✅ Introduction
Alveolar Osteitis (dry socket) remains one of the most common and painful complications following tooth extraction. Its incidence reportedly ranges from 2 % to 5 % in routine extractions, and rises significantly (up to 30 %) after impacted third-molar removal.
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✅ Definition & Etiology
Dry socket is defined as the loss or disintegration of the blood clot in the extraction socket, resulting in exposed alveolar bone, radiating pain, and delayed healing.
Key etiologic factors include:
▪️ Smoking, which reduces blood supply and promotes fibrinolysis.
▪️ Traumatic extraction, including excessive force or bone removal.
▪️ Use of oral contraceptives, which may increase fibrinolytic activity.
▪️ Pre-existing local infection or poor oral hygiene.
▪️ Systemic conditions such as diabetes or immunosuppression.
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Clinically, dry socket typically presents 2–4 days post-extraction with the following features:
▪️ Severe, throbbing pain radiating to ear or temple, not resolving with standard analgesics.
▪️ Socket appears empty or grey-yellow, lacking the typical blood clot.
▪️ Halitosis or foul taste may be present.
Diagnosis is largely clinical, but risk assessment and identification of modifiable factors are integral to prevention.
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1. Pre-operative Phase
▪️ Conduct a risk assessment: smoking status, oral contraceptive use, systemic health, oral hygiene.
▪️ In selected cases, perform pre-operative chlorhexidine rinse (0.12 %) for 60 seconds.
▪️ Avoid scheduling high-risk extractions (e.g., smoking + OCP) without adequate prophylaxis.
2. Intra-operative Phase
▪️ Utilize atraumatic extraction techniques, minimal bone removal, appropriate irrigation.
▪️ Ensure adequate haemostasis and clot formation.
▪️ Avoid excessive suction or manipulation post-extraction.
3. Post-operative Phase
▪️ Advise no smoking for 48–72 hours, no straws, no vigorous rinsing/spitting.
▪️ Prescribe chlorhexidine gel 0.2 % placed intra-socket immediately post extraction. Meta-analysis shows RR ≈ 0.47 for CHX gel reducing AO.
▪️ Continue chlorhexidine mouthwash 0.12 % twice daily for 5–7 days.
▪️ Provide clear written post-operative instructions, including analgesic plan (ibuprofen/paracetamol) and emergency contact.
4. Adjunctive Measures
▪️ Some emerging evidence supports platelet-rich fibrin (PRF) or biomaterials placed in socket to reduce dry socket incidence.
▪️ Maintain rigorous oral hygiene and pre-operative scaling in patients with high risk.
Clinical trials and systematic reviews consistently support the use of chlorhexidine (CHX) formulations as the most robust preventive measure for dry socket. For instance, a meta-analysis found CHX gel applied intra-socket reduced incidence of AO with a relative risk of 0.43.
While standardization of protocols remains a challenge (due to varying definitions of dry socket), the integration of risk assessment, antiseptic prophylaxis, and patient education forms the backbone of prevention efforts.
Despite advances, gaps remain in quantifying the role of systemic antibiotics solely for prevention of AO, given concerns over resistance and overuse. Dental professionals should focus on modifiable risk factors, particularly smoking cessation and optimization of surgical technique.
✍️ Conclusion
Implementing structured, evidence-based clinical protocols dramatically reduces the incidence of dry socket and enhances patient comfort. Key strategies include pre-operative risk stratification, atraumatic extraction, post-operative antiseptic protocols (especially CHX), and comprehensive patient education. These measures empower dental professionals to deliver predictable and safer outcomes.
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▪️ Integrate a dry socket risk checklist into the pre-operative workflow.
▪️ Use chlorhexidine gel 0.2 % intra-socket for patients with moderate to high risk.
▪️ Provide clear, written discharge instructions, emphasizing smoking cessation, avoidance of straws and rinsing, and medication schedule.
▪️ Monitor and audit extraction outcomes, aiming to maintain AO incidence below 2 %.
▪️ Stay updated on emerging adjunctive therapies (e.g., PRF) and adopt when supported by local protocols.
馃摎 References
✔ Brignardello-Peterson, R., et al. (2017). Does chlorhexidine prevent alveolar osteitis after third molar extraction? Journal of the American Dental Association, 148(6), e74. https://doi.org/10.1016/j.adaj.2017.03.025
✔ Bowe, D. A., & Rogers, S. N. (2022). Clinical management of alveolar osteitis: A systematic review. British Journal of Oral and Maxillofacial Surgery. https://doi.org/10.1016/j.bjoms.2021.11.001
✔ Ren, Y., & Malmstrom, H. (2015). Prevention of alveolar osteitis with chlorhexidine: a meta-analytic review. Journal of Oral & Maxillofacial Research, 6(2). DOI not available.
✔ Tabrizi, A., Valizadeh, S., & Bahrami, H. (2023). The use of platelet-rich fibrin (PRF) in the management of dry socket: A systematic review. International Journal of Molecular Sciences, 25(18), 10069. https://doi.org/10.3390/ijms251810069
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