A Case of Dry Socket (alveolar osteitis)
A Case of Dry Socket (alveolar osteitis). A dry socket is one from which the blood clot is lost before it can become stabilized by ingrowth of granulation tissue. Loss of blood clot is thought to be the result of excessive fibrinolysis caused by bacterial, local tissue or salivary factors.In the absence of a blood clot, healing is delayed because soft tissue must grow from the gingival margin to cover the bone and fill the socket.
CASE: A 36-year-old lady presents with severe pain a few days after tooth extraction
Chief Complaint: Patient complains of severe pain a few days after tooth extraction since yesterday
History of presenting Illness: She complains of a distressingly severe pain from an extraction socket in the left side of her mandible. The patient is complaining of pain near to the extraction socket. The tooth is not sensitive to cold or hot food however pain is severe on chewing, and is not sensitive to hot or cold. It is a constant pain and even is not relieved by medications. The intensity of the pain is so severe that if prevents her normal activity.
The patient had surgically removed the lower left third molar 4 days ago. The extraction was more difficult and time was taken longer than expected. There was also use of bur during the extraction. Following the extraction, bleeding stopped normally. The extraction was painful but was slowly healing until yesterday when the severe pain started.
Since then she has also noticed halitosis and a bad taste.
Medical History: There is no relevant medical history.
- Extra-oral examination(Symptoms):
- Extraoral swelling of the face overlying the extraction socket and some early discolouration of the skin by ecchymosis.
- Limited mouth opening. (26 mm interincisal opening)
- No palpable lymph nodes
- Halitosis is noticeable.
- The socket of the extracted tooth had nos signs of any healing tissue.
- The surrounding soft tissues are slightly swollen but not significantly inflamed as judged by redness.
- Dry socket (alveolar osteitis):
- Pain from surgical trauma:
- Retained root fragments:
Among these, most possible diagnosis on the basis of history, signs and symptoms is Dry socket (alveolar osteitis):
Justification for the possible diagnosis: The diagnosis is most likely to be a dry socket (alveolar osteitis). Since there is history of severe and constant pain localized to the tooth socket, 2-3 days after extraction. The lack of local inflammation or enlarged lymph nodes is compatible with this diagnosis and argues against post extraction infection either in the bone or soft tissue. The blood clot has been lost from the socket which can confirm the dry socket. Halitosis might be the result of food debris in the socket which usually is degraded by a partially anaerobic bacteria. The trismus might be due to surgical trauma of extraction.
- At this stage, the history and examination are completely compatible with the diagnosis and no investigations are indicated.
- If there were features of infection, culture of pus and antibiotic sensitivity would be necessary and the temperature should be taken.
- Radiographs are not useful unless a root fragment is suspected but cannot be seen or palpated.
- Even if osteomyelitis is suspected, radiographs would not provide useful information because there has been insufficient time for the characteristic radiographic changes to develop.
FINAL DIAGNOSIS: Dry socket (alveolar osteitis)
- Local treatment to the socket is the most effective measure. Irrigate the socket gently with warm saline or 0.12% chlorhexidine to remove the debris. Place a dressing into the mouth of the socket to prevent impaction of further food.
- Effective socket cleansing and socket hygiene are more important than the type of dressing used and the patient should be recalled every 2 days for retreatment if necessary.
- The trismus should be monitored and should reduce.
- Antibiotics should not be prescribed because they are ineffective. A nonsteroidal anti-inflammatory drug should be adequate for most cases.
- Improvement of symptoms will usually be noted within minutes or up to an hour, and more quickly if the dressing contains a local anaesthetic agent.
- Pain may start again a day or two after dressing, gradually increasing in severity. After a few days the pain will reduce and re-dressing may not be necessary
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