Infection v Dry Socket
Introduction: Infection v Dry socket
Are you experiencing pain after a tooth extraction? It can be tricky to figure out if you’re dealing with a post-operative infection or a dry socket since both can cause significant discomfort.
In this article, I’ll chat about the main differences between these two tooth extraction complications and help you identify which one you might be experiencing. By learning the symptoms, causes, and treatments for both post-operative infections and dry sockets, you’ll be better prepared to take the right steps toward healing and managing your dental health.
|Postoperative Infections||Dry Socket (Alveolar Osteitis)|
|Pain||At the surgical site||Severe, throbbing|
|Other symptoms||Redness, swelling, pus, fever||Partial/total loss of blood clot, bad breath, unpleasant taste|
|Primary causes||Bacterial contamination||Blood clot dislodgement|
|Contributing factors||Poor surgical technique, compromised immune system||Smoking, oral contraceptives, poor oral hygiene, infection|
|Medications||Antibiotics||Pain relief (NSAIDs), antibiotics (if infected)|
|Non-pharmaceutical||Proper wound care, drainage (if necessary)||Rinsing with saline solution, placing medicated dressings|
Tooth extractions are the treatment many people choose when they have a toothache, a tooth infection, or a badly broken down tooth that costs too much to repair. As a dentist, I typically will not recommend an extraction unless it is the last resort because it is generally better for you to keep your natural tooth.
Having said that, I have still extracted thousands of teeth in my career. Why? Because I’ve seen plenty of cases where the tooth was unrestorable (I can’t save it regardless of the efforts we make and treatments we offer) and other cases where extraction of the tooth was in the patient’s best interest, whether for financial reasons, the risk for spreading infection, access to care or time constraints. For example, when I worked in dental clinics on overseas mission trips, repairing an infected tooth was not feasible because there was no permanent dental clinic in the area. This lack of access to other dental care meant that removing the tooth was the only option to prevent the patient from suffering a progressively worsening infection.
A tooth extraction is considered a type of surgery. It involves the removal of a part of your body – in this case, a tooth. All surgeries carry the risk of postoperative complications, and extractions are no exception. The location of the surgical site (inside the mouth) makes complications after an extraction relatively common. There are so many factors that contribute to someone’s risk for complications after extracting a tooth. Sometimes, it is easy for me to predict when someone is likely to experience a post-op infection or dry socket. Other times, the complication surprises us. Obviously, we always try to reduce the risk for complications as much as possible.
From my experience, I would say that the most predictive risk factor for postoperative complications is the complexity of the surgery itself. In general, the more easily a tooth comes out, the lower the risk for complications. How does the patient know if the surgery is complex? If the patient is awake during the procedure, he or she can simply evaluate the situation. Does it seem like the dentist is having a hard time getting that area of the mouth completely numb? Is it taking much longer than you expected (or longer than the dentist expected)? Even though you are feeling no pain, does it seem like the dentist is struggling to get the tooth out? Is the tooth breaking into multiple small pieces that are coming out one by one? These are all signs that it may be a more complex extraction.
Wisdom teeth extractions tend to present with more post-op complications for good reason: they are typically more complex than simple, individual tooth extractions. Most wisdom teeth are either partially or completely submerged in the gums and/or jawbone. Many wisdom teeth are not aligned straight but at a funny angle in the jawbone. Because wisdom teeth are more difficult to remove, their extractions are more complex, and therefore, their risk for post-op complications is higher.
The prevalence of post-extraction infections is pretty difficult to pin down. This is because so many teeth are pulled because they are already infected. A post-extraction infection can be related to a pre-existing infection, or it can arise after extraction of a healthy tooth (i.e. for orthodontic purposes). In a healthy person, the risk for post-op infection after extraction of a healthy tooth is low. It should be almost zero if the patient follows the post-op instructions carefully.
The exception to this rule is wisdom teeth. They are often relatively healthy, uninfected teeth when removed, but the complexity of their extraction, the difficulty of keeping the surgical sites clean, and the lack of compliance with post-op care all increase the risk for infection. A Cochrane review of carefully conducted studies revealed that fit and healthy youngsters undergoing third molar extractions face a 10% chance of postoperative infections. However, the odds increased to 25% if the patient was suffering from a weakened immune system before undergoing the tooth extraction.
Symptoms Of A Post-Op Infection
Infections do not always cause pain, and in the event of tooth extractions, they do not always cause swelling either. Again, it is hard to determine whether the infection is the result of a pre-existing infection (the reason we pulled the tooth in the first place) or a new infection due to an open wound in the mouth.
