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2. 1
Introduction
A dry socket also referred to as alveolar osteitis is a postoperative complication
following tooth extraction. Both terms “dry socket” and “alveolar osteitis” have
been used interchangeably in the dental literature. It can be defined as
“postoperative pain within and around the extraction site, which rises in severity
at any time between the first and fifth days after the tooth extraction,
accompanied by a partial or complete disintegration blood clot within the
alveolar socket and with or without halitosis” [1]. It occurs in 0.5–5% of routine
dental extractions and 25–30% following the extraction of impacted mandibular
wisdom tooth. Females are more frequently affected than males, but this
appears to be related to oral contraceptive use rather than any underlying gender
predilection [2]. Unlike other forms of wound infection, alveolar osteitis occurs
frequently in the young age group, although wound infection, in general, is
more likely to occur with increasing age. Even, in this era of cell and molecular
biology, the specific etiology of the dry socket has not yet been defined.
However, numerous local and systemic elements make contributions towards it .
Some of the risk factors are difficult surgical extraction, trauma,
microbiological origin, smoking, age, and contraceptive pill use. Presence of
periodontal disease, acute necrotizing ulcerative gingivitis, local bone disease,
or previous history of developing a dry socket has also been implicated. Clinical
and experimental research studies have described an elevated fibrinolytic
activity as a major factor for the etiology of the dry socket [3].
Signs of dry socket
1- An empty socket, which is partially or totally devoid of blood clot.
2- Exposed bone may be visible which is extremely painful and sensitive to
touch .

3. 2
3- Remaining food debris inside the socket that may hide the exposed bone
4- Inflammation of the soft tissues around the socket.
5- Delayed Healing of the socket [4].
Symptoms of dry socket
1- Severe pain and discomfort from the extraction site that starts on the second
or third day after the extraction.
2- The pain may radiate to other parts of the head such as the ear,eye,and neck.
3- Intraoral halitosis.
4- Bad taste in the mouth.
Causes of dry socket
● Smoking.
● Traumatic Extraction.
● Poor oral hygiene.
● Patients with history of dry sockets.
● Surgical extraction of wisdom teeth.
● Rinsing and spitting alot or drinking through a straw.
● Pre-existing infection in the mouth such as necrotizing ulcerative gingivitis or
Chronic periodontitis.
● Teeth with pericoronitis are more likely to cause a dry socket after extraction.

4. 3
Different methods in the management of dry socket
Being an old surgical puzzle, many different methods have been advocated to
treat alveolar osteitis (dry socket) , such as the application of local turmeric [5],
zinc oxide eugenol, alvogyl, honey or vitamin C , and socket irrigation with
hydrogen peroxide . However, these conventional treatment approaches merely
solve the symptoms but do not target the key etiology. Furthermore, most of
these approaches do not completely alleviate the pain and other symptoms.
More recent approaches come into play based on experience of wound healing
management in other surgical specialty areas, and these include the use of low
intensity pulsed ultrasound therapy (LIPUS) , low level laser therapy (LLLT) ,
ozone therapy , and the use of plasma rich in growth Factors (PRGF) in general
and oral wound healing.
As the knowledge on the biology of wound healing advances, the role of
cytokines and growth factors in the healing of alveolar osteitis becomes more
significant. Understanding the molecular aspects of wound healing plays an
important role in dry socket healing.
Over the past two decades, plasma rich in growth Factors (PRGF) has been
used in many surgical fields as an additional remedy for supporting wound
healing [6].
Using Growth Factor in the Healing of Dry Socket
Growth factors are the driving force for tissue regeneration by regulating many
aspects of cellular behavior, the function of which has been widely accepted.
For example, transforming growth factor-beta (TGF-β) and insulin-like growth
factor promote cell proliferation; TGF-β and vascular endothelial growth factors
(VEGF) enhance cell migration; bone morphogenetic proteins (BMPs) and
fibroblast growth factor 2 (FGF2) stimulate osteogenic differentiation; VEGF

