Dry socket (alveolar osteitis) is a very painful dental condition that may occur after a tooth extraction or wisdom tooth removal. It is excruciatingly painful because a blood clot has failed to form over the extraction socket, which leaves the bone and nerves exposed.
That means every time food, water, or air touches the exposed bone and nerves, it will result in intense pain. Under normal circumstances this wouldn’t happen because the blood clot is supposed to cover and shield the socket from all stimuli. Unfortunately for a dry socket, the blood clot is missing in action.
How common is it?
According to various studies, the incidence of alveolar osteitis can be as high as ~5%.
- A study from Melbourne, Australia found a 2.3% incidence rate.
- A different study found the incidence to be about 2.6%.
- A study of the South Chennai population found an incidence rate of 5.37%.
Overall it appears that women were at higher risk and the mandibular teeth were 3x more likely to get it than maxillary teeth.
Excruciating pain is a hallmark trait of a dry socket and that is how you can tell that you have it. Our patients often tell us that the toothache is worse than before they had the extraction. That should give you an idea of how bad it can feel.
Signs and symptoms of a dry socket:
- Severe pain. The pain feels unbearably painful that can throb and radiate.
- Missing blood clot. Tooth socket is missing a clot and it looks empty.
- Exposed bone. Due to lack of blood clot, you can visibly see the jaw bone.
- Bad breath. Food getting stuck in the hole can ferment and cause bad breath.
- Unpleasant taste. Lodged food that is many days old can cause a bad taste.
- Lack of blood. Socket is devoid of blood.
- Delayed healing. The extraction socket will close very slowly.
Dry socket vs Normal socket
|Dry Socket||Normal socket|
|Appearance||Yellow (exposed bone)||Red (blood clot) or white (white stuff)|
|Feeling||Increasing pain over time||Decreasing pain over time|
|Odor||Bad breath, smell, taste||Bad breath, smell, and taste since food can get stuck as well|
|Healing speed||Delayed closure of socket||Gum slowly closes with each passing day|
For actual clinical photos of what it may look like in the mouth, please check out this study on PubMed. We’re trying our best to keep afterva appropriate for all ages, which is why we won’t have them here.
There is no cure for a dry socket where a single treatment can make the condition go away. Despite the bad news, the upside is that it will heal all on its own when given enough time.
Nonetheless, it doesn’t mean that your dentist can’t do anything for you in the meantime. All of the current available treatments focus on alleviating pain and attempts at inducing healing while your body does its job.
Treatments for alveolar osteitis:
- Induce bleeding. Your dentist may attempt to drill various small holes into the jaw bone to get it to bleed. This is in hopes that it may stimulate the formation of a blood clot.
- Curettage and irrigation. Alternatively, your dentist may curettage (scrape) the inside of the socket to clean it and hopefully it may induce healing. Finally they’ll flush out the site with an antibiotic solution or saline.
- Place stitches. Stitching up the extraction hole tightly will decrease the size of it and hopefully it’ll prevent food and debris from getting into it. This may help reduce the incidences of painful sensations.
- Dry socket paste. A special eugenol based medication in the form of a paste that can be placed inside of the socket. It was designed to be soothing and help alleviate socket pain. The dry socket paste is typically left inside of the hole for 3-5 days. It does not need to be removed since it gets washed out all on its own during the healing process.
- Mouth rinse. Frequently rinsing with salt water or chlorhexidine can keep the area clean and free of debris. This may help reduce pain and promote healing.
- Pain medication. Alveolar osteitis is painful and what better way to alleviate pain than to take pain medication. Ibuprofen, acetaminophen, or even opioids can help reduce pain.
The prospects aren’t as grim as they may seem because dry sockets do heal on their own without any intervention. What you can expect is about a 1-2 week delay in the normal healing time if you have this condition.
This condition just heals slower than normal but it will heal up. The only caveat is that it tends to hurt more than a normal healing socket. No complications are expected since we’ve never seen a non-healing dry socket. They simply need more time to recover.
