Does Intra-Alveolar Application of Chlorhexidine Gel in

Combination With Platelet-Rich Fibrin Have an

Advantage Over Application of Platelet-Rich Fibrin in
Decreasing Alveolar Osteitis After Mandibular Third
Molar Surgery? A Double-Blinded Randomized Clinical
Trial
Majid Eshghpour, DDS, MS,* Nasrin Danaeifar, DDS,y Hamed Kermani, DDS, MS,z
and Amir Hossein Nejat, DDS, MSx

Purpose: To evaluate the effectiveness of chlorhexidine (CHX) gel and platelet-

rich fibrin (PRF) compared with PRF alone in preventing the development of
alveolar osteitis (AO).
Materials and Methods: In a double-blinded trial, patients undergoing surgical
management of bilateral impacted mandibular third molars were randomly
divided into 2 groups; 1 group received PRF in 1 extraction socket with the other
socket as its control and the other group received 0.2% CHX gel plus PRF in 1
socket with the other socket serving as its control. The study and control sides
were unknown to the surgeon and the patient. The predictor variables were PRF
application (PRF vs non-PRF) and PRF plus CHX application (PRF-CHX vs non–
PRF-CHX). The outcome variable was the development of AO during the first
week after surgery. Age, gender, surgical difficulty score, surgeon’s experience,
number of anesthesia cartridges injected, and irrigation volume were other
variables. Data were analyzed in SPSS 11.5 using the t test and c2 test, with the
confidence interval set at 95%.
Results: In total, 482 surgeries were performed on 241 patients (mean age, 24 yr).
The overall frequencies of AO in all surgeries, the PRF group, and the PRF-CHX
group were 15.14, 17.37, and 13%, respectively. The frequency of AO in the PRF
and PRF-CHX sockets was significantly lower than in the non-PRF (relative risk
= 0.46) and non–PRF-CHX (relative risk = 0.18) sockets, respectively (P < .05).
Moreover, the risk of developing AO in the PRF-CHX sockets was significantly
lower than in the PRF sockets (relative risk = 0.37; P < .05).
Conclusion: According to the present findings, the application of CHX gel with
PRF increases the efficiency of PRF in lowering the risk of developing AO after
surgical removal of impacted mandibular third molars.

Alveolar osteitis (AO) or dry socket is one of the most common

postoperative complications after surgical and nonsurgical tooth extractions.1
Based on the literature, the frequency of AO after surgical removal of impacted
mandibular third molars varies from 5 to 30%.2 AO starts 1 to 3 days after
surgery with severe and progressive pain, regional lymphadenitis, halitosis, and
foul taste. AO is a self-limiting complication and resolves 5 to 10 days after
surgery without any treatment.1,3
Various risk factors have been identified in the development of AO,
including smoking habits,4,5 age,6 gender,7 oral contraceptives,7,8 menstrual
cycle in women,9 preoperative infection,10,11 amount of trauma during
surgery,12 difficulty of surgery,13 surgeon’s experience,12 and amount of socket
irrigation. 14 Different protocols to inhibit the development of AO have been
investigated, including antifibrinolytic agents, clot support agents, local
antibiotics, steroidal anti-inflammatory drugs, systemic antibiotic prescription,
chlorhexidine (CHX) mouthwash, CHX gel, and platelet-rich fibrin (PRF)
application. 15-18
PRF is considered the second generation of platelet concentrates. Although
PRF contains various immune cells and cytokines, its structural strength allows its
use as a membrane and a wound cover that can be sutured. Hence, PRF is an
appropriate membrane not only to cover a wound but also to improve the healing
process.19 PRF has been used successfully in the management of periodontal
diseases, bone augmentation, angiogenesis, and plastic surgeries.20
CHX is an antiseptic agent used intraorally as a mouthwash and as a
bioadhesive gel. The gel has the additional benefit of releasing the active agent for
a longer duration and enhances the bioavailability of the active agent inside the
extraction socket.21 Moreover, during the first postoperative day, the patient
needs to avoid rinsing the socket with CHX mouthwash to preserve the blood clot,
whereas the gel can be applied immediately after surgery.22
Previous studies have reported that the application of PRF17,18 or CHX
gel23-25 decreases the frequency of AO development. However, there is no
published study that addresses the effectiveness of applying PRF and CHX gel in
an extraction socket in preventing AO development. Hence, the aim of the present
study was to investigate whether the risk of developing AO after impacted third
molar surgery would differ when applying PRF or CHX gel plus PRF within the
extraction socket. The first null hypothesis was that the frequency of AO with and
without application of PRF in the extraction socket would be equal. The second
null hypothesis was that the frequency of AO with and without the application of
CHX gel plus PRF would be equal. The third null hypothesis was that the
frequency of AO development after the surgical removal of mandibular third
molars with and without adding CHX gel to PRF application would be equal. The
specific aims of the research were to determine the frequency of developing AO
1) with and without PRF or PRF-CHX application, 2) in PRF versus non- PRF
sockets, 3) in PRF-CHX versus non–PRF-CHX
sockets, and 4) in PRF-CHX versus PRF sockets.

