What is the appropriate treatment for dry socket (alveolar osteitis)?

Dry Socket Treatment

The treatment of dry socket (alveolar osteitis) requires immediate socket debridement with removal of all granulation tissue, followed by pain management with NSAIDs or acetaminophen (with or without opioids for severe pain), and placement of a medicated dressing such as zinc oxide eugenol paste. 1, 2

Immediate Socket Management

The cornerstone of dry socket treatment is mechanical debridement, not antibiotics:

• Remove all granulation tissue from the socket using a degranulation bur to expose healthy bone and promote healing 1
• Irrigate the socket with saline or chlorhexidine to cleanse debris 3
• Create small perforations in the socket wall if blood supply appears poor, as this improves vascularization and promotes healing 1
• Antibiotics show no benefit for localized alveolar osteitis and should not be used routinely 1

Pain Management Protocol

Pain control is critical and should follow a structured approach:

Mild to Moderate Pain

• Start with acetaminophen or NSAIDs alone, or in fixed combination with opioids (oxycodone or hydrocodone) 1
• Administer NSAIDs during the acute phase at maximum tolerated dosage, as they significantly reduce pain compared to placebo 1
• Use fixed-interval dosing rather than PRN when frequent dosing is required, since pain is easier to prevent than treat 1

Severe Pain

• Use opioids such as fentanyl, morphine, or hydromorphone for severe, uncontrolled pain 1
• The oral route is preferred for convenience, ease, and cost; parenteral analgesia is rarely necessary 1

Socket Dressing Application

After debridement, socket dressing significantly reduces pain and promotes healing:

• Place zinc oxide eugenol paste or medicated packing (containing eugenol, balsam of Peru, and petroleum jelly) into the socket 2, 4
• Immediate placement of medicated packing reduces dry socket complications from 26% to 8% (P=0.001) 4
• Pack the dressing to the crest of the alveolar ridge without overfilling 4
• Remove the dressing after 1 week 4

Alternative Advanced Options

For cases with significant bony dehiscence or poor healing:

• Extend an envelope between bone and periosteum up to ≥5 mm around any bony defect 1
• Place L-PRF (leukocyte and platelet-rich fibrin) membranes in double layers over exposed bone, extending 3-5 mm over bony borders 1
• Pack L-PRF plugs tightly throughout the socket and seal the entrance with additional L-PRF membranes 1

Suturing Technique

• Suture only to keep dressing material in place, NOT to achieve primary closure 1
• Healing by secondary intention is preferred over primary closure 1
• Place sutures over and supported by alveolar bone to avoid pulling on soft tissues or creating pressure on the graft 1
• Do not place sutures directly over bony dehiscence as this may push dressing material out 1

Follow-Up Care

• Delay chlorhexidine rinses until day 3-5 post-treatment to avoid interfering with early soft tissue healing 1
• Re-evaluate the patient within 2-4 days to assess pain control and healing 3
• If pain persists despite initial treatment, consider socket re-irrigation and fresh dressing placement 3

Common Pitfalls to Avoid

• Do not attempt primary closure of the socket - this impairs healing and increases complications 1
• Do not prescribe antibiotics routinely - they provide no benefit for uncomplicated dry socket 1
• Do not use PRN dosing for moderate-severe pain - scheduled dosing prevents pain more effectively than treating established pain 1
• Avoid aggressive curettage that removes excessive bone, but ensure all necrotic tissue is debrided 2

Evidence Quality Note

The strongest evidence supports curettage with irrigation plus adjunctive therapy (zinc oxide eugenol, low-level laser therapy, or platelet-rich growth factors) for optimal pain relief and healing 2. The immediate placement of medicated packing shows statistically significant reduction in complications 4, though most treatment recommendations remain empirical due to limited high-quality randomized trials 3.