What are the symptoms and treatment options for dry socket (alveolar osteitis)?

Dry Socket: Signs, Symptoms, and Treatment

Clinical Presentation

Dry socket (alveolar osteitis) presents as severe pain developing 2-3 days after tooth extraction, with exposed bone in the socket that is partially or totally devoid of a blood clot, often accompanied by halitosis. 1

Key Diagnostic Features

• Severe pain that typically begins 1-5 days postoperatively, often more intense than expected for routine extraction 2, 1
• Exposed alveolar bone visible in the extraction socket, not covered by blood clot or healing epithelium 2
• Halitosis (foul odor) from the socket 1
• Necrotic debris may be present in or around the socket 3
• Tenderness on examination of the affected area 3

Differential Diagnosis to Rule Out

Before confirming dry socket, exclude:

• Infection/abscess: Look for gingival swelling, increased tooth mobility, purulent drainage, or parulis; check for fever or systemic signs 4
• Retained root fragments: Palpate for sharp edges or obtain radiographs if concerned 4
• Bony irregularities or fracture: Assess for sharp edges that could cause pain 4
• Referred pain from adjacent structures 4

Treatment Algorithm

Step 1: Socket Preparation (Primary Treatment)

The key principle is that dry socket treatment is primarily surgical (debridement), not antibiotic-based, as antibiotics show no benefit for localized alveolar osteitis. 5

• Carefully remove all granulation tissue using a degranulation bur (highly recommended) 5
• Create small perforations in the socket wall to improve vascularization in cases of poor blood supply 5
• Irrigate the socket with chlorhexidine or saline 6

Step 2: Socket Dressing

For standard cases:

• Consider placing a non-resorbable obtundant dressing in the socket (used in 56% of cases in clinical audit) 6

For cases with bony dehiscence:

• Extend an envelope between bone and periosteum ≥5 mm around the dehiscence 5
• Place a double layer of L-PRF membranes over the bony dehiscence, extending 3-5 mm over bony borders 5
• Pack L-PRF plugs tightly throughout the socket 5
• Seal the entrance with L-PRF membranes 5
• Suture only to keep dressing material in place—do not attempt primary closure 5

Step 3: Pain Management

Pain relief is essential as dry socket pain can be severe due to the highly sensitive periosteum underlying the ear canal skin. 7

• Mild to moderate pain: Acetaminophen or NSAIDs alone or in fixed combination with opioids (oxycodone or hydrocodone) 7
• Administer NSAIDs during acute phase—significantly reduces pain compared to placebo 7
• Use fixed-interval dosing rather than PRN when frequent dosing is required, as pain is easier to prevent than treat 7
• Severe pain: May require opioids such as fentanyl, morphine, or hydromorphone 7
• Oral route preferred for convenience, ease, and cost; rarely parenteral analgesia may be necessary 7

Step 4: Home Care Instructions

• Instruct in home rinsing with chlorhexidine (used in 44% of cases) 6
• Delay chlorhexidine use until 3-5 days post-extraction to avoid interfering with early soft tissue healing 5

Critical Treatment Pitfalls to Avoid

• Do NOT attempt primary closure of the socket—healing by secondary intention is preferred 5
• Do NOT place sutures directly over bony dehiscence—this might push dressing material out 5
• Ensure sutures are placed over and supported by alveolar bone—avoid pulling on soft tissues 5
• Do NOT rely solely on antibiotics—they show no benefit for localized alveolar osteitis 5

Epidemiology and Risk Factors

• Incidence: Approximately 3% for routine extractions, reaching over 30% for impacted mandibular third molars 6, 1
• Smoking: Tobacco smokers have a more than three-fold increase in odds of dry socket (13.2% incidence in smokers vs 3.8% in non-smokers) 3
• Most common site: Mandibular molar teeth 1

Prevention for Future Extractions

Chlorhexidine rinse (0.12% or 0.2%) used both before and 24 hours after extraction substantially reduces dry socket risk with an OR of 0.38 (95% CI 0.25 to 0.58). 1

• Chlorhexidine gel (0.2%) placed intrasocket after extraction reduces odds by 58% (OR 0.44,95% CI 0.27 to 0.71) 1
• NNT varies by baseline risk: For 30% baseline risk (impacted third molars), NNT is 7 patients; for 5% baseline risk (routine extractions), NNT is 33 patients 1
• Minor adverse effects of chlorhexidine rinse include taste alteration, tooth staining, and stomatitis 1