Post Extraction Complications

Question 1

What is Trismus?

Answer 1

Jaw stiffness/inability to open mouth fully

Question 2

What are the causes of Trismus?

Answer 2

Related to surgery (oedema/muscle spasm)
–patient opens mouth for long period of time, can result in spasm
Haematoma (medial pterygoid)
Damage to TMJ
–oedema/joint effusion (swelling of the cartilage of the joint from stretching)

Question 3

How do you alter the drug schedule of Apixaban or Dabigatran (DOACs) if the patient is taking them twice a day when performing an extraction?

Answer 3

Miss the morning dose
Take evening dose as scheduled

Question 4

How do you alter the drug schedule of Rivaroxaban or Edoxaban (DOACs) if the patient is taking one dose a day in the morning when performing an extraction?

Answer 4

Delay morning dose and take 4 hours after haemostasis has been achieved

Question 5

How do you alter the drug schedule of Rivaroxaban or Edoxaban (DOACs) if the patient is taking one dose a day in the evening when performing an extraction?

Answer 5

Do not alter the drug dose
Take at the usual time in the evening

Question 6

Before an extraction, what must you check if the patient is taking warfarin/phenindione/acenocoumarol (Vitamin K Antagonist)?

Answer 6

Check INR ideally no more than 24 hours before the procedure
If INR is below 4 treat without interrupting medication

Question 7

Name the 3 types of sensory change.

Answer 7

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

Question 8

What is hypoaesthesia?

Answer 8

Reduced sensation

Question 9

What is hyperaesthesia?

Answer 9

Increased/heightened sensation

Question 10

What are the 3 anatomical descriptions of nerve damage?

Answer 10

Neurapraxia
-contusion of nerve/continuity of epineural sheath and axons maintained
Axonotmesis
-continuity of axons but not epineural sheath disrupted
Neurotmesis
-complete loss of nerve continuity/nerve transected

Question 11

What is the anatomical name for dry socket?

Answer 11

Alveolar Osteitis

Question 12

Where is alveolar osteitis most likely to occur?

Answer 12

Mandible
More likely the further posterior the extraction is

Question 13

What happens during alveolar osteitis?

Answer 13

Normal blood clot disappears
Appear to be looking at bare bone/empty socket- partially or completely lost blood clot

Question 14

What are the symptoms of alveolar osteitis?

Answer 14

Dull aching pain- moderate to severe
Usually throbs/can radiate to patient’s ear
Continuous pain
Keeps patient awake at night
Exposed bone is sensitive and is the source of the pain
Characteristic smell/bad odour & patient frequently complains of bad taste

Question 15

Name 4 predisposing factors of alveolar osteitis.

Answer 15

Molars more common
Mandible more common
Smoking
Female
Oral contraceptive pill
Infection from tooth that has been XLA
Excessive trauma during extraction
Excessive mouth rinsing post extraction
Family history/previous dry socket

Question 16

What is the management of alveolar osteitis?

Answer 16

Reassurance/systemic analgesia
LA
Irrigate socket with warm saline
Curretage/debridement
–encourages bleeding/new clot formation
Antiseptic pack (alvogyl)

Question 17

What is alvogyl?

Answer 17

Brown fibrous paste that contains iodoform, butamben and eugenol which works as an antiseptic and relieves discomfort
Resorbable

Question 18

What is sequestrum?
Treatment?

Answer 18

Bits of dead bone in the socket site
Delays healing
Need to remove

Question 19

What is osteomyelitis?

Answer 19

Term means inflammation of the bone marrow
Clinically the term implies an infection of the bone

Question 20

How does Osteomyelitis occur?

Answer 20

Usually begins in the medullary cavity involving the cancellous bone
Then extends and spreads to the cortical bone
Then eventually the periosteum (overlying mucosa is red and tender)
Invasion of bacteria into the cancellous bone causes soft tissue inflammation (or necrosis of the tissue) and oedema in the closed bony marrow spaces
Compromised blood supply results in soft tissue necrosis and the involved area becomes ischaemic and necrotic

Question 21

What are the major predisposing factors for osteomyelitis?

