Patient guide

What is the first visit for?

Most patients arrive with a referral from their dentist, and sometimes an image, and they have two questions: what is the problem, and what should be done? The ADA says the decision about removing a wisdom tooth is made after an examination and an X-ray, and that every patient’s situation is different. So the first visit is mostly about listening, looking and assessing. The surgeon hears your concern, examines your mouth and jaw, looks at your images and, if needed, asks for a new one. None of this means surgery is already decided.

What should you bring?

• Earlier images. MyOMS recommends sending your images to the surgeon’s office before the visit. The ADA also says old images can usually be obtained from your previous dentist and do not have to be taken again. Bring the file or disc, and if you only have a photo on your phone, show that too.
• A list of all your medications. MedlinePlus asks you to bring a list that includes prescription and over-the-counter medicines, occasional medicines, vitamins, supplements and herbal products, with the amount and how often you take each. The medicine boxes or a photo of the prescription sheet are enough. You can read the reason in Medications to tell your surgeon about before surgery.
• Allergy history. To medicines, latex, adhesive tape, iodine or disinfectants. MedlinePlus asks about all of these.
• Bleeding and clotting history. Any problem you had with an earlier surgery or anesthesia, and whether you have had bleeding problems or blood clots.
• Habits. Cigarettes or waterpipe, alcohol and drugs. The surgeon asks for planning, not to judge. MyOMS says smoking slows healing and raises the risk of complications.
• Illnesses and earlier operations. Diabetes, heart or lung disease, osteoporosis, cancer, and any condition for which you take medicine or have injections. Be sure to mention an artificial heart valve, a past heart valve infection, radiotherapy to the head and neck, and pregnancy.
• Your questions. MyOMS says to bring something to take notes with and a list of questions.

Who should come with you?

If surgery may happen that day or soon after, it is good to have someone with you who can write down what the surgeon says and stay with you afterward. For surgery with sedation or anesthesia, MyOMS says a trusted adult should take you, stay during the procedure and bring you home.

What questions should you write down?

• What exactly is my problem, and what happens if I do nothing?
• What image is needed, and why? (Read about OPG and CBCT here)
• What options do I have, and what are the possible complications of each?
• Local anesthesia, sedation or general anesthesia? Where will the surgery take place?
• How many days of rest do I need, and who follows up with me after surgery?
• If a problem comes up, who should I call, and on what number? (Warning signs)

One last thing

If you have a sign that cannot wait, such as difficulty breathing, rapid swelling of the floor of the mouth or neck, or heavy bleeding that does not stop with pressure, do not wait for the visit. Call 115, Iran’s emergency number. The details are in When should I call right away?.

Why does preparing matter?

Minor mouth surgery is usually short, and most patients go home the same day. Larger jaw operations need a hospital stay. Either way, what you do before the operation affects anesthesia, bleeding and healing. Everything on this page is general. If your surgeon has told you something different, follow the surgeon’s instructions.

In the days before surgery

• Tell the surgeon about your medications and supplements. MyOMS says to tell the surgeon about all of them, even the ones you think are unimportant, because they may interact with the anesthetic or with the medicines used after surgery. MedlinePlus says the surgeon may give instructions several days, or even two weeks, ahead about some medicines, such as blood thinners and anti-inflammatory pain relievers. Do not lower, raise or stop any medicine yourself. That decision belongs to the surgeon and the doctor who prescribed it. The details are in Medications to tell your surgeon about before surgery.
• Report any new illness. MedlinePlus says that if you get a cold, fever, flu or any other illness in the days before the operation, tell the surgeon right away. The operation may need to be postponed.
• Keep underlying conditions under control. Diabetes, for example. MedlinePlus says better control of a condition lowers the risk of problems after surgery. If you use insulin, the NHS stresses that the care team must know.
• Smoking and alcohol. MyOMS says smoking slows healing and raises the risk of complications, and to ask your surgeon when you should stop smoking and drinking. MedlinePlus says the same and recommends quitting smoking.
• Other dental work. If you have other dental work planned, ask the surgeon about the timing.
• Buy soft food. Yogurt, soup, purees and the like for the first days. The full list is in the food guide.
• Someone with you, and time off. MyOMS says to leave free time for work or university and to arrange a trusted adult who will take you, stay there and bring you home. If you are having anesthesia or sedation, MyOMS reminds you to have someone with you for 24 hours afterward.

