Dry Socket – Diagnosis and Management

Dry socket is a relatively common post-operative complication following a tooth extraction. This post discusses the aetiology, the symptoms, diagnosis and management of a dry socket.

What is a Dry Socket?

A dry socket, or alveolar osteitis, occurs when a blood clot fails to form in a socket post-extraction, or is dislodged/lost from the socket before healing has occurred.

Typically, following an extraction a blood clot forms which serves two purposes:

1. It protects the underlying bone and nerves – exposure of this can cause intense pain
2. It forms the basis for new bone and soft tissue formation in the socket

Therefore, loss of the clot will impact healing as well as trigger pain.

Aetiology of a Dry Socket

The exact aetiology of a dry socket is still up for significant debate, however there are certain risk factors that increase the likelihood of developing a dry socket. Typically, these are factors that would impact the ability of the blood clot to form or to remain in place. Some common risk factors include:

• Smoking and tobacco use – this could be due to nicotine causing vasoconstriction. Other chemicals in cigarettes may also disrupt wound healing.
• Failure to follow post-operative advice – poor oral hygiene or rinsing within the first 24 hours following a procedure may disrupt the clot.
• Radiotherapy – this causes hypovascularity of the bones and therefore a reduction in the ability to form clots. Patients are also at risk of osteoradionecrosis.
• Extraction site – dry sockets are more common in the mandible than the maxilla (due to a relatively poorer bloody supply) and more common in posterior teeth than anterior teeth (again due to a poorer bloody supply but also larger extraction sockets). Dry sockets are extremely common following removal of third molars.
• Trauma – the risk of a dry socket increases with a greater degree of trauma during an extraction. This may be due to damage to surrounding vasculature and therefore a reduced healing capacity.
• Oral contraceptive pill – changes in oestrogen levels, particularly higher levels, are thought to impair healing capacity.
• Infection – they are more likely to occur when there is a pre-existing infection in the mouth.

Signs and symptoms

A true dry socket is not an infection, therefore there will be an absence of pyrexia, lymphadenopathy and pus exudate. Usual signs and symptoms include:

• A moderate-severe dull, throbbing pain from the extraction site. This may radiate to surrounding anatomy. Pain usually develops a few days after the extraction and may not be controlled with regular, or even stronger, analgesia. This pain is often described by patients as being worse than the original toothache.
• A bad taste (often metallic) and halitosis
• Partial or complete loss of the clot will expose the bony socket – this will be extremely painful
• Localised inflammation but relatively minimal due to a lack of infection

Diagnosis

Diagnosis is clinical. Patients will usually present a 2-4 days after extraction with worsening pain. Clinical examination will reveal an exposed socket. Often gentle irrigation with saline is required to remove any food or tissue debris that is in the socket.

The patient usually has a known risk factor as above. There is usually an absence of signs of infection, though infections do often occur with dry sockets as many of the risk factors are similar.

Management

Management is mainly symptomatic:

• Gentle irrigation of the socket, with saline or local anaesthetic, to remove any debris that may impede healing
• Packing of a sedative dressing in to the socket to relieve pain, such as Alvogyl
• Prescription/advice on regular analgesia – ensure patients are staggering their analgesia to get maximum effect and progress them up the WHO pain ladder

Reviews may be necessary and often repeated dressings are required.

Prevention

There is varied evidence of effective ways of preventing a dry socket from occurring. There have been various scientific papers on pre-treatment chlorhexidine mouthrinses and prophylactic antibiotics. Some clinicians debride sockets or opt for adrenaline-free local anaesthetic, however no evidence supports these.

Ultimately, key methods to prevent dry sockets from occurring is to avoid the main causes:

• Ensure patients follow post-operative advice – no rinsing/spitting in the first 24 hours, minimal increases in blood pressure, maintaining good oral hygiene etc
• Ensure patients avoid smoking
• Ensure extraction is as atraumatic as possible

Summary

• Dry sockets are an extremely common post-operative complication
• Aetiology is not completely understood, however certain risk factors have been identified including smoking, extraction site and infection
• The most common symptom is a moderate-severe throbbing pain. Other symptoms include halitosis and a bad taste. Clinically, an exposed socket will be evident
• Diagnosis is a clinically carried out
• Management involves socket irrigation, packing and analgesia
• Prevention should be considered in all situations – primarily mitigating risk factors

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Recommended Reading

• Essentials of Oral and Maxillofacial Surgery
• Dry Socket: Incidence, Clinical Features and Predisposing Factors
• Clinical Concepts of Dry Socket