LETTERS TO THE EDITOR
surgical repair indicated that all patients returned to either
normal or near normal sensory function. When adequate
follow-up has been completed on the remaining 26 patients
in the study, the results compared with a control group will
be submitted for publication. Recently, we reported on the
results of microsurgical repair of 222 lingual nerves for
various causes (success rate, 90.5%)2 and on the success
rate of repair of 42 lingual, inferior alveolar, and long buccal
nerves (85.2%) injured during performance of the mandib-
ular sagittal split osteotomy.3 These results compared with
the preliminary results of the use of a biodegradable nerve
sleeve indicate there may be a favorable effect, in our hands,
on healing of a repaired nerve (prevention of axonal leakage
or ingrowth of scar tissue, localization of nerve growth
factors, creation of a conduit to guide axonal sprouts in the
case of a residual “nerve gap,” and so on).
Finally, we urge that all studies reporting on sensory
function after microsurgical repair of peripheral trigeminal
nerves adopt the Medical Research Council scale4,5 for
assessing sensation in a strictly objective manner with rig-
idly defined endpoints. This will make it possible for clini-
cians in our specialty to communicate with each other as
well as with those in other specialties (hand surgeons,
orthopaedists, physiatrists, neurosurgeons, and so on) who
use neurosensory assessment in their clinical work and
research. Although Pogrel6 has defined criteria for postop-
erative assessment of repaired inferior alveolar and lingual
nerves, his criteria have not been accepted or widely ap-
plied in our specialty. Other specialties have adopted the
concept of “useful sensory function” originated by the Med-
ical Research Council scale.
ROGER A. MEYER, DDS, MD
Smyrna, GA
SHAHROKH C. BAGHERI, DMD, MD
Marietta, GA
References
1. Farole A, Jamal BT: A bioabsorbable collagen nerve cuff
(NeuraGen) for repair of lingual and inferior alveolar nerve
injuries: A case series. J Oral Maxillofac Surg 66:2058, 2008
2. Bagheri SC, Meyer RA, Khan HA: A retrospective review of
microsurgical repair of 222 lingual nerve injuries. J Oral Maxil-
lofac Surg 66:32, 2008 (suppl 1)
3. Bagheri SC, Meyer RA, Shahriari A: Microsurgical repair of the
peripheral trigeminal nerve after mandibular sagittal split osteot-
omy. J Oral Maxillofac Surg 66:34, 2008 (suppl 1)
4. Birch R, Bonney G, Wynn Parry CB. Surgical Disorders of the
Peripheral Nerves. Philadelphia, PA, Churchill Livingstone,
1998, pp 235-236
5. Meyer RA, Rath EM: Sensory rehabilitation after trigeminal nerve
injury or nerve repair. Oral Maxillofac Clin N Am 13:365, 2008
6. Pogrel MA: The results of microneurosurgery of the inferior
alveolar and lingual nerve. J Oral Maxillofac Surg 60:485, 2002
doi:10.1016/j.joms.2008.11.002
METHOHEXITAL AND PROPOFOL IN AMBULATORY
PROCEDURES
To the Editor:—The article entitled “Comparison of Metho-
hexital and Propofol Use in Ambulatory Procedures in Oral
and Maxillary Surgery” (J Oral Maxillofac Surg 66:1996,
2008) deserves commendation and comment. Collection of
such extensive data over a 7-year period is remarkable and
2551
helpful to the clinician. It is also easy to question some of
the reported findings and conclusions because of the mas-
sive amount of material accumulated. The opportunity for
bias to intrude is almost inevitable.
The use of oxygen with or without nitrous oxide is not
mentioned (?). The role of narcotics strikes me as the most
likely cause for the “significant adverse events” noted dur-
ing and after recovery from surgery.
It is an unpleasant morbidity with a potential for aspira-
tion of vomitus.
Generally the use of narcotics/opioids is intended for
pain control; however, effective local anesthesia in oral
surgery is reliably achieved by regional and infiltrative in-
jection, and also provides immediate and prolonged post-
operative pain relief. Why do we use fentanyl or other
similar drugs?
Narcotics also affect the baroreceptors, lowering blood
pressure while centrally depressing respiration. This report
also notes a significant incidence of “respiratory arrest/
hypoventilation,” “prolonged emergence,” and “syncope”—
all attributable to the narcotic.
Narcotics are wonderful agents when necessary, but they
are not titrateable short of causing respiratory depression.
When used in office practice they are given by an educated
estimate of dose.
This article gives us a gratifying record of successful
ambulatory surgery—which has long been a hallmark of the
oral and maxillofacial surgeon.
