Clinical Practices and Attitudes of Dental Practitioners in Managing Alveolar Osteitis: A Cross-Sectional Survey in Yemen

Abstract

Background

Alveolar osteitis (AO) is a common and challenging complication after tooth extraction, with significant variability in clinical practices despite existing guidelines. This study evaluated the practices and attitudes of dental practitioners regarding AO prevention and management and identified factors associated with evidence-based preventive practices in Sana’a, Yemen.

Methods

A cross-sectional survey was conducted among 412 dental practitioners using a validated questionnaire. Data on demographic characteristics, preventive and management practices, and attitudes were collected. The composite prevention practice score (PS), evidence-based management score (EBMS), and non-evidence-based practice score (NEPS) demonstrated good reliability (Cronbach’s α = 0.73–0.84). Descriptive statistics, independent t-tests, one-way ANOVA, Pearson’s chi-square test, and multivariable logistic regression were performed. Statistical significance was set at p < 0.05.

Results

The sample was predominantly young (56.8% aged 24–29 years), male (63.1%), and in early career (47.3% with <5 years’ experience). The mean composite scores were as follows: PS, 4.09 ± 0.63; EBMS, 4.17 ± 0.67; and NEPS, 2.77 ± 0.89. Notably, 17.2% of dental practitioners “always” prescribed routine antibiotic prophylaxis, and 25.5% “always” performed additional curettage. Independent predictors of high prevention practices (defined as PS ≥ median 4.13) included 11–15 years of practice (aOR = 1.87, 95% CI: 1.01–3.46), >20 extractions weekly (aOR = 2.44, 95% CI: 1.10–5.41), frequent surgical extractions (aOR = 1.98, 95% CI: 1.10–3.57), continuing education (aOR = 2.19, 95% CI: 1.32–3.63), positive feasibility attitudes (aOR = 1.55, 95% CI: 1.17–2.06), and greater confidence (aOR = 1.41, 95% CI: 1.07–1.87).

Conclusion

Dental practitioners in Sana’a, Yemen, demonstrate moderate-to-good adherence to evidence-based AO care, but a minority employ non-evidence-based practices, particularly routine antibiotics and curettage. Continuing education, positive attitudes, and confidence are associated with better practices. Given the cross-sectional design, causal inferences are precluded. These findings support targeted educational interventions, with interventional studies needed to confirm their effectiveness.

Introduction

Alveolar osteitis (AO), commonly termed the “dry socket”, represents one of the most frequent and distressing postoperative complications following tooth extraction.1,2 Clinically, it is defined by the onset of severe pain within two to four days post-extraction, accompanied by partial or complete loss of the blood clot from the extraction socket and exposure of the underlying alveolar bone.3,4 Although AO is rarely life-threatening, its consequences are substantial: it causes marked patient discomfort, delays normal healing, necessitates additional clinic visits, inflates healthcare costs, and diminishes patient satisfaction.5

The reported incidence of AO varies considerably and is influenced by extraction type, patient-related risk factors, surgical technique, and operator experience. A recent systematic review and meta-analysis encompassing over 41,000 extractions estimated a pooled prevalence of 6.7% (95% CI: 4.6–9.1%) following impacted mandibular third molar removal, although substantial heterogeneity across studies was detected.2 Established risk factors include tobacco smoking, poor oral hygiene, oral contraceptive use, a history of previous AO, traumatic extraction, and operator inexperience.3,6,7

Despite the availability of evidence-based clinical recommendations, substantial variability in AO prevention and management persists. High-level evidence supports preventive measures such as minimizing surgical trauma, providing standardized postoperative instructions, advising smoking cessation, and utilizing chlorhexidine mouthwash or gel.8,9 A 2025 scoping review confirmed that more than 70% of studies reported favorable outcomes with chlorhexidine application in oral wound healing, particularly for AO prevention following third molar extractions.10 Conversely, practices such as routine antibiotic prophylaxis and indiscriminate socket curettage lack robust evidence and may contribute to antimicrobial resistance or delayed healing.11 A recent meta-analysis confirmed that while metronidazole can reduce the incidence of AO, routine perioperative antibiotic use is not recommended for healthy patients.12

Several recent surveys have explored the knowledge, attitudes, and practices of dental professionals regarding AO. A 2025 cross-sectional study among dental interns in Saudi Arabia and Egypt reported moderate knowledge levels but significant gaps in evidence-based management, particularly concerning antibiotic prescribing.13 Another study among final-year dental students revealed low self-perceived confidence in managing complications such as dry sockets, highlighting deficiencies in undergraduate training.14 Similarly, a 2024 assessment of continuing education needs in dental traumatology identified substantial clinical preparedness gaps among interns.15 However, large-scale surveys focusing on practicing dentists in low- and middle-income countries—particularly those employing validated instruments to quantitatively assess prevention and management practices alongside attitudes—remain conspicuously scarce. To our knowledge, no previous study in Yemen has comprehensively evaluated AO practices using a validated, multi-domain instrument. This study therefore addresses a critical evidence gap by providing quantitative, generalizable data from a resource-constrained setting where evidence-based guidelines are inconsistently disseminated. The Yemeni context is of particular interest given the unique challenges of practising in a resource-constrained setting with limited access to continuing professional development and evidence-based guidelines.

