Accepted Manuscript

Title: Common risk factors of dry socket (alveolitis osteitis)

following dental extraction: a brief narrative
review<!–<RunningTitle>Risk factors of dry
socket</RunningTitle>–>

Author: Vahid Rakhshan

PII: S2468-7855(18)30100-9
DOI: https://doi.org/doi:10.1016/j.jormas.2018.04.011
Reference: JORMAS 178

To appear in:

Received date: 20-10-2017

Revised date: 31-3-2018
Accepted date: 23-4-2018

Please cite this article as: Vahid Rakhshan Common risk factors of dry
socket (alveolitis osteitis) following dental extraction: a brief narrative
review<!–<RunningTitle>Risk factors of dry socket</RunningTitle>–> (2018),
https://doi.org/10.1016/j.jormas.2018.04.011

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Common risk factors of dry socket (alveolitis osteitis) following dental extraction: a brief
narrative review

Running title: Risk factors of dry socket

Review Article
Common risk factors of dry socket (alveolitis osteitis) following dental extraction: a brief

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narrative review
Running title: Risk factors of dry socket

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Vahid Rakhshan, DDS, PhD candidate 1

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1
Member of Center for Orofacial Bioengineering Research; Member of Research Council,
Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences; Scientific
Faculty Member and Lecturer, Department of Dental Anatomy and Morphology, Dental Branch,
Islamic Azad University, Tehran, Iran; Department of Cognitive Neuroscience, Institute for
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Cognitive Science Studies, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Correspondence to: Vahid Rakhshan, #22 Behrouzi Alley, Karegar St. Tehran, Iran, PO Box
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14188-36783; Phone: +982166929055; E-mail: vahid.rakhshan@gmail.com.

Conflict of interest: The author declares no conflict of interest.

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Abstract
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Dry socket is a common complication of dental extraction, especially extraction of third molars.
Knowledge of the frequent risk factors of alveolitis osteitis is useful in determining high-risk
patients, treatment planning, and preparing the patients mentally. The aim of this narrative
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review was to summarize the common risk factors of dry socket. A bibliographic search was
carried out to find literature regarding risk factors of dry socket after tooth extraction. Each full
article or abstract was read at least twice, and the relevant information was summarized. Except
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for surgery difficulty, surgeon's experience, oral contraception use, and oral hygiene, the
influences of other risk factors (age, gender) were rather inconclusive. The case of female or oral
contraceptive effect might relate mainly to estrogen levels (when it comes to dry socket) which
can differ considerably from case to case. Many risk factors might be actually a combination of
various independent variables, which should be targeted instead, in more comprehensive designs.

Keywords: Dry Socket (alveolitis osteitis); Risk Factors; Extraction.

Page 1 of 11
Introduction
One of the most common practices carried out in dental clinics is dental extraction and especially
extraction of wisdom teeth. Such surgeries accompany certain complications such as iatrogenic
(e.g., nerve injury, bone fractures, etc.) and inflammatory sequelae (such as dry socket,
postoperative pain, delayed healing, postoperative infection, hematoma, swelling, trismus, etc).
[1-6] The overall complication rate is usually low and they are mostly minor.[3,7] Nonetheless,
since dental extraction is frequently exercised, the morbidity of complications in the population

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may be noticeable; which this calls for methods to identify and control such issues.[3]
Furthermore, not all the complications are rare. There are frequent and debilitating complications
as well, including dry socket.

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Dry socket is an extraction alveolus lacking a blood clot and accompanying a postoperative
discomfort followed by a sudden intense and lancing pain in and around the extraction site,

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beginning at any time between the first and third post-extraction days (or between the
second/third or between the fourth/fifth days according to other sources)[2,3,8,9]; the pain
increases upon chewing or suction.[10-16] The condition is discomforting to the clinician and
patient, since it is painful and usually needs many postoperative visits for treatment.[11-
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13,16,17] Although its etiology is not clear-cut, the main etiology has been suggested as the
prevention of clot formation through a cascade of fibrinolysis induced by the bacterial enzymatic
activity.[9-12,16-19] Despite its unknown etiology, knowledge of its risk factors might assist in
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its prevention by determining high-risk patients, treatment planning, and preparing the patients
mentally. This essay briefly reviews the most common risk factors of dry socket.
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Search strategy
An Internet search was conducted to find relevant articles published until January 2018 regarding
risk factors of dry socket. The used search engines were Google Scholar, Pubmed/Medline, ISI
Web of Science, and Scopus. The keywords were: extraction, removal, dry socket, alveolitis,
alveolar osteitis, risk factor, prognostic factor, and predictor.

