LECTURE: EXODONTIA

TOOTH EXTRACTION

Painless removal of the whole tooth, or tooth

root, with minimal trauma to the investing tissues, so that the wound heals uneventfully and no postoperative prosthetic problem is created. - Geoffrey L.Howe

INDICATIONS FOR EXTRACTION.

1. SEVERE CARIES
2. PULPAL NECROSIS 3. SEVERE PERIODONTAL DISEASE. 4. ORTHODONTIC REASONS. 5. MALPOSED TEETH 6. CRACKED TEETH 7. PREPROSTHETIC EXTRACTIONS. 8. IMPACTED TEETH. 9. SUPERNUMERARY TEETH. 10. TEETH ASSOCIATED WITH PATHOLOGIC LESIONS. 11. AESTHETICS 12. TEETH INVOLVED IN JAW FRACTURES. 13. ECONOMICS.

CONTRAINDICATIONS
Systemic contraindications End stage renal disease Uncontrolled diabetes & Hypertension Leukemia Uncontrolled cardiac disease Bleeding diathesis: Hemophilia, thrombocytopenia

RELATIVE CONTRAINDICATIONS
Pregnancy Drugs- anti coagulants

immunosuppresants e.g., corticosteroids

LOCAL CONDRAINDICATIONS
Teeth: in tumour

irradiated bone Relative contraindication- acute infection i)acute gingival infections like fusospirochetal or streptococcal ii) acute pericoronal infections iii) acute maxillary sinusitis- extraction of maxillary bicuspids and molars is contraindicated.

Pre-operative evaluation

Clinical assessment

Radiological assessment

CLINICAL ASSESSMENT
Heavy restoration

Grossly decayed
Inclined/rotated Firm/mobile Supporting structures may be diseased or

hypertrophied Attrition Non-vital teeth Accessibilty to tooth Sound tooth substance remaining.

INDICATIONS OF PREOPERATIVE RADIOGRAPHS

A history of difficult or attempted extraction.

Tooth which is abnormally resistant to forceps

extraction. Heavily restored or pulpless teeth. If it has been decided to remove the tooth by dissection. All mandibular 3rd molars, instanding premolars or misplaced canines. The root pattern of such teeth is often abnormal.

INDICATIONS OF PREOPERATIVE RADIOGRAPHS

Any teeth or roots in close relationship to

either the maxillary antrum, inferior dental and mental nerves. Any tooth affected by periodontal disease accompanied by some sclerosis of supporting bone. Any tooth which has been subjected to trauma. Partially erupted or unerupted tooth Retained root.

INDICATIONS OF PREOPERATIVE RADIOGRAPHS

An isolated maxillary molar, especially if it is

unopposed & over erupted. The bony support of such a tooth is often weakened by presence of a large maxillary antrum predisposing to either creation of oro-antral communication or fracture of maxillary tuberosity. Any tooth with abnormal crown might indicate possibility of dilaceration, gemination or odontome.

INDICATIONS OF PREOPERATIVE RADIOGRAPHS

Any condition which predisposes to dental or

alveolar abnormality, e.g. a)Osteitis deformans- hypercementosis b)Cleido-cranial dysostosis- hooked roots c)Osteopetrosis-difficult extraction d)irradiated bone-osteonecrosis.

RADIOGRAPHIC EVALUATION OF TOOTH FOR EXTRACTION.

RELATIONSHIP OF ASSOCIATED VITAL

STRUCTURES
CONFIGURATION OF ROOTS CONDITION OF THE SURROUNDING BONE. PERIAPICAL PATHOLOGIES

TYPES OF EXTRACTION:
CLOSED METHOD/FORCEPS

EXTRACTION/INTRA-ALVEOLAR EXTRACTIONconsists of removing the tooth or root by use of forceps or elevators or both.
OPEN METHOD/SURGICAL/TRANS-ALVEOLAR

EXTRACTION-consists of dissecting the tooth or root from bony attachments by removal of some bone investing the tooth/roots,which are then delivered by use of elevators and/or forceps

PRINCIPLES OF EXODONTIA

Pain and anxiety control

Position of the patient

Position of the operator Clear access to and vision of the surgical field Use of controlled force- elevators & forceps Unimpeded path of removal

POSITION OF THE PATIENT

Chair Angulation Chair Height

POSITION OF PATIENT
Angulation of the patient Chair is angulated such that operative field is most visible and accessible position. Occlusal surface of the mandibular teeth are parallel or at 100 to the floor, when operator is working on the mandibular teeth and standing in front of the patient. When operator standing behind patient, angle of the occlusal plane of mandibular teeth is increased until the tooth can be grasped. When working on the maxilla, the chair should be angulated so that the occlusal plane of the maxillary teeth is between an angle of 450 & 600 to the floor.

