Tooth extraction

A HAPPY New Year to all readers of the health column, wishing you all a very healthy 2017 ahead filled with bright, white and radiant smiles.

This month I will focus on some very basic and common dental procedures and a brief description of their:

— indications (why and which patients they should be done on)

— contraindications (when they should not be done)

— how they are done

— what to expect

— post procedure instructions to avoid complications

The purpose of my articles this month is to make visits to the dentist more relaxed and pleasant, reduce the possible risk of complications, and ensure that patients make more informed decisions about their treatment options. I also hope to eradicate the many misconceptions and fear of the dentist that so many people have.

This week’s article will be about tooth extraction.

Definition

A dental extraction (also referred to as exodontia, exodontics, or informally, tooth pulling) is the removal of a tooth or teeth from the dental alveolus (socket) in the alveolar bone.

Indications

Generally most dentists will try, patient finances allowing, to save each and every tooth a patient has by all other means possible before extracting a tooth.

For the following there is no sensible alternative treatment option:

teeth severely damaged by decay, roots left inside the tooth socket

teeth severely damaged by periodontal disease (gum disease)

teeth with peri-apical (infection in the tooth root area) infections that can neither be preserved endodontically nor by surgery and have caused an extensive inflammation (eg of the maxillary sinus or the soft tissue) or a cyst.

teeth damaged by trauma (multiple fractures, longitudinal fracture, extensive bony defect in the periodontal (gum and root) region)

In case of crowding or impeded (delayed) eruption, milk teeth and permanent teeth should be extracted for orthodontic reasons.

during prosthodontic (dental prosthesis) treatment in order to maintain normal occlusion (elongated or heavily tilted teeth, particularly with previous contacts)

during tumor surgery, teeth located within the area of the tumor.

Supernumerary (teeth that appear in addition to the regular number of teeth) teeth which are blocking other teeth from coming in.

Preventive/prophylactic removal of healthy impacted wisdom teeth (wisdom teeth which do not fully erupt into the mouth because of blockage from other teeth)

Treatment of symptomatic impacted wisdom teeth whose impaction (wisdom teeth which do not fully erupt into the mouth because of blockage from other teeth) is causing pain and discomfort that will lead to yet more (infection, inflammation, bone resorption).

Cosmetic — to remove teeth of poor appearance, unsuitable for restoration.

Reduced cost compared to other treatments

Contraindications

Contra-indications for an extraction usually concern the general medical suitability of the patient for surgery (bleeding tendency, immunosuppression, condition following myocardial infarction more commonly known as a heart attack less than six months prior to the day of extraction), or a local surgical disorder (abscess, tumor). The tooth/teeth should then be extracted after adequate pre-treatment and, if necessary, under what are referred to as risk conditions.

Local contra-indications

taking inflammation into consideration

during radiation and chemotherapy

general medical contra-indications

anti-coagulation, hemorrhagic diathesis or hemophilia — in these cases, the responsible physician must be consulted with regard to current coagulation parameters and necessary substitution or a change of medication

acute phase of a myocardial infarction

acute leucocytosis and agranulocytosis

severe cardiac insufficiency

Procedure

Simple extractions are performed on teeth that are visible in the mouth, usually under local anaesthetic, and require only the use of instruments to elevate and grasp the visible portion of the tooth (crown). Typically the tooth is lifted using an instrument called an elevator, and using dental forceps it is rocked back and forth until the periodontal ligament has been sufficiently broken and the supporting alveolar bone has been adequately widened to make the tooth loose enough to remove.

Surgical extractions involve the removal of teeth that cannot be easily accessed, either because they have broken under the gum line or because they have not erupted fully. Surgical extractions almost always require an incision. In a surgical extraction the doctor may elevate the soft tissues covering the tooth and bone and may also remove some of the overlying and/or surrounding bone tissue with a drill. Frequently, the tooth may be split into multiple pieces to facilitate its removal.

Surgical extractions are usually performed under a general anaesthetic.

Immediately following surgery

Bite firmly on the gauze pads covering each extraction site to help stop the bleeding, keep biting the gauze firmly for the next hour. Remember to remove gauze before eating or drinking. You may have difficulty feeling your lips, cheeks or tongue due to numbness. This is a temporary feeling and will wear off within two to six hours. Please take care not to bite your lips, cheeks or tongue.

Bleeding

When you get home, fold and place a gauze pad directly over the extraction site and bite firmly for 30 minutes. If excessive bleeding continues, apply another fresh gauze pad for an additional 30 minutes. Excessive bleeding is defined as pooling or dripping blood out of the extraction sites within 15-20 seconds of removing the gauze. Don’t use the amount of blood on the gauze as a guide, because minimal bleeding may persist for up to 24 hours. It is not unusual for saliva to be slightly blood-tinged for several days following surgery.

Medication

You may receive a prescription for an antibiotic and/or a pain reliever. Take all medications as instructed by your dentist.

Pain management

Some amount of discomfort is to be expected following any surgery. If your dentist feels you will benefit from a prescription pain medicine, you will receive a prescription following your surgery. Please follow the instructions carefully.

Diet

If possible chew on the opposite side of your extraction site. For multiple extractions, you should have soft foods on the day of surgery and the day following surgery. Soft foods include ice cream, pudding, jelly, yoghurt, soup (lukewarm), pancakes, mashed potatoes, scrambled eggs, pasta. Avoid hard, crunchy foods such as chips or nuts that may disturb the extraction site for at least one week. After the third day, you may eat anything you wish, unless given other specific instructions by the doctor. No alcoholic beverages should be consumed for at least 24 hours following general anaesthesia or as long as you are taking pain medications.

Smoking

Do not smoke for at least 3 days following surgery. The longer you avoid smoking, the better your healing will progress.

Brushing/Rinsing

Avoid all brushing, rinsing or spitting the day of the surgery. The day after your surgery, you may brush your teeth, but avoid brushing near the surgical site(s) for 3 days. Rinse with ½ cup warm water and a pinch of salt beginning 3 days after surgery.

Straws

Do not use a straw for 3 days following surgery.

Sutures/“stitches”

Your sutures dissolve on their own and may come out any time after surgery. You may notice that they are loose after the swelling of your gum tissue decreases. This is completely normal.

Resuming activities

Do not drive or engage in strenuous activities for at least 24 hours. You may return to work or school when you feel you are recovered. If you have undergone general anaesthesia, you should go home immediately and rest for the remainder of the day.

Dry socket

After tooth extraction, it’s important for a blood clot to form to stop the bleeding and begin the healing process. A dry socket occurs when the blood clot is dislodged from the surgery site exposing the bone and nerve endings. This condition is more common in back teeth, particularly wisdom teeth, although it can occur in any extraction site. Dry socket occurs two or more days after an extraction and can last 5-6 days.

Avoiding dry socket

Do not smoke.

Clean the extraction site as instructed and follow all at-home instructions.

Avoid sucking action from smoking, spitting or using straws for the first 24 hours.

Do not rinse mouth excessively; it interferes with blood clotting.

Follow-up appointment

You may be asked to return for a post-operative follow-up visit 10 to 14 days following surgery. Please make every effort to return to have your surgical sites examined for proper healing.

Always remember to feel free, ask questions at all your dental appointments, it is the duty of every dentist to ensure that patients fully understand any procedure and why it must be done.

‘‘A healthy you is a happy you.’’

Kimberley Eve Nyathi

Final year BDS

Lviv National Medical University