Answer 21

Odontogenic infections
Fractures of the mandible
Immunocompromised patients

Question 22

Why is osteomyelitis more common in the mandible?

Answer 22

Primary blood supply is the inferior alveolar artery and dense overlying cortical bone limits penetration of periosteal blood vessels- so poorer blood supply and more likely to become ischaemic and infected

Question 23

What are the main bacteria involved in infection of the mandible?

Answer 23

Streptococci
Anaerobic cocci (peptostreptococcus)
Anaerobic gram negative rods such as fusobacterium and prevotella

Question 24

What is the treatment of osteomyelitis?

Answer 24

Need to swab to plan medication
Investigate patients host defences
Antibiotic treatment
–generally amoxicillin
–longer courses than normal required
Surgical treatment
–drain pus if possible
–remove any non-vital teeth in the area of infection
–remove any bony sequestra
–excision of necrotic bone

Question 25

What is osteoradionecrosis (ORN)?

Answer 25

Seen in patients who have received radiotherapy of the head and neck to treat cancer The bone within radiation beam becomes virtually non-vital Area has a reduced blood supply (endarteritis) Turnover of any remaining viable bone is slow Self-repair is ineffective

Question 26

How do you prevent ORN?

Answer 26

Scaling/chlorhexidine mouthwash leading up to extraction Careful extraction technique Antibiotics, chlorhexidine mouthwash and review Hyperbaric oxygen (to increase local tissue oxygenation & vascular ingrowth to hypoxic areas) before and after extraction

Question 27

How do you treat ORN?

Answer 27

Irrigation of necrotic debris Loose sequestra removed Hyperbaric oxygen Severe cases -resection of exposed bone, margin of unexposed bone and soft tissue closure

Question 28

What do bisphosphonates treat?

Answer 28

Osteoporosis Paget's Disease Malignant bone metastases

Question 29

What do bisphosphonates do?

Answer 29

Inhibit osteoclastic activity and so inhibit bone resorption and therefore bone renewal (no bone remodelling) Drugs remain in the body for years

Question 30

What drugs can cause MRONJ? Give 2 examples of each.

Answer 30

Bisphosphonates --Zolendronic acid --Alendronic acid RANK-L inhibitors --Denosumab --Xgeva Monoclonal antibodies --Bevacizumab --Sunitinib

Question 31

What duration of bisphosphonates increases risk of MRONJ?

Answer 31

5 years

Question 32

What is the management of MRONJ?

Answer 32

Prevent invasive treatments Reassure patients Manage symptoms with analgesics Antibiotic therapy Chlorhexidine mouthwash Debridement of the bone Hyperbaric oxygen Resection

Question 33

What is actinomyces?

Answer 33

Rare bacterial infection The bacteria have low virulence and must be innoculated into an area of injury and susceptibiliy It erodes through tissues rather than follows typical fascial planes and spaces Chronic

Question 34

What is the treatment for actinomyces?

Answer 34

Incision and drainage of pus accumulation Excision of chronic sinus tract Excision of necrotic bone & foreign bodies High dose antibiotics for initial control Long-term oral antibiotics to prevent recurrence

Question 35

What can be prescribed for a cover before extracting teeth in patients who are at an increased risk of infective endocarditis?

Answer 35

Amoxicillin 3g 60 mins before procedure Clindamycin 600mg (2 capsules) 60 mins before procedure Azithromycin 500mg (12.5ml) 60 mins before procedure

Question 36

What is thought to contribute to Infective Endocarditis after an extraction?

Answer 36

Bacteria in the bloodstream following extraction would circulate to the heart and colonise vegetations/scarring/artificial valves and lead to Infective Endocarditis