Debra Ferraiolo DMD, FAGD; Silvia Spivakovsky DDS
Chlorhexidine gel (0.2 percent) applied every 12 hours for seven days after extraction would be the best option for prevention of dry socket.
How efficacious is CHX in preventing DS using different concentrations and delivery systems?
In December 2008, the authors searched three electronic databases for randomized and nonrandomized clinical trials that evaluated CHX at any concentration or delivery system. The authors excluded studies in which the same patient received both CHX and antibiotic interventions. For trials that lacked a placebo control, the authors used data from another trial that evaluated patients with similar characteristics.
The search produced 12 clinical trials with a total of 1818 patients treated.
Eight trials (five randomized and three nonrandomized) used CHX rinses alone or in combination with 0.12 percent or 0.2 percent CHX irrigation. In two studies, patients started using rinses before extraction. Four studies evaluating 0.12 percent CHX rinse (used twice daily) reported statistically significant differences (P < 0.05), but only two of the studies were randomized controlled trials. Of the studies evaluating 0.2 percent rinse, only one small randomized controlled trial showed statistically significant results.
One randomized controlled trials (RCTs) evaluated 0.2 percent CHX gel. Statistically significant, reduction from 30% in the placebo group to 11% (p < 0.04) favoring the gel in a study that compared 0.12 percent rinses with 0.2 percent topical gels. Overall, there was no benefit from preoperative intervention with CHX.
The authors concluded that beginning a twice-daily regimen of Chlorhexidine gel (0.2 percent) applied every 12 hours for seven consecutive days can help reduce incidence of DS.
Source of Funding:
Importance and Context:
Dry socket is a painful complication that commonly occurs after dental extractions, particularly with third molar extractions. For any patient undergowing such a rutine procedure, it is important to be able to provide modalities such as chlorhexidine (rinse or topical gel) considering the potential to lower their risk of developing dry socket.
Strengths and Weaknesses of the Systematic Review:
The reviewers comprehensively searched three electronic databases. The clinical question was clearly stated. The authors limited their search to English only publications and did not conduct a hand-search for additional literature. They did not provide information about the number of reviewers who participated, their input, nor how disagreements were resolved. Studies were included on the basis of research design. The authors did not conduct a quality assessment of the included studies and presented only a limited summary of the evidence.. For trials that did not include a placebo control group, the authors reported using data from other studies that evaluated patients with similar characteristics. Although the authors indicated that they conducted a “meta-analysis”, they did not use a traditional meta-analytic approach. Instead they added the number of events from all the studies to derive a total number of DS events in the test versus the control group and presented the results from individual studies in a narrative format. Publication bias was also not assessed.
Strengths and Weaknesses of the Evidence:
Although there were several RCT’s included within this review, the studies were varied in terms of the frequency an duration of use of chlorhexidine. Further, the lack of a quality assessment by the author’s of the systematic review limits us from gauging the strength of the evidence to answer the clinical question.
Implications for Dental Practice:
This review shows use of CHX following extractions may reduce the incidence of DS. The magnitude of its effect and best regimen for use remains unclear. A gel at 0.2 percent CHX applied every 12 hours for seven days postextraction shows promising results. In the United States there are less products containing chlorhexidine . Chlorhexidine rinse at 0.12% is available and more studies on effect of rinse in reducing incidence of dry socket would have clinical relevance.