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New guidelines have been issued by the AHA ( American Heart Association) regarding premedicating for dental work and cleanings. 

In the past years, it was believed that IE ( Infective Endocarditis) was caused by bacteria in the blood also known as “Bacteremia”. It was believed that after dental procedures, the bacteria in the bloodstream could settle on susceptible areas , such as prosthetic valves and so on. New evidence has found many variances.

Previous AHA guidelines on the prevention of IE were largely based on opinion and limited studies. The most recent commendations were developed through an evidence based approach that was made after 20 years of extensive review. The new recommendation reduces the number of conditions that require premedication. Guidelines went under review due in part to the risk associated with widespread immunity to antibiotic treatment.

Patients with these conditions NO LONGER require prophylactic antibiotic:

1. Mitral valve prolapse
   
2. Rheumatic heart disease
   
3. Bicuspid valve disease
   
4. Calcified aortic stent
   
5. Congenital heart disease , like ventricular septal defect, atrial defect, and hypertophic cardiomyopathy

The new recommendation suggest antibiotic treatment for patients with the following conditions:

1. Prosthetic cardic valve
   
2. Previous infective endocarditis
   
3. Congential Heart disease
   
4. Unrepaired cyanotic CHD, including pallative shunts and conduits
   
5. Completely repaired congential heart defect during the first 6 months after the procedure
   
6. Cardiac repaired transplant patient who develop cardiac valvulopathy
   
7. Patients with any of these conditions should consult a medical doctor and bring a letter with your physician’s recommendations to keep in your dental file. For more information, questions, or to schedule and appointment, contact Smiles by Design!

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Scaling and root planning therapy is a procedure that involves removing bacterial plaque and tartar from the root surface below the gum-line with instruments and ultra-sonics. The goal of this treatment is to allow reattachment of the gums to the clean root surface and to shrink the periodontal pockets to levels that can be maintained by daily flossing and brushing. The following guidelines have been prepared for you in order to maximize healing and minimize any discomfort. 

Things to Avoid for the first 24 hours:

• Vigorous physical exercise, but you may return to work
• Drinking through a straw or sucking motions.
• Do not smoke. DO NOT SMOKE. Do not smoke.
• Drinking alcoholic beverages will slow the healing process.
• Food that is extreme in temperature or spicy.
• Avoid using any strong mouthwashes that contain alcohol.

Things to Do:

• You may take a non-aspirin analgesic to relieve any tenderness or discomfort, such as ibuprofen (Advil) or acetaminophen (Tylenol).
• Eat a well-balanced soft diet for today. You may chew on the opposite side of the treated area until it is comfortable to chew normally.
• Rinse with a warm salt water rinse, a 1 teaspoon in an 8 oz. glass of water, 3 times a day.
• Brush your teeth very lightly in the treated area the first night. Then begin flossing lightly as well the next day, gradually increasing to normal force by the week’s end.
• After flossing and brushing, rinse with (Peridex), if it was prescribed, for at least 60 seconds. Do this at least twice daily.

Several days after treatment your gums should begin to appear pinker, less swollen, and will bleed less when you floss. These are signs of healing and improving periodontal health.

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Your root canal treatment is complete.  It is normal for your tooth to be sore for 2-3 days after treatment.  It may actually become more sore on the second day.  Tenderness to biting may persist for up to two weeks following treatment but will gradually get better over time.

DO NOT eat or drink anything for the next half hour.  DO NOT try to feel around your tooth with your tongue.  You have a temporary filling in the tooth and it takes about half an hour to harden.  We recommend that you take 600-800mg of Ibuprofen (3-4 Advil or Motrin tablets) every 4-6 hours after the procedure and thereafter as necessary for pain.  If you are unable to take Ibuprofen, Advil or Motrin due to an allergy, stomach ulcer, or as per your physician’s advice, you may take 1000mg Acetaminophen (two extra strength Tylenol) every 6 hours. You can also take Motrin and Tylenol concurrently for extra pain relief.  It is a good idea to take the ibuprofen even if the tooth is not sore to help prevent soreness in the next few days.

