Post extraction complications -Immediate post-operative/short term post-operative Flashcards
What post exctraction complications can occur
Pain/Swelling/Ecchymosis
Trismus/ Limited mouth opening
Haemorrhage / Post-op bleeding
Prolonged effects of nerve damage
Dry Socket
Sequestrum
Infected Socket
Chronic OAF / root in antrum
What is the most common complication of extraction, how does it occur and how do you manage it
Pain
Rough handling of tissues
-laceration / tearing of soft tissues
-leaving bone exposed
-incomplete extraction of tooth
Warn patient/advise or prescribe analgesia
What is caused by Part of the inflammatory reaction to surgical interference
Swelling (Odema)
What is Ecchymosis and how it is worsened
Brusing
Increased by poor surgical technique
e.g. rough handling of soft tissue / pulling flaps / crushing tissues with instrument, tearing of periostium
What is trismus and how does it occur
Jaw stiffness / inability to open mouth fully
Variety of causes:
- related to surgery (oedema / muscle spasm)
- related to giving LA – IDB (medial pterygoid muscle spasm)
- Haematoma, medial pterygoid or less likely masseter (haematoma/clot organises and fibroses)
- damage to TMJ, oedema/joint effusion
How do you manage trismus
Monitor it
Could take iboprofen
Gentle mouth opening exercises (trismus screw)
What happens in a immediate post op haemorrhage
reactionary / rebound bleeding
- occurs within 48 hours of extraction
- vessels open up / vasoconstricting effects of LA wear off / sutures loose or lost / patient traumatises area with tongue/finger/food
What is secondary bleeding
- often due to infection
- commonly 3-7 days
- usually mild ooze but can occasionally be a major bleed
- medication related
If there is a heamorrhage in soft tissue or bone what do you do
If soft tissue:
–Pressure (mechanical –finger/biting on damp gauze swab)
–Sutures
–Local Anaesthetic with adrenaline (vasoconstrictor)
–Diathermy (cauterise/burn vessels precipitate proteins which form proteinaceous plug in vessel)
If bone:
–Pressure (via swab)
–LA on a swab
–Haemostatic agents
–Blunt instrument
–Bone Wax
–Pack & Suture
What haemostatic agents can you use
Adrenaline containing LA – vasoconstrictor
Oxidised regenerated cellulose – Surgicel / equitamp
-Provides framework for clot formation
Haemocollagen Sponge –absorbable/meshwork for clot formation
Thrombin liquid and powder
Floseal
What does Oxidised regenerated cellulose do
provides framework for clot formation
What haemostatic agent must you be careful of and when
Oxidised regenerated cellulose
Careful in lower 8 region – acidic – damage to IDN
What systemic haemostatic aids are there
Vitamin K (necessary for formation of clotting factors)
Anti-Fibrinolytics e.g. Tranexamic acid (prevents clot breakdown/stabilises clot – systemic tablets or mouthwash)
Missing Blood Clotting Factors
Plasma or whole blood
Desmopressin
How do you manage post op bleding
If bleeding severe get pressure on immediately / arrest the bleed
Calm anxious patient / separate from anxious relatives
Clean patient up / remove bowls of blood / blood-soaked towels
Take a thorough but rapid history while dealing with haemorrhage
Get inside mouth apply suction remove clot
identify where bleeding from
Apply pressure- finger/biting on damp gauze
LA with vasoconctrictor
Haemostatic aids, bone wax in socket
Ligation of vessels if needed
If you cannot manage bleeding what do you do
Urgent hospital referral
weekdays- dental hospital/ maxillofacial outpatients
evnings/weekends- maxillofacial on call or A&E
How can you prevent post op haemorrhage
Thorough MH
Atraumatic extraction/ surgical technique
Obtain and check good haemostatis at end of surgery
provide good instructions to patient
What are the post op instructions
Do not rinse out for several hours (better not to rinse till next day, then avoid vigorous mouth rinsing – wash clot away)
Avoid trauma - do not explore socket with tongue or fingers/hard food
Avoid hot food that day
Avoid excessive physical exercise and excess alcohol – increase blood pressure
Advice on control of bleeding
- Biting on damp gauze/tissue
-Pressure for at least 30min (longer if bleeding continues)
-Points of contact if bleeding continues
Wha are the 3 types of sensory change and what type of sensation change could it be
Anaesthesia (numbness)
Paraesthesia (tingling)
Dysaesthesia (unpleasant sensation/pain)
The sensation change could be
-Hypoaesthesia (reduced sensation)
-Hyperaesthesia (increased/heightened sensation)
What are the 3 types of nerve damage
Neurapraxia – Contusion of nerve/continuity of epineural sheath and axons maintained
