Difficulties with extractions are unpredictable. Having a thorough medical history prior to surgery will allow the surgeon to better deal with complications that may arise. Be certain to always follow proper surgical techniques, and know your limitations prior to beginning any extractions. If and when difficulties develop, it is always recommended to explain the situation to the patient.

Factors That Increase Extraction Difficulty
In most instances, extraction of non-impacted teeth is routine dental procedure. Extraction difficulty increases when the following conditions exist: strong supporting tissues, difficult root morphology ( divergent, hooked locked, ankylosed, geminated or misshaped) teeth exhibiting hypercementoses, teeth containing weakened coronal surfaces due to large restorations, teeth that have been abraded or exhibit abfractions or deep caries, dedicated or brittle teeth associated with endodontic treatment, patients experiencing inflammatory disorders associated with alveolar bone including Paget’s disease, patients with radionecrotic bone caused by radiation therapy, and patients with limited opening or trismus.

Normal healing process
Immediately after teeth are extracted, blood flowing from the alveolar bone and gingiva begin to clot. The clot functions by preventing debris, food and other irritants from entering the extraction site. It also protects the underlying bone from the 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 the 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 is restored. Finally compact bone forms of the surface of the alveolus, and remodeling continues as the bone shrinks.

Bleeding Challenge
Bleeding challenges sometimes 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 tissue that leaves large openings in the alveolus. Unlike other wounds or surgical openings, there is an inability to apply and sustain direst pressure to the socket of an extracted tooth Other forces exist to even complicate things further, such as disruptive forces from the tongue, 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
A thorough medical history should be taken, including question 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 and maxillofacial surgeons or dentists that have had extensive training in managing the 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. Broad-spectrum antibiotics decrease vitamin K production which is necessary for coagulation factors produced in the liver. Chronic alcohol abuse can lead to liver cirrhosis and decreased production of liver-dependent coagulation factors. Chemotherapeutic agents that interfere with the hematopoietic system can reduce the number of circulating platelets. Patients who are known or suspected to have bleeding disorders should be evaluated and laboratory tested before surgery. Prothrombin time (PT) can be ascertained.

Bleeding
Once the tooth is completely remove. The wound should be properly cleaned. It should be inspected for the presence of any specific bleeding arteries or other potential anomalies. If and when arteries exist in the soft tissue, they should be controlled with direct pressure by claming and eventual ligation with resorbable suture. If no arteries exist in the extraction field, complete hemostatic control can usually be maintained for most procedures by using direct pressure over the area of the soft tissue for approximately five minutes.

Bleeding from isolated vessels within the bone can occur. Treatment involves crushing the foramen with the closed ends of the hemostat. This will usually occlude the bleeding vessel. Once the foramen is crushed, the socket should be covered with a damp 2x2 inch gauze sponge that ahs been folded to fit directly into the extraction site. The patient should be instructed to bite down firmly on this damp gauze sponge for at least 30 minutes. Do mot dismiss the patient from the office until hemostastis has been achieved, Check the patient’s extraction socket approximately fifteen minutes after the completion of the surgery, The patient should open his/her mouth widely, the gauze should be removed, and the area should be inspected carefully for any persistent bleeding. Replace the gauze with a new piece and repeat again in thirty minutes. If bleeding persists and inspection reveals no arterial bleeding, the surgeon should immediately place a hemostat into the socket. After placing the hemostatic agent, a gauze sponge should be placed over the top of the socket and is held with pressure.

Hemostatic Agents
The most commonly used least expensive hemostatic agent is absorbable gelatin sponge (Gelfoam, Pfizer). Gelfoam sterile compressed sponge is a pliable surgical hemostat prepared for specially treated purified gelatin solution. It is capable of absorbing and holding within its meshes many times its weight in whole blood. It is designed to be inserted in the dry state, and functions wonderfully as a hemostatic agent. Gelfoam forms a scaffold for the formation of a blood clot. Gelfoam has been sued to aid in primary closure for large extraction sites, and is placed into the socket and retained with a suture. Oxidized regenerated methylcellulose (Surgicel, Johnson and Johnson) is another hemostat used in dental surgery. It binds platelets and chemically precipitates fibrin. It is placed into the socket and sutured. I can not be mixed with thrombin.

