Extraction Complications Flashcards
(100 cards)
1
Q
Why might a patient have difficult access?
A
Trismus
Reduced aperture of mouth
Crowded/malpositioned teeth
2
Q
If a patient has difficult access, what can you do to improve this?
A
Get the patient to move their head into a better position.
Good lighting.
Suction the area rigorously.
3
Q
What factors may cause there to be abnormal resistance when trying to extract a tooth?
A
Ankylosis
Hypercementosis
Thick cortical bone
Shape.form of the roots- divergent/hooked
Number of roots- extra roots.
4
Q
What factors make a tooth/root fracture more likely?
A
Caries
Small crown with large bulbous roots
Fused roots
Convergent or divergent roots
Extra roots
Hypercementosis
Ankylosis
5
Q
Which teeth are most likely to cause an alveolar bone fracture?
A
Canines or molars.
- canines have a big buttress adjacent and they have the largest roots.
Usually the buccal plate.
6
Q
Why might you get an alveolar bone fracture?
A
If you take out a tooth too quickly.
7
Q
What would be the management of alveolar bone fracture?
A
If the bone is still attached to underlying mucoperiosteum- suture it back together.
if it is detached, you may need to dissect the bone free and then suture.
8
Q
What factors may increase the chance of developing a jaw fracture?
A
Atrophic mandible
Large cyst
Impacted wisdom tooth
9
Q
What are the signs of a fractured jaw?
A
Teeth no longer meeting together as they were.
Tear in the gingivae.
Mandible appears to be moving in 2 parts.
10
Q
How would you manage a jaw fracture?
A
Inform patient.
Post-op radiograph- OPT.
Refer
Ensure analgesic
Stabilise
If delay, antibiotics.
Ask the patient to not eat or drink anything- incase they require surgery.
11
Q
What factors make a tuberosity fracture more likely?
A
Last standing molar
Extracting in wrong order- always go from back to front.
Inadequate alveolar support
Pathological gemination
Unknown unerupted wisdom tooth.
12
Q
Outline the management of a tuberosity fracture?
A
Dissect out and close wound or reduce and stabilise.
Put bit of bone back in place, splint- buccal arch wire.
Take teeth out of occlusion, treat the pulp, antibiotics, remove tooth 8 weeks later.
13
Q
Describe the peri-operative complications.
A
Haemorrhage
Difficult access
Tooth/root fracture
Jaw fracture
Tuberosity fracture
Abnormal resistance
OAC
Loss of tooth
Extracting wrong tooth
Soft tissue damage
Damage to nerves
Dislocation of TMJ
Damage to adjacent teeth/restorations
Broken instruments.
14
Q
If you are extracting a tooth and you lose it. What would you do?
A
Ask the patient if they can feel it in their mouth, can they feel it down their throat?
Sometimes teeth can fall into the buccal sulcus or lingual sulcus.
If you cannot find it, you must assume it was swallowed.
Urgent referral to A&E.
Explain to the patient what is going on, reassure them and you know how to manage it.
15
Q
How can damage to nerves occur?
A
Crushing injuries
Transection
Cutting.shredding injuries
Damage from LA
16
Q
What is neurapraxia?
A
Contusion of nerve/continuity of epieneural sheath and axons maintained
17
Q
What is axonotmesis?
A
Continuity of axons but epieneural sheath disrupted
18
Q
What is neurotmesis?
A
Complete loss of nerve continuity/nerve transected.
19
Q
What is anaesthesia?
A
Numbness
20
Q
What is paraesthesia?
A
Tingling
21
Q
What is dysaesthesia?
A
Unpleasant sensation/pain
22
Q
What is hypoaesthesia?
A
Reduced sensation
23
Q
What is hyperaesthesia?
A
Increased sensation
24
Q
What might cause damage to vessels?
A
Sharp bits of bone left behind.
25
What factors may increase the chance of haemorrhage?
Alveolar wall fracture
Mucoperiosteal tear
Sharp bone left in socket
Liver disease
Warfarin
Antiplatelet medication
26
What is the appropriate management of a peri-operative haemorrhage?
Soft tissue- Apply pressure with damp gauze
LA with adrenaline
Sutures
Diathermy
Ligatures/haemostatic forceps.
Bone- Pressure via swab
LA on a swab or injected into socket
Surgicel
Bone wax
Pack
27
What is the appropriate management of TMJ dislocation?
Relocate immediately.
Give LA to masseter intra-orally, then try relocate.
If struggling, refer to MAXFACS.
28
How do you relocate the mandible into the coronoid fossa?
Downward pressure and backwards.
Stand in front of the patient for this.
29
Under what circumstances, is it common for damage to adjacent teeth to occur?
Large restoration in an adjacent teeth.
