but by far, the most common is that the patient is in pain and wants to relieve the pain as quickly, permanently and as inexpensively as possible. This does not mean that there are not other ways of relieving the pain. But the other methods are likely to be more expensive or inconvenient. Other reasons are:
1. Simple extractions
A Simple extraction is one in which the dentist can remove the tooth simply by loosening the gums around it, grasping the crown above the gumline with a plier-like forceps and then moving it side to side until it loosens from the bone. Teeth are normally held into the bone by a thin sheathe of soft tissue that separates it from the bone like a sock separates a foot from a shoe. This sheathe is called the periodontal ligament, and it is this structure which ultimately enables the dentist to remove the tooth. The key to simple extractions is to rock the tooth side to side slowly enlarging the socket in the bone while at the same time breaking the ligament which binds the tooth in the socket.
2. Complex (surgical) extractions
Unfortunately, not all extractions can be done by simply grasping the tooth with forceps and rocking it out. What if there is nothing left above the gumline to grasp? Or what if the crown breaks off leaving the roots still in the bone? These things can and do happen, and any dentist that extracts teeth will have to deal with them routinely. In these cases, it becomes necessary to surgically remove the tooth. This means that the dentist must make an incision into the gums around the tooth and raise a flap of tissue exposing the tooth and its surrounding bone.
Sometimes, after the flap is raised, there is enough tooth exposed to grab and remove it as in a simple extraction (#1 above). But more often, the tooth is submerged below the level of the bone. In this case, the dentist must take a handpiece (drill) and cut away some of the surrounding bone in order to gain a purchase on the tooth. After the tooth has been pried out of the artificially enlarged socket, the dentist then sutures (sews) the flap of tissue back in place so that healing can proceed normally.
3. Impacted teeth
When a tooth does not fully erupt into the mouth, but remains below the gums, it is said to be impacted. Impacted teeth can present special health problems for most patients, and they are generally removed to prevent future difficulties. The extraction of such teeth proceeds like the surgical extraction explained above with a few modifications. Sometimes, the only surgical procedure is the raising of the soft tissue flap. If after raising the flap, the extraction can proceed as a simple extraction, the tooth is said to be a “tissue impaction” because there was enough of the crown left above the bone to grab and extract with forceps.
But many times the crown is submerged below the level of the bone. The tooth may even be lying on its side under the bone which complicates the extraction further. In these cases, not only must the dentist remove surrounding bone in order to expose the tooth, but he must cut and break the tooth itself into sections so that each section can be removed separately. Teeth in this condition are said to be “bony impactions” and are further classified as vertical, horizontal or angular depending on the angle of the tooth under the bone.
Wisdom teeth are known as third molars in dentistry. In the X-ray film above, if you count the number of large teeth from the front of the mouth to the back, you can see that the “third” ones are impacted (as defined above). They are called wisdom teeth because they erupt at about the age of 17 or 18 when people are supposed to begin to assume the mantle of adulthood (I can only assume that this name must be a hangover from centuries ago when people only lived to 25).
During the course of evolution, our faces tended to get shorter, but the number of teeth did not decrease as rapidly as the shortening of the jaws. Most people do not have enough room in the dental arches for their wisdom teeth, and they tend to remain fully or partially impacted, under the bone of the jaw, or at least partly under the gums (as in the image above). In some cases, the wisdom teeth may remain impacted all of a person's life without causing trouble, but in a high stress society, these people are in the minority.
What's stress got to do with it? You'll see.
A molar (wisdom tooth) buried under swollen gums. You might think that a tooth that is totally buried under the gums should not come into contact with germs from the mouth, and thus should not be prone to infection. Usually, however, the enamel on the crown of the impacted wisdom tooth is in contact with the enamel on the crown of the second molar, which is erupted and immediately in front of the wisdom tooth. Gums cannot attach to enamel.
Thus the gums lie over the crown of the wisdom tooth like a glove lies over the hand, in close approximation, but not attached to it. Germs can leak under the gums at the place where the enamel of the second molar contacts the enamel of the wisdom tooth, Therefore, there is almost always a communication between the germs that live in the mouth and the space surrounding the wisdom tooth.
It is a tooth you cannot brush. When your body's resistance is normal, the germs surrounding the impacted tooth are kept at bay by the body's normal immune system.
But if the body's resistance is decreased, through sickness or emotional stress, the germs can get the upper hand and you find yourself with an infection around the wisdom tooth. These infections are called “pericoronitis” which means (appropriately), “an infection around an unerupted tooth”.
