Postekstrakcijska bol je komplikacija koja se javlja nakon vađenja zuba. Najčešće nastaje u molarnoj regiji donje čeljusti. U ovome radu uspoređene su dvije metode liječenja postekstrakcijske boli: konzervativna i kirurško - konzervativna metoda. Svrha rada bila je odrediti najdjelotvorniji način liječenja te komplikacije. Istraživanje je provedeno na trideset pacijenata sa simptomima postekstrakcijske boli. Petnaest pacijenata liječeno je konzervativnom metodom, a petnaest kirurško - konzervativnom metodom. Pacijenti su klinički praćeni do prestanka simptoma. Dobiveni rezultati pokazuju da je kirurško - konzervativna metoda liječenja djelotvornija jer u kraćem vremenu smiruje simptome boli.Postextraction pain or alveolitis sicca dolorosa is a complication which appears after tooth extraction, usually in the molar region of the lower jaw. In this paper two methods were compared: conservative and surgical-conservative method. The research was carried in order to establish which method is more advantageous and more effective. The pain treatment lasted for one year. Thirty patients were treated and each of them were separately conducted during three weeks after the treatment. Fifteen patients were submitted to conservative therapy, and fifteen others to surgical-conservative therapy. The results (tables and charts) show that both methods are effective and that both methods lead to symptom termination. However, surgical- conservative method appeared to be more effective, because in
the first seven days after the therapy, approximately 75% of the patients no longer had alveolitis symptoms