Types of numbing and anesthesia

The NHS names three options: local anesthesia, where an injection numbs the gum; sedation, to help you feel calmer; and general anesthesia, during which you are asleep. The NHS says sedation and general anesthesia are chosen more often for harder teeth or for anxious patients. The surgeon suggests the type based on your situation, so ask.

The night before and the day of surgery

• Fasting. If you are having intravenous sedation or general anesthesia, MyOMS says to follow the eating and drinking instructions exactly. The NHS stresses that if you are told not to eat, even light snacks and sweets are not allowed, and you should ask your doctor about water. The reason is to keep the stomach empty so the risk of an anesthesia complication is lower.
• That day’s medicines. Ask the surgeon which of your regular medicines to take that day. MedlinePlus asks for the same.
• Clothing. MyOMS suggests loose, comfortable clothing and says to leave off makeup, jewelry and artificial nails.
• Mouth. Brush your teeth before you go.
• Pain relievers or anti-anxiety medicine. If the surgeon has prescribed something to take before the operation, follow the timing and method exactly as written on the prescription.
• Driving. The NHS says not to drive for 48 hours after general anesthesia and for 24 hours after injected sedation.

What should you bring?

Your medication list, images of your mouth and jaw, referral papers, and the name and number of the person who is staying with you. If you wrote down questions earlier, bring that note.

If you are unsure

Call before the day of surgery and ask. Most offices prefer to hear a question in advance. If the night before you notice an urgent sign such as difficulty breathing or rapid swelling of the neck, call 115, Iran’s emergency number. The full list of signs is in When should I call right away?.

First, a note

This page is a general guide and does not replace your surgeon’s instructions. Surgeries differ, and if you were given a personal instruction sheet, follow that.

The first hours: protect the blood clot

After a tooth is removed or after surgery, a blood clot forms in the wound. The NHS says this clot plays an important part in healing. Most of the advice after surgery is meant to keep the clot in place.

• Bleeding. A little oozing of blood on the first night is normal. MyOMS says to place clean gauze or a damp tea bag on the area and bite down gently. The NHS says to press with a clean cloth or cotton for at least ten minutes, and Cleveland Clinic mentions fifteen minutes. If it does not stop with steady pressure, call your surgeon. If there is a lot of blood or you feel faint, call 115.
• No straws. Strong sucking can dislodge the clot. MyOMS rules out straws and says to drink from a cup or a squeeze bottle. The ADA says no straws for the first 24 hours, and in its section on dry socket MyOMS mentions 24 to 48 hours. If your surgeon gave a different length of time, follow that.
• Cigarettes and waterpipe. The NHS says smoking raises the risk of infection. Cleveland Clinic writes that smoke and vapor narrow the blood vessels and reduce the blood supply to healing tissue. MyOMS says to stop smoking completely for at least a few days.
• Do not spit or rinse hard. MyOMS and Cleveland Clinic both advise against spitting and vigorous swishing. Keep your tongue away from the area as well.

Swelling, bruising and pain

• Swelling. It is normal. MyOMS suggests an ice pack or cold compress on the cheek, not on the wound. Cleveland Clinic uses ice for twenty minutes and then twenty minutes off. The NHS says discomfort and puffiness can last up to two weeks, but ease after a day or two. Bruising of the cheek, a stiff jaw and pain when chewing or swallowing are also possible.
• Pain. Cleveland Clinic says the third day is usually the most painful. Take pain relievers only as your surgeon directs, and ask before using any other medicine. MyOMS says the surgeon may prescribe a pain reliever or suggest an over-the-counter one.
• White patch. Cleveland Clinic says a white area over the healing site is normal. But if the pain is getting worse, or you think you can see bone in the socket, tell your surgeon.

Mouth hygiene

• Keep brushing, but be very gentle near the wound. MyOMS says to be careful with the clot in the first 24 to 48 hours. The ADA says not to clean the teeth next to the site.
• MyOMS recommends gentle rinsing with warm salt water several times a day, and says that for at least the first 24 hours you should neither rinse hard nor brush near the wound. The NHS also mentions gentle rinsing. Your surgeon gives the exact timing, because the sources differ a little on this.
• If a medicated mouthwash was prescribed, use only that, as prescribed.

Activity and driving

MyOMS recommends a few days of rest and says to avoid exercise and heavy work. Cleveland Clinic says to stay away from strenuous exercise and heavy lifting for the first 48 to 72 hours, because a higher heart rate increases pain and bleeding. Cleveland Clinic writes that most people return to daily activities after two or three days. The NHS says not to drive for 48 hours after general anesthesia.

