Tooth Extraction Complications

Tooth Extraction Complications

The good news about complications associated with tooth extractions is that they rarely cause any long-term problems.  When a complication does occur, your surgeon will help you successfully manage any pain or delayed healing that results.

Unforeseen complications will occur, and every dentist who extracts teeth faces them.  Your dentist has undergone extensive education and training to develop the knowledge and skills necessary to address complications as they arise. Your dentist not only knows how to deal with complications, but they also take measures to prevent complications and minimize their occurrence for each and every tooth extraction performed.

Should a complication occur, your dentist will inform you about it, explain the measures taken to address it and monitor your healing closely until all issues related to the extraction are resolved.

Complications during the tooth extraction

Complications that arise during the extraction of a tooth give your surgeon the opportunity to immediately intervene and manage the issue.  This is an advantage over those that may occur after the patient has been dismissed because many patients prefer to attempt addressing the problem on their own without notifying their doctors.  We will discuss those in a later section.

If a complication arises during the surgery, your dentist or oral surgeon may choose to tell you at the time of the issue or wait until the end of the procedure.  This decision is at the surgeon’s discretion and does not change the outcome of the procedure.  In many cases, the patient has been sedated, so having a detailed conversation is not possible and must wait until the anesthesia has dissipated.  

It is important to remember, as you read through these potential complications, that the risk of each is very low.  The majority of tooth extractions have no complications associated with them.  If your risk for a complication is higher than average, your dentist will determine that from the pre-operative imaging and planning and inform you of the possibility that one could occur during your procedure.

Displacement into Adjacent Spaces

One potential complication of the extraction of a tooth is the displacement of that tooth into adjacent spaces.  This is possible when there is little to no surrounding healthy jawbone (the scientific name of which is alveolar bone).  The extraction forces rarely causes a displacement of the tooth into the spaces underneath the cheek or tongue.  On upper premolars or molars, displacement into the sinus cavity just above the teeth is possible.  

This type of complication is rare, and if it does occur, your dentist or surgeon would continue the extraction procedure to remove the tooth from the displaced location.  Again, this complication is quite rare and typically occurs as a result of weak or inadequate bone surrounding the tooth.  Since the patient would still be anesthetized and not feel any painful sensations, the surgeon is able to remove the tooth without causing any noticeable discomfort for the patient.  The retrieval may lead to a larger surgical site, which can increase the time needed for healing after the procedure.

Displacements into the sinus cavity also carry additional post-operative instructions involving care of the sinus cavity until the area heals completely.  As with all complications, it is important for patients to follow all post-operative instructions very closely.

Loss of Tooth in the Pharynx

Loss of a tooth in the patient’s pharynx simply means that the tooth is either swallowed or aspirated after its removal from the jawbone.  The pharynx is the opening between the nose and mouth and throat.  This is also an extremely rare complication.  It may occur if the tooth slips from the doctor’s forceps, which is unlikely.  Dentists and surgeons routinely take measures to prevent anything from entering the pharynx.

It is important to identify the location of the tooth.  Swallowing the tooth places it in the digestive tract, and this causes no long-term complications.  The tooth will simply “pass” at some point in the near future.

Aspiration is a more dangerous scenario because it means the tooth is in the patient’s airway.  This places the patient at risk for a lung infection.  An x-ray is necessary to determine the tooth’s location and the next steps to resolving the situation.  

In the event of this type of complication, your dentist or surgeon will refer you to a medical specialist for imaging and retrieval of the tooth if necessary.

Injury to Temporomandibular Joint

In rare cases, the jaw joints can suffer damage during an extraction procedure.  The damage may be the result of hyperextension (over-opening) of the jaw.  More often, aggravation of pre-existing TMJ disorder occurs.  This can result in either temporary or permanent symptoms in the jaw joints.

TMJ hyperextension may result from downward forces applied to the lower jaw during the extraction of a lower tooth.  Dentists and surgeons can mitigate this risk by placing a small mouth prop to hold the mouth in an open position that is not over-extended.

