Postoperative care and complications

Postoperative care and complications

Plan :

Ⅰ- Introduction

Ⅱ- The main post-operative complications:

       1- edema

       2- Subcutaneous emphysema

       3- pain 

       4- bleeding

       5- infection: 

                    5.1 Factors favoring infection

                    5.2 Alveolitis or alveolar osteitis 

                    5.2 Cervicofacial cellulite 

                    5.3 Osteitis 

                    5.4 Infections at a distance from the surgical site

       6- Nerve damage

Ⅲ Conclusion: post-operative instructions:

Postoperative care and complications

Ⅰ- Introduction

The main post-operative complications encountered after dental surgery are: 

• Swelling and edema
• The pain 
• the bleeding 
• infection

These complications depend on the patient’s condition (terrain) and surgical difficulties and incidents.

Ⅱ- The main post-operative complications:

1. edema:

Oral surgery often results in edema, more or less significant depending on the inflammation: unilateral, non-extensive swelling. 

It appears immediately after the intervention in the form of a unilateral, non-extensive swelling, with a maximum intensity between the 48th ^and 72nd ^hour ; it regresses spontaneously around the 5th–7th postoperative day.

1.1 Pathophysiology of edema  :

Edema is due to a post-surgical inflammatory reaction with local release of inflammatory mediators (histamine, prostaglandins) leading to vasodilation and increased vascular permeability.

The exudation of fluid from the vessels is responsible for swelling which will compress the nerves and give rise to pain.

1.2 Clinical features of edema: 

It is found during intraoral examination in the form of a swelling of the mucous membrane which is hard, tense, painful; accompanied by redness and heat to the touch.

There is no dysphonia or dyspnea. 

There are no general signs of infection (fever, asthenia, etc.).

1.3 Treatment of edema:

Cryotherapy: the cold induces cellular hypometabolism which will slow down the synthesis of chemical mediators of inflammation. 

It is a local treatment which consists of:

•  Apply an ice pack next to the operated area, the ice is isolated from the skin by a cloth, and will be applied for 45 minutes every 2 hours, to avoid skin burns.
• Duration of treatment 1 to 4 days.

1.4 Prevention of edema:

The enzymatic activity responsible for the synthesis of inflammatory mediators increases with increasing temperature. 

Hence the usefulness of post-operative advice to give to patients:

• Avoid wearing a scarf or handkerchief around your neck;
• Avoid hot drinks.

2. Subcutaneous emphysema (SCE):

It is the presence of air in the subcutaneous tissues of the face and neck. Its occurrence is rare, but it can lead to serious, potentially fatal complications: pneumothorax and pneumomediastinum.

The spread of microorganisms from the oral cavity can pose an infectious risk.

2.1 Clinical characteristics of ESC:

The clinical examination found a localized swelling on the face and neck on the side of the surgical site, painless and non-erythematous, with a sensation of snowy crepitation on palpation. 

There are no signs of local inflammation such as erythema, edema, tenderness and lymphadenopathy.

Paraclinical examinations are not necessary unless there is extension to the thoracic region.

2.2 Causes of ESC:

It is due to the propagation of air under pressure in the subcutaneous tissues, from a lesion (the dental alveolus, mucous membrane). This can be caused:

• by the surgeon (iatrogenic): it occurs quickly, encouraged by certain practices: use of air turbines, dental lasers, air flow devices, etc. 
• by the patient : rarer, it occurs late, encouraged by coughing, sneezing, blowing the nose, vomiting, etc.

2.3 Treatment:

• In most cases it disappears spontaneously;
• Regression occurs in less than 5 days, without special measures.
• Antibiotic therapy may be prescribed if there are signs of infection.
• If the emphysema extends to the thorax: hospitalization is recommended for clinical and radiological monitoring: to look for serious complications: pneumomediastinum, pneumothorax.

3. Post-operative pain:

The pain corresponds to post-surgical neuropathies. The most commonly mentioned site is the territory of the inferior alveolar nerve, after avulsion of the 3rd mandibular molar, implant placement or locoregional anesthesia. 

It must be assessed objectively with a scale: exp EVS (simple verbal scale)

Persistent pain: is rare, it is late postoperative pain, resistant to analgesic treatment.

