Post-op instructions for Extractions

PAIN:

Some pain following extractions is not uncommon. Any discomfort you may have may be controlled with different combinations of medication. If one combination doesn’t work, please call our office so we may recommend a different combination. For mild to moderate pain, if bleeding isn’t an issue, take two aspirin or aspirin substitute tablets. (Bufferin, Anacin, Empirin, Tylenol, Advil, etc.) every 3 to 4 hours. Children, especially young children, should receive similar doses of between ¼ and ½ the adult dose, and only if necessary. (DO NOT GIVE CHILDREN ASPIRIN IF FLU SYMPTOMS EXIST). A prescription has been given to you for additional pain relief. Use the prescription as directed, together with aspirin or Advil intermittently.

BLEEDING:

A certain amount of bleeding is to be expected following tooth extractions or other surgeries. If you feel the bleeding is unusual, call immediately to alert the office for more specific instructions. This is important because it may be necessary to come back in, especially while office hours are still in progress so that you can be attended to.

If a “normal” amount of bleeding occurs, place a small folded pad of gauze, slightly moistened, directly over the bleeding area. Then place a larger wad of gauze over the first piece and bite or hold down firmly for 30 minutes to 1 hour. Remove any large excess jellied blood clots before applying pressure. Repeat the above process if necessary, but only for 30 minutes. If bleeding persists, avoid hot liquids and stop all mouth rinses or sucking motions, (i.e. no straws). Sit or sleep upright and avoid exercise. Moist hot pads may be added intra-orally. A good thing to do is place a hot tea bag directly onto the extraction site, which helps stop bleeding. Note: regular caffeinated tea bags are stronger than decaf/herbal brand. Repeat as necessary. (Tannic acid cauterizes and warmth coagulates the proteins in the blood and turns it into sludge to slow it.) If bleeding continues, call the office. It is normal for your saliva to be slightly colored for 1-2 days since few drops of blood in a lot of saliva looks like more than it really is. It is also normal to wake up with blood on your pillow in the morning, so do not be alarmed. Don’t sleep with gauze in mouth unless one end is exiting oral cavity or you could be in danger of inhaling it in your sleep.

SWELLING:

You may expect some swelling after dental surgery; rebound swelling is to be expected as the Medrol dose pak starts to taper off. Swelling is a part of the natural healing process and may last several days to weeks. This is dependent upon the nature and extent of your surgery. Individuals with fair skin or who bruise easily may experience some discoloration of the skin in the area surrounding the surgical procedure(s). Such discoloration (from seepage of blood from soft tissue planes) surrounding the surgical area and at the site of the intravenous infection may occur after a day or so, or even up to a week later. This, again, is a normal body reaction and will resolve on its own in a few days up to a few weeks. Water-tight closure can make blood back up (i.e. two black eyes) and gravity can also make blood seep in a dependent fashion- i.e. top jaw to bottom jaw, neck, etc.

To reduce ordinary, immediate, post-operative swelling, apply an ice pack or washcloth saturated with ice water to the face over the operated site immediately for 6-8 hours. The ice pack should be applied for 5 minutes on, then 5 minutes off, etc. for the first 24-48 hours for best results. Swelling, discoloration, and restricted jaw movements are expected, (can be greatest on the second post-operative day). Keeping your head elevated (while awake and asleep) will limit the tendency to swell. On the 3rd day, ice may be continued, or moist heat (not a heating pad) may be applied to increase comfort. To treat discoloration, application of witch hazel and warm moist soaks to the arm at the IV site with elevation of the arm, plus anti-inflammatories, are advised. Continue your antibiotics. Should the IV site become red or painful, please contact the office immediately at (361) 992-3873.

SORE THROAT:

A sore throat for 24-48 hours is common after a general anesthesia case where you have been intubated with a breathing tube; slight bloody discharge from the nose is also common initially. Please contact the office should either symptom persist.

NAUSEA:

As with all general anesthetics, some nausea and vomiting may occur in certain individuals. Limit intake to clear liquids only, such as tea, water, soda, etc. until symptoms subside. If nausea continues, contact this office for assistance. A prescription can be called in for your convenience in either oral or suppository form (Compazine or Tigan suppositories).

