Pehodontics

Postoperative infections and tetracycline prophylaxis in periodontal surgery:a retrospective studyL. Checchi* / L. Trombeiii*^ / M. Nonato^*

The aims of this retrospective study were to a.ssess the incidetice of infection afterperiodontal surgery, in relation to the type of surgical procedute, and the effectivenessof prophylactic tetracydine administration. Nineteen (4.4%) of 445 surgieal proce-dttres in patients who were given tio tetracycline resulted in signs of infection, whiletwo (3.8%) in patients who were treated with ¡etracycline resulted in signs of infection.There was tw statistically significant difference between these incidences, suggestingthat there is no reason for routine tetracycline prophylaxis in periodontal surgeryThere was no statistically significant difference in the incidence of infection whether ornot bone (ostectomy or osteoplasty) or tooth extraction was involved in the surgicalprocedure. (Quintessence Int 1992;23:l9l-}95.)

Introduction

Administration of antibiotics to prevent postoperativeinfections followitig oral, and in particniar periodon-tal, surgery is a controversial procedure.'"^ Although awell-directed antibiotic treatment is necessary to curean infectious process, the routine administration ofprophylactic antibiotics after periodontal surgery seemsto be a tentative approach. This criticism is supportedby two observations: (1) the low incidence of infectionsafter periodontal surgery, although no comprehensiveand accurate survey has been published, and (2) thelack of evidence that antibiotic treafment is effective inpreventing or even minimizing surgical complications.

Postoperative morbidity after periodontal surgerydoes not appear to be favorably affected by antibioticadministration. No significant differences in severityof inflammation and swelling were found betweenpatients with antibiotic coverage and those without.^

Cattedra di Chirurgia Spéciale O don tost orna to lógica, Uniof Bologna, School of Dentistry via S Vitale 59 40100 BoItaly

u don tost orna to lógica, universityry, via S Vitale 59, 40100 Bollogna,

ily.

of Bologna, School of Dentistry, via S Vitale 59, 40100 BolognaItaly.

** University of Ferrara, Sehool of Dentistry, 44100 Ferrara, ItalyAddress all correspondence to Prof L. Checchi, Studio di Parodontologia, via Mazzitii 53/2, 40137 Bologna, Italy,

The Studies by Dal Pra and Strahan'* and Kidd andWade' have both shown that the principal effect ofprophylactic penicilhn is one of reduction of pain afterperiodontal surgery.

A retrospective study of periodontal surgical patientsshowed a similarly low incidence of infections in pa-tients who received prophylactic antibiotic administra-tion and patients who did not.^ Moreover, whereasantibiotics should be given prophylactically whenthere is a medical indication (in patients with diabetes,rheumatic fever, heart valve replacement, etc), it hasnot yet been determined whether the development ofpostoperative infections is affected by the type ofsurgical procedure.

Because of these observations, a large-scale retro-spective study of patients who underwent periodontalsurgery in a private practice was undertaken with thefollowing goals: (J) to establish the incidcticc of post-operative infections in relation to the type of surgery,atid (2) to assess the effectiveness of tetracychnesprophylactically prescribed after periodontal surgery.

Method and materials

The study population cotnprised all patients who hadbeen surgically treated for periodontal disease in the

Quintessence International Volume 23, t^umber 3/1992 191

Periodontios

years 1986 to 198S in a private periodontai practice.The sample consisted of 231 patients. S9 male and 142female, who ranged in age from 16 to 67 years (meanage of 46 years). None of tlie patients had a disease orcondition that might affect healing or that requiredprophylactic antibiotics and none was allergic to tet-racyclines.

Prior to surgery, all subjects were given oral hygieneinstructions and scaling and root planing sessions.Surgery was carried out when the plaque index'' waslower than 20%.

