Complication of Perio Banu

7/30/2019 Complication of Perio Banu

1/112

Complications

Following Flap Surgery


2/112

Contents

Introduction

Classification

Factors to be considered to prevent or minimizecomplications.

Complications

Studies related to the complications

Conclusion


3/112

Introduction

All surgical procedures should be carefully planned.

The patient should be adequately prepared medically,

psychologically and practically for all aspects of

intervention.


4/112

Complications of Flap surgery

(Wang and Greenwell, 2001)Complications during surgery

1. Syncope

2. Anaphylactic shock

3. Hyperventilation4. Pain due to failure of

anesthesia

5. Excessive tissue injury

6. Flap perforation, abrasion,

tearing

7. Hemorrhage

8. Tissue emphysema

Complications after surgery

Pain

Hemorrhage

Swelling / Hematoma

Tissue emphysema

Root sensitivity,

Flap sloughing,

Infection

Root caries, resorption or ankylosis,

Some loss of alveolar crest,

Abscess formation

Irregular gingival contours

Gingival recession


5/112

Factors to be Considered to Prevent or

Minimize the Complications of Flap

Surgery


6/112

Preparation of the Patient

Re-evaluation after Phase I Therapy.

Every patient undergoes the initial or preparatory

phase of therapy, which consists of thorough

scaling and root planing and removing all irritants

responsible for the periodontal inflammation.


7/112

These procedures

Eliminate some lesions entirely,

Render the tissues more firm and consistent, thus

permitting more accurate and delicate surgery,

Acquaint the patient with the office and the operator

and assistants, thereby reducing the patient's

apprehension and fear.


8/112

The reevaluation phase consists of re-probing and re-

examining all the pertinent findings that previously indicated

the need for the surgical procedure.

Persistence of these findings confirms the indication for

surgery.

The number of surgical procedures, expected outcome andpost-operative care necessary are all decided before therapy.

These are discussed with the patient and a final decision is

made, incorporating any necessary adjustments to theoriginal plan.


9/112

Premedication

Ariado 1969 reported reduced post-operative

complications including reduced pain and swelling

when antibiotics are given before periodontal

surgery and continuing for 4 to 7 days after

surgery.


10/112

Other pre-surgical medications include

administration of a non-steroidal, anti-inflammatory

drug such as ibuprofen 1 hr before the procedure

and one oral rinse with 0.12% chlorhexidine

gluconate which minimizes the post-operative

complications.

(Sanz 1988)


11/112

Smoking The deleterious effect of smoking on healing of periodontal

wounds has been amply documented (Jones 1992).

Patients should be clearly informed of this fact and requested to

quit or stop smoking for a minimum of3 to 4 weeks before and

after the procedure.

For patients who are unwilling to follow this advice, an alternate

treatment plan not including highly sophisticated techniques

should be considered.


12/112

Measures to Prevent Transmission of Infection

Transmitting infections to the dental team or vice versa

has become apparent, particularly with the threat of

acquired immune deficiency syndrome and hepatitis B.

Autoclaving all surgical instruments to ensuresterilization.

Universal precautions, including protective attire and

barrier techniques are strongly recommended which

include the use of disposable sterile gloves, surgical

masks and protective eyewear.


13/112

All surfaces possibly contaminated with blood or

saliva that cannot be sterilized must be covered

with aluminum foil or plastic wrap.

Aerosol-producing devices should not be used on

patients with suspected infections.

Special care should be taken when using and

disposing of sharp items such as needles and

scalpel blades.


14/112

Complications


15/112

Syncope or Transient Loss of Consciousness

The most common emergency.

The common cause is fear and anxiety.

Anxiety causes increased release of

catecholamines which cause decreased peripheral

vascular resistance, resulting in the peripheral

pooling of blood and fall in arterial blood

pressure. This results in hypotension and reduced

cerebral blood flow.


16/112

Clinical presentation

Pre-syncope:

Nausea

Sensation of warmth

Diaphoresis

Pallor

Tachycardia

Syncope:

Hypotension

Bradycardia

Dilation of pupil

Peripheral chill

Visual disturbance

Loss of consciousness


17/112

Management

The patient should be placed in a supine position with

the legs elevated; tight clothes should be loosened, and awide-open airway ensured.

Administration of oxygen is useful.

Crystals of ammonia can be placed under the nose to

trigger the respiratory reflex.

