When did they change the ingredients of Alvogyl?! It’s the return of Oral Surgery Specialty Dentist and sensible man Dr. Chris Waith – this time to answer our Oral Surgery Complication questions starting with Dry Socket prevention and management!
“It will be better no matter what we do, whether we dress it or not, it’s just whether you can live with that timeframe.” – Dr Chris Waith
In this group function we discuss:
- How can we prevent dry sockets? 3:54
- Can suturing help in preventing dry socket? 10:43
- How to manage patients in pain with dry socket 15:39
- Does Irrigation and Alvogyl actually help in managing dry sockets? 19:09
Click for ->Chris Waith’s Oral Surgery Course
If you enjoyed this episode, check out Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth
Click below for full episode transcript:Opening Snippet: Welcome to group function, where the Protruserati worked together to find good solutions to worthy problems in dentistry with your host, Jaz Gulati...
Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati and welcome back to another group function this time with all surgeons specialists, Chris Waith. Yes from that epic episode on how to section and elevate teeth. Listen, if you haven’t listened to Episode 85, it is huge, because it just gives so much. I wish I had that when I was just one or two years qualified. In fact, let me tell you a story. Kamila. Kamila, you posted on YouTube when you watch the video which got like over 1000 views now, which is awesome. Guys, I appreciate it very much. Now, Kamila posted on one of the comments saying that, ‘Thanks for you know, I discovered your podcast. And thanks for this episode. I was able to on my last day in dental foundation training, I was able to section and elevate a tooth with confidence, and is only possible due to this episode.’ So thanks for epic episode with Chris Waith, she was able to do that, which is just amazing. That’s the kind of feedback I absolutely love. And that’s the reason I keep this podcast growing. So thanks so much guys who always comment and like on the YouTube or if you listen on your commute, I really appreciate it. Now, this episode is very fundamental, right? Like dry sockets. Such a huge thing. Actually, Lucky you. I’ve got Chris Waith to talk about three things over three group functions. We’re talking dry sockets, OACs, and those dreaded tuberosity fractures. So let’s listen to what Chris Waith has say about what’s the best way to prevent a dry socket. And if you are unlucky enough to have a patient’s who’ve got dry socket, how can you manage it? And I’ll be honest with you, I don’t think I’ll be doing what Chris says like on reflection. I don’t think I’ll be doing what he says because it’s a very interesting approach. It surprised me and it will might surprise you. And you may or may not do what he says. So let me know, you know, reach out to me the protrusive Instagram pages @protrusivedental, so it’d be great to connect on there. But let me know what you think about Chris’s advice.
Main Interview: [Jaz] Chris Waith, a man who needs no introduction after that podcast episode we did about extractions and how to section and elevate. Chris, how you doing, mate?[Chris]
I’m really good. Thanks, man. [Jaz]
I’m brilliant. And we were just chatting before I hit the record button. I asked you have had you seen the comments that we got on our YouTube video. And it’s had like over you know, 1.2k views on it, which is great. But overall, over 4000 dentists over the world have listened to that episode. And I sometimes thinking why do I do this? Why do I do what I do. And when I get comments, like I saw, it was amazing. It was young lady, foundation dentist who said that, on my last day of FD, I was able to tackle a difficult molar and I had the confidence to section and elevate and help this patient. And I wouldn’t have done it if it were if I didn’t listen to this episode. So just that was like, wow [Chris] A remote appointment isn’t? [Jaz] Absolutely and I know you’ve been doing some you’ve been a busy boy teaching these skills to everyone. You’re doing like a countrywide tour. I’ll be seeing you in Brighton in a few days time for the Tubules Congress, very much looking forward to that. But today’s group function, I’m probably gonna split it into three, three little bite sized chunks, okay? We’re going to cover in these three chunks. We’re going to cover dry socket, we’re going to cover OACs, and we’re going to cover that dreaded tuberosity fracture. So Chris, I’m gonna hit you straight away because people have heard your intro and yours interesting oral surgery. And how awesome you are, we know already from that episode. If you haven’t listened to that episode that we did with myself, Chris and Zak, all about sectioning and elevating that is going to profoundly improve your extractions come Monday morning, do go back and listen to that. But now hit me, Chris. Dry sockets is an annoying complication. It’s an annoying complication. And over the years, I like to say it’s happened less and less to me. But I couldn’t honestly tell you whether it is just me getting quicker, better, cleaner extractions? Or are there other things at play? How can we prevent dry sockets? [Chris]