A total of 498 surgical procedures were performedby one periodontist (LC). Mucoperiosteal reversebevel flap and osseous contouring (ostcctomy and/orosteoplasty) were carried out in 360 cases. Surgeryusually involved one quadrant or sextant and could becombined with tooth extraction. Mucogingival surgerywith no hone involvement was performed in 138 cases.Local anesthesia was administered to all patients be-fore surgery. The flaps were sutured, and in most casesthe wound was protected with a surgical dressing (CoePack, Coe Laboratories Inc), which was removed 5 to7 days postoperatively.

In 53 of 498 procedures, 250 mg of tetracycline hy-drochloride, orally, four times a day, or lOfl mg ofminocychne, orally, twice a day. was prophylacticallyadministered to patients immediately after surgery for7 days. In all patients, noramidopyrine was adminis-tered at a constant dosage only on the day of thesurgery and for the first day postoperatively. Cases inwhieh a prolonged and uncontrolled self-administra-tion of the drug was recorded were excluded from thestudy. Chlorhexidinc mouthrinses (10 mL of 0.2% solu-tion, twice daily) or chlorhexidine gel (1% gel, twicedaily) were given to all patients for 14 to 21 days post-operatively.

The patients were monitored for 7 days after surgeryand instructed to report any increased and progressivepain and swelling that occurred 48 to 72 hours postsur-gically. These signs were considered to be pathog-nomonie for a postoperative infection.

The data collected contained the following infor-mation for each patient: number of surgical proce-dures, number and type of osseous and mucogingivalsurgicai procedures, size of the surgical site, pro-phylactic tetracycline administration, developmentof postoperative infection, and therapeutic admini-stration of antibiotics to treat postoperative infec-tion.

These data were then coded and analyzed with thechi-square test, when appropriate, and with Fisher's

exact probability test when frequencies were too smallto use the other procedure.

Results

Infections followed periodontai surgery in 21 (4.2%)of 498 cases. There was no statistically significant dif-ference in the incidence of infection following flapsurgery with bone involvement (ostectomy and osteo-plasty) and that recorded after flap surgery withoutbone involvement, in patients who received no tet-raeyeline prophylaxis (Fig 1). In the same patients,there was also no statistically significant difference inthe incidence of infection whether or not tooth extrac-tion was performed during osseous surgery (Fig 2).However, a significantly higher (P = .022) nnmher ofinfections was found after quadrant osseous surgerythan after sextant osseous surgery (Fig 3). With regardto the number of teeth involved in free gingival grafts(one, two, or three teeth), the incidence of postopera-tive infection decreased as the number of teeth in-volved inereascd, but this relationship was not statisti-cally significant.

In Fig 4, the incidence of postoperative infection inpatients treated with tetracycline is compared to theincidence in patients given no tetracycline. Of 445 sur-gical procedures performed in patients without tet-racycline coverage, 19 (4.4%) resulted in postoperativeinfection. In all cases, tetraeycline therapy was effec-tive in reducing infection within 2 or 3 days. Of 53 pro-cedures performed in patients who were given tet-racychne prophylactically, two (3.8%) resulted in post-operative infection: these infections were effectivelycontrolled by administration of penicillin. Statisticalcomparison revealed no difference between the twogroups.

Discussion

This retrospective study showed that the incidence ofpostoperative infection in patients after periodontaisurgery was low among a large number of surgical pro-cedures performed in a private office setting.

The development of postoperative infection did notseem to be related either to the intraoperative extrac-tion of a tooth or to the surgical involvement of bonetissue. Indeed, the incidence of complications follow-ing osseous and mucogingival surgery was similar. Incontrast, statistical analysis of the results revealed asignificant increase in the incidence of complicationsas the size of the surgical site increased (quadrant ver-

192 Quintessence International Volume 23, Number 3/1992

Periodontics

I Infections I I Surgical prixsdurss

Fig 1 Incidence of infection after periodontai surgery withor without osteoplasty/ostectomy in patients treated with-out tetracyeline prophylaxis. Statistical comparison usingthe chi-square test with Yates correction showed no signifi-cant differences (P = .859).

