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J Oral Maxillofac Surg66:943-947, 2008

Treatment of Delayed-Onset InfectionsAfter Impacted Lower Third

Molar Extraction

Rui Figueiredo, DDS,*

Eduard Valmaseda-Castellón, DDS, PhD,†

Daniel M. Laskin, DDS, MS,‡

Leonardo Berini-Aytés, DDS, MD, PhD,§ and

Cosme Gay-Escoda, DDS, MD, PhD�

Purpose: To describe the treatment of delayed-onset infections after lower third molar removal.

Patients and Methods: A retrospective study was made of 33 delayed-onset infections afterimpacted lower third molar extraction diagnosed between 2001 and 2005 in the Oral Surgery andImplantology Department of the School of Dentistry of the University of Barcelona, Spain.

Results: Antibiotic treatment was effective in 22 patients, whereas the remaining 11 needed anadditional surgical procedure to resolve this postoperative complication. Patients with prolongeduse of antibiotics after the onset of the infection were more likely to require surgical intervention.

Conclusions: Patients with delayed-onset infections should be treated initially with antibiotics for7 days. If the infection does not respond favorably within that time, surgical debridement of theextraction site should be done.© 2008 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 66:943-947, 2008

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he prevention and treatment of postoperative in-ections after the removal of impacted mandibularhird molars is of major concern to the oral andaxillofacial surgeon. Many articles have focused

n the clinical features and risk factors associatedith this problem.1-8 Although the incidence ofelayed infections is rare, ranging from around.5% to 6.7%,9-12 it can result in serious conse-uences. Lower third molars with total soft tissueoverage, a lack of distal space, or with a vertical oresioangular tilt seem more prone to developing

his complication.13

*Associate Professor of Oral Surgery, Professor of the Master

egree Program in Oral Surgery and Implantology, School of Den-

istry of the University of Barcelona, Barcelona, Spain.

†Associate Professor of Oral Surgery, Professor of the Master

egree Program in Oral Surgery and Implantology, School of Den-

istry of the University of Barcelona, Barcelona, Spain.

‡Professor and Chairman Emeritus, Department of Oral and Maxil-

ofacial Surgery, Virginia Commonwealth University, Richmond, VA.

§Dean, Professor of Oral and Maxillofacial Surgery, Professor

f the Master Degree Program in Oral Surgery and Implantology,

chool of Dentistry of the University of Barcelona, Barcelona,

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943

There is very little published information regard-ng the treatment of this problem. As a result, therere no established therapeutic guidelines. Theresent study was designed to analyze the treat-ent outcomes of delayed-onset infections after

mpacted lower third molar removal in an outpa-ient clinic and to develop a protocol for the man-gement of such patients.

atients and MethodsA retrospective study was made of 33 delayed-

nset infections that had occurred after impacted

�Chairman and Professor of Oral and Maxillofacial Surgery, Director

f the Master Degree Program in Oral Surgery and Implantology,

chool of Dentistry of the University of Barcelona; and Oral and

axillofacial Surgeon of the Teknon Medical Center, Barcelona, Spain.

Address correspondence and reprint requests to Dr Valmaseda-

astellón: Facultat d’Odontologia, Campus de Bellvitge, Universitat

e Barcelona (UB), Pavelló de Govern; 2a planta, Despatx 2.9,

/Feixa Llarga s/n, E-08907–L’Hospitalet de Llobregat, Spain; e-mail:

duardvalmaseda@ub.edu

2008 American Association of Oral and Maxillofacial Surgeons

278-2391/08/6605-0017$34.00/0

oi:10.1016/j.joms.2008.01.045

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944 TREATMENT OF DELAYED INFECTIONS

ower third molar extractions done between 2001nd 2005 in the Oral Surgery and Implantologyepartment of the School of Dentistry of the Uni-ersity of Barcelona, Spain. The inclusion criterionas an inflammatory swelling of the operated area

ccompanied by pain or the presence of suppura-ion that began at any time subsequent to sutureemoval 1 week postoperatively.