It is a really a tough one, I think not to beat ourselves up too much. We’ll never prevent it completely. It’s just one of those things that you’ve got an open wound healing in a difficult environment. And some of those patients, they’re always going to have the risk factors that make them more prone to it, which we can’t do anything about. I love having lunch across the road. And watching my last patient walk out and light up after I’ve just spent two minutes telling them not to smoke for as long as possible, just little things like that. But I think going back to the last podcast that the thing that we can do is look after your extraction so make it I mean reduce that trauma as much as you can. Sectioning a tooth rather than just putting your forceps on will always mean that the patient starting off on the right foot. I think once you finish your extraction, just spend a minute with a currette or a Mitchell’s or a dental excavator. Just something in the socket. Get rid of all the little bone chippings, filling chippings, tooth chippings. If there’s some pathology there, get rid of the pathology. And then after you’ve got that point, you’ve got to just think about the blood clot, anything you can do to support that blood clots. We were talking about this on the course this weekend that I just think I’m going to have to pick a month or two, where I just suture every single socket that I put in, because I want to know what my incident rate of dry socket will be compared to when I don’t suture it. [Jaz] And you did this little experiment? Yeah? [Chris] No, this is what I think I’m gonna have to do, because we talk about it all the time. And it’s like when people are saying how to prevent it, I just think really, the only things we can do is make our extractions less traumatic, and support the blood clot. And not necessarily put a sponge in or surgicel or something like that. But actually just suture the socket, bring the side in, try and make sure that the clot stay in there. I think that’s probably all we can do. There’s no evidence for antibiotics or mouthwashes, or anything like that. They’re all hearsay, I think with the exception of wisdom teeth, where there’s a tiny little bit of evidence about pre op ABs, but not enough that I think it’s ever changed how everyone behaves. [Jaz]
Two behaviors. I’m going to share with you Chris, that some of my colleagues have suggested. One by the time this episode comes out last week, we had Nekky Jamal from Canada talking just exclusive about wisdom teeth, and I’ve done his little course and whatnot on wisdom teeth, and he’s a huge fan of PRF, right? Platelet-Rich fibrin. Obviously not every GDP, they have access to able to do venipuncture and actually made the good stuff and then put in the socket. A) you do that? B) Any evidence you aware of that, that is a beneficial thing to do? [Chris]
I don’t do it. But I don’t do it because there’s not enough evidence for it, to prove to me that it’s worth it. And PRF are really interesting one because the breadth of how people have engaged with it is huge, really, from that kind of scenario, just simple just placing it into a socket to the other end of the scale where you’ve gotten MRONJ patients where they’re trying to use it in disease sockets, and to implant work where people put them in sinuses, across grafts in all sort. It is what is one of those regimes where I think the evidence hopefully will come and it will build up and it might be that we’re sitting on the cusp of something new. Purely if we’re talking about dry sockets and socket so I think the cost and the techniques and the time of committing to venipuncture putting it in the centrifuge [Jaz]
and the degree of invasiveness like you know everyone’s not going to have easy veins. [Chris]
Yeah, it puts that barrier up that I think it will probably never just work into general practice. [Jaz]
I mean I think my colleague, Nekky, he all he does is wisdom teeth, right? Surgical. So for him that surgical background implant stuff. He’s got the kit already, and he’s a big believer in it. Early Adopter. And so it makes sense. I mean, for those who are listening who don’t know what this is, I guess a crude explanation will be taking out the patient’s blood, putting in a spinny centrifuge machine and extracting the Platelet Rich fibrin hence the term and looks like this yellow jelly, doesn’t it? [Chris]
