Facial bruising after dental implants: how many days does it last, and when is it a sign of a problem?

The medical name for a bruise is ecchymosis: blood leaking from small damaged vessels collects under the skin. Cleveland Clinic describes a bruise as vessels leaking underneath while the skin is intact, without bleeding to the outside. In implant surgery the gum is opened, the bone is drilled and sometimes bone is added; in the process some of the capillaries are damaged. Most of the bleeding inside the mouth flows into the mouth and is stopped with gauze, but some of it spreads into the soft tissue. A few hours or a day later, this blood shows as colour on the cheek, under the chin or around the lips.

The colour of a bruise changes over time, and this change is an indicator of healing. MedlinePlus writes that a bruise starts pinkish red, then turns a bluish colour, after that greenish yellow, and finally returns to normal skin colour. In people with dark skin, according to Cleveland Clinic, a bruise may look purple, dark brown or black, and turns light brown, green or yellow as it heals. The colour turning yellow is not a worsening but a sign that the body is clearing the leaked blood.

A bruise usually does not stay directly over the surgical area but moves downwards. When the work is in the lower jaw it can spread under the chin and to the neck, and in the upper jaw to the cheek and sometimes under the eye. The reason for this is gravity and the loose structure of the soft tissue layers in the face; the leaked blood travels downwards through the tissue spaces. A yellowish patch appearing on the neck shows that the bruise you saw in the first days has moved down and is fading; on its own it does not mean new bleeding.

How much bruising you should expect is determined by the type of procedure. In a study that assessed 339 patients in Hong Kong and Nanjing every day in the first week and on day 14, the most swelling and bruising in the first three days was seen in the group that had bone grafting (guided bone regeneration) in the same session as the implant. With simple implant placement carried out without adding bone, the signs of healing resembled those of a simple tooth extraction. At the end of two weeks, complaints had fallen to a level close to zero in all groups.

Duration matters too. In a study carried out in Singapore with 468 patients who had implant and gum surgery, patients reported more complaints under every heading except bleeding, bruising included, after surgery lasting longer than 60 minutes. In the same study, male sex and a short duration of surgery were associated with a lower complaint score; under every heading, scores fell close to zero within a week. These studies are observational and based on patients' own reports; that is, they do not prove the cause of bruising, they only show in which situation it is seen more often.

Personal factors play their part too. Cleveland Clinic lists ageing skin, blood thinners, aspirin, anti-inflammatory painkillers taken regularly (ibuprofen, naproxen), cortisone, a low platelet count, liver disease and a deficiency of vitamin C or K among the conditions that predispose to easy bruising. At an advanced age the skin thins and the vessels under the skin are damaged more easily; so it is not surprising to see a wider bruise on the face of an elderly patient after the same procedure. The fact that a significant proportion of patients having full-mouth treatment are of advanced age and take heart medication also explains why this subject is asked about so often.

How do blood thinners affect bruising? In a case-control study of 120 patients who had a fixed full-arch prosthesis fitted on four implants in a single session, bleeding after surgery and bruising around the mouth (purpura) were seen more often in the group taking warfarin than in those taking rivaroxaban and those taking no medication. No patient developed serious bleeding or a haematoma, and the procedure was carried out without the medication being stopped or changed. A meta-analysis combining seven studies also reports that, when local measures to stop bleeding are used, continuing blood thinners taken by mouth does not significantly increase the risk of bleeding, while for warfarin-type drugs there is a trend towards an increase that is not statistically significant.

There are two pictures that need to be distinguished from bruising. The first is a haematoma: not a change of colour under the skin but blood collecting in one place and forming a raised, tense and painful swelling. Cleveland Clinic lists a lump appearing where the bruise is, and painful swelling, among the reasons to consult a doctor. The second and most important is bleeding in the floor of the mouth. In implant surgery carried out at the front of the lower jaw, around the canine, if the drill perforates the inner (tongue-side) surface of the bone and damages the vessel under the tongue, blood can spread rapidly into the loose tissue in the floor of the mouth. In published case reports it is reported that the tongue was pushed upwards and backwards, the airway narrowed and some patients were intubated. It is a rare picture, but it is life-threatening; the reason it is explained on a page about bruising is that noticing it in the first hours is vital.

