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 consistently found that smokers are significantly more prone to dry socket formation, as opposed to extraction patients who don't. (Bowe)

As an example, a frequently cited historic study (Sweet) evaluated the healing outcome of 400 patients who had lower wisdom teeth removed. Within this population, it was found that:

  • Patients who smoked 10 cigarettes per day (half a pack) experienced a greater than fourfold increase in the incidence of dry socket formation (12% vs 2.6%).
  • The incidence rate for patients who smoked 20 cigarettes (one pack) daily was higher yet at 20%.
  • Smokers who smoked on the day of their surgery, or within 24 hours following their procedure, experienced a 40% incidence rate for this complication. (Remember, that's in comparison to a 2.6% rate for the non-smoking portion of this study's subjects.)

Why does smoking cause dry sockets?

The precise cause and effect relationship between smoking and alveolar osteitis has yet to be definitively determined. However, the following explanations have been proposed. They seem to fall into two categories: 1) Effects on the blood clot that forms in the tooth's socket and 2) Inhibiting the body's normal healing process.

Graphic of a 'no smoking' sign.

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

  • The negative-pressure sucking action of smoking may dislodge or disrupt the blood clot that's formed in the tooth's socket. Or the hot gases themselves may have a compromising effect on it.
  • Several studies have found that the sockets of smokers don't fill in with blood as readily after an extraction, thus leading to sub par clot formation.

    This effect is in part blamed on nicotine, which triggers vasoconstriction. (A constriction of blood vessels, which leads to reduced blood flow).

  • As a person smokes, the carbon monoxide that enters their bloodstream combines with blood cell hemoglobin more readily than oxygen.

    This effect serves to reduce the amount of oxygen that can be carried to, and therefore is available for, their extraction site's healing tissues.

  • Nicotine creates other effects that tend to interfere with the normal healing process, ranging from inhibiting the production of compounds needed for tissue repair, to affecting the proliferation of types of cells that play important roles in the healing process.
  • At a local level, direct exposure to tobacco smoke may damage or be toxic to cells.

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) [linked above]

Illustration of oral contraceptive dispenser.

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

B) Oral contraceptives.

Studies suggest that women who take birth control pills are at greater risk for developing a dry socket. For example:

  • A study by Garcia followed 267 women following their lower wisdom tooth extractions. 87 of these subjects were currently taking oral contraceptives.
  • 11% of women in the oral-contraceptive group developed a dry socket. Of the remaining subjects, only 4% experienced one.
Background

An interesting backstory associated with this risk factor is its history.

  • Up until the 1960's, it was generally considered that the incidence of dry socket formation was similar for both men and women. From this decade on however, this statistic was found to have changed. The assumption being that the shift was due to the increased use of birth control pills that began at that time.
  • This factor may have been more of an issue during those earlier decades when oral contraceptives were formulated with a larger dosing of the hormone estrogen than they are nowadays.

Reference: Bowe [linked above]

Why does taking oral contraceptives increase the risk of dry sockets?

It's thought that this correlation is due to increased fibrinolysis activity triggered by the hormone estrogen. Fibrin is a key component of blood clots, and its destruction through this process contributes to clot instability, therefore increasing the possibility of its loss from the tooth's socket.

Prevention guidelines for this risk factor.

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 most products, this will be those days (days 23 to 28 of your tablet cycle) when no pill, or else a placebo pill, is taken.

 Reference: 


C) Oral bacteria.

The theory that bacteria play a role in dry socket formation has been postulated for a long time. But as of yet, no definitive cause and effect (such as the identification of specific micro-organisms) has been proven.

Identified risk factors.

This theory stems from reports were the following factors and issues have been found to be associated with an increased risk of dry socket formation.

  • Poor patient oral hygiene practices.
  • A high bacterial count (anaerobic bacteria in particular) in the region of the extraction site, either before or after the patient's procedure.
  • A pre-extraction infection having been associated with the tooth. This includes 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).

Prevention guidelines for this risk factor.

As a part of investigating these observations, studies have suggested that the following steps may 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.
  • Starting the patient on systemic antibiotics (usually oral) prior to their procedure.
  • Placing an antibacterial or antibiotic-impregnated packing into the socket immediately following the tooth's removal.

Without definitive evidence about the effectiveness of antibacterial measures, or specifically what medication or delivery method should be used, it's simply for the treating dentist to decide what their role should be.

 Reference: 

Daly B, et al. Local interventions for the management of alveolar osteitis (dry socket).

Bowe DC, et al., Blum IR., Kolokythas A, et al. - Linked above.

Dry sockets are not usually treated with antibiotics.

Despite whatever role oral bacteria may play in causing them, protocols for treating dry sockets typically do not include the routine use of systemic antibiotics. (Bowe) [linked above]

That's because their usage at this stage does not address the issues at hand (delayed wound healing, controlling the patient's discomfort). They may serve as a preventive measure if taken before the patient's procedure but except for special circumstances aren't an effective measure postoperatively.

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.

References: Bowe DC, et al., Noroozi AR, et al. [both linked above]

As a rule of thumb, it seems safe enough to say that relatively younger patients are generally 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 tooth removal, more complete root development. Both of these factors can increase procedure difficulty, and therefore the potential for surgical trauma (a known risk factor).

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

Prevention guidelines for this risk factor.

  • Following your dentist's postoperative instructions as closely as possible is always a good idea and should help to reduce your risks.
  • With wisdom teeth, if you're in the ideal age group for their removal and your dentist has made a satisfactory case in favor of it, give their proposal serious consideration.
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E) Tooth location.

A patient's risk for developing a dry socket has been shown to correlate with the location of the tooth being extracted. As examples:

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.

  • Having a back tooth pulled (especially a molar) tends to pose a greater risk than when front teeth are removed.
  • The risk is 10 times higher when a lower tooth is extracted as opposed to an upper one.
  • The greatest level of risk for dry socket formation is with impacted lower wisdom tooth extractions (see picture). The incidence rate for these surgeries has been reported to be as high as 45%.
  • As a point of curiosity, a study by Nusair found a higher incidence of dry sockets with single-tooth extractions vs. multiple ones (7.3% vs 3.4%).

 Reference: 

Why this relationship?

The characteristics of the bone that surrounds teeth in different areas of the mouth varies, most notably upper vs. lower jaw. By nature, the bone tissue of the lower jaw is denser and less vascular than that of the upper, and for that reason may have a less robust healing capacity.

In regard to the high prevalence of dry sockets with lower impacted wisdom teeth, beyond bone quality issues, the surgical nature of the procedure that's required may be the predominant risk factor involved.

Reference: Kolokythas A, et al. [linked above]

Prevention guidelines for this risk factor.

If the location/positioning of your tooth is one that places you at greater risk for a dry socket, as preventive measures you can:

  • Make sure to follow your dentist's post-op instructions as closely as possible.
  • If your extraction is surgical in nature, choosing a practitioner whose skill level and expertise is commensurate with your procedure (for example, choosing an oral surgeon vs. a dentist) can help to minimize your risks.

Our next page discusses how dentists treat dry sockets. ▶

 

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


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