Alveolar osteitis - A comprehensive review in etiology, prevention and management

Definition:

 Most common term is “dry socket” tooth which was described by Crawford in 1896
 “FIBRINOLYTIC ALVEOLITIS” is considered to be the most accurate of all the terms of dry socket,
however this term is also the least used in the literature as Alveolar osteitis is more commonly
used.
 Dry socket is a type of postoperative pain in and around the extraction site that worsens
between one and three days after the extraction.

Signs and Symptoms

 The exposed alveolar bone that has been denuded might be painful and tender.
 'Intense continuous pain' irradiating to the ipsilateral ear, temporal region, or eye may also be
reported by certain individuals.
 Lymphoma in the region (occasionally)
 Unappetizing flavor (occasionally)
 Trismus is a rare complication of mandibular third molar extractions, most likely as a result of
the lengthy and traumatic surgery.

Pathophysiology:

 After tooth extraction, a blood clot forms in the socket of the extracted tooth, primarily to limit
blood loss from the extraction and to prevent the alveolar bone from being exposed to the oral
environment.
 When this blood clot fails to form or is removed from the socket, the alveolar bone is exposed to
oral saliva, bacteria, and food debris.
 This causes localized inflammation of the alveolar bone, resulting in acute throbbing pain that
extends to the affected side's jaws, ears, and eyes.

Incidence:

 Incidence of the dry socket tooth is more in the mandible compared to the maxilla reaching 45%
for mandibular third molars
 Alveolar osteitis affects women more than men in the ratio of 5:1 because of changes in
endogenous estrogens during the menstrual cycle, and estrogens indirectly activate the
fibrinolytic system in females

Onset and Duration

 Dry socket takes place 1-3 days after the tooth has been extracted and varies from 5 to 10 days
depending on the severity.

Etiology-

 Alveolar osteitis comes from a multifactorial origin due to various factors that may influence the
severity and occurrence of the dry socket.
 o Oral microorganisms - Dry sockets have become less prevalent when antibacterial
measures are used.
 Poor oral Hygiene
 Pre-existing local infection
o Difficulty and trauma during surgery
 Excessive trauma results in delayed wound healing due to: the compression of
bone lining the socket, thrombosis of the underlying vessels, trauma with a
reduction in tissue resistance and consequent wound.
 Less experienced surgeons
o Roots or bone fragments remaining in the wound –
 Logical that fragments and debris remnants could lead to disturbed wound
healing.
o Excessive irrigation and curettage
 Excessive irrigation interferes with the formation of blood clot and could give
rise to infection
 Violent curettage might injure the alveolar bone
o Local blood perfusion & anesthesia
 There are patients who needs repeated injections of the local anesthesia may
have a lower pain tolerance, which could explain the complaints pain in the
extraction socket.
o Oral contraceptives
 Oral contraceptives increase plasma fibrinolytic activity, which influences the
clot's stability after extraction. it has been hypothesized that "estrogen"-like
pyrogens found in contraceptive pills will indirectly activate the fibrinolytic
system.
o Smoking
 Nicotine found in the cigarette causes platelet aggregation, which raises the risk
of microvascular thrombosis and peripheral ischemia.
 Incidence of dry socket is greater than 40% among patients who had smoked on
the day of surgery or on the first post-operative day.

 Prevention
o Antibiotics
 Using of systemic antibiotics is shown to be effective in preventing the incidence
of dry sockets such as Penicillin, Clindamycin, Erythromycin and Metronidazole.
o Chlorhexidine
o Eugenol containing dressing
o Steroids
o Antifibrinolitics
o Low level laser therapy
 Treatment
o To treat a dry socket, a dentist will rinse the affected alveolus with a solution to remove
any debris.
o To avoid additional pain and discomfort, a topical anesthetic or nerve block may be
administered.
o During the healing process, the socket may need to be re-rinsed.
o After it has been cleared of debris, a medicated bandage comprising analgesics and
antiseptics is lightly put into the open socket.
o Oral analgesics may also be prescribed.
o After the dentist judges that the socket dressings are no longer required, the patient will
be shown how to rinse the socket to keep it clean and to speed up the healing process.