POST-EXTRACTION PATIENT MANAGEMENT

SEQUELAE OF SURGERY: B. Pain and Discomfort

a. Pain
b. Swelling • The pain a pt may experience after a surgical procedure (e.g.,
c. Complications exo) is highly variable and to a great extent, depends on the pt’s
preop expectations
• Postop instructions should explain:
o What the pt is likely to experience PAIN AFTER ROUTINE EXO:
o Why these phenomena occur a. The pain is usually not severe and can be managed in most pts
o How to manage and control typical postop situations with over-the-counter analgesics
• Instructions should be given verbally or in written form - All pts should be given instructions concerning analgesics
o Should describe the most common complications and before they are discharged, even when the surgeon
how to identify them believes that no prescription analgesics are necessary
o Should include a telephone number at which the b. The peak pain experience occurs about 12 hours after exo and
surgeon can be reached in cases of emergencies diminishes rapidly after that
- First dose of analgesic medication should be taken before
*** CONTROL OF POSTOP SEQUELAE *** the effects of the LA subside
o May take 60-90 minutes for the analgesics to
A. Hemorrhage become fully effective
c. Significant pain from exo rarely persists longer than 2 days post-
• Right after exo for control of postop bleeding → placement of surgery
folded gauze (may be moistened) directly over the socket,
continuous and firmly for 30 minutes Analgesics for Post-exo Pain
• It is normal for a fresh extraction site to ooze slightly for up to 24 Oral Narcotic Usual Dose
hours after the extraction procedure Mild Pain
• If the bleeding is more than a slight ooze, the pt should be told Ibuprofen 400-800 mg q4h
Acetaminophen 325-500 mg q4h
how to reapply a folded piece of gauze directly over the area of
Moderate Pain
the extraction Codein 15-60 mg
o Hold this second gauze pack in place for as long as 1 Hydrocodone 5-10 mg
hour Severe Pain
• If necessary, by the pt placing a tea bag (contains tannic acid → local Oxycodone 2.5-10 mg
Tramadol 50-100 mg
vasoconstrictor) in the socket and biting on it for 30 minutes

❖ Analgesics with a lower potency per unit dose are typically sufficient → potent
AVOID THINGS THAT MAY AGGRAVATE THE BLEEDING. analgesics not required in most routine exo
a. Talking should be kept to a minimum for an hour ❖ Narcotics → drowsiness and ↑ chance of GI upset
- Avoid taking on an empty stomach
b. Pts should be encouraged to stop or limit smoking
❖ Ibuprofen → control discomfort from exo
- Tobacco smoke and nicotine interfere with wound healing - ↓ in platelet aggregation and bleeding time
c. Do not suck thick fluids through a straw when drinking → ❖ Acetaminophen → does not interfere with platelet function → useful if pt has
- Creates negative intraoral pressure platelet defect
❖ Combi drug with acetaminophen and narcotic – 500-650 mg of acetaminophen per
d. Do not spit during the first 12 hours after surgery dose
- Involves negative pressure and mechanical agitation of the
exo site → trigger fresh bleeding CODEINE NUMBERING SYSTEM:
No. 1 7.5 mg
e. Swallow saliva instead of spitting it out No. 2 15 mg
f. No strenuous exercise for the first 12-24 hours after exo No. 3 30 mg
- ↑ BP = greater bleeding No. 4 60 mg

❖ When a combination of analgesic drugs is used, the dentist must keep in mind that
→ Probable blood stain on pillowcases in the morning it is necessary to provide 500 to 1000 mg aspirin or acetaminophen every 4 hours
- Oozing and staining of saliva while asleep to achieve maximal effectiveness from the nonnarcotic
o ADULT DOSE: 2 tabs of the compound every 4 hours
→ If they are worried about bleeding, they should call to get
additional advice
C. Diet
- Prolonged oozing, bright red bleeding, large clots → return
visit
• A high-calorie, high-volume liquid or soft diet is best for the first
12 to 24 hours
• Adequate intake of fluids
o At least 2 L during the first 24 hours

