Post Extraction Complications Flashcards
List some examples of post-op complications (8)
- Pain/swelling/bruising
- Trismus
- Haemorrhage
- Prolonged effects of nerve damage
- Dry socket
- Sequestrum
- Infected socket
- Chronic OAF/Root in antrum
Less common post-op complications (5)
- Osteomyelitis
- Osteoradionecrosis
- MRONJ
- Actinomycosis
- Bacteraemia
- Infective endocarditis
How can we cause pain post op? (3)
- Rough handling of tissues
- Laceration/tearing of soft tissues
- Incomplete extraction of tooth
How can we cause swelling (oedema) post op?
- Increased by poor surgical technique
- Pulling flaps
- Crushing lip with forceps
List some causes of trismus (4)
- Related to surgery (oedema/muscle spasm)
- Related to giving LA - IDB
- Muscle medial pterygoid
- Haematoma/spasm
3.Bleed into muscle
- Damage to TMJ
- Oedemea/joint effusion
How is a haemorrhage managed intra-operatively?
Surgicel + pressure
How quick does an immediate reactionary/rebound haemorrhage occur?
Occurs within 48 hours of extraction
How quick does a secondary bleed haemorrhage occur?
Often due to infection
Commonly 3-7 days
How can soft tissue bleeding be managed? (5)
- Pressure
- Sutures
- LA with adrenaline
- Diathermy
- Ligatures
How can bone bleeding be managed? (4)
- Pressure
- Bone wax
- LA on swab or injected into socket
- Haemostatic agents
- Surgicel
- Kaltostat
Management of post op bleeding:
Protocol if pt has a bleeding disorder
- Haemophilia
- VW disease
- Liver disease
Urgent referral/contact haematologist
Management of post op bleeding:
Protocol if pt on warfarin
Get GMP to do INR/urgent hospital referral if bleeding not arrested
What is surgicel, and how does it work?
Haemostatic agent - Oxidised cellulose
- acts as a framework for clot formation
List some examples of haemostatic agents (5)
- Adrenaline containing LA
- Oxidised regenerated cellulose
- Surgicel
- Framework for clot formation - Gelatin sponge
- Thrombin liquid + powder
- Fibrin foam
List examples of systemic haemostatic acids (2)
- Vit K
- Anti-fibrinolytics
- Tranexamic acid
- Prevents clot breakdown/stabilises clot
How do we prevent intra-op and post-op extraction haemorrhage (4)
- Med hx
- Atraumatic extraction + surgical technique
- Obtain + check good haemostasis at end of surgery
- Provide good instruction to patient
List some post extraction instructions (5)
- Do not rinse for several hours
- Preferably next day
- Avoid vigorous mouth rinsing (wash clot away) - Avoid trauma
- Do not explore socket with tongue or fingers/hard food - Avoid hot food
- Avoid excessive physical exercise + alcohol (increase bp)
- 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
How quick can nerve damage improve?
Improvement can occur up to 18-24mths
How often does a dry socket affect 3rd molars?
20-35%
Main feature: dull aching pain (moderate to severe)
When does a dry socket normally start?
3-4 days after extraction
How long does a dry socket take to resolve?
7-14 days
Localised osteitis - inflammation affecting lamina dura
Dry socket symptoms (2)
- Dull aching throbbing pain can radiate to patients ear
- Often continuous
- Can keep patient awake at night - Characteristic malodour+ patient c/o bad taste
What are some pre-disposing factors for a dry socket? (10)
- Molars from common
- Risk increases from anterior to posterior - Mandible more common
- Smoking
- Reduced blood supply - Females
- Oral contraceptive pill
- LA with vasoconstrictor
- Infection from extracted tooth
- Excessive trauma during extraction
- Excessive mouth rinsing post extraction
- FH/previous dry socket
Management of a dry socket (5)
- Supportive
- Reassurance
- Analgesia + hot salty washes/warm saline irrigation - LA block
- Curettage/debridement
- Encourage bleeding/new clot formation - Antiseptic pack
- Review patient
- Change packs + dressing
- As soon as pain resolves get packs out to allow healing
Why do we not prescribe antibiotics for the management of a dry socket?
It’s not an infection
What to rule out before a dry socket diagnosis
No tooth fragments or bony sequestra remain
- They can prevent healing
How does an infected socket present? (2)
- Infected socket with pus discharge
- Check for remaining tooth/root fragments/bony sequestra
Tx for infected socket (3)
- Radiograph
- Explore/irrigate + remove
- Consider antibiotics
Management of acute OAC if small or sinus intact (3)
- Inform patient
- If small:
- Encourage clot + suture margins - Antibiotics + post op instructions
Management of Acute OAC if large or lining torn (2)
- Close with buccal advancement flap
2. Antibiotics + nose blowing instructions
Management of Chronic OAF (6)
- Excise sinus tract
- Buccal advancement flap
- Buccal fat pad w buccal advancement flap
- Palatal flap
- Bone graft
- Tongue flap
What radiographs do we use to confirm a root in antrum (3)
- OPT
- Occlusal
- Periapical
Define osteomyelitis
Inflammation of the bone marrow
- Usually mandible
- In deep seated infection may see altered sensation due to pressure on IAN
How does osteomyelitis lead to an oedema
Invasion of bacteria into cancellous bone causes soft tissue inflammation + oedema
What does an oedema as a result of osteomyelitis lead to?
