Extraction complications Flashcards
(102 cards)
1
Q
What are some peri-operative complications?
A
- Difficult access
- Abnormal resistance
- Fracture of tooth/root
- Fracture of alveolar bone
- Jaw fracture
- Involvement of the maxillaryantrum
- Fracture of tuberosity
- Loss of tooth
- Soft tissue damage
- Damage to nerves/vessels
- Haemorrhage
- Dislocation of TMJ
- Damage to adjacentteeth/restorations
- Extraction of permanent toothgerm
- Broken instruments
- Wrong tooth
2
Q
What to do if the tooth is lost during surgery?
A
- Stop
- Look for it
- Use suction
- Radiographs to find it
3
Q
How to reduce risk of soft tissue damage?
A
- Pay attention
- Correct placement using correct instrument
- Take time positioning instruments
- Application point
- Controlled pressure
- Sufficient but not excessive force
4
Q
What is the definition of Neurapraxia?
A
- Contusion of nerve/continuity of epineural sheath and axons maintained
5
Q
What is the definition of Axonotmesis?
A
- Continuity of axons but epineural sheath disrupted
6
Q
What is the definition of Neurotmesis?
A
- Complete loss of nerve continuity/nervetransected
7
Q
How can damage to nerves occur?
A
- Crush injuries
- Cutting/shredding injuries
- Transection
- Damage from surgery or damage from LA
- May not know all the time
8
Q
What can occur if there is damage to nerves?
A
- Anaesthesia(numbness)
*Paraesthesia(tingling)
*Dysaesthesia(unpleasant sensation/pain)
*Hypoaesthesia(reduced sensation) - Hyperaesthesia(increased/heightened sensation)
9
Q
What can occur if there is damage to the vessels?
A
*Veins (bleeding +++)
*Arteries (spurting/haemorrhage +++)
*Arterioles (spurting/pulsating bleed)
*Vessels in muscle
*Vessels in bone
10
Q
Why can Haemorrhage occur?
A
- Most bleeds occur due to local factors (mucoperiosteal tears or fractures of alveolar plate/socket wall)
- Very few occur due to undiagnosed clotting abnormalities (haemophillia/ von Willebrands)
- Some due to liver disease (alcohol disease) as clotting factors made in liver
- Some due to medications like Warfarin/ antiplatelet agents (aspirin/ clopidogrel)
- Other anticoagulant drugs like rivaroxaban (Pradaxa) and Dabigatran (Xarelto)
11
Q
What to do if Haemorrhage is in soft tissue?
A
- Pressure(mechanical –finger/biting on damp gauze swab)
–Sutures
–Local Anaesthetic with adrenaline(vasoconstrictor)
–Diathermy(cauterise/burn vessels precipitate proteins which form proteinaceous plug in vessel)
–Ligatures/haemostatic forceps (artery clips) for larger vessels
12
Q
What to do if Haemorrhage is in bone?
A
–Pressure (via swab)
–LA on a swab or injected into socket
–Haemostatic agents
–Blunt instrument
–Bone Wax
–Pack
13
Q
What to do if TMJ is dislocated?
A
*Relocate immediately(analgesia and advice on supported yawning)
*If unable to relocate try local anaesthetic into masseterintra-orally
*If still unable to relocate – immediate referral
14
Q
How can damage to adjacent teeth/restorations occur?
A
- Hit opposing teeth with forceps
- Crack/Fracture/move adjacent teeth with elevators
- Crack/fracture/remove restorations/crowns/bridges on adjacent teeth
15
Q
How do you manage damage to adjacent teeth/restorations?
A
- Temporary dressing/restoration
- Arrange definitive restoration
- If large restoration next to extraction site warn patient of the risk
16
Q
When can extraction of permanent tooth germ happen?
A
- When removing deciduous molars resulting in extraction or damage to developing permanent premolar
- Very rare
17
Q
What to do if an instrument is broken during surgery?
A
- Can be tips of elevators and luxators or burs
- Use radiograph to determine location and retrieve
- If unable to retrieve then refer
18
Q
What are the safety checks you do so you don’t remove the wrong tooth during surgery?
