The returning patient

Question 1

What examinations should be done?

Answer 1

-Visual:
Patient’s general appearance

-Extra Oral
Temperature
Swelling
Lymphadenpathy
Trismus

-Intra oral (in an appropriate clinical area)
Site of surgery
Swelling 
Bleeding
Suppuration
halitosis

Question 2

What is a dry socket / Alveolar Osteitis?

Answer 2

• Inflammation of the alveolar bone.
• Usually post extraction.
• Thought to be loss of blood clot leaving alveolar bone exposed to the oral environment.

Incidence:
1-20% of routine extractions
Up to 30% of surgical third molar extractions

Symptoms:
-Occurs a  few days after tooth removal
-Painful
-Associated with bad taste and odour
?gram negative odour / halitosis
-Not relieved with analgesics
-Not associated with pyrexia
-Not associated with swelling / infection

Question 3

What are the possible causes of a dry socket?

Answer 3

Cause: Unknown
Factors influencing occurrence:
Smoking
Oral contraceptive
Local infection ANUG / pericoronitis
Compromised patient
Diabetes
Immune suppression
Radiotherapy
? Vasoconstrictors
Altered bone metabolism – ie pagets
Excessive trauma at the time of extraction

Question 4

What’s the management of a dry socket?

Answer 4

Examination: consider radiograph for retained root
Irrigation of socket with saline or chlorhexidine
Obtundant pack
Alveogyl - resorbable
Zinc oxide eugenol pack (fish pack) requires removal
Bismuth subnitrate and iodoform paste (BIPP)
Lidocaine based gels / ointments
Analgesics

Question 5

What’s alveogyl?

Answer 5

A brown fibrous paste which contains per 100 g the following active ingredients : 25.70g of butamben, 15.80g of iodoform and 13.70 g of eugenol.
It also includes other ingredients: olive oil, spearmint oil, sodium lauryl sulphate, calcium carbonate, penghawar djambi and purified water.
Penghawar djamb (fern with ? Medicinal properties)

Make sure you take the alveogyl out of the container with sterile tweezers and put some in a separate container before using it. It’s resorbable so does not need removing.

Question 6

Do antibiotics help with a dry socket?

Answer 6

Thought not to influence dry socket
Some evidence that prophylactic use may help
Transient
Antibiotic resistance
Evidence to support use in compromised patients

Question 7

What does the bleeding time tell you?

Answer 7

Within 24 hours:

• Trauma of extraction
• Patient factor such as clotting deficiency

Delayed:
-Usually due to infection

Question 8

What’s the management for bleeding?

Answer 8

Assess patient for vital signs / airway
Consider blood loss and need for resuscitation with fluids of transfusion
Review patient medical history
Review history of extraction

Question 9

What are the local measures that can be taken for bleeding?

Answer 9

Move to suitable clinical area
Good light
Suction
Assistance
Sutures
Haemostatic aids (Surgicel) / Fibrin blocks)

Question 10

What may be given for infection?

Answer 10

Where antimicrobials are indicated for dental infections the dose for amoxicillin is as follows:
Adults
500 mg every 8 hours, dose doubled in severe infection
Children
• 1 month–1 year, 62.5 mg every 8 hours, dose doubled in severe infection;
• 1–5 years, 125 mg every 8 hours, dose doubled in severe infection;
• 5–18 years, 250 mg every 8 hours, dose doubled in severe infection”

Question 11

What type of antibiotic may be prescribed for dental infection?

Answer 11

If an oral antibiotic is indicated prescribe a 5-day course of either amoxicillin (500mg three times a day), or phenoxymethylpenicillin (500-1000 mg four times day).
If the person has atruepenicillin allergy prescribe clarithromycin (500 mg twice a day) for 5days.
Consider concomitant treatment with metronidazole (400 mg three times as day for 5 days) if the infection is severe or spreading (lymph node involvement, or systemic signs ie fever or malaise).
If an adult is allergic to, or cannot tolerate metronidazole, clindamycin (300 mg four times a day for 5 days) may be considered as an alternative to metronidazole.

Question 12

What analgesics are advised?

Answer 12

Ibuprofen, or paracetamol if ibuprofen is contraindicated or unsuitable, is recommended first-line.
Over-the-counter (OTC) analgesics containing paracetamol, aspirin, or ibuprofen are available with or without codeine.
Paracetamol and ibuprofen can be taken together if pain relief with either alone is insufficient.
For adults, if taking paracetamol and ibuprofen together does not provide enough pain relief, consider adding codeine phosphate or switching to an alternative nonsteroidal anti-inflammatory drug (NSAID) such as naproxen or diclofenac.
In people at risk of cardiovascular adverse events, ibuprofen up to 1200mg per day or naproxen up to 1000mg per day are preferred to diclofenac.
Diclofenac is now contraindicated in people with ischaemic heart disease, cerebrovascular disease, peripheral arterial disease, mild, moderate, or severe heart failure.
For women who arepregnant or breastfeeding, paracetamol is preferred. A short course of codeine may be added if paracetamol alone is insufficient.