Leaving the gauze in place until all bleeding stops will help prevent blood from seeping into the stomach which can also cause nausea. In addition, narcotic prescriptions are known for causing nausea in most individuals, therefore discontinue these and limit your pain medicine to the non-steroidal anti-inflammatories such as Advil and Dolobid with food. Coating your stomach with Mylanta or Peptobismol when taking meds may also help. Over-the-counter meds, such as Pepsid, Zantac, Axid, etc. may also help.

MOUTH RINSE/ DRY SOCKET:

Vigorous mouth rinsing may stimulate bleeding. Therefore, do NOT rinse the mouth following extraction surgery. You may brush your teeth and let the water run out gently, but do not spit or rinse as you risk spitting out your clot and getting a “dry socket.”

A dry socket, or alveolar osteitis, is a phenomena that can occur approximately 3 to 5 days following an extraction. A patient will prematurely lose their clot, leaving an exposed hole with raw nerve endings exposed. This is extremely painful and may have an odor, and will require packing of the surgical site with a natural sedative dressing. Although exact etiology is unknown, we find that spitting out a clot can contribute to this, so we ask that you do not spit or rinse for the first week following the extractions. When you brush your teeth, be careful not to hit the stitches or you may bleed, and let the water gently fall out of your mouth so as not to dislodge the clot in the extraction site.

We also find that performing physical activity too soon can lead to loss of the clot, so do not exercise or run up and down the stairs, no bending or lifting, for a week following your surgery. Smoking also leads to dry socket formation, as well as trauma. The more difficult the extraction, the more likely a dry socket will form. Cleocin, the prescribed antibiotic, helps prevent dry socket formation. There is a hereditary component to dry socket formation, so ask if a parent or sibling has ever had one.
You may rinse your mouth if you had surgery other than an extraction that doesn’t have a “hole” where you don’t have to worry about losing a clot- i.e. apicoectomies, implants, biopsies, etc. In such cases, Periogard or Peridex (Chlorhexidene rinse) is prescribed.

Short term use (under approximately 2 to 3 weeks) will tend not to stain your natural teeth. However, you may add a capful of peroxyl, peroxide, or water to decrease staining. If staining should occur, it will come off by the cleaning your dentist/hygienist provides. You may switch over to diluted Listerine after 2 weeks of Periogard should teeth staining occur or if your tongue turns “black” from the rinse.

TEMPERATURE:

Temperature may be elevated for the first 24-48 hours following treatment. Tylenol, every 3-4 hours and increased fluid intake will alleviate this condition, as well as rest. If the temperature should persist, please notify this office and/or your M.D.

DIET:

Start with a clear liquid diet, such as tea, apple juice, clear broth, soda, etc. If this is well tolerated, light soft foods such as pastina, apple sauce, soup, jello, mashed potatoes, scrambled eggs, etc., which require little chewing, may be taken. Avoid chewing in the area of operation. An adequate diet is very important to healing. You may use Instant Breakfast, Dietary supplements, etc. Consume at least 2 quarts of fluid daily.

It is advisable to stay away from anything with small particles such as sesame seeds, poppy seeds, popcorn kernels, chopped nuts from ice cream sundaes, seeds from tomatoes, or soups with small particles (rice) that collect there. The patient is permitted to eat anything processed in a blender. Stay away from milk products for a few days because bacteria likes to grow in milk. Italian ices and tofutti is allowed because they are not milk products. We prefer you do not have cottage cheese, yogurt, or ice cream for the first few days.

DO NOT DRINK WITH A STRAW. NO DAIRY PRODUCTS FOR AT LEAST 24-72 HOURS, such as yogurt, ice cream, shakes, cottage cheese etc., should be taken since bacteria love to grow in mike and could enhance infection. (Milk in your coffee or tea is acceptable.) After three days, you may make egg nogs in a blender as a protein supplement—milk, 2 eggs, banana/cocoa, sugar.

SUTURES:

Sutures (stitches) may have been placed in order to minimize post-operative bleeding and to facilitate healing. They will be removed as a subsequent visit.

