Peri and Post Operative Complications Flashcards
What causes Difficult Access?
Trismus (limited mouth opening)
Reduced aperture of mouth (congenital/syndromes)
Crowded/malpositioned teeth (palatally/lingually)
TMJ spasm- cannot open mouth wide
What can cause Abnormal Resistance when extracting a tooth?
A thick cortical bone
Shape/form of the roots e.g. divergent roots or hooked roots
Hypercementosis
–excess build up of normal cementum on the roots (more work to loosen the tooth)
Ankylosis
–Tooth is directly bonded to the surrounding bone, there is no PDL
Where is the alveolar bone more likely to fracture?
Usually the buccal plate
Usually canine or molars
Where does the jaw normally fracture?
Mandible
What do you do if the jaw does fracture?
Inform the patient
Post-op radiographs
Refer (phone local maxillofacial surgeon and explain)
Ensure analgesia
Stabilise
If there is a delay in access to treatment, give antibiotics and can splint the teeth either side of the fracture to prevent the movement which causes pain
What are some signs of a jaw fracture?
Moving in 2 parts
Tear in gingivae
Teeth are no longer occluding like they were before extraction
Loud crunch or crack
What is an oro-antral communication (OAC)?
When extracting an upper tooth and you create a hole into the sinus (NAME FOR WHEN IT HAS JUST HAPPENED)
What is an oro-antral fistula (OAF)?
If an oro-antral communication (OAC) has been left for a period of time without being closed properly, the channel becomes epithelialised and you can have a tract that leads from the sinus to the oral cavity
HAS BEEN PRESENT FOR A WHILE FOR THIS TO OCCUR
How can an OAC be created?
Root being in the actual sinus
Root fracture occurs, when luxating can push root into the sinus
Fracturing the tuberosity
How can you tell if you have just created an OAC?
Bubbling of blood- sign of air passing from the sinus to the mouth
Nose holding test (careful as this can create an OAC)
–blow out gently against closed nostrils, if OAC is present patient can feel air escape into their mouth
–too much pressure can create an OAC
Direct Vision
–can see a hole, normally a bone
Blunt Probe
–more recommended for a fistula than directly after extraction
What are some risk factors for an OAC?
Extraction of upper molars and premolars
Close relationship of roots to sinus on radiograph
Last standing molars
Large bulbous roots
Older patients
Previous OAC
Recurrent sinusitis
What is the management of a small OAC or if the sinus in intact?
Encourage clot (can act to seal a small sinus)
Suture margins
Antibiotics always given (prevents sinusitis or chronic infections)
Post-op instructions
What is the management of a large OAC or if the lining is torn?
Close with buccal advancement flap
-pulling gum from buccal side over to the palatal side and stitching tightly for the gum to heal over properly
-2 vertical incisions and score the underside of the mucoperiosteum flap to give it more stretch and flexibility and secure it to the palatal
Prescribe antibiotics and give nose blowing instructions
-use decongestants or steam inhalation to prevent mucous build up
How can a tuberosity fracture occur?
Inadequate alveolar support
Extracting in wrong order
-take teeth out from back to front if multiple extractions
Single standing molar more likely to occur
How can you diagnose a tuberosity fracture?
Noise
Movement notes both visually or with supporting fingers
More than one tooth movement
Tear on palate
What is the management of a tuberosity fracture?
Dissect out and close wound or reduce and stabilise
-Put tooth and bone back into place (using splint) and ensure tooth is in occlusion, if it will not go back into occlusion reduce cusp size and place back in
Fixation
-splints, orthodontic wires
What can cause damage to the nerves?
Crush injuries
Cutting/shredding injuries
Transection
Damage from surgery or damage from LA
What is Neurpraxia?
Contusion of nerve/continuity of epineural sheath and axons maintained
What is Axonotmesis?
Continuity of axons but not epineural sheath disrupted
What is Neurotmesis?
Complete loss of nerve continuity/nerve transected
What is the name of a numbness sensation?
Anaesthesia
What is the name for a tingling sensation?
Paraesthesia
What is the name for an unpleasant sensation or a painful sensation?
Dysaesthesia
What is the term for a reduced sensation?
Hypoaesthesia
What is the name for an increased/heightened sensation?
Hyperaesthesia
What is the management of a soft tissue haemorrhage?
Pressure (mechanical-finger/biting on damp gauze swab) for 20 minutes
Sutures - pack site with surgicel
LA with vasoconstrictor
Diathermy (cauterise/burn vessels precipitate proteins which form proteinaceous plug in vessel)
Ligatures/haemostatic forceps (artery clips) for larger vessels
What is the management of a bone haemorrhage?
