|Year : 2022 | Volume
| Issue : 2 | Page : 120-127
Microbiological Evaluation of the Antibacterial Vicryl Suture in the Mandibular Third Molar Extraction Surgery
Milad Etemadi Sh1, Sameen Rahgozar2, Golnaz Tajmiri DDS 3, Javad Alizargar4, Sayed Arash Mirsatari5
1 Department of Oral and Maxillofacial Surgery, Dental Implants Research Center, Dental Research Institute, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
2 Dental Students’ Research Committee, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
3 Dental Implants Research Center, Dental Research Institute, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
4 Research Center for Healthcare Industry Innovation, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
5 Department of Anesthesiology and Intensive Care Medicine, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||20-May-2022|
|Date of Decision||20-Aug-2022|
|Date of Acceptance||25-Aug-2022|
|Date of Web Publication||10-Jan-2023|
Research Assistant, Postal address: Dental Implants Research Center, Dental Research Institute, School of Dentistry, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Introduction: Suture materials selection and application have gained more importance, especially with the increasing number of patients seeking oral surgeries. Since lying in a bacterial-filled environment, sutures make the tissue prone to infection. Suture material plays an essential role in reducing the risk of infection. This study aimed to assess the success rate of an antibacterial suture, Vicryl Plus (Ethicon Inc, Johnson and Johnson Company, Somerville, NJ), in preventing bacterial growth in the surgical site of the mandibular third molar. Materials and Methods: About 27 patients were included in this double-blinded randomized clinical trial study. Surgical extraction of the mandibular wisdom tooth was done, and the incision was managed by randomly using Vicryl Plus and Vicryl (Ethicon Inc) sutures. After 7 days, sutures were removed and assessed microbiologically. Indicator species of Streptococcus mutans and Lactobacillus were assessed, and the total number of colonies on each suture was counted. Results: There was a significant difference between the two suture materials in the colony number-length ratio of Lactobacillus (P = 0.031) and total bacterial colonies (P = 0.016), but not for S. mutans species (P = 0.201). Conclusion: Antibacterial Vicryl suture can be a useful tool to reduce bacterial accumulation on the suture material in third molar extraction surgery.
Keywords: Bacterial adhesion, surgical wound infection, suture material, third molar surgery
|How to cite this article:|
Sh ME, Rahgozar S, Tajmiri G, Alizargar J, Mirsatari SA. Microbiological Evaluation of the Antibacterial Vicryl Suture in the Mandibular Third Molar Extraction Surgery. J Orofac Sci 2022;14:120-7
|How to cite this URL:|
Sh ME, Rahgozar S, Tajmiri G, Alizargar J, Mirsatari SA. Microbiological Evaluation of the Antibacterial Vicryl Suture in the Mandibular Third Molar Extraction Surgery. J Orofac Sci [serial online] 2022 [cited 2023 Feb 1];14:120-7. Available from: https://www.jofs.in/text.asp?2022/14/2/120/367440
| Introduction|| |
The mandibular third molar is the most common tooth extracted by surgical procedures, which causes an interruption in tissue integrity and wound formation. For maximal wound repair and decreasing morbidity, surgeons must have enough information about significant factors that affect wound repair. One of these major factors is the selection of suture material which may cause wound infection by improper utilization.,, It also can be the route of bacterial transmission to the wound site due to bacterial adhesion. This bacterial adhesion partly depends on the bacterial species, characteristics, and chemical structure of the suture material.,
Silk is the most commonly used suture material in oral surgery. Silk is cheaper than other materials and easy to manipulate, while on the other hand, silk is comparatively prone to biofilm attachment and bacterial colonization. For these reasons, oral surgeons have sought a better replacement for silk sutures in the last two decades. In recent years, antibacterial-coated sutures were manufactured and introduced to the market and are used without adequate clinical studies and scientific evidence.
Recently, the intraoral application of nylon suture material is claimed to be superior to the polyfilamentous suture materials in terms of microbial accumulation mainly since bacterial adhesion to the monofilament nylon is significantly less than silk, Vicryl, and polyester.
Triclosan (5-chloro-2-(2,4-dichlorophenoxy)phenol, TCS) is a halogenated phenol and a broad-spectrum antimicrobial agent which is used all over North America, Europe, and Asia as an agent in disinfectant materials, soap, toothpaste, mouth rinse, cloth, deodorant, shampoo, and as an additive to plastic materials. TCS is an effective agent against many species of bacteria and particular kinds of fungi. It penetrates the cell wall by targeting multiple cytoplasmic and membrane receptors; it changes bacterial RNA synthesis and macromolecule production, interfering with bacterial growth and causing cellular death.
