We Now Offer Exparel for Oral Surgery

We are pleased to announce that we are offering Exparel for non-opioid pain relief after oral surgical procedures such as wisdom teeth extractions. We are one of only a handful of dental offices across Connecticut publicly offering this solution. Dr. Nick Calcaterra personally administers Exparel himself in our Orange, CT office.

What is Exparel?

Exparel is a medication used to provide long lasting pain relief after invasive surgical procedures such as wisdom teeth removal with IV sedation. It is a liquid medication that comes in vials. Dr. Calcaterra administers the medication directly into the surgical sites immediately upon completion of the procedure. Once administered, Exparel acts as a long lasting numbing agent, providing pain relief for up to 4 days.

Exparel non-opioid pain reliever seen in Orange, Connecticut

A box of Exparel medication that Dr. Nick Calcaterra administers after wisdom teeth surgery in our office in Orange, CT

When used along with traditional pain medications such as high dose Motrin (a.k.a. ibuprofen), our patients need reduced amounts of opioids, or in many cases do not need opioids at all.

Why Exparel?

Vicodin prescribed after oral surgery in Orange, CT

Vicodin – called hydrocodone – is typically prescribed after oral surgery

As you are likely aware, the use of opioids (a.k.a. narcotics such as Vicodin and Percocet) in the United States has created a crisis. There are many factors behind the crisis, but the end result for certain users of opioids is addiction, disability, and sometimes even death.

There is a wealth of research which shows that for many patients – typically older teenagers and young adults – their first exposure to opioids is after third molar extractions. Generally speaking, research has shown that those individuals who received narcotic prescriptions for wisdom teeth were more likely to develop addiction problems later on in life.

Given the risks associated with opioids and the crisis, Exparel was developed. Exparel has been proven in clinical studies to reduce the need for opioids following wisdom teeth removal.

Are Opioids Still Necessary for Wisdom Teeth Extractions?

Sometimes (in our opinion and experience).

Pain affects people differently. Wisdom teeth cases vary significantly in their surgical complexity and invasiveness. Our patients’ medical histories, age, and other factors also impact how much pain they will experience and what type of medications they will require afterwards.

Dr. Nick Calcaterra with Exparel for wisdom teeth extractions in Orange, Connecticut

Dr. Nick Calcaterra with Exparel he is about to administer after a wisdom teeth removal case in Orange, CT

Given the dynamic and unpredictable nature of post-surgical pain, we will re-phrase the question:

Do we still prescribe opioids after tough surgical cases? Sometimes

But we feel comfortable stating the following:

Based on our own use of Exparel on patients requiring wisdom teeth extractions, we’ve witnessed firsthand a reduction and sometimes elimination of the need for opioids.

Can Exparel Help?

The short answer is: probably.

Talk to your dentist or oral surgeon. See if they offer Exparel. See what their experiences have been. Use the internet. Learn more on our Exparel page. Read about Exparel on Reddit.

Appointment request for wisdom teeth surgery with exparel

Do you need your wisdom teeth out and want Exparel to reduce the pain afterwards? Are you looking to avoid opioids after oral surgery? Do you need IV sedation? Then you’ve come to the right place. Call us at (203) 799 – 2929 or visit this page to request an appointment.

Liz’s IV Sedation Video – Over 110,000 YouTube Views!

(Note: this post was updated to reflect the total number of views)

That’s right. Our video – Liz’s IV Sedation Wisdom Teeth Journey – has been viewed over one hundred thousand times on YouTube! And even more impressive, it racked up this number of views in only 18 months. In the video, you see Liz during her third molar extraction procedure – being sedated and having her teeth removed – and then hear her talk about it when we interview her several weeks later.

Is the viral YouTube popularity due to our brilliant videography? Our excellent surgical techniques? Our expertise in IV sedation? Our awesome staff? All of the above? Check it out and see for yourself:

What do you think? Did you watch all 6 minutes of it? We bet you did – along with over 110,000 other YouTube viewers!

We believe the explosive YouTube popularity has to do with several factors:

  1. Great videography and editing by our multifunctional Dental Assistant Cyndi.
  2. Compassionate surgical and anesthesia skills exhibited by Dr. Nick in the video.
  3. A great patient – Liz – who remembers almost nothing of the procedure – but who was kind enough to allow us to document her surgical journey.

It could also be due to her virtually painless healing period afterwards. Or the mango sherbet (go to the 3:55 point to see Liz as for it during the sedation).

Want to be featured in one of our YouTube videos and become an overnight viral sensation? OK – we can’t guarantee that – but we can guarantee a great experience with one of Connecticut’s most experienced sedation dentists.

appointment request with Dr. Nick Calcaterra Sedation DentistInterested in learning more about IV sedation with Dr. Nick? Need your wisdom teeth removed and want twilight anesthesia? Call us at (203) 799 – 2929 or visit this page to request an appointment.

