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Preventing Dry Socket A Simple Procedure that Works
P R E V E N T IN G
A SIMPLE PROCEDURE THAT WORKS N O R M A N T R IE G E R , D .M .D ., M .D . G R E G O R V D. S C H L A G E L , D .D .S.
^ ^ f t e r several years of treating dry socket postoperatively, we recently found that placing a topi cal clindamycin saturated gelatin sponge (Gelfoam) square into an extraction site at surgery helps pre vent dry socket. In a previous study at Montefiore Medical Center, we found that using topical clindamycin phos phate, an anti-anaerobic antibiotic,
as a rescue medication suggests that anaerobic bacteria contribute to the development of dry socket. A recent double-blind study involving 172 mandibular bony third molar impactions in 86 patients, with each patient serving as his or her own control, was completed. In this study, no antibiotics were used for at least two weeks before surgery or postoperatively. We col
lected data on the incidence of cigarette smoking, birth control medication, anesthetic used and duration of each surgical procedure (as an index of surgical difficulty). One socket was dressed with a Gelfoam square ( l x l centimeters) saturated with 1 milliliter of clin damycin phosphate solution (150 milligrams/milliliters) taken from a prepared numbered vial accord
67
ing to a randomized distribution. Neither the surgeon nor the patient knew which vial contained the saline placebo and which contained the antibiotic. Seven patients developed typical dry socket symptoms with intense pain unre lieved by the anal gesic medication prescribed. Decoding revealed that all seven dry socket sites devel oped in placebo treated sockets only. (Statistical signifcance was demonstrated at the P < 0.5 level.) Despite the absence of systemic antibiotics postoperatively, no pyo genic or septic complication devel oped. Five patients were taking birth control pills and two of these women developed dry socket. Dry socket is described as a com mon local complication following third molar extraction characterized by intense pain often radiating to the ear on the same side, a necrotic blood clot, fetid odor and delayed onset. Other terms describing the condition include alveolitis sicca dolorosa, fib rinolytic osteomyelitis, alveolalgia, alveolar osteitis and post-extraction osteomyelitic syndrome.'.2 The reported rate of dry socket occurrence following the removal of mandibular molars, specifically mandibular third molars ranges from 5 percent to 10 percent to a . high of 30 percent. ^ v I y Several studies con^ ^ ^ ^ F ^ s i d e r e d and rejected three predisposing f I factors: associated trauma,2- ^ the com promised blood supply at the site when using vasoconstrictors in the local anesthetic,14-2! and patients older than 40 years of age.®22 Another factor not only consid ered in the past but also in this dou
68
ble-blind study is the higher inci dence of dry socket after third molar surgery for females on birth control m e d i c a t i o n . A n elevated plasma fibrinolytic activity is attributed to oral contraceptives, contributing to dry socket.2« Several researchers have impli cated bacteria in its develop ment.^is,27-30Nitzan2?searched for a bacterial cause and concluded that Treponema denticola could be a possible etiologic agent as its anaer obic nature can produce the fetid odor and bad taste of dry socket along with strong fibrinolytic activ ity. Also T. denticola is not found in the oral environment during child hood, a time when dry socket is vir tually unknown. Others found that anaerobes can , play a major role in the development of dry socket when they used metron' idazole (Flagyl) to reduce its incidence successfully.22 In another study, bacteroides predominated at 38.5 percent of the anaerobic isolates in samples and in cultures from 47 different species. Antibiotic resistance was found against penicillin at 23 per cent, erythromycin at 23 percent and metronidazole at 22 percent. None was resis tant to chloram phenicol.^ Our results and those of oth ers suggest that anaerobic bacte Dr. Trieger is profes ria are a major sor and chairman, Department of cause of dry Dentistry, Oral and socket. Thus, Maxillofacial Surgery, Albert clindamycin Einstein College of —an anti-anaer Medicine/Montefiore obic antibiotic— Medical Center, 111 E. 210th St., Bronx, can reduce its N.Y. 10467. Address incidence. requests for reprints to Dr. Trieger.
This study was made pos sible with a grant from Upjohn, Kalamazoo, Mich.
