Post Extraction Complications Flashcards
What are some post operative complications that can occur?
- Pain/Swelling/Ecchymosis
- Trismus/ Limited mouth opening
- Haemorrhage
- Prolonged effects of nerve damage
- Dry Socket (alveolar/localised osteitis)
- Sequestrum
- Infected Socket
- Chronic OAF/root in antrum
What are some less common post-extraction complications that can occur?
- Osteomyelitis
- Osteoradionecrosis
- Medication induced osteonecrosis
- Actinomycosis
- Bacteraemia/Infective endocarditis – note current guidance
What is the most common post-op complication?
Pain
What would you tell/advise the patient about post op pain?
- that its normal and to be expected (warn the patient)
- advise about analgesia and how to take them
Note: if warn the patient they are less likely to come back
What things during the extraction might make the pain worse post operatively?
•Rough handling of tissues – more pain
- laceration/tearing of soft tissues
- exposed bone
- incomplete extraction of tooth
Describe post-op swelling and how you would tell if it was normal or a possible infection.
- swelling varies amoung patient but tends to go up for 48 hours then goes down (swells straight after procedure)
- if the swelling doesn’t start til day 2 or 3 then it could be an infection
Why do you want to reassure the patient and tell them of all the common post op complications?
Becuase if the patient is well informed and knows what to expect then a lot less likely to come back to you
Post operative swelling can be increased due to what?
Poor surgical technique:
- rough handling of tissues
- pulling flaps
- crushing lip with forceps
What is ecchymosis and what increases it?
brusising
-rough handling of tissues/poor surgical technique
(try let the brusing be because of the procedure and not our rough handling)
Why might a patient have jaw stiffness/limited mouth opening after a procedure?
- related to surgery (oedema/muscle spasm - mouth open for a long time causing the oedma)
- related to giving LA – IDB (muscle (medial pterygoid) - haematoma/spasm - needle go into muscle and get blood)
- bleed into muscle (haematoma) – medial pterygoid/
- masseter (haematoma/clot organises and fibroses)
- damage to TMJ – oedema/joint effusion
What is trismus?
Limited mouth opening to to muscle spasm
How would you manage limited mouth opening?
- monitor it - may take several weeks to resolve
- gentle mouth opening exercises/wooden spatulae/trismus screw
If there is a haemotoma in a muscle, how would you manage it?
- monitor as will take a few weeks to clear up
- if it isnt settling then refer the patient to oral surgery
Haemorrhages can happen at 3 different times. What are these?
- intra-operatively
- immediate post-op period
- secondary bleeing
Describe immediate post operative bleeding and why it might happen.
- reactionary/rebound
- occurs within 48 hours of extraction
Can happen because:
- vessels open up/vasoconstricting effects of LA wear off
- sutures loose or lost
- patient traumatises area with tongue/finger/food
What is secondary bleeding often due to, when does it tend to occur and what is it normally like?
- often due to infection
- commonly occurs between days 3 and 7
- usually a mild ooze but occasionally be a major bleed
(is rarely due to warfarin but INR can go up and down and can get bleeding)
If a patient comes in with a post-operative bleed/haemorhage, what are the first things you would do?
- 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
Note: remove the patient from the waiting room as other patients will not like to see this
When thinking about taking a thorough but rapid medical history when dealing with post-operative bleeding, what do you need to think about and what would you do if you found something out you didnt previously know?
- Must rule out bleeding disorder – haemophilia/ von Willebrands/Liver Disease
- Medication – Warfarin/ Combination of Aspirin and other antiplatelet drugs (e.g. Clopidogrel), NOACs.
- Urgent referral/contact haematologist if bleeding disorder. If on Warfarin get GMP to do INR/urgent hospital referral if bleeding not arrested
What might you see when you look inside a patient’s mouth who has come back with post-operative bleeding? Describe it and what you would do with it.
- There is often a large jelly-like clot
- This clot is just an unsuccessful clot and is doing the patient no good.
- You want to remove the clot from the socket, clean the area and follow through with the normal post-op bleeding management
What are the steps in dealing with post-operative bleeding? (assumming jelly-like clot has been removed and no relavent medical history cause of the bleeding)
- Pressure – finger/biting on damp packs
- Local anaesthetic with vasoconstrictor
- 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
After dealing with post-op bleeding, what would you do?
- give patient point of contact if bleeding resumes (you or hospital)
- review the patient
If an unco-operative child comes in with post-op bleeding, what might you have to do?
