Contents

Introduction

Exodontia

Pre operative complication

o Syncope

o Failure to secure anesthesia

o Adverse drug reaction

Intra operative complication

o Fracture of

Crown of tooth being extracted

Roots of tooth being extracted

Alveolar bone

Maxillary tuberosity

Adjacent or opposing tooth

Mandible

o Dislocation of

Adjacent tooth

TMJ

o Displacement of a root

Into the soft tissue

Into the maxillary antrum

Under general anesthesia in the dental chair

Post operative complications

o Excessive haemorrhage

o Post operative pain due to

Dry socket

Acute osteomyelitis of the mandible

Tramatic arthritis of TMJ

o Post operative swelling due to

Odema

Haematoma formation

Trismus

Respiratory arrest

Cardiac arrest

Oro-antal communication

Post Operative instruction

Conclusion

References

Introduction

Extraction of a tooth has been considered a very formidable procedure by the layman,

and it is perhaps because of the horrifying experiences associated with tooth

extractions in the past that even today the removal of a tooth is avoided by the patient

almost more than any surgical procedure.

Dentist often considered tooth extraction a minor and unimportant operation and,

without proper training, attempt difficult cases, hoping that all will go well and then

depend on a specialist to help if complication are encountered or serious infection

begin. Before undertaking the extraction of tooth, one should thoroughly evaluate the

problem involved. The type of anesthesia to be used also should be carefully

considered, and a good radiograph should be taken to help in the recognition of

abnormalities that may make extraction difficult. In this way, hasty use of forceps can

be avoided, and the procedure can be selected that is most likely to yield the best

results.

Haste is the principle cause of all the complications which occur during the extraction

procedure.

Exodontia

Definition:- An ideal tooth extraction is defined as "the painless removal of the whole

teeth, or tooth root, with minimal trauma to the investing tissues, so that the wound

heals uneventfully and no postoperative prosthetic problem is created."

Geoffrey L.Howe

Indications

Teeth affected by advanced dental caries and its sequalea.

Teeth affected by the periodontal diseases.

Over retained deciduous teeth.

Extraction of healthy teeth to correct malocclusion.

Extraction of teeth for esthetic reasons.

Extraction of teeth for prosthodontic reasons.

Unrestorable tooth.

Impacted and supernumerary teeth

Extraction of decayed first or second molars to prevent the impaction of third

molar.

Teeth involved in the fracture line.

Teeth involved in tumors or cyst.

Teeth as foci of infection.

Before radiation therapy in cancer patient.

Traumatic avulsion or intrusion due to fracture of the alveolar bone.

Teeth not treatable by apeoctomy.

Teeth with non vital pulps.

Contraindication

Local

Teeth that are located within an area of tumor.

History of therapeutic radiation for cancer. Extractions performed in an area of

radiation may result in osteoradionecrosis.

Patients who have severe pericoronitis around an impacted mandibular third

molar.

In acute dento alveolar abscess.

Teeth adjacent to the site of jaw fracture.

Patient with limited mouth opening.

Presence of acute infections such as necrotizing ulcerative gingivitis (vincent's

infection) or herpetic gingivostomatitis.

Systemic

Severe uncontrolled metabolic situation such as uncontrolled diabetes,

hyperthyrodism, osteoporosis, end stage of renal disease with uncontrolled

uraemia.

Malignant disease such as leukaemia, lymphoma etc.

Cardiac diseases such as myocardial infection or stroke in the past 6 months.

Pregnancy.

Blood dyscrasias such as hemophillia, platelet disorders etc.

Patients on steroids.

Rheumatic fever in childhood is often forgotten by the patient, extraction could

affect the heart.

Complication

Definition

Complication is define as unanticipated problem that arises following, and is a result

of a procedure, treatment or illness. A complication is named so because it

complicates the situation.

Classification of complication

Complications can be classified into 4 groups:

i) Pre operative

ii) Operative

iii) Post Operative

iv) Persistant

i) Pre operative : Pre operative complications are the problems that may be

encountered before treatment.

It can be :- a) local b) systemic

ii) Operative : are the problems that may occur during treatment. It can be local

or systemic.

iii) Post operative : are the problems that may occur after treatment. It can be

local or systemic.

iv) Persistent : A problem that may persist way long after treatment.

Pre Operative Complication Syncope

Definition

It is the medical term for fainting. It refers to generalized weakness of muscles, loss

of postural tone, inability to maintain erect posture and loss of consciousness, while

faintness implies only lack of strength and sense of impending loss of consciousness.

Causes

I. Decreased Cerebral Perfusion

a) Inadequate Vasoconstrictive Mechanism

Vasovagal

Postural hypotension

Carotid sinus syncope

Antihypertensive drugs

b) Hypovolaemia

Haemorrhage (blood loss)

Addison's disease

c) Reduction of venous return

Cough

Micturation

Mediastinal compression

Straining at stool evacuation

d) Reduced cardiac output

Aortic stenosis or hypertrophic subaortic stenosis

Myocardial infarction

Cardiac temponade due to pericardial effusion

Pulmonary embolism

e) Arrhythmias

AV blocks

Ventricular asystole

Ventricular tachycardia and fibrillation

Supraventricular tachycardia

f) Cerebrovascular disturbance

Transitory ischaemic attack

Hypertension

Vertebrobasitar in sufficiency

II. Non Circulation Causes

Hypoxia

Anaemia

Prolonged bed rest

Anxiety neurosis

Clinical Features

Dizzyness, weak and nauseated, cold, pale and sweating skin.

