Pre and Post Operative Care

Pre and Post Operative Care of Extraction Cases
By Henry B. Clark, Jr., B.S., M.D., D.D.S.,
St. Paul, Minnesota
Introduction:
The extraction of a tooth is most certainly a surgical procedure, the opinions of the uninformed laity to the contrary notwithstanding! Accordingly I believe it maybe somewhat enlightening to consider the subject from that angle for a few moments.
Granted that we have entered the field of true surgery, we must comply with the customary rules thereof. The most important of these are a complete and through history, examination, and subsequent diagnosis of the patient himself. Too often we are inclined to regard a patient’s ailment as something entirely part from him, or, at best, merely attached to him. This attitude may be permissible for minor afflictions, or in cases where the treatment is slight or hasty, but cannot be tolerated where we are contemplating surgery, including tooth extractions.
Physical Condition of Patient Should Be Known
It is not often that all the important features of a patient’s physical condition are known to the dental surgeon. The fault is not entirely his, for little if anything is taught him in his professional school along the lines of systemic diagnosis. Some will go father and complain that the dentist is limited by law to the oral cavity, and must not allow himself to diagnose or treat conditions apart from those in the mouth.
But about this attitude I think we must accept the sane, sensible, and reasonable point of view, that, if for the dentist’s selfish interests alone, he must be intelligently alert to the patient himself, of whom the mouth is only a part.
There are, of course, many profound and serious diseases to which the patient may be host when he enters your office with an aching tooth. Some will be related to the dental complaint and will thus be concerned in your diagnosis and treatment. Others will be degenerative diseases, simply the effects of old age or improper living, and still others will be entirely coincidental.
The unfortunate incidents that we are prone to call “tough luck” or “bad breaks” are very seldom that. They are usually the inevitable consequence of some error in our technique somewhere along the line. It is with the hope of showing how these slips may be avoided that these remarks are being presented.
In ideal medicine or surgery, save in instances of emergencies, patients receive no treatment whatsoever until every possible hit of diagnostic data has been collected. These data are, essentially, history, physical examination, and laboratory tests. Of the three the history is the one of which we shall speak most here because this element constitutes no less than 75 percent of most diagnoses. Yet most exodontia procedures are conducted subsequent to an oral examination and perhaps one or two questions about how long the tooth has been hurting, with no actual history taking in the routine. The rich reservoir of helpful information that could be had (literally) for the asking is not tapped. Accordingly, let us briefly consider some of the things to keep in mind when questioning your patient before extraction.
Selecting Cases For Surgery
ACUTE INFECTIOUS DISEASES such as scarlet fever, measles, pneumonia, influenza, and the like, are always preceded by what is known as a PRODROMAL PERIOD. In this stage the individual feels somewhat ill, runs a slight fever, and frequently has dull aches and pains in the face, teeth, and rest of the body. It is entirely possible to have an acutely infected tooth, by sheer coincidence, on one of those days, or, of course, the pain may be a transient hyperemia of the pulp, due to a generalized toxemia.
Should a patient come to the dentist in the prodrome of such an illness, and everything be ignored but the tooth, the sequence of events is all too likely to be: extraction, followed by the full-blown pneumonia, influenza, or whatnot, and then a most trying situation for the dentist, to say the least. The general population is all too prone to believe that the extraction caused the illness in question. For the dentist to feebly explain that the patient “didn’t tell” him she was “coming down” with such-and-such disease, is practically to admit that the patient knows more than he does, and is sure proof that he does not believe in questioning his patients before the removal of teeth.
Much the same course of reasoning is to be followed with regard to ARTHRITIS. It is now disease, just as there are divers forms of lung infections. The old way of calling every pneumonic infection either broncho or lobar pneumonia is being supplanted by a classification on an etiological basis, such as “Type 2 Pneumoccic Pneumonia.” or “Pneumonia due to Hemolytic Streptococcus.” In much the same fashion, we should not speak of “rheumatism” or unqualified “arthritis,” as not all joint troubles respond the same way to treatment. The practice of extracting teeth in the hope of relieving undiagnosed joint pains is thus an unjustifiable procedure. Two forms of arthritis, namely Still’s Disease in children, and Atrophic Arthritis of adults, are definitely believed to be due to focal infection.
EARLY eradication of all infected areas in the body constitutes the one most important phase of treatment. On the other hand Hypertrophic (Degenerative) Arthritis is a more or less senile disease, occurring after the age of 40, apparently connected with heredity, and its course is not altered in most instances by extracting teeth or doing other elective surgery.
