Postextraction Patient Management

Hemorrhage

Once an extraction has been completed, the initial maneuver to control postoperative bleeding is the placement of a folded gauze directly over the socket. Large packs that cover the occlusal surfaces of teeth adjacent to the extraction site do not apply pressure to the bleeding socket and are therefore ineffective ( Fig. 11.1 ). The gauze may be moistened so that the oozing blood does not coagulate in the gauze and then dislodge the clot when the gauze is removed. The patient should be instructed to bite firmly on this gauze for at least 30 minutes and not to chew on the gauze. The patient should hold the gauze in place without opening the mouth.

Patients should be informed that it is normal for a fresh extraction site to ooze slightly for up to 24 hours after the extraction procedure. Patients should be warned that a small amount of blood mixed with a large amount of saliva might appear to be a large amount of blood. If the bleeding is more than a slight ooze, the patient should be told how to reapply a folded piece of gauze directly over the area of the extraction. The patient should be instructed to hold this second gauze pack in place for as long as 1 hour to gain control of bleeding. Further control can be attained, if necessary, by the patient placing a tea bag in the socket and biting on it for 30 minutes. The tannic acid in regular tea serves as a local vasoconstrictor.

Patients should be cautioned to avoid things that may aggravate the bleeding. Talking should be kept to a minimum for an hour. Tobacco smoke and nicotine interfere with wound healing, so patients should be encouraged to stop or limit smoking. The patient should also be told not to suck thick fluids through a straw when drinking because this creates negative intraoral pressure. The patient should not spit during the first 12 hours after surgery. The process of spitting involves negative pressure and mechanical agitation of the extraction site, which may trigger fresh bleeding. Patients who strongly dislike having blood in the mouth should be encouraged to bite firmly on a piece of gauze to control the hemorrhage and to swallow their saliva instead of spitting it out. Finally, no strenuous exercise should be performed for the first 12 to 24 hours after extraction because the increased blood pressure may result in greater bleeding.

Patients should be warned that there may be some oozing and staining of their saliva while they are asleep and that they will probably have some blood stains on their pillowcases in the morning. Forewarning them of this probability will prevent many frantic telephone calls to the surgeon in the middle of the night. Patients should also be instructed that if they are worried about their bleeding, they should call to get additional advice. Prolonged oozing, bright red bleeding, or large clots in the patient's mouth are indications for a return visit. The dentist should then examine the area closely and apply appropriate measures to control the hemorrhage and consider having a surgical specialist assist with patient management.

Pain and Discomfort

All patients expect a certain amount of discomfort after any surgical procedure, so it is useful for the dentist to discuss this issue carefully with each patient before the procedure begins. The surgeon should help the patient have a realistic expectation of what type of pain may occur and correct any misconceptions of how much pain is likely to occur.

Patients who make a point of informing the surgeon that they expect a great deal of pain after surgery should not be ignored or automatically told to take an over-the-counter analgesic because these patients are most likely to experience pain postoperatively. It is important for the surgeon to assure patients that their postoperative discomfort can and will be effectively managed.

The pain a patient may experience after a surgical procedure such as tooth extraction is highly variable and to a great extent depends on the patient's preoperative expectations. The surgeon who spends some time discussing these issues with the patient before surgery will be able to design the most appropriate analgesic regimen.

All patients should be given instruction concerning analgesics before they are discharged. Even when the surgeon believes that no prescription analgesics are necessary, the patient should be told to take ibuprofen or acetaminophen postoperatively to prevent initial discomfort before the effects of the local anesthetic disappear. Patients who are expected to have a higher level of pain should be given a prescription analgesic to help control the pain. The surgeon should also take care to advise the patient that the goal of analgesic medication is management of pain and not elimination of all discomfort.

It is useful for the surgeon to understand the three characteristics of the pain that occurs after routine tooth extraction: (1) The pain is usually not severe and can be managed in most patients with over-the-counter analgesics, (2) the peak pain experience occurs about 12 hours after the extraction and diminishes rapidly after that, and (3) significant pain from extraction rarely persists longer than 2 days after surgery. With these three factors in mind, patients can be appropriately advised regarding the effective use of analgesics.

The first dose of analgesic medication should be taken before the effects of the local anesthetic subside. If this is done, the patient is less likely to experience the intense, sharp pain after the effects of local anesthesia subside. Postoperative pain is much more difficult to manage if administration of analgesic medication is delayed until the pain is severe. It may take 60 to 90 minutes for the analgesic to become fully effetive. If the patient waits to take the first dose of analgesic until the effects of local anesthesia have subsided, the patient may become impatient, waiting for the effect, and may take additional medication thus increasing the likelihood of nausea and vomiting.

