Oral Surgery Postoperative Instructions

What to Expect After Oral Surgery

Some teeth are imbedded or positioned in the jaw in such a way that bone surgery is necessary for their removal. This is especially true of impacted wisdom teeth. The removal of such teeth is quite different from the extraction of erupted teeth. The following conditions may occur, all of which may be considered normal in the first few days after surgery.

The area operated on will swell. The swelling will reach its peak about 36 hours after surgery.

Trismus (tightness) of the muscles may cause difficulty in opening the mouth.

You may have a slight earache and a sore throat may develop.

Note that you have been given a long-acting local anesthetic. This anesthetic may last as long as 8 to 12 hours. Even if your procedure involved I.V. sedation, you are still given local anesthetic although you may not remember even getting it. Therefore, you will experience numbness for several hours. Numbness around the corner of the mouth or in the lip or tongue on the side from which the tooth was removed may persist. This is called “paresthesia” and is generally a temporary condition which will resolve. It may persist for a few days to several months. In remote instances, it may be permanent. If numbness persists long-term, there may be surgical treatment available.

If the corners of the mouth are stretched, they may dry out and crack. Your lips should be kept moist with a cream or ointment.

There will be a cavity or socket where the tooth was removed. This will eventually fill in with tissue. Black and blue or yellow discoloration may occur on the outside of the face near the area of the surgery. This occurrence is not unusual and will disappear within several days.

There may be a slight elevation in temperature for 24 to 48 hours. If this continues, please notify the office.

Instructions Following Removal of Impacted and Surgically Extracted Teeth

1. PAIN – Take your pain medicine as directed. Medication instructions must be followed very carefully including not exceeding recommended doses, not combining different medications unless specifically directed, and not driving, operating machinery, or making important decisions while taking medication that can cause drowsiness or impair judgment. Note that elevation of the head (i.e. not lying flat) and use of ice packs as described below will both contribute to relief of pain. Note also that some pain medications may cause dizziness. You should stand up slowly while taking these medications. If you are lying down, sit up first and then stand up slowly to avoid dizziness that could result in a fall. Do not drink any alcohol while taking pain medication.

2. SWELLING – To help minimize ordinary immediate postoperative swelling, apply an ice pack to the face over the operated area (15 minutes on, 15 minutes off, repeat) for the first 36 hours following surgery. After 36 hours, discontinue the ice packs and begin moist heat compresses. It is not unusual to have additional swelling on the second or third day. Do not go to sleep with an ice pack or hot compress in place.

3. BLEEDING – A certain amount of bleeding is to be expected following the operation. Blood tinted saliva may be seen for about 36 hours. If bleeding occurs after you return home, place a small moistened gauze pad (about the size of a tea bag) or a moistened tea bag directly over the socket for at least 30 minutes, holding it in place with firm biting pressure. If your wisdom teeth have been removed, the correct position of the gauze pack will be behind the last tooth in the mouth. It may be necessary to repeat this procedure. If bleeding continues, please call the office. If bleeding is excessive, call the office immediately.

4. DO NOT DISTURB THE BLOOD CLOT – Its grayish or yellowish appearance and slight odor do not indicate an infected condition. Keep fingers, toothpicks, or other matter that may cause infection out of the mouth. Keep your tongue away from the surgical area. Do not smoke, rinse your mouth vigorously or drink through a straw for 48 hours. These activities create suction in the mouth which could dislodge the clot and delay healing. Forceful spitting and excessive physical activity tend to increase and prolong bleeding as does bending over to pick up objects. A semi-reclining position and rest for the first few hours is recommended. Limit strenuous activity for at least 24 hours after the extraction. This will reduce bleeding and help the blood clot to form. Avoid vigorous exercise for the first 3-5 days. Contact sports should be avoided until healing is complete to avoid the possibility of jaw fracture.

5. MOUTH RINSING – Vigorous mouth rinsing may stimulate bleeding by breaking clots which have formed. Therefore, do not rinse the mouth for 24 hours following extractions. The exception to this would be the patient on anticoagulants who is prescribed tranexamic acid, as discussed below. After 24 hours, you may gently rinse the mouth with a warm salt water solution (½ teaspoon salt in an 8 ounce glass of warm water) 4-5 times a day for several days. If bleeding continues, stop all mouth rinsing and follow instructions in paragraph 3 above regarding bleeding. Do not rinse with commercial mouthwashes. After 24 hours you may gently brush the teeth.