Accordingly, this study was designed to (1) comprehensively describe self-reported prevention and management practices for AO among dental practitioners in Sana’a, Yemen; (2) assess their attitudes toward AO prevention; (3) examine demographic and professional factors associated with evidence-based practices; and (4) identify independent predictors of high prevention practice scores.

Methods

Study Design and Setting

This cross-sectional, questionnaire-based survey was conducted among dental practitioners in Sana’a, Yemen, between March and April 2026. The study received ethical approval from the Research Ethics Committee of the Faculty of Dentistry, Ibn Al-Nafis University for Medical Sciences, Sana’a, Yemen (Approval No. 206, dated 15 February 2026). The study was conducted in full accordance with the Declaration of Helsinki.16 Written informed consent was obtained from all participants prior to data collection.

Participants and Eligibility Criteria

Dental practitioners (including general dentists and specialists) practising in Sana’a at the time of data collection were eligible for inclusion if they met the following criteria: (1) actively licensed to practice dentistry by the Yemeni Dental Association; (2) currently performing tooth extraction procedures in their routine clinical practice; and (3) willing and able to provide written informed consent. Participants were excluded if they (1) were dental students or interns (who lacked independent clinical practice experience); (2) did not routinely perform tooth extractions in their current clinical role; (3) completed the questionnaire with >10% missing items; or (4) declined to provide written informed consent. The participant recruitment process is illustrated in Figure 1.

Figure 1.

Participant recruitment process.

Sample Size Determination

The sample size was calculated via the single proportion formula: n = Z² × P(1-P)/d², assuming a 50% expected prevalence of evidence-based prevention practices among dental practitioners (as a conservative estimate to maximize sample size), a 95% confidence level (Z = 1.96), and a 5% margin of error (d = 0.05). This calculation yielded a minimum required sample of 384 participants. To account for an anticipated 15% incomplete or invalid response rate, a total of 450 questionnaires were distributed. A final sample of 412 complete responses was obtained, exceeding the minimum requirement and providing sufficient statistical power for subgroup analyses and multivariate regression, which is consistent with similar recent surveys.13,17

Questionnaire Development, Validity, Reliability, and Pilot Testing

The questionnaire was developed through a systematic literature review of evidence-based guidelines for AO prevention and management.5,17,18 An English version was translated into Arabic and back-translated by two independent bilingual translators. Content validity was assessed by a panel of five experts (two oral surgeons, two general dentists, and one epidemiologist), who rated each item independently on a 4-point scale; the item-level content validity index (I-CVI) ranged from 0.80–1.00, and the scale-level average CVI (S-CVI/Ave) was 0.92. Disagreements were resolved through consensus. Face validity was confirmed with 15 practising dentists, leading to minor wording adjustments. A pilot test on 30 dental practitioners assessed feasibility and clarity; the mean completion time was 12 minutes, with no problematic items identified. Reliability was assessed via Cronbach’s α: 0.84 for the prevention practice score, 0.81 for the evidence-based management score, and 0.73 for the non-evidence-based practices score. Test-retest reliability in a subset of 30 participants (two-week interval) yielded intraclass correlation coefficients (ICCs) of 0.82, 0.79, and 0.76, respectively, indicating good temporal stability. Exploratory Factor Analysis (EFA) was performed using principal axis factoring with Promax rotation (given expected correlations between subscales). The Kaiser-Meyer-Olkin (KMO) measure was 0.82, and Bartlett’s test of sphericity was significant (p < 0.001), confirming sampling adequacy. Factor extraction was based on eigenvalue >1 and scree plot inspection. Items with factor loadings <0.40 or cross-loadings >0.30 were excluded. Three distinct factors emerged, corresponding to the PS, EBMS, and NEPS domains, explaining 61.4% of the total variance. The detailed steps of questionnaire development and validation are summarized in Figure 2.

Figure 2.

Sequential steps in questionnaire development.

Questionnaire Structure

The final questionnaire comprised 30 questions organized into four parts. The following demographic and professional characteristics (8 items) were collected: age, sex, years of clinical practice, highest dental qualification, main practice setting, average number of extractions per week, frequency of performing surgical/complex extractions, and whether the participant had received continuing education on AO within the preceding three years. The second part assessed prevention practices via 8 items on a 5-point Likert scale (1 = Never to 5 = Always), encompassing documentation of previous AO history; assessment of patient-specific risk factors; provision of standardized postoperative instructions; advice to smokers to refrain; minimization of surgical trauma; selective chlorhexidine use; and scheduling follow-up for high-risk cases. The third part evaluated management practices (9 items) on the same 5-point Likert scale, including written postoperative instructions; repeated dressing/reviews; socket irrigation; medicated intra-alveolar dressing; additional curettage (non-evidence-based); analgesics/NSAIDs; systemic antibiotics for uncomplicated AOs (non-evidence-based); referral to an oral surgeon; and recording the AO in the patient file. The fourth part measured attitudes toward AO prevention (5 items) on a 5-point Likert scale (1 = Strongly disagree to 5 = Strongly agree), addressing the following: whether AO is a significant clinical problem; whether evidence-based guidelines improve outcomes; whether preventive protocols are feasible; whether prevention efforts are justified; and whether personal responsibility is important.

