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Full text of "Contemporary Oral and Maxillofacial Surgery,4th Ed Part II Principle of Exodontia"

Postoperative 
Patient 
Management 



Larry J. Peterson 




CHAP T E R 



Chapter outline 



CONTROL OF POSTOPERATIVE BLEEDING 

CONTROL OF POSTOPERATIVE PAIN AND DISCOMFORT 

Diet 

Oral Hygiene 

Edema 

Control of Infection 

Trismus 

Ecchymosis 
POSTOPERATIVE FOLLOW-UP VISIT 
OPERATIVE NOTE FOR THE RECORDS 



Once the surgical procedure has been completed, 
patients should be given proper instructions on 
how to care for themselves for the remainder of 
the day of surgery and for a few days afterward. If the 
patient is to receive intravenous (IV) sedation, the post- 
operative management instructions must be discussed 
before the sedation is given. These instructions should 
also be repeated to the patient's escort before discharge 
from the office. 

Postoperative instructions should predict what the 
patient is likely to experience, explain why these phe- 
nomena occur, and tell the patient how to manage and 
control the typical postoperative sequelae. The instruc- 
tions must be given to the patient verbally and on a writ- 
ten sheet. The instruction sheet should describe the typi- 
cal problems and their management. It should also 
include a phone number at which the surgeon can be 



reached in an emergency. The language must be clear and 
simple enough to be followed by all patients. A typical 
postoperative instruction sheet is found in Appendix V. 
This chapter discusses common postoperative prob- 
lems and methods of controlling them. 

CONTROL OF POSTOPERATIVE BLEEDING 

Once an extraction has been completed, the initial maneu- 
ver to control postoperative bleeding is the placement of a 
small, damp gauze pack directly over the empty socket. 
Large packs that cover the occlusal surfaces of the teeth do 
not apply pressure to the bleeding socket and should not 
be used (Fig. 10-1). The gauze should 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 



214 



Postoperative Patient Management 



CHAPTER 10 



21 




30 minutes and not to chew on the gauze but rather to 
hold it without opening or closing the mouth. Talking 
should be kept to a minimum for 3 or 4 hours. 

Patients should be informed that it is normal for a 
tooth socket to ooze slightly for 24 hours after the extrac- 
tion procedure. They should be warned that a small 
amount of blood and a large amount of saliva would 
appear to be a large amount of blood. If the bleeding is 
more than a slight ooze, the patient should be instructed 
on how to reapply a small, damp gauze pack directly over 
the area of the extraction. The patient should be instruct- 
ed to hold this second gauze pack in place for as long as 
1 hour to gain control of bleeding. 

Patients should be cautioned about things that may 
aggravate the bleeding and therefore be avoided. Patients 
who smoke should be encouraged to avoid smoking for 
the first 12 hours or, more commonly, if they must smoke, 
to draw on the cigarette very lightly. The negative pressure 
created by this suction in the mouth may promote bleed- 
ing and should be discouraged. The patient should be told 
not to suck on a straw when drinking; this also creates 
negative pressure. The patient should be advised not to 
spit during the first 12 hours after surgery. The process of 
spitting involves negative pressure and mechanical agita- 
tion of the extraction, which may prolong bleeding. 
Patients who object to having blood in the mouth should 
be encouraged to bite firmly on a piece of gauze to control 



FIG. 10-1 A, Fresh extraction site will bleed excessively unless a 
properly positioned gauze pack is placed. B, Small gauze pack is 
placed to fit only in area of extraction; this permits pressure to be 
applied directly to socket. C, Large or mispositioned gauze pack is 
not effective in controlling bleeding. Pressure of biting is not 
directed to socket. 



the hemorrhage and to swallow their saliva instead of spit- 
ting it out. Finally, no strenuous exercise should be per- 
formed for the first 12 to 24 hours after extraction, 
because the increased circulation may result in bleeding. 

Patients should be warned that there may be some 
oozing during the night and that they will probably have 
some blood on their pillows. This will prevent many fran- 
tic telephone calls to the surgeon in the middle of the 
night. 

