tooth extraction

1. PRESENTED BY
DR. VISHAL BHARDWAJ
PG 2ND YEAR
1
COMPLICATIONS OF
IMPACTIONS AND ITS
MANAGEMENT

2. CONTENTS
 INTRODUCTION
 SOURCES OF COMPLICATION
 LOCAL AND SYSTEMIC COMPLICATIONS
 MANAGEMENT
 CONCLUSION
 REFERENCES
2

3. Introduction
 Any adverse , unplanned events that tend to increase
the morbidity above what would be expected from a
particular operative procedure under normal
circumstances.
3

4. Sources of complications
Surgical complications may arise from either one or a
combination of the following factors.
THE PATIENT- Medically compromised patient leading to
an persistent haemorrhage or delayed healing.
THE CLINICIAN
-level of training,skills and experience.
-attitudes towards total patient care.
THE SURGICAL PROCEDURE
risks depend on :-
-complexity of the procedure.
-local anatomy of the surgical site
-proximity of important vital structures. 4

5. COMPLICATIONS OF TOOTH
EXTRACTION
 Local complications
Immediate
Delayed
Late
 Systemic complications
Immediate
Late
5

6. LOCAL COMPLICATIONS
 Immediate
 Failure of local anesthesia
 Failure to move the tooth
 Fracture of the tooth or Root being extracted
 Fracture of alveolus
 Displacement of tooth or a root into the tissue
6

7.  Loss of a tooth or part of a tooth into pharynx
 Fracture or subluxation of an adjacent tooth
 Collateral damage to surrounding soft tissues
 Hemorrhage
 Dislocation of the TMJ
 Fracture of the mandible
 Damage to Inferior alveolar nerve.
7

8. Delayed
 Excessive pain, swelling and trismus
 Dry socket
 Infection of soft tissues
 Nerve damage
8

9. Late
 Chronic osteomyelitis
 Nerve damage
 Chronic pain
9

10. SYSTEMIC COMPLICATIONS
 Immediate
 Syncope
 Hypoglycaemia
 Hyperventilation
 Myocardial infarction
 Convulsions
 Respiratory obstruction
10

11. late
 Infective endocarditis
 Transmissable viral infection
11

12. FAILURE TO SECURE ANESTHESIA
 Faulty technique.
 Insufficient dosage of anesthetic agent.
 The presence of collateral nerve supply must be
anticipated and appropriate technique such as
periodontal ligament injection employed.
 Tooth extraction Under local anaesthesia should be
possible in almost all co-operative patients and the
surgeon should strive to perfect techniques which ensure
the procedure is painless
12

13. FAILURE TO -REMOVE THE TOOTH WITH
EITHER FORCEPS OR ELEVATOR
 Tooth fails to yield to the application of reasonable
force applied with either forceps or elevator.
13

14. Management
 Tooth dissection
14

15. 15

16. FRACTURE OF THE CROWN OF A
TOOTH OR ROOT BEING EXTRACTION
 Weakened tooth- caries or large restoration
16

17.  Improper application of the forceps
 Excessive force
 proper application of forceps or elevator will deliver
the tooth or Transalveolar method
17

18. ROOT FRACTURE
18
Faulty technique
-Apical one third of the
impacted 3rd molar molar.
Changes in Root pattern
Management:- Radiographic
examination & Transalveolar
extraction
A)fractured root(B) resorbed
root.(C) shows incompletely
formed root.

19. FRACTURE OF THE ALVEOLAR BONE
 Movements are abrupt and awkward,
 Ankylosis of the tooth in the alveolar process,
 Labial, buccal, palatal or lingual cortical plate may be
removed together with the tooth.
.
19

20. Management
 Small broken part of alveolar bone is removed
 Remaining bone should be smoothed
 Irrigation with saline solution and wound is sutured
 If the broken part of the alveolar process is still
attached to the overlying soft tissues, then it may
remain after stabilization and suturing of the
mucoperiosteum.
20

21. FRACTURE OF MAXILLARY
TUBEROSITY
 Occur during the extraction of a maxillary 3rd molar
 Create problems for the retention of a full denture in
the future.
 Usually due to the following reasons:
1. The extraction of a molar is performed with forceful
and careless movements.
21

