Int. J. Oral Maxillofac. Surg.

2009; 38: 160165

doi:10.1016/j.ijom.2008.11.023, available online at http://www.sciencedirect.com

Clinical Paper
Oral Surgery

Preoperative antiseptics in D.
D.
L.
Kosutic1, V. Uglesic2,
Perkovic3, Z. Persic3,
Solman1, S. Lupi-Ferandin2,
Knezevic2, K. Sokler4,
clean/contaminated
P.
G. Knezevic4
1
Department of Plastic and Reconstructive
Surgery, University of Maribor General

maxillofacial and oral surgery: Hospital, Maribor, Slovenia; 2Department of

Maxillofacial Surgery, University of Zagreb
Clinical Hospital Dubrava, Zagreb, Croatia;

prospective randomized study

3
Department of Microbiology, University of
Zagreb School of Medicine, Zagreb, Croatia;
4
Department of Oral Surgery, University of
Zagreb School of Dentistry, Clinical Hospital
Dubrava, Zagreb, Croatia
D. Kosutic, V. Uglesic, D. Perkovic, Z. Persic, L. Solman, S. Lupi-Ferandin,
P. Knezevic, K. Sokler, G. Knezevic: Preoperative antiseptics in clean/contaminated
maxillofacial and oral surgery: prospective randomized study. Int. J. Oral Maxillofac.
Surg. 2009; 38: 160165. # 2009 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. In order to show the effectiveness of preoperative antiseptic mouthwash the

authors undertook a prospective study in 120 patients who underwent elective
surgery under general or local anesthesia. Patients were allocated toone of 4 groups,
depending on whether the oral cavity was washed preoperatively with 1%
cetrimide, chlorhexidine, povidon-iodine or sterilized normal saline solution
(control group). Aerobic and anaerobic bacterial samples were taken from the
inferior vestibulum mucosa before surgery, 5 min after the start of the operation and
at the end of the procedure. The results show a statistically significant reduction in
bacterial counts during procedures in which antiseptics are used to wash the oral
cavity preoperatively. 1% cetrimide solution was the most successful in reducing
Keywords: preoperative oral cavity washing;
intra-oral bacterial counts and produced the longest lasting antiseptic effect.
antiseptics; bacterial counts reduction; intra-
Chlorhexidine is a good option for procedures longer than 1 hour, while povidon- oral surgery; postoperative infections.
iodine is recommended for procedures lasting up to 1 hour. Normal saline reduced
bacterial counts in the specimen taken 5 min after washing but this short-lasting Accepted for publication 24 November 2008
effect is due to mechanical cleansing rather than the antiseptic effect. Available online 22 January 2009

Local postoperative infections are one of
the main causes of morbidity in max-
illofacial and oral surgery. The risk of
infection is increased in intra-oral surgi-
cal procedures because it is practically
impossible to attain aseptic conditions
owing to the large number of bacteria
in the normal mouth. Infections in this
region are polymicrobial (caused by
anaerobic and aerobic bacteria)3. Quali-
tative microbiological analyses show
that local wound contamination by the
intra-oral bacterial flora is the usual
cause of infection19,10. The normal bac-
terial flora in the oral cavity is variable
and consists of potentially pathogenic
anaerobic (90%)2 and aerobic bacteria
at an average concentration of 107108
colonies per 1 ml of saliva14 or 1011/
cm2,8. According to Johnson et al.13,
76% of intra-oral bacteria are Bacter-
oides spp., usually B. melaninogenicus
and B. oralis. Temporary reduction of
intra-oral bacterial counts can reduce the

