Extractions

What are the most common reasons that a tooth would require extraction?

Severe decay
Deep fracture
Chronic abscess
Advanced periodontal disease/ lose teeth

Should I be extracting a tooth that is causing me acute pain?

Typically a tooth that hurts a lot would require either root canal therapy or extraction. At You Smile we always recommend trying to save and restore such teeth. However, if the patient does not want to undergo the procedure of root canal therapy, we would agree and proceed with extraction, which will end the toothache.

Which prescription drugs might cause complications if an extraction is required?

a. Bisphosphonate medication. These are drugs used typically for osteoporosis. This is a contra-indication for extractions. You must discuss thoroughly with your dentist your prescription. Intravenous bisphosphonates pose severe risks for osteonecrosis and extractions should be avoided. Intra-oral bisphosphonates require a hospital environment for extraction, only if necessary. BE AWARE that these drugs stay active in the body for a very long time after stopping them! Please make sure that you fill your medical history carefully and inform your dentist.

The following drugs belong to the family of bisphosphonates: Alendronic acid (Fosamax), Disodium Etidronate (Didronel), Disodium Pamidronate (Aredia Dry Powder), Ibandronic acid (Bondronat, Bonviva), Risedronate Sodium (Actonel), Sodium Clodronate (Bofenos, Clasteon), Tiludronic acid (Skelid), Zoledronic acid (Aclasta, Zometa) and Strontium Ranelate (Postelos).

b. Anti-coagulation therapy. Patients receiving anticoagulants to prevent Thromboembolic disease, maybe liable to excessive bleeding after extraction. The risk for excessive post-extraction bleeding is significantly high when a combination of more than one anticoagulant drugs is prescribed, like for example Warfarin with Aspirin. Warfarin on its own, while it still requires a measurement of your INR before the extraction, is less of a threat than rumoured to be. INR is the test that shows if you are able to have an extraction. For a patient requiring long-term warfarin, the INR should be assessed within 24 hours before your extraction. It is wise to assess the INR an extra time (3-4 days before) and adjust the dose, according to your doctor’s advice, to achieve on your second test an INR number that allows extraction. Patients who have an INR number of 4.0 or smaller within 24 hours from the scheduled extraction can proceed safely.

The most common anticoagulant drugs, known as ‘’blood thinners’’ are: Warfarin, Heparin, Acenocoumarol (Nicoumalone), Phenindione, Dabigatran Etexilate or Rivaroxaban. ASPIRIN, although a common painkiller, interacts with these anticoagulants and it significantly intensifies the blood thinning effect! Note that Aspirin is frequently used as a chronic low dose to prevent thromboembolic disease and affects the blood for 10-15 days after you stop taking it! There other common drugs as well that interact with Warfarin! These include many anti-inflammatories and also antibiotics like Erythromycin, Metronidazole, Miconazole, Clarithromycin. Please inform your dentist of all the medication you are Currently taking!

c. Antibiotics. This is a risk only for people that are allergic to the drastic substances of certain antibiotics. The most common allergy that consists a great danger for the patient is the allergy to Penicillin (Amoxicillin and others). Less commonly used antibiotics that you maybe allergic to are: Erythromycin, Metronidazole, Cephalosporin. Please inform your dentist of all possible allergies. If you have had an incident of allergic reaction to anything you should mention this to your dentist! Note that allergies can appear randomly to any age and people may become allergic to something that they are used to be taking safely in the past! In the event of experiencing any abnormal reaction that resembles ‘rush’ like symptoms after taking antibiotics stop the medication immediately and contact your dentist.

Antibiotics should not be used after every extraction as they are unnecessary and long term this creates more resistant bacteria. At You Smile Dental Care we provide the antibiotics on site but only when it absolutely beneficial for the patient.

Which Systemic diseases might cause complications with an extraction?

