1. PRESENTED BY DR. SHEETAL KAPSE 1st YEAR, P.G. STUDENT
MODERATORS - DR. SUNIL VYAS DR. M. SATISH DR. MANISH PANDIT DR.
DEEPAK THAKUR
2. CONTEMPORARY VIEWS ON DRY SOCKET (ALVEOLAR OSTEITIS): A
CLINICAL APPRAISAL OF STANDARDIZATION, ETIOPATHOGENESIS AND
MANAGEMENT: A CRITICAL REVIEW I. R. Blum: 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: 309317. 2002
International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Science Ltd.
3. Author I. R. Blum Division of Oral and Maxillofacial
Surgery, Department of Oral and Maxillofacial Sciences, University
Dental Hospital of Manchester, Higher Cambridge Street, Manchester
M15 6FH, UK
4. Search strategy and literature selection criteria A
computerized literature search using MEDLINE was conducted
searching for articles published from 19682001. Mesh phrases used
in the search were: Dry socket, alveolar osteitis, localized
osteitis, fibrinolytic alveolitis, prevention and management of dry
socket. Manual searches of selected internationally reviewed
journals. Only papers in English and those which stated the
diagnostic criteria were reviewed.
6. Abstract The objective of this article is to - Harmonize
descriptive definitions. Review and discuss the etiology and
pathogenesis of alveolar osteitis. The need for the identification
and elimination of risk factors. The preventive and symptomatic
management of the condition . Aim - provide a better basis for
clinical management of the condition.
7. Introduction One of the most common postoperative
complications following the extraction of permanent teeth is a
condition known as dry socket. This term has been used in the
literature since 1896, when it was first described by CRAWFORD.
BIRN labeled the complication fibrinolytic alveolitis . which is
probably the most accurate of all the terms, but is also the least
used in the literature. In most cases, the more generic lay term
dry socket tends to be used. In this article, the condition will be
referred to as alveolar osteitis, AO.
9. Definition - The variety of definitions used in the
literature for the clinical assessment of alveolar osteitis, A
descriptive definition that could be used universally as a
standardized definition for AO: postoperative pain in and around
the extraction site, which increases in severity at any time
between 1 and 3 days after the extraction accompanied by a
partially or totally disintegrated blood clot within the alveolar
socket with or without halitosis.
10. Sign & symptoms 1. The denuded alveolar bare bone may
be painful and tender. Initially blood clot appears dirty gray
disintegrates grayish yellow bony socket bare of granulation tissue
2. Some patients may also complain of intense continuous pain
irradiating to the ipsilateral ear, temporal region or the eye. 3.
Regional lymphadenopathy (occasionally). 4. unpleasant taste
(occasionally). 5. Trismus is a rare occurrence in mandibular third
molar extractions probably due to lengthy and traumatic
surgery.
11. True AO, must be distinguished from conditions in which
pre-existing alveolar bone hypovascularity, such as- 1. vascular or
haematological disorders, 2. radiotherapy-induced osteonecrosis, 3.
osteopetrosis, 4. Pagets disease 5. cemento-osseous dysplasia
prevent initial formation of a coagulum. Any other cause of pain on
the same side of the face.
12. This becomes costly to the patient as well as to the
surgeon, as 45% of patients who develop AO typically require At
least four additional postoperative visits in the process of
managing this condition.
13. Incidence AO occurs approximately 10 times more frequently
following the removal of 3rd molars than from all other locations.
1% to 45% after the removal of mandibular third molars .( BARCLAY
JK. Metronidazole and dry socket: prophylactic use in mandibular
third molar removal complicated by nonacute pericoronitis. New
Zealand Dent J 1987: 7: 7175. ) 2530% after the removal of impacted
mandibular third molars . FRIDRICH KL, OLSON RAJ. Alveolar osteitis
following removal of mandibular third molars. Anaesth Prog 1990:
37: 3241. 34% following routine dental extractions .
14. Onset and duration Mostly 13 days after tooth extraction .
( FRIDRICH KL, OLSON RAJ. Alveolar osteitis following removal of
mandibular third molars. Anaesth Prog 1990: 37: 3241.) Within a
week - In 95% and 100% of all cases of AO. ( FIELD EA, SPEECLY JA,
ROTTER E, SCOTT J. Dry socket incidence compared after a 12 year
interval. Br J Oral Maxillofac Surg 1988: 23: 419427. ) Unlikely -
before the first postoperative day. because the blood clot contains
anti-plasmin that must be consumed by plasmin before clot
disintegration can take place. The duration of AO varies to some
degree, depending on the severity of the disease, but it usually
ranges from 510 days.
