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BDS3 Oral surgery > Post-operative extraction complications > Flashcards

Post-operative extraction complications Flashcards

1
Q

What post-operative extraction complications are there

A
  • pain/swelling/ecchymosis
  • trismus/limited mouth opening
  • haemorrhage
  • prolonged effects of nerve damage
  • dry socket
  • sequestrum
  • infected socket
  • chronic OAF/ root in antrum
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2
Q

less common post-operative complications

A
  • osteomyelitis
  • osteoradionecrosis
  • medication induced osteonecrosis
  • actinomyosis
  • bacteraemia/infective endocarditis
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3
Q

How to deal with pain

A
  • most common complication of extraction
  • warn patient/advise or prescribe analgesia
  • rough handling of tissues - more pain
    • laceration/tearing of soft tissues
    • exposed bone
    • incomplete extraction of tooth
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4
Q

how to deal with swelling (oedema)

A
  • part of the inflammatory reaction to surgical interference
  • increased by poor surgical technique
  • wide individual variation
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5
Q

how to deal with ecchymosis (bruising)

A
  • good surgical technique and gentle handling of tissues
  • individual variation
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6
Q

what is trismus

A
  • jaw stiffness/inability to open mouth fully
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7
Q

what causes trismus

A
  • related to surgery
  • related to giving LA-IDB
  • bleed into muscle (haematoma) - medial petygoid/masseter (haematoma/clot organises and fibroses)
  • damage to TMJ - oedema/joint effusion
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8
Q

how to deal with limited mouth opening

A
  • monitor (may take several weeks to resolve)
  • gentle mouth opening exercises/wooden spatulae/trismus screw
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9
Q

what are the different types of haemorrhage you can get

A
  • intra-operative
  • immediate post operative period
    • reactionary/rebound
    • occurs within 48 hours of extraction
    • vessels open up/vasoconstricting effects of LA wear off/sutures loose or lost/patient traumatises area with tongue/finger/food
  • secondary bleeding
    • often due to infection
    • commonly 3-7 days
    • usually mild ooze but can occasionally be a major bleed
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10
Q

what damage to vessels can occur

A
  • veins (lots of bleeding)
  • arteries (spurting/haemorrhage, lots of bleeding)
  • arterioles (spurting/ pulsating bleed)
  • vessels in muscle
  • vessels in bone
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11
Q

how can dental haemorrhage occur

A
  • most bleeds due to local factors - muscoperiosteal tears or fractures of alveolar plate/socket wall
  • very few bleeds due to undiagnosed clotting abnormalities
  • liver disease
  • medication e.g. warfarin
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12
Q

how to deal with soft tissue bleeding

A
  • pressure
  • sutures
  • LA with adrenaline
  • diathermy
  • ligatures/haemostatic forceps for larger vessels
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13
Q

how to deal with bleeding from bones

A
  • pressure (via swab)
  • LA on a swab or injected into socket
  • haemostatic agents e.g. surgicel/kaltostat
  • blunt instrument
  • bone wax pack
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14
Q

how do you deal with post-operative bleeding

A
  • if bleeding severe get pressure on immediately/arrest the bleed
  • calm anxious patient/separate from anxious relatives
  • clean patient up/remove bowls of blood/blood soaked towels
  • take a thorough but rapid history while dealing with haemorrhage
  • must rule out bleeding disorder
  • medication - warfarin/combination of aspirin and other antiplatelet drugs
  • urgent referral/ contact haematologist if bleeding disorder. If on warfarin get GMP to do INR/urgent hospital referral if bleeding not arrested
  • get inside mouth/good light and suction
  • mouth often filled with large jelly-like clot
  • remove clot
  • patient may be vomiting if blood swallowed
  • identify where bleeding from
  • Pressure
  • LA with vasoconstrictor
  • haemostatic aids e.g. surgicel, bone wax in socket
  • suture socket - interrupted/horizontal mattress sutures
  • ligation of vessels/diathermy
  • give point of contact if bleeding resumes
  • review patient
  • an un-opperatiev child will need a GA
  • large vol of blood lost/medical problems/extremes of age - hospital admission/A and E
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15
Q

what are some examples of local haemostatic agents

A
  • adrenaline containing LA
  • oxidised regenerated cellulose - surgicel - framework for clot formation
  • gelatin sponge - absorbable/meshwork for clot formation
  • thrombin liquid and powder
  • fibrin foam
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16
Q

examples of systemic haemostatic aids

A
  • vitamin K
  • anti-fibrinolytics e.g. Tranexamic acid
  • missing blood clotting factors
  • plasma or whole blood
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17
Q

how can we prevent intra-operative and post-operative extraction haemorrhage

A
  • thorough medical history/anticipate and deal with potential problems
  • atraumatic extraction/surgical technique
  • obtain and check good haemostasis at end of surgery
  • provide good instructions to the patient
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18
Q

