Dry Sockets - Causes, risk factors & prevention -

Factors and situations that make it more likely that you'll get a dry socket. | Blood clot loss. | A previous history of dry sockets. | Difficult or surgical extractions.

Topic Alveolar Osteitis logo.

Tooth extraction site.

Risk factors for dry sockets.

This page explains various factors that can play a role in increasing your risk for developing alveolar osteitis (a dry socket). Issues discussed are:

a) Not following your dentist's postoperative instructions -

Possible consequences of failing to do so include dislodging the blood clot that's formed in your tooth's socket. Or inadvisably participating in activities or habits that may otherwise lead to its demise.

b) Having a history of previously experiencing dry sockets -

Understanding why you've been at risk before may help you to avoid this complication with future extractions.

c) Having undergone a difficult or surgical extraction -

Studies indicate that the higher the level of tissue trauma created during the extraction process, the greater the chances of dry socket formation. And while this may seem a risk factor beyond your control, we explain why it isn't entirely.

(Our second page of this series discusses details about why smoking, birth control pills, age and tooth location are also contributing factors for alveolar osteitis.)

What's to be gained by knowing about risk factors?

  • Understanding - For people currently suffering with this complication, the event can be a significant one. And a discussion about risk factors may help them to at least understand what has transpired in their case.
  • Prevention - For past or present sufferers who have additional extractions in their future, or for anyone else simply reading up and preparing for one, understanding a few basic issues, and subsequently taking steps associated with them, might play a major role in the prevention of a dry socket with their up coming procedure.

Dry socket risk factors - Part 1.

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

The blood clot that forms in your tooth's socket following its removal plays an important role in the healing process to come, with its loss (complete or partial) being a major causative factor in the formation of dry sockets.

As a preventive measure, many of the items listed as do's and don'ts in your dentist's post-extraction instructions have to do with limiting activities and behaviors that may be detrimental to this goal. Here's an example of some of the issues frequently addressed:

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) Protecting the clot from physical loss.

Once a clot has formed, a patient must be careful not to disrupt it. In aiding with 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.
  • Minimize physical activities and exercise.
  • Avoid hot liquids such as coffee and soup. (It's thought that hot items tend to dissolve blood clots.)

Each of the factors above could place the blood clot at increased risk of being dislodged and physically lost, and for that reason should be avoided.

How much of an issue is patient clot disruption?

Unlike other dry socket risk factors we discuss on our pages, there isn't much scientific literature that supports the theory that patient activity resulting in the loss of the clot is a major contributory factor to dry socket formation.

In response, we will state that:

  • We've read through a number of post-extraction instruction sets found on dentist and oral surgeon websites. And it's our impression that the vast majority do include this consideration in their directions. (As do we, see link below.)
  • Protecting the clot from premature loss certainly seems to make sense, especially since that's what would normally be expected to occur during socket healing. Also, it's hard to imagine a scenario where taking this precaution would be detrimental in any way.
  • However, with the lack of scientific evidence supporting this issue, it might be better categorized as a "best practice" as opposed to major preventive factor. Either way, it's important to note that this is something that you (the patient) has a great deal of control over.

Prevention guidelines for this risk factor.

Don't forget, your dentist's instructions include other directions too.

Beyond the abbreviated do's and don'ts we've outlined above related to controlling bleeding and blood clot protection, your dentist should also provide you with a comprehensive list of additional postoperative directions.

They should include instructions for both the first 24 hours, and then the days beyond. As an example of what they will include, we begin our discussion of common post-extraction instructions here.

Note: A separate risk factor covered in post-op instructions that you control (and therefore can be used as a preventive measure) is smoking avoidance.

B) Having a previous history of experiencing dry sockets.

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

Research.

A study by Reekie (2006) followed 302 patients who had routine extractions performed by general dentists. 16 of these subjects had a history of experiencing a dry socket before.

  • Out of the group of 16 participants with a previous history, 6 (37.5%) developed a dry socket.
  • Of the remaining 286 subjects, only 17 (5.9%) developed this complication.

Prevention guidelines for this risk factor.

The unanswered question with the above study would simply be whether the major risk issues involved were primarily patient related (systemic/medical issues, at-risk behaviors) and therefore likely to continue to exist. Or more so factors associated with the procedure itself (initial conditions, way in which the procedure was performed, etc...) which might vary between surgeries.

Either way, as a patient, the factors you most control are those associated with your dentist's list of postoperative instructions. So especially when a previous history of experiencing dry sockets exists, strictly adhering to proper post-extraction protocol should always be considered of paramount importance and your best chance of lowering your risks.


C) Trauma associated with difficult or surgical tooth extractions.

Studies have generally confirmed that surgical trauma/difficulty of surgery plays a primary role in the risk of developing alveolar osteitis.

