Before your tooth extraction - Issues and concerns that must be addressed before having your tooth pulled. -

Tooth socket immediately after extraction.

Setting the stage for your tooth extraction.

Here's what must be done:

• A pretreatment examination (including x-ray evaluation of your tooth).
• Taking your medical history and identifying associated risks.
• Evaluating your current medications and identifying potential complications. (Blood thinners, bisphosphonates/Fossamax®, etc...).
• Making preparations for your procedure: 1) Will premedication with antibiotics be needed? (active infection, medical conditions, post-op infection prevention)   2) Will some type of patient sedation be used?

A) The pre-extraction dental examination.

Your dentist will need to examine your teeth and mouth before they can make a determination that getting your tooth out is warranted.

The relative ease and simplicity of having your tooth pulled might seem to be an attractive choice when compared to the cost, time and effort needed to salvage, or even just repair it. But in many situations, extracting your tooth is unlikely to make the best, or even the cheapest, option when the long-term is considered. (Here's why.)

After performing their examination, your dentist will explain their findings. It's their obligation to discuss the advantages and disadvantages of all of the different treatment options that are available for your tooth.

All tooth extractions require a pretreatment x-ray(s).

It aids in both diagnosis and treatment planning.

An x-ray of your tooth will be required.

• The current condition of your tooth and its supporting tissues.
• What options other than just extraction might provide a suitable solution for your situation. (In all cases, it's your dentist's obligation to advise you if another type of treatment, such as root canal therapy or performing gum treatments might provide a way of salvaging your tooth.)
  
• Factors associated with the tooth, surrounding bone tissue and nearby structures that might affect the level of difficulty of the extraction.
  

  This includes: 1) Root formation and curvatures. 2) Pathology associated with the tooth or associated structures. 3) The position of nearby nerves or sinuses. 4) Surrounding bone density.

B) Taking your medical history.

Before they can remove your tooth, your dentist will need to collect and evaluate your relevant medical information. That's because the most important thing they can do to avoid complications associated with your procedure is to carefully check that you're able to tolerate it.

Even if they don't ask, make sure to report if you've had any problems with previous tooth extractions or have any bleeding disorders. Also make sure to report all medical conditions you've been diagnosed with, both treated and untreated.

(A complete list of the medications you take, including non-prescription and herbal ones, must be reported to your dentist too. See below.)

a) Some medical conditions require special management.

Several medical conditions are well known for creating risks and potential complications during oral surgery. Some of them include:

• Insulin-dependent diabetes mellitus - Patients with IDDM are at risk for developing hypoglycemia when placed in situations where their regular insulin regimen, dietary intake or stress levels are disrupted. Uncontrolled diabetics also have an elevated risk for post-extraction infections.
  

  The dentist's management of diabetic patients includes scheduling comparatively shorter procedures, preferably in the morning shortly after breakfast. Helping to ensure that the patient's dental care doesn't interfere with their ability to maintain their needed diet. Having appropriate medicines and dietary supplements on hand for treating diabetic emergencies (hyperglycemia, hypoglycemia).

• Patients with uncontrolled/untreated diabetes, or adrenal insufficiency, hypothyroidism, or renal disease, must be evaluated by a medical professional before an extraction can be planned.
  
• Cardiovascular disease - The elevated levels of stress that frequently accompany oral surgery can place the patient at risk for experiencing a cardiovascular emergency during their extraction procedure.
  

  The physician of patients who have experienced a cardiovascular episode (angina, heart attack, bypass surgery, stroke) within the previous 6 months should be consulted before an extraction is performed.

  Angina patients should take their nitroglycerin tablets with them to their appointment. Supplemental oxygen is often administered to at-risk patients during their procedure as a precaution. Additionally, anti-anxiety measures can help to decrease the patient's risk of experiencing a cardiac event.

• The dentist needs to be aware of any heart anomalies the patient may have. This includes murmurs, heart valve damage, artificial valves, congenital heart conditions, or damage caused by rheumatic fever.
  

  After evaluation, it may be determined that the patient must be considered at-risk for postoperative complications associated with heart-related bacterial infection, and therefore should be premedicated with antibiotics prior to their oral surgery.

• Congestive heart failure - A dentist will be concerned if the circulatory function of their patients suffering from congestive heart failure can meet the demands imposed during a tooth extraction.
  

