Dedicated to our late teacher professor dr umar khitab who taught us with full dedication .his legacy lives in the form of his students through out the world

1. KHITAB’S CLASSIFICATION
& MANAGEMENT OF POST
EXTRACTION PAIN
DR.UMAR KHITAB
Assistant Professor
Department of maxillofacial surgery
Khyber College of Dentistry

2. INTRODUCTION
PAIN
The distressing sensation
excited by noxious
stimuli of sufficient
intensity acting on
nerve endings.

3. Ideal extraction ?

4. Classification of Post Extraction
Pain
 Infection
 Traumatic surgery
 Dry socket
 Psychogenic

5. Graph.2
shows Distribution of Post Extraction Pain
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Infection
Tramatic
Surgery
Dry Socket
Psychogenic

6. • Dolor (Pain)
• Tumor (Swelling)
• Calor (heat)
• Rubar (redness)
• Functiolaesia
• Pyrexia
• Bleeding after 48 - 72 hrs.
Infection

7. Infection

8. Management
 Don’t touch
 Strong re-assurance
 Prescription

9. Traumatic Surgery
Signs & Symptom
 Severe pain
 Expose and sharp bone.
 Wear tear of the flap
 Foreign bodies
 Root or tooth fragments
i) Amalgam pieces
ii) Cotton fibers
iii) Any others

10. Traumatic surgery

11. Management
i) Remove/ cut the bone.
ii) Remove the foreign body if any
iii) Irrigate the socket
iv) Repair to cover the socket to
preserve the clot
a) Normal tissue covering the
socket
b) If not possible then Flap
surgery with repair

14. Table.1
Reduction of Severity of pain in 35 patients with Surgical Intervention
with and without diclofenac injection for traumatic post extraction pain
Duration Results of 18 patients
(Pain relief in %age)
with diclofenac
(Voren) injection.
Results of 17
patients (Pain relief in
%age) with out
diclofenac (voren)
injection.
8hrs 90% 80%
24hrs 90% 80%
2nd day 90% 90%
3rd day 95% 95%
4th day 100% 100%
5th day 100% 100%
6th day 100% 100%
7th day 100% 100%

15. Dry Socket
Dry socket is 1– 2% complication
of routine extractions

16. Aetiology and Pathogenesis
Trauma/infection Inflammation of the bone
marrow present in the
alveolar bone
Release tissue
Activators (Streptokinase
and Kinase)
Plasminogen Plasmin
Dissolves clot Releases Kinins
PAIN
Mostly anaerobic micro organism – Treponema denticola

17. PRE-DISPOSING FACTORS
1) Sex
2) Age
3) Site
4) Single Versus Multiple
5) Trauma / Difficulty of extraction
6) Smoking

18. 7) Poor oral hygiene
8) Previous Hx.
9) Systemic diseases e.g Diabetes.
10) Medicines e.g Oral contraceptives.
Steroids, Bisphosphonates,
Antibotics etc.
11) Irradiated bone.

19. CLINICAL FEATURES
• Severe throbbing pain (24 – 72 hours).
• Marked halitosis and a bad taste.
• Empty socket or filled with blood /debris.
• Bare alveolar bone.
• Extremely sensitive to touch.
• Surrounding gingivae may appear swollen .
• Regional lymphadenitis.
• Rarely pyrexia.
• Debilitated due to pain.

20. MANAGEMENT
a)Local Irrigation and Dressing
 Zinc oxide eugenol + cotton wool,
 White head’s varnish (bismuth sub
nitrate and Iodoform in paste),
 Dextranomer – mix with glycerin
 Metronidazole (mixed with orabase )
 Chlorohexidine gel
 Pure honey
 Alvogyl

21. Table.2
Reduction in Severity of pain of 15 dry socket patients by using
Zinc Oxide Eugenol with Cotton Wool
Duration Results of 13 patients
(Pain relief in %age)
Results of 02
patients (Pain relief in
%age)
8hrs 30 % 30%
24hrs 50% 50%
2nd day 70% 55%
3rd day 80% 60%
4th day 100% 60%
5th dy 100% 60%
6th dy 100% 60%
7th day 100% 60%
Result: Pain of 86.7% patients subsided
Pain of 13.3 % patients NOT subsided.

23. Table.3
Reduction in Severity of pain of 15 dry socket patients by using
Alveogel
Duration Results of 14 patients
(Pain relief in %age)
Results of 01
patients (Pain relief in
%age)
8hrs 30 % 30%
24hrs 50% 50%
2nd day 70% 55%
3rd day 80% 60%
4th day 100% 60%
5th dy 100% 60%
6th dy 100% 60%
7th day 100% 60%
Result: Pain of 93.3% patients subsided
Pain of 6.7% patients NOT subsided.

26. Table.4
Severity of pain relief of 15 dry socket patients by doing Surgery with and
without diclofenac injection
Duration Results of 08 patients
(Pain relief in %age +
diclofenac injection)
Results of 01
patients (Pain relief in
%age without
diclofenac injection)
8hrs 80 % 70%
24hrs 80% 80%
2nd day 90% 90%
3rd day 95% 95%
4th day 100% 100%
5th dy 100% 100%
6th dy 100% 100%
7th day 100% 100%
Result: Pain in 93.3% patients subsided.
6.7% failure due to dehiscence.

27. Graph.1
shows comparison of three ways of treatment for management of
dry socket
Surgery
Alveogyl
Z.O.Eug
enol

28. 4. PSYCHOGENIC
Pain after a few days
 Not attended by the doctor, he /she wish
to extract.
A. EARLY
Management
Strong Re-assurance

29. Early Psychogenic

30.  Pain / burning after months / years.
 Severe burning oral mucosa.
 Headache.
 Neck-ache.
 Backache.
 Ear Tinnitus.
 Nose blockage.
 Heart burn.
 Sleep disturbance.
 Cancer Phobia.
B. LATE

31. Late Psychogenic

32. Management
 Strong Re-assurance .
Anxiolytics
 Close Review.
 Continue Re-assurance, if agrees.
 If, no response and non-cooperative, refer to
Psychiatrist.
 If, reluctant to go to the Psychiatrist, then

33. a)Sleep – O.K. and young
Tri-cyclic, Anti-depressant,
Sensival Tab. 10mg.
Dose: Monthwise
OD,BD,TDS, then
BD,OD, and 1/2 for six months
b)Sleep disturb – Old Age
Tab Modrin – Doze (as above)

34. Conclusion
 Proper diagnosis on the basis of this
classification is important for proper
management.
 Pain due to traumatic surgery can be
managed by surgical intervention as
soon as possible.
 Patients repeated visits for dressings
can be avoided by one setting
surgical procedure.

35. Recommendations
 Further studies are recommended for
early surgical intervention in case of
post extraction pain due to traumatic
extraction & dry socket.

36. Thank you
 Any Questions?