Food

In the first days, eat soft food and avoid hot, spicy and hard food and drinks. Avoid alcohol too, because MyOMS says it reduces the effect of pain relievers and slows healing. See the full list in the guide to food after surgery.

What should you watch for?

• Dry socket. If severe pain begins a few days later and keeps getting worse, has a bad smell or taste, or spreads to the ear, temple or neck, MyOMS considers this a possible sign of dry socket. Call your surgeon early. There is more in the article What is dry socket?.
• Infection. MyOMS names fever, increasing pain, spreading swelling or redness, pus, or a bad taste that does not go away. Cleveland Clinic lists a fever of 38 degrees Celsius or higher, pus-like discharge, and pain that pain relievers do not ease.
• Numbness of the lip, chin or tongue. MyOMS says it is usually temporary and that lasting numbness is less common. The NHS says it usually improves and may take several weeks or months. If you are still numb the day after surgery, let your surgeon know. After an implant in the lower jaw, tell the surgeon the same day.
• Upper teeth. If you notice discharge from the nose or sinus pain, tell your surgeon. MyOMS says the roots of upper teeth are sometimes close to the sinus.
• Follow-up visit. MyOMS says to attend all follow-up appointments so the surgeon can see how healing is going.

For signs that cannot wait, such as difficulty breathing, being unable to swallow, or rapid swelling of the floor of the mouth and neck, call 115, Iran’s emergency number, right away. The full list is in When should I call right away?.

Why does food matter?

After surgery, the blood clot over the wound needs to stay undisturbed and the stitches should not be under pressure. Hard or tiny-grained food puts both at risk. MyOMS says full healing takes several weeks and that soft or liquid food suits the first few days. Because every surgery is different, if your surgeon gave you a food sheet, that comes first.

The first few days

MyOMS suggests foods that need very little chewing:

• Yogurt, applesauce, broth-based soup, ice cream
• Mashed food, or firmer food softened in milk or broth
• Smoothies, as long as you do not use a straw (drink from a cup or use a spoon)

The NHS and Cleveland Clinic also recommend soft food. Cleveland Clinic gives rice, pasta, eggs and yogurt as examples. The NHS says to eat soft or liquid food until chewing is comfortable.

A few days later

When you feel more comfortable, MyOMS mentions adding oatmeal, mashed potatoes, scrambled eggs, soft pasta, and shredded meat or fish. Do not chew near the wound, and use the other side of your mouth. Bring back normal food slowly, at a pace that feels comfortable to you.

What should you avoid?

MyOMS has a specific list:

• Acidic fruits such as oranges and tomatoes
• Carbonated drinks, including soda and sparkling mineral water
• Tiny seeds, nuts and popcorn
• Sticky candy
• Spicy food
• Hot drinks

The NHS also avoids hard and crunchy food, and tiny seeds that could get stuck in the wound, and says alcohol and very hot drinks can increase bleeding or cause burns. MyOMS avoids alcohol too, because it reduces the effect of pain relievers and slows healing.

No straws

Do not use a straw. Sucking can dislodge the clot and may lead to dry socket. MyOMS says to be careful for the first 24 to 48 hours, while the ADA warns about straws for the first 24 hours and Cleveland Clinic warns about them in general. What is dry socket?

Water and fluids

Drink plenty of fluids, but from a cup or a squeeze bottle.

If food gets into the wound

MyOMS says to rinse gently with warm salt water and not to use store-bought mouthwash. Do not rinse hard in the first 24 hours, and do not poke at the wound with a toothpick or finger. If it does not come out this way, call your surgeon.

Implants and other surgeries

During implant healing, MyOMS also recommends soft food in the first days to reduce pressure on the site. Your surgeon can give more personal advice on the right food.

What signs should you watch for?

If you cannot eat or drink, or pain and swelling get worse, tell your surgeon. Urgent signs such as difficulty breathing or being unable to swallow are described in When should I call right away?, and in those cases call 115, Iran’s emergency number.

Why are images taken before surgery?

Looking in the mouth shows only the surface. The tooth roots, bone, nerves and sinuses lie under the gum. MyOMS says routine dental X-rays are often not enough to assess an impacted tooth, and that a more advanced image helps the surgeon judge the position of the tooth, the space available, any cyst or infection, and how close it is to a nerve, so the surgical approach can be planned for that patient.

Panoramic image (OPG)

MedlinePlus writes that in this image the machine rotates around the head and captures all the teeth and jaws in a single two-dimensional picture. What is it useful for?

