O riginal Article

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CONTROLLED CLINICAL TRIAL TO UNDERSTAND THE NEED FOR

ANTIBIOTICS DURING ROUTINE DENTAL EXTRACTIONS
1

Murali R 2Satish Kumaran 3Vinay KN

Professor and Head, Department of Public Health Dentistry, Krishnadevaraya College of Dental Sciences, Bengaluru,
India.

Reader, Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Barielly, UP, India.

Senior Lecturer, Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Barielly, UP, India.

Correspondence: Murali R, Professor and Head, Department of Public Health Dentistry, Krishnadevaraya College of Dental Sciences,
Bengaluru ,India. Email: iyemurali@gmail.com
Received Nov 15, 2011; Revised Dec 8, 2011; Accepted Dec 24, 2011

ABSTRACT
Introduction: Antibiotics are the most potent tools available for health care professionals to combat the myriad
infections affecting the humans. However, improper and rampant use of antibiotics over the years had led to resistant
organisms causing antibiotic resistant diseases. Antibiotic use in dentistry is also reaching epidemic proportions and
quite a few prescriptions are not warranted.
Aim: The purpose of this study was to better understand the need for antibiotics during routine dental extractions. The
hypothesis at the start of the study was that antibiotics are essential for routine dental extractions.
Materials and methods: A randomized control trial was designed to understand the need for prescribing antibiotics
post extraction.
Results: The results showed that contrary to expectations, subjects who did not take antibiotics had event free healing
experience as compared to those who were administered antibiotics.
Conclusion: This study suggests that prescription of antibiotics after routine extractions are not required and thus
one of the most common practices of abusing antibiotics can be avoided.
Keywords: Antibiotics, extraction, bacteria, infection.
INTRODUCTION
The abuse of antibiotics among dental health
professionals is reaching alarming proportions and we may
soon reach a day when the most powerful tool available to
combat microbial attack may become less effective.
Remedial measures have to be initiated to prevent further
deterioration of the problem and we should stop the
indiscriminate use of antibiotics. Antibiotics have to be
prescribed in those patients who are having underlying
systemic problems like diabetes mellitus, immunodeficiencies, etc. Antibiotics are indicated for myriad
conditions among which some of the more common are
dentoalveolar abcesses, pericoronitis and fascial space
infections secondary to a dental causes1.
It is generally observed that most dentists
prescribe antibiotics post extraction assuming that the
healing will be uneventful, patients would not complain of
pain and recall visits could be minimized. However, recent
studies show that antibiotics are not recommended for
routine extractions1,2,3. The common practice of prescribing
antibiotics post extraction has minimal effect as bacteremia

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has already occurred as a result of extraction and the

defense mechanism can cope with the healing process. For
different reasons, most dentists prescribe antibiotics post
extraction and this has become such a common feature that
the patients themselves request a prescription.
MATERIALSAND METHODS
A randomized, controlled trial was designed to determine if
antibiotics were necessary post extraction to aid in healing
process with the hypothesis that antibiotics are required
for routine dental extractions. Patients who needed routine
extractions only were included based on inclusion and
exclusion criteria. The study group consisted of individuals
who were prescribed antibiotics post extraction (amoxicillin
500mg, TID for 3 days) while the participants in the control
group were not prescribed antibiotics post extraction. The
scientific proven regimen is amoxicillin 500mg, TID for 5-7
days. The standard protocol used in the department of oral
surgery of the college, was amoxicillin 500mg, eight hourly
for a minimum of three days4,5,6. The study was designed to
follow the protocol being practiced in the department to
mimic the real life situation. It is important to maintain

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Murali R et al

internal validity of the study rather than alter the protocol

specifically for the study. The final year students and interns
were routinely allotted patients on a rotation basis and the
procedure was carried out under supervision by the faculty
members. The purpose of the study was to evaluate whether
there was any difference in the healing process post
extraction among the two groups. In order to promote patient
compliance and eliminate bias, both the groups were
administered an across the counter multivitamin (Vitamin B
complex) table. The usual time taken for extraction was about
20 minutes and there were no reported complications.

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Formula).The patients in the age groups over 60

were more likely to be medically compromised and
firm teeth were a rarity in this age group.)
3.

Patients with teeth that could not be salvaged or

those who preferred extraction only.

Exclusion Criteria:
1.

Chronic oral infections.

2.

Immune compromised patients.

