Tooth extraction swelling. –

Post-extraction edema.

Edema (swelling) is a normal postoperative event following dental surgery, like having a tooth pulled. And while the level of swelling that forms will vary between patients and procedures, there is a standard set of remedies used to minimize and manage it.

What steps does the management (prevention and treatment) of swelling involve?

For the most part, a patient’s care is divided into two phases:

• The initial treatment stage 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 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 area of swelling.

This page explains the steps involved with both.

Post-extraction tissue swelling – What’s normal?

Characteristics and guidelines –

a) Does swelling always occur?

No, but any tooth extraction does have the potential to trigger postoperative edema. It’s part of your body’s normal response to experiencing trauma.

Tissue inflammation.

• A part of this process involves the movement of fluids that transport white blood cells into the area of the traumatized tissues. (These cells play an important role in the healing process to come.)
• It also stimulates blood circulation to the area. (This is an important transport method for the nutrients and types of cells that are necessary for tissue repair.)

▲ Section references – Sortino

b) What type of extractions are most likely to trigger post-op swelling?

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

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

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

• The swelling that forms can be expected to gradually increase in size, until it ultimately peaks 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.

• By day 4, that swelling that has formed should start to subside.
• From that point on, it should continue to slowly diminish, with full resolution usually occurring by day 7 following the patient’s procedure.
• 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 your dentist. (Postoperative infection might be suspected. What are the chances?)

▲ Section references – Susarla, Motamedi, Koerner

d) Where will the swelling occur?

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 (like surgical extractions, or removing several teeth), 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 lower eyelid.
• 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.)

e) 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 jawbone, 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 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.

Treatment and control of post-extraction edema.

Stage 1: Minimizing the total amount of swelling that forms.

a) Cold (ice) application.

You can help to minimize the amount of postoperative swelling that forms by applying cold packs to the outside of your face in the region of your extraction site. This process can be started immediately following the completion of your surgery.

Here’s an outline of a way that this technique can be implemented.

a) Select a cold source.

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

  (Your dentist may be interested in offering 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.

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 amount of swelling that’s expected is 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.

▲ Section references – Sortino, Fragiskos, Koerner

How does post-extraction cold/ice therapy minimize swelling?

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 for post-op swelling that you the patient has an opportunity to perform.

▲ Section references – Sortino

b) An additional remedy for minimizing swelling.

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.

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

Swelling that forms in response to the tissue trauma created during the extraction process can be expected to peak 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.

Heat application.

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.

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 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.

How does heat therapy work in reducing post-extraction swelling?

1. The warmth of the heat compress causes the blood vessels in the area to dilate (become enlarged).
2. 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).
3. As a result, the reduction of your swelling occurs more quickly.

It’s important to pay attention to your progress.

As mentioned above, swelling typically starts to resolve on its own by about day 4 after your surgery. If 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 your dentist also.

Back to our post-extraction complications page. ►