Cochrane · intervention · CD006968

Local interventions for the management of alveolar osteitis (dry socket)

Daly, BJM, Sharif, MO, Jones, K, et al. · Cochrane Database of Systematic Reviews · 2022 · Cochrane Library

Oral Health Oral and maxillofacial surgery3 versionsAMSTAR 2: not assessed

Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.

Questions

current version

GRADE rated

No studies

Included studies

as reported

No studies 3 · 5.8%Ungraded 44 · 84.6%Very low 2 · 3.8%Low 1 · 1.9%Moderate 2 · 3.8%High 0 · 0%

Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.

Review question

Element	Planned (methods)	Found (results)
Population	Adults over 18 years who had undergone an extraction (routine or more complex surgical) of one or more permanent teeth under local anaesthesia (with or without sedation) or general anaesthesia, or who had developed dry socket post-extraction; smokers included; immunocompromised participants or those with comorbidities/medical conditions affecting oral healing excluded	6771 participants across 49 trials; 39 prevention trials (6219 participants) and 10 treatment trials (552 participants); all but five studies involved extraction of third molars
Intervention	Any type of local intervention used for the prevention or treatment of dry socket (antiseptic rinses, intrasocket gels/medicaments, tissue patches, autologous platelet concentrates, obtundent dressings); concomitant pain medication allowed if equal between groups; systemic antibiotics and surgical techniques excluded (covered by separate reviews)	Chlorhexidine rinse 0.12%/0.2% (n=6); Chlorhexidine gel 0.2% (n=7); Chlorhexidine gel vs rinse (n=2); Platelet rich plasma (n=2); Honey (n=1); Gaseous ozone (n=1); Chlorhexidine monoject irrigation (n=1); Herbal mouthrinse (n=1); Tap water irrigation (n=1); Povidone iodine 1% (n=1); Oral tissue patch (n=1); Chlorhexidine gel 1% vs 0.2% (n=1); Acellular dermal matrix (n=2); Iodine tampon (n=1); Platelet rich fibrin (n=1); Bovine fibroblast growth factor (n=1); Metronidazole gel (n=1); Apernyl (n=1); Tranexamic acid (n=1); P-hydroxybenzoic acid (n=1); Heal-all tissue patch (n=1); Artemisia desertorum spreng Shahaosan/Yunnan (n=1); Zinc oxide eugenol/Alvogyl (n=2); Neocone (n=1); Topical anaesthetic gel (n=1); Plasma rich in growth factors PRGF (n=1); Advanced platelet rich fibrin (n=1); Metronidazole (n=1); Alvogyl vs SaliCept/no treatment (n=1); Alvogyl vs platelet rich fibrin (n=1)
Comparison	A different local intervention; placebo; or no treatment	Placebo/no treatment; Chlorhexidine rinse; Chlorhexidine gel; Saline; Eugenol; Alvogyl; Zinc oxide eugenol; Control
Outcomes	Prevention primary: proportion of participants presenting with a dry socket within 1 week post-treatment. Treatment primary: time to heal dry socket and socket healing indices; pain (severity and duration); swelling; limitation of chewing or swallowing; fever. Secondary: quality of life; patient satisfaction; costs. Adverse effects reported in a table	Presence of dry socket (n=39 prevention); Pain VAS (treatment; n=5+); Time to initial pain relief and complete resolution of pain (n=1); Duration of treatment (n=1); Healing (n=2); Exposed bone (n=1); Adverse events (tabulated)
Study designs	Randomised controlled trials only (split-mouth/cross-over designs allowed for prevention)	RCT (n=49)
Timing	Clinically important time points: at the end of the intervention and during follow-up of up to 2 weeks	Prevention median 7 days follow-up; treatment pain assessed at 48 hours to day 7

Search date: 2021-09. Databases: Cochrane Oral Health's Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE Ovid; Embase Ovid; ClinicalTrials.gov; trial registries

Questions and results

Show all 3 versions

Chlorhexidine rinse (0.12% and 0.2%, pre- and post-extraction) vs Placebo or no treatment