TMJ inflammation can cause pain in the facial muscles, headaches, tenderness in one or both joints, popping or clicking sounds and joint locking.  Temporary irritation of the joint is relatively common, and permanent damage is far more rare.

Many patients experience tenderness when chewing for the first week or two following a tooth extraction.  It can be difficult for the patient to discern whether the pain comes from the joint or the surgical site itself.

Patients who experience TMJ pain or other symptoms following an extraction need to alert their dentists or surgeons as quickly as possible in order to address the problem and reduce the pain.

Oroantral Communication 

An oroantral communication is an opening between the mouth and the maxillary sinus cavity.  This air space resides inside the skull just behind the cheekbones and just above the upper back teeth.  The roots of upper premolars and molars often stick up into the sinus cavity, with only a thin layer of alveolar bone separating the two.  In many cases, a dental infection inside the tooth spreads into this tiny layer of bone and destroys it completely.  This makes an oroantral communication an unavoidable complication.

The good news is that this type of situation is typically easy for your dentist to identify on pre-operative imaging.  Your dentist or surgeon can then plan for the complication and be ready to immediately address it during the surgery.

Because large infections on upper molars and premolars are relatively common, this complication is also relatively common.  Being common is actually a good thing because it means your surgeon is better equipped to address it when it occurs.

Typically, the repair of this complication involves the placement of a small membrane and a socket dressing to create an artificial barrier between the mouth and the sinus cavity.  An oroantral communication will usually heal on its own, even when it is not surgically repaired.  

An oroantral communication does slow down the healing phase and requires strict adherence to post-operative instructions on the part of the patient.  Your dentist will take images of the surgical site at regular intervals to monitor the healing of the new bone between the mouth and the sinus.

Soft Tissue Burns and Lacerations

Injuries to the soft tissues of the mouth can occur during any type of dental procedure.  They are actually very rare during simple tooth extractions.  The forceps used to extract a tooth may pinch the soft tissues if the dentist is not watchful.  Most injuries are superficial and allowed to heal on their own with some minor post-operative care by the patient.

In the extremely rare case of a deep laceration, your dentist or surgeon would close the cut with stitches in order to ensure that the bleeding stops and the wound heals well.  It is important to understand that this type of complication is rare because dentists and surgeons take the utmost care with the soft tissues surrounding the extraction site during the procedure. 

Damage to Adjacent Teeth or Restorations

It is possible for the forces applied to the tooth being removed to cause damage to the neighboring teeth or their dental work.  This could include chipped teeth, dislodged fillings or crowns, or luxation (moving) of the teeth.  Your dentist may be able to anticipate damage when the neighboring teeth appear weak or the existing dental work is in a poor state.  It is very difficult to damage healthy teeth or good dental work by extracting a tooth nearby.  

Your dentist also mitigates this risk by using the proper technique to loosen the tooth to be extracted.  Improper technique can put unnecessarily high forces on adjacent teeth.  

Treatment to repair the damage may be necessary, and your dentist will discuss your options after the procedure.  The ideal scenario is when the dentist anticipates a problem and discusses it with you before the complication occurs.  Then you are both prepared for the treatment that will follow.

Instrument Fracture

It is extremely rare for dental instruments to fracture or break during use.  Dentists and surgeons use high-quality stainless steel instruments that are able to withstand extreme temperatures and high forces.  Perhaps if a dentist purchased less expensive instruments from overseas that do not undergo quality testing, fracture would be a possibility.  Another possibility would be instruments that have been sharpened extensively over the years, which causes them to become thinner and weaker over time.  This is more common in instruments used to clean the teeth than in those used for tooth extractions.

If an instrument fracture occurs, your surgeon simply retrieves any fragments and continues with the procedure.  Because the patient has been anesthetized, there is no increased discomfort or even awareness of the issue.

