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Indian J Stom atol 2010;1(1):1-5

AbstractAlveolar osteitis (dry socket) is a com m on and painful com plication after tooth extraction. The incidence of dry socket ranges

from 3% to 20% with a higher frequencyafter the extraction of m andibular posterior teeth. Although the etiology of dry socket isd e b a te d , i t i s p r o ba b l y m u lt i f a ct o r ia l , a n d i t s p a t ho g e ne s i s r e m ai n s u n k no w n. T h e r e a r e v a r io u s w e l l- e s ta b l is h e d p r e ve n t iv em easures against dry socket. Despite the num ber of remedies available for dry socket, we have tried a new com bination of drugsie., M ercurochrome and Chlorom ycetin, which yields effective results in the m anagem ent of dry socket.

Keywords: Dry socket; Chloromycetin; Mercurochrome; alveolar osteitis; extraction.

Role of Mercurochrome and Chloromycetin in the Management of Dry Socket: A Clinical Study With a

New Approach

1 1 1 2A s ho k B a ns a l , S h iv a ni J a in , S r im a th y A r or a , S h ip r a G u pt a

7Introduction anaestheticwhich reducesthe blood supply to the area.A l v eo l a r o s t ei t i s ( d r y s o c ke t ) is a p a i nf u l c o m pl i c at i o n 2 . E xc es si ve i rr ig at io n a nd c ur et ta ge o f so ck et d ur in g

3,8after tooth extraction m ainly traum atic, which affects extraction.m i l li o n s o f p a t i en t s a r o u nd t h e w o r ld . D r y s o c k e t h a s b e e n 3 . P r es e nc e o f r o ot a n d/ o r b on e f r ag me n t, f o re i gn b o dy

3used in the literature since 1896, when it was first described l i k e c a l c u l us i n t h e s o c ke t .1

by Crawford. This painful condition can be avoided in a 4 . E x c es s i ve s p i tt i n g, r i n s i ng a n d s u c k in g o f w o u n d f ol l -3m ajority of cases by proper understanding. It will save owing extraction.

u n n ec e s sa r y a g on y t o p a t ie n t s a n d l o s s o f c o u nt l e ss h o u rs 5 . P o o r o ra l h y gi e n e , sm o ki n g , s ne e z i ng p r e d is p o se t o t h eof dentist's practice in dealing with it. f o r ma t i on o f d r y s o ck e t a s i t c a n i m pe d e h e a l in g o f D r y s oc k et i s a n a c u te , n on - su pp u ra t iv e i nf l am ma t or y wounds, possibly due to the decreased am ount of oxy-

9process localized in the dental alveolus and is character- gen availablein the healing tissues.i z e d by l a t e o n s et ( 2 - 4 da y s p o s t e x t ra c t i on ) , s ev e r e a n d 6 . I n s uf f i ci e n t b l o od su p p ly of th e b o n e p a r t ic u l ar l y i nradiating pain, absence of typical inflam m atory signs, a g ed p a ti e nt s b e ca u se o f s c le r os i s o f b on e a n d ot h er

3,9unpleasant taste, fetid odour, em pty socket, gingival infla- debilitating diseases like diabetes, anem ia etc.m m at i o n, r e g i o na l l y m p ha d e no p a th y a n d s e n si t i vi t y o f 7 . T he f e ma l e p a t ie n ts o n o r a l c o n tr a ce p ti v es a r e a t h ig h er

2i n ta k e o f f o od o r d r in k s. T h e p a in i n cr e as e s o n m a st i ca - r i s k o f d ev e l op i n g d r y so c k et a s e s t r og e n s l o ws d o w n

