Also called: Pulled Tooth
Andrew M. Sicklick, D.D.S.
Tooth extraction is a procedure to remove a tooth from its socket. It is commonly performed and may be a simple extraction or a surgical extraction. A simple extraction removes a tooth that has erupted into the mouth without cutting into the gum. A surgical extraction removes a tooth through the gum and possibly through the jawbone. The most common reason for tooth extraction is removing seriously damaged teeth (e.g., excessive tooth decay, fractured or broken teeth). The procedure may also be used when a tooth cannot erupt fully (e.g., impacted tooth), to reduce dental crowding or the risk of infection and to prepare for a complete denture or radiation therapy.
The patient will need a dental examination before a tooth extraction. The dentist will generally collect the patient’s medical and dental history and take an x-ray. The x-ray helps the dentist to determine the best way to extract the tooth. In some cases, dentists may prescribe antibiotics for the patient to take before the procedure. Patients may also need to prepare for anesthesia that may be used, such as by not eating several hours before the procedure and arranging for a ride home.
A simple extraction can usually be performed by a general dentist using only local anesthesia. Surgical extractions are more complicated than simple extractions and are usually performed by an oral and maxillofacial surgeon using stronger anesthesia (e.g., conscious sedation, general anesthesia).
Bleeding is normal after a tooth extraction and may last about a day. A gauze pad applied to the extraction site helps to control the bleeding. Pain, swelling or jaw stiffness generally lasts no more than a couple of days after the procedure and may be treated with medications and warm or cold compresses. To keep the site clean, gently rinsing the mouth with warm salt water can be used several times a day after the first day.
Dry socket is a common complication of tooth extraction that can cause severe pain. Other risks of the procedure include damage to nearby teeth and dental appliances, prolonged pain or stiffness of the jaw, infection and damage to the sinus cavities, nerves or jaw.
About tooth extraction
A tooth extraction is a commonly performed procedure to remove a tooth from its socket. The most common reason for tooth extraction is removing seriously damaged teeth (e.g., excessive tooth decay, abscessed teeth, fractured or broken teeth). Dentists will generally try to save a damaged tooth, but sometimes there is too much damage to restore the tooth.
Extractions may be simple extractions or surgical extractions. A simple extraction involves removing an erupted tooth without damaging the gum. This procedure can be performed by a general dentist, typically with local anesthesia.
A surgical extraction requires removing the tooth through the gum and possibly the jawbone. It is performed on teeth that have not erupted and teeth that are broken at the gumline and cannot be removed with a simple extraction. This is a more complicated procedure that is usually performed by an oral and maxillofacial surgeon and often requires stronger anesthesia (e.g., conscious sedation, general anesthesia). The degree of complexity depends on the condition of the tooth to be extracted. For example, sideways tilted impacted teeth are more difficult to extract that those in a vertical position.
Sometimes, a tooth does not fully erupt. It may be impacted in the bone, blocked by extra teeth (e.g., a primary tooth that never fell out) or it may erupt partially, leaving a flap of gum where infection can set in (pericoronitis). Wisdom teeth, for example, are frequently impacted or only partially erupt and often need to be extracted.
Other reasons for tooth extraction include:
- Dental crowding. Crooked teeth may crowd together, leaving little or no room for orthodontic work, such as braces. Some teeth may be extracted to create spaces to move the teeth into a straighter position.
- Risk of infection. Any teeth that have a high risk of infection may need to be extracted before patients undergo any kind of therapy that will weaken the immune system (e.g., chemotherapy, immunosuppressant medications for organ transplant patients).
- Preparation for a complete denture. Any remaining teeth (particularly upper teeth) may occasionally be extracted to prepare the mouth for a complete denture. However, if the teeth are healthy, dentists generally prefer to leave them in the mouth and use a partial denture or bridge instead, especially when treating the lower teeth.
