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Tooth Extraction

Overview

Background

Tooth extraction is linked to dentists who perform oral surgery. Teeth that are embedded in bone (eg, impacted or wisdom teeth) must be removed by an oral and maxillofacial surgeon who is trained for 4-6 years after obtaining a dental or medical degree.

Compared with removal of an impacted tooth, tooth extraction appears to be a relatively simple technical procedure. However, both tooth extraction and removal of an impacted tooth must be performed in accordance with surgical principles that have evolved from both basic research and centuries of trial and error. Tooth extraction leaves a surgical wound, which has to heal. Accordingly, a basic understanding of wound healing is essential for performing this surgical procedure in the oral cavity.

Like any other minor surgical procedure, tooth extraction requires careful medical evaluation of the patient. Patients with diabetes, hypertension, renal disease, thyroid disease, adrenal disease, or other organ disease must be treated and their disease controlled before tooth extraction. Treatment with medications such as oral anticoagulants and bisphosphonates might cause postoperative complications and necessitate special care and medical treatment adaptation. Because the oral cavity is full of microorganisms, any surgical procedure in this area may give rise to postoperative infection, especially in immunocompromised patients. In all patients, antibacterial mouth rinse is necessary in every case of oral surgery.

Before, during, and after tooth extraction, pain management is an important issue. Medical, surgical, and legal considerations exist; for example, removing the wrong tooth is malpractice, as is breaking the jaw during extraction or causing paresthesia after extracting the mandibular third molar in close proximity to the inferior alveolar nerve without proper informed consent or suggesting an alternative such as coronectomy. In addition, complications such as postoperative bleeding due to inappropriate behavior of the patient or continuation of oral anticoagulants should be prevented as much as possible, mainly by adaptation of the medical treatment and good local hemostasis. Jaw bone necrosis due to the use of bisphosphonates should also be prevented by monitoring bone turnover before oral surgery and by avoidance of surgical extraction in patients receiving intravenous bisphosphonates.

Indications

Teeth are important for aesthetic purposes and for maintaining masticatory function. Accordingly, all efforts to avoid tooth extraction must be exhausted before the decision is made to proceed with removal of a tooth. Nevertheless, there are circumstances in which it is clear that a tooth must be extracted, such as the following:

A tooth that cannot be restored, because of severe caries

A mobile tooth with severe periodontal disease, pulp necrosis, or periapical abscess, for which root canal treatment is required that the patient cannot afford (or for which endodontic treatment failed)

Overcrowding of teeth in the dental arch, resulting in orthodontic deformity

Other conditions that may necessitate extraction include the following:

Malposed teeth causing soft tissue trauma to the cheek

Cracked teeth from trauma

Supernumerary teeth

Teeth adjacent to a pathologic lesion that must be excised

Planned radiation or intravenous (IV) bisphosphonate treatment, warranting prophylactic extraction

Teeth in the line of fracture

Aesthetic considerations (eg, teeth with endogenous staining)

Economic considerations (eg, teeth for which extensive restoration is required that the patient cannot afford
)

Contraindications

There are few contraindications for tooth extraction, and most of those that do exist can be modified by additional medical consultation and treatment. Some contraindications can be so severe that extraction should not be performed until the severity of the medical condition has been resolved.

Essentially, contraindications may be divided into local and systemic. Local contraindications are limited to the extraction sites. An example is an extraction site that was heavily exposed to radiation; if extraction is performed in the irradiated area, osteoradionecrosis results. Other local contraindication is proximity to a malignancy; extraction in the area of malignancy may increase the chances of dissemination of malignancy.

Extraction may be contraindicated in an area of infection that has not been adequately treated (eg, an impacted third molar associated with pericoronitis that is not treated with an antibiotic). Extraction may also be contraindicated when it is adjacent to the site of jaw fracture, because the teeth may be required for stabilization of the fractured bone. If the patient has very limited mouth-opening ability, extracting a tooth may be extremely difficult because of limited access to local anesthesia.

A systemic contraindication is systemic bisphosphonate therapy for malignancy. Extraction in patients receiving such therapy results in osteochemonecrosis, which is more severe than osteoradionecrosis and is more difficult to treat.
Other systemic contraindications include brittle uncontrolled diabetes, end-stage renal and liver disease, uncontrolled leukemia, lymphoma, hypertension, cardiac dysrhythmias, and cerebrovascular accidents.

Pregnancy is a relative contraindication in the first or last trimester; extractions are deferred until after childbirth. Hemophiliac patients and those with severe platelet disorders or other bleeding diatheses should undergo extraction only after these coagulopathies have been corrected. Caution and extreme care are required before extraction in patients on long-term corticosteroids, immunosuppressants, or cancer chemotherapeutic agents.

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