Efficacy of different methods used for dry socket prevention and risk factor analysis: A systematic review

Dry Socket Prevalence and Risk Factors in Third Molar Extractions: A Prospective Observational Study

Background Third molar extraction is a routine oral surgical procedure that is often complicated by the development of a dry socket (alveolar osteitis). This prospective observational study aimed to investigate the prevalence of dry sockets and identify associated risk factors and causes, contributing to a comprehensive understanding of the postoperative outcomes of oral surgery. Methods This study employed a prospective observational design with a 12-month follow-up period. Participants aged 18-40 years scheduled for third molar extraction were included, whereas those with coagulopathies, pregnant or lactating women, patients with vitamin deficiencies, and individuals on medications affecting healing were excluded. Data collection involved comprehensive assessments at baseline, intraoperative details, and postoperative evaluations at 48 hours, one week, and two weeks. Statistical analyses included descriptive statistics, chi-square tests, t-tests, or Mann-Whitney U tests, and logistic regression for the risk factor analysis. Results A total of 238 participants with diverse demographic characteristics were enrolled in this study. The prevalence of dry sockets increased progressively from 20.6% at 48 hours to 41.2% at two weeks post-extraction. Smoking, poor oral hygiene, and surgical technique emerged as significant risk factors, with corresponding odds ratios of 6.41 (95% CI: 2.86-14.36, p < 0.001), 9.53 (95% CI: 2.12-42.84, p = 0.003), and 3.27 (95% CI: 2.08-5.15, p < 0.001), respectively. Pain intensity, measured using a Visual Analog Scale, gradually decreased from 48 hours to two weeks post-extraction. Conclusion This study provides valuable insights into the prevalence and risk factors associated with dry sockets following third molar extractions. Smoking, poor oral hygiene, and poor surgical techniques were identified as significant contributors, emphasizing the importance of preoperative counseling and targeted interventions.

Hyaluronic acid in tooth extraction: a systematic review and meta-analysis of preclinical and clinical trials

OBJECTIVES

To assess whether in animals or patients with ≥ 1 tooth extracted, hyaluronic acid (HyA) application results in superior healing and/or improved complication management compared to any other treatment or no treatment.

MATERIALS AND METHODS

Three databases were searched until April 2022. The most relevant eligibility criteria were (1) local application of HyA as adjunct to tooth extraction or as treatment of alveolar osteitis, and (2) reporting of clinical, radiographic, histological, or patient-reported data. New bone formation and/or quality were considered main outcome parameters in preclinical studies, while pain, swelling, and trismus were defined as main outcome parameters in clinical studies.

RESULTS

Five preclinical and 22 clinical studies (1062 patients at final evaluation) were included. In preclinical trials, HyA was applied into the extraction socket. Although a positive effect of HyA was seen in all individual studies on bone formation, this effect was not confirmed by meta-analysis. In clinical studies, HyA was applied into the extraction socket or used as spray or mouthwash. HyA application after non-surgical extraction of normally erupted teeth may have a positive effect on soft tissue healing. Based on meta-analyses, HyA application after surgical removal of lower third molars (LM3) resulted in significant reduction in pain perception 7 days postoperatively compared to either no additional wound manipulation or the application of a placebo/carrier. Early post-operative pain, trismus, and extent of swelling were unaffected.

CONCLUSIONS

HyA application may have a positive effect in pain reduction after LM3 removal, but not after extraction of normally erupted teeth.

CLINICAL RELEVANCE

HyA application may have a positive effect in pain reduction after surgical LM3 removal, but it does not seem to have any impact on other complications or after extraction of normally erupted teeth. Furthermore, it seems not to reduce post-extraction alveolar ridge modeling, even though preclinical studies show enhanced bone formation.

