The Risk Factors, Prevention, And Management of Dry Socket-Review Article

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4 J. Family Dent. 2013, Vol. 7. No. 4Family Dent. 2013, Vol. 7. No. 4Dent. 2013, Vol. 7. No. 4

The Risk Factors, Prevention,

and Management of Dry Socket Review Article

Wei-Yo Chang, Yin-Lai Wang

Department of Dentistry, Kaohsiung Armed Forces General Hospital

With the progress of dentistry, the requests of patients for their oral health and function are getting

higher. Tooth extraction is one of the necessary treatments among the dental treatment plan, while some

complications are accompanied with it. Dry socket is a well-known postoperative complication following

dental extraction. However, the real etiology of this condition is still unclear. Several factors contribute

to the occurrence of dry socket have been discussed in many literatures, such as surgical extractions,

poor operator's technique, smoking, patient's gender and age, the use of oral contraceptives and bacterial

infection. In order to reduce the discomfort of patient and the incidence of dry socket, we have to know the

prevention and management although the treatment of this complication is still controversial. Therefore, we

can reduce the medical cost and prevent the distrust of patients. ( J. Family Dent. 7(4): 4-10, 2013 )

Key words: dry socket, fbrinolysis, surgical extraction, alveolar osteitis, alveolitis

Received: April 9, 2012 Revised: April 12, 2012 Accepted: April 18, 2012

Correspondence to: Dr. Wei-Yo Chang, Department of Dentistry, Kaohsiung Armed Forces General Hospital

No.2, Zhongzheng 1st Rd., Lingya Dist., Kaohsiung City 802, Taiwan (R.O.C.)

Tel: 07-7494572 Fax: 07-7498239 E-mail: [email protected]

Introduction

Dry socket, also known as alveolar osteitis or

alveolitis, is a well-known postoperative complication

following dental extraction. This term was frst described

by Crawford in 1896,1and most authors have accepted the

theories that dry socket occurs due to the disintegration of

the blood clot by fbrinolysis.2

The most recent definit ion of dry socket is

"postoperative pain inside and around the extraction

site, which increases in severity at any time between the

frst and third day after the extraction, accompanied by a

partial or total disintegrated blood clot within the alveolar

socket with or without halitosis".3

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5J. Family Dent. 2013, Vol. 7. No. 4Family Dent. 2013, Vol. 7. No. 4Dent. 2013, Vol. 7. No. 4

Incidence

According to the statistics of different literatures,

the incidence of dry sockets following routine dental

extractions has been reported in the range 0.5% to 5%.4

The occurrence of this complication is more frequent

after extraction of mandibular third molars, which is

generally accepted the incidence is about 20% to 30%

of dental extractions.3,5

There are also some researchers

reported different incidence varies from 0% to 45%.4,6,7

Comparison to non-surgical extractions, surgical

extractions result in about 10 times higher incidence of

dry socket.3

Factors

Although the mechanism is unknown, several factors

contribute to the occurrence of dry socket have been

discussed in many literatures.