- Radiation therapy. Some teeth may be obstacles to radiation therapy for the head and neck, which is common among cancer patients. In these cases, the teeth may need to be extracted to improve the effectiveness of the therapy. Surgery to smooth the jaw bone (alveoplasty) may be performed at the same time to speed healing after an extraction, allowing radiation therapy to be performed sooner.
Before the tooth extraction procedure
Before a tooth extraction can occur, the patient requires a dental examination. The dentist generally will also collect the patient’s medical and dental history and take an x-ray. The x-ray helps the dentist to determine the best way to extract the tooth. This is particularly important for surgical extractions, where the exact location of the tooth may not be obvious. If many teeth need to be extracted (e.g., all wisdom teeth), a panoramic x-ray may be made to show all the teeth as well as the location of the sinuses and major nerves.
In some cases, dentists may prescribe antibiotics for the patient to take before the procedure. During the extraction, bacteria in the mouth may enter the blood stream and infect other areas of the body. Preventative antibiotic use is most common for patients at a high risk of infection, such as people with weakened immune systems, heart murmurs, the very young or elderly, those who require a more complicated surgery, and people with artificial implants (e.g., artificial hip). If an infection is already present, it will also need to be treated with antibiotics before any teeth are extracted.
If a stronger anesthesia (e.g., conscious sedation, general anesthesia) is used, patients are often asked to wear clothing that will allow the use of an intravenous (I.V.) line, such as short sleeves. They may need to refrain from eating or drinking before the procedure (e.g., six hours) and will require a ride home after the extraction.
If the patient is a woman and the extraction involves a high risk of dry socket (e.g., extraction of a lower back molar), the dentist may decide to schedule the procedure at the end of the patient’s menstrual cycle (e.g., between days 23 and 28 of the cycle). This may help to reduce the risk of dry socket.
During the tooth extraction procedure
The actual procedure depends on the type of extraction that is performed. A simple extraction can usually be performed by a general dentist using only local anesthesia, although anti-anxiety medications may be used for some patients. After the extraction area is numb, the dentist uses forceps to firmly grasp the tooth and loosens it in the socket by rocking it back and forth. After the tooth is loosened, it is removed by simply pulling it out. If the tooth is difficult to loosen, a luxator (device that can be positioned between the tooth and the gum) may be used.
Surgical extractions are more complicated than simple extractions and are usually performed by an oral and maxillofacial surgeon using stronger anesthesia (e.g., conscious sedation, general anesthesia). In some cases surgical extractions can be performed with local anesthesia. Steroids may also be injected to help reduce the swelling that will occur after the surgery. The surgeon reaches the tooth by making an incision in the gum and pulling it back, then removing any bone that may be in the way. The connective tissue that secures the tooth to the jawbone may need to be separated, and the tooth may have to be cut or broken into smaller pieces for complete removal.
After the tooth is removed, the area is closed and the gums are stitched (sutured) back together. Dissolvable stitches are usually used and these disappear over time, although it may take one or two weeks. If the stitches are not dissolvable, they will need to be removed a few days following the procedure.
After the tooth extraction procedure
Bleeding is normal after a tooth extraction and may last about a day. The dentist will apply a gauze pad on the extraction site. The pad needs to be left in place for about 30 to 45 minutes. After this time, it can be replaced. As long as bleeding continues, a damp gauze pad needs to be applied to the area. These should be replaced regularly, before they become saturated in blood.
Pain, swelling or jaw stiffness generally lasts no more than a couple of days after the procedure. Dentists may give a prescription for pain medications or recommend an over-the-counter pain medication, although these are often not necessary for simple extractions. The dentist may also prescribe antibiotics if there is a high risk of infection. After the first day, a cool cloth, ice bag or warm compress may be used to help relieve swelling and stiffness.
Patients are generally urged to continue to floss and brush the unaffected teeth, but avoid the teeth directly around the extraction site for a few days. To keep the site clean, a gentle mouth rinse of warm salt water can be used several times a day after the first day. Patients are typically advised to stick to soft, bland foods (e.g., gelatin, pudding, soup) at first and to gradually add other foods as the area heals.
