Dentistry Review 2 (2022) 100035

Contents lists available at ScienceDirect

Dentistry Review
journal homepage: www.elsevier.com/locate/dentre

Management of Dry Socket: New regenerative techniques emerge while old

treatment prevails
Aqsa Kamal a,b, Marzuki Omar b, A.R. Samsudin a,∗
a
College of Dental Medicine, University of Sharjah, PO Box 27272, Sharjah, UAE
b
School of Dental Sciences, Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia

a r t i c l e i n f o a b s t r a c t

Keywords: Objective: Although dry socket has been recognized for more than a century, its etiology is still poorly under-
Dry socket stood, and treatment approach is diverse with varying outcome. The aim of this review is to investigate, classify,
Alveolar osteitis summarize, and discuss the treatment of dry socket.
Dry socket remedies
Method: Four databases (PubMed, Science Direct, Scopus and Medline) were searched from April 2000 till April
Platelet rich plasma
2020 for articles featuring the key words: ‘dry socket’, OR ‘alveolar osteitis’, OR ‘post-extraction complication’, OR
regenerative approach
Low level laser ‘treatment of dry socket’, OR ‘treatment of alveolar osteitis’, OR ‘treatment of pain following tooth extraction’. The
Standard Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were adopted for data gathering.
Results: A total of 3,857 results were found and 17 articles were finally selected and reviewed thoroughly. Treat-
ment initiatives were categorized into empirical approach, conventional approach and regenerative strategies. 19
treatment products were identified. Earlier therapeutic approaches focus on pain control, infection prevention and
resolving inflammation while current strategies modulate angiogenesis and granulation tissue formation. These
latter armamentariums use blood-based products such as Platelet-Rich Plasma; employing laser and ultrasound
technology that initiate and propagate tissue regeneration.
Conclusion: While evidence support a regenerative approach for dry socket healing, the old treatment modality
controlling infection, inflammation and pain prevails.

1. Introduction
Dry socket is the most common post tooth extraction complication
[1]. The condition is also known as alveolalgia, localized osteitis, fibri-
nolytic osteitis or alveolitis sicca dolorosa [2]. The leading symptom is
severe pain related to a recent tooth extraction socket, commonly occur
from day one to day five post-extraction, and is also characterized by
halitosis, disturbed masticatory function but generally without systemic
upset. Dry socket is known for its dry appearance of the socket, exposing
bare bone, filled with slough. The condition is also known as fibrinolytic
osteitis or alveolar osteitis and has been described by Crawford in 1896
[3].
The incidence of dry socket has reported to be 1% to 4% worldwide
[4]. It rarely occurs in children but is common among both healthy and
medically compromised patients. Despite its clear symptom and sign
which could be clinically recognized immediately without the aid of
further special investigations, its etiology is bizarre and much poorly
understood.
Trauma following forced tooth extraction, excessive use of vasocon-
strictors in local anesthetics, infection, dislodgement of blood clot from
socket due to forceful mouth rinsing, use of contraceptives and heavy
smoking have all been implicated in the etiology of dry socket [5]. In-
crease local fibrinolysis at the wound site is another possible mechanism
[6].
Due to its poorly understood etiology, a range of treatment modali-
ties has been implicated in the treatment of dry socket with varying suc-
cess claims by dental practitioners. To date, treatment for dry socket has
never been satisfactory and patients suffer from pain and delay in socket
wound healing. There is no standard recommendation for treatment of
dry socket, and it is commonly missing in clinical practice guidelines
in many dental centers. Therefore, the aim of this study is to conduct
a mini review on the types of treatment advocated for management of
dry socket among healthy patients in general dental practice.
2. Materials and methods
A systematic literature database search was conducted using
PubMed, Science Direct, Scopus and Medline from April 2000 till April
2020. The search included the following sets of key words : ‘dry socket’,
OR ‘alveolar osteitis’, OR ‘post-extraction complication’, OR ‘alveolar

∗
Corresponding author at: University of Sharjah, College of Dentistry, United Arab Emirates.
E-mail addresses: draqsakamal@student.usm.my (A. Kamal), marzukie@usm.my (M. Omar), drabrani@sharjah.ac.ae (A.R. Samsudin).

