Dental Surgery Guidebook
Preparation Information for Dental Surgery
You, the ‘Patient’, have made the decision to go ahead with sedation. In our practice, we use a form of conscious sedation which is very effective in creating an extremely pleasant and relaxing experience for a procedure that not too many of us look forward to.
Response to sedation can be different depending on a patient’s gender, alertness, apprehension, age, weight, medication use and personal health history. These factors are all taken into consideration when we carefully calculate a customized dose that fits you exactly.
In order to receive sedation, you must select a responsible, trustworthy individual who is greater than 19 years, your ‘Guardian’, who will look after you until the sedative effects have worn off. Based on the patient’s preference, this can range anywhere from 6-8 hours when a full dose of sedative is given and 4-5 hours when only a half dose of sedative is administered.
The guardian will be responsible for:
· Providing 8 hours of supervision for a full dose of sedative or 4 hours of supervision for a half dose of sedative.
· Taking the patient directly home or to the designated place of rest without any additional stops.
· Ensuring proper hydration of the patient with up to 2 cups of fluid following the appointment such as apple, blueberry, grape juice, Gatorade or any other fluid replacement.
· If the patient is diabetic, hypoglycaemic, or glucose intolerant, blood glucose levels will have to be monitored more frequently as well as reducing and/or diluting the selected fluid replacement in order to drink up to the 2 cups that is recommended.
Ensure that you and your selected guardian are familiar with the information found in this guidebook prior to your appointment. If there are any questions or concerns regarding any of the information provided in this booklet or following the consultation or following your surgery appointment, feel free to call the provided phone numbers.
Any significant changes in your health prior to your appointment date should be reported to our office.
Please call in the order listed:
|#1||Office (Wednesday-Saturday 8:00am to 5:00pm)
|#2||Andrew (24 hour on-call contact cellular number)||250-306-7005|
|#3||Carole (between 7:00am to 7:00pm on-call contact cellular)||250-309-8820|
|#4||Stephanie (between 7:00am to 7:00pm on-call contact cellular)||250-309-8821|
Pre-Sedation Patient Instructions
*For the safe treatment of the patient, the following instructions must be followed very carefully*
In our practice setting, we implement a very effective form of conscious sedation which allows a person to undergo a state of calm and relaxation.
The benefits to using such forms of sedation, is that it allows a person to remain in somewhat of a conscious state where feedback can be provided throughout the appointment but the greatest benefit for the patient is the amnesia effect created by the medication. This will prevent memory of the significant events during the appointment.
Sedation will be provided in a liquid or tablet form and is generally swallowed with a full glass of water or juice. The liquid and tablet forms are absorbed primarily in the small intestine and generally take 20-30 minutes to begin to take effect following administration at the dental office. At this point, you will be evaluated by members of the dental office to determine the progression of your sedation experience and whether a dose adjustment is required. Your appointment will generally commence approximately 45 minutes to 1 hour following initial administration of the sedative.
It is essential that the stomach and small intestine be empty when the sedative is taken for the surgery appointment. Do not eat any solid foods for 6-8 hours prior to your appointment time. Generally we advise you to skip breakfast the morning of the appointment, unless you are diabetic, hypoglycaemic or glucose intolerant where you may need a very light meal that morning and this will be discussed in further detail at your consultation appointment. It is best if you can eat later in the evening the night before your appointment which helps to lessen the desire to eat in the morning. We can accommodate early morning appointment times to help lessen the feeling of missing breakfast.
There are certain juices that should be avoided for 7 days prior to your appointment and these include grapefruit, cranberry, lemon, lime or pomegranate. This is due to the organic bitter flavanoids present within these juices that inhibits an enzyme in our body which assists in the breakdown of the sedative and thus results in a more pronounced and longer sedative effect.
It is best to also avoid drinking any caffeinated coffee, tea, and to a lesser extent, chocolate based drinks which all increase alertness and work against the sedative effects.
It is ok to have some water or a decaffeinated beverage the morning of your appointment.
