Thousands of teeth are extracted annually, in the United States alone, primarily because of decay, severe periodontal disease, infection, or trauma. The jaw bone that supports the teeth, “alveolar bone”, which is generally soft and vascular, often melts away or resorbs following tooth removal. Such bone resorption can result in significant cosmetic or functional defects, including loss of surrounding gum tissue. Today, however, bio-engineering has led to simple but effective surgical techniques that can either totally prevent or greatly reduce the bone and soft tissue loss that normally occurs following extraction
Tooth extraction is one of the most common dental procedures. Healing of the resulting extraction socket normally occurs uneventfully. However, even with completely normal healing, there is often some resorption or melting away of surrounding bone. Resulting in less height and width than were present prior to tooth extraction. In addition, as bone is lost, overlying gum tissue also tends to lose both volume and its normal anatomic form. These changes can occur anywhere in the mouth but the most severe loss of bone and gum tissue tends to occur following the removal of incisor teeth located in the front of the mouth.
- Bio-Oss® and Dental Implants
- What is Bio-Oss?
- Causes and treatments for bumps on the gums
- Tips for Recovering from a Tooth Extraction
- How a tooth extraction is performed
- Aftercare for a tooth extraction
- What foods you can eat after your tooth extraction
- How to manage pain after a tooth extraction
- Tooth extraction healing. – A timeline of the daily/weekly stages of post-extraction healing.
- How long does it take for a tooth extraction to heal?
- A) The initial 24 hours following your tooth extraction.
- What will you notice?
- Restrictions on activities. / How long should you take off after getting a tooth pulled?
- Common guidelines –
- B) Extraction site healing – Weeks 1 and 2.
- C) Extraction site healing – Weeks 3 and 4.
- D) Bone healing – Filling in the socket.
- What will you notice as the bone fills in?
- The shape of your jawbone will change.
- Treatment timing – Making plans to replace your missing tooth.
- A Tooth Extraction With a Side of Jawbone
- Interventions for treating permanent front teeth that have been damaged and then become fused to the bone
- So Why is this Important?
- What Can Be Done about Dental Ankylosis?
- Medication Related Osteonecrosis of the Jaw
- Osteonecrosis of the Jaw Bone Appearing In Patients Never Exposed To Bisphosphonates
- Post-Op Follow Up Is Important As Mucosal Healing Time After Tooth Extraction Was Three Weeks Longer In Patients Exposed to Bisphosphonates
- Dry Socket Instructions
The Importance of Bone Preservation
Loss of bone and gum tissue following tooth extraction often results in both functional and cosmetic defects. Such tissue loss often results in an unsightly collapsed appearance, especially in the front of the mouth where proper maintenance of tissue health is critical to normal esthetics. In addition, loss of bone and gum tissue often compromises the dentist’s ability to adequately replace the missing tooth or teeth with either conventional removable or fixed bridgework or with a dental implant supported restoration. Sometimes the loss of bone is so severe that additional surgical procedures are required prior to replacing missing teeth.
Bio-Oss® and Dental Implants
Dental implants can be used in conjunction with the Bio-Oss® bone and gum tissue preservation technique. Depending upon the condition of the remaining extraction socket, an implant may be placed immediately into the extraction socket following tooth removal or may be place three or four months later. Bio-Oss® graft material helps support bone growth needed to stabilize the dental implant, while at the same time helping to preserve the surrounding bone and gum tissue. Bio-Oss® is one of the grafting products that is sometimes used in conjuction with dental implant placement at Pi Dental Center.
What is Bio-Oss?
Bio-Oss is a safe, effective bone graft material. Under the electron microscope, Bio-Oss looks very similar to human bone and is highly successful in helping new bone to form. Bio-Oss acts as a framework onto which bone forming cells and blood vessels travel along the Bio-Oss framework, healthy new bone is formed and the defect is repaired. It is prepared from specially processed bovine sources. Every batch of Bio-Oss goes through highly controlled processing and sterilization procedures which remove all impurities. At the end of this procedure, every batch of Bio-Oss must pass rigorous sterility and purity tests, assuring total safety of the materials.
Bio-Oss is produced by Osteohealth Co (A Division of Luitpold Pharmaceuticals, Inc.) One Luitpold Drive, Shirley, NY 11967 1-800-874-2334
What happens to surrounding bone when a tooth is extracted?
Causes and treatments for bumps on the gums
Each of the following conditions may cause bumps to develop on the gums:
More than 50% of people in the United States develop canker sores. These are small, round, painful bumps that may develop in the following areas:
- soft palate
- inner cheeks
Experts do not know what causes canker sores, but some believe they develop when the immune system mistakenly attacks the mucosal cells that line the mouth.
Around 80% of sores measure less than 1 centimeter (cm) in diameter and cause only minor pain and irritation. These usually resolve within a week.
Around 15% of sores measure more than 1 cm in diameter. These can cause severe pain and may take 2 or more weeks to heal. They often leave a scar.
Approximately 5% of sores develop in small clusters, which may merge to form ulcers. These clusters take around a week to heal.
