Post-extraction complications Flashcards
What can post operative extractions be split into
immediate
short term
long term
What are post operative extraction complications
pain/swelling/ecchymosis trismus/limited mouth opening haemorrhage prolonged effects of nerve damage dry socket sequestrum infected socket chronic OAF/root in antrum
What are less common post-op complications
osteomyelitis osteoradionecrosis medication induced osteonecrosis actinomycosis bacteriaemia/infective endocarditis
What is the most common complication of extraction
pain
What should you advise patients on pain
warn them
prescribe analgesia
What can we do to try and minimise pain during operation
minimise rough handling of tissues as this causes more pain
avoid laceration/teraing of soft tissues, exposed bone and incomplete extraction of tooth
What is oedema
part of the inflammatory reaction to surgical interference
What can increase edema
increased by poor surgical technique such as rough handling of soft tissue, pulling flaps, crushing lips with forceps
wide individual variation
What can result in ecchymosis
rough handling of tissues/poor surgical technique
individual variation
What is trismus
jaw stiffness/inability to open mouth fully
What are the variety of causes of trismus
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
What should be done for trismus
monitor - may take several weeks to resolve
gentle mouth opening exercises can be used
What makes trismus different from limited mouth opening
its due to muscle spasm
What is immediate post operative bleeding due to
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
When does secondary bleeding occur
commonly 3-7 days
What is secondary bleeding often due to
infection
usually a mild ooze but can occasionally be a major bleed
What are most dental bleeds due to
local facors e.g mucoperiosteal tears
very few due to undiagnosed clotting abnormalities
sometimes due to liver disease
sometimes due to medications
What is the management options for bleeding of soft tissue
pressure suture LA with adrenaline diathermy ligatures/haemostatic forceps (artery clips) for large vessels
What is the management options for bleeding of bone
pressure LA on swab or injecte dint socket hemostatic agent blunt instument bone wax pack
If the bleeding is severe what can be done
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
What is management of post operative bleeding
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
What do you do if you cannot arrest the hemorrhage
urgent hospital referral
What are local hemostatic agents
adrenaline containing LA oxidized regenerated cellulose which is a framework for clot formation gelatin sponge thrombin liquid and powder fibrin foam
Why should you be careful with oxidized regenerated cellulose in lower 8 region
acidic and can cause damage to IDN
What are systemic hemostatic aids
vitamin K
anti-fibrinolytic e.g tranexamic acid
missing blood clotting factors
plasma or whole blood
How can we prevent intra operative and post operative extraction hemorrhage
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
What are the post extraction instructions
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
Why should the px avoid rinsing their mouth
as it will wash the clot away
How should the px avoid trauma
do not explore the socket with their tongue or fingers/hard food
Why should the px avoid excessive physical exercise/alcohol
will increase BP
What is the advice on control of bleeding we give to the patient
biting on damp gauze / tissue
pressure for at least 30 min (longer if bleeding continues)
points of contact if bleeding continues
What is the prolonged effect of nerve damage
already discussed
nerve damage can be temporary or permanent
improvement can occur up to 18 - 24 months
What are the different sensations that can occur from damage to nerves
anaesthesia paraesthesia dysaesthesia hypoaesthesia hyperaesthesia
What is anaesthesia
numbness
What is paraesthesia
tingling
What is dysaesthesia
unpleasant sensation/pain
What is hypoaesthesia
reduced sensation
What is hyperesthesia
increased/heightened sensation
What is neurapraxia
contusion of nerve/continuity of epieneural sheath and axons maintained
What is axonotmesis
continuity of axons but not epieneural sheath disrupted
What is neurotmesis
complete loss of nerve continuity/nerve transected
What is a dry socket also known as
alveolar/localised osteitis
What is a dry socket due to
the normal clot disappearing
it appears to be looking at bare bone or an empty socket
What is the main feature of a dry socket
intense pain
When does a dry socket normally occur
3-4 days after extraction
How long does dry socket take to resolve
7-14 days to resolve
What is localized osteitis
inflammation affecting lamina dura
What are symptoms of dry socket
dull aching pain - moderate to severe
usually can radiate to patients ear and can keep them awake at night
characteristic smell/bad odor
What is the source of the pain in a dry socket
exposed bone
Is dry socket an infection?
