Complications of Exodontia

Complications of ExodontiaIntroductionPatients visit the alveolar clinic for a routine or planned visit for treatment, conditions related to the oral cavity or due to pain sensation. Even with the invention of advanced alveolar consonant techniques in restoration of teeth, extraction is unmatchable of the most routinely carried out dental procedure (El-Kenawy and Ahmed, 2015). Exodontia toilet be defined as Painless removal of the whole tooth or tooth grow with minimal impairment to the investing tissues, so the wound heals un-eventfully (Datarkar and Datarkar, 2007). Dental extraction procedures require a nifty understanding of anatomical structures along with adequate armamentarium and good technique. Successful treatment depends on good diagnosis, planning, appropriate surgical technique and well monitored post operative current. Even though it is a straight forward-moving procedure, on that point is a possibility of tortuositys during various stages of exodontia and th e surgeon should be able to cope with it (Louis, 2015).Complications atomic number 18 unforeseen events that tend to increase the morbidity, above what would be expected from a particular operative procedure under normal circumstances (Venkateshwar, et.al, 2011). They are rare and stack arise due to a full variety of factors. This report covers arrangementic and local complications forPre-operativePeri-operativePost-operativeDiscussionPre-operative complication and warinessPre-operative Systemic complicationsPre-operative evaluation of the patients in-depth history (medical, dental or social) past and puzzle and carnal examination is crucial (Thakur, et.al, 2014). The patient should be asked about their chief complaint and history of present illness describing onset, quality, intensity, duration, location, radiation, exacerbating or relieving factors, medications (prescribed or over the counter) existence taken including any allergies and the type of allergic response. A not e of patients family history might uncover inherited illnesses such as haemophilia. Patients social support system should also be noted along with habits such as alcohol/drug intake and tobacco use.A ROS should be completed and it might reveal undiagnosed medical conditions. Questionnaires are used for this purpose ( addition 1). The common medical conditions and their wariness are discussed belowCardiorespiratory Angina, myocardial infarction, hypertension and asthma are most common. Symptoms are crushing chest pain, dyspnoea, oedema and palpitations. Patients will have difficulty in going up more than 20 stairs, also there is cough and wheeze. Minor treatment set up be performed in shimmy of stable angina, but elective dental care deferred in unstable or recent angina. The risk of MI in higher(prenominal) within the first 6 months of prior MI and are classified as ASA class IV and high risk procedures deferred. Elective dental care can be normally performed safetyly in asympt omatic patients with more than 12 months MI. Premedication is administered to patients having BP value surrounded by 160-190/95-110 mmHg (oral or inhalation sedation). There is no proof of cardiac risk reducing even in case of delaying surgery in patients who have BP higher than 180/110 mmHg (Andersson et al, 2010).Bleeding disorders Questions should be asked about bleeding or bruising and family history. (Minimum platelet count for surgery 100,000 per micro litre). 5% tranexamic acid address wash given and patient on anticoagulants should have INR Endocrine disorders Diabetes (Morning appointment 1- 1.5 hrs later breakfast, this avoids hypoglycaemic reaction), hyperthyroidism, hypothyroidism.Epileptic seizures Type, frequency, precipitating factors.Allergies Including local anaesthetics, antibiotics, analgesics, dental materials.Use of anticoagulants INR of 2.0-3.5 is the safe range for performing simple exodontia procedures. The range is reduced to 1.6-1.9 for complicated proce dures.Bisphosphonates, Gastrointestinal disorders, Liver disorders and jaundice, Infections- HIV, hepatitis, syphilis or gonorrhoea, Pregnancy, Radiotherapy also need to be monitored as they could lead to complications. In all the above disorders the anxiety control protocol should be followed and pre-operative medications given if required. Physiological examination is also carried out to have dental or medical conditions along with the vital signs (Appendix 2). ASA classification for minimum pre-operative requirement is a protocol to be followed (Appendix 3).Pre-operative local complicationsPain It can be odontogenic or non-odontogenic. Patient should be asked questions as explained in HOPI (2.1.1). It is treated based on WHO classification (Appendix 4)Infection It can be a localised abscess or can spread into spaces (submandibular, sublingual or maxillary) adjoining the tooth causing severe complications as well as affect the use of anaesthetics during surgery. It is treated wit h the use of antibiotics (Yousuf, et.al, 2016).Peri-operative complications and their management2.2.1 Peri-operative Systemic complicationsThe following are the most commonly encountered conditions in dental practise (0.7 cases per dentist per year, Girdler, 