Prevalence, Clinical Picture, and Risk Factors of Dry Socket in a Jordanian Dental Teaching Center

Prevalence, Clinical Picture, and Risk Factors of Dry Socket in a Jordanian Dental Teaching Center

Aims: The aims of this study were to determine the prevalence, clinical picture, and risk factors of dry socket at the Dental Teaching Center of Jordan University of Science and Technology (DTC/JUST).

Methods and Materials: Two specially designed questionnaires were completed over a four-month period.

One questionnaire was completed for every patient who had one or more permanent teeth extracted in the Oral Surgery Clinic. The other questionnaire was completed for every patient who returned for a post-operative visit and was diagnosed with dry socket during the study period.

Results: There were 838 dental extractions carried out in 469 patients. The overall prevalence of dry socket was 4.8%. There was no statistically significant association between the development of dry socket and age, sex, medical history, medications taken by the patient, indications for the extraction, extraction site, operator experience, or the amount of local anesthesia and administration technique used. The prevalence of dry socket following non-surgical extractions was 3.2%, while the prevalence following surgical extractions was 20.1%

(P< 0.002). The prevalence of dry socket following surgical and non-surgical extractions was significantly higher in smokers (9.1%) than in non-smokers (3%) (P = 0.001), and a direct linear trend was observed between the amount of smoking and the prevalence of dry socket (P = 0.034). The prevalence of dry socket was significantly higher in the single extraction cases (7.3%) than in the multiple extraction cases (3.4%) (P = 0.018). The clinical picture and management of dry socket at DTC/JUST were similar to previous reports in the literature. The prevalence of dry socket, its clinical picture, and management at DTC/JUST are similar to those reported in the literature.

Abstract

Introduction

Dry socket is one of the most common complications of tooth extraction and is characterized by severe pain starting usually on the second or third day postoperatively. Its prevalence has been reported to vary from 0%¹ to more than 35%² and is more common following mandibular third molar extraction.^3-9 Patients experience pain and may experience loss of productivity. This makes the condition costly to both patient and society, as 45% of patients require multiple postoperative visits in the process of managing this painful condition.¹⁰ The exact pathogenesis of dry socket is not well understood. However, disintegration of the blood clot by fibrinolysis remains the most widely accepted theory.¹¹ Several contributing factors have been reported to be associated with an increased risk of dry socket. They include traumatic extraction,^3-4,11 preoperative infection,^11-12 smoking,¹³ sex,^11,14site of extraction,^8,14 use of oral contraceptives,¹⁵ use of local anesthetics with vasoconstrictors,¹⁶inadequate postoperative irrigation,¹⁷and low level of operator experience.^4,8

Several methods have been advocated to reduce the incidence of dry socket including the use of antiseptic mouthwashes^18-20 antifibrinolytic agents,²¹antibiotics,^22-23steroids,²⁴ clot supporting agents,²⁵and other intra-alveolar dressings and medicaments.^9,27-28

While this condition cannot be completely treated as long as the exact etiology is not firmly established, its management appears to be simple and effective. It usually involves reassurance of the patient, cleaning and

irrigation of the affected socket, and insertion of a medicated pack.^2,25,29-30

This is the first study of dry socket at the Dental Teaching Center of Jordan University of Science and Technology (DTC/JUST) and in Jordan . Its aims were to identify the prevalence and risk factors as well as to describe the clinical picture of this painful condition at this Jordanian dental teaching center.

Methods and Materials

The DTC/JUST was the setting for the study.

This center is located in Irbid, in North Jordan, and is involved in the training of undergraduate and postgraduate dental students. It serves the community of the city of Irbid and its neighboring towns and villages, which have a total population of approximately 750,000.

This prospective study was totally observational without any interference with any of the clinical procedures normally followed at DTC/JUST.

Description of the Sample

During the study period, 838 permanent tooth extractions were carried out in 469 patients.

There were 225 (48.0%) male patients and 244 (52.0%) female patients. The age of patients Conclusion: Smoking and surgical trauma are associated with an increased incidence of dry socket. Moreover, patients who had single extractions were more likely to develop dry socket than those who had multiple

extractions in the same visit.

Keywords: Dry socket, incidence, signs, symptoms, risk factors, Jordan

Citation: Nusair YM, Younis MHA. Prevalence, Clinical Picture, and Risk Factors of Dry Socket in a Jordanian Dental Teaching Center. J Contemp Dent Pract 2007 March;(8)3:053-063.

ranged from 11 to 80 years with a mean of 36.96 (±15.53) years.

Data Collection

Data were collected over a period of four months using two questionnaires. The first questionnaire was completed for each patient who had an extraction of one or more permanent teeth at the Oral Surgery Clinic. Patients who had only deciduous teeth extracted were not included in the study. The questionnaire was completed by the person who performed the extraction.