15. Etiology Multifactorial origin Following have been
implicated most commonly as etiological, aggravating and
precipitating factors: 1. Oral micro-organisms 2. Difficulty and
trauma during surgery 3. Roots or bone fragments remaining in the
wound 4. Excessive irrigation or curettage of the alveolus after
extraction 5. Physical dislodgement of the clot 6. Local blood
perfusion & anesthesia 7. Oral contraceptives 8. Smoking
16. 1. Oral micro-organisms The role of bacteria in AO has long
been postulated . ( MACGREGOR AJ. etiology of dry socket: A
clinical investigation. Br J Oral Surg 1968: 6: 4958. ) increased
frequency of AO in patients with 1. poor oral hygiene, ROZALIN J, S
IDF, WARREN BA. Is dry socket preventable? J Can Dent Assoc 1977:
43: 233236. 2. pre-existing local infection such as pericoronitis
and advanced periodontal disease . RUD J. Removal of impacted lower
third molars with acute pericoronitis and necrotising gingivitis.
Br J Oral Surg1970: 7: 153160. Reduced incidence of AO in
conjunction with antibacterial measures. ROOD JP, MURGATROYD J.
Metronidazole in the prevention of dry socket. Br JOral Surg
17. ROZANIS et al : Highlighted the possible association of
Actinomyces viscosus and Streptococcus mutans in AO by inoculation
of these organisms in animal models. ROZALIN J, S IDF, WARREN BA.
Is dry socket preventable? J Can Dent Assoc 1977: 43: 233236.
Presence of large number of bacilli & Vincents spirochete was
introduced by SCHROFF & BARTEL 1929.
18. NITZAN et al : (NITZAN D, SPERRY JF, WILKINS D.Fibrinolytic
activity of oral anaerobic bacteria. Arch Oral Biol 1978: 23:
465470. ) showed a possible significance of anaerobic organisms
Treponema denticola (which are also the predominant organisms in
pericoronitis) in relation to the aetiology of AO. observed high
plasmin-like fibrinolytic activities from cultures of the anaerobe
Treponema denticola . In addition, AO virtually never occurs during
childhood, a period when this organism has not yet colonized the
mouth. Certain species constantly secrete pyrogens & bacterial
pyrogens are indirect activators of fibrinolysis in vivo.
19. CATELLANI : studied the efficacy of bacterial pyrogens for
treating thromboembolic disease where pyrogens injected
intravenously produced a sustained increase in fibrinolysis.
(CATELLANI JE. Review of factors contributing to dry socket through
enhanced fibrinolysis. J Oral Surg 1979: 37: 4246.)
20. 2. Difficulty and trauma during surgery more likely cause
Surgical extractions that involve the reflection of a flap and
sectioning of the tooth with some degree of bone removal . LILLY
GE, OSBORN DB, RAEL EM. Alveolar osteitis associated with
mandibular third molar extractions. J Am Dent Assoc 1974: 88:
802806. & Less experienced surgeons (higher incidence of
complications after the removal of impacted third molars) SISK AL,
HAMMER WB, SHELTON DW, JOY ED. Complications following removal
of
21. Excessive trauma results in delayed wound healing 1.
Compression of the bone lining the socket, which impairs its
vascular penetration. 2. Thrombosis in the underlying vessels. 3.
Trauma with a reduction in tissue resistance and consequent wound
infection.( TURNER PS. A clinical study of dry socket. Int J Oral
Surg 1982: 11: 226 231)
22. BIRN : (BIRN H. Etiology and pathogenesis of fibrinolytic
alveolitis (dry socket). Int J Oral Surg 1973: 2: 215263.)
