Dry Socket – Symptoms, Treatment & Prevention

Dry socket (also known as Alveolar Osteitis) is a common complication after having a tooth extracted and it is PAINFUL!! I know this from personal experience.

After a pretty routine wisdom tooth extraction at hospital, I was in excruciating, throbbing pain for four days after the extraction. I was not sleeping. Every time I breathed it sent shooting pains up the right side of my face. I was dosing up on painkillers. The event was so traumatic, it is now permanently etched into the front of my memory.

Fortunately as I am a dentist, I knew it was dry socket so went back to the clinic. They put Alvogyl inside the socket and the pain relief was instant and MAGNIFICENT! I slept like a baby that night and I am eternally grateful to the hospital staff at Guy’s Hospital.

Why does Dry Socket Occur?

Dry socket happens when the normal post extraction healing process is interrupted due to the loss of the blood clot. When the blood clot is dislodged, it exposes the bone to saliva, air, food and bacteria. The food, saliva and bacteria then becomes packed into the hole next to the bone.

The  bone contains many nerves and pain receptors which do not like being exposed. These pain receptors will constantly fire until they are covered again.

When does Dry Socket Occur?

Dry socket occurs in between 2 to 5 percent of tooth extractions. There are some factors which make the likeliness of getting dry socket more likely. These are:

Poor Oral Hygiene

Patients with poor oral hygiene have an increased incidence of dry socket (Bowe 2011)

Brushing your teeth twice a day and flossing (or using interdental brushes) is integral to preventing dental diseases. Dry socket is no different. People with poor oral hygiene are more at risk of developing dry socket after a tooth extraction. This is because anaerobic bacteria in the mouth could  play a role in the breakdown of the blood clot.

P.S. If you need some awesome tips about getting healthy teeth I would recommend checking out these articles:

• Best Electric Toothbrush
• Best Children’s Electric Toothbrush
• How to brush your teeth properly step by step
• Oral-B vs Sonicare

Being Female

Incidence of dry socket in females 4.1% vs 0.5% in males (Sweet and Butler 1978)

Yes unfortunately women get the short end of the stick. The exact reason for this is unknown however some researchers have postulated that it may be related to oestrogen. Oestrogen increases fibrinolysis activity which leads to a weaker blood clot (Bowe 2011). Fibrinolysis simply means the breakdown of blood clots. This makes it more likely that the blood clot will become dislodged. This links nicely into the next factor.

Oral Contraceptive

Women taking oral contraceptive are 1.8 times more likely to develop dry socket than women not taking birth control (Pablos 2016)

The oral contraceptive pill works by altering the menstrual cycle. In the combined pill, this is achieved by giving your body synthetic oestrogen. As stated above, oestrogen has been linked to a weaker blood clot. It therefore should come as no surprise that the pill significantly increases your risk of dry socket.

Patient Age

Dry socket occurs most frequently between the ages of 20-40 years old (Bowe 2011)

This may in part be due to younger peoples’ bone being less dense and have more blood flowing through it. It could also be related to “sub 20 year olds” being less likely to smoke (more on this later) and take the oral contraceptive. As a rule of thumb, the older a person is the more likely they are to develop dry socket.

Tooth Location

Up to 45% of impacted lower wisdom teeth extractions result in dry socket (Cordoso 2010)

If you do not know what I mean by impacted, check out the unhappy tooth in the picture above. Instead of the tooth coming out straight, it has come out at an angle “impacting” the next tooth. If you are unfortunate enough to have one of these suckers removed (I have), then it is incredibly likely that you will develop dry socket (I did). As you can imagine these teeth are extremely difficult to extract and is why they are referred to hospital or a specialist.

Two rules of thumb that I like to stick by for tooth location is:

• Lower teeth extractions are more likely to develop alveolar osteitis than upper teeth
• Back teeth extractions are more likely to develop dry socket than front teeth especially if they need to be extracted surgically.