Height Of Dental Chair

Maxillary teeth extraction- chair should be

adjusted so that the site of operation is about 8cm (3 in.) below shoulder level of the operator. Mandibular teeth extraction- tooth to be extracted is about 16cm (6 in.) below the level of the operators elbow. When operator standing behind the pt- chair should be lowered sufficiently or use a operating box.

POSITION OF THE OPERATOR

Posture

Relation to the patient

Dentists left hand

POSTURE Dentist should stand as nearly erect as possible with his weight equally distributed to each foot.
Any other position will eventually result in

curvature of the spine resulting in discomfort and incapacitating effects.

POSITION OF THE OPERATOR

When extracting any tooth except right

mandibular molars, premolars and canines, the operator stands on the rt hand side of the patient

POSITION OF PATIENT CHAIR AND OPERATOR:

EXTRACTION OF MAXILLARY TEETH

 Operator stands behind the patient for

removal of the right mandibular cheek teeth.

Sometimes the operator must stand upon a

raised platform or operating box in order to achieve the optimal working position.

EXTRACTION OF MANDIBULAR TEETH

THIRD QUADRANT

FOURTH QUADRANT

ROLE OF DENTISTS LEFT HAND

DURING FORCEPS APPLICATION

DURING TOOTH LUXATION

AFTER TOOTH EXTRACTION

ROLE OF DENTISTS LEFT HAND:

DURING FORCEPS APPLICATION Retraction of the lips, cheek and tongue. Guiding beaks of forceps onto tooth Stabilizing patients head during operation on the maxillary and mandibular teeth. In maxilla ,index finger and thumb of left hand is used to support the maxilla and rest 3 fingers to stabilize patients head In mandible,index and middle finger is used to retract and support intraorally ,while thumb supports the mandible.If dentist is standing behind the patient then thumb and index finger is used intraorally and rest 3 fingers support mandible.

DURING TOOTH LUXATION

Supporting buccal and lingual cortices.

Estimating the amount of pressure applied

and the amount of pressure applied and amount of alveolar bone dilatation. Counteracting the pressure applied. Prevention & protection against slipping of forceps & elevators. Removal of broken fillings, tooth fragments or whole tooth before it reaches oropharynx.

AFTER TOOTH EXTRACTION

Compressing the buccal & lingual cortical

plates back into position. Examination of the surgical field and detection of sharp, bony edges, bony undercuts or loose bone fragments.

LIGHT
Good illumination of the operative field is

absolutely essential. To illuminate the field, a well adjusted headlight which can be regulated to throw a 3-inch diameter beam of intense light is preferable

SURGEONS PREPARATION
After patient & chair properly adjusted Operator must wear- head cap mask shatter resistant glasses

operator must remove rings & watch should scrub his hands and arms put sterile gown & gloves

DRAPING PATIENT
Patients head, shoulders & chest should be

covered with a green drape (30 in. wide by 48in. Long with an oblong opening 6 by 4 inches in the centre and 20in. From the top)- Archer

MECHANICAL PRINCIPLES OF EXTRACTION

The three mechanical principles of extraction are 1. Expansion of the bony socket

2. The use of a lever and fulcrum.

3. The insertion of wedge or wedges.

EXTRACTION TECHNIQUE
PROCEDURE FOR CLOSED EXTRACTION Step 1:Loosening of soft tissue attachments from the tooth. Step 2:Luxation of the tooth with a dental elevator. Step 3:Adaptation of the forceps to the tooth. Step 4:Luxation of the tooth with the forceps Step 5:Removal of the tooth from the socket.

USE OF ELEVATORS
1.

2.
3.

4.
5. 6.

