Dental Extraction
In this section, we will cover:
- What is a dental extraction?
- Why do I need a dental extraction?
- What are the risks?
- Do I need to see a specialist?
- What should I do before the procedure?
- What does the procedure involve?
- What do I need to do after?
- Will I need antibiotics?
- What about the gap?
What is a dental extraction?
A dental extraction is the technical term for having a tooth removed.
Why do I need a dental extraction?
The most common reasons for having your tooth removed are:
- Unrestorable tooth decay
- Dental infection/abscess
- Failed root canal treatment
- Extensive periodontal disease with chronic infection/periodontal abscess
- Vertical fracture along root of tooth
- Dental trauma
There is the option of having no treatment but this comes with the risk of spreading/recurrent infection, swelling and sepsis.
What are the risks?
Common Risks
Having a tooth removed is a bit like falling over and hurting your knee. After the extraction, you may have:
- pain/discomfort
- bleeding
- bruising
- swelling
Less Common Risks
- damage to other teeth/gum/restorations
- tooth breaks needing further treatment (surgical extraction or referral to a specialist)
- infection
- dry socket
Tooth-specific Risks
For an upper molar:
- Oro-antral communication
This is a passage between your mouth ("oro") and sinus ("antral" - the air space inside your cheek). This can happen when the roots of your tooth are close to, or in, the sinus. This can sometimes heal by itself or your dentist may need to pull the gum over the hole and place some stitches.
For wisdom teeth: see here
There are also certain risks which relate to your medical history so it is important to discuss this thoroughly with your dentist before any treatment.
- Dry socket
What is it: inflammation of the bony socket after an extraction due to poor blood clotting
Patients at risk: smokers, pregnant women, those on the oral contraceptive pill - MRONJ (medication-related osteonecrosis of the jaw)
What is it: a condition in which the jawbone dies due to lack of blood supply and this bone becomes exposed as the gum does not heal over it
Patients at risk: long-term or intravenous bisphosphonates or anti-angiogenics - ORN (osteoradionecrosis)
What is it: a condition in which the jawbone dies due to lack of blood supply and this bone becomes exposed as the gum does not heal over it
Patients at risk: history of radiotherapy at the extraction site - Excessive bleeding
Patients at risk: those with bleeding disorders or taking blood thinning medication (warfarin, NOACs, clopidogrel, aspirin) - Infective endocarditis
What is it: bacterial infection of the heart lining
Patients at risk: those with a congenital heart defect, artificial heart valve or history of rheumatic fever
Do I need to see a specialist?
Most teeth can be removed under local anaesthetic by your local dentist.
If your dentist feels the tooth will be difficult to remove, they may refer you to an oral surgeon in a dental practice or hospital. An oral surgeon is somebody who specialises in removing teeth and performing other surgical procedures in the mouth.
Reasons you may need to see an oral surgeon for treatment include:
- if your tooth is very broken down
- if you need a wisdom tooth removed
- if your tooth is impacted (stuck under the gum, in the bone or behind/under another tooth)
You may be referred to a (dental) hospital if:
- you need multiple difficult teeth removed under general anaesthetic (this will be with an experienced team of dentists and anaesthetic doctors)
- you have a complex medical background (e.g. bleeding disorders, long term intravenous bisphosphonate treatment). If you have many medical problems, it is safer to be treated in a hospital as they are better equipped to manage immediate and long term complications.
If you are very anxious, you may benefit from having the procedure done under sedation to help settle your nerves. This can be done in dental practice or a hospital-based oral surgery department. Some general dentists can offer this service if they are trained to do so.
What should I do before the procedure?
For treatment under local anaesthetic:
- Eat before your appointment
This is to reduce the chances of you feeling unwell during the procedure and because you won't be able to eat for 2-3 hours after as you will be numb. - Take a painkiller
You should take a painkiller, such as ibuprofen, 30-60 minutes before your appointment. This will help reduce the discomfort when the anaesthetic starts to wear off. It is more effective to take a painkiller before the anaesthetic wears off than after.
If you are having sedation or a general anaesthetic, follow the instructions given to you by the dentist or nurse. You will usually need to fast for 8 hours prior to a general anaesthetic. If you are having intravenous sedation or general anaesthetic, you will need an escort (a responsible adult) to take you home and look after you for the next 24 hours.
What does the procedure involve?
A simple dental extraction under local anaesthetic will usually take 20-30 minutes to complete.
So what are the stages?
- Local anaesthetic
Local anaesthetic is a medicine used to numb the tooth and gum. It is given by a small injection next to the tooth. If you need a lower back tooth removed, your dentist will need to give an injection at the back of the mouth which numbs the teeth, gum, tongue, lip and chin on that side.
This will ensure you don't feel any pain but you will still feel some pressure. - Making the tooth wobbly
Your dentist will use a series of instruments to make the socket around the tooth larger. It is normal to feel pushing and pressure during this. - Removing the tooth
Once the tooth is sufficiently wobbly, your dentist will be able to remove your tooth with a special instrument designed to grip your tooth firmly. Again, you will feel a lot of pressure and any squelchy/cracking sounds are normal. - Checking for a blood clot
After the tooth is removed and your dentist is happy the whole tooth has come out, they will apply some gauze/cotton roll to the extraction site and ask you to bite down. It is important to keep pressure here as the aim is to stop the bleeding. After a few minutes, your dentist will check the bleeding has stopped. If it has, you can go home but take it easy for the rest of the day. If it hasn't, your dentist may place a dressing and/or stitches to control the bleeding.