It included items such as patient demographic data, smoking habits, medical history and medications, teeth extracted, indication for the extraction for each tooth, extraction technique, level of experience of the operator who performed the extraction, amount and technique of local anesthesia, and postoperative medications. If the extracted tooth was an impacted third molar, its depth and angulation were also recorded (Figure 1).

The second questionnaire was completed for each patient who came back to the clinic during the study period and was diagnosed with a dry socket. A modification of the Blum’s definition of dry socket was adopted in this study.²⁵

Patients were diagnosed with a dry socket if they had at least two of the following signs and symptoms:

a. Empty socket with or without food debris b. Pain in or around the socket occurring any

time within one week of the extraction This questionnaire was completed by one of the researchers and included items such as the patient demographic data, socket affected, signs and symptoms, onset of symptoms, and treatment provided (Figure 2).

Study Groups

Patients were divided into four age groups as follows: <18 years, 18-33 years, 34-49 years, and ≥50 years. These four groups were then organized as follows:

1. The extracted teeth were classified according to their anatomical location into upper

anterior teeth, upper posterior teeth, lower anterior teeth, and lower posterior teeth.

2. Extraction techniques were classified into:

• Non-surgical extractions (extractions which needed simple elevation or root separation without reflecting a mucoperiosteal flap).

• Surgical extractions (extractions which involved the reflection of a mucoperiosteal flap with or without bone removal).

3. Local anesthetic techniques were classified into:

• Infiltration anesthesia

• Regional block anesthesia

4. Amount of local anesthesia used was divided into two categories: <2 cartridges and ≥2 cartridges per tooth.

5. Patients were divided according to their medical history into two groups: medically fit patients and patients with systemic diseases.

6. Patients were divided according to their smoking habit into:

• Non-smokers: patients who did not smoke and x-smokers

• Smokers: patients who smoked up to 20 cigarettes per day

• Heavy smokers: patients who smoked more than 20 cigarettes per day and those who smoked a water pipe (Shisha) regularly.

Data Analysis

Data were then analyzed using SPSS^® for

Windows (version 9; SPSS Inc, Chicago, IL, USA) and Epi-info^® (CDC, Atlanta, GA, USA) statistical software. Descriptive statistics and bi-variant data analysis using chi-square tests were done as appropriate. The critical level of significance was set at P < 0.05. Multiple binary logistic P regression was used to test for the significance of associations between selected variables after adjusting the effect of others.

Results

A total of 122 (26%) patients were smokers, of whom 33 (7% of the total sample) were heavy smokers (smoked more than 20 cigarettes per day). The proportion of smokers was higher in the male group than in the female group (44.9%

and 8.6%, respectively). Although the majority of patients (358 (76.3%)) were fit and healthy at the time of extraction, 111 (23.7%) had varying underlying systemic conditions and 90 (19.1%) were taking different medications (Tables 1 and 2).

Figure 1.

Questionnaire
used
for
all
subjects.

Dry Socket in the Dental Teaching Center Extraction Sheet

Please check all that apply

Patient’s
name:














































File
number:















Date:

Gender:
^!
Male


^!
Female Age:















years

Smoking:
^!
No






^!
Yes






















cigarettes
/
day

Medical
History:


























































































































Medications:
































































































































Teeth
Extracted:

Reason
for
extraction: !
Advanced
caries !
Advanced
periodontal
disease

!
Orthodontic
treatment !
Pericoronitis

!
Others,
specify





















































































Extraction
technique: ^!
Simple
elevation ^!
Root
separation

!
Flap
without
bone
removal !
Flap
with
bone
removal Operator: !
4^th
year
dental
student !
5^th
year
dental
student

!
Resident ^!
Postgraduate
student

!
Consultant

Number
of
local
anaesthetic
cartridges
used:















































































Technique
of
local
anaesthesia: !
Labial/
buccal
infiltration !
Lingual/
palatal
infiltration

!
ID/
lingual
block ^!
Mental
block

If the tooth is an impacted wisdom tooth:

Depth
of
impaction: !
Partially
erupted

!
Soft
tissue
impaction

!
Bony
impaction

Angulation: ^!
Vertical

!
Mesioangular

!
Distoangular

!
Horizontal

!
Other,
specify

































































Postoperative
instructions
given? ^!
Yes ^!
No

Postoperative
medications
prescribed:

Upper anterior teeth and upper posterior teeth constituted 105 (12.5%) and 324 (38.7%) of the total number of extractions, respectively, whereas lower anterior teeth and lower posterior teeth constituted 98 (11.7%) and 311 (37.1%) of the total number of extractions, respectively. A total of 761 (90.9%) extractions were non-surgical (731 (87.2%) simple elevations and 30 (3.6%) root separations), while 77 (9.1%) teeth needed surgical extraction (59 (7%) needed a flap with bone removal and 18 (2.1%) needed only a flap without bone removal).

