Oral Surgery - Post-operative Complications

Question 1

List common post operative complications. (8)

Answer 1

Pain, swelling and ecchymosis

Trismus

Haemorrhage

Prolonged effects of nerve damage

Dry socket

Sequestrum

Infection

Chronic OAF

Question 2

List uncommon post operative complications. (5)

Answer 2

Osteomyelitis

Osteoradionecrosis

Medication induced osteonecrosis

Actinomycosis

Bacteraemia/infective endocarditis

Question 3

How long can truisms last?

Answer 3

commonly 1/2 weeks

Question 4

What causes truisms? (4)

Answer 4

Oedema from surgery

LA needle intointo medial pterygoid muscle

Bleeding into the master or medial pterygoid muscle

Damage to the TMJ

Question 5

List the 3 main types of haemorrhage and how long after surgery they occur.

Answer 5

periopertaive

immediate post op = within 48 hours

secondary bleeding = 3-7 days

Question 6

what is the common cause of secondary bleeding/haemorrhage?

Answer 6

infection

Question 7

What are the post extraction instructions given In order to prevent haemorrhage?

Answer 7

avoid exercise, alcohol and any other activities that raise BP for 24 hours

Don’t explore socket with finger, tongue, TB

Don’t rinse for 24 hours then after that rinse regularly after eating (warm/warm salty water) and gently spit

Avoid very hot and hard foods for 24 hours and eat on the opposite side

Question 8

what is dry socket?

Answer 8

localised osteitis = inflammation of the lamina dura

delayed healing not caused by infection

Question 9

what causes dry socket?

Answer 9

when the clot partially/fully disappears or doesn’t form at all.

Question 10

what are the symptoms of dry socket? (5)

Answer 10

Intense, dull aching, throbbing pain that keeps the patient up at night.

Pain can radiate to the ear

Bad smell

Bad taste

Question 11

when does dry socket start to cause symptoms?

Answer 11

3/4 days after extraction

Question 12

how long can dry socket last?

Answer 12

7-14 days

Question 13

what predisposing factors make a patient more likely to develop dry socket? (7)

Answer 13

smoking/ex-smokers - reduced blood supply

previous ds

females

OCPs

the use of lots of LA with vasoconstriction

trauma during extraction

mouth rinsing post extraction

Question 14

how do we manage dry socket? (8)

Answer 14

Check that there’s no tooth fragments/bony sequestra remaining and take radiograph to confirm

Reassurance that this is common

advise analgesics and hot salty mouthwashes

or

LA block

Irrigate socket with warm saline with regular appointments

Debride the socket to encourage new clots (controversial)

Antiseptic pack e.g. alvogyl: packed into the socket and it disintegrates itself. No sutures.

or

BIP paste/gauze packed into the socket, needs to be replaced as they don’t dissolve. Suture over the top.

Question 15

do we prescribe antibiotics for dry socket?

Answer 15

Don’t prescribe antibiotics as its not an infection

Question 16

is chlorhexidine used in fresh wounds?

Answer 16

no - can force the product into the bloodstream and cause anaphylaxis

Question 17

what is sequestrum?

Answer 17

fragments of dead bone, amalgam or tooth which delays healing

Question 18

What is osteomyelitis?

Answer 18

where a bacterial infection of the cancellous bone spreads to cortical bone then the periosteum.

Question 19

what factor makes a patient more likely to develop osteomyelitis?

Answer 19

compromised host defences from diabetes, alcoholism, IV drug use, malnutrition and myeloproliferative disease.

Question 20

what are the symptoms of osteomyelitis?

Answer 20

systemically unwell with a fever

altered sensation

can be similar to dry socket or localised infection

Question 21

what dentally related predisposing factors make a patient more likely to develop osteomyelitis? (3)

Answer 21

fracture of the mandible

odontogenic infection

bad periodontal disease

Question 22

how does osteomyelitis appear on a radiograph?

Answer 22

patchy or uniform radiolucency - moth eaten appearance

can be areas of radiopacity within radiolucent areas

Question 23

what is osteoradionecrosis?

Answer 23

where the radiation causes endarteritis obliterates and leaves the bone non-vital.

bone turn over slows down and self-repair is ineffective

Question 24

what structure is most commonly affected by osteoradionecrosis and why?

Answer 24

the mandible - only has one main artery

Question 25

how can we prevent osteoradionecrosis related complications during dental treatment? (5)

Answer 25

most likely refer

Scaling and chlorhexidine mouthwash before extraction

Careful technique

Prescribe antibiotics, chlorhexidine and then review

Hyperbaric oxygen before and after the extraction:

Give vitamin E 6 weeks before extraction

Question 26

how is hyperbaric oxygen used to prevent osteoradionecrosis?

Answer 26

increases tissue oxygen and increases vascular ingrowth to hypoxic areas.

Question 27

Describe how medication causes medication related osteonecrosis? (MRONJ)

Answer 27

medication used to inhibit osteoclast activity i.e. Bisphosphonates

Question 28

what structures are affected by MRONJ?

Answer 28

the jaws only

Question 29

who is affected by MRONJ? (6)

Answer 29

those with Bisphosphonates for osteoporosis, padgets, malignancy

anti-angiogenic drugs

anti-resorptive drugs

(risk increases when taking these together or alongside steroids)

smokers

diabetes

Question 30

what are high risk dental treatments for those with MRONJ?

Answer 30

Those who have had trauma from dentures

Those with infection

Those with periodontal disease

Impact on bone: extraction

Question 31

how do we manage patients with MRONJ?

Answer 31

prevent invasive treatment where possible

extractions can be done in primary care

drug holidays when the medication is used for prevention

Question 32

what Is actinomycosis?

Answer 32

A rare chronic bacterial infection which erodes through tissues (rather than following fascial planes/spaces)

Question 33

who is affected by actinomycosis?

Answer 33

Only present in patients who’s host defences are compromised by diabetes, alcoholism, iV drug use, malnutrition and myeloproliferative disease etc

Or

Where the bacteria has been introduced into an area

Question 34

what are the signs of actinomycosis? (3)

Answer 34

multiple skin sinuses

swellings

thick lumpy pus