Bleeding disorders
Diabetes
Heart murmur
Artificial joints
High Blood pressure (un-regulated)
Severe chronic infections
Auto-immune diseases and syndromes

While none of the above conditions is an absolute restriction for having your needed extraction, it is imperative that the dentist knows about any of the above before the procedure, so that he can adjust the treatment to your needs and give you the proper instructions for a safe and successful extraction.

What are the most common complications related to tooth extractions?

a. Dry Socket (alveolar disease) or commonly known as a ‘bad socket’ or ‘infected socket’. This is a very common problem after having a tooth out. Clinically the patient will experience acute pain (can be really painful!) that tends to radiate along that whole side of the face up to the head. The pain usually starts around 2-4 days after the extraction and is typically accompanied by a bad taste of decay coming out of the socket. The socket is very dry and not bleeding at all.

- What is the dry socket? What is causing this?

Dry socket in simple words is a bad and slow healing, due to poor blood supply of the bone that used to host the tooth. Although it is a nasty situation causing grief, it is also not a worrying one, as it is just a longer healing cycle that will eventually conclude in about 3 weeks (even without treatment). Nothing is really causing the dry socket but there are factors that significantly increase the risk of having one. These factors are:

Difficult extractions
Having being smoking for years before
Smoking after the extraction
Immunodeficiency
In-experienced dentists

- What do I do if I get a Dry socket?

You must immediately contact the dentist. There is a special treatment that significantly reduces the symptoms and the duration of the dry socket! Here at You Smile dental care we offer the treatment of the dry socket free to all the patients that had extraction with us and are suffering. A treated dry socket will subside gradually in around 10 days while an untreated one will double and being more severe. The treatment needs you to call us and make a 10 minutes appointment. Rarely you would need another visit and very seldom a 3rd one. For our patients here at our dental practice in Market Rasen, all dry socket treatments are free of charge.

- Should I just take antibiotics since I have an infected socket?

No, contrary to what people might think, antibiotics have proven to be the least useless against a dry socket. That is because the dry socket does not get any blood so the drastic substance of the medication will never reach the infected area. In our dental practice the treatment consists of local cleaning and disinfection performed by the dentist. Antibiotics will only be used when there is a co-existing swelling and infection beyond the socket.

b. Excessive bleeding After having an extraction you might find that the socket keeps bleeding later on. This is common for patients that are suffering from blood disorders, taking blood thinning medication, having had difficult and extended (multiple) extractions, or just not following the post care advice properly.

- What should I do if I notice prolonged or excessive bleeding?

Prevention: Please follow your post care advice after the extraction!:

Keep a good pressure on the socket with the biting gauze we have placed for a full 20minutes.
Avoid rinsing the socket with water (Never try to stop the bleeding by rinsing with water! It makes it worse!)
Do not disturb the socket the first few days! (Avoid direct brushing and chewing on the socket!)

Cure: In the event of excessive bleeding the first thing to do is to bite on the extra piece of sterile gauze we have given you leaving the practice after the extraction. Make sure that the bite is firm and continuous for 20 minutes (avoid talking and opening). Also please make sure you keep some sterile gauze at home in case you need more later.

Contact: If the above measures do not work and you find the blood quantity excessive please give us a ring to the practice number. At You Smile dental care in Market Rasen we have a 24/7 emergency line available for you in case of a dental emergency, like excessive bleeding. Please call the number given on the answering machine and leave a voicemail. A private dentist will contact you within the hour.

c. Post extraction abscess In case of swelling (face or inside of the mouth around the cheeks and gum), it is most likely to need antibiotics. Please contact us to book an urgent review appointment and most likely receive your antibiotics at our dental practice in Market Rasen.

d. Remaining tooth, broken roots. Rarely under our care, a tooth will have to break out leaving part of the root inside. In such complex extractions in our practice we are fully equipped and skilled in minor oral surgery. Dr D. Alexakis has postgraduate qualifications in Oral surgery from the University of Lancaster (Preston) and a great experience in surgical extractions. At first he would always procced immediately with the surgical removal of the broken root. Only if the fragment is too tiny, fused and harmless it would be left inside always letting you know of its existence and verifying this with a radiograph.