Diagnosis and treatment
People should see a dentist if the sore lasts for longer than 10 days. A dentist will inspect the sore to rule out other conditions.
Treatment aims to decrease pain, speed up healing, and prevent recurrence. Common treatments include emollients and antiseptic agents.
Share on PinterestImage credit: Sol Silverman, Jr., D.D.S., 1999
Oral thrush, or candidiasis, is a yeast infection that affects the mouth. It occurs due to an overgrowth of a type of yeast called Candida.
People with oral thrush may notice white bumps or patches on the gums, inner cheeks, tongue, or roof of the mouth.
Other symptoms of oral thrush include:
- mouth redness or soreness
- a cotton-like feeling in the mouth
- redness and cracking at the corners of the mouth
- loss of taste
- pain when eating or swallowing
Candida usually lives harmlessly inside the body, without causing any problems. However, the following factors can cause these yeast to multiply:
- poor oral health
- taking certain medications, such as antibiotics and inhaled corticosteroids
- a weakened immune system
Diagnosis and treatment
A doctor can usually diagnose thrush simply by looking inside the mouth.
Treatment may include application of an antifungal medication, such as clotrimazole, miconazole, or nystatin.
For severe infections, a doctor may prescribe an antifungal tablet such as fluconazole.
Share on PinterestImage credit: Coronation Dental Specialty Group, 2014
A dental cyst is a fluid filled sac of tissue in the gum that can develop when the soft tissues or pulp within a tooth die.
Cysts usually form around the roots of dead teeth or in areas where teeth have not developed properly.
Dental cysts and dental abscesses are not the same thing. A dental abscess is a pocket of pus that develops near the root of a tooth due to bacterial infection.
Symptoms of a dental cyst include:
- swelling of the gum around the tooth
- a feeling of pressure around the tooth
- intense pain in the tooth and surrounding tissues
- signs of decay in nearby teeth
As the cyst grows, it can weaken the bones around the teeth. In severe cases, it can result in tooth loss.
Diagnosis and treatment
People who suspect that they have a dental cyst should visit a dentist. Without prompt treatment, a cyst may become infected and develop into an abscess.
A dentist will take an X-ray or MRI of the tooth in order to pinpoint the location of the cyst.
Following this, treatment may include:
- Endodontic therapy: This involves the dentist cleaning out the infected tooth pulp using a file-like instrument.
- Surgery: This involves opening up the area around the gums to gain access to the cyst. Surgery may be necessary if the cyst is deep inside the jaw.
- Tooth extraction: The dentist may need to remove the tooth and clean out the socket. If they do, they will then pack the space with an artificial bone compound to prevent the cyst from coming back.
Share on PinterestImage credit: DRosenbach, 2010
A periodontal abscess is an accumulation of pus within the gums surrounding a tooth. They are an immune system response to infection.
A periodontal abscess may appear as a red bump that pushes through the inflamed gum tissue. People with an abscess may also experience a throbbing pain in nearby teeth.
This type of abscess is often the result of severe gum disease, or periodontitis. In periodontitis, the gums become inflamed and pull away from the tooth.
This results in the formation of deep pockets between the tooth and gum, which accumulate bacteria.
Diagnosis and treatment
A dentist will take a dental X-ray to determine the location and extent of the abscess.
Treatment involves removing the source of the infection and draining the pus. This may include:
- Incision and drainage: This involves cutting the gum to drain the abscess.
- Root canal treatment: This involves drilling into the tooth to gain access to the roots. The dentist will then remove the abscess, fill the root canal, and seal the tooth with a filling or crown.
- Tooth extraction: This may be necessary if root canal treatment is not possible.
Share on PinterestImage credit: DRosenbach, 2010
A mandibular torus is a harmless bony growth inside the mouth. It may occur in following areas:
- the floor of the mouth
- the roof of the mouth
- the outer gum of the upper molars
Mandibular tori often develop in pairs, with each growing on opposite sides of the mouth. Although they can be quite large, they are not painful and rarely cause symptoms.
Diagnosis and treatment
Mandibular tori usually do not require treatment. In most cases, a dentist will simply monitor the size and shape of the growths during routine checkups.
In rare cases, a mandibular torus may become large enough to interfere with speech or oral hygiene practices. In such cases, the dentist may recommend surgery to remove it.
Share on PinterestImage credit: Klaus D. Peter, 2009
An oral fibroma is a noncancerous growth that develops inside the mouth. The bumps it causes can be a millimeter to several centimeters in size, and they tend to be white or pink. They rarely cause symptoms aside from a bump.
Oral fibromas usually grow in response to injury or irritation. They can develop in any of the following places:
- inner cheeks
- inner lips
- floor of the mouth
Diagnosis and treatment
Although most oral fibromas are harmless, a dentist may recommend removing them if there are irritating.
After removing the growth, the dentist may send it for further analysis. This is a precaution to check for the presence of cancerous cells.
Oral cancer is a cancerous growth or irritation that develops in any part of the mouth or the upper part of the throat.
