacaine hydrochloride, Sterling Drug Inc, New York, NY) 0.5% 1:200,000 epineph-
445 rine was used in all cases. No steroids were used intraoperatively or postoperatively. For all teeth that were not completely erupted, an envelope flap was used to reflect the mucosa. Bone removal or sectioning was completed with a Hall System drill and 703 bur, with irrigation consisting of normal saline. No record was kept on whether the sites were closed with suture or left open. Patients were assigned randomly to one of the three test groups or the control group by drawing a card. All patients were volunteers and gave their informed consent. The first test group of 20 patients was asked to rinse for 1 minute with 0.12% chlorhexidine gluconate (Peridex), and then expectorate. Following the extraction of each mandibular third molar, the surgical site was irrigated with 15 mL of Peridex diluted with 15 mL of normal saline. The second test group of 20 patients were similarly treated with the substitution of 0.05% cetylpyridium (Cepacol) for Peridex. The third test group of 20 patients received 10 mL of Peridex for a timed l-minute preoperative oral rinse, and the surgical site was irrigated with 30 mL of normal saline. The control group received no preoperative rinse but had each surgical site irrigated with 30 mL of normal saline immediately following the extraction. In all cases, the preoperative rinses were timed and observed. The intraoperative irrigation was accomplished with a syringe and blunted needle. Volume of final intraoperative irrigation was constant. The data collected included the patient’s name, age, sex, sites of surgery, and name of surgeon. Extractions were classified as erupted, soft tissue impaction, partial bony impaction, or complete bony impaction. No effort was made to time the surgery. In all cases the surgeon was a resident or staff surgeon from the Oral and Maxillofacial Surgery Service. Previous studies show that between the fourth and seventh day, 70.7% and 95.7%, respectively, of all patients with alveolar osteitis return for treatment.5 All patients in this study were recalled for follow-up examination between 3 and 7 days postoperatively. In all cases, the examiner was not the surgeon. The patients were examined for evidence of a denuded socket with or without necrotic debris or fetid breath. They were asked to characterize any discomfort and to describe its onset and course. The patients were examined to rule out frank postoperative infection. Patients who did not return for evaluation were excluded and replaced. This is a potential source of error, as asymptomatic patients were more likely not to seek follow-up. The number of patients who did not return was small and af-
446
CHLORHEXIDINE
fected the groups equally. Postoperative instructions were identical for each group and included avoiding all commercial mouthwashes for 48 hours postoperatively. No patient received postoperative antibiotics unless postoperative infection was identified and the patient was then excluded from the study. The data were analyzed to compare the number of occurrences of alveolar osteitis for the four test groups statistically. The type of impaction was also analyzed for the incidence of dry socket.
A total of 80 patients were included in the study. The sex distribution was equal. The age range of the subjects was from 16 to 40 years, with a mean of 21.4 years. One hundred fifty-seven mandibular third molars were extracted. Thirty-four cases of alveolar osteitis developed in 22 patients. The incidence of alveolar osteitis varied from 17.95% to 23.68% for the test groups. Data for the individual test groups are shown in Tables 1 to 4 and summarized in Table 5. Chi-square analysis showed a nonsignificant difference between test groups. Discussion The rationale for the use of antimicrobial agents in the prevention of alveolar osteitis is that bacterial infection is the initiating factor in the pathogenesis of dry socket. Work by MacGregor and Hart23 has shown that extraction sites are routinely contaminated with bacteria. In a study of 71 mandibular third molar extractions, they found that all produced bacterial growth. Most sockets had two or three species of bacteria, some as many as seven. The organisms found most frequently were Streptococcus viridans, Corynebacterium xerosis, BacStaphylococcus lactis, Vibros fusobacteria, teroides melaninogenicus, Neisseria pharyngis, and Staphylococcus aureus.
Erupted Soft tissue impaction Partial bone impaction Bony impaction Total
Symptomatic
Total
1
1
2
2
0
2
10 19 32
0 6 7
10 25 39
Incidence of alveolar osteitis, Gamble) was the rinse used.
