Extraction Complications 3 Flashcards
What are the main post-op complications?
Pain/swelling/ecchymosis
Trismus
Haemorrhage/post-op bleeding
Prolonged effects of nerve damage
Dry socket
Sequestrum
Infected socket
Chronic OAF/root in antrum
What are the less common post-op complications?
Osteomyelitis
Osteoradionecrosis (ORN)
Medication induced osteonecrosis (MRONJ)
Actinomycosis
Bacteraemia/infective endocarditis
What can cause post-op pain and what can be done?
Rough handling of tissues, laceration/tearing of soft tissues, leaving bone exposed, incomplete extraction of tooth
Warn patient/advise or prescribe analgesia
Why can swelling occur post-op?
Part of the inflammatory reaction to surgical interference
Increased by poor surgical technique
Why can ecchymosis occur post-op?
(Bruising)
Can be increased by rough handling of soft tissues
May be underlying medical issues
What can cause trismus post-op?
Related to surgery - oedema/muscle spasm
Related to giving LA - IDB medial pterygoid muscle spasm
Haematoma - medial pterygoid or less likely masseter - clot organises and fibroses causing damage to TMJ
How is trismus managed?
Monitor - may take several weeks to resolve
Gentle mouth opening exercises/ use wooden spatula and trismus screw
What should be done if a patient is on a vitamin K antagonist?
INR check within 24 hours prior to surgery
Check why they are on it and what their target INR is
What should be done if a patient is on an antiplatelet?
If aspirin alone - treat without interrupting medication
If any in combo with aspirin - treat without interrupting medication
What should be done if a patient is on a direct oral anticoagulant (DOAC)?
If low bleeding risk - treat without interrupting medication
If higher bleeding risk - advise patient to miss or delay morning dose before treatment
Describe haemorrhage immediately post-op
Reactionary bleeding
Occurs within 48 hours of extraction
Vessels open up and vasoconstriction effects of LA wear off
Sutures loose or lost and patient traumatises area with younger/finger/food
Describe secondary bleeding
Often due to infection
Commonly 3-7 days
Usually mild ooze but can occasionally be a major bleed
Can be medication related
How should haemorrhage be managed in soft tissues?
Pressure - biting on damp gauze
Sutures
LA with adrenaline
Diathermy
How should haemorrhage be managed in bone?
Pressure (via swab)
LA on a swab
Haemostatic agents
Blunt instrument
Bone wax
Pack and suture
Give examples of haemostatic agents
Adrenaline containing LA
Oxidised regenerated cellulose - equitamp - provides framework for clot formation
Haemocollagen sponge - absorbable mesh work for clot formation
Thrombin liquid and powder
Floseal
Give examples of systemic haemostatic aids
Vitamin K - necessary for formation of clotting factors
Anti-fibrinolytics eg - tranexamic acid
Missing blood clotting factors
Plasma or whole blood
Desmopressin
What are the steps of managing post op bleeding?
Immediate pressure to arrest the bleed
Calm anxious patient
Clean patient up
Take a history while dealing with haemorrhage
Get inside mouth with good light and suction
Mouth often filled with large jelly-like clot
Remove clot
Patient may be vomiting if blood swallowed
Identify where bleeding is from
How is haemorrhage prevented?
Thorough medical history
A traumatic extraction technique
Obtain and check good haemostasis at the end of surgery
Provide good instructions to the patient
What are the post-op instructions?
Do not rinse out for several hours
Avoid trauma - do not explore socket
Avoid hot food that day
Avoid excessive physical exercise and excess alcohol
What are the post-op instructions if bleeding occurs?
Bite on damp gauze/tissue
Pressure for at least 30 minutes (longer if bleeding continues)
Give points of contact if bleeding continues
What are the types of sensory change in nerve damage?
Anaesthesia - numbness
Paraesthesia - tingling
Dysaesthesia - unpleasant sensation/pain
What are the sensation changes in nerve damage?
Hypoaesthesia - reduced sensation
Hyperaesthesia - increased/heightened sensation
What are the anatomical descriptions of nerve damage?
Neurapraxia - contusion 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
How common is a dry socket?
Affects 2-3% of all extractions
Affects up to 20-35% of lower 8s
What is a dry socket and when does it start and end?
Starts 3-4 days after extraction
Takes 7-14 days to resolve
Localised osteitis - inflammation affecting lamina dura
What are the symptoms of a dry socket?
Dull aching pain - moderate to severe
Usually throbs/can radiate to patient’s ear/often continuous and can keep patient awake at night
The bone is sensitive and is the source of the pain
Characteristic smell/bad odour and patient frequently complains of bad taste
What are the predisposing factors of a dry socket?
Molars more common - risk increases from anterior to posterior
Mandible more common
Smoking - reduced blood supply
Female
Oral contraceptive pill
Local anaesthetic - vasoconstrictor
Infection from tooth
Haematogenous bacteria in socket
Excessive trauma during extraction
Excessive mouth rinsing post extraction - clot washed away
Family history/previous dry socket
How are dry sockets managed?
Supportive reassurance
Systemic analgesia
LA
Irrigate socket with warm saline
Curettage/debridement
Antiseptic pack (alvogyl)
Advise patient on analgesia and hot salty mouthwash
Review patient/change packs and dressings
Do not prescribe antibiotics as it is not infection
Remember to check initially that it is a dry socket and that no tooth fragments or bony sequestra remain
What is sequestrum and what does it do?
Usually bits of dead bone
Can also be pieces of amalgam/tooth
Prevents and delays healing
Quite common
Describe an infected socket
Infection is a rare complication
Mor common after minor surgical procedures involving soft tissue flaps and bone removal
Infection delays healing
How is an infected socket managed?
Check for remaining tooth/root fragments/bony sequestra/foreign bodies
Get radiographs, explore, irrigate, remove any of the above
Consider antibiotics
