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When a tooth is no longer restorable, has a poor long term prognosis because of decay, wear, or a fracture, is the cause of considerable pain and anxiety, or requires removal as part of an overall treatment plan, an ‘extraction’ is then required.
During cancer treatment, some people receiving radiation to the head and neck may need to have ‘suspect’ teeth removed prior to the commencement of radiotherapy. Whilst others receiving chemotherapy may be at risk of developing infections from teeth that have poor gum support due to their weakened immune system and therefore teeth may require extraction.
People receiving an organ transplant and immunosuppressive medications may also need some teeth extracted if the teeth are at risk of becoming sources of infection after the transplant.
Every person seems to have or heard of some horror story involving dental treatment, and extractions are no exception. Complications inevitably occur on occasions, but in general however, having a tooth removed does not need to be a traumatic experience when it is well planned and carried out.
In addition, it is quite common for people to say they have been told or heard that they cannot have a tooth removed as there is an infection present. This simply is not all that true and most infections in the mouth are there because of the tooth or poor gum support. Remove the tooth, and you remove the infection. It is true that infections can make anaesthesia more difficult, but in general there are not too many teeth that can not be removed because of an infection. In a large proportion of cases, leaving an infected tooth in the mouth and placing a person on antibiotics just prolongs a patients’ pain and can place them at risk of complications from the infection or the antibiotics.
Another misconception is that people on anticoagulant (blood thinning) treatment need to stop their aspirin or warfarin prior to having a tooth extracted. This practice can sometimes be quite dangerous for a patient whom is at high risk of cardiovascular complications should they cease their medications. Treatment of patients taking ‘blood thinners’ is explained further under “Medically Compromised Patients”.
There are generally two types of extractions, and these are called “Simple Extractions” and “Surgical Extractions”.
Simple Extractions
Simple extractions are typically performed on a tooth that can be readily seen in the mouth and are commonly performed under local anaesthetic in the dental chair. Typically, simple extractions are performed with a pair of forceps and / or an elevator by applying slow and controlled pressure to the tooth until it becomes loose within the socket and can be elevated without difficulty. Simple extractions with experience generally can be performed in less than 10 minutes in most circumstances. More complicated extractions such as lower molar teeth, people with dense jaw bones, or teeth that are broken down, may take longer as more time is needed to gently pry the tooth from its socket and prevent teeth from fracturing.
Some extractions require ‘sectioning’ due to their root structure (shape), or they have little remaining coronal (top of) tooth structure remaining for application of the forceps or elevator. Or the patients bone is so dense, it is better to remove the tooth in portions rather than one piece. This is not a ‘surgical extraction’ but rather the tooth is drilled and a small amount of bone is removed to allow all portions of the tooth to be removed simply and without applying excessive pressure to the jaw and temporomandibular joints. Sectioning of teeth is quite commonplace and is better to be done sooner rather than later when a simple extraction is not going to plan. Sectioning a tooth is far easier and more comfortable for the patient (and dentist) than persisting with an extraction for 15 minutes or more and then realising the tooth is not going to come out in one piece.
Most simple extractions and sectional extractions do not cause much discomfort after the procedure and require only simple analgesia such as Paracetamol (Panadol) and Ibuprofen (Nurofen) for several days, whilst some patients do not require much pain relief at all.
Surgical Extractions
Occasionally a tooth may fracture during the extraction, or due to a curved root structure, or because of its proximity to a nerve canal or sinus space, a tooth will require surgical removal. This can occur unexpectedly during the process of a simple extraction, or it can be planned prior to the extraction when looking at a patients x-ray. Or other people may require multiple teeth to be removed at the same time, and it is preferable to perform a combination of surgical and simple extractions to prevent unnecessary bone loss, prevent fractures,
Surgical extractions are often performed in the chair or they can be performed under a general anaesthetic in hospital. A surgical extraction involves making an incision into the gum and removing small pieces of bone, and drilling out the tooth, and then placing sutures (stitches) to allow healing to occur.
Occasionally, the socket may be packed with a resorbable sponge to help blood clotting and stem the flow of any post operative bleeding, or it may be packed with a synthetic bone material to help the jaw bone recover quicker and prevent a loss of bone structure after the extraction.
Sutures are typically removed 5-7 days after the surgical extraction and the patient may require stronger analgesics such as Panadeine Forte and a high dose Ibuprofen. Antibiotics may also be prescribed if there is a high risk that the patient may develop an infection.
Medically Compromised Patients
As the population ages, so too does the number of patients with complex medical conditions that requires assistance from a dentist or oral surgeon.
As mentioned previously, patients having cancer treatment, organ transplants, are taking multiple medications, are on anticoagulant treatment, have immunosuppression, diabetes, thyroid dysfunction, obesity, or even general old age and frailty require additional care and attention.
Often these people do not require a specialist but rather thorough pre-planning and preparation from a dentist with experience in treating medically compromised patients. Generally, any extractions will be performed in communication with the patients GP or treating specialist physician.
Patients on anticoagulant treatment for example should not cease their medications prior to having extractions performed, but rather plan to have a blood test taken several days before to assess their INR (bleeding time). Appropriate measures such as sutures, clotting packs, and transexamic acid mouthwashes can then be used by the dentist (or oral surgeon) to assist in bleeding control post operatively.
In all cases, it is usually just a matter of having a consultation prior to any planned simple or surgical extractions so that a suitable treatment plan can be arranged and discussed with the patient, their GP and / or Physician.
Site © 2007-2008 Dr. Tony Eldridge B.D.S. Last modified July 23, 2008.