Eating for oral surgery

Eating after dental work is hard.  You have balance total calories, protein, vitamins, and other nutrients against pain, stress, and a limited capacity to chew.  In my case, you have bonus digestive track issues.  In the hopes that this could be useful to someone else about to undergo oral surgery, here’s a list of recipes and tasks to help.

 

Before Surgery

  1. Find a protein powder you like with a neutral taste.  I use Thorne MediClear because it’s what my doctor recommended.  Before I found out I was sensitive to milk and eggs I used MLO Milk and Egg Powder.  A lot of supplements use soy.  Soy is a great thing to eat in small doses, but it contains xenoestrogens, so be wary using it as your main source of protein.  
  2. The neutral taste is because we’re going to be mixing that powder in with other things.  If you’d like to just drink some protein, consider finding a shake or a flavored powder as well.
  3. Figure out what vitamin supplements you need, and if your protein powder contains them.  This can be very specific to you and your surgery, so ask your doctor.  Mine put a special emphasis on omega three fats (because I have nerve involvement), so I picked up a fish oil supplement.  Post surgery, I’ve also found myself craving iron (which makes sense, since my red meat consumption was low to begin with and is now lower) and Diindolylmethane (DIM).  DIM is a compound found in Cruciferous vegetables like broccoli and brussel sprouts that activates several liver enzymes that can aid in removing toxins from the body; my conjecture is that the surgery and recovery are generating a lot of waste products and this is helping to clear them.  Obviously eating the real vegetables is ideal, but I only have so much chewing in me.
  4. Make stock.  As usual you can throw in whatever you want, but my usual recipe is onions, garlic, ginger (a stomach settler), maybe some spinach, bones (which have meat + marrow still on them), and organ meats.  My dentist loved this idea particularly for the healthy fats.  Freeze the stock before surgery so you can dole it out afterwords.
  5. Make juice.  Ideally, have a friend with a juicer so you can make several Tupperware containers worth of juice from the materials of your choice.  You really can do whatever you want here: the difference in value between produce is so much smaller than the difference between eating it and not that you should optimize for what you’ll drink the most of.  Do try and get a variety, both because it’s healthier and because you will get sick of any one thing really fast.
  6. Find a comfort food that doesn’t require chewing.  I used fudge.  Ice cream is an excellent choice if you eat dairy.
  7. If you plan on taking pain meds, and you should, talk to your doctor about supporting your digestive track.  NSAIDs can do a real number on your stomach especially when it’s empty, which it will be because eating is work.  I was taking so much naproxen before my surgery that I developed serious stomach pain, and had to take some support vitamins.

During recovery

  1. DO NOT USE A STRAW.  I love straws more than anyone older than 7.  In this situation straws look like your friends because they let you consume liquid with less work and keep it away from your surgery site, but it is a dirty, dirty lie.  The suction can dislodge the blood clot protecting your surgery site (the infamous dry socket complication of wisdom tooth removal).  They tell you this is extremely painful, but what they don’t mention is that it also leaves the surgery site vulnerable to infection, requiring many painful and exhausting surgeries to correct.  Learn from my example
  2. Take your pain seriously.  We have a tendency to try and tough out pain, or dismiss it as unimportant.  It’s not.  First, your suffering matters.  Second, pain is extremely disruptive to the healing process.  It makes it hard to eat and sleep.  Third, fear of pain will slow your recovery.  Right after surgery, a lot of activities will hurt you, like eating and talking and in my case, breathing.  It is healthy to restrict those activities for a while (except the breathing, although I did try).  But it is not healthy, physically or emotionally, to hold yourself rigid and withdrawn because you don’t know if you’ve healed enough to do something.  The availability of pain relief can enable you to take more chances, which ultimately leaves you healthier.
  3. Alternate comfort food with one of the medical foods.  For example, I would take a long sip of stock (possibly mixed with protein powder), and then a bite of fudge.  This wasn’t just a bribe or a comfort: the fudge triggered my brain to recognize that I was eating and it should take steps to digest it, and the stock got caught it the cross fire.  This let me eat a lot more medical food than I would have otherwise.  

