Vol. xx No.

x Month 2012

Antibiotic prophylaxis in third molar surgery: a review

Marjolijn A. E. Oomens, MD, and Tymour Forouzanfar, MD, DDS, PhD

Objective. Controversy exists about the efficacy of antibiotic prophylaxis in preventing complications after lower third molar
surgery. For evidence-based recommendation, a review was performed on clinical trials reporting the use of antibiotic
prophylaxis compared with no treatment or placebo with “infection” as outcome.
Study Design. Useful studies were identified using Embase, Cochrane, and Ovid Medline (1966-January 2011) and references
in retrieved reports and review articles. Twenty-three eligible studies were identified and reviewed by independent
investigators using 2 quality assessment scales.
Results. The review procedure revealed 15 “low-quality” and 8 “high-quality” articles, with major differences in treatment
modalities and heterogeneity of design.
Conclusions. There is limited evidence supporting the efficacy of commonly used antibiotics in preventing complications after
lower third molar removal. Well designed and well reported high-quality randomized trials considering known risk factors
and taking clinical outcomes into account are needed to reach final consensus on the efficacy of antibiotic prophylaxis to
allow evidence-based recommendations. (Oral Surg Oral Med Oral Pathol Oral Radiol 2012;xx:xxx)

The removal of impacted lower third molars is a com-
mon procedure in oral and maxillofacial surgery. In
the literature, many complications associated with
lower third molar removal are described, e.g., pain,
swelling, trismus, infection, inflammation, and nerve
damage. One of the more common complications is
alveolar osteitis (i.e., alveolitis sicca dolorosa, dry
socket, or localized osteitis), with rates ranging from
0 to 68%.1,2
There is controversy about the use of antibiotics as
prophylaxis to prevent complications after lower third
molar removal. Several authors claim that prophylactic
antibiotics are useful in preventing postoperative com-
plications and infections after third molar removal.3-14
Decreased pain, swelling, and trismus also are re-
ported.5,6,10,12 Quality of life is stated to be higher
when antibiotics are prescribed.13 On the other hand,
additional studies were not able to demonstrate the
effectiveness of antibiotic prophylaxis.15,16
Antibiotic prophylaxis for preventing postoperative
wound infections accounts for ⬎30% of antibiotic pre-
scriptions in general hospitals.17 Excessive and inap-
propriate use of antibiotics can lead to bacterial resis-
tance and increase the economic burden of health
care.18 Other risks of indiscriminate antibiotic therapy
include the development of secondary infection, aller-
gic reactions, and toxicity of the antibiotic.19,20
Ren et al.14 conducted a thorough meta-analysis of
randomized controlled clinical trials (RCTs) of the ef-
fectiveness of antibiotic prophylaxis in third molar sur-
gery.14 They concluded that systemic antibiotic prophy-
laxis given before surgery is effective in reducing the
frequencies of alveolar osteitis and wound infection.
According to Song et al.,21 significant results are
more likely to get published than nonsignificant find-
ings, which can distort the findings of meta-analysis.
The need to assess quality stems mainly from a desire
to estimate the effects of bias on the results of an RCT.
Meta-analysts need to take this into account.22 In the
study by Ren et al.,14 no extensive criteria list for
judging the methodologic quality was used; however, a
classification was made into 3 quality categories based
on the rigor of the study design. Analysis was made
showing differences between the various quality cate-
gories in effect size and variation of treatment effect.
Although Ren et al.14 demonstrated the effectiveness
of antibiotic prophylaxis, there is still no consensus on
the use of antibiotics as prophylaxis in surgical removal
of lower third molars.
The objective of the present study was to provide an
evidence-based recommendation on the efficacy of an-
tibiotics in preventing infectious complications after
third molar surgery by reviewing eligible randomized
controlled trials on lower third molar removal.

Department of Oral and Maxillofacial Surgery/Oral Pathology, Vrije Statement of Clinical Relevance
Universiteit Medical Center/Academic Center for Dentistry Amster-
dam, Amsterdam, The Netherlands. Prescription of antibiotics in third molar surgery, a
Received for publication Jun 10, 2011; returned for revision Oct 4,
frequent procedure, is an important topic. In search-
2011; accepted for publication Oct 13, 2011.
© 2012 Elsevier Inc. All rights reserved. ing the evidence, it can be questioned if this com-
2212-4403/$ - see front matter mon practice should still be recommended.
doi:10.1016/j.oooo.2011.10.023

