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3e. BDS3 CDS Oral Surgery > L98/106. Post-Extraction Complications > Flashcards

L98/106. Post-Extraction Complications Flashcards

1
Q

List some post-operative complications?

A
  • Pain/ swelling/ ecchymosis (bruising);
  • Trismus/ limited mouth opening;
  • Prolonged nerve damage;
  • Dry socket;
  • Sequestrum;
  • Infected socket;
  • Chornic OAF/ root in antrum;
  • Osteomyelitis;
  • Osetoradionecrosis;
  • Medication induced osteonecrosis;
  • Actinomycosis;
  • Bactaraemia/ IE.
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2
Q

What is the most common side effect of any oral surgery?

A

Pain

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3
Q

What can you do to limit pain, swelling or bruising?

A
  • Soft/ gentle handling of tissues;
  • Don’t leave exposed bone;
  • Don’t leave necessary tooth/ bone fragments.
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4
Q

In what time frame is normal post-operative swelling likely to occur within?

A
  • Comes up within 48 hours;

- Disappears within a week.

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5
Q

When is post-operative swelling likely to indicate an infection? (time wise)

A

Appears 2-3 days after surgery

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6
Q

What is the most important thing to do to reassure patients before any post-op side effects appear?

A
  • Warn them of common side effects;

- Reassure them that you’re there to help or for them to contact.

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7
Q

What can cause limited mouth opening/ trismus?

A
  • Oedema around soft tissues;
  • Muscle spasm;
  • Related to LA administration (muscle haematoma/ spasm);
  • Bleed into muscle (haematoma);
  • Damage to TMJ (after being open for a while - oedema/ joint effusion)
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8
Q

Which muscle is likely to be effected if limited mouth opening is a result of LA administration?

A

Medial pterygoid

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9
Q

Which muscle(s) is likely to be effected if limited mouth opening is a result of haematoma?

A
  • Medial pterygoid;

- Masseter.

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10
Q

When would you expect typical limited mouth opening to subside?

A

After a week or so (if not then refer)

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11
Q

What can you recommend to improve limited mouth opening?

A
  • Gentle mouth opening exercises;
  • Use of wooden spatulae;
  • Trismus screw.
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12
Q

What types of post-operative bleeding can you get?

A
  • Immediate;

- Secondary.

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13
Q

How can immediate post-operative bleeding occur?

A
  • Reactionary/ rebound;
  • Vessels open up/ vasoconstriction effects of LA wear off;
  • Sutures loose or lost;
  • Patient traumatises area with tongue/ finger/ food.

[usually within 48 hours]

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14
Q

Why does secondary post-operative bleeding usually occur?

A

Due to infection (can be change in INR of warfarinised patient but very rare)

[commonly 3-7 days after as a mild oozing]

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15
Q

How should you manage a patient presenting with post-operative bleeding?

A
  • Calm the situation;
  • Separate anxious patient;
  • Reassure patient (this will help to lower bp);
  • Clean patient up/ remove any soaked towels etc;
  • (If big ‘jelly-like’ clot in socket - remove);
  • Apply pressure;
  • Same measures as before;
  • Take a thorough but rapid history;
  • Urgently refer if particularly concerned/ would like bloods checked.
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16
Q

How common is dry socket?

A

2-3% of all extractions

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17
Q

Which teeth are most commonly affected by dry socket?

A
  • Lower teeth;
  • The further back you go, more risk of dry socket.

[i.e. lower 8s at highest risk, 25-25%]

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18
Q

What is the main feature of a dry socket?

A

Intense pain

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19
Q

What is dry socket?

A
  • Localised osteitis (inflammation of lamina dura/ socket wall);
  • Slow-healing socket;
  • No clot present (can see bone);
  • Some say clot does not form, others say clot breaks down.
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20
Q

When does dry socket usually present?

A

Day 3 or 4

not dry socket if patient says pain was present as soon as LA wore off

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21
Q

How should you manage a dry socket?