Your tooth only has a temporary filling at this time.  It is critical that you make an appointment for placement of the definitive restoration as soon as possible.  We will place a crown, onlay, or filling to seal the root canal and help protect the tooth from fracture.  AVOID CHEWING ON THE TREATED TOOTH UNTIL THE RESTORATION IS PLACED!

If you experience swelling or pain (which is not comfortably controlled by medication), or if there are complications with your medicines, please call the office at 334-687-0088.  We will be glad to assist you with any questions you may have. 

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• Sensitivity, especially to cold, is common for a time following treatment
• Plastic temporary restorations will serve you for a short period of time while your permanent veneer is being made. They are attached only slightly to the underlying tooth so they can be removed easily so avoid chewing foods such as gum or taffy.
• If a veneer comes off, call us and we will replace it immediately. If you are in a situation that will not allow you to come in, place the temporary back in place with some Fixodent™ (denture adhesive). You must still see us as soon as possible.
• The size, shape, and color of the temporary may not resemble the final veneer.
• Temporary veneers may leak saliva or food onto the tooth. Sensitivity to hot, cold, pressure, or sweets is not uncommon. You may also see stains under the temporaries. These will be removed prior to final cementation.
• Avoid heavy brushing of the temporaries and do not floss between them because you may pull them off.
• Your final porcelain veneers will be as close to the natural beauty and function of teeth as possible. They look and feel normal in every way.

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Bite with light, steady pressure for 30 minutes to an hour on the gauze that we placed in your mouth today.  Mild bleeding after an extraction is normal…If you still have bleeding after 3-4 hours, raise your head higher than the rest of your body. Then bite with firm pressure on a moist gauze pad or wet tea bag for 20 minutes. If bleeding does not stop, please call our office.

• Do not rinse or spit for 24 hours after surgery.
• Keep fingers and tongue away from socket or surgical area.
• Use ice packs on surgical area (side of face) for first 24 hours, apply ice 20 minutes on – 10 minutes off. (Bags of frozen peas work well.)
• For mild discomfort take Tylenol or Ibuprofen every three to four hours.
• For severe pain use the prescription given to you.
• Drink plenty of fluids. (Do not use a straw!)
• If the muscles of the jaw become stiff, chewing gum at intervals will help relax the muscles, as well as the use of warm, moist heat to the outside of your face over these muscles.
• After the first post-operative day, use a warm salt-water
  rinse following meals for the first week to flush out particles of food and debris, which may lodge in the surgical area. (1/2 teaspoon of salt in a glass of warm water. Mouthwash can be added for better taste.)
• Diet may consist of soft foods, which can be easily chewed and swallowed. No seeds, nuts, rice, popcorn, chips, etc.
• We suggest that you do not smoke for at least 5 days after surgery. Nicotine may break down the blood clot and cause a “dry-socket,” which is an undesirable side effect.
• After 24 hours, some mild bleeding may persist. Continue to take your medication if pain persists.
• You may expect swelling for ten days to two weeks and a fever of 99 degrees F to 100 degrees F.
• 24 hours after surgery, rinse mouth gently with a solution of one-half teaspoonful of salt dissolved in a glass of water. Repeat after every meal or snack for seven days. Rinsing is important because it removes food particles and debris from the socket area and thus helps prevent infection and promotes healing.
• After 24 hours, brush tongue with a dry toothbrush to keep bacteria growth down, but be careful not to touch the extraction site. Resume your regular tooth brushing, but avoid disturbing the surgical site so as not to loosen or remove the blood clot.
• If you have heavy bleeding, severe pain, continued swelling two or three days, or a reaction to the medication, call our office immediately.

