Periodontist
Wisdom Tooth Extractions
Your dentist and dental hygienist will evaluate your wisdom teeth and if they determine that a problem exists, or the potential for a problem exists, they will refer you to a Periodontist, or Maxillofacial Surgeon for further evaluation. Not all wisdom teeth need to be extracted. But if your wisdom teeth have the potential to cause a problem, it is advisable to have them out prior to the onset of symptoms, rather than to wait until symptoms occur. Lower (mandibular) impacted wisdom teeth have the potential to damage the teeth in front of them, to become infected, to cause crowding of the teeth, and as the roots grow deeper in the bone, to cause severe pain, as the roots will often compress the nerve that gives feeling to the lower teeth, and lip.
For that reason, it is often best to remove impacted third molar teeth before the roots are completely formed. If the roots are in close proximity to the mandibular nerve, the likelihood of post surgical nerve paresthesia increases markedly. Generally, it is best to evaluate third molars at the age when jaw growth has stopped (about age 15 in girls, age 16 or 17 in boys).
Third molar extraction is generally performed with a combination of local anesthesia and some type of sedative medication. General anesthesia is generally reserved only for those exceptionally difficult cases, or patients with severe dental anxiety. Intraveneous Sedation or Oral Sedation/Anxiolysis is generally sufficient for most patients. Oral medications have several great advantages over Intraveneous medications. Formost is the absence of veneous access (and IV needle and catheter). Of even greater significance however are the increased safety of non-narcotic medications. In many instances, narcotic medicaitons are overused, and the potential for catastrophic negative effect is always present. If oral medications are used, there is little effect on the respiratory drive, the medication is as effective at reducing anxiety and overall a much safer alternative in injectable drugs. A loading dose is often given the night prior to surgery, so the patient is able to get a restful night sleep, and there is no need to be without food or water prior to surgery, so one is well hydrated and nourished beforehand, a clear advantage.
Following third molar extraction, infection, bleeding, pain and swelling may occur. To minimized these post-surgical factors, pain medications will be prescribed. A non-narcotic pain medication (Naproxyn) is the primary pain medication, and it should be taken twice per day for 10 days following surgery. Naproxyn will not make you drowsy, and it should be taken without interruption for maximum effect. In addition to relief of mild to moderate pain, Naproxyn is a very potent anti-inflammatory drug and will reduce swelling as well as speed up healing of the extraction sites. A stronger narcotic pain medication will generally be prescribed in the event that the primary pain medication is insufficient for the level of pain being experienced. The first dose is taken immediately after the surgery.
A systemic antibiotic will be prescribed as well as an oral rinse to reduce the incidence of infection following wisdom tooth extraction. Azithromycin is generally the most effective antibiotic to reduce the organisms which likely will cause an infection. Two tablets are taken immediately after the surgery, and one each morning for 4 days after. Chlorhexidine oral rinse will also be used, though its use should begin the day after extraction to not disturb the blood clot. Chlorhexidine should be used twice per day for 5 days after surgery. A capful swished around the mouth for 30 seconds twice per day is sufficient. It should not be rinsed with water afterward.
A steroid medication will generally be prescribed to reduce post operative swelling. Swelling is the chief cause of discomfort following wisdom tooth extraction, and it is most effectively addressed by using a tapering dose of steroid medication, starting the day after the procedure. Generally a Methylprednisolone (Medrol) dose pack is prescribed. The dose is 6 tablets the first day, taken at intervals throughout the day, with one less tablet taken each of the succeeding days. Directions are on the inside packet.
Some simple actions make third molar extraction surgery much less invasive. A good night’s rest the night before surgery, good nutrition, both before, and after surgery are very important. Light to moderate exercise is encouraged starting the day following surgery. It is best to avoid spitting, smoking and drinking with a straw after surgery, to reduce the likelihood of damaging the blood clot, a condition known as “dry socket.” Generally we recommend consuming a healthy fruit smoothie immediately after surgery, and prior to taking any medications. This smoothie ideally should be very cold and be made with probiotics (yogurt), vitamin and mineral supplement powder and protein powder. It is important to get a dose of good nutrition to kick start the healing process, cold is better applied directly to the tissues affected, and a smoothie will buffer the stomach from the effects of swallowing blood, saline, a nd post-operative medications, which tend to upset the stomach. It is also less likely that the patient will bite the tongue, lips or cheek while drinking a smoothie, than if they were to eat solid food.
