Dry Socket: Everything You Need to Know

Dry socket is a very painful condition that occurs after a tooth extraction. Here’s a guide from Flossy with everything you need to know about it.

September 29, 2022
Dry Socket: Everything You Need to Know

Dry socket — also known as alveolar osteitis — Is a severely painful complication following a dental extraction. Dry socket occurs in approximately 3% of all tooth extractions and can be as high as 30% for extracted third molars.

Researchers and clinicians are not exactly sure what causes the dry sockets to form in some individuals. Before, dentists used to think that dry socket was caused by bacterial accumulation. However, more recent research shows that there may be other causes of the dry sockets that are not related to bacteria.

In this guide from Flossy, we’ll go over this relatively common complication that follows a large portion of tooth extractions. We will review the causes of dry socket, how your dentist can treat it, and what you can do to prevent it from happening to you.

Why Would You Need a Tooth Extraction?

While mild and moderate forms of tooth decay can be treated with a simple cavity filling, some tooth decay can progress so much that it affects the root of the tooth. Your dentist may not think that the tooth can be saved and may suggest an extraction to prevent any further complications, such as the infection spreading to other parts of your body. 

A tooth extraction is a very common procedure with relatively few complications. Of course, healthy healing is important for preventing complications. 

Immediately following a tooth extraction, you should experience some bleeding in the first 24 hours. Shortly after, a blood clot will begin to form in the space where your tooth used to be. 

About a week after the extraction, a membrane called granulation tissue will begin to form in the extraction site. This type of tissue is made up of collagen, blood vessels, and white blood cells and is off-white in color.

Granulation tissue helps to protect the blood clot until new bone begins to form in the extraction site. It should take about eight weeks for a new bone to begin forming. After this, you will be on your way to recovery from the procedure and may even have an implant put in several months after. 

However, sometimes proper healing may not take place following a tooth extraction. One possible complication it's called dry socket. In the following section, we will explain what it is and why it happens.

What Is a Dry Socket?

“Dry socket” is an informal term used to describe a complication known as alveolar osteitis. It refers to a condition in which the tooth socket following an extraction has some or all of your bone exposed. This happens because a blood clot does not form, and a layer of tissue does not cover the extraction site.

We all expect to feel some pain immediately after a tooth extraction, which may last two or three days. However, for those with dry socket, the pain may persist beyond that. In some cases, it may be hard to prevent bits of food or even the tongue from making contact with the empty socket, which can be incredibly painful.

In addition, a dry socket is a sign that the extraction site isn't healing properly. This can make it difficult to put a dental implant into the dry socket.

Dry socket occurs in approximately 3% of all regular tooth extractions. In addition, it can affect almost 30% of third molar extractions.

What Are the Signs and Symptoms of Dry Socket?

Most often, patients who go on to develop dry socket report a reduction in pain over the first 24 hours following their tooth extraction. However, immediately after, they may go on to develop severe pain that continues for several days and becomes most intense in the 72 hours following the extraction.

The pain that these patients experience may not respond to over-the-counter painkillers. 

It is not uncommon to experience a bad taste or smell coming from the extraction site. In addition, because the socket is not covered with a blood clot, it may be filled with a mixture of food debris and saliva.

The gums surrounding the extraction site might be red, inflamed, and tender to the touch. However, there is usually no indication of any type of bacterial infection.

What Causes a Dry Socket?

  • Food particles
  • Trauma during extraction
  • Smoking
  • Hormonal differences
  • Age

Food Particles 

Food particles can dislodge a blood clot inside a tooth socket. It’s also possible for food particles to prevent a dislodged blood clot from re-forming. Last, food particles can prevent the healing tissue from making contact with the exposed bone. 

In some cases, food particles can accumulate in the dry socket and begin to fermentate. This fermentation may result in toxins being formed, which can irritate the exposed bone, increase pain throughout the jaw, and produce a foul taste or smell. That said, there is little evidence to suggest that bacteria alone cause a dry socket. 

Trauma During Extraction 

There is a relationship between the difficulty of an extraction — which increases the risk of trauma — and the incidence of dry socket. 

Trauma during the removal of a tooth leads to inflammation in the socket. This can lead to the release of issue activators and kininogenase enzymes, which are chemicals that can increase the breakdown of blood clots. 

Trauma can also result in traumatic thrombosis, which is a condition in which a blood clot blocks blood vessels. This can delay the healing of the extraction site and prevent the formation of blood clots. 

Studies support the relationship between traumatic extraction and the incidence of dry sockets. Surgical extractions — complex procedures that are performed by maxillofacial surgeons — are more likely to involve trauma during the procedure. In comparison to simple extractions, they are associated with a ten-fold increase in the incidence of dry socket.  

Smoking

Nicotine — one of the main ingredients in cigarettes — is a vasoconstrictor which means it reduces circulation throughout the body.

Not surprisingly, cigarette smokers show a reduced filling of the wound with blood. As such, smokers have a much higher incidence of dry socket (12%) as compared to non-smokers (4%).  

Hormonal Differences 

Dry socket frequently occurs in females, which can suggest a possible hormonal cause. The incidence of dry socket is approximately 4% in females as opposed to 0.5% in males. However, the incidence of dry sockets was similar between males and females prior to the 1960s.

