Information concerning tooth extraction & oral surgery

Frequently asked questions concerning the following topics:

• Pain after surgery
• Painkillers after surgery
• Swelling after surgery
• Post-operative infection
• Dry socket
• Post-operative bleeding
• Surgery for patients taking Warfarin
• Patients on anticoagulants other than Warfarin
• When to take your medications after surgery
• Stitches are usually dissolving
• Brushing teeth after dental surgery
• What food to eat after dental surgery
• Should you use warm salt water after surgery
• How to get help or advice after surgery

If you read this and feel there is an area of information we have left out, please contact us through our website (www.nqsurgicaldentistry.com.au) and we can address the information you would have liked to find.

Q. The most often asked question – “Will I be in pain immediately after the tooth extraction or surgery?”

No!  After your surgery you will remain numb for a period of time.

If you have been treated under general anaesthetic (asleep in hospital) as a day surgery patient, you will remain numb for 8-12 hours because you were given a long acting anaesthetic injection in the mouth called Bupivacaine.

If you have been treated at the dental practice, in most cases you will remain numb for around 2-4 hours having been given an injection of Articaine.  In certain circumstances you may be given Marcaine to provide longer pain relief after surgery in the practice, particularly if you have to face a long journey home.

Q. What about the pain after the local anaesthetic wears off?

As your local anaesthetic injections in your mouth start to wear off, it is important to have the pain control tablets already working.

For this reason we advise that if you have been treated as a day case under general anaesthetic and have a long acting injection (lasts 8-12 hours), start to take all your medications around 8 hours after surgery. However, if you have had surgery at the practice and received the usual 2-4 hour injection, it is wise to begin taking your control medication as soon as practical after surgery, either at the practice before you leave or as soon as you get home.

Q. How much pain can I expect?

Your pain after surgery can vary a great deal from person to person. Although pain is variable it is only rarely severe.

For minimal pain it is suggested you take Naproxen 500mgs every 12 hours (the anti-inflammatory) as prescribed by Dr Priestland, and simple Paracetamol (also known as Panadol), 2 tablets every 6 hours for adults.  Avoid more than 8 Paracetamol tablets in 24 hours or you may damage your liver.

For moderate pain take your Naproxen 500mgs every 8 hours and 2 Paracetamol 500mg tabs (Panadol)  every 4-6 hours remembering the maximum dose of 8 tabs in 24 hours.

For severe pain use your Naproxen 500mgs every 8 hours as prescribed and 2 Paracetamol 500mg tabs (Panadol) every 4-6 hours not exceeding 8 in 24 hours.  You may experience pain through this strong pain control regime and if so you will need to obtain a prescription for Oxycodone (Endone) from you GP. One Endone 5mg tab can be take every 4-6 hours for break-through pain. It is unlikely that this will be required for more than a day or two.

Oxycodone (Endone) is a strong painkiller. If you take Endone you are taking a narcotic controlled drug with several potential side effects.

The unwanted side effects include:

• drowsiness,

• dizziness,
• disorientation,
• nausea,
• vomiting
• Hallucinations
• constipation.

This is why we always suggest you use the least strong medication that keeps you comfortable.

If you are suffering from intense pain and pain control medication you have been prescribed does not control it adequately, then you will need to contact Dr Priestland.

Sometimes if a procedure is expected to cause severe pain after day surgery under general anaesthetic at the Mater Hospital Day Surgery Unit, your anaesthetist may give you a prescription for Endone (Oxycodone) just in case you need it to save you going to see your GP to obtain additional pain control.

Remember, that if you are taking Endone, you should only take Paracetamol and avoid any medicines containing Codeine. NEVER take Endone with Panadeine Forte.

When taking controlled analgesics like Oxycodone (Endone) you must not drive, use machinery, make legally binding decisions or sign legal documents, nor should you work in a dangerous work environment like mine sites. You may obtain a letter to employers regarding the drugs you have been prescribed.