The exact cause of a dry socket is still a mystery and all we have are theories by researchers and clinicians. Although what we do know is that the condition seems to be a result of a biological process and not a mechanical one.
Mechanically disrupting the blood clot via rinsing, spitting, or drinking through a straw has no bearing on a dry socket occurring. A lot of sources seem to like perpetuating the misconception that drinking through a straw will cause one. That is simply incorrect and shows a lack of understanding of its mechanism. That also means swallowing normally will not cause it either since that creates less pressure than a straw.
Theories for alveolar osteitis:
- Bacteria. One hypothesis is that bacteria may have initiated the dry socket lesion. They may also prolong the duration of the condition as well. Taking antibiotics do seem to decrease the incidence.
- Plasmin-induced fibrinolysis. According to Birn, there appears to be an increased concentration of plasmin and fibrinolytic activity for dry sockets. The theory is that during a traumatic extraction, somehow the plasmin gets activated.
- Osteoblast necrosis. An alternative theory is that during traumatic extractions, the high compressive forces may have caused the osteoblast cells to have died. The death of osteoblasts may trigger fibrinolytic activity.
All of the these are merely theories which have not been proven nor disproven. Perhaps one day we will finally figure out what causes this painful dental condition after extractions.
The cause for dry socket may not be completely understood but there are risk factors that can increase your chances of getting it. Overall it appears that women seem to be at higher risk.
- Smoking. Studies have shown that smokers (12%) are 3 times more likely to get dry socket vs non-smokers (4%).
- Traumatic extraction. Particularly difficult extractions do increase the incidences of it.
- Birth control. Studies have shown that the incidence of alveolar osteitis was significantly higher for those using birth control.
- Middle of Menstrual cycle. In addition to taking birth control, researchers also found that women during the middle of a menstrual cycle were more likely to get it.
- Had it before. If you’ve had alveolar osteitis in the past, you’re more likely to get it again.
It is impossible to completely prevent a dry socket from happening because we don’t even know what causes it exactly. The only thing we can do is minimize the risk factors and keep the extraction site as clean as possible.
- No smoking. Smoking after a tooth extraction can increase the chances of getting dry socket by a factor of 3.
- Pause oral contraceptives. If you’re able to take a break from taking birth control, it would help decrease the chances of it occurring.
- Take antibiotics. Studies have shown that taking antibiotics do decrease the chances of it occurring. However it is not standard protocol to prescribe antibiotics for every single extraction because you also run the risk of creating super bugs. These are antibiotic resistant bacteria.
- Improve oral hygiene. It always helps to keep the extraction site as clean as you can. A reduction in plaque, bacteria, and food debris is helpful.
- Salt water rinsing. Studies have shown that rinsing with salt water can decrease the incidence of dry socket, 2.5% vs 25% for those who do vs those who don’t.
What does not prevent alveolar osteitis:
- Stitches. Whether or not you have stitches have no effect on developing a dry socket. Although if you do happen to get it, placing stitches may reduce the pain but that is about all that it can do for you.
When can I stop worrying about a dry socket?
The onset of dry socket symptoms typically occur 24-96 hours after the time of extraction. That means it is fair game for you to get the condition even four days after the procedure was done!
In our opinion, you can stop worrying about alveolar osteitis if 5-7 days have passed and you don’t have any symptoms. You can let out a sigh of relief at that point but do you know what all of this implies? The first week of the tooth extraction aftercare or wisdom teeth removal aftercare is the most crucial. You should follow the instructions “to the T” during that time.
Dry socket is a risk for all extractions, especially for wisdom teeth removal. The more impacted they are, the higher the risk because it’ll most likely be a traumatic surgery. There is simply no way of avoiding it because researchers don’t even know the cause of it.
However, what we are certain of is that if you smoke after the procedure your chances of getting it are 3x higher than a non-smoker. Therefore it is of utmost importance to hold off on smoking for as long as you can!
Nonetheless, if there was any consolation the condition does heal on its own. It just takes time for it to happen but at least your dentist does have palliative treatment available to reduce some of the discomfort!