11

Postextraction Patient Management

JA ME S R . H UP P

C H A P T E R OU T L I N E

M
any patients have more preoperative concerns about
Control of Postoperative Sequelae, 185 the sequelae of surgery—such as pain, swelling, and
Hemorrhage, 185 complications—than about the procedure itself. is
Pain and Discomfort, 186 is particularly true if they have con dence in the surgeon and
Diet, 188 planned anesthesia. e surgeon can do many things to mitigate
Oral Hygiene, 188 the common problems patients face after surgery. is chapter
Edema, 188 discusses those strategies. is chapter also discusses the most
Trismus, 189 common complications, some minor and some more serious, that
Ecchymosis, 189 occur during and after oral surgical procedures. ese are surgical
Postoperative Follow-up, 189 complications, as opposed to medical complications, which are
discussed in Chapter 2.
Operative Note, 189 Once the surgical procedure has been completed, the patient
Prevention and Management of Complications, 190 and anyone accompanying him or her should be given proper
Soft Tissue Injuries, 190
instructions on how to care for common postsurgical sequelae that
Tear of a Mucosal Flap, 190
may occur on the day of surgery and that often last for a few days.
Puncture Wound, 191
Postoperative instructions should explain what the patient is likely
Abrasion or Burn, 191
to experience, why these phenomena occur, and how to manage
and control typical postoperative situations. e instructions should
Problems With a Tooth Being Extracted, 192 be given to the patient verbally and in written or printed form on
Root Fracture, 192 paper, in easily understood layperson terms. ese postoperative
Root Displacement, 192 instructions should describe the most common complications and
Tooth Lost Into the Pharynx, 193 how to identify them so that problems such as infection can be
Extraction of the Wrong Tooth, 193 caught at an early stage. e instructions should also include a
Injuries to Adjacent Teeth, 194 telephone number at which the surgeon or covering on-call doctor
Fracture or Dislodgment of an Adjacent Restoration, 194 can be reached in case of an emergency.
Luxation of an Adjacent Tooth, 195
Injuries to Osseous Structures, 195 Control of Postoperative Sequelae
Fracture of the Alveolar Process, 195
Fracture of the Maxillary Tuberosity, 197 Hemorrhage
Fracture of the Mandible, 197
Once an extraction has been completed, the initial maneuver to
Injuries to Adjacent Structures, 197 control postoperative bleeding is the placement of a folded gauze
Injury to Regional Nerves, 197 directly over the socket. Large packs that cover the occlusal surfaces
Injury to the Temporomandibular Joint, 198 of teeth adjacent to the extraction site do not apply pressure to
Oroantral Communications, 198 the bleeding socket and are therefore ine ective (Fig. 11.1). e
gauze may be moistened so that the oozing blood does not coagulate
Postoperative Bleeding, 199 in the gauze and then dislodge the clot when the gauze is removed.
Delayed Healing and Infection, 201 e patient should be instructed to bite rmly on this gauze for
Wound Dehiscence, 201 at least 30 minutes and not to chew on the gauze. e patient
Dry Socket, 202 should hold the gauze in place without opening the mouth.
Infection, 203 Patients should be informed that it is normal for a fresh extraction
site to ooze slightly for up to 24 hours after the extraction procedure.
Patients should be warned that a small amount of blood mixed with
a large amount of saliva might appear to be a large amount of blood.
If the bleeding is more than a slight ooze, the patient should be told
how to reapply a folded piece of gauze directly over the area of the
extraction. e patient should be instructed to hold this second

185
186 PA RT I I Principles of Exodontia

A B

Fig. 11.1 (A) A fresh extraction site will bleed excessively unless
a gauze pack is properly positioned. (B) A large or malpositioned
gauze pack is not effective in controlling bleeding because the
pressure of biting is not precisely directed onto the socket. (C) A
C small gauze pack is placed to t only into the area of extraction;
this permits pressure to be applied directly on the bleeding socket.

gauze pack in place for as long as 1 hour to gain control of bleeding. Pain and Discomfort
Further control can be attained, if necessary, by the patient placing
a tea bag in the socket and biting on it for 30 minutes. e tannic All patients expect a certain amount of discomfort after any surgical
acid in regular tea serves as a local vasoconstrictor. procedure, so it is useful for the dentist to discuss this issue carefully
Patients should be cautioned to avoid things that may aggravate with each patient before the procedure begins. e surgeon should
the bleeding. Talking should be kept to a minimum for an hour. help the patient have a realistic expectation of what type of pain
Tobacco smoke and nicotine interfere with wound healing, so may occur and correct any misconceptions of how much pain is
patients should be encouraged to stop or limit smoking. e likely to occur.
patient should also be told not to suck thick uids through a Patients who make a point of informing the surgeon that they
straw when drinking because this creates negative intraoral pressure. expect a great deal of pain after surgery should not be ignored or
e patient should not spit during the rst 12 hours after surgery. automatically told to take an over-the-counter analgesic because
e process of spitting involves negative pressure and mechanical these patients are most likely to experience pain postoperatively.
agitation of the extraction site, which may trigger fresh bleeding. It is important for the surgeon to assure patients that their postopera-
Patients who strongly dislike having blood in the mouth should tive discomfort can and will be e ectively managed.
be encouraged to bite rmly on a piece of gauze to control the e pain a patient may experience after a surgical procedure such
hemorrhage and to swallow their saliva instead of spitting it out. as tooth extraction is highly variable and to a great extent depends
Finally, no strenuous exercise should be performed for the rst 12 on the patient’s preoperative expectations. e surgeon who spends
to 24 hours after extraction because the increased blood pressure some time discussing these issues with the patient before surgery
may result in greater bleeding. will be able to design the most appropriate analgesic regimen.
Patients should be warned that there may be some oozing and All patients should be given instruction concerning analgesics
staining of their saliva while they are asleep and that they will before they are discharged. Even when the surgeon believes that
probably have some blood stains on their pillowcases in the morning. no prescription analgesics are necessary, the patient should be told
Forewarning them of this probability will prevent many frantic to take ibuprofen or acetaminophen postoperatively to prevent
telephone calls to the surgeon in the middle of the night. Patients initial discomfort before the e ects of the local anesthetic disappear.
should also be instructed that if they are worried about their Patients who are expected to have a higher level of pain should
bleeding, they should call to get additional advice. Prolonged oozing, be given a prescription analgesic to help control the pain. e
bright red bleeding, or large clots in the patient’s mouth are indica- surgeon should also take care to advise the patient that the goal
tions for a return visit. e dentist should then examine the area of analgesic medication is management of pain and not elimination
closely and apply appropriate measures to control the hemorrhage of all discomfort.
and consider having a surgical specialist assist with patient It is useful for the surgeon to understand the three characteristics
management. of the pain that occurs after routine tooth extraction: (1) e pain
 CHAPTER 11 Postextraction Patient Management 187

is usually not severe and can be managed in most patients with analgesics are frequently used to control pain after tooth extraction.
over-the-counter analgesics, (2) the peak pain experience occurs e most commonly used drugs are codeine, the codeine congeners
about 12 hours after the extraction and diminishes rapidly after oxycodone and hydrocodone, and tramadol. ese narcotics are
that, and (3) signi cant pain from extraction rarely persists longer well absorbed from the gut but may produce drowsiness and
than 2 days after surgery. With these three factors in mind, patients gastrointestinal upset. Opioid analgesics are rarely used alone
can be appropriately advised regarding the effective use of in dental prescriptions; instead, they are formulated with other
analgesics. analgesics, primarily aspirin or acetaminophen. Codeine can be a
e rst dose of analgesic medication should be taken before useful postextraction analgesic because it carries little narcotic abuse
the e ects of the local anesthetic subside. If this is done, the patient potential. However, it is important to note that a large percentage
is less likely to experience the intense, sharp pain after the e ects of the population lacks the enzyme necessary to make codeine
of local anesthesia subside. Postoperative pain is much more di cult e ective. When codeine is used, the amount of codeine is frequently
to manage if administration of analgesic medication is delayed designated by a numbering system. Compounds labeled No. 1 have
until the pain is severe. It may take 60 to 90 minutes for the 7.5 mg codeine; No. 2, 15 mg; No. 3, 30 mg; and No. 4, 60 mg.
analgesic to become fully e etive. If the patient waits to take the When a combination of analgesic drugs is used, the dentist must
rst dose of analgesic until the e ects of local anesthesia have keep in mind that it is necessary to provide 500 to 1000 mg aspirin
subsided, the patient may become impatient, waiting for the e ect, or acetaminophen every 4 hours to achieve maximal e ectiveness
and may take additional medication thus increasing the likelihood from the nonnarcotic. Many of the compound drugs have only
of nausea and vomiting. 300 mg aspirin or acetaminophen added to the narcotic. An example
e strength of the analgesic is also important. Potent analgesics of a rational approach would be to prescribe a compound containing
are not required in most routine postextraction situations; instead, 300 mg of acetaminophen and either 30 mg codeine (No. 3) or
analgesics with a lower potency per unit dose are typically su cient. 5 mg hydrocodone. e usual adult dose would be 2 tablets of
e patient can then be told to take one or two unit doses as the compound every 4 hours. Should the patient require stronger
necessary to control pain. More precise pain control is achieved analgesic action, 2 tablets of acetaminophen and codeine may be
when the patient takes an active role in determining the amount taken for increased e ectiveness. Doses that supply 30 to 60 mg of
of medication to take. codeine or 5 mg of hydrocodone but only 300 mg of acetaminophen
Patients should be warned that taking narcotic medications fail to provide full advantage of the analgesic e ect of acetaminophen
often results in drowsiness and an increased chance of gastric upset. (Table 11.2).
In most situations, patients should avoid taking narcotic pain The Drug Enforcement Administration controls narcotic
medications on an empty stomach. Prescriptions should be written analgesics. To write prescriptions for these drugs, the dentist must
with instructions to the patient to have a snack or a meal before
taking a narcotic analgesic.
Ibuprofen has been demonstrated to be an e ective medication TABLE 11.2 Commonly Used Combination Analgesics
to control discomfort from a tooth extraction. Ibuprofen has the Brand Name Amount (mg) Amount (mg)
disadvantage of causing a decrease in platelet aggregation and
bleeding time, but this does not appear to have a clinically important Codeine–Acetaminophen Codeine Acetaminophen
e ect on postoperative bleeding in most patients. Acetaminophen Tylenol No. 2 15.0 300
does not interfere with platelet function and may be useful in Tylenol No. 3 30.0 300
certain situations in which the patient has a platelet defect and is
likely to bleed. If the surgeon prescribes a combination drug Tylenol No. 4 60.0 300
containing acetaminophen and narcotic, it should be a combination Oxycodone–Aspirin Oxycodone Aspirin
that delivers 500 to 650 mg of acetaminophen per dose. Percodan 5.0 325
Drugs that are useful in situations in which patients have varying
degrees of pain are listed in Table 11.1. Centrally acting opioid Percodan-demi 2.5 325
Oxycodone–
Acetaminophen Oxycodone Acetaminophen
TABLE 11.1 Analgesics for Postextraction Pain Percocet 2.5 325
Oral Narcotic Usual Dose 5.0 325
Mild Pain Situations Tylox 5.0 325
Ibuprofen 400–800 mg q4h
Hydrocodone–Aspirin Hydrocodone Aspirin
Acetaminophen 325–500 mg q4h Lortab ASA 5.0 325
Moderate Pain Situations Hydrocodone–
Codeine 15–60 mg Acetaminophen Hydrocodone Acetaminophen
Vicodin 5.0 325
Hydrocodone 5–10 mg
Vicodin ES 7.5 325
Severe Pain Situations
Oxycodone 2.5–10 mg Lorcet HD 5.0 325
Tramadol 50–100 mg Lortab Elixir 2.5 mg/5 mL 170 mg/5 mL

