Original Article

EFFICACY OF CHLORHEXIDINE GEL VS CHLORHEXIDINE RINSES IN

REDUCING INCIDENCE OF DRY SOCKET IN MANDIBULAR
THIRD MOLAR SURGERY
1
SHOAIB YOUNUS, BDS, FCPS
2
NAJEEB ULLAH GHUMMAN, BDS, FDS RCS
3
KHURRAM LATIF, BDS, FCPS
4
MUHAMMAD SALMAN CHISHTY, BDS
ABSTRACT

Objective of this study was to highlight the efficacy of chlorhexidine gel in prevention of dry
socket in the post-operative period of mandibular third molar surgical extraction in comparison to
chlorhexidine rinses. One hundred patients seen at the department of Oral and Maxillofacial Sur-
gery, Institute of Dentistry, CMH Lahore Medical College, were included in this study. The study was
conducted from July 2012 to June 2013.

The trial group (n=50) was instructed to apply 0.2% chlorhexidine gel to the extraction wound
during the first postoperative week, while the control group (n=50) was prescribed a 0.2% chlorhexidine
rinse for the same period.

Results of this study revealed a 67% reduction in postoperative dry socket in the gel group (P <
0.05). The incidence of postoperative dry socket in the gel group was 6% (3/50) as compared to 18%
(9/50) in the mouthwash group.

It was concluded that topical application of chlorhexidine gel to the extraction wound significantly
reduced the incidence of dry socket.

Key Words: Chlorhexidine gel, dry socket, chlorhexidine rinses.

INTRODUCTION dry socket are; alveolar osteitis, alveolitis sicca dolo-

rosa, alveolalgia, osteomyelitis or fibrinolytic osteitis,
Dry socket (DS) is one of the most feared complica- postextraction osteomyelitis syndrome, fibrinolytic
tions after extraction of a tooth, especially in mandibular alveolitis, and localized alveolar osteitis.1,2
third molar surgery. Initially described by Crawford
in 1896, over the years different names attributed to Blum described it partial or total disintegration of
the intra-alveolar blood clot, and which may be accom-
1
Assistant Professor, Oral & Maxillofacial Surgery, Institute of
Dentistry, CMH Lahore Medical College, University of Health panied by pain and halitosis.3
Sciences, Lahore. Cell; 0333-428669, Email: dr.shoaibyounus@
gmail.com. Res; House # E-38, Street # 8, Peer Colony, Walton Literature shows frequency of dry socket from 1%
road, Lahore Cantt. to 70%. According to most of the studies the average
2
Assistant Professor, Oral & Maxillofacial Surgery, Institute of
Dentistry, CMH Lahore Medical College, University of Health incidence of dry socket post extraction is around 5%,
Sciences, Lahore. Cell; 0333-5211760, Email: billracy63@live.com. other than mandibular third molars, for which incidence
Res; L1-71, Valencia homes, Valencia town, Lahore.
3
Assistant Professor, Head of Department of Oral and Maxillofa-
ranges from 20 to 30 %, about 4 to 6 times more than
cial Surgery, Faryal Dental College. Near Faizpur Interchange, associated with all other teeth.3,4,5,6,7
M2 motorway, Bhulay Androon, Sheikhupura road, Lahore. Cell;
0331-4943520, Email: drkhurramshah@hotmail.com. The probable risk factors to develop dry socket de-
4
FCPS Resident, Department of Oral & Maxillofacial Surgery/
Mayo Hospital, King Edward Medical University, Lahore. Cell;
scribed by various studies are; difficulty of extraction,
0321-4174061, Email: salmanchishty@gmail.com. surgeon’s inexperience, use of oral contraceptives,
Received for Publication: February 19, 2014 advanced age, female gender, smoking, immunosup-
Revision Received: April 9, 2014 pression, and trauma from surgery.8,9,10
Revision Accepted: April 13, 2014

