Dry Socket (Alveolar Osteitis)

Characteristic of "Dry socket " or Alveolar Osteitis that occurs 2-4 days after tooth extraction are:
  • A socket either wholly or partially void of blood clot
  • Throbbing pain and intense pain that radiates to the front of the ear
  • Erythema of the gingiva around the socket
  • Putrid odor
  • Other symptoms such as a headache, insomnia, and dizziness may present

 How dry socket forms

In normal condition, immediately after extraction, bleeding occurs.  Blood quickly renders and confines insoluble proteins to cover the wound. Blood clot (coagulation) forms inside a *socket and the healing process begins in steps below: 
  • During the first 24 hours, a fibrin-covered clot adheres to the socket bone.  
  • Within few days, fibroblasts enter the wound, this process called "Organization of the clot" and simultaneously the removal of debris (dead cell, necrotic tissue) takes place.  
  • Within a week, the clot is slowly replaced by collagen fiber in granulation tissue.  
  • In 10-15 days, the periphery of the socket reveals a formation of immature bone.  The amount of the immature bone increases from the base of the cavity toward the surface and from the edge of the socket to the center. 
  • In approximately three weeks to six months, the mature bone replaces immature bone. 
*Note: Socket is the hollow part of the bone where the tooth roots located.

In dry socket, few days after tooth removal, a total or partial premature loss of the blood clot occurs in the socket. Direct exposure of the bone and nerve endings to the oral environment without blood clot, results in severe pain radiating toward the ear and halitosis.

Dry socket is an inflammation, not an infection; therefore, antibiotics are not indicated unless secondary bacterial infection begins at a later time.

The incidence of the dry socket has ranged from 1% to 4% of extractions; 45% occurs in mandibular third molars (lower wisdom teeth). Dry socket occurs more frequently in difficult extraction compare to routine tooth removal, according to a clinical study by Dr. Porus Turner.  In general, the healing process of dry socket takes place in 2-4 weeks.

According to the International Journal of Oral Surgery, the incidence of the dry socket may be prevented by the open surgery method. Another study by Mount Sinai Hospital, Toronto reviewed the effectiveness of the local application of clindamycin in Gelfoam reduced the incidence of dry socket formation.

Contributing factors of Dry socket:

  1. Oral contraceptives increase the risk of a 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. Traumatic and complicated extraction 
  3. Injection of local anesthesia with vasoconstrictors as in the technique used in intraligamentous anesthesia caused insufficient supply of blood to the socket
  4. Remaining of bone fragments in the socket may interfere with the healing process
  5. Dry socket tends to have greater incidence after wisdom tooth extraction especially impacted teeth
  6. History of dry socket after tooth extraction
  7. Rinsing too soon or too vigorously; causing the clot to dislodge from the wound
  8. Ignore home care instruction provided by a dentist
  9. Periodontal disease or poor oral hygiene 
  10. Uncontrolled diabetes
  11. The use of Immunosuppressant drugs: Corticosteroids such as prednisolone (Deltasone, Orasone), Mycophenolate (CellCept), Cyclosporine (Sandimmune, Neoral), Azathioprine (Imuran) increase the incidence of dry socket
  12. The 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.
  13. Dry socket often occurs in the age group of 40-50 years old
  14. Females are prone to have dry socket than male
  15. Smoker patient has an incident of the dry socket than non-smoker according to a study reporting in Journal of Canadian Dental Association. Nicotine is a vasoconstrictor that can delay the healing process.
How to prevent dry socket
  1. Before an extraction, schedule to have your teeth cleaned. The cleaning helps reduce plaque and bacteria in the oral environment
  2. Use mouth rinse with 0.12% chlorhexidine gluconate just before surgery and as irrigation for at least a week after tooth extraction to reduce the risk of dry socket. (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 tooth extraction and 72 hours after tooth extraction.  The action of smoking can dislodge the clot
  4. Avoid vigorous mouth rinse for the first 24 hours after tooth extraction
  5. Brush your teeth gently after extraction
  6. Follow the dentist instruction and see a dentist immediately if the pain increases after few days or bad taste coming out from the extracted wound
  7. According to the research, women who use oral contraceptives should schedule surgery during the lowest level of estrogen, e.g., during days 23 through 28 of the tablet cycle.  The hormone can interfere with blood clotting in the socket.
  8. Avoid using a straw for drinking, the suction may dislodge the blood clot in the socket
  9. 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 a dry socket or how do you feel when you have the dry socket?  

Here are some of the signs and symptoms of patient who has dry socket:
The appearance of dry socket
1. The pain at the socket that is improving during the first few days after extraction abruptly reversing to excruciating sharp shooting pain. If the extracted tooth is in the lower jaw, the pain sometimes radiates to the ear.

2. The usual 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. Patient may experience bad breath (Halitosis) and bad taste

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

8. If secondary bacterial infection occurs; the regional lymph nodes on the affected side become swelling and patient begins to have fever

Note: Some patients 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 a dry socket paste to relieve pain, prevent food debris from 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).

    It is necessary to change the dressing every few days (24-48 hours) for one week. The pain will improve within an hour after applying the dressing. Once the pain is tolerable, the treatment is discontinued. Prolong use of a dry socket paste may delay the healing process. Adverse reaction of Eugenol is 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 antibiotics

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

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

Remove food debris
from dry socket:
  1. Use syringe with warm salt water to clean the wound
  2. Gently switch your mouth with warm salt water,
  3. Rinse with Listerine or 0.12% Chlorhexidine digluconate (prescribed by the dentist).

Alleviate the pain from dry socket: use Clove oil (from over-the-counter) or other products that contain oil of clove (Eugenol) such as Red Cross Toothache kits.
  1. Add few drops of clove oil to cotton pellet or gauze (cut into a small size to fit the socket) and carefully apply to the wound using tweezers. To avoid burning and stinging sensation, do not allow clove oil to contact the surrounded soft tissue
  2. Place another regular size gauze over and bite down to hold the dressing in place.
  3. Change to new dressing when the dressing no longer relieves pain. This method has been successfully alleviating the pain within an hour in most cases.
Note: Due to clove oil's ability to delay the healing process, use a minimum amount necessary for the pain and stop using it as soon as pain subsides.

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:
    For mild pain use:
    • 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:   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

    For moderate pain use:
    • 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 every four hours:
      • If you begin with 1000 mg Acetaminophen or 2 extra-strength Tylenol, after 4 hours switch to
      • 400 mg of Ibuprofen or 2 tabs of Advil. You may alternate this regimen not more than few days.

        Do not use this regimen if you have a history of peptic ulcer, liver disease, hypertension.  Do not take Tylenol more than 4,000 mg a day.

    For severe pain
    • Codeine - Acetaminophen and Ibuprofen

To relieve swelling from dry socket:

First 24 hours after extraction;
Apply an ice pack or cold towel 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 the microwave for 10-20 seconds or dip a 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 use 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 severe 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, a small amount of Benzocaine is used to lessen the pain in the area before injection in children older than two years and adults.

Signs and symptoms of Methemoglobinemia may occur within minutes up to two hours after using Benzocaine.  Call for emergency medical assistant if there are any of these symptoms:
  • Rapid heart rate
  • Confusion
  • A light headache
  • Short of breath with a pale blue or gray appearance of the skin, fingernails, and lips