J Oral MaxillofacSurg 49:932-937, 1991
The Effect of a Chlorhexidine Rinse on the Incidence of Alveolar Osteitis Following the Surgical Removal of Impacted Mandibular Third Molars PETER E. LARSEN, DDS* A prospective randomized double-blind placebo-controlled study was conducted with 139 patients (278 bilaterally impacted mandibular third molars) to determine the effect of a perioperative 0.12% chlorhexidine gluconate rinse on the incidence of alveolar osteitis following surgical removal of impacted mandibular third molars. A statistically significant 60% reduction in the incidence of alveolar osteitis was obtained in the chlorhexidine group compared with the placebo group. In most subgroups analyzed, chlorhexidine was associated with at least a 50% reduction in alveolar osteitis compared with control groups.
Alveolar osteitis (dry socket) following the extraction of mandibular third molars is an important postoperative problem for both the patient and surgeon. The patient experiences pain, loss of productivity, and the need for multiple return office visits. This is also costly to the surgeon, as 45% of patients who develop alveolar osteitis will require at least four additional postoperative visits in the process of managing this condition.’ Several risk factors have been identified in association with alveolar osteitis. These include increased difftculty of extraction,‘,’ an inexperienced use,6-’ ’ surgeon3 tobacco4,5 or oral contraceptive the use of perioperative corticosteroids, the use of a local anesthetic with a vacoconstrictor,” and inadequate irrigation during and after extraction.13 Fibrinolysis with subsequent loss of the blood clot is believed to be the general cause of alveolar osteitis.r4 As the primary role of bacteria in this process has been documented,‘4 the most effective method for reducing alveolar osteitis has been
through the use of agents that systemically’5-‘7 or topically’8-‘3 reduce the oral microbes within the wound. Oral rinsing with chlorhexidine has been shown to reduce the quantity of oral microbial populations,‘4725 and thus may be effective in reducing the incidence of alveolar osteitis. However, most previous studies have not been adequately controlled. To provide usable data, controlled studies are needed. The purpose of this prospective, risk-factor-controlled, double-blind study was to determine the effectiveness of a 0.12% chlorhexidine solution used as a perioperative rinse in reducing the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. Materials and Methods All patients presenting for surgical removal of bilaterally impacted mandibular third molars were considered for inclusion in the study. Patients with acute infection or those using antibiotics or requiring antibiotic prophylaxis prior to treatment were excluded. Using a computer software routine supplied by the sponsor (Procter and Gamble Co, Cincinnati, OH), balance and assignment was performed by separating the subjects by sex, oral contraceptive use within females, and by tobacco use for both sexes. Within strata subjects were randomly assigned into two groups: experimental (chlorhexidine [Peridex]) or placebo (the identical solution without chlorhexidine).
* Assistant Professor and Program Director, Department of Oral and Maxillofacial Surgery, College of Dentistry, The Ohio State University, Columbus, OH. Address correspondence and reprint requests to Dr Larsen: Department of Oral and Maxillofacial Surgery, College of Dentistry, The Ohio State University, 305 W 12th Ave, Room 2131 Pestle Hall, Columbus, OH 43210. 0 1991 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391/91/4909-0003$3.00/0
932
933
PETER E. LARSEN
At the initial appointment, patients were given a 16-0~ bottle of mouth rinse with instructions to rinse with 15 mL for 30 seconds twice per day for 1 week prior to and 1 week after surgery. Placebo and experimental rinses appeared identical, differing only by the presence of 0.12% chlorhexidine gluconate in the experimental solution. A standardized intraoral photograph of the maxillary anterior teeth was taken at this visit. Each impacted third molar was evaluated on a current panoramic radiograph and assigned a relative degree of difficulty, based on its position. A single experienced surgeon who did not participate in the surgery graded each impaction on the radiographic parameters of vertical position, location within the ramus, axial inclination, and root morphology. Random radiographs were periodically reevaluated without the grader’s knowledge to assess intrarater consistency. The operating surgeon had no knowledge of the score given to the teeth prior to extraction. Immediately prior to surgery, the patient rinsed with 15 mL of their assigned solution. All surgery was performed by one of two surgeons using a standard technique. Both surgeons had forma1 training in third molar removal, but differed in their clinical experience, one being experienced and one being inexperienced. High-speed, nitrogen-powered handpieces were used for bone removal and sectioning of teeth, and copious sterile water was used for irrigation throughout the procedure. Regardless of the method of anesthesia used, all patients received 8 mg of dexamethasone intravenously preoperatively. Two percent lidocaine with 1: 100,000 epinepherine was used for local anesthesia in all patients. Inferior alveolar nerve block and long buccal infiltration were performed on each side. Following tooth removal, 40 mL of sterile water was used to irrigate each extraction site. Silk suture (30) was used for closure of all incisions. The time necessary for extraction was recorded on a stop watch starting with the incision and ending with placement of the last suture. No intraoperative or postoperative antibiotics were given. Postoperatively, patients were instructed to begin rinsing with the prescribed rinse the day following surgery. Patients received twenty analgesic tablets (325 mg acetomenaphen with 30 mg of codeine). Patients were instructed to return in 1 week, or sooner. if any bothersome pain persisted or increased after the second day. On the seventh day, or on preceding days if pain was present, the extraction sites were evaluated for abnormal healing, including exposed bone. presence of necrotic tissue, and loss of clot. Patients who had not returned prior to the seventh day were questioned about increasing pain during the postoperative period. Al-
veolar osteitis was defined as persistent or increasing postoperative pain beginning after the second day, which was associated with necrotic tissue in the socket, exposed bone, or loss of the clot on clinical examination. A record was made of the volume of rinse solution used. Prior to performing the statistical analyses, it was determined that each extraction site should be treated independently. Therefore, the analyses were performed with teeth as the sampling unit as opposed to the subject being the sampling unit. The data were analyzed using Fisher’s exact test. Results One hundred fifty patients were enlisted into the study. Eleven failed to continue the study to completion. One hundred thirty-nine patients for whom data were recorded satisfactorily completed the study, were in compliance with required rinse use, and were included in these results. Sixty-seven patients used placebo and 72 used chlorhexidine. The subjects were well balanced according to all recorded presurgical variables between the experimental and placebo groups (Table I ). Patients were also evenly distributed between the two surgeons with respect to these variables. The rate of formation of alveolar osteitis was analyzed individually for the right and left teeth. There was no statistical difference in the rate of formation between the two sides. There were 12 of 144 extraction sites with alveolar osteitis in the chlorhexidine group (8%) and 28 of 134 sites developed alveolar osteitis in the placebo group (21%) (P = .Ol). Alveolar osteitis developed in 9 of 114 extraction sites in patients in the chlorhexidine group treated by the experienced surgeon (8%), while 16 of 102 sites in the placebo group developed alveolar osteitis (16%). The patients of the less experienced surgeon had alveolar osteitis in 3 of 30 sites in the chlorhexidine group (10%) and 12 of 32 sites in the placebo group (38%) (Table 2). This represents a 50% (P = .06) reduction and a 73% (P = .Ol) reduction in the incidence of alveolar osteitis over that seen in the placebo group for the experienced and less experienced surgeon, respectively. Patients who used tobacco had an increased incidence of alveolar osteitis in both the chlorhexidine and placebo groups. In the nonsmoking group, placebo patients had 16 of 110 sites develop alveolar osteitis (15%), compared with 6 of 116 (5%) in the chlorhexidine group. This reduction was statistically significant (P = .Ol). In the smoking group, placebo patients had 12 of 24 sites develop alveolar osteitis (.50%), while it occurred in only 6 of 28 sites (21%) in the chlorhexidine group (P = .03) (Table 2).
