OS- post extraction complications

Question 1

What is the most common complication of extraction?

Answer 1

PAIN.

So we warn the patient and advise regarding analgesia.

Question 2

How do you know if the swelling is an inflammatory reaction to surgery or an post op infection?

Answer 2

If swelling occurs in first 48 hours- it is swelling due to the inflammatory reaction.

If swelling occurs in the next 3-7 days- it is swelling due to a post-op infection.

Question 3

What is ecchymosis?

Answer 3

Bruising.

Question 4

Compare limited mouth opening and trismus.

Answer 4

Limited Mouth Opening can have multiple causes :

• Muscle spasm- surgery or LA
• Damage to the muscle- odema / bleeding into the muscle/ haematomas/ clot fibrosing)
• Damage to the TMJ (oedema/joint effusion)

Trismus is limited mouth opening DUE TO MUSCLE SPASM.

Question 5

How is trismus treated?

Answer 5

Monitoring- should go away after 1-2 weeks.

Teach patient to use:

Gentle mouth moving exercises (to get the patient to try and open slightly)

Trismus screw- to gradually screw open the jaw a bit every day. .

Question 6

What is the likely cause of a bleed within 48 hours of extraction?

Answer 6

Reactionary or rebound bleed due to:

• The vessels opening up
• The LA vasoconstrictor wearing off
• Loose sutures
• Trauma (e.g. Food/ tongue)

Question 7

What is the likely cause of secondary bleeding? (3-7 days after extraction)

Answer 7

Post operative infection

Question 8

What is dry socket?

Answer 8

This is partial or complete loss of a blood clot. As a result the socket looks empty . It is common with 2-3% of all extractions resulting in a dry socket.

It is a slow healing socket.

Question 9

What are the main symptoms of dry socket?

Answer 9

Intense Pain

Smell and bad taste

Question 10

Discuss the expected timeframe of dry socket?

Answer 10

This starts 3-4 days after extraction

This takes 7-14 days for it to heal

Question 11

How do we manage dry socket?

Answer 11

• Saline wash- LA block clean out the debris and food from the socket using a saline wash.
• Debridement and curettage- we scrape and clean out the socket to encourage a new clot forming.
• Antiseptic pack- you pack the socket and suture it to hold it in. This stops food and debris getting in.
• Alovygl- This is placed in the socket and will disintegrate over time.
• Teach the patient to wash out their own socket.

Question 12

What is sequestrum?

Answer 12

A piece of dead bone tooth or restorative material that delays healing.

Question 13

The patient returns with bleeding that looks spotted or speckled and pus discharge, what could it be?

Answer 13

An infected socket.

We want to check for remaining tooth/ root fragments/ bony sequestra or foreign bodies that could be causing it.

Question 14

What does this radiograph show?

Answer 14

This shows osteomyelitis.

We can see the increased radiolucency (Uniform or patchy with a “moth-eaten appearance”)

Question 15

What is osteomyelitis and how does it happen?

Answer 15

This is infection and inflammation of bone.

1. invasion of Bacteria into the cancellous bone
2. Resulting in soft tissue inflammation and oedema in the closed bony spaces.
3. There is increased hydrostatic pressure
4. Blood supply is compromised causing soft tissue necrosis.
5. Bacteria proliferate because normal blood borne defences do not reach the tissues

Question 16

What are the symptoms of osteomyelitis.

Answer 16

Feeling systemically unwell and Fever

tender area of extraction.

Altered sensation due to pressure on the IADN

Question 17

Why is osteomyelitis more likely to occur in the mandible than the maxilla ?

Answer 17

The mandible has a poorer blood supply.

Question 18

How do we treat osteomyelitis?

Answer 18

We refer the patient

This patient will then get a medical consultation then antibiotics and surgical treatment.

Question 19

What is osteoradionecrosis ?

Answer 19

This is bone damage seen in patients who have recieved radiotherapy of the head and neck to treat cancer.

This results in:

• Bone within radiation beam becoming virtually non-vital.
• Reduced blood supply.
• Slow turnover of any remaining viable bone.
• Ineffective self repair of bone.

Question 20

How do we routinely treat patients with osteradionecrosis?

Answer 20

Ensure mouth is clean prior to extraction (Scale and use chlorohexidine mouthwash)

Careful extraction technique

Consider antibiotics- if there is a secondary infection.

Use chlorohexidine (once the socket has healed)

Question 21

What does this clinical image show?

Answer 21

Medication related Osteonecrosis of the jaw OR osteoradionecrosis.

Question 22

How do we know if a patient has osteoradionecrosis or MRONJ

Answer 22

You need to look at the patients medical history;

It is only osteoradionecrosis if the patient has had radiotherapy to treat head and neck cancer.

Otherwise it is Medication related osteonecrosis of the jaw. This can be caused by: Bisphosphonates, RANKL inhbitors e.g. Denosumab

and antiangiogenic e.g. Bevacizumab.

(So think patients with osteoporosis or cancer)

Question 23

What is actinoymocosis and how do we treat it

Answer 23

This is a rare bacterial infection that erodes through tissues in areas of injury and susceptibility to produce thick lumpy pus.

We refer this for the patient to have an incision and pus drainage.

The patient is then prescribed antibiotics.

Question 24

How do we grade MRONJ

Answer 24

0- jaw pain without clinically noticable cause.

1- asymptomatic exposed necrotic bone

2- symptomatic/ signs of infection.

3- Exposed bone extending out of the alveolar bone.

Question 25

How do we treat MRONJ?

Answer 25

Small exposure- Monitoring/ OHI/ antibiotics/ antibacterial mouthwash.
Large exposure-May need surgery (Surgical debridement)