Materials and Methods

The present study was conducted at the Oral and Maxillofacial Surgery
Clinic of the Mashhad Dental School (Mashhad, Iran). The study protocol was
approved by the ethical board of the Mashhad University of Medical Sciences and
all patients provided a signed detailed informed consent.

STUDY DESIGN
To address the study objective, the authors designed and implemented a
split-mouth double-blinded clinical trial based on the consent statement and
published guidelines.26
STUDY SAMPLE
The study sample consisted of patients presenting for management of
bilateral impacted lower third molars from October 2014 through March 2016.
 To be included in the present study, the patients had to have American
Society of Anesthesiologists status I or II, be 18 to 35 years of age, and have
bilateral mandibular third molars with a moderate difficulty level according to the
Pederson classification (sum score of the spatial direction of the tooth, depth of
impaction, and the tooth’s relation to the ramus on
panoramic radiograph).27,28
Patients who had smoking habits, were lactating or pregnant, using oral
contraceptives, had pericoronitis of the mandibular third molar(s), had periapical
lesion(s) on panoramic radiograph, received an antibiotic regimen within the past
2 weeks, or had received more than 2 dental anesthetic cartridges on each side
during the administration of local anesthesia of the mandible were excluded as
study subjects.
STUDY VARIABLES
The predictor variable was the application of PRF alone or in combination
with 0.2% CHX gel in the extraction socket. For half the patients, PRF was placed
in 1 extraction socket and the other socket served as the control side and received
no treatment. For the remainder of the patients, PRF and 0.2% CHX gel were
placed in 1 socket (study side) and no treatment
was provided for the other socket (control side). In this study, the frequency of
AO was the outcome variable. The criteria to diagnose a socket with AO were
progressive, throbbing, and severe pain starting 24 to 72 hours after the surgery,
halitosis, foul taste, regional lymphadenitis, or loss of the blood clot (exposure of
the alveolar wall) inside the socket.
In addition, data on demographic (age and gender), preoperative (surgeon’s
experience and radiographic difficulty score for surgery), and perioperative
(number of anesthetic cartridges and irrigation volume) variables were collected.
DATA COLLECTION
To produce PRF, before the surgery, venous blood 10 mL was obtained
from the patient’s cephalic or basilica vein using a 19-gauge needle and placed in
a sterile blood collection tube. The blood sample was immediately centrifuged at
3,000 rpm (Labofuge 400R centrifuge; Heraeus, Hanau, Germany) for 10 minutes
to obtain the PRF (the fibrin clot floating in the middle of the test tube).
An experienced surgeon performed all surgeries under a similar protocol:
applying povidone iodine around the mouth; obtaining local anesthesia using 2%
lidocaine with 1:80,000 epinephrine dental cartridges; preparing access with a
mucoperiosteal envelope flap with no release, removing the alveolar bone,
sectioning the impacted tooth, and recontouring the bone using a low-speed
handpiece under sufficient irrigation with sterile normal saline; socket irrigation
with sterile normal saline 100 mL; and suturing the flap with 3-0 silk sutures.
Amoxicillin (500 mg 3 times daily; n = 21) and acetaminophen (500 mg 3 times
daily for a maximum of 3 days) were prescribed for use after surgery.
The impacted third molars were surgically removed during the same
appointment. Before suturing the extraction socket, 1 socket randomly (using a
coin flip) received PRF (PRF group, n = 118) or 0.2% CHX gel and PRF (PRF-
CHX group, n = 123). The contralateral extraction socket in either group received
no treatment and served as the control group (non-PRF, n = 118; non–PRF-CHX,
n = 123). To keep the study double blinded, an instructed operator inserted PRF
with or without CHX gel and sutured the extraction sockets. Hence, the patient
and the surgeon were blinded as towhich side the treatment (PRF in PRF group
and CHX gel + PRF in PRF-CHX group) had been inserted. The randomization
data were kept unknown throughout the duration of the study.
To evaluate the extraction sockets, 2 follow-up appointments were
scheduled (days 2 and 7 after surgery). Moreover, patients were instructed to
return for an evaluation if they experienced any persistent throbbing or
progressive pain between follow-up visits. During the postoperative appointments,
patients were examined by a calibrated examiner (unaware of the groupings) for
clinical signs of AO. To treat patients who developed AO, socket irrigation was
performed with sterile normal saline and an intra-alveolar dressing was placed
using Alvogyl iodoform (Septodont, Cambridge, ON, Canada). In addition, some
patients were further managed with systemic analgesics and systemic antibiotics.
STATISTICAL ANALYSIS
Appropriate descriptive statistics (mean, standard deviation, frequency) were
determined for each variable. Inter-subject (between treatment and control sides)
and intra-subject (between PRF sockets and PRF-CHX sockets) analyses were
performed with the t test and c2 test in SPSS 11.5 (SPSS, Inc, Chicago, IL). The
confidence interval was set at 95%.

