In this country, like any so-called underdeveloped country, extraction constitutes the major procedure performed in all dental clinics. But do these patients know enough of what it entails? Now the extractions are performed for a wide variety of reasons. Among tooth decay (dental caries) that has destroyed sufficient tooth structure to prevent restoration is the most frequent indication for extraction of teeth. These are commonly referred to as “stumps.” Extractions of impacted or problematic wisdom teeth are routinely done, as are extractions of some permanent teeth to make space for orthodontic treatment (straightening of teeth). There are many other reasons why teeth are extracted such as badly damaged, abscessed, shaking badly, “riders” etc.
Extractions are often categorised as “simple” or “complex.” 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/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. Complex extractions involve the removal of teeth that cannot be easily accessed, either because it has broken under the gum line or because it has not come in yet.
In a complex extraction the dentist makes an incision in the gum to reach the tooth and may also require the removal of overlying bone tissue. After the tooth is removed, a clot will usually form in the socket. Occasionally this clot can become dislodged, resulting in a condition called dry socket also known as alveolar osteitis. This is not uncommon and occurs almost exclusively after extraction of lower molars, due to their lesser blood supply than their maxillary counterparts. Certain factors contribute to its development, such as age, smoking, birth-control pills, extent of surgery performed to extract the tooth, duration of time the extraction site was surgically exposed, and various others. Dry-socket lengthens the healing process and usually causes severe pain and discomfort that is often not manageable with pain medications. It is sometimes treated with a medicated gauze, resorbable gel-foam or surgical packing that is changed (or replaced) every two to three days until granulation tissue can cover the bone at the extraction site. Often, these dressings contain a material called “eugenol,” an obtundant which alleviates dry-socket pain.
Occasionally complications may include infection and the dentist may opt to prescribe antibiotics pre- and/or post-operatively if he/she determines the patient to be at risk. Also, prolonged bleeding could occur. The dentist has a variety of means at his/her disposal to address 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 is often dictated by the amount of surgery performed to extract a tooth (e.g. surgical insult to the tissues both hard and soft surrounding a tooth). Generally, when a surgical flap must be elevated (i.e. and the gum covering the bone is thus injured), minor to moderate swelling will occur. A poorly-cut soft tissue flap, for instance, where the periosteum is torn off rather than cleanly elevated off the underlying bone will often increase such swelling. Similarly, when bone must be removed using a drill, more swelling is likely to occur.
Sinus exposure and oral-antral communication can occur when extracting upper molars (and in some patients, upper premolars). The maxillary sinus ( a large natural cavity) sits right above the roots of maxillary 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 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 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 granulation tissue to accumulate. Patients are typically provided with prescriptions for antibiotics that cover sinus bacterial flora, decongestants, as well as careful instructions to follow during the healing period.
An extraction could also involve nerve injury which is primarily an issue with extraction of third molars. However, this 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):
1. the inferior alveolar nerve, which 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.
2. The lingual nerve (one right and one left side), which branches off the mandibular branches of the trigeminal nerve and courses just inside the jaw bone, entering the tongue and supplying sense of touch and taste to the right and left half of the anterior 2/3 of the tongue as well as the lingual gingiva (i.e. the gums on the inside surface of the dental arch).

(Dr BERTRAND R. STUART D.D.S)