I. General Instructions for Oral Surgery

The Day Before Surgery:

1. Start taking the medication prescribed by our office, following the instructions on the prescription bottle.
   

The Day Of Surgery:

1. Take none of your medication prescribed by our office unless you have received special instructions from our office. For instance, patients who are required to take antibiotics prior to any dental procedures (i.e. for mitral valve prolapse, history of rheumatic fever, prosthetic joints, etc.) should take those antibiotics with sips of water. Also, some patients may take a pre-operative sedative for anxiety or an antiemetic to prevent nausea prior to surgery with sips of water.
   
   
2. Dress casually. Please wear either short sleeves or loose, unbuttonable cuffs. Ladies, wear either slacks and a shirt or a two-piece dress; no girdles or high heels; and please remove all fingernail polish prior to surgery.
   
   
   1. Contact lenses, jewelry, and dentures must be removed at the time of surgery. If you have an illness such as a cold, sore throat, stomach or bowel upset, please notify the office.

II. Anesthesia instructions if your surgery is to performed with:

Local Anesthesia:

1. Have a light meal a few hours prior to surgery.
   
   
2. For more intensive procedures, you may wish to have someone drive you home.
   
   
3. Plan to rest for a few hours after surgery.
   

Intravenous Sedation or General Anesthesia:

1. Nothing to eat or drink (including water) for 6-8 hours prior to surgery. If you are taking regular medications, please check with the doctor as to whether or not you should take them the morning of the surgery. If you are told to take them, take them with only a small sip of water.
   
   
2. You MUST have a responsible adult accompany you to our office on the day of your surgery. This person must remain in our reception room while the procedure is being performed, drive you home, apply ice to the face, and take care of you until the effects of the anesthesia have completely diminished and you are physically capable of taking care of yourself.
   
   
3. Plan to rest for the remainder of the day. Do not drive a vehicle, operate power tools, machinery, etc. for 24 hours after surgery.
   
   
4. No smoking at least 12 hours before surgery. Ideally, cut down or stop smoking as soon as possible prior to the day of surgery.

**Patients taking birth control pills in conjunction with prescribed antibiotics should either refrain from sexual activity or take alternative precautions while taking the antibiotics.  Such combinations of medications have led to reported cases of ineffective birth control pills, contributing to unplanned pregnancies.

III. After Oral Surgery

Post-operative care is very important. Unnecessary pain and the complications of infection and swelling can be minimized if the instructions are followed carefully.

Immediately Following Surgery:

1. You will leave our office with gauze over the surgical areas. You will take the gauze out when you get home. At this time, you will need to drink at least 8 oz. of clear liquids containing sugar. For example Gatorade, sports drinks, soft drinks or even sweet tea is often sufficient. If your general health does not allow sugar containing liquids (e.g. some diabetic patients,) you may drink just clear liquids. After liquids have been ingested, place more gauze over the surgical areas and leave for about 30-45 minutes. After this time, the gauze should be removed and discarded.

Please note: Drinking clear fluids after surgery is important to minimize any effects of swallowing blood on an empty stomach as this can cause nausea and/or vomiting.

1. Vigorous mouth rinsing or touching the wound following surgery should be avoided. This may initiate bleeding by causing the blood clot that has formed to become dislodged.
   
   
2. Take the prescribed pain medicine as soon as you feel discomfort. This will usually coincide with the local anesthetic wearing off.
   
   
3. If a surgical packing (other than the absorbent gauze) was placed over a surgical site, leave it alone. If it gets dislodged or falls out, do not be alarmed. Please contact our office the next business day during normal business hours for additional instructions.
   
   

Bleeding

A certain amount of bleeding is to be expected following surgery. Slight bleeding, oozing, or redness in the saliva is not uncommon. Excessive bleeding may be controlled by first gently rinsing or wiping any old clots from your mouth, then placing a gauze pad over the area and biting down firmly for 30 minutes. Repeat if necessary. If bleeding continues, bite on a moistened tea bag for thirty minutes. The tannic acid in the tea bag helps to form a clot by constricting bleeding vessels. To minimize further bleeding, do not become excited, sit upright, and avoid exercise. If bleeding does not subside, call for further instructions. If you have had an immediate denture placed, do not remove the denture unless the bleeding is severe. Expect some oozing around the sides of the denture.

