Dry socket is a potential complication of tooth extraction, and studies have shown that it occurs after anywhere from 15% to 30% of the time after the extraction of an impacted mandibular third molar (wisdom tooth). However, in my practice, I went the final ten years of my practice doing hundreds of extractions of mandibular third molars, including many full bony impactions, without a single incidence of dry socket. Let me tell you how I did it.

As I began my practice, I had a special interest in oral surgery. In dental school I had won the award as the outstanding oral surgery student of my graduating class. I considered specializing in oral surgery, but decided I really wanted to be a general dentist. I did decide, however, to try to tackle difficult extractions, gradually increasing in difficulty until I didn’t refer any of them to oral surgeons unless the patient was over 40. With these extractions, I had a normal incidence of dry socket in my patients.

One day, when I had two patients return to me with dry socket, I realized that in the case of both of these patients I had used a great deal of force in extracting the teeth. This gave me the idea that forceful compression of the mandibular bone was a precipitating factor for dry socket. From then on, if I couldn’t get a lower wisdom tooth out with moderate elevator force, I would section the tooth and/or remove bone until I could. I was very pleased that this dramatically decreased my incidence of dry socket. Over the next seven years I had only two dry sockets in my patients. This was up until around 1991 or ’92.

Then I read a study in a journal where the researchers had tried placing a square of Gelfoam soaked in a suspension of clindamycin antibiotic into the socket after the extraction and suturing the tissue over it. They did this on one side of each patient, and left the other side untreated. For every patient that developed dry socket after the extractions, it never occurred on the side that was treated with clindamycin. I am unable to find what journal that was in, but I was able to find an online reference to that study on the website of a Dr. Ted Rothstein.

I found the study very persuasive, so I applied this practice routinely for every impacted lower third molar that I extracted, and for the next ten years, extracting all sorts of impacted lower wisdom teeth, didn’t have a single incidence of dry socket. And I did not shy away from any difficult extractions. I did partial and full bony impactions including horizontal impactions, disto-angular impactions, whatever.

The “inside-the-box” thinking on the causes of dry socket is pretty rudimentary. The blood clot is missing, therefore the patient must have sucked it out! So therefore, don’t suck through a straw and that will reduce the incidence of dry socket. Similarly, if you smoke after the extraction you will suck it out. There are no clinical studies that give any credence to these simplistic theories. I don’t believe them and didn’t pass them on to my patients.

– Dr. Hall

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