Extractions


Our dentists prioritize preserving natural teeth, but extractions become necessary due to severe decay, advanced periodontal disease, or other issues like malformation or impaction. Extractions, which are considered surgery, may involve various procedures. Depending on the tooth removed, replacement options such as implants, bridges, or dentures are available.

Extractions involve removing a tooth from its socket due to decay, trauma, or impacted wisdom teeth. In some cases, teeth are extracted to alleviate crowding, often seen in orthodontics.

Tooth extraction is usually straightforward, performed under local anesthesia. However, some cases may require a surgical approach, particularly for deeply buried teeth. Post-extraction care includes applying pressure to stop bleeding and avoiding disturbing the blood clot to prevent complications like dry socket. Smoking should be avoided for at least 24 hours. A hot salt water rinse starting 24 hours post-extraction aids in cleaning and promoting wound healing.

Simple extractions are performed on visible teeth, typically under local anesthesia. Instruments like elevators and forceps are used to gently loosen the tooth by breaking the periodontal ligament and widening the alveolar bone. Controlled pressure is applied to remove the tooth smoothly.

Surgical extractions are necessary for teeth inaccessible due to breaking under the gum line or incomplete eruption. This procedure typically involves incisions and may require lifting soft tissues and removing surrounding jaw bone tissue with instruments like drills or osteotomes. Often, the tooth is fragmented to ease extraction.

Anticoagulant Use

Studies have shown a link between anti-coagulant drug use post-dental extractions and bleeding. In one review, oral anti-coagulants were prescribed to subjects undergoing dental surgery, with 9% experiencing delayed bleeding and 3.5% deemed serious cases. Definitions of bleeding severity vary across studies. However, most agree that regular consumption of oral anticoagulants poses little risk of major bleeding during simple dental extractions.

For simple extractions, continuing therapeutic anti-coagulation is generally safe, considering the higher risk of thromboembolism compared to serious bleeding. Complex extractions carry a higher bleeding risk, necessitating consultation with the patient's doctor. Patients on anticoagulants should inform their dentist, allowing for tailored treatment plans, confirmation of medication, and consideration of INR levels. Referral to a specialist may be needed for INR levels exceeding 4.0, particularly in the elderly, who are more vulnerable to post-surgical bleeding due to dental issues.

To enhance anticoagulant effectiveness and minimize bleeding risks, collagen sponges, sutures, and 5% tranexamic acid mouthwash can be utilized.

Overall, patients on long-term anticoagulant therapy like warfarin or aspirin typically don't need to discontinue treatment before tooth extraction. Dentists should be informed of all medications prior to the procedure, ensuring the least traumatic extraction method is employed.

Antibiotic Use

Dental professionals may prescribe antibiotics to mitigate certain post-extraction complications. Evidence suggests that administering antibiotics before or after impacted wisdom tooth extraction can reduce infection risk by 70% and lower dry socket incidence by a third. Approximately one infection is prevented for every 12 individuals treated with antibiotics following impacted wisdom tooth removal. However, antibiotic use doesn't appear to directly affect fever, swelling, or trismus manifestation seven days post-extraction.

A 2013 Cochrane review analyzed 18 randomized controlled, double-blinded experiments. Despite acknowledging study biases, moderate overall evidence supports routine antibiotic use to reduce infection risk after third molar extraction. However, concerns persist regarding potential adverse effects and antibiotic resistance, discouraging prophylactic antibiotic use in practice.

Post-extraction Healing

Following tooth extraction, bleeding is common and typically controlled by applying pressure with gauze to form a blood clot. Dental practitioners use various measures such as gauze, oxidized cellulose, and fibrin sealant for hemostasis. Continuous pressure for up to 30 minutes may be needed to stop bleeding fully. Movement, like talking, can disrupt pressure and prolong bleeding.

Although rare, clotting disorders like hemophilia may be discovered post-extraction. Dislodged blood clots can lead to further bleeding or dry socket formation. While some surgeons scrape socket walls to prevent dry socket, evidence supporting this practice is lacking.

Bleeding decreases as healing progresses and usually stops within 24 hours. Bleeding beyond 8–12 hours is considered abnormal and termed post-extraction bleeding. Epithelial cells cover the blood clot within about 10 days, initiating an inflammatory response involving neutrophils and macrophages. Osteogenic cells proliferate from adjacent bone marrow around 10 days post-extraction, starting bone formation. Bone remodeling occurs over 10–12 weeks, with the socket outline disappearing from X-ray images. Long-term, alveolar process resorption and maxillary sinus pneumatization may occur, especially in posterior maxillary teeth.