934
CHLORHEXIDINE
Table 1. Distribution of Patients According to Monitored Variables
Sex Male Female Age (yr) 18-22 23-26 >26 Race Black White Other Tobacco Yes No Oral contraceptive Yes No Radiographic score Right Left Time (min) Right Left
Chlorhexidine
Placebo
32 41
30 37
34 32
36 23 8
67 5
3 60 4
14 59
12 55
13 28
11 26
8.4 8.4
8.3 8.0
5.8 5.3
5.5 5.7
There was no statistical difference in distribution between the placebo and chlorhexidine groups.
of patients
Of the 78 female patients included in the study, 24 were using oral contraceptives at the time of treatment. In the patients not using oral contraceptives, 6 of 56 extraction sites in the chlorhexidine group developed alveolar osteitis (11%) and 16 of 52 sites in the placebo group developed alveolar osteitis (31%). This reduction was statistically significant (P < .Ol). In those patients using oral contraceptives, the chlorhexidine group had 2 of 26 (8%) sites with alveolar osteitis and the placebo group had 3 of 22 (14%). This reduction in patients using oral contraceptives was not statistically significant most likely due to the small number of patients using oral contraceptives (Table 2). In the age range of 18 to 22 years, 9% of extraction sites in patients using chlorhexidine developed alveolar osteitis, while 19% of the placebo sites did so. In the ages 23 to 26, 5% of extraction sites in patients using chlorhexidine developed alveolar osteitis compared with 22% of the sites in those using placebo. In those patients over age 26, 21% of the sites in patients using chlorhexidine developed alveolar osteitis, while 25% of the sites in those using placebo did. The decreases seen with chlorhexidine approached statistical significance for age group 18 to 22 (P = .06), was significant for age group 23 to 26 (P < .Ol) but was not statistically significant in patients over 26 years old when looked at individually. There was a trend towards a greater incidence of alveolar osteitis in patients over 26 years of age in both the chlorhexidine and control groups.
RINSE AND ALVEOLAR
OSTEITIS
Separate analyses for each surgeon according to extraction time were performed by making a frequency distribution of the total extraction time (tooth 17 plus tooth 32) for each surgeon separately and by arraying the times from low to high and separating the subjects based on median time into low and high times. The median time for the experienced surgeon was 9.6 minutes and for the inexperienced surgeon was 12.9 minutes. In both the short and long extraction times, the trend was for a decreasing incidence of alveolar osteitis in the chlorhexidine group for both surgeons when compared with placebo. For the more experienced surgeon, chlorhexidine was associated with a decrease in the incidence of alveolar osteitis of 38% for the shorter cases and 64% in the longer cases, when compared with the placebo. For the less experienced surgeon, the chlorhexidine also appeared to reduce the incidence during both short and long extraction times, with a 100% reduction in the shorter time and 40% reduction in the longer time over that seen in the placebo group. Due to decrease in sample size secondary to creation of multiple subgroups, only the reduction seen for the less experienced surgeon in shorter cases was statistically significant (P < .05) (Table 3). Comparison of pretreatment photographs with posttreatment photographs of the maxillary anterior teeth revealed no evidence of staining in either the experimental or control group. There were no adverse reactions to the solution. Discussion
The incidence of alveolar osteitis following routine extraction of erupted teeth has been reported as 1% to 3%.2,‘4 The reported incidence following the extraction of impacted mandibular third molars ranges from 1% to 65%.26*27This great variability is most likely due to differences in diagnostic criteria and uncontrolled variation within the population evaluated. If only well controlled, prospective studies with carefully defined diagnostic criteria are considered, the incidence of alveolar osteitis falls in The incidence of the range of 20% to 3 1%. 16,19,28-30 alveolar osteitis in the placebo group in this study, 21%, corresponds well with these previous studies. It has been reported that 45% of patients who developed alveolar osteitis following third molar extractions needed four or more postoperative office visits before symptoms resolved.’ This represents significant pain and suffering for the patient and could have a substantial economic impact on the patient as well as the practitioner. The pathogenesis of alveolar osteitis appears to result from the conversion of plasminogen to plasmin resulting in fibrinolysis of the blood clot within
935
PETER E. LARSEN
Table 2.
Incidence of Alveolar Osteltis
Incidence by Site*
No. With Placebo (%)
No. With Chlorhexidine (%)
% Reduction
Overall ES NES Tobacco Yes No Women BCP-Yes BCP-No Age 18-22 23-26 >26
28/134 (21) 16/102 (16) I?/32 (38)
12/144 (8) 9/l 14 (8) 3/30 (10)
60 50 73
.Ol .06 .Ol
12/24 (50) 161110(15)
6128 (21) 6/l 16 (5)
57 64
.03 .Ol
3122 (14) 16152 (31)
2126 (8) 6/56 (11)
44 65
.42 .Ol
14/72 (19) IO/46 (22) 4/16 (25)
6168 (9) 3162 (5) 3/14 (21)
55 78 14
.06
P Value t
.Ol >.S
Abbreviations: BCP. oral contraceptives; ES, experienced surgeon; NES. less experienced surgeon. * There was no statistical difference in the rate of alveolar osteitis formation between right and left teeth. t P values were calculated using Fisher’s exact test.
the extraction socket.” Multiple factors have been implicated in the etiology of alveolar osteitis, including surgical trauma,32 level of experience of the surgeon,’ smoking,4*5 use of oral contraceptives ,6*1’ perioperative corticosteroids, regional blood supand bacterial contamination.33-35 ply,‘2 Evidence suggesting that bacterial contamination is a major etiologic factor has been demonstrated repeatedly. An increased incidence of dry socket occurs in the presence of periapical infection, pericoronitis, gingivitis, periodontitis, and in patients with poor oral hygiene.i4 Patients with higher preoperative and postoperative oral microbial counts have a higher incidence of alveolar osteitis,33*34 and a higher anaerobic bacterial count may be even more important.35 Indirect evidence for the etiologic role of bacteria in the development of alveolar osteitis exists in that the use of Table 3. Incidence of Alveolar Osteltis-The Effect of Extractlon Difficulty as Represented by Surgical Time Incidence of Alveolar Osteitis by Surgical Site in Cases Lasting Shorter than median time Experienced surgeon (c9.6 min) Inexperienced surgeon (~12.9 mitt) Longer than median time Experienced surgeon (S9 mitt) Inexperienced surgeon (212.9 mitt)
No. With Chlorhexidine I%)
No. With Placebo % Reduction (%)
6160 (10)
8150 (16)
38
o/14 (o)*
7/16 (44)
100
3154 (6)
8152 (15)
64
3116 (19)
5/16 (31)
40
Statistical significance of reduction seen with chlorhexidine using Fisher’s exact test (if no value given, then not statistically significant).