ORAL SURGERY – ENDTERM (SAYSON, MAG) 1

• Food in the first 12 hours should be soft and cool F. Trismus
o Cool and cold foods help keep the local area
comfortable → less tendency to cause trauma and • Limitation in mouth opening, results from trauma and the
cause rebleeding resulting inflammation involving the muscles of mastication
• Pts who have DM should be encouraged to return to their nomal • May also result from multiple injections of the local anesthetic,
insulin and caloric intake ASAP especially if the injections have penetrated muscles (medial
pterygoid muscle)
D. Oral Hygiene • Surgical extraction of impacted Md 3rd molars usually result in
some degree of trismus because the inflammatory response to
• Pts should be advised that keeping the teeth and the whole the surgical procedure is sufficiently widespread to involve
mouth reasonably clean results in a more reliable healing of several muscles of mastication
surgical wounds
• Mouth rinses with agents like diluted hydrogen peroxide G. Ecchymosis
o Rinsing 3-4 times a day for approximately 1 week after
surgery may result in more reliable healing • Blood oozes submucosally and subcutaneously
o This appears as a bruise in the oral
ON THE DAY OF SURGERY tissues, the face, or both
• Pts may gently brush the teeth that are away from the area of surgery in the usual • Usually seen in OLDER PTS because of their
fashion decreased tissue tone, increased capillary
• Avoid brushing the teeth immediately adjacent to the exo site to prevent a new
bleeding episode and to avoid disturbing sutures and inducing more pain fragility, and weaker intercellular
FIRST POSTOP DAY
attachments
• Not dangerous and does not increase pain or infection
• Pts should begin gentle rinses with dilute salt water
• Water should be warm but not hot enough to burn tissue • Typically, the onset of ecchymosis is 2-4 days after surgery and
it usually resolves fully within 7-10 days
3RD OR 4TH DAY POST-SURGERY

• Most pts can resume preop oral hygiene measures

• Dental floss should be used in the usual fashion on teeth (A) and (P) to the exo sites *** POSTOP FOLLOW-UP ***
as soon as the pt is sufficiently comfortable doing so

• A follow-up visit at 1 week is usually adequate

E. Edema o Sutures should be removed, as needed, at the 1-week
postop appointment
• Swelling usually reaches its maximum 36-48 hours postop • Earlier visits/follow-ups if problems arise
• Pts should be informed that a moderate amount of swelling is a
normal and healthy reaction of tissue to the surgery MOST LIKELY REASONS FOR AN EARLIER VISIT:
• Swelling begins to subside on the 3rd or 4th day and is usually a. Prolonged bleeding
resolved by the end of the first week b. Pain that is not responsive to the prescribed medication
• Sleeping in a more upright position by using extra pillows will c. Suspected infection
help reduce facial edema
3RD/4TH DAY POSTOP
COLD COMPRESS
• If pt begins to develop swelling with surface redness, fever, pain, or all of
a. Help minimize the swelling and make the pt feel more these symptoms on the 3rd postop day or later, it can be assumed that
comfortable the pt has developed an INFECTION until proven otherwise
• Postsurgical pain that decreases at first but begins to ↑ on the 3rd or 4th
b. Ice should not be placed directly on the skin; preferably a layer day, although not accompanied by swelling or other signs of infection, is
of dry cloth should be placed between the ice container and the probably a symptom of DRY SOCKET
tissue to prevent superficial tissue damage
c. Should be kept on the local area for 20 minutes, and then kept
*** OPERATIVE NOTE ***
off for 20 minutes over a period of 12-24 hours

2ND POSTOP DAY Elements of an Operative Note

a. Date
• Neither ice nor heat should be applied to the face b. Pt name and identification
c. Dx of problem to be managed surgically
3RD AND SUBSEQUENT POSTOP DAYS d. Review of medical history, medications, and vital signs
e. Oral examination
• Warm compression f. Anesthesia (amount used)
• Application of heat may help to resolve the swelling more quickly g. Procedure (including description of surgery and complications)
• Heat sources such as hot water bottles and heating pads are h. Discharge instructions
recommended i. Medications prescribed and their amounts (or attach copy of prescription)
• Sleeping in a more upright position by using extra pillows will help j. Need for follow-up appointment
reduce facial edema k. Signature (legible or printed underneath)