Cruz et al. assessed the effect of manipulation of sutures coated with antiseptic ointment (iodoform + calendula) in the reduction of bacterial colonization in a clinical trial study on 40 volunteer patients. The patients were randomly divided into two groups, case and intervention. Two millimeters (mm) of the suture were removed on days 1 and 15 after the surgery, and they evaluated the colony-forming units per milliliters (CFU/mL) in each group. There was a significant decrease in bacterial growth in the case group (P = 0.002). So, they concluded that the antiseptic ointment is effective in bacterial growth decline on silk sutures.
In 2011, Galal and El-Hindawy evaluated the effect of coating the suture materials with TCS, as an antibacterial agent, on the incidence of infection in surgical sites. In this prospective randomized double-blinded study, the total number of 450 patients was divided into two groups: 230 patients in the control group and 220 patients in the intervention group. The comparison was made according to the risk factors of infection in the surgical sites. The incidence of infection was 7% in the case group and 15% in control one (P = 0.011). They concluded from this study that antimicrobial Polyglactin 910 suture material can save health care resources as much as 1.5 million USD annually.
Recent studies in fields other than oral surgery have shown that TCS is an effective agent in reducing bacterial growth on the skin and the incidence of postoperative infection due to its antimicrobial properties. However, there are contradictory studies in the field of oral surgery which have shown that antibacterial Vicryl suture (Ethicon Inc, Johnson and Johnson Company, Somerville, NJ) is ineffective in reducing the number of gram-negative bacteria and can have adverse effects on normal oral flora; thus, its use is not recommended. On the other hand, systematic review studies have evaluated the effectiveness of Vicryl Plus (Ethicon Inc) suture against Vicryl suture material in a meta-analysis showing a significant difference in surgical site infection (SSI) based on low-graded Randomised Controlled Trial (RCTs) with a high risk of bias and imprecision.
Despite the extensive advertisement for Vicryl Plus suture materials, limited research has evaluated the effectiveness of this new product in surgeries involving mucosa. Besides, the different microbiological characteristics of the skin and mucosa and the rinsing effect of saliva can probably have an ablative effect on Vicryl Plus sutures leading to the nonsignificant clinical and microbiological difference between coated and noncoated sutures. Due to all the abovementioned factors, we decided to assess the efficacy of these suture materials in bacterial growth reduction in the oral cavity.
This study aimed to compare the efficiency of the Vicryl (noncoated) and Vicryl Plus (TCS-coated) sutures in reducing the number and variety of bacterial species related to the manipulation of these suture materials in the oral cavity during the third molar surgery.
| Materials and Methods|| |
The sample size calculation (27 patients and 52 samples, respectively) was done using the formula for comparison of two means, and a difference of 1.3 × 104 CFU/mL was considered statistically significant with α-error = 0.05 and 1 − β = 0.80. This study was a double-blinded study in which none of the patients, surgeons, and microbiological technicians knew the exact location of Vicryl and antibacterial Vicryl sutures.
This study followed the Declaration of Helsinki on medical protocol, and ethical approval for this study (IR.MUI.RESEARCH.REC.1398.038) was provided by the Regional Ethical Review Board of Isfahan University of Medical Sciences, Isfahan, on May 7, 2019. All patients who participated in this study signed informed consent. The patient’s unwillingness to continue participating in the study came into consideration. All patients’ information was kept confidential in this study. This study has been registered on the Iranian clinical trial registry website.
Samples were selected among patients referred to the specialty section of the oral and maxillofacial department of the dentistry faculty of Isfahan University of Medical Sciences between May 2019 and July 2019. To be included in this study, patients had to have good oral hygiene and at least one mandibular third molar indicated for surgical extraction with the same degree of difficulty (type A mesioangular impaction), which was diagnosed through clinical and radiographic examination. Biographic data were taken (age, gender, address, and telephone number). Then medical and dental history, including pregnancy and breastfeeding, overall systemic condition, history of using medications in the last month, and history of pulpitis or any malignant lesion at the site of surgery, were evaluated and recorded through clinical and radiographic examination. Patients with underlying systemic diseases, using systemic or oral medication affecting normal oral flora and colonization, smoking and drug addiction, alcohol addiction, presence of intraoral inflammation before the surgery, pregnancy, and lactation, known or suspected allergy to suture material or other materials used in this study, loss of sutures before 1 week, presence of removable prosthesis in the oral cavity, and presence of infection after surgery or any other condition indicated for antibiotic therapy were excluded from this study.
