Post-operative Complications Flashcards
1
Q
Provide examples of possible post operative complications
A
- pain
- swelling
- ecchymosis/bruising
- trismus/limited mouth opening
- haemorrhage/post-op bleeding
- prolonged effects of nerve damage
- dry socket
- sequestrum
- infected socket
- chronic oroantral fistula (OAF)
- osteomyelitis
- osteoradionecrosis (ORN)
- medication induced osteonecrosis (MRONJ)
- actinomycosis
- bacteraemia/infective endocarditis
2
Q
Discuss pain as a post-operative complication
A
- most common complication of extraction
- inform patient
- advise or prescribe analgesia
- standard is paracetamol and ibuprofen
- rough handling of tissues increases pain
- laceration or tearing of soft tissues
- exposure of bone
- incomplete extraction of tooth
3
Q
Discuss swelling as a post operative complication
A
- oedema is soft
- resolves within 48 hours
- part of the inflammatory reaction to surgical interference
- increased by poor surgical technique
- rough handling of soft tissue
- pulling flaps
- crushing tissues with instrument
- tearing of periosteum
- wide individual variation
4
Q
Discuss ecchymosis as a post operative complication
A
- bruising
- increased by poor surgical technique
- rough handling of soft tissue
- pulling flaps
- crushing tissues with instrument
- tearing of periosteum
- may indicate underlying medical issues
- antiplatelet and anticoagulant medication increase risk
- individual variation
- around surgical area
- gravity pulls downwards
- 8-10 days post-op
5
Q
Discuss trismus as a post operative complication
A
- jaw stiffness
- inability to open mouth fully
- variety of causes
- related to oedema/muscle spasm
- related to administration of local anaesthetic
- IDB
- medial pterygoid muscle spasm
- haematoma
- medial pterygoid, less likely master
- haematoma organises and fibroses
- causes spasm in muscle
- damage to TMJ
- particularly if wide opening is required
- oedema
- joint effusion
- swelling of cartilage within joint capsule
- monitor and mouth open exercises
- several weeks to resolve
- wooden spatula
- trismus screw
6
Q
Discuss prolonged bleeding as a post extraction complication
A
- usually related to medical conditions and medications
- bleeding disorders
- liver disease
- DOACs
- vitamin K antagonist
- injectable anticoagulant
- anti platelet drugs
- combined anticoagulant/antiplatelet
7
Q
How is risk assessed for different oral surgery procedures?
A
- procedures divided into 3 categories
- dental procedures that are unlikely to cause bleeding
- dental procedures that are likely to cause bleeding
- low risk of post-operative bleeding
- high risk of post-operative bleeding
8
Q
What procedures are considered unlikely to cause bleeding
A
- LA by infiltration, intraligamentary or block
- BPE
- supra gingival PMPR
- direct or indirect restoration with supra gingival margins
- endodontics - orthograde
- impressions and other prosthetics procedures
- fitting and adjustment of orthodontic appliances
9
Q
What procedures are considered likely to cause bleeding but are low risk?
A
- simple extractions (1-3 teeth)
- incision and drainage of intra-oral swellings
- detailled 6PPC
- root surface debridement
- direct or indirect restorations with sub gingival margins
10
Q
What procedures are considered likely to cause bleeding and are high risk?
A
- complex extractions (large wound/more than 3 teeth)
- flap raising procedures
- gingival recontouring
- biopsies
11
Q
How do vitamin K antagonists affect oral surgery procedures?
A
- INR must be checked within 24 hours prior to surgery
- can be up to 72 hours if patient is stably anti coagulated
- INR below 4 allows treatment without interrupting medications
- limit initial treatment and stage extensive/complex procedures
- suturing and packing after extractions
- INR above 4 requires delay of invasive treatment
- unless life threatening delay
- expected INR varies for reason on warfarin
- AF or previous DVT around 2.5
- metal heart valve replacement around 3.5
12
Q
How do antiplatelet drugs affect oral surgery procedures?
