Tooth Removal Warnings




Teeth are removed for a number of reasons.  Typically, the tooth is extensively decayed or fractured and is causing chronic infection and discomfort.

Sometimes, the tooth has to be removed surgically.  Surgical removal is needed when simple extraction is not possible because of the condition of the tooth
.

The following list of warnings regarding tooth extraction is neither exhaustive nor is it predictive.  The most pertinent warnings have been included here.


Common Surgical Consequences
:

Pain.  As it is a surgical procedure, there will be soreness after the tooth removal.  This can last for several days.  Painkillers such as Ibuprofen, Paracetamol, Solpadeine or Nurofen Plus are very effective.  Obviously, the painkiller you use is dependent on your medical history & the ease with which the tooth was removed.

Swelling.  There will be swelling afterwards.  This can last up to a week.  Use of an ice-pack or a bag of frozen peas
pressed against the cheek adjacent to the tooth removed will help to lessen the swelling.  Avoidance in the first few
hours post-op, of alcohol, exercise or hot foods / drinks will decrease the degree of swelling as well.

Bruising.  Some people are prone to bruise.  Older people, people on aspirin or steroids will also bruise that much
more easily.  The
bruising can look quite florid; this will eventually resolve but can take several weeks (in the worst cases).

Stitches.  The extraction site will often be closed with stitches.  These dissolve and ‘fall out’ within 10 – 14 days.

Limitation of Mouth Opening (Trismus)
.  Often the chewing muscles and the jaw joints are sore after the procedure so
that mouth opening can be limited for the next few days.  If you are unlucky enough to develop an infection afterwards
in the socket, this can make the limited mouth opening worse and last for longer (up to a week).

Post-op Infection.  You may develop an infection in the socket after the operation.  This tends to occur 2 – 4 days later and is characterised by a deep-seated throbbing pain, bad breath and an unpleasant taste in the mouth.  This infection is more likely to occur if you are a smoker, are on the Contraceptive Pill, on drugs such as steroids and if bone has to be removed to facilitate tooth extraction.

If antibiotics are given, they are likely to react with alcohol and/or the
Contraceptive Pill (that is, the ‘Pill
’ will not be
providing protection).

Adjacent Teeth
.  The surrounding teeth may be sore after the extraction; they may even be slightly wobbly but the teeth should settle down with time.  It is possible that the fillings or crowns of the surrounding teeth may come out, fracture or become loose.  If this is the case, you will need to go back to your dentist to have these sorted out.  Every effort will be made to make sure this doesn’t happen.  In very rare instances, the surrounding teeth may actually come out as well as the intended tooth.

Surgical Removal
.  To ease the removal of teeth, it is sometimes necessary to cut the gum and/or remove bone from around the tooth.  If this is the case, you can expect the extraction site to be more sore afterwards, the swelling to be greater and more likely to become infected.  Hence, stronger painkillers are needed; use of icepacks necessary and antibiotics will probably be prescribed.  The bone grows back to a greater extent.  Care though will be taken not to be ‘wasteful’ in bone removal as this effects afterwards the provision of dentures, bridges and implants.

Less Common Surgical Consequences
:

Numbness / Tingling / 'Burning' of the Lip, Chin and/or Tongue.  The nerves that supply feeling to the tongue, lower lip and the chin run close to the root-ends of the lower molar teeth and exit onto the gum close to the roots of the premolars / bicuspids.  There is a risk that when back lower teeth (wisdom teeth especially) are removed, these nerves can be crushed, bruised or stretched resulting in numbness (at the worse end of the scale) to altered sensation (at the other end of the scale) in the region of the lower lip, chin and/or tongue.

This nerve bruising tends to be temporary (rarely is it permanent) but ‘temporary’ can stretch from several days to several months.  It is hard to predict who will get nerve bruising and if it will be temporary / permanent and if temporary, how long for.

Left Behind Tooth Tips
.  In rare instances, the very ends of the teeth may be left behind.

In the lower jaw, this is done because in trying to remove these root tips, the nerve supplying feeling to the lip, chin &
tongue may be damaged.  If they are left behind, there is not likely to be any problems associated with this.

In the upper jaw, these root tips may stay where they are in the socket or may be
pushed into the sinus or into a local blood vessel network (pterygoid plexus).  If these tips are left behind in the socket, there is not likely to be any problems associated with this.  However, if the root tips have gone out of the socket into the local anatomy, they will need to be recovered.

Bony Flakes.  Occasionally, bony flakes (sequestra
) from the sockets of the extracted teeth can work their way loose and through the gums.  These can be quite sore.  They often work their way loose without any problems but may need to be teased out or even smoothed.  If a number of teeth are removed at one go, the resulting gums may feel a bit rough.  In many cases, the gums become less rough with time however, it may be necessary to smooth the underlying bone for this to happen.

