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Oral Surgery > Post Extraction Complications > Flashcards

Post Extraction Complications Flashcards

1
Q

What are some post operative complications that can occur?

A
  • 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
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2
Q

What are some less common post-extraction complications that can occur?

A
  • Osteomyelitis
  • Osteoradionecrosis
  • Medication induced osteonecrosis
  • Actinomycosis
  • Bacteraemia/Infective endocarditis – note current guidance
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3
Q

What is the most common post-op complication?

A

Pain

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4
Q

What would you tell/advise the patient about post op pain?

A
  • 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

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5
Q

What things during the extraction might make the pain worse post operatively?

A

•Rough handling of tissues – more pain

  • laceration/tearing of soft tissues
  • exposed bone
  • incomplete extraction of tooth
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6
Q

Describe post-op swelling and how you would tell if it was normal or a possible infection.

A
  • 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
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7
Q

Why do you want to reassure the patient and tell them of all the common post op complications?

A

Becuase if the patient is well informed and knows what to expect then a lot less likely to come back to you

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8
Q

Post operative swelling can be increased due to what?

A

Poor surgical technique:

  • rough handling of tissues
  • pulling flaps
  • crushing lip with forceps
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9
Q

What is ecchymosis and what increases it?

A

brusising

-rough handling of tissues/poor surgical technique

(try let the brusing be because of the procedure and not our rough handling)

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10
Q

Why might a patient have jaw stiffness/limited mouth opening after a procedure?

A
  • 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
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11
Q

What is trismus?

A

Limited mouth opening to to muscle spasm

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12
Q

How would you manage limited mouth opening?

A
  • monitor it - may take several weeks to resolve
  • gentle mouth opening exercises/wooden spatulae/trismus screw
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13
Q

If there is a haemotoma in a muscle, how would you manage it?

A
  • monitor as will take a few weeks to clear up
  • if it isnt settling then refer the patient to oral surgery
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14
Q

Haemorrhages can happen at 3 different times. What are these?

A
  • intra-operatively
  • immediate post-op period
  • secondary bleeing
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15
Q

Describe immediate post operative bleeding and why it might happen.

A
  • 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
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16
Q

What is secondary bleeding often due to, when does it tend to occur and what is it normally like?

A
  • 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)

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17
Q

If a patient comes in with a post-operative bleed/haemorhage, what are the first things you would do?

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

Note: remove the patient from the waiting room as other patients will not like to see this

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18
Q

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?

A
  • 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
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19
Q

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.

A
  • 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
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20
Q

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)

A
  • 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
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21
Q

After dealing with post-op bleeding, what would you do?

A
  • give patient point of contact if bleeding resumes (you or hospital)
  • review the patient
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22
Q

If an unco-operative child comes in with post-op bleeding, what might you have to do?

A

Send to kids hospital for emergency GA

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23
Q

When might you want to refer your patient to the hosptial? (apart from kids)

A
  • if you cant arrest the haemorrhage
  • extremes of age
  • medical problems
  • large volume of blood loss

NOTE: an uncontrolled haemorrhage is life-threatening

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24
Q

What are some local haemostatic agents that can aid you in dealing with post-operative haemorrhages?

A
  • 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
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25
Q

What are some systemic haemostatic aids?

A
  • 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
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26
Q

How can you help prevent intra-operative and post-operative extraction haemorrhages?

A
  • 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
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27
Q

What are the basic post-extraction instructions?

A
  • 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

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28
Q

What advice would you give a patient for bleeding control?

A
  • Biting on damp gauze/tissue
  • Pressure for at least 30min (longer if bleeding continues)
  • Points of contact if bleeding continues
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29
Q

In what time frame can nerve damage improve?

A

improvement can occur up to 18-24months but after this little chance of further improvemet

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30
Q

What happens in a dry socket/common features?

A
  • 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)
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31
Q

When does dry socket tend to start and how long does it take to resolve?

A
  • often starts 3-4 days after extraction
  • Takes 7-14 days to resolve
32
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 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
33
Q

Is dry socket associated with infection?

A

No- it is delayed healing but not associated with infection

34
Q

What are some predisposing factors for a dry socket?

A
  • 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)
35
Q

How would you reassure a patient who has a dry socket/why do they sometimes think its sore?

A

They often think youve extracted the wrong tooth and its another tooth that is causing the pain

reassure them and give systemic analgesia

36
Q

Describe how you would manage a dry socket.

A
  • suppotive (reassure and analagesi)
  • LA block
  • irrigate socker with warm saline (wash out food and debris)
  • curettage/debridement to encourge bleeding
  • antiseptic pack
37
Q

What antiseptic packs are there to be used for a dry socket? Describe them and their function.

