J Oral Maxillofac Surg

53:53-60, 1995

Prophylactic Antibiotics for

Third Molar Surgery:
A Supportive Opinion
JOSEPH F. PIECUCH, DMD, MD,* JOSEPH ARZADON, DMD, MD,1-
AND STUART E. LIEBLICH, DMD::I:

In considering the question "should antibiotics be Antibiotic Prophylaxis for Medically

used for third molar surgery?" one can give at least Compromised Patients
five possible reasons. Use antibiotics when 1) an infec-
tion is present that must be treated; 2) the patient is
Antibiotic prophylaxis may be considered for sev-
medically compromised and requires antibiotic pro-
eral groups of patients, including cardiovascular pa-
phylaxis against metastatic infection; 3) the patient or
tients with susceptible lesions, immunocompromised
the patient's family demands antibiotics; 4) the stan-
patients, and patients with orthopedic prostheses.
dard of care in the oral surgery community is to use
In 1990, the American Heart Association (AHA)
antibiotics, and hence not to use them violates this
published its most current recommendations, which are
standard; and when 5) the risk of postoperative infec-
based on in vitro studies, because " N o adequate, con-
tion is high and, consequently, prophylaxis is needed.
trolled clinical trials of antibiotic regimens for preven-
This article explores the rationale behind these reasons
tion of bacterial endocarditis in humans have been
for use of antibiotics in third molar surgery. Further, it
done." i These recommendations are, nonetheless, ac-
presents a review of infection rates in our own practice,
cepted by most surgeons as being scientifically valid.
comparing different antibiotic regimens and the degree
As regards patients who are immunocompromised,
of impaction.
a recent article documented a 10 times greater risk of
postoperative complications in human immunodefi-
The Presence of Infection at the ciency virus (HIV)-positive patients undergoing den-
Time of Surgery tal extractions (not confined to third molars) when
compared with HIV-negative patients. 2 Risk increased
The first indication for use of antibiotics is therapeu- with the severity of the HIV infection. Antibiotic pro-
tic rather than prophylactic, and will not be developed phylaxis in this group is not disputed, although there
at length in this article. Treatment of an active infection are no clear-cut guidelines.
includes both surgical drainage and antibiotics. Conse- There are still no definitive recommendations from
quently, the use of antibiotics for cases in which third any authoritative source on the role of prophylactic
molars are removed in the presence of an ongoing antibiotics for third molar surgery in patients with or-
infection is not in dispute. thopedic prostheses. In 1990, the American Dental As-
sociation published a belated report of a 1987 work-
shop that cited insufficient data to support the
* Associate Clinical Professor, Oral and Maxillofacial Surgery, effectiveness of antibiotic prophylaxis for dental pro-
University of Connecticut Health Center; Senior Staff, Hartford Hos-
pital. cedures. 3 In 1992, the Working Party of the British
t Resident, Oral and Maxillofacial Surgery, University of Con- Society for Antimicrobial Chemotherapy advised
necticut Health Center. against routine antibiotic prophylaxis. 4 A questionnaire
Assistant Clinical Professor, Oral and Maxillofacial Surgery,
University of Connecticut Health Center; Senior Staff, Hartford Hos- sent to department heads of US dental schools revealed
pital. that 54% of respondents did teach students to use anti-
Address correspondence and reprint requests to Dr Piecuch: 34 biotic prophylaxis for these patients, but 18 different
Dale Rd, Avon, CT 06001.
regimens were recommended and individual depart-
© 1995 American Association of Oral and Maxillofacial Surgeons ments within the same dental school were sometimes
0278-2391/95/5301-0011 $3.00/0 at variance. 5 No authoritative orthopedic organization

53
54 PROPHYLACTIC ANTIBIOTICS FOR THIRD MOLAR SURGERY

has made a specific recommendation, although individ- Table 1. Routine Use of Antibiotics in Patients
ual orthopedic surgeons often request antibiotic cover- Who Are Not Medically Compromised
age. Spread of intraoral bacteria to orthopedic prosthe-
No. of
ses has been poorly documented. Type of Surgery Respondents* Yes (%) No (%)
A computer simulation study showed that the minus-
cule risk of fatal anaphylaxis in dental patients receiv- Maxillary impactions 93 25 (27) 68 (73)
ing prophylactic antibiotics is actually higher than the Mandibular erupted 88 17 (19) 71 (81)
Mandibular soft tissue
risk of late prosthetic joint infection causally related
impactions 96 41 (43) 55 (57)
to dental therapy. 6 These investigators suggested that Mandibular partial
only dental patients undergoing procedures with a high bony impactions 97 53 (55) 44 (45)
risk of bacteremia (periodontal therapy, impaction sur- Mandibular full bony
gery) should receive antibiotic prophylaxis. impactions 97 56 (58) 41 (42)

