Perioperative and post operative complication and anti-inflammatory

Present by: Bushara PING 6th DDS Faculty of Dentistry Phnom Penh

Perioperative Complications

• Fracture of the crown of the adjacent tooth or luxation of the adjacent tooth

• Soft tissue injuries• Fracture of the alveolar process• Fracture of the maxillary tuberosity• Fracture of the mandible• Broken instrument in tissues• Dislocation of the temporomandibular joint• Subcutaneous or submucosal emphysema• Hemorrhage• Displacement of the root or root tip into soft tissues• Displacement of an impacted tooth, root or root tip into the

maxillary sinus• Oroantral communication• Nerve injury

Postoperative Complications

• Trismus• Hematoma• Ecchymosis• Edema• Postextraction granuloma• Painful postextraction socket• Fibrinolytic alveolitis (dry socket)• Infection of wound• Disturbances in postoperative wound healing

Hemorrhage

Etiology:

• Traumatism: to the T & V in the region of exo

• Blood coagulation problems: ( severe) hemophilia

• Post-op bleeding in healthy Patient: due to insufficient compression, inadequate remove of inflammatory hyperplastic tissue.

Menagerment

• Compression

• Ligation

• Suturing

• electro coagulation

• use of haemostatic agents.

Compression1. Aim of compression is to

decrease the permeability of cacillaries: biting on a gauze 10-30 min.

> Bone wax is consideration if compression can’t stop bleeding, to arrest bone bleeding

> Iodoform gauze: antiseptic may arrest bone bleeing as well ( place in the cavity 10 min to 3-4 days which it is removed.

Suturing

• obstructs theseveredend of the bleeding vessel.

• The gauze is paked over the wound for 2-3 day.

Gauze pack, sutured over a postextractionwound

Suturing of woundmargins with a figure-eight suture

Ligature

• To stop the soft tissue bleeding involve a large vessel, if during operation bleeding due to large vessel an hemostat is used to clamp and ligature the vessel.

Electrocoagulation

• A technical to

coagulate the Blood

through the application of

heat, resulting in the

retraction of tissues in a necrotic mass.

Hemostat materiel

• vasoconstrictors(adrenaline), alginic

acid, desiccated alum, etc.,

• Other materials are alsoused, such as:fibrin sponge,gelatin sponge,oxidized cellulose, etc.,• These materials are suitableonly for local application and areused to arrest generalizedcapillary bleeding,especially to controlbleeding of thepostextraction alveolus.

Hemostat meteriels

Oxidized cellulose in pellet form, ( topical)

Absorbable hemostatic natural collagen sponges.( topical)

Hemostat materiel

Gelatin sponges.( topical)

Packing of the alveolus with hemostaticmaterials: gelatin sponge, collagen, etc.

Nerve injury

• is one of the most serious complications during oral surgical procedures.

• Most common: inferior alveolar, mental, and lingual nerves. > (anesthesia or hypesthesia,

paresthesia, dysesthesia.

• resulting in various undesirable situations, such

as a burning sensation, tingling, needles and pins, biting of the tongue and lips, abnormal chewing, burns through consumption of hot foods, etc.

Nerve Injury

• Seddon’s classification (Seddon 1943): neurapraxia, axonotmesis, neurotmesis.

Risk of injury of the mental nerve

Question is……

• neurapraxia, axonotmesis, neurotmesis. ????

Nerve injury

Etiology:

• nerve block IDB, and Mental nerve(rarely)

• incision extension to metal foramen,..,

• incision at the alveolar ridge of an edentulous patient

• flap retraction: region of the mental nerve or at the lingual region of the third molar.

• not irrigated: bone near a nerve is excessively heated

• case of removal of impacted teeth: the teeth is close to mental or inferior alveolar nerves.

• perforation of the lingual cortical plate,

Fibrinolytic Alveolitis (Dry Socket)

Definition

• Dry socket (alveolar osteitis) is a painful dental condition that can occur after extraction of a permanent adult tooth.

• occurs when the blood clot at the site of the tooth extraction has been dislodged or has dissolved before the wound has healed. Exposure of the underlying bone and nerves results in severe pain.

• Dry socket delays the healing process.

Fibrinolytic Alveolitis (Dry Socket)

Symptoms

• Severe pain

• total loss of the blood clot

• Visible bone in the socket

• Bad breath

• Unpleasant taste in your mouth

• Swollen lymph nodes around your jaw or neck

Fibrinolytic Alveolitis (Dry Socket)

Causes

• Bacterial contamination of the socket ( infection) during exo and after exo.