Send to kids hospital for emergency GA
When might you want to refer your patient to the hosptial? (apart from kids)
- if you cant arrest the haemorrhage
- extremes of age
- medical problems
- large volume of blood loss
NOTE: an uncontrolled haemorrhage is life-threatening
What are some local haemostatic agents that can aid you in dealing with post-operative haemorrhages?
- 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
What are some 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
How can you help prevent intra-operative and post-operative extraction haemorrhages?
- 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
What are the basic post-extraction instructions?
- 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 bleeding control
What advice would you give a patient for bleeding control?
- Biting on damp gauze/tissue
- Pressure for at least 30min (longer if bleeding continues)
- Points of contact if bleeding continues
In what time frame can nerve damage improve?
improvement can occur up to 18-24months but after this little chance of further improvemet
What happens in a dry socket/common features?
- the normal clot disappears (will be looking at bare bone/empty socket - can be partially or complete loss of blood clot)
- INTENSE pain is a main feature
- Localised osteitis (inflammation affecting lamina dura)
When does dry socket tend to start and how long does it take to resolve?
- often starts 3-4 days after extraction
- Takes 7-14 days to resolve
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 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
Is dry socket associated with infection?
No- it is delayed healing but not associated with infection
What are some predisposing factors for a dry socket?
- molars (lower and the further back = higher risk)
- smoking - reduced blood flow
- females
- oral contraceptive pill
- LA with vasoconstrictor
- excessive mouth rinsing post extraction (Wash clot away)
How would you reassure a patient who has a dry socket/why do they sometimes think its sore?
They often think youve extracted the wrong tooth and its another tooth that is causing the pain
reassure them and give systemic analgesia
Describe how you would manage a dry socket.
- suppotive (reassure and analagesi)
- LA block
- irrigate socker with warm saline (wash out food and debris)
- curettage/debridement to encourge bleeding
- antiseptic pack
What antiseptic packs are there to be used for a dry socket? Describe them and their function.
- BIP – Bismuth subnitrate and Iodoform Pack. Comes as a paste or impregnated gauze. Antiseptic and Astringent.
- Alvogyl – mixture of LA and antiseptic
- Soothe pain/prevent food packing
Once you have dealt with the dry socket initially, what would you do to follow it up?
- Advise patient on Analgesia and hot salty mouthwashes
- Review patient/change packs and dressings (as soon as pain resolves get packs out to allow healing)
NOTE: DONT prescribe antibiotics as not infection
What should you remember to check inititally before determining if it is a dry socker?
-check that there are no tooth fragments left or bont sequestra
What are sequestrum and why do we need to keep an eye out for them?
They are usually dead bits of bone
Are quite common after an extraction and need to be removed as they prevent healing
What would a sequestrum look like?
Can see white spicules coming through the gingivae (patient often thinks youve left a part of the tooth behind)
How do you remove sequestrum?
Can often wiggle it through the gum but may need to open the gum again and suture
Is an infected socket or dry socket more common after a routine dental extraction?
Dry sockets
Infected socket is rare but can be seen
When are infected sockets more common and what might you see?
Are more commonly seen after minor surgical procedures involving soft tissue flaps and bone removal
Might see an infected socket with pus discharge
How would you manage an infected socket?
-Check for remianing tooth/root fragments/bony sequestra/foreign bodies
Treatment - radiographs and irrigate/remove any of the above
Consider antibiotics if there is a big abscess and if there is a chance that the patient is systemically unwell
NOTE: the bone is not infected here, just the socket
Infection delays healing
How would you manage a chronic oral antral fistula?
- Excise sinus tract (get rid of tube of tissue in the communication so it heals properly)
- Buccal Advancement Flap
- Buccal Fat Pad with Buccal Advancement Flap
- Palatal Flap
- Bone Graft/Collagen Membrane
What does the term osteomyelitis mean?
Means inflammation of the bone but clinically implies an infection of the bone
It is rare
How might a patient present with osteomyelitis?
- P often systemically unwell
- Site of extraction very tender
- in a deep seated infection in the mandible may also see altered sensation due to pressure on IAN (might say lip is numb or tingly)
In what jaw is osteomyelitis more common and why?
The mandible as its primary blood supply is the inferior alveolar artery (only one main artery supplying it)
The maxilla has a rich bloody supply
The poorer blood supply of the mandible makes it more susceptible
Where does osteomyelitis tend to start from and how does it spread?
