Dry Socket : ( Alveolitis sicca dolorosa, Alveolar osteitis )

SYNONYMS

Alveolitis sicca dolorosa, Alveolalgia,Postoperative osteitis, Localized acute alveolar osteomyelitis,Alveolar osteitis

A dry socket is a fairly common complication of tooth extraction characterized by severe pain. It occurs when the tooth socket loses the blood clot that forms after a tooth is extracted and the bone inside the socket becomes exposed. It is one of the most painful dental problems one can experience.

A dry socket will occur in only 1% to 3% of all tooth extractions, but it becomes much more common in the extraction of lower (mandibular) wisdom teeth. In lower impacted (covered) wisdom teeth, as many as 25% to 30% of cases result in a dry socket.

Pathophysiology

Fibrinolytic activity is currently thought to be responsible for premature clot loss and severe pain in dry
socket.
Clot lysis occurs by two mechanisms:

Plasminogen dependent pathway-by Birn,
Plasminogen independent pathway
Plasminogen is hepatically synthesized and released into the circulation. It transforms into plasmin, which in turn acts on the fibrinogen and fibrin, causing clot dissolution.

Bacteria including Anaerobic microorganisms( e.g Traponema Denticola- Acc to Nitzin's Theory ) and Spirochetes, Fusiform Bacilli may also play a significant role in the development of this condition.

Causes

1. Failure of clot formation due to the use of Vasoconstrictors in the Local Anesthesia solution. However Dry socket also occurs after extraction under general Anesthesia.
2. Infection by Treponema Pallidum
3. Infection of the Clot and Underlying bone.
4. Traumatic Devitalisation of the Socket wall
5. Smoking after extraction.
6. Loss of blood clot due to rinsing the mouth or Sucking the wound.
7. Loss of blood clot due to excess intra alveolar fibrinolytic ester of P-hydroxy benzoic acid PEPH significantly reducing the incidence of dry socket.
8. Conditions with Sclerotic and relatively avascular bone also predisposes to dry socket formation

Clinical Features

The Critical period for the development of a drysocket is First 4 days after Extraction after which Granulation tissue starts to invade the clot

A. Dry socket is observed commonly in patients of 40 to 45 years old, and the incidence in all extracted sockets is 1 to 4%.
B. Mandible( 3X) is affected more commonly than maxilla.
C. Starts by the 2nd-3rd postoperative day and lasts for 7 to 10 days and is extremely painful
D. The pain may Radiate to the ear and neck.
E. Low-grade fever and ipsilateral lymphadenopathy & Foul smell and taste.
F. The exposed bone is necrotic, and sequestration of fragments is common.

Prevalence of alveolar osteitis is 20% in patients who smoke more than one pack of cigarettes per day and increases to 40% for those who smoke on the day of surgery or within 24 hours after surgery.
H. Heavy sucking or spitting by the patient after surgery also has been implicated in dislodgement and loss of the alveolar clot.

Diagnosis:

Mostly Based on History And Signs and Symptoms
History Of Recent Traumatic Extraction, Severe Throbbing type of pain Which started  4-5days after Extraction.
Exposed Necrotic Bone, Foul Smell
Radiograph is taken to exclude Retained Apices, Bony Fragments, Fractures of Alveolus, Body of Mandible Which can be mis-diagnosed as Dry Socket

Treatment

Aim of Treatment is Relief of Pain and speeding of resolution.

1. The socket should be irrigated with warm normal saline and the socket debridement done.
2. Sharp bony spurs should be either excised with rounger forceps or smoothened with a Bur.
3. A loose dressing composed of Zinc Oxide and Oil of Cloves on cotton wool is tucked into the socket. it must not be picked tightly in the socket or it may set hard and become very difficult to remove.
4. Analgesic tablets and hot saline mouth rinses are prescribed and patient is recalled after 24 hrs.
5. After 24 hours if pain stops then no need to replace dressing, but if pain persists then dressing and irrigation has to be replaced.
6. Analgesics  and Antibiotics are to be used simultaneously to relieve Pain and as well as infection.

