- Patient Education
- Home care
- Follow-up care
- When to seek medical advice
- Case Report Hematoma – A Complication of Posterior Superior Alveolar Nerve Block
- What Is an Oral Hematoma?
- The PSA nerve block
- Complications following tooth extraction and oral surgery
- Swelling after tooth extraction: how to remove and how long it will take?
- In which cases oedema often occurs after tooth extraction.
- How can you prevent the development of severe bloating after tooth extraction?
- Which symptoms may be edematous and worth visiting a doctor as soon as possible?
- How long does the swelling usually last after the tooth is extracted?
A hematoma is a collection of blood trapped outside of a blood vessel. It is what we think of as a bruise or a contusion. It is usually seen under the skin as a black and blue spot on your arm or leg, or a bump on your head after an injury. It can be almost anywhere on or in your body. It can also occur in an internal organ where it can be more serious.
A hematoma is caused by an injury with damage to small blood vessels. This causes blood to leak into the tissues. Blood forms a pocket under the skin that swells and looks like a purplish patch. Hematomas sometimes form under the skin from bleeding during childbirth and can be particularly serious. Another serious form of hematoma forms after a fall on the head, called a subdural hematoma.
Gradually the blood in the hematoma is absorbed back into the body. The swelling and pain of the hematoma will go away. This takes from 1 to 4 weeks, depending on the size of the hematoma. The skin over the hematoma may turn bluish then brown and yellow as the blood is dissolved and absorbed. Usually, this only takes a couple of weeks but can last months.
Limit motion of the joints near the hematoma. If the hematoma is large and painful, avoid sports and other vigorous physical activity until the swelling and pain goes away.
Apply an ice pack (ice cubes in a plastic bag, or a frozen bag of peas, wrapped in a thin towel) over the injured area for 20 minutes every 1 to 2 hours the first day. Continue with ice packs 3 to 4 times a day for the next 2 days. Continue the use of ice packs for relief of pain and swelling as needed.
If you need anything for pain, you can take acetaminophen, unless you were given a different pain medicine to use. Talk with your healthcare provider before using this medicine if you have chronic liver or kidney disease. Also talk with your healthcare provider if you have had a stomach ulcer or digestive tract bleeding, or are taking blood-thinner medicines.
Follow up with your healthcare provider, or as advised. If X-rays or a CT scan were done, you will be notified if there is a change in the reading, especially if it affects treatment.
When to seek medical advice
Call your healthcare provider right away if any of the following occur:
Redness around the hematoma
Increase in pain or warmth in the hematoma
Increase in size of the hematoma
Fever of 100.4ºF (38ºC) or higher, or as directed by your healthcare provider
If the hematoma is on the arm or leg, watch for:
Increased swelling or pain in the extremity
Numbness or tingling or blue color of the hand or foot
Hematoma – A Complication of Posterior Superior Alveolar Nerve Block
The unintentional nicking of the blood vessels (artery or vein) with needle during the injection of local anesthesia might results in effusion of blood into the extravascular spaces with subsequent hematoma formation. Puncture of vein by needle may or may not results in the formation of hematoma but perforation of artery subsequently develop hematoma which rapidly increases in size until treatment is instituted due to significantly greater blood pressure within the artery. The size of the hematoma also depends upon the density of the tissues surrounding the blood vessel.
The posterior superior alveolar (PSA) nerve block targets the posterior superior nerve in the infratemporal fossa. It is accomplished by depositing the anesthetic agent along the posterior surface of the maxilla. The needle must be advanced medially, superiorly and posteriorly at a 45 degree angle to the maxillary occlusal plane to reach the infratemporal fossa. The improperly placed posterior superior alveolar nerve block can result in various complications. The hematoma formation due to trauma to the pterygoid plexus of veins is one of the most common complications. A very uncommon and rare complication of bell’s palsy can result due to improper placement of the needle into the inferior part of the parotid gland resulting to the trauma of the cervicofacial division of the facial nerve. This along with trauma of the lateral and medial pterygoid muscles could result in trismus.
The injury of the blood vessel due to penetration of needle to far distally during Posterior superior alveolar nerve block may leads to temporary unaesthetic hematoma extraorally in the lower buccal tissue region of the mandible. The injury of the blood vessel related to this nerve results in effusion of the blood into the infratemporal fossa which accommodate a large volume of the blood from where it progress inferiorly and anteriorly towards the lower region of the cheek resulting in the swelling and discoloration of the involved region which occurs within few minutes after completion of the injection.
It is difficult to apply pressure to the bleeding site due to the location of the involved blood vessels which are located posterior, superior and medial to maxillary tuberosity. Bleeding normally stops when external pressure on the blood vessels exceeds the internal pressure or the clotting occurs. The chances of hematoma formation might increase in patients suffering with hematological disorders or condition.
A 45 years old female patient reported to our dental centre with chief complaint of severe pain in the maxillary right posterior region which aggravates during sleeping and on intake of the hot food. The clinical and radiographic evaluation reveals carious exposed maxillary right first molar (The intraoral photograph was taken after removal of carious lesion and temporary restoration). The root canal treatment followed by fabrication of the crown was planned for the same. When the local anesthesia was administered for the posterior superior alveolar nerve block, forthe RCT of 16, a swelling alongwith large extraoral discoloration in the mandibular lower region (Figure 1) and a small intraoral hematoma (Figure 2) formation takes place immediately within minutes of administration of anesthesia. The patient became very apprehensive about the unaesthetic appearance of large discoloration on the side of the face. The follow up of the case was done for 4 weeks during which discoloration was completely disappeared within in 3 weeks.
