How to manage swelling following a tooth extraction. –

Post-extraction swelling.

Swelling (more formally termed “edema”) is a normal postoperative tissue reaction in response to having surgery, like having a tooth pulled. And while the amount that forms will vary with each patient and the type of procedure they’ve had, there is a standard set of remedies used to minimize and manage this complication.

The steps of treating post tooth extraction swelling. – Prevention and management.

Treatment is performed in two stages:

• The initial treatment phase takes place during the first 24 to 48 hours following your extraction. Its focus is centered on minimizing the total amount of swelling that forms, primarily by way of placing cycles of cold (ice) applications on your face in the area of your surgery.

• The second phase (starting 48 to 72 hours after your extraction, and then continuing on for the days beyond) addresses reducing the swelling that has occurred as quickly as possible via the use of cycles of moist heat applications to the affected area.

Here’s a link to where this page’s section covering What to do about swelling starts off. Then, following those instructions, we provide tips and pointers about how those steps are best carried out.

Then, the remainder of this page contains background information that explains why you’ve experienced what you have. It covers …

Background details about post-tooth extraction swelling.

• Why it forms.
• Does it always occur?
• Factors likely to trigger swelling.
• Swelling timeline.
• How much is normal?
• Where will it form?

Treatment and control of post-extraction swelling. – What to do.

a) Steps for minimizing post-extraction swelling.

• Place ice packs on the outside of your face in the area where your teeth were removed.
• Leave the packs in place for 15 minutes and then off for 15 minutes.
• Continue these alternating on-off cycles of cold application for the remainder of the day.

FYI: You’ll get more effective results via the immediate use of ice packs following your surgery.

Here are detailed instructions about best practices for Cold Therapy.

b) Steps for bringing down post-extraction swelling.

Once your swelling has reached its maximum peak (usually 2 to 3 days following your surgery) …

• Apply warm, moist heat packs on the outside of your face in the areas where swelling has formed.
• Leave them in place for 20 minutes and then off for 20 minutes.
• Continue these alternating on-off cycles of heat application multiple times throughout your day for the next 1 to 2 days.

Here are detailed instructions about best practices for Heat Therapy.

How long does swelling last after a tooth extraction?

Normal post-surgical edema should show some evidence of starting to come down by about day 4 following your procedure. If instead at this point it remains the same or has increased, you should report this fact to your dentist. Swelling that hasn’t fully subsided by day 7 should be reported to them too.

More details: Post-extraction Swelling Timeline.

What other steps do you need to take with your extraction site while managing its swelling?

During the same time frame when dealing with edema may be necessary (days 1 through 7), your body will be in the process of transforming your surgical site from an open bleeding wound to a state where its healing process is substantially underway. (Here’s a link to our page that outlines the post-extraction Healing Timeline.)

To assist this transformation, your dentist will give you a list of important aftercare instructions to follow. (We cover this subject in detail on these pages: Extraction aftercare instructions – The first 24 hours. Next day & beyond. )

In short, here’s a breakdown of steps you’ll need to take and how they may impact your need to perform cold or heat applications.

Days 1 and 2.

These are the days during which Cold Therapy is implemented in an attempt to minimize the amount of swelling that forms.

Needed aftercare events and activities include:

• During your first hour post-op, your dentist will have you bite on the gauze pad they have placed over your surgical site. Doing so aids with blood clot formation.

  If prolonged or excess bleeding becomes a problem, this step is repeated (preferably using a moistened tea bag, a source of the astringent tannic acid, instead of gauze) until the bleeding is controlled. Cold/ice applications will in no way interfere with following these instructions.

  Additional aftercare directions will include: No spitting, do not rinse, do not use a straw, do not explore your extraction site with your tongue, and avoid hot liquids (soups, hot beverages). All of these tend to dislodge blood clots.

• The local anesthetic used to numb your surgical area will wear off during your first few hours post-op and normal sensation will return. It’s during this loss of numbness when you may first notice discomfort and begin to take pain medication.

  If the prescribed pain medication chosen for your case is a narcotic, be aware that taking it may affect your behavior or induce drowsiness, which may interfere with performing your cold applications appropriately. (Excessive duration would be a concern.)