The pictures in the first list mostly suggest ordinary bruising that passes by itself. If an item from the second list applies to you, the bruise stops being merely a matter of colour and an assessment is needed.

The order deliberately starts from the danger: first the picture that threatens the airway is ruled out, then the course of the bruise is monitored.

1. 1

   First look under the tongue and at your breathing

   If an implant was placed at the front of the lower jaw, check under your tongue in the mirror in the first hours and on the first night. If there is a rapidly growing purple swelling under the tongue, the tongue being pushed towards the palate, muffled speech, being unable to swallow saliva or shortness of breath, call 112. In this picture, according to the publications, the first step of treatment is securing the airway.

2. 2

   Take a photograph in the same light every morning

   The colour and borders of a bruise change from day to day; relying on memory is misleading. Taking a photograph every morning in the same light and from the same angle shows you and your dentist clearly whether the bruise is growing and whether its colour is fading.

3. 3

   Is the colour growing, or is the swelling growing?

   The area of a bruise widening, especially downwards, is most often the leaked blood changing place. The real question is the course of the swelling: as we explain in our guide to swelling, swelling peaks at the end of day 2 and then goes down; swelling that grows after day 3 is a different picture.

4. 4

   Check warmth and tension by touch

   Touch the bruise lightly with a clean hand. Being soft and slightly tender is ordinary; a swelling that is tense, warm, steadily hardening or throbbing suggests a haematoma or infection and should be shown to a dentist.

5. 5

   Review your list of medicines

   Besides blood thinners, medicines such as ibuprofen or naproxen that you take on your own for pain can also increase bruising. Cleveland Clinic recommends consulting a doctor before using anti-inflammatory painkillers when you have a bruise. Do not add any medicine other than the painkiller prescribed for you.

6. 6

   Examination by the dentist

   The dentist looks at whether there is blood collected under the bruise, the floor of the mouth, the movement of the tongue, the wound and the stitches. If bleeding in the floor of the mouth is suspected, the assessment is carried out in hospital; the publications report that CT was used to show the site of the bleeding. If you take blood thinners, adjusting the medication is discussed together with the doctor who prescribed it.

Once a bruise has formed, there is no method that wipes it away in an instant. The following limit its growth and make it easier for it to fade.

The following are decisions that make a bruise bigger or overlook the real danger.

The sequence below is a general framework; bone grafting, the duration of the procedure and medicines change the timing. What sets it apart is that the swelling also goes down as the colour fades.

1. The first day

   The bruise is usually not yet visible, or starts as slight redness over the surgical area. Cold compresses, resting with your head raised and stopping the bleeding at the site are the work of this day.

2. Days 2 and 3

   The bruise approaches its darkest and widest and starts to move downwards. Swelling also peaks at the end of day 2. From day 3 you move on to warm compresses.

3. The fourth to the seventh day

   The colour turns from bluish to green-yellow and the edges fade. In the lower jaw the patch may have moved down as far as the neck; if the colour is fading, this is it resolving.

4. The second week

   Cleveland Clinic writes that most bruises disappear within two weeks. In people who take blood thinners and those who had bone grafting, fading may take a little longer.

5. After two weeks

   Cleveland Clinic lists a bruise that lasts longer than two weeks among the reasons to consult a doctor; it also notes that larger bruises and haematomas can last a month or longer. At this point, show the bruise at your check-up.

A bruise does not need any additional treatment on its own. However, how pronounced it will be and whether an additional assessment is needed are determined by these items:

The scope of the surgery

A single implant, more than one implant, bone grafting and working on both jaws in the same session change the size of the bruise.

Duration of the procedure

In studies, more complaints, bruising included, are reported after surgery lasting longer than 60 minutes.

Medicines taken

Blood thinners, aspirin and anti-inflammatory painkillers widen a bruise; the medication plan before the procedure is made with the doctor who prescribed the medication.

The need for an additional assessment

Where a haematoma or bleeding in the floor of the mouth is suspected, an examination, imaging and, if necessary, monitoring in hospital come into it.