Dental Extraction

Dental extraction A dental extraction (also referred to as tooth extraction, exodontia, exodontics, or informally, tooth pulling) is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache. Sometimes wisdom teeth are impacted (stuck and unable to grow normally into the mouth) and may cause recurrent infections of the gum (pericoronitis). In orthodontics if the teeth are crowded, sound teeth may be extracted (often bicuspids) to create space so the rest of the teeth can be straightened. Dental extraction Surgical extraction of an impacted molar ICD-9-CM 23.0 -23.1 MeSH D014081 [edit on Wikidata] Procedure Out-patient oral surgery Tooth extraction is usually relatively straightforward, and the vast majority can be usually performed quickly while the individual is awake by using local anesthetic injections to eliminate pain. While local anesthetic blocks pain, mechanical forces are still felt. Some teeth are more difficult to remove for several reasons, especially related to the tooth's position, the shape of the tooth roots, and the integrity of the tooth. Dental phobia is an issue for some individuals, and tooth extraction tends to be feared more than other dental treatments such as fillings. If a tooth is buried in the bone, a surgical or trans alveolar approach may be required, which involves cutting the gum away and removing the bone which is holding the tooth in with a surgical drill. After the tooth is removed, stitches are used to replace the gum into the normal position. Immediately after the tooth is removed, a bite pack is used to apply pressure to the tooth socket and stop the bleeding. After a tooth extraction, dentists usually give advice which revolves around not disturbing the blood clot in the socket by not touching the area with a finger or the tongue, by avoiding vigorous rinsing of the mouth, and avoiding strenuous activity. Sucking, such as through a straw, is to be avoided. If the blood clot is dislodged, bleeding can restart, or alveolar osteitis ("dry socket") can develop, which can be very painful and lead to delayed healing of the socket. Smoking is avoided for at least 24 hours as it impairs wound healing and makes dry socket significantly more likely. Most advise hot salt water mouth baths which start 24 hours after the extraction. The branch of dentistry that deals primarily with extractions is oral surgery ("exodontistry"), although general dentists and periodontists often carry out tooth extraction routinely since it is a core skill taught in dental schools. Periodontists are performing more and more extractions, since they often follow up and place a dental implant. Reasons Extracted wisdom tooth that was horizontally impacted Extracted tooth The most common reason for extraction is tooth damage, due to breakage or decay. There are additional reasons for tooth extraction: Severe tooth decay or infection (acute or chronic alveolar abscess, such as periapical abscess - collection of infected material (pus) forming at the tip of the root of a tooth.).[1] Despite the reduction in worldwide prevalence of dental caries, it is still the most common reason for extraction of (non- third molar) teeth, accounting for up to two thirds of extractions.[2] Severe gum disease, which may affect the supporting tissues and bone structures of teeth. Treatment of symptomatic impacted wisdom teeth, who have or cause certain diseases such as nonrestorable caries or cysts.[3] Preventive/prophylactic removal of asymptomatic impacted wisdom teeth. Although many dentists remove asymptomatic impacted third molars,[4][5] both American and British Health Authorities recommend against this routine procedure, unless there is evidence for disease in the impacted tooth or the near environment.[6] The American Public Health Association, for example, adopted a policy, Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth), because of the large number of injuries resulting from unnecessary extractions.[7] Supernumerary teeth which are blocking other teeth from coming in. Supplementary or malformed teeth Fractured teeth Cosmetic - to remove teeth of poor appearance, unsuitable for restoration Teeth in the fracture line In preparation for orthodontic treatment (braces) Teeth which cannot be restored endodontically Prosthetics; teeth detrimental to the fit or appearance of dentures[8] Head and neck radiation therapy, to treat and/or manage tumors, may require extraction of teeth, either before or after radiation treatments Lower cost, compared to other treatments[9]:98 Deliberate, medically unnecessary, extraction as a form of physical torture.[10] It was once a common practice to remove the front teeth of institutionalized psychiatric patients who had a history of biting.