Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2017; 62: 412–419

doi: 10.1111/adj.12526

Postoperative interventions to reduce inflammatory

complications after third molar surgery: review of the
current evidence
H Cho,* AJ Lynham,* E Hsu†
*School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
†Maxillofacial Unit, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia.

ABSTRACT
Inflammatory complications such as pain, swelling, trismus, infection and alveolar osteitis have an adverse affect on the
quality of life of patients after third molar removal. This review presents the current evidence on postoperative strategies
to reduce these complications. A literature search was performed to identify articles published in English between 2000
to 2016 using the following keywords: third molar(s), wisdom tooth/teeth, pain, swelling, trismus, infection, alveolar
osteitis and dry socket. In total, 221 papers were reviewed. Methods published included analgesics, antibiotics, corticos-
teroids, mouthwashes, topical gels, cryotherapy and ozone therapy. This review highlights the variability in evidence
available and summarizes the findings from best-quality evidence. In conclusion, paracetamol and ibuprofen are effica-
cious in managing postoperative pain. Corticosteroids and antibiotics should only be used in selected cases. Chlorhexi-
dine reduces alveolar osteitis. The benefits of cryotherapy, postoperative irrigation and ozone gel are yet to be
established.
Keywords: Complications, oral surgery, postoperative, third molar(s), wisdom teeth.
Abbreviations and acronyms: IR = immediate release; NNT = number needed to treat; NSAIDs = non-steroidal anti-inflammatory
drugs; SR = slow release.
(Accepted for publication 3 May 2017.)

essential to effectively reduce complication rates post-

INTRODUCTION
Surgical removal of third molars can result in postop-
erative complications. The most commonly researched
are those relating to inflammation, which result in dis-
comfort and significant morbidity. These problems
include pain, swelling, trismus, surgical site infection
and alveolar osteitis (dry socket).1 Many patients
report a negative impact on lifestyle and oral function
after third molar surgery.2,3 Therefore, clinicians have
a great interest in minimizing these complications, to
improve patient satisfaction and reduce additional fol-
low-up visits.
The aim of this study is to evaluate the current lit-
erature on interventions performed after third molar
surgery. This includes oral medications, topical agents
as well as newer technologies such as ozone gel.
Recently, additional randomized controlled trials and
meta-analyses have been published that contribute to
the overall body of evidence. An understanding of the
potential risks and benefits of each modality is
operatively.
METHODS
A literature search was conducted using four data-
bases searched systematically: PubMed, Cochrane
Library, ScienceDirect and Google Scholar. Strings
of MeSH and text search terms (‘molar, third’ OR
‘wisdom teeth’) AND (‘post-operative’ OR ‘post-
op’) AND (‘complications’) were used in searching
the databases. In addition, specific postoperative
complication keywords were searched: pain, swel-
ling, oedema, trismus, infection, alveolar osteitis
and dry socket. The review was limited to studies
published from 2000 to 2016. From the search
results, articles were selected for review based on
their relevance to the research question. Only post-
operative interventions employed after patients’ dis-
charge were included. Abstracts were assessed and
a full copy of the articles that met inclusion

412 © 2017 Australian Dental Association

 Interventions after third molar surgery

Table 1. Summary of postoperative interventions and strength of evidence

Postoperative intervention Recommendation Grade of recommendation Level of evidence

Paracetamol 1000 mg doses decrease pain. No difference A I

between IR and SR
Ibuprofen 400 mg doses decrease pain A I
Codeine 30–60 mg doses may decrease pain C I
Oxycodone 5–10 mg doses decrease pain B I
Corticosteroids Decrease swelling and trismus. May reduce pain. A I
Drug, route and dosing requires clarification
Postoperative antibiotics Should not be routinely prescribed A I
Chlorhexidine mouthwash Used on day of surgery and twice daily for 1 week A I
decreases risk of dry socket
Chlorhexidine gel Used twice daily for 1 week decreases risk of dry socket A I
Ozone gel Used twice daily for 5 days decreases pain, swelling C II
and trismus
Monoject irrigation Irrigation twice daily, for 1 week decreases dry socket C II
Cryotherapy Application of cold decreases pain and swelling C II

IR = immediate release; SR = slow release.