A
- Concentrate
- Check clinical situation against notes/radiographs (mislabelling of radiographs/errors in notes can occur)
- Safety checks
- Count teeth
- Verify with someone else if still unsure
- Contact defence union
19
Q
What are some post extraction complications?
A
- Pain/Swelling/Ecchymosis
- Trismus/ Limited mouth opening
- Haemorrhage / Post-op bleeding
- Prolonged effects of nerve damage
- Dry Socket
- Sequestrum
- Infected Socket
- Chronic OAF / root in antrum
20
Q
What are some less common post-operative complications?
A
- Osteomyelitis
- Osteoradionecrosis (ORN)
- Medication induced osteonecrosis (MRONJ)
- Actinomycosis
- Bacteraemia/Infective endocarditis – note current guidance
21
Q
What is the most common complication of extraction?
A
- Pain
- Warn the patient/advise
- Prescribe analgesia
22
Q
What can cause more pain during extraction?
A
- Laceration/ tearing of soft tissues
- Leaving the bone exposed
- Incomplete extraction of tooth
23
Q
Why does swelling (oedema) occur after extraction?
A
- Part of the inflammatory response to surgical interference
- Increased by poor surgical technique
e.g. rough handling of soft tissue, pulling flaps, crushing tissue with instruments, tearing of periosteum - Depends on individual
24
Q
What is Ecchymosis and why does it occur after extraction?
A
- Bruising
- Increased by poor surgical technique
- Can be increased due to underlying medical condition
- Individual variation
25
What is trismus?
- Muscle spasms in temporomandibular joint
- Inability to open mouth/ open mouth fully
26
What are some causes of trismus?
- Related to surgery due to oedema or muscle spasms
- Giving LA in IDB (medial pterygoid muscle spasm)
- Haematoma in medial pterygoid or less likely masseter
- Damage to TMJ via oedema or joint effusion
27
How to manage patient with limited mouth opening?
- Need to monitor as may take several weeks to resolve
- Gentle mouth opening exercises like using a wooden spatula or trismus screw
28
What to do if patient is taking Vitamin K antagonist? (warfarin, acenocoumarol or phenidione)
- Check INR ideally no more than 24hrs before procedure (up to 72hrs if patient is stably anticoagulated)
If INR below 4
- Treat without interrupting medication
- Limit initial treatment and staging extensive or complex procedures
- Strongly suture and pack
If INR above 4
- Delay invasive treatment or refer if urgent
29
What to do if patient is on antiplatelet drug aspirin only?
- Treat without interrupting medication
- Limit initial treatment areas and staging extensive or complex procedures
- Local haemostatic measure
30
What to if patient is taking Clopidogrel, dipyridamole, prasugrel or ticagrelor single or dual therapy with aspirin?
- Treat without interrupting medication
- Expect prolonged bleeding
- Limit initial treatment area
- Consider staging extensive or complex procedure
- Strongly consider suturing and packing
31
What to do if patient taking Direct Oral anticoagulant (apixaban, dabigatran, rivaroxaban, edoxaban) and you are doing a low bleeding risk dental procedure?
- Treat without interrupting medications
- Treat early in day
- Limit initial treatment area and assess bleeding
- Before continuing consider staging extensive or complex procedures
- Strongly consider suturing and packing
32
What to do if patient taking Direct Oral anticoagulant (apixaban, dabigatran, rivaroxaban, edoxaban) and you are doing a high bleeding risk dental procedure?
- Advise patient to miss or delay morning dose before treatment
- Treat early in day
- Limit initial treatment area and assess bleeding
- Before continuing consider staging extensive or complex procedures
- Strongly consider suturing and packing
- Advise when to restart medication
33
What to do when patient is on apixaban or dabigatran and you are performing high bleeding risk procedure?
- Usual drug schedule twice a day
- Miss morning dose pre treatment
- Usual time in evening post treatment dose
34
What to do when patient is on Rivaroxaban and you are performing high bleeding risk procedure?
