J Oral Maxillofac Surg

62:587-591, 2004

Tetracycline Compound Placement to

Prevent Dry Socket: A Postoperative
Study of 200 Impacted Mandibular
Third Molars
J.M. Sanchis, MD, PhD,* U. Sa
ez, DDS, PhD,
M. Pen
arrocha, MD, PhD, and C. Gay, MD, PhD
Purpose:

Our objective was to study whether the placement of intra-alveolar tetracycline prevents dry
sockets or improves the postoperative period.
Patients and Methods: A comparative clinical study of the surgical removal of 200 impacted mandibular third molars is made, with particular reference to postextraction pain, inflammation, trismus, and
the incidence of dry socket. In 50% of these cases, a pharmacologic preparation that includes tetracycline
was placed in the socket after removal of the impacted molar.
Results: Dry socket was diagnosed in 4 cases (2%), with no relation to intra-alveolar tetracycline
placement being observed. The patients who were administered intra-alveolar tetracycline had less pain
and trismus and consumed fewer analgesics than the patients who received no such treatment, although
statistical significance was not reached.
Conclusions: The intra-alveolar placement of tetracycline compound after the surgical removal of
impacted mandibular third molars did not affect the incidence of dry socket.
2004 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 62:587-591, 2004
socket, with or without halitosis.1 The pain is not
relieved with mild analgesics.2,3 The incidence of dry
socket is 1% to 3% after extractions,4 whereas recent
research places the figure at between 20%4 and 30%5
after third molar surgery. With the use of chlorhexidine rinses,6-9 intra-alveolar antiseptics,10 metronidazole11 or fibrinolytic agents,12,13 tetracyclines,14-17
clindamycin,18 or other intra-alveolar pharmacologic
preparations,5 this incidence has been reduced to 2%
to 8%, according to a study by Bloomer in 2000.5
In the present study, we investigate whether the
placement of a pharmacologic preparation that includes tetracycline in the postextraction sockets of
impacted mandibular third molars modifies the incidence of dry socket and/or is able to influence the
postoperative course (pain, inflammation, and trismus).

Dry socket, or alveolitis sicca, is one of the most

frequent complications of impacted mandibular third
molar surgery, and it manifests as an intense pain in
the extraction zone commencing on the third to fifth
postoperative day. Dry socket is a postoperative pain
that occurs in and around the extraction site and
increases in severity at any time between 1 and 3 days
after the extraction accompanied by a partially or
totally disintegrated blood clot within the alveolar
*Associate Professor of Oral Surgery, Valencia University, Medical and Dental School, Valencia, Spain.
Dentist and Master of Oral Surgery and Implantology, Valencia
University, Medical and Dental School, Valencia, Spain.
Assistant Professor of Oral Surgery, Director, Master of Oral
Surgery and Implantology, Valencia University Medical and Dental
School, Valencia, Spain.
Professor and Chairman of Oral and Maxillofacial Surgery, Director, Master of Oral Surgery and Implantology, Barcelona University Medical and Dental School, Barcelona, Spain.
Address correspondence and reprint requests to Dr Pen
arrocha:
Clnicas Odontolo
gicas, Gasco
Oliag 1, 46021 Valencia, Spain; email: Miguel.Penarrocha@uv.es

Patients and Methods

A total of 200 patients with impacted mandibular
third molars were studied. Our objective is to study
whether the placement of intra-alveolar tetracycline
prevents dry sockets or improves the postoperative
period. We divided the cases into a group of 100
patients who underwent extraction of 1 third man-

2004 American Association of Oral and Maxillofacial Surgeons

0278-2391/04/6205-0073$30.00/0
doi:10.1016/j.joms.2003.08.035

587

588
dibular molar, in which a pharmacologic preparation
was placed in the postextraction socket consisting of
9 mg of tetracycline hydrochloride (antibiotic), 12 mg
of tetracaine hydrochloride (analgesic), 6 mg of antipyrine (analgesic, antipyretic), 20 units of fungal protease (proteolytic enzymes), and 200 mg of excipient
(Conalgil; Lab. SPAD, Dijon Cedex, France); and a
control group of 100 patients who underwent extraction of one third mandibular molar, in which no
compounds were placed in the sockets. No patients
served as both control and experimental subject in
this study. Patients with acute infection were excluded, as were those with pericoronitis or tetracycline allergy, and subjects receiving antibiotic therapy.
All extractions were performed in the same outpatient operating room, using the same material and
surgical instruments, and involving a team of surgeons
with similar experience (third-year students of the
Master of Oral Surgery and Implantology). In all cases,
the inferior alveolar, lingual, and buccal nerves were
anesthetized with 2 anesthetic cartridges containing
2% lidocaine with 1:100,000 epinephrine. A doubletrajectory incision was made, involving a first incision
distal from the posterior portion of the retromolar
trigone to the second molar, and a second anterior
and oblique incision was made in the mesial zone of
the second molar. After extraction of the molar, the
socket was examined, cleaned, and sutured with 00
silk sutures.
Data recorded included patient age and gender,
oral hygiene, tobacco smoking, and the use of oral
contraceptives. Hygiene was scored with the Simplified Oral Hygiene Index (OHI-S) as follows: good, 0 to
1.2; regular, 1.3 to 3; and poor, 3.1 to 6. Smoking was
in turn coded as 1) nonsmoker, 2) up to 10 cigarettes
per day, 3) 11 to 20 cigarettes per day, and 4) more
than 20 cigarettes per day. Oral contraceptive use was
evaluated as either 1) yes or 2) no. Surgical difficulty
was rated (in millimeters) by measurement of the
Winter line, corresponding to the perpendicular
traced from the line joining the bony septum distal to
the molar and the septum between the first and second molar, to the hypothetical point of application
corresponding to the cementoenamel junction of the
third molar17 (Fig 1).
Pain was rated individually by each patient at 2, 6,
and 12 hours after extraction and then everyday for
the first 6 postoperative days, based on a visual analog
scale from 0 to 10. Inflammation was always in turn
evaluated by the same observer (U.S.), using a subjective 4-point scale of no inflammation, mild inflammation (small degree of intraoral inflammation), moderate inflammation (significant intraoral inflammation),
and severe inflammation (significant intraoral inflammation with an extraoral component). Before surgery,