Once you get a case of pericoronitis, it can be controlled temporarily by a having the dentist clean around the tooth and following up with a course of antibiotics. But pericoronitis tends to return at regular intervals until the offending tooth is finally removed.
As a rule impacted upper wisdom teeth cause few symptoms if no obvious oral infection is present. But in the case of peircoronitis, the infection can sometimes be transferred to the sinus causing typical sinus headaches and congestion. Conversely, the extraction of a wisdom tooth in this location can occasionally cause problems with the sinus.
People ask all the time if the problems they are having with their sinuses are caused by their otherwise non symptomatic impacted wisdom teeth. The answer is that it is always possible that there is a connection, but generally impacted wisdom teeth rarely cause sinus discomfort directly unless an obvious infection like pericoronitis is present.
I usually tell my patients that in rare instances, the removal of these teeth can be associated with the relief of chronic headaches, but there is no guarantee that there is a connection between their headaches and their wisdom teeth.
It is more likely that the patient is suffering from some of the symptoms of TMJ which are caused by the unconscious habit of grinding and clenching the teeth (bruxing). Click here to learn more about dentally related headaches.
Aside from pericoronitis, there are two other complications associated with impacted wisdom teeth. They both involve the uncontrolled expansion of the follicle (the space in the bone where the tooth was originally formed). This follicle is lined with cells which are supposed to transform into the lining of the sulcus of the gums when the tooth erupts. But if they are kept submerged for too long, they sometimes forget their original mission and begin to produce fluid which expands the follicle causing a cyst.
These cysts can become very large and cause distortion of the bone and face, and can lead to such weakness in the bone the jaw may be prone to fracture.
The second, very rare complication arising from uncontrolled follicular growth is a form of tumor called amyloblastoma. This tumor is not considered a cancer because it does not tend to metastasize (spread to other areas of the body), but it is locally invasive which means that it grows uncontrollably and can cause major damage and weakness in the bone if it is not thoroughly removed.
Amyloblastoma is most likely to attack young adult males. It is less frequent in females or older people of either sex. Since it is always associated with an impacted tooth, usually a wisdom tooth, (but not always, as seen in the images above) it rarely occurs before the age of 18. It is difficult to remove entirely, and the surgeon will usually perform a wide excision (ie. he takes a lot of extra bone along with the tumor) just to be sure that he has removed it all.
Following this discussion of what you should and should not do after an extraction, I will go into the complications that can arise if you do not follow this advice. If you have any doubt about the need to follow these instructions, skip ahead and read about the complications.
1. You are sick, even if you don't know it yet. (Wait until the anesthesia wears off and then you will know it.) Go home and act sick! I mean go home, put your head down and do not exercise for at least 12 to 24 hours. Do NOT go to work just because you feel great while your mouth is still numb. The nicer you are to yourself today, the more likely it is that you will be able to resume a normal life tomorrow.
2. When you leave the office, you should have a piece of gauze over the socket. Keep biting on the gauze for at least two hours. Do not chew on the gauze. Just keep constant, even, gentle pressure on it so that the socket is covered, and the bleeding is stemmed. There is only one way to stop bleeding, and that is to keep biting on the gauze. If you go to the emergency room with bleeding, they will sit you down in a chair and make you bite gauze for another two hours. Be sure that the extraction socket is completely covered by the gauze. You do not have to change the gauze unless it becomes soaked with blood.
If you have kept the socket covered firmly for at least two hours, the blood in the socket should have clotted. The clot then acts like a cork and keeps you from bleeding further. If the clot is kept intact you may fall asleep and wake up with some blood on the pillow, but this is just a bit of blood oozing from the clot while it continues to organize itself. The blood mixes with saliva and can can appear worse than it really is.
3. Do not spit for 24 hours. If you spit, you tend to suck, and this will dislodge the clot causing renewed bleeding, or even a dry socket. You may gently bring blood and saliva forward with your tongue and wipe it away with a tissue, but avoid forceful spitting at all costs.
4. Do not smoke for 48 hours! If you smoke, you WILL get a dry socket because the chemicals in the smoke get into the saliva and dissolve the clot. Even worse, the continued smoking irritates the bone in the socket and the dry socket will be especially painful and persistent. If you have ever had a dry socket, you will do ANYTHING to avoid another one.
5. Wait until the anesthesia wears off before eating anything solid, and when you can feel your mouth, you can eat whatever you can tolerate.
6. Take your medications. If you have been prescribed an antibiotic such as penicillin or erythromycin, take it on schedule until it is all used up. Dental infections can be not only painful, but quite dangerous. The pain medications can reduce swelling and speed your recovery. If you are prescribed a narcotic like codeine, Vicodin or Percocet, do not drive or operate equipment under the influence.
