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JORMAS-795; No. of Pages 4

J Stomatol Oral Maxillofac Surg xxx (2020) xxx–xxx

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Original Article

Evaluation of the effects of intra-alveolar irrigation with clindamycin,

rifampicin and sterile saline in alveolar osteitis treatment
A.T. Çebi
Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Karabuk University, Karabuk, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Background: To evaluate the efficacy of intra-alveolar irrigation made with clindamycin, rifampicin and
Received 6 September 2019 sterile saline on pain and alveolar mucosa healing in the treatment of alveolar osteitis (dry socket).
Accepted 16 January 2020 Methods: Fifty-four patients diagnosed with alveolar osteitis were divided into three groups for the
treatment protocol. Sterile saline was used in Group A, rifampicin was used in Group B and clindamycin
Keywords: was used in Group C for intra-alveolar irrigation. In the groups, the patients were evaluated for their pain
Alveolar osteitis levels and alveolar mucosa healing.
Rifampicin
Results: The incidence of alveolar osteitis was significantly higher in females and mandibles at a
Clindamycin
Pain
statistically significant. In the group that used clindamycin for intra-alveolar irrigation, the pain level
Alveolar mucosa healing was found lower than the two other groups. Clindamycin and rifampicin groups were superior to the
sterile saline group in clinical alveolar mucosa healing.
Conclusion: Irrigation with clindamycin appears to reduce the pain associated with alveolar osteitis when
compared to rifampicin and sterile saline. In the treatment of alveolar osteitis, irrigation with antibiotics
following curettage was found effective for pain relief and alveolar mucosa healing.
C 2020 Elsevier Masson SAS. All rights reserved.

1. Introduction traumatic extractions, tooth and bone fragments left in the

Tooth extraction is the most commonly applied surgical
procedure in the oral surgery routine [1]. One of the most common
complications experienced after tooth extraction is alveolar
osteitis. Alveolar osteitis is a wound healing disorder which is
partially or totally characterized with disintegrated blood clot
within the alveolar socket [1,2]. Alveolitis are infectious compli-
cations after tooth extraction. They appear under two forms: dry
socket; characterized by a postoperative pain in and around the
extraction area, accompanied by a partially or totally disintegrated
blood clot within the alveolar socket, with or without halitosis and
suppurative form; which becomes identified by provoked pain and
alveolus filled [1–4].
The incidence of alveolitis after a routine tooth extraction is
around 3%. However, this rate rises to around 30% after impacted
mandibular third molar extractions [1]. The etiology of alveolar
osteitis has not been fully explained despite a good number of
studies conducted on this issue [3,4]. However, oral bacteria
(especially Treponema denticola), poor oral hygiene, use of
vasoconstrictor anesthetics, pre-existing infection, difficult and
E-mail address: ahmettaylancebi@karabuk.edu.tr
extraction socket, overcurettage of the extraction socket, disrup-
tion of the blood clot, the use of oral contraceptive, alcohol and
smoking are emphasized as reasons in the etiology [3–5].
Inflammation occurs in the bone marrow cavities due to the
infected alveolar socket. This inflammation disturbs the cells and
releases tissue activators. At the end of this fibrinolytic activity,
plasminogen in the clot transforms into a plasmin, which destroys
the fibrin network and dissolves the clot formed in the alveolar
socket [3]. The plasmin also causes pain by revealing quinine,
which is a pain mediator [3,6].
When alveolar osteitis occurs in mandible, it causes pain
reaching to ear and temporal region. When it occurs in maxilla,
alveolar osteitis causes pain reaching to forehead and suborbital; it
causes malaise and malodor in the general systemic case [4,6]. It
occurs 1–3 days after the extraction. The pain mostly is not
relieved by analgesic agents and lasts for 7–10 days [4,6].
To prevent alveolar osteitis; it is recommended to have good
oral hygiene, to perform an atraumatic tooth extraction, not to use
alcohol and cigarettes after tooth extraction, and not to make a first
24 hours strong mouth rinse (to prevent the clot formation in the
socket from deteriorating). On the other hand, systemic and local
antibiotic practices, antiseptic mouthwash (involving chlorhexi-
dine content), irrigation of the extraction socket with serum

