Category Archives: Postoperative Patient Management

OPERATIVE NOTE FOR THE RECORDS

The surgeon must enter into the records a note of that transpired during each visit. Some critical f.u tors must-be entered into the chart. The first is the date of the operation and a brief identlfication of the patient; then the surgeon
states the diagnosis and .reason for the extraction  e.g., non restorable caries or severe periodontal disease). Comments regarding the patient’s pertinent medical history, medications, and vital signs should be mentioned
next in the chart. This information should.  in the chart before the surgery is performed, to confirm that the dentist has reviewed these issues with the patient and that the patient’s current status is satisfactory for the surgical procedure.

POSTOPERATIVE FOLLOW UP VISIT

All patients should be given a return appointment so that the surgeon can check the patient’s progress after the. surgery. In routine, uncomplicated procedures, a follow-up visit at 1 week is usually adequate. If sutures are to be removed, that can be done at the I-week postoperative  appointment. ‘
‘Moreover, patients should be informed that shouldany question or problem arise, they should call the dentist and request an earlier follow-up visit. The most likely reasons for an earlier visit are prolonged and. bothersome bleeding, pain that is not responsive to the prescribed
medication, and infection. If a patient who has had surgery begins to develop .swelling with surface redness and pain’ on the third postoperative
day or later, the patient can be assumed to have developed an infection until this is proven otherwise. The patient should be instructed to call for an appointmentat the dentist’s office as soon as possible. The surgeon must then inspect the patient carefully to confirm or rule out the diagnosis of infection. If an infection is diagnosed, appropriate therapeutic measures should be taken (see-Chapter 15). Postsurgical pain that decreases at first but on the third or fourth day begins to increase, yet is accompanied by
no swelling or other signs of infection, is probably a sign  of “dry socket.” This annoying problem is simple to manage but requires that the patient return to the office several times (see Chapter 11).  It is important that the patient know that the dentist,is available to answer any postoperative questions and· treat any postoperative problems that arise. Even if a
postoperative tallow-up  does not appear to be necessary,  one-should be made  the patient an 01 portunity

Ecchymosis

In some patients blood oozes submucosally (SM) and subcutaneously (SC), which appears as a bruise in the oral tissues on the face (Fig, 10-3), Blood in the subcutaneous tissues is known as ‘ecchvmosis. This is usually seen in older
patients because of their decreased tissue tone and weaker intercellular attachment. Ecchymosis is not dangerous and does not increase pain or infection. Patients, hower

er, should be warned that ecchymosis may occur, because if they awaken on the second postoperative day and see  bruising in the cheek or submandibular area, they maybecome very apprehensive about their progress. This anxiety is easily preventable by postoperative instructions.
Typically the onset of e chymosis is 2 to 4 days after surgery and usually resolves with 7 to 10 days.

 

 

Trismus

Lxtraction of teeth may result in trismus. or limitation in opening  the mouth. This is the result of inflammationinvolving the muscles of mastication. The trismus may be a result of multiple injections of local anesthetic, especially
if the injections have’ penetrated muscles. The muscle most likely to be involved is ‘the medial pterygoid muscle,which may be  nadvertently penetrated by {he local anesthetic   needle during the inferior ‘alveolar nerve block. Surgical extraction of impacted mandibular third molars frequently results in trismus, because the inflammatory response to the surgical procedure is sufficiently widespread to involve several muscles of mastication. Trismususually is not severe and does not hamper the patient’s activity. However, to prevent alarm, patientsshould be warned that thi henomenon might occur,The application of heat mav be helpful in helping to
resolve persistent trismus and swelling, It ~s dear that for maximum effectiveness, the application of heat must be  by use of moist heat. Because of the closer contact with the skin, heat transfer to the tissue is most effective when the heat source is from a wet surface.

