It is possible to bleed to death following the extraction of a tooth. But it almost never happens. All you have to do is follow directions #1 and #2 on the post-op instruction page and the bleeding will stop. The only patients that may still be in danger from excessive bleeding are those who are taking anticoagulant drugs (blood thinners) like Coumadin or Heparin for cardiovascular problems, or people with bleeding disorders like Hemophilia or related clotting cascade disorders . These patients should consult their physicians before having a tooth extracted. People taking aspirin and other non steroidal anti inflammatory drugs (NSAID's) like Advil or Aleve may experience prolonged bleeding times, but in my experience, these drugs have never presented a problem as long as the patient keeps the extraction site covered with gauze to stem the bleeding. The blood WILL clot eventually!
The mouth is alive with bacteria, especially in people with poor oral hygiene. Infection is a constant problem after extractions, and most dentists have developed a personal protocol on whether or not a particular patient needs preventive antibiotics. People who present at the office with swollen faces, teeth tender to light pressure, swollen gums or tongue, or bleeding and pus around a tooth are generally already infected. They should expect to be given prophylactic (preventive) antibiotics after an extraction.
Patients may develop infections after an extraction even if they were not infected before the extraction. This is a common complication and is due to the fact that that the mouth is teeming with bacteria and cannot be sterilized prior to the extraction. (They are NOT due to any error on the part of the dentist!) The first sign of an infection after an extraction is often renewed bleeding after 48 hours. The bleeding is not generally severe, but it is an indication that the patient should return to the dentist's office for evaluation and possibly a prescription for antibiotics. Other signs of infection include renewed swelling around the extraction site and surrounding parts of the face, as well as increased pain after 48 hours. Signs of infection two days after an extraction should be attended to as soon as possible. Click here to see how severe tooth related infections can become.
Some dentists will give a patient an antibiotic and send them home for several days to allow the infection to clear before attempting the extraction. The reason for this is because the local anesthesia does not work as well in acid environments and it may take a lot of shots to get the patient numb. However, if the dentist gives enough anesthesia, it is possible to extract a tooth under such circumstances. In general, I have never found that extraction of a tooth in the presence of an active infection has presented special problems as long as the patient takes the antibiotics prescribed faithfully.
It is NOT necessary to take antibiotics after every extraction. A simple extraction in a clean, uninfected mouth generally does not require prophylactic antibiotics.
Whenever the extraction requires the cutting of any tissue (see surgical and impacted extractions above), it is generally a good idea to give prophylactic antibiotics, and the patient SHOULD fill the prescription and take the drug faithfully, or he may suffer an extended convalescence.
A dry socket, while not potentially life threatening like bleeding or infections, is one of the most painful, common, debilitating and dreaded post extraction problems encountered in dentistry. Patients often state that they felt fine for a day or two after the extraction, but then the extraction site began to become painful. They may also say they have a bad taste in their mouth. Dry sockets are much more common following the extraction of lower teeth than they are after extraction of upper teeth. They can happen after even the simplest of extractions. If you get a dry socket, it is not (necessarily) your fault. Nor is it the fault of the dentist. They are a quirk of nature. You may THINK you are going to die. You won't!
Patients who are more likely to get a dry socket are those who smoke during the first 48 hours after the extraction, women on birth control pills, and persons who tend to constantly grind and clench their teeth (see my page on TMJ)
What is a dry socket?
A dry socket is a condition in which the blood clot that forms in the extraction site becomes detached from the walls of the socket, or dissolves away leaving the bare bone exposed to saliva and the foods you eat. The bone becomes inflamed due to bacteria and contaminants in the saliva, and this inflammation is persistent and painful. The socket begins to emanate a bad odor. The pain is "deep pain". That is, it comes from tissues buried deep in the body, and your brain has no experience of pain from these regions. When the brain receives pain signals through these unusual channels, it is unsure of the exact location of the pain, so it tells you that the pain is coming from areas on that side of your face and head that are far removed from the actual source. Pain like this is called referred pain. It seems to shoot up the side of the head, or makes your eye ache.
