Good practice

• Hold the compresses firmly and do not remove them for 2 hours.
• If bleeding has not stopped after you remove the pressure dressing, contact the dentist.
• Do not suck on the extraction site, so you do not dislodge the blood clot.
• Avoid rinsing the mouth forcefully for 12 hours after removing the compresses.
• Stop smoking for at least 24 hours.
• Avoid sleeping on the side of the extraction.
• Normal tooth brushing resumes from the day after the extraction.
• Rinsing with mouthwash or calendula/thyme tea is recommended.
• Avoid hard, very hot or very cold foods, dairy products and fizzy drinks for 3 days.
• If you were prescribed anti-inflammatories or antibiotics, follow the instructions exactly.
• If you have pain you may use mild analgesics.
• After laborious extractions or small oral-surgery procedures, to avoid or reduce swelling apply cold compresses on the skin (a cold damp towel). Keep them 45 minutes on, 15 minutes off.
• After laborious extractions (wisdom teeth), trismus (muscle contraction with limited mouth opening) may appear.
• Come for a check the day after the extraction. If you received other instructions about when to come, follow those.
• Sutures should be removed after 7–10 days.

• Apply cold compresses (ice) on the face over the operated area for 15 minutes, with a 15-minute pause after each application, for 4–6 hours. Do not continue after 36 hours. Post-operative swelling is not unusual. Swelling (oedema) is a normal consequence of surgery. You should expect swelling. If it appears it will peak at 48–72 hours, then start to go down.
• Take the prescribed antibiotics as recommended, until the end. Take the recommended painkillers only while discomfort is present. It is best to start pain medication BEFORE the anaesthetic wears off. For mild discomfort or moderate pain take 1–2 tablets of ibuprofen (Nurofen, Rupan, Advil, Motrin) every 3–4 hours. Do not exceed 2400 mg in 24 hours. In addition you may use acetaminophen (Tylenol Extra Strength, paracetamol), 1–2 tablets every 6 hours. Medicines can upset the stomach. Taking them with food reduces that effect.
• Do not rinse the mouth vigorously with water in the first 18–24 hours. Start the prescribed rinse (special mouthwash — 0.12% chlorhexidine gluconate — or warm salt water) after the first 24 hours and rinse gently after meals and between meals 6–8 times a day for at least a week.
• Take fluids as soon as possible. Drink 6–8 glasses of water after surgery until bedtime. Avoid using a straw, because suction can weaken the clot and cause bleeding.
• In the first 24 hours eat soft, cool foods that are easy to chew or swallow. Avoid eating or drinking very cold or hot items (coffee, soup, tea). Avoid hard, spicy, acidic or difficult-to-chew foods for a few days. Keep a balanced diet.
• Do not lift the lip or pull the cheek to look at the operated site. You could tear the sutures.
• Slight bleeding or pink saliva is normal after surgery. If you are worried, apply a moist tea bag firmly to the area for 30 minutes, or longer if needed. If bleeding continues, please contact the clinic.
• Avoid brushing and flossing in the operated area for the first 6 days. After 6 days brush and floss very gently. Start brushing NON-SURGICAL areas the day after surgery. Good oral hygiene is essential for rapid healing.
• Do not smoke, spit, blow your nose or drink alcohol in the first 24 hours. These actions can delay healing, increase discomfort, cause bleeding and lead to complications.
• Rest quietly with your head raised after surgery until bedtime. Do not do physical effort. Always get up slowly from a resting position to prevent dizziness. To encourage rapid healing, please REST!

• FOR THE NEXT 4 WEEKS any activity that raises nasal and oral pressure is STRICTLY FORBIDDEN.
• Do not blow your nose (use drops and only wipe the nose), do not sneeze holding your nose (sneeze with the mouth open), do not drink with a straw, do not spit!
• Do not sleep on the operated side for a few days!
• Do not smoke for 10–14 days after the procedure. Smoking can interfere with healing (it slows it), can cause bleeding and even infection of the site.
• Avoid diving and flying in pressurised aircraft, which can raise sinus pressure.
• Avoid bending to lift heavy objects, inflating balloons, playing wind instruments or any activity that raises oral–sinus pressure.
• Do not be alarmed if blood runs from the nose; lie on your back and apply an ice pack (10 minutes on, 10 minutes off) on the bleeding nostril.
• Do not do physical effort.
• If bleeding from the mouth continues a few hours after the procedure, contact the dentist.
• If you need to use compresses at home, roll them into a wad large enough to cover the wound and give light pressure.
• Keep the compress on the site by pressing (biting on it) for 30 minutes. This pressure helps reduce bleeding and form the blood clot.
• Take the prescribed antibiotics as recommended, until the end.
• It is normal to feel slight discomfort. Take the recommended analgesics only while discomfort is present. It is best to start pain medication BEFORE the anaesthetic wears off.
• Swelling (post-operative oedema) is a normal consequence of surgery.
• Apply cold compresses (ice) on the face over the operated area for 15 minutes, with a 15-minute pause after each application, for 4–6 hours. Do not continue after 36 hours.
• Possible bruising is limited by applying heparin ointment on the outer skin at the site.
• Avoid brushing and flossing on the day of the procedure, in the operated area.
• From the next day, start brushing NON-SURGICAL areas and the operated area very gently. Good oral hygiene is essential for rapid healing.
• Do not rinse the mouth vigorously with water in the first days. Start the prescribed rinse (special mouthwash — 0.12% chlorhexidine digluconate) after the first 24 hours and rinse gently after meals and between meals for at least 1 week.
• In the first days eat soft foods. Avoid eating or drinking hot or very cold items, dairy and fizzy drinks. Chew on the opposite side for at least 24–48 hours.
• As after any surgical procedure, an unexpected course may occur. If you notice air or fluids passing between mouth and nose, particles of bone graft coming from the nose, nasal or sinus congestion on the operated side, or swelling increasing in the mouth, on the cheek or under the eye after 3 days, contact the doctor.
• Come for a check the day after the procedure, or if you received other instructions about when to come, follow those.
• Sutures can be removed after 10–14 days.

How long recovery takes depends on several factors: the individual characteristics of your body, the method and materials used and how complex the operation was. On average the gums heal in one to two weeks. For faster and more reliable healing it is necessary to follow the clinician’s recommendations.

In the first week after surgery

• Come for the post-operative check the day after the procedure, or on the date agreed with the clinician.
• Stop smoking. Smoking can delay healing, cause bleeding and lead to infection of the operated area.
• Avoid forceful sneezing, spitting and blowing your nose. These actions can delay healing, increase discomfort, cause bleeding and lead to complications.
• Avoid hard, very hot or very cold foods on the operated side, as well as fizzy and alcoholic drinks.
• Avoid physical effort, the sauna and hot baths. Rest quietly with your head raised until bedtime. Do not lean on or sleep on the operated side.
• Avoid using the oral irrigator.

Pain, swelling and bleeding

• After bone grafting it is quite likely that short-lived pain will appear in the operated area. Swelling and pain are normal, but they — like slight bleeding and a small rise in body temperature — should not last more than 3 days.
• Take the recommended painkillers, but only while discomfort is present. It is best to start pain medication before the anaesthetic wears off. For mild discomfort or moderate pain take 1–2 tablets of ibuprofen (Nurofen, Rupan, Advil, Motrin) every 3–4 hours, without exceeding 2400 mg in 24 hours. In addition you may use acetaminophen (Tylenol Extra Strength, paracetamol), 1–2 tablets every 6 hours. Medicines can upset the stomach; taking them with food reduces that effect.
• Take the prescribed antibiotics as recommended, until the end. They are generally prescribed for five to ten days after the procedure.
• If swelling appears it will peak at 48–72 hours, then start to go down. To reduce it, apply an ice pack on the cheek over the operated area, repeatedly (15 minutes on, 15 minutes off, for 4–6 hours), as far as possible during the first 24 hours. Do not continue after 36 hours. If you are still swollen, continue with warm compresses over the area.
• Possible bruising is limited by applying heparin ointment (Hepatrombin, Arnica) on the outer skin at the site. Haematomas resolve on their own in about 7–10 days.
• Heavy bleeding can occur immediately after surgery. It can be controlled by biting on a sterile compress for half an hour to two hours. Slight bleeding is normal in the first 24 hours. Do not take aspirin, as it can increase bleeding. If bleeding persists, contact the dentist.

Oral hygiene after the procedure

• Good oral hygiene is essential for healing. Brush the teeth very carefully, especially those near the operated area. Resume brushing the day after surgery.
• In the first week rinse with warm salt water.
• In the second week use a special mouthwash with 0.12–0.2% chlorhexidine gluconate (Cuasept Implant, Corsodyl, Parodontax), twice a day, morning and evening, 30 minutes after brushing with toothpaste, for two weeks.
• Rinse very gently and without pressure. After meals it is advisable to rinse the mouth lightly with water, so that no food debris remains in the operated area, which could lead to infection.
• For the fastest and safest healing we recommend applying antibacterial products (Elugel, Curasept-Curaprox, Gengigel) on the operated area for 7–14 days, 3–4 times a day. Apply by touching the area gently for 30–60 seconds, with a cotton bud or a finger.

The graft and the sutures

• Take care to keep any trauma in the area to a minimum.
• If you wear a temporary denture, try to avoid contact between it and the graft site. If you feel it puts excessive force on the operated area, contact the clinician.
• It is normal for very small pieces of the graft to come loose. They will feel like small granules in the mouth. This is no cause for concern: most of the graft material stays in place.
• Non-resorbable sutures are removed at 10–14 days. Contact the clinician if before then you notice the sutures opening significantly along the incision lines.