A New Approach for Explaining and Treating Dry Sockets: A Pilot Retrospective Study

Objective Dry socket, a common complication following a tooth extraction, is characterized by severe and radiating pain that typically begins one to four days after the extraction. Despite several risk factors, the exact cause and underlying mechanisms of dry sockets remain unclear. This study aims to propose a novel pathogenesis and management approach for dry sockets based on an infectious process. Methods The study was conducted by reviewing medical records, at a private dental clinic, of patients who fit the inclusion criteria; these patients appeared to have come between April 2022 and April 2023. The study included all patients with age ≥17 years diagnosed with dry socket that was resistant to conventional topical treatment, and who received treatment with ciprofloxacin 500 mg three times per day during the study period. Results Out of 15 patients who received treatment with ciprofloxacin 500 mg three times per day during the study period, 11 patients (73.3%) were completely relieved of symptoms within 24 hours, with no need for additional painkillers or nonsteroidal anti-inflammatory drugs (NSAIDs). In addition, two patients (13.3%) had a partial response after 48 hours, where their pain was ameliorated from severe to moderate with the use of conventional painkillers (including paracetamol and NSAIDs) and steroidal anti-inflammatory drugs such as dexamethasone (8 mg IM daily) to have total relief. On the other hand, the other two patients (13.3%) had a negative response to the treatment and were out of reach for follow-up. Conclusion These clinical outcomes, coupled with previous laboratory data, could explain all clinical aspects of dry sockets and provide substantial support for the hypothesis that an infectious mechanism plays the principal role in the pathophysiology of dry sockets.

Photobiomodulation for Pain Relief After Third Molar Extraction: A Randomized Double-Blind Split-Mouth Clinical Trial

Objective: To evaluate the local and systemic application of photobiomodulation (PBM) to reduce pain after third molar extraction. Background: PBM has been applied locally to reduce pain after third molar extraction, but there are no published studies evaluating its systemic application for this purpose. Methods: Thirty patients with two erupted third molars indicated for extraction were included in this split-mouth clinical trial. Extractions were performed 3 weeks apart in each patient, with one extraction socket being randomly assigned to local and systemic PBM (PBM group) and the other to no PBM (control group). Postoperative analgesia consisted of oral acetaminophen for 3 days. Outcomes included pain (visual analog scale), swelling, and quality of life (14-item Oral Health Impact Profile) assessed before and immediately, 24 h, 48 h, and 7 days after extraction. Results were analyzed by Kruskal-Wallis test, followed by Student-Newman-Keuls test. Results: In the control group, pain increased significantly at 24 and 48 h after extraction (p = 0.0000), decreasing after 7 days (before: 0.36; immediately after: 1.06; 24 h: 4.26; 48 h: 2.53; 7 days: 0.36). In the PBM group, patients reported no pain at all time points, indicating effectiveness of local and systemic PBM in relieving pain after third molar extraction (p = 0.2151) (before: 0.30; immediately after: 0.36; 24 h: 0.86; 48 h: 0.30; 7 days: 0.03). PBM also had a modulatory effect on the inflammatory process and improved comfort after extraction. Conclusions: Combined local and systemic PBM can be useful for pain relief, swelling control, and quality-of-life improvement in patients undergoing third molar extraction.

Antimicrobial Prophylaxis in Dentistry: Survey among Dental Surgeons in Porto Alegre, Brazil, and the Metropolitan Region

The irrational use of antimicrobial drugs has become a serious epidemiological problem due to the development of bacterial resistance, causing consequences for global health. In dentistry, antibiotics are the second most common pharmacological class prescribed. Thus, we evaluated the use of antimicrobial prophylaxis by dentists in Porto Alegre, Brazil, and the metropolitan region using an online questionnaire. Dentists were asked to complete an anonymous questionnaire concerning antimicrobial prescription. The questionnaire was prepared on the Microsoft Forms platform and shared with dentists through social media and was available for a period of 40 days. The questionnaire was answered by 82 dentists, and 85.3% of them reported prescribing antibiotic prophylaxis (AP). Many different protocols were observed, but the majority of dentists prescribe amoxicillin (2 g) 1 hour before a procedure. The greatest diversity was found in the prescriptions for post-procedure prophylaxis, but most professionals prescribe 500 mg of antibiotics every 8 hours for 7 days. An overwhelming 91.5% of participants think that guidelines for prescribing antibiotics in dentistry are necessary, and 62.2% believe that the use of AP can have some impact on bacterial resistance. There is a wide range of different prescriptions for antimicrobials, suggesting a need for better aligned guidelines and education of professionals on the proper use of antimicrobials and its consequences on bacterial resistance to antibiotics.