*p=
.OT _.
systemic and/or topical antibiotics dence 17.19.20.22.23.29.36.37
reduces its inci-
Support in the literature for and against the effectiveness of antimicrobial solutions for irrigation or rinsing as a preventive measure in alveolar osteitis formation is questionable. Several poorly controlled studies have produced conflicting results. Phenolated antiseptic mouthwash6 and use of a 0.2% chlorhexidine solution38.39 have been shown to decrease the incidence of alveolar osteitis. However, in a recent study,30 neither 0.12% chlorhexidine or 0.05% cetylpyridium chloride proved to be any more beneficial than normal saline as a preoperative rinse and intraoperative irrigant with respect to reduction of alveolar osteitis. Several problems with the design of each of these studies exist. Numerous variables remained uncontrolled. These include the use of multiple surgeons with varying levels of experience, inclusion of patients taking oral contraceptives without balance and assignment equally into control and placebo groups, and failure to use any rinse in the placebo group or use of a rinse differing from the experimental group by more than one ingredient. In a relatively well controlled study,40 no significant difference in the incidence of alveolar osteitis between four different perioperative rinses: normal saline, chloramine-T, povidone iodine, or sodium bicarbonate was found. The incidence of alveolar osteitis in the control group (4.5%) was much lower than that seen in other well controlled studies and it makes comparison of the significance of these results difficult. Chlorhexidine was not tested in the study. In another well controlled study, signiticant reductions in alveolar osteitis in patients using perioperative 0.2% chlorhexidine rinses with and without oral penicillin V were seen.16 In this study, the
936 decreased incidence seen with penicillin V in combination with chlorhexidine was not statistically different than that seen with chlorhexidine alone, and the incidence of alveolar osteitis seen with both of these regimens was significantly less than that seen in the control group. The results of our study would indicate a lower concentration of chlorhexidine is equally effective. The greater incidence of alveolar osteitis in women not using oral contraceptives was unexpected. A reduction of alveolar osteitis in both groups (those using and not using oral contraceptives) was achieved with chlorhexidine. Previous studies have found as much as a 300% increase in the incidence of alveolar osteitis in patients using oral contraceptives.6 An explanation for the lack of this observation in the present study is that the subgroup of patients using oral contraceptives was small, and younger patients with less complicated teeth tended to be the patients using oral contraceptives. These variables may have had more of an effect on decreasing the incidence of alveolar osteitis than the use of oral contraceptives had on increasing it. Although an attempt was made to evaluate the incidence of alveolar osteitis according to difficulty of extraction as represented by surgical time, doing so produced too small of a sample size to yield statistically significant results. The trend was for reduction in the incidence of alveolar osteitis in all groups using chlorhexidine for both surgeons. Even though this study examined a relatively large number of extraction sites (278), because of the control of multiple variables, it was not possible to achieve statistically significant results when data were broken down into subgroups such as oral contraceptive use, age, and length of extraction. It should not be overlooked, however, that in most cases the incidence of alveolar osteitis was reduced by 50% or more in those patients using chlorhexidine compared with placebo for each of these subgroups. Acknowledgment I would like to thank the following people for assistance with this project: Larry Peterson, DDS, George Rebitski, Victoria Vick, RDH, and Timothy Conley, DDS.
References 1. Osbom TP, Frederickson G, Small IA, et al: A prospective study of complications related to mandibular third molar surgery. J Oral Maxillofac Surg 43:767, 1985 2. Heasman PA, Jacobs DJ: A clinical investigation into the incidence of drv socket. Br J Oral Maxillofac Sura 22:11.5, 1984 3. Sisk AL, Hammer WB, Shelton DW, et al: Complications following removal of impacted third molars: The role of the experience of the surgeon. J Oral Maxillofac Surg 44:855, 1986
CHLORHEXIDINE
RINSE AND ALVEOLAR
OSTEITIS
4. Sweet JB, Butler DP: The relationship of smoking to localised osteitis. J Oral Surg 13:160, 1979 5. Meecham JG, Macgregor IDM. Roger SN, et al: The effect of smoking on immediate post extraction socket tilling with blood and on the incidence of painful socket. Br J Oral Maxillofac Surg 26:402, 1988 6. Lilly GE, Osbom DB, Rae1 EM, et al: Alveolar osteitis associated with mandibular third molar extractions, J Am Dent Assoc 88:802, 1974 7. Schow SR: Evaluation of postoperative localized osteitis in mandibular third molar surgery. Oral Surg 38:352, 1974 8. Gersel-Pedersen N: Blood fibrinolytic activity before and after oral surgery. Int J Oral Surg 6:42, 1977 9. Sweet JB. Butler DP: Increased incidence of postoperative localized osteitis in mandibular third molar surgery associated with patients using oral contraceptives. Am J Obstet Gynecol 127:518, 1977 10. Catellani JE: Review of factors contributing to dry socket through enhanced fibrinolysis. J Oral Surg 37:42, 1979 11. Catellani 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 12. Howe GL: Minor Oral Surgery (ed 3). Wright, Bristol, 1985, P390 13. Sweet JB, Butler DP: Predisposing and operative factors: Effect on the incidence of localized osteitis in mandibular third molar surgery. Oral Surg 46:206, 1978 14. Awang MN: The aetiology of dry socket: A review. Int Dent J 39:236, 1989 15. Rood JP, Murgatroyd J: Metronidazole in the prevention of dry socket. Br J Oral Surg 17:345, 1979 16. Krekmanov L, Nordenram A: Postoperative complications after surgical removal of mandibular third molars: Effects of penicillin V and chlorhexidine. Int J Oral Maxillofac Surg 15:25. 1986 17. Mitchell DA: A controlled clinical trial of prophylactic tindazole for chemoprophylaxis in third molar surgery. Br Dent J 160:284, 1986 18. Quinley JF. Royer RQ, Groves RJ: Dry socket after mandibular odontectomy and use of soluble tetracyclin HCL. Oral Surg 13:38. 