Postoperative care and troubleshooting following wisdom teeth removal or dental extractions

Thank you for having surgery with me today. The following is a list of postoperative instructions and troubleshooting for any problems you may have after your surgery.

If you have any queries or concerns please do not hesitate to call my rooms on 03 7000 4000 or my after hours pager number for emergencies 03 93871000.

Please note the first part of the document has simple explanations for common problems you may encounter and there is a more comprehensive explanation for each area. Simply forward to the area of concern for a more detailed answer.

Postoperative Review

Regarding review after your surgery you have two options.

  1. Be seen if there are any problems but otherwise no specific review date set.
    The majority of patients after surgery heal very fast without problems. These days most patients are comfortable knowing if they develop any problems they can simply contact my rooms during office hours on 03 7000 4000 or my pager service after hours for emergencies on 93871000. I can easily see you within a short time frame if needs be or can answer any postoperative queries that way. This seems to be the most popular system in place.
  2. Arrange a routine follow up appointment usually about 2-3 weeks.
    Please let me know at surgery if you wish to set a routine review and I can get my staff to contact you to arrange a suitable date at one of my consulting premises close to where you reside. Occasionally I may request that I see you for a routine review to check if your surgery has been complex eg. nerve close at surgery, difficult surgery, implants etc. so I will advise you if this is the case on the day of surgery.

Normal Postoperative Events

Numbness: Your mouth and jaws will be numb for approximately 12-24 hours after surgery due to local anaesthetic being administered around where your surgery has been performed.

It is important to make sure you have taken pain relief before 12 hours so that by the time the local anaesthetic is wearing off you have adequate pain relief. (See Appendix 1 for a more detailed explanation)

Bleeding: It is normal for your wounds to ooze a bit after surgery despite stitches placed. This will often make your saliva look a bit red. This is completely normal but can often look like a lot when it dilutes in saliva. Do not spit out the blood as this only increases the bleeding. Most of this bleeding will settle after a few hours.

If you have troublesome bleeding the best option is to bite onto square gauze or an old handkerchief / cut tea towel for at least 20 minutes. Don’t keep taking it out and checking, you need firm constant pressure directly over the wound area. Often it is best to watch TV or read a book and time it. It is also important to sit in a chair and relax as moving around only encourages bleeding. If this fails to alleviate the bleeding after numerous attempts and it is a big amount of blood filling your mouth please call my rooms during normal hours on 03 7000 4000 or my after hours emergency pager service on 03 9387 1000 (See Appendix 2 for a more detailed description)

Stitches: These are dissolvable and should fall out after 1-2 weeks. Occasionally they can persist for a while and if they are annoying you please return to see me to have them removed. If you swallow them this is no problem. (See Appendix 3 for a more detailed description)

Pain: It is normal for you to have pain for approximately 3-5 days during which time you should take the pain relief prescribed by the anaesthetist. Most patients after this surgery can wean or cease their pain relief after 4-5 days down to Paracetamol, Ibuprofen. Pain that is increasing after 4-5 days is a bad sign and may indicate dry socket or an infection. If this is the case please call my rooms for a review as its best to get onto these problems early.

Eating and Diet: On the first day you should return home and have a liquid diet such as soup, jelly, custard, smoothies and yogurt. On the following day you can commence soft foods such as well cooked meat, pasta, noodles and vegetables. It’s best that you eat using your front teeth to chew. After one week most patients who have had wisdom teeth removed can commence normal foods but still be careful for about another week to not accidentally damage your healing wounds.

Mouth care: On the first night of your surgery you can brush your teeth as best you can to freshen your mouth but do not start any mouth rinses until the following day. The following day you can use salt water rinses ( 1-2 teaspoons of salt in a small glass of luke warm water) or alternatively any of the commercially available mouth rinses such as Savacol, Chlorhexidine, very diluted Listerine etc. You should do your mouth rinses 3-4 times a day for 1-2 weeks if possible.

Swelling: Swelling is a normal consequence from surgery and usually peaks at about 48 hours and most of it has resolved by 5-7 days. To reduce swelling apply icepacks to your face using a sports gel pack or frozen bag of vegetables for approximately 15 minutes on and off over the first 48 hours. This also has the added benefit soothing the area and many patients feel it reduces their pain. Also remember to sleep up at about 20-30 degrees using pillows as lying flat encourages swelling for the first 3-4 days.

