Effect of lavage on the incidence of localized osteitis in mandibular third molar extraction sites
AI rccrnt stutl- by us’” has sliown that a high-~olunie lavagc with normal saline solution imnictliatcly after clstraction significantly retluccs the inciclcncc of lwalizcct ostcitis. \Yhcn a 350 ml. lavage with 71ornial saline solution was usd ilt C’ilCll Cstl’il~tiOll sitv, the over-all it~~itlcnce of lowlizctl osteitis wils 0.5 Jwr wilt. tlilily (luring the The sul),jccts of the stutly wvw inpatients who W~~I'C olwrvctl \v~llTililt~Yl Furthc>r posioJ~c~rati\-c Jwriotl. Thcsc~ fin(Jings IVWC cllconraging, alltl st77tLy to clctcrniiilc \vhcther thcrc is ilit 0ptilnill volume which will rcvlnw the> iw c4clcnw of locaalizcvl ostcitis. The prcwnt study \vils nntlt~rtalwn to tletermincl l\-hcthet. ;I sul)st:~ntially r~tl71~~~~1 lij\-tlge ~0177m~>:\oultl giw (squally dfwtivc rcs17lts. Theso tlata \vvre thc77 conrparcyl to t ~OSC> of ii (*(~lltrol group whicdli rcccivwl 11 minimal alll0lll~t Of 1ilVarC’ after cstra($ion. METHODS
I’aticnts with bilatc~ral impavttd mandibular thirtl molars mere screened arid sclcc*tccl for inclusiol7 in the study. I’alloramic ratliographs were take11 on all patients. Only patients with bilatc~riilly symmctri~wl inipi~cti017s with wgarcl to tlcpth and aiigulation wro iiivlntlctl; partial or complctc impactions were a~‘ccptctl. I’aticnts WCIY~15 to 30 y‘ars of age. and all wprc in pot1 health with no cornplicating medical factors. I’ativnts \vith wiclencc 0 t’ acute infection or sc\w( Jwricoronitis in the region of thr third molars w’cro esclutled from the stu(ly. J’rocctlures wrc performed 011 an outpatient basis with the 77s~of intravenous Y~~tliltiOll (diazcpam, 10 to 30 mg.) anal local ancslhcsia (2 per cent lidocainc with 1 :lOO,OOO cpincphrine) 177 oath patient, both nlandil)ul:~r third molars wercl rcmo\-ccl surgically at the sanic session. Most patients also hat1 onr or two maxillary third nioln~~s rc~movctl, 1,111tlwsc 0Jwrations xvcrc not included in tliv 1 cm. distal to the mantlibnlar ilircstigation. Air incision WilS ma&~ approximatclv SCCOl7Cl molar which c~stelltlccl iIllt~~l*i~~l~l~~ al~olllld thra wcwlld I~lOlil1~ to tilt> l)ll~(‘ill Xpc‘ct of the first nlolilr. A frill-thic*lincss m77copcriosteal flap was then rtflcctcd to J)roritlc atiequate csJ~osurc to tho third-molar region. In most casts, rcmo~al ot’ surrolulclillg boric W'NS rcquirwl, an(1 in 177i~7~~ vases, swtioni7p of the tooth \\-iIs il ISO wquirctl. This was uwomJ~lishct1 l,- ii~strurnc77tatio77 with it rotatiug lnu. ‘l’ll(’ IOOtll \VilS tll?ll cXtl’a(*tCyl \vitli t~lc~:~tOl*S,iIlltl ill1 1Tlnilillillg portioiis Ol tll(’ tl(‘lltiIl I’ollirlc. CJ-St, 01’ ab7lormal tissw wcrc rcmo\-cd. ‘J’hr surgical tccllIricjrlw, ilap clrsigi1, alIt sutnrc~ ~~li1(‘~‘l~l~‘llt \vcxre awomJ~Jishc~tIon (vI(~h side Of’ the (II’;11 cdiIVit>. it1
iIS ll~~ilrl!
tllC
saline solution
SilI1lC
nl;liltloi*
ilS
Iwssil)lt~.
