OS - Complications Flashcards
What are the 16 peri-operative complications?
DAFFFJILSDHDDEBW Difficulty access Abnormal resistance Fracture of the tooth Fracture of the alveolar plate Fracture of the tuberosity Jaw fracture Involvement of the maxillary antrum Loss of tooth Soft tissue damage Damage to nerves Haemorrhage Dislocation of TMJ Damage to adjacent teeth and restorations Ex of the permanent tooth germ Broken instruments Wrong tooth
What are some possible reasons for the difficulty of access?
Trismus (decrease in mouth opening due to spasm of the M.O.M)
Lack of mouth opening
Crowded/malpositioned teeth
What are some possible reasons for abnormal resistance?
Thicker cortical bone Curved and divergent roots Number of roots Ankylosis - trauma Hypercementasis (linked with pituitary giantism, acromegaly and Paget's disease)
What is a possible reason for ankylosis?
Trauma and then boney healing has occurred
Reasons for possible tooth or root fracture in Ex
Grossly caries teeth and Forceps not being placed far enough down the tooth.
Root fractures can occur for the same reasons as abnormal resistance. Fused roots, hypercementosis, hooked or divergent roots
Where does a Fracture of the alveolar plate most often take place?
The canine or molar buttress.
Where does a fracture of the tuberosity most often take place?
In the PM and M maxillary region of the mouth.
Aetiology of tuberosity fractures?
Not got the proper support
Last standing molars
Ex from the back, forwards
Have the adequate support from alveolar bone
How would you diagnose a tuberosity fracture?
Noise - tear sound
More than one tooth moving
Tear of the palate as often sharp bone is created.
How to treat a tuberosity fracture?
don’t remove the tooth, stabilise it by treating pulp if necessary. Then stabilise the area with orthodontic wire. Allow the bone to heal before attempting to re Ex the tooth in min of 8 weeks time.
WHere is a jaw fracture more common?
In the mandible
Aetiologies of jaw fractures?
Present of cysts,
impaired vision
atrophic mandible
Edentulous patients
How do you minimise the chances of jaw fracture?
Prepare and risk assess
Take radiographs - to check the bone quality
Support the jaw and tooth fully when removing and avoid excessive force
Management of jaw fracture?
Must tell patient and refer straight away to MaxFax.
If you cant get referral that day then consider analgesia, antibiotics prophylaxis, extra LA and stabilise with ortho wire
What are the 3 ways maxillary antrum can be involved?
OAC and OAF
Root in antrum
tuberosity fracture
What can you do to diagnose and access the risk of OAC?
Take radiographs before - OPT or occlusal
Look at the maxillary teeth from 3’s back and if roots long and close to the maxillary antrum.
Management of acute OAC?
Inform patient
If small or sinus intact;
encourage clot formation, suture the margins, prescribe antibiotics and give the patient post-operative instructions.
If large, close with buccal advancement flap, antibiotics and nose blowing instructions.
Why shouldn’t you use an air generated drill?
Surgical emphysema
For surgical removal of a root in the antrum, what type of flap should you use?
Buccal advancement flap
What are the post-operative instructions for OAC and OAF?
Leave it alone
Do not rinse vigorously, gentle rinse the next day.
Continue to brush as normal
Avoid straws, wind instruments and sucking air into the area
closed mouth sneeze
Avoid nose blowing
Talk to the patient the next day and follow up at 6-8weeks
If you lose a tooth where should you look?
The buccal mucosa in the flap Under the tongue suction bottle Radiograph the maxillary antrum Ask patient if swallowed anything and refer
What is neurapraxia?
Temporary damage to the nerves, axon still intact
What is axonotmesis?
Axon and myelin sheath are damaged
What is neurotmesis?
Cut - complete damage of the nerve and loss of nerve transmission.
Define Anaesthesia Paraesthesia Dynathesia Hypoaesthesia Hyperaesthesia
Anaesthesia - numbness Paraesthesia - tingling Dynathesia - pain Hypoaesthesia - reduced sensation Hyperaesthesia - increased sensation
What must you tell the patient before any Ex in relation to nerves?
Must tell the patient in simple terms about the risks of permanent and temporary damage.
Reasons for haemorrhage?
Mucoperiosteals tears in a region of vessels or fractures of the alveolar plate/socket wall
Bleeding disorders, liver damage, medications
management of soft tissue bleeding?
PRESSURE LA (vasoconstrictor) Diathermy Suture Clamps
management of bleeding from the bone?
