Surgical Instructions

Before Intravenous Anesthesia Sedation

• You may not have anything to eat or drink (including water) for eight (8) hours prior to the appointment.
• A responsible adult must accompany the patient to the office, remain in the waiting room during the procedure and drive the patient home, following surgery.
• No smoking at least 12 hours before surgery. Ideally, cut down or stop smoking as soon as possible prior to the day of surgery.
• The patient should not drive a vehicle or operate any machinery for 24 hours following the anesthesia experience.
• Please wear loose fitting clothing with sleeves which can be rolled up past the elbow, and low-heeled shoes.
• Contact lenses, jewelry, and dentures must be removed at the time of surgery.
• Do not wear lipstick, excessive makeup, or nail polish on the day of surgery.
• If you have an illness such as a cold, sore throat, stomach or bowel upset, please notify the office.
• If you take routine oral medications, please check with Drs. , or prior to your surgical date for instructions.
• No cell phones are allowed in the operatory on the day of surgery.
• Anyone accompanying the patient on the day of surgery, will kindly be asked to remain in the waiting area, until the conclusion of the procedure.

Dental Implant Surgery

After Placement of Dental Implants

Do not disturb the wound. Avoid rinsing, spitting, or touching the wound on the day of surgery. There might be a metal healing abutment protruding through the gingival (gum) tissue.

Bleeding

Some bleeding or redness in the saliva is normal for 24 hours. Excessive bleeding can be controlled by biting on a gauze pad or a tea bag placed directly on the bleeding wound for 30 minutes. If bleeding continues please call us for further instructions.

Swelling

Swelling is a normal occurrence after surgery. To minimize swelling, apply an ice bag, or a plastic bag, or towel filled with ice on the cheek in the area of surgery.

Diet

Drink plenty of fluids. Avoid hot liquids or food. Soft food and liquids should be eaten on the day of surgery. Return to a normal diet as soon as possible unless otherwise directed.

Pain

You should begin taking pain medication as soon as you feel the local anesthetic wearing off. For moderate pain, 1 or 2 Tylenol or Extra Strength Tylenol may be taken every 3-4 hours. Ibuprofen (Advil or Motrin) may be taken instead of Tylenol. Ibuprofen, bought over the counter comes in 200 mg tablets: 2-3 tablets may be taken every 3-4 hours as needed for pain. For severe pain, the prescribed medication should be taken as directed. Do not take any of the above medication if you are allergic, or have been instructed by your doctor not to take it.

Antibiotics

Be sure to take the prescribed antibiotics as directed to help prevent infection.

Oral Hygiene

Good oral hygiene is essential to good healing. The night of surgery, use the prescribed Peridex Oral Rinse before bed. The day after surgery, the Peridex should be used twice daily, after breakfast and before bed. Be sure to rinse for at least 30 seconds then spit it out. Warm salt water rinses (teaspoon of salt in a cup of warm water) should be used at least 4-5 times a day, as well, especially after meals. Brushing your teeth and the healing abutments is no problem. Be gentle initially with brushing the surgical areas.

Activity

Keep physical activities to a minimum immediately following surgery. If you are considering exercise, throbbing or bleeding may occur. If this occurs, you should discontinue exercising. Keep in mind that you are probably not taking normal nourishment. This may weaken you and further limit your ability to exercise.

Wearing your Prosthesis

Partial dentures, flippers, or full dentures should not be used immediately after surgery and for at least 10 days. This was discussed in the pre-operative consultation.

Wisdom Tooth Removal

After Wisdom Tooth Removal

The removal of impacted teeth is a serious surgical procedure. Post-operative care is very important. Unnecessary pain and the complications of infection and swelling can be minimized if the instructions are followed carefully.

Immediately Following Surgery

• The gauze pad placed over the surgical area should be kept in place for 30-45 minutes. After this time, the gauze pad should be removed and discarded. You should repeat this process until bleeding is controlled.
• Vigorous mouth rinsing or touching the wound area following surgery should be avoided. This may initiate bleeding by causing the blood clot that has formed to become dislodged.
• Take the prescribed pain medications as soon as you begin to feel discomfort. This will usually coincide with the local anesthetic becoming diminished.
• Restrict your activities the day of surgery and resume normal activity when you feel comfortable.
• Place ice packs to the sides of your face where surgery was performed. Refer to the section on swelling for explanation.

* DO NOT EVER DRINK OR EAT ANYTHING WHILE GAUZE IS STILL IN YOUR MOUTH, you must remove the gauze out of your mouth before you eat or drink anything. Failure to do so could lead to serious life threatening obstruction of your airway.