ORAL SURGERY – ENDTERM (SAYSON, MAG) 2

 *** PREVENTION AND MANAGEMENT OF COMPLICATIONS *** • Soft tissue burns can occur if instruments freshly out of the
autoclave or dry heat sterilizer are not allowed to cool before
PREVENTION OF SURGICAL COMPLICATIONS IS ACCOMPLISHED BY: coming in contact with the pt’s skin or mucosa
1. A thorough preop assessment. • If an area of ORAL MUCOSA is abraded or burned, little
- First step is always a thorough review of the pt’s medical hx treatment is possible other than keeping the area clean with
2. Comprehensive tx plan followed by careful execution of the regular oral rinsing
surgical procedure. o Heal in 4-7 days without scarring
- Carefully evaluate training and abilities before deciding to • On SKIN, cover with an antibiotic ointment
perform a specific surgical task o Do not spread onto intact skin
- Obtaining adequate images and carefully reviewing them o May cause ulceration or rash
- Radiographs must include the entire area of surgery o Heals within 5-10 days
o Apices of the roots of the teeth o Keep the area moist with small amounts of ointment
o Anatomic structures such as the adjacent parts of during the entire healing period to prevent eschar
the maxillary sinus or the inferior alveolar canal formation and delayed healing
o Abnormal tooth morphology
o Presence of ankylosis *** PROBLEMS WITH A TOOTH BEING EXTRACTED ***

*** SOFT TISSUE INJURIES *** Prevention of Root Fracture and Displacement
a. Always consider the possibility of root fracture
Tear of a Mucosal Flap b. Use surgical extraction if high probability of fracture exists
c. Do not use strong apical force on a broken root
• MOST COMMON SOFT TISSUE INJURY DURING ORAL SURGERY
• Results from an initially inadequately-sized envelope flap that is Root Fracture
forcibly retracted beyond the ability of the tissue to stretch
• Long, curved, divergent roots that lie in dense bone are the most
Prevention of Soft Tissue Injuries likely to be fractured
a. Pay strict attention to soft tissue injuries • Use open extraction technique and remove bone to decrease the
b. Develop adequate-sized flaps amount of force necessary to remove the tooth
c. Use minimal force for retraction of soft tissue
Root Displacement
Puncture Wound
• Most commonly displaced into unfavorable anatomic spaces: Mx
• May be caused by a straight elevator or MPE → may slip and molar root into Mx sinus
puncture/tear adjacent soft tissue
• Result of using uncontrolled force IF ROOT DISPLACEMENT INTO THE MX SINUS OCCURS:
o Best prevented by use of controlled force with finger a. The surgeon must identify the size of the root lost into the sinus
rests or support from opposite hand b. Assess whether there has been any infection of the tooth or PA
o If the instrument slips from the tooth or bone, tissues
surgeon’s finger can catch the operating hand before c. Asses the preop condition of the Mx sinus
injury occurs
• If puncture wound occurs, ensuing treatment is primarily aimed • If the tooth root is infected or the pt has chronic sinusitis, the pt
at preventing infection and allowing healing to occur through should be referred to an OMF surgeon for removal of the root tip
SECONDARY INTENTION via a Caldwell-Luc or endoscopic approach
• If the wound bleeds excessively, the hemorrhage should be ↳ Into the Mx sinus in the canine fossa region followed
controlled by direct pressure applied to the wound by removal of the tooth
• Once hemostasis is achieved, the wound is usually left open • If the displaced tooth fragment is a small 2- or 3-mm root tip and
unsutured the tooth and sinus have no preexisting infection, the surgeon
o Even if a small infection were to occur, there would be should make a brief attempt at removing the root
an adequate pathway for drainage • Triangular elevators such as the Cryer elevator are usually used
to elevate broken tooth roots of mandibular molars
Abrasion or Burn
REMOVING THE ROOT:
• Usually result from the rotating shank a. A radiograph of the fractured tooth root should be taken to
of the burr rubbing on soft tissue or document its position and size
from a metal retractor coming in b. Irrigate through the small opening in the socket apex and then
contact with soft tissue suction the irrigating solution from the sinus via the socket

