Assessment of Healing Using Alvogyl and Platelet Rich Fibrin in Patients with Dry Socket - An Evaluative Study

Abstract

Introduction:

Dry socket is one of the most common postoperative complications following the extraction of permanent teeth, which is characterized by pain and exposed bone. The usual protocol followed for its management is irrigation of the socket and packing of the socket with medicated gel or paste to provide relatively faster pain relief and allow normal wound healing. In this study, we evaluated the outcome of management of dry socket with platelet-rich fibrin (PRF) and intraalveolar alvogyl dressing, in terms of improvement in pain and socket epithelialization after the treatment.

Methodology:

Thirty participants with established dry socket were randomly divided into two groups: Group A and Group B. The participants in Group A were treated with alvogyl and those in Group B were treated with PRF. Clinical parameters were assessed for both groups on the 1^st day of the procedure and on the 3^rd and 10^th-day postoperatively for the reduction in pain and wound healing.

Results:

There was a significant decrease in pain and the number of socket wall exposure in both the groups by the 3^rd postoperative day. In both the groups, the pain had completely resolved and socket fully epithelialized by the 10^th postoperative day.

Discussion:

The use of PRF in the present study yielded promising results in terms of both pain reduction and improved wound healing which was comparable to the conventional alvogyl dressing. It may be concluded that PRF is an effective modality for the management of dry socket.

INTRODUCTION

The term dry socket has been used in the literature since 1896 after it was first described by Crawford.[1] Various other terms have been used referring to this condition, Birn labeled the complication as “fibrinolytic alveolitis.”[2,3]

Dry socket was first described as a complication of the disintegration of the intraalveolar blood clot with an onset of 2–4 days after an extraction. According to Fazakerlev and Field,[4] the alveolar socket empties, and there is denudation of the osseous surrounding after which there appears yellow-gray necrotic tissue layer with surrounding mucosal erythema. Clinically, it is characterized by intense radiating pain and putrid odor.

Studies have reported that the onset of alveolar osteitis occurs 1–3 days after extraction[5,6] presenting with exposed bone and moderate-to-severe pain, and its duration varies to some degree, depending on the severity, but it usually ranges from 5 to 10 days. The usual protocol followed for the management of dry socket is irrigation of the socket to flush out any food particles or debris that may lead to further infection and packing of the socket with medicated gel or paste to provide relatively faster pain relief and allow normal wound healing.

Systemic antibiotics, topical antibiotics, chlorhexidine, parahydroxybenzoic acid, tranexamic acid, polylactic acid, steroids, eugenol-containing dressings, etc., have been proposed to assist in the prevention of dry socket. However, this area remains controversial as no single method has gained universal acceptance.[7] Most agree that the primary aim of dry socket management, as indicated by Fazakerlev and Field,[4] is pain control until the commencement of normal healing.

The use of intraalveolar dressing materials is widely suggested in the literature, but different medicaments and carrier systems that are available commercially have little scientific evidence to guide a selection process for their use.[7] The most commonly used intraalveolar dressing material for dry socket is alvogyl (Septodent, Inc, Wilmington, DE), which rapidly provides pain relief and soothing effect throughout the healing process. The active ingredients of alvogyl include eugenol (effective analgesic action), butamben (effective anesthetic action), and iodoform (antimicrobial action).

The purpose of this study was to evaluate the outcome of management of dry socket with platelet-rich fibrin (PRF) and widely used intraalveolar alvogyl dressing, to determine the improvement in pain and socket epithelialization after treatment.

METHODOLOGY

Patients reporting with postextraction pain, who fit the criteria for dry socket, were selected for this study after an informed consent. Patients who did not consent for the study and patients below 14 and above 60 years of age were excluded from the study. A detailed history consisting of chief complaint, relevant past medical history, drug history/allergy, and personal history were recorded for every patient. Patients were examined both symptomatically and clinically. A total of thirty patients were included in the study based on the prevalence of dry socket (0.5%–5.6%)[8] and were randomly divided into two Groups (Group A and Group B), with 15 patients in each group using simple randomization. The participants in Group A (control group) were treated for dry socket with gentle irrigation with warm saline. After isolation and debridement, the socket was then packed with alvogyl and sutured using 3.0 Mersilk with a figure of eight to avoid immediate elimination of the dressing from the socket [Figure 1]. The participants in Group B (test group) were treated with PRF in the extraction socket. The standard-operating procedure was followed by irrigating the socket with warm saline. After isolation and debridement, the PRF membrane was placed in the socket and sutured using 3.0 Mersilk with a figure of eight [Figure 2].

Figure 1.

Alvogyl group. (a) = Day 1 (at the time of presentation), (b) = Day 1 (after alvogyl and suturing), (c) = Day 3 postoperative, (d) = Day 10 postoperative

Figure 2.

