L98/106. Post-Extraction Complications Flashcards
List some post-operative complications?
- 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.
What is the most common side effect of any oral surgery?
Pain
What can you do to limit pain, swelling or bruising?
- Soft/ gentle handling of tissues;
- Don’t leave exposed bone;
- Don’t leave necessary tooth/ bone fragments.
In what time frame is normal post-operative swelling likely to occur within?
- Comes up within 48 hours;
- Disappears within a week.
When is post-operative swelling likely to indicate an infection? (time wise)
Appears 2-3 days after surgery
What is the most important thing to do to reassure patients before any post-op side effects appear?
- Warn them of common side effects;
- Reassure them that you’re there to help or for them to contact.
What can cause limited mouth opening/ trismus?
- 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)
Which muscle is likely to be effected if limited mouth opening is a result of LA administration?
Medial pterygoid
Which muscle(s) is likely to be effected if limited mouth opening is a result of haematoma?
- Medial pterygoid;
- Masseter.
When would you expect typical limited mouth opening to subside?
After a week or so (if not then refer)
What can you recommend to improve limited mouth opening?
- Gentle mouth opening exercises;
- Use of wooden spatulae;
- Trismus screw.
What types of post-operative bleeding can you get?
- Immediate;
- Secondary.
How can immediate post-operative bleeding occur?
- 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]
Why does secondary post-operative bleeding usually occur?
Due to infection (can be change in INR of warfarinised patient but very rare)
[commonly 3-7 days after as a mild oozing]
How should you manage a patient presenting with post-operative bleeding?
- 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.
How common is dry socket?
2-3% of all extractions
Which teeth are most commonly affected by dry socket?
- Lower teeth;
- The further back you go, more risk of dry socket.
[i.e. lower 8s at highest risk, 25-25%]
What is the main feature of a dry socket?
Intense pain
What is dry socket?
- 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.
When does dry socket usually present?
Day 3 or 4
not dry socket if patient says pain was present as soon as LA wore off
How should you manage a dry socket?
- 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.
What are the symptoms of dry socket?
- 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.
What are the predisposing factors for dry socket?
- 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.
When is chlorhexidine used?
In presence of an infection or with risk of infection (not on open wounds)
What are sequestrum?
- 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.
How should you manage sequestrum?
- Remove if necessary;
- With or without LA;
- With or without sutures.
How should you manage an infected socket (pus discharge present)?
- 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]
How do you manage OAC and OAF?
See previous Qs (L58/80)
How do you manage a root in antrum?
See previous Qs (L58/80)
What is osteomyelitis?
- 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]
What is the treatment for osteomyelitis?
- Antibiotics;
- Surgery;
- Investigate host defences.
What are the predisposing factors for osteomyelitis?
- Odontogenic infections;
- Fractures of the mandible;
- Host defences compromised (diabetes, alcoholism, IVDU, malnutrition, myeloproliferative disease).
How does osteomyelitis appear radiographically?
- 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).
What is an involucrum?
- An area of increased bone density surrounding a radiolucent area;
- Result of an inflammatory reaction and bone production increased.
What antibiotics would be prescribed for osteomyelitis?
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]
What does surgical treatment for osteomyelitis involve?
- 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.
Why does surgical treatment for osteomyelitis differ to treatment for RONJ?
Greater bone destruction with RONJ - can’t cut back to healthy bone
What is osteoradionecrosis?
- 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.
How should you manage an extraction with RONJ?
- 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.
What is hyperbaric oxygen use?
Occasionally used with RONJ patients before and after extractions, to increase local tissue oxygenation and vascular ingrowth to hypoxic areas
(oxygen chamber)
How should you treat RONJ?
- 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.
What is MRONJ?
- 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.
What are bisphosphonates used for?
- 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.
What is the suffix for bisphosphonate drugs?
-ate
What medications can cause MRONJ?
- Antiresorptive (inc. BPs);
- Immune modulating drugs (like monoclonal antibodies).
Where should you look for guidelines on treating MRONJ patients for other treatments, like implants?
SDCEP (MRONJ, 2017)
At what common sites do you see MRONJ?
- Maxilla;
- Behind mandibular tori, like lingual tori;
- Sites of tooth removal.
What is actinomycosis?
- 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.
How should you manage actinomycosis?
- 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.
What is infective endocarditis?
Infection/ inflammation of the endocardium, particularly affecting heart valves, caused by strep. viridans/ staph. aureus
