Complications During and After Dental Prophylaxis

Professional dental cleanings (PZR) and periodontal therapies are often delegated by dentists to specially trained dental staff. In addition to dental instruments, ultrasonic tips, powder-water jet devices, various rinsing solutions, and polishing pastes are used during dental cleanings and periodontal treatments. Although in most cases the process runs smoothly, complications can arise.

Consultation with the Dentist

Dental hygienists and dental assistants are trained and qualified professionals whose areas of expertise mainly include prophylaxis and periodontal therapy. They greatly relieve the dentist in this regard. However, despite all caution and routine in treatment, complications can occasionally occur. Particularly at risk are vulnerable groups, including immunocompromised patients, patients with cardiovascular diseases, metabolic disorders or allergies, as well as patients with pre-existing endocarditis, pacemakers, organ transplants, or diabetics. Complications can also occur in patients with advanced periodontal disease during treatment. Therefore, it is always important to consult with the attending dentist before treatment and to inform them immediately of any complications that arise in serious cases.

Emphysema

Emphysema refers to non-physiological air or gas inclusions in the soft tissue. These can occur during dental cleaning, for example, through the use of powder-water jet devices (Fig. 1a and b). Problematic and particularly susceptible are periodontally compromised teeth or peri-implant tissues that have changed, where there is no tight and dense margin sealing. The specially designed tips for pocket cleaning for the powder-water jet device usually have both mesial and distal openings, from which the powder or water can escape. As a result, the powder-water jet not only hits the tooth surface but is also sprayed directly into the soft tissue on the other side (Fig. 1c). In the case of emphysema, patients often complain of a suddenly occurring severe pain. The air inclusion leads to swelling and possibly a crackling sound upon palpation. However, these symptoms are often mistaken for allergic symptoms, for example, due to the local anesthetic.

It is important that a dentist is consulted if there is a suspicion of soft tissue emphysema. If the emphysema has a large extent or exerts pressure on air and/or blood vessels, it can rarely lead to life-threatening circumstances. A referral to a specialist in oral and maxillofacial surgery (OMFS) or to a clinic is then unavoidable. The therapy of choice is an antibiotic and pain therapy. In most cases, patients show no symptoms after three days.

Tip for the practitioner: Before using powder-water jet devices, check the probing depths. If there are very deep pockets without buccal bony boundaries, either use the device very carefully or resort to manual cleaning. If something happens despite caution, inform the patient and prescribe both antibiotics and analgesics. A follow-up check the next day is recommended.

Periodontal Abscesses After Teeth Cleaning

In patients with severe periodontitis and high bacterial load with pocket secretion, or in situations with unrecognized endo-perio lesions, abscess formation can occur during professional teeth cleaning in the hygiene phase. The reason for this is that cleaning the tooth surfaces can lead to spontaneous healing of the inflamed gum margin. In this case, the fibers in the gum become taut, closely adhere to the tooth, and form a kind of "sealing." However, since the bacterial load in the deep periodontal pockets is not reduced by teeth cleaning, the now healthy sealing gum prevents the drainage of pocket secretion. This leads to an accumulation of inflammatory secretion and abscess formation (Fig. 2a and b). This results in painful swelling of the gums. Therefore, the dentist must decide in advance whether it makes sense to skip the hygiene phase before periodontal therapy in such cases and to start periodontal therapy immediately or to take endodontic action to prevent the "sealing" and thus abscess formation. However, if abscess formation occurs, the pocket must be cleaned immediately or, in worse cases, the abscess must be surgically opened. In exceptional cases, antibiotics may also be necessary.

