Like many other treatments, implant treatment is a complex therapy. Many participants may be involved including the dentist, surgeon, prosthodontist, dental nurses and, of course, the patient. It is not enough that the team should be very skilled in performing the treatment, but patients, too, must take responsibility for their part in the treatment. This module will describe how the dental team prepares patients to participate in implant surgery and instructs them on how to behave before and after the surgery to avoid complications and negative side effects. This includes preoperative information including instructions for oral hygiene procedures and medication as well as postoperative care and the postoperative medication regime.

After completing this ITI Academy Module, you should be able to inform the patient about the surgical procedure, including preoperative oral hygiene, indicate the most appropriate preoperative medication, describe the postoperative care and behavior, including oral hygiene, and indicate the most appropriate postoperative medication.

When the decision has been made to place an implant, it is time to provide the preoperative information to the patient to ensure a satisfying result to the implant surgery. It is important that the patient understands that infection control prior to implant insertion is a prerequisite to ensuring uneventful healing in the short and long term. The patient should also be informed about the most common postoperative precautions. On the day of surgery, the patient should have a normal meal before arriving at the office. After that oral hygiene must be performed by brushing and flossing the teeth. Just before implant placement the patient should be instructed to rinse with chlorhexidine. Regular medication must be taken as normal or as agreed upon with the surgeon. Implant treatments carried out using an appropriate aseptic technique rarely result in infections. As such, the routine use of antibiotic prophylaxis for surgical implant procedures is not indicated. However, due to medical reasons some patients will need treatment with antibiotics taken 1 hour before surgery. If the surgeon is in doubt the patient’s physician should be consulted. Some patients may be instructed to take a corticosteroid and a non-steroid anti-inflammatory drug in order to reduce the inflammatory response that will occur due to the surgery. The patient should understand that reducing this inflammatory response helps to control postoperative pain, swelling and trismus. It should be stressed that use of corticosteroids is recommended for major implant surgeries only.

On the day of the surgery, the surgical procedure should be explained to the patient before starting. This includes information on the following aspects: The implant placement is performed under aseptic conditions. This means that the patient will be covered with surgical drapes. A local anesthetic will be administered and the surgery will not start before the local anesthesia has taken effect. Patients should not feel any pain during the procedure but they may experience pressure and vibration from the drilling. Saline water will be used for cooling and suction will be used to remove the water from the mouth. If the patient has questions or needs information during the procedure, this will be provided by the surgeon. In some practices patients can bring along music, which can provide a distraction during the surgical procedure and muffle the noise from the drilling. After the implant is placed, the area will be sutured and often a radiograph is also taken.

Finally postoperative instructions are given to the patient. Patients should know that they must limit their physical activities on the day of surgery as well as on the following day. They need to follow the instructions for medication to control postoperative pain. They should eat a soft diet and drink sufficient liquid after the surgery. To ensure uneventful healing, postoperative oral hygiene is mandatory. Daily cleaning can continue but care should be taken not to brush in close contact to the affected area. After a week the operated area can also be brushed. In addition, rinsing twice a day with chlorhexidine can be recommended. After providing all this preoperative information, the patient is ready for implant surgery.

Preoperative Information, Key Learning Points: Preoperative information is a prerequisite to ensure optimal healing with the patient’s cooperation. Preoperative information aims to educate patients about the surgical procedure and postoperative care. Preoperative oral hygiene is essential to minimize the risk of postoperative complications.

Infection control before, during and after surgery is mandatory in order to ensure uneventful healing of the implant site. Before surgery, adequate infection control is a must. The periodontal tissue must present without any pathology. On the day of surgery thorough oral hygiene must be performed by the patient. There is no strong scientific evidence that preoperativ treatment with antibiotics prevents infection and thereby prevents implant failure. Despite this, it is common practice to administer prophylactic antibiotics as a single dose treatment one hour before implant placement. Amoxicillin or - in the case of a penicillin allergy - clindamycin are usually used. Since the recommendations for dosage of prophylactic antibiotics may differ from country to country, clinicians should refer to local guidelines. They should also make their own judgment about the need for systemic antibiotics to further prevent postoperative infection. In combination with the antibiotic treatment, aseptic procedures must be used and thorough postoperative oral hygiene must be performed by the patient.