0901-5027/020160 + 06 $30.00/0 # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

risk of postoperative infection26,30. Peri-
operative antibiotic prophylaxis has been
used for several decades; usually intra-
venously, seldom topically or in combi-
nation, but almost exclusively for
procedures performed under general,
not local, anaesthesia. There is no gen-
erally accepted universal protocol for
perioperative antimicrobial prophylaxis
in maxillofacial and oral surgery11.
The most frequently used antibiotic for
perioperative, intravenous prophylaxis in
maxillofacial surgery, cephasolin, does
not affect postoperative intra-oral bac-
terial counts30. The preoperative use of
antiseptics in maxillofacial and oral sur-
gery is controversial. Many studies con-
firm they reduce intra-oral bacteria and
decrease bacteraemia during intra-oral
surgical procedures21,27,31,35 but most
surgeons are not convinced of their
effect on intra-oral bacterial counts or
reduction in postoperative infections11.
The most frequently used antiseptic
solutions in maxillofacial and oral sur-
gery are 0.12%, 0.2% and 1% chlorhex-
edine solutions and 1% povidone-iodine
solution. A few large reports compare
the in vivo effect of these two antiseptics
for preoperative use in intra-oral surgical
procedures in maxillofacial and oral
surgery21,23. A few studies investigate
the effect of washing the oral cavity
with antiseptic solution instead of
using the antiseptics as a preoperative
mouthwash24,30, especially for surgical
procedures under local anaesthesia. In
vivo prospective studies using 1% cetri-
mide solution for preoperative deconta-
mination of the oral cavity have not been
published.
The purpose of this study was to
compare preoperative oral cavity decon-
tamination using 3 different antiseptic
solutions (1% solutions of povidone-
iodine, chlorhexidine-gluconate and cetri-
mide) and a sterilized physiological
solution (control group) to reduce intra-
oral bacterial counts during and at the end
of clean/contaminated surgical procedures
within the oral cavity and to determine the
most efficient one.
Materials and methods
Study design
This single-blind, prospective, rando-
mized clinical study included 120 patients
who underwent elective surgery within the
oral cavity. Only patients with exclusively
elective intra-oral surgical procedures
under local or general anesthesia were
included in the study.
Pre-operative antiseptics in maxillofacial and oral surgery
Inclusion and exclusion criteria
Exclusion criteria were: acute maxillofa-
cial trauma; malignant tumor of the oral
cavity, oropharynx or larynx; intra-oral
surgical procedure within 2 weeks of the
study; antibiotic therapy within 2 weeks of
the study; active infection or open wound
intra-orally; and allergies to any substance
investigated in the study. All patients gave
their informed consent before inclusion.
Hypotheses
The hypotheses were: mechanical cleans-
ing or preoperative oral cavity washing
with a solution that has no known bacter-
icidal effect (sterilized physiological
solution in the control group) will not
reduce intra-oral bacterial counts during
surgery in the oral cavity; and preopera-
tive oral cavity washing with antiseptic
solution can efficiently reduce intra-oral
bacterial counts during surgery and
decrease the incidence of local postopera-
tive infections.
Bacterial sampling and timing
Patients were randomized into four
groups, with 30 patients each, in which
the oral cavity was washed preoperatively
with: sterilized 0.9% NaCl solution (nor-
mal saline; control group); 1% chlohex-
idine-gluconate solution; 1% povidone-
iodine solution; and 1% cetrimide solu-
tion. Six samples for quantitative micro-
biological analysis were taken from the
inferior oral vestibulum in each patient:
preoperatively before oral cavity washing
with one of the study solutions (aerobic
and anaerobic bacteria); preoperatively
5 min after oral cavity washing (aerobic
and anaerobic bacteria); and at the end
of the surgery (aerobic and anaerobic
bacteria). Sampling was based on a perso-
nal modification of a Count-Tact range
(bioMerieux, Marcy-lEtoile, France)
standardized method for surface bioconta-
mination microbiological control. The ori-
ginal method uses sterile (previously
irradiated) culture media plates that allow
direct application to the test surface (walls,
floors, skin, mucosa) as described by the
manufacterer and has been quality control
certified (ISO standard). For testing sur-
face bacterial contamination, the agar
plate is applied directly to the tested sur-
face for 10 s and then incubated according
to the indications. This idea of direct
contacttransfer of bacterial sample from
the oral cavity mucosa to the culture media
via sterilized micropore tapes was used.
Micropore tapes (3M00 , St.Paul, MN,
161
USA), 1  1 cm in dimension, previously
sterilized under pressure (13 min/134 8C/
202, 6 kPa), were used to take a print
from the mucosa of the inferior vestibulum
for 5 s. The sample was transferred imme-
diately to an appropriate culture media for
aerobes (aerobic sheep blood agar plate)
and anaerobes (anaerobic brucella agar
enriched with 5% sheeps blood and sup-
plemented with vitamin K and hemin) and
taken to 37 oC in a thermostat. Anaerobic
samples were cultivated under anaerobic
conditions (Genbox anaer, bioMerieux,
Marcy-lEtoile, France). The number of
bacterial colonies was counted after 48
72 h of incubation for aerobes and 57
days for anaerobes by an experienced
microbiologist. A direct method of asses-
sing the number of bacterial colonies was
performed using the Zeiss-Micro-Video-
mat opto-electronic image analyzer (Carl-
Zeiss, Jenna, Germany), which allowed
accurate examination of the agar plate,
counting of the bacterial colonies by con-
tinous magnification and illumination,
and the detection and recording of differ-
ences in optical density between bacterial
colonies and agar. The enumeration and
surface evaluation was performed automa-
tically and could be read immediatelly
in analogue values, indicating absolute
counts in parts per thousand of the area
of the colonies in the observation field.
Preoperative antiseptic oral cavity wash-
ing was performed with sterilized gauze
soaked in 30 ml of study solution. Data on
age, gender, diagnosis, type of and length
of procedure, allergies, smoking, antisep-
tic solution used for preoperative oral
cavity washing, and clinical evidence of
local postoperative infection 7 days after
intra-oral surgery were collected from
every patient at a follow-up examination.
Statistical analysis
The statistical methods used for correlat-
ing changes in anaerobic and aerobic bac-
terial counts after the oral cavity had been
washed with one of the study solutions in
relation to preoperative and postoperative
intra-oral bacterial counts were non-para-
metric sign and signed rank tests. The
non-parametric Wilcoxon exact test for
independent samples was used to correlate
the changes in intra-oral anaerobic and
aerobic bacterial counts and the occurence
of local postoperative infection depending
on the solution used. The same test was
used to evaluate the connection between
the length of surgery and postoperative
infection as well as smoking and intra-oral
bacterial counts. The connection between
the type of surgery and intra-oral bacterial
162 Kosutic et al.

