Dental Extractions
 

What should I do After Having a Tooth Out?

How you are advised to look after your socket when you have had an tooth extraction may vary slightly from practice to practice and country to country, but the essence remains the same…

Below is a combination from various sources of the best and most common advice aimed at obtaining a good blood clot, preventing damage and infection and creating the speediest recovery possible.

  • Numbness
If your lip is numb be careful not to bite it. The anaesthetic will take a few hours to wear off, during this time, be careful and take it really easy. You will not be able tell temperature, so- ‘NO HOT’ foods or liquids today (only lukewarm) and the control of your mouth when eating and drinking will, as you know be significantly effected until the anaesthetic has fully worn off. If you are unsure of the temperature, test it with a finger. If you are in public, you may find you are dribbling or spilling your drink without knowing... you have been warned.

  • Exercise
Avoid physical exercise or anything that raises your blood pressure for at least 24 hours. We are trying to get a nice clot to form and this can burst the clot and start the socket bleeding. The more extensive and difficult the extraction, the more you will need to rest -(luckily for us, the more you will want to…) so go home and put your feet up. Plan time off work, your dentist can advise you if this is likely to be needed. If work involves 'manual labour' or 'exertion' of some sort, it is best to take the rest of the day off.

  • Alcohol
No alcohol should be consumed on the day of your extraction either before or after the extraction procedure, as this will make you prone to bleeding. Alcohol causes your blood vessels to open up (dilate), so if you are planning a big night out ,or celebration make sure you take this into account.

  • Head up
Sleep or rest with your head raised and a towel on your pillow as some blood in your saliva is common. Lying down will make you more likely to bleed.

  • Diet
Eat a soft diet for a couple of days and chew on the other side of your mouth where possible.

  • Avoid sucking through a straw
The pressure inside your mouth can dislodge the blood clot or start it bleeding.

  • Do not rinse your mouth today
This will wash away the top layer of blood and start the socket bleeding again. You can drink, that is fine but don’t purposefully swill over the socket we want a good clot to form and stay in place.

  • Do not smoke
For at least 3 days after your procedure and up to a week if you can. Do what is necessary- patches etc. to get you through this time. You must tone it down as much as possible, as smoking is the main cause of getting a painful dry socket and it may cause delayed healing, wound breakdown, and leave you prone to infection.

  • Bleeding
If the socket bleeds heavily, place a gauze pack (this should be provided by your dentist, but is also available from your pharmacy), or if you run out, a clean handkerchief over the socket and bite firmly down for 15 minutes. This is essentially what the dentist will have asked you to do right after removing the tooth and the pressure should stop the bleeding. Do not use tissue- it will dislodge the clot when you try to remove it and avoid putting gauze in and out repeatedly- this will actually be disturbing the clot rather than letting it heal.

  • Spitting
It is normal for you to bleed a little. The blood often mixes with saliva to appear more than it really is. In this case, just gently wipe your mouth with a tissue; avoid a massive spit as this may pull the whole clot out.

  • Pain
I generally advise taking a Paracetamol or Nurofen as directed on the packet, after an hour of leaving the surgery. This means you have something to kick in, as the anesthetic is wearing off. Some pain and soreness is to be expected and is quite normal. If you take medication from your doctor, check with your pharmacist which painkillers or analgesics are suitable.

  • Brushing
Avoid brushing the area of the extraction, but you can brush all your other teeth normally. Sometimes if you have had a nasty surgical procedure, I may advise dipping a cotton bud in Savacol and gently wiping this around the wound, as you are unable to brush. This will help stop/slow plaque formation around the site.

  • Swelling
This will depend on if you have had bone removed and how traumatic the surgical procedure was. A hamster like appearance is common after difficult impacted wisdom teeth extractions particularly if you have had general anaesthetic. The application of ice packs to the sides of the face for the first 8 hours (20 minutes on the face – 20 minutes off the face) may help to reduce the swelling. The dentist may also provide you with anti-inflammatories at the time of the procedure or for afterwards.