• Severe bone and tissue trauma at the surgical site due to a difficult extraction

• Very small fragments of roots or bone remaining in the wound after surgery

• Infiltration of anesthesia.

• Dens and sclerotic bone around the tooth.

Fibrinolytic Alveolitis (Dry Socket)

Risk factors

• Smoking and tobacco use: contaminate the wound site, Sucking action from smoking, sneezing, coughing, spitting or sucking, within the first 24 hours.

• Oral contraceptives: estrogen levels from oral contraceptives may disrupt normal healing

• Improper at-home care: . Failure to follow guidelines

• Having dry socket in the past:

• Tooth or gum infection: Current or previous infections around the tooth to be extracted.

Treatment

• Irrigation gently

• Place gauze with eugenol ( replace every 24h till the pain subside)

• Or: Zinc-Oxide/eugenol5 day

• Or : Alvogyl by Septodont

Anti-Inflammatory

NSAID Steroid

• NSAID: pain medicationsand to reduce swelling. Commonly used in orthopedic problems such as arthritis, bursitis, and tendonitis.

• Steroid: derivative of a natural hormone of the body. commonly used in orthopedics.

Mediator inflammtary

Complement system histamine serotoninbradykinin - major contributors to symptoms of inflammationleukotrienes - increase vascular permeability

- increase mobilization of endogenous mediators of inflammationprostaglandins PGE2 - promote edema and leukocyte infiltration

PGI2 - increase vascular permeability, enhance pain producing properties of bradykinin

NSAIDs

• the NSAIDs are thought to act by

• inhibiting prostaglandin(a group of naturally occurring fatty acids that act within the body to regulate acid secretion of the stomach,

• regulate body temperature

• platelet aggregation, and control inflammation,)

• 1. cycloo1xygenase-1 (COX-1), the enzyme thathelps to maintain the stomach lining; and

• 2. cyclooxygenase-2 (COX-2), the enzyme thattriggers pain and inflammation.

Introductory Clinical Pharmacology (7th Ed) and Lww 2007 Drug Guide Package

Sign of inflammatory

Redness - due to local vessel dilatationHeat - due to local vessel dilatationSwelling – due to influx of plasma proteins and phagocytic cells into the tissue spacesPain – due to local release of enzymes and increased tissue pressure

NSAIDs

• NSAIDs work to block the effect of an enzyme called cyclooxygenase.This enzyme is critical in your body's production of prostaglandins

( mediator inflammatory) • Prostaglandins also have other important

functions in the body as a:– gastric lining.– Renal ( renal blood flow, > Hyper kaliémie..)– Platelet aggregation – Body temparature…

NSAIDs

• Traditional NSAIDs work against both COX-1 and COX-2, both types of this enzymes that function in your body ,

• But The new medications (e.g. Celebrex) work primarily against COX-2, and allow COX-1 to function normally. Because COX-1 is more important in producing the protective lining ( gastric mucosa) . Due to Less Risk to gastric ulcer.

What is this Technique???

NSAIDs

NSAIDs should NOT be used if:• pregnant : • breastfeeding : ?• history of stomach ulcers• taking blood thinning medication ( anticoagulant

drug)• Hypertension: B-blocker ???• Asthma: bronchospasme.• Kidney problem• Other medication is taking ( should know clearly)

NSAIDs

• pregnant : Lead to:

- Reduce fetal weight

- Prolongs the duration of gastation

- Dystocia

NSAIDs

• history of stomach ulcers: Lead to: gastric ulcer,

In server case > Hemorrhage gastric.

• Prostaglandine: important for gastric mucosa

NSAIDs

• Kidney problem: Lead to:

– Fluid sanguid

– Retention Na+

– Hyper-Kaliémie

– Néphrite

– Insufficient Renal chronic

Referance

• Oral Surgery: Springer 2007• http://orthopedics.about.com/cs/paindrugs/a/nsaids.htm• Berger, RG "Nonsteroidal Anti-inflammatory Drugs: Making the Right Choices" J. Am. Acad. Ortho.

Surg., Oct 1994; 2: 255 - 260. • van Tulder MW, et al. "Non-steroidal anti-inflammatory drugs for low-back pain The Cochrane

Database of Systematic Reviews 2006 Issue 1

• http://drugsafetysite.com/sulindac/• http://www.dentalgentlecare.com/dry_socket.htm• Mayo clinic: http://www.mayoclinic.com/health/dry-

socket/DS00778• http://www.webmd.com/oral-health/dry-socket-symptoms-and-

treatment• Introductory Clinical Pharmacology (7th Ed) and Lww 2007 Drug

Guide Package