A history of previous syncopal attacks during dental

appointments should be explored before treatment isbegun and, if these are reported, extra efforts to relieve

the patient's fear and anxiety should be made.


18/112

Anaphylactic Shock

Anaphylaxis is an IgE mediated acute, allergic

reaction that is characterized by a sudden and

severe collapse of the cardiovascular system

(hypotension), Respiratory compromise

(bronchospasm).

Other manifestations are urticaria, angioedema,upper airway obstruction and gastrointestinal

disturbances.


19/112


Onset:

For injected medications 5-30mts

For oral medicationupto 2hrs.

The more immediate reaction, the more severe

it is.


20/112


SkinFlushed

face, urticaria(itching,flushing),tingling (lips,axilla,groin,hand and

feet),angioedema(lips,eyes,tong-ue)

RespiratoryLaryngeal

edema

(Hoarseness,dysphagia,

lump in throat,airway

obstruction,drooling),

apnea,abnormal

breath sounds,coughing,

bronchospasm

CNSDiaphoresis,

altered / loss ofconsciousness,seizure, slurred

speech.

Cardiovascularcyanosis,

pallor,dizziness,

hypotension,tachycardia/

bradycardia,vascular

collapse,Myocardialinfarction,

cardiac arrest.

Gastrointestinaldisturbances

nausea,vomoting,diarrhea,

abdominal pain

RhinitisNasalcongestion,

itching, sneezing


21/112

Management.

Place the patient in supine position

Administer 100% oxygen, ventilate if necessary Monitor pulse and blood pressure

Epinephrine 0.3-0.5mg (1:1000 solution)

administered sublingual or intra-muscular Start IV fluids ( 1000/500 ml normal saline/

ringers lactate).

If the patient is having bronchospasmadminister salbutamol inhalation,Dexamethasone 4mg IV/ hydrocortisone 100mgIV.

H l i


22/112

HypoglycemiaCharacterized by decreased plasma glucose concentration to a

level


23/112

Management:

Hypoglycemia can be treated with the oral

administration of glucose.

In advanced state of hypoglycemia ( seizure,

coma) treatment should be stopped or

postponed until the patient has received

adequate medical care.


24/112

Hyperventilation

It is a condition where the patient is breathing

at a faster rate than their normal breathing.

Pattern and breathing more deeply than the

body requires to maintain the normal oxygen-

carbon dioxide balance.

It is usually triggered by an imbalance in the

bodys natural levels of O and CO.


25/112


Anxiety

Nervousness

Stress

Pain Feeling of air hunger

Numbness/tingling ofhands and feet

Nausea

Vomiting

Headache

Epigastric pain

Diaphoresis

Vertigo Blurred vision

Loss of consciousness

Muscle cramps


26/112

Management:

Terminate the procedure, Place patient in upright position,

Maintain airway,

Attempt to verbally calm the patient,

Monitor blood pressure/pulse,

Reduce CO eliminationby re-breathing into paper bag,

Diazepam 1-2 mg IV slowly.


27/112

Sedation and Anesthesia

Periodontal surgery should be performed painlessly.

The most reliable means of providing painless surgery is

the effective administration of local anesthesia.

The area to be treated should be thoroughly anesthetized

by means of regional block and local infiltration

injections. Injections directly into the interdental papillae may also

be helpful.


28/112

Apprehensive and neurotic patients require

special management with anti-anxiety or

sedative hypnotic agents.

Modalities for the administration of these

agents include inhalation, oral, intramuscularand intravenous routes.

The simplest, least invasive method to alleviate

anxiety in the dental office is nitrous oxide and

oxygen inhalation sedation.


29/112

Oral Benzodiazepine Agents Commonly Used for

Pre-operative Anti-anxiety and Sedation

Drug Adult dose

(mg)

Onset (hrs) Half life (hrs)

Alprazolam 0.25-0.5 1-2 12-15

Diazepam 2-10 0.5-2 30-70

Lorazepam 1-4 1-6 10-18

Triazolam 0.125-0.5 1-2 15-5.5


30/112

Soft tissue management

Tissue manipulation should be precise, deliberate and

gentle.

Thoroughness is essential, but roughness must be

avoided because it produces excessive tissue injury,

causes post-operative discomfort and delays healing.

Observe the patient at all times. Facial expressions,pallor, and perspiration are some distinct signs that may

indicate the patient is experiencing pain, anxiety or fear.


31/112

Instruments must be sharp to be effective.

