gesics and steroids admistration [18]. Proper patient education (post operative instruction) and atraumatic surgical technique were followed as discussed in material and methods that may reduces postoperative complications [9,18], administration of antibiotics reduces the incidence of wound infection and alveolar osteitis [19,20], analgesics may be helpful in reducing post-operative swelling and pain [18] and single dose of preor peri-operative administration of Dexamethasone has been shown to reduce swelling and discomfort [18,21,22].

In dry socket, the primary aim of treatment is pain relief and empirical treatment with a variety of socket dressing (Zinc oxide eugenol pack, collagen paste, fibrin sealants, iodoform gauze and whiten varnish) is the main stay of management. Zinc oxide eugenol packing is popular because of their clinical effectiveness in relieving the pain in the dry socket. In other hand bland, non irritants, obtundant dressings such as collagen paste, fibrin sealants, iodoform gauze and whiten varnish shows promise; as these do not retard socket healing in the same way as Zinc oxide eugenol packing. But disadvantage of course, is the lack of any analgesics properties. Perhaps combinations with a proven topical anesthetic agents and analgesics are the future for such medications. Finally the host healing potential determines the severity and duration of the condition [8,23].

According to previous studies the incidence rate of dry socket formation after surgical removal of impacted mandibular third molar has been documented from low (0%) [16] to high (44.46%) [3]. A possible explanation for this wide range may be found in the lack of uniform diagnostic criteria employed by various authors. In the present study, out of 63 patients, only 4 (6.3%) subjects developed dry socket, which is also representative of previous literature. Also study conducted by Benediktsdottir I.S. et al. in 2004, reported that incidence of dry socket was 5.90% after surgical removal of 388 cases of impacted mandibular third molar [24]. Incidence of dry socket in the present study was higher due to small sample size.

In the present study, mean age group was 24.25 ± 5.50. Hence the mean age range was 19 to 30 years for study group. This was similar to study conducted by Birn H [4]. He reported that incidence of dry socket formation was directly proportional to the stable tissue activator which is predominantly found in connective tissue type of bone marrow between the age of 20 - 40 years. But before 18 years of age, bone marrow is hemapoietic type and after 40 years bone marrow changes to fat marrow therefore incidence of Fibrinolytic Alveolitis was minimum or none because of absence of stable tissue activator. Hence incidence of dry socket was more common in this age group.

In the present study incidence of dry socket in female patients was 3 (75%) whereas 1 (25%) in male patients. This indicates female predominance of dry socket which was a common finding in the study conducted by Larsen P. E. et al. [6], Sheikh M. A. et al. [15], Benediktsdottir I. S. et al. [24], Rood J. P. et al. [25], Al Jadid O. G. [26], Bortoluzzi M. C. et al. [27] and Ahmed A. et al. [28]. This high incidence of dry socket in female patient was due to use of oral contraceptives which causes increased fibrinolytic activity associated with higher estrogen level [29].

In present study, higher incidence of dry socket was found in cases of pre-existing infection 3 (75%) whereas 1 (25%) in normal case which was similar to study by Birn H [4] Susarla S. M. et al. [12], Cardoso C. L. et al. [14], Krekmanov L. et al. [20,30], Rood J. P. et al. [25], Knoedler D. et al. [31], Khorasani M. [32] and Chuang S. K. et al. [33] they also reported the higher incidence of dry socket in cases of pre-existing infection. Birn H. [4] reported that pre-existing infection causes inflammation of bone marrow that was responsible for the release of stable tissue activator factor which finally causes alveolar osteitis.

In present study the mean PDI (Pederson difficulty index) was 6.25 ± 1.50. It ranged between 5 to 8, which indicates moderately difficult to very difficult impactions and was equally distributed, this was similar to the study conducted by Yuasa H. et al. [34] and Benediktsdottir I. S. et al. [24] they also observed that the incidence of dry socket was more in cases of radiographically difficult impactions scored by PDI which was similar to our findings.

In the present study tobacco use was not significantly related to incidence of dry socket formation after 3rd molar surgery, which was similar to study conducted by Biesbrock A. R. et al. [35]. However most authors observed that incidence rate of dry socket formation was significantly high in habitual tobacco users. In the present study the incidence rate of dry socket formation was not significant with tobacco use as this might be due to strict postoperative instruction of stopping tobacco use for 7 days. Al-Belasy F. A. [36] and Balaji S. M. [37] have also observed that incidence of dry socket formation decreases after cessation of tobacco use.

Many previous studies have reported that onset of dry socket was 1 - 3 days after tooth extraction [4,9,12,15, 25, 38] and within a week almost all cases registered [9]. In the present study, in 3 (4.8%) patients onset of symptoms was observed at 48 hrs. In 1 (1.6%) patients it was after 72 hrs which is similar to previous studies. Onset of fibrinolytic alveolitis may vary, but most often takes place on the second day postoperatively. Clot contains antiplasmin which must be used up before dissolution of the clot can takes place [4].

In a study conducted by Blum I. R. in 2002, dry socket patients had at least two of the following signs and symptoms: that is empty socket, pain in or around the socket, with or without halitosis [13]. In the present study we found that pain, bare bone, and halitosis were present in three patients on 1st postoperative visit (3rd day) and 1 patient had empty socket which was similar to above observations. These findings were consequence of inflammatory reactions.

In the present study on 2nd postoperative visit all subjects in study group had pain, empty socket and bare bone but only 50% subjects had halitosis. Out of these findings, pain was common in study by Birn H. [4], Pitekova L. [7], Blum I. R. [9], Bouloux G. F. et al. [10], Susarla S. M. et al. [12], Cardoso C. L. et al. [14], Sheikh M. A. et al. [15] and Ruvo T. A. et al. [39] empty socket was common with the study of Blum I. R [9] and Bouloux G. F. et al. [10] and bare bone was common finding of Birn H [4], Bouloux G. F. et al. [10], Mercier P. et al. [11], Susarla S. M. et al. [12] and Sheikh M. A. et al. [15]. Except halitosis, which was a common finding with the study of Blum I. R. [9] none of the patients in our study group had any other complications.

In the present study all cases of dry socket were treated with warm saline irrigation and Zinc oxide eugenol packing and it was observed that this relieves acute pain episode.

The higher incidence of dry socket formation observed in our study was among young adults, especially females on right side of mandible. Those were radiographically difficult impactions, with pre-existing infection and were habitual tobacco users. Therefore incidence of dry socket formation is multifactorial and care has more to be given to patients with predisposing factors to reduce the incidence rate of dry socket formation.

5. SUMMERY & CONCLUSION

In our study we found that incidence of dry socket was (6.3%) after surgical removal of impacted mandibular third molars. We also noticed onset of symptoms mostly appears within 48 hours postoperatively, along with pain, bare bone and halitosis, on 3rd postoperative day. Pain, empty socket and bare bone were most significant clinical features on 7th postoperative day. Variables like patients mean age between 19 - 30 years; females, preoperative infection, radiographically difficult impaction and habitual tobacco use are considered as pre disposing factors and are related to higher incidence of dry socket formation. In present study all cases of dry socket were treated with warm saline irrigation with Zinc oxide eugenol packing and it was observed that this procedure relieved acute pain episodes.

The higher incidence of dry socket formation observed in our study was among young adults, especially females. Those were radiographically difficult impactions, with pre-existing infection and were habitual tobacco user. Therefore incidence of dry socket formation is multifactorial and more care has to be taken in these patients to reduce the incidence of dry socket formation.

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NOTES

*Corresponding author.

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