1960 19. Hall HD, Bildman BS, Hand CD: Prevention of dry socket with local application of tetracycline. J Oral Surg 29:35, 1971 20. Goldman DR. Kilgore DS, Pauzer JD, et al: Prevention of dry socket by local application of lincomycin in gelfoam. Oral Surg 35:472, 1973 21. MacGregor AJ. Hutchinson D: The effect of sulfonamide on pain and swelling following removal of ectopic 3rd molars. Int J Oral Surg 4:184, 1975 22. Syrjanen SM, Syrjanen KJ: A new combination of drugs intended to be used as preventive measures for the post extraction complication. A preliminary report. Int J Oral Surg 10:17, 1981 23. Julius LL, Hungerford RW, Nelson WJ, et al: Prevention of drv socket with local application of terra-cotril in gelfoam. J &al Maxillofac Surg 40:285, 1982 24. Schiott CR, Loe H, Jensen SB, et al: The effects of chlorhexidine mouthrinses on human oral flora. J Periodont Res 5:84, 1970 25. Veksler AE, Kayrouz GA, Newman MG: Chlorhexidine reduces salivary bacteria during scaling and rootplaning. J Dent Res 69:240. 1990 26. Belinfante LS, Marlow CD, Myers W, et al: Incidence of dry socket complications in third molar removal. J Oral Surg 31:106, 1973 27. Osbon DB: Postoperative complications following dentoalveolar surgery. Dent Clin North Am 17:483, 1973 28. Ritzau M: The prophylactic use of tranexamic acid on alveolitis sicca dolorosa. Int J Oral Surg 2:1%, 1973 29. Krekmanov L: Alveolitis after operative removal of third molars in the mandible. Int J Oral Surg 10:173, 1981 30. Berwick JE, Lessin ME: Effects of a chlorhexidine gluconate oral rinse on the incidence of alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg 48444, 1990
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MICHAEL E. LESSIN
3 I. Bim H: Fibrinolytic activity of alveolar bone in dry socket. Acta Odont Stand 30:23, 1972 32. Alling CC, Kerr DA: Trauma as a factor causing delayed repair of dental extraction sites. J Oral Surg 15:3, 1957 33. Brown LR, Merrill SS, Allen RE: Microbiologic study of intraoral wounds. J Oral Surg 28:89, 1970 34. MacGregor AJ, Hart P: Bacteria of the extraction wound. J Oral Surg 28:885, 1970 35. Krekmanov L, Hallander HO: Relationship between bacterial contamination and alveolitis after third molar surgery. Int J Oral Surg 9:274, 1980 36. Nordenram A. Sydnes G, Odengaard J: Neomycinbacitracin cones in impacted third molar sockets. Int J Oral Surg 2279, 1973
J Oral Maxillofac 49:937,
37. Bystedt H. Nord CE: Effect of antibiotic treatment on postoperative infections after surgical removal of mandibular third molars. Swed Dent J 4:27, 1980 38. Legarth J, Munster Swendsen J: Klorheksidins virkning pa vdviklingen af alveolitis sicca dolorosa efter operativ tjernelse af visdomstaender i under kaeben. Tandolgenbladeh 81:451, 1977 39. Field EA. Nind D, Varga E: The effect of chlorhexidine irrigation on the incidence of dry socket: A pilot study. Br J Oral Maxillofac Surg 26:395. 1988 40. Sweet JB. Macynski AA: Effect of antimicrobial mouth rinses on the incidence of localized alveolitis and infection following mandibular third molar surgery. Oral Surg 59:24, 1985
Surg
1991
Discussion The Effect of a Chlorhexidine Rinse on the lnctdence of Alveolar Osteitis Following the Surgical Removal of Impacted Mandibular Third Molars Michael E. Lessin, DDS Geisinger
Clinic and Medical Center.
Danville. PA
Dr Larsen presents an evaluation of the effect of a l-week, twice-a-day, preoperative rinse of chlorhexidine gluconate .12% with a similar postoperative rinse schedule using a placebo rinse without the chlorhexidine gluconate. An attempt was made to tightly control the many variables thought to effect the incidence of alveolar osteitis. The results presented show a dramatic decrease in alveolar osteitis with removal of mandibular third molars overall in those groups using the .12% chlorhexidine gluconate rinse preoperatively and postoperatively as prescribed. This is in conflict with the results presented by Bexwick and Lessin when using .12% chlorhexidine gluconate as a preoperative rinse on a one-time basis and as a diluted intraoperative socket irrigation.’ In reviewing the results, the surprisingly high incidence of alveolar osteitis in those patients not taking oral contraceptives, as compared with those who were taking them, is explained on the basis of the female taking the oral contraceptives being younger and consequently having easier teeth to remove. This is not necessarily true in many cases and perhaps the difference would have been better related to the evaluated degree of difficulty. Much effort was taken to grade the teeth according to difliculty by an independent observer, and we are told this was factored into the population treated by both the experienced and not-so-experienced surgeon. No results based on the degree of difficulty, other than short and long operating times, are included. This does not necessarily relate directly to the degree of difficulty of the teeth involved. Moreover, it is noted that the experienced surgeon performed 113 of the surgeries, compared with 31 cases performed by the less-experienced surgeon. It would seem that better case distribution between the two surgeons might have been more appropriate. In addition. the reader is not told whether the postsurgical evaluations are performed by the surgeons directly involved with the
surgery or by an independent observer. Conceivably. this could have affected the results, as the interpretation of what should or should not be treated teitis is possibly open to interpretation
as an alveolar
os-
by the postsurgical
evaluator. Although a placebo rinse not containing the .12% chlorhexidine was used and shown to be inferior, perhaps a third group using a similar placebo rinse without the 11.6% alcohol might also have been appropriate, as many of us prefer our patients not to use mouthwashes with alcohol full strength following surgery because tissue injury and fibrinolysis have been attributed to the alcohol. When looking at the racial distribution of the cases reported, a special population apparently was studied. Only 3% of the cases reported were black, 91% white, and 6% “others.” This certainly differs from the population studied by Berwick and Lessin, which was a heterogeneous military and military-dependent population. Did this affect the results? Perhaps Dr Larsen has hit on the right answer to the prevention of alveolar osteitis on a microbial-fibrinolysis basis, although it is not without some additional expense (ie, the cost of the rinse) and some potential risk tie, potential hypersensitivity and allergic reactions). Additional studies with a more heterogeneous group by race, with more women over the age of 26 using oral contraceptives, performed at different institutions, would be of interest. Until then, most of us will continue to do whatever we have done previously to control alveolar osteitis. I, for one, will use .12% chlorhexidine as a one-time preoperative rinse as a part of barrier control to decrease the microbial population and perform as precise and rapid a surgery as possible with sufficient quantites of normal saline irrigation at the completion of the surgery on each site. Most importantly, I will continue to emphasize postsurgical care and hygiene and the early return of the patient should pain not improve or become worse 72 hours after the surgery is completed.
