After Wisdom Tooth Removal

The removal of impacted wisdom teeth is a serious surgical procedure. Post-operative care is very important. Unnecessary pain and the complications of infection and swelling can be minimized if the instructions are followed carefully.

Please call our office at Omaha Office Phone Number 402-397-7777 for any questions you have after your wisdom tooth removal.

Day of Surgery (Day 0)

SUPERVISION

Our patients, adult or child, should not be left alone.  A parent, guardian, caretaker, or responsible and fully capable adult (able to provide full assistance and transportation needs) must be present at all times to provide any necessary postoperative assistance.

ACTIVITY

Stay home and rest.  Follow our postoperative instructions. Do not work or engage in sports or other strenuous activities.  As you will be under the effects of sedation, do not operate any vehicle, machinery, stove, microwave, or run hot water to reduce the risk of injuring yourself.  Rest in a recliner chair or rest with your head and shoulders elevated above the level of your heart.

CLEANING YOUR MOUTH

Don’t touch or play with the surgical site(s) or sutures.

Don’t allow your tongue to “investigate”.  This will cause injury or loosen the sutures.

BATHROOM USE

To prevent a fall today, someone must accompany you to the bathroom.

EATING

Do not eat or drink until you are alert and awake enough not to choke on food or drink.

Remove any gauze from the mouth before eating or drinking.

Do not use a straw to drink for 3 days after surgery.

It is very important to only have a liquid diet while your lips, tongue, cheeks, gums or teeth are numb.  Any chewing while numb could result in injury.  Your surgeon may use a long lasting local anesthesia.  Your face can be numb up to 12 hours.

Start with cool liquids (milkshakes, jello, fruit juice, iced tea, etc.).  Avoid carbonated beverages and anything with small seeds (strawberries, blueberries, raspberries, etc.).

It is important to get something in your stomach as soon as possible once you get home to reduce the chance of nausea and to avoid getting dehydrated.  Dehydration can cause headaches, muscle cramps, nausea, dizziness, fainting, or a low grade temperature.

 First Day after Surgery (Day 1)

SUPERVISION

Children need supervision.  Adult patients normally do not need supervision now unless taking narcotic medication every four hours.  Those still taking narcotics cannot operate vehicles, machinery, cook, or engage in other physical activity.

ACTIVITY

No physical activity.  Stay home and rest.  Keep the head and shoulders above the level of your heart.  You may take a bath or shower but do not take a long, hot shower or bath.  This will increase swelling.  Keep your tongue, fingers, etc. away from the 4 surgical sites.

CLEANING THE MOUTH

You may carefully brush your teeth the day after your surgery.  Avoid the surgical site(s).

Do not disturb the sutures (stitches).  Use minimal toothpaste.

Do not vigorously rinse.

Do not spit.

Do not use mouthwash unless prescribed by your surgeon.  Gently rinse with saltwater (1/2 teaspoon per cup of warm tap water) after each meal.  If you were prescribed a mouth rinse, you will start using this today (Day 1) as directed.

If you notice fluid moving from the mouth into the sinus, this indicates a sinus opening may have occurred (please read sinus precautions).  Please call Midwest OMS on the next business day.  In the meantime be gentle with your sinus; do not blow your nose, and try to keep fluids from passing from your mouth to the sinus.

RETAINERS

You may resume wearing your retainer if it causes no pain.  Don’t wear it if it puts any pressure on the surgical site(s).  It may not seat completely on your teeth initially but you will be able to slowly seat it into place over time.

EATING

Continue eating soft foods along with liquids.  Avoid sharp, crunchy, and chewy foods or foods with seeds.  They will injure the surgery site(s) and cause infection.

Do not use a straw.

PAIN MANAGEMENT

Pain and swelling typically increase during the first three days after surgery.  Do not be alarmed if you have more discomfort today than you did the day of surgery.  If you can tolerate Ibuprofen, continue to take it every six hours or four times daily to control pain and reduce swelling.

If you would prefer not to take the narcotic and are able to tolerate Tylenol, you may substitute Tylenol alone for the narcotic/Tylenol combination medication.  You may also alternate between taking 600mg Ibuprofen and 1000mg Tylenol throughout the day.

If you need to start taking the narcotic/Tylenol medication again, restart it only after waiting at least four hours after the last dose of regular Tylenol.

