What are the potential sequelae after tooth extraction?

From the Guidelines

To minimize the risk of osteoradionecrosis (ORN) after tooth extraction, patients with a history of head and neck radiation therapy should receive pentoxifylline 400 mg twice daily and tocopherol 1000 IU once daily for a mean of 11 weeks preoperatively and 13.6 weeks postoperatively, along with perioperative antibiotics and chlorhexidine 0.2% mouthwash and/or 1% gel for 7-14 days after the procedure. This approach is based on the study by Patel et al 1, which reported a low ORN rate of 1.2% (0.26% at the tooth level) in patients who underwent 390 dental extractions. The use of pentoxifylline and tocopherol, as well as perioperative antibiotics, is crucial in reducing the risk of ORN, especially in patients with a longer time interval between radiation therapy and dental extraction. Some key considerations after tooth extraction include:

• Taking prescribed pain medications as directed
• Applying an ice pack to the outside of the face for 20 minutes on, 20 minutes off during the first 24 hours to reduce swelling
• Biting gently on the gauze pad placed by the dentist for about 30-45 minutes to control bleeding
• Resting for 24 hours and avoiding strenuous activities for 2-3 days
• Eating soft foods like yogurt, applesauce, and soup for the first few days
• Avoiding rinsing, spitting forcefully, or using a straw for 24 hours to avoid dislodging the blood clot
• Rinsing gently with warm salt water (1/2 teaspoon salt in 8 ounces water) several times daily after 24 hours
• Avoiding smoking and alcohol for at least 72 hours as they can delay healing
• Monitoring for signs of infection like fever or pus, and contacting the dentist immediately if severe pain, excessive bleeding, or signs of infection occur. The study by Aggarwal et al, also cited in 1, utilized a similar regimen and reported higher ORN rates among patients with a longer time interval between radiation therapy and dental extraction, highlighting the importance of careful planning and management in these cases.

From the Research

Sequels after Tooth Extraction

• Sequels after tooth extraction can include infectious complications, dry socket, pain, fever, and adverse effects 2
• The use of systemic antibiotic prophylaxis may reduce the risk of postsurgical infectious complications and dry socket in patients undergoing third molar extractions 2
• However, the evidence for the effectiveness of antibiotics in preventing other sequels such as pain, fever, and adverse effects is uncertain 2

Antibiotic Prescription after Tooth Extraction

• A retrospective cohort study found that dentists did not discriminate prophylactic antibiotic prescription with regard to endocarditis risk status, and that the number of extracted teeth was a factor influencing prescribing behavior 3
• The most frequently prescribed antibiotic medicines were clindamycin and amoxicillin/clavulanic acid 3
• Another study found that amoxicillin was effective in preventing post-extraction bacteraemia, with a statistically significant difference compared to the control group and the chlorhexidine group 4

Management of Acute Dental Pain

• A clinical practice guideline recommends the use of nonopioid medications, such as nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen, as first-line therapy for managing acute dental pain after tooth extraction 5
• The use of opioids should be reserved for clinical situations when first-line therapy is insufficient to reduce pain or there is contraindication of nonsteroidal anti-inflammatory drugs 5

Prevention of Alveolar Osteitis

• A double-blind clinical study found that the use of chlorhexidine gel and tranexamic acid agents in the extraction socket may reduce the incidence of alveolar osteitis 6
• The study also found that pain and edema scores significantly decreased in the absorbable gelatin sponge group on the 7th day 6