Association of different socket irrigation solutions with postoperative sequelae after removal of mesioangular middle/low impacted mandibular third molars: a retrospective cohort study

Association of different socket irrigation solutions with postoperative sequelae after removal of mesioangular middle/low impacted mandibular third molars: a retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association of different socket irrigation solutions with postoperative sequelae after removal of mesioangular middle/low impacted mandibular third molars: a retrospective cohort study Yaling Xiang, Zhang Tao, Jinfen Zhang, Yi Chen, Dajun Lai This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8957951/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Postoperative pain, swelling, and trismus are common after removal of impacted mandibular third molars. Socket irrigation is routinely performed to clean the alveolar sockets, yet comparative evidence for commonly used solutions in clinical practice remains limited. Methods This retrospective cohort study reviewed consecutive patients who underwent removal of a mesioangular middle- or low-impacted mandibular third molar at the Department of Stomatology, The People’s Hospital of Zhongjiang, between January 2020 and January 2025. Patients were categorized into three groups according to the irrigation solution documented in the operative record: compound chlorhexidine, povidone-iodine, or physiological saline. Eligibility criteria and outcome definitions were prespecified. Outcomes included pain score, change in maximum interincisal opening, facial swelling measured by a three-line method, alveolar osteitis, postoperative infection, and postoperative bleeding. Statistical analyses were conducted with SPSS 22.0 (two-sided α = 0.05). Results A total of 102 patients (102 extraction sites) were included. Baseline characteristics were comparable across groups. Postoperative pain scores, reduction in mouth opening, and facial swelling were lowest in the compound chlorhexidine group, intermediate in the povidone-iodine group, and highest in the physiological saline group. Postoperative infection occurred least frequently in the compound chlorhexidine group and most frequently in the physiological saline group. No significant between-group differences were observed in alveolar osteitis or postoperative bleeding. Conclusions In routine clinical practice, socket irrigation with compound chlorhexidine after removal of mesioangular middle/low impacted mandibular third molars was associated with less pain, less trismus, less facial swelling, and a lower postoperative infection rate compared with povidone-iodine and physiological saline. compound chlorhexidine impacted mandibular third molar tooth extraction postoperative sequelae socket irrigation Figures Figure 1 1. Introduction Impaction of mandibular third molars is common and may cause pericoronitis and damage to adjacent teeth, often requiring surgical removal[ 1 ]. In clinical practice, impaction severity is frequently described using the Pell-Gregory classification[ 2 ]. Mesioangular impaction is among the most prevalent patterns and may account for up to 43% of impacted mandibular third molars[ 3 ]. Based on depth, mesioangular impactions are commonly classified as high, middle, and low[ 4 ]. Middle- and low-depth mesioangular impactions are typically more difficult to remove. The crown is often below the occlusal plane, bony resistance is substantial, and proximity to the mandibular canal is not uncommon. These cases frequently require flap elevation, osteotomy, and odontotomy, which increase surgical trauma and may aggravate early postoperative sequelae, including pain, facial swelling, and restricted mouth opening[ 5 – 7 ]. Socket debridement and irrigation are routinely performed after extraction. Physiological saline provides mechanical lavage but has limited antimicrobial activity. Therefore, an ideal irrigant should assist in cleaning the socket while reducing microbial burden and postoperative inflammation. Commonly used solutions include chlorhexidine and povidone-iodine; chlorhexidine has broad antimicrobial activity with substantivity, whereas povidone-iodine provides rapid broad-spectrum killing through free iodine release[ 8 – 10 ]. Compound chlorhexidine, a combination formulation mainly containing chlorhexidine and metronidazole, may offer complementary coverage, particularly against anaerobes[ 11 ]. Although antiseptic/antimicrobial irrigants may reduce postoperative complications compared with physiological saline, direct comparisons among compound chlorhexidine, povidone-iodine, and physiological saline for socket irrigation after removal of mesioangular middle/low impacted mandibular third molars remain limited. Early postoperative sequelae can impair oral function and patient experience, and infection or alveolar osteitis may prolong recovery. We therefore compared pain, swelling, trismus, and postoperative complications among patients receiving these three irrigation solutions in routine practice. 2. Materials and methods 2.1 Study design and participants Patients receiving removal of a mesioangular middle- or low-impacted mandibular third molar at the Department of Stomatology, The People’s Hospital of Zhongjiang between January 2020 and January 2025 were enrolled. Depending on the type of irrigation solution used, a total of 102 patients were allocated to three groups (n = 34 per group): the compound chlorhexidine group, the povidone-iodine group, and the physiological saline group. The inclusion criteria were as follows: Healthy patients aged from 18 to 60 years and required surgical removal of a mandibular third molar. The extracted tooth was a mesioangular mandibular third molar with middle or low impaction depth. Oral condition was acceptable, with no residual roots/crowns and no severe periodontitis. Patients were in good general health and had no contraindications to surgery. Patients who fully participated in and had their follow-up records kept. The exclusion criteria were as follows: Severe local infection at the surgical site (severe pericoronitis; alveolar abscess; apical periodontitis; periodontitis). Severe periodontitis. Major systemic conditions likely to affect healing or infection risk (e.g., uncontrolled diabetes; severe hematologic disease). Malignancy with chemotherapy/radiotherapy history. Pregnancy or lactation (or attempting to conceive during perioperative period). Insufficient follow-up records for outcome evaluation. 