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3. Oral Surgery > Post Operative Complications > Flashcards

Post Operative Complications Flashcards

1
Q

What are the 3 types of complications?

A

Immediate/intra op/peri op

Immediate post op/short term post op

Long term post op

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2
Q

What are the 2 types of complications (easier)?

A

peri-operative

post-operative

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3
Q

Where are some post operative complications?

A

pain

Swelling

Ecchymosis (bruising)

Trismus

Haemorrhage

Prolonged effects of nerve damage

Dry socket

Sequestrum

Infected socket

Chronic OAF or root in antrum

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4
Q

What is the most common post op complication?

A

Pain as forces that disrupt the pdl leads to pain

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5
Q

What advice do we give in regards to pain?

A

we must let pt know that they may experience some pain and this is completely normal and not to worry!

then give advice on analgesics - take within 1-2 hours of leaving before la wears off

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6
Q

What can increase post op pain?

A

if tissues are handled more roughly

if there is lacerations or tearing of soft tissues

exposed bone

incomplete extraction

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7
Q

What is oedema a reaction to?

A

inflammatory reaction to surgical interference

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8
Q

What is oedema increased by?

A

poor surgical technique

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9
Q

What poor surgical techniques can increase risk fo oedema?

A

rough handling of soft tissues

crushing lips with forceps

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10
Q

When will swelling post operatively develop?

A

over 48 hours - if its on day 2/3 then this is a sign of infection

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11
Q

What advice do we have for pts with swellings post op?

A

Cold pack - on for 5 off for 5 for 1-2 hours

sleeping propped up

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12
Q

What do we tell pt in regards to swelling?

A

You may or may not swell up - it is different with every pt but if you do notice swelling dont panic - if it comes up over the next 48 hours and goes away after a week this is normal however if swelling just starts on day 2-3 then you can contact me

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13
Q

What is ecchymosis?

A

Bruising

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14
Q

What pts may bruise more freq post op?

A

pts who already bruise easily

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15
Q

What can increase freq of bruising post operatively?

A

rough handling of tissues

poor surgical technique

leaning on pts lip

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16
Q

What is trismus?

A

LIMITED MOUTH OPENING DUE TO MUSCLE SPASM

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17
Q

How can we describe trismus to pts?

A

this is where your jaw may be a bit stiff to open close and can last for 1-2 weeks but make sure to still eat and drink as normal however if very limited or if unable to eat then come see me

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18
Q

What can cause limited mouth opening?

A

Swelling from surgery

Muscle spasm –> trismus

Bleed in the muscle

bleed into master causing muscle to spasm and mouth unable to open

the injection needle going though MEDIAL PTERYGOID and a bleed causing hameatoma or muscle to spasm

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19
Q

What muscle can the inject for idb go through?

A

Medical ptyergoid and haematoma can form or muscle can spasm causing limited mouth opening

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20
Q

When do we refer in limited mouth opening?

A

If no improvement in 1-2 weeks

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21
Q

How do we let pt know they may experience some limited mouth opening?

A

Because you will have your mouth open for a while and we are leaning on your lower jaw you may have some limited mouth opening which will settle after a week or two however if its really bothers you then come back and see me or give me a phone

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22
Q

How can we increase mouth opening?

A

gentle mouth opening exercises

wooden spatula

trismus screw

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23
Q

What can a haemorrhage be? (3)

A

Intra operative

immediately post op

secondary bleed

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24
Q

How do we manage intra-operative haemorrhages?

A

pressure

surgicel - cellulose oxidise which provides framework for clot to form

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25
Q

What is an immediate post op bleed?

A

this is a reactionary/rebound bleed that occurs within 48 hours of extraction

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26
Q

What can cause immediate post op bleeds?

A

wearing off of LA opening up vessels again

sutures coming loose

pt traumatising area with tongue/finger/food/toothbrush

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27
Q

What is a secondary bleeding often due to?

A

infection and commonly lasts 3-7 days

usually a mild ooze but can be a major bleed

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28
Q

What is common to see in terms of secondary bleeds?

A

mild bleed

spotting

mild ooze

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29
Q

What vessels can be damaged in extractions?

A

veins

arteries

arterioles

vessels in muscle

vessels in bone

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30
Q

How do we manage bleeding vessels?

