Complications of tooth extraction

Question 1

3 stages of complications

Answer 1

Preoperative (anticipation): medical history related problems, anatomical factors
Perioperative (immediate): fracture of bone or tooth, creation of oro-antral communication, bleeding
Postoperative (delayed/ late): pain, swelling, bleeding, dry socket, other infection

Question 2

Complications may arise at

Answer 2

The site of surgery
-e.g. bleeding from lacerated gingiva
-damage to an adjacent tooth or restoration
Distant site
-e.g. burnt or crushed lip
-endocarditis (bacteria in blood)

Question 3

Complications may be

Answer 3

Minor
-e.g. removal of small amount of alveolar bone with tooth during extraction
Serious
-e.g. permanent sensory deficit
General
-pain, swelling, bleeding
Specific to the procedure
-lingual/ ID nerve injury in 3rd molar removal

Question 4

Anticipation: failure to complete or fractured tooth

Answer 4

Previous history
Age, size of px
Root filled teeth
Bruxism
Heavily restored/ carious/ broken down teeth
Abnormal anatomy, ankylosis

Question 5

Management of failed extraction: anticipatory phase

Answer 5

• don’t start unless you can complete or have contingency plan
• warn px
• make referral to colleague

Question 6

Failure to complete extraction: immediate

Answer 6

Resistance to movement
Fracture of crown
Fracture of root

Question 7

Management of failed extraction: immediate phase

Answer 7

Assess - is it you or is it the tooth
Use different instruments/ technique
-e.g. different forceps, elevators, luxators, transalveolar surgical approach

Question 8

Management of failed extraction: postoperative phase

Answer 8

Palliate - dressing/ extirpation/ antibiotics?
Proceed immediately to surgical removal or complete later
Refer

Question 9

Trans-alveolar approach

Answer 9

Raise a muco-periosteal flap
Remove bone
Section roots
Elevate roots
Close flaps with sutures

Question 10

Pain and swelling

Answer 10

Expected - not complication?
To minimise
-careful extraction technique
-NSAIDs
-post-op advice

Question 11

Consent

Answer 11

Px needs to be informed about complications

Question 12

Analgesics

Answer 12

Paracetamol 500mg - 1g 6 hourly (max 8 per day)
Co-codamol 500/8mg - as above
Co-codamol 500/30mg - as above
NSAIDs
-aspirin 300-900mg 6 hourly
-ibuprofen 200-400mg 8 hourly
-diclofenac 25-50mg 8 hourly
-use with caution in elderly, pxs with allergies, asthma, bleeding problems, kidney disease and gastric problems

Question 13

Trismus

Answer 13

Limitation of mouth opening
Several causes
-inflammatory swelling and pain
-haematoma
-abscess
-cellulitis (trauma/ cancer)

Question 14

Signs and symptoms of infection

Answer 14

Pain and swelling
Trismus +/-
Difficulty swallowing
Lymphadenopathy
Pyrexia
Tenderness
Tense tissues or fluctuation if abscess formation

Question 15

Anticipation and prevention of infections

Answer 15

Pre-existing infection
Chlorhexidine mouthwash pre-op
Wound care
Antibiotics if
-infection present
-px compromised
-post-op infection likely or potentially serious

Question 16

Treatment of infections

Answer 16

Drain abscess

Antibiotics

Question 17

Bone infections

Answer 17

Antibiotics, debridement

Question 18

Bleeding

Answer 18

> risk in pxs with
-clotting disorders/ anticoagulants
-platelet disorders/ antiplatelet drugs
Most problems are local and not systemic (trauma/ infection)
Primary, secondary or reactionary

Question 19

Management of bleeding

Answer 19

Pre-op precautions e.g. INR
Apply pressure
Suture across socket
Haemostatic dressing in socket

Question 20

Dry sockets

Answer 20

Localised osteitis
More likely
-smokers
-lower extractions
-pxs on the OCP
Painful
Develops typically a few days post extraction

Question 21

Management of dry sockets

Answer 21

Px education
Irrigate socket
Dress socket

Question 22

Antral complications

Answer 22

May occur following removal of upper and posterior teeth

More likely in lone standing teeth and where the maxillary antrum is large

Question 23

Types of antral complications

Answer 23

Oro-antral communications
Fistula formation
Root or tooth into sinus

Question 24

Anticipation of antral complications

Answer 24

Anatomical features

Age

Question 25

Symptoms of oro-antral communication

Answer 25

Fluid in nose
Unable to achieve an oral seal
Air passing into mouth

Question 26

Signs of oro-antral communication

Answer 26

Bone extracted with tooth (egg shell)
Large void into sinus
Antral lining visible via socket
Bubbles in socket
Prolapsed antral lining

Question 27

What to do in case of oro-antral communication

Answer 27

Assess degree of damage
Buccal advancement flap or leave open
Give appropriate POI
Antibiotics - amoxicillin
Decongestants (e.g. ephedrine nasal drops)
Review

Question 28

Antral POI

Answer 28

The usual instructions following surgery PLUS

• inform px
• no nose blowing
• sneeze with mouth open
• do not blow up balloons or play wind instruments

Question 29

Roots or tooth in sinus - what to do

Answer 29

Generally avoidable
May be able to retrieve with small sucker or instrument if stuck under lining
Give antibiotics and refer
Surgeon can retrieve via Caldwell-Luc incision or endoscopy

Question 30

Fractured tuberosity and signs

Answer 30

More likely in lone standing upper molars where antrum is large
Signs:
-tearing of palatal mucosa
-mobility of adjacent teeth and alveolus

Question 31

What to do - fractured tuberosity

Answer 31

Stop
Replace and splint
-suture tears
-palliation, soft diet
-refer or remove tooth surgically a few weeks later
Raise flap and remove at time

Question 32

When to refer

Answer 32

Before problems arise - if there is high probability of complications arising which you will not be able to manage yourself
When you get stuck and need help

Question 33

How to refer

Answer 33

By letter if not urgent
-e.g. carious mandibular 3rd molar intimately associated with ID canal
By phone, with fax and/ or letter to follow if urgent - speak to consultant or on-call registrar or SHO
-e.g. uncontrollable haemorrhage, fractured mandible