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Cause and Treatment of Dry Socket
CAUSE AND TREATMENT OF DRY SOCKET By W
il l ia m
E. S h e a , M .D ., San Francisco, C alif.
I N C E the pub lication o f m y article on treatm en t o f d ry socket1 in Sep tem ber 1940, I h a ve been interested in the nom enclature o f dry socket and the possibility' th a t it m igh t add some th in g to the scientific study of the sub je c t to catalogue fo r fu tu re referen ce the three theories regard in g coagulation of b lo o d : (1 ) the ferm en t th e o r y ; (2) the im m unologic theory, and (3) the ph ys icoch em ical theory. I shall not go into a description of these theories, as they are availab le in the usual textbooks o f chem ical labora tory m ethods, b u t w ou ld suggest H o w ell’s idea2 as the most plausible. T h e absence o f clo t form ation in dry socket is no doubt sym ptom atic o f a m etabolic disturbance due to a lowered vitam in B content in the tissues, w hich results in a fibrinogen, prothrobin, c a l cium and blood platelet alteration. A l though the platelets m a y be decreased to 60,000, or less, p er cu b ic m illim eter, clots m ay be o f a feathery consistency, disinte gratin g rap id ly ow in g to avitam inosis, p articularly o f vitam in B , as observed in the follow in g c a se s:
S
Mrs. P. C . T h e coagulation time was six and one-half minutes; bleeding time, 4 m in utes. V itam in B, 13,333 units, was given. O ne hour later, the coagulation tim e was one and one-half minutes; bleeding time, three and one-half minutes. M r. J. D . T h e coagulation time was three and one-half minutes; bleeding time, two minutes. V itam in B, 20,000 units, was given intram uscularly. O ne hour later, the coagu lation time was tw o and one-half minutes; bleeding time, two minutes. M r. J. D . T h e coagulation time was three minutes; bleeding time, two and one-half minutes. V itam in B, 20,000 units, was given intram uscularly. O ne hour later, the coagu
Jour. A.D.A., Vol. 30, February 1, 1943
lation time was two minutes; bleeding time two minutes. M r. O . M . T . T h e coagulation time was three and one-half minutes; bleeding time, two and one-half minutes. V itam in B, 20,000 units, was given intram uscularly. O ne hour later, the coagulation time was two and onehalf minutes; bleeding time, two minutes. Mrs. G . W . F. T h e coagulation time was four minutes; bleeding time, two and onehalf minutes. V itam in B, 20,000 units, was given intram uscularly. O n e hour later, the coagulation time was one and a h alf m in utes; bleeding time, one minute. M r. P. J. O ’S. T h e coagulation time was four minutes; bleeding time, one and oneh alf minutes. V itam in B, 20,000 units, was given intram uscularly. O ne hour later, the coagulation time was two and one-half m in utes; bleeding time, one minute. M r. O . J. T h e coagulation time was four minutes; bleeding time, three minutes. V ita m in B, 16,666 units was given intram uscu larly. O ne hour later, the coagulation time was two and one-half minutes; bleeding time, two minutes.
