The Incidence of Clinical Infection After PeriodontalSurgery

A Retrospective Study*Philip D. Packt and Jerome Habért

Accepted for publication 12 December 1982

A large-scale retrospective study was undertaken to determine the incidence of clinicalinfection after periodontal surgery and the effectiveness of prophylactic antibiotic therapyin preventing postoperative infection. All second-year postgraduate students reviewed theirpatient records and completed a questionnaire. Eight infections were found in 884 operationsperformed without antibiotics, while one infection was found in 43 operations performedwith antibiotics. Of 268 operations involving osseous surgery, six infections were noted whiletwo infections were observed following 336 operations involving flap surgery withoutosteoplasty or ostectomy. The data indicated that the incidence of infection after periodontalsurgery is very low in patients treated with or without antibiotics. It was concluded thatunless there is a medical indication, there is no justification for using prophylactic antibiotictherapy to prevent infection following periodontal surgery.

Infection is a potential complication following per-iodontal surgery and is characterized by delayed onset,pain, swelling, suppuration and delayed wound healing.While several authors' 2 have suggested that the inci-dence of postoperative infection is low, no large-scalestudies have determined the actual rate of infection.These data are important since it is often assumed thatthe risk of postoperative infection, especially after os-seous surgery, is high enough to warrant prophylacticantibiotic therapy. Although prophylactic antibiotictherapy has been shown to be ineffective in preventinginfection following oral3"5 and general surgical proce-dures,6 7 only one report has assessed its effectivenessin preventing infection after periodontal surgery.8 Inthat study, 19 patients were followed and no differenceswere found in the incidence of postoperative infectionbetween the antibiotic-treated and placebo groups.

In view of these observations, a large-scale retrospec-tive study was undertaken to determine the incidenceof infection after periodontal surgery and the effective-ness of prophylactic antibiotic therapy in preventingpostoperative infection.

MATERIALS AND METHODS

The study population comprised all patients treatedsurgically for periodontal disease during the previous 2years by 2nd year postgraduate students at Tufts Uni-versity School of Dental Medicine. The sample of 218patients included 89 males and 129 females of all agegroups (Table 1). A total of 927 surgical procedureswere carried out. Techniques employed included gin-givectomy, flap surgery, osseous surgery, osseous grafts,free gingival grafts, lateral sliding flaps, frenectomy androot amputations. The surgery was performed in a

typical dental school clinic without special filtration toreduce airborne bacterial counts. All operations werecarried out with local anesthesia and usually involvedone sextant or quadrant. In most instances the surgicalsites were sutured and a dressing (Coe Pak) was placedfor 1 week postoperatively. The operations were per-formed by a postgraduate student under the directsupervision of a clinical instructor. Prophylactic anti-biotic therapy was instituted for patients with a historyof rheumatic fever or diabetes. For those with a historyof rheumatic fever, guidelines established by the AHA9were followed. For other patients, penicillin or eryth-romycin was usually prescribed according to the follow-ing regimen: 250 mg orally 4 times daily for 7 daysstarting on the day of surgery.

A questionnaire was designed to gather the followinginformation: the number and types of surgical proce-

* Department of Periodontology, Tufts University School of Den-tal Medicine Boston, MA 02111.

t Formerly a postgraduate student in the Department of Periodon-tology, Tufts University School of Dental Medicine, Boston, MA02111.

Assistant Research Professor, Department of Periodontology,Tufts University School of Dental Medicine. Boston, MA 02111.

441

442 Pack, HaberJ. Periodontol.

July. 1983

Table 1Sex and Age Distribution of the Patient Population

Sex Number ofpatients Age (years) Number of

patientsMalesFemales

89129

0-2021-4041-60

>61

2I 177524

dures, the surgical sites, whether prophylactic antibiotictherapy was used and the number of postoperativeinfections observed. Postoperative infection was de-fined as increased and progressive pain and swellingoccurring 48 to 72 hours postoperatively. All 2nd yearpostgraduate students reviewed their patient recordsand completed the questionnaire. The results were tab-ulated and analyzed with the Fisher Exact ProbabilityTest.

