This is a list of detailed postoperative instructions. These serve as a general guideline and may not cover every situation. For specific questions, contact our office.

1. Pain.  Most patients will receive long-acting local anesthesia unless requested otherwise.   As the numbness of the area (anesthesia) wears off, pain will start.  The key to pain management is to take painkillers (analgesics) well before pain starts (i.e., take the pain killers at least two hours before) and keep taking them around the clock. The preoperative use of ibuprofen has been shown to effectively reduce overall pain levels.It is difficult to predict degree of pain after surgery since individual pain tolerance varies, and degree of pain will be somewhat proportional to difficulty and duration of surgery.

• Analgesics (Pain killers) – High-dose ibuprofen will be prescribed unless contraindicated.  Tylenol can be added to ibuprofen for greater pain relief.  Tylenol, either by itself or in combination with opioids, is prescribed as an alternative.

2. Swelling.  The use of cold compresses or ice packs is advised to minimize postoperative swelling.  Place an ice pack over the affected area for 20 minutes and remove it for 20 minutes.  Repeat the cycle.

• Cold compresses are unnecessary for routine extractions but advised after significant bone removal or large soft tissue flap elevation, like wisdom teeth extractions.

3. Discoloring/ Bruising. Bruising occurs when there is slow bleeding in the muscle layers occurring among the elderly population, and discoloration is due to oxidation of iron in hemoglobin.  The purplish discoloration will transition to blue and light green hues before gradually fading, typically within 7 to 10 days.

4. Bleeding. Active bleeding is managed before discharge.  Slight bleeding, oozing, or red saliva is not uncommon.  Postoperative bleeding on the first day is commonly associated with incorrect positioning of gauze, which is used to apply pressure at the surgical site.

• The best way to control bleeding is to bite down gauze(s) for two hours without interruption. Discard gauze when bleeding ends; changing it is usually unnecessary.

If it bleeds again, place gauze over the extraction site and bite down or hold down gauze with fingers for 30 minutes uninterrupted.  Repeat this until bleeding stops.  If gauze is unavailable, alternatives such as clean paper towels or paper napkins may be used.    Use of red tea bags or black tea bags may help with hemostasis.

Certain local and systemic conditions can cause prolonged bleeding, such as chronic inflammation around teeth, anatomic abnormalities, systemic conditions like hemophiliacs, low platelet count and chronic liver diseases may contribute.

If patients are taking anticoagulants, such as coumadin (Warfarin), clopidogrel (Plavix), rivaroxaban (Xarelto), apixaban (Eliquis), they must be stopped at least 4-5 days in advance, unless discussed with doctor prior to surgery.

If you have uncontrolled bleeding, go to an Emergency Room.

5. Diet   Maintain adequate hydration, particularly following IV sedation.

Patients can start with soft foods and gradually return to a regular diet as tolerated.

Avoid hot liquids (to avoid burn injury) or hard/crunchy foods (to avoid disruption of wounds).

Food particles will enter the extraction sockets even with proper precautions. The body’s healing mechanisms usually resolve this issue, except in cases where food is tightly packed in the socket.

6. Oral Hygiene

1. After extraction of teeth

   Do not rinse your mouth, brush your teeth, or use drinking straws on the day of surgery to avoid dislodging the blood clot.

   The primary focus is on resuming a regular diet and normal daily activities.   Bite down on gauze until bleeding stops.  Take analgesics (pain killers) as soon as possible.

   Sutures – If sutures are placed, most will dissolve within one week.

2. After extraction of teeth under IV sedation/general anesthesia

   Maintain adequate hydration particularly following IV sedation.

   Following IV sedation, do not drive or operate heavy machinery.  Do not make any important decisions after IV sedation.

   Do not get involved in strenuous activities or sports for 24 hours.

3. After extraction of (lower) wisdom teeth under IV sedation

   Combine instructions above of both A & B.

   Chance of dry sockets occurrence is higher after extraction of lower wisdom teeth.  Do not rinse your mouth, brush your teeth, or use drinking straws on the day of surgery to avoid dislodging the blood clot.  Avoid use of water pick or extreme gargling for 3-4 days.