Some common signs of post-extraction infection include:
- Swelling of the gums inside the mouth
- Swelling that is visible from a full-face perspective
- Increased pain after the tooth extraction
- Pus draining from a pimple-like abscess or from the extraction socket (this often tastes salty)
- Redness and swelling around the surgical site
- Swollen lymph nodes in the neck on the side where the tooth was removed
If I anticipate that someone might experience a post-extraction infection due to high-risk factors, I usually prescribe oral antibiotic therapy for the patient to take both before and after the extraction. This is pretty common because most teeth I extract are already infected. If someone develops an infection after the extraction that we were not expecting, we will start them on antibiotics as soon as possible to aid them in the healing process.
In addition to antibiotic therapy, we can treat post-extraction infections by cleaning the surgical site. This is sometimes necessary to help the body overcome any infection in the socket, but it creates a new wound by reopening the socket, so it does not completely eliminate the risk of infection. Any open wound in the mouth is at risk for infection. We also stress the importance of overall oral hygiene and care of the socket. Reducing the risk of infection must include a clean mouth! In fact, some patients actually require deep cleaning of their other teeth before having one extracted because the bacterial load in the mouth is so high. It sounds crazy to clean teeth that you’re going to pull, but it actually reduces the risk of infection after the surgery.
Risk Factors For Dry Socket
Smoking | Surgical trauma | single extractions | age | sex | medical history | systemic disorder |extraction site | amount of anesthesia | operator experience | antibiotics use prior to surgery n |difficulty of the surgery |oral contraceptives | menstrual cycle | immediate post-extraction socket irrigation with normal saline |
A dry socket is, unfortunately, a pretty common complication after tooth extractions. In my personal experience, I have only had a few patients develop dry socket. I think the reason for the low prevalence in my personal practice is that I did not extract impacted wisdom teeth, which have a much higher risk for dry sockets.
A dry socket, officially termed alveolar osteitis, is the inflammation of the jawbone in an extraction socket that occurs when there is no clot to fill in the socket. In an extraction socket that heals normally, the blood clot fills the socket and covers the jawbone. In a dry socket, the jawbone is exposed and “dry” without the protective coverage of a blood clot. The formation of a healthy blood clot is the first stage of the tooth extraction healing process
A variety of issues can lead to this lack of a blood clot.
- The clot can fail to form at all. This happens in people who do not have good blood flow to their extremities (i.e. smokers and diabetics).
- The clot can form and then be dislodged by suction forces. This is why we tell you not to smoke or drink through straws. The sucking force can pull the clot out of the socket.
- The clot can form and then be dissolved by chemical forces. This is why we tell patients not to drink carbonated drinks (sodas) or alcohol.
- Dry socket is more likely to develop after a particularly complicated surgical extraction (again, why this is more common with wisdom teeth), so even with perfect compliance to post-op care instructions, you could still experience it.
Smoking: Patients who smoke more than 20 cigarettes per day have a higher incidence of dry socket compared to non-smokers.
Surgical trauma: A study of 1,355 patients who underwent dental extractions identified a significant connection between the level of difficulty in removing the tooth and a dry socket. A different study of 1305 dental extractions performed in 805 patients backed up this conclusion by showing that simple non-surgical extractions resulted in 1.7% cases of dry sockets compared to 15% when the procedure was a more complex surgical procedure.
Amount of anesthesia: The amount and type of anesthetic have been linked to cases of dry sockets.
Symptoms of a Dry Socket
Many people ask me how they will know if they have a dry socket. The good news is that it is relatively easy to identify. The bad news is that it is extremely painful. Here are signs and symptoms that you might have dry socket:
- A sharp increase in pain three to five days after the extraction
- A bad smell (severe bad breath)
- A bad taste in the mouth
- If the socket is in an area you can see, it will look empty and dry.
Dry socket is terribly painful, but we can do something about it. My patients have experienced immediate relief from the pain of dry socket by returning to the office for me to place a medicated dressing directly into the socket. This dressing does require replacement, so you’ll have to make multiple trips to the dentist until it begins healing (usually after the first week or so). Treatment is not necessary for the socket to heal. We simply provide it to help patients manage their pain. If you’re unable to return to the dentist, it will eventually feel better.
