Naveed Khawaja BDS, MCPS, DOMS, MSc-OPath (UK), FADI
Kauser Parveen BDS, MCPS
Abdullah Almotreb BDS
Rashed Tashkandi BDS
OBJECTIVE: Dry Socket (DS) is one of the complications following tooth extraction, reported usually 2-4 days postoperatively with moderate to severe pain. The concept of Dry Socket is not clear and there is disagreement among dental practitioners about diagnosis and management. The objective of this survey was to evaluate the knowledge of dry socket and its treatment among General Practitioners.
METHODOLOGY: One hundred and twenty-nine structured questionnaires were distributed among Dental Practitioners (DP) of Riyadh city with 78% response rate. This study was composed of two part; first about knowledge and second regarding treatment options. Data was collected, tabulated and analyzed using updated SPSS version 22.
RESULTS: According to the results, 75.2% (n=76) practitioners agreed that dry socket is dislodgment of clot in socket, and 20.8% (n=21) agreed that dry socket could be due to contamination of socket. Moreover, 32.7% (n=33) dental practitioners claimed that dry socket patients experienced discomfort symptom but most of the dentists 75.2%n (n=76) reported acute and stabbing pain in dry socket.
CONCLUSION: The overall knowledge of diagnosis and treatment of general practitioners was adequate.
KEY WORDS: Dry Socket; Knowledge; Dental Practitioner; Treatment
HOW TO CITE: Khawaja N, Parveen K, Almotreb A, Tashkandi R. The survey of the knowledge of dry socket and management among dental practitioners; still controversy?. J Pak Dent Assoc 2019;28(4):192-196.
Received: 21 December 2018, Accepted: 04 September 2019
Exodontia is a common procedure in Dentistry. Dry Socket (DS) is one of the delayed post-extraction complication, reported usually 2-4 days postoperatively with moderate to severe pain with the incidence of 0.5-5% in routine extractions.1-2 The name dry socket is used because blood clot is lost and covered by a green-grayish membrane. This term was first used in 1896 by Crawford.3
Since then, other terms have been used to describe dry socket: localized osteitis, alveolar osteitis (AO), fibrinolytic alveolitis, alveolitis sicca dolorosa, and localized osteomyelitis.4 Dry socket is dislodgment of clot with exposed intrasocket bone (denuded bone) as acute painful complication arising 72 hours postoperatively.5,6 Most of published data states that the incidence of dry socket is 1-5% for all routine dental extractions and up to 40% for impacted mandibular third molars.7-11 The incidence of dry socket is higher in the mandible than maxillae12, occurring up to 10 times more often for mandibular molars compared with maxillary molars because of dense bone.13 Clinically dry socket is characterized by severe throbbing pain, marked halitosis, foul odor, and greyish look.
Several theories have been documented on the etiology of dry socket including bacterial infection, trauma, and biochemical agents.9
According to one theory, there is increased fibrinolytic activity and activation of plasminogen to plasmin in the presence of tissue activators in dry sockets.14 This fibrinolytic activity is thought to affect the integrity of the post-extraction blood clot. 2 Microscopically, dry socket is characterized by the presence of inflammatory cellular infiltrate, with numerous phagocytes and giant cells in the remaining clot, associated with presence of bacteria and necrosis of the lamina dura.15
Birn reported that the inflammatory process can extend to the medullar spaces and sometimes the periosteum,
resulting in connective tissue inflammation of the contiguous mucosa, with microscopic features typically of osteomyelitis.16 Degradation of the blood clot in association with dissolution of erythrocytes and fibrinolysis, deposits of hemosiderin, and the absence of organized granulation tissue has been described in histopathologic investigation of dry socket.15
The treatment of Dry Socket depends on each professional’s clinical experience mainly due to its complex etiology, although many authors have published research on the management of dry socket. Therefore, the concept of management mainly depends upon diagnosis which is mostly conservative but confusion still exist among practitioners in approach to diagnosis and treatment.17 Ideally recommended treatment is to irrigate the socket to
debride and place ZOE / Alveogyl dressing for pain and inflammation.17
The objective of this study was to evaluate the knowledge of dry socket and its management among dental practitioners in Riyadh.
