This fourth and final installment in the SmilER series covers the diagnosis and management of 2 common dental conditions that present to the emergency department: pericoronitis and dry socket.

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

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Learning Objectives

  1. Understand diagnostic criteria of pericoronitis and alveolar osteitis (dry socket).
  2. Understand treatment modalities for patients with pericoronitis and alveolar osteitis (dry socket).
  3. Name some of the pharmacological adjuncts to aid in recovery.
  4. Review key points to include in discharge instructions.

Diagnosis

Patients may present to the ED with pericoronitis, an inflammation of the gingival soft tissue overlying a mandibular third molar. This soft tissue is subject to trauma from the patient biting down and may lead to pericoronitis due to normal oral flora. Patients with compromised host defenses may more easily develop pericoronitis. Repeated trauma to the operculum, the soft tissue overlying a partially erupted tooth, may lead to increased swelling more easily subject to subsequent trauma—a vicious cycle leading to worsening pain and erythematous swelling. Food may also become entrapped under the soft tissue due to difficulty maintaining oral hygiene.

Pericoronitis is a clinical diagnosis and does not require imaging.

Treatment, discharge, and follow up

  1. Irrigation: In the emergency department and as an outpatient, irrigation of food debris under the operculum using chlorhexidine or normal saline can acutely reduce bacterial counts.
  2. Antibiotics: The patient can be prescribed penicillin, or clindamycin if allergic to penicillin. If not treated, pericoronitis may result in a localized soft tissue infection (see SmilER 103).

The patient should follow-up with an outpatient dentist to prevent recurrent infections. This typically involves the patient undergoing definitive treatment, that is, extraction of the offending tooth.

Diagnosis

Dry socket, also known as alveolar osteitis, is moderate to severe pain experienced after dental extraction due to exposure of bony surfaces. The pain typically begins 3-5 days following a tooth extraction. Although the cause is unclear, it is thought to be related to fibrinolytic activity within the extraction socket, which leads to lysis of the developing blood clot. The subsequent exposure of bone leads to moderate to severe pain that may be dull and aching. This pain may radiate to the ipsilateral ear. Associated symptoms include a foul odor or taste. Although dry socket is rare (2%) following routine dental extractions, it is more commonly associated with extraction of the mandibular third molars.

Dry socket diagram

Dry socket illustration for exposed bone and nerve after a blood clot is dislodged

Treatment, discharge, and follow up

Treatment of a dry socket is relatively simple. The premise is to NOT dislodge any newly forming blood clot, which serves as a protective covering.

  1. Irrigate the socket with sterile saline
  2. Gently suction away the excess saline, but do not go too deep into the socket as to evacuate the developing blood clot. The area also should NOT be curetted, as this will often worsen and possibly dislodge beneficial blood clots.
  3. Insert a medicated dry socket dressing (iodoform gauze) into the socket. These may be available in your emergency department or, alternatively, can be obtained from the pharmacy or as a commercial preparation from a dental supply company. Ingredients in this dressing include: eugenol to help with pain, topical anesthetic such as benzocaine, and a carrying vehicle such as balsam of Peru. Upon application, the patient should experience immediate relief within 5 minutes. Unfortunately, many emergency departments do not stock dry socket paste or Dressol-X. An alternative is ribbon gauze or Gelfoam impregnated with eugenol, iodine, or oil of cloves.

The patient should follow-up with an outpatient dentist or oral surgeon within 2 days to have their dry socket dressing changed every other day for the next 3-5 days.

References

  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019. 
  2. Berman L, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby; 2006.
  3. Kademani Deepak. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
Richard Ngo, DMD

Richard Ngo, DMD

Richard Ngo, DMD
Oral and Maxillofacial Surgery Resident
Massachusetts General Hospital
Richard Ngo, DMD

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Cameron Lee, DMD, MD

Cameron Lee, DMD, MD

Cameron Lee, DMD, MD
Chief Resident in Oral and Maxillofacial Surgery
Massachusetts General Hospital
Cameron Lee, DMD, MD

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Andrew Eyre, MD, MS-HPEd

Andrew Eyre, MD, MS-HPEd

Andrew Eyre, MD, MS-HPEd
Assistant Program Director, Harvard Affiliated Emergency Medicine Residency
Director of External Programs, STRATUS Center for Medical Simulation
Attending Emergency Physician, Brigham and Women’s Hospital
Andrew Eyre, MD, MS-HPEd

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Chris Nash, MD

Chris Nash, MD

Chris Nash, MD
Medical Education Fellow and Emergency Physician
Massachusetts General Hospital
Chris Nash, MD

@ChrisNashMD

Resident @EMRES_MGHBWH. @DukeU + @NUFeinbergMed alum, @HGSE student. Assoc Director of Growth @ALiEMteam. Chief Tech Officer #ALiEMU. Tweets≠Medical Advice
Chris Nash, MD

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