* Not all surgeons answered each question. Percentagesrefer to

Use of Antibiotics Because of respondents for each item.
Patient D e m a n d
third molars (Table 1). Dose regimens varied widely.
Pressure toward early antibiotic intervention exists Sixty-seven of the respondents (63%) reported their
in our society. "Americans like quick fixes. When a dose schedule of oral antibiotics for non-medically
doctor doesn't prescribe an antibiotic, they will look compromised patients (Table 2). Twenty surgeons used
for one who will. ''7 Most Americans are not aware of 2-dose perioperative antibiotics, while 47 used longer
the risks of indiscriminate antibiotic use, such as the dose schedules ranging from 2 to 10 days. Some of
development of resistant strains of bacteria. In fact, these longer regimens began just prior to surgery and
Americans ingest antibiotics every day in dairy prod- some the day before, but most surgeons began the
ucts and meat because animals are routinely given anti- antibiotics after surgery. Three other surgeons stated
biotics in very large doses to prevent infection. The that they used a 1-week postoperative course of antibi-
US Federal Drug Administration (FDA) permits milk otics when they thought that the patient was at risk for
to contain small amounts of 80 different antibiotics infection (criteria for risk varied), and one surgeon
(they are used on dairy cows to prevent udder infec- used an every-8-hour dose regimen but did not state
tions), s length of treatment.
Rarely do patients refuse antibiotics. However, the Nineteen of the respondents (18%) used some form
request of patients for antibiotics without medical indi- of antibiotic paste or powder directly within the extraction
cation is never a justifiable rationale. socket, whereas 64 (60%) did not. The other 21 respon-
dents did not answer the question. Twenty-four respon-
Standard of Care in t h e C o m m u n i t y dents (23%) used chlorhexidene oral rinses (mostly after
surgery--a few began before to the operation), whereas
There are no published standards or surveys of ac- one surgeon directly irrigated lower third molar sockets
tual usage of prophylactic antibiotics by oral and max- with it. Fifty-six respondents stated they did not use chlor-
illofacial surgeons. In an attempt to clarify actual prac- hexidene, and 24 surgeons did not answer the question.
tice by oral and maxillofacial surgeons, a one-page, From these data it is clear that a majority of respon-
"yes or n o " survey form was mailed in January 1994 dents routinely use prophylactic antibiotics for third
to the active members of the Connecticut Society of molar surgery for non-medically compromised pa-
Oral and Maxillofacial Surgeons. Eighty-five percent tients, particularly with partial bony or full bony im-
(104 of 122) responded to the survey. Not all surgeons pactions. Although this information would suggest the
answered each question, resulting in the number of existence of a community standard, at least in the State
responses to each question being less than the 104 of Connecticut, it is our opinion that such a standard
respondents to the questionnaire. All 103 respondents is not valid because the dose schedule in many cases
to a question regarding antibiotic prophylaxis for medi- violates a basic principle of antibiotic prophylaxis, ie,
cally compromised patients stated that they did use the presence of the antibiotic in the tissues at the time
antibiotics for this purpose. Specific compliance with of the surgery. 9 Furthermore, continuing antibiotic ad-
current AHA guidelines I was not ascertained. ministration after surgery does not decrease the inci-
Surgeons were asked to respond yes or no to a state- dence of wound infection. 1°
ment asking if they "routinely use antibiotic prophy-
Risk of Postoperative Infection is High,
laxis" for certain types of third molar conditions in
T h e r e f o r e Prophylaxis is Required
"non-medically compromised patients." Affirmative
responses ranged from 19% for erupted mandibular There is no consensus in the literature on whether
third molars to 58% for full bony impacted mandibular the risk of infection with third molar surgery is high
PIECUCH, ARZADON, AND LIEBLICH 55

