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. 2022 Sep 26;9(9):CD006968.
doi: 10.1002/14651858.CD006968.pub3.

Local interventions for the management of alveolar osteitis (dry socket)

Blánaid Jm Daly  1 , Mohammad O Sharif  2 , Kate Jones  3 , Helen V Worthington  4 , Anna Beattie  5
Affiliations

Local interventions for the management of alveolar osteitis (dry socket)

Blánaid Jm Daly et al. Cochrane Database Syst Rev. .

Abstract

Background: Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012. OBJECTIVES: To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.

Search methods: An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies.

Selection criteria: We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence.

Main results: We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate-certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively. Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate-certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low-certainty evidence). The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low-certainty evidence). A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) -1.40, 95% CI -1.75 to -1.04; P < 0.00001; 2 studies, 80 participants; very low-certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects.

Authors' conclusions: Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate-certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol.

PubMed Disclaimer

Conflict of interest statement

There are no financial conflicts of interest and the review authors declare that they do not have any associations with any parties who may have vested interests in the results of this review. Helen V Worthington is an Editor with Cochrane Oral Health, and was previously Co‐ordinating Editor. She was not involved in conducting the editorial process for the review.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: Prevention of dry socket, Outcome 1: Chlorhexidine rinse versus placebo
1.2
1.2. Analysis
Comparison 1: Prevention of dry socket, Outcome 2: Chlorhexidine gel versus placebo/no treatment
1.3
1.3. Analysis
Comparison 1: Prevention of dry socket, Outcome 3: Chlorhexidine gel versus chlorhexidine rinse
1.4
1.4. Analysis
Comparison 1: Prevention of dry socket, Outcome 4: Platelet rich plasma versus placebo
2.1
2.1. Analysis
Comparison 2: Treatment of dry socket, Outcome 1: Alvogyl versus zinc oxide eugenol day 7 VAS score (0‐10)
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References