Patients should also be instructed that if they are wor- 
ried about their bleeding, they should call the dentist to 
get additional advice. Prolonged bleeding, bright red 
bleeding, or large clots in the patient's mouth are all indi- 
cations for a return visit. The dentist should then exam- 
ine the area closely and apply appropriate measures to 
control the bleeding (see Chapter 1 1). 

CONTROL OF POSTOPERATIVE PAIN 

AND DISCOMFORT 

All patients expect a certain amount of pain after a surgical 
procedure, so it is important for the dentist to discuss this 
issue carefully with each patient before discharge from the 
office. The surgeon must help the patient have a realistic 
expectation of what type of pain may occur. The surgeon 
must therefore pay attention to the patient's concerns and 
preconceived ideas of how much pain is likely to occur. 



216 PART II 



Principles rf'Exadontia 



Patients who tell the surgeon that they expect a great 
deal of pain after surgery should not be ignored and told to 
take an aspirin if it hurts, because these are the patients most 
likely to experience pain postoperatively. It is important 
for the surgeon to assure patients, especially the latter 
group, that their postoperative pain can be effectively 
managed. 

The pain a patient may experience after a surgical 
procedure, such as tooth extraction, is highly variable 
and depends a great deal on the patient's preoperative 
frame of mind. The surgeon who spends several 
minutes discussing these issues with the patient before 
surgery will be able to recommend the most 
appropriate medication. 

All patients should be given advice concerning anal- 
gesics before they are discharged. Even when the 
surgeon believes that no prescription analgesics are 
necessary, the patient should be told to take aspirin or 
acetaminophen postoperatively to prevent initial 
discomfort when the effect of the local anesthetic 
disappears. Patients who are expected to have a higher 
level of pain should he given prescriptions for analgesics 
that will 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 soreness. 

The surgeon must understand the three 
characteristics of the pain that occurs after tooth 
extraction. First, it is usually not severe and can be 
managed in most patients with mild analgesics. Second, 
the peak pain experience occurs about 1 2 hours after the 
extraction and diminish-es rapidly after that. Finally, 
the pain from extraction rarely persists longer than 2 
days after surgery. With these factors kept in mind, 
patients can best be advised regarding the effective use 
of analgesics. 

The first dose of analgesic medication should be 
taken before the effect of the local anesthetic subsides. If 
this is done, the patient will not experience the intense, 
sharp pain after the loss of the local anesthesia. By 
preventing the sudden onset of surgical pain, the 
subsequent control of it is more easily and predictably 
achieved with mild analgesics. Postoperative pain is 
much more difficult to overcome if administration of 
analgesic medication is delayed. If the patient waits to 
take the first dose of analgesic until the effects of the 
local anesthesia have disappeared, it will take up to 90 
minutes for the analgesic to become effective. During 
this time, the patient is likely to become impatient and 
take additional medication that will increase the 
chance of nausea and vomiting. 

The strength of the analgesic is also of importance. 
Potent analgesics are not required in most extraction sit- 
uations; instead, analgesics with a lower potency per dose 
are effective. The patient can then be told to take one, 
two, or three tablets as necessary to control pain. By 
allowing the patient to assume an active role in deter- 
mining the amount of medication to take, a more precise 
and realistic control can be achieved. 

Patients should be warned that taking too much of 
the medication will result in drowsiness and an 
increased chance of an upset stomach. In most 
situations, patients should take medication with some 
type of food to decrease its irritating effect on the 
stomach. 



Aspirin has been demonstrated to be an effective med- 
ication to control the pain and discomfort of a tooth 
extraction. This drug works primarily peripherally, inter- 
fering with prostaglandin synthesis. If the surgeon pre- 
scribes a combination drug of aspirin and narcotic, it 
should be a combination that delivers 500 to 1000 mg of 
aspirin per dose. If the patient cannot tolerate aspirin, 
acetaminophen in a similar dose is a good alternative 
drug. Aspirin 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 post- 
operative bleeding. Acetaminophen does not interfere 
with platelet function at all, and it may be useful in cer- 
tain situations where the patient has a platelet defect and 
is likely to bleed. Aspirin remains the drug of choice for 
control of mild-to-moderate pain after tooth extraction. 

