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BDS3 CDS Oral Surgery > 4. Post-operative Complications Following Extraction > Flashcards

4. Post-operative Complications Following Extraction Flashcards

1
Q

Define OAC.

A

Acute condition - communication between oral cavity and maxillary sinus which can self-heal or require surgical fixation.

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2
Q

Define OAF.

A

Chronic condition - epithelial lined sinus tract formed between oral cavity and maxillary sinus.

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3
Q

How often after extraction will a OAC begin to epithelialise into OAF ?

A

> 6 weeks.

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4
Q

What are 6 ways in which OAC can be diagnosed ?

A

Size of tooth.
Radiographic position of roots in relation to antrum.
Bone at trifurcation of roots.
Bubbling of blood.
Nose holding test.
Direct vision with good light and suction.

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5
Q

How should a small OAF (or intact sinus) be managed ?

A
  1. Encourage clot and suture margins - normal haemostat measures.
  2. Post-operative instructions - drink with straw, sneeze with mouth open, no nose blowing.
  3. Antibiotic prescription - only where significant pus or apical infection in area.
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6
Q

How should a large OAF (or lining torn) be managed ?

A
  1. Close with buccal advancement flap.
  2. Antibiotic prescription - only where significant pus or apical infection in area.
  3. Decongestants - reduces risk of infection by clearing sinus.
  4. Nose blowing instructions.
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7
Q

How should chronic OAF be managed ?

A
  1. Excise sinus epithelial tract.
  2. Close via -
    - Buccal advancement flap with tension free closure via periosteal release.
    - Buccal fat pad with buccal advancement flap.
    - Palatal flap.
    - Bone graft/collagen membrane.
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8
Q

How can a tension free closure of OAF be achieved ?

A

By scoring periosteum causing periosteal release.

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9
Q

How should foreign body in maxillary sinus be managed ?

A
  • Confirm radiographically - OPT, occlusal, PA.
  • Referral or if retrieval possible ?
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10
Q

Define osteomyelitis.

A

Inflammation of bone marrow due to invasion of bacteria into cancellous bone causing soft tissue inflammation in closed bone marrow spaces.

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11
Q

Why is osteomyelitis more common in mandible (as oppose to maxilla) ?

A

Primary blood supply of mandible is inferior alveolar artery and dense overlying cortical bone limits penetration of periosteal blood vessels - so poorer blood supply making it more likely to become ischaemic and infected.

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12
Q

What are two symptoms which you might see in patient with acute osteomyelitis ?

A

Systemically unwell - high temperature.
Altered sensation due to pressure on IAN.

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13
Q

What are 3 radiographic changes which you might see in patient with osteomyelitis ?

A

Patchy radiolucencies and sclerosis of bone.
Bony sequestra in area.
Involucrum if long standing.

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14
Q

Define sequestra.

A

Unresorbed islands of bone in socket.

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15
Q

Define involucrum.

A

A layer of new bone growth outside existing bone seen in osteomyelitis i.e. increase in radiodensity surrounding radiolucent area as a result of inflammatory reaction where bone production is increased (osteoblastic activity).

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16
Q

What are 3 risk factors for development of osteomyelitis ?

A

Odontogenic infection.
Fractures in mandible.
Compromised host defence system i.e. diabetes, alcoholism, IV drug use, myeloproliferative disease.

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17
Q

What symptoms would a patient present with acute osteomyelitis ?

A

Similar to dry socket or localised infection into socket with no radiographic change.

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18
Q

How long does it take for radiographic changes to be detectable with infection ?

A

Usually 10-12 days.

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19
Q

What symptoms would a patient present with chronic osteomyelitis ?

A

+/- pus and radiographic bone destruction in area of infection.

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20
Q

What are the four stages to osteomyelitis treatment ?

A
  • Bacterial swab - for antibiotic treatment.
  • Blood investigations and glucose levels.
  • Antibiotic treatment.
  • Surgical treatment - I&D.
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21
Q

What is first line antibiotic for osteomyelitis ?

A

Amoxicillin (prolonged).

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22
Q

Define osteoradionecrosis.

A

Reduced bony turnover and ineffective self-repair of jaw due to previous radiotherapy of head and neck to treat cancer causing bone to become non-vital and reduced blood supply (endarteritis).

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23
Q

Define endarteritis.

A

Reduced blood supply in bone.

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24
Q

What are the three types of drugs associated with MRONJ ?

A

Bisphosphonates.
RANKL inhibitors.
Anti-angiogenic.

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25
Q

How do bisphosphonates work ?

A

Inhibitor osteoclast activity and inhibit bone resorption and bone renewal.

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26
Q

What 3 conditions are bisphosphonates used to treat ?