Data Collection

Paper-based questionnaires were distributed to dental practitioners working in public and private dental clinics across Sana’a, Yemen. Paper-based questionnaires were chosen over digital platforms due to (1) limited internet access and digital literacy in our target population, (2) inability to ensure a representative sample using digital platforms (as many dentists may not have reliable internet access), (3) higher response rates typically achieved with paper-based surveys in this setting, and (4) the need for anonymity to minimize social desirability bias (sealed envelopes). To minimize selection bias, clinics were randomly selected from the list of registered dental clinics in Sana’a provided by the Yemeni Dental Association, stratified by clinic type (public vs private). Trained research assistants approached potential participants, explained the study objectives, assured anonymity, and obtained written informed consent. The participants completed the questionnaire in a private area and placed the sealed, unmarked envelope into a locked collection box. Among the 450 distributed questionnaires, 436 were returned (96.9% response rate), with 412 forms included in the final analysis after 24 questionnaires were excluded because >10% of the items were missing or incomplete. All the responses were double-entered into a password-protected electronic database by two independent data entry operators, and any discrepancies were resolved by cross-referencing the original paper forms.

Statistical Analysis

The data were entered into Microsoft Excel, verified for completeness and accuracy, and analyzed via SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Categorical variables are summarized as frequencies and percentages, whereas continuous variables are expressed as the means ± standard deviations (SDs). Comparisons between two groups were performed via the independent-samples t test, whereas one-way analysis of variance (ANOVA) was used for comparisons involving more than two groups. Associations between categorical variables were examined via Pearson’s chi-square (χ²) test.

Composite scores were calculated as the mean of the constituent items: The Prevention Practice Score (PS) comprised 8 items (Cronbach’s α = 0.84), the Evidence-Based Management Score (EBMS) comprised 5 evidence-based items (Cronbach’s α = 0.81), and the Non-Evidence-Based Practices Score (NEPS) comprised 2 non-evidence-based items (Cronbach’s α = 0.73). A “high prevention practice score” was defined using the median split method, with participants scoring ≥4.13 (the median PS) classified as having high prevention practice scores.

Before performing multivariable logistic regression, multicollinearity was assessed using variance inflation factors (VIF) and tolerance values. All VIF values were <1.8 (range: 1.04–1.76), and all tolerance values were >0.55, indicating no significant multicollinearity among predictors. Variables with p < 0.05 in the bivariate analyses, together with clinically relevant variables identified from the literature, were entered into a multivariable binary logistic regression model to identify independent predictors of high prevention practices. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) are reported. All the statistical tests were two-tailed, and p < 0.05 was considered statistically significant.

Results

Participant Characteristics

A total of 412 dental practitioners completed the questionnaire and were included in the final analysis. More than half of the participants were aged 24–29 years (56.8%), followed by those aged 30–39 years (27.2%), whereas only 1.7% were aged ≥50 years. Males constituted 63.1% of the study population. Nearly half of the respondents (47.3%) had fewer than five years of clinical experience, and 61.7% held a Bachelor of Dental Surgery (BDS/DDS/DMD) degree. With respect to the practice setting, almost half worked in private clinics (49.8%), whereas 20.4%, 7.5%, and 22.3% worked in public, university, and mixed practice settings, respectively. Approximately one-third of the participants performed 0–5 tooth extractions per week, and one-third reported frequently performing surgical or complex extractions. Notably, only 40.8% had previously attended continuing education activities related to alveolar osteitis (Table 1).

Table 1.

Demographic and Professional Characteristics of the Participating Dentists (N = 412)

Variable	Category	N (%)
Age	24–29 years	234 (56.8)
	30–39 years	112 (27.2)
	40–49 years	59 (14.3)
	≥50 years	7 (1.7)
Sex	Male	260 (63.1)
	Female	152 (36.9)
Years of clinical practice	<5 years	195 (47.3)
	5–10 years	113 (27.4)
	11–15 years	76 (18.4)
	>15 years	28 (6.8)
Highest dental qualification	Undergraduate	31 (7.5)
	BDS/DDS/DMD	254 (61.7)
	Postgraduate	101 (24.5)
	Fellowship/Board/PhD	26 (6.3)
Main practice setting	Private	205 (49.8)
	Public	84 (20.4)
	University	31 (7.5)
	Mixed	92 (22.3)
Extractions per week	0–5	137 (33.3)
	6–10	126 (30.6)
	11–20	104 (25.2)
	>20	45 (10.9)
Surgical/complex extractions	Never/Rarely	96 (23.3)
	Sometimes	178 (43.2)
	Often/Always	138 (33.5)
Continuing education on AO	Yes	168 (40.8)
	No	244 (59.2)

Reliability and Descriptive Statistics of the Composite Scores

The composite scales demonstrated satisfactory psychometric properties (Table 2). The prevention practice score exhibited excellent internal consistency (Cronbach’s α = 0.84), with an intraclass correlation coefficient (ICC) of 0.82 and a mean score of 4.09 ± 0.63. The evidence-based management score also demonstrated good reliability (Cronbach’s α = 0.81; ICC = 0.79), with a mean value of 4.17 ± 0.67. The non-evidence-based practice score showed acceptable reliability (Cronbach’s α = 0.73; ICC = 0.76) and a lower mean score (2.77 ± 0.89).

