Comparison of Two Irrigation Solutions in the Surgical Removal of the Mandibular Third Molars- A Randomized Trial

Aim: To evaluate the effect of postoperative irrigation with chlorhexidine saline irrigation and metronidazole saline irrigation on non-inflammatory complications after the extraction of lower third molar under local anesthesia. Materials and Methods: In this study a total of 120 patients with age range 18-80 years who had impacted tooth which required surgical removal were included. The patients were separated into two groups using Block Randomization to avoid sampling bias. Group A and Group B had 60 patients each. Group A patients were irrigated with 1% Chlorhexidine Saline and Group B patients were irrigated with 1% Metronidazole Saline during the surgical removal of their mandibular third molars. The patients were measured for the pain, swelling and checked for dry socket after 7 days of procedure. Results: The mean age of the patient was 28.08 + SEM years. Out of three parameters (Pain, Swelling, Dry Socket) assessed, only alveolar osteitis showed a statistical significant difference Original Research Article Reddy et al.; JPRI, 32(28): 28-35, 2020; Article no.JPRI.59796 29 between 1% Metronidazole and 1% Chlorhexidine with p value 0.041(>0.05). Trismus and pain did not differ significantly (p>0.05) in the two groups with p-values of 0.431 for trismus and 0.750 for pain. Conclusion: Metronidazole had better efficacy in alveolar osteitis, while in the other parameters viz, pain and mouth opening there was no difference in the two treatments.


INTRODUCTION
Removal of impacted wisdom tooth is the most common dental surgical procedure performed in dental surgery. Pain, trismus, swelling, or anatomical variation after the removal of a third molar can make the maintenance of oral hygiene difficult, and the accumulation of food debris around the surgical site increases the risk of infection and dry socket particularly when lower wisdom teeth have been removed because of the effects of gravity [1]. Irrigation solutions also play an important role in the surgical removal of impacted teeth. Cooled irrigation solutions allow the guttered and recipient bone to cool thereby preventing thermal necrosis. Irrigating solution that is used during surgical removal of the wisdom tooth does not only prevent injury to the bone but also irrigates the working field and improves the vision of the dentist. In previous animal studies, it was shown that cutting the bone without water spray produced a greater width and intensity of inflammatory exudates and cellular debris at the margins of the defect compared to those with irrigation when viewed under the microscope [1,2]. Normal saline is preferred than sterile water because it is isotonic [3][4][5][6][7][8][9][10][11][12][13][14]. Adding antibiotics to the normal saline irrigation during surgical guttering of the bone when surgically removing the third molar may help in the removal of iatrogenic microbes. In this study we aimed to compare the efficacy of 1% metronidazole saline irrigation and 1% chlorhexidine saline irrigation after surgical removal of the mandibular third molar.

Study Setting and Sampling
The present study was a double-blinded randomized study, conducted in Saveetha Dental College and Hospital, Chennai from June 2019 to March 2020. A total of 120 patients [males (66) Females(54)] referred to the Department of Oral and Maxillofacial Surgery were recruited for the study.

Study Design
A panoramic radiograph was taken to assess the position of impacted teeth and to include mesioangular impaction according to Pell Gregory's class-I.

Inclusion and Exclusion Criteria's
The following categories of patients were included in the study; The 120 patients were randomly allocated by using a sealed envelope method to reduce the selection bias. Patients were divided equally into two Groups: Group A irrigation with 1% chlorhexidine saline solution and Group B irrigation with 1% metronidazole saline solution.
Surgical protocol: All patients who underwent surgical removal of mandibular third molars were selected randomly in group A and group B. Patients were are informed about the complications of the surgery before the procedure. Local anesthesia was performed via inferior alveolar nerve block w 1:2,00,000 dilution of adrenaline. A standard mucoperiosteal flap was elevated, round bur, bone trimming was done with copious saline mixed with 1% chlorhexidine solution for Group-A and 1% metronidazole for Group patients. The tooth was sectioned and removed. Wound closure was done with 3 After surgical procedure patients were prescribed piroxicam 20 mg twice daily for pain control. Patients were evaluated for a complication after 7-day post-operation. Post extr trismus and dry socket were evaluated.

Evaluation Protocol
All patients were recalled 7procedure. Three parameters pain, alveolar osteitis and trismus were evaluated.

Pain
Evaluation of pain was done using a analog scale (VAS), with 0 being the absence of pain to 10 being intolerable pain. Patients were asked to fill according to their experience on the respective evaluation days.

Alveolar Osteitis
Alveolar osteitis was measured by presence of pain, halitosis, and clot dislodgement after 3 days of surgical procedure.

Trismus
Trismus was evaluated by measuring the amount of mouth opening, measured as interincisal opening.