Additional Treatments may include

• Gauze moistened with Iodoform compound. Can be left for 2-3 week
• Gauze moistened with Local anesthetic agent Butacaine/Benzocaine
• Antifibnolytic agents like Propyl Ester of parabenzoic acid, Dextranomer granules, Iodoform paste

Prevention

Probably the most important single factor in the prevention of extraction complications is gentleness in handling living tissues. One should strive to produce as little trauma as possible, consistent with the successful completion of the operation.

Prescription of Proper Analgesics and Antibiotics Post operatively & Proper Post extraction instructions

External Links

1.Dry socket - WebMd 

2.Dry Socket - Wikipedia

Dentigerous Cyst

Definition

An Odontogenic cyst that surrounds the crown of impacted tooth, caused by fluid accumulation between the reduced enamel epithelium and the enamel surface, resulting in a cyst in which the crown is located within the lumen.This is the most common developmental Odontogenic cyst.Also called as Follicular Cyst

Etiology:

Develops by accumulation of fluid between the reduced enamel epithelium and the tooth crown after crown formation.

Common Sites:

• Mandibular and Maxillary Third Molars and Maxillary cuspid regions
• Dentigerous cyst always is associated with the crown of a normal permanent tooth.

Clinical Features:

It is always associated initially with the crown of an impacted, embedded or unerupted tooth. Dentigerous cyst may also be found enclosing a complex compound odontoma or imvolving a supernumerary tooth. Multiple bilateral cysts usually associated with syndromes like Cleidocranial dysplasia & Maroteaux-Lamy Syndrome.
Dentigerous Cyst is an Aggressive Lesion and shows rapid Expansion of bone with facial asymmetry,Extreme Displacement of teeth,Severe root resorption and in some cases displacement of roots into distant sites. Pain occurs in cases of infection.
Dentigerous Cyst involving an Unerupted Mandibular Third molar results in Hollowing out of Entire Ramus upto the coronoid process, Expansion of cortical plate, Displacement of Third molar which sometimes gets compressed against the inferior border of the mandible.
Dentigerous Cyst involving an Unerupted Maxillary Cuspid may cause Expansion of the Anterior maxilla which resembles Acute Sinusitis or Cellulitis,No pain unless Secondarily infected Seen mostly in the second and third decades of life with Male : Female ratio of– 3:2

Radiographic Features:

Radiolucent area is associated with un-erupted tooth crown.

Radiolucency Symmetrically surrounds the tooth crown.

Radiolucent space will be more than 5mm   

Radiologic variants:

Central Variety: Crown is enveloped symmetrically, this pushes the crown towards the lower border of the Mandible

Lateral Type: Dilatation of the follicle on one aspect of the crown

Circumferential Type: The follicle expands in a manner which appears to envelope the Entire tooth. Sometimes the radiolucent area is surrounded by a thin sclerotic line representing bony reaction.

Histologic Features:

Thin connective tissue wall with a layer of stratified squamous epithelium lining the lumen Thin layer of epithelium, 2 – 3 layers thick with no rete ridge formation, unless infected Presence of odontogenic epithelium in islands in the connective tissue wall – which may give rise to the development of Ameloblastoma.
Rushton Bodies – Peculiar, linear, often curved, hyaline bodies with variable staining of uncertain origin and unknown significance, but probably of hematogenous origin, found within the lining epithelium – especially in areas of inflammation.

The cystic lumen contains thin watery yellow fluid, occasionally blood stained. Aspirated fluid protein content is about >4gm/100 ml. Connective tissue is thick and composed of fibrous tissue.

Complications

1) Development of Ameloblastoma - From lining epithelium and in the islands of odontogenic epithelium.
2) Development of Mucoepidermoid Carcinoma & Epidermoid Carcinoma

Treatment

Mostly basesd on size of the lesion
Smaller lesions: Enucleation
Larger lesions: Marsupilisation and Surgical Curettage
Recurrence is rare unless there is neoplastic transformation.