Failure of Anæsthesia
.  In rare cases, the tooth can be difficult to ‘numb up’.  This can be due to a number of reasons. The more common ones include inflammation ± infection associated with the tooth, anatomical differences & apprehension.  If the tooth fails to ‘numb up’ then its removal will be rescheduled with antibiotic cover or perhaps done under sedation or even a GA.

Bleeding into Cheeks
.  Swelling that does not resolve within a few days may be due to bleeding into the cheek.  The cheek swelling will feel quite firm.  Coupled with this, there may be limitation to mouth opening and bruising.  Both the swelling, bruising and mouth opening will resolve with time.

Mouth-Sinus Communications.  Upper molar and premolar teeth often have their roots in close proximity to the sinus.  
In removing these teeth, there is a chance that a ‘hole’ can be made between the mouth & the sinus (this is sometimes not evident at the time of operation but may develop several weeks afterwards).  If this ’hole’ persists or is left un-repaired, every time you drink, fluid can come out of the nose and you may develop a marked
sinusitis
.

This ‘hole’ if small enough, can spontaneously close.  It can be assisted in this by ‘cover plates’ that prevents food &
fluids going into the sinus allowing the hole to close naturally.  However, ‘holes’ above a certain size need to be
surgically closed.

Fractured Tuberosity.  The upper molars can, from time to time, be fused with the bone around them so that in removing the molar tooth, the bony socket within which the tooth sits (tuberosity) comes with it.  This can make the
mouth-sinus communication larger (see above) and sometimes, the adjacent teeth and their bony sockets comes attached with the extracted tooth.

Closure of the ‘hole’ is
followed with antibiotics, painkillers & decongestants.  Nose-blowing is forbidden for a week
afterwards (at least).

Rare Surgical Consequences
:

Prolonged Period of Disability
.

Prolonged Pain
.

Prolonged Limitation of Mouth Opening (Trismus).  This can be due to medial pterygoid contracture / spasm.

This spasm may be the result of injury of the
medial pterygoid muscle caused by a needle (repeated injections
during Inferior Alveolar Nerve block) or by trauma of the surgical field especially when difficult lengthy surgical
procedures are performed.  Other causative factors are inflammation of the post-extraction wound,
hæmatoma
and
post-operative
œdema
.

The management of
trismus
depends on the cause.  Most cases do not require any particular therapy.  When acute
inflammation or a
hæmatoma is the cause of trismus
, hot mouth rinses are recommended initially and then broad-
spectrum antibiotics are administered.

Other supplementary therapeutic measures include:

  • Heat therapy, i.e., hot compresses are placed extra-orally for approximately 20 min every hour until symptoms subside.
  • Gentle massage of the TMJ area.
  • Administration of painkillers, anti-inflammatory and muscle relaxant (such as sedatives) medication.
  • Physiotherapy lasting 3 – 5 min every 3 – 4 hours, which includes movements of opening and closing the mouth, as well as lateral movements, aimed at increasing the extent of mouth opening.
  • Administration of sedatives for management of stress which worsens while trismus persists, leading to an increase of muscle spasm in the area


Prolonged Bleeding from the Extraction Site.  Incidence: 0.6 - 5% with higher incidence in older age groups.

Most patients with a bleeding disorders are diagnosed early in life and their medical history is available to the oral
surgeon.  Nevertheless, cases are still occasionally diagnosed for the first time following dental extraction.

The majority of patients who bleed after extractions do not have any underlying
hæmatological
disorder and they
generally have had extractions previously without complication, suggesting a purely local factor in the
hæmorrhage
.

Pre-operative screening of patients with no relevant history for blood-clotting disorders is not an effective means of
identifying patients who may bleed postoperatively.

There exists a small group of patients who bleed after dental extractions on each occasion but do not bleed after extra-oral trauma and do not show any abnormality on hæmatologic testing.  It has been suggested that
oral fibrinolysis, probably of salivary origin, may be responsible for destruction / lysis of the blood clots and consequent hæmorrhage in such patients.  Fibrin-stabilising factors, such as ε-aminocaproic acid and transexamic acid may be helpful in these cases.

Prolonged Swelling
.  Discomfort, swelling and œdema are normally considered inevitable consequences of wisdom tooth removal but as part of general improvement in patient care, all reasonable steps would have been taken to minimise them.

Excessive operative time, difficulty of extraction (such as bone removal) and flap retraction increase the swelling associated with surgery.

