oral surgery

oral medicine
oral pathology
Withsecti~ns on oral and maxillofacial radiology
and endodontics

oral surgery
Editor.
ROBERT B. SHIIRA, DDS
School of Dental Medicine
Tufts University
1 Kneeland Street
Boston, Massachusetts 02111

Alveolar osteitis after surgical removal of

impacted malndibular third molars
Identiification of the patielnt at risk

Peter .E. Larsen, DOS,” Columbus, Ohio

OHIO STATE. UNIVERSITY COLLEGE OF DENTISTRY

One hundred thirty-eight impacted mandibular third molars were surgically removed. A prospective
study of risk factors associated with the development of alveolar osteitis (dry socket)
postoperatively was undertaken. Two surgeons, one experienced and one inexperienced, removed
the teeth. Patients were controlled for age, sex, use of oral contraceptives, radiographic difficulty of
the extraction, and tobacco use. IPatients treated by the inexperienced surgeon and those using
tobacco had a significantly greater incidence of alveolar osteitis. Previously identified risk factors of
increased age, female sex, oral contraceptive use, and increased surgical time were not associated
with an increased incidence of dry socket. Recommendations are made regarding prevention of
alveolar osteitis in those patients identified as being at high risk.
(ORAL SIJRC ORAL MED ORAL PATHOL 1992;73:393-7)

A lveolar osteitis (dry socket) is a pamful condition

that occurs after the removal of teeth. The incidence
is between 1% ,and 3% for all extractions’; however,
it is much higher after the surgical removal of
impacted mandibular third molars. Several prospec-
tive studies recorded. the incidence after surgical re-
moval of impacted mandibular third molars to be in
the range of 20% to 30%.2M5
Alveolar osteitis is associated with severe throbbing
pain with radiation to the ear. Pain usually begins 3
aAssistant Professor and IDirector of Oral and Maxillofacial
gery Residency Program.
7112134573
to 5 days after surgery, at a time when the patient ex-
pects to have progressed beyond the most severe pain.
This pain is frequently refractory to the usual postop-
erative analgesics prescribed after third molar re-
moval. Previous studies showed that more than 45%
of patients in whom dry socket develops need four or
more postoperative appointments before complete
resolution of the symptoms occurs.6 This constitutes
a significant cost to the patient in both lost productiv-
ity and suffering and to the practitioner in terms of
using personnel to treat a potentially avoidable prob-
Sur-
lem.
The etiology of alveolar osteitis is widely accepted
as fibrinolysis of the clot as a result of bacterial inva-
393
39 Larsen
Table 1. Distribution of patients between
experienced and inexperienced surgeons
Inexperienced
Experienced
surgeon
(n = 51)
Tobacco 8151
Oral contraceptives 8126
Sex
M 25151
F 26151
Age (yr)
18-22 29151
>26 l/51
Mean radiographic score of difficulty*
Tooth 17 8.0
Tooth 32 8.3
*Radiographs were scored on a scale from 3 to 13 on the basis of angulation,
vertical depth, ramus relationship, and root formation.
sion. It is also clear that several other factors may be
related to this process. Frequently cited risk factors
include a difficult extraction, an inexperienced sur-
geon, tobacco use, inadequate irrigation, oral contra-
ceptives, corticosteroids, and use of local anesthetics
with a vasoconstrictor. The importance of many of
these factors is not clearly documented, with evidence
for and against resulting from poorly controlled stud-
ies or anecdotal clinical impressions.
When alveolar osteitis develops, the treatment is
generally directed toward decreasing the symptoms
and allowing an adequate environment for healing.
Irrigation and placement of sedative dressings can
