Unraveling Post-Tooth Extraction Sequelae in Older Adults

According to the American Dental Association’s website on aging and dental health, the demographics of the dental practice is changing, with an increase in the number of adults ages 65 and older seeking treatment.¹ While older adults want to save their natural teeth, chronic systemic diseases, periodontal diseases, medication-induced xerostomia, and increased risk for root caries may result in tooth loss.

A variety of factors, such as surgical trauma, medical and medication history, smoking and alcohol use, advanced age, and limited understanding of postoperative instructions, may lead to postextraction complications. Bleeding, poor socket healing, dry socket pain, trismus, paresthesia, viral or bacterial infections, osteonecrosis, osteitis, and osteomyelitis may also occur.^2,3 Although less common, reactive tissue developing in the gingiva or alveolus shortly after extraction is a significant complication. This case series presents three cases of tooth extraction sequelae with reactive tissue growth and delayed wound healing in patients with a mean age of 75, 1 to 6 weeks postsurgery.

Case #1

A 72-year-old man presented to the Midwestern University Dental School Clinic in Glendale, Arizona, with advanced periodontal disease, tooth loss, and extensive interproximal gingival cervical root decay on several teeth, including both lower right premolars. The patient had a significant medical history of hypertension, diabetes mellitus with most recent HbA1C at 7, depression, and cardiac surgery with valvular replacement. Per the cardiologist’s request, the patient was prescribed an antibiotic premedication before dental treatment.

The polypharmacy medication list included losartan, citalopram, aspirin, tramadol, amlodipine, omeprazole, metoprolol, and budesonide inhaler. The patient had previously been a two-pack-a-day smoker.

Clinical oral examination was within normal limits. Due to the extent of the decay on #28 and 29, surgical extraction with bone troughing were required. The socket was debrided with a curet and sterile saline rinse; chromic gut sutures were placed. Four additional nonrestorable teeth were removed at the same time (#3, 4, 5, and 31).

The patient returned for the 1-week postoperative evaluation complaining of pain and swelling on the lower right and was prescribed clindamycin. The patient presented for continuing dental care 1 month later and all extraction sites had healed except for those at #28 and 29. The nonhealing sockets exhibited an overlay of a soft, hyperplastic lesion measuring 12 x 8 mm on and above the alveolar mucosa (Figure 1).

Radiographic examination revealed the presence of radiopaque bone sequestrate (Figure 2). The formation of this reactive granulation tissue was related to the retained bony sequestrum. The granulation tissue was curetted, the bone spicule removed, and an antibiotic was prescribed. Re-evaluation 1 month later showed complete healing. At the 16-month follow-up, the lesion had not recurred.

Case #2

The second patient was a 73-year-old man who presented with extensive dental caries from medication-induced xerostomia. The patient denied cigarette smoking or alcohol consumption but did report using medical marijuana. The medical history was significant for hepatitis A, B, and C; musculoskeletal injury; osteoarthritis; sleep apnea; depression; and hypertension. Medications included amlodipine, pregabalin, alprazolam, pravastatin, sildenafil, metoprolol, and prazosin.

Clinical oral examination was within normal limits. The upper right first molar had extensive mesial subgingival decay and was deemed nonrestorable. Tooth #3 was extracted with elevation and forceps, the socket was debrided with a curette and irrigated with sterile saline; no sutures were placed. At the 1-week postoperative appointment, the patient complained of pain and gingival inflammation. The patient may have continued smoking medical marijuana immediately post-extraction. Amoxicillin was prescribed.

Three months later, the patient presented for continued restorative services and reported a painless “swollen gum.” The radiograph showed no bone or tooth fragment. Clinical examination revealed primary closure of the extraction site of #3, but a 3 x 6 mm soft, inflammatory lesion was present on the distal gingiva of tooth #4 (Figure 3). The granulation tissue was excised with a scalpel and a 970 nm diode laser was utilized for minor tissue ablation. The gingiva was verified to have healed 10 days later. At the 5-month follow-up, no recurrence was present.

