Wisdom Tooth Removal

Postsurgical Instructions Wisdom Teeth Extraction with General Anesthesia

Care of your mouth after surgery has an important effect on healing. Swelling, discomfort, restricted jaw function, and skin discoloration is to be expected. However, following these instructions closely will help to insure a rapid and uneventful recovery.

Sedation slows reflexes for 24 hours

The effect of the general anesthetic can make you lightheaded, dizzy or faint if you get up too quickly. Sit for 1 minute before standing up. Move slowly and be aware that you may need to sit down immediately. Do not drive or operate machinery for 24 hours after sedation.

Pain Management Overview

Baseline Pain Control Regimen

• 650 mg Tylenol (Acetaminophen) 2 x 325 mg tablets 4 times per day. Breakfast, lunch, dinner, and right before bed. (Avoid Tylenol if you have been told not to take this medication or have liver failure)
• 200-600 mg Advil (Ibuprofen) 1-3 x 200mg tablets 4 times per day. Breakfast lunch, dinner, and right before bed. (Avoid ibuprofen if you have been told not to take this medication or if you have a history of stomach ulcers, kidney disease, or take a blood thinning medication)

If Additional Pain Control is Needed

• 2.5 – 5 mg Oxycodone ½ – 1 x tablet up to 4 times per day if needed for additional pain control.
• Do not stop taking the baseline pain control regimen if you need the oxycodone

Pain Management Philosophy and Science

• Postoperative pain control is of paramount importance to us and our patients after surgery. We want you to be as comfortable as possible as you recover from your surgery. When you return home and the local anesthesia (numbing medicine) wears off, you will transition to oral pain medications to assist in pain control. The goal of postoperative pain management is to use oral pain medications to reduce pain to a tolerable level while the body heals and reduces pain naturally overtime. This may result in a maximal oral medication regimen which can be progressively decreased over the recovery process.
• Modern medicine uses three common classes of medications to achieve this goal, Acetaminophen (e.g. Tylenol), Non-Steroidal Anti-Inflammatory Drugs (NSAID e.g. Ibuprofen/Advil), and opiates (e.g. Oxycodone). Each act on different pain pathways within the body which allows them to all work synergistically at the same time. Using different classes of pain medications allows us to maximize the potential benefits of any one class while minimizing their respective side effects. During the postoperative period we want to maximize your pain control while minimizing any potential side effects.
• All pain medicine should be used in an “as needed” fashion. If you are not in pain, you do not need to take pain medicine. However, the baseline pain control regimen outlined above can be more effective if taken on a “scheduled” basis, regularly spaced time intervals, during the postoperative period where significant pain is anticipated. The baseline pain control regimen is more effective if taken on a “scheduled” basis rather than waiting for significant pain before taking the pain medicine. This “scheduled” strategy allows you to maintain a constant level of pain control in your blood which ultimately results in more effective pain control. If you would like to take the baseline pain control regimen on a “scheduled” basis to maximize its effectiveness we recommend taking these medications ~ 4 times per day, convenient times for most patients are breakfast, lunch, dinner, and right before you go to bed. The baseline pain control regimen can be taken together as instructed above for up to 1 week without concern for significant side effects in a healthy patient. However, if you find yourself continuing to need a “scheduled” baseline pain control regimen after 1 week, please let us know so we can make sure that you are healing appropriately.
• Opiate derived pain medications, like oxycodone, have rightfully received a lot of attention in the media recently due to their addictive potential. While this class of medication can be addictive it is important to note that addiction occurs when these medications are used for prolonged durations for chronic pain, not for acute postoperative pain. As such, these medications are safe to use as prescribed for a short duration after your surgery. However, they have other side-effects as well such as nausea, constipation, and drowsiness which are undesirable. As a result, we still reserve this class of medication for as needed additional pain control if the baseline pain control regimen above is insufficient.
• We hope all our patients recover as painlessly as possible. However, recovering from surgery is typically uncomfortable. The strategies and philosophies outlined above will not make the recovery from surgery painless, but they should serve to reduce the pain to a tolerable level while the body heals and subsequently reduces pain naturally. If you ever feel that the pain is unbearable despite these medications, please let us know so we can make sure that you are healing appropriately.

Bleeding Overview

• “Oozing blood” – Saliva mixed with thin, pink blood is normal for 24 hours spontaneously and 72 hours with oral activity (eating, drinking, brushing teeth etc.)
• “Significant bleeding” – Dark red, thick clots which collect in the mouth. This amount of bleeding should be treated with pressure as described below. If it does not resolve with the methods below you should call our office 650-342-0213 to reach the doctor on call or go to the emergency room for evaluation.
• Stopping Bleeding – Prolonged pressure stops bleeding. Gauze, itself, does not stop bleeding. Gauze is simply a way to apply pressure. To apply pressure using gauze, fold the gauze ~ 4 times into the size of a Quarter and place the gauze directly on top of the bleeding area. Apply pressure by biting down or using your thumb or index finger for 30 minutes.

Bleeding Management Philosophy and Science

• Immediately after surgery gauze was likely placed in your mouth to help create pressure to reduce bleeding. This gauze can be removed ~ 30 minutes after surgery, typically by the time you get home from your procedure.
• Always remove gauze when eating or sleeping. NEVER SLEEP WITH GAUZE IN YOUR MOUTH.
• “Oozing blood” is thin, light red, saliva that may persist for up to 24 hours spontaneously or 72 hours after oral activity such as tooth brushing or eating. Oozing blood is not harmful and is likely more trouble to try to stop then to allow it to resolve naturally. This small amount of blood is not dangerous and it is best to just swallow then try to spit or wipe out. Spitting or wiping out this blood often causes the bleeding to persist or worsen. Swallowing this amount of blood will not contribute to nausea.
• “Significant bleeding” forms dark red, thick clots which are the consistency of a stewed tomato. These clots often slowly fill the back of the mouth or area between the teeth and cheek until they are wiped away or spit out. These clots are a sign of uncontrolled bleeding which your body is having a hard time stopping on its own. This bleeding needs to be controlled by using the strategies listed below. If does not resolve you should seek urgent medical attention.
• Pressure Stops Bleeding. Your body can form a healthy clot and stop bleeding naturally as long as the bleeding is slowed for a long enough time to allow for clot formation. Bleeding can be slowed by applying direct pressure to the area that is bleeding. Therefore, it is prolonged, targeted pressure which allows your body to form a clot and stop bleeding naturally. Once a clot is formed, and the bleeding has stopped, pressure is no longer necessary.
• Gauze is a vehicle by which pressure can be applied. Gauze, itself, does not inherently stop or slow bleeding. Gauze allows you to easily apply focused pressure in your mouth to the area that is bleeding. In order for gauze to apply effective pressure you should fold the gauze ~ 4 times to the size of a quarter such that it is a tight wad. Place this directly over the area of bleeding and apply pressure. Pressure can be applied in two ways in your mouth. The most common and convenient is by biting on the gauze firmly. This requires a tooth opposing the area of bleeding. However, if there is not a tooth opposing the area of bleeding, biting may not be an effective way to apply pressure. If you are having a hard time applying pressure because you do not have an opposing tooth, you can use your thumb or index finger to press firmly on the gauze to create pressure. Regardless of how you apply the pressure, pressure must be applied constantly and firmly for up to 30 minutes. If you are having trouble stopping the bleeding, adhering strictly to these guidelines can help.
  1. Fold the gauze tightly and placed directly over the site of bleeding
  2. Hold firm, constant pressure for 30 minutes by biting or with a finger/thumb
  3. Look at the clock when you start to time 30 minutes, this may feel like a long time
  4. During this 30 minutes of applied pressure do not drink, spit, eat, or talk as this will break the period of constant pressure and restart the clock.
• If, despite trying the above measures, significant bleeding persists please call our office at 650-342-0213 to reach the doctor on call or seek urgent medical attention at the nearest emergency department.

Swelling Summary Swelling Reduction Strategy

• First 72 hours –Limit Swelling Accumulation
  1. Apply ice to limit accumulation of swelling. 20 minutes on and 20 minutes off while awake. (e.g. ice packs and head wrap provided, frozen peas/corn)
  2. Take NSAIDs (Ibuprofen/Advil) if instructed as part of the baseline pain control regimen above
• After 72 hours – Promote Resolution of Swelling
  1. Apply moist heat to promote drainage of swelling which has accumulated during initial healing phase. (e.g. clay heat packs sold in drug store, moist towel heated in microwave)
  2. Elevate your head while sleeping and resting by using several pillows such that your head is above your heart.

Swelling Management Philosophy and Science

• Swelling is a natural part of your body’s healing process. During the early phases of recovery from surgery tiny vessels called capillaries become increasingly porous resulting in fluid escaping and accumulating in your tissues. This accumulation of fluid allows for your body’s healing machinery to access the injured area. However, this typically results in undesirable tension and a reduction in range of motion of muscles in the area. Both of these things can contribute to postoperative pain and discomfort which is why we attempt to reduce postoperative swelling, although we will never eliminate it completely.
• Swelling is a natural part of your body’s healing process and typically begins hours after surgery ends and continues to increase over the next 48 to 72 hours. As a result, we expect the average patient to be the most swollen on ~ day 3 after surgery. During this period of increasing swelling we have two methods of reducing swelling, ice and NSAIDs (Ibuprofen/Advil). Ice causes constriction of the small vessels in the area which results in a reduction of the fluid that escapes and thereby reducing the accumulation of swelling. Ice should only be applied when a patient is awake because prolonged application of ice can result in burns. We recommend 20 minutes of ice application to the affected area and a 20 minute period to allow the tissue to recover, repeating this cycle while you are awake. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen/Advil reduce signaling pathways in your body which reduce pain mediators and the accumulation of swelling.
• We expect swelling to peak ~ 72 hours after surgery and then slowly dissipate. Swelling typically takes much longer to dissipate than to accumulate. During this period of swelling resolution we have two methods to reduce swelling, moist heat and elevation. Moist heat promotes dilation of the small vessels in the area and allows the body to recapture accumulated fluid and remove it from the affected area more efficiently. Moist heat should be warm, but not so hot that it causes discomfort. Moist heat can be applied using warmed heating pads available at most pharmacies or with a damp towel heated in the microwave for a short duration. Elevating the surgical area allows gravity to naturally pull swelling from the surgical site. During the day most patients naturally elevate their head, however, sleeping on several pillows such that the head remains elevated at night as well can further expedite the resolution of the swelling.
• Swelling is part of your body’s natural healing process and we cannot eliminate it entirely. Swelling typically peaks ~ 72 hours after surgery and can contribute to postoperative pain and reduced mobility while healing. We can reduce its accumulation and promote is resolution by implementing the strategies outlined above.

Diet

• While You are Numb – For the first few hours after returning home your lips will still be numb from the local anesthesia given during surgery. While your lips and tongue are numb it is safe to eat and drink, but best to not chew to avoid inadvertent injury when accidently biting or burning your lip or tongue. Examples of foods you can eat without chewing include any liquid, smoothies, milk-shakes, ice cream, yogurt, creamy soups etc.
• After the Numbness Wears Off –  Numbness of the lips and tongue may persist through the first evening. Once the numbness begins to wear off you should let your body be your guide to your diet. The first ~ 3 days it is going to be much more comfortable to eat small bites of soft foods. However, very few foods are dangerous at this time, some may just be uncomfortable or painful to eat if they require significant chewing and should be avoided for comfort. The only foods that need to be specifically avoided are anything with small seeds or kernels such as popcorn which can cause a problem if they become lodged in the extraction sockets. Eating is important for your body to recover. Do your best to eat small meals multiple times per day, up to every 2-3 hours. This will help you get your energy back and make the pain medicine easier on your stomach. Finally, do not rinse vigorously, suck on a straw, spit, or smoke, for the first 48 hours.

Miscellaneous

• Dry Socket – A “dry socket” is a painful condition that results from premature loss of the blood clot and irritation of the underlying bone of the jaw. Symptoms of a dry socket typically occur on the 4th or 5th post-operative day. Sudden increased, severe, throbbing pain, which is not responsive to pain medication is the most common symptom. This condition is similar to a sunburn. It is not inherently dangerous but is painful until it heals. Fortunately, our doctors can treat a dry socket by placing a topical dressing inside the socket. It does not make the dry socket heal faster but it does make it less painful while it is healing, much like aloe on a sunburn. Pain relief is often immediate once the site is treated. A few visits may be necessary in some cases.
• Nausea – If you experience nausea or vomiting stop taking the pain medication and soft foods. Wait for 1 hour for the nausea to pass then sip on coke, tea or ginger ale slowly over a 15-minute period. Follow this with clear broth and crackers. Advance to more solid foods slowly.
• Tooth Brushing and Mouth Rinse (Peridex) – Starting the day after surgery, you should brush your teeth and rinse gently. After brushing your teeth, you should use the prescription mouth rinse (Peridex) provided to rinse gently for 30 seconds and spit. This will help supplement tooth brushing and keep the mouth clean. Your surgical site heals best next to clean teeth but you do not need to do anything that hurts.
• Sharp Edges/Sutures – If you feel something hard or sharp edges around the surgical areas, you are likely feeling the bony walls, which once supported the removed tooth or the ends of the sutures. Occasionally, small slivers of bone may work themselves out during the following weeks. This is normal but if they cause concern or discomfort, please call the office. Dissolvable stitches begin to melt away as you heal. Generally, stitches fall out when you are eating and are digested normally. If they fall out when not eating you may notice them in your mouth. They will look like a small noodle. These sutures may begin to fall out after 1 day or last up to a week. It is never too early for a suture to fall out. Even if it falls out the day after surgery, it does not need to be replaced.
• Mouth Opening Exercises – Starting on day 2 after surgery, most of the pain is due to muscle pain from the large muscles near the lower wisdom teeth. Try to open your mouth wide enough to put 1 or 2 fingers vertically in your mouth once an hour. This will help increase mobility of these muscles and eventually decrease soreness.
• Allergic Reaction – If you develop hives or a rash, discontinue all medications and immediately contact our office.

Telephone Support 24/7: (650) 342-0213

Post-surgical follow-up is an important part of your care. We want you to have a successful and comfortable recovery. Please call the office if you have any questions or concerns about your procedure or postoperative healing.