How painful is having a tooth pulled? –

Tooth extraction procedure pain.

Will it hurt when you have your tooth pulled?

No, you don’t have to expect that having your tooth pulled will hurt. But we’d be leading you astray if we said that getting one taken out never did. And that’s basically what this page is all about. It explains…

• What types of sensations usually are felt when teeth are extracted.
• Details about the disappointing, hopefully minor, pain sensations that may occur during a patient’s procedure and why they’re felt. (Along with statistics from research studies about what percentage of patients have a painful experience.)
• What you and your dentist can do along the way to create a comfortable, trusting environment for your extraction process. And one that is as pleasant and pain-free as possible.

What’s usually felt when a tooth is pulled?

Here are some routine sensations you should expect to experience during your extraction process:

• You may feel the pinch of the needle as your dentist numbs up your teeth and gums.
• You will feel the back-and-forth pressure that’s used to loosen up your tooth until it’s free enough to come out (but this shouldn’t be confused with feeling pain).

But other than that, the odds are that you shouldn’t feel any discomfort during your procedure.

But what if you do feel pain?

Yes, it’s true, studies do show that a minor percentage of people will report that they felt pain during their extraction. But, really, that’s not so surprising. The currents of life always contain ripples and some patients will simply require some type of extra attention or additional steps beyond what their dentist initially felt was required to keep them comfortable during their procedure.

And knowing that some exceptions will exist is precisely why dentists test for numbness at the beginning of a patient’s procedure and set up an unambiguous “it hurts” signal with them so they know immediately if something has gone amiss.

So, even if pain is felt, what you experience should be just brief and minor. And then, once your dentist knows that something additional is needed, they can go ahead and take those extra steps.

Here are more details …

A listing of painful events that might occur during your extraction procedure.

1) Numbing up your tooth.

Every extraction begins with numbing up your tooth. And the way that’s done is the same as when any other type of dental work is performed. Your dentist will give you one, or more likely two or more, dental injections (“shots”).

Your tooth and surrounding bone and gum tissue must all be numbed up.

What may be different when having a tooth pulled is that all of the tissues that surround it (gum tissue and bone, not just your tooth) must be adequately anesthetized too. In comparison, for a lot of other dental procedures, like routine fillings, numbing up these additional aspects often isn’t needed.

That means that with an extraction you may end up getting more total shots, and therefore have more potential for feeling needle pricks, than you’ve experienced before. But as far as the way the injections are done, it’s all pretty much the same as with other procedures.

Use this link to access our page that explains details about getting dental shots (types of injections, the way they’re given, which hurt the most, etc…). Jump to page.

2) Testing to see if you do feel pain.

Once your initial round of injections has been completed, there’s no reason why you should expect to feel any pain for the remainder of your extraction procedure.

Having said that, there can be times when this initial round hasn’t numbed up the tooth or its surrounding tissues enough. That’s never the dentist’s intention. It’s just something that statistically can happen.

a) How does a dentist test for numbness?

Since a dentist knows that some percentage of people will need further numbing, they’ll follow a protocol that’s designed to test and evaluate their patient’s status before the work of actually removing their tooth is begun. That way whatever level of pain is felt is kept to a brief, bare minimum.

Here are some of the ways they’ll evaluate and test, with each method explained in greater detail below on this page.

How a dentist checks for numbness before proceeding with an extraction.

• i) Asking what “lip signs” (lip numbness) you notice.
• ii) Deliberate finger manipulation of your tooth to test for discomfort.
• iii) Testing your gum tissue for pain response.
• iv) Easing into the extraction process, so to see how you’re doing.

Of course, each of these last three tests means that you’ll need to have an agreed-upon “it hurts” signal so you can communicate what you feel accurately. Here’s more information …

i) Does your lip feel tingly?

Your dentist knows the specific portions of your mouth that each type of injection they give should numb up. And they’ll quiz you about how these areas feel to see if they have.

For example, before extracting lower back teeth a dentist will usually ask their patient if their lower lip feels tingly. That’s typically a sign that the anesthetic that’s been given has been effective.

But this type of questioning about how things feel is only valid in some situations. For example, the injections used to anesthetize upper back teeth may have been fully effective without causing much change in the way the adjacent lip or cheek tissues feel at all.

ii) Pressing and wiggling on your tooth.

• Since teeth are extracted by way of applying forces to them (via the use of dental instruments such as forceps and elevators How they’re used.), the pressure of this testing somewhat replicates what you’re in store for. If you feel discomfort now, you would during your tooth’s removal too.
• This test also gives you an introduction to the sensation of pressure that you can expect to feel during your procedure.