The posterior superior alveolar nerve is a branch of the maxillary division of the trigeminal nerve. It originates from the main trunk in the pterygopalatine fossa, passes inferiorly along the posterior wall of the maxilla, and enters the bone about 1 cm superior and posterior to the third molar tooth. This nerve supplies the buccal gingivae, periodontium, and alveolus associated with the upper molar teeth. It provides innervation to the pulps of all the upper molar teeth with the possible exception of the mesiobuccal pulp of the first molar, which is supplied bythe middle superior alveolar nerve in approximately 50% ofindividuals.
The extraoral discoloration on the side of face had great psychological effect on the patient related to the duration of unaesthetic discoloration. The patient is usually very much concerned about the complication and might doubt the capability and experience of the dentist. The situation is embarrassing for the concerned dentist. So prior information, before injection of local anesthesia to the patient about the possible complication of posterior superior alveolar nerve block is very important to minimize the psychological effect of the complication if it occurs.
The swelling and discoloration of the involved region usually subsides in 10 – 15 days. The patient might also experience soreness and trismus. The patient should be advised to take analgesic, avoid any heat application which might increase the size of the hematoma due to vasodilatation, application of ice immediately after developing hematoma helps in minimizing the size by vasoconstriction and also have palliative effect. Ice packs 30 minutes per hour for the first 24 hours after surgery following which intermittent hot moist packs can be used to resolve the condition . Any dental treatment in the involved region should be avoided until symptoms and signs resolve.
Hematoma place pressure on tissues / wounds, decrease vascularity and increase tension on the wounds edges and also acts as culture media potentiating the development of a wound infectionso antibiotic therapy should be prescribed if the hematoma is large.
To prevent formation of hematoma during any nerve block, thorough knowledge of normal anatomy of that particular region is very important. The injection technique can be modified as dictated by the patient’s anatomy. The risk of hematoma formation during posterior superior nerve block is highest followed by the inferior alveolar nerve and mental/incisive nerve block. To minimize the risk of hematoma formation, use of short needle and minimum number of needle penetration into tissues should be considered.
The unaesthetic appearance due to the discoloration of the hematoma on the side of face have a great psychological effect on the well being of the patient and embarrassing situation for the dentist. The knowledge of this possible complication for the dentist and prior information to the patient about the same before injection of local anesthesia is very important which helps patient not to lose his/her faith of the administrator. The swelling and discoloration usually subsides in 10 -15 days.
What Is an Oral Hematoma?
— Stella, Arkansas
Halitosis, or bad breath, is a very common problem. There are both dental and medical causes for the condition. In looking for causes, I would first consider the obvious — that it is dental in origin. Below is a list of possible causes of halitosis:
- Poor oral hygiene without regular brushing and flossing
- Decay or cavities in teeth, which accumulate bacteria and cause a bad smell
- Caps or crowns on teeth that may be losing cement (“cement washout”), which can cause a bad taste or smell
- Eating certain foods that can lead to bad breath
- Bacteria on the tongue, which can be cleaned with a toothbrush or tongue scraper
- Lack of regular dental cleanings every three to six months to remove plaque buildup
- Acid reflux disease or GERD
These are some of the more common reasons why one may have bad breath. I would make sure you have a complete dental examination by a dentist and a full mouth cleaning by a competent hygienist. It is important first to rule out the obvious oral causes of bad breath. If every dental possibility is eliminated, I would then seek counseling with an ear, nose, and throat physician who can eliminate other causes like postnasal drip, diet, and acid reflux.
Q. 6 What can I do to get rid of my bad breath? I’ve tried everything, from scrubbing my tongue to brushing and flossing regularly. I chew gum and it doesn’t help! Do you have any other tips?
— Gilda, Florida
Bad breath, or halitosis, forms either in your mouth, which is where your digestive system starts, or farther along in your digestive tract — perhaps from acid reflux or the types of foods you eat.
Acid reflux occurs when partially digested food or digestive enzymes from your stomach come up into your esophagus, possibly burning the back of your throat. If you eat late at night and then go to sleep, or if you have a lot of alcohol, caffeine, or spicy, acidic foods, you’re at risk for acid reflux. The bad breath is caused by the partially digested food.
Also, it’s very common for people with poor dental hygiene to have a lot of bacterial plaque in their mouths. Bacterial plaque mixes with little bits of food and lingers in the mouth, potentially causing pocketing between teeth and gums, bone loss, and bad odor. One of the first signs that you need to clean your teeth more thoroughly is gums that bleed when you brush. If you are not brushing twice a day and flossing once a day, you are susceptible to bad breath. In addition, periodontal disease can cause bone destruction, gum destruction, and bad odor.
It is critical that you see your dentist and have him or her take a full set of X-rays and perform a thorough examination to make sure that you have no underlying periodontal disease, root canal problems, or cavities or decay in your mouth — all of which can cause bad breath.
Q7. I often get canker sores in my mouth. What can I do about this painful problem?
— Barbara, California
A canker sore (also known as aphthous stomatitis) is a painful condition that unfortunately affects upwards of 85 percent of the population at some time in their lives. These painful sores can occur in children as young as ten but tend to mostly affect adults in their 30s and 40s.
These small ulcers are red with white or yellow centers, and they may be preceded by burning or tingling in the mouth. This is followed by the appearance of the sore, which can last ten to 14 days and be quite painful, especially while eating or even talking.