e1
ORAL AND MAXILLOFACIAL SURGERY
e2 Oomens and Forouzanfar
MATERIALS AND METHODS
Literature search
A computer-assisted search of the Embase, Cochrane,
and Ovid Medline databases from 1966 through Janu-
ary 2011 was conducted using the key words “wisdom
tooth,” “third molar,” “alveolitis,” “dry socket,” and
“alveolar osteitis” in combination with “anti* agents.”
A search with the combination of the Medical Subject
Headings Terms (MeSH) “Molar, Third” and “Antibac-
terial Agents” or “Antibiotic Prophylaxis” was also
conducted. All reference lists in the obtained literature
were checked for additional relevant articles. The Co-
chrane highly sensitive search strategy for identifying
randomized trials was applied to restrict studies to
clinical trials in Medline, and a language restriction for
“English” was imposed.
Type of study and participants
RCTs were included that compared antibiotic prophy-
laxis with placebo treatment or no treatment in prevent-
ing infection or inflammation in patients undergoing
surgical removal of the lower third molar. Only studies
written in English were included.
Type of interventions
Studies making a comparison between antibiotic pro-
phylaxis and a placebo or no treatment were included.
Antibiotics were considered if used as prophylaxis,
independently from concentration, frequency of use,
duration, and technique of administration.
Type of outcome
Trials describing infections, wound infections, inflam-
mations, dry sockets, alveolitis, or alveolar osteitis
were considered as eligible studies.
Quality assessment of studies
An RCT is mostly assessed on internal validity, exter-
nal validity, and statistical analysis.23 In the literature,
there are several criteria lists measuring the methodo-
logic quality of randomized controlled trials. Olivo et
al.24 showed in their systematic review that the Delphi
List and Jadad Scale are the most valid quality assess-
ment scales.23,25 Therefore, in the present study, both
criteria lists were used.
In Table I, both criteria lists are shown. Maximum
scores for the Delphi List and Jadad Scale are 9 and 5,
respectively. Two independent investigators (the au-
thors) scored methodologic quality of the trials. Dis-
agreement was resolved by consensus between the 2
investigators. If no agreement could be reached, a third
investigator was consulted. Where needed, authors of
studies were contacted for additional information to
resolve ambiguities. Final assessment resulted in a hi-
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Month 2012
erarchic list in which higher scores indicate studies with
a higher methodologic quality.
Statistics
Agreement regarding the required minimum score for
methodological quality was reached in a consensus
meeting.
A score of 3 for the Jadad Scale and a score of 5 for
the Delphi List was chosen as a cutoff point for meth-
odologic quality. These scores were combined, which
means that only studies with a Jadad score of 4-5 and a
Delphi score of 6-9 were assessed to be of “high qual-
ity.” Studies with a Jadad score of 0-3 or a Delphi score
0-5 were considered to be of “low quality.” Only stud-
ies considered to be high quality were described exten-
sively. However, in the synthesis of results, all studies,
including those of “low quality,” were reflected on.
RESULTS
Literature searches
As shown in Figure 1, the search resulted in 117 titles
as potentially relevant studies. After reviewing the ab-
stracts, 32 articles involving orally or intravenous ad-
ministered antibiotics were identified. Four more po-
tentially relevant studies were identified from the
references. By evaluating full article content, with in-
formation provided by correspondence with authors
when needed, these remaining 36 citations were limited
to 23 (see Table II for reasons for exclusion of stud-
ies13,26-37). Methodologic assessment of the 23 eligible
publications revealed 8 methodologically “high-qual-
ity” articles, and 15 “low-quality” studies. A list of the
quality scores is presented in Table III. Eleven clinical
RCTs scored ⬎3 on the Jadad Scale and 10 trials scored
⬎5 on the Delphi List. A total of 8 studies scored above
the cutoff points both for the Jadad Scale and the
Delphi List and were therefore considered to be “high-
quality” studies. The mean Jadad quality score was 3.00
points (range 1-5 points), and mean Delphi score was
4.78 points (range 0-9 points). The investigators man-
aged to resolve disagreements by consensus and a third
investigator was never involved.
Study description
The 8 high-quality studies were diverse (Table IV) with
2 originating from New Zealand38,39 and 1 each from
the USA,40 Poland,41 Spain,10 India,16 Sweden,42 and
Denmark.43 All reports were placebo-controlled trials
and were published from 1987 to 2010. The study
conducted by Siddiqi et al.38 was the only split-mouth
trial and the only trial reporting to have been performed
without external funding. Halpern et al.40 reported to
have been externally supported in part. All of the other
OOOO REVIEW ARTICLE
Volume xx, Number x Oomens and Forouzanfar e3