Table 2. 0.05 Cetylpyridium Rinse and lntraoperative Irrigation Type of Extraction Erupted Soft tissue impaction Partial bony impaction Bony impaction Total
Asymptomatic
Symptomatic
Total
2
0
2
5
1
6
9 15 31
2 6 9
11 21 40
MacGregor and Hart24 also found that the pattern of occurrence of aerobic organisms was similar to that found in saliva, but that the anaerobic population of the extraction sites contained more fusiforms, Bacteroides melaninogenicus, and vibros than saliva. It was noted in patients who reported with alveolar osteitis that S virid&s and C xerosis were associated with all occurrences, and S aureus with half. Brown et aL6 in a study of 90 patients, found that patients with alveolar osteitis associated with mandibular third molars had higher preoperative and postoperative microbial counts than clinically normal patients. A diverse number with mandibular third molars had higher preoperative and postoperative microbial counts than clinically normal patients. A variety of organisms were detected, but the presence of streptococcal organisms was impressive and consistent. The isolation of microbes from the alveolus does not in itself indicate that they play a significant role in alveolar osteitis. Several previous studies using prophylactic local or systemic antibiotics have demonstrated a reduction in alveolar osteitis, giving credence to a role for infection as a causative factor 12,25,26 Chlorhexidine gluconate 0.12% is an antimicrobial oral rinse. Schiott et alI6 noted an 85% decrease in oral flora in subjects 24 hours after initiating Table 3. 0.12% Chlorhexidine Rinse and lntraoperative Irrigation With Saline
Table 1. 0.1296 Chlorhexidine Rinse and Intraoperative Irrigation Asymptomatic
OSTEITIS
Incidence of alveolar osteitis, 22.5%. Cepacol (Lakeside Pharmaceuticals/Division of Merrill Dow) was the rinse used.
Results
Type of Extraction
ORAL RINSE AND ALVEOLAR
17.95%. Peridex (Proctor and
Type of Extraction Erupted teeth Soft tissue impaction Partial bony impaction Bony impaction Total
Asymptomatic
Symptomatic
Total
4
0
4
7
4
11
5 13 31
2 3 9
7 16 40
Incidence of alveolar osteitis, Gamble) was the rinse used.
22.5%. Peridex (Proctor and
447
BERWICK AND LESSIN
Table 4. Normal Saline Intraoperative Irrigation Type of Extraction
Asymptomatic
Erupted Soft tissue impaction Partial bony impaction Bony impaction Total
Symptomatic
Total
I
1
2
3
1
4
8 17 29
2 5 9
10 22 38
incidence of alveolar osteitis, 23.68%.
twice-daily oral rinses with 0.2% chlorhexidine. Chlorhexidine is active against both aerobic and anaerobic, gram-negative and gram-positive organisms, as well as yeast. It has a high affinity for the cell wall of micro-organisms and induces changes in the surface structures, resulting in the loss of osmotic equilibrium and precipitation of the cytoplasm. In addition to immediate killing of the bacteria during rinsing, chlorhexidine binds to anionic surfaces of the oral cavity and is then gradually released to provide a continuing bacteriostatic effect. Rinsing or irrigation with chlorhexidine preoperatively and during surgery is likely to reduce bacterial contamination of the surgical site. Several previous studies have indicated chlorhexidine to be useful in the reduction of alveolar osteitis.‘7.‘8,20 Legarth et a12’ found a reduction in the incidence of alveolar osteitis from 13.7% to 7.5% when twicedaily postoperative rinses with 0.2% chlorhexidine were used following surgery. Tjernberg,i7 in a study Table 5.
Summary of Observed Values-Cell Format 0.12% Chlorhexidine*
Rinse With Irrigation Symptomatic Count Percentage Total Row Column Asymptomatic Count Percentage Total Row Column Total Count Percentage Total
of 60 patients presenting for extraction of partially erupted mandibular third molars, compared dental prophylaxis and pre- and postoperative oral rinses of chlorhexidine against a control group without benefit of cleaning or rinsing. He found a reduction in alveolar osteitis from 17% in the control group to 3% in the test group. Krekmanov and Nordenram” studied 100 patients presenting for extraction of impacted lower third molars. The study compared test groups receiving systemic penicillin for 3 days in addition to dental prophylaxis, gingival sulcus irrigation with 0.02% chlorhexidine, and 0.2% chlorhexidine oral rinse against a similar test group not receiving antibiotics. The control group received no medication, prophylaxis, or rinse. Alveolar osteitis incidence was 19.4% in the control group, 5.4% in the group receiving antibiotics, and 8.1% in the group treated with prophylaxis and chlorhexidine. A recent pilot study by Field et all9 compared the incidence of alveolar osteitis in the extraction of 324 lower premolars or molars with irrigation of the gingival sulcus and a 2-minute oral rinse of 0.2% chlorhexidine or normal saline versus no irrigation. They found a significant reduction between the number of cases of alveolar osteitis between the chlorhexidine groups and the saline group or norinse group. The results of our study are in contrast to the previous studies. Our data showed no statistical difference in the incidence of alveolar osteitis between 0.12% chlorhexidine, 0.05% cetylpyridium chloride, and normal saline. Our test groups consisted of young, healthy active duty service members or
0.05% Cetylpyridiumt Rinse With Irrigation
-0.12% Chlorhexidine* Rinse With Saline Irrigation
Normal Saline Irrigation Only
Total
7
9
9
9
34
4.46 20.59 17.95
5.73 26.47 22.50
5.73 26.47 22.50
5.73 26.47 23.68
21.66
32
31
31
29
123
20.38 26.02 82.05
19.75 25.20 77.50
19.75 25.20 77.50
18.47 23.58 76.32
78.34
39
40
40
38
157
24.84
25.48
25.48
24.20
100.00
x2 = .442; df = 3; P = .9315. * Peridex (Proctor and Gamble). t Cepacol (Lakeside Pharmaceuticals,
Division of Merrill-Dow).
448
their dependents. A possible explanation for the difference in the other studies include, with the exception of Fields’ study,” is that the test groups received measures which included dental prophylaxis and the benefit of mechanical debridement (irrigation) while the controls did not. Fields’ study involved only a relatively small group of third molars,32 with only three cases of alveolar osteitis evenly divided among the three groups. There is some evidence to suggest why antimicrobial agents, including chlorhexidine, may be ineffective in preventing alveolar osteitis. Schiott et all6 noted in their research on the effect of chlorhexidine mouth rinses on human oral flora that whereas salivary bacterial counts were reduced by up to 95%, the saliva still contained numerous bacteria. The bacterial levels following rinse may still be high enough to initiate bacterial fibrinolysis and alveolar osteitis. Chlorhexidine’s effectiveness in preventing plaque formation is perhaps more related to its alteration of bacterial adsorption and their ability to attach to teeth than to its direct antimicrobiai effect. Although this would make chlorhexidine effective against periodontal disease, it would be irrelevant to incidence of alveolar osteitis. Chlorhexidine’s activity is decreased by blood and calcium. This would also reduce the antimicrobial effect in the actual extraction site.27 Although MacGregor and Hart,28 found chlorhexidine to be an excellent agent for eliminating bacteria on the mucosal surface preoperatively, they found that bacterial distribution within the extraction site was not significantly different from the untreated surgical site. The etiology of alveolar osteitis is still not fully understood. Birn’ has demonstrated that fibrinolysis of the blood clot is probably responsible for the pathogenesis of this disorder. Although bacteria, particularly streptococcal organisms, have been reliably associated with extraction sites, they have been found to have only weak fibrinolytic activity. The importance of infection as the agent of fibrinolysis may be overrated. The results of this pilot study have shown that a preoperative rinse and immediate postextraction irrigation with 0.12% chlorhexidine (Peridex) or Cepacol, or preoperative oral rinsing with 0.12% chlorhexidine and postextraction irrigation with saline is no more effective in preventing the incidence of alveolar osteitis than the use of postextraction normal saline irrigation. References 1. Crawford JY: Dry socket. Dent Cosmos 38:929, 1896 2. Bim H: Etiology and pathogenesis of tibrinolytic alveolitis. Int J Oral Maxillofac Surg 2:211, 1976
CHLORHEXIDINE
ORAL RINSE AND ALVEOLAR
OSTEITIS
3. Huebsch RF: Clinical and histological study of alveolar osteitis. .I Oral Surg 16:473. 1958 4. Alling CC, Kerr Di: Trauma as a factor causing delayed renair of dental extraction sites. J Oral Surg 15:3. 1957 5. Adkisson SR, Harris PF: A statistical study of alveblar osteitis. US Armed Forces Med J 7:1749, 1956 6. Brown LR, Merrill SS, Allen RE: Microbiologic study of intraoral wounds. J Oral Surg 28:89, 1970 7. Belinfante LS, Marlow CD, Meyers W, et al: Incidence of dry socket complication in third molar removal. J Oral Surg 31:106, 1973 8. Erickson RI, Waite DE, Wilkinson RH, et al: Study of dry sockets. J Oral Surg 13:1046, 1960 9. MacGregor AJ: Aetiology of dry socket: A clinical investigation. Br J Oral Maxillofac Surg 6:49, 1968 10. Heasman PA, Jacobs DJ: A clinical investigation into the incidence of dry socket. Br J Oral Maxillofac Surg 22: 115, 1984 11. Field AE, Speechley JA, Rotter E, et al: Dry socket incidence compared after a 12 year interval. Br J Oral Maxillofac Surg 23:419, 1985 12. Rood JP, Muratroyd J: Metronidazole in the prevention of dry socket. Br J Oral Maxillofac Surg 17:62, 1979 13. Rutledge JL, Marcoot RM: Terracortril/Gelfoam for reduction of the incidence of localized osteitis following mandibular third molar removal. J Oral Med 39%) 1984 14. Ritzau M, Therkildsen P: Antifibrinolytic prevention of alveolitis sicca dolorosa. Int J Oral Maxillofac Surg 7:534. 1978 15. Lilly GE, Osbon DB, Raele M, et al: Alveolar osteitis associated with mandibular third molar extractions. J Am Dent Assoc 88:802, 1974 16. Schiott CR, Harald LS, Borglum J, et al: The effect of chlorhexidine mouthrinses on the human oral flora. J Periodont Res 5:84, 1970 17. Tjemberg A: Influence of oral hygiene measures on the development of alveolitis sicca dolorosa after surgical removal of mandibular third molars. Int J Oral Maxillofac Surg 8:430, 1979 18. Krekmanov L, Nordenram A: Postoperative complications after surgical removal of mandibular third molars. Int J Oral Maxillofac Surg 15:25, 1986 19. 