Risks and when to contact us

Bone grafting is a safe dental procedure with a low risk of complications. Even so, there are certain risks every patient should be aware of:

• Infection of the wound and surrounding tissues. In this situation severe pain, significant swelling, red gums, purulent discharge and fever may appear. See a clinician immediately.
• Heavy bleeding.
• Complications from the anaesthetic.
• Rejection of the graft.
• Exposure of the membranes.
• Acute or purulent sinusitis.

Patients who smoke or who have diabetes, for example, are at higher risk of complications after bone grafting. Other risk factors include age and other medical conditions. For any question or uncertainty, please contact us early: the sooner we act, the smaller the complications.

The success of dental implants or of the prosthetic work that follows depends on correct healing; the graft needs several months to integrate with the bone.

After an antibiotic paste is applied to the gums

• Do not eat, drink or rinse the mouth for about 30–60 minutes.

After non-surgical treatment (SRP / closed curettage)

In the first stage of periodontal treatment the roots of your teeth were cleaned deeply of calculus and bacteria.

• Do not eat or drink hot liquids until the anaesthetic has completely worn off (risk of accidentally biting the cheek or tongue). In the first days after treatment avoid very hard foods, nuts, seeds or foods with small grains that can lodge under the gum.
• Avoid smoking for at least 48 hours. Nicotine slows the healing of the gum.
• Even if the gums are slightly tender or bleed in the first 2–3 days, do not stop brushing. Bleeding decreases as the gum heals. Use a soft-bristled brush (Extra Soft or Ultra Soft) held at 45 degrees, with movements from gum toward tooth.
• Start using interdental brushes in the sizes recommended by the clinician. They remove bacteria from the freshly cleaned spaces.
• Rinse with a chlorhexidine mouthwash (0.12% or 0.20%) for 7–10 days, twice a day, 30 minutes after brushing.

What is normal in the first days:

• Thermal sensitivity. Teeth may be more sensitive to cold, heat or sweetness. The feeling fades gradually over 1–2 weeks. Use a toothpaste for sensitive teeth.
• “Longer” teeth or open spaces. As the inflammation settles, the gum deflates and returns to its real, healthy level. This is normal and shows that the treatment worked.
• Slight bleeding. In the first days after scaling or curettage the gums may still bleed a little when brushed. Do not stop brushing: the bleeding will stop as the gum heals.

After surgical treatment (flap surgery)

The post-surgical phase requires special care of the teeth and gums that were treated.

• Avoid brushing and flossing in the operated area for the first 6 days. After 6 days brush and floss very gently. Start brushing the non-surgical areas the day after surgery. Good oral hygiene is essential for rapid healing. One week after the procedure, add interdental brushing with interproximal brushes soaked in mouthwash.
• Do not rinse the mouth vigorously with water in the first 18–24 hours. Start the prescribed rinse (special mouthwash with 0.12% chlorhexidine gluconate, or warm salt water) after the first 24 hours and rinse gently after meals and between meals, 6–8 times a day, for at least a week.
• Do not spit, do not expectorate and do not drink alcohol in the first 24 hours. These actions can delay healing, increase discomfort, cause bleeding and lead to complications.
• Smoking must stop for the first two weeks after surgery. Smoking dramatically increases the risk of graft failure.
• Slight bleeding or pink saliva is normal after surgery. If you are worried, apply sterile compresses. If bleeding continues, please contact the clinic.
• Post-operative swelling is not unusual. If it appears it will peak at 48–72 hours, then start to go down. Apply cold compresses (ice) on the face over the operated area for 15 minutes, with a 15-minute pause after each application, for 4–6 hours. Do not continue after 36 hours.
• Take fluids as soon as possible. Drink 6–8 glasses of water after surgery until bedtime. Avoid using a straw, because suction can weaken the clot and cause bleeding.
• In the first 24 hours eat soft foods at room temperature that are easy to chew or swallow. Avoid very cold or hot liquids and foods (coffee, soup, tea). Avoid hard, spicy, acidic or difficult-to-chew foods for a few days. Keep a balanced diet.
• Do not lift the lip or pull the cheek to look at the operated site: you could tear the sutures. Do not apply pressure with the tongue or fingers over the graft, as it is mobile during initial healing. Do not touch the surgical areas in the first week, as you may dislodge the healing tissue and compromise the graft.
• Take the prescribed antibiotics as recommended, until the end. Take the recommended painkillers only while discomfort is present. It is best to start pain medication before the anaesthetic wears off. For mild discomfort or moderate pain take 1–2 tablets of ibuprofen (Nurofen, Rupan, Advil, Motrin) every 3–4 hours, without exceeding 2400 mg in 24 hours. In addition you may use acetaminophen (Tylenol Extra Strength, paracetamol), 1–2 tablets every 6 hours. Taking them with food reduces stomach discomfort.
• Rest quietly with your head raised until bedtime. Do not do physical effort.
• Sutures are removed after 7–10 days.
• The appearance of the graft will change over the following weeks: first it whitens, then it turns pink. This is normal graft healing.

After laser treatment

Protecting the blood clot, in the first 24–48 hours:

• Strictly forbidden: do not drink through a straw, do not spit forcefully and do not rinse the mouth on the first day. These actions create suction in the mouth and can dislodge the protective clot.
• No pressure: do not touch the treated area with the tongue, fingers or toothpicks.
• Controlling bleeding: the Nd:YAG laser coagulates very well, but if slight bleeding appears, apply a sterile compress to the area and bite gently for 20 minutes.

Special oral-hygiene protocol:

• Restriction phase (days 1–7): do not brush or floss directly on the treated gum. Clean the untreated teeth normally.
• Passive rinses (from day two): rinse the mouth 3 times a day with warm saline (a teaspoon of salt in a glass of water) or with an alcohol-free antiseptic mouthwash, for example chlorhexidine-based, but without vigorous cheek movements — simply let the liquid run out of the mouth.
• Resuming brushing (after one week): use only an ultra-soft surgical brush. Place the bristles on the tooth and sweep only from gum toward the edge of the tooth.
• Longer-term restrictions: do not use an electric toothbrush, an oral irrigator or dental floss in the treated areas for at least one month, unless the clinician advises otherwise.

Diet, stage by stage:

• First 24 hours: only cold or room-temperature liquids (smoothies, strained soups, yoghurt). The low temperature helps stabilise the clot and reduces inflammation.
• Days 2–7, soft diet: move to foods with the consistency of purées or scrambled eggs (soft polenta, well-cooked pasta, fish, steamed vegetables). Chew on the side opposite the treated one.
• Strictly forbidden for 10 days: crunchy or hard foods and foods with small particles (seeds, poppy seeds, nuts, crisps, popcorn, rice). These can get under the freshly treated gum and cause infection or detach tissue that is reattaching.

The appearance of the gum, and medication:

• Do not be alarmed if the gum turns whitish, grey, yellowish or slightly purple in the first days. Do not try to remove the whitish film: it is fibrin, essential for healing.
• Smoking is completely forbidden in the first 72 hours and not advisable throughout healing.
• Combined Er:YAG / Nd:YAG therapy is minimally invasive and discomfort is usually low. If throbbing or thermal sensitivity appears, take ibuprofen (400–600 mg) or paracetamol on the clinician’s advice.
• Sensitivity to heat or cold, or slight throbbing, is normal and passes within a few days.

After gingivectomy, gingivoplasty or treatment of gum recession

• Once the anaesthetic wears off you may feel local discomfort. The treated area can stay tender for a week; painkillers may be used to control post-operative pain. Infection is rare after a gingivectomy.
• Local bleeding is normal in the first 2–3 days. Some medicines, such as aspirin, can encourage bleeding.
• Avoid smoking in the first week after the procedure.
• Brush the gums gently, without traumatising the surgical wound. The operated area will be ulcerated, tender and may bleed slightly during brushing; even so, keeping it clean during healing is important.
• Chlorhexidine mouthwashes should also be used to keep the mouth clean.
• For the first post-operative days eat soft food. Do not chew with the treated teeth for one week. Avoid salty, spicy and crunchy foods, and hot food or drink, for one week after surgery.
• Resorbable sutures disappear in 5–10 days and should not be removed. If the sutures are not resorbable, the clinician will remove them 7–10 days after surgery.
• The final appearance of the gums can be seen 3–4 weeks after the operation.

After a periodontal dressing is applied

• The clinician applies this material to protect the wound and encourage healing. The periodontal dressing becomes semi-rigid within a few hours and will withstand moderate chewing forces without breaking.
• After surgery and application of the dressing, take only cold liquids and food that is easy to chew and not sticky.
• Brushing, floss and the other aids (chlorhexidine mouthwashes) should be used rigorously, but not on the same day as the surgery.
• The dressing should stay in place as long as possible. If pieces come away but no sharp edges are left, come to the clinician after the agreed interval of 7–10 days. If the dressing comes away completely sooner than 5 days, come to the clinician, who will decide whether it needs replacing.
• While the dressing is in place you may notice mild pain or discomfort in the cheek or inside the mouth. The edge of the dressing can irritate the tissues. Please contact the clinic if the pain persists.

