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FINALS - Oral Surgery > Extraction Complications > Flashcards

Extraction Complications Flashcards

1
Q

What can lead to difficult access for XLA?

A

Trismus
Reduced mouth aperture
Crowded/malpositioned teeth.

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2
Q

Why might there be abnormal resistance when performing an extraction?

A

Thick cortical bone
Shape/form of roots
Number of roots
Hypercementosis
Ankylosis.

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3
Q

What is ankylosis of teeth?

A

Fusion of the teeth to bone.

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4
Q

Why might a tooth/root fracture during XLA?

A

Tooth may be compromised due to caries, its size, alignment, and root morphology.

Roots can be fused
Divergent/convergent, Ankylosis
Hypercementosis.

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5
Q

When is alveolar bone most likely to fracture?

A

Usually on the buccal plate of canines/molars.

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6
Q

What steps might you need to take if alveolar bone fractures?

A

Dissect free bone
Smooth edges of fracture Suture soft tissues

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7
Q

Why might a jaw fracture occur?

A

Poor application of force when extracting an impacted wisdom tooth.

More at risk if there is pathology, such as a large cyst or an atrophic mandible.

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8
Q

List the signs that the maxillary antrum might be involved in an extraction?

A

Large tooth
Radiographic loss of root into antrum
Bone at trifurcation of roots
Bubbling of blood

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9
Q

What management is required for involvement of the maxillary antrum?

A

Inform patient

If sinus intact: Then susture, encourage cot, and give an antibiotic.

If lining torn, close with buccal advancement flap, give antibiotics and nose blowing instructions.

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10
Q

How could you detect a tuberosity fracture?

A

Noise
Movement of more than one tooth
Tear on palate.

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11
Q

How do you mange a tuberosity fracture?

A

Dissect out and close wound if severe.

If less severe fixate mobile teeth with arch ortho wire and composite.

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12
Q

What steps can be taken to avoid soft tissue damage during an extraction?

A

Pay attention
Correct instrument placement
Controlled pressure
Sufficient but not excessive force

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13
Q

What damage can be done to nerves during extraction?

A

Crush injuries
Cutting/shredding
Transection
Damage from LA

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14
Q

What is neurapraxia?

A

Contusion of nerve/epieneural sheath, but axons are maintained.

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15
Q

What is axonotmesis?

A

Continuity of axons is compromised, but epieneural sheath is in tact.

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16
Q

What is neurotmesis?

A

Complete loss of nerve, and it is transected.

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17
Q

How may nerve damage present itself in a patient?

A

Anaesthesia (numbness)
Paraesthesia (tingling)
Dysaesthesia (unpleasant sensation)
Hypoaesthesia (reduced sensation)
Hyperaesthesia (increased sensation)

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18
Q

What could be the cause of haemorrhage during extraction?

A
  • Mucoperiosteal tear
  • Fracture of alveolar plate
  • Undiagnosed clotting abnormality (haemophilia/von Willebrands)
  • Liver disease
  • Medication (antiplatelets/blood thinners)
    -Anti-coagulant drugs.
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19
Q

What steps should be taken if a TMJ dislocation occurs?

A

Relocated immediately
Consider LA into massater to relax muscles
Urgent referal to A+E if you can’t relocate it

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20
Q

What steps can you take in the event of soft tissue haemorrhage?

A
  • Pressure with damp gauss
  • Sutures
  • LA with Adrenaline
  • Cauterise/diathermy
  • Ligatures with haemostatic forceps
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21
Q

What steps could you take in the event of a bone haemorrhage?

A
  • Pressure with swab
  • LA into socket or swab
  • Local haemostatic agent
  • Bone wax
  • Pack
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22
Q

What is the mechanism which allows adrenaline in local anaestetic to act as a haemostatic agent?

A

Through its action on alpha-1 receptors, adrenaline induces increased vascular smooth muscle contraction. This leads to vasoconstriction and reduces local bleeding.

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23
Q

What is the mechanism which allows surgicel to act as a haemostatic agent?

A

It is a mesh of oxidised regenerated cellulose framwork, which provides physical scaffold for a blood clot to form, and is then absorbed as the area heals.

24
Q

What is the mechanism which allows haemocollagen sponge to act as a haemostatic agent?

A

Its a mesh of collagen, which acts a phsyical scaffold for the clot to form, and then is absorbed as the area heals.

25
Q

What would you do in the event of damaging adjacent teeth?

A

Provide a temporary dressing, and arrange for a definitive restoration.

26
Q

What is a rare risk when extracting a deciduous molar?

A

Extraction of permanent tooth germ along with deciduous tooth.

27
Q

What the common post extraction complications?

A
  • Pain/swlling/ecchymosis (bruising)
  • Trismus
  • Haemorrhage
  • Nerve damage
  • Dry socket
  • Sequestrum
  • Infected socket
  • Chronic OAF (root in antrum)
28
Q

What may increase pain/swelling/bruising?

A

Poor surgical technique/rough handling of tissues.

29
Q

Why might a patient bruise after a dental extraction?

A

Bleeding disorder, poor handling of the patient, some people are naturally more prone to bruising.

30
Q

What are the operative causes of trismus?

