Postsurgical Instructions

Application of pressure

The surgical area should be covered with a sterile gauze and pressed with the fingers softly, firmly and constantly for 5-10 minutes, to stabilize the natural fiber bridge that will result in new clot formation1. When this manual pressure has been removed, the patient should be told to either bite the gauze (occlusive pressure) or press with the tongue on the gauze (palatine and lingual pressure). This gauze is removed before the patient leaves the office to check that there is no bleeding. A new dry gauze is put back and should remain in place completely still for 1 hour.

Cold dressing

A cold dressing has to be applied and pressed firmly on the zone at intervals of 20 minutes, resting 20 minutes, and so on for 8 hours. The immediate reduction in temperature and the pressure not only slow the blood flow and stimulate intravascular dotting, but intercept and counteract "the hemorrhagic rebound effect” and ultimately decrease postsurgical bleeding and swelling. The cold also desensitizes the peripheral nerve endings and becomes an effective analgesic.

After 8 hours, this intermittent cold application should be discontinued because reduced blood flow is no longer desirable and may impede tissue healing by interfering with the inflammatory response.

Patient instructions

Postsurgery instructions have to be slowly explained to the patient and his or her companion, and these instructions should be repeated in a written copy. Leave the patient in a quiet area to relax for 15-20 minutes. Ask the patient if he or she has any questions. If a question arises after the patient has left the office, he or she can call at any time, or a 24-hour phone number will be provided.

Analgesics

All microsurgery techniques have been developed to reduce tissues trauma and to speed up the healing process5, so endodontic postsurgery pain is extremely rare if proper management of soft and hard tissues has been achieved during every surgical step6. Pain should be at most of short duration just on the day of surgery. Complicated or long surgeries can produce more pain. However, pain is a patient-related factor, so some considerations should be taken into account. For example, a patient with presurgi-cal pain is more prone to have postsurgical pain. Also, a placebo effect occurs more commonly when patient expectations of relief are high and the therapist has conveyed enthusiasm for, and confidence in, the medication8'9. Unfortunately there are no definitive personality traits that indicate a patient will or will not be predisposed to the placebo effect, but it is good practice to ask the patient on which analgesic he or she relies most, and adapt postsurgery medication to this.

Non-narcotic Analgesics

Pirazolone derivates

Magnesic metamizol (Nolotil) acts centrally and peripherally with analgesic, antipyretic and spasmolitic action. An oral ampule (2 g) or a tablet (575 mg) can be given before starting the postsurgery manual pressure.

Alcohol should be avoided.

Do not give this drug during the first and last trimesters of pregnancy nor during breastfeeding.

There can be cross-sensitivity in patients who have had asthma symptoms, rhinitis or hives after being given acetylsalicylic acid, paracetamol or NSAIDs.

Paraminophenol derivates

Acetaminophen (Paracetamol, Tylenol, APAP) is an analgesic and antipyretic, but not anti-inflammatory. It is without gastrointestinal damage with peripheral action. The dose is 1000 mg initially and then 650 mg every 4 h. The maximum adult dose is 4 g/day.

The combined use of acetaminophen (1000 mg) and ibuprofen (600 mg) has proved to be as effective for pain as the narcotics, without their undesirable secondary effects12. Doses can be repeated every 6-8 h when needed during the first two days after surgery.