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British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx

Incidence and treatment of complications in patients who

had third molars or other teeth extracted
I. Miclotte ∗ , J.O. Agbaje, Y. Spaey, P. Legrand, C. Politis
Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Kapucijnenvoer 33, Leuven 3000, Belgium

Accepted 4 February 2018

Abstract

The aim of this study was to compare the incidence of complications after extraction of third molars (M3) or other teeth, and to describe their
management. We made a retrospective cohort study of patients having M3 or other teeth extracted, and recorded complications up to two
years’ follow-up. A total of 142 complications developed after 2355 procedures (6%) – 7% after extraction of M3 compared with 5% after
extractions of other teeth (p = 0.024). The three most common complications were wound infection (2%), pain without apparent cause (<1%),
and oroantral communication (<1%). Patients who had M3 extracted were at increased risk of complications compared with those who had
other teeth extracted (Odds ratio (OR) 1.5, p = 0.024), particularly for infection (OR 5.9, p < 0.001) and hypoaesthesia (OR 8.4, p = 0.027).
Half of all patients with a complication were treated with antibiotics orally. The incidence of postoperative bleeding was 0.6% as a result of
suboptimal management of antithrombotic drugs in extractions of teeth other than M3. Finally, optimal treatment of the complications was
compared with the available evidence. Prevention and treatment of these complications could reduce the incidence, particularly of bleeding.
© 2018 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.

Keywords: dental extraction; alveolar osteitis; oral bleeding; antithrombotics

Introduction
Dental extractions are common for patients of all ages. In
some cases, the extraction of third molars (M3) or other teeth
can be challenging because of technical difficulties such as an
intimate relation between the roots of the teeth and the max-
illary sinus or the nerve, medical conditions, or the use of
antithrombotic drugs. The reported complication rates range
from 3.5% to 14.8% for extraction of M3, but few recent data
are available about extraction of other teeth.1–5 The optimal
management of both types of extraction, such as the use of
prophylactic antibiotics and the management of antithrom-
botic drugs, are still the subjects of clinical research.
∗ Corresponding author. Tel.: +32 16 33 24 62.
E-mail address: isabel.miclotte@uzleuven.be (I. Miclotte).
https://doi.org/10.1016/j.bjoms.2018.02.001
0266-4356/© 2018 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
The aim of the current study was to compare the incidence
and management of intraoral postoperative complications
after extractions of M3 and those of other teeth with the
current available evidence, to identify possible areas of
improvement.
Methods
We designed a retrospective cohort study that was approved
by our hospital’s ethics committee, and followed the princi-
ples of the declaration of Helsinki. We identified all patients
who had had dental extractions in the outpatient clinic of
the Department of Oral and Maxillofacial Surgery during
a one-year period, and recorded their age, number of M3
or other teeth extracted, use of antithrombotic drugs, com-
plications, and timing and management of complications