* DO NOT ever go to sleep with gauze still in your mouth, you must remove all gauze out of your mouth before you sleep. Failure to do so may lead to serious life threatening obstruction of your airway.

Bleeding

A certain amount of bleeding is to be expected following surgery. Slight bleeding, oozing, or redness in the saliva is not uncommon. Excessive bleeding may be controlled by first rinsing or wiping any old clots from your mouth, then placing a gauze pad over the area and biting firmly for thirty minutes. Repeat if necessary. If bleeding continues, bite on a moistened tea bag for thirty minutes. The tannic acid in the tea bag helps to form a clot by contracting bleeding vessels. To minimize further bleeding, do not become excited, sit upright, and avoid exercise. If bleeding does not subside, call for further instructions.

Swelling

The swelling that is normally expected is usually proportional to the surgery involved. Swelling around the mouth, cheeks, eyes and sides of the face is not uncommon. This is the body’s normal reaction to surgery and eventual repair. The swelling will not become apparent until the day following surgery and will not reach its maximum until 2-3 days post-operatively. However, the swelling may be minimized by the immediate use of ice packs. Two baggies filled with ice, or ice packs should be applied to the sides of the face where surgery was performed. The ice packs should be left on continuously while you are awake. After 36 hours, ice has no beneficial effect. If swelling or jaw stiffness has persisted for several days, there is no cause for alarm. This is a normal reaction to surgery. Thirty-six hours following surgery, the application of moist heat to the sides of the face is beneficial in reducing the size of the swelling.

Pain

For moderate pain, one or two tablets of Tylenol or Extra Strength Tylenol may be taken every three to four hours or Ibuprofen, (Motrin or Advil) two-four 200 mg tablets may be taken every 3-4 hours.

For severe pain, take the tablets prescribed as directed. The prescribed pain medicine will make you groggy and will slow down your reflexes. Do not drive an automobile or work around machinery. Avoid alcoholic beverages. Pain or discomfort following surgery should subside more and more every day. If pain persists, it may require attention and you should call the office.

Diet

After general anesthetic or I.V. sedation, liquids should be initially taken. Do not use straws. Drink from a glass. The sucking motion can cause more bleeding by dislodging the blood clot. You may eat anything soft by chewing away form the surgical sites. High calorie, high protein intake is very important. Refer to the section on suggested diet instructions at the end of the brochure. Nourishment should be taken regularly. You should prevent dehydration by taking fluids regularly. Your food intake will be limited for the first few days. You should compensate for this by increasing your fluid intake. At least 5-6 glasses of liquid should be taken daily. Try not to miss a single meal. You will feel better, have more strength, less discomfort and heal faster if you continue to eat. Caution: If you suddenly sit up or stand from a lying position you may become dizzy. If you are lying down following surgery, make sure you sit for one minute before standing.

Keep the mouth clean

No rinsing of any kind should be performed until the day following surgery. You can brush your teeth the night of surgery but rinse gently. The day after surgery you should begin rinsing at least 5-6 times a day especially after eating with a cup of warm water mixed with a teaspoon of salt.

Discoloration

In some cases, discoloration of the skin follows swelling. The development of black, blue, green, or yellow discoloration is due to blood spreading beneath the tissues. This is a normal post-operative occurrence, which may occur 2-3 days post-operatively. Moist heat applied to the area may speed up the removal of the discoloration.

Antibiotics

If you have been placed on antibiotics, take the tablets or liquid as directed. Antibiotics will be given to help prevent infection. Discontinue antibiotic use in the event of a rash or other unfavorable reaction. Call the office if you have any questions.

Nausea and Vomiting

In the event of nausea and/or vomiting following surgery, do not take anything by mouth for at least an hour including the prescribed medicine. You should then sip on coke, tea or ginger ale. You should sip slowly over a fifteen-minute period. When the nausea subsides you can begin taking solid foods and the prescribed medicine.

