Sinus Precautions After Surgery

     Because of the close relationship between upper back teeth and the sinus it is not uncommon when having an upper molar or premolar tooth removed that a small opening (communication) will develop between the mouth and the sinus.  Most of the time there is a very thin layer of bone between the roots of the upper back teeth and the sinuses however larger tooth roots or teeth that have infections around them often extend into the actual sinus.  It is a fairly common occurrence; there is no reason for alarm when this happens.  You will have been informed at the time of your surgery and will have been told to read these instructions in order to give the site the best chance to heal on its own.  However, sometimes the communication may develop after the surgery and not be known until a later date.  Also, some do not resolve on their own and may require a second procedure, particularly if these instructions are not followed or due to factors beyond the control of anyone involved. 

First you should follow all of the postoperative instructions for a regular extraction as well as the ones that are listed below. 

1. Take all prescriptions as instructed.  Is very important that you complete the full course of postoperative antibiotics. Pain medication should only be taken if needed. 

2. Do not spit forcefully for several days and no spitting at all the first 24 hours after surgery.

3.  Do not smoke for 10 to 14 days. 

4.  Do not use a straw or drink through a water bottle with a suction tip for 1 week. 

5.  Do not blow your nose for at least one week and only gently if you must during the second week after surgery.  It is preferable if you do not blow your nose for the first two weeks.  If your sinuses feel "stuffy" or "clogged" or you develop a post nasal drip or a runny nose you can start taking an over the counter (OTC) decongestant orally.  Examples: Sudafed or Actifed tablets.

Only take these decongestants if you do not have any medical condition that prohibits the use of them, if you're unsure check with your medical doctor before starting them.  See ***note below for contraindications of using pseudoephedrine. 

ONLY TAKE THE ORAL MEDICATION; DO NOT USE NASAL SPRAY DECONGESTANTS.  If your nose is extremely dry you can use a saline nasal spray but spray use sparingly and very gently and do not blow your nose after use.

6.  Try not to sneeze if possible, it will cause undesired sinus pressure. If you must sneeze, keep your mouth open. This is very important! Open mouth sneezing...DO NOT CLOSE YOUR MOUTH AND HOLD IT IN.

7.  Eat only soft foods for several days, trying to chew on the opposite side of your mouth.

8.  You are to start rinsing your mouth 24 hours after surgery but only very gently for the first few days.  Rinse only with salt water; do this 3 to 4 times a day for the first two weeks, most importantly after meals and before bedtime.  Do not use mouthwash, only salt water.

9. Slight bleeding from the nose is common for several days after surgery.  Typically the day of surgery and the first day after surgery this is very common so do not panic this is normal.  It is likely you will wake up with some blood on your pillow the morning after surgery so you may want to cover your pillow with a towel before going to bed.  Try to sleep with your head elevated the first night (propped up on 2 to 3 pillows or sleep in a reclining chair. 

10. It is also very important that you refrain from any strenuous exercise (weight lifting, boxing, swimming etc) for the first two weeks after surgery.   

***Contraindications for using pseudoephedrine: DO NOT USE pseudoephedrine unless cleared by your physician if you have: 

1.     Diabetes: Sugar problems        

2.     Cardiovascular disease: Heart problems

     3.  Severe or uncontrolled High blood pressure 

     4.  Coronary artery disease, clogged arteries

     5.  Prostatic hypertrophy: an enlarged prostate. 

     6.  Hyperthyroidism 

     7.  Closed angle Glaucoma 

     8.  If you are pregnant or think you possibly could be pregnant 

     9.  Patients who are prone to anxiety or panic attacks should use pseudoephedrine with caution,   as anxiety and restlessness are common side effects, mostly due to the drug's stimulant properties.

Drug interactions:

DO NOT USE Pseudoephedrine products (Sudafed/Actifed) if you have recently been on (previous fourteen days) monoamine oxidase inhibitor (MAO inhibitors) this can lead to very, very high blood pressure leading to a hypertensive crisis.  

Use with caution if taking methyldopa, mecamylamine, reserpine and veratrum alkaloids it may increase blood pressure.  

