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Complications of Periodontal surgeries

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Salem Tariq

on 4 February 2014

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Transcript of Complications of Periodontal surgeries

Needle breakage

Paresthesia

Facial nerve paralysis

Trismus

Soft tissue injury

Hematoma

HAEMATOMA
Effusion of blood into extravascular spaces can result from inadvertently nicking a blood vessel during injection.
It rarely develops after a palatal injection.
A large hematoma may result after PSA or inferior alveolar nerve block.
Rarely produces significant problems aside from the resulting bruise.
Possible complications include trismus & pain. Management :
Immediate- application of direct pressure to the bleeding site.
Susequent- ice may be applied, acts as an analgesic & vasoconstrictor.
- heat may be applied next day, as an analgesic & vasodilator
Swelling & discoloration usually subsides within 7 – 14 days.
Prevention : good anatomical knowledge
TRISMUS
Prevention :
- practise atraumatic insertion & injection technique.

- avoid multiple insertions.

- use minimum effective volumes.

Management :

- heat therapy
- warm saline rinses
- analgesics & muscle relaxants
- initiate physiotherapy
- chewing gum

Complications of Periodontal surgeries
Dr. Salem Tariq
Why do we talk about Complications
Depression
Confusion
Incompetence
Failure
Give up?
GOD!!!
Complication; noun a condition, event, etc., that is complex or confused
A disease or disorder arising as a consequence of another disease
A mark of a good surgeon is to anticipate and treat complications that arise during any surgery

GOOD MORNING!
Pre-op Evaluation:
Complete Medical history
Complete Allergic history
Previous Dental history
Drug History

Local complications of Local Anesthetic
Pain on injection

Burning on injection

Infection

Edema

Sloughing of tissues

Postanaesthetic intraoral lesions

NEEDLE BREAKAGE
Needles, when they break, always break at the hub.

Causes :
- Weakening of the needle by bending it
- Sudden unexpected movement by the patient
- Smaller needles are more likely to break than larger needles

Prevention:
Larger- gauge needles for techniques requiring penetration of significant depths. Eg. Inferior alveolar, PSA.
Do not insert needle into tissues to its hub.
Do not redirect the needle once its inserted into the tissues.

Removal:
Macgill intubation haemostat
PARAESTHESIA
Defined as persistent anaesthesia or altered anaesthesia well beyond the expected duration of anesthesia.
Causes :
- trauma to any nerve
- LA solution contaminated by alcohol
- trauma to nerve sheath : electric shock sensation along the entire nerve
- hemorrhage into or around the neural sheath

can lead to self inflicted injury: biting, thermal or chemical insult can occur.

- sense of taste impaired (Chorda Tympani nerve).

- hyperesthesia & dysesthesia may also be noted.
Management :

- mostly resolves in 8 weeks without treatment.

- “Tincture of time” : recommended medicine.

- if sensory deficit still evident 1 year : consultation with neurologist.
FACIAL NERVE PARALYSIS
The seventh cranial nerves carries motor impulses to the muscles of facial expression, of the scalp & external ear & other structures.
Cause :
- by introduction of solution into the capsule of the parotid gland.

Problems :
- loss of motor functions: face appears lopsided, protective lid reflex is abolished, winking & blinking is impossible.

Prevention :
- needle tip in contact with bone before depositing solution.

Management :
- eye patch should be applied



SOFT TISSUE INJURY
Self inflicted trauma to lips & tongue may be caused by the patient when anaesthetized.

Trauma occurs mostly in younger children or disabled children or adults.

Prevention :
- LA of apt duration should be selected for brief appointments.
- cotton roll may be placed between lips & teeth.

PAIN
Palatal injections always hurt.

Rapid deposition of the solution may cause tissue damage.

Needles with barbs may produce pain as they are withdrawn from tissue.

Problem : pain on injection increases patient anxiety & may lead to sudden movement, increasing the risk of needle breakage.

Prevention :
- use sharp needles

- use topical anesthetic properly

- inject slowly


BURNING
Primary cause of a mild burning sensation is the pH of solution being deposited into the soft tissues.

