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BDS3 - Oral Surgery > post extraction complications > Flashcards

post extraction complications Flashcards

1
Q

what are some common post-operative complications

A
  • Pain/swelling/ecchymosis (bruising)
  • Trismus/limited mouth opening
  • Haemorrhage
  • Prolonged effects of nerve damage
  • Dry socket
  • Really painful
  • Sequestrum
  • Infected socket
  • Chronic OAF/root in antrum
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2
Q

what are some less common post-operative complications

A
  • Osteomyelitis
  • Osteoradionecrosis
  • Medication induced osteonecrosis
  • Actinomycosis
  • Bacteraemia/infective endocarditis
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3
Q

what s the most common complication

A
  • pain
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4
Q

what can enhance pain

A
  • rough handling of tissues
    • Laceration/tearing of soft tissues
    • Exposed bone
    • Incomplete extraction of tooth
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5
Q

what is swelling/oedema

A
  • • Part of inflammatory reaction to surgical interference
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6
Q

what can increase swelling/oedema

A
  • Increased by poor surgical technique

* E.g., rough handling of soft tissue/pulling flaps/crushing lip with forceps

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7
Q

how can you tell if swelling is infection or not

A
  • If it doesn’t swell until day 2-3 then it is more likely to be an infection
  • Infection tends not to build up till day 2-3 but post-op builds up within 48 hours
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8
Q

what is ecchymosis

A
  • bruising
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9
Q

what is trismus

A

• Trismus is limited mouth opening due to muscle spasm

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10
Q

what can cause trismus/limited mouth opening

A
  • Related to surgery = oedema/muscle spasm
  • Mouth open too long in surgery
  • Related to giving LA = IDB (muscle (medial pterygoid) hit causing haematoma/spasm)
  • Bleed into muscle (haematoma) = medial pterygoid/masseter
  • Haematoma/clot organises and fibroses
  • Damage to TMJ = oedema/joint effusion
  • More fluid in the joint
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11
Q

how ling can trismus last

A
  • up to 2 weeks
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12
Q

how can trismus/limited mouth opening be helped

A
  • Gentle mouth opening exercises/wooden spatulae/trismus screw
  • Screw
  • Little cone with spiral screw on it
  • Can gently open bite by turning screw
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13
Q

what causes an immediate post-operative period haemorrhage

A
  • 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
  • Could be warfarin patient or someone on NOAC
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14
Q

what cause secondary bleeding

A
  • Often due to infection
  • Commonly 3-7 days
  • Usually, mild ooze but can occasionally be a major bleed
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15
Q

what type of bleeding comes from what vessels

A
  • Veins = +++bleeding
  • Arteries = spurting/haemorrhage +++ bleeding
  • Arterioles = spurting/pulsating bleed
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16
Q

what causes a dental haemorrhage

A
  • Most bleeds due to local factors – mucoperiosteal tears or fractures of alveolar plate/socket wall
  • Very few bleeds due to undiagnosed clotting abnormalities – haemophilia/VWD
  • Some due to liver disease (alcohol problems) – clotting factors are made in the liver
  • Some due to medication – warfarin/antiplatelet agents/NOACs
  • Aspirin/clopidogrel/apixaban
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17
Q

how can soft tissue bleeding be treated

A
  • Pressure – mechanical  finger/biting on dam gauze swab
  • Sutures
  • LA with adrenaline – vasoconstrictor
  • Diathermy = cauterise/burn vessels – precipitate proteins – form proteinaceous plug in vessel
  • Ligatures/haemostatic forceps (artery clips) for larger vessels
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18
Q

how can bone bleeding be treated

A
  • Pressure (via swab)
  • La on a swab or injected into socket
  • Haemostatic agents = surgical/kaltostat
  • Blunt instrument
  • Bone wax
  • Pack
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19
Q

