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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 21-23

Alveolar osteitis in a patient with common variable immunodeficiency


Department of Oral and Maxillofacial Surgery, ITS Dental College and Research Centre, Greater Noida, Uttar Pradesh, India

Date of Submission21-Nov-2019
Date of Decision07-Jan-2020
Date of Acceptance28-Jan-2020
Date of Web Publication28-Mar-2020

Correspondence Address:
Preksha Dubey
Department of Oral and Maxillofacial Surgery, ITS Dental College and Research Centre, Greater Noida - 201 308, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_70_19

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  Abstract 


Patients with primary immunodeficiency disorders are prone to dental problems, and a lack of proper communication with surgeon may create complications following invasive dental procedure. We present the case of a patient with common variable immunodeficiency disorder (CVID) who underwent a dental extraction and later on, developed alveolar osteitis. A 26-year-old male reported to the outpatient department, with a complaint of severe pain in his left lower jaw following the extraction of mandibular molar 1 week ago. The clinical picture was suggestive of suppurative alveolitis. The fact that he was a diagnosed case of CVID was not revealed to the operating surgeon. He was undergoing treatment for the past 6 years at another center that included intravenous immunoglobulin G (IgG) administration. Serum IgG level performed about 10 months back was 6.1 g/L. The patient recovered fully after a week of treatment with zinc oxide pack and oral metronidazole. CVID is a known risk factor for the development of alveolar osteitis. Proper communication is vital for avoiding complications in such cases.

Keywords: Alveolar osteitis, common variable, dental extraction, immunodeficiency


How to cite this article:
Dubey P, Thapliyal GK. Alveolar osteitis in a patient with common variable immunodeficiency. J Dent Res Rev 2020;7:21-3

How to cite this URL:
Dubey P, Thapliyal GK. Alveolar osteitis in a patient with common variable immunodeficiency. J Dent Res Rev [serial online] 2020 [cited 2020 Jun 4];7:21-3. Available from: http://www.jdrr.org/text.asp?2020/7/1/21/281509




  Introduction Top


Development of alveolar osteitis or dry socket is not an uncommon postextraction complication. Not only it leads to increased morbidity but also it is an economic burden on the patient. The origin of alveolar osteitis is multifactorial, and various aggravating and precipitating factors have been identified. Locally increased fibrinolytic activity has been implicated in the pathogenesis of alveolar osteitis. It is also known as localized osteitis, postoperative alveolitis, alveolalgia, alveolitis sicca dolorosa, septic socket, necrotic socket, localized osteomyelitis, and fibrinolytic alveolitis.[1]

Clinical and histological evidence suggests that alveolar osteitis is a consequence of disturbed healing of the extraction wound.[2] The etiopathogenesis is probably related to a complex interaction between localized trauma, bacterial invasion, and their association with plasmin and fibrinolytic system.[2] Possibility of the association of a genetic factor cannot be ruled out also. The genetic predisposition is likely consequent to polymorphism of one or more genes. However, large association studies or transdisequilibrium testings are required to establish the same.[2]

The prevention of alveolar osteitis mandates reducing the number of risk factors and meticulous performance of the procedure.

Patients with primary immunodeficiency disorders are prone to dental problems. Apart from regular dental care, proper communication with a dental surgeon before undergoing any invasive dental procedure is extremely important. Immunocompromised individuals are more prone to develop true alveolar osteitis. Intravenous immunoglobulin G (IgG) administration to optimize the serum level before undergoing a dental procedure is one of the important prophylactic measures.

The common variable immunodeficiency disorder (CVID) is one of the most common primary immune deficiency diseases. Mostly, the clinical history in CVID is frequent infections in patients between the ages of 20 and 40 years.[3]

IgG replacement through intravenous or subcutaneous routes reduces the incidence of acute bacterial infections. However, major systemic illnesses and development of cancer, the major cause of morbidity and mortality cannot be avoided by IgG replacements.[3]

We present the case of a patient with CVID who underwent a dental extraction and later on, developed alveolar osteitis. A lack of communication about this condition probably contributed to this development.


  Case Report Top


A 26-year-old male reported to the outpatient department with a complaint of severe pain in his left lower jaw for the past 5 days. He had undergone extraction of his left mandibular molar 1 week ago. Unknown to the operating surgeon, he was a diagnosed case of CVID undergoing treatment for the past 6 years at another center that included intravenous IgG administration. The serum IgG level performed about 10 months back was 6.1 g/L.