It is essential to discuss with your dentist whether or not you should take medication(s) you otherwise take on a regular basis including herbal medications such as St. John’s Wort. It is also very important to inform your dentist regarding your alcohol consumption and any illicit and/or recreational drugs that you may take on a regular or occasional basis.
Do not drink any alcohol or take any recreational drugs within 24 hours prior to, and 24 hours following your surgery appointment where sedation will be administered.
IMPORTANT: Sedatives are very safe when taken by itself but if combined with alcohol and/or illicit and/or recreational drugs, there is a risk that you may stop breathing.
Birth Control (female patients only)
The effectiveness of birth control pills could be affected as a result of the sedative which could be administered to you as well as the medications you will be taking following the surgery appointment. As a result, additional precautions should be taken during the current menstrual cycle to avoid or prevent pregnancy.
IMPORTANT: PREGNANT WOMEN CANNOT TAKE ANY FORM OF SEDATION. PLEASE ADVISE THE DENTIST IF THERE IS ANY RISK OF PREGNANCY.
Nausea and Vomiting
It is very unusual for a patient to experience nausea and mild vomiting as a consequence of taking an oral sedative but it may happen and more so to the patient that is not used to skipping a meal.
Following the surgery appointment, a patient may experience nausea and mild vomiting as a result of the awkward taste of the concentrated antibiotic pack that is placed within the sockets after the tooth is removed. This pack is absorbed by the body and is used to prevent infection after tooth removal.
It is advised to remove contact lenses prior to your sedation appointment and glasses should be worn instead. Loose, comfortable clothing is recommended for the appointment because with any sedative, your body temperature decreases and you may feel chilled. We do provide blankets for your comfort.
Patient Management Issues Associated with Sedation
*Patients who have taken a sedative can experience any or none of the following behavioural characteristics. It is important that patients and guardians are both familiar with the listed behavioural traits in order to ensure that a sedated patient is properly cared for.*
· Having only ‘partial or no memory of an activity’. Patients may not have any memory of events over an extended period of time or they may experience ‘skipped memory’ such that they remember only bits and pieces of events which happened.
· Appearing somewhat intoxicated. A patient who has received sedation may appear sleepy, may have periodic double vision (diplopia), impaired balance, impaired coordination of muscle movements, and slurred speech.
· Being unstable; accidental injury, such as falling down stairs while sedated. A patient with periodic double vision may have difficulty walking up and down stairs or on uneven ground.
· Any form of sedative is very effective in reducing and/or eliminating a patient’s built in control system. Reducing a patient’s control system means that a patient will become susceptible to suggestions which can be expressed from an external source or from an internally self created desire. Patients can exhibit the true definition of ‘free spirit’ and may participate in spontaneous abnormal activity which they may not normally participate in. For example, while recovering at home, a sleeping sedated patient could spontaneously wake up, stand up from the couch and decide to ‘walk to Bob’s house’, a trip of some 30 kilometres. This is where the importance of having a supervising guardian is necessary to say ‘No, not today, please sit down’ and the patient will oblige and sit down. It is extremely rare for a patient who has received sedation not to follow directions from a guardian.
· Revealing information if asked a question as a result of a patient’s reduced control or protective systems. This information could be potentially embarrassing and may not be accurate at all. A patient could just as easily make up a fictitious story, relate a true event, or combine false and truthful information within a storyline which the patient watched on television or read in a book 6 months ago. A sedated patient should not be interrogated as there is a strong potential for inaccurate information.
· Vocalizing and/or generating a statement ‘out of the blue’ which is, or which may appear unrelated to anything happening at the time. At the doses commonly used for surgery, patients could be in a type of twilight zone—an unsettled state between two opposing conditions such as reality and fantasy. For example, a sedated patient on their way home could spontaneously say ‘I don’t like that gas station’. When these ‘out of the blue’ statements are made, the guardian is to just say ‘that’s fine’ rather than make further enquiries as to what the patient is talking about. A sedated patient’s thought process is very short and can be quite random.