BLEEDING

As you talk and eat more during recovery, you may notice bleeding that comes and goes or taste blood throughout the day.  This is common.  Rarely will you need to use gauze.  If a clot has formed above the level of the gum tissue and it is bleeding continuously, carefully wipe excess clot away with gauze, push clot back into the socket site, and hold direct pressure over the site for five minutes.

SWELLING

Swelling will start today and will be worse the second and third days after surgery.  Continue to ice surgical area during the day of surgery and for 24-48 hours after for 15 minutes on/15 minutes off.  Keep your head elevated.  No physical activity.  Limit talking.

NUMBNESS

Numbness from injections can last for multiple days.  Swelling and inflammation inside the jaw can also cause numbness.  If you are still numb after 7 days, call us during regular business hours to schedule a follow-up appointment.

NAUSEA/VOMITING

Nausea and vomiting are rare the day after surgery unless you take pain medication or antibiotics on an empty stomach.  It is important to eat something and wait 15 minutes before taking any medication.  If vomiting happens, please see the “Common Postoperative Concerns” section.

 Two Days after Surgery (Day 2)

Supervision, Activity, Eating, and Pain management are the same as Day 1 after Surgery.

Don’t be surprised if you have more swelling on the second day after surgery than you did on the first day after surgery.  You are going to continue to swell.  Swelling generally peaks three days after surgery.  It is important to continue icing over the surgical areas for 24-48 hours after surgery 15 minutes on and 15 minutes off.  Keep your head elevated.  Limit physical activity.  Limit talking.  It is not unusual to be more swollen on one side of the face than the other.

Three Days through Ten after Surgery

SWELLING

Facial and oral swelling will peak around the third day after surgery (Day 3) and start to lessen over the next seven days.  If swelling continues to increase after Day 5 or is red, warm, hard, and extremely painful, please call Midwest OMS.

BRUISING

Occasionally bruising may develop and can last from seven to fourteen days.  Bruising can move from the surgical site to the cheek, lower eyelids, chin, and to the neck or even chest area.  This is the normal progression of facial bruising.

SUTURES

The sutures (stitches) are slowly dissolving.  They will weaken and can begin to fall out in fragments after day three.  Do not pull on any sutures.  If loose ends begin to unravel, you can trim them back with small scissors or come in to our office to have them trimmed.

HEALING OF SURGICAL SITES

It is common for the extraction site(s) to open up as the sutures begin to weaken.  Continue rinsing with saltwater to keep the sites clean.  Clots in the surgical site by this time will look an off-white or yellow-white color because the saliva has washed away the blood pigments. It will look like a piece of food.  Do not pick at the surgical sites or try to remove these clots.  Saltwater rinses will wash food debris out of the extraction sites.

An irrigation syringe has been supplied to you to help keep the food and debris out of your lower extraction sockets (sites).  Start using the irrigation syringe on the third day (Day 3) after surgery.  After eating, fill the syringe with warm water; insert the tip into the sockets (under the gum tissue) and flush out food particles.  Continue irrigating sockets after eating until the extraction sites are clean (no food or debris present).  You may notice some bleeding after irrigation which is normal.  Syringe use may be required for 2-3 weeks or until the extraction site is closed.

If the pain worsens after Day 5 and the pain medication is ineffective, you may have developed a dry socket.  Please call Midwest OMS if the pain worsens after Day 5.

NUMBNESS

Please call if you are still numb in your teeth, lips, or chin seven days after surgery.

ACTIVITY

All patients have different pain tolerances and recover from surgery at different rates.  It is difficult to predict when you will be able to resume normal activity.  If your pain is controlled with Ibuprofen, you do not require a narcotic, and you can tolerate a normal diet, you may resume normal activity.

CLEANING YOUR MOUTH

Continue to gently brush your teeth and rinse with saltwater.  Usually by Day 8, you may brush the gums around the surgical sites as they have begun to heal.  Once you are comfortably able to brush the surgical sites with a toothbrush and toothpaste, you can discontinue the saltwater rinses.  You may return to using an over the counter mouthwash also if that is part of your normal oral hygiene practice.  Continue irrigating the surgical sites at least once daily until the gums completely close over the surgical sites.

