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The Risk Factors, Prevention, and Management of Dry Socket Review Article
Wei-Yo Chang, Yin-Lai Wang Department of Dentistry, Kaohsiung Armed Forces General Hospital
With the progress of dentistry, the requests of patients for their oral health and function are getting higher. Tooth extraction is one of the necessary treatments among the dental treatment plan, while some complications are accompanied with it. Dry socket is a well-known postoperative complication following dental extraction. However, the real etiology of this condition is still unclear. Several factors contribute to the occurrence of dry socket have been discussed in many literatures, such as surgical extractions, poor operator's technique, smoking, patient's gender and age, the use of oral contraceptives and bacterial infection. In order to reduce the discomfort of patient and the incidence of dry socket, we have to know the prevention and management although the treatment of this complication is still controversial. Therefore, we can reduce the medical cost and prevent the distrust of patients. ( J. Family Dent. 7(4): 4-10, 2013 )
Key words: dry socket, fibrinolysis, surgical extraction, alveolar osteitis, alveolitis
Introduction
alveolitis, is a well-known postoperative complication by Crawford in 1896, and most authors have accepted the
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"postoperative pain inside and around the extraction site, which increases in severity at any time between the first and third day after the extraction, accompanied by a socket with or without halitosis".
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theories that dry socket occurs due to the disintegration of the blood clot by fibrinolysis.
Received: April 9, 2012 Revised: April 12, 2012 Accepted: April 18, 2012 Correspondence to: Dr. Wei-Yo Chang, Department of Dentistry, Kaohsiung Armed Forces General Hospital No.2, Zhongzheng 1st Rd., Lingya Dist., Kaohsiung City 802, Taiwan (R.O.C.) Tel: 07-7494572 Fax: 07-7498239 E-mail: xiaoyo1006@hotmail.com
Incidence
the incidence of dry sockets following routine dental extractions has been reported in the range 0.5% to 5%.
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basis of this reason; many authors believe that operator's experience is a risk factor for the development of dry socket. Some literature claims that following extractions performed by the less experienced operators, a higher incidence of dry socket was reported.
12,13
after extraction of mandibular third molars, which is generally accepted the incidence is about 20% to 30% of dental extractions.
3,5
the prevalence of dry socket was higher after single extractions than multiple extractions.
14,15
Comparison to non-surgical extractions, surgical extractions result in about 10 times higher incidence of dry socket.
3
4,6,7
mobile and periodontally compromised teeth, these teeth are generally simple to be extracted, and may be less traumatic. A previous study, discussed the incidence of dry socket, also recommended if several adjacent teeth are to be extracted, it is better to perform in one operation. Individual / Systemic difference a correlation with smoking. According to the study of mandibular third molars have been statistically analysed, Many studies demonstrated that dry socket has
16
Factors
contribute to the occurrence of dry socket have been discussed in many literatures. Traumatic factors comparison to nonsurgical extractions, result in about
3
Sweet et al, which a total of 4000 surgically removed there was a dose dependent relationship between smoking and the incidence of dry socket. In this study, patients who smoked a half-pack of cigarettes a day had a four- to compared to nonsmokers. The incidence of dry socket
agree that surgical trauma and difficulty of surgery play a significant role in the development of dry socket. This is secondary to bone marrow inflammation following the more difficult and, hence, more traumatic extractions.
2 4
five-fold increase in dry socket (12% versus 2.6%) when increased to more than 20% among patients who smoked a pack per day, and 40% among patients who smoked period.
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on the day of surgery or in the immediate postoperative smoked on the same day of surgery had a higher incidence postoperatively.
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common following the extraction of mandibular third studies suggest that the anatomical site specificity are molars. In addition to the effect of surgical trauma, some
8,9
of dry socket than those who smoked on the second day There was a statistically significant difference
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responsible for this complication, such as increased bone of producing granulation tissue. However, no evidence blood supply.
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density, decreased vascularity, and a reduced capacity indicated that a link between dry socket and insufficient Poor operator's technique or experience may also
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interfere the healing process of alveolar tissue through the formation of clot by suction effect.
3
introduction of pollutants to the surgical wound, or the Since oral contraceptives became popular in 1960s,
create a bigger trauma during the extraction, especially surgical extraction of mandibular third molars. On the
J. Family Dent. 2013, Vol. 7. No. 4
found. Some studies conducted after 1970s show a significant higher incidence of dry socket in females that take oral contraceptives.
19-21 2
a factor of dry socket in some studies, but different aspects have been proposed, and it has not always been
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fibrinolysis. Fibrinolysis is a normal body process that keeps naturally occurring blood clots from growing and causing problems. This process can be also activated due to a medical disorder, medicine, or other cause. Estrogen, one of the ingredient of oral contraceptives, fibrinolytic process. It is believed to indirectly activate
which should not be ignored for the development of dry socket. If patients with poor oral hygiene, or preperiodontal disease),
27 26
has been proposed to play a significant role in the the fibrinolytic system (increasing factors II, VII, VIII, X, and plasminogen) and therefore increase lysis of the blood clot. The use of oral contraceptives is thought to
5 22
existing local infection (such as pericoronitis or advanced the incidence of dry socket
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appeared increase. One author postulated that bacterial pyrogens in vivo are indirect activators of fibrinolysis.