Successful treatment is not possible without

sharp instruments.

Dull instruments inflict unnecessary trauma

due to poor cutting and excessive force applied

to compensate for their ineffectiveness.

A sterile sharpening stone should be available

on the operating table at all times.


32/112

Flap Perforation

Causes for flap perforation

Improper tissue handling

Thin gingival bio-type

Excessive pressure during flap reflection

Improper instrument stabilization


33/112

Flap Tearing

Causes for tissue tearing

Injudicious use of instruments

Improper elevation of the flap

Exercise of excessive force on the flap


34/112

Soft tissue abrasion

These injuries are caused by careless use of

rotary instruments.

Thermal injuries:

Caused when instruments taken out from

autoclave or hot air oven are used immediately

intraorally.


35/112

Management of soft tissue injuries

If the tear, abrasion or perforation are large,

suturing should be done for closure.

Scars produced by thermal injuries can be

managed by application of petroleum jelly.


36/112

Flap Necrosis

Causes:

Excessive tension from the sutures

Use of chemical irrigants

such as paraformaldehyde


37/112

Avoid dead space

Failure to use pressure for adaptation of flaps andgrafts after suturing may lead to formation of a

large fibrin clot, resulting in down growth of the

epithelial attachment and bulbous contours . Large blood clot is an excellent medium for

bacterial growth and hinders effective healing

Inadvertently forcing the periodontal dressing

beneath the flap may result in permanent tissue

defects


38/112

Injury to Lingual Nerve

During procedures in the posterior mandible, the lingual nerve

can be damaged, if the lingual flap is not retracted carefully.

Clinicians should be aware that 15 to 20% of the time the

lingual nerve is found at or coronal to the crest of bone lingualto the mandibular third molar.

On average, the lingual nerve is located 2 mm horizontally

from the cortical plate in the flap and 3 mm apical to the crest.

Lingual nerve is in contact with the cortical bony plate 22% of

the time.


39/112

Therefore to avoid lingual nerve damage,

the elevator should be used to protect the

nerve located in the flap underneath the

periosteum, and the elevated tissue should

be managed gently to avoid inducing a

transient traction injury.

Whenever possible, lingual vertical

releasing incisions should be avoided.


40/112

Tissue Emphysema (Raznik JC 1990)

Caused by inadvertent introduction of air into tissues under the

mucous membranes.

Air from a high-speed hand piece, air/water syringe or air

polishing or air abrasive device can be forced into a sulcus,

surgical wound, or a laceration in the mouth .

The air can follow the facial planes and create a unilateral

enlargement of the facial and/or submandibular regions.

It can appear during the procedure or several hours after

therapy.


41/112

When the skin / mucosa is palpated, it usually

produces a crackling sensation as the gas is pushed

through the tissue. This is referred to as crepitus.

The crackling sound is diagnostic for tissue

emphysema, and pain is not a usual feature of

tissue emphysema.

Emphysema can also occur without crepitus.


42/112

Management:

Treatment of tissue emphysema usually consists of

antibiotic and mild analgesic therapy, close

observation, and reassurance.

Antibiotics are prescribed because bacteria may

have been introduced into the tissue with the

compressed air.

Symptoms usually subside in 3 to 10 days.


43/112

Soft tissue emphysema after irrigation of pocket with

3%hydrogenaperoxide under pressure.


44/112

Hemorrhage

Periodontal surgery normally severs only smallblood vessels. So significant hemorrhage is not

a frequent complication of periodontal surgery

when local anesthetics and vasoconstrictor

drugs are used.

The average amount of blood loss during one

session of periodontal surgery has been

reported to be 37 ml. (Berdon, 1965).


45/112

Excessive bleeding may be due to systemic disorders

such as platelet deficiencies, coagulation defects,

medications, and hypertension.

Abnormal bleeding may be related to unexpected onset

of menstrual period.

There may be accidental severing of larger blood

vessels during surgery, provoking extensive bleeding.


46/112

As a precaution, all surgical patients should be asked

about current medications that may contribute tobleeding, any family history of bleeding disorders, and

hypertension.

All patients, regardless of health history, should have

their blood pressure evaluated prior to surgery, and

anyone diagnosed with hypertension must be advisedto see a physician before surgery.


47/112

Patients with known or suspected bleeding

deficiencies or disorders must be carefully

evaluated before any surgical procedure.

A consultation with the patient's physician is

recommended and laboratory tests should be

done to assess the risk of bleeding.


