Clinical + Histological aspects of socket healing

Question 1

What leads to platelet activation after an extraction?

Answer 1

Exposure of platelets to collagen

Question 2

What do platelets release to promote the aggregation of more platelets?

Answer 2

Stored granules

Question 3

How long do we expect before a patient begins to clot?

Answer 3

5-10 mins

Question 4

What are the stages that occur during clot formation?

Answer 4

1 - Fibrinogen converted to fibrin

• Fibrin mesh formed
• Mesh traps more platelets
• Clot formation

Question 5

Histologically, what do we see on the clot periphery?

Answer 5

Loose aggregate of erythrocytes

Question 6

Why is the blood clot vulnerable to detachment in the initial stages?

Answer 6

There is weak adherence of the clot to the PDL.

Question 7

How do we encourage clot formation to prevent reactionary haemorrhage?

Answer 7

Placement of cellulose matrix, placing sutures, tranexamic acid on a gauze.

Question 8

How many days after extraction does the blood clot begin to breakdown?

Answer 8

2 days

Question 9

What enzyme breaks down the fibrin blood clot?

Answer 9

Plasmin

Question 10

How does transexamic acid work?

Answer 10

By preventing the activation of plasminogen to plasmin to prevent clot degradation.

Question 11

What 4 steps do we need to take after an extraction to optimise healing?

Answer 11

1) Check the whole tooth has been removed, flush socket and remove roots
2) Remove apical pathology such as cysts.
3) Curettage and saline flush to remove any debris
4) Pack socket with a haemostatic agent and place a suture.

Question 12

What is dry socket and when does it occur?

Answer 12

Dislodging of the blood clot leading to throbbing radiating pain 2-3 days after removal.

Can occur is the blood clot gets knocked out the socket or if there is early and excessive fibrinolysis.

Question 13

What increases the chances of getting a dry socket?

Answer 13

• Female
• Mandibular tooth
• Excessive rinsing
• Smoking
• Single extractions

Question 14

How do we manage patient with dry socket?

Answer 14

• Reassure them
• Flush socket out, place a dressing
• Pain control
• No antibiotics given

Question 15

What is the name of a common dressing used for dry socket?

Answer 15

Alvogyl

Question 16

How can dry socket be prevented?

Answer 16

• Good post-operative instructions
• Minimally invasive surgery
• Transexamic acid
• Primary closure of socket

Question 17

What do we expect 4 days post-extraction?

Answer 17

• Formation of granulation tissue
• Stable clot
• Reduced risk of dry socket
• Debris above clot
• Epithelium at gingival margin beginning to grow over socket base

Question 18

What do we expect to see 8 days after extraction?

Answer 18

• Socket filled with granulation tissue with superficial inflammatory cell layer

Question 19

What can lead to secondary haemorrhage and how do we manage it?

Answer 19

• Due to secondary infection of socket
• Due to increases inflammation and vascularity in region
• Due to small vessels that have eroded and resulted in bleeding
• Due to a sudden rise in INR
• Trauma leading to clot dislodgement

Management:

• Give LA
• Curettage, flush out socket, bite on gauze
• Consider antibiotics if area in infected

Question 20

What occurs during late healing (18 days)?

Answer 20

• Socket is filled with granulation tissue
• Woven bone begins to fill socket
• Epithelization of socket surface is complete

Question 21

What is the main difference between woven and lamellae bone?

Answer 21

Lamellae bone is more dense.

Question 22

Name some local and patient factors that can affect wound healing?

Answer 22

Local:

• Difficulty of extraction
• Mandibular tooth
• If the tooth was infected
• Associated pathology such as tumours
• Post operative dry socket

Patient:

• Smoking
• Alcohol
• Immunocompromised
• Age
• Oral hygiene maintenance
• Bisphosphonate treatment
• Radiotherapy