Statistical Analysis
Independent t-test was used to evaluate pain and trismus, while alveolar osteitis was evaluated using Chi-square test. p-value of less than 0.05 was considered as statistically significant. 30 complications of the surgery before the procedure. Local anesthesia was performed via inferior alveolar nerve block with lignocaine 1:2,00,000 dilution of adrenaline. A standard mucoperiosteal flap was elevated, and using a round bur, bone trimming was done with copious saline mixed with 1% chlorhexidine solution for A and 1% metronidazole for Group-B tooth was sectioned and removed. Wound closure was done with 3-0 silk sutures. After surgical procedure patients were prescribed piroxicam 20 mg twice daily for pain control. Patients were evaluated for a complication after operation. Post extraction like pain, trismus and dry socket were evaluated.
-days after the procedure. Three parameters pain, alveolar osteitis and trismus were evaluated.
Evaluation of pain was done using a Visual (VAS), with 0 being the absence of pain to 10 being intolerable pain. Patients were asked to fill according to their experience on the Alveolar osteitis was measured by presence of n, halitosis, and clot dislodgement after 3 days Trismus was evaluated by measuring the amount of mouth opening, measured as interincisal test was used to evaluate pain and trismus, while alveolar osteitis was evaluated value of less than 0.05 was considered as statistically significant.

RESULTS
In the studied population, 68 patients were males and 52 were females (Fig. 1). Participants age ranged from 17 to 57 years with mean age is 28.08 SEM years. The results indicated that the right mandibular lower third molar teeth( 50.43%) were more than the left mandibular third molar(49.57%). The pain visua (VAS)score for Group-A for most patients was 3(22.41%) and 2(18.97%) after one week of procedure with mean VAS score of 2.84±1.776. Pain score for Group-B showed that 25.42% of patients had zero (0)VAS score and 22.03% patients had VAS score of one (1)with mean score of 2.19±1.719). Mouth opening for Group 32 mm in 22.41% of patients followed by 35 mm in 13.79% of patients. Mouth opening for Group B was 35 mm of mouth opening for 16.95% of patients with mean opening of 32.1 alveolar osteitis 17.24% of patients in Group A had alveolar osteitis (dry socket), while 6.78% patients in Group B had alveolar osteitis after one week of procedure.
Correlation between tooth extracted and alveolar osteitis indicated that the presence of alveol osteitis was more in the left lower mandibular third molar( 6.84%) than right mandibular lower third molar (5.13%).The Relationship between pain and type of irrigation showed that VAS pain score of 0 and 1 was predominant in Group (12.82%) whereas in Group Pearson chi square was5.068, df was 8 and p value was0.750(>0.05) which is statistically insignificant (Fig. 3). Maximal mouth opening of 38 mm was more in Group-B than Group 4). The presence of alveolar osteitis was more in Group A (8.55%) than Group (Fig. 5).

DISCUSSION
The term impaction refers to the failure of a tooth to erupt in its original position in expected amount of time, which is caused by many In the studied population, 68 patients were males 52 were females (Fig. 1). Participants age ranged from 17 to 57 years with mean age is 28.08 SEM years. The results indicated that the right mandibular lower third molar teeth( 50.43%) were more than the left mandibular third molar(49.57%). The pain visual analog scale A for most patients was and 2(18.97%) after one week of procedure with mean VAS score of 2.84±1.776.
B showed that 25.42% of patients had zero (0)VAS score and 22.03% e of one (1) Correlation between tooth extracted and alveolar osteitis indicated that the presence of alveolar osteitis was more in the left lower mandibular third molar( 6.84%) than right mandibular lower third molar (5.13%).The Relationship between pain and type of irrigation showed that VAS pain score of 0 and 1 was predominant in Group-B Group-A, it was5.98%. Pearson chi square was5.068, df was 8 and p value was0.750(>0.05) which is statistically insignificant (Fig. 3). Maximal mouth opening of B than Group-A. Most common such complications include pain, oedema, trismus, infection, dry socket, haemorrhage, nerve injury [18]. In our have discussed most common complications such as trismus, alveolar osteitis and pain by using two types of irrigation medicaments. Irrigation is typically performed with regular saline during wisdom teeth removal helps to minimize the heat produced by the straight hand piece, and it often helps to better see the surgical site by minimizing blood, bone debris and foreign bodies. Using irrigation with some antibiotic properties helps in better healing and to counteract the postoperative complicatio Chlorhexidine is known intra-oral rinse which is bactericidal against gram positive and gram negative microorganisms [19]  [15], and this t study was based on the impacted molars. Based on the position of the impacted molars, various classification systems have been proposed. Pell Gregory classification was on the depth level with respect to the occlusal surface of second molar vertically and to ontally [16]. Winter's based on the angulation of the third molar with respect to the second molar [17]. This study used both Pell Gregory and Winters classification systems to classify types of impactions for the subjects, and only sioangular impaction according to winter's A or B form, and Pell I were included in the study. Most common such complications include pain, oedema, trismus, infection, dry socket, . In our study we have discussed most common complications such as trismus, alveolar osteitis and pain by using two types of irrigation medicaments. Irrigation is typically performed with regular saline during wisdom teeth removal helps to ed by the straight hand piece, and it often helps to better see the surgical site by minimizing blood, bone debris and foreign bodies. Using irrigation with some antibiotic properties helps in better healing and to counteract the postoperative complications.