Reflect mucoperiosteal membrane, To luxate and remove teeth, which cannot be engaged by beaks of forceps, To remove roots, fractured and carious, To loosen teeth prior to the application of forceps, To split teeth which have grooves cut in them, To remove interradicular bone.

RULES OF ELEVATORS
1. NEVER use an adjacent tooth as a fulcrum unless that tooth is also to be extracted. NEVER use lingual plate as fulcrum, ALWAYS use finger guards to protect patient if elevator slips. Forces applied should be under control,

2. 3.

4.

PARTS OF AN ELEVATOR
Blade

Shank

handle

CLASSIFICATION
Elevators are classified according to

- their use, or - their form.

 According to use
1L & 1R

1. Elevators designed to remove entire tooth. (1L- 1R)

2. Elevators designed to remove roots broken off at the gingival line. (30-4-5)
3. Elevators designed to remove roots broken off halfway to apex. (30-4-5, or 14L-14R or 11R-11L)

14 L & 14R

11L & 11R

4. Elevators designed to remove the apical third of the root. (apical fragment ejectors No. 1,2 & 3) 5. Elevators designed to reflect mucoperiosteum before forceps or extracting elevators are used. (periosteal elevators)

 According to form

1. Straight: Wedge type, 2. Angular: Right and left,

3. Cross bar (Handle at right angle to shank)

TYPES OF ELEVATORS
Ohms periosteal elevator Freys elevator

Howaths elevator

Straight elevator

Coup land's elevator

Winters Crossbar

Warwick-James Elevator

Cryers Elevator

Apexo Elevator

MECHANICAL PRINCIPLES INVOLVED IN EXTRACTION 1. LEVER PRINCIPLE OF FIRST ORDER: 3 basic components-fulcrum,effort,load Fulcrum is b/n effort and load Maximum advantage is when effort arm is longer than load arm Used in forceps along with wheel and axle and in elevators

MECHANICAL ADVANTAGE

Lever of first order Long arm is of the total length Short arm is of total length Downward force of 10 lbs acting at end of long arm causes an output force of 30 lbs at the end of short arm

Mechanical Advantage = output force = 30 lbs =3 input force 10 lbs Therefore mechanical advantage is 3

2. WEDGE PRINCIPLE: Here 2 movable inclined planes with a base on one end and blade on other end Effort is applied to the base of the plane and resistance has its effect on slant side Used to split, expand or displace the portion that receives it Elevators to luxate tooth when applied b/n bone and tooth Forceps when inserted b/n mucoperiosteum and surface of tooth

MECHANICAL ADVANTAGE
FormulaR=Resistance L=Length

E=Effort H=Height

EXL=RXH

or

R\E = L\H

Mechanical advantage = L\H

L = 10mm H = 4mm L\H= 10\4 =2.5

Mechanical advantage is 2.5

3.

WHEEL AND AXLE PRINCIPLE:

Effort is applied to circumference of wheel which turns the axle so as to raise the weight Greater the diameter of wheel more is the mechanical advantage Used in crossbar elevators for removal of mandibular roots

WHEEL AND AXLE PRINCIPLE

FormulaEffort X Radius of wheel = Resistance X Radius of axle

R = Resistance E = Effort Rw = Radius of wheel Ra = Radius of axle

E X Rw = R X Ra or R\E=Rw\Ra
Mechanical advantage = Rw \ Ra Rw=42mm Ra=9mm Rw/Ra=4.6 Therefore, Mechanical Adv= 4.6 Each pound of pressure applied to crossbar is multiplied 4.6times.

APPLICATION OF ELEVATOR

Rotation of the elevator along the long axis

PARTS OF FORCEPS
BEAKS HINGE

HANDLE

RULES OF APPLICATION OF FORCEPS

Selection of appropriate forceps

Grasp forceps at far ends of handles with firm

grip of the palm. Long axis of forceps beaks must be parallel to long axis of the tooth. Forceps beaks must grasp firmly the sound root structure and not enamel of the crown. Beaks must not impinge on adjacent teeth during the luxation.

APPLICATION OF FORCEPS
GRIP:

Thumb is positioned just below the joint of the forceps & forceps handles in the palm with a firm grip. The little finger is placed inside the handle & used to control the opening of forceps blades during application. When the tooth gripped the little finger is placed outside the handle.

