Dry socket prevention: eugenol or chlorhexidine?

Dry socket (alveolar osteitis) is a troublesome complication to tooth extraction and is reported to occur in around 0.5- 5% of routine extractions with a higher incidence being reported in mandibular molars, particularly impacted wisdom teeth.

The aim of this study was to compare the effect of application of 0.2% chlorhexidine gel, a eugenol-based paste on the postoperative incidence of alveolar osteitis in patients having third molars extracted.

Methods

Patients having third molar extractions were randomised to having 0.2% chlorhexidine gel, Alvogel or nothing placed in the extraction socket prior to suturing. Patients were prescribed metronidazole 400 mg three times daily for 3 day and aceclophenac + serratiopeptidase twice daily for 3 days, and were reviewed on postoperative days 1, 3, and 7.

Results

270 patients (160 male and 110 female) were randomised 90 per group.
11 of the 270 patients (4%) developed alveolar osteitis on postoperative day 7; 9 patients in the control group (10%) and 2 (2%) of the chlorhexidine group.
Mean VAS main scores were highest for the control group on day 1, 3 and 7.
Wound healing was poorest in the control group on day 7 with a mean score of 2.51 compared to 1.69 and 1.32 in the chlorhexidine and eugenol groups.

Conclusions

The authors concluded:

Eugenol proved to be the most effective of the two interventions not only in relation to the incidence of alveolar osteitis but also the presence of pain, infection, inflammation, and wound healing. We suggest the routine use of eugenol paste (Alvogyl) after extraction of a third molar not only as a preventative measure against alveolar osteitis but also to reduce pain, inflammation, and promote wound healing.

Comments

The 2012 Cochrane review by Daly et al (Dental Elf – 13^th Dec 2012) looked at local interventions for the management of alveolar osteitis and found some evidence to support the use of chlorhexidine gel but insufficient evidence for any of the other interventions including the use of Alvogel, so it is interesting to see them compared in this study.

While the authors report that they undertook a sample size calculation they do not state on which outcome measure it was based. There is also limited information on the number of surgeons participating and also which teeth are extracted for. Although third molars are mentioned in the title and the abstract, they are not mentioned in the methodology.

There is also a lack of detail on the randomisation process and no indication of who assessed the outcome although it is suggested that this is a double blind study. The authors note that the incidence of the main outcome was low (4%). This could have been due to the use of antibiotics, exclusion of smokers people who misused alcohol, and women on oral contraceptives, which have been identified as possible risk factors and point highlighted by the authors.

However, extraction trauma has been highlighted as an important risk (Dental Elf – 14^th Feb 2012) and complex or duration of the extraction procedure has not been discussed. The Cochrane review only included 2 trials, which looked at the use of Alvogel so high quality studies are needed to clarify the size of the effect.