Protocol Necessary to Decrease Bleeding After Some Dental Extractions

[drsushant]

It’s essential for clinicians to have a protocol to lower the risk of bleeding after dental extractions in cardiac patients taking anticoagulant medications.

The Journal of Oral Implantology came to this conclusion in the current issue. The study indicated the use of leukocyte- and platelet-rich fibrin material, a material dentists use to promote healing and help tissue, is a safe filling.

The research team analyzed the impact of the biomaterial on 50 heart patients who had some type of oral anticoagulant therapy.

The researchers treated the 50 heart patients after anticoagulant therapy with leukocyte- and platelet-rich fibrin clots, which were put into post-extraction sockets. There were just two patients who had some kind of major complication involving bleeding. There were 10 patients who suffered mild bleeding but the issue was gone within a few hours after the oral surgery procedure.

The study showed that there wasn’t much pain involved in any of the study’s participants. The soft tissue healed at a rapid pace and all wounds were sealed up after one week. That’s why leukocyte- and platelet-rich fibrin is the ideal choice for heart patients with an anticoagulant regimen.

        

[drmithila]

 

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 2×2 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.

 

 

        

[Drsumitra]

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).

 

        

[drmithila]

The physiologic loss of hard and soft tissues after tooth extraction from caries, trauma, or advanced periodontitis often leads to osseous deformities of the alveolar ridge. These deformities can present difficulty in achieving proper pontic design. In an inappropriately contoured ridge, removable dentures may exhibit compromised retention, and ideal endosseous implant placement might not be possible. Many of these problems could be eliminated if the alveolus had been preserved after tooth extraction.

Although the prevention of postextraction alveolar bone loss was first described by Greenstein and colleagues1 and Ashman and Bruins2 in 1985, the term socket preservation was first coined by Cohen in 1988 to describe a procedure designed for prosthetic socket maintenance, ridge preservation, and augmentation.3 He defined socket preservation as a surgical procedure in which graft material or a scaffold is placed in a fresh extraction socket to preserve the alveolar ridge for a future prosthesis.2,3 In 2007, the Expert Committee on Socket Preservation unanimously decided to use the term socket preservation specifically for the treatment of fresh extraction sockets with intact buccal bone walls.4 In contrast, ridge preservation was deemed an appropriate term for situations involving deficient buccal bone walls. The rationale behind this terminology is that the presence of the buccal bone wall is believed to have a relevant influence on bone healing, and these terms reflect the differences between the situations.4

Socket-Alveolus Healing

Healing of the extraction socket is a highly dynamic process, beginning with a cascade of inflammatory reactions activated immediately after tooth extraction. It occurs in five different stages (Table 1) starting with the formation of a blood clot and ending with fully mature hard- and soft-tissue structures.5

Animal studies have analyzed the dimensional ridge changes after tooth extraction.6 The remodeling process has been described in two phases. During the first phase, the bundle bone is remodeled and replaced by newly formed woven bone, causing a reduction in the vertical ridge. In the second phase, the buccal surface of the alveolar ridge is remodeled, causing a horizontal volume reduction as well as additional vertical volume reduction.

Rationale Behind Socket Preservation

A striking feature of the healing extraction socket is the chronic progressive catabolic remodeling of the residual alveolar process that results in atrophy of the alveolar process described as reduction of residual ridges.7 As a part of the extraction socket healing process and because of a lack of tooth support, bone resorbs to a flat contour, resulting in the thinning of bony structures.5 The rate of postextraction bone loss is rapid in the first 6 months, followed by gradual modeling and remodeling of the remaining bone with approximately 40% of the alveolar height and 60% of alveolar width lost in the first 6 months.8 Studies have shown that most bone loss occurs at the labial/buccal side of the alveolar process compared with the lingual/palatal side.6 The margins of the facial alveoli are thin, mostly cortical (although in rare cases they contain cancellous bone), knife-edged, and frail. The significance of implementing a less traumatic extraction (eg, using periotomes) can be emphasized when looking at the healing of damaged extraction sockets. Damaged bony walls as well as both systemic and local factors may alter the healing process and may result in the formation of fibrous tissue rather than a complete bony fill.5 The remodeled alveolar process can affect the success of prosthetic therapy with a conventional or implant-retained prosthesis, thereby underlining the importance of socket preservation.8

