Knowledge and Awareness of Postextraction Complications among Dental Seniors and Interns in Riyadh Province.

BACKGROUND: Postextraction complications are multifactorial. Taking proper medical and dental history, thorough planning, and a skillful dentist can help the prediction and reduction of these complications.
OBJECTIVE: This study aims to assess and compare the knowledge of senior students and interns regarding postextraction complications in government and private colleges in Riyadh Province.
MATERIALS AND METHODS: A random sampling technique was used to select a minimum of 250 participants for this study. A self-designed, close-ended questionnaire was disseminated through an online platform in a manner. Sixth-year (senior) dental students and interns were included in the study. Data were coded and entered into spreadsheet software and analyzed using Chi-square tests.
RESULTS: More than half were dental interns (54.04%), and the rest were senior students (45.96%). Male participants comprised 52.57% of the total participants, whereas females were 47.43%. Most participants were from government colleges (53.31%), whereas 46.69% belonged to private colleges. Male interns from government colleges demonstrated the best knowledge among all the participants. In private colleges, females demonstrated better knowledge than males in both the senior and intern groups, and the difference was statistically significant. The difference in knowledge between participants from government and private colleges was found to be statistically significant (P = 0.001). Government colleges were found to demonstrate more complications than private colleges, and the difference was statistically significant (P = 0.003).
CONCLUSION: Male interns from government colleges had the best knowledge about the postextraction complications among the candidates. Copyright:

INTRODUCTION

Exodontia is removal of the tooth from its alveolar socket and supportive structures by means of surgical instruments. Lack of knowledge, surgical experience, or skills in extractions might lead to many complications. Such complications can be minimized by properly taking medical and dental history, correct planning of the surgical procedure, and skillful removal by dentists.[12] Earlier study has shown that about 78.3% of the undergraduate dental students have agreed on the fact that taking proper medical history can reduce the occurrence of postextraction complications.[3]

Extraction is a very common procedure in dental clinics worldwide.[34] Extraction can be of two types, simple and transalveolar extractions. Teeth are extracted for a variety of reasons such as caries, pulpal necrosis, periodontal disease, orthodontic reasons, malposed teeth, cracked teeth, impacted teeth, supernumerary teeth, teeth associated with pathologic lesions, radiation therapy, teeth involved in jaw fractures, and financial issues. Every surgical procedure may induce some complications, and for frequent procedures like dental extractions, every dentist should be well trained, aware of its common and rare complications and their management, even though they occur infrequently.[5678]

Complication means a secondary disease or condition aggravating an already existing one. Dental extraction may cause pain or even swelling.[3] Different types of postextracted complications include prolonged bleeding (the most common complication). Patients who are on medications such as anticoagulants, uncontrolled hypertension, liver diseases, platelet deficiency, hemophilia, von Willebrand factor deficiency, or Vitamin K deficiency may also pose a significant risk for postoperative bleeding.[78] Dry socket (alveolar osteitis) causes postoperative pain inside and around the extraction site, which increases in severity at any time between the 1st and 3rd days after the extraction. In a study, the total incidence of dry socket following the removal of 642 third molar teeth was 114 instances or 17.8% of the total cases.[9] Ecchymosis is the next most common complication following a tooth extraction, and it usually occurs in elderly patients. Pain, trauma to adjacent structures, oroantral communication, and sinus perforation (the floor of the sinus is usually the closest to the palatal root of the upper first molars) are few complications after the extractions of upper molars.[79101112]

Nerve injury (inferior alveolar nerve and artery are both contained within the inferior alveolar canal) is one of the complications after the extraction of the mandibular molars. The lingual nerve travels medially to the lingual plate near the second and third molar regions. The aggressive technique, sectioning of the molar during extraction, and the lingual flap can result in injury to the lingual nerve. The overall incidence of inferior alveolar nerve and lingual injury during mandibular molar extractions ranges between 0.6% and 5%.[7] Rare complications such as necrotizing fasciitis, herpes zoster, Ludwig's angina, parapharyngeal infection, and infections of the submandibular and submasseteric spaces can occur after the extraction of the teeth.[13] The dentist should have adequate knowledge about these complications and the correct way to diagnose and manage these complications or to refer them to the physician. Some of the risk factors for postextraction complications are age, sex, medical status, medications, habits (such as smoking), history of past complications, and the nature of the extraction itself – whether traumatic or atraumatic. Moreover, operator-related risk characteristics such as level of experience and the duration of the procedure are considered relevant risk factors. Extraction difficulty increases when the following conditions such as excessively dense supporting bone, difficult root morphology, teeth with large restorations or decay, adjacent teeth with large restorations, and brittle teeth associated with endodontic treatment.[1011121314]

MATERIALS AND METHODS

This is a cross-sectional study conducted in Riyadh Province. A random sampling technique was used to select 250 participants for this study. A self-designed, close-ended questionnaire was disseminated through an online platform. Sixth-year (senior) dental students and interns were included in the study. Senior students who had not completed the oral surgery clinical rotation/course were excluded. Data were coded and entered into spreadsheet software and analyzed using Chi-square tests.