Yeah. Like for sockets. But PRF make sense, it’s like, biologically, it’s that slightly M rich version of the factors that we want to promote healing. If we’re just talking about simple extraction sockets, I think Well, we’ve got hopefully, platelet plug in the socket, with or without PRF. So on a simple level, and for the simple level for the gdps out there, I think you know, sometimes don’t get sucked in by equipment, fancy techniques. It might be that your wisdom teeth and your implants and your sinuses benefit from it, but actually basic extractions, I’m all for keeping it simple, I think. Get your suture technique, perfected suture a little bit more, keep that clot stable. Give all your instructions that you can to the patient. And as certain as I can be, I think that’s enough to bring your incidents down. I always think such word that I don’t get a massive amount of dry socket. You’d expect particularly the type of extractions that I sometimes have to take on that my incidence might be a little bit higher because the probably a bit more traumatic [Jaz]
Any percentage to go by? You know, if I was saying at 1%, 5% anything you can give in that regard? [Chris]
So I always say that if you look at all the journals, you’d have it in your head that about 1 in 20 is right. I don’t think ours is that high. I think mine is probably like 1 in 75, when I look at it. Now, it’s difficult for me because I’m referral base, I know that I probably missed some of my follow up. So it might be a little bit higher than that, because they may go back to their GDP for it. But we try and call our patients, so we call a day later and a week later. So we’re trying to make sure that we mock up anything that’s happened that we might not have known about. But think about 1 in 75. And I don’t do anything too special for that. I just clean the socket, make sure it’s cluttered and when it needs it, suture it. [Jaz]
So let’s talk about the suturing in this as a wrap up this prevention side about you know, what, what is it potentially that we can do. Suturing, once the principal who is very much like really pro like after you take out a tooth, turn that secondary healing into primary healing, like he was really going chasing the primary closure to the extent that he was actually releasing the periosteum and trying to cover over. Is there a real massive benefit of doing that? Or should we just let the sockets heal by secondary intention, which they do quite routinely? [Chris]
Yeah, I wouldn’t go as far as that. I think if you go to that extreme, what you’re trying to gain to get your socket to heal. I think you’re losing by disturbing your normal anatomy. And if you’re advanced in the flat, really you may be obliterating the sulcus and making your prosthetics more difficult down the line. I’ve all before, I’d be all for trying to keep it as natural as you can. But I think I’d be suturing, it’s not so much that you’re going for primary closure, you’re just going for stability. So something like a horizontal mattress across the middle of your socket, actually bring the edges of your socket together, just so there’s something physical to hold the clot on, I wouldn’t be going for anything more than that, I don’t think. [Jaz]
I think you summed up well to get that stability. So you haven’t got something that’s too floppy or moving, you know, any moving parts just want to secure the area. So that’s covered it perfectly in terms of what we can do in our best intentions, prevention. But like you said, it’s one of those things that can’t be avoided and do what we can in terms of a clean surgical technique to to maximize our chance of not getting that dreaded phone call. Now, when we do get that dreaded phone call, and your patient has got dry socket, Our duty is to help them and I want to really help this patient, you see these patients in absolute agony. So what is the the gold standard way? And what is I mean, is what we’re doing okay, I’ll just tell you what we usually do a lot of me and my colleagues, you know, patient comes in, sometimes we’ll just rinse it out with the saline, and then just stick some good Alvogyl in it. And that’s it, should we be doing more? Because I read some colleagues saying that, ‘Hey, you got it, you’ve got to make it bleed.’ But I’m thinking if I’ve got to make it bleed, already they’re in pain, then are we supposed to be numbing out these patients to actually, you know, produce a new blood clot? [Chris]
Yeah, it’s a really difficult one, I mean, my way of approaching it, I’d go two ways, I’d look at what you do beforehand, to get the patient prepared, your instructions afterwards, and then what you do when the patient’s in the surgery. So I think beforehand, the most sensible thing is as long as they’re okay, taking them, get the Brufen, their NSAIDs on board before the extraction makes loads of sense because it helps your anaesthetic work better. But also, it means that pain levels controlled as the anesthetics wearing off, which is loads more comfortable for their body, rather than letting them get a big blip of pain that they then have to try and blast to control. So pre emptive NSAIDs, great, get those on board if you can, after your extraction, and particularly if that patient ticks a few of the boxes. So longer, more difficult extraction mandibular, ladies more than man, oral contraceptive, the pre existing infection, all of those that I’m ticking, I think, right, just spend a couple of minutes now with this patient and just say ‘So this is what I think is normal. This is what I think might be abnormal. And so two, three days down the line, any increase of pain, struggling more with your analgesia give us a call. ‘ But I’ll try and hammer home. How important it is for them to respect taking the full dose of analgesia so the paracetamol and ibuprofen for a few days, so that when they call if they’re not doing actually I might just hammer that home again and say, ‘Right, so this is the important that you need to take your paracetamol and your ibuprofen regularly.’ Because a lot of the patients just get in that analgesic regime correct will be what they need without me putting my hands in the mouth or doing anything. [Jaz]
