Use of Chlorhexidine in Preventing Alveolar Osteitis After Third Molar Extractions [Meta-Analysis]

Date: 8th May 2018

Alveolar osteitis or dry socket is one of the most common complications arising from the extraction of permanent teeth. While this condition can occur with the extraction of any tooth, it is 10 times more likely in third molars than in other teeth.

There is little understanding of the etiopathogenesis of alveolar osteitis. However, one of the leading theories believes it to be linked to the decomposition of the fibrin blood clot that forms at the bottom of a socket, post tooth extraction. The condition can be very painful and may continue to cause discomfort several days after the extraction and may also be accompanied by bad breath.

This often results in increasing the economic burden for patients due to additional dentist visits and time lost from work. As a result, many strategies have been employed to reduce the occurrence of dry socket including antibiotics, antiseptic rinses, saline rinses, anti-inflammatory steroids, among others.

However, a meta-analysis concluded that chlorhexidine (in different formulations and concentration) was the only method that showed some evidence of reducing the risk of alveolar osteitis. The purpose of the systematic review was to determine the efficacy and effectiveness of chlorhexidine in the prophylaxis of alveolar osteitis post third molar extractions.

While several studies have been conducted, none have provided sufficient clinical evidence. Hence, the authors of the study, ‘Does Chlorhexidine Prevent Alveolar Osteitis After Third Molar Extractions? Systematic Review and Meta-Analysis’, Fabio Rodrı´guez Sanchez, Carlos Rodrı´guez Andres, and Iciar Arteagoitia Calvo, carried out a new meta-analysis that includes the largest number of high-quality randomized controlled trials for more reliable results.

The primary aim of this study was to:

● Compare the occurrence of dry socket in patients treated with and without chlorhexidine
● Compare the efficacy and effectiveness of chlorhexidine rinse and gel

Materials and Methods

For the meta-analysis, a study population was formed that contained all published articles on the efficacy of chlorhexidine in preventing alveolar osteitis post third molar extractions. These studies were dated from 1979 to 2015 and the eligibility criteria to be included in the meta-analysis was:

● The studies must be randomized controlled trials (RCTs) (with or without placebo).
● The patients (irrespective of age or gender) in these studies should have undergone maxillary or mandibular third molar extractions.
● These studies must have analyzed the role of only chlorhexidine (irrespective of concentration, formulation, or treatment regimen) in the prevention of dry socket.

According to the above criteria, a total of 122 records were identified. After a thorough review of these records, 18 trials were identified as relevant to the aim and included in the quantitative synthesis. Once included in the meta-analysis, 2 researchers extracted and examined the data from all 18 studies.

Results

The data from 18 trials from 1979 to 2015 revealed a total of 2824 third molar extractions (1458 in experimental and 1366 in control group), which were included in the study. Upon examination of these extractions, the meta-analysis produced the following results:

● The overall relative risk was determined to be 0.53, indicating that treating patients with chlorhexidine helps in preventing dry socket.

● The overall number needed to treat was found to be 8 (95% CI, 7-11). This suggests that 8 patients must be treated with chlorhexidine to prevent 1 case of alveolar osteitis.

● The preventable fraction indicated that 47% of the dry socket cases would have been avoided if the control group was treated with chlorhexidine.

● A comparison between the efficacy of two of the most frequently used chlorhexidine formulations (gel and rinse) revealed that the gel is comparatively more effective at preventing alveolar osteitis than the rinse. However, this difference is statistically insignificant.

● The following complications were reported by some patients with the use of chlorhexidine in 3 of the 18 trials:
    – Staining of dentures and oral mucosa
    – Alterations in taste
    – Bad taste of chlorhexidine rinse
    – Glossitis or inflammation of tongue (1 case)
    – Brief stomach upset (1 case, reported by a patient from the control group)
    – Stomatitis (1 case, reported by a patient from the control group)

Conclusion

This study proposed that a protocol should be established for prophylaxis of alveolar osteitis since it is a common occurrence after third molar extraction. Moreover, the condition results in increased health care costs and intense pain lasting for extended periods. In conclusion, chlorhexidine, used in any formulation, concentration, or regimen is effective in preventing dry socket or alveolar osteitis in patients post third molar extraction.

Limitations

The authors of this meta-analysis weren’t able to reach a conclusion regarding the:

● Best dosing regimen; since different trials used different protocols.

● Evaluation of different efficacies between the gel and rinse formulations to improve clinical application guidelines.

ICPA Products for Prevention of Dry Socket

As the study indicated, chlorhexidine is the only course of treatment that aids in the prevention of alveolar osteitis. As one of the leaders in the Indian oral healthcare segment, ICPA recommends the following two products to dentists for prevention of dry socket in third molar extractions:

Hexigel Antiseptic Mouth Gel (Chlorhexidine gluconate solution I.P. equivalent to chlorhexidine gluconate 1.0% w/w in a pleasantly flavoured base)

Hexidine Mouthwash (Chlorhexidine gluconate solution I.P. diluted to chlorhexidine gluconate 0.2% w/v in a pleasantly flavoured base)

To read the full study, click here.

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