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Another Sinus Perforation – Did My Dentist Treat it Right?

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Hello Dr Hall,

First off I would like to thank you for sharing your time and knowledge. Today I had 12 teeth extracted. Upon removal of an upper molar, my sinus was perforated. The dentist put a compound in to increase blood clotting. Immediately I was able to breath quite easily through the perforation. Will a perforation allowing air through easily heal properly? I was prescribed a 10-day antibiotic to help prevent infection. I am also not currently experiencing any real pain or discomfort. Kinda strange while normal at rest breathing I feel the air in my mouth. I am currently using gauze to apply pressure although I have no bleeding. Any information you can offer will be greatly appreciated. Thank you for your time.

– Robert L.

(see Dr. Hall’s response below)


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Robert,
I don’t want to paint myself as the country’s greatest expert on sinus perforations, though I’m getting a lot of questions on this. I had only had this happen to my patients a handful of times as I was practicing, and I followed the procedure I was taught. I packed the socket with gelfoam—a resorbable sponge that assisted in the retention of the blood clot and its conversion into replacement bone, and then I pulled some of the gum tissue around the tooth I had extracted. This tissue becomes loose when the tooth is gone and it was easy to pull that over the extraction site and suture it down to close it over. Then I advised each patient not to blow their noses for a few days. The cases healed in a few days and without complications. Bone grafting materials are now readily accessible to oral surgeons, and they can be used to accelerate the creation of new bone—which is the goal here—to re-create a layer of bone between the teeth socket and the sinus.

What I was taught was to eliminate that air passageway between the mouth and the nose so that the perforation would heal. Now you’re telling me that you have a hole in that perforation that hasn’t really been closed. Will it heal? I’m guessing that eventually it will, but I’m not entirely sure, and it could take quite a long time. But meanwhile you have a situation susceptible to infection and every time air goes through the hole it’s going to want to open that hole a little more—not how I was taught and it seems to me a recipe for very slow healing. Plus what do you do when you’re eating peas and they get up into your nose? :-). I know some kids who would love that, but that can’t be how this is supposed to work.

What to do? I would ask for a referral to an oral surgeon to close this. The future health of your mouth including the ability to place implants to replace the teeth requires a good thick foundation of bone to work with here and that will be enhanced by proper healing of this sinus perforation.

Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Preventing Dry Socket

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Dry socket is a potential complication of tooth extraction, and studies have shown that it occurs after anywhere from 15% to 30% of the time after the extraction of an impacted mandibular third molar (wisdom tooth). However, in my practice, I went the final ten years of my practice doing hundreds of extractions of mandibular third molars, including many full bony impactions, without a single incidence of dry socket. Let me tell you how I did it.

As I began my practice, I had a special interest in oral surgery. In dental school I had won the award as the outstanding oral surgery student of my graduating class. I considered specializing in oral surgery, but decided I really wanted to be a general dentist. I did decide, however, to try to tackle difficult extractions, gradually increasing in difficulty until I didn’t refer any of them to oral surgeons unless the patient was over 40. With these extractions, I had a normal incidence of dry socket in my patients.

One day, when I had two patients return to me with dry socket, I realized that in the case of both of these patients I had used a great deal of force in extracting the teeth. This gave me the idea that forceful compression of the mandibular bone was a precipitating factor for dry socket. From then on, if I couldn’t get a lower wisdom tooth out with moderate elevator force, I would section the tooth and/or remove bone until I could. I was very pleased that this dramatically decreased my incidence of dry socket. Over the next seven years I had only two dry sockets in my patients. This was up until around 1991 or ’92.

Then I read a study in a journal where the researchers had tried placing a square of Gelfoam soaked in a suspension of clindamycin antibiotic into the socket after the extraction and suturing the tissue over it. They did this on one side of each patient, and left the other side untreated. For every patient that developed dry socket after the extractions, it never occurred on the side that was treated with clindamycin. I am unable to find what journal that was in, but I was able to find an online reference to that study on the website of a Dr. Ted Rothstein.

I found the study very persuasive, so I applied this practice routinely for every impacted lower third molar that I extracted, and for the next ten years, extracting all sorts of impacted lower wisdom teeth, didn’t have a single incidence of dry socket. And I did not shy away from any difficult extractions. I did partial and full bony impactions including horizontal impactions, disto-angular impactions, whatever.

The “inside-the-box” thinking on the causes of dry socket is pretty rudimentary. The blood clot is missing, therefore the patient must have sucked it out! So therefore, don’t suck through a straw and that will reduce the incidence of dry socket. Similarly, if you smoke after the extraction you will suck it out. There are no clinical studies that give any credence to these simplistic theories. I don’t believe them and didn’t pass them on to my patients.

