Post-Extraction Complications

What Is Tooth Extraction?

According to Howe (1961), “an ideal tooth extraction is defined as the painless removal of the whole tooth or tooth root with minimal trauma to surrounding tissues so that the wound heals uneventfully.”

What Are the Reasons for Tooth Extraction?

There are many reasons why a tooth needs to be extracted. They are as follows,

• Grossly decayed teeth.

• Root stumps.

• Periodontal problem and associated with supporting bone that is alveolar bone loss, followed by loosening of teeth.

• Fracture of teeth.

• Root caries.

• Fracture of teeth after root canal treatment.

• When root canal treatment and re-root canal treatment failure happens.

• Tooth associated with severe trauma and fracture of the bone.

• In orthodontic treatment for crowding, usually, the premolars are extracted.

What Are the Factors Influencing the Complication of Tooth Extractions?

• Tooth-Related Factors: Teeth morphology plays a major role in difficulties associated with extraction. If the teeth’ roots are long and deep, roots are curved, and if roots are together, it becomes difficult to extract. The teeth which have good bone support will be difficult to extract. The root canal-treated teeth are usually difficult to extract.

• Patient Factors: Difficulties and complications in extraction can depend on the patient's medical conditions. If the patient has diabetes or any immunocompromised diseases, the complications are more after extraction. The main complication is the delay of the healing and spread of infections in the socket. If the patient has a history of radiotherapy of the jaws, the blood supply to the teeth gets reduced and delays healing. In case the food particles are trapped in the socket after extraction, the process of healing will be delayed. The patient’s habits also affect the healing process and cause complications. Smoking also affects wound healing. It affects the blood supply to the teeth and surrounding tissues.

What Are the Complications After Extraction?

1. Pain: Pain is a common complication that occurs after tooth extraction. It usually occurs a few hours after the extraction. The pain varies from mild to moderate to severe. The patient may experience severe pain associated with any infections.

• Management of Pain: Treatment is done by prescribing analgesic drugs.

2. Bleeding: Usually, tooth extraction is followed by bleeding. The bleeding soon after a tooth extraction is normal. Manual pressure is applied on the extraction socket buccolingually to stop the bleeding gradually. The socket will have a blood clot, and this is normal. But the patients with a history of bleeding disorders like hemophilia will have more bleeding.

• Management of Bleeding: After extraction, and manual pressure in the socket, the patient is advised to wait for ten minutes to check for bleeding. If the patient has bleeding even after ten minutes, suturing can be done to control bleeding. The patient is asked to wash their mouth with cold water. If the bleeding does not stop even after the sutures, then the bleeding is from the bone and not from the socket. Now the tannic acid powder and bone wax can be added to the socket. It reduces the bleeding. Then the patient can be referred to a hospital, and fluid management can be done. IV (intravenous) Calcium Gluconate injection, Vitamin C, and K are given.

3. Swelling: Swelling is seen after extraction. It is a second common complication after extraction. It is spotted a few days after the extraction. It is due to the use of blunt forceps and elevators, tearing more areas of flaps for access, bur injury in lips and other soft tissues while bone cutting, poor surgical techniques, and tight sutures. If the patient develops a swelling the next day after the extraction, that might be due to a hematoma. This acute swelling will subside gradually.

• Management of Swelling: Swelling will be reduced with antibiotics taken for three days. It can also be reduced by cold pack application for 30 minutes. The warm saline rinse also helps in minimizing swelling. If fluctuations in the swelling are noticed, then the pus is usually present. The pus has to be evacuated using a needle. Paracetamol and antibiotics are prescribed. Antibacterial mouthwashes are also prescribed. Topical gels for oral swelling are also given for swelling control and infection control.

4. Hematoma and Ecchymosis: Hematoma is usually seen on the first postoperative day. Hematoma occurs due to over-tight suturing, patients with clotting disorders, and lack of drainage. Ecchymosis is seen after impaction on the first postoperative day.

• Management of Hematoma: Hematoma can be managed by avoiding or removing over tight sutures, antibiotics, and saline rinse. Ice pack applications for ten to fifteen minutes a day will help in reducing hematoma. The discoloration changes to normal gradually after hemoglobin breakdown in the accumulated erythrocytes.

5. Limited Mouth Opening (Trismus): Trismus is seen after the extraction of impacted teeth. It may be due to pain and hematoma formation and the discomforts due to it. It usually occurs after the anesthetic effect has ended.

• Management of Trismus: Trismus can be managed by prescribing analgesics, antibiotics, muscle relaxants, physiotherapy including exercises, and heat pack application.

6. Paraesthesia: The deep vertical incisions in the buccal surface of lower premolars during extraction or impaction may cause damage to mental nerves. The lower third molar root impaction will usually cause paraesthesia, loss of sensations in the lower lip or chin. This is because, during impaction, the roots may be in close proximity to the inferior alveolar nerve block. The improper use of elevators while removing root apices also causes paraesthesia. The lip sensation is recovered after the anesthetic effect ends. But it may again develop two days after the extraction.

• Management of Paraesthesia: Treatments for paresthesia include removal of the cause. Antibiotics, nonsteroidal anti-inflammatory drugs, corticosteroids, and vitamin B supplements are given.

