Normal Hemostasis and Bleeding Control
Normally, the socket quickly fills with blood, which clots within a few minutes. Hemostasis adequacy is checked by asking the patient to bite down firmly on a sterile gauze pad. After 20–30 minutes, a mandatory control examination is performed — the patient is discharged only when bleeding has completely stopped.
If bleeding continues, the physician firmly compresses the wound edges with their fingers for differential diagnosis. Cessation of bleeding indicates soft tissue damage. In this case, the gingiva is sutured on both sides with interrupted sutures using resorbable thread (Vicryl).
If bone tissue is bleeding when the edges are compressed, a mechanical method is applied: gentle tapping on the bottom and walls with a curette or elevator to crush the bone trabeculae. Alternatively, a hemostatic sponge is inserted or tight packing from the bottom is performed with an iodoform gauze strip, leaving it in place for 5–7 days.
Management Tactics in Case of Alveolitis
If a full-fledged clot is not retained, is washed out by oral fluid, or food debris accumulates in the depression, alveolitis develops. After 1–3 days, mounting pain appears, often radiating to the eye or ear. The socket itself remains empty or becomes covered with a grayish fibrinous coating.
Management of the infected wound is performed strictly under local anesthesia:
- Jet irrigation with a warm 0.05% chlorhexidine solution using a syringe with a blunt needle to wash out food debris.
- Gentle surgical curettage — removal of disintegrated clot remnants with a curette.
- Thorough drying of the walls.
- Insertion of a gauze strip with iodoform and application of Metrogyl ointment on top of it.
Dressings must be repeated daily until healthy granulation tissue appears (the process is usually resolved within 5–7 days). Without proper treatment, alveolitis can transform into localized socket osteomyelitis.
Actions in Case of Maxillary Sinus Perforation
During the extraction of upper premolars or molars, the thin bone septum of the sinus floor may fracture. With a small defect and the absence of purulent inflammation, the main goal is to achieve the formation of a blood clot, which spontaneously occurs in only 30% of cases. The orifice of the socket is tightly packed with an iodoform gauze strip and fixed with a figure-of-eight suture. A clot forms beneath the pack, and the strip itself is left in place for 5–7 days.
A large perforation defect requires closure. The physician smooths the sharp edges of the socket, removes freely lying bone or tooth fragments, and performs mandatory de-epithelialization of the mucosa. Then, a trapezoidal mucoperiosteal flap is raised. After mobilization (periosteal release), it is placed over the palatal surface without tension and sutured with non-resorbable threads, which are removed on days 10–12.
Management of Root Fractures and Bone Structures
Rough handling with forceps can lead to fracture of the alveolar process margins. Small bone fragments must be gently separated from the soft tissues with a periosteal elevator or blunt instrument and removed, and the resulting sharp edges smoothed.
If the tooth root fractures during the procedure and its immediate removal is impossible (due to technical difficulties or the patient's worsening condition), the operation is terminated. The wound is tightly sutured or covered with an iodoform gauze strip. Anti-inflammatory therapy and physical therapy (UHF therapy, microwave therapy, laser therapy) are prescribed to the patient. Revision surgery to remove the fragment is performed 7–14 days later, once inflammatory symptoms have completely subsided.
Briefly: answers to topical questions
What systemic pharmacological drugs are prescribed to the patient in the complex treatment of alveolitis?
In the complex treatment of alveolitis, nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed as general drug therapy.
What surgical instruments are used to smooth sharp socket edges and excise bone?
Bone rongeurs, a dental drill with a fissure or round bur, a rotary bur, and for deeply seated roots, forceps with narrow converging beaks are used to smooth sharp socket edges and excise bone. Burs and rotary instruments are used with cooling.
What are the contraindications to socket curettage following tooth extraction?
Socket curettage is strictly contraindicated after tooth extraction for acute periodontitis. Performing this surgical manipulation under such conditions promotes the destruction of the protective "demarcation zone." As a result, there is a high risk of the infectious process spreading deep into the surrounding bone tissue. Instead of curettage, rinsing the socket with antiseptic solutions, performing novocaine blockades, and prescribing physical therapy are indicated for inflammation prevention.
To easily recall the basic treatment algorithm for socket alveolitis, use the acronym "IRDP": Irrigation with chlorhexidine, Surgical curettage, Drying, Iodoform dressing (plus antimicrobial ointment).
Class and exam questions
What to do if a tooth root is pushed into soft tissues during extraction?
If the root is palpable beneath the mucosa (often in the region of the mylohyoid groove), it is removed via an incision directly over it. If the displacement is deep (into the posterior sublingual region), extraction is performed strictly in an inpatient setting following X-ray diagnostics.
How to clinically determine the source of bleeding from the socket?
The physician must firmly compress the gingival margins with their fingers. If bleeding stops after this, the soft tissues are injured. If bleeding continues, the source is located within the bone structures of the alveolus.
How many days should dressings be changed in case of alveolitis?
The infected socket requires daily cleaning and replacement of dressings with antimicrobial agents. Patient management with daily dressings continues until the wound walls are covered with young granulation tissue.
Is it possible to close a sinus perforation if a root fragment has been pushed into the sinus?
Categorically no. Before closing the defect and performing flapplasty, a thorough revision of the maxillary sinus must be performed, and the pushed-in tooth or bone fragment must be retrieved.
What else to study on this topic
- Technique for performing "nose tests" to diagnose maxillary sinus perforation
- Specifics of detecting an oroantral communication in sinus polyposis (cheek-puff test)
- Indications for hospitalization and radical antrostomy in complicated perforations
- General risk factors for socket bleeding (hypertension, hemophilia, anticoagulant use)
- Tactics for diagnosis, reduction, and prevention of temporomandibular joint dislocation
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