Tooth Extractions: Steps that need to be completed before having your tooth pulled. -

An overview of issues you need to know about. | The pretreatment examination. | How medical conditions, medicines and active infections may affect your procedure.

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

Tooth socket immediately after extraction.

The more a dental patient knows about getting teeth pulled in general, the less eventful having their own tooth removed will be.

That's because having a realistic idea of what to expect will help the person to be more relaxed for their procedure, a generally more cooperative patient, and more likely to understand the importance of following their dentist's postoperative instructions.

All of these factors combined will help the procedure itself (and the healing process that follows) to go as quickly and smoothly as possible.

Here's what you need to know ...

We've broken the subject of tooth extractions down into the following subtopics.

If you don't have the time or inclination to read everything, just use the links above to jump ahead.

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 insure 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, if you have any bleeding problems, and identify any and all medical conditions you have, both treated and untreated.

Some medical conditions require special management.

Several medical conditions are well known for creating risks and potential complications:

  • 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 exercise/stress levels are disrupted. They also have an elevated risk for post-extraction infections.
  • Patients with uncontrolled/untreated adrenal insufficiency, hypothyroidism, diabetes or renal disease must be evaluated by a medical professional before an extraction can be planned.
  • Sickle-cell anemia presents challenges to providing treatment for the patient, including the type of procedures that should be performed during crisis and medicines used. Sickle-cell disease also places the patient at increased risk for post-surgical infection.

    Other hematological conditions that require special consideration and evaluation before dental treatment are: acute leukemia, lymphoma, cytotoxic chemotherapy and bone marrow transplantation.

  • 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).
  • Liver disease (hepatisis, cirrhosis, alcoholic hepatisis) places the dental patient at increased risk for complications with bleeding.
  • Person's having HIV may develop imunogenic thrombocytopenic purpura, a condition that places them at risk for complications with bleeding.
  • Cardiovascular disease - The physician of patients who have experienced a cardiac episode (angina, heart attack, bypass surgery) 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.
  • Inherited bleeding disorders - The patient's physician must be consulted prior to scheduling an extraction.
  • High blood pressure - As a general rule, treatment for patients who have a systolic pressure over 170mmHg or a diastolic value over 100mmHg should be postponed until a physician has been consulted.
  • Patients with a history of head and neck radiation treatments are at risk for developing osteoradionecrosis (a bone complication) following extractions.

Pregnancy.

Being pregnant on its own is not a reason that you can't have a tooth taken out. But there are general guidelines that should be followed.

  • If possible, elective oral surgery should be postponed until after the baby is born.
  • When more urgent care is required, extractions are preferably targeted for the 2nd trimester.
  • With proper consultation from the patient's obstetrician, extractions can often be done at any stage of pregnancy.

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 and preferably not during the first trimester.

Premedication with antibiotics.

Some medical conditions place patients at risk for developing a bacterial infection after having dental procedures performed that involve bleeding (such as extractions).

In these cases, it's mandatory that the patient take "prophylactic" antibiotics before their dental surgery is performed. Doing so helps to minimize this risk.

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

  • Various cardiac conditions (artificial valves, mitral prolapse with regurgitation, some congenital heart conditions, a previous history of bacterial endocarditis).
  • Prosthetic (artificial) joints, 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.

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:

  • Aspirin can interfere with the blood clotting process (ibuprofen, ginko biloba, and ginseng can have an effect on clotting too). So can prescription blood thinners such as warfarin/Coumadin®.

    In some instances your dentist may ask you to discontinue taking the drug for some days before your extraction, then resume afterward.

    In cases where the continued use of the drug is needed, a decision may be made to remove a fewer number of teeth per appointment. Additionally, extra steps will be taken after removing any teeth to help insure 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 (such as Fossmax®) used to treat bone diseases (including osteoporosis, Paget's disease, cancer) can place a patient at risk for complications associated with bone healing.
  • Patient's 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 post-opertative infections.
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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 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, especially if there is also evidence of systemic symptoms. This includes: elevated temperature, 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) Will sedation be used?

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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