Comparison of Tooth Extraction Infection and Dry Socket
As I mentioned initially, it can be difficult to tell which complication you are experiencing. Typically, from the patient’s perspective, all you know is that something hurts! The best thing you can do is return to your dentist for an evaluation and treatment of the complication. I’ll try to give you some information to help you make an educated guess on which you may be suffering. But you still need to see your dentist.
Similarities Between Infections and Dry Sockets
Although they are different conditions, they share some similarities in their development, symptoms, and risk factors. They will both improve when you see the dentist for follow-up care.
- Development: Both infections and dry sockets occur as complications after tooth extraction. They are caused by disruptions in the natural healing process of the extraction site. Infections can result from bacteria entering the wound, while dry sockets develop when the blood clot protecting the extraction site is dislodged or fails to form properly.
- Symptoms: Both conditions can present similar symptoms, which can sometimes make it tricky to tell the difference between the two. Common symptoms include:
- Pain: Both infections and dry sockets cause pain at the extraction site, which may radiate to the jaw, ear, or neck.
- Swelling: Inflammation can occur in both cases, leading to localized swelling and tenderness.
- Bad taste or odor: Both infections and dry sockets can produce a foul taste or smell in the mouth due to the presence of bacteria or dead tissue.
- Risk factors: Some risk factors are common to both infections and dry sockets, increasing the likelihood of their development. These include:
- Poor oral hygiene: Inadequate oral care can increase the risk of bacterial infection and hinder the healing process.
- Smoking: Smoking can impair the immune response, reduce blood flow to the healing site, and increase the risk of clot dislodgment.
- History of complications: A previous history of post-extraction complications may predispose an individual to infections or dry sockets.
Differences in Symptoms
A dry socket usually does not cause large swelling in the jaw. The dry socket does typically follow a timeline, occurring between three to five days after the extraction. Infections can, but don’t always, cause swelling either inside the mouth or in the jaw/cheek area. Your dentist can easily tell the difference between these conditions through an evaluation of the socket.
An important consideration is that it is rare, but possible, for a patient to experience both complications at the same time. If you suspect that you might have one or both, please go see your dentist!
Differences in Treatment Options for Infections and Dry Sockets
These two conditions are not addressed in the same way. An infection usually needs antibiotic therapy, and a dry socket does not. The placement of a medicated dressing will reduce the pain of a dry socket almost immediately, and it would not alleviate the pain of an infection in the same way.
Differences in Severity Between Infections And Dry Sockets
The severity of pain is usually worse with dry sockets, but that doesn’t mean it is a more dangerous condition. The dry socket will heal on its own without treatment. An infection might not.
In terms of the severity of the condition, a post-extraction infection is far more dangerous because it could spread within the jawbone. Spreading oral infections, in rare cases, have caused patients to die because they spread into vital areas, like the airway, bloodstream or brain.
Prevention Of Infections And Dry Sockets
The best strategy for preventing postoperative infections is to follow your dentist’s care instructions to the letter! If you have a specific risk factor that makes you more likely to experience a complication, your dentist will customize the post-op care for your situation. Don’t follow random instructions you found on the internet. Your dentist knows your medical history, your oral health condition, your unique risk for complications, and how your extraction procedure went. Your dentist is the only one who can give you the best advice.
For example, if your dentist thinks your risk for infection is high and gives you a prescription for oral antibiotics, get the Rx filled and take it exactly as directed. Don’t stop taking it when you feel better. Don’t save it for later when you might have an infection. Take it as instructed.
Conclusion: Infection v Dry Socket
Some post-extraction complications are unavoidable and hard to distinguish from one another. By working closely with your dentist, you can reduce your risk for these complications and improve your healing if you do experience one. If you think you might have a problem, but you are not sure, call your dentist. Waiting to see if it gets worse only puts you at risk for more pain!
And of course, the best course of action is always prevention. Commit yourself to great oral hygiene and healthy habits now so you don’t have to experience infected teeth in the future. Not only will it help you avoid tooth extractions and their potential post-op complications; it makes you healthier overall!
Dr. Lara Coseo DDS, FAGD
Dr. Lara Coseo is a licensed dentist and a Fellow of the Academy of General Dentistry (FAGD). DDS stands for Doctor of Dental Surgery, which is the degree she earned to become a dentist. The FAGD designation signifies that she has achieved a high level of professional education and is committed to staying current in her field through continuing education.
Dr. Coseo is not only a licensed dentist but also an educator, sharing her knowledge and experience with dental students at the Texas A&M College of Dentistry.