Extraction of teeth Is a surgical procedure that presents a severe challenge to the- body’s hemostatic mechanism. Several reasons exist for this change First, the tissues of the mouth and jaws are highly vascular. Second” the extraction of a tooth leaves an open wound, with both soft tissue and bone open, which allows additional oozing  and bleeding. Third, it is almost impossible to apply
dressing material with enough pressure and sealing to prevent additional bleeding during surgery. Fourth, patients tend to play with the area of surgery with their tongues and occaslonallydislodge blood clots, which tiates secondary bleeding. The tongue may also cause secondary bleeding by creating small negative pressures that suction the blood clot from the ·socket. Finally, salvary enzymes may lyse the blood clot before it has .organized
and before the ingrowth of granulation tissue.

BOX 11-9

Prevention of Postoperative Bleeding
I. Obtain history of bleeding.
2. Use atraumatic surgical technique.
3. Obtain good hemostasis at surgery:
4. Provide excellent patient instrutions

As with all complications, prevention of bleeding is, the best way to manage this problem (Box 11-91_ One of the prime factors in preventing bleeding is the taking of a thorough history from tbfl patient regarding this specific
potential problem. Several questions should be asked of the patient concerning any history of bleeding. If affirmative answers to any of these questions are given, the surgeon should take special efforts to control bleeding. The first question that patients should be asked is if they have ever had a problem with bleeding in the past. The surgeon should inquire about bleeding after previous tooth. extractions or previous surgery (such as a tonsillectomy) and persistent bleeding after accidental lacerations. The surgeon must listen carefully to the patient’s answers to the questions, because the patient’s idea of “persistent” may actually be normal. For example, it is quite normal for a socket to ooze small amounts of blood for the first 12 to 24 hours after extraction. However, if ‘! patient relates a history of bleeding that persisted for more than 1 day or that required special attention from the dentist, then the surgeon’s degree of suspicion should be substantially elevated. The surgeon should inquire about any family history . of bleeding. If anyone in the patient’s family has or had
a history of prolonged bleeding,further inquiry about its cause should be pursued. Most congenital bleeding disorders are familial, inherited characteristics. These congenital  disorders vary from very mild to very profound, the latter requiring substantial efforts to control. . The patient should next be asked about anY”medications currently being taken that might interfere with coagulation. Drugs such as anticoagulants may cause
prolonged bleeding  after extraction. Patients receiving anticancer chemotherapy or who are alcoholics may also tend to bleed.’ .  The patient who has a known or suspected coagulopathy should be evaluated by laboratory testing before surgery is performed to determine the severity of the disorder. It is usually advisable to enlist the aid of a hematologist
if the patient  has a familial coagulation disorder.The means to measure the status of intentional anti- . coagulation is to use the International Normalized Ratio (lNR). This value takes into account both the patient’s
prothrombin time (PT) and -the control. Normal anticoagulated status for most medical indications will have an INR of 2.0 to 3.0. It is reasonable to perform extractions on patients who have an INR of 2.5 or less without reducing the anticoagulant dose. With special precautions, it is. reasonably safe to do minor amounts of surgery in’ patients with an INR of up to 3.0, if special local hemostatic measures are taken. Primary control of bleeding during routine surgery  depends on gaining control of all factors that may prolong bleeding. Surgery should be as atraumatic as possible, with clean incisions and gentle management of the Soft tissue. Care should be taken not to crush the soft tissue, because crushed tissue tends to ooze for long periods. Sllilrp bony spicules should be smoothed or removed. All granulation tissue should be curetted from the periapical region of the socket and from around the necks of adjacent teeth and soft tissue flaps. This deferred when anatomic restrictions, such as the sinus or inferior alveolar canal, are present (Fig. 11-12). The wound should be carefully inspected for the presence of any specific bleeding arteries. If such arteries exist in the soft tissue, they should be controlled with direct pressure or, if pressure fails, by clamping the artery with a hemostat and ligating it with a resorbable suture. For most oral surgical procedures, direct pressure over the soft tissue bleeding area for 5 minutes results in complete control. The surgeon should also check for bleeding from thebone. Occasionally, a small, isolated vessel bleeds from a bony fora men. If this occurs, the foramen can be crushed with the closed ends of the hemostat, thereby occluding the. bleeding vessel. Once these measures have been accomplished, the bleeding socket is covered with a damp gauze sponge that has been folded to fit directly into the area from which the tooth was extracted. The patient bites down firmly on this gauze for at least 30 minutes. The surgeon should not dismiss the patient from the office until hemostasis has been achieved. This requires that the surgeon check the patient’s extraction socket about 15 minutes after the completion of surgery. The patient should open the mciuth widely, the gauze should b e rermoved.vand the area should be inspected carefully for any persistent oozing.Initial control should have been achieved. New damp gauze is then folded and placed into position, and the patient is told to leave-it in place for an additional 30 minutes.  If bleeding persists but careful inspection of the socket reveals that it is not of an arterial origin, the surgeon should tak e additional measures to achieve hemostasis. Several different materials can be-placed in the socket to help gain hemostasis (Fig. 11-13). The most commonly used and the least expensive is the absorbable gelatin sponge (e.g., Gelfoam). This. material is placed in the extraction socket and held in place with’ a figure eight suture placed over the socket. The absorbable gelatin sponge forms a scaffold for the formation of a blood clot, and the suture helps maintain the sponge in position during the coagulation process. A gauze pack is then placed over the top of the socket and. is held with pressure. A second material that can be used to control bleedingis oxidized regnerated cellulose (e.g., Surgicel). This material promotes coagulation better than the absorbable gelatin sponge, bemuse it can be packed into the socket under pressure. The gelatin sponge becomes very friable when wet and cannot be packed into a bleeding socket. When the cellulose is packed into the socket, it almost always causes delayed healing of the socket. Therefore, packing the socket with cellulose is reserved for more persistent bleeding. If the surgeon has special concerns about the patient’sability to clot, a liquid preparation of topical thrombin (prepared from bovine thrombin) can be saturated onto a gelatin sponge and inserted into the tooth socket. The thrombin bypasses all steps in the coagulation cascade and helps to convert fibrinogen to, fibrin enzymatically, which formsa clot. The sponge with the topical thrombin is secured in place with a figure-eight suture. A gauze pack is placed over the extraction site in the usual fashion.A final material that can be used to help control a bleeding socket is collagen. Colla gen promotes platelet aggregation and thereby helps accelerate blood coagulation.Collagen is currently available in several different forms. Microfibular collagen (e.g., Avitene) is available as a .fibular material that is loose and fluffy but can be

