Alveolitis sicca
| Classification according to ICD-10 | |
|---|---|
| K10.3 | Alveolitis of the jaws, including dry socket |
| ICD-10 online (WHO version 2019) | |
A alveolitis sicca (of lat. Alveolus "hollow" and siccus , synonyms "dry"): dry socket , alveolitis sicca dolorosa , post-extraction pain or dry socket is a complication after a tooth extraction , particularly in the area of the posterior teeth of the mandible, and there again in the jaw angle area , because the bone in this region is very compact and less perfused. The alveolitis sicca typically occurs two to four days after the extraction. This leads to an inflammation of the bony tooth socket (alveolus).
The cause is a disintegration of the blood clot . This protects the alveolus from the penetration of germs from the oral cavity until the surface of the wound is overgrown with mucous membrane.
Name of the disease
The name alveolitis sicca emphasizes the location (alveole) and the nature (inflammation - " -itis ") of the disease. The addition “dry” (sicca) indicates the empty alveolus (without coagulum ). The direct English translation is logically: dry socket (dry alveole).
In contrast, the term Dolor post extractionem ( pain after extraction) emphasizes the main symptom - pain. In practice, Dolor post is usually only referred to casually for a short time .
The term post-extraction syndrome leaves all options open. It should be used when an accompanying neuritis occurs . However, this distinction is of little help in practice, since neuritis-like pain occurs with every alveolitis sicca . However, with classic neuritis the pain is attack-like, while with typical alveolitis sicca it is constant.
Another name is ostitis alveolaris (inflammation of the bone in the alveolus).
Normal wound healing after extractions
The real wound healing after tooth extraction takes place as primary healing . The alveolus bleeds completely, a coagulum forms in the alveolus, which after a few days is supplied with blood by injecting capillaries and turns into scar tissue via granulation tissue .
Causes and risk factors for alveolitis sicca
The exact etiology is unknown. Certain germs, particularly heavily infected teeth or traumatic or difficult tooth extractions were suspected. Normal wound healing is prevented because a stable coagulum does not form in the alveolus or because it disintegrates again. There are several reasons for the destruction of the coagulum. The blood clot shrinks a little after a few hours. If the original wound is large, this can create a gap in the edge area. Bacteria penetrate these and break down the blood clot. In addition, the plug is attacked by strong chemical or mechanical stimuli and disintegrates. Occasionally, patients think the yellowish layer of fibrin that forms on the clot after a day is a contaminant and try to remove it. This can also destroy the plug.
It is also conceivable that the coagulum will be torn from the wound with the swab that the patient has in the mouth for some time (10–50 minutes) after the extraction.
If the bleeding from the extraction wound is very weak - this may also be due to the addition of a vasoconstrictor in the local anesthetic - a coagulum may not form at all. Another cause could be that the tooth was not completely removed or infected tissue was left behind (e.g. apical periodontitis or an odontogenic cyst ).
The risk of alveolitis sicca can be greatly reduced by avoiding nicotine and caffeine in the hours before the procedure and mechanical manipulation after the procedure.
After surgical removal of the wisdom teeth
After the surgical removal of a wisdom tooth , especially the wisdom teeth of the lower jaw, severe postoperative pain in the sense of alveolitis sicca occurs more often. This can possibly be prevented by primary wound closure. On the other hand, after the surgical removal of the upper wisdom teeth, alveolitis sicca occurs extremely rarely. The reason for this is the different bone structure of the upper jaw . The upper jawbone has a much better blood supply - and is thus better equipped for healing and defense, because the cancellous bone predominates. In the movable lower jaw, the bone must be very compact in order to be able to absorb the forces that occur. The same applies to osteomyelitis of the jaw, which also occurs preferentially in the lower jaw bone.
Symptoms and diagnosis
The exposed bone causes strong, radiating pain (lat. Dolor), which is the main symptom and also the namesake for the name dolor post extractionem (i.e.: pain after tooth extraction) . Also, bad breath (lat. Foetor ex ore) can occur. Despite the inflammation, there is no suppuration or abscess formation. Initially, the pain is the only significant sign of inflammation . However, this can be very severe and has an increasing tendency. Patients cannot sleep at night and are really sick because of the pain. Pain pills are of little help. For this reason, it is also justified to leave the patient on sick leave for one or two days until therapy works.