  Patients whose condition is well controlled can typically tolerate routine dental surgery. As precautions, the use of anxiety control and supplemental oxygen during the patient's procedure can help to reduce their risks.

• High blood pressure - Generally speaking, persons whose systolic pressure is over 160mmHg or their diastolic value over 95mmHg are considered to be at-risk patients and as such their oral surgery is postponed until their physician can be consulted.

• Having liver disease (hepatitis, cirrhosis, alcoholic hepatitis) places the dental patient at increased risk for complications with bleeding. Additionally, the use of medications metabolized by the liver must be judiciously monitored.
  

  Clotting tests (partial prothrombin time, prothrombin time) are useful in evaluating persons with severe liver damage and their ability to tolerate oral surgery. Cases involving patients that have infectious liver diseases can typically be managed appropriately using routine universal precautions.

• Bleeding disorders and hematological conditions, including anemia, sickle-cell anemia, acute leukemia, lymphoma, cytotoxic chemotherapy, bone marrow transplantation and clotting disorders, must be evaluated and considered in light of the patient's oral surgery, with appropriate measures taken.
  
• Epilepsy - The dentist should be aware of what's typical for the patient in terms of seizure frequency, severity, and duration. Appointments should be scheduled within a reasonable time period after the patient takes their seizure-control medication.

• Patients undergoing renal dialysis require special management. The timing of appointments in regard to dialysis scheduling, as well as the dosage and types of medicines used, are issues that must be managed. Patients having grafts or catheters typically require premedication with antibiotics (see below).
  
• Patients with a history of head and neck radiation treatments are at risk for developing osteoradionecrosis (a bone complication) following extractions.

▲ Section references - Fragiskos, Koerner

b) Pregnancy - Concerns and issues with oral surgery.

Being pregnant doesn't constitute a reason why you can't have a tooth taken out. But if you do, there are some general guidelines that should be followed.

• When possible, oral surgery procedures should be postponed until after the baby is born.
  

  However, with proper consultation from the patient's obstetrician, and depending on the urgency of the situation, extraction is possible during any stage of pregnancy.

• Extractions are preferably targeted for the second trimester.
  

  Patients with problem-free medical histories are generally considered low-risk patients (mother and fetus) during this time frame. However, for women who have a history of previous spontaneous abortion, oral surgery procedures during both the first and second trimesters should be avoided.

• During the third trimester, extractions should be especially avoided during the last several days of pregnancy because of the possibility of birth occurring during the dental visit.
  
• Keeping near-term patients in the supine position (lying back in the dental chair) should be avoided because this positioning tends to restrict the mother's blood flow to the fetus.

• During all trimesters, concerns about the effects of medications on the mother, fetus and pregnancy must all be considered.
  

  Drugs whose use is considered to be the safest during pregnancy are acetaminophen, penicillin, codeine, erythromycin, and cephalosporin. (Koerner)

• The use of proper x-ray protocol, including the use of a lead apron, makes the risks associated with taking x-rays small. But only essential radiographs should be taken, especially during the first trimester.

▲ Section references - Wray, Fragiskos, Koerner

c) Conditions that may require patient premedication with antibiotics.

Some medical conditions can place the patient at risk for developing a bacterial infection after having a dental procedure performed that involves bleeding, like an extraction. The point of bleeding in the mouth (no matter how small) provides the entry point for the bacteria. The infection that develops may be in a non-oral location (heart, joint).

When their risk is considered high for this complication, it will be mandatory for the patient to take "prophylactic" antibiotics before their dental surgery is performed. Especially in matters involving endocarditis (infection in the interior lining or valves of the heart), not doing so could be life-threatening.

• Cardiac conditions - Mitral prolapse with regurgitation, damaged or scarred heart valves (like from rheumatic fever), some congenital heart or valve defects, hypertrophic cardiomyopathy, a previous history of bacterial endocarditis.
• When foreign objects have been placed in your body - Prosthetic (artificial) heart valves, prosthetic joints (knee, hip, etc...), renal dialysis catheters.
  
• Other medical conditions - Uncontrolled diabetes, renal failure, HIV, lupus.

Our list above is not all-inclusive and is purposely vague. Research findings, as well as the opinions of the doctors and organizations who evaluate these studies when formulating recommendations and guidelines, are constantly evolving.

Don't be surprised if your dentist feels that they must consult with your physician before they make a determination that antibiotics are, or are not, needed.