TETRACYCLINE COMPOUND TO PREVENT DRY SOCKET

FIGURE 1. Measure of Winter length, A, Distance between distal

bone of the third mandibular molar and intraseptal osseous between
first and second molars. B, Winter length.

the active maximum interincisal oral aperture (in millimeters) was measured using a millimeter ruler from
the upper incisal margin to the incisal margin of the
lower incisors. Dry socket was determined by increased severity of pain and loss of the blood clot in
the days following extraction.
All patients received amoxicillin (500 mg/8 hours
for 4 days). Forty-eight hours and 7 days after surgery,
evaluations were made of oral aperture, the number
of analgesic tablets (metamizole) used by each patient, and the possible complications, such as neurologic damage. The sensitivity of the mental nerve
region was evaluated in a subjective way by the patient and by the same observer on clinical examination.
STATISTICAL ANALYSIS

A descriptive study was made of each of the variables, and the associations between different parameters were investigated using the 2 test for qualitative variables and the Student t test for quantitative
parameters, with verification of variance homogeneity in each case. In addition, calculations were made
of the percentage variance associated with group assignment in those cases where the results proved to
be significant. Analysis of variance was performed for
the comparison of more than 2 variables.

Results
We recorded the pain and inflammation in the first
7 days of the postoperative period. The greatest pain
appeared after 6 hours, and maximum inflammation,
1 day after third molar extraction, respectively. The
mean decrease in oral aperture after 48 hours was
18.5 mm versus 9.9 mm after 7 days. The average
analgesic consumption after 48 hours and 7 days was
2.5 and 3.9 tablets of metamizole, respectively. The 2
groups were homogeneous, as a result of which the
distributions of mean patient age, male/female proportion, smoking, oral hygiene, and surgical difficulty

589

SANCHIS ET AL

Table 1. DESCRIPTIVE STATISTICS SHOWING

INTERGROUP HOMOGENEITY

No
Tetracycline Tetracycline
Mean age (yr)
Gender (n)
Male
Female
Tobacco use (n)
Nonsmoker
10 Cigarettes/d
10 to 20 Cigarettes/d
20 Cigarettes/d
Hygiene (n)
Good
Regular
Poor
Surgical difficulty
(mean Winter
distance)

25.84

25.33

26
74

38
62

64
19
16
1

66
19
11
4

72
27
1

60
33
6

Table 3. ANALGESIC CONSUMPTION

P
.69*
.09
.43

.07

8.32

8.55

No Tetracycline

Tetracycline

P*

48 Hours
Day 7

2.71
4.42

2.38
3.56

.206
.164

*Student t test.

or oral hygiene was observed. Of these 4 women,

only 1 used oral contraceptives; that is, the incidence
of dry socket among the women taking oral contraceptives (14 subjects) was 7.1% (1 woman) versus
2.3% among those not using such drugs (3 of 122
patients). Dry socket was related to surgical difficulty;
the mean Winter distance among the 4 affected
women was 10.25 mm versus 8.39 mm in the 196
patients without dry socket.

.64

Discussion

*Student t test.
2 Test.

were similar in both the tetracycline and control

groups (Table 1).
The incidence of dry socket was 3% among the
patients administered tetracycline (3 cases) and 1%
among those who received no such treatment. The
comparative analysis showed the former to have comparatively less pain (Table 2), with a lesser consumption of analgesic (Table 3), although the differences
between groups were not significant. The patients
treated with topical tetracycline also showed less trismus than the controls (although not significant) (Table 4). The placement of tetracycline did not influence the course of inflammation. In no case was
neurologic damage in the mental nerve region found.
There were 4 cases of dry socket (2%) in patients
aged an average of 38.2 years, significantly older than
the remainder of the series (25.4 years); all 4 patients
were women. No relation to either tobacco smoking

Table 2. COURSE OF PAIN IN THE FIRST

POSTOPERATIVE WEEK

Time

No Tetracycline

Tetracycline

P*

6 Hours
12 Hours
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7

4.18
3.85
3.35
2.94
2.29
1.69
1.21
0.9
0.5

3.96
3.76
3.22
2.7
2.05
1.46
1.14
0.8
0.1

.513
.794
.711
.424
.229
.216
.778
.620
.363

*Student t test.

