DRY SOCKET

Sometimes,Patient comes with pain and feeling of tooth remnant inside the socket after two or few days later after extraction of tooth and complaint about previous extraction procedure and dentist. It’s a time to know what patients usually complaints,

1- I am having Pain and it was started after two days of extraction of this tooth and it’s very painful.

2-I think my dentist did not extract the whole tooth because I’m still feeling that there is something (tooth fragment) in it and this is very painful if I touch it with tongue or finger.

3- I cannot chew from this side.

4-Painkillers are not making me relief completely.

5-My Dentist took too much time to extract the tooth and made me more uncomfortable during extraction procedure.

6-Sometimes, patients can tell you that sir /ma’am; my previous dentist did not tell/give me this/these post-operative instructions that you just told me.

7- And many more complaints can be told.

Remember – More you ask, more you know the case .So appropriate and chronological history is the key for correct diagnosis and treatment plans.

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> Self-healing condition.
> Pain after 2 days.
> Empty or partially empty socket.
> Exposed Bone/ nerves.
> No tooth fragment on IOPA(X-Ray).
>with or without Bad breath or a foul taste in the mouth or socket can be found as gray or dark yellow in color.

> Most common in mandible posterior teeth.
> May causative factors such smoking, birth pills, traumatic extraction, poor oral hygiene, bacterial contamination etc.

> If occurs, it should be treated by irrigation with saline, dressing (such as eugenol dressing every 24 hours till symptoms get subside), and pain killers and antibiotic (if required).

> Should be differentiated between,

1.Normal extraction pain ( usually occur within 2 days and relief with time).
2.Alveolar fracture pain.
3.Pain due to partially extracted tooth.
4.Unknown pain.

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Dry socket is one of the most studied complications in dentistry, and a great number of studies have searched for an effective and safe method for its prevention and treatment. The pathophysiology, etiology, prevention, and treatment of dry socket are very important in the practice of oral surgery.

•“Dry socket” was first described in the literature in 1896 by Crawford. Since then, other terms have been used to refer to this complications, such as “alveolar osteitis/AO”, “alveolitis”, “localized osteitis”, “alveolitis sicca dolorosa”, “localized alveolar osteitis”, “fibrinolytic alveolitis”, “septic socket”, “necrotic socket”, and “alveolalgia”, among others. The term fibrinolytic osteitis is the least used in the literature . “Dry socket”, which is the generic term and “alveolar osteitis”, are more commonly used terms.

•Eighteen definitions of AO have been reported and The most recent defines AO as “postoperative pain inside and around the extraction site, which increases in severity at any time between the first and third day after the extraction, accompanied by a partial or total disintegrated blood clot within the alveolar socket with or without halitosis” *

*I. R. Blum, “Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review,” International Journal of Oral and Maxillofacial Surgery, vol. 31, no. 3, pp. 309–317, 2002

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•The typical scenario for dry socket is the occurrence of throbbing pain about two to four days after the tooth is extracted. Dry socket pain is often accompanied by bad breath and a foul taste in the mouth.

•Alveolar osteitis refers to the inflammation of alveolar bone following extraction of tooth. It occur when the blood clot at the site of the extraction is dislodged, exposing underlying bone and nerves and thus causing increasing pain.

Note – The occurrence of dry socket is relatively rare, occurring in about 2% of tooth extractions. However, that percentage rises to at least 5-15% when it involves the removal of mandibular impacted third molars. But can be reached up to 30 to 50 % in same case.

Important Note -The best differentiation between normal extraction pain and dry socket pain is timing and Post extraction pain peaks and wanes within a 24 hour period and reduce with time, but dry socket pain peaks two to five days after the extraction and will take weeks (5 to 14 days) to go away unless treated by professionally.
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Diagnostic tips

Although alveolar osteitis is a condition in which there is loss of blood clot from socket, however, sometimes the socket may not completely empty and still contain a partially necrotic blood clot, often seen as a gray or dark yellow material. Diagnosis is confirmed by gently passing a small probe into the extraction wound. During probing, bare bone is encountered, where is extremely sensitive. Moreover food debris can be found in socket and most importantly IOPA should be taken to identify the presence of any retained tooth structure or other surgical site complication, such as alveolar fracture.

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Signs and symptoms of dry socket may include:

•Severe throbbing pain within(commonly after three to five days) a few days after a tooth extraction.

