Dental MythBuster #16 – You Shouldn’t Have an Infected Tooth Pulled

Tooth with an abscess infection needing treatment

This infection needs treatment ASAP.

This myth is quite pervasive on the internet, but I’ve rarely seen it in private practice. The typical scenario is as follows:

A patient, most often in intense pain and with significant swelling, goes to a dentist. The dentist diagnoses the patient as having an infection. He/she then extracts the tooth and often prescribes antibiotics. 1 to 2 days later, the patient is still having some pain and swelling, and then reaches the conclusion that the tooth should not have been pulled. Ultimately, the infection/swelling resolve.

There are many variations to this dental myth, but the net result is the assumption by the patient that the tooth should not have been extracted because it was infected.

What Causes Dental and Oral Infections

There are many different types of dental infections. Some originate in the tooth itself. Others originate in the tissues directly surrounding a tooth. Still others occur on surfaces within the mouth such as the tongue, cheeks, and floor of the mouth. But the vast majority develop first within a tooth and then spread to the surrounding gums and bone.

decayed and extracted tooth photo that caused an infection

This decayed tooth first developed an infection inside but then it spread to the surrounding areas. Immediate extraction was the only way to deal with this infection.

The above tooth shows a large cavity underneath a crown. The cavity is the source of the infection and is filled with bacteria. Stated another way, the infection first developed within the tooth. With time, it spread to the surrounding gums and bone, resulting in pain and swelling. Immediate extraction was the only option.

Why Infected Teeth Need Immediate Treatment in Nearly all Cases

We’ll take this quote from an Oral Surgery textbook:

“The primary principle of management of teeth infections is to perform surgical drainage and to remove the cause of the infection” (From Contemporary Oral and Maxillofacial Surgery by James Hupp, DMD, MD)

Or, to quote another unnamed surgeon:

“Never let the sun set on pus”

So, what do all these quotes mean? It basically means that surgical intervention is required for tooth infections.

“Surgical intervention” can range from extracting the tooth to draining the pus to other techniques.

Cases When a Tooth Should Not be Extracted

Keep in mind that each and every tooth infection is unique and needs to be evaluated on its own. Factors that a dentist or oral surgeon will consider include the location of the infection, size, consistency (is it a hard swelling or softer), patient’s age, patient’s medications, patient’s medical conditions(s), presence of systemic symptoms (fever, malaise, blood analysis), tooth or teeth involved, previous antibiotic use, and many other factors.

There are some clinicians who believe that immediate extraction should not be done in cases of a very unique type of dental infection called pericoronitis. They recommend surgical drainage instead.

pericoronitis of a lower wisdom tooth showing the infection

Pericoronitis of a lower third molar. Note the redness and swelling of the gum tissue overlying the tooth. Some clinicians believe that immediate extraction should not be done.

But there are other clinicians and textbooks which recommend immediate extraction in cases of pericoronitis.

Dental Myth Busted

As stated earlier, every tooth infection is different and the recommended treatment is based on the unique qualities of that infection. As we learned earlier, in cases of acute infection, surgical intervention is required. And in nearly all cases, getting the tooth pulled is appropriate. So it is a myth to say “you shouldn’t have an infected tooth pulled.”

Dental MythBuster #15: I Don’t Have to be Numb to Have an Extraction of a Tooth That’s Had a Root Canal

This is one dental myth that I personally don’t see too often. On average, I see it approximately once a month. This myth is based on this perception: because a root canal treated tooth has no nerve, if it needs to be extracted, then you don’t have to be numb (since the nerve is gone).

On the surface, this might make sense. After all, if there is no nerve, you won’t feel anything, right? Well, it turns out that is not the case. Let’s see why:

What Root Canal Treatment Does

root canal treatment x-rays

X-rays showing completed root canal treatment. Note the vertical white lines showing the canal filling material.

When a root canal is performed, the nerve tissue that lies deep inside the tooth is removed, and then that space is filled with a special filling material. The two x-rays on the left illustrate this. The top one shows the pre-operative condition of the tooth and the bottom x-ray shows the completion of the procedure with a filling material in the root canal space.

Once complete, because the nerve is now gone, the tooth will no longer be able to feel hot or cold. So if you try to swish really cold water around a tooth that’s had a root canal, you won’t feel it.

However, there are still plenty of things around the tooth that are still “alive.” The gum tissue around the tooth is alive. The ligament that holds the tooth in the socket is still alive. If you bite down hard on the tooth – you’ll feel it. All of these things…

Why You Have to be Numb for Tooth Extractions

dental elevator used for teeth extractions

Elevator used for extractions.

This may sound slightly obvious. But, to bust this myth, we need to understand why.

When a tooth is extracted, local anesthesia is given to numb the nerves associated with the tooth. What nerves would those be? They include:

  • The nerves of the tooth itself.
  • The nerves going to the ligaments holding the tooth in the socket.
  • The nerves going to the bone immediately surrounding the ligaments and tooth.
  • The nerves going to the adjacent teeth.
  • The gum tissue around the tooth.