The authors thank Drs. Sidney Eisig, Lynn Anne Greene, Richard Kraut and Merwyn Wolf of the Department of Dentistry, Oral and Maxillofacial Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, N.Y. Special microbiologic support was provided by Drs. John McKitrick, Mary Motyl and Ms. Corinne Zorzon of the Division of Microbiology, Montefiore Medical Center. 1. Crawford JY. Dry socket. Dental Cosmos 1896;38:929. 2. Birn H. Etiology and pathogenesis of fibrinolytic alve olitis. Int J Oral Surg 1973;2:211-63. 3. MacGregor AJ. Etiology of dry socket: A clinical inves tigation. Br J Oral Surg 1968;6:49-58. 4. Tlirner PS. A clinical study of dry socket. Int J Oral Surg 1982;11:226-31. 5. Krekmanov L, Hallander HO. Relationship between bacterial contamination and alveolitis after third molar surgery. Int J Oral Surg 1980;9:274-80. 6. Allen LS, e ta l. Complications following removal of impacted third molars: the role of the experience of the sur geon. J Oral Maxillofac Surg 1986;44:855-59. 7. Quinley JF, e t al. Dry socket after mandibular odontectomy and use of soluble tetracycline hydrochloride. Oral Surg Oral Med Oral Pathol 1960;13:38-42. 8. Lilly GE, Osbon DB, Rael EM, et al. Alveolar osteitis associated with mandibular third molar extractions. JADA 1974;88:802-6. 9. Hansen EH. Alveolitis sicca dolorosa (dry socket). Frequency of occurrence and treatment with trypsin. J Oral Surg 1960;18:409-16. 10. Turner PS. A clinical study of “dry socket.” Int J Oral Surg 1982;11:226-31. 11. Swanson AE. Reducing the incidence of dry socket. A clinical appraisal. J Can Dent Assoc 1966;32:25-33. 12. Sw eet JB, Butler DP. Predisposing and operative fac tors: effect on the incidence of localized osteitis in mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 1978;46:206-15. 13. Ritzau M, Swangsilpa K. The prophylactic use of propylic ester of p-hydrobenzoic acid on alveolitis sicca dolorosa. Oral Surg Oral Med Oral Pathol 1977;43:32-7 14. Lehner T. Analysis of one hundred cases of dry socket. Dent Pract 1958;8:75. 15. Gustafson G, Wallenius K. Effect of local application of trypsin on postextraction alveolar osteitis. Oral Surg Oral Med Oral Pathol 1961;14:280-6. 16. Rud J, Baggesen H, Moller F. Effects of the sulfa cones and suturing on the incidence of pain after removal of impacted lower third molars. J Oral Surg 1963;21:219-66. 17. Deutch E, Eisner PL. The mechanisms of fibrinolysis induced by bacterial pyrogens. Thromb et Diathesis Haem 1959;3:286. 18. Rud J. Removal o f impacted lower third molars with acute pericoronitis and necrotizing gingivitis. Br J Oral Surg 1970;7:153-9. 19. Kay LW. Investigations into the nature of pericoronitis II. Br J Oral Surg 1966;4:52-78. 20. Meyer RA. Effect of anesthesia on the incidence of alveolar osteitis. J Oral Surg 1971;29:724-6. 21. Birn H. The vascular supply of the periodontal mem b rane-A n investigation of the number and size of perfora tions in the alveolar wall. J Perio Res 1966;1:51-68. 22. Rood JP, Murgatroyd J. Metronidazole in the preven tion of dry socket. Br J Oral Surg 1979-80;17:62-70. 23. Catellani JE. Review of factors contributing to dry socket through enhanced fibrinolysis. J Oral Surg 1979;37:42-6. 24. Nordenram A, Grave S. Alveolitis sicca dolorosa after removal of impacted third molars. Int J Oral Surg 1983;12:216-31. 25. Gersel-Pedersen N. Tranexamic acid in alveolar sock ets in the prevention of alveolitis sicca dolorsa. Int J Oral Surg 1979;8:421-9. 26. Ygge J, et al. Changes in blood coagulation and fibri nolysis in women receiving oral contraceptives. Am J Obstet Gynecol 1969;104:87-98. 27. Nitzan DW. On the genesis of dry socket. J Oral Maxillofac Surg 1983;41:706-10. 28. Barclay JK. Metronidazole and dry socket: prophylac tic use in mandibular third molar removal complicated by nonacute pericoronitis. NZ Dent J 1987;83:71-5. 29. Goldman DR, Kilgore DS, Panzer JD, et al. Prevention of dry socket by local application of lincomycin in Gelfoam. Oral Surg Oral Med Oral Pathol 1973;30:472-4. 30. Sorenson DC, Preisch JW. The effect of tetracycline on the incidence of postextraction alveolar osteitis. J Oral Maxillofac Surg 1987;45:1029-33. 31. Blignaut E, Combrink LW, Joubert J. The microbiology of dry sockets. J Dent Res (abstract no. 4 ) 1986:618.