Intraoperative Bleeding

Bleeding is a normal part of the extraction of a tooth.  The presence of extensive infection and/or inflammation can lead to increased bleeding at the surgical site.  Many teeth are extracted because they are infected, so this minor complication is relatively common.  

Intraoperative bleeding can cause the procedure to take longer simply because it interferes with the dentist or surgeon’s ability to see the surgical site.  This is not something your dentist worries about because he or she can easily manage this issue in order to successfully extract the tooth.  

For some patients with low blood pressure, increased bleeding during the procedure could cause them to become light-headed or faint during or after the extraction.  Both the dentist and the patient need to exercise caution as the patient begins moving around the building and making his or her way home.

When your dentist notes prolonged bleeding from an extraction site, he or she may address the issue by placing materials or medications to promote clotting.  This can be an injected medication at the site or a dressing that is packed into the socket.

Dentoalveolar Fracture 

Simply referred to as a jaw fracture, this complication is extremely rare.  It is rare, but possible, for the forces necessary to extract a tooth to cause the bone of the jaw to fracture.  It is so rare because it only happens in fragile bones.

The upper and lower jawbones (called alveolar bones) exist to hold teeth.  Once teeth are lost, the bone begins to deteriorate and shrink.  When someone has lost multiple teeth and the jawbone has become very small and weak, these fractures are more likely.  They are also more likely in patients with health conditions affecting the bones, such as osteoporosis.

A jaw fracture is a serious complication, and if one occurs, additional treatment may be necessary to aid healing.  A patient who has experienced a jaw fracture would remain under the care of an oral and maxillofacial surgeon until the fracture heals.

Sometimes surgery, including metal plates and tiny screws, is necessary to hold the fractured bone together.

Post-Operative Tooth Extraction Complications

While post-operative complications are typically less dangerous than those that can occur during a procedure, they can actually be more difficult to manage.  An intraoperative complication is under the complete awareness and control of the treating doctor.  After a patient leaves the office, complications are less predictable because the patient is now in control.  Each person has the choice to decide whether or not to notify the surgeon when experiencing a complication.  Unfortunately, many people attempt to manage problems on their own without asking the doctor for help.  The most important thing to do when you experience a post-operative complication is contact your treating doctor.  They cannot help you if they do not know you are having a problem.

The most important thing to do after any type of medical procedure is to follow the post-operative instructions as closely as possible.  Taking these measures is essential to promote the fastest healing.  Your doctor will customize the instructions to your particular needs, and following them will reduce your risk for post-operative complications.

Dry Socket

A dry socket is the most common complication that occurs following a tooth extraction.  After a tooth is removed, the first step in the healing process is the formation of a blood clot in the empty socket.  A dry socket occurs when the blood clot no longer fills the socket, and the underlying bone is exposed and “dry”.  

A dry socket causes severe pain, and it usually starts three to five days after the extraction.  The more difficult the extraction is, the more likely this complication is.  This is likely due to the fact that a tooth that is harder to remove leads to more trauma to the tissues.  

Other factors that lead to dry sockets include sucking forces that can pull the clot out of the socket or chemical forces that can dissolve it.  This is why your doctor will caution you against smoking and using a straw (the sucking forces) or alcohol and carbonated drinks (chemical forces).

When someone has a dry socket, the surgeon can help manage the pain by placing a dressing into the socket to seal it while it continues to heal in the absence of the blood clot.  A dry socket does delay the healing process.

The most challenging aspect of a dry socket is pain management.  Most people are unable to achieve adequate pain relief with over-the-counter pain medications.  The dressing placed by the doctor provides significant relief, so it is important to contact your doctor if you think you may have a dry socket.

Osteomyelitis

Osteomyelitis is an infection in the bone, which is a post-operative risk after any extraction due to the presence of bacteria in the mouth.  As an extraction site is healing, it is possible for bacteria to penetrate the surgical wound and lead to an infection.  The surgery does not cause the infection, but any open wound carries the risk for infection, and those in the mouth are no exception.