  Being able to distinguish between pressure and pain (and understand that the two are unrelated, see discussion below) is a big deal. There’s nothing more important for the patient to be able to comprehend and differentiate during their extraction procedure than the issue of pain vs. pressure.

iii) Testing your gum tissue.

A dentist knows which areas of your mouth should have been numbed up with the anesthetic they’ve given you. So as a test, it’s common for them to use a pointed dental tool and deliberately poke your gum tissue in those areas, just to make sure you don’t feel anything (other than possibly the pressure involved).

Just so you’re not surprised or confused, we’ll state that where they test may be some distance from the tooth that’s going to be taken out. (For example, they may test your lower lip even though it’s a back lower molar that will be pulled.)

iv) Testing as your extraction gets started.

• One of the first steps of the extraction process involves the dentist using a tool to detach (strip away) the gum tissue surrounding the tooth.

  Your dentist will be gentle as they first start to do this, so they can test out how you’re doing. Then once they’ve confirmed that you’re feeling no pain, they’ll continue on with this task in earnest.

• Likewise, when a dentist initially begins the process of loosening up a tooth, they’ll ease into applying full pressure. That way they can look for confirmation from you that all is going well.

Setting up an “it hurts” signal.

Even with all of the checks mentioned above, it’s still possible that your tooth isn’t as numb as it needs to be and you will start to feel some degree of pain (hopefully just minor) as your extraction procedure gets started up.

Creating a trusting relationship by setting up an “it hurts” signal in advance.

Due to the uncertainty of knowing what the patient will feel, it’s basic protocol for a dentist to set up a signal with their patient. A sign that can be used to unambiguously communicate to them that something is amiss, even when you are unable to speak.

• One common signal is simply having the patient raise their hand immediately upon noticing that something isn’t right.
• Even when this motion isn’t in the dentist’s direct line of vision, their peripheral vision will easily notice this type of signal.

The agreement between the dentist and patient should be one where work is stopped upon the signal without hesitation. That way the patient is guaranteed that if something does hurt it’s kept to a minimum and just minor levels.

Numbing up a tooth for extraction.

3) Pain felt during your extraction procedure.

How likely is it that your first shots won’t be totally effective in numbing your tooth?

A couple of papers have investigated this topic. And while the numbers they’ve reported may not be entirely reassuring, with just a little explaining you’ll find they aren’t really as bad as they initially seem.

Wong (2001)

Title: Adjuncts to Local Anesthesia: Separating fact from fiction.

This paper reviewed published literature that had evaluated the subject of:

• Numbing up lower molars. (Probably the most challenging teeth to numb, per Nusstein [reference linked above]) …
• … by way of using conventional dental shots. (An inferior alveolar nerve block [“IANB”]. Types of dental injections.)

This review concluded that the use of conventional methods (IANB injections) to numb up asymptomatic molars (teeth that weren’t hurting at the time of their extraction) was only successful 69% of the time.

Kanaa (2012)

Title: A Prospective Randomized Trial of Different Supplementary Local Anesthetic Techniques after Failure of Inferior Alveolar Nerve Block in Patients with Irreversible Pulpitis in Mandibular Teeth.

While this paper focused on a different topic, it contained a section that provided background information about this subject. It cited two studies that placed the effectiveness of initial rounds of anesthesia for lower teeth at 63% and 76%.

Your dentist is quite aware of the possibility of numbing failure.

A person could look at the figures above and have some concerns about how painless their procedure will be. After all, those statistics suggest that about one-fourth to one-third of patients being prepared for a tooth extraction won’t be adequately numbed up after getting their initial injections. [At least with lowers. The numbers are likely higher for upper, usually easier to anesthetize, teeth.]

Don’t think for a second that your dentist doesn’t recognize the potential for this problem. And with all extractions, not just lowers. That’s why they use a protocol laden with evaluation and testing aimed at identifying ahead of time those patients whose situation requires further anesthesia.

Actually, this is the way you want it to be.

As much as you don’t want to feel pain during your extraction procedure, what you also don’t want is for your dentist to initially administer more anesthetic than is reasonably expected to be required. That’s because doing so can lead to complications:

• Administering more than that quantity that was needed to be effective serves no purpose.
• Administering more will require additional shots, some of which might be felt.
• There are limits on the total amount of anesthetic solution that can be safely used with a patient. (Maximum dosages are typically based on the patient’s weight.)

  Having expended most of this quantity needlessly can jeopardize the procedure if later on pain control becomes a problem, or if the procedure runs long and the anesthetic that’s already been given begins to wear off.

Numbing up “hot” teeth for extraction can be even more difficult.

The numbers reported above are for numbing up asymptomatic teeth (teeth that weren’t hurting at the time of their extraction).