An identification number (ID number) from one to 27 was considered for each patient. Similar sterile sets were used for all patients. The surgery site was prepared with Betadine, Daru Gostar Hejrat, Tehran, Iran and draping was performed for all patients in the same manner. Local anesthesia was obtained for all patients with lidocaine 2% and epinephrine 1:80,000. After reflecting a standard mucoperiosteal flap, bone removal and extraction of the tooth were performed and suturing was done with randomly placed Vicryl suture and Vicryl Plus suture in the mesial and distal part of the surgical site. For randomization purposes, in patients with an odd ID number, Vicryl suture was placed in the mesial part and Vicryl Plus sutures in the distal part of the flap. In patients with an even ID number, the Vicryl Plus suture was placed in the mesial part of the flap, while the Vicryl suture was placed in the distal part. All the instruments, including the injection needle, blade, elevator, and suture, were initially sterile. For blinding purposes, all procedures were performed by a single surgeon; sutures were peeled open out of the surgeon’s sight and then given to him. Cutting was done to permit 3 mm of the suture to be held out of the tissue. After considering a code for each type of suture material, the exact location of the suture at the surgical site was documented (i.e., “1M” means Vicryl suture in mesial and “2D” means Vicryl Plus suture in distal). Ibuprofen (soft gel capsule/400 mg) was prescribed as a pain control medicament and extra gauze was given to the patient for application on the surgical site for 1 hour. Postsurgical patient instruction for oral hygiene was done. Patients were also instructed not to use any antiseptic mouth rinse for the first week after surgery before they were discharged. After 7 days, patients were recalled to remove the sutures, and each suture was placed in a 5 cc saline-filled test tube with a code number on it as recorded at the surgery. The test tubes were transported to the microbiological laboratory of Amin Hospital in <1 hour. Patients were carefully evaluated for wound complications, including bleeding and wound dehiscence, and clinical examination was done to assess signs and symptoms of SSI postsurgically.
In the laboratory, after measuring the length of the removed sutures, they were transferred separately to the thioglycolate culture media and processed within 1 hour. A one-tenth diluted solution with 0.9% NaCl was made for each sample. The samples were vortexed (15 seconds, Cyclomixer, Becton Dickinson, New Jersy, USA, CM 101), then inoculated on the dry Mitis Salivarius agar (Becton Dickinson, New Jersy, USA) for detecting Streptococcus mutans and Rogosa agar (Difco) for detecting Lactobacillus spp. The plates were incubated at 37°C in a 5% to 10% CO2 jar for 48 hours. After 48 hours, colony characteristics were studied and the CFU count was determined. Afterward, the carbohydrate fermentation test (including mannitol, sorbitol, raffinose, arginine, and arginine urea), bile esculin test, and Voges–Proskauer test were performed and bacterial species were diagnosed using the Finegold table. Gram coloring was done and cellular morphology was assessed under an optical microscope. S. mutans and Lactobacillus were considered as predominant bacterial species regarding the outcomes of similar studies evaluating the bacterial load following oral surgeries, which had reported these two species as predominant ones. The number of colonies (CFU/mL) for S. mutans and Lactobacillus was counted, and an evaluation of colonies with different morphology, color, size, and the hemolytic reaction was performed to determine the predominant bacterial species. For making measurements comparable, the mean number of colonies for S. mutans, Lactobacillus, and the total number of colonies were divided into the length of the suture material (CFU-length ratio) to get the number of colonies per length of suture for comparison. The decrease in the predominant and total species was calculated by subtracting the number of species in the Vicryl Plus from the Vicryl sutures in each patient. The statistical method used in this study was descriptive analytics and the exact test was performed with the SAS statistical software version 9.4 (SAS Institute, Cary, NC).
| Results|| |
Three samples were lost in three patients when returned for suture removal appointments (one Vicryl Plus and two Vicryl sutures); the total number of samples was 51 from 27 patients with a mean age ± SD of 23.7 ± 3.1 years, including six men (22%) and 21 women (78%). No wound complication, including bleeding and wound dehiscence, was detected after surgery, and there was no clinical sign or symptom of SSI postsurgically. The two most frequent bacterial species were S. mutans and Lactobacillus [Figure 1]. The mean length of Vicryl Plus (5.97 ± 2.37) suture was slightly greater than Vicryl (5.22 ± 2.03) suture but not statistically significant (paired t test, P = 0.06). The mean CFU-length ratio ± SD for the total bacterial species in the patients of our study for Vicryl and Vicryl Plus was 1.19 ± 0.44 and 1.03 ± 0.31, respectively. This ratio for S. mutans was 0.55 ± 0.21 and 0.52 ± 0.17 and for Lactobacillus was 0.31 ± 0.15 and 0.27 ± 0.10, respectively [Figure 2]. By using Vicryl Plus sutures, the total colonies of bacteria and Lactobacillus had decreased (compared to Vicryl) in 21 patients (77.78%) and 20 patients (74.07%), respectively (P = 0.005 and 0.019, respectively) [Table 1]. The decrease in the CFU-length ratio in each patient can be seen in [Figure 3],[Figure 4],[Figure 5].