Table 2. Type of Antibiotics Used for Non- receiving antibiotics developed infections, whereas
Medically Compromised Patients (N 67)* =
9.4% (20 of 212) of patients who did not receive antibi-
otics developed infections.
Perioperative~ 2-d 3-d 4-d 5-d 6-d 7-d 10-d Other
Capuzzi et al j9 saw no statistical difference in their
20 1 2 3 10 3 20 3 5 146 patients, half on postoperative amoxicillin for 4
days and half without antibiotics, in terms of pain and
* Antibiotic usage varied widely within each group. Some sur- swelling, but did not comment on the infection rate.
geons gave antibiotics for a day or two preoperatively,others gave
a "loading dose" preoperatively,and others gave antibioticspostop- This study violated a principle of antibiotic prophylaxis
eratively only. This chart indicates total number of days. Specific in that no antibiotics were in tissue before the surgery. 9
antibiotic and dose schedule were also variable. Other investigators have written editorials advising
]- A single dose preoperativelyfollowedby a single dose postoper- against the use of antibiotics on the basis of possible
atively. adverse reaction to the drug, 2° or on emotion. 2~

enough to warrant the use of prophylactic antibiotics. Literature for Antibiotic Use
Many dental and oral surgical textbooks recommend
against the use of prophylactic antibiotics for extrac-
tions, including third molar surgery, unless active in- Investigators who favor the use of antibiotics include
fection is present at the time of s u r g e r y . I H 4 Others those commenting on direct application within sockets
recommend routine antibiotic use for "deep, difficult as well as those favoring systemic antibiotics. Antibiot-
impactions, a n d . . , for a minimum of 5 to 7 days". ~5 ics placed directly into the socket, including tetracy-
Of interest is the fact that none of the recommendations cline, 22'23 metronidazole, 24 and both lincomycin and
in these texts is referenced. oxytetracycline 25 have been shown to be very effective
Scientific journal articles offer conflicting opinions in reducing significantly the incidence of alveolar oste-
as to the efficacy of antibiotics in the prevention of itis (dry socket), whereas one prospective, double blind
postoperative infection. Most articles involve either ex- study comparing 85 patients with neomycin/bacitracin
tremely small numbers of patients in prospective stud- cones with 59 controls showed a 7.1% infection rate
ies or larger numbers in retrospective studies, none of in the antibiotic group and a 20.3% rate in the control
which state whether the patients were all seen postop- group. 26
eratively. We could find only one article other than Gold-
berg's is dealing with the use of systemic antibiotics
Literature Against Antibiotic Use in which the incidence of infection was compared in
antibiotic and nonantibiotic groups. Mitchell reported
Investigators concluding that prophylactic antibiot- a 4% (4 of 45) incidence in his tinidazole group versus
ics should not be used include Curran et al, 16 who a 45% (20 of 44) incidence in his placebo group. 27 A
divided 68 patients who had 133 mandibular bony im- subsequent comparison study by the same author
pactions into two regimen groups: 1) penicillin intra- showed similar infection rates in groups given either
muscularly 1 hour before surgery followed by oral of pivampicillin or tinidazole, but there was no control
penicillin for 4 days; 2) no antibiotics. No statistics group. 28 Four articles support the use of antibiotics on
were used in this report. Curran's conclusions contra- the basis of either decreased trismus, 29'3° swelling, 3°
dicted the results because 7.8% (5 of 64) of the sockets pain, 29'31'32or better wound healing, 31'32but do not spe-
that were treated with antibiotics got infected whereas cifically comment on infection rates. One randomized
8.7% (6 of 69) of the sockets without antibiotics be- prospective article studied bacterial growth in third
came infected. Happonen et a117 divided 136 patients molar sockets of 120 patients: 40 with preoperative
who had mandibular third molar extractions into three and postoperative penicillin, 40 with preoperative and
random groups, each of which was given an intramus- postoperative scopolamine (to reduce salivary flow),
cular injection 1 hour preoperatively and 15 tablets and 40 with no medication. Growth of both aerobic and
over 5 days postoperatively. Of the patients receiving anaerobic bacteria within the sockets was significantly
penicillin, 13.6% (6 of 44) became infected, whereas decreased in the group on penicillin. 33
10.6% (5 of 47) who received tinidazole and 11.1% Thus, a review of the literature reveals no clear-cut
(5 of 45) who received placebo developed infections. guidelines. Most of the articles discouraging antibiotic
These differences were not statistically significant. use are flawed in either scientific method or conclu-
Goldberg et a118 made the statement that " . . . antibi- sions, whereas most of those supporting antibiotic use
otic prophylaxis is not useful in the prevention of post- study the problem tangentially. Even the incidence of
surgical wound infection"; however, analysis of the infection as quoted in the literature seems to be contra-
data in this article shows that 1.1% (1 of 90) of patients dictory, with a few articles identifying much lower
56 PROPHYLACTIC ANTIBIOTICS FOR THIRD MOLAR SURGERY