A
- aspirin alone
- treatment without interrupting medication
- consider local haemostatic measures
- consider staging treatment
- clopidogrel, dipyridamole, prasugrel, tricagrelor (singal or dual)
- can be in combination with aspirin
- treatment without interrupting medication
- expect prolonged bleeding
- consider staging treatment
- consider local haemostatic measures (suturing and packing)
13
Q
How do DOACs affect oral surgery procedures?
A
- for low bleeding risk treat without interrupting medication
- for higher bleeding risk adjust medication
- apixaban and dabigatran
- miss morning dose and take usual time in evening - rivaroxaban and edoxaban
- delay morning dose and take 4 hours after haemostasis
- apixaban and dabigatran
- treat early in the day
- consider staging treatment
- consider local haemostatic measures
14
Q
What is immediate post-operative bleeding?
A
- reactionary/rebound bleeding
- within 48 hours of extraction
- local anaesthetic wears off, vessels open up, sutures can be lost, patient traumatises area
15
Q
What is secondary bleeding?
A
- often due to post-operative infection
- 3-7 days after treatment
- usually mild oozing but occasionally can be a major bleed
- can be medication related
16
Q
What haemostatic agents are used in oral surgery?
A
- adrenaline containing local anaesthetic
- LA infused swab
- patient bites on swab
- combined vasoconstriction and pressure is often effective
- oxidised regenerated cellulose
- surgicel and equitamp
- provides framework for clot formation
- care in lower 8 region, acidic can damage IAN
- suture over socket to keep in place, can become gelatinous
- haemocollagen sponge
- absorbable meshwork for clot formation
- thrombin liquid and powder and floseal
- injectable or packed into socket
- good for patients with haemophilia, coagulation defects, medications
17
Q
What systemic haemostatic aids are available?
A
- vitamin K
- necessary for formation of clotting factors
- anti-fibrinolytics
- tranexamix acid
- prevents clot breakdown
- stabilised clot
- tablets or mouthwash
- missing blood clotting factors
- plasma or whole blood
- desmopressin
18
Q
How is post-operative bleeding managed?
A
- immediate pressure
- severe bleeding
- attempt to arrest the bleed
- bite on damp gauze
- calm anxious patient
- separate from anxious relatives
- clean patient up
- remove bowls of blood
- remove blood soaked towels
- take a thorough but rapid history while dealing with haemorrhage
- use good lighting and suction
- identify where bleeding is coming from
- remove clot
- mouth often filled with large, jelly like clot
- be aware of vomiting
- after swallowing blood
- local haemostatic aids
- local anaesthetic with vasoconstrictor
- surgicel
- bone wax
- suture socket (interrupted/horizontal)
- ligation of vessels
- diathermy is available
- urgent hospital referral if haemorrhage cannot be arrested
- dental hospital/maxillofacial outpatients during the week
- maxillofacial on call or local hospital A&E at weekend and evenings
19
Q
How can intra-operative and post-operative extraction haemorrhage be prevented?
A
- take a thorough medical history
- anticipate and deal with potential problems
- atraumatic extraction and surgical technique
- obtain and check good haemostasis before end of surgery
- provide good instructions to the patient
20
Q
What should post operative instructions to the patient include?
A
- do not rinse for several hours
- better not to rinse till the next day
- avoid vigorous mouth rinsing
- risks clot being washed away
- avoid trauma
- do not explore socket with tongue or fingers
- do not eat hard food
- avoid hot food that day
- avoid any drastic increase in blood pressure
- excessive physical exercise
- excessive alcohol consumption
- if socket starts bleeding bite on damp gauze or tissue
- pressure for at least 30 minutes
- make contact if bleeding continues
21
Q
Discuss nerve damage as a post extraction complication
A
- mostly when working in third molar region
- also if large pathology, especially in maxilla affecting superior alveolar branches - if no improvement after 18 months unlikely it will further improve
22
Q
Discuss dry socket as a post extraction complication
A
- alveolar osteitis
- common
- affects 2-3% of all extractions
- 20-35% of lower 8s
- normal clot disappears
- bare bone/empty socket visible
- partial or complete
- intense pain
- worse than toothache
- kept awake at night
- accompanied by moderate to severe, dull aching pain
- throbs, radiates to ear
- exposed bone is sensitive and source of pain
- 3-4 days after extraction
- 7-14 days to resolve - localised osteitis
- inflammation affecting the lamina dura
- debate whether clot does not form or clot breaks down/dislodges
- characteristic smell
- bad odour
- patient may complain of bad taste
23
Q
What are the predisposing factors for dry socket?
