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BDS4 > Post-operative extraction complications > Flashcards

Post-operative extraction complications Flashcards

1
Q

List 8 post XLA complications other than swelling , pain and bruising?

A
  • Trismus
  • Bleeding
  • Prolonged effects of nerve damage
  • Dry socket
  • Sequestrum
  • Infected socket
  • Chronic OAF and root in antrum
  • Osteomyelitis , ORN , MRONJ
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2
Q

What is the most common complication of extraction?

A
  • Pain
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3
Q

How would you reduce post op pain? (3)

A
  • Good handling of tissues
  • Avoid leaving bone exposed
  • Ensure all tooth is extracted
  • Analgesia
  • Warn patient about risk
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4
Q

What increases oedema/bruising post XLA?

A
  • Rough handling of soft tissues
  • Pulling flaps
  • Crushing tissue with instrument
  • Tearing of periosteum
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5
Q

What is trismus?

A

Jaw stiffness and inability to open mouth fully

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6
Q

4 causes of trismus post extraction?

A
  • Related to surgery - muscle spasm or oedema
  • IDB may cause medial pterygoid spasm
  • Haematoma - medial pterygoid or masseter
  • Damage to TMJ
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7
Q

4 management options for post-op limited mouth opening?

A
  • Monitor as may resolve within weeks
  • Gentle mouth opening exercises
  • Wooden spatulae
  • Trismus screws
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8
Q

5 dental procedures that are unlikely to cause bleeding?

A
  • LA by infiltration or blocks
  • BPE
  • Supragingival PMPR
  • Direct restorations
  • Orthograde endodontics
  • Impression taking
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9
Q

5 dental procedure that have low risk of bleeding?

A
  • Simple extractions
  • Incision and drainage of intra-oral swelling
  • 6PPC
  • RSD
  • Restorations with subgingival margins
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10
Q

5 dental procedures that are considered high risk of bleeding?

A
  • Complex extractions
  • more than 3 extractions at once
  • Flap raising procedures
  • Biopsies
  • Gingival recontouring
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11
Q

Patient on aspirin/ clopidegrol/ticagrelor or dual antiplatelet therapy , how would you manage medication if high bleeding risk procedure?

A
  • Treat without interrupting medication but expect prolonged bleeding if on dual therapy
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12
Q

What consideration other than altering medication could you do to reduce risk of bleeding?

A
  • Limit initial treating area
  • Staging complex procedure
  • Use haemostatic measures such as sutures and packing
  • Treat early on the day for pt on DOAC
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13
Q

How would you manage a patient on DOAC regarding medication in a low bleeding risk procedure

A

treat without interrupting medication

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14
Q

How would you manage a patient on DOAC regarding medication in a high risk bleeding procedure?

A
  • Miss or delay morning dose
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15
Q

How would you manage a patient on Warfarin regarding medication if procedure is likely to cause bleeding?

A
  • Check INR no more than 24h before treatment ( if stable up to 72h)
  • INR below 4 - treat without interrupting medication
  • If INR above 4 - delay treatment or refer if urgent
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16
Q

Patient on IV antigoagulant (enoxaparin) , how would you manage medication if patient is getting an extraction?

A
  • In low doses - treat without interruption
  • In high doses - consult with prescribing clinician
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17
Q

If patient is taking anti-platelets and anticoagulants , how would you manage medication for a patient getting an extraction?

A
  • Consult with prescribing clinician
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18
Q

2 things to ask a patient on Warfarin other than their INR?

A
  • Why are they on the drug
  • What is their target INR
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19
Q

Patient taking Rivaroxaban or Edoxaban in the evening and is getting an extraction, how would you treat?

A

Do not interrupt medication
* if in the morning miss morning dose and take after 4 hours after haemostasis has achieved

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20
Q

Patient taking apixaban or dabigatran and is getting XLA , how would you treat?

A
  • miss morning dose and take evening dose as normal
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21
Q

Explain immediate post operative bleeding?

A
  • Reactionary bleeding
  • Occurs within 48 hours of XLA
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22
Q

3 causes of immediate post op bleeding during the first 48 hours after XLA?

