Services & Procedures

Studies have shown that there is a correlation between consumption of anti-coagulant drugs after dental extractions and the amount of bleeding. In one such review, oral anti-coagulants were prescribed to multiple subjects, all of whom were undergoing dental surgery. 89 out of 990 subjects (9%) had delayed postoperative bleeding, and 3.5% of these cases were not controlled by local measures (‘serious cases’). Other studies have reported greater numbers of patients with minor post-operative bleeding.However, it is difficult to standardize bleeding as the definitions used to categorize the extent of the bleeding tend to differ from study to study. However, the majority of studies concur that there is little risk of a major bleed if a patient is regularly consuming oral anticoagulants at the time of a simple dental extraction.

For simple extractions, therapeutic anti-coagulation can be continued, as the bleeding risk is not high and the risk of a thromboembolism is much higher than that of a serious bleed following the extraction. However, for complex extractions (3 or more teeth or multiple adjacent teeth), the risk of bleeding is higher, and the dentist should consult the patient’s doctor. Patients undergoing a course of treatment using anticoagulants should notify their dentist when organizing the procedure. An individual treatment plan should be drawn up for the patient, and the patient’s doctor should be contacted to confirm the anticoagulant being used, and the dose type. The patient’s INR should also be taken into account. When the patient has an INR of 4.0 or over, they should be referred to a specialist. The risk of hemorrhage is increased in the elderly (especially after post-surgical dental extractions) as they are more susceptible to dental caries and periodontal diseases. This should also be taken into account by the dentist.

To increase the effectiveness of oral anticoagulant drugs, bleeding risks can be further minimized by the usage of collagen sponges, sutures and rinsing 5% tranexamic acid mouthwash four times a day.

Overall, patients utilizing long-term anticoagulant therapies such as warfarin or salicylic acid (Aspirin) do not need to discontinue its use prior to having a tooth extracted. The extraction should be performed utilizing the least traumatic extraction procedure and patients should make sure to tell their dentist or oral surgeon about any medications they may take before the procedure.

Antibiotics can be prescribed by dental professionals to reduce risks of certain post extraction complications. There is evidence that use of antibiotics before and/or after impacted wisdom tooth extraction reduces the risk of infections by 70% and lowers incidence of dry socket by one third. For every 12 people who are treated with an antibiotic following impacted wisdom tooth removal, one infection is prevented. Use of antibiotics does not seem to have a direct effect on manifestation of fever, swelling or trismus seven days post-extraction. In the 2013 Cochrane review, 18 randomized controlled, double-blinded experiments were reviewed. After considering the biased risk associated with these studies, it was concluded that there is moderate overall evidence supporting the routine use of antibiotics in practice in order to reduce risk of infection following a third molar extraction. There are still reasonable concerns remaining regarding the possible adverse effects of indiscriminate antibiotic use in patients. There are also concerns about development of antibiotic resistance which advises against the use of prophylactic antibiotics in practice.

Immediately following the removal of a tooth, bleeding very commonly occurs. Pressure is applied by biting on a gauze swab, and a thrombus (blood clot) forms in the socket. Common homostatic measures include local pressure application with gauze and the use of oxidized cellulose (gelfoam) and fibrin sealant. Dental practitioners usually have absorbent gauze, hemostatic packing material (oxidized cellulose, collagen sponge) and suture kit available. Sometimes 30 minutes of continuous pressure is required to fully arrest bleeding. Talking, which moves the mandible and hence removes the pressure applied on the socket, instead of keeping constant pressure, is a very common reason that bleeding might not stop. This is likened to someone with a bleeding wound on their arm, when being instructed to apply pressure, instead holds the wound intermittently every few moments. Coagulopathies (clotting disorders, e.g. hemophilia) are sometimes discovered for the first time if a person has had no other surgical procedure in their life, but this is rare. Sometimes the blood clot can be dislodged, triggering more bleeding and formation of a new blood clot, or leading to a dry socket (see complications). Some oral surgeons routinely scrape the walls of a socket to encourage bleeding in the belief that this will reduce the chance of dry socket, but there is no evidence that this practice works.