The risk for osteomyelitis increases in the presence of a severe dental infection prior to the tooth extraction.  This type of infection can spread into the surrounding soft tissues and lead to an acute facial abscess (a large swelling in the face and/or neck).  

The risk for post-operative infection also increases with improper post-operative care of the surgical site.  These infections can lead to increased pain, swelling, spreading infection, and delayed wound healing.  Patients can reduce the risk for dangerous post-operative infections by closely following all of their post-operative instructions.

Typically, osteomyelitis or other types of post-op infections require intervention with antibiotic therapy and could even require additional surgery.

Post-operative Hemorrhage

It is normal for an extraction site to bleed.  Typically, the bleeding will stop within 24-48 hours following the procedure.  In general, the bleeding slows to a light oozing of blood within the first few hours after the extraction.  Prolonged bleeding can be the result of clotting disorders, vitamin deficiencies, alcoholism, high blood pressure, certain prescription medications, and other medical conditions.  

Any abnormal bleeding needs immediate attention, so this is not a complication you should attempt to address on your own.  You should call your treating doctor as soon as you realize that the bleeding is not slowing down.  

Excessive bleeding can lead to low blood pressure and fainting or light-headedness, so you should exercise caution when walking around, and you should not try to drive yourself.  

Your doctor will most likely treat excessive post-op bleeding by placing a dressing into the socket that will promote clotting.  This may also include stitches to hold a dressing in place.  

TMJ Disorder

TMJ complications can arise following a tooth extraction.  These would manifest in symptoms like jaw pain, muscle pain or headaches, clicking or popping sounds in the jaw joints, locking jaws, or ringing in the ears.  In general, these symptoms are temporary and resolve themselves.  

Some may persist for longer and require intervention, so it is advantageous to alert your treating doctor as soon as you notice a problem.  It is possible for over-opening of the jaws to cause TMJ problems, but it is far more likely that the extraction procedure aggravates pre-existing TMJ conditions.

Typical TMJ therapy involves physical therapy-type exercises, chiropractic care, wearing an appliance, etc…. In rare cases, some patients may need more invasive interventions, like joint injections, to resolve their symptoms.

Nerve Injury

Nerve injury, officially termed paresthesia, occurs when there is damage to one of the nerves supplying sensation to the area undergoing extraction.  Most commonly, this happens on the lower lip and/or tongue.  In some cases, nerve injury is unavoidable as the tooth itself contacts the nerve, and removal of the tooth causes the damage.

Nerve injury causes lingering numbness to the affected area, which can be either temporary or permanent.  Most cases of nerve injury resolve themselves over time, but it is important to understand that it can take more than six months for normal feeling to return to the area affected by a damaged nerve.  The most effective treatment is anti-inflammatory therapy, which must be prescribed and monitored by your treating doctor.

Epulis Granulomatosa 

The creation of granulation tissue inside an extraction socket is a normal stage in the tooth extraction healing process. Granulation tissue is progressively replaced by bone and gingival soft tissue.

Epulis Granulomatosa is a rare postoperative complication characterized by an overgrowth of tissue in the extraction socket.   Development of these lesions is unpredictable but usually more prevalent in areas of chronic inflammation or infection.  Some of these growths may resolve on their own, but many need to be surgically removed.  

The increased blood flow to the site may cause increased pain as the socket is healing.  Any type of tissue coming out of the extraction socket needs evaluation by your treating doctor.  Follow your post-operative instructions closely, and schedule a follow-up visit for examination of the site as soon as possible.

Summary

Tooth extraction complications are rare but they can occur. All complications can be treated effectively, so if you feel that you are not recovering as quickly as expected, then you should consult your dentist or oral surgeon immediately.

Warning signs –

• Excessive or prolonged bleeding
• Excessive or prolonged swelling
• Unmanageable pain
• Difficulty eating, speaking or swallowing