Control of Infection

To control infection the surgeon must carefully adhere . to the principles of surgery. No other special measures must be taken with the average patient. However, some patients, especially those with depressed host defense
responses, may require antibiotics to prevent , infection. Antibiotics in these. patients should bead ministered before the surgical procedure is begun
(see Chapter 15). Additional antibiotics after the surgery are usually not
necessary. A surgeon who decides to give additional antibiotics must carefully discuss the timing of administration with the patient that a clear  understanding is reached

 

 

 

 

Edema

Most surgical procedures result in a’ certain amount of edema or swelling after surgery. Simple extraction of a single tooth will probably not result. in swelling that the  patient can see, whereas the extraction of multiple impactedteeth with reflection of soft tissue and removal of bone·may result in large amounts of swelling (Fig. 10-2). Swelling usually reaches its maximum 24 to 88 hours after the surgical procedure. It begins to subside on the third or fourth day and is usually resolved by the end of the first
week: Increase  swelling after the third day may be anindication of infection rather than postsurgical edema. Once the surgery is completed and the patient is ready to be discharged, application of ice packs to the area may
help minimize the swelling and make the patient feelmore comfortable; it also allows patients to playa role in their postsurgical care. Ice should not be placed directly  on the skin, but rather a layer of dry cloth should be
placed between the ice container and the tissue to preventsuperficial tissue damage. The ice bag should be kept on the local area for 20minutes and then left ‘off for 20 minutes. Ice pack application should be maintained for no more than 24 hours, because longer application does not help. Ice packs are only minimally effective in controlling edema. Some surgeons  prefer the intraoral application of ice. This can beaccomplished by having the patient hold ice chips in the mouth or by sucking on a flavored Popsicle,
On the second postoperative day, neither ice nor heat should be applied to the face. On the third and subsequent postoperative days, application of heat may help to resolve the swelling more quickly. Het sources such as
hot water bottles and heating pads are recommended. Patients should be warned to avoid high-level heat for long periods jo keep from burning 01 injuring the skin.

Oral Hygiene

Patients “should be advised that keeping the teeth and mouth reasonably clean results in a more rapid healing oftheir surgical wounds. On the day of surgery patients (an gently brush the teeth that are away from the area of surgeryin the usual fashion. They should avoid brushing the teeth immediately adjacent to the extraction site to prevent a new bleeding episode and to avoid pain.
The next day, patients should begin gentle rinses with warm water. The water should be warm but not hot enough to burn the tissue ..Most patients can resume preoperative oral hygienic methods by the third or fourth day after surgery. Dental floss should be used in the usual fashionon teeth anterior and posterior to the ex:traction sites as soon as the patient is comfortable enough to do so. Uoral hygiene is likely to be compromised after extractions  in multiple areas of the mouth, local antibioticmouth rinses with agents such as chlorhexidine may be used. Twice-daily rinses for approximately 1 week after
surgery may result in more rapid healing.

Diet

Patients who have had extractions may avoid eating because of local pain or fear of pain when eating. Therefore they should be given very specific instructions regarding their postoperative. diet. A high-calorie, highvolume
liquid diet is best for the first 12 to 24 hours.  The patient must have an adequate intake of fluids,usually at least 2 quarts, during the first 24 hours. The flu ids can be juices, milk, water, or any other beverage that
appeals to the patient. Food in the first 12 hours should soft and cool. Cool and cold foods help keep the local uacomfortable. Ice cream and milkshakes, unlike solid foods, tend not cause local trauma or initiate rebleeding episodes.
If the patient had multiple extractions in alflareas of the mouth, a soft diet is recommended for days after the surgical procedure. In n patient have surgery only in an isolated quadrant or  mouth, which leaves the opposite side free to chew. the patient should be advised to rett;rn to a normal diet as soon as possible. Patients wlto are dibetic should be encouraed 0return to their normal insulin and diet routine as soon as possible. For such patients the surgeon should plan gery in only one side of the mouth at each surgical sitting.
thereby not interfering with the normal dietary intake.

