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Alveolar osteitis (AO), commonly known as dry socket, represents one of the most common and painful complications following tooth extraction, particularly after mandibular third molar removal. This report synthesizes findings from multiple meta-analyses examining chlorhexidine’s effectiveness in preventing this condition.
Current meta-analytic evidence strongly supports chlorhexidine’s role in preventing alveolar osteitis following tooth extractions. A comprehensive meta- analysis by Rodríguez Sanchez et al. (2017) reviewed 18 trials spanning from 1979 to 2015, examining 2,824 third molar extractions. Their findings revealed an overall relative risk (RR) of 0.53, indicating that chlorhexidine treatment reduces dry socket incidence by approximately 47%.7, 8. The number needed to treat was determined to be 8, meaning that for every 8 patients treated with chlorhexidine, one case of alveolar osteitis would be prevented 7, 8
Another meta-analysis by Rodríguez-Pérez et al. (2017) specifically evaluated 0.2% chlorhexidine gel, finding it reduced alveolar osteitis risk by 62% following mandibular third molar extractions (RR = 0.38)1. Similarly, a double- blind randomized clinical trial involving 822 patients demonstrated that chlorhexidine 0.12% mouthwash reduced AO incidence by 63% in high-risk patients. 3.
Several meta-analyses have compared the efficacy of different chlorhexidine formulations, primarily gel versus rinse preparations. While both formulations demonstrate effectiveness, there is some evidence suggesting gel may be superior.
A 2021 meta-analysis found that 0.12% chlorhexidine rinse showed significant effectiveness (RR = 0.54), as did 0.2% chlorhexidine gel (RR = 0.39)4.Interestingly, when examining studies that directly compared rinse versus gel formulations, the gel appeared to be more effective, with a significantly lower incidence of AO in patients treated with the gel preparation (RR = 0.61). 4.
Rodríguez Sanchez’s meta-analysis compared chlorhexidine rinse (RR = 0.58) and gel (RR = 0.47), concluding that while gel was moderately more efficacious, the difference wasn’t statistically significant. 7, 8. They concluded that “chlorhexidine, in any formulation, concentration, or regimen, is efficacious and effective in preventing AO.”8.
Different concentrations of chlorhexidine have been studied across the meta- analyses, with significant evidence supporting both 0.12% and 0.2% formulations.
For rinses, a 2021 meta-analysis found 0.12% chlorhexidine rinse to be significantly effective (RR = 0.54), while 0.2% chlorhexidine rinse did not reach statistical significance (RR = 0.84) 4. Regarding gels, both 0.2% and 1% concentrations have demonstrated efficacy. A study examining 1% chlorhexidine gel showed promising results in reducing dry socket occurrence, with a significantly lower incidence in the experimental group (4%) compared to the control group (28%). 2.
The timing and frequency of chlorhexidine application appear crucial to its effectiveness. A meta-analysis examining single versus multiple rinse protocols found that multiple rinses beginning on the day of surgery and continuing for several days afterward significantly reduced AO incidence, while a single rinse showed inconclusive results. 5.
One meta-analysis reported that “rinsing with chlorhexidine on the day of the extraction and for seven days post extraction resulted in a reduction in the incidence of dry socket” 11.
Another review indicated that while 0.12% chlorhexidine rinse has demonstrated effectiveness, “0.2% chlorhexidine gel applied to the socket every 12 hours for seven days post extraction is the most effective therapeutic option” 11.
A 2012 systematic review published in Evidence-Based Dentistry identified only two effective application protocols (single application of 0.2% gel or multiple application of 0.12% rinse) but questioned the quality of evidence due to high risk of bias in the studies 9.
Several meta-analyses have noted limitations, including inability to determine the optimal dosing regimen, variations in study protocols, and difficulties evaluating differences in efficacy between formulations 7.
Across meta-analyses, chlorhexidine appears to cause minimal adverse effects compared to placebo. Reported side effects include staining of dentures and oral mucosa, taste alterations, and occasionally mild reactions such as glossitis 7. However, these effects were generally minor and did not outweigh the benefits in preventing alveolar osteitis.
The preponderance of meta-analytic evidence supports chlorhexidine’s effectiveness in preventing alveolar osteitis following tooth extractions, particularly third molar removals. Both gel and rinse formulations demonstrate efficacy, with some evidence suggesting gel formulations may be marginally superior.
Multiple applications appear more effective than single applications, with protocols extending several days after extraction showing the best results.
Future research should focus on standardizing application protocols and directly comparing different formulations and concentrations to establishoptimal clinical guidelines for preventing this painful complication of dental extractions.
1. https://onlinelibrary.wiley.com/doi/10.1111/odi.12553
2. https://www.scirp.org/journal/paperinformation?paperid=43735
3. https://www.scielo.br/j/jaos/a/mJYsxb7vy pKQMCMXCvhdJpR/
4. https://journals.lww.com/jnr- twna/fulltext/2021/02000/preventing_alveolar_osteitis_after_molar.9.aspx
5. https://www.nature.com/articles/6400333
6. https://www.medscape.com/viewarticle/881000_5
7. https://www.icpahealth.com/use-of-chlorhexidine-in-preventing-alveolar- osteitis-after-third-molar-extractions-meta-analysis/
8. https://pubmed.ncbi.nlm.nih.gov/28189661/
9. https://www.nature.com/articles/6400882
10. https://pubmed.ncbi.nlm.nih.gov/28526078/
11. https://www.lenus.ie/bitstream/handle/10147/236012/DecJanart2.pdf
12. https://pubmed.ncbi.nlm.nih.gov/15660084/
