Dry Sockets (alveolar osteitis) -

What are they? | Signs and symptoms. | Pictures. | How long do they last? | Healing time frame. | Frequency of occurrence.

Picture of a tooth socket, post-extraction.

A tooth socket after extraction.

What is a dry socket?

This condition, more formally termed alveolar osteitis, is a common postoperative complication associated with having a tooth extracted.

It involves a situation where an extraction site's healing process is interrupted (delayed) due to the loss of the blood clot that normally occupies the empty tooth socket.

(Our picture above shows an x-ray image displaying the outline of an empty tooth socket following extraction.)

a) Signs and Symptoms

While specifics can vary, the predominant characteristics of a dry socket are:

  1. Throbbing pain.
  2. A foul odor and/or taste coming from the extraction site.
  3. A timing where these events first appear a few days following the tooth's extraction.

More details about signs and symptoms ...

b) Treatment

Pain medications on their own, even prescription ones, are seldom effective in managing the discomfort associated with a dry socket.

The most effective treatment is one where the patient's dentist inserts a medicated dressing (daily if needed) directly into the wound. In a pinch, there are some home remedy methods that can be used to provide pain relief.

c) Risk Factors / Prevention

Research and clinical observation have identified a number of factors that correlate with a patient's risk for developing a dry socket. Understanding these factors can be useful in preventing their formation.

Learn more about risk factors and prevention ...

Etiology - Why do dry sockets form?

The exact pathogenesis of dry socket formation is not fully understood but it is known that the following factors are involved.

1) The blood clot is lost.

A course of events takes place where the blood clot that normally forms in a tooth's socket following its removal isn't properly retained. It either:

Picture of a tooth socket, immediately after extraction.

The blood clot that begins to form immediately after an extraction is an important part of the healing process.

  • Disintegrates by way of a chemical process termed fibrinolysis.

    (Fibrin is a tough fibrous protein whose formation is triggered by the clotting process. Pieces join together to form long strands that then crosslink with others. As this process continues, and the web that's formed snares platelets, it develops into what's referred to as a blood clot.)

    It's hypothesized that the compounds responsible for this fibrinolytic activity may come from the socket's bone itself, either as a consequence of infection or as a result of trauma created during the extraction process. (Noroozi)

  • Is dislodged by an event or activity.

    (Common scenarios involve loss of the clot as a result of vigorous swishing or rinsing, or the creation of a sucking action, like when drinking using a straw.)

Section references - Noroozi

2) Healing is delayed.

The lost blood clot would have played an important role in the healing process of the extraction site. However, due to its loss, the progress of the socket's healing is interrupted (delayed).

Graphic stating that if an extraction site's blood clot is lost, a dry socket will form.

If the blood clot is lost, the socket's bony interior is exposed instead of protected.

3) Bone tissue becomes exposed.

The clot would have also covered over and protected the bony walls of the empty socket as it heals. Now that it's been lost, the walls are exposed and become irritated, resulting in pain and sensitivity.

The signs and symptoms of dry sockets.

The key to being able to determine that you have a dry socket forming is to compare the symptoms you notice with what's normally expected with post-extraction healing.

a) What's the norm? What usually happens after a tooth is pulled?
  • In most cases, a patient will notice some degree of pain from their extraction site on the day of their surgery. (Hopefully this will just be minor.)
  • And then with each day that follows, the level of discomfort they notice gradually tapers off until it finally disappears.

 

b) What happens when a dry socket starts to form?

With this scenario:

  • The patient will first find that their initial discomfort does gradually fade for the first few days following their extraction. (Just like with normal healing.)
  • But then, usually somewhere between days 2 and 4 after their procedure, their level of pain begins to intensify.
While the exact timing of a person's symptoms will vary, 95% of dry socket cases are noticed within the first week after the patient's surgery.

Section references - Kolokythas

More details about the characteristics of dry sockets -

1) Pain.

As just stated, the discomfort from the extraction site usually starts to intensify on days 2 to 4 after the tooth was initially removed (24 hours following the procedure, or later). This detail alone is an important clue to your dentist that you do in fact have a dry socket. Other characteristics are:

  • The discomfort is often (almost characteristically) described as a dull throbbing pain.
  • It can be moderate to severe in intensity, possibly even debilitating.
  • What's felt may be constant or intermittent. In the latter case, the frequency of onset can vary. Later on, the pain is more likely to be constant.
  • The pain may remain localized to just the extraction site, or it may radiate to other areas on the same side of the patient's head such as the ear or temple, or possibly even the eye or neck. Experiencing headaches is also reported.
  • The pain usually reaches its most intense level around 72 hours post-extraction (Bowe). The pain may be so debilitating that it causes loss of sleep and affects the person's daily function.

