I. PREOPERATIVE INSTRUCTIONS FOR PATIENTS UNDERGOING ORAL SURGERY

1. Anesthesia Considerations: First of all, you need to decide if you will be sedated ("go to sleep"). Most people clearly prefer to be unaware of the experience when they have their wisdom teeth removed. Dr. Conover will provide you with appropriate anesthesia options. All outpatient surgery is performed under appropriate anesthesia to maximize your comfort. Our office staff has the training, license, and experience to provide various types of anesthesia to allow patients to select the most appropriate alternative. These services are provided in an environment of optimum safety, utilizing modern monitoring equipment and staff experienced in anesthesia techniques. The Surgical Care Team, the office facilities, and Dr. Conover are licensed and inspected on behalf of the California Board of Dental Examiners on a regular basis.

2. The evening before your surgery. Try to get a good night's sleep so you will be well rested on the day of the procedure. After midnight on the morning of your surgery, you should not have anything to eat or drink including water, unless you are taking prescription medications. In that case, you should follow the instructions given to you by our office. That usually means taking your regular prescription medication with a small sip of water at the regularly scheduled time. If your appointment is after 12 noon, we may give you special instructions about taking fluids in the morning.
2. On the day of your procedure. Please bring a responsible adult with you so that they can drive you home after the surgery is performed. Your procedure will take less than an hour and you will be in the office for approximately 1 ½ hours. Please wear loose fitting clothing with sleeves which can be rolled up past the elbow, and low heeled shoes. Contact lenses, jewelry, and dentures must be removed at the time of surgery.

3. In the office prior to the procedure. When you are seated in the Surgical Room, you will be allowed to breathe nitrous oxide (laughing gas), which will make you more comfortable. After this, we will start a small IV in your arm where we will administer the medication. We have found that most patients are not aware of the procedure being performed. We will give you a local anesthetic while you are sleeping so you will be comfortable when you wake up.
Our surgical assistants will review your post-operative instructions. When you leave the office you will be comfortable and drowsy. You should go home and rest with no other physical or scholastic activities planned for at least two to three days. You should not drive a vehicle or operate any machinery until the day following the anesthesia experience.

II. ORAL CARE FOLLOWING SURGERY (Summary)

1. Do not rinse or spit until the day following surgery.
2. Keep fingers and tongue away from socket or surgical area.
3. Use ice packs on surgical area (side of face) for the day of surgery and the first day after- apply ice 10 minutes on - 10 minutes off. Bags of frozen peas work well. You may use heat starting the second day after if you wish.
4. For mild discomfort take Tylenol or Ibuprofen every three to four hours.
5. For medium or severe pain use the prescription we have given to you.
6. Drink plenty of fluids. (Do not use a straw)
7. Starting the second day after, use a warm salt-water rinse following meals for the first week to flush out particles of food and debris which may lodge in the surgical area. (1/2 teaspoon of salt in a large glass of warm water).
8. Diet may consist of soft foods which can be easily chewed and swallowed. No seeds, nuts, rice, popcorn, etc.
9. A certain amount of bleeding is to be expected following surgery. Bleeding is controlled by applying pressure to the surgical area using small rolled gauze for 30 to 60 minutes. After that time remove the gauze and then you may eat or drink. If bleeding persists, additional gauze packs, or a moist teabag should be placed in the area of bleeding with a gauze above to provide additional pressure. You should bite down in thirty minute intervals and repeat as necessary. This will aid in clotting blood. If you have any questions about persistent bleeding please call our office.
10. We suggest that you do not smoke for at least 5 days after surgery. Nicotine may break down the blood clot and cause a "dry-socket".
11. Feel free to contact us if any doubt arises as to your progress and recovery.

III. DETAILED POST-OP INSTRUCTIONS FOLLOWING EXTRACTIONS AND OTHER ORAL SURGERY PROCEDURES. Follow the simple instructions below to minimize complications and help ensure prompt recovery.

To control bleeding

Immediately following procedure. . .keep a steady pressure on the bleeding area by biting firmly on the gauze placed there by your surgeon. Pressure helps reduce bleeding and permits formation of a clot in the tooth socket. You may remove the compress after approximately thirty minutes. Gently remove the compress after the local anesthesia has worn off and normal feeling has returned. After that time remove the gauze and then you may eat or drink. If bleeding persists, a moist teabag should be placed in the area of bleeding with a gauze above to provide additional pressure. You should bite down in thirty minute intervals and repeat as necessary. Some oozing of blood may persist even up to 24 hours after surgery.

To relieve pain

Immediately following procedure... begin taking medication as directed by your surgeon to minimize discomfort when the anesthesia wears off and feeling is back to normal. Application of an ice bag can also help relieve discomfort.

When the prescribed pain medication is not sufficient, it is O.K. to add an additional, different category of medication. If you are taking Tylenol/Codeine, Vicodin (Hydrocodone), or Darvocet, you may add up to 400 mg. of ibuprofen per 6 hour period. It is important NOT to take additional Tylenol! You may take up to 2400 mg of ibuprofen per 24 hour period.

After 24 hours. . .continue to take your medication if pain persists, and use an ice bag if needed.

To minimize swelling

Immediately following procedure. . .apply an ice bag over the affected area. Use 10 minutes on and 10 minutes off for 24 to 48 hours to help prevent development of excessive swelling and discomfort. If an ice bag is unavailable, simply fill a heavy plastic bag with crushed ice. Tie end securely and cover with a soft cloth to avoid skin irritation.

