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
axonotmesis
continuity of axons but not epineural sheath disruptied
neurotmesis
complete loss of nerve continuity/nerve transected
how to manage nerve damage
Monitor for a few days – ensure not infection – if gets to week -> refer (sooner Tx better outcome but never guaranteed with nerve treatment – can make worse)
dry socket
alveolar/localised osteitis
occurance of dry socket
- Affects 2- 3% of all extractions
- Some say up to 20-35% of lower 8s
dry socket is
- normal clot disappears or never formed
- appear to be looking at bare bone/empty socketNormal clot disappears or never formed
- partially or completely lost blood clot
main feature of dry socket
intense pain
- described as worse than toothache/patient kept awake at night
- check not infection - no swelling or pus
Localised Osteitis – inflammation affecting lamina dura
time space for dry socket
Often starts 3-4 days after extraction
- If started straight after LA wore off, then check if nothing left in socket as dry socket takes a few days to come on
Slow healing socket - localised osteitis - inflammation affecting lamina dura
Takes 7-14 days to self resolve
- help through – analgesia, wash with warm saline
symptoms of dry socket
- Dull aching pain – moderate to severe
- Usually throbs/can radiate to patient’s ear/often continuous and can keep 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
- Absent swelling and pus
Some suggest subclinical infection but does not show features of overt infection
- no fever/ swelling/ pus
It is delayed healing but not associated with infection
dry socket predisposing factors
- Molars more common – risk increases from anterior to posterior
- Mandible more common – less blood supply (1 artery)
- Smoking – reduced blood supply
- Female
- Oral Contraceptive Pill
- Local Anaesthetic – vasoconstrictor
- ?infection from tooth
- ?haematogenous bacteria in socket
- Excessive trauma during extraction – crushed bone, long procedure
- Excessive mouth rinsing post extraction (clot washed away)
- Family history/ previous dry socket
management of dry socket
- Supportive
- reassurance/ systemic analgesia (patients often think you have extracted wrong tooth and another tooth is causing pain – check don’t disregard)
- LA Block immediate pain relief, and allow irrigation
- Irrigate socket with warm saline
- wash out food and debris
- Curettage/debridement small curette, Mitchells – remove remanence
- encourage bleeding/new clot formation
- some suggest this should not be carried out as it produces more bare bone and removes any remaining clot
- often irrigate and see again and assess over regular apps
- some suggest this should not be carried out as it produces more bare bone and removes any remaining clot
- encourage bleeding/new clot formation
- Antiseptic pack (BIP, Alvogyl)
- advise pt on analgesia and hot salty mouthwashes
- Eat and drink as normal
- Reassure and say contact if needed
- No longer chlorohexidine – reactions
- Review patient/change packs and dressings
- as soon as pain resolves – get packs out to allow healing
Generally, do not prescribe antibiotics as it is not infection
Remember to check initially that it is a dry socket and that no tooth fragments or bony sequestra remains/foreign bodies
antiseptic packs
Soothe pain and reduce food packing
- used for dry socket management
If not dissolving, need to replace, suture in
BIP – Bismuth subnitrate and Iodoform Pack.
- Comes as a paste or impregnated gauze.
- Antiseptic and Astringent.
Alvogyl – mixture of LA and antiseptic
infected socket post extraction
- Infection is a rare complication after a routine dental extraction
- Dry socket more common
- But occasionally see an infected socket with pus discharge
- check for remaining tooth/root fragments/bony sequestra/foreign bodies.
- Treatment - radiograph/explore (cysts?)/irrigate/remove any of the above/consider antibiotics.
- check for remaining tooth/root fragments/bony sequestra/foreign bodies.
