Postoperative Complications

FIG 10.1 Mechanism of action for nonsteroidal antiinflammatory drugs (NSAIDs) and steroids in the reduction of inflammation. Steroids block arachidonic acid and NSAIDs interfere with cyclooxygenase in the reduction of edema. (From Misch CE: Contemporary implant dentistry, ed 3, St Louis, 2008, Mosby.)
Nonsteroidal Antiinflammatory Drugs.

NSAIDs have an analgesic effect as well as an antiinflammatory effect. This drug class reduces inflammation by inhibiting the synthesis of prostaglandins from arachidonic acid. Therefore the use of the popular analgesic drug ibuprofen has a secondary beneficial antiinflammatory effect. NSAIDs do not have a ceiling effect for inflammation (i.e., ceiling effect for analgesia is 400 mg); however, higher doses to achieve antiinflammatory qualities are accompanied by serious side effects.

Recommendation: Ibuprofen 400 mg for Type 1–4 procedures (see Misch Prophylactic Medication Protocol, Table 10.1).

TABLE 10.1

Procedure-Specific Pharmacologic Protocol for Oral Implantology

Category Patient Selection Procedures Antibiotic Glucocorticoid Antimicrobial Analgesic
Category 1

ASA1/ASA2

>ASA2 = Category 2

Single implants with minimal reflection

Amoxicillin 1 gm

One hour before surgery

None Chlorhexidine: image oz. BID for two weeks Pain control protocola PCP 1–2
Category 2

ASA1/ASA2

>ASA2 = Category 4

Traumatic extractions with pathology

Amoxicillin 1 gm

One hour before surgery, then 500 mg 6 hours after

Decadron 4 mg

1 tab AM day of surgery

Chlorhexidine: image oz. BID for two weeks Pain control protocol PCP 1–2

Socket grafting

Single tooth implants with extensive reflection

Multiple implants with minimal tissue reflection

SA1 sinus procedures

Immediate implants without pathology

Category 3

ASA1/ASA2

>ASA2 = Category 4

Single implants with bone grafting and excessive tissue reflection

Multiple implants with extensive reflection

Bone grafting (Allograft/Autograft)

SA2 sinus procedures

Amoxicillin 1 gm

One hour before surgery, then 500 mg TID for 3 days

Decadron 4 mg

1 tab AM day of surgery

1 tab AM day after surgery

1 tab AM two days after surgery

Chlorhexidine: image oz. BID for two weeks Pain control protocol PCP 2–3
Category 4

Any of the following:

>ASA2

Long duration surgery

Less experienced surgeon

Immunocompromised

Active periodontal disease

Any Category 3 procedures with surgical or patient factors

Immediate implants with pathology

Autogenous onlay grafting

Amoxicillin 1 gm

One hour before surgery, then 500 mg TID for 5 days

Decadron 4 mg

2 tab AM day of surgery

2 tabs AM day after surgery

1 tab AM two days after surgery

Chlorhexidine: image oz. BID for two weeks Pain control protocol PCP 3–4
Category 5

All

SA3/SA4

Sinus patients

All

SA3/SA4

Sinus procedures

Augmentin

(875 mg/125 mg): 1 tab BID starting one day before, then 1 tab BID for 5 days

Decadron 4 mg

2 tab AM day before surgery

2 tabs AM day of surgery

1 tab AM day after surgery

1 tab AM two days after surgery

Chlorhexidine: image oz. BID for two weeks Pain control protocol PCP 2–3

aSee Table 10.5 for pain control protocols.

ASA, American Society of Anesthesiologists; NSAID, nonsteroidal antiinflammatory drug; SA, subantral.

Alternative Medications:

Amoxicillin (1 gm) = Cephalexin (1 gm), Clindamycin (600 mg)

Augmentin (875/125) = Ceftin (500 mg) = Doxycycline (100 mg)

(Note: SBE Prophylaxis : change preoperative antibiotic dose to Amoxicillin [2 gm], Cephalexin [2 gm], or Clindamycin [600 mg])

Ibuprofen (400 mg) > Acetaminophen (500 mg) or Naproxen Sodium (375 mg)

Hydrocodone (5 mg/500 mg) > Tylenol # 2/Tramadol (50 mg)

Hydrocodone (7.5 mg/750 mg) > Tylenol # 3/Tramadol (100 mg)/Nucynta (50, 75, 100 mg)

Hydrocodone (10 mg/660 mg) > Oxycodone (Percocet) 7.5/500 mg

(Note: If patient cannot take medication by mouth, [1] Ibuprofen Oral Suspension (OTC); [2] Lortab Elixar [7.5 mg hydrocodone/500 mg APAP/15 ml])

Glucocorticosteroids.

