Enhanced Recovery After Surgery Protocol: Post-Operative and Medication Instructions

Download and Print

Enhanced Recovery After Surgery (ERAS) is a new surgery protocol that streamlines patient processes before, during, and after surgery. The program aims to shorten the recovery period, drastically decrease opioid utilization, and facilitate early return to a daily routine while improving outcomes and overall surgical experiences. Please follow instructions carefully; doing so will add to your post-procedure comfort and hasten your recovery. Not all the following information applies to every patient. If you are uncertain regarding specific information, be sure to ask your doctor.

Continue Pre-Operative ERAS Protocol After Surgery as Follows

  1. Continue drinking plenty of fluids (water and electrolytes). It will help prevent dehydration after surgery.
  2. Eat nutritious foods. This will give your body nutritional support to optimize its healing potential.
  3. Continue for at least one-week post-surgery. Particularly:
    1. Zinc: enhances the immune system
    2. Calcium: supports bone healing
    3. Vitamin C: support soft tissue healing
  4. The next dose of ibuprofen 400-600mg (as directed by your doctor) will be 6 hours after your pre-op dose. This will give you a head start on pain and swelling control. In addition, start taking Tylenol 325mg-500mg (as directed by your doctor). Continue this combination every 6 hours on a schedule for the medicine to work effectively.

Anesthesia often leaves the lips, teeth, tongue, and even the nasal area numb after an oral operation. Avoid chewing and hot liquids to prevent accidental injury until the numbness wears off. Taking ibuprofen or/or Tylenol before the local anesthesia wears off can significantly reduce pain and swelling. Temperature and pressure sensitivity, as well as gum soreness, are to be expected in the days after your procedure.

After a tooth extraction, it is crucial that a blood clot forms and remains in the extraction socket. The clot protects the socket and promotes bone growth and soft tissue migration over the tooth socket. Premature loss of the clot results in an unprotected socket, commonly referred to as a dry socket. Symptoms of a dry socket usually appear 5+ days after the procedure. Characterized by severe, radiating pain unresponsive to recommended pain medication. If you are experiencing these or related symptoms, please call the office for treatment. Treatment is simple and very effective. Prevention of dry socket: Do not smoke, drink through a straw, or rinse forcefully for at least 5-7 days after the procedure. Drink directly from the glass or use a spoon.

The following will help in the preservation of the blood clot. Gauze will be placed over the surgical site(s) immediately after your procedure. Firm biting pressure over the area(s) for 30 minutes and repeat every 30 minutes for 2 hours. Continue this regime until the bleeding stops, or you may also apply it with a moistened tea bag wrapped in gauze to control the bleeding.  Do not chew on the gauze.   If bleeding starts again, repeat the cycle. Some bleeding following oral surgery is to be expected, and slight oozing may persist for the first 24-48 hours after surgery.   Do not take aspirin or aspirin products since they may prolong bleeding. If pressure on the surgical site does not control bleeding, please call your doctor. Some degree of swelling and discomfort following the surgery is to be expected. Discoloration and a slight stiffness of the jaw can be normal post-operative events. Do not be alarmed; swelling is expected to peak on the third day and may last for several days.

Good nutrition must be maintained following oral surgery. First, plenty of liquids are needed, and the diet should be increased to soft or regular foods as soon as possible. Though soreness and jaw stiffness may be present, do not miss meals. Following oral surgery, you may consume non-acidic juices, smoothies, ice cream, puddings, yogurt, Jell-O®, soup broth, scrambled eggs, and pureed or blended foods.

Good hygiene is important for normal healing.  You can brush teeth unaffected by the surgery, along with gentle tooth brushing of the teeth adjacent to the surgical area. Avoid undue irritation to the surgical site. Rinse your mouth with salt water after every meal and before bed.  Mix 1 teaspoon of salt in a 12-ounce glass/bottle, rinse for about 30 seconds, and expectorate/spit; do not swallow salt water.