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be a factor that raises the prevalence of dry socket among increased estrogen dose in the oral contraceptives, the incidence of dry socket increases.
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in the development of dry socket or not. In brief, the quantity of bacteria is the main point. Other uncertain factors there are some different opinions have been proposed. In vasoconstrictor may cause temporary ischemia, and the
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system, especially in the days 23 to 28 of the menstrual menstrual cycle is also a risk factor in the occurrence of dry socket.
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one study, the author believes that local anesthetic with following poor blood supply will lead to increase the
frequency of dry socket. However, other studies hold a contrary opinion, since temporary ischemia would be integration of the blood clot is not affected. According to
2,6
followed by reactive hyperemia in one to two hours, the this reason, local ischemia due to vasoconstrictor in local anesthesia has no role in the development of dry socket.
hormone during the menstrual cycle. Furthermore, the makes the surgeries more difficult and traumatic may also inuence the normal healing process.
Prevention
antifibrinolytic agents are used to prevent the early disintegration of the blood clot. Tranexamic acid (THA), also known as Transamin, is one kind of the C o n s i d e r i n g t h e f i b r i n o l y t i c t h e o r y, t h e
ability of immunocompromised or diabetic patients researchers also have suggested that systemic disease
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could be associated with dry socket. However, no scientific evidence exists to prove a relationship between altered healing ability and dry socket.
4
extraction socket, it has been speculated to prevent the However, another study
reported no significant reduction in the incidence of dry socket when compared to a placebo group.
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mandibular third molars. Ragno et al. found a significant reduction as much as 50% in the incidence of dry socket
38
studies. Some literature reported a lower incidence of dry socket when PHBA was topically used in extraction wounds.
4,24
in patients who prerinsed with chlorhexidine solution indicated that using 0.12% or 0.2% chlorhexidine before and/ or after surgery is beneficial.
39
antifibrinolytic properties and antimicrobial properties to attribute the effect to which properties of PHBA.
may reduce the incidence of dry socket, it is not possible Some literature reported the incidence of dry socket
Management
no treatment exists at the present time. Most authors agree that the primary aim of dry socket management is pain control until commencement of normal healing.
4
reduced with the intraoperative lavage using different quantities (25 ml, 175 ml and 350 ml) of saline solution, of lavage increased (10.9%, 5.7% and 3.2% of the incidence in each group, respectively).
33,34
saline solution for intra-alveolus irrigation with careful aspiration. One study proposed that force the bleeding in the alveolus and the formation of a new clot due to curettage was not suggested. Medication with systemic There is another study suggested that patient should syringe.
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antibiotics and antiseptics were used as a measure of The antibiotics can be used in systemic and
analgesics or antibiotics may be necessary or indicated. be irrigated daily with saline solution using a needless Some authors advise the placement of intraalveolar
4
clindamycin, erythromycin, and tetracycline, were reported to be effective in the prevention of dry socket. However, the development of resistant bacterial strains and unnecessary destruction of host commensals due to the routine use of systemic pre- and/ or postoperative antibiotics prophylatically is still disputed.
4
dressing materials such as antimicrobial agent or local dressings delay healing of the extraction socket, anesthetics. Although it is generally acknowledged that
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carried into the operative wound in many forms. with the application of topical tetracycline.
35,36
the literature does not show clear evidences in favour of concentration locally and avoiding the entrance of food debris to the alveolus.
and
Due to
Conclusions
not uncommon in clinical work. Although the etiology still controversial, it goes without saying that the most Dry socket is a displeasing complication and is
tetracycline in a petrolatum base into a surgical site is not Chlorhexidine is the antiseptics that mostly being
is not clear and the treatment of this complication is important goal of management is pain control. According
used. Several studies have reported that the use of 0.12% chlorhexidine pre- and perioperatively decreases
J. Family Dent. 2013, Vol. 7. No. 4
to the literatures reviewed, the use of analgesics to release healing process is indicated.
the discomfort of patients until commencement of normal Smoking proved to have a great influence in the
8. Jaafar N, Nor GM. The prevalence of post-extraction complications in an outpatient dental clinic in Kuala Dent J, 2000; 23:24-8. Lumpur Malaysia--a retrospective survey. Singapore 9. Amaratunga NA, Senaratane CM. A clinical study of 1988; 26:410-18.
development of dry socket, and should be avoided after tooth extraction, especially on the day of surgery.
0.2% chlorhexidine pre- and post-operatively showed effective in preventing the development of dry socket. In my clinical experience, using -iodine for local sterilization is also useful. Perhaps the incorporation of these methods to the protocol of exodontias would be third molars. We can also educate our patients to use mouthrinses with cholohexdine for home care. In conclusion, the best option is prevention.
10. Nusair YM, Abu Younis MH. Prevalence, clinical picture, and risk factors of dry socket in a Jordanian 8:53-63. Dental Teaching Center. J Contemp Dent Pract, 2007; 11. Larsen PE. Alveolar osteitis after surgical removal of the patient at risk. Oral Surg Oral Med Oral Pathol, 1992; 73:393-97.
12. Alexander RE. Dental extraction wound management: Oral Maxillofac Surg, 2000; 58:538-51.
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