Dry Socket

Dry socket (alveolar osteitis, localised osteitis) is a painful complication of tooth extraction in which the blood clot in the socket is lost or lysed prematurely, leaving exposed alveolar bone. Incidence is 1 to 4 percent of routine extractions and 20 to 30 percent of impacted mandibular third molar extractions. It occurs mostly in the mandible, with onset 2 to 4 days after extraction.

Mechanism: increased local fibrinolysis, triggered by trauma, bacteria and local factors, converts plasminogen to plasmin and dissolves the clot, exposing bone and nerve endings.

Risk factors include:

• smoking
• oral contraceptives (high oestrogen)
• traumatic or difficult extraction
• previous dry socket
• pre-existing infection (pericoronitis)
• poor oral hygiene
• female sex
• age over 25 years
• rinsing or spitting vigorously within 24 hours
• use of a straw

It is self-limiting over 7 to 14 days but pain can be severe. Infection and osteomyelitis are rare complications.

• Severe, throbbing, constant pain of onset 2 to 4 days after extraction, radiating to the ear, temple and neck, not relieved by usual analgesics.
• Halitosis, foul taste.
• Empty looking socket with exposed, tender bone and no clot; food debris within the socket; surrounding gingiva red and tender.
• Regional lymphadenopathy; fever is uncommon and suggests infection.
• Red flags: facial swelling, fever, trismus, pus, persistent pain beyond 2 weeks, and numbness (exclude osteomyelitis, retained root, bone fracture).

• Clinical diagnosis: postoperative pain increasing 2 to 4 days after extraction with partial or total loss of the clot and exposed bone.
• Gentle irrigation of the socket with saline reveals bare bone, causing severe tenderness on gentle probing with a blunt probe.
• Radiograph (periapical) if retained root, bone fragment, fracture, or osteomyelitis is suspected; usually normal in dry socket.
• Measure temperature, examine for lymphadenopathy and trismus.
• Exclude post-extraction infection, retained root or fragment, bone sequestrum, fracture of mandible, trigeminal neuralgia, and, in patients with radiation or bisphosphonate history, osteonecrosis.

• Irrigate the socket with warm normal saline (0.9 percent) or chlorhexidine 0.12 to 0.2 percent using a blunt syringe to clear debris; do not curette the socket (risk of spreading infection and bleeding).
• Place a medicated dressing: zinc oxide eugenol paste on gauze strip, or iodoform gauze, or a commercial preparation containing eugenol, benzocaine and butamben; gently insert into the socket without packing tightly. Change the dressing every 24 to 48 hours at first, then every 2 to 3 days until pain subsides (usually 2 to 3 dressings over 7 to 10 days). Hyaluronic acid or platelet rich fibrin gel are alternatives where available.
• Analgesia: ibuprofen 400 to 600 mg orally every 8 hours with food and paracetamol 1 g every 6 hours (maximum 4 g daily); for severe pain add codeine 30 mg orally every 6 hours for up to 3 days. Children: ibuprofen 5 to 10 mg/kg every 8 hours and paracetamol 15 mg/kg every 6 hours.
• Antibiotics are not indicated for uncomplicated dry socket. If there is spreading infection, fever, or immunosuppression: amoxicillin 500 mg every 8 hours for 5 days, with metronidazole 400 mg every 8 hours for 5 days.
• Chlorhexidine gluconate 0.12 to 0.2 percent mouthwash, 10 mL twice daily for 7 days, after the first 24 hours, with gentle rinsing.
• Stop smoking for at least 72 hours (preferably longer).
• Prevention: atraumatic extraction technique, chlorhexidine 0.12 percent rinse 1 minute before extraction of lower third molars, and chlorhexidine gel 0.2 percent placed in the socket after extraction, avoiding extraction during menstruation for oral contraceptive users (days 23 to 28 of cycle are best), no smoking, no spitting or straws for 24 hours, and antibiotic prophylaxis only in specific medical risk.
• Follow up: review in 24 to 48 hours; healing complete within 2 to 4 weeks; refer if pain persists beyond 2 weeks.
• Counselling: pain relief is expected within 24 hours of dressing; maintain soft diet and oral hygiene.