The intraoral inspection reveals a bloodless alveolus because the blood clot, which often smells very bad, has disintegrated.
Differential diagnosis
Diagnostically difficult delimitations arise in particularly sensitive or complacent patients if the severe pain already occurs on the day of extraction or on the following day. In case of doubt, these patients are treated as for alveolitis sicca.
The differential diagnosis is osteomyelitis (osteomyelitis) to consider, but that are very rarely occurs in connection with a tooth extraction. In contrast to Dolor post extraction, osteomyelitis typically occurs as a multiple abscess with multiple fistulas .
An iatrogenic opening of the maxillary sinus ( mouth-antrum connection ) during the extraction should also be considered. If this remains undetected after the extraction of an upper posterior tooth, for example because an attempt to blow the nose or a probing was not carried out after the extraction, it can lead to inflammation of the maxillary sinus. However, the pain that occurs is usually less extreme and diffuse. If in doubt, you can still try to blow your nose.
treatment
The treatment consists of a surgical revision under local anesthesia to remove the necrosis and create fresh wound surfaces (clearing out the disintegrating coagulum and scraping out the alveolus ( excochleation )). Local anesthesia is required because the exposed bone is extremely sensitive to pain.
Then either a tamponade is inserted, which can be soaked with disinfecting and pain relieving medication. This must be changed regularly by the dentist until it is completely healed in order to prevent further infection. Or an absorbable paste is applied directly into the alveolus with a cannula. In this case, a gauze carrier strip and its subsequent removal can be dispensed with.
Systemic antibiotic administration is not indicated - it has no effect.
In milder cases, the treatment can be limited to careful cleaning and rinsing of the wound area without local anesthesia, namely if the patient presents for treatment after several days with a "delayed" alveolitis sicca that is already subsiding . Radical clearing and freshening of the alveolus is no longer indicated in such a case, since normal wound healing has already started and further wound healing would be delayed or set back by several days through curettage .
Overall, wound healing after alveolitis sicca can take several weeks until the entire bone is overgrown with mucous membrane again from the side . The acute symptoms usually subside significantly after just one or two medicinal inserts. The insoles are changed daily at first, later every two to three days. Rinsing the cleaned alvole with 3% hydrogen peroxide for the purpose of cleaning by foam formation (mechanical cleaning) and introduction of oxygen is also indicated.
frequency
The frequency is around 1%. However, the information on the frequency varies greatly, which suggests a certain dependence on the practitioner.
prevention
Prevention has been tried in various studies by giving:
- Antifibrinolytics ,
- Antiseptics,
- steroidal or nonsteroidal anti-inflammatory drugs ,
- Antibiotics (applied locally or systemically )
The meta-analysis of 32 clinical studies (2004/2005) showed that when antibiotics were administered (eight studies), the topical application of tetracyclines was most effective as part of the prophylaxis of alveolitis - with an absolute risk reduction of 12 to 31%, while the systemic use of antibiotics ( Amoxicillin , clindamycin, or metronidazole ) wasn't as effective.
Local irrigation with chlorhexidine was also effective (five studies) - with an absolute risk reduction of 3 to 25%. Prophylactic treatment with antifibrinolytics, diclofenac , ibuprofen , tranexamic acid , diflunisal, codeine , dexamethasone or injections with local anesthetics have proven to be ineffective. The use of sterile gloves does not show any prophylactic effectiveness either.
Since the routine administration of antibiotics for the prevention of occasional alveolitis does not seem to be practicable ( resistance development , allergies , systemic toxicity ), pre- and postoperative prophylactic chlorhexidine rinsing with few side effects is preferred.
Web links
Individual evidence
- ↑ L. Hedstrom, P. Sjogren: Effect estimates and methodological quality of randomized controls trials about prevention of alveolar osteitis following tooth extraction: a systematic review. In: Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiol. In: endod 2007; 103: 8-15.
swell
RSR Buch et al .: Dolor post extractionem - The local therapy of alveolitis with medicinal insoles. In: zm 95, no. 20, October 16, 2005, pp. 54–58.