Other Complications

• If numbness of the lip, chin, or tongue occurs there is no cause for alarm. As stated before surgery, this is usually temporary in nature. You should be aware that if your lip or tongue is numb, you could bite it and not feel the sensation. So be careful. Call [last_name] if you have any questions.
• Slight elevation of temperature immediately following surgery is not uncommon. If the temperature persists, notify the office. Tylenol or ibuprofen should be taken to reduce the fever.
• You should be careful going from the lying down position to standing. You were not able to eat or drink prior to surgery. It was also difficult to take fluids. Taking pain medications can make you dizzy. You could get light headed when you stand up suddenly. Before standing up, you should sit for one minute then get up.
• Occasionally, patients may feel hard projections in the mouth with their tongue. They are not roots, they are the bony walls which supported the tooth. These projections usually smooth out spontaneously. If not, they can be removed by Drs. , or .
• If the corners of your mouth are stretched, they may dry out and crack. Your lips should be kept moist with an ointment such as vaseline.
• Sore throats and pain when swallowing are not uncommon. The muscles get swollen. The normal act of swallowing can then become painful. This will subside in 2-3 days.
• Stiffness (Trimus) of the jaw muscles may cause difficulty in opening your mouth for a few days following surgery. This is a normal post-operative event which will resolve in time.

Finally

Sutures are placed the area of surgery to minimize post-operative bleeding and to help healing. Sometimes they become dislodged, this is no cause for alarm. Just remove the suture form your mouth and discard it. The sutures will be removed approximately one week after surgery. The removal of sutures requires no anesthesia or needles. It takes only a minute or so, and there is no discomfort associated with this procedure. So it’s really nothing to worry about..

The pain and swelling should subside more and more each day following surgery. If your post-operative pain or swelling worsens or unusual symptoms occur call my office for instructions..

There will be a cavity where the tooth was removed. The cavity will gradually over the next month fill in with the new tissue. In the mean time, the area should be kept clean especially after meals with salt water rinses or a toothbrush..

Your case is individual, no two mouths are alike. Do not accept well intended advice from friends. Discuss your problem with the persons best able to effectively help you: Drs. , or or your family dentist..

Brushing your teeth is okay – just be gentle at the surgical sites..

A dry socket is when the blood clot gets dislodged prematurely from the tooth socket. Symptoms of pain at the surgical site and even pain to the ear may occur 2-3 days following surgery. Call the office if this occurs..

If you are involved in regular exercise, be aware that your normal nourishment intake is reduced. Exercise may weaken you. If you get light headed, stop exercising.

BOTOX® Cosmetic Post Treatment Care

1. Try to exercise your treated muscles 1-2 hours after treatment (e.g. practice frowning, raising your eyebrows or squinting). This helps to work Botox into your muscles. Although this is thought to help, it will NOT impact your treatment.
2. Do NOT rub or massage the treated areas for 2 hours after your treatment. Do NOT do strenuous exercise for 4 hours after treatment. Also avoid facials or saunas for 4 hours after treatment. This will minimize the risk of raising your blood pressure and therefore minimize the risk of temporary bruising. Feel free to shower and go about most other regular daily activities.
3. Do NOT lie down for 4 hours after treatment. This is to avoid the risk of pressure on the treated areas (from your pillow) and to avoid the risk of having the area rubbed accidentally.
4. Be assured that any tiny bumps or marks will go away within a few hours. If you need to apply makeup within 4 hours after treatment, use a gentle touch to avoid rubbing the treated area.
5. Results of your treatment may take up to 14 days to take full effect. Please wait until this time period has passed before assessing your final result.
6. Our office will need to see you for a 2 week followup visit. If there are areas that require further augmentation, this can be discussed with your surgeon.
7. BOTOX® requires a special technique in order to customize the injections to your individual musculature. It is important that your muscle activity recovers, but that your skin does not show the same crease lines present prior to treatment.
8. BOTOX® is a temporary cosmetic procedure, with initial results lasting approximately 3-4 months. If you maintain your treatment with the frequency recommended, the duration of each treatment may last longer than 4 months.
9. To schedule your two week followup visit, please contact our office.

Restylane® Post Treatment Care

Please observe the following after treatment with Restylane®

• Cold compresses (a cloth dipped in cold water, wrung out, and applied to the injected area) may be used immediately after treatment to reduce swelling
• Avoid touching the treated area within six hours following treatment so you do not accidentally injure your skin while the area is numb. After that, the area can be gently washed with soap and water.
• Until there is no redness or swelling, avoid exposure of the treated area to intense heat (sun lamp or sun bathing).
• If you have previously suffered from facial cold sores, there is a risk that the needle punctures could contribute to another occurrence. Speak to your physician about medications that may minimize a recurrence.
• Avoid taking aspirin, non-steroidal anti-inflammatory medications, St. John’s Wort, and high dosese of Vitamin E supplements for one week after treatment. These agents may increase bruising and bleeding at the injection site.

Exposure of an Impacted Tooth

Do not disturb the wound. If surgical packing was placed, leave it alone. The pack helps to keep the tooth exposed. If it gets dislodged or falls out do not get alarmed.

