Extraction complications Flashcards
What are some peri-operative complications?
- Difficult access
- Abnormal resistance
- Fracture of tooth/root
- Fracture of alveolar bone
- Jaw fracture
- Involvement of the maxillaryantrum
- Fracture of tuberosity
- Loss of tooth
- Soft tissue damage
- Damage to nerves/vessels
- Haemorrhage
- Dislocation of TMJ
- Damage to adjacentteeth/restorations
- Extraction of permanent toothgerm
- Broken instruments
- Wrong tooth
What to do if the tooth is lost during surgery?
- Stop
- Look for it
- Use suction
- Radiographs to find it
How to reduce risk of soft tissue damage?
- Pay attention
- Correct placement using correct instrument
- Take time positioning instruments
- Application point
- Controlled pressure
- Sufficient but not excessive force
What is the definition of Neurapraxia?
- Contusion of nerve/continuity of epineural sheath and axons maintained
What is the definition of Axonotmesis?
- Continuity of axons but epineural sheath disrupted
What is the definition of Neurotmesis?
- Complete loss of nerve continuity/nervetransected
How can damage to nerves occur?
- Crush injuries
- Cutting/shredding injuries
- Transection
- Damage from surgery or damage from LA
- May not know all the time
What can occur if there is damage to nerves?
- Anaesthesia(numbness)
*Paraesthesia(tingling)
*Dysaesthesia(unpleasant sensation/pain)
*Hypoaesthesia(reduced sensation) - Hyperaesthesia(increased/heightened sensation)
What can occur if there is damage to the vessels?
*Veins (bleeding +++)
*Arteries (spurting/haemorrhage +++)
*Arterioles (spurting/pulsating bleed)
*Vessels in muscle
*Vessels in bone
Why can Haemorrhage occur?
- Most bleeds occur due to local factors (mucoperiosteal tears or fractures of alveolar plate/socket wall)
- Very few occur due to undiagnosed clotting abnormalities (haemophillia/ von Willebrands)
- Some due to liver disease (alcohol disease) as clotting factors made in liver
- Some due to medications like Warfarin/ antiplatelet agents (aspirin/ clopidogrel)
- Other anticoagulant drugs like rivaroxaban (Pradaxa) and Dabigatran (Xarelto)
What to do if Haemorrhage is in soft tissue?
- Pressure(mechanical –finger/biting on damp gauze swab)
–Sutures
–Local Anaesthetic with adrenaline(vasoconstrictor)
–Diathermy(cauterise/burn vessels precipitate proteins which form proteinaceous plug in vessel)
–Ligatures/haemostatic forceps (artery clips) for larger vessels
What to do if Haemorrhage is in bone?
–Pressure (via swab)
–LA on a swab or injected into socket
–Haemostatic agents
–Blunt instrument
–Bone Wax
–Pack
What to do if TMJ is dislocated?
*Relocate immediately(analgesia and advice on supported yawning)
*If unable to relocate try local anaesthetic into masseterintra-orally
*If still unable to relocate – immediate referral
How can damage to adjacent teeth/restorations occur?
- Hit opposing teeth with forceps
- Crack/Fracture/move adjacent teeth with elevators
- Crack/fracture/remove restorations/crowns/bridges on adjacent teeth
How do you manage damage to adjacent teeth/restorations?
- Temporary dressing/restoration
- Arrange definitive restoration
- If large restoration next to extraction site warn patient of the risk
When can extraction of permanent tooth germ happen?
- When removing deciduous molars resulting in extraction or damage to developing permanent premolar
- Very rare
What to do if an instrument is broken during surgery?
- Can be tips of elevators and luxators or burs
- Use radiograph to determine location and retrieve
- If unable to retrieve then refer
What are the safety checks you do so you don’t remove the wrong tooth during surgery?
- Concentrate
- Check clinical situation against notes/radiographs (mislabelling of radiographs/errors in notes can occur)
- Safety checks
- Count teeth
- Verify with someone else if still unsure
- Contact defence union
What are some post extraction complications?
- Pain/Swelling/Ecchymosis
- Trismus/ Limited mouth opening
- Haemorrhage / Post-op bleeding
- Prolonged effects of nerve damage
- Dry Socket
- Sequestrum
- Infected Socket
- Chronic OAF / root in antrum
What are some less common post-operative complications?
- Osteomyelitis
- Osteoradionecrosis (ORN)
- Medication induced osteonecrosis (MRONJ)
- Actinomycosis
- Bacteraemia/Infective endocarditis – note current guidance
What is the most common complication of extraction?
