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BDS3 CLINICAL Oral Surgery > Post-extraction complications > Flashcards

Post-extraction complications Flashcards

1
Q

What can post operative extractions be split into

A

immediate
short term
long term

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2
Q

What are post operative extraction complications

A 
pain/swelling/ecchymosis
trismus/limited mouth opening
haemorrhage
prolonged effects of nerve damage
dry socket
sequestrum
infected socket
chronic OAF/root in antrum
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3
Q

What are less common post-op complications

A 
osteomyelitis
osteoradionecrosis
medication induced osteonecrosis
actinomycosis
bacteriaemia/infective endocarditis
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4
Q

What is the most common complication of extraction

A

pain

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5
Q

What should you advise patients on pain

A

warn them

prescribe analgesia

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6
Q

What can we do to try and minimise pain during operation

A

minimise rough handling of tissues as this causes more pain

avoid laceration/teraing of soft tissues, exposed bone and incomplete extraction of tooth

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7
Q

What is oedema

A

part of the inflammatory reaction to surgical interference

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8
Q

What can increase edema

A

increased by poor surgical technique such as rough handling of soft tissue, pulling flaps, crushing lips with forceps

wide individual variation

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9
Q

What can result in ecchymosis

A

rough handling of tissues/poor surgical technique

individual variation

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10
Q

What is trismus

A

jaw stiffness/inability to open mouth fully

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11
Q

What are the variety of causes of trismus

A

related to surgery (edema/muscle spasm)
related to giving LA (IDB hitting MP)
bleeding into muscle (hematoma of MP or masseter)
damage to TMJ - edema/joint effusion

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12
Q

What should be done for trismus

A

monitor - may take several weeks to resolve

gentle mouth opening exercises can be used

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13
Q

What makes trismus different from limited mouth opening

A

its due to muscle spasm

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14
Q

What is immediate post operative bleeding due to

A

reactionary/rebound
occurs within 48h of extraction
vessels open up/vasoconstricting effect of LA wear off
sutures loosen or get lost
patient traumatizes area with tongue/finger/food

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15
Q

When does secondary bleeding occur

A

commonly 3-7 days

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16
Q

What is secondary bleeding often due to

A

infection

usually a mild ooze but can occasionally be a major bleed

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17
Q

What are most dental bleeds due to

A

local facors e.g mucoperiosteal tears
very few due to undiagnosed clotting abnormalities
sometimes due to liver disease
sometimes due to medications

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18
Q

What is the management options for bleeding of soft tissue

A 
pressure
suture
LA with adrenaline
diathermy
ligatures/haemostatic forceps (artery clips) for large vessels
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19
Q

What is the management options for bleeding of bone

A 
pressure
LA on swab or injecte dint socket
hemostatic agent 
blunt instument
bone wax
pack
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20
Q

If the bleeding is severe what can be done

A

get pressure immediately and arrest
calm patient
clean patient up
take a thorough but rapid history while dealing
rule out bleeding disorder and medicaiton
urgent referral if there is bleeding disorder and if on warfarin get referral for INR

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21
Q

What is management of post operative bleeding

A

get inside mouth with good light and suction
remove the clot
patient may be vomtiign if blood swallowed
identify where bleeding from

then:
pressure,
LA with VC
hemostatic aids to act as framework for clot formation
suture socket - interrupted horizontal mattress sutures
ligation of vessels/diathermy if available
gie px contact if bleeding resumes

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22
Q

What do you do if you cannot arrest the hemorrhage

A

urgent hospital referral

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23
Q

What are local hemostatic agents

A 
adrenaline containing LA
oxidized regenerated cellulose which is a framework for clot formation
gelatin sponge
thrombin liquid and powder
fibrin foam
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24
Q

Why should you be careful with oxidized regenerated cellulose in lower 8 region

A

acidic and can cause damage to IDN

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25
Q

What are systemic hemostatic aids

A

vitamin K
anti-fibrinolytic e.g tranexamic acid
missing blood clotting factors
plasma or whole blood

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26
Q

How can we prevent intra operative and post operative extraction hemorrhage

A

through medical history/anticipate and deal with potential problems
atraumatic extraction/surgical technique
obtain and check for good haemostasis at end of surgery
provide good instructions to the patient

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27
Q

What are the post extraction instructions

A 
do not rinse out for several hours
avoid trauma
avoid hot food that day
avoid excessive physical exercise and alcohol 
advice on control of bleeding
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28
Q