The more difficult challenge is when dentists numb up “hot” teeth (teeth that are painful because they are experiencing irreversible pulpitis).

• The review of published literature mentioned above (Wong) determined that only 30% of initial attempts at numbing up extremely sensitive (“hot”) lower molars using conventional methods (IANB injections) were successful.
• Not all studies put this number for “hot” teeth (numbed via initial IANB injections) so low. Research by Zain reported a 63% success rate for lower molars. The above-mentioned study by Kanaa found a success rate of 67% for lower teeth in general, not just molars.

▲ Section references – Wong, Kanaa, Zain

Why these numbers really aren’t so negative.

The variation reported above withstanding, it’s doubtful that any dentist would dispute that numbing up “hot” teeth can be a challenge. And that point alone is where good news lies. It means they’ll know to take extra measures.

All dentists know that the use of adjunct (supplemental, extra) injections can improve the patient’s level of anesthesia (see statistics below). So, any dentist treating a “hot” tooth will know that these techniques are probably needed and therefore will go ahead and take these additional steps right off the bat. After all, your dentist doesn’t want your extraction to hurt any more than you do.

How much can adjunct numbing techniques help?

The Wong paper [linked above] mentioned above also reviewed studies that evaluated the use of supplemental techniques with lower molars after an initial round of conventional (IANB) injections had failed.

• For asymptomatic teeth, success rates could be raised from 69% to 97% with the addition of adjunct methods.
• For “hot” teeth, the 30% number reported above could be raised to 83% effective.

That means with just routine discovery (all of the steps we mentioned above that a dentist takes to make sure that their patient really is numb), the vast majority of people can expect to enter the actual work of their extraction process having profound tooth anesthesia.

What happens if pain is felt during an extraction? – What additional steps can be taken?

For those patients who haven’t been adequately numbed up initially and have felt discomfort during their extraction procedure, a dentist has options available to them to resolve the issue.

• In some cases, they may repeat your initial injections.

  The goal here is not simply placing more anesthetic solution but instead an additional quantity in a slightly different (more on-target) location in hopes that doing so will create a more profound effect. (Nusstein)

• In other instances, some type of supplemental technique might be used. – This could include giving you a shot in an entirely different location or using a different injection method.

You may not feel these additional injections.

▲ Section references – Nusstein

How much pain can you expect to feel during your tooth extraction?

Statistics from studies.

We found a couple of studies that evaluated intraoperative pain (discomfort experienced during the extraction process alone).

• Intraoperative pain was generally defined as discomfort that took place after giving the patient the shots needed to numb up their tooth. (Procedure discomfort that followed whatever level of injection pain might have been felt.)
• We’re of the opinion that this definition would include the following scenario: 1) after the tooth had been numbed, 2) the extraction process was begun, 3) pain was felt, 4) additional injections were given, and 5) the extraction process was then resumed and completed.

Research findings.

[Similar to those cited above, the studies discussed here evaluated the extraction of mandibular (lower) teeth using conventional methods (IANB injection), which is probably the most challenging numbing situation.]

Kammerer (2012)

Title: Comparison of 4% articaine with epinephrine (1:100,000) and without epinephrine in inferior alveolar block for tooth extraction: double-blind randomized clinical trial of anesthetic efficacy.

This study asked its 88 subjects who had lower molars removed to rate the level of pain they experienced during their procedure from 0 to 10, with 10 being the worst. The average of the scores reported was between 0 and 1.

Bataineh (2016)

Title: Patient’s pain perception during mandibular molar extraction with articaine: a comparison study between infiltration and inferior alveolar nerve block.

This study evaluated intraoperative pain levels (rated 0 to 100) experienced by 52 patients having lower molars removed.

• On average, the level of injection pain (IANB injection) was rated as 41 (the high end of the mild pain range).
• As for the level of pain experienced during their extraction, 81% of patients reported mild pain, 17% moderate pain and 2% severe pain.
• 89% of subjects reported that the level of discomfort they felt during their procedure was less severe than expected, 11% the same as expected and 0% felt it was greater.

• “… the intense pressure felt by some patients during the extraction, which may be difficult to differentiate from pain …”

Pain vs. pressure is a critically important distinction that the patient must be able to make. We discuss why in our next section below.

Rousseau (2002)

Title: A Comparison of Pain Levels During Pulpectomy, Extractions, and Restorative Procedures.

This study evaluated 50 patients who rated their intraoperative pain from 0 to 100. Some of the extractions involved “hot” teeth. (These are teeth that were painful because they were experiencing irreversible pulpitis. As mentioned above, “hot” teeth are generally more difficult to anesthetize.)

