Postoperative extraction complications Flashcards
What are the potential post-operative extraction complications
- pain/swelling/ecchymosis
- trismus/limited mouth opening
- haemorrhage
- prolonged effects of nerve damage
- dry socket
- sequestrum
- infected socket
- chronic OAF/root in antrum
what are less common post-operative extractions
- osteomyelitis
- osteoradionecrosis
- medication induced osteonecrosis
- actinomycosis
- bacteraemia/infective endocarditis
what is the most common post extraction complication
pain
how do you manage pain
make sure patients know it is normal to experience discomfort after an extraction
warn patients and advise/prescribe analgesia
Rough handling causes more pain
- laceration of tissues
exposed bone
-incomplete extraction of tooth
when should you be concerned about post-operative swelling
if it only begins about three days after the extraction
what can cause post-operative trismus
related to surgery - oedema or muscle spasm
related to giving LA - IDB ( if needle goes into medial pterygoid, it can cause a bleed and a haematoma. Or the muscle may go into a spasm resulting in limited mouth opening
Bleed in muscle - haematoma in medial pterygoid or masseter
damage to TMJ - oedema/join effusion
How do we initially deal with a patient who’s returned with bad post-operative bleeding
- put pressure on immediately
- calm the patient
- clean patient, remove bowls of blood etc
- take a thorough but rapid history
- rule out bleeding disorder and question anti platelet medication
- refer urgently if there is a bleeding disorder
- Remove the large jelly-like clot
- identify where bleeding is from
what type of haemorrage can occur post operatively
immediate post-operative period - within 48 hours, vessels that have been shut down open up and LA vasoconstriction effects wear off. Sutures also loosen or patient traumatises with finger/tongue
Secondary bleeding - often due to infection at 3-7 days. Usually mild ooze of blood
how do we manage/ stop haemorrhage
- pressure with finger or damp gauze packs
- local anaesthetic with vasoconstrictor
- haemostatic aids (surgicel - oxidised cellulose acts as a framework for clot formation)
- bone wax in socket
- suture the socket
ligation of vessels/diathermy
what post extraction instructions should you give to a patient who has been bleeding
- Do not rinse for several hours
- Avoid trauma - don’t explore socket with tongue or fingers
- Avoid hot food
- Avoid excessive exercise and alcohol (increases blood pressure)
- Give advice on control of bleeding (damp gauze, pressure for 30 minutes, points of contact if bleeding continues)
what is the proper name for dry socket
alveolar osteitis
what is the definition of dry socket
a condition occurring after tooth extraction which results in a dry appearance of the exposed bone in the socket, due to disintegration or loss of the blood clot
what is the main feature of dry socket
intense pain, described as worse than toothache and keeps patient awake at night
what is the aetiology of dry socket
- starts 3-4 days after extraction
- takes 7-14 days to resolve if you do nothing
- inflammation affecting the lamina dura (socket wall)
- some say cot does not form, others say it forms then breaks down
- ensure you help with pain control
what are the symptoms of dry socket
- dull aching pain (moderate to severe)
- usually throbs and can radiate to patient’s ear
- can keep patient awake at night
- exposed bone is sensitive and source of pain
- characteristic bad smell
- patient complains of bad taste in mouth
what are common predisposing factors of dry socket
- molars more common (risk increases from anterior to posterior)
- mandible more common (less blood supply)
- smoking (reduced blood supply)
- female
- oral contraceptive pill
- local anaesthetic with vasoconstrictor
what are less common predisposing factors of dry socket
- haematogenous bacteria in the socket
- excessive trauma during extraction
- excessive mouth rinsing post extraction (clot washes away)
- family history or previous dry socket
how do you manage a dry socket
- Reassure and give pain relief
- provide LA for pain relief
- Irrigate socket with warm saline to wash out food and debris
- curettage/debridement - encourage bleeding and new clot formation (Dr Bell doesn’t do this)
- Antiseptic pack (BIP or Alvogyl)
BIP is a bit of gauze with iodine base chemical in it. it doesn’t dissolve and you need to change them (maybe suture in place) see patient in a few days to remove or change
Alvogyl - take out with tweezers and pack into socket, will disintegrate (mixture of LA and antiseptic)
- Advise on analgesia and hot salty mouthwashes
- No antibiotics - not an infection
- Check that it is a dry socket and that no tooth fragments or bony sequestra remain
What is osteomyelitis
inflammation of the bone marrow
where is osteomyelitis more common
the mandible
what is the aetiology of osteomyelitis
- invasion of bacteria into cancellous bone causes soft tissue inflammation and oedema in the closed bony marrow spaces
- oedema in an enclosed space leads to increased tissue hydrostatic pressure
- the compromised blood supply results in soft tissue necrosis
- the involved area becomes ischaemic and necrosis
- the bacteria proliferate because normal blood borne defences do not reach the tissue
- osteomyelitis spreads until arrested by antibiotics and surgical therapy
why does osteomyelitis occur in the mandible more than the maxilla
the mandible primary blood supply is via the inferior alveolar artery and dense overlying cortical bone limits the penetration of periosteal vessels
Therefore, the mandible has a poorer blood supply and is more likely to become ischaemic and infected
what are predisposing factors for osteomyelitis
- odontogenic infections and fractures of the mandible
- host defences compromised
> diabetes
> alcoholism
> IV drug use
> malnutrition
Mmyeloproliferative disease
what bacteria are involved in osteomyelitis
- streptococci
- anaerobic cocci
- anaerobic gram negative rods such as fusobacterium and prevotella
what is the treatment for osteomyelitis
antibiotics - clindamycin/penicillins with longer courses than normal
surgical - drain pus and remove non-vital teeth around infection and any loose pieces of bone
Excise necrotic bone until we reach actively bleeding healthy bone
what is osteoradionecrosis
- bone within he radiation beam becomes non-vital after patients have received radiotherapy to head and neck to treat cancer
how do you prevent osteoradionecrosis
- scaling/chlorhexidine mouthwash leading uptown an extraction
- Careful extraction technique
- antibiotics
- hyperbaric oxygen
how do you treat osteonecrosis
- irrigation of necrotic debris
- antibiotics not overly helpful unless there is secondary infection
- loose sequestra removed
what is MRONJ
a progressive death of the jawbone in a person exposed to a medication known to increase the risk of the disease
When can MRONJ occur
post extraction
following dental trauma
spontaneously
what factors can affect MRONJ
- length of time patient has been on drug
- diabetics
- steroids
- anticancer chemotherapy
- smoking
what drugs can cause MRONJ
bisphosphonates
- alendronate
- clodronate
- etidronate
- ibandronate
- pamidronate
- risendronate
- tiludronate
- zoledronate
Antiresorptive
- praia
denosumab
Antiangiogenic
what are the risk factors for MRONJ
- dental treatment
- duration of bisphosonate drug therapy
- dental implants
- other concurrent medication
- previous drug history
