Understanding Dry-Socket: Managing Tooth Extraction-Pain

A dry socket typically causes throbbing pain for several days after tooth extraction.

A dry socket is a condition of inflammation of the jawbone (or alveolar bone) after tooth extraction. Also called "alveolar osteitis," it is one of the many complications that can occur from a tooth extraction.

• A dry socket is relatively rare, occurring in about 2% of tooth extractions.
• However, that percentage rises to at least 20% when it involves the removal of mandibular impacted third molars (lower wisdom teeth).

The typical scenario for a dry socket is the occurrence of throbbing pain about two to four days after a tooth is pulled. Dry socket pain is often accompanied by bad breath (halitosis) and a foul taste in the mouth. This onset of pain is a sign proper healing has been interrupted.

Normally, after a tooth extraction, a blood clot forms in the socket to protect the surrounding bone and nerves as they heal. A dry socket is an empty or partially empty tooth socket that may appear pale due to the exposure of the bone and tissues in the absence of a protective blood clot. Without this protective blood clot, the underlying bone and nerves are exposed to air, food particles, and bacteria, which can cause the dry socket to appear green or yellow in color and lead to substantial discomfort and slower healing.

The most common cause of dry sockets is a complication often associated with wisdom tooth extractions. This occurs when blood clots fail to form properly or dislodge within three to five days after the extraction.

A dry socket is caused by the partial or total loss of a blood clot in the tooth socket after tooth extraction. Normally, after a tooth is extracted, a blood clot will form as the first step in healing to cover and protect the underlying jawbone. If the blood clot is lost or does not form, the bone is exposed and healing is delayed.

In general, a dry socket is a result of bacterial, chemical, mechanical, and physiologic factors, such as:

• Bacterial: Preexisting infection present in the mouth before a dental extraction such as periodontal disease (or periodontitis) can prevent the proper formation of a blood clot. Certain oral bacteria can cause the breakdown of the clot.
• Chemical: Nicotine used by smokers causes a decreased blood supply in the mouth. As a result, the blood clot may fail to form at the site of recent tooth extraction.
• Mechanical: Sucking through a straw, aggressive rinsing, spitting, or dragging on a cigarette or vape pen causes dislodgement and loss of the blood clot.
• Physiologic: Hormones, dense jawbone, or poor blood supply are factors that prevent blood clot formation.

Before tooth extraction, risk factors for developing a dry socket include smoking, the presence of an impacted wisdom tooth, being female, and being above age 30.

Smoking is a risk factor for developing a dry socket due to the nicotine found in cigarettes. Exposure to nicotine reduces the blood supply available to the healing socket and can prevent the proper formation of a blood clot at the extraction site. Chewing tobacco also contains nicotine and additionally carries the risk of infection.

Extraction of impacted third molars (wisdom teeth) can be traumatic, as some surrounding gum tissue and jawbone may need to be removed or may be adversely affected during surgery. Although the extraction is necessary, the resulting trauma can increase the chances of a dry socket.

Previous infections such as periodontal disease or pericoronitis at the site of the extraction can predispose an individual to a dry socket.

Women tend to develop a dry socket more often than men. This may be related to hormonal factors such as the use of oral contraceptives or normal hormonal changes during a woman's cycle.

Patients older than 30 years of age with impacted third molars have an increased risk of dry sockets. With age, the jawbone becomes denser and has less blood supply available. A dense jawbone increases the risk of a traumatic extraction, and less blood supply decreases the chances of blood clot formation and timely healing.

A tell-tale sign of a dry socket is a socket that has a partial or total loss of a blood clot. The jawbone may be visible in the socket and the surrounding tissue may appear gray due to poor healing.

Early signs and symptoms of a dry socket include:

• A throbbing steady pain presents a few days after tooth extraction.
• Pain that may radiate to other parts of the head such as the ears and eyes on the same side of the face.
• Bad breath and a bad taste may also be present due to the accumulation of food debris and bacteria in the socket.

The diagnosis of a dry socket is based on the history of dental treatment, clinical examination, and the individual's symptoms. The timing of when symptoms begin may be an indicator of a dry socket. During normal healing, the discomfort of extraction should lessen over time. However, if the pain increases, this is an indication healing is delayed and could be due to a dry socket.