ORAL SURGERY – ENDTERM (SAYSON, MAG) 3

c. Surgeon should check the suction solution and confirm SWALLOWED TOOTH
radiographically that the root has been removed → Tooth will pass through the GI tract within 2-4 days
→ It may be prudent to have the pt go to an ER and have a
→ If this technique is not successful, no additional surgical radiograph of the abdomen taken to confirm that the tooth is
procedure should be performed through the socket, and the root indeed in the GI tract and not in the respiratory tract
tip should be left in the sinus
- A small, noninfected root tip can be left in place because it Extraction of the Wrong Tooth
is unlikely to cause any troublesome sequelae
• MOST COMMON CAUSE OF MALPRACTICE LAWSUITS AGAINST
MANAGEMENT OF OROANTRAL COMMUNICATION: DENTISTS
a. Figure-of-eight suture over the socket • Result of inadequate attention to preoperative assessment
b. Sinus precautions • Exo referral for orthodontic purposes
c. Antibiotics
d. Nasal spray REASONS FOR REMOVING THE WRONG TOOTH:
- Lessens chance of infection by keeping ostium open a. Dentist removes a tooth for another dentist (pt referral)
b. Use of differing tooth numbering systems
DISPLACEMENT OF MX 3RD MOLARS: c. Differences in the mounting of radiographs
→ Commonly into the infratemporal space
→ Tooth is usually lateral to the lateral pterygoid plate and inferior Prevention of Extraction of Wrong Teeth
to the lateral pterygoid muscle
a. Focus attention on the procedure
→ If tooth is not removed after single effort: b. Check with the pt and the assistant to ensure that the correct tooth
- Antibiotics should be given to help decrease the possibility is being removed
of an infection c. Check, then recheck, images and records to confirm the correct tooth
- Routine postop care should be provided
• If the wrong tooth is extracted and the surgeon realizes this error
LINGUAL CORTICAL BONE immediately, the tooth should be replaced quickly into the
→ Located over the roots of the molars tooth socket
→ Becomes thinner as it progresses posteriorly
→ Fractured Md molar roots that are being removed with apical *** INJURIES TO ADJACENT TEETH ***
pressures may be displaced through the lingual cortical plate and
into the submandibular space
• Injury is often caused by the use of a burr to remove bone or to
→ PREVENTION: avoid all apical pressures when removing Md
divide a tooth for removal
roots
Fracture or Dislodgement of an Adjacent Restoration
Tooth Lost into the Pharynx

• MOST COMMON INJURY TO ADJACENT TEETH

• Pt should be turned toward the surgeon and placed in a position
• In presence of large restorations, pt should be informed about
with the mouth facing the floor as much as possible
possibility of fracturing or displacing it during exo
o Pt encouraged to cough and spit the tooth out
o Prevention is achieved by avoiding instrumentation
• If the pt has no coughing or respiratory distress, it is most likely
and force on the restoration
that the tooth was swallowed and has traveled down the
• Teeth in the opposite arch may be injured as a result of
esophagus into the stomach
uncontrolled forces
• If the pt has a violent episode of coughing or shortness of
o Occurs when BL forces inadequately mobilize a tooth,
breath, the tooth may have been aspirated through the vocal
excessive tractional forces are used, or both
cords into the trachea and from there into a mainstem bronchus
o Tooth is suddenly released from the socket, and the
o Pt should be sent to the ER
forceps strikes the teeth of the opposite arch, chipping
o Chest and abdominal radiographs should be taken to
or fracturing a cusp
determine the specific location of the tooth
o More likely to occur with extraction of lower teeth,
especially when using cowhorn forceps
ASPIRATION
→ Removal of tooth with bronchoscope
PREVENTION:
→ Urgent management is to maintain the pt’s airway and
a. Avoid the use of excessive tractional forces
breathing
b. Tooth should be adequately luxated with apical, buccolingual,
→ Supplemental oxygen may be appropriate if signs of respiratory
and rotational forces to minimize the need for tractional forces
distress are observed
→ The surgeon or assistant should protect the teeth of the opposite
arch by holding a finger or suction tip against them

