DRY SOCKET
All you need to know about dry sockets
A dry socket, or alveolar osteitis, occurs when a blood clot fails to form in a socket post-extraction or is dislodged or lost from the socket before healing has occurred. The blood clot forms two purposes following an extraction.
PURPOSE OF BLOOD CLOTS
- Firstly, it forms the basis for new bone and new soft tissue to form in the area so that things can return to normal.
- And secondly, it helps protect the underlying bone and nerves and therefore, if it is lost, these are exposed, and the patient usually experiences pain.
So, if the clot is lost, patients will have impaired healing and they’ll also experience symptoms i.e pain. If we look at the aetiology or the causes of a dry socket this is an area that is up for intense debate, however there are some obvious risk factors that increase your risk of developing a dry socket.
RISKS
The first one of these is smoking and tobacco use.
For example, we know nicotine causes vasoconstriction and with vasoconstriction you will have a reduced blood supply to the area to help healing. Therefore, we advise patients not to smoke for as long as possible following an extraction. Like this, patients who have had radiotherapy have hypovascular bones, so they have reduced blood supply to these areas. Therefore, along with their risk of developing osteoradionecrosis following an extraction, they also have a potentially higher risk of developing a dry socket. If we look at the extraction itself, the area the tooth is being taken out from also has an impact.
So anatomically the maxilla has a lower incidence compared to the mandible and the more posterior the tooth the higher the risk of a dry socket compared to an anterior tooth. The reason behind this again comes down to vascularity.
So, the maxilla is more vascular compared to the mandible and the more posterior the tooth the lower the vascularity compared to an anterior tooth. Additionally posterior teeth tend to have larger sockets and therefore the demand in terms of healing is greater – there’s a bigger socket to heal, more blood is needed and therefore the capacity for a dry socket increase. So, the mandible has a higher risk than the maxilla and posterior teeth have a higher risk than anterior teeth.
Additionally, if the extraction is particularly traumatic then the patient is usually at a higher risk of dry socket, so this is why dry sockets are extremely common following extraction of lower third molars because they’re in the mandible, they’re posterior teeth and they’re typically a difficult extraction so there’s a lot going against them.
Additionally, if patients fail to follow the post-operative advice, their risk may be higher, so we advise patients to not rinse and not spit out following an extraction and the reason behind this is to avoid that blood clot either failing to form or dislodging completely once it has formed. However, if patients fail to follow this advice, that blood clot is going to struggle to stay in place and their risk of a dry socket will increase. Other factors that may increase the risk of a dry socket include if the patient’s got a pre-existing infection and hormonal changes, so patients who are on the oral contraceptive pill for example, we tend to see a higher rate of dry sockets, and this may be due to the fact that hormone changes can impair your ability to heal.
SIGNS AND SYMPTOMS
It’s important to note that a true dry socket is not an infection, so a patient will typically not have a fever or pyrexia, they will not usually have enlarged lymph nodes or lymphadenopathy, and typically there won’t be any pus in the socket. However, patients who are typically at a higher risk of a dry socket, are also at a higher risk of infection and therefore we often see them occurring together. If we look at the true symptoms of a dry socket the most important one is that patients will experience pain. Now this is typically moderate-severe, dull, throbbing pain from the area of extraction. It usually develops a few days after the extraction and a lot of patients will describe it as being worse than the pain they experienced before in terms of toothache.
Typically, you can’t control it with regular analgesia. Additionally, patients may be experiencing bad breath or halitosis and they may have a bad taste in their mouth, usually metallic taste. If we then clinically looked at the socket in terms of the signs that we’d see there would either be a loss of the clot completely or a partial loss of the clot in the socket. There may also be some debris in the socket and usually there is localised inflammation of the soft tissues surrounding the socket. To diagnose a dry socket, we don’t necessarily need any imaging of sorts – this is usually a diagnosis that is done through clinical factors and looking at the patient’s history.
MANAGEMENT
It becomes obvious when the patient mentions the symptoms that we’ve discussed and we see the signs that we’ve discussed, a dry socket is usually the obvious diagnosis. Now in terms of management – managing a dry socket is usually symptomatically done. So, we first gently irrigate the socket with saline or with a local anesthetic and this helps get rid of any debris that’s in the socket that may be impairing healing. This may also encourage some bleeding from the socket and the fresh blood may form a new clot. We then usually put a sedative dressing into the socket, such as Alveogyl, this helps relieve the patient’s pain, but it also again can form the basis for a new clot to form.
Next, we want to ensure that the patient follows the correct post-operative advice. So, we need to remind them not to rinse, not to spit out, no exertions so that when the new clot is forming, it can stay there, and it won’t get dislodged again. Additionally, patients may need some advice regarding analgesia so either we need to work through the WHO pain ladder and just recommend what they should use, or we need to prescribe them something to help manage their pain if necessary.
Now finally, if the patient does have an infection along with the dry socket, then we may have to prescribe antibiotics if they’ve got systemic signs. So, there we go, we’ve looked at what a dry socket is, the risk factors for developing a dry socket, the signs, and symptoms and how we diagnose a dry socket as well as the management of a dry socket.
These are important things to know because it’s such a common post-extraction complication it’s something that can easily be handled in practice.
