DRY SOCKET IDENTIFICATION
Dry socket delays the healing of the extraction site and surrounding bone. Dry socket can be diagnosed by looking for certain symptoms. Moderate to severe localized pain near the extraction sites developing on or after the third or fourth day post extraction is a sure giveaway.
Patients can state that there is an apparent improvement in discomfort on the second day only to be followed by a sudden worsening of the pain.
The pain is moderate to severe, consisting of a dull aching sensation, usually throbbing which radiate to the ear.
Examination will reveal an empty socket, exposed bone surfaces, with a partially or
completely lost blood clot. A bad odor and taste may or may not be present. Loss of sleep is caused by pain; control of the pain is very difficult even with narcotic analgesics. Dramatic relief within an hour can be seen after placement of dry socket medicaments.
Patients can state that there is an apparent improvement in discomfort on the second day only to be followed by a sudden worsening of the pain.
The pain is moderate to severe, consisting of a dull aching sensation, usually throbbing which radiate to the ear.
Examination will reveal an empty socket, exposed bone surfaces, with a partially or
completely lost blood clot. A bad odor and taste may or may not be present. Loss of sleep is caused by pain; control of the pain is very difficult even with narcotic analgesics. Dramatic relief within an hour can be seen after placement of dry socket medicaments.
DRY SOCKET INCIDENCE
The incidence of dry socket has been reported in the literature by many investigators, and ranges between .5% - 68.4%, depending on which study is reviewed. The average is approximately 3% of all extractions. It has been shown that occurrence of dry socket is between 9-30% in impacted mandibular third molars. The condition occurs two times as often after single extractions as compared to multiple extractions completed during the same time frame.
DRY SOCKET ETIOLOGY AND PREDISPOSING FACTORS
Fibrinolysis is the breakdown or failure of normal clot formation due to high levels of fibrinolytic or proteolytic activity in and around the socket. Fibrinolytic activity results in lysis of the blood clot and subsequent exposure of the bone.
Mandibular teeth are most commonly associated with dry socket. Sites affected are ranked in order from highest to lowest as follows: lower molars, upper molars, premolars, canines and incisors.
Studies have demonstrated that the more difficult the extraction, the higher the chance of dry socket. It has also been demonstrated that less-experienced dental surgeons have a higher incidence of dry socket in lower third molars. The peak age for dry socket is 30-34 years. Most reported cases occur between the ages of 20 and 40.
Bacteria, especially anaerobic, have been linked to the formation of dry sockets. Investigators have found strains of Streptococci, Fusospirochaetal, Treponema denticola, and bacteroides within extraction sites.
Researchers have identified that women have a 20% better chance to develop dry socket than males. Oral contraceptives are also linked to higher incidence of dry socket along with post extraction trismus and pain.
Patients with uncontrolled diabetes mellitus have a greater incidence of dry socket and should be monitored carefully.
PREVENTION OF DRY SOCKET
Developing cures and techniques that will prevent dry socket has been a topic of interest in oral surgery for many years. Well controlled studies indicate that the incidence of dry socket after mandibular third molar surgery can be reduced.
Proper surgical techniques should include thorough debriding and irrigation of the extraction site with copious quantities of saline. This should be first on your list in controlling the incidence of dry socket.
The incidence of dry socket may be decreased by preoperative and post operative rinsing with antimicrobial mouth rinses, such as chlorhexidine gluconate (Peridex Zila Pharmaceuticals). A study was performed involving preoperative prophylaxis in conjunction with chlorhexidine gluconate 0.2 percent rinses. Incidence of dry socket was decreased to some degree. Use of other medicaments such as Betadine Mouthwash may also be useful in reducing bacterial loads prior to surgery.
Use of topically placed antibiotics administered within the extraction site immediately after completion of the extraction has been the most widely studied modality to reduce dry socket. Antibiotics such as clindamycin or tetracycline have been successfully used to help decrease the incidence of dry socket in mandibular third molars.
Tetracycline
Tetracycline has been studied to determine if it can prevent dry socket when placed directly into the extraction site, immediately following surgery. One study showed that placement of tetracycline in a suspension with a few drops of saline combined with a square of Gelfoam significantly reduce the incidence of dry socket when used as a dressing after impacted mandibular third molar extractions. This study supports findings reported by other authors. Both the tetracycline studies had strikingly similar findings showing an average of 3.8% incidence of dry socket when using tetracycline prophylactically.
Another study looked at neomycin, bacitracin, and tetracycline combined with saline, soaked in Gelfoam, and placed in the extraction socket of third molars. Results demonstrated that tetracycline was far more effective than either neomycin or bacitracin (combined with Gelfoam) in decreasing dry socket.
Clindamycin
Effects of a 1x1 cm square of Gelfoam soaked with 1ml of clindamycin phosphate solution (150 milligrams/milliliter) compared to controls using no clindamycin was studied. Results indicated that out of 172 impacted molar sites, only 7 dry sockets occurred, all of which were control sites that were not exposed to clindamycin. Clindamycin is especially preferred as the drug of choice in the prevention of dry socket due to its anaerobic properties.
A study of 520 mandibular teeth in 270 patients was performed, in which extractions sites were irrigated with Betadine (Purdue Frederick) prior to placement of clindamycin. One site received Gel foam soaked in clindamycin, the other received Gelfoam without clindamycin. Results indicated that there was a significant decrease in dry socket in the sites that received Gelfoam soaked in clindamycin.
These studies demonstrate reduction in dry socket is as low as 3% from 36% when antibiotic medicaments were placed. There is evidence that bacteria through mechanisms not yet understood play a role in the fibrinolytic phenomenon of dry socket.
TREATING OF DRY SOCKET
If dry socket (alveolar osteitis) should arise, treatment should be focused on relieving pain. If the patient does not receive treatment for the relief of pain, the healing process will eventually resolve itself with no difference in time as if treated. Treatment should begin by gently irrigating with saline, and the insertion of medicated dressing. Do not curette the socket because this will increase the amount of exposed bone and the pain, and remove parts of the blood clot that have not been lysed. The socket should then be carefully suctioned of all excess saline. Then, a small piece of gelatin sponge or gauze soaked with the medication should be placed. This may need to be repeated for 3-6 days depending on the severity of the pain.
At each visit, the socket will need to be irrigated, and insertion of the medicated dressing repeated.
Medicaments used to treat dry socket may contain a combination of the following ingredients: bone pain relievers (Eugenol, benzocaine), antimicrobials (idoform), and carrying vehicles (balsam of Peru, Penghawar).
Dry socket pastes and liquids (various manufacturers) can be used and placed directly in the socket alone or using absorbable products such as Gelfoam.
Once place in the extraction socket, the patient will experience profound relief from pain within 5 minutes. Generally, anesthesia is not recommended when placing those products.
CONCLUSION
This continuing dental education course was designed to review the etiology and treatment modalities associated with complications associated with extractions. A review of the literature uncovered numerous studies aimed at exploring solutions to post extraction problems. Further research is still needed, along with education geared toward teaching surgical techniques and therapeutic solutions.