After splinting of the teeth

• Temporary splinting of periodontally affected teeth creates favourable conditions for the periodontium to heal, especially after periodontal surgery, and gives stability to teeth that are being reshaped or scaled. The procedure is kept in place for 2–6 months.

Reminder for patients with periodontal disease

Once periodontal treatment has started, oral hygiene becomes a compulsory step in maintaining the result. A three-step daily routine is recommended, using brush and toothpaste, dental floss and an antimicrobial rinse, combined with an irrigator.

• Teeth should be brushed with brush and toothpaste twice a day. The brush may be soft, but only with an uneven bristle profile. Electric toothbrushes are perfectly acceptable.
• To clean the spaces between the teeth, use interdental brushes and dental floss before brushing. This applies after every meal.
• To clean the interdental spaces and massage the gums, use an irrigator (oral shower) regularly, without giving up the toothbrush and floss.

Assessment of inflammation and regular professional cleaning are vital, at intervals set according to the severity of the periodontal disease and your individual risk of progression. These visits are usually scheduled every three or every six months. It is very important to check regularly that the disease is not recurring, or that recurrences are caught early and treated at once. Three months after periodontal surgery a supragingival scaling is performed.

The information below can help you and your baby to a better and faster recovery.

Bear in mind that feeding will improve gradually after this procedure. Changes may be small and gradual over 2–4 weeks. In some cases the frenectomy does not solve every feeding difficulty and other kinds of therapy are needed: physiotherapy, cranio-sacral therapy or osteopathy.

What is normal after the procedure

• More fussiness and irritability.
• Bleeding at the frenectomy site.
• Difficulty latching.
• The baby may choke or bring milk back up more often.
• Increased salivation.
• Sleepiness.

How healing progresses

The first 24–48 hours:

• Most babies have local discomfort.
• The baby may be fussier or more irritable than usual.
• A white diamond-shaped area forms under the tongue.
• It may bleed slightly after feeding or after the exercises.

The first week:

• Discomfort decreases gradually.
• The baby is still slightly unsettled.
• The white area gets smaller as it heals.
• The baby learns to latch better and feeding becomes more efficient.

Weeks 2–4:

• The baby is no longer bothered.
• The white area keeps getting smaller.
• An IBCLC assessment is recommended.

Feeding

• The baby can be put to the breast straight away.
• An older child or an adult should not eat for 1–2 hours. For about 3–4 days they should avoid foods that can irritate the area (salt, pepper or other hot spices) and should be given soft, purée-like food.

Hygiene

• After feeding, the child’s mouth must be cleaned. The area can be rinsed with salt water.
• The diamond is covered by a white layer of fibrin, healing tissue. Touch it gently, without removing it (we do not use gauze). It may be yellow, greenish or grey. It should shrink after day 7 and close completely after 21 days.
• If the classic technique was used, the sutures may dissolve on their own or you will need to return to the clinician after 7–10 days to have them removed.

For pain or discomfort

• Paracetamol, as advised by the clinician — the dose varies with weight and age.
• Homeopathic medication.
• Teething gel without anaesthetic.

The exercises

Their purpose is to prevent the frenum from reattaching and to develop the mobility of the tongue muscles. Six hours after the procedure the exercises can begin, four times a day for the first two weeks. They can be done after a feed or in the middle of one.

• With clean hands, place the index fingers under the tongue on either side of the diamond. Press gently toward the floor of the mouth and bring them slightly together. Pass twice over the diamond: right to left, left to right.
• Lift the tongue gently five times, with upward movements.
• An older child should do certain exercises, such as sticking the tongue far out or whistling very often, in the first 4–5 days after the procedure.
• Patients who wear a denture should use it consistently, straight after the procedure.

The acute priority includes avulsion, alveolar fracture, extrusive and lateral luxation and root fractures. Treated within the first hours, the outlook for these injuries can be improved considerably.

First aid in avulsion (a tooth knocked completely out)

Replantation should be carried out wherever possible. Baby teeth are not replanted. For permanent teeth:

• Handle the tooth by the crown, avoiding contact with the root.
• If it is dirty, rinse it for 10 seconds in cold water (do not scrub) and reposition it in less than 30 minutes from the accident.
• If repositioning is not possible, place the tooth in a storage medium: milk, saliva (held in the cheek towards the back) or saline. Do not store it in water. Transporting the tooth dry is contraindicated. With a co-operative child, the tooth can be kept in the mouth of the person who lost it, between the cheek lining and the gum line. If the tooth is broken into pieces, collect all the fragments and transport them in one of the media above.
• If the socket is bleeding, rinse the mouth with water, place a cotton pad over the socket and apply pressure there. The pressure should stop the bleeding.
• Do not eat or drink if a tooth has been broken, displaced or lost.

The emergency dental appointment

• Any wounds are sutured.
• The position of the replanted tooth is checked clinically and radiographically.
• A flexible splint is placed for 2 weeks.
• Systemic antibiotics are given — tetracycline or doxycycline twice a day for 7 days, at a dose set by age and weight. Because tetracycline is not given under the age of 12 owing to the risk of discolouration, it can be replaced with penicillin V.
• Tetanus cover if the tooth was in contact with soil.
• Root canal treatment 7–10 days after replantation and before the splint is removed.

Crown and root fractures

• In crown fractures, if the crown fragment exists, the mobile segment is temporarily stabilised for the patient’s comfort until the treatment plan is set.
• Root fractures require reduction by repositioning and fixation to the adjacent teeth for 4 weeks. If the root fracture is in the cervical third, or if the tooth is still mobile when the splint is removed, splinting is kept for longer, up to 4 months.

Less urgent situations

• The subacute priority includes intrusion, concussion, subluxation and crown fracture with pulp exposure. Delaying treatment by a few hours does not appear to affect the outcome. For the patient’s comfort a splint can be placed for a maximum of 2 weeks.
• The late priority covers non-penetrating crown fractures, which respond well even to treatment delayed by more than 24 hours.

After the primary treatment

• A semi-solid diet for one week.
• Good oral hygiene, brushing with a soft toothbrush.
• Rinsing with 0.12% chlorhexidine.

Secondary treatment of dental trauma includes monitoring and clinical and radiographic assessment of the state of the pulp and the supporting tissues.

After the anaesthetic

• How long the anaesthetic lasts differs from person to person and depends on the site and type of injection, from 30 minutes up to 4–5 hours.
• Avoid chewing and drinking hot liquids until the numbness has gone. It is very easy to bite or burn your tongue or lips while the anaesthetic is still working.
• You may feel pain for a few days at the injection site.

After a temporary dressing is placed

• Do not eat for about 1.5–2 hours. You may drink whatever you like, but avoid rinsing for 1–2 hours.
• Until the next appointment, avoid chewing on the side with the temporary dressing.
• Brush normally.
• If you taste medication in your mouth (especially after eating on that side), or if the dressing has come out completely, tell the dentist.

After a definitive filling with a material not cured by lamp

• Do not eat for about two hours, so the material can set. With amalgam fillings you should not eat or drink for 3 hours.
• It is normal to feel sensitivity to heat, cold or pressure after the tooth has been rebuilt. If sensitivity on chewing lasts more than a few days, or if sensitivity to cold or heat increases, contact us. In general, the deeper the decay was, the more sensitive the tooth will be afterwards, but the sensitivity should fade with time.
• If your bite feels uneven, if the filling feels high, or if you have any question at all, do not hesitate to contact us.

After a tooth-coloured composite filling, cured with the lamp

• You may eat and drink whatever you like straight away.
• Because the resin can fracture under very high forces, take care with hard foods (pistachios, hazelnuts, almonds), sticky foods (chewing gum, toffees) and harmful habits (opening bottle caps with your teeth, grinding).
• It is normal to feel sensitivity to heat, cold or pressure after the tooth has been rebuilt. If sensitivity on chewing lasts more than a few days, or if sensitivity to cold or heat increases, contact us. In general, the deeper the decay was, the more sensitive the tooth will be afterwards, but the sensitivity should fade with time.
• If your bite feels uneven, if the filling feels high, or if you have any question at all, do not hesitate to contact us.

If the gum hurts and bleeds after a filling

• In teeth that are missing one or more walls, the gum can be traumatised while the filling is placed and finished. The gum may therefore be sore for a few days and may bleed.
• Do not be alarmed, this passes. You may use Elugel (a chlorhexidine gel) for faster healing.

After endodontic drainage

• Keep the drainage opening free. Before meals place a small piece of cotton wool inside the tooth, in an amount that will not be dislodged while chewing, and remove it after the meal. Rinse the mouth well.
• Regularly press on the tooth with your tongue, to draw out its contents.
• Wrap your finger in a sterile compress and massage from gum toward tooth. Pain, bleeding or pus may appear.
• The tooth should be left open only until the symptoms settle. Once drainage is complete and the source of infection is controlled, intracanal antimicrobial medication is placed and the tooth is closed with a coronal filling.

After vital pulp extirpation (removal of the nerve)

After vital extirpation you may feel pain for a few days, both at the injection site and in the tooth itself. It is therefore advisable to take an ordinary anti-inflammatory (Nurofen, Panadol, paracetamol, Ketonal, Aulin).

If you have an antiseptic dressing and the pain starts to increase or you swell, remove the temporary dressing. The pain will then settle within a few hours. Until the next appointment, which should be within 24–48 hours, you must:

• Press on the tooth with your tongue and draw out its contents.
• Keep the tooth clean, rinsing the mouth thoroughly after meals.
• Before meals, place a piece of cotton wool in the tooth that will not move while chewing, and remove it immediately after the meal.
• Remember that trapped food will block the canals, ferment and bring on another episode of intense pain.