Investigation

Measurement of serum electrolytes, glucose and haematocrit

Blood and urine toxological screens.

ECG, halter monitoring

Electrophysiological cardiac testing

Upright till table testing

Others depending on the cause eg. MRI, Doppler.

Treatment

The patient should be treated immediately with the first aid.

The head should be lowered by lowering the back of the dental chair.

With some designs of chair the use of this method may entail considered delay

and in these circumstances the patient's head should be put between his knees

after insuring that his collar has been loosened.

Care should be taken to maintain the airway and to insure that the patient cannot

fall out of the chair.

No fluids should be given by mouth until the patient is fully conscious.

When consciousness returns a glucose drink may be given if the patient has

missed a meal & is being treated under local anasthesia.

Alternatively, spr Ammon. Aromat BPC (sal volatile) 3.6 ml (I drachm) in

atleast one third of a tumbler ful of water may be administered.

If the circumstances permit, the blood pressure should be recorded at intervals

and an intravenous injection of 250mg of aminophylline injection 80 may be

given slowly.

Failure of Secure Anasthesia : is usually due to faulty technique or insufficient

dosage of the anasthetic agent. It is possible to extract teeth well unless both the

operator & the patient have complete confidence in the anasthesia under which the

operation is performed. When LA is employed its efficacy should be tested before the

extraction is started. After explaining to the patient that although he may feel

pressure he should not feel any sensation of sharpness, a blunt probe is pushed firmly

into the gingival crevice on the buccal and lingual surfaces of the tooth to be

extracted. If nothing is felt by the patient anaesthesia has been secured. If he feels

pressure but not pain, analgesia has been obtained, but pain indicate that a further

infection of local anaesthetic solution is required.

If a tooth fails to yield to the application of resonable force applied with either forceps

or an elevator the instrument should be put down and the cause of the difficulty

sought. In most cases the tooth will be better removed by dissection.

Intra Operative Complication

Fracture of the crown of a tooth during extraction may be unavoidable if the tooth

is weakened either by caries or a large restoration. However, it is often caused by the

improper application of the forceps to the tooth, the blades being either applied to the

crown instead of the root or root mass or with their long axis across that of the tooth.

If the operator chooses a pair of forceps with blades which are too broad and given

only 'one point contact' the tooth may collapse when gripped. If the forceps handles

are not held firmly together the blade may slip off the root and fracture the crown of

the tooth. Hurry is usually the underlying cause of all these errors of technique,

which are avoidable if the operator works methodically. The exhibition of excessive

force in an effort to overcome resistance is unwarrantable and may cause a fracture of

the crown.

When coronal fracture occurs the method used to remove the retained portion of the

tooth will be governed by the amount of tooth remaining and the cause of the mishap.

Sometimes a further application of the forceps or elevator will deliver the tooth, and

on other occasions the trans alveolar method should be used.

Fracture of the alveolar bone is a common complication of tooth extraction &

examination of extracted teeth reveals alveolar fragments adhering to a number of

them. This may be due to the accidental inclusion of alveolar bone within the forceps

blades or to the configuration of roots, the shape of the alveolus, or to pathological

change in the bone itself. The extraction of canines is frequently complicated by

fracture of the labial plate, especially if the alveolar bone has been weakened by

extraction of the lateral incisor and/or the first premolar prior to the removal of the

canine. If these three teeth are to be extracted at one visit, the incidence of fracture of

the labial plate will be reduced if the canine is removed first.

Fracture of the maxillary tuberosity: Occasionally during the extraction of an upper

molar, the supporting bone & maxillary tuberosity are felt to move with the tooth.

This accident is usually due to the invasion of the tuberosity by the antrum, which is

common when as isolated maxillary molar is present, especially if the tooth is

overerrupted. When fracture occurs the forceps should be discarded and a large

buccal mucoperiosteal flap raised. The fractured tuberosity and the tooth should be

freed from the palatal soft tissue by blunt dissection and lifted from the wound. The

soft tissue flaps are then apposed with mattress sutures which evert the edges and are

left in situ for at least 10 days.

Fracture of an adjacent or opposing tooth during extraction can be avoided.

Careful preoperative examination with reveal whether a tooth adjacent to that to be

extracted is either carious, heavily restored, or in the line of withdrawal. If the tooth

to be extracted is an abutment tooth, the bridge should be divided with a vulcarbo or

diamond disk before extraction caries and loose or overhanging fillings should be

removed from an adjacent tooth and a temporary dressing inserted before the

extraction. No force should be applied to any adjacent tooth during an extraction, and

other tooth should not be used as a fulcurum for an elevator unless they are to be

extracted at the same visit. Opposing teeth may be either chipped or fractured if the

tooth being extracted yields suddenly to uncontrolled force and the forceps strike

them. Careful controlled extraction technique prevents this accident.

