|Year : 2017 | Volume
| Issue : 6 | Page : 265-268
Prophylactic antibiotics after extraction: Needed or not needed?
M Deepa, Deepthi Mony, Tusha Ratra
Department of Oral and Maxillofaical Surgery, Sri Rajiv Gandhi College of Dental Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||20-Dec-2017|
Dr. M Deepa
1004, Saaya Serene, Panduranga Nagar, Bengaluru - 560 076, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: Our study aimed to evaluate the need to prescribe antibiotics before every extraction even in healthy individuals. Materials and Methods: A prospective, randomized clinical trial was done on 483 patients who were indicated for undergoing extraction under local anesthesia. The patients were evaluated for signs of infection that included pain, edema, fever, pus discharge, erythema, and decreased interincisal opening. They were evaluated on the 1st, 3rd, and 7th postoperative day for the same. The patient was considered to have an active infection if they showed pain and any other two signs of infections. Statistical Analysis: Descriptive and inferential statistical analysis has been carried out in the present study. Results: Out of the 483 patients evaluated two patients had pain and showed slight edema and erythema. These patients were considered as having an active infection and were prescribed therapeutic antibiotics. Conclusion: In our study, 0.4% showed signs of active infection after undergoing extraction without prophylactic antibiotics. Further studies have to be undertaken to create definitive guidelines for prescribing antibiotics after extraction.
Keywords: Antibiotic prophylaxis, antibiotics, extractions, prophylactic antibiotics
|How to cite this article:|
Deepa M, Mony D, Ratra T. Prophylactic antibiotics after extraction: Needed or not needed?. J Int Oral Health 2017;9:265-8
|How to cite this URL:|
Deepa M, Mony D, Ratra T. Prophylactic antibiotics after extraction: Needed or not needed?. J Int Oral Health [serial online] 2017 [cited 2019 Aug 24];9:265-8. Available from: http://www.jioh.org/text.asp?2017/9/6/265/221255
| Introduction|| |
Extraction is probably the most frequently and one of the most basic procedures performed in an oral surgery practice. Extraction is considered as a clean-contaminated surgery and sometimes a dirty surgery, especially in those cases involving a concomitant incision and drainage of an abscess. The prescription of antibiotics as prophylaxis in patients who are neither medically compromised nor having a frank infection is not scientifically justified and is therefore controversial. The principles that every antibiotic prophylaxis should follow were classically defined by Peterson. First, it was mentioned that the local infection risk of any surgical procedure had to be >10% to receive antibiotic prophylaxis. The risk of infection following surgical extraction of third molars is small (precisely between 1% and 6%). This value is even lower in other teeth.
This study was aimed to evaluate the need to prescribe prophylactic antibiotics after routine extraction under local anesthesia.
| Materials and Methods|| |
A prospective, randomized evaluation study was carried out on 483 patients. The institutional review board gave ethical clearance before the study started. A sample size of 500 patients was initially taken, but out of which 17 patients had not returned for the 1st postoperative day, hence, were not considered part of the study.
The study group consisted of patients, who reported to the Department of Oral and Maxillofacial Surgery, who were indicated for extraction. Our study was done to evaluate the need to prescribe prophylactic antibiotics after extraction under local anesthesia. All healthy individuals of both genders, who were at least 18 years of age were taken as part of the study. Only patients who were willing to be a part of the study were considered, and a written informed consent was obtained. They were explained about the follow-up required for the study. Baseline measurements of mouth opening were done before the start of the procedure.
Patients who were medically compromised, female patients who are pregnant or lactating and those with active signs of infection were not included in the study. Patients who were known cases of diabetes mellitus, but under medication and with control of blood sugar level were also considered as part of the study.
Before all procedures, an informed written consent was obtained from every patient. All procedures were done using aseptic precautions. Patients were given chlorhexidine mouthwash before the procedure. Local anesthetic, i.e., 2% lignocaine hydrochloride with 1:80,000 epinephrine, was administered as per requirement. The tooth was extracted, and the socket was inspected and debrided. Hemostasis was achieved. Interrupted sutures were given as and when required using 3–0 braided silk. After all extractions, patients were given standard postoperative instructions and analgesics for 5 days.
An evaluation was done on the patients on the 1st, 3rd, and 7th postoperative day. A visual analog scale assessed the severity of the patient's pain perception; 100 mm in length, where “0” is marked as “no pain” and “10” is “marked as most severe pain imaginable.” The severity of edema was assessed as none, slight, average and much. The interincisal distance was measured, and any decrease in value was noted. The presence or absence of fever was assessed. The presence or absence of erythema was assessed. The presence or absence of pus discharge was assessed. Patients were considered to have active infection postoperatively if they were positive for any of the two criteria mentioned above along with pain. They were considered to have an active infection if they had presented with pus discharge (with or without any other symptom) at the site of extraction. These patients were given rescue medication of antibiotics.
