PERIOPERATIVE PATIENT MANAGEMENT
The removal of Impacted third molars is a surgical procedure that is associated with a large amount ‘of patient anxiety. In .addition, this surgical procedure can involve-unpleasant noises and sensations. As a result, surgeons who routinely perform surgical removal of impacted
third molars com monly recommend to their patientssome type of profound anxiety control such as a general anesthetic or deep intravenous (IV) sedation. The choice of technique is based on the surgeon’s preference.
However, the goals are to achieve a level ofpatient comfort that allows the surgeon to work efficiently and that limits the patient’s experience to the
minimal number of unpleasant effects. Whether a deep IV sedative or a Iight general anesthetic is used, most surgeons intend their patients to have little, if any, unpleasant memory of the surgical experience. In addi-tion to the increased need for anxiety control, a variety of medications are required to control the sequelae of third molar extraction surge~y. The’ use of longacting local anesthetics should be considered in themandible. They will provide the patient with a pain-free period of 4 to 6 hours during which prescriptions can be. filled and analgesics taken. The surgeon should consider ‘writing a prescription for a potent oral analgesic for every
patient w ho undergoes surgical removal ofarr impactedthird molar. Enough tablets should be prescribed to last for 3 or 4 days. Combinations of codeine or codeine congeners with aspirin or acetaminophen are commonly used. Nonsteroidal antiinflammatory drugs (NSAf[)s)
may be of some value for certain patients.To minimize the swelling common after the removal of impacted third molars, some to give parenteral steroids. amount of a glucocorticoid steroid provides sufficient antunrlammatory activity to give relief to swelling.
Although many different regimens and protocols for steroids exist, a relatively common one is the single administration of 8 mg of dexamethasone before surgery. This is a relatively long-acting steroid, and its efficacy in controlling third molar postsurgical swelling is documented.
Although ster ids given in this manner have few side effects or contraindicatlons, the general philosophy of weighing the risks and benefits of drug administration must be carefully followed before the decision is made to give these dru gs routinely. .Many surgeons recommend the use of ice packs on the face to help prevent postoperative swelling. Although it is
unlikely that the ice has much effect on preventingswelling, patients ‘frequently report that the ice made them feel more comfortable. Something cool applied to . the face often makes patients more comfortable. It also
provides them the opportunity to participate in theirpostoperative care, which is important for many patients. The intraoral use of ice may have additional benefit. Gently sucking on small pieces of ice or even on commerciai Popsicles may be of some value in helping patients feel more comfortable, although any measurable decrease in swelling in patients who use this technique is unlikely. Another medication that is sometimes used is an antibiotic. If a patient has had a preexisting pericoronitis, it iscommon to prescribe antibiotics for a few days after surgery. However, if the patient is healthy and the clinician finds no systemic indication for antibiotics. or a preexisting local infection, antibiotics are usually not indicated.The normal postoperative experience of a patient after surgical. removal of an impacted’ third molar is more involved than after a routine extraction. The patient can expect a modest amount of swelling in the area of the surgery
for 3 to 4 days, with the swelling completely dissipatingby about 5 to 7 days. A modest amount of discomfort usually follows the procedure. This discomfort can be effectively controlled with potent oral analgesics.
Patients us ually require analgesics for 2 or 3 days on a routlne basis and intermittently for several more days. The patient may have some mild soreness in the region for 2 to 3 weeks after the surgery. Patients who have had mandibular third molars surgically removed frequently have mild-to-moderate trismus. This inability to open the mouth interferes with the
patient’s normal or al hygiene and eating habits. Patients should be warned that they will be unable to open their mouths normally after surgery. The trismus gradually resolves, and the ability to open the mouth should return
to normal by 10 to 14 days after surgery. All of the sequelae of the surglcal removal of impacted teeth are of less intensity in the young, healthy patient
and of far greater intensity in the older, more debilitated patient. Even healthy adult patients between the ages of to 40 years have a significantly more difficult time after the extraction of impacted ‘third molars than do
healthy 17-year-ol d pattents. See Chapter 10 for a more detalled escription of postoperative care