https://doi.org/10.1016/j.jormas.2020.01.004
2468-7855/ C 2020 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Çebi AT. Evaluation of the effects of intra-alveolar irrigation with clindamycin, rifampicin and sterile
saline in alveolar osteitis treatment. J Stomatol Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.jormas.2020.01.004
G Model
JORMAS-795; No. of Pages 4
2 A.T. Çebi / J Stomatol Oral Maxillofac Surg xxx (2020) xxx–xxx
physiology, eugenol and iodoform-containing local analgesic agent
applications, topical and systemic steroid use, low-dose laser
therapy use are treatment options [7–10]. Treatment includes
administration of drugs either locally or systemically in attempt to
initiate wound repair. The primary aim of the treatment is to
control pain until the usual healing starts [11,12].
The aim of this study was to evaluate the efficacy of intra-
alveolar irrigation made with clindamycin, rifampicin and sterile
saline on pain and alveolar mucosa healing in the treatment of
alveolar osteitis.
2. Materials and methods
This research was carried out in accordance with the guiding
principles of the ‘‘Helsinki Declaration of Human Rights’’. The study
started after the approval of Karabuk University Ethical Committee
(decision no: 2/11, 07.02.2018). The study was performed between
October 2016 and December 2018 at the Oral and Maxillofacial
Surgery Clinic. All patients were included in the study after
detailed information had been provided regarding the study and
the patient consent forms had been signed. A total of 54 patients
who applied to the clinic the first day after routine tooth extraction
with severe pain in and around the extraction area, with/without
halitosis complaints and been diagnosed with alveolar osteitis (dry
socket) after clinical examination were included in the study.
Diagnosis of alveolar osteitis (dry socket) was made clinically by
researcher (oral and maxillofacial surgeon). The wound was
checked for necrotic bone, halitosis, pain, swelling, and pus
discharge. Patients older than 18 years and without any drug
allergy were included in the study. Pregnant and breastfeeding
women, patients with cardiovascular, renal, pulmonary and
gastrointestinal system disorders, diabetes and drug allergy,
patients’ use of cigarettes and alcohol, patients’ have poor oral
hygiene and patients with pre-infection of the tooth to be
extracted were not included in the study. The patients were
assigned to Groups A, B, and C for the treatment.
Treatment protocols in the groups are as follows:
 Group A: curettage of the alveolar socket, intra-alveolar
irrigation with 4 mL sterile saline every 2 days, placement of
alvogyl (manufactured by Septodont India Pvt. Limited. Content
– iodoform 15.8 gm, eugenol B.P. 13.7 gm, and butamben
25.7 gm) in the alveolar socket with a sterilized tool following
the irrigation every 2 days. Use of mouthwash with 0.12%
chlorhexidine content on three times per day. Furthermore,
patients in Group A were given dexketoprofen trometamol
(arveles 25 mg, Ufsa Drug, Turkey) on two times per day as an
analgesic;
 Group B: curettage of the alveolar sockets, intra-alveolar
irrigation with 4 mL rifampicin-containing antibiotic agent (rif
125 mg IM vial, Kocak Farma Drug, Turkey) every 2 days,
placement of alvogyl (manufactured by Septodont India Pvt.
Limited. Content – iodoform 15.8 gm, eugenol B.P. 13.7 gm, and
butamben 25.7 gm) in the alveolar socket with a sterilized tool
following the irrigation every 2 days. Use of mouthwash with
0.12% chlorhexidine content on three times per day. Further-
more, patients in Group B were given dexketoprofen trometamol
(arveles 25 mg, Ufsa Drug, Turkey) on two times per day as an
analgesic;
 Group C: curettage of the alveolar socket, intra-alveolar
irrigation with 4 mL clindamycin-containing antibiotic agent
(clindan 600 mg I.M/I.V vial, Bilim Drug, Turkey) every 2 days,
