Dry Socket – Causes, Signs and symptoms

Dry Socket

Also called: Dental Alveolitis, Alveolar Osteitis, Post Extraction Alveolitis, Alveolitis

Reviewed By:
Andrew M. Sicklick, D.D.S.

Summary

Dry socket is a condition characterized by severe pain after a tooth extraction. The pain generally begins a day or two following the extraction and can last for one to several weeks. It occurs when the blood clot that protects the tooth socket (alveolus) either does not form normally or is dislodged, leaving the bony socket open and exposed.

Dry socket is more likely to occur following the extraction of teeth on the lower jaw than the upper jaw and is most common after wisdom teeth are extracted. Dry socket occurs most commonly in people with diabetes, people who smoke and women, especially those taking oral contraceptives.

The severe pain of dry socket typically radiates out from the site of extraction and cannot be relieved by over-the-counter painkillers. If the extracted tooth was on the lower jaw, there is usually additional pain around the ear on the side of the extraction. Dry socket may also cause bad breath, a bad taste in the mouth and spasms in the jaw muscles.

Treatment of dry socket is generally very effective in reducing the pain while the tooth socket heals. X-rays may be performed to look for additional complications, such as fragments of the tooth that may remain in the socket. To treat dry socket, a dentist rinses the affected tooth socket to remove any debris. Then, a medicated dressing containing analgesics and antiseptics is lightly packed into the open socket. This helps to relieve pain, prevent bacterial or fungal infection or other forms of irritation, and prevent food particles from building up in the socket. The dressing will be replaced daily or more frequently if necessary.One major aspect of prevention is risk assessment before tooth extraction.

The dentist or oral surgeon will compile a thorough medical and dental history to evaluate the patient’s risk of developing dry socket. If the risk is high, a dentist may choose a method of tooth extraction designed to cause less trauma. Dentists also frequently recommend a professional dental cleaning before the tooth is extracted to ensure that plaque and tartar levels are at a minimum. Gentle tooth brushing and mouth rinses are typically recommended for seven days after the extraction. Patients are usually told to avoid rinsing their mouths vigorously for at least the first day.

About dry socket

Dry socket is a common complication of tooth extraction. It is characterized by severe pain at the site of the extraction that tends to get worse over time. The pain generally begins a day or two following the extraction and can last for one to several weeks.

In normal conditions, a blood clot forms in the tooth socket, or alveolus, after a tooth extraction to protect the socket while it heals. When dry socket occurs, the blood clot either does not form normally or is dislodged, leaving the bony socket open and exposed to air, food particles and infection. The lack of this intact blood clot causes pain and delays healing.

Dry socket develops most commonly after extractions of particular teeth. The extractions that most frequently result in dry socket are those of the lower molars, particularly the third molars (wisdom teeth), or premolars. When these teeth are impacted, dry socket is even more likely to occur. Reports on the incidence of dry socket vary. One study by the American Association of Oral and Maxillofacial Surgeons showed that dry socket occurs in up to 13 percent of wisdom tooth extractions among patients 25 years of age and older.

Dry socket occurs more commonly in diabetes patients, people who smoke and women, especially those taking oral contraceptives. People with diabetes have an impaired ability to heal, which raises the risk for dry socket after an extraction. People who smoke are exposed to substances in tobacco that interfere with normal cell function and impair healing. The fluctuating hormonal cycles in women appear to increase the risk, and the high estrogen levels associated with taking oral contraceptives influences the development of dry socket.

Risk factors and causes of dry socket

A particular patient’s risk of developing dry socket following a given tooth extraction can often be deduced by evaluating the risk factors. These may include:

  • Extraction of lower teeth. Dry socket is more likely to occur following the extraction of teeth on the lower jaw than the upper jaw.
  • Extraction of wisdom teeth. Dry socket is most common following the extraction of wisdom teeth, especially if they are impacted and/or located on the lower jaw.
  • Difficult tooth extractions. Extractions that are particularly difficult or cause increased trauma or other damage to the immediate area are more likely to result in dry socket. For example, if a tooth fractures during extraction, the patient has a higher risk of dry socket.
  • Dental hygiene and health. Dry socket is more common in patients with poor oral hygiene, especially if there is a buildup of plaque and tartar at the time of the extraction or active or recent gingivitis or other forms of infection. The risk is considerably less when healthy teeth are extracted.
  • Dental and medical history. Patients with a history of dry socket are more likely to experience another episode of dry socket following subsequent tooth extractions. People with increased bone density, such as those with certain medical conditions (e.g., Paget’s disease) are also more likely to experience dry socket. The complication is also more common in patients with medical conditions such as diabetes.
  • Gender. Dry socket is more common in women than men, especially in women using oral contraceptives. The degree of risk varies during particular phases of the menstrual cycle. This is apparently due to elevated amounts of certain female hormones.
  • Smoking. People who smoke also have an increased risk of developing dry socket. Tobacco contains many chemicals that interfere with normal healing and contaminate the tooth socket. Smoking on the day of surgery significantly increases the risk of dry socket, although smoking on the second and third day after surgery also increases the risk. How much a person smokes is also a factor, with heavy smokers having a higher risk than people who smoke infrequently. The method of smoking is not an influence. Women who smoke and take oral contraceptives are even more likely to develop dry socket.

