CLINICAL ARTICLES

J Oral Maxillofac Surg

62:3-8, 2004

Postoperative Prophylactic Antibiotic

Treatment in Third Molar Surgery
A Necessity?
Paul W. Poeschl, MD,* Doris Eckel, MD, DDS,
and Ellen Poeschl, MD
Purpose:

We evaluated the need for prophylactic postoperative oral antibiotic treatment in the
removal of asymptomatic third molars.
Materials and Methods: In a prospective study of more than 30 months, a total of 528 impacted lower
third molars were surgically removed in 288 patients. All patients were referred to our department by a
dentist or a general practitioner. No patient showed any sign of pain, inflammation, or swelling at the
time of removal. Three groups were established. In the first group, antibiotic treatment with amoxicillin/
clavulanic acid as an oral medication was carried out for 5 days postoperatively. In the second group, we
used clindamycin. In the third group, the patients received no antibiotic treatment. Clinical and
radiologic factors were recorded for each case, and the rationale for assigning the patients to the groups
was strictly random. The surgical technique was the same in all cases, and the follow-up period was 4
weeks. Parameters that were evaluated were pain, differences in mouth opening, infection, the occurrence of dry socket, and adverse postoperative side effects.
Results: We could not find any significant difference between the 3 groups regarding the evaluated
parameters, but in 69.6% of the patients with dry socket, the teeth were partially erupted, which showed
a significant difference.
Conclusions: The results of our study show that specific postoperative oral prophylactic antibiotic
treatment after the removal of lower third molars does not contribute to a better wound healing, less
pain, or increased mouth opening and could not prevent the cases of inflammatory problems after
surgery, respectively, and therefore is not recommended for routine use.
2004 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 62:3-8, 2004
The surgical removal of lower third molars is one of
the most frequently performed procedures in oral and
maxillofacial surgery and represents a standard operation. It accounts for about $150 to $400 million per
year in the United States1 and a total of approximately
50 million in the United Kingdom.2 Therefore, much

controversy has arisen about this topic during the

past 3 decades regarding the necessity of third molar
surgery, especially in asymptomatic patients. Although
most authors focus on the problem of prophylactic
removal of third molars3-5 or the use of different
techniques to prevent damage to the inferior alveolar
or the lingual nerve,6-8 less literature exists about the
need for an adequate perioperative antibiotic treatment strategy to prevent postoperative problems.
Antibiotic prescribing in third molar surgery remains
controversial. The wound infection rate after the removal of a third molar is higher than that after a
routine tooth extraction,9 although the exact incidence of infection is difficult to assess. The overall
infection rate in dentoalveolar surgery is estimated at
1% to 5%.10 The most common form of antibiotic
prophylaxis is still systemic administration,11,12 although the use of antiseptic mouthwashes and placement of antibiotics in the extraction socket have been

Received from University Hospital for Cranio-Maxillofacial and Oral

Surgery, Vienna Medical School, Vienna, Austria.
*Resident.
Resident.
Scientific Co-worker.
Address correspondence and reprint requests to Dr P. Poeschl:
University Hospital for Cranio-Maxillofacial and Oral Surgery, Vienna Medical School, Waehringer Guertel 18-20, A-1090 Vienna,
Austria; e-mail: maxillofacials@hotmail.com
2004 American Association of Oral and Maxillofacial Surgeons

0278-2391/04/6201-0002$30.00/0
doi:10.1016/j.joms.2003.05.004

FIGURE 1. Amoxicillin/clavulanic acid group, angulation types.

shown to be partially effective in the prevention

of postoperative infection. The principal antibiotic
agents used for antibacterial prophylaxis in the past
were penicillin and metronidazole. During the past
decade, broad-spectrum antibiotics like amoxicillin or
amoxicillin in combination with clavulanic acid have
been increasingly prescribed in dentoalveolar and
third molar surgery, because of their broader bactericidal activity.13 Clindamycin also has become very
popular in the past few years in oral and maxillofacial
surgery, especially in patients allergic to penicillin.
The aim of the present work was to evaluate the
effect of the application of 2 different antibiotics,
amoxicillin/clavulanic acid and clindamycin, after the
removal of third molars in a prospective, randomized,
controlled clinical study over 2.5 years.

