What are the treatment options for a patient who has developed a dry socket after tooth extraction?

Treatment of Dry Socket (Alveolar Osteitis)

The primary treatment for dry socket is surgical debridement of the socket to remove necrotic tissue and stimulate bleeding, not antibiotic therapy, as antibiotics provide no benefit for localized alveolar osteitis. 1

Initial Management Protocol

Step 1: Socket Debridement (Essential)

• Remove all granulation tissue from the socket using a degranulation bur 1
• Create small perforations in the socket wall to improve vascularization, particularly when blood supply appears compromised 1
• Irrigate the socket with chlorhexidine (0.12% or 0.2%) or saline to cleanse debris 2

Step 2: Intrasocket Dressing Options

For standard dry socket cases:

• Place chlorhexidine gel (0.2%) directly into the socket, which reduces pain and promotes healing 3
• Alternatively, use zinc oxide eugenol paste as an obtundant dressing 2

For cases with bony dehiscence (exposed bone):

• Extend an envelope between bone and periosteum ≥5 mm around the bony dehiscence 1
• Place a double layer of L-PRF membranes over the dehiscence, extending 3-5 mm beyond bony borders 1
• Pack L-PRF plugs tightly throughout the socket 1
• Seal the entrance with additional L-PRF membranes 1

Step 3: Suturing Technique

• Place sutures only to stabilize dressing material, not to achieve primary closure 1
• Ensure sutures are positioned over and supported by alveolar bone to avoid tension on soft tissues 1
• Never place sutures directly over bony dehiscence as this may displace the dressing 1
• Allow healing by secondary intention 1

Pain Management

While the evidence does not provide specific analgesic protocols, systemic pain control with NSAIDs and/or opioids is standard practice based on pain severity. The socket debridement and dressing placement itself provides significant pain relief within 24-48 hours.

Patient Instructions

• Rinse with chlorhexidine mouthwash (0.12% or 0.2%) twice daily for one minute, continuing for at least 3 weeks 4
• Delay chlorhexidine use until 3-5 days post-treatment to avoid interfering with early soft tissue healing 1, 4
• Maintain soft food diet with no biting/chewing in the treated area for 1 week 4
• Avoid mechanical cleaning of the treated area for 1 week 4

Follow-Up Schedule

• Re-evaluate at 24-48 hours to assess pain reduction and healing
• If pain persists, repeat socket irrigation and dressing replacement
• Continue follow-up every 2-3 days until symptoms resolve (typically 7-10 days)

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for uncomplicated dry socket - they provide no benefit for localized alveolar osteitis 1
• Do not attempt primary closure of the socket - healing by secondary intention is the preferred approach 1
• Avoid placing sutures under tension or directly over exposed bone 1
• Do not use chlorhexidine immediately after debridement - wait 3-5 days 1

Alternative Treatment: Alvogyl

For patients with persistent severe pain at day 7, Alvogyl (old formulation) may be more effective than zinc oxide eugenol at reducing pain (mean difference -1.40,95% CI -1.75 to -1.04), though this evidence is of very low certainty 3. However, the primary surgical debridement approach described above remains the foundation of treatment.

Risk Factor Counseling

Inform patients with a history of dry socket that they have an 11.45-fold increased risk of developing dry socket again with future extractions (95% CI: 1.06 to 123.74) 5. Other risk factors include mandibular location, poor oral hygiene, and difficult extractions 5.