Sir, I was drawn to the current thread of correspondence1,2 relating to dry socket, as it is an area which I have taken considerable interest in over recent years.

Having established a new in-hours emergency dental service in Oldham in 2006 we found our appointment books were filling quickly, with pressure falling on appointment slots to the extent that the incidence of post-operative complications was impacting on service capacity and efficiency.

With roughly half the patients accessing our service receiving an extraction we had no problems conducting an audit of hundreds of cases, finding our service incidence rate of dry socket to be about 5%, with a noticeable variation between operators that proved hard to explain given the consistency of approach to case selection and care.

We resisted the temptation to draw too much inference in comparison of our results with the wide variation in reported rates of dry socket given our understanding of the complex array of variables in the presentation, diagnosis and recording of complications. Our concern from the outset was to reduce the incidence as much as we could for the benefit of our patients and those we were at risk of turning away.

In our consideration of measures we could implement we made reference to the national clinical guidelines on the prevention of dry socket.3 We were looking for simple measures over which we would have control, that were cheap, practical and easy to administer, and that were evidence based.

As a result we decided to implement a simple regimen of one minute, pre-operative chlorhexidine mouthwash rinses in an effort to reduce plaque levels pre-operatively, which on further audit revealed an immediate reduction in our dry socket incidence of 50%. This represented a considerable saving in patient suffering and inconvenience, and freed up our appointment slots for more urgent care.

Whilst I appreciate that the national guidance was evidence based I am caused to question the practicality of two of the suggested preventive measures: that patients who smoke should be 'enjoined to cease the habit pre-operatively and for at least two weeks post-operatively'; and that 'wherever possible, for female patients using the oral contraceptive extractions should be performed during days 23 through 28 [sic] of the tablet cycle'.

I would be interested to hear if anyone has managed to implement either of these measures with any success!