Sutureless socket technique after removal of third molars: a multicentric, open, randomized controlled trial

BACKGROUND

Although wisdom-tooth extraction is a routine intervention, the postoperative period remains marked by local inflammation classically manifesting as pain, edema and trismus. Furthermore, there is no consensus on the best operative techniques, particularly for the mucosal closure stage on impacted mandibular wisdom teeth.

METHODS

This parallel, randomized, non-blinded study compared pain following removal of impacted third molars, with and without sutures. Patients were electronically allocated 1:1 to extraction with versus without sutures. Patients ≥ 14 years' old scheduled for extraction of four impacted wisdom teeth under general anesthesia at three French hospitals were eligible for inclusion. Exclusion criteria included taking antiplatelet agents or anticoagulants, coagulation disorders or immunosuppression, and planned orofacial surgical procedures or emergency pain/infection. The primary objective was pain evaluated by Visual Analogue Scale on Day 3. Secondary outcomes were edema, trismus, healing, complications, painkiller consumption and quality of life on Day 3 and 31.

RESULTS

Between June 2016 and November 2018, 100 patients were randomized. Finally, 44 patients in the Suture group and 50 patients in the Without Suture group were analyzed. Mean age was 16.5 years and 66.6% of patients were female. After adjustment on center, age and smoking, no statistical difference was seen between groups for pain on Day 3 (p = 0.904). No differences were seen for swelling, trismus, consumption of painkillers, healing, complications or quality of life. Smokers had a 3.65 times higher complications rate (p = 0.0244).

CONCLUSIONS

Sutureless removal of third molars is thus a reliable technique without negative consequence on outcomes, and allows shorter operating time. Smoking is a risk factor for postoperative complications. Trial registration www.

CLINICALTRIALS

gov (NCT02583997), registered 22/10/2015.

Previous dry socket as a risk factor for alveolar osteitis: A nested case-control study in primary healthcare services

Background

Dry socket is one of the most common complications following tooth extraction, though no studies have been made on its main risk factors in the primary healthcare services of Barcelona (Spain). Objectives: To analyze the influence of different factors upon the appearance of dry socket in patients attended in the primary care setting, and to determine the possible presence of risk factors in patients who have suffered a previous episode of dry socket.

Material and Methods

During 24 months, questionnaires were filled with data on the patients seen in different public primary healthcare services in the area of Barcelona (Spain). A case-control study was conducted to identify the main risk factors for developing complications in the form of dry socket.

Results

A mandibular location of the extracted tooth, poor oral hygiene, difficult extraction, and previous dry socket increased the risk of developing this complication. In patients with dry socket in the past, the risk of developing the same complication again, adjusted for difficulty of extraction, was seen to increase 11.45-fold (OR: 11.45; 95%CI: 1.06 to 123.74; p = 0.045).

Conclusions

The risk factors for dry socket are a mandibular location of the extracted tooth, poor oral hygiene, difficult extraction, and particularly a history of dry socket in the past. The identification of these factors the prevention of dry socket in each patient could be improved.

Key words:Dry socket, risk factors, extraction, complications.