Postoperative care and complications

1. factors that contribute to pain:

• related to surgery : – Surgical difficulties; 

• Duration of the intervention;
• Surgeon’s experience.
• in relation to the patient : – Oral hygiene; 

• Smoking; 
• Existence of preoperative pain; 
• Anxiety, depression.

2. Pain treatment:

Analgesia is systematic, it must be administered before the onset of pain and for a sufficient duration.

Mild pain  : paracetamol at an effective dosage (1g per dose every 6 hours)

Moderate to severe pain :

• NSAIDs  : which have marketing authorization for this indication (propionics), avoid aspirin, take into account contraindications (infection, pregnant women). Ibuprofen: 1 tablet (400 mg) per dose, to be repeated if necessary every 6 hours, do not exceed 3 tablets/day (i.e. 1200 mg per day).
• opioids  :

– Tramadol: 50 to 100 mg per dose, every 4 to 6 hours, without exceeding 400 mg/24 hours 

– Paracetamol/codeine: at appropriate dosages (50 to 60 mg of codeine) 

Persistent and resistant pain:

multimodal analgesia combining: NSAIDs (less than 72 hours and outside their contraindications), paracetamol + codeine or tramadol per os taken systematically for a sufficient duration.

Persistence or recurrence of higher pain levels should lead to a postoperative consultation with the surgeon to screen for possible complications.

3.3 Pain prevention:

The preventive pain strategy is based on:

• Patient information  : Information must be clear, detailed and adapted to the expected pain after the procedure, and to the means of prevention and treatment.
• Anticipatory analgesia  : Postoperative analgesia is administered routinely before the onset of pain.

4. bleeding:

Bleeding is a frequently encountered post-operative symptom. It can be seen for a few hours (4 to 5 hours) up to 24 hours after any dental surgery (or extraction).  

This is the result of the lifting of vasoconstriction induced by the vasoconstrictors contained in local anesthetics.

It is controlled in most cases by local treatment. If the bleeding cannot be controlled, the patient must be treated in a hospital setting.

4.1 Factors promoting bleeding:

The risk of bleeding is greater in patients with hematological disorders or under anticoagulant treatment:

– Thrombocytopenia;

– Thrombopathies; 

• Congenital coagulopathies: Hemophilia Type A and B, Willebrand disease;
• Acquired drug-induced coagulopathies: antiplatelet treatment (aspirin, plavix), anticoagulant treatment (antivitamin K, etc.).

Postoperative care and complications

2. causes of bleeding:

causes related to the intervention:

• Hemostasis not controlled by the surgeon;
• Absence of revision of the surgical site;
• Persistence of inflammatory tissues at the surgical site;

Patient-related causes preventing clot formation:

• Early or excessive mouthwashing;
• certain behaviors such as repeated sucking or spitting.

3. The treatment:

It is a local treatment that consists of ensuring hemostasis by compression at the surgical site. Compression is done using sterile gauze folded over the site of the intervention and by clenching the jaws with constant pressure for 30 minutes to 1 hour.

If bleeding persists beyond 24 hours, hospital treatment is required: ensure medical and surgical hemostasis if necessary.    

4.4 Complications:

A persistent hematoma can be seen when there is neglected hemorrhage or a hemostasis disorder. It can quickly take on a voluminous and diffuse character that can cause compression of the upper aerodigestive tract.

 This is an emergency because life may be at risk: 

Management should begin with stabilization of the respiratory state, oxygenation, orotracheal intubation if necessary, then lifting the compression by drainage and ensuring hemostasis.

4. Prevention of bleeding:

Some tips on post-operative patient behavior are useful for managing bleeding:

• Avoid spitting and swallow saliva normally;
• Avoid mouthwash as this may make the bleeding worse by preventing the clot from forming;
• Avoid running your tongue over the extraction site;
• Apply pressure to the compress by biting on it, and maintain the pressure for at least 30 minutes.

5. infection:

An infection may occur postoperatively, its severity is linked to the increased risk of locoregional and general dissemination leading to serious infectious complications.

The most common infectious complications are alveolitis or alveolar osteitis; other complications may occur such as cervicofacial cellulitis and osteitis.

