Unchalee Kitiviriyakul

Dry socket

lAlveolar osteitislAlveolitis sicca dolorosalAlveolitislLocalized acute alveolar osteomyelitislPostextraction osteomyelitis syndrome lFibrinolytic alveolitis

lDry socket is the most common painful complication following dental extraction

Definition

l A condition which blood clot disintegrates with the production of a foul odor and severe pain but no supparation

Incidence

lOverall incidence 0.5 – 68.4 %lAll extraction 1 - 3 %l Impacted mandibular molar 25 – 30 %lMandibular molar > mandibular premolar >

maxillary premolar > maxillary molar > canine > incisorlThe highest between 20 and 40 years of

age

S & S

l Intolerable pain ,radiation to the earlNot relieved by medicatorlHistory of extraction within 5 dayslExposed alveolar bone lFoul taste , breath , and smell lSign and symptom may last from 10 – 40

days

Timing

3-5 days after surgery

Location

mandibular third molar region

Confirm diagnosisl probing or passing a small curette into the

socket lextremely painful upon light palpation

Etiology

l Precise etiology is unknownl Increase in bacterial

count results in increased fibrinolyticactivity with clot dissolution

Healing of wound extraction

บาดแผล บาดแผลที่หายแลว บาดแผลที่เย็บแลว

first intention healing

Healing of wound extraction

บาดแผลที่มีชองวาง ล่ิมเลือดที่เกิดขึ้นระหวาง สะเก็ดแผลปรากฏขนาดใหญ ชองวางของบาดแผล อยูที่บาดแผลที่หาย

Second intention healing

Healing of wound extraction

Third intention healing

Healing of wound extraction

-Coagulative phase -Proliferative phase -Osteogenic-remodeling phase-Epithelium formation

Coagulative phase

lCoagulation reaction l Inflammatory reaction lThe clot composed fibrin strand , red blood

cells and plateletslNeutrophilic infiltrationlCentral portion : hypoxia lPeripheral : more oxygen tension

Coagulative phase

lBleeding controllElimination of contaminant bacterialCreation of an environment conducive to

healing

Proliferative phase

lDissolution of the blood clotlFormation of a connective tissue matrixlDevelopment of a blood supply to the

woundlTransformation of osteoprogenitor cells

into osteoblasts

Proliferative phase

lSocket is filled with a dense connective tissuelMatrix containing large numbers of

fibroblastslNumerous osteoblasts appear near the

walls of socket

Osteogenic-remodeling phase

lThe secretion of osteoidlThe mineralization of the matrixlThe remodeling of the bone

Epithelium formation

Healing extraction socket

Risk factors

l Coagulopathiesl Traumal Smokingl Agel Effect of anesthesial Gender predilectionl Blood supplyl Presence of pericoronitisl Role of bacterial fibrinolysisl etc

Coagulopathies

lThere are six groups of drugs that can prolong bleeding time

ü Aspirin and NSAIDsü Anti-inflammatoryü Alcoholü Anticoagulantsü Anticancerü antibiotics

Trauma

lextraction difficulty

¡Traumatic extraction interfere healing of PDL

¡Highly incidence of infection

Smoking

lmajor risk factor : smokers have impaired healing responselNicotine ¡vasoconstriction of capillary¡impair collagen synthesis and protein secretion¡interfere healing mechanism

lTar and other component l:contaminate the site

Carbon monoxide (co)

l Interfere with the uptake of oxygen by the bloodlBinding with hemoglobin 200-300 times

greater than oxygen

Age

lOlder have a cellular response to injury less than younger

1995 study by De Boer et al :complications increase with age

>25 years : 18.9%<25 years : 11.4%

Effects of anesthetic

lExcessive infiltration of anesthetics containing vasoconstrictors ,especially injecting to PDL : decrease blood supplylLocal anesthesia¡2% lidocaine 1:80,000 more incidence than 3%

prilocaine with felypressin¡Intraligamental injection

Gender predilection

lFemale > male¡Related with menstrual cycle and taking oral

contraceptives

lEarly menstrual cycle

l Injectable contraceptives not same oral contraceptives

Estrogen

lOral contraceptive related the dose of estrogenl First half of the menstrual cycle¡ high serum estradiol- to- progesterone ratio ¡ Lower incidence of dry socket

l Days 18-26(latter half of the menstrual cycle)¡ High levels range of serum progesterone¡Lower incidence of dry socket¡Low serum estradiol- to- progesterone ratio