5. 4
and platelet-derived growth factor (PDGF) are essential in the process of
angiogenesis.Native growth factors are embedded within the extracellular
matrix (ECM). However, exogenous growth factors applied alone in tissue
engineering have a short life due to rapid proteolysis [7].
Concentrated growth factor (CGF)
Is the third generation of autologous plasma extract prepared by a special
centrifugal program. CGF scaffolds possess unique three-dimensional (3D)
fibrin networks, which may establish a conducive microenvironment for newly
formed tissue growing inwards. Particularly, the optimized manufacturing
process endows CGF with a higher level of growth factors, platelets, and
cytokines than the traditional platelet concentrates such as platelet-rich plasma
(PRP) and platelet-rich fibrin (PRF) [8].
In previous studies, CGF has been suggested as potentially ideal scaffolds for
bone defect repair due to its osteogenic promotion effect on bone marrow stem
cells (BMSCs).Moreover, recent studies investigated that CGF promoted the
proliferation and migration activity of periodontal ligament stem cells
(PDLSCs) and Schwann cells (SCs) in vitro, and CGF treatment led to
functional nerve recovery in the sciatic nerve injury rat model [9].

6. 5
Treatment
the socket was curetted and irrigated under local anesthesia and CGF in gel
form was inserted into it. Preparation of CGF was performed by obtaining about
9 ml of the patient’s blood into a vacuum test tube. CGF was prepared using
Medifuge centrifuge machine, Silfradent, Italy, following a cycle duration of 5
minutes at 1,000 revolutions. The processing time is about 12 minutes and
finally a thick yellowish color gel layer was produced known as CGF. This CGF
gel was directly delivered into the socket using a surgical tweezer .
Treatment with CGF showed a higher potency of the healing process.
Concentrated growth factors are ideal for clotting as it contains essential growth
factor: platelet-derived growth factor (PDGF), transforming growth factor
(TGF), platelet factor interleukin (IL), vascular endothelial growth factor
(VEGF), epidermal growth factor (EGF), insulin-like growth factor IGF, and
fibronectin. Together, this cocktail of growth factors speeds up the development
of the delicate fibrovascular granulation tissue. Different studies have shown
that the presence of growth factors can speed up the healing process . CGF
promotes cell proliferation and migration and regulates the biological behavior
of diverse cell types and supports angiogenesis which is a key element in any
wound healing process [10].
Platelet-Rich Plasma ( PRP )
PRP is a patient’s blood enriched with extra platelets from another sample of
the same patient’s blood. While blood is mainly a liquid called plasma, there are
also solid components as well, including red cells, white cells, and platelets.
PRP is liquid plasma with a higher concentration of platelets and growth factors
that speed healing and decrease post-op pain. Dry socket can be dramatically
decreased with the use of PRP.

7. 6
PRP is made by special processing of the patient’s own blood. A small volume
of blood is drawn just before the tooth extraction procedure and is placed in two
test tubes. The tubes are then put in a centrifuge that separates the blood’s
components. The plasma layer, now separated, is removed from the centrifuge
and then placed in the socket left after removing the wisdom tooth has been
removed.
PRP can decrease the incidence of dry socket and its symptoms, speed up the
healing process, and reduce pain. PRP is great for preventing dry sockets and
enhancing the recovery process following wisdom teeth extraction [11].
How Does PRP Reduce Dry Socket?
The healing power of PRP comes from applying a supraphysiologic
concentration of platelets directly to damaged tissue. Platelets are the primary
drivers of wound healing throughout the body. They are tiny fragments of
megakaryocytes, large progenitors of hematopoietic stem cells located in bone
marrow. During the final stages of maturation, megakaryocytes extend
proplatelet elongations into sinusoidal blood vessels. The proplatelet

8. 7
elongations continue to mature inside the blood vessel and eventually release
platelets into the bloodstream. They are just a fraction of the size of red blood
cells and circulate through the blood at about 150,000 to 450,000 platelets per
microliter of whole blood or about 1 trillion per adult.
Platelets play an essential role in clot formation by changing shape, releasing
alpha-granules and aggregating in response to blood vessel injury. Growth
factors released during degranulation increase tissue regeneration by increasing
cell mitosis, chemotaxis and stimulating angiogenesis. In the presence of a
wound, as with the open socket left behind after molar extraction, growth
factors signal to surrounding epithelial cells to increase proliferation.
Complete healing from tooth extraction requires the regeneration of soft tissue
and, in many cases, bone. Postoperatively a healthy patient will regenerate
connective tissue and osteoblasts as needed. Growth factors contained in PRP
such as insulin-like growth factor, vascular endothelial growth factor, epidermal
growth factor, nerve growth factor, transforming growth factor-β1&2, and
platelet-derived growth factors rapidly increase the patient’s healing potential
by increasing collagen production and vascular ingrowth at the surgical
opening. Platelets also release cytokines such as angiopoietin-2 and interleukin-
1 which notify surrounding and distant cells to migrate to the site of injury.
After extraction, filling the open tooth socket with activated PRP gel acts as a
natural clot, but with the added benefit of growth factors and far superior
adhesion. A natural blood clot is composed primarily of red blood cells with
approximately 5% platelets and less than 1% white blood cells. The activated
PRP gel forms a dense fibrin clot composed of 94% platelets, 5% red blood
cells and approximately 1% white blood cells [12].

