Complications of extractions Flashcards
What do we do to prevent TMJ dislocation during extractions?
- support with non-dominant hand
- McKesson’s mouth prop if patient struggling to support jaw themselves (bites down to counteract pressure during extraction)
- alternative approach or abandoning procedure if patient has TMJ issues or is at risk of dislocation
What alternative approach might be used to extract a tooth for a patient at risk of TMJ dislocation?
surgical approach - raise flap, remove bone etc. to reduce amount of pressure needed
If a TMJ dislocation occurs how is this treated?
reduce the dislocation
- sit patient down, against wall if possible
- thumbs intraorally on the external oblique ridges bilaterally with fingers curled under inferior border of mandible extraorally
- exert downward pressure on mandible with aim of pushing joint back over the articular eminence to reinstate it in glenoid fossa
- hold mouth closed for a period
What are some of the bone related postoperative complications?
- alveolar osteitis - ‘dry socket’
- sequestrum
- exposed bone
- MRONJ
- ORN
What is alveolar osteitis?
dry socket
- inflammation of the bone in the alveolus
What is the prevalence of dry socket?
0.5% to 68% range
What % of routine extractions does dry socket affect?
0.5% to 5%
Extraction of which teeth are more affected by dry socket?
mandibular molars
What % of impacted 3rd molars are affected by dry socket after extraction?
1% to 37.5%
What is the most commonly reported % incidence of dry socket?
<5%
In what age is dry socket reportedly most common?
4th decade
What is the pathogenesis of dry socket?
- complete absence of blood clot
- formation of initial clot which is subsequently lysed
- inflamed alveolar bone
- release of tissue activators - plasmin precursor (plasminogen) in plasmin
What are the risk factors for dry socket?
- women
- smoking - vasoconstriction
- trauma
- medications - OCP, antipsychotics, antidepressants
- anatomy - mandibular third molars
What are some additional factors (other than standard risk factors) which may increase chance of dry socket?
- infection
- inadequate oral hygiene
- poor after care
- ??spitting, sucking through a straw, coughing or sneezing??
What surgical factors may increase risk of dry socket?
- flap extent and design
- surgical trauma
- experience of the surgeon
- perioperative patient stress
- focal fibrinolytic activity
What is the presentation of dry socket?
- after an extraction
- onset anytime, usually 2-3 days
- worsening pain cf better
- refractory to analgesia
- dull aching throb (severe)
- bad taste
- discharge
- halitosis
What is the management of dry socket?
- LA ideally
- gentle exploration of socket
- remove debris
- sequestrum?
- irrigation - saline
- sedative dressing - alvogel
- establish new blood clot?
- do nothing?
What are sequestrum?
- small (usually) fragments of bone which have become detached from the extraction site
- radiograph may be useful
How is a sequestrum managed?
- if small, LA and remove with tweezers
- if large, LA and may require exploration of the socket
What may occur if a sequestrum is large?
possible for the entire socket alveolus to become a sequestrum and become ejected
Other than bone, what else may be exfoliated from an extraction site (sequestrum)?
small shards of tooth/enamel/dentine
If soft tissue trauma during an extraction is more severe at the crestal area, what may happen?
large areas of exposed bone, if they persist may require reduction to get them below mucosal level
What area is it common for exposed bone to be visible?
lingual posterior mandible due to prominence, thin mucosa and thin cortical plate
What are bisphosphonates?
antiresorptive medication used to treat osteoporosis, bone metastasis, primary malignancy, Paget’s disease
What are some common bisphosphonates?
- alendronate
- ibandronate
- zoledronate
- pamidronate
What type of bisphosphates pose a higher risk of MRONJ?
IV infusions used for treating malignancy
Other than bisphosphonates, which other drugs can be linked to MRONJ?
- RANKL inhibitors e.g. denosumab
- anti-angiogenics e.g. bevacizumab, sunitinib, aflibercep
What does ORN stand for?
osteo radioncerosis
What causes ORN?
can occur in irradiated patients - head and neck cancer
- secondary to trauma
- 10-35% of cases occur spontaneously
What is the incidence of ORN?
5-15%
What happens during ORN?
avascular bone which is at risk fo similar types of processes to MRONJ, irreversible
What is the risk of ORN following dental extraction?
~6%
Where does ORN happen more commonly, mandible or maxilla?
mandible
How does ORN present?
