Alveolar osteitis - DIKIOHS DUHS

1. Alveolar Osteitis
Current Concepts
Presentation By: Dr.Shaharyar Hamid

2. Alveolar osteitis (AO), more commonly known as
‘‘DRY SOCKET,’’ is INFLAMMATION of the
alveolar bone characterized by PAIN at, or near, the site of a
tooth extraction and HALITOSIS.
It is a postoperative complication of dental extractions originally
described by Crawford in 1896.

3. AO has been defined in 17 different ways from 1986 to 2018
including
• Septic socket,
• Necrotic socket,
• Localized osteitis,
• Postoperative alveolitis,
• Localized osteomyelitis, and
• Fibrinolytic alveolitis.

4. Etiology and Pathogenesis

5. ONCE A TOOTH HAS BEEN REMOVED
• A fibrin meshwork is delivered to the site via the vascular supply,
which facilitates fibrin deposition and formation of the blood clot.

6. • In contrast, fibrinolysis (destruction of the clot) occurs
through the liberation of tissue kinases during the
inflammation caused by the trauma of the extraction.
• Direct or indirect activation of
plasminogen leads to the
formation of plasmin, which
disintegrates the clot.

7. • In contrast, fibrinolysis (destruction of the clot) occurs
through the liberation of tissue kinases during the
inflammation caused by the trauma of the extraction.
• Direct or indirect activation of
plasminogen leads to the
formation of plasmin, which
disintegrates the clot.
PlasminMan

8. • Birn postulated that AO develops from localized infection of the
socket occurring after extraction of a tooth and could result from
either
• the complete absence of a blood clot or
• the formation of an initial clot that was subsequently lysed soon
after formation.
• In the second scenario, alveolar bone within the socket gets
inflamed,
• Stimulating the release of tissue activators, which facilitate the
conversion of plasminogen into plasmin.

9. Plasmin
• Plasmin is responsible for 2 main functions:
• The degradation of the blood clot and
• The activation of kinins that induce a state of
hyperalgesia.
• Thus providing an explanation for the exquisite pain
experienced by patients with AO.

10. ROLE OF BACTERIA
• Nitzan implicated BACTERIA as the causative agent in the
pathogenesis of AO.
• Treponemes (specifically Treponema denticola) are found near
the gingival sulcus and periodontal pocket.
• Healthy tissue surrounding necrotic areas of periodontal disease
can be seen to be invaded by treponemes and
• This finding is particularly relevant when the LINK between AO
and poor oral hygiene.

11. The LINK
• Patients with poor oral hygiene were found to have 3 times the
incidence of dry socket after impacted third molar extraction.
• A recent prospective cohort study of 284 patients and 564
extractions found that 100% of the cases of AO had developed in
patients with poor oral hygiene.
• Patients who underwent mandibular third molar surgery
experienced more severe pain with poorer oral hygiene, suggesting
that pain might have been link between Pericoronitis and AO.

12. ROLE OF TRAUMA
• It has been suggested that bone marrow inflammation during
extraction can result in the release of the direct tissue activators that
mediate fibrinolysis.
• The prospective study by MacGregor examined 10,199 nonsurgical extractions
and found that teeth that had fractured or had been categorized as ‘‘difficult
extractions’’ resulted in a significantly greater incidence of AO.
• A Scandinavian study showed that patients treated by students were
10- fold more likely to develop dry socket compared with patients
treated by ORAL-MAXILLOFACIAL SURGEONS.

13. ROLE OF SMOKING
• SMOKING has been suggested to increase the incidence of AO by
negative pressure which dislodge blood clot, but
• Coughing, sneezing, and sucking on straws have also been
thought to cause premature dislodgement of the clot.
• A second hypothesized mechanism is exposure to nicotine, a
potent vasoconstrictor that leads to reduced vascularity and
impaired fibrin deposition.

14. ROLE OF MEDICATIONS
• Oral contraceptive pills (OCPs) have been associated with
an increased risk of AO in studies before 1960.
• Also, a recent prospective study of 267 women who had
undergone third molar surgery showed that women taking
OCPs were 2 to 3 times more likely to develop AO.

