Post-Operative Instructions: Extraction (With Bone Grafting)

Immediately Following Surgery

• The gauze pad placed in the surgical area should be kept in place for 30 minutes. After this time, the gauze pad should be removed and discarded. Once you are home, please change the gauze and use firm biting pressure over the extraction site(s) until the bleeding stops.
• Vigorous mouth rinsing and/or touching the wound area following surgery should be avoided on the day of surgery, as it may cause bleeding.
• Take the recommended pain medication as soon as possible following the surgery, ideally before the numbness from local anesthesia has worn off.
• Restrict your activity on the day of surgery and resume normal activity when you feel comfortable.

Bleeding

• Bleeding is normal following surgery. Slight bleeding, oozing, or redness in the saliva or gauze pad is not uncommon and is expected. When the gauze pads have little or no blood on them, they are no longer necessary. It can take a variable amount of time for bleeding to resolve but usually resolves within a few hours, although a small amount of bleeding is common for up to 24 hours.
• Excessive bleeding (i.e., rapidly fills up or pools in your mouth) may be first controlled by gently rinsing or wiping any old clots from your mouth, placing a fresh gauze pad over the surgical site, and applying firm biting pressure on the extraction site for 30 minutes. Repeat as necessary. If excessive bleeding continues, you may apply biting pressure on the extraction site with a moistened black tea bag for 30 minutes. Repeat as necessary. Repeatedly replacing or using gauze in the absence of excessive bleeding (i.e., rapidly fills up or pools in your mouth) will delay the clotting process and prolong bleeding. If bleeding continues excessively, please call for further instructions.

Swelling

• Swelling is normal following surgery. Swelling may not present immediately following surgery, as it usually increases or peaks in the days following surgery. It can take a variable amount of time for swelling to resolve, but usually improves within a week or two.
• To minimize swelling, apply an ice bag, or a plastic bag or towel filled with ice, on the cheek or jaw outside the surgical area. Apply the ice continuously (20 minutes on, 20 minutes off) for the first 24 hours, as tolerated.
• Keeping the head elevated with a couple of pillows for the first few days following surgery can also help reduce swelling.
• Some patients, especially those on blood thinners, may experience cheek or jaw bruising following surgery. This is not unusual and typically improves over several days.

Diet

• In general, you may return to a normal diet as soon as possible unless otherwise directed.
• For the first day of surgery, eat soft foods and drink liquids as this will help with discomfort and help allow blood clots to form undisturbed.
• Avoid straws as this may cause the blood clot to dislodge.
• Avoid hot liquids and hot food as these may cause discomfort.
• You should be encouraged to eat regularly and drink plenty of fluids, as these will help with recovery.
• You may advance your diet to normal foods as your comfort and tolerance allows.
• If you had a bone graft placed at the time of your surgery, it is advisable to chew on the opposite side of the surgical site for 2 weeks following the surgery.

Pain

• Pain and/or discomfort is normal following surgery. Pain may not present immediately following surgery as it usually increases or peaks in the days following surgery. It can take a variable amount of time for pain to resolve, but usually improves within a week or two.
• You should take non-steroidal anti-inflammatory drugs (NSAIDs, e.g., ibuprofen) as first-line pain therapy, unless otherwise stated by your doctor. The recommended maximum daily dose of ibuprofen is 3,200 mg and, typically, two to four 200 mg tablets may be taken every 6 hours.
• If you are unable to take NSAIDs, acetaminophen (e.g., Tylenol^®) is recommended as first-line pain therapy. Typically, Extra Strength Tylenol may be taken every 4–6 hours.
• Ibuprofen and Tylenol, taken simultaneously, work as well or better than opioids in their pain management effect. Often, taking Tylenol between doses of ibuprofen provides better pain control than taking Tylenol at the same time as the ibuprofen.
• You may be prescribed an opioid pain medication (e.g., hydrocodone/acetaminophen). Typically, this is prescribed for “breakthrough pain” and can be taken with ibuprofen as a substitute for Tylenol. If your ibuprofen alone does not improve your pain, you may take ibuprofen and the opioid together. Often, taking the opioid between doses of ibuprofen provides better pain control than taking the opioid at the same time as the ibuprofen.
• It is recommended to take pain medication with food as this will help prevent nausea or stomach irritability.
• If you are taking an opioid pain medication, you should not drive or operate heavy machinery.
• Use pain medication as directed and taper your use as you feel more comfortable. If pain is not improved with the recommended pain regimen, please call for further instructions.