Swelling

The swelling that is normally expected is usually proportional to the extensiveness of the surgery. Swelling around the mouth, cheeks, eyes and sides of the face is not uncommon. This is the bodyís normal reaction to surgery and healing. The swelling will not become apparent until the day following surgery and will not reach its maximum until 2-3 days post-operatively. However, the swelling may be minimized by the immediate use of ice packs. A ziplock bag filled with ice or commercial ice packs should be applied to the side(s) of the face where surgery was performed as soon as possible after surgery. The ice packs should be left on continuously while you are awake. After 36 hours, ice has no beneficial affect. If swelling or jaw stiffness has persisted for several days, there is no cause for alarm. This is a normal reaction to surgery. Thirty-six hours following the surgery, the application of moist heat to the sides of the face is beneficial in reducing the size of the swelling. Many patients may be prescribed Dexamethesone or Medrol tablets to help reduce post-surgical swelling. Please take those as directed for best results. There is also some good anecdotal evidence that drinking 1-2 glasses (12 ounces) of pineapple juice a day for 7-14 days prior to surgery may reduce swelling especially for more extensive oral surgical procedures (such as orthognathic surgery or difficult wisdom teeth.)

Pain

For mild to moderate pain, 500mg of Tylenol may be taken every 6 hours or 600mg of Ibuprofen (Motrin or Advil) may be taken every 6 hours for 2-3 days after surgery if you normally tolerate these over the counter medications.

For severe pain, take the narcotic pain reliever prescribed for pain as directed. The prescribed pain medicine may make you groggy and will slow down your reflexes. Do not drive an automobile or work around machinery. Avoid alcoholic beverages. Pain or discomfort following surgery should subside more and more each day. If pain persists, it may require attention and you should call the office.

Please note that many of the prescription pain relievers such as Lortab (Hydrocodone) and Percocet(Oxycodone) often already contain Tylenol (known as acetaminophen and abbreviated APAP.) Taking additional Tylenol is not advised, however, taking intermittent doses of Ibuprofen (Advil or Motrin) between the narcotic pain reliever usage may improve the pain relief. If you are taking a narcotic that does not contain Tylenol or Ibuprofen (examples include Merpergan Fortis, Meprozine, Demerol) then taking the recommended doses of Tylenol or Ibuprofen as previously described will improve pain relief

Diet

After IV anesthesia, clear liquids should be taken at first. Milk products are not recommended until you have had the clear fluids and have successfully kept them in you stomach for at least an hour. Do not use straws. Drink from a glass. The sucking motion can cause more bleeding by dislodging the blood clot. You may eat anything soft (jellos, puddings, soup, etc.) by chewing away from the surgical sites. If you have had a denture placed, remain on liquids and soft foods until otherwise instructed. High calorie, high protein intake is very important. Nourishment should be taken regularly. You should prevent dehydration by taking fluids regularly. Your food intake will be limited for the first few days. You should compensate for this by increasing your fluid intake. At least 5-6 glasses of liquid should be taken daily. Try not to miss a single meal. You will feel better, have more strength, less discomfort and heal faster if you continue to eat. Caution: If you suddenly sit up or stand from a lying position, you may become dizzy. Therefore, immediately following surgery, if you are lying down, make sure you sit for one minute before standing.

Oral Hygiene After Surgery

Keeping your mouth clean after surgery is imperative! The day after surgery you should begin rinsing at least 5-6- times a day especially after eating with a cup of warm water mixed with a teaspoon of salt. Brush your teeth normally as best you can. Use the pink sponges given to you around the surgery areas for the next couple of days after surgery to keep the surgery area clean

Discoloration (Bruising)

In some cases, discoloration of the skin follows swelling. The development of black, blue, green, or yellow discoloration is due to blood spreading beneath the tissues. This is a normal post-operative occurrence, which may occur 2-3 days after surgery. Moist heat applied to the area may speed up the removal of the discoloration.