Platelet rich fibrin group. (a) = Day 1 (at the time of presentation), (b) = Day 1 (After platelet rich fibrin and suturing), (c) = Day 3 postoperative, (d) = Day 10 postoperative

Preparation of platelet-rich fibrin

Under aseptic precautions, 10 ml of venous blood was drawn from the antecubital vein of the patients. This blood was centrifuged in two vacutainers (Becton Dickinson) of 5 ml each that were devoid of any anticoagulants. The vacutainers were then centrifuged at a speed of 3000 rpm for 10 min in a table-top centrifuge (Remy C-852) to obtain PRF gel. Three layers were isolated after centrifugation with the first layer of red blood cells at the bottom, the second layer of white blood cells in the middle, and the PRF layer at the top. The topmost PRF gel layer was isolated and squeezed on sterile saline-soaked gauze pieces to obtain the PRF membrane which was then used for the study.

Both groups were prescribed paracetamol 500 mg thrice daily for analgesia postoperatively and oral hygiene instructions were given. Clinical parameters were assessed for both groups on the 1^st, 3^rd, and 10^th day postoperatively for the reduction in pain and wound healing. The pain was measured using a subjective 10-point Visual Analog Scale by the patient in the presence of the operator. The wound healing was assessed by the number of socket walls that were exposed. The results of the above documentations were tabulated in a case pro forma, analyzed, and inferences were made.

RESULTS

Statistical methods applied

1. Friedman test

2. Wilcoxon signed-rank test.

DISCUSSION

One of the most commonly encountered complications of exodontia is a dry socket. Studies have reported that the onset of dry socket occurs 1–3 days after tooth extraction.[5,6,9] Duration of the dry socket varies depending on its severity, but usually, it ranges from 5 to 10 days.[9]

The management of dry socket has been a less controversial one[6] than its etiology and prevention. Many authors agree that the primary aim is pain control until the commencement of normal healing as suggested by Fazakerley.[4] In some instances, systemic analgesics or antibiotics may be necessary or indicated.[10] The use of intraalveolar dressing materials is also suggested in the literature,[11,12] although it is generally acknowledged that dressings delay healing of the extraction socket.[13]

Alvogyl has been widely used in the management of dry socket and is frequently mentioned in the literature. It is known to rapidly provide pain relief and soothing effect throughout the healing process. Some authors[7,14] noted that there was delayed healing when the sockets were packed with Alvogyl, but there has been no definite literature evidence against its usage.

PRF is characterized by the slow polymerization during its preparation that generates a fibrin network very similar to the natural one that enhances cell migration and proliferation.[15] PRF is a reservoir of platelets, leukocytes, cytokines, and growth factors. It is reported to allow the slow release of cytokines, transforming growth factor, platelet-derived growth factor, vascular endothelial growth factor, and epidermal growth factor play a vital role on angiogenesis, tissue healing, and cicatrization.[16,17]

Choukroun et al.[17] in France advocated the use of PRF which is a second-generation platelet concentrate. PRF is a stringently autologous fibrin matrix. Dohan et al.[16] suggested that PRF addition can correct destructive reactions in the natural process of healing of wound tissues suggesting that PRF contributes to the immune regulatory mechanism. Choukroun et al.[17] demonstrated a clinical example in which they used the PRF as a filling material in the extraction socket. They confirmed that neovascularization and epithelial coverage of the extraction socket can be achieved with the use of PRF.

In this study, we found, in terms of pain, a statistically significant difference for pain reduction in both Group A and Group B. Therefore, patients of both groups showed a similar decrease in pain by the 10^th postoperative day [Table 1 and 2].

Table 1.

Group A (Alvogyl) NPar tests of Visual Analog Scale scores

Descriptive statistics
	n	Mean	SD	Minimum	Maximum
vas_d1	15	9.6667	0.48795	9.00	10.00
vas_d3	15	1.1333	0.83381	0.00	2.00
vas_d10	15	0.0000	0.00000	0.00	0.00
Friedman test Ranks
				Mean rank
vas_d1				3.00
vas_d3				1.87
vas_d10				1.13
			Test statisticsa
n				15
χ2				28.429
df				2
Asymptotic significant				0.000

^aFriedman test. SD=Standard deviation

Table 2.

Group B (platelet-rich fibrin) NPar tests of Visual Analog Scale scores

Descriptive statistics
	n	Mean	SD	Minimum	Maximum
vas_d1	15	9.5333	0.51640	9.00	10.00
vas_d3	15	0.2667	0.45774	0.00	1.00
vas_d10	15	0.0000	0.00000	0.00	0.00
Friedman test Ranks
				Mean rank
vas_d1				3.00
vas_d3				1.63
vas_d10				1.37
Test statisticsa
n				15
χ2				28.204
df				2
Asymptotic significant				0.000

^aFriedman test. SD=Standard deviation

In terms of the degree of epithelialization, a statistically significant reduction was noted in the number of socket walls exposure posttreatment in both Group A and Group B. Both groups showed satisfactory healing by the 10^th postoperative day [Table 3 and 4].