The recipes

  1. Bone stock + water, salt, and protein powder to taste.
  2. Juicer juice + water, salt, and vitamins.  At a gut level I feel like protein goes with stock and vitamins go with juice, but your gut may vary.
  3. Oatmeal + protein powder + sweetener. It is filling, requires minimal chewing, and gives you protein.  
  4. Oatmeal + nut butter.  Like above, but with one fewer steps.
  5. Congee.  The base recipe is to boil rice for four hours.  It is easy to chew and filling.  You can add some nutritional value by boiling it in bone stock instead of water, or by putting stock ingredients in the pot with the rice (which you remove before eating).  The texture is gross but I love it because I can feel the nutrition coming off it.  I have to toss the fat when I make bone stock because it’s just too gross, which has always been a shame because it has all the fat soluble vitamins, and is an extra shame in this case because my dentist wants me to get omega 3s so much.   With this I can let the rice absorb the fat, and get the vitamins from there.  I plan on continuing to eat this after I’ve healed.  Also, while the texture starts pretty gross, it does not get any more gross on reheating and it keeps for a surprisingly long time.
  6. Applesauce with protein powder.  Apples are actually not as nutritious as their PR would leave to believe, and applesauce doesn’t even have the fiber or skin.  But it’s a fruit, and you’re mixing protein powder in it, and that is good enough for now.
  7. Berries.  They’re relatively easy to chew, full of nutrients, and delicious.  

Pain, Concentration, and Achievement

The timeline is as follows:

  1. [unknown number of months]: oral pain increases steadily
  2. surgery removes source of pain.  Surgery itself or sheer disorientation leave nerve completely numb.
  3. Two blissful days in which I am completely exhausted but mostly pain free.
  4. Nerve function returns, leaving me to experience the pain of having a portion of my jaw scraped off.  Although actually very little of the pain is at the surgery site.  It’s more likely a compressed nerve due to the influx of blood and lymph

I feel like this has given me a natural experiment of the effect of pain on productivity and concentration, since the shifts were so sharp.

I went to sleep pretty much as soon as I got home from the dentist.  When I woke up 16 hours later, I grabbed the book on my bed and read.  Eventually I looked up, it was two hours later and I’d finished half the book.  I couldn’t remember the last time that happened.  I finished a book a day in the pain free period.  Reading had a sense of flow that I didn’t remember it having in years.  And some of those books were not amazing, but they were pleasant and I felt absorbed, which also hadn’t happened in a long time.  The same thing happened with video games- I was able to enjoy some fun low-brain games instead of something socially worthy like Mass Effect or Papers, Please.  I began to entertain the idea that I might one day play an RPG again.

In the last four days I’ve struggled with two books by authors I’ve enjoyed before.  I dropped one and only finished the other because I figured out what I’m about to tell you:it was impossible for me to have a sense of reading flow.  I’ve always been a little fixated on updating my progress on books on goodreads- down to a percent or two if I’m listening to a mediocre book on my bus commute.  Less in other cases, but present.  That disappeared with the pain, and came back with it too.

Productivity wise, I at least felt way more productive while I was exhausted-but-unpained.  I would watch an episode of TV, do one little chore, then take a three hour nap.  My apartment was actually trending upwards, and I was getting very high quality sleep.  In pain, I don’t sleep well, so I don’t have that burst of energy that lets me clean, so I don’t tire myself, so now both pain and jitters are keeping awake, so I’m spending a lot of time in a stupor accomplishing nothing, including healing.  I have more energy in the sense of “I can walk farther without collapsing”, but am ever so slightly losing to entropy.  I’m not physically incapable of putting my dishes away, and I notice that it needs to be done, just not when I have any reserves to do it.

Elodie Under Glass (no relation) has a guest post up on Captain Awkward about the low mood cycle.  It’s brilliant and you should read it on those merits, but the important point for my story is that humans can get in a cycle of not doing anything because they don’t have any motivation, and not having any motivation because they never get anything done.  She calls it the thought->behavior->outcome cycle.  That point where outcome feeds thoughts and make you feel better?  I call it getting a hit of Accomplishment.*  When I’m in this much pain, there is no hit. I have a few possible explanations speculations for this:

  1. Body has narrowed success criteria for all actions to “did you make the pain go away?”  Moving my dirty dishes in the dishwasher did not make the pain go away, therefor it was a failure, therefor no Accomplishment.
  2. Normally there’s a mini flow state between initiating the action and evaluating the outcome.  When in pain, that walk from the couch to the dishwasher is interrupted every half a second asking if I’m done yet, and registering a failure when I haven’t.  With a 10 second walk, that’s 19 failures to one success- and that’s assuming the washer can accept the dish with no further work, and I don’t see any additional failures in the kitchen to deal with.
  3. Some combination of these
  4. Okay I thought I had more but apparently those are the only two.  In my defense, it’s amazing I’m writing this well considering the level of pain I’m in.

Whatever the explanation, pain clearly is constantly pushing me towards the low mood cycle.  I can break out of it with a big enough Thing, but Things that big are impossible to sustain, leading the cycle to collapse back down to low mood.  One of the few things I’ve been able to sustain for long periods is working at crisis chat, because when people talk it’s a jolt of energy, but then there’s some down time before they respond.**

You may blame the lack of proper closing paragraph on my screaming jaw or the fact that this post is completely speculative.  Or feel free to substitute your own reason.  Ideally something flattering.

*I am going to feel very dumb if there’s an actual drug with the street name of Accomplishment.

**After a few hours at crisis center I came home and couldn’t leave the apartment for two days.  I think that’s an energy thing.

Nerve function has returned a good deal faster than the pain has receded.  In rather a lot of pain now.  Shiny feelings towards surgery decreasing rapidly.

Quick tip: medicinal straws and crazy straws

I don’t know if this helps the sensory issues or the digestive ones and I don’t care.  I was prescribed a medicinal crazy straw for the sensory integration issues.  The biggest mechanism of action is something something ear fluid pressure, but there are other, subtler ones.*  At this point I don’t know why it works and I don’t care: sucking on the crazy straw makes me feel better and less sensitive to noise.  Even if it’s a placebo effect, I can’t think of what damage I could possibly do to myself drinking through a crazy straw, so I’m not questioning it.

My bonus discovery was that straws seem to help with digestion/nutrient absorption too.  Most vitamin dosages are too high for me, so I spill some of the contents into water and drink that.  If I take too much, I get symptoms ranging from “stomach ache” to “vaguely icky.”  If I drink that water with a straw, I can take a higher dose (of anything) than if I drink the water directly.

My hypothesis is that sucking stimulates the “nutrients are incoming” reflex that chewing is supposed to, and thus my gastrointestinal system is more prepared to accept and use the bounty I am giving it.  This definitely falls under “plausible but not proven”, but it seems to be working for me.

*The sensory therapist was not good at Science, and I was in shock after doing the evaluation, so my recollection of her statements is not of much value here. 

Another easy one: video games for sensory integration disorder

There’s two goals that can be served by video games, or any other SID therapy.  One is long term improvement by teaching the body new patterns.  For example, you could put a patient on something that produced constant motion (like a horizontal swing) and vary the angle of their head.  This teaches their body how an given motion and angle feels in their vestibular canals, which they will recognize in the future (like when they’re on the subway), thus lessening the stress on their system.  This is the equivalent of rehab exercises after a knee injury.  The other is short term calming of a sensory system that’s in overload.  Once a person hits overload, even stimulus they could usually handle becomes painful, often making the overload worse.  This is awesome not only for the immediately obvious reasons, but because it returns a sense of control when you need it most.

I haven’t read anything official on this, but from a patient’s perspective, the difference between these is a matter of degree.  The ideal stimulus for the first is something novel enough that I’m gaining a new skill, but familiar enough that I can relate it to something I already know, and learn by analogy.  The ideal stimulus for the second is very familiar, because a large part of the goal is to return a sense of control.  But both benefit from coordinating multiple types of input (aural, visual, kinesthetic)- one because it gives a new pattern more places to hook in, the other because it makes input more predictable.

With that said, here’s a list of video games I have found that do either of these things.