Ana-Marija Blažeković

Božidar Pavelić

Davor Katanec

Tihomir Kuna

Zoran Ivasović

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A S CActa Stomatol Croat, Vol. 37, br. 4, 2003. 471Postextraction pain treatmentpossibilitiesSummaryPostextraction pain or alveolitis sicca dolorosa is a complicationwhich appears after tooth extraction, usually in the molar region ofthe lower jaw. In this paper two methods were compared: conservative and surgi-cal-conservative method. The research was carried in order to establish which method is moreadvantageous and more effective. The pain treatment lasted for oneyear. Thirty patients were treated and each of them were separatelyconducted during three weeks after the treatment. Fifteen patients were submitted to conservative therapy, and fifteenothers to surgical-conservative therapy.The results (tables and charts) show that both methods are effec-tive and that both methods lead to symptom termination. However, sur-gical-conservative method appeared to be more effective, because inthe first seven days after the therapy, approximately 75% of the patientsno longer had alveolitis symptoms.Key words: alveolitis, postextraction pain, conservative therapy, sur-gical-conservative therapy.Davor Katanec1Ana-Marija BlaæekoviÊ2Zoran IvasoviÊ1Boæidar PaveliÊ3Tihomir Kuna11Department of Oral Surgery,School of Dental MedicineUniversity of Zagreb2Fifth year studentSchool of Dental MedicineUniversity of Zagreb3Department of DentalPathologySchool of Dental MedicineUniversity of ZagrebActa Stomat Croat2003; 471-475PROFESSIONAL PAPERReceived: November 10, 2003Address for correspondence:Doc. dr. sc. Davor KatanecZavod za oralnu kirurgijuStomatoloπki fakultetGunduliÊeva 5, 10000 ZagrebCroatiadavorkatanec@yahoo.comIntroductionPostextraction pain or dolores post extractionemis a pathological disorder of normal healing of awound in which, because of many factors, the phys-iological formation of a blood clot does not occuror the blood clot disintegrates (colliquation). In bothcases the consequences are the same. Local infectionof alveoli occurs and free nerve-endings are exposedto different mechanical, thermal and chemical impactswhich result in the occurrence of intensive pain (1).This is usually a pulsing or sharp pain which isextremely painful at night. This kind of pain is asomatic, deep osteomuscular type that is bone-painwith the manifestation of central excitatory phe-nomenon (2). In fact, every postextraction pain whichA S C Acta Stomatol Croat, Vol. 37, br. 4, 2003.472D. Katanec et al. Postextraction Pain Treatment Possibilitieslasts longer than 24 hours, or starts two to three daysafter tooth extraction may be diagnosed as dolorespost extractionem. This complication is differentlynamed in literature, i.e. alveolitis sicca dolorosa,alveolalgia, alveolar osteitis, dry socket, and in thisresearch we will call it by a term “dolor post ex”(1, 3). The pain appears as a complication in 2-5% ofall exctractions. The most usual alveolitis localiza-tion is the molar region of the lower jaw. This regionis present in 73% of the dolor post extractionemcases (4).Etiological factors which influence the dolor postextractionem occurrence may be divided into gen-eral and local factors. General etiological factors,according to McGregor, are: D and E hypovita-minosis, hypoproteinemia, diabetes mellitus and oralcontraceptives (5). According to some authors (6), age, gender andinadequate mouth hygiene are very important in painoccurrence.Of the local factors, Killey and Kay (7) mentionthat the trauma of the socket with rough manipula-tion and mucous and submucous injury, withremains of osseus particles and pieces of fillings andteeth are some of the most important factors in dolorpost extractionem occurrence. Excessive woundrinsing during the first hours after the procedure mayalso lead to injury and tearing off the blood clotwhich afterwards cannot be fibrously organised. Also, carbonated beverages may tear off theblood clot from the alveole (8).According to some authors (9), weaker alveoliblood flow in the lower jaw and the inducement ofischemia with vasoconstrictors, which are added inlocal anaesthesia, are important factors in the occur-rence of this problem. Mouth bacterial flora is important for the occur-rence of dolor post extractionem. In some circum-stances, dynamic equilibrium in bacterial flora is dis-rupted in the area of the extracted tooth. In that casesome nonpathogenic microorganisms become path-ogenic and that leads to blood clot disintegration andlocal alveoli infection (alveolitis sicca). The influ-ence of anaerobic microorganism Treponema den-ticola, which has strong fibrinolitical influence andleads to disintegration of blood clot, is very impor-tant. It is isolated in 75% of dolor post extractionem.This pathogenic spyrohete resettles mouth and pro-duces enzymes which then mix with the defencemechanism of the host. Binding of a bacterium onfibroblasts results with cell death, and binding on toerythrocytes leads to agglutination and also celldeath, which is a direct cause of blood clot decom-position (10, 11). This bacterium is usually con-nected to other periodontal diseases because it is iso-lated from gingival sulcuses and pockets (12, 13).Each theory has its own advantages and disad-vantages. Most probably, the sum of different sys-tematic and local factors lead to dolor post extrac-tionem if they occur at the same time.The goal of the dolor post extractionem treatmentis establishment of conditions in the alveolus whichwill lead to the formation of a healthy blood clot, itsfibrous organisation and finally ossification and reshap-ing of the bone at the place of the extracted tooth.The dolor post extractionem may be:• Conservative therapy: it consists of rinsing of thealveolus and taking medical implants which haveanalgesic, antipyretic and antifibrinolytic effect.