What is the management plan for dry socket (alveolar osteitis)?

Management of Dry Socket (Alveolar Osteitis)

The management of dry socket should focus on thorough debridement, irrigation, and placement of medicated dressings to relieve pain and promote healing, with zinc oxide eugenol showing superior efficacy for pain relief compared to other dressings. 1

Initial Assessment and Diagnosis

• Dry socket (alveolar osteitis) is a common post-extraction complication with an incidence of approximately 3% for routine extractions and up to 30% for impacted mandibular third molars 2
• Clinical presentation includes severe pain developing 2-3 days after extraction, partially or completely empty socket, halitosis, and exposed bone 3
• Thoroughly examine the socket to assess for infection, exposed bone, and involvement of deeper structures 4

Treatment Protocol

Step 1: Socket Preparation

• Thoroughly irrigate the socket with normal saline to remove debris and bacteria 1, 2
• Carefully remove all granulation tissue (using a degranulation bur is highly recommended) 4
• Create small perforations in the socket wall to improve vascularization in cases of poor blood supply 4

Step 2: Pain Management

• Apply a medicated dressing to provide pain relief:
  • Zinc oxide eugenol paste mixed with cotton pellet shows superior efficacy for both initial and final pain relief compared to Alvogyl 1
  • Place the medicated dressing directly into the socket after irrigation 1, 5
• Prescribe appropriate analgesics such as acetaminophen or ibuprofen for additional pain control 5

Step 3: Follow-up Care

• Change the dressing daily until pain subsides 1
• Continue socket irrigation with each dressing change 2
• Monitor for signs of healing and resolution of symptoms 5

Advanced Treatment Options

For Cases with Bony Dehiscence

• Extend an envelope between bone and periosteum up to ≥5 mm around the bony dehiscence 4
• Consider using L-PRF (Leukocyte and Platelet-Rich Fibrin) membranes:
  • Place a double layer of L-PRF membranes over the bony dehiscence, extending 3-5 mm over bony borders 4
  • Pack L-PRF plugs tightly throughout the socket 4
  • Seal the entrance with L-PRF membranes 4
• Suture without attempting primary closure, only to keep the dressing material in place 4

Prevention Strategies

• Chlorhexidine mouthrinse (0.12% or 0.2%) used before and after extraction reduces risk of dry socket by approximately 62% 3
• Placing chlorhexidine gel (0.2%) in the socket after extraction reduces risk by approximately 56% 3
• Delay use of chlorhexidine until 3-5 days post-extraction to avoid interfering with early soft tissue healing 4
• Consider prophylactic antibiotics for high-risk extractions 3

Common Pitfalls and Caveats

• Avoid attempting primary closure of the socket, as healing by secondary intention is preferred 4
• Ensure sutures are placed over and supported by alveolar bone to avoid pulling on soft tissues 4
• Do not place sutures directly over bony dehiscence as this might push dressing material out of the socket 4
• The efficacy of platelet-rich plasma for prevention of dry socket is not well-established (insufficient evidence) 3
• While Alvogyl has been traditionally used, recent evidence suggests zinc oxide eugenol may provide better pain relief 1, 3