Axonotmesis – Continuity of axons but not epineural sheath disrupted
Neurotmesis – Complete loss of nerve continuity/nerve transected
What is the clinical word for dry socket
Alveolar Osteitis
What are the stats of dry sockets
Affects 2- 3% of all extractions
Some say up to 20-35% of lower 8s
What causes dry socket
Normal clot disappears or breaks down (appear to be looking at bare bone/empty socket – partially or completely lost blood clot)
Localised Osteitis – inflammation affecting lamina dura
What is the main feature of dry socket
Intense pain
When does dry socket occur
3-4 days after extraction
How long does dry socket take to resolve
7-14 days
What are the symptoms of dry socket
Dull aching pain – moderate to severe
Usually throbs/can radiate to patient’s ear/often continuous and can keep patient awake at night
Characteristic smell/bad odour & patient frequently complains of bad taste
What is the source of the pain in dry socket
The exposed bone is sensitive and is the source of the pain
What are predisposing factors to dry socket
Molars more common – risk increases from anterior to posterior
Mandible more common
Smoking – reduced blood supply
Female
Oral Contraceptive Pill
Local Anaesthetic – vasoconstrictor
Excessive trauma during extraction
Excessive mouth rinsing post extraction (clot washed away)
Family history/ previous dry socket
What is the management of dry socket
Supportive – reassurance / systemic analgesia
LA
Irrigate socket with warm saline (wash out food and debris)
Curettage/debridement maybe (encourage bleeding/new clot formation)
Antiseptic Pack (Alvogyl)
Advise patient on Analgesia and hot salty mouthwashes
Review patient / change packs and dressings (as soon as pain resolves get packs out to allow healing)
Generally, do not prescribe antibiotics as it is not infection
Remember to check initially that it is a dry socket and that no tooth fragments or bony sequestra remain
What is a sequestrum
Usually bits of dead bone (can see white spicules coming through gingivae)
Quite common
Prevent healing
Can remove it if prevents healing
What are the signs of an infected sdocket
Pus discharge
What do you do for a infected socket
check for remaining tooth/root fragments/bony sequestra/foreign bodies.
Treatment
-radiograph/explore/irrigate/remove any of the above/consider antibiotics
Infection more commonly seen after minor surgical procedures involving soft tissue flaps and bone removal
What dental procedures are unlikely to cause bleeding
LA by infiltration/ intraligamentry/ mental nerve block/ IDB
BPE
SupG. removal of plaque, calculus and stain
Direct or indirect restorations with supG margins
Impresssions
Fitting and adjustmetns of ortho appliances
Endodontics orthograde
What dental procedures are low risk to cause bleeding
Simple extractions, 1-3 teeth with restricted wound size
Incision and drainage of intra-oral swellings
Detailed 6 ppc
RSD
Direct or indirect restorations with SubG margins
What dental procedures are higher risk to cause bleeding
Complex extractions, adjacent extractions that will cause a large wound or more than 3 extractions at once
Flap raising procedures
-elective surgical procedurs
-perio surgery
-preprosthetic surgery
-periradicular surgery
-crown lengthening
-Implants
Gingival recountouring
Biopsy
If a a patient takes a Vitamin K antagonist (eg warafin) what do you do
Check INR within 24hrs of procedure
If below 4= treat without interupting
If above 4= postpone
If a patient takes antiplatelet drugs what do you do
If aspirin alone- treat without interupting medication, use local haemostatic measures
If Clopidogrel, dipyridamole, prasugrel or ticagrelor or dual therapy( (combo with aspirin)- Treat without interupting medication but expect prolonged bleeding, dont take >3 teeth and use haemoststic measures
If patient takes DOACS what do you do
Low bleeding risk procedure- treat without interupting medication but treat early in day
Higher bleeding risk procedure- advise patient to miss or delay morning dose (advise patient when to restart medication)
If patient takes Apixaban or dabigatran whats the usual drug schedule, morning dose (pretreatment), post treatment dose
twice a day
miss moring dose
usual time in evning
If patient takes Rivaroxaban whats the usual drug schedule, morning dose (pretreatment), post treatment dose
once a day morning
delay morning dose
4 hours after haemostatis has been achieved
If patient takes Edoxaban whats the usual drug schedule, morning dose (pretreatment), post treatment dose
Once a day evening
not appicable
usual time in evening
