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J Bagh College Dentistry Vol. 21(1), 2009 The effect of locally ….. advised to use the drug as adjunctive therapy for infected periodontal sites (18) . To our knowledge no previous study has been made to investigate the possible effect of small topical doses of Ciprofloxacin, applied to extraction site both intra and immediate postoperatively, on the incidence rate of dry socket. MATERIAL AND METHODS This randomized, controlled, clinical trial was conducted at the oral and maxillofacial Department of the College of Dentistry– Baghdad University and a private clinic owned by the second investigator. The basic inclusion criterion in our study was having a complicated extraction of lower posterior teeth. The extraction procedure was lengthy, required the use of chisels, elevators, rotary cutting instruments, it involved roots sectioning, bone cutting, often mucoperiosteal flaps raising and resulted in inflicting surgical trauma judged by the two operators to be of moderate degree of severity i.e. much higher than that severity of a simple forceps extraction but did not mount to reach that caused by the surgical extraction of deeply buried mandibular third molars, the amount of bone cut and crushed during surgery in addition to the soft tissue damage amount were the factors that governed the investigators decision on trauma degree of severity ranking. All patients presenting for the extraction of lower posterior teeth were considered for inclusion. Patients who have had acute periapical or marginal infections, patients who were taking antibiotics, and females taking oral contraceptives at the time of the extraction or shortly before were all excluded from the study. A total of 81 healthy adults of both sexes, 41 female and 40 males aged between 19 – 62 years (age mean 30.9 years) met the criteria above and were included in the study. They were assigned into two almost equal groups, an experimental and a control group. The extraction sites in patients of the experimental group were irrigated both intra and immediate post operatively with 0.5ml/ root socket of the standard 0.2% Ciprofloxacin intravenous infusion solution (CIPREF– OUBARI PHARMA-Syria). Irrigation was made at two stages, half of the dose was used to irrigate the exposed bony walls of the socket and the surrounding gingiva during the extraction procedure, the remainder was used to fill the empty socket and irrigate the surrounding gingiva immediately following the delivery of the tooth. Extraction sockets of the patients with control group were irrigated in the same way with a similar volume of a normal saline. All extractions were done under local anesthesia using Xylocaine 2% with 1/80000 adrenaline solution. Interrupted 3/0 black silk sutures were placed to properly hold the interdental papillae in all extraction sites and to force patients to come back for suture removal and re-examination after 7 days, all patients have had cotton wool pressure packs applied post operatively to their extraction sockets and for the same period of time which was one hour, and were prescribed ten 500mg acetaminophen tablets (Panadol–Smithkline Becham– Ireland) to control pain following surgery. No antibiotics were used in our study. The patients were given the usual post extraction instructions and they were clearly informed to come back to surgery immediately or as soon as possible if they develop one or more of the following: Severe continuous or throbbing pain that develops at the extraction site during the second post extraction day or later, not relieved by the usual dose of Panadol. a. Massive facial swelling. b. Bleeding that does not stop after 24 hours. If non of the above occur, patients were instructed to return back to surgery for examination and suture removal after 7 days. A positive diagnosis of dry socket was made on the basis of both clinical and subjective findings. The clinical findings include completely or partially empty socket with exposed sensitive bony wall, or socket filled with foamy disintegrating blood clot. The subjective findings, were severe or increasing persistent post operative pain that could be throbbing in character develops during the second post extraction day or later, and is not usually relieved by the usual dose of Panadol. The number of Panadol tablets taken by the patient and whether or not he had to refill the prescription were all considered before reaching a diagnosis of dry socket. RESULTS Quantitative Data A total of five cases of dry socket have developed in the present study (table 1). Dry socket developed in one of the fourty-one extraction sites of the experimental group and in four of the forty extraction site of the control group. The incidence rate of dry socket in the experimental group was 2.4% versus 10% in the control group. This represents a 76% reduction in the incidence rate of dry socket following the Oral and Maxillofacial Surgery and Periodontology 89
