Maxillofacial & Dental
Question 101 of 300
A 45 year old man presents to the Emergency Department complaining of dental pain referred to the ear. He had a molar extraction 2 days previously. You suspect alveolar osteitis (dry socket). Which of the following is a risk factor for developing this condition post-extraction?
Answer:
It is much more common among smokers and oral contraceptive users and occurs mainly after removal of mandibular molars, usually wisdom teeth.Post-Extraction Complications
Maxillofacial & Dental
Last Updated: 12th February 2021
Complications after a dental procedure include:
- Swelling and pain
- Alveolar osteitis/alveolitis (dry socket)
- Osteomyelitis
- Bleeding
- Osteonecrosis of the jaw
Swelling and pain
- Swelling is normal after oral surgery and is proportional to the degree of manipulation and trauma.
- Management:
- An ice pack should be used for the first day. Cold is applied for 25-minute periods every hour or 2.
- If swelling does not begin to subside by the 3rd postoperative day, infection is likely and an antibiotic may be given.
- Postoperative pain varies from moderate to severe and is treated with analgesics.
Alveolar osteitis/alveolitis
- Post-extraction alveolitis is pain emanating from bare bone where a blood clot fails to develop in the tooth socket or if the blood clot becomes dislodged.
- Although this condition is self-limiting, it is quite painful and usually requires some type of intervention. It is much more common among smokers and oral contraceptive users and occurs mainly after removal of mandibular molars, usually wisdom teeth.
- Typically, the pain begins on the 2nd or 3rd postoperative day in the vicinity of the extraction site, is referred to the ear, and lasts from a few days to many weeks. There may be tenderness of the alveolar socket wall and an unpleasant taste or odour from the affected area.
- Management:
- Recommend optimal analgesia.
- Advise the patient to avoid smoking and maintain good oral hygiene.
- Advise the patient to seek urgent dental care.
- Consider:
- Irrigating with saline.
- Applying a suitable material to dress the socket e.g. Alvogyl.
- Do not prescribe antibiotics unless there are signs of spreading infection, systemic infection, or for an immunocompromised patient.
Osteomyelitis
- Osteomyelitis, which in rare cases is confused with alveolitis, is differentiated by fever, local tenderness, and swelling. If symptoms last a month, a sequestrum, which is diagnostic of osteomyelitis, should be sought by x-ray.
- Management:
- Osteomyelitis requires long-term treatment with antibiotics effective against both gram-positive and gram-negative organisms and referral for definitive care.
Post-extraction bleeding
- Post-extraction bleeding usually occurs in the small vessels.
- Bleeding can be immediate due to failure to secure adequate initial haemostasis, within a few hours (reactionary) or within a week of an extraction (indicative of possible infection)
- Management:
- Gently rinse the mouth once with warm (not hot) water to wash out excess blood.
- Advise the patient to place a rolled up piece of cotton or a gauze swab moistened with saline or water over the socket and to bite firmly on it. Maintain the pressure for 20 minutes before checking whether the bleeding has stopped. If necessary, repeat.
- If application of pressure does not work, find the source of the bleeding.
- Consider:
- Applying a haemostatic dressing to the socket (e.g. oxidised cellulose such as Surgicel or hemocollagene sponge).
- Suturing the wound to achieve good soft-tissue closure and/or to stabilise the socket edges.
- After the bleeding has stopped, advise the patient to avoid drinking alcohol, smoking or
exercising for 24 hours and to avoid disturbing the blood clot.
Osteonecrosis of the jaw
- Osteonecrosis of the jaw (ONJ) is an oral lesion involving persistent exposure of mandibular or maxillary bone, which usually manifests with pain, loosening of teeth, and purulent discharge.
- ONJ may occur after dental extraction but also may develop after trauma or radiation therapy to the head and neck. It may also be caused by some medications e.g. bisphosphonates.
- Management:
- Recommend optimal analgesia.
- Advise the patient to rinse their mouth with 0.2% chlorhexidine mouthwash.
- If of recent onset, advise the patient to seek urgent care. If chronic, advise the patient to seek non-urgent care.
- Do not prescribe antibiotics unless there is a discharge.
- Management of osteonecrosis of the jaw is challenging and typically involves limited debridement, antibiotics, and oral rinses.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
