7 - Post-op compilations 3 Flashcards
What are the common post-operative complications?
- pain/swelling/bruising
- trismus
- haemorrhage
- nerve damage
- dry socket
- sequestrum
- infected socket
- chronic OAF
What are the more uncommon post-operative complications?
- osteomyelitis
- osteoradionecrosis (ORN)
- medication related osteonecrosis (MRONJ)
- actinomycosis
- bacteraemia/infective endocarditis
What can increase the pain experience post-op?
- poor technique
- rough handling of instruments
- laceration of tissues
- leaving bone exposed
- incomplete extraction
What should post-op swelling feel like?
Soft not hard
What can increase swelling post-op?
- very individual response
- poor technique
- rough handling of instruments
- pulling at flaps or crushing tissues
- tearing periosteum
What can increase bruising post-op?
- very individual response
- poor technique
- rough handling of instruments
- pulling at flaps or crushing tissues
- tearing periosteum
Describe the appearance of bruising post-op.
- gravity pulls blood down so bruise can appear down neck
- if severe check for underlying medical issues
- very individual response
What causes trismus post-op?
- LA deposited in meidal pterygoid
- oedema
- muscle spasm from having mouth open for extended period
- haematoma in medial pterygoid or masseter
- damage to TMJ (oedema or effusion)
How do you manage trismus?
- reassurance and analgesia
- monitor as may take weeks to resolve
- mouth opening exercises include trismus screw and using wooden spatulas
What is considered low risk for bleeding?
- simple extractions (1-3 teeth)
- incision/drainage of intra-oral swellings
What is considered high risk for bleeding?
- complex extractions
- adjacent extraction with larger wound
- more than 3 extractions at once
- flap raising procedures
- biopsy
How do you manage a patient taking an antiplatelet drug?
- treat without interrupting medication
- expect prolonged bleeding with clopidogrel, dipyridamole etc and consider suturing and packing wound
How do you manage a patient taking a DOAC?
- low risk procedure, treat without interrupting medication BUT limit initial treatment to assess bleeding
- high risk procedure, advise patient to delay or miss AM dose and advise when to restart (usually PM)
What causes immediate post-op bleeding?
- reactionary or rebound bleeding
- within 48 hours
- vessels open as vasoconstriction wears off, patient traumatises area with tongue or finger, suture is lost
What causes secondary bleeding?
- infection
- 3-7 days post-op
- can be medication related
What are examples systemic haemostatic aids?
- vitamin K
- anti-fibrinolytics (eg tranexamic acid)
- missing blood clotting factors
- plasma or whole blood
- desmopressin
How do you manage post-operative bleeding?
- remove clot
- identify where bleed is coming from
- pressure
- LA with vasoconstrictor
- suture socket with packing agent
What is the procedure if you cannot arrest bleeding?
- urgent hospital referral
- weekdays - dental hospital or maxillofacial outpatient
- weekends - A&E
How do you prevent haemorrhage post-op?
- thorough medical history
- atraumatic technique
- obtain and check good haemostasis
- POI
What are the POI you should tell your patient after the procedure?
- do not rinse for several hours (next day best)
- avoid touching socket as may traumatise
- avoid hot food
- avoid alcohol
- avoid excessive physical exercise
What is dry socket?
- alveolar osteitis
- common in 2-3% of extractions
- the normal clot disappears so that you can see bone
- causes intense pain
When does dry socket happen?
- 3-4 days post op
- takes 1-2 weeks to resolve
What are the symptoms of dry socket?
- dull aching pain (moderate to severe)
- throbbing pain which radiates to ear
- keeps patient awake at night
- exposed bone is source of pain
- bad smell or taste from area
What are the risk factors for developing a dry socket?
- molars are more common
- mandible is more common
- smoking
- female
- oral contraceptive pill
- LA with vasoconstrictor (BUT always necessary)
- excessive trauma
- mouth rinsing post op
What is the management of a dry socket?
- reassurance and systemic analgesia
- LA
- irrigate socket with warm saline
- curettage and debridement encourages new clot to form
- alvogyl antiseptic pack
What is a sequestrum?
- small pieces of dead bone that appear through gingiva
- sometimes small pieces of tooth or amalgam
- delay healing and require removal
Describe an infected socket.
- very rare complication (dry socket more common)
- pus discharges from socket
How do you manage an infected socket?
- check for remaining tooth or root fragments
- radiograph and explore socket
- irrigate
- remove any debris
- consider antibiotics