PRINCIPLES OF FORCEPS USE:

Forceps can be applied in five major motions. 1.Apical pressure 2.Buccal pressure 3.Lingual pressure 4.Rotational pressure 5.Tractional pressure

Beaks of forceps act as wedge to expand alveolar bone and displace tooth in occlusal direction

BASIC FORCES EXERTED IN EXTRACTION OF MAXILLARY TEETH: First is the apical force. Central incisors-labial pressure,palatal,then labial with mesial rotation Lateral incisors-labial pressure with mesial rotation Cuspids- labial, palatal, labial with mesial rotation 1st PM-Buccal, palatal & removal in buccal direction 2nd PM-Buccal, palatal & removal in palatal or buccal direction 1st & 2nd Molars -buccal, palatal & removal in buccal direction 3rd molar-buccal & distal rotation

BASIC FORCES EXERTED IN EXTRACTION OF MANDIBULAR TEETH: First is the apical force. Central & lateral incisors-labial,lingual,slight mesiodistal & removal in labial direction Cuspids-labial pressure with mesial rotation 1st & 2nd PM-Buccal pressure with slight mesio-distal rotation 1st,2nd & 3rd molar-buccal,lingual & removal in buccal direction

The forcep is seated as far apically as possible.

Luxation is begun with labial force.

Slight lingual force is used.

The tooth is removed to the labial-incisal

Common Errors In Forceps Extraction

Failure to grip the root firmly

fracture of teeth

Incorrect allignment of forceps

blades to the long axis of root.

CAUSES FOR TOOTH FRACTURE:

1.Operators fault -application of incorrect instrument and force -improper technique of application -improper motions 2.Structural abnormality of tooth -excessively curved roots -RC treated nonvital tooth -teeth with gross filling -extensively carious teeth -ankylosis or hypercementosis 3.Surrounding bone-sclerosis or condensing osteitis 4.Unco-operative patient

METHODS FOR RETRIEVAL OF FRACTURED ROOT:

Retained roots might prove as a source of infection,chronic irritation giving rise to neuralgic pain or might interfere with proper functioning of denture

Closed technique when tooth is well luxated and mobile before fracture Root tip pick,small elevator,forceps with slender beaks,reamers If not then open method should be attempted

ORDER OF EXTRACTION:
First is usually maxillary teeth as they get

anesthetized earlier and prevents fall of enamel or amalgam/debris into mandibular socket Most posterior teeth is extracted first The order is 3rd molar,2nd molar,2nd premolar,1st molar,1st premolar,lateral incisor,canine,central incisor.

EXTRACTION OF DECIDUOUS TEETH:

Indications-gross caries involving pulp -retained primary teeth interfering with normal eruption of permanent successor -periapical pathology/root fracture Technique -smaller forceps -for U/L anteriors labial pressure with mesial rotation and removed to labial side -for U/L molars buccal pressure ,lingual pressure and removed to lingual side -force applied is less and forcep need not be inserted too deep along the root -care should be taken not to damage permanent successor

TRANS-ALVEOLAR EXTRACTION INDICATIONS: Any tooth which resists attempt at closed extraction Heavy/dense bone,short clinical crown due to attrition Hypercementosis,ankylosis,geminated & dilacerated roots Impacted tooth Retained fractured tooth/roots which cannot be grasped with forceps or elevators Roots in close proximity with vital structures like nerve or sinus Grossly destructed,heavily restored,RCTreated Prosthetic considerations

PROCEDURE:
Anesthesia-LA,plan for incision

Elevation of mucoperiosteal flap

Removal of bone-chisel mallet or bur Division of tooth if required

Removal of tooth and roots

Control of bleeding Alveoloplasty if required Toileting of the alveolar socket Suturing of flap

MUCOPERIOSTEAL FLAP: The term local flap indicates a section of soft tissue that Is outlined by a surgical incision Carries its own blood supply Allows surgical access to underlying tissues Can be replaced in the original position Can be maintained with sutures and is expected to heal

DESIGN: -Base of flap must be broader than free gingival margin -must be of adequate size to provide access & visibility -long,straight incision over intact bone -full thickness flap -6-8mm away from bony defect to prevent collapsing of flap into it -preserve vital structures -vertical releasing incision is oblique incision which cross free gingival margin at line angle of tooth and not on facial aspect or papilla.

