Post-operative extraction complications Flashcards
List 8 post XLA complications other than swelling , pain and bruising?
- Trismus
- Bleeding
- Prolonged effects of nerve damage
- Dry socket
- Sequestrum
- Infected socket
- Chronic OAF and root in antrum
- Osteomyelitis , ORN , MRONJ
What is the most common complication of extraction?
- Pain
How would you reduce post op pain? (3)
- Good handling of tissues
- Avoid leaving bone exposed
- Ensure all tooth is extracted
- Analgesia
- Warn patient about risk
What increases oedema/bruising post XLA?
- Rough handling of soft tissues
- Pulling flaps
- Crushing tissue with instrument
- Tearing of periosteum
What is trismus?
Jaw stiffness and inability to open mouth fully
4 causes of trismus post extraction?
- Related to surgery - muscle spasm or oedema
- IDB may cause medial pterygoid spasm
- Haematoma - medial pterygoid or masseter
- Damage to TMJ
4 management options for post-op limited mouth opening?
- Monitor as may resolve within weeks
- Gentle mouth opening exercises
- Wooden spatulae
- Trismus screws
5 dental procedures that are unlikely to cause bleeding?
- LA by infiltration or blocks
- BPE
- Supragingival PMPR
- Direct restorations
- Orthograde endodontics
- Impression taking
5 dental procedure that have low risk of bleeding?
- Simple extractions
- Incision and drainage of intra-oral swelling
- 6PPC
- RSD
- Restorations with subgingival margins
5 dental procedures that are considered high risk of bleeding?
- Complex extractions
- more than 3 extractions at once
- Flap raising procedures
- Biopsies
- Gingival recontouring
Patient on aspirin/ clopidegrol/ticagrelor or dual antiplatelet therapy , how would you manage medication if high bleeding risk procedure?
- Treat without interrupting medication but expect prolonged bleeding if on dual therapy
What consideration other than altering medication could you do to reduce risk of bleeding?
- Limit initial treating area
- Staging complex procedure
- Use haemostatic measures such as sutures and packing
- Treat early on the day for pt on DOAC
How would you manage a patient on DOAC regarding medication in a low bleeding risk procedure
treat without interrupting medication
How would you manage a patient on DOAC regarding medication in a high risk bleeding procedure?
- Miss or delay morning dose
How would you manage a patient on Warfarin regarding medication if procedure is likely to cause bleeding?
- 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
Patient on IV antigoagulant (enoxaparin) , how would you manage medication if patient is getting an extraction?
- In low doses - treat without interruption
- In high doses - consult with prescribing clinician
If patient is taking anti-platelets and anticoagulants , how would you manage medication for a patient getting an extraction?
- Consult with prescribing clinician on the impact of the drug combination on the patient bleeding risk
2 things to ask a patient on Warfarin other than their INR?
- Why are they on the drug
- What is their target INR
Patient taking Rivaroxaban or Edoxaban in the evening and is getting an extraction, how would you treat?
- if in the morning miss morning dose and take after 4 hours after haemostasis has achieved
Patient taking apixaban or dabigatran and is getting XLA , how would you treat?
- miss morning dose and take evening dose as normal
Explain immediate post operative bleeding?
- Reactionary bleeding
- Occurs within 48 hours of XLA
3 causes of immediate post op bleeding during the first 48 hours after XLA?
- Vessels open up due to wearing off of vasoconstrictor effect
- Sutures become loose or lost
- Patient traumatise area with tongue, finger or food
Bleeding occurs after 3-7 days of XLA , what might 3 reasons of this secondary bleeding?
- Infection or medication related
5 local haemostatic agents ?
- LA with adrenaline
- Oxidised regenerated cellulose matrix
- Haemocollagen sponge
- Thrombin liquid or powder
- Floseal
Why would you avoid placing Surgicel in lower 8 region?
It might cause damage to IDN as it is acidic
What are 5 systemic haemostatic agents?
- Vitamin K
- Anti-fibrinolytics - transexamic acid
- Missing blood clotting factors
- Plasma or whole blood
- Desmopressin
Why is vitamin K a good systemic haemostatic agent?
- necessary for the formation of clotting factors
Why is transexamic acid a good haemostatic agent?
- prevents clot breakdown and stabilise clot
How would you manage a post op bleeding?
- Pressure with finger or damp gauze + take rapid history
- Local anaesthetic with vasoconstrictor
- Haemostatic aids
- Suture socket
- Ligation of vessels or diathermyy
If you could not arrest the bleeding what would you do?
