Download Systemic contra-indications - كلية طب الاسنان

‫ فرع الجراحة‬-‫ جامعة بغداد‬- ‫كلية طب األسنان‬
O. Surgery-3rd year -exodontias--Dr-Jamal abid
Lecture no :-4----------------2016-2017
contra-indications:
in general ,there is no absolute contra-indication for extraction of teeth
but most of them are relative and temporary in nature ,that is to say that
some conditions need :a- to postponed till the acute phase resolved ( acute myocardial infarction
,unstable angina, acute infection ,sever trismus ,pregnancy )
b .Other conditions may need physician consultation and special
arrangement (hemophilia ,leukemia) and preparations , precautions like
(aids,viral hepatitis ,patient on anticoagulant ) .
in general the contra-indications are divided into groups :1-local contra-indications .
2-systemic contra-indications
1- Local contra-indications (l.Cs)
There are several l.Cs for extractions of teeth :1-acute and uncontrolled infection :Extraction in the presence of acute and uncontrolled infection (acute
peirapical abscess , facial abscess especially in medically compromised
patient ) may lead to spread of infection locally or systemically leading to
many complications some of them are dangerous and life threatening
(e,g. cavernous sinus thrombosis, mediastinitis, ludwig's angina. in
addition to that limitation of mouth opening (trismus ) due to infection
may interfere with the accessibility to the operating area .
2- previous radiotherapy:Extraction in case of irradiated jaw may lead to osteoradionecrosis ( death
of the bone ), Previous therapeutic radiation in oral and maxillofacial
region for treatment of cancer lead to fibrosis and decreased vascularity
of the tissue or area of extraction and end with a condition in the bone
called osteoradionecrosis. This condition occurs 3-10% of patients.
Osteoradionecrosis develops as irradiation diminishes the bone’s ability
to withstand trauma and avoid infection ( hypoxia ,hypocellularity
,hypovascularity ), and it can be facilitated by poor nutrition and hygiene.
This process may be spontaneous or result from trauma (extraction),
leading to non-healing soft tissue and bone lesions (unhealed socket ),
followed by bone necrosis. The non-healing bone may become
secondarily infection leading to chronic unhealed area, sloughing of soft
tissue , exposed bone ,continues pain and many other complications .
3- Teeth located within area of tumor (malignant growth) :Especially in cases of malignant tumors, teeth should not be extracted
because extraction may lead to dissemination of the tumor , unhealed
socket and other postoperative complications , such as postoperative and
intraoperative bleeding .
4- Central hemangioma (inside the bone) and arteriovenous
malformation .hemangioma is a benign tumor characterized by proliferation of
blood vessels (vascular ), It occurred within the mandible and maxilla ,while
arteriovenous malformation defined as an abnormal (usually congenital)
connection between arteries and veins , extraction in such conditions
may lead to sever uncontrolled bleeding ,some of these bleeding may be
fetal .
Systemic contra-indications :Systemic contra-indications preclude extraction because the patient's
systemic health is such that the ability to withstand the surgical work may
be compromised . so extraction should be postponed until the severity of
the problem has been resolved and maybe arranged after consultation
with physician to perform extraction safely without complications so
caution is advised in the following conditions :1-sever uncontrolled metabolic disease , e.g. uncontrolled diabetes ,
end –stage renal disease.
2-uncontrolled leukemia's and lymphomas.
3-sever uncontrolled cardiac disease e.g myocardial infarctions ,
unstable angina pectoris , dysrhythmias .
4-sever uncontrolled hypertension .
5-pregnancy.
6-bleeding disorder e.g
- hemophilia , platelet disorder . patient on anticoagulants .
7-patients who take a variety of medications .
- patient on steroid and immunosuppressive drugs .
- chemotherapy .lead to (leukopenia, thrombocytopenia ,anemia ).
- bisphosphonate drug :- may lead to ( osteonecrosis).
8-uncontrolled epilepsy.
preoperative (Pre-extraction) evaluation for extraction patient :P.E.E is very valuable and necessary for successful extraction practice .
hurry and inadequate P.E.E of the case my lead to many embarrassing
intra-operatively for the operator , in addition to the postoperative
problems to the patient P.E.E include :1-clinical preoperative evaluation.
2- radiological evaluation.
1-clinical P.E.E also includes:a) General evaluation.
b) Local evaluation.
General evaluation includes : General impression of patient .
 History of general diseases ,nervousness, orientation .
 General oral hygiene .
 Gingival inflammation , calculus , neglected mouth .
Local factors or evaluation includes:1-Clinical examination to the accused tooth .
The tooth to be extracted is examined, teeth malpositioned
lingually,palatally,rotated, or inclined ,or single standing teeth
in occlusion are all potentially difficult .certain teeth frequently
have abnormal root formation like the upper and lower third
molars. Presence of periodontitis predispose to postoperative
bleeding and infection.
