5-Management of Complications 2024

Preventing Complications

  • Review med history

    • “Never treat a stranger”

    • Look for gaps or inconsistencies

      • lots of followup questions/clarifications

  • Radiographs-current, accurate

  • Surgical site confimed/documented

    • diagnosis included

  • Informed consent explained, questions answered, THEN signed by patient/guardian

Medical History

  • Unknown medications

    • “I’m taking something but don’t know name or dosage.”

    • Update/confirm medical history/meds

      • EVERY VISIT

  • Has prescription, but are they taking it?

    • “Ran out but haven’t gotten refill”

  • Call MD office, pharmacy if questions

  • Medical consultation as needed

Radiographs

  • Current= within ONE YEAR

    • unchanged visually in mouth!

  • Properly mounted?→ can be imported backwards or on viewbox backward

  • scanned films may lack dates

Complications

  • Nerve injuries

  • Sinus Perforation

  • Alveolar osteitis

  • Bleeding

  • Infection

  • Nausea and vomiting

  • Soft tissue and adjacent osseous tissue injury

  • Temporomandibular joint injury

  • Pain and Swelling – to excess

  • Injuries to adjacent teeth

  • Displacement of tooth/foreign bodies

  • Mandible fracture- rare

    • ALL SHOULD BE IN THE INFORMED CONSENT!!!!!

Nausea and Vomiting Management

  • Pain meds?

  • Still bleeding?

    • New bleeding from vomiting?

  • Clear liquids

  • Anti-emetic

    • PO (oral?); Zofran ODT 4 mg

    • IM,IV, PR (rectal suppository)

Alveolar Osteitis- “Dry Socket”

  • Clinical presentation

    • Increasing pain, usually 3 to 5 days after surgery

    • Different quality/type of pain

    • Pain not relieved by previously effective meds

      • No relief of pain

      • Get partial relief for short period of time

    • Radiates to ear

    • Temporal headache same side

    • Whole side of jaw hurts

    • NO CLOT in socket

  • Differential Diagnosis

    • Postoperative pain

      • Difficult case, just surgical pain→ pain meds and time

    • Wound Dehiscence or Exposed Bone?

      • Anesthetize and re-suture?

    • Postoperative infection

    • MPD Syndrome (myofascial pain dysfunction)

    • Dental pain – Now the 2nd chief complaint hurts!

      • Other source, not related to surgery

  • Treatment

    • Anesthetize? (Maybe, but not always)

    • NS irrigation until clear return

    • Nu-Gauze; Gelfoam – carriers for medicament

      • Some carriers need to be removed, some don’t

      • Many commercial preparations

        • Eugenol – strong taste of cloves!, but effective; usual ingredient in any preparation

    • One dressing at a time

      • Large ext site →1 longer Nu-Gauze strip – best solution ; option→ 2 dressings…make OBVIOUS note of 2 dressings

    • Insure removal (gauze) → post op infection if not removed

    • Burning and stinging when socket first packed

      • Let patient know before packing

      • B&S goes away in about 20-30 min; so does pain

    • This lessens the pain but doesn’t go from 10/10 to 0/10, OTC meds generally work well after packing

    • Packing may need to be changed out every 2-3 days for continued relief – saliva dilutes it

    • Usually 7-10 days of healing before no packing needed –adequate tissue coverage

    • Don’t remove pack on start of week-end

Bleeding: Systemic Factors

  • Medical History

    • ASA, Anticoagulant, alcohol, chemotherapy

    • bleeding disorders

  • Blood Pressure

  • Intraoral Factors

    • Intra-operative – KNOW YOUR ANATOMY!!!

      • Soft tissue

        • Vessel – steady, pumping?

        • Muscle ooze

      • Bone

        • Nutrient canal

        • Cancellous bone

        • Chronic granulation tissue

        • IA neurovascular bundle

    • Post-operative

      • soft tissue

      • Bone

      • Liver clot-ineffective clotting

        • Oozing continues underneath- need to be removed

  • Control of Bleeding

    • Same modalities for intra-op and post-op:

      • Pressure

      • local hemostatic agents

      • ligation

      • Cautery

      • Suturing

  • Local Hemostasis

    • Gelfoam (Gelatin)

      • MOA: Helps stabilize clot formation (does not activate coagulation cascade or platelets)

      • Compressive forces- no

      • Gelfoam and suture

      • Gelfoam/topical thrombin/suture

    • Surgicel (Cellulose)

      • MOA: Helps stabilize clot formation (does not activate coagulation cascade or platelets)

      • Delays socket healing – use smallest amt that is effective

      • Compressive forces - yes

      • No topical thrombin

    • CollaPlug (Collagen) $

      • MOA: Activates platelet aggregation

    • Bone Wax

      • Salicylic acid and beeswax

      • MOA: Mechanical blockage of small bone channels

    • Topical Thrombin $ (Fibrin Formation)