Periodontal Complications
.  Removal of wisdom teeth is often carried out to preserve gum / periodontal health or,
in some situations, to treat existing gum disease-pyorrhoea /
periodontitis
.  With a partially impacted lower wisdom tooth, there is already a periodontal pocket on the mesial aspect of the wisdom tooth as well as a bony / osseous defect in the bone on the distal root of the second molar.  This situation can, under certain circumstances, progress to rapid periodontal destruction.

Post-operative measurements show lower bone levels and deeper pocket depth than desirable.

Some studies have grouped patients into treatment groups according to age.  It is suggested that patients < 19 years,
between 20 - 35 years, > 35 years may have different
periodontal healing potentials
following lower third molar removal.

In most young patients (< 19 years), bone height after wisdom tooth removal appears similar to the pre-operative level.  In fact, some studies even show a gain in bone level following surgery.  If the bone level distal to the second molar is compromised before wisdom tooth removal, it normally remains below the normal level post-operatively.

The greatest bone defects occur in older patients (> 35 years), in whom the wisdom teeth have already
resorbed
part of the second molar.  Periodontal pocket depth appears to be the same post-operatively as pre-operatively and in older patients, pocket depth may even increase following removal of the wisdom tooth.

In younger patients, however, there appears to be no adverse effect on pocket depth.  In younger patients, reduction in pocket depth can occur for up to 4 years following surgery though this benefit may not occur in older patients.

Systemic Medical / Surgical complications / Death during Operative / Post-Operative Period.

Complications associated with
Local Anæsthetic, Sedation or General Anæsthetic.

Development of Excessive Blood Clot / Bruising
.  Development of excessive blood clot (hæmatoma) in chewing muscles, tissue spaces etc may manifest itself on the face and slump into the submandibular region and then down the neck onto the chest.

Also, effects of blood clots being converted into scar tissue – prolonged
trismus.  Hæmatoma
formation outwith the socket can occur and may require drainage.

Unscheduled Secondary Surgical Procedure
.

Ludwig’s Angina
.

Acute / Chronic / Local / Systemic Infection including
Development of
Osteomyelitis
.

Persistence of / Development of New Pathology
(eg. recurrent or residual cyst or tumour)

Post-Extraction Granuloma.  This complication occurs 4 – 5 days after the extraction of the tooth and is the result of the presence of a foreign body in the tooth socket e.g. amalgam remnants (from the tooth filling), bone chips, small tooth fragments, calculus etc.  Foreign bodies irritate the area, so that post-extraction healing ceases and there is suppuration of the wound.

This complication is treated with debridement of the socket and removal of any / every causative agent.

Lingual Plate Fracture.  This is seen with:

  • horizontally / mesially impacted lower wisdom teeth that have been partially erupted for awhile together with
  • low-grade infection associated with them (such as pericoronitis or periodontitis)
  • African origin (denser bone)
  • the more mature patient (sclerotic bone)
  • the use of chisels / osteotomes, utilised in the decoronating of lower wisdom teeth (Lingual Split Technique used to ‘saucerise the socket’).

The plate fragment is often adherent to the wisdom tooth.  Dependent on its size, it can be dissected out.  The socket
will need to be ‘tidied up’ (the archaic term “
wound toilet” is used).  It is very likely that the Lingual Nerve has been
traumatised whilst this is being done.  This will result in nerve damage that ranges from numbness of the tongue to
'
pins and needles' or 'burning
' of that side of the tongue as the extraction to loss of taste.

Introduction / Displacement of Tooth, Tooth Fragments or other Foreign Body / Bodies into Adjacent Anatomical Zones.

  • Maxillary sinus
  • Tissue spaces
  • Inferior Dental Canal
  • Aero-digestive tract


Jaw Dislocation.  It can be extremely uncomfortable having a lower molar tooth extracted, not because of pain at the
surgical site but because of traction on the
temporomandibular joints (TMJ) / jaw joints, consequent to the oral surgeon pushing down on the tooth with the extraction forceps.  It is important that the surgeon fully supports the lower jaw during extractions in order to relieve stresses on the TMJ.

Where extractions are performed under General Anæsthetic, it is all too easy to forget the TMJ.  On completion of treatment, immediately prior to removing the throat pack, the oral surgeon should manipulate the lower jaw into centric occlusion to ensure that it is not dislocated (i.e. the lower jaw has gone back into its correct position).  If it is not, then the dislocation should be reduced before the anæsthetic is reversed and the patient woken up.

Removal of wisdom teeth may cause / exacerbate a pre-existing
TMJ problem.  This complication is best prevented by allowing the patient to bite on a prop and rest every few minutes if the procedure is prolonged.  If TMJ problems do occur following wisdom teeth removal or other oral surgical procedures, they must be treated in the normal way utilising predominantly non-surgical modalities, such as rest, heat, muscle relaxants and possibly, bite-raising appliances / occlusal splints.

