Prevention & management of extraction complications_part 2 Flashcards
1
Q
PREVENTION OF COMPLICATIONS
* Thorough preoperative assessment
(2)
A
- MEDICAL HISTORY REVIEW!!
- Adequate and up to date images
2
Q
- Comprehensive treatment plan
(3)
A
- Detailed surgical plan
- Needed instrumentation
- Pain/anxiety management
3
Q
- Careful execution of surgical procedure
(3)
A
- Clear visualization and access to surgical field
- Use of controlled force → finesse
- Asepsis, atraumatic handling of tissue, hemostasis, debridement (as needed)
4
Q
- Complications can STILL occur; however,
A
the complications begin to become more predictable and will become routinely
managed
5
Q
PREVENTION OF COMPLICATIONS
(3)
A
- Perform procedures that are within the limits of their capabilities
- Be cautious of unwarranted optimism
- Referral is ALWAYS an options
6
Q
- Be cautious of unwarranted optimism
(1)
A
- Clouds judgment leading to increased post-op complications
7
Q
- Referral is ALWAYS an options
(2)
A
- Is a moral obligation to practitioners → primum non nocere
- Will provide peace of mind
8
Q
ORAL HEMOSTATIC MECHANISM CHALLENGES
(5)
A
- Tissues in the mouth are highly vascular
- Extractions leave an open wound
- Impossible to apply dressing with enough pressure and sealing to prevent additional
bleeding - Patients tend to explore areas of surgery with their tongues, occasionally dislodging clots,
which initiates secondary bleeding - Salivary enzymes may lyse blood clots prior to maturation/organization
9
Q
PREVENTION
(4)
A
- Obtain a history of bleeding
- Use atraumatic surgical technique
- Obtain good hemostasis at surgery
- Provide excellent patient instructions
10
Q
MEDICAL HISTORY REVIEW
(7)
A
- Has the patient ever had any prolonged bleeding after surgery?
- Does the patient bruise easily?
- Is there a family member with a history of prolonged bleeding/easy
bruising/systemic disease? - Medication review looking for anticoagulants/antiplatelets/chemotherapy
- Social history of alcoholism/liver disease?
- Systemic diseases related to prolonged bleeding?
- Is there a history of uncontrolled hypertension?
11
Q
LABORATORY TESTING
(3)
A
- Helps determine stability of the disorder
- Platelets defects → platelet number and bleeding time
- Coagulation cascade defects → INR
12
Q
Platelets defects → platelet number and bleeding time
(3)
A
- Bleeding time is an archaic test:
- Razor blade cuts arm and the bleeding observed until stopping
- Normal bleeding time 3-10 min
13
Q
- Coagulation cascade defects → INR
(4)
A
- International Normalized Ration: is a record of prothrombin time and a standardized control
(due to laboratory differences across nation) - Normal INR 1
- Normal anticoagulated patient INR 2-3
- If above 3, physician needs consultation prior to treatment
14
Q
INITIAL CONTROL OF BLEEDING
A
- Gaining control of all factors that prolong bleeding
- Atraumatic surgery
- Clean incisions
- Gentle management of soft tissues
- Removal of all granulation tissue
- Increased vascularity noted in granulation tissue
- Smooth sharp bony projections
- Inspect socket for bleeding nutrient canals
- Can crush bone into canal to stop bleeding
15
Q
NITIAL CONTROL OF BLEEDING
* Direct pressure of socket with moistened gauze, folded to fit over socket
* Pressure for at least —
* Only dismiss patient if bleeding is controlled with gauze
A
30 – 45 min
16
Q
FURTHER CONTROL OF BLEEDING
* Materials sued for hemostasis:
(4)
A
- Gelfoam: absorbable gelatin
- Surgicel/ActCel: oxidized cellulose
- Collagen
- Thrombin
17
Q
GELFOAM®
A
- Absorbable gelatin sponge
- Acts as a physical tamponade, increases in size to exert internal
pressure of bone - Acts as lattice for clot to form on
- Liquefies in 2-5 days
- Least expensive
- Held in place with figure of eight suture
- Can be used with topical thrombin
18
Q
SURGICEL®, ACTCEL ®
A
- Oxidized regenerated cellulose
- Promotes coagulation better than gelfoam
- Can be packed into socket under pressure (does increase in size
but not to the extent of gelfoam) - Acts as lattice for clot to form on
- Bactericidal due to low pH
- More expensive
- CAN NOT be used with topical thrombin → thrombin is
inactivated - Packed into socket and stabilized with figure of eight suture
19
Q
COLLAGEN
A
- Avitene®, CollaPlug®, Collatape®
- Promotes platelet aggregation
- Good for patients with qualitative platelet defects
- Can be packed into socket
- Very expensive
- Figure of eight suture placed to stabilize
20
Q
THROMBIN
A
- Comes in separate powder and liquid vials, mix together
and then placed - Great for coagulation factor defects
- Thrombin bypasses extrinsic and intrinsic systems and
directly convert fibrinogen (factor 1) to fibrin (factor 1a) - Used with gelfoam
- Inactivated by oxidized cellulose
21
Q
SECONDARY BLEEDING (POST-OPERATIVE)
A
- Continual bleeding from extraction site after patient left office
- Advise to rinse mouth out with chilled water, and replace moistened gauze (bite for 1 hour)
- If continued, bite on tea bag (take advantage of tannins/tannic acid)
- If continued, bring patient back
- Have orderly planned regimen and armamentarium set up
- Asses where bleeding is coming from
- Good visualization and lighting
- Repack in office and bite down
- If continued, give local anesthesia via block and curette socket clean (remove ineffective clot)
- Visualize soft tissues and socket, place gelfoam/surgical and over-sew with suture (with or without thrombin)
- Replace pressure gauze and monitor for at least 30 min
- If continue bleeding → high likelihood of systemic defect
- Can advise PCP of surgical findings (call directly vs send letter), and let the physicians order appropriate laboratory testing, PCP may require
consultation from Hematologist
22
Q
COMPLICATION OF POSTOP BLEEDING
A
- ECCHYMOSIS!!!