It is very common and completely understandable that a patient would confuse himself thinking there is tooth left inside, while in fact it is onl little bone fragments that are pushed out slowly by the body and eventually come out of the empty hole, sometimes even months after the extraction. Patients often think the dentist had left some tooth in, while this is not the case. In our dental practice the dentist always works with a microscope and is very well aware if something was left in, in which case you would always be informed about it. The opposite has never happened in You Smile Dental Care.

Sometimes the dentist after the extraction puts inside the socket a healing sponge. This is an absorbable patch that is white in colour and looks like a piece of tooth to the patient. Please rest assured this is not tooth and it should stay there to intergrade with the healing clot and minimize bone loss.

e. Bone loss Unfortunately, every extraction is followed with loss of the supporting bone around the tooth. That results in the jaw bone shrinking in that area. How that affects you?

If the plan is to replace the tooth that was extracted with an implant, then losing a lot of bone around the socket might lead to needing ‘bone grafting’ before you would be able to have an implant in the future.

If the plan is to have a denture after multiple extractions, then that denture will have to be relined from time to time as the bone loss continues long term around large bare gum areas.

If there are neighbouring teeth to the extraction, these will lose bone around their own roots and may become sensitive or lose.

In our dental practice we take the outmost care for minimal post extraction bone loss by using atraumatic techniques and titanium coated instruments.

f. Oral-nasal communication Rare but possible during the extraction of upper molar teeth, is that the thin membrane above the tip of the roots will be perforated and then air will find way from the nose straight into the mouth cavity, through the empty tooth socket. This happens when the roots of upper molar are deeply fused in the sinus floor and then it is unavoidable. In our practice we identify the danger before hand by performing radiographic examination and discussing with you if you want to take the risk and go ahead. Another reason why e sinus floor could be perforated is when the dentist is inexperienced.

How do I know it happened? What should I do now? Are there any dangers?

When this complication happens, the patient will have typically water coming out of his nose when he tries to drink!...a rather unpleasant symptom.

The first think to do is to call the practice and inform us. A review appointment will be made. Treatment and follow up is as follows:

Antibiotics for 2 weeks, broad spectrum
Avoiding the build-up of intra-oral air pressure (avoiding sneezing or blowing the nose and avoiding vigorous mouth-washing)
Avoiding sucking back, avoiding drinking with straws and any negative pressure.
Having the drinks carefully from the other side (not very hot ones!)
Eating carefully from the other side
Brushing softly without disturbing the wound.
Coming back for a review after 1 week, 2 weeks 1 month, 3 months and there after 6 monthly.

Note: If the wound is serious and not healing naturally or if tooth fragments have been pushed into the sinus the problem will require specialized jaw surgery for which you will be referred to the county hospital, maxillofacial department. Neglecting to deal with the problem will lead to chronic and re-occurring sinusitis infections.

g. Stability loss Maybe the most important complication after a losing a tooth is the loss of the integrity of the dental arch. We find this the most important because it will almost always follow the loss of a tooth, even when things have gone perfect during and immediately afte the extraction. Stability loss comes at a delayed stage, sometimes months or years after losing a tooth.

What is stability loss? How does it affect my oral health? How can it be avoided?

The neighbouring teeth will bend and slowly travel towards the gap.
The opposing teeth from the dental arch across will over-erupt and elongate into the gap, as it does not find anything to stop it.
The fore-mentioned teeth will succumb to gum pocketing formations around their roots due to improper position and inability and plaque retention.
Finally all the fore-mentioned teeth will be in very high risk of getting lose and falling out as well.

In summary, the dental arch is supposed to stay intact and losing a unit breaks the integrity of function and like in any machine this creates a domino effect that eventually may lead to more teeth getting lost and the whole mastication system malfunctioning.

This is why we should always replace extracted teeth soon after the extraction, ideally 4 months after, when the bone will have taken much of its ‘final’ form.

Extracted teeth can be replaced with: