dry sockets and bisphosphonates Flashcards
What happens in the first week of socket healing?
Blood clot form WBCs Vasodilation Fibroblasts and capillaries infuse Early bone resorption Epithelia proliferates on top of socket
What happens in the second week of socket healing?
Epithelial continuity will be achieved
Bone resorption
Osteoid formation
Maturing granulation tissue
What happens from the 4th week to the 6-12th month in socket healing?
New bone formation
What is a dry socket?
Aka alveolar osteitis, fibrinolytic alveolitis
Early disruption of healing process due to blood clot being lost
Local inflam of bone limited to socket wall
Symptoms- severe pain, resistant to simple analgesics, foul taste and smell, localised inflam and tenderness, partial/total loss of blood clot
What isn’t a dry socket?
Septic socket- infection of socket
Osteomyelitis- infection inv. cancellous bone (marrow)
Osteonecrosis- death of portion of jaw bone
Why might a dry socket form? (Aetiology)
Failure of clot to form- poor blood supply, smoking, sclerotic bone
Clot degradation- fibrinolytic due to oestrogen, trauma, bacterial pyrogens
Clot loss- excessive mouth wash
Bacterial colonisation- further breakdown of clot
What is the incidence of dry socket?
Depends on tooth
Average- 0.5-5%
Lower wisdom tooth- 25% (lower jaw denser than upper jaw, more traumatic extraction)
What are patient risk factors for dry socket?
Female Oestrogen and menstruation Smoker Failure to comply w POI Age (older- poor blood supply) Poor healing
What are technical risk factors for dry socket?
Posterior Mandible Pre existing infection/pericoronitis Traumatic extraction Surgeon experience Inappropriate irrigation LA load (vasoconstrictor)
Why might poor healing occur?
Smoking Steroid therapy Immunosuppression/therapy Poorly controlled diabetes Bone pathology Poor hygiene Previous radiotherapy
How are dry sockets managed?
Preventative-
~post op mouthwash
~avoid smoking
~pre-emptive Alvogyl
Therapeutic- ~irrigate ~dress (Alvogyl) ~analgesia ~smoking cessation ~gentle mouth bathing
What is Alvogyl?
Butamben (LA)
Iodoform (antiseptic)
Euganol (analgesic)
Derived from fern fibres (trichomes) taken from rhizomes
What is a septic socket?
Dry socket + infection
Symptoms- swelling, lymphadenopathy, pus formation
Manage as dry socket +/antibiotics (metronidazole)
How can septic socket be prevented?
POI
Antibiotics prophylactically for compromised patients or history of septic socket
Antibiotics if surgical site is infected at time of surgery
How might you consider delayed healing affecting a socket?
Granulation tissue in socket
Most consider other diagnoses- retained root/bony sequestrum/OSCC
Treatment- curettage +/ dressing
What is osteomyelitis?
Infection into cancellous part of bone
Rare following extraction
Symptoms- pain, altered sensation, pus, sinus formation
Manage- antibiotics and debridement
Acute vs Chronic (4+ weeks)
What does osteomyelitis look like histologically?
Necrotic bone- loss of osteocytes from lacunae
Leukocytic infiltration in marrow spaces
Scalloping of bone
What is the microbiology of osteomyelitis?
Polymicrobial ~bacteriodes ~porphyromonas ~prevotella ~staphylococci (esp if pathological fracture due to link w oral cavity)
What is osteoradionecrosis?
Patient exposed to radiotherapy
Endarteritis obliterans (arteries flaring up in bone)- bone cells damaged and has poor blood supply
Mandible more predisposed as denser and has poor blood supply anyways
Exposure of 65 Grays is threshold
How can osteoradionecrosis be managed?
Prevention better than cure
Remove doubtful teeth before radiotherapy
Good oral health + fluoride
Antibiotics and careful surgery
Depends on severity
Hyperbaric O2, debridement
Cut back bone to bleeding state- shows blood supply
What is MRONJ?
