Dental alveolitis is the most common complication following tooth extraction. There are three forms of dry socket: dry socket, suppurative socket, which contains pus, and patchy osteic socket, affecting bone and appearing around the third week after extraction. Their causes remain poorly understood, but they are linked to poor healing, and therefore to a problem related to the blood clot supposed to form once the tooth has been removed. Treatments exist; Dry socket, by far the most common, often progresses spontaneously towards recovery after ten days. Analgesics will aim to relieve the pain, which can be very intense. antibiotics will be used in some cases.

Definition of dry socket

Dental alveolitis is a complication that occurs after a tooth is extracted. This infection affects the socket, which is the jaw cavity in which the tooth is placed.

These alveolitis following extraction are due to inflammation of the wall of the alveolus. Dry socket is more common after the extraction of wisdom teeth, and more particularly those of the mandible, that is to say of the lower jaw.

Causes of dry socket

There are three forms of alveolitis: dry socket, suppurative socket, and patchy osteitic alveolitis (linked to infection of bone tissue). Their etiology remains a subject of questioning, as few studies exist. 

The alveolitis is, however, explained by the poor formation of the blood clot which, once the tooth has been removed, should allow healing.

Dry socket, or dry socket, is the most frequent form of alveolitis, and therefore post-extraction complications. Its pathogenesis is not yet fully elucidated, three theories attempt to explain the causes:

• It could be related to the absence of formation of a blood clot, due to an insufficient blood supply around the alveolus, and in particular at the level of the mandible, the bone which forms the lower jaw. 
• It could also be due to the malformation of the blood clot following the trauma following tooth extraction.
• It could finally be caused by lysis of the blood clot. This is the most widely shared theory. This lysis, or fibrinolysis, is due to enzymes (proteins capable of causing chemical reactions), found in the cavity of the oral mucosa, in particular. It can also be activated by the bone mechanism generated by the extraction, and also by microorganisms in the oral cavity, such as Treponema denticola. In addition, drugs such as anti-inflammatory drugs and oral contraceptives, or even tobacco, activate this fibrinolysis. 

Suppurative alveolus is caused by superinfection of the socket, or the clot formed after extraction. It is favored by:

• lack of asepsis (precautions and procedures to prevent infection);
• the presence of foreign bodies such as bone, dental, or tartar debris;
• infections that already existed before the extraction, or appeared after the extraction;
• infection from adjacent teeth;
• poor oral hygiene.

Finally, patchy osteic alveolite (or 21st day cellulitis) is caused by a superinfection of the granulation tissue (the new tissue formed following scarring, and heavily irrigated by small blood vessels). His particuliarity ? It occurs around the third week after tooth extraction. It can be trained by:

• the presence of foreign objects, such as food debris.
• the inappropriate use of nonsteroidal anti-inflammatory drugs (NSAIDs) after surgery.

Diagnosis of dry socket

It is the dentist who can make the diagnosis of dental alveolitis, in particular by confirming the absence of a blood clot in the socket of the tooth that was removed.

• Dry socket occurs a few hours, or up to five days after a tooth is extracted. Early signs may favor its diagnosis, such as fatigue and painful episodes.
• Suppurative alveolitis occurs on average five days after extraction, and its diagnosis can be made especially if a fever of 38 to 38,5 ° C accompanies pain, less intense than in the case of dry socket.
• The diagnosis of patchy osteic alveolitis will be made in the event of fever, also from 38 to 38,5 ° C, and also accompanied by pain that has persisted for a fortnight.

The people concerned

Dry socket is the most frequent complication of dental extractions: it concerns 1 to 3% of patients who have undergone simple extraction, and 5 to 35% of patients following surgical extractions.

The typical subject most at risk of developing the most common form of dry socket, dry socket, has been described as a woman, aged 30 to 50, under stress, taking an oral contraceptive, and whose oral hygiene is average to poor. The risk is all the more heightened for her if the tooth to be extracted is a molar of the lower jaw – or a wisdom tooth.

Poor aseptic conditions during an operation is a major risk factor for dry socket, as is poor oral hygiene. In addition, women are more prone to it, especially when taking oral contraceptive treatment.

Main symptoms of dry socket

Dry socket occurs after a few hours, and up to five days after tooth extraction. Its main symptom is marked by pain of varying intensity. These are sometimes small, discontinuous painful episodes, which radiate to the ear or the face. But most often, these pains are intense and continuous. And they turn out to be less and less sensitive to level 1 or even level 2 analgesics.

