Tooth Extraction: Types and Risks

Tooth extraction is the removal of a tooth from its socket in the bone.

If a tooth has been broken or damaged by decay, your dentist will try to fix it with a filling, crown or other treatment. Sometimes, though, there's too much damage for the tooth to be repaired. In this case, the tooth needs to be extracted. A very loose tooth will also require extraction if it can't be saved, even with bone replacement surgery (bone graft).

Here are other reasons:

• Some people have extra teeth that block other teeth from coming in.
• Sometimes baby teeth don't fall out in time to allow the permanent teeth to come in.
• People getting braces may need teeth extracted to create room for the teeth that are being moved into place.
• People receiving radiation to the head and neck may need to have teeth in the field of radiation extracted.
• People receiving cancer drugs may develop infected teeth because these drugs weaken the immune system. Infected teeth may need to be extracted.
• Some teeth may need to be extracted if they could become a source of infection after an organ transplant. People with organ transplants have a high risk of infection because they must take drugs that decrease or suppress the immune system.

Wisdom teeth, also called third molars, are often extracted either before or after they come in. They commonly come in during the late teens or early 20s. They need to be removed if they are decayed, cause pain or have a cyst or infection. These teeth often get stuck in the jaw (impacted) and do not come in. This can irritate the gum, causing pain and swelling. In this case, the tooth must be removed. If you need all four wisdom teeth removed, they are usually taken out at the same time.

If you expect to undergo any medical treatment prior to teeth extractions, be sure to discuss this with your dentist first to ensure that the treatments will not negatively impact each other. If any teeth need to be extracted, this should be done before your drug treatment begins. Having a tooth extraction after bisphosphonate treatment increases the risk of osteonecrosis (death of bone) in the jaw.

Your dentist or oral surgeon will take an X-ray of the area to help plan the best way to remove the tooth. Be sure to provide your full medical and dental history and a list of all medicines you take. This should include both prescription and over-the-counter drugs, vitamins and supplements.

If you are having wisdom teeth removed, you may have a panoramic X-ray. This X-ray takes a picture of all of your teeth at once. It can show several things that help to guide an extraction:

• The relationship of your wisdom teeth to your other teeth
• The upper teeth's relationship to your sinuses
• The lower teeth's relationship to a nerve in the jawbone that gives feeling to your lower jaw, lower teeth, lower lip and chin. This nerve is called the inferior alveolar nerve.
• Any infections, tumors or bone disease that may be present

Some doctors prescribe antibiotics to be taken before and after surgery. This practice varies by the dentist or oral surgeon. Antibiotics are more likely to be given if:

• You have infection at the time of surgery
• You have a weakened immune system
• You will have a long surgery
• You have specific medical conditions

You may have intravenous (IV) anaesthesia, which can range from conscious sedation to general anaesthesia. If so, your doctor will have given you instructions to follow. You should wear clothing with short sleeves or sleeves that can be rolled up easily. This allows access for an IV line to be placed in a vein. Don't eat or drink anything for six or eight hours before the procedure.

If you have a cough, stuffy nose or cold up to a week before the surgery, call your doctor. He or she may want to avoid anaesthesia until you are over the cold. If you had nausea and vomiting the night before the procedure, call the doctor's office first thing in the morning. You may need a change in the planned anaesthesia or the extraction may have to be rescheduled.

Do not smoke on the day of surgery. This can increase the risk of a painful problem called dry socket.

After the extraction, someone will need to drive you home and stay there with you. You will be given post-surgery instructions. It is very important that you follow them.

There are two types of extractions:

1. A simple extraction is performed on a tooth that can be seen in the mouth. General dentists commonly do simple extractions. In a simple extraction, the dentist loosens the tooth with an instrument called an elevator. Then the dentist uses an instrument called a forceps to remove the tooth.
2. A surgical extraction is a more complex procedure. It is used if a tooth may have broken off at the gum line or has not come into the mouth yet. Surgical extractions commonly are done by oral surgeons. However, they are also done by general dentists. The doctor makes a small incision (cut) into your gum. Sometimes it's necessary to remove some of the bone around the tooth or to cut the tooth in half in order to extract it.

Most simple extractions can be done using just an injection (a local anaesthetic). You may or may not receive drugs to help you relax. For a surgical extraction, you will receive a local anaesthetic, and you may also have anaesthesia through a vein (intravenous). Some people may need general anaesthesia. They include patients with specific medical or behavioural conditions and young children.