Nonsteroidal antiinflammatory analgesics (NSAIDs), 
such as ibuprofen, are also useful for patients who have 
had a tooth extraction. Well-controlled studies have doc- 
umented their effectiveness. They are effective for mild- 
to-moderate pain. A subcategory of NSAIDs, COX-2 
inhibitors, causes less irritation of the gastric mucus, has 
less effect on platelet function, and may provide for 
longer periods of analgesia. They may be useful in the 
management of postoperative pain that is expected to 
last for more than several days. Currently, no published 
data indicates that COX-2 inhibitors are superior to other 
NSAIDs in the control of routine postextraction pain. 

Drugs useful in situations with varying degrees of pain 
are listed in Table 10-1. Centrally acting analgesics are also 
frequently used to control pain after tooth extraction. The 
most commonly used drugs are codeine and the codeine 
congeners such as oxycodone, hydrocodone, and dihy- 
drocodeine. These narcotics are well absorbed from the 
gut; when used in equipotent doses, they produce similar 
pain relief, drowsiness, and gastrointestinal upset, They 
are rarely used alone; instead, they are formulated with 
other analgesics, primarily aspirin or acetaminophen. 
When codeine is used, the amount of codeine is frequent- 
ly designated by a numbering system. Compounds labeled 
no. 1 have 7.5 mg of 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 of aspirin or acetaminophen every 6 
hours to achieve maximal effectiveness from the nonnar- 
cotic. Many of the compound drugs have only 300 mg of 
aspirin or acetaminophen added to the narcotic. An 
example of a rational approach would be to prescribe a 
compound containing 300 mg of aspirin and 15 mg of 
codeine (no. 2). The usual adult dose would be two 
tablets of this compound every 4 hours. This two-tablet 
(30 mg of codeine and 600 mg of aspirin) dose provides a 
nearly ideal analgesia. Should the patient require stronger 
analgesic action, three tablets can be taken with increased 
effectiveness of both aspirin and codeine. Doses that sup- 
ply 30 or 60 mg of codeine but only 300 mg of aspirin fail 
to take advantage of aspirin's analgesic effect (Table 10-2). 

Other drugs that can be used as analgesics that pro- 
duce effects centrally are pentazocine, meperidine, and 
hydromorphone. Pentazocine and meperidine are useful 
but definitely second-choice drugs compared with the 
aspirin and codeine combination. 



Postoperative PatU'iit Management 



CHAPTER 10 



217 



: TABLE 10-1 • 


Analgesics for Postextraction Pain 


Oral Narcotic 


Usual Dose 


MILD PAT7S1 SITUATIONS 


Aspirin 500-1 000 mg q4h 
Acetaminophen 500-1000 mg q4h 

MODI RA'l "li PAIN SITUATIONS 


Ibuprofen and 400-800 mg q4h 
other NSAIDs 

Codeine 30-60 mg 

With aspirin (500 mg) 

With acetaminophen (500 mg) 

Propoxyphene 1 00 mg 

With acetaminophen (500 mg) 

SEVERE PAIN SITUATIONS 


Oxycodone 
Hydrocodone 


5-10 mg 

With aspirin (500 mg) 

With acetaminophen (500 mg) 

5-10 mg 

With aspirin (500 mg) 

With acetaminophen (500 mg) 



1 TABLE 10-2 f 



Commonly Used Combination Analgesics 



The Drug Enforcement Administration (DEA) controls 
narcotic analgesics. To write prescriptions for these drugs, 
the dentist must have a DEA permit and number. The 
drugs are categorized into four basic schedules based on 
their liability for abuse. Several important differences 
exist between Schedule II and Schedule III drugs con- 
cerning writing prescriptions (see Appendix III). 

It is important to emphasize that the most effective 
method of controlling pain is to build a close relationship 
between surgeon and patient. Specific time must be spent 
discussing the issue of postoperative discomfort, with 
concern clearly expressed by the surgeon. Prescriptions 
should be given with clear instructions about when to 
begin the medication and how to take it at each 
interval. If these procedures are followed, mild analgesics 
given for a short time (usually no longer than 2 to 3 
days) will be all that is required. 



