Post-operative Complications

Question 1

Provide examples of possible post operative complications

Answer 1

• 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

Question 2

Discuss pain as a post-operative complication

Answer 2

• 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

Question 3

Discuss swelling as a post operative complication

Answer 3

• 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

Question 4

Discuss ecchymosis as a post operative complication

Answer 4

• 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

Question 5

Discuss trismus as a post operative complication

Answer 5

• 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

Question 6

Discuss prolonged bleeding as a post extraction complication

Answer 6

• usually related to medical conditions and medications
• bleeding disorders
• liver disease
• DOACs
• vitamin K antagonist
• injectable anticoagulant
• anti platelet drugs
• combined anticoagulant/antiplatelet

Question 7

How is risk assessed for different oral surgery procedures?

Answer 7

• 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

Question 8

What procedures are considered unlikely to cause bleeding

Answer 8

• 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

Question 9

What procedures are considered likely to cause bleeding but are low risk?

Answer 9

• 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

Question 10

What procedures are considered likely to cause bleeding and are high risk?

Answer 10

• complex extractions (large wound/more than 3 teeth)
• flap raising procedures
• gingival recontouring
• biopsies

Question 11

How do vitamin K antagonists affect oral surgery procedures?

Answer 11

• 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

Question 12

How do antiplatelet drugs affect oral surgery procedures?

Answer 12

• 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)

Question 13

How do DOACs affect oral surgery procedures?

Answer 13

• 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
• treat early in the day
• consider staging treatment
• consider local haemostatic measures

Question 14

What is immediate post-operative bleeding?

Answer 14

• reactionary/rebound bleeding
• within 48 hours of extraction
• local anaesthetic wears off, vessels open up, sutures can be lost, patient traumatises area

Question 15

What is secondary bleeding?

Answer 15

• 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

Question 16

What haemostatic agents are used in oral surgery?

Answer 16

• 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

Question 17

What systemic haemostatic aids are available?

Answer 17

• 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

Question 18

How is post-operative bleeding managed?

Answer 18

• 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

Question 19

How can intra-operative and post-operative extraction haemorrhage be prevented?

Answer 19

• 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

Question 20

What should post operative instructions to the patient include?

Answer 20

• 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

Question 21

Discuss nerve damage as a post extraction complication

Answer 21

• 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

Question 22

Discuss dry socket as a post extraction complication

Answer 22

• 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

Question 23

What are the predisposing factors for dry socket?

Answer 23

• 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

Question 24

How is dry socket managed?

Answer 24

• 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
• 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

Question 25

Discuss sequestra as a post extraction complication

Answer 25

• 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

Question 26

Discuss infected socket as a post extraction complication

Answer 26

• 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

Question 27

How are acute oro-antral communications managed?

Answer 27

• 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

Question 28

How long does it take for an oroantral communication to become an oroantral fistula?

Answer 28

• 6 weeks
  
  • length of time it takes epithelium to grown

Question 29

How are chronic oroantral fistulas managed?

Answer 29

• 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

Question 30

How can foreign bodies be retrieved from the antrum?

Answer 30

• 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

Question 31

Discuss osteomyelitis as a post extraction complication

Answer 31

• 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

Question 32

Discuss osteoradionecrosis as a post extraction complication

Answer 32

• 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)

Question 33

Discuss medication related osteonecrosis of the jaw as a post extraction complication

Answer 33

• 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)
• prevent invasive treatment
  
  • extractions in primary care setting

Question 34

Discuss actinomycosis as a post extraction complication

Answer 34

• 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

Question 35

Discuss infective endocarditis as a post extraction complication

Answer 35

• 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)