Oral Surgery Bleeding and Hemorrhage Management Quiz

Postoperative Bleeding and Hemorrhage Management in Oral Surgery

• Postoperative bleeding can occur due to coagulation failure, dislodged clots, or elevated blood pressure.
• Secondary hemorrhage after 7 to 10 days post-surgery can result from partial blood vessel division and wound infection.
• Local treatments for intermediate or recurrent hemorrhage include suturing, direct pressure, vasoconstrictors, and local agents to aid blood coagulation.
• Reasons for bleeding in healthy patients can be local anatomical structures, trauma, iatrogenic factors, preoperative history and exams, anesthesia, incision-suture, and postoperative exams.
• Systemic causes of bleeding include anticoagulant therapy, thromboembolism risk, and various coagulopathies such as hemophilia, von Willebrand disease, and thrombocytopenia.
• Mechanisms of hemostasis involve vascular, platelet, and coagulation phases, with tests including INR, PT, aPTT, bleeding time, thrombin time, and platelet count.
• Internal hemorrhage management involves obtaining hemostasis in all wound depths, pressure, cold compress, elevated head, elimination of systemic problems, pressure bandage, and placement of a removable drain if necessary.
• Management of external hemorrhage varies based on the type (capillary, arterial, venous, intraosseous) and may involve compression, ligation, cauterization, or bone crushing to control bleeding.
• Vascular hemorrhage may require ligation for large vessels and cauterization for smaller vessels, while capillary oozing from bone or soft tissues can be managed with pressure, absorbable hemostatic gauze, or additional sutures.
• Trauma to the sublingual artery in the floor of the mouth may be difficult to ligate and may require bi-manual pressure control until appropriate ligation can be performed in the neck.
• Management of external hemorrhage in procedures such as autogenous block grafting and implant placement involves simple compression as the first step in all types of bleeding.
• Overall, postoperative bleeding and hemorrhage management in oral surgery require a combination of local and systemic measures to ensure hemostasis and prevent complications.

Maxillofacial Infections: Causes, Management, and Pathophysiology

• Odontogenic infections are caused by dental and oral issues, while non-odontogenic infections can involve salivary gland infections, otitis media, and tonsillitis, among others.
• Management of odontogenic maxillofacial infections involves determining severity, evaluating host defenses, deciding on the setting of care, surgical treatment, medical support, antibiotic therapy, proper administration of antibiotics, and frequent patient evaluation.
• Odontogenic infections are primarily caused by normal oral bacterial flora, including aerobic and anaerobic gram-positive cocci and anaerobic gram-negative rods.
• These infections are almost always polymicrobial, involving a combination of aerobic and anaerobic bacteria in approximately 50% to 60% of cases.
• The erosion through bone in odontogenic infections depends on the location of the infection source and the thickness of the cortical bone.
• Odontogenic infections in soft tissues manifest in four stages: inoculation (edema), cellulitis, abscess, and resolution.
• The most commonly encountered odontogenic infection in clinical practice is a vestibular space abscess of endodontic origin, which may rupture and drain spontaneously, preventing spread to deeper potential spaces.
• Determining the severity of infection involves a complete history, physical examination, and ancillary testing, including radiographic imaging and laboratory studies.
• Physical examination should be comprehensive and organized, beginning with vital signs and progressing from “big to small” or “outside then inside.”
• Compromised host defenses, indicated by a characteristic “toxic appearance,” require aggressive management with surgical treatment and adjunctive antibiotic therapy.
• Medical comorbidities that adversely affect host defense include inadequately controlled metabolic diseases and conditions that directly affect the immune system, such as poorly controlled diabetes, severe alcoholism, and HIV infections.
• The decision to treat a patient with maxillofacial infections should be based on location, severity, surgical access, and the status of host defenses, determining whether the patient should be treated by a general dentist or an oral and maxillofacial surgeon.

Fascial Space Infections and Management

• Antimicrobials alone may not cure the condition as the focus of infection from necrotic pulp or periapical tissues still remains and may cause recurrence of the infection if the therapy is stopped.
• The fascial spaces in the head and neck are potential spaces between the various fascia normally filled with loose connective tissue and bounded by anatomical barriers usually of bone, muscle, or fascial layers.
• Facial planes offer anatomic highways for infection to spread superficially to deep planes.
• Antibiotic availability in fascial spaces is limited due to poor vascularity.
• An odontogenic infection follows the path of least resistance.
• A periapical infection may perforate the nearest or the weakest cortex and travel along the soft tissue, initially as cellulitis and eventually resulting in abscess formation.
• Various Space Infections and Their Relative Severity: MILD—Vital structures and airway may be mildly threatened; MODERATE—Airway may be compromised; HIGH—Vital structures or airway under direct threat.
• Six possible locations for space infections are: vestibular abscess, buccal space, palatal abscess, sublingual space, submandibular space, and maxillary sinus.
• Canine Space/Infraorbital Space is a source of infection from upper canine and premolars and has clinical features such as pain, tenderness, and swelling in the anterior cheek region.
• Management of Canine Space/Infraorbital Space includes drainage of the space infection either intraorally or percutaneously and aggressive antibiotic therapy to prevent the spread.
• Buccal Space is a source of infection from maxillary and mandibular premolar and molar teeth root apices and has clinical features such as pain, tenderness, and diffuse swelling on the side of the cheek.
• Management of Buccal Space involves drainage of the space infection and addressing the involved tooth through removal or root canal treatment with multiple dressings.