Traumatic factors

We have mentioned that surgical extractions, in

comparison to nonsurgical extractions, result in about

10 times higher incidence of dry socket.3Most authors

agree that surgical trauma and diffculty of surgery play a

signifcant role in the development of dry socket.4

This is

attributable to more liberation of direct tissue activators

secondary to bone marrow inflammation following the

more diffcult and, hence, more traumatic extractions.2

The frequency of dry socket has been shown more

common following the extraction of mandibular third

molars.8,9

In addition to the effect of surgical trauma, some

studies suggest that the anatomical site specificity are

responsible for this complication, such as increased bone

density, decreased vascularity, and a reduced capacity

of producing granulation tissue.9However, no evidence

indicated that a link between dry socket and insuffcient

blood supply.10

Poor operator's technique or experience may also

create a bigger trauma during the extraction, especially

surgical extraction of mandibular third molars.11

On the

basis of this reason; many authors believe that operator's

experience is a risk factor for the development of dry

socket. Some literature claims that following extractions

performed by the less experienced operators, a higher

incidence of dry socket was reported.12,13

Some previous and current studies indicated that

the prevalence of dry socket was higher after single

extractions than multiple extractions.14,15

This is possibly

because multiple extractions are mostly performed on

mobile and periodontally compromised teeth, these teeth

are generally simple to be extracted, and may be less

traumatic. A previous study, discussed the incidence of

dry socket, also recommended if several adjacent teeth are

to be extracted, it is better to perform in one operation.16

Individual / Systemic difference

Many studies demonstrated that dry socket has

a correlation with smoking. According to the study of

Sweet et al, which a total of 4000 surgically removed

mandibular third molars have been statistically analysed,

there was a dose dependent relationship between smoking

and the incidence of dry socket. In this study, patients

who smoked a half-pack of cigarettes a day had a four- to

fve-fold increase in dry socket (12% versus 2.6%) when

compared to nonsmokers. The incidence of dry socket

increased to more than 20% among patients who smoked

a pack per day, and 40% among patients who smoked

on the day of surgery or in the immediate postoperative

period.17

It has also been reported that patients who

smoked on the same day of surgery had a higher incidence

of dry socket than those who smoked on the second day

postoperatively.18

There was a statistically significant difference

in the incidence of dry socket between smokers and

nonsmokers.5

It has been speculated that smoking may

interfere the healing process of alveolar tissue through the

introduction of pollutants to the surgical wound, or the

formation of clot by suction effect.3

Since oral contraceptives became popular in 1960s,

an unexpected side effect in dental treatment has been

The Risk Factors, Prevention, and Management of Dry Socket


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found. Some studies conducted after 1970s show a

signifcant higher incidence of dry socket in females that

take oral contraceptives.19-21

According to Birn's fibrinolytic theory,2

dry socket

occurs due to the disintegration of the blood clot by

fibrinolysis. Fibrinolysis is a normal body process that

keeps naturally occurring blood clots from growing and

causing problems. This process can be also activated

due to a medical disorder, medicine, or other cause.

Estrogen, one of the ingredient of oral contraceptives,

has been proposed to play a significant role in the

fibrinolytic process. It is believed to indirectly activate

the fibrinolytic system (increasing factors II, VII, VIII,

X, and plasminogen) and therefore increase lysis of the

blood clot.22

The use of oral contraceptives is thought to

be a factor that raises the prevalence of dry socket among

female patients.5

One study also concluded that with

increased estrogen dose in the oral contraceptives, the

incidence of dry socket increases.23

The changing endogenous estrogens during the

menstrual cycle would also influence the fibrinolytic

system, especially in the days 23 to 28 of the menstrual

cycle.3Therefore; timing of dental extraction according to

menstrual cycle is also a risk factor in the occurrence of

dry socket.13

Despite the use of oral contraceptives, some authors

regard female gender as a predisposing factor of dry

socket.14

It is possibly due to the changing endogenous

hormone during the menstrual cycle. Furthermore, the

smaller size of their jaws and limited surgical feld which

makes the surgeries more diffcult and traumatic may also

influence the normal healing process.

One literature proposed that the altered healing

ability of immunocompromised or diabetic patients

possibly induce the development of dry socket.24

Some

researchers also have suggested that systemic disease

could be associated with dry socket.2 However, no

scientifc evidence exists to prove a relationship between

altered healing ability and dry socket.4

The general axiom is that the older the patient, the

greater the risk.12

The advanced age has been considered

a factor of dry socket in some studies, but different

aspects have been proposed,25

and it has not always been

statistically significant.11

Perhaps the true factor is not

aging itself but the physiological change individually.

Bacteria

Most authors agree that bacterial infection is a risk

which should not be ignored for the development of

dry socket. If patients with poor oral hygiene,26

or pre-

existing local infection (such as pericoronitis or advanced

periodontal disease),27

the incidence of dry socket

appeared increase. One author postulated that bacterial

pyrogens in vivo are indirect activators of fbrinolysis.28

It is a controversial issue that saliva is a risk factor

in the development of dry socket or not.4

In brief, the

quantity of bacteria is the main point.

Other uncertain factors

About using local anesthetic with vasoconstrictor,

there are some different opinions have been proposed. In

one study, the author believes that local anesthetic with

vasoconstrictor may cause temporary ischemia, and thefollowing poor blood supply will lead to increase the

frequency of dry socket.29

However, other studies hold

a contrary opinion, since temporary ischemia would be

followed by reactive hyperemia in one to two hours, the

integration of the blood clot is not affected.2,6

According to

this reason, local ischemia due to vasoconstrictor in local

anesthesia has no role in the development of dry socket.

