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Post-extraction pain, or periosteitis, begins as the local anesthetic agent wears off. The pain begins to diminish, most of the time, within 12 hours. The prescription of nonsteroidal anti-inflammatory drugs will provide analgesia and comfort while the pain subsides over 1 to 2 days. Narcotic analgesics may occasionally be required for the first 24 to 48 hours.

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Pain that develops 2 to 4 days after the tooth extraction most likely indicates a localized alveolar osteitis or a dry socket. A dry socket occurs most commonly with the extraction of the third mandibular molar, but can be associated with any tooth that has been extracted. The pain is quite severe in nature and is localized to the area of the extraction site. The extraction site may emit a foul odor and the patient often complains of a bad taste in their mouth.1,2 Physical examination may reveal the socket is missing a clot, but this is sometimes difficult to identify. The signs of an infection are absent.

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The exact etiology or the pathogenesis of a dry socket is not clear.16 It may be multifactorial due to smoking, a localized infection, a poor blood supply, traumatic extractions, a foreign body in the socket, and certain medications. These factors result in an increased level of fibrinolysis of the blood clot in the socket before the clot has had the time to be replaced by granulation tissue. The clot falls out of the socket and exposes the bony surface of the socket to the oral cavity. The exposed bone is extremely sensitive to air, resulting in severe pain.14

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The single and utmost therapeutic goal of alveolar osteitis is to relieve the patient's pain during the healing process. This procedure should be performed on all patients with a dry socket.

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There are no contraindications to the management of a dry socket.

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  • Dental mirror
  • 2 × 2 gauze squares
  • Scissors
  • Dry socket paste or Dressol-X
  • Gelfoam
  • Irrigating syringe
  • Normal saline solution
  • Frazier suction catheter
  • Suction source and tubing
  • Forceps
  • Iodoform ribbon gauze
  • Eugenol-impregnated ribbon gauze
  • Oil of cloves

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Explain the risks, benefits, potential complications, and aftercare to the patient and/or their representative. A signed consent is not required for this procedure. Place the patient sitting upright or reclining. A multipositional dental chair is ideal and allows for a variety of positions to visualize the affected tooth. This procedure may be accomplished with no anesthesia. Some may consider performing a dental block to temporarily alleviate the patient's pain and allow the procedure to be accomplished with minimal discomfort, and increase the level of patient satisfaction. If performed, use lidocaine without epinephrine because the procedure is quickly performed and the anesthesia wears off while the patient is still in the Emergency Department. Refer to Chapter 176 for the complete details regarding dental anesthesia and analgesia. Consider obtaining a plain ...

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