1999). In the event of an attack, stay calm, stop dental treatment, appoint the environment safe, make patient sit upright in most cases, monitor vital signs, check for AVPU (Appendix 5) in conscious patient and follow ABCDE (Appendix 6) draw close in unconscious patients (Scully,2014). In non-responding patients always call 999 and initiate CPR (Appendix 7). Emergency drugs and equipment list (Resuscitation council UK, 2013 Joshi Acharya, 2016) (Appendix 8).Asthma Few activations of patients own salbutamol inhaler (100 mcg/actuation) or 10 activations using large volume spacer device, repeated every 10 mins and oxygen (15 litres/min).Anaphylaxis Give oxygen (15 litres/min), i.m adrenaline (anterolateral aspect of the middle third of vastus lateralis) in a process 0.5 mL injection of 11000, repeated at 5 minute gap after monitoring vital signs. Paediatric dose given (Appendix 9).Angina 2 GTN sprays (400 mcg/actuation) sublingually, oxygen (15 litres/min). Patient does not recover in 3 minutes treat for MI.MI Call 999 immediately, sublingual GTN if not already given, single dose aspirin (300mg) orally to be chewed, oxygen (15litres/min).Epileptic seizures Do not attempt to restrain movement, give oxygen (15litres/min), single dose of 10mg midazolam buccally.Hypoglycaemia Conscious patient give oral glucose, repeated in 10 minutes. Unconscious patient give glucagon i.m passage (1mg adults, 0.5mg childrenSyncope The patient should be laid flat immediately and legs elevated, give oxygen (15litres/min).Choking Allow patient to cough vigorously, remove any conspicuous foreign bodies, give 5 sharp back blows and if there is no dislodgement of the foreign system 5 abdominal thrusts are delivered (Heimlich ) (Appendix 10).2.2.2 Peri-operative Local complicationsThese can be prevented by proper treatment planning, use of good surgical knowledge and technique. Pre-operative X-rays will help the dentist to locate any abnormalities in apprisal to the tooth and position of anatomical structures. Patient past dental history and blood test reports checked (Appendix 11). The experience of the surgeon plays a very important determination in preventing these complications and effectively managing them.Soft tissue injuries Due to improper manoeuvring or slippage of instruments. Common areas injured are lips, cheeks, palate, floor of mouth, tongue.Management Good flap observance and luxation of tooth ensuring proper grip of instrument and soft tissue protection using thumb and forefinger of free hand. Small injuries need no treatment. In gigantic injuries bleeding needs to be controlled and wound sutured.Tooth root fracture Common event due to extensive caries, large restoration and endodonti cally treated tooth. Root extremity fractures are common in posterior multirooted teeth. These are caused due to improper luxation and use of excessive forces using forceps.Management If root fracture is noted, irrigate socket soundly and directly visualise root. If root tip (Crown fracture or luxation of adjacent tooth Crown fracture (extensive caries or large restoration) and luxation of adjacent tooth go past when large amount of force is applied to extract a tooth using the adjacent tooth as fulcrum.Management Avulsed tooth repositioned and stabilised using splints for atleast 3-4 weeks. If there is any pain after this period the tooth needs to be restored with root canal treatment.Haemorrhage Frequently occurs in most dental surgical procedures. It is mainly due to the trauma to the blood vessels or disorders of blood coagulation.Management Control bleeding and attempt to find the origin. Haemostasis obtained by Compression, Cellulose (Surgicel), Haemostatic Collagen (CollaP lug, CollaTape), Bone wax, 5% Tranexamic acid mouth wash, sutures and Electrocautery (Bagheri, et.al, 2016). upper jawFracture of maxillary tuberosity may create problem for denture retension and is because of extraction of the maxillary posterior teeth (bone weakened by maxillary sinus pneumatising into alveolar process), ankylosis of the tooth or decreased resistance of bone and poor technique (Von and Lozanoff,2017).Management If periosteum is not detached from the fractured segment, the bone is repositioned, tissue approximated, sutured and extraction rescheduled after 2 months. If bone segment completely reflected from tissues, tooth is first extracted, bone smoothened and wound sutured. Antibiotics with broad spectrum are prescribed.Displacement of tooth into maxillary sinus Occurs when trying to steal impacted maxillary third molar.Management Make the patient sit in upright position and take radiograph. If tooth is visible it can be out locating by forcing positive pressure through sinus by closing nostril and exhaling. If this fails tooth can be removed by trephination using Caldwell-Luc (Appendix 12) or Lindorf come (Boucree, et.al, 2015)Oroantral communication Due to extraction of maxillary posterior teeth. It is confirmed from bubbling of blood from post extraction site when patient tries to breathe out enchantment nostrils are pinched (Valslava test).Management small sized communication treated by filling alveolus with collagen and suturing using figure of 8 method. If tissues dont