Unchalee Kitiviriyakul

Dry socket
l Alveolar osteitis l Alveolitis sicca dolorosa l Alveolitis l Localized acute alveolar osteomyelitis l Postextraction osteomyelitis syndrome l Fibrinolytic alveolitis

l Dry 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
l Overall incidence 0.5 68.4 % l All extraction 1 - 3 % l Impacted mandibular molar 25 30 % l Mandibular molar > mandibular premolar > maxillary premolar > maxillary molar > canine > incisor l The highest between 20 and 40 years of age

S&S
l Intolerable pain ,radiation to the ear l Not relieved by medicator l History of extraction within 5 days l Exposed alveolar bone l Foul taste , breath , and smell l Sign and symptom may last from 10 40 days

Timing
3-5 days after surgery Location mandibular third molar region

Confirm diagnosis
l probing or passing a small curette into the socket l extremely painful upon light palpation

Etiology
l Precise etiology is unknown l Increase in bacterial count results in increased fibrinolytic activity with clot dissolution

Healing of wound extraction

first intention healing

Healing of wound extraction

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
l Coagulation reaction l Inflammatory reaction l The clot composed fibrin strand , red blood cells and platelets l Neutrophilic infiltration l Central portion : hypoxia l Peripheral : more oxygen tension

Coagulative phase
l Bleeding control l Elimination of contaminant bacteria l Creation of an environment conducive to healing

Proliferative phase
l Dissolution of the blood clot l Formation of a connective tissue matrix l Development of a blood supply to the wound l Transformation of osteoprogenitor cells into osteoblasts

Proliferative phase
l Socket is filled with a dense connective tissue l Matrix containing large numbers of fibroblasts l Numerous osteoblasts appear near the walls of socket

Osteogenic-remodeling phase
l The secretion of osteoid l The mineralization of the matrix l The remodeling of the bone

Epithelium formation

Healing extraction socket

Risk factors
l l l l l l l l l l l Coagulopathies Trauma Smoking Age Effect of anesthesia Gender predilection Blood supply Presence of pericoronitis Role of bacteria fibrinolysis etc

Coagulopathies
l There are six groups of drugs that can prolong bleeding time
Aspirin and NSAIDs Anti-inflammatory Alcohol Anticoagulants Anticancer antibiotics

Trauma
l extraction difficulty
Traumatic extraction interfere healing of PDL Highly incidence of infection

Smoking
l major risk factor : smokers have impaired healing response l Nicotine
vasoconstriction of capillary impair collagen synthesis and protein secretion interfere healing mechanism

l Tar and other component

l :contaminate the site

Carbon monoxide (co)

l Interfere with the uptake of oxygen by the blood l Binding with hemoglobin 200-300 times greater than oxygen

Age
l Older 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
l Excessive infiltration of anesthetics containing vasoconstrictors ,especially injecting to PDL : decrease blood supply l Local anesthesia
2% lidocaine 1:80,000 more incidence than 3% prilocaine with felypressin Intraligamental injection

Gender predilection
l Female > male
Related with menstrual cycle and taking oral contraceptives

l Early menstrual cycle l Injectable contraceptives not same oral contraceptives

Estrogen
l Oral contraceptive related the dose of estrogen l First half of the menstrual cycle
high serum estradiol - to- p rogesterone 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
l Relative 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 Meyers study showed a significant difference between with and without the use of antibiotics

Role of bacteria
l Bacteria are the primary etiology of dry socket l Higher microbial count ( Staphylococcus lactis,Streptococcus viridans,Corynbacterium xerosis )can increase the incidence l Bacterial contamination cause of clot break down

Fibrinolysis
l cause of clot dissolution l bacteria produce enzymes that invasion to the extraction wound

Fibrinolysis

Etc.
l Radiotherapy l Osteosclerotic disease l Excessive use of mouthwash l Curette after extraction

Prevention
l Constant irrigation of bone during cutting phase of extraction l Careful irrigation and debridement following procedure and prior to suturing l Limiting trauma and bone removal l Pre and post operative rinsing with 0.12% chlorhexidine l Systemic prophylactic antibiotics

Prevention
l Avoid smoking,drinking alcohol,and oral contraceptive l Rinsed twice daily with 15 ml of 0.12 or 0.2% Chlorhexidine gluconate for 30 seconds for one week before and after extraction l Irrigate after extraction with 175 ml of NSS,especially with reflection of mucoperiosteal flap l Do not dislodge clot with over aggressive irrigation or high speed suction

Prevention
l Place 250 mg of clindamycin or tetracyclin antibiotic powder into extraction site l Caution the patient about the 5Ss
l No smoking (24 - 4 8 hours both before and after surgery) l Spitting l Sucking through a straw l Carbonated soft drinks l Maintenance of a soft diet for 24 - 4 8 hours

Prevention
l A suspension made from a tetracycline capsule or Terra cortril l 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 syringe l Dry-Lac has not been saturated with the blood

Treatment
l Inspection of the socket and confirmation of diagnosis l Examination with radiographs l Local anesthesia l Gentle irrigate with warm normal saline l Do not curette the extraction site l Pressing pack with medicated dressing common :use with a 1/4 inch strip of iodoform gauze or surgical pack ( eugenol + vaseline )

Treatment
l Recheck in 24 hours l change the pack every 2 days l Demonstrate 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.third edition. l Pederssen and Gordon W.Oral surgery. W.B.Saunders company 1980. l Paul H Kwon,Daniel M. Laskia .Clinicals manual of oral and maxillofacial surgery.Quntessence publish co,Inc.1991. l www.google.com

Special thanks

....

Thank you for your attention

Question?