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Fig 2 Incidence of infection after csseus surgery with orwithout tooth extraction in patients treated without tet-racyeline prophylaxis, Statisticai comparison using Fisher'sexact test shewed no significant differences (P = ,704).

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Fig 3 Incidence of infection after sextant or quadrantosseous surgery in patients treated without tetracyciineprophylaxis. Statisticai comparison using Fisher's exact testshowed a significantly higtier incidence of infection afterquadrant surgery (P = .022|.

I I Surgical ptocedures

Fig 4 Incidence of infection after periodontai surgery inpatients treated with or wittiout tetracyciine proptiylaxis.Statistical companson using Fisher's exact test shewed nosignificant differences (P= .609],

sus sextant), when the surgical procedure involvedbone tissue. Factors related to the surgical procedureor fo the postoperative course (extent of surgicaltrauma, duration of operation, extension of sutures,difficulty for patients to perform home care oralhygiene) may account for this difference.

However, the incidence of infections, even afterquadrant osseous surgery, was so low that routine useof prophylactic antibiotics catinot be supported.Moreover, comparison between the incidence of com-plications following quadrant osseous surgery in pa-tients given postoperative tetracyline and the incidence

Quintessence International Volume 23, Number 3/1992193

Periodontics

in patients not given the antibiotic showed no statisti-cally significant difference.

A similar number of postoperative infections wasfound after free gingival graft proccdnres involving dif-ferently sized areas. This could be accounted for bythe surgical technique used. A thin (0.3- to 0.7-mm)graft'" on a submarginal, partial-thickness receivingsite ensured an adequate blood supply to the graftarea, thus limiting the occurrence of infection.

Results of this investigation support the conclusionof a previous retrospective study on the incidence ofinfections after periodontal surgery. Pack and Haber'̂observed a 1% incidence of complications, regardlessof bone tissue involvement and whether or not aprophylactic antibiotic had been given. Although thesame criteria were used to diagnose infections in bothstudies, the present results showed a slightly higherincidence of complications. This difference is possiblydue to the different operative conditions, with regardto the number of surgeons (multiple surgeons versusone surgeon) and the different health care environment(dentai school clinic versus private office setting).

Measurement of pain and swelling is extremely dif-ficult and tends to be subjective. Although noramido-pyrine administration was time-limited at constantdosage, difficulties in evaluating pain and swelling asrecorded by patients may have resulted in the overes-timation of the incidence of postoperative infection.

In this study, all patients were given topical chlor-hexidine (0.2% solution or 1% gel) postoperatively.Clinical and experimental evidence seems to suggestthat chlorhexidine enhances wound healing followingperiodontal surgery"'" and is effective in reducingpostoperative pain and swelling.' It is not possible todetermine to what extent and under what conditionschlorhexidine may have contributed to the low inci-dence of infection. Further studies are needed to assesswhether chlorhexidine may be given in selected casesas an effective substitute for systemic prophylactic anti-biolics.

The results showed that tctracycline was effective inthe treatment of postoperative infections, but it wasunreliable in preventing complications when adminis-tered prophylactically. These findings are in accordwith those of Seopp et al.''' who found no statisticallysignificant differences in pain experience and amountof inflammation between tetracycline and placebogroups following periodontal surgery.

In view of the well-estabhshed antibacterial effect oftetracycline, the question arises as to why the antibio-tic did not affect postoperative complications to any

significant extent. It is possible thai microorganismscausing inflammation in the surgical site were plasmid.mediated resistant strains. Moreover, the tetracyclineadministration was started after Ihe surgery. Pendrilland Reddy^ suggested that more beneficial effects mayresult if antibiotics are given prior to surgery, thusreducing the incidence of postsurgical bacteremias.However, Appleman et ai" found no correlation be-tween the incidence of polymicrobic hacteremias andobjective signs of tissue healing in patients treatedwith or withou! antibiotic coverage.

