Overview

Dry socket (alveolar osteitis) is a painful complication that can develop after having a tooth extracted. Under normal circumstances a blood clot forms at the extraction site, this clot is responsible for protecting the bone and the nerves at this site, and also responsible for starting the healing process. 

Dry socket happens when the blood clot fails to form or when it gets dislodged. This leads to severe pain when the nerves and the bone are exposed. The socket becomes irritated, inflamed and infected. Food can become trapped in the socket, making the pain even worse. 

Dry socket can occur in 2 to 5% of extractions, it can happen with any extracted tooth, but it is more common with wisdom teeth, especially impacted mandibular wisdom teeth.¹

Signs and symptoms of dry socket

Symptoms of dry socket usually start 1 to 3 days after the extraction, and they include the following:

• Severe throbbing pain that radiates to the ear or the eye on the same side of the face 
• Bad breath (halitosis) from the empty socket
• Bad taste coming from the socket
• Exposed empty socket
• Symptoms can be accompanied by a low-grade fever

Causes of dry socket

The cause of this complication is an increase in fibrinolytic activities resulting in the breakdown of the post-surgical blood clot. Fibrinolysis is the natural process of the body that breaks down and removes blood clots in response to trauma or pathological thrombosis. Researchers believe that the increased fibrinolysis is due to an introduction of bacteria into the socket during tooth extraction, or injury to the extraction site due to increased difficulty of tooth removal  (usually happens with wisdom teeth). ²

Risk factors of alveolar osteitis

Many factors can increase your chance of developing dry socket after extraction, including the following:³ 

• Smoking and tobacco use: the chemicals in cigarettes and tobacco can delay the healing process, and sucking while smoking can dislodge the clot easily
• Birth control pills: high oestrogen levels from oral contraceptive pills can delay the healing process and result in dry socket
• Traumatic extraction
• Pre-existing tooth or gum infection: this can lead to contamination of the extraction site and increase the risk of dry socket
• Poor oral hygiene
• Not following post-extraction instructions given by the dentist
• Previous history of dry socket may increase the likelihood of developing it
• Some medical conditions like diabetes have been linked to increased risk of dry socket

Diagnosis of dry socket

Severe pain after extraction is an indicator of dry socket. Your dentist will do a clinical examination to determine the location of the pain and to examine the socket for blood clot, a dental x-ray could be done to confirm or rule out other causes of pain like bone infection and to ensure no tooth fragments or roots were left after extraction.⁴

Management of dry socket  

According to dental guidelines, management focuses mainly on symptom control as opposed to disease control. Treatment of alveolar osteitis focuses mainly on reducing pain and discomfort and promoting healing. The following steps are included in treatment of dry socket:⁴ 

• Reassurance of the patient
• Irrigation and debridement of the socket under local anaesthesia: your dentist will clean out the socket using saline or chlorhexidine to ensure food debris or materials that could cause more pain are removed
• Topical local anaesthesia, and oral analgesia, primarily a non-steroidal anti-inflammatory drug (NSAID) are administered after irrigation to relieve the pain
• Placing a medicated dressing at the extraction socket can provide quick pain relief
• Recent evidence suggests that low-level laser therapy is effective in managing the symptoms of dry socket
• Pain medication: your dentist will prescribe the right pain medication based on your medical history
• Antibiotics may be prescribed if infection is suspected
• Self-care at home: following post-operative instructions and regular oral hygiene measures at home is crucial for fast healing

Complications of dry socket

A dry socket can be extremely painful if left untreated, but it rarely causes serious complications. Delayed healing is guaranteed after a dry socket. On rare occasions, infection of the socket and surrounding bone can progress to a more serious infection of the surrounding area.

Prevention of dry socket

Following your dentist's post-extraction instructions is key to preventing dry socket. Here are the steps you should follow to ensure healing of the extraction socket:

• Preventative antibiotics can be prescribed if patients pose a higher risk for developing infections (e.g. immunocompromised patients or those with significant systemic diseases)⁵
• Do not touch the extraction socket with your hand or your tongue to avoid dislodging the blood clot
• Avoid harsh rinsing on the first day of extraction.
• Gently rinse with warm salt water or antiseptic mouthwash twice a day after extraction to ensure a clean area around the socket.
• Inform your dentist about any medication you are taking before the extraction
• Avoid drinking from a straw 
• Avoid alcohol and smoking
• Eat soft food for the first 24 hours
• Avoid hard, crunchy food or food containing pips
• Avoid chewing on the same side of the extraction to minimise the risk of removing the blood clot
• Avoid brushing around the extraction socket, but brush and floss the rest of your teeth normally
• Contact your dentist if you feel pain that lasts more than 3 days after the extraction

When to see a dentist?

Make an appointment with your dentist if you experience the following after extraction:  

• Persistent severe pain
• Bleeding
• Swelling at the same side of the extraction
• Fever
• Bad breath or unusual bad taste

FAQs

Will a dry socket heal itself?

Yes, in most cases dry socket heals after some time, but the pain and discomfort most people experience is the reason they go back to their dentist.

How long is dry socket a risk after tooth extraction?

The second and the third day after the extraction is when the risk of developing a dry socket is the highest.

Can I eat with a dry socket?

Yes, but eating soft food for the first 24 hours is better to avoid irritation of the socket. Avoid caffeine, alcohol and smoking. It is also better to avoid drinking with straws because the sucking action can dislodge the blood clot easily.

Can I take antibiotics for a dry socket?

Antibiotics can be used as a preventive measure in certain cases, but the use of antibiotics for the treatment of dry socket is questionable and not recommended.

How painful is a dry socket?

Dry socket exposes the bone and the nerve endings at the extraction socket to food debris and air. Pain can be sharp and throbbing similar to toothache.

Conclusion

Dry socket is a painful condition that can occur after tooth extraction when the blood clot that normally forms at the extraction site doesn’t form or is removed. It is characterised by severe pain after extraction, bad mouth odour, and bad taste. 

The exact cause of dry socket is not fully understood but certain risk factors can increase your risk for developing dry socket. Smoking and tobacco use, oral contraceptives use, history of dry socket, and poor oral hygiene are all factors that should be taken into consideration. 

Dry socket can be prevented by following pre- and post-extraction instructions provided by your dentist. Dentists have an obligation to educate patients about dry socket and all possible complications that can occur after dental extraction, by understanding all aspects of dry socket patients can take proactive steps to ensure smooth recovery after extraction.