2.2 Surgical procedure and irrigation protocol All patients underwent preoperative CBCT for surgical planning. Under local anesthesia (inferior alveolar nerve block with lidocaine), a full-thickness mucoperiosteal flap was elevated. Osteotomy was performed using a high-speed handpiece with saline cooling. Odontotomy (T-shaped sectioning) was performed when indicated, and the tooth was delivered along the planned path. The socket was thoroughly debrided to remove granulation tissue and debris, followed by irrigation with compound chlorhexidine (Jinkouxin, Jiangsu Chenpai Bande Pharmaceutical Co., Ltd., Jiangsu, China), povidone-iodine (Yisuxin, Zhejiang, China), or physiological saline (Keli Bag, Sichuan Kelun Pharmaceutical Co., Ltd., Sichuan, China). The flap was repositioned and closed with interrupted 3 − 0 sutures. Patients applied pressure with gauze for 30 minutes for hemostasis. 2.3 Outcome measures 2.3.1 Pain score Pain score was assessed using a 100-mm visual analog scale on postoperative day 7. Patients marked their overall pain during the healing period; the distance from the “no pain” anchor (mm) was recorded as the VAS score. 2.3.2 Maximum interincisal opening Maximum interincisal opening was measured as the distance between the incisal edges of the maxillary and mandibular central incisors at maximal mouth opening. Measurements were recorded preoperatively and on postoperative day 3. Change in maximum interincisal opening was calculated as postoperative minus baseline. 2.3.3 Facial swelling As shown in Fig. 1 , facial swelling was measured using a three-line method (tragus-to-oral commissure, tragus-to-submental point, and mandibular angle-to-lateral canthus) [ 12 ]. The mean of the three distances was recorded preoperatively and on postoperative day 3. Change was calculated as postoperative minus baseline. 2.3.4 Dry socket Dry socket was diagnosed according to modified Blum criteria, typically 3–5 days after extraction, characterized by severe radiating pain with partial/complete loss of the clot and exposed bone, often with fetor[ 13 ]. 2.3.5 Postoperative infection Postoperative infection was defined clinically by local signs of inflammation (erythema, swelling, warmth, pain) with purulent exudate when present, with or without trismus or systemic inflammatory signs. 2.3.6 Postoperative bleeding Bleeding was graded as obvious bleeding (2), mild bleeding (1), or none (0) based on symptoms and clinical examination during follow-up. 2.3.7 Statistical analysis SPSS 22.0 was used. Continuous variables were expressed as mean ± standard deviation and compared using one-way ANOVA. Categorical variables were reported as n (%) and compared using chi-square tests. Ordinal outcomes were analyzed using non-parametric tests. A two-sided α of 0.05 was applied. 3. Results 3.1 Participant characteristics A total of 102 participants were included (48 males and 54 females; age 30.19 ± 10.21 years). There were 61 middle-depth and 41 low-depth mesioangular impacted mandibular third molars. Age, sex, and impaction depth did not differ significantly among groups (Table 1 ). Table 1 Baseline characteristics of the patients in the three groups Age Compound chlorhexidine Povidone-iodine Physiological saline P 29.85 ± 11.03 29.38 ± 8.05 31.32 ± 11.42 0.72 Sex Male 16 17 15 0.89 Female 18 17 19 Classification of mesioangular impacted teeth 0.75 Middle position 22 20 19 Low position 12 14 15 3.2 Pain score VAS pain scores differed among groups ( p < 0.0001), with the lowest scores in the compound chlorhexidine group, intermediate scores in the povidone-iodine group, and the highest scores in the saline group (Table 2 ). Table 2 Postoperative VAS scores Compound chlorhexidine VAS score( \(\stackrel{-}{x}\) ±s) Intergroup comparison 3.31 ± 2.01 a, b Povidone-iodine 4.34 ± 1.46 a Physiological saline 5.64 ± 1.68 b P <0.0001 a: statistically significant compared with the physiological saline group ( P < 0.05); b: statistically significant compared with the povidone-iodine group ( P < 0.05). 3.3 Maximum interincisal opening Reduction in maximum interincisal opening on postoperative day 3 was smallest in the compound chlorhexidine group, greater in the povidone-iodine group, and greatest in the saline group (Table 3 ). Table 3 Changes in postoperative maximum interincisal opening Interincisal opening(mm) Preoperative 3 days postoperatively Change value Intergroup comparison Compound chlorhexidine 49.68 ± 2.18 39.00 ± 2.06 -0.68 ± 1.17 a, b Povidone-iodine 39.32 ± 2.65 37.76 ± 2.52 -1.56 ± 1.28 a Physiological saline 40.03 ± 2.67 37.68 ± 2.50 -2.35 ± 1.57 b P 0.51 0.04 <0.0001 a: statistically significant compared with the physiological saline group ( P < 0.05); b: statistically significant compared with the povidone-iodine group ( P < 0.05). 3.4 Facial swelling Facial swelling change also differed among groups, with the compound chlorhexidine group showing the smallest increase and the saline group the largest (Table 4 ). Table 4 Degree of postoperative facial swelling Facial swelling(mm) Preoperative 3 days postoperatively Change value Intergroup comparison Compound chlorhexidine 125.40 ± 5.05 39.00 ± 2.06 1.62 ± 2.12 a, b Povidone-iodine 124.50 ± 5.07 37.76 ± 2.52 3.68 ± 3.03 a Physiological saline 125.90 ± 5.23 37.68 ± 2.50 5.65 ± 4.51 b P 0.54 0.16 < 0.0001 3.5 Dry socket The incidence of dry socket was low and did not differ significantly among groups (Table 2 ). Table 5 Incidence of dry socket Dry socket [n (%)] Yes No Statistical value P Compound chlorhexidine 1(2.94) 33(8.82) Povidone-iodine 1(2.94) 33(8.82) χ 2 = 0.52 0.77 Physiological saline 2(5.88) 32(94.12) 3.6 Postoperative infection Postoperative infection occurred least frequently in the compound chlorhexidine group and most frequently in the saline group. Compared with saline, the compound chlorhexidine group showed a significantly lower infection rate (Table 6 ). Table 6 Postoperative infection rates Postoperative infection [n (%)] Yes No Statistical value P Intergroup comparison Compound chlorhexidine 1(2.94) 33(8.82) a Povidone-iodine 4(11.76) 30(88.24) χ 2 = 6.52 0.04 Physiological saline 8(23.53) 26(76.47) a: statistically significant compared with the physiological saline group ( P < 0.05). 