2-Adjoining structures .
should be noticed for inflammation , swelling ,growth ,presence
of traces of blood or oozing , Discharging sinus issue, abnormal
discoloration of the surrounding soft tissue. heavy filled teeth
,crowned teeth ,
3-Access to the tooth . this includes the mouth opening ,
location of the tooth (e.g. buccally malposed, instanding) may
present difficulty in positioning the dental forceps for
extraction, so you may need to remove such a tooth surgically.
4- Tooth mobility: The mobility of the tooth to be extracted
shou1dbe assessed preoperatively, greater than normal mobility
is frequently seen with sever periodontal disease but sometimes
it maybe because of the underlying pathology Like neoplasm.
 Condition of the crown:- e.g.
a) Carious destruction.
b) The presence of large restoration.
c) Presence or absence of the adjoining teeth.
d) Non-vitality.
e) State of the supporting tissue.
f) Shape, position, long axis and size of the crown.
g) Attrition.
Good P.O.E resulted from correction of data collected from history,
clinical examination, radiographs and laboratory aids in addition to
that P.E.E need good knowledge and experience in the basic sciences
e.g. anatomy, physiology, pathology.
In general, P.O.E may help you in:
a) determine the method of extraction and type of anesthesia. .
b) Reduce the time spend for extraction.
c) Reduce the intra and post-operative crisis and complications.
2- Radiological evaluation:
Preoperative clinical assessment maybe supplemental some times by
preoperative radiographs to have a complete preoperative
assessment. it is not practicable to take a preoperative radiograph
before every extraction ,but one should always be taken if any of the
following positive indications exist :1) A history of difficult or unsuccessful extraction.
2) A tooth which is abnormally resist to forceps extraction.
3) Heavily restored teeth ,pulpless (non-vital ) ,these teeth are
normally brittle and easily fractured during extraction .
4) If after clinical examination you decide to remove the tooth
surgically by dissection .
5) Any teeth or roots in close relationship to important structures like
inferior dental or mental nerve ,maxillary sinus, nasal cavity.
6) Attritioned teeth in elderly patient (maybe associated with
hypercementosis).
7) if a tooth is partially erupted or unerupted or retained root.
8) Any tooth which has been subjected to trauma, fracture of the root
and/or alveolar bone maybe present.
9) An isolated maxillary molar especially if it is unopposed and over
erupted. The bony support of such a tooth is often weakened by an
extension into it of maxillary sinus and this may predispose to either
the creation of oro-antral communication or fracture of the maxillary
tuberosity.
10) Whenever, underlying bony pathology is suspected e.g. cystic
lesion, tumors.
11) All mandibular third molars, instanding premolars or
misplaced canine , the root pattern of such teeth is often abnormal
12) Any tooth whose abnormal crown or delayed eruption might
indicate the possibility of dilaceration ,gemination ,or the presence
of odontome .
13) Any systemic condition which may predispose to dental or
alveolar abnormality like:
a) Ostetitis deforms (Paget’s disease), in which the roots
hypercementosed, ankylosis leading to difficult extraction,
infection of socket (chronic osteomyelities ) .
b) Cleido-cranial dystosis, for pseudo-anadontia(multiple
impactions, hooked roots occur, supernumerary teeth).
c) patient who have received therapeutic irradiation to the jaw
who may have to predispose to osteoradionecrosis.
d) Osteopetrosis (marble bone disease), which cause extraction
very difficult and predispose to chronic osteomyelities.
 Requirements of the pre-extraction radiograph :-
1- must show the whole root structure and the alveolar bone
investing the tooth .
2- in most cases an intra-oral periapical view will suffice
,but sometimes an extra-oral view like latteral oblique
mandible or orthopantomograph (OPG) will be required to
demonstrate this entire root ,or the state, structure ,and
amount of the supporting bone .
 A good radiograph and careful interpretation may enable or
aid the operator to detect many factors that may cause
difficulty in extraction of teeth, e.g.:
1- Abnormal number of roots, and shape of roots.
2- An unfavorable root pattern.
3- Caries extending to the root mass.
4- Fracture or resorption of the root.
5- Hypercementosis of roots.
6- Ankylosis (there is no space in periodontal ligament), and
sclerosis of the bone.
7- Germination (the development of two teeth from one bud).
8- Impacted teeth .
9- Bony sclerosis and pathological lesions.
 Also careful interpretation of the radiograph may also
reveal or show the possibility of the following complications:
1) Involvement of, and damage to inferior dental nerve and
mental nerve .
2) The creation oforo-antral or or-nasal communication.
3) The retention of intra-bony pathology e.g. cyst.
4) The displacement of root or tooth into maxillary sinus.
5) Fracture of maxillary tuberosity.