• Typically, dry socket symptoms develop two to four days after tooth extraction.
• Most dry sockets happen within the first week after tooth extraction.

Dry socket treatment usually involves symptomatic support while the socket heals.

• Initially, the dentist will gently irrigate to clear the socket of food debris.
• Next, an analgesic (pain relieving) medicated dressing or packing is placed within the socket to cover the exposed bone. This usually provides immediate relief. This dressing may need to be replaced every few days during the healing process. The dressing is often coated with "dry socket paste," which is made up of ingredients with pain-relieving properties, including eugenol (clove oil).
• Additionally, medications can be prescribed to manage the pain.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen [Advil, Motrin] or naproxen [Aleve])
  • Narcotics (such as hydrocodone/acetaminophen [Vicodin]) may be prescribed to relieve pain

Home treatment for a dry socket usually involves temporary management of pain until a dental professional can be seen for treatment.

Dry socket self-care methods to provide some pain relief include:

• Over-the-counter pain medications for pain management
• A cold compress or an insulated ice pack on the affected side of the face (15 minutes on and 15 minutes off)
• Practicing good dry socket oral hygiene, including rinsing with salt water to remove food debris
• Use of clove oil (place one to two drops of clove oil on a clean cotton swab and gently apply to the affected area)

Again, these methods are only for temporary relief of pain. Delaying a follow-up visit with the dentist or surgeon could prolong the pain as well as the recovery time.

The prognosis for dry socket is good, as there usually are no long-term consequences. Once the tissue can cover the bone, the healing will progress normally.

The average healing time for a dry socket is seven 7 to 10 days, as this is the amount of time it takes for new tissue to grow to cover the exposed socket.

Dry sockets are painful and difficult to ignore, but they are generally not dangerous. However, if a dry socket goes untreated, it can cause more serious problems. An untreated dry socket can cause delayed healing or an infection that can spread into your jawbone.

The prevention of developing a dry socket may be influenced by the methods used by the dentist or surgeon performing the tooth extraction. Such preventive methods for how to avoid dry socket include:

• Placement of packing at the surgery with or without antibiotics (for example, tetracycline).
• Placement of sutures to protect the blood clot. These details can be discussed with the dentist or surgeon before the procedure to determine if these preventive methods would be recommended.

After extraction, there are a few day-to-day activities that should be avoided: smoking, drinking with a straw, and vigorous spitting or rinsing.

A soft food diet is best. The area should be kept as clean as possible with gentle rinsing with an antibacterial solution, such as chlorhexidine rinse (Peridex). This oral rinse can be prescribed by your surgeon. It is important to follow any special instructions given by the dentist or surgeon in caring for the extraction site at home.

Lastly, recent studies have shown that the incidence of a dry socket in women is significantly decreased when tooth extractions are performed during their menstrual period (menses). When tooth extractions can be electively planned, the recommendation is to perform this procedure during the menstrual period. In this way, the risk of a dry socket due to cycle-related hormonal changes can be eliminated.

• When can I stop worrying about dry socket? You can stop worrying about dry socket around 7 to 10 days following a tooth extraction. By this time, the gum tissue has typically healed significantly, and the likelihood of the blood clot becoming dislodged is minimal. To further reduce the risk of having a dry socket, strictly follow after-care instructions given by your dentist during this period.
• Will it be obvious if I have a dry socket? A dry socket will be obvious. When your dentist examines the extraction site, they may notice an empty socket with exposed bone rather than a black blood clot. You may also notice certain symptoms such as severe pain that starts a few days after the tooth extraction and spreads to your ear, eye, neck, or temple on the same side you underwent the extraction. You may also notice an unpleasant odor or taste in your mouth.
• What is the fastest way to get rid of a dry socket? The fastest way to get rid of a dry socket is to seek treatment from your dentist or surgeon. They can clean the socket to remove debris and apply a medicated dressing to promote faster healing. You may be prescribed pain medicines for pain relief. Your dentist will give you self-care advice, such as washing your mouth gently with a saltwater solution, refraining from smoking, and maintaining proper oral hygiene to prevent infection and help with recovery.