    • Epinephrine

    • Sutures

    • Pressure

  • Bleeding: Anti-Fibrinolytic Agents

    • Systemic Medications

      • aminocaproic acid (Amicar)

      • tranexamic acid

    • In consultation with Hematologist

    • Von Willebrand, Some Hemophilias

  • Management of Post-operative Bleeding

    • If contacted by a patient experiencing prolonged bleeding, review the patient’s medical history and medications. Give the patient explicit instructions to gently remove any “liver clots” and bite down on gauze (OR TEA BAG) with continuous pressure for at least 30 minutes. If the patient complains of continued ACTIVE bleeding, they should be evaluated at the office.

    • At the office, you apply gauze over the extraction sites and have patient bite with pressure again.

    • If initial measures do not control the bleeding, surgical intervention is indicated.

    • The Magic of the Tea Bag

      • Tea contains “tannic acid” which helps coagulate the blood.

      • Wet the bag, wring it out, bite on it like a gauze pad

      • No “herbal” tea

    • Get all instruments/equipment out you may need while patient is biting on the gauze.

      • Full surgery tray, suction, irrigation, hemostatic agents, etc.

    • Inspect the surgical site

      • Good lighting and suction are essential.

    • If the use of local anesthetic is required, utilize one that does not contain a vasoconstrictor (this may give you temporary control, but may hinder your ability to determine the source of bleeding).

    • If sutures are present, they should be removed so the surgical site can be evaluated adequately.

    • Determine if the bleeding is coming from hard or soft tissues.

      • Soft tissue bleeding can often be controlled with direct pressure;

      • if the source of bleeding is granulation tissue, it should be removed

      • If source is vessel – clamp, suture, electrocautery (except – bleeding from IAN vessels)

    • Bleeding from bone

      • If the bleeding is from a pinpoint area the bone can be burnished, or bone wax is used

      • If the bleeding is more diffuse, a hemostatic adjunct should be packed into the socket and direct pressure applied.

Management of Displaced Teeth and Fragments

  • Submandibular space:

    • Thin lingual cortex, thinner to the posterior

    • If displacement occurs into the submandibular space, immediately place upward external pressure on the lingual cortex to prevent further displacement.

    • If possible, attempt to manipulate the root fragment back into the extraction site.

    • If retrieval attempt is unsuccessful, place patient on antibiotics and refer.

    • Antibiotics are considered mandatory because a fascial space has been violated by the tooth.

  • Mandibular Canal:

    • If displacement of root fragment into the mandibular canal is suspected, a periapical and occlusal radiograph should be obtained to verify position. Often the root fragment is not in the mandibular canal, but in a large marrow cavity.

    • Referral is indicated.

  • Infratemporal Fossa

    • Distoangular Maxillary 3rd molar most often

    • Prevention: After your flap is elevated and the tooth is visualized, a retractor should be placed posterior to the tooth to prevent displacement distally under the flap.

    • Do not attempt removal unless there is good access, light and visibility

    • Make only ONE attempt

      • Multiple attempts push tooth farther away

    • If unsuccessful, close, antibiotics, refer

    • Expect 4 - 6 week wait for fibrosis

    • Patient may elect to leave in place if asymptomatic

  • Sinus

    • Prevention

      • Avoid excessive apical force when using elevator or root tip pick

    • 2-3 mm without pathology or infection - consider leaving; inform patient; offer referral

    • Large fragment or whole tooth, small fragment with pathology or infection – remove

      • Don’t attempt to retrieve through the socket!

      • For removal of roots with pathology or larger roots, the Caldwell-Luc approach should be used.

Oroantral Communications

  • Sequelae include

    • Post-Op Sinusitis

    • Chronic Oroantral fistula

  • Management Depends on:

    • Size

    • Location (Apex vs Coronal portion)

  • PREVENTION IS KEY

    • Section Max Molars

    • Easy on the irrigation

    • Careful with apical pressure

  • Management

    • 2mm or less: no treatment necessary

    • 2-6 mm: gently place Gelfoam, suture, sinus cautions no sneezing, nose blowing, antibiotics, decongestants

    • 7 mm or larger: flap procedure (buccal) antibiotics, decongestants

Sinus Precaution

  • Don’t Blow Your Nose

  • If You Must Sneeze, LET IT FLY, Do Not Stifle It

  • No Sucking In or Blowing Out

    • No Straws, No Smoking, No Blowing Up Balloons, No Trumpet Practice

  • No Strenuous Workout or Heavy Lifting

    • We don’t want to get your blood pumping

  • Avoid Bending Over

    • sleep with an extra pillow- Head above heart

Fracture of Mandible

  • Rare, but almost always associated with removal of impacted third molars

    • Inform patient at pre-op, should be on consent form

  • Prevention: avoid excessive force, especially with elevators

    • expect the possibility in deeply impacted teeth, very thin mandible, or large area of pathology

