post extraction complications Flashcards
what are some common post-operative complications
- 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
what are some less common post-operative complications
- Osteomyelitis
- Osteoradionecrosis
- Medication induced osteonecrosis
- Actinomycosis
- Bacteraemia/infective endocarditis
what s the most common complication
- pain
what can enhance pain
- rough handling of tissues
• Laceration/tearing of soft tissues
• Exposed bone
• Incomplete extraction of tooth
what is swelling/oedema
- • Part of inflammatory reaction to surgical interference
what can increase swelling/oedema
- Increased by poor surgical technique
* E.g., rough handling of soft tissue/pulling flaps/crushing lip with forceps
how can you tell if swelling is infection or not
- 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
what is ecchymosis
- bruising
what is trismus
• Trismus is limited mouth opening due to muscle spasm
what can cause trismus/limited mouth opening
- 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
how ling can trismus last
- up to 2 weeks
how can trismus/limited mouth opening be helped
- Gentle mouth opening exercises/wooden spatulae/trismus screw
- Screw
- Little cone with spiral screw on it
- Can gently open bite by turning screw
what causes an immediate post-operative period haemorrhage
- 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
what cause secondary bleeding
- Often due to infection
- Commonly 3-7 days
- Usually, mild ooze but can occasionally be a major bleed
what type of bleeding comes from what vessels
- Veins = +++bleeding
- Arteries = spurting/haemorrhage +++ bleeding
- Arterioles = spurting/pulsating bleed
what causes a dental haemorrhage
- 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
how can soft tissue bleeding be treated
- 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
how can bone bleeding be treated
- Pressure (via swab)
- La on a swab or injected into socket
- Haemostatic agents = surgical/kaltostat
- Blunt instrument
- Bone wax
- Pack
how can post-op bleeding be managed
- 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
what are some haemostatic aids
- 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
what will an uncooperative child with a severe bleed need
- GA
what do you need to do if there has been large volumes of blood loss
- hospital admission/A&E
why do you need to be careful using Surgicel in the lower 8 region
- acidic
- can damage IDN
what are some systemic haemostatic aids
• 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
what are post-extraction instructions
- 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
what are the prolonged effects of nerve damage
- Nerve damage an be temporary or permanent
* Improvement can occur up to 18-24 months after incident
what are different damages to nerves
- Anaesthesia – numbness
- Paraesthesia – tingling
- Dysesthesia – unpleasant sensation/pain
- Hypoesthesia – reduced sensation
- Hyperaesthesia – increased/heightened sensation
what are some definitions of nerve damage
• 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
what is a dry socket
- Alveolar/localised osteitis
- Common
- Affects 2-3% of all extractions
- Some say up to 20-35% of lower 8’s
how does a dry socket occur
• 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
wat is the main feature of a dry socket
- Intense pain
* Described as worse than toothache/patient kept awake at night
what are the features of a dry socket
• 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
what are the symptoms of a dry socket
- 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
what are some predisposing factors of a dry socket
• 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
what is the management of a dry socket
- 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
what’s important about irrigating dry socket
- 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
how do you curette/debride a dry socket
- 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
what are antiseptic packs
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
how ling can dry sockets take to heal
1-2 weeks
why do we not irrigate with chlorohexidine anymore
- can get into bloodstream, and cause anaphylaxis
what is sequestrum
- 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
how is an infection treated
- radiographs
- explore
- consider AB’s
- remove any bone fragments, bony sequestra, foreign bodies
are infections common after a routine extraction
- no
- more common after minor oral surgical procedure
what is the difference between OAC and OAF
- acute = OAC
- chronic = OAF
what is a OAC/OAF
- 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
how do you diagnose a OAC
• 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
how do you manage acute OAC if small or sinus intact
• 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
how do you manage acute OAC if large or lining torn
• 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
how do you manage chronic OAF
• 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
how do you remove OAF
• 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
why can’t you use cold saline to clean out OAF
- because although LA has been used around OAF, maxillary sinus is not numb
how do you confirm a root in antrum
- radiographically by OPT, occlusal or periapical
how do you retrieve root in antrum
• 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
what is osteomyelitis
- 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
where does osteomyelitis often begin
- medullary cavity involving cancellous bone
- then extends and spreads to cortical bone
how does osteomyelitis happen
- 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
why is osteomyelitis less likely to happen in maxilla
- maxilla has several arterial supplies where as mandible only has 1 so it is more likely to become ischamic and necrotic
what are major predisposing factors for osteomyelitis
- odontogenic infections and fracture of mandible
in what indivuals is osteomyelitis more likely to occur
- those with compromised host defence
- diabetes/alcoholism/IV drug use/malnutrition/myeloproliferative disease
- Leukaemia’s, sickle cell disease, chemotherapy treated cancer
when can osteomyelitis be detectable on radiogaph
- 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
how does osteomyelitis appear on radiograph
• 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
what is an involucrum
• In long-standing chronic osteomyelitis there may be an increase in radiodensity surrounding the radiolucent area
what bacteria cause osteomyelitis predominately
- 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
what is the treatment for osteomyelitis
- 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
what is the antibiotic treatment for osteomyelitis
- 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)
what is the surgical treatment for osteomyelitis
- 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
what is osteoradionecrosis
- 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
what is endarteritis
- reduced blood supply
- common in mandible due to only being on one blood supply
what is alveoplasty
- cutting down of bone to allow gum to close over completely
how can osteoradionecrosis be prevented
- 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
how is osteoradionecrosis treated
• 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
what did medication related osteonecrosis of the jaw (MRONJ) used to be called
- BRONJ
- bisphosphonate related osteonecrosis of the jaw
what are bisphosphonates
- 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
when does MRONJ/BRONJ occur
- post extraction/following denture trauma/ spontaneous
what type of bisphosphonates causes high risk of BRONJ
- IV
what other factors can influence MRONJ/BRONJ
- length of time patient on drug
- diabetes
- steroids
- anticancer chemotherapy
- smoking
what can be done instead of an extraction for patients on bisphosphates
- could decorate the tooth rather than extract
- seal over roots
what is the treatment for MRONJ/BRONJ
- 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
what are some examples of bisphosphonates
- alendronate
- clodronate
- etidtronate
- ibandronate
- pamidronate
- risedronate
- tiludronate
- zoledronate
what other medication can cause MRONJ
- any biological agent, immune modulator, antiresorption, antiangiogenic medication
what is the incidence of MRONJ
- cancer patients on anti-resorptive and anti-angiogenic drugs = 1.6-14.8%
- osteoporosis patients treated with anti-resorptive drugs = 0.1-0.5%
what types of drugs are associated with MRONJ
- bisphosphonates
- RNAKL inhibitor
- anti-angiogenic
what are the risk factors for MRONJ
- 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
what is actinomycosis
- 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
how can you treat actinomycosis
• 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
what is infective endocarditis
- Inflammation of the endocardium, particularly affected heart valves or CMP caused by bacteria
- Rare – 10:100,000 per annum
- Significant mortality 20%
what is the guidance on infective endocarditis
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
what is prescribed for IE
- 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