Smoking

Patients who smoke ten cigarettes a day are four times more likely to develop dry socket (Sweet 1979)

If you need another reason to stop smoking other than gum disease, oral cancer, cancer in general, lung disease, heart disease, stroke… (Yeah smoking is pretty bad for you), then the increased risk of dry socket may just be the ticket.  The reason cigarette smoke increases your risk is two fold:

• Numero uno is that the sucking motion on the cigarette can dislodge the blood clot
• Numero dos is that the nicotine within cigarette smoke reduces the blood supply to the extraction site (vasoconstrictor). This leads to poor blood clot formation.

P.S. If I can even get one of you to stop smoking then this blog post has been a success. Get the information you need to stop smoking NOW.

Surgical Extractions

Surgical extractions have a ten fold increase in dry socket incidence (Torres-Largares 2005)

Difficult teeth to get out, typically back teeth may need to be extracted surgically. This is particularly so for impacted wisdom teeth. When a tooth is extracted surgically, a small cut is made in the gum, bone is gently removed and the gum is stitched back together. This increased trauma has been linked to a higher incidence of dry socket.

What does Dry Socket look like?

Dry socket effectively looks like a hole. When a tooth extraction socket is “not dry” it has a dark blood clot present. This blood clot prevents food and bacteria from packing inside the socket.

In alveolar osteitis that blood clot has been lost  meaning that all  you can see is an empty hole with a whitish bit of bone peeking out from its base. This does not remain like this for long as it quickly gets filled with food debris, saliva and general gunk. Yuck!

In almost all cases you will know you have dry socket based off the pain you feel, rather than what it looks like. If you are in any doubt, then go see the dentist who pulled your tooth. This is not a bravery test.

Dry Socket Prevention

The simple advice

• Follow your dentists post operative instructions to the letter. Ideally you should have received some written and verbal instructions about how to look after the socket post extraction. If you are in any doubt then phone the dental clinic that pulled the tooth and they will be more than happy to help.
• Having good oral hygiene will decrease the likeliness of developing dry socket and help prevent all sorts of dental diseases. If you need help developing a good oral hygiene regime click here. Brush your teeth twice a day and clean between your teeth once a day, before and after the tooth extraction
• Avoid brushing near the extraction site for the first 72 hours as this could dislodge the clot.
• Stop smoking, ideally forever. If you cannot manage that then aim for 5 days post extraction.
• Avoid playing around with the extraction site or generally shoving your tongue into the area.
• Start gently rinsing three times a day with a warm salty mouthwash 24 hours after the extraction. If you rinse out your mouth too often it can actually dislodge the clot so DON’T DO IT. I did and I ended up with dry socket.
• Don’t do strenuous exercise in the first 5 days after the tooth extraction. The increase in blood pressure can dislodge the blood clot making dry socket more likely.
• Don’t drink through a straw.

The controversial advice

• Using a chlorhexidine mouthwash prior to tooth extraction and one week post extraction can reduce incidence of dry socket (Bowe 2011). There is some dispute on this point with the Scottish Dental Clinical Effectiveness Programme (SDCEP) saying “there is no evidence in favour of its use for treatment of dry socket”. If you are going to use chlorhexidine then be careful because there is a risk of an allergic reaction, it stains teeth and it temporarily alters taste.
• Planning the timing of your extraction may help particularly for women taking the oral contraceptive tablet. Research has suggested that dental extractions could be carried out on day 23-28 of the oral contraceptive tablet cycle (Bowe 2011). This is when the oestrogen levels are at the lowest and the potential risk of dry socket is minimized.