23. 3. Roots or bone fragments remaining in the wound BIRN :
supported (BIRN H. Etiology and pathogenesis of fibrinolytic
alveolitis (dry socket). Int J Oral Surg 1973: 2: 215263.) SIMPSON
: (SIMPSON HE. The healing of extraction wounds. Br Dent J 1969:
126: 550557.) such fragments are commonly present after normal
extraction or surgical removal of teeth, and that small bone and
tooth remnants do not necessarily cause complications during
healing as they are often externalized by the oral epithelium. lack
of scientific evidence logical that fragment and debris remnants
could lead to disturbed wound healing
24. 4. Excessive irrigation or curettage of the alveolus after
extraction (BIRN H. Etiology and pathogenesis of fibrinolytic
alveolitis (dry socket). Int J Oral Surg 1973: 2: 215263.)
Energetic repeated irrigation of the alveolus might interfere with
clot formation and give rise to infection. Violent curettage might
injure the alveolar bone. DRAWBACKS - 1. lack of scientific
evidence 2. energetic excessive irrigation is not easily
measurable, it is difficult for it to be assessed.
25. 5. Physical dislodgement of the clot Energetic repeated
irrigation - interfere with clot formation and give rise to
infection. lack of scientifically sound investigations energetic
excessive irrigation is not easily measurable
26. 6. Local blood perfusion & anesthesia KRUGER : (KRUGER
GO. Textbook of Oral and Maxillofacial Surgery. St Louis:
Mosby1973: 226.) Associated poor local blood supply with an
increased incidence of AO in mandibular molar extractions. CAUSES -
thick cortical bone BIRN : (BIRN H. Etiology and pathogenesis of
fibrinolytic alveolitis (dry socket). Int J Oral Surg 1973: 2:
215263.) demonstrated that the mandibular molar region is one of
the most richly vascularized regions of the mandible, Its blood
supply being far better than that of the incisal region.
27. use of vasoconstrictors in local anesthetic solutions The
vasoconstrictors in local anesthetic solutions have been suggested
as alternative factors in the pathogenesis of AO AO also follows
tooth extractions carried out under general anesthesia where no
vasoconstrictor was used. MEECHAN JG, VENCHARD GR, ROGERS SN. Local
anesthesia and dry socket: A clinical investigation of single
extractions in male patients. Int J Oral Maxillofac Surg 1987: 16:
279284.
28. REPEATED INJECTIONS OF LOCAL ANESTHETIC SOLUTION patients
who requires repeated injections of local anesthetic solution may
have a reduced pain threshold, which may account for complaints of
pain originating from the extraction socket.
29. periodontal intraligamental (PDL) injections Claimed an
increase in the incidence of AO when periodontal intraligamental
(PDL) injections were used rather than block or infiltration
injections . These findings have been attributed to the spread of
bacteria, especially with multiple injections to the affected site
. MEECHAN JG, VENCHARD GR, ROGERS SN. Local anesthesia and dry
socket: A clinical investigation of single extractions in male
patients. Int J Oral Maxillofac Surg 1987: 16: 279284 TSIRLIS et al
: Who have shown that PDL anesthesia did Contemporary views on dry
socket not result in a higher frequency of AO than when block
anesthesia was used. TSIRLIST AT, IAKOVIDIS DP, PARISSIS NA. Dry
socket: frequency of occurrence after intraligamentary anesthesia.
Quint Int 1992: 23: 575577.
30. 7. Oral contraceptives prior to1960 1960s onwards Less use
of oral contraceptives lower incidence of AO occurring in females .
increased use of oral contraceptives higher incidence of AO
occurring in females . Others studied the effect of oral
contraceptives on the coagulation and fibrinolytic system SWEET JB,
BBUTLER DP. Increased incidence of postoperative localized osteitis
in mandibular third molar surgery associated with patients using
oral contraceptives. Am J Obstet Gynecol 1977: 127:518519.
31. ESTROGEN It has been proposed that estrogens, like pyrogens
will activate the fibrinolytic system indirectly. CATELLANI et al :
CATELLANI JE, HARVEY S, ERICKSON SH, CHERKINK D. Effect of oral
contraceptive cycle on dry socket (localized alveolar osteitis). J
Am Dent Assoc 1980: 101:777780. the probability of AO increases
with increased oestrogen dose in the oral contraceptive and that
fibrinolytic activity appears to be lowest on days 23 through 28 of
the menstrual cycle. YGGE Y, BRODY S, KORSAN-BBENGTSEN K, NILSSON
L. Changes in blood coagulation and fibrinolysis in women receiving
oral contraceptives. Am J Obstet Gynaecol1969: 104: 8798.