Antibiotics

If you have been placed on antibiotics, take the tablets or liquid as directed until completed. Antibiotics will be given to help prevent infection. Discontinue antibiotic use in the event of a rash or other unfavorable reaction. Call the office if you have any questions.

Nausea and Vomiting

In the event of nausea and/or vomiting following surgery, do not take anything by mouth for at least one half hour including any prescribed medicine. You should then sip on coke, sprite, tea, or ginger ale. Taking 12-25mg of Benadryl or Phenergan (Promethazine) at this time may also be helpful. You should sip slowly over a one-hour period. Once the clear liquids have been ingested successfully and the nausea has subsided, you can begin taking solid foods and resume the prescribed medicine.

Other Complications

• If numbness of the lip, chin, or tongue occurs, there is no cause for alarm. As stated before surgery, this is usually temporary in nature. You should be aware that if your lip or tongue is numb you could bite it and not feel it so be very careful. Call our office if you have any questions about this.
  
  
• Slight elevation of body temperature immediately following surgery is not uncommon. If the temperature persists, notify the office. Tylenol or Ibuprofen should be taken to help reduce the fever.
  
  
• You should be careful going from the lying down position to standing as you were not able to eat or drink prior to surgery and this may cause weakness/dizziness. Taking pain medications can also make you dizzy. You could get light headed when you stand up suddenly. Before standing up, you should sit for one minute then get up.
  
  
• Occasionally, patients may feel hard projections in the mouth with their tongue. These are not roots. They are the bony walls which supported the tooth. The projections usually smooth out spontaneously and rarely require re-contouring. Please do not pick at them with your fingernails nor objects such as toothpicks as this will cause a painful bone exposure that may require additional bony recontouring in our office.
  
  
• The removal of many teeth at one time is quite different than the extraction of one or two teeth. Because the bone must be shaped and smoothed (especially prior to the insertion of a denture,) the following conditions may occur, all of which all are considered normal:
  
  

1. The operated area will swell reaching a maximum in approximately 2 days. Swelling and discoloration on your face and/or inside your mouth may occur. The application of a moist warm towel will help eliminate the discoloration quicker. The towel should be applied continuously for as long as tolerable beginning 36 hours after surgery (remember ice packs are used for the first 36 hours only.)
   
   
2. A sore throat may develop. The muscles of the throat are near the extraction sites. Swelling into the throat muscles can cause pain. This is normal and should subside in 2-3 days.
   
   
3. If the corners of the mouth are stretched, they may dry out and crack. Your lips should be kept moist with an ointment containing aloe or lanolin. There may be a slight elevation of temperature for 24-48 hours. However, temperatures of 101 degrees Fahrenheit or less, in adults, are typically managed nicely with small doses of Tylenol or Ibuprofen. If temperature continues, please notify the office.
   
   
4. If immediate dentures have been inserted, sore spots may develop. In most cases, your dentist that fabricated the dentures will see you within 24-48 hours after surgery and make the necessary adjustments to relieve those sore spots. Failure to do so may result in severe denture sores, which may prolong the healing process.
   
   

• Sore throats and pain when swallowing are not uncommon. The muscles get swollen. The normal act of swallowing can then become painful. This will subside in 2-3 days.
  
  
• Stiffness (Trimus) of the jaw muscles may cause difficulty in opening your mouth for a few days following surgery. This is normal post-operative event, which will resolve in time and may improve more quickly with warm moist compresses and jaw exercising (gentle opening and closing).
  
  

Finally

• Reabsorbable sutures are sometimes placed in the area of the surgery to minimize post-operative bleeding and to help healing. Sutures typically ìfall outî within 1-7 days and do not require removal.
  
  
• After 72 hours, the pain and swelling should subside more and more each day following surgery. If your post-operative pain or swelling worsens or unusual symptoms occur, call the office for instructions.
  
  
• There will be a cavity where the tooth was removed. The cavity will gradually, over the next month or so, fill in with new tissue and bone. In the meantime, the areas should be kept clean, especially after meals with salt-water rinses or a toothbrush. Five days after surgery you may begin to irrigate lower sockets with a plastic irrigation syringe filled with warm water. If our office feels you will require an irrigation syringe, you will receive this from our office on the day of your surgery. DO NOT start this before 5 days as this may dislodge the blood clot from the socket prematurely and increase the risk of causing a painful socket.
  
