Extractions Flashcards
What are the indications for extractions?
Unrestorable caries Pulpitis Periapical disease Periodontal disease Trauma Failed restorative treatment including endodontics Orthodontics / Restorative dentistry Teeth involved with pathology Prophylactically e.g. radiotherapy
What instruments are used for extractions?
Forceps
Elevators
Luxators
Whee are forceps applied?
to the roots of teeth, apically to dilate the socket
Why are the forceps applied near the fulcrum?
To reduce the risk of the fracture
What movement do the forceps carry out on upper anterior teeth and lower premolars?
apical then rotation
What movement do the forceps carry out lower anterior teeth?
Buccal movement
What movement do the forceps carry out lower molars?
Figure of 8 and/or buccally
What movement do the forceps carry out on upper pre-molars?
Gentle bucco-palatal movement
What movement do the forceps carry out on upper molars?
Buccal movement
What are the principles of use an elevator?
Applied to roots
Rotational movement to remove teeth and roots
Not used as a lever
Potentially dangerous
What should you do on completion of the extraction?
Assess contour of socket Place gauze in the mouth Remove sharps Give post op instructions Confirm haemostasis Write notes
What should the post operative advice cover?
Supported by written information leaflet Should cover; Bleeding – how to avoid and manage Pain Hygiene How to access help if required Other information as appropriate
What are the post operative instructions for an extraction?
For the 1st day avoid: Mouth rinsing Hot food or drink Alcohol Smoking Strenuous activity If bleeding develops, bite on a clean handkerchief or cloth for 10 minutes Take simple analgesics as required
From the 2nd day:
Use hot salt mouthwashes – after meals until socket(s) healed over
What do you check for a new patient needing an extraction?
Introduce yourself
Check you have the correct patient
Check the notes to see what patient has been referred for – confirm with patient
Which tooth / teeth to be removed and why
Are they medically fit for treatment
Review radiograph if one is available
What structures do you assess pre-operatively?
Crown
Root
nerves
surrounding bone
in what 3 stages can complications occur?
before - MH, anatomy
during - fracture of bone/tooth, bleeding
after - pain swelling bleeding dry socket etc
What are common complications of extractions?
Failure to complete extraction Fracture of tooth Pain Swelling Trismus bleeding infected sockets
Antral complications:
OAC (oro-antral communication)
Root or tooth in sinus
Fractured tuberosity
Post-op infections
How may you anticipate the failure to complete extraction or a tooth fracture?
Previous history Age, size of patient Root filled teeth Bruxism Heavily restored / carious / broken down teeth Abnormal anatomy, ankylosis
How can you possibly prevent or warn of a failed extraction?
Don’t start unless you can complete or have contingency plan
Warn patient
Make referral to colleague
What is the management for a failed extraction?
Palliate
-dressing / extirpation / (antibiotics?)
Proceed immediately to surgical removal or complete later
Refer
What is the trans-alveolar approach?
Raise a muco-periosteal flap Remove bone Section roots Elevate roots Close flap with sutures
How can you minimise pain and swelling?
Careful extraction technique
NSAIDs
Post-op advice
What analgesics and doses might be recommended after extraction?
Paracetamol 500mg – 1g 6 hourly - (max 8 per day)
Co-codamol 500/8mg – as above
Co-codamol 500/30mg – as above
What NSAIDs and doses might be recommended after extraction?
Aspirin 300 – 900mg 6 hourly Ibuprofen 200 – 400mg 8 hourly Diclofenac 25 - 50mg 8 hourly (POM)
What patients have to be cautious of NSAIDS?
Use with caution in the elderly, patients with known allergy, (asthma), bleeding problems, kidney disease and gastric problems
What can cause trismus?
Inflammatory swelling and pain Haematoma Abscess Cellulitis: Trauma Cancer
What is trismus?
Limitation of mouth opening
What are the signs and symptoms of infection after extraction?
Pain and swelling Trismus +/- Difficulty swallowing Lymphadenopathy Pyrexia - raised body temp Tenderness Tense tissues or fluctuation if abscess formation
How can you anticipate and prevent an infection?