Reference I. Berwick JE, Lessin ME: Effects of a chlorhexidine
gluconate rinse on the incidence of alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg 48444, 1990
The Effect of a Chlorhexidine Rinse on the Incidence of Alveolar Osteitis Following the Surgical Removal of Impacted Mandibular Third Molars PETER E. LARSEN, DDS* A prospective randomized double-blind placebo-controlled study was conducted with 139 patients (278 bilaterally impacted mandibular third molars) to determine the effect of a perioperative 0.12% chlorhexidine gluconate rinse on the incidence of alveolar osteitis following surgical removal of impacted mandibular third molars. A statistically significant 60% reduction in the incidence of alveolar osteitis was obtained in the chlorhexidine group compared with the placebo group. In most subgroups analyzed, chlorhexidine was associated with at least a 50% reduction in alveolar osteitis compared with control groups.
Alveolar osteitis (dry socket) following the extraction of mandibular third molars is an important postoperative problem for both the patient and surgeon. The patient experiences pain, loss of productivity, and the need for multiple return office visits. This is also costly to the surgeon, as 45% of patients who develop alveolar osteitis will require at least four additional postoperative visits in the process of managing this condition.’ Several risk factors have been identified in association with alveolar osteitis. These include increased difftculty of extraction,‘,’ an inexperienced use,6-’ ’ surgeon3 tobacco4,5 or oral contraceptive the use of perioperative corticosteroids, the use of a local anesthetic with a vacoconstrictor,” and inadequate irrigation during and after extraction.13 Fibrinolysis with subsequent loss of the blood clot is believed to be the general cause of alveolar osteitis.r4 As the primary role of bacteria in this process has been documented,‘4 the most effective method for reducing alveolar osteitis has been
through the use of agents that systemically’5-‘7 or topically’8-‘3 reduce the oral microbes within the wound. Oral rinsing with chlorhexidine has been shown to reduce the quantity of oral microbial populations,‘4725 and thus may be effective in reducing the incidence of alveolar osteitis. However, most previous studies have not been adequately controlled. To provide usable data, controlled studies are needed. The purpose of this prospective, risk-factor-controlled, double-blind study was to determine the effectiveness of a 0.12% chlorhexidine solution used as a perioperative rinse in reducing the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. Materials and Methods All patients presenting for surgical removal of bilaterally impacted mandibular third molars were considered for inclusion in the study. Patients with acute infection or those using antibiotics or requiring antibiotic prophylaxis prior to treatment were excluded. Using a computer software routine supplied by the sponsor (Procter and Gamble Co, Cincinnati, OH), balance and assignment was performed by separating the subjects by sex, oral contraceptive use within females, and by tobacco use for both sexes. Within strata subjects were randomly assigned into two groups: experimental (chlorhexidine [Peridex]) or placebo (the identical solution without chlorhexidine).
* Assistant Professor and Program Director, Department of Oral and Maxillofacial Surgery, College of Dentistry, The Ohio State University, Columbus, OH. Address correspondence and reprint requests to Dr Larsen: Department of Oral and Maxillofacial Surgery, College of Dentistry, The Ohio State University, 305 W 12th Ave, Room 2131 Pestle Hall, Columbus, OH 43210. 0 1991 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391/91/4909-0003$3.00/0
932
933
PETER E. LARSEN
At the initial appointment, patients were given a 16-0~ bottle of mouth rinse with instructions to rinse with 15 mL for 30 seconds twice per day for 1 week prior to and 1 week after surgery. Placebo and experimental rinses appeared identical, differing only by the presence of 0.12% chlorhexidine gluconate in the experimental solution. A standardized intraoral photograph of the maxillary anterior teeth was taken at this visit. Each impacted third molar was evaluated on a current panoramic radiograph and assigned a relative degree of difficulty, based on its position. A single experienced surgeon who did not participate in the surgery graded each impaction on the radiographic parameters of vertical position, location within the ramus, axial inclination, and root morphology. Random radiographs were periodically reevaluated without the grader’s knowledge to assess intrarater consistency. The operating surgeon had no knowledge of the score given to the teeth prior to extraction. Immediately prior to surgery, the patient rinsed with 15 mL of their assigned solution. All surgery was performed by one of two surgeons using a standard technique. Both surgeons had forma1 training in third molar removal, but differed in their clinical experience, one being experienced and one being inexperienced. High-speed, nitrogen-powered handpieces were used for bone removal and sectioning of teeth, and copious sterile water was used for irrigation throughout the procedure. Regardless of the method of anesthesia used, all patients received 8 mg of dexamethasone intravenously preoperatively. Two percent lidocaine with 1: 100,000 epinepherine was used for local anesthesia in all patients. Inferior alveolar nerve block and long buccal infiltration were performed on each side. Following tooth removal, 40 mL of sterile water was used to irrigate each extraction site. Silk suture (30) was used for closure of all incisions. The time necessary for extraction was recorded on a stop watch starting with the incision and ending with placement of the last suture. No intraoperative or postoperative antibiotics were given. Postoperatively, patients were instructed to begin rinsing with the prescribed rinse the day following surgery. Patients received twenty analgesic tablets (325 mg acetomenaphen with 30 mg of codeine). Patients were instructed to return in 1 week, or sooner. if any bothersome pain persisted or increased after the second day. On the seventh day, or on preceding days if pain was present, the extraction sites were evaluated for abnormal healing, including exposed bone. presence of necrotic tissue, and loss of clot. Patients who had not returned prior to the seventh day were questioned about increasing pain during the postoperative period. Al-
veolar osteitis was defined as persistent or increasing postoperative pain beginning after the second day, which was associated with necrotic tissue in the socket, exposed bone, or loss of the clot on clinical examination. A record was made of the volume of rinse solution used. Prior to performing the statistical analyses, it was determined that each extraction site should be treated independently. Therefore, the analyses were performed with teeth as the sampling unit as opposed to the subject being the sampling unit. The data were analyzed using Fisher’s exact test. Results One hundred fifty patients were enlisted into the study. Eleven failed to continue the study to completion. One hundred thirty-nine patients for whom data were recorded satisfactorily completed the study, were in compliance with required rinse use, and were included in these results. Sixty-seven patients used placebo and 72 used chlorhexidine. The subjects were well balanced according to all recorded presurgical variables between the experimental and placebo groups (Table I ). Patients were also evenly distributed between the two surgeons with respect to these variables. The rate of formation of alveolar osteitis was analyzed individually for the right and left teeth. There was no statistical difference in the rate of formation between the two sides. There were 12 of 144 extraction sites with alveolar osteitis in the chlorhexidine group (8%) and 28 of 134 sites developed alveolar osteitis in the placebo group (21%) (P = .Ol). Alveolar osteitis developed in 9 of 114 extraction sites in patients in the chlorhexidine group treated by the experienced surgeon (8%), while 16 of 102 sites in the placebo group developed alveolar osteitis (16%). The patients of the less experienced surgeon had alveolar osteitis in 3 of 30 sites in the chlorhexidine group (10%) and 12 of 32 sites in the placebo group (38%) (Table 2). This represents a 50% (P = .06) reduction and a 73% (P = .Ol) reduction in the incidence of alveolar osteitis over that seen in the placebo group for the experienced and less experienced surgeon, respectively. Patients who used tobacco had an increased incidence of alveolar osteitis in both the chlorhexidine and placebo groups. In the nonsmoking group, placebo patients had 16 of 110 sites develop alveolar osteitis (15%), compared with 6 of 116 (5%) in the chlorhexidine group. This reduction was statistically significant (P = .Ol). In the smoking group, placebo patients had 12 of 24 sites develop alveolar osteitis (.50%), while it occurred in only 6 of 28 sites (21%) in the chlorhexidine group (P = .03) (Table 2).