https://doi.org/10.1016/j.dentre.2022.100035
Received 29 December 2021; Accepted 14 January 2022
2772-5596/© 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
A. Kamal, M. Omar and A.R. Samsudin
osteitis management’, OR ‘treatment of dry socket’, OR ‘treatment of
alveolar osteitis’, OR ‘treatment of pain following tooth extraction’, OR
‘management of tooth-socket healing’. The search terms employed were
key words classified under the general (all fields) category. The search
terms were combined with an ‘OR’ and categories were combined using
‘AND’ or ‘NOT’ to create a final search query. The following filters were
applied to these terms: Full text, published in the last 20 years (since
2000), English and academic journals only.
The search was conducted by two authors. Inclusion criteria were
clinical studies in English Language pertaining directly to local treat-
ment of dry socket or alveolar osteitis, and only performed on healthy
patients with suitable controls. Articles concerning management of pain
following tooth extraction, post-extraction pain and management of
tooth-socket healing were carefully read and were only accepted if the
study is related to dry socket condition. Literature on treatment of in-
fected extraction wound, post-operative pain without a diagnosis of
dry socket, single case report and case series without controls were ex-
cluded. All other related articles concerning etiologies, pathologies and
animal studies related to dry socket research were also excluded. The
focus questions were:
(1) What was the material or technology use for treatment of dry socket?
(2) What is the direct action of the material or technology on healing of
the socket?
(3) What are the characteristics of the materials or technology selected?
(4) Was the material or technology used alone or being compared with
other materials and technologies?
(5) What is the outcome of treatment in relation to the material and
technologies used?
The selected articles were read and summarized based on treatment
technique, material, medications and technology used, the active com-
pound employed, mechanism of dry socket healing advocated, and out-
come of treatment achieved. A database was developed to compare and
assess the literature based on the Preferred Reporting Items for System-
atic Reviews and Meta-Analyses (PRISMA) statement guidelines.
3. Results
A total of 3,857 results were identified from all the searches. Follow-
ing screening and removing duplicate records, 112 articles which met
the inclusion criteria were included. Further eligibility was assessed by
all authors based on whether the articles answered the focus questions
through full text reading. A total of 17 articles were found eligible and
were selected, reviewed thoroughly and independently by all authors.
A descriptive summary of the findings based on the focus questions
are tabulated in Table 1. The bioactive material and technologies used
for dry socket management in the 17 studies were classified into reme-
dies, medicaments, topical drugs and blood-products while the technolo-
gies used were Low Level Laser Therapy and Low-Intensity Pulsed Ul-
trasound. The mechanism of action for each of these armamentarium
used was categorized into pain control, sedative, anti-halitosis, anti-
inflammatory, antioxidant, antiseptic, anti-microbial and regenerative
strategies (Table 2).
4. Discussion
The art and science of wound healing has its roots for many centuries
across all civilizations. Throughout history, management of the difficult
wound has been among the greatest challenge faced by surgeons and
nurses caring for such unfortunate patients. The struggle against poor
wound healing lead to a vast array of treatment innovations where many
found little scientific basis. Dry socket management follows a similar
journey and experienced a wide range of treatment strategies with un-
satisfactory outcomes. In this review the authors classify the wide array
of treatment options for dry socket into ‘empirical approach’, ‘conven-
tional treatment’ and ‘regenerative strategies’.
2
Dentistry Review 2 (2022) 100035
This review observed treatment strategies for dry socket among
healthy patients only. All articles in this review were clinical studies
conducted on patients in Asia, Middle East, Europe and North America.
It shows the incidence of dry socket is between 1% and 4 % worldwide
[4] and the clinical features were identical across the globe, without
any specific geographical predilection. Identification of subjects suffer-
ing from dry socket is straight forward with obvious clinical symptoms
and signs of severe pain in the extraction wound about 24 to 36 hours
post-operative associated with a bare dry socket filled with superficial
slough is diagnostic of the condition. The number of study subjects in
this review range between 10 and 178 patients due to its low incidence
experience in each center.
A total of 19 treatment products in the form of remedies, medica-
ments, topical drugs and blood-products and technologies have been
advocated for treatment of dry socket over the past 20 years and these
initiatives contributed to a combination of 9 clinical effects that support
the healing of dry socket (Table 2). Pain relieve has always been the key
outcome investigated in all the studies since it is the principal symptom
in dry socket. Six studies observed response to a single treatment only
while most studies were comparing the outcome between two treatment
options.
In the ‘empirical approach’ to dry socket treatment, the remedies ap-
plied in this review include honey, turmeric, aloe vera and vitamin C [7].
The term remedy has been coined in this context to denote a substance
that relieves or occasionally able to cure a disease or injury. Remedies
for dry socket has established its ground for centuries in wound heal-
ing management and has become a common prescription in the field of
allopathic and alternative medicine too. Honey, turmeric and aloe vera
are herbal in origin and use as part of nutritional supplement. Honey is
derived from nectar gathered and modified by the honeybee, Apis mel-
lifera. It is a carbohydrate-rich syrup derived from floral and other plants
nectars and secretions [8]. Honey has been used in folk medicine since
ancient times and has more recently been rediscovered by medical re-
searchers for its use in dressing acute and chronic wounds [9]. Turmeric
is a perennial plant from India and South East Asia that has found medic-
inal values in wound infection [10]. Aloe vera is a shrubby, xerophytic,
green plant, grows mainly in the dry regions of Africa, Asia, Europe
and America. It is a vital nutrient having vitamins A (beta-carotene),
C, and E, which are antioxidants [11]. Aloe vera has calcium, copper,
magnesium, potassium and zinc which are essential for the proper func-
tioning of various enzyme systems in different metabolic pathways [12].
Honey, turmeric and aloe vera are analgesic, anti-inflammatory, antiox-
idant, antibacterial and promotes immunomodulation for the body to
fight infection. Vitamin C gel is a potent antioxidant placed in socket
that also promotes tissue regeneration through stimulation of collagen
synthesis [7,13]. Being non-toxic and no known allergy are the strength
of remedies compared to other pharmacological therapeutics. In addi-
tion, remedies described in our review are basically food supplement
that can be purchased over the counter and showed high efficacy in sup-
porting dry socket. However, the clinical use of remedies in dry socket
will require the appropriate clinical and scientific investigations to en-
sure safety, quality assurance and professional licensing requirements.
‘Conventional treatment’ for dry socket advocate medicaments and
drugs for local treatment. The procedure begins with gentle curettage
to debride the slough in socket, followed by irrigation and creation of a
new blood clot. The irrigation solution use may comprise of only physi-
ological saline solution or other irrigant solution such as chlorhexidine
and hydrogen peroxide [14]. This is then followed by insertion of a
dressing into the socket that comprise of medicaments such as alvogyl,
zinc oxide eugenol, oil of clove/eugenol, antihomotoxic, colloidal silver,
SaliCept or antibiotic dressing such as chlortetracycline, rifampicin, clin-
damycin and metronidazole gel [15,16]. This treatment strategy is con-
sidered ‘conventional’ because curettage and wound debridement is the
basic principle of management in poor wound healing and creation of a
new clot revive the wound healing mechanism by repeating the clotting,
inflammatory and proliferative phases. Insertion of other therapeutic