J Bagh College Dentistry Vol. 21(1), 2009 The effect of locally ….. application of Ciprofloxacin to the extraction sites in the experimental group. The data were analyzed using Fisher's exact test to compare the number of occurrences of dry socket for the two groups for statistical significance. Fisher's exact test showed no significant difference between the two groups in regard to number of occurrences of dry socket (p=0.16). Investigator's Impressions From gross clinical observations the two investigators noticed that the soft tissue covering the extraction sites in the experimental group showed milder edema and congestion on the seventh postoperative day than that of patients in the control group. Table 1: The occurrence of dry socket in the experimental and the control groups. Group No. of % of No. of No. of Dry Dry patients Extractions Sockets Socket Experimental 41 41 1 2.4% Control 40 40 4 10% Total 81 81 5 DISCUSSION Dry socket develops because of high fibrinolytic activity in and around the alveolus triggered by the release of stable tissue activators of plasminogen from the osteoblasts of the endosteum and probably to a lesser extent from the surrounding gingiva and epithelium caused by inflammation in these tissues. The inflammation may have two different causes; infection of the alveolus or trauma, which may often work together to create the degree of inflammation necessary for the development of dry socket. The conflicting opinions as to the importance of the later two causes in the development of dry socket, often encountered in the literature, are probably due to the fact that one has been more pronounced than the other in individual studies (1) . The 2.4% dry socket incidence rate in patients of the experimental group, when compared with the (10%) rate of the control group though may indicate an apparent preventive role for Ciprofloxacin, definitive conclusions in this regard can not be drawn owing to the small sample size and the small size of the biologic data in the present study. The incidence rate of dry socket among patients of the control group was considerably higher than the 7.3% reported by Hansen (10) occurring following the surgical extraction of mandibular posterior teeth in his study. This could be due to differences in the diagnostic criteria and uncontrolled variations within the populations evaluated. The single dry socket occurrence among patients of the experimental group indicates that the preventive role of Ciprofloxacin was incomplete, a fact which may suggest that bacterial infection is an important but not the sole etiologic factor in dry socket. REFERENCES 1. Birn H. Etiology and pathogenesis of fibrinolytic alveolitis. Thesis: Int J Oral Surg 1973; 2: 211–63. 2. Birn H. Fibrinolytic activity in ((dry socket)). Acta Odont Scand 1970; 28: 37–58. 3. Birn H. Fibrinlytic activity of normal alveolar bone. Acta Odont Scand 1971; 29:141-53. 4. Braun LR, Merril SS and Allen RE. Microbiologic study of intra oral wounds. J Oral Surg 1970; 28: 89- 95. 5. Cattelanic JE. Review of factors contributing to dry socket through enhanced fibrinolysis. J Oral Surg 1977: 37: 42 – 6. 6. Fong IW, Ledletter WH, Vandenbrucke AC, Simbul M, Rahm V. Ciprofloxacin concentration in bone and muscle after oral dosing. Antimicrob Agents chemother 1986; 29(3): 405-8. 7. Fridrick KL, Olsen RA. Alveolar osteitis following surgical removal of mandibular third molars Anesth Prog 1990; 37(1): 32-41. 8. Goldman DR, Panzer JD, Athkinson MA. Prevention of dry socket by locally applied Lincomycin in gel foam. Oral Surg 1973; 35: 472-4. 9. Hall HO, Bildman BS, Hand CD. Prevention of dry socket with local application of Tetracycline. J Oral Surg 1971; 29:35-7. 10. Hansen E. ALveolitis Sicca dolorosa (dry socket): Frequency of occurrence and treatment with trypsin. J Oral Surg 1960; 18:409-16. 11. Holland MR, Tan JC. The use of pure crystalline penicillin G tablets in extraction wounds. Oral Surg 1954; 7: 145. 12. Kay LW. Investigations into the nature of pericoronitis. Br J Oral Surg 1966; 4: 52-78. 13. Metin M, Tek M, Sener I. Comparison of two chlorhexidine rinse protocols on the incidence of alveolar osteitis following the surgical removal of impacted third molars. J Contemp Dent Pract 2006; 7: 79-86. 14. Neidle EA, Yagiela JA. Pharmacology and therapeutics for dentistry 3 rd ed. St. Louis: Co. Mosby 1989; 543-4. 15. Ritzan M. The prophylactic use of tranexamic acid (CYCLOCAPRON) on alveolitis sicca dolorosa. Int J Oral Surg 1973; 2: 196-9. 16. Rud J. Removal of impacted lower third molars with acute pericornitis and necrotizing gingivitis. Br J Oral Surg 1970; 7:153-9. 17. Seward GR, Harris M, McEowan DA. Killey and Kay's Outline of Oral Surgery, part one. 2 nd ed. Bristol Wright: 1987: 174-8. 18. Tozum HF, Yildrim A, Caglaya NF, Dinsel A, Bozkurt A. Serum and gingival crevicular fluid levels of Ciprofloxacin in patients with periodontitis. J Am Dent Assoc 2004; 135: 1728-32. Oral and Maxillofacial Surgery and Periodontology 90
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