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BDS3 Oral Surgery > Extraction Complications > Flashcards

Extraction Complications Flashcards

1
Q

What are some reasons for difficult access during extractions?

A

Trismus
Reduced aperture of mouth - congenital syndromes
Crowded teeth
Poor gag reflex

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2
Q

Why might there be abnormal resistance during extraction?

A

Thick cortical bone
Shape/ form roots - hooked
Number of roots
Ankylosis
Hypercementosis

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3
Q

What are the 3 anatomical structures that can fracture during extraction?

A

Tooth fracture
Alveolar bone fracture
Jaw fracture

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4
Q

What should you do if jaw fracture occurs during extraction?

A

Inform patient
Post-op radiograph
Refer (phone call)
Ensure analgesia
Stabilise
If there is delay, prescribe antibiotic

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5
Q

How should a large OAC be managed? (and/ or if lining is torn)

A

Close with a buccal advancement flap
Antibiotics and nose-blowing instructions

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6
Q

How should a small OAC (and/ or sinus intact) be managed?

A

Encourage clot
Suture margins
Antibiotic
Post-op instructions

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7
Q

What may happen if you do not expand the socket appropriately when extracting?

A

Fracture of the crown or alveolar bone - taking the tooth out too quickly

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8
Q

Where is the most common region for the buccal, alveolar plate to fracture?

A

The canine region

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9
Q

What should you do if there is an alveolar bone fracture but it is STILL ATTACHED to the periosteum?

A

Put the bone back in place, and suture the soft tissue back together

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10
Q

What are some indicators that tuberosity fracture has occurred?

A

Noise
Movement noted visually and/ or with supporting fingers
More than one tooth movement
Tear on the palate

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11
Q

What is the definition of neurapraxia?

A

Epineural sheath and axons are maintained.
Neurapraxia is the mildest form of peripheral nerve injury commonly induced by focal demyelination or ischemia.
In neurapraxia, the conduction of nerve impulses is blocked in the injured area. Motor and sensory conduction are partially or entirely lost.

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12
Q

What is axonotmesis?

A

2nd most severe type of nerve damage.
Nerves stretch and become damaged.
Epineural sheath is not damaged.

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13
Q

What is neurotmesis?

A

Complete loss of nerve continuity - nerve is severed.

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14
Q

What are the 5 types of nerve sensation?

A

Anaesthesia (numbness)
Paraesthesia (tingling)
Dysesthesia (unpleasant sensation)
Hypoaesthesia (reduced sensation)
Hyperaesthesia (increased/ heightened sensation)

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15
Q

What should you do if you think a patient has inhaled their tooth?

A

Refer to A&E for chest and abdominal imaging.

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16
Q

How to minimise likelihood of soft tissue damage?

A
  • Correct placement of forceps - close the beaks around crown of tooth and work beaks down root of tooth while beaks are STILL CLOSED.
  • Correct application point - for luxator and elevator
  • Good retraction
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17
Q

What blood vessel is most likely to have been damaged if blood is spurting?

A

Artery or arteriole

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18
Q

What local factors cause most bleeds?

A

Mucoperiosteal tears or fractures of alveolar plate/ socket wall
Damage to soft tissues

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19
Q

What medical conditions are likely to cause increased bleeding following extraction?

A

Haemophilia
Von Willebrand’s
Liver disease

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20
Q

Why is there increased bleeding following extraction with liver disease?

A

Clotting factors are made in the liver

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21
Q

What steps should be taken if there is a haemorrhage in the soft tissue?

A

Pressure - finger/ biting on damp gauze swab
Sutures
LA with adrenaline (vasoconstrictor)
Diathermy (cauterise/ burn vessels)
Ligatures/ haemostatic forceps (artery clips) for larger vessels

22
Q

What steps should be taken if there is a haemorrhage in the bone?

A

Pressure (via swab)
LA on swab INSERTED into socket
Haemostatic agents
Blunt instrument
Pack BONE WAX into socket

23
Q

What should you to if unable to relocate TMJ after dislocation?

A

Try LA into masseter intra-orally
If still unable to relocate - immediate referral

24
Q

Give some examples of haemostatic agents used to stop post-op bleeding.

