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 exquisitely sensitive to even gentle probing. Halitosis 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 (1%-65%) 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 3% and 20% of all extractions with lower pre-molar and molar sockets most commonly involved.
These guidelines are intended to assist in the prevention and management of the condition.
1. RISK FACTORS
1.1 Extraction of mandibular rather than maxillary teeth.
1.2 Extraction of third molars especially impacted lower third molars.
1.3 Singleton extractions.
1.4 Traumatic and difficult extractions.
1.5 Female sex especially if using oral contraception.
1.6 Poor oral hygiene and plaque control.
1.7 Active or recent history of acute ulcerative gingivitis or pericoronitis associated with the index tooth(teeth).
1.8 Smoking, especially if > 20 cigarettes per day.
1.9 Increased bone density either locally or generally (eg Paget's disease and osteopetrosis).
1.10 Previous history of dry sockets following extractions.
2. PREVENTIVE MEASURES
2.1 A comprehensive history with identification of risk factors.
2.2 Wherever possible pre-operative oral hygiene measures to reduce plaque levels to a minimum should be instituted.
2.3 Where the clinical history and/or radiographic examination suggests a particularly difficult extraction consideration should be given to an elective trans-alveolar approach.
2.4 All 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.
2.5 Avoid extracting lower third molars in the presence of active infection or ulcerative gingivitis.
2.6 For 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.
2.7 Patients who smoke should be enjoined to cease the habit pre-operatively and for at least two weeks post-operatively whilst the socket(s) heals.
2.8 Wherever possible, for female patients using the oral contraceptive extractions should be performed during days 23 through 28 of the tablet cycle.
2.9 Patients should be advised to avoid vigorous mouth rinsing for the first 24 hours post extraction and to use gentle tooth brushing and mouth rinses for 7 days post-extraction.
2.10 Patients should be advised to return to the surgery/hospital immediately if they develop increasing pain or halitosis.
2.11 Pre- and post-operative verbal instructions should be supplemented with written advice to ensure maximum compliance.
3. DIAGNOSTIC CRITERIA
3.1 Severe and persistent pain arising 24 - 48 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
3.2 Absence of a normal healthy post-extraction blood clot in the socket(s) which may be empty or contain fragments of disintegrating blood clot.
4.1 All patients with signs and symptoms suggestive of a possible dry socket
should be reviewed immediately by the operating clinician.
4.2 If appropriate patients should be x-rayed to exclude the possibility of retained fragments of tooth or foreign body.
4.3 The affected socket(s) should be gently irrigated with 0.12% warmed chlorhexidine and all debris dislodged and aspirated. In extremely painful cases local anaesthesia may be required and in this instance regional nerve blocks should be employed wherever possible.
4.4 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.
4.5 Appropriate analgesics should be prescribed. Members of the Non Steroidal Anti-inflammatory Group of drugs are recommended provided there are no individual medical contraindications for their use.
4.6 Patients' progress should be reviewed the following day but they should be informed to return sooner if problems worsen in the intervening period. Admission to hospital is rarely required.
4.7 Steps 4.3 and 4.4 should be repeated as frequently as necessary to keep the patient comfortable and pain free. Analgesic efficacy should be reviewed and analgesic regimes altered appropriately. When it is considered that socket dressings are no longer required the patient can be instructed in home socket irrigation techniques using an appropriate appliance and 0.12% chlorhexidine.
4.8 Patients should be kept under review until they are pain free and socket healing is ensured.
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