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 Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 5  |  Page : 13-17  

Necessity of antibiotics to reduce inflammatory complications after third molar extractions: A prospective study

1 General Practitioner, Ministry of Health, Al Qassim, Saudi Arabia
2 General Practitioner, King Fahad Specialist Hospital, Ministry of Health, Al Qassim, Saudi Arabia
3 General Practitioner, Prince Sultan Hospital, Ministry of Health, Ash-Sharqiyyah, Saudi Arabia
4 General Practitioner, Ministry of Health, Alhassa, Saudi Arabia

Date of Web Publication7-Feb-2019

Correspondence Address:
Dr. Mohammed jafnan al harbi
General Practitioner, Ministry of Health, Al Qassim
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPBS.JPBS_232_18

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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±6.3kg/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.

Keywords: Alveolar osteitis, antibiotic, extraction, surgical site infection, third molar

How to cite this article:
al harbi Mj, A Alomaym M, Mohammed Aldohan M, Fahad Alkurdi I. Necessity of antibiotics to reduce inflammatory complications after third molar extractions: A prospective study. J Pharm Bioall Sci 2019;11, Suppl S1:13-7

How to cite this URL:
al harbi Mj, A Alomaym M, Mohammed Aldohan M, Fahad Alkurdi I. Necessity of antibiotics to reduce inflammatory complications after third molar extractions: A prospective study. J Pharm Bioall Sci [serial online] 2019 [cited 2020 Oct 21];11, Suppl S1:13-7. Available from:

   Introduction Top

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.[1],[2] However few others did not showed any beneficial effects.[3],[4]

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 Top

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

  1. Patients who underwent M3 removal

  2. Patients whose postoperative data were available

Exclusion criteria

  1. Dental practitioners other than oral surgeons

  2. Dental practitioners outside Saudi Arabia

  3. 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 36h 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 Top

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±6.3kg/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

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Graph 1: Summary of study variables

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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

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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)

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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)

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Graph 2: Bar graph showing postoperative antibiotic exposure versus postoperative inflammatory complications (alveolar osteitis or surgical site infection)

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[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

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[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)

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   Discussion Top

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.[1], [2],[3],[6]

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 2g 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%.[10],[11] 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%).[12],[13]

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.[11],[12],[13]

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 62.5mg) or other antibiotics. Our findings are in accordance to previous similar studies.[14],[15]

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

  1. Treating physician recorded the findings

  2. Study was carried out after giving training to the doctors


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 Top

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


Conflicts of interest

There are no conflicts of interest.

   References Top

Morrow AJ, Dodson TB, Gonzalez ML, Chuang SK, Lang MS. Do postoperative antibiotics decrease the frequency of inflammatory complications following third molar removal? J Oral Maxillofac Surg 2018;76:700-8.  Back to cited text no. 1
Xue P, Wang J, Wu B, Ma Y, Wu F, Hou R. 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.  Back to cited text no. 2
Ren YF, Malmstrom HS. Effectiveness of antibiotic prophylaxis in third molar surgery: A meta-analysis of randomized controlled clinical trials. J Oral Maxillofac Surg 2007;65:1909-21.  Back to cited text no. 3
Prajapati A, Prajapati A, Sathaye S. Benefits of not prescribing prophylactic antibiotics after third molar surgery. J Maxillofac Oral Surg 2016;15:217-20.  Back to cited text no. 4
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.  Back to cited text no. 5
Dodson TB, Gonzalez ML. American association of oral and maxillofacial surgeons’ anesthesia and third molar extraction benchmark study: Rationale, methods, and initial findings. J Oral Maxillofac Surg 2016;74:903-10.  Back to cited text no. 6
Lacasa JM, Jiménez JA, Ferrás V, Bossom M, Sóla-Morales O, García-Rey C, et al. Prophylaxis versus pre-emptive treatment for infective and inflammatory complications of surgical third molar removal: A randomized, double-blind, placebo-controlled, clinical trial with sustained release amoxicillin/clavulanic acid (1000/62.5mg). Int J Oral Maxillofac Surg 2007;36:321-7.  Back to cited text no. 7
Monaco G, Staffolani C, Gatto MR, Checchi L. Antibiotic therapy in impacted third molar surgery. Eur J Oral Sci 1999;107:437-41.  Back to cited text no. 8
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;114:199-208.  Back to cited text no. 9
Courvalin P. Why is antibiotic resistance a deadly emerging disease? Clin Microbiol Infect 2016;22:405-7.  Back to cited text no. 10
Parthasarathi K, Smith A, Chandu A. Factors affecting incidence of dry socket: A prospective community-based study. J Oral Maxillofac Surg 2011;69:1880-4.  Back to cited text no. 11
Sigron GR, Pourmand PP, Mache B, Stadlinger B, Locher MC. The most common complications after wisdom tooth removal: Part 1: A retrospective study of 1,199 cases in the mandible. Swiss Dent J 2014;124 (10):1042-6, 1052-6.  Back to cited text no. 12
Pourmand PP, Sigron GR, Mache B, Stadlinger B, Locher MC. The most common complications after wisdom tooth removal: Part 2: A retrospective study of 1,562 cases in the maxilla. Swiss Dent J 2014;124 (10):1047-51, 1057-61.  Back to cited text no. 13
Macy E. Penicillin and beta-lactam allergy: Epidemiology and diagnosis. Curr Allergy Asthma Rep 2014;14:476.  Back to cited text no. 14
Lang MS, Gonzalez ML, Dodson TB. Do antibiotics decrease the risk of inflammatory complications after third molar removal in community practices? J Oral Maxillofac Surg 2017;75:249-55.  Back to cited text no. 15


  [Graph 1], [Graph 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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