Abstract: Full Title of manuscript: Prevention of Post extraction complications.

Background: Post extraction swelling, haematoma, pain, bleeding, trismus and ulcers are not uncommon in dental practice. Having the knowledge of causes and management of post extraction complication would be helpful for the Dentist to explain and manage the situation in a simple and easier manner. Aim and objectives: The aim of this article is to discuss the common causes and management of post extraction complications. Design and Settings: Vinayaka University, Department of oral surgery, VMS Dental College Salem Materials and methods: This study was based on the experience gained from my patients in my private hospital and in VMS dental college from 1989 may to till date. The post extraction complications and its management in various aspects are discussed. Conclusion: Having a thorough medical history and knowledge of extraction technique prior to extraction of a tooth will allow the surgeon to manage better with complications that may arise.

Article: Title: Prevention of Post extraction complications. Introduction: Post extraction swelling, haematoma, pain, bleeding, trismus and ulcers are not infrequent complications in dentistry. Having the knowledge of causes and management of post extraction complication would be helpful for the Dentist to explain and manage the patient in a simple and easier manner. This will improve the patient to dentist relationship. Post extraction pain due to tissues damage, exposure of alveolar bone [due to loss of tissue], broken alveolar bone impinging the tissues near socket, and dry socket are more common than any other complications. Having a thorough medical history, knowledge of extraction technique, knowledge of post extraction observation and care will allow the surgeon to prevent post extraction pain. Proper surgical techniques and knowing our limitations prior to beginning any extractions will prevent unwanted complications. When unexpected complications arise during and after extraction, the dentist would be able to manage the complications when he is aware of such complications. Objective: The aim of this article is to discuss the etiology and management of complications associated with extractions. Techniques to manage complications occurring during and post-operatively and days after will be discussed. Materials and methods: This study was based on the experience gained from my patients in my private practice and in VMS dental college from 1989 may to till date. The post extraction complications and its management in various aspects are reported. Discussion: Etiology of post extraction pain Failure to compress the socket after extraction, Failure to remove the broken alveolar bones of socket, Failure to remove sharp irregular alveolar bones impinging the tissues, Failure to smoothen the rough alveolar margins, Failure to remove visible prominent inter radicular bone [multi rooted tooth] and inter dental bone in multiple tooth extractions. Failure to suture the accidental tissues tear can lead to post extraction pain Exposure of bone due to loss of tissue should be removed when it is small but when large area of bone is exposed, it should be covered by zinc oxide eugenol impression paste. Placement of small cotton inside the socket may Evert the socket and result in Post Extraction pain. Placement of large cotton on the buccal side of extraction socket compresses the socket.

Pain may be due to infection, mild and moderate infections are treatable with routine antibiotics and analgesics. When it is due to immune compromised patients management will be difficult. This could be avoided by careful history. Extraction difficulty increases when the following conditions exist: strong supporting bone, multiple roots, divergent, hooked locked, ankylosed, geminated or misshaped root, hyper cementosis tooth, weakened coronal surfaces of tooth due to large restorations, teeth that have been abraded or in attrition or deep caries, brittle teeth associated with endodontic treatment, patients experiencing inflammatory disorders associated with alveolar bone including Pagets disease, patients with radio necrotic bone caused by radiation therapy, and patients with limited opening or trismus may end up in breakage of teeth during extraction. Dentist with good knowledge of surgical removal should perform those extractions to minimize complications. Briefly I would like to refresh the normal healing process after extraction. Immediately after teeth are extracted, blood flowing from the alveolar bone and gingival tissue begin to clot. The clot functions by preventing debris, food and other irritants from entering the extraction site. It also protects the underlying bone from the bacteria and finally acts as a supporting system in which granulation tissue develops. Tissue damage provokes the inflammatory reaction, and the vessels of the socket expand. Leucocytes and fibroblasts invade from the surrounding connective tissues until the clot is replaced by granulation tissue. Leucocytes gradually digest the clot, while epithelium begins to proliferate over the surface during the second week post-operatively. This eventually forms a complete protective covering. [At this stage frequent gaggling, spitting, handling and any other mechanical disturbance could result in loss of clot which eventually results in Dry socket.] During this time, there is an increased blood supply to the socket which is associated with the resorption of the dense lamina dura by osteoclasts. Small fragments of bone which have lost their blood supply are encapsulated by osteoclasts and eventually pushed to the surface or resorbed. Approximately one month after an extraction, coarse woven bone is then laid down by osteoblasts. Trabecular bone then follows, until the normal pattern of the alveolus is restored. Finally compact bone forms of the surface of the alveolus, and remodeling continues as the bone shrinks. Bleeding complications: Once a tooth is extracted, direct primary wound closure is always not possible. Due to the lack of soft tissue that leaves large openings in the alveolus. Unlike other wounds or surgical openings, there is an inability to apply and sustain direst pressure to the socket of an extracted tooth Other forces exist to even complicate things further, such as disruptive forces from the tongue, passage of food, and normal speech. Salivary enzymes also interfere with blood clotting and the processes that follow in the dislodgement of the clot. Prevention: To prevent bleeding a thorough medical history should be taken, including question regarding bleeding problems. Some conditions that may prolong bleeding are: non-alcoholic liver disease (primarily hepatitis) and hypertension, haemophilia, leukemia, thrombocytopenia and central haemangioma of bone. Techniques to manage bleeding may employ the administration of blood transfusions containing adequate factor replacement which will allow for hemostasis. The health history should include questions that discover bleeding problems associated with minor scrapes and cuts. Family medical history is also important in order to detect possible genetic diseases