References to studies included in this review

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Eshghpour 2014 {published data only}
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Farooq 2019 {published data only}
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Field 1988 {published data only}
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Fotos 1992 {published data only}
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Garibaldi 1995 {published data only}
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Goldman 1973 {published data only}
    1. Goldman DR, Kilgore DS, Panzer JD, Atkinson WH. Prevention of dry socket by local application of lincomycin in Gelfoam. Oral Surgery, Oral Medicine, and Oral Pathology 1973;35(4):472-4. - PubMed
Goldsmith 2012 {published data only}
    1. Goldsmith SM, De Silva RK, Tong DC, Love RM. Influence of a pedicle flap design on acute postoperative sequelae after lower third molar removal. International Journal of Oral and Maxillofacial Surgery 2012;41(3):371-5. - PubMed
Gonzalez‐Serrano 2021 {published data only}
    1. Gonzalez-Serrano J, Lopez-Pintor R, Cecilia-Murga R, Torres J, Hernandez G, Lopez-Quiles J. Application of propolis extract, nanovitamin C and nanovitamin E to prevent alveolar osteitis after impacted lower third molar surgery. A randomized, double-blind, split-mouth, pilot study. Medicina Oral, Patologia Oral y Cirugia Bucal 2021;26(2):e118-25. - PMC - PubMed
Goyal 2012 {published data only}
    1. Goyal M, Marya K, Jhamb A, Chawla S, Sonoo PR, Singh V, et al. Comparative evaluation of surgical outcome after removal of impacted mandibular third molars using a Piezotome or a conventional handpiece: a prospective study. British Journal of Oral and Maxillofacial Surgery 2012;50(6):556-61. - PubMed
Guazzo 2018 {published data only}
    1. Guazzo R, Perissinotto E, Mazzoleni S, Ricci S, Peñarrocha-Oltra D, Sivolella S. Effect on wound healing of a topical gel containing amino acid and sodium hyaluronate applied to the alveolar socket after mandibular third molar extraction: a double-blind randomized controlled trial. Quintessence International 2018;49(10):831-40. - PubMed
Hall 1971 {published data only}
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Haraji 2010 {published data only}
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Haraji 2012a {published data only}
    1. Haraji A, Khamverdi N, Khanzadealishahi H. The effect of 0.2% chlorhexidine gel in prevention of pain and dry socket following mandibular third molar surgery. Journal of Research in Dental Sciences 2012;9(2):63-7.
Haraji 2012b {published data only}
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Haraji 2014 {published data only}
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Haraji 2015 {published data only}
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Haupt 2015 {published data only}
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Hill 2006 {published data only}
    1. Michael Hill C, Sindet-Pederson S, Seymour RA, Hawkesford JE 2nd, Coulthard P, Lamey PJ, et al. Analgesic efficacy of the cyclooxygenase-inhibiting nitric oxide donor AZD3582 in postoperative dental pain: comparison with naproxen and rofecoxib in two randomized, double-blind, placebo-controlled studies. Clinical Therapeutics 2006;28(9):1279-95. - PubMed
Hooley 1995 {published data only}
    1. Hooley JR, Golden DP. The effect of polylactic acid granules on the incidence of alveolar osteitis after mandibular third molar surgery. A prospective randomized study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 1995;80(3):279-83. - PubMed
Jadhao 2018 {published data only}
    1. Jadhao VA, Rao A, Hande P, Mahajani M, Raktade P, Gedam R, et al. The efficiency of three irrigating solutions after surgical removal of impacted mandibular third molars: a cross-sectional study. Journal of Contemporary Dental Practice 2018;19(9):1147-51. - PubMed
Jesudasan 2015 {published data only}
    1. Jesudasan JS, Wahab PUA, Sekhar MRM. Effectiveness of 0.2% chlorhexidine gel and a eugenol-based paste on postoperative alveolar osteitis in patients having third molars extracted: a randomised controlled clinical trial. British Journal of Oral & Maxillofacial Surgery 2015;53(9):826-30. - PubMed
Johnson 1988 {published data only}
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Jolley 1972 {published data only}
    1. Jolley HM, Torneck CD, Siegel I. A topical choline salicylate gel for control of pain and inflammation in oral conditions - a controlled study. Journal of the Canadian Dental Association 1972;38(2):72-4. - PubMed
Jovanovic 2011 {published data only}
    1. Jovanović G, Urić N, Krunić N, Tijanić M, Stojanović S. Assessment of the effectiveness of low level laser in the treatment of alveolar osteitis [Procena efikasnosti primene lasera male snage u terapiji alveolarnogosteitisa]. Vojnosanitetski Pregled 2011;68(6):506-10. - PubMed
Julius 1982 {published data only}
    1. Julius LL, Hungerford RW, Nelson WJ, McKercher TC, Zellhoefer RW. Prevention of dry socket with local application of Terra-Cortril in gelfoam. Journal of Oral and Maxillofacial Surgery 1982;40(5):285-6. - PubMed
Kamal 2020a {published data only}
    1. Kamal A, Salman B, Razak N, Qabbani A, Samsudin R. The efficacy of concentrated growth factor in the healing of alveolar osteitis: a clinical study. International Journal of Dentistry 2020;2020:9038629. - PMC - PubMed
Kamal 2020b {published data only}
    1. Kamal A, Salman B, Razak N, Samsudin A. A comparative clinical study between concentrated growth factor and low-level laser therapy in the management of dry socket. European Journal of Dentistry 2020;14(4):613-20. - PMC - PubMed
Kaplan 2020 {published data only}
