Extraction Complications 4 Flashcards
What are the 5 less common post-operative complications mentioned in the lecture?
- Osteomyelitis
- Osteoradionecrosis (ORN)
- Medication induced osteonecrosis (MRONJ)
- Actinomycosis
- Bacteraemia/Infective endocarditis
Differentiate between an OAC and an OAF.
OAC (oral antral communication): Acute condition
OAF (oral antral fistula): Chronic condition
List 6 methods for diagnosing an oro-antral communication.
- Size of tooth
- Radiographic position of roots in relation to antrum
- Bone at trifurcation of roots
- Bubbling of blood
- Nose holding test (careful as can create an OAF)
- Direct vision/good light and suction/blunt probe
How should a small oro-antral communication with intact sinus be managed?
- Inform patient
- Encourage clot
- Suture margins
- Consider antibiotics
- Provide post-op instructions
What is the appropriate management for a large oro-antral communication or when the sinus lining is torn?
- Close with buccal advancement flap
- Prescribe antibiotics and decongestants
- Provide nose blowing instructions
List 5 surgical approaches to manage a chronic oro-antral fistula.
- Excise sinus tract
- Buccal Advancement Flap or Palatal Rotation Flap
- Buccal Fat Pad with Buccal Advancement Flap
- Bone Graft/Collagen Membrane
What are the three surgical approaches for retrieving a root or foreign body in the antrum?
- OAF type approach/through the socket
- Caldwell-Luc approach (via buccal sulcus/buccal window)
- ENT – Endoscopic approach (FESS)
Explain the pathophysiological sequence that occurs in osteomyelitis.
- Bacteria invade cancellous bone causing inflammation and edema
- Edema in enclosed space increases tissue hydrostatic pressure
- Blood supply is compromised when pressure exceeds arterial pressure
- Tissue becomes ischemic and necrotic
- Bacteria proliferate due to absence of blood-borne defenses
- Infection spreads until arrested by antibiotics/surgery
Why is osteomyelitis more common in the mandible than the maxilla?
Maxilla: Rich blood supply from several arteries
Mandible: Primary blood supply from inferior alveolar artery and dense cortical bone limits periosteal blood vessel penetration, resulting in poorer blood supply and greater susceptibility to ischemia and infection
What are the major predisposing factors for osteomyelitis, and what conditions compromise host defense?
Major predisposing factors:
Odontogenic infections
Mandibular fractures
Host defense compromising conditions:
Diabetes
Alcoholism
IV Drug Use
Malnutrition
Myeloproliferative Disease (e.g., leukemias, sickle cell disease, chemotherapy-treated cancer)
Describe the radiographic progression and features of acute versus chronic osteomyelitis.
Acute suppurative osteomyelitis: Little/no radiographic change (10-12 days required for lost bone to be detectable)
Chronic osteomyelitis: Increased radiolucency (uniform or patchy with ‘moth-eaten appearance’)
Advanced features: Radiopaque islands within radiolucent regions (sequestra) and in long-standing cases, increased radiodensity surrounding the radiolucent area (involucrum)
How does the microbiology of mandibular osteomyelitis differ from osteomyelitis in other bones?
Mandible: Similar to odontogenic infections (streptococci, anaerobic cocci like peptostreptococcus, anaerobic gram-negative rods like Fusobacterium & Prevotella)
Other bones: Staphylococci predominate
What is the recommended antibiotic approach for osteomyelitis and what is the typical duration of treatment?
First-line drug: Penicillins (effective against odontogenic infections with good bone penetration)
Duration:
Acute osteomyelitis: Weeks (at least 6 weeks after resolution of symptoms)
Chronic osteomyelitis: Months (up to 6 months in some cases)
Severe acute cases may require hospitalization and IV antibiotics
List 6 surgical interventions for the treatment of osteomyelitis.
- Drain pus if possible
- Remove non-vital teeth in the infected area
- Remove loose pieces of bone
- Remove any wires/plates/screws in fractured mandible
- Corticotomy (removal of bony cortex)
- Excision of necrotic bone (until reaching actively bleeding bone tissue)
What pathophysiological changes occur in irradiated bone that lead to osteoradionecrosis?
- Bone within radiation beam becomes virtually non-vital
- Endarteritis develops, reducing blood supply
- Turnover of any remaining viable bone is slow
- Self-repair becomes ineffective
- Condition worsens with time and radiation dose
What preventive measures should be taken before extracting teeth in patients who have received radiotherapy?
- Scaling and chlorhexidine mouthwash prior to extraction
- Careful extraction technique
- Antibiotics, chlorhexidine mouthwash, and review
- Consider hyperbaric oxygen therapy before and after extraction
- Consider referral for specialist extraction
What are the treatment options for osteoradionecrosis?
- Irrigation of necrotic debris
- Removal of loose sequestra
- Antibiotics (limited effectiveness unless secondary infection)
- For severe cases: Resection of exposed bone, margin of unexposed bone, and soft tissue closure
- Hyperbaric oxygen therapy
What categories of drugs are associated with Medication Related Osteonecrosis of the Jaw (MRONJ)?
- Antiresorptive drugs:
Bisphosphonates (e.g., Alendronate, Zoledronate)
RANK-L inhibitors (e.g., Denosumab)
- Antiangiogenic drugs:
Monoclonal antibodies (e.g., bevacizumab)
Small molecules binding tyrosine kinase receptors (e.g., sunitinib, sorafenib)
What are the risk factors that increase the likelihood of developing MRONJ?
- Dental treatment (extractions, denture trauma, infection, periodontal disease)
- Duration and dose of drug therapy
- Dental implant placement (in high-dose cancer management cases)
- Concurrent medications (steroids + anti-resorptive drugs or anti-resorptive + anti-angiogenic)
- Previous drug history (even after discontinuation)
What are the current recommendations for managing patients on anti-resorptive or anti-angiogenic drugs who need extractions?
- Prevention of invasive treatment when possible
- Extractions can be performed in primary care setting
- No benefit from referral to secondary care based solely on drug exposure
- Two management approaches:
Initial management (prior to or just after commencing drug)
Continuing management (established drug regimen)
What treatment options are available for established MRONJ?
- Symptom management
- Removal of sharp bone edges
- Chlorhexidine mouthwash
- Antibiotics for suppuration
- Note: Debridement, surgical sequestrectomy, resection, and hyperbaric oxygen have not proven particularly successful
Describe the key clinical and pathological features of actinomycosis.
- Rare bacterial infection (Actinomyces israelii/A. naeslundii/A. viscosus)
- Low virulence bacteria requiring inoculation into injured tissue
- Erodes through tissues rather than following fascial planes
- Chronic presentation with multiple skin sinuses and swelling
- Distinctive thick lumpy pus with “sulphur granules” (bacterial colonies)
- Initially responds to antibiotics but recurs when treatment stops
What is the comprehensive treatment approach for actinomycosis?
- Incision and drainage of pus accumulation
- Excision of chronic sinus tracts
- Excision of necrotic bone and foreign bodies
- High-dose antibiotics for initial control (often IV)
- Long-term oral antibiotics to prevent recurrence
- Antibiotic options: Penicillins, doxycycline, or clindamycin
What is the current approach to antibiotic prophylaxis for prevention of infective endocarditis in dental procedures?
Individual assessment of patient risk
European Cardiac Society advises prophylaxis for patients with:
Prosthetic valves
Valve repair with prosthetic material
Previous IE
Cyanotic CHD
CHD repair with prosthetic material
For dental procedures involving manipulation of gingival/periapical region or perforation of oral mucosa
Scottish Adult Congenital Cardiac Service has adopted ECS guidelines