· Gender can cause a noticeable difference in the reaction to a sedative. Males are generally more susceptible to the sedative effects whereas females can be more physically mobile while sedated and may require greater supervision by the guardian. Females can also display wider fluctuations in emotional states than a male when sedated.
· As a sedative is broken down in the body, the sedative effects immediately subside. The sedative effects may last slightly longer in an overweight patient because fatty tissue can absorb and store the sedative whereas in a lean, muscular patient, the sedative effects generally wear off faster.
Post-Operative Care Instructions Following Surgery with Sedation
Discharge from office
Following your surgery appointment, you will discharged into the care of a responsible adult or appointed guardian who will be responsible for transporting, delivering and looking after you for the required time frame until the sedative has completely worn off.
For the patient who received what is considered full sedation, a required 6-8 hours of supervision must be provided by the guardian.
For the patient who received what is considered light sedation, a required 4-5 hours of supervision must be provided by the guardian.
Do not operate motor vehicles, boats, power tools, or machinery for 24 hours, or longer if drowsiness or dizziness persists. Do not operate an aircraft for at least 48 hours following minimal or moderate sedation. Do not sign or enter into any legal contract for at least 24 hours.
Following surgery, we will be placing gauze over the extraction sites and it is advised to bite on this gauze firmly with constant pressure for approximately 1 hour. If bleeding has subsided after that first hour, then the clot has formed and no extra gauze will be needed. If bleeding is still present and moderate to heavy, then continue placing gauze until it is only light to none. The gauze can also be substituted by a tea bag where the tannic acid in a regular tea bag has a clotting effect.
Towels should be used as a protective barrier wherever possible for the remainder of the day following surgery. Dental anesthetic (freezing) will not let you feel yourself drooling and there is the possibility of having light blood mixed into the saliva and this can be a problem with staining furniture or mattresses.
It is very important to reduce physical activity for the first 2 days following oral surgery as with any physical activity, blood pressure is increased which will promote additional bleeding. This increased blood pressure can also cause a release in the blood clot that has formed which is extremely fragile in the first few days. If this blood clot releases, the most likely outcome will be a ‘dry socket’ which will need to be addressed by your general dentist or by Dr. Hokhold as pain will typically commence 2-4 days following the extraction. Symptoms to indicate a dry socket can include extreme pain, a foul taste, bad breath, and swelling in the infected area. The incidence of dry socket is generally very low.
Food and Beverage
Once a patient arrives home and no longer needs to be biting on gauze once bleeding has subsided, a soft food diet including clear liquids for hydration are permitted. Generally this time frame is approximately 1 hour after you have left the dental office. For more information as to what is recommended, please refer to the section at the back of this booklet regarding ‘Diet and Nutrition’.
Fluid hydration is strongly recommended following surgery as this will help you recover from the effects of the sedative. This can include water or juices such as apple, blueberry, grape juice or an electrolyte drink such as Gatorade. Replacing fluids following surgery will help prevent dizziness, shakiness or drowsiness as a result of low blood glucose levels due to not eating that morning.
Most ideally, smoking should be avoided for 7 days following oral surgery. The majority of patients who develop complications after surgery are those who smoke. These complications can include infection, dry socket and delayed healing.
Smoking cessation aids, such as Nicoderm and Habitrol, are over-the-counter patches which contain nicotine and release nicotine through the skin into your bloodstream. These patches can be used as a temporary aid to reduce your craving to smoke. Patches are the best alternative over chewing gums and lozenges as these can damage the surgical area. Discuss these products with your Pharmacist prior to your appointment.
If, and ONLY if, you have to smoke after oral surgery, which is STRONGLY discouraged, you could try the following technique to help minimize the harm which smoking can cause to the surgical site:
· Wet 2×2 inch gauze(s) in water, fold it to fit the surgical site(s), place the moistened gauze over the surgical site(s), bite gently to keep the gauze in place, and then CAREFULLY smoke with your teeth somewhat closed. After you have smoked, discard the gauze and use fresh pieces of gauze if you must smoke again.