Case #3

A 79-year-old woman presented with a complaint of pulpal pain in the upper left maxillary second molar. Clinical oral examination was within normal limits. Dental examination confirmed medication-induced xerostomia with high caries risk and noted extensive subgingival decay on the lingual root under an existing porcelain to metal crown on #15. The tooth was deemed nonrestorable and surgical removal was scheduled.

The patient reported no tobacco or alcohol use. The medical history included osteopenia and osteoarthritis, iron deficiency anemia due to peptic ulcers and gastrointestinal bleeding, thyroidectomy, depression, and frequent urinary tract infections requiring long-term antibiotic treatment. The patient’s medications included calcium and iron supplements, pantoprazole, famotidine, levothyroxine, topical estradiol for postmenopausal symptoms, ciprofloxacin, and escitalopram oxalate. Additionally, the patient was on ibandronate, an oral bisphosphonate for treatment of osteoporosis, for the past 2 years. Even though recent systematic review of the literature indicates that serum cross linked beta-C-terminal telopeptide blood test (CTX) has little to no predictive value when determining the risk of medication-related osteonecrosis of the jaw (MRONJ) in patients taking oral bisphosphonates,⁴ a CTX test was performed due to the patient’s medical history. The test result was 175 pg/ml and determined to be in the “none to minimal” range for MRONJ risk.

Tooth #15 was extracted with elevation and forceps. The Valsalva test⁵ was performed with a negative outcome, and no oral-antral sinus communication was noted. The socket was debrided with a curette and flushed with sterile saline; sutures were placed. At the 1-week postoperative examination, the extraction site appeared to be healing and she reported no pain. She continued to have general dental procedures performed without complaint.

Six weeks after the extraction, the patient presented for crown preparation on adjacent tooth #14 at which time an asymptomatic exophytic lesion at the extraction site of #15 was observed (Figure 4). The lesion was smooth, erythematous, with a sessile base, and measured approximately 9 mm (about 0.35 in) in diameter. In updating the medical history, she reported recent blood tests for hemoglobin, hematocrit, and red blood cell count with all results reporting low. The extraction site was evaluated by an oral surgeon due to concerns over possible MRONJ. No clinical exposed bone, infection, or radiographic indicators were present. Re-evaluation in 2 weeks was recommended.

At this re-evaluation, the lesion was reduced in size and appeared to be healing with a decrease in inflammation (Figure 5). A second evaluation 6 weeks later continued to show improvement and an even greater reduction in size (Figure 6). Radiographs of the site indicated no bone spurs, no tooth fragments, and no sinus involvement. The lesion may have resolved on its own, but for patient comfort, the remaining granulation tissue was removed. A 970 nm diode laser was utilized for minor tissue ablation and hemostasis. The patient returned 4 weeks later and the area had completely healed and was asymptomatic. The patient will continue to be monitored for recurrence, if the possible causative influences, such as xerostomia, anemia, or hormone treatment, are not resolved.

Discussion

A study by Lu et al⁶ showed that not only are patients ages 70 to 79 the most likely to undergo tooth extractions, they also have the highest rates of hypertension, diabetes, and cardiovascular diseases, which may delay healing.⁶

The patients in the case series were all in their 70s with complex medical histories including diabetes, and both men had hypertension and cardiac issues. Both were on amlodipine, a calcium channel blocker antihypertensive associated with gingival hyperplasia. Delayed wound healing most often is influenced by a myriad of systemic conditions in older adults with anemia, poorly controlled diabetes, on anticoagulant medications, poor nutrition, and poor oral hygiene.² Though the patients in our case series denied using, tobacco smoking and alcohol use after dental extractions are major contributors to poor healing and alveolar osteitis.^2,7

The patients in this case series had periodontal diseases, tooth loss, xerostomia, and high decay rates. Postextraction sequelae have been associated with highly carious dental lesions at or below the gingival level, which occurred in all three patients, difficult surgical extractions with bone troughing such as in patient #1, and/or postextraction sites with bone spicules, sequestrum, or infection.^8,9 Additionally, foreign bodies in the socket — such as enamel, amalgam, bone fragments, or calculus — may also delay tissue repair and lead to postoperative pain (Figure 2, page 33 ).^3,7

