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Oral Surgery > Post extraction complications -Immediate post-operative/short term post-operative > Flashcards

Post extraction complications -Immediate post-operative/short term post-operative Flashcards

1
Q

What post exctraction complications can occur

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

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2
Q

What is the most common complication of extraction, how does it occur and how do you manage it

A

Pain

Rough handling of tissues
-laceration / tearing of soft tissues
-leaving bone exposed
-incomplete extraction of tooth

Warn patient/advise or prescribe analgesia

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3
Q

What is caused by Part of the inflammatory reaction to surgical interference

A

Swelling (Odema)

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4
Q

What is Ecchymosis and how it is worsened

A

Brusing

Increased by poor surgical technique
e.g. rough handling of soft tissue / pulling flaps / crushing tissues with instrument, tearing of periostium

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5
Q

What is trismus and how does it occur

A

Jaw stiffness / inability to open mouth fully

Variety of causes:
- related to surgery (oedema / muscle spasm)
- related to giving LA – IDB (medial pterygoid muscle spasm)
- Haematoma, medial pterygoid or less likely masseter (haematoma/clot organises and fibroses)
- damage to TMJ, oedema/joint effusion

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6
Q

How do you manage trismus

A

Monitor it

Could take iboprofen

Gentle mouth opening exercises (trismus screw)

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7
Q

What happens in a immediate post op haemorrhage

A

reactionary / rebound bleeding

  • occurs within 48 hours of extraction
  • vessels open up / vasoconstricting effects of LA wear off / sutures loose or lost / patient traumatises area with tongue/finger/food
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8
Q

What is secondary bleeding

A
  • often due to infection
  • commonly 3-7 days
  • usually mild ooze but can occasionally be a major bleed
  • medication related
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9
Q

If there is a heamorrhage in soft tissue or bone what do you do

A

If 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)

If bone:
–Pressure (via swab)
–LA on a swab
–Haemostatic agents
–Blunt instrument
–Bone Wax
–Pack & Suture

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10
Q

What haemostatic agents can you use

A

Adrenaline containing LA – vasoconstrictor

Oxidised regenerated cellulose – Surgicel / equitamp
-Provides framework for clot formation

Haemocollagen Sponge –absorbable/meshwork for clot formation

Thrombin liquid and powder

Floseal

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11
Q

What does Oxidised regenerated cellulose do

A

provides framework for clot formation

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12
Q

What haemostatic agent must you be careful of and when

A

Oxidised regenerated cellulose

Careful in lower 8 region – acidic – damage to IDN

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13
Q

What systemic haemostatic aids are there

A

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

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14
Q

How do you manage post op bleding

A

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 apply suction remove clot

identify where bleeding from

Apply pressure- finger/biting on damp gauze

LA with vasoconctrictor

Haemostatic aids, bone wax in socket

Ligation of vessels if needed

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15
Q

If you cannot manage bleeding what do you do

A

Urgent hospital referral

weekdays- dental hospital/ maxillofacial outpatients

evnings/weekends- maxillofacial on call or A&E

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16
Q

How can you prevent post op haemorrhage

A

Thorough MH

Atraumatic extraction/ surgical technique

Obtain and check good haemostatis at end of surgery

provide good instructions to patient

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17
Q

What are the post op instructions

A

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

18
Q

Wha are the 3 types of sensory change and what type of sensation change could it be

A

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

The sensation change could be
-Hypoaesthesia (reduced sensation)
-Hyperaesthesia (increased/heightened sensation)

19
Q

What are the 3 types of nerve damage

A

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

20
Q

What is the clinical word for dry socket

A

Alveolar Osteitis

21
Q

What are the stats of dry sockets

A

Affects 2- 3% of all extractions

Some say up to 20-35% of lower 8s

22
Q

What causes dry socket

A

Normal clot disappears or breaks down (appear to be looking at bare bone/empty socket – partially or completely lost blood clot)

Localised Osteitis – inflammation affecting lamina dura

23
Q

What is the main feature of dry socket

A

Intense pain

24
Q

When does dry socket occur

A

3-4 days after extraction

25
Q

How long does dry socket take to resolve

A

7-14 days

26
Q

What are the symptoms of dry socket

A

Dull aching pain – moderate to severe

Usually throbs/can radiate to patient’s ear/often continuous and can keep patient awake at night

Characteristic smell/bad odour & patient frequently complains of bad taste

27
Q

What is the source of the pain in dry socket

A

The exposed bone is sensitive and is the source of the pain

28
Q

What are predisposing factors to dry socket

A

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

29
Q

What is the management of dry socket

A

Supportive – reassurance / systemic analgesia

LA

Irrigate socket with warm saline (wash out food and debris)

Curettage/debridement maybe (encourage bleeding/new clot formation)

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

30
Q

What is a sequestrum

A

Usually bits of dead bone (can see white spicules coming through gingivae)

Quite common

Prevent healing

Can remove it if prevents healing

31
Q

What are the signs of an infected sdocket

A

Pus discharge

32
Q

What do you do for a infected socket

A

check for remaining tooth/root fragments/bony sequestra/foreign bodies.

Treatment
-radiograph/explore/irrigate/remove any of the above/consider antibiotics

Infection more commonly seen after minor surgical procedures involving soft tissue flaps and bone removal

33
Q

What dental procedures are unlikely to cause bleeding

A

LA by infiltration/ intraligamentry/ mental nerve block/ IDB

BPE

SupG. removal of plaque, calculus and stain

Direct or indirect restorations with supG margins

Impresssions

Fitting and adjustmetns of ortho appliances

Endodontics orthograde

34
Q

What dental procedures are low risk to cause bleeding

A

Simple extractions, 1-3 teeth with restricted wound size

Incision and drainage of intra-oral swellings

Detailed 6 ppc

RSD

Direct or indirect restorations with SubG margins

35
Q

What dental procedures are higher risk to cause bleeding

A

Complex extractions, adjacent extractions that will cause a large wound or more than 3 extractions at once

Flap raising procedures
-elective surgical procedurs
-perio surgery
-preprosthetic surgery
-periradicular surgery
-crown lengthening
-Implants

Gingival recountouring

Biopsy

36
Q

If a a patient takes a Vitamin K antagonist (eg warafin) what do you do

A

Check INR within 24hrs of procedure

If below 4= treat without interupting

If above 4= postpone

37
Q

If a patient takes antiplatelet drugs what do you do

A

If aspirin alone- treat without interupting medication, use local haemostatic measures

If Clopidogrel, dipyridamole, prasugrel or ticagrelor or dual therapy( (combo with aspirin)- Treat without interupting medication but expect prolonged bleeding, dont take >3 teeth and use haemoststic measures

38
Q

If patient takes DOACS what do you do

A

Low bleeding risk procedure- treat without interupting medication but treat early in day

Higher bleeding risk procedure- advise patient to miss or delay morning dose (advise patient when to restart medication)

39
Q

If patient takes Apixaban or dabigatran whats the usual drug schedule, morning dose (pretreatment), post treatment dose

A

twice a day

miss moring dose

usual time in evning

40
Q

If patient takes Rivaroxaban whats the usual drug schedule, morning dose (pretreatment), post treatment dose

A

once a day morning

delay morning dose

4 hours after haemostatis has been achieved

41
Q

If patient takes Edoxaban whats the usual drug schedule, morning dose (pretreatment), post treatment dose

A

Once a day evening

not appicable

usual time in evening

Oral Surgery (5 decks)

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