02 Nov Dry Socket. Prevention and Management.
Written by: Dr Pasquale Venuti
Alveolar osteitis, also called “dry socket”, remains amongst the most commonly encountered complications following extraction of teeth. This condition would result in severe pain and repeated visits.
Dry socket” was first described in the literature in 1896 by Crawford. Since then, other terms have been used to refer to this complications, such as “alveolar osteitis”, “alveolitis”, “localized osteitis”, “alveolitis sicca dolorosa”, “localized alveolar osteitis”, “fibrinolytic alveolitis”, “septic socket”, “necrotic socket”, and “alveolalgia”.
The dry socket has the following clinical signs and symptoms:
- the socket is empty or partially full of necrotic greyish coagulum and food remnants
- the patient refers to intense pain, that increases 48-72 hours after the extraction
- the patient refers a bad smell coming from the socket with halitosis
- the area surrounding the socket is extremely painful at the palpation
The exact pathogenesis of the dry socket is not well understood. Anyhow, some pre-operative and intra-operative variables seem to be associated with more frequency to dry socket:
- mandibular teeth, especially third molars. Indeed, it is much less frequent after the extraction of upper teeth
- difficult extractions, requiring the use of burs onto the bone
- root canal treated teeth
- teeth with acute apical periodontitis
- smokers patients
- women, especially elder women, and especially in women taking contraceptive drugs
- older the patients, higher the frequency
- intraligamentary anaesthesia, especially using vasoconstrictors
- positive anamnesis for pain episodes after previous extractions
On the base of my experience, there is no effective measure to prevent dry socket, except minimizing the use of intraligamentary anaesthesia. We should just advise the patient of this possibility, especially when one or more of the variables cited before are present, and especially when the patient reports at the anamnesis similar episodes of pain after the previous extraction!
Telling the patient before means INFORMING, telling the patient after means EXCUSING. The patient should preventively be informed of such a complication and how you intend to manage it.
Always on the base of my experience, the treatment should be just addressed to contain the pain. The use of antibiotics is useless, or even harmful (because exposes the patient to complications like diarrhoea and candidosis, with no impact on the outcome of alveolitis). Alveolitis is not an infective condition. It is an inflammatory condition, whose main feature is a pain.
I have been trying over the years several medicaments and drugs in order to contain the pain. The most efficacious treatment – and with no complications that I can report – during my last 15 years of practice has been “Alveogyl“. Thanks to this local medicament, I have avoided my patients also to assume pain killers.
It is one of the products that I could not live without. It makes my dentistry predictable, and the life of patients better and it is a powerful creator of loyalty among my patients and me.
Alveogyl is used as a dressing for dry socket conditions. It provides a fast soothing effect in the area, proving pain relief for 24-48 hours. Active ingredients are:
- eugenol of analgesic action
- butamben for anaesthetic action
- iodoform for antimicrobial action
It has fibrous consistency – thanks to Penghawar fibres – that allows an easy filling of the socket and a good adherence to the alveolus. It is spontaneously expelled by the socket when the healing starts and progresses.
The application of Alveogyl is very easy:
- first, we are going to debris the socket from food debris and necrotic coagulum. I would just flush the area with simple water from the syringe of the dental chair and my assistant will use suction for collecting the debris.
- I would fill the empty socket with the filaments of Alveogyl
The application of the filaments can create a bit of discomfort to the patient. But then, the pain relief starts to happen in 5-10 minutes. And in 20 minutes the pain would vanish. The analgesic effect lasts 24-48 hours. In some cases – if the healing does not start – it might be necessary to repeat the application of Alveogyl.
You must always inform the patient of such complication after extraction and how you intend eventually to manage it. The patient should know that typical pain from dry socket would start 48-72 hours from the extraction, accompanied by a bad smell coming from the socket. You should inform him that this pain does not sign of infection, therefore it does not need to take any antibiotics (patients are very prone to self-prescribing antibiotics). If this happens, he should call the office for scheduling an appointment the same day or maximum the day later for the application of the Alveolgyl into the socket. You should inform him that the pain relief from Alvelogyl would last 24-48 hours and in very rare cases it could be necessary to repeat this medication.