This is likely because, after the 1960s, there was an increase in women taking hormonal contraceptives. One of the primary ingredients in hormonal contraceptives is estrogen, which increases levels of plasminogen — an enzyme that prevents blood from clotting. 

Studies support this. In one study of 267 women following a tooth extraction, dry sockets occurred more frequently in those taking oral contraceptives (11%) than those not taking oral contraceptives (4%). 

In addition, research shows that when extraction surgery is performed on days 23-28 of the menstrual cycle — when estrogen is at its lowest — the incidence of dry socket decreases. 

Age 

Dry socket is incredibly rare in those who are younger than 20 years of age. This may be due to a higher healing capacity, better circulation, and greater bone elasticity. 

Dry socket occurs more frequently in those who are 20-40 years of age. This is likely because there is a greater proportion of third molar extractions in this age group. In addition, there is a greater prevalence of smoking in this age group. 

How Do You Treat Dry Socket?

Dry socket is a self-limiting condition, which means it should resolve on its own. However, because it can cause severe pain, it often needs to be treated. 

The treatment for dry socket is highly individualized and should be decided after careful consideration of the patient’s condition. Usually, it includes a combination of sanitization of the socket, placement of self-eliminating dressing, and placement of topical painkillers. In some cases, antibiotics may be needed.

How To Prevent Dry Socket 

Here is a breakdown of the treatment strategies: 

  1. Assessment
  2. Sanitization
  3. Dressing
  4. Pain management
  5. Monitoring

Assessment

After an extraction, it’s possible that there are remnants of bone fragments in the empty socket, which can be causing the pain. This should be eliminated as a possible cause with an X-ray before treatment begins.

Sanitization

In order to remove dead tissue, food debris, and any bacterial deposits, the socket should be cleaned with an antiseptic solution. If the pain is extreme, then anesthesia may be required. While saltwater is a popular sanitizing solution, chlorhexidine is more effective. In addition, it can be used at home to manage dry sockets outside of the clinical setting. 

Dressing

After the socket has been rinsed out, it can be packed with a dressing to prevent food debris from entering and from further irritation to be caused to the exposed bone. The dressing should contain special antibacterial and antifungal ingredients to prevent possible infection, such as zinc oxide powder. Ingredients such as lidocaine may also be included in the dressing to reduce pain.

Pain Management

Dry socket is often intensely painful. To help manage pain at home, doctors prefer to prescribe non-steroidal anti-inflammatory drugs (NSAIDs), which are available over-the-counter or — at higher strength — by prescription.

Monitoring

It can take up to two weeks to heal from a dry socket. With the above steps, your dentist can see you for frequent follow-ups while monitoring your treatment outcomes at home.

How To Avoid Dry Sockets

  • Follow your doctor’s aftercare instructions
  • Avoid smoking
  • Consult your dentist if using birth-control

Follow Your Doctor’s Aftercare Instructions

Follow your doctor’s instructions after your extraction. It is crucial to prevent blood clots from dislodging, and it’s important to avoid rinsing vigorously. In addition, you should avoid using a straw for up to 48 hours, as the suction from the straw can pull the blood clot away from the socket. Try to avoid eating any foods that are hard in texture for up to a week.

Make sure you’re clear on aftercare instructions before you leave your dentist’s office following the procedure. However, following aftercare instructions does not guarantee that you will not develop dry socket. You should discuss with your dentist any possible factors that could put you at risk of developing dry socket.

Avoid Smoking

For instance, if you are a smoker, then you may have a higher chance of developing dry socket. It might help to avoid smoking several days before and after the extraction.

Consult Your Dentist if Using Birth-control

If you are taking a hormonal contraceptive, your chances of a dry socket may increase. While your dentist is unlikely to recommend quitting birth control, it is still helpful to discuss the issue with them. In two-phase birth control pills, you may even be able to schedule your procedure during a certain time in the cycle.

If you are not taking a hormonal contraceptive and have a regular cycle, then studies show a decreased incidence of dry socket during days 23-28 of the menstrual cycle — which is associated with low estrogen levels. Bring up the possibility of scheduling your procedure around this time with your dentist. 

What To Do Next

Dry socket is a painful complication that develops after a tooth extraction. It occurs in approximately 3% of all general extractions and in as many as 30% of third molar extractions.

Currently, clinicians are unsure of the exact causes of dry socket. However, some risk factors — such as trauma during extraction, history of smoking, and hormonal differences — can increase complications following tooth extraction.

If you have a dry socket, then the condition can be unbearably painful. To help you manage, dentists in Flossy’s network have years of experience and the latest tools and technology to help bring you relief. Schedule a consultation today.

Sources: 

Dry Socket Etiology, Diagnosis, and Clinical Treatment Techniques | PMC

Dry Socket: Frequency, Clinical Picture, and Risk Factors in a Palestinian Dental Teaching Center | PMC

Effect of oral contraceptives in the incidence of dry socket after mandibular 3rd molar extraction | Oral Journal

Effect of oral contraceptive cycle on dry socket (localized alveolar osteitis) | NCBI

Dry Socket: Frequency, Clinical Picture, and Risk Factors in a Palestinian Dental Teaching Center | NCBI

Current uses of chlorhexidine for management of oral disease: a narrative review | PMC