Gentle Healing

Preparing for post-operative pain is a gesture that patients deeply appreciate.

Feb 1st, 2004

by Debra Seidel-Bittke, RDH, BS

"Pain,"
"hurt,"
and
"rough"

are words that dental hygienists hear all too often. Who would have thought that in the 21st century the field of dentistry would still be confronted with patients who describe their dental experiences as "painful?" It's time for the dental hygiene profession to boost its armory of pain-reducing procedures and products.

The fear of pain overwhelms, controls, and drives people to neglect their oral health. The first step in reducing feelings of pain is to ask patients, especially those who have avoided the dental office for years, why they have stayed away for so long. It is critical that the practitioner reviews not only the patient's medical history, but also the patient's dental history and takes into account their total well-being. It is important for practitioners to be empathetic and show we care!

Just as with tonsillitis, appendicitis, and gastritis, the disease processes we encounter daily — gingivitis and periodontitis — are inflammatory conditions. For a person with tonsillitis, swallowing is very painful. Hygienists should, therefore, inform their patients that they have a moderate to severe disease process and that any chronic inflammation in the body can result in sensitive, tender, and swollen tissues. If you effectively explain to your patients the reason why a procedure may leave them sore, or why you want to apply a pain-relieving medicament, or follow an at-home regimen, your office will not be receiving phone calls from irate patients saying they never want you to "clean" their teeth again.

Let the patient know you care by explaining pain, not ignoring it. When patients know you have addressed the problem upfront, and know what to expect, they will respond with a "thank-you" instead of, "She hurt me!"

The use of a pleasantly flavored topical gel may be just the ticket for slight to moderate gingivitis, as well as those who are just a bit overdue for a prophylaxis. This helps to avoid that call saying, "She was rough!" or "I want to see a different hygienist."

Some of the dental procedures that may cause patients pain and/or fear include surgical extractions, endodontic treatment, periodontal surgery, scaling and root planing, and regular dental hygiene appointments.

It is considered the standard of care to provide treatment of periodontal disease by scaling and root planing procedures. Sometimes a chemotherapeutic agent is indicated, and this can also contribute to the healing process.1

So what can hygienists do to ease the post-operative pain our patients so often experience (and after which they remain absent from the dental office for years)? The following are a few remedies you may already use in your daily practice and some that may be new to your dental practice.

Over-the-counter products

There is, of course, the typical "old school" remedy of warm salt-water rinses. But, for the past 20-plus years, some of us have been using products such as Colgate Peroxyl Rinse® or Colgate Peroxyl Gel® by Colgate Pharmaceuticals or Glyoxide® distributed by SmithKline Beecham. Colgate Peroxyl Rinse contains 1.5 percent hydrogen peroxide and also contains 6 percent ethyl alcohol. The hydrogen peroxide helps debride the gingival tissues, helps soothe oral irritations, and promotes healing. This is also available in a smaller size to send home with your patient after that dreaded and often difficult hygiene appointment.

Colgate Orabase Gel® soothes and heals mouth irritations and contains 20 percent benzocaine. For patients who experience increased pain, this is very helpful — not only because of the anesthetic properties but also for the protective barrier that lasts for hours on the affected area. Colgate Soothe and Seal® is also a nice post-operative product for hygiene patients, but it doesn't contain benzocaine.

Glyoxide contains 10 percent carbamide peroxide, anhydrous glycerol, and citric acid. Carbamide peroxide (also known as hydrogen peroxide) is used as an antiseptic agent and also helps get things "whiter." Anhydrous glycerol promotes healing and helps to reduce swelling. Think of citric acid as a shot of vitamin C for your patient. This product can be purchased in half-ounce bottles to be used in the office at the time of the appointment.

Prescription products

Gelclair™ is a new post-operative care product that will help relieve pain due to mouth sores, apthous ulcers, mucosititis, tissue trauma, abrasions, irritations, and/or various dental diseases. Gelclair adheres to and coats the inside of the patient's mouth and provides a barrier that protects tissue from further irritation. When a hygienist offers Gelclair to a patient at the end of a particularly difficult hygiene appointment, he or she can become a hero to that patient. The product has been available since 2002. This is the perfect way to let your patient know that you "care enough to give the very best."

The hygienist just empties a package of Gelclair into a cup and adds one tablespoon of water. The patient swishes for about one minute to coat the oral mucosa and leaves the office with a pleasant feeling in the mouth, not to mention the healing properties that begin to take effect. A prescription can be written for the patient to have on hand for use after subsequent visits.

Gelclair is a bioadherent oral gel that provides a protective coating over the exposed nerve endings and provides rapid oral pain relief. The product has an appealing light licorice taste.