Cold applications may be effective in reducing the swelling for up to 48 hours. Remember that the swelling peaks at about 48 hours and may persist up to two weeks. It is also not uncommon to have a low-grade fever of 99 degrees F to 100 degrees F for a day or two.

Special considerations following removal of impacted teeth:

• Removal of impacted teeth is a surgical procedure. Postoperative problems are not unusual, and you must take extra care to avoid complications.
• Severity of postoperative pain will depend on the procedure and your physical condition. Many pain medications are prescribed on an as-needed basis. However, they tend to work better after a certain level of the medication builds up, and this usually takes more than one dose. For more involved procedures, you should consider taking the first dose of pain medication before the local anesthesia wears off.
• Healing of the surgical site is variable. It is usually slower than patients expect.
• Swelling can be expected. Be certain to apply ice bags as directed above.
• You should anticipate some difficulty in opening your mouth widely and discomfort upon swallowing.
• You may experience numbness of lips and/or tongue on the affected side for a variable period of time.

Oral hygiene is important

Try not to rinse the mouth on the day of surgery so as to avoid dislodging the blood clot. (You can still eat and drink, though!) Beginning the day following surgery, rinse mouth gently with a solution of one-half teaspoonful of salt dissolved in a large glass of water. Repeat after every meal or snack for seven days. Rinsing is important because it removes food particles and debris from the socket area and thus helps prevent infection and promote healing. Brush tongue daily with a toothbrush to keep bacteria growth down, but be careful not to touch the extraction site.

The day following the procedure, you may resume your regular tooth brushing, but avoid disturbing the surgical site so as not to loosen or remove the blood clot.

Maintain a proper diet

Have your meals at the usual time. Eat soft, nutritious foods and drink plenty of liquids - with meals and in between. Have what you wish, but be careful not to disturb the blood clot. Add solid foods to your diet as soon as they are comfortable to chew.

III. POST-OPERATIVE CONDITIONS SEEN AFTER SURGICAL TOOTH REMOVAL. The removal of impacted wisdom teeth and surgical extraction of teeth is quite different from the extraction of erupted teeth. The following conditions may occur, all of which are considered normal:

1. The surgical area will swell.
2. Swelling peaks on the 2nd or 3rd post -operative day
3. Trismus (stiffness) of the muscles may cause difficulty in opening your mouth for a period of days.
4. You may have a slight earache.
5. A sore throat may develop.
6. Your other teeth may ache temporarily. This is referred pain and is a temporary condition.
7. If the corners of the mouth are stretched out they may dry and crack. Your lips should be kept moist with cream or ointment.
8. There will be a space where the tooth was removed. After 24 hours this area should be rinsed following meals with warm salt water until it is healed. This cavity will gradually fill in with new tissue.
9. There may be a slight elevation of temperature for 24 to 48 hours. If temperature continues, notify us.
10. It is not unusual to develop bruising in the area of an extraction.
11. Please take all prescriptions as directed.
12. Women please note: Some antibiotics may interfere with the effectiveness of your birth control pills. It is recommended that you use an alternative form of contraception in addition to your birth control pills while you are taking antibiotics if you are sexually active. Please check with your pharmacist.

The most commonly asked questions

Here are the most common quesiotns we answer in post-op phone calls:

1. I'm still bleeding- is that normal? Well that depends on how much, when, and whether it's "starting and stopping" or continuous. Because the local ansthesia contains a medication to constrict blood vessels, we often see bleeding that stops for the first 1-3 hours, and then begins again. If the bleeding seems to increase as the anesthesia is wearing off, this is normal and generally can be controlled by biting again on the gauze packs. If the bleeding has been continuous since the surgery, you should then assess how much blood you see. It is very common to "ooze" for the first 24 hours. This means if you bite on a gauze for 30 minutes, there will be some blood present. You should call in any case where you see saturation of the pack over a 10 to 15 minute period that is not controlled within an hour (i.e. after re-packing every 15 minutes for four times).

2. I took my pain medication but it is still severely hurting. What should I do? First, it usually takes a couple of doses of pain medication for it to work at the maximum. Second, there are strategies for maximizing the effectiveness of the pain medication. You should take the maximum dosage for at least the first two doses (that usually means two tablets/capsules per dose). Unfortunately the maximum recommended daily dosage of most pain medicaltions is 8 per 24 hour period. You therefore should not continuously take the maximum dose every four hours. One way to work around this limitation is to add another type of pain medication to the reigimen. The most common suggestion is to take 1-2 Vicodin or Tylenol/Codeine every 4-6 hours (up to 8 per 24 hours) and to add 200-400 mg of ibuprofen every 4-6 hours (up to 2400 mg per 24 hours) in alternating doses. That is, take Vicodin dose, then 2-3 hours later take ibuprofen dose, and so on.

3. Should I be concerned because my stitches came out? Generally we place stitches to help pull the tissue tighter against the socket and reduce bleeding. The stitches will not close the socket completely. If stitches come out, they will not be replaced anyway.

In case of questions

You should have the best experience if you follow the instructions and suggestions as outlined. If you should have any problems such as excessive bleeding, pain, or difficulty in opening your mouth, call us immediately for further instructions or additional treatment.

Remember your follow-up visit

It is often advisable to return for a postoperative visit to make certain healing is progressing satisfactorily. A follow-up visit is scheduled in many cases. We encourage an earlier follow-up check if you have any concerns or questions about your healing. Please do not hesitate to call us.