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Oral Surgery > Post Extraction Complications > Flashcards

Post Extraction Complications Flashcards

1
Q

List some examples of post-op complications (8)

A
  1. Pain/swelling/bruising
  2. Trismus
  3. Haemorrhage
  4. Prolonged effects of nerve damage
  5. Dry socket
  6. Sequestrum
  7. Infected socket
  8. Chronic OAF/Root in antrum
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2
Q

Less common post-op complications (5)

A
  1. Osteomyelitis
  2. Osteoradionecrosis
  3. MRONJ
  4. Actinomycosis
  5. Bacteraemia
    - Infective endocarditis
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3
Q

How can we cause pain post op? (3)

A
  1. Rough handling of tissues
  2. Laceration/tearing of soft tissues
  3. Incomplete extraction of tooth
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4
Q

How can we cause swelling (oedema) post op?

A
  1. Increased by poor surgical technique
    - Pulling flaps
    - Crushing lip with forceps
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5
Q

List some causes of trismus (4)

A
  1. Related to surgery (oedema/muscle spasm)
  2. Related to giving LA - IDB
    - Muscle medial pterygoid
    - Haematoma/spasm

3.Bleed into muscle

  1. Damage to TMJ
    - Oedemea/joint effusion
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6
Q

How is a haemorrhage managed intra-operatively?

A

Surgicel + pressure

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7
Q

How quick does an immediate reactionary/rebound haemorrhage occur?

A

Occurs within 48 hours of extraction

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8
Q

How quick does a secondary bleed haemorrhage occur?

A

Often due to infection

Commonly 3-7 days

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9
Q

How can soft tissue bleeding be managed? (5)

A
  1. Pressure
  2. Sutures
  3. LA with adrenaline
  4. Diathermy
  5. Ligatures
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10
Q

How can bone bleeding be managed? (4)

A
  1. Pressure
  2. Bone wax
  3. LA on swab or injected into socket
  4. Haemostatic agents
    - Surgicel
    - Kaltostat
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11
Q

Management of post op bleeding:

Protocol if pt has a bleeding disorder

  • Haemophilia
  • VW disease
  • Liver disease
A

Urgent referral/contact haematologist

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12
Q

Management of post op bleeding:

Protocol if pt on warfarin

A

Get GMP to do INR/urgent hospital referral if bleeding not arrested

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13
Q

What is surgicel, and how does it work?

A

Haemostatic agent - Oxidised cellulose

- acts as a framework for clot formation

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14
Q

List some examples of haemostatic agents (5)

A
  1. Adrenaline containing LA
  2. Oxidised regenerated cellulose
    - Surgicel
    - Framework for clot formation
  3. Gelatin sponge
  4. Thrombin liquid + powder
  5. Fibrin foam
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15
Q

List examples of systemic haemostatic acids (2)

A
  1. Vit K
  2. Anti-fibrinolytics
    - Tranexamic acid
    - Prevents clot breakdown/stabilises clot
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16
Q

How do we prevent intra-op and post-op extraction haemorrhage (4)

A
  1. Med hx
  2. Atraumatic extraction + surgical technique
  3. Obtain + check good haemostasis at end of surgery
  4. Provide good instruction to patient
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17
Q

List some post extraction instructions (5)

A
  1. Do not rinse for several hours
    - Preferably next day
    - Avoid vigorous mouth rinsing (wash clot away)
  2. Avoid trauma
    - Do not explore socket with tongue or fingers/hard food
  3. Avoid hot food
  4. Avoid excessive physical exercise + alcohol (increase bp)
  5. Advice on control of bleeding
    - Bite on damp gauze
    - Pressure for at least 30 min (longer if bleeding continues)
    - Points of contact if bleeding continues
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18
Q

How quick can nerve damage improve?

A

Improvement can occur up to 18-24mths

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19
Q

How often does a dry socket affect 3rd molars?

A

20-35%

Main feature: dull aching pain (moderate to severe)

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20
Q

When does a dry socket normally start?

A

3-4 days after extraction

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21
Q

How long does a dry socket take to resolve?