Dry Socket Symptoms and Signs

• A severe throbbing pain that is most intense three days after the tooth extraction. The pain is constant, debilitating and will keep you up at night. There will be no doubt in your mind that you have dry socket.
• Bad breath (halitosis) and a foul taste often accompanies the pain with dry socket. This is because of the bacteria and food debris stuck inside of the extraction socket.
• An empty extraction socket with visible bone at the base of the socket.
• There is often NO swelling, no pus and no systemic infection

Dry Socket Treatment

If you suspect that you have dry socket then contact your dentist ASAP for an emergency appointment. After the initial examination of the extraction site, the dentist may take an x-ray to exclude other diagnosis. If the diagnosis is dry socket, the dentist will then treat it in the following way:

1. Flush the food debris and bacteria out of the extraction site. This will either be with saline or chlorhexidine dependent on the dentist.
2. Pack the empty socket with a medicated dressing. The most frequent dressing I come across is Alvogyl®. It contains Eugenol (oil of cloves), butamben and iodoform. These ingredients act as antiseptics and analgesics. It provides fantastic pain relief and should start working immediately.
3. Very infrequently the dentist may prescribe antibiotics if your immune system is compromised or have signs of a spreading infection and/or systemic infection.

Home Remedies for Dry Socket

The most important thing to do if you suspect you have dry socket is to get an emergency appointment with the dentist ASAP. Once this is done, there are some things you can do to manage the pain

Over the Counter Painkillers

Over the counter painkillers such as paracetemol and ibuprofen can help ease the pain. Always follow the manufacturer’s instructions and NEVER take more than the recommended maximum dose.

Warm Salty Mouthwash

Rinse the food debris and bacteria out of the dry socket by using a warm salty mouthwash, half a teaspoon of salt to a whole glass of water. If this does not remove the food debris then a curved irrigation syringe can be used gently to give the extraction socket a more thorough flush. This is only to be used on extraction sites with dry socket. If used on a normal healing (non-dry socket) extraction site, it will remove the blood clot and cause dry socket.

Oil of Cloves

Once the dry socket is empty of food debris, oil of cloves (eugenol) can be used to provide lasting pain relief. Oil of cloves comes in gels such as Dentogen or liquid form. For both make sure that it can be used for dental purposes and is not limited to external use only. Always follow the manufacturers instructions.

When applying clove oil in liquid form apply one or two drops onto a cotton swab and dab it against the gum where the tooth was extracted. Some websites recommend placing the clove oil cotton swab inside of the extraction socket using tweezer and replacing this every 24 hours. I would NOT recommend this because if you press too hard then it can be almost impossible to get it out. Attempt this at your own risk.

Honey and dry socket?

There are two studies (Singh 2014 and Soni 2016) that suggest that honey could have some benefits in treating dry socket. This is by no means substantial evidence however there is unlikely to be any detrimental effects of applying honey to the extraction site area. At least it will taste nice!

Frequently Asked Questions about Dry Socket

How long does dry socket last?

Dry socket typically lasts for 7-10 days. It takes this long for the body to produce granulation tissue to start to protect the exposed bone. Usually the pain is at its worst on the fourth day and tapers off afterwards.

As the dry socket has interfered with the body’s healing process, it may take a week longer for the socket to completely heal.

Is there any long lasting adverse effects of dry socket?

Fortunately there are no long lasting adverse effects. Dry socket is a self limiting disease which usually does not cause widespread systemic effects. It does hurt a lot when you have it but long term it should be fine.

How can I tell if I have dry socket or not?

The only real way is to have the extraction site checked out by a dentist. There are some tell tale signs that may indicate you have dry socket.

• The pain will ease in the first 24 hours post extraction however will suddenly become very severe after 4 days
• The dry socket will look like a “black hole” instead of having a dark red blood clot inside of it
• The pain will be very severe, keeping you up at night and throbbing

If in doubt, seek a professional opinion.

How often does dry socket occur?

It occurs between 2 to 5 % of cases.

References:

• Pablos, T. (2016,) – Are women at increased risk for dry socket?
• Bowe, D (2011) – The management of dry socket/alveolar osteitis
• Singh (2014) – Honey a sweet approach to alveolar osteitis: A study
• Soni (2016) – Effects of honey in the management of alveolar osteitis: A study
• Sweet, D.B., Butler, D.P (1978) – Predisposing and opeRative factors: effect on the incidence of localised osteitis in mandibular third-molar surgery
• Torres-Largares (2005) – Update on dry socket:a review of the literature