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 20. Legarth J, Munster R, Swendsen J: Klorheksidins virkning pa vdriklingen of alveolitis sicca dolorosa efter operativ tjernelse of visdomstaender i under kaeben (abstract). Tanalaegebladet 81:451, 1977 21. MacGkgo; AJ, Hart P: The topical antiseptic effect of chlorhexidine on bacteria of third molar wounds and their _.. complications. J Oral Surg 29:481, 1971 22. Schow SR: Evaluation of postoperative localized osteitis in mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 38:352, 1974 23. MacGregor AJ, Hart P: Effect of bacteria and other factors on pain and swelling after removal of ectopic mandibular third molars. J Oral Surg 27: 174, 1969 24. MacGregor AJ, Hart P: Bacteria of the extraction wound. J Oral Surg 28:885, 1970 25. Kay LW: Investigations into the nature of pericoronitis. Br J Oral Maxillofac Surg 4:52, 1966 26. Mitchell DA: A controlled clinical trial of prophylactic tinidozole for chemoprophylaxis in third molar surgery. Br Dent J 160:284, 1986 27. Cioncio SG: Pharmacology of Oral Antimicrobials in Perspectives of Oral Antimicrobial Therapeutics. Littleton, MA, PSG Publishing, 1987, pp 25-35 28. MacGregor AJ, Hart P: The topical antiseptic effect of chlorhexidine on bacteria of third molar wounds and their complications. J Oral Surg 29:481, 1971
Surg
45:444-441990
Effects of a Chlorhexidine Gluconate Oral Rinse on the incidence of Alveolar Osteitis in Mandibular Third Molar Surgery MAJ JAMES E. BERWICK, DDS,* AND COL MICHAEL
E. LESSIN, DDSt
Alveolar osteitis (dry socket) continues to be a frequent sequela of third molar surgery. Chlorhexidine 0.12% used as an oral rinse has been reported to reduce the incidence of dry socket. This study compares the effectiveness of 0.12% chlorhexidine used as a preoperative rinse and immediate postextraction irrigant with 1) similarly used 0.05% cetylpyridium, preoperative chlorhexidine rinse and postextraction saline irrigation, and 2) only postextraction irrigation with normal saline in the reduction of alveolar osteitis in mandibular third molar extractions. The results indicate that chlorhexidine and cetylpyridium were no more effective in the reduction of alveolar osteitis than postextraction irrigation with normal saline.
Alveolar osteitis (dry socket), as first described by Crawford’ in 1896 continues to be a common complication of the extraction of teeth. The clinical presentation is classic but subjective. The patient complains of throbbing pain not relieved by analgesics which develops or persists several days following surgery. The patient typically has fetid breath. Inspection of the surgical site reveals a partially or completely denuded alveolus. The alveolus may be covered by necrotic debris, but the presence of an organizing blood clot is conspicuously absent. The etiology and pathogenesis of alveolar osteitis
have been the subject of much study and debate since the condition was first recognized. Despite this, no model of pathogenesis or etiologic factor is accepted universally as the basis for generation of alveolar osteitis. Birn’s studies,* which attribute alveolar osteitis or fibrinolytic alveolitis to increased fibrinolytic activity within the alveolus and clot are the most widely accepted. The etiology of alveolar osteitis has variously been attributed to inadequacy of blood supply to the alveolus3 trauma to the alveolus,4 infection,5,6 fibrinolytic activity,2 and a variety of other less likely initiating factors including seasonal variation, nutrition, excessive bleeding, and choice of anesthetic. Studies on the incidence and distribution of alveolar osteitis show that it occurs in from O.5%7 to 68.4%’ of all extractions, with an average of about 3%.279*10 Alveolar osteitis occurs much more frequently after the extraction of mandibular teeth and most frequently with mandibular third molars.5,9-‘1 The peak age of occurrence is from 20 to 40 years, alveolar osteitis being relatively rare in the young and the old. Numerous agents and methods have been used to prevent alveolar osteitis and its attendant morbidity. Antibiotics have been used with some effec-
* Chief, Oral and Maxillofacial Surgery Service, Gorgas Army Hospital, Panama. t Formerly, Chief, Oral and Maxillofacial Surgery Service and Director of Residency Training, Brooke Army Medical Center, Fort Sam Houston, TX; currently, Associate in Oral and Maxillofacial Surgery at Geisinger Medical Center, Danville, PA. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Address correspondence and reprint requests to MAJ Berwick: PSC 3001, APO Miami, FL 34092. 0 1990 American
Association
of Oral
and Maxillofacial
Sur-
geons 0278-2391/90/4805-0002$3.00/O
444
BERWICK
AND LESSIN
