Complications of Surgical Dentistry Flashcards
What is sequelae?
An after-effect of surgery inherent to the procedure
E.g. pain, swelling, trismus, ecchymosis
What is a complication?
An undesirable, unintended and direct result of an operation affecting a patient which would not have occurred if the operation had gone as well as could reasonably be hoped
How to differentiate complications from sequelae?
Suppuration, abscess formation
Systemic symptoms
Different timeline of pain and different progression
> Sequelae usually peaks at 2nd or 3rd day, either stays the same or gets better
Swelling extending to spaces beyond what is normal
> Pain on swallowing
> Voice changes
> Difficulty breathing
Types of pre-operative complications
Inaccurate diagnosis
Inappropriate treatment plan
Types of intra-operative complications
Intra-operative haemorrhage
Injury to adjacent tissues
Tooth fragment/foreign body left in-situ
Displacement of fragment or foreign body
Hardware failure
Aspiration/ingestion of fragment or foreign body
Surgical emphysema
Types of post-operative complications
Post-operative haemorrhage
Alveolar osteitis
Wound healing complications
Paresthesia
Types of haemorrhage
Primary
> Occurs at time of surgery
> Due to direct injury to vessels
> Can be arterial, venous or capillary
> Arterial blood is higher pressure and in spurts, high flow, requires intervention like packing
> Venous blood is darker, high flow, requires intervention like packing
> Capillary blood is lighter in colour than venous, oozing
Reactionary
> Within 24-48h of surgery
> Due to dislodgement of clot, cessation of vasospasm/vasoconstriction
Secondary
> Usually after 7 days
> Mainly due to infection, sloughing/necrosis of vessel wall
> Rare
Types of injury to adjacent tissues
Soft tissues
> Flap
> Papilla
> Cheek
> Lip
> Palate
> Tongue
> Nerve
Hard tissues
> Alveolar bone (buccal plate, max tuberosity)
> Mandible
> TMJ (e.g. dislocation)
> Teeth
Oral-antral perforation
Where can fragment/foreign bodies displace?
Max
> Caldwell-Luc procedure if displaced into max sinus
> Infratemporal fossa
Mand
> Sublingual space
> Esp if used too much force, fractured lingual plate
> Submand and pterygomandibular spaces
What to do if kena aspiration/ingestion of fragment or foreign body
Aspiration has a tendency to go into right bronchus as it is more vertical
Refer immediately if aspirated
If ingested, determine how safe the swallowed object is
> Small and round? Monitor stools
> Large, sharp or magnetic? Higher risk
Post-operative haemorrhage risk factors
> Family history
Medical history
Medications
Antiplatelets (aspirin, clopidogrel etc)
Anticoagulants (warfarin, apixaban etc)
Warfarin INR should be below 3.0!
Liaise with medical colleagues to correct coagulopathy
Controlling bleeding intra-operatively
Intra-operatively
> Minimize trauma
> Make clean incisions
> Remove granulation tissue (if any)
> Excessive, prolonged bleeding? Use Surgicel, hemostatics, compression, suture, electrocauterize
Controlling bleeding post-operatively
Post-operatively
> Monitor for 30 mins before discharging
> Post-op instructions
> Tranexamic acid gargle/soaked gauze
> Black jelly/curd-like substance outside socket, bleeding on poking? Liver clot - need to suction out whole clot and restart wound healing process
> Can happen if patient doesn’t bite properly on gauze, where clot forms outside socket
How to deal with uncontrolled bleeding
Uncontrolled bleeding?
> Suction
> Determine source
> Apply pressure to achieve hemostasis
> First, surgicel and suture. If not, move on to TXA soaked gauze
> If still doesn’t work, may be from a larger arterial vessel, so reopen wound and find exact bleeding spot, apply direct pressure or hemostatic, or bone wax if from cancellous bone
Adjuncts?
> LA
> Tranexamic acid soaked gauze/adrenaline soaked gauze
> Bite on teabag?
> Local measures
> Hemostatic agent
> Suturing
> Electrocautery
Presentation of alveolar osteitis
5-20%, most frequent painful complication of extractions!
Usually presents only around day 3-5, pain vv severe, cannot drink water or speak, can radiate
Risk factors of alveolar osteitis
Increased age
Smoking
Females
Prolonged/difficult extraction
Oral contraceptives
Mandible > maxilla, posterior > anterior
Infection
Dislodgement of clot??
Mx of alveolar osteitis
Self-limiting, will resolve after up to 2 weeks so just treat symptomatically
Irrigate, dress, apply alvogyl (anaesthetic, antimicrobial and analgesic)
Give painkillers like ibuprofen and tramadol
Signs and symptoms of alveolar osteitis
Bad smell
Exposed bone (can feel bone when probing instead of soft tissue)
Highly sensitive to gentle probing
Causes of alveolar osteitis
During trauma, there is release of plasminogen tissue activators
This causes plasmin-induced lysis of the blood clot, dislodging the clot and exposing bone
This causes inflammation of alveolar bone, lingering for several days until covered by epithelium
May also have bacterial influence, dislodging blood clot via enzymes and biofilm formation preventing healing over exposed bone
Wound healing complications
Wound dehiscence
Osteonecrosis of jaw
Infection
Paresthesia
IDN injury only 0.5-5% chance, with only 1% permanent
Can use CBCT in high risk cases
Can do coronectomy or just observe (if asymptomatic) if root and nerve are very close
Risk factors for paresthesia
Higher risk esp with darkening of root, diversion of canal and interruption of white line of canal
Operator skill
Anatomic factors such as deeper osseous impactions
Increased age
Where can infection spread?
Vestibular space
Buccal space
Palatal space
Sublingual space
Submandibular space
Maxillary sinus
Submasseteric space
Pterygomandibular space
Temporal space
Infection of muscles
Infection close to muscles causes inflammation of muscles, trimus and spasms
Under GA patient cannot open mouth, airways cannot be accessed, v dangerous