3.7 Postoperative bleeding No significant differences was observed in postoperative bleeding grades (Table 7 ). Table 7 Postoperative bleeding conditions Postoperative bleeding [n (%)] Marked bleeding Slight bleeding No bleeding Statistical value P Compound chlorhexidine 2(5.88) 26(76.47) 6(17.65) Povidone-iodine 5(14.70) 19(55.88) 10(29.41) H = 0.25 0.88 Physiological saline 3(8.82) 22(64.71) 9(26.47) 4. Discussion In this study, the choice of socket irrigation solution was associated with early postoperative outcomes after removal of mesioangular middle/low impacted mandibular third molars. Overall, compound chlorhexidine irrigation was associated with lower pain scores, less limitation in mouth opening, less facial swelling, and a lower postoperative infection rate compared with physiological saline, while povidone-iodine showed intermediate performance. A plausible explanation for the observed advantage of compound chlorhexidine is its combined antimicrobial profile. Chlorhexidine is a cationic antiseptic with broad activity and substantivity and it can adsorb to oral tissues and exert sustained antibacterial effects[ 14 ]. Metronidazole provides activity against anaerobic bacteria through intracellular reduction and DNA damage, which is relevant in odontogenic infections[ 15 ]. The combination may therefore reduce bacterial burden within the socket and attenuate early inflammatory responses, leading to less edema and pain[ 16 ]. Povidone-iodine provides broad-spectrum killing via release of free iodine and oxidative damage[ 17 , 18 ]. However, its clinical effect may be limited by reduced persistence in a fluid-rich wound environment and potential local irritation, which could partly explain why its effect on pain and swelling appeared less pronounced than compound chlorhexidine in this cohort. In contrast, physiological saline mainly provides mechanical lavage. While it can remove debris, it does not offer pharmacologic antimicrobial activity, which may contribute to weaker control of postoperative inflammation and a higher infection rate after complex third molar surgery[ 19 , 20 ]. We did not observe statistically significant between-group differences in dry socket. The overall incidence was low, and the study may have been underpowered for this outcome. In addition, dry socket is multifactorial and may be influenced by factors beyond irrigation choice, such as surgical difficulty, clot stability, and postoperative behavior[ 21 ]. Similarly, postoperative bleeding did not differ across groups, suggesting that socket irrigation solution alone is unlikely to be a major determinant of postoperative hemostasis in this setting. The clinical use of biomaterials such as collagen sponges and CGF to promote tissue healing remains necessary[ 22 – 24 ]. These findings have practical implications. Middle/low impacted mandibular third molars often require flap elevation, osteotomy, and tooth sectioning, resulting in larger wounds and high risk of postoperative reaction. In this context, an irrigant with sustained antiseptic activity and anaerobic coverage may be more beneficial than physiological saline, particularly for reducing early postoperative reaction. There were several limitations. First, the retrospective design is susceptible to confounding, including differences in surgical difficulty, operative time, and postoperative compliance that may not be fully captured in routine records. Second, although the total sample size met basic statistical requirements, each group included only 34 cases, limiting power for low-incidence outcomes such as dry socket. Third, follow-up focused on early postoperative sequelae and complications, and long-term bone healing and soft-tissue remodeling were not assessed. In summary, compound chlorhexidine appears to be a suitable option for socket irrigation after removal of mesioangular middle/low impacted mandibular third molars, with potential advantages in reducing early postoperative sequelae and postoperative infection compared with saline irrigation. 5. Conclusion Socket irrigation with compound chlorhexidine after removal of mesioangular middle/low impacted mandibular third molars was associated with reduced pain, less trismus, less facial swelling, and a lower postoperative infection rate compared with povidone-iodine and physiological saline. Declarations Ethics approval and consent to participate This retrospective study has been reviewed and approved by the Medical Ethics Committee of The People’s Hospital of Zhongjiang (JLSY-2025-046). Written informed consent was obtained from all participants. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding This study received no external funding. Author Contribution Yaling Xiang: Conceptualization, Methodology, Formal analysis, Writing - original draft, Supervision. Zhang Tao: Investigation, Data curation, Validation. Jinfen Zhang: Data curation, Formal analysis, Visualization. Yi Chen: Resources, Methodology. Dajun Lai: Writing - review & editing, Validation. All authors read and approved the final manuscript. Data Availability The authors confirm that the data supporting the findings of this study are available within the article. 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Augmentation of Therapeutic Efficacy of Extraction of Causative Teeth by Irrigation for Odontogenic Maxillary Sinusitis. in vivo 2024, 38(3):1236–1242. Cigerim L, Orhan ZD, Kaplan V, Cigerim SC, Feslihan E. Evaluation of the efficacy of topical rifamycin application on postoperative complications after lower impacted wisdom teeth surgery. J Stomatology Oral Maxillofacial Surg. 2024;125(4):101501. Kuśnierek W, Brzezińska K, Nijakowski K, Surdacka A. Smoking as a risk factor for dry socket: a systematic review. Dentistry J. 2022;10(7):121. Chen L, Cheng J, Cai Y, Zhang J, Yin X, Luan Q. Efficacy of concentrated growth factor (CGF) in the surgical treatment of oral diseases: a systematic review and meta-analysis. BMC Oral Health. 2023;23(1):712. Elayah SA, Liang X, Sakran KA, Xie L, Younis H, Alajami AE, Tu J, Na S. Effect of concentrated growth factor (CGF) on postoperative sequel of completely impacted lower third molar extraction: a randomized controlled clinical study. BMC Oral Health. 2022;22(1):368. Zhu Y, Zhang C, Zou L. Effect of High-Speed Turbine–Assisted Minimally Invasive Tooth Extraction Combined With Collagen Sponges in Patients With Complex Impacted Teeth. J Rehabil. 2026;53(2):549–55. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8957951","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":599514769,"identity":"9bc164eb-93b9-46c4-8858-c3c71e19c704","order_by":0,"name":"Yaling Xiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYDACZgglw8bA2PjwQ4WEnDyxWnjYGJibjSXOWBgbNhBpGQ8DA3ubBG9bRSLDAQJKDY4zP3v4tc2Oh0+6sUFCcp5EAmMD88NHN/BokWxmMzeWbUvmYZM52GBQuE0ij52Bzdg4B48WfmYGM2nJNmYeNonEhgTJbRLFjA08bNL4tLAxs38DaqkHaznAOwdEEtDCz8xjJvmx7TBIS2MDbwMRWiSbecqkGc4dB2lpZpY4JmFs2EzALwbnj2+T/FFWLSc/I/35zw81dXLy7M0PH+PTAgLMvGwoXALKQYDxxx8iVI2CUTAKRsHIBQAgVkFcl8H72gAAAABJRU5ErkJggg==","orcid":"","institution":"The People’s Hospital of Zhongjiang","correspondingAuthor":true,"prefix":"","firstName":"Yaling","middleName":"","lastName":"Xiang","suffix":""},{"id":599514770,"identity":"3f975465-1dc1-4f53-ad7b-f3f9ba461869","order_by":1,"name":"Zhang Tao","email":"","orcid":"","institution":"The People’s Hospital of Zhongjiang","correspondingAuthor":false,"prefix":"","firstName":"Zhang","middleName":"","lastName":"Tao","suffix":""},{"id":599514771,"identity":"398dbc35-032c-4f1f-9fb0-9afd99a1e0bc","order_by":2,"name":"Jinfen Zhang","email":"","orcid":"","institution":"The People’s Hospital of Zhongjiang","correspondingAuthor":false,"prefix":"","firstName":"Jinfen","middleName":"","lastName":"Zhang","suffix":""},{"id":599514772,"identity":"df8b4c19-aaa9-4a63-ba49-4a67cf2f59f9","order_by":3,"name":"Yi Chen","email":"","orcid":"","institution":"Deyang Stomatological Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Chen","suffix":""},{"id":599514773,"identity":"59abf735-4bb6-44de-b768-4b11216e3c85","order_by":4,"name":"Dajun Lai","email":"","orcid":"","institution":"The People’s Hospital of Zhongjiang","correspondingAuthor":false,"prefix":"","firstName":"Dajun","middleName":"","lastName":"Lai","suffix":""}],"badges":[],"createdAt":"2026-02-24 13:23:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8957951/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8957951/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104175704,"identity":"a104f85e-3931-4d9e-95b0-b638bb740ca8","added_by":"auto","created_at":"2026-03-08 16:32:15","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":51413,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of Laskin’s method for facial swelling measurement\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8957951/v1/c25e17002d9703aab87dbd86.jpeg"},{"id":107518212,"identity":"0f4f382f-7674-4c92-b5bf-fbbe16f23801","added_by":"auto","created_at":"2026-04-22 08:43:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":506918,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8957951/v1/ee7a22ae-7e3c-4d49-aec2-80851736746a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of different socket irrigation solutions with postoperative sequelae after removal of mesioangular middle/low impacted mandibular third molars: a retrospective cohort study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eImpaction of mandibular third molars is common and may cause pericoronitis and damage to adjacent teeth, often requiring surgical removal[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In clinical practice, impaction severity is frequently described using the Pell-Gregory classification[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Mesioangular impaction is among the most prevalent patterns and may account for up to 43% of impacted mandibular third molars[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Based on depth, mesioangular impactions are commonly classified as high, middle, and low[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMiddle- and low-depth mesioangular impactions are typically more difficult to remove. The crown is often below the occlusal plane, bony resistance is substantial, and proximity to the mandibular canal is not uncommon. These cases frequently require flap elevation, osteotomy, and odontotomy, which increase surgical trauma and may aggravate early postoperative sequelae, including pain, facial swelling, and restricted mouth opening[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSocket debridement and irrigation are routinely performed after extraction. Physiological saline provides mechanical lavage but has limited antimicrobial activity. Therefore, an ideal irrigant should assist in cleaning the socket while reducing microbial burden and postoperative inflammation. Commonly used solutions include chlorhexidine and povidone-iodine; chlorhexidine has broad antimicrobial activity with substantivity, whereas povidone-iodine provides rapid broad-spectrum killing through free iodine release[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Compound chlorhexidine, a combination formulation mainly containing chlorhexidine and metronidazole, may offer complementary coverage, particularly against anaerobes[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough antiseptic/antimicrobial irrigants may reduce postoperative complications compared with physiological saline, direct comparisons among compound chlorhexidine, povidone-iodine, and physiological saline for socket irrigation after removal of mesioangular middle/low impacted mandibular third molars remain limited. Early postoperative sequelae can impair oral function and patient experience, and infection or alveolar osteitis may prolong recovery. We therefore compared pain, swelling, trismus, and postoperative complications among patients receiving these three irrigation solutions in routine practice.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1 Study design and participants\u003c/h2\u003e\n\u003cp\u003ePatients receiving removal of a mesioangular middle- or low-impacted mandibular third molar at the Department of Stomatology, The People\u0026rsquo;s Hospital of Zhongjiang between January 2020 and January 2025 were enrolled. Depending on the type of irrigation solution used, a total of 102 patients were allocated to three groups (n\u0026thinsp;=\u0026thinsp;34 per group): the compound chlorhexidine group, the povidone-iodine group, and the physiological saline group.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\n\u003cp\u003eHealthy patients aged from 18 to 60 years and required surgical removal of a mandibular third molar.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eThe extracted tooth was a mesioangular mandibular third molar with middle or low impaction depth.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eOral condition was acceptable, with no residual roots/crowns and no severe periodontitis.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ePatients were in good general health and had no contraindications to surgery.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ePatients who fully participated in and had their follow-up records kept.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe exclusion criteria were as follows:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\n\u003cp\u003eSevere local infection at the surgical site (severe pericoronitis; alveolar abscess; apical periodontitis; periodontitis).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eSevere periodontitis.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eMajor systemic conditions likely to affect healing or infection risk (e.g., uncontrolled diabetes; severe hematologic disease).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eMalignancy with chemotherapy/radiotherapy history.