- Blood escaping into tissue spaces, more specifically subcutaneous tissue space
- Usually seen in elderly patients, due to
- Decreased tissue tone
- Increased capillary fragility
- Weaker cellular attachment
- Is not dangerous, does not cause pain, does not increase risk of infection
23
Q
OROANTRAL COMMUNICATION
* Definition:
* Perforation –
* Fistula –
A
original hole into the sinus through the socket
epithelialized tract that forms after the unsuccessful attempt at health of the
perforation, weeks out
24
Q
- Oroantral communications can result in:
(2)
A
- Oroantral fistulas (OAF)
- Chronic sinusitis
25
Q
CAUSES OF OA COMMUNICATIONS
A
- Severe pneumatization
- Should be caught on pre-operative radiologic evaluation in an attempt
to prevent - Difficult or island maxillary molar extraction
- Bony floor of sinus comes out with tooth
- Inappropriate elevator technique with subsequent pushing root or
instrument through sinus - Bur sectioning molar furcation
26
Q
DIAGNOSIS
A
- Look at root tip of tooth to evaluate if bony floor fractured and delivered with tooth
- Evaluate the socket to observe Schneiderian membrane
- Is membrane intact or also perforated
- Do not use curettes or probes if unsure
- Can easily turn a small hole into a big one
- Light Valsalva maneuver with nose pinched closed
- Can hear air escaping or see blood/saliva bubble in socket
- Suction directly over site
- Can hear a hallow sound
27
Q
PREVENTION
A
- Preoperative assessment
- When in doubt, perform open surgical extraction
- Be careful not to let bur cut into sinus in the area of the furcation
28
Q
TREATMENT
A
- Depends on three factors:
- Size of perforation
- Health of sinus
- If chronic sinusitis there poor prognosis
- Location of the opening
- Close to alveolar crest (seen with increased sinus pneumatization)
- Apex of root
29
Q
< 2 MM OPENING
A
- No additional treatment, good prognosis
- Place patient on “sinus precautions” – avoid pressure changes
- No blowing nose forcibly
- No sucking on straws
- No smoking
- Protect blood clot with figure of eight suture over socket
- Antibiotics for short duration (3-5 days)
- Nasal decongestants
- Saline nasal spray
30
Q
2 – 6 MM OPENING
A
- Sinus precautions
- Pack gelfoam and secure with figure of eight suture over packing
- Antibiotics for 5-7 days
- Augmentin vs PCN vs amoxicillin
- Afrin (oxymetazoline) nasal decongestant
- Keeps sinus nasal ostium patent to allow normal sinus drainage through naris, thus prevent infection
- Careful as excessive use can lead to rhinitis medicamentosa
- Saline nasal spray
31
Q
> 6 MM OPENING
A
- Sinus precautions
- Sinus medications
- Referral to OMS for closure
- Buccal mucosal advancement flap
- Palatal finger flap coverage
- Buccal fat pad advancement
32
Q
OROANTRAL COMMUNICATION
* Post-operative follow-up
A
- Good idea to have patient follow up in two weeks to make sure the communication does not
turn into fistula, and require additional surgical procedures
33
Q
MANDIBLE FRACTURE
* Causes:
(2)
A
- Excessive force with elevator, most often with
impacted third molar - Straight elevator use, can also occur with cross
bar elevator
34
Q
MANDIBLE FRACTURE
* Prevention:
(2)
A
- Controlled forces and finesse
- Attention to mandibular flexing during luxation
35
Q
MANDIBLE FRACTURE
* Treatment:
(1)
A
- Refer to OMS for open reduction and internal
fixation vs closed reduction
