A dry socket typically appears 24-48 hours post-extraction in difficult extraction cases, often in the mandible, in females on birth control and if the clot has been dislodged due to increased negative pressure in the oral cavity -- such as with forceful spitting or use to a straw or smoking a cigarette. Typically the socket is irrigated thoroughly with saline and a iodoform/eugenol-soaked gauze is placed into the socket for 48 hours. This alleviates pain and promotes healing. Providing monojet-syringes helps reduce food impaction in the socket.

As all the previous posts have described, dry socket typically sets in 2-3 days after extractions and commonly radiates pain to the forehead/ear. In addition to being able to identify patient complaints of dry socket, I think it is equally important to identify when post-extraction pain is not due to alveolar osteitis. I have had experience with patients calling me after extractions and automatically assuming their discomfort is due to dry socket. It is important to realize if their complaints of pain are ~1-2 weeks after the extraction, then it cannot be dry socket. Often little particles of food get lodged in narrow sockets that are in the process of healing and cause irritation. Our school provides monojet syringes for patients post-extraction, and I instruct patients to gently irrigate the site using the syringe as needed. Similarly, if any bony spicules remain or interseptal bone has become loose between multiple extraction sites, the area will not heal properly and results in inflammation and pain. The patient needs to come back as soon as possible for evaluation and removal of unattached bone.

Dry sockets can definitely be tricky to diagnose, and as mentioned below, dry sockets typically occur 2-3 days post extraction. A dry socket is simply exposed alveolar bone. Patients may have exposed bone (alveolar osteitis) and have no symptoms at all, whereas other patients who have exposed bone experience severe pain. Another indication, that has't been listed below, that helps identify whether a patient might have a dry socket is if they have a history of dry sockets. At my school when a patient presents with a dry socket, we typically refill their pain medication script (after assessing that they are not abusing the pain meds) then flush the socket to remove food/debris and insert a medicament on foam or gauze in the socket. If the patient lives far away and is unable to come back a few days later to remove the gauze, then we will place the Gel Foam which dissolves.

Great topic! As a fourth year dental student I have seen a lot of dry socket in my experience as well. I find that most of my patients cannot hold off from smoking. Just recently I was doing a rotation in an underserved area and the patient came in twice for dry socket that week. Though this is not often the case, the dentist that was working at the clinic told me to be aware that some patients might use dry socket as a way to attain a prescription for narcotics and may try to keep the dry socket from healing. No matter what case, it is important to reiterate post-operative care.

Usually if a patient has a dry socket they will complain of pain that radiates to their ear. It occurs mostly in smokers, patients that had a traumatic extraction, and patients that use straws even though instructed not to among other situations. The solution to treat dry socket is rather simple. At my school we simply place Gel Foam soaked in eugenol in the socket and it seems to resolve the problem.

Diagnostically, alveolar osteitis consists of an empty alveolus 2-3 days after an extraction, severe pain that often radiates, and halitosis (Alexander 2000). While people can heal at different rates, the incidence of those three factors together is diagnostic for a dry socket. 2-3 days is typical because the clot has formed at that point and is no longer making anti-fibrinolytic factors. Therefore, fibrinolysis is able to occur and cause the dry socket. You mentioned that the socket may still be open a week or two after an extraction, but if the alveolar bone is exposed that is a dry socket. Patients can be predisposed to dry sockets if they are female, on oral contraceptives, smoking, surgical trauma/surgeon inexperience, and possible the presence of pericoronitis or preexisting infection.