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Complications after extractions
of teeth
1. Bleeding
It is possible to bleed to death following the extraction of
a tooth. But it almost never happens. All you have to do is follow
directions #1 and #2
on the post-op instruction page and the bleeding will stop. The only patients
that may still be in danger from excessive bleeding are those who are taking
anticoagulant drugs (blood thinners) like Coumadin or Heparin for
cardiovascular problems, or people with bleeding disorders like Hemophilia or
related clotting cascade disorders . These patients should consult their
physicians before having a tooth extracted. People taking aspirin and other non
steroidal anti inflammatory drugs (NSAID's) like Advil or Aleve may experience prolonged
bleeding times, but in my experience, these drugs have never presented a
problem as long as the patient keeps the extraction site covered with
gauze to stem the bleeding. The blood WILL clot eventually!
2. Infection
The mouth is alive with bacteria, especially in
people with poor oral hygiene. Infection is a constant problem after
extractions, and most dentists have developed a personal protocol on whether
or not a particular patient needs preventive antibiotics. People who present
at the office with swollen faces, teeth tender to light pressure, swollen gums or tongue, or
bleeding and pus around a tooth are generally already infected. They should
expect to be
given prophylactic (preventive) antibiotics after an
extraction.
Patients may develop infections after an
extraction even if they were not infected before the extraction. This is
a common complication and is due to the fact that that the mouth is teeming
with bacteria and cannot be sterilized prior to the extraction. (They
are NOT due to any error on the part of the dentist!) The first sign of
an infection after an extraction is often renewed bleeding after 48
hours. The bleeding is not generally severe, but it is an indication
that the patient should return to the dentist's office for evaluation and
possibly a prescription for antibiotics. Other signs of infection
include renewed swelling around the extraction site and surrounding parts of
the face, as well as increased pain after 48 hours. Signs of infection two days
after an extraction should be attended to as soon as possible. Click
here
to see how severe tooth related
infections can become.
Some dentists will give a patient an antibiotic
and send them home for several days to allow the infection to clear before
attempting the extraction. The reason for this is because the
local anesthesia does not work as well in
acid
environments and it may take a lot of shots to get the patient numb.
However, if the dentist gives enough anesthesia, it is possible to extract a
tooth under such circumstances. In general, I have never found that
extraction of a tooth in the presence of an active infection has presented
special problems as long as the patient takes the antibiotics prescribed
faithfully.
It is NOT necessary to take antibiotics after every extraction. A simple extraction in a clean, uninfected mouth
generally does not require prophylactic antibiotics.
Whenever the extraction requires the cutting of
any tissue (see surgical and impacted extractions
above), it is generally a good idea to give prophylactic antibiotics, and the
patient SHOULD fill the prescription and take the drug faithfully, or he may
suffer an extended convalescence.
3. Dry Sockets
A dry socket, while not potentially life threatening like
bleeding or infections, is one of the most painful, common, debilitating and
dreaded post extraction problems encountered in dentistry. Patients
often state that they felt fine for a day or two after the extraction, but
then the extraction site began to become painful. They may also say
they have a bad taste in their mouth. Dry sockets are much
more common following the extraction of lower teeth than they are after
extraction of upper teeth. They can happen after even the simplest of
extractions. If you
get a dry socket, it is not (necessarily) your fault. Nor is it the fault of the
dentist. They are a quirk of nature. You may THINK you are going
to die. You won't!
Patients who are more likely
to get a dry socket are those who smoke during the first 48 hours after the
extraction, women on birth control pills, and persons who tend to constantly grind and clench their teeth
(see my page on
TMJ)
What is a dry socket?
A dry socket is a condition in which the
blood
clot that forms in the extraction site becomes detached from the
walls of the socket, or dissolves away leaving the bare bone exposed to
saliva and the foods you eat. The bone becomes inflamed due to
bacteria and contaminants in the saliva, and this inflammation is
persistent and painful. The socket begins to emanate a bad odor. The pain is "deep pain". That is, it
comes from tissues buried deep in the body, and your brain has no experience
of pain from these regions. When the brain receives pain signals
through these unusual channels, it is unsure of the exact location of the
pain, so it tells you that the pain is coming from areas on that side of
your face and head that are far removed from the actual source. Pain
like this is called
referred pain. It seems to shoot up the side of the head, or makes your eye
ache.