Corticosteroids are naturally produced by the adrenal cortex and play a major role in the reduction of the inflammatory response. This anti-inflammatory response is desirable in a clinical setting, when excessive inflammation after implant surgery causes postoperative swelling, pain and trismus. A short-term treatment with corticosteroids such as methylprednisolone has been reported to control pain, trismus and swelling when given to healthy subjects preoperatively to extraction of mandibular third molars. It should be noted that the pain that potentially arises after the removal of mandibular third molars is normally much more severe than the pain occurring after placement of a single implant. Prolonged administration of corticosteroids, however, is associated with bone loss. It is assumed that glucocorticoids play a regulatory effect in the activation of osteoclasts to increase bone resorption. This may affect the osseointegration of implants even after short-term use. The use of corticosteroids should therefore be limited to major implant surgeries like bone grafting procedures and multiple implant placement. If corticosteroids are used they should be given one hour prior to implant placement and continued only for the first one or two days after surgery.

Preoperative Medication, Key Learning Points: If it is determined that antibiotic prophylaxis is indicated, a single dose treatment of amoxicillin 1 hour before implant placement is recommended. Clindamycin can be recommended if the patient is allergic to penicillin. A short course of corticosteroids may have a limiting effect on postoperative pain, swelling and trismus but its use should be limited to major implant surgeries. If corticosteroids are used, they should start 1 hour before surgery and continue for up to 2 days postoperatively only.

Once the implant has been placed, patients should be given instructions on how to behave and take care of themselves for the remainder of the day of surgery and for the days to come. Postoperative instructions should predict what patients are likely to experience, why these phenomena occur and how to manage the typical postoperative side effects. The instructions should be given verbally and in written form. The written version should include a phone number at which the surgeon can be reached in case of questions. To make sure that patients have understood all the information given, it is beneficial to phone them on the first day postoperatively. This will ensure that patients follow the instructions and will make them feel more secure.

Postoperative bleeding is not very common after implant surgery. However, there can be some oozing from the wound. The patient should be informed that this is expected and that it can be treated by firmly biting on a moistened gauze placed over the wound area for 30 minutes. Oozing may continue for approximately 24 hours. The patient must avoid activities such as smoking, spitting and drinking by means of a straw. Such activities may aggravate bleeding since negative pressure is created and the wound is irritated mechanically. No strenuous exercise should be taken for the first 24 to 48 hours after implant placement, because the increased blood pressure may result in bleeding. In some patients blood oozes submucosally and subcutaneously, which appears as a bruise in the oral tissues or on the skin. These bruises, termed ecchymosis or hematoma, often appear on the second postoperative day. Patients should be instructed to cool the area by applying ice packs, bags of frozen peas or gel packs extraorally to prevent or reduce bruising. Patients on antithrombotic and anticoagulant medication should be followed carefully because of the increased risk of bleeding. They should be informed that postoperative bleeding can be prolonged and severe. Such patients may benefit from a gauze compress soaked in tranexamic acid. Clinicians should refer to local guidelines for the concentration. Additional mouth rinsing with tranexamic acid four to six times daily for two to three days after surgery may be indicated, depending on the bleeding tendency.

Most surgical procedures result in a certain amount of edema or swelling after the surgery. Reflection of the soft tissue and preparation of the implant site in the bone will induce an inflammatory reaction. This inflammatory response in combination with hemodynamic changes such as vasodilatation are responsible for the swelling. Swelling usually reaches its peak 24 to 72 hours after implant placement. It begins to subside on the third or fourth day and is usually resolved by the end of the first week after implant placement. Increased swelling after the third day may indicate an infection rather than postsurgical edema. Application of ice packs, bags of frozen peas or frozen gel packs to the area may help to minimize the swelling and make the patient feel more comfortable. A damp cloth should be placed between the ice pack and the skin. The ice pack should be applied locally for 10 minutes followed by a rest period. The patient should be advised that cooling for longer time periods may be advantageous. However, it may not be practical to recommend application of ice packs after retiring for the night. The cooling effect on the swelling is likely to fade on the second postoperative day but will still have a mitigating effect on the area for the next couple of days. Trismus or limitation in mouth opening is the result of an inflammation involving the muscles of mastication. The trismus may be caused by the injected local anesthetic, especially if the injection has penetrated muscles. Trismus is usually not severe and does not hamper the patient's activity even though eating can be more difficult. The trismus should fade after a week.