Granted, then, that teeth are to be extracted in a case of Still’s Disease or Atrophic Arthritis. Should the dentist’s opinion be considered in deciding which ones are to come out? By all means; it is most fitting that the dental attendant’s opinion should receive at least equal weight with that of the physician. In this way the best possible judgment will be reached, and such errors as advising the removal of badly stained or slightly carious teeth will be avoided. The matter of HOW MANY TEETH TO REMOVE AT A TIME is a frequent cause of controversy. Some feel that the toxic systemic effect caused by extracting infected teeth should be spread over a period of time. Our opinion is that from a practical standpoint it is better to do the entire thing at one sitting. This attitude cannot be taken in every instance, and in every debilitated and septic patients we may be obliged to do the extractions a few at a time.
The dentist should have as complete an understanding as a physician of the more important BLOOD DYSCRASIAS. The terms: hemophilia, blood platelet, purpura, agranulocytic angina, and retraction time should all mean something very specific to him. This would not be so if it were not that many hemophiliacs finally meet their untimely end as a result of a tooth extraction, and many with purpuras of one sort or another, under the same circumstances, may lose an alarming amount of blood, because the dentist had not determined ahead of time if there was a tendency to bleed.
One good method of determining bleeding and clotting time is as follows: Have in readiness a sharp scalpel blade or lancet, alcohol, sterile cotton, a few filter papers, a watch with second hand, and several capillary glass tubes about 3 inches long. The latter are readily made by heating a section of ordinary ¼ inch glass tubing over the Bunsen flame known that there are several different types of joint till molten, then quickly drawing out to 2 or 3 feet. The exact caliber is not important. The lobe of the ear is used to draw blood, as the sensation is less acute here than in the finger tip. It is cleansed well with alcohol, dried with sterile cotton, the scalpel well into the tissue. If the part is supported by the opposite index finger a good deep cut can be made the first time. One end of a capillary tube is touched to the drop of blood (which should not be encouraged by squeezing or massage) when the capillary action will promptly fill the tube. It is then laid aside for two minutes before first testing for fibrin formation. Beginning then, a small section is carefully cracked off one end and the fragments carefully separated.
This process is repeated each 15 seconds till a fine sticky string of fibrin stretches between them, at which time the coagulation time has been reached. Anything over 4 to 5 minutes is a prolonged reading. Meanwhile, each 15 seconds from the time the wound was made the blood is blotted off with the edge of the filter paper. When no more flows out of its own accord, the bleeding time has been reached. Normal is 3 to 4 minutes, or less.
HEMOPHILIA is a rather rare, heriditary disease, manifested in males, but transmitted through the female. The tendency to bleeding, with or without trauma, is due to a failure of the blood to clot properly. That is, the coagulation time is greatly PROLONGED, though the bleeding time is NORMAL. Small scratches will cease bleeding promptly. Blood platelets are present in normal numbers, but are defective in that they are not friable, and do not break up to produce thromboplastin when a wound is sutained. (The platelets are to be distinguished from red or white cells. They are about one-frouth the size of a red cell, are probably derived from the megakaryocytes of the bone marrow, and about 250-000 are found in each cu. mm. of normal blood. Special strains are necessary to demonstrate them under the microscope.) But thromboplastin can also be formed from lacerated tissue cells, as well as by the disintegration of platelets.
Addis explains that when a wound in the skin or mucous membrane occurs blood escapes and fills the cavity. At the periphery of the cavity thromboplastin from the injured tissues mixes with the blood and a firm fibrin layer is formed. This layer prevents tissue elements from reaching the blood which flows from the injured vessels. Since the escaping blood is thus made to depend upon liberation of thromboplastin from the platelets –a process which is very slow in hemophilia –there is no wonder that an imperfect clot is formed, and that oozing of blood continues. Several observers have pointed out that if all the blood clot is carefully removed from a contused wound in a hemophiliac and cotton wool soaked in normal blood applied to the entire wounded area, bleeding will cease.
Individuals with hemophilia are usually acquainted with the fact, but frequently will not tell the operator unless he questions them in the course of hi preoperative routine. Dental caries in these people must be promptly attended to, with the hope of avoiding surgery, or at least delaying it. Frequently the blood takes on the ability to coagulate properly later in life.
If an extraction becomes unavoidable, the assistance of a physician should be enlisted. He will probably give a course of calcium lactate. He will probably give a course of calcium lactate, drams i l.i.d. for a few days, inject one of the tissue extract substances (10 to 20 cc. intravenously or 20 to 30 cc. subcutaneously( just prior to the operation, and have a suitable transfusion donor in readiness. The dentist may construct a vulcanite splint to fit closely over the ridge after the extraction, and have the usual styptics, etc. (see below) at hand. One observer reports successful use of fresh pigeon’s muscle applied locally, though probably any fresh animal tissue would serve. Such measure include the best judgments on this problem, and will usually succeed in controlling the hemorrhage.