- Pain
- Warn the patient/advise
- Prescribe analgesia
What can cause more pain during extraction?
- Laceration/ tearing of soft tissues
- Leaving the bone exposed
- Incomplete extraction of tooth
Why does swelling (oedema) occur after extraction?
- Part of the inflammatory response to surgical interference
- Increased by poor surgical technique
e.g. rough handling of soft tissue, pulling flaps, crushing tissue with instruments, tearing of periosteum - Depends on individual
What is Ecchymosis and why does it occur after extraction?
- Bruising
- Increased by poor surgical technique
- Can be increased due to underlying medical condition
- Individual variation
What is trismus?
- Muscle spasms in temporomandibular joint
- Inability to open mouth/ open mouth fully
What are some causes of trismus?
- Related to surgery due to oedema or muscle spasms
- Giving LA in IDB (medial pterygoid muscle spasm)
- Haematoma in medial pterygoid or less likely masseter
- Damage to TMJ via oedema or joint effusion
How to manage patient with limited mouth opening?
- Need to monitor as may take several weeks to resolve
- Gentle mouth opening exercises like using a wooden spatula or trismus screw
What to do if patient is taking Vitamin K antagonist? (warfarin, acenocoumarol or phenidione)
- Check INR ideally no more than 24hrs before procedure (up to 72hrs if patient is stably anticoagulated)
If INR below 4
- Treat without interrupting medication
- Limit initial treatment and staging extensive or complex procedures
- Strongly suture and pack
If INR above 4
- Delay invasive treatment or refer if urgent
What to do if patient is on antiplatelet drug aspirin only?
- Treat without interrupting medication
- Limit initial treatment areas and staging extensive or complex procedures
- Local haemostatic measure
What to if patient is taking Clopidogrel, dipyridamole, prasugrel or ticagrelor single or dual therapy with aspirin?
- Treat without interrupting medication
- Expect prolonged bleeding
- Limit initial treatment area
- Consider staging extensive or complex procedure
- Strongly consider suturing and packing
What to do if patient taking Direct Oral anticoagulant (apixaban, dabigatran, rivaroxaban, edoxaban) and you are doing a low bleeding risk dental procedure?
- Treat without interrupting medications
- Treat early in day
- Limit initial treatment area and assess bleeding
- Before continuing consider staging extensive or complex procedures
- Strongly consider suturing and packing
What to do if patient taking Direct Oral anticoagulant (apixaban, dabigatran, rivaroxaban, edoxaban) and you are doing a high bleeding risk dental procedure?
- Advise patient to miss or delay morning dose before treatment
- Treat early in day
- Limit initial treatment area and assess bleeding
- Before continuing consider staging extensive or complex procedures
- Strongly consider suturing and packing
- Advise when to restart medication
What to do when patient is on apixaban or dabigatran and you are performing high bleeding risk procedure?
- Usual drug schedule twice a day
- Miss morning dose pre treatment
- Usual time in evening post treatment dose
What to do when patient is on Rivaroxaban and you are performing high bleeding risk procedure?
- Usual drug schedule once a day morning
- Delay morning does pre treatment
- 4 hrs after haemostasis achieved take dose
What to do when patient is on Edoxaban and you are performing high bleeding risk procedure?
- Usual drug schedule once a day evening
- Take dose usual time in evening (treatment done in morning)
What is the immediate post-operative period?
- Reactionary/ rebound bleeding can occur
- Occurs within 48hr of extraction
- Vessels open up/ vasoconstriction effects of LA wear off/ sutures loose or lost/ patient traumatises area with tongue, finger or food
What is secondary bleeding?
- Often due to infection
- Commonly 3-7days
- Usually a mild ooze but can be major bleed
- Can be medication related
What to do if there is Haemorrhage in soft tissue?
–Pressure(mechanical –finger/biting on damp gauze swab)
–Sutures
–Local Anaesthetic with adrenaline(vasoconstrictor)
–Diathermy(cauterise/burn vessels precipitate proteins which form proteinaceous plug in vessel)
What to do if there is Haemorrhage in bone?
–Pressure (via swab)
–LA on a swab
–Haemostatic agents
–Blunt instrument
–Bone Wax
–Pack & Suture
What are some haemostatic agents?
- Adrenaline containing LA is a vasoconstrictor
- Oxidised regenerated cellulose – Surgicel / equitamp which provides framework for clot formation (Careful in lower 8 region – acidic – damage to IDN)
- Haemocollagen Sponge –absorbable/meshwork for clot formation
- Thrombin liquid and powder
- Floseal