it does not show overt infection features
it is delayed healing but not associated with infection
What are predisposing factors to dry socket
molars more common and risk increases as u go more psoterior
more common in mandible
smoking
female
oral contraceptive pill
LA vasoconstrictor
Why is dry socket more common in mandible
blood supply is from one main artery
Why is smoking a risk for dry socket
reduced blood supply
What are more local predisposing factors for a dry socket
infection from tooth hematogenous bacteria in socket excessive trauma during extraction excessive mouth rinsing post extraction family history/previous dry socket
What is the management of dry socket
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
How do we give support to a px with a dry socket
reassurance/systemic analgesia
as px may think u have extracted wrong tooth
What do we irrigate the dry socket with
warm saline
wash out food and debris
What does curettage/debridement do
encourage bleeding/new clot formation
some suggest this should not be carried out as it produces more bare bone and removes any remaining clot
What is BIP
bismuth substrate and iodoform pack
comes as a pate or impregnated gauze
antiseptic and anstringent
What is alvogyl
mixture of LA and antiseptic
When do we remove packs
when pain resolves
need to do this to allow healing
What is sequestrum
usually dead bits of bone
can also be pieces of amalgam or tooth
Why is sequestrum an issue
prevents healing
remove
How does infected socket usually present
pus discharge
check for foreign bodies
more commonly seen after MOS involving flaps and bone removal
What is treatment for infected socket
need to manage bc delays healing
check for remaining tooth/root fragments/bony sequestra/foreign bodies
What is an ora-antral communication
acute
make communication in the cavity into maxillary air sinus at time of complication
What is an ora-antral fistula
the OAC becomes epithelial lined tract
How do we diagnose an OAC
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
Why do we have to be careful when doing nose holding test and blunt probe to diagnose OAC
that you don’t create an OAF as thin membrane may still be intact
What is the management for oro-antral communication if small or sinus intact
inform patient encourage clot suture margins AB post op instructions
What is the management for oro-antral communication if large or lining torn
close with buccal advancement flap
AB and nose blowing instructions
What is chronic OAF management
excise sinus tract buccal advancement flap buccal fat pad with buccal advancement flap palatal flap bone graft/collagen membrane
How do we confirm a root in the antrum
radiographically by OPT, occlusal or PA
What is the OAF type approach for root from antrum retrieval
flap design open fenestration with care suction - efficient and narrow bore small curettes irrigation or ribbon gauze close as for oro-antral communication
What is the caldwell-luck approach for root retrieval from antrum
buccal sulcus
buccal window
What is ENT approach for root retrieval
endoscopic approach
What is osteomyelitis
means inflammation of bone marrow
clinically term implies infection of bone
What is the presentation of osteomyelitis
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
Where does osteomyelitis begin
medullary cavity involving the cancellous bone
then extends and spreads to cortical bone
then eventually to periosteum (overlying mucosa red and tender)
What is the pathology behind osteomyelitis
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
What is required to stop spread of osteomyelitis
it won’t stop spreading until arrested by AB and surgical therapy
Why is osteomyelitis more common in the mandible
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
What are major predisposing factors to osteomyelitis
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
What are conditions which may see compromised host defense
diabetes alcoholism IV drug use malnutrition myeloproliferative disease
What can early osteomyelitis be difficult to distinguish form
dry socket or localized infection
How does acute supportive osteomyelitis present
doesn’t show much change on radiograph
takes 10-12 days for lost bone to be detectable
How does chronic osteomyelitis present
may be some pus
bony destruction seen in area of infection
What is the radiographic appearance of osteomyelitis
uniform or patchy with moth eaten appearance
What are the areas of radiopacity that may be seen in the radiolucent region in the osteomyelitis radiograph
unreserved islands of bone - sequestra
What can be seen surrounding the radiolucent areas in chronic osteomyelitis on the radiograph
increase in radiodensity
called an involucrum
result of inflammatory reaction - bone production increased
Why is the mandible osteomyelitis different from other areas of body
bacteria involved similar to those in odnotogenic infection
streptococci, anaerobic cocci, anaerobic gram negative rods
What is the main bacteria in osteomyelitis in other parts of the body
staphylococci
What are the two types of tx required for OM
medical and surgical
investigate host defenses using blood investigations and glucose levels
What is the antibiotic regime for osteomyelitis
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
Why do we need to use clindamycin and penicillin for osteomyelitis
as need good bone penetration and effective against odontogenic infections
What is surgical tx for osteomyelitis
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
What is a corticotomy
removal of bony cortex
What is the treatment for chronic osteomyelitis
requires aggressive AB and surgical tx
What is osteoradionecrosis
seen in px who have received radiotherapy of head and neck to tx cancer
How does osteoradionecrosis occur
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
Why is the mandible more effected with ORN
poor blood supply
What are suggestions for tx for those with ORN
careful routine extraction
alveoplasty
primary closure of soft tissue
What is osteoradionecrosis prevention
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
What is hyperbaric oxygen for
cinrease local tissue oxygenation and vascular ingrowth to hypoxic area
What is tx for osteoradionecrosis
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
What do severe cases of ORN require
resection of exposed bone, margin of unexposed bone and soft tissue closure
What are bisphosphonates prescribed for
class of drugs used to treat osteoporosis, Paget’s disease and malignant bone metastases
What do bishosphonates do
inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal
drug can remain in body for years
When does mRONJ occur
post extraction/following denture trauma/spontaneous
Where does MRONJ occur
exclusive to both jaws
Which px are at highest risk of MRONJ
IV bisphosphonates
What is the range of MRONJ
small asymptomatic areas of exposed bone to extensive bone exposure/dehiscence/pus/pain
What are other important factors in risk of mRONJ
length of time px on drugs diabetes steroids anti cancer chemo smoking
What is management of MRONJ
avoid extraction if possible
if required use careful technique, monitor px and warn of signs
take advice and refer
How do we manage/treat MRONJ
tx not v good
manage symptoms - remove sharp edges of bone, chlorhexidine mouthwash, AB if suppuration
What are the bisphosonates
end with donate
clodronate, pamidronate and zoledronate are IV
What drugs can cause MRONJ
antiresorptive (bisphosonates)
RANK-L inhibitors - monoclonal antibodies for cancer tx
antiangiogenic - monoclonal antibodies and small molecules
What are the classes of drugs that cause risk of MRONJ
any biological agent, immunomodulator, antiresorption, antiangiogenic meds
What are the risk factors for MRONJ
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
What is actinomycosis
rare bacterial infection
What are the bacteria involved in actinomcyosis
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
What is the presentation of actinomycosis
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
What is treatment for actinomycosis
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
What are the AB for actinomycosis
penicillins, doxycycline, clindamycin
Who are the patients at risk of infective endocarditis
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
What drugs are prescribed for IE prophylaxis
amoxicillin
clindamycin capsules
azithromycin