When that tooth is extracted, great forces are exerted on not just the tooth, but the surrounding tissue. One of the instruments used is a dental elevator, which is pictured to the right. This instrument pushes the tooth out but does so by placing reciprocal forces on the structures next to the teeth.

No Local Anesthesia = Pain

alt

Even though the tip of your fingernail can’t feel much, try pulling out the nail itself!

So what would happen if an extraction was attempted on a tooth that’s had a root canal but without local anesthesia (a.k.a no “novocaine“)?

OUCH!

When the elevator is inserted (or other instrument for that matter) – the tooth itself might not “feel” anything, but the surrounding tissue will.

An analogy to how it would feel might be like having a fingernail pulled off. Sure, you can cut the tip of your fingernail and not feel anything – but try to pull it off – and you’ll be in a lot of pain!

So, if you need to have a tooth extracted, and that tooth has had a root canal – you’ll need to very numb.

 

Dentistry and Art: A Tooth Puller by Jan Steen

Jan Steen (b. 1626 d. 1679) was a Dutch painter known for painting daily life in the Netherlands in the 17th century. Just like today, people developed teeth problems (albeit more frequently back then), and thus dentistry was a part of everyday existence. Back then, there were no HIPAA laws nor sterilization protocols, so dentistry was frequently performed in public for all to see:

A Tooth Puller painting by Jan Steen showing a dentist

A Tooth Puller by Jan Steen, painted in 1651. Clicking on the photo will show a larger version.

The above work can be found in the Mauritshuis in The Hague, Netherlands.

You see the usual onlookers featured in nearly all paintings of this era. By the looks of it, this “dentist” appears to be a travelling one, going from village to village pulling teeth.

Nearly all dental paintings of that era show one thing: tooth extractions. Back then, there was no such thing as porcelain veneers, smile makeovers, or teeth whitening. Cocaine, the first local anesthetic (and what inspired novocaine), was still 200 years away from being used in dental procedures. If you had a problem back then, that meant only one thing: that tooth was going to come out and it was going to hurt!

Aren’t we all glad that dentistry has changed in the past 350 years or so?

 

What Does a Cavity Under a Crown Look Like?

As this blog approaches nearly 3 years of age and well over 150,000 views, I am able to see what the more popular dental topics are out there. Currently, the fourth most popular post on this site, clocking in with a little more than 19,000 views (as of July 2015), is Dental MythBuster #9: You can’t get a cavity under a crown.

In analyzing what people search for online, many readers – hundreds that is – searched for some variation of: what does a cavity under a dental crown look like?

I had just finished compiling this information when a long time patient of mine – one who I had been telling for several months now about decay under one of her crowns – called to finally schedule her extraction.

Photos and X-rays of Cavities Under a Crown

In this particular case, the decay was so deep that her only option was extraction (see below for why extraction was her only options). Below is a bitewing x-ray:

dental bitewing x-ray showing decay under a crown

The x-ray shows the definite shadow of decay underneath a crown.

I had first diagnosed this nearly a year ago primarily based on the x-ray. In this area of the mouth – the last tooth on the lower left – the cheek drapes up against the tooth – making it very difficult to see – and very difficult to brush!.

I then removed the tooth. And no, I did not put my knee on her chest! The decay was unmistakable. Upon completing the procedure and having the patient go home, the first thing I thought was: “this will make a great photo for my blog!” So here it is:

high quality detailed photo of extracted tooth with decayed cavity under a dental crown

The extracted tooth in all its glory. If you dare, you can click on it to see a larger version!

You can clearly see the decay on this crown when it is out of the mouth. However, when it was in her mouth, it was nearly impossible to see. It could only be “felt” with a dental instrument. But the x-ray showed it.

Why was the tooth extracted?

If you get decay underneath a crown, it doesn’t always mean that the tooth has to be extracted. Before I explain why this was extracted, let’s look at one where the tooth was able to be fixed:

high quality photo of a cavity under an incisor crown

The decay underneath this crown was predictably fixed with a new crown.

The tooth directly above could be saved because the decay was easily accessible and only extended slightly underneath the gum tissue. The tooth had already had a root canal.

For the first tooth, the decay extended deep underneath the gum tissue and went into the furcation (the furcation is where the two roots of two-rooted tooth meet). No amount of modern dental procedures could have saved the tooth. So we extracted it and placed a dental implant.

Please note that I have greatly simplified the criteria for when a tooth can be saved vs. extracted. There are dozens of other factors – all beyond the scope of this post.

So, to summarize:

  • You can get decay or cavities underneath a crown.
  • The extent and location of the decay as well as other factors will dictate the treatment needed to correct the problem.

As always, your dentist should answer all your questions. If he/she doesn’t, it’s time to look for a new one.