Alveolar osteitis

Alveolar osteitis. Note exposed bone as marked by the arrow.

Alveolar osteitis or, colloquially, a dry socket, is a complication of wound healing following extraction of a tooth. The term alveolar refers to the alveolus, which is the part of the jawbone that surrounds the teeth, and osteitis means simply "bone inflammation".

Signs and symptoms

Dry socket usually occurs 3-5 days after tooth extraction and causes severe throbbing and radiating pain which is difficult to localize. Dry socket is characterized by detritus, grayish slough, severe pain and foul odor.^[1][2][3] The foul odor, in particular, is a result of the disintegration of the blood clot by putrefaction rather than by orderly resorption. If a probe is gently passed in the tooth extraction socket, then bare bone is encountered which is very sensitive. ^[1]

Cause

Multiple types of alveolar osteitis can result from disturbances in the healing process. The type that is commonly referred to as dry socket is one in which the disturbance is from the time a blood clot forms immediately after tooth extraction to the initiation of healing in the 4-5 day period after extraction occurs. The healing tissue that is supposed to replace the blood clot, known as granulation tissue, may fail to grow or be disrupted after beginning to grow, leading to the well known symptoms of dry socket.^[1]

Wound healing is a complex process and can be positively and negatively affected by many factors.^[4] Alveolar osteitis is the most common healing disturbance of extraction sockets.^[1]

Suppurative osteitis results when the disturbance of extraction socket wound healing occurs later, during the third stage of healing from day 14-16 after extraction, and is a manifestation of the disruption of connective tissue development. This form usually results from an infection and exhibits a purulent discharge (pus) from the extraction socket.^[1]

Disruption of the extraction socket during an even later stage of healing might result in necrotizing osteitis in which encapsulated shards of bone (bony sequestrae) will be noted alongside inflammatory cells.^[1]

Prevention

True alveolar osteitis, as opposed to simple postoperative pain, occurs in only about 1-3% of extractions.^[5] No one knows for certain how or why dry sockets develop following dental extraction but certain factors are associated with increased risk. One of these factors is the complexity of the extraction. Smoking may be a contributing factor, possibly due to the decreased amount of oxygen available in the healing tissues. It is advisable to avoid smoking for at least 48 hours following tooth extraction to reduce the risk of developing dry socket.

Women are generally at higher risk than men of developing dry socket, because estrogen slows down healing. Dentists recommend that their female patients have extractions performed during the last week of their cycle, when estrogen levels are lowest, to minimize chances of developing dry socket.^[6]

Patients are also advised to avoid drinking through a straw as the negative pressure created by drawing liquids through the straw can dislodge the clot. Additionally, patients may be told not to spit out saliva (or anything else for that matter) excessively due to the negative pressure created in the mouth immediately prior to spitting. Maintaining good oral hygiene during the healing period by brushing all non-tender areas regularly and rinsing with warm salt water is often advised, beginning 24 hours after the extraction.

Treatment

The pain from alveolar osteitis usually lasts for 24–72 hours. There is no real treatment for dry socket — it is a self-limiting condition that will improve and disappear with time — but certain interventions can significantly decrease pain during an episode of dry socket. These interventions usually consist of a gentle rinsing of the inflamed socket followed by the direct placement within the socket of some type of sedative dressing, which soothes the inflamed bone for a period of time and promotes tissue growth. This is usually done without anesthesia.^[7] The active ingredients in these sedative dressings usually include substances like soluble aspirin, zinc oxide, eugenol, and oil of cloves. It is usually necessary to have this done for two or three consecutive days, although occasionally it can take longer. Because true dry socket pain is so intense, additional analgesics are sometimes prescribed.

References

1. ^ ^{a b c d e f} Amler, MH. Disturbed healing of extraction wounds. J Oral Implant 1999;25(3):179-184
2. ^ What is Dry Socket? - How is it treated?, Louisiana Dental Center
3. ^ Dry socket symptoms and treatments, Animated-Teeth.com
4. ^ Colby, RC. The general practitioner's perspective of the etiology, prevention and treatment of dry socket. Gen Dent 1997;454:461-467
5. ^ Shafer, WG; Hine, MK; Levy, BM. A Textbook of Oral Pathology 3rd Ed. Philadelphia: WB Saunders, 1984. pages 605-608.
6. ^ Academy of General Dentistry. "Check Menstrual Calendar For Tooth Extraction." Accessed on 2007-03-24.
7. ^ Dry socket symptoms and treatments, Animated-Teeth.com

External links

• Dry socket information at WebMD
• How to prevent dry socket after a tooth extraction
• Wisdom: A Tale of Dental Redemption: An entertaining story about the pain suffered from dry socket.