Post-Operative Instructions Oral Surgery

Question 1

3 types of post op oral surgery instructions

Answer 1

• Post extraction instructions (non-surgical)
• Post-surgical instructions
• Post biopsy/soft tissue surgery instructions

All fairly similar

Question 2

importance of good clear post operative instructions

Answer 2

Clear post-operative instructions are as important, if not more so, than the procedure itself.

Time well spent
- But often done poorly/not at all

If patients know what to expect the vast majority of them will not phone you or come back to the practice with concerns over routine post-operative symptoms

Question 3

why post op instructions done poorly

Answer 3

Time pressures/ next patient waiting

Operator tired after procedure/ stressed after procedure

Patient stressed/ upset after procedure

Question 4

best technique for delivering post op instructions

Answer 4

– verbal with eye contact and followed up by written leaflets to take home

Question 5

if patients do not know what to expect after a procedure

Answer 5

They will often panic over things that are normal e.g. pain after an extraction

This will result in patients contacting (perhaps out of hours)
Or
Coming to the practice for extra emergency appointments
Or
Attending other dental emergency clinics
When there is no need to!

Ensure pt is aware of what to expect so they don’t panic

Question 6

4 points in post extraction instructions

Answer 6

Expect pain & how to deal with it

How to avoid/deal with bleeding

Things that will help/delay healing

Other post operative symptoms that are to be expected

Question 7

pain post extraction

Answer 7

Tell patients to expect post-op pain

Always tell patients that they will be sore when the local anaesthetic wears off

• Tell them normal pain killers should keep the pain under control
• start painkillers before the anaesthetic wears off (tell them within the next 1-2 hours, although local anaesthesia can last longer)
• get on top of the pain before it starts you have a much better chance of keeping it under control

Tell them this is normal
- Vary in severity between people

Let them know this will settle over the next few days (occasionally 1-2 weeks for those who get a dry socket

Question 8

how to control pain post extraction

Answer 8

Tell patients to use regular analgesia for 1-3 days

Then

Use analgesia as required

Question 9

best analgesia for extraction

Answer 9

If you can take Ibuprofen it is one of the best painkillers for dentoalveolar pain

Make sure the patient knows to take it after food/ not on an empty stomach

Question 10

caution when prescribing ibuprofen

Answer 10

Previous or active peptic ulceration/ gastro-oesophageal reflux disease (GORD)/

The Elderly

Pregnancy & lactation

Renal, cardiac or hepatic impairment

History of hypersensitivity to Aspirin & other NSAIDs

Asthma (do not give Ibuprofen to patients with asthma unless they have taken it before with no problems)

Patient taking other NSAIDs

Patients on long term systemic steroids

Question 11

ibuprofen dose

Answer 11

200, 400mg or 600mg tablets
- (Dental use: 200mg or 400mg tabs)

1. 2 – 1.8g daily in 3 – 4 divided doses preferably after food
   - Max. dose 2.4g daily

Child: reduced dose, depends on age/weight (see BNF)

Question 12

paracetamol (acetaminophen)

Answer 12

useful for dentoalveolar pain
especially in patients who can’t take Ibuprofen:

Different mode of action to the NSAIDs

• Mainly centrally mediated
• No effects on bleeding time
• Less irritant to GIT

simple analgesic with anti-inflammatory activity

Question 13

paracetamol cautions

Answer 13

1. Hepatic impairment
2. Renal impairment
3. Alcohol dependence

Question 14

paracetamol dose

Answer 14

500mg tablets

Adults: 1-2 tablets (0.5-1g) every 4-6 hours
- Max. Dose 4g daily (8 tablets)

Always warn patient off and emphasise they should not exceed this

Children: Depends on weight/age – see BNF

Question 15

paracetamol overdose risk

Answer 15

As little as 10-15g (20-30 tablets) or 150mg/kg of paracetamol taken within 24 hours may cause severe hepatocellular necrosis,
- less frequently, renal tubular necrosis