- non-healing bone
- severe pain
- recurrent infections
- halitosis/foul smell
- oro-facial fistula
- suppuration
- pathological fracture
How is ORN managed?
exceptionally difficult to manage
- one option is to resect and replace with graft
- symptom management - irrigation, antibiotic therapy
- accept pathological fracture
- HBO (hyperbaric oxygen therapy) prior to surgery
- pentoxyphylline/tocopherol
What are the mechanisms of trismus?
- pain
- muscular
- haematoma
- infection
- chronic limitation
- trauma
- neoplasia
- TMJ derangement/osteoarthritis
- soft tissue fibrosis
- normal for some people
What is the average normal mouth opening distance?
30-40mm
What is sepsis?
Sepsis is an extreme body response to an infection. It is a life-threatening medical emergency. Sepsis occurs when a pre-existing infections (can be at any site, most often lung, skin, GI or urinary - but any infection) initiates a systemic sequence of events.
What is septic shock?
a subset of sepsis in which underlying circulatory and cellular metabolic abnormalities are profound enough to increase mortality substantially
Why is sepsis important in dental practice?
failure to recognise or implement appropriate treatment can result in rapid progression leading to tissue damage, organ failure, and death
What is the epidemiology of sepsis/who is more at risk of sepsis? (long list)
- less common in women
- higher in non-whites
- age >75yrs
- recent trauma, surgery, invasive procedure
- indwelling line, IVDU, broken skin
- HIV/aids
- cirrhosis
- asplenia
- autoimmune disease
- solid organ transplant
- neutropenia
- solid or haematological cancer
- inflammatory disorder
- primary immunodeficiency
- possibly alcohol and smoking
What are the main sites of infection which lead to sepsis?
- lungs (64%)
- abdomen (20%)
- bloodstream (15%)
- renal or genitourinary tract (14%)
Of those cases which have positive microbiology, what are the common bacteria associated with sepsis?
- 47% of isolates were gram +ve (S aureus 20%)
- 62% gram -ve (20% pseudomonas spp and 6% E. coli)
- 19% fungal
How do you recognise sepsis?
consider sepsis in any patient presenting with a source of infection and two or more:
1. tempt >38 degrees or <36 degrees
2. heart rate >90 (high risk >130/min)
3. resp rate >20 (high risk >25 breaths/min)
4. WCC >12 or <4 (x10’’12/ml)
5. BP systolic <100 (high risk <90 mmHg)
What tools are available to help you recognise sepsis?
sepsistrust.org screening tools
What patient categories does the sepsis trust screening tools split into?
- adults
- 5-11yo
- <5 yo
- pregnant pt
What are the red flags for sepsis?
- altered mental state/confusion
- unable to stand/collapse
- unable to catch breath/speak
- fast breathing
- skin pale, mottled, ashen or blue
- rash that won’t fade
- recent chemotherapy
- oliguria
What are the amber flags for sepsis?
- behaviour change/reduced activity
- immunosuppressed
- trauma, surgery/procedure last 8 weeks
- breathing harder than normal
- reduced urine output
- temp <36 degrees
- wound infection
- no urine 12-18 hours
What is the SEPSIS pneumonic?
Slurred speech
Extreme shivering
Passed no urine in a day
Severe breathlessness
Illness so bad feels like they’re dying
Skin mottled/discoloured/ashen, rash that doesn’t blanch with pressure, cyanosis of lips/skin/tongue
How do you manage sepsis?
The sepsis six
1. give O2 to keep SATS above 94%
2. take blood cultures
3. give IV antibiotics
4. give a fluid challenge
5. measure lactate
6. measure urine output
(give 3 things, take 3 things)
What does BUFALO stand for in sepsis management?
Blood cultures + septic screen, U&Es
Urine output - monitor hourly
Fluid resuscitation
Antibiotics IV (microbiology)
Lactate measurement
Oxygen - to correct hypoxia
What issues may flag up in the pre-operative assessment that indicate bleeding risk?
- vascular abnormalities
- platelet deficit - number
- platelet deficit - quality/function
- clotting mechanism
Broadly speaking, if platelet level is 50x10’’9L, what would likely present?
petechial haemorrhage
Broadly speaking, if platelet level is 20-50x10’’9L, what would likely present?
petechial haemorrhage + ecchymosis
Broadly speaking, if platelet level is <20’’9L, what would likely present?
melaena, haematemesis, haematuria
What is the normal platelet level range?