Materials and Methods

A total of 528 lower third molars were surgically
removed in 288 patients during a period of 30
months. The patients mean age was 20.7 years (age
range, 14 to 61 years). All patients were free of pain or
other inflammatory symptoms like swelling, hyperemia, or decreased mouth opening at the time of
surgery. None had had other antibiotic treatment during a period of at least 3 months preoperatively. Only
nonsmokers were included in the study. Written consent to participate was obtained from each patient.

POSTOPERATIVE PROPHYLACTIC ANTIBIOTICS

FIGURE 3. Amoxicillin/clavulanic acid group, degree of retention.

Three groups were established. In the first group

(Figs 1-3), postoperative antibiotic treatment was administered with 1 g amoxicillin/clavulanic acid (Augmentin; SmithKline Beecham GmbH Austria, Brunn
am Gebirge, Austria) 2 times daily orally starting directly after surgery and given for 5 days. In the second
group (Figs 4-6), 300 mg clindamycin (Dalacin; Pharmacia & Upjohn GmbH Austria, Vienna, Austria) 3
times daily was prescribed for 5 days as an oral medication starting directly after surgery as well. The third
group (Figs 7-9) received no antibiotic medication
and served as the control group. The rationale for
assigning the patients to the groups was strictly random and was done after surgery by using prepared
randomizations in sealed envelopes. Clinical and radiologic factors were recorded for each patient preoperatively and postoperatively. The distribution of
different angulation types according to Winter and
the degree of eruption were almost the same in each
group and did not differ significantly (Figs 1-9). Almost all patients could be examined on days 2 and 10
and 4 weeks postoperatively. Only 2 patients did not
return after surgery for the first postoperative examination, 4 patients did not return for removal of the
sutures on day 10, and a total of 7 did not appear for
the last appointment 4 weeks after surgery. All of
these patients were therefore excluded from the
study. Parameters for our investigations were the following:
1. Differences in mouth opening (interincisial distance preoperatively and postoperatively)

FIGURE 2. Amoxicillin/clavulanic acid group, demographics, ethnic

character.

FIGURE 4. Clindamycin group, angulation types.

POESCHL, ECKEL, AND POESCHL

FIGURE 5. Clindamycin group, demographics, ethnic character.

FIGURE 7. Control group, angulation types.

Results
2. Infection of the wound region (local swelling,
hyperemia, purulent drainage, painfulness of the
mucosa in the region around the sutures)
3. Dry socket (lack of a coagulum, exposed bone,
necrotic and malodorous debris in the socket,
extremely painful socket walls)
4. Pain scores from 1 to 10 on a visual analog scale
(VAS)
5. Side effects (as described in Table 1)
The standard surgical procedure was the same in all
cases and only one lower third molar was removed at
a time. A mouth rinse of 0.2% chlorhexidine solution
for 1 minute was used before surgery. Articaine in
combination with epinephrine (1:100,000) was used
for local anesthesia. Only nonresorbable atraumatic
4-0 sutures were used for wound closure, and their
removal took place on day 10. Intraoperatively, only a
physiologic saline solution containing no antibacterial
agents was used for rinsing the operative site. The
hematoma was released on day 2. In cases of partial
eruption, a local iodoform gauze drain was applied,
which was removed on day 2 as well. All patients
were prescribed 500 mg mefenamin acid orally
(Parkemed; Pfizer Corporation Austria, Vienna, Austria) as a rescue analgesic according to the need, with
only 1 tablet administered at a time with intervals of at
least 6 hours. Statistical analysis was performed by
using 1-way analysis of variance, Students t test, and
2 test. A value of P .05 was considered statistically
significant.

FIGURE 6. Clindamycin group, degree of retention.