Results
A total of 265 patients met the inclusion criteria and were entered into the
study; however, 11 patients in the PRF group and 7 patients in the PRF-CHX
group received more than 2 dental anesthetic cartridges, 1 patient in the PRF
group and 3 patients in the PRF-CHX group did not attend the follow-up
appointments, and 2 women in the PRF group had used emergency oral
contraceptives during the follow-up week and were excluded as study subjects. As
a result, 118 patients (k = 236 teeth) remained in the PRF group (49 men and 69
women; mean age, 23.94 _ 3.77 yr) and 123 patients (k = 246 teeth) remained in
the PRF-CHX group (50 men and 73 women; mean age, 24.74 _ 3.96). When
comparing demographic variables (age and gender) between the PRF or PRF-
CHX sides and their corresponding control sides, no statistically relevant
differences were found because each patient served as his or her control (Table 1).
Moreover, no relevant differences were observed between the PRF and PRF-CHX
groups according to mean age, age group distribution, gender, surgical difficulty
(Pederson scale), and number of anesthetic cartridges injected during surgery
(Table 1).
Of 482 surgeries performed in this study, 73 cases were diagnosed with
AO, for a frequency of 15.14%. Based on the c2 test, the frequency of AO showed
no relevant differences in the demographic, preoperative, and postoperative
variables in the PRF and PRF-CHX groups (Table 2). In addition, no relevant
difference was observed between the PRF and PRF-CHX sockets according to the
background variables (Table 2). The frequency of AO had a relevant association
with the application of PRF or CHX gel plus PRF (Table 3).
In the PRF group, the risk of developing AO was 0.46 of the control sockets; in
the PRF-CHX group, the risk of AO development was 0.18 of the control sockets.
According to the c2 test, a statistical association was observed between the type of
intervention (PRF or CHX plus PRF) and frequency of AO. The risk of
developing AO in sockets receiving CHX plus PRF was 0.37 of the sockets
receiving PRF only (Table 3).