The most important esthetic goals of socket preservation are the maintenance or enhancement of the facial and interproximal gingival contours and the height of the interproximal papilla.9 The soft-tissue color, consistency, and contour are some of the important parameters that affect the esthetic outcomes of this procedure. The severity of the healing pattern poses two problems for clinicians: it creates an esthetic problem when fabricating an implant-supported restoration or a conventional prosthesis and it may make the placement of an implant challenging, if not unfeasible. However, it is possible to minimize such problems by simply carrying out ridge or socket preservation procedures in extraction sockets using grafted materials with or without barrier membranes.8 Most general dentists perform routine tooth extractions; therefore, they should consider incorporating a simple, fast, and relatively inexpensive procedure of socket preservation into their practices. In short, socket preservation: minimizes residual ridge resorption; preserves crestal ridge volume after extraction; allows ideal implant placement in relation to bone and gingival tissues; reduces or eliminates ridge augmentation procedures during implant placement; and prevents loss of both hard and soft tissues, thus providing optimum esthetic outcomes. Figure 1 depicts a schematic diagram of the procedure and importance of socket preservation.

Mechanism of Socket Preservation

The exact mechanism of alveolar ridge resorption and preservation has been said to involve a complex cascade of events.

Biomechanical Stimulation

Many authors have suggested that the random orientation of the graft placed in extraction sites provides physiologic and bioelectric stimulation of the adjacent bone via attachment and load transmission from the overlying prosthesis during normal jaw function.10 Therefore, indirect physiologic forces on the bone–graft interface may contribute to bone preservation.

Wound Isolation and the Scaffolding Effect

Wound isolation by the principles of guided tissue regeneration with membranes prevents invagination of the oral epithelium into the socket, favoring bone-regenerating cells to complete the bone fill.11 The presence of an osteoconductive bioactive framework or scaffold allows osteoblasts to migrate and form bone more efficiently within the extraction space, which facilitates bone healing.12

Modification of Cellular Activity

The physiochemical and structural characteristics of implanted bioactive material evokes a cellular response from the adjacent tissues by providing a biomimetic environment for initiating bone repair.13

Techniques Used for Socket Preservation

Various prophylactic measures that minimize injury to the alveolar process and surrounding soft tissues during tooth extraction have been attempted to minimize bone resorption. Postextraction therapeutic measures include physiologic preservation of the alveolar process by retention of the natural roots, application of prefabricated root form implants, and modified versions of guided tissue regeneration and guided bone-regeneration techniques.14

Currently, the most commonly used methods are placement of the graft/membrane alone, placing a graft and covering it with a membrane or collagen wound dressing, or placing a sponge in the socket with or without any coverage.15 All these procedures can be followed by flap advancement to achieve complete or partial primary closure (Table 2).8,13,16-39

Materials Used for Socket Preservation

An ideal graft material for the alveolar socket should prevent the volume reduction that often occurs after tooth extraction and remain in situ as a scaffold until sufficient healing (bone formation) has occurred.23 Bone-replacement materials must allow the initiation of osteogenesis and serve as a supportive frame for ingrown bone. Various graft materials, including autogenous, allogenous, xenogeneic, and alloplastic bone grafts as osseoinductive and/or osteoconductive materials, have been used in attempts to preserve the alveolar ridge. When the socket walls are intact, osteoconductive graft materials can be used and barrier membranes may not be necessary. On the contrary, when socket walls are missing, regenerative techniques using osseoinductive graft materials and/or the use of barrier membranes are used.

