Tooth extraction

Definition

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

Purpose

Extraction is performed for positional, structural, or economic reasons. Teeth are often removed because they are impacted. Teeth become impacted when they are prevented from growing into their normal position in the mouth by gum tissue, bone, or other teeth. Impaction is a common reason for the extraction of wisdom teeth. Extraction is the only known method that will prevent further problems with impaction.

Teeth may also be extracted to make more room in the mouth prior to straightening the remaining teeth (orthodontic treatment), or because they are so badly positioned that straightening is impossible. Extraction may be used to remove teeth that are so badly decayed or broken that they cannot be restored. In addition, some patients choose extraction as a less expensive alternative to filling or placing a crown on a severely decayed tooth.

Demographics

Exact statistics concerning tooth extraction are not available. Experts estimate that over 20 million teeth are extracted each year in the United States. Many of these are performed in conjunction with orthodontic procedures. Some extractions are due to tooth decay.

Description

Tooth extraction can be performed with local anesthesia if the tooth is exposed and appears to be easily removable in one piece. The dentist or oral surgeon uses an instrument called an elevator to luxate, or loosen, the tooth; widen the space in the underlying bone; and break the tiny elastic fibers that attach the tooth to the bone. Once the tooth is dislocated from the bone, it can be lifted and removed with forceps.

If the extraction is likely to be difficult, a general dentist may refer the patient to an oral surgeon. Oral surgeons are specialists who are trained to administer nitrous oxide (laughing gas), an intravenous sedative, or a general anesthetic to relieve pain. Extracting an impacted tooth or a tooth with curved roots typically requires cutting through gum tissue to expose the tooth. It may also require removing portions of bone to free the tooth. Some teeth must be cut and removed in sections. The extraction site may or may not require one or more stitches (sutures) to close the incision.

Diagnosis/Preparation

In some situations, tooth extractions may be temporarily postponed. These situations include:

• Infection that has progressed from the tooth into the bone. Infections may complicate administering anesthesia. They can be treated with antibiotics before the tooth is extracted.
• Use of drugs that thin the blood (anticoagulants). These medications include warfarin (Coumadin) and aspirin . The patient should stop using these medications for three days prior to extraction.
• People who have had any of the following procedures in the previous six months: heart valve replacement, open heart surgery, prosthetic joint replacement, or placement of a medical shunt. These patients may be given antibiotics to reduce the risk of bacterial infection spreading from the mouth to other parts of the body.

Before extracting a tooth, the dentist will take the patient's medical history, noting allergies and other prescription medications that the patient is taking. A dental history is also recorded. Particular attention is given to previous extractions and reactions to anesthetics. The dentist may then prescribe antibiotics or recommend stopping certain medications prior to the extraction. The tooth is x rayed to determine its full shape and position, especially if it is impacted.

Patients scheduled for deep anesthesia should wear loose clothing with sleeves that are easily rolled up to allow the dentist to place an intravenous line. They should not eat or drink anything for at least six hours before the procedure. Arrangements should be made for a friend or relative to drive them home after the surgery.

Aftercare

An important aspect of aftercare is encouraging a clot to form at the extraction site. The patient should put pressure on the area by biting gently on a roll or wad of gauze for several hours after surgery. Once the clot is

A dental surgeon uses special forceps to pull out a tooth (A). In its place, a blood clot forms (B), which becomes new bone with gum tissue over the top (C). If the blood clot does not form or falls out, a dry socket occurs (D). No new bone forms, and the nerves are exposed, causing pain. (

Illustration by GGS Inc.

)

For the first two days after the procedure, the patient should drink liquids without using a straw and eat soft foods. Any chewing must be done on the side away from the extraction site. Hard or sticky foods should be avoided. The mouth may be gently cleaned with a toothbrush, but the extraction area should not be scrubbed.

Wrapped ice packs can be applied to reduce facial swelling. Swelling is a normal part of the healing process; it is most noticeable in the first 48–72 hours after surgery. As the swelling subsides, the patient's jaw muscles may feel stiff. Moist heat and gentle exercise will restore normal jaw movement. The dentist or oral surgeon may prescribe medications to relieve postoperative pain.