22. 2. Ankylosis of a maxillary
molar that presents
great resistance to
movements during the
extraction attempt.
3. Decreased resistance of
the bone of the region,
due to a semi-impacted
or impacted third molar.
22

23. Management
 The fractured segment has not been reflected from
the periosteum, repositioned and sutured.
 If, oroantral communication occurs, the tooth is
first removed and the bone is then smoothed and
the wound is tightly sutured.
 Broad-spectrum antibiotics
 Nasal decongestants
23

24. FRACTURE OF AN ADJACENT OR OPPOSING
TOOTH  Precautions :
 Careful pre-op examination
(carious, heavily restored,
loose, line of withdrawal)
 No force should be applied to
any adjacent tooth
 Other teeth should not be
used as fulcrum for an
elevator.
 Under General Anesthesia –
Injudicious use of gags &
props
 Any loose, heavily restored
tooth should be noted &
brought to the notice of
anesthetist. 24

25. Management
 When an adjacent tooth is inadvertently luxated or
partially avulsed, the tooth is stabilized for
approximately 40–60 days
 If the tooth is dislocated, it must be repositioned
and stabilized for 3–4 weeks.
25

26. FRACTURE OF THE MANDIBLE
Excessive or incorrectly applied force
 Pathological changes of mandible
 Senile osteoporosis
 Atrophy
 Osteomyelitis
 Previous therapeutic irradiation
 Unerupted teeth, cysts, hyperparathyroidism or
tumours may also predispose to fracture
26

27. 27
Fig shows Photoelastic model of the mandible, showing the
development of stress during a luxation attempt of the third
molar when insufficient bone has been removed from the
tooth peripherally

28. Management
 When a fracture occurs during the extraction, the
tooth must be removed along the line of the
fracture.
 Intermaxillary fixation
 Broad-spectrum antibiotics are administered.
28

29. DISLOCATION OF ADJACENT TOOTH
Causes same as those giving
rise to fracture of adjacent
tooth
 During elevation a finger should be
placed upon the adjacent tooth to
support it .
 An elevator is wedged between the
tooth to be extracted and the
adjacent bone . With gentle
rotation using the bone as a
fulcrum, the elevator is used to
compress the space between the
tooth and the bone. 29

30. DISLOCATION OF
TEMPOROMANDIBULAR JOINT
 Application of excessive force
 Failure to support the mandible while extracting
a difficult tooth
 Low anterior articular tubercle.
 Round head of condylar process.
 More likely to occur under general anesthesia
when mastication muscles are relaxed
30

31. MANAGEMENT
 Support mandible during
extraction
 Do not open mouth too
widely.
 Reduction is done with the
thumb wrapped with gauze
or bandage to avoid injury
by teeth and placed on the
occlusal surfaces of
mandibular posterior teeth
and finger under the lower
border of the mandible.
31

32.  Mandible is then pushed
downward backward
rotating the chin
upwards with this
manpower the condyles
are moved downwards
and backwards over the
articular eminences of
temporal bone.
32

33.  Patient should be warned not to open his mouth
too widely or to yawn for postoperatively .patient
is instructed to support the jaw during yawning.
• Extra oral bandage support for the joint is applied
and worn until tenderness in the affected joint
subsides.
• Failure to reduce dislocation reduction can be
attempted under 5-10 mg of IV/IM valium.
33

34. • Failure to reduce the dislocation or if there is
resistance encountered LA solution is injected
high in the buccal sulcus bilaterally adjacent to
maxillary third molar region similar to the
technique of posterior superior alveolar nerve
block. This helps in paralyzing lateral pterygoid
muscles and over comes Muscular spasm
• Under GA it is easy to reduce dislocation
34

35. DISPLACEMENT OF A ROOT INTO
THE SOFT TISSUES/BONY CAVITIES
 This complication may occur in the following
situations:
 When the buccal or lingual cortical plate, as well as
the root tip region of maxillary posterior teeth is
eroded.
 Root tip may easily be displaced during luxation
towards the buccal soft tissues
 The floor of the mouth
 Between the bone and mucosa of the maxillary sinus
35

36.  Occur during an attempt
to luxate an impacted
maxillary third molar,
 When the impacted tooth
is close to the maxillary
sinus. forces exerted
during luxation are
maximally controlled.
 A root or root tip (usually
the palatal root of a
molar) may also be
displaced into the
maxillary sinus during
the removal attempt
36