In order to evaluate the healing process, pain and

discomfort post extraction among the two groups, it was
imperative that the patient returns for evaluation after a
week. In an effort to improve patient compliance and to
make sure all the cases were evaluated, a single suture was
placed after extraction and specific instructions given to
the patient to return after a week to get the suture removed.

3.

Patients on specific drugs.

4.

Tobacco users in any form.

5.

Chronic alcoholics

6.

Pregnant and lactating mothers.

RANDOMIZATION AND BLINDING

7.

Patients receiving chemotherapy or radiation

therapy.

8.

Patients already on antibiotics before seeking care

at our hospital.

9.

Patients needing total extraction or with severe

periodontitis.

Randomization was done by allotting cases and

controls on a lottery basis with odd numbers favoring
antibiotic administration and for even numbers, no antibiotic
was administered. The cases and controls were recalled
after one week for evaluation and to determine the healing
process. The participants, the primary investigator and the
evaluator were blinded to which group they belonged. The
evaluation was done based on standard criteria of oral
examination and checking for classical symptoms of
infection and the healing process recorded for both the
groups. We were looking for no evidence of post extraction
swelling, edema, pain and any localized pus discharge from
the extraction site.
SAMPLE SIZE
A total of one hundred subjects were included
equally dividing them between the two groups and a
decision to keep the sample size at one hundred was made
to eliminate bias and improve the validity of the study.
Inclusion Criteria:
1.

Healthy individuals who visit the department of

oral and maxillofacial surgery as outpatients for
routine extractions.

2.

Males and females between the ages of 15 and 60

years. (Most patients in the lower age group had
very few indications for extractions the emphasis
being on preservation as also they required a much
lower dose as compared to adults(Youngs

10. Patients suffering from trauma or other

pathologies.
STATISTICALANALYSIS
The data were reviewed for completeness and to
develop a coding scheme. Then the data was entered on
Microsoft Excel after assigning specific codes for all the
variables. The data was analyzed using SPSS Version 13
statistical package. Descriptive analyses including
percentages, averages and measures of central tendency
were used.
RESULTS
Of the 100 subjects enrolled, 99 patients reported
back for suture removal and thus evaluation was possible
(fig-1). Fifteen subjects had pain and possible infection
post extraction.
The interesting feature, contrary to expectations,
was that, of these fifteen subjects, twelve patients
belonged to the group that took antibiotics and only three
patients who did not take antibiotics developed pain and
localized infection (purulent drainage or dry socket).

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Controlled Clinical Trial To Understand The Need For Antibiotics During Routine Dental Extractions

Looking at the sex distribution of the fifteen

patients who developed pain and possible infection, six
were females and nine males. Further, four female patients
and eight male patients who were on antibiotic cover
developed pain and infection (there was calor, rubor, dolor
and swelling) (fig-2a, b). Comparing the age of the patients
who developed inflammation, there was no particular trend.
A teenager who underwent extraction of premolars for
orthodontic treatment and an elderly patient with chronic
generalized periodontitis developed infection / dry socket.
However, almost 50% of patients who developed
inflammation were diagnosed to have chronic irreversible
pulpitis, followed by 25% with chronic generalized
periodontitis (fig-3). Looking at teeth distribution,
mandibular extractions (73%) had more predilection for
inflammation compared to the maxillary teeth. Mandibular
molar extraction followed by mandibular premolars seemed
to contribute most for the inflammation.

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Fig: 3Distribution of patients who developed infection

post antibiotic administration (ORTHO-Orthodontic
treatment, IM-Infected Molar, GP-Grossly Destructed tooth,
CIP-Chronic Infective Pulpitis, CGP-Chronic Generalized
Periodontitis, CAP-Chronic Apical Periodontitis, AIP-Acute
Infective Pulpitis, AAP-Acute Apicial Periodontitis).
DISCUSSION

Fig: 1 Proportion of Females and Males in the study

Fig: 2aDistribution of subjects who developed

infection with administration of antibiotics.

Fig: 2bDistribution of subjects who developed

infection without antibiotic administration.