The adrenal cortex, which uses cholesterol as a substrate, synthesizes and secretes two types of steroid hormones—the androgens and corticosteroids. The corticosteroids are classified additionally by their major actions: (1) glucocorticoids, which have effects on carbohydrate metabolism and have potent antiinflammatory actions, and (2) mineralocorticoids, which have sodium-retaining qualities. The use of synthetic glucocorticosteroids has become very popular in the postoperative management of inflammation after oral surgical procedures. These synthetic glucocorticoids have greater antiinflammatory potency in comparison to natural steroids with very little sodium and water retention. Most steroids have similar chemical structures; however, they differ in their milligram potency.2 The antiinflammatory effects are achieved by altering the connective tissue response to injury, causing a decrease in hyperemia, which results in less exudation and cellular migration along with infiltration at the site of injury.3

Glucocorticoids bind to glucocorticoid receptors within cells and form a glucocorticoid-GR complex. This complex alters the synthesis of mRNA from the DNA molecule, affecting the production of different proteins. By suppressing the production of proteins that are involved in inflammation, glucocorticoids also activate lipocortins, which have been shown to inhibit the action of phospholipase A2 (PLA2). PLA2 is a key enzyme involved in the release of arachidonic acid from cell membranes.

Arachidonic acid is an omega-6 fatty acid that is incorporated into cell membranes. When a cell is damaged, arachidonic acid is released from cell membranes and is converted into inflammatory and pain prostaglandins by cyclooxygenase (COX)-2 enzymes. The release of arachidonic acid requires the activation of enzyme PLA2. However, lipocortins, which cause the inhibition of PLA2, prevent the release of arachidonic acid, thereby reducing the amounts of inflammatory prostaglandins.

There is a wide range of glucocorticoid preparations available for local, oral, and parenteral administration. In relation to the naturally occurring cortisol (hydrocortisone), synthetic glucocorticoids are longer acting and more potent. The main differences are based on the classification as short acting (<12 hours), intermediate acting (12–36 hours), and long acting (>36 hours). A summary of the most common glucocorticosteroids is shown in Table 10.2.

TABLE 10.2

Synthetic Glucocorticoids

Glucocorticoids Antiinflammatory Potency Equivalent Dose (mg) Duration (h)
Short Acting
Hydrocortisone 1.0 20 <12
Cortisone 0.8 25 <12
Intermediate Acting
Prednisone 4.0 5 24 to 36
Prednisolone 4.0 5 24 to 36
Long Acting
Dexamethasone 25 0.75 >48

From Misch CE: Contemporary implant dentistry, ed 3, St Louis, 2008, Mosby.

The ideal synthetic glucocorticoid for dental implant surgery should maintain high antiinflammatory potency with minimal mineralocorticoid effects. The glucocorticoid that best suits the requirements is the long-acting glucocorticoid dexamethasone (Decadron). It is imperative this drug be administered before surgery so that adequate blood levels are obtained. Also, it should be given in the morning in conjunction with the natural release of cortisol (~8:00 am). This timing will interfere the least with the adrenocortical system. Because inflammation usually peaks between 48 and 72 hours, the postoperative regimen of dexamethasone should not exceed 3 days after surgery. This high-dose, short-term glucocorticoid therapy has been shown not to significantly affect the hypothalamic–pituitary–adrenal axis (HPA axis), which controls many of the bodies processes, including reactions to stress.4

A significant additional benefit of the administration of dexamethasone is the potent antiemetic effects for the prophylactic treatment of postoperative nausea and vomiting. This is now an accepted medication for hospital-based outpatient surgery, usually given in doses of 8–10 mg intravenously.5

Contraindications to the use of corticosteroids include active infections (viral, bacterial, fungal), tuberculosis, ocular herpes simplex, primary glaucoma, acute psychosis, and diabetes mellitus. Special attention must be given to diabetic patients because glucocorticoids have an antiinsulin action that results in increased serum glucose and glycosuria.6 Usually, corticosteroids are contraindicated with insulin dependent diabetics. For oral and diet controlled diabetics, a medical consult should be completed prior to any treatment.

Recommendation: Decadron 4 mg for Type 1–4 procedures (see Table 10.1, Misch Prophylactic Medication Protocol).

Cryotherapy.

Cryotherapy (application of ice) is one of the simplest and most economical modalities in the management of postoperative soft tissue inflammation. The use of ice to reduce pain and swelling dates back to the ancient Egyptians, over 4000 years ago.7

The use of cryotherapy is highly advised in any dental implant procedure in which excessive inflammation is expected. The mechanism of action involves a reduction in fluid accumulation within the body tissues, slowing of metabolism, control of hemorrhage, and a decrease in the excitability of peripheral nerve fibers leading to an increase in pain threshold.8

Caution must be taken to limit the application of ice to no longer than 2 days because prolonged use may cause rebound swelling and cell destruction. Improper and prolonged use of ice may result in cell death due to prolonged vasoconstriction, ischemia, and capillary thrombosis.9

After 2 to 3 days, moist heat may be applied to the region to increase blood and lymph flow to help clear the area of the inflammatory consequences. This also helps reduce any ecchymosis that may have occurred from the tissue reflection. Although usually safe, the application of ice is cautioned in patients suffering from cold hypersensitivities and intolerances and peripheral vascular diseases. Additionally, ice application may be problematic in patients who are elderly or very young because they may have impaired thermal regulation and limited ability to communicate. Care should be exercised in using facial bandages because prolonged ice administration may result in soft tissue injury.