Dance Dance Revolution (available on all consoles, and a grey market PC knock off): the original rhythm game.  DDR has you tap a dance pad with your feet in time with signals on the screen.  Technically, the signals don’t have to match up with the beat of the music, and sometimes they don’t on advanced music.  I refuse to play those levels.  DDR is great because it uses the whole body, teaching you where you are in space.  It also involves jumping, which my OT says helps reset the vestibular system.

Enjoy this video of a four year old boy being better at DDR than you will ever be.

Patapon (PSP): control a tiny army by typing patterns rhythmically.  Patapon is awesome because the rhythm is in service to a greater goal, it is progressive but allows you to replay old levels (so you can push yourself for long term therapy or play an easy level to treat acute dysregulation), and because they did a great job coordinating the visual, auditory, and even spatial cues (if you play with headphones the sound of a beat corresponds to where the button is on the controller) .  There’s a very subtle visual indicator for the “beat”, which was invaluable when I was starting out.  The PSP is portable, so you can take it to stressful things like say your job and use it to keep one bad thing from ruining your day.

Synthesia/playing an instrument (PC/flexible).  Instruments coordinate physical motion and sound.  If you’re starting from scratch the piano is a good choice because playing individual notes is easy (as opposed to wind or most string instruments, where just getting a note out is a challenge), but I may be biased because that was my mom’s choice of instrument for me as a child.  I hated it then, but as an adult playing pop songs of her choosing, I’m really enjoying it.  There is something really calming about getting the right note, the one that matches the song in my head.  Additionally, music is heavily tied into the emotional systems, and can provide a way to express or access feelings people (especially children, especially ASDers) have trouble expressing.

Synthesia is DDR for the piano.  The song selection is a little limited, which is why I haven’t bought it yet, but just watching the videos calms me down.

Synthesia’s not the only learn-to-play-piano software, and if you’re really interested it’s worth researching.  The right software/piano combination will even light up the keys for you.

Speaking of which: if you’re buying an electronic piano, you have a lot of choices over a very wide price range. The ones don’t actually sound that much worse, but the keys are way less satisfying.  They don’t resist properly, and the cheapest ones don’t even modulate based on pressure.  I got used to playing on the $2000 keyboards at work, which have very satisfying keys.  I wasn’t willing to spend that much, but I discovered that the learning Yamahas (at least the PSR E433 and E343) are a pretty good compromise.  Their keys don’t have the same heft to them, but their speakers vibrate the keys ever so slightly, which gives a different kind of feedback.  They also have displays showing you exactly which key you’re hitting, which is really helpful when you’re still learning to read music.

WiiFit/other Wii Balance board games (Wii): these were pretty meh for me, there wasn’t enough kinesthetic feedback.  But they are a great way to provide visual feedback on balance, if that’s your particular issue.

Guitar Hero/Rock Band (XboX 360/PS3): these fill the same niche as DDR and piano, but have never worked for me.  Guitar is too hard, drums are too easy, and no one will ever let me sing.

Thomas was Alone (PC, PS3, iOS, PS Vitae): A game about rectangles making friends.  This has nothing to do with sensory integration but it’s my favorite game and I couldn’t not mention it.

Book Review: It’s Always Something, by Gilda Radner

I will read any autobiography written by a comedian, regardless of the quality of their other work.  They’re great because they can’t turn off their comedian analysis skills no matter how bad it makes them look, so even when they’re trying to lie you can learn a lot.  This is how I ended up surprise reading a cancer memoir.

I’ve never had cancer, but I did read it in the immediate aftermath of my surgery correcting a previous surgery correcting a previous surgery, so I felt a little kinship with the  cycle of pain and uncertainty.  And I think she did a really good job portraying that- the ups and downs, what a positive attitude can and can not get you, the costs and benefits of fighting doctors and using alternative treatments.  It was a very honest description of both hope and despair without become overwhelming.

The book ends while she’s in treatment for recurrence, which would later go on to kill her.  In some ways that’s not very hopeful.  But I think it’s a good book anyway. 

Frying pan, slightly warm stovetop.

The first time I had this surgery, I was terrified of nerve damage- either from the infection itself, or from injury to the nerve during the operation.  There is nothing like feeling post surgical pain and trying to guess if it’s temporary healing pain, permanent nerve damage, or lingering infection.  So I’m kind of surprised how serene I feel right now despite having some pretty severe (albeit probably temporary) nerve damage.  Right now my right lower lip, chin, cheek, and gum feel like they’ve been novacained up.  The lip in particular feels like someone applied liquid nitrogen to it.