Undergraduate and postgraduate students carried out 743 (88.7%) extractions [(182 (21.7%) by fourth year students, 460 (54.8%) by fifth year

students, and 101 (12.2%) by postgraduate students)], while consultants and resident dentists carried out 50 (6%) and 45 (5.3%) extractions, respectively.

Advanced caries was the most common cause of extraction and lead to the extraction of 345 (41.2%) teeth. This was followed by periodontal diseases, which accounted for 200 (23.9%) extractions. A combination of caries and periodontal disease was the reason behind the extraction of 158 (18.9%) teeth. In addition, pericoronitis and orthodontic treatment were the indications for the extraction of 66 (7.9%) and 50 (6%) teeth, respectively. Only 19 (2.3%) teeth were extracted because of a missing opposing tooth.

Figure 2.

Questionnaire
used
for
subjects
with
a
dry
socket.

Dry Socket in the Dental Teaching Center Dry Socket Sheet

Please tick all that apply:

Patient’s
name:















































File
number:
















Date:

Gender:
^!
Male


^!
Female Age:

















years

Socket
affected:

Signs
and
symptoms: ^!
Pain

!
Empty
socket

!
Bare
bone

!
Halitosis

!
Others:

Onset
of
symptoms: ^!
Immediately
after
extraction

!
24
hours
after
extraction

!
48
hours
after
extraction

!
72
hours
after
extraction

!
Other,
specify

Treatment
provided: ^!
Irrigation
with
normal
saline

!
Packing
with
Alvogyl

!
Medications:

Table 1. Summary of the medical history of the study population.

Table 2. Medications used regularly by the study population at the extraction.

A total of 131 mandibular third molars were extracted, of which 74 (56.6%) were impacted and needed surgical extraction. Of the impacted ones, 47 (63.5%) were partially erupted, 23 (31.1%) were covered with soft tissues, and 4 (5.4%) were covered with bone. The angulation of 29 (39.2%) impacted lower third molars was vertical, 24 (32.4%) were mesioangular, 12 (16.2%) were horizontal, and 9 (12.2%) were distoangular.

All teeth were extracted under local anesthesia using 2% Xylestesin^®(Lidocaine) with 0.015 mg/ml epinephrine (3M ESPE AG, Seefeld, Germany). Infiltration around the tooth was used in 470 (56.1%) extractions, while regional block anesthesia was used in 368 (43.9%) extractions.

The amount of local anesthesia used was less than two cartridges per tooth in 484 (57.8%) extractions and two or more cartridges per tooth in 354 (42.2%) extractions.

All patients received oral postoperative instructions by the operators. Post-extraction medications were prescribed for 176 (37.5%) patients. Analgesics (ibuprofen and/or

paracetamol) were prescribed alone for 130 (27.7%) patients, whereas a combination of antibiotics (either amoxicillin or metrondizole or both) and pain killers were prescribed for 46 (9.9%) patients.

Dry Socket Prevalence

The overall prevalence of dry socket was 4.8%

(40 dry sockets in 838 extractions). Some patients developed more than one dry socket, which made the overall prevalence per patient 6.4%

(30 patients with dry sockets out of 469 patients who had extractions). In addition, dry socket prevalence (per tooth) following non-surgical extractions was 3.2% (24 of 761), while it was 20.1% (16 of 77) following surgical extractions.

This difference was statistically significant (P< 0.002) (Figure 3).

There was no statistically significant association between the development of dry socket and patient’s age, sex, medical history, medications (preoperative or postoperative), indications for extraction, operator’s experience, and the amount or technique of local anesthesia.

Patients who developed dry sockets were 16 (53%) males and 14 (47%) females. The prevalence of dry socket in female patients was 4.3% (14 dry sockets in 327 extractions) compared to 5.1% (26 dry sockets in 511

extractions) in male patients. This difference was statistically insignificant (P = 0.553).

The peak prevalence of dry socket was in the 18 to 33 year age group and was 7.9% (21 dry sockets in 266 extractions) compared to 2.7%

Figure 3. Prevalence of dry socket following surgical and non-surgical extraction.

(7 dry sockets in 263 extractions) in patients whose ages ranged from 34 to 49 years and 4.3%

(12 dry sockets in 281 extractions) in patients who were older than 50 years. None of the patients under 18 years of age developed dry sockets.

These differences were statistically insignificant (P = 0.383).

Regarding extraction technique and operator’s experience, the prevalence of dry socket was 3.3% (21 of 642) and 2.1% (1 of 49) following non- surgical extractions performed by undergraduate and postgraduate students, respectively. This difference was statistically insignificant (p = 0.588).

Following surgical extractions, the prevalence of dry socket was 23.1% (12 of 52) when postgraduate students performed the extractions and 18.2% (4 of 22) when consultants performed the extractions. This difference was also

statistically insignificant (P= 0.513). In addition, the prevalence of dry socket was 2.2% (1 of 45) following extractions performed by resident dentists.