- Usual drug schedule once a day morning
- Delay morning does pre treatment
- 4 hrs after haemostasis achieved take dose
35
What to do when patient is on Edoxaban and you are performing high bleeding risk procedure?
- Usual drug schedule once a day evening
- Take dose usual time in evening (treatment done in morning)
36
What is the immediate post-operative period?
- Reactionary/ rebound bleeding can occur
- Occurs within 48hr of extraction
- Vessels open up/ vasoconstriction effects of LA wear off/ sutures loose or lost/ patient traumatises area with tongue, finger or food
37
What is secondary bleeding?
- Often due to infection
- Commonly 3-7days
- Usually a mild ooze but can be major bleed
- Can be medication related
38
What to do if there is Haemorrhage in soft tissue?
–Pressure (mechanical –finger/biting on damp gauze swab)
–Sutures
–Local Anaesthetic with adrenaline (vasoconstrictor)
–Diathermy (cauterise/burn vessels precipitate proteins which form proteinaceous plug in vessel)
39
What to do if there is Haemorrhage in bone?
–Pressure (via swab)
–LA on a swab
–Haemostatic agents
–Blunt instrument
–Bone Wax
–Pack & Suture
40
What are some haemostatic agents?
- Adrenaline containing LA is a vasoconstrictor
- Oxidised regenerated cellulose – Surgicel / equitamp which provides framework for clot formation (Careful in lower 8 region – acidic – damage to IDN)
- Haemocollagen Sponge –absorbable/meshwork for clot formation
- Thrombin liquid and powder
- Floseal
41
What are some systemic haemostatic aids?
- Vitamin K (necessary for formation of clotting factors)
- Anti-Fibrinolytics e.g. Tranexamic acid (prevents clot breakdown/stabilises clot – systemic tablets or mouthwash)
- Missing Blood Clotting Factors
- Plasma or whole blood
- Desmopressin
42
What is the management of post-operative bleeding?
- If bleeding severe get pressure on immediately / arrest the bleed
- Calm anxious patient / separate from anxious relatives
- Clean patient up / remove bowls of blood / blood-soaked towels
- Take a thorough but rapid history while dealing with haemorrhage
- Get inside mouth/good light & suction
- Mouth often filled with large jelly-like clot
- Remove clot
- Patient may be vomiting if blood swallowed
- Identify where bleeding from
- Pressure with finger/biting on damp packs
- LA with vasoconstrictor
- Haemostatic aids like surgicel
- Suture socket using interrupted or horizontal mattress sutures
- Ligation of vessels/diathermy if available
43
What to do if you can't haemorrhage?
- Urgent hosptial referral
- Weekdays is dental hospital /maxillofacial outpatients
- Evenings/weekdays is maxillofacial on call or local hospital A&E
- Uncontrolled haemorrhage is life threatening
44
How to prevent intra-operative and post-operative extraction haemorrhage?
- Thorough MH and anticipate and deal with potential problems
- Atraumatic extraction/ surgical technique
- Obtain and check good haemostasis at end of surgery
- Provide good instructions to patients
45
What are the post extraction instructions for patient?
- Do not rinse out for several hours (better not to rinse till next day, then avoid vigorous mouth rinsing – wash clot away)
- Avoid trauma - do not explore socket with tongue or fingers/hard food
- Avoid hot food that day
- Avoid excessive physical exercise and excess alcohol – increase blood pressure
- Advice on control of bleeding
- Biting on damp gauze/tissue
- Pressure for at least 30min (longer if bleeding continues)
- Points of contact if bleeding continues
46
How long is the time span for improvement of nerve damage?
- Nerve damage can be temporary or permanent
- Improvement can occur up to 18months (after there is little chance of improvement)
47
What are the 3 types of sensory change?
- Anaesthesia (numbness)
- Paraesthesia (tingling)
- Dysaesthesia (unpleasant sensation/pain)
Can be either
- Hypoaesthesia (reduced sensation)
- Hyperaesthesia (increased/heightened sensation)
48
What is dry socket?