Controlled release of silibinin in GelMA hydrogels inhibits inflammation by inducing M2-type macrophage polarization and promotes vascularization in vitro

A dry socket is one of the most common complications after tooth extraction. The main etiologies are the loss of blood clots in the socket and the inflammation reaction caused by infection. Current studies on how to prevent dry sockets could not solve these two etiologies at the same time. Recent studies have demonstrated the anti-inflammation role of silibinin. In this study, silibinin was engineered into GelMA hydrogels (Sil-GelMA) with a concentration of 30 mM. The surface characteristics were observed by scanning electron microscopy and the successful loading of silibinin was detected by FTIR spectrometry. The Sil-GelMA hydrogels presented the sustained release ability of silibinin and slow degradation performance of GelMA. Furthermore, silibinin inhibited the inflammatory reaction by inducing M2-type macrophage polarization, promoting the secretion of anti-inflammatory factors (CD206, IL-10) and inhibiting the secretion of anti-inflammatory factors (IL-1β, iNOS). Silibinin also increased the secretion of vascularization-related factor VEGF and promoted vascularization in vitro. This study suggested that the Sil-GelMA hydrogels not only had an anti-inflammatory effect, but also had the potential to promote vascularization. Based on these results, the Sil-GelMA hydrogels might provide a promising prospect for prevention of dry sockets in the future.

Clinical management of alveolar osteitis. A systematic review

Background

Alveolar Osteitis (AO) is one of the most common complications of tooth extraction. Several therapeutic interventions have been described for the treatment of AO, however, there are no treatment standardized protocols. The aim of this study was to conduct a systematic review on the efficacy in pain control of the different treatments for AO. The feasibility of the application of these interventions is also discussed.

Material and Methods

A structured electronic and hand search strategy was applied to PubMed, Scopus, Cochrane Library, OpenGrey, and Google Scholar between January 2010 and July 2020 to identify studies according to PRISMA guidelines. The inclusion criteria were original English and Spanish clinical trials that analyzed pain-control parameters according to visual analog scale (VAS, 0-10 scale), or pain relief patients’ percentages. Those treatments that reach VAS ≤ 4 on day 2 or before; or ≥ 85% of patients with absence of pain symptoms at day 7 or before were considered accepTable for their recommendation.

Results

The final review included 17 clinical trials. Among them, there were analyzed a total of 39 different AO treatments. 53,8% of the treatments fulfill the proposed parameters for pain control.

Conclusions

Treatment alternatives are multiple, heterogeneous, and difficult to compare. The management of AO is summarized in basic (intra-alveolar irrigation) and specific procedures (Alveogyl®, Neocones®, SaliCept Patch®, Low-Level Laser, Platelet-Rich Fibrin) that reach pain control success. They could be selected according to their availability and advantages or disadvantages.

Key words:Dry socket, alveolar osteitis, treatment, management, pain control, pain relief.

Antibiotics or No Antibiotics, That Is the Question: An Update on Efficient and Effective Use of Antibiotics in Dental Practice

The antimicrobial resistance (AMR) phenomenon is an emerging global problem and is induced by overuse and misuse of antibiotics in medical practice. In total, 10% of antibiotic prescriptions are from dentists, usually to manage oro-dental pains and avoid postsurgical complications. Recent research and clinical evaluations highlight new therapeutical approaches with a reduction in dosages and number of antibiotic prescriptions and recommend focusing on an accurate diagnosis and improvement of oral health before dental treatments and in patients’ daily lives. In this article, the most common clinical and operative situations in dental practice, such as endodontics, management of acute alveolar abscesses, extractive oral surgery, parodontology and implantology, are recognized and summarized, suggesting possible guidelines to reduce antibiotic prescription and consumption, maintaining high success rates and low complications rates. Additionally, the categories of patients requiring antibiotic administration for pre-existing conditions are recapitulated. To reduce AMR threat, it is important to establish protocols for treatment with antibiotics, to be used only in specific situations. Recent reviews demonstrate that, in dentistry, it is possible to minimize the use of antibiotics, thoroughly assessing patient’s conditions and type of intervention, thus improving their efficacy and reducing the adverse effects and enhancing the modern concept of personalized medicine.

Current uses of chlorhexidine for management of oral disease: a narrative review

Objectives

Chlorhexidine (CHX) is a commonly used antiseptic mouthwash, used by dental practitioners and the public, due to its antimicrobial effects. The aim of this article was to provide a narrative review of current antimicrobial uses of CHX relevant to dentistry in the context of oral diseases, highlighting need for further studies to support its safe and appropriate use.