Among its other symptoms:

• a slight fever (or febrile), between 37,2 and 37,8 ° C;
• slight fatigue;
• insomnia related to severe pain;
• bad breath (or halitosis);
• greyish-white cell walls, very sensitive to touch;
• inflammation of the lining around the socket;
• foul odor from the socket on swabbing.

Usually, the x-ray examination will not reveal anything.

Main symptoms of alveolitis suppurativa

Suppurative alveolitis usually occurs five days after a tooth is extracted. The pains are less intense than for dry socket; they are deaf, and appear by impulses.

His other symptoms:

• a fever of between 38 and 38,5 ° C;
• pathological enlargement of the lymph nodes (called satellite lymphadenopathy);
• swelling of the vestibule (part of the bony labyrinth of the inner ear), whether or not associated with a fistula in the mucous membrane around the socket;
• the socket is filled with a blood clot, having a brownish or blackish color. The socket bled, or let foul pus gush out.
• the walls of the cell are very sensitive;
• at the bottom of the socket, bone, dental or tartaric debris are frequently found.
• The development cannot resolve spontaneously, and can cause complications, such as patchy osteic alveolitis.

Main symptoms of patchy osteic alveolitis

Plot of osteic alveolitis results above all in persistent pain during the fifteen days following the extraction. This pain is accompanied by:

• fever of 38 to 38,5 ° C;
• sometimes an inability to open your mouth (or trismus);
• asymmetry of the face, due to cellulitis around the lower jaw, that is, an infection of the fat of the face;
• a filling of the vestibule;
• the presence or not of a skin fistula.
• The x-ray, in general, shows a bone sequestration (a bone fragment which is detached, and has lost its vascularization and its innervation). Sometimes, too, this x-ray will not reveal anything.

The evolution can be done towards elimination of the sequestrant, in the absence of treatment. It can also lead to more serious infectious complications.

The treatment of dry socket mainly consists of pain relief, by analgesics. Physiological healing, or a spontaneous evolution towards a cure, generally occurs after about ten days. Time that can be shortened if the patient is treated.

This dry socket is by far the most frequent, and constitutes an emergency in dentistry: protocols have thus been tested, allowing it to be cured. Two trials were, for example, carried out by the team from the Abidjan consultation and odonto-stomatological treatment center and consist of:

• Apply dressings inside the socket, based on bacitracin-neomycin combined with eugenol.
• Apply a dressing of ciprofloxacin (in its ear drop form) to the painful socket.

The treatment is aimed at healing the socket.

In fact, the treatments for dry socket are above all preventive (consisting essentially of eliminating the possible causes). They are also curative:

• The curative treatment of suppurative and osteitic alveolitis is based on systemic antibiotic therapy, analgesics, and local care, such as rinsing with a saline or antiseptic solution, and intra-alveolar dressings.
• For suppurative alveolitis, if local care is performed very early, and in the absence of fever, the prescription of antibiotics is not necessary.
• For dry socket, several antibiotics, used alone or in combination with other various substances, exist, the most recommended being tetracycline and clindamycin. However, Afssaps does not recommend the use of antibiotics, in the general population, or in immunocompromised patients, for the treatment of dry socket; she recommends it only in cases of high risk of infective endocarditis, until mucosal healing.

In addition, the essential oil of clove diluted in a vegetable oil, such as olive oil or coconut oil, and deposited on the socket, would, according to some patients, relieve pain, or even cure the dry socket. However, care must be taken to dilute this clove oil. This essential oil is, therefore, a natural antibiotic, herbalists believe. However, it should not be given to pregnant women and children, or replace other treatments prescribed by the dentist.

Good overall oral hygiene before a procedure, as well as good aseptic conditions during the extraction are among the essential preventive factors against dry socket.

In order to avoid dry socket, which is very painful, the advice given by the dentist after removing the tooth should be strictly followed, such as:

• keep a compress on the socket and change it regularly, for 2 to 3 hours. This will promote the formation of the blood clot;
• do not rinse your mouth too much;
• do not spit;
• take care when brushing your teeth, and avoid rubbing too close to the socket of the removed tooth;
• do not pass the tongue where the extraction took place;
• chew away from the area where the tooth was extracted;
• finally, smoking should be avoided for at least three days.