Oral cancers can differ in texture and appearance. They may look like:
- lumps or bumps
- thickened areas
- rough spots or crusts
- persistent sores or irritations
- red or white patches
- small, eroded areas
Other symptoms of oral cancer include:
- a sore throat, or a feeling that something is stuck in the throat
- hoarseness or changes to the voice
People who experience any of the above symptoms for 2 weeks or longer should visit their doctor or dentist.
Diagnosis and treatment
A dentist may detect abnormalities in the mouth during a routine checkup and may refer someone to a doctor for a more thorough examination.
In some cases, a doctor may perform a biopsy. This involves removing all or part of the lesion and sending it to a laboratory for further examination. Diagnosis may also include X-rays or MRIs of the affected area.
The precise treatment depends on the type and stage of the cancer, but it usually consists at least one of the following:
- radiation therapy
Tips for Recovering from a Tooth Extraction
Tooth extraction, or the removal of a tooth, is a relatively common procedure for adults, even though their teeth are meant to be permanent. Here are a few of the reasons someone may need to get a tooth removed:
- tooth infection or decay
- gum disease
- damage from trauma
- crowded teeth
Read on to learn more about tooth extraction and what you need to do after this dental procedure.
How a tooth extraction is performed
You schedule a tooth extraction with your dentist or an oral surgeon.
At the procedure, your dentist injects you with a local anesthetic to numb the area and prevent you from experiencing pain, though you’ll still be aware of your surroundings.
If your child is having a tooth removed, or if you’re having more than one tooth removed, they may choose to use a strong general anesthetic. This means your child or you will sleep throughout the procedure.
For a simple extraction, your dentist will use a device called an elevator to rock the tooth back and forth until it becomes loose. They’ll then remove the tooth using dental forceps.
Molars or impacted teeth
If you’re getting a molar removed or if the tooth is impacted (meaning it sits beneath the gums), surgical extraction may be necessary.
In these cases, the surgeon will make an incision to cut away the gum and bone tissue that covers the tooth. Then, using forceps, they will rock the tooth back and forth until it breaks away.
If the tooth is especially difficult to extract, pieces of the tooth will be removed. More complex surgical extractions are likely to be performed under general anesthetic.
Once the tooth is removed, a blood clot will usually form in the socket. Your dentist or oral surgeon will pack it with a gauze pad to stop the bleeding. In some cases, a few stitches are also necessary.
Aftercare for a tooth extraction
Though aftercare may differ based on the type of extraction and location of your tooth, you can usually expect to heal in a matter of 7 to 10 days. It’s important to do what you can to keep the blood clot in place in the tooth socket. Dislodging it can cause what’s called dry socket, which can be painful.
There are a few things you can try to speed up healing time:
- Take painkillers as prescribed.
- Leave the initial gauze pad in place until about three to four hours after the procedure.
- Apply an ice bag to the affected area immediately following the procedure, but only for 10 minutes at a time. Leaving ice packs on for too long can result in tissue damage.
- Rest for 24 hours following the operation and limit your activity for the next couple of days.
- To avoid dislodging the blood clot, don’t rinse, spit, or use a straw for 24 hours after the procedure.
- After 24 hours, rinse your mouth with a salt solution, made with half a teaspoon of salt and 8 ounces warm water.
- Avoid smoking.
- When sleeping, prop your head up with pillows, as lying flat can prolong healing.
- Continue brushing and flossing your teeth to prevent infection, though avoid the extraction site.
What foods you can eat after your tooth extraction
During the healing process, you’ll want to eat soft foods, such as:
You can add smoothies to your diet, but you must eat them with a spoon. As your extraction site heals, you’ll be able to incorporate more solid foods into your diet, but it’s recommended to continue with this soft foods diet for a week after your extraction.
How to manage pain after a tooth extraction
You’ll most likely feel some discomfort, soreness, or pain after your extraction. It’s also normal to see some swelling in your face.
The painkillers you’ll get from your doctor will help reduce these symptoms. They may also recommend a number of over-the-counter medications.
If your discomfort doesn’t subside two or three days after the extraction, you’ll want to contact your dentist. If your pain suddenly worsens several days later, you’ll want to call your dentist immediately so they can rule out an infection.
After a healing period of one to two weeks, you’ll most likely be able to go back to a regular diet. New bone and gum tissue will grow over the extraction site as well. However, having a missing tooth can cause teeth to shift, affecting your bite.
You may want to ask your doctor about replacing the extracted tooth to prevent this from happening. This can be done with an implant, fixed bridge, or denture.
Tooth extraction healing. – A timeline of the daily/weekly stages of post-extraction healing.
– How long does it take? (for the gums to heal, for bone to fill in.) | What will you notice? What’s normal? | Precautions and restrictions during the healing process. | Pictures of healing progress.
X-ray of an empty tooth socket.
How long does it take for a tooth extraction to heal?
Once your tooth’s extraction procedure has been completed, you’ll no doubt want to know how long it will take for its socket to heal. In providing an answer, we’ve broken our discussion into the following time frames:
- A) The initial 24 hours following your surgery.