9tion and interferes with the norm al activity of the patient. the healing process.T h e m ai n c h ar a ct e ri s ti c o f t h e d r y s oc k et is t he d e nu de d 8 . F ib ri no ly ti c a nd p r ot eo ly ti c a ct iv it y i n t he b lo od c lo tappearance of the socket due to disintegration of blood clot because of infection due to anaerobic m icro-organism sleaving behind a gray or grayish yellow bony socket bare of e s p e c i a l l y T r e p o n e m a d e n t i c o l a , a n a n a e r o b i cg r a nu l a ti o n t i s su e . T h e d i a gn o s is i s c o n f ir m e d b y ge n t ly s pi ro ch et e w it h l yt ic c ap ac it y f ol lo we d b y Fusiform

passing a sm all probe into the extraction wound; in the bacilli and Streptococci a pp ea r to ha ve a r ol e i n th e2,6a lv eo la r o st ei ti s b ar e b on e i s e nc ou nt er ed , w hi ch is onset of dry socket.

e x t re m e ly s e n si t i ve . T h e p a i n i s c a u se d b y t h e t h e rm a l a nd 9 . P r e - ex i s ti n g i n f e c ti o n l i k e p e r i ap i c al i n f e c t i on , p e r i o d -3chem ical irritation of the exposed term inal nerve endings ontitisand pericoronitis.

i n la mi na d ur a l in in g th e a lv eo la r so ck et a nd i n th e 1 0 . P o o r s t e r i li z a ti o n o f t h e i n s tr u m en t s , s e pt i c s u r gi c a lr e m na n t s o f p e ri o d on t a l l i g am e n t t o a i r, f o o d a n d l i q ui d s procedure and excessive instrum entation during extra-

10t ha t e nt er s t he m ou th . I t i s a ls o n am ed a s f oc al os te o- ction.m y e li t i s, a lv e o la r os t e it i s , a l v eo l i ti s s i c c a d o l or o s a a n d By avoiding all possible adverse factors, risk of dry socket3fibrinolytic alveolitis. f or ma ti on c an b e r ed uc ed . Th er e a re v ar io us w el l-I n s p i te o f t h e b e s t c a r e t a k en an d a s e pt i c t e c h ni q u e u s e d e s t ab l i sh e d p r e v en t i ve m e a su r e s l i k e m e t ic u l ou s a p p ro a c hd ur i ng e x tr a ct i on o f a t o ot h , t he i n ci d en c e o f d ry s o ck e t t o t h e e x tr a ct i on al o ng w i th at r au ma t ic e x tr a ct io n a n d

4f o r ma t i on va r i e s f r o m 0 % t o m o re t h a n 3 0 % . I t o c c ur s aspectic procedures, providing antibiotics, anti-fibrinoly-m ore frequently in m andibular m olars particularly third t i cs a n d ph y si c al m e th o ds t ha t p ro mo te o r a cc e le r at e

11,14m o la r s w i t h a n i nc i d e nc e o f 2 0% t o 30 % a nd i s m o r e w i t h alveolar reconstruction such as use of soft laser.s i n gl e t o o th e x t r a c t io n a s c o m pa r e d t o m u l ti p l e t o o th e x t r - Va r i ou s t r e a tm e n ts l i k e p r e sc r i b in g a n a l g e s ic s a n d a n t i b i -

5,6actions. o t i cs , m o ut h r i n s e s w i t h t e t ra c y cl i n e s o l ut i o n, p a c k i n g o f

obtundent dressing like zinc oxide eugenol, topical anaest-Pathogenesis h e t ic l i k e b e n z oc a i ne , f o l l ow i n g l oc a l i r r ig a t io n o f t h e

The pathogenicity of dry socket form ation is not yet fully socket with warm sterile isotonic saline solution or a dilutee s t ab l i sh e d , b ut i t m a y b e p r o du c e d b y a c o m bi n a ti o n o f h y d ro g e n p e r ox i d e s o l ut i o n t o r e m o ve n e c ro t i c m a t er i a l sseveral following predisposing factors: a n d o t he r d eb r is h a ve b e en r e co mm e nd e d fr o m ti me t o1 . U s e o f e x c es s i ve a m ou n t o f a d r e na l i ne c o n ta i n in g l o c a l tim e. M ercurochrom e, Covam ycin D, corticosteroids and

1 2Dep artmen t o f Oral an d Max illo facial Su rg ery , Swami Dev i Dy al Ho spital an d Den tal Co lleg e, Hary an a, Dr. Harv ansh Sin g h Ju d g e