The strength of the analgesic is also important. Potent analgesics are not required in most routine postextraction situations; instead, analgesics with a lower potency per unit dose are typically sufficient. The patient can then be told to take one or two unit doses as necessary to control pain. More precise pain control is achieved when the patient takes an active role in determining the amount of medication to take.

Patients should be warned that taking narcotic medications often results in drowsiness and an increased chance of gastric upset. In most situations, patients should avoid taking narcotic pain medications on an empty stomach. Prescriptions should be written with instructions to the patient to have a snack or a meal before taking a narcotic analgesic.

Ibuprofen has been demonstrated to be an effective medication to control discomfort from a tooth extraction. Ibuprofen 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 in most patients. Acetaminophen does not interfere with platelet function and may be useful in certain situations in which the patient has a platelet defect and is likely to bleed. If the surgeon prescribes a combination drug containing acetaminophen and narcotic, it should be a combination that delivers 500 to 650 mg of acetaminophen per dose.

Drugs that are useful in situations in which patients have varying degrees of pain are listed in Table 11.1 . Centrally acting opioid analgesics are frequently used to control pain after tooth extraction. The most commonly used drugs are codeine, the codeine congeners oxycodone and hydrocodone, and tramadol. These narcotics are well absorbed from the gut but may produce drowsiness and gastrointestinal upset. Opioid analgesics are rarely used alone in dental prescriptions; instead, they are formulated with other analgesics, primarily aspirin or acetaminophen. Codeine can be a useful postextraction analgesic because it carries little narcotic abuse potential. However, it is important to note that a large percentage of the population lacks the enzyme necessary to make codeine effective. When codeine is used, the amount of codeine is frequently designated by a numbering system. Compounds labeled No. 1 have 7.5 mg codeine; No. 2, 15 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 aspirin or acetaminophen every 4 hours to achieve maximal effectiveness from the nonnarcotic. Many of the compound drugs have only 300 mg aspirin or acetaminophen added to the narcotic. An example of a rational approach would be to prescribe a compound containing 300 mg of acetaminophen and either 30 mg codeine (No. 3) or 5 mg hydrocodone. The usual adult dose would be 2 tablets of the compound every 4 hours. Should the patient require stronger analgesic action, 2 tablets of acetaminophen and codeine may be taken for increased effectiveness. Doses that supply 30 to 60 mg of codeine or 5 mg of hydrocodone but only 300 mg of acetaminophen fail to provide full advantage of the analgesic effect of acetaminophen ( Table 11.2 ).

The Drug Enforcement Administration controls narcotic analgesics. To write prescriptions for these drugs, the dentist must have a Drug Enforcement Administration permit and number. The drugs are categorized into four basic schedules based on their potential for abuse. Several important differences exist between schedule II and schedule III drugs concerning writing prescriptions (see Appendix 2 ). Unfortunately, prescription narcotics are susceptible to misuse. Oxycodone- and hydrocodone-containing drugs are particularly sought after and abused. Narcotics tend to be addictive, leading to problems such as patients seeking drugs even when not in pain or nonpatients stealing drugs for their own use or to sell to others. The dental profession and others have developed guidelines for dentists to help limit the overprescription of narcotics and to manage any unused doses that might otherwise fall into the hands of a patient's family members or others with access to the patient's medications. Dentists should take advantage of professional educational offerings related to managing patient pain and the use of analgesic medications. Dentists should also have frank discussions with patients about the problem of opioid abuse and how they can help avoid its impact in their own lives.

It is important to emphasize that the most effective method of controlling pain is the establishment of a close relationship between the surgeon and the patient. A specific amount of time must be spent discussing the issue of postoperative discomfort, with the surgeon clearly demonstrating his or her concern for patient comfort. A prescription should be given with clear instructions about when to begin the medication and at what intervals it should be taken. If these procedures are followed, mild analgesics given for a short time (usually no longer than 2 to 3 days) are usually all that is required.

Diet

Patients who have had extractions may avoid eating because of local pain or fear of pain occurring when eating. In addition, the physical and emotional stress of undergoing surgery frequently lessens the appetite. Therefore they should be given specific instructions regarding their postoperative diet. A high-calorie, high-volume liquid or soft diet is best for the first 12 to 24 hours.

The patient must have an adequate intake of fluids, usually at least 2 L, during the first 24 hours. The fluids can be juices, milk, water, or any other nonalcoholic beverage that appeals to the patient.