A possible relation between the anesthetic techniques and dry socket development was investigated through analysis of data related to extractions of lower anterior teeth (the only area in which different anesthetic techniques were used). The prevalence of dry socket was 8.1%

(5 of 62) following regional block anesthesia (inferior alveolar and lingual nerve block) and 5.5% (2 of 36) following infiltration anesthesia.

This difference was statistically insignificant (P = 0.473). In addition, the prevalence of dry socket following the use of less than two cartridges of local anesthesia per tooth was 3.5%, whereas it was 6.5% following the use of two cartridges or more. This difference was also statistically insignificant (P = 0.187).

The prevalence of dry socket was 9.1% (23 dry sockets in 263 extractions) following extractions in smokers and heavy smokers compared to 3% (17 dry sockets in 575 extractions) in non-smokers. This difference was statistically significant (P = 0.001).

In addition, the prevalence of dry socket was 6.1% and 17.1% following extractions in smokers and heavy smokers, respectively. This difference was statistically significant (P = 0.002) (Figure 4).

When anatomical site was considered, there were 6 (15%) cases of dry socket in the upper jaw compared to 34 (85%) cases in the lower jaw. The prevalence of dry socket was 1.4%

following maxillary extractions and 8.3% following mandibular extractions. This difference was statistically significant (P = 0.002) (Figure 5).

Figure 4. Prevalence of dry socket in relation to smoking.

Also, the prevalence of dry socket was highest following the extraction of lower posterior teeth at around 8.7% (27 of 311). The next highest was dry socket occurring after extraction of lower anterior teeth at 7.1% (7 of 98), followed in order by 2.8% (3 of 105) after the extraction of upper anterior teeth, and a prevalence of 0.9% (3 of 324) following the extraction of upper posterior teeth. The differences in dry socket between anterior and posterior teeth within the same jaw were statistically insignificant.

There were a total of 17 lower wisdom teeth surgically extracted and subsequently developed dry sockets. Of these, ten (58.8%) were partially erupted and seven (41.2%) were soft tissue impacted. None of them (0.0%) were bony impacted.

The prevalence of dry socket following extraction of partially erupted and soft tissue impacted molars was 21.3% (10 of 47) and 30.4%

(6 of 23), respectively. This difference was statistically insignificant (P = 0.736). In addition, vertical angulation was found in eight cases of impacted wisdom teeth which developed dry socket, whereas six and three cases were in mesioangular and distoangular angulation, respectively.

Extractions of wisdom teeth with horizontal angular position were not followed by dry

sockets. The incidence of dry socket following the

extraction of wisdom teeth in a vertical position was 27.6% (8 of 29), and it was 25% (6 of 24) and 33.3% (3 of 9) following the extraction of lower third molars in mesioangular and distoangular positions, respectively. These differences were also statistically insignificant (P = 0.902).

Patients were grouped into single-extraction cases (302) and multiple-extraction cases (167). The prevalence of dry socket in the first group was 7.3% (22 of 302), while in the second group it was 3.4% (18 of 536). This difference was statistically significant (P = 0.018) (Figure 6).

Clinical Picture of Dry Socket

Regarding the clinical picture of dry socket, a combination of pain, empty socket, bare bone, and halitosis were the presenting signs and symptoms in 16 (40%) dry socket cases. This was followed by the presence of pain, empty socket, and bare bone without halitosis in 14 (35%) cases. Pain, empty socket, and halitosis were present in four (10%) cases, and only pain with empty socket was present in six (15%) cases. Thus, pain and empty socket were present in 40 (100%) cases, bare bone was present in 30 (75%) cases, and halitosis was present in 20 (50%) cases (Figure 7).

The onset of symptoms was found to range from immediately to 72 hours after the extraction with a mean of 36.6 hours. Symptoms started immediately after the extraction in two cases (5%), Figure 5. Prevalence of dry socket in the maxilla and mandible.

following 24 hours in 20 (50%) cases, following 48 hours in 13 (32.5%) cases, and following 72 hours in 5 (12.5%) cases (Figure 8).

With regards to management of dry socket, all affected sockets were irrigated with normal saline and Alvogyl packing was used in 33 (82.5%) cases. Thirteen patients had medications prescribed. These were pain killers (ibuprofen and/or paracetamol) in ten (33.3%) cases and

a combination of painkillers, metrondizole, and Chlorhexidine mouthwash in three (10%) cases.

Discussion

Dry socket is a clinical complication of considerable importance. It is characterized by severe pain starting usually on the second or third day postoperatively. The generally accepted etiology of dry socket is an increased local fibrinolysis leading to disintegration of the Figure 6. Prevalence of dry socket following single and multiple

extractions.