accomplish this. In this situation the pain that leads
to the diagnosis and treatment and the pain associated
with the treatment itself is unavoidable. Clearly, pre-
vention is the most effective method of managing this
problem.
This study was undertaken to help establish the
relative importance of various factors commonly as-
sociated with alveolar osteitis and to allow the iden-
tification of those patients that are at increased risk.
Steps can be taken to inform these patients of the po-
tential complication preoperatively and measures to
decrease the risk of development of alveolar osteitis
can be employed.
ATERIAL. AND METHODS
The following protocol was approved by the Ohio
State University Human Subjects Committee. Sev-
enty consecutive patients seen for surgical removal of
bilaterally impacted mandibular third molars were
enlisted into the study. These patients were the con-
trol group for a larger study that was being conducted
@RAL SURG ORA, ?IJED :>RAi PATHOL
April 1992
to evaluate the effect of 0.12% chlorhexidine on the
incidence of alveolar osteitis.7 Patients with acute in-
fection, recent antibiotic use, or the medical need for
surgeon antibiotic prophylaxis were excluded. Patients gave
(n = 16) informed consent for participation. Patients were as-
signed randomly to an experienced or inexperienced
4116
surgeon. The inexperienced surgeon, although not an
3/11
oral surgeon, had received formal training in third
5116 molar removal but lacked extensive clinical experi-
11116 ence. The experienced surgeon was a formally trained
oral and maxillofacial surgeon.
7116
A current standardized panoramic radiograph was
l/16
graded in a blinded manner by an examiner and was
8.0 assigned a score of relative difficulty based on depth,
8.2 angulation, and root formation. The surgeons had no
knowledge of the score given to the radiograph.
Surgery was performed in a standardized fashion
with both surgeons using a similar technique.
Eidocaine 2% with 1: 100,000 epinephrine was given
to all patients as an inferior alveolar block and long
buccal injection, regardless of the use of other seda-
tion or general anesthetics. All patients also received
8 mg of dexamethasone intravenously. Teeth were
removed with a nitrogen-powered handpiece with co-
pious sterile water irrigation. Wounds were closed
with 3-O silk sutures. The time necessary for surgery
was measured for each tooth as the time from onset
of incision to placement of the last suture. No perio-
perative or postoperative antibiotics were used. Pa-
tients received a prescription for 20 325 mg acetami-
nophen with 30 mg codeine tablets (Tylenol 3). Fol-
low-up appointments were made for 1 week after
surgery. Patients were instructed to return earlier if
any problems arose.
A functional definition of alveolar osteitis was em-
ployed. Alveolar osteitis was defined as pain occurring
3 to 5 days after surgery that required the need for
follow-up earlier than the scheduled postoperative
appointment. The history of pain and the need for
early follow-up was believed to be most important to
the patient and practitioner of any of the potential
factors associated with dry socket. The overall inci-
dence of alveolar osteitis and the association of var-
ious risk factors were examined. Chi-square test was
used to evaluate statistical significance of results
(Fisher’s Exact Test was used if the expected fre-
quency was small).
RESULTS
Of the 70 patients who were initially enrolled in the
study, three failed to arrive for the scheduled surgery
and were dropped from the study. Data were collected
for the remaining 67 patients who underwent surgery.
Of these, 5 1 patients were treated by the experienced
Volume 73 Alveolar osteitis after third molar removal 395
Number 4

