What you should do after an extraction

Following this discussion of what you should and should not do after an extraction, I will go into the complications that can arise if you do not follow this advice.  If you have any doubt about the need to follow these instructions, skip ahead and read about the complications. 

1.  You are sick, even if you don't know it yet. (Wait until the anesthesia wears off and then you will know it.)  Go home and act sick! I mean go home, put your head down and do not exercise for at least 12 to 24 hours. Do NOT go to work just because you feel great while your mouth is still numb.  The nicer you are to yourself today, the more likely it is that you will be able to resume a normal life tomorrow.  

2. When you leave the office, you should have a piece of gauze over the socket.  Keep biting on the gauze for at least two hours.  Do not chew on the gauze.  Just keep constant, even, gentle pressure on it so that the socket is covered, and the bleeding is stemmed.  There is only one way to stop bleeding, and that is to keep biting on the gauze.  If you go to the emergency room with bleeding, they will sit you down in a chair and make you bite gauze for another two hours.  Be sure that the extraction socket is completely covered by the gauze.  You do not have to change the gauze unless it becomes soaked with blood.  

If you have kept the socket covered firmly for at least two hours, the blood in the socket should have clotted.  The clot then acts like a cork and keeps you from bleeding further. If the clot is kept intact you may fall asleep and wake up with some blood on the pillow, but this is just a bit of blood oozing from the clot while it continues to organize itself. The blood mixes with saliva and can can appear worse than it really is.

3. Do not spit for 24 hours.  If you spit, you tend to suck, and this will dislodge the clot causing renewed bleeding, or even a dry socket.  You may gently bring blood and saliva  forward with your tongue and wipe it away with a tissue, but avoid forceful spitting at all costs.

4. Do not smoke for 48 hours!  If you smoke, you WILL get a dry socket because the chemicals in the smoke get into the saliva and dissolve the clot.  Even worse, the continued smoking irritates the bone in the socket and the dry socket will be especially painful and persistent.  If you have ever had a dry socket, you will do ANYTHING to avoid another one.  

5. Wait until the anesthesia wears off before eating anything solid, and when you can feel your mouth, you can eat whatever you can tolerate.  

6. Take your medications. If you have been prescribed an antibiotic such as penicillin or erythromycin, take it on schedule until it is all used up.  Dental infections can be not only painful, but quite dangerous.  The pain medications can reduce swelling and speed your recovery.  If you are prescribed a narcotic like codeine, Vicodin or Percocet, do not drive or operate equipment under the influence. 

7. If, after 48 hours, the pain gets worse, or you start bleeding again, call the dentist.  You could be getting a dry socket, or an infection. 

Complications after extractions

1. Bleeding 

It is possible to bleed to death following the extraction of a tooth.  But it almost never happens.  All you have to do is follow directions #1 and #2 above and the bleeding will stop.  The only patients that may still be in danger from excessive bleeding are those who are taking anticoagulant drugs (blood thinners) like Coumadin or Heparin for  cardiovascular problems, or people with bleeding disorders like Hemophilia or related clotting cascade disorders .  These patients should consult their physicians before having a tooth extracted.  People taking aspirin and other non steroidal anti inflammatory drugs (NSAID's) like Advil or Aleve may experience prolonged bleeding times, but in my experience, these drugs have never presented a problem as long as the patient keeps the extraction site covered with gauze  to stem the bleeding.  The blood WILL clot eventually!

2. Infection

The mouth is alive with bacteria, especially in people with poor oral hygiene.  Infection is a constant problem after extractions, and most dentists have developed a personal protocol on whether or not a particular patient needs preventive  antibiotics.  People who present at the office with swollen faces, teeth tender to light pressure, swollen gums or tongue, or bleeding and pus around a tooth are generally already infected.  They should expect to be given prophylactic (preventive) antibiotics after an extraction.  

Patients may develop infections after an extraction even if they were not infected before the extraction.  This is a common complication and is due to the fact that that the mouth is teeming with bacteria and cannot be sterilized prior to the extraction.  (They are NOT due to any error on the part of the dentist!)  The first sign of an infection after an extraction is often renewed bleeding after 48 hours.  The bleeding is not generally severe, but it is an indication that the patient should return to the dentist's office for evaluation and possibly a prescription for antibiotics.  Signs of infection two days after an extraction should be attended to as soon as possible.  Click here to see how severe tooth related infections can become.

Some dentists will give a patient an antibiotic and send them home for several days to allow the infection to clear before attempting the extraction.  The reason for this is because the local anesthesia does not work as well in acid environments and it may take a lot of shots to get the patient numb.  However, if the dentist gives enough anesthesia, it is possible to extract a tooth under such circumstances.  In general, I have never found that extraction of a tooth in the presence of an active infection has presented special problems as long as the patient takes the antibiotics prescribed faithfully.  

It is NOT necessary to take antibiotics after every extraction.  A simple extraction in a clean, uninfected mouth generally does not require prophylactic antibiotics.

Whenever the extraction requires the cutting of any tissue (see surgical and impacted extractions above), it is generally a good idea to give prophylactic antibiotics, and the patient SHOULD fill the prescription and take the drug faithfully, or he may suffer an extended convalescence.  

3. Dry Sockets 

A Dry Socket, while not potentially life threatening like bleeding or infections, is one of the most painful, common, debilitating and dreaded post extraction problems encountered in dentistry.  They are much more common following the extraction of lower teeth than they are after extraction of upper teeth.  They can happen after even the simplest of extractions.  If you follow all of the post surgical directions listed above, you have done the most anyone can do to prevent them.  Unfortunately, no matter how hard you try, you may still get one.  If you get one, it is not (necessarily) your fault.  Nor is it the fault of the dentist.  They are a quirk of nature.  You may THINK you are going to die.  You won't! 

The two classes of patients who are most prone to dry sockets are those who smoke during the first 48 hours after the extraction, and persons who tend to constantly grind and clench their teeth (see my page on TMJ)

What is a dry socket?

A dry socket is a condition in which the blood clot that forms in the extraction site becomes detached from the walls of the socket, or dissolves away leaving the bare bone exposed to saliva and the foods you eat.  The bone becomes inflamed due to bacteria and chemicals in the mouth, and this inflammation is  persistent and painful.  The pain is "deep pain".  That is, it comes from tissues buried deep in the body, and your brain has no experience of pain from these regions.  When the brain receives pain signals through these unusual channels, it is unsure of the exact location of the pain, so it tells you that the pain is coming from areas on that side of your face and head that are far removed from the actual source.  Pain like this is called "referred" pain.  It seems to shoot up the side of the head, or makes your eye ache.  

How are dry sockets treated?

Left alone, dry sockets will always heal.  It takes a month or two, and the pain is persistent for the entire period of healing.  Antibiotics are not useful in curing a dry socket, and the usual pain medications are not very effective.  It is better to go back to the dentist who extracted the tooth and let him or her "pack" the socket.  This is a procedure done (usually) without anesthesia even though it can be painful, because it does not take too long, and the pain relief is almost complete, beginning an hour or so after the socket is packed.  The first packing will provide relief for about 24 hours.  As you return to the dentist and the old packing is removed, the socket washed out and new packing is placed in, each succeeding packing debrides  (cleans) the socket and renews the pain relief.  A second packing may last 24 to 48 hours, and succeeding packings last longer still. Within a week (or sometimes more depending on the severity of the dry socket), The socket begins to heal from the bottom up and can be left empty without pain.