Necessity of Antibiotics to Reduce Inflammatory Complications after Third Molar Extractions: A Prospective Study.

AIMS AND
OBJECTIVES: To determine the relationship between the usage of antibiotics postoperatively and inflammatory complications following third molar extractions.
MATERIALS AND METHODS: The sample was derived from Saudi Arabia private practitioners who were oral surgeons and was randomly categorized into two groups: group A, who took postoperative antibiotics, and group B, who have not taken antibiotics. The observed primary variable was the occurrence of inflammatory complications subsequent to removal of third molar.
RESULTS: The data were obtained from 35 oral surgeons, who gave details about 725 patients in whom 965 third molars were removed. A total of 455 (62.75%) patients have taken antibiotics postoperatively. The mean age was 28 ± 14.8 years. We noticed a very high male preponderance of 543 (74.89%). Mean body mass index was 26.7 ± 6.3 kg/m2. The mean Preoperative Disease Severity Score and Operative Difficulty Score was 2.13 ± 2.1 and 12.1 ± 6.3, respectively.
CONCLUSION: Fewer postoperative inflammatory complications were observed in subjects who have taken antibiotics after third molar removal.

INTRODUCTION

Third molar (M3) removal is one of the frequent procedure in daily oral surgery (OS) practice. In few patients, inflammatory complications were observed after its removal. Even though complications are rare, owing to the large number of M3 extractions, these complications must be considered seriously and measures must be taken to limit them. One such measure adopted commonly by oral surgeons to reduce complications is by prescribing antibiotics. Few studies showed favorable effects of antibiotics in lowering postoperative inflammatory complications.[12] However few others did not showed any beneficial effects.[34]

Marcussen et al.[5] in their systematic review showed that a single preoperative dose of amoxicillin lessened the occurrence of surgical site infection (SSI) and a single dose of penicillin lessened alveolar osteitis (AO) incidence. We carried out our study to verify the relation between postoperative antibiotic usage and inflammatory complications (SSI or AO) after M3 removal. Our hypothesis was that postoperative antibiotics will lessen inflammatory complications.

MATERIALS AND METHODS

We carried a prospective cohort study. We derived the sample from the enrolled patients in a Practice-Based Research Collaborative (P-BRC) of Saudi Arabia private practitioners who were oral surgeons, from January 1, 2017, to May 31, 2018.

Inclusion criteria

Patients who underwent M3 removal

Patients whose postoperative data were available

Exclusion criteria

Dental practitioners other than oral surgeons

Dental practitioners outside Saudi Arabia

Patients with systemic diseases

The study has registered ethical committee approval and consent was obtained from all subjects (KFSH/E15A/2017). Sample size was determined from a similar studies using the formula: n = [(z∝ + zβ)σd]2. With a confidence interval of 95% and power of 95% for the study, a sample size of 35 was obtained. The sample was randomly categorized in to two study groups: group A, in whom postoperative antibiotic was given, and group B, where antibiotic was not prescribed. The observed primary variable was occurrence and type of inflammatory complication (AO or SSI) after M3 removal. SSI was considered if there was a frank purulence at the extraction site or edema postoperatively. AO was diagnosed on basis of a history of new-onset or increased pain after 36 h postoperatively and clinically at extraction site showing loss of blood clot with exposed bone. Other aspects assessed were gender, age, body mass index (BMI), habits, and medical history.

Before extractions, Preoperative Disease Severity Score (PDS) was assessed by adding the whole number of preoperative disease conditions such as caries, periodontal disease, infection, resorption, fracture, adjacent tooth pathology, or supra eruption. If M3 were disease free, a zero score was assigned. Similarly Operative Difficulty Score (ODS) was measured by a scale of 0 to 6 (0, M3 not extracted; 1, erupted, nonsurgical removal; 2, erupted, surgical; 3, impacted in soft tissue; 4, impacted in bone partially; 5, impacted in bone fully; 6, impacted in bone, complicated or difficult).

Thus obtained data were entered on a Microsoft Excel sheet and descriptive statistics were computed for all the study variables using SPSS 22.0 software program (SPSS® Statistics; IBM, Armonk, NY). A P value of less than 0.05 was treated as significant.

RESULTS

Thirty-five oral and maxillofacial surgeons took part in the P-BRC. A total of 972 patients were enrolled with 1396 third molars removed. When the desired data regarding whether antibiotic was used or not were considered, the sample reduced to 725 in whom 965 M3 were removed. We found that 455 (62.75%) patients have taken antibiotics postoperatively.

Demographic details showed that the mean age was 28 ± 14.8 years. We observed a very high male preponderance of 543 (74.89%). Mean BMI was 26.7 ± 6.3 kg/m2. Habit history revealed 114 patients (15.72%) were consuming tobacco in some or other forms. The average number of M3 removed per person was 1.33. The mean PDS per patient was 2.13 ± 2.1 and the mean ODS was 12.1 ± 6.3 [Table 1 and Graph 1].

