I decided to deal with this topic, which, incidentally I am writing in Honolulu, Hawaii where I am attending the American Dental Association’s annual meeting, whereby a Continuing Education (CE) course treats with the socio-economic impact of widespread extractions in a population similar to ours. Like any so-called underdeveloped country, extractions constitute the major procedure performed in all our government dental clinics. But do these patients know enough of what it entails?

Now, extractions are performed for a wide variety of reasons. Of the six reasons that justify when a tooth should be extracted, toothache is not one of them. I know that sounds unbelievable but it is true. One of the major functions of a dentist is saving teeth and not extracting them.

However, if the tooth’s crown is destroyed significantly by chronic decay, insufficient tooth structure remaining would then prevent restoration and therefore extraction is the only option. Extractions of impacted or problematic wisdom teeth are routinely removed, as well as some permanent teeth to make space for orthodontic treatment (straightening of teeth). There are other reasons a tooth is extracted such as supernumeraries (extra teeth), “riders”, retained baby teeth, etc.

Extractions are often categorised as “simple” or “surgical”. Simple extractions are performed on all teeth that are visible in the mouth, usually under local anaesthetic, and require only the use of instruments to elevate and/or grasp the visible portion of the tooth. Typically the tooth is lifted using an elevator, and subsequently using forceps, rocked back and forth until it is loosened from the alveolar bone, before being removed from the socket.
Surgical extractions involve the removal of teeth that cannot be easily accessed, either because it has been broken or decayed under the gum line or because it has not erupted.

What dentists dread the most is when such a tooth has bulbous roots. Imagine taking a light bulb out of sand in comparison with taking it out of wood. So, in a surgical extraction, the dentist makes an incision in the gum to reach the tooth and may also require the removal of overlying bone tissue with a drill. After the tooth is removed, a blood clot will usually form in the socket. Occasionally this clot can be dislodged, resulting in a condition called dry socket which is known as alveolar osteitis. The patient would suffer from terrible “after pain”.

This is not uncommon and occurs almost exclusively after extraction of lower molars due to their lesser blood supply than their upper counterparts. Certain factors contribute to its development, such as age, smoking, birth control, extent of surgery performed to extract the tooth, duration of time the extraction site was surgically exposed, and various others. Dry sockets prolong the healing process and usually cause severe pain and discomfort. Most of the common pain relievers do not ease the suffering. The treatment for this condition is usually managed by your dentist.

At times infections occur, although relatively rare. In these cases antibiotics may be prescribed. Occasionally, the dentist decides that prophylactic medication is preferred depending on the oral health propensity of the patient.

The dentist has a variety of means at his/her disposal to address excessive bleeding, However, it is important to note that small amounts of blood mixed in the saliva after extractions are normal–even up to 48 hours after extraction. Swelling may occur which is often dictated by the amount of surgery peformed to extract a tooth (e.g. surgical insult to the tissues both hard and soft surrounding a tooth).

There are instances in which this can occur when extracting upper molars in some patients. The maxillary sinus is right above the roots of upper molars and premolars. There is a bony floor of the sinus dividing the tooth socket from the sinus itself. This bone can range from thick to thin from tooth to tooth and from patient to patient. In some cases it is absent and the root is in fact in the sinus.

At other times, this bone may be removed with the tooth, or may be perforated during surgical extractions. The doctor typically mentions this risk to patients, based on evaluation of x-rays showing the relationship of the tooth to the sinus. It is important to note that the sinus cavity is lined with a membrane called the Sniderian membrane, which may or may not be perforated. If this membrane is exposed after an extraction, but is intact, a “sinus exposed” has occurred. If the membrane is perforated, however, it is a “sinus communication”.

These two conditions are treated differently. In the event of a sinus communication, the dentist may decide to let it heal on its own or may need to surgically obtain primary closure, depending on the size of the exposure as well as the likelihood of the patient to heal. In both cases, a resorbable material called “gelfoam” is typically placed in the extraction site to promote clotting and serve as a framework for closure.

Patients are typically provided with prescriptions for antibiotics that cover sinus bacterial flora, decongestents, as well as careful instructions to follow during the healing period. Nerve injury is primarily an issue with the extraction of third molars, however, it can technically occur with the extraction of any tooth should the nerve be in close proximity to the surgical site. Two nerves are typically of concern, and are found in duplicate (one left and one right side).

The inferior alveolar nerve, enters the mandible at the mandibular foramen and exits the mandible at the sides of the chin from the mental foramen. This nerve supplies sensation to the lower teeth on the right or left half of the dental arch, as well as sense of touch to the right or left half of the chin and lower lip. Then there is the lingual nerve (one right and one left side). Damage to these may affect sensation to the tongue.