Post Operative Complications Flashcards
What are the 3 types of complications?
Immediate/intra op/peri op
Immediate post op/short term post op
Long term post op
What are the 2 types of complications (easier)?
peri-operative
post-operative
Where are some post operative complications?
pain
Swelling
Ecchymosis (bruising)
Trismus
Haemorrhage
Prolonged effects of nerve damage
Dry socket
Sequestrum
Infected socket
Chronic OAF or root in antrum
What is the most common post op complication?
Pain as forces that disrupt the pdl leads to pain
What advice do we give in regards to pain?
we must let pt know that they may experience some pain and this is completely normal and not to worry!
then give advice on analgesics - take within 1-2 hours of leaving before la wears off
What can increase post op pain?
if tissues are handled more roughly
if there is lacerations or tearing of soft tissues
exposed bone
incomplete extraction
What is oedema a reaction to?
inflammatory reaction to surgical interference
What is oedema increased by?
poor surgical technique
What poor surgical techniques can increase risk fo oedema?
rough handling of soft tissues
crushing lips with forceps
When will swelling post operatively develop?
over 48 hours - if its on day 2/3 then this is a sign of infection
What advice do we have for pts with swellings post op?
Cold pack - on for 5 off for 5 for 1-2 hours
sleeping propped up
What do we tell pt in regards to swelling?
You may or may not swell up - it is different with every pt but if you do notice swelling dont panic - if it comes up over the next 48 hours and goes away after a week this is normal however if swelling just starts on day 2-3 then you can contact me
What is ecchymosis?
Bruising
What pts may bruise more freq post op?
pts who already bruise easily
What can increase freq of bruising post operatively?
rough handling of tissues
poor surgical technique
leaning on pts lip
What is trismus?
LIMITED MOUTH OPENING DUE TO MUSCLE SPASM
How can we describe trismus to pts?
this is where your jaw may be a bit stiff to open close and can last for 1-2 weeks but make sure to still eat and drink as normal however if very limited or if unable to eat then come see me
What can cause limited mouth opening?
Swelling from surgery
Muscle spasm –> trismus
Bleed in the muscle
bleed into master causing muscle to spasm and mouth unable to open
the injection needle going though MEDIAL PTERYGOID and a bleed causing hameatoma or muscle to spasm
What muscle can the inject for idb go through?
Medical ptyergoid and haematoma can form or muscle can spasm causing limited mouth opening
When do we refer in limited mouth opening?
If no improvement in 1-2 weeks
How do we let pt know they may experience some limited mouth opening?
Because you will have your mouth open for a while and we are leaning on your lower jaw you may have some limited mouth opening which will settle after a week or two however if its really bothers you then come back and see me or give me a phone
How can we increase mouth opening?
gentle mouth opening exercises
wooden spatula
trismus screw
What can a haemorrhage be? (3)
Intra operative
immediately post op
secondary bleed
How do we manage intra-operative haemorrhages?
pressure
surgicel - cellulose oxidise which provides framework for clot to form
What is an immediate post op bleed?
this is a reactionary/rebound bleed that occurs within 48 hours of extraction
What can cause immediate post op bleeds?
wearing off of LA opening up vessels again
sutures coming loose
pt traumatising area with tongue/finger/food/toothbrush
What is a secondary bleeding often due to?
infection and commonly lasts 3-7 days
usually a mild ooze but can be a major bleed
What is common to see in terms of secondary bleeds?
mild bleed
spotting
mild ooze
What vessels can be damaged in extractions?
veins
arteries
arterioles
vessels in muscle
vessels in bone
How do we manage bleeding vessels?
Pressure - bite on damage gauze
sutures if needed
LA with adrenaline
Diathermy to cauterise vessels causing protein precipitation which forms a protein plug
artery clips for bigger vessles
How do we manage bone bleeds?Q
Apply pressure with swab
la onto swab or inject into socket
haemostats agents such as surgicel or kalsostat
blunt instrument to apply bone wax
If bleeding is severe what must we do?
Apple pressure immediately to arrest the bleed
Calm the pt - separate ethem for their relatives
If pt comes back to surgery with post op bleed what do we do?
- immediate pressure
- Calm the pt - measure them
- clean up pt - any blood soaked towels
- take a through but quick history (I just want to double check ur med history)
- lift out jelly like clot and clean up area and then apply pressure
CLEAN –> PRESSURE –> FIND BLEEDING SOURCE
What do we do with jelly like clots?
Remove clot as its an unsuccessful attempt at forming a clot
What bleeding disorders must we rule out?
Haemophillia
VWBs
liver disease
What do we do if despite all efforts we can’t get bleeding to stop?
call a&e or local max fax dept or oral surgery department however if worried phone 999
Describe the steps of management if pt comes in with post op bleeding
Look inside mouth with good light and suciton
will often see jelly like clot which we remove
pt may vomit if swallowing blood
identify bleeding source
use haemostatic agent - surgicel or kalsistat
What must we do after management of secondary bleed?