    1. Kaplan V, Hasanoglu Erbasar GN, Cigerim L, Altay Turgut H, Cerit A. Effect of St John's wort oil and olive oil on the postoperative complications after third molar surgery: randomized, double-blind clinical trial. Clinical Oral Investigations 2020;25(4):2429-38. [PMID: 10.1007/s00784-020-03639-0. Epub 2020 Oct 15.] - PubMed
Karthik 2021 {published data only}
    1. Karthik KP, Balamurugan RB. Evaluation and comparison of anti-inflammatory properties of ibuprofen using two drug delivery systems after third molar surgery: using chitosan microspheres as a carrier for local drug delivery in to the third molar socket and through the oral route. British Journal of Oral & Maxillofacial Surgery 2021;59(2):191-6. - PubMed
Keskitalo 1973 {published data only}
    1. Keskitalo E, Persson G. A clinical trial of Apernyl cones and tamponade with Ward's Wondr Pak in the treatment of dry socket. Svensk Tandlakare Tidskrift [Swedish Dental Journal] 1973;66(5):475-9. - PubMed
Kilinc 2017 {published data only}
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Kim 2020 {published data only}
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Kirk 2007 {published data only}
    1. Kirk DG, Liston PN, Tong DC, Love RM. Influence of two different flap designs on incidence of pain, swelling, trismus, and alveolar osteitis in the week following third molar surgery. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 2007;104:e1-e6. - PubMed
Krekmanov 1981 {published data only}
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Krekmanov 1986 {published data only}
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Krishnan 2020 {published data only}
    1. Krishnan S, Periasamy S, Arun M. Evaluating the efficacy of Abgel soaked in manuka honey following extraction of infected mandibular molars. International Journal of Pharmaceutical Research 2020;12(1):1789-97.
Kudiyirickal 2012 {published data only}
    1. Kudiyirickal M, Hollinshead F. Clinical profile of orofacial infections: an experience from two primary care dental practices. Medicina Oral, Patologia Oral y Cirugia Bucal 2012;17(4):e533-7. - PMC - PubMed
Lao 2012 {published data only}
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Liu 2011 {published data only}
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Long 2012 {published data only}
    1. Long H, Zhou Y, Liao L, Pyakurel U, Wang Y, Lai W. Coronectomy vs total removal for third molar extraction: a systematic review. Journal of Dental Research 2012;91(7):659-65. - PubMed
Lopez‐Cedrun 2011 {published data only}
    1. López-Cedrún JL, Pijoan JI, Fernández S, Santamaria J, Hernandez G. Efficacy of amoxicillin treatment in preventing postoperative complications in patients undergoing third molar surgery: a prospective, randomized, double-blind controlled study. Journal of Oral and Maxillofacial Surgery 2011;69(6):e5-14. - PubMed
MacGregor 1973 {published data only}
    1. MacGregor AJ, Hutchinson D. The effect of Nivemycin on pain and swelling following lower third molar removal. British Journal of Oral Surgery 1973;10(3):321-5. - PubMed
MacGregor 1975 {published data only}
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Majid 2010 {published data only}
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Malkawi 2011 {published data only}
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Mehlisch 2010a {published data only}
    1. Mehlisch DR, Aspley S, Daniels SE, Southerden KA, Christensen KS. A single-tablet fixed-dose combination of racemic ibuprofen/paracetamol in the management of moderate to severe postoperative dental pain in adult and adolescent patients: a multicenter, two-stage, randomized, double-blind, parallel-group, placebo-controlled, factorial study. Clinical Therapeutics 2010;32(6):1033-49. - PubMed
Mehlisch 2010b {published data only}
    1. Mehlisch DR, Aspley S, Daniels SE, Bandy DP. Comparison of the analgesic efficacy of concurrent ibuprofen and paracetamol with ibuprofen or paracetamol alone in the management of moderate to severe acute postoperative dental pain in adolescents and adults: a randomized, double-blind, placebo-controlled, parallel-group, single-dose, two-center, modified factorial study. Clinical Therapeutics 2010;32(5):882-95. - PubMed
Mishra 2012 {published data only}
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Mitchell 1986a {published data only}
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Mitchell 1986b {published data only}
    1. Mitchell DA. A controlled clinical trial of prophylactic tinidazole for chemoprophylaxis in third molar surgery. British Dental Journal 1986;160(8):284-6. - PubMed
Moberly 2007 {published data only}
    1. Moberly JB, Xu J, Desjardins PJ, Daniels SE, Bandy DP, Lawson JE, et al. A randomized, double-blind, celecoxib- and placebo-controlled study of the effectiveness of CS-706 in acute postoperative dental pain. Clinical Therapeutics 2009;29(1):399-412. - PubMed
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Njokanma 2019 {published data only}
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Nordenram 1973 {published data only}
    1. Nordenram A, Sydnes G, Ödegaard J. Neomycin-bacitracin cones in impacted third molar sockets. International Journal of Oral Surgery 1973;2(6):279-83. - PubMed
Olson 1987 {published data only}
    1. Olson RAJ, Fridrich KL. Alveolitis sicca dolorosa following impacted mandibular 3rd molar surgical removal. Journal of Dental Research 1987;66(1 Suppl):174 (Abs No 542).
Olusanya 2011 {published data only}
    1. Olusanya AA, Arotiba JT, Fasola OA, Akadiri AO. Prophylaxis versus pre-emptive antibiotics in third molar surgery: a randomised control study. Nigerian Postgraduate Medical Journal 2011;18(2):105-10. - PubMed
Osunde 2014 {published data only}
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Osunde 2015 {published data only}
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Osunde 2017 {published data only}
