Post-operative careInstructions : - clear communication ( verbal & written ). Hemorrhage, edema, nausea& vomiting, starvation, wound hygiene, rest, nutrition, smoking, alcohol & pain relief. 1 – hemorrhage : hemostasis& oozing must be achieved at the conclusion of the surgery& before patient discharge. stages of hemorrhage : a- primary: patient should bite on gauze pack for 20-30 minutes, ( repeat if necessary ), otherwise you may need suturing or inserting a haemostatic agent ( gelfoam or surgicel into the socket ). b- reactionary hemorrhage: occurs after 24-48 hours. Avoid hot foods, hot liquids, vigorous exercise& stress, fingers& tongue away from surgical site, avoid smoking & others. If bleeding persists contact specialist or surgeon. c- secondary haemorrhage: occurs after 8-10 days, often due to infection.

2- edema : normal reaction of the body to oral surgery. How to minimize facial swelling ? - careful surgery, operator experience (reduced operating time). - ice packs immediately after surgery( theoretically reduce blood flow). - the use of steroids to dampen the body inflammatory response, but steroids best reserved for difficult, prolonged surgical cases. -dexamethasone 4-8 mg I.V., intraoperatively, then, 4 mg every 8 hours for 24 hours. - methyleprednisolone 100 mg I.V., intraoperatively, followed by 50-100 mg every 6-8 hours for 24 hours. - NSAIDS : have failed to demonstrate any ability to reduce postoperative swelling.

3- nausea & vomiting : mostly after G.A.& this may be due

to ( narcotics, blood in the stomach, starvation ).

narcotics: give antiemetics ( maxolon 10 mg or

stemetil 12.5 mg I.M., 6-8 hours routinely added to

their drug chart. Patients are encouraged to take

fluids, lemonade.

blood in the stomach: reassurance, antacids.

4- starvation: I.V. dextrose or Hartmann’s solution during

surgery under G.A. to maintain fluid, electrolyte&

sugar balance.

5 – wound hygiene : - oral surgical wounds have no higher incidence of infection than surgical wounds on the skin. Also, you cannot brush teeth, so, the best is mouth rinse. - S.W.M.W. : saline, 4-6 times/day, keep in mouth for two minutes. It sooths the surgical wound, promotes rapid healing. - antiseptic M.W. : 0.2% chlorhexidine ( after each meal ), if used more than one week , it causes teeth stain. - better no rinse on the surgery day6 – rest : - is part of recovery & this must be emphasized to patient, who is stressed & exhausted after surgery. - exercise should be discouraged, especially, in the first 24 hours. Vigorous exercise, football, rugby, weight-lifting should be delayed for 3-4 weeks. - sick leave: this depends on the complexity of the surgery& the type of work the patient is engaged in & not on the patient request.

7 – nutrition :

- benefits of adequate nutrition: increase body immunity,

resistance to infection,& improve wound healing.

- limitations of diet : pain, swelling, trismus. So, diet is

confined to: soft food& or processed solid food,

lemonade, fruit juices fortified with vitamins& minerals, milk.

Broth from pharmacy.

8 - smoking & alcohol: in addition to general health hazards, these

may cause: increased potential for reduced healing ( delayed

healing), for wound infection (dry socket ), postoperative

bleeding, especially, in chronic alcoholism. Also, decreased

immune capacity.

- respiratory complication, when under G.A.

- adverse drug interaction between alcohol& postoperative

medications (e.g.) narcotic analgesics, antibiotics such as

metronidazole. Patients advised to abstain from smoking &

alcohol during recovery period.

9 – Pain relief :

- pain is a subjective phenomenon, depends on complexity of

the surgery & patient’s response to pain, (clinician must

distinguish between pain relief & control).

- selection : the choice of analgesics depend on the following

factors : history of allergy, patient tolerance of the

medication, complexity of the surgery,& cost.

- prescription: (take as required philosophy ), provides brief

periods of relief. Now, it is acceptable to take analgesics at

regular intervals for a certain period of time.

Types of analgesics : mild, moderate, strong for severe pain.

A - NSAIDS : are effective for mild to moderate pain arising

from superficial tissues ( skin, mucosa, joints). The most

common used drugs :

1 – aspirin: rapidly metabolized in liver& plasma.

effective in acute pain of an inflammatory nature

including surgery.Now, mainly used in painful arthritis &

as a prophylaxis against vascular occlusive disease.

Side effect : gastric ulcerogenic.

dose : 600 mg every 6-8 hours

Continuation :

paracetamol (acetaminophen) : an alternative to

aspirin, analgesic & antipyretic but with weak anti- inflammatory activity.safe in children, elderly,& in pregnancy (except in first trimester). No gastric irritation or interference with platelet function.Side effect : hepatotoxic.

Dose : 500 mg 1-2 tablets 4-hourly (>4g/day ). Ibuprofen : It is gaining popularity as a first choice analgesic following M.O.S.( analgesic & anti-inflammatory effect ).Less gastric irritation.

Dose : 400-600 mg 8-hourly.

Other NSAIDS : indomethacin, naproxen: are rarely used in M.O.S., because of their longer half-lives & it is more suitable for chronic inflammatory conditions rather than acute surgical pain

B - Narcotics : opiates narcotics act on specific receptors in the C.N.S.( central analgesic effect, unlike NSAIDS, is not confined to pain arising from inflammatory process).It dampens patient’s emotional response to pain rather than eliminating the pain sensation itself.They still feel pain but are able to tolerate it.

They are more useful for severe pain arising from deep or visceral structures. Used in combination with NSAIDS.

the most common narcotics used are : Codeine 30-60 mg every 4-hours Dextropropoxyphene 50-100 mg every 4-6 hours Oxycodone 5-10 mg every 6-hours Hydrocodone 5-10 mg every 6-hours Side effects :

nausea& vomiting, constipation, hypotension, respiratory depression. Tolerance after one week, & must increase dose for the same analgesic effect

N.B. : warn patient of potential drowsiness( driving or operating machinery ).

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C- compound analgesics : Combination of narcotics & NSAIDS will give greater analgesia

by use of smaller doses (e.g.) : - aspirin 325 mg+ codeine 30 mg 1-2 tablets 4-hourly - paracetamol 500 mg + codeine 8 mg 1-2 tablets / 4-hourly - paracetamol 500 mg + codeine 30 mg 1-2 tablets / 4-hourly - paracetamol 500 mg + hydrocodone 5 mg 1-2 tablets / 4-6hours. Intraoperative analgesics : maximum intensity of pain after 3-hours. so, commence

analgesia intraoperative & you get effective analgesia after surgery (e.g.) long-acting local anesthesia drug before the end of surgery.

Intraoperative narcotics & NSAIDS are less effective than L.A. Hint : bupivacaine (marcain) 0.5% plain or with adrenaline, 2 ml of solution infiltrated in & around surgical site, intraoperatively, analgesia could last for 8-hours, but some patients may be concerned about numbness (I.D.N. block). D- strong analgesics : pethidine & morphine: only for in-patient ( controlled prescription). Antibiotics: penicillin group, clindamycin.