A
- mandibular molars most common
- smoking (reduced blood supply)
- female
- oral contraceptive pill
- local anaesthetic (vasoconstrictor)
- infection from tooth
- haematogenous bacteria in socket
- excessive trauma during extraction
- excessive mouth rinsing post extraction
- family history/previous dry socket
24
Q
How is dry socket managed?
A
- support and reassurance
- systemic analgesia
- patients fear wrong tooth has been extracted
- local anaesthetic
- irrigation of socket with warm saline
- wash out for and debris
- curettage/debridement
- encourage bleeding and new clot formation
- may produce more bare bone and removes any remaining clot
- antiseptic pack
- alvogyl
- brown fibrous paste
- butamben, idoform, eugenol
- resorbable
- can place dissolvable suture
- alvogyl
- advise patient on analgesia and hot salty mouthwashes
- review patient and change packs/dressings
- as soon as pain resolves, remove packs to allow healing
- do not prescribe antibiotics as not infection
- check for bony sequestra or tooth fragments
- confirm as dry socket
25
Q
Discuss sequestra as a post extraction complication
A
- quite common
- prevent healing
- delays healing
- required removal
- can encourage dry socket
- usually bits of dead bone
- white spicules visible coming through gingiva
- patient may think part of tooth bas been left
- can be amalgam or tooth tissue
26
Q
Discuss infected socket as a post extraction complication
A
- infection rare as a complication
- more common after minor surgical procedures involving soft tissue flaps and bone removal
- pus discharge visible
- check for sequestrum and foreign bodies
- radiographs
- explore and irrigate socket
- consider antibiotics
- delays healing
27
Q
How are acute oro-antral communications managed?
A
- inform patient
- if small or sinus is intact
- encourage clot
- suture margins
- prescribe antibiotics
- if large or lining is torn
- close with buccal flap advancement
- prescribe antibiotics
- decongestants
- nose blowing instruction
- deliver post op instruction
28
Q
How long does it take for an oroantral communication to become an oroantral fistula?
A
- 6 weeks
- length of time it takes epithelium to grown
29
Q
How are chronic oroantral fistulas managed?
A
- excise sinus tract
- remove epithelium
- buccal advancement flap
- remove epithelium
- create buccal flap
- score periosteum to release it for tension free closure
- buccal fat pdf with buccal advancement flap
- for particularly large defect
- accessed intraorally through blunt direction through buccal flap
- palatal rotational flap
- sometimes palatal finger flap
- base stays attached to posterior palate
- can be difficult to incise, cauterisation required
- not common
- bone graft/collagen membrane
- barrier to ingress of bacteria
- resorbed and integrated to collagen matrix of ginginae
30
Q
How can foreign bodies be retrieved from the antrum?
