Reading this post may be as hard as pulling teeth. It’s about pulling teeth, after all, and that’s not a pleasant subject. Tooth extraction means removing the tooth from its bone socket. Although in the not-too-distant past dental extraction was a common remedy for all-too-common dental problems, things have changed.  Tooth extraction today, except for certain orthodontic reasons, generally is the last resort. In Orlando, in the 21st Century, we usually do it only when prevention has failed and things are too far gone for less radical treatment options.  There are some relatively less common reasons for pulling teeth,  which we’ll touch on briefly.

IN THE PAST

If thy tooth offends thee, pull it out.  That’s a pretty good summary of the practice of tooth extraction in the past. For most people, dental health was addressed by waiting for unbearable pain to develop, then getting the offending tooth pulled. Current thinking by some historians is that dental health (in Europe, at least) was surprisingly good up until about the 19^th Century. Things changed, apparently, when increasing global trade made sugar cheap and widely available. Oral hygiene practices didn’t keep up with this new threat to dental health. In earlier times, ironically, tooth decay had been a “privilege” of wealth and position. Who else had access to sugar and sugary treats? The recently-discovered teeth of England’s King Richard III (died 1485) tell the story.

We’re all familiar with the cartoon-like cliché of the Toothache Kid. One end of a string tied to an aching tooth, the other end to the knob of an open door. Ouch. In fact, that’s a comparatively humane method of dental extraction. In the 1800s, for example, Americans would go to barbers to get their aching teeth pulled. Or to blacksmiths. The tools these “providers” used were often pretty horrifying.  Anesthesia? Are you kidding? Maybe some whiskey, if the customer could afford it.

In England, meanwhile, things were somewhat more …advanced? By the end of the 19^th Century, for example, dental practitioners were using nitrous oxide (“laughing gas”) and cocaine injection as general and local anesthetics, respectively. We still use nitrous oxide today, though we consider it a sedative rather than an anesthetic. That’s why when we use laughing gas, we generally also inject lidocaine into the patient’s gums. Lidocaine, by the way, is a distant chemical relative of cocaine. Similar enough to numb tissues when applied locally.

TRANSITION TO MODERN TIMES

As dental practitioners became better trained and the available technology developed, tooth extraction took some strange turns.  A gap had opened between the decay epidemic caused by changing diets and the prevention and treatment methods in use. The top dental practitioners were remarkably proficient but very expensive and comparatively rare. For ordinary people, tooth extraction became the option of choice for nearly all intolerable dental issues. As a matter of fact, more than a few people elected to have teeth pulled before problems, and terrible pain, developed.  Professor Joanna Bourke, in her documentary Drills, Dentures, and Dentistry: An Oral History, reports that as late as the early 1900’s some young people elected to have all their teeth pulled… to prevent tooth decay! Complete extraction, she shows, was a popular gift for a 21^st birthday, or a new bride.

We’ll close our discussion of the past with one more observation. In the 1700s and even a bit later, people tried to replace extracted teeth.  1n 1771, an English doctor had written a book titled A Natural History of The Human Teeth. This book pioneered knowledge still applied by dentists today. However, the author, John Hunter, also had some very strange ideas. Turner suggested replacing extracted teeth with implants. Sound modern? Well, he also suggested using human teeth for these implants. That is, transplants. From living and from dead donors, both. This idea caught on for a while. It set off a wave of grave robbing, and also of scavenging on the battlefields of Europe. It was a bad idea. The knowledge to prevent and treat infections, for one thing, was totally lacking. Let’s be glad that’s all in the past.

TOOTH EXTRACTION TODAY

Nowadays, we in the developed countries are doing much, much better at keeping our teeth in our heads. We’re far from perfect, however. At least 178 million American adults are missing at least one of their teeth. Moreover, about one in three Americans over the age of 65 has no natural teeth at all. To be sure, more of us are living longer in the past. Which raises the question:  how long are human teeth meant to last?

Well, the answer may be similar to Abe Lincoln’s remark about how long a man’s legs should be. “Long enough to reach the ground”, said Honest Abe. Perhaps it’s that a person’s adult teeth are meant to last as long as he or she lives. Research, as a matter of fact, is showing that there’s a connection between a person’s life expectancy and that of his or her teeth. It’s not clear which way the connection goes, however.

In any case, dentists are still extracting patients’ teeth.

REASONS FOR TOOTH EXTRACTION TODAY

Nowadays, we have the technology, skills, and experience to effectively treat a great many of the common dental conditions. Tooth decay is the most prominent of these. Fillings, crowns, and other treatments work well.  Tooth decay,  today, leads to tooth extraction pretty much only by the road of neglect. If a person dodges the dentist and ignores developing signs and symptoms, decay can make it impossible to save a tooth.

Here are some of the other reasons for tooth extraction today:

• Developmental, such as teeth that block the eruption of other teeth
• Orthodontic – removal of teeth to permit proper alignment of others
• Cysts, abscesses, and infections
• Compromised immune systems at risk of infection from teeth
• Removal of teeth blocking radiotherapy in neck and head areas
• Problematic wisdom teeth

HOW WE EXTRACT TEETH TODAY

General dentists perform both simple and surgical extractions, though the latter are often done by oral surgeons.  When the dentist can see the problem tooth in the patient’s mouth, it’s a simple extraction. If the tooth is inside the gum (impacted), or broken at the gumline, it’s a surgical extraction.

In either case, the procedure is, today, essentially painless. The dental practitioner will decide what method of anesthesia, local or general, is appropriate to the case. Both are very, very effective. In a surgical extraction, the practitioner has to first cut through the gum and possibly bone enclosing the problem tooth. In both simple and surgical extractions, the actual removal is by gripping the tooth with forceps. By rocking it, the practitioner loosens it in its socket, and eventually, it comes out. Not always in one piece, though, but that’s not considered a complication.

AFTER AN EXTRACTION

When the tooth comes out, there’s bleeding into the now-empty socket. This is fine. It’s a natural bandage, in fact. The blood clots, which both covers the exposed tissues (such as the bone) and stops further bleeding. We want that clot there.  In fact, if it pops out of place we’ll probably put a dressing over the exposed socket while new bleeding forms a new clot.

Primary healing usually takes a few weeks. We prescribe antibiotics and pain medications on a case-by-case basis. Patients receive complete instructions for diet, hygiene, self-care, and meds.  In follow-up exams, practitioners monitor healing. We also carefully monitor any movement of the patient’s other teeth. Such movement guides decisions about replacing the extracted tooth with a bridge, denture, or … an implant.

A modern, artificial implant, to be sure. Tooth extraction today is not your grandfather’s tooth extraction. We do it when there are no other choices. And today, thankfully, we more often have other choices.