Postextraction Problems

Swelling is normal after oral surgery and is proportional to the degree of manipulation and trauma. An ice pack (or a plastic bag of frozen peas or corn, which adapts to facial contours) should be used for the first day. Cold is applied for 25-minute periods every hour or 2. If swelling persists or increases after 3 days, or if the pain becomes severe, then the patient should be referred back to their dentist or surgeon (1).

Postoperative pain varies from moderate to severe and is treated with analgesics (see Treatment of Pain).

Postextraction bleeding usually occurs in the small vessels. Any clots extending out of the socket are removed with gauze, and a 4-inch gauze pad (folded) or a tea bag (which contains tannic acid) is placed over the socket. Then the patient is instructed to apply continuous pressure by biting for 1 hour. The procedure may have to be repeated 2 or 3 times. Patients are told to wait at least 1 hour before checking the site so as not to disrupt clot formation. They also are informed that a few drops of blood diluted in a mouth full of saliva appear to be more blood than is actually present.

If bleeding continues, the site may be anesthetized by nerve block or local infiltration with 2% lidocaine containing 1:100,000 epinephrine. The socket is then curetted to remove the existing clot and to freshen the bone and is irrigated with normal saline. Then the area is sutured under gentle tension. Local hemostatic agents, such as oxidized cellulose, topical thrombin on a gelatin sponge, or microfibrillar collagen, may be placed in the socket before suturing.

In most cases, patients taking anticoagulants (eg, aspirin, clopidogrel, warfarin, direct-acting oral anticoagulants) need not stop therapy before dental surgery (2). In those who are at increased risk of bleeding due to comorbid disease or in those undergoing more extensive procedures, consulting with their patient's physician about timing of antiplatelet or anticoagulant dosing or a brief 24- to 48-hour interruption in therapy is indicated.

Postextraction alveolitis is pain emanating from bare bone if the socket’s clot lyses. Although this condition is self-limited, it is quite painful and usually requires some type of intervention. It is much more common among people who smoke or use oral contraceptives and occurs mainly after removal of mandibular molars, usually wisdom teeth. Typically, the pain begins on the second or third postoperative day, is referred to the ear, and lasts from a few days to many weeks.

The socket should be rinsed with saline (chlorhexidine may be used for debridement only). For pain relief, a topical local anesthetic gel can be applied or a local anesthetic can be injected. Another option for symptom relief has been to place a 1- to 2-inch iodoform gauze strip saturated in eugenol (an analgesic) or coated with an anesthetic ointment, such as lidocaine 2.5% or tetracaine 0.5%, into the socket (3). The gauze is changed every 1 to 3 days until symptoms do not return after the gauze is left out for a few hours. More recently, a commercially available mixture of butamben (an anesthetic), eugenol, and iodoform (antimicrobial) has become more commonly used. Although not resorbable, this mixture washes out of the socket spontaneously after a few days. These procedures typically eliminate the need for systemic analgesics, although nonsteroidal anti-inflammatory drugs (NSAIDs) may be given if additional pain relief is needed. Patients should follow up with a dentist in 24 hours.

Osteomyelitis, which in rare cases is confused with alveolitis, is differentiated by fever, local tenderness, and swelling. If symptoms last a month, a sequestrum (ie, localized area of necrotic bone), which is diagnostic of osteomyelitis, should be sought by dedicated dental radiograph or CT scan. Osteomyelitis requires long-term treatment with antibiotics effective against both gram-positive and gram-negative organisms and referral to an oral surgeon for monitoring and/or definitive care.

Osteomyelitis

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Image courtesy of Byron (Pete) Benson, DDS, MS, Texas A&M University Baylor College of Dentistry.

Osteonecrosis of the jaw 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.

Medication-related ONJ (MRONJ) refers to the association discovered between use of antiresorptive agents and ONJ. These agents include antiresorptive medications (eg, bisphosphonates, denosumab) and antiangiogenic medications (eg, sirolimus, bevacizumab). Although similar in clinical course to osteonecrosis of the jaw, MRONJ is not always preceded by a tooth extraction or other oral surgery.

Management of osteonecrosis of the jaw is challenging and typically involves palliation, limited debridement, antibiotics, and oral rinses.

1. 1. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc. 2019;150(11):906-921.e12. doi:10.1016/j.adaj.2019.08.020

2. 2. American Dental Association Library & Archives, Research Services and Scientific Information. Oral anticoagulant and antiplatelet medications and dental procedures. Key Points. Accessed November 1, 2024.

3. 3. Daly BJ, Sharif MO, Jones K, Worthington HV, Beattie A. Local interventions for the management of alveolar osteitis (dry socket). Cochrane Database Syst Rev. 2022;9(9):CD006968. Published 2022 Sep 26. doi:10.1002/14651858.CD006968.pub3