Table I. Jadad Scale and Delphi List

Answer Score
Jadad Scale
A Randomization
Was the study described as randomized (this includes the use of words ⫺/⫹ 0/2
such as randomly, random, and randomization)?
Give 1 additional point if the method to generate the sequence of ⫹1
randomization was described and it was appropriate (table of random
numbers, computer-generated, etc.)
Deduct 1 point if the method to generate the sequence of randomization ⫺1
was described and it was inappropriate (patients were allocated
alternately or according to date of birth, hospital number, etc.)
B Double blinding
Was the study described as double blind? ⫺/⫹ 0/2
Give 1 additional point if the method of double blinding was described ⫹1
and it was appropriate (identical placebo, active placebo, dummy, etc.)
Deduct 1 point: if the study was described as double blind but the ⫺1
method of blinding was inappropriate (e.g., comparison of tablet vs.
injection with no double dummy)
C Withdrawals and dropouts
Was there a description of withdrawals and dropouts? (the number and the ⫺/⫹ 1
reasons for withdrawal in each group must be stated)
Delphi List
Treatment allocation (2 criteria)
A Was a method of randomization performed? ⫺/?/⫹ 0/0/1
B Was the treatment allocation concealed? ⫺/?/⫹ 0/0/1
C Were the groups similar at baseline regarding the most important prognostic ⫺/?/⫹ 0/0/1
indicators
D Were the eligibility criteria specified? ⫺/?/⫹ 0/0/1
Blinding (3 criteria)
E Was the outcome assessor blinded? ⫺/?/⫹ 0/0/1
F Was the care provider blinded? ⫺/?/⫹ 0/0/1
G Was the patient blinded? ⫺/?/⫹ 0/0/1
H Were point estimates and measures of variability presented for the primary ⫺/?/⫹ 0/0/1
outcome measures?
I Did the analysis include an intention to treat analysis? ⫺/?/⫹ 0/0/1

Table II. Studies not included in the present review

Study Reason(s) for exclusion
Macgregor38 No relevant outcomes reported
Macgregor and Hutchinson39 No systemic antibiotics were used
Akota40 No systemic antibiotics were used
Limeres13 No relevant outcomes reported
Kaziro41 No relevant outcomes reported
Capuzzi42 No relevant outcomes reported
Hedström43 Article in Swedish
Lombardia Garcia44 Article in Spanish
Lloyd45 No control group
Cannell46 Not for third molar extraction and
no relevant outcomes reported
Graziani47 Control group used medication
(NSAIDs) that influences the
outcomes
Fig. 1. The search resulted in 117 titles as potentially relevant Cioacã48 Not for third molar extraction
studies. Luaces-Rey49 No control group

high-quality trials did not report any source of fund-
ing.10,16,39,41-43
The study conducted by Halpern et al.40 administered
the treatment modalities intravenously, whereas the
other studies used oral administration. Metronidazole
was used as intervention in 4 studies.16,39,42,43 Two of
these studies administered metronidazole in a single
dose preoperatively,42,43 1 study administered a preop-
erative dose and continued postoperatively,39 and 1 trial
compared a single preoperative dose with solely post-
ORAL AND MAXILLOFACIAL SURGERY OOOO
e4 Oomens and Forouzanfar Month 2012