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New wearers often report a “full-mouth” feeling, as though the partial or dentures are too big and pushing the lips forward. This feeling will wear off as you adjust. Your partial or dentures may feel like they don’t fit properly at first. They may “gag” you, or cause you to bite your cheeks or tongue. If you wear an upper denture, it may take some time for your tongue to get used to the feeling of being pressed against the denture and not your palate. Don’t worry. These problems will lessen over time. Because a denture is a “foreign object” in the mouth, you may produce more saliva for a while. This, too, will lessen and eventually go away. Something as simple as sucking a mint will encourage you to swallow more frequently, clearing away excess saliva. Some soreness is to be expected, usually within a few hours of putting your dentures in your mouth. However, if soreness becomes a problem, make an appointment with our office for an adjustment. Never try to make adjustments to your partial or dentures yourself. Patience and practice will help you build confidence with the important activities of speaking and eating.

When you speak, much of the sound of your own voice reaches your ears through vibrations in the bones of the jaw and skull. Wearing dentures changes the sound and makes it seem louder. This change will be much less noticeable to others than to you. If your dentures “click” when you speak, try speaking more slowly. Slower speech helps avoid movements that raise or move the lower denture. The muscles of your lips, cheeks, and tongue are learning to keep the denture in place. Time and practice will help overcome this difficulty. For confident speaking try to bite and swallow to position your dentures before you speak. Practice reading aloud in front of a mirror to help your tongue to get used to your dentures. A small amount of denture adhesive like Fixodent will also increase your sense of security.

To improve eating, begin with small amounts of food. Instead of biting into food with your front teeth, cut it into smaller pieces. When you put food in your mouth, divide it so that you are chewing one half on the back left side of your mouth and the other half on the back right. This will even out the pressure on your dentures. Start with soft foods such as eggs, fish, chopped meat, cooked vegetables, and puddings. Once you’ve gained more confidence with your dentures, try tougher foods like steak and celery. At first you may feel that food has lost its flavor. This is because the messages your brain is receiving about your dentures can, for a short time, overpower those from your taste buds.

You may also have trouble sensing how hot food and drinks are at first. Taste carefully so you don’t burn your mouth.

Steps to cleaning your dentures

Plaque can form on dentures, just like natural teeth. If it is not removed every day, your dentures may look less white and bright. It is important to clean dentures daily to avoid denture odor.

• Clean your dentures over a sink filled with water to avoid breakage if they drop.
  
• Rinse dentures thoroughly in warm water to remove any loose food particles.
  
• Use a denture cleaner such as Fixodent. (Some conventional toothpaste, bleach, vinegar, and soaps are not designed for denture cleaning and could, in some cases, cause damage. Scratched dentures will harbor unsightly plaque and bacteria, causing denture odor. Harsh products like bleach may even turn the pink parts of your denture white.
  
• Moisten a denture brush (not a soft-bristle toothbrush) to clean all surfaces of your denture gently. Brushing too hard can damage any plastic or metal parts. Rinse and brush in clean warm water.
  
• Use a soft-bristle toothbrush and toothpaste to brush your gums, tongue, palate, and natural teeth before reinserting your dentures. This removes plaque from your mouth and stimulates circulation.
  
• Rinse with a mouthwash for a refreshing feeling.

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You have finished a very important phase of your implant treatment, and now it is time to begin the healing process. It is important to understand that some discomfort, swelling, and bruising is normal.

Once your implant has been placed by Dr. Johnston, follow these directions and report any abnormalities to their office immediately. Our final restoration phase will begin typically around 6 months following today’s implant placement.

Things to Avoid for the first 24 hours:

• Vigorous physical exercise, but you may return to work
• Drinking through a straw or sucking motions.
• Do not smoke. DO NOT SMOKE. Do not smoke.
• Drinking alcoholic beverages will retard the healing process.
• Food that is extreme in temperature or spicy.
• Avoid using any strong mouthwashes that contain alcohol.

