DRY SOCKET

SYNONYMS :
Alveolar osteitis
Postoperative alveolitis
Painful dry socket
Necrotic alveolar socket
Alveolagia
Post extraction syndrome
Localized alveolar osteitis
 The term Dry socket was introduced by CRAWFORD in
1896.
 It is a postoperative complication that occurs after dental
extraction .
 DEFINITION: It can be defined as a postoperative pain
in and around the dental alveolus, which increases in
severity at some moment between the first and third day
after a dental extraction ,accompanied by partial or total
disintegration of the intra-alveolar clot, causing a foul
smell.
AETIOLOGY
Difficult or traumatic extraction
Use of oral contraceptives
Hormonal changes
Tobacco
Inadequate intraoperatory irrigation
Advanced age
 CLINICAL FEATURES
Absence of a normal healthy postextraction
blood clot formation .
 Pain appears on the second or third day and
usually lasts for about 10 to 15 days.
Pain is localized and will be sensitive to even
gentle probing.
Pain increases with suction or mastication.
Halitosis
Pain radiates to the ear and the ipsilateral
side of the head
 NORMAL PHYSIOLOGY
 After tooth extraction ,an orderly sequence of events
causes normal tissue healing .
 The alveolar socket fills with blood and that undergoes
coagulation and contraction.
 Angioblastic ingrowth occurs into the clot, while
epithelium covers the clot.
 Fibroplasia into the clot, cellular elimination of fibrin and
blood debris .
 Production of osteoid by induced mesenchymal cells.
 Woven bone is formed, followed by osteoblastic and
osteoclastic activity that ends in mature bone
formation,often with loss of total bone volume
 PATHOPHYSIOLOGY
Sometimes, early clot formation in the
socket followed by premature clot
necrosis or loss accompanied by pain
and fetor oris.
Theories of dry socket :
• Birn’s fibrinolytic theory
• Bacterial theory
BIRN’S FIBRINOLYTIC THEORY
FIBRIN

KINASE PLASMINOGEN

CLOT
DISINTEGRATIO
N

DRY SOCKET
 BACTERIAL THEORY
 Anaerobic microorganisms are generally
found and the alveolar pain is due to bacterial
toxins present on the nerve endings.
 Actinomyces viscousus and Streptococcus
mutans have been related to dry socket and
retard postextraction healing.
 Treponema pallidum –increases fibrinolytic
activity and it is a periodontopathogenic
microorganism.
 PREVENTIVE MEASURES
A comprehensive clinical history and
radiographic examination
Preoperative oral hygiene measures
Minimum amount of trauma and
maximum amount of care
Appropriate antibiotic prophylaxis
In people smoking, advise not to
smoke preoperatively and for at least
2 weeks postoperatively
 Avoid extracting lower third molars in the
presence of active infections or ulcerative
gingivitis
 In female patients using contraceptives,
extractions should be performed during days 23
through 28 of the tablet cycle, when fibrinolytic
activity is suppressed
 Patient is advised to avoid vigorous mouth
rinsing for the first for the first 24 hours
postextraction and to use gentle tooth brushing
and mouth rinses for 7 days postextraction .
 MANAGEMENT
Radigraph : To exclude the possibility of retained
fragments of tooth or foreign body
The affected socket should be gently irrigated with 0.12%
warmed chlorhexidine and all debris dislodged and
aspirated
In extremely painful conditions, local anaesthesia may be
required
Appropriate analgesics as NSAIDS are useful in managing
pain
Home socket irrigation using 0.12% chlorhexidine
 Intra-alveolar pastes consisting of Zinc
oxide eugenol paste, anaesthetic and an
antibiotic [metronidazole] can be placed
 Topical application of an emulsion of
oxytetracycline and hydrocortisone has
shown to significantly decrease alveolar
osteitis after impacted mandibular third
molar removal
 PHBA-decreased incidence of third molar
dry socket and is antibacterial
 Patient should be kept under review until
they are pain free and socket healing
ensured