Dry Socket Treatments and Medications

Removing a tooth is a routine procedure. Most patients will be sore for a day or two, and that will be that. Sometimes, however, the healing process doesn’t go as planned. The result is a “dry socket,” an empty tooth socket with some of the jawbone exposed to the outside world. Like many other dental problems, it’s not technically a big problem, but the pain can be agonizing. What can you do about the pain? Fortunately, a dentist can fix that.

What is dry socket?

“Dry socket,” also called alveolar osteitis or fibrinolytic osteitis, is the most common complication of a tooth extraction. Dry socket occurs when a blood clot—that normally covers the bottom of the empty socket—does not form or breaks down before the healing process is complete. Bone and nerves are exposed to the outside world. The pain can be excruciating when the extraction site is irritated by food debris or other particles.

Any tooth extraction can result in dry socket, but the complication most often happens when wisdom teeth are removed. About one in three wisdom tooth extractions will result in dry socket complications, but only 3% of other tooth extractions have similar problems. Dry socket is also more likely to happen when the tooth is extracted from the lower jaw than the upper jaw.

There is no consensus on why some tooth extractions result in dry socket and others don’t. The known causes of dry socket include a particularly traumatic extraction, inadequate blood flow to the injury, or the patient traumatizing the socket by rinsing too vigorously or brushing the socket.

Some patients are more likely to experience dry socket than others. Risk factors for dry socket are

• Smoking–nicotine constricts blood vessels

• Using birth control pills–oral contraceptives also constrict blood vessels

• A difficult or traumatic extraction

• A previous history of dry socket

• Poor oral hygiene

• Not following the dentist’s instructions after the extraction

How is dry socket diagnosed?

A dentist will diagnose dry socket by taking a history and visually examining the socket.

Before you visit the dentist, be prepared to answer the following important questions:

• Where is the pain?

• When did the pain start?

• Do pain relievers help settle the pain?

• Do you have other symptoms such as bad breath or fever?

The symptoms of dry socket begin about two to four days after a tooth removal. This is just about the time that the pain caused by the extraction settles down, so increased pain three days after extraction is often a clear indicator of dry socket.

Dry socket symptoms usually include:

• Dull, throbbing pain in the tooth socket that begins about three days after the extraction

• Radiation of the pain to other parts of the head such as the ears, temples, eyes, and neck

• Bad breath (halitosis)

• A bad taste in the mouth

Many patients are initially afraid that dry socket pain may be due to an infection, but dry socket typically does not include a low-grade fever or swollen lymph nodes, which are both likely to occur if the socket is infected.

A dentist will closely examine the socket, often using a microscope, and may probe the socket and surrounding tissues. The presence of exposed bone and severe pain when the bone is probed are usually sufficient for a diagnosis. Even so, the dentist will probably take an X-ray of the area to determine if there is any remaining tooth fragment in the socket or to rule out more severe conditions such as osteomyelitis, an infection of the jawbone.

Dry socket treatment options

Dry socket treatment focuses on pain relief and helping the mucosal tissue heal and cover over the exposed bone. A socket is healed when it is completely covered by a protective layer of tissue.

Pain management

In many cases, dry socket treatment can be limited to pain management with over-the-counter pain medications. Dry socket pain usually lasts for 24 to 72 hours, so pain management will require a few days of analgesics. More severe pain may require topical anesthetics.

Curettage, irrigation, and dressing

The pain is caused by irritation of the exposed bone and nerves. If pain medication does not work, which is common, a dentist will clean and dress the wound to protect the area and prevent infection. First, the dentist will anesthetize the area and scrape away (“curette”) any dead tissue on the exposed bone. The dentist will then wash out the socket with a chlorhexidine or saline rinse to remove food debris and microbes. The dentist will then “pack” the extraction site with a simple or medicated dressing. The dressing will protect the exposed bone from mechanical irritation, food debris, and bacteria for a few days to allow the healing process to advance. Dressings, however, lengthen the time a dry socket takes to heal, but they provide immediate, dramatic pain relief for three to five days.

Antibiotics

A small category of patients may require oral or topical antibiotics to prevent or treat an infection.

Surgery

Some cases may require that the dentist file down the bone so that the tissues can more quickly grow over the wound.

Other treatments

Low-level laser light therapy (LLLT), platelet-rich plasma (PRP), and platelet-rich fibrin (PRF) are increasingly used in dental surgery. All of these treatments markedly speed up the healing of dental procedure injuries. They are less commonly used to treat dry socket, but some dentists will use them to speed up the healing process.

Dry socket medications

Because dry socket heals on its own, medications are used to manage the pain and prevent or treat infections. Over-the-counter pain medications, topical anesthetics, saline or antibacterial rinses, and medicated dressings make up the standard arsenal of dry socket medications.

Pain relievers

Dry socket will heal without intervention in about seven to 10 days, but the pain lasts for only one to three days. For many patients with moderate pain, over-the-counter pain relievers such as ibuprofen or acetaminophen provide sufficient pain relief as the healing process progresses.

Dressings

When pain relievers don’t work, the dentist will clean the socket and apply a basic or medicated dressing, called “packing.” Dressings can be simple dressings or coated in medications. The most common dressings used are SaliCept, a hydrogel, Dressor-X, made of cotton gauze, or medicated dry socket paste. Dressings are “packed” lightly into the socket and provide immediate pain relief. They typically remain in place for three to five days. Some will slowly break up in a few days, but gauze may require another trip to the dentist to be removed.

Topical anesthetics

Many dry socket dressings include a topical anesthetic such as eugenol or lidocaine, but the dentist may apply a stronger topical anesthetic such as lidocaine viscous or prilocaine in cases of severe pain. Over-the-counter clove oil (eugenol) and lidocaine can be used to numb the pain when treating dry socket at home.

Antiseptics

When the dentist cleans out the socket, the rinse will contain an antiseptic, a substance that kills microbes. The most commonly used antiseptic for rinsing dry socket is chlorhexidine, commonly found in prescription gingivitis mouthwash. The dentist may also use highly diluted hydrogen peroxide, also an antiseptic, to facilitate removal of debris from the socket.

Antibiotics

Antibiotics are only rarely used to treat dry socket. Patients with a compromised immune system or a history of dry socket may be prescribed a single-dose antibiotic when the tooth is removed to prevent infection. The most common antibiotic used to prevent dry socket is amoxicillin, but dentists may also prescribe azithromycin before a tooth extraction or apply topical clindamycin or lincomycin to the socket after a tooth extraction.

Choosing the best medication

Medications for dry socket focus mainly on pain relief, although antibiotics may be used in rare cases where the infection is a risk. There is no “best” medication for dry socket. Dentists can choose among several alternatives. In general, however, cleaning and dressing the socket along with over-the-counter pain relievers will provide sufficient pain relief as the socket heals.

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