ORAL SURGERY – ENDTERM (SAYSON, MAG) 4

 Luxation of an Adjacent Tooth MANAGEMENT OF ALVEOLAR BONE FRACTURES:
a. If the bone has been completely removed from the tooth socket
• Prevented by judicious use of force with elevators and forceps along with the tooth…
• If the tooth to be extracted is crowded and has overlapping - It should not be replaced
adjacent teeth, a thin, narrow forceps such as the No. 286 - Surgeon should make sure that the soft tissue has been
forceps may be useful repositioned to the best extent possible over the remaining
• SIGNIFICANT LUXATION OR PARTIAL AVULSION OF ADJACENT bone to prevent delayed healing
TOOTH: reposition the tooth into its appropriate position and - Smooth any sharp edges that may have been caused by the
stabilize it so that adequate healing can occur fracture
• MOBILIZATION OF LUXATED TOOTH: stabilize tooth with b. If such sharp edges of bone exist…
semirigid fixation to maintain it in its position - Surgeon should reflect a small amount of soft tissue and use
o A silk suture that crosses the occlusal table and is a bone file to round off the sharp edges or use a rongeur to
sutured to the adjacent gingiva is usually sufficient remove the sharp edges
o AVOID rigid fixation → external root resorption and
ankylosis FRACTURE OF THE BUCCAL CORTICAL PLATE
→ Bone remains attached to the periosteum and usually heals if it
*** INJURIES TO OSSEOUS STRUCTURES *** can be separated from the tooth and is left attached to the
overlying soft tissue
→ Surgeon must carefully dissect the bone with its attached
Fracture of the Alveolar Process
associated soft tissue away from the tooth
- Tooth must be stabilized with forceps and a small sharp
• The most likely cause of fracture of the alveolar process is the
instrument (i.e., No. 9 MPE) to elevate the buccal bone
use of excessive force with the forceps, which fractures the
from the tooth root
cortical plate
→ Tooth is removed and the bone and the soft tissue flap are
• If excessive force is necessary to remove a tooth, a soft tissue
reapproximated and secured with sutures
flap should be elevated and controlled amounts of bone should
be removed so that the tooth can be delivered or, in the case of
Fracture of the Maxillary Tuberosity
multirooted teeth, the tooth should be sectioned
• Age is a factor to be considered because the bones of older or
• Commonly result from exo of an erupted Mx 3rd molar or from
larger patients are likely to be less elastic → prone to fracture
exo of the 2nd molar
• The Mx tuberosity is important for the construction of a stable
COMMON PLACES FOR BONE FRACTURES:
retentive Mx denture
a. Buccal cortical plate over the Mx canine
b. Buccal cortical plate over the Mx molars (1st molar)
MANAGEMENT:
c. Portions of the floor of the Mx sinus that are associated with Mx
→ The surgeon, using finger support for the alveolar process during
molars
the fracture (if the bone remains attached to the periosteum),
d. Mx tuberosity
should take measures to ensure the survival of the fractured
e. Labial bone over Md incisors
bone

Prevention of Fracture of Alveolar Process IF TUBEROSITY IS MOBILE AND CANNOT BE DISSECTED:

a. Conduct thorough preop clinical and radiographic examinations a. Splint the tooth being extracted to adjacent teeth and defer the
b. Do not use excessive force extraction by 6 to 8 weeks, allowing time for bone to heal
c. Use surgical extraction technique to reduce the force required
- Tooth is extracted with an open surgical technique
b. Section the crown of the tooth from the roots and allow the
THE SURGEON SHOULD… tuberosity and tooth root section to heal
a. Inspect the root form of the tooth to be removed and assess the - After 6 to 8 weeks, tooth roots can be removed in usual
proximity of the roots to the Mx sinus fashion
b. Consider the thickness of the buccal cortical plate overlying the
tooth to be extracted IF TUBEROSITY IS COMPLETELY SEPARATED FROM SOFT TISSUE:
c. Take special measures to prevent fracturing excessive portions a. Smooth the sharp edges of remaining bone
of bone if the roots diverge widely, if they lie close to the sinus, b. Reposition and suture the remaining soft tissue
or if the patient has a heavy buccal cortical bone
MAJOR THERAPEUTIC GOAL OF MANAGEMENT:
• When the Mx molar lies close to the Mx sinus, surgical exposure → To maintain the fractured bone in place and provide the best
of the tooth, with sectioning of the tooth roots into two or three possible environment for healing
portions, usually prevents the removal of a portion of the Mx
sinus floor
o Helps prevent formation of oroantral fistula

ORAL SURGERY – ENDTERM (SAYSON, MAG) 5

 Fracture of the Mandible Injury to the TMJ

• Associated with the surgical removal of impacted 3rd molars Prevention of Injury to the TMJ
• Result of the application of a force exceeding that needed to a. Support the mandible during exo
remove a tooth b. Do not force the mouth to open widely
• Often occurs during the forceful use of dental elevators
• May occur during removal of impacted teeth from a severely • If the jaw is inadequately supported during removal of Md molar
atrophic mandible teeth, the pt may experience pain in this region
• Fracture must be adequately reduced and stabilized • The use of a bite block on the contralateral side may provide an
adequate balance of forces so that injury does not occur
*** INJURIES TO ADJACENT STRUCTURES *** • The surgeon or assistant should also support the jaw by holding
the lower border of the mandible
Injury to the Regional Nerves
TMJ PAIN AFTER EXO:
Prevention of Nerve Injury a. Use of heat
b. Resting the jaw
a. Be aware of the nerve anatomy in the surgical area
b. Avoid making incisions or stretching the periosteum in the nerve area c. Soft diet
d. 600-800 mg ibuprofen q4h
e. 500-1000 mg acetaminophen (for pts who cannot tolerate
Branches of the 5th Cranial Nerve
NSAIDs)
→ Most likely to be injured during exo
- Mental, lingual, buccal, nasopalatine nerves
→ Provide innervation to the mucosa and skin *** OROANTRAL COMMUNICATIONS ***