Discussion
The aim of the present study was to investigate the effect of CHX gel plus
PRF application versus PRF application alone on the frequency of AO after
surgical removal of impacted mandibular third molars. The first null hypothesis
was that the frequency of AO after surgical extraction with and without
application of PRF would be equal. The second null hypothesis was that the
frequency of AO after surgery with and without 0.2% CHX gel plus PRF would
be equal. The third null hypothesis was that the frequency of AO after surgical
removal of mandibular third molars with and without PRF plus CHX gel
application would be equal. The aim was to evaluate and compare the frequency
of AO development after impacted mandibular third molar surgery in PRF, non-
PRF, PRF-CHX, and non– PRF-CHX sockets. The first 2 null hypotheses were
rejected because the frequency of AO in the PRF and PRF-CHX sockets was
notably lower than in the non- PRF and non–PRF-CHX sockets, respectively. In
addition, the third null hypothesis was rejected because the frequency of AO in
the PRF-CHX sockets was markedly lower than in the PRF sockets.
There was no statistical association between age groups, gender, difficulty
score of the surgery based on the radiograph, or number of anesthetic cartridges
and the frequency of AO development in the PRF and PRF-CHX groups.
AO is one of the most common postoperative complications after the
surgical removal of impacted mandibular third molars. The frequency of this
complication varies from 5 to 30% in the literature.2 In the present study, the total
frequency of AO development was 15.14%, which was in accord with previously
published reports.
In the present study, the application of PRF after surgical removal of
impacted mandibular third molars markedly lowered the risk of developing AO;
the risk of AO development in PRF sockets was 0.46 of the non-PRF socket.
These findings were in accord with the authors’ previous study in which the
application of PRF inside the extraction socket markedly decreased the frequency
of AO after third molar surgery, and the risk of developing AO in PRF sockets
was 0.44 of non-PRF sockets.18 Moreover, Hoaglin and Lines17 found that the
application of PRF notably decreased the frequency of AO after mandibular third
molar surgery.
In addition, the findings of the present study showed that the efficacy of
PRF in decreasing the risk of AO development could be enhanced considerably by
the adjunct application of CHX gel. In accord with the present study, Haraji and
Rakhshan,25 Torres-Lagares et al,23 and Rubio-Palau et al24 reported that a
single intra-alveolar application of 0.2% CHX gel decreased the risk of AO
development. However, the present study was the first to address the effect of the
application of CHX gel plus PRF in lowering the risk of AO after surgical
removal of impacted third molars.
PRF possesses hemostatic and cicatricial properties that could contribute
to its efficiency in decreasing the risk of AOdevelopment.20 Birn10 reported that
sockets with AO have higher fibrinolytic activity compared with normal
extraction sockets. The result is decreased integrity of the blood clot formed
inside the extraction socket and the increased possibility of losing the clot and
developing AO. PRF acts as a reservoir of leukocytes, platelets, and different
cytokines.29 Moreover, the 3-dimensional structure of PRF provides a matrix that
decreases the risk of mechanical dislodgement of the newly formed blood clot.18
The other mechanism that contributes to the development of AO is
bacterial infection and the release of bacterial byproducts.2 The sealing ability of
PRF could decrease the bacterial load of the extraction socket. In addition, PRF
improves the migration of neutrophils and enhances the immune response at the
site of extraction.29 Moreover, CHX is a strong antiseptic agent that is effective
against a wide spectrum of aerobic and anaerobic pathogens of the oral cavity.21
The results of the present study indicated that applying the CHX gel considerably
enhanced the effectiveness of the PRF application.
Hence, in the PRF-CHX sockets, the 2 mechanisms described earlier that
contributed to the development of AO were inhibited by the sealing, hemostatic,
and immunity-related properties of PRF combined with the antiseptic activity of
CHX. As a result, the bacterial load and fibrinolytic activity of the extraction
socket were decreased and mechanical dislodgment of the blood clot inside the
extraction socket was inhibited. This combination decreased the frequency of AO
to 4.06%, which is lower than the reported range of AO development after third
