Indian Indian J Stomatol J Stomatol 2012;3(3):153-55.

2010;1(1):1-5

Role of Mercurochrome and Chloromycetin in the Management of Dry Socket: A Clinical Study With a New Approach
Ashok Bansal , Shivani Jain , Srimathy Arora , Shipra Gupta
1 1 1 2

Abstract Alveolar osteitis (dry socket) is a common and painful complication after tooth extraction. The incidence of dry socket ranges from 3% to 20% with a higher frequency after the extraction of mandibular posterior teeth. Although the etiology of dry socket is debated, it is probably multifactorial, and its pathogenesis remains unknown. There are various well-established preventive measures against dry socket. Despite the number of remedies available for dry socket, we have tried a new combination of drugs ie., Mercurochrome and Chloromycetin, which yields effective results in the management of dry socket. Keywords: Dry socket; Chloromycetin; Mercurochrome; alveolar osteitis; extraction. Introduction Alveolar osteitis (dry socket) is a painful complication after tooth extraction mainly traumatic, which affects millions of patients around the world. Dry socket has been used in the literature since 1896, when it was first described by Crawford.1 This painful condition can be avoided in a majority of cases by proper understanding. It will save unnecessary agony to patients and loss of countless hours of dentist's practice in dealing with it. Dry socket is an acute, non-suppurative inflammatory process localized in the dental alveolus and is characterized by late onset (2-4 days post extraction), severe and radiating pain, absence of typical inflammatory signs, unpleasant taste, fetid odour, empty socket, gingival inflammation, regional lymphadenopathy and sensitivity of intake of food or drinks.2 The pain increases on mastication and interferes with the normal activity of the patient. The main characteristic of the dry socket is the denuded appearance of the socket due to disintegration of blood clot leaving behind a gray or grayish yellow bony socket bare of granulation tissue. The diagnosis is confirmed by gently passing a small probe into the extraction wound; in the alveolar osteitis bare bone is encountered, which is extremely sensitive. The pain is caused by the thermal and chemical irritation of the exposed terminal nerve endings in lamina dura lining the alveolar socket and in the remnants of periodontal ligament to air, food and liquids that enters the mouth. It is also named as focal osteomyelitis, alveolar osteitis, alveolitis sicca dolorosa and fibrinolytic alveolitis.3 In spite of the best care taken and aseptic technique used during extraction of a tooth, the incidence of dry socket formation varies from 0% to more than 30%.4 It occurs more frequently in mandibular molars particularly third molars with an incidence of 20% to 30% and is more with single tooth extraction as compared to multiple tooth extractions.5,6 Pathogenesis The pathogenicity of dry socket formation is not yet fully established, but it may be produced by a combination of several following predisposing factors: 1. Use of excessive amount of adrenaline containing local anaesthetic which reduces the blood supply to the area. 2. Excessive irrigation and curettage of socket during extraction.3,8 3. Presence of root and/or bone fragment, foreign body like calculus in the socket.3 4. Excessive spitting, rinsing and sucking of wound foll3 owing extraction. 5. Poor oral hygiene, smoking, sneezing predispose to the formation of dry socket as it can impede healing of wounds, possibly due to the decreased amount of oxygen available in the healing tissues.9 6. Insufficient blood supply of the bone particularly in aged patients because of sclerosis of bone and other debilitating diseases like diabetes, anemia etc.3,9 7. The female patients on oral contraceptives are at higher risk of developing dry socket as estrogen slows down the healing process.9 8. Fibrinolytic and proteolytic activity in the blood clot because of infection due to anaerobic micro-organisms especially Treponema denticola , an anaerobic spirochete with lytic capacity followed by Fusiform bacilli and Streptococci appear to have a role in the onset of dry socket.2,6 9. Pre-existing infection like periapical infection, periodontitis and pericoronitis.3 10. Poor sterilization of the instruments, septic surgical procedure and excessive instrumentation during extraction.10 By avoiding all possible adverse factors, risk of dry socket formation can be reduced. There are various wellestablished preventive measures like meticulous approach to the extraction along with atraumatic extraction and aspectic procedures, providing antibiotics, anti-fibrinolytics and physical methods that promote or accelerate alveolar reconstruction such as use of soft laser.11,14 Various treatments like prescribing analgesics and antibiotics, mouth rinses with tetracycline solution, packing of obtundent dressing like zinc oxide eugenol, topical anaesthetic like benzocaine, following local irrigation of the socket with warm sterile isotonic saline solution or a dilute hydrogen peroxide solution to remove necrotic materials and other debris have been recommended from time to time. Mercurochrome, Covamycin D, corticosteroids and
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1 Department of Oral and Maxillofacial Surgery, Swami Devi Dyal Hospital and Dental College, Haryana, 2Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Chandigarh, India. Correspondence: Dr. Shipra Gupta, email: teena1472@yahoo.in

