8 - Post-op complications 4 Flashcards
What is an OAC?
- oral antral communication
- acute problem
- self heal or surgical, if present for more than 6 weeks then becomes OAF
What is an OAF?
- oral antral fistula
- chronic problem
- epithelial lined sinus tract
How do you diagnose an OAC?
- size of tooth
- radiographic position of roots in relation to antrum
- bone at trifurcation
- bubbling of blood
- nose holding test
- direct vision
- good light and suction
- blunt probe
How can you diagnose an OAC with suction?
Will echo if OAC present
How do you manage an OAC?
- inform patient
- if small, encourage clot and suture margins
- if large or lining torn, close with buccal advancement flap
- POI
What are POI for an OAC?
- use a straw
- don’t blow nose
- sneeze with mouth open
- may required decongestants
How do you manage an OAF?
- excise sinus tract
- close with a flap (buccal advancement ± buccal fat pad, palatal rotation, collagen membrane)
How do you confirm a root/foreign body has entered the antrum?
Radiographically by OPT, occlusal or PA
What are the different methods of retrieving a root/foreign body from the antrum?
- via OAF/through socket
- Caldwell-Luc approach
- ENT via endoscope
How do you retrieve a FB via an OAF?
- open fenestration with care
- use suction
- small curettes
- irrigation or ribbon
- close as OAC
How do you retrieve a FB with the Caldwell-Luc approach?
- lift a buccal flap in the sulcus
- drill away bone to open a window into the antrum
What is osteomyelitis?
- infection of the bone
- rare
- patient is usually systemically unwell
- most common in mandible
- site of extraction tender
- deep infection near IAN may alter sensation
Describe the development of osteomyelitis.
- begins in medullary cavity in the cancellous bone
- spreads to cortical bone
- then spreads to periosteum and causes overlying mucosa to become red and tender
- oedema in the enclosed space causes ischaemia of supplying BVs and soft tissue necrosis
- blood borne defences cannot access site to combat bacteria and bacterial proliferation continues until antibiotic ± surgical therapy occurs
Why is osteomyelitis more common in the mandible?
- maxilla has a rich arterial blood supply
- mandible has dense cortical bone and is supplied primarily by the inferior alveolar artery
What are predisposing factors to osteomyelitis?
- odontogenic infections
- fracture of mandible
- compromised host defence (diabetes, alcoholism, IV drug use, malnutrition, cancer patients)
How long does it take for acute osteomyelitis to be detectable on a radiograph?
10-12 days
Describe the radiographic appearance of osteomyelitis.
- increased radiolucency
- either uniform or patch (moth-eaten appearance)
- may be patches of radiopacity within the radiolucent region due to bony sequestra
- surrounding sound bone may be more radiopaque due to inflammatory response (involucrum)
What bacteria are involved in osteomyelitis of the jaw?
- streptococci
- anaerobic cocci
- anaerobic gram negative rods eg fusobacterium and prevotella
What is the management of osteomyelitis?
- medical and surgical
- check culture for antibiotics
- investigate host defences (FBC, glucose levels)
What is the antibiotic treatment of osteomyelitis?
- penicillin is first line drug (good bone penetration)
- 6-12 week course or via IV (can be up to 6 months for chronic cases)
What is the surgical treatment of osteomyelitis?
- drain pus
- remove any non-vital teeth in area
- remove sequestra
- remove any wires/screws etc if fractured mandible
- corticotomy (removal of bony cortex)
- perforation of bony cortex
- excision of necrotic bone until actively bleeding bone is reached
What is ORN?
- osteoradionecrosis
- seen in patients who receive radiation to the head and neck for cancer
- bone within beam becomes non-vital
- endarteritis (reduced blood supply)
- turnover of remaining viable bone is slow and self repair is ineffective
- effects increase with time and dose
What are treatments for ORN?
- careful routine extraction
- surgical extraction, alveoplasty primary closure of soft tissues
How do you prevent ORN?
- PMPR and chlorohexidine mouthwash prior to extraction
- careful technique
- antibiotics and chlorohexidine mouthwash
- hyperbaric oxygen before and after extraction
What is MRONJ?
- medication related osteonecrosis of the jaw
- caused by medications that inhibit osteoclast activity and bone renewal
- occurs post XLA, denture trauma or spontaneous
- ranges from asymptomatic to bone exposure
Give examples of bisphosphonates.
- alendronate
- ibandronate
- zoledronate
What other drugs can cause MRONJ?
- RANKL inhibitors (denosumab)
- monoclonal antibody drugs
- antiangiogenic drugs (bevacizumab)
What are the risk factors for developing MRONJ?
- impact on bone eg XLA
- trauma from dentures
- infection
- periodontitis
- duration of drug therapy
- implants
What is the management of MRONJ?
- prevent invasive treatment
- XLA can be conducted in primary care
What is actinomycosis?
- rare bacterial infection
- bacteria has low virulence and must be treated in the area
- erodes through tissue rather than follow fascial planes
- presents with multiple skin sinuses and swellings
- pus is thick and lumpy (like cottage cheese)
How do you treat actinomycosis?
- incision and drainage of pus
- excision of chronic sinus tracts
- excision of necrotic bone and FBs
- high dose antibiotics (often IV)
- long term antibiotics to prevent recurrence
What antibiotics can be used to treat actinomycosis?
- penicillins
- doxycycline
- clindamycin
- based on culture sensitivity
What is the guidance surrounding IE?
- infective endocarditis
- antibiotic prophylaxis used to be standard
- now choice is discussed with patient and cardiologist regarding risk and procedure
What prophylaxis antibiotics can be prescribed for someone at risk of IE?
- amoxicillin
- clindamycin
- azithromycin (second line if allergy)
