MANAGEMENT AND PREVENTION OF DRY SOCKET

INTRODUCTION Dry socket, also termed alveolar osteitis is a well recognised complication of tooth extraction. It is characterised by increasingly severe pain in and around the extraction site, usually starting on the second or third post-operative day and which may last for between ten and forty days. The pain may radiate and typically pain in the ear is one of the symptoms of a dry socket in the mandible. The normal post-extraction blood clot is absent from the tooth socket(s , the bony walls of which are denuded and ex!uisitely sensitive to even gentle probing. "alitosis is invariably present. The condition probably arises as a result of a complex interaction between surgical trauma, local bacterial infection and various systemic factors. There is great variation in reported incidence rates (#$-%&$ between series usually due to inconsistency in diagnostic criteria, variation in microbial prophylaxis and study sample heterogeneity. The true incidence rate probably lies somewhere between '$ and ()$ of all extractions with lower premolar and molar sockets most commonly involved. These guidelines are intended to assist in the prevention and management of the condition. MANAGEMENT 1. Risk Factors 1.1 *xtraction of mandibular rather than maxillary teeth. 1.2 *xtraction of third molars especially impacted lower third molars. 1.3 +ingleton extractions. 1. Traumatic and difficult extractions. 1.! ,emale sex especially if using oral contraception. 1." -oor oral hygiene and pla!ue control. 1.# .ctive or recent history of acute ulcerative gingivitis or pericoronitis associated with the index tooth(teeth . 1.$ +moking, especially if / () cigarettes per day. 1.% Increased bone density either locally or generally (eg -aget0s disease and osteopetrosis . 1.1& -revious history of dry sockets following extractions. 2. Pr'(')ti(' M'as*r's 2.1 . comprehensive history with identification of risk factors. 2.2 1herever possible pre-operative oral hygiene measures to reduce pla!ue levels to a minimum should be instituted. 2.3 1here the clinical history and2or radiographic examination suggests a particularly difficult extraction consideration should be given to an elective trans-alveolar approach. 2. .ll extractions should be completed with the minimum amount of trauma, the maximum amount of care and as rapidly as possible commensurate with the degree of difficulty and experience of the operator. If the extraction is beyond the capability of the clinician then the patient should be referred to an appropriate capable clinician. 2.! .void extracting lower third molars in the presence of active infection or ulcerative gingivitis. 2." ,or difficult lower third molar bony impactions, for immunocompromised patients and for patients with a history of previous pericoronitis or ulcerative gingivitis, appropriate antibiotic prophylaxis should be administered. 2.# -atients who smoke should be en3oined to cease the habit pre-operatively and for at least two weeks post-operatively whilst the socket(s heals. 2.$ 1herever possible, for female patients using the oral contraceptive extractions should be performed during days (' through (4 of the tablet cycle. 2.% -atients should be advised to avoid vigorous mouth rinsing for the first (5 hours post extraction and to use gentle toothbrushing and mouth rinses for 6 days post-extraction. 2.1& -atients should be advised to return to the surgery2hospital immediately if they develop increasing pain or halitosis. 2.11 -re- and post-operative verbal instructions should be supplemented with written advice to ensure maximum compliance. 3. Dia+)ostic Crit'ria 3.1 +evere and persistent pain arising (5 - 54 hours following tooth extraction localised to the extraction socket(s which is(are sensitive to even gentle probing. Typically the pain radiates to the ear with mandibular lesions. 3.2 .bsence of a normal healthy post-extraction blood clot in the socket(s which may be empty or contain fragments of disintegrating blood clot. 3.3 "alitosis.