approximate, parting of bone is removed to facilitate buccal and palatal tissue approximation. Large communications are treated using pedicle mucoperiosteal flaps. Antibiotics prescribed if tooth was infected along with nasal decongestants.MandibleFracture of mandible associated with extraction of impacted third molars, due to excessive force applied by elevators or forceps, large pathological lesions.Management If there is any fracture while extraction, tooth remo val needs to be completed to prevent infection of the fracture line. Afterwards, case on case basis jaw segment stabilisation can be achieved by either intermaxillary fixation or rigid internal fixation for a period of upto 6 weeks. Administration of broad spectrum antibiotics is necessary.Dislocation of TMJ Due to lengthy procedure on patients with TMJ disorders. There is mandibular deviation in the direction of the healthy side in unilateral dislocation, but there is prognathic movement of the mandible in bilateral dislocation. There is also restriction in mandibular movement and patients exhibit open bite. To prevent such problems mandible must be firmly supported in exodontia procedures.Management Thumbs placed on occlusal surfaces of teeth, the body of the mandible on both sides are supported by the other fingers. Thumbs are used to exert a downward pressure and at the aforementioned(prenominal) time the other fingers are used to push the mandible upwards and posteriorly, unti l condyle moves in its original position.Post-operative complication managementPost operative Local complicationImmediate- haemorrhage (2.2.2 d)Delayed-Haemorrhage (2.2.2 d)Swelling and pain (2.1.2)Alveolar osteitis Noticed couple of days after extraction due to blood clot disintegration resulting in necrosis in bone surface of the socket (Tong, et.al, 2014).Management Gentle irrigation of the wound area with saline and application of medicated packing to the area, e.g. eugenol dressings, and aggressive use of oral analgesics (Akinbami and Godspower, 2014).Late- organization injury Inferior alveolar, mental, and lingual nerves. aspect trauma may cause sensory disturbances (anesthesia, hypesthesia, paresthesia, dysesthesia) resulting in resulting in burning sensation, tingling, biting of tongue and lips, abnormal chewing. Nerve damage can be due to neurapraxia, axonotmesis, and neurotmesis.Management Usually palliative, painful situations require analgesics also attempt is made to restore sensation using vitamin B complex. Often, the injured nerve segment needs to be replaced by using graft or suturing has to be performed on severed segments.Trismus Masticatory muscle spasm causes restriction in mouth opening, normally with third molar extraction.Management Heat therapy, muscle relaxant medication, administration of analgesics, anti-inflammatory and physiotherapy lasting few minutes every 4 hours.Osteonecrosis Can be due to MRONJ, 60% of patients had bone necrosis at extraction site. (Mansoor,2015 Heufelder,2014 ).Management Antibiotics prescribed to control infection. In advanced cases surgical removal of the necrotic bone is advised. Also microbial rinse along with daily irrigation can be done. Exposed bone can also be covered using a removable appliance.Post Operative systemic complications are mainly related to haemolytic and haemorrhagic diseases and can be managed by using methods previously.ConclusionExodontia is a simple procedure, practice of which i nevitably can lead to complications from time to time. The complications arising due to these procedures can start from a simple (dry socket) to the more complicated ones like everlasting nerve damage and displacement of tooth into maxillary sinus. There is a saying prevention is discover than cure which is always best applied when trying to prevent the occurrence of these complications (Oliver, 2014). The surgeon should always be sure of patients past and present medical and dental history, make appropriate pre-operative tests and x-rays and formulate a treatment plan that is best for the patient.AbbreviationsABCDE Airway, breathing, circulation, disability, exposureASA American Society of AnesthesiologistsAVPU Alert, voice, pain, unresponsiveCPR Cardiopulmonary resuscitationGTN Glyceryl trinitrateHOPI History of present illnessi.m IntramuscularINR internationalist normalised ratioMI Myocardial infarctionMRONJ Medication-related osteonecrosis of jawsROS Review of syst emsTMJ Temperomandibular jointWHO World health organisationReferencesAkinbami, B.O. and Godspower, T., 2014. Dry Socket incidence, clinical features, and predisposing factors. International journal of dentistry, 2014.Bagheri, S.C., Bohluli, B. and Meyer, R.A., 2016. Oral surgery complications. Avoiding and Treating Dental Complications Best Practices in Dentistry, p.103.Boucree II, T.S. and Garri, J.I., 2015. 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Scientifica, 2016.Appendix 1pocketdentistry.comAppendix 2pocketdentistry.comAppendix 3anesthesiallc.comAppendix 4img.medscape.comAppendix 5pocketdentistry.comAppendix 6pocketdentistry.comAppendix 7Appendix8resus.org.uAppendix 9allergy.orgAppendix 104.bp.blogspot.comAppendix 11cllhealed.files.wordpress.comAppendix 12image.slidesharecdn.com