Exploring Giving Antibiotics Before Third Molar Surgery (Wisdom Teeth Removal) in Spain

An issue that one asks when having third molar surgery (wisdom teeth removal) is one whether should have antibiotics administered before or after surgery (or not at all). See for example http://www.teethremoval.com/antibiotic_resistance.html

In a recent article appearing in J Evid Base Dent Pract 2012, issue 12, pp. 149-150, Manal A. Awad, reviewed a study exploring amoxicillin administration to those who were having wisdom teeth extracted. The original study was titled “Efficacy of amoxicillin treatment in preventing postoperative complications in patients undergoing third molar surgery: a prospective, randomized, double-blind controlled study,” by Lopez-Cedrun JL, Pijoan JI, Fernandez S, and Santamaria J, Hernandez G and appeared in the electronic 2011 version pages 5 -14, issue 69, number 6. It is well known that amoxicillin is useful in treating oral infections.

In the study 123 healthy patients between the ages of 18 and 46 years which included mostly females (90) were randomly divided into 3 groups: 1) received amoxicillin preoperatively (n = 39), 2) received placebo (n = 44), and 3) received amoxicillin postoperatively (n = 40).  The patients in the study were having at least 1 impacted wisdom teeth removed. Patients and clinicians were blinded as to what group they were in (and what their treatment was).

The authors of the original study (Lopez-Cedrun and et. al)  looked at several clinically important outcomes in their patients after surgery. The researchers found that the patients who did not receive any amoxicillin and just placebo had statistically significantly more pain 7 days after surgery. Futhermore the patients who did not receive any amoxicillin and just placebo had statistically significantly more difficulty in opening their mouth 7 days after surgery. No statistically significant differences in swelling between the 3 study groups 7 days after surgery were found.

The reviewer (Awad) took issue with what the researchers said was a clinically important difference in mouth opening. The authors said that a 5 mm difference  in mouth opening is clinically important, but the researchers did not report the mean difference in millimeters in mouth opening between patients, only if the 5 mm difference was reached or not. The reviewer also questioned whether or not a large enough sample size was used in the study.

Awad states in the conclusion of his review (final paragraph):

“Whether antibiotic use is beneficial to patients who undergo surgical removal of third molars is still inconclusive. Clinical trials that are large enough to assess the effect of antibiotic use on the most common complication of surgical removal of third molars are still needed”

The review by Awad did not go into all of the findings in the original study. Five sockets in the study became infected after surgery and they were all from the group which did not receive any amoxicilin.  Several side effects were reported by patients but no statistically significant differences between the groups occurred for side effects.

Regarding taking an antibiotic before and/or after wisdom teeth removal essentially 3 options can occur.

  1.  an antibiotic before surgery in a single dose or multiple doses started several days before
  2. an antibiotic after surgery in a single dose or multiple doses maintained for several days afer
  3. an antibiotic before surgery and after surgery

The researchers in this study reviewed tested option 1 and option 2 above and not option 3. In addition, they state their findings seems to show that an antibiotic after surgery produce better study results than an antibiotic before surgery.

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