One hundred and twenty-nine (129) structured questionnaires were distributed consisting of fourteen questions among Dental Practitioners (DP) of Riyadh city. One hundred and one (n=101; 78%) GP responded about Knowledge of Dry Socket and its management. Only completely filled questionnaires were included in final analysis.
First part of questionnaires was related to features / diagnosis and second part was the management of Dry Socket.
Data was tabulated and statistical analysis was evaluated by SPSS version 22. Frequency and percentage was calculated for study variables.
One hundred and one (78%) out of 129 dental general practitioners responded the self-administrated questionnaire.
Among them, Ninety one (90.1%) were male and Ten (9.9%) were female dental practitioners. Ninety-four (93.1%) practitioners were graduates by qualification and Seven (6.9%) were postgraduates dentist. The survey for was divided into two part; knowledge of dry socket and its management.
Knowledge of Dry Socket
Table 1: Knowledge of dry socket among dental general practitioners Table 1 Shows the responses of study participants about the knowledge of dry socket among dental practitioners. In the results of this study, Seventy-Six (75.2%) practitioners agreed that dry socket is dislodgment of clot in socket, and on the other hand Twenty-one (20.8%) also agreed that dry socket could be due to contamination of socket. Moreover, thirtythree (32.7%) dental practitioners claimed that dry socket patients may have discomfort symptom. Most of the dentists (n=76, 75.2%) reported acute and stabbing pain as symptom of dry socket whereas Fourteen (13.9%) dentist responded dull, continuous pain.
Fifty-five (54.4%) reported pain was after of extraction 72 hours. Twenty-nine (28.7%) reported 24 hours, six (5.9%) reported immediately and Eleven (10.9%) dentists did not respond. Proportion t-test were significant. Analysis showed significant results.
Regarding complicating factor, sixty-nine (68.3%) dentists were of view that dry socket is mainly due to surgical procedure. A total of Ninety-four (93.1%) dental practitioners reported diagnosing dry socket on basis of clinical examination and symptoms whereas Four (4%) diagnosed on symptoms only.
Knowledge of Dry Socket management
Table 2: Concept of management of dry socket among dental general practitioners
Table 2 Depicts about knowledge of management of dry sockets. Seventy-nine (78.2%) dentists claimed that dry socket can be managed by saline irrigation (p 0.000) whereas Fifty-three (52.5%) agreed that dry socket could be treated by intra-socket sedative dressing (p 0.619), however most of practitioner favored irrigation as well as intra-socket sedative dressing (p 0.000). Eight (7.9%) dentists suggested to leave the wound as such for healing without any application and Thirty-six (35.6%) suggested antibiotic intake only to manage dry socket (p 0.004).
On the other hand, sixty-five (64.4%) were in the favor of curettage (p 0.003) and Six (5.9%) suggested to manipulate aggressively to use drill. Ninety-two (91.2%) dentists suggested that no surgery was needed to manage dry socket (p 0.000) and 62 (61.4%) dentists did not suggest antibiotic in the cases of dry socket (p 0.017).
Moreover, sixty-five (64.4%) dental practitioners suggested non-steroidal anti-inflammatory drugs to reduce pain and Twenty-three (22.8%) suggested paracetamol as painkiller.
In this study, Seventy Six (75.2%) practitioners agreed that dry socket is dislodgment of clot in socket, 21 (20.8%) also agreed that dry socket could be due to contamination of socket. Most of the dentists 76 (75.2%) documented acute and stabbing pain in dry socket whereas 14 (13.9%) dentist reported that patients with dry sockets experience pain. Overall, dentist knowledge about diagnosis of dry socket showed statistically significant results (< 0.000). On the other hand, 79% agree on saline irrigation and 53% of dentists rely on intra-socket sedative dressing. Interestingly, 92 (91.2%) dentists do not agree that surgery is required to manage dry socket which was significant (p 0.000). Dry socket may present as a challenge for the dentists and specialist alike.