TYPES OF MUCOPERIOSTEAL FLAPS:

1. ENVELOPE FLAP: most common flap -2 teeth anterior and one teeth posterior to area of surgery -releasing incision 1 tooth ant and 1 tooth post -3 cornered or 4 cornered 2. SEMILUNAR :to approach root apex -avoids trauma to papilla & gingival margin -limited access -used in periapical surgery 3. Y INCISION :palatal tori, preserves greater palatine artery

TECHNIQUES FOR DEVELOPING MUCOPERIOSTEAL FLAP:

-No.15 blade is used on a no.3 scalpel handle and held in a pen grasp -blade is held at an angle & incision is made posteriorly to anterior in gingival sulcus -smooth,continuous stroke with blade in contact with bone

-if vertical incision is to be placed ,tissue is apically reflected,with opp hand tensing the alveolar mucosa

-start reflecting from papilla using woodson elevator or sharp end of no.9 periosteal elevator -carried out in pushing stroke,posteriorly and apically -once reflected flap is held with austin retractor resting firmly on sound bone.

BONE REMOVAL:

Bone removal must be limited carried out with dental burs or chisel with hand or mallet pressure CHISEL & MALLET: Quicker and cleaner Maxillary buccal and lingual plates can be removed Limiting cuts are placed vertically and then joined by horizontal cut If force is not controlled it might lead to fracture of basal bone or adjacent teeth DENTAL BURS: Used for dense mandibular bone Round bur no.8 or rose head burs are used,cut efficiently,do not clog,easier to control.

flap must be held away from the site with a retractor Bur must not be allowed to overheat during bone removal,frequent irrigations with sterile normal saline should be used to prevent this and also removes debris and prevent bur from clogging Bone might be removed by either simply cutting it away or by bone guttering.

A row of small holes is made with small bur along buccal crest and joined with fissure bur or chisel cuts.A gutter is formed.This is called postage stamp method.
In case of lower PM,bone removal should be maximal medial to 1st PM and distal to 2nd PM to minimize damage to nerve & vessels traversing mental foramen

ODONTECTOMY
It is the surgical removal of a tooth or teeth by

reflection of an adequate mucoperiosteal flap and also bone from between the buccal roots of molars, by means of chisels, burs and/or rongeurs. Advantages: -reduction in fractured crowns/roots during extraction -less danger of creating oro-antral fistula -preventing injury to neurovascular bundle in mandible. -less chances of tearing out large areas of cortical & cancellous bone.

INDICATIONS OF ODONTECTOMY
Hypercementosis Divergent roots Locked roots Dilacerated teeth Teeth with post crowns

Extensively decayed teeth

RCT Thick dense buccal/labial cortex Thin mandible

Hollow maxillary tuberosity

Malposed teeth, impactions, unerupted teeth & supernumeraries Ankylosed roots When customary force fail to produce luxation.

TOOTH SECTIONING:
Accomplished with a straight hand piece with a

straight bur such as no.8 round bur or fissure bur no.557 or no.703 Sectioning is done from below upwards so that operator knows when the roots are completely divided

TECHNIQUE FOR OPEN EXTRACTION OF SINGLE ROOTED TEETH:

TECHNIQUE FOR SURGICAL REMOVAL OF MULTIROOTED TEETH:

REMOVAL OF FRACTURED ROOTS BY OPEN METHOD:

POLICY FOR LEAVING ROOT FRAGMENTS:

Root fragment must be small,not more than 3-4mm It must be deeply embedded in bone,to prevent subsequent bone resorption from exposing tooth root & interfering with prosthesis. Must not be infected & no radiolucency around root apex than The risk of surgery must be greater than benefit such as: Removal causes excessive destruction of surrounding tissue,bone or gingiva Endangers vital structures like inferior alveolar nerve There are chances of displacing root into tissue spaces or into maxillary sinus Patient must be informed about the judgement and consent must be obtained.