A

LA + adrenaline
Oxidised regenerated cellulose - surgicel/ equitamp - provides framework for clot formation
Haemocollagen sponge
Thrombin liquid and powder
Floseal

25
What are the common post-extraction complications?
Pain Swelling Trismus/ Limited mouth opening/ jaw stiffness Haemorrhage / Post-op bleeding Prolonged effects of nerve damage Dry Socket Sequestrum (bone necrosis when detaches from healthy tissue) Infection Chronic OAF / root in antrum
26
What are the post-extraction instructions?
Do not rinse out for several hours Avoid hot food Avoid excessive physical exercise that day Avoid alcohol and smoking - for 3 days Warm salty mouth rinse after 24 hours to promote healing
27
How long post-extraction should a patient not smoke?
72 hours/ 3 days
28
After what time period, if nerve damage has not improved, is it likely to never change?
18 months. After 18 months, there is very little chance of further improvement.
29
Why does dry socket occur and what is the main feature of dry socket?
Occurs when the normal clot disappears - upon exam, socket looks empty/ looking at bare bone. Main feature - intense pain - worse than toothache - keeps patient up at night.
30
What group of patients are likely to get osteoradionecrosis following an extraction and briefly describe what ORN is?
Patients who have received radiotherapy. ORN is when there is bone necrosis of the jaw, and occurs when patient's get extractions after radiotherapy. This is why any teeth that need to be extracted or are likely to need extracted in the future should be taken out prior to radiotherapy.
31
Give examples of some systemic haemostatic aids.
Vitamin K (necessary for formation of clotting factors) Anti-fibrinolytics e.g. tranexamic acid Plasma or whole blood DDAVP
32
When does dry socket typically start and how long does it usually take to resolve?
Often starts 3-4 days post-extraction Takes 7-14 days to resolve.
33
What are the symptoms of dry socket?
Intense, dull, aching pain Usually throbs and keeps pt. awake at night Exposed bone is sensitive and source of pain Bad smell and bad taste
34
What are some predisposing factors for dry socket?
Molars more common Mandible more common Smoking - reduced blood supply Female Oral contraceptive pill LA - vasoconstrictor Excessive trauma during extraction Excessive mouth-rinsing post X (clot washed away) Family history of dry socket
35
What is the management for dry socket?
LA - for pain Irrigation with saline Debridement - to promote bleeding/ clot formation Antiseptic pack - alvogyl - helps control haemostasis and foster healing Advise warm salty mouth-rinse (after 24 hours) Reviews
36
Why do you NOT prescribe antibiotics for dry socket?
It is not an infection
37
What is a bony sequestrum?
A necrotic bit of bone fragment.
38
What are examples of less common post-operative complications?
Osteomyelitis Osteoradionecrosis (ORN) Medication induced osteonecrosis (MRONJ) Actinomycosis Bacteraemia/ infective endocarditis
39
How can you improve limited mouth opening over time (following trismus)?
Gentle mouth opening exercises Wooden spatulae Trismus screw
40
How soon prior to an extraction should an INR be checked?
24 hours Extract within 24 hours of results If they have been anti-coagulated for a long time and have stable anti-coagulation, 72 hours is reasonable.
41
According to SDCEP guideline, what steps should be followed for an extraction for someone taking aspirin?
Treat without interrupting medication Limit initial treatment area and staging extensive or complex procedures (do not take out 3 teeth beside each other for example) Use local haemostatic measures.
42
What are the dosage recommendations for apixaban and higher-bleeding risk dental procedures?
Miss morning dose (usual drug schedule is 2 doses per day) Post-treatment dose - usual time in evening
43
What are the dosage recommendations for rivaroxaban and higher-bleeding risk dental procedures.
Delay morning dose (usual drug regime - once a day in morning) Post-treatment dose - 4 hours after haemostasis has been achieved.
44
Why does secondary bleeding occur?
Secondary bleeding occurs 3-7 days post-op Often occurs due to infection Usually mild ooze but can be major bleed Medication-related
45
What are the general recommendations for higher bleeding risk procedures and DOAC's?
Treat early in the day Limit initial treatment area Assess bleeding before continuing staging extensive or complex procedures Strongly consider suturing and packing
46
What is definition of OAF (chronic)?
When you get a sinus tract developing between oral mucosa and the maxillary sinus. Epithelial-lined and never closes.
47
What sign, when looking at the roots of an extracted tooth would indicate an OAC?
Bone at the tri-furcation of the roots.
48
How should a chronic OAF be managed?
Excise sinus tract EITHER Buccal advancement flap (+/- buccal fat pad) OR Palatal flap
49
What is osteomyelitis?
Inflammation of bone marrow - very rare Patient often systemically unwell/ raised temperature Area becomes ischaemic and necrotic Spreads until arrested by antibiotic and surgical therapy.
50
What are major pre-disposing factors for osteomyelitis?
Odontogenic infections and fractures of the mandible
51
What is actinomycosis?
Rare bacterial infection Erodes through tissues Chronic

BDS3 Oral Surgery (4 decks)

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