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\begin{document}

\title{Self-extraction: A cautionary tale}



\author[1]{PRACHET DAKSHINKAR}%
\author[1]{Dr. Apoorva Mishra}%
\author[1]{Anendd  Jadhav}%
\author[1]{Nitin Bhola}%
\affil[1]{SPDC}%


\vspace{-1em}



  
  \date{June 18, 2024}


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\begin{abstract}
The author's intent is to bring one such case to focus wherein just mere
lack of knowledge and casual approach towards one's own health having
undiagnosed underlying blood coagulation disorder led to catastrophic
sequence of events, leaving behind a cautionary learning tale from a
loss of life.%
\end{abstract}%



\sloppy


\textbf{Self-extraction: A cautionary tale}

\textbf{Abstract:}

Literature is rich on complications related to tooth extraction, which
is a commonly performed oral surgical procedure. It is widely accepted
as one of the simplest procedures when performed in a controlled
environment with due precautions. Often simple procedures in terminology
of doctors and medical professionals are interpreted in a similar manner
or fashion amongst the laymen. This misinterpretation or
misunderstanding usually results in a casual approach towards one's own
health. Or in other terms, Illiteracy and sparse knowledge about the
controlled environment and complications associated with it in presence
of comorbidities can lead to irreversible complications and may even
sometimes be fatal in nature. For an example, undiagnosed blood
coagulation disorders can really be fatal. The author's intent is to
bring one such case to focus wherein just mere lack of knowledge and
casual approach towards one's own health having undiagnosed underlying
blood coagulation disorder led to catastrophic sequence of events,
leaving behind a cautionary learning tale from a loss of life.

\textbf{Keywords: Tooth Extraction, Extractions, Extraction, Tooth.}

\textbf{Introduction:}

Tooth extraction is one of the most commonly performed oral surgical
procedure.\textsuperscript{1} Whenever it is performed with due
precautions in controlled environment the chances of untoward incidences
are minimal. Socio economic status, literacy and oral health awareness
go a long way in realizing this goal. Owing to these constraints many
people in India are still averse to visiting a Hospital for seeking
Dental treatment. Many individuals seldom get their routine health
checkup done which makes them susceptible to undiagnosed systemic
conditions. An individual unaware of the consequences is often tempted
to remove a mobile tooth by himself/herself which is termed as
self-extraction. Amer in 2014 was of the view that evidence of bleeding
beyond the pressure pack to be labelled as post extraction
bleeding.\textsuperscript{2} Lockhart in 2003 specified certain
criteria's for ascertaining post extraction bleeding: persistent bleed
beyond 12 hours; return of patient to the concerned person who performed
extraction: progressive hematoma or ecchymosis; or requiring transfusion
of blood and hospitalization.\textsuperscript{3} Most individuals
performing self-extraction get away with post extraction bleeding and
fail to develop any threatening complications. But some individuals can
have catastrophic events which can even be a potential threat to
life.\textsuperscript{4}

We intend to report a case of self-extraction which reported to our
Hospital and discuss the possible cause of succeeding series of events

\textbf{The case}

A 56 year old male reported to the outpatient Department of Oral and
Maxillofacial Surgery, Sharad Pawar Dental College with a complaint of
bleeding from extraction socket of left first mandibular molar. Patient
self-extracted the aforementioned tooth 6 days back. Even after elapsing
of 2 hours after extraction the bleeding ceased to stop. This raised an
alarm in the patients mind. He went to the same Dentist where suturing
of the socket was done, evident by the residual suture tags. Even after
that oozing was present from extraction site. Patient did not pay much
attention to the ooze and continued his daily activities in the
anticipation of stoppage of bleeding over course of time. He gave no
history of any bleeding or clotting disorder, hemophilia, episode of
myocardial infarction or any other systemic condition. He gave history
of chronic alcohol consumption. He presented with no history of long
term medication known to impede blood clot formation or blood thinning
therapy

Intra-oral examination revealed continuous ooze from the socket. Buccal
cortical plate was found to be missing. Clots from around the surgical
site were retrieved. Local hemostatic control measures yielded no
encouraging results. On systemic inspection Petechiae were found on the
chest and back region. At the outset patient was reluctant to get
admitted in anticipation of a minor problem. On persistent persuasion
and counselling he and his relatives agreed upon. Preliminary
hematological investigations were performed .MCV (Mean corpuscular
volume) was found to be 132 FL, MCH (Mean corpuscular hemoglobin) 40Pg,
hematocrit value was found to be 35.1, MCHC (Mean corpuscular hemoglobin
concentration) of 30.1 which suggested of macrocytic anemia. This could
be attributed to his habit of chronic alcoholism .Prothrombin time was
found to be 16 seconds. He was found to be thrombocytopenic having a
platelet count of 20000/mm3.Peripheral smear was suggestive of acute
myeloid leukemia. Bone marrow biopsy was planned to confirm the
diagnosis At this point of time initial focus of treatment was on
controlling acute bleeding. Local hemostatic measure in form of gelatin
sponge packing followed by suturing was instituted. Systemic
administration of Vitamin K yielded no encouraging results. Infusion of
fresh frozen plasma was about to be initiated.

