Is alveolar osteitis more prevalent since COVID-19? A cross-sectional study

Sample design

From January 2021 to August 2022, patients treated in the Department of Oral and Maxillofacial Surgery (OMFS) at Sri Venkateshwara Dental College and Hospital made up the cross-sectional study sample. Baseline information was gathered from databases of patients who had been diagnosed with dry socket and had been documented as part of standard case history recordings. The baseline data also included the COVID vaccination status and COVID history. Fifty patients, all of whom matched the inclusion criteria, were enrolled in the study.

Study design

The demographic information was recorded as part of the customary case history paperwork when they visited the department of OMFS. Before performing the procedure, prophylactic antibiotics and analgesics were administered to symptomatic individuals. The surgical procedures were carried out in sterile conditions. Following the administration of the necessary nerve blocks, all extractions were carried out with the use of local anesthesia containing 2% lidocaine hydrochloride and 1:80,000 adrenaline. Whenever necessary, the surgical wounds were approximated using 3-0 silk sutures. After the surgery, the patients received comprehensive post-operative instructions as well as the appropriate analgesics and antibiotics. Follow-ups were conducted on a regular basis. All the patients who had post-surgical complications were thoroughly evaluated clinically and all the details were recorded in questionnaire format [Figures 1 and 2].

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Figure 1:

Questionnaire 1.

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Figure 2:

Questionnaire 2.

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Inclusion criteria

All of the study’s participants, who ranged in age from 15 to 83 years, had either undergone surgical extractions or extractions of single or multiple teeth and who had returned with dry socket (Alveolar osteitis) with or without COVID-19 history or symptoms. These patients’ follow-up sessions after the extraction surgery were further examined to gather information about their post-operative healing.

Exclusion criteria

Every patient below 15 years of age and those without any post-operative complications, such as dry sockets, and those who did not undergo any extractions were eliminated from the study.

Procedure

Before any procedures were undertaken, patients had their COVID-19 vaccination status checked, and they were asked to bring their COVID-19 test results. Age, gender, systemic medical history, COVID-19 history, site of extraction, type of extraction, and other characteristics including their adverse habit of the patients were recorded as variables in the study. Demographic baseline information and the patients’ medical histories were all gleaned through case history recordings, as previously described. After clinical examination, the patients were instructed to get an intraoral periapical radiograph or orthopantomogram for better assessment. In addition, some individuals had systemic issues such as thyroid disorders, diabetes, hypertension, and asthma. Before the surgery, all of these patients were required to have their doctors’ approval. Patients with diabetes were also counseled to undergo standard check-ups like random and fasting blood sugar tests.

The surgical site was checked for healing when the patients returned for regular follow-ups. Three days after surgery, the patient experienced acute pain that was unmanageable with analgesics and an empty, rancid-smelling socket with loss of the main sutures. Examination of infection and swelling, if present, revealed localized swelling in the surgical site which is tender with discharge happening 3–5 days after surgery. To obtain results for the research, each of these variables was meticulously examined and noted.

After receiving all the data, it was analyzed with the aid of descriptive analysis and inferential statistics using SPSS software. Chi-square test was also used to obtain relationship between the COVID-19 and alveolar osteitis.

Alveolar osteitis

According to researchers, the following defines a dry socket: “post-operative pain surrounding the alveolus that increases in severity for some period from 1 to 3 days after extraction, followed by partial or total clot loss in the interior of the alveolus, with or without halitosis.”^[7,13]

Alveolar osteitis was initially identified as a side effect of breakdown in the blood clot inside the socket, which manifested 2–4 days following tooth removal.^[14] The surrounding mucosa typically turns erythematous, the alveolus empties, and the osseous surrounds are denuded and covered in a layer of yellow-grey necrotic tissue, claim Fazakerlev and Field.^[15] Clinically, it is distinguished by a foul smell and severe discomfort that extends to the ear and neck.^[16] Pain is the most significant indication of alveolar osteitis. Other symptoms including headache, insomnia, and dizziness may also exist, and its frequency and intensity can vary.^[17]

Bone that is exposed and extremely painful to touch may not be protected from mechanical stimulation either by tongue or food particles, leaving the patient in constant, and excruciating pain. All areas of a dry socket lesion, excluding the exposed bone, can be delicately touched with an irrigation needle tip or periodontal probe without causing excruciating discomfort.

Dry socket is generally characterized as “an inflammation in the alveolus of recently extracted teeth, for which discomfort and the time of onset are particular clinical indicators indicative of accurate diagnosis.”