q4h, Every 4 hours. ASA, Acetylsalicylic acid.

188 PA RT I I Principles of Exodontia

have a Drug Enforcement Administration permit and number. e the rst postoperative day, patients should begin gentle
e drugs are categorized into four basic schedules based on their rinses with dilute salt water. e water should be warm but not
potential for abuse. Several important di erences exist between hot enough to burn the tissue. Most patients can resume their
schedule II and schedule III drugs concerning writing prescriptions preoperative oral hygiene measures by the third or fourth day after
(see Appendix 2). Unfortunately, prescription narcotics are sus- surgery. Dental oss should be used in the usual fashion on teeth
ceptible to misuse. Oxycodone- and hydrocodone-containing drugs anterior and posterior to the extraction sites as soon as the patient
are particularly sought after and abused. Narcotics tend to be is su ciently comfortable doing so.
addictive, leading to problems such as patients seeking drugs even If oral hygiene is likely to be di cult after extractions in multiple
when not in pain or nonpatients stealing drugs for their own use areas of the mouth, mouth rinses with agents such as dilute hydrogen
or to sell to others. e dental profession and others have developed peroxide may be used. Rinsing three to four times a day for
guidelines for dentists to help limit the overprescription of narcotics approximately 1 week after surgery may result in more reliable
and to manage any unused doses that might otherwise fall into healing.
the hands of a patient’s family members or others with access to
the patient’s medications. Dentists should take advantage of profes-
sional educational o erings related to managing patient pain and
Edema
the use of analgesic medications. Dentists should also have frank Some oral surgical procedures result in a certain amount of edema
discussions with patients about the problem of opioid abuse and or swelling after surgery. Routine extraction of a single tooth will
how they can help avoid its impact in their own lives. probably not result in swelling that the patient can see, whereas
It is important to emphasize that the most e ective method of the extraction of multiple impacted teeth with re ection of soft
controlling pain is the establishment of a close relationship between tissue and removal of bone may result in moderately large amounts
the surgeon and the patient. A speci c amount of time must be spent of swelling (Fig. 11.2). Swelling usually reaches its maximum 36
discussing the issue of postoperative discomfort, with the surgeon to 48 hours after the surgical procedure. Swelling begins to subside
clearly demonstrating his or her concern for patient comfort. A on the third or fourth day and is usually resolved by the end of
prescription should be given with clear instructions about when to the rst week. Increased swelling after the third day may be an
begin the medication and at what intervals it should be taken. If indication of infection rather than renewed postsurgical edema.
these procedures are followed, mild analgesics given for a short time Once the surgery is completed and the patient is ready to be
(usually no longer than 2 to 3 days) are usually all that is required. discharged, some dentists use ice packs or bags of frozen peas to
help minimize the swelling and make the patient feel more comfort-
Diet able; however, there is no evidence that the cooling actually controls
this type of edema. Ice should not be placed directly on the skin;
Patients who have had extractions may avoid eating because of preferably a layer of dry cloth should be placed between the ice
local pain or fear of pain occurring when eating. In addition, the container and the tissue to prevent super cial tissue damage. e
physical and emotional stress of undergoing surgery frequently ice pack or small bags of frozen peas should be kept on the local
lessens the appetite. erefore they should be given speci c instruc- area for 20 minutes and then kept o for 20 minutes over a period
tions regarding their postoperative diet. A high-calorie, high-volume of 12 to 24 hours. e bags of peas should be refrozen after they
liquid or soft diet is best for the rst 12 to 24 hours. warm.
e patient must have an adequate intake of uids, usually at
least 2 L, during the rst 24 hours. e uids can be juices, milk,
water, or any other nonalcoholic beverage that appeals to the patient.
Food in the rst 12 hours should be soft and cool. Cool and
cold foods help keep the local area comfortable. Ice cream and
milkshakes, unlike harder solid foods, have less tendency to cause
local trauma or initiate rebleeding episodes.
If the patient had multiple extractions in all areas of the mouth,
a soft diet is recommended for several days after the surgical
procedure. However, the patient should be advised to return to a
normal diet as soon as possible.
Patients who have diabetes should be encouraged to return to
their normal insulin and caloric intake as soon as possible. For
such patients, the surgeon may plan surgery on only one side of
the mouth at each surgical appointment, thus not overly interfering
with normal caloric intake.

Oral Hygiene
Patients should be advised that keeping the teeth and the whole
mouth reasonably clean results in a more reliable healing of surgical
wounds. Postoperatively, on the day of surgery, patients may gently
brush the teeth that are away from the area of surgery in the usual Fig. 11.2 Extraction of impacted left maxillary and mandibular third
fashion. ey should avoid brushing the teeth immediately adjacent molars was performed 2 days before this photograph was taken. The
to the extraction site to prevent a new bleeding episode and to patient exhibits a moderate amount of facial edema, which resolved within
avoid disturbing sutures and inducing more pain. 1 week of surgery.
 CHAPTER 11 Postextraction Patient Management 189

On the second postoperative day, neither ice nor heat should

be applied to the face. On the third and subsequent postoperative
days, application of heat may help to resolve the swelling more
quickly. Heat sources such as hot water bottles and heating pads
are recommended. Patients should be warned to avoid high-level
heat for long periods to prevent injuring the skin.
It is important to inform patients that some amount of swelling
is to be expected. ey should also be warned that the swelling
may tend to wax and wane, occurring more in the morning and
less in the evening because of postural variation. Sleeping in a
more upright position by using extra pillows will help reduce facial
edema. Patients should be informed that a moderate amount of
swelling is a normal and healthy reaction of tissue to the trauma
of surgery. Patients should not be concerned or frightened by
swelling because it will resolve within a few days.

Trismus
Extraction of teeth, administration of a mandibular block,
or both may result in trismus (limitation in mouth opening).
Trismus results from trauma and the resulting inflammation
involving the muscles of mastication. Trismus may also result
from multiple injections of the local anesthetic, especially if the
injections have penetrated muscles. e muscle most likely to be
involved is the medial pterygoid muscle, which may be penetrated Fig. 11.3 Moderate widespread ecchymosis of right side of face and
by the local anesthetic needle during the inferior alveolar nerve neck is exhibited in an older patient after extraction of several mandibular
block. teeth.
Surgical extraction of impacted mandibular third molars usually
results in some degree of trismus because the in ammatory response
to the surgical procedure is su ciently widespread to involve several
muscles of mastication. Trismus is usually not severe and does not are prolonged bleeding, pain that is not responsive to the prescribed
hamper the patient’s normal activities. However, to prevent alarm, medication, and suspected infection.
patients should be warned that this phenomenon might occur and If a patient who has had surgery begins to develop swelling with
that it will likely resolve within a week. surface redness, fever, pain, or all of these symptoms on the third
postoperative day or later, it can be assumed that the patient has
developed an infection until proven otherwise. e patient should
Ecchymosis be instructed to call the dentist’s o ce immediately. e surgeon
In some patients, blood oozes submucosally and subcutaneously; should then inspect the patient carefully to con rm or rule out the
this appears as a bruise in the oral tissues, the face, or both (Fig. presence of an infection. If an infection is diagnosed, appropriate
11.3). Blood in the submucosal or subcutaneous tissues is known therapeutic measures should be taken (see Chapter 16).
as ecchymosis. Ecchymosis is usually seen in older patients because Postsurgical pain that decreases at rst but begins to increase
of their decreased tissue tone, increased capillary fragility, and on the third or fourth day, although not accompanied by swelling
weaker intercellular attachments. Ecchymosis is not dangerous and or other signs of infection, is probably a symptom of dry socket.
does not increase pain or infection. Patients should, however, be is problem is usually con ned to lower molar sockets and does
warned that ecchymosis may occur because if they awaken on the not represent an infection. is annoying problem is straightforward
second postoperative day and see bruising in the cheek, subman- to manage but may require that the patient return to the o ce
dibular area, or anterior neck, they may become apprehensive. several times (see Chapter 10).
is anxiety is easily prevented by postoperative instructions.
Typically the onset of ecchymosis is 2 to 4 days after surgery and Operative Note
it usually resolves fully within 7 to 10 days.
e surgeon must enter into the records a note of what transpired
Postoperative Follow-up during each visit. Whenever surgery is performed, some critical
factors should be entered into the record. e rst is the date of
All patients seen by novice surgeons should be given a return the operation and a brief identi cation of the patient; then the
appointment so that the surgeon can check the patient’s progress surgeon states the diagnosis and reason for the extraction (e.g.,
after the surgery and learn about the appearance of a normally nonrestorable teeth due to caries or severe periodontal disease).
healing socket. In routine, uncomplicated procedures, a follow-up Comments regarding the patient’s pertinent medical history,
visit at 1 week is usually adequate. Sutures should be removed, as medications, and vital signs should be noted in the chart. e oral
needed, at the 1-week postoperative appointment. examination done at the time of surgery should be documented
Patients should be informed that if any question or problem brie y in the record.
arises, they should call the dentist and, if necessary, request an e surgeon should record the type and amount of anesthetic
earlier follow-up visit. e most likely reasons for an earlier visit used. For example, if the drug prescribed was lidocaine with a
190 PA RT I I Principles of Exodontia