If an infection was to develop, it usually sets in after 3 to 4 days. General signs and symptoms of infection are:
· Malaise—you will feel tired and lacking in energy. You may sleep more than usual, or not feel up to doing your normal activities. These feelings are also common for patients who are recovering from surgery who do not have an infection but the difference is that normal recovery means feeling a bit better each day whereas a person developing an infection may feel better for a few days then suddenly feel exhausted and lethargic.
· Fever—a fever is often accompanied by feeling chilled. A fever can also decrease your appetite, lead to dehydration and a headache. A low-grade fever, 37.8 C or 100 F or less, is common in the days following surgery but a fever of 38.4 C or 101 F or more should be reported to your dentist.
· Pain—your pain should slowly and steadily diminish as you heal. If pain increases at the surgery site for no apparent reason, an infection may be developing.
· Other—swelling, redness, drainage from the surgical site, odour, and a bad taste in the mouth can indicate the start of an infection.
Post-Operative Oral Management
Rinsing and Brushing
· Do not rinse your mouth for 24 hours following surgery as this could damage the forming blood clot.
· Brush your teeth very gently, taking care to avoid sutures (stitches), if any were placed.
· Be careful of hot liquids during the first day while the freezing is still present as you will not be able to feel temperature and could very well burn your mouth without knowing until the next day.
· Starting 24 hours after your surgery appointment, you can begin to gently rinse your mouth with a solution of ½ teaspoon of salt in a glass of warm water. Rinse very, very gently as to not disturb the healing process.
· Avoid vigorous spitting following rinsing. It is better to let the rinse dribble out of your mouth over the sink. As each day passes, rinse more aggressively to keep the surgical areas clean. By day 5 after your surgery, you can incorporate the use of the plastic syringe supplied by our office in your ‘Care Package’. Fill the syringe with a warm salt water mixture, aim the syringe towards the areas you wish to clean, release the water with a steady stream to dislodge food debris around or within the tooth socket.
· If there is debris within any surgical site which cannot be dislodged with the syringe, contact your general dentist or Dr. Hokhold and we will be able to help without causing damage to the surgical site.
Dissolving or Non-dissolving Sutures (stitches)
Dissolving or non-dissolving sutures may be used. In most cases, a dissolving suture will be used following surgery. These will dissolve in 10-14 days but may come out sooner. If a non-dissolving suture is used, these will have to be removed by your general dentist or by Dr. Hokhold 5-7 days after surgery. We will advise you if non-dissolving sutures were used in your mouth.
Your body may cast off bone chips or fragments after oral surgery. Bone chips or fragments are not left behind at the time of surgery but rather after the bone is cut, your body will decide whether or not to repair or cast off damaged bone. Larger fragments of bone sometimes work out of the gums by themselves and may need to be removed by your dentist by way of a minor procedure. On rare occasions, a larger piece of bone can be cast off of the jaw and be mobile underneath the gums. In this case, your body will treat this large bone fragment as a foreign body and begin an inflammatory response (swelling) around the fragment in a similar fashion like you body would react to a wooden sliver. The inflammation response can also include pain and sometimes pus in the area and this could indicate the need for an antibiotic as well as removal of the bone fragment.
Diet and Nutrition Information
It is very important to have adequate fluid and nutrient intake after oral surgery to promote healing and return to normal functioning as soon as possible. Some precautions must be taken with the food and fluids you ingest so that the surgical sites do not become irritated or damaged.
Eating firm or hard foods can damage the surgical area by dislodging the forming blood clot, tear stitches, and become trapped within the surgical sites which could delay healing. Sucking, slurping and chewing can also dislodge the protective blood clot and can result in a dry socket.
In general, a soft food diet should be followed for at least 24 to 48 hours after surgery. This will prevent damaging the surgical sites as well as preventing biting and/or chewing one’s lips, cheeks and tongue while still numb.
