Painful Socket (Dry Socket)

Dry socket, the most common postoperative complication from tooth extractions is characterized by the partial or total premature loss of a blood clot that forms after extraction, exposed bone and nerves to outside, results in severe pain and delay the healing process.

In normal condition, after extraction, blood clot forms inside a socket (a hole in the bone where the tooth has been removed) and the healing process begins. During the first 24 hours, a fibrin-covered clot adheres to the socket bone.  Within 3-4 days, fibroblasts form and the clot is stabilized.  The clot is slowly replaced by granulation tissue.  In approximately 1 month, the socket is filled with new bone. 


In dry socket, the clot dislodges or dissolves too soon (few days after extraction), leaves the bone and nerve exposed to outside environment which then leads to severe pain and halitosis. Dry socket is not an infection, therefore antibiotics is not indicated unless secondary bacterial infection begins at a later time.

The incidence of dry socket has ranged from 1% to 4% of extractions; 45% occurs in mandibular third molars (lower wisdom teeth) and ten times greater in the lower teeth than the upper teeth.In general, the healing process takes place in 3-4 weeks.

Contributing factors of Dry socket:

1. Smoking increases risk 2-5 times
2. Taking oral contraceptives increases risk 2-5 times. Try to schedule during the last week of the cycle, during that time the estrogen level are inactive
3. Trauma during extraction, difficult extraction
4. Wisdom tooth extraction especially impacted teeth
5. History of dry socket, previous pericoronitis or ulcerative gingivitis (appropriate antibiotic prophylaxis should be administered prior to wisdom tooth extraction)
6. Rinsing too soon or too vigorously; causing the clot to dislodge from the wound
7. Using straw after extraction
8. Ignore home care instruction provided by the dentist
9. Poor oral hygiene
10. Taking Immunosuppressant drugs: Corticosteroids such as prednisolone (Deltasone, Orasone), Mycopehnolate (CellCept), Cyclosporine (Sandimmune, Neoral), Azathioprine (Imuran)
11. Recent history of Acute Ulcerative Gingivitis (Trench Mouth), Pericoronitis (infection around the crown of the tooth) associated  with the extracted tooth
12. In the age group of 40-50 years old.  Female are prone to dry socket than male.
13.  Presence of local bacteria infection such as ulcerative gingivitis
14. Trauma from surgery or existing inflammation - generally occurs as early as the second day after extraction. According to Birn's theory, trauma from surgery or existing inflammation causes bone and adjacent tissue to release stable tissue activators, which convert plasminogen in the blood clot to plasmin.  Plasmin is a fibrinolytic agent which dissolves the blood clot.

How to prevent dry socket

1. Pre-operative oral hygiene - have your teeth cleaned before extraction to reduce plaque and bacteria
2. Use mouthwash with 0.12% chlorhexidine digluconate just before surgery and as irrigation after extraction reduce risk in some patients
   
3. Stop smoking prior to surgery and 72 hours after extraction
4. Avoid vigorous mouth rinse for the first 24 hours after extraction
5. Use gentle toothbrush and gentle mouth rinse with 0.12% chlorhexidine digluconate for at least a week after extraction
6. Follow the dentist instruction and see the dentist immediately if the pain increase after few days or bad taste coming out from the wound
7. For women who use oral contraceptives; schedule surgery when you get the the lowest dose of estrogen, during days 23 through 28 of the tablet cycle, the hormone can interfere with blood clotting
8. Avoid smoking, the action of smoking can dislodge the clotting and contaminate the wound
9. Avoid using straw for drinking, the suction will interfere or dislodge blood clotting
10. For women, schedule extractions during the last week the menstrual cycle, estrogen level is lower during that time

How can you tell if you have dry socket

1. The pain at the socket which is improving during the first few days after extraction abruptly reversing to excruciating sharp shooting pain. If the extracted tooth is in lower jaw, pain is so intense sometimes it can radiate to the ear. 
2. The normal post extraction blood clot is absent from the socket
3. The socket is empty, bone is covered by a yellow-gray of necrotic tissue
4. Swelling of gum tissue around the socket
5. You may have bad breath (Halitosis) and bad taste in your mouth
6. Inability to open your mouth normally (Trismus). Trismus develop between 10-40 days after extraction
7. Swelling of regional lymph nodes at the affected side
8. Fever, headache, insomnia and dizziness

You might not feel all these symptoms at the same time.

