Post extraction/surgical complications Flashcards
1
Q
What should be the ideal INR for patients on warfarin ?
A
between 2-4 - ideally constant
the INR should be performed at a minimum of 72 hours prior to dental surgery
(3 days)
2
Q
Give examples of conditions which need further considerations prior to dental surgery
A
- poorly controlled angina, asthma, diabetes, epilepsy
- pregnancy (possible induction of labour?, risk of DVT)
- immunocompromised patients
3
Q
Oral bisphosphonates are often prescribed for …
A
osteoporosis
4
Q
Give examples of oral bisphosphonates used to treat osteoporosis
A
- Alendronic acid/alendronate (fosamax)
- disodium etidronate (didronel)
- Ibandroate (bonviva)
5
Q
Briefly describe absorption of oral bisphosphonates
A
poorly absorbed into bone
6
Q
Give examples of IV bisphosphonates
A
- Zoledronate (zometa)
- Ibandroate
- Pamidronate
7
Q
Briefly describe the absorption of IV bisphosphonates
A
extremely well absorbed into bone
8
Q
Outline the uses of IV bisphosphonates
A
to control bone metastases of certain cancers e.g. breast cancer
9
Q
Outline the suggested protocol for XLA for a patient on oral bisphosphonates
A
- antiseptic mouthwash
- XLA as normal
- monitor
10
Q
Outline the suggested protocol for XLA for a patient on IV bisphosphonates
A
- pre/post antibiotics
- antiseptic mouthwash
- close monitoring
11
Q
Antibiotics only reduce the risk of ________ infection
A
secondary
12
Q
What are the eating instructions given to a patient who suffers from hypoglycaemic episodes undergoing MOS ?
A
- eat before coming to appt
- post-op: do not eat for the next 2 hours
13
Q
Outline the bioloical process that occurs before a vaso-vagal syncope
A
- stress- brief tachycardia
- vasodilation
- increased vagal tone
- bradycardia
- hypotension
- decreased cerebral blood flow
- syncope
14
Q
What does a syncope refer to ?
A
temporary loss of consciousness
15
Q
What are the signs/symptoms of a vaso-vagal syncope ?
A
- light-headedness
- nausea
- sweating
- tinnitus
- weakness and visual disturbances
- fitting
- incontinence
16
Q
What treatment is appropriate for a vaso-vagal syncope?
A
- call for help
- lie flat
- reassure
- monitor
- oxygen if prolonged (15L/min)
17
Q
Outline instances which may lead to increased need for glucose
A
- pain
- lack of sleep
- anxiety
- stress
- infection
18
Q
Outline the symptoms of hypoglycaemia
A
- shakiness
- tachycardia
- sweatiness
- pallor
- confusion
- aggression
- light headedness
- collapse
19
Q
What is the normal blood sugar range?
A
4-6mmol/L
20
Q
What is the blood glucose range for hypoglycaemia ?
A
<3mmol/L
21
Q
What treatment can be offered for a patient experiencing a hypoglycaemic attack?
A
- call for help
- reassure
- glucose drink/hypostop/can also give long carbohydrate to prevent a dip
- monitor
22
Q
Outline immediate local complications of MOS
A
- fracture- crown/root/bone
- soft tissue tear- gingiva or alveolar mucosa
- haemorrhage
- OAC
- fractured instrument (luxators)
23
Q
Outline immediate regional/distant complications of MOS
A
- crushed/burnt lip
- nerve damage
- lacerated tongue or palate (from using luxators)
- swallowed/inhaled tooth or instrument
24
Q
Outline delayed local complications of MOS
A
- alveolar osteitis (dry socket)/local infection
- delayed or secondary haemorrhage
- osteonecrosis
25
Outline delayed regional/distant complications of MOS
* spreading infection
* myofascial pain dysfunction
* injection haematoma
26
What could be a potential cause of delayed/secondary haemorrhage?
* LA wearing off
* pt touching the site
27
What increases risk of osteonecrosis?
* immunomodulators
* bisphosphonates
* steroids (impaired wound healing)
28
Outline late local complications of MOS
alveolar atrophy
29
Outline late regional/distant complications of MOS
* osteomyelitis
* actinomycosis
30
Outline POI/warnings following XLA/MOS
* numbness due to LA; be careful with lip/tongue/cheek
* avoid hot drinks, hard foods until numbness has worn off
* protect socket
* do not gargle for 24 hours
* no excessive exercise
* avoid smoking
* avoid alcohol
* keep mouth clean
* advice on pain relief- paracetamol/ibuprofen
31
What should smoking be avoided following XLA?
* can delay clot formation
* leads to infected socket
32
Why should alcohol be avoided following XLA?
* can cause clot to break down
* leads to bleeding
33
What instructions should be given to pt for 24 hours after XLA/MOS?
* rinse regularly every few hours with warm salt water
* pain relief
* advice on bleeding if occurs post- op
34
What is the appropriate concentration of salt water that can be used for rinsing ?
