-Nupur Parik Intern 2012-13

The possible complications of extractions are many and varied, and may occur even if utmost care is exercised. These are, however, avoidable through proper precautions and careful pre-operative assessment.

The possible complications that may arise following extractions are listed in the following slides..

Following an extraction, the patient should be prescribed appropriate analgesic medication to control post-op pain. Pain which varies in degree, character & duration may complicate the healing process and may be due to various reasons.

Failure to handle soft tissues carefully may cause an oedematous swelling, soreness & delayed healing. Use of blunt instruments, Excessive retraction of badly designed flaps, If sutures are tied too tightly, post-op swelling may occur due to oedema and hematoma formation which may cause breakdown of the suture line.

Treatment: Usually such conditions regress if the patient uses warm saline mouth-wash frequently for 2-3 days.

Post-op pain and swelling may result due to wound infection as well.
IF FLUCTUATION PRESENT: The pus should be drained prior to the institution of antibiotic therapy. SEVERE INFECTION: Antibiotic therapy must be started promptly.

MILD INFECTION: Frequent hot saline mouth-baths are indicated, and the patient is cautioned against application of heat extra-orally.

Post-op pain may even be caused by avoidable trauma during extractions such as clumsy instrumentation which may bruise bone, or bone may be damaged by overheated burs during bone removal. Smoothing of sharp bony edges and socket toilet eliminate this post-op pain.

The condition is characterized by an acutely painful tooth socket containing bare bone and broken down blood clot. It is usually regarded as a localized osteitis involving either the whole or a part of the lamina dura.

INCIDENCE: It is said to complicate 3% of all dental extractions, and around 14-37% of lower 3rd molar extractions. Incidence is significantly higher after removal of a single tooth as compared to multiple extractions. Mandibular teeth are more frequently affected than maxillary teeth.

Pregnant women and those on oral contraceptives appear to be more susceptible to dry socket.

Etiology: The exact etiology of dry socket is unknown , however its found to occur more frequently in wounds which display poor filling with blood clot in the immediate post-op period. Vasoconstrictors in the LA solution may contribute to the formation of a dry socket by interfering with blood supply.

Some studies suggest that the spirochete Treponema denticolum may have an etiological role in the formation of a dry socket.

Aim of treatment: pain relief + speeding of resolution. The socket should be irrigated with warm normal saline and all degenerating blood clot removed. Sharp bony spurs should be removed with a bone rongeur.

A loose dressing composed of zinc oxide eugenol on a cotton swab is tucked into the socket, but not packed tightly as it may become difficult to remove later. Analgesic tablets and hot saline mouthwashes are prescribed, and the patient is recalled in 3 days.

Metronidazole tablets in the dosage of 400mg t.d.s. for 5 days have been shown to provide prompt relief from pain following the occurrence of dry socket.

Following extraction, the patient should be instructed to avoid very hot food or drinks for the rest of the day to avoid post-op hemorrhage. If bleeding occurs, the patient should be instructed to rinse the mouth with warm saline immediately before going to bed on the day of the extraction.

Healing is aided by use of hot saline mouthwashes frequently for the following 2-3 days. A firm gauze pack should be placed upon the site of hemorrhage and the patient should be instructed to bite on it. When the hemorrhage is coming from the gingiva surrounding the tooth socket, interrupted horizontal mattress sutures are indicated to control the bleeding.

In the rare case that the bleeding is from the bone, hemorrhage can be stopped by crushing the bony channel containing the involved vessel by applying pressure using a blunt instrument.

If these measures fail to control the hemorrhage, gelatin or fibrin foam may be tucked into the wound under the sutures. The patient should be referred to the nearest hospital for further treatment.

It is the inability to open the mouth which may be caused by several reasons including post-op oedema, hematoma formation or soft tissue inflammation following a dental extraction.

Management: Application of intra-oral heat by means of short wave diathermy, Use of hot saline mouth-wash, Patients may require administration of antibiotics to relieve symptoms.

Osteomyelitis may be defined as the inflammation of the bone and its marrow contents. It may be difficult to distinguish between a patient suffering from dry socket and acute osteomyelitis of the mandible. The latter condition causes much more general prostration and toxicity.

Traumatic extraction of a lower molar under LA in the presence of acute gingival inflammation predisposes to acute osteomyelitis of the mandible.