BOX 11.1 Elements of an Operative Note to a specialist is an option that should always be exercised if the
planned surgery is beyond the dentist’s own skill level. In some
situations, this is not only a moral obligation but also wise medi-
colegal risk management and provides peace of mind.
In planning a surgical procedure, the rst step is always a
thorough review of the patient’s medical history. Several of the
complications discussed in this chapter can be caused by inadequate
attention to medical histories that would have revealed the presence
of a factor that would increase surgical risk.
One of the primary ways to prevent complications is by obtaining
adequate images and carefully reviewing them (see Chapter 8).
Radiographs must include the entire area of surgery, including the
apices of the roots of the teeth to be extracted as well as local and
regional anatomic structures such as the adjacent parts of the
maxillary sinus or the inferior alveolar canal. e surgeon should
vasoconstrictor, the dentist would write down the dosages of look for the presence of abnormal tooth root morphology or signs
lidocaine and epinephrine in milligrams. that the tooth may be ankylosed. After careful examination of the
e surgeon should then write a brief note about the procedure radiographs, the surgeon may need to alter the treatment plan to
performed and any problems that occurred intraoperatively. prevent or limit the magnitude of the complications that might
A comment concerning discharge instructions, including be anticipated with a closed extraction. Instead, the surgeon should
postoperative instructions that were given to the patient, should consider surgical approaches to removing teeth in such cases.
be recorded. e prescribed medications are listed, including the After an adequate medical history has been taken and the
name of the drug, its dose, and the total number of doses. Alter- radiographs have been analyzed, the surgeon goes on to preoperative
natively, copies of the prescriptions can be added to the record. planning. is is not simply a preparation of a detailed surgical
Finally, the need for a return appointment is recorded if indicated plan and needed instrumentation but also a plan for managing
(Box 11.1; see Appendix 1). patient pain and anxiety and postoperative recovery (instructions
With electronic record keeping, built-in elds are often present and modi cations of normal activity for the patient). orough
to document certain aspects of patient visits. e requirements preoperative instructions and explanations for the patient are
for patient documentation described previously still apply, but essential in preventing or limiting the impact of the majority of
these details may be recorded in various ways, depending on the complications that occur in the postoperative period. If the instruc-
software program used. tions are not carefully explained and the importance of compliance
made clear, the patient is less likely to comply with them.
To keep complications at a minimum, the surgeon must always
Prevention and Management follow basic surgical principles. ere should be clear visualization
of Complications and access to the operative eld, which requires adequate light,
adequate soft tissue retraction and re ection (including lips, cheeks,
As in the case of medical emergencies, the best way to manage tongue, and soft tissue aps), and adequate suction. e teeth to
surgical complications is to prevent them from happening. Preven- be removed must have an unimpeded pathway for removal.
tion of surgical complications is ideally accomplished by a thorough Occasionally bone must be removed and teeth sectioned to achieve
preoperative assessment and comprehensive treatment plan followed this goal. Controlled force is of paramount importance; this means
by careful execution of the surgical procedure. Only when these nesse, not force. e surgeon must follow the principles of asepsis,
are routinely performed can the surgeon expect to have few atraumatic handling of tissues, hemostasis, and thorough debride-
complications. However, even with such planning and the use of ment of the wound after the surgical procedure. Violation of these
excellent surgical techniques, complications still occasionally occur. principles can lead to an increased incidence and severity of surgical
In situations where the dentist has planned carefully, the complica- complications.
tion is often predictable and can be managed routinely. For example, Prevention of complications should be a major goal. When
in extracting a maxillary rst premolar that has long thin roots, complications do occur, skillful management is the most essential
it is far easier to remove the buccal root than the palatal root. requirement of the competent surgeon.
erefore the surgeon will use more force toward the buccal root
than toward the palatal root so that if a root does fracture, it will Soft Tissue Injuries
more likely involve the buccal root rather than the palatal root.
In most cases buccal root retrieval is more straightforward. Injuries to the soft tissue of the oral cavity are almost always the
Dentists must perform surgery that is within the limits of their result of the surgeon’s lack of adequate attention to the delicate
capabilities. ey must therefore carefully evaluate their training nature of the mucosa, attempts to do surgery with inadequate access,
and abilities before deciding to perform a speci c surgical task. rushing during surgery, or the use of excessive and uncontrolled
us, for example, it is inappropriate for a dentist with limited force. e surgeon must continue to pay careful attention to soft
experience in the management of impacted third molars to undertake tissue while operating on bone and tooth structures (Box 11.2).
the surgical extraction of an embedded tooth. e incidence of
operative and postoperative complications is unacceptably high in Tear of a Mucosal Flap
this situation. Surgeons must be cautious of unwarranted optimism,
which can cloud their judgment and prevent them from delivering e most common soft tissue injury during oral surgery is tearing
the best possible care. e dentist must keep in mind that referral of the mucosal ap during surgical extraction of a tooth. is
 CHAPTER 11 Postextraction Patient Management 191

BOX 11.2 Prevention of Soft Tissue Injuries

Fig. 11.5 The small straight elevator can be used to luxate a fractured
Fig. 11.4 Mucoperiosteal ap badly torn due to inadequate care during root. When a straight elevator is used in this position, the surgeon’s hand
its re ection. must be securely supported on adjacent teeth to prevent inadvertent slip-
page of the instrument from the tooth and subsequent injury to adjacent
tissue.
usually results from an initially inadequately sized envelope ap
that, as the surgeon tries to gain needed surgical access, is then preventing infection and allowing healing to occur, usually by
forcibly retracted beyond the ability of the tissue to stretch (Fig. secondary intention. If the wound bleeds excessively, the hemorrhage
11.4). is results in tearing, usually at one end of the incision. should be controlled by direct pressure applied to the wound.
Prevention of this complication is threefold: (1) creating adequately Once hemostasis is achieved, the wound is usually left open
sized aps to prevent excess tension on the ap, (2) using controlled unsutured; thus even if a small infection were to occur, there would
amounts of retraction force on the ap, and (3) creating releasing be an adequate pathway for drainage.
incisions when indicated. If a tear does occur in the ap, the ap
should be carefully repositioned once the surgery is completed. If Abrasion or Burn
the surgeon or assistant sees a ap beginning to tear, the hard
tissue surgery should be stopped while the incision is lengthened Abrasions or burns to lips, corners of the mouth, or aps usually
or while a releasing incision is created to gain better access. In result from the rotating shank of the burr rubbing on soft tissue
most patients, careful suturing of the tear results in adequate but or from a metal retractor coming in contact with soft tissue (Fig.
somewhat delayed healing. If the tear is especially jagged, the 11.6). When the surgeon is focused on the cutting end of the
surgeon may consider excising the edges of the torn ap to create burr, the assistant should be aware of the location of the shank of
a smooth ap margin before closure. is step should be performed the burr in relation to the patient’s cheeks and lips. However, the
with caution because excision of excessive amounts of tissue leads surgeon should also remain aware of the shaft’s location. Soft tissue
to closure of the wound under tension and probable wound burns can occur if instruments freshly out of the autoclave or dry
dehiscence, or it might compromise the amount of attached gingiva heat sterilizer are not allowed to cool before coming in contact
adjacent to a tooth. with the patient’s skin or mucosa.
If an area of oral mucosa is abraded or burned, little treatment
is possible other than keeping the area clean with regular oral
Puncture Wound rinsing. Usually such wounds heal in 4 to 7 days (depending on
e second soft tissue injury that occurs with some frequency is the depth of damage) without scarring. If such an abrasion or
inadvertent puncturing of soft tissue. An instrument such as a burn does develop on the skin, the dentist should advise the patient
straight elevator or a periosteal elevator may slip from the surgical to keep it covered with an antibiotic ointment. e patient must
eld and puncture or tear adjacent soft tissue. apply the ointment only on the abraded area and not spread it
Once again, this injury is the result of using uncontrolled force onto intact skin because the ointment may cause ulceration or a
and is best prevented by the use of controlled force, with special rash. ese abrasions usually take 5 to 10 days to heal. e patient
attention given to using nger rests or support from the opposite should keep the area moist with small amounts of ointment during
hand if slippage is anticipated. If the instrument slips from the the entire healing period to prevent eschar formation and delayed
tooth or bone, the surgeon’s ngers can catch the operating hand healing and to keep the area reasonably comfortable. Scarring or
before injury occurs (Fig. 11.5). If a puncture wound does occur permanent discoloration of the a ected skin may occur but is
in the mucosa, the ensuing treatment is primarily aimed at usually prevented with proper wound care.
192 PA RT I I Principles of Exodontia