REFER TO A&E IMMEDIATELY

Question 16

co-codamol

Answer 16

often used by patients:

Doses: 8mg Codeine 500mg Paracetamol
- 30mg codeine 500mg Paracetamol

Do not take with paracetamol
- Tell patients to check what is in any over the counter brand name medications they buy – they may contain paracetamol – and if they take them with paracetamol this can lead to accidental overdose

Question 17

what is one of the best analgesia routines if patient can take

Answer 17

Ibuprofen and Paracetamol interspersed

E.g. Take 400mg Ibuprofen, then 2 hours later take 1g Paracetamol, then around 4 hours after this take 400mg Ibuprofen, then 2-4 hours later another 1g Paracetamol and so on. But do not exceed recommended doses

Question 18

post operative bleeding instructions

Answer 18

Tell the patient post-op bleeding is unlikely but it is a possibility
- Better to expect it as often contact or come back due to

Do not explore the socket with finger/ tongue/ toothbrush – this will disturb the clot and may result in bleeding

Do not exercise that day/ avoid rushing about/ avoid anything that increases blood pressure which may result in bleeding

Question 19

methods to help healing post extraction

Answer 19

Avoid hot/hard foods

• Otherwise – eat and drink normally but keep it to the other side of the mouth for a few days
• Stick to a softer diet for a few days

Avoid alcohol for that day (some say for the next 24hours)

Do not rinse out for several hours or until the next day (some say 24 hours)
- this may disturb the clot and start bleeding (or result in dry socket/slow healing socket, (which can be extremely painful) because healing clot has been removed)

Question 20

issue of hot foods and post extraction bleeding

Answer 20

The patient will still be numb and may burn the lip or tongue with hot food/drinks and not realise it has happened
heat causes vasodilation and may encourage bleeding

Question 21

issue with hard foods and post extraction bleeding

Answer 21

may traumatise the socket.
If patient is still numb they may not feel the injury occurring.
Also the trauma from hard/sharp foodstuffs may result in bleeding
Pack into socket

Question 22

alcohol problem post extraction

Answer 22

Alcohol may affect a healthy clot formation and result in bleeding or delay the healing process

Question 23

rinsing instructions for post extraction

Answer 23

Do not rinse out for several hours or until the next day

After this they should start rinsing gently with warm water or warm salty water.

• should use water at the temperature of a cup of tea
• hot salty mouthwash (HSMW) they should dissolve a teaspoonful of salt in a glass or cup of warm water

Rinse around 4 times a day, especially after eating
- Keep wound clean

Rinse gently and do not spit out too forcefully
- Residue aids healing

Question 24

brushing instruction post extraction

Answer 24

brush teeth as normal but don’t rinse.
- Just spit toothpaste out

Continue to clean teeth as normal

Luke warm water may be more comfortable

Keeping the mouth as clean as possible will help with healing

If there are problems cleaning around the operative site use damp tissue/gauze or cotton buds until it is possible to brush and floss in the area again.
- Brush/floss the rest of the teeth as normal

If it is difficult to keep the mouth clean you may give or advise on the use of chlorhexidine mouthwash
- Chlorohexidine in open wounds – anaphylaxis
As healing may feel unable to keep clean, can use not immediately though (coming days)

Question 25

chlorohexidine and open wounds

Answer 25

anaphylaxis

As healing may feel unable to keep clean, can use not immediately though (coming days)

Question 26

instructions for if wound bleeds at home post extraction

Answer 26

Roll up some clean tissue/kitchen roll and gauze, make it damp and bite on it for 20-30minutes

• Dry tissue will stick to socket and remove clot – bleed again
• Pressure should be firm and even - Too firm will result in rebound bleed as vessels open up again when the pressure released

If bleeding persists bite on a fresh piece again – this time for up to an hour

If bleeding persists contact - your practice if it is during the day/during the week/ or the out of hours emergency contact you have in place at night and weekends.

