O riginal Article www.ejournalofdentistry.

com

CONTROLLED CLINICAL TRIAL TO UNDERSTAND THE NEED FOR

ANTIBIOTICS DURING ROUTINE DENTAL EXTRACTIONS
1
Murali R 2Satish Kumaran 3Vinay KN
1
Professor and Head, Department of Public Health Dentistry, Krishnadevaraya College of Dental Sciences, Bengaluru,
India.
2
Reader, Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Barielly, UP, India.
3
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 has already occurred as a result of extraction and the

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, immuno-
deficiencies, 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
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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internal validity of the study rather than alter the protocol Formula).The patients in the age groups over 60
specifically for the study. The final year students and interns were more likely to be medically compromised and
were routinely allotted patients on a rotation basis and the firm teeth were a rarity in this age group.)
procedure was carried out under supervision by the faculty
members. The purpose of the study was to evaluate whether 3. Patients with teeth that could not be salvaged or
there was any difference in the healing process post those who preferred extraction only.
extraction among the two groups. In order to promote patient
compliance and eliminate bias, both the groups were Exclusion Criteria:
administered an across the counter multivitamin (Vitamin B
1. Chronic oral infections.
complex) table. The usual time taken for extraction was about
20 minutes and there were no reported complications. 2. Immune compromised patients.
In order to evaluate the healing process, pain and 3. Patients on specific drugs.
discomfort post extraction among the two groups, it was
imperative that the patient returns for evaluation after a 4. Tobacco users in any form.
week. In an effort to improve patient compliance and to
make sure all the cases were evaluated, a single suture was 5. Chronic alcoholics
placed after extraction and specific instructions given to
the patient to return after a week to get the suture removed. 6. Pregnant and lactating mothers.

RANDOMIZATION AND BLINDING 7. Patients receiving chemotherapy or radiation

therapy.
Randomization was done by allotting cases and
controls on a lottery basis with odd numbers favoring 8. Patients already on antibiotics before seeking care
antibiotic administration and for even numbers, no antibiotic at our hospital.
was administered. The cases and controls were recalled
after one week for evaluation and to determine the healing 9. Patients needing total extraction or with severe
process. The participants, the primary investigator and the periodontitis.
evaluator were blinded to which group they belonged. The
10. Patients suffering from trauma or other
evaluation was done based on standard criteria of oral
pathologies.
examination and checking for classical symptoms of
infection and the healing process recorded for both the STATISTICALANALYSIS
groups. We were looking for no evidence of post extraction
swelling, edema, pain and any localized pus discharge from The data were reviewed for completeness and to
the extraction site. develop a coding scheme. Then the data was entered on
Microsoft Excel after assigning specific codes for all the
SAMPLE SIZE variables. The data was analyzed using SPSS Version 13
statistical package. Descriptive analyses including
A total of one hundred subjects were included
percentages, averages and measures of central tendency
equally dividing them between the two groups and a
were used.
decision to keep the sample size at one hundred was made
to eliminate bias and improve the validity of the study. RESULTS
Inclusion Criteria: Of the 100 subjects enrolled, 99 patients reported
back for suture removal and thus evaluation was possible
1. Healthy individuals who visit the department of
(fig-1). Fifteen subjects had pain and possible infection
oral and maxillofacial surgery as outpatients for
post extraction.
routine extractions.
The interesting feature, contrary to expectations,
2. Males and females between the ages of 15 and 60
was that, of these fifteen subjects, twelve patients
years. (Most patients in the lower age group had
belonged to the group that took antibiotics and only three
very few indications for extractions the emphasis
patients who did not take antibiotics developed pain and
being on preservation as also they required a much
localized infection (purulent drainage or dry socket).
lower dose as compared to adults(Young’s

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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.
Fig: 1— Proportion of Females and Males in the study
Fig: 2a—Distribution of subjects who developed
infection with administration of antibiotics.
Fig: 2b—Distribution of subjects who developed
infection without antibiotic administration.
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Fig: 3—Distribution 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
Our study clearly shows that for routine
extractions, the body’s defence mechanism is able to take
care of the healing process without having to administer
antibiotics. Antibiotics are often employed as “drugs of
fear”7, 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
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.
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.
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.
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Source of Support : Nil, Conflict of Interest : Nil
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