A Commentary on

Camps-Font O, Sábado-Bundó H, Toledano-Serrabona J, Valmaseda-de-la-Rosa N, Figueiredo R, Valmaseda-Castellón E

Antibiotic prophylaxis in the prevention of dry socket and surgical site infection after lower third molar extraction: a network meta-analysis. Int J Oral Maxillofac Surg 2024; 53: 57–67.

GRADE Rating:

Commentary

Lower third molar (L3M) extraction is a common dental procedure under anesthesia1. However, it often comes with risks like dry socket (DS) and surgical site infection (SSI), which can cause discomfort and, in rare cases, severe infections that may be fatal. SSI incidence after third molar removal is about 30%, while DS incidence ranges from 0.5% to 30%2,3.

Antibiotic prophylaxis (ABP) has been proposed as a way to prevent DS and SSI4. While antibiotics can reduce the incidence of these complications, their use must be evidence-based. Inappropriate or unnecessary prescribing of antibiotics not only wastes healthcare resources but also contributes to the critical issue of antimicrobial resistance (AMR)5,6. It is essential to explore non-antibiotic strategies that could be effective in preventing these complications. Enhanced tooth extraction techniques, such as lessening tissue trauma and reducing extraction time -factors that are heavily influenced by the operator’s experience-can significantly reduce the risk of infection and dry socket7. Using antiseptic mouthwashes before and after procedure has also been suggested as helping to control bacterial load in the oral cavity8,9,10. By ensuring patients understand and adhere to post-operative care instructions, such as avoiding smoking and following appropriate oral hygiene practices, the likelihood of complications can be further minimized9. These strategies not only reduce the need for antibiotics but also empower patients to take an active role in their recovery, potentially leading to better outcomes and a reduction in the incidence of post-surgical complications.

This study analysed data from 16 randomized clinical trials involving 2158 patients. It assessed the effectiveness of antibiotics like Amoxicillin, Amoxicillin with Clavulanic acid, Metronidazole, Azithromycin, and Clindamycin compared to a no-treatment or placebo group. The results showed that ABP significantly reduces the risk of DS and SSI, with a number needed to treat (NNT) of 25 for DS and 18 for SSI. This means that while antibiotics are effective, many patients might receive them without direct benefit—only one in 25 or one in 18 patients treated with antibiotics will actually avoid DS or SSI, respectively. This highlights the need for targeted antibiotic use, reserving prophylaxis for patients at higher risk of complications, rather than applying it broadly to all patients undergoing L3M extraction. Such an approach can reduce unnecessary antibiotic prescriptions and help mitigate the risk of AMR.

The study appropriately focuses on DS and SSI as primary outcomes, given their clinical relevance11. However, the definitions and diagnostic criteria for DS and SSI vary across studies, leading to inconsistencies. Furthermore, this study failed to sufficiently consider the operator’s clinical proficiency in completing lower tooth extraction, a crucial aspect that greatly impacts the probability of developing dry socket following the extraction.

Most of the selected trials (13 out of 16) focused on Amoxicillin, either alone or combined with Clavulanic acid, reflecting the common use of this antibiotic in dental practice. This broad focus ensures the findings are relevant to typical clinical settings. However, the trials varied in the timing and combination of antibiotic administration (preoperative, postoperative, or both). This inconsistency could affect the validity of the SUCRA rankings, as combining different protocols might introduce variability that is not fully accounted for.

A significant limitation of the study is its inability to perform a network meta-analysis for adverse effects (AEs) due to high heterogeneity among the trials and insufficient data, with only seven out of sixteen studies evaluating AEs. This lack of comprehensive reporting introduces a notable reporting bias, likely leading to an underestimation of the true incidence of complications such as nausea, vomiting, diarrhea, and other mild AEs. The discussion on AEs is also limited and does not provide detailed insights into their frequency and severity, nor does it fully explore the implications in the specific context of dental antibiotic use.

While the study acknowledges the general safety of Amoxicillin and its broad spectrum of activity, it would benefit from a more focused and detailed analysis of AEs directly related to the use of antibiotics in preventing DS and SSI after L3M extraction. Future research should aim for more rigorous and standardized reporting of AEs to enhance the understanding of the risk-benefit profile of ABP in this clinical setting. Drafting guidelines for prescribing after extracting L3M, considering various aspects such as effectiveness, necessity, safety, and social impact, can prevent unnecessary antibiotic prescriptions and mitigate their detrimental effect on public health. It is imperative that dental practitioners consider the long-term implications for their prescribing habits, improve their understanding and awareness of AMR in dentistry, and resist the temptation to prescribe antibiotics under patient pressure12,13. By adhering to evidence-based practices, clinicians can play a critical role in curbing the spread of AMR.

The overall certainty of the evidence, as evaluated using the GRADEpro tool, was rated very low.