EATING

You may begin to eat your food at any temperature that is comfortable because no more swelling should occur.  Continue eating a soft diet until Day 7, when you return to a regular diet.  Continue to refrain from eating hard, crunchy foods like chips, popcorn, nuts, crunchy peanut butter, croutons, etc.  Don’t eat foods with seeds like strawberries, blueberries, poppy seeds, sesame seeds, raisins, cranberries, and other foods until the gums have completely closed over the surgical sites.

Common Post Operative Complications

BLEEDING

After surgery you don’t leave our office until the initial clot has formed in the surgical sites.  A slow trickle of blood is normal immediately after surgery.  For your comfort, you will leave our office with gauze over the extraction sites.  Keep pressure over the extraction sites with the gauze that is in the mouth.  Take out the gauze after 60 minutes.  It will be soaked with saliva and blood.  This is normal.  It can take 8 hours for the clot to fully form.  A slow trickle of blood is normal for the first 8 hours after surgery.

To prevent choking on the gauze, DO NOT leave it in the mouth while you are sleeping.  When you sleep, prop yourself up on pillows or sleep in a reclining chair.  Keep your head above the level of your heart (a 30 degree angle or more) which will reduce postoperative bleeding.  It is normal for blood stained saliva to pool in your mouth when you sleep.  Because your mouth can be numb for hours, drooling may occur.  Expect some blood stained saliva.  Protect pillows, chairs, etc with old towels or sheets to prevent blood stains.

Note:  Blood stains are effectively removed from material by using hydrogen peroxide repeatedly applied to the fresh blood stain until it bubbles away.  A detergent like ERA, applied directly to the stain, or presoaking the garment in OxyClean Free prior to washing will usually get the blood stain out.  It is best to use clean old clothes, old sheets, and old towels during recovery.

If Bleeding Starts Once You get Home

Because it takes up to 8 hours for a mature clot to form, recurrent bleeding can occur when the clot is dislodged after surgery.  Any activity of the mouth (talking, eating, chewing, spitting, rinsing, etc.) can restart the bleeding by dislodging the clot that is forming.

Increased blood pressure may also cause bleeding to begin.  If you take blood pressure medications or heart medications, take your usual dose after surgery at the intervals your physician has prescribed.  Postoperative pain can increase blood pressure and can cause bleeding.  Please follow our prescription pain medication recommendations to reduce pain and postoperative bleeding.

USING GAUZE

The extra gauze given to you is to be used if the bleeding is more than a small trickle.  To properly place the gauze, fold it into a small cube and place it directly over the extraction sites for 60 minutes.  If bleeding is occurring around the recently placed gauze this could mean the gauze was not placed properly.

Replacing the gauze too frequently (less than 60 minutes) will disturb the clot before it has a chance to get firm.  You will tear the soft blood clot, and the bleeding will continue.  You must keep firm pressure with the gauze for 60 minutes.  When you remove the gauze, it will be soaked with saliva and blood.  You should only see, at most, a trickle of bleeding from the extraction site .

If active bleeding continues:

Remove the soaked gauze

Place one/two tea bags over the bleeding site (not herbal: regular tea only)

Place gauze over the tea bags

Bite down on the gauze and tea bag for 60 minutes with firm pressure

If bleeding continues after 60 minutes of biting on the tea bag, use your fingers to push the tea bag firmly over the extraction site for five minutes, and then while leaving the tea bag in place, bite down on the tea bag for 60 minutes.  Normally direct pressure will stop the bleeding, but if excessive bleeding persists then please call our office.

SWELLING

Preventing or reducing postoperative swelling is accomplished by cooling down the surgical area(s), keeping the head/shoulders elevated above the heart, and taking Ibuprofen (if you are able).  Reducing postoperative swelling will help you recover from surgery faster.

Use ice packs, place ice cubes in a plastic bag, or use a bag of frozen peas/corn for 15 minutes on, 15 minutes off of the jaw where the surgery was performed.  Do this for the first 24 to 48 hours after your surgery.  You will have little swelling during the first 24 hours after your surgery.  Do not let this fool you into a false sense that there will be no swelling; swelling may increase for the first 3 days after surgery.  The key to preventing swelling is to start icing right after surgery.  Not only will these measures reduce swelling, they will also reduce postoperative pain.  If your swelling is hard, warm, red and extremely painful call Midwest OMS.