All patients had 1 lower third molar removednder local anesthesia, generally with a 4% Artic-ine solution containing epinephrine 1:100,000 (Ul-racain; Normon, Madrid, Spain). The surgical tech-ique used was similar to that described in previouseports.13,14 After the operation, the patient wasrescribed an antibiotic (usually amoxicillin 750g every 8 hr for 4 to 7 days [Clamoxyl 750; Glaxo

mithKline, Madrid, Spain]), a nonsteroidal anti-nflammatory drug (usually either sodium diclofe-ac 50 mg every 8 hr [Diclofenac Llorens 50 mg;lorens, Barcelona, Spain] or ibuprofen 600 mgvery 8 hr for 4 to 5 days [Algiasdin 600; Esteve,arcelona, Spain]), an analgesic (usually metamizol75 mg every 4 hr for 3 to 4 days [Nolotil; Boehr-

nger Ingelheim, Sant Cugat del Vallès, Spain]), andmouthrinse (0.12% chlorhexidine digluconate ev-

ry 12 hr for 15 days [Clorhexidina Lacer; Lacer,arcelona, Spain]). Postoperative instructions andse of the prescribed drugs were explained orallynd also on a printed sheet of paper that was giveno the patient.

Patients who developed delayed postoperativenfections were first treated by irrigation of theocket and oral antibiotics (amoxicillin, amoxicillinlus potassium clavulanate, clindamycin, or metro-idazole), usually for 7 days. The dosage was asollows: amoxicillin, 750 mg every 8 hours; amoxi-illin, 875 mg plus clavulanate 125 mg every 8ours; clindamycin, 300 mg every 6 hours; metro-idazole, 500 mg every 8 hours. Initially, if thehort-term antibiotic therapy did not resolve thenfection, it was changed before surgery was con-idered (8 cases tried more than 1 antibiotic). How-ver, when it became clear that antibiotic treat-ent alone was not always effective, subsequentatients were immediately subjected to surgery ifhe initial antibiotic therapy failed. The area wasxposed by means of a full-thickness flap and theranulation tissue and any bone particles or foreignaterial inside the extraction socket were re-oved. The socket was then irrigated with sterile

aline; the flap was repositioned with 3-0 silk su-ures; and an antibiotic was prescribed (Table 1).

All clinical records were examined by a singlenvestigator. The following data were retrieved:ge, gender, the time elapsed from removal of the

ower third molar to onset of the infection, the c

ntibiotics prescribed to treat the infection, theumber of days of such treatment, and the need forsurgical procedure (Table 1).Data were processed with the Statistical Package

or the Social Sciences (SPSS version 12.0; SPSS, Chi-ago, IL). Parametric and nonparametric tests (Pear-on �2, Fisher exact test, and Mann-Whitney U test)ere used to determine significant associations. The

evel of significance was set at P less than .05.

esults

The mean age of the patients was 26.3 � 8.9ears (SD). Twenty-two were females and 11 wereales. The median time elapsed from extraction to

he delayed-onset infection was 29 days (range, 11o 210 days) (Fig 1). The duration of postinfectionntibiotic treatment ranged from 4 to 28 days (me-ian � 7 days) (Table 1). Twenty-two of the 33

nfections resolved with antibiotics alone (Table 1).ineteen of 22 patients were managed with a single

ntibiotic (amoxicillin-3, amoxicillin plus clavu-anate-11, clindamycin-4, metronitazole-1) and theemaining 3 required a change in antibioticsamoxicillin and clavulanate to clindamycin-2,moxicillin to clindamycin-1).

Eleven patients required surgery in addition tontibiotics to treat the infection. Of these cases, 6emained on the original antibiotic (clindamycin-3,moxicillin and clavulanate-3) and 5 required ahange in antibiotic. Of the latter, 2 had a singlehange (amoxicillin and clavulanate to clarithromy-in-1, amoxicillin and clavulanate to clindamycin-1)nd 3 had a double change (cases 1, 19, 32, Table). In 2 of 3 cases with a double change, clindamy-in was the successful antibiotic. Patients who re-uired a surgical procedure in addition to antibiot-

cs had a longer period of initial postinfectionntibiotic treatment than those who were treateduccessfully with antibiotics alone (Fig 2, Table 1)Mann-Whitney U test � 32.5; Z � �3.477; P �001). These patients also had a higher time elapsedrom extraction to delayed-onset infection (Fig 1)Mann-Whitney U � 57.5; Z � �2.427; P � .015).ll other variables did not show any statistical sig-ificant association with the applied treatment (P �

05).

iscussion

Several reports have established the main fea-ures of delayed-onset infections.10-12,15 Some largeample studies report that 1.5% of lower third mo-ar extractions develop this complication.10,11,15 Aecent case-controlled study in our department con-

luded that total soft tissue coverage, a lack of distal

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FIGUEIREDO ET AL 945

pace, and a vertical or mesioangular tilt are signif-cant risk factors for the development of delayed-nset infections.13 Furthermore, it also identified an

mportant relationship to smoking, tooth sectioning,

Table 1. DELAYED-ONSET INFECTION MANAGEMENT A

Case Age (yr) GenderAntibiotic

Treatment (days)