•Partial or total loss of the blood clot at the tooth extraction site, which an empty-looking (dry) socket can be seen.

•Visible bone in the socket.

•Pain that radiates from the socket to ear, eye, temple or neck on the same side of face of extraction.

•Bad breath or a foul odor coming from the mouth.

•Unpleasant taste in mouth.

•Swollen lymph nodes around jaw or neck.

•Slight fever.

•Trismus may be seen.
Note- The socket is very sensitive to chemical and thermal irrigation due to exposure of nerve endings in alveolar bone. Regional lymphadenopathy is occasionally seen. Moreover fever as well as swelling is uncommon.

Note – Dry socket is not true infection and don’t have usually signs and symptoms of typical infection such as fever, swelling or erythema. It is just delaying healing.
Note – The signs and symptoms may last from 10 days to 40 days
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Causes

•Bacterial contamination of the socket.

•Severe bone and tissue trauma at the surgical site due to a difficult extraction.

•Very small fragments of roots or bone remaining in the wound after surgery.

•Poor oral hygiene.

•Menstrual cycle( usually , middle of menstrual due to hormonal changes).

•Radiotherapy (resulting in decreased blood supply).

•Smoking or chewing tobacco.

•Use of oral contraceptive.

•Immunocompromised individuals.

•Presurgical infection of site (such as necrotizing ulcerative gingivitis or chronic periodontitis, pericoronitis incase of third molar cases).

•Age (40 to 50 age group patients).

•Site (most common in lower impacted third molar or poster teeth).

Note – In fact, studies have shown that the prevalence of dry socket is 20% in patients who smoke more than one pack of cigarettes per day and increase to 40% for those who smoke on the day of surgery or within 24 hours after surgery.

Note -Females are more frequently affected than males, but this appears to be related to oral contraceptive or menstrual cycle rather than any underlying gender predilection.

Note -It is commonly occur in the mandible than the maxilla, due to the relatively poor blood supply of the mandible and also because food debris tends to gather in lower sockets more readily than upper ones. It more commonly occurs in posterior teeth than anterior, possibly because the size of the created surgical defect is relatively larger, and because the blood supply is relatively poorer at these sites. Dry socket is especially associated with extraction of lower teeth. Inadequate irrigation of the socket has been associated with increased likelihood of dry socket.

Note – Other possible risk factors include periodontal disease, acute necrotizing ulcerative gingivitis, local bone disease, Paget’s disease of bone, osteopetrosis, cemento-osseous dysplasia,
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Treatment –

The goals of treatment are relief the pain and prevent bacterial contamination inside the socket or nearby. However, if the patient receives no treatment, no sequela other than continued mild to severe pain exists (treatment does not hasten healing of the socket)

•Flushing out the socket( warm sterile isotonic saline solution, betadine solution).

•Medicated dressings (zinc oxide eugenol past* on iodoform gauze for acute pain and should be change after every 24 hours till symptoms subside).

•Medication (NASID, topical antibiotic, systematic antibiotic (usually metronidazole) in case of immunocompromised patients may be indicated).

•Self-care (antibiotic mouth wash and maintains good oral hygiene , avoids touching the socket and avoid spicy as well as hard food or mastication from same side etc.)

Tips –

First- the tooth socket should be clean with sterile saline (should not be curetted with bare bone).

Second- insert the medicated dressing and repeat it every 24 hours until symptoms get subside.

Remember – The dressing should not be given once pain is decrease, because it may act as a foreign body and further prolongs wound healing.

*foreign body reaction may be occurred with zinc- oxide/ eugenol mix , avoiding this body reaction dextranomer granules( Debrison) and collage paste( formula K) should be use and this is introduced by Mattherw’s( 1982) and Mitchell’S( 1986).

Note – To prevent dry socket in mandibular third molar or suspected area of extraction of tooth, wound should be irrigate with saline under pressure and effectively. Moreover, small amount of antibiotic ( e.g tetracycline) can be placed inside the socket alone or on getatine sponge.

Note- alveolar osteitis is a self-limiting condition and therefore it generally resolves spontaneously. As there is no real treatment for alveolar osteitis itself, management of alveolar osteitis is directed primarily towards the relief of pain and infection

This article was originally uploaded on  Pathways’ of dental sciences(PDS) by ‎DrSumit Panchal‎ 



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