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Medical Forum / General / Dentistry / March 2007gelfoam effect - - clot is shrinking - lower third molar , pending dry socket ?
Post extraction had distinct clot for 35 hours, follwed all instructions religiously. at 45 hours, despite careful avoidance of disturbance, clot has lost 30% of surface diameter, shrunk. At 55 hours, what remains of the clot is a tiny center in a white setting. No pain at this point. There is really no cavity, as the gelfoam fills it completely. Q: Is the normal outcome that the gelfoam itself "becomes" the clot, since it is filling the aveola completely ? Q2: Even postoperatively, after the 30 min, gauze compression period, the bloodclot was never very high, i.e. though broader, it was at most 2 mm above the gelfoam surface I see now. Q3: Dry socket is described in the literature as "grey bone is visible". When I shine a strong LED light on the area, the aevolar bone mesially surrounding the area seems white, same color as the gelfoam? Bucally the stitches are visiable. Q4: In normal outcome, how long does the clot persist? My remaining clot is at most 1/8 the size of the socket, sitting in the center. Q5: Will the gelfoam dissolve, and does the dry socket start then ? I.e. goes gelfoam delay dry socket complaints onset (normal is 3-5 days) ? This was an uneventful extraction under use of gelfoam/tetracycline, with pre-extraction cl.hexidine flush, post extraction twice daily, soft syringe irrigation after meals. (2 soups w. inclined head, 2 swallowed soft scrambled eggs) As my oral tissue does either not absorb anesthetic well, or the vascul. removes it too rapidly, we did use additional shots, (mandible block and prob. local) with 1 :100,000 epinephrine, which does put me in dry socket risk category due to additional vasoconstriction. Comments appreciated, am in the lifesciences myself, ..had upper ones out, faintly remember a larger, longer lasting clot. 51 year old male, non smoker, teetoaler, not under any medication, no spitting, straw use. Jim (operator was an established oral surgeon w. 19 years practice) > Post extraction had distinct clot for 35 hours, follwed all > instructions religiously. at 45 hours, despite careful avoidance of > disturbance, clot has lost 30% of surface diameter, shrunk. At 55 > hours, what remains of the clot is a tiny center in a white setting. > No pain at this point. There is really no cavity, as the gelfoam > fills it completely. When you pack gelfoam into a bleeding socket, it absorbs the blood and acts as a framework for the clot to be established. In my experience, once it has soaked up the blood (which happens before you leave the office), you can't actually see the gelfoam anymore (it becomes part of the clot), and certainly not over 50 hours later. All you see is the clot at this point. What you are likely seeing now is granulation tissue (ie. gums and tissue growing into the area) filling in the socket area at the clot diminishes in size. > Q: Is the normal outcome that the gelfoam itself "becomes" the clot, > since it is filling the aveola completely ? [quoted text clipped - 7 lines] > bone mesially surrounding the area seems white, same color as the > gelfoam? Bucally the stitches are visiable. Keep in mind that granulation tissue in the mouth appears whitish/grey in colour...not pink. Without seeing you, I would be surprised if the white you see mesially is actually bone. More likely the white tissue mesially is just granulation tissue. > Q4: In normal outcome, how long does the clot persist? My remaining > clot is at most 1/8 the size of the socket, sitting in the center. Sounds like granulation tissue is filling in from the outer parts of the socket and replacing the clot. This is normal healing. Length of time for the clot does not matter...it could take a few days or a few weeks to dissipate. > Q5: Will the gelfoam dissolve, and does the dry socket start then ? > I.e. goes gelfoam delay dry socket complaints > onset (normal is 3-5 days) ? Gelfoam dissolves on its own....As I said, at this point, you can't tell the gelfoam from the clot as its all mixed together. > This was an uneventful extraction under use of gelfoam/tetracycline, > with pre-extraction cl.hexidine flush, [quoted text clipped - 10 lines] > medication, no spitting, straw use. > Jim (operator was an established oral surgeon w. 19 years practice) It sounds like you are doing everything possible to prevent a dry socket. However, it may still occur. If you begin having significant pain 3-5 days from the surgery that is poorly controlled with analgesics, you must see your surgeon. Of course, if you have any concerns...see or telephone your surgeon. John >> Post extraction had distinct clot for 35 hours, follwed all >> instructions religiously. at 45 hours, despite careful avoidance of [quoted text clipped - 8 lines] >can't actually see the gelfoam anymore (it becomes part of the clot), and >certainly not over 50 hours later. >All you see is the clot at this point. >What you are likely seeing now is granulation tissue (ie. gums and tissue >growing into the area) filling in the socket area at the clot diminishes in >size. Nope. What is seen at this point in healing is the fibrin clot. Granulation tissue forms when the revascularization starts. Generally 7-10 days or longer. >> Q: Is the normal outcome that the gelfoam itself "becomes" the clot, >> since it is filling the aveola completely ? [quoted text clipped - 51 lines] > >John >>All you see is the clot at this point. >>What you are likely seeing now is granulation tissue (ie. gums and tissue [quoted text clipped - 6 lines] > Granulation tissue forms when the revascularization starts. > Generally 7-10 days or longer. I agree with you that the blood clot is replaced by the fibrin plug prior to vascularization. However, granulation tissue, by definition is tissue filled with immature capillaries and fibroblasts. This is likely already present at the very margins of the wound. John >>>All you see is the clot at this point. >>>What you are likely seeing now is granulation tissue (ie. gums and tissue [quoted text clipped - 13 lines] > >John I'd buy that for a dollar. Thanks John, eerie situation re granulation tissue: On day two the clot was a tiny red center, now, day three, it has completely disappeared. In place of the molar sits now what looks like a child''s tooth, with