The Survey of the Knowledge of Dry Socket and Management Among Dental Practitioners; Still Controversy?

Naveed Khawaja           BDS, MCPS, DOMS, MSc-OPath (UK), FADI

Kauser Parveen            BDS, MCPS

Abdullah Almotreb       BDS

Rashed Tashkandi        BDS

INTRODUCTION

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.

METHODOLOGY

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.

RESULTS

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.

DISCUSSION

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.

CONCLUSION

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

None declared

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1. 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.
2. Lecturer, Dental Health Department, College of Applied Medical Sciences, College of Dentistry, King Saud University, Riyadh.
3. Intern; College of Dentistry, King Saud University, Riyadh.
4. Intern; College of Dentistry, King Saud University, Riyadh.
   Corresponding author: “Dr. Naveed A. Khawaja” < nakhawaja@yahoo.com >