A
  • Vessels open up due to wearing off of vasoconstrictor effect
  • Sutures become loose or lost
  • Patient traumatise area with tongue, finger or food
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23
Q

Bleeding occurs after 3-7 days of XLA , what might 3 reasons of this secondary bleeding?

A
  • Infection or medication related
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24
Q

5 local haemostatic agents ?

A
  • LA with adrenaline
  • Oxidised regenerated cellulose matrix
  • Haemocollagen sponge
  • Thrombin liquid or powder
  • Floseal
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25
Q

Why would you avoid placing Surgicel in lower 8 region?

A

It might cause damage to IDN as it is acidic

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26
Q

What are 5 systemic haemostatic agents?

A
  • Vitamin K
  • Anti-fibrinolytics - transexamic acid
  • Missing blood clotting factors
  • Plasma or whole blood
  • Desmopressin
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27
Q

Why is vitamin K a good systemic haemostatic agent?

A
  • necessary for the formation of clotting factors
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28
Q

Why is transexamic acid a good haemostatic agent?

A
  • prevents clot breakdown and stabilise clot
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29
Q

How would you manage a post op bleeding?

A
  • Pressure with finger or damp gauze + take rapid history
  • Local anaesthetic with vasoconstrictor
  • Haemostatic aids
  • Suture socket
  • Ligation of vessels or diathermyy
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30
Q

If you could not arrest the bleeding what would you do?

A
  • Urgent hospital referral
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31
Q

4 ways to prevent haemorrhage?

A
  • Atruamatic extraction
  • Thorough medical history
  • Obtain and check haemostasis is acheived after procedure
  • Give good post operative instructions
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32
Q

5 post op instructions?

A
  • Do not rinse mouth for several hours and after that rinse gently
  • Do not explore socket with tongue or fingers
  • Avoid hot food on the day of extraction
  • Avoid excessive physical activity
  • Avoid smoking and alcohol
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33
Q

How would you advice the patient to control bleeding after extraction? (2)

A
  • Bite on damp gauze or tissue for at least 30 minutes
  • If bleeding continues seek help immediately
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34
Q

Patient ask if the damage to their nerves will get any better , what would you say?

A

Improvement can occur within 18 months , after this there is little chance of further improvement

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35
Q

What is the clinical name of dry socket?

A

Alveolar osteitis , 2-3% of all extractions

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36
Q

What tooth is more likely to get a dry socket?

A

lower 3rd molars

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37
Q

Define dry socket?

A

Inflammation of lamina dura due to the breakdown of normal clot or not formation of the blood clot assicuated with intense pain

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38
Q

When do dry socket usually starts?

A

3-4 days after extraction

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39
Q

How long does it take for dry socket to resolve?

A

7-14 days

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40
Q

5 symptoms of dry socket?

A
  • Moderate to severe Dull aching pain
  • Radiates to the ear
  • Keeps patient awake at night
  • Bad smell
  • Bad taste
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41
Q

10 predisposing factors of dry socket?

A
  • Molars
  • Mandible more common
  • Smoking due to reduced blood supply
  • Females
  • Oral contraceptive pills
  • Vasoconstrictor In LA
  • infection from tooth
  • bacteria in socket
  • excessive trauma during extraction
  • excessive mouth rinsing post extraction
  • Previous dry socket or family history
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42
Q

8 management options of dry socket ?

A
  • Reassure patient
  • Analgesia
  • LA
  • Irrigate socket with warm saline
  • Curettage of socket to encourage new clot formation
  • Antiseptic pack (alvogyl)
  • HSMW
  • Review patient to change packs
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43
Q

When would you remove alvogyl and why?

A

As soon as pain resolves to allow healing

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44
Q

What are the active ingredients in alvogyl?

A
  • butamben
  • iodoform
  • eugenol
45
Q

What is sequestrum?

A

Pieces of bone - can also be pieces of tooth or amalgam

46
Q

What may be the effects of sequestrum?

A
  • Prevent healing
47
Q

A patient present with an infected socket post extraction, what would your management be ?

A
  • Check for remaining tooth or root fragements , Sequestra or foreing body visially
  • Take radiograph
  • LA and irrigate and remove any from the above
  • Consider antibiotics

infection can delay healing

48
Q

5 management options for chronic OAF?