PRESSURE LA bone wax Diathermy surgicel - acts as a framework for clot formation
Management for TMJ dislocation
Want to re-locate straight away if you can. Then give analgesia, and advice on supportive yawning.
If cannot reposition straight away then inject LA to the masseter (IO) and retry.
If this still doesn’t work then refer to maxfax or Aand E immediately
Why should you relocate the TMJ immediately?
As muscles will start to spasm and make it much more difficult.
What are some reasons for broken instruments?
Faulty instruments
Not using them for their appropriate function.
What are the 13 postoperative complications?
PTHPDSICOOMAB Pain/swelling/bruising Trismus Haemorrhage Prolonged nerve damage Dry socket (localised osteitis) Sequestrum Infective socket chronic OAF and root in the antrum Osteomyelitis Osteoradionecrosis MRONJ Actinomycosis Bacterial infective endocarditis
Pain, swelling and bruising are the most common post-Ex complication. How would you manage it and what would you say to the patient?
Would prescribe analgesia, tell them to ice it and say it should resolve completely in 1-2weeks post-Ex.
Trismus is predominantly caused by a muscle spasm of which muscle?
Medial pterygoid
What are some possible causes of trismus?
LA into the muscle tissue
surgery and formation of scar tissue
Due to haematoma
Damage to TMJ
Management of postoperative bleeding?
Suction out all the blood and find the source of the bleed. While doing this take a brief history to rule out bleeding disorders, liver damage and medications.
Then once found bleed, apply pressure, LA (VC), surgicel, suture, diathermy and good post-operative instructions
Check-in on a patient at the end of the day and if still bleeding then A&E
What can you do to prevent post-Ex haemorrhage?
Plan - Good risk assessment and thorough medical history
Atraumatic Ex
Achieve good haemostasis after Ex
Give good post-operative instructions
What is 5 post-operative instruction that you should always tell the patient after an Ex?
Do not rinse out your mouth straight after and avoid vigorously rinsing that day (clot) Avoid trauma (don't explore the socket with your tongue or fingers) Avoid Hot food that day Avoid excessive physical exercise and alcohol Advice on the use of damp gauze and bite down for 30minutes if it starts to bleed again before you call in for an emergency.
What is a dry socket also referred to as?
Localised osteitis
What is a dry socket?
Its when the clot doesn’t form properly and inflammation of the lamina dura occurs which results in intense pain.
When does a dry socket occur? where does it occur more and how long does it last?
3-4 days after Ex
Posterior teeth of the mandible (females more also)
lasts 7-14 days (slow healing)
Where can dry socket pain radiate?
The ear and down the side of the face
Keep Them awake at night as so intense.
What are some predisposing factors for dry socket?
Molar teeth mandible Females smoking excessive trauma during Ex Excessive mouth rinsing post-Ex Family history Had dry socket before LA used Oral contraceptive pill
Management of Dry socket?
Support patient - reassure them it’s a side effect and that you took the right tooth.
Prescribe analgesia
Give LA to alleviate pain
Irrigate socket and teach them to rinse with warm salty water
Review every few days
What is a sequestrum?
Refers to anything left in the socket, which shouldn’t be and will therefore prevent healing.
If you leave some sequestra in the socket what can happen?
The socket can become infected
what is osteomyelitis and who can it affect?
Inflammation of the bone marrow
Rare and usually only affect people how are medically or immunosuppressed.
What types of antibiotics are good for osteomyelitis and odontogenic infections?
Penicillin
Clindamycin (allergy to penicillin)
What is osteoradionecrosis?
This occurs in patients who have had radiotherapy for head and neck cancers. the beams cause the bones to become non-vital.
WHere can ORN happen more often in the mouth and why?
the mandible as has a much poorer blood supply
What are bisphosphates? and what are they used to treat?
Bisphosphates are used to inhibit bone remodelling and osteoclast activity so the bone isn’t resorbed.
Treats osteoporosis
Paget’s disease
bone cancers
How many years do you have to be on bisphosphates before MRONJ is a problem?
5 years
Risk factors that increase chances of MRONJ?
Length of time on the drugs Steroids Diabetes smoking IV instead of orally
What is actinomycosis?
Rare bacterial infection
What are the at-risk groups for bacterial endocarditis?
Acquired valvular heart disease
Prosthetic heart valve or valve replacement
Structural congenital heart defects
History of IE
What is the treatment for infective endocarditis?
Optimum OH and oral health before any treatment
Lease with their cardiologist if prophylaxis is necessary.
30mins before treatment take a single dose of antibiotics;
either amoxicillin 2g IV
Clindamycin 600mg IV