No severe complications like perimandibular abscess or cellulitis occurred in any patient in any
group. The results for each parameter in each group
are given (Figs 10-14 and Table 1). There was no
significant difference between the groups regarding
the overall occurrence of local infection symptoms
after surgery (range, 3.4% to 4.4%; mean, 3.98%). The
same is true for differences in mouth opening and
pain scores. Interestingly, 69.6% of the patients with
dry sockets had partially erupted third molars. This
rate was the same in each group (62.5% to 75%) and
did not vary significantly; it seems that the mucosal
retention of a third molar per se is the most important
factor for intraoral wound healing problems, especially the occurrence of an alveolitis. According to
our protocol, all third molars with mucosal retention
were treated with an iodoform gauze drain and therefore we cannot compare different types of postoperative treatments within this group. When comparing
the side effects after surgery, we found that the incidence of nausea and diarrhea was not higher in either
of the 2 antibiotic groups. The amount and distribution
of the intake of mefenamin acid as a rescue analgesic
did not vary significantly among the 3 groups.

Discussion
It is common practice in third molar surgery to use
antibiotics as a prophylactic therapy against the potential infection caused by susceptible microorgan-

FIGURE 8. Control group, demographics, ethnic character.

POSTOPERATIVE PROPHYLACTIC ANTIBIOTICS

Table 1. POSTOPERATIVE SIDE EFFECTS

FIGURE 9. Control group, degree of retention.

isms, although the timing and protocol vary widely.13

But does this practice adhere to the principles of
antibiotic prophylaxis as delineated by Peterson?14
First, the surgical procedure should have a significant
risk of infection. Second, the correct antibiotic for the
surgical procedure should be selected. Third, the antibiotic level must be high. Fourth, antibiotic administration must be correctly timed. Fifth, the shortest
effective antibiotic exposure should be used. Although principles 2 through 5 deal with the correct
administration and protocol, only the first principle
determines the need for such a therapy. Third molar
surgery is usually considered clean-contaminated surgery, and therefore the use of routine antibiotic prophylaxis is a controversial topic. Several reviews of
complications after third molar surgery show an incidence of 1% to 5.8% of minor postoperative infections.15-17 Another study about deep space infections
also shows only a very low incidence of severe infectious complications arising from third molar surgery,
all occurring in cases with preoperative pericoronitis.18,19 Therefore, the routine administration of prophylactic antibiotics is to be questioned. A very accurate study concerning this topic was made by
Happonen et al.20 They compared the effect of tinidazole and penicillin in third molar surgery in a randomized, double-blind, placebo-controlled clinical
study and concluded that the use of these 2 antibiotic
substances did not have a significant effect on the
reduction of postoperative infectious complications.
Another study supporting this opinion was performed
by Curran et al.21 In their series, they compared antibiotic therapy with no antibiotic therapy and found
no difference regarding postoperative infections.
Two literature reviews by MacGregor22 and Sands et
al23 did not recommend the routine administration of
antibiotics for third molar surgery, except for the
most difficult cases. A study by Barclay24 with highrisk nonacute pericoronitis patients showed no significant effect of metronidazole compared with a placebo group regarding postoperative pain and
alveolitis. However, when looking at the side effects
in this study, 3 patients of the metronidazole group
had to be excluded from the study because of nausea.

Side Effects

Amoxicillin/
Clavulanic
Acid Group
(n)

Clindamycin
Group (n)

Control
Group
(n)

Headache
Weakness
Insomnia
Nausea
Fever
Tremor
Constipation
Diarrhea
Total

11
2
1
4
5
2

2
27

9
3

3
4
1

2
22

12
3
1
2
5

24

Similar results can be found in another study comparing metronidazole with no antibiotic by Lyall.25 Different outcomes can be seen in a randomized, doubleblind, placebo-controlled clinical study by Mitchell,26
in which tinidazole was compared with a control
group regarding the prevention of postoperative infection after third molar surgery. A significant reduction of infection was found in the tinidazole group.
Nevertheless, the author recommends only an anaerobicidal antibiotic for bony impacted wisdom teeth.
Other studies supporting these findings were performed by Kaziro,27 MacGregor and Addy,28 and Bystedt and Nord.29 However, these authors recommend only the use of antibiotics after traumatic
surgery or in cases in which the tooth is difficult to
remove, and propose that this decision can be made
after surgery.
A very crucial point in the debate about prophylactic antibiotics in third molar surgery is the timing of
administration. Usually the antibiotic is prescribed
after surgery as an oral medication, and therefore high
serum levels are reached only some hours after the
removal of the tooth. However, there is evidence that
preoperative administraton of antibiotics has a significant effect on the reduction of postoperative wound
infections.30 Stone et al31 have shown that surgical
wound infections were lowest in patients who re-

FIGURE 10. Differences of mouth opening in millimeters.