Bleeding

Some bleeding or redness in the saliva is normal for 24 hours. Excessive bleeding which results in your mouth filling rapidly with blood can frequently be controlled by biting with pressure on a gauze pad placed directly on the bleeding wound for 30 minutes. If bleeding continues please call for further instructions.

Swelling

Swelling is a normal occurrence after surgery. To minimize swelling, apply an ice bag or a plastic bag or towel filled with ice cubes on the cheek in the area of surgery. Apply the ice continuously as much as possible for the first 36 hours.

Diet

Drink plenty of fluids. Avoid hot liquids or food. Soft food and liquids should be eaten on the day of surgery. Return to a normal diet as soon as possible unless otherwise directed.

Pain

You should begin taking pain medication as soon as you feel the local anesthetic wearing off. For moderate pain, 1 or 2 Tylenol or Extra Strength. Tylenol may be taken every 3-4 hours. Ibuprofen (Advil, Motrin) may be taken instead of Tylenol. Ibuprofen bought over the counter comes in 200 mg tablets: 2-3 tablets may be taken every 3-4 hours as needed for pain. For severe pain, the prescribed medication should be taken as directed.

Oral Hygiene

Mouth cleanliness is essential to good healing. Clean your mouth thoroughly after each meal beginning the day after surgery. Brush your teeth as best you can. Rinse with warm salt water (1/2 teaspoon of salt in a cup of warm water) six times a day. Continue this procedure until healing is complete.

REMEMBER: A clean wound heals better and faster.

Activity

Keep physical activities to a minimum immediately following surgery. If you are considering exercise, throbbing or bleeding may occur. If this occurs, you should discontinue exercising. Be aware that your normal nourishment intake is reduced. Exercise may weaken you. If you get light headed, stop exercising.

Extractions

After tooth extraction, it’s important for a blood clot to form to stop the bleeding and begin the healing process. That’s why we ask you to bite on a gauze pad for 30-45 minutes after the appointment. If the bleeding or oozing still persists, place another gauze pad and bite firmly for another 30 minutes. You may have to do this several times.

After the blood clot forms, it is important not to disturb or dislodge the clot as it aids healing. Do not rinse vigorously, suck on straws, smoke, drink alcohol or brush teeth next to the extraction site for 72 hours. These activities will dislodge or dissolve the clot and retard the healing process. Limit vigorous exercise for the next 24 hours as this will increase blood pressure and may cause more bleeding from the extraction site.

After the tooth is extracted you may feel some pain and experience some swelling. An ice pack or an unopened bag of frozen peas or corn applied to the area will keep swelling to a minimum. Take pain medications as prescribed. The swelling usually subsides after 48 hours.

Use the pain medication as directed. Call the office if the medication doesn’t seem to be working. If antibiotics are prescribed, continue to take them for the indicated length of time, even if signs and symptoms of infection are gone. Drink lots of fluid and eat nutritious soft food on the day of the extraction. You can eat normally as soon as you are comfortable.

It is important to resume your normal dental routine after 24 hours. This should include brushing and flossing your teeth at least once a day. This will speed healing and help keep your mouth fresh and clean.

After a few days you will feel fine and can resume your normal activities. If you have heavy bleeding, severe pain, continued swelling for 2-3 days, or a reaction to the medication, call our office immediately.

Multiple Extractions

A small amount of bleeding is to be expected following the operation. If bleeding occurs, place a gauze pad directly over the bleeding socket and apply biting pressure for 30 minutes. If bleeding continues, a moist tea bag can be used for 30 minutes. If bleeding occurs, avoid hot liquids, exercise, and elevate the head. If bleeding persists, call our office immediately. Do not remove immediate denture unless the bleeding is severe. Expect some oozing around the side of the denture.

Use ice packs (externally) on the same side of the face as the operated area. Apply ice for the first 36 hours only. Apply ice continuously while you are awake.

For mild discomfort use aspirin, Tylenol or any similar medication; two tablets every 3-4 hours. Ibuprofen (Advil, Motrin) 200mg can be taken 2-3 tablets every 3-4 hours.

For severe pain use the prescription given to you. If the pain does not begin to subside in 2 days, or increases after 2 days, please call our office. If an antibiotic has been prescribed, finish your prescription regardless of your symptoms.

Drink plenty of fluids. If many teeth have been extracted, the blood lost at this time needs to be replaced. Drink at least six glasses of liquid the first day.

Do not rinse your mouth for the first post-operative day, or while there is bleeding. After the first day, use a warm salt water rinse every 4 hours and following meals to flush out particles of food and debris that may lodge in the operated area. (One half teaspoon of salt in a glass of lukewarm water.). After you have seen your dentist for denture adjustment, take out denture and rinse 3 to 4 times a day.

