How do I manage a patient presenting with dry socket?

Introduction

Treatment alternatives focus on providing symptomatic relief and include two main approaches (7). The first one consists of debris removal from the socket by applying saline solution irrigation and the use of analgesic medication (3,8). There are several intra-socket medications, including antibacterials, topical anesthetics, and obtundents, or a combination of all three(3). The routine intra-alveolar medication generally consists of alvogyl paste, whose primary components are eugenol, butamben, and iodoform (8,9); zinc oxide eugenol (ZOE), which has sedative properties and iodoform gauze impregnated with 5% eugenol (5). The second alternative includes the use of autologous platelet concentrates (7), such as platelet-rich fibrin (PRF), which has gained attention as a potential therapeutic option since it promotes epithelization of the alveolar socket, improving bone coverage and allowing optimal healing (7,10). Preparation is simple and presents minimal risk to the patient (11,12). The application of PRF delivers a concentrated source of healing factors directly to the extraction site, enhancing outcomes beyond mere symptom relief. It promotes faster tissue regeneration, reduces pain intensity and duration, and decreases the risk of secondary complications (5,13-15).

Efficacy of platelet-rich-fibrin for the treatment of alveolar osteitis: a systematic review and meta-analysis. Copyright: © 2025 Medicina Oral S.L. Creative Commons Attribution 2.5 International (https://creativecommons.org/licenses/by/2.5/).

Abstract

BACKGROUND: Alveolar osteitis (dry socket) is a complication of dental extractions more often&#xa0;involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively&#xa0;with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased&#xa0;postoperative visits. This is an update of the Cochrane Review first published in 2012.&#xa0; OBJECTIVES: To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction. SEARCH METHODS: An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies. SELECTION CRITERIA: We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques&#xa0;because these interventions are evaluated in separate Cochrane Reviews. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence. MAIN RESULTS: We included 49 trials with 6771 participants;&#xa0;39 trials (with 6219 participants) investigated&#xa0;prevention of dry socket and 10&#xa0;studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3&#xa0;studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38&#xa0;(95% CI 0.25&#xa0;to 0.58; P < 0.00001; 6&#xa0;trials, 1547 participants; moderate-certainty&#xa0;evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was&#xa0;162 (95% CI 155&#xa0;to 240), 33 (95% CI 27 to 49),&#xa0;and&#xa0;7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively.&#xa0; Compared to placebo, placing chlorhexidine gel&#xa0;intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR&#xa0;of 0.44 (95% CI 0.27&#xa0;to 0.71; P = 0.0008; 7&#xa0;trials, 753 participants; moderate-certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket&#xa0;was 180 (95% CI 137 to 347),&#xa0;37 (95% CI 28 to 72), and&#xa0;7 (95% CI 5 to 15)&#xa0;for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2&#xa0;trials, 383&#xa0;participants; low-certainty evidence).&#xa0; The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket&#xa0; Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33;&#xa0;P = 0.17; 2 studies, 127 participants; very low-certainty evidence).&#xa0; A further 21&#xa0;intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) -1.40, 95% CI -1.75 to -1.04; P < 0.00001; 2 studies, 80 participants; very low-certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects. AUTHORS' CONCLUSIONS: Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate-certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21&#xa0;preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol.

Abstract

BACKGROUND: Alveolar osteitis (AO) is a poorly understood, common, painful complication following exodontia. It is sometimes managed by inappropriate prescription of antibiotics which contributes to the global threat of antimicrobial resistance. Use of intra-alveolar chlorhexidine also presents a serious risk of anaphylaxis to the patient. OBJECTIVE: This scoping review aims to investigate the aetiology, prevention and management of AO and highlight the extent of inappropriate prescribing and intra-alveolar chlorhexidine use. DESIGN: A scoping review was undertaken using the PRISMA guidelines. Medline, Ovid and Pubmed were searched between 2010 and 2020, from which 63 studies were selected for review that related to the aetiology, prevention or management of AO. Data were analysed for frequency of studies reporting information on risk factors for aetiology, prevention strategies and management including inappropriate management using antibiotic prescribing and intra-alveolar chlorhexidine. RESULTS: Impaired immune response, surgical technique and age were identified as significant factors in the development of AO, while there is conflicting evidence regarding the effects of smoking and gender. With regard to prevention, the use of prophylactic antibiotics is not supported within the literature. Saline irrigation and eugenol pastes used preventively have been shown to be cheap and effective alternatives to chlorhexidine with no adverse effects. Hyaluronic acid and low-level laser therapies showed a significant reduction in pain and soft-tissue inflammation in the management of AO compared to Alveogyl. CONCLUSIONS: Further understanding of the pathophysiology of AO is needed, in addition to large high-quality RCTs or long-term observational studies into the aetiology, prevention, and management of AO to produce up-to-date evidence-based clinical guidelines. Clinicians should also be mindful of their contribution to growing antimicrobial resistance and avoid inappropriate prescribing of antibiotics. Saline should replace chlorhexidine as the intra-alveolar irrigant of choice.