the operation as a ~OOli~llt for 7’0. tatillg-lnir illSt~l7rnc~llti~tiO~~. At’tcxr ?YWlO\-ill of thv impadvtl tooth, iiIl(l just prior IO (‘IosI11’c, Cwh surgical site \VilS irrigatcvl with il spwific w~liinlc~ of’ normal salifrcl solution : 011(~CstriIc*tioll site rwc~ivcvl 175 rtll. of si-crilc IlO~~llill saline Sollltiotr, ;IlrcJ the opposite si(k rcwivctl no niorv tliail 25 ml. of the SBI~C~solution. NO~llMl
was 17sPtl tlurinp
1lilT’iI~~’ Ivils irc~c~Onl~)lisht~clwith
il cwll\-wtion;ll
liilnfl
spingc
in most casw
IIOw
(‘\.(‘I’, ill thirt;--two (‘;Is(‘s a niwh;lnic~al irrigating clc\-icy> ( \Viltl>r I’ili Alode 17) \V:IS nscvl for lavapc~ ilt tllc> llighr7*-\-olurr7e site. Tlio 7nuc’oJ)criostcaI flap was l’oI)liiC’C‘Cl to its original position ant1 ~~loscclwith onv or two silk sutures. Tii cavli
Patients Male Female Oral contraceptives No oral contraceptives All except those on oral contraceptives
Total
Extraction sites
Localized osteitis
Extraction sites
Localized osteitis
Per cent
Toral
6
5.7 5.1
106 105
12 II
11.3 10.5
212 210
18
2
11.2
18
‘3
27.8
36
x7
4
4.6
87
ti
6.9
174
193 211
10
5.2
193
5.7
211
18 23
9.3
12
10.9
386 422
106 105
6
Per ten 1
~‘olnlllr~ 44 Srlmll~~r I Table
l,frrugc
osteifis
17
II. Incidence of localized ostcitis according to laragc volume ant1 age I75 ml. Lavage Extraction sites
15-20 21-25 26-30 Total
Table
rrud loccrlized
III.
110 67 34 211
Incitlencc
25 ml. Lavage
Localized osteitis
Per cent
: 4 12
3.6 6.0 11.8 5.7
Extraction sites 110 67 34 211
Localized osteitis I IO 6 23
Per cent 6.4 14.9 17.6 10.9
Total 220 134 68 422
of localized osteitis according to layage rolume and impaction
type 25 ml. Lavage
175 ml. Lavage Extraction sites Partial Complete Total
88 123 211
Localized osteitis
Per cent
3 9 12
3.4 1.3 5.7
Extraction sites 88 123 211
Localized osteitis
Per cent
Total
5 18 23
5.7 14.6 10.9
176 246 422
had reduced incitiences of localized osteitis in all age groups ant1 in both sexc~ (Tahlcs 1 and II). A tooth was classified as a partial impaction if a portion was exposed to the oral cavity or as a complete impaction if it was totally covered by tissue. One hundred seventy-six of the teeth cxtraeted were partial impactions, and 246 were c~ompletc impactions. Tdocalized osteitis occurred at eight of the 176 partial-impaction sites (4.5 per taent), and at twenty-seven of the 246 complete-impaction sites ( 11 per cent). This diffcrcnce in incitlence was also statistically significant (p < 0.05). As in other groups, thc~ higher-volume lavage group had less osteitis (Table ITI). Eighteen female patients were taking oral contraceptives at the time of operation. 111this group, seven of thirts-six extraction sites (19.1 per cent) devclnped localized osteitis, whereas ten of 17-4 extraction sites (5.7 per cent) developed osteitis in fcmalc patients on no medication. This difference was statistically significant (p < 0.025). As in other groups, the sites which rcccivecl the highervolume lavage also had a rcducrd incidence of localized ostcitis (11.2 versus 27.8 per cent). I’ostoperative infection was diagnosed at seven extraction sit,es ( 1.4 per cent). Nest cases occurred between the seventh and tenth postoperative days. Sagnosis was made clinically on the basis of localized swelling, increased pain, and purulent exudate at the extraction site. Treatment consisted of obtaining drainage, either by incision or re-elevation of the mucoperiostcal flap, copious lavage with saline solution, and antibiotic therapy. Infection occurred at one site in the higher-volume lavage group (0.,5 per cent) and at six surgical sites (2.8 per cdcnt) in the group which received minimal lacage (Table IV). This suggests that the higher-volume lavage will reduce the incidence of infection, but the differWc~3 art’ not statistically significant.