37.  Mostly roots displaced
in;
 Mandibular Canal
 Lingual Pouch
Maxillary Sinus
37
Fig. shows Displacement of the root tip of
the third molar into the mandibular canal
during an extraction attempt

38.  Precautions
 This complication can be avoided if the operator
attempts to grasp roots only under direct vision.
 Never apply forceps to a maxillary root unless sufficient
of its length exposed.
 Never attempt to remove a maxillary roots by passing
instruments up the socket .if indicated then raised the
flap and remove enough bone to permit an elevator to
remove the broken root piece.
38

39. Management
 Antibiotic treatment
 Nasal decongestants are also administered,
 Surgical removal is scheduled. The exact position of
the tooth or root tip must be confirmed with
radiographic examination.
 Removal of the tooth or root from the maxillary sinus
is usually achieved with trephination of the maxillary
sinus using a Caldwell–Luc procedure.
39

40. Caldwell-luc procedure
 A surgical procedure used especially for clearing a
blocked or infected maxillary sinus that involves
entering the sinus through the mouth by way of an
incision into the canine fossa above a canine tooth,
cleaning the sinus, and creating a new and enlarged
opening for drainage through the nose
40

41. ASPIRATION OF TOOTH/ROOT
 Procedure should be stopped immediately & patient’s
head brought forwards.
 After cough reflex has returned the mouth is examined
& pack carefully removed & inspected
 Radiographs – socket & chest
41

42. DAMAGE TO ADJACENT TISSUES
Damage to the gum can be avoided by careful selection of
forceps & good technique.
The lower lip may be crushed between the handles of the
forceps & anterior teeth.
precautions
 Skilled use of operators left hand.
 Instruments should be allowed to cool before use after being
sterilized.
 Tongue & floor of mouth damage can be prevented by
effective use of left hand.
42

43. 43
Fig. shows Injury of sublingual area as a
result of elevator
slippage during extraction
Fig. shows Burn of lower lip due to
overheating of a surgical
handpiece (micromotor)

44. NERVE INJURY
 Occur during oral surgical procedures.
 The most common nerve injuries are
 Inferior alveolar,
 Mental, and
 Lingual nerves.
44

45. Nerve trauma may cause sensory disturbances
 ANESTHESIA OR HYPERSTHESIA
 PARESTHESIA
 DYSESTHESIA
In the innervated area, 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.
According to Seddon’s classification (Seddon 1943)
of nerve injuries, there are three types of nerve damage:
 NEURAPRAXIA
 AXONOTMESIS
 NEUROTMESIS
45

46.  1. Neurapraxia: This type of damage has the most
favorable prognosis and may occur even after
simple contact with the nerve.
 Nerve conduction failure is usually temporary and
there is complete recovery, without permanent
pathologic and anatomic defects.
 Recovery is quite rapid and occurs gradually within
a few days to weeks.
46

47. 2. Axonotmesis: This is a serious injury of the nerve
resulting in degeneration of the nerve axons, without
anatomic severance of the endoneurium.
Regeneration and recovery of sensation is slower
than in neurapraxia and usually begins as paresthesia
6–8 weeks after injury. Regeneration of the nerve
may be exceptionally favorable, but there is a chance
of a certain degree of sensory disturbance of the
area remaining.
47

48. 3. Neurotmesis: This is the gravest type of nerve injury,
resulting in discontinuation of conduction due to
severance of the nerve or due to the formation of scar tissue
at the area of trauma.
Neurotmesis may be produced by: trauma of the nerve
branch due to traction, ischemia due to prolonged
compression, severance or tearing of the nerve, as well as
certain chemical substances.
This type of injury may cause permanent damage to nerve
function, including paresthesia or even anesthesia.
The formation of scar tissue may also prevent axon
regeneration.
48

49. Etiology.
 Nerve injury may occur in the following cases:
 During administration of a nerve block (rarely) of the
inferior alveolar nerve and mental nerve.
 While creating an incision that extends to the region of the
mental foramen and the lingual vestibular fold.
 While creating an incision at the alveolar ridge of an
edentulous patient, whose mental foramen, due to bone
resorption, is localized superficially
 During excessive flap retraction and compression with
retractors during retraction in the region of the mental
nerve or at the lingual region of the third molar.
49