After devital extirpation (deadening the nerve with chemical agents)

• Deadening the nerve with chemical agents takes between 2 and 14 days.
• If an arsenic-based agent is used, you must return for a new appointment within 24–48 hours. Otherwise the following can occur: darkening of the tooth, destruction of the tissue supporting the tooth in the bone, bone resorption and infection, gum necrosis and the need to extract the tooth. If arsenic is left in place for a long time, signs of general ill health appear: nausea, vomiting, general weakness, change in body temperature, skin that becomes pale or bluish and clammy to the touch.
• With non-arsenic agents, the effect takes about 10–14 days.
• Toothache in the first 2–3 hours after the paste is placed is normal. You may take non-steroidal anti-inflammatories: ibuprofen, Nurofen, metamizole or paracetamol.
• Do not remove the temporary dressing. If it has come out, remove the devitalising paste from inside the tooth with a thick sterilised needle and rinse the mouth well with water.

After an antiseptic dressing is placed

• During root canal treatment it is important to disinfect both the main canal and the accessory canals (branches of the main canal), which cannot be instrumented.
• An antiseptic dressing works for between 1 and 7 days. Do not exceed that period, as it will no longer be effective.
• Follow the instructions in the section on the temporary dressing.
• You may feel pain after this procedure. It is therefore advisable to take an ordinary anti-inflammatory (Nurofen, Panadol, paracetamol, Ketonal, Aulin).
• If the pain increases and you notice swelling, remove the temporary dressing with a toothpick and follow the instructions above for endodontic drainage or vital extirpation, or contact the dentist urgently.

After the canal is filled

• After the root filling you may still feel pain, at rest or on chewing, which can last up to 14 days.
• After root canal treatment we recommend taking an ibuprofen-based anti-inflammatory on the day of treatment, whether or not you have symptoms. This helps reduce inflammation at the root tip.
• Avoid chewing on that side for a few days, until the sensitivity has gone.
• The quality of the root filling is checked on a radiograph, as advised by your clinician.

After scaling and professional cleaning

• Because the bacterial load has been reduced, you must change your toothbrush. Depending on the clinician’s advice, you may use a medium, soft or extra-soft manual brush, or an electric brush.
• After scaling the gums may bleed for a few days. Use mouthwash after brushing, twice a day, morning and evening.
• After scaling you may feel spaces you did not notice before. This is normal: calculus had pushed the gum away and created a space, over which the gum will come back.

After a fluoride application

• Do not eat, drink or rinse the mouth for 30 minutes.

After in-practice whitening

• After the treatment in the practice, the agents keep working for another 48–72 hours, during which the shade of the teeth changes visibly from one day to the next. Careful dental care during that time is therefore very important.
• For a few days after the procedure the teeth will be more sensitive, and there may be gum soreness. If sensitivity persists and causes discomfort, take a painkiller such as Ketonal or Nurofen.
• Brush twice a day, morning and evening, with a desensitising fluoride toothpaste for about 2 weeks. After that, use a normal toothpaste or one with whitening properties.
• Avoid substances that stain the teeth: coffee, tea, red wine, tomato juice, soy sauce, balsamic vinegar, berry juice, sour cherries, beetroot.
• Drink liquids through a straw to avoid staining.
• If you have sensitivity, avoid acidic foods (oranges, fizzy drinks) for at least 1–3 days after treatment.
• Do not smoke for 24 hours after treatment.
• How long the result lasts depends largely on you. With good oral hygiene and correct brushing, especially after coloured food or drink, the result can last several years (3–5 years). If you drink coffee or red wine or use tobacco, maintenance whitening will be needed every six months, or the procedure repeated after a shorter interval (2–3 years).

Home whitening

The dentist takes impressions of your teeth and makes trays into which the whitening gel is placed. These trays with gel are fitted on the teeth and worn during sleep, between 2 and 8 hours depending on the concentration of the product.

How to use them:

• Brush your teeth. Fill the tray with the whitening gel.
• Seat the tray on the teeth and press gently, to spread the gel evenly. Take care: if you press too hard, gel can escape from the tray.
• Gently remove excess gel from the gum with a toothbrush or with your finger.
• Once the trays are in place, it is best not to eat, drink or talk too much.

Please note:

• Do not use whitening products if you are pregnant or breastfeeding.
• Do not eat while wearing the trays.
• Do not use tobacco products while wearing the trays. Do not smoke during the treatment.
• Do not expose the syringes to heat or sunlight. Do not freeze them; store them cold, in the fridge.

PRF injections deliver, into areas affected by inflammation or injury, plasma enriched with platelets and growth factors. These recruit and accelerate the proliferation of repair cells, stimulating regeneration and the healing and repair of the affected tissue in a way that cannot be reproduced by other methods.

Repair after PRF injections generally begins with an inflammatory stage lasting around 2–3 days, followed by cell proliferation, in which new cells and growth factors are released at the site. The last stage is tissue remodelling, in which the newly formed cells differentiate and take the place of those that were destroyed.

When they are indicated

PRF injections are indicated in the following muscle and joint conditions: arthritis and osteoarthritis, meniscal and ligament injuries, chondropathy, muscle tears, epicondylitis, synovitis, fractures and pain, and for rapid recovery after surgery.

• If you have thrombocytopenia, severe anaemia, a clotting disorder, if you are on long-term anticoagulants, or if you have hepatitis, an infection or an autoimmune condition (for example lupus), speak to the clinician before this treatment, because the injections may be less effective than in patients without these conditions.
• It is advisable to have your vitamin D and cholesterol measured, as these values enhance the effect of the PRF procedure.

The advantages of PRF injections include: a simple method with quick preparation that helps regenerate the affected tissue, reduces recovery time and pain, starts the body’s own healing mechanisms and carries no risk of allergy, while the cost is significantly lower than that of other treatments.

After a PRF injection

• Remember that PRF is not a medicine that takes the pain away at the first application.
• PRF is a biostimulating product based on growth factors, so at least 4 sessions are needed, 14–28 days apart, for symptoms to settle. Complete relief of pain depends on internal and external factors such as the number of injections, your general health, the severity of the joint or muscle condition, your living and working conditions and any harmful habits.
• At the end of a session you should stay in the practice for 10–15 minutes, doing flexion and extension exercises that help the product integrate into the tissues.
• Side effects are few and complications minimal, but pain or discomfort at the injection site, infection, or damage to nearby tissue or nerves can occur — similar to what is associated with cortisone injections.
• Take painkillers for 2 days after the injection (for example paracetamol) if needed.
• During and immediately after the procedure, anti-inflammatory medicines must not be taken (for example aspirin, Ketonal, Aulin, Nurofen, Arcoxia).
• There is no absolute contraindication to physical activity, but resting for about 2–3 days is recommended to keep pain to a minimum.
• Some time after the last injection it is usually advisable to start physiotherapy, set according to your condition.

The long-term success of implant treatment depends crucially on how the implants are maintained and cleaned, both at home and in the dental practice. After the prosthetic restoration is placed on the implants, the oral tissues need time to get used to the new situation. For this reason, certain minor reactions may appear, such as:

• mild gum pain — because the margins of the fixed work sit slightly below the gum, to hide the join between crown and implant. Mild analgesics may be used if needed. Come to the practice if the pain does not settle in a few days. With dentures, painful symptoms, irritation and mucosal lesions are fairly common and can increase during chewing. A short adjustment of the dentures in the practice is needed, after you have worn the denture continuously for about 12 hours.
• a feeling of discomfort when chewing, shown as pain when “biting” food or the sense that the work is “too high”. You must come to the practice as soon as possible for an occlusion adjustment.
• increased salivary flow and more difficult speech.

Once the mouth adapts to the new prosthetic work, these problems will disappear. Any discomfort must be reported to the dentist as soon as possible!

Stop or at least reduce smoking! Patients who do not stop smoking before and during implant healing can expect a higher rate of complications, especially infections (because nicotine reduces salivary flow). You may eat any food, but implant restorations must not be used in an exaggerated way. Avoid reckless actions (opening packages, chewing hard objects, nail biting), very hard foods (hard bread crusts, nuts, pistachios), very hot foods (dental implants are metal devices and can conduct heat much faster to the hard tissues) or hot–cold temperature swings (cracks may appear and turn into fractures of the ceramic of the prosthetic work).

Certain conditions can overload dental implants (e.g. night or day bruxism, clenching). At the first signs of these conditions (involuntary grinding/rubbing of the teeth, wear of teeth or dental work, pain in the oral muscles and the temporomandibular joint), come to the dentist.

After dental implants are placed, oral hygiene must become very rigorous!

Dental floss is used before brushing, to clean the spaces between teeth and between natural teeth and those on implants. Attention! The gum around dental implants is easy to damage, without pain appearing if floss is used carelessly. Aggressive flossing around implants will open “pockets” in the gum, where bacteria accumulate and cause inflammation of the mucosa (peri-implant mucositis) and of the bone (peri-implantitis).

Use floss only if you can clean around the implant without going more than 1–2 mm under the gum. Otherwise, replace floss with other cleaning methods (e.g. an oral irrigator).

Brushing is done at least twice a day — morning and evening. Medium or soft brushes are recommended, used carefully on natural teeth and those on implants, with vertical movements from gum toward tooth, to avoid injuring the surrounding gum.