FIG. "-12 Granuluma of second premolar. Surgeon should not curette periapically around this second premolar to remove granuloma because risk for sinus perforation is high.
FIG. “-12 Granuluma of second premolar. Surgeon should not curette periapically around
this second premolar to remove granuloma because risk for sinus perforation is high.

packed into a tooth socket and held in by suturing and gauze packs, as with the other materials. A more highly cross-linked collagen is supplied as a plug (e.g., Collaplug) or as-a tape (e.g., Collatape). These materials are more
readily packed into a socket (Fig. 11-14) and are easier to use. They are also more expensive. Even after primary hemostasis has been achieved, patients occasionally call the dentist with bleeding from the extraction site, ‘referred to as secondary’ bleeding. The patient should be told to rinse the mouth gently with very cold water, then place appropriate-sized g~uze over the area and bite firmly. The patient should sit quietly for 30 minutes, biting firmly on the gauze. If the bleeding persists, the patient ‘should repeat the cold rinse and bite down on a damp tea bag. The tannin in the tea will frequently help . stop the bleeding. If neither of these techniques is successful, the patient should return to the dentist.The surgeon must have an orderly, planned regimen to control this secondary bleeding. The patient should be positioned in the dental chair, and all blood, saliva, and fluids should be suctioned from the mouth. Such patients will frequently have large “liver clots” in their mouth, which must be removed. The surgeon should visualize the bleeding site carefully with good light to determine
the precise source of bleeding. If it is clearly seen to be ageneralized oozing, the bleeding site is covered with a folded, damp gauze sponge held in place with firm pressure by the surgeon’s finger for at least 5 minutes.