50.  When bone near a nerve is excessively heated, if
the bur of the surgical handpiece is not irrigated
with a steady stream of saline solution.
 In the case of removal of impacted teeth, roots and
root tips that are deep in the bone and are close to
the mental or inferior alveolar nerves
 During perforation of the lingual cortical plate,
 When roots of a posterior tooth are sectioned or if
a crown of an impacted third molar is sectioned
(injury to lingual nerve).
50

51. NERVE INJURY
Inferior dental nerve
 Close proximity of mandibular third molar roots.
 Careless surgical technique,
 Roots are curved around the canal or grooved
 Risk of damage while taking incision and during elevation
of lingual periosteum.
 Risk of direct trauma form bur or chisels used for removal
of bone or sectioning of the tooth
51
Fig. shows Diagrammatic illustration
showing injury of the
inferior alveolar nerve when the tooth is
close to the mandibular
canal and the bur is driven deeply

52.  Damage can be prevented or minimized only by pre-op
radiographic diagnosis & careful dissection.
52
AREA OF SENSORY DEFICIT FOLLOWING
INFERIOR ALVEOLAR NERVE INJURY

53. Mental nerve
 Injury is caused due to surgery in the area of mental
nerve.
 Over extension of incision in the depth of mucobuccal
fold in premolar region
53
Fig. shows Risk of injury of the mental
nerve, after exposure,
if excessive force is used with the
retractors holding
the flap

54. Prevention:
The nerve injury can be prevented by
Careful surgical technique –
• Proper placement of incision,
• Careful bone removal
• Retraction and less manipulation
54

55.  Treatment.
No particular therapy is indicated for neurapraxia
or axonotmesis, unless there is a root tip or other
foreign body compressing the nerve, must be removed.
Treatment is usually palliative, including the
administration of analgesics in painful situations, and
multi-vitamin supplements of the vitamin B complex
to restore sensation more rapidly.
Damage to the nerve as a result of neurotmesis must
be treated as soon as possible; often, a graft must
replace the injured nerve segments or the severed
segments must be sutured.
55

56. POST EXTRACTION
BLEEDING/HEMORRHAGE
 Causes (of primary)
 Local or systemic
 Local causes:
 Trauma
 Mechanical dislodgement of the clot
 Damage to blood vessel or soft tissue
 Fracture of alveolar bone
 Damage to nutrient blood vessel
56

57.  Infection
 Presence of granulation tissue
 Chronic inflammation of gingiva
 Acute infection of bone and soft tissue
 Local abnormality
 Unusually large bone marrow space
 Presence of Hemangioma
57

58. Systemic causes
 Disorder related to systemic disease
 leukemia, multiple myeloma, Aplastic anaemias
 Platelet disorders: Thrombocytopenia
 Coagulation defects : Haemophilia
 Structural malformation : hereditary hemorrhagic
telengectesia
 Drug therapy: Aspirin, Anti coagulant therapy
58

59. Management
Physical methods
 Pressure packs
 Use of LA solution with vasoconstrictors
 Socket suturing
 Hemostatic packs
 Splints
 Thermal measures- cautery, hot saline packs
59

60. Firm gauze roll should be placed upon the socket &
patient asked to bite upon it .
Horizontal mattress suture

61. Hemostatics
 TOPICAL AGENTS
 VASOCONSTRICTORS
Adrenaline
 ABSORBABLE AGENTS
Oxidized cellulose
Oxidized regenerated cellulose
Gelatin sponge
Fibrin foam
Calcium alginate
 THROMBOPLASTIC AGENTS
Thrombin
61

62. CHEMICAL AGENTS
Tannic acid
Ferric chloride
Zinc chloride
Alum
Hydrogen peroxide
SOCKET PLUGS
Bone wax
White head’s varnish on ribbon gauze
62

63. 63
Gel foam
Botroclot (hemocoagulase solution)
Surgigel

64. Systemic agents
 ENDOGENOUS
Whole blood
Fresh frozen plasma
Cryoprecipitate
64
EXOGENOUS
Ethamsylate
Vitamin K
Epsilon amino caproic
acid(EACA)