Rapid injection especially in the denser more adherent tissues of palate, produces a burning sensation.

Solutions warmed to normal body temperature usually are considered too hot by the patient.

Although usually transient, the sensation indicates that tissue irritation is occurring.

Prevention :
-slowing the injection: ideal rate, 1ml/min
INFECTION
The major cause is contamination of the needle before administration of the anesthetic.

May lead to trismus if not recognized.

Management :
- immediate treatment consists of those procedures used to manage trismus.
- if no response within 3 days, then antibiotics for 7-10 days

EDEMA
Causes :
- trauma during injection
- infection
- allergy: angioedema common response to ester type topical anesthetic.
- hemorrhage
- injection of irritating solutions

SLOUGHING
Prolonged Ischaemia
Sterile abscess :
- secondary to prolonged ischemia resulting from the use of LA with vasoconstrictor (NE).
- usually on hard palate.

Prevention :
- allow the solution to contact mucous membranes for 1-2 mins to maximize its effectiveness & minimize toxicity.
- PRESSURE....DIFFUSE

Management : symptomatic


LESIONS
After 2 days of injection, ulcerations around the site if injection with intense pain can occur.

Causes :
- recurrent aphthous stomatitis
- herpes simplex
- trauma to tissues

Problem : acute sensitivity

Management : is symptomatic.

- topical anesthetic solutions
may be applied to the painful areas.

- a mixture of equal amounts
of diphenhydramine & milk of magnesia
rinsed in the mouth, relieves pain.

- tannic acid preparations may be applied.

SYNCOPE
Defined as a sudden transient loss of consciousness, secondary to cerebral ischemia.


Psychogenic factors like
1. Fright
2. Anxiety
3. Emotional stress
4. Receiving unwelcome news
5. Pain of sudden onset and unexpected nature
6. Sight of blood or surgical or dental instruments.

Non-psychogenic factors like
1. Sitting in an upright position/standing which decreases blood flow to the brain due to pooling of blood in the periphery
2. Hunger from dieting or missed meal which decreases the glucose supply to the brain below minimal levels
3. Exhaustion, poor physical condition, hot humid or crowded environment

PRESYNCOPE-SYNCOPE-POSTSYNCOPE

RELEASE OF CATECHOLAMINES WITH NO MUSCULAR ACTIVITY...PERIPHERAL POOLING...

MANAGEMENT
1. First and foremost thing to be done is place the patient in supine position with feet slightly elevated.
2. ABC
3. O2....Monitor vital signs
4. Follow up treatment, determine factors causing syncope, prevent reoccurrence
of syncope, and arrange for patient to be taken home by friend or a relative,
no further treatment for 24 hours.

PAIN
Anxiety of the patient
Patient well informed about procedure
Pain control
Proper selection of topical and local anesthetics
Consider longer acting local anesthetics in time consuming procedures
“Hospital periodontal surgeries” - Considerations

BLEEDING
Primary
Reactionary
Secondary
First 48 hours – reactionary –clot in the vessels has got disturbed or a due to a defective suture

8 -14 days – Secondary – when the wound is infected and capillaries have eroded surfaces leading to bleeding

POST OPERATIVE
Retarded healing
Continuance of inflammation
Necrotic or hyperplastic responses
Malformations and tumor like lesions
Post-operative bleeding or exudation

Procedures
Emergencies
Summary
CONCLUSION
REFERENCES
JOP Vol 43, June 1972
INFECTION
uncommon complication
bone exposure, flap displacement, Perio lesions...pulp degeneration.
sutures and particles of impacted debris
tissue laceration and impaired vascularization
impacted calculus and bacterial plaque
systemic conditions such as diabetes mellitus, atherosclerosis ad malignancy.
Therapeutic use of immunosuppressive drugs and cortico-steroids