surgeon and 16 were treated by the inexperienced Table II. Incidence of alveolar osteitis”
surgeon. There was no statistically significant differ-
1 Incidence (W) 1 &‘igni$cance
ence between the experienced and inexperienced sur-
geon with respect to patient distribution according to Overall 20/134(21)
the monitored variables of tobacco and oral contra- Surgeon
ceptive use, sex, age, or radiographically predicted Inexperienced 12/32 (38)
p = 0.0102
Experienced 16/102(16)
difficulty of the extraction (Table I). Sex
Overall, alvleolar osteitis developed in 20 of 134 M 7/50 (14)
F 12/52 (23) p = 0.35
surgical sites (2 1%). Individual risk factors were then
evaluated for their effect on the incidence of alveolar Extraction time
< mean 8/50 (16)
osteitis (Table II). With the experienced surgeon, al- > mean 8/52 (15) p = 0.85
veolar osteitis developed in 16 of 102 surgical sites Oral contraceptive use
(16%), compared with 12 of 32 sites with the inexpe- Yes 3/16 (19)
No 9136 (25) p = 0.91
rienced surgeon (38%). This represents an increase of
greater than 1130%in the incidence of alveolar ostei- Age (yr)
18-22 14/72 (19)
tis for the inexperienced surgeon and was statistically >26 4116 (25) p = 0.84
significant @ = 0.0102) (Table II). Because of the Tobacco use
significant effect of surgeon experience on the inci- Yes 7116 (44)
No 9/86 (10) p = 0.0035
dence of alveolar osteitis, only data from the experi-
enced surgeon were used in analysis of the remaining *There was no statistical difference in the rate of formation betweenteeth
risk factors. This was done to avoid any bias that the 17 and 32 and data for both sideswere combined.
level of experience of the surgeon might have on the
remaining variables.
Dry socket developed in female patients in 12 of 52 of tobacco use was statistically significant
surgical sites (23%), whereas alveolar osteitis devel- (p = 0.0035) (Table II).
oped in 7 of 50 sites (14%) in male patients. This trend
DISCUSSION
toward a higher incidence of alveolar osteitis in the
female patients was not statistically significant Alveolar osteitis is the most common complication
(p = 0.35) (Table Ill). after surgical removal of impacted mandibular third
The mean extraction times were 5.52 minutes and molars. It is widely accepted that the cause of alveo-
5.74 minutes for teeth 17 and 32, respectively. The lar osteitis is fibrinolysis of the clot. Antifibrinolytic
incidence of alveolar osteitis in extractions requiring agents, when placed topically into the extraction site,
less than the mean time was 16% (8/50) and 15% (8/ have been shown to decrease the incidence of alveolar
52) for those requiring greater than the mean time. 0steitis.s 9 Oral bacteria are the most likely cause of
There was no statistical difference between these two this fibrinolysis. Direct evidence to support the role of
groups (p = 0.85) (Table II). these bacteria in the fibrinolytic process exists. It has
No statistically significant difference was found been shown that saliva with a higher microbial titer
between the rale of dry socket formation as a result has significantly greater clot dissolution ability in vit-
of oral contraceptive use. In 3 of 16 surgical sites in ro. lo Indirect evidence to support the role of oral mi-
women using birth control pills (19%) alveolar ostei- crobes also exists because the incidence of alveolar
tis developed, companed with 9 of 36 sites in females osteitis is significantly greater in patients with poor
not using oral contraceptives (25%) (p = 0.91) (Ta- oral hygiene or pericoronitis,’ l-l4 and numerous stud-
ble II). ies have documented the decreased incidence of alve-
Two age groups were compared to see what effect olar osteitis when topica115-20or systemic21, 22 antibi-
age might have on the incidence of alveolar osteitis. otics are employed.
Patients aged 18 to 22 years had an incidence of al- It is also clear, however, that several risk factors
veolar osteitis of 19% (14/72), whereas patients older increase the incidence of alveolar osteitis. Factors that
than 26 years h!ad an incidence of 25% (4/ 16). This have been associated with increased incidence of al-
trend for increa,sed incidence in older patients was not veolar osteitis include inexperienced surgeon,23 diffi-
statistically significant (p = 0.84) (Table II). cult extraction63 24 tobacco25726 or oral contraceptive
In nonsmoking patients alveolar osteitis developed use 4, 27-31inadequate intraoperative irrigation,32 and
in 9 of 86 sites (10%) compared with 7 of 16 sites in&eased age. The mechanism by which most of these
(44%) in tobacco users. This increase of more than factors increase the risk of alveolar osteitis is not
300% in the incidence of alveolar osteitis as a result clearly defined.
 Larsen
The importance of the surgeon’s level of experience
has been demonstrated in previous studies. Sisk et
a1.23found a significant increase in the incidence of
postoperative complications, including alveolar ostei-
