Postoperative patient management

Question 1

• Patients have more — concerns about the sequelae of surgery (pain,
  swelling) than about the procedure itself

Answer 1

preoperative

Question 2

• Give adequate and complete post-operative instructions to patient and patient’s ride (if
  present)
  (3)

Answer 2

• Verbal & Written forms
• In lay terms (easier understood)
• Give most common post-op sequelae and how to manage

Question 3

• Regarding IV sedation patients: instructions given

Answer 3

prior to appointment, and also given to
ride/escort (should have one since patient is receiving sedation)

Question 4

CONTROL OF POSTOPERATIVE HEMORRHAGE
* Placement of gauze over socket (4 cm x 4 cm rolled into 1cm x 1cm x 2 cm shape)

Answer 4

• Do not cover occlusal surface of adjacent teeth
• No pressure applied to extraction site
• Slightly moistened
• Coagulated blood can adhere to dry gauze
• When gauze is removed it will remove clot
• Firm pressure for at least 30-45 min (I tell pts one hour)
• Take advantage of patient being numb, once local wears off it will be painful to bite on gauze
• Remove and throw away after 1 hour, if pack is pink in color

Question 5

CONTROL OF POSTOPERATIVE HEMORRHAGE
* Patients should be told they might expect mild continual oozing over next 24 hours

Answer 5

• A small blood spot on the pillow is normal (~ size of a quarter)
• Warn the patient that a small amount of blood will mix with saliva and appear to be a lot
  more
• If continued oozing after removal of gauze (45min – 1 hour later), patient should reapply gauze
  that is provided to them on discharge (advising to use slightly wet gauze)
• Again bite firm pressure for another 1 hour
• If still oozing after removal of second gauze pack, patient can bite on tea bag for another 1
  hour
• Directions: boil tea bag, remove from hot water to cool, wrap in gauze, bite hard 1 hour
• Tannic acid is a local vasoconstrictor and pro-coagulant

Question 6

CONTROL OF POSTOPERATIVE HEMORRHAGE
* Patients should avoid things that aggravate bleeding
(2)

Answer 6

• Smoking (avoid for at least 24 hours if possible)
• Nicotine interferes with wound healing
• The pull of the cigarette/pipe/cigar causes negative pressure, potentially pulling the clot
  out of the socket

Question 7

CONTROL OF POSTOPERATIVE HEMORRHAGE
* No other changes in pressure inside the mouth
(4)

Answer 7

• No sucking through straw → negative pressure change
• No spitting → negative pressure change
• No blowing nose against closed mouth → positive pressure change can push clot out
• No stopping sneeze → positive pressure change
• Okay to sneeze, but keep mouth open to allow air escape

Question 8

• When should patients get concerned?
  (3)

Answer 8

• If bright red blood fills the mouth in matter of minutes
• If there is a large liver clot present over socket
• Most often darker in color, but can be bright red

Question 9

• What should patients do if concerned?
  (2)

Answer 9

• Call surgeon to schedule return visit as soon as possible
• If no ability to contact someone affiliated with the clinic, might
  need to go to Emergency Room

Question 10

All patients will experience some sort of — after any surgical procedure

Answer 10

discomfort

Question 11

It is the job of the surgeon to:
(2)

Answer 11

• Give the patient a realistic expectation of what type of pain may occur
• Correct misconceptions of how much pain is likely to occur

Question 12

Amount of pain after extraction is highly variable, and depends in part on the patient’s
preoperative expectations
* Thus, surgeons who spend time — to the procedure to discuss these issues can create the most
appropriate analgesic regimen
* Also, can catch potential problems after

Answer 12

prior
extraction → think about the opioid addiction patient population

Question 13

ALL patients receive instructions concerning analgesics before they are discharged

Answer 13

• Even if no narcotics are written for patient, they should be advised to take Ibuprofen and
  Tylenol (!! if they are able, remember patients with gastric ulcers as well as kidney and liver disease patients !!), and
  how the patient is to take each medication as well as the amount in milligrams.

Question 14

Higher expected levels of pain might necessitate

Answer 14

narcotic prescriptions
* i.e. - surgical extraction or entire quadrant extraction

Question 15

Advise the patient that complete resolution of pain is not the goal,

Answer 15

the reduction of
pain to be able to perform ADLs (activities of daily living) is the goal
* About 3-5 out of 10 on the pain scale

Question 16

Three characteristics of post-extraction pain:
(3)

Answer 16

• Pain is usually not severe and can be managed in most patients with OTC medications
• Peak pain occurs after 12 hours after procedure and diminishes rapidly after that
• Significant pain rarely persists longer than 2 days

Question 17

First dose of medication should be taken before local anesthetic wears off

Answer 17

• Instruct the patient to take a dose of medication ~1 hour after procedure was completed, even
  if they are still numb
• If using lidocaine w/ epi, anesthesia duration range is ~ 2 – 4 hours
• Medication needs to be absorbed and then distributed to CNS for effect, which takes at least 45 min

Question 18

Simple extraction/s: Ibuprofen 600 mg Q6H alternating with Tylenol 500 mg Q6H

Answer 18

• Translates to one form of medication every three hours
• If taking Ibuprofen at 12pm, 6pm, 12am, 6am
• Then Tylenol at: 3pm 9pm 3am 9am
• OR take both medications at the same time, every 6 hours
• Easier for patient to remember
• Meds taken together sometimes have improved pain control than taken both meds separately

Question 19

Surgical extractions/full mouth extractions:

Answer 19

• Codeine compounds:Tylenol #2 vs #3 vs #4
• -codone compounds: hydrocodone/apap vs oxycodone/apap
• Limit to two-three days
• Due to opioid concern in US
• If patient needs more pain medications, it is best to have the patient come to the office for evaluation

