Post Extraction complications Flashcards
complications can occur
- Immediate/ intra-operative/ peri-operative
- Immediate post-operative/ short term post-operative
- Long term post-operative
post extraction complications
common
- Pain/Swelling/Ecchymosis (bruising)
- Trismus/ Limited mouth opening l
- Haemorrhage
- Prolonged effects of nerve damage
- Dry Socket = pain
- Sequestrum (something in socket that shouldn’t be there)
- Infected Socket
- Chronic OAF/root in antrum
less common post operative complications
- Osteomyelitis
- Osteoradionecrosis
- Medication induced osteonecrosis
- Actinomycosis
- Bacteraemia/Infective endocarditis – note current guidance
pain
Most common complication of extraction
- Warn patient, advise or prescribe analgesia – normal
- Tell them how to take safely
Rough handling of tissues = more pain
- laceration/tearing of soft tissues
- exposed bone
- incomplete extraction of tooth
what can cause more pain post extraction
- Rough handling of tissues = more pain
- laceration/tearing of soft tissues
- exposed bone
- incomplete extraction of tooth
swelling
oedema
Part of the inflammatory reaction to surgical interference
Increased by poor surgical technique
- e.g. rough handling of soft tissue/ pulling flaps/ crushing lip with forceps, length
Wide individual variation
occurs in 48 hours and dissipates in the week
- Later than 48 hours, more infection likely
If at all worried, contact me – instructions: sleep propped up, cold packs
swelling that occurs more than 48 hours after extraction
more likely to be infection
echhymosis
bruising
- Rough handling of tissues/poor surgical technique (leaning on pt)
- Be careful – try to minimise your impact
- Individual variation
trismus definition
limited mouth opening due to muscle spasm
trismus/jaw stiffness post extraction
Jaw stiffness/ inability to open mouth fully (stiff to open and close)
Variety of causes:
- related to surgery (oedema/muscle spasm)
- related to giving LA – IDB (muscle (medial pterygoid) – haematoma/spasm)
- bleed into muscle (haematoma) – medial pterygoid/ masseter (haematoma/clot organises and fibroses)
- damage to TMJ – oedema/joint effusion
Monitor – may take several weeks to resolve
- Gentle mouth opening exercises/ wooden spatulae – gradual opening day by day/ trismus screw
- If lasts more than 2 weeks or making you unable to eat or drink – contact
- Refer if not settling
causes of trismus
- related to surgery (oedema/muscle spasm)
- related to giving LA – IDB (muscle (medial pterygoid) – haematoma/spasm)
- bleed into muscle (haematoma) – medial pterygoid/ masseter (haematoma/clot organises and fibroses)
damage to TMJ – oedema/joint effusion
management of trismus
Monitor – may take several weeks to resolve
- Gentle mouth opening exercises/ wooden spatulae – gradual opening day by day/ trismus screw
If lasts more than 2 weeks or making you unable to eat or drink – contact
Refer if not settling
haemorrhage post extraction
2 types
depends on when occur
immediate post-operative period
- reactionary/rebound
seconday bleeding
immediate post-operative bleeding
- reactionary/rebound
- occurs within 48 hours of extraction
- vessels open up/vasoconstricting effects of LA wear off/ sutures loose or lost /patient traumatises area with tongue/finger/food
secondary bleeding
post extraction
- often due to infection
- commonly 3-7 days
- usually mild ooze but can occasionally be a major bleed
possible damage to vessels in extractions
- Veins (bleeding +++)
- Arteries (spurting/haemorrhage +++)
- Arterioles (spurting/pulsating bleed)
- Vessels in muscle
- Vessels in bone
dental haemorrhage causes
- Most bleeds due to local factors – mucoperiosteal tears or fractures of alveolar plate/socket wall
- Very few bleeds due to undiagnosed clotting abnormalities (haemophilia/von Willebrands)
- Some due to Liver Disease (alcohol problems) – clotting factors made in liver
- Some due to medication – Warfarin/ antiplatelet agents/NOACs (e.g. Aspirin/Clopidogrel/Apixaban)
how to manage bleeding from soft tissue
- Pressure (mechanical –finger/biting on damp gauze swab)
- Sutures
- Local Anaesthetic with adrenaline (vasoconstrictor)
- Diathermy (cauterise/burn vessels – precipitate proteins – form proteinaceous plug in vessel)
- Ligatures/haemostatic forceps (artery clips) for larger vessels
how to manage bleeding from bone
- Pressure (via swab)
- LA on a swab or injected into socket
- Haemostatic agents - Surgicel/ Kaltostat
- Blunt instrument
- Bone Wax
- Pack
management of post operative bleeding
If bleeding severe get pressure on immediately/ arrest the bleed
Calm anxious patient/ separate from anxious relatives
- Out of waiting room
- Clean patient up/ remove bowls of blood/blood-soaked towels
Take a thorough but rapid history while dealing with haemorrhage
- Must rule out bleeding disorder – haemophilia/ von Willebrands/Liver Disease
- Medication – Warfarin/ Combination of Aspirin and other antiplatelet drugs (e.g. Clopidogrel), NOACs.