Q. When will I become swollen?

From the time your surgery begins, the tissues in the surgical field will react to the surgical trauma by swelling. Usually swelling is extremely slow but continues for up to 3 to 3.5 days. By then your face may look very swollen, but this is a normal reaction of the body. Usually on day 4 after surgery, the swelling begins to subside.

Q. How can I limit the swelling?

The degree to which you swell will depend on the type of surgery and how well you follow the post-operative instructions you were given. For example, if you take the anti-inflammatory drugs (Naproxen) there will be less severe swelling.

You should also use ice packs on the outside of the face to cool the tissues. This limits swelling and reduces discomfort. We usually advise you use a small bag of frozen peas wrapped in a damp face washer or kitchen chux. Change the bag of frozen peas regularly. Use of an ice pack for 20 minutes every 1-2 hours is usually effective.  Sucking ice fragments of ice cubes will also help with swelling and with pain from oral surgery.

Q. What about post-operative infection?

Avoiding an infection is important and this is why you should use Curasept mouthwash or Savacol mouthwash as a gentle mouth bath for 2 minutes every morning and night after brushing your teeth for 3 days before surgery (if possible) and for 10 days after surgery. This will help to control the vast numbers of bacteria that exist in your mouth and thereby help to reduce the chance of infection. Savacol will cause brown staining of teeth and tongue if used for more than 2 weeks while Curasept does not stain. Savacol can be obtained from any pharmacy while Curasept can only be obtained at any of the large Chemist Outlet at Domain Central or Friendlies Chemist in Castletown shopping centre.

It is best to bath the mouth gently. You MUST NOT “swish” the mouthwash around the mouth vigorously. If you “swish” around you may open up the stitches or disturb the surgical site and the blood clot that has formed. If the blood clot is lost from the extraction socket, then the tooth socket can become a food trap. Consequently bacteria and food accumulate and an infection may occur leading to a “dry socket”.

 

Q. What is a dry socket and how does it occur?

In the upper jaw the blood supply to the jawbone is very good and usually the body’s immune system can deal with any minor infection therefore healing takes place without complication.

In the lower jaw the blood supply to the bone is far less efficient because the bone is far more dense. As a result infection occurs more commonly and may lead to a condition known as a dry socket where the blood clot that formed after the tooth was removed is lost from the tooth socket. This leaves a hole where food debris can gather. Bacterial accumulation in the presence of this food debris quickly leads to infection. A dry socket is characterised by increasing severe pain, usually arising 3-7 days after surgery. Usually the gum surrounding the extraction site is very tender.

Q. What do I do if I get a dry socket?

Dry sockets are easy to cure but you will need to call the practice (normal working hours from Mon to Thu 0800-1730 call 4725 1656) or call Dr Priestland’s mobile number outside these hours (his number is to be found on the post-operative instruction leaflet you were given at your consultation appointment and on the practice business and appointment cards).

You will need to make an appointment to return as soon as we can see you to gently flush out any accumulated food particles and then Dr Priestland will place a dry socket dressing called Alvogyl, into the infected tooth socket. Within 30 minutes much of the pain will have been eliminated and over the next 24-48 hours the dressing will treat the infection.

Q. Can infection be prevented?

In an attempt to prevent infection, Dr Priestland will normally ask you to use a mouthwash known as Curasept or Savacol (containing 0.2% Chlorhexidine) for 2-3 days before your surgery. Chlorhexidine is an antiseptic that kills many of the bacteria that live in the mouth.  By reducing the number of bacteria present, you reduce the chance of infection after surgery. Savacol will cause brown staining of teeth and tongue if used for more than 2 weeks while Curasept does not stain. Savacol can be obtained from any pharmacy while Curasept can only be obtained at any of the large Chemist Outlet at Domain Central or Friendlies Chemist in Castletown shopping centre.

