Post-extraction complications Flashcards
1
Q
What can post operative extractions be split into
A
immediate
short term
long term
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
3
Q
What are less common post-op complications
A
osteomyelitis osteoradionecrosis medication induced osteonecrosis actinomycosis bacteriaemia/infective endocarditis
4
Q
What is the most common complication of extraction
A
pain
5
Q
What should you advise patients on pain
A
warn them
prescribe analgesia
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
7
Q
What is oedema
A
part of the inflammatory reaction to surgical interference
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
9
Q
What can result in ecchymosis
A
rough handling of tissues/poor surgical technique
individual variation
10
Q
What is trismus
A
jaw stiffness/inability to open mouth fully
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
12
Q
What should be done for trismus
A
monitor - may take several weeks to resolve
gentle mouth opening exercises can be used
13
Q
What makes trismus different from limited mouth opening
A
its due to muscle spasm
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
15
Q
When does secondary bleeding occur
A
commonly 3-7 days
16
Q
What is secondary bleeding often due to
A
infection
usually a mild ooze but can occasionally be a major bleed
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
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
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
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
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
22
Q
What do you do if you cannot arrest the hemorrhage
A
urgent hospital referral
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
24
Q
Why should you be careful with oxidized regenerated cellulose in lower 8 region
A
acidic and can cause damage to IDN
25
What are systemic hemostatic aids
vitamin K
anti-fibrinolytic e.g tranexamic acid
missing blood clotting factors
plasma or whole blood
26
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
27
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
```
28
Why should the px avoid rinsing their mouth
as it will wash the clot away
29
How should the px avoid trauma
do not explore the socket with their tongue or fingers/hard food
30
Why should the px avoid excessive physical exercise/alcohol
will increase BP
31
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
32
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
33
What are the different sensations that can occur from damage to nerves
```
anaesthesia
paraesthesia
dysaesthesia
hypoaesthesia
hyperaesthesia
```
34
What is anaesthesia
numbness
35
What is paraesthesia
tingling
36
What is dysaesthesia
unpleasant sensation/pain
37
What is hypoaesthesia
reduced sensation
38
What is hyperesthesia
increased/heightened sensation
39
What is neurapraxia
contusion of nerve/continuity of epieneural sheath and axons maintained
40
What is axonotmesis
continuity of axons but not epieneural sheath disrupted
41
What is neurotmesis
complete loss of nerve continuity/nerve transected
42
What is a dry socket also known as
alveolar/localised osteitis
43
What is a dry socket due to
the normal clot disappearing
| it appears to be looking at bare bone or an empty socket
44
What is the main feature of a dry socket
intense pain
45
When does a dry socket normally occur
3-4 days after extraction
46
How long does dry socket take to resolve
7-14 days to resolve
47
What is localized osteitis
inflammation affecting lamina dura
48
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
49
What is the source of the pain in a dry socket
exposed bone
50
Is dry socket an infection?
it does not show overt infection features
| it is delayed healing but not associated with infection
51
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
52
Why is dry socket more common in mandible
blood supply is from one main artery
53
Why is smoking a risk for dry socket
reduced blood supply
54
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
```
55
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
```
56
How do we give support to a px with a dry socket
reassurance/systemic analgesia
| as px may think u have extracted wrong tooth
57
What do we irrigate the dry socket with
warm saline
| wash out food and debris
58
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
59
What is BIP
bismuth substrate and iodoform pack
comes as a pate or impregnated gauze
antiseptic and anstringent
60
What is alvogyl
mixture of LA and antiseptic
61
When do we remove packs
when pain resolves
| need to do this to allow healing
62
What is sequestrum
usually dead bits of bone
| can also be pieces of amalgam or tooth
63
Why is sequestrum an issue
prevents healing
| remove
64
How does infected socket usually present
pus discharge
check for foreign bodies
more commonly seen after MOS involving flaps and bone removal
65
What is treatment for infected socket
need to manage bc delays healing
| check for remaining tooth/root fragments/bony sequestra/foreign bodies
66
What is an ora-antral communication
acute
| make communication in the cavity into maxillary air sinus at time of complication
67
What is an ora-antral fistula
the OAC becomes epithelial lined tract
68
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
```
69
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
