Tooth extraction is a routinely performed operation in general dental practice. An occasional complication of dental extraction is alveolar osteitis (dry socket) with an incidence of 0.5 – 7% reported for routine extractions and 1-37.5% for surgical removal of third molars. Blum’s definition of alveolar osteitis as, postoperative pain in and around an extraction site, which increases in severity between 1 and 3 days after the extraction, accompanied by a partially or totally disintegrated blood clot within the alveolar socket, with or without halitosis (Blum 2002), is the most widely used.
The aim of this Cochrane Review update was to assess local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.
Searches were conducted in the Cochrane Oral Health’s Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. Split-mouth or cross-over design randomised controlled trials (RCTs) using validated criteria for alveolar osteitis based on Blum’s definition were considered. Two reviewers independently selected studies and extracted data with analysis following standard Cochrane methodological approaches. Dichotomous data was reported as risk ratios (RR) or odds ratio (OR) instead with 95% confidence intervals (CI) using random-effects models. GRADE was used to assess the certainty of the body of evidence.
- 49 RCTs involving 6771 patients were included, 39 trials (6219 patients) on prevention of dry socket and 10 trial on treatment.
- 16 studies were considered to be at high risk of bias, 3 at low risk and 30 studies at unclear risk of bias.
- Compared to placebo chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket, OR = 0.38 (95%CI; 0.25 to 0.58) [ 6 RCTs, 1547 patients, 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% ; OR = 0.44 (95%CI;0.27 to 0.71)[ 7 RCTs, 753 patients, 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).
- 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) was found but most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash.
- No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket.
- In comparison with 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); [ 2 studies, 127 patients; very low-certainty evidence].
- 21 intrasocket interventions to prevent dry socket were evaluated in single studies providing insufficient evidence to determine their effects.
- 2 studies (80 patients) showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7; mean difference = -1.40 (95%CI; -1.75 to -1.04) [ very low-certainty evidence].
- 9 interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects.
The authors concluded: –
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.
This Cochrane review updates the 2012 version and looks at both the prevention and treatment of alveolar osteitis. While 49 studies were included the majority of these relate to the extraction of third molars with only 5 involving routine extractions. Seven of the studies involved a split mouth design and one a cross-over approach and there is some discussion as to whether these approaches are the most appropriate. In relation to the findings for the effectiveness of chlorhexidine in management of alveolar osteitis the findings are broadly similar to other reviews with moderate certainty evidence in their support. However, this review found insufficient data on the use of platelet rich fibrin to aid socket healing compared to other reviews that have shown that platelet rich fibrin significantly reduced the risk of dry socket (Dental Elf – Alveolar Osteitis Blogs).
Daly BJ, Sharif MO, Jones K, Worthington HV, Beattie A. Local interventions for the management of alveolar osteitis (dry socket). Cochrane Database Syst Rev. 2022 Sep 26;9(9):CD006968. doi: 10.1002/14651858.CD006968.pub3. PMID: 36156769; PMCID: PMC9511819.
Blum IR. Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review. Int J Oral Maxillofac Surg. 2002 Jun;31(3):309-17. doi: 10.1054/ijom.2002.0263. PMID: 12190139.
Dental Elf – Alveolar Osteitis Blogs
It should be highlighted that there have been two cases of fatal adverse reactions to chlorhexidine following its use for socket irrigation in patient with dry socket (Pemberton and Gibson 2012).
In their 2022 scoping review Ghosh et al., stated that
“given the recent history of fatal adverse reactions, the benefits of chlorhexidine use do not outweigh the risks of intra-alveolar use.”
Pemberton MN, Gibson J. Chlorhexidine and hypersensitivity reactions in dentistry. Br Dent J. 2012 Dec;213(11):547-50. doi: 10.1038/sj.bdj.2012.1086. PMID: 23222325.
Ghosh A, Aggarwal VR, Moore R. Aetiology, Prevention and Management of Alveolar Osteitis-A Scoping Review. J Oral Rehabil. 2022 Jan;49(1):103-113. doi: 10.1111/joor.13268. Epub 2021 Oct 22. PMID: 34625985.