FIG. 11-13 Material that can be used in a bleeding socket. Clockwise from the canine tooth: collagen plug, microfibular collagen, regenerated oxidized cellulose, collagen tape, and absorbable gelatin sponge. r
FIG. 11-13 Material that can be used in a bleeding socket.
Clockwise from the canine tooth: collagen plug, microfibular collagen,
regenerated oxidized cellulose, collagen tape, and absorbable
gelatin sponge.
FIG. 11-14 A, Collagen shaped into the. form of a plug is similar in size to the root of a maxillary canine. Band C, The collagen plug is placed into the socket with cotton pliers (arrow). D, A figureeight suture isplaced over the socket to maintain the collagen in the socket.
FIG. 11-14 A, Collagen shaped into the. form of a plug is similar in size to the root of a maxillary
canine. Band C, The collagen plug is placed into the socket with cotton pliers (arrow). D, A figureeight
suture isplaced over the socket to maintain the collagen in the socket.

This measure is sufficient to control most bleeding. The reason for the> bleeding is usually some secondary trauma that is potentiated by the patient’s continuing to suck on the area or to spit blood from the mouth instead of continuing to apply pressure with a gauze sponge. If 5 minutes of this treatment does not control the bleeding, the surgeon must administer a local anesthetic so that the socket can be treated more aggressively. Block
techniques are to be encouraged instead of local infiltration techniques. Infiltration with solutions containing epinephrine cause vasoconstriction and may control the bleeding temporarily. However, when the effects of the
epinephrine dissipate, rebound hemorrhage with recurrent bothersome bleeding may occur. Once local anesthesia has been achieved, the surgeon
should gently curette out the tooth extraction socket and suction all areas of old blood clot. The specific area of bleeding should be identified as clearly as possible. As with primary bleeding, the soft tissue should be checked for diffuse oozing versus specific artery bleeding. The bone tissue should be checked for small nutrie t artery bleeding or general oozing. The same measures described for control of primary bleeding should be used. The surgeon must then decide if a hemostatic agent should be inserted into the bony socket. The use of an absorbable gelatin sponge with topical thrombin held in position with a figure-of-eight stitch and reinforced with application of firm pressure from a small, damp gauze pack is standard for local control of secondary bleeding. This technique works well in almost every bleeding socket. In many. situations an absorbable gelatin sponge and gauze pressure are adequate. The-patient should be given specific instructions on how to apply the gauze packs directly to the bleeding site should additional bleeding occur. Before the patient with secondary bleeding is discharged from the office, the surgeon should monitor the patient for at least 30 minutes to ensure that adequate hemostatic control has been achieved. If hemostasis is not achieved by any of the local measures just discussed, the surgeon should consider performing additional laboratory screening tests to determine if the patient has a profound hemostatic defect. The dentist usually requests a consultation from a hematologist, who orders the typical screening tests. Abnormal- test results will prompt the hematologist to investigate the patient’s hemostatic system further. A final hemostatic complication relates to intraoperative and postoperative bleeding into the adjacent soft tissues. Blood that escapes into tissue spaces, especially subcutaneous tissue spaces, appears as bruising of the overlying soft tissue 2 to 5 days after the surgery. This bruising is termed ecchymosis (see Chapter 10). removal.  careful asepsis and thorough wound debridement a fter surgery can best achieve prevention of infection after surgical flap procedures. This means that the ‘area of bone removal under the flap must be copiously irrigated with saline and that all foreign debris must be removed with a curette. Some patients are predisposed to postoperative wound infections and should be given perioperative prophylactic antibiotcs (see Chapter 15).

