DOI: https://doi.org/10.

53350/pjmhs2115123614
ORIGINAL ARTICLE

Post-Operative Complications after Simple Tooth Extraction in Diabetic

Patients with and without Antibiotic Prophylaxis
ARSLAN MAHMOOD1, ZIAUR RAHMAN KHAN2, BAKHTAWAR SALEEM3, ZUNAIR AKBAR MEMON4, BABAR ABRO5, GHAZANFAR
HASSAN6
1
Senior Registrar Oral & Maxillofacial Surgery Department Muhammad Dental College, Mirpurkhas
2
Assistant Professor Oral Medicine Department Baqai Dental College, Baqai University Karachi
3
Resident Prosthodontics Department Liaquat University of Medical & Health Sciences, Jamshoro
4
Senior Registrar Oral Medicine Department Isra Dental College, Isra University Hyderabad
5
Lecturer Oral Pathology Department Dr Ishratul Ibad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi
6
Professor Oral & Maxillofacial Surgery Department Liaquat University of Medical & Health Sciences, Jamshoro
Corresponding author: Ghazanfar Hassan, Email: [email protected]

ABSTRACT
Objective: To compare early post-operative complications after simple tooth extraction in diabetic patients with and without
antibiotic prophylaxis.
Material and Methods: This Randomized Control Trial study was conducted at department of Oral &Maxillofacial Surgery
Liaquat University Hospital Hyderabad. The duration of study was from November 2020 to October 2021. A total of 190 patients
diagnosed as diabetics were randomly allocated into two groups. Pain, bleeding, infection, fever and dry socket was assessed
from1st, 3rd and 7th post-operative days.
Results: The average age of the patients was 35.39±6.09 years. Rate of pain (28.4% vs. 12.6%; p=0.007), bleeding (25.3% vs.
11.6% p=0.015), infection (20% vs. 6.3% p= 0.005) and dry socket (18.9% vs. 8.4% p=0.035) was significantly high in group B
than group A while fever was not significant.
Conclusion: It is concluded that the prescription of prophylactic antibiotics in subjects who got extraction has low incidence of
post-operative complications than extraction in diabetics without prophylaxis.
Keywords Tooth extraction, Periodontal disease, Prophylactic antibiotics

INTRODUCTION with and without antibiotic prophylaxis respectively among general

Most of patient undergoes removal of teeth every year for variety population .13
of surgical indications like caries, pulpal necrosis, and periodontal Simple tooth extractions in diabetics with and without use of
disease. It is defined as “painless removal of tooth from alveolar prophylactic antibiotics were compared in very small number of
socket.”1,2,3 studies and nothing was stated clearly 15. Use of prophylactic
Despite tooth extraction is done both as a treatment or as antibiotics seems to have an extra advantage of periodontal
palliation in odontogenic infections and periodontitis, usually as an infection prevention, decreased risk of disseminated infections and
outpatient case, it carries in itself a morbidity ranging from prevention of non-healing of dental sockets, bad odor and foul
Psychological disturbances to Nutritional impairment and from taste but is burden on patient and health care system if not
disturbed routine activities to surgical complications like pain, justified. Besides, patients treated without prophylactic antibiotics
bleeding, truisms, facial swelling, bad odor, altered sensation of showed the above mentioned complications in excess and were at
taste and dry sockets to systemic disturbances like fever, a risk of ethical issue if complications develop. Negligible number
endocarditis and osteoarthritis specially when done in with of studies have evaluated the differences in commonest post-
patients diabetics who have high subspecialty to develop operative complications like pain, bleeding, infection, fever and dry
infections.4, 5 sockets in both the scenarios i:e with and without use of
Through a variety of research done on cases of tooth prophylactic antibiotics and none have recommended a single
extraction especially in diabetics conflicting evidence came in technique as a procedure of choice. Whether or not to use
existence. Some reported that diabetics and non-diabetics have no prophylactic antibiotics in diabetics undergoing simple tooth
significant difference in outcome and use of prophylactic antibiotics extraction with clarity and confidence will help to reduce the post-
is not necessary in diabetics as in non-diabetics while performing operative complications and burden on hospitals and patients.
tooth extraction.6,7,8 On the other hand some reported glycemic Taking into considerations afore mentioned facts, stage is
control to be controversial in dental socket infections while set for comparison of the simple tooth extractions in diabetics with
admitting the use of antibiotics to prevent local and systemic and without use of prophylactic antibiotics to select a better option
infections 6 while penicillin’s being the drug of choice.7 in terms of early post-operative complications.
Two common techniques have been described for tooth
extractions, namely, Simple Tooth Extraction and Surgical tooth MATERIALS AND METHODS
extraction, the former being more commonly performed. 10,11 Both This Randomized Control Trial (RCT) with non-probability
these techniques have been studied thoroughly for their Consecutive sampling technique was carried out in Department of
effectiveness and post-operative outcomes with no clarity and Oral and Maxillofacial Surgery, Liaquat University hospital,
authenticated use of prophylactic antibiotics in diabetics. Jamshoro/Hyderabad from November 2020 to October
Depending on the expertise available dental surgeons adopt these 2021.Sample size calculated With an expected proportions of 3.2%
techniques.9,10 & 15.4% for dry socket with and without antibiotic prophylaxis 13
Different studies published from international journals states respectively and at 5% level of significance and 80% power to
that diabetic patients are prone to develop 73.33% of any sort of detect the difference, the maximum sample size required for each
dental infection but another study claims that use of prophylactic group is 95, i:e 190 collectively.
antibiotics among diabetics can decrease infection rate to Inclusion Criteria:
0.5%.12,15and, on contrary some authorities claim 0.4% showed • All patients of either sex between the ages of 15-50 years
signs of active infection after undergoing extraction without who are planned to undergo simple tooth extraction having un-
prophylactic antibiotics among diabetics, other say should be no restorable tooth or not willing for restoration of tooth.
use of antibiotics for prophylaxis among diabetics as it can • All such patients diagnosed as diabetics at least a year ago
increase resistance among antibiotics, and is financial burden on either type-I or type-II managed on oral hypoglycemics or insulin
patient.3,4,16.while others describe 3.2% and 15.4% for dry socket and having random blood sugar levels between 90 mg/dl to 200