A

Osteoporosis.
Paget’s disease.
Malignant bone metastases.

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27
Q

Are oral or IV bisphosphonate treatments more likely to cause MRONJ ?

A

IV.

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28
Q

What are 6 risk factors for development of MRONJ ?

A

Type of surgical treatment.
Duration of bisphosphonate treatment.
Dental implants.
Other concurrent medication.
Previous drug history.
Drug holidays.

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29
Q

What medication combined with anti-resorptive and anti-angiogenic drugs can cause increased risk of MRONJ development ?

A

Steroids.

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30
Q

What are 3 factors which render patient low risk of developing MRONJ ?

A

Only where osteoporosis or non-malignant bone disease i.e. Paget’s disease.
- Bisphosphonate treatment for <5 years who are not concurrently being treated with systemic glucocorticoids.
- Quarterly or yearly infusions of IV bisphosphonates for <5 years who are not concurrently being treated with systemic glucocorticoids.
- Treated with denosumab and not with systemic glucocorticoids.

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31
Q

What are 4 factors which render patient high risk of developing MRONJ ?

A
  • Previous diagnosis of MRONJ.
  • Treated with anti-resorptive and anti-angiogenic drugs as cancer management.
  • Quarterly or yearly infusions of bisphosphonates >5 years.
  • Bisphosphonates or denosumab for any length of time and who are concurrently being treated with systemic glucocorticoids.
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32
Q

What are 4 factors which render patient high risk of developing MRONJ ?

A
  • Previous diagnosis of MRONJ.
  • Treated with anti-resorptive and anti-angiogenic drugs as cancer management.
  • Quarterly or yearly infusions of bisphosphonates >5 years.
  • Bisphosphonates or denosumab for any length of time and who are concurrently being treated with systemic glucocorticoids.
33
Q

How would you manage a patient at risk of MRONJ ?

A

Treat normally in primary care setting.
Referral when only symptomatic of MRONJ.
Prevent invasive treatment via prevention techniques.

34
Q

Define actinomycosis.

A

Rare bacterial infection which erodes through tissues (rather than following typical fascial planes and spaces).

35
Q

What bacteria are associated with actinomycosis ?

A

Actinomyces Israelii.
Actinomyces naeslundii.
Actinomyces viscosus.

36
Q

What are symptoms of actinomycosis ?

A

Chronic.
Multiple skin sinuses and swelling.
Thick lumpy pus ‘cottage cheese’.
Smell.
Responds to antibiotic therapy then recurs when stopped.

37
Q

What are risk factors for infective endocarditis ?

A

Previous rheumatic fever diagnosis.
Heart murmurs.
Prosthetic heart valves after cardiac surgery.

38
Q

Why does rheumatic fever make it more likely to develop infective endocarditis ?

A

Scarring and vegetations form on heart valves meaning bacteraemia can circulate and colonise.

39
Q

What is the first line antibiotic prophylaxis prescription which should be given to patient at risk of developing infective endocarditis after consultation with GMP or specialist medic ?

A

Amoxicillin 3g oral powder sachet.
1x sachet (3g) 60 mins before procedure.

40
Q

Where patient is allergic to penicillin - what are the second line antibiotic prophylaxis prescription which should be given to patient at risk of developing infective endocarditis after consultation with GMP or specialist medic ?

A

Clindamycin capsule 300mg.
2x 300mg capsule (=600mg) 60 mins before procedure.

Azithromycin oral suspension 200mg/5ml.
500mg/12.5ml 60 mins before procedure.

41
Q

Name common post-operative extraction complications.

A

Pain.
Swelling.
Ecchymosis.
Trismus.
Haemorrhage and post-op bleeding.
Prolonged effects of nerve damage.
Dry socket or infected socket.
Sequestrum.
Chronic OAF or OAC.
Root in antrum.

42
Q

Name some less common post-operative extraction complications.

A

Osteomyelitis.
Osteoradionecrosis.
MRONJ.
Actinomycosis.
Infective endocarditis.

43
Q

What medication should be recommended to patient suffering post-op pain ?

A

Ibruprofen.

44
Q

What will increase likelihood of patient experiencing pain and oedema post-operatively ?

A

Handling of tissues - laceration, tearing, leaving exposed bone, incomplete XLA of tooth, leaving bony sequestra.

45
Q

How quickly after extraction should soft swelling resolve ?

A

Within 24 hours.

46
Q

What will increase the likelihood of a patient developing ecchymosis post-operatively ?

A

Antiplatelets and anticoagulants.
Rough handling of tissues.
Bleeding tendencies.

47
Q

What are the 4 causes of post-operative trismus ?