Table 1
Summary of 17 clinical studies on local treatment of dry socket in healthy patients.
Title of study/ Author/Year
Clinical management and control
of alveolalgia (dry socket) with
vitamin C. Halberstein RA et al.
2003 [7]
The Efficacy of a Topical
Anesthetic Gel in the Relief of
Pain Associated with Localized
Alveolar Osteitis. Burgoyne CC
et al. 2010. [21]
Comparison of Alvogyl, SaliCept
Patch, and Low-Level Laser
Therapy in the Management of
Alveolar Osteitis. Kaya GŞ et al.
2011. [41]
3
The Effectiveness of GECB Pastille
in Reducing Complications of Dry
Socket Syndrome. Abbas
Haghighat et al. 2012 [22]
Comparison Between Neocone,
Alvogyl and Zinc Oxide Eugenol
(ZOE) Packing for the Treatment
of Dry Socket: A Double Blind
Randomised Control Trial. Sayed
Faizel et al. 2014 [24].
Management of Alveolar Osteitis:
A Comparative Study of
Two-Treatment Techniques.
Charles Anyanechi. 2013 [26]
No. of
Type of study subjects Treatment Methods
Clinical prospective 24 Dry socket patients were given 4,000
study mg/day dosages of Vitamin C.
Prospective 35 Patients were divided into two groups.
randomized clinical Control Group was given eugenol on
study gauze strips while the Test Group was
given thermosetting gel. Followed up
after 48 hours post-treatment.
Randomized 104 Patients were divided into 4 groups.
prospective clinical Group I was treated with saline irrigation
trial. and curettage, Group II was treated with
irrigation, curettage and alveogyl
dressing, Group III was treated with
SaliCept patch following irrigation and
curettage and Group IV was treated with
low level laser therapy.
Randomized clinical 30 Patients were divided into two groups.
trial. Group I was given GECB pastille (3%
Guaiacol, 3% Eugenol 1.6%
Chlorobutanol) and Group II was given
zinc oxide eugenol.
Double blind 105 Patients were divided into three groups.
randomized control Group A patients were treated with
trial alvogyl, Group B patients were treated
with ZOE and Group C patients were
treated with neocone. Pain relief and
healing of socket was compared up to day
10.
Prospective study 42 Patients were divided into two groups.
The experiment group sockets were
irrigated with dilute hydrogen peroxide
while the other group was given
traditional treatment with gauze
impregnated with zinc oxide eugenol.
Mechanism of Action
Vitamin C is compulsory in the secretion,
synthesis and maturation of collagen.
Vitamin C supplements help to regulate
wound healing.
The anesthetic gel contained prilocaine
and lidocaine with anesthetic effects on
nerve endings.
SaliCept has acemannan, which acts as
anti-inflammatory, anti-bacterial and
immune modulating, whereas Alvogyl has
eugenol, iodoform and butamen which
acts as sedative, anti-microbial and
anesthetic. Low level laser therapy works
at the molecular level to enhance
proliferation and promote wound healing
and pain relief.
The effective ingredients of GECB are 3%
eugenol (Merck), 3% Guaiacol (Merck),
and 1.6% chlorobutanol in the pastille.
Guaiacol enhance cellular proliferation.
GECB and ZOE both have eugenol but
GECB is better in pain-relieving properties
and are superior to ZOE
Neocone contains polymyxine B sulfate
which has anti-microbial properties
against gram negative bacteria,
tyrothricin which has effects on gram
positive bacteria and spirochetes,
neomycin sulfate which has a
broad-spectrum impact and tetracaine
hydrochloride works as a local anesthetic.
Hydrogen peroxide is an oxidizing agent
which releases oxygen and creates a
foaming action which removes the food
debris and kills the anaerobic bacteria
such as actinomyces viscosus, strept
mutans and treponema denticola which
play a role in the etiology of dry socket.
A. Kamal, M. Omar and A.R. Samsudin
Study Findings
The dry socket showed faster
recovery following treatment
with vitamin C.
Thermosetting gel showed
significant pain relief compared
to eugenol.
Low level laser therapy showed
superior results among 4 groups.
Salicept patch is an acceptable
alternative of alvogyl in the
treatment of dry socket.
GECB showed significant
reduction in pain symptoms
while zinc oxide eugenol showed
acceptable results.
Alvogyl was quicker in initial
pain relief but neocone showed
complete pain relief and faster
healing.
The duration of treatment was
less in the experiment group
compared to the traditional
group. Hydrogen peroxide is
effective and safe for use in the
Dentistry Review 2 (2022) 100035
treatment of dry socket.
(continued on next page)

