Post operative complications

Question 1

What happens when the TMJ is dislocated?

Answer 1

The condylar head is dislocated outside the glenoid fossa and over the articular eminence.

Question 2

4 ways to prevent TMJ dislocation?

Answer 2

• Support with NON-DOMINANT HAND.
• McKesson’s Mouth Prop.
• Alternative approach (ex. surgical).
• General anesthesia.

Question 3

What are the 2 functions of the McKesson’s Mouth Prop?

Answer 3

• Holds mouth OPEN
• Helps STABILIZE the mandible

Question 4

What is another term for dry socket?

Answer 4

Alveolar Osteitis.

Question 5

4 post operative complications involving bone?

Answer 5

• Alveolar osteitis (dry socket).
• Exposed bone.
• Sequestrum.
• MRONJ.

Question 6

4 “categories” of post-operative complications?

Answer 6

• Bone
• Bleeding
• Sepsis
• Trismus

Question 7

What is alveolar osteitis?

Answer 7

INFLAMMATION of the bone and alveolus rather than infection.

Question 8

What percent of routine extractions does alveolar osteitis affect? What is its general prevalence?

Answer 8

• 0.5% to 5% of ROUTINE extractions.
• 0.5% to 68% range.

Question 9

What teeth are most often affected by alveolar osteitis? What age?

Answer 9

• MANDIBULAR MOLARS.
• 40s.

Question 10

What is the % of impacted 8s affected by alveolar osteitis?

Answer 10

1-37.5%.

Question 11

What is the importance of fibrin deposition during clot formation?

Answer 11

Acts as a BARRIER to prevent the movement of bacteria into nearby tissues.

Question 12

What causes clot breakdown?

Answer 12

• The clot is broken down (fibrinolysis) through the release of tissue kinases.
• Leads to PLASMIN formation and clot disintegration.

Question 13

What are the 2 mechanisms thought to cause alveolar osteitis?

Answer 13

1. Complete absence of a blood clot.
2. Formation of an initial clot which is subsequently lysed.

Question 14

How is the initial blood clot lysed during the process of alveolar osteitis?

Answer 14

Through the release of TISSUE ACTIVATORS which turn the plasmin precursor (plasminogen) into plasmin.

Question 15

5 risk factors for alveolar osteitis.

Answer 15

• Women
• Smoking (vasoconstriction + sucking).
• Trauma
• Medications (OCP, antipsychotics, antidepressants).
• Anatomy (mandibular 3rd molars).

Question 16

How does smoking contribute to alveolar osteitis (2)?

Answer 16

• Vasoconstrictor.
• Negative pressure created from sucking.

Question 17

3 types of drugs that increase alveolar osteitis risk?

Answer 17

• OCP.
• Antidepressants.
• Antipsychotics.

Question 18

6 patient related ACTIONS/ FACTORS that can increase risk of dry socket?

Answer 18

• Infection
• Inadequate OH
• Poor after care
• Spitting, sucking through a straw, coughing, sneezing.
• Perioperative patient stress.
• Focal fibrinolytic activity.

Question 19

3 OPERATOR related factors that can increase risk of dry socket?

Answer 19

• Flap extent and design.
• Surgical trauma.
• Experience of surgeon.

Question 20

When do patients present with alveolar osteitis? What may the patient complain of?

Answer 20

• 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.

Question 21

What is the ideal management of dry socket?

Answer 21

• LA ideally.
• Explore socket with irrigating needle and sterile saline.
• Place sedative dressing - ALVEOGYL.

Question 22

What is placed in dry socket after irrigation?

Answer 22

ALVEOGYL - sedative dressing.

Question 23

What is a sequestrum?

Answer 23

• Small (usually) fragments of BONE lost from the extraction site.
• May also be tooth fragments.

Question 24

Two common sites/ circumstances where we might see exposed bone?

Answer 24

• Following SEVERE soft tissue trauma at the CREST.
• At the LINGUAL POSTERIOR MANDIBLE due to prominence + thin mucosa.

Question 25

What is another term for MRONJ?

Answer 25

Phossy jaws.

Question 26

What are bisphosphonates? Name 4 examples (or at leas suffix).

Answer 26

ANTIRESORPTIVE medications. - Alendronate, ibandronate, zolendronate, pamidronate.

Question 26

3 drug types that increase MRONJ risk?

Answer 26

- Bisphosphoantes. - RANKL inhibitors - Anti-angiogenics.

Question 27

Name a RANKL inhibitor

Answer 27

denosumab

Question 28

3 antiangiogenic drugs?

Answer 28

- Bevacizumab. - Sunitinib. - Aflibercep.

Question 29

What is ORN? Who is at risk?

Answer 29

- Osteoradionecrosis. - IRRADIATED patients for H and N cancer.

Question 30

What is the risk of ORN following a procedure?

Answer 30

6%

Question 31

Is the maxilla or mandible more prone to ORN?

Answer 31

Mandible.

Question 32

What is the incidence of ORN?

Answer 32

5-15%

Question 33

What is a common cause of ORN? can it be healed?

Answer 33

- IRREVERSIBLE. - Often SECONDARY TO TRAUMA although 10-35% of cases SPONTANEOUS.

Question 34

What will the patient complain of clinically when having ORN ?

Answer 34

- Severe pain. - recurrent infection - Halitosis/ foul smell. - Oro-facial fistula. - Suppuration - Pathological fracture (if diseased bone becomes large).

Question 35

What is other management for ORN?

Answer 35

- **Resection of bone and replaced with graft** (risks leading to 2 areas of ORN). - **Hyperbaric oxygen** (not much evidence + difficult to access). - **Pentoxyphilline/Tocopherol**

Question 36

What 2 drugs have been shown to reduce the incidence of ORN following extraction?

Answer 36

- Pentoxyphylline. - Tocopherol.

Question 37

What is the usual management for ORN?

Answer 37

- Analgesia - Irrigation - Antibiotics - Accept not union of the mandible (if fracture), hyperbaric oxygen therapy.

Question 38

What is trismus?

Answer 38

Limited mouth opening.

Question 39

What is normal mouth opening? Mild, moderate and severe trismus?

Answer 39

- Normal: 30-40mm. - Mild: 20-30mm. - Moderate: 10-20mm. - Severe: less than 10mm.

Question 40

10 potential causes of trismus?

Answer 40

- Pain. - Muscular. - Haematoma. - Infection. - Chronic limitation. - Trauma. - Neoplasia. - TMJ derangement/ osteoarthritis. - Soft tissue fibrosis. - Normal.

Question 41

What kind of neoplasia can lead to trismus?

Answer 41

Pharyngeal carcinoma.

Question 42

Infection of which spaces can result in significant trismus (3)?

Answer 42

- Submasseteric. - Medial. - Pharyngeal.

Question 43

4 cases where bisphosphonates/antiresorptive drugs are prescribed?

Answer 43

- Pagets disease. - Primary malignancy. - Osteoporosis. - Bone metastasis.