Review Article

The Risk Factors, Prevention, and Management of Dry Socket Review Article
Wei-Yo Chang, Yin-Lai Wang Department of Dentistry, Kaohsiung Armed Forces General Hospital

With the progress of dentistry, the requests of patients for their oral health and function are getting higher. Tooth extraction is one of the necessary treatments among the dental treatment plan, while some complications are accompanied with it. Dry socket is a well-known postoperative complication following dental extraction. However, the real etiology of this condition is still unclear. Several factors contribute to the occurrence of dry socket have been discussed in many literatures, such as surgical extractions, poor operator's technique, smoking, patient's gender and age, the use of oral contraceptives and bacterial infection. In order to reduce the discomfort of patient and the incidence of dry socket, we have to know the prevention and management although the treatment of this complication is still controversial. Therefore, we can reduce the medical cost and prevent the distrust of patients. ( J. Family Dent. 7(4): 4-10, 2013 )

Key words: dry socket, fibrinolysis, surgical extraction, alveolar osteitis, alveolitis

Introduction
alveolitis, is a well-known postoperative complication by Crawford in 1896, and most authors have accepted the
2

Dry socket, also known as alveolar osteitis or

following dental extraction. This term was first described

1

"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 socket with or without halitosis".
3

The most recent definition of dry socket is

theories that dry socket occurs due to the disintegration of the blood clot by fibrinolysis.

partial or total disintegrated blood clot within the alveolar

Received: April 9, 2012 Revised: April 12, 2012 Accepted: April 18, 2012 Correspondence to: Dr. Wei-Yo Chang, Department of Dentistry, Kaohsiung Armed Forces General Hospital No.2, Zhongzheng 1st Rd., Lingya Dist., Kaohsiung City 802, Taiwan (R.O.C.) Tel: 07-7494572 Fax: 07-7498239 E-mail: xiaoyo1006@hotmail.com

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The Risk Factors, Prevention, and Management of Dry Socket

Incidence
the incidence of dry sockets following routine dental extractions has been reported in the range 0.5% to 5%.
4

basis of this reason; many authors believe that operator's experience is a risk factor for the development of dry socket. Some literature claims that following extractions performed by the less experienced operators, a higher incidence of dry socket was reported.
12,13

According to the statistics of different literatures,

after extraction of mandibular third molars, which is generally accepted the incidence is about 20% to 30% of dental extractions.
3,5

The occurrence of this complication is more frequent

the prevalence of dry socket was higher after single extractions than multiple extractions.
14,15

Some previous and current studies indicated that This is possibly

Comparison to non-surgical extractions, surgical extractions result in about 10 times higher incidence of dry socket.
3

reported different incidence varies from 0% to 45%.

There are also some researchers

4,6,7

because multiple extractions are mostly performed on

mobile and periodontally compromised teeth, these teeth are generally simple to be extracted, and may be less traumatic. A previous study, discussed the incidence of dry socket, also recommended if several adjacent teeth are to be extracted, it is better to perform in one operation. Individual / Systemic difference a correlation with smoking. According to the study of mandibular third molars have been statistically analysed, Many studies demonstrated that dry socket has
16

Factors
contribute to the occurrence of dry socket have been discussed in many literatures. Traumatic factors comparison to nonsurgical extractions, result in about
3

Although the mechanism is unknown, several factors

Sweet et al, which a total of 4000 surgically removed there was a dose dependent relationship between smoking and the incidence of dry socket. In this study, patients who smoked a half-pack of cigarettes a day had a four- to compared to nonsmokers. The incidence of dry socket

We have mentioned that surgical extractions, in

agree that surgical trauma and difficulty of surgery play a significant role in the development of dry socket. This is secondary to bone marrow inflammation following the more difficult and, hence, more traumatic extractions.
2 4

10 times higher incidence of dry socket. Most authors

five-fold increase in dry socket (12% versus 2.6%) when increased to more than 20% among patients who smoked a pack per day, and 40% among patients who smoked period.
17

attributable to more liberation of direct tissue activators

on the day of surgery or in the immediate postoperative smoked on the same day of surgery had a higher incidence postoperatively.
18

common following the extraction of mandibular third studies suggest that the anatomical site specificity are molars. In addition to the effect of surgical trauma, some
8,9