Risks

Potential complications of tooth extraction include postoperative infection, temporary numbness from nerve irritation, jaw fracture, and jaw joint pain. An additional complication is called dry socket. When a blood clot does not properly form in the empty tooth socket, the bone beneath the socket is exposed to air and contamination by food particles; as a result, the extraction site heals more slowly than is normal or desirable.

Normal results

The wound usually closes in about two weeks after a tooth extraction, but it takes three to six months for the bone and soft tissue to be restructured. Such complications as infection or dry socket may prolong the healing process.

Morbidity and mortality rates

Mortality from tooth extraction is very rare. Complications include a brief period of pain and swelling; post-extraction infections; and migration of adjacent teeth into the empty space created by an extraction. Most people experience some pain and swelling after having a tooth extracted. With the exception of removing wisdom teeth, migration into the empty space is common. Braces or orthodontic appliances usually control this problem.

Alternatives

Alternatives to tooth extraction depend on the reason for the extraction. Postponing or canceling an extraction to correct tooth crowding will cause malocclusion and an undesirable appearance. Not removing an impacted wisdom tooth may cause eventual misalignment, although it may have no impact. Not removing a decayed or abscessed tooth may lead to septicemia and other complications.

See also Wound care .

Resources

BOOKS

Harris, N. O., and F. Garcia-Godoy. Primary Preventative Dentistry , 6th ed. Englewood Cliffs, NJ: Prentice Hall, 2003.

Peterson, L. J. Contemporary Oral and Maxillofacial Surgery , 4th ed. Amsterdam: Elsevier Science, 2002.

Scully, C. Oral and Maxillofacial Medicine: A Practical Guide. London, UK: Butterworth-Heinemann, 2003.

Tronstad, L. Clinical Endodontics. New York: Thieme Medical Publishers, 2003.

PERIODICALS

Devlin, H., and P. Sloan. "Early Bone Healing Events in the Human Extraction Socket." International Journal of Oral and Maxillofacial Surgery 31 (December 2002): 641-645.

Magheri, P., S. Cambi, and R. Grandini. "Restorative Alternatives for the Treatment of an Impacted Canine: Surgical and Prosthetic Considerations." Practical Procedures and Aesthetic Dentistry 14 (October 2002): 659-664.

Moscovich, H. "Fitting Restorations from Extracted Teeth." Journal of the South African Dental Association 55 (August 2000): 411-412.

Rosted, P., and V. Jorgensen. "Acupuncture Treatment of Pain Dysfunction Syndrome After Dental Extraction." Acupuncture in Medicine 20 (December 2002): 191-192.

ORGANIZATIONS

American Association of Oral and Maxillofacial Surgeons. 9700 West Bryn Mawr Ave., Rosemont, IL 60018-5701. (847) 678-6200. http://www.aaoms.org .

American Board of Oral and Maxillofacial Surgery. 625 North Michigan Avenue, Suite 1820, Chicago, IL 60611. (312) 642-0070; FAX: (312) 642-8584. http://www.aboms.org .

American Dental Association. 211 E. Chicago Avenue, Chicago, IL 60611. (312) 440-2500. http://www.ada.org .

British Association of Oral and Maxillofacial Surgeons, Royal College of Surgeons. 35–43 Lincoln's Inn Fields, London, UK WC2A 3PN. http://www.baoms.org.uk .

OTHER

American Dental Association. [cited April 3, 2003]. http://www.ada.org/public/topics/extractions.html .

Bristol Biomed. [cited April 3, 2003]. <www.brisbio.ac.uk/ROADS/subject-listing/toothextraction.html� 3E; .

Dental Review Online. [cited April 3, 2003]. http://www.dentalreview.com/Tooth_Extraction.htm .

Emory University. [cited April 3, 2003]. <www.emory.edu/COLLEGE/CULPEPER/RAVINA/PROJECT/Ancient_pages/Toot _extraction.html> .

L. Fleming Fallon, Jr., MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

In 2003, teeth are most often extracted by maxillofacial or oral surgeons. Occasionally, a general dentist will extract a tooth. Teeth are most commonly removed in an outpatient facility adjacent to a hospital under general anesthesia.

QUESTIONS TO ASK THE DOCTOR

• Why are you suggesting a tooth extraction?
• What will my mouth look like after surgery?
• Is the oral surgeon board certified in maxillofacial surgery?
• How many teeth extractions has the oral surgeon performed?
• What is the oral surgeon's complication rate?
• Will I need medication after surgery?