Why should the px avoid rinsing their mouth

A

as it will wash the clot away

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29
Q

How should the px avoid trauma

A

do not explore the socket with their tongue or fingers/hard food

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30
Q

Why should the px avoid excessive physical exercise/alcohol

A

will increase BP

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31
Q

What is the advice on control of bleeding we give to the patient

A

biting on damp gauze / tissue
pressure for at least 30 min (longer if bleeding continues)
points of contact if bleeding continues

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32
Q

What is the prolonged effect of nerve damage

A

already discussed
nerve damage can be temporary or permanent
improvement can occur up to 18 - 24 months

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33
Q

What are the different sensations that can occur from damage to nerves

A 
anaesthesia
paraesthesia
dysaesthesia
hypoaesthesia
hyperaesthesia
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34
Q

What is anaesthesia

A

numbness

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35
Q

What is paraesthesia

A

tingling

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36
Q

What is dysaesthesia

A

unpleasant sensation/pain

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37
Q

What is hypoaesthesia

A

reduced sensation

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38
Q

What is hyperesthesia

A

increased/heightened sensation

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39
Q

What is neurapraxia

A

contusion of nerve/continuity of epieneural sheath and axons maintained

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40
Q

What is axonotmesis

A

continuity of axons but not epieneural sheath disrupted

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41
Q

What is neurotmesis

A

complete loss of nerve continuity/nerve transected

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42
Q

What is a dry socket also known as

A

alveolar/localised osteitis

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43
Q

What is a dry socket due to

A

the normal clot disappearing

it appears to be looking at bare bone or an empty socket

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44
Q

What is the main feature of a dry socket

A

intense pain

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45
Q

When does a dry socket normally occur

A

3-4 days after extraction

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46
Q

How long does dry socket take to resolve

A

7-14 days to resolve

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47
Q

What is localized osteitis

A

inflammation affecting lamina dura

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48
Q

What are symptoms of dry socket

A

dull aching pain - moderate to severe
usually can radiate to patients ear and can keep them awake at night
characteristic smell/bad odor

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49
Q

What is the source of the pain in a dry socket

A

exposed bone

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50
Q

Is dry socket an infection?

A

it does not show overt infection features

it is delayed healing but not associated with infection

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51
Q

What are predisposing factors to dry socket

A

molars more common and risk increases as u go more psoterior

more common in mandible

smoking

female

oral contraceptive pill

LA vasoconstrictor

52
Q

Why is dry socket more common in mandible

A

blood supply is from one main artery

53
Q

Why is smoking a risk for dry socket

A

reduced blood supply

54
Q

What are more local predisposing factors for a dry socket

A 
infection from tooth
hematogenous bacteria in socket
excessive trauma during extraction 
excessive mouth rinsing post extraction
family history/previous dry socket
55
Q

What is the management of dry socket

A 
supportive
LA block
irrigate socket 
curettage/debridement 
antiseptic pack 
BIP
alvogyl
soothe pain/prevent food packing 
advise on analgesia and salty moutwash
review px and change packs and dressing 
generally do not prescribe AB 
ensure it is a dry socket and no tooth fragments or bony sequestra remain
56
Q

How do we give support to a px with a dry socket

A

reassurance/systemic analgesia

as px may think u have extracted wrong tooth

57
Q

What do we irrigate the dry socket with

A

warm saline

wash out food and debris

58
Q

What does curettage/debridement do

A

encourage bleeding/new clot formation

some suggest this should not be carried out as it produces more bare bone and removes any remaining clot

59
Q

What is BIP

A

bismuth substrate and iodoform pack
comes as a pate or impregnated gauze
antiseptic and anstringent

60
Q

What is alvogyl

A

mixture of LA and antiseptic

61
Q

When do we remove packs

A

when pain resolves

need to do this to allow healing

62
Q

What is sequestrum

A

usually dead bits of bone

can also be pieces of amalgam or tooth

63
Q

Why is sequestrum an issue

A

prevents healing

remove

64
Q

How does infected socket usually present

A

pus discharge
check for foreign bodies
more commonly seen after MOS involving flaps and bone removal

65
Q

What is treatment for infected socket

A

need to manage bc delays healing

check for remaining tooth/root fragments/bony sequestra/foreign bodies

66
Q

What is an ora-antral communication

A

acute

make communication in the cavity into maxillary air sinus at time of complication

67
Q

What is an ora-antral fistula

A

the OAC becomes epithelial lined tract

68
Q

How do we diagnose an OAC

A 
size of tooth
radiographic position of roots in relation to antrum
bone at trifurcation of roots
bubbling of blood
nose holding test
direct vision
good light and suction
blunt probe
69
Q

