Chapter 178. Post-Extraction Pain and Dry Socket (Alveolar Osteitis) Management

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.

The exact etiology or the pathogenesis of a dry socket is not clear.1–6 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.1–4

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
• Eugenol-impregnated ribbon gauze
• Oil of cloves

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 radiograph or panorex to rule out a retained root tip or foreign material in the socket.

Identify the defective tooth. Gently and thoroughly irrigate the socket with warm normal saline and low-level suction to remove any debris. Use a forceps to pack dry socket paste into the socket. Dry socket paste is composed of balsa wood fragments saturated with eucalyptol and looks like chewing tobacco. Completely fill the socket with the dry socket paste. The patient will experience almost instant pain relief if a dental block was not performed. Place a piece of Gelfoam on top of the dry socket paste. Compress the Gelfoam and dry socket paste into the socket. Instruct the patient to bite down against a 2 × 2 gauze square placed over the socket for 5 to 10 minutes. Dressol-X may be used instead of dry socket paste if available.

Unfortunately, few Emergency Departments stock dry socket paste or Dressol-X. An alternative is ribbon gauze or Gelfoam impregnated with eugenol, iodine, or oil of cloves. Ribbon gauze tends to dry out and fall out sooner than commercially available dry socket paste. Use a forceps to pack the socket completely with the impregnated ribbon gauze (Figures 178-1A to C) or Gelfoam. Place a piece of plain Gelfoam on top of the socket (Figure 178-1D). Compress the plain Gelfoam and the underlying impregnated ribbon gauze or impregnated Gelfoam into the socket. Instruct the patient to bite down against a 2 × 2 gauze square placed over the socket for 5 to 10 minutes.

The patient should experience almost immediate pain relief after the socket is packed. If a dental block was performed, allow the local anesthetic to wear off to ensure the patient's pain truly has resolved.

The patient may be discharged immediately after the procedure, or after the local anesthetic has worn off. Nonsteroidal anti-inflammatory drugs are usually adequate to provide analgesia. Narcotic analgesics are not needed nor required. Arrange follow-up as soon as possible with the Dentist or Oral Surgeon who performed the extraction procedure. The dressing must be replaced daily, or as needed, until the patient is pain free. Instruct the patient to begin a soft diet, to not ingest extremely hot or cold substances, and to not play with the packing with their tongue. Instruct the patient to also not suck anything, use a straw, gargle, spit, or smoke. All these activities will produce negative pressure within the oral cavity and remove the clot from the extraction site.

The decision to prescribe antibiotics to cover the oral flora is physician dependent. There is no literature to support or refute this practice. Consult the Dentist or Oral surgeon who extracted the tooth. Oral penicillin VK (500 mg QID) is the preferred antibiotic if they are prescribed. Clindamycin (300 mg QID) is an alternative for patients allergic or intolerant to penicillin.

There are no complications associated with this procedure. A potential complication is the aspiration of the material used to pack the socket. This has never been reported in the literature. The packing may fall out and result in the patient's pain recurring. Instruct the patient to return to the Emergency Department if the packing falls out prior to their follow-up appointment.

A dry socket can be extremely painful. Packing an empty socket is easy, quick, simple, and provides the patient with significant relief. The packing needs to be changed daily for several days and then less frequently after that, until the patient is free of pain. Prescribe antibiotics to cover oral flora and analgesics to manage pain.