Can a dry socket be prevented?
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Studies have shown that in-office pre-operative and
post-operative rinsing with 0.12% chlorhexidine (Peridex) reduces the
incidence of dry sockets. It is a good idea for the patient to be
given a prescription for a bottle of chlorhexidine to be used for
rinsing three times a day for several days starting 24 hours after the
extraction.
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Removing third molars within the ideal window of time
when the roots are 1/2 to 2/3 developed, about age 17 for boys and 16
for girls, reduces the likelihood of dry socket.
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Treating the socket immediately post-operatively with a
small amount of tetracycline on a piece of Gelfoam has been shown to
reduce the likelihood of dry socket.
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Patient should maintain good oral hygiene and follow
post-op instructions.
How are dry sockets treated?
Left alone, dry sockets will always heal.
It may take a month or more, and the pain is persistent for the entire period of
healing. Antibiotics are not useful in curing a dry socket, and the
usual pain medications are not very effective. It is better to go back
to the dentist who extracted the tooth and let him or her "pack" the
socket. This is a procedure done (usually) without anesthesia even
though it can be painful. It
does not take too long, and the pain relief is almost complete, beginning a
few minutes after the socket is packed. The first packing will provide
relief for 12 to 24 hours. As you return to the dentist and the old
packing is removed, the socket is washed out and a new packing is placed.
Each succeeding
packing debrides (cleans) the socket and renews the pain relief. A
second packing may last 24 to 48 hours, and succeeding packings last longer
still. Within three packings, or sometimes more depending on the severity of the dry
socket, the wound begins to heal from the bottom up and can be left empty
to heal without pain.
4. Broken Jaws
Yes, it does occasionally happen. The fracture
of a lower jaw is unusual, principally because dentists who extract teeth
routinely do not place great force on any instrument to remove a tooth.
Teeth are generally "finessed out" with a minimum of pressure
applied to the jaw through the surgical instruments. There are, however,
some situations in which a dentist can look at the x-ray and see that the
jawbone that surrounds the tooth is much more fragile than is usually the
case, and will usually warn the patient that fracture of the jaw is a possibility.
People are not like cars, every one identical. Everyone is unique and
presents unique circumstances under which the dentist must labor. The
chances that the removal of any given tooth will result in a fractured lower
jaw run about the same for any dentist who attempts the extraction. That
particular patient is usually more prone than other people to a broken jaw due
to any traumatic incident such as a traffic accident or a blow
to the jaw during a sporting event. Unfortunate, but true, and a fact of life
for any dentist who extracts teeth.
5. Sinus perforation
 The image to the right is a detail from a
panoramic
film. The roots of the upper back teeth
are always in close approximation to the maxillary sinus. Since
everyone is built differently, The roots of the teeth may actually appear
to be inside the sinus. There is always a thin wall of bone between
the root and the sinus, but is can be very thin indeed. Most of the
time, the bone remains intact, but upon occasion, a piece of the bone
separating the root from the sinus may break off and be removed with
the tooth. This creates a direct connection between the sinus and
the mouth! That means that you would be unable to suck on a straw,
because air would rush into your mouth from your nose through the socket.
Sometimes a sinus perforation will go unnoticed
by the dentist or the patient. If the perforation is small, the only
symptom could be a nosebleed. If this happens, call the dentist so he
can prescribe the proper drugs so that healing can proceed normally
When a sinus perforation occurs, the dentist
will prescribe an antibiotic to prevent infection and a decongestant to keep
the sinuses clear during healing. The patient bites on his gauze as is
usual
after any extraction, and a clot will form in the socket as usual.
If nothing disturbs the clot, it will organize during healing and close the
perforation. Dry sockets rarely happen after
extraction of upper teeth unless the patient smokes.
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It is IMPERATIVE, however that the patient do
NOTHING that could disturb the clot.
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Do not suck on anything for at least a week.