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ePregnancy or lactation (or attempting to conceive during perioperative period).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eInsufficient follow-up records for outcome evaluation.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e2.2 Surgical procedure and irrigation protocol\u003c/h2\u003e\n\u003cp\u003eAll patients underwent preoperative CBCT for surgical planning. Under local anesthesia (inferior alveolar nerve block with lidocaine), a full-thickness mucoperiosteal flap was elevated. Osteotomy was performed using a high-speed handpiece with saline cooling. Odontotomy (T-shaped sectioning) was performed when indicated, and the tooth was delivered along the planned path. The socket was thoroughly debrided to remove granulation tissue and debris, followed by irrigation with compound chlorhexidine (Jinkouxin, Jiangsu Chenpai Bande Pharmaceutical Co., Ltd., Jiangsu, China), povidone-iodine (Yisuxin, Zhejiang, China), or physiological saline (Keli Bag, Sichuan Kelun Pharmaceutical Co., Ltd., Sichuan, China). The flap was repositioned and closed with interrupted 3\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures. Patients applied pressure with gauze for 30 minutes for hemostasis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003e2.3 Outcome measures\u003c/h2\u003e\n\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n\u003ch2\u003e2.3.1 Pain score\u003c/h2\u003e\n\u003cp\u003ePain score was assessed using a 100-mm visual analog scale on postoperative day 7. Patients marked their overall pain during the healing period; the distance from the \u0026ldquo;no pain\u0026rdquo; anchor (mm) was recorded as the VAS score.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\n\u003ch2\u003e2.3.2 Maximum interincisal opening\u003c/h2\u003e\n\u003cp\u003eMaximum interincisal opening was measured as the distance between the incisal edges of the maxillary and mandibular central incisors at maximal mouth opening. Measurements were recorded preoperatively and on postoperative day 3. Change in maximum interincisal opening was calculated as postoperative minus baseline.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\n\u003ch2\u003e2.3.3 Facial swelling\u003c/h2\u003e\n\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, facial swelling was measured using a three-line method (tragus-to-oral commissure, tragus-to-submental point, and mandibular angle-to-lateral canthus) [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. The mean of the three distances was recorded preoperatively and on postoperative day 3. Change was calculated as postoperative minus baseline.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\n\u003ch2\u003e2.3.4 Dry socket\u003c/h2\u003e\n\u003cp\u003eDry socket was diagnosed according to modified Blum criteria, typically 3\u0026ndash;5 days after extraction, characterized by severe radiating pain with partial/complete loss of the clot and exposed bone, often with fetor[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\n\u003ch2\u003e2.3.5 Postoperative infection\u003c/h2\u003e\n\u003cp\u003ePostoperative infection was defined clinically by local signs of inflammation (erythema, swelling, warmth, pain) with purulent exudate when present, with or without trismus or systemic inflammatory signs.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\n\u003ch2\u003e2.3.6 Postoperative bleeding\u003c/h2\u003e\n\u003cp\u003eBleeding was graded as obvious bleeding (2), mild bleeding (1), or none (0) based on symptoms and clinical examination during follow-up.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n\u003ch2\u003e2.3.7 Statistical analysis\u003c/h2\u003e\n\u003cp\u003eSPSS 22.0 was used. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and compared using one-way ANOVA. Categorical variables were reported as n (%) and compared using chi-square tests. Ordinal outcomes were analyzed using non-parametric tests. A two-sided \u0026alpha; of 0.05 was applied.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant characteristics\u003c/h2\u003e \u003cp\u003eA total of 102 participants were included (48 males and 54 females; age 30.19\u0026thinsp;\u0026plusmn;\u0026thinsp;10.21 years). There were 61 middle-depth and 41 low-depth mesioangular impacted mandibular third molars. Age, sex, and impaction depth did not differ significantly among groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the patients in the three groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompound chlorhexidine\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePovidone-iodine\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysiological saline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.85\u0026thinsp;\u0026plusmn;\u0026thinsp;11.03\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.38\u0026thinsp;\u0026plusmn;\u0026thinsp;8.05\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.32\u0026thinsp;\u0026plusmn;\u0026thinsp;11.42\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification of mesioangular impacted teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle position\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow position\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Pain score\u003c/h2\u003e \u003cp\u003eVAS pain scores differed among groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with the lowest scores in the compound chlorhexidine group, intermediate scores in the povidone-iodine group, and the highest scores in the saline group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative VAS scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCompound chlorhexidine\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVAS score(\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e\u0026plusmn;s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntergroup comparison\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ea, b\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePovidone-iodine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.34\u0026thinsp;\u0026plusmn;\u0026thinsp;1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiological saline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ea: statistically significant compared with the physiological saline group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05); b: statistically significant compared with the povidone-iodine group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Maximum interincisal opening\u003c/h2\u003e \u003cp\u003eReduction in maximum interincisal opening on postoperative day 3 was smallest in the compound chlorhexidine group, greater in the povidone-iodine group, and greatest in the saline