Complications of Exodontia Lecture 12

Question 1

Normal post-op of dentoalveolar surgery?

Answer 1

Swelling, pain, infection, bruising, bleeding, trismus and sutures

Question 2

Pre-operative complications?

Answer 2

• Wrong patient
• Wrong treatment plan
• Wrong x-ray
• Medical emergency- e.g. collapse
• Spread of infection- pain, swelling, airway compromise or systemic symptoms

Question 3

Peri-operative complications?

Answer 3

• Failed LA
• Complications of LA, vasovagal syncope/facial palsy
• Fracture to tooth to be extracted
• Retained fragments
• Oro-antral communication
• Bone fracture
• Displaced fragments
• Damage to adjacent teeth/restorations or soft tissue
• Haemorrhage
• Inhaled tooth/debris
• Ingested tooth
• Wrong tooth (LA or exo)

Question 4

Post-operative complications?

Answer 4

• Infection
• TMJ complications: trismus, subluxation or dislocation
• Pain
• Infection
• Haemorrhage
• Dry socket
• Osteonecrosis
• Osteoradionecrosis
• Swelling/bruising
• Anesthesia/paraesthesia

Question 5

Fracture of tooth to be extracted, management?

Answer 5

• Stop
• Access
• Suction
• Danger to other structures
• Mobility
• Remove fractures portion with forceps/elevators or picks if possible
• May require surgical procedure- lift mucoperiosteal flap and bone removal

Question 6

When do you leave a fragment?

Answer 6

In almost every case if tooth requires extraction then not safe to leave fragment behind, but if requires significant surgery with risks then small fragment may be left.
Can leave if:
- No evidence of apical infection/pathology
- root tip is less than 3mm and not associated with periapical infection
- Risk of damage high e.g. IAN, close to sinus
- No risk of distant infection
- Patient declines further surgery, you must inform them of the risks
- Antibiotics should be given

Question 7

When there is a tooth fragment you must?

Answer 7

• Inform the patient
• Record in your notes
• Take x-ray if suspicious root has been displaced
• Deal with problems if they occur- REVIEW

Question 8

Trauma to adjacent teeth management?

Answer 8

• Inform the patient
• Record in notes
• Place temporary restoration
• Book for permanent restorationz

Question 9

Oro-antral communication, upper 5,6,7 and 8 more likely to have close association with maxillary sinus because?

Answer 9

• Upper 5,6,7 and 8 have close association with the maxillary sinus
• More likely to occur in the elderly, lone standing tooth or pneumotised sinus

Question 10

Risk assessment for oro-antral communiction?

Answer 10

• Pneumatisation of sinus
• Periapical pathology
• Lone standing molar
• Bone atrophy
• Difficult exo

Question 11

Root in antrum?

Answer 11

• Caused by uncontrolled upward pressure
• Refer for retrieval
• Antibiotics and analgesics
• Nasal decongestant, 0.5mg/mL oxymethazoline nasal spray
• Minimise risk of infection and subsequent breakdown of mucosal repair

Question 12

Oro-antral communication?

Answer 12

• Infection in the maxillary sinus
• Fluid comes out of nose when drinking, due to communication of maxillary sinus and nasal cavity through hiatus semilunaris
• Difficulty smoking
• See bubbles of blood or hear passage of air on examination
• If small, 5mm will need repair by local flap- buccal advancement flap.

Question 13

Mandibular fracture, management?

Answer 13

• STOP
• Explain situation to the patient
• Urgent referral to OMF unit for advice and treatment- telephone

Question 14

Maxillary tuberosity fracture treatment?

Answer 14

• If bone still attached to periosteum then it is vital
• Option 1: Splint tooth and bone in place and allow to heal and deal with symptoms, leave for 6-8 weeks and then remove tooth surgically
• Option 2: remove tooth and attached bone and close surgically to repair OAC, best to consult OMF unit/refer

Question 15

Extracting the wrong tooth, causes?

Answer 15

• Operator error
• Poor notes
• Poor communication
• Wrong x-ray
• Mixed dentition, especially when teeth have exfoliated between treatment planning and extractions

Question 16

Extraction of wrong tooth prevention?

Answer 16

• Always check the treatment plan
• Use clinical judgement, does this tooth need to be removed?
• Each time place forceps or elevator on tooth, be sure it is the correct one
• When administering LA again check it is the right tooth. and then re-check once done that
• Use tie-out to help prevent this avoidable error

Question 17

Extracting wrong tooth management?