Wound Dehiscence

Another problem of delayed healing is wound dehiscence (Box 11-10). If a soft tissue flap is replaced and sutured without an adequate bony foundation, the unsupported soft tissue flap ‘often sags and separates along the line of incision. A second cause of dehiscence is suturing the wound under tension. If the soft tissue flap is sutured under tension, the sutures cause ischemia of the flap margin with subsequent ’tissue necrosis, which allows the suture to pull through the flap margin and results in wound dehiscence. Therefore sutures should always be placed in tissue without tension and tied loosely enough to prevent blanching of the tissue.  A common area of exposed bone after tooth extraction is the internal oblique ridge. After extraction of the first and second molar, during the initial healing, the lingual flap becomes stretched over the internal oblique (mylohyoid) ridge. Occasionally, the bone will perforate through the thin ‘mucosa, causing a sharp projection of  one in the area. The two major treatment options are (1) to leave the projection alone, or (2) to smooth it with bone file. If the area is left to heal untreated, the exposed bone ‘Will
slough off in 2 to 4 weeks. If the irritation of the sharp bone is low, this is the preferred method. If a bone file is .used, 110 flap should be elevated, because this will result in an increased amount of exposed bone. The file is used only to smooth off the sharp projections of the bone. This procedure usually requires local anesthesia. Patients who are -quite annoyed by the sharp bone will usually choose this method .

Dry Socket

Dry socket or alveolar osteitis is delayed healing but is not associated with an infection. This postoperative complication causes moderate-to-severe pain but Is without the usual signs ‘and symptoms of infection, such as ever, swelling, and erythema. The term dry socket describes  he appearance of the tooth extraction socket when the pain

BOX 11-10

Prevention of Wound Dehiscence
1. Use aseptic technique.
2. Perform atraumatic surgery.
3. Close incision over intact bone.
4. Suture without tension.

begins. In the usual clinical course, pain develops on the third or fourth day after removal of the tooth. On examination the tooth socket appears to be empty, with a partially or completely lost blood clot, and the bony surfaces
of the ‘socket are exposed. The exposed bone is extremely sensitive and is the source of the pain. The dull” aching’ pain is moderate to severe, usually throbs, and frequently radiates to the patient’s ear.The area of the socket has a bad odor  the patient frequently complains of a bad taste.The cause of alveolar osteitis is not absolutely clear, but it appears to be the result of high levels of fibrinolytic activity in and around the tooth extraction socket. This fibrinolytic activity results in lysis of the blood dot and subsequent exposure of the bone. The fibrinolytic activity may be the result of subclinical infections, inflammation of the marrow space of the bone, or other factors. The occurrence of, a dry socket after a routine tooth
extraction is relatively rare (2% of extractions), but it is quite frequent after the removal of impacted mandibular third molars (20% of extractions). ,
Prevention of the dry socket syndrome ,requires,that the surgeon minimize trauma and bacterial contamination in the area.of surgery. The surgeon should perform atraumatic surgery with clean incisions and soft tissue
reflection. After the surgical procedure, the wound should be thoroughly debrided and irrigated with large quantities of saline. Small amounts of antibtottcs (e.g., tetracycline) placed in the socket alone or OI:l a gelatin
sponge may help to decrease the incidence of dry socket in mandibular third molars. The incidence of dry socket can also be decreased by preoperative and postoperative ,rinses with antimicrobial mouth rinses, such as chlorhexidine. Well-contralled studies indicate that the incidence
of dry socket after impacted mandibular third molar surgery can be reduced by up to Se The treatment of alveolar osteitis is dictated by the
single therapeutic goal of relieving the patient’s pain during the period of healing. If the patient receives no treatment, no sequela other than continued pairi exists (treatment does not hasten healing).  Treatment is straightforward and consists of gentle irrigation and insertion of a medicated ‘dressing. First, the. tooth socket is gently irrigated with saline. The socket should not be curetted down to bare bone, because this increases both the amount of exposed bone and the pain. Usually the entire blood clot is not lysed, and the part that is intact should be retained. The socket is carefully suctioned of all excess saline, and a small strip of  soaked with the medication Is inserted into the socket. The medication contains the following principal ingredients: eugenol, which obtunds the pain from the bone tissue; a topical anesthetic, such as benzocaine and a carrying vehicle, such as balsam of Peru. The medication can be made by the surgeon’s pharmacist or can he obtained as a commercial preparation from dental surgery houses. The medicated gauze is gently inseted into the socket,   nd the patient usually experiences profound relief from pain within 5 minutes. The dressing is changed every-day or every other day for the next 3 to 6 days, depending on the severity of the pain. The socket is gently irrigated with saline at each dressing change. Once the patient’s pain decreases, the dressing should not be replaced, because it acts as a foreign body and further prolongs wound healing.

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