Antibiotic use in third molar extraction: a systematic review of current evidence and clinical implications

Abstract

Antibiotic prescription following third molar extraction remains controversial because of variable clinical practices, uncertain indications, and concerns regarding antimicrobial resistance. This systematic review aimed to evaluate current evidence regarding the effectiveness and appropriateness of antibiotic use in healthy patients undergoing third molar extraction.

Methods: The review was prepared with reference to the Cochrane Handbook and PRISMA 2020. A PROSPERO identifier was reported in the submitted documentation (CRD420261405197). MEDLINE via PubMed, the Cochrane Library, and Google Scholar were searched for eligible studies published from 1 January 2016 to 31 March 2026. Thirteen studies were included and grouped by clinically distinct comparisons. Because interventions, comparators, designs, and outcome definitions were heterogeneous, findings were synthesized descriptively without meta-analysis. Formal GRADE assessment was not undertaken.

Results: The evidence comprised randomized and observational studies evaluating systemic prophylaxis or postoperative therapy, local antibiotic delivery, antibiotic-dose comparisons, and antibiotics versus non-antibiotic local strategies. Individual studies produced inconsistent and often imprecise estimates. Selected studies reported lower incidences of alveolar osteitis with local rifamycin (2/35 vs 6/35 sockets), an oxytetracycline-impregnated drain (5/100 vs 23/100 sockets), and adjunctive oxytetracycline-hydrocortisone gauze (2/215 vs 9/46 participants). The latter comparison was observational and all participants also received systemic amoxicillin. A placebo-controlled trial of preoperative amoxicillin reported postoperative infection in 2/77 versus 5/77 participants. Interpretation was limited by clinical heterogeneity, sparse events, incomplete methodological documentation, and the absence of a reproducible formal risk-of-bias assessment.

Conclusions: The included studies do not support indiscriminate antibiotic prescribing for every healthy patient undergoing uncomplicated third molar surgery, but they also do not establish absence of preventive benefit. Previous evidence syntheses suggest possible modest reductions in postoperative infection and alveolar osteitis, with low certainty and relatively high numbers needed to treat. Decisions should be individualized according to patient and procedural risk, adverse effects, and antimicrobial-stewardship principles.