post extraction complications Flashcards

Question

what are post-extraction instructions

Answer 1

- don't rinse out for several hours = preferably not till next day - avoid trauma = hot food, tongue, ifngers - avoid excessive physical exercise and alcohol = increase bp - advice on bleeding control = biting on gauze with pressure for 30 mins - give point of contact if bleeding doesnt stop

Answer 2

* Nerve damage an be temporary or permanent | * Improvement can occur up to 18-24 months after incident

Answer 3

* Anaesthesia – numbness * Paraesthesia – tingling * Dysesthesia – unpleasant sensation/pain * Hypoesthesia – reduced sensation * Hyperaesthesia – increased/heightened sensation

Answer 4

• 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

Answer 5

* Alveolar/localised osteitis * Common * Affects 2-3% of all extractions * Some say up to 20-35% of lower 8’s

Answer 6

• Normal clot disappears • Appear to be looking at bare bone/empty socket – partially or completely lost blood clot • Some say normal clot forms and disappears ◦ Breaks down or has been washed out from vigorous cleaning • Some say normal clot never formed in the 1st place

Answer 7

* Intense pain | * Described as worse than toothache/patient kept awake at night

Answer 8

• There is no swelling or pus • Often starts 3-4 days after extraction ◦ If pain is immediately there after LA wore off need to check that there isn’t still part of tooth there or something else is wrong as it is not a dry socket • Takes 7-14 days to resolve ◦ If a true dry socket • Localised osteitis ◦ Inflammation affecting lamina dura

Answer 9

* Dull aching pain – moderate to severe * Usually throbs/can radiate to patient’s ear/often continuous and ca keep patient awake at night * The exposed bone is sensitive and is the source of the pain * Characteristic smell/bad odour and patient frequently complains of bad taste

Answer 10

``` • Molar more common – risk increase from anterior to posterior • Mandible more common ◦ Could be because there is only a single blood supply to mandible compared to maxilla which has multiple • Smoking – reduced blood supply • Female ◦ Hormones might have a role to play • Oral contraceptive pull • LA with a vasoconstrictor • Less common things: ◦ Could be infection from tooth • Haematogenous bacteria in socket ◦ Excessive trauma during extraction ◦ Crushed a lot of bone ◦ Excessive mouth rinsing post extraction ◦ Clot washed away ◦ Family history/previous dry socket ```

Answer 11

* Supportive – reassurance/systemic analgesia * LA block * Irrigate socket with warm saline * Curettage/debridement * Antiseptic pack * Advise patient on analgesia and hot salty mouthwashes * Review patient/change packs and dressings

Answer 12

* Wash out food and debris * Being warm isn’t so important once patient numbed up * Teach patient how to wash out socket themselves * Be gentle doing it * 2-4 times a day * Don’t go too far into socket to disturb healing tissue

Answer 13

* Encourage bleeding/ne clot formation * Some suggest this should not be carried out as it produces more bare bone and removed any remaining clot * Rarely done * Get a small curette and scrape the pocket and the bone and clean it all out and debride the socket * Get rid of material not working and let healing process begin again * Some say not to do it as just takes away bone again and process has to start all over again but other say it is good

Answer 14

``` BIP or Avlogyl • BIP ◦ Iodine based and is packed into socket ◦ Not dissolving and need to change them ◦ Suture over it and then see patient a few days later to remove it an change it ◦ Bismuth subnitrate and iodoform pack ◦ Comes as a paste or impregnated gauze ◦ Antiseptic and astringent • Alvogyl ◦ Little strands ◦ Take out with tweezers and don’t need to suture it and don’t need to remove it as it will dissolve away ◦ Mixture of LA and antiseptic ``` soothe pain/prevent food packing

Answer 15

- can get into bloodstream, and cause anaphylaxis

Answer 16

* Quite common * Not as common as dry socket * 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, need to remove

Answer 17

- radiographs - explore - consider AB's - remove any bone fragments, bony sequestra, foreign bodies

Answer 18

- no | - more common after minor oral surgical procedure

Answer 19

- acute = OAC | - chronic = OAF

Answer 20

* Make a communication from the oral cavity into the maxillary sinus at the time of extraction * If it doesn’t heal up, epithelium grows into that space and forms and epithelial lined tube/tract from the mouth to the maxillary sinus and that is an OAF

Answer 21

• Size of tooth ◦ If roots are huge could think that a communication may form ◦ Affect any tooth from the 3 backwards • Radiographic position of roots in relation to antrum • Bone at trifurcation of roots • Bubbling of blood as patient breathes • Nose holding test – careful as can create an OAF • Direct vision • Good light and suction – echo • Blunt probe – take care not to create an OAF

