Complications of Dentoalveolar Surgery

Question 1

What are some common oral surgery complications?

What is the most common complication?

Answer 1

Overall complication rate: 19%

• Alveolar Osteitis: 7%
• Infection: 1%
• IAN/Lingual Nerve Sensory Dysfunction: 1%
• Prolonged Trismus: 1%
• Hemorrage: 0.15%
• Retention/aspiration/migration of tooth fragments/mandibular fracture: 0%
• Injury to adjacent teeth: 0.07%
• Oro-antral/Oro-nasal fistula: 0.10%

Question 2

What are some risk factors associated with third molar complications?

Answer 2

• Age > 25 years
• Level of impaction (Pell and Gregory)
• Evidence of periodontal condition
• Associated pathology
• Medical comorbidities
• Surgeon skill

Question 3

What are 4 things you can do to prevent third molar complications?

Answer 3

1. Thorough patient evaluation
2. Thorough treatment planning
3. Use of appropriate imaging
4. Performance of procedures within your ability

Question 4

What are 4 common postop sequalae?

Answer 4

1. Bleeding
2. Swelling
3. Pain
4. Trismus

Question 5

Is oozing a common sequelae of oral surgery?

Answer 5

Yes!

Normal for an extraction site to ooze slightly for 24 hours

Small amount of blood in a large amount of saliva

Question 6

What should you tell a patient to do if the surgery site is more than oozing?

Answer 6

Reapply a small damp gauze and keep steady pressure on it for an hour or so

Oozing is a common sequalae

Bleeding is a complication

Question 7

What is this a picture of?

Answer 7

Postoperative Oozing

Question 8

What is the first series of steps a clinician should take to identify intraoperative bleeding?

Answer 8

• Identify the source
• Headlight
• Suction
• Anesthsia

Question 9

What are some methods of controlling bleeding clinically once identified?

Answer 9

• Pressure and time
• Oversewing
• Gelfoam
• Surgicel
• Thrombin

Question 10

What is a method to control arterial bleeding?

Answer 10

• Isolate vessel if arterial
• Utilize a hemostat and 2-0 silk
• Electrocautery

Question 11

How would you control bleeding clinically regarding hard tissue? (Not including nerve)

Answer 11

• Compress trabeculae
• Bone wax

Question 12

If initial attemtps to control bleeding are not successful, what are your next steps?

Answer 12

• Pack
• Labs
• To OR

Question 13

What labs could you order to aid in your assessment of bleeding?

Answer 13

• PT
• PTT
• CBC
• Platelet Function Assay
• TEG: A heparinase TEG is used to assess for heparin associated anticoagulation as the cause of hemorrhage

Question 14

What are some items a clinician can deliver to aid in bleeding after labs are collected?

Answer 14

• Aminocaproic Acid (TXA)
• Pressure Stent
• Fresh Frozen Plasma
• Platelets, RBCs
• Factor Replacement

Question 15

There are 4 bottom lines for controlling bleeding, and they are…

Answer 15

• Thorough patient history
• Minimized by good surgical technique
• Most hemostasis is achieved by pressure over extraction site with moist gauze
• In some patients other measures may be necessary

Question 16

At how many hours does swelling peak at?

Answer 16

72 hours postoperatively

Question 17

How long does it typically take swelling to resolve?

Answer 17

1 week

Question 18

What is swelling directly related to?

Answer 18

• Difficulty of extraction
• Degree of surgical intervention
• Handling of soft tissues

Question 19

Overall, swelling can be minimized by 4 factors, can you name them?

Answer 19

• Good surgical technique
• Use of corticosteroids intraoperatively
  
  • Dexamethasone (Decadron) 6-10 mg IV
• Ice packs for first 24 hours after surgery
• Elevation of head at night

Question 20

What does pain usually parallel and related to regarding OS?

Answer 20

• Typically parallels the inflammatory/swelling phase
• Directly related to length and difficulty of surgery

Question 21

What are some ways to prevent pain regarding OS?

Answer 21

• Good surgical technique
• Short surgical time
• Long-lasting local anesthesia
  
  • 0.5% Bupivicaine with Epi 1:200,000 (gets them home and meds on board)

Question 22

What are some treatment options regarding pain?

Answer 22

• PO analgesics - usally combination of NSAID and Acetaminophen/Narcotic agonist combination
• HAve patient take NSAID scheduled
• OTC APAP (acetaminophen) instead of narcotic if narcotic not taken
• Avoid the roller coaster or playing catch up on the pain

Question 23

What are some non pharmaceutical techniques to manage pain?

Answer 23

• Distraction
• Ice
• Warm Compress
• HOB (head of bed) Elevated
• Soft Diet
• Ice Cream

Question 24

What is Trismus?

How long does it typically last?

Answer 24

• Inability to open mouth to full extent
• Secondary to…
  
  • pain
  • swelling
• Resolves within 1 week
• Patients should be instructed to begin stretching open at third of fourth postop day

Question 25

What is Localized Alveolar Osteitis?

Answer 25

• Inflammation of the bony socket associated with recently extracted tooth
• Etiology not well understood
  
  • Associated with fibrinolysis of blood clot
• Incidence
  
  • Ranges between 5% and 20%

Question 26

What is this picture dipicting?

Question 27

What are some risk factors that may influence the incidence of Alveolar Osteitis?

Answer 27

• Smoking
• Oral contraceptives
• Age greater than 30 y/o
• Females
• Pericornitis
• Traumatic Extraction
• Inadequate Irrigation

Question 28

What are some surgical adjuncts that have been utilized to address localized alveolar osteitis?

Answer 28

• Copious saline irrigation of extraction site
• Irrigation of extraction site with chlorhexidine
• Pre-and/or postoperative use of chlorhexidine rinses
• Tetraycline powder placed into extraction site
• Packing extraction site at time of tooth removal
• Postoperative antibiotics (questionable)