- AKA Alveolar Osteitis
- Normal clot disappears and appear to be looking at bare bone/empty socket
- Main feature is intense pain (kept awake at night)
49
When does dry socket occur?
- Often 3-4days after extraction
- Takes 7-14 days to resolve
- Causes localised osteitis (inflammation affecting lamina dura)
- Can be clot not form or clot breaks down
50
What are the symptoms of dry socket?
- Dull aching pain – moderate to severe
- Usually throbs/can radiate to patient’s ear/often continuous and can keep patient awake at night
- The exposed bone is sensitive and is the source of the pain
- Characteristic smell/bad odour & patient frequently complains of bad taste
51
What are some predisposing factors of dry socket?
- Molars more common – risk increases from anterior to posterior
- Mandible more common
- Smoking – reduced blood supply
- Female
- Oral Contraceptive Pill
- Local Anaesthetic – vasoconstrictor
- Excessive trauma during extraction
- Excessive mouth rinsing post extraction (clot washed away)
- Family history/ previous dry socket
52
How do you manage a dry socket?
- Supportive – reassurance / systemic analgesia
(patients often think you have extracted wrong tooth and another tooth is causing pain)
- LA
- Irrigate socket with warm saline (wash out food and debris)
- Curettage/debridement
(encourage bleeding/new clot formation) – some suggest this should not be carried out as it produces more bare bone and removes any remaining clot
- Antiseptic Pack (Alvogyl)
- Advise patient on Analgesia and hot salty mouthwashes
- Review patient / change packs and dressings (as soon as pain resolves get packs out to allow healing)
- Generally, do not prescribe antibiotics as it is not infection
- Remember to check initially that it is a dry socket and that no tooth fragments or bony sequestra remain
53
What is a bony sequestrum?
- Quite common
- Prevent healing
- Usually bits of dead bone (can see white spicules coming through gingivae – patient often thinks you have left a part of the tooth)
- Can also be pieces of amalgam/tooth
- Delays healing/remove
54
What is an infected socket?
- Rare complication after extraction
- Occasionally infected socket with pus discharge
- More common after minor surgical procedures involving soft tissue flaps and bone removal
- Infection delays healing
55
How to treat infected socket?
- Check for remaining tooth/ root fragments/ bony sequestra/ foreign bodies
- Radiograph
- Explore
- Irrigate
- Remove any of above
- Consider antibiotics
56
What are some less common post-op complications?
- Osteomyelitis
- Osteoradionecrosis (ORN)
- Medication induced osteonecrosis (MRONJ)
- Actinomycosis
- Bacteraemia/infective endocarditis
57
What are OAF/OAC?
- Acute = OAC (Oral antral communication)
- Acute is immediate large communication
- Chronic = OAF (Oral antral fistula)
- Chronic is small fistula that hasn't healed
58
How do you diagnose Oro-antral communication?
- Size of tooth
- Radiographic position of roots in relation to antrum
- Bone at trifurcation of roots
- Bubbling of blood
- Nose holding test (careful as can create OAF)
- Direct vision
- Good light and suction (echo)
- Blunt probe (Take care not to create OAF)
59
What is the management of OAC if small or sinus is intact?
- Inform patient
- Encourage clot
- Suture margins
- Antibiotics ?
- Post-op instructions
60
What is the management of OAC if large or lining torn?
- Close with buccal advancement flap
- Antibiotics, decongestants and nose blowing instructions
61
What is the management of chronic OAF?
- Excise sinus tract
- Buccal advancement flap
- Buccal fat pad with buccal advancement flap
- Bone graft/collagen membrane
62
What to do if think there is a root in the Antrum?
- Confirm radiographically by OPT, occlusal or periapical
- Decision on retrieval
63
What is the approach for retrieval of foreign body in antrum?
- Flap design
- Open fenestration with care
- Suction with efficient and narrow bore
- Use small curettes
- Irrigation or ribbon gauze
- Close as same for OAC
64
What is the Caldwell-Luc approach for retrieval of root in antrum?