Table 2. National Health and Medical Research RESULTS

Council grades of recommendations4
Grade of Description
recommendation
A Body of evidence can be trusted
to guide practise
B Body of evidence can be trusted
to guide practise in most situations
C Body of evidence provides some
support for recommendation(s)
but care should be taken in its
application
D Body of evidence is weak and
recommendation must be
applied with caution
A total of 221 papers have been included in this liter-
ature review. During the past 16 years, interventions
used postoperatively for the management of inflamma-
tory complications include analgesics, corticosteroids,
antibiotics, chlorhexidine mouthwash, topical gels,
irrigation and cryotherapy. Findings from meta-ana-
lyses, systematic reviews and randomized controlled
trials were synthesized. The National Health and
Medical Research Council (Australian Government)4
body of evidence matrix and evidence hierarchy were
applied to determine the grades of recommendations
and levels of evidence respectively. The results are
summarized in Tables 1–3.

Table 3. National Health and Medical Research DISCUSSION

Council evidence hierarchy4
Analgesics
Level Intervention
Various analgesics have been used to control postop-
I A systematic review of level II studies
II A randomized controlled trial erative pain and swelling following surgical removal
III-1 A pseudo-randomized controlled trial (i.e. alternate of impacted molar teeth. Paracetamol and non-steroi-
allocation or some other method) dal anti-inflammatory drugs (NSAIDs) are widely used
III-2 A comparative study with concurrent controls:
• Non-randomized, experimental trial and are considered mainstay for many practitioners.
• Cohort study This may be in combination with opioids5 or corticos-
• Case–control study teroids.6 Their efficacy has been demonstrated repeat-
• Interrupted time series with a control group
edly and are routinely prescribed.7
III-3 A comparative study without concurrent controls:
• Historical control study Weil et al.8 conducted a systematic review of 21
• Two or more single arm study high-quality trials. They concluded that paracetamol
• Interrupted time series without a parallel
was a safe and effective drug for the treatment of
control group
IV Case series with either post-test or pretest/post-test postoperative pain following third molar removal. In
outcomes a Cochrane review of 2241 patients, Bailey et al.9
found that ibuprofen provided better postoperative
analgesia than paracetamol. In addition, the combina-
criteria was obtained. Reference sections of tion of ibuprofen and paracetamol appeared to be
accepted articles were screened to identify further more effective than the drugs taken singly when mea-
articles that may be relevant. sured at 6 h after surgery. Participants taking the

