The most common and painful complication in the healing of human extraction wounds is called as Dry socket. Dry socket is also called as Alveolar osteitis, Alveolitis sicca dolorosa, Alveolalgia, Post-operative osteitis or localized acute alveolar osteomyelitis.
Dry socket is a post-operative socket which lacks the physiological clot both in quality and quantity in which the blood clot disintegrates exposing an infected necrotic socket wall. It is known as dry socket as after the clot is lost, thesocket has dry appearance because of exposed bone. The blood clot helps in stopping the bleeding and lays framework for new tissues to develop there but in case of dry socket, the clot is dislodged and the bone is exposed. This bare bone is exposed to bacteria in the saliva and the food which the patient consumes and the bone becomes infected and painful.
Initially, the clot has dirty grey appearance, and then it disintegrates, ultimately leaving a gray or grayish yellow bony socket bare of granulation tissue. When first seen, the socket may not be always completely empty and it may contain a partially necrotic blood clot.
The diagnosis of Dry Socket is confirmed by gently passing a small probe into the extraction wound. In case of dry socket, bare bone is encountered which is extremely sensitive.
Causes of Dry Socket
Cause of dry socket is variably ascribed to:
1-Pre-existing infection
2-Trauma to the bone during the extraction
3-Infection entering the socket after the tooth has been removed
4-Loss of blood clot due to rinsing the mouth or sucking the wound or by smoking or by drinking any cold drink with straw which creates negative pressure in the mouth.
5-Decreased bleeding due to hemostatic effect of epinephrine or other vasoconstrictor injected with the local anesthetic
6-General debilitation
7-Women on contraceptive pills have high chances of developing dry socket. High level of estrogen increases the chances of dry socket.
8- Extraction of a impacted wisdom tooth increases the chances of dry socket.
9-Too vigorous rinsing with warm saline water.
10-Taking medications like prednisolone, cyclosporine, azathioprine etc.
11-People within the age group of 40-50 years are also more prone to dry socket.
None of these reasons is completely tenable. It is suggested that trauma and infection causes inflammation of the bone marrow which causes release of tissue activators. Plasminogen which is present in the clot is converted into plasmin by the action of tissue activators. Plasmin is afibrinolytic agent and will dissolve the blood clot. It will also release kinins which will cause severe pain to the patient.
causes and pathogenesis of dry socket
The patient should not smoke minimum for 48 hours after the tooth extraction. Smoking in the first 48 hours increases the susceptibility to dry socket. Smoking decreases healing and blood supply to that area and brings toxic products to the area. Due to negative pressure because of smoking, the clot gets dislodged and dry socket occurs. That is why it is advised to avoid smoking few days after the tooth extraction to prevent dry socket.
Dry socket Symptoms
Pain few days after the tooth extraction is normal. But the intensity of pain starts decreasing after some time. In case of dry socket,
1-Dry socket pain usually occurs 3-5 days after the Tooth Extraction.
2-There is severe throbbing pain present that is radiating to ear and neck.
3-It is difficult to pin point site of pain in case of dry socket.
4-If a person looks in the mirror, completely empty socket or partially necrotic blood clot is seen in the socket.
5-If a probe is gently passed into the extraction wound, then bare bone is encountered which is extremely sensitive.
6-Patient having bad breath, halitosis.
7-Patient is not able to open the mouth.
8-Dry socket is sometimes accompanied with fever, headache and insomnia.
So, if a person has these signs and symptoms, then he is having dry socket. Dentist or the oral surgeon needs to be consulted in case of dry socket.
Clinical Features of Dry Socket
It is more common in women as compared to men and is more common in lower jaw as compared to the upper jaw because of the poor blood circulation of the lower jaw.
Pain in case of dry socket is severe and is radiating. The pain is usually described as a throbbing ache and is caused by thermal and chemical irritation of the exposed nerve endings in the periodontal ligament and the alveolar bone. Because of the extreme intensity of pain, it is the most distressing post-operative sequel to tooth extraction. It occurs despite the most exacting operative techniques and aseptic procedure and regardless of the ability and the judgment of the surgeon.
Suppuration that is pus is generally absent but a foul odor is present in case of dry socket.
The symptoms of dry socket generally start on third to fifth day after the extraction of the tooth and if the condition is left untreated, and then it may last for 7-14 days. It rarely occurs a week or longer after the extraction.
Sometimes, the dry socket may be associated with low grade fever and lymphadenopathy. The exposed bone is necrotic and sequestration of fragments is common.
The extraction socket wound normally heals in 7days after simple or closed extraction but in case of dry socket, the extraction socket wound may take 15days to 3months to heal completely.
Healing of Extraction socket after Tooth Extraction
Treatment of Dry Socket
Healing of extraction socket wound with dry socket is extremely slow and the treatment is directed primarily towards the relief of pain.
1-Pain relief is done by 2ways:
Local therapy
2-Antipyretic analgesic or a narcotic
Local therapy consists of irrigation of the socketwith a warm sterile isotonic saline solution or a dilute solution of hydrogen peroxide to remove necrotic material and other debris followed bydressing of eugenol or some other dry socket paste which is available with the dentists which will relieve the pain. In 5-10 minutes, the pain will be relieved. First dressing relieves the pain for 12 to 24hours. After that, the procedure has to be repeated. Second dressing relieves the pain for longer duration. After three or so dressings, thetooth extraction socket wound starts healing from inside out and the bone is covered. After that, it is left open to heal.
Antipyretics and analgesics (Pain relieving meds) are given along with the local treatment and not alone. They won’t be effective if used alone because of the poor vascularity of the necrosed bone.
Most of the patients become free from the symptoms after one or two dressings.
The routine use of antibiotics is not recommended in the treatment of dry socket because the major problem is of pain control rather than unlimited infection. The use of antibiotics alone is an ineffective method for relief of patient’s pain. In rare instance where suppuration does exist, the antibiotic should be used systemically rather than topically in the socket
The incidence of Dry Socket can be prevented by taking certain precautions like:
Doing Chlorhexidine mouth rinses or rinses with some mild anti-microbial mouth wash 24 hours after the extraction, thrice a day. The rinses should be done gently so that blood clot covering the extraction socket is not dislodged. Excessive mouth rinsing for first 24hrs after extraction should be avoided as it can dislodge the clot.
Patient should not smoke minimum after 48 hours of extraction. Smoking creates negative pressure in the mouth which can further dislodge the clot and increases susceptibility to dry socket.
Patient should follow all the post extraction instructions like avoiding sucking, spitting, drinking through the straw after the extraction. Sucking and spitting will create negative pressure in the mouth and can dislodge the clot.
If dentist feels and prescribe the antibiotics, patient should take them regularly.
Patient should try to maintain good oral hygiene. There should be no food impaction in the socket area. The food should be chewed from the other side of the jaw after extraction.
See Also Orthodontic Diploma
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