tis, after third molar removal when resident surgeons
rather than more experienced faculty surgeons per-
formed the surgery. What about the inexperienced
surgeon specifically leads to the higher incidence of
alveolar osteitis is not clear. Many authors24,33, 34
have hypothesized that the less experienced surgeon
is more likely to create greater trauma and require
more time for the surgery, increasing the chance of
alveolar osteitis. This is supported by some evidence
that the incidence of alveolar osteitis is related to the
relative level of trauma induced by the surgery. In this
study and in others,2 increased trauma as reflected by
!onger surgical times was not associated with an
increased incidence of alveolar osteitis. This may
support the conclusion that, regardless of the inva-
siveness or length of a surgical procedure, if one ad-
heres to proper technique, the incidence of complica-
tion is not increased. More likely it may indicate only
that the length of extraction is a poor indicator of the
level of surgical trauma produced. It does not ade-
quately explain the importance of the level of surgi-
cal experience. An explanation for an increased inci-
dence of alveolar osteitis with the less experienced
surgeon was not found and is likely multifactorial.
Females tend to have a higher incidence of alveolar
osteitis than males.35 This is frequently explained as
resulting from oral contraceptive use in this popula-
tion. This appears reasonable given the overwhelming
data indicating a causal relationship between oral
contraceptive use and alveolar osteitis.4, 27-31 This
study failed to demonstrate an increase in the inci-
dence of alveolar osteitis in women using oral contra-
ceptives. This is likely due to the small sample of pa-
tients using oral contraceptives. It is also possible that
previous studies, most done several years ago, studied
women who were using oral contraceptives containing
higher estrogen levels than those used currently. De-
spite the lack of effect as a result of oral contracep-
tive use, there was still a trend toward increased al-
veolar osteitis in female patients.
Previous studies suggest that a variety of methods
are clinically successful in reducing the incidence of
alveolar osteitis. These include thorough intraopera-
tive irrigation, 32 placement of clot stabilizing factors,
antifibrinolytics,‘l 9 or topical antibiotics1s-20 within
the socket; antimicrobial rinses3, 36,s’; and systemic
antibiotics2’, 52 Of these, intraoperative lavage, top-
ical tetracycline placed within the socket, or periop-
erative 0.12% chlorhexidine rinses appear to be the
best methods of prophylaxis. Systemic antibiotics also
cm.!. SURG 3RAu~kD f;)RAL ?~Ttith
April 1992
decrease the incidence of alveolar osteitis but are no
-more effective than topical antibiotics or rinses3 and
are associated with unacceptable side effects.
With the findings of this study as a guide, the fol-
lowing recommendations can be made:
For the less experienced surgeon or for one who
removes third molars on an occasional basis,
prophylactic measures should be considered for
all patients because of the high incidence of al-
veolar osteitis in all groups when a less experi-
enced surgeon performs the extraction.
All patients who use tobacco should be consid-
ered at high risk for development of alveolar os-
teitis, and appropriate preventive measures
should be employed.
CONWJSION
Data from this prospective study of the incidence of
alveolar osteitis after the removal of 138 consecutive
impacted mandibular third molars suggest that an
inexperienced surgeon and tobacco use by the patient
are the most significant factors associated with an in-
creased incidence of alveolar osteitis. Qther variables
such as increased patient age and female sex were as-
sociated with a trend toward higher incidence that
was not statistically significant. Other variables such
as oral contraceptive use and increased length of sur-
gery, both traditionally associated with an increased
incidence of alveolar osteitis, were found to have no
effect on incidence in this study.
As a result of these data, I recommend that
aggressive prophylaxis for alveolar osteitis be under-
taken for patients at high risk for development of al-
veolar osteitis.
REFERENCES
1. Awang MN. The aetiology of dry socket: a review. Int Dent J
1989;39:236-40.
2. Krekmanov L. Alveolitis after operative removal of third mo-
lars in the mandible. Int J Oral Surg 1981;10:173-9.
3. Krekmanov L, Nordenram A. Postoperative complications af-
ter surgical removal of mandibular third molars: effects of
penicillin V and chlorhexidine. Int J Oral Maxillofac Sure
i986;15:25-9.
4. Lilly GE, Osborn DB, Rae1 EM, Samuels HS, Jones JC. Al-
veolar osteitis associated with mandibular third molar extrac-
tions. J Am Dent Assoc 1974;88:802-6.
5. Berwick JE, Lessin ME. Effects of a chlorhexidine gluconate
oral rinse on the incidence of alveolar osteitis in mandibular