Table 3. Infection Rates for Mandibular Third tion of degree of impaction (erupted, soft tissue, partial
Molars Reported in the Literature bony, full bony) and use of prophylactic antibiotics
(no antibiotic, perioperative systemic antibiotics, tetra-
No. of No. of Infections
Investigator Teeth Infections (%) cycline powder placed into the socket, both periopera-
tive systemic antibiotics and tetracycline in the socket,
Curran et al]6 133 11 8.2 and postoperative antibiotics with and without tetracy-
Happonen et aliv 136 16 11.8 cline). Perioperative antibiotics were defined as two
Nordenram et a126 143 18 12.6
doses, one before and one after surgery. 1
Mitchell27 99 24 27
Mitchell and Morris28 172 19 11 The definition of infection for purposes of this article
Goldberg et alt8 500 21 4.2 was broad and included the following criteria: 1) pres-
Osborne et a134 16,127 553 3.4 ence of cellulitis, 2) presence of fluctuance, 3) presence
Sisk et al3s 1202 14 1.2 of purulent or nonpurulent drainage from the socket
more than 72 hours after surgery, 4) pain and swelling
that either worsened or failed to improve 48 hours after
surgery, 37 and 5) hyperpyrexia (more than 100°F) 48
rates of infection than others (Table 3). All articles
or more hours after surgery without local signs or
with a higher incidence 16'17'26-28 document that every
symptoms, if no other source for the fever can be
patient was examined after surgery, whereas none of
found. Patients with signs and symptoms 4 and 5 were
the three articles with a lower incidence 1s'34'35 make
diagnosed as having "incipient infections" and treated
that statement. Is it possible that some infections in
with therapeutic antibiotics although more definitive
these groups were not identified because all patients
signs of infection were absent. Incidence of infection
were not seen or contacted after surgery? Or were the
was recorded by tooth, not by patient. Presence or
articles with the higher infection rates studying only
absence of infection was identified as early (within 10
deep bony infections? The definition of level of im-
days of surgery) or late (more than 10 days after sur-
paction, or even of what constitutes infection, varies
gery). All patients diagnosed with late infections were
from article to article. In any event, " a v e r a g e " infec-
previously noted to be free of infection at their routine
tion rates of 1 % 36 o r 3% to 5 % 18 frequently quoted in
7 to 10 day postoperative visit.
the literature are not substantiated.
Results
Retrospective Evaluation of 6 , 7 1 3 Third
Molar Extractions All Teeth

To develop more information regarding the interplay Based on the previous criteria, the overall infection
of antibiotics, third molar surgery, and infections, we rate for 6,713 third molar extractions was 3.5% (2.6%
undertook a retrospective review of the records of all early and 0.9% late). Maxillary surgical sites rarely
2,134 patients who underwent extraction of 6,713 third became infected; of 3,270 maxillary extractions, only
molar teeth between June 1, 1985, and March 31, 1994, 5 early infections (0.2%) and 4 late infections (0.1%)
in our practice. Two thousand thirty-one patients were were recorded. In the 3,443 mandibular extractions,
examined within 10 days after surgery. There were 172 early infections (5%) and 54 late infections (1.6%)
103 who did not return, but they were included in the were recorded. These differences were statistically sig-
study because each of these patients had no less than nificant. The incidence of serious postoperative infec-
two postoperative phone conversations recorded in tions requiring hospitalization and intravenous antibi-
their chart, one within 48 hours and another a week otics, or extraoral incision and drainage, was zero.
later in which full recovery without any symptoms of
infection had been recorded. Maxillary Infections by Antibiotic
One thousand eight hundred sixty-eight (57%) max-
Materials and M e t h o d s illary third molars were extracted without antibiotic
coverage, whereas 1,377 (42%) were extracted with
Patient ages ranged from the early teens through the perioperative systemic antibiotics. The rate of infection
late 80s, with the average being in the early 20s. The was extremely small in each group, 0.37% without
male:female ratio was approximately equal. antibiotics, 0.15% with antibiotics, and 0.27% overall.
Surgical procedures were performed in the office or Twenty-five (1%) teeth in this group were extracted
at the hospital by one of two board-certified surgeons without preoperative antibiotics but the patients were
and all records were independently reviewed by one placed on a therapeutic course of antibiotics immedi-
resident, who also did the statistical analysis (chi- ately after surgery for a variety of reasons. The differ-
square). Specific variables studied included classifica- ences between groups was not statistically significant.
PIECUCH, ARZADON, AND LIEBL1CH 57