A
  • Radiograph to confirm nothing is stuck in the socket;
  • Allow 7-14 days for it to heal;
  • Reassurance with analgesia;
  • Irrigate with warm saline;
  • Curettage debridement (to encourage bleeding/ new clot formation);
  • LA block;
  • Antiseptic pack (different ones contain different things to soothe pain and prevent food packing);
  • Review patients.
22
Q

What are the symptoms of dry socket?

A
  • Dull, aching pain (moderate to severe);
  • Usually throbs and can radiate to patient’s ear;
  • The exposed bone is sensitive;
  • Characteristic bad taste/ smell (anaerobic);
  • Absence of swelling/ puss;
  • Some argue it is a subclinical infection.
23
Q

What are the predisposing factors for dry socket?

A
  • Molars more common;
  • Mandible more common (blood supply from one main artery - IAA));
  • Smoking (reduced blood supply)/ ex-smoker;
  • Female;
  • Oral contraceptives;
  • Use of lots of LA (with vasoconstrictor);
  • Infection from extracted tooth/ socket?;
  • Excessive trauma during extraction;
  • Excessive mouth rinsing post-extraction;
  • Family hx of dry socket.
24
Q

When is chlorhexidine used?

A

In presence of an infection or with risk of infection (not on open wounds)

25
Q

What are sequestrum?

A
  • Quite common;
  • Usually bits of dead bone/ foreign material;
  • Prevents healing;
  • Often appear as white spicules as they work their way out of soft tissues.
26
Q

How should you manage sequestrum?

A
  • Remove if necessary;
  • With or without LA;
  • With or without sutures.
27
Q

How should you manage an infected socket (pus discharge present)?

A
  • Check socket for any remaining fragments/ foreign body with good light and suction;
  • Radiograph to explore socket/ bone for cysts etc.;
  • Determine cause;
  • Consider antibiotics.

[not common in routine extractions - dry sockets more common]

28
Q

How do you manage OAC and OAF?

A

See previous Qs (L58/80)

29
Q

How do you manage a root in antrum?

A

See previous Qs (L58/80)

30
Q

What is osteomyelitis?

A
  • Infection/ inflammation of the bone marrow;
  • This causes increased hydrostatic pressure and pain;
  • When this pressure > bp of feeding arterial vessels, compromised blood supply;
  • Area becomes ischaemic and necrotic;
  • Bacteria proliferate;
  • More common in the mandible;
  • Patient often systematically unwell/ raised temperature;
  • Patient usually immunocompromised;
  • Site of extraction often very tender;
  • In deep-seated infection, may see altered sensations due to pressure on IAN.

[usually begins in the medullary cavity involving the cancellous bone then extends and spreads to cortical bone, then eventually to periosteum]

31
Q

What is the treatment for osteomyelitis?

A
  • Antibiotics;
  • Surgery;
  • Investigate host defences.
32
Q

What are the predisposing factors for osteomyelitis?

A
  • Odontogenic infections;
  • Fractures of the mandible;
  • Host defences compromised (diabetes, alcoholism, IVDU, malnutrition, myeloproliferative disease).
33
Q

How does osteomyelitis appear radiographically?

A
  • Increased radiolucency;
  • Boney destruction (uniform or patchy ‘moth-eaten’);
  • May see areas of radiopacity (unresorbed islands of bone - sequestra);
  • In long-standing, chronic osteomyelitis you may see radiopacity surrounding the radiolucent area - involucrum).
34
Q

What is an involucrum?

A
  • An area of increased bone density surrounding a radiolucent area;
  • Result of an inflammatory reaction and bone production increased.
35
Q

What antibiotics would be prescribed for osteomyelitis?

A

Clindamycin/ penicillins - effective against infections and good bone penetration

[longer courses than usual - up to 6 weeks after resolution of symptoms/ 6 months if chronic, severe cases might require IV antibiotics]

36
Q

What does surgical treatment for osteomyelitis involve?

