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Dodging the dreaded dry socket: Tips on preventing this painful possibility

Here's what dental professionals need to know about alveolar osteitis, or dry socket, including prevention, patient education, and treatment.

The mere mention of dry socket makes dental professionals cringe. Following an extraction, dry socket is one of the most dreaded occurrences that can affect our patients. We all feel compassion for these patients, but do you know the clinical details that can help with this agonizing condition? In this article we’ll look at potential causes of dry socket, preventive steps, and information you can share to quell your patients’ fears prior to an extraction.

The facts about dry socket
Dry socket, also known as alveolar osteitis, is a condition that develops when the blood clot in an extraction site dissolves, does not form properly, or becomes dislodged shortly after the removal of a tooth. A blood clot normally protects bone and nerve tissue in the extraction site during the healing process. When this area is exposed, contaminants may become trapped in the socket and cause problems.1

Dry socket can occur anywhere from 2% to 5% of the time with the extraction of a tooth.2 Mandibular teeth are affected by this condition more often than maxillary teeth. Dry socket is most common in molar extractions and especially in wisdom teeth, where it can occur up to 30% of the time.2

Patients with this condition typically experience a consistent throbbing pain a few days after the tooth is removed. The pain may radiate to other areas of the face and a foul odor may be present. Drinking cold water and breathing in air may also cause discomfort. Food debris commonly collect in the empty socket and aggravate the problem.

When dry socket is suspected, the patient should be advised to return to the dentist or oral surgeon as soon as possible. Many patients try to tough it out due to lack of knowledge about the condition.

Treatment of dry socket often consists of irrigating the area to remove food and other possible irritants and then applying a zinc oxide (ZnO) eugenol dressing to the area. Pain generally subsides quickly after treatment is provided. Over-the-counter pain medications can also provide relief as this area heals.

Addressing dry socket prevention with patients
Patients are often fearful of getting dry socket when they have teeth extracted. They may have heard about others’ terrible experiences. Patient concerns should be addressed preemptively to help prevent them from delaying treatment. You can empower patients by explaining that steps can be taken to dramatically decrease their chances of experiencing dry socket. As always, education is key!

Many of you may already know a few simple precautions that can be taken to prevent dry socket, such as avoiding the use of a straw and refraining from smoking for at least 48 hours after an extraction. Smoking limits blood supply at the extraction site, negatively affects the clot, and can delay healing.3 It is also advisable to avoid spitting and swishing vigorously during this critical period of time. Patients should refrain from drinking carbonated beverages, which can cause problems.

Many people are not aware that what they eat can affect healing after an extraction. It is recommended to eat food that does not pose a risk of leaving remnants behind. This includes nuts, popcorn, rice, and pasta. These types of foods can dislodge blood clots from extraction sites and cause dry socket. Better suggestions for your patients include soft foods such as mashed potatoes, applesauce, yogurt, and gelatin.

Proper dental hygiene is also extremely important in the prevention of dry socket. This includes gently brushing teeth that are close to the extraction site to decrease the quantity of bacteria present in the area. Rinsing with warm salt—but with limited force—can help remove food debris and keep the mouth clean.2

Another effective way to prevent the occurrence of dry socket is to reduce the number of bacteria present in the mouth by using chlorhexidine rinses. A Cochrane Review of four clinical trials published in 2014 showed that there was moderate evidence that chlorhexidine rinses before and after extractions prevented dry socket approximately 42% of the time.4 As this method of dry socket prevention is very easy to implement, most patients should be highly compliant with this suggestion.

Many patients who are smokers find it difficult to refrain from smoking after extractions. Make sure to educate your patients on how smoking dramatically increases their risk of experiencing a dry socket. In a study conducted in 2011 in Palestine, 12% of smokers experienced dry socket compared to only 4% of non-smokers.5 If your patients can discontinue smoking for 24 hours, it will make a difference—and 48 hours is even better. The frequency of smoking was also found to increase the incidence of dry socket.

It is advisable to recommend some type of nicotine replacement therapy during this timeframe if your patient has trouble tolerating their nicotine cravings.6 Patches, inhalers, or sprays work best in this situation, as they do not involve the oral cavity. Lozenges or gum are not advisable, as they are placed directly in the mouth and may only cause more complications after extractions. Hopefully, successfully refraining from smoking for a few days can help your patient consider quitting smoking on a permanent basis.

Other factors to consider with dry socket
Women tend get dry socket more often than men. In fact, according to the Academy of General Dentistry, women who take oral contraceptives are twice as likely to get dry socket due to increased estrogen levels.7 It is recommended that these women wait until the last week of their menstrual cycle, if possible, to have extractions done, as estrogen levels will be inactive at that time.

Another factor to consider is that dry socket occurs more frequently in surgical extractions versus non-surgical extractions.5 This is one of the reasons that dry socket occurs more with the extraction of wisdom teeth. The 2011 Palestinian study previously mentioned above showed that dry socket occurred in only 1.7% of the time with the less involved non-surgical extractions.6 If your patient is in the higher risk group, stress to them how seriously all preventative measures should be taken to avoid dry socket.

Treating patients with ozone is another possibility being researched as a method to prevent dry socket. In a pilot study published in the European Journal of Dentistry, 30 people with bilateral impacted third molars of mandible were treated with surgical extractions.8 This group was at a high risk for dry socket in accordance with the type of extractions needed. With the experimental group, ozone gas was administered for 12 seconds to the intraalveolar area after the extractions. Patients were reevaluated 48 hours and seven days post-treatment, and dry socket was present in 16.67% of the control group and in 3.33% of the treated group. This treatment method needs further research, but it looks promising in the prevention of dry socket, especially in high-risk groups.

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