CHAPTER 11: POST-EXTRACTION PATIENT MANAGEMENT

from ppt + discussions + book

control of postoperative sequelae

diet, oral hygiene

pain and discomfort

hemorrhage, edema

ecchymosis, trismus

INR ≤ 2.5

extractions usually safe

INR 2.5–3.0

minor surgery with special local measures

INR >3.0

consult physician

why bleeding is common after extraction

oral tissues are highly vascular

tongue movement may dislodge clots

salivary enzymes can break down early clots

open socket leaves bone and soft tissue exposed

difficult to apply constant pressure during surgery

best management of post-op bleeding

prevention

take thorough bleeding history

review medications and conditions

suspected coagulopathy → lab tests and physician consultation

primary intraoperative bleeding control

get to know the source of the bleeding

smooth sharp bone; curette granulation tissue

atraumatic technique and gentle tissue handling

confirm hemostasis before dismissing the patient

place damp gauze and have patient bite firmly for 30 minutes

control bleeding vessels with pressure, ligation, tea bag (tannic acid), bone wax, electrocautery, suture

local hemostatic agents

topical thrombin

oxidized cellulose (surgicel)

collagen (plugs / tape / microfibular)

absorbable gelatin sponge (gelfoam)

absorbable gelatin sponge (gelfoam)

scaffold for clot

secured with figure-ofeight suture

topical thrombin

enhances clot formation

oxidized cellulose (surgicel)

for persistent bleeding

stronger but delays healing

collagen (plugs / tape / microfibular)

promotes platelet aggregation

secondary bleeding – at home

gentle cold water rinse

bite firmly for at least 30 minutes (do not chew or talk).

slight oozing for up to 24 hours is normal.

• if bleeding continues:

  • reapply gauze for up to 1 hour.

  • bite on a tea bag (tannic acid helps clotting) for 30 minutes

• avoid:

  • talking (first hour), smoking

  • using straws, spitting (first 12 hours)

  • strenuous activity (12–24 hours)

• expect minor blood staining during sleep

• return to dentist if:

  • prolonged bright red bleeding with large clots

secondary bleeding – in clinic

suction blood & remove “liver clots”

identify bleeding source

apply damp gauze for 5 minutes

• if persistent:

  • use regional/block anesthesia, curette socket, remove old clot

  • apply local hemostatic measures

    • gelatin sponge ± thrombin

    • figure-of-eight suture

    • gauze pressure

  • monitor ≥30 minutes before discharge

• if bleeding still uncontrolled:

  • consider bleeding disorder, order lab tests

  • refer to hematologist

postextraction tooth socket care

• sharp bone:

  • palpate; and smooth sharp edges if present

• debris removal and irrigation:

  • gently remove calculus, amalgam, or tooth fragments if visible

• socket compression:

  • gently compress buccolingual plates to original position to prevent bony undercuts

• curettage:

  • perform only if a periapical lesion or debris is present; avoid routine curettage to promote healing

• hemostasis:

  • place moistened gauze directly into socket space and have patient bite down; use larger gauze if needed

pain and discomfort

• is expected and varies; usually:

  • mild to moderate

  • peaks at ~12 hours

  • rarely lasts more than 2 days

• take analgesics before anesthesia wears off

centrally acting opioid analgesics

taken every 4hours (q4h)

may take 60-90 minutes to become fully effetive

are commonly used for post-extraction pain control

are well absorbed orally but may cause drowsiness and gastrointestinal upset

• opioids are usually combined:

  • aspirin

  • acetaminophen

• goal:

  • control pain, not eliminate it completely

drug for common mild pain situations

ibuprofen 400-800mg q4h

acetaminophen 325-500mg q4h

drug for moderate pain situations

codeine 15-60mg q4h

hydrocodone 5-10mg q4h

[ prescription drugs, avoid taking narcotics on an empty stomach ]

drug for severe pain situations

tramadol 50-100mg q4h

oxycodone 2.5-10mg q4h

diet

patients may avoid eating due to pain or stress

• first 12–24 hours:

  • adequate hydration (~2 L)

  • soft, high-calorie diet and cool foods → help reduce discomfort and lower the risk of bleeding

• diabetic patients should:

  • resume normal caloric and insulin intake asap!

oral hygiene

• day of surgery:

  • brush away from extraction site only

• after 24 hours:

  • start warm saltwater rinses

• resume normal hygiene by day 3–4.

• floss when comfortable.