Clinical Features: Marked pyrexia, severe pain; Often the mandible is exquisitely tender on extra-oral palpation; Onset of impairment of labial sensation some hours or even days after the extraction may be seen. This condition should be regarded as an emergency and the patient should be referred to a hospital for the appropriate treatment immediately.

Prolonged oral surgical procedures and extractions when the lower jaw isnt supported throughout the procedure might result in complete or partial dislocation of the TMJ. It may even occur due to injudicious use of mouth gags.

Management: the dislocation must be immediately reduced. The operator stands in front of the patient and places his thumbs intra-orally on external oblique ridges in the mandibular molar regions and his fingers extra-orally under lower border of mandible.

Downward pressure with the thumbs and upward pressure with the fingers reduce the dislocation.

Treatment should not be delayed, or else it may become impossible to reduce the dislocation except under GA. The patient should be warned not to open his mouth too widely or yawn for a few days post-operatively.

The unpleasant symptoms of labial anesthesia and paraesthesia may be of varying severity and may persist for periods lasting from a few hours to many months, depending on the damage sustained by the involved nerves.

The lingual nerve may be damaged either during a traumatic extraction of a lower molar in which lingual soft tissues are trapped in the forceps, or during removal of bone by being caught up in the bur. Techniques must be employed to reduce the risk of nerve damage during removal of roots from the edentulous mandible and during extraction of impacted lower 3rd molars.

Fractures of the body of the mandible, acute osteomyelitis of the mandible, and acute infections in tissues related to the mental nerve may cause impairment of labial sensation.

This may be sue to faulty technique or due to insufficient dosage of the local anesthetic agent. If nothing is felt by the patient post injecting the LA, anesthesia has been obtained. If he/she feels pressure but no pain, then analgesia has been obtained. If he/she still feels pain, a further injection of LA solution is indicated.

Excessive force applied during extraction of teeth may even cause mandibular fractures. The mandible may be weakened by senile osteoporosis, osteomyelitis, previous radiation therapy, or such osteodystrophies and proper history should be recorded prior to extraction.

The patient should be informed preoperatively of the possibility of a mandibular fracture and should this complication occur, treatment must be instituted at once.

Abnormally prolonged and deep breathing is a hysterical manifestation of fear and may produce altered consciousness in an overly apprehensive patient during extractions. Such a patient is said to be hyperventilating, panting and pale, and may complain of tingling in the fingers or lips. The volume, rhythm and rate of pulse are normal.

Management: The patient is asked to breathe in and out of a paper bag to increase the partial pressure of CO2 in the blood to reverse these symptoms.

Syncope is defined as a transient, selflimited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery. In most cases in a dental practice, syncopal episodes are vasovagal attacks due to a sudden fall in blood supply to the brain causing cerebral hypoxia, and spontaneous recovery is usual.

Syncope due to a vasovagal attack is usually characterized by profound bradycardia and so the presence of a weak, slow pulse is helpful in differential diagnosis.

Presyncopal symptoms reported may include the following:

Prior faintness, dizziness, or light-headedness; Prior vertigo, weakness, diaphoresis, epigastric discomfort, nausea, blurred or faded vision, pallor, or paresthesias; Red flag symptoms: Exertional onset, chest pain, dyspnea, low back pain, palpitations, severe headache, focal neurologic deficits, diplopia, ataxia, or dysarthria.

Management of vasovagal syncope: Recommended acute treatment involves returning blood to the brain by positioning the person with legs slightly elevated or leaning forward and the head between the knees for at least 1015 minutes, preferably in a cool and quiet place.

Management of syncope may also require the following: Intravenous access Oxygen administration Advanced airway techniques Glucose administration Defibrillation or temporary pacing

While treating an HIV positive patient, the operator must use an HIV kit.

Performing extractions on diabetic patients is a complicated problem, which is connected with the type of diabetes and the various complications related to this disease. The main concern is to avoid acute incidents, hyper- or hypoglycemic comas during the extraction and to secure a smooth postoperational course, namely an undisturbed healing.

Prior to performing an extraction for a diabetic patient, a physicians written consent is required allowing the dentist to perform the extraction.

The high prevalence of cardiac disease in the population, particularly ischaemic heart disease, makes it the most common medical problem encountered in dental practice. The provision of dental treatment under both local anaesthesia and sedation has an excellent safety record in such patients.

Minor Oral Surgery, Third Edition: Geoffrey L. Howe; PubMed.gov; British Dental Journal; www.google.com.