A

Pressure - bite on damage gauze

sutures if needed

LA with adrenaline

Diathermy to cauterise vessels causing protein precipitation which forms a protein plug

artery clips for bigger vessles

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31
Q

How do we manage bone bleeds?Q

A

Apply pressure with swab

la onto swab or inject into socket

haemostats agents such as surgicel or kalsostat

blunt instrument to apply bone wax

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32
Q

If bleeding is severe what must we do?

A

Apple pressure immediately to arrest the bleed

Calm the pt - separate ethem for their relatives

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33
Q

If pt comes back to surgery with post op bleed what do we do?

A
  1. immediate pressure
  2. Calm the pt - measure them
  3. clean up pt - any blood soaked towels
  4. take a through but quick history (I just want to double check ur med history)
  5. lift out jelly like clot and clean up area and then apply pressure
    CLEAN –> PRESSURE –> FIND BLEEDING SOURCE
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34
Q

What do we do with jelly like clots?

A

Remove clot as its an unsuccessful attempt at forming a clot

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35
Q

What bleeding disorders must we rule out?

A

Haemophillia

VWBs

liver disease

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36
Q

What do we do if despite all efforts we can’t get bleeding to stop?

A

call a&e or local max fax dept or oral surgery department however if worried phone 999

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37
Q

Describe the steps of management if pt comes in with post op bleeding

A

Look inside mouth with good light and suciton

will often see jelly like clot which we remove

pt may vomit if swallowing blood

identify bleeding source

use haemostatic agent - surgicel or kalsistat

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38
Q

What must we do after management of secondary bleed?

A

Give pt point of contact to call if bleeding resumes (if bleeds again tonight her is a number to phone me but if its significant then this is nearest a&e)

review the pt

if pt has lost large volume of blood and is elderly or has med problems then consider hospital admission

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39
Q

If we can’t arrest the haemorrhage what do we do?

A

Phone hospital and speak to someone and find out where pt is to go and who we are speaking to - write this down in notes

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40
Q

What are some examples of haemostatic agents?

A

LA containing adrenaline

surgicel - oxidised cellulose

gelatine sponge

thrombin liquid and powder

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41
Q

What must we take care with when using oxidised cellulose?

A

In lower 8 region as its acidic and can damage IDN

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42
Q

Post extraction should the pt rinse out?

A

NO! - avoid rinsing out, exercise, hot and hard foots to avoid disrupting clot

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43
Q

What are some systemic haemostatic aids?

A

vitamin K

Ani fibrinolytic

plasma or whole blood

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44
Q

What is vitamin k used for?

A

Vitamin K is vitally important to blood clotting because the proteins that create the fibrin webbing in the second part of the clotting process depend on this vitamin. Vitamin K is needed for the clotting proteins to be activated and start the final part of the clotting process.

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45
Q

What is an example of an anti-fibrinolytic?

A

tranexamic acid

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46
Q

What does tranexamic acid do?

A

Tranexamic acid is an antifibrinolytic that competitively inhibits the activation of plasminogen to plasmin

prevents clot being broken down and stabilises the clot

can be taken as tablets or mouthwash

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47
Q

How do we prevent intra op and post op bleeding?

A

take thorough history so we can anticipate and deal within potential problems

provide good instructions to pt post tx

obtain and check for good haemostats before they leave

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48
Q

What are some post op extraction instructions?

A

No exercise

Try avoid alcohol - can affect the healing

Dont rinse out for at least a few hours - 1 day and avoid any vigorous rinsing as this can disrupt the clot

avoid hot food - burn risk when numb

Avoid trauma - dont poke about clot with finger, toothbrush

If bleeding then dampen gauze and bite on it for at least 30 mins

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49
Q

How long do we monitor nerve damage for?

A

few days to a week to rule out infection and if not settling then can refer pt

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50
Q

What is anaesthesia?

A

Numbness

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51
Q

What is paraesthesia?

A

Tingling

52
Q

What is dysaethesia?

A

unpleasant sensation/pain

neuralgic pain

53
Q

What is hypoaestheisa?

A

reduced sensation

54
Q

What is hyperaesthesia?

A

Increased sensation

55
Q

What is neurapraxia?

A

Contusion of nerve/continuity of epineural sheath and axons maintained

56
Q

What is axonotmesis?

A

continuity of axons but epineural sheath disrupted

57
Q

What is neurotmesis?

A

tHIS IS WHEN THERE IS COMPLETE LOSS OF NERVE CONTINUITY AND NERVE IS TRANSECTED

58
Q

how common is dry socket?

