Int. J. Oral Maxillofac. Surg.

1987: 16:279-284
(Key words: anaesthesia, local," alveolitis; extraction, teeth; surgery, oral and maxillofacial)

Local anaesthesia and dry socket

A clinical investigation of single extractions in male patients

J. G. MEECHAN, G. R. VENCHARD, S. N. ROGERS, R. S. HOBSON, I. PRIOR, C. TAVARES

AND S. MELNICENKO

Department of Oral Surgery, The Dental School, The University of Newcastle upon Tyne, UK

ABSTRACT- 1533 single intra-alveolar permanent tooth extractions in

males were investigated in a study to determine if the type and technique
of local anaesthesia influenced the occurrence of dry socket. The results
show that the incidence of dry socket was significantly greater after the
use of Xylocaine compared to Citanest and that the use of repeated
injections or intraligamental techniques increased the likelihood of this
painful post-extraction condition.

(Accepted for publication 1 July 1986)

Dry or painful socket is a post-operative no effect on dry socket production as there

complication which occurs after about 3%
of extractions 19.
Various etiological factors have been pro-
posed for the condition and they fall into
two categories2~; firstly poor clot formation
in the socke0 ~, 12 due to any of a number
of factors and secondly breakdown o f an
originally satisfactory clot 2. One cause sug-
gested for p o o r clot formation is the pres-
ence of vasoconstrictors in local anaesthetic
solutions. In addition, adrenaline and other
vasoactive agents possess fibrinolytic ac-
tivityl, 7, 2~,26.2s. Therefore, regardless o f the
mechanism of dry socket production, the
choice of local anaesthetic might exert an
effect on the incidence of this condition.
Some workers consider the influence of the
vasoconstrictor to be important 5, ~s,23. NIT-
Z A N 25 claims the vasoconstrictor can have
is no difference in incidence following local
and general anaesthesia ~7, ~s, although ME-
YER'S23 results dispute this suggestion. BIRN2
states that any vasoconstrictor effect is un-
proven.
It was the object of this study to deter-
mine whether the amount, type and tech-
nique o f local anaesthesia employed for exo-
dontia influenced the incidence of dry sock-
et after the extraction of a single permanent
tooth in male patients.
Material and methods
It has previously been shown that the incidence
of dry socket differs between males and females
and between single and multiple extractions19;
thus, in order to reduce the number of variables,
it was decided to limit the investigation to male
subjects who were to have one permanent tooth
280 MEECHAN ET AL. I

removed under local anaesthesia in the depart- Table 3. Tooth distribution

ment of Oral Surgery at the Newcastle upon Tyne No. No.
Dental School. This also meant that the amount Citanest Xylocaine
of local anaesthetic administered could be con- Tooth type extractions extractions
trolled. Extractions were subjectively classified by
the operator as either easy or difficult. All teeth Mandibular molars 208 117
that required surgical removal were excluded Maxillary molars 236 139
from the study. A total of 1533 extractions were Mandibular premolars 59 28
included in the investigation. The anaesthetic sol- Maxillary premolars 91 49
utions employed were as follows. For conven- Mandibular incisors and
tional local anaesthesia, i.e., infiltration in the canines 14 6
maxilla and block anaesthesia in the mandible, Maxillary incisors and
either Xylocaine* (2% lignocaine with 1:80,000 canines 41 24
adrenaline) or Citanest* (3% prilocaine with 0.03 2,z= 1.3505; N.S.
IU/ml felypressin) was administered. 2.2 ml car-
tridges were used. A full cartridge was used for
each extraction.
If repeat anaesthesia was required to complete tive anaesthetic solution was administered. Thus
the extraction, either the original or the alterna- the repeat anaesthetic group is made up of every
combination of Citanest and Xylocaine.
When intraligamental anaesthesia was em-
ployed, specialised periodontal ligament syringes
Table 1. Dry socket incidence were used with Xylotox** (2% lignocaine with
No. No. 1:80,000 adrenaline); 0.2 ml of solution was in-
extrac- dry Incidence jected per buccal root and 0.2 ml was deposited
Tooth type tions sockets (%) in the palatal/lingual periodontal ligament.
Mandibular molar 565 32 5.7
Maxillary molar 506 8 1.6
Mandibular pre-
molar 145 7 4.8 Table 4. Extraction difficulty
Maxillary premolar 190 2 1.1 No. No.
Mandibular incisors Citanest Xylocaine
and canines 40 0 0 Classification extractions extractions
Maxillary incisors Easy extractions 527 288
and canines 87 0 0 Difficult extractions 113 70
Total 1533 49 Z2=0.5632; N.S.
Average 3.2 9 Citanest and 5 Xylocaine not classified.