[11] Types Dental extraction forceps commonly used on teeth in the maxillary arch Extractions are often categorized as "simple" or "surgical". Simple extractions are performed on teeth that are visible in the mouth, usually with the patient under local anaesthetic, and require only the use of instruments to elevate and/or grasp the visible portion of the tooth. Typically the tooth is lifted using an elevator, and using dental forceps, rocked back and forth until the periodontal ligament has been sufficiently broken and the supporting alveolar bone has been adequately widened to make the tooth loose enough to remove. Typically, when teeth are removed with forceps, slow, steady pressure is applied with controlled force. Molar cut up during surgical extraction - the curvature of the three roots (top right) prevented simple extraction Surgical extractions involve the removal of teeth that cannot be easily accessed, for example because they have broken under the gum line or because they have not erupted fully. Surgical extractions almost always require an incision. In a surgical extraction the doctor may elevate the soft tissues covering the tooth and bone, and may also remove some of the overlying and/or surrounding jawbone tissue with a drill or osteotome. Frequently, the tooth may be split into multiple pieces to facilitate its removal. Anticoagulant use Studies have shown that there is a correlation between consumption of anticoagulant drugs after dental extractions and the amount of bleeding. In one such review, oral anticoagulants were prescribed to multiple subjects, all of whom were undergoing dental surgery. 89 out of 990 subjects (9%) had delayed postoperative bleeding, and 3.5% of these cases were not controlled by local measures (‘serious cases’).[12] Other studies have reported greater numbers of patients with minor post-operative bleeding.[13] However, it is difficult to standardise bleeding, as the definitions used to categorise the extent of the bleed differ from study to study. However, the majority of studies concur that there is little risk of a major bleed if a patient is regularly consuming oral anticoagulants at the time of a simple dental extraction. For simple extractions, therapeutic anticoagulation can be continued, as the bleeding risk is not high[14][15][16] and the risk of a thromboembolism caused by a temporary withdrawal from the anticoagulant is much higher than that of a serious bleed following the extraction[17] However, for complex extractions (three or more teeth, or multiple adjacent teeth), the risk of bleeding is higher,[18] and the dentist should consult the patient’s doctor. Patients undergoing a course of treatment using anticoagulants should notify their dentist when organising the procedure. An individual treatment plan should be drawn up for the patient, and the patient’s doctor should be contacted to confirm the anticoagulant being used, and the dose type.[18] The patient’s INR should also be taken into account. When the patient has an INR of 4.0 or over, the patient should be referred to a specialist.[17] The risk of haemorrhage is increased in the elderly (especially after post-surgical dental extractions), as they are more susceptible to dental caries and periodontal diseases.[19] This should also be taken into account by the dentist. Studies found that rivaroxaban impose a high risk of bleeding when compared to the other oral anticoagulants, in contrast to Dabigatran, which was found to have fewer postoperative bleeding incidents.[20] To increase the effectiveness of oral anticoagulant drugs, bleeding risks can be further minimized by the usage of collagen sponges and sutures and rinsing 5% tranexamic acid mouthwash four times a day.[19] Overall, patients utilizing long-term anticoagulant therapies such as warfarin or salicylic acid do not need to discontinue its use prior to having a tooth extracted. The extraction should be performed utilizing the least traumatic extraction procedures,[21] and patients should make certain to tell their dentist or oral surgeon about any medications they take before the procedure. Antibiotic use Antibiotics can be prescribed by dental professionals to reduce risks of certain post-extraction complications. There is evidence that use of antibiotics before and/or after impacted wisdom tooth extraction reduces the risk of infections by 70%, and lowers incidence of dry socket by one third. For every 12 people who are treated with an antibiotic following impacted wisdom tooth removal, one infection is prevented. Use of antibiotics does not seem to have a direct effect on manifestation of fever, swelling, or trismus seven days post- extraction. In the 2013 Cochrane review, 18 randomized control double-blinded experiments were reviewed and, after considering the biased risk associated with these studies, it was concluded that there is moderate overall evidence supporting the routine use of antibiotics in practice in order to reduce risk of infection following a third molar extraction. There are still reasonable concerns remaining regarding the possible adverse effects of indiscriminate antibiotic use in patients.

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