A
  • Excise sinus tract
  • Buccal advancement Flap
  • Buccal fat pad with buccal advancement flap
  • Palatal flap
  • Bone graft and collagen membrane
49
Q

Describe the procedure of retrieving a root from the antrum through the socket?

A
  • Flap design
  • Open fenestration
  • Suction
  • Small curetted
  • Irrigation or ribbon gauze retrieval
  • Close with buccal advancement flap
50
Q

2 other techniques to retrieve a lost root in the antrum other than through the socket?

A
  • Caldwell luc appoach through a buccal window
  • Endoscopic approach
51
Q

What is osteomyelitis?

A
  • infection of the bone
52
Q

A patient comes to your practice , and you suspect osteomyelitis, what 4 things you expect to notice?

A
  • Raised body temperature
  • Affecting the mandible
  • Very tender site of extraction
  • Altered sensation due to pressure on IAN
53
Q

What are 5 predisposing factors of osteomyelitis?

A
  • Odontogenic infections
  • Fractures of the mandible
  • Malnutrition
  • Alcoholism
  • Diabetes
54
Q

Describe the distribution of osteomyelitis? (3)

A
  • Usually begin in medullary cavity involving the cancellous bone
  • Then extends and spreads to cortical bone
  • Then eventually to periosteum (overlying mucosa red and tender)
55
Q

Describe the pathogenesis of osteomyelitis?

A
  • invasion of bacteria in cancellous bone leads to inflammation of soft tissue and oedema in bone marrow spaces
  • Oedema leads to increased tissue hydrostatic pressure more than blood pressure of feeding arteries
  • this leads to compromised blood supply and therefore tissue necrosis
  • bacteria continue proliferating and spread until arrested by ABs or surgical therapy
56
Q

Why is osteomyelitis more common in mandible than maxilla?

A
  • in the maxilla there is rich blood supply unlike the mandible where the primary blood supply is from the inferior alveolar artery and dense cortical bone limits penetration of blood vessels - so more likely to become ishaemic and infected
57
Q

Why is it difficult to differentiate between acute osteomyelitis and dry socket or infected socket?

A

No radiographic change in acute osteomyelitis as it takes 10-12 days for lost bone to be detectable radiographically

58
Q

How would you describe the radiographic appearance of osteomyelitis ?

A
  • moth eaten appearance which can be uniform or patchy
  • some areas are radiopaque representing sequestra
59
Q

2 signs of osteomyelitis

A
  • Pus may be present
  • Bony destruction in area infected
60
Q

Why on a radiograph of long standing chronic osteomyelitis there might be an increase radiodensity surrounding the radiolucent area?

A

due to increased bone production as a result of inflammation
* this is called and involucrum

61
Q

Which bacteria is involved in mandible osteomyelitis?

A
  • Fusobacterium
  • Provotella
  • Streptococci
62
Q

Which bacteria is involved in osteomyelitis in bones other than mandible?

A
  • S.predominate
63
Q

What special investigations other than radiograph would you carry out for osteomyelitis?

A
  • FBC
  • Glucose levels
  • Biopsy for microbiological analysis
64
Q

How would you manage osteomyelitis?

A

Referral for surgical and antibiotic treatment

65
Q

Give 7 surgical managements of osteomyelitis?

A
  • Drain pus
  • Remove any non vital teeth in the area of infection
  • Remove sequestra
  • Remove of plates/ wires and screws in the area in fractured mandible cases
  • Corticotomy
  • Excision of necrotic bone
66
Q

Describe the antibiotic treatment for Osteomyelitis?

A
  • Penicillin is the first line
  • often weeks for acute and months for chronic
  • May require IV antibiotics in severe cases
67
Q

What is Osteoradionecrosis?

A

Necrosis of bone due to radiotherapy for cancer treatment due to low bony turnover

68
Q

Why does osteoradionecrosis affect the mandible more than the maxilla?

A
  • poorer blood supply
69
Q

How to prevent osteoradionecrosis?