Fracture of the mandible may complicate tooth extraction if excessive or incorrectly

applied force is used, or pathological change have weakened the jaw. Excessive force

should never be used to extract teeth. The mandible may be weakened by senile

osteoporosis and atrophy, osteomyelitis, previous therapeutic irradiation, or such

osteodystrophies as osteitis deformans, fibrous dysplasia or fragilities ossium.

Unerupted teeth, cysts hyperparathyroidism, or tumors may also predispose to

fraction. In the presence of one of these conditions, extraction should be attempted

only after careful clinical & radiographic assessment & the construction of splints

preoperatively. The patient should be informed before operation of the possibility of

mandibular fracture and should this complication occur treatment must be instituted at

once. If a fracture occurs in the dental surgery extra oral support should be applied

and the patient referred immediately to a hospital where facilities for treatment exist.

Dislocation of an adjacent tooth during extraction is an avoidable accident. The

causes are similar to those giving rise to a fracture of an adjacent tooth. Even during

the correct use of an elevator some pressure is transmitted to the adjacent tooth

through the interdental septum. For this reason an elevator should not be applied to

the mesial surface of a first permanent molar, because the smaller second premolar

may be dislodged from its socket. During elevation a finger should be placed upon

the adjacent tooth to support it and enable any force transmitted to it to be detected.

Dislocation of the temporomandibular joint occurs readily in some patients and a

history of recurrent dislocation should never be disregarded. This complication of

mandibular extractions can usually be prevented if the lower jaw is supported during

extraction. The support given to the jaw by the left hand of the operator should be

supplemented. It may also be caused by the injudicious use of gags. If dislocation

occurs it should be reduced immediately.

The operator stands in front of the patient and placed his thumbs intra orally on the

external oblique ridge lateral to any mandibular molars which are present and his

fingers extra orally under the lower border of the mandible. Downward pressure with

the thumbs and upward pressure with the fingers reduce the dislocation. The patient

should be warned not to open his mouth too widely or to yawn for a few days

postoperatively and an extra oral support to the joint should be applied and worn until

tenderness in the affected joint subside.

Displacement of a root into the tissue is usually the result of ineffectual attempts to

grip the root when visual access is inadequate. This complication can be avoided if

the operator attempts to grasp roots only under direct vision.

A root displaced into the antrum is usually that of a maxillary premolar or molar

and is most often the palatal root. The presence of a large antrum is a pre disposing

factor, but the incidence of this complication would be greatly reduced if the

following simple rules were observed:-

i) Never apply forceps to the maxillary check tooth or root unless sufficient of its

length is exposed, both palatally and buccally, to allow the blades to be applied

under direct vision.

ii) Leave the apical one third of the palatal root of a maxillary molar if it is retained

during forceps extraction unless there is a positive indication for removing it.

iii) Never attempt to remove a fractured maxillary root by passing instrument up the

socket.

If root is lost while teeth are being extracted under general anaesthesia, the

anaesthesia should be stopped immediately & the patient's head brought forwards.

After the cough reflex has returned the mouth is examined & the pack carefully

removed and inspected. If proper safeguards have been taken the root is found in the

pack is most instances, but if the root cannot be located after removal of the pack,

radiograph should be taken of both the socket & the chest. The latter film is taken to

ensure that the root has not passed into the bronchi. If root is located in bronchi,

patient must immediately be referred to a hospital where it can be removed by

bronchoscopy before either a lung abscess or atelectasis supervenes. If the root is not

located the patient should be given an appointment for examination in 3 days.

Post Operative Complications of Exodontia

A. Hemorrhage

Some slight oozing of blood for several hours following tooth extraction is

considered normal, although usually bleeding will stop after few minutes.

Persistent bleeding (primary haemorrhage) that cannot be controlled by 30 to

60 minutes of pressure from biting on a gauze pack, plus the use of an ice bag

on the face, requires more definitive therapy.

Primary Haemorrhage :- It is the one which occurs at the time of injury or

operation.

Reactionary Haemorrhage :- It is the one which occurs within 24 hours of

injury or operation. In many cases reactionary haemorrhage occurs within 4-6

hrs such haemorrhage takes place due to dislogment of blood clots on slipping

of ligature. This mostly occurs due to rise of blood pressure when the patient

is recovering from anaesthesia or shock. Such a bleeding may also occur due

to restlessness, coughing or vomiting which raises the venous pressure.

Secondary haemorrhage :- This occurs usually after 7-14 days of injury or

operation. This is usually due to infection and sloughing of part of the arterial

wall.

Clinical features of haemorrhage

- In case of an external haemorrhage the bleeding is seen from outside and the

diagnosis is confirmed.

- In case of an internal haemorrhage there is increase pulse rate, low blood

pressure, pallor, restlessness and deep sighing respiration (air hunger).

- Cold and clammy extermities, empty veins are also characteristically seen

when the bleeding is continuing.

Grading scale to measure severity of bleeding

WHO (World Health Organization) made a standardized grading scale to measure the

severity of bleeding.