The exact etiology and mechanism of dry socket are not known but several factors have been associated. Careful analysis into pathophysiology of dry socket stated that poor oral hygiene, vasoconstrictors and reduced blood supply are an important factors but reports have emphasized on trauma from difficult extractions causing fibrinolysis and release of pain inducing chemical substances.18 One recent study 19 emphasized need to educate patients properly for postextraction instructions and significant association of compliance with instructions and the reduced incidence of dry socket (p 0.015). A study conducted by Birn et al 20 with similar survey on the internship dentist’s knowledge
about dry socket documented results on the causes and reported that gender, oral contraceptives and antibiotics effect on dry socket.
In present study, seventy six percent reported dislodgment of clot with acute stabbing pain with-in 72 hours and sixty nine reported that dry socket is due to surgical procedure. These results show that the study respondents had adequate knowledge about dry socket. One recent similar survey21 in 2017 reported similar observations and concluded that the study participants had an adequate knowledge of diagnosis of dry socket with symptoms.
Studies have already documented that oral contraceptives were associated with a significant increase in the frequency of dry socket after extraction of mandibular third molars.
The probability of dry socket increases with the estrogen that has fibrinolytic action. Catellini JE et al22 in 1980 documented the risk of dry socket associated with oral contraceptives can be minimized by performing extractions during days 23 through 28 of the tablet cycle. Ogunlewe MO et al in 201023 concluded that females (63.2%) have more incidence of dry socket as compared to males, reasons may be hormonal coupled with use of contraceptives. In this study, we did not include questions on contraceptive therapy and therefore is a limitation of our study.
Many options of management discussed in literatures include curettage and irrigation, LLLT (low level laser therapy), irrigation and packing with zinc oxide eugenol / iodoform paste, alvogyl and plasma rich in growth factors in remission of pain and alveolar mucosa healing. 24 Few studies are published on different treatment options and preventive measures to control its occurrence. A systemic review study in 201525 illustrated that the dry socket is one of the most common post-extraction complications in dental practice. One study26 used 2% lidocaine jelly in a prospective double-blind study of 30 adult patients diagnosed with dry socket and found that the experimental group had significantly lower pain perception immediately and up to 60 min after irrigation than in those sockets that had been treated with placebo. No side effects due to topical lidocaine use were found. However, many other studies documented reduction of incidence of dry socket using pre-operative measures like chlorhexidine, antibiotic (local and systemic), metronidazole, smoking cessation and many other measures. 27-33
In this study, 53% believed on intra-socket dressing with sedative / pain killer without any surgical intervention. On the other hand, more than 90% practitioners did not agree on surgical approach and aggressive manipulation of socket but 64.4 % were in favor of curettage which is really a controversy and debatable issue. However, curettage is not recommended due to the induction of more pain. Curettage involves administration of anesthesia, surgical debridement of socket, and primary closure by advancement flap. Turner 9 stated that curettage and removal of granulation tissue resulted in fewer visits than zinc oxide eugenol or iodoform gauze with eugenol techniquesmoking cessation and many other measures. 17 However there is no granulation tissue in typical dry socket.
Controversy is still going on among some practitioner in this study regarding diagnosis and management. Recommendation is only to debride the socket with saline and pack with sedative dressing for 48 hours. Many textbooks explained dry socket and its treatment but Kruger34 reported that practitioners still rely on intra-socket curettage. There is a commercial dressing available (Alveogyl, Iodoform+Butylpara-minobanzoate) for dry socket
management, few fibers can be placed intra-socket after irrigation, without need for removal.35 Proper teaching of knowledge of this complication should be an important which sometimes comes across in routine dental practice. However careful in managment after proper diagnosis is very important clinically. In future, many other important aspects related to occurrence of dry socket can be considered.