Table 4. Mandibular Infections With and Without Antibiotics

No. of No. No. With No. With Overall Infection

Total Without Early Late Incidence No.
Treatment Teeth Infection Infection Infection (%)

No antibiotic 332 283 45 4 49 (14.8%)

Systemic antibiotic 1242 1114 96 32 128 (10.3%)
Tetracycline 1597 1555 28 14 42 (2.6%)
Systemic and tetracycline 250 244 3 3 6 (2.4%)
Postoperative systemic 9 8 0 1 1 (11.1%)
Postoperative systemic and tetracycline 13 13 0 0 0 (0%)
Total 3443 3217 172 54 226 (6.6%)

Note: two-way chi-square revealed: no antibiotic vs systemic antibiotic, P = .002; no antibiotic vs Tetracycline, P = .000; no antibiotic vs
systemic and Tetracycline, P = .000; systemic antibiotic vs Tetracycline, P = .000; and systemic antibiotic vs systemic and Tetracycline, P
= .000.

Mandibular Infections by Antibiotic (Table IV) difference between any of these values because the
rate o f infection was so low in each category.
The overall infection rate for 3,443 mandibular third
molars was 6.6% (Table 4). Of 332 teeth removed
without any antibiotics, 14.8% became infected, as did Mandibular Infections by Site Classification and
10.3 % of 1,242 teeth removed with systemic periopera- Antibiotic
tive antibiotics. O f 1,597 teeth that were removed and
There appeared to be some statistical significance
had tetracycline powder placed in the socket, 2.6%
difference between different antibiotic variables within
became infected, whereas 2.4% o f 250 teeth removed
each level of impaction. Consequently, the results for
in patients received both systemic perioperative antibi-
each level o f impaction (erupted, soft tissue, partial
otics and tetracycline in the socket became infected.
bony, full bony) are presented separately (Tables 6
Differences between each of these groups was highly
through 9).
significant except for the tetracycline versus systemic
1) Erupted mandibular third molars. Based on the
antibiotic plus tetracycline groups. Twenty-two other
findings shown in this table, only the difference be-
third molars were removed and the patients placed on
tween no antibiotic and tetracycline was statistically
postoperative therapeutic antibiotics. Comparison with
significant (Table 6).
this group was not possible because of the small num-
2) Soft tissue impacted third molars. No compari-
ber.
son between any o f the groups was statistically sig-
nificant at the P < .05 level, although comparisons
Maxillary Infections by Site Classification and
between no antibiotics and both the systemic perioper-
Antibiotic
ative and tetracycline groups were close to the P <
Detailed figures relating to the incidence of infection .05 level (Table 7).
after maxillary third molar extraction and the level of 3) Partial bony impacted third molars. Based on
impaction to use of antibiotics are presented in Table 5. chi-square analysis, the differences between the no an-
Chi-square analysis revealed no statistical significance tibiotic group and each of the three variations of antibi-

Table 5. Maxillary Infections by Classification and Antibiotic

No. With No. With No. With

No AB/ No. With No AB/ AB/ Postoperative/ Postoperative/ Total
Classification Total No Infection AB/Infection No Infection Infection No Infection Infection Infection

Erupted 1,352 860 0 483 0 9

Soft tissue 1,001 586 4 403 I 7
Partial bony 559 287 0 271 0 !
Fully bony 358 128 3 218 1 8
Total 3,270 1,861 7 1,375 2 25

Abbreviation: AB, antibiotic.