A

Length of treatment.
Medial pterygoid spasm in IDB where needle passes through muscle.
Haematoma affecting MP or masseter.
Damage to TMJ - oedema or joint effusion.

48
Q

Define joint effusion.

A

Swelling of cartilage in TMJ (in capsule).

49
Q

What length of time should it take for normal mouth opening to resume after post-operative trismus ?

A

A few weeks.

50
Q

What medications will increase likelihood of intra-operative haemorrhage ?

A

Warfarin.
DOACs - apixaban or rivaroxaban.

51
Q

When should the INR be checked of a patient prior to extraction ? Stable and unstable.

A

Unstable - within 24 hours.
Stable - within 72 hours.

52
Q

What is the target INR pre-operatively for patient being treated for AF or DVT ?

A

INR 2.5

53
Q

What is the target INR pre-operatively for patient being treated after metal heart valve replacement ?

A

INR 3.3

54
Q

What should a patient’s INR be to undertake extraction in primary care setting ?

A

INR 2-4

55
Q

What should a patient’s INR be to undertake extraction in hospital setting ?

A

INR 1-2

56
Q

Name 5 local haemostatic aids.

A

Adrenaline containing LA.
Oxidised regenerated cellulose i.e. Surgicel.
Haemocollagen sponge.
Thrombin liquid and powder.
Floseal.

57
Q

Why should care be taken using Surgicel in extraction of lower 8s ?

A

Highly acidic - risk of chemical damage to IAN.

58
Q

What is Surgicel ?

A

Oxidised regenerated cellulose - absorbable collagen framework for facilitation of clot formation.

59
Q

Name 5 systemic haemostatic aids.

A

Vit K.
Anti-fibrinolytics i.e. tranexamic acid - tablets or mouthwash.
Missing blood clotting factors.
Plasma or whole blood transfusion.
Desmopressin.

60
Q

When should hospital referral be made if post-operative haemostasis cannot be achieved ?

A

30 mins - MaxFax or haemophiliac clinic.

61
Q

What are 5 types of sensory change ?

A

Anaesthesia.
Paraesthesia.
Dysesthesia.
Hyperaesthesia.
Hypoaesthesia.

62
Q

Define anaesthesia.

A

Numbness.

63
Q

Define paraesthesia.

A

Tingling.

64
Q

Define dysesthesia.

A

Unpleasant sensation or pain (similar to trigeminal neuralgia).

65
Q

Define neuropraxia.

A

Contusion (bruising) of nerve with continuity of epieneural sheath and axons maintained.

66
Q

Define axonotemsis.

A

Continuity of axons bur epieneural sheath disrupted.

67
Q

Define neurotmesis.

A

Completely loss of nerve continuity/nerve transected.

68
Q

How long should it take for temporary nerve damage to resolve ?

A

18 months.

69
Q

After how long will temporary nerve damage become permanent ?

A

> 18 months.

70
Q

What 3 nerves are most likely to be damaged during extractions ?

A

8s - IAN and lingual nerve.
Anterior incisors - superior alveolar nerve branches.

71
Q

When will alveolar osteitis tend to begin ?

A

3-4 days after extraction.

72
Q

When will alveolar osteitis tend to resolve ?

A

7-14 days after extraction (even with intervention).

73
Q

Define alveolar osteitis (or dry socket).

A

When the blood clot at the site of the tooth extraction fails to develop, or it dislodges or dissolves before the wound has healed.

74
Q

What are the symptoms characteristic of alveolar osteitis ?

A

Continuous dull aching pain - moderate to severe.
Radiation to ear.
Keep patient awake at night.
Exposed bone sensitive.
Bad smell.
Bad taste.

75
Q

Extractions of what teeth are most likely to result in alveolar osteitis ?

A

Mandibular molars (risk increases from anterior to posterior).

76
Q

What are predisposing factors to alveolar osteitis ?

A

Smoking.
Females - especially on contraceptive pill.
Infected tooth.
Excessive trauma during XLA.
Excessive mouth rinsing post-XLA.
FH.
Previous dry socket.

77
Q

Why does smoking increase risk of alveolar osteitis ?

A

Reduced blood flow to wound.

78
Q

Management for alveolar osteitis ?

A
  1. Supportive - reassurance and systemic analgesia.
  2. LA.
  3. Irrigate socket with warm saline and check for no tooth fragments and bony sequestra.
  4. Debride - encourage bleeding and new clot formation.
  5. Alvogyl (antiseptic pack) - antiseptic and analgesic absorbable material.
  6. Suture if appropriate.
  7. Review patient to change packs and dressing.
79
Q

What are the 3 constituents of Alvogyl ?

A

Butamen, iodoform, eugenol.

BDS3 CDS Oral Surgery (4 decks)

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