- B) Weeks 1 & 2.
- C) Weeks 3 & 4.
- D) Bone tissue healing timeline (hole closure).
Additional issues associated with the extraction healing process.
Since they’re closely related subjects, we also address the following questions on this page:
▶ How much time will you need to take off after your extraction?
It only makes sense that you’ll need to know how long you may need to take time off from work or school or limit your activities after having your tooth pulled.
And while your dentist is really the one in the best position to know, this page explains how different factors can affect what you’ll end up needing to do.
▶ When can future dental work be started?
In the case where a tooth that’s been pulled will need to be replaced, we explain how extraction site healing will affect the timing of this future dental work.
Things you’ll need to keep in mind while reading this page.
Wound size matters.
The type of healing progress that’s taken place at any point in time will generally be the same for any extraction. But you’ll need to keep in mind that more involved wounds (larger, deeper, wider) simply take longer to heal over and fill in than comparative smaller ones.
So if you’ve just had a wisdom tooth surgically removed, your healing time frame will extend out longer than someone who just had a lower incisor or baby tooth pulled.
Factors concerning you matter.
Each person has their own varying capacity to heal. For example, factors directly stemming from their genetic makeup will play a role. So will issues associated with their current status, such as age, medical condition or personal habits (e.g. smoking).
Also adding into this mix is the status of the tooth that’s been extracted. For example, a socket’s healing timeline can be affected by pathology that was originally connected with the tooth, like infections associated with gum disease or pericoronitis (infection around an impacted tooth).
▲ Section references – Cohen
A) The initial 24 hours following your tooth extraction.
Tooth sockets immediately after the extraction process.
Blood clots have begun to form.
What will you notice?
What you’ll see in terms of actual healing progress during the first 24 hours after your surgery won’t seem like much. But what has taken place is vitally important. You should notice that:
- A blood clot has filled the tooth’s empty socket. (It’s the clot’s formation that actually triggers the healing process.)
- And the bleeding from your wound has stopped. (Persistent bleeding disturbs the formation of the tissues needed for the healing process to progress.)
- You’ll hopefully notice that the level of discomfort associated with your extraction site has begun to slowly subside.
- You’ll probably find that the region immediately adjacent to the empty socket is tender when touched.
- Traumatized gum tissue immediately surrounding your socket may have a whitish appearance.
- It’s possible (especially in the case of a relatively involved or difficult extraction) that you’ll find some degree of swelling has already started to form, both in the tissues that surround your extraction site and possibly your face too.
If so, this swelling should peak within the first 48 to 72 hours and then start to subside.
What’s taking place with the gum tissue around your extraction site at this point?
While you won’t really be able to notice anything, the creation of new gum tissue around the edges of your wound has already begun. This starts as early as 12 hours post-extraction.
What’s going on inside your tooth’s socket?
Immediately following your tooth’s extraction its socket will fill with blood and the formation of a clot will begin. The blood clot typically fills the socket up to the level of the gum tissue surrounding it.
The clot itself is composed of platelets (sticky cell fragments that initiated the clot’s formation) and red and white blood cells, all embedded together in a fibrin gel. (It’s the fibrin gel that gives the clot its semi-solid consistency.)
Starting at this point, and continuing on during the days that follow, the platelets in the clot, along with other types of cells that have been attracted to it, begin to produce chemical compounds that initiate and advance the healing process.
▲ Section references – Farina, Politis, Cohen
How long does the blood clot last after a tooth extraction?
What happens to the blood clot that forms after a tooth is pulled?
This isn’t such a cut and dried question to answer because during the healing process the clot isn’t specifically lost or discarded. Instead, over time, it’s infiltrated by other types of cells and newly forming tissues.
In essence, it becomes the scaffolding for all of the participants of the healing process to follow. So that means that the blood clot that fills in the tooth’s socket after an extraction isn’t so much “lost” as it is “transformed.”
On this page, in each healing period’s “What’s going on inside your tooth’s socket?” section, we describe the transformation that’s taking place at that point.
Restrictions on activities. / How long should you take off after getting a tooth pulled?
The amount of postoperative rest and recuperation you require following your extraction will vary according to the circumstances of your procedure.
Recommendations about how much time you should take off.
a) With routine extractions, take the rest of the day off.
Most patients are probably best served by just going on home after their tooth extraction and taking it easy.
- Doing so will give you some privacy and adjustment time during that awkward period while your anesthetic is wearing off and your site’s bleeding is coming to an end.
- It will also give you an opportunity to familiarize yourself and get in sync with your dentist’s all-important postoperative instructions.
Common guidelines –
When can you return to work or school?
Returning to routine non-strenuous activities (going to an office job, attending class, shopping) the next day should present no problem. If you have more aggressive or involved activities in mind (including during the next several days) you should clear them with your dentist.
Generally speaking, for people who are healthy who have had the easiest, most routine kind of extraction:
- After a short period of recuperation, you may be able to return to non-strenuous activities even the same day of your surgery.