I75 ml. Lavage Exlraction sires Infection
211
Infection I
25 ml. Lavage Per cent
Extracrion sites
0.5
211
lnjecrlon 6
Per cent
Total
2.8
422
t~lootl-c~lotting factorslh. lo and suggest that fibrinol-tic activity is incrcascd in patients who arc rccciving these agents.“‘~ 21 These ~lianges ill the hc~niostatic niechalrism may bc rcsponsihlc for the ill~rY%~setl incitlrllcc of loc~aliectl osteitis. It was previously shown that mechanical lavagc (\Vatcr I’ik Motlcl 47) antI conventional hand lavagc arc c~~u;dly effecti\-(3 in rc(luein, fl localizccl ostcitis.‘” In extraction sites the prvsvnt study, osteitis oecurrctl at only oiiv of thirty-two The sample W\:~IS very snlilll, (3.1 p(‘r cent) whcrv mechanical lavagc was usttl. lmt, this incidencr compares fa\orably with the 6.1 per cciit (eleven of 179 sites) rate of oc(~urrcn(~~~at the sites which \vcrc suhjcvtccl to 175 ml. lavagc in thv conventional manner. Perhaps furthrr investigation wilt rcvcal that the mechanical la\agc is more cffectirc. It is-important to notice that, in all age groups, and all types of impaction, thr> incidence of localized ostcitis was reducetl by approsimatrly on(’ half at thts sitts which wcrv subjcc+cl to the higher lavagc volume, as compar(vl to thr sites which received lower-volume lavagc (Tables 1, II, and IV). This study rc~als a low over-all incidence of infection (1.4 pvr cent) which is consistent with previous findings (1 per cent) .I5 The rcducctl incidence of infection at the higher-\-olume laragc sites (0.5 per cent) may also possibly bc esplaincd b; removal of boric fragments, soft-tissue debris, and microorganisms that otherwise remain in the alveolus and lead to infection. SUMMARY
l+‘our hundrccl twenty-two mandibular third molars were extracted in 211 patients. After extraction, one half of the surgical sites were subjected to a 175 ml. lavage with normal saline solution, and the other half receiccd a larage of less than 25 ml. of normal saline solution. Comparisons revealed the following: 1. The o\-cr;311incidence of localized osteitis was 8.3 per cent (thirtyfive of 422 sites). 2. Localized osteitis occ~nrrrtl at t,wclvc of 211 (5.7 per cent) sites which were subjected to the higher-volume lavagc. 3. Localized osteitis occurrctl at twenty-three of 211 (10.9 per cent) sites which were sut)jectctl to minimal larage. 4. The incidence of localized ostritis was determind in the various age groups as follows: ages 15 to ‘LO,5.0 per cent : ages 21 to 35, 10.4 per cent; ages 26 to 30, 14.7 per cent. .i. L0cilliZetl ostcitis oc~vurrcti at eight of 175 (4.5 per cclnt) partialimpaction sites, whereas it occurred at twclnt\--sclrcn of 246 ( 1 1 per cent) (.onll’lctc-impnctioii sites. 6. The inciclcncc> of tocaliztvl ostcitis iIt cstr;lctioll sites in fcmalc patients taking oral c~ontI’ac’cl)ti~c‘s was 19.4 per vent (SCWII of thirtysis sites) 7. l’ostoperativc infection occ9irred at scvon of 422 cdraction sites il.4 per cent) ; six of thcsv ovcurrcd sites which were sL7bjcc~tcdto minimal liLVtl@2. Thcsc results intlicatc that the IN’ of :I 175 ml. tilragc with norn1a.l salillc> solution nftcr extraction of m;~~ldib~~l~.l~thirtl molars I\-ill significantly rctlncc the ilt