Can a dry socket be prevented?
Dry sockets can be prevented if the patient opts to spend more money on one of the three forms of socket preservation. Click on the toothless skeleton to read how the dentist can prevent dry sockets and keep your skeleton from looking like the one in the image.
Studies have shown that in-office pre-operative and post-operative rinsing with 0.12% chlorhexidine (Peridex) reduces the incidence of dry sockets. It is a good idea for the patient to be given a prescription for a bottle of chlorhexidine to be used for rinsing three times a day for several days starting 24 hours after the extraction.
Removing third molars within the ideal window of time when the roots are 1/2 to 2/3 developed, about age 17 for boys and 16 for girls, reduces the likelihood of dry socket.
Treating the socket immediately post-operatively with a small amount of tetracycline on a piece of Gelfoam has been shown to reduce the likelihood of dry socket.
Patient should maintain good oral hygiene and follow post-op instructions.
How are dry sockets treated?
Left alone, dry sockets will always heal. It may take a month or more, and the pain is persistent for the entire period of healing. Antibiotics are not useful in curing a dry socket, and the usual pain medications are not very effective. It is better to go back to the dentist who extracted the tooth and let him or her "pack" the socket. This is a procedure done (usually) without anesthesia even though it can be painful. It does not take too long, and the pain relief is almost complete, beginning a few minutes after the socket is packed. The first packing will provide relief for 12 to 24 hours. As you return to the dentist and the old packing is removed, the socket is washed out and a new packing is placed. Each succeeding packing debrides (cleans) the socket and renews the pain relief. A second packing may last 24 to 48 hours, and succeeding packings may last longer still. Within three packings, or sometimes more depending on the severity of the dry socket, the wound begins to heal from the bottom up and can be left empty to heal without pain. Some unfortunate people seem to have more prolonged dry sockets, but they all heal eventually.
Yes, it does occasionally happen. The fracture of a lower jaw is unusual, principally because dentists who extract teeth routinely do not place great force on any instrument to remove a tooth. Teeth are generally "finessed out" with a minimum of pressure applied to the jaw through the surgical instruments. There are, however, some situations in which a dentist can look at the x-ray and see that the jawbone that surrounds the tooth is much more fragile than is usually the case, and will usually warn the patient that fracture of the jaw is a possibility. People are not like cars, every one identical. Everyone is unique and presents unique circumstances under which the dentist must labor. The chances that the removal of any given tooth will result in a fractured lower jaw run about the same for any dentist who attempts the extraction. That particular patient is usually more prone than other people to a broken jaw due to any traumatic incident such as a traffic accident or a blow to the jaw during a sporting event. Unfortunate, but true, and a fact of life for any dentist who extracts teeth.
The image to the right is a detail from a panoramic film. The roots of the upper back teeth are always in close approximation to the maxillary sinus. Since everyone is built differently, The roots of the teeth may actually appear to be inside the sinus. There is always a thin wall of bone between the root and the sinus, but is can be very thin indeed. Most of the time, the bone remains intact, but upon occasion, a piece of the bone separating the root from the sinus may break off and be removed with the tooth. This creates a direct connection between the sinus and the mouth! That means that you would be unable to suck on a straw, because air would rush into your mouth from your nose through the socket.
Sometimes a sinus perforation will go unnoticed by the dentist or the patient. If the perforation is small, the only symptom could be a nosebleed. If this happens, call the dentist so he can prescribe the proper drugs so that healing can proceed normally
When a sinus perforation occurs, the dentist will prescribe an antibiotic to prevent infection and a decongestant to keep the sinuses clear during healing. The patient bites on his gauze as is usual after any extraction, and a clot will form in the socket as usual. If nothing disturbs the clot, it will organize during healing and close the perforation. Dry sockets rarely happen after extraction of upper teeth unless the patient smokes.
It is IMPERATIVE, however that the patient do NOTHING that could disturb the clot.
Do not suck on anything for at least a week. This puts pressure on the clot and could dislodge it into the mouth.