- With extractions involving small-sized wounds whose bleeding has been easily controlled (think small single-rooted tooth vs. large multi-rooted molar), returning to moderate physical activity the day following your extraction may be permissible too.
Ask your dentist for instructions. And of course, it always makes sense to error on the side of caution.
b) With difficult or involved extractions, you may need to take off a few days.
In the case of relatively involved or difficult extractions, or cases where some method of patient sedation has been used, your dentist may feel strongly that you must limit your activities during the initial 24 hour period following your surgery.
- As far as participating in routine non-strenuous activities (school, desk work, running errands) the following day, even with your dentist’s OK the way you feel (or look, if pronounced swelling has occurred) may factor into your decision about how active to become.
- In regard to strenuous physical activities, your dentist’s concern about your well-being may extend for some days after your surgery, and as such they may request that you limit your activities for a day or two after your extraction. You’ll need to ask.
It’s important to follow their recommendation, your safety may be involved. And remember, the way you take care (or don’t take care) of your extraction site during this initial period will set the stage for the healing process that follows.
c) Taking time off from school or work. / Sick leave. – What research studies have found.
Here are some examples of what researchers have reported about the amount of time off patients typically require after having wisdom teeth taken out (a level of surgery that is frequently more involved than just a routine tooth extraction).
This paper followed the healing outcomes of 522 patients that had 3rd molars removed (from the simplest to very involved surgeries). 81% of the patients took time off from work, for an average of 3 days (with a range of 0 to 10 days). 19% of the patients took no time off.
This study also evaluated patient healing outcomes associated with 3rd molar extractions (about 2000 of them). It found that on average patients missed 1.2 days of work, or were unable to perform normal daily activities.
40% of the teeth removed were erupted (had come through the gums into a relatively normal position). Removing erupted teeth typically creates less surgical insult than impacted ones, thus possibly explaining the lower amount of recuperation time reported by this study.
▲ Section references – Lopes, Hu
Tooth extraction healing pictures.
What a tooth extraction site looks like when healing, day 1 to 4 weeks.
B) Extraction site healing – Weeks 1 and 2.
During the first two weeks following your surgery you should notice that the gum tissue that surrounds your extraction site has completed a significant amount of repair.
- In comparison to skin on the outside of your body, oral soft tissue wounds generally heal more rapidly.
- As a point of reference, it’s usually considered that enough gum tissue healing has taken place by days 7 through 10 that stitches can be removed.
Especially towards the end of this time frame, your extraction area should look much improved, and shouldn’t pose any significant inconveniences or concerns.
How much will your socket have closed up?
The total amount of healing that’s been able to take place by this point in time (weeks 1 & 2) will be influenced by the initial size of your wound.
- The sockets of smaller diameter, single-rooted teeth (such as lower incisors) may appear mostly healed over by the end of two weeks. The same goes for baby teeth.
- Wider and deeper wounds left by comparatively larger teeth (canines, premolars) or multi-rooted ones (molars), or wounds resulting from surgical extractions (like needed to remove impacted wisdom teeth), will require a greater amount of time to heal over and show signs of filling in.
So in these types of instances, the contours of the gum tissue in the region may still show quite an indentation or divot in the area of the tooth’s socket.
What’s going on inside your tooth’s socket during this time frame?
During the first week after your extraction, the blood clot that originally formed in your tooth’s socket will have become partially colonized (it’s in the process of being fully replaced) by granulation tissue. This is a primordial type of tissue that’s rich in collagen (an important tissue building-block protein) and developing blood vessels.
Toward the end of this time period, and as a next stage, mesenchymal cells (“adult” stem cells) will begin to form a dense network within this granulation tissue (and later on fully replace it). These cells will ultimately differentiate into more specialized types of cells, such as bone tissue.
▲ Section references – Cohen, Farina
Restrictions on activities.
Since the new tissues that form during this time frame are quite vascular in nature (they contain a large number of blood vessels), if you traumatize your extraction site it’s likely to bleed easily. So be careful when eating foods or brushing. You can also expect this new tissue to be tender if touched or prodded.
But other than that, and especially towards the end of this two-week period, you should find that your extraction area is of minimal concern and does not need to be a major consideration in regard to performing routine activities.
C) Extraction site healing – Weeks 3 and 4.
By the end of the 3rd to 4th weeks after your tooth extraction, most of the soft tissue healing will have taken place.
- You’ll probably still be able to see at least a slight indentation in your jawbone that corresponds with the tooth’s original socket (hole).
- Where large or several teeth in a row have been removed, or with cases where a significant amount of bone was removed during the extraction process (like with impacted wisdom teeth), a relatively significant indentation may still remain. It may persist, even for some months.
What’s going on inside your tooth’s socket at this point?
During this phase, mesenchymal cells will continue to proliferate into the socket’s granulation tissue and organize into a dense network. At this point, they’ll have replaced about half of the granulation tissue that originally formed.
Many of these mesenchymal cells will transform into bone cells, and they will begin to create the socket’s first new bone tissue. This new bone growth takes place adjacent to the existing walls of the socket, which means that it will fill in from the bottom and sides (as opposed to across the top). This explains why tooth sockets become narrower and more shallow as they heal.