Oedema in an enclosed space leads to increased hydrostatic pressure - Compromised blood supply
What does a compromised blood supply as a result of osteomyelitis lead to?
Soft tissue necrosis
The osteomyelitis spreads until arrested by antibiotic + surgical therapy
Why does osteomyelitis tend to occur in the mandible over the maxilla?
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
What are the major disposing factors for osteomyelitis? (2)
- Odontogenic infections
2. Fractures of the mandible
Compare:
- Acute suppurative osteomyelitis
- Chronic osteomyelitis
- Acute suppurative osteomyelitis
- Little/no radiographic change
- At least 10-12 days required for lost bone to be detectable radiographically - Chronic osteomyelitis
+- pus
- Bony destruction in the area of infection
- Radiographic appearance = increased radiolucency (moth eaten appearance)
What are the main bacterias present in mandibular osteomyelitis? (3)
- Streptococci
- Fusobacterium
- Prevotella
What is the main bacteria present in osteomyelitis in other bones?
Staphylococci predominate
What are the 2 types of tx routes for osteomyelitis?
- Medical tx - antibiotics
2. Surgical tx
Medical tx for osteomyelitis
ANTIBIOTICS
> Penicillins
> Effective against odontogenic infections + good bone penetration
Course of antibiotics for
acute vs chronic osteomyelitis
ACUTE
weeks
CHRONIC
months
What tx may severe acute osteomyelitis require?
Hospital admission + IV antibiotics
Surgical tx for osteomyelitis (7)
- 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
Tx for chronic osteomyelitis
Aggressive antibiotic + surgical tx
In what patients is Osteoradionecrosis seen?
Radiotherapy H+N cancer patients
How does osteoradionecrosis from radiotherapy occur?
- Bone within radiation beam becomes virtually non-vital
- Endarteritis
- Reduced blood supply
(so common in mandible) - Turnover of any remaining viable bone is slow
- Self repair ineffective
- Worse with time
Why is the mandible most commonly affected by osteoradionecrosis?
Poorer blood supply
Protocol if osteoradionecrosis patient requires an extraction?
- Careful routine extraction
- Surgical extraction
- Alveoplasty
- Primary closure of soft tissue
What is an alveoplasty?
Cutting down alveolus to allow space for the gum to close over completely
List examples of osteoradionecrosis prevention
- Scaling/chlorrhexidine mouthwash leading up to extraction
- Careful extraction technique
- Antibiotics,
- Hyperbaric o2 (to increase local tissue oxygenation + vascular ingrowth to hypoxic areas) before and after extraction
- Take advice/refer pt for extraction
Osteoradionecrosis tx (2)
- Irrigation of necrotic debris
2. Loose sequestra removed
How quickly do small wounds from osteoradionecrosis tx heal?
Small wounds under 1cm heal over a course of weeks/months
Protocol if the wound is severe or getting worse and bigger? (2)
Surgical intervention
- Resection of exposed bone
- Margin of unexposed bone + soft tissue closure
- Hyperbaric o2
What drug causes MRONJ?
Bisphosphonates
- Used to tx osteporosis
- Risk higher in IV bisphosphonates but can still occur in patients taking oral ones
Function of bisphosphonates
Inhibit osteoclast activity + inhibit bone resorption
This inhibits bone renewal
When can MRONJ occur? (3)
- Post extractions
- Following denture trauma
- Spontaneous
Exclusive to jaw - mandible + maxilla
What other factors are important in causing MRONJ?
- Length of time patient on the drug
- Diabetes
- Steroids
- Anticancer chemo
- Smoking
What procedure to avoid if patient has MRONJ?
Extractions
- If required need careful technique + monitor patient and look for signs
Tx for MRONJ (6)
Not v successful
INSTEAD
- Manage symptoms
- Remove sharp edges of bone
- Chlorrhexidine mouthwash
- Antibiotics if suppuration
- Debridement
- Major surgical sequestromg/resection/hyperbaric o2
Example of a bisphosphonate
Aledronic acid
High risk vs low risk guidelines:
For patients being tx’d for osteoporosis or other non-malignant disease of bone (4)
LOW RISK
- Oral bisphosphonates for less than 5yrs and not being tx’d with systemic glucocorticoids
- Quarterly/yearly infusions of IV bisphosphonates for less than 5yrs who are not being tx’d with systemic glucocorticoids
HIGH RISK
- Oral bisphosphonates or quarterly/yearly infusions of IV bisphosphonates for more than 5yrs
- Bisphosphonates or denosumab for any length of time who are being tx’d with systemic gluocorticoids
Risk factors for MRONJ
- Dental implants
- Avoid in high doses of anti-resorptive or anti-angiogenic drugs for the management of cancer - Other meds
- Steroids + antiresorptive drugs - Previous drug hx
- Drug holidays
What is actinomycosis?
Rare bacterial infection
Thick lumpy pus
Responds initially to antibiotic therapy/recurs when we stop antibiotics
Actinomycosis tx
- Incise + drain pus
- 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:
- Peniccilin
Define infective endocarditis
Inflammatoin of the endocardium, particularly affecting heart valves
Significant mortality of infective endocarditis
20%
Antibiotic prophylaxis for infective endocarditis high risk patients
- Amoxicillin
- 3g oral powder sachet
2 Clindamycin capsules 300mg
- Azithromycin oral suspension 200mg