32. 8. Smoking SWEET JB, BBUTLER DP. Increased incidence of
postoperative localized osteitis in mandibular third molar surgery
associated with patients using oral contraceptives. Am J Obstet
Gynecol 1977: 127:518519. a four- to five-fold increase in AO (12%
vs 2.6%) compared to non-smoking patients. total of 400 surgically
removed mandibular third molars, those who smoked a half-pack of
cigarettes per day
33. > 20% > 40% Among patients smoking more than a pack
per day, Among patients who smoked on the day of surgery, or on the
first postoperative day. SWEET JB, BBUTLER DP. Increased incidence
of postoperative localized osteitis in mandibular third molar
surgery associated with patients using oral contraceptives. Am J
Obstet Gynecol 1977: 127:518519.
34. Pathogenesis Partial or complete lysis and destruction of
the blood clot was caused by tissue kinases liberated during
inflammation by a direct or indirect activation of plasminogen in
the blood . (BIRN H. Etiology and pathogenesis of fibrinolytic
alveolitis (dry socket). Int J Oral Surg 1973: 2: 215263.)
35. Factor XIIa CLOTTING SYSTEM KININ SYSTEM FIBRINOLYTI C
SYSTEM COMPLEM ENTSYSTE M Factor XII CONTACT This conversion is
accomplished in the presence of tissue or plasma pro-activators and
activators.
36. Plasminogen Activators IndirectDirect 1. Factor XII
dependent activator 2. urokinase, 1. Tissue plasminogen activators
2. Endothelial plasminogen activators 1. streptokinase 2.
staphylokinas e plasminogen activator complex Intrinsi c
Extrinsic
37. Fibrinolytic system Plasminogen activator (kallikrein,
XIIa, leukocytes, endothelium) Plasminog en Plasmi n C3 C3a Fibri n
Fibrin split products
38. pathway of Kinin system Factor XII Factor XIIa
Prekallikrein activator Plasma Prekallikrein Kallikrei n Kininoge n
Bradykini n
39. Cause of pain Presence and formation of kinin locally in
the socket . Kinins activates the primary afferent nerves, which
may have already been presensitized by other inflammatory mediators
and algogenic substances (even in concentrations as low as 1 ng/ml)
He stated that: fibrinolytic alveolitis resulted when fibrinolysis
or another proteolytic activity in and around the alveolus was
capable of destroying the blood clot. BIRN H. Kinins and pain in
dry socket. Int J Oral Surg 1972a: 1: 3442.
40. Role of alveolar bone The surrounding bone of the alveolus
contains, among other components, stable tissue activators that may
explain the local fibrinolytic activity in AO . Birn H,
Myhre-Jensen, G. Cellular fibrinolytic activity of human alveolar
bone. Int J Oral Surg 1972: 1: 121125
41. Factors influencing the healing 1. Infection 2. Size of
wound 3. Blood supply 4. Resting of part 5. Foreign bodies 6.
General condition of the patient
42. Prophylactic management References in the literature
correlating to the prevention of AO can be divided into 1.
Non-pharmacological and 2. Pharmacological preventive
measures.
43. Non-pharmacological preventive measures Include a
comprehensive history of the patient with identification, and if
possible, elimination of risk factors.
44. Risk factors associated with true AO 1. Previous experience
of AO . 2. Deeply impacted mandibular third molar (risk factor is
directly proportional to increasing severity of impaction) . 3.
Poor oral hygiene of patient . 4. Active or recent history of acute
ulcerative gingivitis or pericoronitis . 5. Associated with the
tooth to be extracted . 6. Smoking (especially >20 cigarettes
per day) . 7. Use of oral contraceptives . 8. Immunocompromised
individuals .
45. 1. Use of good quality current preoperative radiographs 2.
Careful planning of the surgery 3. Use of good surgical principles
4. Extractions should be performed with minimum amount of trauma
and maximum amount of care 5. Confirm presence of blood clot
subsequent to extraction (if absent, scrape alveolar walls gently)
Non-pharmacological measures
46. 6. Wherever possible preoperative oral hygiene measures to
reduce plaque levels to a minimum should be instituted 7. Encourage
the patient (again) to stop or limit smoking in the immediate
postoperative period . 8. Advise patient to avoid vigorous mouth
rinsing for the first 24 h post extraction and to use gentle
toothbrushing in the immediate postoperative period . 9. For
patients taking oral contraceptives extractions should ideally be
performed during days 23 through 28 of the menstrual cycle . 10.