Give pt point of contact to call if bleeding resumes (if bleeds again tonight her is a number to phone me but if its significant then this is nearest a&e)
review the pt
if pt has lost large volume of blood and is elderly or has med problems then consider hospital admission
If we can’t arrest the haemorrhage what do we do?
Phone hospital and speak to someone and find out where pt is to go and who we are speaking to - write this down in notes
What are some examples of haemostatic agents?
LA containing adrenaline
surgicel - oxidised cellulose
gelatine sponge
thrombin liquid and powder
What must we take care with when using oxidised cellulose?
In lower 8 region as its acidic and can damage IDN
Post extraction should the pt rinse out?
NO! - avoid rinsing out, exercise, hot and hard foots to avoid disrupting clot
What are some systemic haemostatic aids?
vitamin K
Ani fibrinolytic
plasma or whole blood
What is vitamin k used for?
Vitamin K is vitally important to blood clotting because the proteins that create the fibrin webbing in the second part of the clotting process depend on this vitamin. Vitamin K is needed for the clotting proteins to be activated and start the final part of the clotting process.
What is an example of an anti-fibrinolytic?
tranexamic acid
What does tranexamic acid do?
Tranexamic acid is an antifibrinolytic that competitively inhibits the activation of plasminogen to plasmin
prevents clot being broken down and stabilises the clot
can be taken as tablets or mouthwash
How do we prevent intra op and post op bleeding?
take thorough history so we can anticipate and deal within potential problems
provide good instructions to pt post tx
obtain and check for good haemostats before they leave
What are some post op extraction instructions?
No exercise
Try avoid alcohol - can affect the healing
Dont rinse out for at least a few hours - 1 day and avoid any vigorous rinsing as this can disrupt the clot
avoid hot food - burn risk when numb
Avoid trauma - dont poke about clot with finger, toothbrush
If bleeding then dampen gauze and bite on it for at least 30 mins
How long do we monitor nerve damage for?
few days to a week to rule out infection and if not settling then can refer pt
What is anaesthesia?
Numbness
What is paraesthesia?
Tingling
What is dysaethesia?
unpleasant sensation/pain
neuralgic pain
What is hypoaestheisa?
reduced sensation
What is hyperaesthesia?
Increased sensation
What is neurapraxia?
Contusion of nerve/continuity of epineural sheath and axons maintained
What is axonotmesis?
continuity of axons but epineural sheath disrupted
What is neurotmesis?
tHIS IS WHEN THERE IS COMPLETE LOSS OF NERVE CONTINUITY AND NERVE IS TRANSECTED
how common is dry socket?
affects 2-3% of all extractions
20-35% of lower 8s
What is dry socket?
This is when the clot disappears and instead we are left with bare bone/empty socket with partial or completely lost blood clot
dry socket leaves the bone, tissue, and nerve endings exposed.
What is the main feature of dry socket?
intense pain - worst pain
How long does dry socket take to begin?
3-4 days after xla
When is dry socket unlikly?
If pt says intense pain began straight after LA wore off then unlikely its a dry socket - instead check for tooth left in socket or broken bone
How long does dry socket take to resolve?
7-14 days
If pt has slow healing dry socket what can we do for them?
let them know we will help them through this period
rinse out with warm saline
analgesics
can also numb up the pt to provide them with some relief
What is localised osteitis?
This is inflammation of the socket wall (lamina dura area)
What is the pain of dry socket like?
Dull aching –> severe
variable In pts
throbbing pain
can radiate to the ear - keep pt up at night
Is dry socket infection?
nO - THERE IS NO SWELLING OR PUS SO NO NEED FOR ANTIBITOCIS
What is the source of pain in dry socket?
Exposed bone
What may pt complain about with dry socket?
Bad smell
bad taste
What Is dry socket classed as?
delayed healing not associated with infection
What is a predisposing factor to dry socket?
Molars are at greater risk than anterior teeth
more common in mandible
smokers
female
OCP
What jaw is dry socket more common in?
Mandible
Why is smoking a risk factor for dry socket?
this is because pt has reduced blood supply which leads to less healing so pt should avoid smoking for as long as they can
How do we manage dry socket supportively?
Reassure pt
systemic analgesia advice
What can we do with LA in pts with dry socket?
Can provide LA block which provide pain relief to pt and allows us to irrigate the area
What can we irrigate dry socket with and why do we do this?
Warm saline
to wash out food and debris
Is debridement done in dry socket cases?
Rarely done but some suggest that removing any remaining clot will encourage new bleeding and let healing process start again
What are antiseptic packs?
These are sedative agents, anti-inflame agents or stringent disinfectant type agents that help with pain or discomfort and fill up the socket preventing food impaction
What is BIP?
Bismuth subnitrate which is an impregnanted gauze with iodine in it that is packed into socket and is an antiseptic and astringent
(an astringent is a chemical that shrinks or constricts body tissues)
What is alvogyl?
This is a mixture of LA and antiseptic that soothes pain and prevents food packing
How are pts meant to irrigate own socket?
should be done 2-4 times a day
What is most important thing to do in dry socket pts?
be supportive and reassuring - we understand the significant pain they are in and can discuss systemic analgesia
Before confirming its a dry socket what may we need to do?