Recommendation: Cold dressings (ice packs) should be applied extraorally (not directly on skin: place a layer of dry cloth between ice and skin) over the surgical site for 20 minutes on/20 minutes off for the first 24–36 hours (Fig. 10.2).

image
FIG 10.2 Postoperative edema. (A) Postoperative edema after dental implant surgery, which peaks at 48–72 hours. (B) Cryotherapy to decrease swelling with the use of ice packs. (C) Facial wrap bandages should be used with caution because they may cause prolonged exposure and trauma to the skin area. (A, From Torabinejad M, Fouad A: Endodontics: principles and practice, ed 4, St Louis, 2009, Saunders; B and C, courtesy of Salvin Dental Specialties, Inc., Charlotte, NC.)
Decrease Activities.

Patients should be instructed to decrease activities after surgery because this will minimize swelling postoperatively. The more active the patient and the more strenuous activity the patient engages in, the greater the extraoral swelling.

Recommendation: Activities should be limited for the first 3 days. Elevation of the head (sitting upright) and sleeping on multiple pillows will minimize the postoperative swelling.

Treatment

Swelling is self-limiting and, once it occurs, it is usually difficult to treat (time-dependent). The above mentioned medications/therapy (Decadron, NSAIDs, cryotherapy) will help to reduce postoperative inflammation.

Ecchymosis (Bruising)

Ecchymosis is subcutaneous extravasation of blood within the tissues, which results in discoloration of the skin from the seepage of blood in the tissues. The location of the ecchymosis may be distant to the surgical site because of gravity (i.e., always inform patients preoperatively). Ecchymosis that presents in the inferior mandibular area or neck may be from bleeding under the flap and traveling via fascial spaces due to gravity (Fig. 10.3).

image
FIG 10.3 Ecchymosis. (A) Postoperative bruising. (B) Ecchymosis extending into the neck area. (C) Resolution of the ecchymosis will result in varying degrees of yellow to golden-brown. 

Etiology

The cause of ecchymosis (bruising) is not confined to an existing hematologic disease or to medication induced bleeding. Moderate bruising should be expected after dental implant surgery, especially after longer, more invasive surgeries. Female and elderly patients are more susceptible to bruising. The ecchymosis cascade includes:

1. Blood vessels rupture

2. Red blood cells die and release hemoglobin

3. Macrophages (white blood cells, [WBCs]) degrade hemoglobin via phagocytosis

4. Hemo > bilirubin = bluish-red color

5. Bilirubin > hemosiderin = golden-brown color

Ecchymosis may appear as bright red, black, blue, purple, or a combination of the above colors. It usually consists of nonelevated, rounded, and irregular areas that increase in intensity over 3–4 days postoperation and will diminish and become yellow as they disappear. It may take 2–3 weeks for complete resolution.

Prevention

Unfortunately, even with gentle handling of tissues and good surgical technique, ecchymosis may be unavoidable. To minimize ecchymosis, avoid postoperative aspirin, herbal remedies, and food supplements that may increase bleeding. Always inform the patient preoperatively (preferably in written postoperation instructions) that bruising may occur. Elderly patients are more susceptible to ecchymosis because of decreased tissue tone and weaker intracellular attachment.

Treatment

Ecchymosis is self-limiting and usually resolves without treatment. However, the patient may treat the ecchymosis in the following ways:

Rest/avoid strenuous activity: promotes tissue healing and decreases inflammation.

Elevation: helps decrease inflammation, facilitates proper venous return, and improves circulation to the site.

Analgesics: helps reduce pain associated with the onset of ecchymosis.

Sun exposure: inform patient to avoid sun exposure to the area of bruising as excessive sunlight may cause permanent discoloration.

Trismus

Trismus refers to reduced opening of the jaws, which is caused by trauma or spasm to the muscles of mastication. The limited opening may result in an interference with eating, speech, and hygiene and may cause pain.

Etiology

Trismus after implant surgery can be due to multiple factors. The most likely etiologic factor is local anesthetic, secondary to an inferior alveolar nerve block that penetrates the medial pterygoid muscle. Also, complicated or prolonged surgical procedures that require full-thickness mucoperiosteal flaps with resultant edema can lead to trismus. Normal interincisal opening is approximately 35–45 mm, with mild trismus being classified as 20–30 mm and severe trismus less than 10 mm (Fig. 10.4).1

image
FIG 10.4 Trismus. (A) Commonly caused by prolonged opening resulting in spasms of the muscles of mastication. Care should be exercised in using surgical templates for the placement of implants in the posterior region as access is often compromised. (B) Measurement of maximum opening, which is normally 35–45 mm. 