© 2017 Australian Dental Association 413

H Cho et al.
combined drug also had a smaller chance of requiring
rescue medication. This mirrors the review of the
Cochrane database by Moore et al.10 They compared
21 over-the-counter analgesics and found the combi-
nation of paracetamol (1000 mg) and ibuprofen
(400 mg) more effective than either alone.
Current research also supports the addition of opi-
oids to control pain after third molar extraction. Au
et al.5 performed a meta-analysis of 10 analgesic com-
binations with a total of 3521 subjects. They found
that oxycodone combined with ibuprofen had supe-
rior analgesic efficacy compared with other combina-
tions. In contrast, the efficacy of weaker opioid
combinations such as paracetamol/codeine remains
contentious. Evidence suggests that this combination
is less effective than paracetamol/ibuprofen.11 Smith
et al.12 approached the issue with a systematic review
in 2001. They found only two high-quality trials with
77 patients in unbalanced groups that could skew
results. Macleod et al.13 compared paracetamol with
paracetamol/codeine and found significantly less pain
in patients taking the combination drug at 12 h post-
removal of third molars. The current body of evidence
for paracetamol/codeine use postoperatively is not as
strong as that for paracetamol/ibuprofen.
It is important to consider the side-effects associated
with the use of analgesic medications. For opioids,
this primarily relates to nausea, constipation5 and the
risk of drug abuse.14 NSAID users should be aware of
drug interactions, potential toxicity and gastrointesti-
nal, haematological and renal disorders.15 These
adverse reactions must be considered when prescribing
analgesics postoperatively.
Corticosteroids
Corticosteroids have long been used after surgery.
Their primary role is to reduce inflammation but also
have the benefit of decreasing postoperative nausea
and vomiting.16,17 A number of studies have been
published on the effect of corticosteroids in the peri-
operative management of dentoalveolar surgery.18
While multiple reviews have demonstrated steroids to
be safe when used as a short course,19,20 the case for
routine use to prevent inflammatory complications has
not been substantiated.
Alexander et al.18 performed a literature review
documenting the effects of corticosteroid therapy. The
authors confirmed the utility of i.v., i.m. and p.o.
routes in reducing inflammatory complications. They
recommended that steroids, if used, should be started
before surgery, given at higher doses and continue for
the first and second postoperative days. The authors
also discussed potential side-effects including adrenal
suppression, gastrointestinal upset, exacerbation of
psychosis, infection and interference with the immune
414
system. For these reasons, steroids should only be
used in selected cases.
Markiwicz et al.21 conducted a review and meta-
analysis on the subject. Their research focused on
whether perioperative steroid administration reduced
pain, trismus and oedema after third molar surgery.
Twelve papers met their inclusion criteria. They found
that steroids helped to reduce oedema and trismus in
the early (1–3 days) and late (>3 days) postoperative
phases. However, they could not determine any effect
on pain, as most studies focused on analgesic dosage
rather than a visual analogue scale. It is important to
note that for oedema and trismus, reductions of
0.6 mm and 4.1 mm, respectively, were found in
those who used corticosteroids. Although these results
were statistically significant, it is questionable whether
such small reductions are of clinical significance. The
authors also highlighted the variability of study
designs and the need for further large-scale studies to
determine the optimal drug, timing and dose of corti-
costeroid administration.
A systemic review by Herrera-Briones et al.22 in
2013 provided another update of trials published. A
total 28 research articles were assessed including both
preoperative and postoperative dosing. The authors
concluded that corticosteroids statistically decrease
inflammation and trismus. They also found the par-
enteral route, prior to surgery, the most favourable in
terms of reducing inflammation. A major limitation of
this study was that a full meta-analysis was not able
to be performed due the heterogeneity of the trials.23
The authors also drew conclusions regarding timing
and route of administration from selected trials rather
than summarizing findings as a whole.
The review by Kim et al.19 included nine studies on
the effect of corticosteroids after removal of bilateral
impacted third molars. Eight of these demonstrated
subjects taking corticosteroids had significantly less
swelling than controls. It is important to note that
there was significant inter-study variability in the
routes and timing of steroid administration, as well as
the method of assessing facial swelling. The authors
concluded that steroids, when administrated, should
be at a dose that is equivalent to 300 mg cortisol (e.g.
60 mg prednisone) and continue for 3–5 days for
maximum benefit. This is because swelling peaks 48–
72 h after surgery, whereas most steroids do not exert
their effect beyond 24 h when administrated as a sin-
gle dose. The authors also recommend that steroids be
reserved for complex oral surgical procedures in
which trauma is categorized as moderate to severe.
In general, the research shows that corticosteroids
can bring about a statistical reduction in swelling and
trismus after third molar surgery. However, it is
important to note that the volumetric reduction in
many studies was relatively small and may not be of
© 2017 Australian Dental Association