Signs and symptoms of dry socket

Dry socket is characterized by severe pain that radiates out from around the site of a tooth extraction and cannot generally be relieved by over-the-counter painkillers. This pain tends to begin two or three days after a tooth has been extracted and can last up to several weeks. If the extracted tooth was on the lower jaw, there is usually additional pain around the ear on the side of the extraction.

Other symptoms of dry socket may include:

  • Bad breath (halitosis)
  • A bad taste in the mouth
  • Spasms in the jaw muscles (trismus)

Diagnosis and treatment of dry socket

Treatment of dry socket is generally very effective in relieving the pain while the tooth socket (alveolus) heals.

A patient who complains of pain after an extraction is usually examined by the dentist or oral surgeon who performed the tooth extraction. The dentist will ask about the patient’s medical and dental history and perform a dental examination focusing on the extraction site. X-rays may be performed to look for additional complications, such as fragments of the tooth that may remain in the alveolus. The x-rays may also help to determine if the pain is caused by another condition (e.g., osteomyelitis), instead of dry socket.

To treat dry socket, a dentist rinses the affected alveolus with a solution to remove any debris. A local anesthesia or a nerve block may be used to prevent additional pain and discomfort. The socket may need to be re-rinsed on occasion during the healing process. After it is free of debris, a medicated dressing containing analgesics and antiseptics is lightly packed into the open socket. This helps to relieve pain, prevent bacterial or fungal infection or other forms of irritation, and prevent food particles from building up in the socket. The dressing may be replaced daily or more frequently if necessary. Some dentists use dressings that the body will absorb over time. Oral pain-relief medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), may also be prescribed. In some cases, over-the-counter pain relievers may be recommended.


After the dentist determines that the socket dressings are no longer necessary, the patient will be instructed in how to rinse the socket to keep it free of debris and increase the rate of healing.

Prevention methods for dry socket

Patients and dentists can take many steps to prevent a dry socket from developing both before and after a tooth has been extracted. One major aspect of prevention is risk assessment. The dentist will compile a thorough medical and dental history to evaluate the patient’s risk of developing dry socket before the tooth is extracted (e.g., smoking). If the risk is high, a dentist may choose a particular form of tooth extraction, such as a trans-alveolar extraction. This involves a method that causes less trauma to the area during surgery. In some cases, a dentist may provide an antibacterial mouth rinse for the patient to use before and after the extraction. 

In general, more experienced dental surgeons tend to have fewer instances of dry socket, although it can occur with any extraction. However, choosing a dentist with plenty of extraction experience may help reduce the risk of dry socket.

A patient’s dental hygiene and dental health are important considerations to the risk of developing dry socket. Because of this, dentists often recommend a professional dental cleaning before the tooth is extracted to ensure that plaque and tartar levels are at a minimum. Furthermore, if an infection (e.g., gingivitis, periodontitis) is present, it typically requires treatment before the tooth is extracted, especially a lower wisdom tooth.

Another important aspect of timing deals with a woman’s menstrual cycle. If the patient uses oral contraceptives, the risk of dry socket can be reduced if the tooth is extracted between the 23rd and 28th day of her cycle. This is when certain hormone levels are at their lowest. Women who do not use oral contraceptives but have a prior history of dry socket or high risk factors may reduce the risk by scheduling the extraction during their menstrual period.

After a tooth extraction, it is important for patients to be gentle with the healing area. Gentle tooth brushing and mouth rinses are typically recommended for seven days after the extraction. Patients are usually told to avoid rinsing their mouths vigorously for at least the first day.

Patients should not smoke immediately before the extraction, or for at least two weeks following the extraction. The patient is generally advised to avoid drinking through a straw and spitting. These actions can cause the blood clot that protects the healing socket to dislodge.

Questions for your doctor regarding dry socket

Preparing questions in advance can help patients have more meaningful discussions regarding their conditions. Patients may wish to ask their doctor the following dry socket-related questions:

  1. How high is my risk of developing dry socket?
  2. Can you help to reduce this risk?
  3. Why do you think I may have dry socket?
  4. Is my ear pain related to a dry socket?
  5. What may have caused my dry socket?
  6. How long is my dry socket likely to last?
  7. How will you treat my dry socket?
  8. What kind of pain medication should I take?
  9. What can I do about the bad breath and bad taste caused by my dry socket?
  10. Am I likely to experience another dry socket following future tooth extractions?
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