Dr Priestland may also prescribe some antibiotics (usually Keflex) for you to take every 8 hours. If you had surgery as a day case under general anaesthetic and you have an infection, then you will receive the same antibiotic intravenously while you are asleep just prior to the operation starting.  However you must continue the antibiotic in tablet form for the following week. You will therefore need to start your medications 8 hours after surgery. If you had your surgery at the practice you should have started your antibiotics and anti-inflammatory drugs (both Keflex and Naproxen) the night before surgery and continue them every 8 hours.

Q. What should I do if I start bleeding later at home?

Rarely is post-operative bleeding severe. Mild bleeding usually results from either food or a toothbrush touching the wound margins. Such bleeding is minor and very temporary.

More severe bleeding can occur, and in some cases it may indicate there is an underlying clotting problem or a defect in the later stabilisation of the blood clot. The formation of the initial clot takes place by the sticking together of Platelets (one of the types of Blood cells) forming a platelet plug. A series of chemical reactions then take place resulting in the formation of a stable fibrin blood clot. Some medications can interfere with this process and the most commonly used drug that does so is Aspirin.

If you have been taking Aspirin on a daily basis then all you will need to do is apply firm pressure to a bite pack for around 10-15 minutes. It is not necessary for you to stop taking your daily Aspirin for most dental surgical procedures. Normally clotting would only take 5 minutes but to allow the clot to form with fewer working Platelets, it is best to apply pressure for longer; around 10 minutes should be sufficient.

Pressure packs only work if pressure is applied constantly. If you keep releasing the pressure to see if the bleeding has stopped, then the clotting time starts again when pressure is reapplied. Leave the pressure pack in place with pressure applied continuously for the full time advised.

Q. If I take Warfarin, must I stop this 5 days before surgery to prevent uncontrolled bleeding?

Firstly, Warfarin is used to prevent your blood from clotting spontaneously and causing a clot to form within your circulation. It is therefore important to take it to prevent a blood clot forming and then breaking up and blocking fine blood vessels in your brain leading to a stroke. So never just stop Warfarin without first discussing it with either your GP or your cardiologist.

In some cases the cardiologist may feel that your risk of suffering from a stroke is very low and may be happy to stop Warfarin for 5 days before surgery but in most cases this is not necessary. Always discuss this with your dentist and your GP if there is any doubt.

It is possible to check on the effectiveness of Warfarin therapy by performing a simple blood test called an INR (International Normalised Ratio).  This is a ratio of your ability to stop bleeding compared to an internationally accepted normal value. Generally if you have an INR below 2.5,-3.0 then it is safe to have dental extractions and other dental surgical procedures. If the INR is above 2.0, then your dentist or surgeon must determine the likelihood of significant bleeding. It is possible to apply other procedures to assist in stopping bleeding, including the use of special haemostatic foams in dental extraction sockets that make the blood clot, and stitches can be used to help apply pressure to the wound and assist in bringing bleeding under control.

In more severe cases with a raised INR, and an extensive surgical procedure, a suspension of Tranexamic acid 5% can be applied to bite packs and pressure applied to stop bleeding. This medication is only available on prescription by your surgeon who will advise you on the need for its use if it is required.

Q. I take anticoagulants that are not related to Warfarin. Does an INR measure how effective these are too?

No! An INR only measures the degree of anticoagulant effect in patients taking Warfarin.

Q. Is there any way to assess how much my clotting has been diminished by my alternative anticoagulant drugs?

No! The treatment protocol must be discussed between your cardiologist and the surgeon. Depending on which of the several anticoagulants you are taking, and the risk to which you might to exposed if you stop taking them, a decision will be made by your cardiologist on how best to control your blood clotting.

Alternative anticoagulants may include Clopidogrel, Lepirudin, Dabigatran, Rivaroxaban and Apixaban. They do not all work in the same way and the period of time for which they must be stopped prior to surgery varies from 24 hours for some drugs upto 7 days for others. You will also be advised when it is safe to resume your usual anticoagulant medication after surgery.

Q. When taking medications like antibiotics or anti-inflammatory drugs, is it important to take my tablets on time every time?