The frequency of dry socket has been shown more

It has also been reported that patients who

of dry socket than those who smoked on the second day There was a statistically significant difference
5

responsible for this complication, such as increased bone of producing granulation tissue. However, no evidence blood supply.
10 9

density, decreased vascularity, and a reduced capacity indicated that a link between dry socket and insufficient Poor operator's technique or experience may also
11

in the incidence of dry socket between smokers and

interfere the healing process of alveolar tissue through the formation of clot by suction effect.
3

nonsmokers. It has been speculated that smoking may

introduction of pollutants to the surgical wound, or the Since oral contraceptives became popular in 1960s,

create a bigger trauma during the extraction, especially surgical extraction of mandibular third molars. On the
J. Family Dent. 2013, Vol. 7. No. 4

an unexpected side effect in dental treatment has been

Chang WY, Wang YL

found. Some studies conducted after 1970s show a significant higher incidence of dry socket in females that take oral contraceptives.
19-21 2

greater the risk. The advanced age has been considered

25

The general axiom is that the older the patient, the

12

occurs due to the disintegration of the blood clot by

According to Birn's fibrinolytic theory, dry socket

a factor of dry socket in some studies, but different aspects have been proposed, and it has not always been
11

fibrinolysis. Fibrinolysis is a normal body process that keeps naturally occurring blood clots from growing and causing problems. This process can be also activated due to a medical disorder, medicine, or other cause. Estrogen, one of the ingredient of oral contraceptives, fibrinolytic process. It is believed to indirectly activate

aging itself but the physiological change individually. Bacteria

statistically significant. Perhaps the true factor is not

which should not be ignored for the development of dry socket. If patients with poor oral hygiene, or preperiodontal disease),
27 26

Most authors agree that bacterial infection is a risk

has been proposed to play a significant role in the the fibrinolytic system (increasing factors II, VII, VIII, X, and plasminogen) and therefore increase lysis of the blood clot. The use of oral contraceptives is thought to
5 22

existing local infection (such as pericoronitis or advanced the incidence of dry socket
28

appeared increase. One author postulated that bacterial pyrogens in vivo are indirect activators of fibrinolysis.
4

be a factor that raises the prevalence of dry socket among increased estrogen dose in the oral contraceptives, the incidence of dry socket increases.
23

female patients. One study also concluded that with

in the development of dry socket or not. In brief, the quantity of bacteria is the main point. Other uncertain factors there are some different opinions have been proposed. In vasoconstrictor may cause temporary ischemia, and the
29

It is a controversial issue that saliva is a risk factor

menstrual cycle would also influence the fibrinolytic

3

The changing endogenous estrogens during the

About using local anesthetic with vasoconstrictor,

system, especially in the days 23 to 28 of the menstrual menstrual cycle is also a risk factor in the occurrence of dry socket.
13

one study, the author believes that local anesthetic with following poor blood supply will lead to increase the

cycle. Therefore; timing of dental extraction according to

frequency of dry socket. However, other studies hold a contrary opinion, since temporary ischemia would be integration of the blood clot is not affected. According to
2,6

regard female gender as a predisposing factor of dry

14

Despite the use of oral contraceptives, some authors

followed by reactive hyperemia in one to two hours, the this reason, local ischemia due to vasoconstrictor in local anesthesia has no role in the development of dry socket.

hormone during the menstrual cycle. Furthermore, the makes the surgeries more difficult and traumatic may also inuence the normal healing process.

socket. It is possibly due to the changing endogenous

smaller size of their jaws and limited surgical field which

Prevention
antifibrinolytic agents are used to prevent the early disintegration of the blood clot. Tranexamic acid (THA), also known as Transamin, is one kind of the C o n s i d e r i n g t h e f i b r i n o l y t i c t h e o r y, t h e

ability of immunocompromised or diabetic patients researchers also have suggested that systemic disease
2

One literature proposed that the altered healing

24

possibly induce the development of dry socket. Some

could be associated with dry socket. However, no scientific evidence exists to prove a relationship between altered healing ability and dry socket.
4

antifibrinolytic agent. When applied topically in the development of dry socket.

30

extraction socket, it has been speculated to prevent the However, another study

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The Risk Factors, Prevention, and Management of Dry Socket

reported no significant reduction in the incidence of dry socket when compared to a placebo group.
31

the incidence of dry socket in the removal of impacted

4

of antifibrinolytic agent, also been introduced in many

Para-hydroxybenzoic acid (PHBA), another kind

mandibular third molars. Ragno et al. found a significant reduction as much as 50% in the incidence of dry socket
38

studies. Some literature reported a lower incidence of dry socket when PHBA was topically used in extraction wounds.
4,24

in patients who prerinsed with chlorhexidine solution indicated that using 0.12% or 0.2% chlorhexidine before and/ or after surgery is beneficial.
39

in removal of mandibular third molars. Many authors

has some antimicrobial properties.