Table 1 (continued)
Title of study/ Author/Year
Comparison of the effect of low
level laser therapy with alvogyl
on the management of alveolar
osteitis. Eshghpour M et al. 2015
[40]
Management of dry socket using
Ozone gel vs. Alvogyl –
prospective clinical trial. Anum
Rehman Khan et al. 2015 [32]
Effect of low level laser therapy
and low intensity pulsed
ultrasound on pain following
tooth extraction: a single blinded
study. Anil R. Muragod et al.
2016 [38]
4
Platelet rich fibrin (PRF) in the
management of established dry
socket. Srinivas Chakravarthi.
2017 [35]
Role of turmeric in management
of alveolar osteitis (dry socket): A
randomized clinical study. PA
Lone et al. 2018 [10]
Efficacy of Alvogyl (Combination
of Iodoform + Butylparaminoben-
zoate) and Zinc Oxide Eugenol
for Dry Socket. Supe NB et al.
2018 [18]
Type of study No. of Treatment Methods
subjects
Prospective 60 Patients were divided into three groups.
randomized clinical Group 1 dry sockets were treated with
trial. alvogyl after irrigation, Group 2 patients
were irradiated with low power red laser
(LLLT) and Group 3 with low power
infrared laser (LLLT).
Prospective clinical 10 5 patients were given 1 ml. each of ozone
trial gel via syringe into the socket, while
another 5 patients were given alvogyl as
control.
Clinical comparative 40 The patients were divided into four
prospective study groups. Group A was given infra-red laser
(LLLT), Group B was given placebo laser,
while Group C was given low intensity
pulsed ultrasound (LIPUS) and Group D
received placebo ultrasound. The study
was done to compare the effectiveness
between LLLT and LIPUS.
Clinical prospective 10 The dry socket site was irrigated with
study normal saline and plate rich fibrin (PRF)
was inserted. Patients were followed-up
to fifteenth day postoperatively.
A randomized 178 Patients were divided into two groups. In
clinical study Group A, patients were given turmeric as
a dry socket dressing while Group B
patients were given ZOE dressing.
Single-blinded 50 Patients were divided into two groups.
prospective study. Group I patients were given alvogyl as
dressing and Group II patients were given
zinc oxide eugenol as dressing.
Mechanism of Action
LLLT promote fibroblasts,
epithelialization, collagen maturation,
angiogenesis and reduces pain. It also has
anti-inflammatory effects.
Ozone has strong anti-microbial
properties with ability to penetrate in
both hard and soft tissue; and promote
epithelization.
LIPUS affects the gingival cells and
increase m-RNA of proliferative cells
along with connective tissue growth
factors which the promotes soft tissue
healing.
PRF works at the molecular level. It
enhances angiogenesis, cellular migration,
epithelialization and bone regeneration.
Turmeric contains curcuminoids which
are prostaglandin inhibitors, stabilizer of
the liposomal membrane and inhibitor of
the activity of leucotrienes as well as
thromboxaneB4. It is anti-inflammatory,
antioxidant and anti-microbial, and
enhance regeneration.
Alvogyl has sedating, anti-microbial and
anesthetic effects. ZOE has sedating
effects.
A. Kamal, M. Omar and A.R. Samsudin
Study Findings
In this study LLLT showed
superior results for the treatment
of dry socket.
Ozone gel enhanced healing and
relieved the severe dry socket
pain faster as compared to
alvogyl.
LIPUS showed significantly
superior results when compared
to LLLT, placebo LLLT and
placebo LIPUS for socket pain
control.
PRF showed earlier pain relief
and good wound healing within
24 hours and with minimal
analgesic intake.
Turmeric treated Group A
showed faster pain relief and
faster wound healing.
The study claims that alvogyl
provide faster pain elimination of
dry socket and better results.
(continued on next page)
Dentistry Review 2 (2022) 100035

