Extraction refers to the painless removal of tooth or tooth roots with minimum trauma to the investing tissues so that the socket heals uneventfully without any post-operative complications.

Earlier dentistry was nothing except filling the teeth or extracting them. But now a days, until it is absolute essential the tooth is not pulled out. Normally the dentist tries to save the tooth but sometimes it has to be extracted.

There are various situations where extractions are indicated.

The various reasons for tooth removal are:

1. Severe Caries
2. Pulpal Necrosis
3. Severe periodontal disease
4. Orthodontic reasons
5. In cases of Retained Baby Teeth
6. Malopposed teeth
7. Cracked teeth
8. Preprosthetic extractions
9. Impacted teeth
10. Supernumerary teeth
11. Teeth associated with the pathologic lesions
12. Teeth in line of fracture that too are infectious
13. Preradiation therapy
14. Teeth involved in jaw fractures
15. Esthetics
16. If the patient can’t afford the treatment

Severe Caries: The most common and widely accepted reason to remove a tooth is that it is so severely carious that it can’t be restored. The extent to which the tooth is carious and is judged to be non-restorable is a judgment call to be made between the dentist and the patient.

Grossly decayed teeth present

Pulpal necrosis: Presence of pulp necrosis or irreversible pulpitis which is not amenable to endodontics can be one of the reasons for tooth removal. The patient who refuses to have endodontic treatment or root canal that is tortuous, calcified and untreated by standard endodontic techniques or in cases of repeated endodontic failure, tooth is removed.

Severe Periodontal Disease: Severe periodontal disease with extensive bone loss and mobility of the teeth may require tooth removal. Hypermobile teeth needs to be removed.

Teeth indicated for extraction

Orthodontic Reasons: To relieve the crowding of the teeth and to make teeth straight, teeth may be removed. The most commonly teeth to be extracted are upper and lower first bicuspids. Second bicuspids are also removed in some cases.

Tooth extraction for braces treatment in an adult

Retained Baby Teeth: In some cases, the milk teeth don’t fall itself and the adult teeth starts coming above it. In such cases, the milk teeth are called as Retained Baby teeth and needs to be pulled out.

Malopposed Teeth: Teeth which are malopposed or malpositioned may be indicated for removal in some situations. If they traumatize soft tissue and can’t be repositioned with orthodontic treatment, then they should be removed. Example is maxillary third molar which erupts in severe buccal version and causes ulceration and trauma to the soft tissue is removed.

Cracked Teeth: When there is vertical tooth fracture or fractured root, then it’s always better to pull out the tooth than undergoing endodontic procedures.

Tooth with vertical root fracture

Preprosthetic Extractions: For the prosthetic reasons, the teeth might be removed.

Impacted Teeth: If the tooth doesn’t have enough space to come out, then they are removed. Lower 3rd molars also known as the wisdom teeth are the most commonly impacted teeth. Apart from 3rd molars, the canines are also commonly impacted.

 
Radiograph showing impacted wisdom tooth to be removed

Supernumerary Teeth: Supernumerary teeth are usually impacted and should be removed. They may interfere with eruption of other teeth and can displace and resorb them.

 Supernumerary Tooth between Central Incisors (Mesiodens)

Teeth associated with pathologic lesions: Teeth which are associated with some pathology are removed.

Pre-radiation Therapy: Patients who are to receive radiation therapy for oral tumors should have serious consideration for removing the teeth in line of fractures.

Teeth involved in jaw fracture: In patients with fractures of mandible or alveolar process, occasionally the teeth need to be removed.  

Esthetics: A patient may require tooth removal for esthetic reasons occasionally. For example in cases of severely malopposed and protruding teeth, the patient may undergo extraction.

If the patient can’t afford the treatment: Sometimes tooth has to be extracted when the treatment to save the tooth is expensive and patient cannot afford it.

Conditions in which Teeth are not to be pulled out-

There are absolute and relative conditions in which teeth are not extracted.

Conditions in which teeth are not extracted:

1. Central hemangioma
2. Teeth embedded in malignancies
3. 6months after the myocardial infarction and
4. In teeth which have undergone radiation therapy before

The relative conditions for not pulling out the tooth are:

1. Hypertensive patient
2. Patient with Diabetes
3. Patient with bleeding disorders
4. Patient with uncontrolled leukemia’s and lymphomas
5. Patient with severe myocardial ischemia
6. Pregnant patient
7. Patient with severe pericoronitis

Hypertensive patient: In patients who are severe hypertensive, there is excess of bleeding after the extraction so the tooth is removed when the blood pressure of the person is normal.
 

Excess bleeding in hypertensive patients

The normal range of systemic blood pressure in a person is 60-89 diastolic pressure and 100-139 systolic pressure. If the blood pressure is more than 160/95, then the patient should be referred to a physician. If the blood pressure is around 150/80, then the procedure is done under sedation.

Diabetic patient: High sugar levels in the body reduce the healing process. If the patient has very high sugar levels, then the extraction is delayed till the sugar levels come back to normal. If extraction is done in patients with high diabetes, then the socket will not heal easily.

Patient with bleeding disorders: In patients with severe hemophilia, or severe platelet disorders, tooth should not be removed until the coagulopathy is corrected. Bleeding disorders can be corrected by administration of coagulation factors or by platelet transfusion.

Patient with uncontrolled leukemias and lymphomas: Infection can occur due to non functioning white cells and profound bleeding due to inadequate number of platelets in cases of patients with uncontrolled leukemias and lymphomas. The tooth should not be removed till the leukemia is brought under control.  

Patient with severe myocardial ischemia: Patients with unstable angina pectoris, recent myocardial infarction, and severe cardiac dysrhythmias should have their extraction procedures deferred.

Pregnant patient: Pregnancy is a relative contra-indication. Patients who are in the first and last trimester should have their extractions deferred if possible. In the first trimester, organogenesis takes places and in last trimester, the patient may find the dental chair uncomfortable. Middle trimester is a safe period for simple uncomplicated extractions but more extensive surgical procedures should be deferred until after the child has been delivered.

Patient with severe pericoronitis: Patients who have severe pericoronitis should not have their teeth removed until the pericoronitis has been treated. Pericoronitis refers to the inflammation of the pericoronal flap around the impacted lower third molars.