    1. Osunde OD, Anyanechi CE, Bassey GO. Prevention of alveolar osteitis after third molar surgery: comparative study of the effect of warm saline and chlorhexidine mouth rinses. Nigerian Journal of Clinical Practice 2017;20:470-3. - PubMed
Oyri 2019 {published data only}
    1. Oyri H, Jonsdottir O, Jensen JL, Bjornland T. The use of a tetracycline drain reduces alveolar osteitis: a randomized prospective trial of third molar surgery under local anesthetics and without the use of systemic antibiotics. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology 2019;128(3):205-12. - PubMed
Ozveri 2020 {published data only}
    1. Ozveri Koyuncu B, Isik G, Ozden Yuce M, Gunbay S, Gunbay T. Effect of concentrated growth factors on frequency of alveolar osteitis following partially-erupted mandibular third molar surgery: a randomized controlled clinical study. BMC Oral Health 2020;20(1):222. - PMC - PubMed
Paul 2019 {published data only}
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Pichler 2001 {published data only}
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Prataap 2017 {published data only}
    1. Prataap N, Sunil PM, Sudeep CB, Ninan VS, Tom A, Arjun MR. Platelet-rich plasma and incidence of alveolar osteitis in high-risk patients undergoing extractions of mandibular molars: a case-control study. Journal of Pharmacy and Bioallied Sciences 2017;9(Supp 1):S173-9. - PMC - PubMed
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Rani 2016 {published data only}
    1. Rani A, Mohanty S, Sharma P, Dabas J. Comparative evaluation of Er:Cr:YSGG, diode laser and Alvogyl in the management of alveolar osteitis: a prospective randomized clinical study. Journal of Maxillofacial and Oral Surgery 2016;15(3):349-54. - PMC - PubMed
Rastogi 2018 {published data only}
    1. Rastogi S, Choudhury R, Kumar A, Manjunath S, Sood A, Upadhyay H. Versatility of platelet rich fibrin in the management of alveolar osteitis - A clinical and prospective study. Journal of Oral Biology and Craniofacial Research 2018;8(3):188-93. - PMC - PubMed
Reeshma 2021 {published data only}
    1. Reeshma S, Dain CP. Comparison of platelet-rich fibrin with zinc oxide eugenol in the relief of pain in alveolar osteitis. Health Science Reports 2021;4(3):e354. - PMC - PubMed
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Saez‐Alcaide 2020 {published data only}
    1. Saez-Alcaide LM, Molinero-Mourelle P, Gonzalez-Serrano J, Rubio-Alonso L, Bornstein MM, Lopez-Quiles J. Efficacy of a topical gel containing chitosan, chlorhexidine, allantoin and dexpanthenol for pain and inflammation control after third molar surgery: a randomized and placebo-controlled clinical trial. Medicina Oral, Patologia Oral y Cirugia Bucal 2020;25(5):e644-51. - PMC - PubMed
Sanchis 2004 {published data only}
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Sarkar 2019 {published data only}
    1. Sarkar S, Prashanth NT, Shobha ES, Rangan V, Nikhila G. Efficacy of platelet rich fibrin versus chitosan as a hemostatic agent following dental extraction in patients on antiplatelet therapy. Journal of Oral Biology and Craniofacial Research 2019;9(4):336-9. - PMC - PubMed
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    1. Scopp IW, Morgan FH, Gillette WB, Fredrics HJ, Peskin MJ, Kleinman D. Dialog. A double-blind clinical study of dialog, darvon and a placebo in the management of postoperative dental pain. Journal of Oral Therapeutics and Pharmacology 1967;4(2):123-7. - PubMed
Seethamsetty 2019 {published data only}
    1. Seethamsetty S, Sarepally G, Sanober A, Qureshi Y, Fatima U, Arif SM. A comparative evaluation of the effectiveness of chitosan-based dressing and conventional method of hemostasis in patients on oral antithrombotic therapy without therapy interruption. Journal of Pharmacy & Bioallied Sciences 2019;11(5):S18-S23. - PMC - PubMed
Sharma 2017 {published data only}
    1. Sharma A, Aggarwal N, Rastogi S, Choudhury R, Tripathi S. Effectiveness of platelet-rich fibrin in the management of pain and delayed wound healing associated with established alveolar osteitis (dry socket). European Journal of Dentistry 2017;11(4):508-13. - PMC - PubMed
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Syrjanen 1981a {published data only}
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Syrjanen 1981b {published data only}
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Tek 2014 {published data only}
    1. Tek M, Akkas I, Toptas O, Ozan F, Sener I, Bereket C. Effects of the topical hemostatic agent Ankaferd Blood Stopper on the incidence of alveolar osteitis after surgical removal of an impacted mandibular third molar. Nigerian Journal of Clinical Practice 2014;17(1):75-80. - PubMed
Tjernberg 1979 {published data only}
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Tong 2012 {published data only}
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Torres Lagares 2006 {published data only}
    1. Torres Lagares D, Infante Cossío P, Gutiérrez Pérez JL, Romero Ruiz MM, Serrera Figallo MA. Gel de Clorhexidina intra-alveolar en la prevención de la alveolitis tras la extracción de terceros molares inferiores: estudio piloto. Medicina Oral, Patologia Oral y Cirugia Bucal 2006;11(2):113-8. - PubMed
Torres‐Lagares 2010 {published data only}
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    1. Vu N, Chuenchompoonut V, Jansisyanont P, Sangvanich P, Pham T, Thunyakitpisal P. Acemannan-induced tooth socket healing: a 12-month randomized controlled trial. Journal of Dental Sciences 2021;16(2):643-53. - PMC - PubMed
Wang 2013 {published data only}
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Yuan 2006 {published data only}
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References to other published versions of this review

Daly 2008
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