IMMEDIATE DENTURES (patients should consult with their restorative dentist for specific instructions):

Patients with immediate dentures may be instructed not remove the dentures until they return to the office of the general dentist and should stay on a very soft diet. The general dentist may elect to see the patient approximately 24-48-72 hours following the extractions and placement of the immediate denture according to his/her preference and scheduling. Should the dentures be removed for extended periods prior to the dentist visit, swelling might take place, which would prevent replacement of the dentures at that time. If undue pain is experienced, remove the denture to permit the tissue to breathe and call the dentist for an adjusted appointment in spite of the ensuing swelling (don’t suffer needlessly). Also, contact the restorative dentist if the bite is not comfortable.

REST:

Avoid fatigue. Go to bed early at night and get adequate rest during the day. Avoid exercise, jogging, and running up and down the stairs, etc. for a week because relapse and bleeding can occur, as well as “dry socket” formation following extraction surgery.

IMPACTIONS & OTHER SURGICAL PROCEDURES:

Paresthesia (numbness or abnormal sensations of the lip or tongue and/or lack or alteration of taste) may occasionally occur after surgical removal of impacted teeth or other surgical procedures. This is a result of the proximity of the sensory nerves to the area of surgery. This will usually resolve in time, but occasionally may be permanent. Often soft tissue swelling at the surgical site may cause a temporary numbness, which will resolve as the swelling resolves.

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 of their own accord. If annoying, please return to the office for examination and/or removal of suspected bone fragments or spicules. In time, nature will resorb (smooth down) the sharp edges that are attached, but loose fragments can easily be removed. If this occurs on the tongue-side (lingual) adjacent to lower wisdom teeth, it may be better to “watch and wait” for nature to take its course than to risk injury to the lingual nerve, which lends sensory function to the tongue. Damaging this nerve could result in a “numb tongue” if manipulated surgically.

SMOKING:

Avoid smoking after surgery. It increases bleeding, delays healing and can cause pain (i.e. dry socket following extractions). Patients will ask “when can I smoke?” The answer is “NEVER SMOKE”!!! Since a dry socket can occur 3-5 days after extraction surgery, seventy-two hours is minimum to cease smoking (longer for implant cases—2 to 3 weeks). The carcinogens in tobacco go to the bone receptors to prevent healing and the heat from the smoke burns the tissue directly.

PRE-EXISTING INFECTIONS:

For infections, remember it is not uncommon to be more swollen after an incision and drainage (I&D), since surgery has been performed in the site of an infection. Warm moist soaks should be applied to the outside of the infected area (to open vessels and remove the toxins and decrease swelling). Hot rinses should be performed as often as tolerated on the inside of the mouth to drain out the pus from the infected site (i.e. hourly). The drain may be removed a few days following the I&D. For upper jaw infections, the eye may swell. If double vision should occur, call the office immediately and/or go to the hospital immediately. For lower jaw infections, the infection may cross the midline of the jaw. If difficulty in swallowing and/or breathing should occur, call the office immediately and/or go to the hospital immediately.

BIOPSIES/CYST REMOVAL:

Please be advised that it is within normal limits for an impacted wisdom tooth to still maintain its follicular, odontogenic or tooth sac. We perform a cystectomy procedure and send the cyst-like material away as a biopsy for histological examination to a pathology lab. Since the potential of the sac is to enlarge and cause destruction of anything in its path, as well as turn into an aggressive tumor, it is therefore routine policy for our office to biopsy any soft tissue removed from the body. Written information from our oral pathology text concerning why it is important that every such cyst be biopsied based on the potential for the cyst to grow is provided for you upon your request. Upon receiving this specimen, the lab will send the patient a bill for the histiological examination of the cyst, which can be covered under the patient’s medical insurance. At times, it may be necessary to send your specimen to a specialpathology laboratory and a pathology fee may be incurred that your managed care plan will NOT pay, and which you will be responsible for. Once our oral surgical office receives the result, we immediately send a copy of the result to both the patient and the referring doctor and/or any DDS/physician you request. At this time, the patient may call to discuss the result of the biopsy. The biopsy usually states “cyst of maxilla” or “cyst of mandible.” This is considered a routine cyst which requires no additional follow-up. Any other diagnosis can be discussed with the doctor at the time of the post operative evaluation or by phone. The same procedure is followed for any specimen taken from the body, i.e. cystic material noted during an apicoectomy procedure. Soft tissue lesions that require removal and examination will also be sent for histological evaluation.