BUCCAL AND NASOPALATINE NERVES • Communication between the oral cavity and the Mx sinus
→ Frequently sectioned during the creation of flaps for the removal
of impacted teeth IF…
→ Reinnervation occurs rapidly a. Mx sinus is greatly pneumatized
→ Can be surgically sectioned without long-lasting sequelae or b. Little or no bone exists between the roots of the teeth and the
much bother to the patient Mx sinus
c. Roots of the tooth are widely divergent
MENTAL NERVE
→ Surgical removal of Md premolar roots or impacted Md → It is common for a portion of the bony floor of the sinus to be
premolars, or periapical surgery in the area of mental nerve and REMOVED with the tooth or a communication to be created
foramen even if no bone comes out with the tooth
→ Pt will experience paresthesia or anesthesia of the lip and chin
- If result of flam reflection or manipulation, normal SEQUALAE ↑:
sensation usually returns in a few days to a few weeks a. Postop Mx sinusitis
→ If the mental nerve is sectioned at its exit from the mental b. Formation of a chronic oroantral fistula
foramen or torn along its course, it is likely that mental nerve
function will not return, and the pt will have a permanent state → Depends on the size of the oroantral communication and the
of anesthesia management of the sinus exposure
→ If a three-corner flap is to be used in the area of the mental
nerve, the vertical releasing incision must be placed far enough Prevention of Oroantral Communications
anteriorly to avoid severing any portion of the mental nerve a. Conduct a thorough preop radiographic examination
- It is advisable to make the vertical releasing incision at the b. Use surgical extraction early, and section roots
interdental papilla between the canine and the first c. Avoid excessive apical pressure on Mx posterior teeth
premolar
DX OF OROANTRAL COMMUNCATION:
LINGUAL NERVE a. Examine the tooth once it has been removed
→ Located directly against the lingual aspect of the mandible in the - If a section of bone is adherent to the root ends → assume
retromolar pad region that a communication between the sinus and mouth exists
→ Rarely regenerates if it is severely traumatized - If little to no bone adheres → a communication might exist
→ IMPACTED 3RD MOLARS: buccal aspect only anyway
- Some use the nose-blowing test to confirm
INFERIOR ALVEOLAR NERVE o If a communication exists, there will be passage of
→ Most common place of injury is the area of the Md 3rd molar air through the tooth socket and bubbling of
- May bruise, crush, or sharply injure the nerve in canal blood in the socket area

ORAL SURGERY – ENDTERM (SAYSON, MAG) 6

 o If there is no communication, forceful blowing like *** POSTOP BLEEDING ***
this poses the risk of creating a communication
b. Guess the approximate size of the communication because the REASONS FOR SERIOUS RISK OF EXO:
treatment depends on the size of the opening a. Tissues of the mouth and jaws are highly vascular
- Probing a small opening may enlarge it b. Extraction of a tooth leaves an open wound, with soft tissue and
- If NO BONE comes out with the tooth → the communication bone remaining open
is likely to be 2 mm or less in diameter - Allows additional oozing and bleeding
- If SIZABLE PIECE OF BONE comes out with tooth → the c. It is almost impossible to apply dressing material with enough
opening is of a considerable size pressure and sealing to prevent additional bleeding during
surgery
If the communication is SMALL (≤ 2 mm) … d. Pts tend to explore the area of surgery with their tongues and
→ No additional surgical tx is necessary occasionally dislodge blood clots
- Initiates secondary bleeding, or the tongue may cause
SINUS PRECAUTIONS, AVOID: secondary bleeding by creating small negative pressures
a. Blowing the nose that suction the blood clot from the socket
b. Sneezing violently e. Salivary enzymes may lyse the blood clot before it has organized
c. Sucking on straws and before the ingrowth of granulation tissue
d. Smoking