Secondary caries in adjacent tooth
30
Describe post-operative complications?
Pain/swelling/bruising
Trismus/limited mouth opening
Post-op bleeding
Prolonged effects of nerve damage
Dry socket
Sequestrum
Infected socket OAC/root in the antrum
Osteomyelitis
Osteoradionecrosis
MRONJ
Actinomycosis
Infective endocarditis
31
What makes pain worse?
Taking more teeth out
Poor technique
Leaving some exposed bone
Leaving root within the socket
32
What makes bruising worse?
Being rough
Poor surgical technique
Crushing tissues with instrument
Anti-platelets and anti-coagulants
33
Why might a patient get truisms?
Damage to medial pterygoid via IDB
Oedema in the TMJ
Haematoma- medial pterygoid
34
What management can be employed to help with trismus?
Monitor- wooden sticks
Mouth opening exercises
Trismus screw
Anti-inflammatory drugs
35
If someone starts bleeding within 48 hours post-extraction, what is this called?
Rebound bleeding
May be due to loose sutures, medication, LA has worn off, patient traumatises area
36
What is the most likely cause of secondary bleeding?
Infection- 3-7 days after extraction.
37
What are local haemostatic agents?
LA with adrenaline
Surgicel- oxidised regenerated cellulose
Haemocollagen sponge
Thrombin liquid/powder
Floseal
38
What are systemic haemostatic agents?
Vitamin K
Tranexamic acid
Missing blood clotting factors
Plasma or whole blood
Desmopresisn
39
If you cannot arrest the haemorrhage, what would you do?
Urgent hospital referral- dental hospital/MAXFACS
Out of hours- A&E
40
Nerve damage can improve up until which point?
18 months- after this, it doesn't make much improvement.
41
What is a dry socket?
Alveolar osteitis
Area of exposed bone, where the blood clot has disappeared.
42
What percentage of extractions results in a dry socket?
2-3%
43
What are the signs and symptoms of dry socket?
Dull aching intense pain that starts 3-4 days after extraction.
Patient kept awake at night
Throbbing pain, radiates to the ear.
Exposed bone is sensitive
Patient may say they smell something bad or have a bad taste
44
What are the predisposing factors to dry socket?
Female
Previous dry socket
Contraceptive pill
Smoking
Molars
Mandible
Vasoconstrictor
Excessive trauma during extracting
Excessive rinsing following extraction
Infection
45
Describe the management of a dry socket?
Analgesia advice
LA
Irrigate the socket with warm saline
Curettage/debridement of the socket
Alvogyl into socket
Advise patient on warm salty mouthrinses
46
What is alvogyl?
Brown fibrous paste that contains butamben, iodoform and eugenol.
47
What is sequestrum?
Exposed bone which prevents healing, usually dead bone.
Remove it.
48
What is the difference between a dry socket and an infected socket?
Infected socket you would see discharge of pus.
49
What is the difference between OAC and OAF?
OAC- communication has just happened
OAF- communication has been left open for a period of time, inside of the canal has epithelialised.
50
What would be some signs and symptoms of an OAC?
Bubbling blood in socket
Echo with the suction
Large dark hole
Nose holding test
Bone at trifurcation of roots
Radiographic position of root sin relation to antrum
Size of tooth
Blunt probe
51
Describe the management of an OAC/OAF?
Inform patient
Encourage clot to form
Suture margins
Post-op instruction
If it is an OAF
- Remove epithelialised sinus tract
- Close with buccal advancement flat, buccal fat pad and advancement flap, palatal flap.
- Antibiotics
- Decongestants
- Nose blowing instructions
52
How would you confirm if there was a root in the maxillary antrum?
Radiograph- OPT, occlusal or PA.
53
Describe the procedure for retrieval of a root from the maxillary antrum?
Caldwell-Luc approach- create a window in the buccal sulcus.
Suction, small curettes, irrigation, close as for OAC.
54
What is osteoradionecrosis?
Area of exposed bone which has been present for more than 3 months, which is in an irradiated site and not due to tumour recurrence.
Bone becomes non-vital, reduced blood supply.
55
What steps can be taken to prevent ORN?
Chlorhexidine mouthwash leading up to extraction.
Careful extraction technique
Hyperbaric oxygen
Refer patient for extraction.
Regular dental check ups
OHI
56
Describe the management of ORN?
Irrigation of necrotic debris
Chlorhexidine mouthwash
Loose sequestra removed
Surgical debridement of necrotic bone
Soft tissue closure if large
Hyperbaric oxygen
Nutritional support
57
What is Osteomyelitis?
Inflammation of the bone marrow.
Usually in the mandible, patient usually systemically unwell/raised temperature.