48/112

Bleeding

PrimaryCauses

1. Local infection

2.Tear of any major

blood vessel

ReactionaryCauses

1. Disturbance of theclot due to chewing,

gargling, alcoholconsumption andtaking warm food.

2. Reactionaryvasodilation of theblood vessel whichhad contracted duringadministration oflocal anaesthesia withvasocosntrictor..

Secondary- causes

1. Blood clot may beinfected by certainbacteria likestreptococci which

dissolve the clot andresult in bleeding


49/112

Primary post-operative bleeding starts at the

time of the surgery.

Reactionary hemorrhage starts soon after the

surgery, after having stopped temporarily

following surgery. It is usually associated withbreakdown of an incomplete clot.

The secondary type of post-surgical

hemorrhage may start from 24hrs to 10 days

post-operatively.


50/112

Bleeding

HereditaryHaemophilia

Acquired

1. Hypertension2. Anticoagulant therapy

3. Vitamin K deficiency

4. Thrombocytopenia

5. Liver disorders


51/112

Management1. As soon as continuous bleeding is detected, apply digital

pressure for 2-3 minutes. If bleeding stops, close the wound

by using sutures, which help to stabilize the clot.

2. If the bleeding continues, pack the bony defect with gel

foam.

3. If the bleeding continues, identify the bleeding point and

cauterize it or the vessel may be ligated.

4. A sample blood may be send for testing to find out any

systemic involvement


52/112

Hemostasis is an important aspect of periodontal

surgery because good intra-operative control of bleeding

permits an accurate visualization of the extent of

disease, pattern of bone destruction, anatomy and

condition of the root surfaces.

It provides the operator with a clear view of the surgical

site, which is essential for wound debridement, scaling

and root planing.

Hemostasis also prevents excessive loss of blood into

the mouth, oropharynx, and stomach.


53/112

Periodontal surgery can produce profuse bleeding,

especially during the initial incisions and flap

reflection. After flap reflection and removal of granulation tissue,

bleeding disappears or is considerably reduced.

Control of intra-operative bleeding can be managed

with aspiration.

Continuous suctioning of the surgical site with an

aspirator is indispensable for performing periodontal

surgery. Application of pressure to the surgical wound with

moist gauze can be a helpful.


54/112

Intra-operative bleeding that is not controlled

with these simple methods may indicate a

more serious problem and require additional

control measures.


55/112

Excessive hemorrhaging following initial incisions

and flap reflection may be due to laceration of

venules, arterioles, or larger vessels.

Fortunately, the laceration of medium or large

vessels is rare because incisions near the posterior

mandible (lingual and inferior alveolar arteries)

and the posterior, mid-palatal regions (greater

palatine arteries) are avoided in incision and flap

design.


56/112

Even when all anatomic precautions are taken, it is possible to

cause bleeding from medium or large vessels because

anatomic variations do occur and may result in inadvertent

laceration.

If a medium or large vessel is lacerated, a suture around the

bleeding end may be necessary to control hemorrhage.

Pressure should be applied through the tissue to determine the

location that will stop blood flow in the severed vessel. Then

a suture can be passed through the tissue and tied to restrict

blood flow.


57/112

If the bleeding is an arterial spouting (Palatal arteries)

of light red blood, try to crush the cut artery with a

hemostat Hold the hemostat in position for several

minutes and remove it carefully.

If there is not enough soft tissue available to grasp withhemostat, try to seal the vessel by crushing the bone of

the nutrient bone channel.

If the cut surface is in the soft tissue, ball electrode

from a electrocautery or a hot instrument can be tried.


58/112

Excessive bleeding from a surgical wound may

result from incisions across a capillary plexus.

Minor areas of persistent bleeding from capillaries

can be stopped by applying cold pressure to the site

with moist gauze (soaked in sterile ice water) for

several minutes.

The use of a local anesthetic with a vasoconstrictormay also be useful in controlling minor bleeding

from the periodontal flap.


59/112

Both of these methods act via vasoconstriction,

thus reducing the flow of blood through incised

small vessels and capillaries.

This action is short lived and should not be

relied on for long-term hemostasis.

If a more serious bleeding problem exists or a

firm blood clot is not established, bleeding is

likely to re-occur.


60/112

For slow, constant blood flow and oozing,

hemostasis may be achieved with hemostatic

agents such as :

1. Absorbable gelatin sponge (Gelfoam)

2. Oxydized cellulose (Oxycel),

3. Oxidized regenerated cellulose (Surgicel

Absorbable Hemostat) .