count, depending on the solution used was

evaluated by the Kruskall-Wallis test or
non-parametric ANOVA.

Results
All three antiseptic solutions produced a
statistically significant reduction in aero-
bic and anaerobic oral cavity bacterial
counts in samples taken 5 min after wash-
ing and those taken at the end of surgery
(povidone-iodine P  0.001, chlorhexe-
dine P  0.001, cetrimide P  0.001)
(Figs. 14). 1% povidone-iodine solution
was highly efficacious with a 245 times
decrease in aerobic and 867 times
decrease in anaerobic bacterial counts in
a sample taken 5 min after washing and
decreases of 175 times in aerobic and 81
times in anaerobic bacterial counts com-
pared with bacterial counts before its
application. None of the patients in the
povidone-iodine group developed local
postoperative infection. 1% Chlorhexe-
Fig. 1. Changes in aerobic bacterial counts after oral cavity washing with 1% povidone-iodine
dine solution revealed was stronger in
(Betadine), cetrimide, chlorhexedine and normal saline solution (mean values).
reducing anaerobic (1865 times decrease
5 min after washing) than aerobic bacteria
(13 times decrease 5 min after washing). significant reduction of oral cavity bacterial postoperative infection in the normal saline
Absolute values of intra-oral bacterial counts 5 min after application (sign P = group. There was almost a 6  103
counts were low after application of 1% 0.0004, signed rank P  0.001) in both decrease of aerobic bacterial counts and
chlorhexedine solution indicating its stable aerobic and anaerobic bacteria. Bacterial 1.5  103 decrease in anaerobic bacterial
and prolonged bactericidal effect. None of counts in the group using sterilized normal counts 5 min after washing with 1% cetri-
the patients in this group developed local saline at the end of surgery compared mide solution, and a decrease of almost
postoperative infection. Preoperative oral with starting bacterial counts in relation 7  103 in aerobes and a 100 times decrease
cavity washing with sterilized normal sal- to time show a relatively fast increase in anaerobes at the end of surgery. Local
ine solution produced small (1.5 times towards the preoperative and pre-washing postoperative infection occured in one
decrease for aerobes, 33 times decrease counts, shortly after this small and short patient in the cetrimide group and was
for anaerobes) and a short but statistically reduction. Three patients developed local treated successfully with antibiotics. The
connection between anaerobic bacterial
counts after oral cavity surgery and the
incidence of local postoperative infection
in patients treated with sterilized normal
saline preoperatively was proved (Wil-
coxon exact test P = 0.04). The duration
of surgery was not related to the incidence
of local postoperative infection (Wilcoxon
exact test P = 0.02). Smoking did not affect
the initial number of bacterial counts in the
patients (one sided Z-test P = 0.28). The
number of oral cavity bacteria at the end of
sugery is not connected with the type of
procedure (Kruskall-Wallis test P = 0.54).