If you are receiving conscious sedation, you may be given steroids as well as other medicines in your IV line. The steroids help to reduce swelling and keep you pain-free after the procedure.

During a tooth extraction, you can expect to feel pressure, but no pain. If you feel any pain or pinching, tell your doctor.

Your doctor will give you detailed instructions on what to do and what to expect after your surgery. If you have any questions, make sure to ask them before you leave the office.

Having a tooth taken out is surgery. You can expect some discomfort after even simple extractions. Usually it is mild. Research has shown that taking nonsteroidal anti-inflammatory drugs (NSAIDs) can greatly decrease pain after a tooth extraction. These drugs include ibuprofen. Only take the dose as prescribed by your doctor. Take the first pills before the local anesthesia wears off. Continue taking them as necessary but not more than 10 days. Ask your doctor for complete instructions.

• Surgical extractions generally cause more pain after the procedure than simple extractions. The level of discomfort and how long it lasts will depend on how difficult it was to remove the tooth. Your dentist may prescribe pain medicine for a few days. Most pain disappears after a couple of days.
• A cut in the mouth tends to bleed more than a cut on the skin because it cannot dry out and form a scab. After an extraction, you'll be asked to bite on a piece of gauze for 20 to 30 minutes. This pressure will allow the blood to clot. You will still have a small amount of bleeding for the next 24 hours or so. It should ease off after that. Don't disturb the clot that forms on the wound.
• You can put ice packs on your face to reduce swelling. Typically, they are left on for 10 minutes at a time and removed for 10 minutes. If your jaw is sore and stiff after the swelling goes away, try warm compresses.
• Eat soft and cool foods for a few days. Then try other food as you feel comfortable.
• A gentle rinse with warm salt water, started 24 hours after the surgery, can help to keep the area clean. Use one-half teaspoon of salt in a cup of water. Most swelling and bleeding end within a day or two after the surgery. Initial healing takes at least two weeks.
• If you need stitches, your doctor may use the kind that dissolve on their own. This usually takes one to two weeks. Rinsing with warm salt water will help the stitches to dissolve. Some stitches need to be removed by the dentist or surgeon.
• You should not smoke, use a straw or spit after surgery. These actions can pull the blood clot out of the hole where the tooth was. Do not smoke on the day of surgery. Do not smoke for 24 to 72 hours after having a tooth extracted.

A problem called a dry socket may occur after an extraction. This occurs when a blood clot doesn't form in the hole or the blood clot breaks off or breaks down too early.

In a dry socket, the underlying bone is exposed to air and food. This can be very painful and can cause a bad odour or taste. Typically dry sockets begin to cause pain the third day after surgery.

Dry sockets are more common after the removal of impacted teeth or difficult extractions. Smokers and women who take birth control pills are more likely to have a dry socket. Smoking on the day of surgery further increases the risk. A dry socket needs to be treated with a medicated dressing to stop the pain and encourage the area to heal.

Infection can set in after an extraction. However, you probably won't get an infection if you have a healthy immune system.

Other potential problems include:

• Accidental damage to nearby teeth, such as fracture of fillings or teeth.
• An incomplete extraction, in which a tooth root remains in the jaw — your dentist usually removes the root to prevent infection, but occasionally it is less risky to leave a small root tip in place.
• A fractured jaw caused by the pressure put on the jaw during extraction — this occurs more often in older people with osteoporosis (thinning) of the jaw bone.
• A hole in the sinus during removal of upper teeth (premolars and molars) — a small hole usually will close up by itself in a few weeks. If not, more surgery may be required.
• Soreness in the jaw muscles and/or jaw joint — tt may be tough for you to open your mouth wide. This can happen because of the injections, keeping your mouth open and/or lots of pushing on your jaw.
• Long-lasting numbness in the lower lip and chin — this is an uncommon problem. It is caused by injury to the inferior alveolar nerve in your lower jaw. Complete healing may take three to six months. In rare cases, the numbness may be permanent.

Call your dentist or oral surgeon if:

• The swelling gets worse instead of better.
• You have fever, chills or redness.
• You have trouble swallowing.
• You have uncontrolled bleeding in the area.
• The area continues to ooze or bleed after the first 24 hours.
• Your tongue, chin or lip feels numb more than 3 to 4 hours after the procedure.
• The extraction site becomes very painful - this may be a sign that you have developed a dry socket.