It is important to note that patients who have high blood pressure are not to use this product because licorice is known to raise blood pressure.2

The "gold standard" of care is the use of 0.12 percent chlorhexidine gluconate pre- and post-operatively.3 This has been used for more than a decade as a post-operative product. It is scientifically proven to promote healing and kills all bacteria.

It is imperative that we discuss with our patients the use of antimicrobial rinses, as well as recommend a chemotherapeutic agent, such as minocycline or doxycycline, during periodontal treatment. These procedures promote pocket reduction and reattachment in the gingival crevices.

Furthermore, if a patient notices an increase in pain in the three days following a dental appointment, he or she should immediately contact the office.

It is not usual for a patient to need a prescription for an analgesic such as Vioxx or Vicodin, but it can be necessary at times. These prescriptions help reduce pain and/or reduce inflammation.

Although you may be a very skilled hygienist, it is important to know when to advise a patient that you can't complete his or her treatment in a single appointment. Possibly the patient has missed numerous regular maintenance or continuing care appointments.

It is also possible that a diagnosis of periodontal disease is being made for the first time. With the use of a mirror, you can show the patient areas of inflammation and explain that this is what prevents you from getting to the base of the pocket to assure complete removal of calculus.

This is a perfect time to communicate the important need for oral preventive measures at home on a daily basis. It is a time for patients to feel the responsibility and motivation to care for their own mouths.

The object of the dental hygiene appointment is to meticulously remove calculus, bacteria, and stain from the teeth and to rid the mouth of persistent bleeding and inflammation. Explain that bleeding reduces your visibility and the gum tissues require healing time. This discussion often soothes a patient's fear of pain as the hygienist explains the need for this healing time and subsequent appointments.

It is imperative that dental hygienists have written procedures to give to the patient for post-operative care. See the related article for a suggestion.

There is much we can do to let our patients know we care about the way they feel in our office. For some patients — often the ones that haven't let on that they are uncomfortable — if we take the time to offer them a pain-relieving medicament, gel, or prescription, they will leave happy. A happy hygiene patient means a happy hygienist!


A helpful hygiene tip

Carbamide peroxide is the main ingredient in most bleaching products these days. Add a few drops of the Glyoxide® to your prophy paste while polishing. Not only will this help to heal inflamed tissues, but it will also help to remove tenacious stain. These are common conditions often found in the mouth of an overdue patient.

This slurry, which is easily mixed, causes the patient's mouth to feel silky clean and the patient gains an added value to their hygiene appointment. Hopefully, any negative thoughts about the dreaded dental hygiene visit will be soon forgotten.

Oxyfresh makes a gel that contains two plant derivatives — aloe vera and chamomile. Aloe vera is known for its healing properties and chamomile is known to soothe wounds. The Oxyfresh™ Aloe Vera Gel also contains chlorine dioxide, which has antimicrobial properties. Chlorine dioxide in a topical gel, along with high quality aloe, provides some significant benefits in addition to being an antimicrobial agent. Chlorine dioxide is very effective in oxidizing bacterial metabolic byproducts, such as volatile sulfur compounds. Chlorine dioxide keeps the gingival tissues clean and the aloe soothes the gingival tissues and encourages healing. Aloe has been an accepted agent in promoting healing since ancient times.1


Post-operative care instructions

After your appointment today, your gums may feel tender.

Please follow these instructions for best results:

• Avoid spicy foods, hard foods, popcorn, berries or foods with seeds.
• Eat a soft diet for the next 48 to 72 hours.
• Avoid the use of tobacco.
• Take Advil, Motrin, or Tylenol (ibuprofen or acetaminophen) every four hours.
• The following products may be used to rinse with or applied to irritated areas: Glyoxide Gel®, Peroxyl®, or warm salt water rinses*.

If using a fluoride gel, apply this after using the rinse.

*Please note that people on a salt-restricted diet or who have high blood pressure should not rinse with warm salt water.

Debra Seidel-Bittke, RDH, BS is president of Dental Practice Solutions. She is an international speaker and consults in dental offices throughout the United States. Debra is also a guest lecturer at the University of Southern California Dental School. You may contact Debra at (949) 215-9072 or at debra@dentalpracticesolutions.com. For upcoming CE courses, go to www.dentalpracticesolutions.com.

References
1. Melvin S. Babad DMD Using A Chloride Dioxide Gel for Soft Tissue Healing, Dentistry Today Vol. 18 No. 6 June 1999
2. Department of Polymer Science University of Mississippi. 1995,1996
Web site accessed on August 21, 2003 www.psrc,usm.edu/macrog/nvp.nt.
3. B.B. Beiswanger et al. Clinical Effects of a 0.12% Chlorhexidine Rinse as an Adjunct to Scaling and Root Planing 1992 J. Clin Dent

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