Extraction Complications 3 Flashcards
Classify extraction complications by their timing of occurrence and provide one example of each.
- Immediate/intra-operative/per-operative: Fractured root, displacement of tooth into anatomical spaces
- Immediate post-operative/short-term: Hemorrhage within 48 hours, acute trismus
- Long-term post-operative: Chronic oroantral fistula, permanent nerve damage, osteomyelitis
Name at least 6 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 5 less common post-operative complications mentioned in the lecture?
Osteomyelitis
Osteoradionecrosis (ORN)
Medication induced osteonecrosis (MRONJ)
Actinomycosis
Bacteraemia/Infective endocarditis
Why is pain the most common complication after extraction, and what factors increase it?
Most common complication of extraction
Increased by rough handling of tissues
Contributing factors: laceration/tearing of soft tissues, leaving bone exposed, incomplete extraction of tooth
What causes post-extraction swelling (oedema)?
Part of the inflammatory reaction to surgical interference
Increased by poor surgical technique (rough handling of soft tissue, pulling flaps, crushing tissues with instruments, tearing of periosteum)
Wide individual variation
What causes ecchymosis (bruising) after extraction?
Increased by poor surgical technique (rough handling of soft tissue, pulling flaps, crushing tissues with instruments, tearing of periosteum)
Can be related to underlying medical issues
Exhibits individual variation
What are the causes of trismus/limited mouth opening after extraction?
Related to surgery (oedema/muscle spasm)
Related to giving LA – IDB (medial pterygoid muscle spasm)
Haematoma – medial pterygoid or less likely masseter (haematoma/clot organizes and fibroses)
Damage to TMJ – oedema/joint effusion
How should limited mouth opening be managed?
Monitor – may take several weeks to resolve
Gentle mouth opening exercises
Wooden spatulae
Trismus screw
What is secondary bleeding, and when does it typically occur?
Often due to infection
Commonly occurs 3-7 days post-extraction
Usually mild ooze but can occasionally be a major bleed
Can be medication related
What is reactionary/rebound bleeding and when does it occur?
Occurs within 48 hours of extraction
Vessels open up
Vasoconstricting effects of LA wear off
Sutures loose or lost
Patient traumatizes area with tongue/finger/food
How should you manage soft tissue bleeding?
Pressure (mechanical – finger/biting on damp gauze swab)
Sutures
Local anaesthetic with adrenaline (vasoconstrictor)
Diathermy (cauterize/burn vessels to form proteinaceous plug)
How should you manage bleeding from bone?
Pressure (via swab)
LA on a swab
Haemostatic agents
Blunt instrument
Bone wax
Pack & suture
What haemostatic agents can be used for post-extraction bleeding?
Adrenaline containing LA – vasoconstrictor
Oxidized regenerated cellulose – Surgicel/equitamp (provides framework for clot formation)
Haemocollagen sponge – absorbable/meshwork for clot formation
Thrombin liquid and powder
Floseal
What systemic haemostatic aids are available?
Vitamin K (necessary for formation of clotting factors)
Anti-fibrinolytics e.g., Tranexamic acid (prevents clot breakdown/stabilizes clot)
Missing blood clotting factors
Plasma or whole blood
Desmopressin
What are the initial steps in managing post-operative bleeding?
If bleeding severe, get pressure on immediately/arrest the bleed
Calm anxious patient/separate from anxious relatives
Clean patient up/remove bowls of blood/blood-soaked towels
Take a thorough but rapid history while dealing with haemorrhage
What are the next steps in managing post-operative bleeding once initial control is established?
Get inside mouth/good light & suction
Remove large jelly-like clot that often fills mouth
Identify where bleeding is coming from
Apply appropriate management techniques
What techniques can be used to control post-operative bleeding?
Pressure – finger/biting on damp packs
Local anaesthetic with vasoconstrictor
Haemostatic aids (e.g., Surgicel, bone wax in socket)
Suture socket – interrupted/horizontal mattress sutures
Ligation of vessels/diathermy if available
What should you do if you cannot control the bleeding?
Urgent hospital referral
Weekdays – Dental Hospital/Maxillofacial Outpatients
Evenings/weekends – Maxillofacial On-Call or local hospital A&E
Uncontrolled haemorrhage is life-threatening
How can you prevent extraction haemorrhage?
Thorough medical history/anticipate and deal with potential problems
Atraumatic extraction/surgical technique
Obtain & check good haemostasis at end of surgery
Provide good instructions to the patient
What post-extraction instructions should be given to prevent bleeding?
- Do not rinse out for several hours (better not to rinse till next day)
- Avoid trauma - do not explore socket with tongue or fingers/hard food
- Avoid hot food that day
- Avoid excessive physical exercise and
excess alcohol (increase blood pressure) - Advice on controlling bleeding (biting on damp gauze/tissue, applying pressure)
- Provide points of contact if bleeding continues
What are the 3 types of sensory change in nerve damage?
Anaesthesia (numbness)
Paraesthesia (tingling)
Dysaesthesia (unpleasant sensation/pain)
What are the possible variations in sensation with 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 disrupted but epineural sheath maintained
Neurotmesis – Complete loss of nerve continuity/nerve transected
What are the characteristics of dry socket?
Normal clot disappears (appear to be looking at bare bone/empty socket)
Main feature – intense pain (described as worse than toothache/patient kept awake at night)
Often starts 3-4 days after extraction
Takes 7-14 days to resolve
Localised osteitis – inflammation affecting lamina dura
What are the symptoms of dry socket?
Dull aching pain – moderate to severe
Usually throbs/can radiate to patient’s ear/often continuous
Can keep patient awake at night
The exposed bone is sensitive and is the source of the pain
Characteristic smell/bad odour & patient frequently complains of bad taste
What factors predispose to 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
How should dry socket be managed?
Supportive – reassurance/systemic analgesia
LA
Irrigate socket with warm saline (wash out food and debris)
Curettage/debridement (encourage bleeding/new clot formation) – controversial
Antiseptic Pack (Alvogyl)
Advise patient on analgesia and hot salty mouthwashes
Review patient/change packs and dressings
Remove packs as soon as pain resolves to allow healing
Generally, do not prescribe antibiotics as it is not infection
Check initially that it is a dry socket and no tooth fragments or bony sequestra remain
What are the characteristics of sequestra?
Quite common
Prevent healing
Usually bits of dead bone (can see white spicules coming through gingivae)
Can also be pieces of amalgam/tooth
Delays healing
Treatment: remove
How common are infected sockets and how are they managed?
Infection is a rare complication after routine dental extraction
Dry socket more common
Occasionally see an infected socket with pus discharge
Check for remaining tooth/root fragments/bony sequestra/foreign bodies
Management: radiograph/explore/irrigate/remove any fragments/consider antibiotics
Infection more commonly seen after minor surgical procedures with flaps and bone removal
Infection delays healing