934
CHLORHEXIDINE
Table 1. Distribution of Patients According to Monitored Variables
Sex Male Female Age (yr) 18-22 23-26 >26 Race Black White Other Tobacco Yes No Oral contraceptive Yes No Radiographic score Right Left Time (min) Right Left
Chlorhexidine
Placebo
32 41
30 37
34 32
36 23 8
67 5
3 60 4
14 59
12 55
13 28
11 26
8.4 8.4
8.3 8.0
5.8 5.3
5.5 5.7
There was no statistical difference in distribution between the placebo and chlorhexidine groups.
of patients
Of the 78 female patients included in the study, 24 were using oral contraceptives at the time of treatment. In the patients not using oral contraceptives, 6 of 56 extraction sites in the chlorhexidine group developed alveolar osteitis (11%) and 16 of 52 sites in the placebo group developed alveolar osteitis (31%). This reduction was statistically significant (P < .Ol). In those patients using oral contraceptives, the chlorhexidine group had 2 of 26 (8%) sites with alveolar osteitis and the placebo group had 3 of 22 (14%). This reduction in patients using oral contraceptives was not statistically significant most likely due to the small number of patients using oral contraceptives (Table 2). In the age range of 18 to 22 years, 9% of extraction sites in patients using chlorhexidine developed alveolar osteitis, while 19% of the placebo sites did so. In the ages 23 to 26, 5% of extraction sites in patients using chlorhexidine developed alveolar osteitis compared with 22% of the sites in those using placebo. In those patients over age 26, 21% of the sites in patients using chlorhexidine developed alveolar osteitis, while 25% of the sites in those using placebo did. The decreases seen with chlorhexidine approached statistical significance for age group 18 to 22 (P = .06), was significant for age group 23 to 26 (P < .Ol) but was not statistically significant in patients over 26 years old when looked at individually. There was a trend towards a greater incidence of alveolar osteitis in patients over 26 years of age in both the chlorhexidine and control groups.
RINSE AND ALVEOLAR
OSTEITIS
Separate analyses for each surgeon according to extraction time were performed by making a frequency distribution of the total extraction time (tooth 17 plus tooth 32) for each surgeon separately and by arraying the times from low to high and separating the subjects based on median time into low and high times. The median time for the experienced surgeon was 9.6 minutes and for the inexperienced surgeon was 12.9 minutes. In both the short and long extraction times, the trend was for a decreasing incidence of alveolar osteitis in the chlorhexidine group for both surgeons when compared with placebo. For the more experienced surgeon, chlorhexidine was associated with a decrease in the incidence of alveolar osteitis of 38% for the shorter cases and 64% in the longer cases, when compared with the placebo. For the less experienced surgeon, the chlorhexidine also appeared to reduce the incidence during both short and long extraction times, with a 100% reduction in the shorter time and 40% reduction in the longer time over that seen in the placebo group. Due to decrease in sample size secondary to creation of multiple subgroups, only the reduction seen for the less experienced surgeon in shorter cases was statistically significant (P < .05) (Table 3). Comparison of pretreatment photographs with posttreatment photographs of the maxillary anterior teeth revealed no evidence of staining in either the experimental or control group. There were no adverse reactions to the solution. Discussion
The incidence of alveolar osteitis following routine extraction of erupted teeth has been reported as 1% to 3%.2,‘4 The reported incidence following the extraction of impacted mandibular third molars ranges from 1% to 65%.26*27This great variability is most likely due to differences in diagnostic criteria and uncontrolled variation within the population evaluated. If only well controlled, prospective studies with carefully defined diagnostic criteria are considered, the incidence of alveolar osteitis falls in The incidence of the range of 20% to 3 1%. 16,19,28-30 alveolar osteitis in the placebo group in this study, 21%, corresponds well with these previous studies. It has been reported that 45% of patients who developed alveolar osteitis following third molar extractions needed four or more postoperative office visits before symptoms resolved.’ This represents significant pain and suffering for the patient and could have a substantial economic impact on the patient as well as the practitioner. The pathogenesis of alveolar osteitis appears to result from the conversion of plasminogen to plasmin resulting in fibrinolysis of the blood clot within
935
PETER E. LARSEN
Table 2.
Incidence of Alveolar Osteltis
Incidence by Site*
No. With Placebo (%)
No. With Chlorhexidine (%)
% Reduction
Overall ES NES Tobacco Yes No Women BCP-Yes BCP-No Age 18-22 23-26 >26
28/134 (21) 16/102 (16) I?/32 (38)
12/144 (8) 9/l 14 (8) 3/30 (10)
60 50 73
.Ol .06 .Ol
12/24 (50) 161110(15)
6128 (21) 6/l 16 (5)
57 64
.03 .Ol
3122 (14) 16152 (31)
2126 (8) 6/56 (11)
44 65
.42 .Ol
14/72 (19) IO/46 (22) 4/16 (25)
6168 (9) 3162 (5) 3/14 (21)
55 78 14
.06
P Value t
.Ol >.S
Abbreviations: BCP. oral contraceptives; ES, experienced surgeon; NES. less experienced surgeon. * There was no statistical difference in the rate of alveolar osteitis formation between right and left teeth. t P values were calculated using Fisher’s exact test.
the extraction socket.” Multiple factors have been implicated in the etiology of alveolar osteitis, including surgical trauma,32 level of experience of the surgeon,’ smoking,4*5 use of oral contraceptives ,6*1’ perioperative corticosteroids, regional blood supand bacterial contamination.33-35 ply,‘2 Evidence suggesting that bacterial contamination is a major etiologic factor has been demonstrated repeatedly. An increased incidence of dry socket occurs in the presence of periapical infection, pericoronitis, gingivitis, periodontitis, and in patients with poor oral hygiene.i4 Patients with higher preoperative and postoperative oral microbial counts have a higher incidence of alveolar osteitis,33*34 and a higher anaerobic bacterial count may be even more important.35 Indirect evidence for the etiologic role of bacteria in the development of alveolar osteitis exists in that the use of Table 3. Incidence of Alveolar Osteltis-The Effect of Extractlon Difficulty as Represented by Surgical Time Incidence of Alveolar Osteitis by Surgical Site in Cases Lasting Shorter than median time Experienced surgeon (c9.6 min) Inexperienced surgeon (~12.9 mitt) Longer than median time Experienced surgeon (S9 mitt) Inexperienced surgeon (212.9 mitt)
No. With Chlorhexidine I%)
No. With Placebo % Reduction (%)
6160 (10)
8150 (16)
38
o/14 (o)*
7/16 (44)
100
3154 (6)
8152 (15)
64
3116 (19)
5/16 (31)
40
Statistical significance of reduction seen with chlorhexidine using Fisher’s exact test (if no value given, then not statistically significant).