In stitu te o f Den tal Scien ces an d Ho sp ital, Ch an d ig arh , In d ia. Co rresp o n d ence: Dr. Sh ip ra Gu p ta, email: teen a1 4 7 2 @y ah o o .in

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non steroidal anti-inflamm atory m edication for the m ana- Discussiong e me n t o f p a in a n d i nf l am ma t io n a f te r t h ir d m ol a r s ur ge r y D r y s o ck e t i s a p a in f ul c om pl ic a ti o n w h ic h oc c ur s r o ut i n-

15- 17 e l y i n th e c l i ni c s . I t i s c h a ra c t e ri z e d b y s e ve r e p a i n wh i c hh av e a ls o be en t ri ed . C ur et ta ge o f th e s oc ke t no t on lynd rd

predisposes the patient to the spread of infection but also starts on the 2 or 3 day post-operatively. The generally18- 21 accepted aetiology of dry socket is an increased localdestroysany previous attem pt at norm al healing.

7I n t h e p r e se n t s t u dy w e h a v e e v a l u a t ed t h e c o m bi n e d u s e o f f i b r in o l ys i s l e a di n g t o d i s in t e gr a t io n o f t h e c l o t. S u r gi c a lM e r cu r o c hr o m e a n d C h l or o m yc e t in . T h e s t u dy i s a i m ed t o t r a u ma d u r in g e x t ra c t i on o f t e e th l e a di n g t o l i b er a t i on o f e v a l ua t e t h e ir r o l e i n t h e t r e a tm e n t o f d r y s o c ke t f o r d i f fe r e n t t i s su e a c t iv a t or s a n d b a c te r i a l i n f ec t i on s r e m ai n

immediate relief of pain. the 2 most initiating factors o f this l ocalized fibrinolytic22activity.

M a t e r ia l s a n d m e t h o d M o st o f t h e s t u di e s h a v e g i v en t h e i n c id e n ce o f d r y so c k etA p r o sp e c ti v e c l i ni c a l t r i al o n 5 0 p a t ie n t s w i t h a h i s to r y o f i n a ll e x tr a c ti o n s a s r a n gi n g f r o m 2 % - 4. 4 % an d a s h i g h a sdry socket was conducted over a period of 6 m onths irresp- 1 2 . 5% w h e re a s i n t h ir d m o l ar e x t r ac t i on s , t h e i n c id e n ce o f

7,22,23e c ti v e o f ag e , s e x, r a ce i n th e D e pa r tm e nt o f O r al a nd d ry s oc ke t i s f ro m 0 .5 %- 15 %. T hi s i s l ar ge ly d ue t oMaxillofacial Surgery at Swami Devi Dyal Dental College d i ff e r e nc e s i n d i a g n os t i c c r i t e r i a a n d i n t h e m e t ho d s o f a s s -

24,25a n d H os p it a l, B a rw a la . T he p a ti e nt s w i th t he h i st o ry of e s sm en t , s u rg i ca l te c hn i qu e s o r su rg i ca l sk i ll . I n t h isa l l er g y t o s o me a n t ib i o ti c s o r l o c a l a n e s t h es i a , t h o se r e c e i- study, a m inim um of pain and an em pty socket with foodving treatm ent for hepatic or renal insufficiency, im m uno- d e b ri s a n d s h i ve r p i e ce s o f b l o od w e r e c o n si d e re d d i a gn -deficiency, blood dyscrasia, pregnant and even breast ostic.feeding patients were excluded from thestudy. I n t h is s tu d y, t h e c l in i ca l p i ct u re i n a l l t he p a ti e nt s o f d r yT h e p a t ie n t s r e p or t e d w i t h t h e h i s to r y o f d r y s o c ke t w i t h s o c ke t w a s t h a t o f p a i n a n d e m p t y s o c k e t s w h i c h i s i n a g r e -