- 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)
Describe how the bacteria and infection works in osteomyelitis.
- 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
- The osteomyelitis spreads until arrested by antibiotic and surgical therapy
Osteomyelitis is a rare complication. What are the factors that tend to make osteomyelitis more likely?
- Normally have major predisposing factors
- Odontogenic infections
- Fractures of the mandible
- Also have a compromised host defence on top of this
- Diabetes
- Alcoholism
- IV drug use
- Malnutrition
- Chemotherapy, cancer etc
Why is early osteomyelitis difficult to distinguid from a 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 will chronic osteomyelitis appear clinically and radiographically?
- Chronic osteomyelitis – (+/- pus) – bony destruction in the area of infection
- Radiographic appearance – increased radiolucency (uniform or patchy with a ‘moth-eaten appearance)
Apart from the radiolucent lesion, what else might be seen radiographically with osteomyeltitis?
- 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. It happens as a result of the inflammatory reaction (bone made around the area)
- This is the result of an inflammatory reaction – bone production increased
What is the difference between ostromyelitis in the mandible and osteomyelitis elsewhere in the body?
- In the mandible, th main bacteria involved are similar to those involved in odontogenic infections (streptococci,anaerobic cocci such as peptostreptococcus spp, anaerobic gram negative rods such as Fusobacterium & Prevotella)
- In other bones – staphylococci predominate
How is osteomyelitis treated?
- both medical (antibiotics) and surgical treatment
- Would want GP/medic to check bloods to investigate host defences to make sure youre not missing an underlying cause
What is the antibiotic treatment for osteomyelitis including duration and treatment for severe, acute 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)
- Severe acute osteomyelitis may require hospital admission and IV antibiotics (if systemic symptoms)
Describe the surgical treatment someone would get for osteomyelitis.
- Drain pus if possible
- Remove any non-vital teeth in the area of infection
- Remove any loose pieces of bone
- 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)
What is osteoradionecrosis and how does it develop, what happens?
- Seen in patients who have received radiotherapy of the head & neck to treat cancer
- The bone within radiation beam becomes virtually non-vital
- Endarteritis – reduced blood supply
- Turnover of any remaining viable bone is slow
- Self-repair ineffective
Does osteoradionecrosis get better or worse with time?
Worse - can get it 20 years after radiation treament
What jaw is most commonly affected by osteoradionecrosis and why would you want to try and prevent extractions?
mandible
dont want to fracture it if thin, healing won’t be great
What are some treatment option for osteoradionecrosis?
•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
•
•Hyperbaric oxygen
What is MRONJ?
Medication related osteonecrosis of the jaw
-
What group of drugs are important for MRONJ? What are they used to treat and how is this related to MRONJ?
Bisphosphonates
- used to treat osteoporosis, Paget’s disease and malignant bone metastases
- •They inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal (not good for healing)
- The drugs may remain in the body for years
When does MRONJ normally happen?
Occurs post extraction/following denture trauma or can be spontaneous
NOTE: MRONJ is exclusive to the jaws and occurs at the same rate in the maxilla and mandible
How does the way the patient has their bisphosphonate alter their risk?
Patients recieving IV bisphonsphonates are at higher risk
MRONJ can range from what to what?
•Ranges from small asymptomatic areas of exposed bone to extensive bone exposure/dehiscence/pus/pain
What treatment should you avoid if possible with patients with MRONJ/on bisphosphonates?
Extraction
If required, careful technique & monitor patient/warn patient to look for signs
Take advice/refer
How is MRONJ treated/managed?
- Treatment is 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 (can work sometimes but might also make it worse)
What is actinomycosis?
- Rare bacterial infection
- Actinomyces israelii/ A. naeslundii/ A. viscosus
When might actinomycosis occor?
- The bacteria have low virulence and must be inoculated into an area of injury or susceptibility
- E.g. recent extraction/severely carious teeth/bone fracture/minor oral trauma
The bacteria in actinomycosis can do what?
errode through tissies rather than follow typical fascial planes and spaces
What might you see in a patient with actinomycosis?
- Multiple skin sinuses and swelling
- Thick lumpy pus – colonies of Actinomyces look like sulphur granules on histology
Is actinomycosis acute or chronic?
- Fairly chronic
- responds initially to antibiotic therapy then recurs when antibiotics stop
How is actinomycosis treated?
•I&D of pus accumulation (incision and drainage)
•
•Excision of chronic sinus tracts
•
•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