RESULTS

A total of 273 respondents answered the survey in this study. More than half the participants were dental interns (54.04%), and the rest were senior students (45.96%). Male participants comprised 52.57% of the total participants in the survey, whereas females were 47.43%. Most participants were from government colleges (53.31%), whereas 46.69% belonged to private colleges. The demographic distribution of participants is depicted in Figure 1.

Figure 1

Frequency distribution of participants

We assessed the frequency distribution of participant responses on knowledge regarding postextraction complications. Dry socket (51.47%) was the complication most faced by the participants during their clinical work, whereas 33.82% did not face any complications at all. The rest experienced pain (19.49%), swelling (17.28%), and bleeding (12.50%). When asked what was the most common postextraction complication, the majority of the participants (76.10%) responded with a “dry socket,” whereas some (10.29%) chose “swelling.” Very few chose “pain” (8.46%) and “prolonged bleeding” (3.68%) [Table 1].

Table 1

Knowledge and awareness of postextraction complications among the sample (Question 1-7)

Question	Complication	n (%)
1. Which of the following complications have you facing during your clinical work?	Dry socket	140 (51.47)
	Pain	53 (19.49)
	Swelling	47 (17.28)
	Bleeding	34 (12.50)
	Didn’t face any complications	92 (33.82)
2. The most common postextraction complication which you know?	Pain	23 (8.46)
	Swelling	28 (10.29)
	Sinus perforation	4 (1.47)
	Prolonged bleeding	10 (3.68)
	Dry socket	207 (76.10)
3. After extracting an upper first molar, you note that the palatal root was associated with granuloma and you notice the very darkness of apex what you will do?	Inspect with a sharp instrument	39 (14.34)
	Take a radiograph	128 (47.06)
	Ask the patient to blow his nose	92 (33.82)
	Insert a bone graft	13 (4.78)
4. A patient has communication between oral cavity and maxillary sinus for more than 5 weeks, and the patient is having fever and pus discharge from the communication?	Drainage and antibiotic	110 (40.44)
	Remove of the fistula	104 (38.24)
	Ask the patient to blow his nose	25 (9.19)
	Caldwell-Luc approach	33 (12.13)
5. If a tooth not for extraction has been subluxated during extraction, how would you manage this case?	Stabilization	162 (59.56)
	Leave it and it will heal	86 (31.62)
	Extract the tooth and put an implant	4 (1.47)
	Root canal treatment and leave it	20 (7.35)
6. Displacement of the tooth into the maxillary sinus is highly seen during extraction of?	Maxillary first molar	205 (75.37)
	Maxillary second molar	13 (4.78)
	Maxillary third molar	10 (3.68)
	All of the above	44 (16.18)
7. If and when any complication occurs, it is always recommended to explain the situation to the patient?	Yes	262 (96.32)
	No	6 (2.21)
	I don’t know	4 (1.47)

Most participants (47.06%) responded that they will take a radiograph if they encountered a dark area under the apex after the extraction of an upper first molar that had a granuloma associated with a palatal root. 33.82% chose that they would ask the patient to blow the nose to confirm communication with the sinus, whereas 14.34% will use a sharp instrument into the socket to confirm the same. Very few (4.78%) chose the option of placing a bone graft. When asked about the management of a case where a patient has communication between the oral cavity and the maxillary sinus for more than 5 weeks along with fever and pus discharge from the fistula, majority of the participants (40.44%) chose that the appropriate action would be drainage and administering antibiotics after closure communication. The next most common response was “removal of fistula at the time of communication” (38.24%). Few (12.13%) believed that the Caldwell-Luc procedure was necessary to close the fistula, whereas some (9.19%) would ask the patient to blow the nose to confirm the presence of the communication [Table 1].

In case of subluxation of a tooth not planned for extraction, the majority of the participants (59.96%) believed that stabilization was the best management strategy, whereas 31.62% thought that it is best to leave it and let it heal naturally. Few thought root canal treatments should be done (7.35%), whereas very few (1.47%) also thought that extracting the tooth and replacing it with an implant was an option. When participants were asked which tooth was most commonly displaced into the maxillary sinus, the majority of them (75.37%) responded with “maxillary first molar.” Maxillary second molar and third molar were the next responses (4.78% and 3.68%), whereas 16.18% responded with all of the above. Almost all participants (96.32%) thought that the patient must be informed in case a complication occurred postextraction [Table 1].

