Dry Socket (Alveolar Osteitis) Management

Definition

Dry socket (alveolar osteitis) is a post-extraction complication where the blood clot is lost or fails to form, exposing the bone. Occurs in 1-5% of extractions, more common in lower molars and smokers.

Early Detection - Signs & Symptoms

Timing

Onset: Usually 3-5 days after extraction (can occur up to 2 weeks)
Peak: Days 4-5 post-extraction

Clinical Symptoms

Severe pain: Throbbing, radiating pain (much worse than normal post-extraction pain)
Pain pattern: Increases 3-5 days after extraction (when normal pain should be decreasing)
Foul odor: Characteristic bad smell from extraction site
Visible bone: Exposed bone visible in socket (no blood clot)
Radiating pain: Pain extends to ear, jaw, or neck
Difficulty eating: Severe pain with any food contact
Swollen lymph nodes: Cervical lymphadenopathy may occur

Clinical Examination Findings

Empty socket with no blood clot
Exposed bone (yellowish/white)
Debris and food particles in socket
Foul-smelling exudate
Minimal swelling (unlike infection)
No fever (unless secondary infection)

Prevention of Dry Socket

Patient Instructions (Pre-Extraction)

Stop smoking: At least 24 hours before extraction (ideally 1 week)
Avoid alcohol: 24 hours before extraction
Good oral hygiene: Brush and floss before extraction
Avoid oral contraceptives: If possible, schedule extraction early in cycle (lower estrogen)
Manage stress: Stress increases risk

Surgical Technique to Prevent

Gentle extraction: Minimize trauma to socket
Avoid socket curettage: Don't over-clean socket
Promote clot formation: Allow clot to form undisturbed
Bone wax: Consider using in high-risk cases
Protective dressing: Place eugenol-based dressing in high-risk extractions

Post-Operative Instructions to Prevent

No smoking: At least 1 week (ideally 2 weeks)
No straws: Suction can dislodge clot for 1 week
No rinsing: First 24 hours (avoid disturbing clot)
Gentle salt water rinses: After 24 hours only
Soft diet: Avoid hot, spicy, hard foods
No vigorous exercise: 3-5 days (increases bleeding)
Avoid alcohol: 1 week (interferes with healing)

Treatment of Dry Socket

Immediate Management

Gentle cleaning: Irrigate socket with normal saline to remove debris
Pain relief: Administer local anesthetic (infiltration or block)
Socket dressing: Place medicated dressing in socket

Medicated Dressings

First-Line Dressings:

Dressing	Composition	Application	Replacement
Eugenol-based paste	Zinc oxide + eugenol + iodoform	Pack loosely into socket	Every 2-3 days until healed
Iodoform gauze	Gauze impregnated with iodoform	Pack gently into socket	Every 2-3 days
Alvogyl	Iodoform + eugenol + menthol	Pack into socket	Every 2-3 days

Systemic Medications

Medication	Dose	Frequency	Duration (Days)	Purpose
Ibuprofen	400-600mg	Every 6-8 hours	5-7 days	Pain relief, anti-inflammatory
Paracetamol	500-1000mg	Every 6 hours	5-7 days	Pain relief (if NSAID contraindicated)
Antibiotics (if infected)	Amoxicillin 500mg or Clindamycin 300mg	Three times daily (TDS)	7-10 days	If secondary infection present

Topical Pain Relief

Benzocaine 20% gel: Apply topically as needed for pain
Clove oil: Natural analgesic, apply on gauze to socket
Hydrogen peroxide rinse: 1-3% solution, rinse 3-4 times daily

Follow-Up Care

Dressing changes: Every 2-3 days
Duration: Usually 7-14 days until socket heals
Pain relief: Most pain resolves after first dressing application
Complete healing: 2-4 weeks
Patient education: Reinforce prevention measures

Nutritional Support During Dry Socket

Soft Foods (Easy to Consume with Pain):

Food	Portion	Nutritional Value
Bone broth	1 cup (240ml)	Collagen, minerals, amino acids
Smoothies (with protein)	1 cup (240ml)	Vitamins, protein, easy to consume
Mashed sweet potato	1 cup (200g)	Vitamin A, carbohydrates
Yogurt (plain)	1 cup (245g)	Protein, probiotics
Herbal tea (chamomile)	1-2 cups daily	Calming, anti-inflammatory

Avoid:

Hot foods (can increase pain and bleeding)
Spicy foods (irritate socket)
Hard, crunchy foods (can disturb healing)
Acidic foods (irritate socket)
Alcohol (interferes with healing)

Oral Antral Communication (OAC) After Extraction

Definition:

Communication between oral cavity and maxillary sinus through extraction socket (usually after maxillary molar extraction).

Signs:

Visible opening in socket
Air escaping from socket when patient blows nose
Liquid entering socket when patient drinks
Sinus symptoms (congestion, drainage)

Immediate Management:

Do NOT disturb the site
Place gauze gently over socket
Advise patient NOT to blow nose
Avoid straws and vigorous rinsing
Refer to oral surgeon if large communication

Treatment Options:

Small OAC (<3mm): Usually closes spontaneously with proper care
Large OAC (>3mm): May require surgical closure (flap procedure)
Infected OAC: Requires antibiotics and possible surgical intervention

Medications:

Medication	Dose	Frequency	Duration (Days)
Amoxicillin	500mg	Three times daily (TDS)	7-10 days
Nasal decongestant	Pseudoephedrine 30-60mg	Every 4-6 hours	3-5 days

Clinical Notes:

This is a reference guide for distressed clinicians - use clinical judgment
Dry socket is painful but not serious if treated promptly
Prevention is better than treatment - emphasize post-operative instructions
Refer to oral surgeon if complications arise