• Preoperatively, the patients rated their level of pain as being 61 (defined as moderate pain).
• Postoperatively the patients were asked to rate their procedure pain. They rated it as 24 (defined as mild pain). (With this study, intraoperative pain was defined as including injection discomfort.)

▲ Section references – Kammerer, Bataineh, Rousseau

Why it’s normal to feel pressure during your extraction.

What occurs.

The local anesthetics used in dentistry to numb up teeth and gum tissue are quite effective in inhibiting (conking out) the type of nerve fibers that transmit pain. But they’re not as effective on those that transmit the sensation of pressure.

And because of this, it’s normal and expected that you will feel the pressure, quite possibly a substantial amount of it, that your dentist applies to your tooth with their instruments as they loosen it up during your extraction process.

An explanation why.

The way our bodies are wired is that different types of nerve fibers, each of which transmits a specific type of sensation (pain, pressure, touch, hot and cold, etc…), have different physical characteristics.

And due to these differences (for example, the thickness of the protective insulating sheath that surrounds the nerve), local anesthetics are able to have a more profound effect on some types of fibers as opposed to others.

For the most part, fibers that transmit the sensation of sharp pain (the nerve responds intensely and quickly to painful stimuli) are the type most easily decommissioned by local anesthetic, hence this is the first sensation to be lost.

Following sharp pain is the loss of the ability to feel cold sensations, warmth, touch, and finally pressure, thus explaining why it’s usual and normal for it to be felt during an extraction procedure.

A dentist uses their tools to apply pressure to teeth so they loosen up and can be removed.

How much pressure will you feel?

Comparisons.

As it turns out, that’s a difficult number to find an exact comparison for. We did however discover that regulation basketballs and soccer balls are typically inflated to around 8 psi.

So if you think in terms of putting one of those balls on the floor and pressing hard enough on it to just slightly indent it, when having an upper front tooth extracted you could expect to feel about twice that much pressure.

▲ Section references – Ahel

What does tooth extraction pain feel like?

How to distinguish between pain and pressure during your extraction.

One common problem that occurs during tooth extractions is that patients sometimes confuse the sensation of pressure with pain.

Extraction pain vs. pressure – How to distinguish between the two.

• Some patients may not realize that it’s normal and expected for them to feel pressure, or they may not have anticipated the amount of it involved, and therefore mistake feeling it for experiencing pain.
• Patients may fail to realize that pain characteristically has a sharpness to it whereas pressure does not.
• The patient may incorrectly assume that because they feel increasing levels of pressure they will soon feel pain too.

  Remember, these sensations are carried by different types of nerve fibers. Feeling pressure in no way indicates that your fibers that relay pain haven’t been successfully anesthetized (conked out).

Why making a distinction between the two is so important.

Being accurate in your interpretation of what’s going on (feeling sharp or shooting pain vs. pressure) is vital.

That’s because leading your dentist to believe that you are feeling pain instead of just pressure may lead them to needlessly administer more anesthetic.

• As explained above, administering more anesthetic will do absolutely nothing to alleviate the sense of pressure you are feeling.
• Using additional quantities of anesthetic places you at greater risk for complications during your procedure.
• Since only so much anesthetic solution can be given safely (based on the patient’s weight), administering some of this quantity needlessly could mean that little or none is available for use later on during the procedure (if needed).
• Responding to unwarranted patient complaints that have no solution simply draws your dentist’s attention away from the important task at hand (extracting your tooth).

Extraction pain correlates with anxiety levels.

It’s important for us to mention that research has shown that the level of a patient’s anxiety about their procedure is a predictor of how much pain they will experience during it. This is true for any type of dental work but especially tooth extractions.

Here’s what studies have found:

Fagade (2005)

Title: Intra-operative pain perception in tooth extraction – possible causes.

This paper evaluated 122 patients who had had extractions and found a positive correlation between patient anxiety scores and the level of procedure pain they experienced.

Tickel (2012)

Title: Predictors of pain associated with routine procedures performed in general dental practice.

This study evaluated a group of 451 patients who had varying types of dental work performed (including extractions). Patients rated as “very anxious” were 5 times more likely to report experiencing pain during their procedure.

If you have anxiety about your extraction, make sure to let your dentist know.

A patient’s level of anxiety can be controlled via the use of various sedation techniques administered either before or at the time of their procedure. The decision to employ such methods is both the responsibility of the dentist and the patient.

• The issue should be brought up by the dentist during their pre-extraction examination and the patient’s options explained to them. (We discuss conscious sedation techniques here. Options.)
• The patient must then be willing to admit that they do have apprehensions and be receptive to the dentist’s suggestions and recommendations.

▲ Section references – Fagade, Tickle

Next page: How long do extractions take. Each step. | Start to finish. ►

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