  
• Your case is individual. No two mouths are alike. Do not take seriously well-intended advice from friends. Discuss your problem with the persons best able to effectively help you: Dr. Brown, Dr. Marshall or your family Dentist.
  
  
• Brushing your teeth is okay just be gentle at the surgical sites.
  
  
• Alveolitis, commonly known as a ìdry socketî occurs when the blood clot within a socket does not form properly or gets dislodged from the tooth socket prematurely. Symptoms are classic and usually occur 3-5 days after surgery. They are associated primarily with lower jaw teeth and cause dull throbbing pain that radiates down the jaw line and often into your ear and temple areas on the affected side. Please call our office if the symptoms occur as the ìdry socketî can be treated with medicinal packing. Please note that ìdry socketsî most commonly occur with difficult extractions and people (especially female) that use tobacco products.
  
  
• If you are involved in regular exercise, be aware that your normal nourishment intake is reduced and exercise may weaken you. If you get light headed, stop exercising.
  

Special Situations

1. Implant patients may undergo a ìsubmergedî technique or a ìnonsubmergedî technique (see implant procedure section.) In either case, please keep the incisions clean with warm, salt-water rinses and the pink sponges provided. Any exposure of the implants is typically not a problem but if you have questions, please call during regular office hours.
   
   
2. With the extraction of multiple teeth and placement of immediate dentures, oozing(bleeding) from beneath the dentures is to be expected and can last 12-24 hours. If bleeding seems to excessive, remove the dentures and clean excess blood clots from the mouth followed by the application of pressure using gauze or moist tea bags. Once the bleeding has slowed or ceased, you may replace the dentures or simply leave them out. Often times, patients tolerate upper immediate dentures very well but the lower dentures are too uncomfortable or loose to wear. You may remove dentures if this occurs and consult with our office or your dentist who made the denture the next business day.
   
   

IV. OMS Procedures

Third Molar Extractions (Wisdom Teeth)

Third molars, most commonly known as wisdom teeth, are the last molars to develop in the dental arches and are located in the back part of the mouth. Most people will begin to feel these teeth in their mid-teens to early twenties. As these teeth are the last to mature and a persons upper and lower jaws have ceased to grow, the wisdom teeth frequently will have inadequate space to erupt into a normal functional and hygienic position. These teeth are considered to be impacted and can cause a number of problems, most frequently, pain, swelling and infections.

What is an impacted tooth?

Impacted teeth are any teeth that are unable to erupt into a normal position within the dental arches. Many teeth can be impacted but, by far, the third molar teeth are the most commonly impacted teeth seen in a dental practice. Not all impacted wisdom teeth are the same. The following is a common classification of impacted teeth.

1. Soft Tissue Impactions: These impacted teeth lack adequate space to break through the gum tissue to allow for normal cleaning.
   
   
2. Partial Bony Impactions: These impacted teeth not only have soft tissue covering the tooth but some amount of surrounding bone still in place over the tooth. These teeth are typically removed by sectioning the tooth (cutting it into pieces) and/or removal of bone that may be over the tooth surface.
   
   
3. Full Bony Impactions: These impacted teeth are often not seen in the mouth but only on a radiograph (x-ray) although it is possible to have symptoms (i.e. pain or swelling) associated with these teeth. These teeth remain within the bone of the jaw and typically require both the removal of overlying bone and sectioning (cutting the tooth in pieces) of the tooth for removal.
   
   
4. Difficult Bony Impactions: These impacted teeth may be in an unusual position within bone, have unusually well developed roots, or even roots that have unusual shape or morphology (for instance, the root that looks like a ìfish hookî.) More commonly seen in patients age 25 and older, these teeth require a more extensive surgical procedure.

Why should patients have wisdom teeth removed?

The average age for eruption of wisdom teeth is typically around age 18-20 although the age can vary from age 15 to even age 25. If these teeth are unable to erupt into normal position, a number of problems can arise.

1. Infection: As impacted teeth are not cleansible, infection of the surrounding tissues can lead to swelling, redness, and pain around the tooth. Infections can vary from mild to severe sometimes causing swelling visible on the side of the face. These infections may also cause difficulty with chewing and swallowing.
   