Things to Do:

• You may take a non-aspirin analgesic to relieve any 
  tenderness or discomfort, such as ibuprofen (Advil) or acetaminophen (Tylenol).
• Eat a well balanced soft diet for today. You may chew on the opposite side of the treated area until it is comfortable to chew normally.
• Rinse with a warm salt water rinse, 1 teaspoon in an 8 oz. glass of water, 3 times a day.
• Brush your teeth very lightly in the treated area the first night. Then begin flossing lightly as well the next day, gradually increasing to normal force by the week’s end.
• After flossing and brushing, rinse with chlorhexidine
  gluconate (Peridex), if it was prescribed, for at least 60 
  seconds. Do this at least twice daily.

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Fixed Implant Restorations

If your restoration is a single crown or a bridge with multiple teeth that do not come out of the mouth follow these instructions. Your restoration is cemented to an abutment that is attached to your implant by a screw. Great care was taken to tighten the screw properly so it does not loosen. In rare instances these screws can loosen. It is important to notify us if you think you feel any movement in the tooth. This may indicate that the retaining screw is loosening. Loose screws are prone to fracturing and can be difficult or impossible to remove.

It is also imperative to return for regular dental checkups so we can inspect the implant restoration. Maintain the gum tissue around the implant with normal brushing and flossing. If you experience any slight bleeding or inflammation of the gum tissue, use a warm salt water rinse 3-4 times a day. If not resolved in 3-4 days call our office. Immediately report any excess bleeding or swelling around the implant area. DO NOT USE TOOTHPICKS OR ANY METAL TYPE PICKS AROUND THE IMPLANT. This could cause serious damage to the implant. There are implant safe instruments we can recommend if additional cleaning aids are needed. The crowns attached to your implants require the same care as a normal crown. Do not chew ice as it will cause the porcelain to fracture. Exercise caution when eating very hard foods and do not try to open or tear items with your teeth.

Removable implant Restorations

If you can remove your restoration follow these instructions. Your denture or partial attaches to your implants with various nylon retainers that are embedded into your prosthesis. These retainers will require replacement as time goes on. The time frame varies so if you notice that your prosthesis is loosening it may be time to have the retainers replaced. We recommend that you remove your teeth at night and thoroughly clean them with a denture brush.

Food and tarter can build up around the retainers and prevent them from completely attaching to your implants. Also use a commercial cleaner such as Stain Away of Efferdent at least once a week. Your implants will have receptors attached to them that will either look like a gold bar or a metal basket. These need to be kept thoroughly clean. Food and tarter build up will prevent your attachments from completely seating and your prosthesis will be loose. They also need to be bushed like natural teeth to keep the gum tissue healthy around the implants. DO NOT USE TOOTHPICKS OR ANY METAL TYPE PICKS AROUND THE IMPLANTS. Our office can recommend additional cleaning devices if needed. Your implants are susceptible to gum disease the same way teeth are. If proper hygiene and regular dental cleanings are not followed your implants can be lost to periodontal disease. The retainers attached to your implants are held in by screws. It is extremely important to return to our office periodically to have these evaluated. If you notice any loosening of your receptors, notify our office. Loose screws are prone to fracture and can be difficult or impossible to remove

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The doctors and staff at Dr. Elliott Johnston’s office are here to ensure that your recovery goes smoothly and the healing process moves as quickly and painlessly as possible. Below is a list of helpful post- surgery guidelines. Please do not hesitate to call if your question is not answered below.

Rest for the first 48 to 72 hours.

It is advisable to keep quiet and generally take it easy for 48 to 72 hours after your surgery. Rest facilitates healing while strenuous activity may cause renewed bleeding for 7-10 days. While resting, be sure to keep your head elevated at all times.

Drink Plenty of Fluids

• It is helpful to drink plenty of fluids, preferably warm or at room temperature.
  
• Start with clear liquids (Sprite, 7-Up), progressing to soft foods (soup, mashed potatoes, soft eggs, puddings) for several days. DO NOT chew on implants or bone graft.