- Urgent hospital referral
4 ways to prevent haemorrhage?
- Atruamatic extraction
- Thorough medical history
- Obtain and check haemostasis is acheived after procedure
- Give good post operative instructions
5 post op instructions?
- 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
How would you advice the patient to control bleeding after extraction? (2)
- Bite on damp gauze or tissue for at least 30 minutes
- If bleeding continues seek help immediately
Patient ask if the damage to their nerves will get any better , what would you say?
Improvement can occur within 18 months , after this there is little chance of further improvement
What is the clinical name of dry socket?
Alveolar osteitis , 2-3% of all extractions
What tooth is more likely to get a dry socket?
lower 3rd molars
Define dry socket?
Inflammation of lamina dura due to the breakdown of normal clot or not formation of the blood clot assicuated with intense pain
When do dry socket usually starts?
3-4 days after extraction
How long does it take for dry socket to resolve?
7-14 days
5 symptoms of dry socket?
- Moderate to severe Dull aching pain
- Radiates to the ear
- Keeps patient awake at night
- Bad smell
- Bad taste
10 predisposing factors of dry socket?
- 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
8 management options of dry socket ?
- 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
When would you remove alvogyl and why?
As soon as pain resolves to allow healing
What are the active ingredients in alvogyl?
- butamben
- iodoform
- eugenol
What is sequestrum?
Pieces of bone - can also be pieces of tooth or amalgam
What may be the effects of sequestrum?
- Prevent healing
A patient present with an infected socket post extraction, what would your management be ?
- 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
5 management options for chronic OAF?
- Excise sinus tract
- Buccal advancement Flap
- Buccal fat pad with buccal advancement flap
- Palatal flap
- Bone graft and collagen membrane
Describe the procedure of retrieving a root from the antrum through the socket?
- Flap design
- Open fenestration
- Suction
- Small curetted
- Irrigation or ribbon gauze retrieval
- Close with buccal advancement flap
2 other techniques to retrieve a lost root in the antrum other than through the socket?
- Caldwell luc appoach through a buccal window
- Endoscopic approach
What is osteomyelitis?
- infection of the bone
A patient comes to your practice , and you suspect osteomyelitis, what 4 things you expect to notice?
- Raised body temperature
- Affecting the mandible
- Very tender site of extraction
- Altered sensation due to pressure on IAN
What are 5 predisposing factors of osteomyelitis?
- Odontogenic infections
- Fractures of the mandible
- Malnutrition
- Alcoholism
- Diabetes
Describe the distribution of osteomyelitis? (3)
- 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)
Describe the pathogenesis of osteomyelitis?
- 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
Why is osteomyelitis more common in mandible than maxilla?
- 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
Why is it difficult to differentiate between acute osteomyelitis and dry socket or infected socket?
No radiographic change in acute osteomyelitis as it takes 10-12 days for lost bone to be detectable radiographically
How would you describe the radiographic appearance of osteomyelitis ?
- moth eaten appearance which can be uniform or patchy
- some areas are radiopaque representing sequestra
2 signs of osteomyelitis
- Pus may be present
- Bony destruction in area infected
Why on a radiograph of long standing chronic osteomyelitis there might be an increase radiodensity surrounding the radiolucent area?
due to increased bone production as a result of inflammation
* this is called and involucrum
Which bacteria is involved in mandible osteomyelitis?
- Fusobacterium
- Provotella
- Streptococci
Which bacteria is involved in osteomyelitis in bones other than mandible?
- S.predominate
What special investigations other than radiograph would you carry out for osteomyelitis?
- FBC
- Glucose levels
- Biopsy for microbiological analysis
How would you manage osteomyelitis?
Referral for surgical and antibiotic treatment
Give 7 surgical managements of osteomyelitis?
- 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
Describe the antibiotic treatment for Osteomyelitis?
- Penicillin is the first line
- often weeks for acute and months for chronic
- May require IV antibiotics in severe cases
What is Osteoradionecrosis?
Necrosis of bone due to radiotherapy for cancer treatment due to low bony turnover
Why does osteoradionecrosis affect the mandible more than the maxilla?
- poorer blood supply
How to prevent osteoradionecrosis?
- 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
6 treatment options for Osteoradionecrosis?
- Irrigation of necrotic debris
- ABs
- Remove loose bone
- Monitor
- Resection of exposed bone
- Suturing
- Hyperbaric oxygen
What is the role of hyperbaric oxygen in the management of osteoradionecrosis?
increase tissue oxygenation and vascular ingrowth in the affected area
What is medication related osteonecrosis of the Jaw?
