L1 Common Complications in Oral Surgery Flashcards
What extra-oral signs may a returning patient present with following oral surgery?
- Lymphadenopathy
- Swellings
- Trismus (due to pain or true trismus)
- Pyrexic (37.5 degrees or higher)
- Low BP, low oxygen saturation and tachycardia indicative of sepsis
What intra-oral signs may a returning patient present with following oral surgery?
Surgical site:
- Erythema
- Pus
- Swelling
- Food debris
- Halitosis
Check sutures and clotting
What is the technical term for dry socket?
Acute alveolar osteitis
What are the risk factors for acute alveolar osteitis?
- Smoking
- Mandibular extraction (poorer blood supply than maxilla)
- Oral contracpetive pill
- Previous radiotherapy
- Vasoconstrictors in LA
Describe the general features of acute alveolar osteitis.
Inflammation of the alveolar bone
- NOT an infection
- Usually presents 72 hours after extraction
- Thought to be due to loss of clot from socket, exposing alveolar bone to bacteria
How is acute alveolar osteitis treated?
- Irrigate socket with 0.9% saline
- Alveogyl placed in socket, broken up and placed in layers
- No rinsing for 24 hours
- Reinforce OHI
- Smoking cessation
- Analgesics: 1g paracetamol QDS, 400mg ibuprofen TDS
Why is chlorhexidine not used in the treatment of acute alveolar osteitis?
Risk of anaphylaxis and death
What are the signs and symptoms of post operative infection?
- Generally feeling unwell
- Painful socket
- Worsening swelling
- Bad taste
- Lymphadenopathy
- Pyrexic
- Trismus
- Gingival swelling
- Frank pus
How is post-operative infection managed?
- Establish drainage of pus
- If pt refuses extraction, can try to get pus out through root canals or incision made in buccal sulcus
- Suture removal if applicable, releases pressure and irritation
- Only prescribe antibiotics is pt is systemically unwell or other signs
What antibiotics would be prescribed for infection?
- 500mg amoxicillin TDS 5 days or 500-1000mg phenoxymethylpenicillin QDS
- If allergic to pencillin: 300mg clindamycin QDS 5 days
What is Ludwig’s angina?
A severe bacterial inefction of the tissues of the neck and floor of the mouth.
Causes life-threatening swelling and can comprimise the airway.
What are the symptoms of Ludwig’s angina?
- Trismus
- Drooling
- Difficulty swallowing
- Pyrexia
- Tongue pushed up
What should you consider if a patient returns with post-operative pain?
- SOCRATES
- Consider type of surgery and complexity e.g. 4 wisdom teeth removed under GA will cause more pain than a simple XLA
- Check what painkillers they have taken and have they been taken regularly?
What painkillers are recommended post-op?
- 1g paracetamol QDS and 400mg iburpofen TDS
- Can consider co-codamol, 30mg codeine QDS for max. 5 days
What are the 3 types of post-operative bleeds?
- Immediate: at time of surgery
- Reactionary: a few hours later, usually when the vasoconstrictor of the LA has worn off or pt’s BP increases encouraging bleeding
- Delayed: several days or up to 2 weeks later, usually bleeding secondary to infection (haematoma)
How is immediate bleeding managed?
Pt bites down on gauze for 5-10 minutes post extraction until haemostasis achieved
What is the first line option for bleeding management?
- Good light and suction, identify bleeding point and apply pressure
What can a socket be packed with to achieve haemostasis?
An oxidised cellulose pack e.g. Surgicel
- Cut sheet into small squares and place into socket and suture
- This creates a meshwork for the clot to form on
What other bleeding management techniques can be used (that are unlikely to be used in general practice)?
- Diathermy cautery
- Bone wax to occlude vessel opening in bone
- Topical tranexamic acid: anti-fibrinolytic (prevents breakdown of fibrin)
- Can also use tranexamic mouthwash or tablets
- In A+E IV tranexamic and fluids would be given
What should be considered before surgery with regards to bleeding risk?
- Thorough medical and drug history
- Social history: alcohol intake- impaired platelet function (liver disease), may need to request bloods for clotting screen
- Clotting screen for pts with history of abnormal bleeding or on vit K antagonist (warfarin)
What INR would not be suitable for dental extraction?
INR of 4 or above
What guidelines are followed for the management of patients on anticoagulants and antiplatelets?
SDCEP guidelines 2022 ‘Management of patients taking anticoagulants and antiplatelets guidelines’
Give examples of dental procedures unlikely to cause bleeding.
- LA by infiltration, intraligamentry, inferior dental or mental nerve block
- BPE
- Supragingival removal of plaque, calculus and stain
- Impressions and other prosthetics procedures
- Fitting and adjustment of ortho appliances
Give examples of dental procedures that are likely to cause bleeding but are low risk for post-op bleeding complications.
- Simple extractions, 1-3 teeth with restricted wound size
- Incision and drainage of intra-oral swellings
- 6-PPC
- RSD
- Restorations with subgingival margins
Give examples of dental procedures that are likely to cause bleeding that are high risk for post-op bleeding complications.
- Complex extractions
- Adjacent extractions that will cause a large wound
- More than 3 extractions at once
- Flap raising procedures
- Gingival recontouring
- Biopsies
What is considered when deciding whether or not to leave fractured roots in?
- Size of root, 5mm or less = consider leaving
- Mobility, mobile = remove
- Infected = remove
- Medical history, immunocompromised = remove, haemophiliac less inclined to remove
- Speak to patient and explain risks, gather their opinion, consider time and facilities, operator competence