65. POSTOPERATIVE PAIN
Due to traumatized hard tissues -
Bruising of bone during instrumentation or
overheating of bur during bone removal.
Soft tissues :-
 ragged flap – heals slowly (incision not proper)
Soft tissue become entangled with bur
 Improper Retraction
65

66. DRY SOCKET / ALVEOLAR OSTEITIS/
FIBRINOLYTIC ALVEOLITIS
Acutely painful tooth socket containing bare bone and
broken down blood clot.
Associated with fetid odor
66

67. Predisposing factors :-
1. Infection of socket : release of plasminogen
activators
2. Trauma - use of excessive force
3. Vasoconstrictors (contributory factor)
4. Mandibular extractions (dense & less vascular,
contaminated with food debris)
5. Bacteriological origin - Treponema denticolum.
6. Patient on oral contraceptives, smokers
67

68. Clinical features
 Patient usually presents within 2-4 days : granulation
tissue appears in 2-4 days, it is absent in cases of dry
socket.
 Dull, boring pain to severe throbbing pain, may
radiate
 Gingival margin of socket – swollen & red
 Socket may be filled with food debris or a brown
friable clot on removal of which exposes the bare bone
which is severely tender to touch
 Regional lymph nodes may be tender
68

69. 69
DRY SOCKET CONTAINING DEGENERATING BLOOD CLOT

70. Prevention
:-
1. Scaling & any gingival inflammation – (1 week
prior to extraction).
2. Minimum amount of local anesthetic
3. Atraumatic tooth removal
4. Prophylactic use of antibiotics especially
metronidazole
5. Nerve blocks preferred to LA infiltrations
70

71. Management –
1. Aim – relief of pain & speeding of resolution
2. Socket irrigation with warm saline & all degenerating
blood clot removed.
3. Sharp bony spurs - excised with rongeur forceps
4. Loose dressing – Zinc oxide & Alveogyl dressing is tucked
into the socket.
5. Analgesic tablet & hot saline mouth baths
6. Recall after 3 days 71

72. 72
IRRIGATE THE SOCKET PLACE A ANTISEPTIC DRESSING
DRESSING ; First 24 hours then every alternate day then
every 3-4 days / or more than 2 weeks regular check up

73. POSTOPERATIVE SWELLING
EDEMA :
 If the soft tissues are not
handled carefully during
an extraction traumatic
edema may be formed.
 The use of blunt
instrument, the
excessive retraction of
badly designed flap, or a
bur becoming entangled
in the soft tissues
predispose to this
condition.
73

74.  If sutures are tied too tightly post operative
swelling due to edema or hematoma formation
may cause sloughing of the soft tissues and
breakdown of the suture line.
 Usually both conditions regress if the patient
uses hot saline mouth baths frequently for 2-3
days.
74

75. INFECTION :-
pain and swelling
Mild - hot saline mouth baths
Severe – I & D, Antibiotic & Analgesics
75

76. TRISMUS
 Occurs in cases of extraction of mandibular third
molars, and is characterized by a restriction of the
mouth opening due to spasm of the masticatory
muscles
76

77.  This spasm may be the result of injury of the
medial pterygoid muscle caused by a needle
(repeated injections during inferior alveolar nerve
block)
 When difficult lengthy surgical procedures are
performed. Other causative factors are
inflammation of the postextraction wound,
hematoma, and postoperative edema.
77

78.  Management
 The management of trismus depends on the cause.
 When acute inflammation or hematoma is the cause of
trismus, hot mouth rinses are recommended initially,
 Broad-spectrum antibiotics are administered.
 Other supplementary therapeutic measures include:
 Heat therapy
 Gentle massage of the temporomandibular joint area
 Administration of analgesics, anti-inflammatory and
muscle relaxant medication
78

79.  Physiotherapy lasting 3–5 min every 3–4 h,
 Administration of sedatives [Bromazepam
(Lexotanil): 1.5–3 mg, twice daily], for
management of stress, which worsens while
trismus persists, leading to an increase of muscle
spasm in the area
79

80. ORO-ANTRAL COMMUNICATION
 An Oroantral communication is created by the extraction of maxillary
premolars or molars where
• The uncomplicated extraction of a tooth may fracture
the thin floor of the sinus
• The roots extend well beyond the maxillary sinus
floor
• The extraction is difficult and traumatic
• There is alone standing molar
• The tooth is ankylosed
• The periapical pathology e.g cyst or granuloma
extending beyond the sinus floor
80

