Dry Socket (Alveolar Osteitis)

How dry socket is formed

Dry socket, the most common postoperative complication from tooth extraction is characterized by partial or total premature loss of blood clot that forms after extraction, exposed bone and nerves to oral environment, results in severe pain and delay in healing process.

In normal condition, immediately after extraction, bleeding occurs.  Blood quickly renders insoluble proteins to plug the wound and confines the insoluble proteins to the wound and blood clot (coagulation) forms inside a socket (socket is a hole in the bone where the tooth roots have been removed) and the healing process begins in steps below: 
  • During the first 24 hours, a fibrin-covered clot adheres to the socket bone.  
  • Within 2-4 days, fibroblasts enter the wound, this process called "Organization of the clot" and simultaneously the removal of debris (dead cell, necrotic tissue) take place.  
  • Within a week, the clot is slowly replaced by collagen fiber in granulation tissue.  
  • In 10-15 days the periphery of the socket shows formation of immature bone.  The amount of the immature bone increase from the base of the socket toward the surface of the socket and from the periphery to the center. 
  • In approximately 3 weeks to 6 months, the immature bone is replaced by mature bone. 
In dry socket, the clot dislodges or dissolves too soon (few days after extraction), leaves the bone and nerve exposed to oral cavity environment which then leads to severe pain and halitosis. Dry socket is not an infection, therefore antibiotics are not indicated unless secondary bacterial infection begins at a later time.

The incidence of dry socket has ranged from 1% to 4% of extractions; 45% occurs in mandibular third molars (lower wisdom teeth). In general, the healing process takes place in 3-4 weeks.

Note:
The incidence of dry socket may be prevented by the open surgery method according to The International Journal of Oral Surgery. Another study by Mount Sinai Hospital, Toronto reviewed the effectiveness of locally applied clindamycin in Gelfoam had reduced the incidence of dry socket formation.

Contributing factors of Dry socket:

  1. Taking oral contraceptives increases risk of dry socket according to a study reporting in Journal of Canadian Dental Association. Try to schedule during the last week of the cycle, during that time the estrogen level are inactive
  2. Trauma during extraction or difficult extraction is a contributing cause of dry socket
  3. Dry socket tends to occur more after wisdom tooth extraction especially impacted teeth
  4. History of dry socket
  5. Rinsing too soon or too vigorously; causing the clot to dislodge from the wound
  6. Ignore home care instruction provided by the dentist can cause dry socket
  7. Poor oral hygiene can lead to dry socket
  8. Taking Immunosuppressant drugs: Corticosteroids such as prednisolone (Deltasone, Orasone), Mycopehnolate (CellCept), Cyclosporine (Sandimmune, Neoral), Azathioprine (Imuran) increase the incidence of dry socket
  9. Recent history of Acute Ulcerative Gingivitis (Trench Mouth), Pericoronitis (infection around the crown of the tooth) associated  with the extracted tooth can cause dry socket.  Therefore, appropriate antibiotic prophylaxis should be administered prior to wisdom tooth extraction.
  10. Dry socket occurs often in the age group of 40-50 years old
  11. Female are prone to have dry socket than male
  12. Existing oral inflammation - will cause dry socket to occur as early as the second day after extraction. According to Birn's theory, trauma from surgery or existing inflammation causes bone and adjacent tissue to release stable tissue activators, which convert plasminogen in the blood clot to plasmin.  Plasmin is a fibrinolytic agent which dissolves the blood clot.
  13. Smoker patient has incident of dry socket than non-smoker according to a study reporting in Journal of Canadian Dental Association
How to prevent dry socket
  1. Pre-operative oral hygiene - have your teeth cleaned before extraction to reduce plaque and bacteria
  2. Use mouthrinse with 0.12% chlorhexidine gluconate just before surgery and as irrigation after extraction reduce risk in some patients (chlorhexidine gluconate mouth rinse contains chlorhexidine gluconate, alcohol, glycerin, PEG-40 Sorbitan Diisostearate, Sodium Saccharin, and FD&C Blue no.1)
  3. Stop smoking prior to surgery and 72 hours after tooth extraction
  4. Avoid vigorous mouth rinse for the first 24 hours after tooth extraction
  5. Use gentle toothbrush and gentle mouth rinse with 0.12% chlorhexidine gluconate for at least a week after tooth extraction
  6. Follow the dentist instruction and see the dentist immediately if the pain increase after few days or bad taste coming out from the extracted wound
  7. For women who use oral contraceptives; schedule surgery when you get the the lowest dose of estrogen; during days 23 through 28 of the tablet cycle.  The hormone can interfere with blood clotting in the socket.
  8. Avoid smoking, the action of smoking can dislodge the clot and contaminate the dry socket wound
  9. Avoid using straw for drinking, the suction will interfere or dislodge blood clot in socket
  10. For women, schedule extraction during the last week of the menstrual cycle; estrogen level is lower during that time
How can you tell if you have dry socket
 
1. The pain at the socket which is improving during the first few days after extraction abruptly reversing to excruciating sharp shooting pain. If the extracted tooth is in lower jaw, pain is so intense sometimes it can radiate to the ear. 

2. The normal post extraction blood clot is absent from the socket

3. The bare bony socket wall is visible, sometimes a yellow-gray of necrotic tissue can be seen on the socket wall

4. Swelling of gum tissue around the socket

5. You may have bad breath (Halitosis) and bad taste in your mouth

6. Inability to open your mouth (Trismus). Trismus develops between 10-40 days after extraction

8. Swelling of regional lymph nodes at the affected side

9. Fever, headache, insomnia and dizziness

In dry socket case, patient may not experience all these symptoms.