3614 P J M H S Vol. 15, No.12, DEC 2021

 A. Mahmood, Z. R. Khan, B. Saleem et al

mg/dl on gluco-meter prior to surgery.

Exclusion Criteria:
• Patients having some associated chronic disease like
Tuberculosis, Malignancy, Ulcerative colitis and Crohn’s disease
labeled through history and clinical examination.
• Patients suffering from hypertension, immune suppression
other than diabetes, HIV, hepatitis B & C, labeled through history
and clinical examination.
• Patients having any history of previous malignancy of head
and neck region and chemo-radiotherapy to head and neck region.
• Patients suffering from psychological disorders of any origin
labeled through history and clinical examination.
• Patients suffering from bleeding disorders of any origin
labeled through history and clinical examination.
• Patients allergic to penicillin (drug of choice for prophylaxis)
labeled through history.
Data Collection Procedure: After getting approval of synopsis
from CPSP, patients who meet the inclusion criteria were included
in my study. With their willing, a written and informed consent was Figure 1: Age Distribution Of The Patients With Respect To Groups N=190
taken. Translated versions of the consent form in the patient’s
Table 1: Descriptive Statistics By Groups
preferred language, were presented to the patients.
Patients was divided into 2 groups by slip picking method Age (Years) Glycemic Level
Statistics
namely group A and B. Group A = with prophylactic antibiotics and Group A Group B Group A Group B
group B = without prophylactic antibiotics. Patients enrolled in Mean 36.34 34.45 131.04 127.80
Group A were given capsule amoxicillin 2 grams/orally 1 hour prior
Std. Deviation 5.98 6.09 27.83 19.84
to extraction. Informed consent was taken and questionnaire
based interview was conducted. Patient was given right to 95% Confidence Lower Bound 35.12 33.21 125.37 123.76
withdraw from study at any point in time. Pain, bleeding, infection, Interval for Mean Upper Bound 37.56 35.69 136.71 131.84
fever and dry socket was assessed from1st, 3rd and 7thpost-
operative days. All this data was collected on a pre-formed pro-
forma and variables recorded. On the follow up days variables
present once or twice was labeled as "YES" once. After 7 days
variables found absent was labeled “NO” and pro-forma was
separated for final evaluation which was done after completing the
number of sample size. As this is a comparative study so the final
outcome of the two groups was measured and not the patients
individually i.e. results was presented in tabulated form with
comparison of all variables in both groups. Potential bias
associated with this study include, information bias that the patient
may report altered status of pain, bleeding or fake history of fever.
Researcher was put maximum efforts to take this into account by
building good repo with participants so that accurate information
can be collected. Other possible bias is surveillance bias that the
researcher might introduce. This was controlled by involving
another person to assess the presence or absence of
complications.