Answer 22

• Encourage clot • Suture margins • Antibiotics ◦ Risk of infection as all oral bugs have gone into sinus • Post-op instructions • Don’t have to close socket over completely if small – let it heal • Take up to two wees for it to heal • Majority of communications heal up really well

Answer 23

• Close with buccal advancement flap ◦ Full thickness flap of gingivae back and then release underlying periosteal tissue (whitest/grey material, fibrous) with a scalpel and release it ◦ Sometimes have to try a few different areas to get it to released so that you can close the area without tension as if it is closed with tension the OAF will reform • Antibiotics and nose blowing instructions ◦ Don’t blow nose ◦ Can use steaming method to clear sinuses • Monitor patient • Don’t remove stitches before 10 days ◦ Use absorbable or non-absorbable • If get really bad swelling or sinusitis, then need to come back as could have and infection and need referral

Answer 24

• Excise sinus tract ◦ Cut out tube of epithelium so it doesn’t reform when we close the area up • Buccal advancement flap • Buccal fat pad with buccal advancement flap ◦ Up in cheek there is buccal fat pad ◦ Take a little incision into buccal sulcus to release buccal fat pad ◦ Pull fat pad over and stitch it to palatal mucosa then pull buccal mucosa with buccal advancement flap and then stitch that to the mucosa ◦ Help close an area that is not closing • Palatal flap ◦ Cut a finger-like projection of tissue from palate and cut if down and rotate the palate and stitch it to the buccal mucosa • Bone graft/collagen membrane • Tongue flap – historical/no longer used

Answer 25

• Cut a mucoperiosteal flap ◦ 3-sided flap with 2 vertical relieving incisions ◦ Bring flap of tissue over socket • Get tweezers and curette and scrape out all the granulation tissue • Need to irrigate with warm saline