Use Ice Pack

• Apply ice pack to face, alternating 20 minutes on and 20 minutes off for the first 24 to 48 hours after surgery.

Bleeding is to be Expected

• Slight bleeding mixed with saliva is customary up to 48 hours after your surgery.

You can expect to be uncomfortable for the first day after surgery. The second day you may be even more uncomfortable, with swelling and possible discoloration in areas of cheeks and along the jaw line due to possible slight bruising. The third day is generally a little better, with rapid improvement on the fourth day.

Do not take liquids through a straw

Do not take liquids through a straw. This creates an inward suction and causes tension on your sutures, which could interfere with healing.

Do NOT smoke

Do NOT smoke. Smoking creates a two-fold problem. It creates a harmful inward suction, as well as introducing nicotine, which is harmful to the tissues of the mouth.

Gently Rinse

Avoid vigorous rinsing during the first week. Begin gently rinsing your mouth the day after surgery. Rinse with warm salt water 3-4 times daily, especially after mealtime. (To rinse, gently place water in your mouth and tilt your head from side to side in a slow motion. Empty your mouth by standing over a sink and just let the liquid fall out into the basin – DO NOT SPIT!)

Slight elevation of temperature (1 to 2 degrees) is normal. Please notify our office if it persists.

We know that you are anxious to see the results of your surgery, but please do not forcibly pull your lips or cheeks away to inspect the surgical site. This action could possible tear your sutures.

Prescription Medicine

• Take your medications as prescribed. To avoid stomach discomfort, be sure to eat or drink something before taking your medication.
  
• If upper implants were placed, please do not blow your nose for two weeks. Take decongestants as directed by your physician.
  
• Avoid alcohol consumption for approximately one week after surgery. As long as you are on pain medication, please refrain from alcohol usage entirely. Alcohol dissolves blood clots and interferes with actions of other medications. (Combining alcohol and drugs can cause serious problems.)

Dental Fitting

• Do not wear your partial or denture until your doctor has adjusted it and given you permission.

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Temporary Crown or Bridge

A temporary crown or bridge is a crown or bridge that is placed on the prepared teeth while the final restoration is being made. It protects the exposed dentin so it is not sensitive, prevent food and bacteria from collecting on prepared teeth, and prevent the tooth from shifting and moving, which can make seating of final restoration more difficult.

Temporaries are not strong. They may break or come off occasionally. If so, slip it back on the tooth with some Fixodent™ (denture adhesive) and call us for an appointment. Please do not leave the temporary out of your mouth because the teeth will move and the final restoration will not fit.

• The size, shape, and color of the temporary may not
  resemble the final restoration. 
  
• Temporary restorations may leak saliva or food onto the 
  tooth. Sensitivity to hot, cold, pressure or sweets is not uncommon. If you feel the bite is not correctly balanced, please call for an appointment for a simple adjustment.

Permanent Crowns and Bridges

• Temporary restorations may leak saliva or food onto the tooth. Sensitivity to hot, cold, pressure or sweets is not uncommon. If you feel the bite is not correctly balanced, please call for an appointment for a simple adjustment.
• After the final cementation of your restoration, it may take a few days to get used to the new crown or bridge. Hot and cold sensitivity is possible for a few weeks and occasionally lasts for several months. As with the temporary, if the bite doesn’t feel balanced please call us.
  
• Do not chew hard or sticky foods on the restoration for 24 hours from the time they were cemented. The cement must set up during this time to have optimum strength. 
  
• Proper brushing, flossing, and regular 6-month (minimal) cleanings are required to help you retain your final restoration. The only area that a crowned tooth can decay is at the edge of the crown at the gum line. Often, small problems that develop around the restorations can be found at an early stage and corrected easily, but waiting for a longer time may require redoing the entire restoration.
  
• Approximately 1 out of every 100 porcelain crowns chip and may need replacement