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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.

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.

There has been much work in the prevention of a dry socket.3-8 This prevention focuses on methods in surgical technique and injections that occur at the time of tooth extraction. These methods are not in widespread use yet. Despite these methods, patients still present to the Emergency Department with a dry socket. The Emergency Physician must know how to solve this simple condition.


The exact etiology or the pathogenesis of a dry socket is not clear.1,2,9-12 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.1,2,9,10


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.


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


  • 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

  • Zinc oxide eugenol (ZOE)-impregnated ribbon gauze

  • Oil of cloves

  • Tranexamic acid

  • Neocone (not approved or available in the United States)

  • Alvogyl (eugenol, iodoform, and butamen)



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