Medication related osteonecrosis of the jaws
Due to bisphosphonates and other drugs (monoclonal antibodies eg. Denosumab OR tyrosine kinase inhibitors eg. Sunitinib)
Exposed bone >8 weeks
No history of radiotherapy
Patient on drug linked to MRONJ
What are bisphosphonates?
Risedronate
Alendronate
Etidronate
-given daily or weekly orally
Pamidronate
Zoledronatd
-intravenously for more severe things like metastatic cancer
Bisphosphonates given to reduce bone turnover through effects on osteoclasts
Beneficial for-
~osteoporosis (deposition
How do bisphosphonates work?
2 PO3 groups
Linked by central carbon
2 side chains (R groups)
Phosphonate groups bind to Ca on surface of bone which exposes R group
Types of R groups-
1. Nitrogenous- prevents formation of proteins needed to maintain osteoclast cytoskeleton (reduces folding in ruffle border)
- Non- nitrogenous- compete w ATP leading to osteoclast apoptosis
What are the main clinical scenarios for bisphosphonates?
Metastatic breast cancer
~high dose, intravenous
~10% risk of MRONJ over 3 years
Osteoporosis
~low dose
~1/100000 a year
~1/1000 following extraction
What are the treatment strategies of MRONJ?
At risk- no treatment indicated, pt. education
Stage 0- pain meds, treat other dental problems, monitor
Stage 1- antibacterial mouthwash, education, review needed for BP, monitor
Stage 2- antibacterial mouthwash, antibiotics, pain control, debridement of necrotic bone
Stage 3- above + surgical debridement and resection
What are the stages of MRONJ?
Stage 0- non specific, pain, radiographic changes, no exposed bone
Stage 1- exposed/necrotic bone, no symptoms or infection
Stage 2- exposed necrotic bone, pain, infection +/ pus
Stage 3- above + extends beyond alveolus, EO features, fracture,
Why does MRONJ occur?
Anti-angiogenesis- compromised blood supply
Toxicity to overlying soft tissues- inability to heal over exposed bone
Direct toxicity to cells within bone- necrosis
How can MRONJ be prevented?
Avoid extractions w patients on those meds
For oral bisphosphonates- chlorhexidine mouthwash 1 week pre and post op, no benefits to antibiotics
Stop bisphosphonate?- however drug holiday needs to be 3 months
Piecemeal extractions- reduce mucoperiosteal stripping
CTX not used
What is someone has high dose IV bisphosphonates?
High risk
Antibiotic prophylaxis- low evidence
However lower stage of MRONJ
~American dental association (2 days before and 14 days after)
~BDJ- penicillin V 500mg QDS, 1 hr preop, 5 days post op
How can MRONJ be managed?
Surgery response is poor
Analgesia, chlorhexidine mouthwash, antibiotics if pus, limited debdridement, monitor
Consider withdrawal of bisphosphonates
How can MRONJ be prevented?
Pre treatment dental assessment Ensure good oral health Minimal surgical intervention Review post extraction to assess healing Consent Refer to specialist care if MRONJ develops or high risk patient
What medications might predispose to dry socket?
Steroids Immunosuppressants such as cyclosporins or methotrexate Oestrogen sources Bisphosphonates Vasoconstrictor in LA
What factors (not meds) predispose to dry socket?
Smoking Medical history, eg Paget’s disease, osteopetrosis Site of tooth extraction History of traumatic extraction Inexperienced surgeon Excessive mouth rinsing Non compliance to POI
What treatments can be given for dry socket?
Irrigate w chlorhexidine
Dress w Alvogyl
Provide analgesics
Repeat POI inc. no smoking
What are differential diagnoses to dry socket and how would you rule them out?
Septic socket- full exam, presence of pus, systemic signs of infection, lymphadenopathy
Retained root- radiograph
MRONJ- med history, review healing until 8 weeks
ORNJ- history of radiotherapy
