Management of dry socket

MANAGEMENT OF DRY SOCKET:

A COMPARISON OF TWO TREATMENT MODALITIES
FAHIMUDDIN, BDS, FCPS
IRAM ABBAS, BDS, FCPS
3
MUSLIM KHAN, BDS, FCPS
4
ATTA UR REHMAN, BDS, FCPS
1

ABSTRACT
The objective of this study was to compare the effect of local application of chlorhexidine
digluconate and combination of Iodoform with Butylparaminobenzoate in the management of dry
socket. A Quasi experimental study was carried out on a total of sixty diagnosed cases of dry socket.
Patients were randomly distributed among two treatment groups (30 patients in each group) i.e.
patients of group A were treated by local application of chlorhexidine digluconate gel and of group B
by local treatment with combination of Iodoform + Butylparaminobenzoate (Alvogyl). Both the
treatment groups were given the same systemic analgesic i.e., Ibuprofen 400mg TDS along with
thorough irrigation of the socket. Patients were followed for five consecutive days by replacing dressing
each day and findings were recorded in the proforma. Out of the sixty patients, forty five were males
and fifteen were females (3:1). In group A there were 22 (73.33%) males and 8 (26.66%) females and
in group B there were 23 (76.66%) males and 7 (23.33%) females. Mean age was 31.68 (11.23+S.D).
There was no significant effect of gender (P=0.766) and age (P=0.668) on both of the treatment groups
respectively. All patients measured their pain subjectively as S3 i.e. severe pain on day 1 on visual
analogue scale. There was a significant difference in pain control of the two treatment groups on 2nd,
3rd and 4th treatment day with P=0.000, P=0.000 and P = 0.02 respectively. Significant difference was
noted for sensitivity on gentle probing the extraction socket between the results of two treatment groups
on 3rd and 4th day i.e. p=0.000 for both days.
Iodoform and Butylparaminobenzoate (Alvogyl) had been the most successful combination in
relieving patients pain.
Key Words: Dry socket, Alvogyl, chlorhexidine.
INTRODUCTION
Dry socket or alveolar osteitis is the post extraction socket in which the patient is having pain due to
loss of blood clot thus exposing bone to air, food and
fluids. Prevention of dry socket remains the best strategy that can be achieved by providing an aseptic
environment, avoiding inadvertent instrumental
1

Correspondence: Dr. Fahimuddin, Junior registrar, Department of Oral and Maxillofacial Surgery, Khyber College of Dentistry, Peshawar. Email: fahim79pk@yahoo.com,
Cell: 0321-9693326
Prof. Head of Deptt. Oral & Maxillofacial Surgery, Ayub Medical
College, Abottabad.
Associate Professor, Oral & Maxillofacial Surgery, Khyber College of Dentistry,
Assistant Professor, Oral & Maxillofacial Surgery, Khyber College of Dentistry
Received for Publication:
March 10, 2013
Revision Received:
March 27, 2013
Revision Accepted:
March 31, 2013

Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

trauma, drinking through straw, smoking, excessive

mouth rinsing. There should be sufficient irrigation
when using rotary instruments. In females prevention
can be done if extractions are scheduled during the last
week of menstrual cycle (days 23 through 28) when
estrogen levels are low or inactive.1 Incidence can also
be decreased by use of antiseptic mouth washes,
antifibrinolytic agents, antibiotics, steroids and clot
supporting agents.2
Any treatment modality is considered effective if it
improves patients quality of life by reducing cost of
therapy and relieving patients pain. Various treatment options are available for dry socket. Topical
application of a combination of eugenol, benzocain and
balsam of Peru;3 Iodoform and Butylparaminobenzoate1, 4 and Honey5 have been tried for pain relief.
Prophylactic administration of systemic beta lactamase
inhibitor containing antibiotic have been claimed in
reducing incidence of dry socket.6
31

Management of dry socket

The objective of the study was to compare the efficacy of

topical application of chlorhexidine digluconate with topical
application of combination of Iodoform and
Butylparaminobenzoate in the management of dry socket. The
studywillfurtherhelpustoarriveatbesttreatmentfordrysocket
associated pain.
METHODOLOGY
This study was conducted at the department of oral and
maxillofacial surgery; Dentistry Unit, Ayub Medical College/
Ayub Teaching Hospital, Abbottabad from 10th April, 2007 to 10th
October,2007.Atotalofsixtypatientsofdrysocketwererecruited
in the study. The study design was quasi experimental sampling
technique was convenience or non probability.

cant effect of gender on both of the treatment groups (p=0.766).

