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.
More common in women
- Birth control pills
Most Common Sites of Occurrence
- Distal sites (e.g., third molars)
- More common in the mandible than in the maxilla
- Occurs 3-5 days following a tooth extraction and can last up to 7 days
- Distress and pain
- 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.
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
- 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.
- Osteomyelitis or local infection such as subperiosteal abscess
- Osteonecrosis (in medically compromised patients)
- Bisphosphonate- or drug-related osteonecrosis of the jaw
- Myofascial pain
Common Initial Treatment
Alveolar osteitis is not an infection; an antibiotic therapy will not improve the condition.
- 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.
- 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.
- 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.
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.
- 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.