I’m serene first and foremost because if I’d been given an omniscient choice, I still would have done the surgery.  This freaky numbness is way better than the pain.  Two, as post surgery nerve damage goes, “diminished sense of pain” is a pretty good one.  Three, it’s almost certainly temporary.  My dentist couldn’t tell me how long it would take to return to normal- I get the sense that it’s a long tail distribution- but he seemed very sure I would. Ideally I would like the icy feeling in my lip to go away now, and then for my gum numbness to recede just slightly slower than the pain.  

My dentist has a tendency to give slightly more metaphorical/dumbed down explanations* than I would like, and I haven’t had the cope to press him on it. His explanation for this was that my nerve and the infection had made friends, and without the infection my nerve was sort of lost and confused, like a person reeling from being friend-dumped.  That sounds unlikely to me to be literally true, so I’m going to investigate.

Clue number 1:  the physical placement of numbness is exactly that followed by the novacaine injection I had for the surgery, minus my tongue.  This appears to match the coverage area of the inferior alveovar nerve, although that does not cover the check.  In fact, wikipedia says that a common dental infection site hits exactly that nerve plus the lingual (tongue) nerve.  So IAN numbness without lingual nerve numbness would explain what I’m seeing except for the cheek.  The cheek is covered by the buccal nerve.  The buccal nerve joines with the IAN nerve fairly quickly , but if a single problem was blocking them both there are a number of other sites that should be involved (including the tongue).  There’s a number of possible explanations- I misinterpreted gum numbness as cheek numbness, I have nonstandard anatomy that connects my IAV to my lower cheek, the physical stress of surgery.  But the cheek numbness is fading much faster than the other numbness, so I’m prepared to just ignore it.

Clue 2:  this feels exactly like novacaine numbness**.   The –caines work by blocking the sodium channel, which prevents the sensory nerve from firing.  It’s like being a spy without a way to report to the mother country- you might know a lot, but you have no way to tell anyone.  Humans acclimate to extended doses of novacaine (or other drugs) by altering their chemistry.  For example, cocaine causes your brain to release large amounts of dopamine.  Over time, your brain compensates by reducing the number of dopamine receptors.  It seems plausible to me that toxins produced by the bacteria could have altered the environment the nerve was in enough to cause it to adapt back.  Hypothetically, if they raised the sodium concentration high enough, my reporting nerves may have upped the sodium concentration required to get them to care.  This would explain exactly the symptoms I’m seeing, and provides a convenient mechanism for the problem to fix itself- the nerve will notice nothing is going on and adapt to its new environment just like it did the old one.  And it is consistent with my dentist’s cartoon description of the issue.

Holy shit, I didn’t start checking blogs and playing 2048 until that last paragraph.  Until then I was only writing or researching.  This is amazing.

Of course this is pretty speculative.  I’m not at all confident in the specifics of my explanation.  But honestly regardless of explanation the most helpful thing I can do is give myself an excuse to not freak out, and I’ve done that, so mission accomplished.

 

 

*When I asked about pre-op antibiotics he said “no, because when you use antibiotics the bacteria have babies, and those babies are immune.” Most common antibiotics either work by retarding cell replication, or are effective only against actively dividing organisms. My guesses for what he mean are: “no, I don’t want to create resistant bacteria your immune system can’t reach.  Let’s hold that in reserve” (although I didn’t end up with antibiotics during or after either), or possibly “no, those will kill the actively dividing bacteria but leave colonies of dormant ones that are harder to find on their own.” or if I want to get really speculative “antibiotics do nothing but create resistance if your immune system can’t reach the infection, and your infection is in an area with poor circulation.”  Any of these would be preferable to my dentist believing in Lamarkian evolution.

**Note: novacaine left common use in the US years ago, more effective and less risky equivalents exist.  But while they vary in exact side effect profile and action time, every one I’ve had creates this exact feeling, and they have similar if not identical mechanisms of action, so I’ll go with the name I learned as a child.