POST EXTRACTION CARE OF TOOTH SOCKET:

Saline or betadine irrigation

Thorough curettage in case of periapical lesion

Compress bucco-lingual plates with finger pressure In case of severe periodontitis excessive granulation

tissue must be removed Sharp bony projections if any must be smoothened with bone file Gauze pressure pack for control of bleeding

POST EXTRACTION INSTRUCTIONS GIVEN TO THE PATIENT:

Explain the patient effects of LA

Hold the gauze in mouth for atleast half an hour

Avoid spitting and gargling for the day Warm saline rinses after 24hrs

Not to disturb the area with finger or tongue

Avoid hot,spicy and hard food Analgesics ,antiinflammatory for 3 days Antibiotics if patient is immunocompromised Avoid brushing in the area for 24hrs

COMPLICATIONS OF TOOTH EXTRACTION

Failure to: 1.secure anesthesia

2.remove tooth with forceps/elevators

Fracture of: 1.crown of tooth being extracted

2.roots of tooth being extracted 3.alveolar bone 4.maxillary tuberosity 5.adjacent/opposing tooth

 Dislocation of: 1.Adjacent tooth

2.TMJ Displacement of a root- into soft tissue - into maxillary antrum - under GA in dental chair Excessive hemmorhage: -during tooth removal -on completion of extraction - postoperatively Damage to -Gums -Lips -Inferior alveolar nerve or its branches -Lingual nerve -Tongue & floor of mouth

 Postoperative pain due to:

-Damage to hard & soft tissue -Dry socket -Acute osteomyelitis of the mandible -Traumatic arthritis of the TMJ Postoperative swelling due to- Oedema - Hematoma formation - Infection Trismus Creation of oro-antral fistula Syncope Respiratory arrest Cardiac arrest Anesthetic emergencies

EXTRACTION SOCKET WOUND HEALING Socket heals by second intention. Immediate reaction:
When a tooth is removed, socket fills with blood which coagulates to seal it from oral environment. Inflammation & clearance of debris such as bone fragments.

Events in 1st week

Proliferaion of fibroblasts around entire periphery of clot Epithelium migrates until it meets epithelium from other side

or it finds a bed of granulation tissue. Osteoclasts accumulate along the crestal bone

2nd week
Osteoid deposition along alveolar bone lining

Epithelium may be fully intact

3rd & 4th week

Epithelisation of most socket being complete .
Resorption of cortical bone from crest and wall of socket.

4-6 months
Complete resorption of cortical bone lining takes place. Epithelium moves toward the crest as bone fills socket,

eventually becoming level with adjacent crestal gingiva. Radio graphically loss of distinct lamina dura.

COMPILICATIONS OF EXTRACTION WOUND HEALING DRY SOCKET[ALVEOLAR OSTEITIS] 1. It is due to degeneration of the clot from the socket 2. Characterized by production of foul odor. 3. It has severe pain but no suppuration. 4. Appears dry due to exposure of bone
FIBROUS HEALING OF EXTRACTION: It is another

complication of extraction socket wound healing.

DRY SOCKET

INTRODUCTION
Crawford first given the term socket in 1896

because of lack of exudate and loss of blood clot in the socket. This term has stood the test of time and is still preferred by many. It is unique abnormal healing of socket rather than delayed normal healing that might be expected with poor general health.

SYNONYMS
The term dry socket has various synonyms which

include Necrotic alveolar socket - Alling (1959) Alveolalgia - Bjerke (1960) Localized osteomyelitis Israel (1970) Fibrinolytic alveolitis Birn (1973) Acute alveolar osteitis Shafer (1974) Localized osteitis Alveolitis sicca dolorosa

DEFINITION
Very unpleasant local complication of

extraction of tooth where the disintegration (breakdown) of socket coagulum and exposure of bare bone of the alveolar socket resulting in localized osteitis involving either the whole or a part of the condensed bone, leaving the tooth socket, (the lamina dura) with varying degrees of severity of pain.

SIGNS AND SYMPTOMS

Surrounding gingiva often shows inflammatory reactions,

swollen and dusky red.

The site of pain can be clearly identified as the site of

removal of tooth 48-72 hours later.

regional lymph nodes may be enlarged and tender. Increase in temperature hardly seen. The diagnosis is confirmed by gently passing a small

probe into the socket where in case of dry socket bare bone is encountered, which is extremely sensitive.