NUMBNESS

For your comfort, we use local anesthesia to numb the surgical site.  The numbness can last from 4 to 12 hours and sometimes longer because it is a long-lasting anesthetic.  While numbness is present, please be careful when eating.  While still numb, you could accidentally bite your lip or tongue.  If numbness persists longer than seven days please call Midwest OMS during regular business hours to schedule a follow up appointment.

Children or other patients needing special care should have a responsible adult help watch over the numb area (lips, chin, tongue, and cheeks).  Children tend to rub the numb areas with their fingers or bite their numb lips.  Please keep them from doing this as rubbing or biting an area that is numb could cause significant injury.

SINUS OPENING

When you have teeth removed in the upper posterior jaw you may encounter a hole into the maxillary sinus.  If while drinking you feel water/liquid go into your sinus, or air escaping from an upper molar extraction site when you blow your nose, or develop a nose bleed after upper jaw surgery, you may have a sinus opening.  Call us on the next business day to be seen by your surgeon.  There are special instructions we will give you to aid in the healing of the sinus opening.  Do not smoke, blow your nose, use a straw or CPAP until your surgeon has approved these activities.

NAUSEA/VOMITING

Nausea or vomiting may be side effects of the general anesthesia or I.V. sedation.  Nausea may also be caused by motion sickness during your ride home, prescribed antibiotics, pain medication, and swallowing blood.  If postoperative nausea and/or vomiting occur in the first 24 hours after surgery, it is usually from swallowing small amounts of blood on an empty stomach.  Coating the stomach with liquid nutrition as soon as possible will prevent the effects of blood on the stomach.  This is why it is important to eat/drink foods we have recommended as soon as you are able.

If vomiting occurs, it is usually a one-time event to clear the stomach.  Expect it to be tinged with blood.  Even small amounts of blood on an empty stomach can cause some people to vomit.  You may gently rinse the mouth with water to get the bad taste out of the mouth.  It is important not to disturb the clots that are in the surgical sites.  It helps most people to drink two ounces (1/4 cup) of cola or ginger ale with most of the carbonations stirred out.  Pour the drink over crushed ice and sip small amounts over a 20 minute period.  If there is still some nausea, this can be repeated with another 1/4 cup of cola.  When you are no longer nauseated, you can start to eat the type of foods that have been suggested.  Do not take any pain medication or antibiotics until food has stayed down 15 minutes.  If nausea and vomiting continue please call Midwest OMS.

BOWEL IRREGULARITIES

Be aware that narcotics, dehydration, or antibiotics can cause bowel irregularities.  If you develop constipation, stop the narcotic and drink more fluids.  You may also use a stool softener.  If you develop diarrhea stop the antibiotics and call Midwest OMS.

I.V. SITE IRRITATION

It is not uncommon for there to be some irritation at the I.V. site.  Redness and swelling about the size of the width of your pinky finger may last for four days after surgery.  Using warm moist heat over the swelling at the I.V. site should minimize any discomfort you are feeling.  If it lasts longer or you have concerns, please call our office.

DRY SOCKETS

A blood clot forms to protect the bone and nerve when a tooth is pulled.  Dry sockets occur in 5-25% of cases.  The clot either dissolves or is dislodged, and the bone and nerve are exposed, resulting in severe pain.  The pain can become intense and last several days to a week.  If a dry socket occurs, it can start around the third day after surgery.  A certain amount of pain is normal after surgery.  However, you should be able to manage the pain with the pain medication prescribed.  If your pain is getting worse the fourth or fifth day after surgery and the pain is no longer managed by the pain medication, you should contact Midwest OMS.  Other signs and symptoms of a dry socket include: pain that radiates to your eye, temple, neck or ear, or bad breath or foul odor coming from your mouth.  Factors that increase your risk of developing a dry socket include: smoking, birth control, failure to follow Midwest OMS postoperative instructions, current or previous infection around the tooth, and poor oral hygiene.

 Pain Management and Medication

ABOUT PAIN

We generally approach pain management by using a combination of over-the-counter (OTC) and prescription narcotic medications.  Your doctor may choose to prescribe other medications according to your unique needs.  It is impossible to “turn off ” pain nerve fibers, so it is important to understand that you will have some amount of pain after surgery.  You can minimize discomfort by following your post-surgery instructions.

