Oral Surgery · patient case with 1 question
Extraction in a smoker taking a combined oral contraceptive
Patient: Female, 29 years old
Chief Complaint: “This bottom molar is broken and I want it out.”
Background: Takes Loestrin (norethindrone acetate with ethinyl estradiol). Smokes approximately half a pack daily. No other medical history.
Vital Signs: BP 118/74 mmHg · HR 78 bpm · HbA1c 6.0%
Findings: Tooth #19 non-restorable with gross coronal destruction. No swelling, no acute infection. Extraction planned.
Question 1
Which factor most increases her risk of severe pain after the extraction?
Show answer and explanation
Correct answer: A. Smoking
- A. CORRECT. SMOKING is the strongest modifiable risk factor for ALVEOLAR OSTEITIS (dry socket), raising the risk several-fold. It acts by more than one route: the negative pressure of inhalation physically dislodges the clot, heat and chemical irritants disrupt clot organisation, and nicotine-induced vasoconstriction reduces the local blood supply and healing capacity. Advise abstinence for at least 48 hours before and 72 hours after, and warn about it explicitly.
- B. Norethindrone is the progestin component. The fibrinolytic effect is attributed to the OESTROGEN, not the progestin.
- C. Oestrogen is a genuine and well-documented risk factor for dry socket — it raises fibrinolytic activity and promotes clot breakdown — and it is why extractions are ideally scheduled in days 23 to 28 of the cycle, when oestrogen is lowest. But between the two, SMOKING carries the larger effect, and it is the one the patient can act on today.
- D. An HbA1c of 6.0% is NORMAL — below the 5.7% to 6.4% prediabetic band at its lower end and nowhere near the diabetic threshold of 6.5%. It poses no healing problem and is in the stem as a distractor.
Note: The full risk list for alveolar osteitis: smoking, oral contraceptives, surgical or traumatic extraction, mandibular third molars, previous dry socket, poor oral hygiene, pre-existing infection or pericoronitis, and vigorous rinsing or spitting in the first 24 hours. The presentation is severe throbbing pain 2–4 days after extraction with an EMPTY socket, exposed bone and foul odour, and NO purulence and NO fever — the absence of infection signs is what separates it from a postoperative infection.