81.  Oroantral communicationmay be the result of:
 Displacement of an impacted tooth or root tip into the
maxillary sinus during a removal attempt.
 Closeness of the root tips to the floor of the maxillary
sinus.
 The presence of a periapical lesion that has eroded the
bone wall of the maxillary sinus floor
81

82.  Extensive fracture of the maxillary tuberosity
 Extensive bone removal for extraction of an
impacted tooth or root.
Preventive Measures.
 The following preventive measures are
recommended:
 Radiographic examination of the region
surrounding the tooth to be extracted
 Careful manipulations with instruments,
especially during the luxation of a root tip of a
maxillary posterior tooth
82

83.  Careful debridement of periapical lesions that are
close to the maxillary sinus
 Avoiding luxation of the root tip if visualization of
the area is hindered by hemorrhage
Diagnosis:
Bubbling through the extraction site occurs
when the nose is blocked under pressure. The
patient cannot suck through a straw.
 For diagnostic purpose we do WATER HOLDING
TEST.
83

84. Management
 Immediate alternatives:
Cover defect with anti
septic – soaked ribbon/ gauze
and remove in 2-3 weeks to
allow healing by secondary
intention or
Reduce bony socket
edge and suture margins
together (interrupted
horizontal mattress)
Immediate closure with
a buccal advancement flap
provided the sinus is clear of
infection.
84

85.  Closure of oro-antral fistula
using a buccal flap.
 Show excision of fistula and
buccal incision through
mucoperiosteum.
 Flap raised; note palatal
mucosa trimmed back to
expose ledge of palatal bone.
 Dotted line shows incision
through periosteum only
above line of reflection of
mucosa.
 Mucosa extended once
periosteum is divided.
 Closure effected with buccal
flap resting on palatal
85

86. PALATAL FLAP
 Design of palatal
flap for closure of
fistula showing
the palatine artery
in the flap and the
excision of the
fistula.
 Closure showing
rotation of the
palatal flap and
pack sutured over
the area of bare
bone.
86

87. SYNCOPE / FAINTS
 Collapse
 Feeling dizzy, weak, nauseated : presyncope
 Skin is pale, cold , sweating
 Head end lowered by lowering the back of the dental
chair
 Spirit ammonia
88

88.  Placement of unconscious patient in the supine position with
feet slighlty elevated and airway patency maintained
through use of the head tilt – chin lift method.
89

89. RESPIRATORY ARREST
 Respiratory arrest is the cessation of
normal respiration due to failure of the lungs to
function effectively.
 Respiratory arrest prevents delivery of oxygen to
the body.
 Lack of oxygen to the brain causes loss
of consciousness.
90

90.  Pathophysiology
 Hypoxia, bronchospasm, obstruction, aspiration,
laryngospasm
 Signs and Symptoms
 Apnea
91

91. MANAGEMENT
:
 Lay the pt flat on the floor
 Remove any foreign bodies
by pulling the mandible
upwards and forwards, to
extend neck fully
 Compress pt. nostril with
thumb and finger, mouth-to-
mouth resuscitation be
performed to raise the chest
every 3-4 sec.
 Check carotid pulse and apex
beat at regular intervals as
respiratory cessation could
be followed by cardiac arrest.
92

92. CARDIAC ARREST
 Cardiac arrest, also known as cardiopulmonary
arrest or circulatory arrest, is the cessation of
normal circulation of the blood due to failure of the
heart to contract effective
 Signs of cardiac arrest:
 It strikes suddenly and without warning.
 Sudden loss of responsiveness
 No response to tapping on shoulders
 No normal breathing
 The victim does not take a normal breath when you tilt
the head
93

93. Unless reversed in 3mins,irreversible brain damage
could occur due to cerebral anoxia.
 Pt has deathly pallor & grayness.
 Cold and sweaty skin
 Pulse and apex beat cannot be felt
 Heart sounds cannot be heard
 CPR is carried out until hospital services are available.
Prevention
Healthy diet , exercise, and smoking cessation are
important.
For people at risk of heart disease, measures such as blood
pressure control, cholesterol lowering, and other
medico-therapeutic interventions are used
94