third molar surgery. J Oral Maxillofac Surg 1990;48:444-8.
6. Osborn TP, Frederickson G, Small IA, Torgerson TS. A pro-
spective study of complications related to mandibular third
molar surgery. J Oral Maxillofac Sura 1985:43:767-9.
7. Larsen PE. The effect of a chlorhexidine rinse on the incidence
of alveolar osteitis following the surgical removal of impacted
-mandibular third molars. J Oral Maxillofac Surg 1991;
49~932-7.
8. Birn H. Fibrinolytic activity of alveolar bone in dry socke?.
Acta Odont Stand 1972;30:23-32.
Volume 73
Number 4
9. Ritzau M, Therkildensen P. Antifibrinolytic prevention of al-
veolitis sicca dsolorosa. Int J Oral Maxillofac Surg 1978;7:.534-
40.
10. Timme AG, Buckner RY, Rebitski GF. New evidence impli-
cating oral bacteria in etiology of dry socket [Abstract]. J Dent
Res 1991; 70:349.
11. Krogh HW. Extraction of teeth in the presence of acute infec-
tions. J Oral Surg 1951;9:136-9.
12. Kay LW. Investigation into the nature of pericoronitis. Br J
Oral Surg 196’6;3:188-205.
13. Rovin S, Cortich E, Fleming E, et al. Healing of germ-free and
conventional mice after tooth extraction. J Oral Surg
1966;24:239-46.
14. Rud J. Removal of impacted lower third molar with acute pe-
ricoronitis and necrotizing gingivitis. Br J Oral Surg 1970;
7:153-6.
15. Quinley JF, Royer RQ, Groves RJ. Dry socket after mandib-
ular odontectomy and use of soluble tetracycline HCl. ORAL
SURG ORAL MED ORAL PATHOL 1960;13:38-41.
16. Hall HD, Bildman BS, Hand CD. Prevention of dry socket
withlocalapplicationof tetracycline. JOralSurg 1971;29:35-7.
17. Goldman DR, Kilgore DS, Pauzer JD, et al. Prevention of dry
socket by local application of lincomycin in gelfoam. ORAL
SURG ORAL MED ORAL PATHOL 1973;35:472-4.
18. MacGregor AJ, Hutchinson D. The effect of sulfonamide on
pain and swelling following removal of ectopic third molars. Int
J Oral Surg 1975;4:184-90.
19. Syrjiinen SM, Syrjlnen KJ. A new combination of drugs in-
tended to be used as preventive measures for the postextraction
complication:apreliminaryreport. Int JOralSurg 198 1;10:17-
22.
20. Julius LL, Hungerford RW, Nelson WJ, McKercher TC,
Zellhoefer RW. Prevention of dry socket with local application
of terra-cotril in gelfoam. J Oral Maxillofac Surg 1982;
40:285-6.
21. Rood JP, Murgatroyd J. Metronidazole in the prevention of
dry socket. Br J Oral Surg 1979;17:62-70.
22. Mitchell DA. A controlled clinical trial of prophylactic tinda-
zole for chemoprophylaxis in third molar surgery. Br Dent J
1986;160:284-6.
23. Sisk AL, Hammer WB, Shelton DW, Joy ED. Complications
following removal of impacted third molars: the role of the ex-
perienceof thesurgeon. J Oral Maxillofac Surg 1986;44:855-9.
24. Heasman PA, Jacobs DJ. A clinical investigation into the in-
cidence of dry socket. Br J Oral Maxillofac Surg 1984;22: 115-
22.
Alveolar osteitis after third molar removal 397
25. Sweet JB, Butler DP. The relationship of smoking to localised
osteitis. J Oral Surg 1979;37:732-5.
26. Meecham JG, Macgregor IDM, Roger SN, Hobson RS, Bale
JPC, Dennison M. The effect of smoking on immediate
postextraction socket filling with blood and on the incidence of
painful socket. Br J Oral Maxillofac Surg 1988;26:402-9.
27. Schow SR. Evaluation of postoperative localized osteitis in
mandibular third molar surgery. ORAL SURG ORAL MED ORAL
PATHOL 1974;38:352-8.
28. Gersel-Pedersen N. Fibri,.olytic activity of blood and saliva
before and after oral surgery. Int J Oral Surg 1981;1O(suppl
1):114-21.
29. Sweet JB, Butler DP. Increased incidence of postoperative lo-
calized osteitis in mandibular third molar surgery associated
with patients using oral contraceptives. Am J Obstet Gynecol
1977;127:518-9.
30. Catellani JE. Review of factors contributing to dry socket
through enhanced fibrinolysis. J Oral Surg 1979;37:42-6.
31. Catellani JE, Harvey S, Erickson SH, Cherkin D. Effect of oral
contraceptive cycle on dry socket (localized alveolar osteitis).
J Am Dent Assoc 1980;101:777-80.
32. Sweet JB, Butler DP, Drager JL. Effects of lavage techniques
with third molar surgery. ORAL SURG ORAL MED ORAL
PATHOL 1976;41:152-68.
33. Alling CC, Kerr DA. Trauma as a factor causing delayed re-
pair of dental extraction sites. J Oral Surg 1957;15:3-10.
34. Erickson RT, Waite DE, Rotter E, et al. A study of dry socket.
ORAL SURG ORAL MED ORAL PATHOL 196O;i3:104%8.
35. Field EA. Speechlev JA. Rotter E. Scott J. Drv socket
incidence compared after a 12-year interval. Br .J O;al Max-
illofac Surg 1985;23:419-27.
36. Legarth J, Munster Swendsen J. Klorheksidins virkning pa
vdviklingen af alveolitis sicca dolorosa efter operativ fjernelse
af visdomstaender i under kaeben. Tandolgenbladeh 1977;
81:451.
37. Field EA, Nind D, Varga E. The effect of chlorhexidine irri-
gation on the incidence of dry socket: a pilot study. Br J Oral
Maxillofac Surg 1988;26:395-401.
Reprint requests:
Peter E. Larsen, DDS
305 W. 12th Ave.
Ohio State University College of Dentistry
Columbus, OH 43210