Be careful with vibrating toothbrushes! Vibrations can loosen the internal screw that holds the abutment, and crown stability can be lost. Come to the practice at the first signs of crown instability, to avoid mobility and loss of the implant!

Any toothpaste may be used, but very abrasive pastes should be avoided (they could scratch the prosthetic components of the implants).

If you have a denture, brush the inside and outside twice a day with liquid soap and a soft nail brush, over a sink full of water. Soaking the denture at least once a week in water with a special cleaning tablet (Corega, Protefix) removes unpleasant smell, bacteria and cleans the denture. Particular attention should also be given to the gum and mucosa under the denture.

Mouthwash for 1 minute, twice a day (morning and evening), complements brushing and flossing. A very good way to clean around dental implants is washing at gum level with an oral irrigator. It produces a pressurised water jet that cleans the proximal subgingival spaces between teeth, dental implants or the area under dental bridges. Jet pressure must be well dosed so as not to traumatise the gum around the implant. This cleaning method is mandatory for people with implant restorations!

Super floss is an alternative to the oral irrigator. It has a thin, rigid end used to insert the adjacent, thicker and softer sponge-like portion under the pontic (the part of the work in intimate contact with the gum) or the mesostructure of removable work (e.g. a bar). The portion between gum and restoration is cleaned with a back-and-forth movement.

Thin mini-brushes may be used instead of Superfloss only on the dentist’s advice, carefully, when the space between implants / implants and natural teeth is wide.

It is very important to come for a check in the first year every 3 months, then every 6 months, to prevent infections around the implants. If no complications appear in the first two years, clinical checks are done once a year. During these visits:

• panoramic or periapical radiographs are taken
• the prosthetic work is removed to check: gum condition, height and density of the ridge, implant mobility, oral hygiene, the functional relationship implant–abutment–superstructure, and stability of the restorations
• professional cleaning is done with special instruments, materials and techniques for the implants and prosthetic components
• dentures are relined and the Teflon components that retain them on the implants are replaced. This is indicated once a year, when removable dentures have become too “loose” or the material has worn.

If you choose to have professional cleaning in another dental practice, tell that dentist or hygienist that you have dental implants!

With dental implants, long-term complications may include:

• loss of the implant following bone resorption or mechanical overload. Mucositis and peri-implantitis are destructive inflammatory conditions of the gum and bone around a dental implant, which can lead to implant loss. Treatment ranges from local debridement around the implant with medication, laser treatments, bone-grafting procedures and gingival grafts.
• complications of the bone supporting the implants, as a consequence of your general health. Even with the best care, because of individual differences, a clinician cannot predict or guarantee the success of the proposed treatment with certainty
• fracture of the implant, the abutment or the screw. Treatment ranges from replacing the implant to replacing the abutments and the prosthetic work.
• decementation of the work or loss of screw friction — treatment consists of recementing the work provisionally, tightening or replacing screws. Removable prosthetic work can damage the bone and gum support, as well as other prosthetic components (infra-, meso- and superstructure), so you must come to the dentist at once if there is any sign of instability!
• fracture, wear or aesthetic change of the prosthetic work. In some situations, implant restorations can be remade or repaired without removing the implants from the bone.

Do not forget! Dental implants are expensive treatments that need advanced care! Correcting problems can be a simpler and less costly solution if they are found early!

After a restoration is cemented, temporarily or definitively

• Do not eat for two hours. You may drink whatever you like.
• If the cementation is temporary, even after those two hours avoid very sticky foods (chewing gum, toffees) and harmful habits.
• If some time after cementation you feel that the restoration is moving, contact the dentist at once.

Daily cleaning

• Dental floss is used before brushing, to clean the spaces between teeth and between natural teeth and the teeth in the prosthetic work.
• Brushing should be done twice a day, morning and evening, with movements from gum toward tooth and back-and-forth movements at the molars, for 2 minutes.
• Mouthwash twice a day for 1 minute after brushing helps clean the whole mouth.
• Extra ways to clean prosthetic work are: the oral irrigator, Superfloss and the interdental brush.
• The oral irrigator works with a jet of water and antiseptic, meant to clean the space between the work and the gum and the interdental space.
• Superfloss is a type of dental floss designed to help clean fixed prosthetic work. It has a stiff filament, spongy floss and ordinary floss. Superfloss can be inserted under the prosthesis to clean in detail the space between it and the gum.
• The interdental brush is used to remove food debris from under the dental work and from spaces between teeth where there is no longer a dental papilla.

In the initial adaptation period:

• Do not take the dentures out of the mouth in the first 24 hours, because the dentist will see you the day after the dentures are fitted. If that appointment is not possible and you have pain, remove the dentures, but put them back in 12–24 hours before the next dental appointment.
• The feeling of a “full mouth” and increased salivation will pass with time.
• The gagging sensation may go if you suck a sweet (such as a drop).
• During this period sore spots may appear in the mouth.
• If food seems to have no taste, eat warmer foods or drinks with a clearer aroma and smell (more seasoned).

How you should eat with the denture:

• Cut food into small pieces with a knife.
• Try to chew on both sides at the same time.
• If you bite with the front teeth, the dentures will move and the gums will be affected.
• Avoid sticky foods.
• It takes time to learn to eat with dentures. It will never be quite the same as with natural teeth. Be patient!

Speaking with the new dentures:

• The muscles must be retrained, so that in the end they also help hold the denture.
• The tongue will eventually find its place.
• It takes time to get used to them.
• Read aloud to shorten this period. Repeat the words you find difficult to pronounce.

Cleaning the mouth and the dentures:

• Clean and massage the gums daily with a soft brush.
• Brush the dentures with a soft brush and ordinary soap. Never use toothpaste, because it is too abrasive.
• While cleaning, hold the denture over a bowl of water. If it slips, the water will cushion the fall.
• Leave the denture overnight in one of the following solutions: a commercial denture-cleaning solution / a teaspoon of vinegar in a glass of water, once a week.
• Do not wear the dentures at night if the dentist specifically recommends this.

What you may and may not do:

• Use adhesive products (Corega, Fixodent) only on the dentist’s advice.
• When you cough or sneeze the dentures can come loose, which can be embarrassing; covering the mouth with a handkerchief or the hand avoids this.
• Never try to adjust or repair the dentures yourself!
• Come to the dentist regularly for a routine check — at least twice a year!

Dentures are not everlasting. Changes continue in the bones and gums. See the dentist if you have any of the following problems:

• difficulty chewing food
• repeatedly biting the cheek
• speech difficulties
• red, inflamed gums
• discomfort from wearing the dentures
• cracks at the corners of the lips

After the veneers are fitted you should come back to the dentist, so we can see how they are settling in your mouth.

As with any other dental work, there will be a period of getting used to the new veneers. At first you may find certain consonants such as “v”, “f” or “s” harder to pronounce; the clinician can adjust for this.

What to know beforehand

• Veneering the teeth is irreversible: once they have been prepared, the teeth cannot go back to their previous state, and the original veneers can only be replaced with new ones.
• Once chosen, the shade of the veneers is final.
• The health of the teeth is very important, because if they deteriorate the veneers on them will be lost too. If you look after your teeth with consistent oral hygiene, the veneers can last for as long as the teeth are in place.

Daily hygiene

• Teeth with veneers are cleaned and maintained just like natural teeth. Ideally you would brush after every meal, but at least twice a day can be enough.
• An important point when brushing is to avoid, as far as possible, abrasive toothpastes or those with a high fluoride concentration, because over time they can damage newly placed veneers.
• Use dental floss as well, to remove food debris that can stay between the teeth. An oral irrigator gives better results than floss, because it easily reaches the interdental spaces and the areas under the gums that the classic method cannot clean.
• Regular dental visits are still advised, once every 6 months.

Staining, debonding, grinding

• Veneers, like natural teeth, can stain over time because of certain foods and drinks. Coffee, tea, beetroot, red wine and berries are among the foods known to affect the colour of teeth. Consume them in moderation and brush after every meal.
• There is a risk that a veneer will come off after it has been fitted, but there is no need to worry, as this is easily solved by re-cementing it. To avoid debonding, harmful habits such as biting nails or hard objects are entirely contraindicated. Excessive forces on veneered teeth should also be avoided.
• It is worth remembering that veneers which have cracked or chipped cannot be repaired and must be replaced.
• Bruxism, commonly known as teeth grinding, puts great pressure on the dentition. Although veneers are very strong, the pressure from grinding can seriously affect both the veneers and the natural teeth. A night guard relieves the teeth of that pressure and keeps them intact.

How the appliance works

Orthodontic appliances work by applying pressure to the teeth, which moves them into the desired positions through the dynamic processes of bone resorption and apposition. Through these two processes of remodelling in the jaw bones — some bone disappears and new bone is laid down, in areas directed by the line of pressure — the position of the roots in their sockets changes and the teeth are aligned harmoniously.

The first days after the appliance is fitted

The first week is the most difficult of the whole treatment. As the appliance starts to work, the first effects are felt within a few hours, as pain that is more or less tolerable. To get through this period more easily we recommend:

• If the pain persists, you may take a painkiller, as you would for a headache (Panadol, Nurofen).
• Eat soft, liquid food that does not overload the teeth, which are already under mechanical stress (soups, mashed food).
• Avoid sweet, cold or hot foods, because at this stage the teeth are somewhat hypersensitive.
• A fixed appliance is made of brackets, bands and archwires, which are fixed, bonded or attached to the teeth. Sometimes a bracket pricks, or the wire moves and causes sores on the lips or cheeks; when that happens you can apply wax over that wire or bracket.
• If a bracket comes off, keep it and bring it to the next appointment.
• A removable appliance can increase saliva flow, but this returns to normal shortly.
• Speech may be affected at first, but returns to normal within a few days.