It w ou ld be advisable fo r the dentist and the physician to give from 5,000 to 50,000 units of vitam in B intram uscu la rly fo r the relief of the pain o f dry socket. T h is afford ed relief in less than one hou r in the m ajo rity o f eighty-five cases. O n e patien t developed an allergic reaction, w h ich was relieved b y a h yp o derm ic injection o f 0.5 cc. o f adrenalin chloride solution 1-1000. I m ade cultures from the dental crypts o f these extracted teeth, using b lood -agar and L oeffler’s coagu lated serum and dem onstrated o n ly the usual m ou th organism s, w ith the exception o f tw o cases o f n on-hem olytic streptococci, w hich w ere relieved b y sm aller doses of yitam in B th an w ere used in the other cases. 289
290
T
he
Journal
of th e
A
m e r ic a n
A history o f these cases affords an in teresting v ie w in regard to th e social status o f the in d iv id u a l: M o re o f the m id d le class a re subject to d ry socket, w h ile th e p o orer and th e rich er classes are p ra ctica lly im m une. T h is anom aly m a y be d ue to one o f three fa c ts : i . T h e re are m ore o f us in the m id d le class. 2. T h e poorer class eat vitam in B-contain in g foods fro m necessity. 3. T h e richer class h a v e a better balanced diet. A n o th er class is m ade u p o f those p a tients w h o are d ietin g to reduce. F o r the protection o f th e latter, ph arm aceu tic products con tain in g vitam in B m ust be ad ded to the low ered d ietary régim e. I t is not necessary here to give details as to isolation, sym ptom s o f deficiency, diagnostic m ethods, tolerance and daily requirem ent, ex cep t to call attention to a salient fa c t th a t m ay be of use in d aily practice : T h e average d aily requirem ents fo r an a d u lt are from 300 to 600 units o f vitam in B , com posed o f liver, w h eat germ , rice polishings, w hole gra in cer eals, w hole gra in bread, fruits, egg yolk, m ilk, nuts, legum es, butter, cream cheese, green leafy vegetables, apricots, fresh and dried sweet potatoes and carrots. I t seems to m e th a t d ry socket comes in the avitam inosis B j class, from th e thera peu tic test as em ployed in the relief of anorexia, fa tigu e, gastro-intestinal h yp o tonia, beriberi and other polyneuritic conditions. T h e isoster o f thiam ine h y drochloride ( B i) has been suggested and w orked o u t b y E lderfield and T ra c y , of C olu m b ia U n iversity. T h e vitam in B u n it m entioned in this article is thiam ine hydroch loride 333 I. U ., 1 m g. It w ould seem to m e from practical an d laboratory experience th a t the best test fo r vitam in B deficiency is adm inis tration o f thiam ine hydrochloride in suffi cient dosage to control the p a in o f dry sock et; th a t is, from 5,000 to 50,000 units intram uscularly. T h e circu latin g b lood consists o f a suspension o f erythrocytes, leukocytes
and blood platelets, in a fluid called
D
en tal
A
s s o c ia t io n
plasm a. T h e plasm a contains fibrin, w h ich is essential in coagu lation o f the blood. I f the fibrin is rem oved fro m the plasm a, the rem ain ing fluid is called b lood serum . T h e soluble blood protein is fibrino gen, w h ich is converted in to the insoluble fibrin. Fibrinogen is qu ite different physically and chem ically from the oth er blood proteins. I t is present in the blood in approxim ately 0.4 p e r cent, being form ed in the liver. Fibrinogen is the globulin, b u t goes into the insoluble form o f fibrin. C a lc iu m is not necessary fo r the con version o f fibrinogen into fibrin by throm bin, ow in g to th e fa c t th a t suffi cien t calciu m is fo u n d in norm al blood. BIBLIOGRAPHY
1. S h e a , W. E.: Treatm ent of D ry Socket — Preliminary Report. J.A .D .A ., 27:1482, September ig 4 o. 2. H o w e l l , W. H . : Bull. Johns Hopkins Hosp., 4 2 : i i g ; Am. J. Physiol., 63:434; 71 : 553 ! 77:670; T ext Book of Physiology for M edical Students and Physicians. Phila delphia: W . B. Saunders Co., 1927. 3. S e l d e n , H. M .: Accidents in Exodontia. D. Item s Int., 55:709, September 1933. 4. C l a r k , H. B.: D ry Sockets. D. Surg., 9:30, M arch 1933. 5. H y d e , W . H . : Post-Operative Pain. D. Outlook, 20:383, September 1933. 6. T h o m a s , E. H .: Fundamentals Underly ing Practical Management of: Various Oral Surgery Conditions; Roentgenographic Inter pretation and Mouth Diagnosis from Health Standpoint. J.A .D .A ., 18 :19 16, O ctober 1931. 7. Z i m m e r , M . A .: D ry Socket. D . Cosmos, 71 :1204, December 1929. 8. N o v i t z k y , J o s e f : D . Items Int., 61:348, April 1939. 9. Parke-Davis and Com pany Blue Book. 10. Eli L illy and Company: D e re Medicina. u. E. R . Squibb and Sons: Physicians’ V itam in Reference Book. 12. A s g is , A .: Persistent Problems in Den tistry and Dental Education. Apollonian, 15 : 49, A pril 1940. 13. L u s s i e r , N. A .: V itam in B T herapy in Treatment of D ry Sockets. /. California D. A ., 17 :13 7 , September-October 1941. 14. W hat’s N ew ; Brief Summaries and A b stracts— Abbott 1941. Abbott Laboratories Vitam in Chart.