7. If, after 48 hours, the pain gets worse, or you start bleeding again, call the dentist. You could be getting a dry socket, or an infection.
It is possible to bleed to death following the extraction of a tooth. But it almost never happens. All you have to do is follow directions #1 and #2 above and the bleeding will stop. The only patients that may still be in danger from excessive bleeding are those who are taking anticoagulant drugs (blood thinners) like Coumadin or Heparin for cardiovascular problems, or people with bleeding disorders like Hemophilia or related clotting cascade disorders . These patients should consult their physicians before having a tooth extracted. People taking aspirin and other non steroidal anti inflammatory drugs (NSAID's) like Advil or Aleve may experience prolonged bleeding times, but in my experience, these drugs have never presented a problem as long as the patient keeps the extraction site covered with gauze to stem the bleeding. The blood WILL clot eventually!
The mouth is alive with bacteria, especially in people with poor oral hygiene. Infection is a constant problem after extractions, and most dentists have developed a personal protocol on whether or not a particular patient needs preventive antibiotics. People who present at the office with swollen faces, teeth tender to light pressure, swollen gums or tongue, or bleeding and pus around a tooth are generally already infected. They should expect to be given prophylactic (preventive) antibiotics after an extraction.
Patients may develop infections after an extraction even if they were not infected before the extraction. This is a common complication and is due to the fact that that the mouth is teeming with bacteria and cannot be sterilized prior to the extraction. (They are NOT due to any error on the part of the dentist!) The first sign of an infection after an extraction is often renewed bleeding after 48 hours. The bleeding is not generally severe, but it is an indication that the patient should return to the dentist's office for evaluation and possibly a prescription for antibiotics. Signs of infection two days after an extraction should be attended to as soon as possible. Click here to see how severe tooth related infections can become.
Some dentists will give a patient an antibiotic and send them home for several days to allow the infection to clear before attempting the extraction. The reason for this is because the local anesthesia does not work as well in acid environments and it may take a lot of shots to get the patient numb. However, if the dentist gives enough anesthesia, it is possible to extract a tooth under such circumstances. In general, I have never found that extraction of a tooth in the presence of an active infection has presented special problems as long as the patient takes the antibiotics prescribed faithfully.
It is NOT necessary to take antibiotics after every extraction. A simple extraction in a clean, uninfected mouth generally does not require prophylactic antibiotics.
Whenever the extraction requires the cutting of any tissue (see surgical and impacted extractions above), it is generally a good idea to give prophylactic antibiotics, and the patient SHOULD fill the prescription and take the drug faithfully, or he may suffer an extended convalescence.
A Dry Socket, while not potentially life threatening like bleeding or infections, is one of the most painful, common, debilitating and dreaded post extraction problems encountered in dentistry. They are much more common following the extraction of lower teeth than they are after extraction of upper teeth. They can happen after even the simplest of extractions. If you follow all of the post surgical directions listed above, you have done the most anyone can do to prevent them. Unfortunately, no matter how hard you try, you may still get one. If you get one, it is not (necessarily) your fault. Nor is it the fault of the dentist. They are a quirk of nature. You may THINK you are going to die. You won't!
The two classes of patients who are most prone to dry sockets are those who smoke during the first 48 hours after the extraction, and persons who tend to constantly grind and clench their teeth (see my page on TMJ)
A dry socket is a condition in which the blood clot that forms in the extraction site becomes detached from the walls of the socket, or dissolves away leaving the bare bone exposed to saliva and the foods you eat. The bone becomes inflamed due to bacteria and chemicals in the mouth, and this inflammation is persistent and painful. The pain is “deep pain”. That is, it comes from tissues buried deep in the body, and your brain has no experience of pain from these regions. When the brain receives pain signals through these unusual channels, it is unsure of the exact location of the pain, so it tells you that the pain is coming from areas on that side of your face and head that are far removed from the actual source. Pain like this is called “referred” pain. It seems to shoot up the side of the head, or makes your eye ache.
Left alone, dry sockets will always heal. It takes a month or two, and the pain is persistent for the entire period of healing. Antibiotics are not useful in curing a dry socket, and the usual pain medications are not very effective. It is better to go back to the dentist who extracted the tooth and let him or her “pack” the socket. This is a procedure done (usually) without anesthesia even though it can be painful, because it does not take too long, and the pain relief is almost complete, beginning an hour or so after the socket is packed.
