My Sinus Is Perforated After a Tooth Extraction: Telltale Symptoms and Risks

Sinus perforation after tooth extraction: Symptoms and Risk
One of the major complications following extraction of the back teeth of the upper jaw is perforation and exposure of the sinuses.

The close connection between these structures often leads to sinus issues following dental work on these teeth. The good news is that these problems are usually temporary, and there's a good chance they'll resolve on their own.

In this article, we'll delve into sinus perforation after tooth extraction, discussing its telltale symptoms, risks, complications, and treatment options.

What is a Perforated Sinus?

A perforated sinus, a complication reported in up to 11% of cases, occurs when an unintended opening or hole forms in the thin bone that separates the upper back teeth from the maxillary sinuses.

But before going any further, we must first look at the maxillary sinuses and their intimate relationship with the upper teeth.

What are the maxillary sinuses?

Maxillary Sinus

The maxillary sinuses are paired cavities situated on either side of the cheeks near the nose, named after the upper jawbone, known as the "maxilla."

These sinuses, along with other smaller ones (frontal, sphenoid, and ethmoid) are lined with soft mucous membrane tissue. Their role includes humidifying and filtering the air we breathe before it reaches our lungs. When the mucous membrane lining the sinus becomes inflamed or infected, we talk about a condition called sinusitis.

The relationship between the sinuses and the upper back teeth

The back teeth of the upper jaw and the maxillary sinuses are like neighbors with a delicate relationship.

In some people, a thick layer of bone separates them, minimizing the risk of damage during dental procedures.

However, in some instances, this protective bone layer may be thin, or the tooth roots could extend into the sinus cavity. In such situations, procedures like root canals or extractions on these teeth pose a higher risk of sinus damage, potentially causing perforations or infections.

Approximately 10% of sinus infections originate from dental issues, and a significant portion of these cases result from dental procedures.
The upper back teeth most involved in sinus complication
Second molars pose the highest risk for sinus complications, followed by wisdom teeth, first molars, and first premolars.

Sinus perforation: A Potential Complication of Tooth Extraction

In normal conditions, the sinuses have their enclosed space, isolated from the external mouth environment.

Sinus perforation, or exposure, disrupts this continuity, creating an unnatural communication between the sinus and the mouth, known medically as oro-antral communication.

The primary culprit behind oroantral communications is tooth extraction, accounting for most cases. Other factors include trauma, infections, and various dental procedures like root canals, bone surgery, cyst removal, and implant surgery.

This communication makes the sinuses more vulnerable, allowing saliva, food particles, and bacteria to enter, leading to potential complications such as infections.

Although the risk is generally low when a robust bony barrier isolates the sinuses, there are situations where this protective layer is deficient. Sometimes, the roots of the upper teeth penetrate the bone and connect directly to the soft tissues lining the sinuses.

When your dentist detects these at-risk situations, extreme caution must be taken during the extraction procedure to avoid creating an oral-sinus communication.

The Telltale Symptoms of Sinus Perforation after Tooth Extraction

The symptoms following a sinus perforation post-tooth extraction vary, depending on the perforation size, the time elapsed since the procedure, and whether an infection has developed.

Immediately after the extraction, a tiny perforation might go unnoticed, possibly healing spontaneously. However, you may sense air escaping through the socket, leading to bubbling of fluids and blood.

As the sinuses are air-filled extensions connected to the nose, you may notice changes in your voice resonance.

The exchange can also happen in the opposite direction, from the mouth to the sinuses. Perforation can allow food and liquids to move from the mouth to the sinuses and escape through the nose.

At this initial stage, the perforation and surrounding tissue may appear healthy and heal without infection.

Clinical cases of sinus perforation following upper back teeth extraction

However, if the perforation persists without healing or treatment, there's a risk of infection. Typically, infection occurs in 50% of patients within 48 hours and 90% within 2 weeks.

Signs of sinus infection after tooth extraction include red, swollen, and inflamed tissue around the perforation, with a discharge of clear yellow liquid (pus).

Other associated symptoms are localized pain, tenderness, foul-smelling discharge, persistent nasal discharge, and post-nasal drip. General symptoms like fever and fatigue may also occur in some cases.

Clinical case of sinus infection after tooth extraction

It's important to remember that signs of sinus complications post-tooth extraction are usually localized to the side of the procedure (unilateral). On the other hand, sinusitis due to viral infections or allergies typically affects both the right and left sinuses and nostrils (bilateral).

How Can the Dentist Tell if the Sinus is Perforated?

Early detection of a sinus perforation is crucial to avoid complications later on. Dentists can identify sinus damage during or after surgery.

Detecting sinus perforation during the procedure

During the procedure, signs of a possible perforation include the sensation of an instrument pushing upwards, sudden intense pain, and excessive bleeding.