Prevention of Postoperative Bleeding

BUCCAL FLAP
a. Obtain a hx of bleeding
→ Most commonly used flap for small openings
b. Use the atraumatic surgical technique
→ Mobilizes buccal soft tissue to cover the opening and provide for c. Obtain good hemostasis at surgery
a primary closure d. Provide excellent pt instructions

If the communication is MODERATE (2-6 mm) … ASK THE PT…

MAINTENANCE OF BLOOD CLOT a. Family hx of bleeding
a. Figure-of-eight suture b. Medications currently being taken that might interfere with
b. Clot-promoting substances such as coagulation
gelatin sponge before suturing - Anticoagulants
c. Pt should follow sinus precautions - Chemotherapy, aspirin
d. Pt should be prescribed medications to reduce risk of Mx - Alcoholism
sinusitis - Severe liver disease
i. Antibiotics – amoxicillin, cephalexin, clindamycin – for 5
days
INR
ii. Decongestant nasal spray → to shrink the nasal mucosa
• Normal: 2.0 to 3.0
• If INR is > 3.0, pt's physician should be
If the communication is LARGE (≥ 7 mm) … contacted to determine whether to lower the
→ Repair sinus communication with flap procedure anticoagulant dosage to allow the INR to fall
→ Refer to OMF surgeon

MANAGEMENT OF PTS WITH OROANTRAL COMMUNICATION • Occasionally a small, isolated vessel bleeds from a bony foramen
a. Pts should be monitored for several weeks to ensure that healing o If this occurs, the foramen can be crushed with the
has occurred closed end of a hemostat, occluding the bleeding
b. If communication persists for > 2 weeks, refer to OMF surgeon vessel
c. USUAL COMPLAINT: leakage of fluids from the mouth into the o Bleeding socket is covered with a damp gauze sponge
nose that has been folded to fit directly into the area from
which the tooth was extracted
→ Closure is important because air, water, food, and bacteria go o The pt bites down firmly on this gauze for at least 30
into the sinus, causing chronic sinusitis minutes
→ For pts with full Mx denture, suction seal is broken and o Surgeon should not dismiss the pt until hemostasis has
retention is compromised been achieved

MATERIALS TO HELP GAIN HEMOSTASIS:

a. Absorbable gelatin sponge → Gelfoam
- MOST COMMONLY USED; least expensive
- Held in place with a figure-of-eight suture
- Gauze pack is placed on top of the socket and is held with
pressure

ORAL SURGERY – ENDTERM (SAYSON, MAG) 7

b. Oxidized regenerated cellulose → Surgicel → Bone tissue should be checked for SMALL NUTRIENT ARTERY
- Promotes coagulation better than gelfoam → can be packed BLEEDING or GENERAL OOZING
INTO the socket under pressure
- Reserved for more persistent bleeding; almost always CONTROL OF SECONDARY BLEEDING:
causes delayed healing → Use of an absorbable gelatin sponge with topical thrombin held
in position with a figure-of-eight stitch and reinforced with
c. Topical thrombin application of firm pressure from a small damp gauze pack
- Liquid preparation from human recombinant thrombin
- Saturated on gel sponge → If hemostasis is not achieved at this point, the surgeon should
- Helps convert fibrinogen to fibrin enzymatically → forms a consider performing additional laboratory screening tests to
clot determine whether the pt has a profound hemostatic defect
- Secured with figure-of-eight suture
FINAL HEMOSTATIC COMPLICATION:
d. Collagen → Intra operative and postoperative bleeding into adjacent soft
- Promotes platelet aggregation tissues
- Blood that escapes into tissue spaces, especially
i. Microfibular collagen (e.g., subcutaneous tissue spaces, appears as bruising
Avitene Davol) – available (ecchymosis)of overlying soft tissue 2 to 5 days after the
as a fibular material that is surgery
loose and fluffy but can be
packed into a tooth socket *** DELAYED HEALING AND INFECTION ***
ii. Plug (e.g., Collaplug) –
more highly cross-linked collagen Would Dehiscence
iii. Tape (e.g., Collatape)
• Separation of the wound edges
Secondary Bleeding
• COMMON AREA OF EXPOSED BONE: internal oblique ridge
→ Bleeding from exo site after primary hemostasis has been
achieved
CAUSES:
→ Pts often have large liver clots (clotted blood that resembles
a. If soft tissue flap is replaced and sutured without an adequate
fresh liver) that must be removed
bony foundation
b. Suturing the wound under tension
CAUSE:
- Suture is the only force keeping the edges approximated
→ Secondary that is potentiated when the patient continues to
- Edges spring apart when the suture is removed just after
suck on the area or spits out the blood instead of continuing to
being placed
apply pressure with a gauze sponge
- Sutures cause ischemia of the flap margin → tissue necrosis
→ wound dehiscence
MANAGEMENT:
a. Rinse the mouth gently with chilled water
MAJOR TX OPTIONS:
b. Place appropriate-sized damp gauze over the area and bite firmly
a. Leave the projection alone
on it
- Exposed bone will slough off in 2-4 weeks
c. Pt should sit quietly for 30 minutes, continuing to bite on the
b. Smooth it with bone file
gauze
- No flap should be elevated → increased amount of exposed
d. If bleeding persists, repeat the cold rinse and bite down on a
bone
damp tea bag
- Requires LA
- Herbal teas DO NOT contain tannin