– Dr. Hall

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Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Sinus infection after extraction

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Hi Dr. Hall;
I really like your clear advice. I had an upper molar on the right removed two weeks ago, and my dentist showed me on the X-rays where the root went into the sinus. (It was an old root canal tooth that was redone two years ago by an endodontist due to infection at the root tip. It was finally so consistently painful that I had it removed). When he removed the tooth my dentist told me there was infection in the root that went into the sinus. He cleaned the sockets and filled the holes with bone graft and used stitches – which have now been removed. He put me on a course of clindamyacin antibiotics 150mg for a week. In this time I have been extremely careful to not blow my nose, rinse gently, and brush gently with a soft tooth brush when I got the okay from my dentist. All was going really well. I’ve been off the antibiotics for a week and this morning I started having sinus drainage on that side, pressure and some pain in my face and gum. I took an oral decongestant, but it hasn’t made any difference in the pressure sensation. Do you think I should call my dentist and ask for more or different antibiotics? Are these kinds of sensations normal in the healing process of a tooth extraction with the root in the sinus? I’m concerned that if there is still infection in the sinus from the tooth, that it might affect the bone graft.
Thanks for your help.
– Nicole L.

Nicole,
It sounds like your dentist did everything right, and I appreciate the clear explanation you have given of your history.
The roots of upper molars can lie very close to the maxillary sinus. Sometimes the only thing separating them from the sinus is a thin membrane which would naturally be ruptured during a tooth extraction, causing a sinus perforation. When this happens, the appropriate treatment is to surgically close the perforation. This can be done with a surgical gelatin sponge material called gelfoam, or with bone grafting material as your dentist did, followed by suturing over the opening. Then you need to be gentle with it for a period of time to allow the body to heal over the opening. You did all that. Antibiotics would be called for if there is any infection present, and clindamycin is an excellent choice in this situation.

You do need to get back to your dentist to see why you are having this relapse of the infection. It could be that you just need to get back onto the clindamycin for a longer period of time, or you may need to switch antibiotics.

It is possible that some bone fragment got pushed up into your sinus and will need to be surgically removed in order for this to completely heal. If you take the antibiotics and it gets completely better and you continue the antibiotics for several days after that, and the infection returns again, I would have your dentist refer you to an otorhinolaryngologist (ear, nose, and throat specialist) for an x-ray to see if there is anything like that going on here.

– Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Sinus perforation during tooth extraction – what to do

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My mother had two teeth pulled yesterday, but they pierced her sinus cavity on both teeth and then left a piece of the root behind. What do we do to get this resolved?
– Autumn from Oregon

Autumn,
The roots of upper molar teeth can sometimes be very close to the maxillary sinus, to where there is only a thin layer of bone, or sometimes just a thin membrane and no bone at all between the tip of the root and the sinus. This is one reason a sinus infection can sometimes cause a toothache. So if the sinus cavity was perforated during the extraction, it was probably smart of the dentist to leave the root tip in the bone, as trying to get out that root tip could cause that root tip to be pushed up into the sinus, which would have necessitated sinus surgery to remove it.

Just puncturing the sinus is a rather simple matter to heal. If the dentist suspects that the sinus has been perforated, he or she can ask the patient to blow their nose, and the dentist will see a bubbling of air in the socket. The typical treatment is to pack the tooth socket with a biocompatible resorbable sponge material called gelfoam, which accelerates the growth of tissue to cover the perforation. Or bone grafting material can be carefully placed in the socket. If it’s not too difficult, the dentist can also suture soft tissue over the tooth socket, which also helps accelerate that process. But if it would be too traumatic to move soft tissue to that position, that isn’t necessary. Then the dentist will instruct the patient not to blow their nose for a few days, to give that tissue time to heal without disruption. The opening then heals over with soft tissue, and then gradually over a few months’ time, new bone grows in the socket and the sinus membrane completely heals.

If the dentist has any question about whether any tooth fragments were pushed up into the sinus, he or she may refer the patient to an ear, nose, and throat specialist (otorhinolaryngologist) for an x-ray to check whether or not the sinus is clear.

Leaving a root tip of the tooth in the bone should not cause any problem. There is a tiny risk that it could cause an infection and later need to be removed, but there is a much greater risk, in this situation, associated with trying to remove it now, while there is an opening directly into your sinus.

I hope that is helpful. Anyway, it’s not really a serious situation, but somewhat of an inconvenience. Pretty much all you should have to do is be careful not to create any pressure in your nose and then wait for this to heal itself. I had a couple of these happen when I did tooth extractions, I covered the perforations, and they healed without incident.

Dr. Hall

Links: Please read more about the possible complications of tooth extraction and post-operative care on our tooth extraction page.
Read about wisdom teeth removal.

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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