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Indian J Stomatol 2012;3(3):153-55. non steroidal anti-inflammatory medication for the management of pain and inflammation after third molar surgery have also been tried.15-17 Curettage of the socket not only predisposes the patient to the spread of infection but also destroys any previous attempt at normal healing.18-21 In the present study we have evaluated the combined use of Mercurochrome and Chloromycetin. The study is aimed to evaluate their role in the treatment of dry socket for immediate relief of pain. Materials and method A prospective clinical trial on 50 patients with a history of dry socket was conducted over a period of 6 months irrespective of age, sex, race in the Department of Oral and Maxillofacial Surgery at Swami Devi Dyal Dental College and Hospital, Barwala. The patients with the history of allergy to some antibiotics or local anesthesia, those receiving treatment for hepatic or renal insufficiency, immunodeficiency, blood dyscrasia, pregnant and even breast feeding patients were excluded from the study. The patients reported with the history of dry socket with major complaint of severe radiating pain 2-3 days after the extraction; we decided to apply a combination pack of Mercurochrome and Chloromycetin in the empty socket for immediate pain relief. Random blood samples of the treated patients were taken to know the effect of topical Chloromycetin on blood cell count. Mercurochrome solution was prepared by dissolving 5gm of Mercurochrome crystals in sufficient distilled water to make 100ml solution. First of all the entire socket was cleaned and irrigated with 3% weak hydrogen peroxide solution (an effective germicidal chemical which kills germs by oxidation process) to remove the debris. Then a sterilized cotton pledget was soaked in Mercurochrome solution and the part of pledget, which was to face fundus of the socket, was coated with Chloromycetin powder and packed in the empty socket. The dressing was kept soft and loose to minimize the chances of spread of infection from the socket. Afterwards a cotton pack was given for half an hour to prevent leakage of Chloromycetin in the oral cavity so as to minimize its bitter taste. Patient was advised to chew some candy in order to minimize the bitter taste and warm saline gargles after 3 hours, 3-4 times a day and take some analgesics if pain persists. The dressing was removed after a day. In majority of the patients, there was no need to repeat the dressing. A visual analogue scale was used to measure the intensity of pain in all the patients with dry socket. Results The chief complaint of all the patients with the history of dry socket was shooting pain 2nd or 3rd day post-operatively. Post-operative healing was excellent with no pain on first day in majority of the patients which was asked on the basis of visual analogue scale. Healing took place by secondary intention.Out of 50 patients, 5 patients reported with empty socket with dislogdement of pack and 3 patients reported with mild tolerable pain on first day. All the patients were prescribed analgesics on demand post-operatively but most of the patients did not require analgesics after the dressing. Discussion Dry socket is a painful complication which occurs routinely in the clinics. It is characterized by severe pain which starts on the 2nd or 3rd day post-operatively. The generally accepted aetiology of dry socket is an increased local fibrinolysis leading to disintegration of the clot.7 Surgical trauma during extraction of teeth leading to liberation of different tissue activators and bacterial infections remain the 2 most initiating factors of this localized fibrinolytic activity.22 Most of the studies have given the incidence of dry socket in all extractions as ranging from 2%-4.4% and as high as 12.5% where as in third molar extractions, the incidence of dry socket is from 0.5%-15%.7,22,23 This is largely due to differences in diagnostic criteria and in the methods of assessment, surgical techniques or surgical skill.24,25 In this study, a minimum of pain and an empty socket with food debris and shiver pieces of blood were considered diagnostic. In this study, the clinical picture in all the patients of dry socket was that of pain and empty sockets which is in agreement with the findings of several authors.5,24,26,27 The average onset of symptoms in our study was found to be on 2nd or 3rd days post-operatively but in some studies it was around 36 hours after the extraction which was due to other post-operative complications such as swelling and trismus. Cases in which the onset was a little more delayed is explained by the notion that an infection process was needed to liberate tissue activators and pain mediators. The neurological pain of dry socket is believed to be related to the release of kinins following tissue trauma.26,28 Pain was the chief complaint in all the patients with dry socket. The prevention of dry socket is desirable and a number of studies have shown the efficacy of different preventive measures which include use of topical penicillin; dry socket dressings like zinc oxide eugenol which is placed snugly in the extraction socket; washing the area with 0.12% chlorhexidine gluconate; application of Tranexamic acid to alveolar sockets; topical antibiotics such as metronidazole, tetracycline, amoxicillin, clindamycin and lincomycin gel foam.13,22,27-30 They are frequently associated with post-operative pain, require repeated dressings, foreign body reaction, neuritis and more chances of infection.14,18-21 The management of dry socket has witnessed many reviews over the years like topical viscous 2% lidocaine jelly, use of clindamycin and buccoadhesive metronida-zole tablets or topical metronidazole.27,30,31 As indicated by Fazakerley et al., the primary consideration in the treatment of dry socket is pain control until commence-ment of normal healing, and in the majority of cases local measures are satisfactory.32 In this study mercurochrome and chloromycetin dressing was used in the treatment of dry socket for immediate relief of pain. In majority of patients there was no need of a second dressing. Mercurochrome is an antiseptic and an organo mercuric disodium salt compound which depolarizes the resting membrane potential slightly but completely blocks conduction of the propagated action potential. Mercurochrome has a disadvantage that it may contain metal mercury but no study till date has definitely linked Mercurochrome with mercury poisoning. Mercurochrome cause dark reddish to brown staining of the oral