Table 1

Summary of study variables

Variable	Value
Mean age	28 ± 14.8 years
No. of males	543 (74.89%)
No. of females	182 (25.11%)
Mean BMI	26.7 ± 6.3 kg/m2
No. of patients with tobacco habit history	114 (15.72%)
No. of third molars removed per person	1.33
Mean PDS	2.13 ± 2.1
Mean ODS	12.1 ± 6.3
No. of patients who have taken antibiotics postoperatively	455 (62.75%)

Graph 1

Summary of study variables

Bivariate association among the antibiotic usage and study variables was tabulated [Table 2]. The variables age and PDS showed statistically significant relationship with the usage or not of antibiotic, whereas BMI, ODS, and presence or absence of complications were insignificant.

Table 2

Bivariate analyses of all study variables versus postoperative antibiotic exposure

Variable	Usage of antibiotic		P value
	Yes	No
Age (years)	29.13 ± 4.56	27.31 ± 4.86	<0.001*
Gender
Males	285 (52.49%)	258 (47.51%)	<0.001*
Females	130 (71.43%)	52 (28.57%)
BMI (kg/m2)	26.62 ± 3.63	26.79 ± 3.42	0.5336
ODS	11.92 ± 5.97	12.30 ± 5.89	0.7026
PDS	2.49 ± 2.1	1.88 ± 1.8	0.0469*
Complications	18 (48.65)	19 (51.35%)	0.0677

* = Significant

Bivariate association among the inflammatory complications and study variables was also tabulated [Table 3]. The variables gender, usage of tobacco, and ODS were associated with developing inflammatory complications, whereas age, BMI, and PDS were insignificant.

Table 3

Bivariate analyses of all study variables versus postoperative inflammatory complications (surgical site infection or alveolar osteitis)

Variable	Complications		P value
	Yes	No
Age (years)	29.01 ± 4.56	28.71 ± 4.86	0.7138
Gender
Males	21 (56.75%)	522 (75.87%)	0.0016*
Females	16 (43.25%)	166 (24.13%)
BMI (kg/m2)	26.56 ± 3.54	26.80 ± 3.52	0.6864
ODS	11.32 ± 5.72	13.08 ± 5.91	<0.001*
PDS	2.11 ± 1.9	2.23 ± 2.12	0.4315
Tobacco habit	33 (89.19%)	4 (10.81%)	0.0002*

* = Significant

Bivariate associations among antibiotic usage and inflammatory complications was recorded [Table 4 and Graph 2]. The association showed that 63.73% patients took antibiotics. Frequency of inflammatory complications in the antibiotic group alone was 2.92% compared with 17.27% in the nonantibiotic group (relative risk [RR] = 0.17; 95% confidence interval [CI] = 2.8131 to 18.1790; P = 0.022).

Table 4

Postoperative antibiotic exposure versus postoperative inflammatory complications (alveolar osteitis or surgical site infection)

Inflammatory Complication (AO or SSI)	Yes	No	Total
Yes—postoperative antibiotics	18 (2.48%)	597 (82.34%)	615 (84.82%)
No antibiotics	19 (2.62%)	91 (12.55%)	110 (15.18%)
Total	37 (5.10%)	688 (94.89%)	725 (100%)

Relative risk = 0.17; 95% confidence interval, 0.0919 to 0.3125; P < 0.001.

Graph 2

Bar graph showing postoperative antibiotic exposure versus postoperative inflammatory complications (alveolar osteitis or surgical site infection)

Table 5 depicts the unadjusted association among antibiotic usage and AO. Incidence of AO in the antibiotic group was 4.0% compared with 6.3% in the nonantibiotic group (RR = 0.1677; 95% CI = 0.0854 to 0.3292; P < 0.0001).

Table 5

Postoperative antibiotic versus alveolar osteitis—unadjusted model

Inflammatory complication (AO)	Yes	No	Total
Yes—postoperative antibiotic only	15 (2.06%)	600 (82.75%)	615 (84.82%)
No antibiotics	16 (2.20%)	94 (12.96%)	110 (15.18%)
Total	31 (4.26%)	694 (95.74%)	725 (100%)

Relative risk = 0.1677; 95% confidence interval, 0.0854 to 0.3292; P < 0.0001.

Table 6 shows the unadjusted association among antibiotic usage and SSIs. Incidence of SSI in the antibiotic group was 0.5% compared with 2.73% in the nonantibiotic group (RR = 0.1789; 95% CI = 0.0366 to 0.8748; P = 0.0336).

