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Management of dry socket

1 Correspondence: Dr. Fahimuddin, Junior registrar, Depart-ment of Oral and Maxillofacial Surgery, Khyber College of Den-tistry, Peshawar. Email: [email protected],Cell:0321-9693326

2 Prof. Head of Deptt. Oral & Maxillofacial Surgery, Ayub MedicalCollege, Abottabad.

3 Associate Professor, Oral & Maxillofacial Surgery, Khyber Col-lege of Dentistry,

4 Assistant Professor, Oral & Maxillofacial Surgery, Khyber Col-lege of Dentistry

Received for Publication: March 10, 2013

Revision Received: March 27, 2013Revision Accepted: March 31, 2013

INTRODUCTION

Dry socket or alveolar osteitis is the post extrac-tion socket in which the patient is having pain due to

loss of blood clot thus exposing bone to air, food andfluids. Prevention of dry socket remains the best strat-egy that can be achieved by providing an asepticenvironment, avoiding inadvertent instrumental

trauma, drinking through straw, smoking, excessivemouth rinsing. There should be sufficient irrigationwhen using rotary instruments. In females preventioncan be done if extractions are scheduled during the lastweek of menstrual cycle (days 23 through 28) when

estrogen levels are low or inactive.1Incidence can alsobe decreased by use of antiseptic mouth washes,antifibrinolytic agents, antibiotics, steroids and clotsupporting agents.2

Any treatment modality is considered effective if itimproves patients quality of life by reducing cost oftherapy and relieving patients pain. Various treat-ment options are available for dry socket. Topicalapplication of a combination of eugenol, benzocain andbalsam of Peru;3 Iodoform and Butylparaminoben-zoate1, 4 and Honey5have been tried for pain relief.Prophylactic administration of systemic beta lactamase

inhibitor containing antibiotic

have been claimed inreducing incidence of dry socket.6

MANAGEMENT OF DRY SOCKET:

A COMPARISON OF TWO TREATMENT MODALITIES1FAHIMUDDIN, BDS, FCPS2IRAM ABBAS, BDS, FCPS

3MUSLIM KHAN, BDS, FCPS4ATTA UR REHMAN,BDS, FCPS

ABSTRACT

The objective of this study was to compare the effect of local application of chlorhexidine

digluconate and combination of Iodoform with Butylparaminobenzoate in the management of dry

socket.A Quasi experimental study was carried out on a total of sixty diagnosed cases of dry socket.

Patients were randomly distributed among two treatment groups (30 patients in each group) i.e.

patients of group A were treated by local application of chlorhexidine digluconate gel and of group B

by local treatment with combination of Iodoform + Butylparaminobenzoate (Alvogyl). Both the

treatment groups were given the same systemic analgesic i.e., Ibuprofen 400mg TDS along with

thorough irrigation of the socket. Patients were followed for five consecutive days by replacing dressing

each day and findings were recorded in the proforma.Out of the sixty patients, forty five were males

and fifteen were females (3:1). In group A there were 22 (73.33%) males and 8 (26.66%) females and

in group B there were 23 (76.66%) males and 7 (23.33%) females. Mean age was 31.68 (11.23+S.D).

There was no significant effect of gender (P=0.766) and age (P=0.668) on both of the treatment groups

respectively. All patients measured their pain subjectively as S3 i.e. severe pain on day 1 on visual

analogue scale. There was a significant difference in pain control of the two treatment groups on 2nd,

3rdand 4thtreatment day with P=0.000, P=0.000 and P = 0.02 respectively. Significant difference was

noted for sensitivity on gentle probing the extraction socket between the results of two treatment groupson 3rdand 4thday i.e. p=0.000 for both days.

Iodoform and Butylparaminobenzoate (Alvogyl) had been the most successful combination in

relieving patients pain.

Key Words:Dry socket, Alvogyl, chlorhexidine.


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The objective of the study was to compare the efficacy of

topical application of chlorhexidine digluconate with topicalapplication of combination of Iodoform andButylparaminobenzoate in the management of dry socket. Thestudy will further help us to arrive at best treatment for dry socket

associated pain.

METHODOLOGY

This study was conducted at the department of oral andmaxillofacial surgery; Dentistry Unit, Ayub Medical College/Ayub Teaching Hospital, Abbottabad from 10thApril, 2007 to 10th

October, 2007. A total of sixty patients of dry socket were recruitedin the study. The study design was quasi experimental samplingtechnique was convenience or non probability.

The diagnostic criteria for dry socket was based on history ofextraction of two or more days and pain, clinical examination forsensitivity on gentle probing the extraction socket, trismus,halitosis and condition of tooth socket and radiographic examina-tion for the presence of a broken down root.

Patients with systemic diseases like diabetes mellitus, he-patic dysfunctions, blood dyscrasias, bleeding disorders, previoususe of systemic antibiotics for dry socket, previous treatment fordry socket and history of all kinds of tobacco use including snuffdipping were excluded from the study.

Informed consent of the patients was taken after explainingrisks and benefits associated with treatments. Pain was mea-sured by Visual Analogue Scale (VAS). According to this scalepatients measured their pain from out of three i.e. mild pain as S1,

ranged from 1-4; moderate pain as S2, ranged from 5-7 and severepain as S3 ranged from 8-10. Sensitivity on gentle probing theextraction socket was considered on all or none basis.

Patients were randomly distributed among two treatmentgroups i.e. patients of group A were treated by local application ofchlorhexidine digluconate gel and of group B by local treatmentwithIodoform+ Butylparaminobenzoate(Alvogyl) in the extrac-tion socketsafter thorough irrigation with sterile saline andsystemic administration of Ibuprofen in both of the treatmentgroups. Patients were followed for five consecutive days byreplacing dressing each day and findings were recorded in thedesignated proforma of the patients.

Data were analyzed by SPSS version-10. Descriptive statis-tics were used for calculating frequency of age, gender, pain andsensitivity on gentle probing the extraction socket. Mean andstandard deviation (SD) for age were calculated. Chi-square testwas applied to compare pain relief and sensitivity on gentleprobing the extraction socket between two drug regimens, andeffect of age and gender on two treatment groups. P value of 0.05was taken as significant.

RESULTS

Out of sixty patients of dry socket, forty five were males andfifteen were females with a ratio of 3:1. In group A there were 22

(73.33%) males and 8 (26.66%) females and in group B there were23 (76.66%) males and 7 (23.33%) females. There was no signifi-

cant effect of gender on both of the treatment groups (p=0.766).Mean age at the time of presentation was 31.68 disregardingtreatment groups and majority patients were found in thirddecade. Age had no significant effect on both treatment groups(p=0.668).

Dry socket was more common in mandible than the maxilla(P=0.045). Mandibular first molar was mostly involved i.e. in 19(31.66%) patients while mandibular third molar was involved in15 (25%) cases and mandibular second molar 12 (20%) cases.

All patients measured their pain subjectively as S3 i.e. severepain on day 1 on visual analogue scale. There was a significantdifference in pain control of the two treatment groups on 2nd, 3rd

and 4thpost-treatment day with P=0.000, P=0.000 and P = 0.02respectively.

Significant difference was also noted for sensitivity on gentleprobing the extraction socket between the results of two treat-

ment groups on 3rdand 4thday i.e. p=0.000 for both days.

TABLE 1: DISTRIBUTION ACCORDING TOGENDER

Group A Group B

Gender Cases % Cases %

Male 22 73.33% 23 76.66%

Female 8 26.66% 7 23.33%

Total 30 100% 30 100%

TABLE 2: AGE DISTRIBUTION

Group A Group B

Age in years Cases % Cases %

21-30 11 36.66 6 20

31-40 8 26.66 5 16.6

11-20 5 16.66 7 23.33

41-50 4 13.33 6 20

51-60 2 6.66 6 20

TABLE 3: SITE DISTRIBUTION

Site No. of patients %

Mandibular 1stmolar 19 31.66

Mandibular 3rdmolar 15 25

Mandibular 2ndmolar 12 20

Mandibular 2ndpremolar 4 6.66

Maxillary 1stmolar 4 6.66

Maxillary 1stpremolar 3 5

Mandibular 1st premolar 2 3.33

Maxillary 2ndpremolar 1 1.66


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DISCUSSION

The pain of Dry socket occurs because of release of

kinins which are immediately available following tis-

sue trauma,2exposure of nerve endings to air, food and

fluids in bare bone of the extraction socket1and infec-

tious process which releases tissue activators and pain

mediators.7

Local application of the Alvogyl in the emptysocket can show its effect according to all the possible

causes of pain of dry socket mentioned above. Eugenol

of clove oil (in Alvogyl) depresses sensory receptors

involved in pain perception by inhibition of prostag-

landins biosynthesis. Alvogyl pack itself works by

acting as a physical barrier between the exposed bone

along with exposed nerve endings and the oral envi-

ronment. Iodoform is a powerful antiseptic. Chlorhexi-

dine on the other hand could be considered only for its

antiseptic effect and providing a weak barrier for

covering exposed bone not as strong as Alvogyl. In this

regard, Alvogyl remained superior to Chlorhexidine

i.e. on second, third and fourth day of treatment there

was a tremendous improvement in pain relief of group

B patients (Alvogyl group) with P=0.000, P=0.000 and

P=0.02 respectively and a significant difference of

P=0.000 for sensitivity on gentle probing the extrac-

tion socket. Chlorhexidine if used for preoperative

prophylaxis would remain a good remedy in reducing

incidence of dry socket and might have shown good

results.8,9

Male to female ratio was 3:1 with no significant

effect of gender on both of the treatment groups

TABLE 4: RESULTS OF TWO TREATMENT GROUPS FOR FIVE CONSECUTIVE DAYS

Pain {VAS} (% patients) Sensitivity on gentle probing the extraction socket(% patients)

Group A Group B GroupA GroupB

Day 1 S3=100 S3= 100 P= 100 P= 100

Day 2 S2= 37 S1= 83 P= 100 P= 100

S3= 64 S2= 17

Day 3 S1= 3 S1= 83 P= 100 P= 27

S2= 83 S2= 17 A-73

S3= 13

Day 4 S1= 83 S1= 100 P= 47 A=100

S2= 7 A= 53

Day 5 S1= 100 S1= 100 A= 100 A= 100

{VAS=visual analogue scale, 1-4= mild pain (S1), 5-7= moderate pain (S2) and 8-10= severe pain (S3)P = present; A = absent % patients= total of 60 patients per group considered as 100 %}

(p=0.766). These findings didnt correlate with those of

MacGreoger10 in which the ratio was 2:3. Male to

female ratio in the present study can be attributed to

the social and cultural values of our society where

females face several difficulties in receiving treat-

ment. For example, leaving their children unattended

at home and lack of permission to go to hospital

unescorted. Another factor for the lesser number of

females in this study is because of the lesser use of oral

contraceptives, which is one of the risk factors for thedevelopment of dry socket.4,11,12,13,14,15

Mean age was 31.68 and majority of the patients

were found in third decade. This finding is consistent

with other studies such as that of Oginni FO7,

MacGregor AJ10, Al-Khateeb TL,16Amaratunga NA17

and Field EA.18Age showed no significant effect on

both treatment groups (p=0.668). Prevalence of dry

socket in this age group can be attributed to more solid

nature of bone which is relatively disease free (e.g.

periodontal diseases) that can lead to difficult and

hence traumatic extraction. It is widely accepted that

prevalence of dry socket increases with increase in

extraction difficulty10,19,20,21and surgical trauma.22This

could be due to more release of direct tissue activators

secondary to bone marrow inflammation.19

Dry socket was more common in mandible than

maxilla, which were in accordance with the results

shown by Nusair 2(P=0.045). According to the present

study mandibular molar area was the most common

site for development of dry socket, which is consistent

with other international studies.7,11,18,23,24

Frequentinvolvement of mandibular first molar in this study


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couldnt match with the results of Nusair2and othersin which dry socket was most common in the mandibu-lar third molar area.17,25This might be as a result ofextraction of mandibular first molar mostly by under-graduates in the present study (less experience opera-

tors) which resulted in the development of dry socketmostly at this site. Less experience in extracting teethis one of the risk factors for etiology of the dry socketaccording to Oginni23et al and Alexander.7 Clinicaland radiographic examination revealed that none ofthe post-extraction socket had foreign bodies, loosebone or broken down roots or root pieces.

CONCLUSION AND RECOMMENDATIONS

Adverse effects were not reported in both of thetreatment groups. Alvogyl had been the most success-ful combination for the management of dry socket interms of relieving patients pain, decreasing number ofvisits to the hospital and decreasing financial andpsychological burden on patients in the form of de-creasing intake of systemic medications (antibiotics,analgesics and others). There is a need to progresswith similar studies having a larger study samples.Future research should also include patients withsystemic diseases and tobacco use.

There is no need of systemic antibiotics for treat-ing dry socket. It is superficial inflammation merely ofcortical plate of the extraction socket, hence topicalanesthetic/analgesic/antiseptic will be enough e.g.

Alvogyl or Chlorhexidine and if needed systemic anal-gesics can also be given for controlling pain. Surgicalintervention should never be done unless indicated forother problems e.g. retained root. Reassurance mustbe give to the patient about the problem.

ACKNOWLEDGMENTS

I am grateful to Professor Dr Iftikhar Qayyum(Rehman Medical College, Peshawar), Professor DrAhmad Badar, Assistant Professor Dr Fazal Ghani(BDS, MSc, PhD, Khyber College of Dentistry,Peshawar), Mr Alamgir (Statistician, University ofPeshawar), Mr Amjad Ali (Statistician, regional cen-

ter Peshawar, College of Physicians and SurgeonsPakistan) for their support and cooperation in fulfill-

ing my research work.

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