  When adequate, the use of (non-narcotic) OTC pain relievers (acetaminophen/Tylenol, ibuprofen/Motrin/Advil) avoids this concern.

• It’s important to clean your teeth (brush and floss) but steer your efforts away from your extraction site for fear of disrupting it. As swelling forms, performing effective oral hygiene may become increasingly difficult. Just do your best.
• On your day of surgery, you’ll need to take it easy, rest, and restrict your activities. Doing so provides the perfect opportunity to perform regular cycles of cold therapy.

Related page: How much Time Off should you take after an extraction?

Days 3 through 7.

These are the days during which Heat Therapy might be carried out to bring down swelling more rapidly.

• If at this point you’re still taking prescribed pain medication (narcotics), keep in mind that they may affect your judgment, behavior, or induce drowsiness and therefore interfere with appropriate heat application (too hot, left on for too long).

  By this stage in the healing process, switching to (non-narcotic) OTC pain relievers (acetaminophen/Tylenol, ibuprofen/Motrin/Advil) typically proves adequate.

• During this time frame, you’ll start to return to normal activity. However, if your face is still swollen, you may not want to be too public.

• As the healing process progresses, you’ll be able to brush and floss the teeth immediately adjacent to your extraction site. But if you’re swollen, doing so may still be difficult and elicit tenderness. Until you have better access, your cleaning efforts may provoke some slight bleeding that’s discovered in your saliva.
• During this time frame, normal healing is characterized by a gradual reduction of edema and pain. If you find it differently, you should advise your dentist. These may be an indication of a developing dry socket or infection.
• Sticking with softer foods during the early days of your postoperative period makes a good choice (e.g. yogurt, mashed potatoes, smoothies, etc…). It also makes eating easier if your face and mouth have become swollen.

Specifics about how to perform cold and hot treatments.

Treatment phase 1: Minimizing the total amount of post-extraction swelling that forms.

a) Tips and pointers for the way Cold Therapy (ice application) should be implemented.

DIY ice pack ideas for minimizing post-extraction swelling.

• Ice cubes placed in a disposable surgical glove or ziplock bag. (You may be sent home with this setup.)
• Store-bought packages of frozen vegetables (corn, peas, etc…).
• Place corn syrup, dishwashing soap, salt water, or uncooked rice in a ziplock bag and then freeze it.

a) Ideas about the kind of cold pack to use.

• You might simply use a baggie or surgical glove that’s been filled with ice and tied shut.

  (You may be offered this kind of setup at the end of your appointment so you can begin your cold therapy immediately.)

• You might have (or would like to own) a reusable device, like a hot/cold bag or “cold pac.”

  (Some cold pac products are sized and shaped specifically with dental application in mind. Also, some may have a design or come with strapping that can help to hold them in place against your face.)

• A bag of frozen vegetables, like corn or peas bought at your local store, can even make a good choice. As a plus, its loose bean-bag nature will easily conform to the shape of your face.

b) Wrap the cold source you have chosen in a dishtowel.

This step helps to protect your face from exposure to extreme cold.

Techniques for minimizing post-extraction swelling formation.

• During the first 24 hours post-op, consider applying cycles of ice/cold therapy during waking hours.

  Make sure to follow directions and precautions. Avoid creating a temperature extreme.

• Strive to keep your head elevated, even when reclining.

  Doing so helps to minimize head blood pressure levels, and therefore helps to reduce the amount of post-op swelling formation.

c) Application of the cold pack.

• Hold your cold source firmly against the outside of your face, in the region directly adjacent to where your tooth has been pulled.
• Apply the cold pack for 15 minutes. Then, remove it and leave it off your face for 15 minutes. (15 minutes on, 15 minutes off.)
• If you’ve had teeth removed on both sides of your face, apply the ice pack first to one side and then the other (15 minutes each).

d) Treatment time frame for cycles of cold application.

