Treatment is optimized by first administering an anesthetic nerve block with a long-acting local anesthetic, such as bupivacaine (Marcaine) 0.5% (see Appendix D).
Irrigate the socket with warm normal saline solution or with 0.12% warmed chlorhexidine, and remove all retained debris.
Pack the socket with ¼-inch iodoform gauze soaked in oil of cloves (eugenol).
An alternative to packing with iodoform gauze is to fill the socket with zinc oxide or, when available, commercial dry socket dressing material (Alvogyl). It has been reported that immediate pain relief can be obtained by mixing this paste with one crushed aspirin and 2 drops of eugenol. This mixture can be inserted with the wooden end of a cotton-tipped applicator. Placing a moistened, folded gauze pad over the site will prevent this material from coming out. Have the patient keep it covered for a few hours.
Have the patient take 4000 mg/day of vitamin C. This has been associated with rapid recovery from dry socket in one study.
Prescribe oxycodone (Percocet, Tylox) and nonsteroidal anti-inflammatory drugs (NSAIDs) for additional pain relief.
Refer the patient back to her dentist for follow-up. The gauze packing should be removed and replaced every 24 hours until symptoms subside. Advise the patient that the dry socket paste will dissolve over the next few days and likely need to be replaced by the dentist at least one more time in most cases.
What Not To Do:
Do not try to create a new clot by stirring up bleeding. Scraping the socket can implant bacteria in the alveolar bone, setting the stage for osteomyelitis.
Discussion
Dry socket results from a pathologic process combining loss of the healing blood clot with a localized inflammation (alveolar osteitis). Fibrinolysis produced by bacterial activity may contribute to the production of the dry socket.
It most commonly occurs with difficult extractions of the mandibular molars, especially third retained molars. This condition may be promoted by smoking, spitting, or drinking through a straw—activities that create negative pressure in the oral cavity. Thirty percent of women taking oral contraceptives experience dry sockets after their surgery. (The best time for them to have their wisdom teeth removed is during the last week of their menstrual cycle—days 23 through 28.)
Intractable pain usually responds to a nerve block with long-acting local anesthetics.
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