*p=
.OT _.
systemic and/or topical antibiotics dence 17.19.20.22.23.29.36.37
reduces its inci-
Support in the literature for and against the effectiveness of antimicrobial solutions for irrigation or rinsing as a preventive measure in alveolar osteitis formation is questionable. Several poorly controlled studies have produced conflicting results. Phenolated antiseptic mouthwash6 and use of a 0.2% chlorhexidine solution38.39 have been shown to decrease the incidence of alveolar osteitis. However, in a recent study,30 neither 0.12% chlorhexidine or 0.05% cetylpyridium chloride proved to be any more beneficial than normal saline as a preoperative rinse and intraoperative irrigant with respect to reduction of alveolar osteitis. Several problems with the design of each of these studies exist. Numerous variables remained uncontrolled. These include the use of multiple surgeons with varying levels of experience, inclusion of patients taking oral contraceptives without balance and assignment equally into control and placebo groups, and failure to use any rinse in the placebo group or use of a rinse differing from the experimental group by more than one ingredient. In a relatively well controlled study,40 no significant difference in the incidence of alveolar osteitis between four different perioperative rinses: normal saline, chloramine-T, povidone iodine, or sodium bicarbonate was found. The incidence of alveolar osteitis in the control group (4.5%) was much lower than that seen in other well controlled studies and it makes comparison of the significance of these results difficult. Chlorhexidine was not tested in the study. In another well controlled study, signiticant reductions in alveolar osteitis in patients using perioperative 0.2% chlorhexidine rinses with and without oral penicillin V were seen.16 In this study, the
936 decreased incidence seen with penicillin V in combination with chlorhexidine was not statistically different than that seen with chlorhexidine alone, and the incidence of alveolar osteitis seen with both of these regimens was significantly less than that seen in the control group. The results of our study would indicate a lower concentration of chlorhexidine is equally effective. The greater incidence of alveolar osteitis in women not using oral contraceptives was unexpected. A reduction of alveolar osteitis in both groups (those using and not using oral contraceptives) was achieved with chlorhexidine. Previous studies have found as much as a 300% increase in the incidence of alveolar osteitis in patients using oral contraceptives.6 An explanation for the lack of this observation in the present study is that the subgroup of patients using oral contraceptives was small, and younger patients with less complicated teeth tended to be the patients using oral contraceptives. These variables may have had more of an effect on decreasing the incidence of alveolar osteitis than the use of oral contraceptives had on increasing it. Although an attempt was made to evaluate the incidence of alveolar osteitis according to difficulty of extraction as represented by surgical time, doing so produced too small of a sample size to yield statistically significant results. The trend was for reduction in the incidence of alveolar osteitis in all groups using chlorhexidine for both surgeons. Even though this study examined a relatively large number of extraction sites (278), because of the control of multiple variables, it was not possible to achieve statistically significant results when data were broken down into subgroups such as oral contraceptive use, age, and length of extraction. It should not be overlooked, however, that in most cases the incidence of alveolar osteitis was reduced by 50% or more in those patients using chlorhexidine compared with placebo for each of these subgroups. Acknowledgment I would like to thank the following people for assistance with this project: Larry Peterson, DDS, George Rebitski, Victoria Vick, RDH, and Timothy Conley, DDS.
References 1. Osbom TP, Frederickson G, Small IA, et al: A prospective study of complications related to mandibular third molar surgery. J Oral Maxillofac Surg 43:767, 1985 2. Heasman PA, Jacobs DJ: A clinical investigation into the incidence of drv socket. Br J Oral Maxillofac Sura 22:11.5, 1984 3. Sisk AL, Hammer WB, Shelton DW, et al: Complications following removal of impacted third molars: The role of the experience of the surgeon. J Oral Maxillofac Surg 44:855, 1986
CHLORHEXIDINE
RINSE AND ALVEOLAR
OSTEITIS
4. Sweet JB, Butler DP: The relationship of smoking to localised osteitis. J Oral Surg 13:160, 1979 5. Meecham JG, Macgregor IDM. Roger SN, et al: The effect of smoking on immediate post extraction socket tilling with blood and on the incidence of painful socket. Br J Oral Maxillofac Surg 26:402, 1988 6. Lilly GE, Osbom DB, Rae1 EM, et al: Alveolar osteitis associated with mandibular third molar extractions, J Am Dent Assoc 88:802, 1974 7. Schow SR: Evaluation of postoperative localized osteitis in mandibular third molar surgery. Oral Surg 38:352, 1974 8. Gersel-Pedersen N: Blood fibrinolytic activity before and after oral surgery. Int J Oral Surg 6:42, 1977 9. Sweet JB. Butler DP: Increased incidence of postoperative localized osteitis in mandibular third molar surgery associated with patients using oral contraceptives. Am J Obstet Gynecol 127:518, 1977 10. Catellani JE: Review of factors contributing to dry socket through enhanced fibrinolysis. J Oral Surg 37:42, 1979 11. Catellani 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 12. Howe GL: Minor Oral Surgery (ed 3). Wright, Bristol, 1985, P390 13. Sweet JB, Butler DP: Predisposing and operative factors: Effect on the incidence of localized osteitis in mandibular third molar surgery. Oral Surg 46:206, 1978 14. Awang MN: The aetiology of dry socket: A review. Int Dent J 39:236, 1989 15. Rood JP, Murgatroyd J: Metronidazole in the prevention of dry socket. Br J Oral Surg 17:345, 1979 16. Krekmanov L, Nordenram A: Postoperative complications after surgical removal of mandibular third molars: Effects of penicillin V and chlorhexidine. Int J Oral Maxillofac Surg 15:25. 1986 17. Mitchell DA: A controlled clinical trial of prophylactic tindazole for chemoprophylaxis in third molar surgery. Br Dent J 160:284, 1986 18. Quinley JF. Royer RQ, Groves RJ: Dry socket after mandibular odontectomy and use of soluble tetracyclin HCL. Oral Surg 13:38. 1960 19. Hall HD, Bildman BS, Hand CD: Prevention of dry socket with local application of tetracycline. J Oral Surg 29:35, 1971 20. Goldman DR. Kilgore DS, Pauzer JD, et al: Prevention of dry socket by local application of lincomycin in gelfoam. Oral Surg 35:472, 1973 21. MacGregor AJ. Hutchinson D: The effect of sulfonamide on pain and swelling following removal of ectopic 3rd molars. Int J Oral Surg 4:184, 1975 22. Syrjanen SM, Syrjanen KJ: A new combination of drugs intended to be used as preventive measures for the post extraction complication. A preliminary report. Int J Oral Surg 10:17, 1981 23. Julius LL, Hungerford RW, Nelson WJ, et al: Prevention of drv socket with local application of terra-cotril in gelfoam. J &al Maxillofac Surg 40:285, 1982 24. Schiott CR, Loe H, Jensen SB, et al: The effects of chlorhexidine mouthrinses on human oral flora. J Periodont Res 5:84, 1970 25. Veksler AE, Kayrouz GA, Newman MG: Chlorhexidine reduces salivary bacteria during scaling and rootplaning. J Dent Res 69:240. 