15. • Parthasarathi reported that no patient taking OCPs developed AO;
• however, this aspect of the study was limited by the small sample
size, which included only 14 extractions in patients taking OCPs.
• The same study also found patients with a history of psychiatric
medication usage were significantly more likely to develop AO.
• The link between fibrinolysis and antidepressant usage is still
UNCLEAR.

16. ANATOMIC CONSIDERATIONS
• AO incidence greater after mandibular tooth extractions
(especially third molars);
• The posterior alveolar region has been shown to have greater
vascularity compared with the anterior regions, which contradicts the
previous suggestions that AO is caused by a lack of blood supply to the
socket, but
• Also favors the hypothesis that direct factors carried to the site by the
blood supply are responsible for clot breakdown and AO development.

17. Prevention
Investigator Intervention Results
Halabi et al,
2018
CHX mouthwash (0.12%) vs
placebo in postextraction
sockets
CHX reduced incidence vs
placebo
Delilbasi et al,
2002
0.2% CHX with
amoxicillin + clavulanic acid
vs CHX
Significant reduction in AO
in CHX with
amoxicillin + clavulanic
acid group
Eshghpour et
al, 2014
chlorhexidine gel with
platelet-rich fibrin
Reduced the rates of AO
compared
with chlorhexidine gel or
platelet-rich fibrin
individually.

18. Investigator Intervention Results
Coulthard et
al,2014
Surgical flap type
(triangular vs
envelope flap);
Triangular flaps resulted in a 71%
reduction in AO and reduction in
pain at 24 hours compared with
envelope flaps.
Lodi et al, 2013 Preoperative antibiotics;
postoperative antibiotics;
pre- and postoperative
antibiotics
No evidence of difference vs
placebo
Guazzo et al, 2018 Topical amino acid and
sodium
hyaluronate gel
No significant difference

19. Envelop
Vs
Triangular
Flap

20. Management
• Treatments of AO target symptoms rather than any particular
disease process.
• The Australian oral and dental therapeutic guidelines have
recommended that patients who develop AO should return to a
dentist for evaluation.

21. • Treatment involves STERILE SALINE irrigation of the socket until debris
has been eliminated, followed by
• Placement of an obtundent dressing into the socket.
• Analgesics and mouthwashes suggested for symptom relief.
• The guidelines have also discouraged the prescription of antibiotics.
• Review of the diagnosis if the patient experienced persistent pain for
longer than 3 weeks or
• If the patient presented with signs of disease outside the extraction
socket.

22. • Long-acting local anesthesia, such as bupivacaine or
ropivacaine via regional blockade or infiltration, can be
helpful for immediate symptomatic relief and can be used in
conjunction with systemic analgesia.

23. • The combination of PARACETAMOL AND NSAIDs regimens
have shown to be effective analgesia to control post-extraction
pain.
• Systemic oral opioids are the final step on the WHO drug ladder
for providing analgesia.
• The neuropathic agent PREGABALIN, has been shown to be
superior to placebo in patients undergoing elective molar removal,
although it is unclear whether this would be applicable in the
setting of AO.

24. MEDICATED DRESSINGS
• Medicated dressings often included compounds with
either analgesic or antibacterial action (or both).
• According to the manufacturer Septodont, Alvogyl is
composed of a
• Local anesthetic, antiseptic, and analgesic (25.7%
butamine, 15.8% iodoform, and 13.7% eugenol,
respectively).

25. • The use of butamine and eugenol played a role in reducing the
pain levels;
• However, substances such as alvogyl paste require REMOVAL
from the extraction socket to prevent foreign body reactions.

26. • Another common dressing is the SaliCept patch, which contains
the acemannan hydrogel found in aloe vera plants.
• Acemannan hydrogel is thought to promote wound healing by
isolating the wound site from the outside environment and
• Providing a moist environment for Healing.

27. PHOTOTHERAPY AND SURGERY
• Phototherapy in the form of low level laser therapy (LLLT) is a common
treatment used in the management of AO.
• Financially advantageous.
• Curettage + irrigation and LLLT
(808 nm, 100 mW, 60 seconds, 7.64 J/cm2)
• RESULTS MORE EFFECTIVE form of treatment with no significant
differences between Alvogyl and SaliCept.

28. Thank you