Table III. Hierarchic list of the quality score In most studies it was not clear whether the care pro-
Scores of the vider or the observer was blinded, and the blinding was
Jadad Scale Scores of the Delphi List never evaluated. A further methodologic flaw was that
First author A B C Total A B C D E F G H I Total some studies stated to be randomized but cleared no
Maximum 2 2 1 5 1 1 1 1 1 1 1 1 1 9 method of randomization.3-6,8,9,11,12,15,44-46 Almost all
Arteagoitia10 2 2 1 5 1 1 0 1 1 1 1 1 1 8 of these studies show a lack of statistical power, mean-
Halpern28 2 2 1 5 1 1 1 1 1 1 1 1 0 8 ing that the conclusion is not supported by the sample
Barclay27 2 1 1 4 1 1 1 1 1 1 1 1 1 9 size.
Bergdahl30 2 2 1 5 1 1 1 1 0 1 1 1 0 7
Kaczmarzyk29 2 2 0 4 1 1 1 1 1 1 1 1 0 8
In the high-quality trials, randomization was per-
Mitchell7 2 2 1 5 1 1 0 0 0 1 1 1 0 5 formed by a table of random numbers,39,41 sealed en-
Ritzau31 2 2 0 4 1 1 0 0 1 1 1 1 0 6 velopes,16,38,40 or computer-assisted programs.10,43 In
Sekhar16 2 1 1 4 1 1 1 1 1 0 0 1 0 6 all high-quality trials except that of Sekhar et al.,16 the
Siddiqi26 2 2 0 4 1 1 1 0 0 1 1 1 0 6 administered treatment modality and placebo looked
Lacasa11 1 2 1 4 0 0 1 1 0 1 1 1 0 5
Lyall8 1 2 1 4 0 0 1 0 1 1 1 1 0 5
identical for blinding purposes. Two studies did not
Happonen15 1 2 0 3 0 0 1 0 1 1 1 1 1 6 report sufficient information to assess whether the out-
Curran35 2 0 0 2 1 1 1 1 1 0 0 1 0 6 come assessor was blinded.38,42 Some studies reported
Bulut33 1 2 0 3 0 0 1 0 0 1 1 1 0 4 the blinded surgeon to be the outcome assessor as
Poeschl36 2 0 0 2 1 1 1 0 0 1 0 1 0 5 well.39,40 Two of the 8 high-quality studies reported a
Delilbasi9 1 0 0 1 0 0 1 1 0 1 0 1 0 4
Bystedt5 1 1 0 2 0 0 0 0 0 0 1 1 0 2
power analysis.10,43
Bystedt6 1 1 0 2 0 0 0 0 0 0 1 1 0 2
Monaco34 1 0 0 1 0 0 0 1 1 0 0 1 0 3
Synthesis of results
Monaco12 1 0 0 1 0 0 0 0 1 1 0 1 0 3
Krekmanov3 1 0 0 1 0 0 0 0 0 0 0 1 0 1 Low-quality studies. The studies investigating peni-
Krekmanov4 1 0 1 2 0 0 0 0 0 0 0 1 0 1 cillin as antibiotic prophylaxis show contradictory out-
Ataoğlu32 1 0 0 1 0 0 0 0 0 0 0 0 0 0 comes. Two studies classified as low quality15,47 dem-
onstrated no statistically significant differences when
prescribing penicillin compared with no treatment,
operative administration.16 Other investigated antibiot- whereas 3 other low-quality studies3,4,6 reported peni-
ics included: augmentin,10 clindamycin,41 penicillin40 cillin to decrease the incidence of alveolitis more than
and amoxicillin.38 placebo.
In 7 trials, alveolar osteitis (e.g., “dry socket” or There were 3 low-quality trials investigating the ef-
“alveolitis sicca dolorosa”) was recorded when 2 crite- fectiveness of amoxicillin.12,45,46 Two of these studies
ria were present simultaneously: severe pain radiating demonstrated no significant difference between treat-
from the emptied socket and disintegration of the ment and control groups.45,46 The third study showed a
socket coagulum.10,38-43 Complications were recorded significant reduction in incidence of wound infection
by Arteagoitia et al.10 when presenting dry socket as after 6 months’ follow-up.12
described above accompanied by inflammatory signs, Augmentin administered postoperatively proved to
including intraoral erythema, abscess, and body tem- be effective in reducing the incidence of inflammation
perature ⬎37.8°C (measured orally). Halpern et al.40 and infectious complications in 2 low-quality stud-
distinguished between alveolar osteitis and a “surgical ies.9,11 Two other low-quality trials investigating aug-
site infection” as outcome measure. The criteria for mentin found no significant difference between treat-
“surgical site infection” were visual evidence of frank ment and control groups.44,48
purulence in ⱖ1 of the extraction sites and a positive One low-quality study administered a single dose
Gram stain. Sekhar et al.16 also recorded “dry socket” of metronidazole as intervention and failed to dem-
but theirs was the only article that did not describe the onstrate any preventive effect on the development of
criteria used for diagnosing “dry socket.” Besides dry alveolitis.8 Investigating tinidazole compared with a
socket, they also recorded the state of the wound by placebo treatment demonstrated a statistical signifi-
clinical diagnosis of purulent discharge from the cant decrease in infection.7 A study administering
wound. azidocillin, erythromycin, clindamycin, or doxycy-
cline as intervention compared with placebo treat-
Quality assessment ment stated that all interventions could decrease the
Major methodologic flaws in the reviewed studies clas- rate of infections.5
sified as low quality included poor specification of the High-quality studies. Four high-quality trials16,39,42,43
inclusion criteria, no intention to treat analyses, and investigated the efficacy of metronidazole and did
poor description of number of and reasons for dropouts. not demonstrate a statistically significant reduction
OOOO REVIEW ARTICLE
Volume xx, Number x Oomens and Forouzanfar e5