When a drug is prescribed every 6 hours, 8 hours or 12 hours, it is important to try to stick as closely as possible to the correct times to prevent the blood concentration of the drug from falling to an inadequate level. If the concentration of the antibiotic does fall, then it will no longer be effective at killing bacteria. And likewise if the concentration of pain control drugs falls, then you will suffer greater pain.

Q. After surgery when do I have my stitches removed?

Nowadays, Dr Priestland normally uses dissolving stitches. They normally disappear at some time between 7 and 21 days after surgery. Very occasionally stitches fail to dissolve due to a deficiency of a particular salivary enzyme. If they persist and annoy you, call the practice and we will remove them.

Sometimes Dr Priestland may want some stitches to remain in place for a prolonged period. If so he will use blue polypropylene (Proline) stitches.  They feel a bit like very fine fishing line!! They must be removed.

Q. Can I brush my teeth after surgery?

Please do continue to brush all your teeth other than those in the surgical site. Brushing too early here may result in the premature loss of stitches and delayed healing.

After the first 5 days you can start gently brushing from the gum to the tooth with either a baby’s toothbrush or a post-surgical brush provided. Both these brushes have very soft bristles that cannot harm the tissues.

By 10 days after surgery you should be able to brush the surgical site effectively with your usual toothbrush.

Q. What foods can I eat after surgery?

We always suggest food that is far softer than your normal food. If you need a knife to cut the food, then it is not soft enough. Try whenever possible to eat the food by using the teeth on the opposite side of the mouth to avoid chewing on the surgical area. This may not be possible if you have had teeth removed on both sides.  Soups are good but any food can but put through a blender to make a soft mushy food like baby food. This is just as nutritious.

Remember you need protein to make new tissue as part of the healing process. This is important and is a good reason why patients should not rely on yoghurt, jelly and custard.  You need a balanced diet to heal well and manufacture new tissue in the surgical site. You can add in some protein to your diet by using protein shakes to supplement the protein you are eating in your soft food.

If food appears to be packing into the area of the surgical extraction socket, you must tell us and we can provide you with a small monojet syringe to enable you to flush the site with warm water mixed with some Savacol antibacterial mouthwash 2-3 times a day for a few days after eating.

Q. Many people use warm salty water. Does it help improve healing and avoid infection?

The salt probably does very little; it may feel soothing but it does not prevent infection.

The hot water is definitely a good idea. Using a hot water mouth bath regularly throughout the day will heat up the soft tissues around the surgical site.  The hot tissues go pink as the blood vessels in heated tissues open up allowing a greater blood flow through the tissues. This results in a greater delivery of oxygen and nutrients to the healing tissues with the benefit of improved healing.

The idea of salt is a bit of an old wives tale. The salt gets mixed with the warm water, often with too much salt so that it is a stronger salt solution than your own natural body fluids (0.9% solution).  This results in the salty water mouthwash drawing out water from the tissues in a process we call osmosis. This has the effect of drying the tissues and this could slow healing.

When you use any mouthwash (Curasept, Savacol or hot water) try not to swish it around the mouth as it may disturb the stitches and cause them to burst, opening up the wound. It is best to take the liquid into the mouth and tip the head over to one side for one minute and the repeat tipping to the other side for another minute before gently spitting out. Try to do this with hot water as often as you can.

Any queries?

If you have any questions after reading through this article, do ring our nursing team who will be able to help you or contact us through the website contact and ask a question.

If you have problems and have recently had surgery you can call us on the practice telephone number 07 4725 1656 during our usual working hours Mon to Thur 0830am until 5.30pm. In the case of an emergency, our patients can call Dr Priestland outside his normal working hours on his mobile telephone number that is shown on your printed post-operative instructions and on your appointment card.

Contact the friendly team at NQ Surgical Dentistry today on (07) 4725 1656 or call in to see us at 183 Kings Rd, Pimlico QLD 4812