3. Trismus. . Tr'at,')t .1 .ll patients with signs and symptoms suggestive of a possible dry socket should be reviewed immediately by the operating clinician. .2 If appropriate patients should be x-rayed to exclude the possibility of retained fragments of tooth or foreign body. .3 The affected socket(s should be gently irrigated with ).#($ warmed chlorhexidine and all debris dislodged and aspirated. In extremely painful cases local anaesthesia may be re!uired and in this instance regional nerve blocks should be employed wherever possible. . The socket should be lightly packed with a dressing that contains an obtundant for pain relief and a non-irritant antiseptic to inhibit bacterial and fungal growth. The dressing should prevent the accumulation of food debris and protect the exposed bone from local irritation. Ideally the dressing should resorb and should not excite a host inflammatory or foreign body response. .! .ppropriate analgesics should be prescribed. 7embers of the 8on +teroidal .nti-inflammatory 9roup of drugs are recommended provided there are no individual medical contraindications for their use. ." -atients0 progress should be reviewed the following day but they should be informed to return sooner if problems worsen in the intervening period. .dmission to hospital is rarely re!uired. .# +teps 5.' and 5.5 should be repeated as fre!uently as necessary to keep the patient comfortable and pain free. .nalgesic efficacy should be reviewed and analgesic regimes altered appropriately. 1hen it is considered that socket dressings are no longer re!uired the patient can be instructed in home socket irrigation techni!ues using an appropriate appliance and ).#($ chlorhexidine. .$ -atients should be kept under review until they are pain free and socket healing is ensured. MANAGEMENTU- SI PREVENTIA A-VEO-ITEI USCATE

Introducere Alveolita uscata, de asemenea numita si osteita alveolara este cunoscuta ca complicatie a extractiilor dentare. Se caracterizeaza prin dureri din ce in ce mai severe, n i n jurul locului de extracie , de obicei, cu debut din a doua sau a treia zi post-extractional i care poate dura ntre zece i patruzeci zile . Durerea poate radia si de obicei durerea n ureche este unul dintre simptomele alveolitei uscate la mandibul. Cheagul normal post-extractional de s nge este absent din alveola dintelui, pereii ososi a careia sunt dezgolit i deosebit de sensibili chiar la palparea super!iciala. "alitoza este invariabil prezenta. Alveolita probabil apare ca rezultat al unei interaciuni complexe ntre traumatismul chirurgical , a in!eciei bacteriene locale i a diverilor !actori sistemici . #xist o mare variaie n ratele de incidenta $ %& -'( & ) , de obicei, ca urmare a inconsecvenei n criteriile de diagnostic , a variaiei n pro!ilaxia microbiana i in studierea heterogenitatii . Adevrata rata de incidenta, probabil, se a!l undeva ntre *& i +, & din toate extraciile premolarilor in!eriori i a molarilor. Aceste linii directoare sunt destinate s ajute in prevenirea i gestionarea alveolitei uscate. Management 1.Factori de risc %.% -ai des extractiile dintilor de pe arcada in!erioara, decit de pe cea superioara. %.+ #xtractia molarilor de minte, mai ales a arcadei in!erioare. %.* #xtractii S./01#23/ %.4 #xtractii traumatice, di!icile. %.( 5eprezentantele sexului !eminin, mai ales dac utilizeaza contraceptive orale. %.' .giena orala nesatis!acatoare, prezenta placii dentare.