When participants were asked which radiograph is the best option to take in case of a missing distal root that was broken during the extraction of a lower second molar, most participants chose the chest X-ray (31.99%). The rest chose cone-beam computed tomography (CT), orthopantomogram, and CT scan (28.68%, 26.47%, and 12.87%, respectively). Participants were also asked which nerve is the most likely to have been injured if the patient complained of loss of sensation in the tongue after the extraction of a lower third molar. Majority of the participants (58.46%) chose the lingual nerve, whereas the rest chose the inferior alveolar and mylohyoid nerves (22.43% and 13.60%, respectively). Very few chose the buccal nerve (5.51%). Most participants (66.91%) thought that disruptive movement tongue can disturb the healing clot, whereas 21.69% chose passage of food. 4.04% thought that normal speech can disturb a clot, whereas 7.35% did not know [Table 2].

Table 2

Knowledge and awareness of postextraction complications among the sample (Question 8-14)

Question	Complication	n (%)
8. During extraction of lower left second molar you noticed that the distal root of the tooth was broken, and it wasn’t in the oral cavity, what you will take?	CBCT	72 (26.47)
	OPG	78 (28.68)
	CT scan	35 (12.87)
	Chest X-ray	87 (31.99)
9. After surgical extraction of lower left third molar patient came to you feeling loss of sensation in his tongue, which nerve gets injured?	Inferior alveolar nerve	61 (22.43)
	Lingual nerve	159 (58.46)
	Long buccal nerve	15 (5.51)
	Mylohyoid nerve	37 (13.60)
10. Which of the condition can disturb clot?	Disruptive movement of tongue	182 (66.91)
	Passage of food	59 (21.69)
	Normal speech	11 (4.04)
	I don’t know	20 (7.35)
11. How do you manage prolonged bleeding primarily?	Direct pressure over the socket	146 (53.68)
	Suturing	51 (18.75)
	Crushing the foramen socket with hemostat	16 (5.88)
	Applying hemostatic agents	59 (21.69)
12. Healthy patients come back after 1 week complaining of bleeding with pain in extracting site, what type of bleeding the patient has?	Primary	53 (19.49)
	Secondary	68 (25.00)
	Tertiary	25 (9.19)
	I don’t know	126 (46.32)
13. Which of the following factors may be associated with pain 2 days after extraction?	Smoking	220 (80.88)
	A lot of acidic drink immediately after extraction	25 (9.19)
	Mouth breather	17 (6.25)
	None of the above	10 (3.68)
14. Three days after extracting a right lower third molar, the patient developed pain in the extraction site with bad taste and halitosis; he had no swelling and no fever, What is the most appropriate management?	Irrigation of socket with a placement of a sedative dressing	164 (60.29)
	Curettage of the socket to induce bleeding	62 (22.79)
	Leave untreated and observe for a few days	3 (1.10)
	Start the antibiotics	43 (15.81)

CBCT: Cone beam computed tomography, OPG: Orthopantomogram, CT: Computed tomography

When asked how the participants managed bleeding primarily, most of them (53.68%) chose “direct pressure over the socket,” whereas 21.69% chose “applying hemostatic agents.” 18.75% of the participants thought that suturing is the best option, whereas few (5.88%) thought that crushing the foramen socket with hemostat is the best option [Table 2].

Most of the participants (46.32%) did not know what was the type of bleeding present in a patient who returned after a week along with pain in the extraction site. 25.00% of those who knew thought that it was secondary bleeding, whereas 19.49% thought that it was primary bleeding. Only 9.19% thought it to be tertiary bleeding. Smoking was the factor that was thought to be most associated with pain 2 days after extraction (80.88%), whereas some participants (9.19%) thought that acidic drinks consumed immediately after extraction can cause pain 2 days postextraction. Only a few thoughts that mouth breathing could be the reason for the pain (6.25%), whereas 3.68% responded with “none of the above” [Table 2].

Finally, participants were asked about the management of a case wherein the patient developed pain in the extraction site with halitosis and bad taste 3 days after the extraction of a lower third molar. The majority of them (60.29%) responded that irrigation of the socket with the placement of a sedative dressing was the best option, whereas 22.79% thought that curettage of the socket must be done to induce bleeding. 15.81% were of the opinion that an antibiotic regimen should be started, whereas very few (1.10%) believed that the site should be left untreated and observed for a few days [Table 2].