LASER FOR SOFT TISSUE SURGERY:

Often it is necessary to surgically remove soft tissue specimens from the oral cavity that are red, white, or pigmented or extruding (i.e. irritational fibromas, mucocoeles, etc.), as well as excessive muscle attachments (i.e. frenectomies or tongue-tied= ankyloglossia). This may be performed comfortably under local anesthesia alone or IV Sedation/General Anesthesia if extensive. Laser surgery often results in no pain, no bleeding, no swelling, and no stitches. Note that some discomfort “may” arise 4-5 days later (similar to sunburn) and that the surgical site may appear white. Please understand that this whitish-tissue is only fibrin= nature’s band-aid, NOT PUS, and that within a month all the tissue will fill in (granulate in) and resemble normal pink tissue again.

POST-OPERATIVE APPOINTMENT:

At the time of the post-operative appointment, a monojet curved tip plastic syringe is given to flush out extraction sites or along the sutures on incision lines. In order to use the monojet syringe, simply pull back on the insert, draw solution into the syringe, and angle it into each socket to flush out the food particles that collect there. It is advisable to do this after every meal. The irrigating solution should consist of warm water with a dash of salt, a dash of peroxide or some diluted Listerine. In some cases, diluted or full-strength Periogard will be used. Proper care following surgery will hasten recovery. If necessary, additional instructions will be given. It may be necessary to be seen a few times following surgery to ensure proper healing. Apicoectomy procedures will be seen six months after the surgery to take a peri-apical x-ray to note bone fill-in.

EXTRACTION CASES may be seen 3-4 months after surgery for a courtesy Panorex and implant consultation to evaluate the healing of the extraction site for implant placement.
IMPLANT CASES will be checked weekly, then on periodic monthly intervals to check for bone healing once osseous-integration has taken place.
ONE STAGE IMPLANTS will then be ready for prosthetic placement, whereas
TWO-STAGE IMPLANTS will be ready for surgical uncovering placement of healing cap/abutment.

For Women:

BIRTH CONTROL PILL WARNING:

Please be advised that birth control pills are ineffective when taking antibiotics (you could become pregnant). Please use an alternate birth control method for the month. If you have further questions, please contact our office or your OB/GYN.

NOTE FOR WOMEN TAKING ANTIBIOTICS:

Please be advised that the possibility exists that while you are taking an antibiotic, a vaginal yeast infection may occur. If this is the case, please contact our office or your own OB/GYN, and we will call in a prescription for you. Oral Difucan in a one-time dose is available. Please note that over-the-counter medication is also available for external use (i.e. Monostat-7)

UNUSUAL SYMPTOMS (CONTACT OFFICE IMMEDIATELY!):

If significant bleeding persists beyond four hours (more than normal oozing)
If the temperature remains elevated beyond four hours or goes above 101 degrees F.
If there is any difficulty breathing or swallowing.
If any allergic reaction to any medication occurs.
If any other signs or symptoms causes concern.

If any unusual symptoms occur, please call (361) 992-3873. If after hours, please leave a message with your name, the time, and a phone number you can be reached at. We will be paged and will call you immediately. If you are not called back within five to ten minutes, try again, as it could be in a dead zone. We can be reached 24 hours a day. For any reason should the system fail, please seek care at the nearest hospital for any medical emergency.

MEDICATIONS:

If you are prescribed a rinse, Periogard (Chlorhexidine) and Peroxyl, pour a capful of Periogard in a cup along with a splash of Peroxyl. Swish and hold for 30 seconds and expectorate(spit) gently. This should be done after each meal, 2 to 3 times a day (a minimum of twice: AM and PM). If you are unable to obtain peroxyl, plain peroxide will suffice, or even tap water. This will help prevent staining of teeth, which should not occur short-term, and can easily be removed by your hygienist.

When taking any medications, if any unusual symptoms should occur (i.e. nausea, vomiting, skin rash or hives, diarrhea, etc.) discontinue the medication immediately and call the office. Consult your M.D. with respect to nonsteroidal anti-inflammatories and Medrol if you have asthma or ulcers or are on blood thinners. Don’t take Seldane if on Erythromycin.