RESULTSThe incidence of postoperative infection for all pro-

cedures was 1% or 9 of 927 (Table 2). There was nodifference in the incidence of postoperative infectionbetween patients treated with and without prophylacticantibiotic therapy. Among 43 surgical procedures per-formed with prophylactic antibiotic therapy, one post-operative infection was observed (2%). Similarly,among the 884 surgical procedures done without pro-phylactic antibiotic therapy, eight postoperative infec-tions were noted (<1%). The incidence of infectionfollowing flap procedures with and without osteoplastyor ostectomy is compared in Table 3. Of268 proceduresinvolving osseous surgery, six infections were noted,while there were two infections after 336 flap proce-dures without osteoplasty or ostectomy. Further com-

parison of the rate of infection following procedures inthe maxilla vs the mandible revealed no difference.Statistical analysis using the Fisher Exact ProbabilityTest showed no differences between any of the treat-ment groups in Tables 2 and 3. All postoperative infec-tions were treated with antibiotics and subsided within48 to 72 hours.

DISCUSSIONIn this study the incidence of infection following

periodontal surgery was extremely low among a largegroup of patients treated in the postgraduate periodon-tics clinic at Tufts University School of Dental Medi-cine. Although the rate of infection was slightly higherafter osseous surgery than after flap surgery withoutosteoplasty or ostectomy. this difference was not statis-tically significant (P = 0.08). Antibiotic therapy wasineffective in preventing postoperative infection, butwas extremely effective in dealing with postoperativeinfection. It was therefore concluded that unless there

Table 2Incidence of infection After Periodontal Surgery in Patients TreatedWith or Without Antibiotics

Treatment* Incidence of postop-erative infection

AntibioticsWithout antibiotics

1/438/884

* Statistical analysis using the Fisher Exact Probability Test showedno differences between the treatment groups (P = 0.938).

Table 3Incidence of Infection After Flap Surgery With or Without OsseousSurgery in Patients Treated Without Antibiotics

Treatment* Incidence of post-operative infection

Without osseous surgeryWith osseous surgery

2/3366/268

* Statistical analysis using the Fisher Exact Probability Test showedno differences between the treatment groups (P = 0.081) although a

trend toward a higher incidence of infection following osseous surgeryis evident.

is a medical indication, there is no basis for the use ofprophylactic antibiotic therapy to prevent infection fol-lowing periodontal surgery. However, prophylactic an-tibiotic therapy, as recommended by the AmericanHeart Association, is mandatory for patients with spe-cific medical problems.9

Several studies have reported the effects ofantibioticson pain, swelling and wound healing after periodontalsurgery.10"14 However, few efforts have been made todetermine the incidence of infection following perio-dontal surgery or the effectiveness of antibiotics inpreventing infection. Pendrill and Reddy8 recentlyfound no difference in the incidence of postoperativeinfection between groups receiving penicillin or a pla-cebo. Diagnosis of infection was made 1 week postop-eratively and was based upon the presence of necrosis,swelling, suppuration and lymphadenopathy. Employ-ing these criteria, the authors reported an overall infec-tion rate of 18% (7 of 39), much higher than the rate inthe present study (1%). This discrepancy probably re-flects differences between these studies in the criteriaused to diagnose postoperative infection. Since lymph-adenopathy, pain, necrosis and swelling are commonlyseen postoperatively in the absence of infection, thediagnostic signs of postoperative infection are suppur-ation and delayed onset of increased and progressivepain and swelling. However, in the present study, clin-ically detectable suppuration was not a consistent find-ing. Pendrill and Reddy found that even though allother criteria were present, in the absence of suppura-tion, it would be impossible to distinguish betweenpostoperative infection and postoperative sequelae notassociated with infection. The result would be an

overestimate of the incidence of postoperative infec-tion.

Volume 54Number 7

Prophylactic antibiotic therapy has been a controver-sial issue in both medicine and dentistry. However,several studies6 7 in the medical literature have shownthat routine antibiotic therapy does not lower the inci-dence of postoperative infection following general sur-gical procedures, but may actually contribute to a

greater risk of infection. Similar results have been ob-served in oral surgery.3"5 In a study of the effectivenessof antibiotics in Orthognathie surgery, Yrastorza3 ob-served a postoperative infection rate of 4.4% amongpatients treated prophylactically with antiobitics, com-pared with no infection among patients treated withoutantibiotics. Patterson et al.4 reported an infection rateof 15.4% following oral and maxillofacial surgery whenprophylactic antibiotic therapy was used, comparedwith an infection rate of 9.9% among patients treatedwithout antibiotics. Finally, in a study of patientsundergoing third molar surgery. Curran et al.5 foundthat 15.1% of the patients treated with antibiotics and14.3% of the patients treated without antibiotics devel-oped infection. Thus, our findings are consistent withstudies in other surgical disciplines, in which prophy-lactic antibiotic therapy was ineffective in preventingpostoperative infection.