Here are some general guidelines:
· Do NOT use a straw for the first few days as the suction created can damage the forming blood clot. So when you make a fruit or milk shake, use a spoon instead.
· Meal replacement drinks such as Ensure and Boost are a good choice if you do not feel up to preparing you own food as they are nutritionally balanced.
· Soups—make sure it is lukewarm on first day as you will be numb; try to avoid soups with little bits like rice that can get stuck in the surgical site. Cream soups made with milk such as cream of mushroom and bean soups such as split pea and lentil would be good choices as are pureed vegetable soups. Clear broth soup can be sipped more as a beverage than a meal.
· Mashed potatoes, sweet potatoes, turnips, squash, carrots and peas can be easily eaten following surgery.
· Beans, peas and lentils are great protein sources and should be very well cooked to a soft consistency and then pureed for easier consumption.
· Pasta that has been cooked to the point of almost being mushy can also be a good option. Adding cheese or cream sauce is a tasty nutritional addition.
· Yogurts, puddings, ice cream, milkshakes, custard, milk (including chocolate), cream and cheese sauces are good forms of dairy products and protein and caloric intake. Dairy alternatives include soy and rice milk where dietary restrictions may be of concern.
· Eggs are an excellent source of protein.
In addition to the use of a sedative, we will be using freezing (local anesthetic) to numb your mouth prior to the surgical procedures. Depending on what areas of the mouth are being frozen and your body metabolism, anesthetic varies in the length of time it stays in the area.
Bupivicaine, the long acting local anesthetic, is generally used when more complex oral surgery is performed. This type of anesthetic can last anywhere from 12 to 22 hours after the surgery. This allows for reduced pain at the surgical sites for a longer period of time. In very rare cases, this freezing has been reported to last up to 33 hours.
If the numbness is still present after the day and a half following surgery, please contact Dr. Hokhold for further information. This could indicate that there may have been possible nerve damage during the surgery and we may need to address the condition with a prescription.
You will be given an anti-swelling medication called Dexamethasone at the time the sedative is administered as well as a care package or prescription to follow your surgery appointment. Dexamethasone, a corticosteroid, will prepare your body for the upcoming procedures and continue to keep any post-surgery swelling under control. Dexamethasone is not a pain killer but rather helps to reduce or prevent inflammation. With little or no swelling, you will have considerably less discomfort. It is important that any Dexamethasone given or prescribed to you by the dentist following your surgery appointment must be taken every 24 hours to be effective. Failure to take the prescribed dosing at the correct intervals could result in considerable swelling and significant pain as a result of the swelling.
Some of the side effects that may be noticed while taking Dexamethasone may include:
· Stomach upset
· Increased appetite
· Feelings of euphoria or depression
· Mood swings
· Trouble sleeping (insomnia)
If any of the above symptoms persist beyond your comfort, please contact Dr. Hokhold and he will discuss options which may include reducing or tapering the daily dosage of Dexamethasone.
IMPORTANT: Dexamethasone can cause blood sugars (glucose) to rise and if you are glucose intolerant, hypoglycaemic or diabetic, you will need to monitor your blood glucose levels more frequently.
If you are taking anti-swelling medication (Dexamethasone) to keep post-surgery swelling suppressed, you should be prepared for ‘rebound inflammation’ at the surgical site 28-32 hours after taking the last Dexamethasone tablet in your prescription. Rebound inflammation means that you may experience a slight bit of swelling at the end of the recovery stages which can come with some discomfort. The reason why this happens is that the Dexamethasone essentially tells your body not to react to the surgery. This gets your body through the days where inflammation would be the worst and rebound inflammation is when your body realizes that something DID happen but this should subside within 1-2 days.
In preparation of the potential for rebound inflammation, you could take a full dose of Ibuprofen (Advil or Motrin) or other pain medication 28 hours after taking the last Dexamethasone tablet as a precautionary measure for any possible discomfort to follow.