Figure 7. Frequency distribution of dry socket signs and symptoms.

clot.¹¹Some antifibrinolytic agents when placed topically in the extraction site have been shown to decrease the incidence of dry socket.⁴¹ Surgical trauma, which leads to liberation of different tissue activators, and bacterial infections remain the two most acceptable initiating factors of this localized fibrinolytic activity.¹¹

The results of this study show the prevalence of dry socket at the DTC/JUST and its clinical features are generally similar to those reported in the literature. The overall prevalence of dry socket was 4.8%, which is only slightly higher than the overall prevalence of 2-4% reported in the literature.^5-7,14

This difference could possibly be attributed to variations in the diagnostic criteria required by different researchers. While some required strict diagnostic criteria and reported a lower incidence,^5,14, others were not as strict and reported a higher incidence.^6,8 In this study a minimum of pain and an empty socket with or without food debris were considered diagnostic.

Another possible explanation for this slightly higher than expected figure is it reflects the overall prevalence following all extractions, including surgical ones. It is well documented surgical extractions result in a higher dry socket prevalence.^3,9-10,42 If surgical extractions are

excluded, the prevalence of dry socket following non-surgical extractions becomes 3.2% which is comparable to previous reports in the literature.

It is widely accepted the prevalence of dry socket increases with the increase in extraction difficulty.11,14,25,31

This could be due to more liberation of direct tissue activators secondary to bone marrow inflammation following the more difficult and, hence, more traumatic extractions.¹¹ In the current study surgical extractions were associated with a significantly higher incidence of dry socket (20.1%), which is consistent with what is well documented in the literature and may give some support to trauma as a contributing factor in the pathogenesis of dry socket.

Figure 8. Frequency distribution of dry socket cases according to onset time.

A number of previous studies^6,14 indicated the prevalence of dry socket was higher after single extractions than multiple extractions, and this was confirmed by the results of this study in which dry socket prevalence was 7.3% following single extractions and 3.4% following multiple extractions.

This difference could possibly be explained by less pain tolerance in patients with single extractions compared to those with multiple extractions who allow their teeth to deteriorate to such an extent multiple extractions are needed and relieve the preoperative pain.⁶ In addition, multiple extractions are usually simple (atraumatic) because they are generally performed on mobile teeth which are periodontally compromised. This is also consistent with the findings of Krough³² who suggested if several adjacent teeth are to be extracted, the best postoperative healing would follow their extraction in one operation.

In this study the difference in the prevalence of dry socket between males (5.1%) and females (4.3%) was statistically insignificant. Although this is similar to the findings of Al Khateeb et al.,¹² it is in disagreement with the results of several other studies^5-6,33including MacGreoger¹⁴who reported a higher incidence of dry socket in females with a male:female ratio of 2:3.

This can be explained by the fact, unlike Western societies in which smoking habits are almost identically distributed among both sexes, the percentage of female smokers in this study was much less than males (8.6% and 44.9%, respectively). Thus, any increased susceptibility of the female sex to dry sockets may have been compensated for by the effect of smoking in the male group of patients.

Another possible explanation is most studies reporting a higher incidence of dry socket in females had a much higher percentage of oral contraceptive users than this study (3%). The use of contraceptives thought to be the reason behind the increased susceptibility of females to dry socket^3,30,33-34was minimal in this study.

The findings of this study also showed the prevalence of dry socket to be highest in the third and fourth decades of life with a peak

incidence in the 18-33 year age group which is in agreement with the findings of many other studies.5-6,8,12,14

The reason for this age dependence is still unclear, but the presence of well developed alveolar bone and the relative infrequency of periodontal diseases at this age (both make tooth extraction more difficult) may provide a possible explanation.⁶Most surgical extractions in this study were performed in this age group, and surgical extractions are associated with a higher incidence of dry socket.

Although the present study results were in agreement with part of the claim made by Hermesch et al.³⁸ showing no dry sockets in patients less than 18 years of age, it contradicted their other study by demonstrating six cases of dry socket in patients above the age of 50 years.

Contrary to the findings of Johnson and Blanton,³⁵ who reported no significant difference in the prevalence of dry socket between smokers and non-smokers, a dose dependent relationship between smoking and the occurrence of dry socket was demonstrated in the present study which is similar to the findings of other studies.^13,42

However, the increased prevalence of dry socket among smokers may also be attributed to their failure to adhere to postoperative instructions.

It has been reported 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.⁴²Whether a systemic mechanism or a direct local affect (heat and suction) on the extraction site is responsible for this increase in the occurrence of dry socket is unclear.

Many workers reported site specificity in the occurrence of dry socket with the mandibular molar area being the most commonly affected

site.^6,8,23,14Although there is no scientific evidence of insufficient blood supply due to normal

anatomical structure around the sockets of the mandibular molars and no evidence of any connection between dry socket and insufficient blood supply,¹¹some authors still believe increased bone density, decreased vascularity, and a reduced capacity of producing granulation tissue are responsible for this site specificity.⁵ It was also suggested this site specificity could be explained in terms of difficulty of extractions.¹⁴ In this study, although there was a statistically significant difference between upper and lower jaws in terms of dry socket incidence (p=0.002), the differences were statistically insignificant between anterior and posterior regions within the same jaw.

