Vu Orthodontics - Orthodontics, Periodontics, and Implants

Dose and Instruction

Major dental surgeries include extracting impacted wisdom teeth (3rd molars), socket graft (for ridge preservation), GBR (Guided Bone Regeneration), horizontal and/or vertical ridge augmentation, sinus lift, GTR (Guided Tissue Regeneration, hard and soft tissues), and dental implants. The author routinely does bone graft for every tooth extraction if ridge preservation is needed. In the extraction case of mandibular 3rd molars, a bone graft is necessary to prevent bony defect distal to the 2nd molars. A study in the literature indicates that this type of bony defect more likely occurs with patients who are older than about 26 years old.

To prevent possible infection associated with these procedures, especially with bone graft and implants, the author recommends the following medications (for adult patients):

1. Antibiotics (must): Amoxicillin, 500 mg, 1 PO (by mouth) 3x/d (t.i.d.) or every 8 hr, for 7 days.  Then consult the dentist. If the patient is allergic to penicillin, then an alternative is clindamycin, 300 mg, 4x/d (q.i.d) or every 6 hr. Note that the loading dose (just before surgery) is double of the maintenance dose. For example,  with amoxicillin, 1000 mg is the loading dose, whereas 500 mg is the maintenance dose.

2. For chronic infection, metronidazole (Flagyl, Metrogel, Noritate) is also recommended to be used (in addition), 500 mg, 1 PO (by mouth) 3x/d (t.i.d.) or every 8 hr, for 7 days. Then consult the dentist. Its dose and usage are the same as with amoxicillin, for convenience. Metronidazole is excellent for controlling anaerobes but not aerobic and facultative anaerobic bacteria. If metronidazole is prescribed, the patient must be warned about not consuming any alcohol which may cause a number of unpleasant side effects, including headaches, stomach cramps, nausea, vomiting, flushing, and irregular heartbeat.

3. Pain control (if needed): ibuprofen (Advil, Motrin), 600 mg, 1 PO every 4-6 hr PRN (abbreviated for the Latin term, "pro re nata" which translates to "as needed"). Take it with food to avoid stomach upset or reduce the risk of side effects. Note that ibuprofen has a weak anti-inflammatory property.  If ibuprofen causes bleeding, the patient should switch to Tylenol Extra Strength (500 mg), 1 PO every 4-6 hr PRN. The recommended maximum dose for Tylenol is 3000 mg per 24 hr, to avoid toxicity to the liver.

4. Anti-swelling (optional): Prednisone, 20 mg, 1 PO, daily (1x/d  or q.d.), with food, for the 1st 3 days (post surgery). Then consult the dentist. Take it with food to avoid stomach upset. After some major surgeries, significant swelling may occur. And the swelling is typically worse in the 2nd or 3rd day, post-surgery. Note that this short-term use of steroid (a few days or less than a week) is safe. As an alternative, some clinicians recommend using an ice pack for swelling control. Taking this medication (only for a few days, to control the swelling) is optional if the patient has discomfort with the swelling.

Some patients may have a concern with taking Prednisone since it is a steroid.  In general, using Prednisone together with ibuprofen may increase the risk of side effects in the gastrointestinal (GI) tract.  These include inflammation, bleeding, and ulceration. Though unlikely, GI perforation might also occur, which is a serious medical emergency.  But, again, short-term use of Prednisone is harmless.

5. Mouth rinse (to prevent infection on the surface of the surgical site): chlorhexidine (CHX or Peridex generic, 0.12%), 2x/d (b.i.d) or every 12 hr. Swish-then-spit CHX for 30 s, and then spit it out.  Do not rinse, drink, or eat, for about half-an-hour. Use it about 24 hr after the surgery. Note that CHX does kill fibroblasts, but the advantage outweighs the risk.  CHX does not penetrate deep into the tissue.

Typical CHX mouth rinse (0.12%) contains 11.6% alcohol and can be purchased from pharmacies, with a prescription.   The CHX mouth rinse that is without alcohol can also be purchased from dental suppliers -- but not through typical pharmacies. The side effects of long-term use of CHX are teeth staining and taste alteration. Note that patients must not use Listerine to avoid sloughing off the soft tissue.