Table 1 (continued)
Title of study/ Author/Year
Choice of the treatment method
of the inflammatory process in
the alveolar tooth socket. Helei
VM et al. 2019 [15]
Evaluation of the effects of
intra-alveolar irrigation with
clindamycin, rifampicin and
sterile saline in alveolar osteitis
treatment. Çebi AT. 2020 [16]
The Efficacy of Concentrated
Growth (CGF) Factor in the
Healing of Alveolar Osteitis: A
Clinical Study. Aqsa Kamal et al.
2020 [36]
5
Management of dry socket with
low-level laser therapy. Aqsa
Kamal et al.2020 [39]
A Comparative Clinical Study
between Concentrated Growth
Factor and Low-Level Laser
Therapy in the Management of
Dry Socket. Aqsa Kamal et al.
2020 [37]
Type of study No. of Treatment Methods
subjects
Clinical prospective 58 Patients were divided in to two groups to
study treat dry socket. Test group consist of 38
patients were prescribed combine drug
therapy (colloidal silver, Traumeel® S,
Polymic®), while the Control group
consist of 20 patients were prescribed
allopathic treatment.
Clinical comparative 54 Patients were divided into three groups.
prospective study Group A dry sockets were irrigated with
sterile saline while Group B were irrigated
with rifampicin and Group C were
irrigated with clindamycin. Patients were
evaluated post-treatment.
Longitudinal cohort 40 Patients were divided into two groups. In
study Control Group I, dry socket patients were
treated using conventional approach in
which the socket undergo gentle curettage
followed by irrigation with normal saline
solution. In Test Group II, following
curettage and irrigation, CGF gel was
inserted in the sockets. The patients were
clinically followed up on day 4 and 7, and
14 for pain score and quantification of
granulation tissue in socket.
Longitudinal Cohort 45 Patients were divided into two groups. In
Study. Control Group I, dry socket patients were
treated using conventional approach in
which the socket undergo gentle curettage
followed by irrigation with normal saline
solution. In Test Group II, Low level laser
therapy (LLLT) irradiation was done The
patients were clinically followed up to
day 14 for pain score and quantification
of granulation tissue in socket.
Longitudinal Cohort 60 Sixty patients with one dry socket each
Study were divided into three treatment groups
group I (n = 30), conventional treatment
comprising of gentle socket curettage and
saline irrigation was done. Group II
(n = 15) dry sockets were treated with
CGF and group III (n = 15) sockets were
lased with LLLT. All dry socket patients
were seen at day 0 for treatment and
subsequently followed-up at 4, 7, 14, and
21 days. Pain score, inflammation,
tenderness, and amount of granulation
tissue formation were noted.
Mechanism of Action
Colloidal silver protects against
Streptococcus mutans, Streptococcus sanguis,
and Streptococcus salivarius and the
biofilm created by these bacteria. It is
biocompatible. Antihomotoxic drugs have
anti-inflammatory properties.
Clindamycin has antibacterial action. It
works by inhibiting ribosomal
translocation or protein synthesis.
Rifampicin carries anti-bacterial action
and works by inhibiting bacterial
DNA-dependent RNA synthesis.
CGF is a cocktail of growth factors which
enhances, angiogenesis, epithelialization,
collagen, cellular proliferation and works
at the molecular level to expedite the
healing process and the granulation tissue
formation. It also has anti-inflammatory
effects and modulate healing and pain
control.
LLLT induced biostimulation. It directly
acts on mitochondria and increases the
amount of ATP, which results in
intracellular metabolic changes
promoting proliferation, migration,
epithelialization and it also stimulates
platelet derived growth factor.
Both CGF and LLLT promote angiogenesisi
and granulation tissue formation in dry
socket through biostimulation and
immunomodulation effects. It facilitate
resolution of inflammation and increases
the wound resistance to infection.
A. Kamal, M. Omar and A.R. Samsudin
Study Findings
Combined use of colloidal silver,
Traumeel S which has
anti-inflammatory action and
Polymic showed faster results to
eliminate socket symptoms up to
2-3 days.
Clindamycin showed significant
results in pain relief when
compared with rifampicin and
sterile saline.
Patients in CGF treated Group II
showed earlier granulation tissue
formation and pain relief by day
4, while Control Group sockets
showed delayed in granulation
tissue formation and prolong
pain.
LLLT irradiation is superior to the
conventional treatment approach
in terms of pain relief and
formation of granulation tissue
within 7 days. Promotes faster
healing of dry socket.
CGF treated socket was superior
to LLLT in its ability to generate
75% granulation tissue and
eliminate pain symptom by day 7
post-treatment.
Dentistry Review 2 (2022) 100035
A. Kamal, M. Omar and A.R. Samsudin Dentistry Review 2 (2022) 100035