If the displaced tooth fragment is a small 2- or 3-mm root tip

and the tooth and sinus have no preexisting infection, the surgeon
should make a brief attempt at removing the root. First, a radiograph
of the fractured tooth root should be taken to document its position
and size. Once that has been accomplished, the surgeon should
irrigate through the small opening in the socket apex and then
suction the irrigating solution from the sinus via the socket. is
occasionally ushes the root apex from the sinus through the socket.
The surgeon should check the suction solution and confirm
radiographically that the root has been removed. If this technique
is not successful, no additional surgical procedure should be
performed through the socket, and the root tip should be left in
the sinus. A small, noninfected root tip can be left in place because
it is unlikely to cause any troublesome sequelae. Additional surgery
in this situation causes more patient morbidity than leaving the
Fig. 11.6 Abrasion of lower lip as a result of shank of burr rotating on
root tip in the sinus. If the root tip is left in the sinus, the surgeon
soft tissue. The abrasion represents a combination of friction and heat
damage. The wound should be kept covered with antibiotic ointment until
should take measures similar to those taken in leaving any root
an eschar forms, taking care to keep the ointment off uninjured skin as tip in place. e patient must be informed of the decision and
much as possible. (Courtesy Dr. Myron Tucker.) given proper follow-up instructions for regular monitoring of the
root and the sinus.
e oroantral communication should be managed as discussed
BOX 11.3 Prevention of Root Fracture and later, with a gure-of-eight suture over the socket, sinus precautions,
Displacement antibiotics, and a nasal spray to lessen the chance of infection by
keeping the ostium open. e most likely occurrence is that the
root apex will brose onto the sinus membrane with no subsequent
problems. If the tooth root is infected or the patient has chronic
sinusitis, the patient should be referred to an oral-maxillofacial
surgeon for removal of the root tip via a Caldwell-Luc or endoscopic
approach.
If a large root fragment or the entire tooth is displaced into
Problems With a Tooth Being Extracted the maxillary sinus, it should be removed (Fig. 11.7). e usual
Root Fracture method is a Caldwell-Luc approach into the maxillary sinus in
the canine fossa region followed by removal of the tooth. is
The most common problem associated with the tooth being procedure should be performed by an oral-maxillofacial surgeon
extracted is fracture of its roots. Long, curved, divergent roots (see Chapter 20).
that lie in dense bone are the most likely to be fractured. e main Impacted maxillary third molars are occasionally displaced into
methods of preventing the fracture of roots is to perform surgery the maxillary sinus (from which they are removed via a Caldwell-Luc
in the manner described in previous chapters or to use an open approach). However, if displacement occurs, it more commonly
extraction technique and remove bone to decrease the amount does so into the infratemporal space. During elevation of the tooth,
of force necessary to remove the tooth (Box 11.3). Recovery of a the elevator may force the tooth posteriorly through the periosteum
fractured root with a surgical approach is discussed in Chapter 9. into the infratemporal fossa. e tooth is usually lateral to the
lateral pterygoid plate and inferior to the lateral pterygoid muscle.
If good access and light are available, the surgeon should make a
Root Displacement single cautious e ort to retrieve the tooth with a hemostat. However,
e tooth root that is most commonly displaced into unfavorable the tooth is usually not visible, and blind probing results in further
anatomic spaces is the maxillary molar root when it is forced or displacement. If the tooth is not retrieved after a single e ort, the
lost into the maxillary sinus. If a fractured root of a maxillary incision should be closed and the operation stopped. e patient
molar is being removed with a straight elevator that is being used should be informed that the tooth has been displaced and will be
with excessive apical pressure, the root can be displaced into the removed later. Antibiotics should be given to help decrease the
maxillary sinus. Other teeth or roots can be displaced into the possibility of an infection, and routine postoperative care should
maxillary sinus in a similar manner. If a root or tooth is pushed be provided. During the initial healing time, brosis occurs and
into the maxillary sinus, the surgeon must make several assessments stabilizes the tooth in a rm position. e tooth is removed later
to determine the appropriate treatment. First, the surgeon must by an oral-maxillofacial surgeon after radiographic localization.
identify the size of the root lost into the sinus. It may be a root Lingual cortical bone over the roots of the molars becomes
tip of several millimeters or an entire tooth or root. e surgeon thinner as it progresses posteriorly. Mandibular third molars, for
must next assess whether there has been any infection of the tooth example, frequently have dehiscence in overlying lingual bone and
or periapical tissues. If the tooth was not infected, management may actually be sitting in the submandibular space preoperatively.
is more straightforward than if the tooth has been acutely infected. Fractured mandibular molar roots that are being removed with
Finally, the surgeon must assess the preoperative condition of the apical pressures may be displaced through the lingual cortical plate
maxillary sinus. For the patient who has a healthy maxillary sinus, and into the submandibular space. Even small amounts of apical
it is more straightforward to manage a displaced root than if the pressure can result in displacement of the root into that space.
sinus is or has been chronically infected. Prevention of displacement into the submandibular space is primarily
 CHAPTER 11 Postextraction Patient Management 193

abandon the procedure and refer the patient to an oral-maxillofacial

surgeon. e usual de nitive procedure for removing such a root
tip is to re ect a soft tissue ap on the lingual aspect of the mandible
and gently dissect the overlying mucoperiosteum until the root
tip can be found. As with teeth that are displaced into the maxillary
sinus, if the root fragment is small and was not infected preopera-
tively, the oral-maxillofacial surgeon may elect to leave the root
in its position because surgical retrieval of the root may be an
extensive procedure or may risk serious injury to the lingual nerve.

Tooth Lost Into the Pharynx

Occasionally the crown of a tooth, a prosthetic crown, or an entire
tooth may be lost in the oropharynx. If this occurs, the patient
should be turned toward the surgeon and placed in a position
with the mouth facing the oor as much as possible. e patient
should be encouraged to cough and spit the tooth out onto the
oor.
In spite of these e orts, the tooth may be swallowed or aspirated.
If the patient has no coughing or respiratory distress, it is most
likely that the tooth was swallowed and has traveled down the
esophagus into the stomach. However, if the patient has a violent
episode of coughing or shortness of breath, the tooth may have
been aspirated through the vocal cords into the trachea and from
there into a mainstem bronchus.
In either case, the patient should be transported to an emergency
A department, and chest and abdominal radiographs should be taken
to determine the speci c location of the tooth. If the tooth has
been aspirated, consultation with regard to the possibility of
removing the tooth with a bronchoscope should be requested. e
urgent management of aspiration is to maintain the patient’s airway
and breathing. Supplemental oxygen may be appropriate if signs
of respiratory distress are observed.
If the tooth has been swallowed, it is highly probable that it
will pass through the gastrointestinal tract within 2 to 4 days.
Because teeth are not usually jagged or sharp, unimpeded passage
occurs in almost all situations. However, it may be prudent to
have the patient go to an emergency room and have a radiograph
of the abdomen taken to con rm that the tooth is indeed in the
gastrointestinal tract and not in the respiratory tract. Follow-up
radiographs are probably not necessary because swallowed teeth
are ultimately passed out along with feces.
B
Extraction of the Wrong Tooth
Fig. 11.7 (A) Large root fragment displaced into the maxillary sinus. The
fragment should be removed by the Caldwell-Luc approach or sinus A complication that every dentist believes can never happen—but
endoscopy. (B) The tooth in the maxillary sinus is the maxillary third molar happens surprisingly often—is extraction of the wrong tooth. is
that was displaced into the sinus during elevation of the tooth. This tooth is usually the most common cause of malpractice lawsuits against
must be removed from the sinus, potentially by the Caldwell-Luc approach. dentists. Extraction of the wrong tooth should never occur if
appropriate attention is given to the planning and execution of
the surgical procedure.
achieved by avoiding all apical pressures when removing mandibular is problem may be the result of inadequate attention to
roots. preoperative assessment. If the tooth to be extracted is grossly
Triangular elevators such as the Cryer elevator are usually used carious, it is less likely that the wrong tooth will be removed. A
to elevate broken tooth roots of mandibular molars. If the root common reason for removing the wrong tooth is that a dentist
disappears during root removal, the dentist should make a single removes a tooth for another dentist. e use of di ering tooth
e ort to remove it. e index nger of the left hand is inserted numbering systems or di erences in the mounting of radiographs
onto the lingual aspect of the oor of the mouth in an attempt can easily lead the treating dentist to misunderstand the instructions
to place pressure against the lingual aspect of the mandible and from the referring dentist. us the wrong tooth is sometimes
force the root back into the socket. If this works, the surgeon may extracted when the dentist is asked to remove teeth for orthodontic
be able to tease the root out of the socket with a root-tip pick. If purposes, especially in patients who are in mixed dentition stages
this e ort is not successful at the initial attempt, the dentist should and whose orthodontists have asked for unusual extractions. Careful
194 PA RT I I Principles of Exodontia