CONTROL OF POSTOPERATIVE PAIN AND DISCOMFORT 

All patients expect a certain amount-of pain after a surgical  procedure, so iris important for the dentist to discuss this -issue carefully with each patient before discharge from the office. The surgeon must help the patient” have a realistic expectation of what type of pain may occur, The surgeon must therefore pay attention to the patient’s concerns and preconceived ideas of how much pain is likely to occur.Patients who tell the surgeon that they expect a great deal of pain after surgery should not be ignored and told to take an aspirin if it hurts, because these are the patients most likely to experience pain post operatively. It is important for the surgeon to assure patients, especially the latter group, that
their postoperative pain can be effectively managed. The pain a patient may experience after a surgical procedure, such as tooth extraction, is highly variable and depends a great deal on the patient’s preoperative frame of mind. The surgeon who spends several minutes discussing these issues with the patient before surgery will be able to recommend the most appropriate medication. All patients should be given advice concerning analgesics
before they are discharged. Even when the surgeon believes that no prescription analgesics are necessary, the patient should be told to take aspirin or acetaminophen postoperatively to prevent initial discomfort when the effect of the local anesthetic disappears. Patients who are
expected to have a higher lave. of pain should be given prescripttonsfor analgeslcs’that wiH conttol the pain, The surgeon should also take care to advise the patient that  the goal- of analgesic m edication is management of pain and not efimination of an soreness.  Tfte surgeon must under-stand the three characteristicsof the pain that occurs after tooth extraction. First, it is
usually not severe and .can be managed in most patients with mild analgesics. Second, the peak pain experience occurs about 12 hours after the extraction and diminishes rapidly after that. Finally, the pain from extraction .rarely persists longer than 2 days after surgery. With these
factors kept in mind, patients can best be advised regarding
the effective use of analgesics. The first dose of analgesic medication should be taken before the effect.of the local anesthetic subsides. If this is
done, the patient’ will not experience the intense, sharppain after the loss of the local anesthesia. By preventing the sudden onset of surgical pain, the subsequent control of it is more ‘easily and predictably achieved with mild
analgesics. Postope rative pain is much more difficult to overcome if administration of analgesic’ medication is delayed. If the patient waits to take the first dose of analgesicuntil the effects of the local anesthesia have disappeared, it will take up to 90 minutes for the analgesic to become effec ive. During this time, the patient is likely to become impatient and take additional medication that  will increase the chance of nausea and vomiting.
The strength of, the analgesic is also of importance.Potent analgesics are not required in most extraction sit- ‘ uations; instead, analgesics with a lower potency per dose are effective. The’ patient can then be told to take, one, two, or three tablets as necessary to control pain. By allowing the patient to assume an active role in deter-‘mining the amount of medication to take, a more precise and realistic control can be achieved.Patients should be warned that taking too much of themedication will result in drowsiness and an increased chance of an upset stomach. In most situations, patients, sh~q~- take medicat on with some type of food to
decr~ its Irntatlng effect on the stomach.Aspirin has been demonstrated to be an effective medication to control the, pain, and discomfort of a toothextraction. This drug work-, pruuarilv peripherally, interfering
with prostaglandin synthcsts. If the surgeon pre’scribes a combination drug of avpirin and narcotic. it should be, a combination that delivers 500 to 1000 mg of aspirin per dose. If the patient cannot tolerate aspirin.acetaminophen in a similar dose is a good alternative
drug. Aspirin has the disadvantage of causing a decrease in ,platelet aggregation and bleeding time, but this does not appear to have a clinically important effect on postoperative bleeding. Acetaminophen ‘does’ not interfere with platelet function at all, and it may be useful in ceratain   ituations where the patient has a platelet defect and is likely to bleed. spirin remains the drug of choice forcontrol of mild-to-moderate pain after tooth extraction. Nonsteroidal antiinflammatory analgesics (NSAIDs),such as ibuprofen, are also useful for patients who havehad a tooth extraction. Well-conttOlled studies have documented  their effectiveness’. They are effective for mildto-moderate pain. It subcategory of NSAIDs, COX:2
inhibitors, causes less irritation of the gastric mucus, hasless effect on platelet function, and may provide for longer periods of analgesia. They, may be, useful in the management of postoperative pain that is expected to
last for more than. several days. Currently, no published data indicates that COX,:2 inhibitors are superior to other NSAIDs.in,tpe control of routine postextraction pain. Drugs useful in situations with varying degrees of pain
are listed in Table 19  1. Centrally acting analgesics are alsofrequently used to control pain after tooth extraction. The” most commonly used drugs are codeine and the codeine congeners such as oxycodone, hydrocodone, and dihydrocodeine. These narcotics are well absorbed from thegut; when used in equipotent doses, they produce·similar pain relief, drowsiness, and gastrointestinal upset. They are rarely used alone; instead, they are formulated with other analgesics, primarily aspirin or acetaminophen.
When codeine is used, the amount of codeine is frequently designated by a numbering system, Compounds label no. 1 have 7.5 mg of codeine; no. 2, IS mg; no. 3, 30 mg;and no. 4, 60 mg., When a combination of analgesic drugs is used, the dentist .must keep in mind that it is necessary to provide
500 to 1000 mg of aspirin or acetaminophen every 6 hours to achieve maximal effectivtness from . Many of the compound drugs have only 300  mg of aspirin. or’ acetaminophen added to the narcotic. An example of a rational approach would be to prescribe a compound containing 300 mg of aspirin and 15 mg of codeine (no. 2). The usual adult dose would be two tablets of this compound every 4 .hours. This two-tablet  (30 mg of codeine and 600 mg of aspirin) dose provides anearly ideal analgesia. Should the patient require stronger analgesic action, three tablets can be taken wit increased effectiveness of both aspirin and codeine. Doses that supply  30 or 60 109 of codeine but only 300 rng of aspirin fail to take’ advantage of aspirin’s analgesic effect (Table 10·2). Other drugs that can be used as analgesics that rroduceeffects centrally are pentazocine, meperidil1e,.3~-hydromorphone. Pentazocine and meperidine are useful but definitely second-choice drugs

