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Dry Socket even WITH Stitches?

Updated: 3 days ago

How do you get dry socket and can you still get it even with stitches? Is it inevitable or is there something that you can do to prevent it?



Table of Contents:



Can you get dry socket with stitches?

Unfortunately, you can still get dry socket even with stitches because the condition is uncorrelated with how covered the extraction socket and stitched up it is.


A common misconception is that dry socket (alveolar osteitis or AO) is caused by dislodgement of the blood clot from within the socket. Therefore, the proposed solution would be to stitch over it to prevent it from occurring. Once again, that is false because the phenomenon develops via a biological process and not from a mechanical one.


Just to drive the point home, the stitches do not prevent the condition from happening so whether or not your dentist gives you any will have no effect on your chances of getting it.


How common is it?

According to some studies, the incidence of alveolar osteitis depends on whether it was a routine extraction or a surgical extraction.

  • Routine extraction is 0.5%-5%

  • Surgical extraction is 1%-37.5%

Another factor that influences how likely you are to get it is if the tooth removal was done on an upper tooth vs a bottom tooth. The studies states that it was about three times more likely for bottom teeth vs top teeth.

  • Upper teeth = 27%

  • Lower teeth = 73%

Last but not least, it is also the wisdom teeth that are more likely to get dry socket with the bottom wisdom teeth being the most common tooth to get it.




When can I stop worrying about dry socket?

Studies typically show that there is about a 24-96 hour delay from the time of extraction to the onset of dry socket symptoms. This means that it may take up to 4 days or 96 hours before you the condition develops.


Ultimately, you can stop worrying about it once 5-7 days have passed and you've experienced no symptoms. You should be in the clear after approximately a week from the extraction. Otherwise you should be extra cautious prior to that time frame because it could still develop at any moment.




Signs and Symptoms

The most obvious symptom of a dry socket would be excruciating pain that feels almost unbearable. The pain is so bad that it actually hurts more than before you had the tooth removed. Aside from intense pain, there are a couple of other signs and symptoms.

  • Unbearable pain. Patients report the pain level typically as a 10 out of 10. It will throb as soon as food or liquids touch the exposed bone.

  • Missing blood clot. Normally there IS a blood clot that forms over the extraction socket but you won't see one here at all.

  • Exposed bone. You can see pieces or parts of the bone inside of the socket. Normally, you wouldn't be able to see it because a formed blood clot should cover it. The bone is also extremely sensitive to anything touching it and that includes all foods and drinks.

  • Bad breath or foul odor. Since there is no clot blocking the socket, a lot of food can get trapped within it. The bacteria that are naturally in your mouth will start fermenting the food and cause a foul odor or bad taste in your mouth. The odor comes from the excreted volatile sulfur compounds from the bacteria.

  • Lack of blood in the socket. After having a tooth removed, you should be at least mildly bleeding or slightly oozing from the site for the next few days. In a dry socket, there is an absence of blood. Don't even mention the blood clot because blood can't get to the area.

  • Slow healing. This condition will make the extraction site heal slower than normal. That means it will take a longer time for the hole to close over.


What a dry socket looks like

It looks very clean because there is no blood in it and all you can see is just the exposed bone. It actually looks better than a normal socket. The normal one looks a lot messier with a blood clot and new epithelium trying to grow over it.



Signs and symptoms of a normal socket

The main distinguishing factor of a normal socket is that the pain decreases with each day of healing. A dry one will have increasing levels of pain that don't seem to subside with each passing day. This means that if you feel better and it hurts less with each day that passes, you most likely have a normal socket.


Here are some addition signs and symptoms:

  • Decreasing amount of pain as it heals. Gets better day after day.

  • Blood clot is present. If you look in the extraction site, it may look messy and a little ugly because that is what a clot looks like. A lot of people mistake it for an infection because it looks very unsightly. A little bit of blood oozing is ok.

  • Mild bleeding or oozing. It is normal to have a little bit of bleeding such as a few specks of bleed a couple of days after the extraction.

  • No exposed bone. You can't see any of the bone underneath because the blood clot is covering it.

  • Redness around opening. The red color is not a sign of irritation but rather a sign of healing.

  • Bad breath or foul odor. This symptom can be indicative of a normal socket as well because food can still be trapped inside of the hole. Any unremoved food will get fermented by bacteria and it will cause a bad stench. This is why it is very important to rinse very well after each meal so that food doesn't get stuck in the hole. This symptom is shared with a dry socket.Bad breath or foul odor


What a normal socket looks like while healing

It looks very different from a dry one because it actually looks worse or less pretty. The healing appearance is often described as the ugly duckling phase. What it looks like is a blob of white material that is stuck inside of the hole. You may see splotches of red, which is blood but that is a good sign because it means the area is able to receive blood and nutrients for healing.

Healing dry socket
Healing dry socket

There are no explicit pictures of a dry socket with stitches because whether or not there are any stitches has nothing to do with developing a dry socket. Here are some additional pictures showing the entire healing process of a normal socket after an extraction. As you can see, with each passing day, the gums will grow over and try to cover up the exposed hole until it completely closes.

post-extraction healing timeline



Theorized causes of dry socket

Despite centuries of research in this topic, the exact cause of a dry socket has still NOT been determined nor fully understood by researchers and clinicians alike. Therefore, all of the proposed causes are theories but none of them give a satisfying and complete answer.


Bacteria

One hypothesis was that it was due to bacteria initiating the dry socket lesions or prolonging the duration of it.


However, there is little evidence that giving antibiotics after every extraction did little to prevent the incidences of dry socket. There was one study that showed giving antibiotics did slightly reduce the chances of it occurring but clinicians questioned whether it was practical to put everyone on antibiotics just to slightly reduce the chances of it happening for a select few individuals.