We Are Innocent...
Antibiotic prophylaxis based on anecdotal and circumstantial evidence (Baltch et al.1982)
Casual association between various dental procedures and bacteremia ( Baltch et al 1982)
No dental procedure linked to endocarditis (Guntheroth 1984, Strom et al. 1998)
Even toothbrushing or chewing produces more bacteremia than periodontal procedures (Gould et al.2006)

By British Society of Antimicrobial Chemotherapy (2006)

395 patients
1,035 doccumented procedures
218 patients
927 procedures
no basis for prophylactic Ab's
PAIN
Gingival Soreness
Tissue trauma triggers local mechanoreceptors and polymodal nociceptors, leading to activation of prostaglandins, bradykinin and histamine (Claffey 1988)
Psycho social factors influence pain experience (Kloostra et al.2006)
Pain experience during diagnosis correlated with the pain experience during surgeries (Steenberg et al.2004)

MGS 3.5x Bone surgery and 6x soft tissue surgery
304 consecutive perio surgeries
none to minimal
Control
Surgeon’s assurance to the patient
Handling of tissues gently
Managing anxiety is first step of managing pain (Chung et al 2003)
Analgesics help the patient to have a more positive experience during periodontal treatment (Ettlin et al.2006)

BLEEDING
Due consideration for patients on anti coagulant and aspirin therapy
“Drug vacation” with physician’s consent


Cyanmethemoglobin technique

blood loss to hypotension is 1ltr
Right handed operators reason for difference in quadrants
>500ml loss...IV fluids
1-3 ltrs water with electrolytes post surgery
HART
one hour prior 3000units of factor VIII
gelatin sponge in donor area and resorbable sutures
stent + EACA 4% epsilonaminocaproic acid
swallow after swishing for GI abs
12 hrs later 3000units 12hrs 2500 12hrs 2500
1 week necrosis at donor site and bleeding
repeat sequence for 2 weeks
total 44,500 units cost:- >20,000USD
weigh the consequences!
SWELLING
Mild swelling often found after surgery
Swelling is always present after osseous surgery
Neutrophils fill...
12hrs native fibroblasts with collagen accumulation...
3 days macrophages
begin to replace the neutrophils, and they produce GFs supporting native fibroblast proliferation,
matrix production, and
angiogenesis
SWELLING/EDEMA
one week later fibroblasts at peak ...collagen plateaus this is GRANULATION phase
systemic cond....delayed
foreign body...delayed or impaired
plaque or calculus...delay or impair
Wikesjo¨ UME, Selvig KA. Periodontal wound healing
and regeneration. Periodontol 2000 1999;19:21-29.
RETARDED EPITHELIZATION
Due to:-
Rough and irregular wound surfaces and tissue tags
Foreign substances embedded in the wound
Donor epithelium required for re-epithelialization is distant to the wound site (1-1.5mm)
Hyper plastic connective tissue substratum due to the production of irregular granulation tissue or infection

Clinical manifestations:-
Bleeding
Exudation
Necrotic surface with fibrino-membraneous cover
Irregular hyper plastic, hyperemic and edematous tissue
Discomfort.

FLAP DISP AND AVULSION
Flap displacement and avulsion may occur as a result of retardation and failure of tissue flap to reattach to bone or tooth and marginal aspect of the periodontal ligament.
Inadequate adaptation of the tissue complex to the underlying receptor area due to
Inadequate number of sutures
Improper placement
Suture breakage
Pack displacement or loss.

BONE EXPOSURE
The untoward post surgical sequelae of the bone exposure may be caused by deficiencies of vascularization.
Resorptive and necrotizing changes are especially notable where bony septa are very thin, labial bone sites are commonly encountered.
The reduced vascularization may be inadequate for the sustenance of viable bone cells and of bone’s crystal structure.