Discussion
Most maxillofacial and oral surgeons are
not convinced of the efficacy of oral cav-
ity decontamination with preoperative
antiseptics30, but the present results
clearly confirm a substantial reduction
in intra-oral bacteria shortly after their
use. The effect of antiseptic solutions
Fig. 2. Changes in aerobic bacterial counts 5 min after washing and after surgery (IIIII on the reduction of bacterial counts in
sample). the oral cavity has been well reported,

Fig. 3. Changes in anaerobic bacterial counts after oral cavity washing with 1% povidone-
iodine (Betadine), cetrimide, chlorhexedine and normal saline solution (mean values).
but most studies used antiseptics only as a
mouthwash8,21,27,31,35. The oral cavity
was mechanically washed with antiseptic
solution in only a few reports24,30. In all
the present patients the oral cavity was
washed preoperatively to mechanically
cleanse it. This mechanical cleansing,
although scientifically underestimated,
contributed to the initial small, but statis-
tically significant, decrease in intra-oral
bacterial counts in a sample taken 5 min
after the oral cavity had been washed with
sterilized normal saline (control group).
Fig. 4. Changes in anaerobic bacterial counts 5 min after washing and after surgery (IIIII
sample).
Pre-operative antiseptics in maxillofacial and oral surgery
This result overuled one of the authors
hypotheses that oral cavity washing with
normal saline would not reduced intra-
oral bacterial counts. This reduction was
short lived and the bacterial counts
showed a relatively fast increase towards
the preoperative and pre-washing counts
which confirms that normal saline has no
antiseptic qualities and cannot be recom-
mended for preoperative oral cavity
decontamination. The occurence of local
postoperative infection in three patients in
the saline group, although statistically
163
insignificant is clinically important, and
shows the inneffectiveness of saline in
reducing oral cavity bacteria. One study30
shows that 14% of maxillofacial surgeons
in the USA use normal saline for preo-
perative oral cavity decontamination.
Most studies concerning the preoperative
reduction of oral cavity bacterial counts
deal with small numbers of patients so do
not reach statistical significance, which
makes the quality of the results and con-
clusions questionnable. In this prospec-
tive randomized study, 120 patients were
divided into 4 groups with 30 patients in
each group which makes, by definition,
the low border of a statistically large
sample. According to current opinion,
systemic preoperative antibiotic prophy-
laxis is the mainstay of good surgical
practice in clean / contaminated proce-
dures. Some studies have shown that
many preoperatively systemically used
antibiotics do not reach an effective con-
centration in saliva18,29, which limits their
effect to only those bacteria that enter the
bloodstream during surgery. Many anti-
biotics used prophylactically do not pos-
sess an adequate spectrum to cover
potential intra-oral pathogens13,20. Sev-
eral meta-analyses demonstrate that less
than two-thirds of surgical patients
receive systemic preoperative antibiotic
prophylaxis within 2 h before surgery,
when it has the desired effect4,28. There
is no generally accepted protocol regard-
ing the type of antibiotic or its dosage to
be used for preoperative prophylaxis in
surgical procedures in the oral cavity.
Topical use of antibiotics, although rela-
tively effective5,6,9,15,16, is not routine for
preoperative prophylaxis probably because
of the possibility of allergic reactions, the
potential for inducing bacterial resistance
and the cost. These negative effects can be
avoided by using antiseptic solutions for
preoperative prophylaxis with similar or
even better efficacy in preventing local
postoperative infections after intra-oral sur-
gery26. The present results confirm the
efficacy of 1% povidone-iodine solution,
which proved statistically significant and
resulted in no local postoperative infections
in that group. This is consistent with a study
in which preoperative povidone-iodine
mouthwash in oral cavity cancer patients
