Dry socket is a well recognized painful complication of Dental Extractions which is localized Osteitis, in which the blood clot disintegrates exposing an infected necrotic socket wall.
Dry socket or Alveolar Osteitis is a very unpleasant, painful local complication of extraction of the teeth or surgical removal of teeth. It is the most common cause of delayed post operative pain.
It can be summarized as the focal osteomyelitis caused due to dislodging of blood clod and is charecterized by:
- Extreme pain (Throbbing type)
- Foul Smell (Necrotic odor)
- No Suppuration (no Pus formation)
- Alveolitis sicca dolarsa
- Localized alveolar Osteitis
- Fibrinolytic Osteitis
Alveolar Osteitis is a condition in which the blood clot disintegrates, leaving the socket bare of granulation tissue.
Causes for Clot Disintegration and Development of Dry Socket:
- Failure of clot formation due to the use of Vasoconstrictors in the Local Anesthesia solution. However Dry socket also occurs after extraction under general Anesthesia.
- Infection by Treponema Pallidum
- Infection of the Clot and Underlying bone.
- Traumatic Devitalisation of the Socket wall
- Smoking after extraction.
- Loss of blood clot due to rinsing the mouth or Sucking the wound.
- Loss of blood clot due to excess intra alveolar fibrinolytic ester of P-hydroxy benzoic acid PEPH significantly reducing the incidence of dry socket.
- Conditions with Sclerotic and relatively avascular bone also predisposes to dry socket formation.
Bacteriology Of Dry Socket:
- Anaerobes play a major role, Streptococci and Staphylococci mixed infection
- According to Nitizin’s theory Treponema denticola is the main micro organism found in Dry Socket
- The cultures show large number of fusiform bacilli and Vincent’s Spirochaetes (Treponema denticola)
- Patient presents within 2-5 days of extraction complaining of severe Radiating Pain to the Ear or other parts of face.
- Socket is devoid of clot or contains brown, friable clot which is easily washed out.
- Foul smell: Due to Food debris accumulated in the socket which starts disintegrating.
- On washing away of the food debris the bare pocket floor can be seen which is extremely sensitive to touch.
- Gingival margin surrounding dry socket is usually swollen and dusky red
- Regional Lymphnodes: Tender and enlarged.
- Occasionally Pyrexia is seen.
- Suppuration is generally absent
The Critical period for the development of a drysocket is First 4 days after Extraction after which Granulation tissue starts to invade the clot.
- 3.2 % of all extractions.
- 22% of Third molar Extractions.
- Males : Females Ratio: 2:3
- Peak age: 20-40 yrs
- Mandibular teeth are 3 times more prone than Maxillary teeth
- Single extractions are 2 times more prone than multiple extractions
Radiograph: It is a must so as to exclude the following conditions which can be mis-diagnosed as Dry Socket:
- Retained Apices
- Bony Fragments
- Fractures of Alveolus, body of Mandible
Careful Aseptic Extraction Technique Incidence is reduced significantly by a three day course of Metronidazole 400 mg t.d.s post operatively. Sulphonamides, Antifibrinolytic agents – tranexamic acid Corticosteroids have been tried prophylactically.
Aim of Treatment: Relief of Pain and speeding of resolution.
- The socket should be irrigated with warm normal saline and the socket debridement done.
- Sharp bony spurs should be either excised with rounger forceps or smoothened with a Bur.
- A loose dressing composed of Zinc Oxide and Oil of Cloves on cotton wool is tucked into the socket. it must not be picked tightly in the socket or it may set hard and become very difficult to remove.
- Analgesic tablets and hot saline mouth rinses are prescribed and patient is recalled after 24 hrs.
- After 24 if pain stops then no need to replace dressing, but if pain persists then dressing and irrigation has to be replaced.
- Analgesics (depends on pain – tab voveron 1tds or bruofen 400-600 mg i tds) and Antibiotics are to be used simultaneously to relieve Pain and as well as infection.
Some other dressings used in the treatment are:
- Gauze moistened with Iodoform compound. Can be left for 2-3 weeks
- Gauze moistened with Local anesthetic agent Butacaine/Benzocaine
- Antifibnolytic agents like Propyl Ester of parabenzoic acid, Dextranomer granules, Iodoform paste