To prevent dry socket and reduce the healing time, patients are advised not to spit, drink through a straw or vigorously rinse their mouths for at least the first 24 hours following the procedure. Smoking needs to be avoided for at least several days after the extraction. These actions can result in the blood clot in the socket dislodging, which can cause severe pain. Patients are also frequently advised to avoid mouthwashes and touching, probing or otherwise disturbing the extraction site (e.g., with fingers or tongue) while the area heals.
While the mouth is still numb, the patient may inadvertently damage the soft tissues of the inner cheek, lip or tongue. To prevent this, patients are advised to avoid biting these areas. They should also generally avoid physical activity and lying flat, which can increase bleeding immediately after the extraction. Pillows can be used to prop up the head when lying down.
Patients are urged to contact their dentist if bleeding is heavy, continues for more than 24 hours or if they experience nausea, fever, chills or severe pain.
Potential risks and benefits of tooth extraction
Tooth extraction eliminates any problems associated with a given tooth, such as infection, major damage or impaction. Tooth extraction can be used to create room in a crowded mouth making space for orthodontic work. Depending on the tooth location and patient circumstances, artificial teeth (e.g., crowns, implants, bridges) can be used as substitutes for missing teeth.
Tooth extraction is associated with a number of risks including:
- Dry socket. A common complication resulting in severe pain. The blood clot that protects the socket and reduces healing time either does not form normally or is lost. Dentists typically attempt to prevent dry socket, but if it does occur, it is only temporary and it can be treated.
- Damage to nearby teeth and dental appliances. The neighboring teeth or dental appliances (e.g., crowns, bridges, implants, braces) may occasionally be damaged during the procedure.
- Prolonged pain or stiffness of the jaw. In some cases, a tooth extraction can lead to jaw pain and stiffness of the jaw (trismus), which can make the mouth difficult to open.
- Infection. Infection can occur after a tooth has been extracted. Bacteria enters at the extraction site and travels through the bloodstream to a susceptible part of the body. This is most common in patients with a weakened immune system, with certain conditions (e.g., heart murmur) or artificial implants (e.g., knee or hip implants). If a patient has a high risk of infection the dentist will generally prescribe antibiotics before and after the extraction.
- Incomplete extraction. A portion of the tooth may be left in the jawbone, increasing the risk of infection. However, there are some instances where a small root tip is intentionally left in the jaw because removing it would be too risky (e.g., potential for damaging a major nerve).
- Damage to the sinus cavities, nerves or jaw. The sinus cavities above the upper jaw may occasionally be damaged, which increases the risk of infection and may require another surgery to repair. The inferior alveolar nerve, an important nerve in the lower jaw, can also be damaged. Nerve damage is usually temporary and heals in three to six months although it may rarely cause permanent numbness in the lower lip and chin. Prolonged numbness may also occur due to inflammation of the nerves. Patients with a weak jawbone (e.g., those with osteoporosis) may have a risk of jaw fracture.
- Other complications. Rarely, patients taking certain medications may experience other complications. For example, recent studies suggest that patients taking a common drug for menopause symptoms who undergo tooth extractions or certain other dental procedures may experience increased deterioration of the jawbone. Thorough dental examinations are typically recommended before beginning these medications, and procedures such as tooth extractions may need to be avoided while on this medications.
Questions for your doctor on tooth extraction
Preparing questions in advance can help patients to have more meaningful discussions regarding their treatment options. Patients may wish to ask their doctor the following tooth extraction-related questions:
- Why do I need a tooth extraction?
- What type of extraction is right for me?
- Which of my teeth need to be removed?
- How complicated will the procedure be?
- Will I need to take antibiotics before and after the procedure?
- What type of anesthesia is right for me?
- Should I not eat or drink before the procedure? For how long?
- What will be done about my missing tooth?
- Will I need to come back to have stitches removed?
- What pain medications do you recommend for after the procedure?