resulted in 5% of postoperative infections
compared with 32% in the control group24.
The authors noted a slight increase in bac-
terial count in the povidone-iodine group
20 min after washing, which was more
pronounced in anaerobes, but still well
under 10% of values before its application.
The authors conclude that this antiseptic
is very effective in reducing oral cavity
164 Kosutic et al.
bacterial counts up to 1 hour from the start
of operation, which makes it suitable for
shorter procedures (oral surgery in local
anaesthesia). These results are supported
by several smaller studies1,7,21,23,36. The
authors also noticed that its favourable
organo-leptic qualities are important when
the oral cavity is preoperatively washed in
awake patient.
Chlorhexedine solution in 0.12% and
0.2% concentrations proved to be effec-
tive in intra-oral procedures in stomatol-
ogy9,15,17,26,35. The results show that 1%
chlorhexedine solution is more efficient
against anaerobic than aerobic bacteria
with overall strong and prolonged bacter-
icidal effect. The authors recommend it for
oral cavity surgical procedures that last
more than 1 hour (general anaesthesia).
The prolonged bactericidal effect is
related to the known adherence of chlor-
hexidine to proteins, bacteria and the
extracellular polysaccharides of the oral
cavity mucosa as well as its gradual
release from the retention site22,32.
Although the intra-oral surgery lasted less
than 1 hour in most patients, the recom-
mendation made above is based on a time-
related bacterial count curve established
after statistical analysis.
Vahtoinemi et al.34 reported an increase
in alpha-haemolitic Streptococccus spp.
one day after 0.2% chlorhexedine
mouthwash, but there was no evidence that
this increase had any clinical impact on
postoperative infections. The authors think
that it is more important to decrease bacter-
ial counts during and at the end of intra-oral
surgical procedures while the mucosal inci-
sions have not been sutured. Some authors
claim that chlorhexedine can be toxic if in
direct contact with submucosal tissues33,
but the authors have not noticed any sign of
toxicity and no side effects other than
unpleasent taste and dryness in the mouth
after washing in patients undergoing sur-
gery under local anaesthesia. Cetrimide
solution has been used for antiseptic pur-
poses for a long time, but there are no
studies regarding its use for oral cavity
decontamination. There are reports of a
strong, prolonged effect from some other
antiseptics in a similar chemical group
(quarter ammonium compounds)12. The
present study investigated the in vivo effi-
cacy of a 1% concentration of cetrimide on
reduction of intra-oral bacterial counts. The
results showed a statistically significant
decrease in the oral cavity bacteria for both
aerobes and anaerobes, which is important
for clinical practice. Such efficacy, in terms
of reduction of bacterial counts and dura-
tion of effect, was not found with any other
antiseptic in this study. One postoperative
local infection occurred, which was not
statistically significant. Aqueous solutions
of cetrimide are theoretically exposed to
contamination by micro-organisms25,
therefore it is necessary to sterilize the
compounds or make the solution shortly
before use. This might preclude its clinical
use until a pre-sterilized fabricated solution
is marketed. Smoking, age of patient and
type of intra-oral surgery did not affect the
intra-oral bacterial counts in this study.
Author agreement
Each author discloses at the time of sub-
mission any commercial associations or
special funding for this work that might
pose or create a conflict of interest with
information presented in this manuscript.
Such associations include consultancies,
stock ownership or other equity interests,
patent-licensing arrangements and pay-
ments for conducting or publicising a
study described in the manuscript.
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Address: Damir Kosutic
Department of Plastic and Reconstructive
Surgery
University of Maribor General Hospital
2000 Maribor
Slovenia
Tel: +386 41 33 44 57
E-mail: dkosutic@hotmail.com