- Infection more commonly seen after minor surgical procedures involving soft tissue flaps and bone removal
- Can cause bleeding into socket
- Infection delays healing
OAC
oral antral communication
acute
OAF
oral antral fistula
chronic
epithelium lined tract/tube
oro antral communication diagnose by
any tooth from 3 back
Diagnose by
- Size of tooth
- Radiographic position of roots in relation to antrum
- Bone at trifurcation of roots
- Bubbling of blood
- Nose holding test (careful as can make bigger)
- Direct vision
- Good light and suction – echo
- Start at mouth of socket, then work to base
- Blunt probe (take care not to create an OAF)
OAC/OAF can occur
to any tooth distal to canine
C/O for OAC/OAF
Bad taste, pus, not able to get good oral seal
management of acute OAC
- Inform patient
- If small or sinus intact:
- Encourage clot
- Suture margins – tighten, encourage healing
- Antibiotic
- 5-7 days – check after
- Post-op instructions
- Avoid blowing nose, steam inhalation for min at time to help clear sinuses
- Can take 2 weeks to heal
- If large or lining torn:
- Close with buccal advancement flap
- Full thickness flap of gingiva back and release the underlying periosteal fibrous tissue (white/grey) needs gently released with a sharp scalpel – change several times throughout
- make mucosa elastic
- close over socket without tension
- Full thickness flap of gingiva back and release the underlying periosteal fibrous tissue (white/grey) needs gently released with a sharp scalpel – change several times throughout
- antibiotics and nose blowing instructions
- Close with buccal advancement flap
healing time for large OAC or lining torn
2 weeks to heal
- Leave closed for that
- Use sutures
Swelling or pain post 2 weeks – refer as may have infection
chronic OAF managment
- Excise sinus tract
- Cut out tube of epithelium
Then - 4 options
- Buccal Advancement Flap
- If large of advancement flap breaks down often Buccal Fat Pad with Buccal Advancement Flap (sturdier)
- Palatal Flap
- Finger like projection from keratinised palatal mucosa and rotate it round over extraction socket and stitch to buccal mucosa
- Bone Graft/Collagen Membrane
- Tongue Flap (Historical/ no longer used)
how to confirm root in antrum
- Confirm radiographically by OPT, occlusal, or periapical
- Decision on retrieval
root in antrum retrieval
- OAF type approach/through the socket:
- Flap Design
- Open fenestration with care
- Suction – efficient and narrow bore
- Small curettes
- Irrigation or ribbon gauze
- Close as for oro-antral communication
- Caldwell-Luc approach:
- Buccal sulcus
- Buccal window
- ENT – Endoscopic approach
osteomyelitis
The term means inflammation of the bone marrow
- implies an infection of the bone - Rare
Patient often systemically unwell/raised temperature
Site of extraction often very tender
In deep seated infection may see altered sensation due to pressure on IAN
osteomyelitis common site
Usually, mandible
- Can occur in maxilla but maxilla supplied by several arteries (rich blood supply)
- Mandible has primary blood supply inferior alveolar artery and dense overlying cortical bone limits penetration of periosteal blood vessels
- so poorer blood supply and more likely to become ischaemic and infected
osteomyelitis course
Usually begins in medullary cavity involving the cancellous bone
- Then extends and spreads to cortical bone
- Then eventually to periosteum (overlying mucosa red and tender)
- Invasion of bacteria into cancellous bone causes soft tissue inflammation and oedema in the closed bony marrow spaces
Invasion of bacteria into cancellous bone causes soft tissue inflammation and oedema in the closed bony marrow spaces
- Oedema in an enclosed space leads to increased tissue hydrostatic pressure
- higher than blood pressure of feeding arterial vessels
Compromised blood supply results in soft tissue necrosis
- Involved area becomes ischaemic & necrotic
Bacteria proliferate because normal blood borne defences do not reach the tissue
- Due to lack of blood supply
The osteomyelitis spreads until arrested by antibiotic and surgical therapy
major predisposing factors to osteomyelitis
- odontogenic infections & fractures of mandible
- But even in these situations’ osteomyelitis still rare unless host defences compromised
- Compromised host defence:
- Diabetes/ Alcoholism/ IV Drug Use/ Malnutrition/ Myeloproliferative Disease (e.g. leukaemias, sickle cell disease, chemotherapy treated cancer)
rarely occurs when host defences are in tact
osteomyelitis differentiatin from dry socket or localised infection