A SIMPLE PROCEDURE THAT WORKS N O R M A N T R IE G E R , D .M .D ., M .D . G R E G O R V D. S C H L A G E L , D .D .S.
^ ^ f t e r several years of treating dry socket postoperatively, we recently found that placing a topi cal clindamycin saturated gelatin sponge (Gelfoam) square into an extraction site at surgery helps pre vent dry socket. In a previous study at Montefiore Medical Center, we found that using topical clindamycin phos phate, an anti-anaerobic antibiotic,
as a rescue medication suggests that anaerobic bacteria contribute to the development of dry socket. A recent double-blind study involving 172 mandibular bony third molar impactions in 86 patients, with each patient serving as his or her own control, was completed. In this study, no antibiotics were used for at least two weeks before surgery or postoperatively. We col
lected data on the incidence of cigarette smoking, birth control medication, anesthetic used and duration of each surgical procedure (as an index of surgical difficulty). One socket was dressed with a Gelfoam square ( l x l centimeters) saturated with 1 milliliter of clin damycin phosphate solution (150 milligrams/milliliters) taken from a prepared numbered vial accord
67
ing to a randomized distribution. Neither the surgeon nor the patient knew which vial contained the saline placebo and which contained the antibiotic. Seven patients developed typical dry socket symptoms with intense pain unre lieved by the anal gesic medication prescribed. Decoding revealed that all seven dry socket sites devel oped in placebo treated sockets only. (Statistical signifcance was demonstrated at the P < 0.5 level.) Despite the absence of systemic antibiotics postoperatively, no pyo genic or septic complication devel oped. Five patients were taking birth control pills and two of these women developed dry socket. Dry socket is described as a com mon local complication following third molar extraction characterized by intense pain often radiating to the ear on the same side, a necrotic blood clot, fetid odor and delayed onset. Other terms describing the condition include alveolitis sicca dolorosa, fib rinolytic osteomyelitis, alveolalgia, alveolar osteitis and post-extraction osteomyelitic syndrome.'.2 The reported rate of dry socket occurrence following the removal of mandibular molars, specifically mandibular third molars ranges from 5 percent to 10 percent to a . high of 30 percent. ^ v I y Several studies con^ ^ ^ ^ F ^ s i d e r e d and rejected three predisposing f I factors: associated trauma,2- ^ the com promised blood supply at the site when using vasoconstrictors in the local anesthetic,14-2! and patients older than 40 years of age.®22 Another factor not only consid ered in the past but also in this dou
68
ble-blind study is the higher inci dence of dry socket after third molar surgery for females on birth control m e d i c a t i o n . A n elevated plasma fibrinolytic activity is attributed to oral contraceptives, contributing to dry socket.2« Several researchers have impli cated bacteria in its develop ment.^is,27-30Nitzan2?searched for a bacterial cause and concluded that Treponema denticola could be a possible etiologic agent as its anaer obic nature can produce the fetid odor and bad taste of dry socket along with strong fibrinolytic activ ity. Also T. denticola is not found in the oral environment during child hood, a time when dry socket is vir tually unknown. Others found that anaerobes can , play a major role in the development of dry socket when they used metron' idazole (Flagyl) to reduce its incidence successfully.22 In another study, bacteroides predominated at 38.5 percent of the anaerobic isolates in samples and in cultures from 47 different species. Antibiotic resistance was found against penicillin at 23 per cent, erythromycin at 23 percent and metronidazole at 22 percent. None was resis tant to chloram phenicol.^ Our results and those of oth ers suggest that anaerobic bacte Dr. Trieger is profes ria are a major sor and chairman, Department of cause of dry Dentistry, Oral and socket. Thus, Maxillofacial Surgery, Albert clindamycin Einstein College of —an anti-anaer Medicine/Montefiore obic antibiotic— Medical Center, 111 E. 210th St., Bronx, can reduce its N.Y. 10467. Address incidence. requests for reprints to Dr. Trieger.
This study was made pos sible with a grant from Upjohn, Kalamazoo, Mich.