Please cite this article in press as: Miclotte I, et al. Incidence and treatment of complications in patients who had third molars or other
teeth extracted. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.02.001
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300
Number of procedures
200
100
0 0
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
Age (years)
Fig. 1. Number of third molars extracted by age. The ages at which they
were extracted were not normally distributed (p = 0.0001), with most being
done before the age of 35 years (mean age 32 years, dotted line).
25
Complication rate (%)
20
15
10
5 5
0 0
20 40 60 80
Age (years)
Fig. 2. Incidence of complications by age after extraction of M3. There is a
peak in complications in patients over 50 years old (mean incidence 7.24%,
dotted line).
(conservative, reintervention, local antibiotics, or systemic
antibiotics). Complications were classified as operative when
they happened during or immediately after the extraction, or
postoperative when they became apparent one or more days
after operation.
A surgical wound infection was defined as a complica-
tion when there were inflammatory changes such as pus, and
fluctuation or swelling with associated pain.1 Root fractures
were defined as a complication if the remaining root was
left in place. Impaired healing was defined as a persistent
mucosal defect or dehiscence one week or more after extrac-
tion. Hypoaesthesia was defined as any reported numbness
or decreased sensation in the region that was confirmed by
pinprick sensitivity and two-point discrimination. A reinter-
vention was defined as any procedure such as incision of an
abscess, placement of a terramycin gauze, or removal of a
bony sequestrum, with the exception of rinsing the wound
with salt solution.
Complications were recorded up to two years’ postoper-
atively. Patients were instructed to contact the department
in case of any symptoms, pain, or questions postoperatively.
Those who were thought to be at increased risk of complica-
tions were given a routine follow-up appointment.
Descriptive statistics were used to tabulate the numbers,
percentages, and age distribution of the complications in the
two groups. The incidence of complications by age was calcu-
lated by dividing the number of complications that developed
in each age category (for example, 15–20 years, 20–25 years,
Please cite this article in press as: Miclotte I, et al. Incidence and treatment of complications in patients who had third molars or other
teeth extracted. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.02.001
300
Number of procedures
200
100
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
Age (years)
Fig. 3. Number of extractions of teeth other than third molars according to
age. The ages followed a normal distribution (p = 0.09) with a mean of 53
years (dotted line).
25
Complication rate (%)
20
15
10
20 40 60 80
Age (years)
Fig. 4. Incidence of complications by age in extractions of teeth other than
third molars. There is no clear difference in the complication rate throughout
the age categories (mean incidence 5%, dotted line).
and so on) by the total number of extractions in that cat-
egory. Incidences of complications were compared between
groups by calculating the odds ratio and 95% CI, and we used
Fisher’s exact test to assess the significance of differences
between groups with the aid of GraphPad Prism (version
6.0, GraphPad Software Inc, La Jolla, California, USA).
Two-tailed probabilities of less than 0.05 were accepted as
significant.
Results
During the one-year period 1/1/2013–31/12/2013, we did
2355 procedures for 2082 patients: 1076 extractions of M3
(mean (range) age 32 (15–95) years) and 1279 extractions of
other teeth (mean (range) age 53 (7–99) years). There was
a total of 142 complications (6%). Most of the extractions
of M3 were in patients less than 38 years old (Fig. 1, 75th
percentile 38 years, mean age 32 years). The incidence of
complications/age category after extractions of M3 increased
with increasing age (Fig. 2). The ages of patients who had
other teeth extracted were normally distributed (Fig. 3) with
no clear trend in the age at which complications developed
(Fig. 4).
The incidence and types of complications are shown in
Fig. 5, and the management, including the reintervention
rate and use of antibiotics, in Table 1. More than half of
the patients who developed a complication were treated with
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Fig. 5. Incidence of complications after extraction of third molars (M3) and of other teeth. Data are number (%) except where otherwise stated.

Table 1
Management of complications.
No Mean (SD) age Mean (SD) days No that required No given
(years) after extraction reintervention antibiotics orally
Wound infection 41 30 (15) 10.9 (12.3) 9 39
Pain 22 44 (20) 12.2 (13.3) 2 7
Oroantral communication 18 48 (18) – 0 3
Bleeding 14 52 (28) 3.9 (3.9) 5 7
Bony sequestrum 13 55 (14) 28.2 (15.6) 11 2
Alveolar osteitis 12 46 (11) 5.8 (2.6) 3 7
Impaired healing 10 52 (22) 17.4 (12.4) 1 7
Hypoaesthesia 8 42 (24) 10.6 (11.7) 0 0
Other 4 43 (28) 4.3 (5.0) 1 0
Total number (SD) or (%) 142 43 (20) 4.2 (12.3) 32 (23) 72 (51)

All patients with an oroantral communications were diagnosed during the procedure, and patients were listed for routine follow-up.

antibiotics orally (n = 72) and patients with wound infections
were the most likely to be treated with antibiotics (n = 39),
followed by patients with impaired healing, alveolar osteitis,
and bleeding (n = 7 each). In total, 32 patients (23%) with
a complication required reintervention. Patients with a bony
sequestrum had the highest rate of reintervention (n = 11).
Fourteen patients developed a bleeding complication
(<1%), seven in each group (p = 0.79). Patients treated
with oral antithrombotic agents were at increased risk of
bleeding (OR 5.1, 95% CI 1.8 to 14.9, p = 0.005). Of
the 304 patients treated with antithrombotics, 180 were
treated with aspirin, 49 with vitamin K antagonists, 17
with clopidogrel, 12 with new oral anticoagulants, 13 with
low molecular-weight heparin, 15 with dual antiplatelet
treatment, and 18 with the combination of antiplatelet and
anticoagulant drugs. Aspirin was interrupted before the pro-
cedure for one patient, while dual antiplatelet treatment
was interrupted for six patients. Vitamin K antagonists
were interrupted in 18 patients. In patients having teeth
other than third molars extracted, six out of seven bleeding
complications occurred in patients treated with antithrom-
botics. The incidence of bleeding was significantly lower
in patients treated with aspirin compared with vitamin K
antagonists or new oral anticoagulants, 1/180 compared with
3/49 and 2/12 respectively, p < 0.001), but there was no
difference in the incidence of bleeding between patients
treated with vitamin K antagonists and those treated with
new oral anticoagulants (p = 0.25). None of the patients
who bled in the M3 group were treated with antithrombotic
agents.