• Surgical - conservative method: consists of exco-hleation of the blood clot decomposition, appli-cation of the medical implement and suturing ofthe wound.• Surgical or radical therapy: after the excohleationof the socket, the wound is covered by the muco-periostal lobe.The goal of this paper was to establish the mosteffective therapy method which would be the fastestway to eliminate dolor post extractionem symptomsand lead to blood clot stabilization which fills in thepostextraction alveoli. This complication usuallyappears in everyday clinical work even after the mostsimple extractions. The pain intensity as the mainsymptom and long duration (up to 20 days), causesmany problems to the patient and to the dentist. Itresponds slowly to therapy. It is very important toestablish a unique doctrine in dolor post extrac-tionem treatment which will be effective and accept-able to each clinical worker.Materials and methodsThe research included 30 examinees aged from20 to 56 years who had dolor post extractionemA S CActa Stomatol Croat, Vol. 37, br. 4, 2003. 473D. Katanec et al. Postextraction Pain Treatment Possibilitiessymptoms after extraction of one or more teeth. Theresearch lasted a year and was carried out in theDepartment of Oral Surgery, School of Dental Med-icine University of Zagreb. The examinees were patients who came to theOral Surgery Clinic because of pain which lasted formore than 2 days after tooth extraction . After clinical and X-ray analysis, which con-firmed dolor post extractionem diagnosis, we deter-mined the appearance of the clinical wound (alveo-lus and soft tissue damage), type and intensity of thepain (Figure 1). Intensity and type of the pain were measured ona so-called qualitative scale i.e. a subjective methodduring which the examinee describes the pain gra-dation from no pain to moderate and sharp pain. Theexaminee ranged his pain into a category such assharp pain or dull constant pain.For this purpose a questionnaire was devised.After a clinical examination one part was complet-ed by a physician and the other part, on intensity ofpain, was completed by the patient. The question-naire consisted of: general data on the patient, inten-sity of pain, completed by the patient, and clinicaldata - X-ray and wound appearance, completed bythe physician (Figure 2).Half of the examinees, 15 of them, with moder-ate symptoms of dolor post ex ( moderate pain withno mechanical damage to alveoli and soft tissues)were submitted to conservative treatment.Conservative treatment consisted of basic alve-oli rinsing with a ph. saline solution and placing anApernyl implant. Apernyl is a drug which consistsof acetylsalicilic acid which has an analgesic effect,and of paraoxybenzoic acid which maintains the for-mation of a blood clot (14, 15).The other half of the examinees, 15 examineeswith more intense dolor post ex symptoms (sharppain with damaged mucous and traumatised alveoli),were submitted to surgical-conservative treatment.Surgical-conserative treatment consists of firmexcohleation of alveoli, i.e. removal of all blood clotremains from the alveoli and inducement of bleed-ing with implementation of an Apernyl implant inorder to form a new, clean clot. The wound edgesget closer by suturing with an individual suture orsingle suture (3-0 cat gut). The procedure is per-formed under local anesthesia. Antibiotics with awide spectre were given to examinees, (Amoxyl3x500mg during 7 days). In the case of allergy toPenicillin, we gave Klindamicin (Dalacin C or Klim-icin 3x150mg during 7 days).After the procedure, the examinees were super-vised for the next 3 weeks. During each medicalexamination a clinical examination of the wound wasmade. The pain intensity was measured by a quali-tative scale, i.e. by a subjective estimate of the exam-inee - both treated by conservative and surgical-con-servative method.From the time of arrival in the Clinic of Oral Sur-gery to the dolor post ex symptom termination, eachexaminee completed the questionnaire with hisphysician (Figure 2). At the end of the investigation,all data were processed and shown in percentages. ResultsAll data were shown in tables and percentages.Out of 30 patients with postextraction pain, 15were subjected to conservative treatment and 15 toconservative-surgical treatment.All data were shown graphically for better pres-entation (Figures 3 and 4).By comparison of both the above treatments ofdolor post ex, we obtained these results: the first dayafter the therapy all patients treated by surgical-con-servative method had intense pain. Seven patients treated by conservative methodfelt moderate pain, eight had sharp pain. After thefirst week of treatment, the number of patients withsharp pain treated by surgical-conservative methoddecreased. Only four patients had sharp pain afterthe first 7 days. Eight patients treated by conserva-tive method experienced sharp pain. Two weekslater, only one patient felt sharp pain during surgi-cal-conservative method. Ten of them had no moresymptoms. Seven patients treated by conservativemethod felt sharp pain and only two had no moresymptoms.Three weeks later, all patients treated by surgi-cal-conservative method had no more symptoms,while three patients treated by conservative methodA S C Acta Stomatol Croat, Vol. 37, br. 4, 2003.474D. Katanec