The cause of these sores is not known (a malfunction in the immune system could be to blame), but certain factors are known to increase the risk of developing them. Family history plays a role, as does physical injury or irritation or emotional stress. Also, a chemical called SLS (sodium lauryl sulfate), which is commonly found in toothpaste, may cause the sores in some people.
You may be able to prevent these sores by avoiding irritants such as spicy foods, not chewing gum, and using a soft toothbrush. After they develop, minor irritations or small ulcers can be treated by gargling with salt water or applying small amounts of milk of magnesia directly to the ulcer. You can also take pain relievers such as acetaminophen or ibuprofen. Over-the-counter options like Orajel can also provide some temporary relief.
If the pain is severe, or many sores are present, a physician can prescribe other medications. These include antibiotics such as tetracycline and topically applied steroid creams. If the sores do not heal in two weeks, a visit to a doctor would be a good idea.
Learn more in the Everyday Health Dental Health Center.
The PSA nerve block
Insertion site: Height of the mucobuccal fold distal to the zygomatic process and superior to apex of the maxillary second molar. Angulations: Outward laterally at 45-degree angle from the midsagittal plane and downward 45-degree angle from the occlusal plane.
Dental hygienists routinely and comprehensively debride the challenging anatomy of the maxillary molar teeth. Anesthesia is frequently required especially for initial debridement procedures.
In fact, the maxillary molars are often the first to develop periodontal problems.1 The PSA block is preferred by this author when anesthetizing the maxillary molars because it reliably demonstrates a high success rate (greater than 95%)2 for profound and sustained anesthesia to the molar pulps and buccal periodontal and soft tissues with one injection, and because it is comfortable for the patient.
The alternative, supraperiosteal injections in the area, often requires multiple needle penetrations (three vs. one), more volume of anesthetic (1.8 mL vs. 0.9-1.8 mL), and usually provides a shorter duration and less profound anesthesia. When the PSA block is combined with the anterior superior alveolar (ASA) block using an infraorbital approach, often referred to as the infraorbital (IO) block, the entire maxillary arch on one side may be anesthetized (except palatal tissues).
When the PSA is combined with the anterior middle superior alveolar (AMSA) block, the entire hemimaxilla may be anesthetized (including palatal tissues).3 It is no wonder that dental hygiene programs require clinical competency for the PSA injection. According to a survey conducted by the author in November 2014, of the 95 responding dental hygiene education program directors (representing 39 states across the country), 95% required clinical competency for the PSA block injection.
Tips for Provision of PSA Block
1. 25-gauge short needle
2. Dry, topical, dry
3. Adequate retraction
4. Syringe barrel:
Outward 45 degrees from midsaggital plane
Downward 45 degrees from occlusal plane
5. Rapid penetration
6. Advance through soft tissue
16mm (normal adult skull)
7. Aspirate in three planes prior to deposition
8. Slow deposition
Respirate in same planeafter every 1/3 cartidge is dispensed
An important approach for providing the PSA block includes the insertion at the height of the mucobuccal fold distal to the zygomatic process and superior to the apex of the maxillary second molar and maintaining orientation of the syringe barrel outward laterally at a 45-degree angle away from the midsagittal plane and downward at a 45-degree angle away from the occlusal plane of the maxillary teeth4 (see Figure 1).
After assembling the proper armamentarium, prepare the patient’s tissues by drying the area of insertion, applying topical as directed, and drying the tissue again. The patient should be asked to partially open and slide the mandible toward the side of the injection. Retract the tissues both upward and outward to facilitate ease of injection. Adequate retraction is very important during the provision of the PSA so that both the angulation and depth of the needle may be observed. A 2X2 gauze may be helpful in keeping tissues dry so that adequate retraction will be maintained throughout the injection.
Resting the barrel of the syringe against the finger providing retraction can also provide additional stability for the syringe during advancement (see Figure 1). Establish a stable and safe fulcrum (extraoral or clinician’s body). Orient the 25-gauge SHORT needle (a 27 short may be used, but is not preferred) and the syringe barrel outward laterally at a 45-degree angle away from the midsagittal plane and downward at a 45-degree angle away from the occlusal plane of the maxillary teeth.
Insert the needle at the height of the mucobuccal fold distal to the zygomatic process and superior to the apex of the maxillary second molar. Advance the needle slowly, toward the target area—the PSA nerve as it enters the maxilla through the PSA foramina on infratemporal surface of the maxilla.2,5
Avoid depositing anesthetic solution before reaching the target. Advancement should not be uncomfortable for the patient as the needle should only be penetrating through soft tissues. Bone should not be contacted. If bone is contacted, the angle of the needle toward the midline is too great, and the needle should be withdrawn slightly and the barrel of the syringe brought closer to the occlusal plane and then re-advanced.2,5
For an adult skull, advance the needle 16mm (3/4 of short needle) and begin aspirations in 3 planes:
Aspirate at target
If negative, rotate syringe a quarter turn toward clinician and aspirate again
Finally, if negative, rotate syringe back to original position and aspirate again.5
After the consecutive negative aspirations, slowly deposit 0.8mL to 1.8mL (1/2-1 cartridge) of anesthetic over a minimum of 60 seconds. In her textbook, Logothetis recommends reaspirating, during deposition, in the same plane, after every ¼ cartridge is deposited.5
For approximately 28% of patients, the mesiobuccal root of the maxillary first molar is innervated by the middle superior alveolar (MSA) nerve instead of the PSA nerve.2 For these patients, a second injection, the MSA block, is required in order to innervate the mesiobuccal root of the first molar.