Orofacial Infections and Management of Submental, Sublingual, and Submandibular Spaces

• Infections from lower anterior teeth, symphyseal or parasymphyseal fractures, and submental lymph nodes can lead to submental space infection
• Submental space boundaries include skin, superficial fascia, mylohyoid muscle, and hyoid bone
• Clinical features of submental space involvement are pain, swelling, difficulty swallowing, and tenderness of lower anterior teeth
• Transcutaneous approach in the chin region is the most effective drainage for submental space infections
• Sublingual space is commonly involved in mandibular odontogenic infections, communicating freely with submandibular space
• Isolated sublingual space abscess presents with no noticeable extraoral swelling, tongue and floor of mouth elevation, and difficulty with speech or swallowing
• Infection sources for sublingual space include mandibular teeth and sublingual gland, with clinical features such as pain, tongue edema, breathlessness, and affected speech
• Sublingual space boundaries include lingual aspect of mandible, body of hyoid bone, mucosa of oral cavity, and mylohyoid muscle
• Intraoral and extraoral approaches are used for draining pus in sublingual space infections, with the extraoral approach providing gravity-dependent drainage
• Submandibular space infections almost always manifest with visible extraoral swelling, occurring caudal to the mylohyoid muscle
• Clinical features of submandibular space infections include pain, tenderness, and visible extraoral swelling
• Management of submandibular space infections involves incision and drainage, with the SLDF and platysma muscle acting as barriers between the abscess cavity and the skin

Oro-Facial Space Infections and Complications

• Clinical features of lateral pharyngeal space infections include minimal external swelling, limited mouth opening, painful neck rotation, dysphagia, uvula displacement, and pharyngeal bulging.
• Management of lateral pharyngeal space infections involves a combination of intra-oral and extra-oral approaches under general anesthesia to secure the airway.
• Infections of the retropharyngeal space can originate from lateral pharyngeal space, lymph nodes draining into Waldeyer’s ring, or rarely from upper respiratory infections.
• Clinical features of retropharyngeal space infections include stiff neck, sore throat, dysphagia, neck swelling, fever, dyspnea, and the potential complication of mediastinitis.
• Boundaries of the retropharyngeal space include the base of the skull, fusion of alar and prevertebral fascia, superior and medial constrictors anteriorly, alar fascia posteriorly, and the carotid sheath and lateral pharyngeal space laterally.
• Management of retropharyngeal space infections involves securing the airway, potentially through elective tracheostomy or fiber optic intubation, and a combination of intraoral and extraoral approaches.
• Peritonsillar abscesses can originate from tonsillitis or rarely from pericoronitis or lateral pharyngeal space infections and present with symptoms such as throat pain, fever, dehydration, dysphagia, and visible swelling and redness.
• Boundaries of peritonsillar abscesses include the anterior and posterior pillars of fauces, the tonsil medially, and the superior constrictor muscle laterally.
• Management of peritonsillar abscesses involves intraoral approaches.
• Ludwig’s Angina is an acute, bilateral, non-suppurating, necrotizing cellulitis affecting the submandibular, sublingual, and submental spaces, primarily of odontogenic origin, and potentially life-threatening.
• Predisposing factors for Ludwig’s Angina include immunosuppression, uncontrolled diabetes, steroid therapy, and debilitating conditions.
• Clinical features of Ludwig’s Angina include the need for aggressive surgical intervention, with a primary focus on life-saving measures such as prompt tracheostomy if dyspnea is present.

Oroantral Communication: Causes, Signs, Examination, and Management

• Progressive pneumatization of the sinus, especially around lone standing molars, can cause oroantral communication (OAC) during maxillary third molar removal, particularly when associated with tuberosity fractures.
• Teeth with periapical pathologies and odontogenic infections can cause bone loss at the sinus floor, increasing the risk of OAC after extractions.
• Aberrant root anatomies, dilacerations, hypercementosis, and ankylosis in teeth pose a risk for developing OAC.
• Lack of adherence to basic principles of dentoalveolar surgery or overzealous/aggressive attempts to remove fractured root tips of maxillary posterior teeth may cause OAC.
• Signs and symptoms of oroantral communication include unpleasant tasting discharge, reflux of fluids and foods into the nose, air leakage, difficulty in tobacco smoking, and some patients being asymptomatic.
• Clinical examination for OAC involves inspection after hemostasis, gentle suctioning of the socket to produce a hollow sound, leakage of air during the Valsalva maneuver, and confirmation through radiographs.
• Patients at high risk of OAC include those undergoing maxillary second molar extractions and those with periapical infection or maxillary sinus floor approximation from teeth apices.
• Radiological features of OAC may not be evident on routine intraoral periapical X-rays, and probing is generally not recommended due to the risk of perforation.
• Management of OAC involves informing the patient about the treatment plan and the importance of post-operative compliance.
• Openings less than 3–5 mm in size may be left without intervention to allow for spontaneous healing, or primary closure may be attempted depending on individual case scenarios.
• Suturing across the socket may not suffice in suspected cases of OAC, and additional measures like reducing the height of the alveolar bone or placing a semilunar relaxing incision may be needed for primary closure.
• If primary closure is not obtained, a buccal full-thickness three-sided flap may need to be raised and advanced to the palatal side, with further details provided in the lecture on OAF surgical closure.