tiveness,i2.13 the rationale being that infection is the etiologic factor in the genesis of alveolar osteitis. Antifibrinolytics2,i4 and anti-inflammatory agents13 have been used with mixed results in an effort to stabilize the clot. Other studies have shown that improving hygiene and the use of antimicrobial rinses have been effective in reducing the incidence of alveolar osteitis in some cases.15-20 If infection of the surgical wound and subsequent fibrinolysis due to bacterial initiation is important in the generation of alveolar osteitis, then an antimicrobial rinse and lavage agent should be effective in the reduction of the incidence of alveolar osteitis. Lilly et al” demonstrated a reduction of alveolar osteitis incidence using an antiseptic mouthwash (Chloraseptic, Proctor and Gamble, Cincinnati, OH) and irrigation. Chlorhexidine gluconate as a mouthwash has been demonstrated to significantly reduce the bacterial population of both anaerobic and aerobic bacteria.16 Several previous studies have shown chlorhexidine gluconate 0.2% mouthwashes alone, or in combination with dental prophylaxis, to be effective in the reduction of alveolar osteitis.“j-*’ A study by MacGregor and Hart,*l however, found chlorhexidine 0.5% used locally over the surgical site to be ineffective in preventing third molar surgery complications. The purpose of this investigation was to study the prophylactic value of a commercially available 0.12% chlorhexidine mouthwash (Peridex, Proctor and Gamble) used as a preoperative rinse and as an immediate postextraction irrigation agent. The chlorhexidine was compared with another antiseptic agent cetylpyridium (Cepacol, Lakeside Pharmaceuticals/ Division of Merrill Dow, Cincinnati, OH), and normal saline used for postextraction irrigation only. Materials and Methods The study included 80 patients. Patients were enrolled in the study if they had mandibular third molars requiring extraction and were in good health. Patients who had pericoronitis or were taking antibiotics for other infections were excluded. Women were not excluded if they were taking oral contraceptives, despite evidence that this predisposes to alveolar osteitis.” No pregnant females were ineluded . In most cases, the patient’s maxillary third molars were removed concomitantly. The surgery was performed under intravenous sedation or outpatient general anesthesia. Local anesthesia consisting of lidocaine 2% with l:lOO,OOO epinephrine and Marcaine (bupivacaine hydrochloride, Sterling Drug Inc, New York, NY) 0.5% 1:200,000 epineph-
445 rine was used in all cases. No steroids were used intraoperatively or postoperatively. For all teeth that were not completely erupted, an envelope flap was used to reflect the mucosa. Bone removal or sectioning was completed with a Hall System drill and 703 bur, with irrigation consisting of normal saline. No record was kept on whether the sites were closed with suture or left open. Patients were assigned randomly to one of the three test groups or the control group by drawing a card. All patients were volunteers and gave their informed consent. The first test group of 20 patients was asked to rinse for 1 minute with 0.12% chlorhexidine gluconate (Peridex), and then expectorate. Following the extraction of each mandibular third molar, the surgical site was irrigated with 15 mL of Peridex diluted with 15 mL of normal saline. The second test group of 20 patients were similarly treated with the substitution of 0.05% cetylpyridium (Cepacol) for Peridex. The third test group of 20 patients received 10 mL of Peridex for a timed l-minute preoperative oral rinse, and the surgical site was irrigated with 30 mL of normal saline. The control group received no preoperative rinse but had each surgical site irrigated with 30 mL of normal saline immediately following the extraction. In all cases, the preoperative rinses were timed and observed. The intraoperative irrigation was accomplished with a syringe and blunted needle. Volume of final intraoperative irrigation was constant. The data collected included the patient’s name, age, sex, sites of surgery, and name of surgeon. Extractions were classified as erupted, soft tissue impaction, partial bony impaction, or complete bony impaction. No effort was made to time the surgery. In all cases the surgeon was a resident or staff surgeon from the Oral and Maxillofacial Surgery Service. Previous studies show that between the fourth and seventh day, 70.7% and 95.7%, respectively, of all patients with alveolar osteitis return for treatment.5 All patients in this study were recalled for follow-up examination between 3 and 7 days postoperatively. In all cases, the examiner was not the surgeon. The patients were examined for evidence of a denuded socket with or without necrotic debris or fetid breath. They were asked to characterize any discomfort and to describe its onset and course. The patients were examined to rule out frank postoperative infection. Patients who did not return for evaluation were excluded and replaced. This is a potential source of error, as asymptomatic patients were more likely not to seek follow-up. The number of patients who did not return was small and af-
446
CHLORHEXIDINE
fected the groups equally. Postoperative instructions were identical for each group and included avoiding all commercial mouthwashes for 48 hours postoperatively. No patient received postoperative antibiotics unless postoperative infection was identified and the patient was then excluded from the study. The data were analyzed to compare the number of occurrences of alveolar osteitis for the four test groups statistically. The type of impaction was also analyzed for the incidence of dry socket.
