Extraction Complications

Pain
 There are several causes of post-operative pain following tooth extraction; potential causes include:
o Dry socket (alveolar osteitis) – occurs when the blood clot at the extraction site fails to develop, is
dislodged, or dissolves before the wound has healed. The blood clot serves as a protective layer over
the underlying bone and nerve endings in the socket; it also provides a foundation for the growth of
new bone and soft tissue healing.
o Retained root/tooth fragment.
o Infection.
o Sequestrum – a piece of dead bone tissue formed within a diseased or injured bone (often seen in
chronic osteomyelitis).
o “Normal” post-operative pain.
 A thorough history should be taken from a patient returning with pain following an extraction. History should
include:
o Site.
o Onset.
o Characteristics.
o Radiation.
o Associated symptoms, e.g. bad taste, headache etc.
o Time/duration.
o Exacerbating factors.
o Severity (score out of 10).
o Analgesic use (type, dose, time, effectiveness).
 Once the cause of pain has been established, the pain should be treated accordingly.
 Normal post-operative pain should be treated with analgesics in a fit and healthy adult. Analgesics should be
taken in a stepped fashion for maximum effectiveness:
o Ibuprofen 400mg tds, taken with food (avoid in asthmatics or patients with history of peptic
ulceration).
o Paracetamol 1g qds – take between ibuprofen doses.
 Paracetamol overdose = > 75mg/kg within 24 hours.

Management of Dry Socket

1. +/- Local anaesthetic
2. Irrigate socket with CHX – removes
blood clot and food debris
3. Dress with alvogyl
4. (ABX if indicated by suppuration)

 Alvogyl is an antiseptic and analgesic paste containing butamben, iodoform and eugenol:
o Eugenol – analgesic action.
o Butamben – anaesthetic action.
o Iodoform for antimicrobial action.
Other methods of dry socket management = BIPP, ribbon gauze, dressing such a lidocaine gel, ZOE
 Antibiotics should not be routinely given in the management of dry socket, however, if suppuration is
suggestive of infection, ABX are indicated:
o Metronidazole 400mg tds, 5/7.
 Dry socket can be caused by OCP, smoking, rinsing mouth too soon post op, local anaesthetic containing
adrenaline.

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Swelling
 Possible causes of post-operative swelling include:
o Infection caused by retained root or bacterial colonisation.
o Haematoma (rare following MOS) – solid collection of clotted blood within the tissues.
o Post-operative oedema.
 History taken from a patient presenting with a post-XLA swelling should include onset, duration and
associated symptoms (e.g. pain, malaise, pyrexia).
 An assessment should be made as to whether the swelling is an airway risk; a swelling that compromises the
airway is a medical emergency.
 Examination of a swelling should assess fluctuance; fluctuance is suggestive of a collection of fluid, possibly
pus.
 To assess fluctuance, two fingers should be positioned either side of the swelling and the centre of the
swelling pressed, if the fingers are displaced, the swelling is fluctuant.
 Normal post-operative oedema should be managed with cold compresses and NSAIDs.
 Large haematomas should be evacuated, however, solidified masses require ABX prescription:
o Amoxicillin 500mg tds, 5/7.

Bleeding
 Bleeding may occur immediately after XLA/MOS (primary haemorrhage) or several days post-operatively
(secondary haemorrhage). There are a number of causes of post-operative bleeding:
o Primary haemorrhage:
 Inadequate clot formation/disturbance of the blood clot (by patient).
 Inadequate suturing.
 Small bleeding vessels in either soft or hard tissues.
 Rebound after vasoconstriction (rare).
o Secondary haemorrhage:
 Infective in origin.
 If a patient presents with bleeding, a systemic coagulopathy should always be considered, although this should
have been picked up during the MH.