The knowledge of Dry Socket and its diagnosis / treatment for general practitioners is an important; one should know baseline of dry socket to treat. However, certain aspects of diagnosis and management is misunderstood.
CONFLICT OF INTEREST
- Daly B, Sharif MO, Newton T, Jones K, Worthington HV. “Local interventions for the management of alveolar osteitis (dry socket)”. Cochrane Database of Systematic Reviews 2012. https://doi.org/10.1002/14651858.CD006968.pub2
- Soames JV; Southam JC. Oral pathology 4th ed. Oxford University Press. Oxford medical publication (1999) 296-98.
- Crawford JY. Dry socket after extraction. Dent Cosmos 1896; 38: 929-31.
- Awang MN. The aetiology of dry socket: a review. Int Dent J. 1989; 39:236-40.
- Colby RC. The general practitioner’s perspective of the etiology, prevention, and treatment of dry socket. Gen Dent 1997;461-67.
- Rood JP, Danford M. Metronidazole in the treatment of dry socket. Int J Oral Surg 1981; 10:345-47. https://doi.org/10.1016/S0300-9785(81)80032-4
- Rud J. Removal of impacted lower third molars with acute pericoronitis and necrotizing gingivitis. Br J Oral Surg 1970;7: 153-59. https://doi.org/10.1016/S0007-117X(69)80015-6
- 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: 309-17. https://doi.org/10.1054/ijom.2002.0263
- Turner PS. A clinical study of “dry socket.” Int J Oral Surg 1982; 11: 226-31. https://doi.org/10.1016/S0300-9785(82)80071-9
- 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 Oral Radiol Endod 1977; 44:14-20. https://doi.org/10.1016/0030-4220(77)90235-3
- Trieger N, Schlagel GD. Preventing dry socket: a simple procedure that works. J Am Dent Assoc 1991; 122:67-8. https://doi.org/10.14219/jada.archive.1991.0067
- Khawaja NA. Incidence of dry socket in Lower Jaw. Pak Oral Dent J 2006; 26: 227-30
- Al-Khateeb TI, EL-Marsafi AI, Butler NP. The relationship between the indications for the surgical removal of impacted third molars and the incidence of alveolar osteitis. Oral Maxillofac Surg 1991; 49: 141- 45. https://doi.org/10.1016/0278-2391(91)90100-Z
- Birn H. Etiology and pathogenesis in fibrinolytic alveolitis (dry socket). Int J Oral Surg 1973; 2: 211-63. https://doi.org/10.1016/S0300-9785(73)80045-6
- Birn H. Bacteria and fibrinolytic activity in dry socket. Acta Odontol Scand 1970; 28: 773-83. https://doi.org/10.3109/00016357009028246
- Amler MH. Pathogenesis of disturbed extraction wounds. J Oral Surg 1973; 31: 666
- Karnure M. Review on conventional and novel techniques for treatment of alveolar osteitis. Asian J Pharm Clin Res 2013;6 Suppl 3:13-7
- Houston JP, McCollum J, Pietz D, Schneck D. Alveolar osteitis: a review of its etiology, prevention, and treatment modalities. Gen Dent 2002; 50: 457-63.
- Akpata O, Omoregie OF, Owotade F. Alveolitis Osteitis: Patients compliance to post-extraction instructions following extraction of molar teeth. Niger Med J 2013; 54:335-38 https://doi.org/10.4103/0300-1652.122360
- Doumani M, Habib A, Doumani A et al. The intership dentist’s knowledge about dry socket. Int J Recent Scientific Res 2017; 8: 19941-3.
- Santhosh Kumar MP. Knowledge about post extraction complications among undergraduate dental students. J Pharm Sci Res 2016; 8: 470-76.