Prevention

When placing implants, especially in the posterior region, care should be taken to minimize excessive opening of the patient to where spasm of the muscles of mastication would result. Bite blocks, short duration treatment, and sedation may decrease the possibility of trismus complications. When using CBCT surgiguides, lateral access openings should be utilized in the guide to prevent extensive opening to accommodate the guide and surgical bur. This mainly occurs in the posterior region of the oral cavity.

Treatment

Usually trismus will resolve with time; however, patients should maintain a soft diet and minimize overactivity. Additional treatment includes the use of physical therapy, passive range of motion exercises, splint therapy, and medications such as NSAIDs, muscle relaxants, and steroids (Medrol Dosepak, Decadron).

Postsurgical Pain

Pain has been documented to be inadequately treated in 50% of all surgical procedures.10 Oral surgical studies have shown pain in the oral cavity to reach its maximum intensity within the first 12 hours after surgery, and 97% of patients reporting postoperative pain being the greatest during the first day of surgery.11

Postsurgical painful experiences predispose the patient to amplification of noxious stimuli (hyperalgesia) and cause typically painless sensations to be experienced as pain (allodynia). Patients who have had painful experiences (surgery) may have increased pain and the need for additional analgesic use in future surgeries. The goal for pain control in oral implantology is to have adequate analgesic levels before the cessation of local anesthesia and a well-administrated postoperative analgesic regimen for patient comfort.

Etiology

The mechanism of painful stimuli is modulated by the peripheral and central nervous systems. Noxious stimuli (e.g., tissue damage or bone preparation) cause peripheral nociceptors to transmit signals along nerve fibers lying in the dorsal root ganglion. Their axons synapse in the dorsal horn of the spinal cord and then travel along the spinothalamic tract of the spinal cord to the thalamus and the cortex. Within the cortex and thalamus, signals originating from tissue damage form the subjective interpretation of pain.

With repeated noxious stimuli, peripheral nociceptors become more responsive. The sensitivity to these receptors is further enhanced by tissue factors and inflammatory mediators released in the course of tissue damage. Numerous inflammatory mediators are present, including prostaglandins, kinins, leukotrienes, substance P, and histamine. These mediators initiate and magnify the nociceptive impulses that are transmitted to the central nervous system for the perception of pain.

The most important mediators, prostaglandins, are extremely important in sensitizing peripheral neurons to the local stimuli. Prostaglandins are also synthesized in the spinal cord and brain and enhance pain sensitivity by recruiting secondary neurons to respond to the primary stimulus.12

One of most commonly used analgesics, NSAIDs, work at the site of tissue damage, preventing prostaglandin formation by inhibiting cyclooxygenase (COX). COX is an enzyme that breaks down arachidonic acid for prostaglandin synthesis. In the tissue there are two well-identified cyclooxygenases, COX-1 and COX-2. COX-1 enzymes support hemostasis (platelet degranulation and adhesion), stomach mucosal integrity, and regulation of kidney function. COX-2 enzymes are an inducible form whose synthesis is activated in damaged tissue, which leads to the formation of proinflammatory prostaglandins that play a major role in inflammation, pain, and fever. A relatively new COX has been described (COX-3) that is found in the brain and is thought to be the site of action of acetaminophen.13

In contrast to NSAIDs, opioids have a different mechanism of action to reduce pain. Opioids act on the central nervous system by binding to specific receptors (m-opioid), thus preventing transmission of nociceptive pathways while also activating inhibitory pathways that descend to the spinal cord. By binding to these m-opioid receptors, substance P is prevented from being released, thus preventing painful stimuli (Fig. 10.5).14

image
FIG 10.5 Pain cascade depicting the breakdown of arachidonic acid into the various forms of prostaglandins. 

Prevention

The following may be used to prevent postoperative pain:

1. Good surgical technique

2. Surgery duration not to exceed patient’s tolerance

3. Postoperative long-acting anesthetics

4. Adequate postoperative pain control and instructions

5. Limitation of patient activities post-operatively.

Treatment

The implant clinician must understand the various aspects of pain control after dental implant surgery. In most cases: (1) pain is not severe and mild OTC analgesics can manage the discomfort, (2) peak pain occurs approximately 12 hours after surgery and diminishes over time, and (3) pain will persist no longer than 2 days. However, this is patient specific.1

The most important principle with pain management after implant surgery is the timing of the medication. Ideally, analgesic medications should be taken before the effects of the local anesthetic subside. With this approach postoperative pain is easier to control, and the patient is less likely to experience the acute, severe pain. If the patient takes medication after pain is present, the patient will inevitably have to take more medication to control the pain, increasing the likelihood of analgesic side effects.