how can post-op bleeding be managed

A
  • If bleeding severe get pressure on immediately arrest the bleed
  • Calm anxious patient/separate from anxious relatives
  • 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 = haemophiilia/VWB/liver disease
  • Medication = warfarin/combination of aspirin and other antiplatelet drugs (clopidogrel), NOACs
  • Urgent referral/contact haematologist if bleeding disorder
  • If on warfarin get GMP to do INR/urgent hospital referral if bleeding not arrested
  • Get inside mouth/good light and suction
  • Mouth often filled with large jelly-like clot
  • Remove clot
  • Patient may be vomiting if blood has been swallowed
  • Identify where bleeding is coming from
  • Pressure – finger/biting on damp packs
  • LA with vasoconstrictor
  • Haemostatis aids
  • Suture socket – interrupted/horizontal mattress sutures
  • Ligation of vessels/diathermy if available
  • Give patent point of contact if bleeding resumes – you or hospital
  • Review patient
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20
Q

what are some haemostatic aids

A
  • Surgicel (oxidised cellulose – acts as a framework for clot formation), bone wax in socket
  • Gelatin sponge  absorbable/meshwork for clot formation
  • Thrombin liquid and powder
  • Fibrin foam
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21
Q

what will an uncooperative child with a severe bleed need

A
  • GA
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22
Q

what do you need to do if there has been large volumes of blood loss

A
  • hospital admission/A&E
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23
Q

why do you need to be careful using Surgicel in the lower 8 region

A
  • acidic

- can damage IDN

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24
Q

what are some systemic haemostatic aids

A

• Vitamin K  necessary for clotting factor formation
• Anti-fibrinolytics = tranexamic acid
◦ Prevents clot breakdown/stabilises clot – systemic tablets or mouth wash
• Missing blood clotting factors
• Plasma or whole blood

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25
Q

what are post-extraction instructions

A
  • don’t rinse out for several hours = preferably not till next day
  • avoid trauma = hot food, tongue, ifngers
  • avoid excessive physical exercise and alcohol = increase bp
  • advice on bleeding control = biting on gauze with pressure for 30 mins
  • give point of contact if bleeding doesnt stop
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26
Q

what are the prolonged effects of nerve damage

A
  • Nerve damage an be temporary or permanent

* Improvement can occur up to 18-24 months after incident

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27
Q

what are different damages to nerves

A
  • Anaesthesia – numbness
  • Paraesthesia – tingling
  • Dysesthesia – unpleasant sensation/pain
  • Hypoesthesia – reduced sensation
  • Hyperaesthesia – increased/heightened sensation
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28
Q

what are some definitions of nerve damage

A

• Neurapraxia
◦ Contusion of nerve/continuity of epineural sheath and axons maintained
• Axonotmesis
◦ Continuity of axons but not epineural sheath disrupted
• Neurotmesis
◦ Complete loss of nerve continuity/nerve transected

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29
Q

what is a dry socket

A
  • Alveolar/localised osteitis
  • Common
  • Affects 2-3% of all extractions
  • Some say up to 20-35% of lower 8’s
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30
Q

how does a dry socket occur

A

• Normal clot disappears
• Appear to be looking at bare bone/empty socket – partially or completely lost blood clot
• Some say normal clot forms and disappears
◦ Breaks down or has been washed out from vigorous cleaning
• Some say normal clot never formed in the 1st place

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31
Q

wat is the main feature of a dry socket

A
  • Intense pain

* Described as worse than toothache/patient kept awake at night

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32
Q

what are the features of a dry socket

A

• There is no swelling or pus
• Often starts 3-4 days after extraction
◦ If pain is immediately there after LA wore off need to check that there isn’t still part of tooth there or something else is wrong as it is not a dry socket
• Takes 7-14 days to resolve
◦ If a true dry socket
• Localised osteitis
◦ Inflammation affecting lamina dura

