Dry Socket- Possible Causes, Symptoms and Management
A dry socket, also known as “Alveolar osteitis” is one of the commonest post-extraction complications. It is a painful condition and the patient will be complaining of foul taste. One of the characteristic features of this condition is the peculiar smell from the patient’s mouth. It occurs, usually after the 3rd or 4th postoperative day andrequires professional intervention for the management and also to rule out some other possible conditions.
Simple intra-alveolar extraction of a tooth is considered as the simplest of oral surgical procedures and most frequently, has an uneventful recovery as well.
However, everyone is not that lucky to go through this procedure without any complications. These complications can be categorized as
Pre-operative – issues relating to medical conditions or anatomy.
Intra-operative – those that occur during the procedure.
Post-operative – those that occur following the procedure.
Postoperative complications are further classified as immediate postoperative and delayed postoperative complications. Furthermore, complications are also classified based upon the location (local or distant), severity (minor or major), and type (general extraction complication or specific to a certain tooth).
To minimize the risk of developing any type of complication related to tooth extraction, one needs a proper evaluation of the patient preoperatively. Thisncludes medical history, drug history( including over the counter medicines), social history (such smoking and alcohol consumption) as these all can contribute towards delayed healing.
Certain habits can make one susceptible to develop a dry socket. Though the etiology is variable and not completely understood, Some factors known to increase the risk include smoking, and failure to comply with post-operative instructions. Many authors also suggest that teeth which have had multiple episodes of recurrent pericoronitis are prone to develop alveolar osteitis postoperatively. Lower Third molars are notoriously known to develop this complication. Some reports also pointed that poor oral hygiene plays a significant role in the risk of having a dry socket post-operatively. A few reports also pointed that females are more prone to developing a dry socket than males.
After the tooth extraction, just like when one gets injured on any other part of their body, the site of the extraction fills with blood and forms a blood clot. A dry socket develops when this all-important blood clot gets detached or lost from the healing socket before the wound has healed, leaving the underlying bone dry and exposed. This is where the concept of a dry socket comes from, as the socket is void of blood and looks denuded.
Prevention is always better than cure and we have to strive to do our best to mitigate the risk of complications. Studies have shown that using Chlorhexidine Mouth Washe a few days before a planned third molar surgery is an effective way to minimize the incidence of a dry-socket. Systemic antibiotics significantly reduce the risk of dry socket and infection in third molar extraction. Management of pericoronitis efficiently when it occurs and extract the tooth after pericoronitis subsides also helps in minimizing the risk of developing a dry socket.. Patients who do not refrain from smoking a day or two before and after extraction, have more chances of developing this complication.
Post extraction instructions should be clear and shouldinclude, avoidance of any strenuous activity as this would increase the blood pressure and risk detaching the clot. One would also need to avoid eating any hot foods as this may cause a new bleed and that may dislodge the clot. Therefore (lukewarm), soft foods will keep that clot in place.
Emphasis on the importance of not smoking for at least 48 hours, as tobacco use would delay the healing process and may increase the risk of complications. Smoking restricts the blood supply to the extraction site and some authors advise to refrain from smoking for 6 weeks or so post-extraction.Last but not least, 24 hours after the extraction, gentle rise of the mouth with lukewarm saltwater as many times a day as possible for about five days. If any undue pain after 2 to 3 days occurs, report to the dentist immediately.
Once patient reports for the pain on 3rd to 5th day postoperatively, few investigations should be performed to rule out local pathologies
A complete extraoral and intraoral examination is required to rule out any local pathology or some other source of pain. It could be pain from a foreign body in the extraction siteA radiograph is required to identify if there is a residual root tip or a bony fragment within the socket. If trismus (limited mouth opening) is present it may be caused by some general inflammation of the mucosa, extraction site or may be due to a local anesthesia needle injury to a muscle. There could also be an infection at the extraction site. Osteomyelitis may occur, however, not a frequent occurrence. Pain may originate from an adjacent tooth having a pulpal or periodontal pathology.
Some of the signs of a dry socket may include denuded bone and inflamed mucosa at the site of extraction. Usually, there is no facial swelling or regional lymph node involvement.
The treatment of dry socket would entail Irrigation of the the site with chlorhexidine or saline to remove any food debris. NEVER CURRETTE THE SOCKET TO INDUCE BLEEDING as this may progress into osteomyelitis.. Pain may be controlled by placing a sedative dressing material like Alvogyl or any similar material and theextraction site should be covered by a resorbable or non-resorbable dressing. Emphasis on maintainance of good oral hygiene is of paramount importance. Nonresorbable dressings should be removed after 48 -72 hours. If patient is still in pain, another sedative dressing is placed in the area.
Systemic analgesics should be prescribed as well to control the pain. Either Tylenol 3 or an NSAID is a good choice depending on the medical history of the patient.. REMEMBER: This is not an infection but inflammation of the bone and thereforesystemic antibiotics should not be prescribed.
1. References: Neville BW, Damm DD, Allen CA, Bouquot JE (2002). Oral & maxillofacial pathology (2nd ed.). Philadelphia: W.B. Saunders
4. Do Systemic antibiotics prevent dry socket and infection after third molar extraction? A systemic review and meta-analysis. Eva Ramos, PhD, Joseba Santamaria MD, DDS, PhD, Gorka Santamaria, DDS, PhD, Iciar Arteagoitia MD, DDS, PhD Oral and Maxillofacial Surgery Volume 122, Issue 4, October 2016
5. How Do I Manage a Patient with Dry Socket? Daisy Chemaly, DMD. J Can Dent Assoc 2013;79:d54