Sometimes a tooth extraction is not as simple as expected but any problems that arise are handled easily by the dentist. For the patient, this usually means that treatment will take longer than planned and that follow up appointments may be required, but they will not feel any pain during the procedure.
Sometimes a tooth will not become mobile enough to extract using normal extraction techniques; this may occur if a tooth has particularly curved roots, or if the roots are difficult to separate from the jaw bone. To overcome this problem, a dentist may choose to either divide the tooth using a high speed handpiece and burs and remove the tooth in several pieces with narrow ended forceps – (root forceps) or elevators, or, they may choose to remove some of the surrounding bone to loosen the tooth, again using a fast handpiece and burs. Although this is a more involved procedure for extraction, it is not any more difficult for the patient and is unlikely to cause any problems following extraction.
If a tooth is brittle, either because of extensive cairies, large existing filling restorations, or if it has previously been root treated, it may fracture during an extraction. If this occurs the dentist will simply remove the fractured tooth piece by piece. This is often at the initial extraction appointment and is done by using an elevator or more narrow forceps. In some cases it is necessary to remove surrounding bone (as above) and then use elevators and forceps. If the fractured fragment is small and is not likely to cause infection a dentist may decide to leave it in place. The body, as it heals will push the fragment of tooth towards the gum surface where it can be removed easily at a later date with either forceps or tweezers. In rare circumstances when roots or large fragments of root have fractured during an extraction a dentist will not remove these pieces at the same appointment, they will allow initial healing to take place and then at a later date re-open the extraction wound using a scalpel and will then remove the fractured part of the tooth with bone removal, elevators and forceps. When this method is used a patient will need sutures to be placed after the procedure and healing will be delayed, therefore this is a fairly uncommon approach to treatment.
On occasion, due to extracted teeth being slippery as they are covered in saliva and blood, the dentist may not be able to hold on to an extracted tooth in the forceps used. If the extracted tooth falls into the patients mouth and is not retrieved quickly the patient may swallow or inhale the tooth. If the tooth is swallowed no further treatment is required as it will pass through the body and be excreted, however, if the tooth is inhaled the patient must attend hospital, have a chest x-ray, and if the tooth is present in the lung or airway an operation must be performed to remove it. This rarely happens in surgery when done under local anaesthetic due to the natural reaction of the body where reflexes cause the patient to cough to prevent choking.
Upper molars and pre-molars sit in close proximity to the sinus floor, just a thin layer of bone separates them, and therefore there are occasions when there is a perforation of this thin layer of bone during an extraction. Usually this doesn’t cause any serious problems and can be resolved either by itself – with the blood clot which forms a barrier between the oral cavity and sinus, or with the placement of a suture -to create a barrier. In some cases it is necessary to perform minor oral surgery and place a flap of gum over the perforation which is sutured in to place; this is fairly rare but can easily be resolved by the dentist under local anaesthetic. When a dentist has extracted an upper molar or pre-molar they will hold the patients nose and ask them to blow, they do this to check whether a perforation has occurred or not, if it has small bubbles will appear in the blood which sits in the socket, another sign of perforation is if the patient feels liquid entering the nose after drinking or rinsing.
Most extractions are fairly simple and serious complications happen only rarely. In all my years working as a dental nurse I have not seen a perforation of the sinus or inhalation of an extracted tooth, but it is important and should be reassuring to patients to know that dentists and nurses know what to look out for, and what to do if these problems present themselves.