A
  • 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
38
Q

Once you have dealt with the dry socket initially, what would you do to follow it up?

A
  • 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

39
Q

What should you remember to check inititally before determining if it is a dry socker?

A

-check that there are no tooth fragments left or bont sequestra

40
Q

What are sequestrum and why do we need to keep an eye out for them?

A

They are usually dead bits of bone

Are quite common after an extraction and need to be removed as they prevent healing

41
Q

What would a sequestrum look like?

A

Can see white spicules coming through the gingivae (patient often thinks youve left a part of the tooth behind)

42
Q

How do you remove sequestrum?

A

Can often wiggle it through the gum but may need to open the gum again and suture

43
Q

Is an infected socket or dry socket more common after a routine dental extraction?

A

Dry sockets

Infected socket is rare but can be seen

44
Q

When are infected sockets more common and what might you see?

A

Are more commonly seen after minor surgical procedures involving soft tissue flaps and bone removal

Might see an infected socket with pus discharge

45
Q

How would you manage an infected socket?

A

-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

46
Q

How would you manage a chronic oral antral fistula?

A
  • 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
47
Q

What does the term osteomyelitis mean?

A

Means inflammation of the bone but clinically implies an infection of the bone

It is rare

48
Q

How might a patient present with osteomyelitis?

A
  • 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)
49
Q

In what jaw is osteomyelitis more common and why?

A

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

50
Q

Where does osteomyelitis tend to start from and how does it spread?

A
  • 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)
51
Q

Describe how the bacteria and infection works in osteomyelitis.

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 – 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
52
Q

Osteomyelitis is a rare complication. What are the factors that tend to make osteomyelitis more likely?

A
  • 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
53
Q

Why is early osteomyelitis difficult to distinguid from a dry socket or localised infection in the socket?

A

•Acute suppurative osteomyelitis shows little/no radiographic change (at least 10-12 days required for lost bone to be detectable radiographically)

54
Q

How will chronic osteomyelitis appear clinically and radiographically?

A
  • Chronic osteomyelitis – (+/- pus) – bony destruction in the area of infection
  • Radiographic appearance – increased radiolucency (uniform or patchy with a ‘moth-eaten appearance)
55
Q

Apart from the radiolucent lesion, what else might be seen radiographically with osteomyeltitis?

A
  • 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
56
Q

What is the difference between ostromyelitis in the mandible and osteomyelitis elsewhere in the body?

A
  • 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
57
Q

How is osteomyelitis treated?

A
  • 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
58
Q

What is the antibiotic treatment for osteomyelitis including duration and treatment for severe, acute osteomyelitis?

A
  • 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)
59
Q

Describe the surgical treatment someone would get for osteomyelitis.

A
  • 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)
60
Q

What is osteoradionecrosis and how does it develop, what happens?

A
  • 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
61
Q

Does osteoradionecrosis get better or worse with time?

A

Worse - can get it 20 years after radiation treament

62
Q

What jaw is most commonly affected by osteoradionecrosis and why would you want to try and prevent extractions?

A

mandible

dont want to fracture it if thin, healing won’t be great

63
Q

What are some treatment option for osteoradionecrosis?

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

•

•Hyperbaric oxygen

64
Q

What is MRONJ?

A

Medication related osteonecrosis of the jaw

-

65
Q

What group of drugs are important for MRONJ? What are they used to treat and how is this related to MRONJ?

A

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
66
Q

When does MRONJ normally happen?

A

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

67
Q

How does the way the patient has their bisphosphonate alter their risk?

A

Patients recieving IV bisphonsphonates are at higher risk

68
Q

MRONJ can range from what to what?

A

•Ranges from small asymptomatic areas of exposed bone to extensive bone exposure/dehiscence/pus/pain

69
Q

What treatment should you avoid if possible with patients with MRONJ/on bisphosphonates?

A

Extraction

If required, careful technique & monitor patient/warn patient to look for signs

Take advice/refer

70
Q

How is MRONJ treated/managed?

A
  • 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)
71
Q

What is actinomycosis?

A
  • Rare bacterial infection
  • Actinomyces israelii/ A. naeslundii/ A. viscosus
72
Q

When might actinomycosis occor?

A
  • 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
73
Q

The bacteria in actinomycosis can do what?

A

errode through tissies rather than follow typical fascial planes and spaces

74
Q

What might you see in a patient with actinomycosis?

A
  • Multiple skin sinuses and swelling
  • Thick lumpy pus – colonies of Actinomyces look like sulphur granules on histology
75
Q

Is actinomycosis acute or chronic?

A
  • Fairly chronic
  • responds initially to antibiotic therapy then recurs when antibiotics stop
76
Q

How is actinomycosis treated?

A

•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

Oral Surgery (9 decks)

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