6. ANTIBIOTICS – If antibiotics have been prescribed for you, take them in accordance with the instructions on your prescription. Discontinue the antibiotics immediately if a rash, hives, itching, swelling, or difficulty breathing occurs. This may be the sign of a serious allergic reaction. The patient who experiences difficulty breathing or swelling and constriction of the throat, mouth and face area should call 911 or their local emergency medical service, as serious allergic reactions can be fatal if not treated promptly. Notify the office so that a different antibiotic can be prescribed. Any infection should be taken seriously and reported to the office.

7. DIET – It is important to maintain a good diet. A liquid to soft diet is advisable for the first few days. It is very important to drink plenty of fluids (6-8 glasses per day). Avoid drinking very hot liquids as these may cause resorbable sutures to break down too quickly. Nutritional intake is very important during the healing stages following surgery. Now is not a good time to go on a diet. You should supplement your vitamin and mineral intake with a supplement such as Centrum, which is available both in tablet form as well as liquid form. Calcium, vitamin D, magnesium, and manganese are important for proper bone healing and can be obtained in a single product form such as Caltrate Plus. A complete nutritional supplement such as Ensure can be taken to insure complete nutrition. Be very careful with anesthetized areas so you do not bite your lip, cheek, or tongue. Do not chew anything until after the numbness wears off. However, you can begin liquids right away provided that they are not too hot. Hard, crunchy foods should be avoided until healing is complete to avoid the possibility of jaw fracture.

8. POST-OPERATIVE OFFICE CARE – Most patients are seen approximately one week after surgery for evaluation and suture removal. If you have any doubts concerning your progress and recovery, please feel free to call the office. There may be a slight elevation in your temperature for 24-48 hours. If this continues, or if any other unusual events such as persistent weakness, lethargy, or malaise occur, please notify the office immediately. You may be seen sooner than one week if you so desire. If pain or swelling occurs after the surgical site has apparently healed, return for an examination. When this type of condition occurs, it usually happens on the third or fourth day after surgery. It may be indicative of a condition called “alveolar osteitis” (dry socket) and is generally treated by placing a medication into the tooth socket with almost immediate relief.

Special Instructions for Special Circumstances

1. NAUSEA – If you experience any nausea with your pain medicine, try taking it with milk, yogurt, ice cream or a milkshake. In rare cases, an anti-nausea drug may be prescribed. In very rare cases when nausea is so severe that the patient cannot keep oral medications down, anti-nausea medication can be administered in suppository form. While significant post-operative nausea is uncommon, it is more common in women and in patients with a history of motion sickness and migraine headaches.

2. EXCESSIVE PAIN – If you still experience pain after taking your prescription pain medication, you may add ibuprofen (such as Advil or Nuprin) or acetaminophen (such as Tylenol). The maximum adult daily dose of ibuprofen is 800 mg three times a day for a total of 2400 mg per day. The maximum adult daily dose of acetaminophen is 1000 mg four times a day for a total of 4000 mg per day. Keep in mind that many prescription pain medications (for example, Vicodin and Percocet) contain acetaminophen and some (for example, Vicoprofen) contain ibuprofen. If your pharmacist fills your prescription with a generic drug, note that the letters “APAP” on the label means that this product contains acetaminophen. Maximum daily doses include all sources of a drug added together. Acetaminophen taken in excess can cause liver failure and death, especially if combined with alcohol. Please be careful not to exceed the maximum daily dose.

3. ATTENTION WOMEN OF CHILDBEARING AGE – Women of childbearing age should keep in mind that all antibiotics have the potential to interact with birth control pills and lessen the effectiveness of the oral contraceptive. Although this has never been proven, alternative nonhormonal forms of birth control should be used after checking with your physician and should be continued for one full week after antibiotics are completed. You should also continue to take your oral contraceptives according to their directions while you are using antibiotics.

4. ANTIBIOTIC MOUTH RINSES – You may receive a prescription for an antibiotic mouth rinse containing chlorhexidine (Peridex, PerioGard, etc.). Do not use this rinse for 24 hours following extractions. After 24 hours, you should use this rinse after meals and before bedtime until the surgery site has healed. Do not swallow the rinse – swish it gently and then spit it out. Although extremely effective against micro-organisms, these rinses may cause staining of your teeth. This is not permanent staining and it can be removed with professional polishing. Staining can be minimized by thoroughly brushing and flossing your teeth at least twice per day.