RESULTS Figure 2: Gender Distribution Of The Patients With Respect To Groups

A total of 190 patients diagnosed as diabetics at least a year ago N=190
either type-I or type-II managed on oral hypoglycemics or insulin
and having random blood sugar levels between 90 mg/dl to 200
mg/dl on gluco-meter prior to surgery that were planned to undergo
simple tooth extraction having un-restorable tooth or not willing for
restoration of tooth. Total 95 patients in group A were given
antibiotics while group B was set as controlled. Age distribution of
the patients is shown in figure 1. The average age was 35.39±6.09
years. Mean age, glycemic control with respect to groups are
reported in table 1. There were 85(44.7%) male and 105(55.3%)
female. Gender distribution with respect to groups is also
presented in figure 2. Quadrant distribution of the patients is
presented in figure 3. Regarding reason of tooth extraction, Carries
was 50(26.3%), periodontal disease 52(27.4%), tooth fracture
52(26.3%) and orthodontic Purpose 38(20%) as shown in figure 4.
Comparison of rate of complications between groups is
shown in table 2. Rate of pain (28.4% vs. 12.6%; p=0.007),
bleeding (25.3% vs. 11.6% p=0.015), infection (20% vs. 6.3% p=
0.005) and dry socket (18.9% vs. 8.4% p=0.035) was significantly
high in group B than group A while rate of fever was not
statistically significant. Figure 3: Quadrant Distribution Of The Patients With Respect To Groups
n=190

P J M H S Vol. 15, No.12, DEC 2021 3615

Post-Operative Complications after Simple Tooth Extraction in Diabetic Patients with and without Antibiotic Prophylaxis

CONCLUSION
The Diabetes worsen the prognosis hence we have used
prophylactic antibiotics to decrease the risk for infection prior to
simple extraction. Hence supporting the Hypothesis that the use of
prophylaxis reduces the risks in diabetic patients undergoing tooth
extraction has low incidence of post-operative complications than
extraction in diabetics without prophylaxis.

