Master, College of Conscious Sedation American Dental Society of Anesthesiology           

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Pre- Extraction/Surgery Pre Implant pre bone graft pre gum graft  Instructions

If you plan to have  comfortable modern sedation that will reduce your stress and make recovery easier and less painful.

Even though patients may not feel it, the body will react to a coming stressful situation by increasing heart rate and blood pressure. For patients sixty and over this stress induction can make it more difficult during surgery, more difficult to gain numbness. It is just not going to be a pleasant experience. A stress reduction protocol is advised so that you take a prescribed sedative the eve before in order to get a good nights sleep. Also you will take one an hour before visit to reduce anxiety and perhaps one at office. When you are brought back to surgery room then you are more relaxed, we can give you relaxing gas and then start an IV most comfortably. The IV line allows us to use IV steroids to prevent swelling, medicine to prevent nausea later, antibiotics if needed, and a drying agent so that you can breath better and have a dry field for which it makes it easier to work and to do better quality work. Thus for stressed patients and patients sixty and over sedation dentistry is advised for a safer more comfortable easy visit.

However, you MUST have a driver and an escort (they can be one and the same:)). You are not to drive for 24 hours. And you are NOT to eat 4 hours before visit unless Dr. Starkey says differently.

Unless this is an emergency situation, the Dental Team wants you to work on keeping your teeth and gums as clean as possible. This means brushing, flossing, brushing your tongue, and using a chlorhexidine or yellow Listerine mouth rinse daily. It is important to disrupt a biofilm that develops on your gums and teeth every 24 hours. Bacteria and toxins live in this film and can interfere with healing resulting in more pain, or complications, and delayed healing.

The use of tobacco products prior to surgery will result in delayed healing, increased complications, and in the case of grafting the failure of a graft. Not smoking is strongly advised. In some situations we cannot do delicate surgery like gum grafting if the patient smokes. It is important that the patient realize the risks and is willing to take responsibility for a negative outcome.

A healthy diet obviously will help with healing. It would also be helpful to take a multi vitamin for a few days before and a few days after. One that contains extra vitamin C or get a vitamin C supplement. At least 500 mg vitamin C a day for a few days before and after. Vitamin C helps in the production of collagen fibers and collagen fibers make up gum tissue.

It would be helpful if you get some drink like Boost or Ensure to get nutrients you need because you will have to be on a soft diet anywhere from 24 hours to a week. In 24 hours a diet with eggs or pasta is okay, then a little harder food the third day. Chewing gum and sticky candy are obviously ridiculous to consider for a week or forever in some cases.

Have a place at home where you can prop yourself up. Have a towel to place over your pillow case or couch so that you don't bleed on your nice sheets and furniture.

You may want to get some straws. Unless Dr. Starkey says otherwise, straws are okay though you  might want to use 2 or three at a time.

The staff will give you ice packs at end of surgery but you may want to make up your own ice packs.

If you can take Advil or Tylenol be sure and have some ahead of time so you don't have to stop to pick any up.

If you are able to take these two meds they work better when taken together.

You will not be able to eat for at least one hour after appointment though fluids are okay. If you eat the food can mix with blood and cause nausea that will last for 24 hours. It is important to have some one to check in on you. Some patients are very susceptible to pain medications especially older patients. Thus for pain control Dr. likes to give long acting anesthetic to manage pain and for older patients someone needs to be with them during the recovery period.

Surgery visits are scheduled for mornings because that is when stress is lowest on patient and so that if there are complications we can see patient in afternoon.

Usually Dr. Starkey will want to see you 10-14 days after surgery to remove sutures. However there are times that he will want to see you the next day  and there are times he will want to leave sutures in place for a much longer time. Some sutures will dissolve on themselves. It depends on the kind of surgery.

Post Surgery Instructions

1. You will not be allowed to leave until bleeding is under control and you are able to walk out of office on your own.

2. You will be given written instructions and verbal instructions will be reviewed.

3. Go home or go to a comfortable place where you can be looked after.

4. Unless Dr. says otherwise you can use a straw if you like. If there is a sinus  communication then do not use straw. Dr. will tell you if there appears to be one.

5. Use Ice pack on affected side. Either one from our office which can be left on for extended periods. If you use an ice pack you have made from refrigerator ice then you should only put it on face for 2-3 minutes then let rest for a couple of minutes because ice can cause a freezer burn of sorts.