What do I need to do after?
After you have had a tooth removed, you will be numb for a few hours and there may be some on/off oozing from the extraction site. When the anaesthetic wears off, the area will be sore and over the next couple of days, you may develop a slightly swollen face. This can take up to a week to settle.
Although it is safe for you to go back to work after having your tooth removed under local anaesthetic (unless your job involves strenuous activity such as construction), you should consider whether it will be comfortable for you to do so given what I have explained above. You may prefer to take the rest of the day, or a couple of days, off. Or arrange your appointment for just before the weekend.
Your dentist or nurse will give you instructions on important steps for after-care.
- If bleeding starts again, take a clean moist handkerchief, roll it up in a sausage and apply pressure to the area for 15-20 minutes. If the bleeding continues, call your dentist for advice.
- If you are taking any blood thinners, please check with your dentist or doctor when it is safe for you to take your next dose.
- If you experience severe pain, especially pain which increases after 3-5 days, you should contact your dentist as you may be suffering from an infection or dry socket (LINK).
DO
- Take it easy for the rest of the day
No heavy lifting, running around or swimming - Take painkillers as needed
You will usually need regular painkillers for the first 2-3 days at least. Paracetamol and ibuprofen (if you can take it) work well in combination (take a paracetamol then 2 hours later, take an ibuprofen). They control pain in different ways, so they are safe to take together. - Use an icepack to reduce facial swelling
It is not unusual for your face to be slightly swollen for a few days following a dental extraction, particularly if it was a difficult tooth or a surgical extraction. - Eat soft foods for the first few days
- After 24 hours (since having the tooth removed), carry our warm salt water mouth rinses after eating and before bed. Continue this for 7-10 days to reduce the risk of infection.
- Continue to brush your teeth twice a day but be gentle where the tooth was removed
DON'T
- Don't smoke
Smoking after having a tooth removed increases your risk of dry socket. This, I have been told, is more painful than toothache. - Wait to eat and drink until the numbness has worn off
It will usually take 2-3 hours before the numbness has worn off. You will be able to talk normally but it may feel a bit strange due to the numbness. - No spitting or rinsing for 24 hours (to avoid dislodging the blood clot - this will delay healing).
- Don't eat anything too hot for the rest of the day (this may set off bleeding).
- Don't take aspirin as it may cause bleeding.
- Don't blow your nose
If you do have an oro-antral communication (your dentist will tell you), it's important you don't blow your nose or sneeze with your mouth closed for the next couples of weeks to avoid increasing pressure within your sinus.
Will I need antibiotics?
Antibiotics are not routinely prescribed before or after a dental extraction.
Some people develop an infection after a tooth is removed. You will usually notice severe pain, swelling and pus/creamy discharge from the socket. If your dentist diagnoses an infection, they will prescribe a short course of antibiotics to help settle this.
Infective Endocarditis
- Infective endocarditis is is a bacterial infection of the heart lining.
- In the UK, prescribing antibiotics prophylactically (i.e. before there are any signs/symptoms of a problem) is no longer recommended for patients at risk of infective endocarditis*. Conditions which increase your risk include a congenital heart defect, artificial heart valve or history of rheumatic fever.
- Your dentist will ask you to monitor your symptoms over the next few days if you are a high risk patient. Symptoms to watch out for include:
- high temperature
- night sweats
- shortness of breath
- tiredness - Some doctors or cardiologists (heart doctors) will still advise you to have antibiotics for a dental extraction. Usually your cardiologist will have given you a document with the details of what antibiotics they want you to take and for what procedures. Your dentist may want to confirm this with them directly so please have their contact details to hand.
*This is true at time of writing but guidelines can change.
What about the gap?
After you've had an adult tooth removed, you will be left with a gap. A new tooth will not grow here.
You do not have to replace the missing tooth. Some people may be happy to leave a gap where the tooth used to be. Others may find the gap makes them feel very self-conscious.
The risks of doing nothing are the teeth around the gap might start to tip/drift into the space. This makes it more difficult to replace the gap in the future. If you choose not to replace the gap and have only a few natural teeth left, they will be under increased force when you are eating and are more likely to fracture.
These are the main options you have to replace the missing tooth/teeth:
- Removable denture
This is commonly used to replace single teeth at the front of the mouth or multiple teeth around the mouth. It is a good immediate option whilst the gum and bone remodel and settle over the following 3-6 months. - Bridge
This is a "fixed" option - i.e. you do not/cannot remove it yourself. There are two main types of bridges: a sticky bridge and a conventional bridge. - Implant
This is another "fixed" option. Dental implants can be placed by a a specialist (oral surgeon or periodontist) or a general dentist who has had some further training.
Choosing the right option for you is not always easy. Factors to consider include:
- Does the gap make you feel self-conscious?
- Is it difficult for you to eat?
- Which teeth, and how many, are missing?
- Is the rest of your mouth healthy?
If you are still working with your dentist to achieve good oral health, now may not be the best time to go for a bridge or implant as they are more likely to fail. If you really cannot tolerate the gaps, a denture may be a good compromise - however, dentures are not easy to get used to. - How much are you able or willing to spend on replacing the missing tooth/teeth?
Speak to your dentist about what options are suitable for you and your mouth. Not all options are suitable for everyone.