Dry Sockets - Causes, risk factors & prevention -

Factors and situations that make it more likely that you'll get a dry socket.

Topic Alveolar Osteitis logo.

Tooth extraction site.

This page explains the role various factors play in increasing your risk for developing alveolar osteitis (a dry socket):

  1. Blood clot loss - (Often due to not following your dentist's post-operative instructions.)
  2. A history of previously experiencing this condition.
  3. Having undergone a difficult or surgical extraction (like impacted wisdom teeth).

Our second page of this series discusses why smoking, birth control pills, age and tooth location are also contributing factors.

Just having a basic understanding of these issues, collectively, can play a major role in helping you to prevent getting a dry socket.


Risk factors - Part 1.

A) Not following your dentist's post-op instructions.

(Note: We've listed this issue first because it's a prevention factor that every patient has a great amount of control over.)

It's a fact. After having a tooth extracted, people who follow their dentist's directions (especially those that address the issue of blood clot formation and protection) tend to have fewer postoperative complications, including getting dry sockets.

Proper blood clot formation helps to prevent dry socket formation.

Animation showing the placement of gauze to promote blood clot formation.

1) The rolled or folded up gauze is placed directly over the extraction site.

2) Enough gauze is placed that when the patient closes they apply firm pressure to it.

1) Clot formation.

Dentists typically advise their patients that after having a tooth pulled they should ...

  • Place firm biting pressure on the gauze packing that has been placed over their extraction site for the next 30 to (preferably) 60 minutes.

Doing so will help to insure that a proper blood clot has a chance to form in their tooth's empty socket.

2) Blood clot protection.

Once a clot has formed, a patient must be careful not to disrupt it. To aid in this goal, during the first 24 hours after their surgery they should ...

  • Avoid vigorous rinsing or spitting.
  • Refrain from creating negative-pressure situations such as sucking on a straw or drawing in on a cigarette.
  • Avoid alcohol and tobacco use in general.
  • Minimize physical activities and exercise.
  • Avoid hot liquids such as coffee and soup.

Each of the factors above place the blood clot at risk. They should be avoided.

3) Additional instructions.

Beyond these abbreviated do's and don'ts, your dentist should also provide you with a comprehensive list of directions. They should include instructions for both the first 24 hours and then beyond. If they don't, ask for them. (We outline common post-extraction instruction sets here.)

Prevention guidelines.

In regard to dry socket prevention, nothing is more important than proper blood clot management.

B) Having a history of experiencing dry sockets.

If you've had one before, you must consider yourself at elevated risk for getting a dry socket with other extractions.

  • In many cases, the factors working against you (such as those listed on our next page) may be very difficult, or even impossible, to control.
  • But don't overlook the obvious. Your previous experience may simply have been due to the fact that you didn't follow your dentist's instructions as closely as you could or should have.

Prevention guidelines.

Whatever the case, keep in mind that strictly adhering to proper post-extraction protocol always helps with dry socket prevention, no matter what your underlying baseline risk might be.


C) Difficult tooth extractions.

Any dentist will tell you that there's a correlation between the amount of tissue trauma that's created during the extraction process and the patient's likelihood for getting a dry socket. In fact, most consider it a major causative factor.

As simple evidence, statistics show that surgical tooth extractions (such as the case where a lower impacted wisdom tooth is removed) are associated with a tenfold greater risk of the patient experiencing one. (Bowe 2017)

Why the greater risk?

The general hypothesis used to explain this relationship is this:

  • Trauma created during the extraction process causes localized inflammation of the bony socket, which leads to the increased release of "tissue activators."
  • These activators in turn trigger the release of plasmin. And it's this compound, whose presence is now at elevated levels, that causes the disintegration (lysis) of the blood clot.
  • Related to the clot's loss, a dry socket subsequently forms.

(Associated with this process is the fact that the presence of inflammation also leads to an increased release of a class of compounds called "kinins." Kinins stimulate nerve pain receptors, an activity that helps to explain why dry sockets can be so painful.)

(Bowe 2017)

Estimating the level of surgical trauma that will be involved.

With some tooth extractions, the dentist may know beforehand that it's likely that a fair amount of tissue trauma will take place.

a) Anticipated traumatic extractions.

A correlation exists between extraction difficulty and risk of dry socket formation.

X-ray showing two teeth that will be difficult to extract and therefore have a higher risk of a dry socket formation.

Both of these extractions offer challenges due to the tooth's condition or positioning.

Example #1 - Some impacted wisdom teeth (like tooth #1 in our picture) are substantially encased in bone.

With this type of situation, the dentist will need to 1) Make an incision through gum tissue and 2) Remove the bone that lies over the tooth, before they can even gain access to the tooth itself so it can be 3) Sectioned (cut into pieces) and ultimately removed.

Cutting gum tissue (creating a "flap"), removing bone tissue and sectioning a tooth each creates localized tissue trauma substantially beyond that associated with a simple, routine tooth extraction.

And due to the need for these additional surgical steps, this patient will be at greater risk for getting a dry socket.

Example #2 - In comparison, when the decayed tooth (tooth #2 in our picture) is removed, far less tissue manipulation will be needed. The dentist already has direct access to the tooth, therefore no gum or bone trimming (or at least much less) should be required.

When compared to our first example, extracting this second tooth should be a far less traumatic procedure. As a result, the patient's risk for a dry socket formation would be expected to be less too.

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b) Unexpected traumatic extractions.

A dentist may begin the extraction process with the expectation that it will be easy, only to discover during the procedure that it won't.

Now, as a relatively more-difficult extraction, the tissues surrounding the tooth will need to be manipulated to a greater extent, over a longer time period. And possibly some additional surgical steps, like those mentioned above, will be needed.

These factors mean that comparatively more tissue trauma will take place during the procedure. And as a result, the person's risk for experiencing a dry socket will be elevated.

Prevention guidelines.

As the patient, you might think that there's little you can do to reduce the level of difficulty of an extraction. To the contrary however, there's a great deal you can do. It's called patient cooperation.

Make it your goal to be as good a patient for your dentist as possible so they can focus their attention on performing their task, rather than managing you.

That difference might mean that they can remove a difficult tooth relatively less traumatically, rather than more so. And as a result help you to prevent having a dry socket.

Operator experience is important.

This is one reason why having a less-experienced/less-skilled dentist remove your tooth may place you at greater risk for having a dry socket. (Blondeau 2007, Bowe 2017)

  • The operator with better skills may be able to remove a tooth less traumatically than their less experienced counterpart.
  • A more experienced dentist may be more likely to recognize a challenging situation initially.

    That's favorable because, on the whole, a planned surgical extraction will likely result in less total tissue trauma than the situation where complications have cropped up and its needed as an additional step.

Our next page discusses additional risk factors and prevention methods. ▶

 

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