BOX 11.4 Prevention of Extraction of Wrong Teeth BOX 11.5 Prevention of Injury to Adjacent Teeth

preoperative planning, clear communication with the referring

dentist, and attentive clinical assessment of the tooth to be removed
before the elevator and forceps are applied are the main methods
of preventing this complication (Box 11.4).
If the wrong tooth is extracted and the surgeon realizes this
error immediately, the tooth should be replaced quickly into the
tooth socket. If the extraction is for orthodontic purposes, the
surgeon should contact the orthodontist immediately and discuss
whether the tooth that was removed can substitute for the tooth
that should have been removed. If the orthodontist believes the
original tooth must be removed, the correct extraction should be
deferred for 4 or 5 weeks until the fate of the replanted tooth can
be assessed. If the wrongfully extracted tooth has regained its
attachment to the alveolar process, then the originally planned
extraction may proceed. In addition, the surgeon should not extract
the contralateral tooth until a de nite alternative treatment plan
has been made. Fig. 11.8 Mandibular rst molar. If the rst molar is to be removed, the
If the surgeon does not recognize that the wrong tooth was surgeon must take care not to fracture amalgam in the second premolar
extracted until the patient returns for a postoperative visit, little with elevators or forceps.
can be done to correct the problem. Replantation of the extracted
tooth after it has dried cannot be successfully accomplished.
When the wrong tooth is extracted, it is important to inform
the patient or the patient’s parents or caregivers (if the patient is application of instrumentation and force on the restoration (Box
a minor) and any other dentist involved with the patient’s care, 11.5). is means that the straight elevator should be used with
such as the orthodontist. In some situations, the orthodontist may great caution, being inserted entirely into the periodontal ligament
be able to adjust the treatment plan so that extraction of the wrong space or not used at all to luxate the tooth before extraction when
tooth necessitates only a minor alteration of the plan. Also, if the the adjacent tooth has a large restoration. If a restoration is dislodged
case did not involve orthodontic care, a dental implant–supported or fractured, the surgeon should make sure that the displaced
restoration may totally restore the patient’s dental status as it was restoration is removed from the mouth and does not fall into the
before the inadvertent extraction. empty tooth socket. Once the surgical procedure has been com-
pleted, the injured tooth should be treated by replacement of the
Injuries to Adjacent Teeth displaced crown or placement of a temporary restoration. e
patient should be informed if a fracture of a tooth or restoration
When the dentist extracts a tooth, the focus of attention is on has occurred and that a replacement restoration is needed (see
that particular tooth and the application of forces to luxate and Chapter 12).
deliver it. When the surgeon’s total attention is completely focused Teeth in the opposite arch may also be injured as a result of
on just this tooth, the likelihood of injury to the adjacent teeth uncontrolled forces. is usually occurs when buccolingual forces
is increased. Injury is often caused by the use of a burr to remove inadequately mobilize a tooth, excessive tractional forces are used,
bone or to divide a tooth for removal. e surgeon should take or both. e tooth is suddenly released from the socket, and the
care to avoid getting too close to adjacent teeth when surgically forceps strikes the teeth of the opposite arch, chipping or fracturing
removing a tooth. is usually requires the surgeon to keep some a cusp. is is more likely to occur with extraction of lower teeth
of the focus on structures adjacent to the site of the surgery. because these teeth may require more vertical tractional forces for
their delivery, especially when using the No. 23 (cowhorn) forceps.
Fracture or Dislodgment of an Prevention of this type of injury can be accomplished by several
methods. e rst and most important method is to avoid the
Adjacent Restoration use of excessive tractional forces. e tooth should be adequately
e most common injury to adjacent teeth is the inadvertent luxated with apical, buccolingual, and rotational forces to minimize
fracture or dislodgment of a restoration or damage to a severely the need for tractional forces.
carious tooth while the surgeon is attempting to elevate the tooth Even when this is done, however, occasionally a tooth will be
to be removed (Fig. 11.8). If a large restoration exists, the surgeon released unexpectedly. e surgeon or assistant should protect the
should warn the patient preoperatively about the possibility of teeth of the opposite arch by holding a nger or suction tip against
fracturing or displacing it during the extraction. Prevention of them to absorb the blow should the forceps be released in that
such a fracture or displacement is primarily achieved by avoiding direction. If such an injury occurs, the tooth should be smoothed
 CHAPTER 11 Postextraction Patient Management 195

A B
Fig. 11.9 (A) No. 151 forceps, which are too wide to grasp the premolar to extract it without luxating
adjacent teeth. (B) Maxillary root forceps, which can be adapted readily to the tooth for extraction.

or restored, as necessary, to keep the patient comfortable until a BOX 11.6 Prevention of Fracture of Alveolar
permanent restoration can be constructed. Process

Luxation of an Adjacent Tooth

Inappropriate use of the extraction instruments may luxate an
adjacent tooth. Luxation is prevented by judicious use of force
with elevators and forceps. If the tooth to be extracted is crowded
and has overlapping adjacent teeth, as is commonly seen in the
mandibular incisor region, a thin, narrow forceps such as the No. removed so that the tooth can be delivered or, in the case of
286 forceps may be useful for the extraction (Fig. 11.9). Forceps multirooted teeth, the tooth should be sectioned. If this principle
with broader beaks should be avoided because they will cause is not adhered to and the surgeon continues to use excessive or
injury and luxation of adjacent teeth. uncontrolled force, bone fractures commonly occur.
A small amount of luxation of an adjacent tooth frequently e most likely places for bone fractures are the buccal cortical
occurs and generally causes no damage. However, if an adjacent plate over the maxillary canine, the buccal cortical plate over
tooth is signi cantly luxated or partially avulsed, the treatment maxillary molars (especially the rst molar), the portions of the
goal is to reposition the tooth into its appropriate position and oor of the maxillary sinus that are associated with maxillary molars,
stabilize it so that adequate healing can occur. is usually requires the maxillary tuberosity, and labial bone over mandibular incisors
that the tooth simply be repositioned in the tooth socket and left (Fig. 11.10). All of these bone injuries are caused by excessive
alone. e occlusion should be checked to ensure that the tooth force from the forceps.
has not been displaced into a hyperocclusion and traumatic occlu- e primary method of preventing these fractures is to perform
sion. Occasionally the luxated tooth is mobile. If this is the case, a careful preoperative examination of the alveolar process both
the tooth should be stabilized with semirigid xation to maintain clinically and radiographically (Box 11.6). e surgeon should
it in its position. A silk suture that crosses the occlusal table and inspect the root form of the tooth to be removed and assess the
is sutured to the adjacent gingiva is usually su cient. Rigid xation proximity of the roots to the maxillary sinus (Fig. 11.11). e
with circumdental wires and arch bars results in increased chances surgeon should also consider the thickness of the buccal cortical
for external root resorption and ankylosis of the tooth and therefore plate overlying the tooth to be extracted (Fig. 11.12). If the roots
should be avoided (see Chapter 25). diverge widely, if they lie close to the sinus, or if the patient has
a heavy buccal cortical bone, the surgeon should take special
measures to prevent fracturing excessive portions of bone. Age is
Injuries to Osseous Structures a factor to be considered because the bones of older or larger
Fracture of the Alveolar Process patients are likely to be less elastic and therefore are more likely
to fracture than to expand.
e extraction of a tooth usually requires that the surrounding With preoperative determination of a high probability for bone
alveolar bone be expanded to allow an unimpeded pathway for fracture, the surgeon should consider performing the extraction
tooth removal. However, in some situations, instead of expanding, by the open surgical technique. Utilizing this method, the surgeon
the bone fractures and is removed still attached to the tooth. e can remove a smaller, more controlled amount of bone, resulting
most likely cause of fracture of the alveolar process is the use of in more rapid healing and a more favorable ridge form for prosthetic
excessive force with the forceps, which fractures the cortical plate. reconstruction.
If excessive force is necessary to remove a tooth, a soft tissue ap When the maxillary molar lies close to the maxillary sinus,
should be elevated and controlled amounts of bone should be surgical exposure of the tooth, with sectioning of the tooth roots
196 PA RT I I Principles of Exodontia

Fig. 11.10 Forceps extraction of these teeth resulted in removal of bone and tooth instead of just tooth.

Fig. 11.12 Patient with a heavy buccal cortical plate, requiring open
A extraction. (From Neville BW, Damm DD, Allen CM, et al. Oral and Maxil-
lofacial Pathology. 2nd ed. St. Louis: Elsevier; 2002.)

multirooted teeth. During a forceps extraction, if the appropriate

amount of tooth mobilization does not occur early, then the wise
and prudent surgeon will alter the treatment plan to the surgical
technique instead of pursuing the closed method.
Management of fractures of the alveolar bone takes several
di erent forms, depending on the type and severity of the fracture.
If the bone has been completely removed from the tooth socket
along with the tooth, it should not be replaced. e surgeon should
simply make sure that the soft tissue has been repositioned to the
best extent possible over the remaining bone to prevent delayed
healing. e surgeon must also smooth any sharp edges that may
have been caused by the fracture. If such sharp edges of bone exist,
B the surgeon should re ect a small amount of soft tissue and use
Fig. 11.11 (A) Floor of sinus associated with roots of teeth. If extraction a bone le to round o the sharp edges or use a rongeur to remove
is required, the tooth should be removed surgically. (B) Maxillary molar the sharp edges.
teeth immediately adjacent to the sinus present increased danger of sinus e surgeon who has been supporting the alveolar process with
exposure. the ngers during the extraction usually feels the fracture of the
buccal cortical plate when it occurs. At this time, the bone remains
into two or three portions, usually prevents the removal of a portion attached to the periosteum and usually heals if it can be separated
of the maxillary sinus oor. is helps prevent the formation of from the tooth and is left attached to the overlying soft tissue.
an oroantral stula, which commonly requires secondary procedures e surgeon must carefully dissect the bone with its attached
to be closed. associated soft tissue away from the tooth. For this procedure the
In summary, prevention of fractures of large portions of the tooth must be stabilized with the forceps and a small sharp instru-
cortical plate depends on preoperative radiographic and clinical ment such as a No. 9 periosteal elevator should be used to elevate
assessments, avoidance of the use of excessive amounts of uncon- the buccal bone from the tooth root. Once the bone and soft
trolled force, and the early decision to perform an open extraction tissue have been elevated from the tooth, the tooth is removed
with removal of controlled amounts of bone and sectioning of and the bone and the soft tissue ap are reapproximated and
 CHAPTER 11 Postextraction Patient Management 197

secured with sutures. When treated in this fashion, it is highly A fracture of the maxillary tuberosity should be viewed as a
probable that the bone will heal in a more favorable ridge form signi cant complication. e major therapeutic goal of management
for prosthetic reconstruction than if the bone had been removed is to maintain the fractured bone in place and provide the best
along with the tooth. erefore it is worth the special e ort to possible environment for healing. is may be a situation that can
dissect the bone from the tooth. best be handled by an oral-maxillofacial surgeon.