|Figure 1 Percentage of the bacterial species following gram coloring in Vicryl and Vicryl Plus groups.|
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|Figure 2 Comparison of the CFU-length ratio of different bacterial species in Vicryl and Vicryl Plus sutures.|
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|Table 1 Changes in the CFU/length in different bacterial colonies by using Vicryl Plus (Vicryl Plus minus Vicryl)|
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|Figure 3 Decrease in the CFU-length ratio regarding the total bacterial species (calculated by subtracting the CFU-length ratio of Vicryl Plus from Vicryl in each patient).|
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|Figure 4 Decrease in the CFU-length ratio regarding S. mutans (calculated by subtracting the CFU-length ratio of Vicryl Plus from Vicryl in each patient).|
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|Figure 5 Decrease in the CFU-length ratio regarding Lactobacillus (calculated by subtracting the CFU-length ratio of Vicryl Plus from Vicryl in each patient).|
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| Discussion|| |
Our results showed that using Vicryl Plus sutures coated with TCS compared to Vicryl in the mandibular third molar surgery significantly reduced the total number of bacterial colonies’ CFU-length ratio and Lactobacillus colonies’ CFU-length ratio. However, it also decreased the S. mutans colonies’ CFU-length ratio, which was not statistically significant in the patients. Previous in vitro studies have shown that Vicryl Plus sutures can effectively inhibit the growth of Staphylococcus aureus, methicillin-resistant S. aureus, Staphylococcus epidermidis, and methicillin-resistant S. epidermidis, all are major microorganisms in SSI in the skin. On the other hand, in a meta-analysis done by Guo et al. in 2016, the effect of TCS-coated sutures on decreasing wound infection was evaluated. Thirteen randomized clinical trials with a total sample of 5256 patients were included. TCS group had a lower risk of SSI in every surgery in comparison with noncoated sutures (risk ratio [RR] = 0.76, 95% confidence interval [CI] = 0.65–0.88, P < 0.001). The same ratio of wound opening was observed in two groups (RR = 0.97, 95% CI = 0.99–0.99, P = 0.92). They concluded that TCS-coated sutures could decrease the prevalence of SSI in abdominal surgeries, yet, microbiological differences in two surgical sites (oral cavity versus abdomen) should be considered. In the later site, sutures were placed in the depth of the wound, which in contrast to the oral cavity, were not exposed to the contaminated environment. In another meta-analysis by Edmiston et al., 3568 patients in 13 RCTs were assessed, showing the effectiveness of Vicryl Plus in reducing postoperative infections. Similar results were reported in Guo et al.’s meta-analysis, which was done on 5268 patients, confirming our work’s outcomes.
However, there should be a more scientific base for judgment if TCS-coated sutures have an actual preventive effect on SSI incidence in nonabdominal surgeries. The results of our study have shown that an antibacterial Vicryl suture reduces bacterial load in the mandibular third molar extraction surgery as a nonabdominal surgery.
Storch et al. reported a 96.7% decrease in S. aureus-related SSI after 48 hours of Vicryl Plus; Ming et al., in a similar study, reported a decrease in S. aureus and Escherichia More Details coli species using Monocryl Plus. Gomez-Alonso et al. expressed an almost 87% decrease in infection by S. epidermidis and E. coli in 16 patients receiving Vicryl Plus sutures. Finally, Marco et al. reported a 66% decrease in S. epidermidis-related SSI in rats. World Health Organization has also recommended using TCS-coated sutures, which are proven to be financially affordable. Despite the histological and microbiological differences in surgical sites (skin versus mucosa), exposure to food particles and constant secretion of saliva, and also being an environment influenced by the breathing process, all of which can have an ablative effect on the efficiency of the antibacterial suture materials, our study has supported the abovementioned results and showed that Vicryl Plus can decrease the bacterial load in the oral surgical site. It is reported in several other studies that Vicryl Plus can be an effective tool in reducing the rate of postoperative infection in abdominal,,,,,, or medullary surgeries, which were consistent with the results of our study.