Table 2.

Reliability and Descriptive Statistics of the Composite Scores

Score	Cronbach’s α	ICC	Mean ± SD	Observed Range
Prevention Practice Score (PS)	0.84	0.82	4.09 ± 0.63	1.86–5.00
Evidence-Based Management Score (EBMS)	0.81	0.79	4.17 ± 0.67	2.00–5.00
Non-Evidence-Based Practices Score (NEPS)	0.73	0.76	2.77 ± 0.89	1.00–5.00

Abbreviations: PS, prevention practice score; EBMS, evidence-based management score; NEPS, nonevidence-based practice score; ICC, intraclass correlation coefficient.

Prevention and Management Practices for Alveolar Osteitis

Overall, the respondents demonstrated a high level of adherence to several recommended preventive measures for alveolar osteitis (Table 3). Smokers who refrained from smoking following extraction achieved the highest mean score (4.55 ± 0.79), followed by those who minimized surgical trauma during extraction (4.39 ± 0.83) and those who provided standardized postoperative instructions (4.31 ± 0.90). High levels of compliance were also observed for scheduling follow-up appointments for high-risk patients (4.10 ± 0.95), selective chlorhexidine use (3.92 ± 1.03), and assessment of patient-specific risk factors (3.89 ± 1.02). In contrast, routine antibiotic prophylaxis had the lowest mean score (3.34 ± 1.27).

Table 3.

Self-Reported Preventive and Management Practices for Alveolar Osteitis Among the Participating Dentists (N = 412)

Practice Item	Never N (%)	Rarely N (%)	Sometimes N (%)	Often N (%)	Always N (%)	Mean ± SD
Self-reported preventive practices
Document previous AO history	22 (5.3)	61 (14.8)	116 (28.2)	131 (31.8)	82 (19.9)	3.44 ± 1.29
Assess patient-specific risk	9 (2.2)	34 (8.3)	95 (23.1)	169 (41.0)	105 (25.5)	3.89 ± 1.02
Standardized postoperative instructions	4 (1.0)	17 (4.1)	56 (13.6)	140 (34.0)	195 (47.3)	4.31 ± 0.90
Advise smokers to refrain	3 (0.7)	8 (1.9)	33 (8.0)	86 (20.9)	282 (68.4)	4.55 ± 0.79
Minimize trauma	2 (0.5)	11 (2.7)	48 (11.7)	113 (27.4)	238 (57.8)	4.39 ± 0.83
Selective chlorhexidine use	12 (2.9)	38 (9.2)	101 (24.5)	160 (38.8)	101 (24.5)	3.92 ± 1.03
Schedule follow-up for high-risk cases	8 (1.9)	24 (5.8)	84 (20.4)	178 (43.2)	118 (28.6)	4.10 ± 0.95
Self-reported management practices
Written postoperative instructions (EB)	11 (2.7)	41 (10.0)	104 (25.2)	167 (40.5)	89 (21.6)	3.80 ± 1.08
Repeated dressing/reviews	4 (1.0)	19 (4.6)	83 (20.1)	188 (45.6)	118 (28.6)	4.09 ± 0.91
Irrigate socket	3 (0.7)	12 (2.9)	49 (11.9)	133 (32.3)	215 (52.2)	4.32 ± 0.84
Medicated intra-alveolar dressing (EB)	7 (1.7)	20 (4.9)	77 (18.7)	188 (45.6)	120 (29.1)	4.09 ± 0.97
Additional curettage (NEB)	8 (1.9)	27 (6.6)	83 (20.1)	189 (45.9)	105 (25.5)	4.02 ± 1.02
Analgesics/NSAIDs (EB)	2 (0.5)	11 (2.7)	51 (12.4)	146 (35.4)	202 (49.0)	4.30 ± 0.84
Systemic antibiotics (NEB)	36 (8.7)	69 (16.7)	116 (28.2)	126 (30.6)	65 (15.8)	3.34 ± 1.28
Refer to oral surgeon (EB)	10 (2.4)	24 (5.8)	98 (23.8)	184 (44.7)	96 (23.3)	3.99 ± 0.99
Record AO in patient file (EB)	13 (3.2)	42 (10.2)	111 (26.9)	157 (38.1)	89 (21.6)	3.79 ± 1.08

Notes: Data are presented as n (%), mean ± SD. The responses were scored on a 5-point Likert scale (1 = never to 5 = always).

Abbreviations: EB, Evidence-based; NEB, Nonevidence-based.

Self-reported management practices are summarized in Table 3. Evidence-based interventions were commonly implemented by participants. The highest mean score was recorded for irrigation of the extraction socket (4.32 ± 0.84), followed closely by the prescription of analgesics or nonsteroidal anti-inflammatory drugs (4.30 ± 0.84). Repeated dressing changes, medicated intra-alveolar dressings, referrals to oral surgeons when indicated, and documentation of alveolar osteitis in patient records were also frequently reported. Conversely, non-evidence-based practices—including routine systemic antibiotic prescription (3.34 ± 1.28) and additional socket curettage (4.02 ± 1.02)—were still reported by a considerable proportion of participants.