I think that’s so true because a lot of people are like me I’m like really anti painkillers. I have to be like literally having the worst man who ever or the worst tangle ever before I even reach for a paracetamol more but a lot of our patients you know they’re the same so for whenever I you know when I have done on my shoulder and I literally was on painkillers for one day, but I’m pretty sure my orthopedic guy probably wanted me to take it for longer. So you’re right, you’re totally right just to reinforce that and the regimen I like to recommend is 600, Ibuprofen 600 milligrams Ibuprofen and a gram of paracetamol and then to even taper that ibuprofen up if needs be in his worst case, and I’m thinking more in irreversible pulpitis to 800 milligrams, but make sure you eat something beforehand. But then obviously don’t exceed the four grams during the day for paracetamol. Any comments on this regimen? [Chris]
Yeah, I mean, there are two things. One is just from a pure effectiveness point of view, but one psychological for the patient. Like from an effectiveness point of view, if you’ve got a dry socket, and that severe pain with it, you do need to up the game with the analgesics, I think at least 400 milligrams of ibuprofen, but probably 600, 4 times a day, just make sure they’re having some food later on in the evening if you’re taking some before bed. I think as well as that, if you start to get to 600 milligrams, which is a dose really that we can prescribe rather than saying to them go to the counter, psychologically, a lot of patients are tuned in to come in to you for a prescription because in the past, they will have just been given some antibiotics, which is wrong. But you can still give them the prescription to say well actually you do need a stronger medicine and this is it. But it’s analgesics and we have loads of patients that come in for it. And I mean, there is a little bit of evidence that there’s some kind of bacterial component, but a dry socket isn’t an infection. So it’s trying to say to somebody, and I mean using your analogy, but not so much shoulder, I just say twisted ankle slightly. If you’ve twisted your ankle, it’s really sore. But it’s very hard not to aggravate it because you’ve got to walk on it. So you’ll be taking painkillers for a few days, and then you’re rested a little bit more when you come. If I gave you antibiotics on that day, when you twisted it, a week down the line, your ankle would feel better, but it’s not the antibiotics. It’s just the fact that your soreness and swelling is gone and you’ve not been walking on it and this is the same in your mouth. The difficulty is that every time you speak, every time you eat, you’re aggravating the socket, you’ve just got to respect the fact that it takes some time for those analgesics to work. But if I gave you antibiotics on day one, and you’re better in a week, it’s not the antibiotics that have done that, it’s just Mother Nature, it’s just nature taking care of socket and you getting over that kind of severe spell. The other thing I say is about picking scabs. It’s like I mean, our youngest right now has a massive sore on his knee because he’s had this scab for about five weeks and he just keeps picking it and you know you try and say to them Just stop it, it won’t heal properly. And that’s dry socket and it’s like, you know your scabs got in, your clots going into the socket. So now you’ve got that horrible sore spot underneath which isn’t fully healed, only it’s worse for you because it’s in your jaw, it’s not even your skin so that’s why it’s so sore. So that if they’re coming and you know people talk about dressings, I wouldn’t necessarily jump into dressing something unless they were really struggling you know, quality of life struggling to sleep, struggling to function, and they just need something to break that pain cycle so that then their analgesics are working better. I think for that patient that’s we’re not irrigate with some saline and put some Alvogyl in. I think for everybody else I would try if they’re on board just to say you know what, you’re going to need your analgesics for a little longer but in you know, 7 to 14 days it will be better no matter what we do, whether we dress it or not, it’s just whether you can live with that timeframe. [Jaz]