Bacteremia

Bacteremia refers to the presence of bacteria in the bloodstream. The oral cavity, with its over 700 different species of bacteria, not only serves as a source of infection but also as a gateway into the bloodstream, the respiratory tract, and the digestive tract. Even small injuries to the oral mucosa can cause bacteria to be carried to other parts of the body. While routine tooth brushing can lead to a bacteremia prevalence of up to 26 percent, the risk increases to up to 40 percent during dental prophylaxis. In periodontal therapy, the prevalence of bacteremia can even reach up to 80 percent, as subgingival debridement is an invasive procedure. However, this largely depends on the inflammatory condition of the gums and the periodontium, as well as the patient's oral hygiene. The rule is: the higher the degree of inflammation and the poorer the oral hygiene, the higher the risk of bacteremia. The junctional epithelium, as the transition from the gum to the tooth and into the tooth socket, is the only place in the body where bacteria can enter other regions due to a disruption of the epithelium and be carried away through the bloodstream. For example, patients with severe periodontitis may show elevated inflammatory markers in their blood tests. Pathogenic microorganisms from the oral cavity can also be detected in blood cultures. Particularly in at-risk patients with pre-existing heart conditions or heart valves, treatment in the dental office can lead to endocarditis. Additionally, poorly controlled diabetics, patients with a history of joint replacement or organ transplantation, as well as rheumatics may be at risk for bacteremia. Since this poses a significant health risk, guidelines such as those from the German Society of Cardiology recommend that these at-risk patients be prophylactically treated with antibiotics before a procedure. These patients should receive 2 g of Amoxicillin orally one hour before the start of treatment, or alternatively, 600 mg of Clindamycin if they are allergic to penicillin. Additionally, a mouth rinse with 0.2% chlorhexidine digluconate is advisable. Therefore, especially for at-risk patients, thorough communication between the dentist and the prophylaxis assistant is essential. It is also strongly recommended that in cases of uncertainty, consultation with the treating general practitioner or specialist should be sought.

But even non-risk patients can complain about symptoms after periodontal therapy. Due to the high bacterial load, in addition to pain in the gum area, a fever reaction can also occur. The release of bacteria from their association and the subsequent transport of pathogenic germs and their toxins into the bloodstream can significantly stimulate the patient's immune defense. Patients should be informed about this possible side effect in advance.

Tip for the practitioner: If there is heavy bleeding, the patient should remain in the practice for monitoring, in addition to hemostatic measures, for some time after the treatment and may need to be scheduled for a follow-up check the next day. In any case, it is important that anticoagulants or platelet aggregation inhibitors should not be discontinued or bridged in the practice under any circumstances.

Patients with Coagulation Disorders

It is well known that patients with altered blood coagulation, especially during surgical procedures, pose a complication risk in the dental practice. However, increased bleeding can also occur during periodontal therapy, and less frequently during a professional teeth cleaning (PZR). If patients are known to be taking platelet aggregation inhibitors such as aspirin, the bleeding risk can be assessed or discussed with the treating general practitioner. Greater danger exists for patients who suffer from undiagnosed hemophilia or von Willebrand syndrome and also have pronounced gingivitis. If heavy bleeding occurs, the dentist should be informed immediately. Measures such as rinsing with tranexamic acid or applying a gum dressing can be used to alleviate the bleeding. It is advisable to have the patient remain in the waiting room for an additional hour for observation in the case of heavy bleeding, in order to monitor the course. This should be particularly noted after the injection of local anesthetics with astringents. Nevertheless, it is true that a PZR or periodontal treatment has far more favorable prognoses for patients with coagulation disorders than persistently inflamed gums. Special caution is required for patients on anticoagulants such as coumarins. If they also receive an antibiotic as part of the therapy, there may be significant disturbances due to the additionally altered vitamin K absorption in the intestine. These incidents are extremely rare.

Tip for the practitioner: In the case of at-risk patients, an up-to-date medical history should always be considered. In case of uncertainties, the guidelines of the AWMF (Association of Scientific Medical Societies in Germany) can help. In case of doubt, coordination with the specialist is essential.

Conclusion

Both a professional tooth cleaning and a closed periodontal therapy can bring complications that are not always predictable beforehand and can have serious consequences. Especially at-risk patients must be discussed with the dentist and, if necessary, with the general practitioner before treatment begins. If a complication occurs, quick and correct action is required from both the dental assistant and the dentist.

The article was published in Dental Tribune .