A patient who has undergone implant surgery may avoid eating after surgery because of local pain or fear of pain when eating. The patient should be informed that nutrition is an important factor for postoperative healing. The patient should avoid chewing and hot drinks until the effects of local anesthesia have worn off completely. In the meantime the patient is allowed to take cold drinks. Solid food tends to cause local trauma or initiate rebleeding episodes. If the patient is not able to chew on the contralateral side maybe due to multiple implant placement, a liquid high-calorie and high-volume replacement diet should be taken for the first 12 to 24 hours. The patient should be advised to return to a normal diet as soon as possible.

To achieve uneventful healing at the implant site, a high level of oral hygiene must be ensured. On the day of surgery the patient is allowed to gently brush the teeth that are located a sufficient distance from the implant site in the usual fashion. However, the patient should avoid brushing the surgical area and the teeth immediately adjacent to the implant site to prevent new bleeding and pain. On the following day the patient can start to gently rinse with chlorhexidine. In addition, the implant site and the adjacent teeth can be cleaned using a cotton bud dampened with chlorhexidine. After a week, brushing of the implant site can begin using a very soft tooth brush dampened with chlorhexidine. Some patients wear a prosthesis or temporary prosthesis. The surgeon must inform the patients when they are allowed to wear these prostheses again and how to clean the prostheses. Many surgeons instruct the patient not to wear the prosthesis before the sutures are removed. However, in some cases this can be very difficult for the patient for psychological reasons. It is important that the patient return for a postoperative appointment after 1 week to monitor healing and oral hygiene and after 2 weeks to remove sutures.

Postoperative Care, Key Learning Points: Postoperative information is important and should be given both verbally and in written form. The surgical procedure will induce an inflammatory response, which is in part responsible for many of the postoperative side effects. Potential postoperative side effects include bleeding, swelling and trismus. Sufficient nutrition is a prerequisite for healing. Oral hygiene is essential to allow short and long-term healing of the tissues. Transitional prosthesis should not interfere with wound healing. Postoperative recall visits include control of oral hygiene and removal of sutures.

Implant placement is a surgical intervention and will provoke tissue damage. This tissue damage will activate nerve receptors or nociceptors and will provoke the release of inflammatory mediators from circulating leucocytes and platelets, from vascular endothelial cells, from immune cells resident in the tissue and from cells in the peripheral nervous system. Many cytokines and other mediators have been identified to directly induce hyperalgesia. Other inflammatory mediators are believed to induce hyperalgesia indirectly by activating other cells, such as the sympathetic postganglionic neurons or neutrophils. Some inflammatory mediators are believed to lower the thresholds of nociceptors. Among those are prostaglandins, serotonin and adenosine.

Postoperative pain in implant surgery is characterized mainly by inflammatory pain. Prostaglandins play a specific role in the inflammatory process: Inhibition of prostaglandin synthesis not only eliminates the direct hyperalgesic action of these mediators, but also decreases the sensitizing effect of other inflammatory mediators. Non-steroidal anti-inflammatory drugs or NSAIDs are the most commonly used analgesics for the treatment of inflammatory pain because their primary action appears to be the inhibition of prostaglandin synthesis.

The management of surgical dental pain is accomplished by three general mechanisms: Nociceptive impulses along the peripheral nerve are blocked by administration of a local anesthetic in the vicinity of the relevant nerve. A long-acting local anesthetic such as bupivacaine is recommended for multiple implant placement and for bone grafting procedures because the postoperative period of such major surgeries is considered to be more painful than that of a single implant placement. Before the anesthetic effect has worn off the patient should be treated with NSAIDs to reduce the nociceptive input from the site of injury. The treatment should start before or soon after the implant surgery has concluded. The perception of pain in the central nervous system can be inhibited by the use of a long-acting local anesthetic in combination with an NSAID. Postoperative pain of moderate to severe intensity may nevertheless affect some patients after major implant surgeries. In these cases, the use of drugs that inhibit the nociceptive transmission to the central nervous system has been proposed. Opioids are generally prescribed for this indication. Their use relieves acute pain but is accompanied by a high incidence of side effects such as nausea, vomiting and drowsiness. In addition, there is a risk of addiction in relation to long-term use of opioids. Relatively high doses of opioids are needed to achieve an analgesic effect.

