Alveolar osteitis: What's in a name?

Sir, alveolar osteitis (dry socket) is a well-recognised and frequently encountered post-extraction complication resulting from premature disintegration of a blood clot in the extraction socket. The clinical presentation of alveolar osteitis is typically marked by moderate to severe, throbbing pain on the 2nd to 4th day after an extraction; tender, exposed alveolar bone; and halitosis. It is best described as delayed healing and the therapeutic goal is to relieve the patient's pain. However, treatment does not hasten healing.1 Alveolar osteitis should be managed with irrigation of the extraction socket with sterile saline to remove necrotic debris and placement of an appropriate medicated dressing like Alvogyl. Curettage of the socket needs to be avoided as it may expose the bone further. Persistence of pain may require replacement of the dressing every other day until the pain subsides.

Anecdotal evidence from general dental practice settings across the country suggests that dentists and nurses frequently tend to equate alveolar osteitis with an 'infected socket' and the same diagnosis is often communicated to the patients. This seems misleading and almost invariably prompts patients to request antibiotics. Although there is a small risk that alveolar osteitis may be complicated by secondary infection, this needs to be evaluated objectively rather than assumed by the dental clinicians. Establishing a diagnosis of an infected socket warrants clinical evidence of suppuration and/or soft tissue swelling and erythema, fever and lymphadenopathy. The Chief Medical Officer in England has repeatedly expressed serious concerns regarding widespread antibiotic resistance and has called upon NICE to develop guidance on antibiotic prescriptions.2 More recently the WHO has also described a 'post antibiotic era' as a major global threat and there is a substantial risk of common infections proving to be fatal due to increasing resistance of microorganisms to available antibiotics.3

Given that dental practices also contribute to the heavy load of total antibiotic prescriptions across the country, it is imperative to revisit this issue to restrict the use of antibiotics only to clinical situations where absolutely indicated. Following routine extractions, dental practitioners are more likely to encounter alveolar osteitis than infection which precludes the need for antibiotic prescriptions.4 Using your esteemed journal's platform I wish to re-emphasise that alveolar osteitis needs to be managed as delayed healing rather than an infection and this should be communicated accordingly to the patients. This will help reassure patients and minimise their demand (and potentially incorrect prescriptions) for antibiotics.

References

  1. 1

    Hupp J R, Tucker M R, Ellis III E . Contemporary oral and maxillofacial surgery. Elsevier Health Sciences, 2013.

  2. 2

    Davies S C, Fowler T, Watson J, Livermore D M, Walker D . Annual Report of the Chief Medical Officer: infection and the rise of antimicrobial resistance. Lancet 2013; 381: 1606–1609.

  3. 3

    World Health Organization. Antimicrobial Resistance Global Report on surveillance 2014.

  4. 4

    Lodi G, Figini L, Sardella A, Carrassi A, Del Fabbro M, Furness S . Antibiotics to prevent complications following tooth extractions. Cochrane Database Syst Rev 2012; 11: CD003811.

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Ali, K. Alveolar osteitis: What's in a name?. Br Dent J 221, 535 (2016). https://doi.org/10.1038/sj.bdj.2016.795

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