4.16 Dental Pain Post Extraction (Dry Socket)

agk’s Library of Common Simple Emergencies

Presentation

The patient develops severe dull throbbing pain two to four days following a tooth extraction. The pain is often excruciating, may radiate to the ear, and is not relieved by oral analgesics. There may be an associated foul odor and taste. The extraction site is filled with necrotic tissue which is delaying wound healing.

What to do:

• Consider an anesthetic nerve block prior to any treatment.
• Irrigate the socket with warm normal saline.
• Pack the socket with 1/4" iodoform gauze soaked in oil of cloves (eugenol).
• Prescribe oxycodone and nonsteroidal anti-inflammatory analgesics for additional pain relief.
• Refer the patient back to his dentist for followup. The gauze packing should be removed and replaced every 24 hours until symptoms subside.

What not to do:

• Do not prescribe antibiotics unless there is a systemic infection. Resolution of the problem depends on granulation the socket rather than elimination of infection.
• Do not try to create a new clot by stirring up bleeding. Scraping the socket cen 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). It is most common with extraction of the mandibular molars. This condition may be encouraged by smoking, spitting or drinking through a straw, which create negative pressure in the oral cavity. Intractible pain usually responds to nerve block with long acting local anesthetics.

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