94. Management
 2 minutes of continuous, uninterrupted
CPR is key before rechecking the rhythm.
 Giving epinephrine every OTHER time
you check the rhythm.
 Don’t delay CPR when you recognize a
cardiac arrest. That means do this first,
and then work on giving oxygen, placing
the patient on various monitors, setting up
the defibrillator, and establishing IV/IO
access. Hence, the C-A-B mnemonic
(Circulation before Airway)
 Chest compressions should be “hard and
fast” — Depth of at least 2 inches and ≥
100 compressions with a target pCO2 on
the end-tidal capnography of ≥10 mm Hg.
95

95. Anaesthetic emergencies
 May occur despite every care exercised
 Anesthetist and operator must be alert for any warning
sign
 In case of collapse STOP ANAESTHETIC
IMMEDIATELY
 CPR ,respiratory relief by tracheostomy, laryngotomy
must be performed.
96

96. REACTION TO MEDICATIONS
GIVEN AFTER TOOTH
EXTRACTION PROCEDURE
 The pain meds and antibiotics which are given
after tooth extraction may have side effects. A
patient may experience nausea, vomiting,
drowsiness from the medicines which are
provided. Patient can consult his dentist in such
cases and can tell him to change his medicines.
97

97. HYPOGLYCAEMIA
 Hypoglycemia means low blood sugar and is caused by
excess insulin (a hormone produced by the pancreas).
 Going to the dentist for some people can be stressful. This
causes the body to release hormones to cope. Adrenaline is
a stress hormone that causes a rapid rising of blood sugar
levels, this triggers an insulin release that drops the blood
sugar levels, and in turn causes hypoglycemia. The person
then “falls into a heap”. Hypoglycemia can both cause the
stress and be the result of stress. This may also cause
sensitivity to adrenaline contained in some local
anesthetics which can heighten its affects on the body such
as heart palpations.
98

98.  There are local anaesthetics that contain no
adrenaline, but the anaesthesia may not be as strong.
It is always beneficial to eat small meals more
frequently and perhaps monitor your blood sugar after
dental treatment.
99

99. HYPERVENTILATION
 Anxiety, fear, and pain in susceptible individuals can
result in a conscious overdrive of ventilation called
hyperventilation.
100
•Signs and Symptoms
• Air hunger,
• Apprehension
• Rapid respiratory rate (may be subtle)
• Circumoral, hand, and foot numbness or tingling
• Carpopedal spasm
• Syncope

100. Management
 Make patient aware of how fast they’re breathing
 Coach the patient to take slower breaths
 Calm and reassure the patient
 Rush the patient to emergency
101

101. MYOCARDIAL INFARCTION
 In myocardial infarction blood clot develops in
one of the coronary arteries completely cutting off
blood supply to a portion of the heart muscle.
 Without a blood supply, the heart muscle dies
within a few hours.
 The ischemic heart is very irritable and susceptible
to cardiac arrhythmias.
 Susceptible to sudden death.
102

102.  Signs and Symptoms
 Central, substernal chest discomfort
 May radiate into shoulders, arms, neck, jaw, or
epigastric region
 Dull, heavy, pressure sensation
 Dyspnea, syncope, diaphoresis, sudden death
 Pain not relieved by nitroglycerine or rest; long
duration (hours)
 Women may experience different signs - upper
abdominal pain and fatigue
103

103.  Management
 Call emergency immediately
 Position patient semi-upright or upright
 Administer oxygen
 Administer nitroglycerin 0.4 mg (sub-lingual) every five
minutes
 Initiate fibrinolysis; if possible, have patient chew 162 to
325 mg of aspirin
 Calm and reassure patient
 Assess and record vital signs; relay to emergency personnel
104

104. CONVULSIONS/SEIZURES
 Convulsions or seizures are caused by waves of
abnormal electrical activity in the brain.
 As these waves spread across the surface of the
brain, they stimulate other cells which are
responsible for motor activity, sensation, or
consciousness.
 Seizures are most commonly seen in patients with
known seizure disorders such as epilepsy.
105

105.  Pathophysiology
 Primary idiopathic epilepsy (cause unknown)
 Hypoxia, Hypoglycemia, Acute arrhythmias, Drug
overdose
 Alcoholism (acute or withdrawal)
 May be precipitated by stressful situations
106