A

7-14 days

Localised osteitis - inflammation affecting lamina dura

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22
Q

Dry socket symptoms (2)

A
  1. Dull aching throbbing pain can radiate to patients ear
    - Often continuous
    - Can keep patient awake at night
  2. Characteristic malodour+ patient c/o bad taste
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23
Q

What are some pre-disposing factors for a dry socket? (10)

A
  1. Molars from common
    - Risk increases from anterior to posterior
  2. Mandible more common
  3. Smoking
    - Reduced blood supply
  4. Females
  5. Oral contraceptive pill
  6. LA with vasoconstrictor
  7. Infection from extracted tooth
  8. Excessive trauma during extraction
  9. Excessive mouth rinsing post extraction
  10. FH/previous dry socket
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24
Q

Management of a dry socket (5)

A
  1. Supportive
    - Reassurance
    - Analgesia + hot salty washes/warm saline irrigation
  2. LA block
  3. Curettage/debridement
    - Encourage bleeding/new clot formation
  4. Antiseptic pack
  5. Review patient
    - Change packs + dressing
    - As soon as pain resolves get packs out to allow healing
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25
Q

Why do we not prescribe antibiotics for the management of a dry socket?

A

It’s not an infection

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26
Q

What to rule out before a dry socket diagnosis

A

No tooth fragments or bony sequestra remain

- They can prevent healing

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27
Q

How does an infected socket present? (2)

A
  • Infected socket with pus discharge

- Check for remaining tooth/root fragments/bony sequestra

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28
Q

Tx for infected socket (3)

A
  1. Radiograph
  2. Explore/irrigate + remove
  3. Consider antibiotics
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29
Q

Management of acute OAC if small or sinus intact (3)

A
  1. Inform patient
  2. If small:
    - Encourage clot + suture margins
  3. Antibiotics + post op instructions
30
Q

Management of Acute OAC if large or lining torn (2)

A
  1. Close with buccal advancement flap

2. Antibiotics + nose blowing instructions

31
Q

Management of Chronic OAF (6)

A
  1. Excise sinus tract
  2. Buccal advancement flap
  3. Buccal fat pad w buccal advancement flap
  4. Palatal flap
  5. Bone graft
  6. Tongue flap
32
Q

What radiographs do we use to confirm a root in antrum (3)

A
  1. OPT
  2. Occlusal
  3. Periapical
33
Q

Define osteomyelitis

A

Inflammation of the bone marrow

  • Usually mandible
  • In deep seated infection may see altered sensation due to pressure on IAN
34
Q

How does osteomyelitis lead to an oedema

A

Invasion of bacteria into cancellous bone causes soft tissue inflammation + oedema

35
Q

What does an oedema as a result of osteomyelitis lead to?

A

Oedema in an enclosed space leads to increased hydrostatic pressure - Compromised blood supply

36
Q

What does a compromised blood supply as a result of osteomyelitis lead to?

A

Soft tissue necrosis

The osteomyelitis spreads until arrested by antibiotic + surgical therapy

37
Q

Why does osteomyelitis tend to occur in the mandible over the maxilla?

A

Maxilla - rich blood supply from several arteries

Mandible - primary blood supply = inferior alveolar artery

> Dense overlying cortical bone limits penetration of periosteal blood vessels

> So poorer blood supply and more likely to become ischaemic + infected

38
Q

What are the major disposing factors for osteomyelitis? (2)

A
  1. Odontogenic infections

2. Fractures of the mandible

39
Q

Compare:

  1. Acute suppurative osteomyelitis
  2. Chronic osteomyelitis
A
  1. Acute suppurative osteomyelitis
    - Little/no radiographic change
    - At least 10-12 days required for lost bone to be detectable radiographically
  2. Chronic osteomyelitis
    +- pus
    - Bony destruction in the area of infection
    - Radiographic appearance = increased radiolucency (moth eaten appearance)
40
Q

What are the main bacterias present in mandibular osteomyelitis? (3)

A
  1. Streptococci
  2. Fusobacterium
  3. Prevotella
41
Q

What is the main bacteria present in osteomyelitis in other bones?

A

Staphylococci predominate

42
Q

What are the 2 types of tx routes for osteomyelitis?

A
  1. Medical tx - antibiotics

2. Surgical tx

43
Q

Medical tx for osteomyelitis

A

ANTIBIOTICS

> Penicillins

> Effective against odontogenic infections + good bone penetration

44
Q

Course of antibiotics for

acute vs chronic osteomyelitis

A

ACUTE
weeks

CHRONIC
months

45
Q

What tx may severe acute osteomyelitis require?

A

Hospital admission + IV antibiotics

46
Q

Surgical tx for osteomyelitis (7)

A
  1. Drain pus if possible
  2. Remove any non-vital teeth in the area of infection
  3. Remove any loose pieces of bone
  4. In fractured mandible:
    - Remove any wires/plates/screws in the area
  5. Corticotomy
    - Removal of bony cortex
  6. Perforation of bony cortex
  7. Excision of necrotic bone
    - Until reach actively bleeding bone tissue
47
Q

Tx for chronic osteomyelitis

A

Aggressive antibiotic + surgical tx

48
Q

In what patients is Osteoradionecrosis seen?