Grade O - no bleeding

Grade 1 - petechial hemorrhage

Grade 2 – mild loss of blood (clinically significant)

Grade 3 – Gross blood loss, requires transfusion (severe)

Grade 4 – debilitating blood loss, retinal or cerebral associated with fatality.

Management of Haemorrhage

Aim of the treatment – It consists of two parts:

a) To stop blood loss

b) To restore the blood volume by blood transfusion, infusion of crystalloid

solution and infusion of plasma or plasma substitutes.

The blood loss is stopped by mainly 3 methods:-

a) Rest

b) Pressure and packing from outside

c) By operative methods

A. Rest

Absolute rest is vital so far as the treatment of haemorrhage is concerned.

Restlessness cause more blood loss. Some sedatives and analgesics may be

prescribed to provide rest to the patient. If the patient become restless due to pain,

haemorrhage will be more. Morphine is a good sedative and is often used

intravenously in the dose of 1/4th gr. It can be given IV or even IM but not

subcutaneously.

Morphine is however contraindicated where there is respiratory depression in head

injuries, where chlorohydrate is more preferred. It is also contraindicated ion children

and in very old individual.

Injection pethidine is a better drug than morphine. The position of the patient

sometimes help to reduce haemorrhage. Trendelenburg position is also harmful as it

increases blood supply to brain & restore BP.

B. Pressure and packing from outside

This is mainly a first aid technique sterile pieces of gauze & bandage may be

used as pressure bandage to reduce bleeding from external wound. If sterile

gauzes & bandage are not available clean linen cloth may be used as a

bandage to reduce bleeding from the wound. The gauze pieces are used as

package.

Use of tourniquet to stop haemorrhage has been obsolete. This is fact cannot

stop arterial bleeding, on the contrary causes venous congestion and increases

venous bleeding.

C. By operative methods

During operation haemorrhage is usually stopped by artery forceps (haemostats) &

clips applied to the bleeding vessels. Now the bleeding vessels is either ligated with

catgut or silk according to the size of the vessel. Small vessels can be co-agulated

with diathermy.

Material used: These include

The most commonly use & the least expensive is the gelatin sponge

(absorbable) eg. Gelfoam. This material is placed in the extraction socket and

held in place with a figure eight suture placed over the socket. The absorbable

gelatin sponge from a scaffold for the formation of a blood clot.

The second material that can be used to control bleeding is oxidized

regenerated cellulose (eg. surgicil). This material promotes co-agulation

better the absorbable gelatine sponge & it can be packed into the socket under

pressure.

A liquid preparation of topical thrombin (prepared from bovine thrombin) can

be saturated onto a gelatin sponge & inserted into the tooth socket. The

thrombin helps to convert fibrinogen to fibrin enzymatically, which forms a

cloth. The sponge with the topical thrombin is secured in place with a figure

eight suture.

The final material which is used is collagen. Collagen promotes platelet

aggregation & thereby help accelerate blood co-agulation collagen is currently

available in several different forms. eg. Anitene, collaplug, etc.

Treatment for the control of secondary bleeding

The patient should be positioned in the dental chair and all the blood, saliva

and fluids should be suctioned from the mouth.

The dentist should visualize the bleeding site carefully with light to determine

the source of bleeding.

If it is seen to be a generalized oozing, the bleeding site is covered with a

folded damp 2 - x - 2 inch sponge held in place with firm pressure by the

surgeon's finger for atleast 5 min. This measure is sufficient to control most

bleeding. The reason for the bleeding is usually some secondary trauma that is

potentiated by the patient's continuing to suck on the area or to spit blood from

the mouth.

If 5 min. of this treatment does not control the bleeding the surgeon must

administer a local anesthetic so that the socket can be treated more

aggressively. Infiltration with solution's containing epinephrine causes

vasoconstriction & may control the bleeding temporarily.

Once local anaesthesia has been achieved, the surgeon should gently curette

out the tooth extraction socket and suction all areas of old blood clot. The

surgeon must then decide if a haemostatic agest should be inserted into the

bony socket.

The use of an absorbable gelatin with topical thrombin held in position with a

figure 8 stich and reinforced with application of firm pressure from a small,

damp gauze pack is standard for local control of secondary bleeding.

Dry Socket (Alveolar Osteitis)

It is also known as:

alveolitis sicca dolorosa

alveolar osteitis

alveolalgia

post operative osteitis

localized acute alveolar osteomyelitis

Definition:- It is a complication of wound healing following extraction of a tooth.

The term alveolar refers to the alveolus, which is the part of the jaw bone that

surrounds the teeth, osteitis means simply bony inflammation.

It is known as dry socket as after the clot is lost, the socket has dry appearance

because of exposed bone. The blood clot helps in stopping the bleeding and lays

framework for new tissues to develop there but in case of dry socket, the clot is

dislodged and the bone is exposed. The bone is exposed to bacteria in the saliva and

the food which the patient consumes and the bone becomes infected and painful.