The data obtained was analyzed using statistical computer software SPSS 11.0 (Statistical Package for Social Sciences 11.O version of SPSS Inc.) Descriptive and inferential statistical analysis was done in the present study. Results on continuous measurements are offered on mean ± standard deviation (Min-Max) and results on categorical measurements are shown in number (%). The significance is assessed at 5% level of significance. Paired proportion test has been used to find the significance on paired proportion basis. P value was noted to be suggestive significance (0.05 < P < 0.10), moderately significant (0.01 < P ≤ 0.05), and strongly significant (P ≤ 0.01).
| Results|| |
In this study, 483 patients were evaluated for the need of prescribing antibiotics after routine extraction procedure under local anesthesia. Based on the data that were collected the following was deduced. The pain score [Table 1] was evaluated and showed that on the 1st postoperative day 70.8% of the patients had mild pain while 9.7% patients had moderate pain and 2.3% had severe pain. By the 7th postoperative day, 91.1% patients had no pain while no patients had severe pain. A statistically significant reduction in the pain was noted on the 7th postoperative day (P < 0.001). One of the patients was lost to follow-up on the 7th postoperative day [Table 2].
The patients were examined for erythema at the extraction site. On the 3rd postoperative day, four patients reported with erythema adjacent to the extraction site (that is 0.8%) probably due to the fact that the inflammation is highest on that day. The increase in edema was statistically significant on day 3 (P = 0.002). None of the patients presented with erythema on the 7th postoperative day [Table 3].
Out of 483 patients, ten patients presented with slight edema on the 3rd postoperative day which completely resolved by the 7th postoperative day. The incidence of edema increased significantly on the 3rd postoperative day with P < 0.001 and then decreased at the 7th day [Table 4].
The interincisal distance decreased in five patients on the 3rd postoperative day, it resolved in all the patients except one. The cause of the trismus was determined to be multiple inferior alveolar nerve blocks, and the patient was prescribed muscle relaxants and taught mouth opening exercises [Table 5].
Out of the 483 patients, two patients (0.4%) had moderate pain as well as slight edema and erythema adjacent to the extraction socket. Hence, according to the criteria of our study, these patients were considered as having an active infection and were prescribed therapeutic antibiotics. No patient presented with fever or pus discharge.
| Discussion|| |
Although the dangers of the misuse of antibiotics, in particular, the emergence of resistance, have been known for decades, recent exposure has brought these concerns into better focus. Newspaper and magazine articles have increased public awareness. Professional articles and editorials have substantiated the consequences of misuse of antibiotics and advocated their prudent use in both medicine and dentistry.
Classically, we recognize certain circumstances as infection risk factors. These include long-lasting surgical procedures >3 h, significant ostectomy degree, previous pericoronitis episodes, placement of foreign bodies at the surgical site (hemostatic materials or even sutures). In addition, poorly controlled metabolic diseases, diseases that interfere with host defences or those taking immunosuppressive drugs are also risk factors susceptible to infection.,
Oral and maxillofacial surgery is performed in an environment that is potentially contaminated with a large quantity of bacteria, and considering that the main postoperative complications are caused by these endogenous microorganisms, the prescribing of antibiotics is deemed to be reasonable for the prevention and reduction of the frequency of postoperative complications. However, the incidence of such complications is low, and hence, no consensus is observed in the choice of administration of antibiotics.
The study was conducted to determine if there was a need to prescribe antibiotics after each and every extraction which is the norm in clinical practice. In our study, we included 483 patients of which only 0.4% of the patient needed to be prescribed therapeutic antibiotics.
Here, we have also included a few patients who had diabetes but with a good control and did not prescribe antibiotics after routine extractions for them. We found that they too did not develop any signs of infection and underwent uneventful healing. Aseptic precautions and use of chlorhexidine mouthwash before the procedure were followed diligently. The patients were also instructed on maintenance of oral hygiene during the postoperative phase. The incidence of postoperative infection was low in our study.
However, this topic has had many conflicting reports and studies, there have been reports that antibiotic use after extraction reduces the occurrence of infection., While various studies done by MacGregor, Sands, Rodrigues et al., and Calvo et al. do not recommend antibiotics for routine third molar surgeries. Further studies done by Prajapati et al., Xue et al., Poeschl et al., and Sidana et al. have also shown that routine administration of antibiotics after extraction is not required.
A trend has been noticed where there is an increased prescription of antibiotics by dentists specifically as opposed to other medical professionals,, as well as a lack of adequate knowledge regarding prescription of antibiotics. As a public health preventative measure, dentists must consider the risks of overuse of antibiotics and must be educated about it. The disadvantage of indiscriminate prescription of antibiotics includes increased risk for allergic/toxic reactions and can lead to antibiotic-resistant microorganisms.
Continuing education programs for practitioners concerning the public health risks, related to the over-prescription of antibiotics, and monitoring the prescription of antibiotics are needed. It is estimated that 6%–7% of patients receiving antibiotics experience some kind of adverse reaction. Hence, the advantages of antibiotic therapy in a patient must exceed the risk of adverse outcomes.
The goal of antibiotic prophylaxis in oral surgery is to prevent the onset of infections through the entranceway provided by the therapeutic action. Therefore, antibiotics are indicated where there is a considerable risk of infection, either because of the characteristics of the operation itself or the patient's local or general condition. An aseptic approach to the surgical site and careful surgical technique to minimize trauma would seem to be the most appropriate mechanisms to minimize these negative outcomes of extraction; many investigators have evaluated antibiotics for their effect on these problems.