AI rccrnt stutl- by us’” has sliown that a high-~olunie lavagc with normal saline solution imnictliatcly after clstraction significantly retluccs the inciclcncc of lwalizcct ostcitis. \Yhcn a 350 ml. lavage with 71ornial saline solution was usd ilt C’ilCll Cstl’il~tiOll sitv, the over-all it~~itlcnce of lowlizctl osteitis wils 0.5 Jwr wilt. tlilily (luring the The sul),jccts of the stutly wvw inpatients who W~~I'C olwrvctl \v~llTililt~Yl Furthc>r posioJ~c~rati\-c Jwriotl. Thcsc~ fin(Jings IVWC cllconraging, alltl st77tLy to clctcrniiilc \vhcther thcrc is ilit 0ptilnill volume which will rcvlnw the> iw c4clcnw of locaalizcvl ostcitis. The prcwnt study \vils nntlt~rtalwn to tletermincl l\-hcthet. ;I sul)st:~ntially r~tl71~~~~1 lij\-tlge ~0177m~>:\oultl giw (squally dfwtivc rcs17lts. Theso tlata \vvre thc77 conrparcyl to t ~OSC> of ii (*(~lltrol group whicdli rcccivwl 11 minimal alll0lll~t Of 1ilVarC’ after cstra($ion. METHODS
I’aticnts with bilatc~ral impavttd mandibular thirtl molars mere screened arid sclcc*tccl for inclusiol7 in the study. I’alloramic ratliographs were take11 on all patients. Only patients with bilatc~riilly symmctri~wl inipi~cti017s with wgarcl to tlcpth and aiigulation wro iiivlntlctl; partial or complctc impactions were a~‘ccptctl. I’aticnts WCIY~15 to 30 y‘ars of age. and all wprc in pot1 health with no cornplicating medical factors. I’ativnts \vith wiclencc 0 t’ acute infection or sc\w( Jwricoronitis in the region of thr third molars w’cro esclutled from the stu(ly. J’rocctlures wrc performed 011 an outpatient basis with the 77s~of intravenous Y~~tliltiOll (diazcpam, 10 to 30 mg.) anal local ancslhcsia (2 per cent lidocainc with 1 :lOO,OOO cpincphrine) 177 oath patient, both nlandil)ul:~r third molars wercl rcmo\-ccl surgically at the sanic session. Most patients also hat1 onr or two maxillary third nioln~~s rc~movctl, 1,111tlwsc 0Jwrations xvcrc not included in tliv 1 cm. distal to the mantlibnlar ilircstigation. Air incision WilS ma&~ approximatclv SCCOl7Cl molar which c~stelltlccl iIllt~~l*i~~l~l~~ al~olllld thra wcwlld I~lOlil1~ to tilt> l)ll~(‘ill Xpc‘ct of the first nlolilr. A frill-thic*lincss m77copcriosteal flap was then rtflcctcd to J)roritlc atiequate csJ~osurc to tho third-molar region. In most casts, rcmo~al ot’ surrolulclillg boric W'NS rcquirwl, an(1 in 177i~7~~ vases, swtioni7p of the tooth \\-iIs il ISO wquirctl. This was uwomJ~lishct1 l,- ii~strurnc77tatio77 with it rotatiug lnu. ‘l’ll(’ IOOtll \VilS tll?ll cXtl’a(*tCyl \vitli t~lc~:~tOl*S,iIlltl ill1 1Tlnilillillg portioiis Ol tll(’ tl(‘lltiIl I’ollirlc. CJ-St, 01’ ab7lormal tissw wcrc rcmo\-cd. ‘J’hr surgical tccllIricjrlw, ilap clrsigi1, alIt sutnrc~ ~~li1(‘~‘l~l~‘llt \vcxre awomJ~Jishc~tIon (vI(~h side Of’ the (II’;11 cdiIVit>. it1
iIS ll~~ilrl!
tllC
saline solution
SilI1lC
nl;liltloi*
ilS
Iwssil)lt~.