A

affects 2-3% of all extractions

20-35% of lower 8s

59
Q

What is dry socket?

A

This is when the clot disappears and instead we are left with bare bone/empty socket with partial or completely lost blood clot

dry socket leaves the bone, tissue, and nerve endings exposed.

60
Q

What is the main feature of dry socket?

A

intense pain - worst pain

61
Q

How long does dry socket take to begin?

A

3-4 days after xla

62
Q

When is dry socket unlikly?

A

If pt says intense pain began straight after LA wore off then unlikely its a dry socket - instead check for tooth left in socket or broken bone

63
Q

How long does dry socket take to resolve?

A

7-14 days

64
Q

If pt has slow healing dry socket what can we do for them?

A

let them know we will help them through this period

rinse out with warm saline

analgesics

can also numb up the pt to provide them with some relief

65
Q

What is localised osteitis?

A

This is inflammation of the socket wall (lamina dura area)

66
Q

What is the pain of dry socket like?

A

Dull aching –> severe

variable In pts

throbbing pain

can radiate to the ear - keep pt up at night

67
Q

Is dry socket infection?

A

nO - THERE IS NO SWELLING OR PUS SO NO NEED FOR ANTIBITOCIS

68
Q

What is the source of pain in dry socket?

A

Exposed bone

69
Q

What may pt complain about with dry socket?

A

Bad smell

bad taste

70
Q

What Is dry socket classed as?

A

delayed healing not associated with infection

71
Q

What is a predisposing factor to dry socket?

A

Molars are at greater risk than anterior teeth

more common in mandible

smokers

female

OCP

72
Q

What jaw is dry socket more common in?

A

Mandible

73
Q

Why is smoking a risk factor for dry socket?

A

this is because pt has reduced blood supply which leads to less healing so pt should avoid smoking for as long as they can

74
Q

How do we manage dry socket supportively?

A

Reassure pt

systemic analgesia advice

75
Q

What can we do with LA in pts with dry socket?

A

Can provide LA block which provide pain relief to pt and allows us to irrigate the area

76
Q

What can we irrigate dry socket with and why do we do this?

A

Warm saline

to wash out food and debris

77
Q

Is debridement done in dry socket cases?

A

Rarely done but some suggest that removing any remaining clot will encourage new bleeding and let healing process start again

78
Q

What are antiseptic packs?

A

These are sedative agents, anti-inflame agents or stringent disinfectant type agents that help with pain or discomfort and fill up the socket preventing food impaction

79
Q

What is BIP?

A

Bismuth subnitrate which is an impregnanted gauze with iodine in it that is packed into socket and is an antiseptic and astringent

(an astringent is a chemical that shrinks or constricts body tissues)

80
Q

What is alvogyl?

A

This is a mixture of LA and antiseptic that soothes pain and prevents food packing

81
Q

How are pts meant to irrigate own socket?

A

should be done 2-4 times a day

82
Q

What is most important thing to do in dry socket pts?

A

be supportive and reassuring - we understand the significant pain they are in and can discuss systemic analgesia

83
Q

Before confirming its a dry socket what may we need to do?

A

Radiograph to ensure no teeth roots remain and check other teeth

84
Q

In diagnosing dry socket what must we always check?

A

The socket - in rare occasions it can be a tumour or oral cancer

85
Q

How often should we see dry socket pts?

A

few times a week

86
Q

What should pt use to irrigate socket?

A

warm saline or warm salty water

NOT CHX as it can enter blood stream and risks anaphylaxis

87
Q

What is sequestrum?

A

a piece of dead bone tissue formed within a diseased or injured bone

88
Q

What prevents healing?

A

Sequestrum - its of dead bone

89
Q

How does bony sequestrum look like intra orally?

A

hite spicules of bone coming through gingivae - pt may think its tooth

90
Q

What must we od with sequestra?

A

Remove it as it delays healing

91
Q

What is a socket with pus discharge?

A

infected socket

92
Q

What do we do if we suspect infected socket?

A

Check to see if any tooth/roots or foreign bodies are present

take radiograph, explore, remove any foreign bodies, roots, consider antibiotics

93
Q

When is infection more likely?

A

After MOSP where soft tissue flaps need raised and bone is removed

94
Q

What does infection delay?

A

healing

95
Q

What is the diff between OAC and OAF?

A

OAC = fresh communication between antrum and oral cavity

OAF = epithelium lined tract or tube that is chronic

96
Q

When might an OAC be created?

