If you’ve ever had a tooth taken out, your dentist has more than likely discussed with you the possibility of dry sockets. Dry sockets are nothing to mess around with, and we are going to talk about just what they are and things we can do to avoid them – as well as discuss risk factors that increase your chances of getting them.

What Are Dry Sockets?

A dry socket, or ‘alveolar osteitis,’ is a clinical condition where an affected extraction site has lost its clot – leaving a bare, bony socket. The bone is left extremely sensitive, causing severe pain and even a foul odor. Along with the pain, it’s not uncommon for fever and soreness around your lymph nodes to develop, as well. The main etiology of dry sockets is still up for debate, but it is thought that premature loss of the initial blood clot is the main perpetrator¹. The formation of the clot is the beginning of the first stages of healing of the extraction site – after the clot forms bone begins to replace it. Alveolar osteitis is still a ‘mysterious’ subject; its etiology, as well as the proper management of them, is still currently being reviewed. With that being said, there are certain factors that can predispose you to forming them.

What Causes Dry Sockets?

Like we mentioned above, it’s still up for debate – but thought to be the premature loss of the initial blood clot. The premature loss isn’t always just a physical act, though (such as spitting the clot out on accident). There is believed to be three primary factors that are linked to the loss of the clot – bacteria, trauma, and medications.

One researcher believes that bacteria may be the main causative agent in dry sockets. Dry sockets were found to be three times more likely in those with poor oral hygiene in a study with impacted third molar extractions. Another study showed, in 284 patients, 100% of the cases of alveolar osteitis that presented with poor oral hygiene also developed dry sockets. So what does this have to do with bacteria and dry sockets? The same bacteria that are found in necrotic tissue around periodontally-involved teeth (those with gum disease) also cause fibrinolysis – meaning they can break up blood clots. This hypothesis links the bacteria with the ability to break up the clot due to their presence in the oral cavity in those who are not orally hygienic².

Trauma is another theory – some have associated the difficulty of the extraction and the experience of the dentist being another factor in the development of alveolar osteitis. If heavy forces are used and crush the surrounding bone, it may induce necrosis of the bone, releasing a plasminogen activator which may cause fibrinolysis of the clot³. This theory would be applied in a situation where a wisdom tooth is horizontally positioned and particularly difficult to remove, or where excessive force is applied when unneeded.

Medications can also have a significant affect on alveolar osteitis. If you are taking oral contraceptives, there has been a significant association with developing dry sockets. In fact, it was found in a meta-analysis that ‘females taking oral contraceptives were 1.8 times more likely to develop DS after the surgical removal of impacted mandibular third molars than those not taking oral contraceptives⁴.’

So How Can I Prevent Dry Sockets? Can We Treat Them?

‘There is no current evidence-based consensus that has been reached on the prevention and management of this condition².’

Alveolar Osteitis: A Review of Current Concepts

I always tell my patients to avoid the three ‘S’s’ – sucking through straws, spitting, and smoking². These three factors alone can cause the physical dislodgment of the clot – leaving the bone beneath the clot bare and susceptible.

The most common risk factors are what were mentioned above (trauma, bacteria, medications) – though there is still a debate and no consensus as to whether smoking, gender, or menstrual cycles are significant risk factors according to a systematic review⁵. Other studies claim that smoking does have a significant impact with the development of post-operative complications⁶. Studies have also been conducted surrounding antibiotic prophylaxis of third-molar extractions – it was found that amoxicillin showed no significant difference in alveolar osteitis rates but use of azithromycin in the socket site may be beneficial for those with immunocompromised status⁶.

The bottom line is exactly this – ‘The occurrence of dry sockets in an everyday oral surgery or dental practice is unavoidable⁶.’ If you do find yourself with dry sockets, the dentist can treat the area with a saline rinse, though even the management of a dry socket is up for debate (and likely why a saline irrigation is the best option). The best practice of avoiding dry socket’s is to keep your oral hygiene clean, avoid physical dislodgment with the ‘Three S’s,’ and taking it easy on the day of the operation.

To Summarize:

• Dry sockets are a condition where the extraction site becomes inflamed and painful
• The cause of dry sockets is still being researched
• Bacteria, trauma, and medication use has been linked to dry sockets
• Preventing dry sockets may be unavoidable, but measures can still be taken
• Avoid spitting, sucking through straws, and smoking after the extraction to prevent physical dislodgment of the clot
• Take it easy on extraction day to prevent high blood pressure/ excessive bleeding
• A saline rinse with an injection tool can help keep the area clean (your dentist can give you one)

References:

¹Chi, Angela, Brad Neville, Douglas Damm, Carl Allen. Oral and Maxillofacial Pathology, 4th Edition. Saunders, 052015. VitalBook file.

²Chow, O., Wang, R., Ku, D., & Huang, W. (2020). Alveolar Osteitis: A Review of Current Concepts. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons, 78(8), 1288–1296. https://doi.org/10.1016/j.joms.2020.03.026

³Mamoun J. (2018). Dry Socket Etiology, Diagnosis, and Clinical Treatment Techniques. Journal of the Korean Association of Oral and Maxillofacial Surgeons, 44(2), 52–58. https://doi.org/10.5125/jkaoms.2018.44.2.52

⁴Xu, J. L., Sun, L., Liu, C., Sun, Z. H., Min, X., & Xia, R. (2015). Effect of oral contraceptive use on the incidence of dry socket in females following impacted mandibular third molar extraction: a meta-analysis. International journal of oral and maxillofacial surgery, 44(9), 1160–1165. https://doi.org/10.1016/j.ijom.2015.05.017

⁵Taberner-Vallverdú, M., Sánchez-Garcés, M. Á., & Gay-Escoda, C. (2017). Efficacy of different methods used for dry socket prevention and risk factor analysis: A systematic review. Medicina oral, patologia oral y cirugia bucal, 22(6), e750–e758. https://doi.org/10.4317/medoral.21705

⁶Tarakji, B., Saleh, L. A., Umair, A., Azzeghaiby, S. N., & Hanouneh, S. (2015). Systemic review of dry socket: aetiology, treatment, and prevention. Journal of clinical and diagnostic research : JCDR, 9(4), ZE10–ZE13. https://doi.org/10.7860/JCDR/2015/12422.5840

Liability Statement:

The medical advice given in this blog should only be utilized by a medical professional who has received a medical degree. I am not responsible for the medical advice given in this blog and each case should be reviewed extensively with sources outside my blog. This blog is for education purposes only and is not meant as a substitute for an academic institution.