Question 20

• Codeine compounds:Tylenol #2 vs #3 vs #4

Answer 20

Used less and less
Morphine is the
active metabolite

Question 21

• Released November 2017
• “Combined acetaminophen, ibuprofen produces similar amount of pain relief as opioids in ED patients.”
• Journal of the American Medical Association
• Dr. Andrew Chang

Answer 21

• The primary outcome was the between-group difference in decline in pain 2 hours after taking the analgesic.
• Pain intensity was assessed using an 11-point numerical rating scale that defined 0 as no pain and 10 as worst possible pain
• He and his colleagues randomized patients at two EDs in New York City to receive either:
• 5 mg of hydrocodone and 300 mg of acetaminophen → pain score decreased after 2 hours was by 3.5
• 5 mg of oxycodone and 325 mg of acetaminophen → pain score decreased after 2 hours was by 4.4
• 30 mg of codeine and 300 mg of acetaminophen → pain score decreased after 2 hours was by 3.9
• 400 mg of ibuprofen and 1000 mg of acetaminophen → pain score decreased after 2 hours was by 4.3
• Each cohort consisted of 104 participants

Question 22

Patients fear eating for concern of worsening pain
(2)

Answer 22

• Reassurance is the best medicine for this
• In fact a high calorie, high volume liquid or soft diet is best for first 12-24 hour

Question 23

Discussion with the patient:

Answer 23

• Okay to eat after the gauze pack is removed w/o continued significant bleeding
• Soft, cold, bland diet the best
• Avoid crunchy food while healing, can interrupt clot in socket
• Avoid hot temperature food while still numb, will burn the area that is anesthetized
• Spicy food has been noted to interrupt clot maturation
• NO STRAWS
• Likely return to normal foods the next day, may require pain medication prior to eating

Question 24

ORAL HYGIENE
* Advise patients to
* Post op day 0:
* Post op day 1:
* POD 2 and on:

Answer 24

keep their teeth and mucosa as clean as possible to prevent infection
or delayed healing

brush gently on teeth not in surgical site
gentle rinses with warm dilute salt water
resume normal oral hygiene

Question 25

EDEMA

Answer 25

• Many procedures will result in a certain amount of edema or swelling
• Simple extractions likely will not result in edema
• Surgical extraction/multiple extractions likely will result is mild to moderate edema
• Reaches maximum 36-48 hours post-op
• If swelling continues after day 4, likely another problem is present and warrants return visit
• Cold compress okay for first three days, then switch to warm compress after
• Make sure there is a layer of towel/paper towel between skin and cold compress
• Avoids cold burn on skin
• Sleeping semi-inclined can prevent worsening of edema overnight

Question 26

Most important measures to prevention of infection:
(3)

Answer 26

• Minimize tissue damage
• Remove sources of infection (granulation tissue, periapical pathology)
• Cleanse the wound

Question 27

• Careful with — patients (primary or secondary)
• May require — pre-operatively and post-operatively
• Watch for signs and symptoms:
• Swelling after — days not normal, see the patient, don’t just call-in antibiotics

Answer 27

immunocompromised
ABX
tumor, rubor, calor, dolor, functio laesa
4

Question 28

TRISMUS

Answer 28

• Limited opening of the mouth likely caused inflammation of or damage to the muscles of
  mastication

Question 29

TRISMUS
Causes:

Answer 29

• Extraction of teeth
• Mandibular IA block
• Multiple injections
• Penetrating medial pterygoid
• Third molar extractions

Question 30

TRISMUS
Usually not

Answer 30

severe and resolves as the inflammation resolves (3-4 days)

Question 31

ECCHYMOSIS

Answer 31

• Blood oozing submucosally and subcutaneously
• Usually seen in elderly patients, due to
• Is not dangerous, does not cause pain, does not increase risk of
  infection
• Ecchymosis onset POD 2-4, and subsides POD 7-10

Question 32

ECCHYMOSIS
* Usually seen in elderly patients, due to
(3)

Answer 32

• Decreased tissue tone
• Increased capillary fragility
• Weaker cellular attachment

Question 33

ECCHYMOSIS
* Is not dangerous, does not cause pain, does not increase risk of
infection
* Unlike hematoma →

Answer 33

large collection of fluid expanding tissue causing pain and
potentially infection

Question 34

POSTOPERATIVE FOLLOW-UP

Answer 34

• All patients seen by novice surgeons may have a follow-up appointment
• Increases the knowledge of “normal” healing signs and symptoms vs “abnormal” healing
• Can cause a change in treatment delivery
• If 90% of patients returning have infections or other poor sequelae, need to change operating technique
• Appoint 1 week out
• Unless patient notices concerning sequelae (uncontrollable pain, swelling, bleeding)
• Increase in swelling, redness, pain, warmth after POD 3-4 → infection until proven otherwise
• Get patient into clinic to treat ASAP!
• Postoperative pain increasing after day 5 which limits PO intake and sleep → dry socket until proven otherwise
• Get patient into clinic to treat, but it is not as urgent as infection
• Localized osteitis is not an infection

Question 35

DOCUMENTATION

Answer 35

• Surgeon must enter records of what transpired during each visit
• If surgery performed, critical elements of documentation are as follows:
• Date
• Patient name and identification
• Diagnosis of problem to be managed surgically
• Review of medical history, medications, vital signs
• Oral examination
• Informed consent
• Anesthesia (kind, amount used, nerve blocked, sites infiltrated)
• Procedure (including description of surgery and complications or lack there of)
• Discharge instructions
• Medications prescribed and their amounts
• Need for follow-up
• Signature (legible or printed underneath)