Post op complications 4 (Longer term post-operative) Flashcards
What can fall under these complications: Longer term post-operative
Acute oral antral communication
Chronic oral antral fistula
Root in antrum
What are less common post operative complications
Osteomyelitis
Osteoradionecrosis (ORN)
Medication induced
osteonecrosis (MRONJ)
Actinomycosis
Bacteraemia/Infective endocarditis
How can you diagnose a OAC
By:
Size of tooth
Radiographic position of roots in relation to antrum
Bone at trifurcation of roots
Bubbling of blood
Nose holding test (careful as can create an OAF)
Direct vision
Good light and suction - echo
Blunt probe (take care not to create an OAF)
How do you manage a OAC
Inform patient
If small or sinus intact:
-Encourage clot
-Suture margins
-?Antibiotic
-Post-op instructions
How would you manage a larger acute OAC
Close with buccal advancement flap
Antibiotics, decongestants, and nose blowing instructions
How would you manage a chronic OAF
Excise sinus tract
Buccal Advancement Flap
Buccal Fat Pad with Buccal Advancement Flap
Palatal Flap
Bone Graft/Collagen membrane
How are roots in antrum confirmed
Radiographically by OPT occlusal or periapical
How would you retrieve a forgein body in antrum
OAF type approach/through the socket:
-Flap Design
-Open fenestration with care
-Suction – efficient and narrow bore
-Small curettes
-Irrigation or ribbon gauze
-Close as for OAC
What is the caldwell luc approach and what is it used for
To retrieve forgein bdy in antrum
The procedure involves creating an incision in the gum line above the upper teeth, and then creating a window in the bone of the maxillary sinus to access and remove any foreign objects that may be present
Performed under GA
What does FESS stand for
Functional Endoscopic Sinus Surgery
What is osteomyelitis
The term means inflammation of the bone marrow
Clinically the term implies an infection of the bone
Where is Osteomyelitis normally affecting
The mandible
What are the symptoms of Osteomyelitis
Patient often systemically unwell/raised temperature
Site of extraction often very tender
In deep seated infection may see altered sensation due to pressure on IAN
Where does osteomyelitis start and spread to
Usually begins in medullary cavity involving the cancellous bone
Then extends and spreads to cortical bone
Then eventually to periosteum
How does osteomyelitis happen
Invasion of bacteria into cancellous bone causes soft tissue inflammation and oedema in the closed bony marrow spaces
Oedema in an enclosed space leads to increased tissue hydrostatic pressure – higher than blood pressure of feeding arterial vessels
Compromised blood supply results in soft tissue necrosis
Involved area becomes ischaemic & necrotic
Bacteria proliferate because normal blood borne defences do not reach the tissue
The osteomyelitis spreads until arrested by antibiotic and surgical therapy
Why does osteomyelitis happen usually in themandible over the maxilla
Mandible has a poorer blood supply
What are the predisposing factors to osteomyelitis
Odontogenic infections & fractures of mandible
Compromised host defence
-(Diabetes/ Alcoholism/ IV Drug Use/ Malnutrition/ Myeloproliferative Disease, chemo etc)
How can you identify osteomyelitis in a radiograph
Areas of radiopacity may occur within the radiolucent region
In long-standing chronic osteomyelitis there may be an increase in radiodensity surrounding the radioluscent area – an involucrum
increased radiolucency (uniform or patchy with a ‘moth-eaten appearance)
how would treat osteomyelitis
Antibiotic/ surgical treatment
how would treat osteomyelitis
Antibiotic/ surgical treatment
What is the antibiotic treatment for osteomyelitis
penicillins generally 1st line drug – effective against odontogenic infections & good bone penetration
Longer courses than normal
Often weeks in acute osteomyelitis (some suggest at least 6 weeks after resolution of symptoms)/months in chronic osteomyelitis (in some cases up to 6 months)
Severe acute osteomyelitis may require hospital admission and IV antibiotics (if systemic symptoms)
What is the surgical treatment for osteomyelitis
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
What is osteoradionecrosis (ORN)
Seen in patients who have received radiotherapy of the head & neck to treat cancer
The bone within radiation beam becomes virtually non-vital
Endarteritis – reduced blood supply
Turnover of any remaining viable bone is slow
Self-repair ineffective
Worse with time and dose
What is more likely to be affected by ORN and why
Mandible due to poor blood supply
How could you prevent ORN
Scaling/Chlorhexidine mouthwash leading up to extraction
Careful extraction technique
Antibiotics, chlorhexidine mouthwash and review