• With routine extractions where the level of edema that forms is expected to be just minimal, application cycles performed over the 4 to 6 hours following your procedure are usually sufficient. (Fragiskos)
• With surgeries where a higher level of swelling is anticipated or noticed, it’s common that cycles are continued to a point 18 to 24 hours post-op (waking hours only).
• Beyond 24 hours, this technique becomes less and less effective. Dentists vary in their opinion (so ask yours) but cold treatment is typically terminated somewhere in the range of 24 to 48 hours after your surgery took place. (Koerner)

e) Important precautions.

The purpose of using on/off application cycles is that it creates the beneficial effect of this treatment (explained below) while minimizing the potential for damage to the tissues in the region from the effects of cold. (Sortino)

Keep in mind that on the day of your extraction you may still be numb. So you must be careful not to create a temperature extreme that you might not be aware of.

Cold application should only be performed during waking hours, so the cyclical on/off nature of the treatment can be maintained.

▲ Section references – Sortino, Fragiskos, Koerner

FYI: How does post-extraction cold/ice therapy minimize surgical edema?

1. The cold environment created by an ice pack causes the blood vessels in the area to constrict (become narrower).
2. This constriction in turn reduces the total volume of fluids that can be transported by and ooze out of the vessels into the surrounding tissues.
3. As a result, a lesser amount of swelling forms.

Does cold/ice application therapy really work?

Surprisingly enough, not all research studies confirm the effectiveness of ice application in reducing post-extraction edema (Sortino). In response we will simply state:

• It’s rare that this remedy isn’t included in a dentist’s list of postoperative instructions, implying that the majority of clinicians feel it is an effective measure.
• This is essentially the only preventive measure that you (the patient) have an opportunity to take.

▲ Section references – Sortino

b) Additional steps to take to minimize postoperative edema.

Positioning your head so its blood pressure is slightly reduced can help to minimize the amount of swelling that forms.

• The general idea is to keep your “head above your heart.”
• As opposed to lying down, sit (or recline) upright.
• When lying down, elevate your head using 2 or 3 pillows.

Treatment phase 2: Bringing down the swelling that forms as rapidly as possible.

a) Tips and pointers for the way Heat Therapy (moist heat application) should be implemented.

Swelling that forms in response to the tissue trauma created during the extraction process can be expected to reach its maximum around 2 to 3 days after your surgery (48 to 72 hours). Once this point has been reached, you can help to bring it down more quickly via the application of warm compresses.

DIY hot pack (moist heat) ideas for bringing down post-extraction edema.

1. Choose a heat source – a) Microwave a damp towel. b) Microwave a sock filled with uncooked rice.
2. Wrap the heat source in a moist dishtowel.
3. Test the heat level before applying.
4. Reheat as is necessary.

a) Select a heat source.

A hot water bottle, moistened towel, or a heat pack purchased from your pharmacy can be used.

b) Treatment precautions.

The goal is to gently warm up the swollen area, not to burn or scald it. So, manipulate the temperature of your heat source accordingly.

• Moist heat will be less irritating to your skin. So wrap your heat source in a lightly moistened dishtowel.
• Lubricating your skin with petroleum jelly can help to minimize irritation too.

Bringing down post-extraction swelling.

• 48 to 72 hours following your extraction (meaning day 3 or 4 post-op), moist heat applications can be begun.
• Apply in cycles of 20 minutes on, then 20 minutes off.
• Perform several cycles per treatment.
• Repeat treatments several times throughout your day’s waking hours.
• Expect some reduction in swelling each day. If not observed, advise your dentist.

c) Application.

• Hold the heat compress against your face in the region of the swelling.
• Leave it in place for 20 minutes, then remove it and leave it off for the next 20. (20 minutes on, 20 minutes off.)
• Repeat this routine for several cycles, multiple times throughout your waking day.

d) Treatment time frame.

This technique shouldn’t be used until that point when your swelling has finally reached its peak, which is generally considered to be 48 to 72 hours after your extraction

That would typically mean starting this process on day 3 or 4 after your surgery (Koerner). Dentists vary in precisely what they recommend, so you’ll need to check with yours.

This technique can then be used over the following days as you feel is required, until your swelling has resolved. Remember, this process doesn’t bring your swelling down immediately, only more quickly than it would have otherwise. It may still take several days.