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33
Q

what are the symptoms of a dry socket

A
  • Dull aching pain – moderate to severe
  • Usually throbs/can radiate to patient’s ear/often continuous and ca keep patient awake at night
  • The exposed bone is sensitive and is the source of the pain
  • Characteristic smell/bad odour and patient frequently complains of bad taste
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34
Q

what are some predisposing factors of a dry socket

A 
•	Molar more common – risk increase from anterior to posterior 
•	Mandible more common 
◦	Could be because there is only a single blood supply to mandible compared to maxilla which has multiple 
•	Smoking – reduced blood supply 
•	Female
◦	Hormones might have a role to play 
•	Oral contraceptive pull
•	LA with a vasoconstrictor 
•	Less common things:
◦	Could be infection from tooth 
•	Haematogenous bacteria in socket 
◦	Excessive trauma during extraction 
◦	Crushed a lot of bone 
◦	Excessive mouth rinsing post extraction 
◦	Clot washed away 
◦	Family history/previous dry socket
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35
Q

what is the management of a dry socket

A
  • Supportive – reassurance/systemic analgesia
  • LA block
  • Irrigate socket with warm saline
  • Curettage/debridement
  • Antiseptic pack
  • Advise patient on analgesia and hot salty mouthwashes
  • Review patient/change packs and dressings
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36
Q

what’s important about irrigating dry socket

A
  • Wash out food and debris
  • Being warm isn’t so important once patient numbed up
  • Teach patient how to wash out socket themselves
  • Be gentle doing it
  • 2-4 times a day
  • Don’t go too far into socket to disturb healing tissue
37
Q

how do you curette/debride a dry socket

A
  • Encourage bleeding/ne clot formation
  • Some suggest this should not be carried out as it produces more bare bone and removed any remaining clot
  • Rarely done
  • Get a small curette and scrape the pocket and the bone and clean it all out and debride the socket
  • Get rid of material not working and let healing process begin again
  • Some say not to do it as just takes away bone again and process has to start all over again but other say it is good
38
Q

what are antiseptic packs

A 
BIP or Avlogyl 
•	BIP 
◦	Iodine based and is packed into socket 
◦	Not dissolving and need to change them
◦	Suture over it and then see patient a few days later to remove it an change it 
◦	Bismuth subnitrate and iodoform pack 
◦	Comes as a paste or impregnated gauze 
◦	Antiseptic and astringent 
•	Alvogyl 
◦	Little strands 
◦	Take out with tweezers and don’t need to suture it and don’t need to remove it as it will dissolve away 
◦	Mixture of LA and antiseptic

soothe pain/prevent food packing

39
Q

how ling can dry sockets take to heal

A

1-2 weeks

40
Q

why do we not irrigate with chlorohexidine anymore

A
  • can get into bloodstream, and cause anaphylaxis
41
Q

what is sequestrum

A
  • Quite common
  • Not as common as dry socket
  • Prevent healing
  • Usually bits of dead bone
  • Can see white spicules coming through gingivae – patient often thinks you have left a part of the tooth
  • Can also be pieces of amalgam/tooth
  • Delays healing, need to remove
42
Q

how is an infection treated

A
  • radiographs
  • explore
  • consider AB’s
  • remove any bone fragments, bony sequestra, foreign bodies
43
Q

are infections common after a routine extraction

A
  • no

- more common after minor oral surgical procedure

44
Q

what is the difference between OAC and OAF

A
  • acute = OAC

- chronic = OAF

45
Q

what is a OAC/OAF

A
  • Make a communication from the oral cavity into the maxillary sinus at the time of extraction
  • If it doesn’t heal up, epithelium grows into that space and forms and epithelial lined tube/tract from the mouth to the maxillary sinus and that is an OAF
46
Q

how do you diagnose a OAC

A

• Size of tooth
◦ If roots are huge could think that a communication may form
◦ Affect any tooth from the 3 backwards
• Radiographic position of roots in relation to antrum
• Bone at trifurcation of roots
• Bubbling of blood as patient breathes
• Nose holding test – careful as can create an OAF
• Direct vision
• Good light and suction – echo
• Blunt probe – take care not to create an OAF