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

2 questions

Outcome	Effect	Evidence	Status / GRADE
Adverse events Follow-up: median 7 days same question in other reviews	3 trials reported no adverse events. 1 study reported adverse events (alterations in taste, bad taste, staining) in 24/62 in chlorhexidine group versus 0/40 in placebo group, Peto OR = 8.42 (95% CI 3.31 to 21.39). A…	6 studies	Ungraded
Presence of dry socket Follow-up: median 7 days same question in other reviews	OR 0.38 [0.25, 0.58] 300 per 1000 (high); 50 per 1000 (moderate); 10 per 1000 (low) vs 140 per 1000	6 studies · 1547 participants	Moderate Downgraded: risk of bias

Chlorhexidine gel (0.2%, intrasocket) vs Placebo or no treatment

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

2 questions

Outcome	Effect	Evidence	Status / GRADE
Adverse events Follow-up: median 7 days same question in other reviews	No adverse events were reported. Six trials (673 participants) reported no adverse events from the use of chlorhexidine gel; one study (Rubio-Palau 2015) reported gastrointestinal discomfort (30, 18%), dizziness (10,…	7 studies	Ungraded
Presence of dry socket Follow-up: median 7 days same question in other reviews	OR 0.44 [0.27, 0.71] 300 per 1000 (high); 50 per 1000 (moderate); 10 per 1000 (low) vs 159 per 1000	7 studies · 753 participants	Moderate Downgraded: risk of bias

Chlorhexidine gel (0.2%, intrasocket) vs Chlorhexidine rinse (0.12%)

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

2 questions

Outcome	Effect	Evidence	Status / GRADE
Adverse events Follow-up: median 7 days same question in other reviews	No adverse events were reported in these two trials (Abu-Mostafa 2015; Hita-Iglesias 2008).	2 studies	Ungraded
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.74 [0.46, 1.20] 300 per 1000 (high); 50 per 1000 (moderate); 10 per 1000 (low) vs 222 per 1000	2 studies · 383 participants	Low Downgraded: risk of bias, imprecision

Chlorhexidine rinse (0.2%) pre- and post-extraction vs Chlorhexidine rinse (0.2%) post-extraction only

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.58 [0.15, 2.17]	1 study · 99 participants	Ungraded

Acellular dermal matrix vs Control

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

2 questions

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.15 [0.04, 0.67]	1 study · 300 participants	Ungraded
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.07 [0.01, 0.50]	1 study · 400 participants	Ungraded

Glucocorticosteroid antibiotic agent (intrasocket) vs Normal saline

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	OR (exact) 0 [0, 2.42]	1 study · 19 participants	Ungraded

Clindamycin phosphate antibiotic solution patch vs Saline patch

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	OR (exact) 0 [0, 0.69]	1 study · 86 participants	Ungraded

Metronidazole gel (25%, intrasocket) vs Placebo gel

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.53 [0.23, 1.20]	1 study · 302 participants	Ungraded

Apernyl (acetylsalicylic acid pellet) vs Placebo

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.25 [0.03, 2.16]	1 study · 100 participants	Ungraded

Platelet rich plasma vs Placebo or no treatment

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

2 questions

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.51 [0.19, 1.33] 300 per 1000 (high); 50 per 1000 (moderate); 10 per 1000 (low) vs 153 per 1000	2 studies · 127 participants	Very low Downgraded: risk of bias, imprecision
Adverse events Follow-up: median 7 days same question in other reviews	No adverse events were reported in these two trials.	2 studies	Ungraded

Tranexamic acid (AMCA cones) vs Placebo (lactose cones)

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.67 [0.30, 1.48]	1 study · 120 participants	Ungraded

P-hydroxybenzoic acid vs Placebo

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.08 [0.00, 1.37]	1 study · 45 participants	Ungraded

Heal-all tissue patch vs No treatment

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.08 [0.00, 1.32]	1 study · 80 participants	Ungraded