Cause:- Destruction of the clot is caused by the action of the proteolytic enzymes

produced by the bacteria or local fibrinolytic activity. Activators of fibrnolysins are

liberated from the alveolar bone and other oral tissue when the alveolar bone is

traumatized clot lysis occur by 2 mechanisms:-

a) Plasminogen dependent pathway and

b) Plasminogen independent pathways

Plasminogen is hepatically synthesized and released into the circulation. It transforms

into plasmin, when in turn acts on the fibrinogen and fibrin, causing the clot

dissolution.

Anaerobic micro organisms may also play a significant role in the development of this

condition.

Clinical Features

It is most common and painful complication in the healing of extraction

wound.

It is basically a focal osteomyelitis in which the blood clot is disintegrated or

been lost, with the production of a foul odoar & severe pain of the throbbing

type, but no suppuration.

Dry socket is also associated with low grade fever and ipsilateral

lymphadenopathy.

This condition is more common in women and tobacco users, and is most

frequently associated with difficult or traumatic extractions and thus most

commonly follows the removal of an impacted mandibular third molar.

It is common in patients taking oral contraceptives since the estrogen

component of oral contraceptive the fibrinolytic activity.

History of extraction 48 to 72 hours before.

Birn's Hypothesis

Trauma and/or Causes Inflammation of Release of Plasminogen

infection bone marrow Tissue activators

Converted

to

Dissolution of lysis of fibrin

the blood clot pain formation of kinins Plasmin

Treatment

The aim of treatment should be the relief of pain and speeding of resolution.

The socket should be irrigated with warm normal saline and all degenerating

blood clot removed.

Sharp bony spurs should be either excised with rongeve forceps or smoothed

with a wheel stone.

A loose dressing composed of zinc oxide and oil of cloves on cotton wool is

tucked into the socket. It must not be packed tightly in the socket as it may set

hard and be very difficult to remove.

Analgesics tablets and hot saline mouth baths are prescribed and arrangements

made to see the patient again in 3 days time.

Most patient report relief of pain, but some require a further dressing or even

chemical cauterization of the exposed bare painful bone.

While zinc oxide and oil of cloves dressings relive pain they undoubtely dealy

healing. Though a pack composed of whitehead's varnish (pigmentum

iodofrom compositum BPC) on either or pom-pom or ribbon gauze is not quite

so effective in controlling pain, it can be left in situ for 2 or 3 weeks & the

socket will be found to be granulation when the dressing is removed.

A pom-pom is a piece of cotton wool enclosed within an outer layer of gauze

the free edges of which are secured by means of a ligature of either dental

floss or suture material.

Acute Osteomyelitis

Definition:- Osteomyelitis is an inflammation of medullary portion of bone or bone

marrow or cancellous bone.

Acute suppurative osteomyelitis of the jaw is a serious sequal of periapical infection

that often result in a diffuse spread of infection throughout the medullary spaces, with

subsequent necrosis of a variable amount of bone.

Microbiology:- It is caused by pyogenic organisms. Most commonly found organism

in osteomyelitis is staphylococcus areus, staphylococcus albus, streptococcus

pyogenes. Anaerobes such as bacteroids, porphyromonas also predominate.

Aetiology

Odontogenic infections such as pericornitis, infected socket, infected cyst,

tumor etc.

Trauma – It is the second leading cause injuries of gingiva become more

significant in patient with low resistance. Instruments used for extraction of

teeth also cause trauma.

Site

It is more common in mandible and involves the alveolar process, angle of mandible,

posterior part of ranus and the coronoid process.

Clinical Features

A) Early cases are characterized by

General constitutional symptoms like high intermittent fever, malaese, nausea,

vomiting, anorexia.

Intermittent paraesthesia or anaesthesia of lower lip, which differentiate it

from the alveolar abscess.

Deep seated bouring, continuous intense pain in the affected area.

The mandible is tender on extra oral palpation. Teeth are tender to percussion

and loose.

B) Established cases are characterized by

Deep pain, malaise, fever, dehydration, anorexia.

Teeth in involved area begin to loosen and become sensitive to percussion.

Purulent discharge occurs through sinuses.

Foetid odour is often present.

Trismus may be present.

Dehydration, acidosis & toxaemia.

Regional lymphadenopathy is usually present.

Radiographic features

They are absent initially

The radiographical changes appear after one to two weeks. Diffuse lytic

changes in the bone begin to appear.

Individual trabeculae become juzzy and indistinct and radiolucent area begin

to appear.

Laboratory Studies

Shows mild leucocytosis (PMNL) & albumin urea.

Management:- The management includes:

A) Conservative treatment B) Surgical treatment

Conservative Management includes

Complete bed rest.

Supportive therapy which include nutritional support in the form of high

protein diet.

Dehydration :- Hydration orally or through administration of IV fluid.

Blood transfusion :- In case RBC's and haemoglobin is low.

Control of pain :- It is controlled with analgesics. Sedation may be employed

for keeping patient comfortable and allow to sleep.

IV antimicrobial agents :- Penecillin remains the time honoured empiric

antibiotic of choice for osteomyelitis of jaws.

