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The Causes and Prevention of Dry Socket
by David A. Hall, DDS

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The topic of the causes and prevention of dry socket is an interesting one. It continues to be asserted by some general dentists, some oral surgeons, and even some textbooks that dry sockets are caused by drinking through a straw or by smoking after wisdom tooth surgery ( However, there are no studies to document these assertions. The assertions appear to be based on rudimentary thinking: the blood clot is missing, therefore the patient must have sucked it out! Or, since smoking decreases blood flow, that's why there is no clot! But science is based on controlled studies. We can do better than this.

There is a good, controlled study on the causes of dry sockets that I reference later. This article is a confirmation of that study, based on anecdotal observations by me, Dr. David A. Hall during my practice, from the extraction of hundreds of impacted third molars with a zero percent rate of dry socket (no dry sockets over a ten-year period).

As I started practice, I had been taught several theories on the causes of dry socket. But there were never any studies cited accompanying these theories on the causes of dry sockets. There were studies on which patients and which teeth tended to be susceptible to dry socket, but that was the limit of it. Being of scientific inclination, I therefore kept the dry socket issue as an unanswered question in my mind.

During my general practice, I came to have quite a bit of success with third molar extractions, and came to prefer to do them myself rather than refer them to oral surgeons. One day in 1985 I had two dry socket patients come back to me the same day. As I was treating them and turning over in my mind again the question of what it might be that caused dry sockets, something struck me about the two cases. I realized that in both cases, I had applied an exceptional amount of force in extracting the impacted lower third molars. Could this be related to the cause? I formed the hypothesis that dry socket was at least in part related to the trauma of bone compression during the procedure. This seemed to fit with the much higher incidence of dry socket in the mandible--the denser bone of the mandible was more severely traumatized during a difficult extraction.

For the next five years, I applied this theory of the prevention of dry socket to my oral surgery. I resolved never to apply any large degree of force during the extraction of lower third molars. I would remove bone and section until I could lift the tooth out with an elevator, never using a forceps to apply force to the tooth. For nearly five years, I never had a dry socket. But then, in the fifth year, one patient returned to me with a dry socket. And then in the seventh year, another.

Coincidentally, at this time I read a controlled clinical study of bilateral impacted lower third molar extractions in which the clinician applied a dressing of clindamycin to one side of the mandible postoperatively, and left the other side untreated. In this study, the rate of dry socket in the treated side was dramatically lower than the control side. Finally, a scientific answer to dry socket prevention! I decided to add this to my technique. For every impacted lower third molar case, I took a clindamycin capsule, broke it into a sterile stainless steel cup, added a few drops of normal saline and mixed. Then I took two squares of Gelfoam and, immediately before suturing the surgical site, I soaked up half of the clindamycin mixture with each Gelfoam square, placed it into the socket, and sutured the wound. I continued to follow my rule of gentleness also, never applying more than moderate force to a lower third molar. I removed bone and sectioned the tooth until I could lift it out with an elevator.

I continued to practice for ten more years after starting this technique. For the next ten years and more, applying this combination of gentleness and clindamycin dressing, I didn't have a single case of dry socket in my practice. My dry socket remedy liquid bottle became old and expired, and I didn't re-order any—I didn't need it. And I did not instruct my patients to not drink through a straw or not to smoke in order to prevent dry socket. My observations were that sucking promoted bleeding, not dry socket.

It would be worthwhile for some enterprising clinicians to see if they could do further clinical study to verify these hypotheses of dry socket prevention. It would be fairly easy to test the hypothesis that sucking promotes dry sockets or that smoking does. Does smoking lead to dry sockets? Or is it that smokers are more susceptible to dry sockets? Those are two very different theories, and they can both be easily tested. Test these theories and others. Try to duplicate the clindamycin study. Scientifically study the apparently true but unconfirmed hypothesis that rough surgical technique promotes dry sockets—that is a doable study. Let's be scientific.

—Dr. David A. Hall

Prevention of dry socket with antibiotic dressings - Reference is made to the same study Dr. Hall cites, as well as several other studies documenting the effectiveness of post-operative antibiotic dressings in the extraction site in preventing dry socket. See

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