Post operative complications Flashcards
What happens when the TMJ is dislocated?
The condylar head is dislocated outside the glenoid fossa and over the articular eminence.
4 ways to prevent TMJ dislocation?
- Support with NON-DOMINANT HAND.
- McKesson’s Mouth Prop.
- Alternative approach (ex. surgical).
- General anesthesia.
What are the 2 functions of the McKesson’s Mouth Prop?
- Holds mouth OPEN
- Helps STABILIZE the mandible
What is another term for dry socket?
Alveolar Osteitis.
4 post operative complications involving bone?
- Alveolar osteitis (dry socket).
- Exposed bone.
- Sequestrum.
- MRONJ.
4 “categories” of post-operative complications?
- Bone
- Bleeding
- Sepsis
- Trismus
What is alveolar osteitis?
INFLAMMATION of the bone and alveolus rather than infection.
What percent of routine extractions does alveolar osteitis affect? What is its general prevalence?
- 0.5% to 5% of ROUTINE extractions.
- 0.5% to 68% range.
What teeth are most often affected by alveolar osteitis? What age?
- MANDIBULAR MOLARS.
- 40s.
What is the % of impacted 8s affected by alveolar osteitis?
1-37.5%.
What is the importance of fibrin deposition during clot formation?
Acts as a BARRIER to prevent the movement of bacteria into nearby tissues.
What causes clot breakdown?
- The clot is broken down (fibrinolysis) through the release of tissue kinases.
- Leads to PLASMIN formation and clot disintegration.
What are the 2 mechanisms thought to cause alveolar osteitis?
- Complete absence of a blood clot.
- Formation of an initial clot which is subsequently lysed.
How is the initial blood clot lysed during the process of alveolar osteitis?
Through the release of TISSUE ACTIVATORS which turn the plasmin precursor (plasminogen) into plasmin.
5 risk factors for alveolar osteitis.
- Women
- Smoking (vasoconstriction + sucking).
- Trauma
- Medications (OCP, antipsychotics, antidepressants).
- Anatomy (mandibular 3rd molars).
How does smoking contribute to alveolar osteitis (2)?
- Vasoconstrictor.
- Negative pressure created from sucking.
3 types of drugs that increase alveolar osteitis risk?
- OCP.
- Antidepressants.
- Antipsychotics.
6 patient related ACTIONS/ FACTORS that can increase risk of dry socket?
- Infection
- Inadequate OH
- Poor after care
- Spitting, sucking through a straw, coughing, sneezing.
- Perioperative patient stress.
- Focal fibrinolytic activity.
3 OPERATOR related factors that can increase risk of dry socket?
- Flap extent and design.
- Surgical trauma.
- Experience of surgeon.
When do patients present with alveolar osteitis? What may the patient complain of?
- Can present at any time, typically 2-3 DAYS following extraction.
- Pain gets worse as days pass.
- Pain resistant to analgesia.
- Dull, aching, throbing pain (severe).
- Bad taste.
- Discharge.
- Halitosis.
What is the ideal management of dry socket?
- LA ideally.
- Explore socket with irrigating needle and sterile saline.
- Place sedative dressing - ALVEOGYL.
What is placed in dry socket after irrigation?
ALVEOGYL - sedative dressing.
What is a sequestrum?
- Small (usually) fragments of BONE lost from the extraction site.
- May also be tooth fragments.
Two common sites/ circumstances where we might see exposed bone?
- Following SEVERE soft tissue trauma at the CREST.
- At the LINGUAL POSTERIOR MANDIBLE due to prominence + thin mucosa.
What is another term for MRONJ?
Phossy jaws.
What are bisphosphonates? Name 4 examples (or at leas suffix).
ANTIRESORPTIVE medications.
- Alendronate, ibandronate, zolendronate, pamidronate.
3 drug types that increase MRONJ risk?
- Bisphosphoantes.
- RANKL inhibitors
- Anti-angiogenics.
Name a RANKL inhibitor
denosumab
3 antiangiogenic drugs?
- Bevacizumab.
- Sunitinib.
- Aflibercep.
What is ORN? Who is at risk?
- Osteoradionecrosis.
- IRRADIATED patients for H and N cancer.
What is the risk of ORN following a procedure?
6%
Is the maxilla or mandible more prone to ORN?
Mandible.
What is the incidence of ORN?
5-15%
What is a common cause of ORN? can it be healed?
- IRREVERSIBLE.
- Often SECONDARY TO TRAUMA although 10-35% of cases SPONTANEOUS.
What will the patient complain of clinically when having ORN ?
- Severe pain.
- recurrent infection
- Halitosis/ foul smell.
- Oro-facial fistula.
- Suppuration
- Pathological fracture (if diseased bone becomes large).
What is other management for ORN?
- Resection of bone and replaced with graft (risks leading to 2 areas of ORN).
- Hyperbaric oxygen (not much evidence + difficult to access).
- Pentoxyphilline/Tocopherol
What 2 drugs have been shown to reduce the incidence of ORN following extraction?
- Pentoxyphylline.
- Tocopherol.
What is the usual management for ORN?
- Analgesia
- Irrigation
- Antibiotics
- Accept not union of the mandible (if fracture), hyperbaric oxygen therapy.
What is trismus?
Limited mouth opening.
What is normal mouth opening? Mild, moderate and severe trismus?
- Normal: 30-40mm.
- Mild: 20-30mm.
- Moderate: 10-20mm.
- Severe: less than 10mm.
10 potential causes of trismus?
- Pain.
- Muscular.
- Haematoma.
- Infection.
- Chronic limitation.
- Trauma.
- Neoplasia.
- TMJ derangement/ osteoarthritis.
- Soft tissue fibrosis.
- Normal.
What kind of neoplasia can lead to trismus?
Pharyngeal carcinoma.
Infection of which spaces can result in significant trismus (3)?
- Submasseteric.
- Medial.
- Pharyngeal.
4 cases where bisphosphonates/antiresorptive drugs are prescribed?
- Pagets disease.
- Primary malignancy.
- Osteoporosis.
- Bone metastasis.