Recommended antibiotic regimens for osteomyelitis of jaws are as follows:-

a) Regimen I – As empirical therapy, penicillin V is given

i) Aqueous Penicillin - 2 million units IV every 4 hrly

ii) Oxacillin – 1gm IV every 4 hourly.

b) Regimen II is based on culture and sensitivity results. Penicillinase resistant

penicillins such as oxacillin, cloxacillin, decloxcillin or flucloxacillin may be

given.

In case of allergy to penicillin, following antibiotics are prescribed

i) Clindamycin 300-600mg orally 6 hourly.

ii) Cephalosprin 250-500mg orally 6 hourly.

- Cefazolin 500mg 8 hourly.

- Cephalenin 500mg 6 hourly.

iii) Erythromycin 2g every 6 hourly IV then 500mg every 6 hourly orally.

Traumatic Arthritis of the Temporomandibular Joint

Definition of arthritis :- It is inflammation of the joints, in one of the most prevelent

disease affecting the human race, and the TMJ does not escape this disease, although

it is certainly not one of the joints most commonly involved.

The common type of arthritis which a dentist must be familial of are:-

Infectious arthritis

Traumatic arthritis

Osteoarthritis

Rheumatoid arthritis

Secondary degenerative arthritis

Traumatic arthritis of TMJ:- It may complicate difficult extraction of the lower jaw

is not supported. The risk of this unpleasant condition occuring can be minimized if

the operator uses his left hand correctly and the anesthetist or an assistant steadies the

mandible by holding it under the angles. If it is known that the patient has a history of

a previous dislocation of the temporomandibular joint it is a wise precaution to get

him to hold a dental puop during a dental extraction.

Causes:- TMJ traumatic arthritis could mainly by divided into two types:-

i) caused by blunt trauma

ii) caused by condyle/condyle fossa fracture.

Clinical features:-

Swelling over the affected joint.

Pain in the TMJ, preauricular region or ear.

Difficult in occluding the posterior teeth.

Tenderness of the affected region.

Chronic masticatory muscle pain, chewing disability and jugular shoulder

muscle pain.

TMJ traumatic arthritis could be clinically classified into : disk disorders,

synovitis, masticatory muscle myositis, joint adhesion and mixed

pathologically changes.

Investigations:- Pain x-rays, blood tests, arthrography, arthroscopy, CT scan, MRI

scan, Bone scan.

Treatment:-

TMJ treatment may range from conservative dental and medical care to

complex surgery.

Depending upon the diagnosis, treatment may include short term non steroidal

anti inflammatory drugs for pain and muscle relexation, bite plate, or splint

therapy and even stress management counseling.

Generally, if non surgical treatment is unsuccessful or there is clear joint

damage, surgery may be indicated. Surgery can involve either arthroscopy

(the method identical to the orthopaedic procedure used to inspect and treat

large joints such as the knee) or repair of damaged tissue by a direct surgical

approach.

Oedema

Edema or odema formely known as dropsy or hydropsy, is an abnormal accumulation

of fluid in the interstitum, which are locations beneath the skin or in one or more

cavities of the body. It is clinically shown as swelling.

Mechanism

Six factors can contribute to the formation of odema:-

Increase hydrostatic pressure.

Reduced oncotic pressure within blood vessels.

Increased tissue oncotic pressure.

Increased blood vessel wall permeability eg. inflammation.

Obstruction of fluid clearance via the lymphatic system.

Changes in the water retaining properties of the tissue themselves.

Many surgical dental extractions results in extraction complication like facial

edema or facial swelling after surgery. Routine extraction of a single tooth will

probably result in swelling that the patient can see, whereas the tooth extraction of

multiple impacted teeth with the resections of soft tissue and removal of jaw bone

may result in moderately large amounts of facial swelling. The facial swelling usually

reaches its maximum size 24 to 48 hours after the surgical extraction procedure. The

facial swelling begins to subside on the 3rd or 4th day and is usually gone by the end of

the test week. Increased swelling after third day may indicate jaw infection at the

surgical tooth extraction.

Management

Once the surgical extraction is completed, the dental surgeon usually advices the

patient to use ice packs to help to minimize the swelling and make the patient feel

more comfortable. The ice pack should not be placed directly on the skin, but rather a

layer of dry cloth should be placed between the ice container and the tissue to prevent

superficial tissue damage. An ice bag or a small bag of frozen peas should be kept on

that local area of swelling for 20 min for 12 to 24 hours.

On the second day, neither ice nor that should be applied to the swollen area of

the face.

On the third day, a application of heat may resolve the swelling move quickly.

Heat sources such as hot water bottles and heating pads are recommended.

Patient should be wanted to avoid high levels heat for long periods to keep

from injuring the superficial layer of the skin.

The swelling may tend to wax and wave, occuring more in the morning and

less in the evening because of postural variance (setting and lying down).

Patients should not be concerned of frightened by the swelling because it will

resolve in a few days.

Ecchymosis and Hematoma

An ecchymosis is the medical term for a subcutaneous purpura larger than 1cm or a

hematoma, commonly called a bruise. It can be located in the skin or in a mucous

membrane.