Table 2
Remedies; medicaments and drugs; blood-based products and technology used for dry socket management between year 2000 and 2020 and their actions in
supporting dry socket healing.

Anti- Anti- Anti- Regenerative: Regenerative:

Pain relieve Antiseptic inflammatory halitosis microbial Sedative Antioxidant Immune modulating Biostimulation

Honey ✔ ✔ ✔ ✔ ✔ ✔ ✔
Turmeric ✔ ✔ ✔ ✔ ✔ ✔
Aloe Vera /Acemannan ✔ ✔ ✔ ✔ ✔ ✔
Vitamin C ✔ ✔ ✔ ✔
Antihomotoxic ✔ ✔ ✔ ✔
Colloidal Silver ✔ ✔ ✔ ✔
/Traumeel
GECB Pastille ✔ ✔
Alvogyl ✔ ✔ ✔ ✔
SaliCept ✔ ✔ ✔ ✔
Zinc Oxide Eugenol ✔ ✔ ✔ ✔
Oil of Clove/eugenol ✔ ✔ ✔ ✔
Anesthetic Gel ✔ ✔
Clindamycin ✔ ✔ ✔
Rifampicin ✔ ✔ ✔
Hydrogen Peroxide ✔ ✔
Ozone Therapy ✔ ✔ ✔
Concentrated Growth ✔ ✔ ✔ ✔
Factor / PRP
Low Level Laser Therapy ✔ ✔ ✔ ✔ ✔ ✔
(LLLT)
Low Intensity-Pulsed ✔ ✔ ✔ ✔
Ultrasound (LIPUS)
PRP: Platelet-rich plasma; GECB: 3%, Guaiacol, 3% Eugenol 1.6% Chlorobutanol

