Socket Healing and Dry Socket

Question 1

What are the stages of healing of an extraction socket?

Answer 1

1. Initial blood clot
   - Activated platelets trigger clot which then retracts (in 4 hours completely retracted)
   - After retraction, clot continues to stabilise by fibrin cross linking
2. Lysis of clot
   - After 2 days
   - Plasmin (fibrinolytic enzyme)
   - Fibrinolysis has started but clot not well anchored to wall increasing the risk of dry socket
3. Stable blood clot
   - 4 Days
   - Capillaries and fibroblasts (granulation tissue) grow into clot from periphery so it is now firmly fixed to socket wall
   - Macrophages grow into clot breaking it down for replacement by granulation tissue
   - Epithelium at gingival margin undergoes hyperplasia and starts growing over clot below surface debris
4. Granulation tissue
   - 8 Days
   - Socket filled with granulation tissue and superficial layers contain inflammatory cells (little collagen)
   - Lamina dura intact and PDL no longer identifiable
5. Woven bone
   - 18 Days the socket filled by granulation tissue and fibroblasts laid down collagen network
   - Lamina dura still visible and woven bone forming around periphery of the socket
6. Lamellar bone
   - 6 weeks, woven bone filled socket and remodelling to lamellar bone
   - Lamina dura persists depending on bone turnover rate

Question 2

How does the rate of ridge resorption vary with time

Answer 2

• Mostly in first 6 months - all height and 2/3rd of width lost
• Slows to minimal rate at 1 year
• Increases with inflammation and periostea elevation
• More on aspect with thinner bone

Question 3

What is dry socket?

Answer 3

• Loss of clot normally filling extraction socket leading to empty socket and bacterial colonisation of exposed bone
• Most frequent painful complication of extractions
• Can progress to osteomyelitis (rarely)
• Alveolar osteitis means inflamed bone not infection

Question 4

What are the predisposing factors to dry socket?

Answer 4

• Pts aged 20-40
• Female
• Difficult/traumatic procedure
• Mandibular tooth extractions
• Single xla (limited local blood supply)
• Smoker
• Oral contraceptives (oestrogen enhances fibrinolytic activity)
• Gingival infection (AUG, pericoronitis, abscess)
• Osteosclerotic disease (Paget’s, cemento-osseous dysplasia)
• Radiotherapy

Question 5

Signs and symptoms of dry socket

Answer 5

Signs

• Empty socket (whiteish, dead bone can be seen/felt with probe) or full of debris
• Mucosa around socket red and tender
• Probing is painful
• Sometimes socket concealed by granulations growing from gingival margins

Symptoms

• Pain usually starts 3-4 days after xla and will continue for a week or two
• Deep-seated severe aching/throbbing pain
• Halitosis
• Lack of lymphadenopathy and lack of local inflammation

Question 6

How do you diagnose dry socket

Answer 6

• No x-rays: no useful purpose except to exclude retention of a root fragment
• Differential:
  Retained root/sequestration of socket wall
  Non-healing socket
  Recurrent dry socket ± intermittent IAN neuropathy
  Osteomyelitis

Question 7

What is the pathology of dry socket

Answer 7

1. Breakdown of clot
   - Excessive local fibrinolytic action
   - Bacterial enzymes break down clot by activating fibrinolysis
   - Traumatic xla can lead to impaired vascular penetration resulting in activating fibrinolysis through inflammation and providing space for bacterial accumulation
2. No clot forms
   - As a result of traumatic extraction (necrotic bone = avascular = no cells for clot)
3. Physical dislodgement of clot

Question 8

How do you prevent dry socket

Answer 8

1. Pre-op infection control
   - Scaling teeth before
   - CHX rinsing pre-op and for 3 days pre-op
2. Atraumatic extraction
3. Adherence to post-op instructions
   - No rinsing
   - Not hot fluids
   - No smoking
4. Post-op antibiotics only for those with particular risk
   - pts who have irradiation for oral cancer, sclerotic bone disease
   - Primarily to prevent osteomyelitis rather than dry socket
   - Generally not given

Question 9

What is the treatment of dry socket

Answer 9

1. Explain to pts that they may have a week or more of discomfort. Inform pain is not due to broken tooth
2. Analgesics to control symptoms until healing is complete, usually after 10 days
3. Keep socket clean and protect from excessive bacterial contamination
   - Irrigate with saline to remove debris
   - Do not use CHX - CHX allergy in this situation can be fatal
4. Place dressing into socket to deliver analgesia and close the opening so further food debris cannot enter