## 4 Discussion  
Dry socket is a frequent complication in exodonia, often associated with the extraction of third molars. Many risk factors are involved, such as traumatic tooth extraction, oral contraceptive intake, smoking, poor hygiene, and the use of a vasoconstrictor in local anesthesia [3; 27]. In our study, the patients were referred from four different dentists and the degree of traumatization cannot be objectively recorded. The role of a vasoconstrictor in local anesthesia in the etiology of AO is not fully established. [PERSON] found that the AO frequency increases with infiltration anesthesia because the temporary ischemia leads to a poor supply [28]. In contrast, other studies have shown that this ischemia lasts for a short time and is followed by reactive hyperemia [29], which allows blood clot formation and stabilization. However, in our study, in one case, the dentist performed intraligamentary anesthesia with a solution of 4% articaine with epinephrine, 1:100,000, for the extraction of a lower first molar, without performing the inferior alveolar nerve block. The intraligamentary injection involves deposition of the local anesthetic solution in the periodontal ligament space around the root. The excessive pressure of the injection, using a Citoject syringe, the use of a vasoconstrictor, and the need for a second infiltration, as reported by the patient's dentist, probably altered the formation of the blood clot, inducing AO. The tissue regeneration or repair process requires a harmonious reaction of various types of cells, including immune cells (neutrophils, macrophages, and lymphocytes), epithelial cells, fibroblasts, and stem cells. The rationale for the use of hemocomponents in the treatment of this condition is that it accelerates the healing of soft and hard tissues by increasing the concentration of growth factors [30; 31]. Platelet growth factors serve as messengers to regulate a well-orchestrated and complex series of events involving cell-cell \begin{table}
\begin{tabular}{c c c c c c} \hline \hline  & **Gender; Age** & **AO Site** & **Type of Anesthesia** & **Anesthetic Used** \\ \hline Patient 1 & F; 26 & 1 st upper premolar & local & & mepivacaine 2\% with 1:100,000 epinephrine \\ Patient 2 & F; 40 & 1 st upper premolar & local & & mepivacaine 2\% with 1:200,000 epinephrine \\ Patient 3 & F; 38 & 2 nd lower premolar & local & & mepivacaine 2\% with 1:100,000 epinephrine \\ Patient 4 & M; 35 & 1 st lower molar & Local and intraligamentary & 4\% articaine with 1:100,000 epinephrine \\ \hline \hline \end{tabular}  
* F: Female; M: Male; AO: Alveolar osteitis.  
\end{table} 
Table 1: Patient demography and clinical characteristics. \begin{table}
\begin{tabular}{c c c c c c c} \hline \hline
**Mean** & **T0** & **T1** & **T2** & **T3** & **T4** & **T5** \\ \hline VAS score & 8.5 & 3.5 & 0.25 & 0 & 0 & 0 \\ GT formation & 0 & 0.25 & 1.75 & 3.25 & 4 & 4 \\ \hline \hline VAS: Visual analog scale; GT: Granulation tissue; (T0) before treatment; (T1) 1 st day; (T2) 2 nd day; (T3) 3 rd day; (T4) 4 th day; and (T5) 5 th day after treatment.  
\end{table} 
Table 2: Descriptive statistics. and cell-matrix interactions and to promote the proliferation of cells at the wound site. Furthermore, platelet concentrates seem to increase the migration and proliferation of osteoblasts and have a positive effect on stem cells and periodontal healing [32]. Additionally, it has been reported that the use of PRF reduces post-operative complications as well as the incidence of AO, especially following third-molar surgery [33; 34; 35]. A summary of the substantial literature on the topic is reported in Table 3.  
In this study, we have used PRF because its strong fibrin architecture, composed of thin fibers with micropores, serves as a scaffold and support for blood clots. The fibrin matrix slowly releases growth factors until seven days post-operatively, which favor cell migration and differentiation.