1 18 Female 152 17 Female 233 22 Female 114 29 Male 75 34 Male 216 17 Female 77 23 Female 78 18 Female 49 34 Male 7

10 19 Female 2011 26 Female 612 51 Female 713 40 Male 2514 17 Female 715 29 Male 1116 17 Female 717 34 Male 718 22 Male 819 25 Female 1820 29 Male 721 23 Female 1922 23 Female 723 25 Male 1024 23 Female 725 22 Female 726 41 Female 527 18 Female 1328 17 Female 729 25 Male 830 23 Male 731 37 Female 732 26 Female 2833 44 Female 7

Abbreviations: A, amoxicillin; AP, amoxicillin and potassium cla

igueiredo et al. Treatment of Delayed Infections. J Oral Maxillo

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7-14 days 15-28 days 29-42 days >43 daysTime elapsed from extraction to infection

SurgicalAntibiotic

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IGURE 1. Relationship between the time elapsed from extraction toelayed-onset infection and the need for an operation. Note thatatients with longer times were more prone to undergo surgical treat-ent (Mann-Whitney U � 57.5; Z � �2.427; P � .015).

tigueiredo et al. Treatment of Delayed Infections. J Oral Maxil-ofac Surg 2008.

one coverage, and depth of impaction. It was con-luded that the probable cause of delayed infection is aead space beneath the soft tissue. If this theory isorrect, the problem could possibly be avoided by notarrying out primary wound closure. It has also beenuggested by several authors that leaving the extrac-ion socket open or with a tube drain can reducether postoperative complications such as swell-

ng.16,17

The treatment of postoperative wound infectionsfter lower third molar removal is not well-definedn the dental literature because most studies focusn the preventive use of antibiotics after third mo-

ar extraction rather than on the management ofstablished infections.6,10,18-20 However, it is com-only accepted that oral antibiotics are usually the

reatment of choice for such early onset complica-ions. According to White et al,21 we can expect

EATMENT OUTCOMES

ioticssed

SurgicalProcedures (n)

Treatment That ResolvedInfection

P, C 1 Surgery and CCL 1 Surgery and CLC None C

None APC None C

None APNone CNone ANone AP

1 Surgery and CNone APNone AP

2 Surgery and CNone APNone MNone AP

1 Surgery and APNone C

L, C 1 Surgery and C1 Surgery and AP1 Surgery and C

None APNone CNone APNone ANone C

C 1 Surgery and CNone C

1 Surgery and APNone ANone AP

P, M 1 Surgery and MNone AP

e; C, clindamycin; CL, clarithromycin; M, metronidazole.

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946 TREATMENT OF DELAYED INFECTIONS

ome additional surgical procedure such as debride-ent (7%) or reopening of the wound (1%). Never-

heless, our study shows that delayed-onset infec-ions should be considered as a separate entityecause one third of the patients needed such anperation. The time elapsed between the extrac-ion and delayed onset infection seemed to be aactor as to when antibiotics alone were effectivend when there was a need for surgical treatment.ine of 16 patients (56%) that had infections start-

ng approximately 1 month after the extractioneeded both pharmacologic and surgical therapyFig 1). In our opinion, when antibiotics alone areneffective, removal of the granulation tissue fromhe socket, debridement of any bone particles, andemoval of any foreign matter are decisive factors inuccess of the treatment.

It has been claimed that amoxicillin and clinda-ycin are 2 of the most suitable antibiotics for

reating oral infections, with very high successates.22 This also was true in our cases in which 18f 19 patients who were cured with a single anti-iotic received 1 of these agents. Moreover, in the1 cases requiring surgery plus antibiotics, 9 pa-ients were on 1 of these 2 antibiotics at the time ofnal treatment.Based on the fact that most patients usually re-

With reoperationNo reoperation

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IGURE 2. Relationship between the duration of pharmacologicalreatment (days) and the need for an additional surgical procedure.he antibiotic treatment was longer in patients who had to be operatedMann-Whitney U � 32.5; Z � �3.477; P � .001).

igueiredo et al. Treatment of Delayed Infections. J Oral Maxil-ofac Surg 2008.

overed after 7 days of antibiotic therapy (52%),

his should be first-line treatment. If this does notesolve the infection after 7 days, surgical treatmenthould be carried out.