5,24,26,27m a j or c o m p l a in t o f s e v e r e r a d i at i n g p a in 2 - 3 d a y s a f t e r t h e e me nt wit h the f ind ing s of se ve ral au tho rs . Th ee x tr a ct i on ; w e d e ci d ed t o a p pl y a c o mb i na t io n p a ck o f average onset of sym ptom s in our study was found to be on

nd rdM ercurochrome and Chlorom ycetin in the em pty socket 2 o r 3 d a ys p os t -o p er a ti v el y bu t in s om e s t ud i es i t wa s

for imm ediate pain relief. Random blood samples of the around 36 hours after theextraction which was due to othert r ea t ed p a ti e nt s w e re t a ke n t o k no w t he e f fe c t of t o pi c al post-operative com plications such as swelling and trism us.Chloromycetin on blood cell count. C a s e s i n w h i c h t he o n s et w a s a l i t tl e m o r e d e l a y ed i s e x p la i -M ercurochrome solution was prepared by dissolving 5gm n e d b y t he n o t io n t h at a n i n fe c t i on p r o ce s s w a s n e e de d t oo f M e r c u ro c h r om e c r y st a l s i n s u ff i c i en t d i s t il l e d w a t e r t o l i b er a t e t i s su e a c t i va t o rs a n d p a i n m e d i a t or s . T h e n e u ro l o -m a k e 1 0 0 ml s ol u t io n . Fi r s t o f a ll t h e e n t ir e s o c ke t w as g i c al p a i n o f d r y s o c k e t i s b e l ie v e d t o b e r e l a te d t o t h e r e l e a -

26,28cleaned and irrigated with 3% weak hydrogen peroxide se of kinins following tissue traum a.s o l ut i o n ( an e f f e c ti v e g e r mi c i da l c h e mi c a l w hi c h k i l ls P a in w a s t h e c h ie f c om pl a in t i n a l l th e p a ti e nt s w i th d r ygerm s by oxidation process) to rem ove the debris. Then a s oc k et . T he p r ev e nt i on o f d ry s o ck e t is d e si r ab l e a n d as t e ri l i ze d c o t t o n p l ed g e t w a s s o a ke d i n M e r c ur o c h ro m e n um be r o f s tu d ie s h a ve s h ow n t he e ff i ca c y of d i ff e re n ts o l ut i o n a n d th e p a r t o f p le d g et , w h i ch w a s t o f ac e f u n du s preventive m easures which include use of topical peni-of the socket, was coated with Chlorom ycetin powder and cillin; dry socket dressings like zinc oxide eugenol which is

packed in the em pty socket. The dressing was kept soft and placed snugly in the extraction socket; washing the areal o o se t o mi n i mi z e t h e c h a nc e s o f s pr e a d o f i nf e c t io n f r o m with 0.12% chlorhexidine gluconate; application of Tran-t h e s o c ke t . A f t er w a r ds a c o t to n p a ck w a s g i v en f o r h al f a n exam ic acid to alveolar sockets; topical antibiotics such ashour to prevent leakageof Chlorom ycetin in the oral cavity m etronidazole, tetracycline, am oxicillin, clindam ycin and

13,22,27- 30s o as t o mi n i mi z e i t s b i t te r ta s t e. P a ti e n t w a s a d v is e d t ol in co my ci n ge l fo am. T he y ar e f r eq ue nt ly a ss oc ia te dc h e w s o m e c a n d y i n o r d er to m i n im i z e t h e b i t te r t a s te a n d with post-operative pain, require repeated dressings, forei-

w a r m s a l in e g a rg l e s a f t e r 3 h o u rs , 3 - 4 t i me s a d a y a n d t a k e g n bo d y r e ac t io n , n e ur i ti s a n d m or e c h an c es o f in f ec t -14,18- 21som e analgesicsif pain persists. The dressing was rem oved ion.

after a day. In m ajority of the patients, there was no need to The m anagem ent of dry socket has witnessed m any revie-r e pe a t t h e d r es si n g. A v is u al a na l og ue s c al e w a s u s ed t o w s o v er t h e y e ar s l i ke t o pi c al v i s co u s 2 % l i do c ai ne j e ll y,m ea s ur e t h e i n te n si t y o f p a in i n a l l t h e p a ti e nt s w i th d r y u se o f c l in da m yc i n a n d b u cc o ad h es iv e m e tr o ni d a- z ol esocket. 27,30,31

t ab le ts o r t op ic al m e tr on id az ol e. A s i nd ic at ed b y F az -akerley et al., the prim ary consideration in the treatm ent of