clinical significance. Its efficacy in reducing postopera-
tive nausea and vomiting has been well documented.
Corticosteroids can be useful in selected cases when
significant surgical trauma is anticipated or the patient
is at risk of excessive oedema. Its use must be bal-
anced against potential risks and side-effects.
Antibiotics
Another method of reducing inflammatory complica-
tions is the use of antibiotics perioperatively. Antibi-
otic prophylaxis has a well-established place for
specific surgical procedures such as joint replacement
and prevention of infective endocarditis.24 However,
their role in routine third molar surgery is not so
clear.
There are a multitude of studies both for and
against antibiotic use. They vary in design as well as
type and route of antibiotic administrated, making
critical appraisal difficult. In 2007, Ren and Malm-
strom25 published a meta-analysis of 16 clinical trials
with a total of 2932 patients. They concluded that
preoperative antibiotics reduced alveolar osteitis by
6.1% and wound infection by 4% with a number
needed to treat of 25 to avoid one such complication.
Susarla et al.26 found a similar benefit and recom-
mended antibiotic administration preoperatively and
postoperatively for 2–7 days.
A Cochrane review by Lodi et al.27 in 2012 anal-
ysed 18 clinical trials with a total of 2456 subjects.
All trials included healthy patients undergoing extrac-
tion of impacted third molars. They found that antibi-
otics administrated prior or just after surgery reduced
the rate of infection and alveolar osteitis by 70% and
38%, respectively. This translates to 12 patients
receiving antibiotics to prevent one case of infection
and 38 patients needing to take antibiotics to prevent
one case of alveolar osteitis. It is also important to
note that for every 21 people who receive antibiotics,
a minor adverse reaction to antibiotics is likely. From
this, the authors’ could not support routine prescrip-
tion of antibiotics for healthy people undergoing
extraction of third molars. The main reasons were the
low risk of infection after tooth extraction in healthy
young adults, the significant increased risk of experi-
encing adverse effects from antibiotics and the poten-
tial development of resistant bacteria.
The most recent meta-analysis by Ramos et al.28
demonstrates a benefit to prescribing antibiotics. Their
review included 22 papers with an overall number
needed to treat (NNT) of 14 to prevent one episode
of infection. However, the study included all regimes,
most of which included antibiotics administrated 1 h
prior to surgery. Only one trial used postoperative
antibiotics exclusively.29 This study found amoxicillin/
clavulanate efficacious in reducing the incidence of
© 2017 Australian Dental Association
Interventions after third molar surgery
inflammatory complications following third molar
extraction, but its use should be limited to select
cases.
The literature demonstrates that antibiotics given at
the time of or prior to third molar surgery can reduce
alveolar osteitis and infection. However, the majority
of infective complications after third molar surgery
are relatively minor and the benefit of antibiotics must
be weighed against potential microbial resistance,
adverse reactions and cost. Furthermore, there is a
lack of evidence to support prescription of antibiotics
postoperatively in healthy patients undergoing routine
removal of third molars.
Antibacterial mouthwashes
Mouthwashes have the benefit of acting locally at the
surgical site as well as providing mechanical debride-
ment. In general, they are cheap and have fewer side-
effects. Mouthwashes do not require a prescription
and no return to clinic is necessary, meaning less cost
for both the patient and clinician. One disadvantage
is the need for patient adherence to the mouth-wash-
ing protocol.
A variety of different types of commercial mouth-
washes have been reviewed in the literature. Com-
monly available mouthwashes include benzydamine
hydrochloride, essential oils, cetylpyridinium chloride,
sodium benzoate, triclosan, oxygenating agents, povi-
done-iodine, peroxidase and fluoride.30 While all of
these have antimicrobial activity, the gold standard is
considered to be chlorhexidine for its ability to reduce
plaque,31 broad spectrum of activity against oral aer-
obes and anaerobes, general tolerability and lack of
bacterial resistance.32 The use of warm saline has also
been reported. The theory is that the hypertonic solu-
tion is believed to be bacteriostatic and promote heal-
ing by causing vasodilation to the extraction site.33
However, objective studies into its efficacy are lacking
and multiple studies have demonstrated chlorhexidine
to be more effective than saline controls.34,35
In 2005, Caso et al.34 published a meta-analysis
review of prevention of alveolar osteitis with
chlorhexidine after lower third molar extractions.
They compared preoperative rinsing, and preoperative
and postoperative rinsing together, with a third con-
trol group. Overall, the studies investigated have pos-
sible cofounders and vary in design. However, there is
strong evidence for the use of chlorhexidine in the
form of a rinse following third molar removal. The
authors concluded that the use of chlorhexidine
mouth rinse on the day of surgery alone was not sta-
tistically significant. However, when this is combined
with chlorhexidine mouthwash used for 7 days post-