Topical thrombin (Thrombostat, Pfizer) is derived from bovine thrombin (5,000 units). Thrombin bypasses all steps in the coagulation cascade and helps to convert fibrinogen to fibrin which forms the clot. It is usually saturate into Gelfoam and inserted into the tooth socket when needed.

Collagen type products can also be used to help control bleeding, by promoting platelet aggregation and thereby accelerating blood coagulation. Microfibular collagen (Avitene Davol) is a fibular material that is loose and fluffy, but able to be packed. Collaplug/Collatape, (Sulzer Calcitek) are more highly cross-linked collagen and can also be packed. Collagen type products stimulate platelet adherence which helps stabilize the clot, but are much more expensive and usually not used.

It is more important to note that when using hemostatic agents, the materials are place in the socket and sutured to the gingival margin surrounding the extraction site. This will assure that they are secure.

Secondary Bleeding
Patients will sometimes return to the office with secondary bleeding, caused in most cases by improper adherence of post-operative instructions. In these cases, the extraction site should be cleared of al blood and saliva suing suction. The dental surgeon should visualize the bleeding site to carefully determine the source of bleeding. If it is determined that the bleeding is generalized, the site should be covered with a folded, damp gauze sponge, and held in place with firm pressure by either the dentist or dental auxiliary for at least 5 minutes. This measure is usually sufficient to control most bleeding. If 5 minutes of this treatment does not control the bleeding, the dental surgeon must administer a local anesthetic so that the socket can be treated more aggressively. Block techniques are encouraged instead of local infiltrations. If infiltration is used and the anesthetic contains epinephrine, temporary vasoconstriction may be achieved and create the impression that the bleeding has stopped permanently. Be cautious.

Once anesthesia has been achieved, gently curette the tooth extraction socket and suction all areas of the old blood clot. The specific are of the bleeding should be identified. The same measures described for control of primary bleeding should be followed. The use of Gelfoam (absorbable gelatin sponge) saturated with topical thrombin, then sutured, is an effective way to stop bleeding. Reinforcement should be repeated with the application of firm pressure. In many situations, Gelfoam and gauze sponge pressure is adequate. Before the patient with secondary bleeding to go home, the clinician should monitor the patient for at least 30 minutes to ensure that adequate hemostatic control has been achieved. Be certain to give the patient specific instructions on how to apply gauze packs and pressure directly to the bleeding site should additional bleeding occur.

Subcutaneous tissue spaces may become collection areas for bleeding associated with some extractions. When this occurs, overlying soft tissue areas will appear bruised 2 to 5 days after the surgery. This bruising is called ecchymosis. Ecchymosis occurs more frequently in elderly patients. Ecchymosis may extend into the neck and as far as the upper anterior chest. Ecchymosis does not increase the potential for infection or other sequelae. Elderly patients should be warned that there is the potential for ecchymosis. Reducing trauma is the best way to prevent ecchymosis. Moist heat may be applied to speed up the recovery.

Delayed Healing
Normal healing of extraction site are dependent on clot formation and the progression ft that clot to a reorganized matrix preceding the formation of bone. It is uncommon for the blood clot to fail to form except in cases where there is interruption of the local blood supply.

It is now thought that the infection is the most common cause delaying wound healing. Signs and symptoms associated with infection can include: fever, swelling and erythema. Careful asepsis and thorough wound debridement should be performed after surgery. Irrigate bone copiously with saline to aid in the control of foreign debris. Patients prone to infection should be given postoperative antibiotics to reduce infection blowups.

Wound dehiscence should be avoided by following food surgical techniques. Leaving unsupported soft tissue flaps can often lead to tissue sagging and separation along the incision line, Suturing wound under tension can cause ischemia of flap margins, which may lead to tissue necrosis.

Other factors, though rarely seen that can delay healing are: prolonged bleeding due to clotting defects, formation of an oro-antral fistulas, proliferation of a malignant tumor, radiation therapy, immunosuppresion due to corticosteroid use, dietary deficiencies including but not limited to vitamin C, and overall immune system disorders.

Vitamin C is needed for the growth and repair of tissues in all parts of your body. It is used to:

Form an important protein used to make skin, tendons, ligaments, and blood vessels
Heal wounds and form scar tissue
Repair and maintain cartilage, bones, and teeth
Vitamin C is one of many antioxidants. Antioxidants are nutrients that block some of the damage caused by free radicals.