▲ Section references – Pagni, Cohen
You may notice that the new gum tissue that has formed has some tenderness, like when jabbed by hard foods. But at this point, even this level of trauma probably won’t cause any significant amount of bleeding.
D) Bone healing – Filling in the socket.
How long does it take the hole to close after a tooth extraction?
After you’ve had a tooth pulled, it’s the healing of the hole in your jawbone (the tooth’s socket) that takes the greatest amount of time (as opposed to your gum tissue).
- New bone formation really doesn’t start to begin until the end of the first week post-op.
- After about 8 to 10 weeks, your tooth’s extraction socket (the hole) will have substantially filled in with newly formed bone. (Around 2/3rds of the way.)
- At around 4 months, the socket will be completely filled in with new bone.
- It then takes on the order of another 2 to 4 months (6 to 8 months post-op) of further healing for the extraction site to finally finish smoothing out evenly with the contours of the surrounding jawbone.
- During the whole process, the newly formed bone gradually matures and becomes more dense. It finally reaches a density similar to that of the surrounding jawbone at around 4 months (as demonstrated by x-ray evaluation).
So in terms of the extracted tooth’s hole filling in to the point where your surgical site no longer shows much of an indentation where your tooth used to be, the amount of time required will be on the order of 4 months plus.
▲ Section references – Politis, Pagni, Cohen
What will you notice as the bone fills in?
During the initial weeks following your extraction, it will be easy for you to see and feel the pronounced hole left in your jawbone.
In some cases, it may be deep enough that it traps food and debris. (Especially large or deep sockets may require “irrigation” to keep them clean during the early weeks of healing.)
As the healing process progresses.
The formation of new bone first starts adjacent to the bony walls of the tooth’s socket, which means that as the healing process progresses the socket will fill in from the bottom and sides first.
In terms of appearance, that means that over time the width and depth of the wound will become more narrow and shallow. What once was a hole will gradually transform into less of one, then just a divot, then a dimple, ultimately smoothing out and blending in with the contours of the surrounding bone.
A healed extraction site.
Note the sunken appearance of the bone (in both height and thickness) due to ridge resorption.
The shape of your jawbone will change.
While the contours of your tooth’s extraction site will ultimately fill in and smooth out, the shape of your jawbone in the immediate area will undergo permanent changes.
Some of the bone’s original height will be lost during the healing process. Resulting in a saddle shape where its lowest point is definitely lower than where it originally lay on the extracted tooth.
There will also be a reduction in the width of the jawbone in the area of the healed socket. Usually this loss is greater on the cheek or lip side, as opposed to the palate or tongue side.
Studies have shown that the dimensional changes associated with premolar and molar extraction healing can run as high as 50% of the bone’s width at 12 months post-op.
Together, these changes in bone dimensions give a healed extraction site a sunken-in look (see picture).
▲ Section references – Walker, Pagni
The height and width changes mentioned above are collectively referred to as “resorption of the alveolar ridge” (the alveolar ridge is that portion of a jawbone that holds its teeth).
One long-term study (measurements were taken 2 to 3 years post-extraction) reported alveolar ridge shrinkage on the order of 40 to 60%. (Pagni – Linked above)
How long do these changes take?
The amount of time it ultimately takes for bone healing, and thus for the “final” shape of the ridge to form, will greatly depend on the size of the original wound. Larger wounds (i.e. multi-rooted teeth like molars, surgical sites from impacted wisdom tooth removal) will take longer to heal and will result in a greater degree of alveolar ridge changes.
- Overall, the rate of resorption (and therefore bone shape changes noticed) will be greatest during the first month post-op.
- At 3 months, two-thirds of the changes will have occurred. By 6 to 12 months out, the bulk of the transformation will have completed.
- Beyond that, some level of continued resorption will continue throughout the patient’s lifetime, albeit at an ever reducing rate (estimated around 0.5 to 1.0% per year).
▲ Section references – Wan der Weijden, Schropp, Pagni
Immediately after an extraction, the outline of the socket is easily seen.
FYI: Bundle Bone
If your dentist would take an x-ray immediately after pulling your tooth, it would show a white line outlining the shape of your tooth’s socket (see our graphic). This is termed “bundle bone” and it’s the layer of bone in which the fibers that anchored your tooth in place (its periodontal ligament) were embedded. Since the tooth is now gone and this outline of bone no longer has a function, as the healing process progresses and new bone is formed, this layer will be gradually resorbed (be broken down and dispersed by your body). After about 18 months or so, it will have totally disappeared and the outline of the socket will have been mostly lost.
As significant as the changes that take place are, it’s really a slow gradual process that during the 6 to 8 months that it takes, you really won’t notice anything going on at all.
Bits and fragments.
The exception might be the case where you discover a small piece of broken tooth or necrotic bone poking through the surface of your gums (your body’s attempt to eject the object).
In most cases these fragments are only of minor concern and are easily removed. This link: Bone and tooth fragments explains this issue in greater detail.
