CSB extractions Flashcards
why do we do extractions
Caries Pulpal necrosis Perio disease Ortho Recurrent infection Supernumerary Cracked teeth Pathology Trauma
what are some systemic contra indication
GH
MH
haemophilics
anxiety
what are some local factors against extractions
sus lesion- need biopsy
acute inflammation
no diagnosis
what factors do we need to consider before exodontia
local anatomy access mobility root morph bone morph
what do we need to consider with extractions and anatomy
Maxillary molars lie very close to the antrum
3rd molars lie very close to the IA nerve (especially if there are long roots)
Mandibular premolars lie very close to the mental nerve
what do we need to warn patients of
All patients should be warned of pain, swelling, bleeding, bruising & infection as standard
Consent should be verbal and written and put in layman’s terms
Montgomery consent (A pt. should be told everything, not what the doc thinks they need to)
what increases the risk of dry socket
Females on the pill, xerostomia, smokers
what increases the risk of post of infection
Lower extractions are difficult and inexperienced operators
what are some other risks
dry socket
post op infection
stiff jaw
damage to IA, mental, lingual nerve
what are the principles of removing teeth
Expansion (pushing and stretching of the alveolar socket)
Separation of the PDL & gingival soft tissue
Using controlled force with elevators, luxators & forceps to expand & frac. alveolar socket
what are luxators
Sharp, think instruments that fit into tight space easily that easily cut PDL
Technique sensitive, breaks easily and shouldn’t be use as an elevator
Should be pushed in the direction of the long axis of the tooth
how do we use luxators
- Finger should be placed om buccal plate and thumb on the palate
- Use a controlled movement and push in the long axis of the tooth
- Patient should start to feel the pocket start to expand
describe elevators
The standard instrument for extractions, acts as a fulcrum and applies force to bone & tooth
Difficult to use when embrasure is too small, almost no crown left, adj. tooth has restoration
Must be careful when using as RO damage to adj. tooth
how do we use elevators
Placed in between tooth + bone (& adjacent tooth)
Rotation and elevating motion is used to sever PDL fibres & expand the socket
what are some types of elevators
Couplands (or chisels) 🡪 1, 2 & 3 in LDI Cryers (L & R) 🡪 Good for breaking inter septal bone, retained roots & 3rd molars Warwick James ( L & R) 🡪 A compromise between elevators and luxators
what do we need to consider post extraction
Check apices are intact and the whole tooth is out
Is anything is on the tooth (granuloma/pathology) may need to send to histology
Squeeze socket walls to encourage blood clot to form
First blood clot that forms is the best you’ll get, don’t irrigate for normal extractions
where do we place cotton wool
we place a pledget into the socket- wet end into the socket and dry end out
what are the post op instructions
Expect pain = Advise analgesics, pain will last 48 hours with 24 hours being the worst
Severe throbbing pain = Could be alveolar osteitis (after 24/48 hours)
Bleeding is normal, expect in saliva, maybe on pillow (bite on gauze for 30 mins)
No exercise for 24 hours
No smoking or vaping (increases RO infection) 24 hours but say don’t smoke for a week
No alcohol
No rinsing or mouth swishing (swallow blood and saliva)
Warm salt water rinses 3 tds for 5/7 days (don’t use CHX with open socket) after 24 hours
Try not to eat on that side = reduces RO food packing
what should the dentist do after the xla
Compress the socket
Place wet gauze in the socket that is visible extra orally
Give post op instructions (oral and written, Inc. contact details)
Confirm bleeding has stopped and throw gauze away
Clear around the mouth
Write up notes and complete final check
what analgesics can we recommend
Advise analgesics (NSAIDS ± paracetamol)
400mg TDS for ibuprofen, 1g QDS for paracetamol
Ibuprofen contra-indicated in:
when is ibuprofen contra indicated
Allergies, asthmatics, elderly, kidney/renal failure, stomach issues
what is a complication of extractions
Any event that would not normally occur or an unanticipated problem
This arises following a procedure, treatment or illness
A complication complicates the situation
how do we prepare for surgery
Thorough history & exam to be undertaken
Know the pt. and their problem
Know your abilities & facilities
Use appropriate investigation – May need a CBCT to look for ID canal near 3rd molar
Have a diagnosis that fits the facts – reversible pulpitis needs a redress not XLA
Agree a treatment plan with the patient
Warn the patients of any complications that may arise
Follow accepted practice & use the correct instruments for practice
what to do if something went wrong
Recognise it and accept it
Be open and honest with the patient
Be objective, factually accurate but sensitive
Record events in detail, accurately and honestly
Investigate if necessary - if broken tooth without a surgery, take a radiograph
Make early reasonable efforts at correction
Involve experts early if unable to correct yourself
Tell the defence organisation – burning lip during procedure
when do we leave the apex in situ
There is considerable risk to structures such as nerves or antrum
Pt. declines further surgery
There is no infection
Fragment is no longer than 1/3 of root
Fragment has not been displaced from base of socket
If you do not plan to remove apex – inform patient & review after 1 month ]
If pt. is having problems re – x ray and may need surgical
how do we recognise a fractured tuberosity
Audible crack of bone fracture on attempted extraction
Movement of tuberosity
Palatal tear (due to movement of bone that has fractured)
The extraction is difficult
how do we manage a fractured tuberosity
Stop!