Early osteomyelitis can be difficult to distinguish from dry socket or localised infection in the socket
- Acute suppurative osteomyelitis shows little/no radiographic change
- at least 10-12 days required for lost bone to be detectable radiographically
- Chronic osteomyelitis – (+/- pus) – bony destruction in the area of infection
- Radiographic appearance – increased radiolucency (uniform or patchy with a ‘moth-eaten appearance)
radiographic evidence of osteomyelitis
- Areas of radiopacity may occur within the radiolucent region
- unresorbed islands of bone – sequestra
- In long-standing chronic osteomyelitis there may be an increase in radiodensity surrounding the radioluscent area – an involucrum
- This is the result of an inflammatory reaction – bone production increased
main bacteria involved in osteomyelitis of mandible
main bacteria involved similar to those involved in odontogenic infections
- streptococci,anaerobic cocci such as peptostreptococcus spp, anaerobic gram negative rods such as Fusobacterium & Prevotella
whereas other bones - staphylococci predominate (skin infection)
treatment of osteomyelitis
- Medical and Surgical Treatment
- Investigate host defences
- Blood investigations/glucose levels – seek medical consultation – check no underlying medical issues
antibiotic treatment of osteomyelitis
- Antibiotics
- clindamycin/penicillins
- effective against odontogenic infections & good bone penetration
- Longer courses than normal
- Often weeks in acute osteomyelitis - some suggest at least 6 weeks after resolution of symptoms). Months in chronic osteomyelitis (in some cases up to 6 months)
- clindamycin/penicillins
- Severe acute osteomyelitis may require hospital admission and IV antibiotics (if systemic symptoms) Pus, swelling seen
surgical treatment of osteomyelitis
- Drain pus if possible
- Remove any non-vital teeth in the area of infection
- Remove any loose pieces of bone – dead bone prevent healing
- In fractured mandible – remove any wires/ plates/screws in the area
- Corticotomy – removal of bony cortex
- Perforation of bony cortex
- Excision of necrotic bone (until reach actively bleeding bone tissue)
- May need reconstruction
who manages osteomyelitis
needs referred
Chronic osteomyelitis requires aggressive antibiotic and surgical treatment
Osteomyelitis needs referred identify that it may be
osteoradionecrosis
Seen in patients who have received radiotherapy of the head & neck to treat cancer
The bone within radiation beam becomes virtually non-vital
- larger areas of bone
Endarteritis – reduced blood supply
- More in mandible – 1 blood supply
Turnover of any remaining viable bone is slow
Self-repair ineffective
Worse with time
Some suggest careful routine extraction, others suggest surgical extraction, alveoplasty & primary closure of soft tissue
prevention of osteoradionecrosis
OH to prevent extractions – have dry mouth due to tx
- Scaling/Chlorhexidine mouthwash leading up to extraction
- Careful extraction technique
- Antibiotics, chlorhexidine mouthwash (but not into open wounds) and review
- Maybe hyperbaric oxygen
- to increase local tissue oxygenation & vascular ingrowth to hypoxic areas
- before and after extraction
- Take advice/refer patient for extraction
treatment of osteoradionecrosis
- Irrigation of necrotic debris
- Antibiotics not overly helpful unless secondary infection
- Loose sequestra removed prevent healing
- Small wounds (under 1cm) usually heal over a course of weeks/months
- Severe cases
- Surgical intervention - resection of exposed bone, margin of unexposed bone and soft tissue closure
- Hyperbaric oxygen - sometimes
medication related osteonecrosis
MRONJ
whole bone affected
MRONJ
Occurs post extraction/following denture trauma/spontaneous
Exclusive to the jaws
- Both mandible and maxilla
- but whole bone
Risk higher in patients receiving IV bisphosphonates but still occurs in patients on oral bisphosphonates
Ranges from small asymptomatic areas of exposed bone to extensive bone exposure/dehiscence/pus/pain
Bisphosphonate and osteoradionecrosis
Bisphosphonates are a class of drugs used to treat osteoporosis, Paget’s Disease & malignant bone metastases
- inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal/healing
- The drugs may remain in the body for years
BRONJ now MRONJ
factors that impact MRONJ likelihood
- length of time patient on the drug/diabetes/steroids/anticancer chemotherapy/smoking
what to avoid if pt MRONJ known
avoid extraction if possible is restore, crown, monitor possible?