If anesthesia of the posterior palate is needed, the greater palatine (GP) block should be provided in addition to the PSA block. Often the palatal roots of the molars are also innervated by branches of the GP nerve, and provision of the GP block may be indicated to fully anesthetize those roots, particularly when there is furcation and root concavity involvement.5
When local anesthetic is deposited lateral to the target, some mandibular anesthesia may occur because the mandibular branches of the trigeminal nerve are located lateral to the PSA nerve. Patients may report some numbness of the tongue and/or lower lip.2,5
Common technique errors include the failure to maintain retraction and to maintain the 45-degree angle away from the midsagittal plane. Often, clinicians begin with proper technique, but subsequently relax retraction and close the angle to the midsagittal plane (allow syringe to move toward buccal aspect of teeth). This usually results in needle movement away from the target and/or insufficient advancement due to obscuring the view of the penetration site.
Some clinicians report that they avoid providing the PSA block due to the risk of hematoma (3%). Although the risk is not as high as with the IA or mental/incisive blocks which are 10-15% and 5.7% respectively,2 the hematoma which can result from the PSA block is the only hematoma that is visible extraorally.6 The risk of hematoma from a PSA injection can be minimized by using a short (to avoid over-insertion) 25-gauge needle, aspirating in 3 planes multiple times (to facilitate reliable aspiration) before and during the slow deposition of anesthetic.2,5-8
The PSA block is an important injection for dental hygienists to master and employ during pain control for a variety of reasons. It is safe, extremely reliable, and very effective when care is taken to follow proper technique. Since dental hygienists often treat wide areas of the mouth during one appointment, limiting both the number of penetrations as well as the volume of anesthetic by using nerve blocks, such as the PSA is prudent. The PSA block when combined with other injections which anesthetize wide areas, such as the AMSA and ASA blocks, promotes efficiency as well as safety and comfort for the patient.
LAURA J.WEBB, RDH, MS, CDA, is an experienced clinician, educator, and speaker who founded LJW Education Services (ljweduserv.com). She provides educational methodology courses and accreditation consulting services for allied dental education programs and CE courses for clinicians. Laura frequently speaks on the topics of local anesthesia and nonsurgical periodontal instrumentation. She was the recipient of the 2012 ADHA Alfred C. Fones Award. Laura can be contacted at [email protected]
1. Beemsterboer P. 2014 Periodontology for the Dental Hygienist, 4th ed; Elsevier.
2. Malamed S. 2013 Handbook of Local Anesthesia 6th ed; Elsevier.
3. Webb, L. The AMSA nerve block: Pair with the PSA nerve block for hemimaxillary anesthesia. RDH magazine.Aug 2017 Vol 37 No 8
4. Bassett, DiMarco, Naughton. 2010 Local Anesthesia for Dental Professionals; Pearson.
5. Logothetis D. 2017 Local Anesthesia for the Dental Hygienist, 2nd ed; Elsevier.
6. Malamed, S. Complications in local anesthesia administration. Dimensions of Dental Hygiene. Oct 2006. 4(10): 28-33
8. Freuen ND, Feil BA, Norton NS. The clinical anatomy of complications observed in a posterior superior alveolar nerve block.The FASEB Journal 2007. 21:776-94.
Complications following tooth extraction and oral surgery
- After tooth extraction, the tooth socket may ooze blood for a few hours. The patient should compress the extraction site by biting onto a gauze swab applied to the socket for 15–20 minutes. This is enough to stop normal post-extraction bleeding.
- The socket will heal through a secondary healing process. After the extraction, a blood clot will develop in the alveolar socket. The clot will turn into a fibrin mesh which will facilitate the formation of granulation tissue. Epithelium lined granulation tissue will grow from the bottom of the socket up towards the sides of the socket.
- Should the clot dislodge, the socket becomes susceptible to post-extraction alveolitis (dry socket), the clinical diagnosis of which is based on the following findings: increasing severe pain 2–3 days after the extraction, halitosis, the alveolar bone visible in the extraction socket, but no purulent exudate present. The incidence of alveolitis following tooth extraction is approximately 1–10%, and it usually involves the lower jaw. Its aetiology remains unclear; according to current understanding the ischaemic bony area necroses and causes local osteitis.
- The treatment consists of irrigation of the affected socket and packing it with a paraffin gauze swab saturated with iodoform. The pack should be changed every 1–3 days until symptoms subside. A iodoform-soaked haemostyptic gelatin sponge may also be used; removal is in this case not needed. Adequate pain relief must be ensured. Systemic antimicrobials are usually of no benefit, but they should, however, be prescribed should generalised symptoms develop.
- A tooth extraction may be complicated by the formation of a haematoma in the surrounding soft tissues. The haematoma may extend from the upper jaw to the eye socket and from the lower jaw to the neck. However, the haematomas are usually not this extensive. Extensive haematomas, accompanied by swelling, pose an infection risk and the prescription of a systemic antimicrobial is warranted.
- The amount of swelling is proportionate to the length of the extraction procedure as well as the degree of soft tissue stretching and trauma involved. Swelling will be the most severe on the day after the procedure.
- The patient may experience difficulties in opening his/her mouth particularly after the extraction of mandibular teeth and nerve block anaesthesia to the lower jaw. These problems may persist for several months and the treatment mainly consists of mouth opening exercises in order to stretch the associated muscles.
