Alveolar osteitis is defined as postoperative pain in and around the
extraction site, which increases in severity at any time between 1 and 3 days after extraction accompanied by a partially or totally disintegrated blood clot within alveolar socket with or without halitosis. Blum (2002) described AO as being the presence of postoperative pain in and around the extraction site, which increases in severity at any time between one and three days after extraction, accompanied by a partially or totally disintegrated clot within the alveolar socket with or without halitosis ETIOPATHOLOGY: There aremany theories regarding AO but FIBRINOLYTIC AND BACTERIAL theories are the main. PREDISPOSING FACTORS: Difficult and traumatic extraction Roots or bone fragments remaining in the bone Vasoconstrictors in local anaesthetic solutions Oral contraceptives Smoking Experience of surgeon Poor oral hygiene PREVENTION: Depending on different aspects numerous medications have been used in its prevention including saline rinses, topical antiseptic rinses, antibiotics, and antifibrinolytic agents. Because primary role of bacteria in this process has been reported, the most effective way for reducing AO has been the use of the agents that systematically or topically reduce the oral microbes within the wound. Antibiotics and antiseptics have been demonstrated to be the most effective, but latter are expensive end may create resistance. Among the antiseptics, chlorhexidine has proved to be a good
prophylactic agent for AO. It is a bis-biguanide antiseptic and is
effective against both aerobic and anaerobis organisms and fungi. Since rinsing with CHX is known to reduce oral microbe population, its effectiveness in reducing the incidence of AO has generated wide spread interest. The introduction of a bio-adhesive gel to deliver the active substance has opened up new lines of treatment and investigations, as its intraalveolar placement allows a more direct and prolonged therapeutic effect of CHX, which is useful in the prevention of AO after extraction of impacted third molar. Cntemporary medical and dental practice demand evidence based decision making, and the surgeon is called on more and more frequently to justify surgical procedures, including the removal of third molars. The removal of impacted mandibular third molars is often advocated for variety of reasons; however absolute indications and contraindications for the removal of these teeth have not been established. AO is considered as one of the most common postoperative inflammatory complication after surgical removal of mandibular third molar. While the reported frequency of AO varies considerably with estimates ranging from 0.5% to 68.5%, most studies have reported frequency of AO between 25-30% after the removal of impacted third molar. Exact pathogenesis of AO is not well understood. Birn suggested that the etiology of AO is an increased local fibrinolysis (resulting from conversion of plasminogen to plasmin, which acts to dissolve fibrin crosslinks) leading to diintergration of the clot. This fibrinolysis is the result of plasminogen pathway activation which can be accomplished via direct (physiology) or indirect (nonphysiologic) activator substances. Direct activators are realesed after trauma to the alveolar bone cells and indirect activators are elaborated by bacteria. This is supported by an increased incidence of dry socket being seen in patients with poor oral hygiene, higher pre and postoperative microbial counts and, in the presence of periapical infection, pericoronitis or peridontitis pre extraction. Nitzan et al. (1983) proposed in particular, the role of anaerobic bacteria, especially Treponema denticola, which showed plasmin-like fibrinolytic activity in vitro.
There several contributing or risk factors for development of AO
including surgical trauma and difficulty of surgery. Difficult extractions tend to be in older dense bone, which may have decreased vascularity and a greater propensity to traumatic thrombosis of the blood vessels. Birn (1973) proposed that trauma during the removal of tooth leads to a localized inflammation of the socket with accompanying release of tissue activators, which act to increase the levels of plasmin in the socket, leading to lysis of the blood clot. A more traumatic extraction leads to increased release of these activators. These tissue activators also release kininogenase enzymes and bradykinins, which play a key role in pain generation. There is a reported inverse relationship between operator experience and AO. Surgical extractions in comparision to non-surgical extractions are reported to result in a ten-fold increase in the incidence of AO, which may be due to the increased trauma associated with surgical extractions. A consistent relationship between smoking and dry socket is reported in the literature. Following extraction tobacco smokers demonstrate reduced filling of the wound with blood and an increased incidence of dry socket. Dry socket occurs more frequently in females than males, pointing to a possible hormonal cause. Sweet and butler (1978) found the incidence of dry socket to be 4.1% in females versus 0.5% in males. Females taking oral contraceptive also have high incidence of dry socket. Oestrogen in oral contraceptives has been shown to increase plasma fibrinolytic activity (due to increased plasminogen levels) and it has been hypothesized tht this may contribute to instability of the blood clot in socket. It has been suggested that extraction should be carried out on days 23-28 of the oral contraceptive tablet cycle, when oestrogen levels are at their lowest, so as to reduce this effect. Garcia et al. (2003) found that in a study of 267 women, 87 of whom were taking oral contraceptive pill, dry socket occurred more frequently in those taking oral contraceptive (11%) than in those not taking oral contraceptive (4%). Excessive irrigation or curettage of alveoius, older age, local anaesthetic with vasoconstrictor, and bone or root fragments remaining in the wound are also some of contributing factors.
Since AO is the most common postoperative complication after
extraction, numerous method and techniques are proposed throughout the literature to assist with its prevention. Although no single method has gained universal acceptance, the most popular method and technique for prevention of AO include use of topical and systemic antibiotics, topical use of parahydroxybenzoic acid as an antifibrionlytic agent in extraction wounds, topical use of tranexamic acid in the extraction socket, use of a clot supporting agent polyactic acid, topical application of an emulsion of hydrocortisone and oxytetracycline, use of eugenol containg dressings, and pre or perioperative use of 0.12% CHX solution. Chlorhexidine is used as an antimicrobial agent for the prevention of dental caries, periodontal diseases, and AO. CHX is a good prophylactic agent for AO, and all realated published studies have confirmed the suitability of CHX rinses; although there were differences in protocol like rinsing with CHX only on the day of surgery and using multiple rinses with CHX. A double blind study carry out bt Torres-Lagares et al.discribed the use of topical (intra-alveolar) administration of CHX in a gel form to see its effectiveness in reducing incidence of AO after lower third molar surgery. They found 30% of AO in control group (group who received placebo gel) and 11% in experimental group (group who received CHX gel), which has significant statisticaliy. In this study, a reduction in the frequency of AO was observed in the CHX (experimental) group, being significant in respect to the control. The application of intra-alveator CHX gel could explain the reduction found in the frequent of AO. No adverse reactions are reported, which include allergy, staining of teeth, mucosal irritation, alteration in taste, bad taste of the solution, and gastrointestinal complaints. Several studies have diagnosed AO between 2nd and 4th postoperative days when patients complained of a painful extraction socket, and by clinically examining extraction sockets which revealed empty socket or disintegrated clot with denuded bone and fetid smell. Management of AO is aimed in controlling pain until commencement of normal healing and in the majority of cases local measures are satisfactory, however in some cases systemic analgesics or antibiotics may be necessary or indicated. Different medicaments and carrier
systems are available and the most widely used preparation is Alvogel, which contains Butamben (anaesthetic), iodophorm (antimicrobial) and eugenol (analgesic).