Teeth that are affected by decay or gum disease or painful wisdom teeth are often removed by dentists. Tooth extraction is a surgical procedure that leaves a wound in the mouth that can become infected. Infection can lead to swelling, pain, development of pus, fever, as well as ‘dry socket’. Dry socket is where the tooth socket is not filled by a blood clot, and there is severe pain and bad odour. These complications are unpleasant for patients and may cause difficulty with chewing, speaking, and teeth cleaning, and may even result in days off work or study. Treatment of infection is generally simple and involves drainage of the infection from the wound and patients receiving antibiotics.
Antibiotics work by killing the bacteria that cause infections, or by slowing their growth. However, some infections clear up by themselves. Taking antibiotics unnecessarily may stop them working effectively in future. This ‘antimicrobial resistance’ is a growing problem throughout the world. Antibiotics may also cause unwanted effects such as diarrhoea and nausea. Some patients may be allergic to antibiotics, and antibiotics may not mix well with other medicines. Dentists frequently give patients antibiotics at the time of the extraction as a precaution in order to prevent infection occurring in the first place. This may be unnecessary and may lead to unwanted effects.
What was the research?
A systematic review to examine whether giving antibiotics as a preventive measure reduces infection and other complications after tooth extraction. We also wanted to understand whether antibiotics work differently in healthy people compared with people with health conditions such as diabetes or HIV.
Who conducted the research?
The research was conducted by a team led by Giovanni Lodi of the Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy on behalf of Cochrane Oral Health. Lorenzo Azzi, Elena Maria Varoni, Monica Pentenero, Massimo Del Fabbro, Antonio Carrassi, Andrea Sardella and Maddalena Manfredi were also on the team.
What evidence was included in the review?
We included 23 randomised controlled trials, with 3,200 participants, who received either antibiotics (of different kinds and dosages) or placebo immediately before or just after tooth extraction, or both. Four studies were conducted in Spain, three each in Brazil, Sweden, and the UK, two in India, and one each in Colombia, Denmark, Finland, France, Poland, New Zealand, Nigeria, and the USA. All but one study included healthy patients in their 20s. Twenty‐one studies assessed the removal of wisdom teeth in hospital dental departments, one assessed the removal of other teeth and one assessed complex oral surgery. None of the included studies assessed tooth extraction in general dental practice for the removal of decayed teeth.
What did the evidence say?
Antibiotics given just before or just after surgery (or both) may reduce the risk of infection and dry socket after the removal of wisdom teeth by oral surgeons. However, antibiotics may cause more (generally brief and minor) unwanted effects for these patients. We found no evidence that antibiotics prevent pain, fever, swelling, or problems with restricted mouth opening in patients who have had wisdom teeth removed.
There was no evidence to judge the effects of preventive antibiotics for extractions of severely decayed teeth, teeth in diseased gums, or extractions in patients who are sick or have low immunity to infection.
How good was the evidence?
Our confidence in the results is limited because we had concerns about aspects of the design and reporting of all of the included studies.
What are the implications for dentists and the general public?
We did not find studies in patients with depressed immune systems, other illnesses, or in young children or older patients, therefore the results of our review probably do not apply to people who may be at high risk of infection. Also, extractions were mainly carried out by oral surgeons, so the review may not apply to dentists working in general practice.
Another concern, which cannot be assessed by clinical studies (i.e. studies testing new medical approaches in people), is that widespread use of antibiotics by people who do not have an infection is likely to contribute to the development of antimicrobial resistance.
We concluded that antibiotics given to healthy people when they are having teeth extracted may help prevent infection, but the decision to use an antibiotic should be judged on an individual patient basis based on their state of health and possible complications of getting an infection.
What should researchers look at in the future?
Future trials should investigate effectiveness in patients at high risk of infective complications, such as immunocompromised people and people who have experienced infective complications following previous extractions, although undertaking research in these groups of people may not be possible or ethical. Future studies should also measure the outcomes of symptoms and clinical assessment using standardised measures and time points, and report these according to CONSORT guidelines.
Lodi G, Azzi L, Varoni EM, Pentenero M, Del Fabbro M, Carrassi A, Sardella A, Manfredi M. Antibiotics to prevent complications following tooth extractions. Cochrane Database of Systematic Reviews 2021, Issue 2. Art. No.: CD003811. DOI: 10.1002/14651858.CD003811.pub3
This post is an extended version of the review’s plain language summary, compiled by Anne Littlewood at the Cochrane Oral Health Editorial Base.