Simple tooth extraction is a procedure that most dentists perform on a regular basis, and postoperative complications can, and often do, occur.1 The negative sequelae most commonly associated with tooth extraction include edema, discomfort, prolonged bleeding, trismus, infection and alveolar osteitis (dry socket).1,2 Dealing with these complications can cause considerable loss of time from work for patients and disruption of normal schedules for dentists.3 Therefore, dentists may find it desirable to incorporate steps into their extraction protocol that can prevent the occurrence of these detrimental sequelae.
These steps can be divided into two areas: case selection and procedural modification. Prudent case selection minimizes the risk of attempting extractions that may prove to be beyond the practitioner’s level of competence4 and, therefore, be subject to a higher complication rate.1 This allows for an appropriate referral to a specialist to be made when needed. Procedural modification can be used to reduce the incidence of postoperative complications when the extraction is performed within the dentist’s capabilities.
In this article, I describe the process I use in my practice to limit the frequency of complications from ordinary extractions in adults who have no limiting medical conditions.
Dentists may find it desirable to incorporate steps into their extraction protocol that can prevent the occurrence of detrimental sequelae.
PROCESS
First, the patient rinses with an oral disinfectant, which has been shown to significantly reduce the occurrence of alveolar osteitis.5 My assistant then gives the patient a sheet with written postoperative instructions that are reviewed orally before any questions the patient may have are answered. I believe it is important to provide both written and oral instructions before the distractions of the procedure occur to ensure the patient’s understanding of and compliance with them.
Next, I administer local anesthetic, which is a key factor for both the degree of postoperative discomfort and the control of postextraction bleeding. For maxillary teeth, I first perform a buccal infiltration using 0.5 percent bupivicaine with epinephrine 1:200,000, and then I achieve palatal anesthesia using the transpapillary technique6 and the same agent. For mandibular teeth, I first use 4 percent articaine hydrochloride with epinephrine 1:100,000 for nerve blocks, as articaine’s properties afford greater efficacy for these types of injections.7,8 After the articaine has taken full effect, I use bupivicaine for a second block. The use of a long-acting local anesthetic, such as bupivicaine, is associated with delayed onset and reduced intensity of postoperative pain.9
After the tooth to be extracted has been profoundly anesthetized, I complete intraligamentous injections at several aspects of the tooth using 2 percent lidocaine with epinephrine 1:50,000 in an intraligamentous injector—the same instrument I used to achieve palatal anesthesia.6 This level of vasoconstrictor aids in postextraction hemostasis,10 and I have almost never known a patient who has been so anesthetized to experience intraoperative pain when I have extracted a tooth devoid of an active pulpitis. When I use this technique, I do not expect the chance of alveolar osteitis or other postoperative complications to increase.11,12
Once the tooth has been extracted, I pack the socket with an absorbable gelatin sponge impregnated with tetracycline and suture the socket. Suture tension should be sufficient to retain the packing material, but not so taut as to cause tissue necrosis due to vascular constriction.1 This kind of dressing will further reduce the possibility of alveolar osteitis and postoperative infection without the need for later removal.3,13 Alternatively, if a ridge preservation procedure is planned, it will serve the same purpose.14 Before dismissal, I give patients the nonsteroidal anti-inflammatory drug ketoprofen and once again review the postoperative instructions, especially the section that recommends taking acetaminophen when local anesthesia begins to subside. This combination of nonnarcotic analgesics can provide opioid-type pain relief without the associated side effects.9,15 It also can diminish inflammation and reduce the extent of edema and trismus present as a result of the surgery.9 I have always prescribed a narcotic pain reliever to patients after performing extractions, but few have reported needing to use it since I introduced these measures.
This process has added 10 minutes at the most to the extraction procedures I perform, with a minimal increase in overhead costs. Since instituting this process, I have experienced a considerable reduction in post-extraction complaints from my patients, and there have been no instances of alveolar osteitis. Only two patients have reported taking the prescribed narcotic when I asked them about it at the time of suture removal, and one other patient said that the narcotic was ineffective and, thus, required a different prescription.
CONCLUSION
The time this process saves me in averting unscheduled palliative appointments is significant. The patient gratification from the decrease in complications this process has generated, as well as the potential dissatisfaction that has been avoided,4 make this a valuable technique for me.
DO YOU HAVE A TIP TO SHARE?
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