›First-line non-opioid analgesia
›Ibuprofen
›Ibuprofen 400 to 600 mg PO every 6 hours with food
›Step down to 400 mg every 6 hours as pain eases and stop when the socket is comfortable
›Maximum 2400 mg in 24 hours
›Avoid if eGFR below 30, active peptic ulcer disease, decompensated heart failure, or pregnancy at 20 weeks or beyond
›Acetaminophen (paracetamol)
›Acetaminophen 1 g PO every 6 hours
›Maximum 4 g in 24 hours
›Maximum 3 g in 24 hours in hepatic impairment, chronic heavy alcohol use, low body weight, or frailty
›Combine the two on a fixed schedule
›Alternating scheduled ibuprofen and acetaminophen controls dental pain better than either drug alone or than a codeine combination
›Reserve opioids for pain that breaks through the scheduled combination
›If an NSAID is contraindicated
›Acetaminophen 1 g PO every 6 hours, maximum 4 g in 24 hours, as the analgesic backbone
›Naproxen 500 mg PO every 12 hours, maximum 1000 mg in 24 hours, is an alternative NSAID but shares every class caution and is not gentler on the kidney or stomach
›Add a short opioid course only if pain remains severe despite the above
›Short opioid course when required
›Hydrocodone 5 mg with acetaminophen 325 mg, 1 tablet PO every 6 hours as needed, maximum 6 tablets in 24 hours, counting this acetaminophen toward the 4 g daily limit
›Limit to 2 to 3 days and the smallest quantity
›Co-prescribe a stimulant laxative such as senna 8.6 to 17.2 mg PO at night
›Tramadol 50 mg PO every 6 hours, maximum 400 mg in 24 hours, is an option but lowers the seizure threshold and is unsafe with SSRIs and in children under 12
›Codeine 30 mg with acetaminophen 300 to 500 mg PO every 6 hours is a common formulation but a poor choice — unpredictable CYP2D6 metabolism, ineffective in poor metabolisers, and dangerous in ultrarapid metabolisers, in children under 12, and in breastfeeding
›Regional nerve block for acute severe pain
›Bupivacaine
›Bupivacaine 0.5% with epinephrine 1:200,000, 1.8 to 3.6 ml, for an inferior alveolar and long buccal block
›Onset 5 to 10 minutes and duration up to 8 hours
›Maximum 3 mg/kg with epinephrine, not exceeding 175 mg
›Aspirate before injection; an intravascular injection risks local anaesthetic systemic toxicity
›Lidocaine
›Lidocaine 2% with epinephrine 1:100,000, 1.8 to 3.6 ml, as a faster, shorter alternative
›Maximum 7 mg/kg with epinephrine, not exceeding 500 mg
›A block buys time for dressing placement and lets the patient eat before discharge; it does not treat the socket
Antiseptic rinses and supportive wound care
›Chlorhexidine
›Chlorhexidine gluconate 0.12% oral rinse, 15 ml swished for 30 seconds twice daily, and not within 30 minutes of toothpaste
›The strongest evidence is for perioperative use to prevent alveolar osteitis; as treatment it is a reasonable adjunct to irrigation and dressing
›Expect transient taste alteration and reversible tooth staining with prolonged use
›Warm saline rinses
›One level teaspoon of salt in 250 ml of warm water, used gently 4 to 6 times daily and after meals, starting 24 hours after the original extraction
›Gentle rinsing only — vigorous swishing can dislodge a forming clot in an adjacent healing socket
›Local heat and general measures
›An external warm compress to the cheek for comfort
›A soft, cool, high-calorie diet with adequate hydration
›Avoid smoking and alcohol until the socket has healed
Antibiotics — limited role
›Antibiotics are not indicated for uncomplicated alveolar osteitis
›Alveolar osteitis is a localised disorder of clot fibrinolysis, not a soft-tissue infection
›Antibiotics do not speed resolution of the pain and add resistance and adverse-effect risk
›Perioperative antibiotics reduce incidence but are not a treatment for the established condition
›Reserve systemic antibiotics for
›Spreading cellulitis, fever, lymphadenopathy, or systemic upset
›A purulent socket with surrounding induration
›Immunocompromise, poorly controlled diabetes, or suspected early osteomyelitis
›Oral regimens when antibiotics are justified
›Amoxicillin-clavulanate 875/125 mg PO every 12 hours for 5 to 7 days
›Amoxicillin 500 mg PO every 8 hours if a narrower agent is preferred, with metronidazole 400 mg PO every 8 hours added for anaerobic cover
›Penicillin allergy: azithromycin 500 mg PO on day 1 then 250 mg PO daily for 4 days, or clindamycin 300 mg PO every 6 hours
›Counsel on Clostridioides difficile risk with clindamycin
›Before azithromycin, check for other QT-prolonging drugs and avoid pairing it with an antiemetic such as ondansetron 4 mg; obtain a baseline ECG if there is cardiac history or multiple QT-prolonging agents
›Parenteral therapy for admitted deep-space infection
›Ampicillin-sulbactam 3 g IV every 6 hours, or ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 8 hours
›Penicillin anaphylaxis: clindamycin 600 to 900 mg IV every 8 hours
›Narrow to culture and sensitivity results once available
When treatment is not working
›Reassess at 48 to 72 hours if pain has not improved
›Confirm the dressing is still in place and correctly positioned
›Confirm the analgesic plan is actually being taken at effective doses
›Re-examine for pus, swelling, progression of trismus, or lip numbness
›Broaden the workup
›Panoramic radiograph, then CT if it is negative, for a retained root, sequestrum, fracture, or osteomyelitis
›Review the antiresorptive and radiotherapy history again for osteonecrosis
›Reconsider neuropathic pain, temporomandibular dysfunction, otitis, and sinusitis
›Escalate care
›Refer to oral and maxillofacial surgery for examination under anaesthesia and curettage if a sequestrum or necrotic bone is confirmed
›Admit for IV analgesia and antibiotics if infection is now evident
›Arrange a pain-service review for refractory or neuropathic pain