- If extraction required – careful technique & monitor patient/warn patient to look for signs
- Take advice/refer – look at guidelines
treatment of MRONJ
not that successful
- Manage symptoms/remove sharp edges of bone/chlorhexidine mouthwash/antibiotics if suppuration
- Debridement/Major surgical sequestrectomy/Resection/Hyperbaric Oxygen have not proved that successful
medications that cause MRONJ (3 groups)
- Antiresorptive
- including bisphosphonates (BP
- Receptor activator of nuclear factor kappa-B ligand [RANK-L] inhibitors)
- Denosumab – Xgeva, Prolia (Cancer drug – monoclonal antibody).
- Stops production of osteoclasts.
- Antiangiogenic
- They are basically divided into two types of drugs:
- Monoclonal antibodies that stop the receptor or growth factor (bevacizumab)
- small molecules, which determine the block by binding the tyrosine kinase receptor (sunitinib and sorafenib).
- They are basically divided into two types of drugs:
be wary of
MRONJ
Any biological agent,immunomodulator, antiresoption, antiangiogenic medication.
- Have a BNF handy!
check SDCEP
risk of MRONJ according to SDCEP
low or high
risk factors for MRONJ include
Risk factors include
1: Dental treatment
- Impact on bone – extractions
- Trauma from dentures
- Infection
- Periodontal disease
2: Duration of bisphosphonate drug therapy
* Increased dose and increased duration both increase the risk of MRONJ
3: Dental Implants
- Unknown
- General consensus is to avoid implant placement in high doses of anti-resoprtive or anti-angiogenic drugs for the management of cancer
- Its not contraindicated in patients with osteoporosis – may be in worse state, inform
- There is insufficient evidence to indicate whether bisphosphonates have a negative impact on implant survival. Failure rates are similar to those not on bisphosphonates.
4: Other concurrent medication
- Concurrent use of steroids + anti-repsorptive drugs = increased risk of MRONJ
- Concurrent use of anti-resporptive and anti-angiogenic = increased risk of MRONJ
5: Previous drug history
- There is no evidence to inform the assessment of risk for patient’s who have previously taken anti-resorptive or anti-angiogenic drugs
- Patient with a history of drug use should still be considered at risk due to the long half life of these drugs
- Denosumab’s effect on bone turnover diminishes after 9 months of finishing treatment
- Anti-angiogenic drugs are not thought to remain in the body for extended periods of time
6: Drug holidays
- There is no evidence for drug holidays
- Dentists should not take responsibility for stopping a patient’s drug
- Responsibility of prescribing physician
Patients with osteoporosis who are being treated with six monthly subcutaneous injections of denosumab may have treatment one month prior to drug administration. Resume drug after soft tissue closure.