Explain to the pt. what has happened
Place a temporary dressing in the tooth to make the pt. pain free
Do not remove the mobile segment as a large OAC will be created
Refer or seek advice (speak to local hospital/maxfax on call)
what are some predisposing factors to OAC
Close to sinus – write on consent form (& explain to pt. may need to close it) Thin alveolar bone Periapical infection Root morphology Long standing molars Iatrogenic factors Traumatic extractions Using a Couplands elevator
what are some signs of an OAC
Look at radiograph to see if root is in the maxillary sinus
A visible defect between the mouth and the antrum looking with mirror
Bone fragments with smooth antral floor adhering to root of tooth
Sometimes bone may have been removed but epithelial lining still separates
DO NOT tell pt. to blow nose if you suspect OAC (If X ray indicates OAC)
how do we investigate OAC
Do not probe for OAC – as may cause an OAC
If suspect get pt. to GENTLY blow nose whilst pinching nostrils
A positive result if there is no OAC
Bubbles of blood and saliva in socket due to Inc. pressure in nasal cavity
If no OAC exists but x rays indicate they do, advise no blowing of nose for several days
signs and symptoms of OAC
Soft tissue proliferation around the socket
Prolapse (bulging) of sinus lining
Discharge of infected material
Reflux of fluid into nose – Drinking tea and it comes out of nose
Air escapes into mouth on nose blowing (unable to blow their nose)
tx of oac
efer to a specialist treatment as minor oral surgery is required
Buccal advancement flap used to cover OAF (with/without buccal fat pad)
Other procedures are required if OAC id large
Review (after about 10 days)
what dow e do if the pt inhales a tooth
Usually lodges in right bronchus due to anatomy of the bronchi
Look everywhere for tooth, floor/aspirated before subject pt. to x rays
If suspected pt. will cough vigorously
If can’t get the tooth out send to surgery
what is the INR protocol
Take INR on the day or within 72 hours of the procedure
INR 4.0 or less - proceed with surgery & suture surgical into socket, ensure haemostasis
If INR > 4.0 - Refer to haematologist for advice
what do we do if there is bleeding after an XLA
pressure with gauze
what are some methods of controlling bleeding
Direct pressure (pressure on socket) Indirect pressure (Pressure on art leading to socket)
Suturing/ligation (closing off a blood vessel)
Cautery (works be denaturing proteins)
Local haemostatic agents (Surgicel, Kaltostat, collagen granules, fibrin foam)
Systemic agents (Vit K is used to counteract the effect of warfarin
describe dry socket
Dry socket is also known as alveolar osteosis (not an infection but inflammation of the bone)
Occurs after 3% of extractions
Usually 2 – 3 days post op
signs of dry socket
Halitosis and foul taste
Severe pain, may radiate and is generally not eased by analgesia
Exam reveals socket that is partly or devoid of blood clot (only greyish remains in socket)
Mucosa may be healing well around the socket but the socket itself is devoid of a blood clot
which groups of people suffer form dry socket more
Smokers Mandibular than maxillary teeth Excessive mouth rinsing (especially in first 24 hours) Single extractions Traumatic/ Difficult extractions Increased bone density Females (especially taking oral contraceptives) Poor OH Perhaps a link to seasonal incidence
tx of dry socket
Explain to Pt. (preferably warned Pt. before – there is an increased risk in smokers)
Irrigate with warmed saline –2 cases of anaphylaxis due to irrigating socket with CHX
place in socket small amount of Alveogyl obtundent dressing (non resorbable)
No need for antibiotics unless a systemic infection is suspected
Self-limiting and will heal eventually
usually recover in 4 weeks
what antibiotics can we give in post op infections
Amoxicillin 500mg TDS PO (double if severe)
Metronidazole 200 mg TDS PO (double if severe)
We can use these together, if they are allergic can use clindamycin
describe osteonecrosis
Caused by antirespoptive medications including bisphosphonates
BP inhibit osteoclastic resorption – decrease the rate of burn turn over
common bisphosphonates which are prescribed
Alendronic acid & Risedronate sodium are most commonly prescribed oral BP’s
what are some other increased risk of osteonecrosis
Increased risk with: Age, Surgical procedures, Duration of medication
what is the tx of osteonecrosis
Treatment – None! 🡪 OHI, Prevention, avoidance of surgical procedures, Refer!