More than 2000 articles were initially found. All the found article titles were reviewed to find
more relevant ones. The articles of interest (original research [retrospective / prospective] or any

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review articles) were collected and evaluated one by one. Also the reference lists of the found
full-texts were sought for relevant reports. The study would be included if it provided
information relevant to at least one of the most common risk factors of dry socket. Due to the

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limitations in the number of citable references, some appropriate articles were subjectively
excluded, based on the number of risk factors presented, or date of publication, or quality of
methodology. Each article was read at least twice, and the proper information was summarized.

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Other keywords were searched for more general evidences (such as the mechanisms underlying
potential effects of smoking, age, gender, oral contraceptives, etc). Most common risk factors
were identified based on the abundance of literature regarding them, as well as the frequency of
significant results pertaining to them. It was subjectively concluded that not an enough number
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of recent or large studies had evaluated certain items such as ethnicity, psychiatric drugs [9], or
dosage of presurgical local anesthesia or the addition of vasoconstriction,[2,12] income status or
maxillary extractions; also many studies on some of such factors had not pointed to significant
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associations with dry socket. As an exclusion strategy, such items were not reviewed. The risk
factors included in this review (based on the abovementioned criteria) were ‘oral hygiene,
extraction difficulty and trauma, expertise of the surgeon, smoking cigarettes, gender, consuming
oral contraceptives, and age’.
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Oral hygiene
Different effective therapeutic protocols for treatment or prevention of postoperative
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complications include application of antibiotics or antiseptics using gels or mouthwashes,[10-

14,17] although not all studies agree on the suitability of such measures.[20] In addition,
preoperative infections might increase the risk of dry socket [21,22]. Therefore, it seems that if
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bacterial control can play a therapeutic role, so does oral hygiene.[4] Maintenance of a proper
level of sanitation and plaque control has been shown important in the success of oral
surgeries.[4,23] Many studies have exhibited the role of this factor in prevention of dry
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socket.[2,9,11,15,16,18,19,24,25] For instance, Egauvoen [2] stated that among 2218 patients,
risk of developing dry socket was 3.65 times greater in patients with poor oral hygiene compared
to those with good oral hygiene. These reports support the suggested role for bacterial activities
in dry socket formation,[10] and might as well justify the success of antiseptic and antibiotic
agents in prevention or reduction of dry socket frequency.[9,10,17] On the other, Momeni et
al.[22] reported a significantly lower rate of dry socket in patients with poor oral hygiene as well
as in patients with systemic diseases compared to systemically healthy patients with good oral
hygiene. They did not justify this interesting finding.

Extraction difficulty and trauma

Page 3 of 11
Bone marrow inflammation occurred by the surgical injury can lead to release of tissue
activators.[10,12,14,16,19] Also local blood circulation is reduced due to the vascular
damage.[10 ,14,16] Additionally, more complicated and lengthier surgeries might need higher
doses of local anesthesia, the vasoconstrictor of which might act as another predisposing factor
for dry socket [26]. Excessive curettage as well has been suggested as a factor damaging the
alveolar bone and possibly increasing dry socket risk [21]. Extensive surgeries would need
suturing, which might be yet another predisposing factor [27]. Hence, traumatizing, difficult, or
lengthy surgeries might increase the odds of postoperative complications [1,7] and dry

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socket.[1,16,18,19,24,28] Nevertheless, a few studies did not find a link.[29-32] Fotos et al.[29]
found no association between dry socket / discomfort in 70 patients with operative variables such
as the operator, surgeon’s dominant hand, time of surgery, surgical site, and difficulty of the

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surgery.[29] Benediktsdóttir et al.[30] evaluated the risk factors of dry socket in 388 extracted
molars, and found no significant associations between dry socket risk and any of the operative
factors assessed.[30] Larsen[8] as well did not find a role for increased surgical time as a dry

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socket risk. On the other hand, Beit,[25] Halabi et al.,[18] Nusair and Younis,[19] Abu Younis
and Abu Hantash,[33] MacGregor,[34] and Haraji and Rakhshan[16] detected significant roles
for trauma / difficulty. Chandran et al.[35] and Egauvoen [2] reported a 4-fold increase in dry
socket prevalence following surgical extraction compared to those following non-surgical
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extraction. Momeni et al.[22] asserted that damaging surgeries might increase dry socket
occurrence, but they did not find associations with other surgical settings (the tooth type and jaw
of extraction). However, Oginni [36] stated that all of dry sockets treated at their department
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during an 18-month period were in posterior teeth, and more than 75% of them were in the
mandible. Such settings might affect both the difficulty of surgery as well as bone density and
thus blood circulation and healing potential [22,34,36,37].
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The operator’s expertise