47
Q

how do you manage acute OAC if small or sinus intact

A

• Encourage clot
• Suture margins
• Antibiotics
◦ Risk of infection as all oral bugs have gone into sinus
• Post-op instructions
• Don’t have to close socket over completely if small – let it heal
• Take up to two wees for it to heal
• Majority of communications heal up really well

48
Q

how do you manage acute OAC if large or lining torn

A

• Close with buccal advancement flap
◦ Full thickness flap of gingivae back and then release underlying periosteal tissue (whitest/grey material, fibrous) with a scalpel and release it
◦ Sometimes have to try a few different areas to get it to released so that you can close the area without tension as if it is closed with tension the OAF will reform
• Antibiotics and nose blowing instructions
◦ Don’t blow nose
◦ Can use steaming method to clear sinuses
• Monitor patient
• Don’t remove stitches before 10 days
◦ Use absorbable or non-absorbable
• If get really bad swelling or sinusitis, then need to come back as could have and infection and need referral

49
Q

how do you manage chronic OAF

A

• Excise sinus tract
◦ Cut out tube of epithelium so it doesn’t reform when we close the area up
• Buccal advancement flap
• Buccal fat pad with buccal advancement flap
◦ Up in cheek there is buccal fat pad
◦ Take a little incision into buccal sulcus to release buccal fat pad
◦ Pull fat pad over and stitch it to palatal mucosa then pull buccal mucosa with buccal advancement flap and then stitch that to the mucosa
◦ Help close an area that is not closing
• Palatal flap
◦ Cut a finger-like projection of tissue from palate and cut if down and rotate the palate and stitch it to the buccal mucosa
• Bone graft/collagen membrane
• Tongue flap – historical/no longer used

50
Q

how do you remove OAF

A

• Cut a mucoperiosteal flap
◦ 3-sided flap with 2 vertical relieving incisions
◦ Bring flap of tissue over socket
• Get tweezers and curette and scrape out all the granulation tissue
• Need to irrigate with warm saline

51
Q

why can’t you use cold saline to clean out OAF

A
  • because although LA has been used around OAF, maxillary sinus is not numb
52
Q

how do you confirm a root in antrum

A
  • radiographically by OPT, occlusal or periapical
53
Q

how do you retrieve root in antrum

A 
•	OAF type approach/through the socket:
◦	Flap design 
◦	Open fenestration with care 
◦	Suction – efficient and narrow bore 
◦	Small curettes 
◦	Irrigation or ribbon gauze 
◦	Feed ribbon gauze into sinus and pull back out 
◦	Close as for OAC
•	Caldwell-Luc approach 
◦	Buccal sulcus 
◦	Lift a flap of gum up and cut rectangular window above alveolus area 
◦	Buccal window 
•	ENT – endoscopic approach 
•	If there is only a tiny bit of root and it is not causing bother, some patients’ opt to leave it in there and just monitor it
54
Q

what is osteomyelitis

A
  • The term means inflammation of the bone marrow
  • Clinically the term implies an infection of the bone
  • Rare
  • Usually, mandible
  • Site of extraction often very tender
  • In deep seated infection may see altered sensation due to pressure on IAN
55
Q

where does osteomyelitis often begin

A
  • medullary cavity involving cancellous bone

- then extends and spreads to cortical bone

56
Q

how does osteomyelitis happen

A
  • 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
  • Compromised blood supply results in soft tissue necrosis
  • Involved area becomes ischaemic and necrotic
  • Bacteria proliferate because normal blood borne defences do not reach the tissue
  • The osteomyelitis spread until arrested by antibiotic and surgical therapy
57
Q

why is osteomyelitis less likely to happen in maxilla

A
  • maxilla has several arterial supplies where as mandible only has 1 so it is more likely to become ischamic and necrotic
58
Q