dressings into the socket following ‘re-freshening’ of the wound healing
cascades is controversial with some benefits and drawbacks. This review
shows alvogyl, zinc oxide eugenol, eugenol and Neocone have stood the
test of time as the most popular dry socket dressing. Alvogyl is an alve-
olar hemostatic-analgesic paste with a fibrous consistency and good ad-
hesion from the Penghawar fibers [17]. It is a one-step, self-eliminating
treatment that requires no suture and no special care [18]. Other stud-
ies have observed damage to granulation tissue within the healing dry
socket when intra-socket dressings are plugged in tightly and the possi-
ble cytotoxicity effects of these materials on stem cells when introduced
in high doses, preventing active angiogenesis during the proliferative
phase. [19,20].
Pain control is considered the primary goal of dry socket treatment.
Topical anesthetic gel applied directly onto the dry bare bone seems
to bring immediate and effective relief, but it does not possess other
beneficial antiseptic or cellular healing effects like eugenol and GECB
[21,22]. Zinc oxide eugenol (ZOE) contains eugenol, which has a more
potent analgesic, sedative and anodyne effects compared to alvogyl as
well as having antibacterial properties. Eugenol alone is an allyl chain-
substituted guaiacol, a member of the allylbenzene class of chemical
compounds [23]. It is a colorless, aromatic essential oil extracted from
clove oil, nutmeg or cinnamon, and has a pleasant, spicy, clove-like
scent, much stronger than alvogyl or ZOE. This property contribute to
the euphoric and soothing scent, relieves pain and eliminate halitosis.
Neocone is an antibiotic-analgesic medicament containing polymix-
ine B sulfate, which has an effect on gram negative bacteria; tyrothricin,
and on gram positive bacteria and spirochetes [24]. Its analgesic ef-
fect is provided by combination with tetracaine hydrochloride as local
anesthetic. Colloidal silver is commonly used in general wound dressing
due to its potency against streptococcus mutans, sangius and salivar-
ius. Currently no FDA-approved over the counter or prescription drugs
containing silver that are taken by mouth. However, there are still col-
loidal silver products available as homeopathic remedies and dietary
supplements, in combination with Traumeel that showed good response
in dry socket treatment [15]. Traumeel is an anti-inflammatory cream
containing Cetostearyl alcohol, liquid paraffin, solid paraffin, purified
water, 96% ethanol Manufactured in accordance with German Home-
opathic Pharmacopoeia (HAB) [25]. These are then named as ‘anti-
homotoxic drugs’ which represent combinations of herbal, mineral, bio-
logical, pharmaceutical and/or biopharmaceutical ingredients prepared
homeopathically. Their use by dental practitioners will need careful con-
sultation and advise from relevant drug authorities enquiry services.
Socket irrigation with appropriate solution is necessary allowing a
clean socket bed to begin its healing process. Dental practitioners prefer
antiseptics or antibiotic irrigating solutions that would enhance the pro-
cedure. A list of irrigant solutions from the literature review is also listed
in Table 2, of which hydrogen peroxide seems to be among the oldest
irrigant use [26]. This is based on the historical account of hydrogen
peroxide usage in managing general surgery and orthopedic wounds. It
serves very well in dental surgery too where its strong oxidizing agent
releases oxygen and kill anaerobes while its foaming action causes ooz-
ing and bubbling out of food debris from the dry socket site. However,
hydrogen peroxide is caustic, and it has been largely replaced with
chlorhexidine gluconate 0.2% or 0.12%. Unfortunately, many wound
healing studies have shown the drawbacks of potent antiseptics that
damages the development of granulation tissue formation [27].
Antibiotic irrigant solutions such as clindamycin, Rifampicin and
Chlortetracycline is clinically effective but controversial due to such
practices of low dose topical antibiotics currently raises the current
global issue of emerging antibiotic resistance in the community, and
the dental practitioner needs to be aware of these implications [16,28].
This treatment caused significant change in the microbiota of the ex-
traction socket by decreasing the number of anaerobes while increasing
the amount of multi-resistant microorganisms [29].
Ozone, represented as O3 , is a naturally occurring gaseous molecule
of triatomic allotrope of oxygen [30]. In dental surgery, ozonated wa-
ter was used to promote homeostasis, enhance local oxygen supply and
inhibit bacterial proliferation [31]. Anum RK et al. did a comparative
study between ozone gel and alvogyl in the treatment of dry socket
[32]. They found Ozone to be superior to alvogyl based on assessment
of the pain symptoms. The regenerative capacity of Ozone therapy is
reflected in its ability to stimulate the expression of vascular endothe-
lial growth factor (VEGF), transforming growth factor-𝛽 (TGF-𝛽), and
platelet-derived growth factor (PDGF) proteins in wound healing [33].
Ozone therapy is safe, non-toxic and the technology is environmentally
friendly.