- The root endings of the upper molars are situated in the maxillary sinus, and extraction of these teeth may create an opening from the mouth cavity into the maxillary sinus. In such a case, the mouth cavity will become filled with air during the Valsalva manoeuvre. A small perforation will usually heal by itself, provided that a decent clot forms in the socket. It is important that the clot does not dislodge, and the patient should therefore be advised to refrain from blowing his/her nose vigorously for 3–4 weeks. If the perforation is large and does not close within 2–3 weeks, a surgical repair will be necessary and the patient should be referred to an oral surgeon.
- A tooth extraction will almost always be followed by pain of varying degree which starts 2–3 hours after the extraction, as the effect of local anaesthetic wears off. The pain will usually subside within 2–3 days.
- The pain can usually be alleviated with a peripherally acting anti-inflammatory drug. In more severe cases, a centrally acting analgesic may be prescribed.
Read full article of Complications following tooth extraction and oral surgery
Swelling after tooth extraction: how to remove and how long it will take?
One of the most common problems faced by patients after a tooth extraction is swelling of soft tissues near the tooth hole. Such oedema can occur during the extraction of any tooth, but often, the most prominent is in the removal of chewing teeth (molars), including wisdom teeth. We will also talk about this problem in more detail and discuss the most exciting questions:
· Whether it is worth worrying about if the gums, even the whole cheek, are very swollen near the hole after a tooth is removed;
· How to prevent the development of severe oedema without additional intervention;
· Accompanying symptoms should be considered very worrying to seek medical attention quickly from your doctor;
· How long the swelling usually lasts after the tooth is extracted and how exactly your situation fits the norm;
· If you misjudge the situation and bring the problem to coincidence, which complications may occur;
· And we’ll also look at what exercises will help a difficult opening of a mouth (usually observed after the forced removal of the lower wisdom teeth).
In which cases oedema often occurs after tooth extraction.
In order to understand how you can eliminate swelling after the tooth is extracted, first, it is important to understand the nature of oedema. Interestingly, many people who come to see a dentist surely forget that they came to the doctor with oedema, they wait for oedema to disappear first day after removal of a tooth. After all, the dental problem seemed to have disappeared, so why didn’t oedema disappear, it also seemed to have increased even more?
A swollen cheek or lip (even before tooth removal) may result from the development of periodontitis (acute stage), periostitis, or odontogenic osteomyelitis. Very few people come to the doctor with the neglected form of the tooth, manifested by the so-called “flux”. By its nature, flux is an inflammation process that is almost always localized in the root region of a neglected tooth located below the alveolar process or infectious origin jaw body.
When a tooth completely destroyed by tooth decay is left untreated for many years, it continues to slowly decay and inflammatory processes occur in the roots.
The body prevents the attack of infection for a while and limits the spread of the capsule-capsule – surrounding granuloma or cyst.
The following photo shows the extracted tooth with cysts in the roots:
However, the sources of immunity are not limitless and the balance of power may deteriorate under various conditions: overload on the tooth, concomitant disease (eg, ARVI), stress – all of which can trigger the spread of infection in the jaw tissue with the accumulation of purulent. And because of such oedema, the asymmetry of the face can be very pronounced.
Although the main problem during the removal of a tooth is eliminated, infectious focus and oedema can be felt for a long time.
In the meantime, it is noteworthy that the relief immediately takes place immediately after removal of a tooth: the sensation of explosion disappears, the swelling decreases, the pain stops. Once extracted with cysts on the diseased tooth roots, the person begins to live normally again (as the patients say).
A number of dentists sometimes work without an incision to reduce the marrow in the wound after an extraction. In this case, the symmetry of the swelling-induced face is restored onto a sterile gauze ball by removing liquids out of the gums. Yes, sometimes it is painful, but it is possible to reduce the swelling very quickly, the patient can see in the mirror how good everything is. Swollen face (cheek, lip) decreases 2-3 times by volume in about 5 minutes.
After removal of the roots of a tooth without granulomas, cysts and even without them, not every human being has an organism, but also copes rapidly with the infection that remains in the hole. No tweezers can remove millions of bacteria, both harmless and pathogenic, from the wound.
Once the tooth is removed, the wound is filled with a blood clot that should allow immune factors to deal with infection factors and initiate the safe healing mechanism of the hole. For many, this mechanism is triggered by a series of inflammatory reactions – as a result, often tooth extraction, pain, swelling, fever and other unpleasant symptoms are not often relieved on day 2, may even intensify to some extent and cause anxiety in the patient. Often this can be observed after the removal of the lower wisdom teeth: difficulty in their eruption, exacerbation of chronic periodontitis, periostitis, etc. In the mandibular teeth area, there are large volumes of loose tissues that are well-fed and innervated. Therefore, the inflammatory reaction herein is often accompanied by severe oedema, fever and pain, especially when swallowed. A completely plausible question arises: can a face swell if a calm tooth is removed? Indeed, not only is there a dental surgeon for decayed teeth, but it is also very strong when there is no infection of the roots.
For example, you can consider the following reasons:
· Due to violation of biting or injury to the cheek mucosa;
· Due to intervention in orthodontic treatment (eg, braces);
· Depending on the interaction with a successful prosthesis (for example, when an unnecessary root of a tooth or a mobile tooth needs to be removed);
· Or, in principle, at the personal request of patients who refuse to treat a tooth, this can also be saved.
In such cases, the swelling also occurs after the tooth is extracted, but is usually less pronounced compared to removing the teeth against the background of purulent exacerbation. However, even in this case, the wound may be infected by significant oedema, pain and fading of the mouth later, especially if the patient is mistaken to care for the hole. Below we will talk about these alarming symptoms. In the meantime, let’s see how you can prevent the development of severe oedema after tooth extraction and thus make the postoperative period more comfortable. And what mistakes should not be allowed?
