Do antibiotics prevent infection after third molar surgery? A network meta-analysis

Uma meta-análise de rede

Abstract

Introduction: The use of antibiotics in third molar surgery is controversial. More than 40 randomized clinical trials testing the effectiveness of antibiotics in third molar surgery have been published. The main concern leading to the use of antibiotics in third molar surgery is the prevention of postoperative infection or dry socket. On the other hand, biotic resistance and the risks versus benefits must be considered when prescribing this type of medication in dental procedures.51 There are many ways to administer antibiotics to prevent infection or dry socket in patients undergoing third molar surgery. Some studies advocate only a single dose preoperatively, others multiple postoperative dosages, and there are also studies that tested the use of these drugs both preoperatively and postoperatively. The types of antibiotics used for this purpose also vary greatly. Amoxicillin in different concentrations is the most tested antibiotic, followed by amoxicillin plus clavulanic acid. Objective: The objective of this systematic review was to determine whether antibiotics, compared with placebo, can prevent infection or dry socket after third molar surgery. A systematic review and network meta-analysis was carried out after protocol registration (CRD42021276266). Methodology: Four databases and gray literature were searched, and articles were selected based on the PICOS question. RoB 2 and GRADE were used to assess the risk of bias and certainty of evidence, respectively. The systematic review and network meta-analysis was performed using Stata. Results: Of the 58 randomized controlled trials identified, 34 were included in the systematic review and network meta-analysis. Patients treated with amoxicillin (relative risk (RR) 0.56, 95% confidence interval (CI) 0.38–0.84; low quality of evidence) and those treated with metronidazole (RR 0.51, 95% CI 0.31–0.84; low quality of evidence) showed a lower risk of infection and alveolitis when compared to patients receiving placebo. Postoperative amoxicillin (750 mg) and amoxicillin plus clavulanate (500 mg + 125 mg or 2,000 mg + 125 mg) and preoperative metronidazole (800 mg) are useful in preventing infection or dry socket when compared to placebo. Discussion: The pathogenesis of odontogenic infections is polymicrobial. There are many types of facultative anaerobic bacteria (such as bacteria from the Streptococcus group) and strictly anaerobic bacteria (such as Prevotella and Fusobacterium) involved in the progression of an odontogenic infection. In odontogenic infections, the majority of causative bacteria are anaerobes (75%); The remaining causative bacteria are aerobic, mainly α-hemolytic streptococci. The treatment or prevention of odontogenic infections with antibiotics must be carried out taking into account the characteristics of the bacteria present. However, as the pathogens are well known in odontogenic infections, empirical treatment with certain types of antibiotics is usually done. Furthermore, antimicrobial-dependent culture testing for anaerobic bacteria takes a long time. Thus, for acute infections, penicillin is the first drug of choice, and after the fifth day, clindamycin becomes the drug of choice. Due to the characteristics of odontogenic infections, other types of antibiotics such as amoxicillin, metronidazole, azithromycin and moxifloxacin were also used. Conclusion: The low infection rate after third molar surgery, the correct concept of antibiotic prophylaxis, and antibiotic resistance should be taken into consideration when choosing to treat healthy patients undergoing third molar surgery with antibiotics.