YIJOM-4321; No of Pages 2
Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx
https://doi.org/10.1016/j.ijom.2019.08.024, available online at https://www.sciencedirect.com
Letter to the Editor
Re: Interpretation of data: does amox-
icillin reduce the risk of infection in
patients after third molar extraction?
Our research team would like to thank the
authors for their critical evaluation and dis-
cussion of the findings reported in the article
titled ‘‘Does the use of amoxicillin/
amoxicillin–clavulanic acid in third molar
surgery reduce the risk of postoperative
infection? A systematic review with meta-
analysis’’1. Explanations for the observa-
tions raised are discussed within the article1.
The authors point out that the results of
our review conflict with those of previous
reviews2. This finding is discussed exten-
sively in the Discussion section of the
article, and the differences in the results
as compared to those of Arteagoitia et al.2
are explained as follows: ‘‘The present
review indicates that both are effective
(amoxicillin and amoxicillin–clavulanic
acid) and that the difference in results
could be attributed to the additional stud-
ies that were excluded from the present
review based on predetermined exclusion
criteria. Studies were excluded if drugs
other than amoxicillin were used in com-
bination with amoxicillin and when the
primary outcome was not postoperative
infection. Hence, Bortoluzzi et al.3 (use
of dexamethasone), Xue et al.4 (mentions
that clindamycin was used in patients
allergic to amoxicillin and did not exclude
or specify the subjects who underwent
treatment with clindamycin), and Bulut
et al.5 (C-reactive protein level as the
outcome) were excluded. Antibiotics are
primarily used for the prevention or treat-
ment of infection. Further, the mechanism
of action of antibiotics may be influenced
by concurrent drug administration. Hence,
our robust inclusion criteria may have led
to the difference in results.
0901-5027/000001+02 ã 2019 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Menon RK. Re: Interpretation of data: does amoxicillin reduce the risk of infection in patients after
third molar extraction?, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.08.024
The authors state that in spite of men- crossover time in those with a split-
tioning that both amoxicillin and mouth design, and exclude studies with
amoxicillin–clavulanic acid are effective, concurrent medication that may influ-
the meta-analysis shows that amoxicillin ence the outcome.
alone is not effective. The article under
discussion states that, taken separately, the
Funding
results of the studies that employed a split-
mouth protocol (risk ratio (RR) 0.41, 95% None declared.
confidence interval (CI) 0.13–1.32,
P = 0.136) and those that employed a par-
Competing interests
allel group protocol (RR 0.22, 95% CI
0.02–2.74, P = 0.237) were not statisti- The authors declare no conflict of interest,
cally significant1. However, an overall including any financial, personal or other
analysis combining both the split-mouth relationship with people or organizations.
and parallel group studies showed that
amoxicillin significantly reduced the in-
Ethical approval
fection rate after third molar extraction
(RR 0.37, 95% CI 0.15–0.92, P Not applicable.
= 0.033). The aforementioned is explained
in the Discussion section as follows: ‘‘The
Patient consent
differences in results when studies with a
split-mouth design were excluded might Not applicable.
have been due to the lack of power as a
result of the limited number of studies R.K. Menon12
1
remaining after exclusion.’’ Conclusions International Medical University, Kuala
from the subgroup analysis may be differ- Lumpur, Malaysia
ent from the overall analysis depending on
2
the sample size and the magnitude of Faculty of Dentistry, University of Hong
effect in each study6. Even though sub- Kong, Hong Kong, China
group analysis may be prone to false-
positive or false-negative results, the inef- K.Y. Li
fectiveness of amoxicillin when split- D. Gopinath
mouth studies are excluded is an interest- M.G. Botelho*
ing observation. Further, the lack of an Faculty of Dentistry, University of Hong
adequate crossover period in the studies Kong, Hong Kong, China
employing a split-mouth protocol is an
*
important observation. Hence, the results Address: Michael George Botelho,
from the sub-group analysis in this case Faculty of Dentistry, The University of
add to the interpretation of results. Hong Kong, Floor 3, Prince Philip Dental
As concluded in the article, we pro- Hospital, Street 34 Hospital Road, Sai
pose that future trials investigating the Ying Pun, Hong Kong, China.
effectiveness of antibiotics should focus Tel.: +852 28590412.
on postoperative infection as the E-mail address: botelho@hku.hk
primary outcome, provide an adequate (K.Y. Li)
YIJOM-4321; No of Pages 2

2 Menon

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Please cite this article in press as: Menon RK. Re: Interpretation of data: does amoxicillin reduce the risk of infection in patients after
third molar extraction?, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.08.024