Restrict your diet to liquids and soft foods, which are comfortable for you to eat. As the wounds heal, you will be able to advance your diet.

The removal of many teeth at one time is quite different than the extraction of one or two teeth. Because the bone must be shaped and smoothed prior to the insertion of a denture, the following conditions may occur, all of which are considered normal:

• The area operated on will swell reaching a maximum in two days. Swelling and discoloration around the eye may occur. The application of a moist warm towel will help eliminate the discoloration quicker. The towel should be applied continuously for as long as tolerable beginning 36 hours after surgery (remember ice packs are used for the first 36 hours only).
• A sore throat may develop. The muscles of the throat are near the extraction sites. Swelling into the throat muscles can cause pain. This is normal and should subside in 2-3 days.
• If the corners of the mouth are stretched, they may dry out and crack. Your lips should be kept moist with an ointment like Vaseline. There may be a slight elevation of temperature for 24-48 hours. If temperature continues, notify our office.

If immediate dentures have been inserted, sore spots may develop. In most cases, your dentist will see you within 24-48 hours after surgery and make the necessary adjustments to relieve those sore spots. Failure to do so may result in severe denture sores, which may prolong the healing process.

Bisphosphonates

What are Bisphosphonate Drugs?

Bisphosphonates are a class of drugs that prevent the loss of bone mass. High potency intravenous bisphosphonates have been shown to modify the progression of malignant bone disease in several forms of cancer, including both breast and prostate cancer. Oral bisphosphonates are used to treat osteoporosis, osteitis deformans (Paget’s disease) and other conditions that lead to bone fragility.

After they are taken orally or intravenously, bisphosphonates bind tightly to the surface of the bone directly beneath the bone cells known as osteoclasts, which actively dissolve bone. The drugs then become incorporated into the osteoclasts, stopping them from dissolving bone. As a result, bone production continues, bone loss decreases, bone density is improved and the risk of fracture is reduced.

IV Bisphosphonates

• Pamidronate (Aredia)
• Zoledronic Acid (Zometa)
• Zoledronate (Reclast)
• Ibandronate (Boniva)

Oral Bisphosphonates

• Etidronate (Didronel)
• Tiludronate (Skelid)
• Aledronate (Fosamax)
• Risedronate (Actonel)
• Ibandronate (Boniva)

Stages for BRONJ

Stage I – characterized by exposed bone, that shows no disease or inflammation of surrounding soft tissue

Stage 2 – distinguished by painful areas of exposed bone accompanied by soft tissue or bone inflammation

Stage 3 – associated with extensive amount of exposed bone, soft tissue inflammation and pathologic fracture

Risk Factors for BRONJ

Use of bisphosphonates – Although this is a common reason for the development of BRONJ, it is the dosage and length of therapy that are the determining factors. IV bisphosphonates used in cancer treatment are much more potent than oral bisphosphonates used to manage osteoporosis, thus increasing the risk for BRONJ in these patients.

Duration or number of treatments with bisphosphonates – The risk of developing BRONJ appears to increase in relation to the number of treatments with an IV bisphosphonate.

Dental procedures – Patients undergoing routine dental surgical procedures, including tooth extractions, periodontal surgery or dental implant placement, while being treated with bisphosphonates compromise about 60% of BRONJ cases.

Prevention of BRONJ

If you are about to being monthly IV bisphosphonate therapy for the treatment of bone cancer, visit your family dentist for a thorough check up. Take care of all necessary procedures, before treatment starts. If you have removable dentures, make sure they fit well and are comfortable.

If you are currently being treated with either IV or oral bisphosphonates, be sure to tell your family dentist and oral and maxillofacial surgeon the reason for bisphosphonate treatment, the method of treatment (IV or oral), and the dosage level before you schedule a surgical procedure.

Oral hygiene is particularly important if you are being treated with bisphosphonates. It is also crucial that you schedule regular examinations with your family dentist so that any infections or problems can be identified and addressed early.

Management of BRONJ

If you are diagnosed with BRONJ, it is very important that your treatment plan include regular and thorough communication between your physician, family dentist and oral and maxillofacial surgeon. There are a number of treatment options available to your surgeon, who will select what is most appropriate for you. Treatment may include: daily irrigation and antimicrobial rinses; antibiotics to control infection; or surgical debridement for advanced cases.

BRONJ: Bisphosphonate Related Osteonecrosis of the Jaw. AAOMS 2012