Table 2. Dry socket incidence in relation to local Table 5. Tooth distribution

anaesthetic used No. single No. repeat
No. No. injection injection
extrac- dry Incidence Tooth types extractions extractions
Anaesthesia tions sockets (%) Mandibular molar 325 223
Single Citanest 649 6 0.9 Maxillary molar 375 118
Single Xylocaine 363 12 3.3 Mandibular premolar 87 47
Repeat conventional 466 25 5.4 Maxillary premolar 140 43
Intraligamental 55 6 10.9 Mandibular incisors and
Significance canines 20 16
Citanest versus Xylocaine 0.01 > p > 0.001 Maxillary incisors and
Single versus repeat 0.001 >p canines 65 19
Single versus intraligamental 0.001 > p 2,2=46.52; 0.001 >p.
Xylocaine versus intraligamental 0.02 > p > 0.01
**Pharmaceutical Manufacturing Co. Herts,
*Astra Pharmaceuticals, Herts, UK. UK.
 DRY SOCKET 281

Table 6. Dry socket incidence in relation to repeat injections for molar extractions
No. No. Incidence
Tooth type extractions dry sockets (%) Significance
Single injection mandibular molars 325 10 3.1
0.01 > p > 0.001
Repeat injections mandibular molars 223 18 8.1
Single injection maxillary molars 375 2 0.5
0.02 > p > 0.01
Repeat injection maxillary molars 118 4 3.4

A patient was considered to have a dry socket likelihood of dry socket production after
if he returned to the dental hospital complaining repeat anaesthesia for mandibular and
of pain from the extraction site and the socket
maxillary molar teeth (Table 6). The major
was either empty or contained necrotic material.
Statistical analysis was performed using the Z2 factor which suggests caution in inter-
test. preting the results after repeated injections,
is that significantly more difficult extrac-
tions were present in this group when com-
Results pared to that group where initial conven-
The results are presented in Tables 1-9. Ta- tional anaesthesia was successful (Table 7).
ble 1 shows that the overall incidence o f dry As far as those teeth most likely to pro-
socket in this study was 3.2% and that, as in duce dry sockets are concerned, there were
other published results, the most c o m m o n proportionately less mandibular and maxil-
sockets affected were those of the lower mo- lary molar teeth in the intraligamental
lars. Table 2 shows that dry socket pro- group; however, there were more mandibu-
duction differed significantly between the
anaesthetic regimes.
Tables 3, 4 show that the variation be- Table 7. Extraction difficulty
tween Citanest and Xylocaine cannot be ex- No. single No. repeat
injection injection
plained by the fact that there were any sig- Classification extractions extractions
nificant differences in the distribution of
Easy 815 339
tooth type between the 2 groups; neither Difficult 183 115
was the spread of easy and difficult extrac- X2= 11.6565; 0,001 >p
tions dissimilar. 12 repeat injection extractions not classified.
A comparison of the results after single
and repeat conventional local anaesthetic Table 8. Tooth distribution
injections is more complex. The tooth distri- No. single No. intra-
bution was such that the spread of tooth injection ligamental
types significantly differed between the Tooth type extractions extractions
groups (Table 5). This difference was such Mandibular molars 325 17
that there were proportionately more o f Maxillary molars 375 13
those teeth more likely to give rise to dry Mandibular premolars 87 11
Maxillary premolars 140 7
sockets, namely mandibular molars and Mandibular incisors and
premolars, in the repeat injection group. canines 20 4
However, when dry socket incidence for the Maxillary incisors and
individual tooth groups is analysed, it is canines 65 3
seen that there is still a significantly greater ;(2__16.6940; 0.01 > p > 0.001
282 MEECHAN ET AL.