Pressure (damp gauze for 20 minutes)
LA on swab or injected into the socket
Haemostatic agents
Bone wax- plug into the socket, effective at stopping the bleed
Pack
What is the management of a TMJ dislocation?
Relocate immediately
If you cannot replace immediately, the muscles will go into spasm and can lock into this position
To relocate put pressure on the mandible downwards or backwards
If unable to relocate try LA into the masseter intra-orally
If still unable to relocate- immediate referral
What are some things to advise a patient after a TMJ dislocation?
Warn patient that they will be sore
Take analgesia
Give advice on supported yawning
Advice on reduced mouth opening afterwards
What causes Ecchymosis and what is it?
Bruising
Causes
-Poor surgical technique (rough handling)
-Underlying medical issues (antiplatelet or anticoagulant medication more likely to bruise)
Tends to occur around the site of extraction, however can then spread downwards towards the clavicle
What is Trismus?
Limited jaw opening
Jaw stiffness/inability to open the mouth fully
What are some causes of Trismus?
Damage to TMJ- oedema/joint effusion (swelling of the cartilage of the joint from overstretching)
Haematoma- medial pterygoid
LA- IDB (medial pterygoid muscle spasm)
Muscle spasm from opening mouth for a long period of time
What kind of extractions are a higher risk for post-operative bleeding complications?
Complex extractions
Adjacent extractions that will cause a large wound
More than 3 extractions at once
What kind of procedures induce an increase in post-operative bleeding complications?
Elective surgical extractions
Periodontal surgery
Preprosthetic surgery
Periradicular surgery
Crown Lengthening
Dental implants
Gingiva recontouring
Biopsies
What types of drugs can cause an increased post-operative bleeding risk?
Vitamin K Antagonists (warfarin)
-must check INR no more than 24 hours before procedure
-INR must be below 4 to treat
Antiplatelet drugs (aspirin, clopidogrel)
-treat without interupting medication
Direct Oral Anticoagulant (DOAC)
-apixaban, dabigatran, rivaroxaban, edoxaban
What should you do to the drug schedule when extracting a patient who is on apixaban or dabigatran?
Miss their morning dose and take at usual time in the evening
What should you do to the drug schedule when extracting a patient who is on rivaroxaban or edoxaban once daily in the mornings?
Delay the morning dose and take 4 hours after haemostasis has been achieved
What are some Haemostatic Agents?
Adrenaline containing LA-vasoconstrictor (soak gauze and get patient to bite down)
Oxidised regenerated cellulose- surgical/equitamp
–careful in lower 8 region, damage to IAN
Haemocollagen sponge- absorbable/meshwork for clot formation
Thrombin liquid and power + Floseal
-for patients we know are more likely to bleed, injections to counteract this
What are Systematic Haemostatic Aids?
Vitamin K (necessary for formation of clots)
Anti-fibrinolytics e.g. Tranexamic acid (prevents clot breakdown/stabilises clot)
Missing blood clotting factors
Plasma or whole blood
Desmopressin
What are the Post Extraction Instructions?
Do not rinse out for several hours (better not to rinse till the next day, then avoid vigorous rinsing as it washes the clot away)
Avoid trauma- do not explore the socket with tongue or fingers/hard food
Avoid hot food that day
Avoid excessive physical exercise and excess alcohol-increase blood pressure
Advice on control of bleeding
-biting on damp gauze/tissue
-pressure for at least 30 mins (longer if keeps bleeding)
What is the more common term for alveolar osteitis?
Dry socket
What is medical term of dry socket?
Alveolar Osteitis
What percentage of extractions does dry socket affect?
2-3%
Where is dry socket more likely to occur?
More likely in mandible
More posterior the teeth
What are the symptoms of dry socket?
Dull aching pain- moderate to severe
Usually throbs/can radiate to patient’s ear/often continuous and can keep the patient awake at night
The exposed bone is sensitive and is the source of the pain
Characteristic smell/bad odour & patient frequently complains of bad taste
What are some predisposing factors of dry socket? List at least 4
Smoking
Female
Oral contraceptive pill
LA-vasoconstrictor
Infection from tooth that has been extracted
Haematogenous bacteria in the socket
Excessive trauma during extraction
Excessive mouth rinsing post extraction (clot washed away)
Family history/previous dry socket
What is the management of a dry socket?
LA
Irrigate socket with warm saline
Curettage/debridement (encourage bleeding/new clot to form)
Antiseptic pack- ALVOGYL
Advise on analgesia and hot salty mouthwashes
Review patient/change packs and dressings
What is a Sequestrum?
Bits of dead bone (can see white spicules coming through gingiva)
Can also be pieces of amalgam/tooth
Delays healing/remove
What is an infected socket?
Rare complication
Pus discharge is present
Infection delays healing