Presentation

After local trauma, RBCs are phagocytosed and degraded by macrophages. The blue

red color is produced by the enzymatic conversion of haemoglobin to bilirubin, which

is more blue green. The bilirubin is then converted into hemosiderin, a golden brown

color, which accounts for the color changes of the bruise.

Haematoma can be subdivided by size

By definition eccymosis are 1-2 cm in size or larger.

Petechial (1-2 mm or less) or pigmented purpuric dermatosis (0.3 to 1mm)

After the extraction procedure

Mild ecchymosis is seen, especially in elderly patients with an increased

capillary fragility and poor tissue elasticity.

Extensive ecchymosis and hematoma formation, however are complications

that usually results from improper hemostasis during surgery.

When there is persistent bleeding from the adjacent alveolar bone or socket, it

is insufficient to assume that closure of the overlying gingival tissue will stop

it. Hemostasis must be obtained in the bone as well as the soft tissue. This

can be accomplished by applying pressure, packing the socket with gelatin

sponge or oxidized cellulose, crushing in bone over the bleeding vessel or

using bone wax.

Management

a) Rest : Taking rest helps heal a trauma better than most other measures.

b) Ice : Ecchymosis and hematoma are treated with intermittent ice packs (30

mins/hour) for the first 24 hours after surgery.

c) Heat : Applying heat over patches can remove any obstruction in the affected

blood vessel. Put a warm cloth soaked in hot water over the region.

Patients should be advised that the discoloration is from bleeding into the

tissue and is not a bruise or a gangrenous process. They should also be told

that the discoloration from the accumulation of RBC and the subsequent

breakdown of the hemoglobin may take several weeks to disappears

completely.

Trismus

It can be defined as inability to open mouth due to muscle spasm and may complicate.

OR

It is defined as a prolonged, tetanic spasm of the jaw muscle by which the normal

opening of the mouth is restricted.

Causes

Trauma to muscle or blood vessels in the infratemporal fossa is the most

common itiological factor in trismus.

Local anaesthetic solutions into which alcohol or cold sterilizing solutions

have diffused produce irritation of tissues, leading to trismus.

Haemorrhage is another cause of trismus. Large volumes of extravascular

blood can produce tissue irritation, leading to muscle dysfunction as the blood

is slowly resorbed.

A low grade infection after an infection can also cause trismus.

Extraction of teeth may also cause trismus as a result either of inflammation

involving the muscle of mastication or direct trauma to the TMJ.

Problems

Although the limitation of movement associated with post injection trismus is

usually minor, it is possible for much more severe limitation to develop.

The average interincisal opening in cases of trismus in 13.7 mm.

In acute phase of trismus, pain produced by haemorrhage leads to muscle

spasm and limitation of movement.

The chronic phase usually develops if treatment is not begun. Chronic

hypomobility is secondary to organization of hematoma, with subsequent

fibrous and scare contracture.

Infection also may produce hypomobility through increased pain, increased

tissue reaction and scaring.

Prevention

Use a sharp, sterile, disposable needles.

Properly care for and handle dental local anasthetic cartridges.

Use aseptic technique.

Practice atraumatic insertion and infection technique.

Avoid repeat injections and multiple insertions into the same area through

knowledge of anatomy and proper technique.

Use minimum effective volumes of local anesthetics.

Management

Heat therapy should be prescribed, warm saline rinses analgesics and if

necessary, muscle relexants to manage the initial phase of muscle spasm.

Heat Therapy : consists of applying host, moist towels to the affected area for

approximately 20 mins every hour.

Warm saline rinse : For this, tea spoon of salt is added to a 12 ounce glass of

warm water and held relieve the discomfort of trismus.

Analgesic : Aspirin (325mg) is usually adequate as an analgesic in managing

pain associated with trismus. Its anti-inflammatory properties are also

beneficial.

One rare occasion, iodine may be necessary if the discomfort is more intense.

Muscle relaxation : Diazepam (approx 10mg Bio) or other benzodiazepine is

used for muscle relexation.

- The patient should be advised to initiated physiotherapy consisting of opening

and closing the mouth as well as lateral excession of the mandible for 5 mins

every 3-4 hours.

- Chewing gum (sugarless) is yet another means of producing lateral movement

of the joint.

- Antibiotics should be added to the regimen described and continue 7 full days.

- Complete recovery from injection related trismus takes about 6 weeks, with a

range of 4 to 20 weeks.

- For severe pain and dysfunction if no improvement is noted within 2-3 days

without antibiotics or within 5 to 7 days with antibiotics, or if the ability to

open the mouth has become limited, the patient should be referred to an oral

and maxillofacial surgeon for evaluation.

Respiratory Arrest

Respiratory arrest or failure is usually due to drug overdose during sedation. The

diagnosis is made by cessation of respiration, cynosis and rapid, weak pulse which

later become irregular and impalpable cardiac arrest may occur.

Management

Stop sedation

Lay the patient flat

Inspect and clear the airway

O2 should be given

Start cardio pulmonary resucilation eg. mouth to mouth breathing.