Differences in Post-Operative Pain in Upper Versus Lower Wisdom Teeth Removal

In our dental office, we remove hundreds of wisdom teeth (a.k.a. third molars) per year. We perform all types of extractions – upper, lower, fully erupted, impacted, horizontal, etc. with our without IV sedation.

upper versus lower wisdom teeth which cause pain

Only 2 of these 4 third molars resulted in significant pain afterwards. Want to guess which ones? Surgery by Dr. Nicholas Calcaterra.

As part of our review of the procedure with our patients, we always discuss post-operative pain relief. And we invariably end up saying something to the effect of:

“When the numbing wears off, you’ll likely be pain free with the top extraction sites, but for the bottom, you’ll definitely need to take the pain medications”

When we see our patients a week later for a follow-up, we then get asked:

“I didn’t feel any pain during the procedure. But the next day, how come the top wisdom teeth removal didn’t hurt but the bottom ones did?”

There are many reasons why upper (also called maxillary) third molar extraction sites often give little post-operative pain but bottom (also called mandibular) extraction sites frequently do. Here are some of the key differences:

Differences in the Bone Holding in the Teeth

Teeth are held in your jaw because they are encased in bone. The bone holds them tightly in place. So it stands to reason that if some bone is denser and can hold the tooth in more securely, those teeth will be harder to remove. Right?

bone impacts why lower wisdom teeth hurt more

This photo of a human skull shows how teeth are held in place by bone.

The bone that holds upper wisdom teeth in place is neither dense nor strong. It can best be compared to Styrofoam. On the other hand, the bone that holds lower wisdom teeth is dense, thick, and strong. It can best be compared to pine wood.

So, if you have a tooth encased in either pine wood or Styrofoam, which do you think will require more effort to get out? Of course it’s the pine. So that extra strength that holds lower wisdom teeth in place – ends up resulting in greater effort to remove – and is one reason that makes lower wisdom teeth hurt more.

Dry Socket Occurs More Often with Bottom Wisdom Teeth

Dry socket, also known as alveolar osteitis, is a painful condition that can occur after any tooth extraction. Research has shown that the incidence of dry socket for all tooth extractions is 2%, but is seen 20% of the time for impacted lower wisdom teeth.

What this means is that, generally speaking, there is a 10 times greater likelihood of a dry socket with a lower wisdom tooth than an upper. This again is another reason why lowers can hurt more.

Different Types and Number of Injections

Some of the other reasons for the difference in post-operative pain include the number and site of injections.

To properly anesthetize an upper wisdom tooth, there are only a couple of injections needed. They are typically shallow and have high success rates. While one of the injections can be painful, it does not result in significant pain post-operatively.

mandibular nerve block lower third molar removal

A mandibular block injection for a lower third molar. The needle goes at least one inch deep through muscle. Expect at least two of these injections for a lower wisdom tooth extraction.

Conversely, lower wisdom will often need multiple injections, including a minimum of two that must penetrate at least an inch through muscle. And because lower wisdom teeth can have many nerves associated with them, it is not uncommon to need 5 or 6 separate injections.

If you received multiple injections into your leg through one inch of muscle until the needle hit bone versus two injections where the needle only went in an eighth of an inch, which would hurt more the next day?

Gravity

After removal, there are empty sockets or holes where the teeth used to be. These holes are the perfect size for small pieces of food to accumulate. Significant accumulation of food can lead to delayed healing, infection, and pain.

Gravity ensures that the lower sockets accumulate much more food debris than the top. This is another reason why lower wisdom teeth surgery leads to more pain than the upper ones.

Proximity to Delicate Anatomy
Impacted lower wisdom tooth that will be painful the next day after removal

This impacted lower third molar is very close to a major nerve and artery.

Impacted lower wisdom teeth are often close to very important anatomical structures such as a major nerve and artery that supply the lower jaw, chin, and other areas. In order to avoid inadvertently damaging those structures, a slow approach is often taken.

The longer a surgical site it open and manipulated, the more post-op pain and swelling will result. And the greater a likelihood of infection.

While upper third molars have their own set of considerations and risks, it is very rare that such a slow approach must be taken. In the x-ray, the upper wisdom tooth took approximately 1 minute to remove, while the lower over 20 minutes.

Which site do you think hurt more the next day?

Exparel is Typically Used for Lower Wisdom Teeth

Have you heard about Exparel? Exparel is an opioid free pain management solution – designed to relieve pain after surgery. We use it in our office after extracting four wisdom teeth. For the most part, we administer it on the bottom.

The vast majority of studies – including this one – typically test the effectiveness for lower wisdom teeth. Why? Because the top ones typically don’t hurt as much.

put to sleep for third molar wisdom teeth removal and extraction.Do you need a wisdom tooth or teeth removed? Interested in a consult? Want IV sedation? Call us at (203) 799 – 2929 or visit this page for an appointment.