Fracture of the Maxillary Tuberosity Fracture of the Mandible

Fracture of a large section of bone in the maxillary tuberosity area Fracture of the mandible during extraction is a rare complication;
is a situation of special concern. The maxillary tuberosity is it is associated almost exclusively with the surgical removal of
important for the construction of a stable retentive maxillary impacted third molars. A mandibular fracture is usually the result
denture. If a large portion of this tuberosity is removed along with of the application of a force exceeding that needed to remove a
the maxillary tooth, denture stability is likely to be compromised. tooth and often occurs during the forceful use of dental elevators.
An opening into the maxillary sinus may also be created. Fractures However, when lower third molars are deeply impacted, even small
of the maxillary tuberosity most commonly result from extraction amounts of force may cause a fracture. Fractures may also occur
of an erupted maxillary third molar or from extraction of the during removal of impacted teeth from a severely atrophic mandible.
second molar if it is the last tooth in the arch (Fig. 11.13). Should such a fracture occur, it must be treated by methods usually
If a tuberosity fracture occurs during an extraction, the treatment applied for treating jaw fractures. e fracture must be adequately
is similar to that just discussed for other bone fractures. e surgeon, reduced and stabilized; thus the patient should be referred to an
using nger support for the alveolar process during the fracture oral-maxillofacial surgeon for de nitive care.
(if the bone remains attached to the periosteum), should take
measures to ensure the survival of the fractured bone.
However, if the tuberosity is excessively mobile and cannot be Injuries to Adjacent Structures
dissected from the tooth, the surgeon has several options. e rst
is to splint the tooth being extracted to adjacent teeth and defer
Injury to Regional Nerves
the extraction by 6 to 8 weeks, allowing time for bone to heal. e branches of the fth cranial nerve, which provide innervation
e tooth is then extracted with an open surgical technique. e to the mucosa and skin, are the adjacent neural structures most
second option is to section the crown of the tooth from the roots likely to be injured during extraction. e most frequently involved
and allow the tuberosity and tooth root section to heal. After 6 speci c branches are the mental, lingual, buccal, and nasopalatine
to 8 weeks the surgeon can remove the tooth roots in the usual nerves. e nasopalatine and buccal nerves are frequently sectioned
fashion. If the maxillary molar tooth was infected before surgery, during the creation of aps for the removal of impacted teeth.
these two techniques should be used with caution. e area of sensory innervation of these two nerves is relatively
If the maxillary tuberosity is completely separated from soft small, and reinnervation of the a ected area usually occurs rapidly.
tissue, the usual steps are to smooth the sharp edges of the remaining erefore the nasopalatine and long buccal nerves can be surgically
bone and reposition and suture the remaining soft tissue. e sectioned without long-lasting sequelae or much bother to the
surgeon must carefully check for an oroantral communication and patient.
provide the necessary treatment. Surgical removal of mandibular premolar roots or impacted
mandibular premolars or periapical surgery in the area of the mental
nerve and mental foramen must be performed with great care. If
the mental nerve is injured, the patient will experience paresthesia
or anesthesia of the lip and chin. If the injury is the result of ap
re ection or manipulation, normal sensation usually returns in a
few days to a few weeks. If the mental nerve is sectioned at its exit
from the mental foramen or torn along its course, it is likely that
mental nerve function will not return, and the patient will have
a permanent state of anesthesia. If surgery is to be performed in
the area of the mental nerve or the mental foramen, it is imperative
that the surgeon be aware of the potential morbidity from injury
to this nerve (Box 11.7). If a surgeon has any doubt about his or
her ability to perform the indicated surgical procedure, the patient
should be referred to an oral-maxillofacial surgeon. If a three-corner
ap is to be used in the area of the mental nerve, the vertical
releasing incision must be placed far enough anteriorly to avoid
A B severing any portion of the mental nerve. On rare occasion it is
advisable to make the vertical releasing incision at the interdental
Fig. 11.13 Tuberosity removed with the maxillary second molar, which
papilla between the canine and the rst premolar.
eliminates the important prosthetic retention area and exposes the maxil-
lary sinus. (A) Buccal view of bone removed with the tooth. (B) Superior
view, looking onto the sinus oor, which was removed with the tooth. If BOX 11.7 Prevention of Nerve Injury
possible, the bony segment should be dissected away from the tooth and
the tooth should be removed in the usual fashion. The tuberosity is then
stabilized with mucosal sutures as previously indicated. (Courtesy Dr.
Edward Ellis III, University of Texas Health Science Center, San Antonio.)
198 PA RT I I Principles of Exodontia

The lingual nerve is usually anatomically located directly if the roots of the tooth are widely divergent, it is common for a
against the lingual aspect of the mandible in the retromolar pad portion of the bony oor of the sinus to be removed with the
region. Occasionally the path of the lingual nerve takes it into the tooth or a communication to be created even if no bone comes
retromolar pad area itself. e lingual nerve rarely regenerates if out with the tooth. If this problem occurs, appropriate measures
it is severely traumatized. Incisions made in the retromolar pad are necessary to prevent a variety of sequelae. e two sequelae of
region of the mandible should be placed so as to avoid coming most concern are (1) postoperative maxillary sinusitis and (2)
close to this nerve. erefore incisions made for surgical exposure formation of a chronic oroantral stula. e probability that either
of impacted third molars or of bony areas in the posterior molar of these two sequelae will occur is related to the size of the oroantral
region should be made well to the buccal aspect of the mandible. communication and the management of the sinus exposure.
Similarly, if dissecting a ap involving the retromolar pad, care As with all complications, prevention is the easiest and most
must be taken to avoid excessive dissection or stretching of the e cient method of managing the situation. Preoperative radiographs
tissues on the lingual aspect of the retromolar pad. Prevention of must be carefully evaluated for the tooth-sinus relationship whenever
injury to the lingual nerve is of paramount importance to avoid maxillary molars are to be extracted. If the sinus oor appears
this problematic complication. close to the tooth roots and the tooth roots are widely divergent,
Finally, the inferior alveolar nerve may be traumatized along the surgeon should avoid a closed extraction and perform a surgical
the course of its intrabony canal. e most common place of removal with sectioning of tooth roots (see Fig. 11.11). Excessive
injury is the area of the mandibular third molar. Removal of force should be avoided in the removal of such maxillary molars
impacted third molars may bruise, crush, or sharply injure the (Box 11.9).
nerve in its canal. is complication is common enough during e diagnosis of an oroantral communication can be made in
extraction of third molars that it is important routinely to inform several ways. e rst is to examine the tooth once it has been
patients preoperatively that it is a possibility. e surgeon must removed. If a section of bone is adherent to the root ends of the
then take every precaution possible to avoid injuring the nerve tooth, the surgeon should assume that a communication between
during the extraction. the sinus and mouth exists. If little or no bone adheres to the
If the lingual or inferior alveolar nerves have been damaged, molars, a communication may exist anyway. Some advocate using
the surgeon should refer the patient to an oral-maxillofacial surgeon the nose-blowing test to con rm the presence of a communication.
for a consultation. is should be done promptly because, if nerve is test involves pinching the nostrils together to occlude the
repair is indicated, the sooner the repair is made, the better the patient’s nose and asking the patient to blow gently through the
chances of full recovery of nerve function. nose while the surgeon observes the area of the tooth extraction.
If a communication exists, there will be passage of air through the
Injury to the Temporomandibular Joint tooth socket and bubbling of blood in the socket area. However,
if there is no communication, forceful blowing like this poses the
Another major structure that can be traumatized during an risk of creating a communication. is is why many surgeons do
extraction procedure in the mandible is the temporomandibular not feel the nose-blowing maneuver should be used in these
joint. Removal of mandibular molar teeth frequently requires circumstances.
the application of a substantial amount of force. If the jaw is After the diagnosis of oroantral communication has been
inadequately supported during the extraction to help counteract established or a strong suspicion exists, the surgeon should guess
the forces, the patient may experience pain in this region. Controlled the approximate size of the communication because the treatment
force and adequate support of the jaw prevent this (Box 11.8). depends on the size of the opening. Probing a small opening may
e use of a bite block on the contralateral side may provide an enlarge it, so if no bone comes out with the tooth, the communica-
adequate balance of forces so that injury does not occur. e tion is likely to be 2 mm or less in diameter. However, if a sizable
surgeon or assistant should also support the jaw by holding the piece of bone comes out with the tooth, the opening is of a consider-
lower border of the mandible. If the patient complains of pain in able size. If the communication is small (≤2 mm in diameter), no
the temporomandibular joint area immediately after the extraction additional surgical treatment is necessary. e surgeon should take
procedure, the surgeon should recommend the use of heat, resting measures to ensure the formation of a high-quality blood clot in
the jaw, a soft diet, and 600 to 800 mg of ibuprofen every 4 the socket and then advise the patient to take sinus precautions
hours for several days. Patients who cannot tolerate nonsteroidal to prevent dislodgment of the blood clot.
antiin ammatory drugs may take 500 to 1000 mg of acetaminophen. Sinus precautions are aimed at preventing increases or decreases
in the maxillary sinus air pressure that would dislodge the clot.
Oroantral Communications Patients should be advised to avoid blowing the nose, sneezing
violently, sucking on straws, and smoking.
Removal of maxillary premolars or molars occasionally results in e surgeon must not probe through the socket into the sinus
communication between the oral cavity and the maxillary sinus. with a dental curette or a root-tip pick. e bone of the sinus may
If the maxillary sinus is greatly pneumatized, if little or no bone possibly have been removed without perforation of the sinus mucosa.
exists between the roots of the teeth and the maxillary sinus, and To probe the socket with an instrument might unnecessarily lacerate