Attitudes Toward Alveolar Osteitis Prevention

The participants generally expressed positive attitudes toward the prevention of alveolar osteitis (Table 4). The strongest agreement was observed for the statement that evidence-based clinical guidelines improve treatment outcomes (mean = 4.08 ± 0.82). Similarly, the respondents agreed that preventive protocols are feasible in routine practice (3.99 ± 0.84), preventive efforts are justified (3.92 ± 0.88), personal responsibility plays an important role in prevention (3.91 ± 0.89), and alveolar osteitis represents a clinically significant postoperative complication (3.89 ± 0.89).

Table 4.

Dentists’ Attitudes Toward the Prevention of Alveolar Osteitis (N = 412)

Item	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	Mean ± SD
AO is a significant clinical problem	5 (1.2)	32 (7.8)	89 (21.6)	204 (49.5)	82 (19.9)	3.89 ± 0.89
Evidence-based guidelines improve outcomes	2 (0.5)	19 (4.6)	73 (17.7)	218 (52.9)	100 (24.3)	4.08 ± 0.82
Preventive protocols are feasible	4 (1.0)	23 (5.6)	84 (20.4)	224 (54.4)	77 (18.7)	3.99 ± 0.84
Prevention effort is justified	5 (1.2)	26 (6.3)	86 (20.9)	213 (51.7)	82 (19.9)	3.92 ± 0.88
Personal responsibility is important	6 (1.5)	27 (6.6)	87 (21.1)	209 (50.7)	83 (20.1)	3.91 ± 0.89

Associations Between Prevention and Management Practice Scores and Participants’ Demographic and Professional Characteristics (Bivariate Associations)

Table 5 summarizes the composite practice scores across demographic and professional characteristics. Prevention practice scores and evidence-based management scores increased significantly with advancing age, greater years of clinical experience, higher academic qualifications, increased weekly extraction volume, more frequent performance of surgical extractions, and previous participation in continuing education on alveolar osteitis (all p < 0.05). No statistically significant differences were observed according to sex or practice setting. Non-evidence-based practice scores also varied significantly according to age, years of practice, qualifications, extraction frequency, surgical experience, and continuing education (all p < 0.05).

Table 5.

Comparison of Prevention Practices, Evidence-Based Management, and Non-Evidence-Based Practice Scores Across Participants’ Demographic Characteristics

Demographic Variable	Category	PS Mean ± SD	p value	EBMS Mean ± SD	p value	NEPS Mean ± SD	p value
Age	24–29 years	3.98 ± 0.66	0.018*	4.05 ± 0.71	0.026*	2.61 ± 0.92	0.041*
	30–39 years	4.16 ± 0.58		4.23 ± 0.63		2.84 ± 0.84
	40–49 years	4.25 ± 0.51		4.31 ± 0.57		2.97 ± 0.76
	≥50 years	4.32 ± 0.49		4.38 ± 0.53		3.02 ± 0.71
Sex	Male	4.12 ± 0.61	0.214	4.19 ± 0.65	0.287	2.80 ± 0.87	0.338
	Female	4.04 ± 0.66		4.13 ± 0.70		2.72 ± 0.92
Years of practice	<5 years	3.95 ± 0.67	0.006*	4.01 ± 0.72	0.012*	2.58 ± 0.94	0.018*
	5–10 years	4.15 ± 0.57		4.22 ± 0.64		2.82 ± 0.84
	11–15 years	4.27 ± 0.50		4.34 ± 0.55		2.98 ± 0.73
	>15 years	4.34 ± 0.48		4.41 ± 0.49		3.05 ± 0.69
Highest qualification	Undergraduate	3.89 ± 0.71	0.022*	3.94 ± 0.76	0.031*	2.49 ± 0.98	0.037*
	BDS/DDS/DMD	4.05 ± 0.63		4.13 ± 0.68		2.73 ± 0.89
	Postgraduate	4.22 ± 0.55		4.29 ± 0.60		2.93 ± 0.78
	Fellowship/Board/PhD	4.31 ± 0.49		4.39 ± 0.54		3.06 ± 0.71
Practice setting	Private	4.14 ± 0.60	0.094	4.20 ± 0.65	0.116	2.83 ± 0.86	0.137
	Public	3.98 ± 0.69		4.07 ± 0.73		2.66 ± 0.94
	University	4.26 ± 0.52		4.34 ± 0.58		2.96 ± 0.74
	Mixed	4.05 ± 0.64		4.14 ± 0.69		2.73 ± 0.90
Extractions per week	0–5	3.91 ± 0.68	0.004*	3.98 ± 0.74	0.009*	2.51 ± 0.96	0.015*
	6–10	4.10 ± 0.61		4.17 ± 0.67		2.76 ± 0.88
	11–20	4.24 ± 0.53		4.30 ± 0.58		2.95 ± 0.77
	>20	4.36 ± 0.47		4.43 ± 0.51		3.08 ± 0.69
Surgical extractions	Never/Rarely	3.88 ± 0.70	<0.001*	3.94 ± 0.76	0.002*	2.48 ± 0.97	0.008*
	Sometimes	4.09 ± 0.61		4.16 ± 0.66		2.76 ± 0.88
	Often/Always	4.27 ± 0.52		4.34 ± 0.57		2.97 ± 0.75
Continuing education on AO	Yes	4.27 ± 0.54	<0.001*	4.33 ± 0.58	<0.001*	2.98 ± 0.76	<0.001*
	No	3.97 ± 0.66		4.05 ± 0.72		2.62 ± 0.94

Notes: Data are presented as the means ± SDs. P values were calculated via independent t tests or one-way ANOVA, as appropriate. *p < 0.05.