Do not smoke...the longer you wait the better. This will dissolve the clot, or could even suck it out of the socket.
Do not blow up balloons or anything else. This puts pressure on the clot and could dislodge it into the sinus.
Avoid sneezing. This explosive event will definitely dislodge the clot.
In the case of very large perforations, or in case the clot dislodges and a perforation between the sinus and the mouth remains after healing, It may be necessary to perform a further surgical procedure in order to draw a flap of gum tissue over the perforation to close it permanently.
(Broken bone fragments that come out weeks after the extraction, but are often mistaken for pieces of tooth.)
Extraction of a tooth requires that the bone surrounding it be expanded, or sometimes even fractured to allow the tooth to slip out of the socket. Most of the time, these fractures are of the type known as "greenstick" fractures which means they are only partial fractures immediately around the top of the socket leaving the bone fragments still attached to the main body of the bony structure beneath. In some instances, these greenstick fractures coalesce to release a bone fragment completely from the underlying bony structure. Even when this happens, the bone fragments tend to heal and reattach to the main body of the bone during healing.
In the oral cavity, however, the presence of oral bacteria, as well as noxious chemicals from the foods we eat and cigarettes we smoke can cause the healing to cease. This is what causes dry sockets. Bony fragments that do not heal properly often loose their blood supply and become "necrotic" (dead tissue). Thus, the body begins the process of ejecting them from the healing socket, a process known as sequestration. The process can be painful, and sometimes requires the dentist to reenter the socket to remove the sequestrum. When the sequestrum comes out on its own, the patient often mistakes this piece of bone for a piece of tooth that the dentist left in the socket.
Sequestrii are a normal complication of extractions. They are often unavoidable, and undetectable at the time of the extraction. They are not considered to be a mistake the dentist made. Once the sequestrum is gone, the healing resumes, the pain subsides and all is well.
A large majority of teeth are removed in one piece when they are extracted by the dentist. However, many do break leaving one or more fragments of varying size in the bone. Most of the time, these root fragments are easily "luxated" using a sharp instrument which is forced down between the root and the surrounding bone. On rare occasions, the root fragment may be too firmly attached to the bone (ankylosis), at too odd an angle, or too close to a vital structure like the sinuses or mandibular nerve to remove in this manner. In most instances, it is NOT essential to remove every root fragment that is left in the bone!! Retained root tips will generally simply heal in place and rarely cause a problem to the patient after healing. When confronted with this situation the dentist must weigh the relative benefits of removal of the root tip versus the complications that the removal will cause the patient. Often, the removal of the offending root fragment necessitates quite a bit of drilling of bone and heavy duty prying, not to mention quite a bit of time. This always results in a much greater degree of pain for the patient during healing. It also increases the likelihood of a dry socket, which is a painful result that most people would rather do without. On the other hand, in most cases, leaving the root tip in place causes much less damage and discomfort to the patient.
In the relatively rare instances in which the root tip does cause a future problem, (usually years after the initial extraction) it is generally quite easy to remove at that time. This is because, in forming an abscess, the body has already "rejected" it, and has loosened it from the surrounding bone. The surgeon will have no difficulty locating and removing it at that time.
Osteonecrosis of the jawbone (ONJ) is a disease resulting from the temporary or permanent loss of the blood supply to the bone. Without a blood supply, the bone dies (the term "osteo" means "bone"; the term "necrosis" means "death"). When this happens, the dead bone becomes exposed to the oral environment. Exposed necrotic bone is not an uncommon complication after extractions of teeth, even in healthy patients who have never had radiation therapy or bisphphonate drug therapy. Simple cases involve only the bone immediately surrounding the extraction socket, and usually, the necrotic bone will heal over spontaneously with time. Unfortunately, more serious cases of ONJ happen to people who are taking bisphosphonates for osteoporosis or as part of a chemotherapeutic regime for some forms of cancer. Serious ONJ also happens to patients who have had radiation therapy to the head or neck for the treatment of cancers. Since the subject is so complex, I have given this subject its own page.