placement of alvogyl (manufactured by Septodont India Pvt.
Limited. Content – iodoform 15.8 gm, eugenol B.P. 13.7 gm, and
butamben 25.7 gm) in the alveolar socket with a sterilized tool
Please cite this article in press as: Çebi AT. Evaluation of the effects of intra-alveolar irrigation with clindamycin, rifampicin and sterile
saline in alveolar osteitis treatment. J Stomatol Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.jormas.2020.01.004
following the irrigation every 2 days. Use of mouthwash with
0.12% chlorhexidine content on three times per day. Further-
more, patients in Group C were given dexketoprofen trometamol
(arveles 25 mg, Ufsa Drug, Turkey) on two times per day as an
analgesic.
Following the intra-alveolar irrigations, a sterile gauze was
placed on the socket after alvogyl had been applied and the patient
was asked to hold the gauze on the area for 15 min These treatment
courses were applied every 2 days for a total of 10 days. No
antibiotics or analgesics were used systemically.
Pain levels were measured with a 10 mm visual analogue scale
based on the 30th min, 1st hour, 2nd hour, 4th hour, 12th hour and
on the 1st day, 2nd day, 3rd day, 5th day, 7th day and 10th day.
Clinical improvement was assessed by the researcher on the 1st,
3rd, 5th, 7th and 10th days by clinical examination regarding the
presence of erythema and redness around the alveolar socket area,
bare bone and presence of bare alveolar socket which did not have
any clot formation.
The statistical analyses were performed using the statistical
program ‘‘Minitab 17’’ (Minitab Inc., State College, PA, USA).
Statistical analysis of the collected data was conducted through by
Student t test and Anova test of proportionality. The results are
presented tables and graphs. P < 0.05 and P < 0.001 were consid-
ered significant in all statistical analyses.
3. Results
The study was conducted on 54 patients aged between 23 and
62 years, 38 (70.4%) female and 16 (29.6%) male. The mean age of
the patients was 40.54  3.85.
There was a statistically significant difference between the area
of the tooth extraction (mandible/maxilla) and the rate of alveolar
osteitis (P < 0.05). More alveolar osteitis cases were observed in
mandible than in maxilla. More alveolar osteitis cases were found
in molar areas of the mandible and the difference was found
statistically significant (P < 0.05) (Table 1).
There were differences between the groups’ terms of VAS levels
in the 4th hour, 12th hour and on the 1st day, 2nd day, 3rd day and
5th day (Table 2).
Group A VAS levels were found statistically significantly higher
than Group B in the 12th hour and on the 1st day, 2nd day, 3rd day
and 5th day (P < 0.05). Although there was no statistically
significant difference between Group A and Group B VAS levels
in the 30th min, 1st hour, 2nd hour, 4th hour and on the 7th day
and 10th day, Group B VAS levels were found lower (Table 2).
Group A VAS levels were found statistically significantly higher
than Group C in the 4th hour, 12th hour and on the 1st day, 2nd
day, 3rd day and 5th day (P < 0.05). Although there was no
statistically significant difference between Group A and Group C
VAS levels in the 30th min, 1st hour, 2nd hour and on the 7th day
and 10th day, Group C VAS levels were found lower (Table 2).
Group B VAS levels were found statistically significantly higher
than Group C in on the 1st day, 2nd day and 3rd day (P < 0.05).
Although there was no statistically significant difference between
Group B and Group C VAS levels in the 30th min, 1st hour, 2nd hour,
Table 1
Incidence of alveolar osteitis amongst tooth region.
n P-value
Mandibular molar 42 a
P < 0.05
Mandibular premolar 7 P > 0.05
Maxillary molar 5
Anova; bold characters: specifies statistical comparison results.
a
P < 0.05.
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A.T. Çebi / J Stomatol Oral Maxillofac Surg xxx (2020) xxx–xxx 3