How can you prevent the development of severe bloating after tooth extraction?
There are many techniques that do not allow you to swell your face after the tooth is extracted, the resulting edema will be small and will only affect the gums in the hole.
Attention should be paid to three main points that have a good effect on the complex:
- Cold on the first day after the tooth is removed;
· Hot, hard and spicy food as well as strong physical activity and warming (bath, sauna, steam room, solarium, hot bath);
· Medications to take (nonsteroidal anti-inflammatory drugs, antihistamines, sometimes – hemostatic)
To prevent severe swelling after tooth extraction, most dentists recommend cold application to the cheek area on the side where the hole is located. However, not all dentists recommend this method because they are aware that patients can perform the same instruction in very different ways.
As a result, in winter, snow can provide that cold effect: best, 1-2 minutes, one or more at the worst hour. For a limited time, not every dentist can tell the patient that it is a cold compress. That is, it is not necessary to freeze the face until it is whitened, but it is important that the skin has a mild effect. If there is a pack of frozen dumplings, if the towel is thin – wrap it in towel in several layers. Cold water bottle is the best option. Again, if the water is frozen, you must wrap it with a towel and remove the towel or change the water when the water becomes hot. Retention time – 15-20 minutes every 2 hours.
Cold as a local decongestant, it is certainly effective, but only with common sense and detailed instruction.
The use of cold is effective only on the first day after tooth extraction. The use of cold will be less effective on the second day.
The cold vessels narrow and reduce blood flow in the wound area, everything about warming the body contributes to the development of strong edema (hot food and drinks, physical activity, bathing, etc.)
It is quite possible to take a shower and wash your hair, but you should set the water to a temperature of about 36-37 ° C.
What else can prevent the appearance of edema after tooth extraction?
Patients suffering from cardiovascular system diseases should closely monitor blood pressure and reduce the medication recommended by your doctor. As a result, edema and hematoma occurring after tooth extraction in such cases are largely the result of alveolar hemorrhage against the background of suspended pressure. Stable blood pressure is a guarantee of comfort in the postoperative period.
As for drugs, there are many drugs that prevent significant edema and even reduce them, even if they have already occurred. They contain antihistamines. People know them first of all as antiallergic drugs, but they can also be called anti-edema.
When choosing a drug, when using it with other drugs, consider the contraindications to the use of the drug as well as its use (eg pregnancy, breastfeeding, childhood, various diseases, etc.). Consider how this antihistaminic drug in your condition will be effective and safe, consult your doctor.
The same applies to nonsteroidal anti-inflammatory drugs, hemostatic agents, glucocorticoids and other drugs that depend on how comfortable postoperative time is. These drugs should be taken under the supervision of a physician.
Despite efforts to reduce the severity of edema, it may still appear and cause discomfort. In particular, this occurs after removal of the affected wisdom teeth in the lower jaw. The post-traumatic inflammatory process, despite the efforts of the doctor and the patient, often leads to the appearance of quite pronounced edema, in connection with the anatomy and features of the location of the teeth of wisdom.
The following picture shows a polyurethane wisdom tooth:
Don’t panic now. Usually, swelling reaches a maximum level within 2-3 days after removal of a wisdom tooth, and here it is important to monitor the situation as a whole, not just a symptom. If you have a serious deterioration in your health (elevated values, even temperature increase for unbearable pain that does not respond to analgesics, suppuration or bleeding through the hole), you should immediately consult your doctor.
Now let’s give some information about the appearance after removing a bruise on the cheek, neck or chin.
Don’t panic when such a bruise appears, even if it looks bad. This is common after swelling of a common hematoma (especially in patients with arterial hypertension) after removal of the lower molars. First hematoma may have a bluish colour, after 3-5 days it becomes yellow and disappears completely without a trace. The emergence of a hematoma after tooth extraction does not indicate any complication or error of the dental surgeon, a common phenomenon.
Hematoma can also occur due to needles that puncture the gums during anaesthesia injection. To prevent unwanted wounds after anaesthesia, several dentists ask you to press the injection site with your hand for 1-2 minutes before removing the teeth. Some doctors believe that this is the remnant of the past: modern techniques working with imported anaesthetics do not run the risk of developing a large hematoma when vessels are injured. However, if there is a risk of hematoma due to the individual characteristics of the patient, the technique of “pressing the injection site” may be considered appropriate in our time.
Which symptoms may be edematous and worth visiting a doctor as soon as possible?
Although the abovementioned methods can significantly remove the oedema after the tooth is extracted, this is not yet a complete guarantee of a safe postoperative period.
The most common symptoms associated with oedema are:
- Increased body temperature;
- Deterioration of welfare;
· Pain (especially when swallowed, chewed, and even during speech);
Increased body temperature often occurs on the first day after tooth extraction. This is a normal reaction of the body in response to surgery, but only in this context: as high as possible in the evening (up to 38.5 ° C), and 36.6 or slightly higher in the morning (not more than 37.5 ° C). In this case, we can say that the body fights the inflammatory process and fights in normal mode. If more than one tooth is pulled at the same time, the body may respond more strongly.
In the photo below – fresh holes after removing two teeth at the same time:
Therefore, high fever for 1-2 days after removal should not be considered pathology, but should also be monitored twice a day (for example at 8 am and then at 8 pm). If the temperature is above 38.5 ° C or lasts more than 2 days and has high morning rates, this is a reason to consult a doctor.