Following this patient went unconscious. He was immediately intubated.

Computed tomography revealed intra-parenchymal bleed in left
fronto-parieto-temporal and gangliocapsular region. Epidural, subdural
and subarachnoid hemorrhage too was observed. (Fig.1) Patient was
immediately shifted to Department of Neurosciences for management. In
the course of treatment he did not improve and eventually succumbed.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Fig. 1: Intra-parenchymal bleed in left fronto-parieto-temporal and
gangliocapsular region

\textbf{Discussion}

Creation of a stabilized clot is of paramount importance for
facilitating unhindered and uneventful healing of the surgical wound
created after tooth extraction. Dormant systemic abnormalities can get
easily triggered by a trivial minor procedure like tooth extraction.
This can lead to ramifications, series of events which can be life
threatening for the patient. Nowadays many patients are on anticoagulant
therapy making them susceptible to post extraction
bleeding.\textsuperscript{5}Such patients invariably are aware of the
medications they are consuming. This makes extraction under controlled
environment possible. People unaware and ignorant about their health
status are like a time bomb which can land them in a state of no
reversal. Chronic alcoholism is such an exigency which requires ardent
attention. It can cause diseases like hepatitis, fatty liver and
cirrhosis. Long standing hepatocellular diseases can predispose to
deficiencies of blood coagulation factors thereby posing as a risk for
occurrence of hemorrhage.\textsuperscript{6}Poor dietary intake in
alcoholics can lead to anemia secondary to folic acid deficiency. Blood
film shows oval and round macrocytes characterizing chronic liver
disease. Such patients are bound to have thrombocytopenia and
deficiencies of coagulation factors. Alcohol is detrimental for bone
marrow which could have led to suspicion of acute myeloid leukemia in
this case. Thrombocytopenia is commonly seen in patients with chronic
liver disease with reports of up to 76\% patients having
cirrhosis.\textsuperscript{7}

Chronic alcoholics are at high risk for developing intra-cerebral
hemorrhage due to reduced liver produced coagulation factors and
platelet abnormalities coupled with
hypertension.\textsuperscript{8}Instant episode of alcohol consumption
along with the stress induced due to extracted tooth could have led to
acute hypertension in this case. Reduced platelet count in conjunction
with their impaired function and deficient coagulation factors must have
triggered an episode of intra-cerebral hemorrhage.

Operating personals prior to extracting a tooth are very much concerned
about the common systemic conditions like diabetes mellitus and
hypertension. They are extremely cautious about patients on
anticoagulant therapy in wake of any hemorrhagic episode. Alcohol
consumption history is mostly not given the necessary importance and is
often skipped during routine dental extractions. In Indian circumstances
Societal taboo in deriving this history is a major hindrance. More-over
patients too are reluctant to divulge this information. Most of the
operating personal are also unaware of the catastrophic sequelae that
can unravel after a chronic alcoholic gets his tooth removed.

It becomes imperative that operating personal should have sound
knowledge of these manifestations and patients too need to be sensitized
and counselled about these possibilities to prevent any attempt of
self-extracting a tooth.

\textbf{Conflict of Interest:} None

\textbf{Funding Source:} None

\textbf{Acknowledgement:} None

\textbf{Consent:} Written informed consent was obtained from the patient
to publish this report in accordance with the journal's patient consent
policy.

\textbf{References:}

1) Imai T, Michizawa M, Shimizu H, et al. Spontaneous intraoral
hemorrhage as manifestation of thoracoabdominal aortic aneurysm
associated disseminated intravascular coagulation: case report and
review. \emph{J Oral Maxillofac Surg} . 2010:68:195-200.

2) Amer MZ, Mourad SI, Salem AS, Abdelfadil E. Correlation between
International Normalized Ratio values and sufficiency of two different
local hemostatic measures in anticoagulated patients. European Journal
of Dentistry 2014: 8:475--80.

3) Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management
considerations for the patient with an acquired coagulopathy. Part 1:
Coagulopathies from systemic disease. British Dental Journal 2003:
195(8):439--45.

4) Brauer HU. Unusual complications associated with thirdmolar surgery:
a systematic review. Quintessence Int. 2009: 40:565--572

5) Iwabuchi H, Imai Y, Asanami S, Shirakava M, Yaname GY, Ogiuchi H, et
al. Evaluation of post-extraction bleeding incidence to compare patients
receiving and not receiving warfarin therapy: a cross-sectional,
multicentre, observational study. BMJ Open. 2014:4(12):e005777.

6) Lockhart PB, Gibson J, Pond SH, Leitch J. Dental
managementconsiderations for the patient with an acquired coagulopathy.
Part1: Coagulopathies from systemic disease. Br Dent J 2003: 195:
439-45.

7) Gonzalez-Casas R, Jones EA, Moreno-Otero R. Spectrum of anemia
associated with chronic liver disease. \emph{World JGastroenterol} 2009:
15(37): 4653-4658

8) Kozararevic D, Vojvodic N, Dawbir N, McGee D, Racic Z, Gordon T,
Zukel W: Frequency of alcohol consumption and morbidity and mortality.
The Yugoslavia Cardiovascular Disease Study. \emph{Lancet} 1980:
l:613-616

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