The authors thank Drs. Sidney Eisig, Lynn Anne Greene, Richard Kraut and Merwyn Wolf of the Department of Dentistry, Oral and Maxillofacial Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, N.Y. Special microbiologic support was provided by Drs. John McKitrick, Mary Motyl and Ms. Corinne Zorzon of the Division of Microbiology, Montefiore Medical Center. 1. Crawford JY. Dry socket. Dental Cosmos 1896;38:929. 2. Birn H. Etiology and pathogenesis of fibrinolytic alve olitis. Int J Oral Surg 1973;2:211-63. 3. MacGregor AJ. Etiology of dry socket: A clinical inves tigation. Br J Oral Surg 1968;6:49-58. 4. Tlirner PS. A clinical study of dry socket. Int J Oral Surg 1982;11:226-31. 5. Krekmanov L, Hallander HO. Relationship between bacterial contamination and alveolitis after third molar surgery. Int J Oral Surg 1980;9:274-80. 6. Allen LS, e ta l. Complications following removal of impacted third molars: the role of the experience of the sur geon. J Oral Maxillofac Surg 1986;44:855-59. 7. Quinley JF, e t al. Dry socket after mandibular odontectomy and use of soluble tetracycline hydrochloride. Oral Surg Oral Med Oral Pathol 1960;13:38-42. 8. Lilly GE, Osbon DB, Rael EM, et al. Alveolar osteitis associated with mandibular third molar extractions. JADA 1974;88:802-6. 9. Hansen EH. Alveolitis sicca dolorosa (dry socket). Frequency of occurrence and treatment with trypsin. J Oral Surg 1960;18:409-16. 10. Turner PS. A clinical study of “dry socket.” Int J Oral Surg 1982;11:226-31. 11. Swanson AE. Reducing the incidence of dry socket. A clinical appraisal. J Can Dent Assoc 1966;32:25-33. 12. Sw eet JB, Butler DP. Predisposing and operative fac tors: effect on the incidence of localized osteitis in mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 1978;46:206-15. 13. Ritzau M, Swangsilpa K. The prophylactic use of propylic ester of p-hydrobenzoic acid on alveolitis sicca dolorosa. Oral Surg Oral Med Oral Pathol 1977;43:32-7 14. Lehner T. Analysis of one hundred cases of dry socket. Dent Pract 1958;8:75. 15. Gustafson G, Wallenius K. Effect of local application of trypsin on postextraction alveolar osteitis. Oral Surg Oral Med Oral Pathol 1961;14:280-6. 16. Rud J, Baggesen H, Moller F. Effects of the sulfa cones and suturing on the incidence of pain after removal of impacted lower third molars. J Oral Surg 1963;21:219-66. 17. Deutch E, Eisner PL. The mechanisms of fibrinolysis induced by bacterial pyrogens. Thromb et Diathesis Haem 1959;3:286. 18. Rud J. Removal o f impacted lower third molars with acute pericoronitis and necrotizing gingivitis. Br J Oral Surg 1970;7:153-9. 19. Kay LW. Investigations into the nature of pericoronitis II. Br J Oral Surg 1966;4:52-78. 20. Meyer RA. Effect of anesthesia on the incidence of alveolar osteitis. J Oral Surg 1971;29:724-6. 21. Birn H. The vascular supply of the periodontal mem b rane-A n investigation of the number and size of perfora tions in the alveolar wall. J Perio Res 1966;1:51-68. 22. Rood JP, Murgatroyd J. Metronidazole in the preven tion of dry socket. Br J Oral Surg 1979-80;17:62-70. 23. Catellani JE. Review of factors contributing to dry socket through enhanced fibrinolysis. J Oral Surg 1979;37:42-6. 24. Nordenram A, Grave S. Alveolitis sicca dolorosa after removal of impacted third molars. Int J Oral Surg 1983;12:216-31. 25. Gersel-Pedersen N. Tranexamic acid in alveolar sock ets in the prevention of alveolitis sicca dolorsa. Int J Oral Surg 1979;8:421-9. 26. Ygge J, et al. Changes in blood coagulation and fibri nolysis in women receiving oral contraceptives. Am J Obstet Gynecol 1969;104:87-98. 27. Nitzan DW. On the genesis of dry socket. J Oral Maxillofac Surg 1983;41:706-10. 28. Barclay JK. Metronidazole and dry socket: prophylac tic use in mandibular third molar removal complicated by nonacute pericoronitis. NZ Dent J 1987;83:71-5. 29. Goldman DR, Kilgore DS, Panzer JD, et al. Prevention of dry socket by local application of lincomycin in Gelfoam. Oral Surg Oral Med Oral Pathol 1973;30:472-4. 30. Sorenson DC, Preisch JW. The effect of tetracycline on the incidence of postextraction alveolar osteitis. J Oral Maxillofac Surg 1987;45:1029-33. 31. Blignaut E, Combrink LW, Joubert J. The microbiology of dry sockets. J Dent Res (abstract no. 4 ) 1986:618.