A total of 80 patients were included in the study. The sex distribution was equal. The age range of the subjects was from 16 to 40 years, with a mean of 21.4 years. One hundred fifty-seven mandibular third molars were extracted. Thirty-four cases of alveolar osteitis developed in 22 patients. The incidence of alveolar osteitis varied from 17.95% to 23.68% for the test groups. Data for the individual test groups are shown in Tables 1 to 4 and summarized in Table 5. Chi-square analysis showed a nonsignificant difference between test groups. Discussion The rationale for the use of antimicrobial agents in the prevention of alveolar osteitis is that bacterial infection is the initiating factor in the pathogenesis of dry socket. Work by MacGregor and Hart23 has shown that extraction sites are routinely contaminated with bacteria. In a study of 71 mandibular third molar extractions, they found that all produced bacterial growth. Most sockets had two or three species of bacteria, some as many as seven. The organisms found most frequently were Streptococcus viridans, Corynebacterium xerosis, BacStaphylococcus lactis, Vibros fusobacteria, teroides melaninogenicus, Neisseria pharyngis, and Staphylococcus aureus.
Erupted Soft tissue impaction Partial bone impaction Bony impaction Total
Symptomatic
Total
1
1
2
2
0
2
10 19 32
0 6 7
10 25 39
Incidence of alveolar osteitis, Gamble) was the rinse used.
Table 2. 0.05 Cetylpyridium Rinse and lntraoperative Irrigation Type of Extraction Erupted Soft tissue impaction Partial bony impaction Bony impaction Total
Asymptomatic
Symptomatic
Total
2
0
2
5
1
6
9 15 31
2 6 9
11 21 40
MacGregor and Hart24 also found that the pattern of occurrence of aerobic organisms was similar to that found in saliva, but that the anaerobic population of the extraction sites contained more fusiforms, Bacteroides melaninogenicus, and vibros than saliva. It was noted in patients who reported with alveolar osteitis that S virid&s and C xerosis were associated with all occurrences, and S aureus with half. Brown et aL6 in a study of 90 patients, found that patients with alveolar osteitis associated with mandibular third molars had higher preoperative and postoperative microbial counts than clinically normal patients. A diverse number with mandibular third molars had higher preoperative and postoperative microbial counts than clinically normal patients. A variety of organisms were detected, but the presence of streptococcal organisms was impressive and consistent. The isolation of microbes from the alveolus does not in itself indicate that they play a significant role in alveolar osteitis. Several previous studies using prophylactic local or systemic antibiotics have demonstrated a reduction in alveolar osteitis, giving credence to a role for infection as a causative factor 12,25,26 Chlorhexidine gluconate 0.12% is an antimicrobial oral rinse. Schiott et alI6 noted an 85% decrease in oral flora in subjects 24 hours after initiating Table 3. 0.12% Chlorhexidine Rinse and lntraoperative Irrigation With Saline
Table 1. 0.1296 Chlorhexidine Rinse and Intraoperative Irrigation Asymptomatic
OSTEITIS
Incidence of alveolar osteitis, 22.5%. Cepacol (Lakeside Pharmaceuticals/Division of Merrill Dow) was the rinse used.
Results
Type of Extraction
ORAL RINSE AND ALVEOLAR
17.95%. Peridex (Proctor and
Type of Extraction Erupted teeth Soft tissue impaction Partial bony impaction Bony impaction Total
Asymptomatic
Symptomatic
Total
4
0
4
7
4
11
5 13 31
2 3 9
7 16 40
Incidence of alveolar osteitis, Gamble) was the rinse used.