6. Do NOT lay flat; sleep with your upper body elevated to reduce swelling, pain, and bleeding.

7. For extractions of any teeth other than wisdom teeth keep gauze in place for one hour. For wisdom teeth extractions or multiple extractions keep gauze pack in place for a minimum of one hour up to three hours.

8. We do not want you to change gauze because you will stimulate bleeding even if the gauze becomes blood soaked.

9. There is extra gauze if you have to change them in emergency however.

10. If there is an unusual bleeding problem please call Dr. Starkey on his cell phone 402.740.9235. If you have any concerns at all you can call Dr. Starkey.

11. NO mouth rinse tonight. You can rinse tomorrow after 24 hours.  We need you to keep the surgical wound clean. Use gauze dipped in Chlorhexidine or Listerine and gently wipe over the wound area. A biofilm will form every 24 hours over the wound area and will impeded healing so it is important to keep it clean.

12. There will be swelling the next day; that is normal. In surgical extractions maximum swelling comes within 72 hours. And then recedes.

13. Sometimes there will be bruising on the cheek or chin where surgery was done. It can look like you got in a brawl.

14. If there was bone grafting the site needs to be kept clean as instructed above.

15. Bone fragments or root tip fragments may exude from one to several weeks later.

16. Sometimes there will be a root tip that is left because it is small or it is near a critical structure and removing it would be worse than leaving it. However the Doctor may want to take an x ray to see where and how it looks.

17. You will need to be checked in any where from 1 to 14 days. Sutures may or may not dissolve on their own. It depends on the situation.

18. NO narcotic pain medication for one hour after leaving the office. If you take the narcotic within the hour it will mix with blood and you will become nauseated.

19. If we place Dentures or partial dentures at the time of surgery you are to leave the dentures in over night. You are to come to the dental office the next day and have doctor or staff help you remove the dentures. You will have sore spots and bleeding that will need to be managed by us.

20. In the case of dental implant placement, soft tissue grafting, or bone grafting you are to AVOID chewing on the implant site. If it is an immediately placed implant bridge you are to have soft diet and we need to check you in twenty four hours unless you are confident everything is okay.

21. Dry sockets are an uncommon but disconcerting problem from extractions especially lower wisdom tooth extractions. Dr. will pack a sponge with anti biotic to help prevent dry socket. But you can help by NOT doing any heavy lifting and NOT using tobacco or alcohol for three days or ever. Dry sockets usually occur when a clot is lost from the socket and that happens about 2-3 days after surgery. NO vigorous rinsing.

22. Cryotherapy (ice packs) for the first 24 hours is the best treatment. Beyond 24 hours it does not work very well.

Oral Surgery Informed Consent

I,_____________________________________ have read and it has been explained to me and I understand the pre operative and during the dental visit and post operative instructions that I am advised to follow in order to have a better more comfortable dental surgeries.

I realize there are many reasons why patients can be stressed from dental and oral surgery work and there are real physical and mental problems from oral and dental surgery because of these reasons if not more:

Instill Fear

Inflict Pain

Inject local anesthetic

Inject potent vaso constrictors that can cause heart flutter

Cause bleeding

Control body position in ways you don't like

Expose to radiation

Expose to Dental materials

Can cause patients to inhale aerosol particles

can cause patients to swallow dental objects

Can cause nerve damage

Prescribe medications

Alter mouth function; make chewing more difficult

Alter appearance of patient in unattractive ways.

To make a problem that was bad enough even worse

Cause PTSD

Cause systemic problems due to stress or due to  medications the doctor prescribes that cause complications due to allergy or due to combination of patient's medications along with dentists medications.

I understand there are Possible Complications due to oral Surgeries or Extractions such as but not limited to:

Swelling, Bruising Pain can occur with any surgery and vary from patient to patient and from one surgery to another.

Adverse Drug reactions:

Respiratory depression, cardiac arrest, seizure, hyp tension, loss of consciousness.

Complications from mediations: multiple medications; certain anti biotics all can inter act and cause bad outcomes. Patients that are diabetic risk diabetic coma or diabetic shock.

Stress of extraction or surgery can induce cardiac pain, angina, fibrillation, cardiac arrest.