Treatment timing – Making plans to replace your missing tooth.
The fact that it takes as long as 6 to 12 months for the bulk of the jawbone’s healing process to take place doesn’t mean that you have to wait that long until your empty space can be filled in with a replacement tooth.
A healing period may be needed.
With some types of restorations (dental bridges, partial dentures, some kinds of dental implants) there is typically a healing ‘wait’ period that must be adhered to for best results. For many cases this may be on the order of just 1 to a few months. With others, it may be 6 months or longer before the final prosthesis should be placed.
The general idea is that the dentist wants to wait for your socket’s healing process to have progressed to a point where the changes it creates in the shape of the jawbone (see discussion above) won’t substantially adversely affect the fit, function or appearance of the replacement teeth.
But even if some sort of wait period is required, your dentist should have some type of temporary tooth or appliance that can be placed or worn until that point in time when your jawbone’s healing has advanced enough.
Our next page discusses post-extraction recovery and care. ▶
Update log –
10/17/2019 – Minor revisions, content added.
Authorship: Written by Staff Dentist
Topic Menu ▶ Tooth Extractions
- The extraction process –
- Preparing for your extraction. – Evaluating your tooth. / Medical issues & considerations. / Pre-op infection.
- The tooth extraction procedure. – The steps involved. / What to expect with each one.
- How long will your extraction take?
- Will having your tooth pulled hurt?
- Dental injections. – Why some are painful.
- Conscious sedation options with oral surgery.
- About surgical tooth extractions.
- Tooth sectioning.
- Alveoloplasty (jawbone reshaping).
- Details about gum tissue flaps and placing stitches.
- How dentists remove stitches.
- Dealing with lost or loose stitches.
- Extraction costs. – Including details about insurance coverage.
- Extraction aftercare and recovery –
- Instructions for the first 24 hours.
- Directions for the day after and beyond.
- Common postoperative complications overview.
- Specifics about – Swelling. | Bone & tooth fragments. | Dry sockets.
- Tooth extraction healing timeline.
- FAQs about extracting teeth.
- Related topics
- Topic: Wisdom Teeth
- Topic: Dental Implants
Page references sources:
Cohen N, et al. Healing processes following tooth extraction in orthodontic cases.
Farina RT, et al. Wound healing of extraction sockets.
Hu ML, et al. Development of an oral and maxillofacial surgery outcomes system for anesthesia and third molar removal: Results of alpha and beta testing.
Lopes V, et al. Third molar surgery: an audit of the indications for surgery, post-operative complaints and patient satisfaction.
Pagni G, et al. Postextraction Alveolar Ridge Preservation: Biological Basis and Treatments.
Politis C, et al. Wound Healing Problems in the Mouth.
Schropp L, et al. Bone Healing and Soft Tissue Contour Changes Following Single-Tooth Extraction: A Clinical and Radiographic 12-Month Prospective Study.
Van der Weijden F, et al. Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review.
Walker C, et al. Evaluation of Healing at Molar Extraction Sites With and Without Ridge Preservation: A Randomized Controlled Clinical Trial.
All reference sources for topic Tooth Extractions.
A Tooth Extraction With a Side of Jawbone
Reading between the lines of your question, it seems to me that your main problem concerns the lack of a definitive diagnosis. The issue of osteoporosis must be addressed; though, if you are suffering from this condition, it would not have been caused by a root-canal treatment or by placing a cap on a tooth. You may actually have osteonecrosis of your jawbone. A very small percentage of people develop this condition, and it often appears after some periodontal surgery or an extraction of a tooth. Also, if your gums were bleeding both before and after treatment, then that issue should have been resolved before the caps were placed. Gum tissue should be in a healthy state prior to placement of permanent caps. It sounds like you may have periodontal disease as well. There are also some blood disorders that show themselves in the gum tissue that can cause bleeding even if your gums are healthy. This must be looked at and diagnosed, which is why I am suggesting that you seek out the highest quality of care in your area for a complete evaluation and diagnosis. This should include a full set of X rays, a full charting of your mouth with periodontal probings, a complete medical history, and a thorough discussion of your dental and medical history. It would also be helpful if you could gather some old X rays from different dentists that you have seen, so a history can be put together. If you can get all that information and go to a university or hospital setting or to an excellent private practitioner (even if it is far away), you will gain the understanding that you need to take the next steps.
Once you have a diagnosis, then the treatment plan should be easy to figure out, and I am sure that your condition can be resolved.
Q4. My son has an overbite and misalignment of his teeth. One of his orthodontists is suggesting braces a year later and no pulling of teeth, and another orthodontist suggests pulling four teeth out and then using braces. I am confused about whom I should trust, and the pros and cons of the different treatments. Please help.
— Lynn, California
An overbite is one type of misalignment of teeth. Usually in an overbite, the upper front teeth are significantly longer and cover the lower front teeth when a person bites down. Many factors must be considered when deciding on the appropriate treatment plan.