Table 2 In the literature, a good number of studies have been conducted

Pain levels in the three treatment groups. on the correlation between the incidence of alveolar osteitis and
Group A Group B Group C P-value gender. In various studies, more alveolar osteitis cases have been
30th min 7.48  1.39 7.40  1.03 7.41  1.19 0.936
reported in females than in males [15,16]. In our study, a parallel
1st hour 7.37  1.27 7.24  1.34 7.09  0.99 0.59 result was obtained; more alveolar osteitis cases reported in
2nd hour 6.88  1.38 6.75  1.49 6.74  1.10 0.821 females than in males. There is a need for more extensive studies to
4th hour 6.86  1.05 6.42  1.23 6.20  1.49 0.019a explain the relationship between alveolar osteitis and gender.
12th hour 6.81  1.05 5.92  1.24 5.75  1.64 0.008a
Nusair and Abu Younis [13] reported that the incidence of alveolar
1st day 6.51  0.74 5.40  0.68 4.88  1.14 0.000b
2nd day 5.98  0.90 5.05  0.68 4.53  1.09 0.000b osteitis was higher in the 3rd and 4th decades of life. The mean age of
3rd day 5.51  0.81 4.52  0.83 4.01  1.02 0.000b the subjects with alveolar osteitis included in the study was
5th day 4.40  1.63 3.98  1.24 3.53  1.04 0.005a 40.54 and this result was parallel to the result of the present study.
7th day 1.71  0.69 1.52  1.06 1.21  0.43 0.137 In the literature, alveolar osteitis has been reported to occur
10th day 0.37  0.62 0.29  0.70 0.14  0.53 0.799
more frequently in mandible than in maxilla in most studies
Student t test. [17]. The alveolar osteitis cases were found statistically signifi-
a
P < 0.05.
b
cantly more in the mandible than in the maxilla.
P < 0.001.
Burgoyne et al. [18] reported that topical anesthetic gel use in
alveolar osteitis cases was more effective than the use of eugenol-
4th hour, 12th hour and on the 5th day, 7th day and 10th day, containing agents on pain. Kaya et al. [19] evaluated the efficacy of
Group C VAS levels were found lower (Table 2). alveogyl, SaliCept and low-dose laser therapy (LLLT) on pain in
In group A, all clinical symptoms such as halitosis, bare bone alveolar osteitis cases and found that all the three treatment
and erythema and redness around the alveolar socket disappeared protocols were more effective than the control group treatment
on the 10th day (Table 3). protocol which only curettage and irrigation therapy without any
In group B, all clinical symptoms such as halitosis, bare bone medication. In another study, Alexander [20] reported that
and erythema and redness around the alveolar socket disappeared alveogyl is very effective in the treatment of alveolar osteitis. In
on the 7th day (Table 3). the present study, eugenol (analgesic), iodoform (antimicrobial)
In group C, all clinical symptoms such as halitosis, bare bone and butamben (anesthetic)-containing alveogyl was used in the
and erythema and redness around the alveolar socket disappeared treatment of extraction sockets with alveolar osteitis.
on the 7th day (Table 3). Ogunlewe et al. [21] reported that pharmacologic treatment,
along with curettage and saline irrigation, was an effective
4. Discussion treatment for alveolar osteitis cases. In the present study,
3 different protocols were used as treatment. Irrigation was
Alveolar osteitis is among the complications that occur after applied with saline, clindamycin and rifampicin-containing anti-
tooth extraction. Although the etiology of alveolar osteitis is not biotics, in addition, topical pharmacology was applied with
fully known, there are various opinions regarding the treatment eugenol and iodoform-containing analgesic agent and chlorhexi-
[13,14]. The present study was designed and implemented on the dine-containing antiseptic mouthwash. The treatment protocol
treatment protocols of alveolar osteitis cases after tooth extraction. involving intra-alveolar irrigation applied with clindamycin was
In the treatment of alveolar osteitis, the primary aim is to reduce found to be more effective on pain and alveolar mucosa healing
pain level and improve the comfort of the patient until the healing is compared to other treatment protocols.
fully ensured. This is usually achieved through the use of agents Caso et al. [22], Hedström and Sjögren [23] reported that the use
such as topical and local analgesics, antibiotics and antiseptic of chlorhexidine before or after tooth extraction was effective on
mouthwash [12]. In this our study, local antibiotic irrigation, use of pain and alveolar mucosa healing. In the present study, chlorhexi-
local analgesic agent and chlorhexidine-containing antiseptic dine-containing mouthwash was used in all treatment groups for
mouthwashes were used for alveolar osteitis treatment. oral disinfection.

Table 3
Symptoms of alveolar mucosa healing.

The passing time following the starting Number of patients with erythema Number of patients with bare alveolar Number of patients
treatment of alveolar osteitis and redness around alveolar socket socket without clot formation with halitosis

n n n
(Patients) (Patients) (Patients)

1st day 18 18 18 Group A

3rd day 18 18 18
5th day 18 18 18
7th day 9 9 0
10th day 0 0 0

1st day 18 18 18 Group B

3rd day 18 18 18
5th day 7 7 0
7th day 0 0 0
10th day 0 0 0

1st day 18 18 18 Group C

3rd day 18 18 18
5th day 10 0 0
7th day 0 0 0
10th day 0 0 0

On the 7th day, in Group A, the 9 patients with erythema and redness around the alveolar socket and bare alveolar socket without clot formation were the same patients. On
the 5th day, in Group B, the 7 patients with erythema and redness around the alveolar socket and bare alveolar socket without clot formation were the same patients.