  • Antibiotics
See below. It has been reported that certain antibiotics may make the contraceptive pill ineffective so take extra precautions.

  • Salt rinses
The following morning do some warm salt rinses. Place a teaspoon of salt into a glass of warm water, as hot as you can comfortably tolerate, and just hold this over the socket- there is no need to rinse vigorously. Repeat this as often as you think about it for the next few days, until swelling and soreness have subsided (at least 3 times per day). This will help to keep it nice and clean for the next few days.

  • Sore jaw
The longer you have spent with your mouth open wide and the more difficult and stressful the procedure, the more stiffness you are likely to get in your jaw muscles. This may limit how wide you can open for a few days.

Do I need to Come Back?

Some dentists like to check you the next day, or one or two days after the extraction if it was particularly difficult. With tricky wisdom teeth, oral surgeons generally like a review appointment, to see how you are healing and to check you have no complications from the extraction.

As a general rule, unless they ask to see you, you have other treatment to be completed or problems arise, then you don’t need to go back till your 6-month recall appointment.

If you have had a surgical extraction and the dentist has needed to place a number of sutures or stitches to replace the gum, then these will need to be removed about a week later, (assuming they are not resorbable). This is a very simple, quick and relatively painless procedure.

When to call the Dentist?

It is normal to experience some pain, bleeding and all the things we have discussed. If you have any concerns you should call the dentist to have those fears put at rest- that is their job.

For the soldiers amongst you, who battle through wind and rain, if you experience any of the following, you should pick up the phone and give them a call:

  • Fever, chills, swollen glands
  • Nausea and vomiting
  • Difficulty breathing or swallowing
  • Worsening pain or swelling (after the first 3 days have passed) particularly if painkillers do not relieve it.
  • Bleeding that persists after 24 hours despite pressure being applied as directed.

What Painkillers (Analgesics) Should I Take?

Ibuprofen is my preferred painkiller as it has a more pronounced anti-inflammatory effect- though paracetomol and aspirin can be effective too.

For children, a children’s paracetamol preparation is advised.

If the extraction has been difficult and much pain or swelling is expected, the dentist may give you a prescription for something stronger over the counter. Commonly this will be a paracetamol/codeine preparation.

In these cases, the dentist may also give some steroid preparation for the inflammation, though this is not routine.

Do I need Antibiotics?

Antibiotics are incredibly useful and can be lifesaving drugs, however, the world has come to associate the word ‘antibiotic’ with making them better, and so almost expect to be given them as a matter of cause when anything is wrong.

The problem is, antibiotics are for bacterial infections; they will not have any effect (except placebo) on viruses and different drugs are specific to particular bacteria.

There is no strong evidence to suggest that prophylactic antibiotics (those given to prevent infection from occurring -not just because you have infection), reduce the rate of infection. In fact because of this, the UK has stopped giving them to prevent bacterial endocarditis. They believe the risk of a reaction to the drugs is higher and more serious, thus outweighing the potential benefits. In Australia, we are still required to cover certain high-risk patients for this condition.

The more we use them inappropriately – giving them out ‘willy-nilly’, the greater the risk, or evolution of resistant strains on which they will simply not work. You may have heard of MRSA (methacillin resistant staphylococcus aeurus), a bacteria responsible for numerous deaths when outbreaks in hospitals occur.

This is exactly what I am referring to, our most commonly used and effective drug- penicillin, no longer affects this bacteria. Add this to the severe allergic and sometimes fatal anaphylactic reactions that are another result of misuse, or over-use and you can understand why we need to be selective about who we give them out to.

So what do I want from you? A favour :) I do ask for them occasionally… Please do not put the doctor or dentist under pressure for antibiotics, you don’t even really need to ask. If it is appropriate for your condition, it will be prescribed - if it is not, then it will be for a good reason; not because they want to see you suffer, or because they have a limited quota, it is quite simple, they don’t (according to their medical knowledge) feel it will help you.