Resultsdry socket is pain control until com m ence-m ent of norm al

T h e c h i ef c o mp l a in t of a l l t h e p a t ie n t s w i t h t h e h i s to r y o f h e a li n g , a n d i n t h e m a j or i t y o f c a s e s l o c al me a s u re s a r end rd

d r y so c k et w a s s h o o t i ng p a i n 2 o r 3 d a y p o s t- o p er a t i ve l y. 32s a t is f a c to r y. I n t h i s s t u dy m e r c u ro c h ro m e a n d c h l or o m y-

P o s t- o p e ra t i ve h e a li n g w a s e x c e ll e n t w i t h n o p a i n o n f i r s tc e t i n d re s s in g w a s u s e d i n t h e t r e a tm e n t o f d r y s oc k e t f o r

d a y i n m a j o ri t y o f t h e p a t ie n t s w h i c h w a s a s k e d o n t h e b a s isim m ediate relief of pain. In m ajority of patients there was

o f v i s u al a n a l o gu e s c a le . H e a l i ng t o o k p l ac e b y s e c on d a r yn o n e e d o f a s e c on d d r e s si n g . M er c u r oc h r om e i s a n a n t i se -

intention.Out of 50 patients, 5patients reported with em ptyptic and an organo m ercuric disodium salt com pound

socket with dislogdem ent of pack and 3 patients reportedwhich depolarizes the resting m em brane potential slightlyw i t h mi l d to l e r ab l e p a i n o n f i r st d a y. A l l t he p a t ie n t s w e r e

but com pletely blocks conduction of the propagated actionprescribed analgesics on dem and post-operatively but m o-

potential. M ercurochrome has a disadvantage that it m ays t o f t he p a ti e nt s d i d n o t r e qu ir e a n al g es ic s a f te r t h e

c o n ta i n m e t al m e r c u r y b u t n o s t u dy t i l l d a t e h a s d e f in i t el ydressing.

linked M ercurochrome with m ercury poisoning. M ercuro-c h r o me c a u se d a r k r ed d i sh t o b r ow n s t ai n i ng o f t h e o r a l

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1 2 . S w ee t JB , B u tl e r DP. P r ed i sp o si n g a n d o pe r at i ve f a ct or s :m ucosa which persisted for 30-60m inutes.E f fe c t o n t h e i n c i de n c e o f l o c a li z e d o s t e it i s i n m a n di b u la r Chlorom ycetin, is a broad spectrum bactericidal antibiotic

third molar surgery. Oral Surg Oral Med Oral Pathol 1978;a n d i s e f f ec t i ve a g a i ns t g r a m +v e , g r am - v e a n d a n a e ro b i c46:206-15.bacteria. It is an inexpensive and readily available drug. On

1 3 . R a g no J R , S z k u tn i k A S . E v a l ua t i o n o f 0 . 1 2% C h l o r he x i di n es ys te mi c u se , i ts d is ad va nt ag e i s r ev er si bl e i .e ., b on e

r i n s e o n th e p r e ve n t io n of a l v eo l a r o s t e it i s . O r a l S u rg O r a lm a r ro w t o x ic i t y a nd r a r e l y a p l a st i c a n a e mi a . I n o u r s t ud y Med Oral Pathol 1991;72:524-26.c a s e s w e h a v e a p p l i e d i t t o p i c al l y a s a b r o ad - s pe c t r um a n t i - 1 4. L ar se n P E. T he e ff ec t of a c hl or he xi di ne r in se o n th e

bacterial agent to com bat the infective com ponent in the in cid en ce o f alv eolar o steitis fo llo win g th e su rg ical remo v alo f i m p a c t e d m a n d i b ul a r t h i r d m o l a r. J O r a l M a x i ll o f a c S u r gdry socket despite of its bitter taste. Chlorom ycetin, which1991;49:932-37.i s h i g hl y h y g ro s c op i c , i s a v a il a b le i n p o w de r e d f o r m i n