A
  • PMPR before XLA
  • Chlorhexidine MW before XLA
  • Careful extraction technique
  • Antibiotics
  • Hyper baric oxygen before and after treatment
  • Refer patient for XLA or seek advice
70
Q

6 treatment options for Osteoradionecrosis?

A
  • Irrigation of necrotic debris
  • ABs
  • Remove loose bone
  • Monitor
  • Resection of exposed bone
  • Suturing
  • Hyperbaric oxygen
71
Q

What is the role of hyperbaric oxygen in the management of osteoradionecrosis?

A

increase tissue oxygenation and vascular ingrowth in the affected area

72
Q

What is medication related osteonecrosis of the Jaw?

A

A condition affecting the jaws that occur post extraction due to medications such as antiresorptive and antiangiogenic drugs resulting in non healing sockets due to inhibition of bone remodelling

73
Q

3 diseases that can be treated with bisphosphonated?

A
  • Paget’s disease
  • Malignant bone metastases
  • Osteoporosis
74
Q

What is the mode of action of bisphosphonates?

A

They inhibit osteoclast activity leading to inhibiting bone resorption and therefore bone remodelling

75
Q

3 examples of oral bisphosphonates ?

A
  • Alendronate
  • Etidronate
  • Risedronate
76
Q

3 examples of IV bisphosphonates?

A
  • Clodronate
  • Pamidronate
  • Zoledronate
77
Q

Example of RANK-L inhibitors?

A

Denosumab - stops osteoclast production

78
Q

3 examples of antiangiogenic drugs?

A
  • Monoclonal antibodies - stop growth factor (bevacizumab)
  • Small molecules that inhibit tyrosice kinase (sunitinib)
79
Q

4 dental cases where MRONJ might happen?

A

Post extraction
Following denture trauma
Infection
Periodontal disease

80
Q

The risk of MRONJ is higher in IV bisphosphonates or oral?

A

IV

81
Q

What is the risk of people treated with antiresorptive and antiangiogenic drugs of developing mronj?

A

1-14%

82
Q

What is risk of people treated with antiresorptives for osteoporosis of developing Mronj?

A

0.1 - 0.5%

83
Q

What are the 6 risk factors for developing MRONJ?

A
  • Dental treatment
  • Duration of bisphosphonate drug therapy
  • Dental implants
  • Other concurrent medications
  • Previous drug history
  • Drug holidays
84
Q

Patient taking steroids and antiresorptives , what is their MRONJ risk?

A

Increased

85
Q

Patient taking anti-resorptive drugs and antiangiogenics , what is their MRONJ risk?

A

Increased

86
Q

Why patients who had a history of antiresorptive or antiangiogenics are still at risk of developing MRONJ?

A

due to the long half life of these drugs
* example - denosumab = 9 months

87
Q

Patient asks about if they should stop their medication what should you say ?

A
  • No evidence for drug holidays
  • It is not the dentist resposibility to stop the medication and should consult prescribing physician
  • If the patient is treated for osteoporosis with injections every 6 months , it is advised to carry out treatment one month prior to that and resume drug when soft tissue closure
88
Q

3 categories of Patients considered to be at low risk of developing MRONJ?

A

osteoporosis or other non malignant bone disease with
* Oral bisphosphonates for less than 5 years in isolation]
* Quarterly or yearly IV bisphosphonates for less than 5 years in isolation
* Denosumab who are not being treated with systemic glucocoritcoids

89
Q

4 Categories of patients at higher risk of developing MRONJ?

A
  • Oral or IV bisphosphonates for more than 5 years in osteoporosis pts
  • Denusumab or bisphosphonates with glucocortocoids in osteoporosis pts
  • Cancer patients taking angioangiogenics or antiresorptive
  • Previous diagnosis of MRONJ
90
Q

10 management options for MRONJ?

A
  • Analgesia
  • remove sharp edges of bone
  • chlorhexidine mouthwash
  • ABs
  • Debridement
  • Resection
  • Hyperbaric oxygen
  • Monitor
  • Refer to secondary care
  • Prevent invasive treatment
91
Q

How are MRONJ patient considered in regards of management ?

A
  • Initial management prior to commencing drugs
  • Continuing management with drug
92
Q

What is actinomycosis?

