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Dental

Management of Post-Extraction Complications Continuing Dental Education Course

2016-05-25 / Categories:hemostatic, sponge,
  
The clot functions by preventing debris, food, and other irritants from entering the extraction site. It also protects the underlying bone from bacteria and finally acts as a supporting system in which granulation tissue develops. Tissue damage provokes the inflammatory reaction, and the vessels of the socket expand. Leucocytes and fibroblasts invade from the surrounding connective tissues until the clot is replaced by granulation tissue. Leucocytes gradually digest the clot, while epithelium begins to proliferate over the surface during the second week post-operatively. This eventually forms a complete protective covering.

During this time, there is an increased blood supply to the socket which is associated with resorption of the dense lamina dura by osteoclasts. Small fragments of bone which have lost their blood supply are encapsulated by osteoclasts and eventually pushed to the surface or resorbed. Approximately one month after an extraction, coarse, woven bone is then laid down by osteoblasts.  Trabecular bone then follows, until the normal pattern of the alveolus restored.  finally, compact bone forms over the surface of the alveolus, and remodeling continues as the bone shrinks.

Bleeding Challenges

Bleeding challenges sometime present themselves due to the nature of the body’s hemostatic system. The high vascularization of the head and neck region is both friend and foe to the dental surgeon. Once a tooth is extracted, direct primary wound closure is sometimes impossible, due to the lack of soft tissues that leave large openings in the alveolus. Unlike other wounds or surgical openings, there is an inability to apply and sustain direct pressure  to the socket of an extracted tooth. Other forces exist to even complicate things further, such as disruptive forces from tongue motion, passage of food, and normal speech. Salivary enzymes also interfere with blood clotting and the processes that follow in the evolution of the clot.

Preventing Problems and Health History

A thorough medical history should be taken, including questions regarding bleeding problems.  Some conditions that may prolong bleeding are non-alcoholic liver disease (primarily hepatitis), and hypertension. Patients with known bleeding disorders should only be treated by oral/maxillofacial surgeons, or dentists that have had extensive training in managing medically compromised patients. Techniques to manage bleeding may employ the administration of blood transfusions containing adequate factor replacement which will allow for hemostasis. The health history should include questions that discover bleeding problems associated with minor scrapes and cuts. Family medical history is also important in order to detect possible genetic diseases that patients are unaware of potentially having. Complete and  current medication lists should be documented and checked against references that may indicate side effects. It is also advisable that patients taking extensive medications receive clearance to undergo surgery from their physician.

Many drugs interfere with coagulation. There are five groups of drugs known to promote bleeding: aspirin, broad-spectrum antibiotics, anticoagulants, alcohol, and chemotherapeutic agents. Aspirin and aspirin containing preparations interfere with platelet function and bleeding time. Anticoagulant drugs speak for themselves. Broad-spectrum antibiotics decrease vitamin K production which is necessary for coagulation factors produced in the liver.