The chance of further bleeding reduces as healing progresses, and is unlikely after 24 hours. If the bleeding occurs beyond 8 –12 hours, this situation is then referred as post-extraction bleeding. The blood clot is covered by epithelial cells which proliferate from the gingival mucosa of socket margins, taking about 10 days to fully cover the defect. In the clot, neutrophils and macrophages are involved as an inflammatory response takes place. The proliferative and synthesizing phase next occurs, characterized by proliferation of osteogenic cells from the adjacent bone marrow in the alveolar bone. Bone formation starts after about 10 days from when the tooth was extracted. After 10–12 weeks, the outline of the socket is no longer apparent on an X-ray image. Bone remodeling as the alveolus adapts to the edentulous state occurs in the longer term as the alveolar process slowly resorbs. In maxillary posterior teeth, the degree of pneumatization of the maxillary sinus may also increase as the antral floor remodels.

Many drug therapies are available for pain management after third molar extractions including NSAIDS (non-steroidal anti-inflammatory), APAP (acetaminophen) and opioid formulations. Although each has its own pain relieving efficacy, they also pose adverse effects. According to Dr. Paul A Moore and Dr. Elliot V. Hersh, Ibuprofen-APAP combinations have the greatest efficacy in pain relief and reducing inflammation along with the fewest adverse effects. Taking either of these agents alone or in combination may be contraindicated in those who have certain medical conditions. For example, taking ibuprofen or any NSAID in conjunction with warfarin (a blood thinner) may not be appropriate. Also, prolonged use of ibuprofen or APAP has GI and cardiovascular risks. There is high quality evidence that ibuprofen is superior Paracetamol in managing postoperative pain.

Socket Preservation or alveolar ridge preservation (ARP) is a procedure to reduce bone loss after tooth extraction to preserve the dental alvelous (tooth socket) in the alveolar bone. At the time of extraction a platelet rich fibrin (PRF) membrane containing bone growth enhancing elements is placed in the wound or a graft material or scaffold is placed in the socket of the extracted tooth. The socket is then directly closed with stitches or covered with a non-resorbable or resorbable membrane and sutured.

Following dental extraction, a gap is left. The options to fill this gap are commonly recorded as Bind, and the exact choice is agreed between dentist and patient based upon several factors.

Treatment option, Advantages, Disadvantages

Bridge Fixed to adjacent teeth Drilling usually required on one or both sides of the gap if conventional bridge (average lifespan about 10 years). Conservative bridge (average lifespan about 5 years) preparation may cause minimal damage to adjacent teeth. Expensive and complex treatment, not suited to all situations, e.g. large gaps in the back of the mouth alveolar bone will still resorb, and eventually a gap may show under bridge.

Implant Fixed to jawbone. Maintains alveolar bone, which would otherwise undergo resorption. Usually a long term lifespan.Expensive and complex, requiring specialist. May involve other procedures such as bone grafting. Relatively contra-indicated in tobacco smokers.

Denture Often a simple, quick and relatively cheap treatment compared to bridge and implant. Not usually any drilling of other teeth required. It is far easier to replace several teeth with a denture than place multiple bridges or implants.Denture is not fixed in mouth. Over time worsens periodontal disease unless there is good level of oral hygiene, and may damage soft tissues. Potential for slightly accelerated resorption of alveolar bone compared to no denture. Potential for poor tolerance in persons with over-sensitive gag reflex, xerostomia , etc. Nothing(i.e. not replacing the missing tooth) Often the choice due to cost of other treatment or lack of motivation for other treatments. Part of a shore end dental arch  plan, which revolves around the fact that not all teeth are required to eat comfortably, and only the incisors and premolars need be preserved for normal function. This is usually the choice taken if the reason of dental extraction is due to impacted wisdom teeth or orthodontics because of limited space.The alveolar bone will slowly resorb over time once the tooth is lost. Potential esthetic concern. Potential for drifting and rotation of adjacent teeth into the gap over time.