BOX 11.8 Prevention of Injury to the BOX 11.9 Prevention of Oroantral Communications
Temporomandibular Joint
 CHAPTER 11 Postextraction Patient Management 199

the membrane. Probing of the communication may also introduce bacteria go from the oral cavity into the sinus, usually causing a
foreign material, including bacteria, into the sinus, thereby further chronic sinusitis. In addition, if the patient is wearing a full maxillary
complicating the situation. Probing of the communication is denture, the suction seal is broken and retention of the denture
therefore contraindicated. is therefore compromised.
If the opening between the mouth and sinus is of moderate
size (2 to 6 mm), additional measures should be taken. To help Postoperative Bleeding
ensure the maintenance of the blood clot in the area, a gure-of-eight
suture should be placed over the tooth socket (Fig. 11.14). Some Extraction of teeth is a surgical procedure that presents a severe
surgeons also place some clot-promoting substances such as a gelatin challenge to the hemostatic mechanism of the body. Several reasons
sponge into the socket before suturing. e patient should also exist for this challenge: (1) the tissues of the mouth and jaws are
be told to follow sinus precautions. Finally, the patient should be highly vascular; (2) the extraction of a tooth leaves an open wound,
prescribed several medications to reduce the risk of maxillary with soft tissue and bone remaining open, which allows additional
sinusitis. Antibiotics—usually amoxicillin, cephalexin, or oozing and bleeding; (3) it is almost impossible to apply dressing
clindamycin—should be prescribed for 5 days. In addition, a material with enough pressure and sealing to prevent additional
decongestant nasal spray should be prescribed to shrink the nasal bleeding during surgery; (4) patients tend to explore the area of
mucosa to maintain patency of the ostium. As long as the ostium surgery with their tongues and occasionally dislodge blood clots,
is patent and normal sinus drainage can occur, sinusitis and sinus which initiates secondary bleeding, or the tongue may cause second-
infection will be less likely. Sometimes an oral decongestant is also ary bleeding by creating small negative pressures that suction the
recommended. blood clot from the socket; and (5) salivary enzymes may lyse the
If the sinus opening is large (≥7 mm), the surgeon should blood clot before it has organized and before the ingrowth of
consider having the sinus communication repaired with a ap granulation tissue.
procedure. is usually requires that the patient be referred to an As with all complications, prevention of bleeding is the best
oral-maxillofacial surgeon because ap development and closure way to manage this problem (Box 11.10). One of the prime factors
of a sinus opening are complex procedures that require special in preventing bleeding is taking a thorough patient history with
training and experience. regard to any existing problems with coagulation. e patient
e most commonly used ap for small openings is the buccal must be questioned thoroughly about any history of bleeding,
ap. is technique mobilizes buccal soft tissue to cover the opening particularly after injury or surgery, because a rmative answers to
and provide for a primary closure. is technique should be these questions should trigger special e orts to control the bleeding
performed as soon as possible, preferably the same day the opening (see Chapter 1).
occurred. e same sinus precautions and medications are usually e rst question that a patient should be asked is whether he
required (see Chapter 20). or she has ever had a problem with bleeding in the past. e
e recommendations just described hold true for patients who surgeon should inquire about bleeding after previous tooth extrac-
have no preexisting sinus disease. If a communication does occur, tions or other previous surgery or persistent bleeding after accidental
it is important that the dentist inquire speci cally about a history lacerations. e surgeon must listen carefully to the patient’s answers
of sinusitis and sinus infections. If the patient has a history of to these questions because what the patient considers “persistent”
chronic sinus disease, even small oroantral communications may may actually be normal. For example, it is normal for a socket to
heal poorly and may result in a chronic oroantral communication ooze small amounts of blood for the rst 12 to 24 hours after
and eventual stula. erefore creation of an oroantral communica- extraction. However, if a patient relates a history of bleeding that
tion in a patient with chronic sinusitis is cause for referral to an persisted for more than 1 day or that required special attention
oral-maxillofacial surgeon for de nitive care (see Chapter 20). from the surgeon, the degree of suspicion should be substantially
e majority of oroantral communications treated by using the elevated.
methods just recommended heal uneventfully. Patients should be e surgeon should inquire about any family history of bleeding.
followed carefully for several weeks to ensure that healing has If anyone in the patient’s family has or had a history of prolonged
occurred. Even patients who return within a few days with a small bleeding, further inquiry about its cause should be pursued. Most
communication usually heal spontaneously if no maxillary sinusitis congenital bleeding disorders are familial, inherited characteristics.
exists. ese patients should be monitored closely and referred to ese congenital disorders range from mild to profound, and the
an oral-maxillofacial surgeon if the communication persists for latter require substantial e orts to control.
longer than 2 weeks. e usual patient complaint in such situations e patient should next be asked about any medications currently
is the leakage of uids from the mouth into the nose. e closure being taken that might interfere with coagulation. Drugs such as
of an oroantral stula is important because air, water, food, and anticoagulants may cause prolonged bleeding after extraction.
Patients receiving anticancer chemotherapy or aspirin, those with
alcoholism, or patients with severe liver disease for any reason also
tend to bleed excessively.

BOX 11.10 Prevention of Postoperative Bleeding

Fig. 11.14 A gure-of-eight stitch is usually used to help maintain the

piece of oxidized cellulose in the tooth socket.
200 PA RT I I Principles of Exodontia

e patient who has a known or suspected coagulopathy should socket about 30 minutes after the completion of surgery. e
be evaluated by laboratory testing before surgery is performed to patient should open the mouth widely, the gauze should be removed,
determine the severity of the disorder. It is usually advisable to and the area should be inspected carefully for any persistent oozing.
enlist the aid of a physician if the patient has a hereditary coagulation Initial control should have been achieved by then. New gauze is
disorder. then dampened, folded, and placed into position, and the patient
e status of therapeutic anticoagulation is measured by using is instructed to leave it in place for an additional 30 minutes.
the international normalized ratio (INR). is value takes into If bleeding persists but careful inspection of the socket reveals
account the patient’s prothrombin time and the standardized control. that it is not of an arterial origin, the surgeon should take additional
Normal anticoagulated status for most medical indications has an measures to achieve hemostasis. Several di erent materials can be
INR of 2.0 to 3.0. It is reasonable to perform extractions on placed in the socket to help gain hemostasis (Fig. 11.16). e
patients who have an INR of 2.5 or less without reducing the most commonly used and the least expensive is the absorbable
anticoagulant dose. With special precautions, it is reasonably safe gelatin sponge (e.g., Gelfoam). is material is placed in the
to do minor amounts of surgery in patients with an INR of up extraction socket and is held in place with a gure-of-eight suture
to 3.0 if special local hemostatic measures are taken. If the INR placed over the socket. e absorbable gelatin sponge forms a
is higher than 3.0, the patient’s physician should be contacted to sca old for the formation of a blood clot, and the suture helps
determine whether the physician would lower the anticoagulant maintain the sponge in position during the coagulation process.
dosage to allow the INR to fall. A gauze pack is then placed over the top of the socket and is held
Primary control of bleeding during routine surgery depends with pressure.
on gaining control of all factors that may prolong bleeding. Surgery A second material that can be used to control bleeding is oxidized
should be as atraumatic as possible, with clean incisions and gentle regenerated cellulose (e.g., Surgicel). This material promotes
management of soft tissue. Care should be taken not to crush soft coagulation better than the absorbable gelatin sponge because it
tissue because crushed tissue tends to ooze for longer periods. can be packed into the socket under pressure. e gelatin sponge
Sharp bony spicules should be smoothed or removed. Granulation becomes friable when wet and cannot be packed into a bleeding
tissue should be curetted from the periapical region of the socket socket. When the cellulose is packed into the socket, it almost
and from around the necks of adjacent teeth and soft tissue aps; always causes some delayed healing of the socket. erefore packing
however, this should be deferred when anatomic restrictions such the socket with cellulose is reserved for more persistent
as the sinus or inferior alveolar canal are nearby (Fig. 11.15). e bleeding.
wound should be carefully inspected for the presence of any speci c If the surgeon has special concerns about the coagulability of
bleeding arteries. If such arteries exist in soft tissue, they should the patient’s blood, a liquid preparation of topical thrombin
be controlled with direct pressure or, if pressure fails, by clamping (prepared from human recombinant thrombin) can be saturated
the artery with a hemostat and ligating it with a nonresorbable onto a gelatin sponge and inserted into the tooth socket. e
suture. thrombin bypasses steps in the coagulation cascade and helps
e surgeon should also check for bleeding from the bone. convert brinogen to brin enzymatically, which forms a clot.
Occasionally a small, isolated vessel bleeds from a bony foramen. e sponge with the topical thrombin is secured in place with a
If this occurs, the foramen can be crushed with the closed end of gure-of-eight suture. A gauze pack is placed over the extraction
a hemostat, occluding the bleeding vessel. Once these measures site in the usual fashion.
have been accomplished, the bleeding socket is covered with a A nal material that can be used to help control a bleeding
damp gauze sponge that has been folded to t directly into the socket is collagen. Collagen promotes platelet aggregation and
area from which the tooth was extracted. e patient bites down thus helps accelerate blood coagulation. Collagen is currently
rmly on this gauze for at least 30 minutes. e surgeon should available in several di erent forms. Micro bular collagen (e.g.,
not dismiss the patient from the o ce until hemostasis has been Avitene Davol) is available as a bular material that is loose and
achieved. is requires that the surgeon check the patient’s extraction u y but can be packed into a tooth socket and held in by suturing
and use of gauze packs and other materials. A more highly cross-
linked collagen is supplied as a plug (e.g., Collaplug) or as a tape
(e.g., Collatape). ese materials are more readily packed into a
socket (Fig. 11.17) and are easier to use, but they are expensive.
Even after primary hemostasis has been achieved, patients
occasionally call the dentist with bleeding from the extraction site,
referred to as secondary bleeding. e patient should be told to
rinse the mouth gently with chilled water and then to place
appropriate-sized damp gauze over the area and bite rmly on it.
e patient should sit quietly for 30 minutes, continuing to bite
rmly on the gauze. If the bleeding persists, the patient should
repeat the cold rinse and bite down on a damp tea bag. e tannin
in the tea frequently helps stop the bleeding. Alert the patient that
herbal teas do not contain tannin and will not be e ective. If
neither of these techniques is successful, the patient should return
to the dentist.
e surgeon must have an orderly, planned regimen to control
Fig. 11.15 Granuloma of second premolar. The surgeon should not this secondary bleeding. Ideally, a trained dental assistant will be
curette periapically around this second premolar to remove granuloma present to help with treatment. e patient should be positioned
because the risk for sinus perforation is high. in the dental chair and all blood, saliva, and uids should be
 CHAPTER 11 Postextraction Patient Management 201

