I Oral Maxillofac l244-1245.

Surg

1990

USE OF CHLORHEXIDINETO PREVENT ALVEOLAR OSTEITIS

groups, making statistical significance of any conclusion questionable. In his discussion, Dr Hall fails to identify these experimental shortcomings, but rather suggests that other mechanisms for prevention of alveolar osteitis be employed rather than oral rinses. As this is a pilot study, perhaps these suggestions could be incorporated into a future study and lead to meaningful clinical data.

rc~theEditor:-The clinical article “Effects of a Chlorlexidine Gluconate Oral Rinse on the Incidence of Alveolar Osteitis in Mandibular Third Molar Surgery” by I.E. Bet-wick and M.E. Lessin (J Oral Maxillofac Surg $8444, 1990) attempts to establish the significance and rationale for using clorhexidine gluconate 0.12% (PeriJex; Procter & Gamble, Cincinnati, OH) as a rinse and u-rigation to reduce the incidence of alveolar osteitis after mandibular third-molar removal. The authors did not, however, adequately control this study, making their conclusions invalid. It is well established in the literature that alveolar asteitis is a multifactorial process. Factors associated with an increased incidence of alveolar osteitis include an inexperienced surgeon/resident, difficult or traumatic extractions, increased age, and oral contraceptive and tobacco use. In this study, a relatively small number of patients (80), were divided into four treatment groups. An attempt was made to distribute extractions according to type. However, one must realize that merely classifying a tooth as erupted, soft-tissue impaction, partial bony impaction, or complete bony impaction hardly indicates the difficulty of the extraction. An unbiased examiner should have been employed to aid in distribution of the extractions by radiographic difficulty among the four groups. Although the authors mention that patients taking oral contraceptives were not excluded from the study, there is no indication that these patients were randomly balanced and assigned to the four treatment groups. Lilly et al’ noted a 300% increase in alveolar osteitis in women taking oral contraceptives. A lack of equal distribution of these patients could markedly affect the results of this study. There was no mention of whether smokers were included or not. In a study performed by Sisk et al,* staff oral and maxillofacial surgeons experienced a significantly lower incidence of dry sockets when compared with residents performing similar extractions. The current study involved multiple surgeons, some of which were residents. No indication was given that each type of surgeon was equally represented in each of the four groups. Even if the surgeons were all equally distributed among the groups, this would further divide the already small number of patients in each group into even smaller sub-

PETER E. LARSEN, DDS Columbus, Ohio

References 1.Lilly GE, Osbon DB, Rae1 EM, et al: Alveolar osteitis associated with mandibular third molar extractions. J Am Dent Assoc 8302, 1974 2. 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 44355, 1986 The author replies:-Dr Larsen’s comments about our article point out a weakness in clinical articles. Each patient and surgical procedure is unique; the number of variables among the patients and surgery are infinite. The variables controllable by the researcher are limited. Establishing true equivalency among test and control groups is very difficult. The validity of any one clinical study is certainly more suspect than some other types of research. Validation by repetition of research is important. In specific response to Dr Larsen’s criticisms, we would like to offer the following points: while the etiology of alveolar osteitis is affected by a multitude of factors, the most widely held theory of pathogenesis is based on Birn’s studies,’ which focus on increased fibrinolysis within the alveolus due to the presence of a local bacterial infection. The rationale of our using antimicrobial agents in the prevention of local osteitis is that bacterial infection is the initiating factor in the pathogenesis of dry socket. We designed our study ta control variables we felt were most appropriate to the rationale of our study. Dr Larsen’s points concerning oral contraceptives, smoking, and age were not considered of primary importance in this study of antimicrobials and were not controlled. Dr Larsen points out that the clinical study by Sisk el al2 shows a significant difference in the incidence 01 alveolar osteitis between patients treated by residents and those treated by staff surgeons. In our study, the residents operating were experienced military exodontists for a minimum of 2 years before beginning formal training. The possibility of some difference in incidence of alveolar osteitis between surgeons exists, but we do not consider it of great enough significance to invalidate the results. Dr Larsen is in error as to our attempting to distribute extractions by type. Subjects were assigned randomly to test groups or the control group if they were healthy,

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Use of chlorhexidine to prevent alveolar osteitis.

I Oral Maxillofac l244-1245. Surg 1990 USE OF CHLORHEXIDINETO PREVENT ALVEOLAR OSTEITIS groups, making statistical significance of any conclusion...
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