How Do I Manage a Patient with Dry Socket?

April 30, 2013
 

Dry Socket (Alveolar Osteitis)

Complication of wound healing following the extraction of a tooth. The patient experiences severe throbbing pain caused by bone exposure at the site of extraction. Following the extraction, a blood clot forms at the socket to protect the bone. When the clot dislodges or dissolves prematurely, the nerves and bone become exposed, leading to pain.

Presentation

Population

More common in women

Risk Factors

  • Smoking
  • Birth control pills

Most Common Sites of Occurrence

  • Distal sites (e.g., third molars)
  • More common in the mandible than in the maxilla

Signs

  • Occurs 3-5 days following a tooth extraction and can last up to 7 days
  • Distress and pain

Symptoms

  • Throbbing, radiating pain that is difficult to localize and which may radiate up to the periauricular area.
  • Initially, the healing seems to be progressing well with pain diminishing—but then pain increases and seems more severe than at the time of extraction.
  • Pain severity:
    • Severe throbbing pain
    • Pain usually lasts anywhere from 24 to 72 h.

Investigation

Rule Out Local Pathologies

Perform a complete extraoral and intraoral examination to rule out local pathology or source of pain:

  • Pain from a foreign body in the extraction site (a radiograph might identify a residual root tip that is causing the inflammation and pain)
  • Trismus (caused by general inflammation of the mucosa, extraction site or a local muscle due to an intramuscular injection that went through the temporalis attachment on the posterior mandible)
  • Infectionat the extraction site
  • Osteomyelitis of the bone
  • Any other conditions associated with adjacent teeth

Diagnosis

Based on:

  • Bone exposure
  • Absence of facial swelling or swelling of the lymph nodes
  • Pain when the extraction site is irrigated/flushed with fluids

Persistent pain beyond 3 days, exposed bone with an inflammation of the mucosa and evidence of swelling, buccal space and sublingual space might suggest other possible diagnoses.

Differential Diagnosis

  • Osteomyelitis or local infection such as subperiosteal abscess
  • Osteonecrosis (in medically compromised patients)
  • Bisphosphonate- or drug-related osteonecrosis of the jaw
  • Myofascial pain

Treatment

Common Initial Treatment

Alveolar osteitis is not an infection; an antibiotic therapy will not improve the condition.

  1. Control the pain with a dressing material (e.g., Alvogyl™ paste, DRESSOL-X™).
    • Irrigate the site with chlorhexidine or saline.
    • Pack the extraction site enough to cover the exposed surgical site with a resorbable or nonresorbable dressing.
    • Instruct the patient to maintain good oral hygiene.
    • If the dressing is nonresorbable, remove it after 2-3 days.
    • If the pain persists, consider repacking the area.
    • Advise the patient to refrain from smoking for at least 6 weeks after the extraction; smoking delays healing and restricts blood supply to the extraction site.
  2. Use postoperative analgesics such as NSAIDs (e.g., ibuprofen) or a mixture of narcotic with acetaminophen and codeine (e.g., Tylenol® 3) in case of severe pain.
    • Ibuprofen: for a 70 kg person, 400 mg q.i.d. or q. 4 h.
  3. If the pain persists beyond 72 h., take radiographs to rule out the existence of a foreign body at the extraction site, bone destruction, or other possible etiologies.

Advice

Prior to the extraction

  • Perform routine dental care and ensure a healthy oral environment.
  • Ask the patient to refrain from smoking.
  • Consider the use of preoperative NSAIDs, if the patient tolerates such medications.
  • Encourage the patient to report the incidence of pain: addressing the issue faster reduces the risk of treating a chronic dry socket.

After the extraction

  • Provide the patient with clear and easy to follow postoperative instructions.
  • Encourage the patient to maintain a good postoperative oral hygiene.

THE AUTHOR

 
 
 

Dr. Chemaly is an oral and maxillofacial surgeon who maintains a private practice in Toronto.

Correspondence to: Dr. Daisy Chemaly, Dr. Daisy Chemaly Dentistry Professional Corporation, 2-2416 Bloor Street West, Toronto, ON  M6S 1M8. Email: daisy_chemaly@hotmail.com

The author has no declared financial interests.

This article has been peer reviewed.

Suggested Resources:

  1. Miloro M, Larsen P, Ghali GE, Waite P. Peterson’s Principles of Oral and Maxillofacial Surgery. 3rd ed. Shelton (CT): People's Medical Publishing House; 2011.

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