Post-extraction alveolar management
Apical infection (Fig 2) is the most common indication for
cheek teeth exodontia, being the reason for 62% of 428 extractions in a
recent study (Kennedy et al. 2020). Exodontia of apically
infected teeth causes a bacteraemia with potential pathogens, including
anaerobes (Kern et al. 2017). Many clinicians administer
pre-operative antibiotics (e.g., penicillin and an aminoglycoside)
including to help prevent the rare spread of bacteria from infected
teeth to distant sites, that can cause infections such as meningitis
(Bach et al . 2014; Arndt et al. 2021). When infection of
the supporting bones is present, longer-term post-extraction antibiotic
therapy is justified. There is less consensus on the routine use of
post-extraction antibiotic therapy in other exodontia cases.
Following exodontia, the alveolus should be digitally and visually
(using a dental mirror or oral endoscope) examined, as should the apical
aspect of the extracted tooth to ensure that no dental fragments remain
in the alveolus. If any doubt remains, and always following repulsion
techniques or where the apex of the tooth is not intact, post extraction
radiography should be performed to ensure that no intra-alveolar dental
(or alveolar bone fragments) remain. Any such identified fragments
should be immediately removed digitally or using long, right-angled
equine dental picks with adjustable heads under visual guidance, and
with use of suction of intra-alveolar blood to allow visualisation of
mandibular alveoli. If suitable picks are unavailable, high pressure
lavage of the alveolus using an equine dental syringe may remove
unattached bone or dental fragments. Formation of a new blood clot
should now be encouraged, if necessary, by alveolar curettage.
Optimal post-extraction healing will occur in an alveolus that did not
have significant pre-existing alveolar bone infection, which has not
sustained excessive exodontia-related alveolar bone damage, does not
contain dental or bone fragments and which contains a large
post-extraction blood clot. The alveolar blood clot should be protected
from masticatory forces and food impaction by placing packing material
(e.g., polysiloxane, acrylic or surgical swabs [gauze] impregnated
with antibiotics, honey or dilute antiseptics) in the more occlusal
(e.g., one third) aspect of the alveolus. Excessively deep alveolar
packing will mechanically reduce or even prevent alveolar healing. Some
clinicians have used antibiotic-impregnated surgical swabs in the more
occlusal half of the alveolus to help treat existing and help control
post-operative alveolar bone infection (Kennedy et al. 2020). The
risk of bacterial antibiotic resistance development must be considered
with such local antibiotic therapy. The use of surgical swabs soaked in
concentrated antiseptic solutions such as Povidine iodine may risk
causing chemical irritation and delayed alveolar healing.
No large objective studies have determined which post-extraction
alveolar management is optimal. However, anecdotal evidence indicates
that just placing packing material in the alveolus following exodontia
and allowing this material to spontaneously dislodge later, is
unsatisfactory. This is especially true following exodontia of apically
infected Triadan 06-08 mandibular cheek teeth in younger horses (Kennedyet al. 2020; Giegert and Bienert 2021). Instead, the
post-extraction alveolus should be actively managed until healing is
complete or near complete. The alveolar packing inserted immediately
post extraction should be removed about 7-10 days later, and the
alveolus digitally examined to assess if it is lined by smooth
(developing granulation) tissue over all its surfaces. Rough areas of
exposed bone such as caused by alveolar sequestration or dry
socket are readily palpated and if these bony areas are loose (i.e. are
sequestrae rather than dry socket), they should be removed digitally or
using picks.
If the alveolus appears to be healing normally at this first
re-examination, it should be gently lavaged, without dislodging the
blood clot. The occlusal aspect of the alveolus should be repacked
(using less packing material on this occasion) and the alveolus
re-examined 1- 2 weeks later to further assess alveolar healing and in
particular, for evidence of delayed sequestration. As noted, the most
rigorous management is needed following extraction of younger mandibular
teeth with apical infection and such cases should have repeated alveolar
examinations until healing is very advanced.