Diet 

Patients who have had extractions may avoid eating 
because of local pain or fear of pain when eating. There- 
fore they should be given very specific instructions 
regarding their postoperative diet. A high-calorie, high- 
volume liquid diet is best for the first 12 to 24 hours. 

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



Brand Name Amount (mg) 


Amount (mg) 


Codeine- asp irin 


Codeine 


Aspirin 


Empirin compound 






No. 3 


30.0 


325 


No. 4 


60.0 


325 


Codein e- acetaminophen 


Codeine 


Acetaminophen 


Tylenol 






No. 2 


15.0 


300 


No. 3 


30.0 


300 


No. 4 


60.0 


300 


Oxycodone- aspirin 


Oxycodone 


Aspirin 


Percodan 


5.0 


325 


Percodan-Demi 


2.5 


25 


Oxycodone- 


Oxycodone 


Acetaminophen 


acetaminophen 






Percocet 


2.5 


325 




5.0 


325 




7.5 


500 




10.0 


650 


Tylox 


5.0 


500 


Hydrocodon e- aspirin 


Hydrocodone 


Aspirin 


Lortab ASA 


5.0 


500 


Hydrocodone- 


Hydrocodone 


Acetaminophen 


acetaminopnen 






Vicodin 


5.0 


500 


Vicodine ES 


7.5 


750 


Lorcet HD 


5.0 


500 


Lorcet Pius 


7.5 


650 


Lorcet 1 0/650 


10.0 


650 


Lortab 2.5/500 


2.5 


500 


Lortab 5/500 


5.0 


500 


Lortab Elixir 


2.5 mg/5 r 


ril 1 70 mg/5 ml 


Hydroc odone- ibuprofen 


Hydrocodone 


Ibuprofen 


Vicoprofen 


7.5 


200 


Dihydrocodeine-aspirin 


Dihydrocodeine Aspirin 


Synalgos-DC* 


16.0 


350 


Propoxyphene- 


Propoxyphene 


Acetaminophen 


acetaminophen 






Darvocet N-1 000 


100 


650 



*Also contains caffeine. 



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 solid foods, tend not 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. In most situations, patients have surgery 
only in an isolated quadrant or half of the mouth, which 
leaves the opposite side free to chew. The patient should be 
advised to return to a normal diet as soon as possible. 

Patients who are diabetic should be encouraged to 
return to their normal insulin and diet routine as soon as 
possible. For such patients the surgeon should plan sur- 



218 PART II 



Principles ofExndontm 



gery in only one side of the mouth at each surgical 
sitting, thereby not interfering with the normal dietary 
intake. 

Oral Hygiene 

Patients should be advised that keeping the teeth and 
mouth reasonably clean results in a more rapid healing 
of their surgical wounds. On the day of surgery patients 
can 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 pain. 

The next day, patients should begin gentle rinses 
with warm water. The water should be warm but not 
hot enough to burn the tissue. Most patients can resume 
pre-operative oral hygienic methods 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 comfortable enough to do 
so. 

If oral hygiene is likely to be compromised after 
extractions in multiple areas of the mouth, local 
antibiotic mouth rinses with agents such as 
chlorhexidine may be used. Twice-daily rinses for 
approximately 1 week after surgery may result in more 
rapid healing. 

Edema 

Most surgical procedures result in a certain amount of 
edema or swelling after surgery. Simple extraction of a sin- 
gle 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 large amounts of swelling (Fig. 
10-2). Swelling usually reaches its maximum 24 to 88 
hours after the surgical procedure. It 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 
postsurgical edema. 

Once the surgery is completed and the patient is 
ready to be discharged, application of ice packs to the 
area may help minimize the swelling and make the 
patient feel more comfortable; it also allows patients to 
play a role in their postsurgical care. Ice should not be 
placed directly on the skin, but rather a layer of dry 
cloth should be placed between the ice container and 
the tissue to prevent superficial tissue damage. 

