1. 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. 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. 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. 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.
5. 5. Inclusions - 1. Abstract 2. Incidence 3. Onset and duration 4. Etiology 5. Pathogenesis 6. Prophylactic management 7. Symptomatic management 8. Discussion 9. References
6. 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. 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.
8. 8. Synonyms : alveolar osteitis (AO), localized osteitis, postoperative alveolitis, alveolalgia, alveolitis sicca dolorosa, septic socket, necrotic socket, localized osteomyelitis, fibrinolytic alveolitis
9. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 22. BIRN : (BIRN H. Etiology and pathogenesis of fibrinolytic alveolitis (dry socket). Int J Oral Surg 1973: 2: 215263.)
23. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 37. Fibrinolytic system Plasminogen activator (kallikrein, XIIa, leukocytes, endothelium) Plasminog en Plasmi n C3 C3a Fibri n Fibrin split products
38. 38. pathway of Kinin system Factor XII Factor XIIa Prekallikrein activator Plasma Prekallikrein Kallikrei n Kininoge n Bradykini n
39. 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. 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. 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. 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. 43. Non-pharmacological preventive measures Include a comprehensive history of the patient with identification, and if possible, elimination of risk factors.
44. 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. 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. 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 .
47. 47. Pharmacological measures - 1. Antibacterial agents 2. Antiseptic agents and lavage 3. Antifibrinolytic agents 4. Steroid anti-inflammatory agents 5. Obtundent dressings 6. Clot supporting agents
48. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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