  • Treatment:

    • Refer

Thermal Injury to lip/Cheek

  • Results from…

    • Heat from friction of rotating shank

      • Lip numb, patient doesn’t feel it

    • Handpiece overheating

    • Mostly important

      • inadequate retraction

      • not using bur guard

      • lack of attention to where handpiece is in mouth

  • 100% PREVENTABLE

    • ALWAYS use bur guard

    • Utilize good retraction

    • Handpiece should NEVER rest against soft tissue

    • Be aware of where the handpiece and bur are AT ALL TIMES when in use in the mouth

    • If handpiece is overheating, DO NOT USE – if handpiece feels hot in your hand, burn risk

Soft Tissue Injury

  • Management:

    • Frank discussion with the patient since these are usually minor complications

    • Bacitracin ointment

    • Clobetasol?

    • Vaseline?

Wrong Tooth

  • Prevention:

    • Confirm surgical site w/patient - “What are we doing today?” Get patient to tell you

    • Careful pre-op assessment, especially when requested by ortho; confirm w/referring DDS

    • Count teeth – check once, check twice, place forcep and check again;

    • Assistant is part of the team – encourage assistant questions

  • Treatment

    • If immediately recognized, rinse with saline and replace

    • If for ortho, consult with orthodontist, they may be able to alter the treatment plan

    • Do not extract contralateral tooth

  • Management

    • Inform patient, patient’s parent(s) if a minor, any other dentist involved in care.

    • Contact your liability carrier for guidance.

    • DO NOT TRY TO HIDE IT

TMJ Injury

  • Prevention: Bite block, support mandible

  • Treatment

    • if subluxated or dislocated - reduce

    • heat, rest, soft diet, NSAIDs

Injury to Adjacent Teeth

  • Fracture of the crown or existing restoration

    • Forcep placement

    • Elevator

  • TALK ABOUT IN PRE-OP CONSENT!!!

Edema

  • Prevention

    • Minimize surgical trauma – good surgical technique

    • Steroids/NSAIDs

    • Ice pack – first 24-36 hrs (change sides q20 min)

      • • Moist heat after 36 hrs

    • Elevate head- extra pillow

  • Treatment

    • Moist heat: 15-20 min, 3-4x/d, reassurance

    • Elevation – sleep with extra 1-2 pillows

    • Continue NSAIDs

Ecchymosis

  • Blood in tissues

  • Occurs with all surgeries

  • Some show more than others

  • May extend down neck – end at clavicles

  • Inform patient that color will change/fade and could take 1-2 weeks to resolve

Subcutaneous Emphysema

  • Prevention: avoid traditional high speed handpiece to perform surgery. Special rear exhaust should be used.

  • Careful when packing for impression and air blast to dry area.

  • Diagnosis: crackly sound like Rice Krispies

  • Treatment: time, antibiotics, reassurance

Trismus

  • Prevention

    • minimize surgical trauma, bite block, chin support

  • Treatment- must be aggressive

    • heat, soft diet, NSAID, opening exercises, muscle relaxant

    • If not responding:

      • tongue blade exercise

      • Physical Therapy referral

      • r/o infection, especially pterygomandibular space infection if no obvious swelling

Wound Dehiscence

  • Dehiscence Prevention:

    • Incisions over sound bone

    • Avoid suturing under tension

  • Management

    • Anesthetize and re-suture

      • Pain similar to “dry socket” – usually as result of apically positioned flap with exposed bone

    • Inform patient and instruct in irrigation, oral rinses-NS, Peridex if tissue can’t be repositioned and sutured; most frequently lingual dehiscence

      • Heal by secondary intention

      • follow-up appts to assess progress and reassure

Bony Sequestrum

  • Prevention:

    • Debridement of surgical

    • Palpate cortical plates

    • Not always preventable

  • Treatment: sequestrectomy

    • full thickness flap, debride, alveoplasty prn, NS irrigation

    • Resuture Flap

Specialist Referral?

  • Severe infection

  • Nerve injury – MONITOR???

  • Severe bleeding

  • Displaced root/tooth

  • O-A fistula

  • Mandible fracture

  • Significant soft tissue injury

  • IF YOU CAN’T DEAL WITH THE ISSUE, SEND TO SOMEONE WHO CAN

    • If the issue is highly likely pre-op:

      • REFER TO BEGIN WITH!!!

      • Listen to that conscience!