4. Microfibrillar collagen hemostat (Collacote,

Collatape, Collaplug)


61/112

Absorbable gelatin sponge

It is a porous matrix prepared from pork skin that

helps stabilize a normal blood clot.

The sponge can be cut to the desired dimensionsand either sutured in place or positioned within

the wound (eg. extraction socket, intra bony

defect).

It is absorbed in 4 to 6 weeks.


62/112

Oxydized cellulose

It is a chemically modified form of surgical

gauze that forms an artificial clot.

The material is friable and can be difficult to

keep in place.

It absorbs in 1 to 6 weeks.


63/112

Oxydized regenerated cellulose

It is prepared from cellulose by reaction with

alkali to form a chemically pure, more uniform

structure than oxidized cellulose.

The material is prepared in a cloth or thin

gauze form that can be cut to the desired sizeand sutured or layered on the bleeding surface.


64/112

It can be used as a surface dressing because it does not

impair epithelialization, and it is bactericidal against

many gram-negative and gram-positive

microorganisms, both aerobic and anaerobic.

Caution should be used when wounds are infected orhave an increased potential to becoming infected (e.g.,

immunocompromised patients) because the absorbable

hemostatic agents can serve as a nidus for infection.

Th bi


65/112

Thrombin It is a drug capable of hastening the process of blood

clotting and intended for topical use only because it is

applied as a liquid or powder.

It should never be injected into tissues because it can

cause serious, even fatal intravascular coagulation.

It is a bovine-derived material, caution should be used

for patients with known allergic reaction to bovine

products.


66/112

Generic Brand Directions Adverse effects Precautions

Absorbablegelatin

sponge

Gelfoam May be cut intovarious sizes and

applied to bleeding

surfaces

Encapsulation,cyst formation

and foreign

body reaction

possible.

Should not beplaced in deep

wounds- may

physically

interfere with

wound healing

and boneformation

Microfibrillar

collagen

Collacote,

Collatape,

Collaplug

May be cut into

various sizes and

applied to bleeding

surfaces

May potentiate

abscess

formation,

hematoma and

wound

dehiscence;

possible allergic

reaction

May interfere

with wound

healing; may

cause increased

pain



67/112


Oxidized

regenerated

cellulose

Surgical

absorbable

hemostat

May be cut into

various sizes and

applied to bleedingsurfaces

May form nidus

for infection or

abscess

Should not be

over packed into

the wound.

Oxidized

cellulose

Oxycel Most effective when

applied to wound dry

as opposed to

moistened

May cause

foreign body

reaction

Extremely

friable and

difficult to

place; should

not be used

adjacent to

bone- impairs

bone

regeneration;

should not be

used as surface

dressing-

inhibits

epithelization


68/112


Thrombin Thrombostat May be applied

topically to bleeding

surface

Allergic

reaction in

patients allergic

to bovine

materials

Must not be

injected into

tissues or

vasculature- can

cause severeclotting


69/112

Pain

Beyond some soreness during the first 24hrsfollowing periodontal surgery, there should be

only minimal pain and discomfort, if the basic

principles of atraumatic surgery were observed

carefully.

Patient should be instructed to contact dentist

if significant post-operative pain develops.


70/112

Pain within the first few days following

surgery results from:

1. Mechanical trauma during surgery,

2. Drying of the bone,

3. Traumatic bone surgery,

4. Incorrectly placed periodontal dressing.


71/112

Periodontal pack impinging the soft tissue


72/112

Do not prescribe analgesics without re-

examining the wound, as the pain may be a

warning that the dressing has had a

traumatic effect upon the tissues in the area

of the surgery.

After the dressing has been changed, the

patient may be given analgesics.


73/112

Infection It is the state or the condition in which the wound is

invaded by an infectious agent which multiplies and

produces an injurious effect.

The prevalence of infections after a variety ofperiodontal procedures ranged from 1% to 5.4%. (Pack

PD 1988, Chechi 1992)

In the same studies patients not receiving antibioticsbefore, during, or after surgery had an infection rate that

ranged from 2.33% to 5.4%.


74/112

Post-surgical pain related to infection usually does

not start until 2-4 days following surgery.

Such pain is usually accompanied by

lymphadenopathy and elevation in temperature.

The patient should be examined, temperature shouldbe recorded and the dressing should be removed.