If you are at all unsure if you should take these medications DO NOT take them until checking with your medical doctor first. 

Please keep our office advised of any changes in your condition, especially if you a bad odor from your mouth or a discolored drainage from the site or if your pain increases. It is important that you keep all future appointments until we are sure that the sinus has completely closed. The majority of the time the sinus communication will close on its own however occasionally a second procedure may be required to close the tissue up around the small opening.  Typically I will allow 4-6 weeks of healing before determining whether any further treatment is required.

A little Humor; The myth's and misconceptions of having "Wisdom teeth"extracted

I wasn't sure what to write about for my first blog so I started out with the basics of Oral Surgery.  I typed up a bunch of information on the removal of wisdom teeth, the reasons for removal, instructions on what to do after extraction of teeth etc., then I started viewing other blogs that people wrote about their experience's when having their wisdom teeth extracted and deleted my first post to go in a new direction.  This blog is mainly for entertainment purposes even though the information is accurate.  If you are one of my patients and are scheduled or just had your wisdom teeth removed please refer to the appropriate Blog post. Before Surgery see Pre-Operative Instructions and Post-Operative Instructions for after surgery.

1.  Whoever is out there telling everyone that is about to have their wisdom teeth removed that it is intensely painful...Please STOP!  The surgery itself should not be painful at all!!  Of course there are exceptions to everything.  If you don't have your wisdom teeth removed early in life and wait until the tooth is abscessed you may experience some pain.  This is no way the doctors fault!  This has to do with the way local anesthesia works and it doesn't work as well in an area that is infected or when the tooth is hurting during the time of extraction. These are the only instances that removing a tooth could be painful.  If you are having an extraction and you feel pain just raise your hand and tell your doctor, he/she should stop and give you more local anesthesia sometimes you may need a little extra.  I know having teeth pulled is scary but it should not be painful and I spend my days making sure my patient's are comfortable during and after the procedure.

2.  Making an incision when removing a tooth does not make the extraction easier by any means.  If your doctor does not make an incision it's because it is not necessary.  Pain and swelling increase post
operatively when incisions need be made so actually you doctor is being good to you.  I sometimes spend a lot of extra time trying to remove a tooth without the incision when I know I can get it done faster with one for the sake of my patients comfort after the procedure.

3.   A fast extraction is NOT always the best extraction!  If a tooth is difficult to remove it typically has to do with the root structure of the tooth, the density of the surrounding bone, and whether any vital anatomy is in the area like nerves or the sinuses.  Some teeth take me a few seconds to remove and some can take 45 minutes it all depends on the patients anatomy.  In the age of the dental implant it is critical to maintain as much of the surrounding bone when doing an extraction so if I make an incision it is because bone needs to be removed, which I am trying to avoid in order to place an implant in the future and prevent my patient unnecessary pain and swelling over the first few days.  On the other hand some teeth need to be sectioned and removed in pieces or bone can remain stuck to the tooth and come out with it, again they are all different and there is no single "right" way to remove a tooth.  All of these factors are being considered at the time of extraction by your doctor, or at least they should be. There is no single right way or wrong way, it all depends on the individual case. 

4.  Your cheek is NOT stitched to your gums and something has not gone wrong.  

The lower jaw flares out and incisions in that area need to be made over bone otherwise we would be making an incision without really knowing what we are cutting through and the nerve that supplies sensation and taste to your tongue is in the soft tissue in that area so the incision extends backwards following the jaw bone.  When you are swollen it may feel tight like it is stitched to the cheek but after it heals this will not be the case.  All will be normal again.

