dry socket

PRESENTED BY –
DR. SHEETAL KAPSE
1st YEAR, P.G. STUDENT
MODERATORS -
DR. SUNIL VYAS
DR. M. SATISH
DR. MANISH PANDIT
DR. DEEPAK THAKUR

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: 309–317. 2002 International
Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Science Ltd.

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

Search strategy and literature
selection criteria
 A computerized literature search using MEDLINE was conducted
searching for articles published from 1968–2001.
 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.

Inclusions -
1. Abstract
2. Incidence
3. Onset and duration
4. Etiology
5. Pathogenesis
6. Prophylactic management
7. Symptomatic management
8. Discussion
9. References

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.

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.

Synonyms :
 alveolar osteitis (AO),
 localized osteitis,
 postoperative alveolitis,
 alveolalgia,
 alveolitis sicca dolorosa,
 septic socket,
 necrotic socket,
 localized osteomyelitis,
 fibrinolytic alveolitis

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.

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.

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. Paget’s disease
5. cemento-osseous dysplasia
prevent initial formation of a coagulum.
 Any other cause of pain on the same side of the
face.

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.

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: 71–75. )
25–30% after the removal of impacted mandibular
third molars .
FRIDRICH KL, OLSON RAJ. Alveolar osteitis following removal of mandibular third
molars. Anaesth Prog 1990: 37: 32–41.
3–4% following routine dental extractions .

Onset and duration
 Mostly 1–3 days after tooth extraction .
( FRIDRICH KL, OLSON RAJ. Alveolar osteitis following removal of mandibular third molars.
Anaesth Prog 1990: 37: 32–41.)
 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: 419–427. )
 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 5–10 days.

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

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:
49–58. )
 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: 233–236.
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: 153–160.
 Reduced incidence of AO in conjunction with antibacterial
measures.
ROOD JP, MURGATROYD J. Metronidazole in the prevention of ‘dry socket’. Br JOral Surg

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: 233–236.
Presence of large number of bacilli & Vincent’s spirochete
was introduced by SCHROFF & BARTEL 1929.

NITZAN et al :
(NITZAN D, SPERRY JF, WILKINS D.Fibrinolytic activity of oral anaerobic bacteria.
Arch Oral Biol 1978: 23: 465–470. )
 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.

 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: 42–46.)

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: 802–806.
&
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

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)

 BIRN : (BIRN H. Etiology and pathogenesis of fibrinolytic alveolitis (‘dry socket’). Int J
Oral Surg 1973: 2: 215–263.)

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: 215–263.)
 SIMPSON : (SIMPSON HE. The healing of extraction wounds. Br Dent J 1969: 126:
550–557.)
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

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:
215–263.)
 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.

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

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: 215–263.)
 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.

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: 279–284.

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.

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:
279–284
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: 575–577.

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: 127:518–519.

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:
101:777–780.
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: 87–98.

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: 127:518–519.
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

>
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: 127:518–519.

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: 215–263.)

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.

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

Fibrinolytic system
Plasminogen activator
(kallikrein, XIIa, leukocytes,
endothelium)
Plasminog
en
Plasmi
n
C3 C3a
Fibri
n
Fibrin
split
products

pathway of Kinin system
Factor XII
Factor
XIIa
Prekallikrein
activator
Plasma Prekallikrein Kallikrei
n
Kininoge
n
Bradykini
n

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: 34–42.

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: 121–125

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

Prophylactic management
References in the literature correlating to the
prevention of AO can be divided into
1. Non-pharmacological and
2. Pharmacological preventive measures.

Non-pharmacological preventive
measures
 Include a comprehensive history of the patient with
identification, and if possible, elimination of risk
factors.

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 .

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

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 .

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

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: 133:106–109.

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.

Penicillins
Development of resistance
Clindamycin
 Pseudomembranouscolitis
Alexander RE. Dental extraction wound management: A case
against medicating postextraction sockets. J Oral Maxillofac
Surg 2000: 58: 538–551.
In some cases, the antibacterial or base material
used to carry the antibiotic has caused more
significant complications than the AO.

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: 43–52.

 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.

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.

 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.

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: 167–170.

 Whitehead’s 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
Whitehead’s 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:
273–278.

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. 22–30, 1979.

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: 152–168.

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:
190–194.

 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: 728–735.

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.

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:
69–72.
FRIDRICH KL, OLSON RAJ. Alveolar osteitis following removal
of mandibular third molars. Anaesth Prog 1990: 37: 32–41.

 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

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: 279–283.

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
3. Topical anaesthetic dressings, and
4. Combinations of 1–3.
 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: 196–199.

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.

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

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.

 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.

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: 309–317. 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

dry socket

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