Complications Following Tooth Extraction and Oral Surgery

Essentials

• Pain, slight swelling and haematoma that appear in the tooth extraction area after the procedure are common and procedure related problems.
• The pain should be treated with appropriate analgesic (ibuprofen or paracetamol are usually sufficient). The pain and the local mild swelling caused by the extraction should subside little by little within 3-4 days after the procedure.
• The blood clot that develops in the extraction socket should not be dislodged. If it dislodges, the patient becomes susceptible to pain that lasts longer.

Tooth extraction

• After tooth extraction, the tooth socket may ooze blood for a few hours. The patient should compress the extraction site by biting onto a gauze swab applied to the socket for 15-20 minutes. This is enough to stop normal post-extraction bleeding.
• The socket will heal through a secondary healing process. After the extraction, a blood clot will develop in the alveolar socket. The clot will turn into a fibrin mesh which will facilitate the formation of granulation tissue. Epithelium lined granulation tissue will grow from the bottom of the socket up towards the sides of the socket.
• Should the clot dislodge, the socket becomes susceptible to post-extraction alveolitis (dry socket), the clinical diagnosis of which is based on the following findings: increasing severe pain 2-3 days after the extraction, halitosis, the alveolar bone visible in the extraction socket, but no purulent exudate present. The incidence of alveolitis following tooth extraction is approximately 1-10%, and it usually involves the lower jaw. Its aetiology remains unclear; according to current understanding the ischaemic bony area necroses and causes local osteitis.
• The treatment consists of irrigation of the affected socket and revitalization, using local anaesthesia as necessary, as well as packing it with a paraffin gauze swab saturated with iodoform. The pack should be changed every 1-3 days until symptoms subside. A iodoform-soaked haemostyptic gelatin sponge may also be used; removal is in this case not needed. Adequate pain relief must be ensured. Systemic antimicrobials are usually of no benefit, but they should, however, be prescribed should generalised symptoms develop.
• A tooth extraction may be complicated by the formation of a haematoma in the surrounding soft tissues. The haematoma may extend from the upper jaw to the eye socket and from the lower jaw to the neck. However, the haematomas are usually not this extensive. Extensive haematomas, accompanied by swelling, pose an infection risk and the prescription of a systemic antimicrobial is warranted.
• The amount of swelling is proportionate to the length of the extraction procedure as well as the degree of soft tissue stretching and trauma involved. Swelling will be the most severe on the day after the procedure.
• The patient may experience difficulties in opening his/her mouth particularly after the extraction of mandibular teeth and nerve block anaesthesia to the lower jaw. These problems may persist for several months and the treatment mainly consists of mouth opening exercises in order to stretch the associated muscles.
• The root endings of the upper molars are situated in the maxillary sinus, and extraction of these teeth may create an opening from the mouth cavity into the maxillary sinus. In such a case, the mouth cavity will become filled with air during the Valsalva manoeuvre. A small perforation will usually heal by itself, provided that a decent clot forms in the socket. It is important that the clot does not dislodge, and the patient should therefore be advised to refrain from blowing his/her nose vigorously for 3-4 weeks. If the perforation is large and does not close within 2-3 weeks, a surgical repair will be necessary and the patient should be referred to an oral surgeon.
• A tooth extraction will almost always be followed by pain of varying degree which starts 2-3 hours after the extraction, as the effect of local anaesthetic wears off. The pain will usually subside within 2-3 days.
• The pain can usually be alleviated with a peripherally acting anti-inflammatory drug. In more severe cases, a centrally acting analgesic may be prescribed.

Surgical tooth extraction

• If the extraction of a tooth has involved a surgical procedure, i.e. the extraction has involved cutting through the gum and removing portions of the bone in order to free the tooth, the possible complications, in addition to the ones listed above, include more profuse post-extraction bleeding, sensory damage to the chin area, postoperative infection and even a fractured jaw.
• After a surgical extraction of a lower wisdom tooth the retromolar arteries or the inferior alveolar artery may cause quite profuse postoperative bleeding. A suitable first aid measure, if possible, is the compression of the site by applying a haemostyptic agent into the socket (Surgicel^® , Gelfoam^® ). If the bleeding continues the wound must be reopened and the vessels ligated. Any bleeding from the bone is controlled by applying pressure with a blunt instrument or with bone wax. Tranexamic acid may be used to complement the compression. It can either be applied onto a gauze swab or it can be administered orally 1-1.5 g three times daily. A blood transfusion to restore the blood volume should be considered if bleeding has been excessive and of long duration.
• The inferior alveolar nerve may be damaged during a surgical extraction of a lower wisdom tooth, if the patient's anatomy is such that the nerve is situated near the tooth. The associated symptom is a loss of sensation around the chin on the side of the injury. If the nerve was not totally severed, sensation will return within 1-12 weeks of surgery. If the nerve was totally severed, nerve repair surgery should not be delayed since the chances of a successful outcome will decline quickly with passing time.
• There is usually no need to routinely prescribe a systemic antimicrobial after a surgical tooth extraction, and its need should be decided individually for each patient Antibiotics to Prevent Complications Following Tooth Extractions. Postoperative infection is possible and is usually treated with penicillin V (1 million IU t.d.s.), either alone or combined with metronidazole (400 mg t.d.s.).
• Postoperative infection differs from alveolitis in that all the classical signs of infection (redness, heat, pain) are present at the site including a purulent discharge, and the patient may be febrile.
• A late infection may develop at the extraction site even after several months following the extraction. In such a case, the causative agent is most likely to be an anaerobic agent, which should be treated with penicillin V combined with metronidazole.
• During the extraction of a lower wisdom tooth, particularly in an older person, the freeing of the tooth often requires the removal of a considerable amount of bone tissue. This, combined with the possible age-related weakening of the skeletal system, will increase the patient's risk of sustaining a fractured jaw. If the patient subsequently gives a history of a snap in his/her jaw whilst eating something hard or after a knock, fractured jaw should be suspected. The patient's bite should be checked and the chin imaged with orthopantomography. The patient should be referred to an oral surgeon or a hospital clinic of oral diseases.

Other oral surgery

• In addition to tooth extractions, many different surgical procedures are carried out in the region of the mouth and chin. The complications of such surgery are in principle similar to those seen after tooth extraction. Bleeding and subsequent haematomas, swelling and pain together with infections are the most frequent postoperative complications that require further management.