ALVEOLAR OSTEITIS AND CHLORHEXIDINE

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).