Radiograph to ensure no teeth roots remain and check other teeth
In diagnosing dry socket what must we always check?
The socket - in rare occasions it can be a tumour or oral cancer
How often should we see dry socket pts?
few times a week
What should pt use to irrigate socket?
warm saline or warm salty water
NOT CHX as it can enter blood stream and risks anaphylaxis
What is sequestrum?
a piece of dead bone tissue formed within a diseased or injured bone
What prevents healing?
Sequestrum - its of dead bone
How does bony sequestrum look like intra orally?
hite spicules of bone coming through gingivae - pt may think its tooth
What must we od with sequestra?
Remove it as it delays healing
What is a socket with pus discharge?
infected socket
What do we do if we suspect infected socket?
Check to see if any tooth/roots or foreign bodies are present
take radiograph, explore, remove any foreign bodies, roots, consider antibiotics
When is infection more likely?
After MOSP where soft tissue flaps need raised and bone is removed
What does infection delay?
healing
What is the diff between OAC and OAF?
OAC = fresh communication between antrum and oral cavity
OAF = epithelium lined tract or tube that is chronic
When might an OAC be created?
Big tooth with big roots in vicinity of sinus
on radiographic exam we see roots close to antrum
What signs indicate OAC?
Bubbling of blood
visible hole
How do we manage a small or intact sinus OAC?
Inform pt
encourage clot
suture margins
antibiotics prescribed
post op instructions - no blowing nose, steam inhalation, no wind instruments
How to do steam inhalation?
Few mins at a time with towel over head to clear air sinus and nose
How long after oac to avoid wind insturments?
2 weeks
If OAC is large or lining is torn what do we do?
Close with buccal advancement flap
full thickness flap of gingiva is pulled back and we release the periosteum tissue
close with slow resorbing sutures or non resorbing
keep eye on pt
antibiotics - 5-7 day course
how long is antibiotic course in OAC?
5-7 days
What is an example of resorbing sutures?
black silk
WHAT IS AN EXAMPLE OF NON RESORBING SUTURES?
VICRYL
How do we manage an OAF?
We must cut out the epithelial lined tube or tract so it doesn’t reform then close with buccal advancement flap
When might we have to use something other than buccal advancement flap to close OAF and why?
We may need to use buccal fat pad with buccal advancement flap to close OAF if the fistula is very large or won’t stay closed
How do we do buccal fat pad with buccal advancement flap?
Take mucoperiosteal flap and release periosteum then go further up into buccal sulcus and release buccal fat pad and pull fat pad over and stitch
What is osteomyelitis?
Osteomyelitis of the jaws is infection and inflammation of the bone marrow, sometimes abbreviated to OM which occurs in the bones of the jaws (i.e. maxilla or the mandible).
What do pts with osteomyelitis appear like?
systemically unwell
raised temp
In deep seated osteomyelitis infections of lower jaw what may we see?
Altered sensation due to pressure on IAN
Where does osteomyelitis begin?
medullary cavity involving cancellous bone which extends and spreads to cortical bone and then to periosteum
What does invasion of bacteria into cancellous bone cause?
soft tissue inflammation and oedema in closed bone marrow spaces
What does oedema in enclosed space lead to?
Increased tissue hydrostatic pressure (higher than BP of feeding arterial vessels) which causes compromised blood supply resulting in soft tissue necrosis
How do we stop oesoemyeltis spreading?
Antibiotics and surgical therapy
Why do bacteria proliferate in osetomyeltis?
Due to normal blood borne defects not reaching tissue due to lack of blood supply
Why is osteomyelitis more likely in mandible?
This is because its primary blood supply is inferior alveolar artery and there is dense overlying cortical bone which prevents penetration of periosteal blood vessels so there is a poorer blood supply with increased chances of ischaemia and infection occurring
Why is osteomyelitis less likely in the maxilla?
rich blood supply
Who is osteomyelitis rare in?
Healthy fit individuals with host defences in tact
What are the predisposing factors to osteomyelitis?
perio pts
infected tooth
Odontogenic fractures and mandible fractures
compromised host defences - alcoholics, diabetes, iv drug use, malnutrition, chemo tx cancer
What does acute suppurative osteomyelitis look like on x-ray?
Little to no change (takes 10-13 days for lost bone to be detectable)
What is the radiographic appearance of osteomyelitis?
Mottled appearance
mOTH EATEND APPEARANCE
INCREASED RADIOLUCENCY
How do we tx osteomyelitis?
Investigate host defences
Antibiotics
Surgical tx
How do we investigate host defences in osteomyelitis pts?
Blood tests
Glucose levels
What antibiotics can we prescribe for Odontogenic infections?
Clindamycin
Penicillin
need longer dose than normal (6 weeks in some)
What surgical tx is done for osteomyelitis?
drain pus
remove non vital teeth in area of infection
remove any loose pieces of bone (dead bone stops healing)
excise nectroic bone