group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges in postoperative maximum interincisal opening\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterincisal opening(mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 days postoperatively\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIntergroup comparison\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompound chlorhexidine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ea, b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePovidone-iodine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiological saline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.03\u0026thinsp;\u0026plusmn;\u0026thinsp;2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ea: statistically significant compared with the physiological saline group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05); b: statistically significant compared with the povidone-iodine group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Facial swelling\u003c/h2\u003e \u003cp\u003eFacial swelling change also differed among groups, with the compound chlorhexidine group showing the smallest increase and the saline group the largest (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDegree of postoperative facial swelling\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacial swelling(mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 days postoperatively\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIntergroup comparison\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompound chlorhexidine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125.40\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.62\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ea, b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePovidone-iodine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124.50\u0026thinsp;\u0026plusmn;\u0026thinsp;5.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.68\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiological saline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125.90\u0026thinsp;\u0026plusmn;\u0026thinsp;5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.65\u0026thinsp;\u0026plusmn;\u0026thinsp;4.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Dry socket\u003c/h2\u003e \u003cp\u003eThe incidence of dry socket was low and did not differ significantly among groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIncidence of dry socket\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDry socket [n (%)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompound chlorhexidine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1(2.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33(8.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePovidone-iodine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1(2.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33(8.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiological saline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(5.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32(94.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Postoperative infection\u003c/h2\u003e \u003cp\u003ePostoperative infection occurred least frequently in the compound chlorhexidine group and most frequently in the saline group. Compared with saline, the compound chlorhexidine group showed a significantly lower infection rate (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative infection rates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative infection [n (%)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntergroup comparison\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompound chlorhexidine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1(2.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33(8.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePovidone-iodine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4(11.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30(88.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;6.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiological saline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(23.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26(76.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ea: statistically significant compared with the physiological saline group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Postoperative bleeding\u003c/h2\u003e \u003cp\u003eNo significant differences was observed in postoperative bleeding grades (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative bleeding conditions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative bleeding\u003c/p\u003e \u003cp\u003e[n (%)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarked bleeding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSlight bleeding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo bleeding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStatistical value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompound chlorhexidine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(5.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26(76.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6(17.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePovidone-iodine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5(14.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19(55.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10(29.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiological saline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3(8.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22(64.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9(26.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this study, the choice of socket irrigation solution was associated with early postoperative outcomes after removal of mesioangular middle/low impacted mandibular third molars. Overall, compound chlorhexidine irrigation was associated with lower pain scores, less limitation in mouth opening, less facial swelling, and a lower postoperative infection rate compared with physiological saline, while povidone-iodine showed intermediate performance.