POESCHL, ECKEL, AND POESCHL

FIGURE 13. Distribution of all cases of dry socket according to the

eruption stage.
FIGURE 11. Cases of local inflammatory symptoms (mean, 3.98%
[95% confidence interval, 3.4% to 4.4%]).

ceived preoperative antibiotics but that the incidence

of infection was the same as that without any antibiotic when the substance was given 1 to 4 hours after
the start of surgery. A prospective study by Classen et
al32 with patients undergoing clean-contaminated surgery (hysterectomy, cholecystectomy, hip and knee
arthroplasty) showed a clear increase in postoperative
infection rates in patients who received antibiotics
more than 3 hours after the initial incision compared
with patients who received antibiotics within 2 hours
of surgery. Another large study by Piecuch et al.33 of
third molar extractions showed a significant reduction in postoperative infection rates for patients about
to undergo surgical removal of full or partial bony
impacted teeth if they received preoperative antibiotic prophylaxis, although they confer no advantage
for soft tissue impactions, where bone removal is not
necessary.
Another critical point is possible side effects occurring from antibiotic administration. Some of the risks

FIGURE 12. Number of cases of dry socket.

of indiscriminate antibiotic therapy include the toxicity

of the substance itself, allergic reactions, secondary infections, and of course the development of resistant
organisms. There is a tendency to overprescribe antibiotics as well as medication in general.34 The motivation
of the surgeon for using routine prophylactic antibiotics
usually is the prevention of infection, but once the
decision for the administration of an antibiotic is made,
it is still important to adhere to principles 2 to 5 of
Peterson.14 The ideal antibiotic agent for a particular
clinical application should be nontoxic and easy to administer and have as narrow a spectrum as necessary to
eliminate possible infections. Broad-spectrum antibiot-

FIGURE 14. Mean pain scores on a visual analog scale (0, no pain;
10, very severe pain).

8
ics like amoxicillin with clavulanic acid or clindamycin
are the most commonly prescribed antibiotic in our
university hospital, and of course they are very popular
because of their broad bactericidal activity. However,
surgeons have to be aware of the possible negative side
effects and evaluate their prescribing routine, which
often results from a lack of detailed information. Every
surgeon wants to be on the safer side. This circumstance may be another reason for overprescribing antibiotics both quantitatively and qualitatively as pointed
out by Knolle in 196835 and emphasized by McHenry
and Weinstein in 198334 and Zeitler in 1995.36
In our study we could not find any significant difference between the 3 groups regarding the evaluated
parameters. The groups were uniform with regard to
age and the preoperative clinical and radiologic findings.
On the basis of our results, we cannot recommend
routine oral postoperative prophylactic antibiotic administration. The 2 antibiotics used in our protocol
could not reduce the overall postoperative infection rate
and did not contribute to a decrease in noninfectionrelated side effects like dry socket, pain, and reduced
mouth opening. Nevertheless, the prophylactic use of
antibiotics has been found to have a significant effect on
infecton-related complications after third molar surgery
when used preoperatively but only in bony impacted
teeth.33 The prevention of negative side effects, especially the occurrence of alveolitis, in teeth with soft
tissue retention still represents a problem. In our series,
we found the majority of all cases of dry socket in this
group (Fig 13). However, further investigations are necessary to optimize the postoperative treatment protocol,
including in particular local medication for these cases.
It should be emphasized that our results apply to situations where strict aseptic conditions can be maintained
in a specially equipped operating room and only in cases
where signs of acute preoperative inflammation are absent.

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