Mean age at the time of presentation was 31.68 disregarding
treatment groups and majority patients were found in third
decade. Age had no significant effect on both treatment groups
(p=0.668).
Dry socket was more common in mandible than the maxilla
(P=0.045). Mandibular first molar was mostly involved i.e. in 19
(31.66%) patients while mandibular third molar was involved in
15 (25%) cases and mandibular second molar 12 (20%) cases.
AllpatientsmeasuredtheirpainsubjectivelyasS3i.e.severe
pain on day 1 on visual analogue scale. There was a significant
difference in pain control of the two treatment groups on 2nd, 3rd
and 4th post-treatment day with P=0.000, P=0.000 and P = 0.02
respectively.

The diagnostic criteria for dry socket was based on history of

extraction of two or more days and pain, clinical examination for
sensitivity on gentle probing the extraction socket, trismus,
halitosisandconditionoftoothsocketandradiographicexamination for the presence of a broken down root.

Significant difference was also noted for sensitivity on gentle

probing the extraction socket between the results of two treatment groups on 3rd and 4th day i.e. p=0.000 for both days.

Patients with systemic diseases like diabetes mellitus, hepatic dysfunctions, blood dyscrasias, bleeding disorders, previous
use of systemic antibiotics for dry socket, previous treatment for
dry socket and history of all kinds of tobacco use including snuff
dipping were excluded from the study.

TABLE 1: DISTRIBUTION ACCORDING TO

GENDER

Informed consent of the patients was taken after explaining

risks and benefits associated with treatments. Pain was measured by Visual Analogue Scale (VAS). According to this scale
patientsmeasuredtheirpainfromoutofthreei.e.mildpainasS1,
rangedfrom1-4;moderatepainasS2,rangedfrom5-7andsevere
pain as S3 ranged from 8-10. Sensitivity on gentle probing the
extraction socket was considered on all or none basis.
Patients were randomly distributed among two treatment
groups i.e. patients of group A were treated by local application of
chlorhexidine digluconate gel and of group B by local treatment
with Iodoform+ Butylparaminobenzoate (Alvogyl) in the extraction sockets after thorough irrigation with sterile saline and
systemic administration of Ibuprofen in both of the treatment
groups. Patients were followed for five consecutive days by
replacing dressing each day and findings were recorded in the
designated proforma of the patients.
Data were analyzed by SPSS version-10. Descriptive statistics were used for calculating frequency of age, gender, pain and
sensitivity on gentle probing the extraction socket. Mean and
standard deviation (SD) for age were calculated. Chi-square test
was applied to compare pain relief and sensitivity on gentle
probing the extraction socket between two drug regimens, and
effect of age and gender on two treatment groups. P value of 0.05
was taken as significant.
RESULTS
Out of sixty patients of dry socket, forty five were males and
fifteen were females with a ratio of 3:1. In group A there were 22
(73.33%)malesand8(26.66%)femalesandingroupBtherewere
23 (76.66%) males and 7 (23.33%) females. There was no signifiPakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

Group A

Group B

Gender

Cases

Cases

Male
Female
Total

22
8
30

73.33%
26.66%
100%

23
7
30

76.66%
23.33%
100%

TABLE 2: AGE DISTRIBUTION

Group A
Age in years
21-30
31-40
11-20
41-50
51-60

Group B

Cases

Cases

11
8
5
4
2

36.66
26.66
16.66
13.33
6.66

6
5
7
6
6

20
16.6
23.33
20
20

TABLE 3: SITE DISTRIBUTION

Site
Mandibular 1st molar
Mandibular 3rd molar
Mandibular 2nd molar
Mandibular 2nd premolar
Maxillary 1st molar
Maxillary 1st premolar
Mandibular 1st premolar
Maxillary 2nd premolar

No. of patients

19
15
12
4
4
3
2
1

31.66
25
20
6.66
6.66
5
3.33
1.66
32

Management of dry socket

TABLE 4: RESULTS OF TWO TREATMENT GROUPS FOR FIVE CONSECUTIVE DAYS

Pain {VAS} (% patients)

Day 1
Day 2
Day 3

Day 4
Day 5

Sensitivity on gentle probing the extraction socket

(% patients)

Group A

Group B

GroupA

GroupB

S3=100
S2= 37
S3= 64
S1= 3
S2= 83
S3= 13
S1= 83
S2= 7
S1= 100

S3= 100
S1= 83
S2= 17
S1= 83
S2= 17

P= 100
P= 100

P= 100
P= 100

P= 100

P= 27
A-73

S1= 100

P= 47
A= 53
A= 100

A=100

S1= 100

A= 100

{VAS=visual analogue scale, 1-4= mild pain (S1), 5-7= moderate pain (S2) and 8-10= severe pain (S3)
P = present; A = absent % patients= total of 60 patients per group considered as 100 %}
DISCUSSION
The pain of Dry socket occurs because of release of
kinins which are immediately available following tissue trauma,2 exposure of nerve endings to air, food and
fluids in bare bone of the extraction socket1 and infectious process which releases tissue activators and pain
mediators.7
Local application of the Alvogyl in the empty
socket can show its effect according to all the possible
causes of pain of dry socket mentioned above. Eugenol
of clove oil (in Alvogyl) depresses sensory receptors
involved in pain perception by inhibition of prostaglandins biosynthesis. Alvogyl pack itself works by
acting as a physical barrier between the exposed bone
along with exposed nerve endings and the oral environment. Iodoform is a powerful antiseptic. Chlorhexidine on the other hand could be considered only for its
antiseptic effect and providing a weak barrier for
covering exposed bone not as strong as Alvogyl. In this
regard, Alvogyl remained superior to Chlorhexidine
i.e. on second, third and fourth day of treatment there
was a tremendous improvement in pain relief of group
B patients (Alvogyl group) with P=0.000, P=0.000 and
P=0.02 respectively and a significant difference of
P=0.000 for sensitivity on gentle probing the extraction socket. Chlorhexidine if used for preoperative
prophylaxis would remain a good remedy in reducing
incidence of dry socket and might have shown good
results.8,9
Male to female ratio was 3:1 with no significant
effect of gender on both of the treatment groups
Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

(p=0.766). These findings didnt correlate with those of

MacGreoger10 in which the ratio was 2:3. Male to
female ratio in the present study can be attributed to
the social and cultural values of our society where
females face several difficulties in receiving treatment. For example, leaving their children unattended
at home and lack of permission to go to hospital
unescorted. Another factor for the lesser number of
females in this study is because of the lesser use of oral
contraceptives, which is one of the risk factors for the
development of dry socket.4,11,12,13,14,15
Mean age was 31.68 and majority of the patients
were found in third decade. This finding is consistent
with other studies such as that of Oginni FO7,
MacGregor AJ10, Al-Khateeb TL,16 Amaratunga NA17
and Field EA.18 Age showed no significant effect on
both treatment groups (p=0.668). Prevalence of dry
socket in this age group can be attributed to more solid
nature of bone which is relatively disease free (e.g.
periodontal diseases) that can lead to difficult and
hence traumatic extraction. It is widely accepted that
prevalence of dry socket increases with increase in
extraction difficulty10,19,20,21 and surgical trauma.22 This
could be due to more release of direct tissue activators
secondary to bone marrow inflammation.19
Dry socket was more common in mandible than
maxilla, which were in accordance with the results
shown by Nusair 2 (P=0.045). According to the present
study mandibular molar area was the most common
site for development of dry socket, which is consistent
with other international studies.7,11,18,23,24 Frequent
involvement of mandibular first molar in this study
33

Management of dry socket

couldnt match with the results of Nusair2 and others

in which dry socket was most common in the mandibular third molar area.17,25 This might be as a result of
extraction of mandibular first molar mostly by undergraduates in the present study (less experience operators) which resulted in the development of dry socket
mostly at this site. Less experience in extracting teeth
is one of the risk factors for etiology of the dry socket
according to Oginni23 et al and Alexander.7 Clinical
and radiographic examination revealed that none of
the post-extraction socket had foreign bodies, loose
bone or broken down roots or root pieces.
CONCLUSION AND RECOMMENDATIONS
Adverse effects were not reported in both of the
treatment groups. Alvogyl had been the most successful combination for the management of dry socket in
terms of relieving patients pain, decreasing number of
visits to the hospital and decreasing financial and
psychological burden on patients in the form of decreasing intake of systemic medications (antibiotics,
analgesics and others). There is a need to progress
with similar studies having a larger study samples.
Future research should also include patients with
systemic diseases and tobacco use.
There is no need of systemic antibiotics for treating dry socket. It is superficial inflammation merely of
cortical plate of the extraction socket, hence topical
anesthetic/analgesic/antiseptic will be enough e.g.
Alvogyl or Chlorhexidine and if needed systemic analgesics can also be given for controlling pain. Surgical
intervention should never be done unless indicated for
other problems e.g. retained root. Reassurance must
be give to the patient about the problem.
ACKNOWLEDGMENTS
I am grateful to Professor Dr Iftikhar Qayyum
(Rehman Medical College, Peshawar), Professor Dr
Ahmad Badar, Assistant Professor Dr Fazal Ghani
(BDS, MSc, PhD, Khyber College of Dentistry,
Peshawar), Mr Alamgir (Statistician, University of
Peshawar), Mr Amjad Ali (Statistician, regional center Peshawar, College of Physicians and Surgeons
Pakistan) for their support and cooperation in fulfilling my research work.

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