Table IV. Characteristics of the high quality studies

Jadad Delphi Patients,
Author score score n Intervention Measurements Follow-up Results primary outcome
Barclay 198727 5 9 100 Metronidazole (400 VAS-pain, dry socket 7d Dry socket: 17.8% in
mg/1 h preop ⫹ (continuous dull pain treatment group vs. 34%
400 mg/3 times from a partially empty in placebo group (P ⫽
daily/3 d) socket or the region of .073); no statistically
the socket) and side significant difference
effects
Ritzau 199931 4 7 270 Metronidazole (1,000 Alveolitis (severe pain 7d Alveolitis: 4.4% in treatment
mg/0.5 h preop) irradiating from the group vs. 5.2% in placebo
empty socket toward the group (P ⫽ 1.00); no
ear and disintegration of significant difference
the socket coagulum)
Sekhar 200116 4 7 151 Metronidazole (1 g/1 Pain by patient perception, 6d No significant differences
h preop) or swelling, mouth opening for all outcomes (P ⫽
metronidazole (400 by interincisal distance, .09)
mg/3 times daily/5 state of the wound
d) defined as normal,
purulent, or discharge
Bergdahl 200430 5 7 120 Metronidazole (1,600 Alveolar osteitis diagnosed 4d Dry socket: 17% in
mg/45 min preop) by no blood clot in the treatment group vs. 22%
socket, foetor ex ore, and placebo; no significant
continuous increasing differences between
postop pain from day 2 groups
to day 4
Arteagoitia 200510 5 8 494 Augmentin (625 mg/3 VAS-pain, postop infection 7d Inflammatory complications:
times daily/4 d and inflammatory 1.9% in treatment groups
postop) complication (dry socket vs. 12.9% in placebo
if absence of blood clot group (P ⬍ .001);
with necrotic remains in significant reduction in
the alveolus accompanied infectious and
by severe mandibular inflammatory
pain), severe pain, complications for the
intraoral abscess treatment group
Halpern 200728 5 8 118 Penicillin IV (15,000 Alveolar osteitis (by history 14 d Significant decrease in
U/kg/1 h preop) and by examination) and surgical site infection: 0%
surgical site infection in penicillin groups vs.
(frank purulence in 8.5% in placebo group
extraction site and Gram (P ⫽ .03) (there were no
stain demonstrating white cases of alveolar osteitis)
blood cells)
Kaczmarzyk 4 8 86 Clindamycin (600 mg/ VAS-pain, alveolitis 7d Alveolitis: 3.25% and 7.14%
200729 1 h preop ⫹ 300 (necrotic gray clot in a in treatment groups vs.
mg placebo/3 times bare bony socket, foetor 14.81% in placebo group
daily/5 d) or ex ore, and pain), (P ⫽ .26); no significant
clindamycin (600 trismus, swelling and differences in frequency
mg/1 h preop ⫹ lymphadenopathy, body of alveolitis
300 mg/3 times temperature
daily/5 d)
Siddiqi 201026 4 7 100 Amoxicillin (1 g/1 h VAS-pain, swelling, 14 d No statistically significant
preop) or interincisal opening, differences in all
amoxicillin (1 g/1 h temperature, dry socket outcomes (P ⬍ .05)
preop ⫹ 500 mg/3 (halitosis, pain and
times daily/2 d) clinical signs of clotless
socket with necrotic
bone)

