Grainne McCloskey*
Principal Dentist, Dental Implants and Oral Surgery, Abbey Dental Clinic, United Kingdom
*Corresponding author: Grainne McCloskey, Principal Dentist, Dental Implants and Oral Surgery, Abbey Dental Clinic, United Kingdom.
Citation: McCloskey G. Complications of tooth extraction. J Oral Med and Dent Res. 5(1):1-8.
Received: February 07, 2024 | Published: Febraury 26, 2024
Copyright© 2024 genesis pub by McCloskey G. CC BY-NC-ND 4.0 DEED. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives 4.0 International License. This allows others distribute, remix, tweak, and build upon the work, even commercially, as long as they credit the authors for the original creation.
Doi: http://doi.org/10.52793/JOMDR.2024.5(1)-52
Abstract
Tooth extraction or exodontia, despite the massive advances in restorative dentistry, is still one of the most common procedures in dental practice. The aim of exodontia is to remove the cause of a patients pain as painlessly and a traumatically as possible. Unfortunately, there are number complications that can arise before, during and after an extraction that can result in a negative treatment outcome. Patient factors, local and systemic and operator factors have a role in the success of an extraction. The aim of this paper is to discuss and identify some of the relevant factors with a focus on prevention of complications.
Keywords
Tooth extraction; Exodontia; Haemorrhage; Extraction of wrong tooth
Introduction
Tooth extraction or exodontia, despite the massive advances in restorative dentistry, is still one of the most common procedures in dental practice. The aim of exodontia is to remove the cause of a patients pain as painlessly and a traumatically as possible. Unfortunately, there are number complications that can arise before, during and after an extraction that can result in a negative treatment outcome. Patient factors, local and systemic and operator factors have a role in the success of an extraction. The aim of this paper is to discuss and identify some of the relevant factors with a focus on prevention of complications. Complications are unforeseen events that cause an increased morbidity or an adverse outcome above what would normally be seen in a normal procedure. Complications can be divided into three categories:
1. Pre-operative
2. Peri-operative
3. Post-operative
Pre-Operative Complications
Patient factors that can lead to complications can often be identified and addressed before the surgery, if a robust and full dental, medical and social history is taken with a good history of pain [1]. The patient’s chief dental complaint along with location, intensity, duration, precipitating factors, relieving factors, radiating pain pathway to confirm that the pain is odontogenic in origin prior to tooth extraction [2]. recently discussed the new classification of orofacial pain produced in 2020 by the Orofacial pain Classification Committee which has divided facial pain into six main categories and detailed a diagnosis pathway to aid a clinician in the identification of non-odontogenic origin. As a guide to the prevalence of non- odontogenic facial pain [3]. reported the incidence within the UK to be between eight and 12.6/100000 population per annum. On average it takes a patient four years and three clinicians to be diagnosed during which 44% have irreversible dental treatment, either root canal therapy or extraction to alleviate their pain [4]. Treatment based on a patient’s history alone without supporting radiographic or clinical findings may be maltreatment. Taking a full medical history and extending into the extended family medical history may discover medical conditions such as diabetes or bleeding disorders which will have impact on treatment during and after, along with allergies and any medications. Overall systemic health will have an effect on the healing capacity of the oral cavity [5]. Between 2009 and 2018, the incidence rate of new clinical diagnoses of type 2 diabetes recorded in a UK primary care database decreased by a third from its peak in 2013–2014, while the incidence of pre-diabetes has tripled [6], after studying a large cohort group of over 400,000 people. Diabetes delays wound healing by reducing oxidation and perfusion of the peripheral blood supply and impairs the function of polymorphonuclear cells and delaying the release of cytokines essential in wound healing [7,8]. However, the research [9]. supports the notion that controlled diabetics have a similar healing capacity to non-diabetics when taking insulin, metformin, specific sulfonylureas, thiazolidinediones, and dipeptidyl peptidase-4 inhibitors but makes a recommendation to research further into what treatment medication would be best to promote wound healing. Additionally, there is little research into the effect of the prediabetic status on healing. This may be worth exploring. Diabetes mellites and hypertension have been shown to increase the chance of developing dry socket after extraction [10]. It is recommended to treat diabetic patients in the morning just after their breakfast to avoid hypoglycaemic crisis. Other medications such as bisphosphonates, warfarin, and factor Xa inhibitors (NOAC’s) will be discussed later. A very important consideration is the ability to achieve good anaesthesia under local anastatic typically more so in the mandible as the inferior dental nerve enters the body of the mandible at the lingual. Inferior dental nerve blocks (IDNB)s has a varying success rate between 65% and 92%, Bartlett and Mansoor, 2016, so alternative techniques have been suggested such as Gow-Gates, intraligamentary, intraosseous, buccal and closed mouth block to help achieve adequate numbness [11]. There would appear to be no difference in lidocaine as an IDNB compared to articaine infiltrations [12]. Anaesthesia is paramount to achieving a satisfactory treatment outcome.