• if difficult:

  • use mouth rinses (ex: dilute hydrogen peroxide)

edema (swelling)

peaks at 36-48 hours, subsides by day 3-4, resolves within 1 week

• ice packs:

  • 20 min on / 20 min off (first 24 hours)

• no ice or heat on day 2

• heat may be used from day 3 onward

• sleep with head elevated

• some swelling is normal!

trismus

common after mandibular procedures

usually mild, resolves within ~1 week

• caused by:

  • muscle trauma

  • injections (especially medial pterygoid)

ecchymosis (bruising)

not dangerous

more common in older patients due to fragile tissues

appears 2–4 days after surgery, resolves in 7–10 days

caused by blood in submucosal or subcutaneous tissues

postoperative follow-up

novice surgeons: always schedule return appointment

• routine cases:

  • follow-up at 1 week

  • remove sutures if needed

• reasons for early visit

  • prolonged bleeding

  • pain not relieved by medication

  • suspected infection

elements of an operative note

• basic information:

  • date of operation, patient identification

  • diagnosis and reason for extraction

• medical details:

  • medical history, medications, vital signs

• clinical findings:

  • brief oral examination

• anesthesia:

  • type used (e.g., lidocaine), dosage (including vasoconstrictor like epinephrine)

• clinical findings:

  • brief oral examination

• anesthesia:

  • type used (e.g., lidocaine)

  • dosage (including vasoconstrictor like epinephrine)

• procedure:

  • description of procedure, any intraoperative problems

• post-operative care:

  • instructions given to patient

  • medications prescribed:

    • drug name, dose, total amount

• follow-up:

  • need for return visit recorded

• electronic records:

  • same information required

  • may be recorded using software-specific fields

prevention and management of complications

soft tissue injuries

postoperative bleeding

injuries to adjacent teeth

oroantral communications

delayed healing and infection

injuries to osseous structures

injuries to adjacent structures

problems with a tooth being extracted

soft tissue injuries

tear of a mucosal flap

puncture wounds

abrasions or burns

tear of a mucosal flap

most common soft tissue injury

• causes:

  • inadequately sized flap, excessive retraction, or rushing during surgery

• prevention:

  • adequate flap size, controlled retraction, releasing incisions if needed

• management:

  • reposition flap and suture carefully

  • stop surgery if tearing begins → adjust flap

  • avoiding tissue tension or loss of attached gingiva

  • smooth jagged edges if needed (avoid excess tissue removal)

puncture wounds

• cause:

  • instrument slipping (elevator, periosteal elevator)

• prevention:

  • controlled force, use finger support/rest

• management:

  • control bleeding (pressure)

  • usually left open and unsutured to allow healing by secondary intention

abrasions or burns

• causes:

  • rotary instrument (burr) contact, hot instruments, retractor injury

• prevention:

  • always moist mucosa, step on the foot pedal once bur is properly positioned, allow instruments to cool

• management of oral tissues:

  • clean area with regular oral rinses

  • healing usually occurs in 4-7 days

• management of skin:

  • apply antibiotic ointment, do not spread on normal skin

  • keep moist to prevent scab

  • heals in 5–10 days

  • possible:

    • minor scarring

    • discoloration (usually preventable)

problems with a tooth being extracted

root fracture

root displacement

tooth lost into the pharynx

extraction of the wrong tooth

root fracture

most common complication

• more likely with:

  • long, curved, divergent roots, dense bone

• prevention:

  • surgical technique, bone removal, open extraction when necessary

  • avoid strong apical force, especially on broken roots

• management:

  • surgical retrieval if needed

root displacement into maxillary sinus

common with maxillary molars

• cause:

  • excessive apical pressure

• key assessments:

  • size of the root

  • preoperative condition of the maxillary sinus

  • any infection of the tooth or periapical tissues

management of small (2-3mm), noninfected root tip & healthy sinus

• take radiograph

• attempt gentle irrigation and suction (may flush root out)

• if unsuccessful:

  • leave root in sinus, inform patient, provide follow-up

• manage with:

  • sutures, sinus precautions, antibiotics, nasal spray

management of infected, large root or diseased sinus

refer to oral-maxillofacial surgeon

removal via caldwell-luc antrostomy or endoscopic approach

caldwell-luc antrostomy

involves creating an opening into the maxillary antrum through the canine fossa via a vestibular approach

canine fossa – a depression on the anterior surface of the maxilla below the infraorbital foramen and lateral to the canine eminence and incisive fossa

root displacement into infratemporal space

usually maxillary third molars

• cause:

  • posterior displacement during elevation

• management:

  • one careful attempt to retrieve

  • if unsuccessful:

    • stop procedure, close wound, inform patient, give antibiotics

    • remove later (after fibrosis) by specialist

root displacement into submandibular space

usually mandibular molars

• cause:

  • thin lingual bone + apical pressure

• prevention:

  • avoid apical pressure

• management:

  • one attempt to apply finger pressure lingually

  • small, non-infected roots may be left in place

  • if unsuccessful, refer to specialist

tooth lost into the pharynx

• immediate management:

  • position patient face downward

  • encourage coughing

• if swallowed:

  • usually passes in 2–4 days

  • take radiograph to confirm location

• if aspirated :

  • signs:

    • coughing, breathing difficulty

  • action:

    • emergency referral, require bronchoscopy

    • maintain airway, give oxygen if needed

extraction of the wrong tooth

• causes:

  • poor preoperative assessment, miscommunication (e.g., referrals)

  • confusion in numbering systems, mixed dentition cases

• prevention:

  • careful planning, clear communication

  • confirm tooth before extraction

• management:

  • if recognized immediately:

    • replant tooth immediately

    • consult orthodontist if applicable

    • delay correct extraction 4–5 weeks

    • do not remove opposite tooth yet

  • if recognized later:

    • replantation not successful

    • consider:

      • orthodontic adjustment

      • dental implant restoration

injuries to adjacent teeth

occur when focus is only on the tooth being extracted

• common causes:

  • burr use near adjacent teeth

  • excessive or uncontrolled force

• prevention:

  • be aware of adjacent structures during surgery

injury to opposite arch teeth

more common in lower tooth extraction

• cause:

  • sudden release of tooth

  • forceps hitting opposing teeth

• prevention:

  • avoid excessive traction

  • adequate tooth luxation before removal

  • protect opposite teeth (finger or suction tip)

• management:

  • smooth or restore damaged tooth

fracture or dislodgment of an adjacent restoration

most common injury

• causes:

  • elevator pressure on restored tooth

  • contact with carious or weakened tooth

• prevention:

  • warn patient preoperatively

  • avoid force on restorations

  • use elevator carefully or avoid if necessary

• management:

  • remove dislodged restoration from mouth

  • replace crown or place temporary restoration

  • inform patient

luxation of an adjacent tooth

• cause:

  • improper use of elevators/forceps, crowded teeth

• prevention:

  • use controlled force, use narrow forceps when needed

• management:

  • mild luxation:

    • usually no treatment needed

  • severe luxation:

    • reposition tooth, check occlusion, stabilize if mobile (semirigid fixation, suture)

  • avoid rigid fixation (risk of complications)

injuries to osseous structures

fracture of the alveolar process

fracture of the maxillary tuberosity

fracture of the mandible

fracture of the alveolar process

• cause:

  • excessive force with forceps

• prevention:

  • careful clinical + radiographic exam

  • assess:

    • root shape, bone thickness, proximity to sinus

  • avoid excessive force

  • use open extraction if needed

  • section multirooted teeth consider patient age (older = higher fracture risk)

• management:

  • bone completely removed with tooth:

    • do not replace bone, reposition soft tissue, smooth sharp edges

  • bone still attached to soft tissue:

    • carefully separate bone from tooth, remove tooth

    • reposition bone and soft tissue, suture in place → better healing outcome

common sites of fracture of the alveolar process

maxillary sinus floor

maxillary tuberosity

labial bone (mandibular incisors)

buccal plate (maxillary canine, molars)

fracture of the maxillary tuberosity

a serious complication

• importance:

  • needed for maxillary denture stability

  • may create maxillary sinus opening

• management:

  • if bone attached to periosteum:

    • support bone, attempt to preserve it

  • if mobile and cannot separate from tooth:

    • option 1:

      • splint tooth to adjacent teeth, delay extraction 6–8 weeks

    • option 2:

      • section crown, leave roots + tuberosity to heal

      • remove roots after 6–8 weeks

    • use caution if infection present

    • if completely separated:

      • smooth bone edges, reposition and suture soft tissue

      • check for oroantral communication

    • goal:

      • preserve bone for healing

    • may require specialist referral

common causes of fracture of the maxillary tuberosity

extraction of maxillary third molar

extraction of last maxillary molar

fracture of the mandible

a rare complication

• usually with:

  • impacted mandibular third molars

  • atrophic mandible

• cause:

  • excessive force (especially elevators)

• management:

  • reduce and stabilize fracture

  • refer to oral-maxillofacial surgeon

injuries to adjacent structures

injury to regional nerves

injury to the temporomandibular joint

injury to regional nerves

• caused by:

  • incisions, retraction, surgical trauma

• prevention:

  • know nerve anatomy, avoid incisions/stretching near nerves

most commonly affected nerve injury

buccal nerve

nasopalatine nerve

mental nerve

lingual nerve

inferior alveolar nerve

buccal & nasopalatine nerve

often cut during flap creation

• effects:

  • small sensory loss

  • usually recover quickly

mental nerve

• injury causes:

  • lip and chin numbness

• mild injury:

  • recovers in days to weeks

• severe injury:

  • may cause permanent anesthesia

• Pprevention:

  • careful incision placement

  • avoid mental foramen area

lingual nerve

• location:

  • lingual side of mandible (retromolar area)

• risk:

  • rarely regenerates if severely damaged

• prevention:

  • incisions on buccal side

  • avoid lingual tissue trauma

inferior alveolar nerve

• commonly affected in:

  • mandibular third molar removal

• injury causes:

  • numbness

• prevention:

  • careful technique

  • inform patient preoperatively

injury to the temporomandibular joint

• causes:

  • excessive force

  • poor jaw support

• prevention:

  • use controlled force

  • support jaw manually

  • use bite block

• management:

  • rest jaw, soft diet, apply heat

  • medications:

    • ibuprofen (600–800 mg)

    • acetaminophen

oroantral communication

abnormal communication between oral cavity and maxillary sinus

• common after extraction of:

  • maxillary premolars/molars

• risk factors:

  • pneumatized sinus, divergent roots

  • thin/no bone between roots and sinus

• main complications:

  • maxillary sinusitis

  • chronic oroantral fistula

• prevention:

  • careful radiographic evaluation

  • If high risk:

    • use surgical (open) extraction, section roots

• diagnosis:

  • bone attached to extracted tooth → likely communication

  • may exist even without bone removal

  • avoid nose-blowing test (may create communication)

valsalva manuever

produces bubbles and frothy fluid in the extraction site

usually done by pinching one’s nose shut as if blowing up a balloon

performed by moderately forceful attempted exhalation against a closed airway

management of <2 mm oroantral communication

no surgical treatment needed

ensure good blood clot

• give sinus precautions

  • gentle sneezing, NO straw, cigarettes

management of 2-6 mm oroantral communication

place figure-of-eight suture

may place gelatin sponge

give sinus precautions

• medications:

  • penicillin, antihistamines, decongestants

management of >7 mm oroantral communication

requires surgical flap closure, usually refer to specialist

• common method: buccal flap

  • aka: Berger’s flap

  • flap is elevated, periosteum is released

  • the flap is extended over the defect and sutured in place

delayed healing and infection

infection

dry socket

wound dehiscence

wound dehiscence

• causes:

  • lack of bony support under flap

  • suturing under tension

• signs:

  • wound edges separate, flap sagging

• mechanism:

  • tight sutures → ↓ blood supply (ischemia)

  • tissue necrosis → sutures tear through → dehiscence

• prevention:

  • use aseptic technique, perform atraumatic surgery

  • close over intact bone, avoid tension in sutures

  • tie sutures loosely (no blanching)

• management:

  • option 1:

    • leave it → bone sloughs off in 2–4 weeks (preferred if mild)

  • option 2:

    • smooth with bone file (no flap elevation)

exposed bone (internal oblique ridge)

common after mandibular molar extraction

bone may protrude through thin mucosa

dry socket / alveolar osteitis

delayed healing with exposed bone, not infection

• causes:

  • traumatic extraction

  • high fibrinolytic activity → loss of blood clot → exposed bone

• prevention:

  • atraumatic surgery, minimize contamination

  • irrigate with saline

  • may use:

    • antibiotics (ex: tetracycline in socket)

• management:

  • goal: relieve pain (not speed healing)

  • irrigate the socket gently, retain any intact clot, do NOT curette socket

  • insert medicated dressing:

    • iodoform gauze

    • eugenol (pain relief)

    • local anesthetic (ex: benzocaine)

    • vehicle (ex: balsam of Peru)

  • change dressing every 2 days (3–5 days total)

  • then remove dressing to allow healing

clinical features of dry socket

• pain:

  • starts day 3–4

  • moderate to severe, throbbing

  • may radiate to ear

• socket:

  • completely empty or partially empty

  • loss of blood clot exposed bone

• other:

  • bad odor, foul taste

  • no swelling or infection signs

infection

most common cause of delayed healing

• more common in:

  • flap surgery

  • bone removal procedures

• prevention:

• follow basic surgical principles:

  • minimize tissue damage, remove infection sources, clean wound thoroughly, copious irrigation, asepsis

• management:

  • antibiotics in immunocompromised patients (given before surgery)

signs of infection

occur 3–4 days after surgery

• symptoms:

  • fever, increased swelling

  • foul taste, , purulent exudate

  • redness, erythema, worsening pain

• findings:

  • inflamed wound, possible pus