Stress can cause fainting

Hypoglycemia: anxiety, fear, coldness, tachycardia, hyptensioin; syncope fainting woarmth loss of color, tachycardia baysea, diapohoresis, hyptoension

Hyper ventilation, rapid shallow breathing, feeling cold, numbness.

Hypertensive crisis: high blood pressure

Epinephrine Reaction:

fear anxiety tenseness, headache, weakness, dizzy, perspiration, pallor, respiratory difficulty.

Complications due to patient's systemic conditions:

1. Older patients, that is to say sixty and older are more susceptible to stressful situations that can result in cardiovascular emergencies. Patients with psycho social problems can have them aggravated by  the pain and suffering of dental surgery.
2. Diabetic patients.  25% of time patient can be an undiagnosed diabetic.
   
3. Patients with renal (kidney) disease. Which 25 percent of the time the patient will have Chronic Kidney Disease and not know it. Thus dental procedures and certain medications (Like ibuprofen) can worsen the problem.
   
4. Patients with cardiovascular disease: high blood pressure; low blood pressure; rapid or irregular heart beat.
   
5. Patients with pulmonary disease: Congestive Heart Failure or COPD- chronic obstructive pulmonary disease.
   
6. Patients unable to easily walk up a flight of stairs.
   
7. Patients with inflammatory disease or auto immune disease. http://www.webmd.com/a-to-z-guides/autoimmune-diseases
   
8. Medications can create difficulties in dental treatment; for example patients that take bone building medications can have necrosis of jaw, patients on blood thinners; patients that are on or have been on steroids.
   

Informed Consent for Dental and Oral Surgery including pre operative, peri-operative (which means at time of surgery) and post operative instructions. That you should be aware of prior to giving your informed consent.

Finally!----

Peri-Surgery- the time at or around surgery:

It is better if you have an escort regardless of sedation or not.

If you are having modern sedation follow those instructions. The highlight  being you  must have a ride and escort. You are NOT to eat four hours before surgery. Take the oral stress reduction medications as directed.

If you are only having local anesthetic.  If you are diabetic check your blood sugar prior to surgery. Whether diabetic or not have a light snack, a cookie, a small treat like mini candy bar. They are in the office up front when you come in. Drink a glass of water or small bottle of water about an hour before. IF you are allowed to take ibuprofen take 800 mg ( four advil or one motrin) an hour before visit. This will help manage the swelling afterwards and make the injections less uncomfortable.

You must tell the staff about any changes in your health status since you were last in.

If there is any change in your medications. Take all your medications as you usually do unless you have previously discussed a different plan with the Doctor.

Regardless of whether sedation is used: Please use the rest room prior to being seated. We want you to use Peridex (chlorhexidine) or yellow Listerine which you can find in the rest room or before coming to the office.

Have surgery visit scheduled for the morning. Please have a ride. You really need some one to give you some attention and sympathy. Experiencing an extraction or surgery on your own can be a lonely fear inducing experience.

Cooperation with the staff will make your visit easier. We will do our best. You will be offered a heated blanket which I recommend you have because the surgery suite is kept cool.

Review the treatment plan with the doctor before we start. Confirm which teeth are going to be treated! We need to get a base line on your cardiac status again.

Local anesthetic will be required, the type however will be based on your level of anxiety or cardiac issues. If you have heart palpitations or fast beating heart or irregular heart beat then non epinephrine anesthetic may be advised. Anesthetic with epinephrine can cause anxiety in some patients.

Additional complications due to gum bone surgery and or extractions

1. Swelling bruising or pain restate
   
2. muscle trismus- a limited opening of jaws caused by inflammation of muscle or tendons due to having mouth open. This is most common with wisdom teeth removal; however when implants are placed this can be time consuming and patient has to keep jaw open for long period of time.
   
3. Infection-Possible with any dental surgery. It is NOT possible for dentist to work in a sterile field but we try to reduce the bacteria problem before and during and after procedures. A bio film will coat the surgery site within  24 hours if patient does not keep biofilm from forming thru careful and gentle cleaning bacteria can enter the wound in larger amounts and cause infection or dry socket.
   
4. Drug interactions which has been discussed above. The result can be a medical emergency or nausea.
5. TMJ- Tempero mandibular joint problems from having to keep the jaw open and from forces required to extract teeth or place implants.
   