Besides, one literature reported that PHBA

32

antifibrinolytic properties and antimicrobial properties to attribute the effect to which properties of PHBA.

Since both the

may reduce the incidence of dry socket, it is not possible Some literature reported the incidence of dry socket

Management
no treatment exists at the present time. Most authors agree that the primary aim of dry socket management is pain control until commencement of normal healing.
4

Since the real etiology of dry socket is still unclear,

reduced with the intraoperative lavage using different quantities (25 ml, 175 ml and 350 ml) of saline solution, of lavage increased (10.9%, 5.7% and 3.2% of the incidence in each group, respectively).
33,34

lower incidence of dry socket were found as the quantities

before the management for the patients. We can use

The anesthesia allows a momentary relief is useful

saline solution for intra-alveolus irrigation with careful aspiration. One study proposed that force the bleeding in the alveolus and the formation of a new clot due to curettage was not suggested. Medication with systemic There is another study suggested that patient should syringe.
40

are a major risk for the development of dry socket, prevention.

Since most studies supported that bacterial infections

antibiotics and antiseptics were used as a measure of The antibiotics can be used in systemic and

analgesics or antibiotics may be necessary or indicated. be irrigated daily with saline solution using a needless Some authors advise the placement of intraalveolar
4

topical routes. Systemic antibiotics, such as penicillins,

clindamycin, erythromycin, and tetracycline, were reported to be effective in the prevention of dry socket. However, the development of resistant bacterial strains and unnecessary destruction of host commensals due to the routine use of systemic pre- and/ or postoperative antibiotics prophylatically is still disputed.
4

dressing materials such as antimicrobial agent or local dressings delay healing of the extraction socket, anesthetics. Although it is generally acknowledged that
24

carried into the operative wound in many forms. with the application of topical tetracycline.
35,36

tetracycline has shown promising results. It can be

Among the use of topical antibiotics, topical

4

the literature does not show clear evidences in favour of concentration locally and avoiding the entrance of food debris to the alveolus.

and

the placement of these pastes, they can increase the drug

However, foreign body reactions have been reported

the probability of myospherulosis, placement of topical suggested.

37

Due to

Conclusions
not uncommon in clinical work. Although the etiology still controversial, it goes without saying that the most Dry socket is a displeasing complication and is

tetracycline in a petrolatum base into a surgical site is not Chlorhexidine is the antiseptics that mostly being

is not clear and the treatment of this complication is important goal of management is pain control. According

used. Several studies have reported that the use of 0.12% chlorhexidine pre- and perioperatively decreases
J. Family Dent. 2013, Vol. 7. No. 4

Chang WY, Wang YL

to the literatures reviewed, the use of analgesics to release healing process is indicated.

the discomfort of patients until commencement of normal Smoking proved to have a great influence in the

8. Jaafar N, Nor GM. The prevalence of post-extraction complications in an outpatient dental clinic in Kuala Dent J, 2000; 23:24-8. Lumpur Malaysia--a retrospective survey. Singapore 9. Amaratunga NA, Senaratane CM. A clinical study of 1988; 26:410-18.

Oral Maxillofac Surg, 2010; 68:1922-32.

development of dry socket, and should be avoided after tooth extraction, especially on the day of surgery.

0.2% chlorhexidine pre- and post-operatively showed effective in preventing the development of dry socket. In my clinical experience, using -iodine for local sterilization is also useful. Perhaps the incorporation of these methods to the protocol of exodontias would be third molars. We can also educate our patients to use mouthrinses with cholohexdine for home care. In conclusion, the best option is prevention.

The use of lavage post-operatively and 0.12% or

dry socket in Sri Lanka. Br J Oral Maxillofac Surg,

10. Nusair YM, Abu Younis MH. Prevalence, clinical picture, and risk factors of dry socket in a Jordanian 8:53-63. Dental Teaching Center. J Contemp Dent Pract, 2007; 11. Larsen PE. Alveolar osteitis after surgical removal of the patient at risk. Oral Surg Oral Med Oral Pathol, 1992; 73:393-97.

beneficial, especially when extraction of the included

impacted mandibular third molars: identification of

12. Alexander RE. Dental extraction wound management: Oral Maxillofac Surg, 2000; 58:538-51.

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