ALLERGY
Patient’s allergic history to be known
Common allergens encountered in dental office
Local Anesthetic
Penicillins
Sulfa derived drugs
Disinfectants such as iodine
Such drugs to be avoided


Patch test...
Protocol:
Drug Interaction:-
Drugs prescribed for periodontal therapy may interact with other drugs patient takes
Hazardous or synergistic action
No new drugs should be prescribed
Interaction with alcohol

RESORPTION AND SEQUESTRATION OF GRAFTS
Graft procedures have been associated with post operative sequestration of graft material and root resorption (Schallhorn et al. 1980)
Sequestration of graft materials begins immediately after surgery and to continue as long as 2 years after graft placement (Listgarten and Rosenberg 1979)
Root resorption has been observed after placement of variety of synthetic and osseous graft (Schallhorn 1972, Jaffin 1985, Forum and Stahl 1987, Johnston 1995)
Less frequent in humans but may be a significant problem after placement of fresh iliac marrow (Dragoo and Sullivan 1973)
RECESSION
Inevitable consequence of periodontal therapy
Result of resolution of inflammation in periodontal tissues
Very common complaint from patient after periodontal surgeries
Deeper pockets show more pronounced signs of recession than shallow sites
(Badersten et al.1984, Lindhe et al.1987, Becker et al.2001)
Treatment involving osseous resection results in more pronounced recession
However there might be a coronal rebound of the soft tissue following surgery (Kaldahl etal.1996, Becker et al.2001)
Mucogingival procedures if deemed possible can be performed
Masking of Gingiva can be done

HYPERSENSITIVITY
Relatively common in periodontal practice (Curro,1990)
Patients with sensitivity before treatment experienced higher sensitivity ( Tamararo et al.2000)
Manifested as pain induced by cold or hot temperature, by citrus fruits or sweets, or by contact with toothbrush or a dental instrument
Scaling and root planing removes the thin cervical cementum leading to sensitivity
Patients should be well informed of the situation
Desensitizing Agents act by reducing the size of the dentinal tubules.
According to Trowbridge and Silver (1990) –managed by
Formation of smear layer by burnishing exposed surface
Topical application of agents that form insoluble precipitates
Impregnation of tubules with plastic resins
Sealing of tubules with plastic resins

Desensitizing agents:
Used by Patient
Dentifrices
In-office
Fluoride solutions
Varnishes and Bonding Agents
Low level Laser (Gerchman 1994, Lan WH 1996)
Ozone


ROOT CARIES
Undoubtedly of microbial etiology
Microbial colonization of exposed root surface
Decreaded salivary secretion rates
Actinomyces species are the major culprits ( Sumney and Jordan 1974)
Oral hygiene improvement, Dietary advises and Fluoride dentifrices and mouthwashes would help prevent such lesions

TOOTH MOBILITY
ABSCESS/CYST
Hereditary or non
Threatening...airway
(H-Autos Dom)
SMOKING
DIABETES
Epithelium in growth...
rest cells of Mallasez...
Epithelial collar must be REMOVED
82 patients
S,RP,MW,FO
Split mouth
FO created the most gingival recession followed by MW, RP, and CS.

Tooth mobility often ensues after periodontal surgery.
Excisional procedures, particularly with flap retraction
and the accompanying removal of interdental tissues,
actually divest a tooth of gingival and periosteal support
on a temporary basis. While initial reattachment may
be evident in the first 10-14 days after surgery more
advanced collagenation and renewal of the gingival
attachment to tooth and bone may require 30-45 days
or more days. Mobility may persist, usually on a diminishing
level, during this period.
Biologic width
WAG
biotype
anatomic deformity
frenal position
Esthetic zone
Armamentarium
sterilization
suction
Assessment
Evaluation
Treatment plan
Preparation
On Call
The skill, experience, and up-to-date knowledge of dentists are the main factors to prevent possible Complications.
Although ‘‘To err is human,’’ careful practice is very important for the principle ‘‘Primum non nocere’’ (‘‘First do no harm’’).
J Periodontol 2005;76:1793-1797.
Carranza'SClinical Periodontology 10th Edition
Clinical Periodontology and Implant Dentistry 5th edition Jan Lindhe
Journal of Periodontology
Journal of Clinical Periodontology
Clinical Advances in periodontics
Annals of periodontology
Perio 2000
Internet Sources
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