▲ Section references - Koerner

C) Your current medications list.

Make sure your dentist is aware of all of the medications and supplements that you take (prescription, over-the-counter, and herbal) because some can cause complications with the extraction procedure or its healing process. As examples:

• Some medications and supplements are known to interfere with the blood clotting process and therefore should be avoided prior to having a tooth extraction. Some common culprits include:
  

  NSAID pain relievers - OTC products: Aspirin (including baby aspirin), ibuprofen (Advil, Motrin), naproxen (Aleve). Prescription products: celecoxib (Celebrex), diclofenac (Zorvolex), indomethacin (Indocin)

  Nutritional and herbal supplements - Garlic, ginseng, ginkgo biloba, feverfew, chamomile, fish oil, vitamin E.

  Prescription blood thinners - Heparin, Coumadin (warfarin), Eliquis (apixaban), Xarelto (rivaroxaban), Pradaxa (dabigatran).

  Platelet inhibitors - Plavix (clopidogrel). Some chemotherapy drugs reduce the number of platelets.

  In some instances, your dentist may instruct you to discontinue taking the drug for a few days to a week or more prior to your extraction appointment, then resume its use as is indicated afterward. In other cases, and especially with those that involve prescription medications, your physician may need to be consulted before an appropriate plan can be formulated.

  In cases where the continued use of the drug is needed without interruption, a decision might be made to remove fewer teeth per appointment. Additionally, extra steps (like the use of clotting aids) will be taken after removing any teeth so to help ensure that post-op bleeding is controlled.

• Women who take oral contraceptives may be at greater risk for developing a "dry socket" after tooth extraction. (Use this link for more details.)
• A history of taking bisphosphonate drugs (including: Actonel, Aclasta, Zometa, Boniva, Fosamax, Skelid, Reclast, Didronel) used to treat bone diseases (including osteoporosis, Paget's disease, cancer) can place a patient at risk for complications associated with bone healing.
  
• Patients undergoing corticosteroid therapy (such as taking prednisone) may need steroid supplementation prior to having an extraction. They also have an elevated risk for the development of postoperative infections.

▲ Section references - Koerner, Wray

D) Making preparations for your extraction appointment.

Once your dentist has collected all relevant information, detailed plans regarding your extraction appointment (timing, additional procedures utilized, etc...) can be made.

1) Existing infection.

During your pre-extraction examination, your dentist will look for signs of active infection (usually evidenced by the presence of swelling). The focus of the infection might be:

• Inside your tooth's nerve space (a tooth abscess).
• Around its roots (a periodontal abscess).
  
• In the gum tissue surrounding your tooth's crown (pericoronitis).

If evidence of infection is found, your dentist may have you take a course of antibiotics starting several days before the date of your appointment.

[Any antibiotics that are prescribed should be taken according to your dentist's directions. If you encounter problems (including the development of a rash or itching sensation), you should report them to your dentist or physician immediately.]

Why can't your dentist just go ahead and pull an infected tooth?

Actually, dentists routinely do pull infected teeth. What they don't do is extract teeth that show signs of active infection (like swelling) in the tissues that surround them. This is especially true if there is also evidence of systemic symptoms, such as elevated temperature, malaise, lymphadenopathy (swelling of regional lymph nodes), trismus (spasm of jaw muscles) or pain when swallowing.

That's because if they did it would place you at greater risk for complications, both during your procedure and the healing process that follows. For example:

• The process of extracting the tooth might spread the infection to nearby tissues or structures.
• Local anesthetics (the agents used to numb up teeth) don't work as effectively in infected tissues.
  
• Pronounced swelling may interfere with the dentist's access to the tooth, including your inability to open as wide as usual.

COVID-19 issues that may affect extraction timing.

Related to the 2020 Coronavirus pandemic, some people may find themselves in a position where they have an active infection associated with a tooth that is slated for extraction. But due to the pandemic, their dentist's office is closed.

Double-check your dentist's availability.

It would be expected that a dentist, even during these unsettled times, still offers emergency services like extractions for their patients of record. (This same level of service may not be offered to new/first-time patients.)

And if so, it's expected that the presence of an active infection associated with your tooth will be timed and handled as described above.

If your treatment must be delayed.

In the case where your dentist cannot offer to extract your tooth, they will probably manage your current active infection as described above. And at the completion of that antibiotic regimen, the hope is that your tooth will remain asymptomatic, indefinitely.

