Post-Operative Complications Flashcards
list them
pain
swelling
bruising
trismus
sequestrum
haemorrhage
prolonged nerve damage
alveolar osteitis
infected socket
root in antrum
ORN
OAC
OAF
osteomyelitis
MRONJ
actinmycosis
infective endocarditis
pain, swelling, bruising
how it is worsened
normal response to xla
poor surgical technique, rough handling, laceration, tearing, incomplete, exposed bone, crushing, tearing periosteum
give analgesia
trismus
why
management
oedema, muscle spasms, IDB into medial pterygoid, haematoma, damage to TMJ
monitor
gentle opening exercises, wooden spatula, trismus screw
how long do nerves have to recover from damage before no more improvements
up to 18mths
describe types of nerve damage
neuropraxia - contusion of nerve, axons maintained
axonotmesis - continuity of axons, epieneural sheath disrupted
neurotmesis - complete loss of nerve continuity
what could be the cause of immediate haemorrhage
reactionary/rebound bleeding within 48hrs
LA vasoconstrictions wear off
sutures loosen
traumatised via tongue/finger
what could be the cause of secondary haemorrhage
infection of clot @ 3-7days, mild ooze
could also be meds, hypertension etc
how would you manage haemorrhage of soft tissue vs bone
soft tissue =
pressure, suture, LA + adrenaline, diathermy, surgicel [oxidised cellulose]
bone =
pressure, LA + adrenaline, haemostatic agents, blunt instrument, bone wax, pack + suture
local haemostatic agents
LA + adrenaline
oxidised cellulose (surgicel)
haemocollagene sponge
thrombin
floseal
systemic haemostatic agents
vitamin k
antifibrinolytic (tranexamic acid) prevents clot breakdown and stabilises
missing blood clot factors e.g. desmopressin
how would you manage pt presenting with haemorrhage following xla a few days ago
reassure
clean area
thorough + rapid history
remove clot
identify bleeding
check for remaining sequestra
follow with haemostatic measures
what are the risk factors for alveolar osteitis
lower molars
mandible
smoking
female contraceptive
LA
infection
traumatic xla
excessive rinsing
straw
FH
previous
alveolar osteitis symptoms + management
lost clot, intense pain 3-4 days, 7-14 days to resolve
dull aching pain, throbs, radiates to the ear, continuous, up at night, exposed bone, bad taste/odour
support, reassure, analgesia
LA, irrigate, curettage/debridement, encourage bleeding and new clot, check no fragments
antiseptic pack, salty MW
how would you differentiate between alveolar osteitis and infected socket
infected socket would have yellow/white pus, associated symptoms such as fever, swelling, lymphadenopathy
would not have missing blood clot
how to manage infected socket
it is rare
check for sequestra, explore, irrigate, consider abx if systemic symptoms
xray, analgesia
usually minor surgery e.g. flap + removal
what would you do if you expect root in antrum
confirm with OPT, occlusal or PA
retrieval via OAF approach through socket, open with care, suction, small curettes, irrigation + ribbon gauze, close as AOC
Caldwell-Luc approach = buccal sulcus/window
endoscopic
OAC
what is it, how to diagnose, how to manage
oro-antral communication
tooth, position xray roots, bone @ trifurcation, bubbling blood, nose hold test, direct vision, good light + suction (echo), blunt probe
CARE NOT TO WORSEN
small/lining intact = encourage clot, suture margins, POI
large/torn lining = close with buccal advancement flap, ABX, decongestants, nose blowing instructions
OAF
what is it, how does it differ from OAC
symptoms
manage
oro-antral fistula which has become epithelialised
OAC which has not healed
unilateral nasal blockage, congestion, sinusitis, whistling noise when speaking, fluid mouth-> nose, bubbling
excise sinus tract and remove epithelium
buccal advancement flap [ideal]
fat pad w flap
palatal flap
bone graft/collagen membrane
explain ORN
why it happens
how to prevent
treatment if occurs
osteoradionecrosis
bone necrosis in radiated sites [cancer]
due to decreased bone turnover and decreased blood supply
prevent via pre-radiotherapy evaluation, excellent OH, scale/chx pre-la, careful technique, abx/mw, review, hyperbaric oxygen, refer
irrigation of necrotic debris, abx if infection, remove sequestra
<=1cm will heal weeks/months
if severe then resect exposed bone
soft tissue closure
hyperbaric oxygen
what is osteomyelitis
why does it happen
what are the risks
inflammation/infection of the bone, rare, mostly mandible
due to invasion of bacteria into cancellous bone, inflammation, oedema, necrosis
poor blood supply and increased hydrostatic pressure
risks =
odontogenic infections, fractures, compromised host defence, DM, alcoholism, IV drug use, malnutrition, leukaemia, poor OH
how to diagnose and manage osteomyelitis
diagnosis =
hard to differentiate
acute will have little xray changes
chronic - bony destruction, pus, increased radiolucency in areas of radiopacity
management =
investigate host response via bloods
determine bacteria
penicillin
drain pus, XLA non vital associated, remove loose bone, corticotomy, excise necrotic bone
REFER OS / OMFS
what is the difference in osteomyelitis and actinomycosis
osteomyelitis is a bone infection
actinomycosis is a chronic infectious disease caused by bacteria which can spread to the bone
actinomycosis
why
symptoms
treatment
rare bacterial infection via actinomyces Israeli
due to bacteria into areas of trauma [xla, caries, fracture], erodes through tissues
swelling, sinus tracts, thick + lumpy pus
management =
incise and drain pus
excision through sinus tracts
excise necrotic bone
IV + oral high dose ABX [penicillin, doxycycline, clindamycin]
what is MRONJ
what drugs cause it
what is the risk of occurrence
medication related osteonecrosis of the jaw
antiresorptive, antiangiogenic
denosumab, bisphosphonates
1.6-14.8%
what are the risk factors for MRONJ
impact on bone [xla, denture trauma, infection, PD disease]
duration of drug [>5 years]
implants
other meds [steroids, antiresoprtive]
drug history
drug holidays
previous MRONJ
female
older
mandible
smoking
how would you prevent MRONJ
prevent =
avoid xla if possible, OHI, pt education, high fluoride, make dentally fit, remove risk factors if possible, smoking cessation, non-invasive alternative tx
MRONJ management
conservative, careful monitoring
specific OH in exposed bones [irrigation needles]
antiseptic mw
ABX if indicated
minimal surgical debridement in select cases
primary closure
remove traumatic causes
GMP liaise for medications
symptomatic relief
analgesics
referral to secondary care
remove sharp bone
hyperbaric oxygen
what is infective endocarditis
what are the risks
prophylaxis ?
bacteria causing life-threatening infection in the endocardium via bloodstream
previous, heart valve replacement, congenital heart defect (VSD)
any gingival manipulation is high risk
amoxicillin 3g 60mins before procedure