Artemisia desertorum spreng (Shahaosan) vs Placebo

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.13 [0.02, 1.02]	1 study · 188 participants	Ungraded

Artemisia desertorum spreng (Yunnan) vs Placebo

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.28 [0.06, 1.28]	1 study · 182 participants	Ungraded

Artemisia desertorum spreng (Shahaosan) vs Artemisia desertorum spreng (Yunnan)

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.47 [0.04, 5.06]	1 study · 178 participants	Ungraded

Topical anaesthetic gel (prilocaine-lidocaine) vs Eugenol

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

1 question

Outcome	Effect	Evidence	Status / GRADE
Pain at 48 hours (VAS 0-10) 48 hours same question in other reviews	MD -0.20 [-1.87, 1.47]	1 study · 35 participants	Ungraded

Metronidazole (intrasocket) vs Placebo

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

1 question

Outcome	Effect	Evidence	Status / GRADE
Duration of treatment (days) same question in other reviews	MD -3.17 [-5.30, -1.04]	1 study · 55 participants	Ungraded

Alvogyl vs No treatment

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

1 question

Outcome	Effect	Evidence	Status / GRADE
Pain (VAS) same question in other reviews	Alvogyl versus No treatment (Kaya 2011): data not usable (medians presented with error bars). Text reports differences in clinical signs and symptoms between control and all 3 treatment groups significant (P<0.05) at…	1 study	Ungraded

SaliCept (acemannan hydrogel) vs No treatment

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

1 question

Outcome	Effect	Evidence	Status / GRADE
Pain (VAS) same question in other reviews	SaliCept (acemannan hydrogel) versus No treatment (Kaya 2011): data not usable (medians presented with error bars). Text reports differences in clinical signs and symptoms between control and all 3 treatment groups…	1 study	Ungraded

Alvogyl vs SaliCept (acemannan hydrogel)

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

1 question

Outcome	Effect	Evidence	Status / GRADE
Pain (VAS) same question in other reviews	Alvogyl versus SaliCept (acemannan hydrogel) (Kaya 2011): data not usable (medians presented with error bars). Text reports differences in clinical signs and symptoms between control and all 3 treatment groups…	1 study	Ungraded

Honey (Manuka, topical) vs Chlorhexidine rinse (0.2%)

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 1.32 [0.41, 4.22]	1 study · 100 participants	Ungraded

Gaseous ozone vs Placebo or control

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.20 [0.02, 1.61]	1 study · 60 participants	Ungraded

Chlorhexidine 0.2% socket irrigation (monoject syringe) vs Chlorhexidine 0.2% mouthrinse

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.26 [0.09, 0.71]	1 study · 95 participants	Ungraded

Herbal mouthrinse vs Chlorhexidine 0.2% mouthrinse

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.50 [0.05, 5.17]	1 study · 50 participants	Ungraded

Tap water irrigation (monoject syringe) vs No rinsing

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.36 [0.18, 0.74]	1 study · 336 participants	Ungraded

Povidone iodine 1% vs Control

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.36 [0.14, 0.98]	1 study · 189 participants	Ungraded

Oral tissue patch vs Placebo or control

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.13 [0.02, 0.98]	1 study · 200 participants	Ungraded

Chlorhexidine gel 1% vs Chlorhexidine gel 0.2%

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.55 [0.15, 2.05]	1 study · 88 participants	Ungraded

Iodine tampon vs Saline irrigation (monoject syringe)

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	Iodine tampon versus rinsing with saline in a syringe (Tuk 2019): Iodine tampon 0/54 Monoject with saline 0/54; no events (effect not estimable)	1 study · 108 participants	Ungraded

Platelet rich fibrin vs Control

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.44 [0.15, 1.35]	1 study · 100 participants	Ungraded

Recombinant bovine fibroblast growth factor gel vs Control

Population: Adults (>18 years) having permanent tooth extraction (predominantly mandibular third molars)