Associations Between the Attitude Score and Participants’ Demographic and Professional Characteristics

As shown in Table 6, the total attitude scores differed significantly according to age (p = 0.028), years of clinical practice (p = 0.011), academic qualifications (p = 0.033), weekly extraction frequency (p = 0.009), frequency of surgical extractions (p < 0.001), and attendance at continuing education activities related to alveolar osteitis (p < 0.001). No statistically significant differences were observed according to sex or practice setting.

Table 6.

Comparison of Total Attitude Scores According to Participants’ Demographic and Professional Characteristics

Demographic Variable	Category	Total Attitude Score Mean ± SD	p value
Age	24–29 years	3.86 ± 0.67	0.028*
	30–39 years	4.02 ± 0.58
	40–49 years	4.11 ± 0.52
	≥50 years	4.18 ± 0.47
Sex	Male	3.97 ± 0.61	0.337
	Female	3.91 ± 0.66
Years of practice	<5 years	3.84 ± 0.68	0.011*
	5–10 years	4.00 ± 0.58
	11–15 years	4.12 ± 0.51
	>15 years	4.20 ± 0.45
Highest qualification	Undergraduate	3.80 ± 0.71	0.033*
	BDS/DDS/DMD	3.93 ± 0.64
	Postgraduate	4.09 ± 0.56
	Fellowship/Board/PhD	4.17 ± 0.49
Practice setting	Private	3.98 ± 0.60	0.121
	Public	3.87 ± 0.69
	University	4.13 ± 0.49
	Mixed	3.92 ± 0.63
Extractions per week	0–5	3.81 ± 0.69	0.009*
	6–10	3.96 ± 0.61
	11–20	4.09 ± 0.53
	>20	4.21 ± 0.47
Surgical extractions	Never/Rarely	3.78 ± 0.71	<0.001*
	Sometimes	3.97 ± 0.60
	Often/Always	4.13 ± 0.52
Continuing education on AO	Yes	4.11 ± 0.54	<0.001*
	No	3.84 ± 0.68

Notes: Data are presented as the means ± SDs. P values were calculated via independent t tests or one-way ANOVA, as appropriate. *p < 0.05.

Predictors of High Prevention Practice Scores

The variables significantly associated with higher prevention practice scores in the multivariable logistic regression are presented in Table 7. The “high prevention practice score” was defined as a PS ≥4.13 (the median). Dental practitioners who had attended continuing education programs on alveolar osteitis were more than twice as likely to achieve high prevention practice scores than those without such training (adjusted OR = 2.19, 95% CI: 1.32–3.63, p = 0.002). Frequently performing surgical extractions (adjusted OR = 1.98, 95% CI: 1.10–3.57, p = 0.023), performing more than 20 extractions per week (adjusted OR = 2.44, 95% CI: 1.10–5.41, p = 0.028), positive attitudes toward the feasibility of preventive protocols (adjusted OR = 1.55, 95% CI: 1.17–2.06, p = 0.002), greater confidence in prevention (adjusted OR = 1.41, 95% CI: 1.07–1.87, p = 0.015), and having 11–15 years of clinical experience (adjusted OR = 1.87, 95% CI: 1.01–3.46, p = 0.045) were independent predictors of high prevention practice scores.

Table 7.

Multivariate Logistic Regression Analysis of Factors Associated with High Prevention Practice Scores Among Participants

Predictor	Adjusted OR	95% CI	p value
Sex
Female	1.16	0.75–1.79	0.503
Years of practice
5–10 years	1.52	0.91–2.53	0.106
11–15 years	1.87	1.01–3.46	0.045*
>15 years	2.11	0.91–4.93	0.081
Highest qualification
BDS/DDS/DMD	1.42	0.66–3.05	0.365
Postgraduate	1.93	0.84–4.41	0.119
Fellowship/Board/PhD	2.21	0.83–5.89	0.112
Practice setting
Public	0.84	0.45–1.57	0.592
University	1.31	0.51–3.37	0.571
Mixed	1.18	0.66–2.10	0.581
Extractions per week
6–10	1.47	0.87–2.49	0.149
11–20	1.88	1.03–3.42	0.039*
>20	2.44	1.10–5.41	0.028*
Surgical extractions
Sometimes	1.51	0.86–2.65	0.149
Often/Always	1.98	1.10–3.57	0.023*
Continuing education on AO (Yes)	2.19	1.32–3.63	0.002*
Feasibility attitude	1.55	1.17–2.06	0.002*

Notes: Data are presented as the means ± SDs. P values were calculated via independent t tests or one-way tests. ANOVA, as appropriate. *p < 0.05 indicates statistical significance.