In implant dentistry, different classifications and mechanisms of pain suppression may be used. A pain control protocol has been established that simplifies and standardizes the various aspects of pain relief (Table 10.3):

1. Nonopioid analgesics (nonnarcotics)

2. Opioid analgesics (narcotics)

3. Adjuvants

TABLE 10.3

Analgesic Agents Used to Control Postoperative Surgical Pain

Analgesic Brand Name Onset (hr) Peak (hr) Duration (hr) Recommended Dose Dosing Interval (h) Maximum Dose/Day
Nonopioid
Acetaminophen Tylenol 0.5 0.5–2 4–6 650–1000 mg 4–6 4000 mg
Ibuprofen

Motrin

Advil

0.5 1–2 4–6 400 mg 4–6 2400 mg
Naproxen Anaprox 1 2–4 5–7 275–550 mg 6–8 1375 mg
Tramadol Ultram 0.5 1–2 4–6 50–100 mg 4–6 400 mg
Opioid
Codeine Tylenol with codeine 0.1–0.3 0.5–1 4–6 60 mg 3–4
Hydrocodone Dicodid 0.25–0.5 0.5 4–8 5–10 mg 4–6
Oxycodone Percocet 0.25–0.5 1 4–6 5–10 mg 4–6
Meperidine Demerol 0.1–0.45 0.5–1 2–4 50–100 mg 6
Propoxyphene Darvon 0.5–1 2–2.5 4–6 65–130 mg 4–6

From Misch CE: Contemporary implant dentistry, ed 3, St Louis, 2008, Mosby.

Nonopioid Medications.

The nonopioid analgesics used in implant dentistry include acetaminophen, NSAIDs, COX-2 inhibitors, and tramadol.

Acetaminophen.

The mode of action of acetaminophen is not known; however, it is believed to involve the prostaglandin pathways within the central nervous system with little influence on peripheral prostaglandin synthesis. COX-3 enzymes have been described as being fully expressed in the brain, spinal cord, and heart. The primary function is to regulate pain responses and fever, and COX-3 has been postulated to be the site of action of acetaminophen.15

Acetaminophen is indicated for mild to moderate pain and as a safe alternative to NSAIDs. It has excellent analgesic and antipyretic properties and is void of side effects that are associated with NSAIDs. Like NSAIDs, acetaminophen also has a ceiling dose (4 g/day) for analgesic effects. However, unlike NSAIDs, acetaminophen has the drawback of having minimal antiinflammatory qualities. The main side effect of acetaminophen is liver damage, which is associated with excessive and long-term use of this drug.

Nonsteroidal antiinflammatory drugs.

The NSAIDs are one of the most commonly used analgesic families in implant dentistry today. Clinical trials have shown that NSAIDs are effective in all levels of pain (mild, moderate, severe).16 The mechanism of action of NSAIDs is thought to arise from the inhibition of the synthesis of prostaglandins from arachidonic acid. With the inhibition of COX, conversion of arachidonic acid to the immediate precursors of prostaglandins is prevented. Thus, with the lack of prostaglandins in the tissue, the hyperanalgesia and edema associated with acute inflammation is minimized.17

The main reasons that NSAIDs are so widely used is the fact that they work very well as analgesics and have variable effects on inflammation (drug and dose dependent). Inflammation and pain are two separate entities, with analgesic doses having a ceiling effect18 and antiinflammatory doses not having a ceiling effect. In regards to the analgesic effect, there is no reason to exceed the analgesic ceiling for the treatment of acute pain because higher doses give no additional pain relief while increasing the likelihood of side effects.

The side effects of NSAIDs are numerous, including gastrointestinal (GI) disturbances (dyspepsia, erosions, ulcerations) and liver, renal, and cardiac effects.19 This group of medications is responsible for the largest number of serious drug-related complications, surpassing all other drugs by a wide margin.20 In 2005 GI-related deaths from NSAIDs were the 14th leading cause of death in the United States, ranked after homicides (13th) and before atherosclerosis (15th).21

NSAIDs have very little effect on platelet aggregation because bleeding times are not prolonged. With prolonged use of NSAIDs, interference with most classes of antihypertensives has been noted. If patients take NSAIDs for more than 5 days postoperatively, blood pressure should be monitored.

Ibuprofen.

Ibuprofen was first introduced in 1969 as a new NSAID and has since been the most popular prescribed NSAID. Ibuprofen is used to treat mild to moderate pain and has been proven to significantly reduce postoperative dental pain in clinical studies. The analgesic ceiling dose is 400 mg/dose and 1200 mg/day.22 At these doses it has been shown to be as safe as acetaminophen, while achieving better analgesia with less nausea and cramping.

Aspirin.