A

Rare bacterial infection with Actinomyces bacteria

93
Q

2 examples of bacteria involved in actinomycosis?

A
  • A. israelii
  • A.viscosus
94
Q

Describe the pattern of invasion of actinomycosis?

A
  • have low virulence and must be inoculated into an area of injury
  • It erodes through tissue rather than spaces
95
Q

2 Symptoms and signs of actinomycosis?

A
  • multiple skin sinuses and swellings
  • Thick pus
96
Q

What do you expect to see on histology of a sample containing actinomycosis bacteria?

A
  • colonies of the bacteria look like sulpher granules
97
Q

5 management options for actinomycosis?

A
  • incise and drain of pus
  • excision of sinus tracts
  • excision of necrotic bone
  • IV antibiotics initially
  • long term antibiotics to prevent recurrence
98
Q

3 antibiotics you can use for actinomycosis?

A
  • Penicillin
  • Doxycycline
  • Clindamycin
99
Q

Describe how NICE guidance evolved with SDCEP guidelines?

A
  • Until 2008 , Abs prophylaxis was advised for people at high risk of developing infective endocarditis undergoing dental procedures
  • In 2008 NICE guidelines advised against Abs prophylaxis for EI for any dental procedure
  • In 2016 NICE guidelines advised against Abs prophylaxis for EI for people at high risk undergoing routine procedures
  • In 2018 , SDCEP in line with NICE guidelines published implementation of this advice
100
Q

Who are people at high risk of developing IE according to SDCEP ?

A
  • Patients with prosthetic heart valve
  • Patient with previous episode of infective endocarditis
  • Patients with congenital heart disease
101
Q

According to NICE guidelines , who are people at increased risk of developing infective endocarditis?

A
  • Patients with certain problems affecting the structure of the heart such as replacement heart valve or hypertrophic cardiomyopathy
  • Previous infective endocarditis
  • Patient undergoing any dental procedure
102
Q

A patient comes to your clinic for an extraction and is at high risk of developing infective endocarditis , how would you manage this patient?

A
  • Offer advise on benefits and risk of antibiotic prophylaxis and prevention of IE
  • Contact patient cardiology consultant / cardiac surgeon ir cardiology centre to determine if prophylaxis should be considered for invasive procedure
103
Q

What points would you cover during antibiotic prophylaxis discussion? (5)

A
  • Advise that there is a very small risk of developing IE due to the patient condition which is 1 case per 10,000 people and undergoing an extraction for example increase the risks of bacteria entering the blood stream
  • Everyday activities such as toothbrushing flossing and chewing can also cause bacteria , so good oral hygiene is the best way to prevent this
  • Dental treatment is no longer thought to be the main cause of infective endocarditis and it is not clear than antibiotic prophylaxis would prevent it
  • Antibiotics can cause nausea diarrhea and anaphylaxis
  • There is also a risk of developing infective endocarditis when undergoing non medical procedures such as piercings or tattoos
  • Advise the patients about the symptoms of infective endocarditis such as high temperature and sweating and breathlessness
104
Q

What is infective endocarditis?

A

Infective endocarditis is an infection of the lining of the heart that often involves the heart valves. It is a very rare but serious condition.

105
Q

What are the sings and symptoms of infective endocarditis?

A
  • A high temperature over 38
  • Sweats or chills especially at night
  • Weight loss
  • Fatigue
  • Muscle and joint or back pain
106
Q

According to SDCEP infective endocarditis guidelines, give 3 invasive dental procedures?

A
  • Placement of matrix bands
  • Placement of subgingival rubber dam clamps
  • Extractions
  • Incision and drainage
107
Q

According to SDCEP , name 4 non invasive dental procedures?

A
  • BPE
  • Supragingival scale and polish
  • Supragingival restorations
  • Removal of sutures
108
Q

What antibiotics would you give a patient for prophylaxis of endocarditis with dose…?

A
  • Amoxicillin, 3g one sachet oral powder
  • Clindamycin - 600mg 2 clindamycin capsules
  • Aithromycin - 500mg oral suspension

ALL 60 minutes before the procedure

BDS4 (69 decks)

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