Dry Socket / Osteitis
What is Dry Socket?
Dry socket (osteitis) is inflammation of a tooth socket following the removal of a tooth. There are many synonyms for the condition, and the most appropriate is fibrinolytic alveolitis, which translates literally to mean “loss of blood clot, followed by inflammation of the tooth socket.”
Dry sockets are very painful, generally begin within 2-3 days following tooth removal, and typically last 10-15 days regardless of whether the patient is treated for them or not. Reports exist of cases lasting over a month.
Dry socket is more common in women, and the likelihood of developing a dry socket increases with use of oral contraceptives, increasing difficulty of tooth removal, surgical skill level, and presence of infection. Dry socket also occurs more frequently for patients who smoke and patients with suppressed immune function. Dry socket is more common when a single tooth is extracted then when multiple teeth are extracted. It is not known why this happens.
The most frequently involved teeth are lower wisdom teeth (third molars). Dry sockets from wisdom tooth removal are about ten times more common than when other teeth are removed.
How does the dentist diagnose Dry Socket?
When patients with dry socket are examined, the normal, healthy blood clot from the extraction site is found to have been lost, exposing the bare, bony walls of the tooth socket, which then become extremely tender. Halitosis is usually present. In lower molar extraction sites, there is typically pain that radiates to the ear. Most often, the patient has difficulty opening their mouth fully. This is a condition called trismus. Lymph nodes generally aren’t enlarged or tender, and there is no drainage present.
How to prevent Dry Socket
Measures can be taken to prevent the likelihood of occurrence, such as avoidance of smoking following the extraction. Studies show incidence of dry socket increases 500% among patients who smoke following tooth removal.
If teeth are scheduled to be removed from a female patient who is taking oral contraceptives, the likelihood of developing a dry socket may be lower on days 23 through 28 of the medication cycle. This is because estrogen levels are lowest at that time, and the presence of estrogens has been shown to produce dissolution of blood clots.
Bacteria have been shown to produce enzymes which can dissolve blood clots, and contribute to dry sockets. If there has been previous infection leading to removal of the tooth, preventive treatment with antibiotics might be considered. The tetracycline family of antibiotics appear to be more effective at preventing dry socket than the penicillins.
Tetracycline medications generally should not be dispensed to women who are pregnant or nursing, or to children. As with any medication, these antibiotics should not be prescribed to patients who are sensitive or allergic to them. Use of systemic antibiotics is becoming less common as the prospect of developing resistance to them has grown.
Development of a dry socket following a tooth extraction is not common in children. In primary teeth it virtually never occurs because primary tooth sockets are not conducive to developing the problem.
Maintaining excellent oral hygiene before and after the tooth is removed is very important to decrease the number of bacteria present in the mouth. Having your teeth cleaned in advance of the extraction is a good idea, especially if oral hygiene is not ideal.
Don’t drink through a straw, smoke, drink carbonated beverages, or rinse your mouth vigorously for the first 24 hours after the tooth is removed. It takes a full day for your body to make a solid fibrous blood clot, and if you interfere with that process, you run a higher risk of getting a dry socket.
Your dentist will likely give you instructions on how to clean and irrigate the tooth extraction socket beginning the second day after the tooth is removed. Use of 0.12% chlorhexidine antiseptic rinse with an irrigation syringe to flush the socket has been shown to cut the incidence of dry sockets in half.
If your dentist places sutures that require removal, be sure to get them out. Many dentists place resorbable sutures (the kind that dissolve on their own), but still recommend having them removed. This is because they can take up to four weeks to dissolve, aren’t functional after the first few days, and can begin wicking bacteria into the wound if left too long.
If your dentist thinks the tooth has a high probability of resulting in a dry socket due to the presence of risk factors, there are surgical steps that can be taken to reduce the risks of developing a dry socket that you may want to discuss pre-operatively.
For example, if the tooth is an impacted lower third molar (wisdom tooth), removing it through the side of the jaw (if possible) rather than the top may reduce the chance of developing a dry socket. Depending on where the nerve and blood vessels lie, the path of removal may not be optional, and only your dentist can say for sure.
Vigorous debridement of the tooth socket when the tooth is removed can promote formation of a more solid clot. Closing the gums together over the socket with sutures may also help, but it isn’t always feasible. Grafting the socket with bone graft material reduces the likelihood of dry socket, and helps to preserve the bony alveolar ridge.
Some dentists have applied antifibrinolytic medications to the tooth socket when the tooth is removed, to prevent the blood clot from dissolving easily or being dislodged. The most effective of these, known as PEPH (for propilic ester of p-hydroxybenzoic acid) has undesirable side effects, so these medications are not typically considered for patients with normal bleeding times.
It has been demonstrated that generous irrigation (250 mL to 500 mL) of the tooth socket with sterile saline solution at the time of extraction significantly decreases the incidence of dry sockets.
Some dentists are now using Platelet Rich Plasma (PRP) to accelerate healing of the surgical wound. It has been correlated with a lower incidence of dry socket; however, it requires a small amount of the patient’s blood to be drawn before the extraction is performed. It also adds cost.
How is Dry Socket treated?
You generally need to be seen by your dentist so that the tooth socket can be evaluated. The dentist may pack it with a medicated plug, which can help to sooth and protect the exposed, inflamed bone. The packing usually contains eugenol, which is derived from cloves. The packing may prolong healing, and act as a local irritant, but often provides significant relief from severe pain. It may need to be re-packed a few times, generally on a 2-3 day interval.
You may be prescribed an antibiotic, and given an irrigation syringe to flush the socket with antibiotic rinses. You may also be prescribed anti-inflammatory medications or prescription-strength pain relievers.
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