Our study clearly shows that for routine

extractions, the bodys defence mechanism is able to take
care of the healing process without having to administer
antibiotics. Antibiotics are often employed as drugs of
fear7, 8 used to cover for errors of omission or commission
and thereby prevent claims of negligence. Approximately
one-half of all antibiotics employed in hospitals are in
patients without signs or symptoms of infection, and in
many cases are used to prevent infections or to ensure that
all was done to prevent later criticism9.
The use of antibiotics to prevent post-treatment
infections by giving the drugs after any dental procedure
(loading dose, drug in the system before surgery begins,
only against a single pathogen, only as long as bacteremia
persists, proper risk-cost/benefit ratio) completely violates
all the principles of antibiotic prophylaxis10. Antibiotic
prophylaxis for the prevention of surgical infections is only
effective if the drug is in the system before the procedure
begins and then only in clean/clean or clean/contaminated
surgery where the drug is discontinued shortly after the
surgery is completed11. The mouth is one of the most heavily
contaminated areas of the body and may not qualify under
this scenario. The pharmacokinetics of antibiotics ensures
that an antibiotic begun sometime after the dental procedure
and without a loading dose may achieve significant blood
levels six to twelve hours after the procedure or sometime
the next day when the issue of whether an infection occurs
has already been decided (in the vast majority of cases
against a postoperative infection).8,12,13
Although no clinical trials have demonstrated the
efficacy of antibiotics in managing acute apical abscesses
that spread into fascial spaces, their use is reasonable. 14-18

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Murali R et al

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The choice of antibiotic is empirical because no definitive

information on the causative pathogenic microorganisms
is available. However, it is known that oral infections are
usually of mixed bacteria with a predominance of obligate
anaerobes19-22. It has been theorized that this diffuse
infection is mediated by streptococci, which elicit factors
that facilitate the rapid spread of bacteria and the infection
through the tissues.23 The antibiotic of choice is penicillin,
administered orally and with aggressive dosages24.

molarextraction in young patients. J Oral Maxillofac Surg.2009 Jul;67(7):146772.

Contrary to the common expectation that patients

on antibiotics will have event free healing, this study
showed that maximum patients with dry sockets were on
antibiotic cover (80%). However, no attempt was made to
validate whether the intervention group completed the
course of antibiotics. The results are an eye opener for
general dentists to shun the rampant use of antibiotics for
routine procedures and be selective in prescribing based
on need. Nature can help heal in most cases without having
to resort to the use of antibiotics.

9. Kunin CA, Editorial response: Antibiotic armageddon. Clin Infect Dis, 1997,
25(2):240-241.

There could be some inherent flaws in the study

which could have contributed to the results. There was no
check/ verification done on whether the patients who were
prescribed antibiotics completed the course or not. Strict
norms were followed and sterilization and asepsis was
maintained for all patients. However, the technique of
extraction could have varied among the patients.
CONCLUSION
This study suggests that prescription of antibiotics
after routine extractions are not required and thus one of
the most common practices of abusing antibiotics can be
avoided. However, antibiotics are one of the most important
tools in preventing morbidity and mortality and extreme
care and discretion should be used while prescribing these
drugs.

6. Al-Asfour A. Postoperative infection after surgical removal of impacted

mandibularthirdmolars: ananalysis of 110 consecutiveprocedures. Med Princ
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appraisal of standardization, aetiopathogenesis and management: a critical review.
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8. Thomas J. Pallasch, DDS, MS.Global Antibiotic Resistance and Its Impact on
the Dental Community, J Calif Dent Assoc. 2000 Mar;28(3):215-33.

10. Pallasch TJ, Gill CJ, Microbial resistance to antibiotics. J Cal Dent Assoc
1986,14(5):25-7.
11. Pallasch TJ, Slots J, Antibiotic prophylaxis and the medically compromised
patient. Periodontol 1996, 10:107-38.
12. Pallasch TJ, Pharmacokinetic principles of antimicrobial therapy. Periodontol
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13. Pallasch TJ, How to use antibiotics effectively. J Cal Dent Assoc 1993,
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14. Lypka M, Hammoudeh J. Dentoalveolar infections. Oral Maxillofac Surg Clin
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15. J Am Dent Assoc. 2010 Jul;141(7):861-6. Cervical necrotizing fasciitis
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16. Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of
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17. Da Lilly-tariah OB, Onotai LO. Abscess of the deep cervical fascial space in
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18. Regueiro Villarn S, Vzquez Barro JC, Herranz Gonzlez-Botas J. Deep
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19. Walton RE, Zerr M, Peterson L. Antibiotics in dentistrya boon or
bane?1997.APUA Newsletter15(1):1-5.
20. Dahlen G, Moller A., Jr . Microbiology of endodontic infection. In: Slots J,
Taubman MA, editors. Contemporary Oral Microbiology and immunology. St.
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