that patients are unaware of potentially having. Complete and current medication lists should be documented and checked against references that may indicate side effects. It is also advisable that patients taking extensive medications receive clearance to undergo surgery from their physician. Many drugs interfere with coagulation. Aspirin and aspirin containing preparations interfere with platelet function and bleeding time. Chronic alcohol abuse can lead to liver cirrhosis and decreased production of liver-dependent coagulation factors. Chemotherapeutic agents that interfere with the hematopoietic system can reduce the number of circulating platelets. Patients who are known or suspected to have bleeding disorders should be evaluated and laboratory tested before surgery. Any abnormality in Bleeding time, clotting time and Prothrombin time (PT) should be diagnosed. Once the tooth is completely removed, the wound should be properly cleaned. It should be inspected for the presence of any abnormally excessive bleeding. If exist in the soft tissue, they should be controlled with direct pressure and eventual suturing with absorbable suture would arrest the bleeding. If bleeding is from bony socket of the extraction field, complete hemostatic control can usually be maintained for most procedures by using direct pressure over the area of the soft tissue for approximately five minutes or with usage of haemostatic agents. Bleeding from isolated vessels within the bone can occur. Treatment involves crushing the foramen with the closed ends of the hemostat. This will usually occlude the bleeding vessel. Once the foramen is crushed, the socket should be covered with a damp 2x2 inch gauze sponge that ahs been folded to fit directly into the extraction site. The patient should be instructed to bite down firmly on this damp gauze sponge for at least 30 minutes. Do not dismiss the patient from the office until hemostastis has been achieved, Check the patients extraction socket approximately fifteen minutes after the completion of the surgery, The patient should open his/her mouth widely, the gauze should be removed, and the area should be inspected carefully for any persistent bleeding. Replace the gauze with a new piece and repeat again in thirty minutes. If bleeding persists and inspection reveals no arterial bleeding, the surgeon should immediately place a hemostat into the socket. After placing the hemostatic agent, a gauze sponge should be placed over the top of the socket and is held with pressure. Haemostatic agents: The most commonly used least expensive hemostatic agent is absorbable gelatin sponge (Gelfoam, Pfizer). Gelfoam sterile compressed sponge is a pliable surgical hemostat prepared for specially treated purified gelatin solution. It is capable of absorbing and holding within its meshes many times its weight in whole blood. It is designed to be inserted in the dry state, and functions wonderfully as a hemostatic agent. Gelfoam forms a scaffold for the formation of a blood clot. Gelfoam has been sued to aid in primary closure for large extraction sites, and is placed into the socket and retained with a suture. Oxidized regenerated methylcellulose (Surgicel, Johnson and Johnson) is another hemostat used in dental surgery. It binds platelets and chemically precipitates fibrin. It is placed into the socket and sutured. I can not be mixed with thrombin. Topical thrombin (Thrombostat, Pfizer) is derived from bovine thrombin (5,000 units). Thrombin bypasses all steps in the coagulation cascade and helps to convert fibrinogen to fibrin which forms the clot. It is usually saturate into Gelfoam and inserted into the tooth socket when needed.It is more important to note that when using

