Dry Socket: How Long to Wait Before Placing an Implant?

Dr JM: A dry socket in a maxillary central extraction site is not very common, but by definition, the exposed bone surface dies and has to heal slowly, with the gingiva and granulation tissue growing over it. This will leave a defect that will most likely require grafting to try to get a decent esthetic result. I would wait six weeks for soft tissue closure and then flap, clean all granulation tissue, obtain good bleeding bone for RAP and graft. If the defect has enough walls, DFDB or beta tricalcium phosphate grafts are a good choice. Don't try to place an implant of the same diameter as the tooth at the CEJ. Good luck

Thanks for above comment. Don't think about it. you know the ethology of dry socket means LACK of bleeding in extraction site and it's more susceptible to infection with poor healing,so do nothing for at least four weeks. After that gently remove granulate tissue and make all socket wall drillinge to bleeding and place some Allograft and waite for four months after you can place an implant. good luck to you. Dr. Vazir from Iran Tehran

Sir, dry socket has a very low incidence rate in maxilla, and when it comes to the incisor area, one must say that the occurrence is really rare.In such cases, a wise and prudent clinician will always suspect a predisposing factor, a systemic disease or even a debilitating condition.I suggest that before making any decision about implant therapy, you should have your patient worked up for the maladies such as blood dyscrasias or bony diseases like pycnodysostosis or/and Albers-Schoenberg disease, etc.

Dr. Jafari is absolutely correct. In 31 years of dentistry I have never seen or heard of a maxillary anterior dry socket. Not that anything can't happen, but this sounds abnormal. My first thought was if the patient had been on bisphosphonates. Brittle Type I diabetic? More information is needed.

Its worth doing implant in completely cured dry socket, and that might take more than 20-25 weeks, provided the patient do not have associated systemic problem(s), notably diabetes. There is no guideline for this. It may vary, but, its better to maintain a consistent and close follow-up with appropriate clinical assessment, and that would be equally spread over the period of time. Perio-charting and checking of bone height and density by radiographic assessment by a specialist would be convincing. Maintenance of good oral hygiene and any rehabilitation of supporting tissue in/around the extraction socket is very important to avoid any failure of the case. Chitta Choudhury PhD, FFDRCS, MPH, BDS ICTOH & MaxFac Surgery Dept of Poole Hospital NHS, UK

Great comments so far. You might also want to check if your patient is a heavy smoker. If so, this can also affect the outcome of any attempted hard/soft tissue ridge augmentation. The good thing is that smoking is a correctable factor, unlike systemic diseases.

As an Oral Maxillofacial surgeon with over thirty years of practice I have seen several anterior Maxillary "dry sockets". They tend to be the most symptomatic, and often their apperance is quite dramatic. Healing is slow and symptoms do not control easily. They are not caused by lack of bleeding. Dry sockets fill with blood,form a clot which then appears to be lost. There is controversy about the actual pathological process. I personally have always felt that there is a strong auto-immune component. This would explain the prediliction for female patients. Often these patients have medical histories which reveal other auto-immune conditions.There is no doubt that other factors can contribute to this process. However I do not find that lack of bleeding is one of these( or is the any evidence based findings to support this idea). As an aside in my practice I have kept an un-scientific tally which shows a 9 to 1 female to male ratio. I would adressivly pack the area with the traditional paste material until symptoms subside. That can require packing every other day in the beginning or even ever day at the start. It may take several weeks for symptoms to subside. I would then allow time for tissue closure to occure.The evaluate what you have left and repair the defect if any. Often these sockets heal by secondary intent and for bone . They do no remain as a tissue filled space. An other idea might be in the future consider an immediate placement of the implant . It eliminates the empty socket problem by filling it from the start.

After 36 years in oral surgery I believe it is not always easy clinically to diagnose a dry socket except in obvious cases . Similar appearance is sometimes seen if socket is lined by a healthy layer of clot but filled by broken down debris and as a result painful . Early syringing and temporary soothing dressing will help . However will placing other foreign body materials such as allografts in true dry sockets help with the healing or slow it down even further ?If there are any good trials in this field I will love to know. Untill then , if I had a similar case I will leave it alone ,lift a flap in six to eight weeks and treat it based on the appearance of the bone and perhaps graft it at that stage if neccessary

Dear Dr.JM Dry socket is very painful and is not very often seen in maksilla.Ä°ts exact cause is not very well known but there is a lack of bleeding in the socket.There may be verious factors one of which is the vasoconstictors in the local anesthetic solutions and the sensitivity of the patient to the material.Ä°n the next surgery I think it will be better if pure anesthetic solution is prefered.Please wait for a soft tissue lining that will cover the inside of the socket whicw will take atleast four weeks then you may do grafting alone or implant placement and grafting at the same time.