In agreement with the findings of other authors^5,7 the results of the present study have shown dry socket is more common following the extraction of mandibular third molars followed by first and second mandibular molars. This is probably due to the large percentage of surgically extracted mandibular third molars (56.6%) and may reflect the effect of surgical trauma rather than the anatomical site. If non-surgical extractions only were considered, dry socket would be seen most commonly after the extraction of the mandibular first molar followed by second and third mandibular molars, respectively. This is in agreement with results of both Oginni et al.⁸and MacGreoger,¹⁴ whose studies involved mainly non-surgical extractions.

Undergraduate and postgraduate students carried out most of the non-surgical extractions during the study period, whereas most of the surgical extractions were performed by postgraduate students and consultants. There was no significant difference in the incidence of dry socket following non-surgical extractions performed by undergraduate and postgraduate students (p = 0.558) and following surgical extractions performed by postgraduate students and consultants (p = 0.513). Thus, the present study has failed to demonstrate the operator’s experience as a risk factor for the development of dry socket. Although this is in agreement with the findings of Larsen¹⁰and Field et al.,⁶ it is different from those of Oginni et al.⁸and Alexander⁴ who reported a higher incidence of dry

socket following extractions performed by the less experienced operators.

The failure of this study to demonstrate a lower prevalence of dry socket following non-surgical extractions performed by postgraduate students could be explained by noting postgraduate students usually performed more difficult extractions than those of undergraduate students although both were included under non-surgical extractions. Moreover, patients who usually presented to postgraduate students kept their follow-up appointments (and, hence, they were more likely to be diagnosed with dry sockets) opposite to those who presented to undergraduate students.

The increased difficulty of surgical cases performed by consultants and the different quality of patients presented to them may also be possible causes of the failure of this study to demonstrate a lower incidence of dry socket following surgical extractions performed by consultants. For the most part, patients who presented to consultants were in the high income and social group of patients; and so they may have had a lower pain tolerance and paid more attention to postoperative complications.

Even though some researchers suggested a relationship between some systemic diseases and dry socket,^11,3in this study no significant difference was found between the incidence of dry socket among medically fit patients and those with underlying systemic diseases.

This was in agreement with MacGreoger¹⁴and Oginni et al.⁸ With regards to medications, only oral contraceptives have been reported to be associated with an increased risk of dry socket.^3,15,33-34However, such a relationship was

not found in this study probably because of the small number of patients who were on oral contraceptives.

Regarding the reason for tooth extraction and its effect on the incidence of dry socket, the results of this study have shown no significant association.

This is in agreement with other studies.^11,14,32 The only exception is teeth with pericoronitis which have been linked to a higher prevalence of dry socket. This, however, could not be demonstrated in this study and the reason was probably the small number of such cases in the study population.

It has been mentioned, but not conclusively proven, there is a possibility of an increased incidence of dry socket following the use of local anesthesia with vasoconstrictors before the extraction.¹¹ Although Krogh³²emphasized the incidence of dry socket was highest in the mandibular molar area (where regional block anesthesia is used), Lehner⁴³ found a higher incidence of dry socket when infiltration anesthesia was used and concluded infiltration anesthesia gave rise to a temporary ischemia leading to poor blood supply to the socket. However, subsequent studies indicate ischemia lasts only for one to two hours and is followed by a reactive hyperemia which makes it of no importance to the subsequent disintegration of the blood clot.^11,36 This concept is currently widely accepted.

In this study there was no significant difference in dry socket prevalence following the extraction of teeth requiring infiltration anesthesia and those requiring regional block anesthesia (both contained adrenaline). These results are in agreement with the assumption local ischemia due to vasoconstrictors in local anesthesia have no role in the pathogenesis of dry socket.

In the same context if there is a possible role for local ischemia in the etiology of dry socket, one should expect an increased incidence of dry socket following the use of an increased amount of local anesthesia with a vasoconstrictor. This study also failed to find any significant difference following the use of different amounts of local anesthesia (< two cartridges and ≥ two cartridges).

However, these results should be interpreted with caution and considered inconclusive since regional block anesthesia was used in the majority

of extractions requiring two or more cartridges of local anesthesia; so, any resulting ischemia would be located away from the socket.

With regards to the use of antibiotics to prevent dry socket development, penicillins and metrondizole were highly suggested in the literature.22-23,39-40

The results of this study failed to show any significant effect of the preoperative antibiotic use on the incidence of dry socket. This, however, should also be considered inconclusive since antibiotics were not prescribed routinely even after surgical extractions and further investigation of this issue may be needed.

The clinical picture of dry socket in this study was comparable to generally described dry sockets in the literature. Pain and empty sockets were found in all patients, which is in agreement with the findings of several authors.3,6,11,14,25

The average onset time of symptoms was around 36 hours after the extraction. This relatively early onset could be attributed to the co-existence of dry socket with other postoperative complications such as swelling and trismus since most cases followed surgical or difficult extractions. This is understandable when one considers the neurological pain of dry socket is believed to be related to the release of kinins, which are immediately available following tissue trauma.

Cases in which the onset was a little more delayed can be explained by the notion that an infection process was needed to liberate tissue activators and pain mediators.⁶

Although exposed or bare bone has been reported as a possible clinical feature of dry socket, in this study bare bone was found in 75%

of cases and was more frequent following simple than surgical extractions. It is possible, however, bare bone was present in some cases that followed surgical extractions but was obscured by the sutured flap over the socket orifice. In addition, halitosis was more frequently found in patients with poor oral hygiene, and this is not surprising since food impaction in the empty socket and its fermentation by bacteria is believed to be the cause of such a problem.⁵

As indicated by Fazakerley,³⁰ the primary aim of dry socket management is pain control until commencement of normal healing, and in the majority of cases local measures are satisfactory.

However, systemic analgesics or antibiotics may be necessary in some cases. In addition, the use of intra-alveolar dressing materials is widely suggested in the literature.^24,26,29

In this study, the management protocol was similar to what is suggested in the literature and involved the traditional methods of normal saline irrigation , and placement of an Alvogyl^® iodoform dressing (Septodont, Cambridge, ON, Canada) along with prescriptions of analgesics and

systemic antibiotics for some patients. Dry socket patients were also instructed to return for follow up appointments during which the socket was examined, irrigated, and re-dressed.

Most patients returned for only one follow up visit during the same week which made the total treatment duration less than the 7-14 days recommended in the literature.4,11,14,24-25

This could be attributed to more pain tolerance, self medication, seeking care from elsewhere, or a combination of these factors.

Conclusions

From the results of this study, the following conclusions can be made:

1. The overall prevalence of dry socket and its clinical picture at DTC/JUST was comparable to previous findings reported in the literature.

2. The prevalence of dry socket following single extractions was significantly higher than following multiple extractions.

3. The prevalence of dry socket was higher following surgical extractions than following non-surgical extractions.

4. There was a dose dependent relationship between smoking and the occurrence of dry sockets.

5. There was no statistically significant

association between the development of dry socket and patient’s age, sex, medical history, medications (preoperative or postoperative), indication for extraction, extraction site, operator’s experience, and amount or technique of local anesthesia.

References

1. Petri WH, Wilson TM. Clinical evaluation of antibiotic supplemented bone allograft. J Oral Maxillofac Surg 1992; 51: 982-987.

2. Erickson RT, Wait DE, Wilkison RH. A study of dry sockets. Oral Surg 1960; 13: 1046-1050.

3. Lilly GE, Osborn DB, Rael EM, Samuels HS, Jones JC. Alveolar osteitis associated with mandibular third molar extractions. J Am Dent Assoc. 1974; 88: 802-806.

4. Alexander RE. Dental extraction wound management: A case against medicating post-extraction sockets. J Oral Maxillofac Surg 2000; 58: 538- 551.

5. Amaratunga NA, Senaratne CM. A clinical study of dry socket in Sri Lanka. Br J Oral Maxillofac Surg 1988; 26: 410-418.

6. Field EA, Speechley JA, Rotter E, Scott J. Dry socket incidence compared after a 12-year interval.

Br J Oral Maxillofac Surg 1985; 23: 419-427.

7. Jaffar N, Nor GM. The prevalence of post-extraction complications in an outpatient dental clinic in Kuala Lumpur Malaysia – a retrospective survey. Singapore Dent J 2000; 23(1): 24-28.

8. Oginni FO, Fatusi OA, Alagbe AO. A clinical evaluation of dry socket in a Nigerian teaching hospital.

J Oral Maxillofac Surg 2003; 61(8): 871-876.

9. Bloomer CR. Alveolar osteitis prevention by immediate placement of medicated packing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 90: 282-284.

10. Larsen PE. Alveolar osteitis after surgical removal of impacted mandibular third molars. Identification of patients at risk. Oral Surg Oral Med Oral Pathol 1992; 73: 393-397.

11. Birn H. Etiology and pathogenesis of fibrinolytic alveolitis (‘dry socket’). Int J Oral Surg 1973; 2:

215-263.

12. Al-Khateeb TL, El-Marsafi AI, Butler NP. The relationship between the indications for the surgical removal of impacted third molars and the incidence of alveolar osteitis. J Oral Maxillofac Surg 1991;

49:141-145.

13. Sweet JB, Butler DP. The relationship of smoking to localized osteitis. J Oral Surg 1979; 37:

732-735.