As examples:

  • A review of published literature by Torres-Largares determined that surgical tooth extractions (such as the case where an impacted wisdom tooth is removed), as opposed to non-surgical ones (no tissue flap raised, no bone removal), resulted in a ten-fold increase in the incidence of dry socket.
  • Blondeau monitored the postoperative healing of 550 patients who had impacted lower wisdom teeth extracted. The study reported that 92% of cases that subsequently developed a dry socket involved surgical procedures where bone tissue had been trimmed.

Why the greater risk?

Several theories have been suggested as an explanation of this relationship. They include:

  • Difficult extractions may result in the compression of the bony walls of the tooth's socket and also cause blood vessel thrombosis (the formation of a blood clot in a vessel), with both interfering with blood perfusion (flow) and thus the formation of an adequate blood clot.

    Or, since difficult extractions often involve older denser (less vascular) bone, a lack of perfusion into the socket may be the norm.

  • Some theories suggest that the above lack of perfusion results in delayed healing, and therefore decreased resistance of the wound's tissues to infection.
  • Trauma created during the extraction process may cause inflammation of the bony socket, which subsequently triggers the release of compounds that cause blood clot lysis (disintegration). More traumatic surgeries are thought to result in higher levels of these compounds.

    This explanation also includes the theory that additional compounds that stimulate nerve pain receptors (kinins) are also release during this reaction, thus explaining why dry sockets can be so painful.

 Reference: 

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

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

Kolokythas A, et al., Noroozi AR, et al. - linked above.

Will your dentist know what level of surgical trauma will be involved?

Yes, they should have some relative expectation. And in fact, developing an opinion is an important part of their planning your extraction. That's because their ability to correctly interpret the challenge that a tooth will pose beforehand will influence the way its removal is initially approached.

For example, attempting to remove a tooth conventionally when a surgical approach is really needed only serves to increase the level of trauma associated with the procedure, and thus the patient's potential for developing a dry socket.

Examples of the level of surgical trauma that an extraction might pose.

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. And with this type of situation the dentist will need to:

  • Make an incision through the gum tissue and reflect it back (create a "flap") so the bone covering the impacted tooth can be accessed.
  • Trim away a portion of the bone that lies over the tooth, so it in turn can be accessed.
  • Section the tooth (cut it into pieces), and then remove each piece through the opening that's been created.

Of these steps, creating the tissue flap and trimming bone are events that create a higher level of surgical trauma than that associated with routine extractions.

And because of their need, this surgical site can be expected to be at relatively greater risk of developing a dry socket.

Example #2 - In comparison, when the decayed tooth (tooth #2 in our picture) is removed, there's a good chance that far less tissue manipulation will be required. The dentist already has direct access to the tooth, so it's likely that no gum or bone trimming will be required.

That means, when compared to our first example, extracting this second tooth should result in less surgical trauma. And that means that the patient's risk for dry socket formation in this location would be expected to be less too.

Example #3 - For this example, we'll continue our discussion about removing tooth #2 in the picture above, and how an unexpected traumatic extraction might come about.

The scenario might be one where the extent of the decay is greater than anticipated. And as a result the tooth breaks, leaving behind a root fragment that simply can't be retrieved conventionally.

What will be needed is some type of surgical intervention, in the sense that now some bone will need to be removed (so the broken portion can be accessed), and maybe even a flap laid (to aid with accessing and removing bone).

The consequences.

If that's what's needed, fine. But the question at hand would be, did the two-phase procedure (failed and then successful attempts at removal) collectively create more procedure trauma, and therefore create a greater risk of dry socket formation, than if a surgical extraction was performed at the start? (This is an issue we'll continue discussing below.)

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Prevention guidelines for this risk factor.

a) Patient cooperation.

As a 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 referred to as patient cooperation.

Make it your goal to be as good of 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 comparatively less traumatically. And as a result, help to set the conditions where it is less likely that you'll have a dry socket.

b) Operator experience is important.

This risk factor is why we included our Example #3 above (the situation where what was thought would be a simple extraction turned into a surgical one). We were trying to point out how having a less-experienced/less-skilled dentist remove your tooth may place you at greater risk for having a dry socket.

This phenomenon is generally considered confirmed by research (Kolokythas, Cardoso) [linked above]. As an example:

  • Oginni followed the healing outcome of over 3000 extraction cases (encompassing all types and level of difficulty) that were performed at a teaching hospital.
  • 70% of the cases that experienced a dry socket were performed by students.

As an explanation:

  • A more experienced operator may be able to tease a tooth out of its socket less traumatically than those with less experience or skill. Also, surgical time, which correlates with level of surgical trauma created, is likely to be shorter with more experienced clinicians.
  • A more experienced dentist may be more likely to recognize a challenging situation initially.

    That's favorable because 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 Example #3 above).

Choosing between a dentist vs. an oral surgeon.

In general, this risk factor means that you should ask your dentist questions. It's their obligation to be forthright with you about their ability to perform a procedure in a fashion that reasonably approaches the level of skill and competence as other practitioners in your area, including specialists. If they can't, a referral might be indicated.

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

 

Authorship: Written by Animated-Teeth Dental Staff

Last revision/review: 9/30/2018 - Major revision. Content added.

Content reference sources.


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