The ice bag should be kept on the local area for 20 
minutes and then left off for 20 minutes. Ice pack 
application should be maintained for no more than 24 
hours, because longer application does not help. Ice 
packs are only minimally effective in controlling edema. 
Some surgeons prefer the intraoral application of ice. 
This can be accomplished by having the patient hold 
ice chips in the mouth or by sucking on a flavored 
Popsicle. 

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 keep from burning 
or injuring the skin. 

It is most important that patients anticipate some 
amount of swelling. 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. Patients should be informed that a moderate 
amount of swelling is a normal and healthy reaction of 
the tissue to the trauma of surgery. They should not be 
concerned or frightened by it, because it will resolve 
within a few days. 

Control of Infection 

To control infection the surgeon must carefully adhere 
to the principles of surgery. No other special measures 
must be taken with the average patient. However, 
some patients, especially those with depressed host- 
defense responses, may require antibiotics to prevent 
infection. Antibiotics in these patients should be 
administered before the surgical procedure is begun 
(see Chapter 15). 

Additional antibiotics after the surgery are usually not 
necessary. A surgeon who decides to give additional 
antibiotics must carefully discuss the timing of adminis- 
tration with the patient so that a clear understanding is 
reached. 




FIG. 10-2 Extraction of impacted right maxillary and mandibular 
third molars was performed 2 days before this photograph was 
taken. Patient exhibits moderate amount of facial edema, which will 
resolve within 1 week of surgery. 



Postoperative Patient Management 



(JHAI>TliR 10 



219 



Trismus 

Extraction of teeth may result in trismus, or limitation in 
opening the mouth. This is the result of inflammation 
involving the muscles of mastication. The trismus may be 
a result of multiple injections of local anesthetic, especial- 
ly if the injections have penetrated muscles. The muscle 
most likely to be involved is the medial pterygoid muscle, 
which may be inadvertently penetrated by the local anes- 
thetic needle during the inferior alveolar nerve block. 

Surgical extraction of impacted mandibular third 
molars frequently results in trismus, because the inflam- 
matory response to the surgical procedure is sufficiently 
widespread to involve several muscles of mastication. 
Trismus usually is not severe and does not hamper the 
patient's activity. However, to prevent alarm, patients 
should be warned that this phenomenon might occur. 



The application of heat may be helpful in helping to 
resolve persistent trismus and swelling. It is clear that for 
maximum effectiveness, the application of heat must be 
by use of moist heat. Because of the closer contact with 
the skin, heat transfer to the tissue is most effective when 
the heat source is from a wet surface. 



Ecchymosis 

In some patients blood oozes submucosally (SM) and sub- 
cutaneously (SC), which appears as a bruise in the oral tis- 
sues on the face (Fig. 10-3). Blood in the subcutaneous tis- 
sues is known as ecchymosis. This is usually seen in older 
patients because of their decreased tissue tone and weak- 
er intercellular attachment. Ecchymosis is not dangerous 
and does not increase pain or infection. Patients, howev- 




FIG.10-3 A, Moderate ecchymosis of floor of mouth, which was evident at time of 
suture removal on sixth day after multiple extractions, is demonstrated. B, Moderate 
widespread ecchymosis of right side of face and neck is exhibited in an older patient after 
extraction of several mandibular teeth. 



220 PARI" II ■ Principles of Exodmitia 



er, should be warned that ecchymosis may occur, 
because if they awaken on the second postoperative 
day and see bruising in the cheek or submandibular 
area, they may become very apprehensive about their 
progress. This anxiety is easily preventable by 
postoperative instructions. Typically the onset of 
ecchymosis is 2 to 4 days after surgery and usually 
resolves with 7 to 10 days. 

POSTOPERATIVE FOLLOW-UP VISIT 

All patients should be given a return appointment so 
that the surgeon can check the patient's progress after 
the surgery. In routine, uncomplicated procedures, a 
follow-up visit at 1 week is usually adequate. If sutures 
are to be removed, that can be done at the 1-week 
postoperative appointment. 