- Go through buccal sulcus
- Buccal window
65
What is another method for retrieval of root in antrum ?
- ENT ( Endoscoptic approach)
66
What is Osetomyelitis?
- Inflammation of the bone marrow (infection of bone)
- Rare
67
What are some symptoms of osteomyelitis?
- Pt Systemically unwell/ raised temp
- Site of extraction very tender
- In deep seated infection may see altered sensation due to pressure on IAN
68
What is the progression route for osteomyelitis?
- Begins in medullary cavity involving cancellous bone
- Extends and spreads to cortical bone
- Eventually into periosteum
- Overlying mucosa is red and tender
69
How does osteomyelitis cause necrosis of soft tissue?
- Invasion of bacteria into cancellous bone
- Soft tissue inflammation and oedema in closed bony marrow spaces
- Oedema in enclosed space lead to increased tissue hydrostatic pressure
- Results in higher blood pressure of feeding arterial vessels
- Compromised blood supply lead to soft tissue necrosis
- Involved area ischaemic and necrotic
70
How is osteomyelitis stopped?
- Spreads until arrested by antibiotic and surgical therapy
- Bacteria proliferate because normal blood borne defences don't reach the tissue
71
Why is osteomyelitis more common in mandible ?
- Mandible has poorer blood supply
- Due to primary blood supply IA artery and dense overlying cortical bone
- This limits penetration of periosteal blood vessels
- Becomes ischaemic and infected
72
What are some predisposing factors of osteomyelitis?
- Odontogenic infections
- Fractures of mandible
- Very rare unless host defences compromised like diabetes/ alcoholism/ IV drug use/ Myeloprolifertaive disease like leukaemia
73
What can early osteomyelitis be confused for?
- Dry socket
- Localised infection in socket
74
Radiographically how does osteomyelitis present?
- Acute suppurative osteomyelitis little to no change (10-12 days to show)
- Chronic = bony destruction in area of infection
- Increased radiolucency
- Uniform or patchy with a moth eaten appearance
75
What is an involucrum?
- Increase in radiodensity surrounding radioluscent area
- Common in chronic osteomyelitis
76
How does sequestra present on radiograph?
- Areas of radiopacity within radiolucent region
77
What are the main bacteria present in osteomyelitis in mandible?
- Streptococci
- Anaerobic gram negative rods like Fusobacterium and Prevotella
78
What is the treatment of Osteomyelitis?
- Medical and surgical treatment
- Investigate host defences (blood investigations/glucose levels) - medical consultation
- Antibiotics
79
What is the antibiotic treatment of Osteomyelitis?
- Penicillin (longer course than normal)
- 6 weeks and up to 6 months for chronic
- Severe may require IV and hospital admission if systemic symptoms
- Refer local OS or OMFS unit
80
What is the surgical treatment of osteomyelitis?
- Drain pus if poss
- Remove any non-vital teeth in area of infection
- Remove any loose pieces of bone
- In fractured mandible remove any wires/plates/screws
- Corticotomy (removal of bony cortex)
- Perforation of bony cortex
- Excision of necrotic bone until reach actively bleeding bone tissue
81
What is Osteoradionecrosis (ORN)?
- Bone within radiation beam becomes virtually non-vital
- Endarteritis (reduced blood supply)
- Bone turnover remaining viable bone is slow
- Self repair ineffective
- Seen in pt who have radiotherapy of head and neck to treat cancer
82
Where does osteoradionecrosis happen worse?
- Mandible due to poorer blood supply
- Is worse with time and dose of radiotherapy
83
How do you prevent Osteoradionecrosis?
- Chlorhexidine mouthwash leading to extraction
- Careful extraction technique
- Antibiotics, chlorhexidine and review
- Hyperbaric oxygen
- Take advice/refer patient for extraction
84
Why is hyperbaric oxygen useful for osteoradionecrosis prevention?
- Increases local tissue oxygenation and vascular ingrowth to hypoxic tissues
- Done before and after extraction
85
What is the treatment for osteoradionecrosis?