Comprehensive pre- and postoperative verbal instructions should be
supplemented with written advice to ensure maximum compliance
.
48. 1. Antibacterial agents Prophylactic antibacterials, either
given systemically or used locally. Systemic antibacterials
penicillins clindamycin erythromycin metronidazole Preoperative
administration of antibacterial agents is more effective. LAIRD
WRE, STENHOUSE D, MACFARLANE TW. Control of postoperative
infection. Br Dent J 1972: 133:106109.
49. Metronidazole - MERIETS 1. Effective against the
microorganism which are generally associated with AO
(anaerobicidal). 2. Fewer and more infrequent side-effects CAUTIONS
With - 1. warfarin, 2. disulfiram, 3. phenytoin 4.
antihypertensives because of possible drug interactions. Concurrent
alcohol should be avoided.
50. Penicillins Development of resistance Clindamycin
Pseudomembranouscolitis Alexander RE. Dental extraction wound
management: A case against medicating postextraction sockets. J
Oral Maxillofac Surg 2000: 58: 538551. In some cases, the
antibacterial or base material used to carry the antibiotic has
caused more significant complications than the AO.
51. Use of topical clindamycin - A significantly reduced
incidence of AO in mandibular third molar sockets following light
socket irrigation with Betadine and the topical application of
clindamycin in Gelfoam. They attributed their findings to the
effectiveness of clindamycin . But the irrigant used by them prior
to wound closure is an iodophore with its own antibacterial
properties . CHAPNIC P, DIAMOND L. A review of dry socket: A
double-blind study on the effectiveness of clindamycin in reducing
the incidence of dry socket. J Can Dent Assoc 1992: 58: 4352.
52. Many studies with topical tetracycline powder, aqueous
suspensions of tetracycline, tetracycline on gauze drain or
tetracycline-soaked Gelfoam sponges have been reported to be
effective. However, side-effects including foreign body giant-cell
reactions have been reported in association with topically applied
tetracycline. The topical application of a petroleum-based
combination of tracycline and hydrocortisone effective. LYNCH et al
: myospherulosis in extraction sites as a result of the action of
the lipid substances of the petrolatum carrier vehicle on the
extravasated erythrocytes.
53. 2. Antiseptic agents and lavage Chlorhexidine (CHX) is a
bisdiguanide antiseptic with antimicrobial properties. RANGO &
SZKUTNIK noted nearly a 50% reduction in the incidence of AO in
patients who prerinsed for 30 s with a 0.12% CHX solution. FOTOS et
al.: placebo-controlled study involving 70 patients with 140
uncomplicated non-infected third molars effect of the topical
insertion of an intra-alveolar chlorhexidine gluconate
solution-soaked Gelfoam into an extraction site and compared it to
an intra-alveolar saline-soaked Gelfoam inserted on the
contralateral side.
54. FOTOS et al.: They also reported that the 0.1%
chlorhexidine solution did not significantly reduce postoperative
discomfort whereas the use of the higher 0.2% concentration was
significantly efficacious in reducing these symptoms. 1. Pre-shaped
Gelfoam morphology does not allow its placement to the full depth
of the socket. 2. No reference was found in the literature
correlating the local applications of the biodegradable
chlorhexidine Periochip nor that of chlorhexidine Corsodyl gel with
AO.
55. 9-aminoacridine, saturated in Gelfoam Gelfoam alone The
antiseptic agent, 9-aminoacridine, saturated in Gelfoam was placed
in mandibular third molar extraction sites. The authors concluded
that 9-aminoacridine was ineffective in reducing the incidence of
AO. JOHNSON WS, BLANTON EE. An evaluation of 9
aminoacridine/Gelfoam to reduce dry socket formation. Oral Surg
Oral Med Oral Pathol 1988: 66: 167170.