molar surgery in the literature (5 to 30%) and is close to the risk of AO
development in nonsurgical tooth extraction (1 to 4%).2,28
Platelet-rich plasma is the first generation of platelet concentrates and PRF
is the second generation. Producing PRF is simple with relatively low cost. There
is no need for biochemical alterations of the PRF, including adding bovine
thrombin, anticoagulants, or calcium chloride. However, the production technique
is sensitive because the collected blood starts to clot immediately. Hence, the
blood needs to be centrifuged promptly after collection. During centrifugation of
the blood, the collision of platelets with the tube wall releases the granules and
results in a slow and gradual fibrin polymerization that leads to a flexible and
strong fibrin membrane with abundant entrapped leukocytes and cyctokines.29,30
The sealing ability of PRF has been implemented in sealing facial defects
and wounds in plastic surgeries. In addition, it has been used in cardiovascular
surgeries to seal microvascular bleedings.31,32 It also has been used as grafting
material in combination with allografts or xenografts in sinus augmentation.33
The healing properties of PRF have been implemented to enhance the healing
process of tendons34 and the periodontal healing process.20
The present study was double blinded, because the side receiving PRF or
CHX plus PRF was unknown to the surgeon and the patient. Moreover, the
operator who applied the biomaterial inside the socket and sutured the extraction
socket was unaware of the surgical difficulty.
One factor determining the risk of AO development is the amount of
trauma induced during the surgical procedure. Surgical trauma to bone leads to
the release of tissue activators that impede postoperative socket maturation.10 The
position of the tooth and, hence, the amount of the bone needed to be removed to
expose the tooth for sectioning determine the amount of trauma.2-18 In the
present study, impacted teeth with a difficulty level of easy or hard were excluded
to limit the confounding effect of this variable. This could explain the slightly
higher frequency of AO in the present study than in the authors’ previous study in
which impacted teeth with a difficulty level of easy were included.18 In addition
to tooth position, the experience of the surgeon affects the amount of trauma
during surgery.12 To eliminate this factor, all surgeries were performed by a
single experienced surgeon.
The risk of developing AO also depends on age, with most reports
indicating 20 to 40 years as the peak age.1,6,9 As a result, the association between
age group and distribution of AO was investigated in the present study, and no
statistical association was observed.
According to the literature, epinephrine could increase the risk of AO
development by decreasing local blood circulation, bleeding, and oxygen tension
and increasing fibrinolytic activity.2 Hence, the possible confounding effect of
local anesthesia injection was eliminated by excluding patients who received more
than 2 lidocaine cartridges.
Another confounding factor in AO development is the amount of socket
irrigation after extraction; Butler and Sweet35 reported that a larger irrigation
volume lowers the risk of AO development. Irrigation removes contaminants,
including enzymes, bacteria, and debris, and a larger irrigation volume might
increase the efficiency of their removal. Hence, all sockets were irrigated with
sterile normal saline 100 mL after the surgery to eliminate irrigation as a
confounding factor.
The other factor influencing the rate of AO development is taking
antibiotics before surgery. It has been reported that receiving antibiotics before
third molar surgery considerably lowers the risk of developing AO.2,15 Hence,
patients who used antibiotics within 2 weeks before surgery were excluded from
the present study.
To conclude, within the limitations of the present study, applying CHX gel
and PRF to the extraction socket after surgical extraction of impacted mandibular
third molar has the potential to decrease the frequency of AO development as low
as the frequency reported for nonsurgical extractions. These 2 biomaterials have
the advantage of availability at reasonable cost. However, the fact that the
statistical difference between the PRF-CHX and PRF groups (P = .041) was close
to insignificant indicates the need for further investigations with larger numbers of
patients on the effect of this combination (CHX gel plus PRF) on not only the risk
and frequency of developing AO but also their effect on other postoperative
complications, including pain and quality of life, to confirm the effectiveness of
this combination.