7. Improper Teeth Alignment: Following the extraction of a tooth, the remaining teeth may supra erupt or undergo a mesial shift leading to the malalignment of the teeth and causing difficulties in chewing, and also certain discomforts. This misalignment can cause disturbances to adjacent sound teeth and make it necessary for dental care and treatment.

• Management of Teeth Malalignment: This can usually be prevented by replacing the missing tooth with a dental implant, bridge, or denture.

8. Injuries to Adjacent Teeth: The adjacent teeth to the extracted teeth might be loosened or fractured during the usage of elevators. The restoration in the adjacent teeth may also be dislodged.

• Management of Adjacent Tooth Injuries: Ensure proper handling and placement of dental forceps and elevators.

9. Bite Collapse: In patients with most of their posterior teeth removed or extracted, bite collapse can occur. This involves the lower jaw movement towards the upper jaw and reduction in vertical dimensions of occlusion. This will lead to chapped lips, cheek malalignment.

• Management of Bite Collapse: Replacement of teeth.

10. Delayed Healing: The medications such as Bisphosphonates can cause delayed healing. The infections and food entrapment also cause delayed healing. Spitting saliva, gargling more, chewing on the extracted side, touching the extraction socket with tongue or fingers also delays healing.

• Management of Delayed Healing: The Bisphosphonate medications are stopped under general physician supervision prior to extraction. Suturing is done to prevent delayed healing. Proper oral hygiene can prevent delayed healing. Proper nutrition is also recommended.

11. Osteoradionecrosis: Patients with a medical history of radiation therapy to jaws and head develop osteoradionecrosis after extraction. The blood supply to the teeth is damaged by the radiation exposure.

• Management of Osteoradionecrosis: Conservative bone sequestrectomy may be required. This procedure can be done by an oral surgeon and general surgeon. Surgical removal of large areas of necrotic bone may be required in consultation with an oral surgeon and general surgeon.

12. Dry Socket (osteitis): After the tooth extraction, a blood clot is usually formed in the extraction socket immediately. This blood clot is normal and good for preventing further decay and infections. This blood clot may dislodge or rupture early, leading to a condition called dry socket. It is also known as alveolar osteitis. It is commonly seen after impacted teeth extraction. It is also seen in patients with less hemoglobin levels. Patients with poor oral hygiene and diabetes are said to have an increased risk of dry sockets. It also occurs due to spitting of saliva after extraction, gargling after extraction, and using a straw. This condition causes pain. It also occurs due to consumption of alcohol, smoking, and in patients under contraceptive pills.

• Management of Dry Socket: The socket has to be irrigated with saline. The debris has to be removed. Then a dressing is given with Zinc Oxide and Iodoform, Eugenol, and Butamben gel along with Metronidazole gel for fast recovery. The Zinc Oxide paste is stuffed in a cotton roll and placed inside the socket. Depending on the area of the socket, cotton with Zinc Oxide is placed such that it covers the entire socket. Antibiotics and analgesics are prescribed. Then salt water rinse is advised.

13. Sharp Bony Irregularities: Sharp bone irregularities are seen after extraction of mandibular third molars. It is usually seen in the lingual cortical plate in the mandible. The socket near the lingual plate becomes painful, and it may perforate the adjacent mucosa also. It is seen in older patients after the total extraction of teeth.

• Management of Bone Irregularities: The bone irregularities are trimmed using a surgical bur or bone rongeur or bone file after opening the flap with vertical and horizontal incisions. If the cortical plate is not mobile but causes pain, then it has to be removed.

14. Nerve Injury: The removal of premolars and third molars usually causes injuries to nerves when compared to other dentitions. The area around the socket may feel numb temporarily or permanently. Nerve injuries are not common complications after extraction. It is noticed in very few numbers of patients.

• Management of Nerve Injury: Consult an oral surgeon for nerve injury.

15. Maxillary Sinus Exposure: The extraction of the upper molars is related to the exposure of the maxillary sinus, which will need to be repaired. It creates communication between the nose and mouth. This is called the oroantral fistula. This is a very rare complication. This occurs when the roots of the upper posterior teeth are deep inside the maxillary sinus. The patient is asked to rinse with water. If the communication is present between nose and mouth, a small quantity of water comes out from the nose.

• Management of Sinus Exposure: Proper handling of forceps and verifying the position of teeth before extraction and consulting oral surgeons.

What Are the Frequently Asked Questions After Dental Extraction?

1. What to Do if Pain Persists After Extraction?

Take the prescribed medications, including analgesics and antibiotics. Do not spit or gargle. Pain will subside gradually.

2. When to Remove the Sutures?

The sutures can be removed around 4-7 days.

3. What to Do if Swelling Appears After Extraction?

Take antibiotics prescribed for three days. Do apply cold packs extra orally. Use a soft brush. Take a soft diet.

4. What to Do if Pain Occurs in the Extraction Socket Along With Black Bone Formation?

It is a dry socket. You have to do a warm saline rinse. And dressing with Zinc Oxide cement is preferred. To prevent this, avoid spitting. Drink cold juice and cold water. Take prescribed antibiotics and analgesics.

Conclusion:

To reduce the risk of difficulties and promote a quick recovery, it is crucial to carefully adhere to your dentist's post-extraction advice. Do not hesitate to speak with your oral healthcare professional if you suffer any alarming symptoms or consequences for advice and suitable treatment.