Acetylsalicylic acid (ASA) was the first prototypical NSAID. It has analgesic, antiinflammatory, and antipyretic properties. However, at analgesic doses its relative risk for GI complications is high. Acetylsalicylic acid is not a drug of choice in the management of dental implant surgical patients because of its very significant antiplatelet effects.

Tramadol.

Tramadol represents a unique classification of analgesic because it is a centrally acting analgesic with two complementary characteristics: opioid and antidepressant. It works by inhibition of norepinephrine and serotonin reuptake within pain pathways of the central nervous system and also by its relatively weak affinity for the m-opioid receptor. Tramadol is a nonscheduled drug and is associated with fewer opioid-like side effects, such as dependence, sedation, respiratory depression, and constipation. Tramadol’s analgesic efficacy is similar to that of codeine (60 mg) and is indicated for moderate to moderately severe pain management. This drug is an appropriate analgesic alternative for the treatment of postoperative pain in patients who have NSAID-related GI and opioid intolerance. Tramadol has been shown to be effective in the reduction of pain when used in combination with acetaminophen. Ultracet (tramadol/acetaminophen) has demonstrated excellent efficacy in pain studies and is supplied as a combination analgesic containing 37.5 mg tramadol and 325 mg acetaminophen.23

Narcotics (Opioids).

Narcotics (opioids) are the primary medications for analgesia of moderate to severe pain from dental origin. They are centrally acting analgesics that act as agonists at μ- and κ-opioid receptors. Morphine, which is a naturally occurring opioid, is generally accepted as the prototypical narcotic. All other narcotics on the market today are compared in potency to morphine.

Unlike nonopioids, opioids do not have a ceiling effect for analgesia. As the dose increases, the analgesic effect increases. However, in addition to relieving pain by m-receptor binding, euphoria, nausea, vomiting, and constipation may occur. With high doses, sedation and respiratory depression are possible. With chronic use, physical and psychologic dependence are common.

The following section discusses the most commonly used narcotics in oral implantology. Structurally, these narcotics are similar to morphine and provide the same degree of pain relief and unlimited efficacy at equipotent doses.

Codeine.

Codeine is a naturally occurring alkaloid that is classified as a mild analgesic. Codeine has excellent antitussive properties; however, it is associated with high degrees of nausea and constipation. Orally administered codeine is only 60% bioavailable, which results in only 10% being demethylated to morphine. This 10% is the only part responsible for analgesic properties, thus 90% or the drug has no analgesic efficacy. Because of the side effects and low potency compared with other opioids, codeine is usually not the first choice of narcotics used in oral implantology.

Hydrocodone.

Hydrocodone bitartrate is a semisynthetic narcotic analgesic and antitussive with multiple actions qualitatively similar to codeine. It is usually used as a combination analgesic, being combined with either acetaminophen or ibuprofen. For several years, this narcotic has been the most frequently dispensed prescription medication in the United States. Hydrocodone is habit forming, and the most frequent adverse reactions are dizziness, sedation, nausea, and vomiting.

Oxycodone.

Oxycodone is a semisynthetic opioid with analgesic action similar to morphine. It is recommended for moderate to severe pain with its principal actions being analgesia and sedation. It has excellent oral bioavailability because it retains half of its analgesic activity when administered orally. Oxycodone has the same adverse effects as most other opioids, with an increased potential for abuse and drug dependence. Oxycodone is marketed as a combination narcotic, combined with either acetaminophen (Percocet) or aspirin (Percodan). A slow-release oxycodone (OxyContin) has been shown to have a high abuse potential.

Combination Analgesic Therapy for Postoperative Pain.

A pain management strategy using multiple analgesics with different mechanisms of action is termed combination analgesic therapy. The goal of combining different types of analgesics is to increase the analgesic effect while decreasing possible side effects. When multiple drugs are used in combination, synergistic and additive effects allow for the use of lower doses of each individual drug (Table 10.4).

TABLE 10.4

Combination Analgesics

Generic Name Brand Name Average Adult Dose Schedule
5 mg codeine/300 mg acetaminophen Tylenol #1 1–2 tablets every 4 h III
15 mg codeine/300 mg acetaminophen Tylenol #2 1–2 tablets every 4 h III
30 mg codeine/300 mg acetaminophen Tylenol #3 1–2 tablets every 4 h III
60 mg codeine/300 mg acetaminophen Tylenol #4 1 tablet every 4 h III
5 mg hydrocodone/500 mg acetaminophen Vicodin/Lortab 5/500 1–2 tablets every 4–6 h (maximum 8 tablets/24 h) III
7.5 mg hydrocodone/750 mg acetaminophen Vicodin ES 1 tablet every 4–6 h III
7.5 mg hydrocodone/650 mg acetaminophen Lorcet 1 tablet every 4–6 h III
10 mg hydrocodone/660 mg acetaminophen Vicodin 1 tablet every 4–6 h III
10 mg hydrocodone/650 mg acetaminophen Lorcet 10/650 1 tablet every 4–6 h III
7.5 mg hydrocodone/200 mg ibuprofen Vicoprofen 1–2 tablets every 6 h III
5 mg oxycodone/325 mg acetaminophen Percocet 5/325 1 tablet every 4–6 h II
7.5 mg oxycodone/500 mg acetaminophen Percocet 7.5/500 1 tablet every 4–6 h/maximum 8/day II
10 mg oxycodone/650 mg acetaminophen Percocet 10/650 1 tablet every 4–6 h II
5 mg oxycodone/400 mg ibuprofen Combunox 1 tablet every 6 h/maximum 4/day II

From Misch CE: Contemporary implant dentistry, ed 3, St Louis, 2008, Mosby.