Antibiotics should be the initial treatment forelayed-onset infections after impacted lower thirdolar removal. If there is not a favorable response

n 7 days, surgical debridement of the socket shoulde done.

cknowledgment

The authors thank Maria Eugenia De-Castro-Avellaner, DDS, forelp in the data sampling.

eferences1. Al-Belasy FA: The relationship of “shisha” (water pipe) smoking

to postextraction dry socket. J Oral Maxillofac Surg 62:10, 20042. Benediktsdottir IS, Wenzel A, Petersen JK, et al: Mandibular

third molar removal: Risk indicators for extended operationtime, postoperative pain, and complications. Oral Surg OralMed Oral Pathol Oral Radiol Endod 97:438, 2004

3. Berge TI, Boe OE: Predictor evaluation of postoperative mor-bidity after surgical removal of mandibular third molars. ActaOdontol Scand 52:162, 1994

4. Bruce RA, Frederickson GC, Small GS: Age of patients andmorbidity associated with mandibular third molar surgery.J Am Dent Assoc 101:240, 1980

5. Chiapasco M, Crescentini M, Romanoni G: Germectomy ordelayed removal of mandibular impacted third molars: Therelationship between age and incidence of complications.J Oral Maxillofac Surg 53:418, 1995

6. Poeschl PW, Eckel D, Poeschl E: Postoperative prophylacticantibiotic treatment in third molar surgery—A necessity? J OralMaxillofac Surg 62:3, 2004

7. Muhonen A, Venta I, Ylipaavalniemi P: Factors predisposing topostoperative complications related to wisdom tooth surgeryamong university students. J Am Coll Health 46:39, 1997

8. Sisk AL, Hammer WB, Shelton DW, et al: Complications follow-ing removal of impacted third molars: The role of the experi-ence of the surgeon. J Oral Maxillofac Surg 44:855, 1986

9. Osborn TP, Frederickson G, Jr, Small IA, et al: A prospectivestudy of complications related to mandibular third molar sur-gery. J Oral Maxillofac Surg 43:767, 1985

0. Piecuch JF, Arzadon J, Lieblich SE: Prophylactic antibiotics forthird molar surgery: A supportive opinion. J Oral Maxillofac Surg53:53, 1995

1. Christiaens I, Reychler H: Complications after third molar ex-tractions: Retrospective analysis of 1,213 teeth. Rev StomatolChir Maxillofac 103:269, 2002

2. Goldberg MH, Nemarich AN, Marco WP 2nd: Complicationsafter mandibular third molar surgery: A statistical analysis of500 consecutive procedures in private practice. J Am DentAssoc 111:277, 1985

3. Figueiredo R, Valmaseda-Castellon E, Berini-Aytes L, et al: De-layed-onset infections after lower third molar extraction: Acase-control study. J Oral Maxillofac Surg 65:97, 2007

4. Leonard MS: Removing third molars: A review for the generalpractitioner. J Am Dent Assoc 123:77, 1992

5. Figueiredo R, Valmaseda-Castellon E, Berini-Aytes L, et al: Inci-dence and clinical features of delayed-onset infections afterextraction of lower third molars. Oral Surg Oral Med OralPathol Oral Radiol Endod 99:265, 2005

6. Pasqualini D, Cocero N, Castella A, et al: Primary and secondaryclosure of the surgical wound after removal of impacted man-dibular third molars: A comparative study. Int J Oral MaxillofacSurg 34:52, 2005

7. Cerqueira PR, Vasconcelos BC, Bessa-Nogueira RV: Compara-

tive study of the effect of a tube drain in impacted lower thirdmolar surgery. J Oral Maxillofac Surg 62:57, 2004

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8. Arteagoitia I, Diez A, Barbier L, et al: Efficacy of amoxicillin/clavulanic acid in preventing infectious and inflammatory com-plications following impacted mandibular third molar extrac-tion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:e11, 2005

9. Ataoglu H, Oz GY, Candirli C, et al: Routine antibiotic prophy-laxis is not necessary during operations to remove third molars.Br J Oral Maxillofac Surg 46:133, 2008

0. Ishihama K, Kimura T, Yasui Y, et al: Azithromycin as prophylaxis

for the prevention of postoperative infection in impacted man-dibular third-molar surgery. J Infect Chemother 12:31, 2006

1. White RP Jr, Shugars DA, Shafer DM, et al: Recovery after thirdmolar surgery: Clinical and health-related quality of life out-comes. J Oral Maxillofac Surg 61:535, 2003

2. Isla A, Canut A, Gascon AR, et al: Pharmacokinetic/pharma-codynamic evaluation of antimicrobial treatments of orofa-cial odontogenic infections. Clin Pharmacokinet 44:305,

2005