Chi-square tests were done to compare the association of correct responses of participants with respect to gender, year of study, and type of school [Table 3]. The difference in knowledge between participants from government and private colleges was found to be statistically significant (P = 0.001). Male interns from government colleges demonstrated the best knowledge among all the participants as they had the highest percentage of correct responses to all questions as compared to other groups. However, when compared with female interns in government colleges, the difference in correct responses was not statistically significant (P > 0.05 for all questions). On the other hand, female seniors from government colleges demonstrated better knowledge than male seniors from government colleges with respect to all questions except question 1, yet the difference was not statistically significant (P > 0.05 for all questions) except for question 9 (P = 0.01). Furthermore, the difference in knowledge between interns and seniors in the government school was also not statistically significant (P = 0.07).

Table 3

Comparisons of knowledge between gender, year of study and type of University-based on correct responses to each question

Government						Private
Senior			Intern			Senior			Intern
Male	Female	P	Male	Female	P	Male	Female	P	Male	Female	P
28	22	0.3	32	29	0.1	19	16	0.02*	16	26	0.01*
11	16	0.2	20	18	0.3	3	4	0.0*	6	13	0.002*
13	13	0.2	20	16	0.3	11	10	0.03*	15	11	0.0*
16	25	0.06	29	21	0.2	12	14	0.02*	19	19	0.02*
21	29	0.08	33	30	0.09	18	20	0.0*	32	28	0.009*
35	16	0.08	37	34	0.06	26	23	0.001*	36	33	0.001*
6	12	0.05	18	16	0.09	5	5	0.02*	7	14	0.0*
19	20	0.06	31	24	0.05	8	12	0.003*	19	18	0.002*
16	29	0.01*	31	23	0.2	12	16	0.6	26	27	0.001*
16	25	0.06	28	16	0.2	9	12	0.03*	19	22	0.01*
7	13	0.09	20	14	0.1	1	3	0.002*	5	5	0.006*
28	28	0.07	34	30	0.06	20	19	0.01*	30	29	0.003*
18	25	0.08	37	24	0.8	12	6	0.0*	23	17	0.02*

*P<0.05 significant

In private colleges, females demonstrated better knowledge than males in both the senior and intern groups, and the difference was statistically significant (P < 0.05 in all questions for both the intern and senior groups except question 9 in the senior group with P = 0.6). However, the difference between the overall knowledge of seniors and interns in private colleges was also not statistically significant (P = 0.9).

Comparisons were also made between complications occurring in private and government colleges [Table 4]. Government colleges were found to demonstrate more complications than private colleges, and the difference was statistically significant (P = 0.003). More participants from the private university did not report any complications (70.66%) than from government universities.

Table 4

Postextraction complications faced by participants in government and private universities

Complications	Government, n (%)	Private, n (%)	Total, n (%)
Dry socket	92 (65.71)	48 (34.9)	140 (51.47)
Pain	34 (64.15)	19 (35.85)	53 (19.49)
Swelling	35 (74.46)	12 (25.54)	47 (17.28)
Bleeding	25 (73.52)	9 (26.48)	34 (12.50)
Didn’t face any complication	27 (29.34)	65 (70.66)	92 (33.82)

DISCUSSION

Complications after any surgical procedure are possible. Dental extraction is one of the most common surgical procedures in the dental clinic.[89] In our study, we aimed to have an overview at our dental student seniors and the dental interns' knowledge of postextraction complications. The incidence of these complications is predictable if the students and interns have the basic knowledge and skills of treating surgical cases. The knowledge of our interns and senior students is fair for the most common postextraction complications, but it is less than the study conducted by Derrbishi et al., 2017.[4]

We assumed in the present study that both senior dental students and dental interns have adequate knowledge about the postextraction complication in Riyadh Province. Our study showed that there is a statistically significant difference in knowledge between females and males in private colleges and the incidence of facing complications between participants in government and private colleges. This difference may be related somehow because a lot of studies confirmed that the clinical experience is the best way for treating postextraction complications. In private colleges, more than half of their participants, i.e., 70.66%, did not face postextraction complications due to less requirement they have because of decreased patient flow. However, female students have good theoretical knowledge in both diagnosis and management of these complications. Furthermore, a similar study was conducted in Riyadh Elm University on its intern with almost the same result.[14] We hypothesized that there is no significant difference in knowledge between seniors and interns, which our study proved. The exposure of the intern on the surgical procedures needs to be increased to improve the knowledge of the complication's management.

CONCLUSION

The exposure of dental students and dental interns in oral surgical procedures has to be increased to improve knowledge of postextraction instructions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.