FYI: How does heat therapy work in reducing post-extraction edema?

• The warmth of the heat compress causes the blood vessels in the area to dilate (become enlarged).
• While dilated, the blood vessels are able to carry away the fluids that have caused your swelling more efficiently (a greater volume of liquid per unit of time).
• As a result, the reduction of your swelling occurs more quickly.

A guide to post-tooth extraction edema.

a) Why does swelling form?

Your body’s response to experiencing trauma, like that associated with having a tooth pulled, is referred to as an “inflammation reaction.”

• A part of this process triggers the movement of fluid that transports white blood cells into the traumatized tissues. (These cells will play an important role in the healing process to come.)
• It also stimulates blood flow to the traumatized area and increases blood vessel permeability. (This increased flow and fluid leakage from blood vessels is an important transport method for the nutrients and types of cells that are needed in the affected area for tissue repair.)

Both of these actions result in the accumulation of fluid in the traumatized tissues, with the result being the formation of edema (swelling).

▲ Section references – Sortino

b) Does swelling always occur after having a tooth pulled?

No, while the formation of edema is a normal reaction to experiencing surgical trauma, the level to which this response takes place can be quite variable.

In some cases (like impacted wisdom tooth removal), the amount of enlargement that develops may be noticeable, possibly even significantly so. With other cases (simple, routine extractions), the effect may be insignificant and essentially undetectable.

Why do some extractions result in noticeable swelling and others don’t?

There’s a wide range of factors involved. Many of them pertain specifically to the patient (genetic factors, age, health status, health conditions, etc…)

Additionally, it’s generally accepted that longer, more difficult, or more extensive tooth extractions result in greater surgical trauma, and therefore the patient experiences a greater amount of postoperative edema.

Extraction characteristics frequently associated with post-op swelling.

• Extensive soft tissue manipulation, including raising a flap.
• A need to expose or remove bone that surrounds the tooth.
• Extended procedure duration.
• Elevated degree of difficulty of the extraction process.

c) What kind of extraction procedures are most likely to trigger post-op swelling?

As a rule of thumb, comparatively easier, less involved extractions generally result in less (frequently negligible) tissue swelling. That’s because a determining factor in the amount of edema that ultimately occurs is the level of trauma that’s been created during the surgical process.

Examples.

Extractions that include the following factors tend to create a comparatively higher level of surgical trauma, and therefore a greater level of postoperative edema.

• Extensive soft tissue manipulation – The more a dentist must work with and handle the soft tissues that surround the tooth being removed, the greater the level of surgical trauma that’s created.

  For example, the tissues might need to be incised and reflected back out of the way (Raising a tissue flap. How that’s done.) so the dentist has the access they need to the tooth and/or the bone surrounding it. This step is typically required with impacted wisdom teeth extractions.

  FYI – Poor procedure planning can result in tissue bruising, stretching, or tearing. The foresight of raising a flap helps to avoid these sources of trauma and therefore can help to minimize the level of post-op swelling that forms.

• Bone tissue removal – In some cases, like with broken teeth or impacted wisdom teeth, some of the bone tissue that surrounds the tooth must be trimmed away before it can be accessed and removed.

  Doing so creates a greater level of surgical trauma, as compared to extractions where this step is not required.

  FYI – Factors like the manner in which the bone is handled, trimmed, and the duration it remains exposed all contribute to the overall level of procedure trauma that’s created and therefore potential for post-op swelling.

• Extended surgical time – Longer procedure times generally correlate with a higher level of surgical trauma being created, and therefore a greater potential for the development of post-op edema.

  A myriad of issues can influence (lengthen) this factor including inadequate case evaluation and/or procedure planning, comparatively more difficult extractions, the skill level of the dentist, and patient cooperation.