The degree of health deterioration after tooth extraction depends largely on the individual characteristics of each individual organism. If the body is weakened against the background of other diseases, there are immune pathologies or older age, then the state of health may deteriorate significantly, and the help of a doctor will be required. After the examination, the doctor can only assess the situation and, if necessary, prepare a report for the patient to gain strength at home.
Some people are very “eager to fight” (to return to work as soon as possible because they do not want to spend a few days in the household). Lower the swelling quickly, if the hole hurts, swallow some anaesthetic pills and go! However, it is important to understand that the postoperative body needs time to heal. Failure to do so may result in a series of progressive serious complications.
The occurrence of severe pain in the background of advanced oedema is a frequent and perhaps the most unpleasant phenomenon, especially when the pain is not relieved by analgesics.
Physicians almost always give painkillers as a recommendation to cope with the painful period in the first days after tooth extraction. However, with the development of tissue edema, both loosening and painful pains may occur, which are not loosening and pain-relieving and are not able to cope on their own. 2-3 days after the development of acute pain and reception of the tooth against fever, severe swelling, bad breath and other alarming symptoms, you should immediately contact your doctor for help.
Oedema may be accompanied by difficulty in opening the mouth (usually observed when removing the lower wisdom tooth). Sometimes opening your mouth a few centimetres can hurt you. When swallowed as in the throat and on the one hand there is a strange sensation of pain. This is due to the anatomical location of the eighth teeth: the spread of oedema captures the chewing muscles of the jaw.
Improvement usually takes place within 3-4 days – opening the mouth decreases pain and other symptoms (if any) slowly disappear, meaning positive dynamics are determined. If this does not happen and you are still having difficulty opening your mouth or getting worse, you should consult a doctor.
Rarely, neurological problems occur – in particular, paresthesia, ie, loss of sensation in the area of the extracted tooth, as well as in the lip, cheek, and jaw area. This is most commonly the case for the removal of the lower wisdom teeth (octets), less frequently the lower sixth and seventh teeth.
The cause may be overly invasive at the site of intervention that damages the mandibular nerve. In the last case, loss of sensitivity is automatically eliminated as oedema (hematoma) in the area of the extracted tooth decreases.
The conditions for restoring the damaged nerve trunk can take quite a long time: 2-3 weeks to 1-2 years, depending on the severity of the violation. However, it is possible to speed up this process a little bit – it is important to consult a doctor over time, determine the cause of paresthesia and start initiating procedures (physiotherapy) on time.
How long does the swelling usually last after the tooth is extracted?
If the doctor has not paid enough attention to the patient after the tooth has been extracted, and has not informed him about the basic recommendations for looking at the hole (this is usually the case in polyclinics), even if minor problems occur, patients often have a fear of panic. This is especially true for the appearance of oedema and severe pain: because of the stress experienced after severe tooth removal, the patient is afraid to go back to the doctor, does not know whether the current situation is dangerous and what to do.
Therefore, in this case, it is useful to know how long the swelling of the tooth extraction area lasts on average and how long other unpleasant symptoms reveal themselves. According to research, oedema can be up to a maximum of 2-3 days, and this deviation from the norm, as well as a slight increase in body temperature, some deterioration in the general situation, such as the emergence of pain appeared to occur. These are all natural and regular manifestations of the post-traumatic inflammatory process. So what to do – should something go uncomfortable after the tooth is removed, should you go to the doctor immediately or wait? Answer: never intervene in reinsurance, you should not expect the swelling to spread around the neck or take half the face (sometimes the eyes do not even open due to swelling). If there is anything uncomfortable, at least it makes sense to call the doctor and ask for advice or make an appointment for an examination.
However, when there is a clear positive tendency (oedema is insignificant and if it starts to occur for 3-4 days, almost no temperature, severe pain, painless mouth opening, paresthesia, bad breath) it is understandable that you do not go regularly every two days.
The average postoperative period is 3 to 10 days. Main symptoms (oedema, pain) can be pronounced severely for 3-4 days. Usually, all unpleasant phenomena pass in one week and in difficult situations – in two weeks. And the main rule here is not self-treatment without advice and control from the dentist.
About possible complications
Now, let’s look at the cases where oedema is associated with possible complications after extraction. In such cases, oedema does not diminish until the underlying disease disappears.
Let’s start with the most common complication, alveolitis. Alveolitis is a result of good infection, ie simply well-inflamed. The degree of oedema may be greater. Often, during alveolitis, gingival pulping occurs around the hole of the extracted tooth, sometimes develops under reinforcing pressure.
It is not worth treating alveolitis independently, you need to consult a doctor. It is important to understand the main causes of this pathology:
- Parts of a tooth or its root may remain in the hole;
- A granuloma or cyst remains at the bottom of the well;
· The so-called “dry hole” (ie, without a blood clotting that protects it);
- Swallowing food remains and rotting there;
· A major violation of doctor’s recommendations (drilling a hole with toothpicks, warming, etc.)
A more serious version of the complication is limited osteomyelitis of the tooth cavity. In rare cases, when alveolitis is neglected or treatment fails, purulent-necrotic inflammation of the bone walls of the hole develops – osteomyelitis. Symptoms are strongly pronounced: a swinging pain may occur in the hole, may extend to adjacent teeth, the person cannot normally sleep, cannot eat. The temperature reaches high values, develops strong oedema, moves on the gums surrounding adjacent teeth, and also on the soft tissues of the face. The fetus smell coming from the mouth starts to disturb the person, there is an increase in lymph nodes.
In such cases, as a rule, special assistance is required for jaw surgery. Possible complications after removal of the tooth include an abscess and phlegmon.