REFERENCES
1. Santana RB, Xu L, Chase HB, Amar S, Graves DT, Trackman PC. A
role for advanced glycation end products in diminished bone healing
in type 1 diabetes. Diabetes. 2003 Jun;52(6):1502-10.
2. Chrysanthakopoulos NA. Reasons for extraction of permanent teeth
in Greece: a five-year follow-up study. Int Dent J. 2011 Feb;61(1):19-
24.
3. Mettes TD, Ghaeminia H, Nienhuijs ME, Perry J, van der Sanden WJ,
Plasschaert A. Surgical removal versus retention for the management
of asymptomatic impacted wisdom teeth. Cochrane Database Syst
Figure 4: Reasons Of Tooth Extraction With Respect To Groups N=190
Rev. 2012 Jun 13;(6):CD003879.
4. Shera AS, Rafique G, Khwaja IA, Baqai S, Khan IA, King H. Pakistan
Table 2: Compare Early Post-Operative Complications After Simple Tooth National Diabetes Survey prevalence of glucose intolerance and
Extraction In Diabetic Patients With And Without Antibiotic Prophylaxis associated factors in North West at Frontier Province (NWFP) of
Group A Group B Pakistan. J Pak Med Assoc. 1999;49:206-11
Complications P-Value
n=95 n=95 5. Shera AS, Rafique G, Khwaja IA, Ara J, Baqai S, King H. Pakistan
Pain 12(12.6%) 27(28.4%) 0.007 national diabetes survey: prevalence of glucose intolerance and
Bleeding 11(11.6%) 24(25.3%) 0.015 associated factors in Shikarpur, Sindh Province. Diabet Med. 1995;
Infection 6(6.3%) 19(20%) 0.005 12:1116-21
Fever 5(5.3%) 85(10.5%) 0.179 6. Singh Gill A, Morrissey H, Rahman A. A Systematic Review and
Dry Socket 8(8.4%) 18(18.9%) 0.035 Meta-Analysis Evaluating Antibiotic Prophylaxis in Dental Implants
Chi-Square test applied for each complication and Extraction Procedures. Medicina (Kaunas). 2018 Dec 1;54(6):95
7. Huang S, Dang H, Huynh W, Sambrook PJ, Goss AN. Thehealing of
dental extraction sockets in patients with Type 2 dia-betes on oral
DISCUSSION hypoglycaemics: a prospective cohort. Aust Dent J 2013;58:89–93.
Diabetes mellitus (DM) is one of the very common diseases seen 8. Wang J, Ahani A, Pogrel MA. A five year retrospective study of
by dentists. Its clinical significance is from the possibility of acute odontogenic maxillofacial infections in a large urban public
consequences, the intensity of which might pose an instant threat hospital. Int J Oral Maxillofac Surg. 2005;34:646– 9.
to the diabetic patient's life and necessitate quick identification and 9. Marioni G, Castegnaro E, Staffieri C. Deep neck infection in elderly
treatment16. Many studies have documented the association of patients. A single institution experience (2000‐2004). Aging Clin Exp
diabetes with occurrence of complications after dental surgery Res. 2006;18:127– 32.
10. Devlin H, Garland H, Sloan P. Healing of tooth extraction sockets in
procedures17,18. experimental diabetes mellitus. J Oral Maxillofac
The bulk of the participants in this research are between the Surg. 1996;54:1087– 91
ages of 31 and 40, with a mean age of 35.39±6.09 years. Our 11. Ship JA. Diabetes and oral health: an overview. J Am Dent
observation regarding gender distribution showing there were Assoc. 2003;134(1):4S– 10S
44.7% males and 55.3% females displaying female prevalence. In 12. Vernillo AT. Diabetes mellitus: relevance to dental treatment. Oral
contrast to prior research, Shera et al4 evaluated the prevalence of Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91:263– 70
type 2 diabetes mellitus in Baluchistan, Pakistan's metropolitan 13. Bell GW, Large DM, Barclay SC. Oral health care in diabetes
mellitus. SADJ. 2000;55:158– 65.
and metropolitan zones. They enlisted the help of 1404 men and 14. Gutiérrez JL, Bagán JV, Bascones A, Llamas R, Llena J, Morales
women. In both urban and rural areas, the total prevalence was A, et al. Consensus document on the use of antibiotic prophylaxis in
13.46 percent, with 14.71 percent of men and 12.89 percent of dental surgery and procedures. Med Oral 0Patol Oral Cir Bucal
females. The prevalence of diabetes was 16.2 % (9.0 percent 2006;11:E188-205.
known, 7.2 % recently diagnosed) in males and 11.7 % (6.3 % 15. Barasch A, Safford MM, Litaker MS, Gilbert GH. Risk factors for oral
known, 5.3 % newly detected) in females in a previous research postoperative infection in patients with diabetes. Spec Care Dentist.
performed by the same writer in Sindh province5. 2008 Jul;28(4):159-66.
16. Bergman SA. Perioperative management of the diabetic patient. Oral
The necessity for antibiotic prophylaxis in individuals having Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Jun;103(6):731-
this sort of surgery has been hotly discussed in recent years, with 7.
cost/benefit analyses being conducted. Topical disinfection of the 17. Fernandes KS, Glick M, de Souza MS, Kokron CM, Gallottini M.
operative field is frequently conducted during the procedure, in Association between immunologic parameters, glycemic control, and
addition to systemic antibiotic prophylaxis, and topical home post extraction complications in patients with type2 diabetes. J Am
remedies are typically provided to be used thereafter19. However, Dent Assoc 2015;146:592–599.
there is constantly the possibility of bacterial infection in the 18. Hutcheson A, Cheng A, Kunchar R, Stein B, Sambrook P, GossA. A
C-terminal cross linking telopeptide test-based protocol for patients
operative area. Prophylaxis has traditionally been defined as the on oral bisphosphonates requiring extraction: a prospective single-
use of an antibiotic before to or during surgery to minimize a local center controlled study. J Oral Maxillofac Surg 2014;72:1456–1462.
or systemic infection problem and its associated clinical effects. 19. Mohsin SF, Ahmed SA, Fawwad A, Basit A. Prevalence of oral
Diabetes has been linked to a longer duration of admission in the mucosal alterations in type 2 diabetes mellitus patients attending a
hospital after surgery, and patients with odontogenic infection have diabetic center. Pakistan Journal of Medical Sciences.
a greater likelihood of deep neck extension. 8,9,20 An animal model 2014;30(4):716-9.
of diabetes in which bone repair after tooth extractions was 20. Peters ES, Fong B, Wormuth DW, Sonis ST. Risk factors affecting
hospital length of stay in patients with odontogenic maxillofacial
hindered provided more indirect confirmation of an elevated infections. J Oral Maxillofac Surg. 1996;54:1386–91
danger of post oral surgical infections.10

3616 P J M H S Vol. 15, No.12, DEC 2021