Wearing the appliance

• You will not be able to remove a fixed appliance yourself.
• A removable appliance is worn all the time. Take it out before meals, clean it and put it in its special box. Remove the appliance from the mouth by pulling only on the side wires. Wear the appliance during meals only if the orthodontist advises it.
• A myofunctional appliance is fitted with the tongue button facing the upper arch. It is worn 10–12 hours a day: 2–3 hours during the day and the rest at night. In the first month the aim is to wear it 2 hours a day, continuously and correctly. That way, from the following month it can be worn all the time, including at night. Not wearing it during the day makes it impossible to keep it in the mouth overnight.
• Do not talk with the myofunctional appliance in and do not rub the teeth against it, as it can be damaged. While wearing it, the mouth is closed, the lips together (the appliance is not visible) and breathing is through the nose.
• When the myofunctional appliance is worn correctly, tooth pain may appear in the morning, especially in the lower incisors. To avoid making this worse, have soft food at breakfast. Wearing the appliance should be accompanied by daily breathing exercises.

During treatment

• After each activation of a removable appliance you may feel tension in the jaw bones and in the teeth.
• You may sometimes notice some mobility of the teeth, but this is normal.
• Report any fault in the appliance (a wire that is bothering you, a bracket that has come off) to the orthodontist at once, because leaving certain problems unresolved can lengthen the treatment.
• If you do not wear the appliance, or if it is not in the correct position, the treatment can suffer and its duration can lengthen significantly.

Oral hygiene while wearing the appliance

Once the appliance is fitted it is very important to keep hygiene as good as it was before. Food particles easily stagnate around the components of the appliance, which makes cleaning harder. Careful brushing, flossing and mouthwash are therefore recommended, preferably after every meal, to prevent plaque build-up, decay and gum disease.

A fixed appliance retains more food debris and encourages rapid plaque build-up. Correct hygiene prevents white spots (demineralisation), decay and gum inflammation during treatment.

Brushing must be done after every meal, for at least 2 minutes:

• Above the brackets: hold the brush at 45 degrees above the bracket, angled down toward the tooth, and use circular and sweeping movements.
• Below the brackets: hold the brush at 45 degrees under the bracket, angled up, cleaning the space between the appliance and the gum margin.
• The front: brush directly on the brackets, perpendicular to the teeth, with gentle circular movements.
• Inner and biting surfaces: clean the backs of the teeth and the chewing surfaces with the normal technique, sweeping from gum toward tooth.

Cleaning between the teeth and under the wire — ordinary brushing cannot reach the areas hidden by the archwire, so follow these steps daily:

• Pass the interdental brush vertically, top to bottom and bottom to top, behind the archwire, on either side of each bracket. Use it for every tooth and wherever the ordinary brush cannot clean completely.
• Orthodontic floss (Superfloss): use the stiffened end to pass it under the archwire. Then slide the spongy portion along the sides of the teeth, going slightly under the gum. Daily flossing is necessary to keep the gums healthy and prevent decay between the teeth.
• Oral irrigator: use it every evening to flush out larger debris from hard-to-reach spaces, before using floss and brush.
• After brushing carefully and flossing, you may rinse thoroughly with a fluoride mouthwash for one minute. Note: mouthwash does not replace brushing; it is an antiseptic complement to correct brushing.

Cleaning removable appliances and aligners

• Clean a removable appliance with a nail brush, liquid soap and warm water. Do not wash it in hot or cold water and do not sterilise it in boiling water. After cleaning, put the appliance in its box to dry, with the lid left open. Periodically (at least once or twice a week) clean it using effervescent tablets for dental appliances and dentures.
• Never put aligners back on unbrushed teeth. Food debris trapped under the tray accelerates decay and demineralisation. Brush for 2 minutes and floss after every meal or snack. Brush carefully around the small composite buttons (attachments) bonded to the teeth, as they retain plaque.
• Cleaning the tray: brush the inside and outside of the aligner with a soft toothbrush and neutral liquid soap or clear washing-up gel. Do not use toothpaste on aligners (it is abrasive and dulls them, so they lose their transparency). Do not wash aligners in hot water, as you risk deforming the medical plastic.
• Once a day, dissolve a special effervescent tablet for dentures or aligners in warm water and leave the trays in the solution for 15 minutes.

If oral hygiene is not good enough, the following appear:

• Irreversible, unsightly white spots — areas of demineralised enamel that turn into cavities and become more visible once the appliance is removed.
• Decay on the tooth surfaces next to the brackets, between the teeth or on the chewing surfaces. These become painful and treatment can be more complicated.
• Gingivitis — inflammation of the gum, which becomes red, swollen and bleeds at the slightest touch.

Practical advice and food rules

• Emergency kit: always carry a compact kit at school or the office with a brush, an interdental brush and orthodontic wax. Place a small ball of wax over the bracket or wire end causing sores or irritation inside the cheeks.
• Diet: avoid hard foods (walnuts, hazelnuts, ice) and sticky ones (toffees, chewing gum, jellies), which can debond brackets. Cut hard fruit and vegetables (apples, carrots) into small pieces before eating them. Do not bite into them with the front teeth.
• Preventing staining: ceramic brackets do not stain, but the clear or white elastics around them absorb colour very easily. Limit coffee, black tea, red wine, mustard, curry, turmeric and tomato sauce. Rinse the mouth thoroughly with water immediately after coloured food or drink, if you cannot brush on the spot.
• Unlike fixed appliances, aligners are removed at mealtimes, which makes cleaning the teeth easier but imposes strict rules for the trays. When you are not wearing them, keep the aligners only in their special box. Do not wrap them in napkins, as you risk throwing them away by mistake.
• While wearing the aligners you may drink only still water, cold or at room temperature. For coffee, tea, juice or hot water the aligners must be taken out: hot drinks deform them and coloured drinks stain them instantly.

Co-operation, check-ups and retention

• Successful orthodontic treatment requires joint effort from clinician and patient. It is your responsibility to look after hygiene and the integrity of the appliance.
• With fixed appliances, avoid debonding brackets through unsuitable food or inattention, because it lengthens the treatment and re-bonding is charged separately.
• During treatment you may need to wear intermaxillary elastics and other removable appliances.
• When worn consistently and correctly, a myofunctional appliance provides functional re-education (breathing, swallowing, musculature) as well as correct repositioning of the teeth and jaws. Treatment may need several stages depending on the severity of the anomaly, and several myofunctional appliances may be required, in which case treatment will last 1.5–2 years. In some situations a fixed appliance is also used.
• With orthodontic appliances, check-ups are best every 4–6 weeks. Do not underestimate the importance of regular check-ups.
• On average, treatment with an appliance lasts between 1.5 and 2 years, depending on how complex the case is. At the end of active orthodontic treatment comes a retention period, in which the new position of the teeth stabilises. Teeth tend to return to their original position, especially just after the appliance is removed.
• There are several types of retainer, each chosen according to the clinical case. Fixed retention consists of two wires bonded behind the teeth, upper and lower, plus a night-time tray. These are almost invisible and cause no discomfort.
• The wearing protocol is adapted to each patient. In general, for treatment carried out in children, retention is kept until growth stops. In adults, retention is kept for life.

We recommend visiting oralhygiene-instruction.com to see the main oral-hygiene methods.

This guide gives step-by-step instructions for keeping your teeth healthy at home.

Cleaning between the teeth, daily, before brushing

A toothbrush cleans only 60% of the tooth surface. The remaining 40% needs special attention.

• Cut about 45 cm of floss and wind it around your middle fingers. Ease the floss gently between the teeth with a back-and-forth movement, avoiding injury to the gum. Curve the floss around the base of each tooth and slide it gently under the gum line. Move the floss up and down against the tooth surface to remove plaque.
• Oral irrigator (optional): use it before brushing, to flush out larger food debris.

Brushing with a manual brush — the roll technique

The roll technique is also known in dentistry as the rotation technique, or “from red to white”.

• Hold the brush head parallel to the dental arch. Place the bristles directly on the gum (the red part), above the tooth. The bristles point up for the lower teeth and down for the upper teeth.
• Apply light pressure on the gum, so the bristles bend slightly. Rotate your wrist to sweep the tooth from gum toward the incisal or occlusal edge, that is, toward the tip of the tooth.
• The movement goes only from red to white, from gum toward tooth. Never make vertical back-and-forth movements and do not scrub horizontally. The reverse movement, from tooth toward gum, pushes bacteria under the gum and causes recession.
• Repeat the rolling movement at least 5–10 times on the same group of teeth. Move the brush to the next group, overlapping the previous area slightly so no space is left uncleaned.
• On the tongue side of the molars, use exactly the same rolling movement, from the gum upward or downward.
• At the front teeth (canines and incisors), where the space is narrow, turn the brush vertically. Place the bristles on the inner gum and sweep outward: upward for the lower arch, downward for the upper.
• Brush morning and evening for 2 minutes, with a fluoride toothpaste.
• Replace the brush (or the head of an electric one) every 3 months, after professional cleaning at the practice or after a cold.