operatively, it produced a significant reduction in
alveolar osteitis.
415
H Cho et al.
Hedstrom and Sjogren36 systematically reviewed 32
randomized controlled trials on prevention of alveolar
osteitis. They concluded that 0.12% chlorhexidine
rinsing preoperatively and 7 days postoperatively
seemed to have significant and clinically relevant pre-
ventive effects on alveolar osteitis, following surgical
removal of lower third molars.
This is supported by a Cochrane review by Daly
et al.37 Their systematic review included 21 trials with
2570 participants. Most of the included studies were
involved extractions undertaken by experienced oral
surgeons in hospital or military minor oral surgery
clinics. The authors found that chlorhexidine mouth-
wash (0.12% and 0.2%) both before and after extrac-
tion prevented approximately 42% of dry sockets.
The NNT with chlorhexidine rinse to prevent one
patient having dry socket was 232, 47 and eight for
control prevalences of dry socket of 1%, 5% and
30%, respectively.
It is also important to note that chlorhexidine has
side-effects although these are generally minimal.
These can include staining of teeth, increased calculus
formation, mucosal irritation and taste alterations.38
However, more severe hypersensitivity reactions have
been reported in the literature. These reactions range
from lip and mucosal swelling to severe anaphy-
laxis.39 In light of this, it is important for practition-
ers to be aware of such reactions.
Topical gels
Topical gels contain antimicrobial agents that are
directly applied to a postoperative surgical site. A
topical gel may be more effective than mouthwash
because the positioning of the gel can prolong release
of medication, generating more direct action on the
alveolus, and also allow more bioavailability. Addi-
tionally, the gel can be applied immediately after
tooth extraction whereas mouthwashes are typically
avoided in the first 24 h due to risk of clot dissolu-
tion.40
Hita-Iglesias et al.41 conducted a randomized con-
trolled trial comparing the efficacy of chlorhexidine
gel versus chlorhexidine mouthwash. The participants
used a twice daily, 7-day postoperative protocol. The
study reported a significant decrease (30%) in the inci-
dence of postoperative alveolar osteitis in the topical
chlorhexidine gel group, which had an incidence of
only 7.5%. This is compared with an incidence of
alveolar osteitis of 25% in the chlorhexidine rinse
group. The authors concluded that the reduced inci-
dence in the gel group was because of the prolonged
release of chlorhexidine from the daily gel application.
Minguez-Serra et al.40 performed a meta-analysis of
chlorhexidine mouthwash and gels. Their paper
included 12 different trials, which used different
416
concentrations and dosing regimes. The authors found
that the application of a 0.2% chlorhexidine gel every
12 h for 1 week after third molar surgery was the
most effective in decreasing the incidence of alveolar
osteitis. In contrast, the meta-analysis by Zhou et al.42
found no significant difference between chlorhexidine
mouthwash and gel. However, they did confirm the
efficacy of chlorhexidine gel compared with no treat-
ment and placebo. The authors concluded that on
average, 0.2% chlorhexidine gel reduced the risk of
alveolar osteitis by 62% following mandibular third
molar extraction.
More recently, ozone gel has been purported as
having a beneficial effect after third molar surgery.
Ozone is a strong oxidant and has broad antimicro-
bial properties. It is also known to enhance oxygen
metabolism, induce enzymes and activate the immune
response.43 This has the effect of reducing the possi-
bility of postoperative infection, improve tissue regen-
eration and speed up wound healing.44
It has been shown that ozone gel applied to the
surgical site can reduce postoperative inflammatory
complications. Sivalingam et al.45 conducted a ran-
domized controlled trial of 66 patients comparing
ozone gel (Aqua Ozone, Akaroa, New Zealand) to
systemic antibiotics. They found a significant reduc-
tion in pain, swelling and trismus in patients using
ozone gel, with no significant adverse effects.
The literature supports the use of chlorhexidine gel
to reduce alveolar osteitis postoperatively. The use of
ozone-containing gels shows promise but more high-
quality, randomized controlled trials are needed to
confirm its efficacy. Practitioners must also bear in
mind the higher cost associated with gels compared
with traditional mouth rinse.
Irrigation
Irrigation in surgery involves delivery of a stream of
fluid for the purpose of washing or debridement. In
third molar surgery, it is used in the postoperative
phase for the management of alveolar osteitis. It has
been postulated that removal of any necrotic debris or
food particles can help to eliminate a potential source
of inflammation and pain.46 Patients with alveolar
osteitis are usually given a plastic syringe with a
curved tip, for home irrigation with chlorhexidine or
saline and instructed to keep the socket clean until the
socket no longer collects debris. The benefit of this
lacks scientific evidence, although the reasoning
appeals to common sense. Daly et al.37 confirmed this
in a Cochrane review, which concluded that there was
insufficient evidence to support any existing treat-
ments for dry socket.
In 2016, Ghaeminia et al.47 published the first
paper on the use of postoperative irrigation by
© 2017 Australian Dental Association

