c 1.1: EXTRACTION OF TEETH & RETAINED ROOTS/PATHOLOGY AND MANAGEMENT OF ASSOCIATED COMPLICATIONS INCLUDING ORO-ANTRAL FISTULA

Question 1

What is the incidence of dry socket (alveolar osteitis) in extraction of mandibular third molars?
Explain

Answer 1

1-37%. Wide variation in reported incidence due to differences in definitions and inclusion and exclusion criteria of the studies

Question 2

What are the factors involved in the formation of a dry socket and the risk factors for formation? x 12

Answer 2

Flap design and extent
Surgical trauma
Experience of surgeon
Mandibular tooth
Perioperative patient stress factors
Fibrinolytic activity
Hormonal changes
Previous experience of dry socket
Smoking
Infection around tooth
Inadequate OH
Forceful removal of clot by spitting/sucking straw/coughing/sneezing  (limited evidence)
Bacterial breakdown and fibrinolysis contributor - no unequivocal evidence

Question 3

Symptoms of dry socket x 7

Answer 3

Continuous, severe, throbbing pain, may not be relieved by analgesics
Radiates to the ear, temple, neck.
Starts 3-5 days post-extraction
Foul taste 
Bad breath
Localised swelling and lymphadenopathy
Symptoms can persist for 10 days

Question 4

Prevention of dry socket x 3

Answer 4

Systemic antibiotics (in patients with history of multiple dry sockets or immunocomprimise - but not generally advocated)
Chlorhexidine mouthrinse pre-operative (high NNT numbers and risk of adverse reaction to chlorhexidine)

Topical mendicants to the socket - PRP, Clot stablisers (gelfoam), antibiotic gels - reported but varying results from evidence

Question 5

Aetiology of alveolar osteitis

Answer 5

Loss, malformation, disruption of the newly formed blood clot from extraction socket

Question 6

Management of dry socket x 4

Answer 6

Consider radiograph to rule out retained root fragments/alveolar fracture
Gentle irrigation of wound area with saline
Medicated dressing - eugenol
Oral analgesics

Question 7

Mandibular fracture and third molar removal
Incidence
Associated factors

Answer 7

0.0033%-0.0049%
More impacted - higher risk, but no specific evidence to link a particular type of impaction with increased risk of fracture.
Fracture most common in 2-3week post-operative period - fits with bony remodelling and osteoclastic activity