Moreover, patients should be informed that should 
any question or problem arise, they should call the 
dentist and request an earlier follow-up visit. The most 
likely reasons for an earlier visit are prolonged and 
bothersome bleeding, pain that is not responsive to the 
prescribed medication, and infection. 

If a patient who has had surgery begins to develop 
swelling with surface redness and pain on the third 
postoperative day or later, the patient can be assumed 
to have developed an infection until this is proven 
otherwise. The patient should be instructed to call for 
an appointment at the dentist's office as soon as 
possible. The surgeon must then inspect the patient 
carefully to confirm or rule out the diagnosis of 
infection. If an infection is diagnosed, appropriate 
therapeutic measures should be taken (see Chapter 
15). 

Postsurgical pain that decreases at first but on the 
third or fourth day begins to increase, yet is 
accompanied by no swelling or other signs of infection, 
is probably a sign of "dry socket." This annoying 
problem is simple to manage but requires that the 
patient return to the office several times (see Chapter 
11). 

It is important that the patient know that the 
dentist is available to answer any postoperative 
questions and treat any postoperative problems that 
arise. Even if a postoperative follow-up visit does not 
appear to be necessary, one should be made to give the 
patient an opportunity to discuss any postoperative 
sequelae. 



A brief mention should be made of the oral examina- 
tion. During any routine long-term care of a patient, the 
dentist should examine the soft tissues of the face, 
mouth, and upper neck periodically. If this is done at the 
time of surgery, it should be noted in the chart. 

The surgeon should enter into the chart the type and 
amount of anesthetic used and the technique that was 
chosen for injection. For example, if the drug were lido- 
caine with a vasoconstrictor, the dentist would write 
down the number of milligrams of lidocaine and of epi- 
nephrine. If the inferior alveolar nerve block technique 
were used, that would be indicated in this portion of the 
note, as would any use of nitrous oxide or IV sedation. 

The surgeon should then write a brief note 
concerning the procedure that was performed, which 
should include a description of surgery and any 
complications. A description of the patient's tolerance 
of the procedure should also be included. 

A comment concerning the discharge instructions, 
including mention of the postoperative instruction list 
that was given to the patient, is recorded. 

The prescribed medications are listed, including the 
name of the drug, its dose, and the total number of 
tablets. Finally, the date of the return appointment is 
recorded in the chart (Box 10-1). (See Appendix II.) 



BOX 10-1 



Elements of an Operative Note 



1 . Date 

2. Patient name and identification 

3. Diagnosis 

4. Review of medical history, medications, and vital 
signs 

5. Oral examination 

6. Anesthesia (amount and type of block technique used) I 

7. Procedure (including description of surgery and 
complications) 

8. Discharge instructions 

9. Medications prescribed and their amounts 
1 0. Return appointment (date and time) 
It. Signature {legible or printed underneath) 



OPERATIVE NOTE FOR THE RECORDS 

The surgeon must enter into the records a note of what 
transpired during each visit. Some critical factors must 
be entered into the chart. The first is the date of the 
operation and a brief identification of the patient; then 
the surgeon states the diagnosis and reason for the 
extraction (e.g., nonrestorable caries or severe 
periodontal disease). Comments regarding the 
patient's pertinent medical history, medications, and 
vital signs should be mentioned next in the chart. 
This information should be noted in the chart before 
the surgery is performed, to confirm that the dentist 
has reviewed these issues with the patient and that the 
patient's current status is satisfactory for the surgical 
procedure. 



BIBLIOGRAPHY 

Alexander RE: Eleven myths of dentoalveolar surgery, J Am 
Dent Assoc 129:1271, 1998. 

Forsgren H et al: Effect of cold dressings in the postoperative 
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May N, Epstein J, Osborne 15: Selective COX-2 inhibitors: a 
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Surg Oral Med Oral Pathol Oral Radiol Endod 92:399, 200 1 . 

Seymour RA, Walton JG: Pain control after third molar sur- 
gery, Int J OralSurg 13:457, 1984. 

Seymour RA, Meechan JG, Blair GS: An investigation in to 
postoperative pain after third molar surgery under local 
angle-sia, Br J Oral Maxillofac Surg 23:410, 1985.