patients after discharge. They compared tap water
irrigation with a Monoject syringe (Tyco Healthcare/
Kendall, Mansfield, MA, USA) with no intervention
using 333 third molar sites. A significant reduction in
inflammatory complications including alveolar osteitis
was found in the group that used irrigation. However,
in this study a large number of patients (42%) failed
to use the irrigation. Also, no comparison was made
with rinsing alone. Nevertheless, it presents an inter-
esting case for a cost-effectiveness and readily accessi-
ble intervention to reduce inflammatory complications
after third molar surgery.
Cryotherapy
The application of ice to the extraoral site of surgery
is simple and favoured by many clinicians. The theory
is that reduced temperatures cause vasoconstriction
and reduces postoperative swelling. It can also reduce
nerve fibre conduction velocity resulting in an anal-
gesic effect.48 Several authors have demonstrated a
good efficacy in reducing postoperative swelling and
pain.48–51
In the treatment of impacted third molars, the use
of ice in the literature remains controversial. Van der
Westhuijzen et al.52 state that there is no scientific evi-
dence to support the use of an icepack in oral and
maxillofacial surgery and report that a slight, but not
significant, difference in swelling was observed in
patients in whom ice was applied continuously for
24 h after extraction of third molars compared with
untreated controls. Similarly, Zandi et al.53 could not
demonstrate any significant difference in postoperative
inflammatory complications in their split-mouth
study. Greenstein’s54 review was also inconclusive
with respect to the clinical benefits of cryotherapy.
Although ice applied to the mandibular angle pro-
duces rapid cooling in the cutaneous layer, the effect
is significantly reduced 2–3 cm beyond the skin sur-
face.48 This means anatomical variation can have a
significant impact on the effectiveness of cryotherapy.
The application of ice for too long can also be harm-
ful. Tissue death can result due to prolonged vasocon-
striction, ischaemia and capillary thrombosis.55 Other
factors to consider include type of cryotherapy (e.g.
crushed ice, ice pack, frozen peas, Hilotherm or chem-
ical gel pack), as well as duration, and amount of
compression used. This multitude of factors is likely
contributory to the variability in study results.
Based on physiological principles, the application of
cold after third molar removal should produce a
favourable response. However, the current evidence
base for this is inconsistent. Much like the manage-
ment of dry socket, clinical anecdotes and techniques
often come before science. Further clinical trials and
© 2017 Australian Dental Association
Interventions after third molar surgery
meta-analyses are needed to provide scientific valida-
tion to use of cryotherapy after third molar surgery.
CONCLUSIONS
This review has presented the different modalities to
reduce inflammatory complications after third molar
removal. There is strong evidence for the use of parac-
etamol and ibuprofen to manage postoperative pain.
Corticosteroids reduce swelling and trismus after sur-
gery; however, they should only be used in selected
cases. Antibiotics reduce infection when used as surgi-
cal prophylaxis but should not be used postopera-
tively in healthy patients undergoing routine third
molar removal. Chlorhexidine mouthwash and gels
are proven to be efficacious in reducing alveolar ostei-
tis. There is conflicting evidence with regards to
cryotherapy. Further research is required to confirm
the benefits of postoperative irrigation and ozone gel.
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lar third molar surgery: a randomized, self-controlled, observer- Email: h.cho@uq.edu.au
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2016;45:118–123.

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