- Catellani JE, Harvey S, Erickson SH, Cherkin D. Effect of oral contraceptive cycle on dry socket (localized alveolar osteitis). J Am Dent Assoc. 1980; 101: 777-80 https://doi.org/10.14219/jada.archive.1980.0420
- Ogunlewe MO, Adeyemo WL, Ladeinde AL, Taiwo OA. Incidence and pattern of presentation of dry socket following non-surgical tooth extraction. Nig Q J Hosp Med 2007: 17: 126-30 https://doi.org/10.4314/nqjhm.v17i4.12691
- Maria Teberner-vallverdu, Mariam Nazir, Maria Angles SanchezGarces, Cosme Gat-Escode. Efficacy of different methods used for dry socket management: A systematic review. Med Oral Patol Oral Cir Bucal. 2015; 20: https://doi.org/10.4317/medoral.20589
- Tarakji B, Saleh LA, Umair A, Azzeghaiby SN, Hanouneh S. Systemic review of dry socket: etiology, treatment, and prevention. J Clin Daign Res 2015; 8: ZE10-13 https://doi.org/10.7860/JCDR/2015/12422.5840
- Betts NJ, Makowski G, Shen YH, Hersh EV. Evaluation of topical viscous 2% lidocaine jelly as an adjunct during the management of alveolar osteitis. J Oral Maxillofac Surg 1995; 53: 1140-44. https://doi.org/10.1016/0278-2391(95)90619-3
- Hermesch CB, Milton TJ, Biesbrock AR. Perioperative use of 0.12% chlorexidine gluconate for the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85: 381- 87. https://doi.org/10.1016/S1079-2104(98)90061-0
- Tjernberg A. Influence of oral hygiene measures on the development of alveolitis sicca dolorosa after surgical removal of mandibular third molars. Int J Oral Surg 1979; 8: 430-44. https://doi.org/10.1016/S0300-9785(79)80081-2
- Rood JP, Murgatroyd J. Metronidazole in the prevention of “Dry socket.” Br J Oral Maxillofac Surg 1979; 17: 62-70. https://doi.org/10.1016/0007-117X(79)90009-X
- Cardoso CL, Rodrigues MTV, Junior OF, Garlet GP, Carvalbo PS. Clinical Concepts of Dry Socket. J Oral Maxillofac Surg 2010; 68:1922-1932 https://doi.org/10.1016/j.joms.2009.09.085
- Bystedt H, Nord CE, Nordenram A. Effect of azidocillin, erythromycin, clindamycin and doxycyline on postoperative complications after surgical removal of impacted mandibular third molars. Int J Oral Surg 1980; 9: 157-65. https://doi.org/10.1016/S0300-9785(80)80014-7
- Laird WR, Stenhouse D, MacFarlane TW. Control of postoperative infection. A comparative evaluation of clindamycin and phenoxymethylpenicillin. Br Dent J 1972; 133: 106-09. https://doi.org/10.1038/sj.bdj.4802883
- Larsen PE. The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted third molars. J Oral Maxillofac Surg 1991; 49: 932-37. https://doi.org/10.1016/0278-2391(91)90055-Q
- Kruger Gustav O. Textbook of Oral & Maxillofacial Surgery. 6th Ed 1984. Saint louis; ISBN-13: 980801627934, Mosby
- Akinbami BO, Godspower T. Dry socket, clinical features, and predisposing factors. Int J Dent 2014: 2014: 796102 https://doi.org/10.1155/2014/796102
- Faculty, Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, KSU, Riyadh. Former Assistant Professor, HoD, Oral Path, Oral & Maxillofacial Surgery Department, Dental Section, NMC, Multan.
- Lecturer, Dental Health Department, College of Applied Medical Sciences, College of Dentistry, King Saud University, Riyadh.
- Intern; College of Dentistry, King Saud University, Riyadh.
- Intern; College of Dentistry, King Saud University, Riyadh.
Corresponding author: “Dr. Naveed A. Khawaja” < firstname.lastname@example.org >