Why do we have to be careful when doing nose holding test and blunt probe to diagnose OAC

A

that you don’t create an OAF as thin membrane may still be intact

70
Q

What is the management for oro-antral communication if small or sinus intact

A 
inform patient
encourage clot
suture margins
AB
post op instructions
71
Q

What is the management for oro-antral communication if large or lining torn

A

close with buccal advancement flap

AB and nose blowing instructions

72
Q

What is chronic OAF management

A 
excise sinus tract
buccal advancement flap
buccal fat pad with buccal advancement flap
palatal flap
bone graft/collagen membrane
73
Q

How do we confirm a root in the antrum

A

radiographically by OPT, occlusal or PA

74
Q

What is the OAF type approach for root from antrum retrieval

A 
flap design
open fenestration with care
suction - efficient and narrow bore
small curettes
irrigation or ribbon gauze
close as for oro-antral communication
75
Q

What is the caldwell-luck approach for root retrieval from antrum

A

buccal sulcus

buccal window

76
Q

What is ENT approach for root retrieval

A

endoscopic approach

77
Q

What is osteomyelitis

A

means inflammation of bone marrow

clinically term implies infection of bone

78
Q

What is the presentation of osteomyelitis

A

mandible usually
px often systemiacally unwell/raised temp
site of extraction often very tender
in deep seated infection may see altered sensation due to pressure on IAN

79
Q

Where does osteomyelitis begin

A

medullary cavity involving the cancellous bone
then extends and spreads to cortical bone
then eventually to periosteum (overlying mucosa red and tender)

80
Q

What is the pathology behind osteomyelitis

A

invasion of bacteria into cancellous bone causing soft tissue inflammation and edema in closed bony marrow spaces

edema in an enclosed space leads to increased tissue hydrostatic pressure and if it is higher than the blood pressure it can compromise the blood supply resulting in soft tissue necrosis

the involved area becomes ischemic and necrotic

bacteria proliferate bc normal blood defenses do not come to the tissues

81
Q

What is required to stop spread of osteomyelitis

A

it won’t stop spreading until arrested by AB and surgical therapy

82
Q

Why is osteomyelitis more common in the mandible

A

maxilla has rich blood supply whereas mandible is mainly supplied from inferior alveolar artery and dense overlying cortical bone limits penetration of periosteal blood vessels so there is a poorer blood supply making it more likely to become ischemic and infected

83
Q

What are major predisposing factors to osteomyelitis

A

doesn’t occur often in those who are healthy

major predisposing factors are odontogenic infections and fractures of mandible

still rare unless host defenses compromised

84
Q

What are conditions which may see compromised host defense

A 
diabetes
alcoholism
IV drug use
malnutrition
myeloproliferative disease
85
Q

What can early osteomyelitis be difficult to distinguish form

A

dry socket or localized infection

86
Q

How does acute supportive osteomyelitis present

A

doesn’t show much change on radiograph

takes 10-12 days for lost bone to be detectable

87
Q

How does chronic osteomyelitis present

A

may be some pus

bony destruction seen in area of infection

88
Q

What is the radiographic appearance of osteomyelitis

A

uniform or patchy with moth eaten appearance

89
Q

What are the areas of radiopacity that may be seen in the radiolucent region in the osteomyelitis radiograph

A

unreserved islands of bone - sequestra

90
Q

What can be seen surrounding the radiolucent areas in chronic osteomyelitis on the radiograph

A

increase in radiodensity
called an involucrum
result of inflammatory reaction - bone production increased

91
Q

Why is the mandible osteomyelitis different from other areas of body

A

bacteria involved similar to those in odnotogenic infection

streptococci, anaerobic cocci, anaerobic gram negative rods

92
Q

What is the main bacteria in osteomyelitis in other parts of the body

A

staphylococci

93
Q

What are the two types of tx required for OM

A

medical and surgical

investigate host defenses using blood investigations and glucose levels

94
Q

What is the antibiotic regime for osteomyelitis

A

clindamycin/penicillins
longer course than normal
often weeks in acute and for chronic can be up to 6 months
severe acute may require hospital admission and IV AB if systemic symptoms present