A
  • Drain pus if possible;
  • Remove any non-vital teeth in the area of infection;
  • Remove any loose pieces of bone;
  • In fractured mandible, remove any wires/ plates/ screws in the area;
  • Corticotomy (removal of bone cortex);
  • Excision of necrotic bone (until actively bleeding bone is reached);
  • Patients sometimes require reconstruction.
37
Q

Why does surgical treatment for osteomyelitis differ to treatment for RONJ?

A

Greater bone destruction with RONJ - can’t cut back to healthy bone

38
Q

What is osteoradionecrosis?

A
  • Bone necrosis/ loss;
  • Mandible most commonly affected (poor blood supply);
  • Seen in H&N cancer patients who have received radiotherapy;
  • The bone in the radiation beam becomes virtually non-vital;
  • Endarteritis (further reduced blood supply);
  • Turnover of remaining bone is slow;
  • Self-repair ineffective;
  • Worse with time.
39
Q

How should you manage an extraction with RONJ?

A
  • Liase with cancer team;
  • Some suggest routine extraction (carefully);
  • Others say to avoid extractions;
  • Others suggest surgical extraction, alveoplasty and primary closure of soft tissue;
  • Often require referral to SCD.
40
Q

What is hyperbaric oxygen use?

A

Occasionally used with RONJ patients before and after extractions, to increase local tissue oxygenation and vascular ingrowth to hypoxic areas

(oxygen chamber)

41
Q

How should you treat RONJ?

A
  • Irrigation of necrotic debris;
  • Remove loose sequestra;
  • Use of chlorhexidine before/ after tx (not on open wounds!);
  • Antibiotics for infected areas;
  • Hyperbaric oxygen before/ after tx.
42
Q

What is MRONJ?

A
  • Medication related osteonecrosis (of the jaw);
  • Previously called bisphosphonate related osteoradionecrosis (of the jaw);
  • Condition restricted to the jaws;
  • Occurs post-extraction/ following denture trauma/ spontaneously;
  • Effects both jaws;
  • Risk higher in patients receiving IV bisphosphonates;
  • Large range in symptoms.
43
Q

What are bisphosphonates used for?

A
  • Class of drugs used to teat osteoporosis, Paget’s disease and malignant bone metastases (from other cancers, like breast);
  • Inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal;
  • Drugs remain in the body for years.
44
Q

What is the suffix for bisphosphonate drugs?

A

-ate

45
Q

What medications can cause MRONJ?

A
  • Antiresorptive (inc. BPs);

- Immune modulating drugs (like monoclonal antibodies).

46
Q

Where should you look for guidelines on treating MRONJ patients for other treatments, like implants?

A

SDCEP (MRONJ, 2017)

47
Q

At what common sites do you see MRONJ?

A
  • Maxilla;
  • Behind mandibular tori, like lingual tori;
  • Sites of tooth removal.
48
Q

What is actinomycosis?

A
  • Rare bacterial infection;
  • Actinomyces israelii/ A. naeslundii/ A. viscous;
  • Low virulence - must be inoculated into an area upon injury/ susceptibility (like site of recent extraction/ area of trauma);
  • Infection erodes through tissues rather than following typical facial planes and spaces (areas of least resistance);
  • Fairly chronic;
  • Multiple skin sinuses and swelling;
  • Thick, lumpy pus (sulphur granules);
  • Responds initially to antibiotics but can recur after.
49
Q

How should you manage actinomycosis?

A
  • Incision and drainage of pus accumulation;
  • Excision of chronic sinus tracts;
  • Excision of necrotic bone and foreign bodies;
  • High dose antibiotics for control (often IV);
  • Long-term oral antibiotics to prevent recurrence;
  • Penicillins, doxycycline or clindamycin.
50
Q

What is infective endocarditis?

A

Infection/ inflammation of the endocardium, particularly affecting heart valves, caused by strep. viridans/ staph. aureus

3e. BDS3 CDS Oral Surgery (5 decks)

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