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Postextraction Problems

By David F. Murchison, DDS, MMS, Clinical Professor, Department of Biological Sciences;Clinical Professor, The University of Texas at Dallas;Texas A & M University Baylor College of Dentistry

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Swelling and pain

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-min 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 (eg, penicillin VK 500 mg po q 6 h or clindamycin 300 mg po q 6 h) until 72 h after symptoms subside.

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

Alveolitis and osteomyelitis

Postextraction alveolitis (dry socket) is pain emanating from bare bone if the socket’s clot lyses. Although assumed to be due to bacterial action, it is much more common among smokers and oral contraceptive users. It is peculiar to the removal of mandibular molars, usually wisdom teeth. Typically, the pain begins on the 2nd or 3rd postoperative day, is referred to the ear, and lasts from a few days to many weeks. Alveolitis is best treated with topical analgesics: a 1- to 2-in iodoform gauze strip saturated in eugenol or coated with an anesthetic ointment, such as lidocaine 2.5% or tetracaine 0.5%, is placed in the socket. The gauze is changed every 1 to 3 days until symptoms do not return after the gauze is left out for a few hours. This procedure eliminates the need for systemic analgesics.

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. Osteomyelitis requires long-term treatment with antibiotics effective against both gram-positive and gram-negative organisms and referral for definitive care.

Osteonecrosis of the jaw (ONJ)

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 (1). ONJ may occur after dental extraction but also may develop after trauma or radiation therapy to the head and neck.

Medication-related ONJ refers to the association discovered between use of antiresorptive agents and ONJ. These agents include bisphosphonates (BP), osteoclast-inhibiting drugs, and cathepsin K inhibitors. Cancer patients receiving IV BP have a 4-fold increased risk of ONJ, perhaps due to greater bioavailability of IV BP. However, oral BP therapy for noncancer patients seems to pose very low risk of ONJ; the prevalence in this population is about 0.1% according to a recent estimate. Stopping oral BP therapy is unlikely to reduce this already low rate of ONJ, and maintaining good oral hygiene is a more effective preventative measure than stopping oral BP before dental procedures. Higher doses and longer duration (therapy > 2 yr) of antiresorptive therapies are associated with ONJ. Other drugs that cause ONJ include the osteoclast inhibitor, denosumab, and some targeted anticancer agents, such as bevacizumab and sunitinib.

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


Postextraction bleeding usually occurs in the small vessels. Any clots extending out of the socket are removed with gauze, and a 4-in gauze pad (folded) or a tea bag is placed over the socket. Then the patient is instructed to apply continuous pressure by biting for 1 h. The procedure may have to be repeated 2 or 3 times. Patients are told to wait at least 1 h 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.

If possible, patients taking anticoagulants (eg, aspirin, clopidogrel, warfarin) should stop therapy 3 to 4 days before surgery. Therapy can be reinstated that evening. If these measures fail, a systemic cause (eg, bleeding diathesis) is sought.


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