\u003c/p\u003e \u003cp\u003eA plausible explanation for the observed advantage of compound chlorhexidine is its combined antimicrobial profile. Chlorhexidine is a cationic antiseptic with broad activity and substantivity and it can adsorb to oral tissues and exert sustained antibacterial effects[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Metronidazole provides activity against anaerobic bacteria through intracellular reduction and DNA damage, which is relevant in odontogenic infections[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The combination may therefore reduce bacterial burden within the socket and attenuate early inflammatory responses, leading to less edema and pain[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Povidone-iodine provides broad-spectrum killing via release of free iodine and oxidative damage[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, its clinical effect may be limited by reduced persistence in a fluid-rich wound environment and potential local irritation, which could partly explain why its effect on pain and swelling appeared less pronounced than compound chlorhexidine in this cohort. In contrast, physiological saline mainly provides mechanical lavage. While it can remove debris, it does not offer pharmacologic antimicrobial activity, which may contribute to weaker control of postoperative inflammation and a higher infection rate after complex third molar surgery[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe did not observe statistically significant between-group differences in dry socket. The overall incidence was low, and the study may have been underpowered for this outcome. In addition, dry socket is multifactorial and may be influenced by factors beyond irrigation choice, such as surgical difficulty, clot stability, and postoperative behavior[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Similarly, postoperative bleeding did not differ across groups, suggesting that socket irrigation solution alone is unlikely to be a major determinant of postoperative hemostasis in this setting. The clinical use of biomaterials such as collagen sponges and CGF to promote tissue healing remains necessary[\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These findings have practical implications. Middle/low impacted mandibular third molars often require flap elevation, osteotomy, and tooth sectioning, resulting in larger wounds and high risk of postoperative reaction. In this context, an irrigant with sustained antiseptic activity and anaerobic coverage may be more beneficial than physiological saline, particularly for reducing early postoperative reaction.\u003c/p\u003e \u003cp\u003eThere were several limitations. First, the retrospective design is susceptible to confounding, including differences in surgical difficulty, operative time, and postoperative compliance that may not be fully captured in routine records. Second, although the total sample size met basic statistical requirements, each group included only 34 cases, limiting power for low-incidence outcomes such as dry socket. Third, follow-up focused on early postoperative sequelae and complications, and long-term bone healing and soft-tissue remodeling were not assessed.\u003c/p\u003e \u003cp\u003eIn summary, compound chlorhexidine appears to be a suitable option for socket irrigation after removal of mesioangular middle/low impacted mandibular third molars, with potential advantages in reducing early postoperative sequelae and postoperative infection compared with saline irrigation.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eSocket irrigation with compound chlorhexidine after removal of mesioangular middle/low impacted mandibular third molars was associated with reduced pain, less trismus, less facial swelling, and a lower postoperative infection rate compared with povidone-iodine and physiological saline.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This retrospective study has been reviewed and approved by the Medical Ethics Committee of The People\u0026rsquo;s Hospital of Zhongjiang (JLSY-2025-046). Written informed consent was obtained from all participants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYaling Xiang: Conceptualization, Methodology, Formal analysis, Writing - original draft, Supervision. Zhang Tao: Investigation, Data curation, Validation. Jinfen Zhang: Data curation, Formal analysis, Visualization. Yi Chen: Resources, Methodology. Dajun Lai: Writing - review \u0026amp; editing, Validation. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRizqiawan A, Lesmaya YD, Rasyida AZ, Amir MS, Ono S, Kamadjaja DB. Postoperative complications of impacted mandibular third molar extraction related to patient\u0026rsquo;s age and surgical difficulty level: A cross-sectional retrospective study. Int J Dent 2022, 2022(1):7239339.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarcı́a AGa, Sampedro FG, Rey JG, Vila PG, Martin MS. Pell-Gregory classification is unreliable as a predictor of difficulty in extracting impacted lower third molars. Br J Oral Maxillofac Surg. 2000;38(6):585\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaraynsingh C, Henry K, Hunte R, Ramlogan N, Bissoon A. Prevalence and pattern of tooth impaction: A radiographic study in a trinidadian population. Niger J Clin Pract. 2024;27(7):837\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantos KK, Lages FS, Maciel CAB, Gl\u0026oacute;ria JCR, Douglas-de-Oliveira DW. Prevalence of mandibular third molars according to the Pell \u0026amp; Gregory and Winter classifications. J Oral Maxillofac Surg. 2022;21(2):627\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChenchev L, Ivanova V, Giragosyan K, Gavrailov T, Chenchev I. Minimally invasive extraction system Benex\u0026mdash;clinical evaluation and comparison. Dentistry J. 2024;12(8):234.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJin B, Alhaskawi A, Dong Y, Zhou W, Zou X, Lu H. Precise Minimally Invasive Extraction of Impacted Teeth: Standardized Techniques and Management Practices. JoVE (Journal Visualized Experiments) 2025(226):e68729.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamada S-i, Hasegawa T, Yoshimura N, Hakoyama Y, Nitta T, Hirahara N, Miyamoto H, Yoshimura H, Ueda N, Yamamura Y. Prevalence of and risk factors for postoperative complications after lower third molar extraction: A multicenter prospective observational study in Japan. Medicine. 2022;101(32):e29989.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVijayakumar G, Sundaram GA, Kumar SP, Krishna VK, Krishnan M, KRISHNA VK. Comparison of the Effectiveness of Four Different Irrigation Solutions on Postoperative Sequelae in Patients Undergoing Lower Third Molar Surgery: A Prospective Study. Cureus 2023, 15(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashemi HM, Mohammadi F, Hasheminasab M, Hashemi AM, Zahraei S, Hashemi TM. Effect of low-concentration povidone iodine on postoperative complications after third molar surgery: a pilot split-mouth study. J Oral Maxillofac Surg. 2015;73(1):18\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho H, David M, Lynham A, Hsu E. Effectiveness of irrigation with chlorhexidine after removal of mandibular third molars: a randomised controlled trial. Br J Oral Maxillofac Surg. 2018;56(1):54\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArteagoitia I, Rodriguez Andr\u0026eacute;s C, Ramos E. Does chlorhexidine reduce bacteremia following tooth extraction? A systematic review and meta-analysis. PLoS ONE. 2018;13(4):e0195592.