Oral Hygiene

• You should resume your normal dental routine after 24 hours. You can brush and floss as tolerated. If you had a bone graft placed at the time of your tooth extraction, it is advisable to avoid brushing directly on the graft site for 2 weeks following the surgery.
• Mouth rinsing should be avoided on the day of surgery. You may begin gently rinsing the mouth with warm salt water the day after surgery and continue for 1 week. You can dissolve a ½ teaspoon of salt in a small glass of warm tap water. Gently rinsing in the morning, at night, and after meals will help with recovery. Vigorous rinsing should be avoided as this may cause bleeding, discomfort, and loss of bone graft particles (if a graft has been placed).
• If you have been given an irrigation syringe, you may start irrigation of the extraction socket on the third day following surgery and continue until the sockets are closed (which may take 2–3 weeks). You can dissolve a ½ teaspoon of salt in a small glass of warm tap water and draw this into the syringe. You can place the tip of the syringe into the extraction socket to irrigate. Gently irrigating in the morning, at night, and after meals will help with recovery.
• Smoking should be avoided. Smoking may increase bleeding, increase pain, delay healing, and cause infection.

Activity

• Unless told otherwise, avoid vigorous physical activity, strenuous exercise, or heavy lifting (>20lbs) for 3 days following surgery. Early physical activity can increase your blood pressure, which can cause an increase in swelling, pain, bleeding, and loss of bone graft particles (if a graft has been placed). You may gradually increase your physical activity level as tolerated as you start to feel better.

Other Considerations

• In the event of nausea and vomiting following surgery, do not take anything by mouth for at least an hour. You should then sip on soda, tea, or ginger ale slowly over a 15-minute period. When the nausea subsides, you can begin taking solid foods and medication as prescribed. If nausea persists, please contact the office.
• Sutures are placed in the area of surgery to minimize post-operative bleeding and to help healing. Sutures placed will dissolve in approximately 5–7 days following surgery. Sometimes they become dislodged or fall out; this is no cause for alarm. Just remove the suture from your mouth and discard it.
• Immediately following the surgery, there will be a cavity where the tooth was removed. The cavity will get smaller and smooth over as it fills in with new tissue over the course of several weeks. If you had a bone graft placed at the time of tooth extraction, you will not have a large cavity.
• Osteitis (dry socket) is when the blood clot in the extraction socket dissolves or gets dislodged prematurely from the tooth socket. There are no certain ways to prevent dry socket, although measures such as avoiding straws, spitting, and smoking are recommended. Symptoms are typically throbbing pain radiating throughout the jaw or ear without improvement with pain medication. Typically, this occurs several days after surgery. While there is no necessary treatment for dry socket, if your pain is not improved with the recommended pain regimen, please call for further instructions.
• Slight elevation of temperature for the first 24–36 hours following surgery is not uncommon. Tylenol or ibuprofen may be taken to reduce the fever. If the temperature persists, please call for further instructions.
• Occasionally, following removal of a tooth, you may feel hard projections in the mouth with your tongue. These are the bony walls of the socket which supported the tooth. These projections usually smooth out spontaneously over time. On occasion, small bony spicules may loosen from the bony walls and project into your gum tissue. You may attempt to gently remove these by massaging them with a Q-tip^®. If these persist or become bothersome, please call for further instructions.
• 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^®.
• Sore throats and pain when swallowing are not uncommon as muscles get swollen. The normal act of swallowing can then become painful. This will subside in 2–3 days.
• 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.
• A large or unstable filling, crown, or fixed bridge near the surgery site may become dislodged at the time of surgery or shortly thereafter.
• Occasionally, root or tooth fragments that reside close to vital structures such as nerves, blood vessels, or sinuses may intentionally not be removed to minimize injury or involvement to these structures.

Additional Information If You Had A Bone Graft Placed

• Your bone graft is made up of many small particles. You may find some small granules in your mouth for the first several days. Do not be alarmed by these. It is normal to have some of them come out of the graft site and into your mouth.
• Do not disturb or touch the wound. Do not apply pressure with your tongue or fingers to the grafted area, as this may cause graft material to dislodge.
• Most sutures placed during the grafting procedure are dissolvable and will dissolve in approximately 5–7 days following surgery. Additionally, surgical glue may be placed to aid with healing. This glue will slough away in the days following the surgery. As the sutures and glue fall out, this is no cause for alarm. This does not mean your graft has fallen out. Just remove the sutures or glue from your mouth and discard it. Your gum tissue will slowly heal over the remaining bone graft.
• If you have been provided a prosthesis such as a “flipper” or an Essix retainer, or a full or partial denture, these generally can be worn immediately after surgery following confirmation by your doctor that wearing them will not disturb the surgical site. Sometimes these prostheses cannot be worn until the surgical site heals or they may require adjustments by your general dentist before wearing them.
• Most bone grafts heal uneventfully and take 3–4 months to heal. If you are concerned about the healing of your graft, please call for further instructions.