A
  • Oedema/muscle spasm from surgery
  • IDB
  • Haematoma
  • Damage to TMJ
31
Q

How long may trismus take to resolve?

A

May take several weeks, can try mouth opening excercises or use wooden spatulae/trismus screw.

32
Q

What systemic haemostatic agents are there?

A
  • Vit K
  • Anti-fibrolytics (tranexamic acid)
  • Factor replacement therapy
  • Plasma/blood transfusion
  • Desmopressin
33
Q

What is the mechanism which allows tranexamic acid to act as a haemostatic agent?

A

Tranexamic acid is an antifibrinolytic agent. It works by blocking the breakdown of blood clots, which prevents bleeding. Be wary of using it topically as it can damge nerves.

34
Q

What is the mechanism which allows desmopressin to act as a haemostatic agent?

A

Desmopressin increases the amount of factor VIII and von Willebrand factor circulating in your blood by around three to five times your normal level. This effect lasts for 12 to 24 hours. The increase is usually enough to control minor bleeding and to avoid bleeding from minor operations, including dentistry.

35
Q

What would you pack a dry socket it with?

A

Alvogyl (an anti-septic pack)

36
Q

Would you prescribe anti-biotics for a dry socket with no signs of supperative infection?

A

No because its not a systemic infection, its localised inflamation of the lamina dura of bone.

37
Q

Why is it unadvisable to leave sequestra in the socket of a patient?

A

Delays healing.

38
Q

What is an OAC?

A

Oro-antral communication - a communication between the root of the teeth and the floor of the maxillary sinus

39
Q

How can you diagnose an OAC?

A

Look at radiographic location of roots.
Bubbling of blood
Nose holding test
Direct vision.

40
Q

What management is there for an OAC?

A

Inform patient

In small/membrane intact then suture margins and consider anti-biotics.

If lining torn close with buccal advancement flap, and prescribe anti-biotics, decongenstants, and nose blowing instructions.

41
Q

What is an OAF?

A

Oro-antral fistula - an epithelised communication between the maxillary sinus and oral cavity. This is typically caused by damage/trauma.

42
Q

What are the treatment options for an OAF?

A

Excise sinus tract
Buccal advancement flap
Bone graft
Buccal fat pad flap/palatal flap.

43
Q

What management is there for a foreign body in the antrum?

A

OAF aproach, buccal advancement flap
Suction
Small curettes
Irrigation
Close as you would an OAF.

Can also do Caldwell-Luc approach (with buccal sulcus/bone window).

44
Q

What is osteomyelitis?

A

Infection of the bone marrow, highly rare and the patient is often systemically unwell. Usually occurs in the mandlbe and may see altered sensation due to pressure on IAN.

45
Q

How does osteomyelitis cause tissue necrosis?

A
  • Bacterial invasion within bone
  • Leads to oedema and increased pressure.
  • Compromises blood supply in surrounding soft tissue
  • Involved area becomes ischaemic and necrotic.
46
Q

What treatment is there for osteomyelitis?

A

Anti-biotics and/or surgical intervention. Requires referal to MOPS and microbiology.

47
Q

Why does osteomyelitis occur more often in the mandible?

A

Primary blood supply is inferior alveolar artery, so overall poorer blood supply from one source. Tissue more likely to become ischaemic.

48
Q

How could you identify chronic osteomyelitis?

A

Lost bone radiogaphically. 10 days since XLA.

+/- pus from area

Increased radiolucency in a uniform/ patchy appearance.

49
Q

What drugs can cause MRONJ?

A

Bisphosphinates
RANK-L inhibetors
Antiangiogenic drugs

50
Q

When is a patient at a higher risk of MRONJ?

A

If they have been on bisphosphinates for longer than 5 years

If they are currently on systemic glucocorticoids

If they are also on anti-resorbative/antiangiogenic drugs

If they’ve previously had MRONJ.

51
Q

What is actinomycosis?

A

A rare bacterial infection caused by actinomyces species. Can target recent extraction sites.

52
Q

How do you treat actinomycosis?

A

I and D of pus accumulation
Excision of chronic sinus tracts
High dose anti-biotics
Long term antibiotics

53
Q

What anti-biotics should be prescribed for prophylaxis before an XLA?

A
  • Amox 3g oral powder, 60 minutes before treatment
  • Clindamycin 600mg 60 minutes before treatment
  • Azithromycin 500mg dose 60 minuts before treatment
54
Q

What is the cause of infective endocarditis from dental related procedure?

A

Bacteraemia (bacteria in blood) caused by dental procedures, which then lead to infection of the cardiac tissues.

55
Q

What should be done if a patient is at a higher risk of infective endocarditis?

A

Prescribe prophylactic anti-biotics if patient is at higher risk of developing IE, and is undergoing invasive dental procedures. Check SDCEP.

56
Q

If you cannot arrest a haemorrhage, who should you refer to?

A

Weekdays - dental hospital, maxfax outpatients.

Evenings/weekend - maxfax on-call or local A+E.

57
Q

Why is it important to keep blood pressure low after an extraction?

A

Higher blood pressure leads to an increased risk of bleeding.

FINALS - Oral Surgery (14 decks)

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