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Tooth Extraction

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.  This is the most common reason for extracting a tooth.  Additional reasons include:

• Some people have extra teeth that block other teeth from coming 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.  These drugs weaken the immune system, increasing the risk of infection.  Infected teeth may need to be extracted.
• People receiving an organ transplant may need some teeth extracted if the teeth could become sources of infection after the 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.  These teeth often get stuck in the jaw (impacted) and do not come in.  They need to be removed if they are decayed or cause pain.  Some wisdom teeth are blocked by other teeth or may not have enough room to come in completely.  This can irritate the gum, causing pain and swelling.  In this case, the tooth must be removed.

Preparation

The Doctor will ask about your medical and dental history, and take an X-ray of the area to help plan the best way to remove the tooth.  It can show several things that help to guide an extraction:

• 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 health care professionals 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 condition(s).
  • If you're going to have conscious sedation or deeper anesthesia, wear clothing that has short sleeves or sleeves that can be rolled up easily.  This allows easy access for an intravenous (IV) line to be placed in a vein.

You will be told not to eat or drink anything for six or eight hours before the procedure.  You also should make sure you have someone available to drive you home after the surgery.

There are two types of extractions

1. Simple Extraction.  A simple extraction is performed on a tooth that can be seen in the mouth.  General dentists commonly do simple extractions.  Most of these can be done using just an injection (a local anesthetic), with or without anti-anxiety drugs.  In a simple extraction, the dentist will grasp the tooth with forceps and loosen it by moving the forceps back and forth.  Then the tooth will be pulled out.  Sometimes the dentist will use a dental "elevator" to help loosen the tooth.  This is an instrument that fits between the tooth and the gum.
2. Surgical Extraction.  A surgical extraction involves teeth that cannot be seen easily in the mouth.  They may have broken off at the gum line or they may not have come in yet.  To see and remove the tooth, the dentist or oral surgeon must cut and pull back the gums.  Pulling back the gum "flap" provides access to remove bone and/or a piece of the tooth. 
   Surgical extractions commonly are done by oral surgeons.  They are done with injections (local anesthesia), and you can also have conscious sedation.  Patients with special medical conditions and young children may be given general anesthesia.  In a surgical extraction, the dentist will need to make a cut (incision) in your gum to reach the tooth.  In some cases, the tooth will need to be cut into pieces to be removed.

If you are having teeth extracted and are receiving conscious sedation, you may be given steroids in your IV line to help reduce swelling after the procedure.

Follow-Up 

Most simple extractions do not cause much discomfort after the procedure.  You may take an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil, Motrin and other brand names) for several days.  You may not need any pain medicine at all. 
Because surgical extractions are more complicated, they generally cause more pain after the procedure.  The level of discomfort and how long it lasts will depend on the difficulty of the extraction.  Your dentist may prescribe pain medicine for a few days and then suggest an NSAID.  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 about 20 to 30 minutes.  This will put pressure on the area and allow the blood to clot.  It still may bleed a small amount for the next 24 hours or so and taper off after that.  Don't disturb the clot that forms on the wound.

You can put ice packs on your face to reduce swelling after the operation.  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, they usually disappear (dissolve) on their own.  They should disappear within 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.  That causes more bleeding and can lead to a dry socket, which occurs in about 3% to 4% of all extractions.  Dry socket occurs 20% to 30% of the time when impacted teeth are removed.  It happens more often in smokers and women who take birth control pills.  It is also more likely after difficult extractions.
 
Risks 

Infection can set in after an extraction, although you probably won't get an infection if you have a healthy immune system.  A common complication called a dry socket 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 odor or taste.  A dry socket needs to be treated with a medicated dressing to stop the pain and encourage the area to heal.

Other potential problems include:

• Accidental damage to teeth near the surgical site, 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.
• A hole in the sinus during removal of an upper back tooth (molar).  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.  It 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 caused by injury (trauma) to the inferior alveolar nerve during removal of the lower wisdom teeth.  Complete healing of the nerve may take three to six months.  In rare cases, the numbness may be permanent.