alveolar osteitis or dry socket is a
severe pain that occurs in patients
after the extraction of a tooth
now it's gonna happen to you eventually
if you're taking teeth out so you need
to know how to manage it and in this
video I'm going to show you my protocol
for managing a dry socket in my office
we're also gonna look at the causes of
dry socket the diagnosis of a dry socket
and the course of treatment so basically
how long this lasts and basically when
it's going to resolve so first off how
do we diagnose a dry socket
well a dry socket is usually diagnosed
when a patient presents to you and they
tell you they are having severe pain
you've just taken a tooth out maybe
three or four days ago that's the
typical onset of the symptoms and they
might even say to you you know what doc
you took that tooth out and everything
was great
came out nice and went home things felt
good and I woke up this morning though
and man is it sore and it's now like I
said three or four days later so they're
taking advil they're taking Tylenol
nothing is touching the pain they have a
pulsatile throbbing pain that is often
radiating over to the ear or up to the
eye depending where that socket is and
they may have a foul taste or a foul
odor that is emanating from that socket
when you look down in there and you see
where that tooth was you're gonna see a
empty socket injury socket and it is
gonna be yellowish grey tissue just a
necrotic tissue and food debris that's
in there it does not look healthy and
around the edges of there you're gonna
see some red inflamed angry tissue it's
not unusual for the lymph nodes to be a
little bit swollen under the jaw or down
the neck of the affected side but the
patient won't be presenting with any
fever or any signs of infection finally
when you irrigate these things typically
they can be a little bit touchy so make
sure that you let the patient know
that's a possibility beforehand and if
you do irrigate it and it gets to be a
little bit sensitive then that is a gain
some confirmation that what you're
dealing with was in fact a dry socket so
how do I deal with this in my office
well the first thing I do is have a
discussion with this patient about
whether or not this
is infection because usually that is
their main concern so the first thing I
do is I lay their fears that this is
indeed not an infection but a very
common thing called dry socket it
presents three to four days later it's
the throbbing pain we go through all the
symptoms and I tell them what we're
gonna do to treat them and when it's
gonna get better
so the treatment that we do for them is
we will irrigate the site so basically
let's say that we took out a lower
second molar and this is where the pain
is now coming from so we're gonna take
our mono jack syringe and in it we have
prepared a 3% peroxide solution at about
20 to 25% of the mixture and 0.12%
chlorhexidine in the remaining 75% we
are going to irrigate and flush down in
that socket with this solution and
what's going to happen is that peroxide
is going to contact the tissues and it's
gonna bubble up oxygenating the area and
lifting out any debris from in that
socket now before we continue I have to
say it's a 3% peroxide and peroxide
itself is not great for osteoblasts so
understand that osteoblast proliferation
is inhibited by peroxide so you do not
want to be using pure peroxide in there
and in fact it's not even ideal to be
using very much of it at all so we want
to be diluting it with our chlorhexidine
which we're doing but we still want to
get that bubbling property and the
oxygenation from there to try to clear
that out and clean things up a little
bit which is why we still use it now if
you're not comfortable with that and
you'd rather just use a sterile saline
that's just fine you may not get all
that debris out quite as easily but it's
a suitable alternative if you're more
comfortable using it now the next thing
that we'll do is we'll suction back
there a bit to kind of dry it up a bit
and then I'm going to use this
Alvia Jill now al via Jill is a nice
dressing material maybe not available to
everyone but it's something that will
last for maybe one to two days giving
that patient almost complete pain relief
and it works literally within minutes
we're going to talk about it in another
video when we take that out and we place
it into that site what we're then going
to do is we're going to use this
instrument here called a gauze Packer so
this is a nice tool that you can use has
these little teeth on the end
and whether you're using Alvia Jill or
you're using say gel foam with a paste
or some other dressing it is a nice way
to basically get that packed slightly
down into the socket now it'll be a
little bit tender down in there for the
patient and you don't want to be packing
it in with force you just want to make
sure that it's in there enough that it's
not going to come out once I get the
Elvia gel in there for the patient I
usually will take a gauze and what I
will do is I will just fold it up and
place it over that area and they will
close gently on this just to soak up
some of the taste coming out of there
that may be leaking out in the fluid
from that Elvia Jill how long is this
going to last so the pain that the
patient's having may last them anywhere
from about four to eight days so the
total time for that socket to granulate
which basically means instead of forming
from that blood clot it has to grow over
the edges and down into the socket
it is gonna take around 7 to 10 days so
it's possible your patient may have pain
for 8 days will it be the severity that
it was at day 3 or 4 absolutely not it's
gonna be improving each time so if you
are choosing to put something in that
socket understand that and explain this
to your patient that it is a foreign
body so when you put something in that
socket you are maybe making it feel
better but you're causing a protracted
period of healing so when you tell your
patient that I find that it will have
them come back less frequently to have
it repacked because usually down the
road once you've done it once or twice
they can deal with a little bit of pain
that's left and manage it with ibuprofen
versus coming to see me this is always a
self-limiting condition so even if we
left it alone and we did absolutely
nothing you could explain that to your
patient as a treatment option it will
get better on its own in that timeframe
that we mention now why do dry sockets
happen Oh a dry socket is caused
basically by a loss of the blood clot so
the blood clot comes out or it either
dissolves or breaks down in those first
few days now some causes of this could
be estrogen that causes fibrinolytic
activity so if you have someone on a
oral contraceptive so young teenage
girls or you know middle-aged girl
adults are going to be taking this
medication that may be causing these
clots not to form properly or to break
down smoking is something that's been
implicated but it's usually if you're
doing maybe half a pack a day or more so
half a pack a day increases your risk
almost fourfold for a dry socket
according to what it says in the
literature some of the theories behind
smoking in general causing dry socket
are may be weak but they think that the
nicotine could be vasoconstricting some
of the vessels around the area causing
it to heal poorly and causing that clot
to break down you could also have
someone who goes home and this happens a
lot they go home and they rinse and
rinse and rinse and they poke in there
and even though you told them don't do
that they present you a few days later
in pain and they tell you I did
everything I should have I went home and
I rinsed right away with salt water and
I brushed really good back there and you
know they tell you everything that you
told them not to do but maybe they
didn't really retain it when you told
them straws are something that have been
implicated in causing dry sockets due to
the suction from the straw pulling they
sought the clot out of the socket now
this is kind of a myth because when you
swallow you're actually generating just
as much force or more than you would be
with a straw so this is probably not a
valid thing you could still tell your
patients to avoid them just to be safe
but if you are doing it it may not be
necessary there's also a theory out
there about too much force being applied
to a tooth to remove it which then
traumatizes the bone around the tooth
socket and that leads to the destruction
of the clot and the release of kinds
which caused pain now I could see
anecdotally this seems to be the case
for me when I've had extractions where I
get the tooth out nothing breaks
nothing's difficult about it other than
I have to apply more force than I
normally would on the forcep or on the
elevator to get that tooth out those
patients can come back with more pain
than normal and often times have
developed a dry socket
[Music]