In this study the incidence of infection followingperiodontal surgery among patients treated in a dentalschool clinic was determined. Further studies areneeded to determine whether the incidence of infectionafter periodontal surgery is similar among patientstreated in an office setting or a hospital operating room.

ACKNOWLEDGMENT

We wish to thank Drs. G. Galovic. R. Golnaraghi. L. Johnson. A.Konstantinidis. W. Sepura and V. Shannon for contributing theirefforts and patient records for study. We also thank Dr. O. W.

Clinical Infection after Periodontal Surgery 443

Donnenfeld for his helpful suggestions in preparation of this manu-

script and Dr. E. Clark for statistical analysis of the data.

REFERENCES1. Ruben. M. P.. Kon. S.. Goldman. H. M., Alpha. ., and

Bloom, . .: Complications of the healing process after periodontalsurgery. J Periodontal 43: 339. 1972.

2. Holroyd. S. V.: Antibiotics in the practice of periodontics. JPeriodontol 42: 584, 1971.

3. Yrastorza. J. .: Indications for antibiotics in Orthognathiesurgery. Oral Surg 34: 514. 1976.

4. Paterson. J. ., Cardo, V. ., and Stratigos. G. T.: An exam-ination of antibiotic prophylaxis in oral and maxillofacial surgery.Oral Surgi»: 753. 1970.

5. Curran. J. .. Kennet, S., and Young. A. R.: An assessmentof the use of prophylactic antibiotics in third molar surgery. Ini ./Oral Surgi: 1. 1974.

6. Johnstone, F. R. G: An assessment of prophylactic antibioticsin general surgery. Surgery 116: 1, 1963.

7. Karl. R. C. Mertz, J. J.. Veith. F. J.. and Dineen. P.: Prophy-lactic antimicrobial drugs in surgery. ' Engl J Med 275: 305. 1966.

8. Pendrill. ., and Reddy. J.: The use of prophylactic penicillinin periodontal surgery../ Periodontol 51: 44, 1980.

9. American Heart Association.: Prevention of bacterial endo-carditis. J Am Dent Assoc 95: 600. 1977.

10. Ariaudo. . .: The efficacy of antibiotics in periodontalsurgery: A controlled study with lincomycin and placebo in 68patients../ Periodontol 40: 150, 1969.

11. Scopp. I. W.. Fletcher, P. D.. Wyman. B. S.. Epstein. S. R..and Fine. .: Tetracyclines: Double-blind clinical study to evaluatethe effectiveness in periodontal surgery../ Periodontol 48: 484. 1977.

12. DeMarco. T. J.. and Kluth. E. V.: The use of cleocin inpostsurgical periodontal patients. J Periodontol 43: 381, 1972.

13. Kidd. . A. M.. and Wade. A. B.: Penicillin control of swellingand pain after periodontal osseous surgery. J Clin Periodontol 1: 52.1974.

14. Dal Pra, D. J., and Strahan. J. D.: A clinical evaluation of thebenefits of a course of oral penicillin following periodontal surgery.Ausi Dent J 17:219. 1972.

Send reprint requests to: Philip D. Pack, 30 E 40th St. New York,NY 10016.

In MemóriámOían . Kibler, DDS

1905-1981We have just been informed that Dr Oían B. Kibler, who practiced dentistry in

Evanston, Illinois before retiring to Leesburg, Florida, died in 1981. He received hisdental education at the Chicago College of Dental Surgery and was graduated in 1927.He joined the American Academy of Periodontology in 1966 and spent approximatelyone-third of his time in practicing periodontics. He served as president of the EvanstonAssociation of Dentistry, president of the North Suburban Branch Chicago DentalSociety and was a delegate or alternate to the American Dental Association a total of sixtimes. Dr Kibler was an ardent worker in organized dentistry and maintained a keeninterest in periodontology. No other details about Dr Kibler are available.