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Dry Socket, also known as dento-alveolar osteitis, alveolar osteitis, alveolitis, focal osteomyelitis without suppuration, alveolalgia, alveolitis sicca dolorosa and alveolar periostitis, is a well-recognised complication of tooth extraction.

It is characterised by increasingly severe pain in and around the extraction site usually starting on the 2 – 4 post-operative day and can last for 10 – 40 days.

The pain radiates typically to the ear. The normal post-extraction blood clot is absent from the tooth socket; the bony walls of the socket are bare and exquisitely sensitive to even gentle probing. Bad breath and an unpleasant taste in the mouth are invariably present.

The condition probably arises as a result of a complex interaction between surgical trauma, local bacterial infection and various systemic factors.

The incidence rate probably lies somewhere between 3 – 20% of all extractions with lower pre molar and molar sockets most commonly involved.

Risk Factors

  • Extraction of ‘wisdom teeth’ especially impacted lower ‘wisdom’ teeth
  • Traumatic & difficult extractions
  • Oral / depot contraception
  • Immunosuppressant drugs such as steroids, cyclosporine & methotrexate
  • Active / recent history of Acute Ulcerative Gingivitis (‘Trench Mouth’) or Pericoronitis (infection / inflammation around the crown of a tooth) associated with the tooth to be extracted
  • Smoking (> 20 cigarettes per day)
  • Increased bone density either locally or generally (eg. Paget’s Disease & Osteopetrosis)
  • Previous history of ‘dry sockets’ following extractions.
Photograph of Dry Socket
Photograph of Dry Socket

Preventive Measures for the Patient

Wherever possible pre-operative oral hygiene measures to reduce plaque levels to a minimum should be instituted, such as using an antiseptic mouthwash.

Patients who smoke should stop before the tooth extraction and for at least 2 post-extraction whilst the socket(s) heals.

Patients should avoid vigorous mouth rinsing for the first 24 hours post-extraction and to use gentle tooth brushing and mouth rinses for 7 days post-extraction.

Patients should return to the Oral Surgeon / Dentist immediately they develop increasing pain from the extraction socket, awful taste in the mouth or bad breath.

Dry Socket Treatment

The infected socket is gently irrigated with an antiseptic mouthwash.

The socket is packed with a dressing that contains sedative and antiseptic ingredients. The dressing prevents the accumulation of food debris in the extraction socket, protects the exposed bone from local irritation and calms down the inflammation-infection within the extraction socket walls.

Antibiotics may be prescribed or changed (if already on painkillers will still need to be taken until the effects of the sedative dressing become apparent and the infection has started to clear.

If the pain does not settle within 48 hours, then get back in contact with the Oral Surgeon / Dentist.

Useful Articles & Websites

Anesth Prog 1990. Clinical Reports. Alveolar Osteitis Following Surgical Removal of Mandibular Third Molars

Medicina Oral S 2005. Intra-alveolar chlorhexidine gel for the prevention of dry socket in mandibular third molar surgery. A pilot study

Evidence-Based Dentistry 2005. Rinsing with chlorhexidine may reduce incidence of dry socket after 3rd molar surgery

BDJ 2006. The Prevention of ‘Dry Socket’ with Topical Metronidazole in General Dental Practice

Evidence-Based Dentistry 2008. Chlorhexidine Gel reduces Incidence of Alveolar Osteitis after Extraction of the Mandibular 3rd Molars

Pakistan Oral & Dental Journal 2009. Alveolar Osteitis – Incidence & Risk Factors Following Third Molar Surgery In Jordan

University of Toronto, Faculty of Dentistry 2009. Alveolar Osteitis Prevention Strategies in Third Molar Extractions. An Evidence-Based Review.

Evidence-Based Dentistry 2009. Chlorhexidine gel reduces incidence of alveolar osteitis after extraction of the mandibular 3rd molars

J Oral Maxillofac Surg 2010. Clinical Concepts of Dry Socket

J Oral Maxillofac Surg 2011. Factors Affecting Incidence of Dry Socket. A Prospective Community-Based Study

J Oral Maxillofac Surg 2011. Comparison of Alvogyl, SaliCept Patch & Low-Level Laser Therapy in the Management of Alveolar Osteitis

Evidence-Based Dentistry 2012. Does chlorhexidine prevent dry socket?

Cochrane Review 2012. Local Interventions for the Management of Alveolar Osteitis (Dry Socket)

JOMS 2013. Effect of Menstrual Cycle on Frequency of Alveolar Osteitis in Women Undergoing Surgical Removal of Mandibular 3rd Molar. A Single-Blind Randomized Clinical Trial

J Indian Aca Oral Med Radiol 2013. Dry Socket (Alveolar Osteitis) – Incidence, Pathogenesis, Prevention & Management

BDJ 2014. Interventions for the Prevention of Dry Socket. An Evidence-Based Update

J Adv Med & Dent Sci Research 2014. Current Recommendations for Treatment of Dry Socket – A Review

J Pharm Sci & Res 2015. Incidence of Dry Socket after Third Molar Extraction

Int J Oral Care Res 2017. Effectiveness of Two Different Methods used for Dry Socket Management – A Comparative Study

J Oral Health Dent Sci 2017. Dry Socket Following Teeth Extraction – Effect of Excessive Socket Saline Irrigation

J Korean Assoc Oral Maxillofac Surg 2018. Dry Socket Etiology, Diagnosis, and Clinical Treatment Techniques

SADJ August 2018. Painful Dry Socket – An Alternative Perspective