A

Big tooth with big roots in vicinity of sinus

on radiographic exam we see roots close to antrum

97
Q

What signs indicate OAC?

A

Bubbling of blood

visible hole

98
Q

How do we manage a small or intact sinus OAC?

A

Inform pt

encourage clot

suture margins

antibiotics prescribed

post op instructions - no blowing nose, steam inhalation, no wind instruments

99
Q

How to do steam inhalation?

A

Few mins at a time with towel over head to clear air sinus and nose

100
Q

How long after oac to avoid wind insturments?

A

2 weeks

101
Q

If OAC is large or lining is torn what do we do?

A

Close with buccal advancement flap

full thickness flap of gingiva is pulled back and we release the periosteum tissue

close with slow resorbing sutures or non resorbing

keep eye on pt

antibiotics - 5-7 day course

102
Q

how long is antibiotic course in OAC?

A

5-7 days

103
Q

What is an example of resorbing sutures?

A

black silk

104
Q

WHAT IS AN EXAMPLE OF NON RESORBING SUTURES?

A

VICRYL

105
Q

How do we manage an OAF?

A

We must cut out the epithelial lined tube or tract so it doesn’t reform then close with buccal advancement flap

106
Q

When might we have to use something other than buccal advancement flap to close OAF and why?

A

We may need to use buccal fat pad with buccal advancement flap to close OAF if the fistula is very large or won’t stay closed

107
Q

How do we do buccal fat pad with buccal advancement flap?

A

Take mucoperiosteal flap and release periosteum then go further up into buccal sulcus and release buccal fat pad and pull fat pad over and stitch

108
Q

What is osteomyelitis?

A

Osteomyelitis of the jaws is infection and inflammation of the bone marrow, sometimes abbreviated to OM which occurs in the bones of the jaws (i.e. maxilla or the mandible).

109
Q

What do pts with osteomyelitis appear like?

A

systemically unwell

raised temp

110
Q

In deep seated osteomyelitis infections of lower jaw what may we see?

A

Altered sensation due to pressure on IAN

111
Q

Where does osteomyelitis begin?

A

medullary cavity involving cancellous bone which extends and spreads to cortical bone and then to periosteum

112
Q

What does invasion of bacteria into cancellous bone cause?

A

soft tissue inflammation and oedema in closed bone marrow spaces

113
Q

What does oedema in enclosed space lead to?

A

Increased tissue hydrostatic pressure (higher than BP of feeding arterial vessels) which causes compromised blood supply resulting in soft tissue necrosis

114
Q

How do we stop oesoemyeltis spreading?

A

Antibiotics and surgical therapy

115
Q

Why do bacteria proliferate in osetomyeltis?

A

Due to normal blood borne defects not reaching tissue due to lack of blood supply

116
Q

Why is osteomyelitis more likely in mandible?

A

This is because its primary blood supply is inferior alveolar artery and there is dense overlying cortical bone which prevents penetration of periosteal blood vessels so there is a poorer blood supply with increased chances of ischaemia and infection occurring

117
Q

Why is osteomyelitis less likely in the maxilla?

A

rich blood supply

118
Q

Who is osteomyelitis rare in?

A

Healthy fit individuals with host defences in tact

119
Q

What are the predisposing factors to osteomyelitis?

A

perio pts

infected tooth

Odontogenic fractures and mandible fractures

compromised host defences - alcoholics, diabetes, iv drug use, malnutrition, chemo tx cancer

120
Q

What does acute suppurative osteomyelitis look like on x-ray?

A

Little to no change (takes 10-13 days for lost bone to be detectable)

121
Q

What is the radiographic appearance of osteomyelitis?

A

Mottled appearance

mOTH EATEND APPEARANCE

INCREASED RADIOLUCENCY

122
Q

How do we tx osteomyelitis?

A

Investigate host defences

Antibiotics

Surgical tx

123
Q

How do we investigate host defences in osteomyelitis pts?

A

Blood tests

Glucose levels

124
Q

What antibiotics can we prescribe for Odontogenic infections?

A

Clindamycin

Penicillin

need longer dose than normal (6 weeks in some)

125
Q

What surgical tx is done for osteomyelitis?

A

drain pus

remove non vital teeth in area of infection

remove any loose pieces of bone (dead bone stops healing)

excise nectroic bone

3. Oral Surgery (9 decks)

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