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

Dry socket occurs when the post-extraction blood clot is lost or fails to form, exposing bone and nerves. It affects 1-5% of routine extractions, up to 30% for impacted mandibular third molars.

Typical Timeline

  • Onset: 2-4 days post-extraction (peak day 3)
  • Duration untreated: 7-14 days
  • With treatment: Pain relief within hours; healing over 1-2 weeks
  • Delayed presentation: Rarely up to 3 weeks

Diagnostic Criteria

  • Severe, radiating pain (ear, temple, neck) starting 2+ days post-extraction
  • Empty socket with visible bone, no clot
  • Halitosis, foul taste
  • Absent purulence (distinguishes from infection)
  • Normal or mildly elevated temperature

Risk Factors

  • Smoking (nicotine vasoconstriction, suction)
  • Oral contraceptives (estrogen → fibrinolysis)
  • Traumatic extraction, excessive curettage
  • Pre-existing infection (periodontitis, pericoronitis)
  • Poor oral hygiene
  • Previous dry socket history

Treatment Protocol

  1. Irrigation: Saline or chlorhexidine to remove debris
  2. Medicated dressing: Eugenol (clove oil) + lidocaine + gauze/zinc oxide paste; changed every 24-48h
  3. Analgesia: NSAIDs (ibuprofen 600-800mg q6h) ± opioids for breakthrough
  4. Antibiotics: Not indicated unless secondary infection (spreading cellulitis, fever, purulence)
  5. Self-care: Warm saline rinses after 24h, soft diet, avoid straws/smoking

Prevention (Evidence-Based)

  • Preoperative chlorhexidine rinse (0.12-0.2%)
  • Socket preservation: PRF, collagen plugs, or suture closure
  • Atraumatic technique, minimal curettage
  • Post-op instructions: no smoking 72h, no straws, gentle hygiene

When to Return

Pain uncontrolled by prescribed regimen, swelling worsening, fever >38°C, pus, or numbness (possible nerve injury).

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