in frequency of alveolitis compared with placebo demonstrated that penicillin decreased the incidence
groups. In the high-quality study by Arteagoitia et of surgical wound infection significantly. Clindamy-
al.,8 augmentin reduced the incidence of inflamma- cin41 and amoxicillin38 were not able to reduce the
tion and infectious complications. Halpern et al.29 frequency of complications.
ORAL AND MAXILLOFACIAL SURGERY
e6 Oomens and Forouzanfar
DISCUSSION
The present review was designed to provide evidence-
based recommendations on the use of antibiotics as
prophylaxis in surgical removal of lower third molars.
Therefore, RCTs that have examined the efficacy of
prophylaxis were reviewed and criticized on their qual-
ity.
Generally, the value of a review of the literature
depends on the success in obtaining the results of all
studies that have been conducted on the subject at
issue.21 Although we put much effort into obtaining all
available studies, some important published and unpub-
lished trials may have been missed (publication bias).
Furthermore, we were not blinded for the outcomes
of the publications in this study, which may have
resulted in some degree of reviewer bias. However,
because the point assignment is demonstrated in Ta-
ble III, the reader can apply different weights to
different criteria.
The only way to assess the quality of a trial is by
relying on the information contained in the trial report.
It is important to recognize that an RCT with a biased
design that is well reported could be judged to be of
high quality and that a well designed RCT that is poorly
reported could be judged to be of low quality.22 There-
fore, all included studies were considered in the syn-
thesis of results and authors were contacted to resolve
ambiguities if needed.
Twenty-three randomized trials meeting the inclu-
sion criteria were identified and after assessing the
quality, we found only 8 trials to be of “high quality.”
After synthesis of results, it seems that augmentin
and penicillin are effective in preventing inflammation
and “surgical site infection” after surgical removal of
the lower third molar. However, the heterogeneity of
the study designs precluded the drawing of firm con-
clusions about the efficacy of these interventions.
Guyatt states: “High-quality evidence doesn’t neces-
sarily imply strong recommendations, and strong rec-
ommendations can arise from low -quality evidence.”49
This means that even when finding statistically high-
quality evidence for the effectiveness of antibiotic pro-
phylaxis, the clinical significance must be determined
by weighing the desirable and undesirable effects be-
fore making a strong or weak recommendation. To
decide whether a statistical significant result is also of
clinical significance, a study has to use, e.g., “quality of
life,” “adverse events,” or “costs” as outcome measures
and balance both advantages and disadvantages of an
intervention. None of the studies included in the present
review measured these as primary outcomes. Therefore,
it is difficult to draw firm conclusions about the clinical
efficacy of antibiotic prophylaxis in third molar sur-
gery.
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Month 2012
The meta-analysis conducted by Ren et al.14 suggests
that there is a role for systemic antibiotic prophylaxis in
third molar surgery and recommends a single dose of
penicillin or its derivates 1 hour before surgical re-
moval of impacted lower third molars. For patients with
known risk factors antibiotics should be administered in
a single dose before surgery and continued 2-5 days
after surgery. Earlier studies identified risk factors such as
pericoronitis and oral conceptives,42 partially erupted mo-
lars and surgical trauma,48 poor oral hygiene,7 age,10,46
and sex.46 The final consensus recommendation in that
meta-analysis was for a new placebo-controlled multi-
center clinical trial taking these risk factors into ac-
count.
Five more RCTs have been published since, and only
2 of them were considered to be of “high quality.”38,41
Four of these trials investigated amoxicillin as inter-
vention but report contradictory outcomes.
In conclusion, there are only a few high-quality and
well reported trials on the efficacy of antibiotic as
prophylaxis in third molar surgery. The performed tri-
als are heterogenic in study design and treatment mo-
dalities. However, all studies using metronidazole
failed to demonstrate statistical efficacy, so it could be
left out of further trials. On the other hand, it seems that
augmentin, penicillin, or its derivatives can show pos-
itive effects in preventing inflammation and “surgical
site infection” after surgical removal of a lower third
molar. The trials fail to investigate clinical outcomes to
decide whether their statistical significance is also of
clinical relevance.
Further research is needed to reach consensus on the
efficacy of antibiotics as prophylaxis in surgical re-
moval of lower third molars. Recommended by Ren et
al.14 is a more high-quality clinical trial; however, in
the current perspective this is not sufficient. In addition
to their recommendation, measurements of clinical out-
come are highly indispensable to interpret the statistical
results and give an evidence-based recommendation.
Further research needs to concentrate on augmentin,
penicillin, or its derivatives as intervention.
Regrettably, after a review of all available trials from
1966 to 2010 on this important topic, there is still no
consensus on the balance of the benefits and disadvan-
tages of antibiotics as prophylaxis in surgical removal
of lower third molars. It is a known fact that costs,
adverse events, and bacterial resistance are to be dealt
with when prescribing antibiotics. Taking into account
that the efficacy of numerous antibiotics has not been
successfully proven, the current recommendation based
on available evidence should be to not prescribe anti-
biotics as prophylaxis in third molar surgery in general.
Obviously, when dealing with a patient with known
OOOO
Volume xx, Number x
risk factors, as mentioned above, antibiotic prophylaxis
should still be prescribed.
The authors thank the authors of the studies included in
this review, especially those who answered requests for
additional information.
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