Antibiotics are reserved for people where the likelihood of delayed healing will lead to post- operative (after the operation) infection. Your doctor/dentist/ oral surgeon will make this decision based on both your medical history and the difficulty of the procedure. They will also liaise with any medical specialists whose care you are under, such as a heart or orthopaedic surgeon and follow any recommendations they provide.

Prophylactic Antibiotics are generally given for anybody who:

  • Has had radiotherapy to the head and neck
  • Is at risk from bacterial endocarditis (depends on the country)
  • Has severely compromised immune systems
  • Anybody the doctor/dentist believes to be at particular risk.

Should you get an infection in your socket following the tooth extraction, with pus discharge associated fever and swelling, antibiotics would likely be given.

How do I Know it is Healing?

As a general guide, it is going to hurt a bit when the anaesthetic wears off- expect it. The longer and more difficult the procedure, the more uncomfortable it may be. Good news is, big holes heal up pretty much the same as small holes and the mouth has a remarkable ability to heal because of the rich blood supply it receives.

For routine extractions, most of my patients say the first day/night isn’t too bad, day two and three are pretty uncomfortable and then life returns pretty much to normal- even though it will continue to be a bit sore. That is assuming you have managed to establish a nice clot and have followed the extraction aftercare instructions.

You should expect the socket after day three to continually improve- you may get the odd day where it feels worse, but the basic trend is that of getting better.

If it is getting worse or becomes very painful and doesn’t seem to be settling, call your dentist and have them take a look- you may have a dry socket or infection.

What Problems Might I get Afterwards?

  • Bleeding
The dentist should not let you go until a clot has formed, though for one reason or another this might start bleeding later. You are not going to die from blood loss from having a tooth removed and the measures described above, should be sufficient to stop or slow the bleeding. If you are concerned or in any doubt, just contact your dentist or if you are that worried, your local emergency department.

  • Bits of bone
I have mentioned this elsewhere in this series, that on occasions, some bits of bony socket may be pushed up during the healing process. This is not a bit of tooth and there is nothing to worry about. If you get a very large piece that doesn’t seem to be moving, then you can always pop back to your dentist to get it checked or removed if you are worried or if it is rubbing your gum or tongue.


  • Infection

How Long will Recovery Take? Do I need Time Off?

This depends on the difficulty of the extraction and on you.

A standard simple extraction might knock you around for a day or so; therefore you might want to plan it on a Friday so you have the weekend to recover. If you have four, heavily impacted wisdom teeth removed under general anaesthetic, I would imagine you are going to want at least a week to let the swelling and bruising go down, perhaps two.

I meet people with immensely high pain thresholds and those at the other end of the scale. There is so much variation. Some patients are good to go the same day; others take considerably longer to recover from a similar procedure.

The key is getting a good clot to form by following the extraction instructions carefully.

The initial healing period- to fully cover the socket generally takes a few weeks. The bone and gum however will continue to remodel over the next 6 months, after which point it will be pretty stable.

It is important to take this into consideration when planning to replace the missing tooth since the appearance of a bridge or implant may be affected, if it is placed too soon.

Can I Exercise?

Not on the day of the extraction- the rise in blood pressure will start you bleeding. One day off training isn’t going to set you back too much. You can exercise the next day if you feel up to it, again this will vary from person to person and on the type and difficulty of the extraction.

What can I Eat?

Eat whatever your feel like, but be careful of temperature while you are still numb. A soft diet for a couple of days is sensible because your jaw has often been pulled around a bit during the extraction, so chewing itself can be a bit sore. I recommend mashed potato, eggs, soups… all the food your mum cooks, or used to cook when you were ill- that sort of thing!

Should I use Mouthwash?

The warm salt rinses are very good for keeping your mouth clean and helping gently swill out food particles. I certainly wouldn’t go using anything like Listerine- ouch, that would sting like crazy and do you little good.

A gentle rinse with a chlorhexidine mouthwash (Savacol) a couple of times a day certainly won’t do you any harm and is what we would recommend when patients have had oral surgery and it is too painful to brush.