Answer 17

• Re-implant tooth if possible
• Always inform the patient
• Medicolegally indefensible

Question 18

Post op advice?

Answer 18

If bleeding occurs roll up damp gauze and place over the socket and bit for 20-30 minutes

• Avoid excessive exercise
• Do not smoke for up to 1 week (one cigarette causes 6 hours of vasoconstriction)
• Avoid excessive exercise today
• Avoid alcohol
• Avoid hot food or drinks for today
• Tomorrow start rinsing 3-4 times a day for next 3-4 days (with saline- 2 teaspoons of salt in warm glass of water)
• Brush teeth normally, but avoid agitating blood clot
• Contact surgery on-call dentist if urgent help needed.
• Remember to give instructions regarding LA

Question 19

Dry socket, facts

Answer 19

• aka alveolar osteitis
• Dicruption of the healing process in an extraction site after clot formation but before wound organisation
• Occurs in 3% of routine extractions
• Usually starts 1-3 days after extraction; pain usually worse than original pain; throbbing, constant pain at extraction site and often resistant to analgesics
• Result of host mediated or microbiologically mediated fibrinolysis or break down of the blood clot
• Exposure of bony walls of socket to bacteria in saliva with resultant severe radiating pain completely out of proportion to clinical signs and symptoms
• Usually minimal swelling and inflammation
• Characteristic foul odour combined with socket full of food debris

Question 20

Dry Socket epidemiology?

Answer 20

• Female > Male
• Oral contraceptive pill
• Mandible
• Traumatic extraction
• Smoker
• Diabetic
• Peak age 20-40 years
• Inexperienced operator

Question 21

Dry socket on examination?

Answer 21

• Socket devoid of blood clot with exposed tender bone
• Greyish remnants of clot remain
• Surrounding mucosa red and tender
• Bad smell and taste
• Severe pain
• Can be local lymphadenopathy but systemic upset is rare

Question 22

Dry socket treatment?

Answer 22

Usually self limiting (1-2 weeks, can take up to 4 weeks)- treatment therefore symptomatic

• LA for immediate pain relief and comfort during procedure
• Wash with warm saline irrigation to remove wound debris
• Antiseptic dressing e.g. alvogyl (contains iodine antiseptic, eugenol and local anaesthetic); left in situ and should be removed after a few days
• Mouth rinses and analgesia
• review

Question 23

Alvogyl prescribing information?

Answer 23

• Not resorbable, so never stitch up after setting the alvogyl in place unless the stitch is there to hold it in place and you plan to leave it there for a few days and remove it yourself

Question 24

Causes of haemorrhage?

Answer 24

Local

• Excessive rinsing; failure to adhere to post op instruction
• Periodontal disease
• Mucosal tear
• Alveolar bone fracture
• Jaw fracture
• OAC

Systemic

• Platelet disorder
• Coagulation disorder
• Acquired/congenital
  e. g. haemophilia, von Willebrand’s disease, coumarin treatment, liver disease

Question 25

Heamorrhage treatment?

Answer 25

- Apply pressure on wound for up to 30 minutes - Check medical history/medication - Remove blood stained items and re-assure patient (anxiety increases blood pressure which increases bleeding) - Also good idea to apply pressure to sides of socket prior to placing gauze as downward pressure can displace the mucoperiosteum away from the socket If continuous bleeding: - Suction to remove clot - Confirm bleed from socket - LA with adrenaline - Suture - Spongostan/gelfoam- gelatine material- acts as a framework to encourage clot formation - Further gauze compression- confirm haemostasis - If ok discharge with instructions including emergency contact number - Diathermy useful if bleeding point - Bone wax should not be used in extraction sockets as it is not resorbable - Tranexamic acid- antifibrinolytic agent - Inhibits activation of plasminogen to plasmin - Plasmin causes degradation of fibrin - Hospital admission? telephone referal to OMF unit

Question 26

Swelling likely occurrence?

Answer 26

- Rare after simple extraction, more common after surgical extraction of lower 8's

Question 27

What is absolute trismus (patient cannot open their mouth) indicative of

Answer 27

Submasseteric abcess

Question 28

What to do when something goes wrong?

Answer 28

- Recognise it- Diagnosis - Investigate as necessary - Be honest and open - Be factually accurate and objective with patients and maintain good records - Make the earliest reasonable efforts at correction - Involve specialists if necessary - Contact defence organisation as it may become a legal matter