Oral surgical procedures are often accompanied by facial swelling, which should not cause alarm.  A noticeable progressive increase in swelling will likely occur during the second or third post-operative day and is expected. Swelling will generally peak on the day 3-4 and slowly subside over the next few days. You may help minimize the swelling by applying an ice bag on the face 30 minutes on and 30 minutes off until bedtime for 24-48 hours.  48 hours after surgery and for several days after, moist, warm heat applied over swelling may be helpful. You may also consider using Arnica Montana, a natural supplement; it has been used medicinally for centuries to help reduce postoperative swelling, pain, and bruising. Apply to the skin of the face over the surgical site 3-4x daily. Do not apply it orally or over broken skin.

Resting with the head slightly elevated the first 2-3 days following surgery will make your post-operative course more comfortable.  Avoid physical heavy exertion or exercise for 3 days post-op and then gradually increase activity as tolerated. Increase your activity level as tolerated.

Sutures (stitches) may have been used to repair the surgical site.  They will generally dissolve in 5-7 days.  However, it is common for the sutures to loosen or become dislodged in 2-3 days or remain beyond 7 days; this is acceptable and should not be cause for concern.

A white area will likely form near the surgical site. This is part of the normal healing process and does not constitute an infection.

After an extraction, the tooth socket (hole in the jaw) will remain open for 4-6 weeks. This is part of the normal healing process. Keep the socket clean of food particles by rinsing it with water after each meal until the socket is closed.

Probiotics have been used to re-establish the normal consistency of bacteria in the gastrointestinal tract (stomach and intestines) and vagina. Antibiotics kill bacteria but don’t discriminate between “friendly and “unfriendly” microorganisms, so the balance between good and bad bacteria in the intestines and vagina can be upset, resulting in diarrhea or vaginitis. Taking probiotics helps restore the healthy balance of bacteria. While taking an antibiotic, you may choose to take a probiotic and use it as directed on the product packaging for at least one week after finishing the antibiotic.

If you have received any sedative or general anesthetic for your oral surgery, do not drive any vehicle or attempt any hazardous tasks on the day of surgery.

Many surgical procedures require the use of Opioid pain medication post-operatively which can make you drowsy and alter your mental status, therefore, do not drive while taking such medicine.

While complications after oral surgery procedures are extremely low, be on the look-out for:

  • Cardinal signs of infection:
    • escalating pain beyond 3-5 days,
    • escalating facial swelling and redness beyond 3-5 days.
    • Fever over 101 degrees, chills, malaise,
    • Foul-tasting discharge from the surgical site
    • Persistent swelling or redness around the implantation site
  • Numbness or altered sensation of the lower lip and or chin that has not resolved by 12 hours after your procedure.

Post-Operative Pain Management Directions

  • Use the prescribed medication as directed below for pain.
    • If you take Motrin (ibuprofen) prior to surgery, then take your next dose 6 hours later and continue on a schedule every 6 hours.
    • In addition, start taking Tylenol 325mg-500mg (as directed by your doctor). For the medicine to work effectively, continue this combination every 6 hours on a schedule.
    • Use the combination of Mortin/Tylenol on a regular schedule for at least 3-5 days post or as needed beyond this time frame.
  • The local anesthetic should wear off around 2 hours after surgery. However, this is quite variable.
    • If you did NOT take Motrin prior to surgery, we recommended your first dose of Motrin and Tylenol before the anesthetic wears off to help control postoperative discomfort more effectively.
  • Please note that a tolerable baseline level of pain is acceptable to help modulate activity and protect the surgical site.
  • The following are safe and effective step ladder approaches to pain control:
    • Acetaminophen/APAP (325 or 500mg)
    • Ibuprofen (400-600mg mg per capsule/tablet) or substitute Aspirin (ASA) 325mg
    • Take the medications individually or in combination every 6 hours.
    • If you experience breakthrough pain with the Motrin/Tylenol regimen, take the prescribed narcotic/opioid medication (Percocet/hydrocodone) as directed for pain that is not controlled by the regimen above. When you have achieved effective pain control, step back to the Motrin/Tylenol regimen as soon as practical.
    • Please note that most narcotic formulations have 325mg of acetaminophen (Norco has 325mg of acetaminophen). Therefore, factor that in when calculating your maximum daily dose of Tylenol (acetaminophen).
      • Please note: The maximum daily healthy adult dose</strong of acetaminophen (Tylenol) is 3000-4000mg under the healthcare provider’s direction. The maximum daily healthy adult dose of Ibuprofen is 3200mg.
    • You may electively use Arnica cream, which helps reduce postoperative bruising and swelling. Apply to the skin over the surgical site 3-4x daily (do not apply intraorally).