Congenital and Acquired Bleeding Disorders

Congenital Acquired
 Haemophilia A  Liver disease
 Haemophilia B  Disseminated Intravascular
 Von Willebrand Disease (vWD) Coagulation (DIC)
 Rare inherited coagulation disorders  Massive blood loss
 Rare platelet disorders  Acquired haemophilia
 Vitamin K deficiency

 An examination of a bleeding patient should involve:

o Visual assessment of blood loss, e.g. piles of blood-soaked gauze.
o Pressure applied to stop/stem the bleed.
o Vital signs:
 Pulse.
 BP.
 Capillary refill time.
o The possibility of hypovolaemic shock must be considered; signs of hypovolaemic shock include
hypotension, pale skin, tachycardia – consider a patient shocked until proved otherwise.
 Management of bleeding is dependent of the source of the bleed. Initial management involves injection of
vasoconstrictor into, and around, the socket and aspiration of friable clot(s); this will enable a visual
assessment of the socket and surrounding soft tissues.
 Hard tissue bleeds come from small cancellous spaces in bone; management may include:
o Bone wax to plug orifice.
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 o Burnishing of orifice.
o Surgical packed into the socket.

 Soft tissue bleeds may come from the inferior alveolar neurovascular bundle or small vessels incised
when cutting relieving incisions; management includes:
o Ligation by suturing around vessel in the flap and tying it off.
o Bipolar/monopolar diathermy (electrocautery).
o Careful packing of socket with surgical (neurovascular bundle bleeding).
 If there is no obvious source of bleeding, the socket should be packed with surgical and sutured.
 If there is no resolution and bleeding continues despite packing, pressure and sutures, consider:
o Contacting haematology – possible systemic coagulopathy; FBC and coagulation screen required.
o 4.8% tranexamic acid mouthwash.
 If a patient presents with secondary haemorrhage, ABX should be prescribed on discharge.
 Surgicel is a resorbable oxidised cellulose matrix it has several of methods of action:
o Decreases pH of the socket, which helps small vessels contract.
o Interacts with intrinsic pathway causing contact activation of platelets.
o Mesh, which increases the SA available for platelets to bind to.

Infection (Bacterial Origin)

 Possible causes of infection include:
o Bacterial contamination during surgery.
o Loss of blood clot, food debris accumulation and stagnation causing bacterial ingress.
o Retained root/tooth fragment.
 Specific question that must be asked if an infection is suspected include whether the patient can breathe,
swallow and eat without obstruction, and whether they feel systemically unwell.
 Examination of a patient with a suspected infection includes:
o Assess for suppuration and/or fluctuant swelling.
o Assess airway risk and risk to angular veins at the medial canthus of the eye or pterygoid plexus at the
posterior aspect of the maxilla.
o Assess the patient’s degree of malaise.
o Temperature- if pyrexic, consider the need for ABX +/- hospital admission (sepsis).
 Management of a bacterial infection is always the same:
o Identify and remove the source of infection.
o Institute drainage.
o Prevent infection spread – ABX prescription.

ABX Prescription for Bacterial Infection

Anaerobic Metronidazole – 400mg tds, 5/7 +/- amoxicillin
bacteria 500mg tds 5/7.
Penicillin allergy Erythromycin – 250mg qds 5/7

Trismus
 Trismus is a protective response to pain of inflammation; the pain can be infective or traumatic in nature.
 History should explore whether the trismus was present prior to the extraction and whether the trismus is
worsening.
 Examination should use a ruler to measure unassisted inter-incisal distance.
 Due to excessive donward pressure or keeping the pts mouth wide open for a long period of time
 Management of trismus includes:
o Identifying any continuing pathology, e.g. infection, and eliminate.
o Reassure and advise on analgesics. Review.
o No improvement on review – consider physiotherapy and exercises.

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Surgical emphysema
 Collection of air that has been forced into the tissue spaces through the extraction wound and forms a swelling
 Crackles on palpation
 Results from increased air pressure in the mouth from using an air spra, blwoing a trumpet or balloon
 Tx = reassure

Healing process
 Tooth sockets heal by secondary intention
o Slower
o No sutures
o More granulation tissue and inflammation
 Clot may fail to form if:
o Little bleeding owing to sclerosis of bone forming tooth socket
o Action of vasoconstrictor in LA
o Packing the socket to arrest hammeorhage

Fracture during xla

 Common alveolar fracture is buccal plate of upper molars
o Interfere with retention of upper denture  peripheral seal inadequate