5.1 Factors favoring infection:

The factors that promote the occurrence of infection are:

• The nature of the surgical procedure performed (invasive or non-invasive)
• Duration of the act (bacterial contamination)
• The patient’s oral condition and oral hygiene 
• Smoking (delays healing)
• Alcoholism
• Advanced age

5.2 Alveolitis or alveolar osteitis:

Dry socket corresponds to the inflammation of the empty alveolus after the loss of the blood clot which plays a protective role, which can develop into superinfection of the alveolus or the blood clot.

This is the most common post-operative infection and has a good outcome if treated early.

It manifests itself in two clinical forms: dry alveolitis and suppurative alveolitis.

5.2.1 Pathophysiology of alveolitis:

The blood clot formed at the level of the roots removed after tooth extraction helps protect the surgical site, rapid healing and reduced pain.

A dry socket occurs when the clot is eliminated early (in part or in whole).

The unprotected alveolus will be invaded by bacteria contained in the saliva, this will prolong the duration of physiological healing and lead to an unfavorable development (inflammation, infection)   

Postoperative care and complications

1. Dry socket: The most common

It develops 2 to 4 days after the surgical procedure. It is marked by an increase or reappearance of pain which becomes: intense, pulsating, radiating towards the neck and ear. 

Clinical examination: found a bare alveolus containing a residue of the clot not adhering to the bone plane and the walls were whitish and very painful.

2. Suppurative alveolitis:

It generally develops 7 days after the surgical procedure, it is due to a superinfection of the alveolus, the pain is more moderate. The clinical examination finds: 

• a whitish carpet at the bottom of the alveolus as well as inflammation of the mucosa (budding, swollen) around the alveolus; 
• a discharge of pus from the socket; 
• general signs of infections: fever, mandibular lymphadenopathy.

Postoperative care and complications

5.2.2 Causes of alveolitis:

Dry alveolitis	Suppurative alveolitis
-per-operative trauma, -partial or premature loss of the blood clot in the alveolus, -Tobacco (vasoconstrictor effect), -early mouthwash.	-Residual debris (bone sequestra, dental fragments, granuloma residues, tartar, food) -the extension of a nearby infection. -Poor oral hygiene.

5.2.3 Treatment of alveolitis  :

• Dry alveolitis: – analgesics to relieve the pain.

                                                      -They heal spontaneously around the 10th ^day .

• Suppurative alveolitis:

• Painkillers;
• General antibiotics: (Augmentin +/- flagyl);

• local care: rinsing with a saline or antiseptic solution, 
• careful curettage of the alveolus under anesthesia without vasoconstrictors.

5.2.4 Prevention of alveolitis:

• keep a compress on the socket and change it regularly, for 2 to 3 hours. This will promote the formation of the blood clot;
• Quitting smoking.
• Good oral hygiene, but avoid mouthwashes and avoid brushing the surgical site for the first 24 hours.
• Perform alveolar revision after tooth extraction.

5.2 Cervicofacial cellulite:

It is an inflammation of the deep cellular-fatty and muscular tissue of the face and neck of infectious origin.

It can follow an untreated or poorly treated suppurative alveolitis (on the 21st ^day post-op) or an alveolar or root fracture.

Most often circumscribed and benign, their seriousness lies in extensive developments (diffuse cellulitis). 

They can cause serious complications that can be life-threatening.

5.2.1 Factors promoting the occurrence of cellulite:

• The existence of a pre-existing latent infection; 
• surgical trauma or poorly conducted surgical treatment;
• Immune deficiency, diabetes; 
• the use of anti-inflammatory treatments (steroidal or not); 
• the existence of a local infectious focus (suppurative alveolitis, fractured alveolar bone fragment).
• alcoholism and smoking.

5.2.2 Clinical forms:

a) circumscribed cellulite :

They generally occur a few days after the operation (between the 3rd and 5th day).

b) Serous cellulite

it is purely inflammatory: edema, redness, heat, and pain, 

c) Suppurative cellulitis : 

It combines local signs (pulsating pain, trismus, dysphagia, fluctuating swelling, adenopathies, salivation) and moderate general signs (fever, asthenia, headache).

