From the Guidelines
Documentation for a chart post wisdom teeth extraction should include the patient's vital signs, procedure details, anesthesia used, complications encountered, and immediate post-operative condition, as this comprehensive documentation is essential for continuity of care, potential insurance claims, and legal protection in case of complications. When documenting, it is crucial to record the number and location of extracted teeth, whether they were impacted, and any bone removal or sectioning performed, as well as the patient's pain level using a numerical scale, bleeding status, and swelling assessment 1. Note all medications administered during the procedure and prescribed for home use, including specific analgesics, antibiotics if indicated, and anti-inflammatory medications with their dosages and durations. Some key points to include in the documentation are:
- Patient's vital signs
- Procedure details, including the number and location of extracted teeth
- Anesthesia used and any complications encountered
- Immediate post-operative condition, including pain level, bleeding status, and swelling assessment
- Medications administered and prescribed, including dosages and durations
- Post-operative instructions provided to the patient, including diet, oral hygiene, activity restrictions, and when to resume normal activities
- Follow-up appointment scheduling and specific warning signs that would necessitate immediate contact with the office. Using a standardized form can improve compliance with documentation and reduce the frequency of sedation-related adverse events, as noted in the AGA Institute review of endoscopic sedation 1. Accurate and complete documentation in the medical record is considered standard clinical practice, with physicians having an ethical, professional, and legal obligation to ensure proper procedural documentation, as stated in the clinical practice guidelines for the use of video capsule endoscopy 1.
From the Research
Post-Operative Care
- After wisdom teeth extraction, patients may experience pain, swelling, and trismus (limited mouth opening) 2, 3, 4.
- Ibuprofen (400 mg) has been shown to be an effective pain reducer for post third molar extraction pain, with a large effect size (SMD ≥ 0.8) 2.
- The combination of ibuprofen and acetaminophen may provide greater pain relief than either medication alone, with fewer adverse effects than opioid-containing formulations 4.
Pain Management
- A systematic review and meta-analysis found that ibuprofen (400 mg) was more effective than a combination of acetaminophen (600 mg) and codeine (60 mg) for pain relief at 6 hours after third molar extraction 2.
- Time-dependent administration of ibuprofen did not show significant differences in pain perception, swelling, or trismus between the control and experimental groups 3.
- Eliminating nighttime ibuprofen intake may be insignificant for pain control after third molar extraction 3.
Infection Prevention
- Amoxicillin-clavulanic acid and amoxicillin may reduce the risk of postoperative infection after third molar extraction, but their use should be viewed with caution due to potential adverse effects and antibiotic resistance 5, 6.
- A systematic review with meta-analysis found that amoxicillin-clavulanic acid was effective in reducing the risk of infection after third molar extraction, but with a higher risk of adverse effects compared to amoxicillin 5.
- A randomized controlled trial found that amoxicillin-clavulanic acid reduced the incidence of infectious and inflammatory complications after third molar extraction, but should not be prescribed in all cases 6.