%.6 0ingivita ulcerativa acuta sau pericoronarita asociata cu dinte inclus, suportate de pacient la moment sau recent. %.7 8umatul, mai ales mai mult de +, tigari pe zi. %.9 Creterea densitii osoase, !ie la nivel local sau general $de exemplu, boala :aget i osteoporoz). %.%, Antecedente de alveolite uscate dup extracii. 2 . Msuri de preventie +.% 3 anamneza complet cu identi!icarea !actorilor de risc . +.+ .n masura posibilitatilor, pre-operator, trebuie e!ectuate masuri de igiena orala pentru a reduce nivelul placii la minim. +.* ;n cazul n care examenul clinic i < sau examenul radiogra!ic sugereaz o extracie deosebit de di!icil ar trebui sa optam pentru o abordare trans - alveolar. +.4 2oate extractiile ar trebui s !ie !inisate cu traumatism minim, maxim ngrijire i in c t mai scurt timp posibil, proporional cu gradul de di!icultate a operatiei i de experien a medicului. ;n cazul n care extracia are un grad de di!icultate mai inalt decit capacitatile medicului, atunci pacientul ar trebui s !ie redectionat la un clinician cu capacitati adecvate. +.( #vitai extragerea molarilor de minte mai mici n prezena unei in!ecii acute sau gingivita ulceroasa . +.' :entru cazurile di!icile ale molarilor trei cu incluzie osoasa, pentru pacienii imunocompromii i pentru pacienii cu antecedente de pericoronarita sau gingivita ulceroas, trebuie administrat pro!ilactic un antibiotic adecvat. +.6 :acientiilor care !umeaza ar trebui s li se interzica practicarea obiceiul pre -operator i pentru cel puin dou sptm ni post-operator, n timp ce are loc vindecarea plagii . +.7 :entru pacienii de sex !eminin care utilizeaz contraceptive orale extractia ar trebui s !ie e!ectuata n perioada dintre a +*-a zi p n la a +7-a zi a ciclului. +.9 :acienii trebuie s!tuii s evite cltirea viguroasa a cavitatii bucale in primele +4 de ore dup extracie, sa execute un periaj bl nd i sa !oloseasca apa de gura timp de 6 zile postextractie . +.%, :acienii trebuie s!tuii s se ntoarc in sectia de chirurgie < spital imediat n cazul n care atesta o cretere durerii sau halenaa . +.%% .nstructiunile verbale pre - i post-operatorii ar trebui s !ie completate cu s!aturi scrise pentru a asigura o claritate maxim . 3. Criterii de diagnostic *.% Dureri severe i persistente mai mult de +4-47 de ore dup extracia dentar, localizate la nivelul alveolei, sensibilitate la palpare super!iciala. De obicei, dupa extractii mandibulare durerea radiaz in ureche. *.+ Absena post-extracie a unui cheag de s nge normal n alveola, care poate !i goala sau poate conine !ragmente de dezintegrare a cheagului de sange. *.* "alena. *.4 2rismus. 4 . Tratament 4.% 2oi pacienii cu semne i simptome sugestive de o posibil alveolita uscata ar trebui s !ie reexaminati imediat de ctre clinician. 4.+ :acienii corespunztori ar trebui s e!ectueze un examen radiologic pentru a exclude posibilitatea reinerii !ragmentelor de dinte sau corp strin . 4.* Alveola a!ectata ar trebui s !ie irigata uor cu ,,%+& solutie clorhexidina nclzita si toate resturile trebuie sa !ie dislocate i aspirate . ;n cazuri extrem de dureroase, poate !i necesar

anestezia local, de exemplu, blocade nervoase regionale, care ar trebui s !ie utilizate in locurile posibile. 4.4 Alveola trebuie s !ie uor acoperita cu un pansament care conine un obtundant pentru ameliorarea durerii i un antiseptic non- iritant pentru a inhiba dezvoltarea bacteriilor i !ungilor. :ansamentul trebuie s mpiedice acumularea de resturi de alimente i sa protejeze osul expus la iritaie local. ;n mod ideal pansamentul ar trebui s se resoarba i sa nu initieze un proces in!lamator sau o reactie de raspuns la corp strin. 4.( Ar trebui s !ie prescrise analgezice adecvate. Se recomanda !olosirea 0rupului de medicamente Antiin!lamatoare /esteroidiene, cu condiia s nu existe contraindicaii medicale individuale pentru utilizarea lor. 4.' :acienii ar trebui s !ie reexaminati n urmtoarea zi, dar ar trebui s !ie in!ormat de adresare mai precoce n cazul n care situatia se agraveaz n acest interval de timp . .nternarea n spital este necesara !oarte rar. 4.6 :aii 4.* i 4.4 trebuie repetati la !el de des c t este necesar pentru a asigura pacientului con!ort i a inlatura durerea. #!icacitatea analgezicelor ar trebui s !ie revizuita i modi!icata n mod corespunztor. C nd se consider c pansamentul nu mai este necesar, pacientul poate !i instruit sa il nlature in conditii de cas. :entru irigarea alveolei este !olosind un aparat adecvat i solutie ,,%+ & clorhexidina . 4.7 :acienii ar trebui supravegheati p n la lipsa totala a dureii i o vindecare totala a plagii .