▲ Section references – Koerner, Bello

• The extraction’s level of difficulty – Closely related to each of the issues above is simply the overall level of extraction difficulty associated with the tooth (both anticipated and actual). That’s because this factor will then dictate what takes place during the patient’s procedure (tissue flap, bone removal, extended procedure time, etc…).
• As evidence, it’s been shown that the comparatively more difficult wisdom tooth impaction types ‘disto-angular’ and ‘horizontal’ are associated with a higher degree of post-op swelling than the comparatively easier ‘vertical’ type. (Impaction classifications. Pictures | Diagrams) Of course, that only makes sense.
• Some studies have found that the degree of postoperative swelling is greater in females.

▲ Section references – Bello, de Santana-Santos

d) What’s the normal course of events with post-extraction swelling?

When it occurs, what you experience should lie within the following guidelines:

Tooth extraction swelling timeline.

1. The swelling that forms can be expected to gradually increase in size until it ultimately reaches its maximum peak at a point 2 to 3 days (48 to 72 hours) following your procedure.

   In some cases, the swelling that forms may not be readily apparent until the day following the person’s surgery. The area of swelling may show signs of bruising. Possible variations.

2. By day 4, that swelling that has formed should start to subside.
3. From that point on, it should continue to slowly diminish, with full resolution usually occurring by day 7 following the patient’s procedure.
4. Note: On the 4th day, if your swelling hasn’t begun to subside, or has shown evidence of increasing, you should contact your dentist so they can determine if an underlying problem exists. Swelling that persists beyond 7 days should also be evaluated by them. (Postoperative infection might be suspected. What are the chances?)

▲ Section references – Susarla, Motamedi, Koerner

e) Where will the swelling occur?

Generally speaking, the edema that forms will be in the soft tissues directly adjacent to your surgical area. However, larger amounts of swelling will involve ever more distant tissues.

Greater amounts of diffuse postop facial swelling may occur after more involved surgeries.

Greater amounts of diffuse postop facial swelling may occur after more involved surgeries.

• With relatively atraumatic cases (routine extractions where the tooth was removed without much difficulty using conventional instruments and technique Here’s how., and therefore just minimal tissue trauma has occurred), only the inside of your cheek immediately adjacent to your surgical site may show any sign of fullness or enlargement.
• With more difficult procedures surgical extractions, removing multiple teeth, removing impacted wisdom teeth (the caliber of procedures frequently performed by an oral surgeon), the amount of swelling that occurs may be more extensive. It may extend into the side of your face, into your neck, or with upper extractions even up to your eye.
• Post-extraction swelling related to surgical trauma will only occur on the same side of your body as your surgical site. (For example, having a back tooth pulled on the right side wouldn’t be the cause of tissue enlargement on your left side.)

f) How much swelling can you expect?

The amount of post-extraction edema that forms is basically a function of the amount of surgical trauma created during your procedure, your body’s reaction to it, and the mitigating effects of any preventive steps that you have taken (see below).

That, of course, means that no one can know for certain how much will occur. But as general guidelines, here’s an idea of what you might expect.

• With routine extractions – If the tooth you’re having removed is reasonably intact and has a relatively normal positioning in your jaw, it’s likely that your dentist will be able to tease it out without too much difficulty using conventional methods and instruments. Extraction techniques.

  If so, you may not experience any significant amount of swelling at all (this is probably the norm for most extractions). Or if you do, it would be common that it’s just a minor amount and therefore easily managed.

• With difficult extractions – Some teeth turn out to be surprisingly difficult to remove, necessitating that the dentist either wrestle with them more forcibly or for a longer duration than is ideal. Or must transform the procedure into a surgical one (where a gum flap is raised and bone tissue is removed). What that entails.

  Similarly, teeth that are extensively decayed, broken, or break during the extraction process and therefore are difficult to access and/or manipulate may also require a surgical procedure.

  These types of events tend to add to the overall level of surgical trauma created. And in response, mild to moderate swelling may form.

• With impacted teeth – Extracting impacted teeth (like wisdom teeth) typically requires reflecting back the overlying gum tissue and removing (sometimes significant) quantities of bone tissue.

  It would seem fairly unrealistic not to expect at least some, possibly quite noticeable, swelling after having one removed. The extraction of lower impacted wisdom teeth frequently is associated with substantial swelling.

Back to our post-extraction complications page. ►