Discussion

This comprehensive survey of 412 dental practitioners provides a detailed contemporary snapshot of clinical practices, attitudes, and confidence regarding alveolar osteitis in Sana’a, Yemen. Our principal findings indicate that while most practitioners adopt several evidence-based preventive measures, a concerning proportion continue to employ non-evidence-based practices, particularly routine antibiotic prophylaxis and additional curettage. Higher practice scores were consistently associated with greater clinical experience, advanced qualifications, larger extraction volumes, and recent continuing education. Furthermore, positive attitudes toward the feasibility of preventive protocols emerged as independent predictors of high prevention practice scores. Given the cross-sectional design, these associations should be interpreted as correlational rather than causal.

Our principal finding—that continuing education is the strongest predictor of high prevention practice scores—directly supports our hypothesis that educational interventions improve evidence-based care. The association between clinical volume and higher scores supports the hypothesis that hands-on exposure reinforces evidence-based habits. Our secondary hypothesis—that positive attitudes predict better practices—was also supported, with feasibility attitudes emerging as an independent predictor.

Comparison with Existing Literature

The mean prevention practice score (4.09 ± 0.63) in our study suggests moderate-to-good adherence to evidence-based preventive measures, which aligns with findings from a 2025 survey of dental interns in Saudi Arabia and Egypt.13 However, our observed mean for chlorhexidine use (3.92 ± 1.03) fell within the “sometimes” to “often” range, indicating substantial room for improvement. This gap is concerning given that chlorhexidine significantly reduces the incidence of AO after third molar surgery.19,20 A 2024 double-blind clinical study further confirmed that the application of chlorhexidine gel in extraction sockets significantly reduces AO.21 The persistent evidence-practice gap highlights the urgent need for more effective guideline dissemination, particularly in resource-constrained settings.

Regarding non-evidence-based practices, our findings that 17.2% of dental practitioners “always” prescribed routine antibiotic prophylaxis and that 25.5% “always” performed additional curettage are concerning. Routine perioperative antibiotic use is not recommended for healthy patients.11 A 2021 systematic review further emphasized that while topical agents show promise, systemic antibiotics should be reserved for select cases.5 A recent study further confirmed that inappropriate antibiotic prescribing for AO remains a significant concern in clinical practice.22 The persistent use of antibiotics is particularly troubling given the increase in antimicrobial resistance. Encouragingly, greater confidence in prevention was associated with less non-evidence-based practice, suggesting that improving self-efficacy through education may reduce inappropriate management.17

Importantly, while additional curettage is classified as non-evidence-based, the evidence is nuanced. The 2022 Cochrane review noted that curettage is commonly performed and may have a role, although high-quality evidence is lacking.18 Similarly, systemic antibiotics may be appropriate in select cases. Our classification reflects guideline recommendations for routine use rather than absolute prohibition.

Emerging therapeutic modalities have shown promise; however, these therapies were not assessed in our questionnaire. Although our survey did not assess the use of these emerging modalities, the limited adoption of advanced therapies in similar settings suggests that substantial educational gaps remain. A 2024 meta-analysis indicated that laser therapy is more effective for AO than conventional dressings.23 A 2024 randomized controlled trial confirmed that the Er:YAG laser provided rapid pain relief and improved healing.24 Furthermore, platelet-rich fibrin (PRF) improves alveolar healing and reduces analgesic use.25 A 2024 randomized controlled trial comparing advanced PRF, photobiomodulation (PBM), pentoxifylline, and alveogyl reported that PRF and PBM provided superior results.26 A 2024 systematic review with meta-analysis further suggested that PBM may enhance bone and mucosal repair.27 We discuss these therapies to (1) contextualize the gap between current evidence and current practice, (2) highlight areas for future continuing education, and (3) identify research priorities for the region.

Recent research has also explored novel preventive agents. A 2024 randomized trial demonstrated that topical tranexamic acid significantly reduced the incidence of AO (5% vs 15%) following premolar extraction.28 Another double-blind clinical study confirmed that the placement of chlorhexidine gel and tranexamic acid in extraction sockets reduces AO and post-extraction pain.21 These findings suggest that locally applied antifibrinolytic agents may offer a safe alternative to systemic antibiotics, meriting further investigation.

Predictors of High Prevention Practices

In our multivariate logistic regression, the strongest independent predictors of a high prevention practice score were receiving continuing education on AO (aOR = 2.19), having a positive attitude toward the feasibility of preventive protocols (aOR = 1.55 per point), and having greater confidence in prevention (aOR = 1.41 per point). These findings are consistent with those of a 2026 study among final-year dental students, where those who received dedicated oral surgery training reported significantly greater confidence in managing dry sockets.14 Similarly, a 2024 study assessing continuing education needs in dental traumatology concluded that structured educational interventions are necessary to improve clinical competence among interns.15 A recent study further reinforced that continuing professional development is a key determinant of evidence-based practice adoption in clinical dentistry.29 A 2020 study evaluating the effectiveness of chlorhexidine usage training for dentists confirmed that comprehensive training can improve dentists’ ability to implement evidence-based preventive measures.30 Importantly, our model also identified clinical volume (extractions per week) and experience (11–15 years of practice) as significant predictors, suggesting that hands-on exposure reinforces evidence-based habits, which aligns with findings that operator experience significantly reduces AO incidence.7

Interestingly, sex and practice setting (private vs public) were not significant in either the univariate or multivariate analyses. This contrasts with some earlier studies that reported that female dentists or those in academic settings had greater adherence to guidelines. However, this finding is consistent with the findings of Khan et al, who reported that health status and extraction type did not significantly differ in AO incidence, and with the findings of Sakka et al, who reported that sex was not a significant predictor of good knowledge.7,13 The lack of difference may reflect the homogeneous professional training standards in our region or the relatively low proportion of university-based practitioners (only 7.5%).

