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Oral Surgery/swelling after surgery

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chin
chin  
QUESTION: Dear Mr. Ryan,

I had my wisdom tooth operation two and the half months ago. The healing process presented difficulties because of bleeding (blood vessel injured during the surgery) and the doctor had to remove the stiches and to leave the wound to heal open. I was told to rinse with salt water, introducing the needle in the wound.

The problem started when a small swelling appeared, a month and the half ago. I tried everything in order to find out why there was a swelling: blood test, computed tomography (CT test) and echography. I took antibiotic Augmentine for 10 days - no changes.

Blood test show slightly elevated sedimentation. TC shows periodontal problem, but no issues on the part of the bone where the extraction was done. Echo - nothing. I have no pain and no fever.

My swelling is small, but it also slightly expanded on the center and the left of my under chin. It is persistent.

One of the doctors I have seen told me that I would have to do another operation in order to clean the area and to extract the sample of my tissue and send to bacteriological analysis, in order to see which is the bacteria that I have and why it is not responding to antibiotic treatment (during all this time I took Clyndamicin, Amixicilin and Augmentine, this doctor sort of felt that the bacteria could have developed resistance)

But, he could not do this operation because his center is too small. I tried with other doctors, who worked in better equipped centers and collaborated with laboratories, but their opinion is that I have - nothing!! According to them I am healthy and everything is fine.

A week ago additional symptoms appeared: my gums became swollen and red, painful to the touch. But, this problem diminished during last few days. It was like a sudden attack of gingivitis …

Is it possible that I am fine? Should I persist trying to find somebody to do the surgery and the bacteriological analysis? I would like to believe that I am fine, but on the other hand, nobody offers answers to the question: why I have this swelling?

Thank you for your opinion and effort. Best, Sasha

ANSWER: Sasha, Thank you for your question. Swelling will not develop if nothing is wrong. It is very difficult to make a clinical judgement. You definitely need to  find out what is causing the swelling. A maxillofacial CT with contrast can look at soft tissue densities and look for things that are not that obvious. It looks to me that there might be an issue with your submandibular glad. I would look into that possibility. I hope that helps.



---------- FOLLOW-UP ----------

TC scan
TC scan  
QUESTION: Dear Mr. Ryan,

Thank you for your answer.

I have a follow up question because I have received new results and opinions today.

Ultrasound check shows that there are no problems with my salivary glands, and other parts in that area. There are two lymph nodes (size 8mm and 10 mm) close to the area of extraction. Is it possible that the swelling is related to these nodes?

I have also seen another surgeon and he tells me that swelling might be related to the periodontal disease. Computed Tomography shows that I have a bone problem (small black spots on TC scan, distributed all along the jaw bone) caused by inflammatory process on my teeth, some kind of periodontitis … This could also explain the elevated blood sedimentation in blood test…  In past 10 days I had swollen and red gums, pains in my gums, bleeding while brushing my teeth and other issues related to gingiva problems. But – the swelling appeared before gingiva symptoms…

I know that it is difficult to say without seeing me, but I would appreciate an opinion or a suggestion.

Best,
Sasa

Answer
Sasha, Ultrasound is not very diagnostic. It could be a subperiosteal infection form debris left under the flap form the surgery. The only way to fix this is to open up the flap again and remove the  debris. It is absolutely not a periodontal infection. This would not cause swelling under the chin. I would look into subperiosteal infections and osteomyelitis. These are the two most likely. I hope that helps.

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James M. Ryan. DDS, MS; Board Certified Oral and Maxillofacial Surgeon

Expertise

Dr. Ryan's expertise is in the field of Oral and Maxillofacial Surgery. Specifically, Dr. Ryan is an expert in Orthognathic Surgery. He holds uniques experience as the former Assistant Program Director of the Oral and Maxillofacial Surgery Residency Training Program at Washington Hospital Center where he trained residents to perform these complicated surgical procedures. Additionally, Dr. Ryan also has a tremendous amount of experience in reconstruction of the maxillofacial skeleton related to trauma and tooth loss. Dr. Ryan is an expert in 3 dimensional treatment planning for Orthognathic Surgery, Dental Implant Surgery and Wisdom Teeth removal. To learn more about Dr. Ryan, his full profile can be seen at www.eosdds.com

Experience

Diplomate of the American Board of Oral and Maxillofacial Surgery with current hospital affiliations at: Washington Hospital Center Holy Cross Germantown Hospital National Institute of Health/NIDCR

Organizations
American Dental Association. American Association of Oral and Maxillofacial Surgeons. District of Columbia Society of Oral and Maxillofacial Surgeons. District of Columbia Dental Society. American Board of Oral and Maxillofacial Surgeons. Health Volunteers Overseas.

Publications
Journal of Oral and Maxillofacial Surgery Journal of The American Dental Association

Education/Credentials
S.U.N.Y @ Stony Brook- B.S. in Biochemistry, Stony Brook, NY. Northeastern University- M.S. in Perfusion Technology, Boston, MA. D.D.S.- New York University College of Dentistry, New York, NY. Certificate and Chief Resident- Washington Hospital Center, Washington, DC. Clinical Fellow- The Johns Hopkins Hospital, Baltimore, MD.

Awards and Honors
Dr. Ryan has received numerous awards including: 2006 American Association of Oral and Maxillofacial Surgeons Dental Student Award, Washington Hospital Center 2008 Nurses' Choice Physician Collaboration Award, 2009 Resident Research Summit Scholarship Award, and the 2011 Outstanding Surgical Attending in the Department of Oral & Maxillofacial Surgery at Washington Hospital Center. He has also authored/coauthored and published several journal articles and held several teaching positions,including assistant professor, while at NYUCD.

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