Dry socket risks & prevention - Smoking / Oral contraceptives / Oral bacteria / Age / Tooth Position -

How and why these factors play a role. | Prevention tips and suggestions.

This page discusses the following causes and risk factors for dry sockets (alveolar osteitis). And how understanding them can help to prevent one.

Our previous page (Part 1 of this topic) explains the role of extraction difficulty, failure to follow post-op instructions and patient history as risk factors.

A) Smoking.

Studies have shown that smokers are significantly more likely to get a dry socket as compared to those who don't.

For example, after evaluating the outcome of 400 wisdom tooth extractions, Sweet (1979) [page references] determined that:

  • Patients who smoked 10 cigarettes a day experienced a more than fourfold rate of dry socket formation (12% vs 2.6%).
  • The rate for patients who smoked 20 cigarettes daily was 20% higher.
  • The rate for patients who smoked on the day of their surgery or on the first day following was 40% greater.

What's the cause?

Each of the following reasons has been given as an explanation or contributor for this relationship:

Graphic of a 'no smoking' sign.

Refraining from smoking after an extraction can help to prevent dry socket formation.

  • The sucking action created when a person smokes may dislodge or otherwise disrupt the blood clot that has formed in their tooth's socket.
  • As a person smokes, the carbon monoxide that enters their bloodstream combines with blood cell hemoglobin more readily than oxygen, thus reducing the amount of oxygen that can be carried to (and therefore is available for) their extraction site's healing tissues.
  • The compound nicotine triggers vasoconstriction (constriction of blood vessels, which leads to reduced blood flow to tissues). Studies suggest that the sockets of smokers don't fill as readily after an extraction, thus leading to sub par blood clot formation. (Meechan 1988)
  • Nicotine also creates additional effects that interfere with the normal healing ranging from inhibiting the production of needed compounds to affecting the proliferation of cells that are important to the healing process.
  • At a local level, direct exposure to tobacco smoke may damage or be toxic to cells.

(Sweet 1979, Ozkan 2014)

Prevention guidelines.

As difficult as it may be, if you're a smoker you can lower your chances of getting a dry socket by not smoking on the day of your surgery, and then for as many days afterward as is possible. (At least 48 hours post extraction. [Bowe 2017])

Illustration of oral contraceptive dispenser.

Women who take oral contraceptives may be at higher risk for dry socket formation.

B) Oral contraceptives.

Women who take birth control pills can be considered to be at greater risk for experiencing a dry socket.

  • This factor seems to have been more of an issue during previous decades when oral contraceptives were formulated with a larger dosing of the hormone estrogen.
  • Prior to 1960 it was generally considered that the incidence of dry socket formation was similar for both men and women. This changed during the 1960's as it became much more common for women to take oral contraceptives.

(Bowe 2017)

What's the cause?

It's hypothesized that the correlation between oral contraceptives and dry socket formation hinges on increased fibrinolysis activity triggered by estrogen. This process contributes to blood clot instability, and subsequently loss from the socket. (Bowe 2017)

Prevention guidelines.

Planning the timing of your extraction may help.

Women who take birth control pills may be able to lessen their risks by scheduling their tooth extraction during those days when the estrogen dosing of their contraceptive regimen is at its lowest.

Ask your dentist for specific details. With some products, this will be those days (days 23 to 28 of your tablet cycle) when no pill, or else a placebo pill, is taken. (Cardoso 2010)

C) Oral bacteria.

Some dental research suggests that bacteria may play a role in dry socket formation, although no direct cause-and-effect relationship has been demonstrated.

Risk factors.

According to this theory, having one or more of the following conditions may place a patient at greater risk.

  • Poor oral hygiene practices.
  • A high bacterial count (existing either before or after the procedure) in the region of the extraction site. (Anaerobic bacteria in particular.)
  • Pre-extraction infection associated with the tooth. This might include gum disease (periodontitis), infection in tissues the that surround the tooth (such as pericoronitis) or periapical infection (infection associated with necrotic nerve tissue inside the tooth).

(Bowe 2107)


Some studies suggest that the following steps can be useful in helping to prevent dry sockets:

  • Having the patient rinse with an antibacterial mouthwash (such as chlorhexidine, a prescription product) before their procedure is performed.
  • Placing an antibacterial or antibiotic-impregnated packing into the socket immediately following the tooth's removal.

(Daly 2012)

Dry sockets are not usually treated with antibiotics.

Despite whatever role oral bacteria may play in causing them, most protocols for treating dry sockets do not routinely include the use of systemic antibiotics (getting a prescription from your dentist and taking pills or capsules) because their usage is not indicated (their benefits do not address the common underlying problem).

D) Patient age.

Several studies have found a correlation between patient age and the formation of dry sockets. However, there's been a lack of agreement about precisely which age group is at greatest risk.

  • It seems this complication is rarely a problem during childhood, or even for patients up to the age of 20 years.
  • Possibly a person's risk peaks in their 30's and 40's.

(Noroozi 2009, Bowe 2017)

As a general rule, it seems safe enough to say that relatively younger patients are at less risk than comparatively older ones. (This is one reason why dentists usually suggest that a patient should have their wisdom teeth removed during their late teens or early 20's.)

Why does this correlation exist?

As an explanation, it's frequently pointed out that relatively older patients tend to have increased jawbone density. And with cases involving wisdom teeth, more complete root development. Both of these factors can increase procedure difficulty, and therefore the potential for surgical trauma (a known risk factor).

Additionally, relatively older people generally have a comparatively lower capacity for healing. And may be more likely to be smokers (a known risk factor).

Prevention guidelines.

If you're in an age group associated with increased risk, simply make sure to follow your dentist's postoperative instructions as closely as possible.

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E) Tooth location.

A patient's risk for developing a dry socket is influenced by the location of the tooth that they're having extracted.

Graphic stating that lower wisdom tooth extractions have a higher incidence of dry socket formation.

Lower impacted wisdom tooth extractions tend to have the highest risk for dry socket formation.

Here are some correlations:

  • Having a back tooth pulled (especially a molar) typically poses a greater risk than a front tooth.
  • The risk of dry socket formation is 10 times higher when a lower tooth is extracted, as opposed to an upper one.
  • The greatest level of risk appears to be associated with having a lower wisdom tooth removed, especially an impacted one (see picture). The risk for these teeth may run as high as 45%.

(Cardoso 2010)

Prevention guidelines.

If the location/positioning of your tooth places you at greater risk, make sure to follow your dentist's post-op instructions as closely as possible.

Our next page discusses how dentists treat dry sockets. ▶


Written by: Animated-Teeth Dental Staff

Content reference sources.


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