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

What x-rays are needed? | Complications associated with medical conditions. | Issues with pregnancy. | Medications that may affect your oral surgery procedure / bleeding. | Indications for pre-extraction antibiotics. | How having active infection may affect your extraction procedure.

An x-ray a tooth socket after having its tooth pulled.

Tooth socket immediately after extraction.

Setting the stage for your tooth extraction.

Before your dentist can even consider pulling your tooth, certain steps must first be taken. Doing so not only helps to ensure that your extraction will go as safely and uneventfully as possible but also that your tooth was removed for good reason.

Here's what must be done:

 

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).

A dental x-ray showing tooth pathology.

It aids in both diagnosis and treatment planning.

An x-ray of your tooth will be required.

As a part of their exam, your dentist will need to take a radiograph (x-ray) of your tooth. Doing so will allow them to evaluate the following:
  • The current condition of your tooth and its supporting tissues.
  • What options, including extraction, might provide a suitable solution for your situation.
  • 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.

Some of the medical situations where antibiotic premedication may be required include:
  • 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.

In cases where the patient is already taking an antibiotic for other reasons, a different one is chosen for use with their upcoming dental procedure.

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.

 

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.

And even with that number (elevated by the inclusion of wisdom tooth extractions), it stated: "Clinicians should consider carefully whether treating 12 healthy patients with antibiotics to prevent one infection is likely to do more harm than good."

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.


An animation illustrating how a missing tooth can allow neighboring teeth to shift.

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

When can having a tooth out be a bad idea?

When the long-term is considered, just having your tooth pulled may not be the simple and cheap solution that you think it is. Here's why.
When one tooth is pulled, neighboring teeth will tend to shift.
After a tooth has been removed, nearby teeth will tend to drift into the now vacant space.

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.

 
 
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 Page references sources: 

Fragiskos FD. Oral Surgery. (Chapter: Medical History)

Koerner KR. Manual of Minor Oral Surgery for the General Dentist. (Chapter: Surgical Extractions)

Lodi G, et. al. Antibiotics to prevent complications following tooth extractions.

O’Connor N, et al. Incidence of deep fascial space infections following lower third molar removal.

Wray D, et al. Textbook of General and Oral Surgery. (Chapter: Oral surgery in the medically compromised patient.)

All reference sources for topic Tooth Extractions.

Comments

Should an extrraction be performed when there an infection?

Hi,

Should a tooth that it has an infection be extracted? I don't have pain, only when I put pressure on it ... the tooth (molar) is loose, due to the infection. It's the upper right molar. Since I'm against root canals ... what are my options here, besides trying to control the infection by natural ways, oil pulling, rinsing with salt, and homeopathy? All the "treatments" seem to be working, but slow. My dentist wants to extract my tooth, even with the infection, is that normal?

Thank you for your consideration,

Maria Teresa

* Comment notes.

Maria

Any tooth that is associated with a persistent infection that can't/won't be resolved should be extracted. Tooth infections are totally unpredictable and can flare up (pain, swelling, etc...) at any time. While the chances are small, the event could be life threatening. Persistent (chronic) infection has the potential to damage the bone surrounding the tooth, and possibly that of adjacent teeth too.

Most tooth related infections are either endodontic (inside the tooth, root canal) or periodontic (in the tissues surrounding the tooth, gum disease) in nature. Both require active hands-on treatment to resolve (so to remove the locus of bacteria causing the problem). The remedies you mention may keep the symptoms of the infection to a minimum, but they can't be considered actual cures.

Teeth are routinely extracted while infection is present. What dentists don't do is pull teeth during acute phases of infection. Doing so can present complications.

Dialysis and dentist

I am on dialysis and don't have a good immune system and was wondering if that makes a difference with how dentist work on my teeth.. I may have to have all my teeth pulled.

* Comment notes.

Brian

Your extraction process itself will be similar to what we describe, simply because that's the only way there is to remove teeth. What will likely be unique to your situation is the planning that takes place before and after your procedure.

For example, your extractions will probably be scheduled for a non-dialysis day ("blood thinners" used during dialysis might cause you to have extra bleeding). Extra post-op steps might be used also to help to minimize your potential for bleeding complications.

In cases where a patient is at increased risk for infection (has a compromised immune system), antibiotics might be prescribed before their extraction.

All of these issues will be sorted out at your initial examination when the planning for your extractions are made, so to make your procedure as risk-free and routine as possible. Good luck, we're sure you'll find you're in good hands.

5 months pregnant with pus pocket, do i need a tooth extraction?