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Indian J Stomatol 2012;3(3):153-55. mucosa which persisted for 30-60 minutes. Chloromycetin, is a broad spectrum bactericidal antibiotic and is effective against gram +ve, gram -ve and anaerobic bacteria. It is an inexpensive and readily available drug. On systemic use, its disadvantage is reversible i.e., bone marrow toxicity and rarely aplastic anaemia. In our study cases we have applied it topically as a broad-spectrum antibacterial agent to combat the infective component in the dry socket despite of its bitter taste. Chloromycetin, which is highly hygroscopic, is available in powdered form in 1gm vial and is well known for causing bone marrow depression on systemic use but we have not found this as a clinical problem in any of our patients. Pain in dry socket is due to irritation of the nerve endings, in the lamina dura lining the alveolar socket. Besides being an antiseptic, Mercurochrome acts as an obtundent by completely blocking conduction of the propagated action potential and control the pain component which is frequently associated with dry socket. Chloromycetin was used as a topical antibacterial agent since it is a broad-spectrum antibiotic. The following study introduces a new, simple and effective method to manage the dry socket. The highlight of this study was the total loss of pain after a single dressing in most of the cases obviating the need for analgesics. Conclusion The occurrence of dry socket in everyday dental practice is unavoidable. Treatment options for this condition are generally limited and directed towards palliative care. Combined use of Mercurochrome and Chloromycetin is an effective single sitting dressing and well-tolerated in the management of dry socket. Further study is warranted to evaluate the use of combination of Mercurochrome and Chloromycetin in the management of dry socket in comparison with other conventional treatments. References
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