Perform percussion test of the teeth in the area of

the surgery.


75/112

If the temperature is not significantly

elevated and the teeth are not noticeably

tender to percussion, place a topical

antibiotic ointment over the wound and

apply a new dressing.


76/112

If the temperature in the area of surgery is

significantly elevated or the teeth in the area

of surgery are noticeably tender to

percussion, the patient should be placed on

systemic antibiotic therapy.

However, severe infections are extremely

rare following periodontal flap surgery.


77/112

Amoxicillin, 2 g, 1 hour before a procedure,

is adequate prophylaxis. (Binahamad, 2005)

But Hossein et al (2005) demonstrated that

a 1-day dose of antibiotics achieved the

same benefit as medication for 1 week.


78/112

There are numerous scenarios in which a

judgment must be made by the clinician as to

the necessity of prescribing antibiotic coverage

for an extended period of time (e.g., if a

surgical procedure is complicated, takes aprolonged period of time, bone grafts were

placed, or the patient was medically

compromised).

(Esposito 2003)


79/112

Immediately after the pack removal

S i /


80/112

Swelling / Hematoma

A sequelea of traumatic periodontal surgery whichresults in blood effusion into the extravascular space.

Extensive soft tissue surgery such as high

mucoperiosteal flaps or distal wedge operations behind

last mandibular molar, may result in swelling.

Infections associated with periodontal surgery may

also induce swelling.


81/112

Hematoma rarely develops in the palatal

region because of the density of tissue in the

palate and its firm adherence to the bone.

The possible complications of hematoma

are:

1. Pain

2. Trismus

3. Swelling

4. Discoloration of the region

Management:


82/112

Management:

Ice packs or ice cubes held in the mouth,

have been used to reduce swelling.

Antihistamines also have been tried.

If there is symptoms of infection such as

elevation of temperature and

lymphadenopathy, antibiotics should be

prescribed.

If there is no evidence of infection no specific


83/112

If there is no evidence of infection, no specific

therapy is indicated.

Facial hematomas may result from direct

trauma to the field of surgery

They may also be the result of bruising contact

by the operator to the skin surface of the jaws.

However it is a rare sequela to carefully

performed periodontal surgery.

D l d H li


84/112

Delayed Healing In areas where part of the alveolar process has been left

exposed after periodontal surgery, where severe trauma

to the bone has occurred during the surgery or where

there is direct pressure on the bone from the

periodontal dressingbare bone may develop.

Such areas of exposed bone may become infected on

the surface. So the granulation tissue will not attach to

it.

Th ti b ill h t b b d b


85/112

The necrotic bone will have to be resorbed by an

inflammatory process in the underlying tissues,

starting from the marrow spaces or the periodontal

ligament.

The dead bone is broken up by the resorptive

process and finally expelled as sequestra.

Such type of delayed healing may take several

weeks and during this time the area should be kept

covered by a periodontal dressing to minimize

infection and discomfort.


86/112

Fortunately such an episode of delayed

healing does not seem to have anydetrimental long-term effect on tissue

attachment level of the teeth, although it

may lead to permanent loss of bone.

The chance of bare bone developing is

much greater following gingivectomy with

electrosurgery.

If i l ti ti d l l f


87/112

If excessive granulation tissue develops as a result of

poorly fitting periodontal dressing or loss of the dressing

shortly after surgery, the granulation tissue should be

removed with a sharp instrument.

This can be accomplished without pain, since the newly

formed granulation tissue is not as yet innervated.

A well fitting periodontal dressing then should be placed

over the wound and left for one week.

R ti t P i d t l D i


88/112

Reaction to Periodontal Dressing

Allergic reactions to periodontal dressings occurespecially in patients who have been wearing

dressings over a prolonged period of time due to

multiple episodes of surgery or delayed healing.

The sensitivity reaction is provoked by the the

eugenol in the zinc oxide eugenol type of dressings.

Very rarely with the non-eugenol containing

dressings.

Th fi t t f iti it ti t


89/112

The first symptom of sensitivity reaction to a

dressing is a burning sensation in the buccal

mucosa and on the surface of the tongue where

contact with the dressing occurs.

The patient should be told at the time of

surgery of the possibility of such symptoms

and instructed to contact the dentist

immediately on experiencing them.

If the dressing is not removed the reaction


90/112

If the dressing is not removed the reaction

progresses from erythema to vesicle formation and

edema.