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaranowska A, Pitułaj A, Makar M, Kowalewski K, Dominiak S, Kubasiewicz-Ross P. The Impact of a Lacto-Ovo Vegetarian Diet on Post-Operative Recovery and Wound Healing Following Mandibular Third Molar Extraction\u0026mdash;A Prospective Study. Nutrients. 2025;17(5):759.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlum IR. Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review. Int J Oral Maxillofac Surg. 2002;31(3):309\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoppolo Deus F, Ouanounou A. Chlorhexidine in Dentistry: Pharmacology, Uses, and Adverse Effects. Int Dent J. 2022;72(3):269\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagaja AS, John RS. Comparison of Normal Saline and Metronidazole as Irrigating Solutions in Surgical Extraction of Third Molars. Libr Progress-Library Sci Inform Technol Comput 2024, 44(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSu\u0026aacute;rez LJ, Arce RM, Gon\u0026ccedil;alves C, Furquim CP, Santos NCD, Retamal-Valdes B, Feres M. Metronidazole may display anti-inflammatory features in periodontitis treatment: A scoping review. Mol oral Microbiol. 2024;39(4):240\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu L, Ye X, Zeng X, Duan X, Xiu Q, Ding Z, Liu F. The Effect of Oral Mucosal Disinfection with Povidone-Iodine in Oral and Maxillofacial Surgery. J Craniofac Surg. 2024;35(8):e730\u0026ndash;733.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmtha R, Kanagalingam J. Povidone-iodine in dental and oral health: a narrative review. J Int Oral Health. 2020;12(5):407\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKato T, Sakagami H. Augmentation of Therapeutic Efficacy of Extraction of Causative Teeth by Irrigation for Odontogenic Maxillary Sinusitis. \u003cem\u003ein vivo\u003c/em\u003e 2024, 38(3):1236\u0026ndash;1242.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCigerim L, Orhan ZD, Kaplan V, Cigerim SC, Feslihan E. Evaluation of the efficacy of topical rifamycin application on postoperative complications after lower impacted wisdom teeth surgery. J Stomatology Oral Maxillofacial Surg. 2024;125(4):101501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuśnierek W, Brzezińska K, Nijakowski K, Surdacka A. Smoking as a risk factor for dry socket: a systematic review. Dentistry J. 2022;10(7):121.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen L, Cheng J, Cai Y, Zhang J, Yin X, Luan Q. Efficacy of concentrated growth factor (CGF) in the surgical treatment of oral diseases: a systematic review and meta-analysis. BMC Oral Health. 2023;23(1):712.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElayah SA, Liang X, Sakran KA, Xie L, Younis H, Alajami AE, Tu J, Na S. Effect of concentrated growth factor (CGF) on postoperative sequel of completely impacted lower third molar extraction: a randomized controlled clinical study. BMC Oral Health. 2022;22(1):368.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu Y, Zhang C, Zou L. Effect of High-Speed Turbine\u0026ndash;Assisted Minimally Invasive Tooth Extraction Combined With Collagen Sponges in Patients With Complex Impacted Teeth. J Rehabil. 2026;53(2):549\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"compound chlorhexidine, impacted mandibular third molar, tooth extraction, postoperative sequelae, socket irrigation","lastPublishedDoi":"10.21203/rs.3.rs-8957951/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8957951/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePostoperative pain, swelling, and trismus are common after removal of impacted mandibular third molars. Socket irrigation is routinely performed to clean the alveolar sockets, yet comparative evidence for commonly used solutions in clinical practice remains limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study reviewed consecutive patients who underwent removal of a mesioangular middle- or low-impacted mandibular third molar at the Department of Stomatology, The People\u0026rsquo;s Hospital of Zhongjiang, between January 2020 and January 2025. Patients were categorized into three groups according to the irrigation solution documented in the operative record: compound chlorhexidine, povidone-iodine, or physiological saline. Eligibility criteria and outcome definitions were prespecified. Outcomes included pain score, change in maximum interincisal opening, facial swelling measured by a three-line method, alveolar osteitis, postoperative infection, and postoperative bleeding. Statistical analyses were conducted with SPSS 22.0 (two-sided α\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 102 patients (102 extraction sites) were included. Baseline characteristics were comparable across groups. Postoperative pain scores, reduction in mouth opening, and facial swelling were lowest in the compound chlorhexidine group, intermediate in the povidone-iodine group, and highest in the physiological saline group. Postoperative infection occurred least frequently in the compound chlorhexidine group and most frequently in the physiological saline group. No significant between-group differences were observed in alveolar osteitis or postoperative bleeding.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn routine clinical practice, socket irrigation with compound chlorhexidine after removal of mesioangular middle/low impacted mandibular third molars was associated with less pain, less trismus, less facial swelling, and a lower postoperative infection rate compared with povidone-iodine and physiological saline.\u003c/p\u003e","manuscriptTitle":"Association of different socket irrigation solutions with postoperative sequelae after removal of mesioangular middle/low impacted mandibular third molars: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 16:32:10","doi":"10.21203/rs.3.rs-8957951/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d6eb76ac-23b5-4223-a9de-c4bcf87858b4","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T08:42:05+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 16:32:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8957951","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8957951","identity":"rs-8957951","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}