ORAL AND MAXILLOFACIAL SURGERY

1. DRY SOCKET
DR DAVIS NADAKKAVUKARAN
M.D.S
ORAL AND MAXILLOFACIAL
SURGEON

2. Contents
 DEFINITION
 SYNONYMS
 ETIOLOGY
 CLINICAL FEATURES
 AETIOPATHOGENESIS
 THEORIES
 PREVENTIVE MEASURES
 MANAGEMENT

3. DEFINITION
 It has been defined as a ‘post operative pain in and around dental alveolus, which
increases in severity at some moment in between the first and the third day after a
dental extraction accompanied by partial or total disintegration of the intra
alveolar clot accompanied with foul smell.
 It is the most common painful condition
 Also known as alveolar ostetitis.

4. SYNONYMS
 Necrotic alveolar socket
 Alveolalgia
 Delayed extraction
 Localized osteomyelitis
 Fibrinolytic osteitis
 Alveolar osteitis
 Localized alveolar osteitis

5. Aetiology
I. Difficult or traumatic extraction
II. Use of oral contraceptives
III. Female sex
IV. Tobacco smoking
V. Inappropriate intra operatory irrigation
VI. Advanced age

7. Clinical features
 Pain appears on second or third day after extraction, and lasts
with or without treatment about 10 to 15 days.
 Pain is localized to extraction socket.
 Halitosis present
 Pain radiate to ear and the homolateral side of the head.

8. AETIOPATHOGENESIS
Tooth extraction
Alveolar socket filled with blood
Coagulation and contraction
Angioblastic in growth of clot and thin covering
Fibroplasia of clot
Osteoid by mesenchymal cell
Woven bone by osteoblstic and osteoclastic activity
mature bone

9. Normal healing impaired
Early clot formation
Clot necrosis
Pain and fetor oris
Alveolitis

10. Two theories
I. Birn’s fibrinolytic theory
 After extraction of tooth an inflammatory process begins that
could affect the formation and retension of clot
 Laboratory and clinical studies shown increase of fibrinolytic
activity in pathogenesis of dry socket.
 Fibrin disintegrate due to effect of kinase liberated in the
inflammation process or due to direct or indirect activation of
plasminogen,which affects stability of clot and facilitate
development of clot.

11.  Plasmingen is a single chain glycoprotein.which is hepatically synthesized an
released into circulation
 Plasminogen is then activated by proteolytic cleavage into active plasmin
 Which in turn acts proteolyticlaly on fibrinogen and fibrin causing dissolution of
clot
 Active plasmin is quickly inactivated by antiplasmins.
 The absorbed plasminogen is cleaved into plasmin by one of number of
plasminogen activator substances.

12. 2.Bacterial theory
 High count of anaerobic bacteria around extraction sites.
 Aneorobic microorganisms are found and alveolar pain is due
to the effect of bacterial toxins on the nerve ends of the
alveolus.
 Most frequent in patient with poor oral hygiene
 actinomyces viscous , treponema denticola and streptococcus
mutans.

13. Preventive measures
 A comprehensive history with identification of risk factors should be
taken.
 The preoperative oral hygiene measures to reduce plaque level to a
min should e instituted.
 If the clinical history and or radiographic examination suggest a
particularly difficult extraction ,consideration should be given to
transalveolar approach.
 All extraction should be completed with min amount of trauma
 Avoid extracting lower third molar in presence of active infection or
ulcerative gingivitis

14.  Appropriate antibiotic prophylaxis should be administered ,for
difficult lower third molar impaction,for immunocompromised
patients,and for patients with history of previous pericoronitis or
ulcerative gingivitis.
 Patients who smoke should be advised to cease smoking
preoperatively and for at least two weeks postoperatively.
 Patient should avoid vigorous mouth rinsing for first 24 hours
postextraction
 Patient should be advised to return to the hospital immediately if
they develop increasing pain or halitosis.

15. Management
 Patients with signs and symptoms should be
reviewed by operating clinician.
 Patient should be radiographed to exclude the
possibility of retained fragments of bone or foreign
body
 Affected socket should be irrigated with 0.12 %
warmed chlorhexidine
 Intra alveolar pastes consisting of zinc oxide,
eugenol paste ,anesthetic(metranidazole) and
antibiotic can be used

16.  Topical steroid use may decrease the local
inflammation and decrease post extraction clot
breakdown.
 Topical application of an emulsion of
oxytetracyclin and hydrocortisone may decrease
alveolar osteitis.
 Topical use of parahydroxybenzoic acid in
extraction wound decrease the incidence of
mandibular third molar dry socket
 Analgesics should be prescribed.

17. References
 Text book of oral and maxillofacial surgery-SM Balaji