If the patient is not treated, a generalized allergic

reaction may develop, including a dermatitis.

So it is very important that the surgical dressing is

needed to be removed completely as soon as any

initial symptoms of an allergic reaction appear.

If a new dressing is needed a non eugenol


91/112

If a new dressing is needed a non-eugenol

containing type of dressing such as Coe-Pak

may be used.

Antihistamines can be administered for 4-5

days to intercept the allergic reaction.

In severe allergic reactions, the patient may

have to be hospitalized and given cortisone

therapy.

S iti it f th t th


92/112

Sensitivity of the teeth

The root surfaces of the teeth that have been exposed tothe oral environment as a result of periodontal surgery

sometimes become extremely sensitive to heat and

cold, as well as to mechanical and chemical stimuli.

With optimal post-surgical plaque control, this

sensitivity usually abates over few weeks or months.

But it may persist over a long period of time.

Management:


93/112

Management:

Desensitizing tooth pastes such as strontium chloride,

potassium nitrate, provide varying degrees of relief for

long term sensitivity.

Topical fluoride application are often used but only with

moderate success.

Combining fluorides and electrical current has been

claimed to reduce sensitivity.

Iontophoretic devices and dentifrices for root

hypersensitivity should be prescribed as possible means

of reducing discomfort, even though results may vary.

Gingi al recession


94/112

Gingival recession

It is an inevitable consequence of periodontal therapy.

Since it occurs primarily as a result of resolution of

inflammation in the periodontal tissues, it is seen both

following non-surgical and surgical therapy.

Irrespective of the treatment modality used, initially

deeper pocket sites will experience more pronouncedsigns of recession than shallow initial probing depths.

(Badersten et al 1984, Lindhe et al 1987, Becker et al 2001)

Non surgically performed scaling and root planing causes


95/112

Non-surgically performed scaling and root planing causes

less gingival recession than surgical therapy.

Surgical treatment involving osseous resection results in the

most pronounced recession. (Badersten 1984).

Long term studies reveal that initial difference seen in

amount of recession between various treatment modalities

diminish over time due to coronal rebound of the soft tissue

margin (Kaldahl et al 1996, Becker et al 2001).

Li dh d N 1980 t d th t


96/112

Lindhe and Neyman 1980, reported that an

apically repositioned flap procedure, the buccal

gingival margin shifted to a more coronal

position (1mm) during 10-11 yrs of maintenance.

Van der veldon 1982Interdental areas denuded

following surgery showed an up-growth of

around 4mm of gingival tissue 3 yrs after surgery

with no significant change in attachment levels.

Gingival Recession


97/112

Gingival Recession

Clinical attachment level(CAL)


98/112

Clinical attachment level(CAL)

In sites with shallow initial probing depth both short term and

long term data suggest that surgery creates a greater loss of

attachment than non-surgical treatment. Whereas in sites with

deeper pockets(7mm) showed a greater gain of clinical

attachment. (Knowles 1979, Lindhe 1984, Becker 2001)

When CAL following surgery with and without osseous

reduction was compared, no difference in therapies was found.

Flap surgery without osseous resection produced greater gain

Lindhe et al 1982 developed the concept of


99/112

p p

critical probing depth (CPD) based on the data

generated from a clinical trial comparing non-

surgical and surgical (Modified widman) root

debridement.

CPD means the level of pocket depth below

which clinical attachment loss would occur asa result of treatment procedure.

CPD is found to be cosistently greater for

surgical approach than for non-surgicalapproach.

For incisors CPD is 6-7mm and molars 4.5mm

Studies on Post-operative complications


100/112

Studies on Post operative complications

The incidence and severity of postoperative complications

and pain in 304 consecutive periodontal surgical cases.

Comparisons were made between plastic soft tissue surgery,

osseous surgery and pure mucogingival procedures.

Postoperative complications were rated as moderate or

severe in only 5.5% of the cases.

Osseous surgery to be three times more likely than pure

mucogingival surgery to cause complications of bleeding,

infection, swelling or adverse tissue changes.

Minimal or no postoperative pain was reported by 51.3% of


101/112

the patients. Pure mucogingival surgery was significantly

related to pain and was 3.5 times more likely to cause painthan osseous surgery and 6 times more likely than plastic soft

tissue surgery.

The duration of surgery was statistically significant for both

complications and pain.

The overall results of the study indicate the risks of

undergoing periodontal surgery, in terms of postoperative

complications and pain, are minimal.