The future direction of this study would be to take a larger sample size. Further, any patients who do report with surgical site infection should be examined for the possible cause of infection, a culture should be taken from the extraction socket, and a culture and sensitivity test should be performed to determine the ideal antibiotic to be prescribed to the patient.
| Conclusion|| |
Our study contributes to the data required to achieve a definitive guideline to prescribe antibiotics for extraction. With the help of the various studies done a definitive guideline should be developed for prescription of antibiotics after extraction for the ease of following for the dentist.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sancho-Puchades M, Herráez-Vilas JM, Berini-Aytés L, Gay-Escoda C. Antibiotic prophylaxis to prevent local infection in oral surgery: Use or abuse? Med Oral Patol Oral Cir Bucal 2009;14:E28-33.
Peterson LJ. Antibiotic prophylaxis against wound infections in oral and maxillofacial surgery. J Oral Maxillofac Surg 1990;48:617-20.
Loukota RA. The effect of pre-operative perioral skin preparation with aqueous povidone-iodine on the incidence of infection after third molar removal. Br J Oral Maxillofac Surg 1991;29:336-7.
MacGregor AJ. Aetiology of dry socket: A clinical investigation. Br J Oral Surg 1968;6:49-58.
Halpern LR, Dodson TB. Does prophylactic administration of systemic antibiotics prevent postoperative inflammatory complications after third molar surgery? J Oral Maxillofac Surg 2007;65:177-85.
Moreno-Drada JA, García-Perdomo HA. Effectiveness of antimicrobial prophylaxis in preventing the spread of infection as a result of oral procedures: A Systematic review and meta-analysis. J Oral Maxillofac Surg 2016;74:1313-21.
Marcussen KB, Laulund AS, Jørgensen HL, Pinholt EM. A systematic review on effect of single-dose preoperative antibiotics at surgical osteotomy extraction of lower third molars. J Oral Maxillofac Surg 2016;74:693-703.
MacGregor AJ. Reduction in morbidity in the surgery of the third molar removal. Dent Update 1990;17:411-4.
Sands T, Pynn BR, Nenniger S. Third molar surgery: Current concepts and controversies. Part 1. Oral Health 1993;83:11-4.
Rodrigues WC, Okamoto R, Pellizzer EP, dos Carrijo AC, de Almeida RS, de Melo WM, et al.
Antibiotic prophylaxis for third molar extraction in healthy patients: Current scientific evidence. Quintessence Int 2015;46:149-61.
Calvo AM, Brozoski DT, Giglio FP, Gonçalves PZ, Sant'ana E, Dionísio TJ, et al.
Are antibiotics necessary after lower third molar removal? Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:S199-208.
Prajapati A, Prajapati A, Sathaye S. Benefits of not prescribing prophylactic antibiotics after third molar surgery. J Maxillofac Oral Surg 2016;15:217-20.
Xue P, Wang J, Wu B, Ma Y, Wu F, Hou R, et al.
Efficacy of antibiotic prophylaxis on postoperative inflammatory complications in Chinese patients having impacted mandibular third molars removed: A split-mouth, double-blind, self-controlled, clinical trial. Br J Oral Maxillofac Surg 2015;53:416-20.
Poeschl PW, Eckel D, Poeschl E. Postoperative prophylactic antibiotic treatment in third molar surgery – A necessity? J Oral Maxillofac Surg 2004;62:3-8.
Sidana S, Mistry Y, Gandevivala A, Motwani N. Evaluation of the need for antibiotic prophylaxis during routine intra-alveolar dental extractions in healthy patients: A Randomized double-blind controlled trial. J Evid Based Dent Pract 2017;17:184-9.
Marra F, George D, Chong M, Sutherland S, Patrick DM. Antibiotic prescribing by dentists has increased: Why? J Am Dent Assoc 2016;147:320-7.
Arteagoitia MI, Ramos E, Santamaría G, Álvarez J, Barbier L, Santamaría J, et al.
Survey of Spanish dentists on the prescription of antibiotics and antiseptics in surgery for impacted lower third molars. Med Oral Patol Oral Cir Bucal 2016;21:e82-7.
Halboub E, Alzaili A, Quadri MF, Al-Haroni M, Al-Obaida MI, Al-Hebshi NN, et al.
Antibiotic prescription knowledge of dentists in kingdom of Saudi Arabia: An online, country-wide survey. J Contemp Dent Pract 2016;17:198-204.
Schwartz AB, Larson EL. Antibiotic prophylaxis and postoperative complications after tooth extraction and implant placement: A review of the literature. J Dent 2007;35:881-8.
Gutiérrez JL, Bagán JV, Bascones A, Llamas R, Llena J, Morales A, et al.
Consensus document on the use of antibiotic prophylaxis in dental surgery and procedures. Med Oral Patol Oral Cir Bucal 2006;11:E188-205.
Zeitler DL. Prophylactic antibiotics for third molar surgery: A dissenting opinion. J Oral Maxillofac Surg 1995;53:61-4.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]