Recent studies have suggested that the broad-spec-trum tetracycline group of antibiotics may have a posi-tive but indirect effect on cell attachment to root stir-faces'*' and a positive effect on bone formation."''^However, further investigations on the potential of tet-racyclines to affect attachment levels and bone heahngare needed to determine their usefulness in the treat-ment of periodontal disease.

Conclusion

In view of the well-known adverse effects of tetracy-cline. and since the antibiotics provided no advantagein preventing postsurgical complications, the routineuse of prophylactic tetracycline following periodontalsurgery cannol be recommended. Prophylactic antibio-tic administration should depend strictly on the pa-tient's medical history.

References

1. Ariaudo AA; The efficaey of iiniibiotics in periodonlalsurgery; a controlled study with lincomycin and placebo in 6iipatients. J Periodomnt 1969;40;lS0-154.

2. Paterson JA, Cardo V. Stratidos G: An examination of anti-biotic prophylaxis in oral and maxillofaeial surgery. / OralSurg Í970;28;753-75ñ.

3. De Marco TJ. Kliith EV: The use of cleocin in postsurgicalperiodontal patients. J Periodoiitol t972;43;381-385.

4. Curran .IB. Kennet S, Young AR; An assessment of tlie use ofprophylaelic antibioties in third molar surgery. Itil J Oral Surgiy74;3:l^.

5. Pendrill K, Reddy J: The use of prophylaetic penieillin inperiodontal surgery. J Periodomoi 198O;51:44-48.

6. Dal Pra JD. Strahan JD; A clinical evaluation of the benefitsof a course of oral perticillin following periodontal surgery.AiLtt Dem J 1972;17;2t9-22t.

7. Kidd EAM, Wade AB; Penicillin control of swelling and painafter periodontal osseous surgery. J Clin Periodomot 1974'r.S2-57.

194 Ouintessenoe International Volume 23. Number 3/1992

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1;,. 14.

Pack PD. Haber J; The incidenee of elinical infection sfterpertodonlal surgerji, J Periodonlot 1983:54:441^43,O'Leary TJ. Drake RB, Naylor JE: Tbe plaque control re-cord, J Periodontni 1972;43:38,

Checchi L, Pirro P: Esili cliniei di innesti gengivali liberi.Denial Cadmos 1987;18:S3-S8,Hatnp SE, Rosling B, Lindhe J: Effect of chlorhexidine ongingival wound bealing in the dog. A histometrie study, / ClinPeriodomol 1975 ;2:143-152.Langebaek J. Bay I: The effect of chlorhexidine mouthrinseon healing after gingivectomy, Scand J Dem Res 1976; 84:224-228,

Bakaeen GS, Strahati JD: Effects of a 1 % ehlorhexidine gelduring tbe healing phase after inverse bevel mueogingivalflap surgery, J Clin Periodomol 19S0;7:20-2S,Scopp IW, Fleleher PD, Wyman BS, et al: Tetraeyelmes: dou-ble-blind elinieal study to evaluate the effectiveness inperiodontal surgery, J Periodonlot 1977;48:484-486,Appletnan MD, Sutter VL, Sims N: Value of antibioticprophyla:(is in periodontal surgery. J Periodomol 19S2;53:319-324.

Terranûva VP, Franietti LC, Hick S, et al: A bioehemieal ap-proach to periodontal regetieration: tetraeyeline treatment ofdentin promotes fibroblast adhesion and growtb. ] PenodomRes 1986;21:330-332,

Golub LM, Ramamurthy N, MeNamara TF, et a¡, Tetraey-clittes inhibit tissue collagenase aetivity, A new mechanism inthe treatment of periodgntal disease, J Perhdonl Res 1984;19:651-654,

Moskow BS: Repair of an extensive periodontal defect aftertetracycline administration, A ease report, J Periodontot 1986;57:29-31, D

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