58
Why is osteomyelitis more common in the mandible?
Dense overlying cortical bone with fewer blood vessels than maxilla.
Poorer blood supply, so more likely to become ischaemic and infected.
59
What are the predisposing factors to osteomyelitis?
Immuno-compromised
Fractured mandible
Odontogenic infections
60
Describe the pathogenesis of osteomyelitis?
Invasion of bacteria into cancellous bone causes soft tissue inflammation and oedema in the bone marrow spaces.
Increased tissue hydrostatic pressure compromises blood supply.
Tissue necrosis.
61
What radiographic features are indicative of osteomyelitis?
Moth-eaten appearance of bone.
62
What bacteria is involved in osteomyelitis?
Strep
Anaerobic gram negative rods- prevotella
63
What is the treatment for Osteomyelitis?
Antibiotics
Surgery- drain pus, remove non-vital teeth, remove loose pieces of bone, remove necrotic bone.
64
What is infective endocarditis?
Infection of the endocardium, particularly affecting the heart valves.
65
What is the incidence of infective endocarditis?
1 in 10,000
66
What factors make a patient more at risk of infective endocarditis?
Acquired valvular heart disease with stenosis or regurgitation
Hypertrophic cardiomyopathy
Previous IE
Structural congenital diseases, unless fully repaired.
Valve replacement.
These patients will still receive routine management.
67
What conditions would put patients into the sub-group of increased risk of IE?
Prosthetic valves or those patients who have had valves replaced with prosthetic material.
Previous IE
Patients with congenital heart disease- cyanosis CHD.
68
What is the routine management of someone with increased risk of IE?
Explain IE and why they are at risk.
Explain pros and cons of antibiotic use.
Why antibiotic prophylaxis is not routinely recommended
Importance of good oral health
Symptoms that may suggest IE and what to look out for.
Risks of undergoing invasive procedures.
If the patient does want antibiotic prophylaxis- discuss with their cardiologist.
69
What is the special consideration management for someone at increased risk of IE?
Consult with their cardiologist and cardiac surgeon with regards to antibiotic prophylaxis.
Either way, it is dealt with the same as routine management.
70
Antibiotic cover should only be given for invasive procedures, what would these be?
Placement of matrix bands
Subgingival rubber dam clamps
Subgingival restorations
Endo treatment before apical stop has been achieved
Anything perio related (apart from supra-gingival PMPR and BPE).
Extractions
Incision and drainage of biopsies
Surgery (apart from removal of sutures).
71
What are the signs and symptoms of IE?
Fatigue
Breathlessness
Chest pain
Swelling in feet or legs
Aching joints and muscles
Sweats or chills at night
Weight loss
72
What is the procedure for the patient taking the antibiotic?
Give the prescription to the patient at the appointment before the surgery appointment.
Ensure to put on it that it is for prophylaxis.
Advise the patient on the risk of anaphylaxis, colitis and hypersensitivity.
Arrange for the patient to take the prescription in the practice, 60 minutes before the surgery and must stay in the practice after they have taken the antibiotic.
- if they have had a history of taking the antibiotic without reaction and they insist on taking it at home, then allow them.
If a patient has already had antibiotic prescription in the last 6 weeks, choose an antibiotic from a different class.
73
What is an appropriate antibiotic regime for IE?
Amoxicillin 3g oral powder sachet.
Taken 60 minutes before procedure.
74
In patients allergic to penicillin, what antibiotic would you prescribe for IE prophylaxis?
Clindamycin 300mg, 2 capsules, 60 minutes before procedure.
75
In patients who cannot take penicillin or swallow capsules, what appropriate antibiotic regime would be best for IE prophylaxis?
Azithromycin oral suspension, 200mg/5ml.
500mg (12.5ml) taken 60 minutes before procedure.
76
Why is antibiotic prophylaxis no longer routinely advised for IE?
Dental procedures are no longer thought to be the main cause of IE.
No solid evidence to suggest that antibiotic prophylaxis will reduce the risk of IE.
Antibiotics can cause side effects- resistance, diarrhoea, allergic reactions, colitis.
77
What are the post-op signs of an OAC?
Salty taste in mouth
Liquid into nose from drinking
Difficulty drinking through a straw
Non-healing socket
78
What do you do once you have confirmed an OAC?
Inform patient and explain what an OAC is
Try to get primary closure- buccal advancement flap or palatal advancement flap- full thickness mucoperiosteal flap, score the underside of the flap and suture to palatal mucosa over bone.
- Ensuring to score the underside of the mucosa so that it is not stretched.
Post op advice
- no using a straw
- No blowing your nose
- Don't play any wind instruments
- Do not smoke
- Steam inhalation and decongestants are helpful- ephedrine nasal drops 0.55 10ml- 1-2 drops 4 time per day.