It can develop into tissue necrosis: gangrenous cellulitis .

d)Severe diffuse cellulitis : 

They appear after 11 days post-op, but can also present in a fulgurant form with necrotizing fasciitis within 2 to 8 hours post-op.

The most common clinical signs are: pain when swallowing (odynophagia), cervical redness and fever, trismus (difficulty opening the mouth), and dysphagia. Dyspnea and dysphonia are rarer signs.

The association of local signs with general signs suggests severe sepsis (fever, confusion, hypotension, etc.) which could put the patient’s life at risk: this is a therapeutic emergency.

5.2.3 Additional examinations:

• Radiological examinations:

The reference examination is the cervico-facial CT scan with injection of contrast product, supplemented by a thoracic CT scan if there is extension of the inflammation to the base of the neck in search of signs of mediastinitis.

•   Biological tests: 

FNS, CRP, blood cultures at fever peak, and bacteriological samples.

5.2.4 Treatment of cellulite:

a) Circumscribed cellulite : 

• medical treatment: antibiotic to stop the spread of the infection: Augmentin or cephalosporin combined with an imidazole
• Surgical treatment:

-An incision of the abscess at the gum level if the abscess is collected

-Ensure good drainage of the infection.

b) Severe diffuse cellulitis:

Management includes respiratory resuscitation measures (oxygenation, orotracheal intubation, sometimes tracheotomy), corticosteroid therapy, probabilistic antibiotic therapy: combination of a 3rd generation cephalosporin and a parenteral imidazole which will be adapted according to the bacteriological results; and surgical treatment of the entry point (incision, washing, drainage).

5.3 Osteitis:

It is an inflammation of the bone tissue (maxilla) related to a dental extraction (3rd ^molar ). It occurs most of the time on a neglected alveolitis focus and often on a particular terrain (fragile bone, irradiation, diabetes).

They are more frequent in the mandible than in the maxilla due to the terminal vascularization in the mandible.

Osteitis can follow cellulitis and vice versa.

Postoperative care and complications

5.3.1 Clinical and paraclinical signs of osteitis:

Clinical signs :

• localized or radiated pain, continuous or paroxysmal, 
• erythema and edema at the site of osteitis 
• Skin fistulas, resulting from pus, sometimes bone denudation, 
• Trismus in case of posterior bone involvement
• general signs: fever and cervical adenopathy.

Facial CT scan with injection of contrast product reveals osteolysis and bone sequestra . 

Biology : hyperleukocytosis, positive CRP.

5.3.2 Treatment:

Treatment is medical-surgical in the majority of cases:

Medical treatment: appropriate antibiotic therapy which has good bone diffusion, analgesic, oxygen therapy (hyperbaric)

Surgical treatment: drainage, curettage, and removal of sequestra.

5.4 Infections at a distance from the surgical site

This is a rare complication, favored by the lack of early and adequate management of surgical site infections. The oral infectious focus can be the cause of distant or generalized infection (septicemia): 

– Cardiac (bacterial endocarditis)

– Ophthalmic (uveitis, keratitis)

– Remote septic emboli (brain abscess, pulmonary, bone, renal abscess , etc.)

6. nerve damage:

These are rare complications, they are reversible if there is compression of the nerve, and irreversible if there is a complete section of the nerve.

The lesion of the inferior alveolar nerve is the most frequent; it is most often caused by the avulsion of the 3rd mandibular molar, can lead to disorders of labio-mental sensitivity: partial or complete anesthesia, hypoesthesia, paresthesia or dysesthesia.

Ⅲ Conclusion: post-operative instructions:

• avoid spitting and mouthwash for 24 hours;
• apply an ice pack immediately after the procedure;
• Keep the compress in your mouth for 1 hour after the procedure.
• Take prescribed pain medication before it starts, avoid aspirin;
• Ensure good oral hygiene after each of the three meals from the day after the procedure (gentle brushing);
• Avoid intense physical activity for 2 to 4 days;
• Semi-liquid and cold/lukewarm diet for the first 2 days. 
• Avoid hot drinks
• Avoid alcohol and tobacco for 1 or 2 weeks

Postoperative care and complications

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Postoperative care and complications