Is tooth extraction painful? -

Questions answered about what patients usually feel (pain, pressure) during tooth extractions. | How likely is it that your procedure will hurt (and how much)? | What dentists do to minimize and manage patient discomfort.

Will you feel pain when your tooth is extracted?

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


What can you expect to feel when you have a tooth pulled?

Here are the standard things that you can expect to experience during any extraction process:

  • You may feel the pinch of the needle as your dentist numbs up your teeth and gums.
  • You'll feel the back-and-forth pressure they use to loosen up your tooth until it's free enough to come out.
  • Other than that, you don't have to expect that you'll feel any pain during the process but some people do (we explain in our next section).

A chronology of potentially painful events during the extraction process.

1) You'll feel your dentist numbing up your tooth.

Just like with so many dental procedures, every extraction begins with numbing up your tooth. And the way that's done is the same as when any other type of work is performed. You'll get some "shots."

What may be different with an extraction is that the gum tissue around your tooth will need to be anesthetized too. And while there's nothing really different about doing that for an extraction either, it may mean that you'll end up getting more total shots and therefore have more potential for feeling needle pricks than with other types of work.

Use this link for specifics about getting dental injections (types of injections, which hurt the most, etc...).

2) Testing your potential for feeling pain.

After 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 procedure.

Having said that, there can be times when a patient's tooth or surrounding gums simply haven't numbed up enough. It's never the dentist's intention, it's just something that statistically can happen.

a) How does a dentist test your numbness?

Since a dentist knows that statistically some people will need further numbing, they'll follow a protocol that's designed to evaluate and test 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:

i) Does your lip feel tingly?

Your dentist knows the specific areas each injection they give should numb up. And they'll quiz you about and test these areas just to make sure 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 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.

ii) Pressing and wiggling on your tooth.

Another way of evaluating a tooth's numbness is for your dentist to press on it firmly, or rock it side-to-side with their fingers.

iii) Testing your gum tissue.

A dentist knows which areas of your mouth should have numbed up with the anesthetic they've administered. (In some cases this might be quite distant from the location where the shot was actually given.)

So as a test for effectiveness, 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.

iv) Testing as your extraction process begins.
  • The first step in removing a tooth involves using a tool to strip away its gum tissue.

    Your dentist will be gentle at first 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 begins the process of loosing up the tooth in it socket they'll ease into applying full pressure, looking for confirmation from their patient's reaction that all is going well.

b) Setting up an "it hurts" signal.

Even with all of the checks above, it's still possible that your tooth isn't as numb as it needs to be to remove it painlessly.

And due to this inherent uncertainty, 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 it's not in the dentist's direct line of vision, their peripheral vision will notice this type of sign.

The agreement between the dentist and patient should be one where work is stopped immediately upon the signal. That way if something does hurt its kept to a minimum and just minor levels.

3) Controlling pain during your extraction process.

Once your dentist knows that you're not numb enough, they'll then determine how to best resolve the issue.

A dentist giving a dental injection.
  • They may repeat your initial injections again. The goal being not to simply place more anesthetic but instead an additional quantity in a slightly different location in hopes of creating a more profound effect. (Nusstein 2010) [page references]
  • Instead, they may use some type of adjunct technique. This might mean giving you a shot in a different location, or using a different injection method.

And while you might find the idea of requiring additional shots to be disappointing, receiving them may be quite uneventful due to the fact that the gum tissue in the area receiving them is already numb.

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 as bad as they initially seem.

Wong (2001)

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

  • Numbing up lower molars (probably the most challenging teeth to numb [Nusstein 2010]) ...
  • ... by way of using conventional dental shots (an inferior alveolar nerve block [IANB], a type of dental injection).

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)

This paper 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. After all, they 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.

But don't think for a second that your dentist doesn't anticipate this problem. 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.

What you 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 has already been 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 the procedure runs long.

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 2001) 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. Zain (2016) reported a 63% success rate for lower molars. Kanaa (2012) found a success rate of 67% for lower teeth in general, not just molars.
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 is where good news lies.

Every dentist knows that the use of adjunct (supplemental) injections can improve anesthesia numbers substantially. So any dentist treating a "hot" tooth would know that these techniques are probably needed and therefore would go ahead and take those 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 (2001) paper 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 mention 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.

For those who aren't adequately numbed up, as soon as their discomfort is evident their dentist will simply continue down their list of solutions to find a way to control it.


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

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

  • Intraoperative pain was generally defined as those events that took place after giving the needed shots to numb up the patient's tooth (discomfort following "injection pain").
  • 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, 5) the extraction process was then resumed and completed.

Research findings.

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

Kammerer (2012)

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)

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.

In regard to the 2% (one person) who felt severe pain, the authors stated that their experience might be attributed to:

  • "... 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)

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.)

So even though this study is somewhat off-target because it includes injection discomfort with intraoperative pain, on average even though some minor level of pain was noticed, what was experienced during the procedure was substantially lower than what the patient had been experiencing before their procedure.


Why you will feel pressure during your extraction.

Background.

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.

[Yes that's right. The way we are wired is that different types of nerve fibers, having different physical characteristics, transmit different types of sensations. And due to these physical differences, local anesthetics are able to have a more profound affect on some kinds of fibers (pain, temperature, touch) as opposed to others (pressure).]

And because of this, you will feel the pressure your dentist applies to your tooth as they loosen it up during your extraction process.

Tooth socket, immediately after extraction.

It takes applying pressure to loosen teeth from their sockets.

How much pressure will you feel?

We actually found a study (Ahel 2015) that evaluated how much force it takes for a dentist to extract teeth (upper front ones). The number came out to around 18 psi (pounds per square inch).

As it turns out, that's a difficult number to find a direct 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. That's really a fairly substantial amount of force.

You must distinguish between pain and pressure!

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

  • They may not realize that it's expected and normal 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 that they will soon feel pain too.
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 place 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).
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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)

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 experience.

Tickel (2012)

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.)
  • The patient must then be willing to admit that they do have apprehensions and be receptive to the dentist's suggestions and recommendations.

Our next page discusses how long extractions take. ▶

 

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