He started experiencing severe localized pain 2 days after extraction that did not radiate elsewhere. On examination, yellow-gray devitalized soft tissue with surrounding erythematous mucosa was observed at the site of extraction [Figure 1]. There was no accompanying regional lymph node enlargement or fever. After obtaining an X-ray, his wound was irrigated with povidone-iodine, and packing was done with zinc oxide. Oral metronidazole was prescribed. The patient recovered fully after a week of treatment.
Figure 1: Suppurative alveolitis

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  Discussion Top


Alveolar osteitis, popularly known as dry socket, is characterized by an inflammation in the alveolus of a recently extracted teeth, for which pain and the period of onset are specific clinical signs, indicative of proper diagnosis.[1] Typically, it appears 1–3 days after extraction and is characterized by severe constant pain that might be localized or usually radiating to the ear on the ipsilateral side. The patient usually reports with sharp shooting pain while drinking water and difficulty in mastication due to the pain. It may be associated with foul taste and halitosis. There may be associated low-grade fever and regional lymphadenopathy. Headache, insomnia, or dizziness may be present. Clinically, an empty socket (lacking a blood clot) with exposed bone is seen. Sometimes, the clot becomes infected and gets covered with greenish-grayish membrane that may contain dental fragments with or without medium intensity pain and fever. This condition is known as suppurative alveolitis.[4] Our patient presented with suppurative alveolitis as suggested by the clinical picture.

CVID is defined as a genetic immune defect, characterized by significantly decreased levels of IgG, IgA, and/or IgM with poor or absent antibody production, with the exclusion of genetic or other causes of hypogammaglobulinemia.[3] The most common one is an IgA deficiency, in which antibody is low or absent in the mucus and saliva of the mouth that makes these patients unable to respond to infections, especially that of mouth and gum. Immunodeficiency is a known risk factor for the development of alveolar osteitis.[2] It has been suggested that annual monitoring for complete blood counts, liver and kidney functions, serum albumin, along with biennial, or annual estimation of serum IgG should be performed in patients with CVID.[3] Patients who are being treated with intermittent IgG administration should have a serum level more than 6 g/L before undergoing any invasive dental procedure. Our patient apparently underwent extraction without knowing the existing serum IgG level. This might have contributed to the development of this complication, as the serum IgG level might have been lower than the required level.

The target trough serum IgG level varies depending on the baseline level of IgG. In a patient with a baseline serum IgG of <100 mg/dL, a suggested trough level would be at least 600 mg/dL, but for another with an initial IgG of 300 mg/dL with no functional antibody, the required trough level might be 900 mg/dL to supply the minimum “normal” level of functional Ig.[3] A comprehensive discussion during history taking and examination can help identify and optimize these patients.

Anaerobic bacteria is known as an etiologic factor for this condition.[1] We prescribed metronidazole since it is widely recommended and considered as the first line of drug for this infection.[5] The use of zinc oxide and eugenol for the treatment of alveolar osteitis has been in practice for more than 50 years and used as a palliative treatment.[6] The use of antibiotics is recommended in patients with a history of multiple dry sockets as well as for immunocompromised patients.[7] He was prescribed amoxicillin at the time of extraction. The patient responded well to our line of treatment.


  Conclusion Top


Patients with CVID undergoing invasive dental procedures are susceptible to infection. Proper communication between the patient, surgeon, and physician is vital for treatment planning and avoiding complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cardoso CL, Rodrigues MT, Ferreira Júnior O, Garlet GP, de Carvalho PS. Clinical concepts of dry socket. J Oral Maxillofac Surg 2010;68:1922-32.  Back to cited text no. 1
    
2.
Blum IR. Contemporary views on dry socket (alveolar osteitis): A clinical appraisal of standardization, aetiopathogenesis and management: A critical review. Int J Oral Maxillofac Surg 2002;31:309-17.  Back to cited text no. 2
    
3.
Cunningham-Rundles C. How I treat common variable immune deficiency. Blood 2010;116:7-15.  Back to cited text no. 3
    
4.
Hermesch CB, Hilton TJ, Biesbrock AR, Baker RA, Cain-Hamlin J, McClanahan SF, et al. Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: Efficacy and risk factor analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:381-7.  Back to cited text no. 4
    
5.
Rood JP, Danford M. Metronidazole in the treatment of “dry socket”. Int J Oral Surg 1981;10:345-7.  Back to cited text no. 5
    
6.
MacGregor AJ. Treatment of dry socket by general dental practitioners. Br Dent J 1967;122:63-5.  Back to cited text no. 6
    
7.
Tarakji B, Saleh LA, Umair A, Azzeghaiby SN, Hanouneh S. Systemic review of dry socket: Aetiology, treatment, and prevention. J Clin Diagn Res 2015;9:ZE10-3.  Back to cited text no. 7
    


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