 Empty alveolar socket, covered by grayish necrotic

tissue
Excruciating pain Halitosis Surrounding gingiva exhibits mild Inflammation Patient is unwell due to lack of sleep Sex distribution:

More frequent in female than male 3:2.

Distribution within dental arch

More common in mandible (3 times more) especially in molar region.

GENERAL FACTORS
Debilitating diseases causes decreased resistance.
Uncontrolled diabetes, liver diseases, syphilis, anemia,

hemorrhagic diathesis, disturbances in the function of endocrine glands, diseases of the sympathetic nervous system.
Protein deficiencies, vitamin A,B,C and D deficiencies,

Ca and phosphorous deficiencies.

Pagets disease, marble bone disease, myelosclerosis,

irradiated jaw- these conditions will have risk of alveolar osteitis and may progress to frank osteomyelitis.

LOCAL FACTORS
Insufficient blood supply to the alveolus either by its normal anatomical

structures or by pathological changes.

Due to more bone density ( pagets , marble bone disease) reduces

the polymorphonuclear leucocytes circulation

Pre- existing infection( Marginal periodontitis, pericoronitis), increase

incidence of dry socket and in Vincents infection it is an invitation to trouble

The use of too large amounts of local anesthetics with

vasoconstrictor- temporarily inhibit the vascular component of the inflammatory reaction and would tend to favour the establishment of local infection.

 Post operative bleeding may also be one of the

causative factor.
Wider stripping of periosteum and severance of the

attachment of muscles, and other trauma lead to liberation of tissue pro-activators accounting for the increased local fibrinolysis.
Trauma to the alveolar bone during extraction damages

and devitalizes the bone of the socket wall and thrombosis of underlying vascular plexus reducing its resistance to infection and increase the local release of plasminogen activators, weakening of local cellular defense mechanism facilitating bacterial invasion

 Infection during or after the extraction caused by the salivary

contamination or by using unsterile instruments. Root or bone fragments or foreign bodies left in the socket. Disturbance of the clot. Excessive irrigation, curettage after extraction Repeated injections or intraligamental techniques increase risk of ASD Heavy spitting or sucking post-operatively Vigorous rinsing, playing with tongue or finger Irradiated jaw has reduced blood supply due to endarteritis obliterance. The factors which influences vascular function, such as the oral contraceptive pill, smoking, menstrual phase increased incidence of dry socket is due to increase in fibrinolytic activity. Pregnancy decrease risk of ASD. Fibrinolytic activity in the blood clot.

BIRNS HYPOTHESIS(1973)

TREATMENT

Objective: Relieving the discomfort and pain. Prevention of further infection. Promotion of healing.

Treatment should be: Symptomatic Relieve pain and to speed up the resolution Socket is irrigated with warm normal saline or dilute solution of 3% H2O2 to remove necrotic material All degenerating blood clot and food debris to be washed, meticulously removed Curettage of socket to stimulate bleeding or to remove debris not favoured allows the infection to penetrate deep into bone and also destroys any previous attempt of normal healing Sharp bony spurs to be excised Cotton wool or gauze soaked in dressing material packed in the socket not tightly but to cover complete bare bone Chemical cauterization of bare bone can also be done Analgesics

 Hot saline mouth baths advised Review once in 2 days and change the

dressing In suppurative type of dry socket Adv antibiotics to prevent progressive involvement of the adjacent parts of the bone, to combat the effects of bacterial contamination and to minimize local inflammatory reaction. Metronidazole 400 mg tid 5 days

SEDATIVE DRESSING

 The dressing materials available:

Chlorophenol camphor menthol after acute symptoms

subsides changed with Neomycin, Bacitracin, gauze Zinc oxide eugenol +LA. (dry socket which has perished for weeks lined with yellow brown bone and which show no signs of healing) Drawback delay in healing due to superficial necrosis of the bone and nerve endings add to local tissue damage) Whitehead varnish (Doesnt relieve pain but good antiseptic, can be kept for 2 or 3 weeks without changing)

Tinc benzoin (Sumatra in coarse powder) Storax Balsam of Tolu Iodoform Solvent ether

- 10 parts (3 gm) - 7 parts (2 gm) - 5 parts (1.5 gm) - 10 parts (3 gm) - 100 parts (28.4 ml)

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