hemostatic agents, the materials are place in the socket and sutured to the gingival margin surrounding the extraction site. This will assure that they are secure. Patients will sometimes return to the office with secondary bleeding, caused in most cases by improper adherence of post-operative instructions. In these cases, the extraction site should be cleared of al blood and saliva suing suction. The dental surgeon should visualize the bleeding site to carefully determine the source of bleeding. If it is determined that the bleeding is generalized, the site should be covered with a folded, damp gauze sponge, and held in place with firm pressure by either the dentist or dental auxiliary for at least 5 minutes. This measure is usually sufficient to control most bleeding. If 5 minutes of this treatment does not control the bleeding, the dental surgeon must administer a local anesthetic so that the socket can be treated more aggressively. Block techniques are encouraged instead of local infiltrations. If infiltration is used and the anesthetic contains epinephrine, temporary vasoconstriction may be achieved and create the impression that the bleeding has stopped permanently. Once anesthesia has been achieved, gently curette the tooth extraction socket and suction all areas of the old blood clot. The specific area of the bleeding should be identified. The same measures described for control of primary bleeding should be followed. The use of Gelfoam (absorbable gelatin sponge) saturated with topical thrombin, then sutured, is an effective way to stop bleeding. Reinforcement should be repeated with the application of firm pressure. In many situations, Gelfoam and gauze sponge pressure is adequate. Before the patient with secondary bleeding to go home, the clinician should monitor the patient for at least 30 minutes to ensure that adequate hemostatic control has been achieved. Be certain to give the patient specific instructions on how to apply gauze packs and pressure directly to the bleeding site should additional bleeding occur. Subcutaneous tissue spaces may become collection areas for bleeding associated with some extractions. When this occurs, overlying soft tissue areas will appear bruised 2 to 5 days after the surgery. This bruising is called ecchymosis. Ecchymosis occurs more frequently in elderly patients. Ecchymosis may extend into the neck and as far as the upper anterior chest. Ecchymosis does not increase the potential for infection or other sequelae but antibiotics should be prescribed to prevent superadded infection. Elderly patients should be warned that there is the potential for ecchymosis. Reducing trauma is the best way to prevent ecchymosis. Moist heat may be applied to speed up the recovery. Normal healing of extraction site is dependent on clot formation and the progression of that clot to a reorganized matrix preceding the formation of bone. It is uncommon for the blood clot to fail to form except in cases where there is interruption of the local blood supply. It is now thought that the infection is the most common cause delaying wound healing. Signs and symptoms associated with infection can include: pain, fever, swelling and erythema. Careful asepsis and thorough wound debridement should be performed after surgery. Irrigate bone copiously with saline to aid in the control of foreign debris. Patients prone to infection should be given postoperative antibiotics to reduce infection blowups. Wound dehiscence should be avoided by following good surgical techniques. Leaving unsupported soft tissue flaps can often lead to tissue sagging and separation along the incision line, Suturing wound under tension can cause ischemia of flap margins, which may lead to tissue necrosis.