An abscess is a limited inflammation and phlegmon is common (and may even threaten the patient’s life). Often, with such serious complications, children go to surgical surgeons.
In a child (especially weak), a few days may develop from oedema to abscess and phlegmon. Unlike adults, children do not always create protection factors against fulmine infection. Therefore, parents should remember that the occurrence of strong pronounced oedema after removal of a tooth (or even primary teeth) is a reason to ring the alarm and seek medical attention immediately.
Special exercises to open the mouth after removal of molar teeth
After removing a molar tooth (usually in the lower jaw, especially the mental tooth), many people are seriously concerned about the fact that it is impossible to open their mouths normally. Problems with opening the mouth (trism) can be observed both in the background of apparent oedema and without it. Sometimes the mouth fails to open even 1-2 centimetres, which creates big problems not only with speech but above all with food intake.
What can you do to quickly approach your normal state? First of all, you should not guarantee that the removal of oedema will provide a successful solution to the problem of opening the mouth. If the trism is “fresh,, the jaw should be developed, otherwise surgical intervention may be required. The conditions for disappearance of trismus are entirely individual – from one week to 1-2 months (depending on how difficult tooth extraction is).
From the first days after tooth extraction, frequent and small chewing movements with the bubble gum accelerate the development of a joint, even against the background of the inflammation process in the chewing muscles. For more complex exercises, you should consult a dentist who is interested in TMJ diseases. Physical therapy for the maxillofacial region – you will get therapeutic physical culture.
A few examples of exercises to improve mouth opening:
1. Slowly opening the mouth (as far as possible) at a slow pace in a a position where the head is thrown back, without muscle tension;
2. With a little effort by lowering the jaw and pushing it forward;
3. With an open mouth (as far as possible), raise the sound by pronouncing the letter “a” aloud;
4. Gently pulling the lower jaw down with both hands is done using the jaw of the head by throwing the head backwards.
The change in tension and relaxation of the muscles of the maxillofacial region has a significant therapeutic effect with the correct and systematic performance of each exercise. In severe cases, especially when trisism persists for several months or more, mechanotherapy is required – a series of exercises using special devices. Often, mechanotherapy is performed in conjunction with physiotherapy procedures (electrophoresis, ultraviolet radiation, thermal mouth baths, paraffin treatment and others).
I have developed an instrument which has been successfully used on a number of occasions, avoiding more aggressive interventions. By using a small piece of Surgicel (haemostatic cellulose4) wrapped around a Toothette (a pink sponge on a stick used to provide moisture to patients who are unable to swallow), the haemostatic matrix can be delivered directly to a bleeding socket as it clings well to the sponge (Fig. 1). The sponge itself can then be easily bitten down on by the patient and moulds to the socket, in contrast to the uncomfortable bulkiness of gauze. An additional advantage of the Toothette is that it can be safely placed in the wound by the patient or clinician with the plastic handle held firmly in the adjacent teeth or lips to ensure the haemostatic agent is kept in place. This is an improvement of a previous design where Surgicel was wrapped around a cotton roll and maintained in the wound with some difficulty. Both products are cheap and readily available in EDs, and when used together provide an effective tool for stopping post-dental extraction haemorrhage.
A Toothette with a the Surgicel in place
The use of modern anesthetics appears to be safe, although a maximum care must be taken when applying an appropriate anesthetics, In addition to that an adequate technique should be used. This implies also the administration of a minimal but effective dose for a certain dental treatment. When a local anesthetic is applied, either infiltration or block, it is of utmost importance to perform aspiration (1). In this way, systemic activity can be avoided. Simultaneously, local activity is being increased. It is a well-known fact that the posterior superior alveolar nerve block and the inferior alveolar nerve block are accompanied with a higher incidence of positive aspiration (4). Moreover, with positive aspiration we can highly expect that a local anesthetic will be administered intravascularly. However, negative aspiration dose does not necessarily mean that the local anesthetic was not injected into the blood vessel. Hematoma formation as a complication of local anesthesia is a result of venous or arterial laceration. In cases of traumatic artery rupture, a hematoma appears instantly and this is an embarrassing situation both for the patient and for the dentist. An elevated intra-arterial pressure causes effusion of blood into the surrounding soft tissues. The size of hematoma depends on the density and compactness of affected tissue, while spreading of the hematoma ends at the moment in which the pressures of the tissue and the pressure in the vessel equalize. When a vein rupture is concerned, hematoma does not necessarily occur. In the presented case it can be said with great certainty that arterial laceration was the issue. From the anatomical point of view, one might speculate that either a branch of upper labial or a distal branch of the infraorbital or a proximal part of angular vein artery was ruptured. In similar cases, we should not completely eliminate a hemangioma as an underlying etiology. The latter was excluded both by clinical examination and panoramic imaging analysis after the hematoma subsided. Therefore, we concluded that there was no need for additional radiological examination such as computed tomography and angiography. Moreover, hemophilia as an underlying cause has also been excluded and the patient was not sent for further laboratory testing. In the end, the most important part is to recognize the symptoms and signs and to start the treatment without delay. The treatment includes compression of the affected site with ice packs and the antibiotic therapy (5). By doing so, a further advancement of the hematoma and its infection are prevented. From the available medical documentation it can be seen that the patient did not receive adequate treatment. In the early stage it was thought that some local allergic reaction occurred. Later on, massage therapy using a heparin cream was recommended without prescription of antibiotic in the first 5 days. At that stage it was clear that infection had already taken place. Fortunately, appropriate but delayed treatment was ultimately undertaken and the situation was resolved.