Non-opioids should be used for mild to moderate pain after surgery and should be used in combination with drugs for more severe pain. Paracetamol/acetaminophen presumably exerts its analgesic action in part by inhibition of cyclooxygenase enzymes - termed COX - in the central nervous system. These enzymes are responsible for the synthesis of pro-inflammatory cytokines. The usual analgesic dose of paracetamol/acetaminophen is 650 to 1000 milligrams every six to eight hours according to the severity of the symptoms. Overdoses can lead to subacute hepatic necrosis. Therefore care should be taken not to raise the dose of paracetamol beyond four grams per 24 hours. In cases of moderate to severe pain, paracetamol/acetaminophen can be replaced or combined with NSAIDs.

NSAIDs are drugs with anti-inflammatory, analgesic and antipyretic effects. Ibuprofen is one of the most widely used NSAIDs for pain control in implant surgery since it seems to have the most favorable risk-benefit profile. Ibuprofen has demonstrated analgesic activity in a dose range of 200 to 800 milligrams and has a duration of effectiveness of four to six hours. So patients should be instructed to take a tablet every six to eight hours. Ibuprofen is frequently prescribed alone or in combination with paracetamol/acetaminophen. Well-known complications of non-specific NSAIDs are gastrointestinal side effects. The risk of gastrointestinal complications increases with advanced age, comorbidities, history of previous gastrointestinal events and the use of anticoagulation. Questions have been raised about the impact of NSAIDs on osseointegration. The use of NSAIDs may impair bone healing at the cellular level as shown by in vitro and animal studies. However, the clinical literature on this topic is controversial. So far NSAIDs are still recommended for pain control after implant surgery.

Caution should be used when prescribing nonsteroidal anti-inflammatories in patients with a history of asthma. Anti-inflammatory medications have been reported to induce or exacerbate asthma attacks in sensitive individuals. Caution is also recommended in patients with a history of gastric ulceration, who may have bleeding issues following use of these drugs. Nonsteroidal anti-inflammatories have also been noted to increase the risk of heart attacks and strokes. Care should be taken in using these medications in patients with other risks factors for these conditions. Some medications when taken together with NSAIDs can increase the risk of side effects. NSAIDs have anticoagulant effects, so concomitant use with other anticoagulants such as warfarin should be avoided. NSAIDs interact with angiotensin converting enzyme inhibitors (commonly known as ACE inhibitors) and angiotensin II receptor blockers, resulting in increased risk of renal damage and renal insufficiency. They can also reduce the renal response to diuretics.

Considering the advantages and disadvantages of the different drugs, the recommended treatment of pain occurring after implant placement is an NSAID such as ibuprofen. If necessary this can be combined with paracetamol/acetaminophen. If this combination is not sufficiently effective it can be supplemented with an opioid for a short period of time.

Postoperative Medication, Key Learning Points: Postoperative pain in implant surgery is mainly inflammatory pain. Prostaglandins play a specific role in the inflammatory process. NSAIDs inhibit prostaglandin synthesis. Treatment with analgesic drugs must start before surgery or soon after. Ibuprofen alone or in combination with paracetamol/acetaminophen is recommended.

Module Pre- and Postoperative Care and Medications for Implant Surgery, Summary: Preoperative information is important as it allows optimal healing due to the patient’s cooperation and knowledge of how to behave. Preoperative and postoperative oral hygiene is a prerequisite for uneventful postoperative healing. Routine use of antibiotic prophylaxis for surgical implant procedures is not advised. If for some medical reason antibiotic treatment is used it is recommended as a single dose treatment of amoxicillin one hour before implant placement. Clindamycin is recommended in cases of penicillin allergy. Corticosteroids may reduce postoperative pain, swelling and trismus but should only be used for major implant surgeries. Postoperative information for the patient is important and should be given both verbally and in written form. Treatment of pain should start before the effect of local anesthesia disappears. NSAIDs such as ibuprofen alone or in combination with paracetamol/acetaminophen are recommended for the treatment of pain but potential side effects should be taken into consideration.