PURPURA means hemorrhage into the skin, and is taken from the Greek, meaning purple. The extravasations into the skin, or bleeding from mucous membranes, are caused either by a reduced number of blood platelets, or a failure of the capillaries to retract, or undue permeability of the capillary walls. From a practical standpoint, patients subjected to surgery while in a purpuric state will exhibit will exhibit hemorhagic phenomena following surgical procedures. These are seldom fatal, but will cause both patient and operator endless worry and trouble, and will skill. Questioning preoperatively about a crop of small purple or red spots like freckles in the skin, joint trouble, tendency to bruise easily, nosebleeds, or undue bleeding after other extractions, should never be omitted.
The dentist should know that any acute infectious disease, eachectic or anemic state, or debilitating condition, is likely to be attended with purpura, though “bleeders; are by no means confined solely to these types.
Purpuras are to be treated essentially the same as hemophilia, from the dentist’s standpoint, but usually respond more readily than hemophilia. Fresh serum from the cellular tissue of any animal –the brain, liver, or gonad –may be applied locally after removal of the clot, often with prompt relief. The usual local styptics such as ferric chloride, tannic acid, Monsell’s Solution, and the vasoconstrictor, epinephrine, you are already familiar with. The latter has a more transient effect, however, and bleeding will usually recur after the effect has worn off.
Preoperative Preparation of the Patient
The question of preoperative preparation of that extraction patient has been called to our attention but recently, but it is a tendency which I can’t encourage too strongly. The work of Crile and his associates has indicated very plainly that all degree of shock are possible, even with the most trivial forms of trauma. The exciting causes may be psychic or physical, or both, either of which can be effectively prevented by blocking as many sensory stimuli as possible. The use of hypnotics and to counteract such eventualities is an accepted routine in general and regional surgery. Why, her, not in dentistry? The fact is that in our experience the results have entirely warranted the addition of this procedure.

Pentobarbital-Sodium Medication
The drugs used vary with different operators. We prefer pentobarbital-sodium, which goes by the trade name of Nembutal. A capsule containing one and a half grains is the average sedative dose for an adult. Given a half hour before surgery it relieves the nervous tension that is so common, and invokes a sense of mild well-being, with slight drowsiness. Technically, it raises the threshold of sensation so that ordinary stimuli are blocked, and the stronger ones re reduced. The neurotic type of female, with a characteristically low nervous threshold, is the indication par excellence for premedication. From a pharmacological aspect the effect is one of synergism when the anesthetic, either local or general, is subsequently introduced into the body. Less anesthetic is required, and a more complete anesthesia is obtained. Patients that “can’t be put to sleep with gas” as they say, become easy to handle. The fear of the needle in novocain cases is almost completely forgotten.
Pentobarbital-sodim has been used with success at the Mayo Clinic and has replaced the other barbiturates and hypnotics in many hospitals and clinics throughout the country. Obstetricians find it a valuable adjunct to other analgesic agents in the first and second stages of labor. In dentistry it is of help not only as a premedication, but also in larger doses such as three grains, for sleepless patient with whom operation has been deferred for one reason or another, and in many cases to assure sleep for the first night or two postoperatively. I know of no reason why it would not be much appreciate by persons who must undergo prolonged or painful operations for operative or crown and bridge work.
Phenobarbital (Luminal) is perhaps the most foolproof of the other preparations. It is safe enough to use on infants, and seldom causes excitement, as sodium amytal or hyoscine occasionally do. Most of these drugs are sedative in small doses and hypnotic (sleep producing) in roughly twice that amount. The bromides have a definite place in this group, but do not seem to have a quieting effect unless the patient is previously excited or nervous. Dosage for sedation is 10 to 15 grains of the sodium, potassium, or ammonium salt. The sedative dose of phonobarbital (Luminal) is one and a half grains, and the hypnotic dose three grains. Sodium amytal may be used in three, six, or nine grain doses, depending on the effect desired, but the chance of producing excitement instead of sedation must always be kept in mind. It seems to usually occur with the six grain dose. Trional and sulphonal in ten grain doses are definite sleep producers. Chloral hydrate and sodium bromide, twenty grains each, by rectum, will frequently bring refreshing sleep to individuals who are vomiting, or otherwise unable to take medications by mouth.