With combination therapy, acetaminophen or NSAIDs are used with an opioid. Because of the ceiling effects of acetaminophen and NSAIDs, further increases in dosage will not provide any additional analgesia; however, they will increase side effects.

Analgesic Agents in Oral Implantology.

The selection of an analgesic or analgesic regimen for management of postsurgical pain is ideally based on the expected pain intensity. This may be based on the patient’s medical history, past pain threshold, type of procedure, extent of tissue reflection, and duration of procedure. Because of the various agents and numerous options for the treatment of postsurgical pain after dental implant surgery, a pain control protocol was formulated to aid in the proper administration of these agents. According to the World Health Organization guidelines, the procedure and patient must be evaluated and classified as mild, moderate, or severe (Table 10.5).

TABLE 10.5

Recommended Pain Control Protocol (PCP)

Drug Dose
PCP 1: Mild Pain Expected
Ibuprofen 400 mg 1 h before
PCP 2: Mild to Moderate Pain Expected
Ibuprofen + hydrocodone (Vicodin)

400 mg 1 h before surgery + continue 4 times daily for 2 days

5 mg/300 mg as needed

PCP 3: Moderate Pain Expected
Ibuprofen + hydrocodone (Vicodin ES)

400 mg 1 h before surgery + continue 4 times daily for 2 days, then as needed

7.5 mg/300 mg 4 times daily for 2 days, then as needed

PCP 4: Severe Pain Expected
Ibuprofen + hydrocodone (Vicodin HP)

400 mg 1 h before surgery + continue 4 times daily for 4 days, then as needed

10 mg/300 mg 4 times daily for 2 days, then as needed

From Misch CE: Contemporary implant dentistry, ed 3, St Louis, 2008, Mosby.

Mild pain.

Mild pain is self-limiting and usually will be resolved with normal recommended doses of NSAIDs.

Moderate pain.

Moderate pain is more intense pain than mild and usually will not be resolved totally by NSAIDs. It will interfere with function and disrupt the activities of daily living.

Severe pain.

Severe pain is defined as pain that interferes with some or all of the activities of daily living. The patient may be confined to bed, and strong opioid treatment will need to be continued for days. Adjuvant drug therapies may be needed for supplementation (Table 10.5).

Control of Postoperative Surgical Pain.

The goal of postsurgical pain management is to optimize patient comfort through pharmacologic and behavioral strategies. The World Health Organization formulated an analgesic “ladder” for the treatment of pain management. The following protocol describes three steps in the treatment of acute pain.24

1. The first step is to maximize the use of NSAIDs (acetaminophen, ibuprofen) for mild to moderate pain. Adjuvant medications such as glucocorticoids and cryotherapy are often suggested.

2. When moderate pain is expected or persists, an opioid (hydrocodone, codeine) should be added to the NSAID. The fixed dose of opioids with the NSAIDs provides additive analgesia. Glucocorticoids and cryotherapy are encouraged.

3. Moderate to severe pain that is expected or persists should be treated by increasing the dosage of the opioid. Glucocorticoids and cryotherapy are of particular benefit when not contraindicated.

With the guidelines from the World Health Organization, a pain control protocol was formulated for treatment of procedures based on the expected postoperative pain (Box 10.1).

 

Box 10.1

World Health Organization Pain Relief Ladder

Three-Step Conceptual Model

1. Nonopioid + adjuvant

2. Nonopioid + adjuvant + opioid (moderate)

3. Nonopioid + adjuvant + opioid (severe)

Adjuvants: long-acting anesthetics, glucocorticoids, tricyclic antidepressants. © Copyright World Health Organization (WHO), 2016. All Rights Reserved.

Treating Each Patient/Procedure the Same Pharmacologically

Complication

Many clinicians treat all dental implant patients with the same prophylactic protocol, irrespective of the patient’s ASA classification and type of procedure. For example, a sinus bone graft has much higher morbidity than a single tooth implant, therefore, a different pharmacologic protocol is indicated. The complications and morbidity of the surgical procedure are proportional and directly related to the medical status of the patient, surgical procedure, length of surgery, and the extent of tissue reflection. The authors have developed a pharmacologic approach that recommends different protocols based the factors mentioned (see Table 10.2).

