Mandible / maxilla
Osteomyelitis
Alveolar osteitis

Author: Annie Morrison, M.D. (see Authors page)
Editor: Kelly R. Magliocca, D.D.S., M.P.H.

Revised: 21 June 2018, last major update November 2014

Copyright: (c) 2004-2018, PathologyOutlines.com, Inc.

PubMed Search: Alveolar osteitis [title]

Cite this page: Morrison, A. Osteomyelitis: alveolar osteitis. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/mandiblemaxillaalveolarosteitis.html. Accessed July 21st, 2018.
Definition / general
  • Multiple definitions of alveolar osteitis exist (J Oral Maxillofac Surg 2010;68:1922) with common elements among these definitions including:
    • Pain within the socket of the tooth removed and possibly surrounding structures
    • Pain which increases in severity along some time interval between the first and third day post-surgery
    • Post-operative complication
    • Clinical observation of partially or completely absent blood clot within the tooth socket site which leads to one or more exposed (socket) bone surfaces
  • Typically not associated with infection
  • Often necessitates post-operative visits for management
  • Associated with delayed healing and increased post-operative recovery time
Terminology
  • Most common synonymous term: dry socket
  • Additional synonyms: fibrinolytic alveolitis, alveolar osteitis, alveolitis, localized osteitis, alveolitis sicca dolorosa, septic socket, necrotic socket, alveolalgia
Incidence
  • The lack of a standardized definition and subjective clinical criteria challenges precise reporting of its frequency
  • Reported range of 0.5 to 5% for routine dental extractions and up to 37% after removal of mandibular third molars (mandibular wisdom teeth, Swiss Dent J 2014;124:1042)
Sites
  • Most commonly reported to involve mandibular dental extraction sites
Pathophysiology
  • Pathogenesis incompletely understood and controversies persist (Int J Dent 2010;2010:249073)
  • One common conceptualization of pathogenesis:
    • After extraction of a tooth, a blood clot is formed at the extraction site with eventual organization of this clot by granulation tissue and gradual replacement by bone
    • Destruction of the initial clot is thought to delay the aforementioned additional series of steps required for uneventful extraction site healing and leads to a clinical condition known as alveolar osteitis
    • Clot is lost secondary to transformation of plasminogen to plasmin, with subsequent lysis of fibrin and formation of kinins which are potent pain mediators
  • Possible risk factors:
    • Degree of surgical difficulty
    • Lack of operatory experience
    • Mandibular third molar site
    • Concurrent use of oral contraceptive medications
    • Concurrent smoking history
Diagrams / tables

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Pathogenesis


Etiology
  • Most commonly quoted etiology is local fibrinolysis
  • The fibrinolytic activity may result from subclinical infections, inflammation of the marrow space of the bone or other factors
  • The pain is attributed to the formation of kinins in the alveolus
  • These activate the primary afferent nerve terminations to produce intense discomfort
  • Plasmin also plays a role in kinin development and may provide an explanation for both the pain and the disintegration of clot
Clinical features
  • Patients may present with symptoms after the first post-operative day but usually 3 - 4 days post-operatively, with nearly 100% of patients reporting their symptoms within the first post-operative week
  • The exposed bone is sensitive and is thought to be the source of the pain
  • The dull, aching pain is moderate to severe, usually throbbing in nature and frequently radiates to the patient's ear
  • The area of the socket has a bad odor and the patient frequently complains of a foul taste
  • Pain may radiate, be difficult to localize and may radiate up to the periauricular area
Diagnosis
  • Requires history of a recent dental extraction / tooth removal, the characteristic associated symptoms reported by the patient and a clinical examination revealing partial or complete loss of the blood clot from within the dental socket
  • Persistent pain despite management or an increase in inflammation of the surrounding mucosa with increased swelling suggest other diagnoses
Radiology description
  • Plain films may be suggested in the work-up of a dry socket to excluding the presence of radiographically detectable material retained in the socket, help exclude additional problems with neighboring teeth and to exclude detectable jaw fractures
Treatment
  • Some authors object to the term 'treatment' for the condition as the etiology and pathophysiology have not been firmly established, therefore, the term 'management' is selected
  • Primary management goal is control of the patient's pain through local measures or systemic medications until the area has healed
  • Often involves one or more post-surgical office visits for clinical examination or possible post-operative radiograph
  • If the patient receives no treatment / management, no sequela other than continued pain exists (i.e. treatment / management does not hasten healing), provided that alveolar osteitis was the correct diagnosis
Microscopic (histologic) description
  • Uncommon to have a surgical specimen, because the procedure is debridement or removal of the residual clot
  • If material is submitted, may be composed of:
    • Inflammatory cellular infiltrate with numerous phagocytes and giant cells in the remaining clot
    • Viable and non-viable bone fragments
Differential diagnosis
  • Myofascial pain
  • Subperiosteal abscess formation