Factors Predisposing Dry Socket, Treatment and ComplicationWhat is a dry socket? A dry socket is one from which the blood clot is lost before it can become stabilized by ingrowth of granulation tissue. The exposed bone surface becomes colonized by anaerobic bacteria and spirochaetes and is partially and superficially devitalized.
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.
What are factors predisposing dry socket?
- The risk factors associated with development of dry socket are:Surgical or traumatic extraction
- Mandibular extraction, especially third molar
- Female patient, especially if on contraceptive medication
- Patient who smokes
- Infection or recent infection at site
- Periodontal disease or acute necrotizing ulcerative gingivitis elsewhere in the mouth
- Local bone disease or sclerosis reducing blood supply for clot formation, as in
- Paget’s disease, cemento-osseous dysplasia or after radiotherapy
- Excessive use of local anaesthetic; vasoconstrictor in excess around the socket may prevent formation of blood clot
- History of previous dry socket
- Young adult to middle-aged patient
How would you treat dry socket patient?
- Reassure the patient that, though extremely painful, this condition does not signify any serious consequence of the extraction. Inform her that the socket will heal normally but more slowly than usual. During the healing period treatment can be provided to relieve the pain though she may have to return for several treatments.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.
- Many proprietary dressings are available, including resorbable materials, antiseptic preparations and analgesic formulations.(Care should be taken not to pack the socket full of the dressing because this would prevent it from filling up with granulation tissue as healing progresses.)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.
- In severe cases a daily dressing may be appropriate initially, and as the socket heals and pain reduces the period between dressing may be extended. The trismus should be monitored and should reduce.
What drugs might you prescribe?
Antibiotics should not be prescribed because they are ineffective. Analgesics are also largely ineffective in the absence of local measures. A nonsteroidal anti-inflammatory drug should be adequate for most cases.
How quickly will the pain be relieved?
- 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. After about 10 days the socket should be filled with tissue and it will probably be asymptomatic for the last a few days of healing.
What if the condition persists for longer than this or appears to be worsening?
- Failure to resolve in the longer term usually indicates the presence of small sequestra of devitalized lamina dura or root fragments.
- These are a normal sequela of extraction and are usually resorbed in the remodelling process during healing.
- Larger pieces may delay healing and sometimes sequestrate through the alveolar ridge mucosa many weeks after extraction, though they are not usually associated with significant pain.
- Periapical radiographs should be taken because only these have the resolution required to see the small sequestra, which may be less than half a millimetre in size.
- Occasionally, larger sequestra of lamina dura may be seen to be separating radiographically. If these are associated with symptoms and are not shed, surgical removal may become necessary.
- In practice this intervention is extremely rarely required, and sequestra are usually small and lost without being noticed.
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