et al. Postextraction Pain Treatment Possibilitiesstill felt moderate pain which stopped 24 days afterthe beginning of therapy.DiscussionAccording to the results of the study, the surgi-cal-conservative method appeared to be better com-pared to the conservative method both practicallyand theoretically. With excohleation of the decom-posed blood clot, we cleaned the socket of necrotictissue and bacteria, and provoked fresh bleeding toform a new clot. A component of Apernyl medica-tion , paraoxybenzoic acid, has an important role inthe formation. We placed it in the alveoli after theexcohleation. Its second component, acetylsalicylicacid, works symptomatically, i.e. it reduces thepatient’s pain. The procedure ends with the sutur-ing of the wound edges with one suture, which thenprotects the wound from external influence and pre-vents the clot falling off. Since antibiotics are pre-scribed to the patients, the possibility of the occur-rence and development of bacterial infection isreduced to a minimum. The whole procedure is doneunder local anaesthesia which makes it pleasant forthe patient.Many authors (16) have studied this problem intheir research. Fedorov reports the possibility of treat-ing dolor post ex with a physical method of vibra-tion in the socket, after which medicamentous pastesare used. With the severe cases of this complication,on the first day after treatment of the wound by thismethod, the pain is removed and, in comparison withthe traditional methods of dolor post ex treatment,much faster healing up is achieved.When analysing surgical-conservative methods,Musbock (17) mentions the use of Koller paste which is introduced into an alveole,tamponed by iodoform band, and the gingival wallspasted, so that they are not exposed to the influenceof saliva. After 14 days, the iodoform band is takenout and the whole procedure is repeated if needed.He also mentions the surgical method of dolor postex. treatment by grinding of alveole according toGabka and Koller. In this case, the alveolus needsto be freshed up to the point of severe bleeding. Then,the treatment is continued with medications or sur-gically, by covering with mucoperiostal lobe.After the excohleation of the socket, Klammt andhis associates (18) applied trapezoidal vestibularmucoperiostal lobe. 3-6 days before tooth extraction,SemenËenko and his associates (19) applied lizozymenzyme and determined decreased occurrence ofdolor post ex. They explain this effect by the decreaseof pathogenic microorganism concentration, as wellas biological characteristics of the preparation, whichenables fast regeneration.In the prevention of alveolitis occurrence Swetand associates (20) used mouth rinsing with differ-ent medications: 0.9% solution of NaCl, 1% solutionof Kloramin-T, providon iodid or sodium bicarbon-ate. The greatest percentage of postoperative painwas experienced by the patients who rinsed theirmouth with ph. saline solution. Rinsing with different antiseptics led to decreasedfrequency of alveolitis with prophylactic factor,regardless of the medication type. KojundæiÊ (21)conducted wide research on the possibilities of alve-olitis treatment. One of the methods was the com-bination of surgical-medicament treatment, with theadditional usage of antibiotic implant. Neocones isan antibiotic-analgesic preparation which consistsof: Sulphate de polymixine B that has an effect ongram -negative bacteria, Tyrothricine which has aneffect on gram -positive bacteria and spyrohete inthe mouth, Neomycine has a wide range of impactand Chlorhydrate de tetracaine - local anaesthetic.Neocones implant is used for the purpose of prevent-ing the local bacterial impact. Besides that, he exposedpatients to the impact of X-rays in the area of the dryalveole in order to achieve better blood flow in thatarea. By doing so, they tried to eliminate the oftenreported etiological factors, clot infection and weakblood flow of the alveole. The second method wasexclusively the surgical method of treatment. Thenovelty introduced by this method was the formingof a lobe which practically seals the alveole and pro-tects the clot from mechanical impact, food, saliva,tongue, etc. By sealing the alveoli with Wasmundlobe, the sterility of the clot was ensured, althoughits bacterial impact could not be avoided. It may evenbe said that the conditions for impact of anaerobeswere improved.In comparison with the results obtained in theabove-investigations, the surgical-conservative methodof dolor post extractionem treatment, applied in ourA S CActa Stomatol Croat, Vol. 37, br. 4, 2003. 475D. Katanec et al. Postextraction Pain Treatment Possibilitiesinvestigation, gives equally good results and any clin-ical worker can simply apply it.ConclusionsAccording to the results of the study presented inthe tables and graphically compared, we can see thatboth methods are effective, although the surgical-conservative method appears to be more effective.According to these results, we can conclude thatimprovement of the symptoms started during the firstweek in the majority of cases. After three weeks oftherapy, all pain had practically gone. In contrast tothe previous method , the conservative method gaveno results. We only noticed slow improvement overa longer period of time. In the end we can conclude that the surgical-con-servative method is more acceptable and availableto every clinical practitioner. It is definitely themethod that should always be applied, at least inthe region of the lower jaw.

Postextraction pain treatment possibilities

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