Alveolar Osteitis "Dry Socket"

Definition:
- Inflammation of the alveolar bone (i.e. the alveolar process of the maxilla or mandible). Classically this occurs as a postoperative complication of tooth extraction.
- Occurs more commonly occur in the mandible than the maxilla, due to the relatively poor blood supply of the mandible and also because food debris tends to gather in lower sockets more readily than upper ones.
- It more commonly occurs in posterior sockets (molar teeth) than anterior sockets (premolars and incisors), where the created surgical defect is relatively larger, and because the blood supply is relatively poorer posteriorly.

Etiology:
This usually occurs where the blood clot fails to form or is lost from the socket, this leaves empty socket with bare bone with inflammation limited to the lamina dura "the bone which lines the socket".

Signs and symptoms:
- An empty socket, which is partially or totally devoid of blood clot.
- Bone may be visible or the clot may be filled with food debris which reveals the exposed bone once it is removed.
- Surrounding inflamed soft tissues may overgrow to cover the socket.
- Dull, aching, throbbing pain, which is moderate to severe.
- The pain may radiate to other parts of the head such as the ear, temple and neck.
- Pain starts from 2-4 days after extraction.
- Pain may persist for 10-40 days, but most commonly is 10-14 days with adequate treatment.
- The pain might be strong enough so that no medication can relief.
- Intraoral halitosis.
- Bad Taste.

Causes:
- Extraction site: Wisdom Teeth, specially the mandibular.
- Infection: Pre-existing infection in the mouth, such as necrotizing ulcerative gingivitis, chronic periodontitis or pericoronitis.
- Smoking: Smoking and tobacco use of any kind causes vasoconstriction of small blood vessels due to nicotine action.
- Surgical trauma: Excessive force or excessive tooth movements impair the repairing process causing the Alveolar osteitis.
- Vasoconstrictors: The use of Vasoconstrictors may increase the risk for alveolar osteitis, although it is used in local anesthetic solution to make a profound analgesia to the area, specially the areas of acute pain and inflammation.
- Oral contraceptives
- Radiotherapy: That decreases the blood supply to the area.

Diagnosis:
- Pain occurs 2-4 days after extraction.
- Usually part of a broken root or bone fragment is left in the socket.
- A dental radiograph (x-ray) may be indicated to demonstrate such a suspected fragment.

Prevention:
- Avoid excessive forces.
- Press on the alveolar plates to decrease the size of the socket opening.
- Instruct the patient to avoid cold food, beverages, toothpicks into socket, cleaning socket using the tongue or fingers and vigorous mouth rinsing.
- Rinsing with chlorhexidine (0.12% or 0.2%) or placing chlorhexidine gel (0.2%) in the sockets.
- Prophylactic antibiotics prior and after extraction for 3 days, although it's not recommended.
- Antifibrinolytic agents applied to the socket after the extraction.
- Debride the bony walls of the socket to encourage hemorrhage (bleeding) in the belief that this reduces the incidence of dry socket "there is no evidence to support this practice".
- Schedule extraction appointment for females taking oral contraceptives on days without estrogen supplementation (typically days 23-28 of the menstrual cycle).
- Scaling the teeth to be extracted prior to extraction.

Treatment:
1. Pain medication " Non-Steroidal Anti-Inflammatory Drugs".
2. Rinsing / cleaning the socket "removing any debris from the hole".
3. Applying medicated dressings. "antibacterials, topical anesthetics and obtundants, or combinations of all three"
4- Schedule a recall visiting every 3 days to rinsing and cleaning socket and changing the dressing.
5- Prescribe antibiotic to avoid infection of the socket.
6- Oral Hygiene Instructions.
7- Ask the patient to wash the mouth by water and salt or by prescribing Oral Mouthwash.

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:: World Of Dentistry :: TEAM