Other factors, though rarely seen that can delay healing are: prolonged bleeding due to clotting defects, formation of an oro-antral fistulas, proliferation of a malignant tumor, radiation therapy, immune suppression due to corticosteroid use, dietary deficiencies including vitamin C, and overall immune system disorders. Diagnosis of Dry socket: It is characterized by increasingly severe pain in and around the extraction site, usually starting on the second or third post-operative day and which may last for between ten and forty days. The pain may radiate and typically pain in the ear is one of the characteristic symptoms of a dry socket in the mandible. The normal postextraction blood clot is absent from the tooth socket(s), the bony walls of which are denuded and exquisitely sensitive to even gentle probing. Halitosis is invariably present. The condition probably arises as a result of a complex interaction between surgical trauma, local bacterial infection and various systemic factors. [2*] Birn, [68], labeled the condition as fibrinolytic alveolitis. Although most authors have accepted Birn's theories, the term fibrinolytic osteitis is the least used in the literature [35]*. Dry socket, which is the generic term and alveolar osteitis, are more commonly used terms. [2*] Mandibular 3rd molar tooth removals are most commonly associated with dry socket. The incidence of dry socket has ranged from 1% to 4% of extractions, reaching 45% for mandibular third molars. [1] It has been shown that occurrence of dry socket is between 9-45% in impacted mandibular third molars. Studies have demonstrated that the more difficult the extraction, the higher the chance of dry socket. It has also been demonstrated that less-experienced dental surgeons have a higher incidence of dry socket in lower third molars. The peak age for dry socket is 30-34 years. Most reported cases occur between the ages of 20 and 40. Bacteria, especially anaerobic, have been linked to the formation of dry sockets. Investigators have found strains of Streptococci, Fusospirochaetal, Treponema denticola, and bacteroides within extraction sites. Researchers have identified that women have a 20% better chance to develop dry socket than males. Oral contraceptives are also linked to higher incidence of dry socket. Patients with uncontrolled diabetes mellitus have a greater incidence of dry socket and should be monitored carefully. Prevention of dry socket: Proper surgical techniques should include thorough debridement and irrigation of the extraction site with copious quantities of saline could prevent dry socket. This should be first on your list in controlling the incidence of dry socket. The incidence of dry socket may be decreased by preoperative and post operative rinsing with antimicrobial mouth rinses, such as chlorhexidine gluconate (Peridex Zila Pharmaceuticals). Use of other medicaments such as Betadine Mouthwash may also be useful in reducing bacterial loads prior to surgery. Use of topically placed [intra alveolar] antibiotics such as clindamycin or tetracycline have been successfully used to help decrease the incidence of dry socket in mandibular third molars. Placement of tetracycline in a suspension with a few drops of saline combined with a square of Gelfoam significantly reduce the incidence of dry socket when used as a dressing after impacted mandibular third molar extractions.

Effects of a 1x1 cm square of Gelfoam soaked with 1ml of clindamycin phosphate solution (150 milligrams/milliliter) decrease the incidence of dry socket. Clindamycin is preferred as the drug of choice in the prevention of dry socket due to its anaerobic properties. Treatment of dry socket: Treatment should be focused on relieving pain.Treatment should begin by gently irrigating with saline, and the insertion of medicated dressing. Do not curette the socket because this will increase the amount of exposed bone and the pain, and remove parts of the blood clot. The socket should then be carefully suctioned of all excess saline. Then, a small piece of gelatin sponge or gauze soaked with the eugenol should be placed. This may need to be repeated for 3-6 days depending on the severity of the pain. At each visit, the socket will need to be irrigated, and insertion of the medicated dressing repeated. Medicaments used to treat dry socket may contain a combination of the following ingredients: bone pain relievers (Eugenol, benzocaine), antimicrobials (idoform), and carrying vehicles (balsam of Peru,).Dry socket pastes and liquids (various manufacturers) can be used and placed directly in the socket alone or using absorbable products such as Gelfoam. Once place in the extraction socket, the patient will experience profound relief from pain within 5 minutes. Generally, anesthesia is not recommended when placing those products. Conclusion: This essay was designed to review the etiology and treatment modalities associated with complications associated with extractions. REFERENCES: 1Camila Lopes Cardoso, DDS, MSc,*Moacyr Tadeu Vicente Rodrigues, DDS, MSc,Osny Ferreira Jnior, DDS, MSc, PhD,Gustavo Pompermaier Garlet, DDS, MSc, PhD,and Paulo Sergio Perri de Carvalho, DDS, MSc, PhD Clinical Concepts of Dry Socket. J Oral Maxillofac Surg 68:1922-1932, 2010 2,International Journal of Dentistry Volume 2010, Article ID 249073, 10 pages .3 Blum IR. Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review. International Journal of Oral and Maxillofacial Surgery. 2002;31(3):309317. [PubMed] 4.Torres-Lagares D, Serrera-Figallo MA, Romero-Ruz MM, Infante-Cosso P, GarcaCaldern M, Gutirrez-Prez JL. Update on dry socket: a review of the literature. Medicina Oral, Patologia Oral y Cirugia Bucal. 2005;10(1):7785. 5. Alexander RE. Dental extraction wound management: a case against medicating postextraction sockets. Journal of Oral and Maxillofacial Surgery. 2000;58(5):538 551. [PubMed]

6. Birn H. Etiology and pathogenesis of fibrinolytic alveolitis (dry socket) International Journal of Oral Surgery. 1973;2(5):211263 7.Birn H. Fibrinolytic activity of alveolar bone in "dry socket". Acta Odontologica Scandinavica. 1972;30(1):2332. [PubMed] 8.Birn H. Bacteria and fibrinolytic activity in "dry socket". Acta Odontologica Scandinavica. 1970;28(6):773783. [PubMed]