Hi,
I am 25 weeks pregnant and have a problem with my tooth#25. It has a pus pocket in the back and keeps having pus daily for the past 3 months. A Periodontist recommended removing this tooth because the gum pocket is 9mm. My dentist then said NO, let's try to save the tooth but it keeps having pus and starting to feel some pressure in the tooth or the pocket with light pain and I am freaking out of the infection as I am pregnant. We keep doing teeth cleaning and nothing helps. It's been a nightmare without a solution.

My question is should I remove this tooth, would that help? How dangerous is while I am pregnant. Also, I never ever take any antibiotics or meds in the past 20 years of my life. Is there a way to avoid the antibiotics, is it risky. What if they remove the tooth and the puss still comes out? I am so scared and really don't know what to do. Any advice or thoughts?
Thank you

* Comment notes.

Jana

We can't comment on your specific case (since we have no firsthand information) but in general terms:

1) Your periodontist specializes in treating conditions like yours. If they consider the tooth hopless, that's an opinion to give some weight to.

2) It's commendable that your dentist wants you to retain the tooth but we can't imagine a scenario where that will be successful, especially considering the periodontist's opinion.

3) Your condition is due to bacterial accumulation on and around the tooth's root surface deep below the gum line. If the tooth is extracted, the source of the problem will no longer exist. There's no reason not to expect that the condition will resolve. (That assumes no neighboring tooth has been affected. Your periodontist would have mentioned if any had.)

4) IF your case requires antibiotics (only your dentist can decide), there are several kinds that are safe to use during pregnancy.

5) Due to the different tooth numbering systems used, we don't know if your mention of tooth #25 is a lower right central incisor or an upper left 2nd bicuspid. Either way, the 9mm periodontal pocket should help to make the extraction process easier than usual. Teeth are routinely extracted during pregnancy.

(Here's a link to our limited content about extractions and pregnancy.)

In terms of what to do, let your dentist know you are having continued problems and your situation requires attention.

extractions of 12 teeth to prepare for complete set of dentures

More than one Dentist has advised extractions of the only teeth I have left. (6 lower and 6 upper)...total of 12. X-rays were taken. MY QUESTION IS, SHOULD I HAVE ALL THE EXTRACTIONS DONE AT THE SAME TIME OR: ONE SIDE AT A TIME...OR: ALL LOWER AND THEN ALL UPPER LATER? IF EXTRACTIONS WERE NOT ALL DONE AT ONCE, WOULD I HAVE TO WAIT BEFORE HAVING THE REST OF THE EXTRACTIONS...IF SO, ABOUT HOW LONG!!!
FOR EXAMPLE IF I HAVE ALL LOWER TEETH REMOVED FIRST, HOW LONG WOULD I HAVE TO WAIT BEFORE HAVING THE UPPER TEETH EXTRACTIONS?? THE DENTIST DOES NOT DO TEMPORARY DENTURES BUT WAITS FOR COMPLETE HEALING AND THEN A PERMANENT SET OF DENTURES.

* Comment notes.

M

We'll mention some things in response to your questions. But only you and your dentist can decide how your extractions should be planned.

The number of teeth taken out at one time generally has to do with what the patient can safely tolerate.
(How difficult are the extractions? How much bleeding occurs. Is the procedure in the dentist's office or in a hospital setting? etc...)

For a conscious patient in a regular dental office, extracting 12 teeth might be a bit much unless the extractions are astoundingly easy.
Often a dentist will schedule multiple appointments, and then during each one simply do that amount of work they think is appropriate (depending on how the patient is doing). Follow up appointments are then utilized if and as needed.

Multiple appointments can be scheduled fairly close together. Most dentists would probably want to wait at least a few days to a week. The primary consideration is once again, how well the patient can tolerate the next procedure. (Is their jaw sore, can they keep their mouth open for extended periods, can the dentist tug their mouth as needed without causing pain, is the patient exhausted from the previous work, etc...)

It's probably more common to remove teeth on the same side vs. all uppers or lowers. (Both sides of the jaw numbed up at the same time is more awkward for the patient postoperatively, same-side work jives well with how a patient needs to bite on gauze after extractions.) But you and your dentist may decide differently.

You seem versed in the difference between "immediate" and conventional denture construction. Waiting 6 to 8 weeks after the last extractions for healing is common, although waiting longer gives the dentist an even more stable ridge to work with (and makes relines less likely for you).

* Comments marked with an asterisk, along with their associated replies, have either been edited for brevity/clarity, or have been moved to a page that's better aligned with their subject matter, or both. If relocated, the comment and its replies retain their original datestamps, which may affect the chronology of the page's comments section.


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