Brushing with an electric brush

An electric brush does the work for you. The golden rule, whatever the technology, is not to scrub: you only need to guide the head from one tooth to the next, with minimal pressure.

• Use a pea-sized amount of toothpaste. Switch the brush on only after you have put it in the mouth and placed it on the teeth, so the paste does not splatter.
• If your brush has a pressure light, watch it carefully. If it turns red, or if the brush changes its sound, you are pressing too hard and risk gum recession.
• Most electric brushes have a built-in timer that vibrates every 30 seconds. This tells you to move to the next quarter of the mouth, giving a total brushing time of at least 2 minutes.

Oscillating-rotating brushes (round head, 2D or 3D movements) clean through rapid rotation-oscillation and pulsation around each tooth.

• Place the round head on the outer surface of a single tooth. Let the bristles wrap around the tooth, following its curve and the gum line.
• Hold the brush in place for 2–3 seconds on that tooth, without back-and-forth movements. Slide gently to the next tooth and repeat.
• Clean all the outer surfaces first, then the inner ones and finally the chewing surface of each tooth.

Sonic brushes (elongated head, high-frequency movements) use acoustic vibrations that create micro-bubbles of fluid — water, saliva and paste — cleaning effectively even beyond where the bristles touch.

• Place the elongated head at 45 degrees to the gum line.
• Switch the brush on and glide it slowly along the arch, covering 2–3 teeth at a time. Hold it on each group for a few seconds, letting the sonic vibrations dislodge plaque.
• You may add an extremely light sweeping movement from gum toward tooth, but without scrubbing horizontally.

Mouthwash and regular check-ups

• Rinse for 30 seconds after brushing, with an alcohol-free fluoride mouthwash. Do not swallow the product.
• Avoid food and water for 30 minutes after using a fluoride mouthwash.
• Visit the practice every 6 months for professional cleaning and a check-up.

We recommend visiting oralhygiene-instruction.com to see how the main oral-hygiene methods are used.

The health of both baby teeth and adult teeth depends directly on the habits formed in the first years of life. Below are the essential rules for each stage of your child’s development.

Babies (0–1 year): before and after the first teeth

Oral cleaning starts in the first weeks of life, long before the first tooth appears.

• Cleaning the gums: wipe the baby’s gums twice a day, morning and evening. Use a sterile gauze moistened in warm water or a soft silicone finger brush.
• The first tooth: from the eruption of the first tooth, at around 6 months, start brushing. Use a rice-grain amount of fluoride-free paste.
• Preventing bottle decay: never put the child to bed with a bottle of milk, sweetened tea or juice.
• The first dental visit: should be planned within 6 months of the first tooth appearing, or by the child’s first birthday at the latest.

Toddlers (1–3 years)

At this stage brushing becomes a compulsory daily routine, carried out entirely by the parent.

• Brush twice a day, for at least 2 minutes. Keep the amount of paste to the size of a grain of rice, up to age 3.
• Use a small-headed, soft-bristled brush. Brush with gentle circular and vertical movements, from gum toward tooth.
• Teach the child to spit out the toothpaste after brushing, without swallowing water. Children who can rinse will use fluoride toothpaste.
• The easiest brushing technique is Fones: the teeth are first held together, with the mouth closed. The bristles are placed perpendicular to the teeth and wide circular movements are made, covering both teeth and gums. For the biting surfaces, with the mouth open, use back-and-forth movements with the bristles perpendicular to the tooth surface.
• Controlling sweets: limit sweet snacks and sugary drinks between meals.
• Keep regular dental visits, every 6 months.

Pre-school and school children (3–12 years)

The child starts to develop dexterity, but adult supervision remains critical until around the age of 8.

• Increase the amount of paste to the size of a pea, using a fluoride concentration suited to the age, usually 1000–1450 ppm. Brush all tooth surfaces: outer, inner and biting.
• After the age of 7 the brushing technique changes to the roll technique, also known as the rotation technique or “from red to white”. Hold the brush head parallel to the dental arch and place the bristles directly on the gum, above the tooth. The bristles point up for the lower teeth and down for the upper teeth. Apply light pressure on the gum so the bristles bend slightly, then rotate your wrist to sweep the tooth from gum toward its tip.
• The movement goes only from gum toward tooth. Never make vertical back-and-forth movements and do not scrub horizontally. Repeat the rolling movement at least 5–10 times on the same group of teeth, then move to the next group, overlapping the previous area slightly.
• On the tongue side of the molars use the same rolling movement. At the front teeth, where the space is narrow, turn the brush vertically, place the bristles on the inner gum and sweep outward.
• Electric brushes can be introduced to make brushing more appealing and more effective.
• Introduce dental floss as soon as the teeth start to touch and crowd. Cut about 45 cm of floss and wind it around your middle fingers. Ease the floss gently between the teeth with a back-and-forth movement, avoiding injury to the gum. Curve the floss around the base of each tooth and slide it gently under the gum line, then move it up and down against the tooth surface.
• We recommend sealing the permanent molars as soon as they erupt, at around 6 and 12 years, to prevent decay in the grooves.
• Keep dental and prophylaxis check-ups every 6 months.

Teenagers (12–18 years)

Hormonal changes and eating on the run increase the risk of gingivitis and decay. The teenager must take full responsibility for oral hygiene.

• Brushing twice a day for 2 minutes, with fluoride toothpaste (1450 ppm), together with daily flossing before bed.
• A fluoride mouthwash is advisable, for extra protection against decay.
• During orthodontic treatment, hygiene must be intensified. Interdental brushes, special floss (Superfloss) and an oral irrigator after every meal are essential.
• Education is needed about the harmful effects of energy drinks, smoking (including vaping) and tongue or lip piercings on oral health.
• A mouthguard during contact sports is advisable to prevent dental injuries.

Periodontal disease is a chronic condition, but it can be kept under control by following the instructions below strictly.

Brushing

• Frequency: at least twice a day, in the morning and, without fail, in the evening before bed.
• Duration: brushing should last at least 2 minutes.
• Type of brush: use only a soft-bristled brush (Extra Soft or Ultra Soft) or an electric brush with a pressure sensor.

The Bass technique (the sulcular technique) is considered the gold standard for controlling plaque at the gum sulcus:

• Place the bristles at 45 degrees to the long axis of the tooth, pointing toward the gum sulcus, where tooth meets gum.
• Apply light pressure, so the bristle tips enter slightly under the gum margin.
• Make very short horizontal vibrating movements, or circular movements on the spot, for 10–15 seconds on each group of teeth, without moving the brush off the teeth.
• Clean the backs of the front teeth holding the brush vertically and moving it up and down. Sweep gently from back to front on the molar surfaces.

The modified Bass technique combines the vibration in the sulcus with a rolling movement toward the free edge of the tooth, from red to white, at the end of each cycle, to remove the dislodged plaque:

• Place the brush at 45 degrees to the gum.
• Make light vibrating movements on the spot, without scrubbing horizontally.
• Roll the brush head from gum toward the edge of the tooth.
• Clean the backs of the front teeth holding the brush vertically and moving it up and down. Sweep gently from back to front on the molar surfaces.

The Stillman technique is indicated where there is marked gum recession: the bristles are placed partly on the gum and partly on the neck of the tooth, at 45 degrees, similar to Bass but higher on the gum. Press lightly until the gum blanches slightly under the pressure, then make an intense but gentle vibrating movement on the spot, followed by a rolling movement toward the edge of the tooth, as in modified Bass.

The Charters method is indicated in patients with absent interdental papillae, exposed roots, moderate interdental recession or after periodontal surgery:

• Unlike other techniques such as Bass, the bristles point not toward the gum but toward the crown of the tooth.
• Place the brush at the gum line, with the bristles at 45 degrees toward the biting surface of the teeth. The bristle tips should sit on the gum area and cover the interdental space.
• Make short vibrating or rotating movements while holding the brush in place, without sliding it horizontally along the tooth. Apply this movement 15 to 20 times on each group of 2–3 teeth.
• Repeat for all the outer and inner surfaces of both arches, then clean the chewing surfaces.

Cleaning between the teeth is essential

Brushing alone cleans only 60% of the tooth surface. Periodontal bacteria develop in the open spaces between the teeth and in the periodontal pockets.

• Interdental brushes are the most important instruments in periodontal disease. Choose the right size, recommended by your clinician. Insert the brush carefully between the teeth and move it in and out. Do not force it if the space is too narrow.
• Dental floss is used daily for the very narrow spaces where an interdental brush does not fit. Cut about 45 cm of floss and wind it around your middle fingers. Ease the floss gently between the teeth with a back-and-forth movement, avoiding injury to the gum. Curve the floss around the base of each tooth and slide it gently under the gum line, then move it up and down against the tooth surface.
• The oral irrigator is used daily, before brushing, to flush food debris from the periodontal pockets. Note: the irrigator removes larger debris but does not replace the mechanical action of interdental brushes.

Adjunctive antiseptics

• Mouthwash: use a chlorhexidine mouthwash, at 0.12% or 0.20%, only for the period recommended by the clinician, usually 7–14 days after treatment at the clinic. Long-term use can stain the teeth.
• Periodontal gels: if you have been prescribed chlorhexidine gels or local antibiotics, apply them directly on the gum, in the areas indicated, after cleaning thoroughly.