6
A. Kamal, M. Omar and A.R. Samsudin
In 1999 the U.S. Food and Drug Administration (FDA) ruled that
these colloidal silver products were not considered safe or effective. Col-
loidal silver products marketed for medical purposes or promoted for
unproven uses are now considered "misbranded" under the law with-
out appropriate FDA approval as a new drug. There are currently no
FDA-approved over-the-counter or prescription drugs containing silver
that are taken by mouth. However, there are still colloidal silver prod-
ucts being sold as homeopathic remedies and dietary supplements. In
1999 the U.S. Food and Drug Administration (FDA) ruled that these col-
loidal silver products were not considered safe or effective. Colloidal sil-
ver products marketed for medical purposes or promoted for unproven
uses are now considered "misbranded" under the law without appropri-
ate FDA approval as a new drug. There are currently no FDA-approved
over-the-counter or prescription drugs containing silver that are taken
by mouth. However, there are still colloidal silver products being sold
as homeopathic remedies and dietary supplements In 1999 the U.S.
Food and Drug Administration (FDA) ruled that these colloidal silver
products were not considered safe or effective. Colloidal silver prod-
ucts marketed for medical purposes or promoted for unproven uses are
now considered "misbranded" under the law without appropriate FDA
approval as a new drug. There are currently no FDA-approved over-
the-counter or prescription drugs containing silver that are taken by
mouth. However, there are still colloidal silver products being sold as
homeopathic remedies and dietary supplements In 1999 the U.S. Food
and Drug Administration (FDA) ruled that these colloidal silver products
were not considered safe or effective. Colloidal silver products marketed
for medical purposes or promoted for unproven uses are now consid-
ered "misbranded" under the law without appropriate FDA approval as
a new drug. There are currently no FDA-approved over-the-counter or
prescription drugs containing silver that are taken by mouth. However,
there are still colloidal silver products being sold as homeopathic reme-
dies and dietary supplements
With the advent of tissue engineering concepts and greater under-
standing in molecular wound healing, current approach in dry socket
management is looking at regenerative strategies in dry socket healing
[34]. The interplay among stem cell, growth factors and cytokines and
chemokines become the key players in this regenerative approach to
dry socket management. Recent refine techniques in safe blood prod-
ucts preparation has allowed feasibility of such treatment option in the
dental office, as demonstrated in this review when employing Platelet
Rich Plasma, Platelet Rich Fibrin and Concentrated Growth Factors
[35,36,37]. Regenerative treatment approach employs the power of the
cell for healing initiatives through two biological mechanisms; immuno-
biomodulation and mechanotransduction.
Delivery of blood-based products into dry socket wound potentiates
the healing capacity [35]. Platelet-Rich Plasma (PRP), Platelet-Rich Fib-
rin (PRF) and Concentrated Growth Factors (CGF) are generated from
the patient’s own blood and formed a concentrated cocktail of growth
factors that determine the fate of cells during the proliferative stage of
wound healing. The growth factor proteins provide the necessary signals
for cell proliferation and differentiation, including fibroblast growth fac-
tor and vascular endothelial growth factor that induces angiogenesis and
help lay down fibro-vascular granulation tissue on the dry socket wound
bed. Rapid and healthy granulation tissue formation is key to wound
healing strategy [36,37].
Other technologies such as Low Level Laser Therapy (LLLT) may also
be applied to dry sockets to achieve photo-biostimulation of the healing
cells during the proliferative stage, producing regenerative effects sim-
ilar to growth factor stimulation [38,39]. LLLT has demonstrated supe-
rior results compared to alvogyl alone in a prospective randomized clini-
cal trial [40]. Its efficacy in pain control was further highlighted by Kaya
GS et al. when they compared LLLT with Alvogyl and SaliCept patch
among 104 dry socket patients, and found LLLT was superior to both
conventional medicaments. They attributed their results to the mecha-
nism played by LLLT at the molecular level, enhancing immunomodu-
lation and healing cells proliferation [41]. When LLLT is compared to
7
Dentistry Review 2 (2022) 100035
CGF, Aqsa et al. found that LLLT showed a delay of 4 days compared
to CGF in granulation tissue formation and pain control. In their study,
CGF treated socket healing was superior to LLLT in its ability to gener-
ate 75% granulation tissue and eliminate pain symptom completely by
day 7 post-treatment. They concluded that CGF is superior to LLLT in
its capacity to generate granulation tissue and eliminate pain symptom
within the first seven days of treatment and enabling early return to
normal oral functions [37].
Healing potential of the tooth socket may be enhanced through
mechano-transduction effects following application of Low Intensity
Pulsed Ultrasound (LIPUS). Ultrasound waves transmit mechanical en-
ergy on extracellular matrix that in turn stimulates integrin to translate
these extracellular physical signals into intracellular downstream bio-
chemical signals. In a single blinded study, Anil et al. compared the ef-
fects of LLLT and LIPUS on tooth extraction pain control and they found
that the LIPUS Group showed significantly lower pain scores compared
to the LLLT Group [38]. Signal transduction using LIPUS has also been
shown to enhance early bony healing in tooth socket around dental im-
plants [42].
5. Conclusions
Dry socket is a common dental complication that has been subjected
to diverse treatment options with varying outcome. Gentle curettage
followed by socket irrigation under local anesthesia is the only recom-
mended invasive procedure in this review. Products containing anal-
gesic and sedative properties that support pain relief, such as alvogyl,
ZOE and oil of clove are most effective in the early phase of dry socket
intervention while products that possess anti-inflammatory properties
such as honey, turmeric, colloidal silver and CECB pastille took a bit
longer to provide relief. Granulation tissue formation is key to healing
of dry socket. Products containing antimicrobials and antiseptics protect
granulation tissue health and help the socket to heal. Earlier treatment
approach mainly focuses on pain control, prevention of infection and re-
solving inflammation while current therapeutic strategies modulate an-
giogenesis, granulation tissue formation and tissue regenerative targets
in dry socket management. These later armamentariums include usage
of blood-based products such as platelet rich plasma and concentrated
growth factors; LLLT and LIPUS that are able to initiate and propagate
fibro-vascular tissue invasion into the socket and complete the initial
phase of healing process. While evidence suggest a comprehensive ap-
proach that combine pain relief and sedation, anti-inflammatory and
antioxidant agents and granulation tissue regeneration strategies that
may be packaged together to achieve the best outcome, there is still
no consensus on the appropriate treatment of dry socket. Although cur-
rent evidence supports a regenerative approach for dry socket healing,
the old treatment modality controlling infection, inflammation and pain
prevails.
Funding
This research did not receive any specific grant from funding agen-
cies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
None.
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