This puts pressure on the clot and could dislodge it into the mouth.
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Do not smoke...the longer you wait the
better. This will dissolve the clot, or could even suck it out of the
socket.
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Do not blow up balloons or anything
else. This puts pressure on the clot and could dislodge it into the
sinus.
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Avoid sneezing. This explosive event will
definitely dislodge the clot.
In the case of very large perforations, or in
case the clot dislodges and a perforation between the sinus and the mouth
remains after healing, It may be necessary to perform a further surgical
procedure in order to draw a flap of gum tissue over the perforation to close
it permanently.
6. Sequestrii
(Broken bone fragments that come out weeks after the
extraction, but are often mistaken for pieces of tooth.)
Extraction of a tooth requires
that the bone surrounding it be expanded, or sometimes even
fractured to allow the tooth to slip out of the socket. Most of the time,
these fractures are of the type known as "greenstick" fractures which
means they are only partial fractures immediately around the top of the socket
leaving the bone fragments still attached to the main body of the bony structure
beneath. In some instances, these greenstick fractures coalesce to release
a bone fragment completely from the underlying bony structure. Even when
this happens, the bone fragments tend to heal and reattach to the main body of
the bone during healing.
In the oral cavity, however, the presence of oral
bacteria, as well as noxious chemicals from the foods we eat and cigarettes we
smoke can cause the healing to cease. This is what causes
dry
sockets. Bony fragments that do not heal properly often loose their
blood supply and become "necrotic" (dead tissue). Thus, the body
begins the process of ejecting them from the healing socket, a process known as
sequestration. The process can be painful, and sometimes requires the
dentist to reenter the socket to remove the sequestrum. When the
sequestrum comes out on its own, the patient often mistakes this piece of bone
for a piece of tooth that the dentist left in the socket.
Sequestrii are a normal complication of
extractions. They are often unavoidable, and undetectable at the time of
the extraction. They are not considered to be a mistake the dentist
made. Once the sequestrum is gone, the healing resumes, the pain subsides
and all is well.
7. Retained roots (Pieces
of tooth left in the bone by the dentist)
A large majority of teeth are removed in one
piece when they are extracted by the dentist. However, many do
break leaving one or more fragments of varying size in the bone. Most of
the time, these root fragments are easily "luxated" using a sharp instrument
which is forced down between the root and the surrounding bone. On rare
occasions, the root fragment may be too firmly attached to the bone (ankylosis),
at too odd an angle, or too close to a vital structure like the sinuses or
mandibular nerve to remove in this manner. In most instances, it is NOT essential
to remove every root fragment that is left in the bone!! Retained root
tips will generally simply heal in place and never cause a problem to the
patient after healing. When confronted with this situation the dentist must weigh the
relative benefits of removal of the root tip versus the complications that the
removal will cause the patient. Often, the removal of the offending root
fragment necessitates quite a bit of drilling of bone and heavy duty prying, not
to mention quite a bit of time. This always results in a much greater
degree of pain for the patient during healing. It also increases the likelihood
of a dry socket, which is a painful result that most
people would rather do without. On the other hand, leaving the root tip in
place causes no further difficulties to the patient most of the
time.
8. Osteonecrosis of the jawbone
Osteonecrosis of the jawbone
(ONJ) is a disease
resulting from the temporary or permanent loss of the blood supply
to the bone. Without a blood supply, the bone dies (the term
"osteo" means "bone"; the term "necrosis" means "death").
When this happens, the dead bone becomes exposed to the oral
environment. Exposed necrotic bone is not an uncommon
complication after extractions of teeth, even in healthy patients
who have never had radiation therapy or bisphphonate drug therapy.
Simple cases involve only the bone immediately surrounding the
extraction socket, and usually, the necrotic bone will heal over
spontaneously with time. Unfortunately, more serious cases of
ONJ happen to people who are taking bisphosphonates for osteoporosis
or as part of a chemotherapeutic regime for some forms of cancer.
Serious ONJ also happens to patients who have had radiation therapy
to the head or neck for the treatment of cancers. Since the
subject is so complex, I have given this subject its own
page.
Next page--Osteonecrosis>>
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