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Dry socket, also known as alveolar osteitis, is a painful dental problem that can develop 4 to 5 days after having a permanent adult tooth pulled out.
The socket refers to the hole in the alveolar bone that is left after the tooth is extracted. Once the tooth is removed, a blood clot typically forms at the site to cover and protect the underlying bone and nerve endings. This protective layer allows the wound to heal by shielding it from further injury or irritation.
The blood clot also promotes the growth of new bone and fresh soft tissue at the site. In the event that this protective layer fails to develop, becomes dislodged, or dissolves, the nerves and bone in the socket will be left exposed to air, food, fluid, and anything that enters the mouth.
Additionally, your tongue will inadvertently touch the exposed bone resulting in frequent acute pain. This complication is referred to as a dry socket.
Most Common Sites of Occurrence
- Distal sites (e.g., third molars)
- More common in the mandible than in the maxilla
Despite being the most common complication associated with adult tooth extraction, dry socket is relatively rare.
In a 2014 study published in the International Journal of Dentistry, 1182 patients with a total of 1362 teeth extracted during the 4-year period were analyzed, out of which 1.4% of teeth developed dry socket. (1) However, an increased incidence of dry socket is reported in cases where the mandibular impacted third molars or lower wisdom teeth are removed.
Approximately 1% to 5% of all tooth extractions result in some degree of dry socket, but the chance of occurrence increases to 38% in mandibular third molar extractions.
What Are the Causes of and Risk Factors for a Dry Socket?
Here are some common factors that can deter the timely formation of a blood clot over the tooth extraction site resulting in a dry socket:
- Preexisting bacterial contamination of the socket
- Bone and tissue trauma during tooth extraction
- A small piece of a fractured bone or sharp edges of alveolar socket remaining in the wound after extraction
- Inadequate post-surgery care and oral hygiene (1)
Some people run a higher risk of developing a dry socket following a tooth extraction due to certain factors, which include:
- Excessive smoking or the use of related products is a major risk factor. Tobacco contains nicotine, which hampers the formation of the blood clot and delays the healing process by reducing blood supply to the affected site. Even if a clot develops, the act of deep inhalation when you suck on a cigarette can readily dislodge the protective covering over the lesion.
- People with dense jawbone are increasingly prone to a traumatic extraction and less blood supply, decreasing the chances of blood clot formation and timely healing. The jawbone tends to become progressively denser and has dwindling blood supply with advancing age, making people over 30 years of age with impacted third molars a high-risk category for a dry socket.
- Women have a greater tendency to develop a dry socket than men, which may be on account of certain hormonal factors. The use of oral contraceptives, estrogen replacement therapy, and normal hormonal changes during menstruation can hamper the healing process and make women more susceptible to this problem.
- Uncontrolled blood sugar levels in people with diabetes increase the risk of a dry socket, as the excess blood sugar harbors more anaerobic bacteria in the bloodstream and thus in the socket also.
- People who have suffered from a dry socket complication in the past are more likely to experience it again.
- Having an ongoing or previous oral infection such as periodontal disease or pericoronitis at the extraction site can predispose one to a dry socket.
- The use of corticosteroids also contributes to the risk of developing a dry socket.
How to Identify a Dry Socket?
The common signs and symptoms of a dry socket include:
- Pulsating pain that presents a few days after the extraction.
- The pain tends to radiate from the socket to the ear, eye, neck, and temple on the same side of the face as the extraction.
- The jawbone may be visible in the socket and it is sensitive to touch.
- The soft tissues surrounding the socket may appear gray and swollen due to poor healing.
- Foul breath and a bad taste in the mouth due to the accumulation of food debris and bacteria in the socket.
- A partial or total absence of blood clot at the extraction site, making it appear like an empty-looking cavity.
- Swollen lymph nodes.
- Mild fever.
Preliminary Medical Treatment for Dry Socket
The conventional treatment for a dry socket primarily hinges on pain management. (2) Prophylactic antibiotic therapy that is prescribed by the dentist on the day of extraction in high-risk patients (uncontrolled diabetics and smokers) may reduce the risk of a dry socket.
- First, the site is gently irrigated with chlorhexidine or saline to remove any debris that could cause pain or infection.
- The dentist or oral surgeon will then pack the surgical site with a resorbable or nonresorbable analgesic-medicated dressing to cover the exposed bone.
- The doctor will determine if and how often you need to change the dressing depending upon the severity of your pain and symptoms. A nonresorbable dressing must be removed after 2–3 days.
- The dentist may also prescribe postoperative pain medication, including NSAIDs (e.g., ibuprofen) or a mixture of narcotic with acetaminophen and codeine (e.g., Tylenol® 3) in case of severe pain.
- The dentist will instruct you about the necessary self-care measures to promote healing once the dressing is removed. You will be expected to flush the socket at home, and the dentist will show you how.
- If there is no respite even after 72 hours of this preliminary treatment, your dentist may take radiographs to rule out the presence of a foreign body at the extraction site, bone destruction, or other possible etiologies.
How is a Dry Socket Diagnosed?
Tooth extraction is accompanied by a certain degree of pain, which dissipates with time as the wound heals. If, however, you experience severe or worsening pain after the surgery, it is necessary to get your socket examined by a dentist or oral surgeon.
The dentist will take an account of your dental history as well as the symptoms that you may be experiencing. Next, your socket will be clinically examined by the doctor to check if there is a blood clot present or whether you have exposed bone, both of which are telltale signs of a dry socket.
The doctor may also suggest X-rays taken of your mouth and teeth to eliminate the possibility of other complications, such as a bone infection (osteomyelitis) or small remnant fragments of the bone or roots of the extracted tooth in the socket after surgery, which may be responsible for your pain.
Complications of a Dry Socket
Painful as it may be, a dry socket is a rather non-threatening condition that tends to resolve with proper treatment and home care. However, if left untreated, the problem can give way to more serious complications. These include:
- Nerve injury, which can cause temporary or permanent problems, such as tingling or numbness.
- Infection in the socket, which can progress into a chronic bone infection (osteomyelitis). If you experience symptoms such as high temperature, yellow or white discharge from the extraction site, and persistent pain and swelling, chances are the wound has been infected.
- Bleeding at the affected site.
When to See a Doctor
A certain degree of pain and discomfort is normal after tooth extraction. However, you should be able to manage the pain with a pain reliever prescribed by your dentist or oral surgeon, and the pain should lessen with time.
If you develop new or worsening pain in the days after your tooth extraction, contact your dentist or oral surgeon immediately.
If you fail to follow your dentist’s instructions regarding at-home care after a tooth extraction, the wound will not heal in time and might even result in a dry socket.
Similarly, the inability to practice good oral hygiene can increase your chances of developing this complication.