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
3 diseases that can be treated with bisphosphonated?
- Paget’s disease
- Malignant bone metastasis
- Osteoporosis
What is the mode of action of bisphosphonates?
They inhibit osteoclast activity leading to inhibiting bone resorption and therefore bone remodelling
3 examples of oral bisphosphonates ?
- Alendronate
- Etidronate
- Risedronate
3 examples of IV bisphosphonates?
- Clodronate
- Pamidronate
- Zoledronate
Example of RANK-L inhibitors?
Denosumab - stops osteoclast production
3 examples of antiangiogenic drugs?
- Monoclonal antibodies - stop growth factor (bevacizumab)
- Small molecules that inhibit tyrosice kinase (sunitinib)
4 dental cases where MRONJ might happen?
Post extraction
Following denture trauma
Infection
Periodontal disease
The risk of MRONJ is higher in IV bisphosphonates or oral?
IV
What is the risk of people treated with antiresorptive and antiangiogenic drugs of developing mronj?
1-14%
What is risk of people treated with antiresorptives for osteoporosis of developing Mronj?
0.1 - 0.5%
What are the 6 risk factors for developing MRONJ?
- Dental treatment
- Duration of bisphosphonate drug therapy
- Dental implants
- Other concurrent medications
- Previous drug history
- Drug holidays
Patient taking steroids and antiresorptives , what is their MRONJ risk?
Increased
Patient taking anti-resorptive drugs and antiangiogenics , what is their MRONJ risk?
Increased
Why patients who had a history of antiresorptive or antiangiogenics are still at risk of developing MRONJ?
due to the long half life of these drugs
* example - denosumab = 9 months
Patient asks about if they should stop their medication what should you say ?
- 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
3 categories of Patients considered to be at low risk of developing MRONJ?
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
4 Categories of patients at higher risk of developing MRONJ?
- 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
10 management options for MRONJ?
- Analgesia
- remove sharp edges of bone
- chlorhexidine mouthwash
- ABs
- Debridement
- Resection
- Hyperbaric oxygen
- Monitor
- Refer to secondary care
- Prevent invasive treatment
How are MRONJ patient considered in regards of management ?
- Initial management prior to commencing drugs
- Continuing management with drug
What is actinomycosis?
Rare bacterial infection with Actinomyces bacteria
2 examples of bacteria involved in actinomycosis?
- A. israelii
- A.viscosus
Describe the pattern of invasion of actinomycosis?
- have low virulence and must be inoculated into an area of injury
- It erodes through tissue rather than spaces
2 Symptoms and signs of actinomycosis?
- multiple skin sinuses and swellings
- Thick pus
What do you expect to see on histology of a sample containing actinomycosis bacteria?
- colonies of the bacteria look like sulpher granules
5 management options for actinomycosis?
- incise and drain of pus
- excision of sinus tracts
- excision of necrotic bone
- IV antibiotics initially
- long term antibiotics to prevent recurrence
3 antibiotics you can use for actinomycosis?
- Penicillin
- Doxycycline
- Clindamycin
Describe how NICE guidance evolved with SDCEP guidelines?
- 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
Who are people at high risk of developing IE according to SDCEP ?
- Patients with prosthetic heart valve
- Patient with previous episode of infective endocarditis
- Patients with congenital heart disease
According to NICE guidelines , who are people at increased risk of developing infective endocarditis?
- 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
A patient comes to your clinic for an extraction and is at high risk of developing infective endocarditis , how would you manage this patient?
- 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
What points would you cover during antibiotic prophylaxis discussion? (5)
- 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
What is infective endocarditis?
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.
What are the sings and symptoms of infective endocarditis?
- A high temperature over 38
- Sweats or chills especially at night
- Weight loss
- Fatigue
- Muscle and joint or back pain
According to SDCEP infective endocarditis guidelines, give 3 invasive dental procedures?
- Placement of matrix bands
- Placement of subgingival rubber dam clamps
- Extractions
- Incision and drainage
According to SDCEP , name 4 non invasive dental procedures?
- BPE
- Supragingival scale and polish
- Supragingival restorations
- Removal of sutures
What antibiotics would you give a patient for prophylaxis of endocarditis with dose…?
- Amoxicillin, 3g one sachet oral powder
- Clindamycin - 600mg 2 clindamycin capsules
- Aithromycin - 500mg oral suspension
ALL 60 minutes before the procedure