Make sure the patient knows who to contact and how. This reassures patients
- If they cannot get the bleeding to stop and cannot get you or a dental emergency team they should go to their nearest A&E

Question 27

what are dry sockets post extraction

Answer 27

sore

not infected, swelling, pus

can look normal or bare socket

can get better with time – but need a bit of extra help

assure them

Question 28

healing and smoking

Answer 28

Avoid smoking for as long as possible

Smokers are at risk of delayed healing/ dry sockets even if they avoid smoking for a few hours after the extraction

• stopped smoking higher risk
• still smoking even higher

But it may be helpful to avoid smoking for as long as possible after the procedure

Question 29

4 other post extraction symptoms to pain and bleeding

Answer 29

sensitivity

pain and stiffness of TMJ/muscles of mastication

swelling

bruising

Question 30

sensitivity instructions post extraction

Answer 30

Sensitivity of adjacent teeth
- loss support and bone on mesial and distal aspect and junction between enamel and cementum

can be sensitive until calmed down in few days to a week or 2

avoid extremes until settles

use lukewarm water to clean

apply sensitive toothpaste on areas

Question 31

pain and stiffness of TMJ?Muscles of mastication post extraction instructions

Answer 31

as jaw open for long time during extraction

experience a limitation in mouth opening
- This should settle over the course of a few days/1-2 weeks

Use painkillers and normal conservative advice for TMJD

If it prevents eating they should seek your advice

If it lasts longer than normal they should seek your advice

Question 32

swelling instructions post extraction

Answer 32

some people swell more than others.

Swelling is more common after a difficult extraction or a surgical procedure.

normally takes around 2 days to reach maximum swelling then resolves over the next few days/week.
- Non-infective swelling 48 hours to peak

Warmth induces swelling – use cold packs
5 mins on, 5 mins off to prevent numbness and damage to tissue

If the swelling continues to increase in size or the patient is worried that there may be an infection they should get in touch with you

• Persists
• Or starts in time after surgery (2-3 days, not immediate)

Affect swallowing or breathing – seen immediately

Question 33

how to manage swelling

Answer 33

cold packs

5 mins on, 5 mins off to prevent numbness and damage to tissue

Question 34

brusing post extraction

Answer 34

Some people bruise more easily and more markedly than others.

Bruising is variable between people and procedures
more difficult procedures/ more difficult extractions/surgical extractions

Question 35

additional information in post surgical instructions (over the extraction instruction)

Answer 35

sutures

antiseptic mouthwash

bruising/swelliing can be more common

Question 36

sutures post surgical instructions

Answer 36

tell them you put them in and why

Tell the patient to leave them alone and not to pull at them

If they come out and the area is not bleeding or overly painful they should just leave them
- unless it is an OAC/OAF closure – these wounds cannot be left open. They need to contact you

Sutures can become uncomfortable as the area heals.
- if this occurs, even if they are dissolving sutures, tell the patient they can come back early and have them removed

Tell the patient if they are resorbable (dissolving) sutures or non resorbing and require another visit for suture removal

Question 37

sutures for OAC/OAF

Answer 37

upper molar/premolar extraction create communication with air sinus need to close straight away

use non dissolving

keep for 10-14 days so doesn’t reopen

Question 38

antiseptic mouthwash instructions post surgery

Answer 38

e.g. Chlorhexidine

Patients should be advised on how to use it
- A capful 2-3 times a day

If it nips/ causes discomfort – dilute it with water

Do not use straight after tooth brushing as it may interact with toothpaste and wash toothpaste away

Do not use just before or just after eating (use HSMW straight after eating).
- Leave at least an hour before and after use with regard to eating.

Chlorhexidine can stain the teeth – this is less likely if you don’t have food particles on the teeth
- If it does stain it is not a major problem. The dentist can polish it off/ remove the staining

Question 39

additional instructions for soft tissue biopsy pt (over surgery)

Answer 39

sites tend to feel a bit “raw”. - You can describe to the patient that they will feel some post-op pain and it may feel like a healing ulcer

sutures, swelling, bruising,, mouthwash, pain, bleed