What the dentist may do to dry socket patient
  1. The dentist may irrigate a socket and remove food particles from the socket and induce bleeding leading to new blood clot formation

  2. Pack the socket with dry socket paste to relieve pain, prevent food debris to accumulate in the socket and protect the exposed bone. The dry socket paste consists of Eugenol, Guaiacol (antiseptic, anesthetic), and Chlorobutanol in anhydrous form (antibacterial and antifungal). The dressing need to be changed every few days (24-48 hours) for 1 week or sooner. The pain will improve within an hour after applying the dressing. Once the pain is tolerable, the treatment is discontinued. Prolong use of dry socket paste may delay healing process. Adverse reaction of Eugenol are hypersensitivity, irritation and cytotoxic when contacts with soft tissue.

  3. If there are clinical signs of infection, e.g., fever, suppuration, the dentist may prescribe Amoxicillin 1,500 mg/day; for patients who are allergic to Amoxicillin, the dentist may prescribe Clindamycin 1,200 mg/day.

  4. Instruct you to gently rinse your mouth with warm salt water (1/2 teaspoon salt in 8 ounces of very warm water) or medicated mouth rinse e.g., 0.12% Chlorhexidine 3 times daily for 7 days.

  5. If the pain persists after 48 hours, return to the dentist for further assessment
What to do at home when dry socket occurs

To remove food debris
from dry socket: use syringe with warm salt water to clean the wound or just gently switch your mouth with warm salt water, Listerine, or 0.12% Chlorhexidine digluconate (prescribed by the dentist).

To alleviate pain from dry socket: use Clove oil (from over-the-counter), add few drops in cotton pellet or gauze (cut into small size to fit the socket), and carefully apply to the wound using tweezers; place another regular size gauze over and bite down to hold the gauze in place. This method has been successfully alleviate pain within an hour in most cases.

Care must be taken to apply only to the dry socket area and not to other soft tissue to prevent unnecessary burn sensation.  Change to new dressing when it no longer help relieving pain.

Note: Use only as needed for pain, prolong use of clove oil can delay the healing process. Stop using clove oil as soon as pain subsides. Other products that contain oil of clove (Eugenol) are Red Cross Toothache kits .

To care for the wound from dry socket during the first 24 hours after extraction; rinse your mouth gently with warm water after each meal.

Consume only soft food e.g., soup.

To relieve pain with pain pills: use non-steroid anti-inflammatory drugs according to the level of pain.  See the list below:
    Mild pain
    • Acetaminophen (Paracetamol; Tylenol) 0.5 - 1g taken every 4 - 6 hours (maximum dose 4000 mg/day).  Avoid using this drug if you have liver disease or history of alcoholics.  Other name brands are:  Aceta, Anacin, Dapacin, Fem-Etts, Genapap, Genebs, Mapap, Maranox, MedaCap, MedaTab, Panadol, Tapanol and some more name brands can be found here

    • Ibuprofen (advil, motrin, mediprin, nurofen, cuprofen) 200 – 400mg taken every 4 - 6 hours 

    Moderate pain

    • Acetaminophen (Paracetamol, Tylenol) 0.5 - 1g + Ibuprofen 200 – 400mg taken every 4 - 6 hour. 

    • Codeine + Ibuprofen 2 tablets every 8 hours (brand names include Nurofen Plus and Solpaflex)

    • Codeine + Acetaminophen (Paracetamol, Tylenol) 2 tablets every 8 hours (brand names include Solpadeine, Paracodol, Solpadol and Kapake)

    • Alternating between Acetaminophen and ibuprofen by taking 1000 mg Acetaminophen or 2 extra-strength Tylenol (not to exceed 4,000 mg in one day) and 400 mg of ibuprofen or 2 tabs of Advil, every 4 hours.  Do not use this regimen if you have history of peptic ulcer, liver disease, hypertension.  Do not take more than few days. 

    Severe pain

    • Codeine - Acetaminophen and Ibuprofen

To relieve swelling from dry socket:

First 24 hours after extraction Apply ice pack or cold towel place outside of your face in the area of extraction alternately 15-20 minutes on and 15-20 minutes off for 6 hours or till bedtime.

More than 24 hours after extraction;
Apply moist heat (wet towel put in microwave for 10-20 seconds or dip towel in hot water) place outside of your face in the area of extraction alternately 10-15 minutes on and 10-15 minutes off.
This routine should be used in all extraction

Note: according to FDA, do not use Benzocaine topical products (gels or liquids) to numb the dry socket areas due to a serious and potentially fatal adverse effect from Methemoglobinemia.

Methemoglobinemia is a blood disorder in which an abnormal amount of methemoglobin (a type of hemoglobin that cannot carry oxygen) is produced.

In dentistry, small amount of Benzocaine is used to lessen the pain in the area before injection in children older than 2 years and adults.

Signs and symptoms of Methemoglobinemia may occur within minutes up to 2 hours after using Benzocaine.  Call for emergency medical assistant if there are any of these symptoms: rapid heart rate, confusion, light headache, short of breath with a pale blue or gray appearance on skin, fingernails, and lips.


7 comments :

  1. I had wisdom teeth removal in Prince George last week and ended up getting a dry socket. I tried to just ignore the pain but it was too much to bare. They put clove in it and instantly it was relieved. I recommend just having clove oil on hand, just in case.

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  4. The points and factors which you have mentioned to prevent dry socket are really very helpful. If a person follows these points he/she will never get the problem of dry socket. Thanks for sharing helpful points.
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  6. I've just head a tooth removed on my lower left nI've just swolled the clot!!!! I do smoke n im worried about this now. I fainted after the extraction. What should I do.

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    Replies
    1. Sorry for the late reply. For future reference; if you loss the blood clot and the wound start to bleed, just place a wet tea bag over the wound and bite down, you will get a new clot. But you must not smoke! Otherwise you will loose the clot again.

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