Some post-operative bleeding is to be expected following third molar extraction. This is generally most noticeable when the local anesthesia wears off. One of the components of local anesthesia is a vasoconstrictor, which reduces bleeding. When the numbness wears off, this does as well, and some bleeding generally occurs. Biting on a square of wet gauze will generally stop the bleeding. If bleeding continues a black teabag (such as Liptons) will generally help a new clot to form. Tea contains tannic acid, which is a powerful clotting agent. If bleeding is persistent and profuse, it is best to return to the dental clinic, or if after hours, to proceed to the nearest urgent care or emergency room. Thankfully, this is a very rare occurrence.
At South River Periodontics, we strive to perform third molar extractions in a very safe, comfortable manner, with gentle and conservative surgical technique to not only get our patients through the procedure well, but to ensure a comfortable post operative course and rapid resolution.
Post-Extraction Care
Immediately after wisdom tooth extraction, you will be both numb and sleepy. Healthy postoperative nourishment and hydration is very important for a good recovery, however it is difficult to eat or drink when one’s mouth is very numb. I recommend a healthy fruit smoothie be consumed immediately after your procedure. It should contain lots of ice, fresh fruit, yogurt or probiotics, protein and vitamin powder. A straw should never be used, as it will likely pull the blood clot from the socket and promote bleeding and possibly lead to increased post operative discomfort. The smoothie is cold, and more effective than an ice pack in cooling the surgical site which will reduce inflammation. It is nourishing and will coat the stomach lining and reduce post operative nausea.
The first medications which should be taken are your non-narcotic pain medication, generally naproxyn sodium 500 mg, and antibiotic, generally azithromycin. One Naproxyn tablet and two azithromycin tablets should be taken after finishing the fruit smoothie. Rest is important for an uneventful recovery, so a nap is recommended. When you wake up, it is likely the local anesthetic will have worn off. If discomfort is tolerable, no furher pain medication is indicated. If necessary, a backup pain medication was prescribed. This medication is generally Tylenol 3, or Tylenol with Codeine, though other medications such as Vicodin or Percocet may have been prescribed. The backup pain medication is dosed so that two tablets taken every six hours as needed are sufficient for most pain not relieved by the primary pain medication.
When the local anesthetic medication wears off, so too will the vaso-constrictor medication, which reduces bleeding in the surgical site. Bleeding may start again, do not be alarmed, simply apply additional wet gauze, or a black teabag may be used to apply pressure to reduce this bleeding. Normal food within reason (softer foods like pasta) may be eaten once the local anesthesia has worn off. Plenty of fluids should be consumed, good healthy food, plenty of liquids and rest are important components of a good post operative course.
At bedtime, another dose of triazolam may be taken to help get to sleep at a normal time. In addition, the next dose of naproxyn should also be taken at bedtime. The morning after wisdom tooth extraction, brush and floss as normal, rinse with peridex, and repeat twice per day. Peridex rinse should be used twice per day for 5 days following extraction. One azithromycin tablet should be taken each morning until all are used, and naproxyn also should be taken, once in the morning and once twelve hours later, again, until all are used. In many cases where swelling is expected to be a problem, a steroid dosepak will have been prescribed (methylprednisolone). This is a tapered dose medication, and the instructions for use are on the inside package.
Just as proper nutrition, rest and hydration are important to a quick recovery, physical activity is very important. You should return to normal activity as soon as possible following third molar extraction. This includes aerobic exersize. The body releases important chemicals during exersize to aid in recovery, and these same chemicals are important in wound healing. Vigorous exercise is encouraged, starting the day after extraction.
Generally, sutures are used to close the third molar extraction sites. These sutures may be resorbable, or they may require removal. If resorbably, they generally will fall out on their own, 1-3 days following extraction. If non-resorbable sutures are used, they will require removal in one to two weeks following extraction. The extraction sockets may accumulate food debris. This should only be removed by rinsing with peridex, salt water or Listerine. Nothing should be inserted into the extraction socket for the first week following extraction, as this may damage the clot. Better to leave impacted food in place than to disturb the clot. After one week, you will be seen in the dental office, and the extraction site irrigated. You will be provided a monoject syringe and given instructions on using it to irrigate food debris.
Post operative swelling, bleeding and discomfort are common following wisdom tooth extraction. Our process is designed to minimize all those events. Persistant numbness of the lips and tongue also commonly occur following third molar extraction, as the wisdom teeth often impinge on the nerves that give feeling to those structures. This is generally transient, and improves in time following extraction. Again, gentle, conservative surgical technique minimizes these events.