9g/L
0.09%
35
Bruising and swelling will always occur in the same place. True or false
false
36
According to guidelines when is it okay to leave a fractured tooth behind ?
* <5mm tooth left
* No periapical lesion
* no PMH/anatomy
37
According to guidelines, when is it appropriate to remove a fractured tooth?
* >5mm tooth left
* periapical lesion
* PMH issue
38
If you lead a fractured tooth behind , what must you do ?
* warn patient
* document
39
What is the most frequently inhaled or swallowed tooth?
upper 8
40
Why should you avoid using dry gauze to control a haemorrhaging site?
this is because it will have clotting tags which will dislodge the clot when removed
41
If bleeding continues after the use of gauze for 10 minutes with pressure, what should you do ?
* haemostatic agent
* suture
42
How long should you leave a non-resorbable suture in and why?
* 7-10 days
* to allow secondary mesh to form
43
Give examples of haemostatic agent that does not contain animal product
surgicel
44
Give examples of haemostatic agents that contain animal product
* hemocollagene
* gelatamp
45
What is tranexamic acid ?
anti-fibronolytic agent
prevents the break down of the clot
46
If there have been many reasonable attempts to control bleeding and it continues, what should you do?
refer to haematology unit
47
What investigations can be undergone in the haematology unit?
* FBC- particularly platelet count
* INR
* APPT (activated partial thromboplastin time)
48
What does the INR monitor?
extrinsic part of the coagulation cascade
49
What does the APTT monitor?
intrinsic part of the coagulation cascade
50
When can nerve injury (ID, mental, lingual) occur?
* during LA
* surgical trauma
51
In what ways can LA cause nerve injury?
* direct trauma from injection needle
* intraneural haematoma
* neurotoxicity of LA- localised chemical damage to the nerve
52
What region of the face can be tested the superior alveolar nerve injuries?
premaxillary region of V2
53
What region of the face can be tested for inferior alveolar and mental nerve injuries?
the mental region of V3
54
Outline factors that affect the risk of IAN damage
* expertise of surgeon
* difficulty depth- crown at CE junction of second molar
* mesial or horizontal impaction
* time taken for procedure
* sectioning tooth several times
* surgical technique employed
* whether roots are completely formed or not
* roots close to NV bundle as defined on x-ray
* increasing age of patient
* distal bone removal
* intra-operative visualisation of mandibular canal
55
What is the most common cause of lingual nerve injury?
third molar surgery
56
88% of lingual nerve injuries associated with 3rd molar surgeries resolve. True or false
True
57
What are some reasons for persistence of peripheral sensory nerve injuries?
* severity of injury
* increased age of patient
* time elapsed since injury
58
Why are lingual nerve injuries likely to occur in 3rd molar surgeries?
operators going more lingual on their flap
more likely to cause damage this way
59
What is alveolar osteitis?
local inflammation of th alveolus due to fibrinolysis and loss of blood clot
59
Why do guidelines insist on the necessity of a pre-operative neurosensory evaluation prior to placement of dental implants?
thsi is because nerve injuries related to dental implant treatment is becoming an increasing problem
60
What are the features of alveoolar osteitis?
* pain after recent extraction
* exposed bone after recent extraction
* infective component
* traumatic component
61
How is alveolar osteitis managed?
* rinse out debris
* irrigate with saline
* dress with sedative material e.g. alveogyl (contains eugenol)
62
Outline instances where fracture of the bone at tooth extraction is more likely
* greater force is used
* force is applied in directions not likely to displace teeth
* force is applied suddently
* bone is thinner or more bone is removed
* bone is removed (osteogenesis imperfecta/pagets disease)
* root is large
* root form makes tooth resistant to extraction
* true ankylosis
63
What is a fistulae ?
epithelialised channel
64
Give a sign for the presence of an OAC
some bubbling may be visible
65
What must you avoid in the presense of an OAC?
* Nose blowing
* smoking
66
What sort of OAC defect may heal spontaneously? What treatment should be offered if an OAC is suspected to heal spontaneously?
* if the defect is less than 5mm
* treatment should be directed at preserving the blood clot
67
Suggest ways that a clot may be preserved in an OAC
* suture with or without pack
* use existing denture to support clot
68
Suggest treatments for OAC/OAF
* surgery- buccal advancement flap/rehmanns flap
* palatal rotation flap
* buccal fat pad
69
What surgical instrument can lead to mandibular fractures?
cow-horns
70
What is osteomyelitis?
inflammation/swelling in bone
71
What are the clinical features of osteomyelitis?
* signs of infection
* reduced sensitivity in lower lip
* tenderness and mobility of adjacent teeth
* patchy or irregular bone loss
* sequestration- bone left unbound and loose
* periosteal thickening
* subperisoteal new bone
* pathological fracture
72
What bacterial is responsible for actinomycosis?
actinomyces israeli
73
Actinomycosis should be included in risks for what type of patients?
immunocompromised