6. Dry socket-this is significant pain in the jaw and ear due to loss of blood clot that forms of socket. It is most common with removal of lower wisdom teeth but can happen anywhere. Smoking and alcohol and strenuous activity can cause dry socket. Dry socket if they happen usually occur 2-3 days after surgery. You must call Dr. if you are having pain three days after surgery.
   
7. Damage to other teeth or fillings or roots of adjacent teeth. From pressure of extraction procedure or bumping the adjacent teeth or having to remove or accidently remove bone that supports adjacent teeth
   
8. Loss of bone due to extraction. Either the bone comes out with the tooth or the bone has to be cut out to access the root of tooth to be removed.
   
9. Loss of gum tissue. Surgery often results in loss of gum tissue as the socket heals from wound. Lost attachment. Sometimes the tight gum tissue around the tooth known as attached gingiva is lost during surgery and may need additional surgeries to replace this tissue.
   
10. Unsightly or annoying gap. When tooth is extracted bone can be lost. In the case of infection where bone is damaged the tissue will collapse and the patient will have a large gap under a bridge or between teeth. This can be unattractive it can also result in food getting stuck in the area where the tooth or teeth were extracted.
    
11. In the case of extractions in addition to any direct bone loss during surgery procedure there will be additional bone loss of 50% or more after several months of healing. Again that means gapping forms under fixed bridge work or under dentures. That is why temporary bridge work is advised before final implants or bridge work for several months.
    
12. Sinus communications. In the case of upper teeth mostly in posterior a hole from the oral cavity into the sinus may result from extraction. This is especially upper posterior teeth that have roots into the sinus or have chronic infection where the thin layer of bone protecting the sinus has been eroded away.
    
13. Numbness of the lip or tongue- this is due to bruising or damaging the lingual nerve and or the mandibular nerve which travels under the lower posterior teeth. It can happen when extracting teeth or when placement of implants. Sometimes it is unavoidable. If you are experiencing numbness beyond 24 hours you must call Dr. Starkey because this is a problem that needs to be addressed as soon as possible to try to reverse problem. Numbness is usually only a temporary problem in rare instances it can be profound and difficult if not impossible to correct.
14. Smoking/tobacco/alcohol will impede healing from surgery the result can be catastrophic failure of gum surgery, soft tissue surgery, bone grafting, tooth extractions, implants. It can result in dry socket and extended time required to heal
    
15. Dry sockets can be so painful that you will want to see Dr. Starkey so he can place a dry socket paste to alleviate the discomfort. It is only temporary  relief you will have to come in 2-4 more times for him to dress the wound.
    
16. Infection and complications can be so bad that it is necessary to have patient go to hospital for treatment.
    
17. Patients even in the 21st century can die from dental infection or allergic reaction.
    
18. Anesthesia-local anesthetic injection can result in extended numbness, electric shock that is very painful, can cause heart palpitations, angina or heart attack and or hypertension, shock and  or fainting. It is rare but sometimes patient's have difficulty getting numb and the procedure itself is still painful.
    
19. Anesthesia-moderate sedation; this is excellent for protecting patient body against stress however it has risks such as patient cannot remember visit, patient needs to have a ride, there can be bruising at injection site, nausea, sometimes IV line cannot be placed. The medications used can cause adverse reaction. For example patients that are on high dose of narcotic over long period of time will have a nervous leg response that lasts for hours if a certain pain control medication is used in IV. It is very very rare but there can be a medical emergency due to IV sedation. There can be dizziness. For a small number of patients moderate (IV sedation) does not work; or the patient is too sick for IV sedation. These patients will need to go to hospital setting or outpatient general anesthesia service.
    

Other possible complications:

I hereby authorize Dr. Michael A. Starkey and his staff to perform the following procedures:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

And to administer the necessary anesthesia. I understand the doctor may discover conditions that required additional procedures other than those previously stated. I authorize Dr. Starkey to perform any procedures that are advisable in his professional judgement. I understand that if I am having sedation dentistry it is not possible to have a clear understanding of the situation and I allow Dr. Starkey to use his best judgement at the time. This may involve a tooth extraction or the start of root canal treatment, or a filling or a temporary crown or bridge. It is rare but this does happen. Especially in complex cases.

I have read and discussed the preceding risks that may occur in connection with the chosen  procedures. I have been given sufficient information to give my consent to surgery and all my questions have been addressed to my satisfaction.

Patient authorization/Legally responsible Person________________

Witness______________________________Date____________________

e.

Dental  Surgery 

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