Prevention & management of extraction complications_part 2

Question 1

PREVENTION OF COMPLICATIONS
* Thorough preoperative assessment
(2)

Answer 1

• MEDICAL HISTORY REVIEW!!
• Adequate and up to date images

Question 2

• Comprehensive treatment plan
  (3)

Answer 2

• Detailed surgical plan
• Needed instrumentation
• Pain/anxiety management

Question 3

• Careful execution of surgical procedure
  (3)

Answer 3

• Clear visualization and access to surgical field
• Use of controlled force → finesse
• Asepsis, atraumatic handling of tissue, hemostasis, debridement (as needed)

Question 4

• Complications can STILL occur; however,

Answer 4

the complications begin to become more predictable and will become routinely
managed

Question 5

PREVENTION OF COMPLICATIONS
(3)

Answer 5

• Perform procedures that are within the limits of their capabilities
• Be cautious of unwarranted optimism
• Referral is ALWAYS an options

Question 6

• Be cautious of unwarranted optimism
  (1)

Answer 6

• Clouds judgment leading to increased post-op complications

Question 7

• Referral is ALWAYS an options
  (2)

Answer 7

• Is a moral obligation to practitioners → primum non nocere
• Will provide peace of mind

Question 8

ORAL HEMOSTATIC MECHANISM CHALLENGES
(5)

Answer 8

• 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

Question 9

PREVENTION
(4)

Answer 9

• Obtain a history of bleeding
• Use atraumatic surgical technique
• Obtain good hemostasis at surgery
• Provide excellent patient instructions

Question 10

MEDICAL HISTORY REVIEW
(7)

Answer 10

• 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?

Question 11

LABORATORY TESTING
(3)

Answer 11

• Helps determine stability of the disorder
• Platelets defects → platelet number and bleeding time
• Coagulation cascade defects → INR

Question 12

Platelets defects → platelet number and bleeding time
(3)

Answer 12

• Bleeding time is an archaic test:
• Razor blade cuts arm and the bleeding observed until stopping
• Normal bleeding time 3-10 min

Question 13

• Coagulation cascade defects → INR
  (4)

Answer 13

• 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

Question 14

INITIAL CONTROL OF BLEEDING

Answer 14

• 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

Question 15

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

Answer 15

30 – 45 min

Question 16

FURTHER CONTROL OF BLEEDING
* Materials sued for hemostasis:
(4)

Answer 16

• Gelfoam: absorbable gelatin
• Surgicel/ActCel: oxidized cellulose
• Collagen
• Thrombin

Question 17

GELFOAM®

Answer 17

• 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

Question 18

SURGICEL®, ACTCEL ®

Answer 18

• 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

Question 19

COLLAGEN

Answer 19

• 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

Question 20

THROMBIN

Answer 20

• 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

Question 21

SECONDARY BLEEDING (POST-OPERATIVE)

Answer 21

• 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

Question 22

COMPLICATION OF POSTOP BLEEDING

Answer 22

• 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

Question 23

OROANTRAL COMMUNICATION
* Definition:
* Perforation –
* Fistula –

Answer 23

original hole into the sinus through the socket

epithelialized tract that forms after the unsuccessful attempt at health of the
perforation, weeks out

Question 24

• Oroantral communications can result in:
  (2)

Answer 24

• Oroantral fistulas (OAF)
• Chronic sinusitis

Question 25

CAUSES OF OA COMMUNICATIONS

Answer 25

* 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

Question 26

DIAGNOSIS

Answer 26

* 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

Question 27

PREVENTION

Answer 27

* Preoperative assessment * When in doubt, perform open surgical extraction * Be careful not to let bur cut into sinus in the area of the furcation

Question 28

TREATMENT

Answer 28

* 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

Question 29

< 2 MM OPENING

Answer 29

* 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

Question 30

2 – 6 MM OPENING

Answer 30

* 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

Question 31

> 6 MM OPENING

Answer 31

* Sinus precautions * Sinus medications * Referral to OMS for closure * Buccal mucosal advancement flap * Palatal finger flap coverage * Buccal fat pad advancement

Question 32

OROANTRAL COMMUNICATION * Post-operative follow-up

Answer 32

* 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

Question 33

MANDIBLE FRACTURE * Causes: (2)

Answer 33

* Excessive force with elevator, most often with impacted third molar * Straight elevator use, can also occur with cross bar elevator

Question 34

MANDIBLE FRACTURE * Prevention: (2)

Answer 34

* Controlled forces and finesse * Attention to mandibular flexing during luxation

Question 35

MANDIBLE FRACTURE * Treatment: (1)

Answer 35

* Refer to OMS for open reduction and internal fixation vs closed reduction