Tooth Removal Warnings

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.

This list of warnings might seem excessive to some
however the legal ruling in the case of Chester vs Afshar
(2004) would suggest that it is quite prudent / necessary
to list them. Others might say that there isn’t enough
information but where do you stop?

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).

Prolonged Bleeding from the Extraction Site.

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.

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. This is a potentially fatal infection that
involves the fascial spaces of the floor of the mouth and
neck. Now rare but still needs to be taken seriously.

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)
root forms that make the tooth more resistant to
extraction
large roots
the sudden application of force
African origin (denser bone)
the more mature patient (sclerotic bone)
fusion of the tooth to the surrounding bone (ankylosis)
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.

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 jawe 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.

Fractured Upper / Lower Jaw secondary to Tooth
Removal.

Fracture / Failure of Instrument with Retention of
Instrument Fragment within Bone / Soft Tissue.

Soft Tissue Damage.