When viewed under a microscope, a dry socket is defined by an inflammatory cellular infiltrate, which includes numerous giant cells and phagocytes in the blood clot, along with the presence of bacteria and necrosis of the lamina dura.^[18]

Etiology and pathophysiology of dry socket

Dry socket’s precise cause is not yet known. However, it is known that a number of regional and systemic factors play a role. Dry socket occurs when the clot inside the socket following tooth removal prematurely dissolves, either completely or partially increased local fibrinolytic activity has been identified in clinical and experimental research as a key component in the formation of dry socket.^[19,20]

When compared to a normal alveolus, Birn found that the alveolus with a dry socket had more fibrinolytic activity. He emphasized that plasminogen’s direct or indirect activation into the bloodstream produces mediators that cause the partial or whole lyse and disintegration of the clot.^[19] After a trauma, the alveolar bone cells release mediators that cause plasminogen to be transformed into plasmin, which ruptures clots by forcing fibrin to disintegrate. This conversion takes place in the presence of additional activators as well as plasmatic or cellular proactivators. The recent classification includes direct (physiologic) and indirect (non-physiologic), as well as subclassifications based on their origins as intrinsic or extrinsic activators.^[21]

Intrinsic factors, such as urokinase and factor XII-dependent or Hageman factor, are derived from plasma components. In contrast, direct extrinsic activators, which also include tissue and endothelial plasminogen activators, come from sources other than the plasma. Tissue plasminogen activators are present in the majority of body cells, including the alveolar bone. The bacterial products staphylokinase and streptokinase, which interact with plasminogen to generate an activator complex that transforms plasminogen into plasmin, are among the indirect activators.^[21]

Kinins that form in the alveolus are regarded as the root of the common alveolar osteitis pain. The primary bundles of nerve terminations are stimulated by kinins, which may already be responsive to different proinflammatory cytokines and chemicals that produce excruciating pain. In addition, kallikrein is transformed into kinins by plasmin inside the marrow. Hence, the important elements of dry socket could be explained by the presence of plasmin.

Dry socket has also been linked to surgical extractions, particularly those involving flaps and tooth sectioning with an osteotomy level.^[22]

Another potential cause of dry socket is the socket’s inclusion of bone and dental remains.^[23]

In experimental dry socket models, a variety of bacteria were found in the biologic material of the alveolus, including Strep viridians, Enterobacteria, Bac. coryneform, Proteus vulgaris, Pseudomonas aeruginosa, and Escherichia coli.^[24] At infancy, when these microorganisms are typically undetectable in the oral environment, dry socket is a rare occurrence.

Smoking is another trigger for dry socket occurrence.^[25] In 1999, Monaco et al. discovered a statistically significant correlation between risky behaviors including smoking and alcohol consumption and difficulties following surgery, such as discomfort and illness.^[26] In addition, higher frequency of alveolar osteitis was noted in individuals who were above the age of 18 years. Furthermore, aging was a risk factor, in which other researchers have previously noticed.^[27]

Effect of COVID-19 on vascularity

Blood vessel endothelium experiences an inflammatory immunological reaction known as endotheliitis. According to many reports, histological examination and electron microscopy of individuals who died from COVID-19 revealed a build-up of viral inclusions and inflammatory cells.^[28]

A systemic inflammatory response must be triggered by SARS-CoV-2’s ability to infect cells of blood vessels and cause a severe inflammatory response locally. Some publications have compared the symptoms of SARS-CoV-2’s systemic inflammation to those of a cytokine storm. This cytokine storm further leads to disseminated intravascular coagulation which has also been detected in COVID-19 infections, but typically in the patients who are seriously unwell.^[29]

Commonly encountered coagulation abnormalities in COVID-19 patients point to a hypercoagulable condition known as COVID-associated hemostatic abnormalities or thromboinflammation.^[30,31] Elevation of D-dimer is a prevalent finding in patients suffering from COVID-19, especially those who have severe disease.^[32] D-dimer forms as a result of the breakdown of fibrin; its presence in the bloodstream indicates that plasmin is breaking down fibrin polymers, and it may be related to the burden of thrombi.

The authors identified hypercoagulability characteristics using whole blood thromboelastography, including a decline in the duration required for fibrin to develop, a reduction in the time it takes for clots to form, and an increase in coagulation strength.^[33]

Effect of COVID-19 on bone

By potentially invading the bone cells (osteoblasts and osteoclasts) and interfering with the bone remodeling process, SARS-CoV-2 has the ability to infect the skeletal system. Beside the inflammatory potential, angiotensin converting enzyme 2 (ACE-2)/Angiotensin (1–7) axis has been identified as being linked with osteoporosis, which is indicated by the action of ACE-2 receptors on osteoblasts and osteoclasts.^[34]

The vast majority of patients who were older than 35 reported having dry sockets. Several patients arrived at the hospital in great discomfort, and a dry socket diagnosis was made during the inspection. Several individuals disclosed a habit of tobacco smoking as well as hyperglycemia as well as other systemic diseases. Several studies have shown a strong connection between smoking, alveolar osteitis, and diabetes. While there is a general immune system deficit that may have hampered the tissue regeneration, it was found in our study that there was a strong link between individuals suffering from systemic illnesses and COVID-19 history of alveolar osteitis, or diabetes.

As a result, cigarette smoke has chemical irritants that can slow tissue regeneration. Dry socket may be averted by abstaining from smoking, adhering to post-operative guidelines, and practicing good dental hygiene as well as by administering antibiotic therapy to diabetic patients before surgery.

All patients with dry socket were treated by thorough curettage, betadine irrigation followed by betadine ointment pack. All patients received the necessary prescriptions for betadine mouthwash, analgesics, and antibiotics. After 2 weeks of follow-up, the inflammation and infections were under control.

This study’s primary flaw is its extremely tiny sample size, which makes it challenging to draw any relationships or draw any conclusive evidence. The study’s findings are appropriate for this topic, nevertheless due to the study’s small sample size, they cannot be generalized to the total population.