450 Sutter Street.
il l ia m
E. S h e a , M .D ., San Francisco, C alif.
I N C E the pub lication o f m y article on treatm en t o f d ry socket1 in Sep tem ber 1940, I h a ve been interested in the nom enclature o f dry socket and the possibility' th a t it m igh t add some th in g to the scientific study of the sub je c t to catalogue fo r fu tu re referen ce the three theories regard in g coagulation of b lo o d : (1 ) the ferm en t th e o r y ; (2) the im m unologic theory, and (3) the ph ys icoch em ical theory. I shall not go into a description of these theories, as they are availab le in the usual textbooks o f chem ical labora tory m ethods, b u t w ou ld suggest H o w ell’s idea2 as the most plausible. T h e absence o f clo t form ation in dry socket is no doubt sym ptom atic o f a m etabolic disturbance due to a lowered vitam in B content in the tissues, w hich results in a fibrinogen, prothrobin, c a l cium and blood platelet alteration. A l though the platelets m a y be decreased to 60,000, or less, p er cu b ic m illim eter, clots m ay be o f a feathery consistency, disinte gratin g rap id ly ow in g to avitam inosis, p articularly o f vitam in B , as observed in the follow in g c a se s:
S
Mrs. P. C . T h e coagulation time was six and one-half minutes; bleeding time, 4 m in utes. V itam in B, 13,333 units, was given. O ne hour later, the coagulation tim e was one and one-half minutes; bleeding time, three and one-half minutes. M r. J. D . T h e coagulation time was three and one-half minutes; bleeding time, two minutes. V itam in B, 20,000 units, was given intram uscularly. O ne hour later, the coagu lation time was tw o and one-half minutes; bleeding time, two minutes. M r. J. D . T h e coagulation time was three minutes; bleeding time, two and one-half minutes. V itam in B, 20,000 units, was given intram uscularly. O ne hour later, the coagu
Jour. A.D.A., Vol. 30, February 1, 1943
lation time was two minutes; bleeding time two minutes. M r. O . M . T . T h e coagulation time was three and one-half minutes; bleeding time, two and one-half minutes. V itam in B, 20,000 units, was given intram uscularly. O ne hour later, the coagulation time was two and onehalf minutes; bleeding time, two minutes. Mrs. G . W . F. T h e coagulation time was four minutes; bleeding time, two and onehalf minutes. V itam in B, 20,000 units, was given intram uscularly. O n e hour later, the coagulation time was one and a h alf m in utes; bleeding time, one minute. M r. P. J. O ’S. T h e coagulation time was four minutes; bleeding time, one and oneh alf minutes. V itam in B, 20,000 units, was given intram uscularly. O ne hour later, the coagulation time was two and one-half m in utes; bleeding time, one minute. M r. O . J. T h e coagulation time was four minutes; bleeding time, three minutes. V ita m in B, 16,666 units was given intram uscu larly. O ne hour later, the coagulation time was two and one-half minutes; bleeding time, two minutes.
It w ou ld be advisable fo r the dentist and the physician to give from 5,000 to 50,000 units of vitam in B intram uscu la rly fo r the relief of the pain o f dry socket. T h is afford ed relief in less than one hou r in the m ajo rity o f eighty-five cases. O n e patien t developed an allergic reaction, w h ich was relieved b y a h yp o derm ic injection o f 0.5 cc. o f adrenalin chloride solution 1-1000. I m ade cultures from the dental crypts o f these extracted teeth, using b lood -agar and L oeffler’s coagu lated serum and dem onstrated o n ly the usual m ou th organism s, w ith the exception o f tw o cases o f n on-hem olytic streptococci, w hich w ere relieved b y sm aller doses of yitam in B th an w ere used in the other cases. 289
290
T
he
Journal
of th e
A
m e r ic a n