Hyperbaric oxygen (to increase local tissue oxygenation & vascular ingrowth to hypoxic areas) before and after extraction
Take advice/refer patient for extraction
What is the treatment for ORN
Irrigation of necrotic debris
Antibiotics not overly helpful unless secondary infection
Loose sequestra removed
Small wounds (under 1cm) usually heal over a course of weeks/months
Severe cases – resection of exposed bone, margin of unexposed bone and soft tissue closure
Hyperbaric oxygen
What are bisphonates used to treat and how
osteoporosis, Paget’s Disease & malignant bone metastases
They inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal
How long do bisphosponates stay in the body for
10 years
Name some bisphosphonates
Alendronate-Fosamax– Oral
Clodronate – Bonefos – IV
Etidronate – Didronel – Oral
Ibandronate – Boniva – Oral
Pamidronate – Aredia – IV
Risedronate – Actonel – Oral
Tiludronate – Skelid – Oral
Zoledronate – Zometa - IV
Who has highr risk of MRONJ
Those that take IV bisphosphonates but theres still risk in others
What other drugs could put a patient at risk of MRONJ
anti-angiogenic and anti-resorptive drug
What are the SDCEP 2017 guidance on MRONJ incidence on thos who take anti-angiogenic and anti-resorptive drugs
cancer patients treated with anti-resorptive and anti-angiogenic drugs: 1.6-14.8%
osteoporosis patients treated with anti-resorptive drugs: 0.1-0.5%
When would MRONJ occur and where
Occurs post extraction/following denture trauma/spontaneous
Exclusive to the jaws
Both mandible and maxilla
What are the risk factors of MRONJ
Dental treatment:
-impact on bone(extractions)/ trauma from dentures/ infection/ perio
Duruation of bisphosphonate drug therapy
Dental implants
-General consensus is to avoid implant placement in high doses of anti-resoprtive or anti-angiogenic drugs for the management of cancer,
Its not contraindicated in patients with osteoporosis
Other concurrent drug use
-Concurrent use of steroids + anti-repsorptive drugs = increased risk of MRONJ
-Concurrent use of anti-resporptive and anti-angiogenic = increased risk of MRONJ
previous drug history
Drug holidays
What puts a patient at low risk of MRONJ
PAtient being treated for osteoporosis or other nonmalignant disease of bone with oral bisphosphonates for less than 5 years who are not systemically being treated with glucocorticoids
Patients being treated for osteoporosis or other nonmalignant disease of bone with quarterly or yearly infusions of IV Bisph for less than 5 years who are not systemically being treated with glucocorticoids
Patients being treated for osteoporosis or other nonmalignant disease of bone with denosumab who are not systemically being treated with glucocorticoids
What puts apatient at high risk of MRONJ
Patients being treated for osteoporosis or other nonmalignant disease of bone with oral BisPh or quarterly or yearly infusions of IV BisPh for more than 5 years
Patients being treated for osteoporosis or other nonmalignant disease of bone with BisPh or denosumab for any length of time who are currently being treated with systemic glucocorticoids
Patients being treated with anti resorptive or anti-angiogenic drugs as part of management of cancer
Patients with previous history of MRONJ
How would you treat MRONJ
Treatment of Medication Induced / Related Osteonecrosis is not that successful
Manage symptoms/remove sharp edges of bone/chlorhexidine mouthwash/antibiotics if suppuration
What is actinomycosis and what is it caused by and how
Rare bacterial infection
Actinomyces israelii/ A. naeslundii/ A. viscosus
The bacteria have low virulence and must be inoculated into an area of injury or susceptibility
-E.g. recent extraction/severely carious teeth/bone fracture/minor oral trauma
What are symptoms of Actinomycosis
Multiple skin sinuses and swelling
Thick lumpy pus – colonies of Actinomyces look like sulphur granules on histology
Responds initially to antibiotic therapy/recurs when stop antibiotics
How do you treat Actinmycosis
I&D of pus accumulation
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: Penicillins, doxycycline or clindamycin
With regards to Infective endocarditis what is an invasive dental treatment
Placement of matrix band/ subgingival rubber dam clamps
SubG resorations
Endo treatment before apical stop established
Preformed metal crowns
Full perio exam
RSB
Icision and drainage of abscess
Extractions
Surgergy involving flaps
Dental implants
With regards to Infective endocarditis what is an non-invasive dental treatment
Infiltration or block
BPE screening
SupraG scale and polish
SupraG restoration
SupraG ortho bands and seperators
Removal of sutures
Radiographs
placement of ROA