Section references - Bowe

A dry socket.

Picture of a dry socket.

Note the loss of the socket's blood clot and exposed bony interior.

2) Appearance.

  • The tooth socket will appear empty instead of being filled in with a blood clot or granulation tissue (new developing tissue), like that which is seen with normal healing.

    (In many cases, visualization into the socket isn't immediately possible because it's filled with saliva, or accumulated food and debris.)

  • Exposed bone is visible (the walls of the socket). It may be partially covered with a gray/yellow layer of necrotic tissue or other debris.
  • The gum tissue immediately surrounding the extraction site shows signs of being inflamed (red, tender, puffy).

 

3) Other signs and symptoms.

  • It's characteristic that the patient will notice a foul odor (halitosis) or bad taste coming from their extraction site.
  • Lymph nodes in the jaw or neck may be tender and enlarged. (A sign of the body's inflammation response to conditions associated with the dry socket's formation.)
  • Dry sockets are typically not associated with the presence of fever, swelling of the surgical region, or obvious signs of infection (local or systemic).

Primary reference sources for entire Characteristics section - Kolokythas, Bowe, Noroozi

How long do dry sockets last?

Healing time frame.

Once the conditions of a dry socket have set in, it usually takes about 7 to 10 days for the healing process to get geared up again and create new granulation tissue that then starts to cover over and protect the socket's exposed bone. (Noroozi) [linked above]

How long will the pain last?

On average, the discomfort from a dry socket usually runs for 4 to 8 days. (That means, you'll likely need attention from your dentist to stay comfortable.)

At times the pain may be quite severe. Towards the end, it will just gradually taper off and disappear.

How long is the healing process delayed?

In general, you can expect that the overall healing time frame of your extraction site will be delayed on the order of a week or longer.


How often do dry sockets occur?

An impacted lower third molar slated for extraction.

Graphic stating that lower wisdom tooth extractions have an elevated incidence of dry socket formation.

The potential for dry socket formation is a concern with these extractions.

  • For routine tooth extractions, the chances of experiencing a dry socket run on the order of 1 to 4%.
  • They're much more likely to occur with lower tooth extractions than upper ones.
  • In general, surgical extractions (like the procedure used to remove impacted teeth) have a tenfold higher incidence rate.
  • Dry sockets may occur in as many as 38 to 45% of the cases involving the removal of mandibular (lower) impacted wisdom teeth (like the tooth shown in our illustration).
  • With all tooth extractions considered collectively, a dry socket is the most common post-surgical complication.

Section references - Cardoso, Bowe

Our next page discusses dry socket risk factors and prevention. ▶

 
 
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 Page references sources: 

Bowe DC, et al. The management of dry socket/alveolar osteitis.

Cardoso CL, et al. Clinical concepts of dry socket.

Kolokythas A, et al. Alveolar Osteitis: A Comprehensive Review of Concepts and Controversies

Noroozi AR, et al. Modern concepts in understanding and management of the “dry socket” syndrome: comprehensive review of the literature.

All reference sources for topic Dry Sockets.

Comments

Pain and odor post 8 days

I received resorbable sutures after having all four wisdom teeth extracted. It has been a week since the surgery and I have a terrible odor/taste in the back of my mouth constantly. Most similar to a fishy smell. This smell is accompanied by pain from the cheeks to the jaw on both sides of my face. Without ibuprofen and Tylenol it is unbareable. I am taking amoxicillin and prednisolone but have about finished the he round of anitibiotcs prescribed. How normal is any of this?

* Comment notes.

Jt

What you need is evaluation by your dentist. Even via initial telephone contact they should be able to develop a fair idea of what is going on and what type of attention you require.

As you'd expect, the usual course of events would be one where pain diminishes with time. Some of what you report seems consistent with a common postoperative complication referred to as a dry socket. That might explain what is going on. Your dentist will need to make that determination.

* Comments marked with an asterisk, along with their associated replies, have either been edited for brevity/clarity, or have been moved to a page that's better aligned with their subject matter, or both. If relocated, the comment and its replies retain their original datestamps, which may affect the chronology of the page's comments section.

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