1990 26. Belinfante LS, Marlow CD, Myers W, et al: Incidence of dry socket complications in third molar removal. J Oral Surg 31:106, 1973 27. Osbon DB: Postoperative complications following dentoalveolar surgery. Dent Clin North Am 17:483, 1973 28. Ritzau M: The prophylactic use of tranexamic acid on alveolitis sicca dolorosa. Int J Oral Surg 2:1%, 1973 29. Krekmanov L: Alveolitis after operative removal of third molars in the mandible. Int J Oral Surg 10:173, 1981 30. Berwick JE, Lessin ME: Effects of a chlorhexidine gluconate oral rinse on the incidence of alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg 48444, 1990
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MICHAEL E. LESSIN
3 I. Bim H: Fibrinolytic activity of alveolar bone in dry socket. Acta Odont Stand 30:23, 1972 32. Alling CC, Kerr DA: Trauma as a factor causing delayed repair of dental extraction sites. J Oral Surg 15:3, 1957 33. Brown LR, Merrill SS, Allen RE: Microbiologic study of intraoral wounds. J Oral Surg 28:89, 1970 34. MacGregor AJ, Hart P: Bacteria of the extraction wound. J Oral Surg 28:885, 1970 35. Krekmanov L, Hallander HO: Relationship between bacterial contamination and alveolitis after third molar surgery. Int J Oral Surg 9:274, 1980 36. Nordenram A. Sydnes G, Odengaard J: Neomycinbacitracin cones in impacted third molar sockets. Int J Oral Surg 2279, 1973
J Oral Maxillofac 49:937,
37. Bystedt H. Nord CE: Effect of antibiotic treatment on postoperative infections after surgical removal of mandibular third molars. Swed Dent J 4:27, 1980 38. Legarth J, Munster Swendsen J: Klorheksidins virkning pa vdviklingen af alveolitis sicca dolorosa efter operativ tjernelse af visdomstaender i under kaeben. Tandolgenbladeh 81:451, 1977 39. Field EA. Nind D, Varga E: The effect of chlorhexidine irrigation on the incidence of dry socket: A pilot study. Br J Oral Maxillofac Surg 26:395. 1988 40. Sweet JB. Macynski AA: Effect of antimicrobial mouth rinses on the incidence of localized alveolitis and infection following mandibular third molar surgery. Oral Surg 59:24, 1985
Surg
1991
Discussion The Effect of a Chlorhexidine Rinse on the lnctdence of Alveolar Osteitis Following the Surgical Removal of Impacted Mandibular Third Molars Michael E. Lessin, DDS Geisinger
Clinic and Medical Center.
Danville. PA
Dr Larsen presents an evaluation of the effect of a l-week, twice-a-day, preoperative rinse of chlorhexidine gluconate .12% with a similar postoperative rinse schedule using a placebo rinse without the chlorhexidine gluconate. An attempt was made to tightly control the many variables thought to effect the incidence of alveolar osteitis. The results presented show a dramatic decrease in alveolar osteitis with removal of mandibular third molars overall in those groups using the .12% chlorhexidine gluconate rinse preoperatively and postoperatively as prescribed. This is in conflict with the results presented by Bexwick and Lessin when using .12% chlorhexidine gluconate as a preoperative rinse on a one-time basis and as a diluted intraoperative socket irrigation.’ In reviewing the results, the surprisingly high incidence of alveolar osteitis in those patients not taking oral contraceptives, as compared with those who were taking them, is explained on the basis of the female taking the oral contraceptives being younger and consequently having easier teeth to remove. This is not necessarily true in many cases and perhaps the difference would have been better related to the evaluated degree of difficulty. Much effort was taken to grade the teeth according to difliculty by an independent observer, and we are told this was factored into the population treated by both the experienced and not-so-experienced surgeon. No results based on the degree of difficulty, other than short and long operating times, are included. This does not necessarily relate directly to the degree of difficulty of the teeth involved. Moreover, it is noted that the experienced surgeon performed 113 of the surgeries, compared with 31 cases performed by the less-experienced surgeon. It would seem that better case distribution between the two surgeons might have been more appropriate. In addition. the reader is not told whether the postsurgical evaluations are performed by the surgeons directly involved with the
surgery or by an independent observer. Conceivably. this could have affected the results, as the interpretation of what should or should not be treated teitis is possibly open to interpretation
as an alveolar
os-
by the postsurgical
evaluator. Although a placebo rinse not containing the .12% chlorhexidine was used and shown to be inferior, perhaps a third group using a similar placebo rinse without the 11.6% alcohol might also have been appropriate, as many of us prefer our patients not to use mouthwashes with alcohol full strength following surgery because tissue injury and fibrinolysis have been attributed to the alcohol. When looking at the racial distribution of the cases reported, a special population apparently was studied. Only 3% of the cases reported were black, 91% white, and 6% “others.” This certainly differs from the population studied by Berwick and Lessin, which was a heterogeneous military and military-dependent population. Did this affect the results? Perhaps Dr Larsen has hit on the right answer to the prevention of alveolar osteitis on a microbial-fibrinolysis basis, although it is not without some additional expense (ie, the cost of the rinse) and some potential risk tie, potential hypersensitivity and allergic reactions). Additional studies with a more heterogeneous group by race, with more women over the age of 26 using oral contraceptives, performed at different institutions, would be of interest. Until then, most of us will continue to do whatever we have done previously to control alveolar osteitis. I, for one, will use .12% chlorhexidine as a one-time preoperative rinse as a part of barrier control to decrease the microbial population and perform as precise and rapid a surgery as possible with sufficient quantites of normal saline irrigation at the completion of the surgery on each site. Most importantly, I will continue to emphasize postsurgical care and hygiene and the early return of the patient should pain not improve or become worse 72 hours after the surgery is completed.
Reference I. Berwick JE, Lessin ME: Effects of a chlorhexidine
gluconate rinse on the incidence of alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg 48444, 1990