the operation as a ~OOli~llt for 7’0. tatillg-lnir illSt~l7rnc~llti~tiO~~. At’tcxr ?YWlO\-ill of thv impadvtl tooth, iiIl(l just prior IO (‘IosI11’c, Cwh surgical site \VilS irrigatcvl with il spwific w~liinlc~ of’ normal salifrcl solution : 011(~CstriIc*tioll site rwc~ivcvl 175 rtll. of si-crilc IlO~~llill saline Sollltiotr, ;IlrcJ the opposite si(k rcwivctl no niorv tliail 25 ml. of the SBI~C~solution. NO~llMl
was 17sPtl tlurinp
1lilT’iI~~’ Ivils irc~c~Onl~)lisht~clwith
il cwll\-wtion;ll
liilnfl
spingc
in most casw
IIOw
(‘\.(‘I’, ill thirt;--two (‘;Is(‘s a niwh;lnic~al irrigating clc\-icy> ( \Viltl>r I’ili Alode 17) \V:IS nscvl for lavapc~ ilt tllc> llighr7*-\-olurr7e site. Tlio 7nuc’oJ)criostcaI flap was l’oI)liiC’C‘Cl to its original position ant1 ~~loscclwith onv or two silk sutures. Tii cavli
Patients Male Female Oral contraceptives No oral contraceptives All except those on oral contraceptives
Total
Extraction sites
Localized osteitis
Extraction sites
Localized osteitis
Per cent
Toral
6
5.7 5.1
106 105
12 II
11.3 10.5
212 210
18
2
11.2
18
‘3
27.8
36
x7
4
4.6
87
ti
6.9
174
193 211
10
5.2
193
5.7
211
18 23
9.3
12
10.9
386 422
106 105
6
Per ten 1
~‘olnlllr~ 44 Srlmll~~r I Table
l,frrugc
osteifis
17
II. Incidence of localized ostcitis according to laragc volume ant1 age I75 ml. Lavage Extraction sites
15-20 21-25 26-30 Total
Table
rrud loccrlized
III.
110 67 34 211
Incitlencc
25 ml. Lavage
Localized osteitis
Per cent
: 4 12
3.6 6.0 11.8 5.7
Extraction sites 110 67 34 211
Localized osteitis I IO 6 23
Per cent 6.4 14.9 17.6 10.9
Total 220 134 68 422
of localized osteitis according to layage rolume and impaction
type 25 ml. Lavage
175 ml. Lavage Extraction sites Partial Complete Total
88 123 211
Localized osteitis
Per cent
3 9 12
3.4 1.3 5.7
Extraction sites 88 123 211
Localized osteitis
Per cent
Total
5 18 23
5.7 14.6 10.9
176 246 422
had reduced incitiences of localized osteitis in all age groups ant1 in both sexc~ (Tahlcs 1 and II). A tooth was classified as a partial impaction if a portion was exposed to the oral cavity or as a complete impaction if it was totally covered by tissue. One hundred seventy-six of the teeth cxtraeted were partial impactions, and 246 were c~ompletc impactions. Tdocalized osteitis occurred at eight of the 176 partial-impaction sites (4.5 per taent), and at twenty-seven of the 246 complete-impaction sites ( 11 per cent). This diffcrcnce in incitlence was also statistically significant (p < 0.05). As in other groups, thc~ higher-volume lavage group had less osteitis (Table ITI). Eighteen female patients were taking oral contraceptives at the time of operation. 111this group, seven of thirts-six extraction sites (19.1 per cent) devclnped localized osteitis, whereas ten of 17-4 extraction sites (5.7 per cent) developed osteitis in fcmalc patients on no medication. This difference was statistically significant (p < 0.025). As in other groups, the sites which rcccivecl the highervolume lavage also had a rcducrd incidence of localized ostcitis (11.2 versus 27.8 per cent). I’ostoperative infection was diagnosed at seven extraction sit,es ( 1.4 per cent). Nest cases occurred between the seventh and tenth postoperative days. Sagnosis was made clinically on the basis of localized swelling, increased pain, and purulent exudate at the extraction site. Treatment consisted of obtaining drainage, either by incision or re-elevation of the mucoperiostcal flap, copious lavage with saline solution, and antibiotic therapy. Infection occurred at one site in the higher-volume lavage group (0.,5 per cent) and at six surgical sites (2.8 per cdcnt) in the group which received minimal lacage (Table IV). This suggests that the higher-volume lavage will reduce the incidence of infection, but the differWc~3 art’ not statistically significant.