Although many studies favored our results, there was some contradiction in some other studies.,, In one study by Tabrizi et al., comparing the ability of TCS-coated sutures to reduce the infection in 320 patients who underwent implant surgery, no differences were reported between Vicryl and Vicryl Plus sutures. One probable reason may be that one crucial requisite for patients undergoing implant surgery is excellent oral hygiene. The site of the surgery may be another factor that can be considered; since the site of surgery in mandibular wisdom tooth extraction is located in the most posterior aspect of the mouth, less accessibility before and after surgery can be a predisposing factor for more bacterial accumulation. Thus, antibacterial suture materials, including Vicryl Plus, can be a helpful tool for the reduction of bacterial load in cases with a high risk of infection due to patient-related factors (i.e., poor oral hygiene or immunosuppressive conditions). Moreover, in our study, an assessment of the anaerobic bacterial species that play an important role in surgical wound infection was not performed, which can be another probable explanation for the different outcomes.
In addition, the application of monofilament suture materials like nylon has shown to be effective in the reduction of bacterial adhesion in comparison to the polyfilamentous materials; however, manipulation of this material can be challenging for the operator and can increase the time of surgery as well as being prone to become untied after the surgery. Also, some studies have shown that using the sutureless technique following secondary wound healing can result in more favorable results regarding postoperative complications, including pain, swelling, trismus, and wound infection.
In another study with a split-mouth design, after surgical extraction of both impacted mandibular wisdom teeth simultaneously, suturing was performed using Monocryl Plus or silk on each side, and microbiological evaluation was done 72 hours and 7 days after surgery. The most common bacterial species were gram-positive cocci, gram-positive bacillus (Lactobacillus), and gram-negative bacillus (Prevotella). Only one case of SSI was reported after 72 hours. The utmost antibacterial effect of Monocryl Plus suture was after 72 hours. However, the difference was not significant after 5 to 7 days which is the routine time of suture removal in everyday practice in dentistry as well as in the present study, but the results were in contrast which may be due to the difference between suture materials used in the two studies; the reason may be the loss of antibacterial effect of Monocryl Plus after 72 hours while Vicryl Plus may have a more prolonged antibacterial effect in the similar situation. It seems that performing a similar study comparing these two suture materials can help assess this theory.
In an in vitro study by Venema et al., Vicryl Plus had no inhibitory effect on Streptococcus sanguis PK1889 or other microorganisms residing in saliva. This study was in contrast with our results. This might be due to the differences in the method of performing these two studies and in vitro nature of Venema et al.’s study versus in vivo nature of our study.
Our study had certain strengths and limitations. The strength of our study is the random allocation and having a parallel design with two simultaneous interventions in each participant, making the results more reliable by having control over confounding variables when compared to a design with separate case and control groups. As per the limitation of our study, since the number of female participants was noticeably more significant than male participants (21 versus six), the results of this study cannot be generalized in terms of gender. Moreover, further studies with more samples can confirm this study’s results and clarify the usefulness of Vicryl Plus sutures in reducing bacterial colonies in the surgical field. Also, using the design of the present study, SSI cannot be assessed after mandibular third molar extraction surgery; therefore, increasing the number of participants and the period of follow-up from 2 to 4 weeks could also help examine the theory whether the application of Vicryl Plus suture material can be an effective tool for reduction of the SSI rate postoperatively and this is suggested for the future studies. Comparing other antibacterial sutures can also help dentists choose the best suture material for oral surgeries. The selection of aerobic species and other common anaerobic species other than those evaluated in our study can increase the accuracy of future studies. Besides, performing other culturing and coloring techniques that were not included in our study due to their complexity and high price can be a good suggestion.
In the case of economic justification, Vicryl Plus can be a better choice due to less colonization than Vicryl. It is recommended that Vicryl Plus be compared with other commonly used suture materials regarding clinical and microbiological properties in routine oral surgeries to reveal the effects more accurately. It would be better if the microbiological laboratory were nearer to the location of performing surgeries. It would be an excellent suggestion to assess more sample numbers and aerobic species.
| Conclusion|| |
The results of our study have shown that Vicryl Plus suture is more beneficial than Vicryl suture in bacterial load reduction after mandibular third molar extraction surgery. This might benefit especially high-risk patients with poor oral hygiene.
Financial support and sponsorship
This study was funded by the Research Council of Isfahan University of Medical Sciences (Grant No. 397711).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]