Table 3.

Group A (Alvogyl) NPar tests of socket-wall exposure

Descriptive statistics
	n	Mean	SD	Minimum	Maximum
Socket_1	15	2.8667	0.63994	2.00	4.00
Socket_3	15	0.6667	0.48795	0.00	1.00
Socket_10	15	0.0000	0.00000	0.00	0.00
Friedman test Ranks
				Mean rank
Socket_1				3.00
Socket_3				1.83
Socket_10				1.17
Test statisticsa
n				15
χ2				28.182
df				2
Asymptotic significant				0.000

^aFriedman test. SD=Standard deviation

Table 4.

Group B (platelet-rich fibrin) NPar tests of socket wall exposure

Descriptive statistics
	n	Mean	SD	Minimum	Maximum
socket_1	15	3.4667	0.51640	3.00	4.00
socket_3	15	0.2000	0.41404	0.00	1.00
socket_10	15	0.0000	0.00000	0.00	0.00
Friedman test Ranks
				Mean rank
socket_1				3.00
socket_3				1.60
socket_10				1.40
Test Statisticsa
n				15
χ2				28.500
df				2
Asymptotic significant				0.000

^aFriedman test

Within the Group A, there was a statistically significant decrease in terms of both parameters, i.e. pain and the number of socket walls exposed, from day 1 to day 3, day 3 to day 10, and day 1 to day 10. This showed that there was a gradual reduction of pain and continued healing process from the 1^st day to the 10^th postoperative day [Table 5].

Table 5.

Group A (Alvogyl) Wilcoxon signed-rank test

Ranks
		n	Mean rank	Sum of ranks
vas_d3 - vas_d1
Negative ranks		15a	8.00	120.00
Positive ranks		0b	0.00	0.00
Ties		0c
Total		15
socket_3 - socket_1
Negative ranks		15d	8.00	120.00
Positive ranks		0e	0.00	0.00
Ties		0f
Total		15
Test statisticsa
	vas_d3 - vas_d1	socket_3 - socket_1
Z	−3.443b	−3.457b
Asymptotic significant (two-tailed)	0.001	0.001

^aWilcoxon signed-ranks test, ^bBased on positive ranks. ^avas_d3 < vas_ d1, ^bvas_d3 > vas_d1, ^cvas_d3=vas_d1, ^dsocket_3 < socket_1, ^esocket_3 > socket_1, ^fsocket_3=socket_1

Within the Group B, there was a statistically significant decrease in terms of pain from day 1 to day 3 and day 1 to day 10. In terms of the number of socket wall exposure, there was a statistically significant decrease from day 1 to day 3 and day 1 to day 10. There was a significant reduction in the number of socket walls exposed in all the patients who were treated with PRF by the 3^rd postoperative day [Table 6].

Table 6.

Group B (platelet-rich fibrin) Wilcoxon signed-rank test

Ranks
	n	Mean rank	Sum of ranks
vas_d3 - vas_d1
Negative ranks	15a	8.00	120.00
Positive ranks	0b	0.00	0.00
Ties	0c
Total	15
socket_3 - socket_1
Negative ranks	15d	8.00	120.00
Positive ranks	0e	0.00	0.00
Ties	0f
Total	15
Test statisticsa
	vas_d3 - vas_d1		socket_3 - socket_1
Z	−3.464b		−3.578b
Asymptotic significant (two-tailed)	0.001		0.000

^avas_d3 < vas_d1, ^bvas_d3 > vas_d1, ^cvas_d3=vas_d1, ^dsocket_3 < socket_1, ^esocket_3 > socket_1, ^fsocket_3=socket_1. ^aWilcoxon signed-rank test, ^bBased on positive ranks

The findings of the present study are in conjunction with the studies done by Sam Paul et al.,[18] Ravi Bhujbal et al.,[19] Ashish Sharma et al.,[20] Srinivas Chakravarthi,[21] and Ivan Chenchev,[22] all of whom have concluded that PRF can be successfully used in the treatment of dry socket.

CONCLUSIONS

The PRF dressing is a good biological material that causes enhanced-tissue healing and a significant reduction in pain in dry socket. The use of PRF in the present study yielded promising results in terms of both pain reduction and improved wound healing which was comparable to the conventional Alvogyl dressing. It may be concluded that PRF is an effective modality for the management of dry socket.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.