Answer 26

- because although LA has been used around OAF, maxillary sinus is not numb

Answer 27

- radiographically by OPT, occlusal or periapical

Answer 28

``` • OAF type approach/through the socket: ◦ Flap design ◦ Open fenestration with care ◦ Suction – efficient and narrow bore ◦ Small curettes ◦ Irrigation or ribbon gauze ◦ Feed ribbon gauze into sinus and pull back out ◦ Close as for OAC • Caldwell-Luc approach ◦ Buccal sulcus ◦ Lift a flap of gum up and cut rectangular window above alveolus area ◦ Buccal window • ENT – endoscopic approach • If there is only a tiny bit of root and it is not causing bother, some patients’ opt to leave it in there and just monitor it ```

Answer 29

* The term means inflammation of the bone marrow * Clinically the term implies an infection of the bone * Rare * Usually, mandible * Site of extraction often very tender * In deep seated infection may see altered sensation due to pressure on IAN

Answer 30

- medullary cavity involving cancellous bone | - then extends and spreads to cortical bone

Answer 31

* Invasion of bacteria into cancellous bone causes soft tissue inflammation and oedema in the closed bony marrow spaces * Oedema in an enclosed space leads to increased tissue hydrostatic pressure * Compromised blood supply results in soft tissue necrosis * Involved area becomes ischaemic and necrotic * Bacteria proliferate because normal blood borne defences do not reach the tissue * The osteomyelitis spread until arrested by antibiotic and surgical therapy

Answer 32

- maxilla has several arterial supplies where as mandible only has 1 so it is more likely to become ischamic and necrotic

Answer 33

- odontogenic infections and fracture of mandible

Answer 34

- those with compromised host defence - diabetes/alcoholism/IV drug use/malnutrition/myeloproliferative disease - Leukaemia’s, sickle cell disease, chemotherapy treated cancer

Answer 35

* Early osteomyelitis can be difficult to distinguish from dry socket or localised infection in the socket * Acute suppurative osteomyelitis shows little/no radiographic change * At least 10-12 days required for lost bone to be detectable radiographically

Answer 36

• Increased radiolucency • Can be uniform or patchy with a ‘moth-eaten’ appearance • Areas of radiolucency may occur within the radiolucent region ◦ Unresorbed islands of bone = called sequestra

Answer 37

• In long-standing chronic osteomyelitis there may be an increase in radiodensity surrounding the radiolucent area

Answer 38

- different in different areas of the body - in mandible = Streptococci, anaerobic cocci such as peptostreptococcus spp, anaerobic gram negative rods such as Fusobacterium and Prevotella - in other bones = staphylococci

Answer 39

* Medical and surgical treatment * Investigate host defences – blood investigations/glucose * Seek medical consultation * Antibiotic treatment * We will mainly refer these patients rather than treat them

Answer 40

* Clindamycin/penicillins * Effective against odontogenic infections and good bone penetration * Longer courses than normal * Often 6 weeks in acute osteomyelitis (some suggest at least 6 weeks after resolution of symptoms) * In chronic osteomyelitis – can need them up to 6 months after * Severe acute osteomyelitis may require hospital admission and IV antibiotics (if systemic symptoms)

Answer 41

* Drain pus if possible * Remove any non-vital teeth in the area of infection * Remove any loose pieces of bone * Remove any sources of infection * In fractured mandible – remove any wires/plates/screws in the area * Corticotomy – removal of bony cortex * Remove outer bone * Perforation of bony cortex * Excision of necrotic bone – until reach actively bleeding bone tissue * Some of these patients may need reconstructive surgery at some point

Answer 42

* Seen in patients who have received radiotherapy in the head and neck to treat cancer * The bony within radiation beam becomes virtually non-vital * Turnover of any remaining viable bone is slow * Self-repair ineffective * Worse with time * Mandible most commonly affected  poorer blood supply

Answer 43

- reduced blood supply | - common in mandible due to only being on one blood supply

Answer 44

- cutting down of bone to allow gum to close over completely

Answer 45

* Scaling/chlorohexidine mouthwash leading up to extraction * Careful extraction technique * Antibiotics, chlorohexidine mouthwash and review * Hyperbaric oxygen (to increase local tissue oxygenation and vascular ingrowth to hypoxic areas) before and after extraction * Going into chambers like divers do if they have the bends * Take advice/refer patient for extraction * May wish to give AB’s after but they don’t tend to penetrate well into bone

Answer 46

• Irrigation of necrotic debris • Antibiotics not overly helpful unless secondary infection • Loose sequestra removed • Small wounds (under 1cm) usually heal over a course of weeks/months • Severe cases – resection of exposed bone, margin of unexposed bone and soft tissue closure ○ May need surgical intervention • Hyperbaric oxygen

Answer 47

- BRONJ | - bisphosphonate related osteonecrosis of the jaw

Answer 48

* Bisphosphonates are a class of drugs used to treat osteoporosis, Paget’s disease and malignant bone metastases * They inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal * The drugs may remain in the body for years

Answer 49

- post extraction/following denture trauma/ spontaneous

Answer 50

- length of time patient on drug - diabetes - steroids - anticancer chemotherapy - smoking

Answer 51

- could decorate the tooth rather than extract | - seal over roots

Answer 52

* Not very successful * Manage symptoms/remove sharp edges of bone/chlorohexidine mouthwash/antibiotics if suppuration * Debridement/major surgical sequestrectomy/resection/hyperbaric oxygen have not proved that successful * Not routine AB’s – only when there is pus * Every time we intervene we are at risk of making it worse or better * Patient needs to know that * Sometimes need major surgery

Answer 53

- alendronate - clodronate - etidtronate - ibandronate - pamidronate - risedronate - tiludronate - zoledronate

Answer 54

- any biological agent, immune modulator, antiresorption, antiangiogenic medication

Answer 55

- cancer patients on anti-resorptive and anti-angiogenic drugs = 1.6-14.8% - osteoporosis patients treated with anti-resorptive drugs = 0.1-0.5%

Answer 56

- bisphosphonates - RNAKL inhibitor - anti-angiogenic

Answer 57

- dental treatments = extractions, perio - duration of drug therapy - dental implants - other concurrent medications - previous drug history - drug holidays = we should not take responsibility for stopping a patient's drug

Answer 58

* Rare bacterial infection * Actinomycosis israelii/A. naeslundii/A. viscosus * The bacteria have low virulence and must be inoculated into an area of injury or susceptibility * It erodes through tissues rather than follow typical fascial planes and spaces * Fairly chronic * Multiple skin sinuses and swelling

Answer 59

• Incision and drainage of pus accumulation • Excision of chronic sinus tracts • Excision of necrotic bone and foreign bodies • High dose antibiotics for initial control (often IV) • Long-term oral AB’s to prevent recurrence • AB’s  penicillin, doxycycline or clindamycin ◦ Weeks or months of it

Answer 60

* Inflammation of the endocardium, particularly affected heart valves or CMP caused by bacteria * Rare – 10:100,000 per annum * Significant mortality  20%

Answer 61

in 2016 NICE changed the guidelines again and added in one word • “Antibiotic prophylaxis against IE is not recommended routinely for those undergoing dental procedures” • They defined group at risk as • Acquired valvular heart disease • Previous IE • Structural congenital heart defect • Valve replacement

Answer 62

- amoxicillin is first choice ◦ 3g oral sachet 60 minutes before procedures - clindamycin if allergic to penicillin ◦600 mg (2 capsules) 60 minutes before procedure - if unable to swallow give azithromycin oral suspicions ◦500mg (12.5ml) 60 minutes before procedure

post extraction complications Flashcards

(88 cards)