Dexamethasone/ Sedation and Breastfeeding
Dexamethasone can stay in our body anywhere from 16-36 hours after taking this medication. When this corticosteroid is being taken, it is excreted in breast milk and can suppress growth or disrupt the baby’s normal corticosteroid production. Optimally breast feeding should be avoided while taking this medication. If you decide that you would like to have Dexamethasone as part of your treatment but you are breastfeeding, we will say for safety sake that the elimination time of this drug is 48 hours after your last dose and the following information must be followed:
· You must pump enough milk that will carry your baby through 10 days of feeding while you are taking Dexamethasone. Generally, we will be giving you this medication the morning of your appointment and then 7 days worth of it to follow which equals 8 days of taking Dexamethasone. Now we must take into account the 2 day (48 hour) elimination period for the drug to be completely out of your system which equates to a total of 10 days.
· Another option that can be utilized to obtain the benefits of Dexamethasone on a smaller scale and shorter time frame would be to pump enough milk that will carry your baby through 2 days of feeding while taking Dexamethasone. This will allow you to have the initial dose of Dexamethasone on the day of your surgery but none to follow. This small dose will prevent some of the first stages of inflammation (which are usually the worst) but you will more than likely experience rebound inflammation possibly by the 3rd day. Any discomfort to follow may need to be addressed with alternative pain killers that are safe for you and baby.
· A third alternative is to completely opt out of having Dexamethasone as part of your surgery appointment or to follow. If a sedative is still being requested, then you will need to pump enough milk that will carry your baby through the 1 day of feeding following your surgery appointment and normal feeding routine can commence by the next day.
Analgesic (Pain Tablet) Management
Pain after oral surgery varies depending on the extent of the procedure and the body’s ability to manage discomfort. Here is a list of possible options to manage pain or discomfort and the instructions must be followed carefully regarding medication dosages:
OPTION #1—IBUPROFEN, ADVIL OR MOTRIN
· Children 6 months to 12 years of age usually are given 5-10mg/kg of Ibuprofen every 6-8 hours.
· Adults and children 12 years of age and older, 400mg to 800mg every 6-8 hours is recommended.
OPTION #2—TYLENOL (ACETAMINOPHEN)
· Children under 12 years of age, recommended dose is 10-15mg/kg every 4-6 hours, NOT to exceed five doses (50-75mg/kg) in 24 hours.
· Adults and children 12 years of age and older, recommended dose is 650-1000mg every 4-6 hours as needed, NOT to exceed 4000mg in 24 hours.
OPTION #3—IBUPROFEN, ADVIL, OR MOTRIN IN COMBINATION WITH TYLENOL (ACETAMINOPHEN)
· Children 6 months to 12 years of age are usually given 5-10mg/kg of Ibuprofen every 6-8 hours, PLUS, 10-15mg/kg Tylenol every 4-6 hours, NOT exceed five doses (50-75mg/kg) in 24 hours.
· Adults and children 12 years of age and older, recommended dose of Ibuprofen is 400-800mg every 6-8 hours, PLUS, 650-1000mg of Tylenol every 4-6 hours as needed, NOT to exceed 4000mg in 24 hours.
OPTION #4—IBUPROFEN, ADVIL OR MOTRIN IN COMBINATION WITH TYLENOL #3 (WITH CODIENE)
· For adults, the recommended dose of Ibuprofen is 400-800mg every 6-8 hours, PLUS, 1-2 tablets of Tylenol #3 every 4-6 hours.
· Tylenol #3 contains codeine which is a narcotic. Codeine may make you feel sedated (drowsy), nauseous, cause vomiting as well as constipation.
· Tylenol #3 should not be used until the sedative effects have worn off.
OPTION #5—IBUPROFEN, ADVIL, OR MOTRIN IN COMBINATION WITH TRAMACET
· For adults, the recommended dose of Ibuprofen is 400-800mg every 6-8 hours, PLUS, 1-2 tablets of Tramacet every 4-6 hours as needed up to a maximum of 8 tablets daily