Comparisons between these groups have no statistical significance.
58 PROPHYLACTIC ANTIBIOTICS FOR THIRD MOLAR SURGERY

Table 6. Infections With Erupted Third Molars Table 8. Infections With Partial Bony Impacted
According to Antibiotic Used Third Molars According to Antibiotic Used

No. No. No. of No. of Total

No. With With Total No. of Early Late Infections
of Early Late Infection Antibiotic Teeth Infections Infections No. (%)
Antibiotic Teeth Infection Infection No. (%)
No antibiotic 74 10 1 11 (14.9)
No antibiotics 86 3 0 3 (3.5)
Systemic antibiotics 89 1 0 1 (1.1) Systemic
Tetracycline 316 0 0 0 (0) antibiotic 372 18 3 21 (5.7)
Systemic and tetracycline 37 1 0 1 (2.7) Tetracycline 802 12 5 17 (2.1)
Postoperative only 1 0 0 0 (0) Systemic and
tetracycline 103 2 0 2 (1.9)
Total 529 5 0 5 (0.9) Postoperative
only 13 0 0 0 (0)
Note: two-waychi-squarerevealed:No antibiotic vs tetracycline, P = .001.
All other comparisons are not statistically significant. Total 1,364 42 9 51 (3.8)

Note: two-way chi-square revealed: no antibiotic vs systemic, P

otic ( e x c e p t p o s t o p e r a t i v e o n l y ) w e r e significant, as = .017; no antibiotic vs Tetracycline, P = .000; no antibiotic vs
systemic and Tetracycline, P = .005; and systemic vs tetracycline,
w a s the d i f f e r e n c e b e t w e e n s y s t e m i c p e r i o p e r a t i v e an- P = .003. All other comparisons are not statistically significant.
tibiotics and t e t r a c y c l i n e . A l l o t h e r c o m p a r i s o n s are
n o t statistically d i f f e r e n t ( T a b l e 8).
4) Full bony impacted third molars. B a s e d on the i n f e c t i o n in the c o m p r o m i s e d host. W e h a v e f o u n d
statistical analysis, d i f f e r e n c e s b e t w e e n the no antibi- n o e v i d e n c e s u p p o r t i n g the use o f antibiotics s i m p l y
otic g r o u p and e a c h f o r m o f a n t i b i o t i c ( e x c e p t p o s t o p - b e c a u s e o f a p a t i e n t ' s request, and h a v e l i k e w i s e dis-
e r a t i v e ) w e r e h i g h l y significant, as w e r e d i f f e r e n c e s c o v e r e d that there is n e i t h e r a u n i f o r m c o m m u n i t y stan-
b e t w e e n the s y s t e m i c p e r i o p e r a t i v e g r o u p and the t w o d a r d for the use o f p r o p h y l a x i s n o r is there an i n t e l l e c -
g r o u p s that r e c e i v e d t e t r a c y c l i n e . T h e d i f f e r e n c e be- tually s o u n d r a t i o n a l e e i t h e r for or against the use o f
t w e e n the t e t r a c y c l i n e g r o u p and the c o m b i n e d sys- antibiotic p r o p h y l a x i s b a s e d o n the literature.
t e m i c and t e t r a c y c l i n e g r o u p w a s n o t significant ( T a b l e T h e results o f o u r o w n r e t r o s p e c t i v e study o f 6,713
9). third m o l a r teeth d e m o n s t r a t e d that a n t i b i o t i c s a p p e a r
not to b e o f benefit in s o m e i n s t a n c e s and are o f sig-
Discussion nificant benefit in o t h e r instances. T h e strength o f o u r
r e p o r t is that it is the o n l y p u b l i s h e d study w i t h large
In this article w e h a v e e x p l o r e d s e v e r a l p o s s i b l e n u m b e r s o f patients that e v a l u a t e d all patients p o s t o p -
r a t i o n a l e s for the use o f antibiotic t h e r a p y in third m o - e r a t i v e l y and that a n a l y z e d i n f e c t i o n rates b y site, b y
lar surgery. S e v e r a l o f t h e s e are c e r t a i n l y j u s t i f i a b l e c l a s s i f i c a t i o n o f i m p a c t i o n , and b y c o m p a r i s o n o f dif-
based on current knowledge, these being therapy for f e r e n t antibiotic r e g i m e n s . T h e w e a k n e s s o f o u r study
o n g o i n g i n f e c t i o n and p r o p h y l a x i s against m e t a s t a t i c