If not, when signs of infection start to reappear your dentist will have you take another round of antibiotics (either the same or a different one, depending upon your previous experience) to once again subdue the infection.

Conceivably, a tooth can be managed this way (repeated courses of antibiotics, initiated only in response to renewed symptoms), until the Coronavirus pandemic has subsided in your area and arrangements can be made to extract it.

2) Prevention of post-op infections.

Some patients may wonder if it's necessary for them to take antibiotics prior to their extraction appointment, as a routine measure in preventing complications with postoperative infection.

In most cases, antibiotics are not indicated.

While clearly only your dentist can make a determination about what's appropriate for your case, generally speaking, for routine extractions involving healthy people, with no medical issues and relatively healthy extraction sites, pre-extraction antibiotics are not needed.

In these types of situations, the patient likely lies at greater risk for complications when antibiotics are used (allergic reaction, systemic side effects [diarrhea, nausea, vaginitis, etc...], development of bacterial drug resistance), as opposed to when they are not.

What does research say?

Unfortunately, there is very little published literature about the need for antibiotics in the prevention of postoperative infections after non-wisdom tooth extractions.

A review that did try to investigate this subject (Lodi), but fell short, did conclude that even with wisdom tooth extractions (see below) included in the pool, the incidence rate of post-extraction infection was 1 out of 13 cases.

▲ Section references - Lodi

Pre-extraction antibiotics - Considerations.

As possible factors to consider, we'll mention the following points.

• The incidence rate of postoperative infection generally rises in relationship to the duration/extensiveness of the patient's extraction procedure. For example, it is very common for a dentist to utilize preoperative antibiotics with impacted wisdom tooth surgeries, especially lower ones.
  

  [The highest post-extraction infection rate is associated with removing lower impacted wisdom teeth. Studies have placed this number at up to 12% of cases (O'Connor).]

• In cases where the use of antibiotics is indicated but not previously planned for, your dentist has some options.
  

  Taking oral antibiotics as little as 1 hour prior to your procedure may provide adequate coverage. They may administer systemic (I.V.) antibiotics (more likely in an oral surgeon's office). They may apply the antibiotic topically (place it in your extraction site immediately following your tooth's removal).

▲ Section references - O'Connor

3) Will sedation be used for your extraction?

If you have any concerns or fears about your upcoming surgery, let your dentist know.

Patient anxiety can be managed through the use of various sedation techniques. But when one is used, prior plans must often be made.

For example, you may require someone to assist you to and from your dentist's office. Rules about food and beverage consumption prior to your appointment may apply.

The space resulting from a tooth extraction can allow neighboring teeth to shift.

When can having a tooth out be a bad idea?

When one tooth is pulled, neighboring teeth will tend to shift.

This change in tooth alignment (both on the same and opposing jaws) can lead to problems with chewing ability and jaw-joint function. It can also result in spaces in between teeth that become traps for food and debris, thus placing them at increased risk for decay and gum disease.

Tooth replacement is needed.

To avoid these scenarios, an extracted tooth must be replaced. However, tooth replacement (dental implant or bridge) can easily cost more than the expense of simply salvaging your existing tooth rather than having it removed.

Update log -

04/06/2020 - COVID-19/extraction timing update.

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Topic Menu ▶  Tooth Extractions

• The extraction process -
  
  • Preparing for your extraction. - Evaluating your tooth. / Medical issues & considerations. / Pre-op infection.
  • The tooth extraction procedure. - The steps involved. / What to expect with each one.
    
    • How long will your extraction take?
    • Will having your tooth pulled hurt?
    • Dental injections. - Why some are painful.
    • Conscious sedation options with oral surgery.
• About surgical tooth extractions.
  
  • Tooth sectioning.
  • Alveoloplasty (jawbone reshaping).
  • Details about gum tissue flaps and placing stitches.
  • How dentists remove stitches.
  • Dealing with lost or loose stitches.
• Extraction costs. - Including details about insurance coverage.
• Extraction aftercare and recovery -
  
  • Instructions for the first 24 hours.
  • Directions for the day after and beyond.
  • Common postoperative complications overview.
    
    • Specifics about - Swelling. | Bone & tooth fragments. | Dry sockets.
  • Tooth extraction healing timeline.
• FAQs about extracting teeth.
• Related topics
  
  • Topic: Wisdom Teeth
  • Topic: Dental Implants