Consider flumazenil (an antidote to benzodiazepis)

Call an ambulance

Defer dental treatment

Cardiac Arrest or Cardiovascular Collapse

It makes sudden stoppage of heart. Recognition of cardiac arrest is difficult in the

sedated or anesthetized patient unless the pulse is continuously monitored. It is

recognized clinically by absence of pulses, no cardiac impulse on auscultation, cold

extremities, cessation of respiration and loss of consciousness followed by

convulsions, respiratory arrest and cynosis.

Pulpitis are initially reactive to light, may become dilated and fixed later one.

There is no measurable blood pressure.

Management

Assess the situation, state the patient and ask in a loud voice "Are you ok"? If

no response then:-

Can someone to get help or shout for medical help yourself.

Start basic life support (BLS) and cardiopulmonary resucitation (CPR), and

continue until help arrives.

Lay the patient flat on the floor.

Clear the airway look into the mouth and throat for any object or foreign body.

If any object is present, try to sweep out the object with 2 fingers.

If the person is not breathing, pinch the nostrils closed with your thumb and

index finger.

Tilt the head backward slightly to open the airway. Lift the chin forward.

Start mouth to mouth breathing even if the heart is beating, until the person's

chest clearly rising taking about 2 sec. for a full expiration.

After 10 ventilations, if person's spontaneous breathing does not take place,

make arrangement to shift the person to the hospital for intubation.

The crucial factor deciding the success of CPR is a sufficient O2 supply. At

about 4 min. after cardiac arrest, cerebral death results.

If the person is still unresponsive full for the carotid pulse, if found absent

start cardiac massage.

To perform the cardiac massage, kneel at the patients right side and interlock

the fingers of your both hands to give external cardiac compression. With

your elbows straight, depress the lower sternum briskly with the heel of your

hands 15 times over a period of 10 seconds. Depress the sternum 3-5 cm

keeping the pressure firm, controlled and applied vertically with abrupt

relaxation. Push down the crest 80-100 times/min.

CPR for an adult includes 15 chest compression & 2 breaths repeat many

times the procedure and watch for the person's chest to fall feel for air being

exhaled.

Oro-Antal Communication

The apices of the maxillary check tooth are often closely related to the antrum.

Sometimes the roots are separated from the antral cavity only by the soft tissue

lining of the all sinus. If this is destroyed by the periapical infection a

perforated during removal of a tooth or root, an oro-antral communication will

be created.

If this complication is suspected, the patient should be asked to grip his nose

and thus occlude the wares. Men if he raises the intranasal & intra antral

pressure by attempting to blow air through his nose, in the presence of an oro-

antral communication, air will be hard to pass into the mouth, blood present in

the socket will be seen to bubble, or a whips or cotton wool held over the

socket will be deflected. If the test is positive or equivocal the lesion should

be treated immediately.

Treatment

Mucoperiosteal flap should be raised and the height of the bony socket reduced

without increasing the size of the bony defect. After loosely suturing the flaps across

the defect with an interrupted horizontal mattress suture the repaired soft tissues and

blood clot should be covering the area with either a quick acylic extension to an

existing denture or by a base plate. Alternatively a sheet of composition impression

material may be moulded to shape, cooled, trimmed and held in place over the area,

either by ligatures placed around adjacent teeth or by sutures. The patient should then

be referred for a second opinion. Under no circumstances should a patient with a

suspected oro-anteral communication be allowed to rinse out before the defect has

been repaired, because the passage of fluid from the mouth will contaminated be

allowed to rinse out before the defect has been repaired, because the passage of fluid

from the mouth will contaminate the air sinus with the bacterial flora of oral cavity.

Post Operative Instructions

Do's

Gauze – to control the bleeding, bite firmly on the gauze placed in your mouth

(pressure pack)

Cold – to reduce swelling, place an ice bag on the cheek, near the extracted

area.

Take the prescribed medium as recommended.

Rinse after eating food and avoid eating from the same side of the extraction.

Limit the activities for the first 24 hours.

Brush your teeth gently.

Adapt liquid or soft food diet for the first two days.

Drink cold things as it causes vasoconstriction of the blood. Vessels and

reduce bleeding.

Advice warm saline rinse mouth wash after one day.

Don't

One should not take any hot liquids as it causes lysis of clot avoid smoking.

Don't split as it will cause discoloration of blood clot.

Do not eat crunchy and sticky food.

Do not drink without straw.

Avoid chewing anything for at least 2 hours after tooth extraction.

Don't touch the site with tongue or finger.

Avoid brushing around the extracted site.

Don't speak too much.

Don't eat hard food.

Conclusion

The complications of tooth extraction are many and some may occur even when the

care is exercised. Other are avoidable if the plan of campaign, designed to deal with

difficulties diagnosed during a careful preoperative assessment, is implemented by an

operator who adheres to sound surgical principles during the extraction.

Prevention of complications should be a major goal of the surgeon. The surgeon who

anticipates a high probability of an unusual specific complications should inform the

patient and explain the anticipated management & squelae. Notation of this should be

made in the informed consent that the patient signs.

References

Oral and Maxillofacial Surgery - Volume Two

o Daniel M. Laskin

The Extraction of Teeth

o Geofferey L. Howe