70
What is the management for oro-antral communication if small or sinus intact
```
inform patient
encourage clot
suture margins
AB
post op instructions
```
71
What is the management for oro-antral communication if large or lining torn
close with buccal advancement flap
| AB and nose blowing instructions
72
What is chronic OAF management
```
excise sinus tract
buccal advancement flap
buccal fat pad with buccal advancement flap
palatal flap
bone graft/collagen membrane
```
73
How do we confirm a root in the antrum
radiographically by OPT, occlusal or PA
74
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
```
75
What is the caldwell-luck approach for root retrieval from antrum
buccal sulcus
| buccal window
76
What is ENT approach for root retrieval
endoscopic approach
77
What is osteomyelitis
means inflammation of bone marrow
| clinically term implies infection of bone
78
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
79
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)
80
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
81
What is required to stop spread of osteomyelitis
it won't stop spreading until arrested by AB and surgical therapy
82
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
83
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
84
What are conditions which may see compromised host defense
```
diabetes
alcoholism
IV drug use
malnutrition
myeloproliferative disease
```
85
What can early osteomyelitis be difficult to distinguish form
dry socket or localized infection
86
How does acute supportive osteomyelitis present
doesn't show much change on radiograph
| takes 10-12 days for lost bone to be detectable
87
How does chronic osteomyelitis present
may be some pus
| bony destruction seen in area of infection
88
What is the radiographic appearance of osteomyelitis
uniform or patchy with moth eaten appearance
89
What are the areas of radiopacity that may be seen in the radiolucent region in the osteomyelitis radiograph
unreserved islands of bone - sequestra
90
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
91
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
92
What is the main bacteria in osteomyelitis in other parts of the body
staphylococci
93
What are the two types of tx required for OM
medical and surgical
| investigate host defenses using blood investigations and glucose levels
94
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
95
Why do we need to use clindamycin and penicillin for osteomyelitis
as need good bone penetration and effective against odontogenic infections
96
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
97
What is a corticotomy
removal of bony cortex
98
What is the treatment for chronic osteomyelitis
requires aggressive AB and surgical tx
99
What is osteoradionecrosis
seen in px who have received radiotherapy of head and neck to tx cancer
100
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
101
Why is the mandible more effected with ORN
poor blood supply
102
What are suggestions for tx for those with ORN
careful routine extraction
alveoplasty
primary closure of soft tissue
103
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
104
What is hyperbaric oxygen for
cinrease local tissue oxygenation and vascular ingrowth to hypoxic area
105
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
106
What do severe cases of ORN require
resection of exposed bone, margin of unexposed bone and soft tissue closure
107
What are bisphosphonates prescribed for
class of drugs used to treat osteoporosis, Paget's disease and malignant bone metastases
108
What do bishosphonates do
inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal
drug can remain in body for years
109
When does mRONJ occur
post extraction/following denture trauma/spontaneous
110
Where does MRONJ occur
exclusive to both jaws
111
Which px are at highest risk of MRONJ
IV bisphosphonates
112
What is the range of MRONJ
small asymptomatic areas of exposed bone to extensive bone exposure/dehiscence/pus/pain
113
What are other important factors in risk of mRONJ
```
length of time px on drugs
diabetes
steroids
anti cancer chemo
smoking
```
114
What is management of MRONJ
avoid extraction if possible
if required use careful technique, monitor px and warn of signs
take advice and refer
115
How do we manage/treat MRONJ
tx not v good
manage symptoms - remove sharp edges of bone, chlorhexidine mouthwash, AB if suppuration
116
What are the bisphosonates
end with donate
| clodronate, pamidronate and zoledronate are IV
117
What drugs can cause MRONJ
antiresorptive (bisphosonates)
RANK-L inhibitors - monoclonal antibodies for cancer tx
antiangiogenic - monoclonal antibodies and small molecules
118
What are the classes of drugs that cause risk of MRONJ
any biological agent, immunomodulator, antiresorption, antiangiogenic meds
119
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
```
120
What is actinomycosis
rare bacterial infection
121
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
122
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
123
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
```
124
What are the AB for actinomycosis
penicillins, doxycycline, clindamycin
125
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
126
What drugs are prescribed for IE prophylaxis
amoxicillin
clindamycin capsules
azithromycin