Swelling that returns after one week is usually a sign of infection so you will need to make contact with my rooms if this occurs. Don’t go to your GP or local dentist.

Bruising: Some patients experience bruising later in the week of surgery. It seems to vary from person to person and does not to correlate with the complexity of their procedure. It can range from simply along the jaw line or into the neck and rarely can extend with gravity to the collarbone area which is where the term “the dentist bruised my chest taking out my wisdom teeth” arises. The bruising should resolve quickly with 1-2 weeks.

Exercise: Most patients can resume exercise after 5-7 days. The main danger is bleeding by raising your blood pressure and vascularity to the head and neck area. It is important that you rest in the first 48 hours though.

Normal wound healing: Your wounds will initially feel puffy and you will feel the ends of the stitches in the wound. After the stitches fall out the swelling in the wound will go down and you may feel it heal flat or alternatively you may have hole or defect where the wisdom tooth was lying. You have been provided a Monoject syringe that can be used after 7 days to start flushing out the wound any debris. The hole will heal very fast as your gum and bone regenerates where the tooth was sitting so you can stop using the syringe after 2-3 weeks.

When you look at the wound in the lower wisdom tooth site it often looks a little white in the first few days due to more keratin being formed as part of normal wound healing. Sometimes patients think this is infection but it is normal and will disappear after a few days. (See Appendix 4 for a more detailed description)

Antibiotics: You will be sent home with a five day course of oral antibiotics. Occasionally they can cause nausea, vomiting or diarrhea. If this is the case please cease taking them.

Constipation: A side effect of opioid containing pain relief such as Panadeine, Mersyndol and Endone are that they can cause constipation. It’s important to have a high fluid intake and plenty of fruits and vegetables. If you experience constipation a simple laxative such a Coloxyl can be purchased over the counter at your pharmacy.

Reasons to be concerned

Pain increasing: This is often a sign of infection or dry socket. An infection usually occurs 1-2 weeks after surgery with return of swelling in one site, bad taste or discharge, pain and fever. Please call my office or after hours emergency pager number if this occurs as I will need to see you either that day or the following morning for a review. Often I can call a local pharmacy to arrange an antibiotic to be dispensed so these can be commenced promptly.

Dry Socket: A dry socket is not a true infection but basically occurs when the blood clot is lost too early from the wound leaving your jawbone exposed with your saliva chemically irritating the bone. It is very painful and normally occurs about 4-5 days after surgery but can occur later. It is more common in older patients and usually a lower jaw extraction site is most commonly involved. The pain often radiates to the temple or ear and does not respond to strong pain relief. There is often no swelling. The best way to explain it is that the wound has opened too early before having a chance to heal.

The treatment for dry socket is to see me at my rooms and have a dressing called Alvogel applied. This numbs up the area locally and protects the underlying bone to allow it to heal quickly. The pain relief is usually very rapid.

To prevent dry socket please do not start rinsing your mouth until the day after your surgery as there is a theory that mouth rinsing too early can wash out your clot.

Reasons to contact my rooms for a review

Bleeding that is not responding to local pressure to the wound as described above. It’s not common to have serious bleeding after wisdom teeth removal and most of the time by putting direct pressure over the wound will stop the bleeding. If you have done this for at least 5-6 times and it is not working and the blood is filling your mouth please call my pager number after hours on 03 9387 1000 or rooms in hours on 03 7000 4000

Swelling returning after a few days indicates an infection and needs review and antibiotics prescribed.

Pain increasing after a few days indicates a dry socket that needs to be dressed to relieve.

Appendix 1: Local Anaesthetic given at surgery.

At your surgical procedure a long acting local anaesthetic has been administered at the site of the surgery. This typically makes the area of surgery numb for 12-24 hours. If you have had lower jaw surgery e.g. wisdom tooth, your cheeks, lips and tongue will be numb for that period as I have given a nerve block that covers those areas. In the upper jaw it is usually closer to the site of the actual surgery.

It is very important that you don’t accidentally chew your lips, tongue and cheeks whilst numb as this can cause painful ulceration at the site of trauma. Children are particularly prone to this as they attempt to feel how numb it is so bite into the soft tissues, so this needs to be emphasized.