Menstrual cycle

Blood supply

lRelative greater density of the bone

Presence of pericoronitis

In a study by De Boer et al : a higher incidence of dry socket was

seen when pericoronal inflammation was present

Meyer’s study showed a significant difference between with and without the use of antibiotics

Role of bacteria

lBacteria are the primary etiology of dry socketlHigher microbial count ( Staphylococcus

lactis,Streptococcusviridans,Corynbacterium xerosis )can increase the incidencelBacterial contamination cause of clot

break down

Fibrinolysis

lcause of clot dissolutionlbacteria produce enzymes that invasion to

the extraction wound

Fibrinolysis

Etc.

lRadiotherapylOsteosclerotic diseaselExcessive use of mouthwash lCurette after extraction

Prevention

lConstant irrigation of bone during cutting phase of extractionlCareful irrigation and debridement

following procedure and prior to suturing lLimiting trauma and bone removallPre and post operative rinsing with 0.12%

chlorhexidinelSystemic prophylactic antibiotics

Prevention

l Avoid smoking,drinking alcohol,and oral contraceptivel Rinsed twice daily with 15 ml of 0.12 or 0.2%

Chlorhexidine gluconate for 30 seconds for one week before and after extractionl Irrigate after extraction with 175 ml of

NSS,especially with reflection of mucoperiostealflap l Do not dislodge clot with over aggressive

irrigation or high speed suction

Prevention

lPlace 250 mg of clindamycin or tetracyclinantibiotic powder into extraction sitelCaution the patient about the “5Ss”

lNo smoking (24- 48 hours both before and after surgery)lSpittinglSucking through a strawlCarbonated soft drinks lMaintenance of a soft diet for 24- 48 hours

Prevention

l A suspension made from a tetracycline capsule or Terra cortrill a gelfoam sponge is

used in each socket

prevention

l Terra-Cortril being placed on Gelfoam

Prevention

l Alternative to medicated Gelfoam : Dry-Lac that put in socket with syringel Dry-Lac has not been

saturated with the blood

Treatment

l Inspection of the socket and confirmation of diagnosis l Examination with radiographsl Local anesthesia lGentle irrigate with warm normal salinel Do not curette the extraction sitel Pressing pack with medicated dressing

common :use with a 1/4 inch strip of iodoformgauze or surgical pack( eugenol + vaseline )

Treatment

lRecheck in 24 hourslchange the pack every 2 dayslDemonstrate the use of a disposable,

plastic syringe that can be use at home for self-irrigation

Treatment

l The socket was irrigated with warm water and pack the iodoform gauze is carefully

treatment

l Iodoform gauze material

l Sutured at the incision line but not fall into the socket

Reference

l Alling Welfrick Alling.Impacted teeth. W.B.Saunders company 1993.l Cowson. Essentials of dental surgery and pathology.l Jamie P. Houston et al .Alveolar osteitis : A review of its etiology ,

prevention and treatment modalities . Journal of general dentistry 2002 sep-oct;457-463.

l Kurt H. Thoma. Volume one oral surgery.C.V.Mosby company.thirdedition.

l Pederssen and Gordon W.Oral surgery. W.B.Saunders company 1980.

l Paul H Kwon,Daniel M. Laskia .Clinical’s manual of oral and maxillofacial surgery.Quntessence publish co,Inc.1991.

l www.google.com

Special thanks

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Thank you for your attention

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