Plasmin-induced fibrinolysis

Birn observed increased concentrations of plasmin and that led to increased fibrinolytic activity in dry sockets. An increase in fibrinolysis can dissolve blood clots and since our condition of interest is a dislodged blood clot, it could potentially be the cause. The plasmin activity could be dissolving and dislodging our needed clot.


The hypothesis was that trauma during extraction or the presence of bacteria could have led to an increased level of plasmin induced fibrinolysis.


However, from what we know about the biological healing process, the fibrinolysis usually also increases bleeding and blood flow to the area. In a dry site, there is not only no blood clot but also an absence of blood and bleeding. Due to this, it makes it unlikely that this theory is true.


Osteoblast necrosis

A different study proposed that due to traumatic extraction forces, the osteoblast cells lining the inside of the socket could undergo necrosis (cell death). The osteoblasts normally contribute to building bone and repairing healing normal sockets. With the death of these cells, it could initiate fibrinolytic activity and that can result in a lack of a blood clot.


The reasoning for causing the death of osteoblasts is from heavy luxation forces during difficult extractions. The forceps could crush the inside surface of the socket and kill all the cells.


However, this model implies that inflammation does not cause dry socket. This makes it a radical departure from how we normally classify the condition by calling it "Alveolar Osteitis" which is another name for dry socket. Since the proposed theory says it is not due to inflammation, the "itis" which signifies inflammation would be incorrect. The author's suggestion is to rename it as "post-extraction peri-alveolar exposed-bone ostealgia syndrome."




Risk factors

Even though we don't really know what the true cause of dry sockets (AO) are, we do know that there are certain factors which can increase the risk of getting it.

  • Smoking. Studies have shown that smokers typically have a higher chance of getting the condition. The statistics for this study showed that the incidence in smokers was 12% vs 4% for the non-smokers. This makes smoking after an extraction, 3 times as likely for you to get the condition. That is the reason why your dentist tells you not to smoke while you're healing.

  • Oral contraceptives. Studies have shown that the incidence of alevolar osteitis was significantly greater for oral contraceptive users.

  • Menstrual cycle. In addition to taking birth control, researchers also found that women during the middle of a menstrual cycle were more likely to get it as well.

  • Previous occurrences. If you've had complications with extractions in the past, you are more likely to get AO again.




Treatment

There is no permanent cure for dry socket because all available treatments only focus on trying to speed up the healing or alleviate the pain.


Induce bleeding

The problem is that there is no blood flow to the socket so a blood clot can't form. In an attempt to promote healing, your dentist may drill a couple of small holes into the bone to induce bleeding. The entry and presence of blood may speed up the healing of the hole.


Curettage and irrigation

An alternative way your dentist may try to induce healing is by cleaning out the socket. Scraping the inside of the socket and also the gums is called curettage. The scraping may stimulate the healing mechanism and promote blood flow to the area. Afterwards your dentist will rinse out the hole witPain medication

h either saline (salt water) or chlorhexidine (antibiotic rinse) in order to remove any dead bone, bone fragments, and food particles that may have been stuck in there.


Stitches

The stitches don't stop dry socket from happening but what they can do is offer pain relief from the exposed bone. Your dentist may try to stretch your gums over the hole and close it up with stitches. The pain that you feel from this condition is from objects and particles that touch the exposed bone. Therefore if you cover it up with the gums and stitches, you should be more comfortable during the healing process.


Placement of medication

A popular medication dressing to be placed in the hole is called Dry Socket Paste, which contains eugenol. The paste is left inside for approximately 3-5 days and may be replaced as needed.


However, some studies state that excess use of eugenol may lead to necrosis of bone, which is counterproductive to what we want. Due to this, many practitioners have been moving away from using this medicament.


Alternatively, honey has been proposed to be placed within the socket in lieu of dry socket paste. Apparently, the study did show that honey significantly reduced inflammation, hyperemia, pain and discomfort for the patients.


Therefore from a pain management standpoint, honey is effective as a treatment option. However from a tooth decay point of view, it leaves much to be desired.


Mouth rinse

Using an at home mouth rinse throughout the healing process is recommended because it can keep inflammation down and the extraction site clean by removing debris. Two common mouth rinsing solutions are salt water and chlorhexidine. These rinses should be used after every meal.


Keeping the socket clean of food and debris will help reduce the pain level since the exposed bone elicits pain whenever it is touched.

The Verdict


Pain medication

Last but not least, in order to reduce the amount of pain, an over the counter pain medication such as ibuprofen or acetaminophen can work wonders. The ibuprofen may be a bit more effective since it is an NSAID, non-steroidal anti-inflammatory drug.

  • For ibuprofen you may take 600-800 mg every 8 hours depending on what your dentist recommends.

  • For acetaminophen you may take 650-1000 mg every 8 hours depending on what your doctor recommends.




Prevention and takeaway

Unfortunately there is no way to prevent dry socket from happening and even if your dentist did not put in stitches, it wouldn't have made a difference.


Fortunately there are ways to reduce the chances of it happening such as abstaining from smoking and using oral contraceptives. There have been studies which have shown that prescribing antibiotics before the procedure may reduce the chances of it happening. However, when taking into account the risk to benefit for the general population overall, the recommendation was to not put the entire population at risk for antibiotic resistance just to prevent dry socket for a select few individuals. Antibiotics are encouraged for those who've had a history of AO.


Last but not least, don't forget to go in for your 6 month dental check ups and cleaning regardless of whether or not you need teeth removed!


Author: Written by a long island city dentist, Dr David Chen.

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