Fig. 1. Pie chart represents gender distribution of the study population
oral rinse which is bactericidal against gram positive and gram ]. Properties of chlorhexidine are not affected and remains unaltered even under extreme conditions like heat produced during drill additional value of residual effect or substantively present there over 48 hrs.' which proves its longer duration of action [21 metronidazole has rapid onset of action and is active against all anaerobic infections study, metronidazole group reduced alveolar osteitis when compared to chlorhexidine group, whereas in other parameters such as pain and trismus it did not exhibit any added advantage over chlorhexidine group.
Ritzau [23, 24 metronidazole failed to produce satisfactory result on alveolar osteitis which is in our result. Another study (Refs chlorhexidine irrigation had significant mouth opening and control of pain, which similar to our findings. . Mouth opening and trismus among our study population were comparable in the two groups, osteitis differed significantly in metronidazole group. . In another studies [24 was compared with superox results showed that trismus and control of pain was effective in both the groups G conducted a study by comparing the effect of metronidazole to an herbal arnica Montana and a placebo among 118 patients, he found that metronidazole group had better effect on control of pain and swelling when compared to arnica and placebo [26]. In a systematic review by Yengopal et al. found that are not affected and remains unaltered even under extreme conditions like heat produced during drill [20]. It has an additional value of residual effect or substantively present there over 48 hrs.' which proves its 21]. On the other hand metronidazole has rapid onset of action and is active against all anaerobic infections [22]. In this , metronidazole group had significantly osteitis when compared to chlorhexidine group, whereas in other parameters such as pain and trismus it did not added advantage over chlorhexidine , 24], reported that produce satisfactory result on alveolar osteitis which is in contrast to our result. Another study (Refs) reported that irrigation had significant effect on mouth opening and control of pain, which is to our findings. . Mouth opening and trismus among our study population were groups, however alveolar osteitis differed significantly in metronidazole 24, 25] chlorhexidine was compared with superoxide solution, their results showed that trismus and control of pain was effective in both the groups [24,25]. Kaziro G conducted a study by comparing the effect of metronidazole to an herbal arnica Montana and a placebo among 118 patients, he found that etronidazole group had better effect on control of pain and swelling when compared to arnica . In a systematic review by found that four out

Fig. 1. Pie chart represents gender distribution of the study population
of six studies comparing the efficacy of chlorhexidine has failed its effectiveness against alveolar osteitis. He concluded that there was no sufficient evidence to prove chlorhexidine against alveolar osteitis [26]. In most of th mentioned here 1% metronidazole was not used locally after procedure, contradictory results may be due to the different route of administration, of six studies comparing the efficacy of chlorhexidine has failed its effectiveness against alveolar osteitis. He concluded that there was no sufficient evidence to prove chlorhexidine against . In most of the articles mentioned here 1% metronidazole was not used locally after procedure, contradictory results may be due to the different route of administration, dosage of metronidazole whereas chlorhexidine has been used locally in many articles. Metronidazole although used in severe infection situations it has adverse effects like nausea, abdominal pain, diarrhea and metallic taste. To avoid such adverse effects in our study we used metronidazole as local irrigation. dosage of metronidazole whereas chlorhexidine has been used locally in many dazole although used in severe infection situations it has adverse effects like nausea, abdominal pain, diarrhea and metallic taste. To avoid such adverse effects in our study we used metronidazole as local The above chart shows the relation between type of irrigation and mouth opening of the patients. X axis type of irrigation and Y axis represents number of patients. is 8.025, df is 8 and p value is 0.431(>0.05) which is statistically insignificant. The maximal mouth opening of 36 mm is more in 1% metronidazole saline irrigation than 1%chlorhexidine saline irrigation the above chart shows the relation between type of irrigation and alveolar osteitis. X axis type of irrigation and Y axis represents number of patients. Pearson chi square is 3.039, df is 1 and p value is 0.041(>0.05) which is statistically significant. The presence of alveolar osteitis is more in 1% chlorhexidine saline irrigation with 8.55%(red color) than 1%metrogyl saline irrigation which has 3.42%

35, 2020; Article no.JPRI.59796
The above chart shows the relation between type of irrigation and mouth opening of the Pearson chi square is 8.025, df is 8 and p value is 0.431(>0.05) which is statistically insignificant. The maximal mouth opening of 36 mm is more in 1% metronidazole saline irrigation than 1%chlorhexidine the above chart shows the relation between type of irrigation and alveolar osteitis. X Pearson chi square is 3.039, e presence of alveolar osteitis is more in 1% chlorhexidine saline irrigation with 8.55%(red color) than 1%metrogyl

CONCLUSION
From the above results it is evident that metronidazole has better significance towards alveolar osteitis when compared to chlorhexidine irrigation. Although metronidazole has better efficacy towards alveolar osteitis, in other parameters such as pain and mouth opening, there is no much difference between metronidazole and chlorhexidine. Further studies are required in the larger population to evaluate the efficacy of these drugs for better treatment.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
Ethical approval was obtained before the study from Saveetha institute of medical and technical sciences.