Get inside mouth/good light & suction
Mouth often filled with large jelly-like clot
- Remove clot
Patient may be vomiting if blood swallowed
Identify where bleeding from
Pressure
- finger/biting on damp packs
Local anaesthetic with vasoconstrictor
Urgent referral/contact haematologist if bleeding disorder.
- If on Warfarin get GMP to do INR/urgent hospital referral if bleeding not arrested
haemostatic aids
eg. Surgicel (oxidised cellulose – acts as a framework for clot formation), bone wax in socket
suture socket
- interrupted/horizontal mattress sutures
3 things that can aid stopping of bleeding
Haemostatic aids
- e.g. Surgicel (oxidised cellulose – acts as a framework for clot formation), bone wax in socket
Suture Socket
- interrupted/horizontal mattress sutures
Ligation of vessels/diathermy if available
important key piece of information regarding bleeding to give pt post op
- Give patient point of contact if bleeding resumes
- you or hospital – ideally where MaxFax team on call
- Review patient
un-coperative child comes in with uncontrollable bleeding after extraction
An un-cooperative child will need an emergency GA to get bleeding to stop
- Large volume blood loss/medical problems/extremes of age
- hospital admission/A&E
- If you cannot arrest haemorrhage
-
urgent hospital referral
- Weekdays – Dental Hospital/ Maxillofacial Outpatients
- Evenings/weekends – Maxillofacial On-Call or local hospital A&E
-
urgent hospital referral
Uncontrolled haemorrhage is life-threatening
Calm down to reduce BP – help slow bleeding
key management technique for uncontrolled bleeding
Uncontrolled haemorrhage is life-threatening
Calm down to reduce BP – help slow bleeding
5 haemostatic aids
- Adrenaline containing LA – vasoconstrictor
- Oxidised regenerated cellulose
- Surgicel – framework for clot formation
- Careful in lower 8 region – acidic – damage to IDN
- Gelatin Sponge
- absorbable/meshwork for clot formation
- Thrombin liquid and powder
- Fibrin Foam
4 systemic haemostatic aids
- Vitamin K (necessary for formation of clotting factors)
- Anti-Fibrinolytics e.g. Tranexamic acid
- (prevents clot breakdown/stabilises clot – systemic tablets or mouthwash)
- Missing Blood Clotting Factors
- Plasma or whole blood
prevention for intra-operative and post-operative extraction haemorrhage
- Thorough medical history/ anticipate and deal with potential problems
- Atraumatic extraction/ surgical technique
- Obtain & check good haemostasis at end of surgery
- Provide good instructions to the patient
post extraction instructions for bleeding
- Do not rinse out for several hours
- better not to rinse till next day, then avoid vigorous mouth rinsing – wash clot away
- Avoid trauma
- do not explore 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 30min (longer if bleeding continues)
- Points of contact if bleeding continues
- Ask – if concerned, and record
reiterate after bleeding again
nerve damage
can be temporary or permanent
- Improvement can occur up to 18-24months
- after this little chance of further improvement
8 types of nerve damage
- anaesthesia
- paraesthesia
- dyseasthesia
- hypoaesthesia
- hyperaesthesia
- neurapraxia
- axonotmesis
- neurotmesis
anaesthesia
numbness
paraesthesia
tingling
dysaesthesia
upleasant sensation/pain
hypoaesthesia
reduced sensation
hyperaesthesia
increased/heightened sensation
neurapraxia
contusion of nerve/continuity of epineural sheath and axons maintained