Study selection, data and sources

Randomised controlled trials, systematic reviews and national (UK and US) guidelines were consulted where available, with search terms for each subject category entered into MEDLINE, PubMed, Google Scholar and the Cochrane database.

Results

Some evidence existed to support adjunctive short-term use of CHX to manage dental plaque, and reduce clinical symptoms of gingivitis, dry socket, as well as reduce aerosolisation of bacteria. However, use must be weighed alongside the less desirable effects of CHX, including extrinsic staining of teeth, antimicrobial resistance to antiseptic agents and the rare, but fatal, allergic reactions to CHX. Conversely, evidence for the effectiveness of chlorhexidine to manage or prevent periodontitis, dental caries, necrotising periodontal diseases, peri-implantitis, and infections associated with extraction and aerosolised viruses remains less certain.

Conclusions

The use of CHX in dentistry and oral healthcare continues to be widespread and thus it is important that dental practitioners understand that, based on its differential mechanisms of action on different microbes, appropriate clinical and dental use of CHX should be oral disease specific. However, further scientific and clinical research is required before full recommendations can be made.

Effect of concentrated growth factors on frequency of alveolar Osteitis following partially-erupted mandibular third molar surgery: a randomized controlled clinical study

Background

The aim of this prospective study was to assess the effectiveness of concentrated growth factors (CGF) in preventing the development of alveolar osteitis (AO) after the extraction of partially-erupted mandibular third molars.

Methods

Seventy patients (26 men and 44 women) 18 years or older (mean age 25.86; range 18–35) underwent 140 third molar extractions. All the patients presented with bilateral, partially-erupted mandibular third molars and underwent surgical extractions. In each case, one socket received CGF and the other served as a control. The predictor variable was the CGF application and the sides were categorized as ‘CGF’ and ‘non-CGF’. The outcome variable was the development of AO during the first postoperative week. Other study variables included age and gender. Data were analyzed using Cochran’s Q test with the significance level set at a P value less than 0.05.

Results

The overall frequency of AO was 11.4% for the control group. The frequency of AO in the CGF group was significantly lower than in the non-CGF group (p < 0.001).

Conclusions

Based on the results of this study, application of CGF fibrin gel may decrease the risk of AO development after mandibular third molar surgery.

Trial registration

This study was registered in ClinicalTrials.gov database on November 1, 2019 (ID: NCT04151147, retrospectively registered).

Factors Influencing the Onset of Intra- and Post- Operative Complications Following Tooth Exodontia: Retrospective Survey on 1701 Patients

Complications after tooth extraction may occur because of several factors correlated to the patient's medical history, surgical site or type of intervention. The aim of this retrospective cohort study was to evaluate type and frequency of complications after exodontic surgery, its correlation with antibiotic administration and between patient's related systemic factors. From June 2015 until February 2016 1701 exodontic interventions, for a total of 2322 extracted teeth, were carried out at the Unit of Oral Surgery in Trieste. Descriptive statistic, and backward multiple logistic regressions were performed to identify the variables associated with the presence of post-operative alveolitis or any other post-operative complication. The presence of coagulopathy and smoking habit were related to high risk of post-operative alveolitis (OR = 5.51, p = 0.035 and OR = 2.5, p = 0.029, respectively). Tooth fracture was found to be correlated with higher probability of post-operative alveolitis (p = 0.001) and concomitant chemotherapy put at a higher risk post-operative complications, including alveolitis (OR = 29.5, p = 0.018). According to the present results, antibiotic consumption did not seem to reduce the incidence of post-operative infective complications (alveolitis). A careful analysis of medical history, the adequate surgical technique, and the correct instructions in post-surgical behavior, prevent the insurgence of intra and post-operative complications.

A quality improvement project to assess the use of preventative measures against acute alveolar osteitis

Aims

A quality improvement project was conducted in a General Dental Practice environment. The aim was to reduce the rate of Acute Alveolar Osteitis, which was locally found to be at 19.4%.

