Extractions

Tooth extractions may range from being “ridiculously easy” requiring only a few seconds to remove or they may be extremely difficult.

Extremely difficult is often partially of fully impacted lower wisdom teeth. These can have variable roots in number and shape that are not always observable on the x-rays. They may also be intimately involved with the mandibular nerve that feeds that half of the lower jaw. Occasionally/rarely the fully impacted lower wisdom teeth may have developed a cyst around them. When it occurs it is usually in older people.

Teeth sit in sockets in the jaw bone. (They do not “wrap around the jaw bone.”) They are attached to the bone by small ligament fibres that normally act as mini-shock absorbers. When removing a tooth, these fibres have to be broken to release the tooth from the socket. This is not a feat of strength. For simple extractions it involves the use of controlled force, meaning the tooth is rocked back and forth along with rotating movements as well as being levered upwards out of the socket.

Surgical extractions are referred to as soft tissue or hard tissue. Hard tissue means there is bone involved covering the tooth to some extent. They may be partial boney or full boney. The tooth may have more than one root that go off in different directions and require the tooth to be sectioned so each root is taken out like a separate tooth. They may further involve a scalpel in order to lift the gum away from the tooth as an attached flap to expose the area of the tooth. Later the gum is placed back down into position and secured using sutures/stitches, which may be dissolving, or non-dissolving which means they must be removed in the next week or two. For hard tissue involvements it is necessary to remove bone in order to get the tooth out. Whenever there is bone involved it usually involves pain and swelling afterwards. (Except with drilling holes in the jaw bone for implants which usually has little or no swelling nor pain.)  The amount of swelling is related to how much damage is done to the tissues in the area surrounding the tooth being extracted while getting it out.

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Teeth may be removed for several reasons: 

  1. There is not enough room so it is an orthodontic problem or the jaw(s) are not long enough to allow wisdom teeth to come in.
     
  2. The baby teeth are ankylosed (attached directly to the bone) and are interfering with the permanent teeth coming in.
     
  3. They are in a  position that just doesn’t work with the rest of the mouth
     
  4. They are damaged beyond repair from bacterial invasion (decay) or trauma
     
  5. The supporting tissue around them has been lost as with advanced periodontal disease. A person may be getting repeated gum infections due to deep pockets around the teeth and/or they may be very loose.
     
  6. They are impacted and may be damaging adjacent teeth.
     
  7. They are impacted and have developed a cyst (a fluid filled sac that usually will continue to expand over time) around them.
     
  8. Their long term survival is questionable because of heavy repairs and there is other extensive treatment being contemplated that would include that area and it would just be better if they were gone.
     
  9. The person has been on the internet and has taken on the voodoo beliefs that root canal treatment is a fiendish plot to allow evil spirits to live inside a tooth. So, if the bacterial invasion/decay has gotten into the centre of the tooth where the small nerve and blood supply reside and they decline root canal treatment then the only option is to extract the tooth.

Medications

Sedation

Ativan (lorazepam) or Medazolam can be taken orally with special instructions, like DONT’T DRIVE!!

Nitrous oxide is an inhaled gas that is controlled by the dentist.
Intravenous which can take a person to a much deeper level of sedation is not offered in our office

Analgesics/Pain Killers

Advil is a very good anti-inflammatory. It acts locally. A person can take up to 2400 mg per day. Usually it is prescribed as “Take 400 mg every 4 hours as required for pain.” We often use this in conjunction with Tylenol.

Tylenol (acetaminophen) works in the brain to block pain. It has no anti-inflammatory properties. It is often started 2 hours after the Advil and at also taken at 4-hour intervals. This means Advil and Tylenol taken two hours apart are “piggy backing each other meaning when one has been absorbed into the body and is at full strength the next one is taken so as the first one starts to wear off this next one is reaching full strength. 

Advil can be started the morning of the extraction day. 

Anti-inflammatory

Dexamethasone
Used for more involved surgical cases including implants and bone grafting associated with that. Usually started the morning of the procedure and continued only for the following two days. 

Antibiotics

Penicillin
Pen V (NoVo pen) is easy on the gut. Amoxicillin, or Clavulin/Augmentin (Amoxicillin plus Clavulanic acid which is good against penicillin resistant bacteria) are much harder on the gut and may require probiotics in conjunction.

Clindamycin
For those allergic to the penicillin. This is also very hard on the gut and should not be taken for more than a week if at all possible.

These are not usually prescribed for simple extractions and not always for more complicated ones but they may be, especially if bone grafting and implants will be involved as well.