14. MacGregor AJ. Aetiology of dry socket: A clinical investigation. Br J Oral Surg 1968: 6: 49-58.

15. Catellani JE, Harvey S, Erickson SH, Cherkink D. Effect of oral contraceptive cycle on dry socket (localized alveolar osteitis). J Am Dent Assoc 1980; 101: 777-780.

16. Meechan JG, Venchard GR, Rogers SN, Hobson RS, Prior I, Tavares C, Melnicenko S. Local anesthesia and dry socket: a clinical investigation in of single extractions in male patients. Int J Oral Maxillofac Surg 1987; 16: 279-284.

17. Butler DP, Sweet JB. Effect of lavage on the incidence of localized osteitis in mandibular third molar extraction sites. Oral Surg Oral Med Oral Pathol 1977; 44: 14-20.

18. Sweet JB, Macynaki AA. Effect of antimicrobial mouthrinses on the incidence of localized alveolitis and infection following mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 1985; 59:

24-6.

19. Field EA, Nind D, Varga E, Martin MV. The effect of chlorhexidine irrigation on the incidence of dry socket: A pilot study. Br J Oral Maxillofac Surg 1988; 26:395-401.

20. Ragno JR, Szkutnik AJ. Evaluation of 0.12% chlorhexidine rinse on the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol 1991; 72: 524-526.

21. Ritzau M, Swangsilpa K. The prophylactic use of propylic ester of p-hydrobenzoic acid on alveolitis sicca dolorosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1977; 43: 32-37.

22. Krekmanov L. Alveolitis after operative removal of third molar in the mandible. Int J Oral Surg 1981;

10: 173-179.

23. Rood JP, Murgatroid J. Metrondizole in the prevention of ‘dry socket’. Br J Oral Surg 1979; 17:

62-70.

24. Swanson AE. Prevention of dry socket: An overview. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1990; 70: 131-136.

25. Blum IR. Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review. Int J Oral Maxillofac Surg. 2002; 31: 309-317.

26. Mitchell R. Treatment of fibrinolytic alveolitis by a collagen paste (Formula K): A preliminary report.

Int J Oral Maxillofac Surg 1986; 15: 127-133.

27. Poor MR, Hall JE, Poor AS. Reduction in the incidence of alveolar osteitis in patients treated with the SaliCept patch, containing Acemennan Hydrogel. J Oral Maxillofac Surg 2002; 60: 374-379.

28. Nitzan DW. On the genesis of ‘dry socket’. J Oral Maxillofac Surg 1983; 41: 706-710.

29. Vezeau PJ. Dental extraction wound management: Medicating postextraction sockets. J Oral Maxillofac Surg 2000; 58: 531-537.

30. Fazakerley M, Field EN. Dry socket: a painful post-extraction complication (A review). Dental update 1991; 18: 31-34.

31. Larsen PE. The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg 1991; 49: 932-937.

32. Krogh HW. Incidence of dry socket. J Am Dent Assoc. 1937; 24: 1829-1836.

33. Sweet JB, Butler DP. Predisposing and operative factors: Effect on the incidence of localized osteitis in mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 1978; 46: 206-215.

34. Garcia AG, Grana OM, Sampedro FG, Diago MP, Rey JM. Does oral contraceptive use affect the incidence of complications after extraction of a mandibular third molar? Br Dent J 2003; 194:

453-455.

35. Johnson WS, Blanton EE. An evaluation of 9-aminoacridine/ Gelfoam to reduce dry socket formation. Oral Surg Oral Med Oral Pathol 1988; 66: 167-170.

36. Tsirlis AT, Iakovidis DP, Parissis NA. Dry socket: Frequency of occurrence after intraligamentary anesthesia. Quint Int 1992; 23: 575-577.

37. Dadson TB. HIV status and the risk of post-extraction complications. J Dent Res 1997; 76: 1644- 1652.

38. Hermesch CB, Hilton TJ, Biesbrock AR, Baker RA, Gerlach RW, McClanahan SF. Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85: 381-387.

39. Bystedt H, Nord CE, Nordenram A. Effect of azidocillin, erythromycin, clindamycin, and doxycycline on postoperative complications after surgical removal of impacted mandibular third molars. Int J Oral Surg 1980:9:157-65.

40. Barclay JK. Metrondizole and dry socket: prophylactic use in mandibular third molar removal complicated by non-acute pericoronitis. New Zealand Dent J 1987; 7: 71-75.

41. Ritzau M, Therkildsen P. Antitibrinolytic prevention of alveolitis sicca dolorosa. Int J Oral Surg 1978;

7: 534-540.

42. Al-Belasy FA. The Relationship of “Shisha” (Water Pipe) Smoking to Postextraction Dry Socket.

J Oral Maxillofac Surg 2004; 62: 10-14.

43. Lehner T. Analysis of one hundred cases of dry socket. Dent Pract Dent Rec 1958; 8: 275-279.

About the Authors