management of MRONJ
- Prevent invasive treatment
- Extractions in primary care setting
- No benefit of referral to secondary care based purely on their exposure to these drugs
- Guidance considers patients in two groups
- Initial management (prior to commencing drug or just commenced)
- Continuing management (established drug regime)
MRONJ
smell unpleasant
actinomycosis
Rare bacterial infection
Actinomyces israelii/ A. naeslundii/ A. viscosus
The bacteria have low virulence and must be inoculated into an area of injury or susceptibility (diabetes/ immune modulated drugs)
- E.g. recent extraction/severely carious teeth/bone fracture/minor oral trauma
It erodes through tissues rather than follow typical fascial planes and spaces
- Normally infection goes through least resistant – planes
Fairly chronic
Multiple skin sinuses and swelling
Thick lumpy pus
- colonies of Actinomyces look like sulphur granules on histology
Responds initially to antibiotic therapy/recurs when stop antibiotics
treatment of actinomyocosis
- Incise & drain of pus accumulation
- Excision of chronic sinus tracts – revision of scars back at MaxFax or Facial
- Excision of necrotic bone & foreign bodies
- High dose antibiotics for initial control (often IV)
- Long-term oral antibiotics to prevent recurrence
- Antibiotics: Penicillins, doxycycline or clindamycin
infective endocarditis
Inflammation of the endocardium, particularly affecting heart valves or CMP caused by bacteria
- Rare – 10:100,000 cases per annum
- Significant mortality of ~20%
CHECK GUIDELINES – CONSTANTLY CHANGING
- was said bacteria in the bloodstream following extraction would circulate to the heart and colonise vegetations/scarring/artificial valves and lead to the life threatening condition Infective Endocarditis
IE key guidance currently
-
SDCEP 2018 is the KEY GUIDANCE
- Scottish Antimicrobial Prescribing Group (SAPG)
- Do not wish to advice on non-routine cases
- Consensus on individual assessment
- Generally, endorse prophylaxis if clinical anxiety
- Scottish Antimicrobial Prescribing Group (SAPG)
- European Cardiac Society (ECS)
- Advise IE proph inpatients with prosthetic valves, valve repair in prosthetic material, previous IE, cyanotic CHD, CHD repair with prosthetic material for 6/12 or lifelong if residual shunt or valve regurg
- Which procedures?
- Dental procedures involving manipulation of gingival or periapical region of teeth or perf of the oral mucosa
- Scottish Adult Congenital Cardiac Service (SACCS)
- Adopted ECS
- SDCEP 2018
antibiotic prophylaxis
prescribe
- Amoxicillin, 3g oral powder sachet
- Give 3g (1 sachet) 60 minutes before procedure (3g prophylactic dose)
- Clindamycin capsules, 300mg
- Give 600mg (2 capsules) 60 minutes before procedure (600mg prophylactic dose)
- If allergic to amoxicilli
- Give 600mg (2 capsules) 60 minutes before procedure (600mg prophylactic dose)
- Azithromycin oral suspension 200mg/5ml
- Give 500mg (12.5ml) 60 minutes before procedure (500mg prophylactic dose)
- If allergic to penicillin and unable to swallow capsules
- Give 500mg (12.5ml) 60 minutes before procedure (500mg prophylactic dose)
Doses altered for children
IE in GG&C pts
- In Oral Surgery we always assess each patient individually, risk assessing and liaising with Cardiologist as required and taking advice on Prophylaxis where necessary
- Oral Health Promotion message to patients on prevention - emphasise
- Monitoring guidance changes on a regular basis
invasive dental procedures
according to SDCEP IE guidance
- placement of matrix bands
- placement of sub-gingival rubber dam clamps
- sub-gingival restorations including fixed prosthodontics
- endodontic treatment before apical stop has been established
- preformed metal crowns (PMC/SSC)
- full perio examination (inc pocket chart in diseased tissue)
- root surface instrumentation/sub-gingival scaling
- incision and drainage of abscess
- dental extractions
- surgery involving elevation of a muco-periosteal flap or muco-gingival area
- placement of dental implants including temporary anchorage devices, mini implants
- uncovering implant sub-structures
non invasive dental procedures
according to SDCEP IE guidance
- infiltration or blocked LA injections in non-infected soft tissue
- BPE screening
- supra gingival scale and polish
- supra gingival restorations
- supra gingival orthodontic bands and separators
- removal of sutures
- radiographs
- placement or adjustment of orthodontic or removable prosthodontic appliances