Ongoing numbness can mean I have worked close to a nerve, ongoing meaning greater than 24 -72 hours. Remember that this doesn’t mean permanent numbness as whenever you work close to a nerve bundle it typically stops working for a period. Tingling, electric pulses and buzzing are signs of nerve regeneration.

For pain relief after surgery its best that we capture the period of time the numbness is wearing off with you taking reasonable pain relief. So for example if you have had your wisdom teeth removed I would expect you to start having pain at about 8-12 hours postoperatively as the local anaesthetic starts to wear off. I would recommend you take the pain relief prescribed even if you have no pain at about 6 hours postoperatively so they are working effectively before the numbness wears off.

Appendix 2: Postoperative Bleeding

As stated above it is normal for slight bleeding post surgery for a few hours. Direct pressure with gauze is the best way to control this oozing. So simply bite firmly on the gauze provided. It is not unusual for some minor persistent oozing for the first night, so a good idea is to put an old towel over your pillow as the bloody saliva that trickles out of your mouth can easily stain your pillow.

Very rarely you may experience a decent bleed post surgery that means you need to call me on 03 93871000. This would be after a few attempts of putting pressure over the wound. The reason for the bleeding can be a soft tissue bleeder or alternatively a vessel in the bone. At surgery I am very careful to make sure that there is not obvious bleeders but at the procedure most vessels spasm so you can occasionally miss one. To fix a serious bleeding issue can mean numbing you up again with local anaesthetic and placing more sutures or packing the wound. Despite sounding complex this is normally a very easy procedure.

Occasionally at about 7-10 days post surgery, if you have an infection it can present with a bleed with bloody saliva. If this is the case please make contact as you will need to take antibiotics and possibly have some further stitches placed.

Appendix 3: Stitches

Stitches are used at surgery to control bleeding and bring the wound edges together to speed up healing. The ones used in the mouth generally fall out after about 1-2 weeks but can persist in some people for longer than that period. If they are still present at 2 weeks, placing a small blob of toothpaste on your finger and gently rubbing them usually causes them to fall out.

Stitches outside of the oral cavity are normally nylon based and need me to remove them at about one week. An appointment will be made with you to have this performed. Occasionally a stitch comes loose early. Don’t panic if this occurs as the wound will still heal very well and I generally place enough stitches so if one does come away it is no concern.

Appendix 4: Normal Healing

When surgery is performed to remove a tooth there is damage to the bone and soft tissue. This means that the bone and soft tissue needs to heal and regenerate. You can imagine that by removing a tooth or working on the bone means there is a defect in the jaw. Early during the healing phase this fills with a blood clot, which subsequently has inflamed healing tissue present, called granulation tissue and then finally new bone formation. The soft tissues above the bone become inflamed and new tissue grows over the bone. It normally looks a bit bizarre in the wound for about the first week. Its is normal for it to appear whitish due to extra keratin being made as normal healing, a bit like the flaky skin you get around a cut as it heals on your skin. Due to the mouth being moist it looks quite white but this is normal.

Whilst the bone heals where surgery has been performed there can be a divot or hole in the gum. The base is the healing tissue that will become bone with time. During that healing time it is not unusual to get food in the site. You can use mouthwash, saline or even water to flush it out. Over about a 2-3 week period this usually disappears.

In older patients the bone healing is a bit slower following surgery. So if you are over 30 years of age it might take 4-6 weeks for the hole to disappear. It is just a slower period compared to when you were younger. The danger is if you are getting food caught in the site and not flushing it out it slows the healing process so please keep your hygiene of the site very good.

Appendix 5: Antibiotics during and post surgery

The mouth contains many bacteria that love to infect the site of surgery, usually about day 5-7 post procedure.

During the surgery you are given antibiotics via the IV cannula placed by the anaesthetist and subsequently oral antibiotics for home for 5 days. The evidence suggests that this can reduce your chance of a postoperative infection. Whilst it is not absolutely necessary to take them post surgery it is my recommendation that you do to prevent an infection.

Sometimes antibiotics can make you sick, e.g. nausea, vomiting, diarrhea. If this is the case please stop them immediately and the above symptoms should settle. Also they can cause swelling or a rash, typically on your trunk, arms, neck or face. If this occurs it’s a sign of an allergy and please cease them immediately. If the rash is itchy and annoying or blistered like welts please taken Claratyne or Telfast and these are antihistamines and can reduce settle the rash and symptoms quickly.