What are the post-extraction instructions

A
  • Don’t rinse out for several hours
  • avoid trauma - don’t explore socket with tongue/ fingers/ hard food
  • avoid hot food that day
  • avoid excessive physical exercise and excess alcohol - increase blood pressure
  • advice on control of bleeding
    • biting on damp gauze/tissue
    • pressure for at least 30 mins (longer if bleeding continues)
    • points of contact if bleeding continues
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19
Q

what are the prolonged effects of nerve damage

A
  • (last lecture)
  • temporary or permanent
  • improvement can occur up to 18 months-24 months
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20
Q

how common is dry socket

A

common

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21
Q

how many extractions does dry socket affect

A

2-3% of all extractions

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22
Q

scientific name for dry socket

A

alveolar/ localised osteitis

23
Q

what happens with a dry socket

A
  • normal clot disappears
  • intense pain
  • often starts 3-4 days after extraction
  • takes 7-14 days to resolve
  • localised osteitis - inflammation affecting lamina dura
24
Q

symptoms of dry socket

A
  • dull aching pain (moderate to severe)
  • usually throbs/can radiate to patient’s ear/often continuous and can keep patient awake at night
  • the exposed bone is sensitive and is the source of the pain
  • characteristic smell/bad odour and patient frequently complains of bad taste
  • no signs of overt infection e.g. fever/swelling/pus
25
Q

predisposing factors for dry socket

A
  • molars more common - risk increases from anterior to posterior
  • mandible more common
  • smoking - reduced blood supply
  • female
  • Oral contraceptive pill
  • LA with vasoconstrictor
  • ?infection from tooth
  • ?haematogenous bacteria in socket
  • excessive trauma during extraction
  • excessive mouth rinsing post extraction
  • family history/previous dry socket
26
Q

what is the management of dry socket

A
  • supportive - reassurance/systemic analgesia
  • LA block
  • irrigate socket with warm saline
  • curettage/debridement
  • antiseptic pack (e.g. BIP) or alvogyl (soothes pain/prevent food packing)
    • bismuth subnitrate and lodoform pack. Comes as a paste or imgregnated gauze. Antiseptic and astringent
    • mixture of LA and antiseptic
  • advise on analgeisa and hot salty mouthwashes
  • review patient/change packs and dressings
  • don’t prescribe antibiotics
  • check the socket initially to make sure it really is dry socket
27
Q

How common is sequestrum

A

quite common

28
Q

how do you spot sequestrum

A
  • prevent healing
  • usually bits of dead bone (can see white spicules coming through gingivae, pt thinks you’ve left part of the tooth)
  • painful until removed from socket
29
Q

how common is an infected socket

A

rare after routine dental extraction

30
Q

what to do if infected socket

A
  • check for remaining tooth/root fragments/bony sequestra/foreign bodies. Treatment - radiograph, explore, irrigate, remove any of the above, consider antibiotics
31
Q

how to treat chronic OAF

A
  • excise sinus tract
  • buccal advancement flap
  • buccal fat pad with buccal advancement flap
  • palatal flap
  • bone graft/collagen membrane
  • tongue flap (historical/no longer used)
32
Q

if you decided to retrieve a root in antrum how would you do this

A
  • OAF type approach/through the socket (flap design, open fenestration with care, suction, small curettes, irrigation or ribbon gauze, close as for OAC)
  • Caldwell-Luc approach (buccal sulcus, buccal window)
  • ENT - endoscopic approach
33
Q

what is osteomyelitis

A

inflammation of the bone

clinically term implies infection of the bone

34
Q

how common is osteomyelitis

A

rare

35
Q

Features of osteomyelitis

A
  • patient often systemically unwell/raised temperature
  • usually mandible
  • site of extraction often very tender
  • usually begins in medullary cavity involving the cancellous bone
  • extends and spreads to cortical bone then eventually to periosteum (overlapping mucosa red and tender)
  • oedema in enclosed space leads to increased tissue hydrostatic pressure
  • compromised blood supply - soft tissue necrosis
  • involved area becomes ischaemic and necrotic
  • bacteria proliferate becacuse normal blood borne defences don’t reach the tissue
36
Q

where does osteomyelitis most often occur and why

A

usually mandible as maxilla has a rich blood supply as supplied by several arteries

mandible - primary blood supply inferior alveolar artery and dense overlying cortical bone limits penetration of periosteal blood vessels (so poorer blood supply and more likely to become ischaemic and infected)

37
Q

major predisposing factors for osteomyelitis

A
  • odontogenic infections
  • fractures of mandible
  • compromised host defence (most important factor)
    • diabetes/alcoholism/ IV drug use/malnutrition/ myeloproliferative disease
38
Q

what does osteomyelitis look like on a radiograph

A
  • early osteomyelitis can be difficult to distinguish from dry socket or localised infection in the socket
  • acute suppurative osteomyelitis shows little/no radiographic change
  • chronic osteomyelitis (+/-) - bony destruction in the area of infection
  • radiographic appearance - increased radiolucency (uniform or patchy with a ‘moth-eaten appearance’)
39
Q

what is an involucrum

A

in long standing chronic osteomyelitis there may be an increase in radiodensity surrounding the radioluscent area