A

Radiotherapy H+N cancer patients

49
Q

How does osteoradionecrosis from radiotherapy occur?

A
  1. Bone within radiation beam becomes virtually non-vital
  2. Endarteritis
    - Reduced blood supply
    (so common in mandible)
  3. Turnover of any remaining viable bone is slow
    - Self repair ineffective
    - Worse with time
50
Q

Why is the mandible most commonly affected by osteoradionecrosis?

A

Poorer blood supply

51
Q

Protocol if osteoradionecrosis patient requires an extraction?

A
  1. Careful routine extraction
  2. Surgical extraction
    - Alveoplasty
    - Primary closure of soft tissue
52
Q

What is an alveoplasty?

A

Cutting down alveolus to allow space for the gum to close over completely

53
Q

List examples of osteoradionecrosis prevention

A
  1. Scaling/chlorrhexidine mouthwash leading up to extraction
  2. Careful extraction technique
  3. Antibiotics,
  4. Hyperbaric o2 (to increase local tissue oxygenation + vascular ingrowth to hypoxic areas) before and after extraction
  5. Take advice/refer pt for extraction
54
Q

Osteoradionecrosis tx (2)

A
  1. Irrigation of necrotic debris

2. Loose sequestra removed

55
Q

How quickly do small wounds from osteoradionecrosis tx heal?

A

Small wounds under 1cm heal over a course of weeks/months

56
Q

Protocol if the wound is severe or getting worse and bigger? (2)

A

Surgical intervention

  • Resection of exposed bone
  • Margin of unexposed bone + soft tissue closure
  • Hyperbaric o2
57
Q

What drug causes MRONJ?

A

Bisphosphonates

  • Used to tx osteporosis
  • Risk higher in IV bisphosphonates but can still occur in patients taking oral ones
58
Q

Function of bisphosphonates

A

Inhibit osteoclast activity + inhibit bone resorption

This inhibits bone renewal

59
Q

When can MRONJ occur? (3)

A
  1. Post extractions
  2. Following denture trauma
  3. Spontaneous

Exclusive to jaw - mandible + maxilla

60
Q

What other factors are important in causing MRONJ?

A
  1. Length of time patient on the drug
    - Diabetes
    - Steroids
    - Anticancer chemo
    - Smoking
61
Q

What procedure to avoid if patient has MRONJ?

A

Extractions

- If required need careful technique + monitor patient and look for signs

62
Q

Tx for MRONJ (6)

A

Not v successful
INSTEAD

  1. Manage symptoms
  2. Remove sharp edges of bone
  3. Chlorrhexidine mouthwash
  4. Antibiotics if suppuration
  5. Debridement
  6. Major surgical sequestromg/resection/hyperbaric o2
63
Q

Example of a bisphosphonate

A

Aledronic acid

64
Q

High risk vs low risk guidelines:

For patients being tx’d for osteoporosis or other non-malignant disease of bone (4)

A

LOW RISK

  1. Oral bisphosphonates for less than 5yrs and not being tx’d with systemic glucocorticoids
  2. Quarterly/yearly infusions of IV bisphosphonates for less than 5yrs who are not being tx’d with systemic glucocorticoids

HIGH RISK

  1. Oral bisphosphonates or quarterly/yearly infusions of IV bisphosphonates for more than 5yrs
  2. Bisphosphonates or denosumab for any length of time who are being tx’d with systemic gluocorticoids
65
Q

Risk factors for MRONJ

A
  1. Dental implants
    - Avoid in high doses of anti-resorptive or anti-angiogenic drugs for the management of cancer
  2. Other meds
    - Steroids + antiresorptive drugs
  3. Previous drug hx
  4. Drug holidays
66
Q

What is actinomycosis?

A

Rare bacterial infection

Thick lumpy pus

Responds initially to antibiotic therapy/recurs when we stop antibiotics

67
Q

Actinomycosis tx

A
  1. Incise + drain pus
  2. Excision of chronic sinus tracts
  3. Excision of necrotic bone + foreign bodies
  4. High dose antibiotics for initial control (often IV)
  5. Long term oral antibiotics to prevent recurrence
  6. Antibiotics:
    - Peniccilin
68
Q

Define infective endocarditis

A

Inflammatoin of the endocardium, particularly affecting heart valves

69
Q

Significant mortality of infective endocarditis

A

20%

70
Q

Antibiotic prophylaxis for infective endocarditis high risk patients

A
  1. Amoxicillin
    - 3g oral powder sachet

2 Clindamycin capsules 300mg

  1. Azithromycin oral suspension 200mg

Oral Surgery (6 decks)

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