5. SPECIAL INSTRUCTIONS FOR PATIENTS ON ANTICOAGULANTS AND PATIENTS WITH BLEEDING DISORDERS – If you are taking Coumadin (warfarin) or other anticoagulant medication or if you have a bleeding disorder, you may be given a special prescription for a mouthwash called tranexamic acid to minimize bleeding. Following the surgery appointment, rinse your mouth with 1 tablespoon for 2 minutes four times daily (every 6 hours) for 7 days. Do not swallow the rinse – swish it gently and then spit it out. Do not eat or drink during the first hour after using this mouthwash. Eat only a liquid diet on the first day after surgery. Contact the doctor if bleeding develops that cannot be controlled by compression by a gauze pad for twenty minutes while sitting upright.

6. SPECIAL INFORMATION FOR PATIENTS WITH IMMEDIATE DENTURES – If you have had immediate dentures placed at the time of surgery, it is extremely important that you do not remove these dentures for any reason until you are instructed to do so by the doctor. If the dentures are taken out too soon, there will most likely be additional swelling and it will be impossible to place the dentures in the mouth again. Please call the office for specific instructions as to when you should remove your immediate dentures.

7. BONE FRAGMENTS – During the healing process, small sharp fragments of bone may loosen and work through the gum. These fragments, which are not roots, usually work out on their own accord, but if they are annoying, return to the office so the dentist can advise or treat you.

8. SMOKING – Smoking will delay healing and may cause increased postoperative pain as well as the formation of a dry socket. Do not smoke for at least 48 hours after any type of oral surgery. This may be a good opportunity to seriously consider quitting smoking permanently.

9. SPECIAL INSTRUCTIONS FOR DIABETIC PATIENTS – Diabetic patients should note that blood glucose levels should be checked more frequently for the first few days following oral surgery. If you are eating less than usual or not eating regularly, you may need to adjust your insulin dosage. Please consult with your physician for additional guidance.

10. SINUS PRECAUTIONS - POSTOPERATIVE INSTRUCTIONS FOR PATIENTS WITH SINUS INVOLVEMENT Because of the close relationship between the upper back teeth and the sinus, a communication (also called a fistula) between the sinus and the mouth sometimes results from oral surgery. A communication between the sinus and the mouth often heals slowly. Certain precautions will assist healing and we ask that you carefully follow these instructions:

1. Take prescription medication as directed.
2. Do not smoke for at least two weeks. Smoking is a severe irritant and significantly delays healing.
3. Do not forcefully blow your nose for at least two weeks, even though your sinuses may feel "stuffy" or there may be some nasal drainage.
4. Try not to sneeze, as sneezing will cause an increase in sinus pressure. If you must sneeze, do so with your mouth open.
5. Do not drink through a straw for at least two weeks.
6. Do not forcefully spit for at least two weeks.
7. Do not rinse vigorously for at least two weeks. Gentle saltwater swishes may be used as needed.
8. Eat only soft foods for several days and chew on the opposite side of your mouth.

Slight bleeding from the nose may occur for several days after surgery. Please call the office if drainage or pain increases. It is very important that you keep all appointments until this complication has resolved. In rare cases, another surgical procedure may be necessary to close the communication between the mouth and the sinus.

10. ADDITIONAL INSTRUCTIONS FOR IV SEDATION PATIENTS – Since you may be drowsy following the appointment, a responsible adult must escort you home. Two adults should accompany children. Arrange to have the entire day off work and limit your activities for the remainder of the day. Do not drive, operate machinery, drink alcohol, or make any important decisions or judgments for 24 hours after the appointment as your faculties and abilities will likely be impaired. Have someone assist you in and out of the car on your way home and up and down the stairs. Stand up slowly; if you are lying down, sit up first and then stand up slowly to avoid any drop in blood pressure that might make you dizzy. If you experience any unusual reactions, report them to the office as soon as possible. Occasionally, the injection site of the IV may become inflamed and tender. This is caused by the anesthesia drugs irritating the vein. If this happens, apply moist heat to the area and the inflammation will eventually resolve.

Please feel free to call anytime you have a question or concern.