Lifestyle and diet

• Smoking is the main enemy of periodontal treatment. Nicotine reduces blood flow in the gums, masking bleeding and blocking natural healing. Cutting down drastically or stopping is recommended.
• Correcting the diet plays a crucial part in halting the disease and supporting the treatment carried out at the practice.
• These help reduce inflammation and strengthen the immune system: oily fish (salmon, mackerel, sardines), leafy vegetables (spinach, lettuce, kale), fruit and vegetables rich in vitamin C (citrus, broccoli, peppers), fermented or organic dairy (plain yoghurt, butter, matured cheese) and healthy fats (avocado, olive oil, flaxseed).
• If the daily diet is lacking, clinicians often recommend supplementing with vitamin D3 and K2, coenzyme Q10 and oral probiotics.
• These accelerate tissue destruction and sustain the infection, so they should be avoided: refined sugar and sweets, refined carbohydrates (white bread, pastry, pretzels), very hard foods (croutons, nuts, crisps), fizzy and acidic drinks, gluten and industrially processed cow’s dairy.

The monitoring programme

Periodontal disease needs lifelong supervision. You must return for a check-up and professional cleaning (periodontal maintenance) every 3–4 months, according to the personalised schedule set by your clinician. Once supporting bone has been lost, bacteria return to the pockets far more quickly.

We recommend visiting oralhygiene-instruction.com to see the main oral-hygiene methods.

Nitrous oxide is a colourless, slightly sweet gas used during dental procedures for relaxation and to remove anxiety.

Before the procedure

• Nitrous oxide is given through a nasal mask. You must be able to breathe through the nose: a blocked nose, a cold or allergies are incompatible with inhalation sedation.
• Avoid solid food for 4 hours before your appointment and liquids for 2 hours before.
• Avoid products containing caffeine. Nitrous oxide can cause nausea, which may lead to gagging.
• On the day of the appointment do not take antidepressants (unless the dentist knows about them) or other sedatives not prescribed by the dentist.

Contraindications

Please tell us if you have any of the following health problems, as nitrous oxide may be contraindicated:

• Chronic obstructive pulmonary disease (COPD).
• Chronic bronchitis.
• Emphysema.
• Respiratory disease.
• Chronic asthma.
• Tuberculosis.
• Cor pulmonale.
• Autoimmune disease.
• Megaloblastic anaemia.
• Hepatitis B or C.
• Middle-ear infections.
• Claustrophobia.
• Pregnancy.
• Substance abuse.

During sedation

• The mask must stay firmly in place throughout the sedation. Do not breathe through the mouth, breathe only through the nose. Tell the clinician if you have difficulty breathing through the nose.
• When inhaled, nitrous oxide can produce feelings of euphoria and sedation. It can also cause drowsiness, warmth and tingling in the hands, feet or around the mouth. Used in the dental practice it will not make you unconscious: you will be able to swallow, speak and cough normally.
• Talking is limited while nitrous oxide is being given. When you talk you breathe the gas out into the room, which reduces the intended effect on you and exposes the practice staff to it.

After the procedure

• Recovery after nitrous oxide sedation is quick. The gas is cleared from your body with oxygen.
• If you feel dizzy after sedation, stay seated and the feeling will pass within a few minutes.
• Do not leave the practice until you feel your thinking is clear and you can walk without difficulty.

Risks

• You may feel nausea, dizziness, drowsiness or claustrophobia during or after sedation.

The sedatives are given by drip, through a cannula, into a vein in the arm or the back of the hand. If needed, the dose can be increased during the procedure. In general, during deep sedation a medicine is given continuously into the vein. You will usually also be given oxygen, through a plastic tube at the nostrils or through a mask.

Before the procedure

• If you have a medical condition, a cold, or if you are pregnant, please tell the clinical team, as sedatives may be contraindicated or the treatment may need to be changed. If you are breastfeeding, tell the clinician on the day of the procedure.
• Bring all the medicines you take with you, including any inhalers.
• Wear loose clothing and shoes, avoiding tight sleeves or collars.
• Nail varnish and false nails should be avoided, as they can interfere with monitoring.
• You will normally be asked to stop eating six hours before treatment, but you may drink clear fluids up to two hours before. Permitted clear fluids include water, diluted juice without pulp, and black tea or coffee without milk or cream. If you have diabetes, ask for specific advice about your medication and about when to stop eating.
• If you care for other people, for example children or elderly relatives, you will need to arrange for someone else to look after them until the following day.
• A competent adult must take you home by car or taxi, ideally avoiding public transport. Because the effects of sedatives can last up to 24 hours, that person should stay overnight to look after you.

During sedation

• The sensation varies from person to person and depends on the dose. During deep sedation you will be asleep, while during minimal sedation you will feel only a pleasant sense of relaxation.
• Going home often depends on how you recover after treatment. With mild or moderate sedation you can usually go home as soon as an hour after treatment. With deep sedation, recovery takes between one and two hours.

After the procedure

• A responsible adult must take you home by car or taxi, ideally avoiding public transport, and must stay with you overnight. If you have not arranged for someone to accompany you home after treatment, you may not be allowed to leave.
• Sedatives can make you feel unsteady on your feet. Take care on stairs and have someone with you if you feel dizzy.
• Your judgement can be affected for up to 24 hours after treatment, so you should not make important decisions during that time. Use social media with care.
• Going to work, caring for others, driving, cooking and operating heavy machinery are not advisable for 24 hours. It can take up to 24 hours for the medicines to leave your body.
• Alcohol and sleeping tablets are not advisable for 24 hours after the procedure.
• If you are on medication, continue taking it, unless your own doctor has advised otherwise.
• The clinician will give you written instructions about any further treatment you need to follow at home.

Remember, this is important: do not drive, do not drink alcohol, do not smoke, do not operate electrical equipment and do not supervise children or other dependent people.

Risks of intravenous sedation

• Your breathing rate may slow. This is common in deep sedation, but it is a risk with all types of sedative. The anaesthetist is trained to monitor you and can support your breathing if necessary.
• Another common effect of sedation is a fall in blood pressure, but the anaesthetist is also trained to treat this.
• Nausea or vomiting can occur, but is not common.
• Allergic reactions to sedative medicines are very rare.
• There is a risk of a small bruise where the cannula is placed or where an injection did not work.
• After sedation you may feel dizzy and may be at greater risk of falling, especially if you are elderly.
• Sedation can affect your judgement and memory for up to 24 hours.

X-rays are a form of radiation of the same kind as visible light, but more penetrating, able to pass through the human body. With suitable techniques and equipment they produce images of the internal structures of the body, in order to diagnose disease. The radiation dose is described using effective dose, expressed in millisieverts (mSv).

Everyone is exposed to radiation from the environment (gamma radiation), which is similar to the X-rays used in medical examinations.

From the environment

• Natural background radiation: 0.01 mSv a day, that is 2–4.5 mSv a year.
• A 3000 km flight: 0.025 mSv.
• Smoking 20 cigarettes a day: 30 mSv a year.

Dental examinations

• Intraoral radiograph: 0.005–0.01 mSv.
• Panoramic radiograph: 0.01 mSv.
• Lateral cephalogram: 0.01 mSv.
• CT of one arch: 0.016 mSv.

General examinations, for comparison

• Radiograph of an extremity: 0.001–0.005 mSv.
• Chest radiograph: 0.2 mSv.
• Abdominal CT: 6–8 mSv.
• Coronary CT angiography: 16 mSv.

What these figures mean

• No international body has set a maximum limit for the effective dose per patient, because the benefits of an X-ray examination for the patient’s health are generally greater than the risk from the radiation.
• The increase in cancer risk resulting from most diagnostic procedures is relatively small — 5–6% for every 100 mSv of dose — compared with the natural risk of cancer, which is 14–40%.
• With modern equipment and good technique, examination of the head and neck can be carried out safely even during pregnancy, without affecting the embryo. Even so, we recommend dental radiographs only where they are absolutely necessary. Radiographic procedures in children should be limited to what is needed for a correct diagnosis.
• We make sure the radiation doses you are exposed to during examinations are very low, using high-performance equipment that produces very clear images with a minimal dose.
• For every radiograph the patient wears a lead protective apron, which prevents other parts of the body from being exposed.

• For 24 hours after injection the treated areas are not touched and not made up. Apply a special cream with anti-inflammatory, antimicrobial / anti-bruise / hydrating effect and a cold ice pack in the first 4–6 hours after injection. With botulinum toxin, for a few hours after the procedure do facial-muscle exercises in the treated muscles to help the toxin bind at the neuromuscular junction. In the first 48 hours, after hyaluronic acid, aPRF or iPRF, do not massage the area.
• A sun-protection cream is mandatory for at least one week after the aesthetic procedure.
• Apart from pain-relief medicines, anti-inflammatory medication is not recommended for 5 days after the procedure.
• No alcohol for 24 hours after treatment.
• For 4–5 hours after the procedure do not keep the head horizontal. If you want to rest in this period, do so with the head on 2–3 pillows. Sleep face-up for at least one night after injection.
• For 7–10 days do not plan important events (weddings, christenings, etc.).
• For 1 week, sun, sunbeds, strong heat, cold, long hot baths, sauna and physical exercise are forbidden.
• In the first 2 weeks it is very important to hydrate with at least 2.5–3 litres of water a day.
• Rinse the mouth with a chlorhexidine mouthwash (Corsodyl, Curaprox).
• Check-ups are recommended 2 weeks after the treatment.