extraction complications 2

Question 1

what should be done if tooth is lost during an extraction

Answer 1

stop and attempt to locate tooth
inform pt
radiograph may be required
if cant locate presume inhaled and send pt to A and E

Question 2

Discuss appearance / cause and treatment if vessels are damaged during an extraction

Answer 2

veins will show a continuous bleed
arteries will pulse/ spurt

most bleeds are due to local factors e.g tears and fractures but may be due to patient factors e.g medications, liver disease

Tx - pressure with damp gauze, sutures, diathermy , pack with surgicel , more LA with vasoconstrictor , bone wax

Question 3

What should be done if an instrument is broken during an extraction

Answer 3

most commonly occurs when instruments used incorrectly
take radiograph and retrieve or refer
if lost bur cant be located presume inhaled and refer to a and e

Question 4

how long should swelling post extraction take to go down

Answer 4

around 48 hours but wide individual variation

Question 5

medical term for bruising

Answer 5

ecchymosis

Question 6

discuss bruising post extraction

Answer 6

individual variation and may be caused by medications or medical conditions
increased risk if poor technique
gravity may pull bruising down towards clavicle about a week post extraction

Question 7

Causes of trismus from extraction

Answer 7

muscle spasm/ oedema - relating to long time with mouth open
LA - IDB into medial pterygoid
hematoma in medial pterygoid
damage to tmj
may take several weeks to resolve

Question 8

tx for trismus post extraction

Answer 8

monitor
mouth opening exercises e.g stacked wooden spatulas

Question 9

what should INR of warfarin patients be and when should it be checked prior to extraction

Answer 9

INR should be less than 4 and should be checked 24 hours prior to surgery
can be up to 72 hours if patient stably anticoagulated but 24 hours is ideal
medication should not be interupted

Question 10

how should pts taking anti platelets be treated for an extraction

Answer 10

antiplatelets - aspirin , clopidogrel, prasugrel
taking aspirin alone - advise no interruption to meds and treat as normal
taking 2 antiplatelets - no medication interruption but expect prolonged bleeding and utilise suturing and packing

Question 11

how should pts taking DOACS be treated for an extraction
(direct oral anticoagulants)

Answer 11

DOACs - apixiban , rivaroxaban
low bleeding risk procedures - treatment with no medication interruptions
high bleeding risk procedures - miss or delay morning dose (delay at least 4 hours post haemostasis)

Question 12

reactionary bleeding

Answer 12

term used to describe bleeding that occurs within 48 hours of an extraction
causes: LA with vasoconstrictor wears off , sutures lost , pt traumatises area with tongue , fingers or food

Question 13

secondary bleeding

Answer 13

term used to describe bleeding that occurs 3-7 days post op
often due to infection
usually mild ooze

Question 14

Pt is bleeding lots post op , pressure on plain damp gauze isnt working , what to do ?

Answer 14

• swap to gauze soaked in LA with vasoconstrictor
• pack socket with surgicel and suture closed
  haemacollagen framework - can be cut to size and inserted into socket to act as framework
  thrombin liquid + powder injection - only for pts of known bleeding risk

Question 15

oxidised regenerated cellulose

Answer 15

e.g surgicel
provides framework for clots to form
absorbed by the body
caution in lower 8 region as these are acidic and could damage IAN

Question 16

what systemic treatments are there for prolonged bleeding for patients on medications increasing their bleeding risk

Answer 16

vitamin K
tranexamic acid - antifibrinolytic which prevents clot breakdown

Question 17

what should be done if the patient develops a large jelly like clot after extraction

Answer 17

this clot may ooze over occlusal surfaces of adjacent teeth making it prone to bleeding due to constant trauma
use LA and remove clot, use local haemostatic measures to promote new clot formation

Question 18

after how many months is nerve damage post op likely to be permanent/ experience no improvement

Answer 18

18 months

Question 19

anaesthesia

Answer 19

numbness

Question 20

paraesthesia

Answer 20

tingling

Question 21

dysaesthesia

Answer 21

unpleasant sensation/pain

Question 22

neuropraxia

Answer 22

‘bruising’ of a nerve
continuity of axons and sheath are maintained

Question 23

axonotmesis

Answer 23

nerve damage
myelin sheath is disrupted but axon continuity is maintained

Question 24

neurotmesis

Answer 24

severe nerve damage
nerve transected , complete loss of continuity

Question 25

medical term for dry socket

Answer 25

alveolar osteitis

Question 26

where is the most common place to get a dry socket

Answer 26

mandible , further back in mouth = more likely so most likely place is lower 8s

Question 27

what does a dry socket look like

Answer 27

an empty socket with no clot, exposed bone
causes intense pain
lamina dura has become inflamed, clot was either never formed or lost early

Question 28

when would a dry socket appear post extraction and how long would it take to resolve

Answer 28

appear 3-4 days post extraction and takes around 7-10 days to heal even with intervention

Question 29

symptoms of a dry socket

Answer 29

• dull, throbbing, aching pain that may radiate to ear and keep pt up at night
• characteristic smell/bad odour , pt may complain of bad taste
• exposed bone is sensitive and is the source of pain

Question 30

predisposing factors for a dry socket

Answer 30

mandible
molars
female
smoker (reduced blood supply)
oral contraceptive pill
excessive trauma during extraction
post op mouth rinsing
family history/ previous dry socket
LA with vasoconstrictor (still always use)

Question 31

treatment for a dry socket

Answer 31

re assure pt
recommend analgesia
put LA in area
irrigate with warm saline
antiseptic pack e.g alvogyl - soothing and resorbable , may want to suture to keep in place
No antibiotics should be prescribed as it is not an infection