Socket grafting with a bacterio-static graft material that sets hard ( soft tissue can granulate over without material loss) could possibly be beneficial solving the food impaction issue and providing a scaffold for regeneration. Just a thought as we now routinely socket graft in difficult cases

The very fact that Dry Socket is also nomenclatured as "Fibrinolytic Alveolitis", gives an idea of the aeitiopathogenesis of the clinical syndrome. A clearly evidenced breakdown in the Fibrin mesh work and its poor adherability to the socket walls as a result of various (hypothesized and proven)mechanisms, is a pointer to the fact that for regular Osteogenesis to take place these very mechanisms need to be re-initiated. Needless to point out,for Osseointegration to set in around an Implant, the role of Fibrinolytic causes needs to be completely assessed and ruled out. If there are lingering causes that will interfere in the Fibrin producing mechanisms or in any way compromise the strength of the meshwork, the eventual result would be a compromise in Osteoblastic movement along the same meshwork in the Bone-Implant-interface. This of course would have a definite bearing on the rate and extent of Osseointegration around the Implant. Hence, more important than the Dry-Socket and its management itself, would be a complete appraisal of the factors that led to the Dry-Socket in the first place ! This would help determine (along with clinical and radiological parameters) when and how to go about restoring the extraction site with an implant. Cheers

If in-effective fibrin producing mechanism plays a key role in the cause of dry socket, then perhaps resorbable collagen placing in the extraction socket to assist blood clot formation would help reducing the dry socket incidence.

Dear Dr.JM After checking if placing an implant is not contra-indicated for the pt. I would suggest to simply treat the dry socket, and wait for 6-8 wks for soft tissue closure, remembering that we're in esthetic zone . Now it depends on your skill, you have 2 options; 1-Open the socket remove all the granulation tissue, be sure there is BLEEDING , then do the socket preservation, give the pt. a temp [ex. an FRC ]and after 5-6 months place the implant safely and of course more predictable. 2-To open the socket, remove all the granulation tissue, check to have BLEEDING ,then check for the integrity of the walls , most especially the buccal one, then placing the implant with regards to the esthetic zone rulls[place it palatally ]close to the palatal wall of the socket ,augment the jumping distance with autogenous bone graft , and if you have dehesence add some fillers like bio-oss , cover it w/ resorbable membrane, and close it thorouly,releasing if needed. best wishes dr.danesh from Iran.

Dear Dr. Danesh First, if it is a real dry socket (that I doubt), You will hardly be able to find any granulation tissue inside the socket. Second, in cases of dry socket occurence (if it really is), any socket curettage is absolutely forbidden and would be very devastating.I hope nobody does that in your country.

Check the medical condition - IF OK. Why don't you thoroughly clean the socket. Graft the socket. Primary closure with a gingival graft for soft tissue. Place implant after 6 months. Sweet & simple :-)

o.k, wait for atleast 4 weeks. becos in drysocket area there will be more chance of infection, lead to implant failure. dr. hussain, cheranmahadevi. tirunelveli. india.

I agree with Dr. Jafari, do not do curettage. Some time ago, it was done in an attempt to cause bleeding and form a new clot, but many times the new clot was just as poor as the old one, and far worse, the healing was extremely painful, and delayed further. In some cases, complete healing can take up to 3 months. Irrigating daily with saline solution or Clorhexidine solution, and AB treatment, is the fastest and safest way to treat this complication. Try to determine the possible cause of the dry socket before planning and placing an implant, in the esthetic zone especially.

Sound advice!

Hi, I was just wondering about if anyone has seen an increased incidence of dry socket based on their extraction technique. I have done quite a lot of Oral Surgery in my time and for the last 5 years I have probably had 3/4 Dry sockets from teeth I had extracted using couplands and forceps. Recently however I have started using periotomes routinely I have had 3/4 dry sockets in the last 10, can anyone suggest what they think I am doing wrong?

Most likely the patient's issues. Try cleaning the extraction site and rinsing with mouthwash prior to the extraction.

I recently did an immediate extraction of the second maxillary bicuspid and implantation. All went perfect and after placing a 14mm implant the patient developed dry socket! I have excellent primary stability. What should be my next step? I have prescribed augmentin for another 7 days and NSAIDS till the symptoms quell. Will this hv any problems with the success of my implant? Thanks in advance.

Dr, A, any reason for putting patient on augmentin for another week? Dry socket IS NOT an infection. No need to put patient on antibiotics unlesss you see active tissue inflammation around it and in turn causes localized pain. When you placed implant, you should've seen blood creeping up as you drilled into socket. If not, then there is a good chance implant won't integrate. By the way, how do you know it's dry socket? Just because the patient is having pain following extraction?

A tough task in managing dry socket is providing the agitated patient with an UNDERSTANDABLE explanation . I am very keen to now what do you say in response to the patient when she\he asks "why did it happen?" and after a complete explanation they probably want to know : " I've had extraction before and this never happened?"(like hammer to my head !)

Dear Dr. P, Wedging a periotome against the cribriform plate and using it as a lever to elevate the tooth/root can cause vascular channels to be flattened and rendered non-functional if pressure generated is too strong. This in turn, will DISRUPT molecular transport, depriving the blood clot of O2 and metabolites necessary for its transformation, leading to its dissolution. Furthermore, cellular degradation causes powerful hydrolytic enzymes from lysosomes to be spilled into the vicinity causing rapid breakdown of organic components leaving the socket to be denuded and free nerve endings to be exposed to this acidic medium, causing pain. It may be a good measure to ligthly run the periotome against the socket, AFTER extraction to loosen and re-activate the vascular channels. Warmest regards,