NORMAN TRIEGER, DMD, MD
New York, NY
doi:10.1016/j.joms.2008.11.008
ABUSE OF ANTIBIOTIC PROPHYLAXIS IN THIRD
MOLAR SURGERIES
To the Editor:—I read with interest the article by Limeres et
al,1 “Patients’ perception of recovery after third molar sur-
gery following postoperative treatment with moxifloxacin
versus amoxicillin and clavulanic acid: A randomized, dou-
ble-blind, controlled study,” describing the effect of antibi-
otic prophylaxis on patients’ quality of life after third molar
surgeries. Although the authors arrived at some valuable
conclusions, the study also has some major shortcomings.
The study was not placebo controlled, and the simple
randomization procedure used in their clinical trial did not
justify using the terms “randomized” and “controlled” to
describe the study design. Furthermore, the treatment allo-
cation of the patients was not concealed.
But, what struck me most was that the authors of the trial
violated an elementary rule of antibiotic prophylaxis—the
correct timing of antibiotic administration. One cannot con-
sider the administration of an antibiotic as a prophylactic
when the antibiotic is not present in the tissue during
surgery. Administration of antibiotic medication after com-
pletion of the procedure is only permissible when there is
definitive evidence of postoperative infection. Yet, the au-
thors decided to administer either the test medication
(moxifloxacin [MX]) or the control medication (amoxicil-
lin/clavulanate [AXC]) after the surgery, and the administra-
tion timing was unspecified. As Lieblich2 rightfully claimed,
for an antibiotic to have true prophylactic effects, the blood
levels of the antibiotic must be at least 3 to 4 times the minimal
inhibitory concentration before the bacterial insult. I wonder
why the authors did not consider this critical issue.
2552
Nevertheless, supposing that the timing of the “prophy-
laxis” administration does not influence the primary goal of
the study (to assess the effect of antibiotic administration on
patients’ quality of life), the important question is whether
the pharmacological interventions with antibiotics could
have had a negative effect on the patients’ quality of life. In
the introduction, the authors do mention the issues of
toxicity, allergies, secondary infections, and the develop-
ment of resistance. However, in the subsequent paragraphs,
it seems that the authors did not expect the side effects of
antibiotics to have an impact on the patients’ quality of life.
Instead, they expected patients’ quality of life to improve
because the medications prevented them from acquiring
potentially dangerous infections. The patients who took MX
returned to work earlier than those who took AXC. Patients
who were given an antibiotic (regardless of which one) had
minimal difficulties with mastication after the sixth postop-
erative day. Patients who took AXC had no headaches after
the surgery (which might be a common postoperative ad-
verse event). The authors concluded that MX shortened the
period of postoperative recovery.
However, the discussion section did raise the possibility
of adverse reactions to amoxicillin, such as mild hepatotox-
icity. One should note, however, that the antibiotic used in
the study by Limeres et al1 was not amoxicillin alone, but
AXC. Serious liver injuries are ninefold more frequent with
AXC than with amoxicillin.3 A Spanish study that thor-
oughly analyzed 440 cases of drug-induced liver injuries
during a 20-year period revealed that the most common
medication for this adverse effect was AXC.4 Likewise, it has
recently been revealed that MX might be responsible for
adverse hepatotoxicity.5 Moreover, both medications are
among the most commonly used drugs that induce Clostrid-
ium difficile infection of the gastrointestinal tract and might
lead to pseudomembranous colitis.6,7 In the study by
Limeres et al,1 considering only the analyzed patient
groups, more than 20% of patients developed diarrhea, and
almost 44% had undesired side effects from the antibiotics.
Limeres et al1 seem to ignore the growing body of evi-
dence that suggests that the surgical extraction of the third
lower molar without active pericoronaritis in generally
healthy individuals does not require any antibiotic prophy-
laxis.8,9 It was in 1985 that MacGregor10 emphasized that
antimicrobial agents appear to have a marginal benefit in
third molar surgery when clinically uninfected teeth are
removed. Almost one quarter of a century has passed and
nothing appears to have changed.11 I believe the time has
come to make it clear that prophylactic administration of
antibiotics for third molar surgeries in generally healthy
individuals is scientifically unjustified. The studies cited in
the report by Limeres et al1 showing antibiotic prophylaxis
in third molar surgeries as effective also had methodological
shortcomings: Poeschl et al12 also administered antibiotic
“prophylaxis” after completion of surgery, and their study
was not blinded and placebo controlled. Lacasa et al13 did
not have a single independent observer who assessed the
infection rate and did not clearly describe the postoperative
wound management, as remarked by Lindeboom.14
It is important that we now realize that antibacterial
drugs should be reserved for the management of active
infectious disease or considered for the prevention of he-
matogenously spread infection, such as endocarditis in
high-risk patients.15 The reason for the alarmingly rapid
growth in the resistance of microflora (including those in
the oral cavity) is the misuse and overuse of antibiotics. In
2002, Sobottka et al16 proved that 100% of strains isolated
from 41 odontogenic abscesses were susceptible to AXC,
LETTERS TO THE EDITOR
but, in 2008, Warnke et al17 found that only 71% of strains
obtained from 94 odontogenic abscesses were sensitive to
AXC (interestingly, the in vitro efficacy of AXC against all
the isolates per patient was only 30%).