An experienced surgeon might practice a cleaner, less traumatic, and yet faster operation.
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Additionally, patients might trust experienced clinicians compared to novice ones. These factors
(trauma, duration of surgery, and anxiety) can play important roles in inducing
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complications.[7,8,13,18,28,30,38-41] Therefore, expert clinicians might obtain better

results.[7,8,28,39-43] Larsen[8] has identified surgeon’s proficiency as a factor influencing the
incidence of dry socket. However, the evidences are controversial, as some authors did not
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denote a link between surgeon’s skill and dry socket [19,20,30,33]. Some of these “experience
levels” were actually different semesters of an undergraduate dentistry course –and thus
trivial.[20] Parthasarathi et al.[9] asserted that skilled surgeons might cause more dry sockets
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compared to dental students. They attributed this finding to the bias that the surgeries finished by
more experienced surgeons are more complicated [9]. Egauvoen [2] reported about a 60%
increase in dry socket risk after surgeries undertaken by dental students compared to surgeries
performed by dentists. It is possible that some skilled surgeons might be less cautious. Also it is
imaginable that patients already at higher risk of dry socket (more difficult cases for example)
would visit experienced surgeons. The role of trauma itself has been reported in a
counterintuitive way;[1] some studies have denoted that extraction of multiple teeth might be
followed by fewer dry sockets.[34,42] Abu Younis and Abu Hantash[33] remarked an
association between dry socket with surgical trauma, but not with surgeon’s experience. This
might be due to the confounding factors such as other characteristics of patients who seek
extraction of multiple teeth versus those of patients who want only one tooth removed.[1,34]

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Such issues need multivariate analyses to address the reasons after controlling for the
confounders.
Tobacco smoking
Smoking might damage healing mechanisms, suction the clot, affect blood vessels, and
contribute to poorly filling of the socket with blood.[9,11,12,14,18,19,40,44] Therefore, it might
increase dry socket odds,[8,18-20,33,40,45,46] with some studies suggesting dose-dependent
effects.[19] Smoking might render cases of multiple extractions more prone to complications.[1]
Nonetheless, some research have failed to detect a role for smoking.[3,9,16,22,24,32] Al-Belasy

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and Fouad[46] observed that smoking in the day of extraction (without specifying before or after
the surgery) increases the chance of dry socket occurrence compared to smoking in the second
postoperative day; they also observed that frequency of smoking per day might be a risk factor;

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and finally their findings exhibited that smoking water pipes might pose marginally significantly
stronger risks than smoking cigarettes [46]. Halabi et al.[18] showed that a significant increase in
the incidence of dry socket is likely in patients who used to smoke at least 5 cigarettes per day.

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Beit,[25] as well identified smoking as a risk factor of dry socket. The causal mechanism (if any)
remains unknown but perhaps cytotoxic substances like nicotine, cotinine, carbon monoxide, and
hydrogen cyanide might be among the culprits [46,47]. Nicotine might increase the risk of
microvascular occlusion, and tissue ischemia by increasing platelet adhesiveness.[48] It might
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also be associated with catecholamine release, followed by vasoconstriction and decreased tissue
perfusion.[48] Moreover, the heat, the suction, and contaminants of smoking byproducts might
compromise the healing potential of surgical bed.[45,47] On the other hand, lower fibrinolytic
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activities in smokers[40,49] might undermine mechanisms responsible for dry socket formation,
and thus might confound its role[16]. In the study of Mudali and Mahomed [47], 31% of patients
who had developed dry socket were smokers and male.
Gender
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A higher risk of dry socket in women is suggested, but it is actually conflicted, as several
analyses did not confirm this,[3,8,9,16,18,19,22,24,25,29,33,35] against those asserting
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significant increases in females.[2,30,34,50,51] An explanation for the debate might be

overlooking the fact that the variable “gender” is actually a combination of numerous factors
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which are not usually measured (habitual, hormonal, etc). Another reason is the disadvantages of
bivariate statistics –forming most of the literature, which can be affected by imbalances of the
sample in terms of other variables; for instance, the higher prevalence of smoking in men
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compared to women might confound bivariate gender-related analyses.[16,19] Antibiotic

prophylaxis as well might benefit men more than women,[44] which again might act as a
confounder in bivariate statistics. Moreover, females not in menopause are already in a
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continuous sinusoidal fluctuation of estrogen levels during different phases of menstrual cycle.
[16,31] These alterations can confound the role of sex,[16] since such hormonal alterations might
affect dry socket risk.[31] Mudali and Mahomed [47] evaluated 2214 patients and reported about
a 2:1 female-to-male ratio of dry socket occurrence. Egauvoen [2] as well reported a similar ratio
of dry socket prevalence among 2218 patients. However, Chandran et al.[35] and Oginni et
al.[37] identified no significant difference between the prevalence of dry socket in males and
females (6.18% versus 7.86% respectively in the study of Chandran et al.[35], and 3.9% versus
5.1% in the study of Oginni et al.[37]). Almeida et al.[52] did not test the hypothesis of men
versus women dry socket prevalence, but presented the data; a chi-square test was used in this
review to analyze their data, which indicated no significant difference between the genders (P =

Page 5 of 11
0.611). Momeni et al.[22] observed a 2-fold higher prevalence of dry socket in women, but their
result did not reach the level of significance (P > 0.1).

