Extraction Complications 3

Question 1

Classify extraction complications by their timing of occurrence and provide one example of each.

Answer 1

1. Immediate/intra-operative/per-operative: Fractured root, displacement of tooth into anatomical spaces
2. Immediate post-operative/short-term: Hemorrhage within 48 hours, acute trismus
3. Long-term post-operative: Chronic oroantral fistula, permanent nerve damage, osteomyelitis

Question 2

Name at least 6 post-extraction complications.

Answer 2

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

Question 3

What are 5 less common post-operative complications mentioned in the lecture?

Answer 3

Osteomyelitis
Osteoradionecrosis (ORN)
Medication induced osteonecrosis (MRONJ)
Actinomycosis
Bacteraemia/Infective endocarditis

Question 4

Why is pain the most common complication after extraction, and what factors increase it?

Answer 4

Most common complication of extraction
Increased by rough handling of tissues
Contributing factors: laceration/tearing of soft tissues, leaving bone exposed, incomplete extraction of tooth

Question 5

What causes post-extraction swelling (oedema)?

Answer 5

Part of the inflammatory reaction to surgical interference
Increased by poor surgical technique (rough handling of soft tissue, pulling flaps, crushing tissues with instruments, tearing of periosteum)
Wide individual variation

Question 6

What causes ecchymosis (bruising) after extraction?

Answer 6

Increased by poor surgical technique (rough handling of soft tissue, pulling flaps, crushing tissues with instruments, tearing of periosteum)
Can be related to underlying medical issues
Exhibits individual variation

Question 7

What are the causes of trismus/limited mouth opening after extraction?

Answer 7

Related to surgery (oedema/muscle spasm)
Related to giving LA – IDB (medial pterygoid muscle spasm)
Haematoma – medial pterygoid or less likely masseter (haematoma/clot organizes and fibroses)
Damage to TMJ – oedema/joint effusion

Question 8

How should limited mouth opening be managed?

Answer 8

Monitor – may take several weeks to resolve
Gentle mouth opening exercises
Wooden spatulae
Trismus screw

Question 9

What is secondary bleeding, and when does it typically occur?

Answer 9

Often due to infection
Commonly occurs 3-7 days post-extraction
Usually mild ooze but can occasionally be a major bleed
Can be medication related

Question 9

What is reactionary/rebound bleeding and when does it occur?

Answer 9

Occurs within 48 hours of extraction
Vessels open up
Vasoconstricting effects of LA wear off
Sutures loose or lost
Patient traumatizes area with tongue/finger/food

Question 10

How should you manage soft tissue bleeding?

Answer 10

Pressure (mechanical – finger/biting on damp gauze swab)
Sutures
Local anaesthetic with adrenaline (vasoconstrictor)
Diathermy (cauterize/burn vessels to form proteinaceous plug)

Question 11

How should you manage bleeding from bone?

Answer 11

Pressure (via swab)
LA on a swab
Haemostatic agents
Blunt instrument
Bone wax
Pack & suture

Question 12

What haemostatic agents can be used for post-extraction bleeding?

Answer 12

Adrenaline containing LA – vasoconstrictor
Oxidized regenerated cellulose – Surgicel/equitamp (provides framework for clot formation)
Haemocollagen sponge – absorbable/meshwork for clot formation
Thrombin liquid and powder
Floseal

Question 13

What systemic haemostatic aids are available?

Answer 13

Vitamin K (necessary for formation of clotting factors)
Anti-fibrinolytics e.g., Tranexamic acid (prevents clot breakdown/stabilizes clot)
Missing blood clotting factors
Plasma or whole blood
Desmopressin

Question 14

What are the initial steps in managing post-operative bleeding?

Answer 14

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

Question 15

What are the next steps in managing post-operative bleeding once initial control is established?

Answer 15

Get inside mouth/good light & suction
Remove large jelly-like clot that often fills mouth
Identify where bleeding is coming from
Apply appropriate management techniques

Question 16

What techniques can be used to control post-operative bleeding?

Answer 16

Pressure – finger/biting on damp packs
Local anaesthetic with vasoconstrictor
Haemostatic aids (e.g., Surgicel, bone wax in socket)
Suture socket – interrupted/horizontal mattress sutures
Ligation of vessels/diathermy if available

Question 17

What should you do if you cannot control the bleeding?

Answer 17

Urgent hospital referral
Weekdays – Dental Hospital/Maxillofacial Outpatients
Evenings/weekends – Maxillofacial On-Call or local hospital A&E
Uncontrolled haemorrhage is life-threatening

Question 18

How can you prevent extraction haemorrhage?

Answer 18

Thorough medical history/anticipate and deal with potential problems
Atraumatic extraction/surgical technique
Obtain & check good haemostasis at end of surgery
Provide good instructions to the patient

Question 19

What post-extraction instructions should be given to prevent bleeding?

Answer 19

• Do not rinse out for several hours (better not to rinse till next day)
• 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 controlling bleeding (biting on damp gauze/tissue, applying pressure)
• Provide points of contact if bleeding continues

Question 20

What are the 3 types of sensory change in nerve damage?

Answer 20

Anaesthesia (numbness)
Paraesthesia (tingling)
Dysaesthesia (unpleasant sensation/pain)

Question 21

What are the possible variations in sensation with nerve damage?

Answer 21

• Hypoaesthesia (reduced sensation)
• Hyperaesthesia (increased/heightened sensation)

Question 22

What are the anatomical descriptions of nerve damage?

Answer 22

Neurapraxia – Contusion of nerve/continuity of epineural sheath and axons maintained
Axonotmesis – Continuity of axons disrupted but epineural sheath maintained
Neurotmesis – Complete loss of nerve continuity/nerve transected

Question 23

What are the characteristics of dry socket?

Answer 23

Normal clot disappears (appear to be looking at bare bone/empty socket)
Main feature – intense pain (described as worse than toothache/patient kept awake at night)
Often starts 3-4 days after extraction
Takes 7-14 days to resolve
Localised osteitis – inflammation affecting lamina dura

Question 24

What are the symptoms of dry socket?

Answer 24

Dull aching pain – moderate to severe Usually throbs/can radiate to patient's ear/often continuous 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

Question 25

What factors predispose to dry socket?

Answer 25

Molars more common – risk increases from anterior to posterior Mandible more common Smoking – reduced blood supply Female Oral Contraceptive Pill Local Anaesthetic – vasoconstrictor

Question 26

How should dry socket be managed?

Answer 26

Supportive – reassurance/systemic analgesia LA Irrigate socket with warm saline (wash out food and debris) Curettage/debridement (encourage bleeding/new clot formation) – controversial Antiseptic Pack (Alvogyl) Advise patient on analgesia and hot salty mouthwashes Review patient/change packs and dressings Remove packs as soon as pain resolves to allow healing Generally, do not prescribe antibiotics as it is not infection Check initially that it is a dry socket and no tooth fragments or bony sequestra remain

Question 27

What are the characteristics of sequestra?

Answer 27

Quite common Prevent healing Usually bits of dead bone (can see white spicules coming through gingivae) Can also be pieces of amalgam/tooth Delays healing Treatment: remove

Question 28

How common are infected sockets and how are they managed?

Answer 28

Infection is a rare complication after routine dental extraction Dry socket more common Occasionally see an infected socket with pus discharge Check for remaining tooth/root fragments/bony sequestra/foreign bodies Management: radiograph/explore/irrigate/remove any fragments/consider antibiotics Infection more commonly seen after minor surgical procedures with flaps and bone removal Infection delays healing