just a few motile brownish, red fibers in the center. Because this was an erupted tooth, with aveolar bone loss surrounding the root, the actual socket was only 1/2 centimeter deep on radiograph. There is no concave structure now, its convex, followed by white material distally. Given that granulation has a lots of intermediate stages, its hard for me to believe that is is vascularized tissue already..hope you ar e right, though. It is annoying that almost all oral surgery textbooks on web and pub med studies I sampled disscuss dry socket as a "empty container" when in clinical practice use of gelfoam is standard. So, if no real clot ever forms or persists, one would still be looking at a piece of white gelfoam, in line with margins of aveolum, right ? Jim IME, gelfoam soaks up blood rapidly and is blood red in a few moments. Gelfoam does not adhere to the walls of the socket. If the clot does not form properly and adhere to the tissue, it is very likely that the mal-formed clot and the gelfoam will be both lost from the socket and there will be an empty hole. Gelfoam also dissolves in just a few days. In any case you will not see white gelfoam left behind. D So, if no real clot > ever forms or persists, one would still be looking at a piece of white > gelfoam, in line with margins of aveolum, right ? > Jim > Thanks John, eerie situation re granulation tissue: On day two the > clot was a tiny red center, now, [quoted text clipped - 14 lines] > gelfoam, in line with margins of aveolum, right ? > Jim No, and I don't believe John said that. Gelatin is quite soluble, and generally acts as a nexus for clot formation. The gelfoam itself is very friable and will generally not be visible by the next day or so. Likewise the clot will largely be covered by fibrinous exudate, and so will not look like blood, but a rather heterogeneous, irregularly whitish/brownish mass. Yes, this clot is invaded fairly quickly by fibroblasts and other elements of granulation tissue, which is in turn more gradually replaced by more mature connective tissue elements and bone. While this is happening, the epithelium of the oral mucosa will advance and cover the socket. You may or may not see evidence of the actual alveolus. I don't recommend you pick around in there. If there is a sharp edge of bone apparent a couple of weeks later, there's a good chance it may sequester off and be lost. After a couple of weeks if there is pain and obvious bone showing above the edge of the extraction socket I'd return to the dentist; it may be necessary to remove some exposed bone (which sounds traumatic but is generally painless). Steve Thx to all, well, today and tomorrow (day 4-5) is the literature consensus of appearance of dry socket pain. Right now, there is a convex pure white structure with a 3mm concave spot in the center. - I'm not picking around in there, thx, but during the post-meal irrigation it can be observed well. Jim >It is annoying that almost all oral surgery textbooks on web and pub >med studies I sampled disscuss dry socket as a "empty container" when >in clinical practice use of gelfoam is standard. Use of gelfoam is not *standard* practice. I only use it if bleeding is persistant. > So, if no real clot >ever forms or persists, one would still be looking at a piece of white >gelfoam, in line with margins of aveolum, right ? Nope. Gelfoam only provides a matrix for clotting to start. It is readily absorbed. >Jim What you are seeing is a fibrin clot. Just like a scab on skin, only the red blood cells wash out in a moist environment. Gelfoam only acts as a substrate (lattice) for the clot to form. Don't fool with the area, the body knows how to heal itself. >Post extraction had distinct clot for 35 hours, follwed all >instructions religiously. at 45 hours, despite careful avoidance of [quoted text clipped - 36 lines] >medication, no spitting, straw use. >Jim (operator was an established oral surgeon w. 19 years practice) Why are you worried ,no pain no problem, problems occur ,ie dry socket 2-5 days post op most usually. Dr Jim . > What you are seeing is a fibrin clot. > Just like a scab on skin, only the red blood cells wash out [quoted text clipped - 43 lines] >>medication, no spitting, straw use. >>Jim (operator was an established oral surgeon w. 19 years practice) Re : worried - I'm candidate for dry socket as I had additional shots, left side of face including upper temple were still numb 3 hours later. The vasoconstriction restricted inflow of blood to area, result is likely weak plug. Current status: day 5, the gelfoam socket, (it is gelfoam, not tissue) has opened a 3 mm foramen in the center, one can see 2 mm deep. The mesial/buccal sides are squeezed together by a self-disolving stitch. The entire site has sunk (gelfoam was debrided during swallowing and chewing), proximal portion is now in shadow of 2nd molar where it previously was visible. The onset of dry socket may be later here because by fasting the first 30 hours the site remained closed, food particles are only entering now. The etiology does require some irritation of the bone by saliva or particles. So far there is no smell or pain, but the air pressure from a non-suppressed cough triggered the nerve, would that happen on day four of a vascularized plug ? Thanks for all the responses - Vylgol paste at the ready ! Cheers, Jim. > Re : worried - > I'm candidate for dry socket as I had additional shots, left side of > face including upper temple were still numb > 3 hours later. The vasoconstriction restricted inflow of blood to > area, result is likely weak plug. Nope. > Current status: day 5, the gelfoam socket, (it is gelfoam, not tissue) > has opened a 3 mm foramen in the center, one can see 2 mm deep. The [quoted text clipped - 11 lines] > Thanks for all the responses - Vylgol paste at the ready ! > Cheers, Jim. Either you're a dental student jacking us around, or you have some serious obsessive issues. ;-) D see continuation of thread in 7-day post extraction, grey area visible... Grey is usually the clot breaking going through normal process of fibrinogenesis. If concerned, have your surgeon look at it.  Signature/ Amatus / > see continuation of thread in 7-day post extraction, grey area > visible... >would that happen on day four of a vascularized plug ? The question is what *is* happening. Am with Dartos. |
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