1 5 . J o n es E F. D e n t a l s e c ti o n . J N a t l M e d A s s oc 1 9 40 ; 3 2: 8 9 -9 1 .1gm vial and is well known for causing bone m arrow depr-1 6. v a n E e de n S P, B to w K . Po s t- o pe r at i ve s e qu e la e o f l o we r e ss io n o n s ys te mi c u se b ut w e h av e n ot fo un d t hi s a s a

t h ir d m o la r r e m o va l : a l i te r at u re r e vi e w a n d p i lo t s t u dy o nclinical problem in any of our patients.th e effect o f Co v o my cin D. SADJ2 0 0 6 ;6 1 :1 5 4 -5 9 .

P a i n i n d r y s o c ke t i s d u e t o i r r i ta t i on o f th e n e r ve e n d in g s ,1 7 . K i m K , B ra r P, J a k ub o w sk i J , K a lt m a n S, L o p ez E . T he u s e

i n t h e l a m in a d u r a l i n i n g t h e a l v eo l a r s o c ke t . B e s i de s b e i ngo f co rtico stero id s an d n o n -stero id al an ti-in flammato ry me-

a n a n t is e p ti c , M e r cu r o c hr o m e a c t s a s a n o b t un d e nt b y d icatio n fo r th e man ag emen t o f p ain an d inflammatio n aftercom pletely blocking conduction of the propagated action th ird mo lar surg ery : a rev iew o f th e literatu re. Oral Su rg Oral

potential and control the pain com ponent which is frequ- Med Oral Path o l Oral Rad io l En d o d 2 0 0 9 ;1 0 7:6 3 0 -4 0 .ently associated with dry socket. Chlorom ycetin was used 1 8. D o lc i E , G a y E s c od a C , Ar n ab a t J . L a p r e ve n ci o n de l a a l ve-

o litis seca. Rev Eu r Od o n to esto mato l 1 9 9 2 ;4:2 6 1 -7 0 .a s a t o p ic a l a n ti b a ct e r ia l a g e nt s i n ce i t i s a b r o a d- s p ec t r u m1 9. Ve z e a u P J . D e n t al e x t r a c t i on w o u n d m a na g e m e n t:antibiotic.

Med icatin g po st ex traction so ck ets. J Oral Max illo fac Su rgThe following study introducesa new, sim ple and effective2000;58:531-37.m et h od t o m an a ge t he d r y s o ck e t. T he h i gh l ig h t o f th i s

2 0 . B r i n er W W, G r o ss m a n n E , B uc k n e r RY, R e b i ts k i G F, S o xs t ud y w as t he t o ta l l os s o f p ai n a f te r a s in g le d r es si n g inTE, Setser RE, Eb ert ML. Assessmen t o f su scep tib ility o f m ost of the cases obviating the need for analgesics.

p lag u e b acteria to ch lo rh ex id ine after six mo n th s o ral u se. JPerio d o n t Res 1 9 8 6 ;2 1 (Su p p l 1 6 ):5 3 -5 9 .

Conclusion 2 1 . M e e c ha n J G , S e ym o u r RA . T h e u s e o f t h ir d m o l ar s u r ge r y i nT h e o c c u rr e n ce o f d r y s o c k et i n e v e r yd a y d e n ta l p r a c ti c e i s clin ical ph armaco lo g y. Br J Oral Maxillo fac Su rg 1 9 9 3 ;3 1 :

360-65.unavoidable. Treatm ent options for this condition are gen-2 2 . 2 2 . Go l d ma n DR , K i l go r e D S , P a n ze r ID , A t k in s o n W H .erally lim ited and directed towards palliative care. Com bi-

Prev en tio n o f d ry so ck et b y lo cal ap p licatio n o f lin co mycinn ed us e o f Me rc ur oc hr om e a nd C hl or om yc et in i s a nin g elfo am. Oral Su rg 1 9 7 3 ;3 5 :4 7 2 -7 4.e f f ec t i ve s i n gl e s i t ti n g d r e ss i n g a n d w e l l- t o le r a t ed i n th e

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