   For many teenager patients, this may be their first surgery.  In numb mouth, it may be difficult to place gauze at the extraction sockets.  Bite down on gauze (to apply pressure over the wound, not just between any teeth) for two hours.  If it bleeds again, place gauze over the extraction site and bite down (or hold down with fingers) for 30 minutes uninterrupted.  Repeat this until bleeding stops.  If gauze is unavailable, alternatives such as clean paper towels or paper napkins may be used.

   On the following day, you may gently brush teeth away from the extraction sites and gently rinse mouth (gentle swishing, not vigorous gargling).  Gargling may be started on day four or five.  Do not use mouthrinse such as Scope or Listerine for 7 days.

4. After implant surgery
   The primary focus is to enhance rapid healing and to prevent infection.  Complete the course of antibiotics even though you don’t have pain.  If chlorhexidine mouthwash has been prescribed, begin using it the following day.  Do not use any other mouthwash for one week.

   Do not disturb the wound.  You may have soft diet, but avoid rinsing, spitting, or touching the wound for a couple of days to prevent loss of bone graft materials.

   Implants may be positioned underneath the gum, or metal healing abutments may be visible above the gum.   These implants require quiet time to heal.  Even the metal shows, do not apply any force, or push with your tongue, or shake it with your fingers.

   Partial dentures, flippers, or full dentures should not be worn for at least 10 days unless adjusted by the doctor.  Remove dentures as much as possible for healing of implants.

   Even after the implant crowns are placed, do not bite down hard foods or clench teeth for two to three months.  Allow time to get adjusted to new teeth.  Sometimes, doctors rush to deliver the crowns because of esthetics and patients’ comfort, but grafted bone and implant fixtures may require a few more months to get stronger.

5. After extractions and Bone Graft (Ridge Preservation)

   Ridge preservation is advised in cases where future implant placement is anticipated and substantial alveolar bone loss has occurred or is expected.   Without ridge preservation, the extraction socket can atrophy significantly, creating suboptimal conditions for implant placement.

   After extraction of a tooth, curettage and debridement of the socket are performed.  The bone graft material is placed first and the membrane is placed over to hold bone graft material together.  To prevent dislodging of membrane, its margins are carefully positioned under gum (gingiva), gum may be pulled to close the gap, and wound is closed using resorbable sutures.  The purpose of bone graft material and membrane is to prevent migration of epithelial tissue and allow bone precursors to grow into bone.  Although grafted bone typically requires several months to harden, and the initial bridging by bone precursors may take over two weeks.

   The main objective after ridge preservation is to keep the bone graft and membrane intact without infection or an opening in the periphery.

   Do not disturb the wound, surgical site, exposed membrane, or suture knots with your tongue.  Avoid rinsing, spitting, or touching the wound to prevent loss of bone graft materials.  Do not gargle vigorously for two weeks.

   Eat soft foods.

   Complete the course of prescribed antibiotics.  Chlorhexidine mouth rinse may be prescribed to help prevent infection.

   Immediate ridge preservation techniques are often correlated with increased patient discomfort, a higher risk of infection, and potential loss of graft materials.   If severe infection is present, then ridge preservation may be delayed.  Usually, smokers have poor outcomes with ridge preservation.

6. Sinus Bone Graft or any Surgery near the sinus or nose.

   Sinus bone graft or osteotome technique may result in nose bleeding.  Sometimes, there may be drainage of mucus or clear fluid.  Most often, it will stop shortly.  Tilt your head back and plug the nares with clean tissue paper.

   Do not blow your nose. Antihistamines and nasal sprays are allowed.

   Sinus bone graft (open, lateral approach) can cause significant facial swelling.  The application of an ice pack is strongly recommended on the day of surgery.   On the day of surgery, sleep with head elevated using two to three pillows.

   Completion of antibiotics is mandatory; failure can cause loss of bone graft material and openings into sinus.