If ineffective… Prevention of Wound Dehiscence

→ Surgeon must administer LA so that socket can be treated more a. Use aseptic technique
b. Perform atraumatic surgery
aggressively c. Close the incision over intact bone
→ Block techniques > LI d. Suture without tension
- Infiltration only controls the bleeding temporarily; when
effects of the epi dissipate, rebound hemorrhage may occu Dry Socket
→ Once LA is achieved, curette out the tooth extraction socket and
suction all areas of the old blood clot
• “Alveolar osteitis”
• Delayed healing but is NOT associated with infection
IN PRIMARY BLEEDING…
• Causes significant pain, but with no signs and symptoms of
→ Soft tissue should be checked for DIFFUSE OOZING versus
infection
specific arterial bleeding
ORAL SURGERY – ENDTERM (SAYSON, MAG) 8
• Pain develops on the 3rd or 4th day after exo BASIC PRINCIPLES OF SURGERY:
• Usually in removal of Md 3rd molars a. Minimize tissue damage
• Tooth socket appears to be empty, with a partially or completely b. Remove sources of infection
lost blood clot, and some bony surfaces of the socket are c. Cleanse the wound
exposed
o BONE is sensitive and is the source of the pain PREVENTED WITH:
o Dull, aching pain is moderate to severe, usually a. Careful asepsis
throbbing and radiates to the ear - Area of bone removal under the flap must be copiously
o Area has bad odor, and pt complains of a foul taste irrigated with saline under pressure
b. Thorough wound debridement
CAUSE OF AO: - All visible foreign debris must be removed with a curette
→ Result from high levels of fibrinolytic activity in and around the
tooth extraction socket SIGNS OF INFECTION:
- Results in lysis of the blood clot and subsequent exposure a. Fever
of bone b. Increased swelling
- May result from subclinical infections, inflammation of the - Purulence is usually present
marrow space of the bone, or other factors c. Reddening of skin
d. Foul taste in mouth
OCCURRENCE: e. Worsening pain 3-4 days after surgery
→ ROUTINE EXO: rare (2%)
→ IMPACTED MD 3RD MOLARS & OTHER MOLARS: frequent (20%)

PREVENTION, MINIMIZE:
a. Minimize trauma
- Atraumatic surgery with clean incisions and soft tissue
reflection
b. Bacterial contamination in the area
- Thorough irrigation of wound with saline under pressure
- Antibiotics (e.g., tetracycline) placed in the socket or on a
gel sponge

TX:
→ Relieving the pt’s pain during the period of healing

a. Irrigation
- With sterile saline
- Socket should not be curetted down to bare bone because
this increases the amount of exposed bone and pain
b. Insertion of a medicated dressing
- Iodoform gauze soaked with medication inserted, with a
small tag of gauze left trailing out of the wound
- MEDICATION:
o Eugenol – obtunds the pain from bone tissue
o Topical anesthetic – benzocaine
o Carrying vehicle – balsam of Peru
- Dressing changed every other day for the next 3-5 days
- Once pain has ↓, dressing should NOT be replaced → acts
as a foreign body and prolongs wound healing

Infection

• MOST COMMON CAUSE OF DELAYED WOUND HEALING

• Primarily seen after oral surgery that involves the reflection of
soft tissue flaps and bone removal
• Pts, especially those with depressed immune host-defense
responses, may require antibiotics to prevent infection

ORAL SURGERY – ENDTERM (SAYSON, MAG) 9