Sharp bony edges of the alveolar margins or residual bone septa mainly cause pain and discomfort, but occasionally lead to perforations.
surgical smoothing of the bone edges
The first week after tooth extraction seems to be the critical phase for fracture occurrence (Iizuka et al. 1997).
The patient reports hearing a "cracking" sound from the jaw region while eating.
It is required by law to inform the patient that mandibular fracture is a potential complication of wisdom tooth extraction (OLG Düsseldorf 1997, OLG Munich 1996).
The incidence of alveolitis ranges between 2.4 % and 8.2 % based on studies of extractions in all tooth groups (Klammt and Schubert 1986).
development of alveolitis:
- no primary blood clot formation in the alveolus, or
- secondary decomposition of the clot
The use of oral contraceptives is associated with a significantly higher risk of alveolitis (Cohen and Simecek 1995).
The higher the estrogen dose, the stronger the stimulation of fibrinolysis.
The risk of alveolitis can be lowered significantly by performing the extraction procedure in the pill-free period (days 22-28 of the menstrual cycle) (Catellani et al. 1980).
Local, not systemic fibrinolytic activity plays an important role in the development of alveolitis.
Inflammation of the medullary spaces of the alveolar bone (caused by bacteria, saliva, trauma) stimulates the release of tissue activators.
These tissue activators convert plasminogen to plasmin, thereby triggering fibrinolysis of the blood clot.
Bradykinin, a tissue hormone with a strong pain component, is released during fibrinolysis (Birn 1972).
Several studies have documented a higher incidence of alveolitis in smokers than in non-smokers (Larsen 1992).
reasons why smoking increases the incidence of alveolitis:
- contamination of the extraction wound with foreign substances
- dislodgement of the blood clot due to suction pressure in the oral cavity during smoking
- nicotine stimulates the local release of noradrenaline (norepinephrine), thus leading to vasoconstriction of the peripheral vessels with a predilection for blood clot formation
- reduced oxygen saturation in the blood due to carbon monoxide binding
- direct destruction of the blood clot due to bacterial infection
- fibrinolysis of the blood clot secondary to bacteria-induced release of tissue factors
The following conditions significantly increase the incidence of alveolitis:
Insufficient primary blood clot formation
- poor oral hygiene (large number of aerobic and anaerobic bacteria before surgery) (MacGregor and Hart 1970)
- pre-existing peri-coronitis (Meyer 1971)
- therapeutic indication for extraction (al-Khateeb et al. 1991)
- reactivation of herpes simplex virus due to iatrogenic nerve injury during extraction (Hedner et al. 1993)
The poorer the blood filling of the alveolus, the higher the incidence of alveolitis (Meechan et al. 1988).
decreased filling of socket with blood:
Mechanical clot destruction
Tooth location and size
- major extraction trauma
- filling generally lower in the maxilla than in the mandible
The risk of alveolitis is higher in the mandible than in the maxilla.
The larger the wound surface (tooth root surface), the higher the risk of alveolitis.
Extraction or surgical trauma
The longer the duration of surgery or the more severe the surgical trauma, the higher the risk of alveolitis.
consequences of major extraction trauma (Meechan et al. 1988):
Skill of the operator
- destruction of bone-borne periodontal tissues
- destruction of reparative cells
- release of chemical mediators of inflammation
- reduced post-operative blood filling of the alveolus because of damage to alveolar blood vessels
When surgical wisdom tooth extraction is performed by an experienced surgeon, the risk of post-operative alveolitis is lower than when performed by an inexperienced surgeon.
Use of vasoconstrictors
The use of vasoconstrictors has no influence on the incidence of alveolitis.
Vasoconstrictor use is only short-term and, when discontinued, results in reactive vasodilatation.
The use of chlorhexidine (0.12–0.2 %) before and/or after extraction significantly reduces the risk of alveolitis.
Bacteria seem to be essential for the development of alveolitis; this factor can be reduced or eliminated by local treatment measures (von Arx 1996).
Systemic or local administration of antibiotics reduces the risk of alveolitis.
The prophylactic use of antibiotics should be reserved for patients at risk for different reasons (sensitization, development of resistance, side effects, economic factors).
The extremely severe pain of alveolitis calls for treatment strategies with primarily analgesic effects.
The pain will subside once the exposed alveolar wall has been covered by granulation tissue.
Zinc oxide eugenol (ZOE) fillings quickly alleviate pain but slow down the healing process.
immediate treatment with zinc oxide eugenol gauze compresses
- curette the alveolus under local anesthesia
- rinsing with 1.5 % hydrogen peroxide solution (H2O2)
- dry the alveolus thoroughly with a pledge
- insertion of a gauze strip impregnated with zinc oxide eugenol in the upper half of the alveolus
- pressure on the gauze strip for 30 minutes
- change the strip after 5 to 7 days
If the symptoms do not improve within the next 2 days, surgical revision can be considered.