Post-Procedure Antibiotic Directions

  • If you were given an antibiotic, please take it as directed on the prescribed schedule until all the medication has been taken.
  • Please consider taking a commercial over-the-counter Probiotic. Use as directed on the package insert while taking the antibiotic to help promote digestive health. Continue for at least one week after finishing the prescribed antibiotic.
  • If you are experiencing stomach cramps or diarrhea, discontinue the antibiotic and call your doctor.
  • Antibiotics can sometimes render birth control pills less effective. If you have been prescribed an antibiotic and you are on birth control pills, use an additional method of contraception for the remainder of your current menstrual cycle.

Important Opioid Safety Tips

  1. Never take an opioid pain reliever unless it is prescribed for you.
  2. Always take opioids as directed. Do not take more opioids or take it more often than is prescribed for you.
  3. Do not use opioids with alcohol or other drugs unless approved by your prescriber.
  4. Protect and lock up your opioids in a safe place at all times, and properly dispose of leftover medicine.
  5. Never share opioids with another person; it is illegal and very dangerous.
  6. Opioid use can have several potential side effects, such as Constipation, itching/rash, nausea/vomiting, sleepiness/dizziness, and addiction…
  7. The following are signs and symptoms of a potential opioid overdose: Loss of consciousness, limp body, shallow breathing, choking, small-pinpoint pupils, Pale/blue/cold skin, slow heart rate…
  8. If you see someone exhibiting any of these symptoms, dial 911 immediately. For Suspected Opioid overdose: For nasal dosage form (Narcan® spray): Adults and children—At first, 4 milligrams (mg) (1 spray into one nostril). Another spray may be given into the other nostril every 2 to 3 minutes until the patient responds or until emergency medical assistance becomes available.

Guidelines for Drug Disposal

Follow any specific disposal instructions on the drug label or patient information that accompanies the medication. Do not flush prescription drugs down the toilet unless this information specifically instructs you to do so. Take advantage of community drug take-back programs that allow the public to bring unused drugs to a central location for proper disposal. Call your city or county government’s household trash and recycling service (see blue pages in the phone book) to see if a take-back program is available in your community. The Drug Enforcement Administration, working with state and local law enforcement agencies, is sponsoring National Prescription Drug Take Back Days throughout the United States. Drug disposal center 5350 2nd St NW, Phone: (505) 823-4200.  If no instructions are given on the drug label and no take-back program is available in your area, throw the drugs in the household trash, but first, take them out of their original containers and mix them with an undesirable substance, such as used coffee grounds or kitty litter. The medication will be less appealing to children and pets and unrecognizable to peo­ple who may intentionally go through your trash. Put them in a sealable bag, empty can, or other container to prevent the medication from leaking or breaking out of a garbage bag.  Before throwing out a medicine container, scratch out all identifying information on the prescription label to make it unreadable. This will help protect your identity and the privacy of your personal health information.  Do not give medications to friends. Doctors prescribe drugs based on a person’s specific symptoms and medical history. A drug that works for you could be dangerous for someone else.  Talk to your healthcare provider or pharmacist when in doubt about proper disposal.

It is our desire that your recovery be as smooth and pleasant as possible. Following these instructions will assist you, but if you have questions about your progress, please call the office at Oral and Maxillofacial Surgery Associates (OMSA) Office Phone Number 505-881-1130 during regular office hours. After office hours, please follow the voicemail prompts to reach Dr. Candelaria.  Calling during office hours will afford a faster response to your question or concern.

PLEASE NOTE: Requests for narcotic/opioid painkillers cannot be taken over the phone or called into a pharmacy and will only be considered following an office visit during business hours.

A Professional association devoted to the practice of Oral and Maxillofacial Surgery (2-24)