Giovanni Lodi, Lorenzo Azzi, Elena Maria Varoni, Monica Pentenero, Massimo Del Fabbro, Antonio Carrassi, Andrea Sardella, Maddalena Manfredi
What is the problem?
Teeth that are affected by decay or gum disease or painful wisdom teeth are often removed (extracted) by dentists. Tooth extraction is a surgical procedure that leaves a wound in the mouth that can become infected. Infection can lead to swelling, pain, development of pus, fever, as well as ‘dry socket’ (where the tooth socket is not filled by a blood clot, and there is severe pain and bad odour).
These complications are unpleasant for patients and may cause difficulty with chewing, speaking, and teeth cleaning, and may even result in days off work or study. Treatment of infection is generally simple and involves drainage of the infection from the wound and patients receiving antibiotics.
Why is this question important?
Antibiotics work by killing the bacteria that cause infections, or by slowing their growth. However, some infections clear up by themselves. Taking antibiotics unnecessarily may stop them working effectively in future. This ‘antimicrobial resistance’ is a growing problem throughout the world.
Antibiotics may also cause unwanted effects such as diarrhoea and nausea. Some patients may be allergic to antibiotics, and antibiotics may not mix well with other medicines.
Dentists frequently give patients antibiotics at the time of the extraction as a precaution in order to prevent infection occurring in the first place. This may be unnecessary and may lead to unwanted effects.
What did we want to find out?
We wanted to know whether giving antibiotics as a preventive measure reduces infection and other complications after tooth extraction. We also wanted to understand whether antibiotics work differently in healthy people compared with people with health conditions such as diabetes or HIV.
What did we do?
We searched for studies that assessed the effectiveness of antibiotics compared to placebo (sham medicine), given when no infection was present in order to prevent infection following tooth extraction. Studies could include people of any age undergoing tooth extraction.
Where possible, we pooled the studies’ results and analysed them together. We also assessed the quality of each study to judge the reliability (certainty) of evidence of individual studies and the body of evidence.
What we found
We found 23 included studies with a total of more than 3200 participants, who received either antibiotics (of different kinds and dosages) or placebo immediately before or just after tooth extraction, or both.
Four studies were conducted in Spain, three each in Brazil, Sweden, and the UK, two in India, and one each in Colombia, Denmark, Finland, France, Poland, New Zealand, Nigeria, and the USA. All but one study included healthy patients in their 20s. Twenty‐one studies assessed the removal of wisdom teeth in hospital dental departments, one assessed the removal of other teeth and one assessed complex oral surgery. None of the included studies assessed tooth extraction in general dental practice for the removal of decayed teeth.
Antibiotics given just before or just after surgery (or both) may reduce the risk of infection and dry socket after the removal of wisdom teeth by oral surgeons. However, antibiotics may cause more (generally brief and minor) unwanted effects for these patients. We found no evidence that antibiotics prevent pain, fever, swelling, or problems with restricted mouth opening in patients who have had wisdom teeth removed.
There was no evidence to judge the effects of preventive antibiotics for extractions of severely decayed teeth, teeth in diseased gums, or extractions in patients who are sick or have low immunity to infection.
How reliable are the results?
Our confidence in the results is limited because we had concerns about aspects of the design and reporting of all of the included studies.
What does this mean?
We did not find studies in patients with depressed immune systems, other illnesses, or in young children or older patients, therefore the results of our review probably do not apply to people who may be at high risk of infection. Also, extractions were mainly carried out by oral surgeons, so the review may not apply to dentists working in general practice.
Another concern, which cannot be assessed by clinical studies (i.e. studies testing new medical approaches in people), is that widespread use of antibiotics by people who do not have an infection is likely to contribute to the development of antimicrobial resistance.
We concluded that antibiotics given to healthy people when they are having teeth extracted may help prevent infection, but the decision to use an antibiotic should be judged on an individual patient basis based on their state of health and possible complications of getting an infection.
How up‐to‐date is this review?
This is an updated review. The evidence is current to April 2020.
Lodi G, Azzi L, Varoni EM, Pentenero M, Del Fabbro M, Carrassi A, Sardella A, Manfredi M. Antibiotics to prevent complications following tooth extractions. Cochrane Database of Systematic Reviews 2021, Issue 2. Art. No.: CD003811. DOI: 10.1002/14651858.CD003811.pub3. Accessed 25 February 2021.