Dry Socket (Alveolar Osteitis): Causes, Symptoms, and Treatment

Dry Socket: A Painful Post-Extraction Complication

Alveolar osteitis ("dry socket") occurs in 2–5% of extractions (up to 30% for mandibular third molars). It results from loss or failure of the protective blood clot, exposing bone and nerves.

Pathophysiology

Normal: Clot forms → organizes → granulation tissue → bone remodeling.
Dry socket: Clot lysed by plasmin (from fibrinolysis) or dislodged → bare bone exposed to oral bacteria, saliva, food.
Inflammation → severe pain, delayed healing.

Risk Factors

Smoking (nicotine vasoconstriction, suction, toxins) – #1 modifiable risk.
Oral contraceptives (estrogen ↑ fibrinolysis).
Poor oral hygiene, pre-existing infection (pericoronitis, periodontitis).
Traumatic/difficult extraction.
Age >25, female sex, lower molars.
Non-compliance with post-op instructions (rinsing, spitting, straws).

Clinical Presentation

Onset: Day 2–4 post-extraction.
Severe, throbbing, radiating pain (ear, temple, neck).
Empty socket: grayish necrotic bone visible, no clot.
Halitosis, foul taste.
Minimal swelling, no pus (unless secondary infection).
Lymphadenopathy.

Treatment

Irrigation: Saline/chlorhexidine to remove debris.
Medicated dressing: Eugenol (clove oil) + lidocaine + gauze (e.g., Alvogyl, Dry Socket Paste)—placed directly on bone; changed q24–48h.
Analgesia: NSAIDs ± opioids; nerve block (inferior alveolar) for severe cases.
Antibiotics: Not routine; only if spreading infection (cellulitis, lymphadenitis).
Follow-up: Until granulation covers bone (typically 7–10 days).

Prevention

Stop smoking 48h before/after extraction (ideally quit).
Gentle oral hygiene; avoid vigorous rinsing/spitting ×24h.
No straws, carbonated drinks, hot liquids ×24h.
Chlorhexidine rinse (0.12%) may reduce incidence.
Suturing, PRF (platelet-rich fibrin), tranexamic acid—evidence mixed.

Dry socket is intensely painful but self-limiting with proper dressing. Prevention—especially smoking cessation—is most effective.