- No opera singing, scuba divide or flying.
- Use warm salty miouthrinses or chlorhexidine.
79
What antibiotics would you prescribe for an OAC?
Phenooxymethylpenicillin- 250mg, 2 tablets 4 times a day for 5 days.
80
If an OAC is not closed promptly, what will happen?
Turn to OAF
Food/saliva accumulation in sinus
Infection
Impaired healing
81
Does chemotherapy and radiotherapy put a patient at increased risk of bleeding?
Yes- chemo in the last 3 months or radiotherapy in the last 6 months.
82
What medical conditions put a patient at increased risk of bleeding?
Haemophillia A or B
VWD
Renal failure
Liver disease
Chemotherapy
Radiotherapy
Stem cell transplant
Dialysis- heparinised
Advanced heart failure
Haematological malignancy
83
What drugs might cause increased risk of bleeding?
Antiplatelets
Anticoagulants
Cytotoxic drugs- methotrexate, azathioprine, mycophenolate, sulfasalazine.
Biologic immunosuppression- infliximab
NSAIDS
SSRIs
Carbamazepine
84
What conditions might cause someone to be on an anti platelet drug?
STEMI or N-STEMI
Stable or unstable angina
Peripheral vascular disease
85
What conditions might cause someone to be on an anti-coagulant?
AF
DVT
Thromboembolism
Prosthetic valves?
86
How does an OAC occur?
Routine extraction
Surgical extraction
Tuberosity fracture
Dentoalveolar/PA infections of molars
Trauma
Maxillary cyst of tumour
Perforation of sinus base caused by an implant
ORN
87
What are the guidelines called that encompass IE?
NHS Education for Scotland- Antibiotic Prophylaxis against Infective Endocarditis.
88
What is the incidence of IE following a general dental procedure?
2-5% of people diagnosed with IE had had an invasive dental procedure within the last 6 months.
89
What is the radiological appearance of an OAF?
Less bone present in the sinus floor
Discontinuation of the sinus floor
90
What might someone C/O if they have an OAF?
Problems with fluid consumption- fluids coming out their nose
Problems with speech or singing- nasal quality
Problems playing brass/wind instruments
problems smoking cigarettes or using a straw
Bad taste, odour, halitosis, pus discharge.
Pain/sinusitis type symptoms.
91
When examining someone with maxillary discomfort, what should you remember?
Close relationship of the sinuses and posterior teeth- some people find it difficult to distinguish pain in the sinus from pain in the teeth.
Aetiology of paranasal sinus inflammation and infection.
Patients with sinusitis usually present to the dentist first.
92
What is sinusitis?
Precipitated by a viral infection.
Inflammation and oedema
Obstruction of ostia
Trapping of debris within sinus cavity
When the sinus can no longer evacuate it's contents efficiently
- build up of pressure.
93
What are the signs and symptoms of sinusitis?
Facial pain
Dental pain
Pressure
Congestion
Nasal obstruction
Fever
Hyposmia
Headache
Halitosis
Fatigue
Cough
Ear pain
Anaesthesia/paraesthesia over cheek
94
What are the indicators on examination that it is sinusitis?
Discomfort on palpation of infraorbital region
A diffuse pain in the maxillary teeth- all TTP
Equal sensitivity from percussion of multiple teeth in the same region
Pain that worsens with head or facial movements
95
What is important to rule out first before diagnosing sinusitis?
Dental pathology- caries, periodical infection, periodontal infection, recent extraction socket.
TMD
Neuralgia or atypical facial pain
96
What is the treatment for sinusitis?
Decongestants- ephedrine nasal drops 0.5%, one drop into each nostril 3 times a day for a maximum of 7 days.
Ensure patient knows that it can cause mucosal atrophy so do not use it for more than 7 days.
97
If antibiotics are required for sinusitis, what would you give?
Only indicated if symptomatic treatment is not effective/symptoms worsen and if symptoms point to bacterial sinusitis.
Amoxicillin 500mg, three times a day for 7 days.
or
Doxycycline 100mg, once a day for 7 days.
98
Trauma can cause sinusitis, what could this be from?
Sinus wall fractures
Orbital floor fractures
Root canal therapy
Implants/sinus lifts
Dental extractions
Deep perio pocketing
Nasogastric tubes
Mechanical intubation
99
What other conditions should be kept in mind when you suspect sinusitis?
Benign sinus lesions- polyps, papillomas, mucoceles.
Odontogenic cysts expanding into the maxillary sinus.
Malignant lesions
100
Which patients should you never stop their anticoagulant medication?
DVT within the last 3 months
Cardioversion
Prosthetic metal heart valves or coronary stents