Please cite this article in press as: Miclotte I, et al. Incidence and treatment of complications in patients who had third molars or other
teeth extracted. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.02.001
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Discussion gastrointestinal bleeding. In addition, partial opioid agonists

Extractions of M3 or other teeth are common procedures,
and complications should be managed optimally. Our aim
here was to describe the incidence and management of com-
plications, and to compare the routine clinical management
with the current available evidence to identify possible areas
of improvement. Our results show a complication rate of 7%
after extractions of M3 compared with 5% after extractions
of other teeth (Fig. 5, p = 0.024). The results for extractions of
M3 are comparable with those of previously reported papers
(3.5% to 14.8%), but in extractions of other teeth the inci-
dence was higher than anticipated (5% compared to 1% in one
historical group).6 Patients over 55 years having extractions
of M3 seemed to have a higher complication rate than younger
patients, which was not seen after extractions of other teeth
(Figs. 2 and 4).
Surgical wound infection
The most common complication was wound infection, with
a higher incidence after M3 extractions than after extractions
of other teeth (3.16% compared with 0.55%, p < 0.0001).
Our results for M3 extractions are comparable with the
incidences of 1%–4% reported elsewhere.7 Almost all the
affected patients were treated with antibiotics given orally
(95%). Some patients required a reintervention such as inci-
sion of an abscess or the placement of a terramycin gauze
(22%). A recent Cochrane analysis showed that prophylactic
antibiotics result in a 70% reduction in the relative risk of
infection in M3 extractions, with the number needed to treat
being 12 (p < 0.0001).8,9 Some other small retrospective or
prospective studies have shown data that militated against the
use of prophylactic antibiotics.10–12 We clearly defined these
infections, which were not just inflammation, and they were
still the leading complication, which suggests the need for
additional prospective clinical studies to evaluate the use of
antibiotics in dental extractions.
Pain
Pain is common for the first days after the procedure as a
result of the trauma of extraction. However, if it does not
decrease after the first few days, or a new type of pain devel-
ops, it is often a symptom of an underlying complication such
as wound infection, bleeding, a bony sequestrum or alve-
olar osteitis, which should then be treated accordingly. In
our series, 22 patients (1%), had pain with no clear aetiol-
ogy, of whom 32% were treated empirically with antibiotics.
The general approach for pain with no clear cause consists
of rinsing the extraction socket with salt solution to exclude
underlying conditions and to remove food remnants. Patients
should preferably be treated with paracetamol. Non-steroidal
anti-inflammatory drugs can be considered if the patient is
not taking antithrombotic drugs and if there is no history of
such as tramadol may be added.
Oroantral communication
The extraction of teeth close to the maxillary sinus is an
increased risk of the development of an oroantral commu-
nication, of which there was an incidence of 0.6% during
extractions of M3 and 0.9% in extractions of other teeth. In
patients in whom one was suspected during the procedure,
we used a Valsalva manoeuvre or nose-blowing test after
the procedure to confirm the diagnosis. Our rates include not
only persistent, clinically relevant oroantral communications,
but all postoperative ones. It is therefore difficult to com-
pare our results with published ones, in which incidences of
0.25%–2.5% after extractions of M3 have been reported.1,7
We treated small ones (<5 mm), with sufficient alveolar depth
to allow for formation of a stable clot, conservatively with
sinus precautions, and shallow or larger defects (5 mm or
more) with immediate closure with a local flap. If the com-
munication was chronic, or closure failed, we treated any
maxillary sinusitis and closed the oroantral communication.
Bleeding
A total of 14 patients had postoperative bleeding (0.6%),
and patients being treated with oral antithrombotics were at
increased risk (OR 5.1, p = 0.005). The management of these
drugs throughout the procedure was suboptimal not only for
those patients with bleeding, but also in the entire group,
which may have contributed to the number of patients who
bled. Although aspirin was almost never interrupted, dual
antiplatelet treatment was interrupted in six patients. Cur-
rent available evidence shows that aspirin, clopidogrel, or the
combination of both (dual antiplatelet therapy) should not be
interrupted, because the risk of bleeding is low compared
with the risk of a cardiovascular event such as myocardial
infarction.13–17 Vitamin K antagonists should not be inter-
rupted if the international normalised ratio (INR) is below
3.5.18,19 However 18 patients on vitamin K antagonists were
not managed this way. We have no data for new oral antico-
agulants in dental extractions, but it is advised not to extract
teeth within 4–6 hours after the last dose.20
Physicians may not be familiar with the optimal man-
agement of antithrombotics, particularly with the newer
molecules, if they do not routinely treat such patients. There
is a need therefore for guidelines for dentists and maxillofa-
cial surgeons on how to manage them. They should be concise
and easy to use by non-experts, otherwise the physician might
not be able to follow them. Guidelines for management of
vitamin K antagonists are available in our hospital, but in
the light of the low compliance in our study, we have made
them more easily available and updated them by including
the newer agents. Finally, patients also often interrupt their
own antithrombotic agents because of fear of bleeding.

