What are dry sockets?
A dry socket, more formally referred to as alveolar osteitis by dentists, is a fairly common complication associated with tooth extractions. The formation of a dry socket involves a scenario where the blood clot which forms in the tooth socket's after the extraction isn't properly retained (either it disintegrates by way of fibrinolysis or becomes dislodged). Since this blood clot is an important factor in protecting the boney socket and initiating the healing process, the healing of the extraction site is interrupted and becomes delayed.
What are the symptoms of a dry socket?
Dry sockets can have a throbbing pain. With most tooth extractions a dental patient will experience some level of discomfort at the extraction site (no matter how minor) on the day the tooth has been removed and then, with each day that passes, less and less pain as the healing process progresses. In those cases where a dry socket forms, the patient typically notices that their level of discomfort does progressively diminish for the first few days but then, between three and five days after the extraction, pain from the extraction site begins to intensify.
Dry socket signs and symptoms ...
The pain associated with a dry socket can be moderate to severe in intensity and often has a throbbing component. The pain can be just localized to the extraction site or it may radiate from the extraction site to the patient's ear or eye (on the same side of their face). Additionally, the dental patient may notice a foul odor or taste emanating from the tooth socket. Upon visual inspection (when possible) the tooth socket will appear to be empty (minimal or no blood clot or granulation tissue present) and when looking down into the socket exposed bone is visible. The term "dry socket" is derived from this empty socket appearance. The lymph nodes in the patient's jaw or neck may become enlarged.
How often do dry sockets occur?
Dry socket formation is often associated with lower wisdom tooth removal.
The frequency of occurrence for dry sockets, when considering for all tooth extractions collectively, is roughly on the order of 1 to 3%. Extractions involving lower teeth, especially molars, are statistically more likely to result in dry socket formation. Dry sockets may occur in as many as 20% of the cases involving the extraction of mandibular (lower) impacted wisdom teeth.
Risk factors: What causes dry sockets?
Dental research has yet to definitively determine the exact pathogenesis associated with dry socket formation. However, as we discussed previously, dry sockets result from a situation where the blood clot that normally forms in the tooth's socket after an extraction has not been properly retained.
Dental researchers have identified a number of factors that appear to be associated with an increase incidence of experiencing a dry socket and we have listed many of these factors below. We should bring to your attention however that the results of many studies are conflicting and therefore not all of the (potential) risk factors we list here are necessarily accepted by the dental community as a whole. Your dentist should be able to shed light on those factors that their experience has demonstrated to them are significant.
Dental patients who don't follow their dentist's postoperative instructions have a greater incidence of dry sockets.
Place the gauze directly over the socket, then apply firm pressure. We've listed this factor first because this is absolutely something you have control over. People who follow their dentist's instructions after having a tooth extracted, especially those regarding allowing a blood clot to form and then protecting it, will have fewer postoperative complications.
Typically a dentist will advise their patients that after a tooth extraction they should, at minimum, place firm biting pressure on the gauze packing that the dentist has placed over their extraction site for the next 30, and probably preferably, 60 minutes. Under normal circumstances this will provide opportunity for a blood clot to form in the tooth socket. Once a blood clot has formed, the patient must be diligent in their efforts not to disrupt it. This means that for the first 24 hours after the extraction the dental patient should avoid vigorous rinsing, refrain from actions like sucking on a straw or cigarette, avoid alcohol and tobacco use in general, minimize physical stress and exercise, and avoid hot liquids such as coffee or soup. Of course these instructions are generalized. Your dentist should provide you with those postoperative instructions that they feel are important for your specific situation. If they don't, just ask.
Dental patients who have experienced dry sockets with past tooth extractions are at greater risk for developing a dry socket with future tooth extractions.
If you have had a dry socket in association with a previous tooth extraction, you should consider yourself to be at somewhat greater risk for experiencing a dry socket again. Of course it's certainly possible that your previous dry socket experience might have been related to not having followed your dentist's postoperative instructions as closely as you should have. If so, your previous experience might be the motivation you need to follow your dentist's instructions more diligently this time.
Traumatic tooth extractions are more likely to result in dry socket formation.
All dentists know that there seems to be a correlation between the amount of tissue trauma created during the tooth extraction process and the potential for a dental patient to experience a dry socket. The general hypothesis is that the traumatized bone in the area of the extraction site releases compounds (tissue activators) that then diffuse into the blood clot that has formed in the tooth socket. These tissue activators cause the blood clot to disintegrate, thus leading to the delayed healing of the socket. It is also thought that some of the compounds released as a result of this blood clot disintegration are kinins, a type of compound known to stimulate pain receptors (hence causing much of the pain associated with dry sockets).
The amount of trauma associated with a tooth extraction might be planned or unplanned. With some wisdom tooth extractions the dentist will know beforehand that a fair amount of tissue trauma will be created. As an example, if an impacted wisdom tooth is entirely encased in the jaw's bone the dentist will need to both make an incision through gum tissue and remove that bone that lies over the impacted tooth before they can access the tooth itself. In comparison, when a dentist extracts a wisdom tooth that has already erupted into normal position in the mouth then the dentist already has direct access to the tooth and therefore no gum incision or bone removal is likely to be needed.
A dentist may approach an extraction hoping that its removal will be straight forward and simple but instead finds that the extraction is much more difficult than expected. (This is why having a less experienced dentist perform your tooth extraction may place you at greater potential for experiencing a dry socket.) With a difficult extraction the tissues surrounding the tooth will be manipulated to a greater degree. The amount of time over which the tissues are manipulated will be increased also. Both of these factors will result in relatively more collective trauma to the area where the extraction has taken place. Subsequently the patient will be at greater risk for developing a dry socket than if the tooth had come out more easily.