56. Whiteheads varnish (a combination of iodoform, balsam
tolutan, and Styrax liquid in a base liquid) HELLEM & NORDERAM
: studied the prophylactic effectiveness of antiseptic dressings by
suturing a gauze sponge saturated with Whiteheads varnish. RESULT -
a significant decrease in the incidence of postoperative pain,
haemorrhage and swelling. BUT the incidence of specifically
diagnosed AO was not HELLEM S, NORDERAM A. Prevention of
postoperative symptoms by general antibiotic treatment and local
bandage in removal of mandibular third molars. Int J Oral Surg
1973: 2: 273278.
57. Alvogyl (Septodent, Inc, Wilmington, DE) Has been widely
used in the management of AO and is frequently mentioned in the
literature. Alvogyl contains - butamben (anesthetic), eugenol
(analgesic), and iodophorm (antimicrobial). Some authors noted
retardation of healing and inflammation when the sockets were
packed with Alvogyl. S. M. Syrjanen and K. J. Syrjanen, Influence
of Alvogyl on the healing of extraction wound in man, International
Journal of Oral Surgery, vol. 8, no. 1, pp. 2230, 1979.
58. Lavage study Incidence was significantly reduced from 10.9%
using 25 ml normal saline solution for lavage to 5.9% with the use
of 175 ml lavage. sufficient lavage mechanically removes more of
the root remnants and/or bone fragments (and other debris) possibly
still left in the extraction socket . SWEET JB, BUTLER DP, DRAGER
JL. Effects of lavage techniques with third molar surgery. Oral
Surg Oral Med Oral Pathol 1976: 41: 152168.
59. 3. Antifibrinolytic agents Fibrinolytic nature of AO ,
Topical use of para-hydroxybenzoic acid (PHBA), in extraction
wounds as Antifibrinolytic agents . Apernyl an alveolar cone with a
formulation of 32 mg acetylsalicylic acid, 3 mg propyl ester of
PHBA 20 mg unknown tablet mass, It is not possible to attribute the
reported findings to PHBA alone or perhaps to the antiinflammatory
properties of acetylsalicylic acid. BIRN H. Antifibrinolytic effect
of Apernyl in dry socket. Int J Oral Surg 1972b: 1: 190194.
60. Subsequent histological studies16 however, showed that
acetylsalicylic acid in contact with bone causes a local irritating
effect accompanied by serious inflammation of the extraction
socket, possibly resulting in AO. CARROLL PB, MELFI RC. The
histologic effect of topically applied acetylsalicylic acid on bone
healing in rats. Oral Surg Oral Med Oral Pathol 1982: 33:
728735.
61. Tranexamic acid (TEA) The antifibrinolytic agent Not shown
a significant reduction in the incidence of AO when compared to a
placebo group. lack of a scientifically confirmed advantage, and
many possible problems, there seems to be no rationale for the use
of these agents. GERSEL-PEDERSEN N. Tranexamic acid in alveolar
sockets in the prevention of alveolitis sicca dolorosa. Int J Oral
Surg 1979: 8: 421 429.
62. 4. Steroid anti-inflammatory agents Use of topical
corticosteroids in the prevention of AO - decreases immediate
post-operative complications - failed to reduce the occurrence of
AO The topical application of a hydrocortisone and oxytetracycline
mixture - decrease the incidence of AO . DRAWBACK - Contribution of
the antibiotic cannot be separated from that caused by the steroid.
Lack of scientific evidence - any benefit to this regimen. LELE MV.
Alveolar osteitis. J Indian Dent Assoc 1969: 41: 6972. FRIDRICH KL,
OLSON RAJ. Alveolar osteitis following removal of mandibular third
molars. Anaesth Prog 1990: 37: 3241.
63. 5. Obtundent dressings Bilateral removal of 200 mandibular
molars claimed a significant decrease in the incidence of AO
following the immediate placement of an eugenol containing dressing
into randomly selected unilateral extraction sockets, The
contralateral sockets were not packed. However, the irritant local
effect of eugenol and the delay in wound healing. ALEXANDER RE.
Dental extraction wound management: A case against medicating
postextraction sockets. J Oral Maxillofac Surg 2000: 58: 538 551.