About 10% of all administered antibacterial drugs are
prescribed by dentists. It is in our hands to significantly
reduce the misuse of antibiotics. We should not treat anti-
biotics as a remedy for patients’ worries after the third
molar surgery.
TOMASZ KACZMARZYK, PHD, DDS
Krakow, Poland
References
1. Limeres J, Sanromán JF, Tomás I, et al: Patients’ perception of
recovery after third molar surgery following postoperative
treatment with moxifloxacin versus amoxicillin and clavulanic
acid: A randomized, double-blind, controlled study. J Oral Max-
illofac Surg 67:286, 2009
2. Lieblich SE: Discussion: Postoperative prophylactic antibiotic
treatment in third molar surgery—A necessity? J Oral Maxillo-
fac Surg 62:9, 2004
3. Salvo F, Polimeni G, Moretti U, et al: Adverse drug reactions
related to amoxicillin alone and in association with clavulanic
acid: Data from spontaneous reporting in Italy. J Antimicrob
Chemother 60:121, 2007
4. Andrade RJ, Lucena MI, Fernández MC, et al: Drug-induced
liver injury: An analysis of 461 incidences submitted to the
Spanish registry over a 10-year period. Gastroenterology 129:
512, 2005
5. Moxifloxacin: Hepatotoxicity and serious skin reactions—Pre-
scribing update. Drug Safety Update 1:10, 2007
6. National Clostridium Difficile Standards Group: Report to the
Department of Health. J Hosp Infect 56:1, 2004
7. Desphande A, Pant C, Jain A, et al: Do fluroquinolones predis-
pose patients to Clostridium difficile associated disease? A
review of evidence. Curr Med Res Opin 24:329, 2008
8. Kaczmarzyk T, Wichlinski J, Stypulkowska J, et al: Single-dose
and multi-dose clindamycin therapy fails to demonstrate effi-
cacy in preventing infectious and inflammatory complications
in third molar surgery. Int J Oral Maxillofac Surg 36:417, 2007
9. Ataoǧlu H, Öz GY, Çandirli C, et al: Routine antibiotic prophy-
laxis is not necessary during operations to remove third molars.
Br J Oral Maxillofac Surg 46:133, 2008
10. MacGregor AJ: The Impacted Lower Wisdom Tooth. Oxford,
Oxford University Press, 1985, p 150
11. Hill M: No benefit from prophylactic antibiotics in third molar
surgery. Evid Based Dent 6:10, 2005
12. Poeschl PW, Eckel D, Poeschl E: Postoperative prophylactic
antibiotic treatment in third molar surgery—A necessity? J Oral
Maxillofac Surg 62:3, 2004
13. Lacasa JM, Jiménez JA, Ferrás V, et al: Prophylaxis versus
pre-emptive treatment for infective and inflammatory compli-
cations of surgical third molar removal: A randomized, double-
blind, placebo-controlled clinical trial with sustained release
amoxicillin/clavulanic acid (1000/62.5mg). Int J Oral Maxillo-
fac Surg 36:321, 2007
14. Lindeboom JAH: The controversy continues! Int J Oral Maxil-
lofac Surg 37:199, 2008
15. ADA, Council on Scientific Affairs: Combating antibiotic resis-
tance. J Am Dent Assoc 135:484, 2004
16. Sobottka I, Cachovan G, Stürenburg E, et al: In vitro activity of
moxifloxacin against bacteria isolated from odontogenic ab-
scesses. Antimicrob Agents Chemother 46:4019, 2002
17. Warnke PH, Becker ST, Springer ING, et al: Penicillin com-
pared with other advanced broad spectrum antibiotics regard-
ing antibacterial activity against oral pathogens isolated from
odontogenic abscesses. J Craniomaxillofac Surg 36:462, 2008
doi:10.1016/j.joms.2009.06.020