extraction of teeth

Question 1

What is a complication?

Answer 1

Any adverse, unplanned event that tends to increase the morbidity above what would be expected from a particular operative procedure under normal circumstances

Question 2

What are three stages of complications?

Answer 2

Before- anticipate, med history, anatomical factors
During- immediate, bleeding, fracture, oro-antral communication
After- delayed/late, pain, swelling, bleeding, dry socket, infection

Question 3

What is an oro-antral communication?

Answer 3

Maxillary sinus/antrum- air filled cavity

Tooth roots v long sometimes and reach the sinus
So if extracted- creates communication between oral cavity and sinus cavity

If small hole- couple mm, might heal by itself

If large- small epithelialised tissue- fistula formed/small tube (7-10 days to form)

Oro-antral fistula- needs to be surgically excised and sealed

Question 4

Where might complications arise?

Answer 4

Site of surgery, eg. bleeding from lacerated gingiva, damage to adj tooth or restoration

Distant site, eg. burned or crushed lip, endocarditis

Question 5

What might the complications be?

Answer 5

Minor- eg. removal of small amount of alveolar bone during extraction

Serious- eg. permanent sensory deficit

General- eg. pain, swelling, bleeding, bruising

Specific- eg. lingual nerve injury in 3rd molar removal

Question 6

What are some antral complications?

Answer 6

OAC/OAF
Root or tooth in sinus
Fractured tuberosity

~more likely in lone standing tooth

Symptoms of OAC- fluid in nose when drink, unable to have oral seal, air passes into mouth

Signs of OAC- bone extracted w tooth (shaped like egg shell), large void into sinus, antral lining (schneiderian membrane) visible, bubbles in socket, prolapsed lining

Question 7

Why might an extraction fail?

Answer 7

Previous history
Age, size of patient
Root filled teeth
Bruxism- bone becomes denser
Heavily restored/carious/broken teeth
Abnormal anatomy- ankylosis (tooth root fused to bone), crowding, high arched palate

Question 8

What is pneumatisation of the sinus?

Answer 8

The lining of the maxillary sinus drops down so the sinus expands due to extracted tooth and age etc

Question 9

How might you manage a failed extraction?

Answer 9

Don’t start unless you can complete or if there’s a contingency plan

Warn patient
Make referral to colleague

Question 10

What might go wrong during an extraction?

Answer 10

Resistance to movement
Fracture of crown/root

Assess- you or tooth?
Use different instruments/techniques- eg. different forceps, elevators, luxators, trans-alveolar surgical approach

Question 11

What are cowhorn forceps?

Answer 11

The tips can get into the furcation- good for lower molars

Question 12

What are eagle-beak forceps?

Answer 12

Similar to cowhorn- additional ‘beak’ for harder to reach areas- again for lower molars

Question 13

What are luxators?

Answer 13

Move and advance root/tooth to make space for use of forceps

V sharp so use safely

Question 14

What does palliate mean?

Answer 14

Lessening the severity of the issue but not curing

Can call it day
Place dressing
Extirpation (remove pulp)
Antibiotics?

Question 15

What is a trans-alveolar approach?

Answer 15

Raise a muco-periosteal flap
Remove bone w fissure burs etc
Section roots
Elevate roots
Close flap w sutures

Question 16

How might you reduce pain/swelling?

Answer 16

Careful extraction technique
NSAIDs eg. ibuprofen
Post-op advice

Question 17

What analgesics can be recommended?

Answer 17

Paracetamol- 500mg-1g, 4-6 hourly, max 8 a day

Care re opioid prescription/short course-
Co-codamol 500/8mg

NSAIDs-
~aspirin 300-900mg, 6 hourly
~ibuprofen 200-400mg, 8 hourly
~diclofenac 25-50mg, 8 hourly
Caution w elderly, allergy (asthma), bleeding problems, kidney disease, gastric problems

Lansoprazole capsules 30mg daily, counters gastric problems

Question 18

What causes trismus?

Answer 18

Inflam swelling and pain
Haematoma
Abscess
Celulitis
Trauma
Cancer

Question 19

What are signs and symptoms of infection?

Answer 19

Pain and swelling
Trismus
Difficulty swallowing
Lymphadenopathy 
Pyrexia
Tenderness
Tense tissues/fluctuation if abscess

Question 20

How might you prevent infection?

Answer 20

May occur if pre existing infection
Chlorhexidine mouthwash pre op
Wound care
Antibiotics if it’s present, patient is compromised, post op infection likely/serious

Question 21

How do you treat the infection?

Answer 21

Drain abscess
Give antibiotics

For bone infections-
~antibiotics
~debridement

Question 22

What bleeding problems should be considered?

Answer 22

Clotting disorders
Anticoagulants 
Platelet disorders 
Antiplatelet drugs
Most problems local and not systemic-
~trauma
~infection
Primary, secondary or reactionary

Question 23

How should bleeding problems be managed?

Answer 23

Pre op precautions eg. INR- max 4
Apply pressure
Suture across socket
Haemostatic dressing in socket

Question 24

What is a dry socket?

Answer 24

Localised osteitis
More likely in-
~smokers
~lower extractions
~patients on the pill
It’s painful and develops typically a few days post op (min 48hrs)

Question 25

How do you treat a dry socket?

Answer 25

Flush w warm saline
Dress with Alvogyl
Immediate relief 10-15mins

Question 26

How should you manage an OAC?

Answer 26

Assess degree of damage

Buccal advancement flap or leave open- seal communication
Can use buccal fat pad to do a bilayer closure

Can do a palatal rotational flap- w greater palatine artery to maintain vascularity

Graft/membrane material?

Give appropriate POI- don’t swim for 2 weeks, sneeze through mouth, don’t go on a flight (pressure), don’t blow nose, don’t blow balloons/play wind instruments

Antibiotics- amoxicillin
Decongestants- eg. Ephedrine nasal drops

Review

Question 27

What happens if a tooth/root gets into the sinus?

Answer 27

May be able to retrieve w small sucker or instruments of stuck under lining

Give antibiotics and refer

Surgeon can retrieve via Caldwell-Luc incision or endoscopy

Question 28

What happens if there’s a fracture tuberosity?

Answer 28

Bone breaks off w tooth
OAC

Signs-
~tear in palatal mucosa
~mobility of adjacent teeth and alveolus

Stop and assess
Replace and splint
Suture tears
Palliation, soft diet
Refer or,
Remove tooth surgically fed weeks later

Raise flap and remove at the time

Question 29

What should you do when things go wrong?

Answer 29

Don’t panic
Recognise problem
Communicate w patient honestly
Deal w problem or refer
Make accurate record in notes
Contact employer/defence organisation

Question 30

If something is inhaled where is it likely to go?

Answer 30

Right main bronchus

Question 31

How do you refer?

Answer 31

By letter
Phone, fax +/ letter to follow
If urgent- speak w consultant/on-call registrar/DCT (eg. Uncontrollable haemorrhage, fractured mandible)