Peri-Operative Complications
Soft tissue injuries to the gingiva, lips, cheeks, palate, and floor of mouth due to movement or slippage of instruments. In adequate support of the instruments and retraction of the gingiva using the thumb and forefinger of your free hand. Local anatomy, especially in the floor of the mouth (lingual artery) and the palate (incisive and palatal arteries), makes these areas very vascular. Small wounds can be left to heal without intervention. Large wounds make require suturing, ligating an artery or cauterisation.
Soft tissue injuries to the gingiva, lips, cheeks, palate, and floor of mouth due to movement or slippage of instruments. In adequate support of the instruments and retraction of the gingiva using the thumb and forefinger of your free hand. Local anatomy, especially in the floor of the mouth (lingual artery) and the palate (incisive and palatal arteries), makes these areas very vascular. Small wounds can be left to heal without intervention. Large wounds make require suturing, ligating an artery or cauterisation.
1. Tooth root fracture commonly occurs in extraction - The incidence of retained root fragments found on radiographic examination is in the incidence of 11-37% [13]. If there is enough root structure left, elevation of the remaining fragment or surgical removable by raising a flap and bone removal may be sufficient. If the root fractures at the apex, it may be best to leave the root in situ and a risk-benefit analysis should be undertaken to see if it is worth removing. Risks involved in removing a retained root include nerve damage, displacement into the maxillary antrum and lingual pouch, damage to the inferior dental nerve and damage to the adjacent teeth. Benefits include maintaining bone as in the socket shield technique. This technique uses a partial shell of buccal root divided from a root and used to maintain the buccal wall bundle bone prior to immediate implant placement [14].
2. Extraction of wrong tooth - No longer classed as a never event by [15]. Prior to this [16]. it accounted for 20- 25% of all wrong site surgery and 9% of all never events. The total incidence is unclear as only hospital-based and community services seem to have reported in this particular study so the figures from general practice are not included. Reasons stated for wrong removal include unclear notation, previous extraction and mesial drift of the adjacent teeth, previous restorations making tooth identification difficult and wrong referral. It may be prudent to ask for the tooth to be extracted to be expressed in both figure and written notation and if unclear, the procedure to be postponed until clarification obtained.
3. Root extruded into the maxillary sinus - Due to the upper molars root apices and their anatomical proximity to the maxillary sinus, it is not uncommon for the apices to displace apically into the maxillary sinus particularly if upward forces are applied to attempt to remove the root. This risk increases with age due to pneumatisation of the sinus and increased alveolar density [13].The risk of thrombosis sepsis of cavernous sinus sepsis which carries a mortality of 20-30% although small is present (Beech and Farrier 2016).When apices fracture high up in the alveolar bone, it may be more prudent to leave in situ and allow to erupt with time to a more favourable position than risk referral to ENT for a Functional endoscopic sinus surgery (FESS) procedure.
4. Restoration/crown fracture of the adjacent tooth – inappropriate use of the adjacent tooth as a fulcrum can lead to luxation and fracture of the adjacent tooth.
5. Luxation of the adjacent tooth.
6. Fracture of the maxillary tuberosity – occurs when awkward and heavy movements are used to extract an upper second or third molar, the risk is increased if the bone is D4 quality (very soft bone) but also conversely very dense bone(D1). There is no firm consensus on how to treat a fracture tuberosity [17]. recommend removal of the teeth and tuberosity simultaneously and closure of the wound with sutures whereas [18]. described a technique to dissection the tooth to be extracted from the tuberosity and suture [19]. discussed several methods to treat including stabilising the tuberosity for four to six weeks with a view to then surgically extracting the tooth.There appears to be no robust literature to support any mode of dealing with tuberosity fracture and would seem to be associated with operator experience and personal preference.
7. Haemorrhage – frequent occurrence enhanced by factor Xa inhibitors (apixaban, rivaroxaban, dabigatran), warfarin and aspirin. Consideration must be taken as to the timing of the extraction for those on anti-coagulants preferably early in the morning to allow for the wound clot to stabilize and to allow for continuation of the medication at a delayed time (for apixaban, the oral dose of medication can continue four hours after clot stabilization) (Curto and Albaladejo 2016).A comparison cohort study of 86 patients taking either warfarin (INR between 2 and 4) or NOAC’s showed no noticeable difference in bleeding events within a flow up of seven-day period [20]. There seems to be no firm evidence to support the use of collagen sponges, haemostatic agents to prevent post- operative bleeding. The use of tranexamic acid mouthwash to arrest bleeding has been advocated by some [21]. However, a systemic review by [22]. state that its superiority over other haemostatics was not proven. Additionally, it stated that histoacryl glue was proven better than gelatine sponges.
8. Creation of an oroantral fistula – [23] found that out of 147 cases repair of an oroantral fistula (OAF) with a buccal fat pad was the most reliable way to close the communication but did not consider the use of alloplast or collagen membrane simultaneous placement with buccal or palatal pedicle flap advancement as an alternative method of OAF closure. The buccal fat pad was seconded as the gold standard to repair an OAF [24]. This may change as developments with evidence to support the use of platelet rich fibrin (PRF) and collagen membrane becomes more substantial. It is widely thought that PRF improves soft tissue healing [25].
9. Fracture of the mandible – [26]. listed age, sex, relative tooth to bone volume, surgical technique, and degree of tooth impaction to be important in the risk of mandible fracture.
10. Displacement of a lower root into the lingual fascial space.
11. Dislocation of the temperomadiblar joint (TMJ) – more common in extraction of lower molars due to excessive force. The repositioning of the TMJ should occur as soon as possible to prevent muscle spasm.
12. Fractured instrument – check for wear and tear of instruments prior to usage.
13. Inhalational or ingestion of root or root fragment.
14. Systemic complications – asthma attack, anaphylaxis, angina, seizure, syncope and hypoglycaemia during the procedure managed by basic life support training.
Post-Operative Complications
1. Immediate or delayed haemorrhage – treated as above.
2. Swelling and pain.
3. Alveolar osteitis – most common complication after the removal of lower wisdom teeth, more prevalent in women than in men, mandibular extractions versus maxillary extractions, difficulty of extraction and smoking have been cited as causes [27].
4. Nerve injury – more common in the lower jaw where the inferior dental nerve and lingual nerves may be damaged affecting sensation along the dermatomes supplied by those branches [28]. found the incidence of inferior nerve damage is one to five percent seven days after third molar surgery which falls to less than one percent after six months. It may be a total or partial paraesthesia which if it does resolve will do so within six months in 85% of cases.
5. Trismus.
6. Osteonecrosis (BRONJ/MRONJ) - described as an area of uncovered bone that does not heal after eight weeks. More prevalent in the mandible than the maxilla, with diabetes mellites being the most frequent relative disease [29]. IV Bisphosphonates tend to have a higher risk of BRONJ than oral bisphosphonates and it has been suggested that extractions prior to three years of oral medication is safe. It may be better to keep in mind that the risk is lower under three years but is not negligible [30]. Other drugs implicated in its pathogenesis include Denosuamb and other cancer drugs. Hyperbaric oxygen, ozone therapy and low-level laser therapy to increase blood flow are treatment options but there is no definite treatment.
Summary
Complications will arise in exodontia ranging from the simpler alveolar osteitis to nerve damage from time to time. It is the best place of the surgeon to assess thoroughly through clinical and radiographic examination, within a robust dental and medical history framework, to present the best treatment plan. The ideal is to execute this plan with an intention of having minimal complications. The surgeon must choose the most appropriate surgical technique available to minimize the Fisk of complications wile acting within their scope of practice.
References
1. Thakur AR, Babshet M, Amur S, Naikmasur VG. (2014) Medical screening of dental patients: 16-year experience in a referral dental hospital. Journal of Medicine and the Person, 12(2):76-83.
2. Pigg M, Nixdorf DR, Law AS, Renton T, Sharav Y, et al. (2021) New International Classification of Orofacial Pain: What is in it for Endodontists? J Endo. 47(3):345-57
3. Hall GC, Carroll D, Parry D, McQuay HJ. (2006) Epidemiology and treatment of neuropathic pain: The UK primary care perspective. Pain. 122(1-2):156-62.
4. Zakrzewska JM. (2013) multi-dimensionality of chronic pain of the oral cavity and face. J Headache Pain. 14(1):37.
5. Shah R, Domah F, Shah N, Domah J. (2020) Surgical Wound Healing in the Oral Cavity: a Review. Dental Update. 47(2):135-43.
6. Pal K, Horsfall L, Sharma M, Nazareth I, Petersen I. (2021) Time trends in the incidence of clinically diagnosed type 2 diabetes and pre-diabetes in the UK 2009–2018: a retrospective cohort study. BMJ Open Diabetes Res Care. 9(1):e001989.
7. Terranova A. (1991) The Effects of Diabetes Mellitus on Wound Healing. Plast Surg Nurs.11(1):20-5.
8. Reinke JM, Sorg H. (2012) Wound Repair and Regeneration. Eur Surg Res. 49(1):35-43.
9. Salazar JJ, Ennis WJ, Koh TJ. (2016) Diabetes medications: Impact on inflammation and wound healing. J Diabetes Complications. 30(4):746-52.
10. Suri N, Dutta A, Siddiqui N, Kaur K, Jangra D. (2021) A literature review on dry socket. IP International Journal of Maxillofacial Imaging. 6(4):97-100.
11. Lee CR, Yang HJ. (2019) Alternative techniques for failure of conventional inferior alveolar nerve block. J Dent Anesth Pain Med. 19(3):125-34.
12. Bartlett G, Mansoor J. (2016) Articaine buccal infiltration vs lidocaine inferior dental block – a review of the literature. Br Dent J. 220(3):117-20.
13. Nayyar J, Clarke M, O’Sullivan M, Stassen LFA. (2015) Fractured root tips during dental extractions and retained root fragments. A clinical dilemma? Br Dent Jour.218(5):285-90.
14. Dayakar M, Waheed A, Bhat H, Gurpur P. (2018) The socket-shield technique and immediate implant placement. J Indian Soc Periodontol. 22(5):451-55.
15. https://www.england.nhs.uk/wp-content/uploads/2020/11/2018-Never-Events-List-updated-February-2021.pdf
16. Pemberton MN, Ashley MP, Saksena A, Dickson S. (2017) Wrong tooth extraction: an examination of “Never Event” data. Br J Oral Maxillofac Surg. 55(2):187-88.
17. Shah N, Bridgman JB. (2005) An extraction complicated by lateral and medial pterygoid tethering of a fractured maxillary tuberosity. Br Dent J. 198(9):543-44.
18. Ngeow WC. (1998) Management of the fractured maxillary tuberosity: An alternative method. Quintessence Int. 198(29):189-202090.
19. Chrcanovic BR, Freire-Maia B. (2011) Considerations of maxillary tuberosity fractures during extraction of upper molars: a literature review. Dent Tra. 27(5):393-98.
20. Brennan Y, Gu Y, Schifter M, Crowther H, Favaloro EJ. et al. (2020) Dental extractions on direct oral anticoagulants vs. warfarin: The dentst study. Res Pract Thromb Haemost. 4(2):278-84.
21. Patatanian E, Fugate SE. (2006) Hemostatic Mouthwashes in Anticoagulated Patients Undergoing Dental Extraction. Ann Pharmacother. 40(12):2205-10.
22. Ockerman A, Miclotte I, Vanhaverbeke M, Verhamme, P, Poortmans LL, et al. (2018) Local haemostatic measures after tooth removal in patients on antithrombotic therapy: a systematic review. Clin Oral Invest. 23(4):1695-1708.
23. Gheisari R, Zadeh HH, Tavanafar S. (2019) Oro-Antral Fistula Repair with Different Surgical Methods: a Retrospective Analysis of 147 Cases. J Dent. 20(2):107-12.
24. Fatani B, Fatani A, Alomar A. (2020) Oro-Antral Communication and Fistula: A Review of the Literature. Saudi J Oral Dent Res. 5(12):575-81.
25. AL-Juboori MJ, AL-Attas MA, Magno-Filho LC. (2018) Treatment of chronic oroantral fistula with platelet-rich fibrin clot and collagen membrane: a case report. Clin Cosmet Investig Dent. 10:245-49.
26. Bodner L, Brennan PA, McLeod NM. (2011) Characteristics of iatrogenic mandibular fractures associated with tooth removal: review and analysis of 189 cases. British Jour Oral Max Surg. 49(7):567-72.
27. Chen Y-W, Chi L-Y, Lee OKS. (2021) Revisit incidence of complications after impacted mandibular third molar extraction: A nationwide population-based cohort study. Plos one. 16(2):e02466.
28. Renton T. (2013) Oral surgery: part 4. Minimising and managing nerve injuries and other complications. Br Dent J. 15(8):393-9.
29. Jang D, Kim J. (2020) Analysis of Implant Associated Medication related osteonecrosis of the jaw: Retrospective clinical study. Clinical Oral Implants Res. 31(S20):197.
30. On S-W, Cho S-W, Byun S-H, Yang B-E. (2021) Various Therapeutic Methods for the Treatment of Medication-Related Osteonecrosis of the Jaw (MRONJ) and Their Limitations: A Narrative Review on New Molecular and Cellular Therapeutic Approaches. Antioxidants. 10(5):680.
31. Beech AN, Farrier JN. (2016) The importance of prompt referral when tooth roots are displaced into the maxillary antrum. Dent update. 43(8):760-65.
32. Ngeow W, Chai W. (2019) Comment on: Medication-related osteonecrosis of the jaw in osteoporotic patients: prevention and management. Singapore Med J. 60(1):52.
33. Patel B. (2015) Pain of Odontogenic and Non-odontogenic Origin. Endodontic Diagnosis, Pathology, and Treatment Planning. 63:1-19.
34. Renton T. (2011) Dental (Odontogenic) Pain. Rev Pain. 5(1):2-7.
35. Seigneur M, Cloitre A, Malard O, Lesclous P. (2020) Teeth roots displacement in the maxillary sinus: characteristics and management. J Oral Medicine Oral Surg. 26(3):34.
36. Tay ZW, Zakaria SS, Zamhari AK, Lee SW. (2018) Dentoalveolar fracture: A complication of extraction of upper left first molar. Clin Case Rep. 6(11):2096-8.