Pakistan Oral & Dental Journal Vol 34, No. 2 (June 2014) 249

Different medications have been used for its preven-
tion including saline rinses, topical antiseptic rinses,
antibiotics, and antifibrinolytic agents. Antiseptics
and antibiotics have been demonstrated to be the most
effective, but the latter are expensive, have significant
side effects and may create resistant bacterial strains.
Among the antiseptics, chlorhexidine (CHX) mouthwash
has proved to be a good prophylactic agent for dry
socket. Chlorhexidine is effective against both aerobic
and anaerobic organisms and yeast.4,11,12
The availability of 0.2% Chlorhexidine in the market
in the form of a gel and its intra-alveolar placement
allows a more direct and prolonged therapeutic effect.13
The aim of this study was to compare the efficacy
of Chlorhexidine in its 2 available forms, i.e. 0.2% gel
and 0.2% mouth wash (topical application and rinse
for one minute 6 hourly, for 7 days) in prevention of
postoperative dry socket following mandibular third
molar surgery.
METHODOLOGY
This study was a randomized controlled prospec-
tive clinical trial in a single centre, carried out at the
department of Oral and Maxillofacial Surgery and
Medicine, Institute of Dentistry, CMH Lahore Medical
College. The study was conducted from July 2012 to
June 2013.
All patients requiring the removal of mandibular
third molar under local anesthesia, who were not to
take antibiotics in the 7 days preceding the surgery,
were included in the study after taking the informed
consent. Patients suffering from systemic disease
which relatively contraindicate oral surgery, known
immune-compromised patients, pregnant or lactating
women, patients with known allergy to local anesthet-
ics, antibiotics, Chlorhexidine and analgesics (also the
patients with acid peptic disease; who needed modifi-
cation of the analgesic), patients requiring more than
one extraction in a single sitting, patients requiring
extraction of third molar associated with bone pathol-
ogy, patients taking oral contraceptives; and mentally
handicapped patients were excluded.
Smokers were advised not to smoke for up to 5 days
postoperatively. Patients in whom the extraction of the
retained third molar lasted for more than 45 minutes
were not included. The principles of the Helsinki Dec-
laration were followed during all the study period and
protocols.
Pakistan Oral & Dental Journal Vol 34, No. 2 (June 2014)
Efficacy of Chlorhexidine Gel vs Chlorhexidine Rinses
Patients were randomly divided into two groups,
using simple lottery method; one group was to use Ch-
lorhexidine 0.2% gel and the other, 0.2% mouth wash,
with the aim to compare the incidence of post-surgical
dry socket.
All patients were operated by single operator under
local anesthesia (i.e. inferior alveolar, lingual and long
buccal block) using 2% lignocaine with epinephrine.
Gingival sulcular incision with distal release was
given (envelope flap raised) for the exposure of the
impacted tooth. Bone grinding and tooth sectioning
were done where needed. After extraction, bony edges
were smoothened and debris cleaned from the socket
and under the flap with normal saline irrigation.
Finally the socket of extracted tooth in trial group
was filled with Chlorhexidine gel and that in the con-
trol group was flooded with 1 to 2 mL of Chlorhexidine
mouth wash and wound closed with 3/0 silk suture. For
post-operative pain control all patients were advised
tablet Flurbiprofen 100 mg in bid dosage, initially for
3 days (till 1st recall). The surgery took from 25 to 40
minutes in all the included cases. The patients in the gel
(trial) group were advised to apply 0.2% Chlorhexidine
gel to the surgical wound 4 times a day for one week
from very that day of surgery. The patients in the rinse
(control) group were advised gentle rinses with 10 mL
of 0.2% Chlorhexidine for 1 minute, 4 times a day, from
the day of surgery to one week post operatively (strict
advise not to rinse vigorously was given). The main
outcome variable was the appearance of postoperative
dry socket, as per Blum’s standardized criteria.
The patients were recalled for evaluation at 3rd
and 7th day postoperatively to assess condition of the
extraction wound. Dry socket was declared when there
was history or complains of increased severity of pain
from first postoperative day onwards, along with the
total or partial loss of clot from the healing socket and
fetid odour.
All the patients were evaluated at their follow-up/
recall visits by a single investigator, trained by the
principal investigators for the healing of extraction
sockets and / or development of dry socket, if any. All
the subjects confirmed the complete following of the
advised / prescribed regimen and instructions postop-
eratively.
The chi square test was applied for the comparison
of the proportions of postoperative dry socket between
the 2 groups (gel and rinse), and student t test for the
comparison of the mean values in quantitative variables.
250
 Efficacy of Chlorhexidine Gel vs Chlorhexidine Rinses

All clinical assessment was carried out by a single theories, the prevalence of one theory over the other has
blind investigator, trained by the directors of this study not been generally accepted, as there is no conclusive
in previous studies sharing the same dry socket crite- data to definitively reject or accept.
ria. All study subjects reported using the medication
prescribed to them. Chlorhexidine (CHX) is a bisdiguanide antiseptic
with antimicrobial properties. The use of Chlorhexidine
RESULTS as a mouth-rinse and as a preoperative irrigant of the
gingival crevice has been shown to significantly reduce
Age range in gel group was 17-32 years with mean the quantity of oral microbial populations. Several
23.46+ 5.06 and in mouthwash group it was also 17-32 studies have reported that the pre or postoperative
years but with mean 22.86+5.16. Results of this study use of Chlorhexidine mouthrinse significantly reduces
revealed a 67% reduction in postoperative dry socket in the incidence of dry socket after the surgical removal
the gel group (P < 0.05). The incidence of postoperative of mandibular third molars. A 50% reduction in the
dry socket in the gel group was 6% (3/50) as compared incidence of dry socket was observed in patients who
to 18% (9/50) in the mouthwash group.
pre-rinsed for 30 seconds with a 0.2% Chlorhexidine
solution. Use of 0.2% Chlorhexidine gel reduced inci-
DISCUSSION
dence of dry socket in percent similar to use of 0.2%
Currently there are 2 main etiopathogenic theories Chlorhexidine mouthwash. No adverse effects were
about dry socket; Birn’s fibrinolytic theory and the observed. Incidence of dry socket in smokers was re-
bacterial theory.14 With respect to these etiopathogenic duced who rinsed with Chlorhexidine. Preoperative
use of Chlorhexidine can reduce the incidence of dry
TABLE 1: DISTRIBUTION BY GENDER socket by approximately 40%.11,15
(GEL GROUP) n=50
In a recent meta-analysis by Caso et al on the use of
Sex of the patient Patients Percentage Chlorhexidine rinse after impacted third molar surgery,
Male 29 58% the authors concluded that the use of Chlorhexidine
Female 21 42% mouth rinse from the day of intervention and during
Total 50 100% the postoperative period produces a decrease in dry
socket incidence. The minimum postoperative period
TABLE 2: DISTRIBUTION BY GENDER of time during which mouthwash should be applied
(MOUTHWASH GROUP) n=50 could not be determined in this study.7

Sex of the patient Patients Percentage In literature among the antiseptics, chlorhexidine
Male 31 62% has shown good results as prophylactic agent for dry
Female 19 38% socket. According to Ragno and Szkutnik, Chlorhexidine
Total 50 100% 0.2% mouthwash produced a considerable decrease of al-
veolar osteitis after impacted 3rd molar removal, i.e. up
TABLE 3: DISTRIBUTION OF DRY SOCKET to 17.5%. After one week post-extraction Larsen found
(MOUTHWASH GROUP) n=50 16% cases of dry socket in the control group (placebo),
whilst 8% reduction in chlorhexidine (0.12%) group).
Dry Socket Patients Percentage
Up to 50 % reduction was observed by Ragno, Bonine
No 41 82% and Hermesch et al, using the same study groups. On
Yes 09 18% the contrary Berwick and Lessin found no difference in
Total 50 100% the incidence of dry socket in the comparative groups
of 0.12% chlorhexidine and 0.05% cetylpyridium.14
TABLE 4: DISTRIBUTION OF DRY SOCKET
(GEL GROUP) n=50 Torres et al discovered an 11% decrease of dry socket
in the experimental group (intra-alveolar bio-adhesive
Dry Socket Patients Percentage
0.2% Chlorhexidine gel) after the removal of retained
No 47 94% mandibular third molars, compared with 30% in the
Yes 03 06% experimental group (intra-alveolar medication versus
Total 50 100% placebo).11

Pakistan Oral & Dental Journal Vol 34, No. 2 (June 2014) 251

The number of patients in this study was sufficient
to assess the main variable: appearance or absence of
dry socket post-extraction. In other studies, this number
ranges between 20 and 67 per group.16,17 The average
age of the patients was higher than that obtained by
other authors. With respect to the proportion of males/
females, there are studies such as those by Torres et al
which coincide with the data, while other authors had
a similar proportion of males/females in their studies.11
In the experimental group (gel) statistically sig-
nificant decrease was found (67%, P < 0.05) in the
incidence of postoperative dry socket compared with
the mouthwash group. These results may be explained
by the properties of the gel, which prolong the release
of Chlorhexidine at the application site. No adverse
effect was recorded in the patients treated, as referred
to in other similar studies.18
The envelop flap design (gingival sulcular incision
with distal release) used for the exposure of the impact-
ed third molar in the current study was the operator’s
preference. This also showed that the level of difficulty
for the removal of all the third molars was almost the
same.
The results of this clinical study show that the ap-
plication of 0.2% Chlorhexidine gel to the postoperative
wound after the removal of retained mandibular third
molars decreases dry socket incidence significantly
when compared with the application of 0.2% Chlor-
hexidine mouthwash under similar circumstances.
CONCLUSION
It was concluded that topical application of ch-
lorhexidine gel to the extraction wound significantly
reduced the incidence of dry socket.
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