Free radicals are made when your body breaks down food or when you are exposed to tobacco smoke or radiation.
The buildup of free radicals over time is largely responsible for the aging process.
Free radicals may play a role in cancer, heart disease, and conditions like arthritis.
The body is not able to make vitamin C on its own, and it does not store vitamin C. It is therefore important to include plenty of vitamin C-containing foods in your daily diet.

For many years, vitamin C has been a popular remedy for the common cold.

Research shows that for most people, vitamin C supplements or vitamin C-rich foods do not reduce the risk of getting the common cold.
However, people who take vitamin C supplements regularly might have slightly shorter colds or somewhat milder symptoms.
Taking a vitamin C supplement after a cold starts does not appear to be helpful.
Food Sources
All fruits and vegetables contain some amount of vitamin C.

Foods that are the highest sources of vitamin C include:

Cantaloupe
Citrus fruits and juices, such as orange and grapefruit
Kiwi fruit
Mango
Papaya
Pineapple
Strawberries, raspberries, blueberries, cranberries
Watermelon
Vegetables that are the highest sources of vitamin C include:

Broccoli, Brussels sprouts, cauliflower
Green and red peppers
Spinach, cabbage, turnip greens, and other leafy greens
Sweet and white potatoes
Tomatoes and tomato juice
Winter squash
Some cereals and other foods and beverages are fortified with vitamin C. Fortified means a vitamin or mineral has been added to the food. Check the product labels to see how much vitamin C is in the product.

Cooking vitamin C-rich foods or storing them for a long period of time can reduce the vitamin C content. Microwaving and steaming vitamin C-rich foods may reduce cooking losses. The best food sources of vitamin C are uncooked or raw fruits and vegetables.

Side Effects
Serious side effects from too much vitamin C are very rare, because the body cannot store the vitamin. However, amounts greater than 2,000 mg/day are not recommended because such high doses can lead to stomach upset and diarrhea.

Too little vitamin C can lead to signs and symptoms of deficiency, including:

Anemia
Bleeding gums
Decreased ability to fight infection
Decreased wound-healing rate
Dry and splitting hair
Easy bruising
Gingivitis (inflammation of the gums)
Nosebleeds
Possible weight gain because of slowed metabolism
Rough, dry, scaly skin
Swollen and painful joints
Weakened tooth enamel
A severe form of vitamin C deficiency is known as scurvy, which mainly affects older, malnourished adults.

Recommendations
The Recommended Dietary Allowance (RDA) for vitamins reflects how much of each vitamin most people should get each day. The RDA for vitamins may be used as goals for each person.

How much of each vitamin you need depends on your age and gender. Other factors, such as pregnancy and illnesses, are also important.

The best way to get the daily requirement of essential vitamins, including vitamin C, is to eat a balanced diet that contains a variety of foods.

Dietary Reference Intakes for vitamin C:

Infants

0 - 6 months: 40* milligrams/day (mg/day)
7 - 12 months: 50* mg/day
*Adequate Intake (AI)

Children

1 - 3 years: 15 mg/day
4 - 8 years: 25 mg/day
9 - 13 years: 45 mg/day
Adolescents

Girls 14 - 18 years: 65 mg/day
Boys 14 - 18 years: 75 mg/day
Adults

Men age 19 and older: 90 mg/day
Women age 19 year and older: 75 mg/day
Smokers or those who are around secondhand smoke at any age should increase their daily amount of vitamin C an additional 35 mg per day.

Women who are pregnant or breastfeeding and those who smoke need higher amounts of vitamin C. Ask your doctor what amount is best for you.

Alternative Names
Ascorbic acid; Dehydroascorbic acid

References
Escott-Stump S, ed. Nutrition and Diagnosis-Related Care. 6th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2008.

Sarubin Fragaakis A, Thomson C. The Health Professional's Guide to Popular Dietary Supplements. 3rd ed. Chicago, Il: American Dietetic Association; 2007.

Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. National Academy Press, Washington, DC, 2000.

Douglas RM, Hemila H, Chalker E, Treacy B. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev; 2007(3):CD000980.

Update Date: 8/30/2011
Updated by: A.D.A.M. Editorial Team: David Zieve, MD, MHA, and David R. Eltz. Previously reviewed by Alison Evert, MS, RD, CDE, Nutritionist, University of Washington Medical Center Diabetes Care Center, Seattle, Washington (2/15/2011).