The key to managing postoperative pain is to stay ahead of the discomfort by starting the pain medication while your lip and or face are still numb.

If you fall behind on pain management by only taking medication when you start to feel pain, more pain medication usually will be needed to decrease the pain, which will increase the negative side effects of the medication(s).

The MAXIMUM DOSE of Ibuprofen is 3200 mg in a 24 hour period.

The MAXIMUM DOSE of Tylenol is 4000mg in a 24 hour period.

IBUPROFEN (ADVIL/MOTRIN)

A non-steroidal anti-inflammatory medication, like Ibuprofen (Advil/Motrin) is in the same broad family of drugs that includes aspirin, Aleve and other drugs that treat muscle and joint pain.  It works to relieve pain at the source and it helps reduce swelling.  We recommend taking Ibuprofen (Motrin, Advil) as soon as you have eaten/drank something.  For most adults, 600mg of Ibuprofen every six hours is the typical starting dose, but this may change depending on your size and how well your stomach tolerates medication.

Your maximum does of Ibuprofen and narcotic medication will be less if you are sensitive to medications, have a kidney or liver condition or are already taking medications that stress the liver or kidney.  If you have any heart or vascular conditions or decreased cardiac output, pain medication dosage wil be lowered as recommended by your physician.  If you are pregnant, it is generally safe to take Tylenol, but not Ibuprofen (Advil/Motrin).  We encourage you to consult your OB/GYN prior to taking any medications if you are pregnant or think you might be pregnant.

NARCOTIC/TYLENOL MEDICATIONS

Narcotic medication like Lortab, Norco, and Vicoden contain both Hydrocodone AND Tylenol (acetaminophen).

Your prescription bottle will have two numbers separated by a slash (/) symbol.

The first number represents the dose of the narcotic and the second represents the dose of Tylenol (acetaminophen).  Take only one tablet for your first dose to see how the narcotic will affect you and manage your postoperative pain.  Narcotics have side effects like nausea, drowsiness, dizziness, confusion, and constipation.  If you experience these side effects, you may want to use a half tablet or discontinue taking the narcotic.

MEDICATION WARNINGS

Misuse of narcotics can cause excessive sedation (sleep) which could lead to death.  DO NOT take Tylenol (acetaminophen) or any other medications containing Tylenol (acetaminophen) while taking your prescribed combination narcotic/Tylenol medication.  Please carefully read the list of ingredients in other medications you may be taking.

If you have liver disease or are on medications that stress the liver, inform your surgeon before taking the narcotics.  You are encouraged to discuss your liver condition and prescription medication with your physician and pharmacist BEFORE taking narcotics.

SIDE EFFECTS

Side effects from narcotics include nausea/vomiting, headaches, constipation, urinary retention (bladder distention), or hyperactivity.  Stop taking the narcotic if any side effects occur.

Itching with no visible rash can occur with narcotics.  25mg to 50mg of over-the-counter Benadryl (diphenhydramine) may be taken every six hours to control itching.  Continue to take narcotic as needed for pain control.

CAUTION: Taking Bendryl and narcotics will increase sleepiness.  Please be careful and start with the lowest dose of Benadryl to avoid excessive drowsiness.

Dizziness or a lightheaded feeling is a common side effect of general anesthesia or I.V. sedation.  When standing up, do so slowly to prevent dizziness.  If you are having dizziness, ask your caretaker to assist you.  Follow the prescribed dietary recommendations closely.  Dehydration can contribute to dizziness.

Fainting can occur when standing too quickly.  If you are dizzy or lightheaded at any time, get assistance from your caregiver.

Antibiotics

Follow the recommended dose carefully.  Do not wake up to take the antibiotic.  It is meant to be taken during waking hours.  Most antibiotics we prescribe should be taken after eating to reduce the chance of nausea.  If your prescription antibiotic needs to be taken on an empty stomach, it will say so on the prescription bottle.

Antibiotics can cause stomach or abdominal pain or loose stools because they affect bacteria in the intestines.  Taking a probiotic (found over-the-counter in the vitamin section of most stores) one hour before or two hours after taking antibiotics will replenish your intestine with good bacteria and lessen abdominal pain or loose stools.  Taking probiotics is a recommendation, but not a requirement.

Important: Antibiotics may render birth control ineffective during the menstrual cycle in which they are taken.