40
Q

osteomyelitis can occur in other areas of body but why is the mandible different

A

main bacteria involved similar to those involved in odontogenic infections, in other bones staphylococci predominate

41
Q

Treatment for osteomyelitis

A
  • medical and surgical
  • investigate host defences - blood investigations/glucose levels
  • antibiotics
    • clindamycin/penicillins (effective against odontogenic infections and good bone penetration)
    • longer courses than normal
    • often weeks in acute osteomyelitis/months in chronic osteomyelitis
    • severe acute osteomyelitis may require hospital admission and IV antibiotics
  • surgical treatment
    • drain pus
    • remove any non-vital teeth in the area of infection
    • remove any loose pieces of bone
    • in fractured mandible - remove any wires/plates/screws in the area
    • corticotomy - removal of bony cortex
    • perforation of bony cortex
    • excision of necrotic bone (until reach actively bleeding bone tissue)
42
Q

In which patients do we see osteoradionecrosis

A

Patients who have received radiotherapy of the head and neck to treat cancer

43
Q

Features of osteoradionecrosis

A
  • endarteritis - reduced blood supply
  • turnover of any remaining viable bone is slow
  • self-repair ineffective
  • worse with time
  • mandible most commonly affected as poorer blood supply
44
Q

How can we prevent osteoradionecrosis

A
  • scaling/chlorhexidine mouthwash leading up to extraction
  • careful extraction technique
  • antibiotics, chlorhexidine mouthwash and review
  • hyperbaric oxygen (to increase local tissue oxygenation and vascular ingrowth to hypoxic areas) before and after extraction
  • take advice/refer patient for extraction
45
Q

Treatment of osteoradionecrosis

A
  • irrigation of necrotic debris
  • antibiotics not overly helpful unless secondary infection
  • loose sequestra removed
  • small wounds (under 1cm) usually heal over a course of weeks/months
  • severe cases - resection of exposed bone, margin or unexposed bone and soft tissue closure
  • hyperbaric oxygen
46
Q

How does MRONJ occur

A

medications (usually bisphosphonates) inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal.

The drugs may remain in the body for years.

47
Q

When does MRONJ occur

A
  • post extraction
  • following denture trauma
  • spontaneous
  • higher risk with receiving IV bisphosphonates but still occurs in patients on oral bisphosphonates
  • other factors: length of time on drug/diabetes/steroids/anticancer chemotherapy/smoking
48
Q

How to treat MRONJ

A
  • avoid extraction if possible, if required careful technique and monitor patient/warn patient to look for signs
  • manage symptoms/remove sharp edges of bone/chlorhexidine mouthwash/antibiotics if suppuration
  • debridement/ major surgical sequestrectomy/ resection/ hyperbaric oxygen
49
Q

Risk factors for MRONJ

A
  1. dental teratment
    1. extractions, trauma from dentures, infection, periodontal disease
  2. dose and duration of bisphosphonate drug therapy
  3. dental implants (unknown)
  4. other concurrent medication
  5. Previous drug therapy
  6. drug holidays (not responsibility of dentist)
50
Q

management of MRONJ

A
  • prevent invasive treatment
  • extractions in primary care setting
  • no benefit of referral to secondary care based purely on their exposure to these drugs
  • guidance considers patients in two groups (before or just starting drug regime or established drug regime)
51
Q

What is actinomycosis

A
  • rare bacterial infection
  • e.g. actinomyces israelii
  • The bacteria have low virulence and must be inoculated into an area of injury or susceptibility
  • e.g. recent extraction/severely carious teeth/bone fracture/ minor oral trauma
  • it erodes through tissues rather than follow typical fascial planes and spaces
  • fairly chronic
  • thick lumpy pus
  • response ininitally to antibiotic therapy/recurs when stop antibiotics
52
Q

Treatment for actinomycosis

A
  • I&D of pus accumulation
  • excision of chronic sinus tracts
  • excision of necrotic bone and foreign bodies
  • high dose antibiotics for initial control (often IV)
  • long-term oral antibiotics to prevent recurrence
  • antibiotis: penicillins, doxycyline or clindamycin
53
Q

what is infective endocarditis

A

inflammation of endocardium particularly affecting heart valves or CMP caused by bacteria

54
Q

Summary

A

we should always make sure we take a full patient history, including medical history, and fully risk assess each patient. If necessary, liase with the patient’s cardiologist or other specialist and take advice if you are not sure. It’s really important to emphasise the Oral health promotion message to avoid the need for dental extrations and other invasive treatment. Always monitor guidance and look out for changes in the guidance.

BDS3 Oral surgery (5 decks)

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