extraction of teeth Flashcards
What is a complication?
Any adverse, unplanned event that tends to increase the morbidity above what would be expected from a particular operative procedure under normal circumstances
What are three stages of complications?
Before- anticipate, med history, anatomical factors
During- immediate, bleeding, fracture, oro-antral communication
After- delayed/late, pain, swelling, bleeding, dry socket, infection
What is an oro-antral communication?
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
Where might complications arise?
Site of surgery, eg. bleeding from lacerated gingiva, damage to adj tooth or restoration
Distant site, eg. burned or crushed lip, endocarditis
What might the complications be?
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
What are some antral complications?
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
Why might an extraction fail?
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
What is pneumatisation of the sinus?
The lining of the maxillary sinus drops down so the sinus expands due to extracted tooth and age etc
How might you manage a failed extraction?
Don’t start unless you can complete or if there’s a contingency plan
Warn patient
Make referral to colleague
What might go wrong during an extraction?
Resistance to movement
Fracture of crown/root
Assess- you or tooth?
Use different instruments/techniques- eg. different forceps, elevators, luxators, trans-alveolar surgical approach
What are cowhorn forceps?
The tips can get into the furcation- good for lower molars
What are eagle-beak forceps?
Similar to cowhorn- additional ‘beak’ for harder to reach areas- again for lower molars
What are luxators?
Move and advance root/tooth to make space for use of forceps
V sharp so use safely
What does palliate mean?
Lessening the severity of the issue but not curing
Can call it day
Place dressing
Extirpation (remove pulp)
Antibiotics?
What is a trans-alveolar approach?
Raise a muco-periosteal flap Remove bone w fissure burs etc Section roots Elevate roots Close flap w sutures
How might you reduce pain/swelling?
Careful extraction technique
NSAIDs eg. ibuprofen
Post-op advice
What analgesics can be recommended?
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
What causes trismus?
Inflam swelling and pain Haematoma Abscess Celulitis Trauma Cancer
What are signs and symptoms of infection?
Pain and swelling Trismus Difficulty swallowing Lymphadenopathy Pyrexia Tenderness Tense tissues/fluctuation if abscess
How might you prevent infection?
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
How do you treat the infection?
Drain abscess
Give antibiotics
For bone infections-
~antibiotics
~debridement
What bleeding problems should be considered?
Clotting disorders Anticoagulants Platelet disorders Antiplatelet drugs Most problems local and not systemic- ~trauma ~infection Primary, secondary or reactionary
How should bleeding problems be managed?
Pre op precautions eg. INR- max 4
Apply pressure
Suture across socket
Haemostatic dressing in socket
What is a dry socket?
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)
How do you treat a dry socket?
Flush w warm saline
Dress with Alvogyl
Immediate relief 10-15mins
How should you manage an OAC?
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
What happens if a tooth/root gets into the sinus?
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
What happens if there’s a fracture tuberosity?
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
What should you do when things go wrong?
Don’t panic Recognise problem Communicate w patient honestly Deal w problem or refer Make accurate record in notes Contact employer/defence organisation
If something is inhaled where is it likely to go?
Right main bronchus
How do you refer?
By letter
Phone, fax +/ letter to follow
If urgent- speak w consultant/on-call registrar/DCT (eg. Uncontrollable haemorrhage, fractured mandible)