9. 8
Conclusion
The studies suggests that the delivery of CGF into a dry socket helps to relieve
pain and expedite the wound healing process as shown by a much lower pain
score and earlier and more rapid formation of granulation tissue when compared
to conventional therapy. Chairside CGF techniques in the dental office are
simple, feasible, and economical with predictable results.
Substantial reduction in the incidence of AO following treatment of the
extraction site with PRP. This simple and cost effective technique appears to be
a viable methodology by which dental practitioners can decrease the incidence
of AO formation in patients. Many researches supports the use of PRP in
mandibular and maxillary extraction sites as a method for reducing patient
postoperative discomfort and the need for multiple postoperative visits that can
be associated with AO.
References
1. I. R. Blum, “Contemporary views on dry socket (alveolar osteitis): a clinical
appraisal of standardization, aetiopathogenesis and management: a critical
review,” International Journal of Oral and Maxillofacial Surgery, vol. 31, no. 3,
pp. 309–317, 2002.
2. M. Chiapasco, M. Crescentini, and G. Romanoni, “*e extraction of the lower
third molars: germectomy or late avulsion?” Minerva Stomatologica, vol. 43,
no. 5, pp. 191–198, 1994.
3. H. Birn, “Etiology and pathogenesis of fibrinolytic alveolitis (“dry socket”),”
International Journal of Oral Surgery, vol. 2, no. 5, pp. 211–263, 1973.
4. Blum IR. Contemporary views on dry socket (alveolar osteitis): A clinical
appraisal of standardization, aetiopathogenesis and management: A critical
review. Int J Oral Maxillofac Surg. 2002;31:309-17.

10. 9
5. P. A. Lone, S. W. Ahmed, V. Prasad, and B. Ahmed, “Role of turmeric in
management of alveolar osteitis (dry socket): a randomised clinical study,”
Journal of Oral Biology and Craniofacial Research, vol. 8, no. 1, pp. 44–47,
2018.
6. Hindawi International Journal of Dentistry Volume 2020, Article ID
9038629, 9 pages https://doi.org/10.1155/2020/9038629
7. Barrientos, S, Stojadinovic, O, Golinko, MS. Growth factors and cytokines in
wound healing. Wound Repair Regen 2008; 16(5): 585–601.Google Scholar |
Crossref | Medline | ISI.
8. Sacco, L, Corigliano, M, Baldoni, E. CGF-una proposta terapeutica per la
medicina rigenerativa. Odontoiatria 2010; 1: 69–81.Google Scholar
9. Qin, J, Wang, L, Sun, Y. Concentrated growth factor increases Schwann cell
proliferation and neurotrophic factor secretion and promotes functional nerve
recovery in vivo. Int J Mol Med 2016; 37(2): 493–500.Google Scholar |
Crossref | Medline
10. R. Jin, G. Song, J. Chai, X. Gou, G. Yuan, and Z. Chen, “Effects of
concentrated growth factor on proliferation, migration, and differentiation of
human dental pulp stem cells in vitro,” Journal of Tissue Engineering, vol. 9,
2018.View at: Publisher Site | Google Scholar
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David A. Johnson.Inhibition of alveolar osteitis in mandibular tooth extraction
sites using platelet rich plasma. Vol. XXXIII/No. Three/2007
12.Prataap N, Sunil PM, Sudeep CB, Ninan VS, Tom A, Arjun MR. Platelet-
rich Plasma and Incidence of Alveolar Osteitis in High-risk Patients Undergoing
Extractions of Mandibular Molars: A Case-control Study. J Pharm Bioallied
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