Table 6

Postoperative antibiotic exposure versus postoperative inflammatory complications (surgical site infection)

Inflammatory complication (AO or SSI)	Yes	No	Total
Yes—postoperative antibiotic only	3 (0.41%)	612 (84.41%)	615 (84.82%)
No antibiotics	3 (0.41%)	107 (14.76%)	110 (15.18%)
Total	6 (0.82%)	719 (99.17%)	725 (100%)

Relative risk = 0.1789; 95% confidence interval, 0.0366 to 0.8748; P = 0.0336.

DISCUSSION

One of the most common surgical procedure carried out in OS clinics is M3 extractions. In most of the situations, M3 extraction is not linked with a high risk for inflammatory complications postoperatively. Generally, in cases where complications arise, they are mild and get resolved fairly rapidly when appropriately treated, and characteristically display no enduring effects. Studies have shown that the inflammatory complications rate to be by and large low (<5%), but M3 removal is common enough that many patients undergo extractions day-by-day basis resulting in recording possible inflammatory complications.[1236]

We noticed a statistically significant lower inflammatory complications in those who took antibiotics postoperatively than those who didn’t (P < 0.001). Our results are in accordance to Lacasa et al.,[7] who found that postoperative amoxicillin and clavulanic acid twice a day was more effective than single preoperative dose in lessening infection rates after surgical M3 extractions.

Conversely Monaco et al.[8] revealed that a postoperative amoxicillin 2 g for 5 days did not lessened postoperative complications considerably in comparison to controls. Calvo et al.[9] also observed akin findings of insignificant enhancement in postoperative events in persons who have not taken antibiotics postoperatively.

Studies revealed that the most common complication after M3 extraction is AO, frequency ranging between 4% and 30%.[1011] In our study, AO was seen in 4.7% of all enrolled patients (postoperative antibiotic group, 2.43%; nonantibiotic group, 14.54%).

Generally the occurrence of SSIs after M3 removal was shown to range between 1% and 27% but normally is seen in less than 5% of cases. We found SSI in 0.83% of all the patients (postoperative antibiotic group, 0.49%; nonantibiotic group, 2.73%).[1213]

Basically oral cavity contains a large variety of bacteria. Even though many presurgical safety measures (i.e., chlorhexidine rinses, antibiotics, sterile instruments) are taken to reduce the bacterial content, the vast number of normally inhabitant bacteria cause inherent surgical site contamination. Even after few studies, the issue of prescribing antibiotics for effectual prevention and reduction of postoperative inflammatory complications is still debated. Although antibiotics are irrefutably potent means in fighting infection, the possibility for adverse reactions and bacterial resistance should be cautiously weighed in comparison to their prospective benefits.[111213]

Studies regarding the incidence of allergies to penicillin and cephalosporins found it to be at 9% and 1%, respectively. Bacterial resistance is a major menace for which no one can predict rates of resistance and dissemination. Medical professionals should make sure that the advantage of averting occasional infectious complications outweighs the negatives of abundant antibiotic prescribing.[14]

In spite of the lacking consensus, antibiotic prescription related with M3 extractions remains widespread practice worldwide including among Saudi Arabia–based and US-based OS practitioners. In our P-BRC, 62.75% of sample have taken antibiotics in some form. We also found significant variations among OS practitioners of the study area in relation to time and route of administration, dosage, and type of antibiotic used. But there was a lack of standardization regarding the aspects such as type, dosage, frequency, and length of postoperative antibiotic administration. Various antibiotics prescribed by OS practitioners were amoxicillin, clindamycin, erythromycin, amoxicillin, and clavulanic acid (1000 and 62.5 mg) or other antibiotics. Our findings are in accordance to previous similar studies.[1415]

All the observations concerned with inflammatory complications were recorded by treating clinician after training them regarding our study methodology and variables AO and SSI standard definitions.

Strengths of the study

Treating physician recorded the findings

Study was carried out after giving training to the doctors

Limitations

Other aspects that were not assessed regarding usage of antibiotics by OS were duration of surgery, amount of tissue trauma, systemic conditions of patients. Other limitation of our study is that we did not considered factors related to the competence and general characteristics of OS such as ability, technique used, level of training taken by them, training location, and practice location.

Future research directions

In future, studies with larger sample size and more standardized model of postoperative antibiotic management, uniform postsurgical follow-up, and impending blinding of participants should be carried out.

CONCLUSION

Our results implies that antibiotic therapy after M3 removal revealed a slightly reduced risk for inflammatory complications (AO or SSI). Although the sample was adequately large to present statistically pertinent data, the study results may not represent real clinical situation. In future, studies with a larger, more uniform sample with consistent postextraction follow-up and probable blinding of subjects to variables being gauged would be valuable to verify or refute the present observations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.