Effects of Intra-alveolar Placement of 0.2% Chlorhexidine Bioadhesive Gel on Dry Socket Incidence and Postsurgical Pain: A Double-Blind Split-Mouth Randomized Controlled Clinical Trial

Aims: To assess the effects of intra-alveolar application of chlorhexidine gel on the incidence of alveolar osteitis (dry socket) and the severity of postsurgical pain. Methods: A total of 160 impacted mandibular third molars were extracted in 80 patients enrolled in this trial. In each subject, a socket was randomly selected and packed to the crest of the alveolar ridge with a gelatin sponge dressing saturated in 0.2% chlorhexidine gel. The contralateral socket was packed with a dry dressing as the placebo. None of the included patients took antibiotics or analgesics. The occurrence of dry socket and patients' pain levels were assessed at the first and third postoperative days. The data were analyzed using Spearman correlation coefficient, McNemar, Wilcoxon, and chi-square tests. Results: Chlorhexidine gel significantly reduced dry socket incidence from 32.6% to 11.3% (P ≤ .001 [McNemar and chi-square], absolute risk reduction = 21.2%, relative risk reduction = 65.4%, odds ratio = 0.263, relative risk = 0.345). It also significantly relieved postoperative pain on both sides in all the patients (P ≤ .001 [Wilcoxon]) and also in the 54 subjects who did not develop dry socket (P ≤ .001 [Wilcoxon]). Conclusions: Besides decreasing the incidence of dry socket, chlorhexidine gel can reduce postsurgical pain in patients with and without dry socket.

alveolar osteitis; chlorhexidine; dry socket; impacted teeth; postoperative pain; third molars; tooth extraction

1. Torres-Lagares D, Gutierrez-Perez JL, Hita-iglesias P, et al. randomized, double-blind study of effectiveness of intra- alveolar application of chlorhexidine gel in reducing in- cidence of alveolar osteitis and bleeding complications in mandibular third molar surgery in patients with bleeding disorders. J Oral Maxillofac Surg 2010;68:1322–1326.

2. Torres-Lagares D, Gutierrez-Perez JL, infante-cossio P, Garcia-calderon M, romero-ruiz MM, Serrera-figallo Ma. randomized, double-blind study on effectiveness of intra-alveolar chlorhexidine gel in reducing the incidence of alveolar osteitis in mandibular third molar surgery. int J Oral Maxillofac Surg 2006;35:348–351.

3. Hita-iglesias P, Torres-Lagares D, flores-ruiz r, Magal- lanes-abad n, Basallote-Gonzalez M, Gutierrez-Perez JL. Effectiveness of chlorhexidine gel versus chlorhexidine rinse in reducing alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg 2008;66:441–445.

4. Torres-Lagares D, infante-cossio P, Gutierrez-Perez JL, romero-ruiz MM, Garcia-calderon M, Serrera-figallo Ma. intra-alveolar chlorhexidine gel for the prevention of dry socket in mandibular third molar surgery. a pilot study. Med Oral Patol Oral cir Bucal 2006;11:e179–184.

5. Minguez-Serra MP, Salort-Llorca c, Silvestre-Donat fJ. chlorhexidine in the prevention of dry socket: Effectiveness of different dosage forms and regimens. Med Oral Patol Oral cir Bucal 2009;14:e445–449.

6. caso a, Hung L-K, Beirne Or. Prevention of alveolar osteitis with chlorhexidine: a meta-analytic review. Oral Surg Oral Med Oral Pathol Oral radiol Endod 2005;99:155–159.

7. Blum ir. contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review. int J Oral Maxillofac Surg 2002;31:309–317.

8. cardoso cL, rodrigues MTV, ferreira Júnior O, Garlet GP, de carvalho PSP. clinical concepts of dry socket. J Oral Maxillofac Surg 2010;68:1922–1932.

9. Hedström L, Sjögren P. Effect estimates and methodological quality of randomized controlled trials about prevention of alveolar osteitis following tooth extraction: a systematic review. Oral Surg Oral Med Oral Pathol Oral radiol Endod 2007;103:8–15.

10. Kolokythas a, Olech E, Miloro M. alveolar osteitis: a comprehensive review of concepts and controversies. int J Dent 2010:249073. Epub 2010 June 24.

11. ragno Jr Jr, Szkutnik aJ. Evaluation of 0.12% chlorhexidine rinse on the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol 1991;72:524–526.

12. Berwick JE, Lessin ME. Effects of a chlorhexidine gluconate oral rinse on the incidence of alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg 1990;48:444–448.

13. Larsen PE. alveolar osteitis after surgical removal of impacted mandibular third molars. identification of the patient at risk. Oral Surg Oral Med Oral Pathol 1992;73:393–397.

14. Bloomer cr. alveolar osteitis prevention by immediate placement of medicated packing. Oral Surg Oral Med Oral Pathol Oral radiol Endod 2000;90:282–284.

15. Larsen PE. The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg 1991;49:932–937.

16. Halabi D, Escobar J, Munoz c, Uribe S. Logistic regression analysis of risk factors for the development of alveolar osteitis. J Oral Maxillofac Surg 2012;70:1040–1044.

17. nusair YM, Younis MH. Prevalence, clinical picture, and risk factors of dry socket in a Jordanian dental teaching center. J contemp Dent Pract 2007;8:53–63.

18. Parthasarathi K, Smith a, chandu a. factors affecting incidence of dry socket: a prospective community-based study. J Oral Maxillofac Surg 2011;69:1880–1884.

19. Delilbasi c, Saracoglu U, Keskin a. Effects of 0.2% chlorhexidine gluconate and amoxicillin plus clavulanic acid on the prevention of alveolar osteitis following mandibular third molar extractions. Oral Surg Oral Med Oral Pathol Oral radiol Endod 2002;94:301–304.

20. Sridhar V, Wali GG, Shyla Hn. Evaluation of the perioperativeuseof 0.2% chlorhexidinegluconateforthepreventionof alveolar osteitis after the extraction of impacted mandibular third molars: a clinical study. J Maxillofac Oral Surg 2011; 10:101–111.

21. noroozi a-r, Philbert rf. Modern concepts in understan ing and management of the “dry socket” syndrome: comprehensive review of the literature. Oral Surg Oral Med Oral Pathol Oral radiol Endod 2009;107:30–35.

22. Dorri M, Shahrabi S, navabazam a. comparing the effects of chlorhexidine and persica on alveolar bone healing following tooth extraction in rats, a randomised controlled trial. clin Oral investig 2012;16:25–31.

23. fotos PG, Koorbusch Gf, Sarasin DS, Kist rJ. Evaluation of intra-alveolar chlorhexidine dressings after removal of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol 1992;73:383–388.

24. Bonine fL. Effect of chlorhexidine rinse on the incidence of dry socket in impacted mandibular third molar extraction sites. Oral Surg Oral Med Oral Pathol Oral radiol Endod 1995;79:154–157.

25. Larsen PE. Use of chlorhexidine to prevent alveolar osteitis. J Oral Maxillofac Surg 1990;48:1244–1245.

26. Pederson GW. Oral Surgery. Philadelphia: WB Saunders, 1988.

27. Larrazabal c, Garcia B, Penarrocha M. influence of oral hygiene and smoking on pain and swelling after surgical extraction of impacted mandibular third molars. J Oral Maxillofac Surg 2010;68:43–46.

28. Hermesch cB, Hilton TJ, Biesbrock ar, et al. Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: Efficacy and risk factor analysis. Oral Surg Oral Med Oral Pathol Oral radiol Endod 1998;85:381–387.