Oral contraceptives
Another lurking variable which might contribute to gender controversies is the consumption of
oral contraceptives by females.[14,19,24,30,51,53] The additional estrogen in oral contraceptives
might raise plasma fibrinolysis.[12,14,30] Some authors have found higher risks for dry
socket[20,31] (or post-extraction complications in general[7]) in women taking OC. However,

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some could not identify such roles for oral contraceptives,[3,8,9,22,43] or discerned a marginally
significant association.[43] A 5-fold higher dry socket risk was seen in a study enrolling women
all taking birth control pills,[30] while no significant increase was detected in women not

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ingesting contraceptives in another research.[24] Blondeau and Daniel [43] observed a greater
risk of dry socket and infection in women, but they did not find a link to contraceptive
consumption. Additionally, Parthasarathi et al.[9] reported no dry socket in patients consuming

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antibiotics, oral contraceptives, bisphosphonates, or oral steroid drugs. On the other hand, Ogata
and Hur [53] and Almeida et al.[52] linked dry socket frequency to consumption of
contraceptives. In the descriptive study of Mudali and Mahomed [47] on more than 2000
patients, 71.4% of females who developed dry socket after the surgery were on oral
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contraceptives. Recent meta-analyses showed that taking oral contraceptives can increase dry
socket risk in women.[51,54]
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Age
Some investigations did not observe ties between age and dry socket,[8,19,25,29,30,33] while
some others did.[16,20,24,31,34,50] Bruce et al.[55] considered aging as a risk for morbidity.
Chuang et al.[56] identified aging as a risk of increased post-extraction morbidities including dry
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socket, but they did not assess its effect on dry socket independently. However, they[57] could
not note a significant role (P = 0.14) for age in postoperative inflammatory complications of
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wisdom tooth extraction. Potential effect of age might be attributable to difficulty of surgery in
these ages. Age might be a determinant of surgical difficulty,[5] due to relative root and bone
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stiffness which leads to more traumatic surgeries,[3,5,19] or lengthier surgeries in older

patients.[3,5,30] The observed effects might be as well an artifact of the higher smoking
prevalence in older individuals.[4,14,16] On the other hand, Haraji and Rakhshan[16] controlled
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for the effects of difficulty of surgery and smoking, while age was still associated with dry
socket risk. This implies other aspects of aging such as decreased wound healing capacity and
slower metabolism in older individuals.[16] A study on 2214 patients [47] suggested that dry
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socket incidence might be the highest in the third and fourth decades of life [47]; which was in
line with some other reports [37]. The authors postulated that the relative infrequency of
periodontal diseases in this age and the presence of a well-developed alveolar bone might make
tooth extraction more difficult, hence causing severer traumas [47]. However, another study on
1013 patients [35] recognized the third decade of life (followed by the fifth decade) as the one
most prone to dry socket.[35] Similarly, Egauvoen [2] and Oginni et al.[37] found the highest
prevalence of dry socket in the third life decade (followed by the fourth[2] and sixth[37]), in
2218 [2] and 3008[37] patients. AlHindi et al [32] suggested it to be more frequent in the fourth
decade. In the study of Momeni et al.[22], patients having dry socket had an average age of about
36 years while those without dry socket were significantly older (about 42 years old).

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Conclusions
Based on the number of studies agreeing that a certain potential factor might likely be a risk
factor, it seems that trauma of surgery and inexperience of surgeon are more likely to be a
causative or risk factors of dry socket. The high levels of estrogen as well seemed a risk factor
for dry socket. Evidence backing up a higher incidence of dry socket in females was
outnumbered by reports against such an association. Nevertheless, consumption of oral
contraceptives might be a contributing factor. The effect of age remained inconclusive.
Depending on the biasing factors such as the age range of the enrolled patients (their minimum

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and maximum ages and the distribution of their ages), dichotomizing or not categorizing the
variable itself, the cut-off for dichotomizing, or using bivariate statistics which cannot control for
the confounders, its effect might be statistically detected or not. Smoking seems to have no

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strong effects on dry socket, at least according to all the multivariate analyses conducted. Oral
hygiene seems to be an important dry socket-preventive factor. Another issue ignored in almost
all studies except a few [15-17,38] is that the variables affecting dry socket are likely interacting

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with each other. Therefore, statistical analyses not accounting for the interactions are much less
accurate and less useful.[16] Studies have usually assessed only a limited range of variables in
different groups of patients.[39] This might be one of the major reasons for the conflicts.[39]
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Conflict of interest: The author declares no conflict of interest.

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