Post extraction complications -Immediate post-operative/short term post-operative

Question 1

What post exctraction complications can occur

Answer 1

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

Question 2

What is the most common complication of extraction, how does it occur and how do you manage it

Answer 2

Pain

Rough handling of tissues
-laceration / tearing of soft tissues
-leaving bone exposed
-incomplete extraction of tooth

Warn patient/advise or prescribe analgesia

Question 3

What is caused by Part of the inflammatory reaction to surgical interference

Answer 3

Swelling (Odema)

Question 4

What is Ecchymosis and how it is worsened

Answer 4

Brusing

Increased by poor surgical technique
e.g. rough handling of soft tissue / pulling flaps / crushing tissues with instrument, tearing of periostium

Question 5

What is trismus and how does it occur

Answer 5

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

Question 6

How do you manage trismus

Answer 6

Monitor it

Could take iboprofen

Gentle mouth opening exercises (trismus screw)

Question 7

What happens in a immediate post op haemorrhage

Answer 7

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

Question 8

What is secondary bleeding

Answer 8

• often due to infection
• commonly 3-7 days
• usually mild ooze but can occasionally be a major bleed
• medication related

Question 9

If there is a heamorrhage in soft tissue or bone what do you do

Answer 9

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

Question 10

What haemostatic agents can you use

Answer 10

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

Question 11

What does Oxidised regenerated cellulose do

Answer 11

provides framework for clot formation

Question 12

What haemostatic agent must you be careful of and when

Answer 12

Oxidised regenerated cellulose

Careful in lower 8 region – acidic – damage to IDN

Question 13

What systemic haemostatic aids are there

Answer 13

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

Question 14

How do you manage post op bleding

Answer 14

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

Question 15

If you cannot manage bleeding what do you do

Answer 15

Urgent hospital referral

weekdays- dental hospital/ maxillofacial outpatients

evnings/weekends- maxillofacial on call or A&E

Question 16

How can you prevent post op haemorrhage

Answer 16

Thorough MH

Atraumatic extraction/ surgical technique

Obtain and check good haemostatis at end of surgery

provide good instructions to patient

Question 17

What are the post op instructions

Answer 17

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

Question 18

Wha are the 3 types of sensory change and what type of sensation change could it be

Answer 18

Anaesthesia (numbness)
Paraesthesia (tingling)
Dysaesthesia (unpleasant sensation/pain)

The sensation change could be
-Hypoaesthesia (reduced sensation)
-Hyperaesthesia (increased/heightened sensation)

Question 19

What are the 3 types of nerve damage

Answer 19

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

Question 20

What is the clinical word for dry socket

Answer 20

Alveolar Osteitis

Question 21

What are the stats of dry sockets

Answer 21

Affects 2- 3% of all extractions

Some say up to 20-35% of lower 8s

Question 22

What causes dry socket

Answer 22

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

Question 23

What is the main feature of dry socket

Answer 23

Intense pain

Question 24

When does dry socket occur

Answer 24

3-4 days after extraction

Question 25

How long does dry socket take to resolve

Answer 25

7-14 days

Question 26

What are the symptoms of dry socket

Answer 26

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

Question 27

What is the source of the pain in dry socket

Answer 27

The exposed bone is sensitive and is the source of the pain

Question 28

What are predisposing factors to dry socket

Answer 28

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

Question 29

What is the management of dry socket

Answer 29

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

Question 30

What is a sequestrum

Answer 30

Usually bits of dead bone (can see white spicules coming through gingivae) Quite common Prevent healing Can remove it if prevents healing

Question 31

What are the signs of an infected sdocket

Answer 31

Pus discharge

Question 32

What do you do for a infected socket

Answer 32

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

Question 33

What dental procedures are unlikely to cause bleeding

Answer 33

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

Question 34

What dental procedures are low risk to cause bleeding

Answer 34

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

Question 35

What dental procedures are higher risk to cause bleeding

Answer 35

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

Question 36

If a a patient takes a Vitamin K antagonist (eg warafin) what do you do

Answer 36

Check INR within 24hrs of procedure If below 4= treat without interupting If above 4= postpone

Question 37

If a patient takes antiplatelet drugs what do you do

Answer 37

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

Question 38

If patient takes DOACS what do you do

Answer 38

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)

Question 39

If patient takes Apixaban or dabigatran whats the usual drug schedule, morning dose (pretreatment), post treatment dose

Answer 39

twice a day miss moring dose usual time in evning

Question 40

If patient takes Rivaroxaban whats the usual drug schedule, morning dose (pretreatment), post treatment dose

Answer 40

once a day morning delay morning dose 4 hours after haemostatis has been achieved

Question 41

If patient takes Edoxaban whats the usual drug schedule, morning dose (pretreatment), post treatment dose

Answer 41

Once a day evening not appicable usual time in evening