what are major predisposing factors for osteomyelitis

A
  • odontogenic infections and fracture of mandible
59
Q

in what indivuals is osteomyelitis more likely to occur

A
  • those with compromised host defence
  • diabetes/alcoholism/IV drug use/malnutrition/myeloproliferative disease
  • Leukaemia’s, sickle cell disease, chemotherapy treated cancer
60
Q

when can osteomyelitis be detectable on radiogaph

A
  • 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
61
Q

how does osteomyelitis appear on radiograph

A

• Increased radiolucency
• Can be uniform or patchy with a ‘moth-eaten’ appearance
• Areas of radiolucency may occur within the radiolucent region
◦ Unresorbed islands of bone = called sequestra

62
Q

what is an involucrum

A

• In long-standing chronic osteomyelitis there may be an increase in radiodensity surrounding the radiolucent area

63
Q

what bacteria cause osteomyelitis predominately

A
  • different in different areas of the body
  • in mandible = Streptococci, anaerobic cocci such as peptostreptococcus spp, anaerobic gram negative rods such as Fusobacterium and Prevotella
  • in other bones = staphylococci
64
Q

what is the treatment for osteomyelitis

A
  • Medical and surgical treatment
  • Investigate host defences – blood investigations/glucose
  • Seek medical consultation
  • Antibiotic treatment
  • We will mainly refer these patients rather than treat them
65
Q

what is the antibiotic treatment for osteomyelitis

A
  • Clindamycin/penicillins
  • Effective against odontogenic infections and good bone penetration
  • Longer courses than normal
  • Often 6 weeks in acute osteomyelitis (some suggest at least 6 weeks after resolution of symptoms)
  • In chronic osteomyelitis – can need them up to 6 months after
  • Severe acute osteomyelitis may require hospital admission and IV antibiotics (if systemic symptoms)
66
Q

what is the surgical treatment for osteomyelitis

A
  • Drain pus if possible
  • Remove any non-vital teeth in the area of infection
  • Remove any loose pieces of bone
  • Remove any sources of infection
  • In fractured mandible – remove any wires/plates/screws in the area
  • Corticotomy – removal of bony cortex
  • Remove outer bone
  • Perforation of bony cortex
  • Excision of necrotic bone – until reach actively bleeding bone tissue
  • Some of these patients may need reconstructive surgery at some point
67
Q

what is osteoradionecrosis

A
  • Seen in patients who have received radiotherapy in the head and neck to treat cancer
  • The bony within radiation beam becomes virtually non-vital
  • Turnover of any remaining viable bone is slow
  • Self-repair ineffective
  • Worse with time
  • Mandible most commonly affected  poorer blood supply
68
Q

what is endarteritis

A
  • reduced blood supply

- common in mandible due to only being on one blood supply

69
Q

what is alveoplasty

A
  • cutting down of bone to allow gum to close over completely
70
Q

how can osteoradionecrosis be prevented

A
  • Scaling/chlorohexidine mouthwash leading up to extraction
  • Careful extraction technique
  • Antibiotics, chlorohexidine mouthwash and review
  • Hyperbaric oxygen (to increase local tissue oxygenation and vascular ingrowth to hypoxic areas) before and after extraction
  • Going into chambers like divers do if they have the bends
  • Take advice/refer patient for extraction
  • May wish to give AB’s after but they don’t tend to penetrate well into bone
71
Q

how is osteoradionecrosis treated

A

• Irrigation of necrotic debris
• Antibiotics not overly helpful unless secondary infection
• Loose sequestra removed
• Small wounds (under 1cm) usually heal over a course of weeks/months
• Severe cases – resection of exposed bone, margin of unexposed bone and soft tissue closure
○ May need surgical intervention
• Hyperbaric oxygen