Table 9. Infections With Full Bony Impacted

Table 7. Infections With Soft Tissue Impacted Third Molars According to Antibiotic Used
Third Molars According to Antibiotic Used
No. of No. of Total
No. of No. of Total No. of Early Late Infections
No. of Early Late Infections Antibiotic Teeth Infections Infections No. (%)
Antibiotic Teeth Infections Infections No. (%)
No antibiotic 121 29 3 32 (26.5)
No antibiotic 51 3 0 3 (5.9) Systemic
Systemic antibiotic 614 75 29 104 (16.9)
antibiotic 167 2 0 2 (1.2) Tetracycline 364 16 8 24 (6.6)
Tetracycline 115 0 1 1 (0.9) Systemic and
Systemic and tetracycline 73 0 3 3 (4.1)
tetracycline 37 0 0 0 (0) Postoperative
Postoperative only 7 0 1 1 (14.2)
only 1 0 0 0 (0)
Total 1,179 120 44 164 (13.9)
Totals 371 5 1 6 (1.6)
Note: two-way chi-square revealed: no antibiotic vs systemic, P
Note: two-way chi-square revealed: no antibiotic vs systemic, P = .002; no antibiotic vs telracycline, P = .0001 no antibiotic vs
= .051; and no antibiotic vs tetracycline P = .053. All other compari- systemic and tetracycline, P = .000; systemic vs tetracycline, P =
sons are not statistically significant. .000; and systemic vs systemic and tetracycline, P = .006.
PIECUCH, ARZADON, AND LIEBLICH 59

is its retrospective and nonrandomized nature. If this less of the level of impaction because the overall
study were repeated on a prospective basis, differences infection rate is so low (0.27%).
between surgeons as to degree of impaction and the 6) Systemic antibiotics are of no benefit when
exact definition of infection could be controlled. In the erupted mandibular third molars are extracted.
current study, there were such differences. For exam- Tetracycline placed in the socket is of benefit.
ple, one surgeon used systemic perioperative antibiot- 7) Systemic antibiotics and tetracycline in the
ics almost exclusively and this surgeon diagnosed a socket have not been proved to be of benefit
far greater percentage of incipient infections than the for soft tissue impacted mandibular third molars.
other surgeon who used tetracycline in the socket al- However, the results are so close to being statisti-
most exclusively. Hence, the differences in infection cally significant that we recommend the surgeon
rate between the systemic perioperative group and the use individual judgement.
tetracycline group may have been increased to statisti- 8) Both systemic antibiotics and tetracycline in the
cally significant levels by a tendency to overdiagnose socket have been shown to significantly reduce
the existence of infection in the former group. infection in partial bony mandibular impaction
On the other hand, the reader should be aware that extractions. However, tetracycline appears better
the only effect that this variability between surgeons than systemic perioperative antibiotics.
could have on the more important comparison of no 9) Both systemic antibiotics and tetracycline have
antibiotics versus antibiotics is to artificially inflate the been shown to significantly reduce infection after
infection rate in the systemic group. Yet, the difference mandibular full bony impaction surgery. Tetracy-
between the no antibiotic group and the systemic group cline is better than systemic perioperative antibi-
was still statistically significant. otics. The combination of systemic antibiotics
It appears from these data that antibiotics in some and tetracycline yields a lower infection rate, but
form may be useful in preventing postoperative infec- the difference from tetracycline alone is not sig-
tions after third molar surgery. We had too few patients nificant.
in the "postoperative only" group to allow for any
conclusions; however, the Capuzzi et al article 19 did References
confirm lack of benefit when antibiotics were given
only after surgery. This finding is consistent with estab- 1. Dajani AS, Bisno AL, Chung KJ, et al: Prevention of bacterial
lished principles of systemic antibiotic prophylaxis, endocarditis: Recommendations of the American Heart Asso-
which state that the systemic antibiotic should be pres- ciation. J Am Dent Assoc 264:2919, 1990
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