Fig. 11.16 Examples of materials used to help control bleeding from an extraction socket. Surgicel (left)
is oxidized regenerated cellulose and comes in a silky fabric-like form, whereas Gelfoam (right) is absorb-
able gelatin that comes as latticework that is easily crushed with pressure. Both promote coagulation.

suctioned from the mouth. Such patients frequently have large patient should be given speci c instructions on how to apply the
“liver clots” (clotted blood that resembles fresh liver), which must gauze packs directly to the bleeding site should additional bleeding
be removed from the mouth. e surgeon should observe the occur. Before the patient with secondary bleeding is discharged
bleeding site carefully under e ective lighting to determine the from the o ce, the surgeon should monitor the patient for at least
precise source of the bleeding. If it is clearly seen to be a generalized 30 minutes to ensure that adequate hemostasis has been achieved.
oozing, the bleeding site is covered with a folded, damp gauze If hemostasis is not achieved by any of the local measures just
sponge held in place with rm pressure by the surgeon’s nger for discussed, the surgeon should consider performing additional
at least 5 minutes. laboratory screening tests to determine whether the patient has a
is measure is su cient to control most bleeding. e reason profound hemostatic defect. In such a case the surgeon usually
for the bleeding is usually some secondary trauma that is potentiated requests a consultation from a hematologist, who will order typical
when the patient continues to suck on the area or spits out the screening tests. Abnormal test results will prompt the hematologist
blood instead of continuing to apply pressure with a gauze sponge. to investigate the patient’s hemostatic system further.
If 5 minutes of this treatment does not control the bleeding, A nal hemostatic complication relates to intraoperative and
the surgeon must administer a local anesthetic so that the socket postoperative bleeding into adjacent soft tissues. Blood that escapes
can be treated more aggressively. Block techniques are to be encour- into tissue spaces, especially subcutaneous tissue spaces, appears
aged instead of local in ltration techniques. In ltration with as bruising of overlying soft tissue 2 to 5 days after the surgery.
solutions containing epinephrine causes vasoconstriction and may is bruising is termed ecchymosis and is discussed earlier in this
control the bleeding temporarily. However, when the e ects of chapter.
the epinephrine dissipate, rebound hemorrhage with recurrent
bothersome bleeding may occur.
Once regional local anesthesia has been achieved, the surgeon Delayed Healing and Infection
should gently curette out the tooth extraction socket and suction Wound Dehiscence
all areas of the old blood clot. e speci c area of bleeding should
be identi ed as clearly as possible. As with primary bleeding, soft Another problem of delayed healing is wound dehiscence (separation
tissue should be checked for di use oozing versus speci c arterial of the wound edges; Box 11.11). If a soft tissue ap is replaced
bleeding. Bone tissue should be checked for small nutrient artery and sutured without an adequate bony foundation, the unsupported
bleeding or general oozing. e same measures described for control soft tissue ap often sags and separates along the line of incision.
of primary bleeding should be applied. e surgeon must then A second cause of dehiscence is suturing the wound under tension.
decide whether a hemostatic agent should be inserted into the is occurs when the surgeon tries to aggressively pull the edges
bony socket. e use of an absorbable gelatin sponge with topical of a wound together with sutures. e closure is under tension if
thrombin held in position with a gure-of-eight stitch and reinforced the suture is the only force keeping the edges approximated. If
with application of rm pressure from a small damp gauze pack the edges spring apart when the suture is removed just after being
is standard for local control of secondary bleeding. is technique placed, the wound closure is under tension. If the soft tissue ap
works well in almost every bleeding socket. In many situations, is sutured under tension, the sutures cause ischemia of the ap
an absorbable gelatin sponge and gauze pressure are adequate. e margin with subsequent tissue necrosis, which allows the suture
202 PA RT I I Principles of Exodontia

A B

C D
Fig. 11.17 (A) Bicon resorbable collagen plug. (B) Collagen being placed into extraction socket. (C)
Collagen in extraction socket. (D) Suture used to help retain collagen plug. (B–D, Courtesy Dr. Edward
Ellis III, University of Texas Health Science Center, San Antonio.)

BOX 11.11 Prevention of Wound Dehiscence e two major treatment options are (1) to leave the projection
alone or (2) to smooth it with bone le. If the area is left to heal
untreated, the exposed bone will slough o in 2 to 4 weeks. If the
sharp bone does not cause much irritation, this is the preferred
method. If a bone le is used, no ap should be elevated because
this will result in an increased amount of exposed bone. e le
is used only to smooth o the sharp projections of bone. is
procedure usually requires local anesthesia.

to pull through the ap margin and results in wound dehiscence.

erefore sutures should always be placed in tissue without tension
Dry Socket
and tied loosely enough to prevent blanching of the tissue. Dry socket or alveolar osteitis is delayed healing but is not associated
A common area of exposed bone after tooth extraction is the with an infection. is postoperative complication causes signi cant
internal oblique ridge. After extraction of the rst and second pain but is without the usual signs and symptoms of infection,
molars, during initial healing, the lingual ap becomes stretched such as fever, swelling, and erythema. e term dry socket describes
over the internal oblique (mylohyoid) ridge. Occasionally bone the appearance of the tooth extraction socket when the pain begins.
perforates through the thin mucosa, causing a sharp projection of In the usual clinical course, pain develops on the third or fourth
bone in the area. day after removal of the tooth. Almost all dry sockets occur after
 CHAPTER 11 Postextraction Patient Management 203

the removal of lower molars. On examination, the tooth socket medication contains the following principal ingredients: eugenol,
appears to be empty, with a partially or completely lost blood clot, which obtunds the pain from the bone tissue; a topical anesthetic
and some bony surfaces of the socket are exposed. e exposed such as benzocaine; and a carrying vehicle such as balsam of
bone is sensitive and is the source of the pain. e dull, aching Peru. e medication can be made by the surgeon’s pharmacist
pain is moderate to severe, usually throbbing in nature and fre- or can be obtained as a commercial preparation from a dental
quently radiating to the patient’s ear. e area of the socket has a supply house.
bad odor, and the patient frequently complains of a foul taste. e medicated gauze is gently inserted into the socket, and the
e cause of alveolar osteitis is not fully clear, but it appears patient usually experiences profound relief from pain within 5
to result from high levels of brinolytic activity in and around the minutes. e dressing is changed every other day for the next 3
tooth extraction socket. is brinolytic activity results in lysis of to 5 days, depending on the severity of pain. e socket is gently
the blood clot and subsequent exposure of bone. e brinolytic irrigated with saline at each dressing change. Once the patient’s
activity may result from subclinical infections, in ammation of pain has decreased, the dressing should not be replaced because
the marrow space of the bone, or other factors. e occurrence of it acts as a foreign body and further prolongs wound healing.
a dry socket after a routine tooth extraction is rare (2% of extrac-
tions), but it is frequent after the removal of impacted mandibular Infection
third molars and other lower molars (20% of extractions in some
series). e most common cause of delayed wound healing is infection.
Prevention of the dry socket syndrome requires that the surgeon Infections are a rare complication after routine dental extraction
minimize trauma and bacterial contamination in the area of surgery. and are primarily seen after oral surgery that involves the re ection
e surgeon should perform atraumatic surgery with clean incisions of soft tissue aps and bone removal. e most important measure
and soft tissue re ection. After the surgical procedure, the wound to prevent infection following routine extractions is for the surgeon
should be irrigated thoroughly with large quantities of saline to adhere carefully to the basic principles of surgery. ese principles
delivered under pressure, as from a plastic syringe. Small amounts are to minimize tissue damage, remove sources of infection, and
of antibiotics (e.g., a tetracycline) placed in the socket alone or cleanse the wound. No other special measures need be taken with
on a gelatin sponge have been shown to substantially decrease the the average patient. Careful asepsis and thorough wound debride-
incidence of dry socket in mandibular third molars and other ment after surgery can best prevent infection after surgical ap
lower molar sockets. procedures. is means that the area of bone removal under the
e treatment of alveolar osteitis is dictated by the single ap must be copiously irrigated with saline under pressure and
therapeutic goal of relieving the patient’s pain during the period that all visible foreign debris must be removed with a curette.
of healing. If the patient receives no treatment, no sequela other Some patients, especially those with depressed immune host-
than continued pain will exist (treatment does not hasten healing). defense responses, may require antibiotics to prevent infection.
Treatment is straightforward and consists of irrigation and the Antibiotics in these patients should be administered before the
insertion of a medicated dressing. First, the tooth socket is gently surgical procedure is begun (see Chapter 16). Additional antibiotics
irrigated with sterile saline. e socket should not be curetted after the surgery are usually not necessary for routine extractions
down to bare bone because this increases the amount of exposed in healthy patients.
bone and pain. Usually the entire blood clot is not lysed, and Infections after routine extractions exhibit the typical signs of
the part that is intact should be retained. e socket is gently a fever, increased swelling, reddening of skin, a foul taste in the
suctioned of all excess saline, and a small strip of iodoform gauze mouth, or worsening pain 3 to 4 days after surgery. Infected oral
soaked in or coated with the medication is inserted into the socket wounds look in amed, and some purulence is usually present.
with a small tag of gauze left trailing out of the wound. e e management of such infections is discussed in Chapter 16.