Table 9. Extraction difficulty procedures with a mean operating time of

No. single No. intra- 65 min. It must be stressed that the time
injection ligamental scale from local anaesthetic injection to in-
Classification extractions extractions itial clot formation following dental extrac-
Easy 815 49 tions is much shorter than that for the surgi-
Difficult 183 6 cal removal of third molars described by
X2= 1.9772; N.S. GERSEL.PEDERSEN8,9. This could be relevant,
as ROSING e t a l ? 6 have demonstrated that
the effect on fibrinolysis produced by adren-
lar premolars (Table 8). There was no sig- aline disappears within 30 min of injection
nificant difference in the distribution of easy and other systemic effects attributable to
or difficult extractions between the intrali- the adrenaline administered during dental
gamental and conventional anaesthetic local anaesthesia have been shown to occur
groups (Table 9). in the early post-injection period creating
a maximum effect about 10 rain following
a d m i n i s t r a t i o n 22. GERSEL-PEDERSEN8 states
Discussion that any attack in the early fibrin network
If the vasoconstrictor in the local anaes- is important in clot breakdown and due to
thetic solution does contribute to the inci- the short time interval from deposition of
dence of dry socket, then it would be expect- the local anaesthetic solution to initial clot
ed that there would be fewer dry sockets formation following dental extractions, an
following the use of Citanest compared to early post-injection transient fibrinolytic ef-
Xylocaine for three reasons. Firstly, the hae- fect of adrenaline might be important.
mostatic ability of the former is poorer 4, 24. For reasons similar to the above, it could
The degree of haemostasis might govern the be predicted that more dry sockets would
amount of clot produced and could exert occur after repeated injections of a vasocon-
an effect on post-operative pain, as ischaem- strictor-containing solution. It would be dif-
ia is a factor in prostaglandin production. ficult to predict what would happen after
Secondly, locally administered adrenaline the use of periodontal ligament anaesthesia,
interferes with healing due to its effect on as the vasoconstrictor is being deposited di-
oxygen tension ~4,~5, whereas felypressin does rectly at the site of bleeding; however, con-
not cause any local cyanosis ~4. Thirdly, va- siderably less solution is injected in com-
soactive drugs increase fibrinolytic activity~7 parison to conventional techniques.
and although vasopressin derivatives have The results recorded in Table 2 show that
such an influence 7,2~, adrenaline affects fibri- in this study, significantly more dry sockets
nolysis by mechanisms additional to its va- occurred after the use of Xylocaine com-
soactive action 26. It should be noted, how- pared to Citanest and that repeat anaes-
ever, that the amounts of adrenaline ad- thesia significantly increased the likelihood
ministered during dental local anaesthesia of the condition, in accord with the predic-
are less than those shown to produce a fibri- tions above.
nolytic effect in volunteers :6, 28. GE~SEL-P~- The results of the present study differ
DERSEN8,9 reported that the local anaesthetic from those of KESKITALO& PERSSONz3 and
did not alter fibrinolytic activity following KREICMANOVz6. The former authors noted
the surgical removal of third molar teeth; no disparity in post-operative symptoms af-
however, these assays were performed be- ter 3rd molar removal between the anaes-
fore and 10 min after the completion of thetic solutions used in this investigation.
 DRY SOCKET
Their study, however, had fewer numbers
and included females in whom other factors
may play an important rrle 29. KREKMANOVt6
reported that the amount of Xylocaine did
not affect the frequency of dry socket after
the surgical removal of mandibular third
molars.
As mentioned in the results section, the
distribution of easy and difficult extractions
differed between the single and repeat injec-
tion groups; thus these results must be inter-
preted with caution. It has been shown that
the more traumatic the extraction, the more
likely a dry socket is to occur 1~,~7.~9. How-
ever, it is interesting to speculate on which
of the two factors, viz., the trauma or the
repeated injections, is the more important,
as many previous workers did not take the
amount of anaesthetic administered into ac-
count. Another factor to consider here is
that patients who require repeat injections
may have a reduced pain threshold and are
therefore more likely to return complaining
of a dry socket 2°. MEYER23 suggests that re-
peated injections spread bacteria and de-
crease tissue resistance.
Table 2 shows that periodontal ligament
anaesthesia significantly increases the prob-
ability of dry socket production when com-
pared to conventional local anaesthetic
techniques, both overall and in comparison
to Xylocaine. In the present study, the intra-
ligamental group contained the smallest
number of extractions and the tooth distri-
bution differed from the conventional local
anaesthetic group. Nevertheless, our results
with intraligamental anaesthesia differ from
those of FAULKNER6 who reported no post-
operative complications following the ex-
traction of 100 teeth using the technique;
however, they agree with TURNER'S3° results
which showed a greater, although not sig-
nificantly so, incidence of dry socket when
lignocaine and adrenaline are forcibly intro-
duced into the tissues. The findings of the
present study would question the claim of
283
GRUNDY l° that after-pain is irrelevant when
intraligamentary anaesthesia is used for
exodontia.
It is not possible to determine from the
present investigation whether periodontal
ligament anaesthesia produced more dry
sockets due to the localised presence of ad-
renaline or to the fact that the injection is
traumatic to the periodontium 3.
In conclusion, the results of this study
show that more dry sockets occurred fol-
lowing single dental extractions in males
after the use of Xylocaine compared to Ci-
tanest. Repeat injections are an indication
of greater likelihood of dry socket than sin-
gle injections and it appears that the use of
periodontal ligament anaesthesia results in
more dry sockets than conventional tech-
niques.
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Address:
John G. Meechan
Department of Oral Surgery
The Dental School
The University of Newcastle upon Tyne
NE2 4BW
UK