Extraction Complications Flashcards
Types of peri-operative complications
- difficult access
- abnormal resistance
- fracture of tooth/root fracture of alveolar bone
- jaw fracture
- involvement of maxillary antrum
- fracture of tuberosity
- loss of tooth
- soft tissue damage
- damage to nerves/vessels
- haemorrhage
- dislocation of TMJ
- damage to adjacent teeth/restorations
- extraction of permanent tooth germ
- broken instruments
- wrong tooth
Reasons for difficult extraction access
Trismus
Reduced aperture of mouth - congenital, syndrome
Crowded/malpositioned teeth
Reasons for abnormal resistance in extraction
- thick cortical bone - less flexibility
- shape/form of roots eg. divergent roots/hooked roots - upper 6 and lower premolars
- number of roots e.g. 3 rooted lower molars
- hypercementosis -build up of cementum on roots
- ankylosis - bonded to surrounding bone no PDL
Reasons for tooth/root fracture during extraction
- caries
- alignment - position its lying in can make it more susceptible to fracture
- size
- root morphology
- fused
- convergent or divergent
- extra roots
- hypercementosis
- ankylosis
CONSENT patient for this
Reasons for alveolar bone fracture
Tooth taken out too quickly
Usually buccal plate
Common in canine and molar region
What needs to be assessed when alveolar bone is broken
- is bone still attached to periosteum
- how big is chunk of bone
- if its still attached can push back in and reattach and suture to hold in soft tissue
- if doesn’t reattach will work its way out - can cause problems when sequestreum
- if its still attached to periosteum and you remove you may need to dissect it free with scalpel
- try and retain especially in canine region as it can lead to thin ridge which affects denture design and retention
- if remove bone need to smooth edges as they can be jaggy - can pierce through and cause wound to break down
How to treat alveolar bone fracture (molars and canines)
Molars
- periosteal attachment
-suture
-dissect free
Canines
-stabilise
-free mucoperiosteum
-smooth edges
Where and why does jaw fracture occur
- mandible
- impacted wisdom tooth, cyst, atrophic mandible
- usually caused by application of force
Tx for jaw fracture
- inform patient
- OPT
-refer to max fax - DONT EAT - analgesia
-stabilise
Signs of jaw fracture
-crack during extraction
-moving in two different parts
-tear in gingivae
- teeth no longer meeting in occlusion
Reasons for involvement of maxillary antrum in extractions
Maxillary sinus just above molars, roots can be very close to
- can fracture tuberosity
-can lose root into antrum - can cause OAF/OAC
How to diagnose OAC/OAF
-size of tooth
-position of roots in relation to antrum
-bone at trifucation of roots
-bubbling of blood
-nose holding test
- juice through nose
-direct vision
-suction
-blunt probe
Risk factors of OAC
- extraction of upper molars and premolars
- close relationship of roots to sinus on radiograph
- last standing molars
- large bulbous roots
- older patient - sinus bigger and drops down slightly
- previous OAC - on other side
- recurrent sinusitis - tooth often close to sinus
Management of OAC/OAF
Small
- encourage clot
- suture margins
-AB
Large
- buccal advancement flap
Give post op instructions
Aetiology of tuberosity fracture
- single standing molar
- unknown un-erupted molar wisdom tooth
- pathological gemination
- extracting in wrong order
- inadequate alveolar support
Diagnosis of tuberosity fracture
- noise
- movement noted both visually or with supporting fingers
- more than one tooth movement
- tear on palate
Management of tuberosity fracture
- Dissect out and suture
- Reduce and stabilise
- reduction then splint
- need to make sure it doesn’t affect occlusion
- AB
-remove tooth 8 weeks after
What type of nerve injuries can occur during extraction
-crush injuries
-cutting/shredding injuries
-transaction
-damage from surgery or LA
Definitions of neurapraxia, axonotmesis, neurotmesis (anatomical descriptions of nerve damage)
- neurapraxia - confusion of nerve/continuity of epineural sheath and axons maintained
