Dry Socket

Question 1

What is the definition of dry socket?

When does it increase in severity?

Answer 1

post-operative pain inside and outside an extraction socket

Between the first and third day after the extraction

Question 2

What will the patient describe the pain as in dry socket?

Answer 2

Deep seated, aching, throbbing,

Question 3

What are the risk factors for dry socket?

Answer 3

• Mandibular extraction
• Females on contraceptive pill
• Excessive rinsing post-operatively
• Single extraction
• Smoker
• Difficult extractions

Question 4

What is the aetiology for dry socket?

Answer 4

• Excessive local fibrinolysis of clot resulting from plasminogen pathway activation

Question 5

What are the stages of clot formation during socket healing?

Answer 5

• Damage to vessel wall leads to vasoconstriction
• Clot formation (loose for several days)
• Clot fibrinolysis (local tranexamic acid - inhibits breakdown of the fibrin clot by preventing plasminogen converting to plasmin)

Question 6

What immediate steps should the dentist undertake following tooth extraction?

Answer 6

• Check socket to ensure all the tooth has been removed
• Remove apical pathology (Cyst, granuloma)
• Curettage and saline flush to remove debris
• Local haemostatic measures if needed

Question 7

How is dry socket managed?

Answer 7

• REASSURE PATIENT
• It does not require antibiotics
• Self-limiting
• Pain control (advise analgesic regime): ibuprofen 400-600mg 4 times a day/ Paracetamol 1g 4x a day
• Irrigation of socket with saline
• Alvogyl into socket
• Telephone review call to ensure no spreading complications

Question 8

What are the most common complications after third molar surgery?

Answer 8

• Pain, swelling, trismus, sensitivity, bad breath, dry socket

Question 9

Give an overview of the socket healing process

Answer 9

1. Response to surgery = vasodilation, platelets, vascular endothelial cells and keratinocytes release inflammatory mediators
2. Polymorphs migrate into areas and engulf any bacteria
3. Granulation tissue comprises of a framework of extracellular matrix of collagen, elastin and inflammatory cells migrate into
4. 7-10 days = collagen cross linking increasing the strength of the blood clot
5. After 21 days = mass of collagen stimulated by growth factors, in growth of blood vessels into area and bone formation

Question 10

How long do we advise the patient that the socket takes to infill?

Answer 10

3-4 months

Question 11

List a group of patients that are at risk of infection

Answer 11

• Infants
• Malnutrition
• Alcoholism
• Diabetes
• Cirrhosis
• Renal failure
• Malignancy
• Leukemia, lymphoma, myeloma
• HIV / AIDS
• Smokers
• Immunosuppressed, steroids, organ transplant, bisphosphonates, radiation therapy