Post-Operative Instructions Oral Surgery Flashcards
3 types of post op oral surgery instructions
- Post extraction instructions (non-surgical)
- Post-surgical instructions
- Post biopsy/soft tissue surgery instructions
All fairly similar
importance of good clear post operative instructions
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
why post op instructions done poorly
Time pressures/ next patient waiting
Operator tired after procedure/ stressed after procedure
Patient stressed/ upset after procedure
best technique for delivering post op instructions
– verbal with eye contact and followed up by written leaflets to take home
if patients do not know what to expect after a procedure
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
4 points in post extraction instructions
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
pain post extraction
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
how to control pain post extraction
Tell patients to use regular analgesia for 1-3 days
Then
Use analgesia as required
best analgesia for extraction
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
caution when prescribing ibuprofen
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
ibuprofen dose
200, 400mg or 600mg tablets
- (Dental use: 200mg or 400mg tabs)
- 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)
paracetamol (acetaminophen)
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
paracetamol cautions
- Hepatic impairment
- Renal impairment
- Alcohol dependence
paracetamol dose
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
paracetamol overdose risk
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
co-codamol
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
what is one of the best analgesia routines if patient can take
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
post operative bleeding instructions
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
methods to help healing post extraction
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)
issue of hot foods and post extraction bleeding
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
issue with hard foods and post extraction bleeding
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
alcohol problem post extraction
Alcohol may affect a healthy clot formation and result in bleeding or delay the healing process
rinsing instructions for post extraction
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
brushing instruction post extraction
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)
chlorohexidine and open wounds
anaphylaxis
As healing may feel unable to keep clean, can use not immediately though (coming days)
instructions for if wound bleeds at home post extraction
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
what are dry sockets post extraction
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
healing and smoking
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
4 other post extraction symptoms to pain and bleeding
sensitivity
pain and stiffness of TMJ/muscles of mastication
swelling
bruising
sensitivity instructions post extraction
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
pain and stiffness of TMJ?Muscles of mastication post extraction instructions
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
swelling instructions post extraction
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
how to manage swelling
cold packs
5 mins on, 5 mins off to prevent numbness and damage to tissue
brusing post extraction
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
additional information in post surgical instructions (over the extraction instruction)
sutures
antiseptic mouthwash
bruising/swelliing can be more common
sutures post surgical instructions
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
sutures for OAC/OAF
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
antiseptic mouthwash instructions post surgery
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
additional instructions for soft tissue biopsy pt (over surgery)
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