The inclination of women toward oral diseases has prompted research, revealing that hormones may play a contributory role in inflammatory gingival and oral alterations.^10-12 Alterations in female hormones can affect gingival inflammatory mediators, tissue vascular permeability, and even alter the growth of fibroblasts.¹¹ Depending on hormone levels, the estrogen receptors in osteoblasts and fibroblasts in the oral mucosa may affect periodontium health by exaggerating the inflammatory response and stimulating the fibrinolytic system.^7,11,13 In a recent case study conducted at the Midwestern University clinic, a 64-year-old woman taking estradiol developed a peripheral giant-cell granuloma (PGCG) 1 year after the extraction of a lower molar.¹⁴

The differential diagnosis for the soft tissue postsurgical sequelae noted in this case series includes epulis granulomatous (EG), pyogenic granuloma (PG), or PGCG.^8,9,13–16 Epulis is a term for a reactive localized tumor growth in the gingiva or mucosa resulting from trauma or irritation. Clinically, EG is vascular and may bleed heavily upon probing and lesion removal.^8,9

EG is clinically and histologically identical to PG,¹³ which is also a non-neoplastic hyperplastic inflammatory tissue reaction to localized irritation. PG can occur anywhere in the oral cavity and has been reported in extraction sites.^13,16  PG has also been associated with the use of oral contraceptives, retinoids, and anticancer medications.¹⁶ PGCG is a rare proliferative asymptomatic lesion, also located in the gingiva or alveolar mucosa, and has recently been reported in the literature to occur in postextraction sites.^14,17

Traditional treatment for a hyperplastic tissue sequelae arising shortly after tooth extraction is removal of the causative bone or other irritants with aggressive curettage, scalpel surgical removal, and/ or diode laser ablation, and follow-up, if indicated.^15,18 Should postextraction sequelae not heal after traditional treatment or if they reoccur, biopsy is indicated. In older patients, there is always a concern for primary malignancy or metastatic disease in maxillary or mandibular sites. In maxillary edentulous sites neoplastic lesions have been reported, including sinus carcinoma or traumatic lesions, such as herniation of the maxillary sinus, postsurgically.^8,18

In this case series, the sequelae healed, no biopsy was indicated, and the lesions did not recur. Epulis-type lesions may return if local irritations persist, hormone levels remain high, systemic disease persists, or incomplete surgical treatment occurs.¹⁹ Manovijay et al⁹ reported that a 64-year-old man had an EG lesion excised 2 weeks after the extraction of a lower central incisor. Months later, a nodular tumor occurred in the same postextraction site and was diagnosed as EG again by histopathology. A suspected underlying and untreated vascular disease was proposed as the cause for recurrence.

One study showed that patients ranging in age from 18 to 67 had little to no postextraction complications and required no postsurgical follow-up.²  This case series indicates that reactive tissue postoperative sequelae may occur, with or without pain, as well as poor wound healing, which is common among older adults, possibly due to medication and medical factors. Therefore, a postextraction evaluation 1 to 2 weeks after the surgery may be advisable especially for a medically compromised or older patient.

Conclusion

This case series highlights that though not reported as frequently as other postsurgical sequelae, reactive hyperplastic lesions can present shortly after tooth extraction. Clinically, the proliferative granulation tissue reactions exhibited differently in each patient, but there was commonality of age, polypharmacy, chronic systemic diseases with medically compromised status, extensive dental caries, and delayed healing of the extraction sockets. Proper inspection, socket debridement, and removal of sharp margins, bony spicules, and granulation tissue during tooth extraction are essential to prevent a reactive tissue response. Likewise, postsurgical evaluation is crucial as reactive lesions present shortly after tooth extraction and may not resolve completely without intervention.

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From Decisions in Dentistry. January/February 2024; 10(1):32-35