Socket preservation: Possible reasons for post-operative pain?

I would treat the breakthrough pain with Toradol 30mg IM works within 15min for pain relief then follow with p.o dosage for 3-5days. Not sure why you prescribed Motrin and Tylenol #3,I would go with just the codeine in the immediate post op. Or if he is a big guy, Vicodin instead of Tylenol #3, he could just be under medicated. The chorhexidine will not help the pain but will keep the membrane clean.

Having done a fair bit of research on ridge preservation ( Socket grafting ) I feel the key is in the curretage of the site . Sharp instruments are the vital tool and aggressive use is needed to denude the site of granulous tissue , then the use of CHX ( more recent research shows the effect on Mesenchymal seels to be lower than thought , I used to say not to use ) in the site . Then graft I prefr fully bio-absorbable material as I will be placing an Implant in the site at 3 months ( Checking with Osstell ) and prefer real living bone ( Yes I have a large number of micro CTs and histo samples from numerous materials . ) as functional turnover is important for long term survival . Then better to use a fleece ( Collagen ) or palatal tissue plug to cover the site for healing . Personally I do not use a membrane (newer materials ) but then Tiger uses a 7 Iron where I would need a Driver . Cross suture closed with vicryl. So the Inflamation could be infection or a reaction to the membrane or even the xenograft material which can be expected . As CRS says keep on this path and monitor. Regards Peter

Peter I have heard that CHX retards the migration of fibroblasts so I stopped using it immediately and wait two weeks to prescribe. I have started using human chorionic membrane, exposed,no primary closure and like the results. This has been used in corneal surgery for years. Thoughts? Also granulation tissue has no nerve endings so I doubt this could the reason for the pain, however I agree with you on sound curettage technique and probably the inflammation from somewhere is the pain culprit.

Hi Apologies if this comment is very basic, however could it be a scenario synoymous to a dry socket?

HI CRS , yes used to work on that pricipal and avoided CHX until after the sutures were removed ( It can also effect vicryl sutures ) but when last at my college in the US it was shown that as I said more recent research shows the contrary . By the way the latest issue of JOMI is a good read with three articles on ridge preservation ( Lay Hom Wang , Michigan review , Tarnow on sockets where he shows techniques that I have used for 10 years to preserve and a case study showing grafting buccaly between the implant and the plate , gain a routine ). Also an interesting Thematic abstract review , Bisphosphonates : a help or a hinderance , good stuff Peter

Sorry went off topic ......... Pain as I said could be imfection from the site which may become involved with the xenograft , hence pain or merely the reaction ( Giant cell ) as said to the materials used. If it does not improve remove the graft . Peter

When would you suggest removing the membrane?

I would remove the membrane. I have found increased discomfort with a nonresorbable membrane. I believe it is inflammatory reaction to either membrane or sutures. I now use allograft mixed with bond bone (m.i.s. calcium sulfate), cover with either allograft or bovine collagen membrane, suture with ptfe sutures. Bio-OSS does not become bone, but rather becomes part of a boney matrix. Allograft is resorbed over time and will be replaced by bone. Vicryl causes inflammatory reactivity. Teflon has also shown to have an inflammatory reaction. Switch antibiotic to cleocin 300mg tid. Although 75% of all bacterial infections in the mouth are sensitive to penicillins, there's the other 25% to worry about. I have seen a cascading osteonectrotic event that starts as unmanageable pain...

Pain and inflammation point to either infection or an immune response. Nonresorbable membranes are bio-inert (hence nonresorbable) and very unlikely to elicit an immune response and also unlikely to become infected. If the pain is not a 10 then it is not a dry socket. It is difficult to distinguish between an infection and an immune response. An immune response to the xenograft will have a brighter red appearance to the tissue. I would advise that you open the site and examine the graft. If it is infected you need to remove the graft and regraft with a material that is unlikely to become infected like a bioglass or a microporous BTCP. If it is an immune response remove the xenograft and graft with anything other than the same graft material. If it is an immune response then this will not go away until all of the graft material is removed. Greg Steiner Steiner Laboratories

I just saw the histo slides (last week). There have been numerous studies and histopathology updates that concur with this. Perioglass (synthetics) and bio-oss (xenograft) like materials are never fully encapsulated into the mature bone matrix. They are volume fillers that merely hold space. They made aid in holding space for osseous building, but are never absorbed into the matrix. The same histo slides with allograft (particularly 250um to 500um) particles show a mature bone matrix without any distinguishable foreign particulate. Add a little bone morphogenic protein and some calcium sulfate (preferably in mono and dihydrate) and you have a sensational osteogenic mix that will result (lest there be an infectious event) in great osseous healing. Btw my favorite histo slide I ever saw was on the cover if a Nobel catalogue showing "osseous integration". It was, in fact, fibrous tissue with clear demonstration of fibroblasts and fibroid matrix. The local Nobel speaker had no comment...

Seth We are in agreement on many things but all I am asking for is one reference that is a histologic study that shows resorption of allografts over any time frame. Greg Steiner Steiner Laboratories

I guess the answer is we don't know. Ghe particles are indistinguishable from the matrix, unlike other graft particulate.

Pain thresholds are drastically different from one patient to the other, however most patients complain of some vague discomfort just before the gortex or vicryl sutures are removed. The pain probably has little to do with the graft, but hard to tell without more information. Bvinci

So i guess greg answered his own question with data that satisfies his "curiosity".

I must point out that i never said resorbed or absorbed, yet incorporated into the mature boney matrix. This makes the particulate difficult to distinguish. Unlike xenografts and synthetics, where particulate is easily identified. This, in my mind, makes a poorer quality matrix with a much greater risk of long term problems. Surgically it is a real bummer to reopen a "grafted" site only to find mush. Fdba with calcium sulfate produces a better mature bone.

How dense was the graft packed? Medical hx? I aggressively current the socket. Sharp curettes. I want the socket with active hemorrhage. If there is a thick cortical plate in the socket I will perf it with a small round but far RAP. I use corticocancellous bone and only lightly condense to the bony crest. Buccal dehiscence - I use resorbable. Cover the graft and suture under lingual flap. If there was any visible suppuration I irrigate with clindamycin and no graft. If no suppuration then it's a clean socket and I incorporate clindamycin in the graft. Only lightly condense! If it is too tightly condensed, you challenge the body to rehab itself. If the surgical site is inflamed, this thing is a surgical failure and no amount of abx will get to it. No circulation. When I do surgery, I want blood. Postoperative meds. Dose pack and NSAIDs for 5 days. Abx 3-10 depending on circumstances. All this isn't from the literature and some anecdotal and from friends who hash it out. I get good results. In the navy....RRR meant Red Right Returning... Buoys to get you into ports... In implant dentistry - for me it means Red Remove Return later. Patients can wait for a good result. Most of them anyway. Bill

I have little experience with non-resorbable membranes and single tooth graft sites, with the exception of about 10 as a resident. There are three foreign bodies at your site. This does not make any sense, with all of the allograft materials and autograft collection gadgets. Bvinci

Toradol 30mg IM then po 1omg q 6-8for 2-3days Is my standard operating procedure for break thru post op pain , alveolar osteitis, leave the site alone let it heal.

I totally agree with your management suggestion, as far as " dry socket ". I use ibuprofen, but have not used po toradol. Bv