test 1 Indications and Contraindications for Tooth Extraction
Indications for Tooth Extraction
Types of Indications
Relative Indications
The tooth can potentially be saved but extraction = the more practical choice.
Examples:
Orthodontic, prosthetic, aesthetic reasons (improperly formed teeth, supernumerary teeth, improperly positioned teeth, tooth not suitable for prosthetic purposes).
when complications arise during endodontic, conservative or prosthetic treatments (extensive caries, periapical lesions, pulp floor perforation).
Immediate Indications
The tooth is beyond repair; extraction = the only option available.
Anything with pain
Examples of Immediate Indications:
Tooth Pathology:
Severely decayed teeth + roots that cannot be restored.
Irreversible pulpitis with calcified canals (untreatable by endodontics).
Pulpal necrosis with recurrent inflammation.
Primary teeth interfering with the eruption of permanent teeth.
Primary teeth with pulpal necrosis.
Periodontal Diseases:
Any form of periodontitis in immunocompromised patients.
Acute and chronic periodontitis in multi-rooted teeth unsuitable for endodontic surgery.
Periapical lesions > than one-third of the root.
Loss of periodontal tissue → prevent regenerative procedures.
Tooth mobility (III degree.)
Recurrent periodontal abscesses.
Odontogenic Inflammation:
Teeth causing acute and chronic infections of maxilla/mandible + soft tissues (osteitis (bone inflam.), lymphadenitis (lymph node infect.) or phlegmon)
Teeth involved in maxillary sinusitis.
Bone and Tooth Trauma:
deep crown fractures making prosthetic reconstruction impossible.
Root fractures when the patient is uncooperative.
deep fracture of single-rooted tooth
primary tooth intrudes into permanent tooth bud
lateral fracture of primary tooth + displacement towards oral cavity
Developmental Disorders:
Impacted teeth → cysts, recurrent inflam. or pressure on adjacent teeth.
Difficult Wisdom teeth → inflammatory issues. / difficult eruption
teeth hindering reconstructive surgery
teeth in cleft palate obstructing surgical, prosthtic or orthodontic treatment.
Odontogenic Infections in Systemic Diseases:
Conditions like rheumatic diseases, cardiac myositis, allergic diseases etc.
Prevention of Complications in Special Treatments:
Patients undergoing head and neck radiotherapy, organ transplants, chemotherapy.
Iatrogenic Conditions:
Roots remaining post-extraction, broken instruments in root canals, pulp chamber perforation.
Behavioural Indications
related to patient’s fear and anxiety / cultural beliefs
Examples:
patient: uncooperative,unreliable, / aggressive patient
bad maintenance of oral hygiene
refusal of necessary treatment procedures
Contraindications for Tooth Extraction
Types of Contraindications
Local Contraindications
Conditions Affecting the Local Area:
Trismus (II or III degree). (lockjaw)
Acute periodontal inflammation (herpes, acute necrotising ulcerative gingivitis etc. various types of mucositis).
Teeth located within the field of radiation (extraction contraindicated up until 12 months after radiotherapy).
Teeth embedded in cancerous tumors.
Teeth near arteriovenous malformation (risk of life-threatening bleeding).
Acute pericoronitis around partially impacted teeth.
Systemic Contraindications
Conditions Affecting Systemic Health:
Anticoagulant therapy: affects blood clotting. (block)
Blood disorders: conditions like anemia, hemophilia.
Uncontrolled hypertension: greater than 160/95.
Endocrine Disorders: uncontrolled diabetes or adrenal insufficiency.
Neurological Diseases: conditions like epilepsy and multiple sclerosis.
Liver and Kidney Diseases: liver cirrhosis, acute renal failure.
Infectious Diseases: untreated infections like hepatitis, HIV.
Pregnancy Considerations: avoid extraction during the first + third trimester (2nd trimester safest); preferable between weeks 14-20. in first trimester only when absolutely necesasary (high risk of miscarriage + anaethetic penetrates thorugh placenta)
Meds: paracetamol, penicillin, cephalosporins
Can use local anaesthics with adrenaline
Heart Conditions:
Special attention required post-myocardial infarction, e.g., postpone extractions for 6 months unless in good health.
Heart and blood vessels diseases
Menstruation: increased risk of bleeding around menstruation. (2days before onset of bleeding and first 3 days of menstruation)
Postpartum period: postpone elective procedures for 6-8 weeks post-delivery.
Principles of Wound Healing Post-Extraction
healing post-extraction = based on blood clot filling the socket after tooth extraction
properly formed, high-quality blood clot = ! for uncomplicated healing
natural biological dressing protecting the socket from penetration of microorganisms from oral enivronment + protects nerve endings
Healing Process
Stages of Healing:
Inflammatory Phase (first 5 days): vascular response → Hemostasis + clot formation, platelet activity, formation of granulation tissue.