BLOOMER CR. Alveolar osteitis prevention by immediate placement of
medicated packing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2000: 90: 282 284
64. 6. Clot supporting agents In the 1980s, a biodegradeable
ester polymer, polylactic acid (PLA) was widely promoted as the
ultimate solution for preventing AO, and it is still available
today under the brand name of DriLac (Osmed, Inc, Costa Mesa, CA
USA). HONEY & GOLDEN : reported a higher incidence of AO when
PLA was used in the control group (23.6% with PLA,13.6% without).
The latter prospective study suggests that the use of PLA might
actually increase the incidence of AO. Lack of scientific evidence
HOOLEY JR, GOLDEN DP. The effect of polylactic acid granules on the
incidence of alveolar osteitis after mandibular third molar
surgery. A prospective randomized study. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1995: 80: 279283.
65. Symptomatic management References in the literature
relating to the management of AO can be divided into non-dressing
and dressing interventions. The active components of the dressings
1. Antibacterial dressings 2. Obtundent dressings 3. Topical
anaesthetic dressings, and 4. Combinations of 13. However, case
reports regarding the occurrence of other local complications have
been described in the literature and it is generally acknowledged
that dressings delay the healing of the extraction socket.ZUNIGA
JR, LEIST JC. Topical tetracycline-induced neuritis: A case report.
J Oral Maxillofac Surg 1995: 53: 196199.
66. Non-dressing interventions to manage AO 1. Remove any
sutures to allow adequate exposure of the extraction site. As the
socket may be exquisitely tender local anaesthesia may be required.
2. Irrigate the socket gently with war sterile isotonic saline or
local anaesthetic solution, which is followed by careful suctioning
of all excess irrigation solution. 3. Do not attempt to curette the
socket, as this will increase the level of pain. 4. Prescription of
potent oral analgesics. 5. The patient is given a plastic syringe
with a curved tip for home irrigation with chlorhexidine solution
or saline and instructed to keep the socket clean. 6. Once the
socket no longer collects any debris, home irrigation can be
discontinued.
67. Surgical Management of Dry Socket Under block anesthesia
The clot devoided socket thoroughly curetted, both from the floor
of the socket as well as from the bony walls, The sharp margins
were trimmed, rounded. Any foreign bodies if present were
thouroghly removed. The detached gingival margins were also
scraped. The desired medications as well as precautions . Patient
was not only without pain, but was also comfortable both physically
as well as psychologically from the very next day. S.C. Anand, V.
Singh, M. Goel, A. Verma, B. Rai: Dry Socket An Apriasal And
Surgical Management. The Internet Journal of Dental Science. 2006
Volume 4 Number 1. DOI: 10.5580/e31
68. Discussion Although the full etiology of AO has yet to be
firmly established . Evidence suggests that it is most particularly
related to a complex interaction between excessive localized
trauma, bacterial invasion and their association to plasmin and
subsequently, the fibrinolytic system. Prevention of AO entails
reducing the number of possible risk factors, meticulous attention
to procedural details and surgical skills.
69. Dressings should not be placed into extraction sockets
possible side effects and unnecessary additional costs Hippocrates
(421 B.C.): At first do no harm Prophylactic effectiveness, economy
and lack of adverse side effects of chlorhexidine solution justify
its use as a preoperative irrigant or mouthrinse in the prevention
of AO.
70. RESOURCES I. R. Blum: 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: 309317. 2002 International Association
of Oral and Maxillofacial Surgeons. Text book 1. textbook of oral
& maxillofacial surgery by Daniel M. Laskin 2. Essential
pathology for dental students by Harsh Mohan Antonia Kolokythas,
Eliza Olech, and MichaelMiloro Alveolar Osteitis: A Comprehensive
Review of Concepts and Controversies Hindawi Publishing Corporation
International Journal of Dentistry Volume 2010, Article ID 249073,
10 pages doi:10.1155/2010/249073. The Effect of Alvogyl TM When
Used As a Post Extraction Packing. Soukaina T. Ryalat1, Mohammad H.
Al-Shayyab1, Ahmed Marmash1, Faleh A. Sawair1, Zaid H. Baqain1,
Ameen S. Khraisat2Jordan Journal of Pharmaceutical Sciences, Volume
4, No. 2, 2011 S.C. Anand, V. Singh, M. Goel, A. Verma, B. Rai: Dry
Socket An Apriasal And Surgical Management. The Internet Journal of
Dental Science. 2006 Volume 4 Number 1. DOI: 10.5580/e31