the alveolar bony socket. A variety of commercially prepared medications are available. The practitioner packs the treated gauze into the socket with cotton pliers. Typically, the patient is instructed to take an anti-inflammatory such as ibuprofen in combination with acetaminophen for pain.
The iodoform-treated gauze should be changed frequently until over-the-counter analgesic medication is sufficient to control pain. When the patient is asymptomatic, the practitioner should provide a Monoject syringe to irrigate the socket with warm salt water to keep it clean. Further measures to prevent dry socket are included in Table 1.
Table 1: Measures that may Prevent Dry Socket 1. Perform an initial patient consultation before scheduling oral surgery.
2. Acquire a complete medical history, a clinical examination, and current radiographs. In addition, review risks such as smoking and oral contraceptive use. Women who are on oral contraceptives should be scheduled on days 23 through 28 of the menstrual cycle. 3. Give an antibacterial mouth rinse preoperatively and postoperatively to decrease bacterial contamination. 4. Avoid local anesthesia via periodontal ligament injection. 5. Exclude trauma to the site as much as possible during the surgical procedure to limit fibrinolytic activity. 6. Inspect the socket for loose debris, and gently irrigate the extraction site with profuse amounts of sterile saline. 7. Insert a small amount of antibiotic, such as tetracycline or clindamycin, into the socket. 8. Encourage the patient to avoid smoking in the immediate postoperative period. 9. Keep the surgical technique consistent to eliminate other factors that may result in a higher incidence of dry socket.
CASE SCENARIO #1
Dr. Collins has known Eric as a patient since he was a young child. Eric is now 24 years old and recently graduated from college with a bachelor’s degree. After graduation he found employment in his hometown and has resumed dental care with Dr. Collins. Nearly six years since his last dental visit, Eric presents to Dr. Collins with a complaint of pain and swelling on the lower left jaw. Dr. Collins can see that the gingiva surrounding tooth #17, which is partially erupted, appears angry and red, with some swelling present on the buccal aspect. Some exudate can be seen around tooth #17. In reviewing Eric’s chart, Dr. Collins sees that he advised Eric to have his third molars removed at the age of 18. He reminds Eric of this recommendation and offers to remove the other three along with tooth #17, which obviously needs to be removed. Eric consents to this treatment plan. From his review of the panoramic x-ray, Dr. Collins is aware that teeth #1 and #16 are fully erupted, with tapered roots, and he expects no complications with their removal. Teeth #17 and #32, however, are mostly impacted within soft tissue and have a mesial angulation. In performing their removal, Dr. Collins incises full-thickness flaps over each tooth and is able to extract them both without any additional bone removal. Both sites are thoroughly cleaned with a curette and copious sterile saline, and the flaps are secured with a single resorbable suture. Moistened gauze packs are placed to keep gentle pressure over the sites while clots form. Three days later, Eric returns in extreme pain on the left side. His interincisal opening is approximately 15 mm, and there is mild edema on both the right and left sides, though it is more pronounced on the left side. He reports a foul taste and says his pain is constant and throbbing, worse than before the extraction. Dr. Collins confirms that the suture on the lower left is missing,
and the blood clot appears to be entirely displaced with visible bony walls. Points to Consider 1. What specific complications are happening as a result of Eric’s surgery? His pain is most likely caused by fibrinolytic alveolitis (dry socket). Trismus is present, which may be a result of injury to the medial pterygoid muscle during injection, or it may be secondary to inflammation. Edema is also present. Although edema is common in surgeries in which mucoperiosteal flaps are created, in this case it is likely exacerbated by inflammation. 2. How can Dr. Collins relieve Eric’s discomfort? He should first irrigate the site thoroughly with copious sterile saline to remove debris. He should then place a dressing (either resorbable or soaked into gauze) containing eugenol and/or topical anesthetic. He may need to do this more than once. Dr. Collins may consider an anesthetic block with additional curettage of the extraction site to clean it and promote formation of a new clot. Anti-inflammatory and other pain medication may be given, but an antibiotic is not likely to be necessary if Eric remains free of infection. 3. What could Dr. Collins tell Eric about his outlook in the short term? Eric should know that new epithelium will cover the extraction site within 10 to 14 days. If severe pain returns, the dressing may need to be replaced during this time. Eric should be advised to reduce strenuous activity and avoid eating hard foods and those that are likely to irritate the area. A Monoject syringe could be provided to irrigate with sterile saline when Eric is asymptomatic.
CASE SCENARIO #2
Clarence is 83 years old and lives alone, having lost his wife 5 years previously. He has not seen a dentist since his wife died and expends little effort on oral hygiene. Clarence has adult children nearby who check in on him and help him with various needs because his strength and mobility have declined significantly in recent years. One morning, when his daughter visits, Clarence mentions that he was kept awake most of the previous night with a terrible toothache on the lower right side of his jaw. His daughter notices some mild swelling on that side and can see that there is a large visible cavity in the last molar. She calls her dentist, Dr. Wagoner, and his receptionist schedules Clarence for an emergency visit early in the afternoon.
At his appointment, Clarence’s blood pressure is 146/92 and his heart rate is 73 beats per minute. According to his medical history, he is currently taking atenolol and hydrochlorothiazide for blood pressure and fluoxetine (Prozac) for depression. Clarence does not list any other medications or past medical illnesses on his medical history form. Dr. Wagoner diagnoses Clarence’s dental pain as an acute periradicular abscess secondary to nonrestorable caries in tooth #31. Although he is working Clarence into a busy afternoon, Dr. Wagoner feels that Clarence is healthy enough to tolerate the extraction of tooth #31 and desires to relieve his pain.
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