(James W. Curtis, Jr., James B, 1985)


102/112

Blood loss during surgical procedures.

determined that, on average, 134 ml blood was

lost (range: 16 to 592 ml) during one sextant of

periodontal surgery.

Baab et al. 1977.

The amount of blood loss will vary depending on several


103/112

y p g

factors: time to complete the treatment, size of the

surgery, vasoconstrictor use, blood pressure, medications,

inflammation of tissues, and health status of the patient.

Clinicians should be aware that when blood pressure

decreases 20 mm Hg during a procedure, blood loss is

>500 ml or the patient experiences an increased heart rate

of 20%, enhanced medical management may be needed(e.g., intravenous solution), which could include referral

to a hospital. (Gladfelter IA 1988)

Intra-Operative Bleeding During Open Flap Debridement


104/112

Intra Operative Bleeding During Open Flap Debridement

and Regenerative Periodontal Surgery - Hadar Zigdon,

J.Periodontol 2011)

In this study the blood loss during periodontal

flap surgery ranged from 6.0 to 145.1 ml with

an overall mean loss of 59.4738.2 ml.

This volume is relatively minimal when

compared with other surgical procedures

Preemptive Dexamethasone and Etoricoxib for Pain and


105/112

Preemptive Dexamethasone and Etoricoxib for Pain and

Discomfort Prevention After Periodontal Surgery: Joao Paulo

Steffens,* Fabio Andre Santos,* Rafael Sartori, and

Gibson Luiz Pilatti. J. Periodontol 2010

This study evaluates the efficacy of using etoricoxib

and dexamethasone for pain prevention after open-flapdebridement surgery.

They concluded that etoricoxib or dexamethasone may

be considered effective for pain and discomfort

prevention after open-flap debridement surgeries


106/112

Long surgical procedures and smoking may

increase the severity and frequency of certain

post-surgical complications such as

Postoperative pain and swelling.

Terrance J, J. Periodontol 2010.

Smoking negatively affects wound healing.Allessandro

scabbia J Periodontol Jan 2001; 73 43-49


107/112

scabbia, J. Periodontol, Jan 2001; 73,43 49.

Smokers exhibited a trend towards less

favorable healing response following flap

debridement surgery compared to non-

smokers both in terms of pocket depth

reduction and clinical attachment gain.

Conclusion


108/112

Conclusion

It is important to have a comprehensive knowledgeof the complications that may be encountered, how

they may be prevented and how they are best

managed if they occur.

Most of the complications that associated with

periodontal surgery are preventable by proper

diagnosis, attentive pre-operative and post-operative

care by a concerned and skillful surgeon.

References


109/112

References

Clinical Periodontology 10th and 11th edition: Carranza,

Neuman &Takei Clinical periodontology and Implant dentistry 5th edition: Jan

Lindhe

The Incidence and Severity of Complications and Pain

following Periodontal Surgery. James W. Curtis, Jr., James B.McLain and Rowland A. Hutchinson

Smoking negatively affects wound healing.Allessandro

scabbia, J. Periodontol, Jan 2001; 73,43-49.

Gary Greenstein, John Cavallaro, George Romanos, andDennis Tarnow*Clinical Recommendations for Avoiding and

Managing Surgical Complications Associated With Implant

Dentistry: A Review. J Periodontol 2008;79:1317-1329.

Joao Paulo Steffens Fabio Andre Santos Rafael Sartori


110/112

Joao Paulo Steffens, Fa bio Andre Santos, Rafael Sartori,

and Gibson Luiz Pilatti. Preemptive Dexamethasone and

Etoricoxib for Pain and Discomfort Prevention After

Periodontal Surgery: A Double-Masked, Crossover,

Controlled Clinical Trial. J.Periodontol 2010.

Terrence J. Griffin, Wai S. Cheung, Athanasios I. Zavras,

and Petros D. Damoulis. Postoperative Complications

Following Gingival Augmentation Procedures.

J.Periodontol 2010.


111/112

Sigurd . P. Ramfjord, Major. M. Ash. Periodontology and

periodontics, modern theory and practice.

Stanley F. Malaed. Text book of local anaesthesia, 5th edition

S.M. Balaji.Text book of oral and maxillofacial surgery.

Dilip G Naik. Text book of periodontology and oral

implantology

James R Hupp. Dental clinical advisor.


112/112

Documents

Complication of Perio Banu