5.  If stitches (sutures) were not placed its because they weren't needed not because your doctor didn't know what he/she was doing.   Typically the only time sutures are needed is when incisions were made to remove the tooth or multiple teeth were extracted in a row.  However, there are always exceptions to this rule.  When removing teeth I make every effort NOT to make incisions, this saves my patients unnecessary post operative pain and swelling.  I personally spend extra time trying to extract a tooth without cutting open the gums (which is why a fast extraction is not always the best extraction) but if I have no choice and am forced to make an incision I try make the smallest incisions possible.  If I am forced to make an incision then it it necessary to suture the tissue back in place.  If I don't make an incision then sutures aren't usually necessary because the gums adhere tightly to the jaw bone and placing a suture will not make the hole (extraction site) any smaller, so there is really no point.  Like I stated above there are exceptions to every rule.  If a tooth is broken or decayed below the gums and I am still able to remove it without an incision the gums may have been slightly lifted up and moved out of the way for me to get under them to remove the broken tooth and now would not be as tightly adherent to the jaw and placing a suture will help with healing and stop the bleeding more quickly.  Another reason to place sutures when incisions were not made during surgery would be if a patient is taking a blood thinner.  Patients on blood thinners take longer to clot and if the blood thinners were not stopped prior to surgery extra measures are necessary to aid in the clotting process.  This usually includes placing a foam clotting agent into the socket and placing sutures to tighten the gum tissue and prevent the foam from falling out. So in conclusion if you didn't get stitches/sutures it's because you didn't need them and typically this means the extraction was not a difficult one and excess bleeding is not expected.  This however in no ways means that its not possible for excess bleeding to occur and if it does call your doctor but most likely this would have happened whether the sutures were placed or not.  It is usually do to the formation of an irregular clot and would have happened whether a suture was placed or not.

DON'T listen to your friends or believe everything you read...Especially, on the internet.  If you come across post by non medical professionals don't even bother reading them

Today I came across these incredibly inaccurate statements people have posted on the internet as to the reasons wisdom teeth need to be removed. 

     Person 1.  Reasons I heard for getting one's wisdom teeth out is that there might be a gap between the last tooth and the wisdom tooth allowing for foods to get trapped, but won't taking out the wisdom tooth just make a bigger gap? 

     Person 2.  The most common reason is that your wisdom teeth are huge, and by coming through, they might fracture your jaw and force other teeth to become displaced.  And as for the food getting stuck: there is no other tooth back there for food to get stuck between. If it went back there, it would just rest on your gum until you moved it.

Believe me - wisdom teeth are incredibly painful, and they usually take them out. A lot of the time, they're unsightly, but it hurts to have them out, and they usually damage your jaw then, too.
     Person 3.  My wisdom teeth were impacted. Which the dentist explained as them growing in at an angle. Apparently, if they had been allowed to keep growing on their own, they would have pushed my existing molars out of my head. At least that's what the dentist claimed.

Let's start with the initial question.  The trapping of debris and bacteria is a valid reason to remove third molars. However, it is not due to a gap in between the 2nd and 3rd molars.  Typically, there is inadequate space for wisdom teeth to erupt into the mouth therefore wisdom teeth often remain impacted (stuck) and angle improperly not allowing adequate cleaning of these teeth which causes the trapping of food debris and plaque in the area.  Inadequate cleaning between the 2nd and 3rd molars over time will lead to decay of both molars, often the tooth decay will be below the gum line and into the root of the 2nd molar.  Once this occurs the 2nd molar would need to be removed as well as the 3rd molar.  So taking out the wisdom tooth when you are young prevents damage and the possibility of having to remove the 2nd molar.  So the actual reason here for removal of the 3rd molar is to prevent damage to the adjacent tooth and maintain its health in the future. 

As far as Person #2 statement is concerned.  Wisdom teeth are typically not any larger than the rest of the molars you have and they do NOT cause jaw fractures when the erupt.  There is nothing accurate about that statement.  They can however cause displacement (shifting) of other teeth as they try to erupt.  Again it's typically a lack of space problem.  So as the wisdom teeth try to enter the mouth they often cause shifting and crowding of the lower incisions.  If orthodontics were done and the teeth straightened previously it is highly recommended to remove the wisdom teeth to prevent relapse and the need for braces a second time.

These statements are the exact reason that you should NEVER believe everything you read (especially on the internet).    

  

I have a feeling I could be up all night blogging about what people perceive is about to happen or has happened to them in an Oral Surgeons office so I will continue later.