What the dentist may do

1. The dentist may irrigate a socket and clean food particles from the socket and induce bleeding leading to clot formation
2. Pack the socket with dry socket paste to relieve pain, prevent food debris to accumulate in the socket and protect the exposed bone. The dry socket paste consists of Eugenol, Guaiacol (antiseptic, anesthetic), and Chlorobutanol in anhydrous form (antibacterial and antifungal). The dressing need to changed every few days (24-48 hours) for 1 week, or sooner if the pain diminished. The pain will improve within an hour after applying the dressing. This treatment doesn't promote healing process, instead it will slow down the healing process. Once the pain is tolerable, the treatment is discontinued.  Adverse reaction of Eugenol are hypersensitivity, irritation and cytotoxic when contacts with soft tissue.
3. If there is clinical signs of infection, such as fever, suppuration, the dentist may prescribe Amoxicillin 1,500 mg/day; for patients allergic to Amoxicillin, the dentist  may prescribe Clindamycin 1,200 mg/day
4. Instruct you to gentle rinse your mouth with warm salt water or other medicated mouth rinse such as 0.12% Chlorhexidine 3 times daily for 7 days.
5. If the pain persist after 48 hours, return to the dentist 

What to do at home

1. Use syringe with warm salt water to clean the wound or just gently switch your mouth with warm salt water, listerine or 0.12% chlorhexidine digluconate (prescribed by the dentist) to remove food debris
2. Use Clove oil (from over-the-counter), add few drops in cotton pellet or gauze (cut into small size to fit the socket), and carefully apply to the wound using tweezers; place another regular size gauze over and bite down to hold the gauze in place. This method has been successfully alleviate pain within an hour in most cases.  Care must be taken to apply only to the socket area and not to other soft tissue to prevent unnecessary burn sensation.  Change to new dressing when it no longer help relieving pain. Note: Use only as needed for pain, prolong use of clove oil can delay the healing process. Stop using clove oil as soon as pain subsides. Other products that contain oil of clove (Eugenol) are Red Cross toothache kits.
3. First twenty four hours after extraction; rinse your mouth gently with warm water after each meal 
4. Eat only soft food such as soup
5. To relieve pain with pain pills, use non-steroid anti-inflammatory drugs:

            Mild pain

• Acetaminophen (Paracetamol; Tylenol) 0.5 - 1g taken every 4 - 6 hours (maximum dose 4000 mg/day).  Avoid using this drug if you have liver disease or history of alcoholis.  Other name brands are:  Aceta, Anacin, Dapacin, Fem-Etts, Genapap, Genebs, Mapap, Maranox, MedaCap, MedaTab, Panadol, Tapanol and some more name brands.
• Ibuprofen (advil, motrin, mediprin, nurofen, cuprofen) 200 – 400mg taken every 4 - 6 hours



Moderate pain

• Acetaminophen (Paracetamol, Tylenol) 0.5 - 1g + Ibuprofen 200 – 400mg taken every 4 - 6 hour. 
• Codeine + Ibuprofen 2 tablets every 8 hours (brand names include Nurofen Plus and Solpaflex)
• Codeine + Acetaminophen (Paracetamol, Tylenol) 2 tablets every 8 hours (brand names include Solpadeine, Paracodol, Solpadol and Kapake)
• Alternating between 1000 mg of Acetaminophen (paracetamol); 2 extra-strength Tylenol (not to exceed 4,000 mg of Tylenol or 8 extra strength Tylenol) in one day, and 400 mg of ibuprofen; 2 tabs of Advil, every 4 hours.  Do not use this regimen if you have history of peptic ulcer, liver disease, hypertension.  Do not take more than few days.



Severe pain

Codeine - Acetaminophen + Ibuprofen

Note:  The pain from dry socket is difficult to control with any kinds of pain pill (analgesic).  A better and immediate relief of pain involves placing medicated dressing from the dental office directly in your socket (extraction site).

       6. To relieve swelling;

First 24 hours after extraction; 

Apply ice pack or cold towel place outside of your face in the area of extraction alternately 15-20 minutes on and 15-20 minutes off for 6 hours or till bedtime.

More than 24 hours after extraction;

Apply moist heat (wet towel put in microwave for 10-20 seconds or dip towel in hot water) place outside of your face in the area of extraction alternately 10-15 minutes on and 10-15 minutes off.
This routine should be used in all extraction


Source : http://www.toothnature.com/2011/05/dry-socket.html