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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses some complications that may be encountered in outpatient dental practice, as well as methods by which to avoid and manage them. Specific highlights include complications in outpatient dental practice are important to consider for various reasons, such as their associated medicolegal implications and potential loss of revenue, and described some of the most common types of complications that can occur.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EDental Anesthesia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESurgical Procedures\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EDental Anesthesia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESurgical Procedures\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDentistry\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EIn an education course, Mehran Hossaini, DMD, University of California, San Francisco, California, USA, discussed some complications that may be encountered in outpatient dental practice, as well as methods by which to avoid and manage them.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EDr Hossaini highlighted that complications in outpatient dental practice are important to consider for various reasons, such as their associated medicolegal implications (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) and potential loss of revenue, and described some of the most common types of complications that can occur.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/38\/11\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Distribution of Professional Liability Claims in Dental Practice, %\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1396932154\u0022 data-figure-caption=\u0022Distribution of Professional Liability Claims in Dental Practice, %\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/38\/11\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/38\/11\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/38\/11\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15003\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EDistribution of Professional Liability Claims in Dental Practice, %\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from M Hossaini, DMD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECOMPLICATIONS OF LOCAL ANESTHESIA\u003C\/h2\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EAccording to Dr Hossaini, common complications of local anesthesia include the following.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003E\n            \u003Cem\u003EPain at the injection site\u003C\/em\u003E: This is typically due to use of a dull needle, rapid injection rate, the presence of inflammation, or poor injection technique. To avoid this complication, Dr Hossaini emphasized the need to pay attention to technique, particularly replacing the needle after multiple uses.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003E\n            \u003Cem\u003EHematoma formation, infection, or trismus\u003C\/em\u003E: These 3 issues can also arise from the use of dull, damaged, or contaminated needles as well as from vascular damage or bleeding disorders in patients. Affected patients may require aggressive physical therapy, anti\u2013inflammatory medication, warm compresses, and antibiotic therapy. Muscle relaxants may also be helpful, and patients should be advised to eat a soft diet.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EDiscussing the problem of trismus, Dr Hossaini stressed the need to attempt forced opening of the jaw to determine whether there is true restriction of movement or whether it is a guarding mechanism due to pain.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003E\n            \u003Cem\u003ENerve damage\u003C\/em\u003E: Because of reporting issues, it is difficult to precisely ascertain the incidence of nerve damage following inferior alveolar local anesthesia; Dr Hossaini stated that extrapolated data show approximately 1 in 20 000 to 850 000 patients, with the lingual nerve affected in 70% of cases.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EAlthough it remains unknown why local anesthesia causes nerve damage, mechanisms such as direct trauma, neurotoxicity, and hemorrhage have been proposed. Medical management of the pain should be considered in these patients, because many respond well to gabapentin therapy. Antidepressant medication may also be helpful, particularly with tricyclic antidepressants or serotonin\u2013 or norepinephrine\u2013reuptake inhibitors.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003E\n            \u003Cem\u003EBroken needle\u003C\/em\u003E: Rarely, a needle may break during injection of the local anesthetic (LA). Typically, this may result from use of a 30\u2013gauge needle, use of a bent needle, insertion of the needle to the hub, or multiple use of the same needle. Affected patients require surgical management to remove the needle. This problem, however, is preventable, and actions should be taken to avoid its occurrence, including modification of the needle type used and needle handling.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003E\n            \u003Cem\u003EOther complications\u003C\/em\u003E: These include toxicity, reaction to vasoconstrictor, syncope, allergic reaction, and missed nerve blocks or inadequate anesthesia.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECOMPLICATIONS OF EXTRACTION\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EComplications associated with tooth extraction include the following.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003E\n            \u003Cem\u003ETooth or implant displacement\u003C\/em\u003E: Common sites for tooth or implant displacement include the sinus, infratemporal fossa, mylohyoid space, bronchial tree and lungs, and esophagus and gastrointestinal tract. Dr Hossaini noted that this may arise due to poor diagnostic imaging, a lack of anatomic recognition, inadequate visualization, improper dissection and retraction, excessive elevation or force, or poor elevation technique. Affected patients require close observation, and may need oral antibiotic therapy. If surgical removal of the displaced tooth or implant is required, intraoperative radiography and fluoroscopy may be necessary. This is also a preventable problem, and action must be taken to prevent its recurrence, including making improvements in patient preoperative evaluation as well as case\u2013selection criteria.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003E\n            \u003Cem\u003ENerve damage\u003C\/em\u003E: Nerve damage is another common complication in outpatient dental practice, most commonly in association with implant placement. Other associations include tooth extraction, endodontic treatment, LA injection, trauma, infection, and the presence of pathologic lesions in the oral cavity. Nerve damage typically arises from improper or inadequate preoperative or postoperative patient evaluation, treatment implementation, management of complications, or referral.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003E\n            \u003Cem\u003EPreoperative or postoperative patient evaluation\u003C\/em\u003E: Dr Hossaini highlighted the need to ensure preoperatively that a particular procedure is actually indicated, and to consider alternative techniques if appropriate. Diagnostic imaging should also be considered, as necessary. Although intraoral radiography has minimal or no surgical diagnostic value, extraoral imaging techniques such as panoramic radiography or cone beam computed tomography may be valuable in some cases. The patient\u0027s medical history should also be thoroughly reviewed.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EDr Hossaini noted that implant\u2013related nerve injury can be indirect or direct.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003E\n            \u003Cem\u003EIndirect\u003C\/em\u003E: This arises in association with retraction or displacement of graft material, as well as edema, hematoma formation, and infection. Common causes include poor flap design and retraction, poor flap hygiene, a lack of anatomic recognition, inadequate hemostasis prior to closure and patient discharge, and inadequate understanding of the patient\u0027s medical history.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003E\n            \u003Cem\u003EDirect\u003C\/em\u003E: This typically arises in association with osteotomy, compression, or implant displacement. It is commonly caused by inadequate risk stratification in particular, as well as poor treatment planning, anatomic recognition, or surgical technique.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EAffected patients require careful observation for at least 2 to 4 weeks initially. Observation is typically indicated in cases where there is no evidence of nerve transection, where the altered sensation is consistent with paresthesia, or where the patient is improving rapidly. However, some may require referral to a dental specialist with expertise in dealing with nerve injury, particularly in cases involving nerve transection or no signs of improvement, or where it is difficult to evaluate nerve function and pathology, or the patient is experiencing dysesthesia, or anesthesia without signs of improvement.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EIMPLANT\u2013RELATED COMPLICATIONS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EAccording to Dr Hossaini, common implant\u2013related complications include nerve damage, implant displacement, implant failure or ailing, and graft complications. He added that additional factors such as infection and bone or soft tissue loss may also compromise treatment and contribute to failure.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EIn his concluding remarks, Dr Hossaini also emphasized the need to be aware of medical complications in patients, particularly medical conditions that mimic dental conditions, and medication\u2013related osteonecrosis associated with treatment with antiresorptive or anti\u2013angiogenic agents.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/38\/11.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzonvp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzonvp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}