Studies have been conducted using various bone grafts and bone-substitute materials, including demineralized freeze-dried bone allograft (DFDBA),15 autologous bone,15 bioactive glass,19,21 hydroxyapatite,18 calcium sulphate,20,29 solvent-preserved cancellous allograft,17,28 and coral granules.22,34 It is also possible to cover the socket to prevent ingress of soft tissues, thereby promoting maximal bone healing. Generally there are two types of membranes used: resorbable and nonresorbable. In the studies, the most commonly placed membranes were expanded polytetrafluoroethylene (e-PFTE) membranes15,23,25 or collagen membranes.13,29,30 In addition, polylactic/polyglycolic (PL/PG) membranes, titanium,27 or acellular dermal matrix26 have also been evaluated in various studies.

Sponges made of PL/PG31,32,34 or collagen have also been placed in extraction sockets to preserve the ridge. The collagen sponges can also act as a carrier for either recombinant human bone morphogenetic protein-2 (rhBMP-2)33 or synthetic cell-binding peptide P-15.13 The authors suggested that the sponge served as a support to prevent the collapse of the surrounding soft tissue into the socket during the healing process.

The use of grafting materials in fresh extraction sockets has been questioned because they seem to interfere with the normal healing process in the sockets in which oral implants have to be inserted.15,16 A substantial number of the studies reported remnants of graft material particles in sockets 6 to 9 months after insertion.16,17,19,37 The long-term effect of residual grafting material on implant survival and success was not reported.

The diverse soft- and hard-tissue regenerative procedures may be technically demanding and unpredictable in the hands of most clinicians. Other evaluated alternatives are minimally invasive socket preservation procedures immediately following tooth extraction known as socket-seal surgery.35 In socket-seal surgery, a soft-tissue graft is harvested from the palate to be placed atop the bone graft in the socket. Also, the rotated pedicle palatal connective tissue flap technique has been used for soft-tissue closure of the grafted extraction sockets in the posterior maxilla without excess tension, producing optimal outcomes.36 In summary, there is strong evidence that ridge preservation significantly maintains more ridge width and height. Most grafting materials are effective and there are only slight differences between them.

Conclusion

Given the current advances in stem-cell technology, in the future it might be possible to place tooth buds in sockets to regrow teeth or place a cellular scaffold in the socket to maintain the bone. Cultivated scaffolds from bone-marrow mesenchymal stem cells have been placed into fresh extraction sockets with results that “show promise.”40

Clinically, it is evident that the healing of postextraction sockets may result in the considerable loss of alveolar ridge height and width. The deficient alveolar ridge may jeopardize its suitability for a future prosthesis, both esthetically and functionally. Hence, the new concept of socket preservation should be given thoughtful consideration to enhance the predictability and success of future prostheses. Dentists often encounter clinical situations in which teeth have to be extracted in areas of esthetic concern. As a result, the alveolar bone gets resorbed, the soft tissues shrink, and the final non-anatomical prosthesis appears to be false. Such negative results usually can be avoided by using socket preservation techniques.

 

        

[drmithila]

Sutures can be removed 3 to 7 days followingsurgery, depending on the material and procedure. Forexample, nylon or silk sutures are removed from 3 to 5days after surgery if adequate healing has taken place.After the extraction site is examined by the dentist,suture removal can be delegated to the assistant.Irrigate or swab the suture site with an antisepticsolution to remove any debris. Locate and account forall the sutures placed during the surgical treatment.Use a hemostat or cotton forceps to gently lift thesuture away from the tissue to expose the attachment ofthe knot. With the scissors in the other hand, slip oneblade of the scissors under the suture and one bladeover the suture. Cut the suture material as close to thetissue as possible so that a minimum of material ispulled through the tissue. Grasp the knot and gentlyslide the suture out of the tissue. Take care not to pullthe knot through the tissue, since this causesunnecessary discomfort to the patient. Continue liftingand snipping the suture material until all sutures areremoved. Count and compare the number of suturesremoved with the number placed as indicated in thepatient’s record.Irrigate the surgical area withantiseptic solution if there is any bleeding.

 

        

[Author]

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