Sometimes, the tooth may come out with a piece of bone. This may suggest a rupture of the sinus floor and thus an oroantral communication.

Detecting sinus perforation after the procedure

After the procedure, direct light on the extraction site may reveal the soft tissue lining of the sinus. Your dentist may also use a mirror placed opposite the extraction site while asking you to breathe through your nose. The appearance of tiny droplets on the mirror indicates a sinus leak, signifying a perforation in the membrane.

The Valsalva maneuver is another diagnostic technique. With nostrils pinched and mouth open, applying pressure as if trying to blow your nose can reveal air noises or liquid running through the extraction site, pointing to oroantral communication.

X-rays are a great tool, providing detailed information on the severity and extent of sinus injuries, as well as infections.

How Does a Perforated Sinus Look Like on X-rays?

A sinus perforation is identifiable on X-rays as a discontinuous line on the sinus floor. In the following X-ray image following the extraction of a first molar, note how the bone of the sinus floor displays a break, indicating the formation of an oroantral communication. This opening means the sinus is no longer isolated, highlighting the presence of a perforation.
Sinus perforation on panoramic dental x-ray

Dental X-rays can also reveal sinus infections. In panoramic dental X-rays, infected sinuses manifest as a white halo, signifying tissue swelling and pus accumulation. In the following panoramic X-ray, observe the white halo in the lower part of the sinus, pointing towards the buildup of pus in connection with an infected tooth.
Sinus infection on panoramic x-ray

Potential Complications of Perforated Sinus after Tooth Extraction

The primary concern of sinus perforation following tooth extraction is fistulization.


When a perforation fails to close naturally, a canal forms, establishing a permanent connection between the sinus and the mouth—this is known as a fistula.

Fistulas typically develop in cases of larger and persistent perforations, often after 48-72 hours have passed without spontaneous healing.
If left untreated, a fistula becomes a gateway for food, saliva, and oral bacteria to enter the sinus. When these accumulate, the result is infection and the onset of sinusitis.

The Different Treatment Options for Sinus Perforation

When treating a sinus perforation after tooth extraction, there's no one-size-fits-all solution. Your dentist will first consider the size of the exposure and the presence of any infection.

Depending on your specific situation, one of the following treatment options may be recommended:

If the Perforation is Small without Sinus Infection:

For minimal perforations, typically less than 2mm, no immediate treatment may be necessary, as these small openings often close spontaneously during the natural healing process. However, if the defect fails to heal on its own, there is a possibility of a fistula forming, necessitating surgical closure to prevent potential infection.

If the Perforation is Large without Sinus Infection:

When the perforation exceeds 2mm, spontaneous recovery becomes less likely. Surgical intervention may be required to close the communication. For moderate-sized openings, the technique involves cutting the gum, pulling it to cover the defect, and suturing it in position. In cases of larger defects, soft tissue grafting may be considered to facilitate closure.

If the Perforation is Large with Sinus Infection:

When the perforation has led to infection, the initial step is to treat sinusitis with the assistance of an Ear, Nose, and Throat (ENT) specialist. The goal is to establish a healthy, bacteria-free environment before considering surgical closure.

Addressing the infection first is crucial, as proceeding directly to surgery could worsen the condition. Once the infection is under control, the next step involves surgical closure of the oroantral communication.

Post-Surgical Care: Ensuring a Smooth Recovery

After undergoing surgical closure for a sinus perforation, proper post-surgical care is crucial to facilitate healing and minimize complications. Here are essential guidelines to follow:

Things to Avoid:

  1. Exerting Pressure on the Site:
    • Refrain from blowing your nose forcefully.
    • Avoid smoking or drinking through a straw.

  2. Hard Foods:
    • Steer clear of consuming hard foods that may aggravate the surgical site.

  3. Chewing on the Treated Side:
    • Do not chew on the side that underwent the surgical procedure.

  4. Strenuous Physical Activity:
    • Avoid engaging in strenuous physical activities during the initial recovery phase.

  5. Touching the Sutures or Surgical Site:
    • Do not touch the sutures or the surgical site with your tongue or fingers for the first 7 days post-surgery.

Things to Do:

  1. Liquid Diet:
    • Prefer a liquid diet in the initial days following surgery to aid in a smoother healing process.

  2. Chew on the Opposite Side:
    • When eating, chew on the opposite side of the treated area to prevent irritation.

  3. Managing Coughs and Sneezes:
    • Keep your mouth open if you need to cough or sneeze to minimize pressure on the surgical site.

  4. Maintaining Oral Hygiene:
    • Keep the wound clean by rinsing with warm saline mouth rinses, starting gently from the second day following surgery.