Dry Socket

A Painful but Not Dangerous Complication of Oral Surgery

Dear Doctor,
I recently had my wisdom teeth removed. Everything seemed to be going fine until I woke up in severe pain a few days later. The oral surgeon treated me for “dry socket” and the pain went away. Can you tell me more about this condition?

Dear Jake,
Dry socket, or alveolar osteitis, is a complication that occasionally develops after oral surgery. Although it is not dangerous, dry socket can be very painful, as you have experienced. This condition can occur when a blood clot doesn’t form properly, breaks down or is dislodged from the socket where a tooth was removed. After tooth extraction, a blood clot forms in the empty socket as part of the normal healing process. The clot serves as a barrier to protect the bone underneath from air, food and fluids as it heals. But in the absence of a protective clot, the bone and nerves can be exposed, causing the moderate to severe pain associated with dry socket.

With dry socket, pain will usually develop on the third or fourth day after a tooth is extracted and will typically lessen after 1 to 3 days. Dry socket is uncommon after a routine extraction, occurring only about 2% of the time, and it rarely happens in upper teeth. In fact, almost all dry sockets develop after lower molars are removed. According to some research reports, 1 in 5 people (20%) experience dry socket after the removal of impacted lower third molars (“wisdom teeth”) or other lower molars.

Signs, Symptoms and Causes of Dry Socket

The term dry socket describes the appearance of the painful tooth socket. When you look at an affected socket, it appears to be empty, with a blood clot partially or completely missing and some exposed bony surfaces which are very sensitive. Dry socket is characterized by dull, aching, throbbing pain that may radiate to the ear. The area of the socket often has a bad odor, and frequently there is a foul taste in the mouth. Dry socket is not usually associated with infection, so it is not typically accompanied by fever, swelling or redness.

People over age 25, smokers and women who take oral contraceptives are more likely than others to get dry socket. Engaging in activities that put pressure on the extraction site too soon after surgery—such as vigorous chewing or tooth brushing—can also contribute to dislodging or breaking down the protective blood clot. In addition, when the extraction procedure is complicated and there is more than usual trauma to the area, dry socket is more likely to occur.

Prevention of Dry Socket

It’s important to keep the mouth clean after an extraction procedure, but ask your dentist whether you should brush your teeth on the first day. You may be advised to simply rinse your mouth. If you brush, do so very gently. Chew very carefully as well, and stick to soft foods at the beginning. Avoid rinsing the mouth too aggressively, drinking through a straw, consuming hot liquids and smoking. For smokers who find it extremely difficult to stay away from cigarettes, a nicotine patch should be used instead for a few days.

Oral surgeons help reduce the risk of dry socket by taking steps to avoid bacterial contamination and minimizing trauma to the area during the extraction. Using an antimicrobial mouth rinse before or after surgery and flushing the area with saline solution after the procedure can reduce the incidence of dry socket. Suturing the extraction area has also been shown to substantially decrease the chance of dry socket. Well-controlled studies indicate that these measures can reduce the incidence of dry socket after impacted lower wisdom tooth surgery by 50% or more.

The risk of dry socket is present until the empty tooth socket is well on its way toward healing, which takes 7 to 10 days in most cases. Dry socket is no longer a risk once the extraction site has healed.

Treatment of Dry Socket

If you develop dry socket after oral surgery, take heart: Profound relief from pain often comes within 5 minutes of beginning treatment at the dentist’s office, and the pain should continue to subside over the following days. To treat this condition, your dentist may irrigate the socket and/or apply a medicated dressing that should be changed every other day for 3 to 6 days. Once the pain decreases significantly, the dressing should not be replaced because it will actually prolong the wound healing process.

Oral antibiotics are generally not used to treat dry socket, but nonsteroidal anti-inflammatory pain relievers such as ibuprofen (Motrin® or Advil®, for example) may be prescribed for a few days if necessary.

Keep in mind that the goal of any treatment for dry socket is to relieve pain, but treating the condition does not speed up healing. If a person receives no treatment for a dry socket, the only negative effect will be continued pain. Even though dry socket does not cause any long-term damage, it’s certainly uncomfortable. Therefore, it’s wise for anyone who thinks they may have dry socket to call their dentist as soon as possible.