I75 ml. Lavage Exlraction sires Infection
211
Infection I
25 ml. Lavage Per cent
Extracrion sites
0.5
211
lnjecrlon 6
Per cent
Total
2.8
422
t~lootl-c~lotting factorslh. lo and suggest that fibrinol-tic activity is incrcascd in patients who arc rccciving these agents.“‘~ 21 These ~lianges ill the hc~niostatic niechalrism may bc rcsponsihlc for the ill~rY%~setl incitlrllcc of loc~aliectl osteitis. It was previously shown that mechanical lavagc (\Vatcr I’ik Motlcl 47) antI conventional hand lavagc arc c~~u;dly effecti\-(3 in rc(luein, fl localizccl ostcitis.‘” In extraction sites the prvsvnt study, osteitis oecurrctl at only oiiv of thirty-two The sample W\:~IS very snlilll, (3.1 p(‘r cent) whcrv mechanical lavagc was usttl. lmt, this incidencr compares fa\orably with the 6.1 per cciit (eleven of 179 sites) rate of oc(~urrcn(~~~at the sites which \vcrc suhjcvtccl to 175 ml. lavagc in thv conventional manner. Perhaps furthrr investigation wilt rcvcal that the mechanical la\agc is more cffectirc. It is-important to notice that, in all age groups, and all types of impaction, thr> incidence of localized ostcitis was reducetl by approsimatrly on(’ half at thts sitts which wcrv subjcc+cl to the higher lavagc volume, as compar(vl to thr sites which received lower-volume lavagc (Tables 1, II, and IV). This study rc~als a low over-all incidence of infection (1.4 pvr cent) which is consistent with previous findings (1 per cent) .I5 The rcducctl incidence of infection at the higher-\-olume laragc sites (0.5 per cent) may also possibly bc esplaincd b; removal of boric fragments, soft-tissue debris, and microorganisms that otherwise remain in the alveolus and lead to infection. SUMMARY
l+‘our hundrccl twenty-two mandibular third molars were extracted in 211 patients. After extraction, one half of the surgical sites were subjected to a 175 ml. lavage with normal saline solution, and the other half receiccd a larage of less than 25 ml. of normal saline solution. Comparisons revealed the following: 1. The o\-cr;311incidence of localized osteitis was 8.3 per cent (thirtyfive of 422 sites). 2. Localized osteitis occ~nrrrtl at t,wclvc of 211 (5.7 per cent) sites which were subjected to the higher-volume lavagc. 3. Localized osteitis occurrctl at twenty-three of 211 (10.9 per cent) sites which were sut)jectctl to minimal larage. 4. The incidence of localized ostritis was determind in the various age groups as follows: ages 15 to ‘LO,5.0 per cent : ages 21 to 35, 10.4 per cent; ages 26 to 30, 14.7 per cent. .i. L0cilliZetl ostcitis oc~vurrcti at eight of 175 (4.5 per cclnt) partialimpaction sites, whereas it occurred at twclnt\--sclrcn of 246 ( 1 1 per cent) (.onll’lctc-impnctioii sites. 6. The inciclcncc> of tocaliztvl ostcitis iIt cstr;lctioll sites in fcmalc patients taking oral c~ontI’ac’cl)ti~c‘s was 19.4 per vent (SCWII of thirtysis sites) 7. l’ostoperativc infection occ9irred at scvon of 422 cdraction sites il.4 per cent) ; six of thcsv ovcurrcd sites which were sL7bjcc~tcdto minimal liLVtl@2. Thcsc results intlicatc that the IN’ of :I 175 ml. tilragc with norn1a.l salillc> solution nftcr extraction of m;~~ldib~~l~.l~thirtl molars I\-ill significantly rctlncc the ilt