• Seeing impacted wisdom teeth
• Early planning for dental implants
• Finding problems in the jaw

MyOMS says this image shows the number, position, angle and stage of eruption of the teeth and is useful for initial assessment and planning, but it has less detail than a cone beam CT. MedlinePlus also says this image is not a good way to find tooth decay unless the decay is very advanced.

Cone beam CT (CBCT)

With this method, MyOMS says the machine rotates around the head and builds a three-dimensional image of the teeth, jaws and surrounding structures. The image shows nerves, sinuses and neighboring teeth in high detail. MedlinePlus says CBCT may be used before surgeries such as placing several implants. MyOMS adds that software allows precise measurements and virtual planning. A global consensus on treating the toothless upper jaw also names CBCT among the tools used to confirm the number of implants.

CBCT is not needed for everyone. Which image you need is decided by the surgeon after examining you and seeing your earlier images.

Comparison at a glance

Feature	Panoramic (OPG)	Cone beam CT (CBCT)
Type of image	Two-dimensional	Three-dimensional
Overview of teeth and jaw	Yes	Yes
Level of detail	Less	More
Common use	Initial assessment, impacted teeth	Surgery and implant planning
Radiation	Less	Usually more

How much radiation is there?

MedlinePlus writes that the radiation from dental X-rays is “very low,” but that unnecessary exposure should still be avoided. The FDA says the dose from a dental CBCT is lower than from an ordinary CT scan but usually higher than from conventional dental X-rays. So a CBCT is taken only when it is needed for diagnosis or treatment, and extra care is needed with children. The ADA also says the radiation dose is much lower than in the past, and still recommends taking an image only when it provides needed diagnostic information. For this reason you do not need an image at every visit. MyOMS says digital imaging is preferred over film because of its lower radiation. If you are pregnant or think you might be, be sure to say so before the image. MedlinePlus says pregnant women should not have X-rays unless necessary.

What should you bring?

• Any earlier images, whether a disc or a file. The ADA says earlier images can often be obtained from your previous dentist so they do not have to be taken again.
• Your list of medications and conditions.

What should you do on the day of the image?

MedlinePlus says no special preparation is needed. Remove metal objects from the area being imaged. The ADA says a lead apron is no longer necessary for every patient, but some centers still use one because of local regulations.

Questions to ask

• For my problem, is a panoramic image enough, or is CBCT needed too?
• Is the image taken in the office, or do I need to go to an imaging center?
• Will you give a copy of the image to my dentist and the doctor who referred me?
• If I already have another image, do I need to repeat it?

The first visit guide shows what else to bring.

Read this first

Most oral surgeries heal without a serious problem. Swelling, bruising and some pain are usually normal. But there are a few signs that should not be left waiting. This page describes them in three levels. If you are not sure, call. A call that turns out to be unneeded does no harm, but telling someone too late can be costly.

Iran’s emergency number is 115.

Level one: call 115 right now

Difficulty breathing, swallowing or speaking

If breathing, speaking or swallowing saliva has become hard, or saliva is drooling from your mouth without control, call right now. MedlinePlus treats difficulty breathing in this situation as a medical emergency and says you should go to the emergency room or call the emergency number immediately.

Swelling of the floor of the mouth, under the tongue, the neck or around the eye

An infection of the floor of the mouth under the tongue sometimes follows a tooth root abscess or an injury to the mouth. MedlinePlus writes that its swelling can quickly block the airway or make it hard to swallow saliva. The signs this source lists:

• Swelling of the tongue, or the tongue pushing out of the mouth
• Difficulty swallowing and drooling
• A muffled voice, as if you had something hot in your mouth
• Fever, pain, swelling and redness of the neck

In this situation, do not wait for the swelling to go down on its own. MedlinePlus considers a blocked airway the most serious risk.

For a dental abscess, the NHS also treats these as reasons to call the emergency services: a lot of swelling in the mouth, a swollen or painful eye, a sudden problem with eyesight, and difficulty opening the mouth. A stiff jaw for a few days after wisdom tooth removal is normal. A mouth that will not open is a warning sign when it comes with spreading swelling or fever.

Heavy bleeding that will not stop

A little oozing of blood on the first night is normal. The NHS says to press firmly with a clean cloth or cotton for at least ten minutes, and to get help right away if the bleeding does not stop. If a lot of blood is still coming after steady pressure, your mouth keeps filling with blood, or you feel weak or dizzy, call 115 or go to the nearest emergency room. If you take a blood thinner, tell them, and do not stop it yourself.