Pre-existing infection Chlorhexidine mouthwash pre-op Wound care Antibiotics if: infection present? patient is compromised post-op infection likely or potentially serious
What is the treatment for an infection?
Treatment
Drain abscess
Antibiotics
Bone infections
Antibiotics , debridement
What patients have an increased risk of bleeding with extraction?
Clotting disorders / anticoagulants
Platelet disorders / antiplatelet drugs
What is the management for a patient with bleeding issues in an extraction?
Pre-op precautions e.g. INR
Apply pressure
Suture across socket
Haemostatic dressing in socket
What is alveolar osteitis?
Dry socket
Who and what is dry socket more likely in?
Smokers
lower extractions
Patients on oral contraceptives
When does dry socket develop?
Typically a few days post op
What is the management of a dry socket?
Patient education -post op instructions avoid smoking for 4 days after BIPP (historical) Platelet rich fibrin ( no evidence) pre-emptive alvogyl Therapeutic: Irrigate socket Dress socket (alvoygl) give advice on analgesics can also: - analgesia - smoking cessation - gentle mouth bathing
When may antral complications arise?
May occur following removal of upper posterior teeth
More likely in lone standing teeth and where the maxillary antrum is large
What antral complications can arise?
Oro – antral communication
Fistula formation
Root or tooth into sinus
What may suggest that there might be an antral complication?
Anatomical features
Age
What are the symptoms of an oro-antral communication?
patient complains of:
Fluid in nose
Unable to achieve an oral seal
Air passing into mouth
What are the signs of an oro-antral communication?
Bone extracted with tooth (egg shell) Large void into sinus Antral lining visible via socket Bubbles in socket Prolapsed antral lining
How do you manage an oro-antral communication?
Assess degree of damage
Buccal advancement flap or leave open
Give appropriate POI
Antibiotics
Amoxicillin
Decongestants (e.g. ephedrine nasal drops)
Review
What instructions are given to a patient with an oro-antral communication?
The usual instructions following surgery PLUS
Inform patient
No nose blowing
Sneeze with the mouth open
Do not blow up balloons or play wind instruments
What do you do if there is a root or tooth in the sinus?
May be able to retrieve with a small sucker or instrument if stuck under lining
Give antibiotics and refer
Surgeon can retrieve via Caldwell-Luc incision or endoscopy
Where is it more likely to get a fractured tuberosity?
lone standing upper molars where the antrum is large
What are the signs of a fractured tuberosity?
Tearing of palatal mucosa
Mobility of adjacent teeth and alveolus
How do you manage a fractured tuberosity?
Replace and splint
Suture tears
Palliation, soft diet
Refer,
or
Remove tooth surgically a few weeks later
Raise flap and remove at the time
What is the immediate reaction in a socket to an extraction?
Blood clot, white cells, vasodilation - inflammatory response but allows healing
What happens in the 1st, 2nd and 4th week of socket healing?
1
What are the symptoms of dry ocket?
Pain foul taste and smell localised inflammation and tenderness partial or total loss of blood clot resistant to analgesics
What is septic socket?
Inflammation of the socket - involving cortical bone only (outer surface)
What is osteomyelitis?
Infection involving cancellous bone
What is osteonecrosis?
Death of portion of jaw bone
What are the causes of dry socket?
failure of clot to form - poor blood supply, smoking, sclerotic bone
clot degradation - fibrinolysis as a result of oestrogens, trauma - traumatic extraction, bacterial pyrogens (clot may be absorbed too early)
clot loss - excessive mouth washing - don’t rinse for first 24 hours
bacterial colonisation - further breakdown of clot
What is the incidence of a dry socket on average and in lower wisdom teeth?