95
Q

Why do we need to use clindamycin and penicillin for osteomyelitis

A

as need good bone penetration and effective against odontogenic infections

96
Q

What is surgical tx for osteomyelitis

A

drain pus if possible
remove any non vital teeth in area of infection
remove any loose pieces of bone
in fractures mandible remove any wires, plates or screws
corticotomy
perforation of bony cortex
excision of necrotic bone until each actively bleeding bone tissue

97
Q

What is a corticotomy

A

removal of bony cortex

98
Q

What is the treatment for chronic osteomyelitis

A

requires aggressive AB and surgical tx

99
Q

What is osteoradionecrosis

A

seen in px who have received radiotherapy of head and neck to tx cancer

100
Q

How does osteoradionecrosis occur

A

bone within radiation becomes virtually non vital
due to endarteritis meaning reduced blood supply
turnover of remaining viable bone is slow
self repair is ineffective and gets worse with team

101
Q

Why is the mandible more effected with ORN

A

poor blood supply

102
Q

What are suggestions for tx for those with ORN

A

careful routine extraction
alveoplasty
primary closure of soft tissue

103
Q

What is osteoradionecrosis prevention

A

scaling/chlorhexidine mouthwash leading up to extraction

careful extraction technique

AB, chlorhexidine mouthwash and review

hyperbaric oxgyen before and after extraction

take advice and refer px for extraction

104
Q

What is hyperbaric oxygen for

A

cinrease local tissue oxygenation and vascular ingrowth to hypoxic area

105
Q

What is tx for osteoradionecrosis

A

irrigation of necrotic debris
AB not overly helpful unless secondary infection
loose sequestra removed
small wounds (under 1cm) usually heal over a course of weeks and months
hyperbaric oxygen

106
Q

What do severe cases of ORN require

A

resection of exposed bone, margin of unexposed bone and soft tissue closure

107
Q

What are bisphosphonates prescribed for

A

class of drugs used to treat osteoporosis, Paget’s disease and malignant bone metastases

108
Q

What do bishosphonates do

A

inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal

drug can remain in body for years

109
Q

When does mRONJ occur

A

post extraction/following denture trauma/spontaneous

110
Q

Where does MRONJ occur

A

exclusive to both jaws

111
Q

Which px are at highest risk of MRONJ

A

IV bisphosphonates

112
Q

What is the range of MRONJ

A

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

113
Q

What are other important factors in risk of mRONJ

A 
length of time px on drugs
diabetes
steroids
anti cancer chemo
smoking
114
Q

What is management of MRONJ

A

avoid extraction if possible
if required use careful technique, monitor px and warn of signs
take advice and refer

115
Q

How do we manage/treat MRONJ

A

tx not v good

manage symptoms - remove sharp edges of bone, chlorhexidine mouthwash, AB if suppuration

116
Q

What are the bisphosonates

A

end with donate

clodronate, pamidronate and zoledronate are IV

117
Q

What drugs can cause MRONJ

A

antiresorptive (bisphosonates)

RANK-L inhibitors - monoclonal antibodies for cancer tx

antiangiogenic - monoclonal antibodies and small molecules

118
Q

What are the classes of drugs that cause risk of MRONJ

A

any biological agent, immunomodulator, antiresorption, antiangiogenic meds

119
Q

What are the risk factors for MRONJ

A 
dental tx - impact on bone
duration of bisphosphonate drug therapy
dental implants 
other concurrent meds
previous drug history important due to long half life
no evidence for drug holiday
120
Q

What is actinomycosis

A

rare bacterial infection

121
Q

What are the bacteria involved in actinomcyosis

A

actinomyces israelii
A. naeslundii
A. viscosus

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

122
Q

What is the presentation of actinomycosis

A

fairly chronic
multiple skin sinuses and swelling
thick lumpy pus - colonies of actinomyces look like sulphur granules on histology
responds intiaily to AB therapy, recurs when you stop AB

123
Q

What is treatment for actinomycosis

A 
incise and drain pus accumulation
excise of chronic sinus tracts
excise necrotic bone and foreign bodies
high dose AB for initial control - often IB
long term oral AB to prevent recurrence
124
Q

What are the AB for actinomycosis

A

penicillins, doxycycline, clindamycin

125
Q

Who are the patients at risk of infective endocarditis

A

adults and children w certain problems affecting structure of heart such as replacement heart valve or hypertrophic cardiomyopathy

adults with children who have previously had infective endocarditis (whether or not they have underlying cardiac problem)

people having any of these procedures

126
Q

What drugs are prescribed for IE prophylaxis

A

amoxicillin
clindamycin capsules
azithromycin

BDS3 CLINICAL Oral Surgery (6 decks)

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