72
Q

what did medication related osteonecrosis of the jaw (MRONJ) used to be called

A
  • BRONJ

- bisphosphonate related osteonecrosis of the jaw

73
Q

what are bisphosphonates

A
  • Bisphosphonates are a class of drugs used to treat osteoporosis, Paget’s disease and malignant bone metastases
  • They inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal
  • The drugs may remain in the body for years
74
Q

when does MRONJ/BRONJ occur

A
  • post extraction/following denture trauma/ spontaneous
75
Q

what type of bisphosphonates causes high risk of BRONJ

A
  • IV
76
Q

what other factors can influence MRONJ/BRONJ

A
  • length of time patient on drug
  • diabetes
  • steroids
  • anticancer chemotherapy
  • smoking
77
Q

what can be done instead of an extraction for patients on bisphosphates

A
  • could decorate the tooth rather than extract

- seal over roots

78
Q

what is the treatment for MRONJ/BRONJ

A
  • Not very successful
  • Manage symptoms/remove sharp edges of bone/chlorohexidine mouthwash/antibiotics if suppuration
  • Debridement/major surgical sequestrectomy/resection/hyperbaric oxygen have not proved that successful
  • Not routine AB’s – only when there is pus
  • Every time we intervene we are at risk of making it worse or better
  • Patient needs to know that
  • Sometimes need major surgery
79
Q

what are some examples of bisphosphonates

A
  • alendronate
  • clodronate
  • etidtronate
  • ibandronate
  • pamidronate
  • risedronate
  • tiludronate
  • zoledronate
80
Q

what other medication can cause MRONJ

A
  • any biological agent, immune modulator, antiresorption, antiangiogenic medication
81
Q

what is the incidence of MRONJ

A
  • cancer patients on anti-resorptive and anti-angiogenic drugs = 1.6-14.8%
  • osteoporosis patients treated with anti-resorptive drugs = 0.1-0.5%
82
Q

what types of drugs are associated with MRONJ

A
  • bisphosphonates
  • RNAKL inhibitor
  • anti-angiogenic
83
Q

what are the risk factors for MRONJ

A
  • dental treatments = extractions, perio
  • duration of drug therapy
  • dental implants
  • other concurrent medications
  • previous drug history
  • drug holidays = we should not take responsibility for stopping a patient’s drug
84
Q

what is actinomycosis

A
  • Rare bacterial infection
  • Actinomycosis israelii/A. naeslundii/A. viscosus
  • The bacteria have low virulence and must be inoculated into an area of injury or susceptibility
  • It erodes through tissues rather than follow typical fascial planes and spaces
  • Fairly chronic
  • Multiple skin sinuses and swelling
85
Q

how can you treat actinomycosis

A

• Incision and drainage of pus accumulation
• Excision of chronic sinus tracts
• Excision of necrotic bone and foreign bodies
• High dose antibiotics for initial control (often IV)
• Long-term oral AB’s to prevent recurrence
• AB’s  penicillin, doxycycline or clindamycin
◦ Weeks or months of it

86
Q

what is infective endocarditis

A
  • Inflammation of the endocardium, particularly affected heart valves or CMP caused by bacteria
  • Rare – 10:100,000 per annum
  • Significant mortality  20%
87
Q

what is the guidance on infective endocarditis

A

in 2016 NICE changed the guidelines again and added in one word
• “Antibiotic prophylaxis against IE is not recommended routinely for those undergoing dental procedures”
• They defined group at risk as
• Acquired valvular heart disease
• Previous IE
• Structural congenital heart defect
• Valve replacement

88
Q

what is prescribed for IE

A
  • amoxicillin is first choice
    ◦ 3g oral sachet 60 minutes before procedures
  • clindamycin if allergic to penicillin
    ◦600 mg (2 capsules) 60 minutes before procedure
  • if unable to swallow give azithromycin oral suspicions
    ◦500mg (12.5ml) 60 minutes before procedure

BDS3 - Oral Surgery (7 decks)

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