A severe allergic reaction

If after taking or being injected with a medicine your throat or tongue swells, breathing becomes hard, you start wheezing, or you feel faint or confused, it may be a severe allergic reaction. The NHS says to call the emergency services right away.

A blow to the face, jaw or head

After a blow to the face or head, call 115 if any of these happen:

• Double vision or any vision problem. MedlinePlus treats double vision and changes in vision or eye movement as a sign of serious injury, and the NHS lists vision problems among the reasons for an urgent call.
• Loss of consciousness, even briefly, being unable to stay awake, or a seizure.
• Confusion, marked drowsiness or a change in behavior. MedlinePlus and the NHS both treat these as urgent.
• Repeated vomiting, or nausea and dizziness. MedlinePlus says to get medical help right away if the injured person vomits more than once. For facial injuries, AAOMS also treats nausea and dizziness as reasons to call the emergency services.
• Severe or worsening headache, or a stiff neck. MedlinePlus puts severe headache and stiff neck on the same list.
• New numbness or weakness in the face or limbs, or trouble walking, balancing or speaking.
• Clear fluid from the nose or ears, or blood from the ear.
• Difficulty breathing or heavy bleeding. For a broken or dislocated jaw, MedlinePlus says these two are reasons to call the emergency number.
• A high-speed blow or a fall. The NHS also lists a head injury in a road accident and a fall from more than one meter or five stairs among the reasons for an urgent call.

If the neck may be injured, do not move the person yourself.

A few more points:

• Taking a blood thinner. The NHS says a person who takes a blood thinner and has a head injury should get advice immediately. Even if you feel well, go to a hospital emergency room right then, or ask 115 for advice.
• A broken or dislocated jaw. MedlinePlus says such a person needs medical care right away. The signs: a mouth that will not close, teeth that do not meet, numbness of the lower lip, or swelling and bruising after a blow. Gently support the jaw with your hand, go to the emergency room, and do not try to put it back yourself. If you tie a bandage under the chin, it must be able to be released quickly in case of vomiting.
• A knocked-out permanent tooth. If there is no other danger, go to a dentist right away. The sooner you get there, the better. Hold the tooth by the crown and do not touch or scrape the root. If you can, put it back in place and bite gently on clean gauze. If you cannot, keep it in milk or saliva. Do not put a baby tooth back, but take the child to a dentist right away.

Do not drive yourself after a head injury. The NHS says an adult should stay with you for at least the first 24 hours.

Level two: call the surgeon the same day

If you do not have the signs above but you have one of these, call your surgeon the same day. If you cannot reach the surgeon, go to a hospital emergency room.

• Fever with swelling or redness that is increasing. MyOMS considers fever, spreading swelling or redness, pus and a bad taste that does not go away to be signs of infection, and says to report them right away. The NHS also mentions pain with a bad taste in the mouth, fever or feeling unwell. Cleveland Clinic points to a fever of 38 degrees Celsius or higher and pus-like discharge. If this swelling reaches under the jaw, the neck or the eye, or opening the mouth becomes hard, see level one.
• Swelling that gets worse or lasts more than a few days. MyOMS includes this in its list of reasons to call the surgeon.
• Severe and increasing pain. The NHS considers severe pain and swelling that pain relievers do not ease a reason to seek care. MyOMS names severe or lasting pain, especially when it resembles dry socket. What is dry socket?
• New bleeding that eases with pressure but keeps coming back.
• Numbness after an implant in the lower jaw. If the lip or chin is still numb after the anesthetic has worn off, or you have new pain, call the same day. A few case reports suggest that attention within the first 36 hours helped feeling return.
• Discharge or sinus pain after surgery on upper teeth. MyOMS includes this in its list of reasons to call the surgeon.

Level three: report it within the next few days

• Lasting numbness of the lip, chin or tongue. If you are still numb the day after surgery, tell your surgeon and do not put it off until your next appointment. MyOMS says nerve injury is mostly temporary and rarely permanent. The NHS says it usually improves but may take several weeks or months.
• Anything else that worries you. MyOMS says to report any other sign that has worried you.

What should you say when you call?

• What surgery or injury it was, and how many days ago
• What sign you have, since when, and whether it is getting worse
• Whether you have a fever
• What medicines you take, especially a blood thinner
• Where you are and who is with you

This list is general and does not cover every situation. If you are worried about how you feel and it is not on this list, still talk to your surgeon or the emergency services.