The first packing will provide relief for about 24 hours. As you return to the dentist and the old packing is removed, the socket washed out and new packing is placed in, each succeeding packing debrides (cleans) the socket and renews the pain relief. A second packing may last 24 to 48 hours, and succeeding packings last longer still. Within a week (or sometimes more depending on the severity of the dry socket), The socket begins to heal from the bottom up and can be left empty without pain.
Yes, it does occasionally happen. The fracture of a lower jaw is unusual, principally because dentists who extract teeth routinely do not place great force on any instrument to remove a tooth. Teeth are generally “finessed out” with a minimum of pressure applied to the jaw through the surgical instruments. There are, however, some situations in which a dentist can look at the x-ray and see that the jawbone that surrounds the tooth is much more fragile than is usually the case, and will usually warn the patient that fracture of the jaw is a possibility.
People are not like cars, every one identical. Everyone is unique and presents unique circumstances under which the dentist must labor. The chances that the removal of any given tooth will result in a fractured lower jaw run about the same for any dentist who attempts the extraction. That particular patient is usually more prone than other people to a broken jaw due to any traumatic incident such as a traffic accident or a blow to the jaw during a sporting event. Unfortunate, but true, and a fact of life for any dentist who extracts teeth.
There is always a thin wall of bone between the root and the sinus, but is can be very thin indeed. Most of the time, the bone remains intact, but upon occasion, a piece of the bone separating the root from the sinus may break off and be removed with the tooth. This creates a direct connection between the sinus and the mouth! That means that you would be unable to suck on a straw, because air would rush into your mouth from your nose through the socket.
Sometimes a sinus perforation will go unnoticed by the dentist or the patient. If the perforation is small, the only symptom could be a nosebleed. If this happens, call the dentist so he can prescribe the proper drugs so that healing can proceed normally
When a sinus perforation occurs, the dentist will prescribe an antibiotic to prevent infection and a decongestant to keep the sinuses clear during healing. The patient bites on his gauze as is usual after any extraction, and a clot will form in the socket as usual. If nothing disturbs the clot, it will organize during healing and close the perforation. Dry sockets rarely happen after extraction of upper teeth unless the patient smokes.
In the case of very large perforations, or in case the clot dislodges and a perforation between the sinus and the mouth remains after healing, It may be necessary to perform a further surgical procedure in order to draw a flap of gum tissue over the perforation to close it permanently.
Whenever a dentist extracts a tooth, it requires that the bone that used to hold the tooth be expanded, or sometimes even fractured to allow the tooth to slip out of the socket. Most of the time, these fractures are of the type known as “greenstick” fractures which means they are only partial fractures immediately around the top of the socket leaving the bone fragments still attached to the main body of the bony structure beneath. In some instances, these greenstick fractures coalesce to release a bone fragment completely from the underlying bony structure. Even when this happens, the bone fragments tend to heal and reattach to the main body of the bone during healing.
In the oral cavity, however, the presence of oral bacteria, as well as noxious chemicals from the foods we eat and cigarettes we smoke can cause the healing to cease. This is what causes dry sockets. Bony fragments that do not heal properly often loose their blood supply and become “necrotic” (dead tissue). Thus, the body begins the process of ejecting them from the healing socket, a process known as sequestration. The process can be painful, and sometimes requires the dentist to reenter the socket to remove the sequestrum. When the sequestrum comes out on its own, the patient often mistakes this piece of bone for a piece of tooth that the dentist left in the socket.
Sequestrii are a normal complication of extractions. They are often unavoidable, and undetectable at the time of the extraction. They are not considered to be a mistake the dentist made. Once the sequestrum is gone, the healing resumes, the pain subsides and all is well.
A large majority of teeth are removed in one piece when they are extracted by the dentist. However, many do break leaving one or more fragments of varying size in the bone. The dentist must decide at the time of the extraction whether or not to remove the remaining tooth fragment. In most instances, it is NOT essential to remove every root fragment that is left in the bone!! Retained root tips will generally simply heal in place and never cause a problem to the patient after healing.
In the few cases in which the root fragment is rejected by the body, it generally sequesters out of the socket like an ordinary bony sequestrum. The dentist must weigh the relative benefits of removal of the root tip versus the complications that the removal will cause the patient. Often, the removal of the offending root fragment necessitates quite a bit of drilling of bone and heavy duty prying, not to mention quite a bit of time. This always results in a much greater degree of pain for the patient during healing. It also increases the likelihood of a dry socket, which is a painful result that most people would rather do without. On the other hand, leaving the root tip in place causes no further difficulties to the patient most of the time.