Tooth extraction: what to do in the first 48 hours

The tooth is out. You’re leaving the practice with gauze in your mouth and an instruction sheet you’ll probably read halfway. And yet it’s that sheet — and specifically the first 48 hours — that decides whether healing goes smoothly or not.

Everything, absolutely everything, comes down to one thing: the clot.

The clot is the construction site

The moment the tooth is removed, a blood clot forms in the empty socket. It’s not waste: it’s the scaffolding on which bone and gum reconstruction will begin. Protecting it in the first hours is the patient’s only real job.

If the clot detaches or dissolves, bone is exposed and dry socket arrives: a deep, dull pain that typically sets in between day one and day five, often worse than the extraction itself. It’s the complication I see most often, and it’s almost always avoidable.

The first 24 hours: protection

The gauze. Bite down on it with constant pressure for 30–60 minutes. The mechanical pressure helps the clot stabilise. Replace it with a clean one and repeat if needed. Light bleeding that colours saliva pink is normal for several hours — it’s different from haemorrhage, as I explain in connection with post-surgical bleeding.

Ice. On the cheek, wrapped in a cloth, in 20-minute on-off cycles. Mainly helps with pain and discomfort in the first hours.

Head elevated. Even at night, an extra pillow. Reduces pressure in the area and bleeding.

Then the list of things not to do, which matters as much:

• No rinsing. No mouthwash.
• No smoking. Suction and nicotine are among the clot’s worst enemies — dry socket risk in smokers is more than triple, covered in detail in smoking after an extraction.
• No straws: suction does the same damage.
• No alcohol, no hot food or drink, no intense physical effort.

From day two: gentle cleaning

After the first 24 hours, the approach changes. The area now needs to be kept clean — but gently.

Rinse with warm saltwater — half a teaspoon in a glass of water — several times a day, after meals. Without force: the movement should be mild.

A clarification that goes against widespread habit. Many patients expect chlorhexidine as the standard mouthwash. Recent literature is more cautious: a review on the aetiology and prevention of dry socket notes saline as a cheap and effective alternative to chlorhexidine, which carries its own — rare but real — risk of serious allergic reactions (Ghosh et al., 2021). For the first days, saltwater is often the better choice. I reserve chlorhexidine for specific indications, not as a default.

Normal brushing resumes on the other teeth, carefully avoiding the extraction site for the first few days.

Pain: what actually works

There’s a lot of confusion about painkillers, and here the data are clear.

For most extractions ibuprofen is the first choice, because post-surgical pain is driven by inflammation and NSAIDs target it directly. Adding paracetamol improves control further: a randomised trial showed that the fixed-dose combination of the two outperforms either drug alone after third-molar removal (Daniels et al., 2018).

And opioids? Not needed for a routine extraction. A synthesis published in the Journal of Dental Research is direct: in post-surgical dental pain, NSAIDs are on average superior to opioids, which also produce more side effects (Hersh et al., 2020).

A note on antibiotics: they shouldn’t be taken “just to be safe” after every extraction. Antibiotic prophylaxis has specific indications — it’s not a reflex — and inappropriate use causes more harm than good.

What to eat, and the sutures

For the first 48 hours: soft, lukewarm food, chewing on the opposite side.

If I placed sutures, feeling them with your tongue is normal. They shouldn’t be touched or pulled. When they come out, whether removal hurts, and what to do if one falls early — all covered in oral sutures: when they come out and whether it hurts.

The dry socket signal

There’s a rule that applies to all oral surgery: pain should decrease day by day.

If instead, after an initial improvement, pain returns and intensifies between day three and day five — often radiating to the ear, with unpleasant breath and a bad taste in the mouth — that’s the classic picture of dry socket. Not dangerous, but very painful and needing treatment: the dentist cleans and dresses the socket. It doesn’t resolve quickly on its own without intervention.

Rare but different: heavy bleeding that doesn’t stop with pressure, swelling spreading rapidly to the neck or floor of the mouth, or difficulty breathing. For those, go to the emergency room.

In brief

Extractions heal well almost always. When things go wrong, it’s usually because of something avoidable in the first 48 hours: a disturbed clot, one cigarette too many, a rinse too vigorous. Knowing the reason behind each rule makes it much easier to follow.

Frequently asked questions

What should I do immediately after a tooth extraction?

Bite down with constant pressure on a sterile gauze pad for 30–60 minutes, to help the clot form. Keep your head elevated, apply ice to your cheek at intervals during the first few hours, avoid rinsing, exertion, and hot food or drink. In the first 24 hours, one goal only: don’t disturb the clot that has formed in the socket.

When can I rinse my mouth after a tooth extraction?

Not in the first 24 hours. From day two you can start gentle rinsing with warm saltwater (half a teaspoon in a glass of water), several times a day after meals. Saline is as effective as chlorhexidine for keeping the area clean, without chlorhexidine’s risks, and is the preferred first rinse after an extraction. Vigorous rinsing should be avoided: it dislodges the clot.

What not to do in the first 48 hours after an extraction?

Don’t smoke, don’t use straws, don’t rinse forcefully, avoid alcohol, hot food or drink, and intense physical exertion. Anything that creates suction or raises blood pressure can detach the clot and cause dry socket — the most painful and most preventable complication of tooth extraction.

Which painkiller should I take after a tooth extraction?

For most extractions ibuprofen is the first choice, optionally combined with paracetamol (acetaminophen): the combination controls pain better than either drug alone and better than opioids, with fewer side effects. Opioids are not needed for a routine extraction. Dosing should always be agreed with your dentist or doctor, taking any contraindications into account.

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Dr. Ernesto Bruschi — periodontist and oral implantologist, Centro Odontoiatrico Denti Più, Frosinone, Italy. ORCID: 0000-0002-4773-5384.

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