Please cite this article in press as: Çebi AT. Evaluation of the effects of intra-alveolar irrigation with clindamycin, rifampicin and sterile
saline in alveolar osteitis treatment. J Stomatol Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.jormas.2020.01.004
G Model
JORMAS-795; No. of Pages 4
4 A.T. Çebi / J Stomatol Oral Maxillofac Surg xxx (2020) xxx–xxx
Kaya et al. [19] reported that irrigation with sterile saline
following alveolar curettage, which is repeated every 3 days,
removes debris from the socket, reduces pain level and is effective
in alveolar mucosa healing. In the present study, intra-alveolar
irrigation was applied with sterile saline, clindamycin and
rifampicin-containing antibiotics every 2 days for 10 days; and
it was found that clindamycin irrigation group had lower pain
levels; and alveolar mucosa healing was more effective. On the
other hand, the pain levels of the rifampicin irrigation group were
found to be lower than the sterile saline group and the alveolar
mucosa healing was found to be more effective.
In the literature, clindamycin and rifampicin have been
reported to be among the most preferred antibiotics for the
treatment of osteomyelitis and bone infections [24]. Clindamycin
has been reported to have very good bone invasion and
biodegradability; and that it can be used either alone or in
combination for long periods in appropriate organisms. Rifampi-
cin, on the other hand, has been reported to enter the macrophage,
destroy microorganisms in the cell, and pass into the biofilm layer.
Clindamycin and rifampicin are effective antibiotics against both
gram-positive and gram-negative bacteria [24]. Stengel et al. [25]
reported that long-term rifampin-ciprofloxacin combination was
effective in staphylococcal infections according to 22 trials
comparing beta-lactam, quinolone, glycopeptide and rifampin
treatments. In the present study, irrigation was applied on infected
bone surface with clindamycin and rifampicin vial; and it was
found that clindamycin was more effective on pain and alveolar
mucosa healing compared to rifampicin.
Chapnick and Diamond [26] reported that locally applied
clindamycin is effective in the treatment of alveolar osteitis.
Clindamycin topically applied in the form of intra-alveolar
irrigation was found to be more effective in treating alveolar
osteitis than rifampicin and sterile saline, in our study.
Many antibacterial agents are applied topically for the
prevention and treatment of infections. Clindamycin and rifampi-
cin are topical antimicrobials that can be used topically and have
proven topical efficacy in previous studies. Since the bactericidal
effect levels and duration of antimicrobial agents used are
different, their activity levels may vary [27,28]. In the present
study, clindamycin and rifampicin were used topically for the
treatment of dry socket. Clindamycin was found to be more
effective than rifampicin at the 4th hour, 12th hour and 1st, 2nd,
3rd, 5th day in the treatment of sequelae. The reason for the lack of
efficacy between the two drug administrations in the 30th min, 1st
and 2nd hours was due to the different processes of action of
antimicrobials and the natural active process of inflammation. We
think that the reason for the absence of activity differences on the
7th and 10th days is the natural healing process of alveolar osteitis.
In conclusion, it was found that intra-alveolar irrigation with
antibiotics was effective in pain and alveolar mucosa healing in the
treatment of alveolar osteitis. We believe that topical antibiotics
can be used as an alternative method in cases where systemic
antibiotics are indicated in the treatment of alveolar osteitis.
However, better levels of evidence (larger number of individuals, in
single or double blind, etc.) and more comprehensive studies are
necessary to affirm the superiority and the real interest of used of
topical antibiotics for treatment of alveolar osteitis (dry socket).
Disclosure of interest
The author declares that he has no competing interest.
Please cite this article in press as: Çebi AT. Evaluation of the effects of intra-alveolar irrigation with clindamycin, rifampicin and sterile
saline in alveolar osteitis treatment. J Stomatol Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.jormas.2020.01.004
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