C L I N I C A L D I R E C T I O N S
Preventing the negative
sequelae of tooth extraction
BARRY F. McARDLE, D.M.D.
imple tooth extraction
S is a procedure that
most dentists perform
on a regular basis, and
postoperative compli-
cations can, and often do, occur.1
The negative sequelae most
commonly associated with tooth
extraction include edema, dis-
comfort, 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 dis-
ruption of normal schedules for
dentists.3 Therefore, dentists
may find it desirable to incorpo-
rate 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 mini-
mizes 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 appro-
priate referral to a specialist to
742 JADA, Vol. 133, June 2002
Copyright ©2002 American Dental Association. All rights reserved.
patient’s understanding of and
compliance with them.
Next, I administer local anes-
thetic, which is a key factor for
both the degree of postoperative
discomfort and the control of
postextraction bleeding. For
maxillary teeth, I first perform
be made when needed. Pro- a buccal infiltration using 0.5
cedural modification can be used percent bupivicaine with
to reduce the incidence of post-
operative complications when
the extraction is performed
within the dentist’s capabilities.
In this article, I
describe the pro-
epinephrine 1:200,000, and then
I achieve palatal anesthesia
using the transpapillary tech-
nique6 and the same agent. For
mandibular
teeth, I first use 4
cess I use in my Dentists may find percent articaine
practice to limit it desirable to hydrochloride
the frequency of incorporate steps into with epinephrine
complications from their extraction 1:100,000 for
ordinary extrac- protocol that can nerve blocks, as
tions in adults articaine’s prop-
prevent the
who have no lim- erties afford
iting medical occurrence of greater efficacy
conditions. detrimental sequelae. for these types of
injections.7,8 After
PROCESS
the articaine has
First, the patient rinses with an taken full effect, I use bupivi-
oral disinfectant, which has caine for a second block. The use
been shown to significantly of a long-acting local anesthetic,
reduce the occurrence of alveolar such as bupivicaine, is associ-
osteitis.5 My assistant then gives ated with delayed onset and
the patient a sheet with written reduced intensity of postopera-
postoperative instructions that tive pain.9
are reviewed orally before any After the tooth to be
questions the patient may have extracted has been profoundly
are answered. I believe it is anesthetized, I complete
important to provide both intraligamentous injections at
written and oral instructions several aspects of the tooth
before the distractions of the using 2 percent lidocaine with
procedure occur to ensure the 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 experi-
ence 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 complica-
tions to increase.11,12
Once the tooth has been
extracted, I pack the socket
with an absorbable gelatin
sponge impregnated with tetra-
cycline and suture the socket.
Suture tension should be suffi-
cient to retain the packing
material, but not so taut as to
cause tissue necrosis due to vas-
cular 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 keto-
profen and once again review
the postoperative instructions,
especially the section that rec-
ommends taking acetamino-
phen when local anesthesia
begins to subside. This combi-
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Copyright ©2002 American Dental Association. All rights reserved.
C L I N I C A L
nation 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 pre-
scribed 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 over-
head 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 pallia-
tive appointments is significant.
The patient gratification from
the decrease in complications
this process has generated, as
well as the potential dissatisfac-
tion that has been avoided,4
D I R E C T I O N S
make this a valuable technique
for me. ■
Dr. McArdle is a general dentist in private
practice, 118 Maplewood Ave., The Captain
Moses House, Suite 7-B, Portsmouth, N.H.
03801, e-mail “drmcardle@mcardledmd.com”.
Address reprint requests to Dr. McArdle.
1. Garibaldi JA. Dentoalveolar surgical
sequelae. Compend Contin Educ Dent
1998;19(4):407-16.
2. Matocha DL. Postsurgical complications.
Emerg Med Clin North Am 2000;18(3):549-64.
3. Vezeau PJ. Dental extraction wound man-
agement: medicating postextraction sockets. J
Oral Maxillofac Surg 2000;58(5):531-7.
4. Hart BT, Zech RK. Clinical, radiographic
indicators of a pending difficult extraction.
Dent Today 1997;16(7):72-3.
5. Hermesch CB, Hilton TJ, Biesbrock AR, et
al. Perioperative use of 0.12% chlorhexidine
gluconate for the prevention of alveolar
osteitis: efficacy and risk factor analysis. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod
1998;85(4):381-7.
6. McArdle BF. Painless palatal anesthesia.
JADA 1997;128:647.
7. Friedman MJ. New advances in local
anesthesia. Compend Contin Educ Dent
2000;21(5):432-40.
8. Malamed SF, Gagnon S, Leblanc D. Arti-
caine hydrochloride: a study of the safety of a
new amide local anesthetic. JADA 2001;
132:177-85.
9. Dionne R. Preemptive vs. preventive anal-
gesia: which approach improves clinical out-
comes? Compend Contin Educ Dent 2000;
21(1):48-56.
10. Jastak JT, Yagiela JA, Donaldson D.
Local anesthesia of the oral cavity. Philadel-
phia: Saunders; 1995.
11. Tsirlis AT, Iakovidis DP, Parissis NA.
Dry socket: frequency of occurrence after
intraligamentary anesthesia. Quintessence Int
1992;23(8):575-7.
12. Svajhler T, Knezevic G. Postextraction
complications and the choice of anesthesia [in
Serbo-Croat]. Acta Stomatol Croat 1990;
24(4):241-51.
13. Leonard M. Preventing and treating dry
socket. Dent Prod Report 2001;35(3):96-100.
14. Ashman A. Ridge preservation: impor-
tant buzzwords in dentistry. Gen Dent
2000;48(3):304-12.
15. Dionne R. Additive analgesia without
opioid side effects. Compend Contin Educ Dent
2000;21(7):572-7.
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