Methods

A range of quality improvement tools were utilised to determine and measure potential interventions, and the results from the initial Plan-Do-Study-Act cycle utilising perioperative 0.2% Chlorhexidine as a preventative method are presented.

Results

The use of perioperative 0.2% Chlorhexidine mouthwash showed an absolute risk reduction of 6.2%.

Discussion

Generalisation from the results is highly dependent on local factors, although the favourable reduction in acute alveolar osteitis and cost savings found supported the project.

Conclusions

This project highlights the strengths of Quality Improvement methodologies in implementing and assessing changes to improve service provision and patient outcomes.

A metagenomic study of patients with alveolar osteitis after tooth extraction. A preliminary case-control study

OBJECTIVE

To identify the microbiome in sockets with alveolar osteitis and compare it with a control group using metagenomic techniques.

MATERIALS AND METHODS

A case-control study was conducted in subjects that had undergone a tooth extraction. Microbiological samples were taken from the sockets of 10 patients with dry socket after tooth extraction (AO group) and 10 patients in whom exodontia resulted in no postoperative complications (control group). Bacterial DNA was isolated, and the 16S rRNA gene was amplified and sequenced. Multiplexed tag-encoded sequencing of DNA from the samples was performed, and the reads were processed by Metagenomic Rapid Annotation.

RESULTS

A total of 151 different species were found: 55 bacteria were only found in the AO group, 51 were specific to the control group, and 45 were common to both groups. The most frequently found genera in both groups were Prevotella. Prevotella nanceiensis, Actinomyces odontolyticus, Treponema maltophilum, Veillonella dispar, Tannerella forsythia, and Leuconostoc mesenteroides were found in several patients with alveolar osteitis, with an abundance greater than 0.5%, and were absent in all the control group samples.

CONCLUSIONS

Patients who develop alveolar osteitis after dental extractions might have a different microbiota from that of patients without postoperative complications. Since this is a preliminary report, further research is needed to assess whether bacteria play an important role in the etiology of dry socket.

CLINICAL RELEVANCE

This study seems to indicate that bacteria may play an important role in the alveolar osteitis etiology. Thus, new prevention and treatment strategies should be considered.

The efficacy of 1% Betadine mouthwash on the incidence of dry socket after mandibular third molar surgery

Background

Dry socket or alveolar osteitis is a delayed healing of alveolar bone after exodontia causing moderate to severe pain 2-4 days after extraction of teeth. Antibacterial agents such as antibiotics and chlorhexidine have been previously proved to prevent or reduce the incidence of dry socket. Betadine is a mixture of iodine and povidone which has bactericidal, antifungal and antiviral effects. The aim of the present study was to evaluate the effect of preoperative povidone iodine 1% mouthwash before surgical extraction of impacted mandibular third molar, however age, gender and oral hygiene were also considered.

Material and Methods

189 patients who needed surgical extraction of Pell and Gregory class A and B mandibular third molars were included in this study. The patients who were not willing to participate in the study, took, women who took oral contraceptives or were in the first 22 days of menstrual cycle were excluded. Patients were randomly assigned to control or test group. 97 patients in the test group took preoperative povidone iodine 1% mouthwash and 92 patients in the control group didn’t take any antibiotic or mouthwash. Patients were examined in days 3 and 7 postoperatively for incidence of alveolar osteitis.

Results

Chi-square test didn’t show any significant relation between dry socket incidence and gender (p value: 0.848) and Oral hygiene (p value: 0.866). However, it revealed a significant relation between age and dry socket incidence (p value: 0.003) and patients older than 30 were reported to have higher incidence of dry socket. Independent T-Test showed a significant difference between the test and control group in incidence of dry socket (p value: 0.036).

Conclusions

Based on the results of this study povidone iodine 1% mouthwash can decrease dry socket incidence also as the age increases, the incidence of dry socket becomes higher.

Key words:Dry socket, impaction, betadine, povidone iodine.