Advice Should Be Given and Made Definite
In the case of incipient, acute alveolar abscess, it is often advisable to postpone extraction for a day or two until the process has become somewhat localized, and the bodily reserves have been called out. The dentist will demonstrate hi sworthiness of the title of Doctor if he does not simply tell the patient to go home and wait till it quiets down, and maybe take some aspirin and a physic. The condition requires every bit as much palliative care as an appendicial abscess, liver abscess, or acute iritis. First, make a careful inspection to see if you can aid drainage. If none is in process, under a whiff of gas or light ethyl chloride anesthesia (an agent that is not used half enough in dentists’ offices) incise the gum over the apex, down through periosteum. Prescribe a hot mouth wash, with intermittent cold to be applied on the cheek outside. This is designed to discourage pointing of the abscess externally. There is no great harm, however, in most cases, of applying heat outside too, if it gives more comfort. Instruct to force fluids, at least one and half to two quarts daily, made up largely of citrus fruit juices. Advise a light dietof soups, custard, toast, milk, and pureed vegetables. If there is marked constipation order citrate of magnesia, ounces twelve. Excessive purging is not rational, and will not be needed if the fluid intake is kept up as suggested. If the pain is but milk prescribe or dispense acetylsalicylic acid (which we know of course as “aspirin”) –but do not simple tell them to take some aspirin. I trust the distinction and reasons are obvious! Anacin has the disadvantages of being easily identified by the patient and of obtaining quinine, which is superfluous, and capable of causing reactions in sensitive patients. The other coal tar derivatives such as antipyrene, amidopyrene, to use acetylsalicylic acid for moderate discomfort (available in pink, green, or white tablets) and for severe pain the following capsule:
Rx
Codeinae ……………………………………………………… grs. i
Acidi Acetylsalicylici ………………………………….. grs. iii
Acetphenetidini ………………………………………….. grs. ii
About 12 such capsules are usually prescribed, 1 to 2 to be given each 3 to 4 hours, for pain.
It may be given two capsules at a time, for severe pain, and will seldom fail to give relief. We have used them routinely for “after pains” following delivery, for the malaise and aches of the acute infectious diseases, follicular tonsillitis and quits and many other forms of pain, with good results. The capsule is commonly called the CAP, from the initials of its constituents. The prescription must contain the date, name and address of the patient, dentist’s narcotic number, his signature, and address. Everything can be printed right on your prescription blank except the date, patient’s name and address, and your signature. The government requires no record of this data unless you wish to actually dispense the preparation right in your office.
Should a hypodermic injection of codeine sulphate or phosphate, or morphine sulphate be required, it is advisable for dentists to make the injection within the oral cavity, in which case the patient need no know that a narcotic is being administered. Pantopon, a preparation containing all the alkaloids of opium, is useful with patients that vomit with plain morphine, and is less constipating than the latter. The dose is one-third of a grain.
With ideas of this sort in mind, I trust it will become second nature to you to skillfully administer supportive treatment to your sick patients. Take my word for it that it is not simply fol de rol, and that your patients will most certainly do better if you insist on such a regime. Such measures are not only your privilege to administer, but your rightful duty. It is not difficult to memorize four or five prescriptions, Latin endings and all, and they will do much to convince your patient that you are well informed and experienced in handling these cases.
Post Operative Care
Skipping over now to postoperative considerations, there are but a few things I should like to add. Novocain cases, should receive two acetylsalicylic acid tablets at the time of making the injection, and ice to the face routinely immediately at the conclusion of the operation, where it should remain for one hour. If pain recurs that evening, moist heat is to be preferred externally. Few people realize that worth of the hot pack in reducing pain and swelling where the edema is due to trauma of infection. The solution used may by hypertonic sodium chloride, saturated magnesium sulphate (Epsom salts), boric acid, or Ochner’s solution, but the moisture and heat are the big things. The other supportive postoperative procedures have been covered under preoperative care of non-operated cases, and prove useful. It is not enough to assume that our patients will do well, and WAIT for them to symptoms and PREVENT DISCOMFORT, rather than wait till it developls. Mouth washes and that the protective blood clot be not disturbed until after firm retraction has taken place. The absence of infection in most extraction wounds has long been a cause for wonder, but it is doubtless due in no small part to the protective influence of a well formed blood clot in the socket.
IN CONCLUSION, let us always bear in mind that the extraction of a tooth is a surgical procedure. As such, it should not be undertaken until everything within your power has been done to determine the exact status of the patient’s physical condition. An effort should be made to determine questionable replies should be investigated farther. Any patient who appears feverish, very pale, debilitated, or who has sustained a recent illness, should not be submitted to operation unless you are convinced the extraction is quite necessary, and will benefit her in all likelihood.
The pre and postoperative management of these cases is every bit as important as in other forms of surgery; it will be greatly appreciated by the patient, will make her management easier, and will tend toward a smoother convalescence.
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