Prevention

Clinicians should have a clear understanding of all prophylactic medications (antibiotics, antiinflammatories, analgesics) that are indicated to minimize postoperative complications and decrease morbidity. Additionally, the implant clinician must be aware of all drug interactions and contraindications to the use of these agents.

Treatment

Because of the many variables (e.g., local, systemic, surgical) that need to be considered with the use of pharmacologic agents in implant dentistry, a protocol has been developed to standardize the prophylactic use of these agents. A four-category pharmacologic classification is proposed based on the patient’s ASA status, type of surgical procedure, and invasiveness of the surgery (see Table 10.2).

Not Giving Adequate Postoperative Instructions

Patients should always receive postoperative instructions both verbally and in writing. Failure to do so may increase the possibility of postoperative complications and loss of confidence in the doctor and place the doctor at risk for medicolegal issues.

Etiology

Unfortunately, many doctors do not have a consistent protocol for the administration of pre- and postoperative instructions. This leads to patient misunderstanding about expectations after surgery, after-hours phone calls, and increased stress for the patient. Additionally, many clinicians have one generic or generalized instruction protocol. Ideally, there should exist an instruction protocol that is specific for the type and invasiveness of the procedure.

Prevention

Detailed postoperative instructions should be given orally and in writing to the patient before and after surgery. The instructions should also be available for the patient on the office website if possible.

Treatment

Comprehensive review of all postoperative instructions is an important part of treatment. Some of the more common topics for which instructions should be presented to patients include the following:

Bruising.

The possibility of bruising or ecchymosis should always be explained to the patient, even for shorter-duration and less invasive surgeries. It is crucial the patient understand the possibility of bruising because this may lead to embarrassment and esthetic issues for the patient. The patient should be made aware that bruising can appear 3–4 days postoperatively and may take up to 10–14 days for complete resolution. Additionally, patients should be informed about the possibility of bruising extending into the submandibular and neck area (because of fascial planes and gravity) because this will minimize the possibility of patients questioning either an aggressive or poor surgical technique by the doctor.

Bleeding.

The incidence of bleeding postoperatively is extremely high after dental implant surgery. Patients should be cautioned on the potential for bleeding during the first 24 hours and instructed on techniques to decrease the bleeding. Patients should always be given gauze (3 × 3 or 4 × 4 gauze is recommended because 2 × 2 pads may result in inadvertent aspiration by the patient) for use as pressure dressings. Recommendations should be given to minimize wearing an interim prosthesis because this may result in increased bleeding. For significant or prolonged bleeding, the patient should be instructed to contact the doctor (see Chapter 7). The patient should also be instructed not to use a straw when drinking fluids because this may create a negative pressure and increase bleeding. Also, spitting and vigorous rinsing may open the surgical wound and cause bleeding.

Swelling.

The patient should be informed that swelling is most likely to occur after implant surgery and will peak at 48–72 hours. Often, patients will exhibit minimal swelling the day of surgery; however, it will most likely increase 2–3 days postoperatively. This will prevent the patient from misinterpreting the swelling as a postoperative infection. The patient should be instructed to use multiple pillows because sleeping with the head elevated decreases head and neck swelling.

Hygiene.

Patients may gently brush their teeth during the first day; however, they should avoid the surgical site. Gentle rinsing with chlorhexidine may be initiated the day after surgery. Potent antiseptics (e.g., Listerine) should be avoided until incision line closure.

Diet.

The patient should be counseled that following dental implant surgery, the body requires adequate fluids and nourishment. Ideally, at least 2 liters of fluids (milk, water, nonacidic juice) should be consumed within the first 24 hours. The patient should gradually progress to more solid foods. A high-calorie diet with increased volume of liquid and soft foods for the first 24 hours is recommended. Soft foods are usually tolerated well. These include milkshakes (use a spoon: NO straw), ice cream, applesauce, pudding, jello, yogurt, mashed potatoes, scrambled eggs, pasta (no tomato sauce). Hot liquids (coffee, tea, soup, etc.) should be avoided until local anesthesia has worn off (~4–8 hours).

If the patient was administered intravenous sedation, the patient should be instructed to have some food intake after surgery because they have been NPO for a minimum of 6 hours prior to surgery. This should be in the form of a soft food such as yogurt, jello, soup, or ice cream.

No Smoking or Alcohol Use.

Patients should have a thorough understanding of the effects of smoking and alcohol use postoperatively on incision line opening and implant/bone grafting morbidity. Smoking cessation should be initiated a minimum of 2 weeks prior to surgery and 6 weeks (ideally) postsurgery. The use of alcohol prior to complete incision line healing should be discussed because this may lead to an increased possibility of incision line opening and possible infection.

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Jan 12, 2018 | Posted by in Implantology | Comments Off on Postoperative Complications
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