A history o f these cases affords an in teresting v ie w in regard to th e social status o f the in d iv id u a l: M o re o f the m id d le class a re subject to d ry socket, w h ile th e p o orer and th e rich er classes are p ra ctica lly im m une. T h is anom aly m a y be d ue to one o f three fa c ts : i . T h e re are m ore o f us in the m id d le class. 2. T h e poorer class eat vitam in B-contain in g foods fro m necessity. 3. T h e richer class h a v e a better balanced diet. A n o th er class is m ade u p o f those p a tients w h o are d ietin g to reduce. F o r the protection o f th e latter, ph arm aceu tic products con tain in g vitam in B m ust be ad ded to the low ered d ietary régim e. I t is not necessary here to give details as to isolation, sym ptom s o f deficiency, diagnostic m ethods, tolerance and daily requirem ent, ex cep t to call attention to a salient fa c t th a t m ay be of use in d aily practice : T h e average d aily requirem ents fo r an a d u lt are from 300 to 600 units o f vitam in B , com posed o f liver, w h eat germ , rice polishings, w hole gra in cer eals, w hole gra in bread, fruits, egg yolk, m ilk, nuts, legum es, butter, cream cheese, green leafy vegetables, apricots, fresh and dried sweet potatoes and carrots. I t seems to m e th a t d ry socket comes in the avitam inosis B j class, from th e thera peu tic test as em ployed in the relief of anorexia, fa tigu e, gastro-intestinal h yp o tonia, beriberi and other polyneuritic conditions. T h e isoster o f thiam ine h y drochloride ( B i) has been suggested and w orked o u t b y E lderfield and T ra c y , of C olu m b ia U n iversity. T h e vitam in B u n it m entioned in this article is thiam ine hydroch loride 333 I. U ., 1 m g. It w ould seem to m e from practical an d laboratory experience th a t the best test fo r vitam in B deficiency is adm inis tration o f thiam ine hydrochloride in suffi cient dosage to control the p a in o f dry sock et; th a t is, from 5,000 to 50,000 units intram uscularly. T h e circu latin g b lood consists o f a suspension o f erythrocytes, leukocytes
and blood platelets, in a fluid called
D
en tal
A
s s o c ia t io n
plasm a. T h e plasm a contains fibrin, w h ich is essential in coagu lation o f the blood. I f the fibrin is rem oved fro m the plasm a, the rem ain ing fluid is called b lood serum . T h e soluble blood protein is fibrino gen, w h ich is converted in to the insoluble fibrin. Fibrinogen is qu ite different physically and chem ically from the oth er blood proteins. I t is present in the blood in approxim ately 0.4 p e r cent, being form ed in the liver. Fibrinogen is the globulin, b u t goes into the insoluble form o f fibrin. C a lc iu m is not necessary fo r the con version o f fibrinogen into fibrin by throm bin, ow in g to th e fa c t th a t suffi cien t calciu m is fo u n d in norm al blood. BIBLIOGRAPHY
1. S h e a , W. E.: Treatm ent of D ry Socket — Preliminary Report. J.A .D .A ., 27:1482, September ig 4 o. 2. H o w e l l , W. H . : Bull. Johns Hopkins Hosp., 4 2 : i i g ; Am. J. Physiol., 63:434; 71 : 553 ! 77:670; T ext Book of Physiology for M edical Students and Physicians. Phila delphia: W . B. Saunders Co., 1927. 3. S e l d e n , H. M .: Accidents in Exodontia. D. Item s Int., 55:709, September 1933. 4. C l a r k , H. B.: D ry Sockets. D. Surg., 9:30, M arch 1933. 5. H y d e , W . H . : Post-Operative Pain. D. Outlook, 20:383, September 1933. 6. T h o m a s , E. H .: Fundamentals Underly ing Practical Management of: Various Oral Surgery Conditions; Roentgenographic Inter pretation and Mouth Diagnosis from Health Standpoint. J.A .D .A ., 18 :19 16, O ctober 1931. 7. Z i m m e r , M . A .: D ry Socket. D . Cosmos, 71 :1204, December 1929. 8. N o v i t z k y , J o s e f : D . Items Int., 61:348, April 1939. 9. Parke-Davis and Com pany Blue Book. 10. Eli L illy and Company: D e re Medicina. u. E. R . Squibb and Sons: Physicians’ V itam in Reference Book. 12. A s g is , A .: Persistent Problems in Den tistry and Dental Education. Apollonian, 15 : 49, A pril 1940. 13. L u s s i e r , N. A .: V itam in B T herapy in Treatment of D ry Sockets. /. California D. A ., 17 :13 7 , September-October 1941. 14. W hat’s N ew ; Brief Summaries and A b stracts— Abbott 1941. Abbott Laboratories Vitam in Chart.
450 Sutter Street.