- Irrigation necrotic debris
- Loose sequestra removed
- Small wounds under 1cm usually heal weeks/months
- Severe cases = resection of exposed bone, margin of unexposed bone and soft tissue closure
- Hyperbaric oxygen
86
What is Actinomycosis?
- Rare bacterial infection
87
What are the bacteria associated with actinomycosis?
- Actinomyces israelli
- A. naeslundii
- A. viscosus
88
How does the bacteria involved in actinomycosis invade tissues?
- Bacteria have low virulence
- So must be inoculated into area of injury or susceptibility
- E.g. recent extraction/ severely carious teeth/ bone fracture
- Erodes through tissues not typical fascial planes and spaces
89
What are some symptoms of actinomycosis?
- Multiple skin sinuses and swelling
- Thick lumpy pus (colonies of it look like sulphur granules on histology)
90
What is the treatment of actinomycosis?
- IandD of pus accumulation
- Excision of chronic sinus tracts
- Excision of necrotic bone and foreign bodies
- High does antibiotics for initial control (often IV)
- Long term oral antibiotics to prevent recurrence
91
What antibiotics can be given for actinomycosis treatment?
- Penicillin
- Doxycycline
- Clindamycin
92
What is infective endocarditis?
- Rare but life threatening infection of endocardium, particularly affecting heart valves
93
What is the 2016 amended NICE guidelines about infective endocarditis?
- Antibiotic prophylaxis against infective endocarditis not recommended routinely for people undergoing dental procedures
94
What are the patients at increased risk of infective endocarditis that require routine management?
- Acquired valvular heart disease with stenosis or regurgitation;
- Hypertrophic cardiomyopathy;
- Previous infective endocarditis*;
- Structural congenital heart disease*, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised;
- Valve replacement
95
What is the sub-group that requires special consideration for non-routine management of infective endocarditis?
- Prosthetic valve, including transcatheter valves, or where any prosthetic material was used for valve repair;
- Previous infective endocarditis;
- Congenital heart disease (CHD):
o any type of cyanotic CHD;
o any type of CHD repaired with a prosthetic material, whether placed surgically or by percutaneous techniques, up to 6 months after the procedure or lifelong if residual shunt or valvular regurgitation remains.
96
What is routine management for infective endocarditis?
- Ensure pt aware of risk of IE and provide advice about prevention inc why antibiotic prophylaxis not routinely recommended / importance of maintaining good oral health/ symptoms of IE and when to seek help/ risk of undergoing non-medical procedures like body piercing and tattoos
- Record discussion in notes
- If they request antibiotic prophylaxis consult cardiology consultant
- Ensure any dental infection is treated promptly to reduce risk of IE
97
What is non-routine management of IE?
- Assess pt and consult with cardiology consultant
- If determined antibiotic prophylaxis not needed then follow routine management
98
What are some examples of invasive dental procedures?
- Placement of matrix band
- Placement of sub-gingival rubber dam
- Preformed metal crowns
- Full periodontal examinations
- Incision and drainage of abscess
99
What are some examples of non-invasive dental procedures?
- Infiltration or block local anaesthetic
- BPE screening
- Removal of sutures
- Radiographs
- Removable pros appliances
100
What can you prescribe for antibiotic prophylaxis for IE if deemed necessary?
- Amoxicillin 3g Oral powder sachet 60 mins before procedure
- Clindamycin capsules 300mg X2 60 mins before procedure
- Azithromycin oral suspension 200mg/5ml - give 500mg before 60 mins before procedure
101
What is antibiotic prophylaxis?
- Prevention of infection complications using antimicrobial therapy
- Used to be routinely given for patients at risk of IE in dental procedures
102
Why is antibiotic prophylaxis not routinely given for invasive dental procedures now?
- Used to be routinely given for patients with predisposing cardiac condition as oral bactereamia was thought to be main cause of IE
- Now lack of microbial data to show that invasive dental procedures cause IE and it can occur due to mechanical brushing of teeth
- Therefore good oral hygiene is important
