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What is an extraction?
When a tooth is removed from the mouth, it is called an extraction.
In order to extract a tooth, the tiny periodontal ligaments that hold the root to the jaw bone are cut and the bony space around the root is enlarged in order to separate the tooth from the bone.
Whilst it may seem a bit strange, there is actually more pushing (to enlarge the bony space around the root and cut the periodontal ligaments) than pulling when extracting a tooth.
Therefore, even after the most gentlest of tooth extractions, you may experience some bruising, swelling and/or discomfort. This is quite normal and your dentist will advise you to take simple analgesics (painkillers) if required.
Root fractureIf a tooth
has more than one root (most usually, premolars and molars), it is especially important to enlarge the bony space around all the roots so that the tooth can be removed with all its roots intact. However, this does not always happen and occasionally a portion of root will break off during the extraction procedure.
Even if an x-ray has been taken to check the shape and position of the roots before starting the extraction, a portion of root may still break off. It is important to remember that an x-ray is still only a 2-D image and there may be unexpected kinks in the root that cannot be seen on the x- ray.
Sometimes, especially if the tooth is badly decayed or is more brittle because of previous root canal treatment, the roots and/or the tooth will break during the extraction.
Just because a tooth or a root breaks off during the extraction procedure, this does not necessarily mean that the dentist has provided substandard care.
However, if a piece of tooth or root breaks off during an extraction, you should be told about this. It is also important that the remaining pieces of tooth and/or root are removed because if they are left, they are likely to cause infection and pain. If this is not done, you may have grounds to make a dental negligence claim.
In some cases, if only a very small piece of the root tip breaks off during the extraction, it may be better to leave it rather than cut the bone and try to find and remove it. However, you should be informed about the presence of the piece of retained root and reviewed to make sure it does not cause any problems.
In order to extract broken bits of tooth and/or root, the dentist may have to cut the gum and maybe also remove a bit of the bone so that the broken tooth/root can be extracted. This is called a surgical extraction.
After a surgical extraction, you may need a couple of sutures (stitches) to hold the gum back in position and you may experience a bit more bruising, swelling and/or discomfort than you would have experienced with a normal extraction. This is normal.
Following a tooth extraction, it is very important to follow the post-operative instructions that your dentist gives you in order to allow the natural healing process to take place.
It is particularly important that you do not dislodge the blood clot that forms in the new socket. This is because the blood clot covers and protects the newly exposed bone in the tooth socket and prevents it becoming infected.
If the newly exposed bone in the tooth socket become infected after an extraction, this is called a dry socket. A dry socket is a very painful complication of a tooth extraction.
Although antibiotics and placing a dressing in the infected socket will successfully treat a dry socket, the healing process will take much longer more than a normal, non-infected tooth socket. You may also need to go back to the dentist for repeat dressings before healing takes place.
A dry socket may also occur where there has been a lot of previous infection around the tooth. In these situations, some dentists will give antibiotics immediately after the extraction in the hope that they will prevent a dry socket. However, other dentists, not wishing to prescribe antibiotics unnecessarily, may simply warn you of the possibility of an infection and ask you to return to be given antibiotics if needed.
The roots of some upper teeth, most usually the upper molars but sometimes also the upper premolars, may be very close to the maxillary sinuses (the air spaces on either side of your nose – they may become blocked and/or infected if you have a bad cold).
In some people, the roots of the upper molars and/or premolars lie so close to the maxillary sinuses that there is very little bone, if any separating the root tips from the sinus. Occasionally, the roots actually extend into the sinus space and only the lining of the sinus separates the tooth from the sinus.
Therefore, when an upper molar and/or premolar is extracted, there is a risk that an opening (a fistula) will be created between the maxillary sinus and the mouth, via the empty tooth socket. This type of fistula is called an ‘oro-antral fistula’.
Whilst a pre-extraction x-ray, which shows the tip of the roots, will be very helpful in assessing the risk of an oro-antral fistula occurring, it is important that the dentist checks that this complication has not occurred after extracting an upper molar and/or premolar tooth.
Although in itself, an oro-antral fistula does not necessarily mean that the dentist has provided substandard care, failing to suspect or to diagnose an oro-antral fistula at the time of the extraction may represent dental negligence.
If a small oro-antral fistula is suspected or diagnosed at the time of the tooth extraction, the dentist may be able to successfully close the opening by placing a couple of sutures (stitches). You should also be given specific advice about how to help the fistula heal (for example, you must not hold or blow your nose because the increased pressure may re-open the fistula).
Sometimes the simple advice not to blow your nose is all that is required to ensure that a small oro-antral fistula closes and heals.
However, if the oro-antral fistula is not diagnosed at the time of the extraction, it is unlikely that you will receive the important post-operative care and advice, in particular about not blowing your nose. This may exacerbate the oro-antral fistula and may mean that you require more complex care and treatment to deal with it.
If the oro-antral fistula is not immediately diagnosed, you may subsequently experience discomfort, infection and a strange taste in your mouth. With a larger oro-antral fistula, you may also experience drinks and/or food coming out of your nose.
If an oro-antral fistula is suspected or diagnosed at some time after an upper tooth has been extracted, you may need to be referred for specialist review and/or treatment.
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