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OS and Pain Management 2 > Prevention & management of extraction complications_part 2 > Flashcards

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
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2
Q
  • Comprehensive treatment plan
    (3)
A
  • Detailed surgical plan
  • Needed instrumentation
  • Pain/anxiety management
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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)
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4
Q
  • Complications can STILL occur; however,
A

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

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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
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6
Q
  • Be cautious of unwarranted optimism
    (1)
A
  • Clouds judgment leading to increased post-op complications
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7
Q
  • Referral is ALWAYS an options
    (2)
A
  • Is a moral obligation to practitioners → primum non nocere
  • Will provide peace of mind
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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
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9
Q

PREVENTION
(4)

A
  • Obtain a history of bleeding
  • Use atraumatic surgical technique
  • Obtain good hemostasis at surgery
  • Provide excellent patient instructions
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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?
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11
Q

LABORATORY TESTING
(3)

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

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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

OS and Pain Management 2 (10 decks)

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