FAQ


Do I require extraction of my tooth?

It depends on the size of the lesion or infection or what you want to achieve with your smile. 

What should I expect during an extraction procedure?

The site will be numbed with local anesthesia, ensuring you feel no pain during the procedure, only pressure. Further details will be discussed based on the location of each tooth.

How long is the healing process?


The healing process begins immediately after the extraction. Initially, a blood clot forms to block the site and initiate gum healing over the first few days. Complete bone healing may take 3-4 months.

Pain Management

Various drug therapies are available for pain management after third molar extractions, including NSAIDs (non-steroidal anti-inflammatory drugs), APAP (acetaminophen), and opioid formulations. Each has its own pain-relieving efficacy but also carries potential adverse effects. According to Dr. Paul A. Moore and Dr. Elliot V. Hersh, Ibuprofen-APAP combinations offer superior pain relief and inflammation reduction with fewer adverse effects. However, certain medical conditions may contraindicate their use, such as taking ibuprofen or NSAIDs alongside warfarin, a blood thinner. Prolonged use of ibuprofen or APAP carries gastrointestinal and cardiovascular risks. High-quality evidence indicates that ibuprofen is more effective than Paracetamol (APAP) in managing postoperative pain.

Socket Preservation

Socket Preservation, also known as alveolar ridge preservation (ARP), is a procedure aimed at minimizing bone loss after tooth extraction, thereby preserving the dental alveolus (tooth socket) in the alveolar bone. During extraction, a platelet-rich fibrin (PRF) membrane containing bone growth enhancers is placed in the wound, or a graft material or scaffold is inserted into the socket of the extracted tooth. The socket is then closed directly with stitches or covered with a non-resorbable or resorbable membrane and sutured.

Atraumatic Extraction

Atraumatic extraction is a modern technique used to remove teeth with minimal trauma to surrounding tissues. It's particularly beneficial for patients prone to complications like bleeding, necrosis, or jaw fractures. This method also preserves bone for future implant placement. It involves minimal forceps use, which can damage socket walls, relying instead on elevators and syndesmotomy.

Missing Teeth Replacement Options

After a dental extraction, a space is left behind. The options to fill this gap are typically categorized as follows:

Fixed Bridge:

Advantages:

  • Provides a stable solution for tooth replacement.

  • Restores chewing function and aesthetics.

  • Prevents adjacent teeth from shifting.

Disadvantages:

  • Requires drilling on adjacent teeth for support.

  • Lifespan varies (average 5-10 years).

  • Conservative bridge preparation may minimize damage to adjacent teeth but still requires some alteration.

  • Complex and costly treatment.

  • Not suitable for all cases, particularly large gaps or situations where alveolar bone resorption may affect long-term stability.


Dental Implant:

Advantages:

  • Fixed directly to the jawbone, preventing alveolar bone resorption.

  • Long-term lifespan.

  • Provides stable tooth replacement.

  • Restores chewing function and aesthetics.

Disadvantages:

  • Expensive and complex procedure.

  • Requires a specialist for placement.

  • Additional procedures like bone grafting may be necessary.

  • Not recommended for tobacco smokers due to increased risk of complications.


Denture:

Advantages:

  • Simple, quick, and cost-effective compared to bridges and implants.

  • Does not require drilling of other teeth.

  • Ideal for replacing several teeth at once.

  • Easy to replace multiple teeth with a denture.

Disadvantages:

  • Not fixed in the mouth, leading to potential issues with stability.

  • Can exacerbate periodontal disease without proper oral hygiene.

  • May cause damage to soft tissues over time.

  • Accelerated resorption of alveolar bone compared to no denture.

  • Poor tolerance in individuals with over-sensitive gag reflex or xerostomia.


    No Replacement:

    Advantages:

    • Often chosen due to lower cost or lack of motivation for other treatments.

    • Part of a short-term dental arch plan, focusing on preserving essential teeth for normal function.

    Disadvantages:

    • Alveolar bone will gradually resorb over time.

    • Potential aesthetic concerns.

    • Risk of drifting and rotation of adjacent teeth into the gap, affecting overall dental alignment.