0.5-5% average risk
up to 25% for lower wisdom tooth
What are the risk factors for dry socket?
patient factors
- female - oestrogen can affect the lot degradation
- OCP and menstruation
- smoker
- failure to comply with post-op instructions
- age - older people at more risk
- poor healing
technical factors
- posterior
- mandible
- pre-existing infection/pericoronotis (infection around wisdom tooth)
- traumatic extraction
- experience of surgeon
- inappropriate irrigation - over irrigation can reduce clotting
- LA load (vasoconstrictor) - too much restricts blood supply with reduces clotting
What are the risk factors for poor healing?
smoking steroid therapy immunosuppression med poorly controlled diabetes bone pathology poor hygiene previous radiotherapy
What three things are in Alvogyl?
butamben (LA)
iodoform (antiseptic)
eugenol (analgesic)
What are the symptoms of septic socket and how would you manage it?
Swelling
lymphadenopathy
fromation of pus - only in the socket
Manage as dry socket with or without antibiotics (metronidazole or pencilin based) + alvogyl
How can you prevent septic socket?
not always possible
careful POI
antiobitics for compromised patients
consider antiobiotics if surgial site is infected at time of surgery especially wisdom
What investigations would you do with delayed healing and what treatment?
x ray - delayed healing cna cause a granulation tissue response in the roots
consider other diagnoses - SCC
curettage - removal of tissue and dressing
What are the symptoms of osteomyelitis?
pain
altered sensation
pus, sinus formation
may progress to involve nerves
How is osteomyelitis treated?
Antibiotics
debridement
refer to OMFS
When does acute and chronic myelitis occur?
acute - 4 weeks
chronic - there after
What would you see histologically osteomyelitis?
Leukocyte infiltration in amrrow space
scalloping of bone
loss of osteocytes from lacunae
necrotic bone
What is osteoradionecrosis?
Bone has died off related to radiotherapy of the jaws
must have had previous radiotherapy to this area
mandible greater than maxilla
65 grays is threshold between low and high risk
reduced incidence over the last few decades - computer aided tech has localised the area more
What is MRONJ?
medication related osteonecrosis of the jaws
BRONJ - bisphosphante related - common cause of osteonecrosis
common in exams ADA criteria: exposed bone > 8 weeks no history of RT patient is on drug linked to MRONJ about 70% preceded by invasive dental surgery only occurs in the craniofacial skeleton
How is osteoradionecrosis managed?
prevention better than cure
remove teeth of doubtful prognosis prior to radiotherapy
good oral health and prevention with fluoride
need antiobitoics and careful surgery
management depends on severtiy
hyperbaric oxygen(high dose), antibiotics if infected, debridement
What are the drugs causing MRONJ?
Bisphosphonates
monocloncal antibodies e.g. denosumab
tyrosine kinase inhibitors e.g. sunitinib
Give some examples of bisphosphonate?
risedronate alendronate etidronate pamidronate - IV greater risk zoledronate -IV greater risk
Why are bisphonates used?
reduction in bone turnover through effects on osteoclast
beeneficial in osteoporosis, Pagets disease, Metastasis (common breast cancer)
What is the structure of a bisphosphonate?
2 x phosphonate groups (Po3)
linked by central carbon
2 x side chains (R groups) - exposed to bone surface, OC contacts this first
reduces SA of osteoclast, fewer chemicals released so reduces bone turnover
What are the 2 main clinical scenarios where people are on bisphosphonate?
Breast cancer - high dose, IV bisphosphonates, 10% risk of BRONJ over a 3 year course
osteoporosis - low dose, oral
1/100000 per year
1/1000 following extraction
Why does MRONJ occur/
anti-angiogenesis
direct toxicity to cells with bone
toxicity to overlying soft tissues
Name three medications that may predispose to dry socket?
steroids, cyclosporins cop methotrexate bisphosphonates vasoconstritor in lA
Give 4 other factors that may predispose to dry socket that are not medications
Oral hygiene smoking site of tooth extraction excessive mouth rinsing hsitor of traumatic extraction
Give three treatments you could offer this patient to improve their symptoms
irrigate socket with chlorhex, normal saline alvogyl dressing analgesia repeat post op instructions advise no further smoking
What would be your differential diagnoses and how would you rule them out ? (for dry socket)
Septic socket - no visble pus
Delayed healing - take an x ray
Mronj
osteoradionecrosis of jaw