Prevention

C o n s i d e r i n g t h e f i b r i n o l y t i c t h e o r y , t h e

antifibrinolytic agents are used to prevent the early

disintegration of the blood clot. Tranexamic acid

(THA), also known as Transamin, is one kind of the

antifibrinolytic agent. When applied topically in the

extraction socket, it has been speculated to prevent the

development of dry socket.30

However, another study

Chang WY, Wang YL


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reported no significant reduction in the incidence of dry

socket when compared to a placebo group.31

Para-hydroxybenzoic acid (PHBA), another kind

of antifibrinolytic agent, also been introduced in many

studies. Some literature reported a lower incidence of

dry socket when PHBA was topically used in extraction

wounds.4,24

Besides, one literature reported that PHBA

has some antimicrobial properties.32

Since both the

antifibrinolytic properties and antimicrobial properties

may reduce the incidence of dry socket, it is not possible

to attribute the effect to which properties of PHBA.

Some literature reported the incidence of dry socket

reduced with the intraoperative lavage using different

quantities (25 ml, 175 ml and 350 ml) of saline solution,

lower incidence of dry socket were found as the quantities

of lavage increased (10.9%, 5.7% and 3.2% of the

incidence in each group, respectively).33,34

Since most studies supported that bacterial infections

are a major risk for the development of dry socket,

antibiotics and antiseptics were used as a measure of

prevention.

The antibiotics can be used in systemic and

topical routes. Systemic antibiotics, such as penicillins,clindamycin, erythromycin, and tetracycline, were

reported to be effective in the prevention of dry socket.

However, the development of resistant bacterial strains

and unnecessary destruction of host commensals due to

the routine use of systemic pre- and/ or postoperative

antibiotics prophylatically is still disputed.4

Among the use of topical antibiotics, topical

tetracycline has shown promising results.4

It can be

carried into the operative wound in many forms.

However, foreign body reactions have been reported

with the application of topical tetracycline.35,36

Due to

the probability of myospherulosis, placement of topical

tetracycline in a petrolatum base into a surgical site is not

suggested.37

Chlorhexidine is the antiseptics that mostly being

used. Several studies have reported that the use of

0.12% chlorhexidine pre- and perioperatively decreases

the incidence of dry socket in the removal of impacted

mandibular third molars.4

Ragno et al. found a signifcant

reduction as much as 50% in the incidence of dry socket

in patients who prerinsed with chlorhexidine solution

in removal of mandibular third molars.38

Many authors

indicated that using 0.12% or 0.2% chlorhexidine before

and/ or after surgery is benefcial.39

Management

Since the real etiology of dry socket is still unclear,

no treatment exists at the present time. Most authors agree

that the primary aim of dry socket management is pain

control until commencement of normal healing.

4

The anesthesia allows a momentary relief is useful

before the management for the patients. We can use

saline solution for intra-alveolus irrigation with careful

aspiration. One study proposed that force the bleeding

in the alveolus and the formation of a new clot due to

curettage was not suggested.40

Medication with systemic

analgesics or antibiotics may be necessary or indicated.

There is another study suggested that patient should

be irrigated daily with saline solution using a needlesssyringe.

Some authors advise the placement of intraalveolar

dressing materials such as antimicrobial agent or local

anesthetics.4

Although it is generally acknowledged that

dressings delay healing of the extraction socket,24

and

the literature does not show clear evidences in favour of

the placement of these pastes, they can increase the drug

concentration locally and avoiding the entrance of food

debris to the alveolus.

Conclusions

Dry socket is a displeasing complication and is

not uncommon in clinical work. Although the etiology

is not clear and the treatment of this complication is

still controversial, it goes without saying that the most

important goal of management is pain control. According



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to the literatures reviewed, the use of analgesics to release

the discomfort of patients until commencement of normal

healing process is indicated.

Smoking proved to have a great influence in the

development of dry socket, and should be avoided after

tooth extraction, especially on the day of surgery.

The use of lavage post-operatively and 0.12% or

0.2% chlorhexidine pre- and post-operatively showed

effective in preventing the development of dry socket.

In my clinical experience, using -iodine for local

sterilization is also useful. Perhaps the incorporation of

these methods to the protocol of exodontias would be

beneficial, especially when extraction of the included

third molars. We can also educate our patients to use

mouthrinses with cholohexdine for home care.

In conclusion, the best option is prevention.

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