Extraction Complications 4

Question 1

What is the common long term post extraction complication?

Answer 1

Chronic OAF / root in antrum

Question 2

What are the less common post-op complications?

Answer 2

Osteomyelitis
Osteoradionecrosis (ORN)
Medication induced osteonecrosis (MRONJ)
Actinomycosis
Bacteraemia/infective endocarditis

Question 3

What is the difference between OAF and OAC?

Answer 3

Oral natural communication is acute
Oral natural fistula is chronic

Question 4

How is an OAC diagnosed?

Answer 4

Size of tooth
Radiographic position of roots in relation to antrum
Bone at trifurcation of roots
Bubbling of blood
Nose holding test (careful can create an OAF)
Direct vision
Good light and suction
Blunt probe (careful can create an OAF)

Question 5

How are OACs managed?

Answer 5

Inform patient
If small or sinus intact: encourage clot, suture margins, give antibiotics and POIs
If large or lining torn: close with buccal advancement flap, give antibiotics, decongestants and nose blowing instructions

Question 6

How are chronic OAFs managed?

Answer 6

Excise sinus tract
Buccal advancement flap
Buccal fat pad with buccal advancement flap
Palatal flap
Bone graft

Question 7

How are foreign bodies in the antrum retrieved?

Answer 7

OAF type approach through the socket:
Flap design
Open fenestration with care
Use suction
Small curettes
Irrigation or ribbon gauze
Close as for OAC

Question 8

Describe the Caldwell-Luc approach to retrieving roots in the antrum

Answer 8

Create a buccal window in the buccal sulcus and take an endoscopic approach

Question 9

What is osteomyelitis?

Answer 9

Invasion of bacteria into cancellous bone causing soft tissue inflammation and oedema
Compromised blood supply results in soft tissue necrosis and involved area becomes ischaemic and necrotic

Question 10

Why does osteomyelitis primarily occur in the mandible?

Answer 10

The maxilla is supplied by several arteries
The mandibles primary blood supply is the inferior alveolar artery and dense overlying bone limits penetration of periosteal blood vessels

Question 11

What are the risk factors for osteomyelitis?

Answer 11

Odontogenic infection
Fractures of the mandible
Compromised host defence - diabetes, alcoholism, malnutrition, IV drug use

Question 12

How does osteomyelitis present radiographically?

Answer 12

Acute osteomyelitis shows little/no radiographic change
Chronic osteomyelitis shows bony destruction in the area of infection
Increased radiolucency with a ‘moth-eaten’ appearance

Question 13

What else may be seen radiographically in a patient with osteomyelitis?

Answer 13

Sequestra - areas of radiopacity which are unresolved islands of bone
Involucrum - an increase in radiodensity surrounding the radiolucency area

Question 14

How long does it take for bone loss to be detectable on a radiograph?

Answer 14

10-12 days

Question 15

How is osteomyelitis treated?

Answer 15

Medical and surgical treatment
Investigate host defences - FBC and glucose levels

Question 16

Describe antibiotic treatment for osteomyelitis

Answer 16

Penicillin 1st line drug as its effective against odontogenic infections and has good bone penetration
Longer course than usual
Severe acute osteomyelitis may require hospital admission and IV antibiotics if symptoms are systemic

Question 17

Describe surgical treatment for osteomyelitis

Answer 17

Drain pus if possible
Remove non-vital teeth in the area of infection
Remove loose pieces of bone
In fractured mandible, remove wires/plates/screws in the area
Corticotomy - removal of bony cortex
Perforation of bony cortex
Excision of necrotic bone until actively bleeding bone tissue is reached

Question 18

What are the signs and symptoms of osteomyelitis?

Answer 18

Patient often systemically unwell
Fever
Site of extraction very tender
Altered sensation due to pressure on IAN

Question 19

What is osteoradionecrosis (ORN)?

Answer 19

Seen in patients who have received radiotherapy of the head and neck to treat cancer
Bone within the radiation beam becomes virtually non-vital
Causes reduced blood supply
Turnover of remaining viable bone is slow
Worsens with time and dose

Question 20

How can ORN be prevented?

Answer 20

Scaling/chlorhexidine mouthwash leading up to extraction
Careful extraction technique
Antibiotics, chlorhexidine mouthwash and review
Hyperbaric oxygen before and after extraction (increases local tissue oxygenation and vascular growth)
Refer patient for extraction

Question 21

How is ORN treated?

Answer 21

Irrigation of necrotic debris
Antibiotics not helpful unless secondary infection
Loose sequestra remover
Small wounds (under 1cm) usually heal over weeks/months
Severe cases - resection of exposed bone, margin of unexposed bone and soft tissue closure
Hyperbaric oxygen

Question 22

What is MRONJ?

Answer 22

Medication related osteonecrosis of the jaw
Occurs post extraction/following denture trauma/spontaneously
Affects the maxilla and mandible
Exclusive to the jaws

Question 23

What are the risk factors for MRONJ?

Answer 23

Patients receiving bisphosphonates - higher risk in IV over orally
Patients receiving RANKL inhibitors
Patients receiving anti-angiogenics

Question 24

What makes a patient low risk for MRONJ?

Answer 24

Patients being treated for non-malignant diseases of bone with oral or IV bisphosphonates for less than 5 years and who are not being treated with systemic glucocorticoids

Question 25

What makes a patient higher risk for MRONJ?

Answer 25

Patients being treated for non-malignant diseases of bone with oral or IV bisphosphonates fore more than 5 years
Patients being treated for non-malignant bone diseases with systemic glucocorticoids
Patients being treated with anti-resorption drugs or anti-angiotensin drugs for management of cancer
Patients with a previous diagnosis of MRONJ

Question 26

How is MRONJ managed?

Answer 26

Prevent invasive treatment
Extractions in primary care setting
Remove sharp edges of bone
Chlorhexidine/antibiotics if suppuration
Debridement is not that successful

Question 27

What is Actinomycosis?

Answer 27

A rare bacterial infection that erodes through tissues rather than follow typical fascial planes and spaces
The bacteria have low virulence and must be inoculated into an area of injury or susceptibility eg - recent extraction, severely carious teeth, bone fracture

Question 28

How is Actinomycosis treated?

Answer 28

Incision and drainage of pus accumulation
Excision of chronic sinus tracts
Excision of necrotic bone and foreign bodies
High dose of antibiotics for initial control (often IV)
Long term oral antibiotics to prevent recurrence
Antibiotics - penicillin, doxycycline or clindamycin

Question 29

When can patients be given antibiotic prophylaxis for infective endocarditis?

Answer 29

If the patient has a cardiac condition from the special consideration sub-group and their cardiologist advises that prophylaxis should be considered for the invasive procedure

Question 30

What cardiac conditions are in the special consideration sub group for antibiotic prophylaxis?

Answer 30

Prosthetic valve
Prosthetics used in cardiac valve repair
If previous episode of infective endocarditis
Patients with congenital heart disease

Question 31

Give examples of invasive dental procedures

Answer 31

Placement of matrix band
Sub-gingival PMPR
Dental extractions
Incision and drainage of abscess

Question 32

Give examples of non-invasive dental procedures

Answer 32

Infiltration or block local anaesthetic
BPE screening
Supra-gingival PMPR
Removal of sutures

Question 33

What is most commonly used for antibiotic prophylaxis?

Answer 33

Amoxicillin, 3g oral powder sachet
60 minutes before procedure