1 question

Outcome	Effect	Evidence	Status / GRADE
Presence of dry socket Follow-up: median 7 days same question in other reviews	RR 0.10 [0.01, 0.76]	1 study · 160 participants	Ungraded

Zinc oxide eugenol vs Alvogyl (old formulation)

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

5 questions

Outcome	Effect	Evidence	Status / GRADE
Swelling same question in other reviews	No studies reported this outcome	0 studies	No studies
Limitation of chewing or swallowing same question in other reviews	No studies reported this outcome	0 studies	No studies
Healing same question in other reviews	Healing: 2 studies (Faizel 2015; Supe 2018) used different healing outcomes and could not be combined; Alvogyl appeared to heal faster than zinc oxide eugenol. Supe 2018: delayed (non-healed after 10 days) 2/25 Alvogyl…	2 studies	Ungraded
Pain (VAS 0-10) Day 7 same question in other reviews	MD 1.40 [1.04, 1.75] Alvogyl: median 1.7 (VAS 0-10) vs Zinc oxide eugenol: 1.04 higher to 1.75 higher	2 studies · 80 participants	Very low Downgraded: risk of bias, inconsistency
Fever same question in other reviews	No studies reported this outcome	0 studies	No studies

Neocone vs Alvogyl

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

2 questions

Outcome	Effect	Evidence	Status / GRADE
Time to initial pain relief (minutes) Initial pain relief same question in other reviews	MD 9.87 [9.12, 10.63]	1 study · 78 participants	Ungraded
Time to complete resolution of pain (days) Complete resolution of pain same question in other reviews	MD -1.62 [-1.86, -1.38]	1 study · 78 participants	Ungraded

Neocone vs Zinc oxide eugenol

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

2 questions

Outcome	Effect	Evidence	Status / GRADE
Time to complete resolution of pain (days) Complete resolution of pain same question in other reviews	MD -3.79 [-4.04, -3.54]	1 study · 78 participants	Ungraded
Time to initial pain relief (minutes) Initial pain relief same question in other reviews	MD -7.77 [-8.86, -6.68]	1 study · 78 participants	Ungraded

Alvogyl vs Zinc oxide eugenol

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

2 questions

Outcome	Effect	Evidence	Status / GRADE
Time to complete resolution of pain (days) Complete resolution of pain same question in other reviews	MD -2.17 [-2.37, -1.97]	1 study · 78 participants	Ungraded
Time to initial pain relief (minutes) Initial pain relief same question in other reviews	MD -17.64 [-18.76, -16.52]	1 study · 78 participants	Ungraded

Plasma rich in growth factors (PRGF) vs Alvogyl

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

2 questions

Outcome	Effect	Evidence	Status / GRADE
Exposed bone (present versus absent) Day 7 (also day 3) same question in other reviews	PRGF versus Alvogyl (King 2018), exposed bone (% patients): day 3 PRGF 9.1% vs Alvogyl 9.1%; day 7 PRGF 0% vs Alvogyl 22.7% (P<0.05 at day 7) Alvogyl: 22.7% (day 7); 9.1% (day 3) vs PRGF: 0% (day 7); 9.1% (day 3)	1 study · 44 participants	Ungraded
Pain (VAS cm) Day 7 (also day 3) same question in other reviews	MD -0.40 [-1.77, 0.97]	1 study · 44 participants	Ungraded

Advanced platelet rich fibrin (A-PRF) vs Control (no treatment)

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

1 question

Outcome	Effect	Evidence	Status / GRADE
Pain (VAS cm) Days 1-7 (day 7 shown) same question in other reviews	MD -3.60 [-4.00, -3.20]	1 study · 40 participants	Ungraded

Alvogyl vs Platelet rich fibrin

Population: Adults (>18 years) with established dry socket following permanent tooth extraction

1 question

Outcome	Effect	Evidence	Status / GRADE
Pain same question in other reviews	Alvogyl versus platelet rich fibrin (Keshini 2020): single study (30 participants); no usable pooled estimate extracted	1 study · 30 participants	Ungraded