22.5%. Peridex (Proctor and
447
BERWICK AND LESSIN
Table 4. Normal Saline Intraoperative Irrigation Type of Extraction
Asymptomatic
Erupted Soft tissue impaction Partial bony impaction Bony impaction Total
Symptomatic
Total
I
1
2
3
1
4
8 17 29
2 5 9
10 22 38
incidence of alveolar osteitis, 23.68%.
twice-daily oral rinses with 0.2% chlorhexidine. Chlorhexidine is active against both aerobic and anaerobic, gram-negative and gram-positive organisms, as well as yeast. It has a high affinity for the cell wall of micro-organisms and induces changes in the surface structures, resulting in the loss of osmotic equilibrium and precipitation of the cytoplasm. In addition to immediate killing of the bacteria during rinsing, chlorhexidine binds to anionic surfaces of the oral cavity and is then gradually released to provide a continuing bacteriostatic effect. Rinsing or irrigation with chlorhexidine preoperatively and during surgery is likely to reduce bacterial contamination of the surgical site. Several previous studies have indicated chlorhexidine to be useful in the reduction of alveolar osteitis.‘7.‘8,20 Legarth et a12’ found a reduction in the incidence of alveolar osteitis from 13.7% to 7.5% when twicedaily postoperative rinses with 0.2% chlorhexidine were used following surgery. Tjernberg,i7 in a study Table 5.
Summary of Observed Values-Cell Format 0.12% Chlorhexidine*
Rinse With Irrigation Symptomatic Count Percentage Total Row Column Asymptomatic Count Percentage Total Row Column Total Count Percentage Total
of 60 patients presenting for extraction of partially erupted mandibular third molars, compared dental prophylaxis and pre- and postoperative oral rinses of chlorhexidine against a control group without benefit of cleaning or rinsing. He found a reduction in alveolar osteitis from 17% in the control group to 3% in the test group. Krekmanov and Nordenram” studied 100 patients presenting for extraction of impacted lower third molars. The study compared test groups receiving systemic penicillin for 3 days in addition to dental prophylaxis, gingival sulcus irrigation with 0.02% chlorhexidine, and 0.2% chlorhexidine oral rinse against a similar test group not receiving antibiotics. The control group received no medication, prophylaxis, or rinse. Alveolar osteitis incidence was 19.4% in the control group, 5.4% in the group receiving antibiotics, and 8.1% in the group treated with prophylaxis and chlorhexidine. A recent pilot study by Field et all9 compared the incidence of alveolar osteitis in the extraction of 324 lower premolars or molars with irrigation of the gingival sulcus and a 2-minute oral rinse of 0.2% chlorhexidine or normal saline versus no irrigation. They found a significant reduction between the number of cases of alveolar osteitis between the chlorhexidine groups and the saline group or norinse group. The results of our study are in contrast to the previous studies. Our data showed no statistical difference in the incidence of alveolar osteitis between 0.12% chlorhexidine, 0.05% cetylpyridium chloride, and normal saline. Our test groups consisted of young, healthy active duty service members or
0.05% Cetylpyridiumt Rinse With Irrigation
-0.12% Chlorhexidine* Rinse With Saline Irrigation
Normal Saline Irrigation Only
Total
7
9
9
9
34
4.46 20.59 17.95
5.73 26.47 22.50
5.73 26.47 22.50
5.73 26.47 23.68
21.66
32
31
31
29
123
20.38 26.02 82.05
19.75 25.20 77.50
19.75 25.20 77.50
18.47 23.58 76.32
78.34
39
40
40
38
157
24.84
25.48
25.48
24.20
100.00
x2 = .442; df = 3; P = .9315. * Peridex (Proctor and Gamble). t Cepacol (Lakeside Pharmaceuticals,
Division of Merrill-Dow).
448
their dependents. A possible explanation for the difference in the other studies include, with the exception of Fields’ study,” is that the test groups received measures which included dental prophylaxis and the benefit of mechanical debridement (irrigation) while the controls did not. Fields’ study involved only a relatively small group of third molars,32 with only three cases of alveolar osteitis evenly divided among the three groups. There is some evidence to suggest why antimicrobial agents, including chlorhexidine, may be ineffective in preventing alveolar osteitis. Schiott et all6 noted in their research on the effect of chlorhexidine mouth rinses on human oral flora that whereas salivary bacterial counts were reduced by up to 95%, the saliva still contained numerous bacteria. The bacterial levels following rinse may still be high enough to initiate bacterial fibrinolysis and alveolar osteitis. Chlorhexidine’s effectiveness in preventing plaque formation is perhaps more related to its alteration of bacterial adsorption and their ability to attach to teeth than to its direct antimicrobiai effect. Although this would make chlorhexidine effective against periodontal disease, it would be