Immediately Following Surgery
The gauze pads placed over the surgical sites should be kept in place for 20 – 30 minutes. After this time, the gauze pads should be removed and discarded. It is not necessary to replace the gauze unless there is active bleeding. Vigorous mouth rinsing or touching the wound area following surgery should be avoided. This may initiate bleeding by causing the blood clot that has formed to become dislodged. Take the prescribed pain medications as soon as you get home, after you have had something to eat. Do not wait until you begin to feel discomfort. Restrict your activities the day of surgery and resume normal activity when you are off the prescription pain medication.
Place ice packs on the sides of your face where surgery was performed. Refer to the section on swelling for further information.
Some bleeding is to be expected following removal of the wisdom teeth, but this is usually minimal. Even after biting on the gauze pads, it is normal to have slight bleeding and oozing for the next 12 – 24 hours. Excessive bleeding is characterized by mouthfuls of bright red blood, or large rubbery clots. If this occurs, please try the following:
- Rinse the mouth (gently, not forcefully) with cool water.
- Wipe away any clots outside the socket with a clean gauze pad.
- Bite firmly on a moistened gauze pad placed directly over the extraction site for 30 minutes. If no gauze is available, you may substitute a moistened tea bag.
- Repeat all of the above as necessary.
It is important to avoid the use of any products that contain hydrogen peroxide, as these products may dissolve the blood clots at the site, and promote dry socket. Strenuous exercise, jogging, or sporting activities that may cause an increase in the blood pressure should be avoided for the first 48 hours. Some bleeding when brushing the teeth may occur for the first week following the surgery. This is completely normal, and should not be a reason to avoid brushing in this area. If bleeding does not subside, call for further instructions.
Some degree of swelling around the mouth, cheeks, eyes and sides of the face is normal after this type of surgery. This is the body’s normal inflammatory reaction to any injury. Similar to expectations about postoperative pain, we usually find patients anticipate much greater swelling than they normally actually experience. When you get home, place ice packs on the back portion of the lower jaw, as this is where the majority of swelling is seen. Despite these factors noted above, it is still normal for patients to be a little swollen for a couple of days, so anticipate that there will still be some puffiness of the cheeks near the surgical sites. The swelling usually peaks around 24 – 48 hours after the procedure
Ice has been shown to be beneficial for the first 12 – 24 hours, but after that time it has very little effect on reducing the swelling. If you are more comfortable applying ice, and want to use the ice pack the next day, it is perfectly acceptable to do this, but it will not make the existing swelling resolve any faster.
There are several things that can be done to minimize the swelling:
Keep the head elevated at a 30 – 45 degree angle. Lying flat will increase the blood flow to the head, and cause more bleeding and swelling.
Place ice packs on the sides of the face. Keep the ice packs on as much as possible for the first afternoon and evening following surgery. It is O.K. to take occasional breaks from the ice packs, but try to leave the packs in place as much as possible. Ice has been shown to be beneficial for the first 12 – 24 hours, but after that time it has very little effect on reducing any existing swelling. If you are more comfortable applying ice, and want to use the ice pack the next day, it is perfectly acceptable to do this, but it will not make the existing swelling resolve any faster.
On many occasions we may prescribe steroid medications for control of the swelling. These are not always necessary, but are often used when bony impacted lower teeth need to be removed. See below for more information about steroids. If swelling or jaw stiffness has persisted for several days after the surgery, there is no cause for alarm. This is a normal reaction to surgery.
On many occasions, we will prescribe steroid medications that are intended to significantly reduce the body’s inflammatory response (which is responsible for swelling in an injured area). These are not the same kind of steroids that most people associate with athletics or body building, but are similar to medications like Cortisone, which most people are familiar with as a medicine to reduce inflammation. We normally use a medication called SoluMedrol, which comes in a (6) day dosage packet called a Medrol Dosepak. We generally recommend that our patients start taking this medication on the day prior to surgery. There are (6) pills on the first day, (5) on the second, etc. We advise patients begin taking this medication starting the day before the surgery.
The day prior to surgery: Take (2) pills in the morning, (2) in the afternoon, and (2) at night before bed.
The morning of the surgery: Do not take any food or liquid by mouth prior to surgery, so wait until you return home after the surgery to start taking the swelling medication. There should be (5) pills in the pack, and it will say “Day 2”. After you have returned home, had something to eat, and taken your pain medication, you should take (1) swelling pill, then (2) more around mid-afternoon, and then the last (2) at night.
The remaining days: Follow the directions on the pack beginning with day 3.
As with any surgical procedure, there will always be some postoperative pain and discomfort. We normally recommend that as soon as the patient returns home from their surgery, they take the pain medication, even though they are still “numb” and not experiencing any pain. This way, the pain medication can begin to take effect as the numbness wears off, making the transition easier than if you were to wait for the pain, and then try to take the pain medication. As you will be on an empty stomach from your surgery visit, it is important that you have something soft and bland to eat as soon as you return home from the office before you take your pain medication. This is important, because most of our prescription pain medications can be very irritating to the stomach. The presence of solid food in the stomach can help counteract this, and will usually help patients tolerate the pain medication more easily. We recommend semi-solid foods, as just liquids alone may be insufficient to counteract the irritating effects of the pain medications. Examples would be foods such as macaroni & cheese, pancakes, scrambled eggs, oatmeal, etc.
Most people will require the prescription pain medication for the first 24 hours following surgery, and are then usually able to switch to the over-the-counter pain medications the following day. It is also important to remember that one should not drive cars or do anything that requires coordination or balance while taking the prescription pain medication
For minimal or moderate pain, Tylenol or Ibuprofen (Motrin or Advil) may be effective. With the Ibuprofen, the maximum dose is 2400 mg per day, which can be taken as two 200 mg tablets every 4 hours, or three 200 mg tablets (600mg) every 6 hours, or four 200 mg tablets (800mg) every 8 hours.
We recommend that you maintain a relatively soft and bland diet for the first few days after surgery. In general, most normal foods are O.K. after the first few days, but it would be best to avoid anything with seeds or particles, such as poppy seeds or sesame seeds. You should avoid popcorn for at least a month after the surgery. Contrary to popular belief, it is O.K. to use straws to drink liquids after surgery. The rationale was that the “suction” created when using the straw would “pull out the blood clots” and cause dry socket, or at least stir up bleeding. There is so little suction created by using a straw, that it is not likely that this will cause any problems at the extraction sites, or stimulate any significant bleeding. We actually prefer our patients to drink through a straw, as this allows the liquid to pass right by the surgical sites, without the liquid washing across the surgical sites that have just been operated on. High calorie, high protein intake is very important. It would be best to avoid very hot foods, as they can dilate the blood vessels in the area and create more bleeding, and may cause the stitches to dissolve prematurely. You should prevent dehydration by taking fluids regularly. Although it is normal to have a decreased appetite after surgery, you will feel better, have more strength, and heal faster if you continue to eat.
Do not forcefully rinse for the first several days. You can brush your teeth the night of surgery but, use a very soft bristle brush, and rinse gently. Expect to see a small amount of blood in the sink when brushing your teeth. This is very normal, and does not mean that you should stop brushing. Do not floss between the last two teeth near the surgical sites in all the extraction sites for at least 2 weeks. Remember to avoid any products that contain Peroxide, as this can very effectively dissolve blood clots, and contribute to dry socket formation. Check your toothpaste tube to see if there is any Peroxide present. The popular whitening toothpastes often contain Peroxide, so be sure to check the list of ingredients.
In some cases, discoloration of the skin follows swelling. The development of black, blue, or yellowish discoloration is due to a small amount of bleeding in the tissues just beneath the skin. This is a normal post-operative occurrence, and it may not be noticed until 2-3 days post-operatively. Moist heat applied to the area may speed up the removal of the discoloration.
Infection is uncommon in routine wisdom tooth surgery, but on some occasions may still occur. It is usually characterized by swelling that increases rather than decreases after the first several days. If swelling is noted to increase after the first several days, contact the office. Sometimes, late infections can occur that may not be seen until several weeks after the surgery. These normally respond quickly to antibiotic treatment, and usually do not require any further surgery.
Nausea and Vomiting
Nausea is our most common postoperative problem that can occur after surgery. It is most often due to the pain medications that are taken after the surgery, but can sometimes can occur after the anesthetic. Swallowing a small amount of blood after surgery is normal, and this can sometimes cause nausea as well. Usually, the intake of food will help settle the stomach, but sometimes, despite having eaten, the patient may still experience nausea. In the event of nausea and/or vomiting following surgery, you can take medications such as Maalox or Pepto Bismol, which may help settle the stomach down. Ginger Ale may also help in alleviating stomach irritation. When the nausea subsides you can resume taking solid foods and the prescribed pain medicine. In some cases of persistent nausea and vomiting, anti-nausea medications can be phoned in.
If numbness of the lip, chin, or tongue persists after the first postoperative day, please let us know. As stated before surgery, this is usually temporary in nature.
Slight elevation of temperature immediately following surgery is not uncommon. If the temperature persists, or becomes higher than 101.5 degrees, notify the office. Tylenol or Ibuprofen should be taken to reduce the fever.
You should be careful when going from the lying down position to standing. You were not able to eat or drink prior to surgery, so you may be slightly dehydrated. The pain medications can also make you dizzy. It may be possible that you could get light headed or faint when you stand up suddenly. Before standing up, you should sit upright for one minute before attempting to get up.
Occasionally, patients may feel hard projections in the mouth with their tongue. They are not roots, they are the bony walls which supported the tooth. These projections usually smooth out spontaneously. They will sometimes become exposed over time, and as they usually occur in the back part of the lower jaw, they can feel sharp to the tongue. If these sharp areas persist, contact the office, as they can sometimes be removed.
If the corners of your mouth are stretched, they may dry out and crack. Your lips should be kept moist with an ointment such as Vaseline.
Stiffness (Trismus) of the jaw muscles may cause difficulty in opening your mouth for a few days following surgery. This is a normal post-operative event which will resolve in time.
There will be multiple sutures in all of the surgical sites. Most commonly after wisdom tooth surgery, there is also normally a stitch between the last two teeth in the back of the jaw. Remember that there is a stitch in this area between the teeth so that you do not think it is a piece of food stuck between the teeth, and attempt to remove it. These sutures will come out by themselves over time. These stitches usually come out after 4 – 5 days, but it is not uncommon to lose a stitch after the first couple of days. Often, a suture will dissolve to the point where it becomes untied, and you may feel a “string” in the mouth. If you are able to see this loose suture, you may reach in and gently remove it. It you run into a “snag”, it is acceptable to carefully cut it short with a nail scissors. The remaining portion will dissolve and come out by itself.
The most common postoperative complication following Wisdom Tooth surgery is known as “dry socket”. This is where the blood clot that normally forms in the socket left by the tooth may dissolve away, leaving an empty socket with bare bone exposed to the mouth. This exposure of the bare bone in the socket is not a serious problem, but causes a dull aching pain, and when it does occur, nearly always occurs in the lower extraction sites. It usually takes at least 48 hours or longer for the clot to dissolve, so the usual scenario with a dry socket is that the patient does well for the first couple of days following the surgery, and then notices steadily increasing pain in one or both of the lower sites. Once a dry socket is recognized, it is usually easily treated by placing a small medicated dressing in the socket, which in most cases provides almost complete relief of the pain.