106.  Signs and Symptoms
 Aura
 Loss of consciousness
 Tonic-clonic contractions
 Apnea, facial grimacing, tongue-biting, cyanosis
 Incontinence of urine and stool
 Vomiting
 Post-ictal coma and confusion
107

107.  Treatment
During Seizure:
 Protect patient from injury, guide motions
 Loosen constrictive clothing
 Do NOT force any object between patient’s teeth
 Do NOT attempt to restrain patient

After Seizure:
 Maintain airway
 Keep patient supine, turn on side to prevent aspiration
 Administer oxygen
 Assess and record vital signs; relay to emergency personnel
 Attempt to ventilate only in recurring seizures
 Allow patient to recover and have an emergency contact
drive them home
108

108. INFECTIVE ENDOCARDITIS
 Endocarditis is a rare, life-threatening inflammation
of the lining of the heart muscle and its valves.
 It is caused by a bacterial infection.
109

109.  Possible symptoms of endocarditis include:
 Unexplained fever
 Night chills
 Weakness, muscle pain, or joint pain
 Sluggishness (lethargy) or malaise (general ill feeling)
110

110.  To prevent endocarditis, patients with certain heart
conditions
 one dose of 3 gm amoxycillin orally one hour pre-
operatively.
 For those who are allergic to penicillin oral
clindamycin 600mg is given one hour pre-operatively.
 1 gm amoxycillin may be given by intravenous injection
followed by 500mg orally six hours later.
111

111. INFECTIOUS DISEASES
 The dental surgeon and staff are at risk from
acquiring infections from patients.
 These include
 COMMON COLD,
 XANTHEMATA,
 TUBERCULOSIS,
 CYTOMEGALOVIRUS,
 HERPES,
 HEPATITIS
 HUMAN IMMUNE DEFICIENCY VIRUS (HIV).
 Precautions must be taken to avoid infection of
the surgical team as well as preventing cross
infection between patients.
112

112. VIRAL HEPATITIS
 Several viruses cause hepatitis.
 Those of importance are virus A, B and C (non-A, non-
B).
 Virus A is transmitted by faecal contamination of food
and water and has an incubation period of 30 days.
 The B virus is transmitted by blood or serum, the
incubation period being about 100 days.
 The virus of hepatitis C has recently been identified
and transmission is by blood and serum.
113

113. HEPATITIS B
 Hepatitis B virus (HBV) is transmitted by infected blood and
possibly saliva .
 Faecal-oral transmission is also possible.
 Infected material is transmitted mostly by the parenteral
route.
 The transmission of HBV in the dental surgery should be
prevented by the routine exercise of good clinical hygiene.
 Patients may carry HBV and be infectious from 1 to 4 months
after contracting the disease.
 Symptoms
 Appear from 2 to 4 months after infection.
 During this period the surface antigen (HBSag) can be
detected in blood.
114

114.  Prevention
 Elective dental treatment for patients likely to be
infectious should be postponed until the
infectious stage has passed;
 This can be confirmed by showing the absence of
HBsAg in blood.
 A high standard of clinical hygiene,
 Use of disposable needles for injections,
 Single dose containers for drugs to be injected,
 Sterilized instruments.
115

115.  Chronic carriers of the hepatitis B - e antigen must
be regarded as highly infectious.
 A very careful operative technique and system for
sterilisation of instruments is required to protect
surgery staff and other patients.
 All staff should be advised to be immunised
against the hepatitis B virus as unrecognised
carriers of the antigen may present for treatment
116

116. Conclusion
Complications should be diagnosed as soon as they
occur & dealt promptly and effectively.

117. REFERENCES
1. Textbook of contemporary oral & maxillofacial surgery;
Peterson, 2nd edition
2. Textbook of Minor oral surgery – Geoffrey L. Howe 2nd Edition
3. Handbook of local Anesthesia; Stanley F. Malamed, fifth
edition
4. Textbook of oral & maxillofacial Surgery; Laskin, volume I
5. Transmission of hepatitis B in dental practice.Int Dent J. 1984
Jun ;34(2):122-6.abstract.
6. Principles of Oral and Maxillofacial Surgery 5th Ed by Moore
118