A
- through tooth locket
- lateral antrostomy
- fenestration created y removing bone
- good light and irrigation to flush out foreign body
- 3 sided flap or Caldwell-Luc approach (buccal sulcus)
- endoscopic approach
- ENT department
- OMFS
31
Q
Discuss osteomyelitis as a post extraction complication
A
- inflammation of the bone as a result of infection
- usually mandibular
- site of extraction often very tender
- altered sensation due to pressure on IAN
- streptococci, anaerobic cocci, anaerobic gram negative rods
- fusobacterium and prevotella
- rare
- usually predisposing factors
- affecting immune system
- patient often present systemically unwell
- raised temperature
- in acute phase difficult to differentiate from dry socket
- in chronic phase presents as bony destruction, maybe pus
- radiographic changes not seen until chronic
- increased radiolucency
- uniform or patchy
- may see bony sequestra
- in longstanding chronic cases may have increased radio density around radiulucent area
- begins in the medullary cavity involving cancellous bone
- extends and spreads to cortical bone
- spreads to periosteum, overlying mucosa is red and tender
-invasion of bacteria causing inflammation and oedema
- oedema increased tissue hydrostatic pressure
- area becomes ischaemic and necrotic
- blood borne defences do not reach tissue
- osteomyelitis spreads until arrested
- antibiotic and surgical therapy
- medical and surgical treatment
- investigate defence (blood work, glucose levels)
- antibiotics (penicillins), longer course (6-8 weeks)
- for severe cases may require IV antibiotics
- drain pus
- remove non-vital teeth
- debride area
- excision of necrotic area (until bleeding bone reached)
- referral to OS or OMFS
- referral to microbiological input
32
Q
Discuss osteoradionecrosis as a post extraction complication
A
- seen in patients receiving radiotherapy for head and neck cancer
- bone within radiation beam becomes non-vital
- endarteritis (reduced blood supply)
- turnover of remaining viable bone is slow
- self-repair ineffective
- worse with time and dose
- mandible most commonly affected
- poorer blood supply
- suggestion of routine extraction, alveoplasty and primary closure of soft tissue
- preventative measures
- scaling and chlorhexidine mouthwash before extraction
- careful extraction technique
- antibiotics, chlorhexidine mouthwash and review
- hyperbaric oxygen (increase oxygenation)
- take advice and refer patient for extraction
- treatment
- irrigation of necrotic debris
- antibiotics only in case of secondary infection
- removal of loose sequestra
- small wounds usually heal over weeks/months
- resection of exposed bone, soft tissue closure
- hyperbaric oxygen (supersaturation)
33
Q
Discuss medication related osteonecrosis of the jaw as a post extraction complication
A
- can be released to bisphosphonates
- osteoporosis, Paget’s disease, malignant bone metastases
- inhibit osteoclast activity (bone resorption)
- drug remains in body for years
- types
- alendronate (oral)
- clodronate (IV)
- etidronate (oral)
- ibandronate (oral)
- other drugs
- antiresorptive
- RANKL inhibitors
- antiangiogenic
- concurrent use with steroids increases risk
- occurs post extraction/denture trauma/spontaneously
- exclusive to jaws (mandible and maxilla)
- higher risk with IV bisphosphonates
- small asymptomatic areas to extensive bone exposure
- low risk for MRONJ
- oral or IV bisphosphonates for less than 5 years
- not on concurrent glucocorticoids
- high risk for MRONJ
- oral or IV bisphosphonates for more than 5 years
- concurrent glucocorticoids
- anti-resorptive or anti-angiogenic drugs for cancer management
- previous MRONJ diagnosis
- treatment is not successful
- manage symptoms
- removal of sharp edges of bone
- chlorhexidine mouthwash
- antibiotics if suppuration - interventions
- major surgical sequestrectomy
- resection
- hyperbaric oxygen (not that successful)
- manage symptoms
- prevent invasive treatment
- extractions in primary care setting
34
Q
Discuss actinomycosis as a post extraction complication
A
- rare bacterial infection
- actinomycete israelii/naeslundii/viscosus
- low virulence
- inoculated into area of injury/susceptibility
- recent extraction, several carious teeth
- bone fracture, minor oral trauma - erodes through tissues
- chronic
- multiple skin sinuses and swelling
- thick lumpy pus
- characteristic bad odour
- initially responds to antibiotic therapy
- recurs when antibiotics stop
- treatment
- incision and drainage of pus accumulation
- excision of chronic sinus tracts
- excision of necrotic bone and foreign bodies
- high dose, usually IV, antibiotics for initial control
- long term oral antibiotics to prevent recurrence
- penicillins, doxycycline, clindamycin
35
Q
Discuss infective endocarditis as a post extraction complication
A
- increase risk of infective endocarditis post dental treatment
- heart valve surgery increases risk further
- most dental treatments can cause bacteraemia
- even toothbrushing
- antibiotic prophylaxis
- highly debated topic
- heart valve replacement, previous endocarditis, CHD
- amoxicillin (3g oral powder sachet), most common
- clindamycin (2x300mg capsules)
- azithromycin (12.5ml (500mg) oral suspension)