Time

The results of the present study show a trend that

tetracycline compound placement after the surgical
extraction of impacted mandibular third molars
yielded less pain and inflammation than in the controls who received no such treatment, although the
differences were not statistically significant. In a study
of human immunodeficiency virus infectionpositive
patients, Pankhurst et al19 found that the injection of
a chlortetracycline solution into the sockets after extraction led to a reduction in pain and improved
healing. According to Verbic20 and Olech,21 antibiotic
use (penicillin and tetracycline) in postextraction
sockets may reduce swelling and trismus, although
this postulate has not been confirmed in recent years.
According to Vezeau,22 the most useful medications
to prevent socket healing derangements include
broad-spectrum antibiotics, specifically clindamycin
and tetracycline, but possibly germane to the subject
of clot stabilization and healing, is consideration of
resorbable substances such as gelatin sponge, polylactic acid, and methylcellulose as clot-stabilizing socket
implants. We observed no direct relation between
tetracycline placement in the postextraction sockets
and inflammation, and recorded only a slightly greater
incidence of trismus in the control group.
The incidence of dry socket was 2% in the present
study. This figure coincides with the best results of

Table 4. DECREASE IN ORAL APERTURE

Time

No Tetracycline

Tetracycline

P*

48 Hours
Day 7

19.74
10.79

17.36
9.15

.062
.161

*Student t test.

590

TETRACYCLINE COMPOUND TO PREVENT DRY SOCKET

some of the studies in the literature, with values of 2%

to 8%.4,5 All of our cases corresponded to women,
although it should be taken into account that females
clearly predominated in the global series (68%). According to Castellani et al,23 the incidence of dry
socket after mandibular third molar surgery is greater
among women taking oral contraceptives, particularly
when surgery is performed between days 1 and 22 of
the menstrual cycle, because a relationship exists
between estrogen levels and dry socket. In our series,
the incidence was higher among the women taking
oral contraceptives (7.1%) than in those who did not
use such drugs (2.4%)the degree of surgical difficulty and mean patient age being similar in both
groupsthough it should be taken into account that
the limited number of cases of dry socket recorded
(4) precludes the drawing of firm conclusions.
In accord with the literature,24,25 the patients with
dry socket were significantly older than the subjects
in whom this complication did not develop. Likewise,
dry socket was more common in situations of increased surgical difficulty. Bloomer5 reported a
greater incidence of dry socket in relation to increased depths of the extracted molar. In this context, it is well established that that the risk of dry
socket increases with the degree of surgical trauma
involved.26,27
Different authors14-17 have associated tetracycline
placement in postextraction sockets with a reduction
in the incidence of alveolitis sicca. However, in our
series, such topical treatment did not influence the
appearance of dry socket, possibly because only 4
cases were recorded in the global series. On the other
hand, the placement of an antiseptic pharmacologic
preparation (basically comprising eugenol and Peru
balsam) in postextraction sockets has recently been
reported to reduce the incidence of dry socket from
26% to 8%.5 Because of these controversial results
concerning the placement of intra-alveolar drugs,
their use does not seem to be indicated at the present
time.28 On the other hand, our patients had no problems associated with the use of intra-alveolar tetracycline, although cases of local sensitization,29,30 foreign
body reactions,31,32 delayed healing,33 and neurosensory alterations34,35 have been described after the
placement of different intra-alveolar preparations, particularly tetracycline; however, according to our results, we believe that intra-alveolar tetracycline placement is not indicated to prevent dry socket, nor the
pain and inflammation of the postoperative course.

2. Adeyemo WL: Critical review on dry socket. Int J Oral Maxillofac Surg 32:111, 2003
3. Cohen ME, Simecek JW: Effects of gender-related factors on the
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4. Larsen PE: Alveolar osteitis after surgical removal of impacted
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6. Field EA, Nind D, Varga E, et al: The effect of chlorhexidine
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7. Bonnie FL: Effect of chlorhexidine rinse on the incidence of dry
socket in impacted mandibular third molar extraction sites.
Oral Surg Oral Med Oral Pathol 79:154, 1995
8. Larsen PE: The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of
impacted mandibular third molars. J Oral Maxillofac Surg 49:
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9. Rango JR, Szkutnik AJ: Evaluation of 0.12% chlorhexidine rinse
on the prevention of alveolar osteitis. Oral Surg Oral Med Oral
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15. Davis WM Jr, Buchs AU, Davis WM: The use of granular gelatintetracycline compound after third molar removal. J Oral Surg
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