 

The Drug Enforcement Administra.lon (DEA) controls narcotic analgesics. To write prescriptions for these drugs,the dentist must have a DEA permit and number. The drugs are categorized into four basic schedules based on
their liability for abuse. Several important differencesexist between Schedule II and Schedule III drugs concerning writing prescriptions (see Appendix Ill). It is important to emphasize that the most effectivemethod of controlling pain is to build a close relationship etween surgeon and patient. Specific time must be spent discussing the issue of postoperative  iscomfort, with concern clearly expressed by the surgeon. Prescriptions should be given with clear instructions about when to begin the medication and how to take it ateach innrval. If these procedures are followed, mild analgesics given for a short time (usually no longer than 2 to 3 days) will be all that is required.

 

 

 

 

 

CONTROL OF POSTOERATIVE BLEEDING

Once an extraction has been completed, the initial maneuver to control postoperative bleeding is the placement of a  small, damp gauze pack directly over the empty socket.Large packs that cover the occlusal surfaces of the teeth <10- not apply pressure to the bleeding socket and should not be used (Fig. 10-1). The gauze should be moistened .the oozing blood does not coagulate in the  dislodge. the clot when the gauze is remover. ill’ patient
should be instructed to bite firmly on this  at least

the hemorrhage and to swallow their saliva instead of spitting  it out. Finally, no strenuous exercise should be performedfor the first 12 to 24 hours after extraction, because the increased circulation may resultin bleeding. Patients should be warned that there may be some oozing during the night. and that they will probably have some blood on their pillows. This will prevent many frantic telephone calls to the surgeon in the middle of the night. Patierits should also be instructed that if they are worried
about their bleeding, they should call the dentist tb get additional advice. Prolonged bleeding, bright red bleeding, or large clots in the patient’s mouth are all indications  for a -return visit. The dentist should then xamine
the area closely and” apply appropriate measures to  control the bleeding (see Cha.pter 11).