irrelevant to incidence of alveolar osteitis. Chlorhexidine’s activity is decreased by blood and calcium. This would also reduce the antimicrobial effect in the actual extraction site.27 Although MacGregor and Hart,28 found chlorhexidine to be an excellent agent for eliminating bacteria on the mucosal surface preoperatively, they found that bacterial distribution within the extraction site was not significantly different from the untreated surgical site. The etiology of alveolar osteitis is still not fully understood. Birn’ has demonstrated that fibrinolysis of the blood clot is probably responsible for the pathogenesis of this disorder. Although bacteria, particularly streptococcal organisms, have been reliably associated with extraction sites, they have been found to have only weak fibrinolytic activity. The importance of infection as the agent of fibrinolysis may be overrated. The results of this pilot study have shown that a preoperative rinse and immediate postextraction irrigation with 0.12% chlorhexidine (Peridex) or Cepacol, or preoperative oral rinsing with 0.12% chlorhexidine and postextraction irrigation with saline is no more effective in preventing the incidence of alveolar osteitis than the use of postextraction normal saline irrigation. References 1. Crawford JY: Dry socket. Dent Cosmos 38:929, 1896 2. Bim H: Etiology and pathogenesis of tibrinolytic alveolitis. Int J Oral Maxillofac Surg 2:211, 1976
CHLORHEXIDINE
ORAL RINSE AND ALVEOLAR
OSTEITIS
3. Huebsch RF: Clinical and histological study of alveolar osteitis. .I Oral Surg 16:473. 1958 4. Alling CC, Kerr Di: Trauma as a factor causing delayed renair of dental extraction sites. J Oral Surg 15:3. 1957 5. Adkisson SR, Harris PF: A statistical study of alveblar osteitis. US Armed Forces Med J 7:1749, 1956 6. Brown LR, Merrill SS, Allen RE: Microbiologic study of intraoral wounds. J Oral Surg 28:89, 1970 7. Belinfante LS, Marlow CD, Meyers W, et al: Incidence of dry socket complication in third molar removal. J Oral Surg 31:106, 1973 8. Erickson RI, Waite DE, Wilkinson RH, et al: Study of dry sockets. J Oral Surg 13:1046, 1960 9. MacGregor AJ: Aetiology of dry socket: A clinical investigation. Br J Oral Maxillofac Surg 6:49, 1968 10. Heasman PA, Jacobs DJ: A clinical investigation into the incidence of dry socket. Br J Oral Maxillofac Surg 22: 115, 1984 11. Field AE, Speechley JA, Rotter E, et al: Dry socket incidence compared after a 12 year interval. Br J Oral Maxillofac Surg 23:419, 1985 12. Rood JP, Muratroyd J: Metronidazole in the prevention of dry socket. Br J Oral Maxillofac Surg 17:62, 1979 13. Rutledge JL, Marcoot RM: Terracortril/Gelfoam for reduction of the incidence of localized osteitis following mandibular third molar removal. J Oral Med 39%) 1984 14. Ritzau M, Therkildsen P: Antifibrinolytic prevention of alveolitis sicca dolorosa. Int J Oral Maxillofac Surg 7:534. 1978 15. Lilly GE, Osbon DB, Raele M, et al: Alveolar osteitis associated with mandibular third molar extractions. J Am Dent Assoc 88:802, 1974 16. Schiott CR, Harald LS, Borglum J, et al: The effect of chlorhexidine mouthrinses on the human oral flora. J Periodont Res 5:84, 1970 17. Tjemberg A: Influence of oral hygiene measures on the development of alveolitis sicca dolorosa after surgical removal of mandibular third molars. Int J Oral Maxillofac Surg 8:430, 1979 18. Krekmanov L, Nordenram A: Postoperative complications after surgical removal of mandibular third molars. Int J Oral Maxillofac Surg 15:25, 1986 19. 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 20. Legarth J, Munster R, Swendsen J: Klorheksidins virkning pa vdriklingen of alveolitis sicca dolorosa efter operativ tjernelse of visdomstaender i under kaeben (abstract). Tanalaegebladet 81:451, 1977 21. MacGkgo; AJ, Hart P: The topical antiseptic effect of chlorhexidine on bacteria of third molar wounds and their _.. complications. J Oral Surg 29:481, 1971 22. Schow SR: Evaluation of postoperative localized osteitis in mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 38:352, 1974 23. MacGregor AJ, Hart P: Effect of bacteria and other factors on pain and swelling after removal of ectopic mandibular third molars. J Oral Surg 27: 174, 1969 24. MacGregor AJ, Hart P: Bacteria of the extraction wound. J Oral Surg 28:885, 1970 25. Kay LW: Investigations into the nature of pericoronitis. Br J Oral Maxillofac Surg 4:52, 1966 26. Mitchell DA: A controlled clinical trial of prophylactic tinidozole for chemoprophylaxis in third molar surgery. Br Dent J 160:284, 1986 27. Cioncio SG: Pharmacology of Oral Antimicrobials in Perspectives of Oral Antimicrobial Therapeutics. Littleton, MA, PSG Publishing, 1987, pp 25-35 28. MacGregor AJ, Hart P: The topical antiseptic effect of chlorhexidine on bacteria of third molar wounds and their complications. J Oral Surg 29:481, 1971