This is when they’re in the chair, so this is when they’ve come to see you so you’re telling me that patients come to see you and for dry socket you’re not always reaching for that Alvogyl and the rinse, is that what you’re saying? [Chris] Yeah [Jaz] Wow, that’s another shock to me. Just like you shocked me the last episode about you know using the fast handpiece to section teeth, this is another shock because it’s so engrained in what we were taught and the way all my colleagues practice is like you know, okay dry socket equals and even the nurses are primed for it. Oh, we got a dry socket. Let me get the Alvogyl ready you know. [Chris]
And don’t get me wrong. It’s definitely got its place but I won’t necessarily jump on it straightaway. I don’t want to sound too heartless with it. But like my old maxfacts consultant used to say he was like you know, in two weeks, your dry socket will be healed whether you’ve dressed it or not [Jaz] Very true [Chris] It’s just which path you take to get there. So if they’re analgesic controls doable, and if they can live with it actually just let Mother Nature take care of that one. It’s when their analgesics aren’t really recovering it. And the suffering, we just need to break that pain cycle before it gets too bad. Those are the ones that I’ll irrigating dressing like, I mean, what you said, for the people who aren’t already in saline instead of Corsodyl. Shouldn’t be putting Corsodyl in sockets because there’s been a couple of anaphylactic deaths with off license use of chlorhexidine. So irrigate them with saline, part of my reason for changing as well as that alvogyl years ago, change to alveogyl which isn’t, I don’t think, as effective because they’ve taken out the butamben and the iodoform. And those are kind of local anesthetic components, which we definitely used to see a big difference almost straightaway, when you applied it. My take on it is, if they really need that help it’s there for them. If they don’t, though, we’re just putting a foreign body into the socket, while it’s trying to heal. And I’m all for trying to avoid doing that. Because I think sometimes you actually, you delaying the healing a little bit more. And we’re really, we’re trying to speed it up, I can see why people say about trying to promote some bleeding and getting it. I don’t do that, but I can see the logic with it. And I think it probably comes down to your patient again. These patients with mandibular teeth who smoke, you take the tooth out, and the socket doesn’t bleed. There that first time while they’re anesthetise, that’s when you make it bleed, go to down on the socket little bit and try and encourage, then I’ll suture it and keep the clock there. I think if you don’t do that, and then then they come back with dry socket, well, that was almost inevitable for you to have to numb them up again, and then go to down on the socket I think, oh, we could have maybe done that last time. But there’s also, there’s a little thing in the back of my head that I think you know, we don’t completely understand the pathogenesis of this. There were all these little elements that we think play a factor. And I think the worst thing that could happen, I mean, I’ve been treated if anybody does do this routinely, I’d love to know how many of those people come back with a second dry socket because that clot breaks down. Because I just think it’s the same person and the same risk factors. The same socket and or, you know, whatever we change put in that second clotting. I can see why they because there’s a physical, a physical barrier to the socket, and it’s the one that’s supposed to be there rather than Alvogyl or something like that. And I think even for alvogyl, we still sometimes have to anesthetize the patient because it’s so sore to irrigate and place it, so it might be that every anesthesize does it make more sense to try and make it bleed again? I don’t think there’s a wrong or a right answer there but I’m much more in favor of natural healing than unnatural healing. And like I said, I’m not trying to be mean to my patients. I’m just trying to get them on board with my way of thinking. And I think whenever we see see on the groups there are loads of people or I think numb people up and currette the sockets and make it bleed again. And I think you do that unless you’ve been doing it for a long time and it worked for you. They that’s certainly anecdotal. I’d love to light no fingers on it. But I think if people do that they must know that for them it works. For me doing nothing, works a lot. [Jaz]
I’ve definitely learned something that and even about the whole Alvogyl versus Alveogyl like Wow, I didn’t even realize that they took away the good stuff, that iodoform and butamben. This is news to me, you know, I didn’t get that memo.
Jaz’s Outro: So there we are. I definitely have less faith in stuff that’s in our drawers at the moment now. And maybe now I think I might do the same thing as you and just give them comforting advice. Make sure you’re on the correct analgesic regimen and some reassurance so that is very useful, and I’ll catch you in the next couple of group functions coming very soon.