Exposure of an Inappropriate / Unplanned Operative Site
(eg. incorrect side)

Extraction of the Wrong Tooth
.  Extraction of the wrong tooth is an avoidable error which can easily be prevented by ensuring that proper identification of the patient and tooth to be extracted, is made.

Teeth commonly extracted in error are upper canines instead of upper first premolars, lower permanent premolars simultaneously with lower deciduous molars and upper second molars instead of upper third molars.  The latter is particularly liable to occur if the upper third molar is partially erupted and difficult to visualise.

Being aware of the possibility of these errors and “counting out” the tooth to be extracted will go some way to minimising their occurrence.

A common source of confusion is the correct identification of one of 2 molar teeth when the other molar is missing or
absent.  Although a naming convention exists for just this situation, longhand notation such as “the first standing lower right molar” instead of the lower right 7 may help avoid confusion where the third molar is erupted and the first molar is absent.

A similar situation occurs when only one of 2 unerupted and adjacent teeth are to be extracted.  Again, this is commonly requested as part of an orthodontic treatment plan and as such should be avoided at all costs.

If the wrong tooth is extracted, the oral surgeon should proceed with removing the correct tooth unless the extractions are for orthodontic purpose when it may be better to seek the advice of the patients’ orthodontist first.

The tooth extracted in error, particularly if it is otherwise healthy, should be immediately replaced in its socket.  If mobile, it should be held in place with a custom made vacuum-formed splint for approximately 4 weeks.  It is likely that it will subsequently require to be root-filled and if there is any doubt about its prognosis, the advice of a consultant restorative dentist should be sought.

Fractured Upper / Lower Jaw secondary to Tooth Removal.  Incidence: 2 - 4% (including alveolar and lingual
plate fractures, so the incidence of actual fractures of the upper and lower jaws is likely to be much less).

This is probably the most feared of all complications following Minor Oral Surgery and like the majority of them is largely preventable.  It is a recognised complication of lower wisdom tooth removal and should be listed as such on a routine consent form.

Fracture of the mandible / lower jaw is a very unpleasant but fortunately rare complication that is associated almost
exclusively with the extraction of impacted lower wisdom teeth

There are a number of predisposing conditions, such as:

  • use of excessive force with the elevator, when an adequate pathway for removal of the impacted tooth has not been created
  • mandibular atrophy
  • deeply impacted tooth
  • a tooth with firm anchorage
  • extensive œdentulous regions
  • an ankylosed tooth
  • osteoporosis and
  • the presence of associated pathology such as a cyst
    or tumour.


When a fracture occurs during the extraction, the tooth must be removed before any other procedure is carried out, in order to avoid infection along the line of the fracture.

The fracture must be repaired if necessary - if the operator is unable to do this, they must arrange an immediate referral.  Afterwards, depending on the case, stabilisation by way of inter-maxillary fixation or rigid internal fixation of the jaw segments is applied for 4 – 6 weeks and broad-spectrum antibiotics are administered.

Patients should be advised to consume a soft diet for several weeks and to return immediately if they become aware of any abnormalities in the jaw.

Fracture / Failure of Instrument with Retention of Instrument Fragment within Bone / Soft Tissue.  Any broken instrument should be removed at the time of the operation.  If not retrievable, the patient should be told and this recorded in the notes.

Suture needles, hypodermic needles and surgical burrs are the items that most frequently fracture / fail in use.  Suture
needles are probably the commonest items to be broken during minor oral surgery.

As a general rule, all fragments of broken instruments should be removed immediately before they have time to migrate deeper into the tissues.

If the fragment cannot be found, radiographs in 2 planes at 90° should be taken of the operative area to locate it.  At this point, a decision will need to be taken as to whether to remove the fragment or leave it in situ depending on its size and site.

Small fragments lying
sub-periostealy
can be safely left as they are unlikely to migrate and cause problems.  If the
decision is taken to remove the fragment, the operative approach will depend on where it is located and a thorough knowledge of the local anatomy is essential if further complications are to be avoided.  It should be remembered that small fine foreign bodies can be extremely difficult to locate and that blind exploration of tissue spaces is wont to displace them deeper.  The use of image intensification can be very helpful in this situation.

Breakage of an instrument in the tissues is the result of excessive force during the removal of the tooth and usually
involves the end of the blade of various elevators or bur.  Breakage may be the result of repeated use of the instrument altering its metallic composition (mainly of the bur).  In these cases, after precise radiographic localisation, the broken piece(s) are removed surgically at the same time as extraction of the tooth or root.

Soft Tissue Damage

  • Mechanical Trauma
  • Thermal Trauma