Please cite this article in press as: Miclotte I, et al. Incidence and treatment of complications in patients who had third molars or other
teeth extracted. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.02.001
YBJOM-5352; No. of Pages 6
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The treatment of a bleeding complication at our cen-
tre consists of removal of the false coagulum under local
anaesthaesia with mepivacaine 3% without a vasoconstrictor,
removal of the sutures, and rinsing with saline. Haemostatic
measures are then applied according to which site is bleeding
and the patient’s condition (no topical haemostatic gauzes are
used in patients taking bone resorption inhibitors or in irra-
diated regions >50 Gy). In addition, the sharp bony edges are
smoothed when necessary. Finally, the wound is resutured
and the patient asked to bite on a gauze pack saturated with
tranexamic acid for 30 minutes.
Bony sequestra
Thirteen patients were diagnosed with bony sequestra (0.6%)
postoperatively, which compares with 0.3% in reported
extractions.2 They were diagnosed late, usually about a one
month postoperatively (Table 1). Since they cause substan-
tial discomfort to patients, there was a high reintervention
rate (n = 11). The presence of a sequestrum remains a clinical
diagnosis, as radiographs rarely reveal their site or extent.
Alveolar osteitis (dry socket)
Ten patients developed alveolar osteitis after extractions
of other teeth and two after extraction of M3, which is
lower than the 3.6% in published studies (Fig. 5).3,4,7 As
expected, patients with symptoms presented about five days
after the procedure. A recent Cochrane analysis showed that
antibiotic prophylaxis reduced the incidence by 39% in M3
extractions.9 However, the authors did not advise routine
prophylactic antibiotics to prevent it, because of the large
number needed to treat (38) and the moderate tolerability of
the antibiotics. Two more recent meta-analyses show num-
bers needed to treat of 18 and 14 in extractions of M3.21,22 We
treat alveolar osteitis with either wound irrigation, removal
of remnants of old clot, curettage, sedative dressings, mild to
strong analgesic prescriptions, or any combination of these,
with reassessment if the subjective complaints persist.
Hypoaesthesia
Seven patients (0.7%) developed hypoaesthesia after M3
extraction; four recovered completely and three partially.
Both the inferior alveolar nerve and the lingual nerve were
affected. As expected from the anatomy of M3, the incidence
of hypoaesthesia was significantly higher after extraction
of M3 compared with that after extraction of other teeth
(p = 0.027). Published reports show a large variability in the
incidence, ranging from 0.35% to 8.4% in mandibular M3
extractions. For patients in whom the inferior alveolar or lin-
gual nerves were damaged during the removal of lower M3,
the algorithm proposed by Robinson et al can be followed to
guide the clinical management.23 Cases of neuropathic pain
can be treated as described by Renton and Yilmaz.24 Better
visualisation of the anatomical relations between the M3 and
Please cite this article in press as: Miclotte I, et al. Incidence and treatment of complications in patients who had third molars or other
teeth extracted. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2018.02.001
5
the mandibular canal on cone-beam computed tomography,
and risk assessment of panoramic radiographs, will hopefully
minimise inferior alveolar nerve damage after extraction of
M3.25
Limitations
These results have some limitations: because the study was
retrospective, the complication rate might have been under-
estimated. Some patients do not seek medical attention for
small complications, or do not visit the same physician. Sec-
ondly, we found no previously reported complications such
as damage to adjacent teeth, fractures of the dentoalveolar
process or mandible, or disorders of the temporomandibular
joint.7 Thirdly, more detailed analysis of the development of
complications such as oroantral communications in relation
to the location of the tooth (upper jaw, premolar, or molar)
was outside the scope of this study. Nevertheless, we have
aimed to provide a comprehensive view of the complications
in a contemporary group of patients that is large enough to
provides data on extractions of both M3 and other teeth, and
point out possible areas of improvement.
Conclusion
We have retrospectively reported the complication rate after
extractions of M3 or other teeth in a contemporary group of
patients, and described their treatment. The management of
antithrombotic drugs was sometimes inconsistent, which led
to a higher than necessary risk of bleeding.
Funding
The work was supported by the Department of Oral & Max-
illofacial Surgery, University Hospitals Leuven, Belgium.
Conflict of interest
We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission
This retrospective study was approved by the hospital’s ethics
committee, and abided by the principles of the declaration of
Helsinki. No informed consent was required.
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