150-450 thousand platelets per microlitre
What is eccyhmosis?
bruising
What is malaena?
blood in the stool
What is haematemesis?
vomiting of blood
What is haematuria?
blood in the urine
What are some of the main hereditary bleeding risks?
- Haemophilia VII and IX
- Factor XIII
- vW disease
- Ehlers Danlos (vascular)
What are common acquired bleeding risks?
- medications
- liver disease
- alcoholism
- haematological malignancy (lymphoma, leukaemia)
What liver cell type is majorly involved in the synthesis of coagulation factors?
hepatocytes
Why may liver disease result in increased bleeding?
either via
- deficiency in several coagulation factors
- abnormal structure and function of fibrinogen
- impaired clearance of activated clotting factors leadings to disseminated intravascular cooagualtion or increased fibrinolysis
Why can alcoholism/prolonged alcohol misuse lead to bleeding risk?
- can lead to liver cirrhosis which can affect coagulation factors
- may have alcohol induced thrombocytopenia (platelet deficit)
For what common medical conditions/PMH may a patient be taking an associated anticoagulant or antiplatelet medication?
- DVT
- PE
- cardiac syndromes
- AF
- MI
- IHD
- CVA - ischaemic stroke
- TIA
- surgical patients at risk of thromboembolism
- pregnancy
What medications fall under acquired bleeding risks?
- antiplatelet
- anticoagulants
- coumarins (e.g. warfarin)
- parenteral heparin
- LMW heparin
- NOACs / non-vit K anticoagulants
What are examples of parenteral medications (acquired bleeding risk)?
- heparin sodium
- LMW heparin
- dalterparin sodium
- enoxiparin
- tinzaparin
What are some examples of antiplatelet drugs?
- clopidogrel
- aspirin/NSAIDs
- prasugrel
- ticagrelor
- dipyridamole
What are some of the common NOACs?
- apixaban
- rivaroxaban
- edoxaban
- dabigatran
What are the common coumarins?
- warfarin sodium
- acenoxoumarol
- phenindione
For patients taking warfarin, what must their INR be to be suitable for procedure?
<4
What is ‘primary’ bleeding?
- intra-operative, soft/hard tissues
- prolonged - platelet deficit
What is ‘reactionary’ bleeding?
2-3 hours post-op bleeding, possible link to LA having worn off
suspect platelet deficiency if prolonged
What is ‘secondary’ bleeding?
up to 14 days post-op, probably due to inflammatory processes linked to infection
How would you manage primary bleeding of soft tissues?
pressure, suture, diathermy
How would you manage primary bleeding of hard tissue?
bone wax, BIPP pack
What length of time does normal bleeding post extraction last?
2-5 minutes
- firm biting pressure/digital pressure can be helpful
How does abnormal bleeding present?
increased volume, extended duration
What is required for management of abnormal (increased) bleeding?
- sufficient expertise
- good light
- physical access
- suction
- availability of materials/instruments
How is abnormal bleeding managed?
- pressure - immediate general
- suture - pressure locally
- bone wax (if bleeding from bone)
- crush (if bleeding from bone)
- electrocautery (soft tissue)
- silver nitrate
- haemostatic agents
- antifibrinolytics (tranexamic acid)
- Vit K?
What are some haemostatic agents?
- gelatin
- collagen
- cellulose based
- adhesives
- topical thrombin
What is tranexamic acid?
an antifibrinolytic
If you have a patient bleeding when should you refer?
- ongoing severe haemorrhage
- reached the extent of capabilities
- decreased BP (100/60)
- increased HR >100bpm
(fluid loss)
What guidelines should be followed regarding patients on anticoagulants or antiplatelet drugs?
SDCEP guidelines
When may haematomas present in the dental setting?
- following blunt trauma
- following mandibular third molar removal or surgical removal or maxillary third molars causing swelling of the cheek
What causes a haematoma?
a persistent arteriolar bleed into soft tissue/anatomic space when potential route of escape has closed up e.g. socket has clotted
What are the risks of haematomas?
- risk of bleeding
- culture medium for bacterial growth, can lead to infection
- bleeding into anatomic (potential spaces) can be very dangerous, causing swelling of FOM or around airway etc.