Proliferation Phase (5-14 days): Epithelial ( superficial wound repair) and connective tissue repair. (collagen synthesis → aggregation → microfibrils → collagen fibres) → fill socket → connective tissue insisde
Maturation Phase (from 14 days): deepest part of socket first, Remodelling and maturation of bone and soft tissue.
Post-Extraction Complications and Management
Local Complications During the Surgical Procedure
Risks include:
Soft tissue injuries, nerve injuries, fractures of teeth, or osseous structures, wrong tooth, injure adjacent tooth, break instruments,TMJ injury
Oroantral communication (OAC) can occur due to extraction.
Local Complications After the Surgical Procedure
Common issues include:
Pain, trismus, postoperative bleeding, dry socket, bacterial infections.
nerve injuries - usually with wisdom tooth extraction
lingual nerve: damage during incisions + pre-elevation of lingualy periosteum; direct trauma from burs / chisels
mental nerve: surgery in its area, overextension of relieving incisoln, removal of bone surrounding mental foramen
inferior aleveolar nerve: close to mandibular 3rd molar roots, careless urgical technique
Oroantral Communication (OAC) (upper teeth)
Risk Factors:
Anatomical predispositions, disease,trauma or iatrogenic causes
Clinical: oroantral communication (connection not lined with epithelium),
Symptoms: Positive Valsalva test indicating communication between oral cavity and sinus. (If oac exists will leave a sound, air or blood from sinus , means there is connection
Management:
Depends on the size of the communication; may involve conservative treatment (collagen sponge) or surgical closure if necessary. (Flap)
Dry Socket (Alveolar Osteitis)
Characteristics:
post-extractive infect of alveolar bones (1-5%, higher in women) Severe pain, halitosis, empty appearing socket (grayish).
flare up 3-4 days after
Caused by improper blood clot formation. / has been washed out
Management:
Socket irrigation (3% sodium bicarbonate, metronidazole, 0.9% NaCL) and possibly curettage under local anesthesia. - severe
pack socket with aspirin (nipas), alveogyl
laser therapy helpful
PRF platelt rich fibrin greatly reduces risk of alveolar osteitis
Post-extraction Recommendations:
only cleaned when necessary (visible change in periapical area on x-ray), rinsed with saline,sterile gauze dressing to stop bleeding
bite pressure dressing + keep 20-30min, minor bleeding maybe for few more hours
no eat or drink for 2hr
cold compress (swelling)
painkillers after 2hr
oral hygiene
24hr no rinse mouth, alcohol, smoking, strenous exercise
Instruments Used in Tooth Extraction
Basic Tools
Dental Syringe: Employed for administering anesthesia.
Elevators and Forceps
Bein Elevator: Straight, pear shaped handle, used to loosen teeth. separate + lift tooth from socket
Lateral Bein Elevator: (bent) Specialized for mandible.
winter elevator: cross bar elevator, only molar roots in mandble (broken roots in socket), try not to use r very aggressive
Heindbrink elevator: fine tip (pointy) root elevator, tiny root apex
Meissner forceps: taken apart, universal, three types
Anatomical forceps: one for each type of tooth
Retractors
Langeback, Farabeuf
Curette and Scalpels
Curette: For removing debris, cyst and granulation tissue after extraction
Scalpel Blades: Various shapes (No. 15,15C,11, No. 12) for incisive surgical needs.
Needle Holder and Elevators
Needle Holders: For suturing. (mathieu,olsen-hegar,castroviejo)
Periosteal Elevator: For reflecting and lifting soft tissues.
sharp, pointed end: reflect dental papillae from between teeth, loosen soft tissues
bora, rounded end; elevate tissue from bone
Antibiotic Therapy in Dental Surgery
General Guidelines
Purpose: Prevention of surgical site infections / future infections or treatment of existing infections. NOT substitute for procedure
Administration: Ideally 30-60 minutes before the procedure; often a single dose.
Specific Recommendations
Immunocompetent Patients: Routine prophylaxis generally not recommended.
Immunocompromised patients: Consultation recommended.
Antibiotic Regimens:
Amoxicillin wo clav.: 2000 mg single dose for adults; alternatives for those with penicillin allergies include Clindamycin 600mg single dose or Cefazolin 1000mg single dose
Specific Procedural Guidelines
Wisdom Teeth Extraction: Not routine in immunocompetent; consider in immunocompromised.
Dental Implant Surgery: Prophylaxis considered, especially alongside bone grafting.
Considerations Post-Exposure Based on Radiation Therapy or Drug Therapy
Short-term prophylaxis: For patients taking bisphosphonates, denosumab post-procedure for 3 days
Long-term: Up to 14 days for high-risk patients.
Conclusion
Comprehensive understanding of indications, contraindications, complications, postoperative management, and appropriate use of antibiotic therapy is essential for successful tooth extraction and patient care in dentistry.