   
2. Damage to Adjacent Teeth and Bone: Impacted wisdom teeth are often in close proximity to the adjacent second molar and can lead to premature bone loss on the distal (back) root of the second molar as well as decay on that root that is often not restorable. This can lead to the premature loss of the second molar as well as the surrounding bone (periodontal disease) prematurely and unnecessarily. Early removal of the impacted tooth (teeth) increases the likelihood of normal bony regeneration on the second molar root and eliminates the risk of caries (decay) associated with the impacted tooth.
   
3. 
   Pathology: The majority of cysts and benign tumors that we see occur around impacted teeth including wisdom teeth. When teeth remain impacted, the associated follicle sac (tooth bud) tissue from which the tooth develops is also retained. The follicle can begin to enlarge and become filled with fluid. As the sac enlarges it begins to behave as a cyst, typically slowly expanding and causing bone destruction and occasionally damage to adjacent teeth or movement and mobility of adjacent teeth. Odontogenic (meaning ìtooth relatedî) tumors can also arise from the follicle around the impacted tooth (teeth.) Although tumors are relatively uncommon and typically benign (not cancerous,) they can, at times, be very aggressive causing extensive bone destruction and premature loss of otherwise healthy teeth. Any impacted tooth with any indication of a surrounding cyst or tumor must be removed.
   
   
4. Unexplained Pain: Many patients often present with unexplained pain in the retromolar region of the jaws (back part of your jaw.) Although similar symptoms can arise with myofacial pain (muscle pain often associated with teeth clenching and grinding) and/or temporomandibular joint disorders (often called ìTMJî,) it is our experience that an impacted tooth can also cause this pain. Often, removal of the impacted tooth will resolve the pain.
   
   
5. Orthodontic Treatment: The presence of impacted third molars may interfere with the proper positioning of the other permanent molar teeth. These third molars should be removed to facilitate your orthodontic treatment.
   
   
6. Dental Crowding: Although a controversial issue, many practitioners feel that the development of the wisdom teeth (especially lower jaw wisdom teeth) can contribute to crowding of the erupted teeth, most commonly the lower jaw front teeth. Orthodontists often refer patients for removal of impacted third molars after orthodontic treatment is complete. Our belief is that impacted wisdom are probably contributory to the development of crowding but are likely not the sole cause and caution patients to continue wearing any orthodontic retainers after removal of the wisdom teeth. Given the many other problems that impacted teeth can cause, we believe it is prudent for patients with a healthy dentition to have the wisdom teeth removed early to minimize the risk of crowding as well as all of the other problems that can occur.
   
   

Should Patients ìwait and seeî?

Many patients in the past were told to not worry about their impacted wisdom teeth as long as they were not causing problems for the patient. This approach can lead to the necessary removal of the teeth when the patient is past the age of 30. These teeth are almost always more difficult to remove with a higher complication rate and prolonged healing. Complications that do occur are typically more difficult to treat as well. In fact, in our office, once the patient has reached the age of 35 or greater, removal of impacted teeth may not be advised unless they exhibit a localized problem either on physical exam or on radiograph (i.e. caries, swelling, pain, loss of periodontal bone support, cysts, tumors, etc,). In some cases, the potential risks of removal of the impacted tooth (teeth) may outweigh the benefits and the procedure should possibly be deferred.

Only a thorough examination and discussion with the oral surgeon may allow you to make a good decision about possible treatment of these teeth.

V. Potential Risks and Complications:

All surgical procedures entail risk to surrounding structures and possible complications after surgery. Although the incidence of these risks and complications is low, it is important that patients are aware of these. The following is a description of the most common complications:

1. Inferior Alveolar Nerve Trauma: The removal of impacted mandibular (lower jaw) wisdom teeth can lead to trauma of this nerve. This nerve provides sensation to your lower jaw and your lip and chin on the operated side. Frequently, advanced root development can lead to the roots lying in close proximity to this nerve. In some very rare cases, the roots can develop around the nerve itself. It is our impression that patients over the age of 25 are most likely to experience trauma to the nerve although it can occur at any age. Patients less than age 20 are least likely to experience trauma to the nerve as their impacted tooth roots are typically less well developed and thus do not lie in close proximity to the nerve.If the nerve is traumatized, patients may experience a tingling or ìnumbî sensation of the lower lip and chin area. The sensation of numbness is typically partial in nature (ìlike Novocain wearing offî) and does not cause any deformity in appearance of the lip. It will typically begin recovering within two weeks after surgery and gradually resolve over a 6-8 week period. Older patients (especially over age 35) may have small areas of persistent decreased sensation of the lip and chin area that can last up to six months but this is rare. Even more rarely, permanent decreased sensation can occur but is most often seen in the older age group or the very difficult impacted teeth.
   
   
2. Lingual Nerve Trauma: The lingual nerve supplies sensation to the side of your tongue. This nerve can also be traumatized during wisdom tooth surgery although it is very rare. In those rare cases though, patients will experience a decreased sensation in the side of the tongue that can alter the taste sensation and cause a ìmetallicî taste. This is usually temporary and will begin to resolve within 2 weeks but may require 6 ñ 8 weeks to fully recover. Many ìnumbî tongue patients we see in our practice are not patients that we have performed treatment on, but instead, have had routine dental restorative procedures. The trauma to the nerve in this case is likely the inadvertent trauma caused by local anesthetic (i.e. Novocain) injection. These can occur during oral surgery as well but seems to recover in the same fashion as described above.
   
   
3. Maxillary Sinus Trauma: Upper wisdom teeth are often closely associated with the posterior wall of the maxillary sinus. Although complications are rare and typically not serious, the following can occur:
   • -During surgery, the sinus floor and associated membrane can be perforated and cause a small amount of blood to collect in the sinus that will ìdrainî from the patients nose or pass into the back of the mouth. Neither is serious and poses no threat to the patient. If either occurs, simply wipe it from your nose or gargle warm water in your throat to clear the blood.
   • -Rarely, a sinus perforation will not heal and a fistula develops that represents a communication between your mouth and sinus cavity. An open fistula can lead to fluid and debris getting into your sinus through the opening and draining from your nose. If we feel you are risk of developing a fistula after your surgery, we will make every effort to repair the area at the time of surgery. After surgery, we ask you to not ìblowî your nose and if it is necessary to sneeze, you should sneeze with your mouth open but covered to prevent excessive pressure from developing within the sinus. If a fistula does develop after surgery in spite of our efforts, please be aware that most fistulas resolve spontaneously but please call our office for instructions. Rarely is a second surgery necessary to close the fistula.
     
     

1. Alveolitis or ìDry Socketî: By far the most common problem patients may experience after wisdom tooth removal, dry sockets are painful sockets that can develop primarily in the lower jaw 3-5 days after surgery. Although the incidence is low, dry sockets are most commonly associated with difficult extractions and patients that smoke. Please see the ìSurgical Instructionsî section of this website for management of this problem.
   
2. Post-Operative Infections: Post-operative infections are uncommon but can occur especially in chronically-ill or immunocompromised patients. Taking antibiotics as prescribed will often prevent and treat infections after surgery. Common symptoms of infection after initial recovery are
   
3. Swelling that increases in size (especially 5-7 days after surgery)
   
4. Swelling in unusual places such as beneath your jaw or under your tongue
   
5. Increasing pain (especially 5-7 days after surgery)
   
6. Fever greater that 101.5 Fahrenheit
   Please call our office if you suspect you may have an infection as you may require additional medication or even surgical care. (See ìSurgical Instructionsî for a description of a normal post-operative recovery.)
   

VI. Conclusion:

In general, all impacted teeth should be considered for removal including wisdom teeth. We consider the ideal age for removal of impacted wisdom teeth to be between ages 15 to 20. At this age, complications are few and manageable and patients tend to recover relatively quickly. Early diagnosis and treatment will often prevent many of the problems associated with extraction of third molars in older patients. Consultation with your dentist and/or orthodontist is advisable. If you are referred for evaluation in our office, we will make every effort to formulate an accurate diagnosis and provide recommendations for your continued good dental health. As with most anything, an ounce of prevention is worth a pound of cure.