- axonotmesis - continuity of axons but not epineural sheath disrupted
- neurotmesis -complete loss of nerve continuity/nerve transected
Reasons for haemorrhage during extraction
- local - mucoperiosteal tears , fractures
- clotting abnormalities - haemophilia
-liver disease
-medications - warfarin , antiplatlet
How to handle haemorrhage of soft tissue (extraction)
- mechanical pressure
-sutures
-LA with vasoconstrictor
-diathermy - haemostatic forceps - larger vessels
How to handle haemorrhage if bone
- pressure (via swab)
- LA on a swab or injected into socket
- haemostatic agents
- blunt instrument
- bone wax
- pack
How to manage TMJ dislocation
- relocate immediately (analgesia and advice on supported yawning)
- if unable to relocate try local anaesthetic into masseter intra-orally
- if still unable to relocate - immediate referral
Management of damage to adjacent teeth during extraction
- temp dressing/restoration
- arrange definitve restoration
- if large restoration next to extraction site warn patient of risk
Common post extraction complications
- pain/swelling/ecchymosis
- trismus/limited mouth opening
- haemorrrhage/post-op bleeding
- prolonged effects of nerve damage
- dry socket
- sequestrum
- infected socket
- chronic OAF/ root in antrum
- osteomyelitis
- osteoradionecrosis (ORN)
- medication induced osteonecrosis
- actinomycosis
- bacteraemia/infective endocarditis - note current guidance
What increases risk of oedema
-poor surgical technique
Causes of trismus after extraction
Surgery - Odema/IDB
LA - medial pterygoid muscle spasm
Haematoma
Damage to TMJ
How to manage trismus
- monitor
-mouth opening exercises
-wooden spatula
-trismus screw
What guidance is used for prolonged bleeding
SDCEP
Management of patients taking anti platelet or anticoagulant
What is warfarin
Vit K agonist
What is management of warfarin for extraction
- check INR - 24 hours before
- INR below 4 for treatment
What are types of antiplatelet
-aspirin
-clopidogrel
How to manage antiplatelet in extraction
Without interrupting
- can stage treatment
Which dental procedures are considered risk of post op bleeding complications for antiplatelet/anticoag
Complex extractions
Extractions
Incision and draining of swelling
6ppc
RSD
Direct or indirect with subgingival margins
How to manage DOAC in extraction
Low risk procedures - treat without interrupting
High risk - miss or delay morning dose before TX
What are types of DOAC
Apixiban
Dabigatran
Rivaroxaban
Edoxaban
Specifically which dose is missed for each DOAC in extraction
Apixaban or dabigatran - miss morning dose - normal dose in evening
Rivaroxaban or edoxaban - delay dose to evening
Reason for immediate post op bleeding
Vessels open
Vasoconstriction effects of LA wear off
Sutures loose
Patient traumatises area
Reasons for secondary bleeding in extraction
- due to infection
- common 3-7 days
- usually mild ooze but occasionally big bleed
- medication related
What are haemostatic agents
Adrenaline containing LA - vasoconstrictor
Oxidised cellulose - surgicel
Haemocollagen sponge
Thrombin liquid and powder
Floseal
What are systemic haemostatic aids
Vitamin K
Anti-fibrinolytic - tranexamic acid
Plasma
Desmopressin
Post op extraction instructions
- don’t rinse till next day
-avoid trauma
-avoid hot food
-avoid exercise - no alcohol or smoking
-advise on gauze
3 types of sensory change in nerve damage
Anaesthesia
Parasthesia
Dysaesthesia
What is alveolar osteitis
Dry socket
2-3% of extractions
Normal clot dissapears
Intense pain
Takes up to 2 weeks to resolve
Symptoms of alveolar osteitis
- dull aching pain - moderate to severe
- usually throbs , can radiate to ears, continuous and can keep awake at night
- the exposed bone is sensitive and is source of pain
- characteristic smell/bad odour and patient frequently complains of bad taste
Predisposing factors of alveolar osteitis
- molars
-mandible
-smoking - reduced blood supply
-female
-oral contraceptive
-excessive mouth rinsing post extraction
Management of alveolar osteitis
-supportive - analgesia, reassurance
-LA
-irrigate with saline
-curretage/debridement
Pack - alvogel
What is sequestrum
-common
-bits of dead bone
-delays healing
What is infected socket
-rare
-pus discharge
-look for remaining tooth or fragments
Different types of flap for OAF
Buccal advancement flap
Buccal fat pad with buccal advancement flap
Palatial rotational flap
Tongue flap
Bone graft
If root in antrum TXp
Flap design
Suction
Curretes
Then close as OAC
Or could to Caldwell luc approach or ENT approach
What is osteomyelitis
Inflammation of bone marrow , infection of bone
How may osteomyelitis present
Systemic unwellness
Mandible usuallly
If infection is deep then possibly some altered sensation
Oedema
Early presentation similar to dry socket or localised infection
How does osteomyelitis spread
Usually in medullary cavity with cancellous bone
Spread to cortical bone
The periosteum
Oedema in cancellous bone (enclosed space)
This leads to increased hydrostatic pressure
Higher than the blood pressure leading to compromised blood supply and necrosis
Normal blood borne defences don’t reach tissue
What is primary blood supply in mandible
Inferior alveolar artery
Why is mandible more likely to become ischaemic in osteomyelitis
Poorer blood supply due to dense overlying cortical bone
What is predisposing factors to osteomyelitis
Odontogenic infections
Fractures of mandible
Immunocompromised host - diabetic , leukaemia , chemo
How would chronic osteomyelitis present
Pus
Bony destruction
Radiographically - after 10 days moth eaten - increased radiolucency
Bacteria involved in osteomyelitis
Steptococci
Anaerobic cocci
Fusobacterium and prevotella
Treatment of osteomyelitis
- AB - Pen V - long course - can be up to 6 months
- drain pus , remove non vital teeth, remove loose bone
-corticotomy and excision of necrotic bone
what is ORN
- patients who received radiotherapy of head and neck
-bone within radiation beam becomes non vital - reduced bloody supply and turnover of viable bone is slow
-mandible more commonly affected
Prevention of ORN
- scaling, chlorhexidine in lead up to extraction
-atraumatic extraction technique
-AB
-hyperbaric oxygen before and after extraction
Treatment of ORN
- irrigation of necrotic debris
- don’t give AB unless secondary infection
- remove sequestra
-if severe - resection of exposed bone and soft tissue closure
What is MRONJ
Medication related osteoradionecrosis of jaw
Side effect of anti-resorptive and antiangiogenic drugs
Which drugs to watch out for for MRONJ
Bisphosphonates - inhibit bone resorption and renewal
Anti-angiogenic -
Rank L inhibitors - stop osteoclast production
Incidence of MRONJ
- about 1%
When does MRONJ occur
Spontaneous
Following extraction
Denture trauma
Small asymptomatic areas of exposed bone to large exposure with pain
When was MRONJ guidance released
2017 SDCEP
What classifies a patient as high MRONJ risk
- Bisphosphonates for more than 5 years
- Bisphosphonates/denosumab with a systemic glucocorticoid
- patients being treated with anti-resorption or anti-angiogenic drugs as part of cancer treatment
-previous MRONJ
Treatment of MRONJ
- manage symptoms
-remove sharp bone
-chlorhexidine - debridement
- prevent invasive retreatment
What is actinomycosis
Rare bacterial infection
Actinomyces israeli
Chronic
Multiple skin sinuses and swelling
Thick lumpy pus
Treatment of actinomycosis
- Incision and drainage of pus
-excision of sinus tract
-excision of necrotic bone and foreign bodies
-high does AB
Then long term AB to prevent recurrence
Pen V, doxycycline
Guidance for IE
SDCEP
Which groups are in special consideration for IE
- prosthetic valve
-previous IE
-cyanotic CHD
-CHD repaired with prosthetic material
Example of invasive procedures I.E
- matrix bands
- clamps
-subgingival restorations
-Endo
-PMC
-extractions
Risks and benefits of IE prophylaxis
Risk
-hypersensitivity
-CDIFF
- antimicrobial resistance
- antibiotic colitis
What is given for AB prophylaxis
Amoxicillin - 3G - 60 mins before
Clindamycin 300mx2 - 60 mins before
Azinthromycin -500mg — 60 mins before