Attitudes Toward the Prevention of Alveolar Osteitis

Overall, attitudes toward AO prevention were positive, with mean scores exceeding 3.9 for all five attitude items. The highest agreement was for the statement “Evidence-based guidelines improve outcomes” (mean 4.08). This is encouraging, as favorable attitudes are a prerequisite for behavioral change according to the theory of planned behavior. However, the moderate confidence levels (means of 3.75 and 3.70 for diagnosis and prevention, respectively) indicate that many dentists still feel uncertain about optimal AO management. This uncertainty is perhaps understandable given that a 2022 Cochrane review of local interventions for AO noted that the prevalence of dry sockets varies from 1% to 5% in routine extractions to over 30% in surgically extracted third molars, reinforcing the need for clear, evidence-based guidance.18 A 2024 comprehensive review of dry sockets further emphasized that understanding the etiology, risk factors, and preventive measures is crucial for reducing the incidence of AO and improving patient outcomes.31

Strengths and Limitations

This study has several strengths. It is one of the largest surveys of dental practitioners’ AO practices in a low- and middle-income country, with a robust sample size (N = 412) and good internal consistency (Cronbach’s α 0.73–0.84). Exploratory factor analysis validated the questionnaire structure, and test-retest reliability (ICC 0.76–0.82) confirmed temporal stability. Stratified random sampling enhanced representativeness, and the multivariate model demonstrated good fit (Hosmer-Lemeshow p = 0.41).

Several limitations must be acknowledged. First, self-reported data may be subject to social desirability bias. We attempted to minimize this through anonymity, but this limitation remains inherent to survey research. Second, the sample was predominantly young (56.8% aged 24–29 years) and male (63.1%), which may limit generalizability. Third, the cross-sectional design precludes causal inferences. Fourth, we did not report patient outcomes. Fifth, the study was conducted in one city, and practice patterns may vary internationally.13 Sixth, the use of paper-based questionnaires, while justified for this setting, may have introduced selection bias toward more accessible clinics and could have affected response patterns compared to digital surveys. Finally, the generalizability of the findings to other Yemeni regions or other low- and middle-income countries requires further investigation.

Implications for Practice and Research

Our findings highlight several actionable points. First, continuing education on AO should be systematically encouraged, as it is associated with significantly higher practice scores (aOR 2.19). Professional bodies should offer regular workshops on evidence-based prevention and management. Second, educational interventions should target non-evidence-based practices and provide clear algorithms. Third, building confidence should be an explicit educational goal through simulation and mentored clinical experience.14,15 Fourth, given the poor awareness of newer modalities,17,23 continuing professional development should introduce emerging evidence-based therapies. Fifth, clinical volume predicts better practice, suggesting that mentorship during early career stages is valuable.

Future research should include prospective observational studies to validate self-reported practices. Interventional studies are urgently needed to test whether targeted education can reduce non-evidence-based management and lower the incidence of AOs. Multicenter international surveys can identify cross-cultural barriers to guideline adherence.13 Additionally, given the promising results of topical tranexamic acid,28 and other emerging agents, future research should investigate cost-effectiveness and practical implementation.

Conclusion

This survey revealed that dental practitioners in Sana’a, Yemen, generally adopt evidence-based preventive measures for alveolar osteitis, but a substantial minority continue to employ non-evidence-based practices—most notably, routine antibiotic prophylaxis and additional curettage. Higher prevention practice scores are independently associated with continuing education, positive feasibility attitudes, and greater clinical volume. Given the cross-sectional design, these are associations rather than causal effects, and causal claims must be avoided. Efforts to improve AO care should focus on targeted continuing education, systematic confidence-building, and the development of clear, context-appropriate clinical algorithms. Interventional studies are needed to confirm the effectiveness of these approaches in reducing non-evidence-based practices and improving patient outcomes.

Funding Statement

No funding was received.

Data Sharing Statement

The datasets created and/or analyzed during the current study are not publicly available due to confidentiality but can be made available by the corresponding author (Basem H. AL-Huthaifi) upon reasonable request.

Ethics Approval and Consent to Participate

Ethical approval for this study was obtained from the Research Ethics Committee of the Faculty of Dentistry, Ibn AlNafis University for Medical Sciences, Sana’a, Yemen (Approval No. 206, dated 15 February 2026). All participants provided informed consent after being fully informed about the study objectives, procedures, and their right to withdraw at any time.

Author Contributions

All authors made a significant contribution to the work reported, whether in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this study.