Patients who smoke tend to have a greater incidence of dry socket formation.
People who smoke are at greater risk for dry sockets. Some studies have suggested that people who smoke are more than four times more likely to experience a dry socket than a nonsmoker. A number of theories have been postulated as to what the association between tobacco smoking and dry sockets might be. Some relate it at the cellular level and the cytotoxicity of the smoke itself while others to the overall systemic effects of nicotine. The carbon monoxide that is introduced into the bloodstream by smoking does reduce the amount of oxygen that can be carried, thus producing a reduced oxygenation of the healing tissues. Additionally, it has been theorized that tobacco smoke might contaminate the wound site or may alter its bacterial population. One other factor to consider, the sucking action associated with smoking may draw out or otherwise dislodge the blood clot that has formed in the tooth socket.
Women who take oral contraceptives are at greater risk for dry sockets.
Women taking birth control pills are at greater risk for dry sockets. Women who take oral contraceptives (birth control pills) seem to be at greater risk for developing dry sockets than those who don't. It is thought that estrogen can play a role in disintegration of the socket's blood clot. It has been suggested that by coinciding their tooth extractions with those days in their oral contraceptive dosing cycle when their medication contains its lowest estrogen levels may help to minimize the occurence of dry sockets. The association between estrogen and dry sockets in general may also explain why women as a group are 20% more likely to experience dry sockets than men.
The presence of bacteria may play a role in dry socket formation.
Your dentist may write you a prescription for an antibiotic. There is some research that supports a view that bacteria might play a role in the development of dry sockets. Some studies have reported that dental patients who have a high pre or postoperative bacterial count in the region of the extraction site are at greater risk for dry socket formation. People who have poor oral hygiene seem to have a greater incidence experiencing dry sockets. People who have active infection in the gum tissue surrounding a tooth (pericoronitis) are also at greater risk.
This is one reason why a dentist might feel that they need to place a patient on a regimen of antibiotics for some days before an extraction is performed. This is also the reason why some studies have suggested that rinsing with an antibacterial mouthwash (chlorhexidine) before a tooth extraction or placing an antibiotic-impregnated packing into the tooth socket at the time of the extraction can be ways of minimizing the occurrence of dry sockets. These findings are not universally accepted by the dental community however and therefore are not universally practiced. While it would always be left up to the discretion of the treating dentist, most protocols for treating dry sockets do not include placing the dental patient on an antibiotic regimen.
The age of the dental patient may be related to the risk for experiencing dry sockets.
Some studies have suggested that there is an association between the age of the dental patient and the incidence of dry socket formation. While not supported by the findings of all studies, the general rule of thumb is that comparatively younger patients are at less risk for dry sockets than comparative older patients. As an example, one study found that dental patients in the age group 15 to 19 years developed dry sockets at a rate of about 3% whereas patients in the age group 30 to 34 experienced them at three times this rate. This is one of the reasons why a dentist might suggest wisdom tooth removal in the age window: late teens to early 20's.
Dry socket formation is often associated with lower wisdom tooth removal.
Dry socket risk: Location, location, location.
The location of the tooth needing extraction seems to correlate with the risk of dry socket formation. In general there is a greater incidence of dry sockets with the extraction of lower teeth as opposed to upper teeth. A greater incidence of dry sockets with molars as opposed to front teeth. The greatest risk of dry socket formation seems to be associated with lower wisdom teeth, especially impacted lower wisdom teeth.
How do dentists treat dry sockets?
The focus of the protocol that a dentist follows when providing treatment for a patient who has a dry socket is usually only supportive and palliative. A dry socket is a situation where the extraction site's healing has been delayed. With time the extraction site will still go ahead and heal on its own, it will just take longer than it would otherwise. Dry socket treatments do not speed up the healing of the wound, they simply help to mitigate the discomfort the patient experiences while the (now prolonged) healing process takes place. A medicated dressing will sooth a dry socket.
It's typical that the discomfort associated with a dry socket is difficult to control with analgesics (pain pills) alone (either non-prescription or prescription). Usually the best treatment solution involves returning to your dentist's office so they can wash out the extraction site and then place a medicated dressing into the socket.
The dressing that is selected for placement into the tooth socket will vary from dentist to dentist depending upon their previous experiences with different products. Some of the more common ingredients incorporated into dry socket dressings are eugenol (an extract of clove oil) and benzocaine (an anesthetic). Usually the dressing is changed (depending on the patient's comfort requirements) every 24 to 48 hours for 3 to 6 days. A patient can experience dramatic relief, even within an hour, once a dry socket dressing has been placed.
Don't be hesitant to seek treatment from your dentist for your dry socket.
All dentists know that the potential for dry socket formation always exists. And although there may be factors that can influence the incidence rate, a patient actually experiencing a dry socket is, to some degree, simply bad luck. A dentist also knows that cleansing and then placing a treatment dressing into the tooth socket can be an important factor in helping the patient manage the pain associated with their dry socket.
For both of these reasons, you'll probably find that your dentist is sympathetic to your cause and accommodating in providing you with assistance. They know that dry sockets, while certainly a disappointing complication associated with tooth extractions, always can and will occur and therefore they fully anticipate that some patients will be contacting them and require assistance with their dry sockets.
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