Extractions Flashcards
What are three things that must be identified in MH to have safe exodontia
Excessive bleeding- haematological conditions, anticoagulation, alcohol
Delayed/non healing-poorly controlled diabetes, immunocompromised, biphosphonates; smoking-dry socket
Collapse- have they eaten, how they managed previous LA, recreational drugs, hypoglycemia, anxiety, vasovagal, Addisonian crisis
Allergy-latex , drugs
Reasons tooth is deemed unrestorable
Irreversible pulpitis
Periapical periodontitis
Dental abscess
Vertical fracture
Unrestorable caries
Advanced periodontitis
Immediate complications during the XLA
Failure of LA
Failure to move tooth
Fracture to tooth/root
Fracture of alveolus
OAC
Displacement of root/tooth into tissues
Thermal/chemical injury
Damage to surrounding tissues/teeth
Haemorrhage
TMJ injury
Fracture of the mandible
Damage to trigeminal nerve
Risk assessment prior XLA/during treatment planning!! Need to be mentioned during treatment planning
Delayed complications of XLA
Pain, swelling, trismus, bleeding, infection, dry socket, oroantral fistula, nerve, nerve damage
Factors making XLA difficult
Tooth and pt factors
Local, regional and systemic factors
Clinical and radiographic factors
Problems with XLA
Acute infection-LA efficacyz pt motivation
Previous treatment -failed XLA, RCTz heavily restored
Longstanding infection -perio bone loss
What to ask about previous XLA?
Did you have stitches?
How long were you in the chair?
Did it hurt during the XLA?
Previous dry socket
E/O regarding the XLA
Swelling- LA efficacy and painful to support mandible if swollen
Attrition and XLA
You can expect dense reactive bone
Two reasons for failure to move tooth
Inadequate experience
Poor surgical technique
Reasons for fractured maxillary tuberosities
Lone standing upper molar- bone is stronger
Hypercementosis
Bulbous roots
Splayed roots
Excessive force
Ankylosis
What radiographic view to ask for maxillary sinus/ OAC
Occipito mental view
Ludwig’s angina
Bilateral sublingual submandibular and submental space infection
Leads to raised and swollen tongue
Pyrexia ,dysphagia, dyspnoea,
Potentially life threatening
Treated by drainage and IV antibiotics
When to refer to hospital regarding infection
Rapid spreading, bilateral swelling
Difficulty swallowing water
Eye closing due to swelling
Severely immunocompromised
Types of post op bleeding sockets
Reactionary-up to 24 h post-op or injury. Due to loss of vasoconstriction effect in LA (clot is dislodged from not following post op instructions)
Secondary- 7-10 days post-op or injury such as infection
Management of bleeding socket
Clean the area
Pack correctly
Check history (predisposing pathology, previous XLA)
Examine (signs of underlying cause)
Investigate ( haemoglobin, clotting screen platelets, bleeding time…)
If bleeding persists ( la, suture, haemostatic agents etc?
Hospital admissions
Transfuse
Specific systemic treatment following the investigation
Risk for dry socket
Smoking more than 20/day
Increased bone density (pagets, osteoporosis)
Previous history of dry socket
oral contraceptives
Complex surgical procedure
Surgical sieve
V-vascular (hemangioma, haematoma)
I- infective/inflammation (abscess, periodontal disease, acute necrotising ulcerative gingivitis etc)
T-trauma, fractured mandible, sharp injury
A- autoimmune (MS, pemphigus, lupus..)
M- metabolic (diabetes)
I- iatrogenic (radiation necrosis, Endo treatment, implant treatment…)
N-neoplastic (cancer/malignancy, benign, cyst, salivary gland lesion)
C- congenital (migraine, epilepsy)
D- degenerative (perio disease, neck arthritis)
E- endocrine/environmental (diabetes, hypoglycemia)
F-functional
Antibiotics for pericoronitis
3 day course of metronidazole
400mg, one tablet three times daily
Other causes of OAC
XLA of upper molars, premolars
Tumours
Bone infections
Operation to maxillary sinus
Trauma
Dentigerous cysts
Apical infections
Factors making wisdom teeth XLA easier
Mesio angular impaction
Fused conical roots
Elastic bone (seen in younger pt)
Wide PDL
Separated from 2nd molar and IDN
Large follicle
Management of bleeding socket
- Squeezing socket
- Pressure by gauze
- Soaking with adrenaline
- Stitches and LA
- Surgicel (oxidised cellulose)/ surgispon(absorbable gellatin sponge)
- Bone wax
- Diathermy
- Tranexamic acid
Anticoagulants/antiplatelets
DOACs( direct oral anticoagulants)- apixaban, rivaroxaban-if low bleeding risk-treat without interruption; if higher bleeding risk-miss or delay morning dose
Treat early in the day, limit initial treatment area and assess bleeding before continuing, consider staging, suturing and packing
Vitamin K antagonists (anticoagulation)-warfarin - check INR (less than 4, in last 72h)
Consider limiting treatment area, staging, pack and suture.
Antiplatelets therapy
1. Aspirin alone- treat without interruption (limit treatment area, stage excessive procedures, use local haemostatic measures)
2. Clopidogrel alone or with aspirin- treat without interrupting medication- except prolonged bleeding, limit treatment area, staging, packing and suturing
Low risk- simple extraction, incision and drainage of intra oral swellings, RSD, 6-point chart, restoration with subgingival margins
Higher risk- complex extractions or more than 3 teeth, flap raising procedures, biopsies…
LA
Esters-procaine; unstable, rapidly resorbable, resorb in plasma-release PABA causing hypersensitivity
Amides-lidocaine,prilocaine, mepivacaine, bupivacaine, articaine
Slowly metabolised by liver, low hypersensitivity
Mode of action of LA- blocking of terminal nerve endings
Depends of LA, technique and pt
Mechanisam-blockage of sodium channel-failure to achieve action potential-blockage
Unionised (lipid soluble) form enters the sodium channels and becomes ionized (water soluble) form causes the sodium channel blockage
Max safe dose of adrenaline 0.25 mg
In 2.2 ml (1:80 000) cartilage there is 0.0275 mg
Max dose in 70kg man-7 cartridges
Felypressin -contracts smooth muscle, not in pregnancy