Food in the first 12 hours should be soft and cool. Cool and cold foods help keep the local area comfortable. Ice cream and milkshakes, unlike harder solid foods, have less tendency to cause local trauma or initiate rebleeding episodes.

If the patient had multiple extractions in all areas of the mouth, a soft diet is recommended for several days after the surgical procedure. However, the patient should be advised to return to a normal diet as soon as possible.

Patients who have diabetes should be encouraged to return to their normal insulin and caloric intake as soon as possible. For such patients, the surgeon may plan surgery on only one side of the mouth at each surgical appointment, thus not overly interfering with normal caloric intake.

Oral Hygiene

Patients should be advised that keeping the teeth and the whole mouth reasonably clean results in a more reliable healing of surgical wounds. Postoperatively, on the day of surgery, patients may gently brush the teeth that are away from the area of surgery in the usual fashion. They should avoid brushing the teeth immediately adjacent to the extraction site to prevent a new bleeding episode and to avoid disturbing sutures and inducing more pain.

The the first postoperative day, patients should begin gentle rinses with dilute salt water. The water should be warm but not hot enough to burn the tissue. Most patients can resume their preoperative oral hygiene measures by the third or fourth day after surgery. Dental floss should be used in the usual fashion on teeth anterior and posterior to the extraction sites as soon as the patient is sufficiently comfortable doing so.

If oral hygiene is likely to be difficult after extractions in multiple areas of the mouth, mouth rinses with agents such as dilute hydrogen peroxide may be used. Rinsing three to four times a day for approximately 1 week after surgery may result in more reliable healing.

Edema

Some oral surgical procedures result in a certain amount of edema or swelling after surgery. Routine extraction of a single tooth will probably not result in swelling that the patient can see, whereas the extraction of multiple impacted teeth with reflection of soft tissue and removal of bone may result in moderately large amounts of swelling ( Fig. 11.2 ). Swelling usually reaches its maximum 36 to 48 hours after the surgical procedure. Swelling begins to subside on the third or fourth day and is usually resolved by the end of the first week. Increased swelling after the third day may be an indication of infection rather than renewed postsurgical edema.

Once the surgery is completed and the patient is ready to be discharged, some dentists use ice packs or bags of frozen peas to help minimize the swelling and make the patient feel more comfortable; however, there is no evidence that the cooling actually controls this type of edema. Ice should not be placed directly on the skin; preferably a layer of dry cloth should be placed between the ice container and the tissue to prevent superficial tissue damage. The ice pack or small bags of frozen peas should be kept on the local area for 20 minutes and then kept off for 20 minutes over a period of 12 to 24 hours. The bags of peas should be refrozen after they warm.

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. Heat sources such as hot water bottles and heating pads are recommended. Patients should be warned to avoid high-level heat for long periods to prevent injuring the skin.

It is important to inform patients that some amount of swelling is to be expected. They should also be warned that the swelling may tend to wax and wane, occurring more in the morning and less in the evening because of postural variation. Sleeping in a more upright position by using extra pillows will help reduce facial edema. Patients should be informed that a moderate amount of swelling is a normal and healthy reaction of tissue to the trauma of surgery. Patients should not be concerned or frightened by swelling because it will resolve within a few days.

Trismus

Extraction of teeth, administration of a mandibular block, or both may result in trismus (limitation in mouth opening). Trismus results from trauma and the resulting inflammation involving the muscles of mastication. Trismus may also result from multiple injections of the local anesthetic, especially if the injections have penetrated muscles. The muscle most likely to be involved is the medial pterygoid muscle, which may be penetrated by the local anesthetic needle during the inferior alveolar nerve block.

Surgical extraction of impacted mandibular third molars usually results in some degree of trismus because the inflammatory response to the surgical procedure is sufficiently widespread to involve several muscles of mastication. Trismus is usually not severe and does not hamper the patient's normal activities. However, to prevent alarm, patients should be warned that this phenomenon might occur and that it will likely resolve within a week.

Ecchymosis

In some patients, blood oozes submucosally and subcutaneously; this appears as a bruise in the oral tissues, the face, or both ( Fig. 11.3 ). Blood in the submucosal or subcutaneous tissues is known as ecchymosis . Ecchymosis is usually seen in older patients because of their decreased tissue tone, increased capillary fragility, and weaker intercellular attachments. Ecchymosis is not dangerous and does not increase pain or infection. Patients should, however, be warned that ecchymosis may occur because if they awaken on the second postoperative day and see bruising in the cheek, submandibular area, or anterior neck, they may become apprehensive. This anxiety is easily prevented by postoperative instructions. Typically the onset of ecchymosis is 2 to 4 days after surgery and it usually resolves fully within 7 to 10 days.