Orthodontic factors include:
- Tongue-swallowing patterns
- Size of upper and lower jaws
- TM joint health
- Grinding and clenching of teeth
- Tooth size (too big or too small) — relation of upper and lower jaws
- Crowding or spacing of teeth
- Age of patient
Without knowing your situation, I would recommend that you get several recommendations from other general dentists: Ask them who they use for their own patients and, particularly, who they would use for their own children.
In general, but not always, orthodontists now try to save teeth by expanding the upper jaw at an early age. Expanding the bone of the upper jaw as a child grows can help the child keep teeth that used to be extracted. Consider consulting with more dentists and call your local dental society for more information or recommendations.
Learn more in the Everyday Health Dental Health Center.
Interventions for treating permanent front teeth that have been damaged and then become fused to the bone
This review was carried out to assess how effective different treatments are for treating permanent front teeth that have been damaged and then fused to the bone (ankylosed front teeth).
Sometimes teeth can fuse to the bone of the jaws after an injury to the tooth, such as when the tooth is knocked and pushed up into the jawbone. This fusion is called ‘ankylosis’. Usually the roots of fused (‘ankylosed’) teeth are resorbed by the body and replaced by the surrounding bone. For some individuals, this can lead to the fused teeth falling out. These teeth do not grow with the normal growth of the jawbones, so can become gradually moved if the injury occurs during childhood. It is not clear which treatment is best for these fused teeth, which is why we have undertaken this review.
Authors from the Cochrane Oral Health Group carried out this review of existing studies, and the evidence is up-to-date to 3 October 2015. There were no studies found that met the inclusion criteria for this review.
Key results and quality of the evidence
This review found that there is currently no high-level evidence available for comparing the effectiveness of different treatment methods for fused front teeth. Further research is needed provide evidence for different treatments and their relative effectiveness and safety.
Dental Ankylosis is an abnormal dental condition where there is a solid fixation of a tooth from a fusion of the root to the bone. Normally, around the roots of our teeth, there is gum tissue that is called the periodontal ligament. Inside the periodontal ligament are fibers that hold the tooth in the dental socket like a sling. The bone and the root do not touch because the gum tissue is between them.
When ankylosis occurs, a bridge of material, either bone or root material, called cementum, builds between the root and the bone and connects the bone to the root. When this occurs the tooth stops erupting and stays in the same place. As the other teeth beside the ankylosed tooth erupt, they will tip due to the ankylosed tooth not moving. If the ankylosed tooth is a primary tooth, it will displace the permanent tooth that is trying to erupt into its position. Also, the ankylosis can cause reduction of the space needed for the permanent tooth to erupt causing an impaction.
A way to determine a tooth is ankylosed is by visual examination. The ankylosed tooth will appear like it’s not erupting or it is sinking back into the gum tissue. In some cases, the ankylosed tooth will completely disappear and be covered up with gum tissue.
Dental Ankylosis can occur with primary (baby) teeth and permanent (adult) teeth. It is more common in primary teeth than permanent teeth.
Besides seeing a tooth that should be level with the adjacent teeth, another way of determining a tooth is ankylosed is by tapping on it. Since the tooth is connected to the bone, it will create a lower frequency sound when tapped by the end of a metal mouth mirror. The orthodontist or family dentist can compare the sounds of adjacent teeth with the suspected ankylosed tooth to determine a diagnosis.
So Why is this Important?
Ankylosis of primary and permanent teeth can have an affect on the growth and development of the jaws and the developing occlusion. Distortion of the alveolar jaw bone, space loss and distortion of jaw height are some conditions caused by dental ankylosis. During the mixed dentition phase of a child, an orthodontist is watching the eruption of the teeth and is concerned about possible problems of eruption. Some problems like ankylosis can be dealt with by diagnosing the ankylosed tooth early. Early consultation with your orthodontist is necessary to monitor eruption of the teeth and should begin at the age of 5 or 6 years old.
What Can Be Done about Dental Ankylosis?
In some cases, the damage has already been done by the ankylosed tooth and the orthodontist tries to let the permanent tooth erupt. After a period of time, if the ankylosed tooth has not exfoliated, it will need to be removed.
In other cases, removal of the ankylosed tooth is necessary to prevent distorted jaw growth, adverse tooth eruption and space loss. If the ankylosed tooth is a second primary molar tooth, a space maintainer is needed to keep the space from closing. Ask your orthodontist about the possible need for a space maintainer after extraction of the ankylosed tooth.
It is suggested that a parent do a visual examination of their child’s teeth looking for teeth that are not level with the adjacent teeth. If you see a tooth that looks submerged, or looks like a stair step from one tooth to the next, call your local orthodontist for a consultation. You may be able to prevent some conditions that are harder to correct at a later date.
Children hit many different milestones in their young lives with some children reaching developmental stages well before others. It’s not uncommon for parents to be concerned and seek our opinion when their child does not lose their baby teeth on time.
While there is a usual pattern and time frame for teeth to emerge into the mouth and others to be lost, as dentists, we begin to become concerned when a tooth/teeth goes well beyond these expected dates and there is a significant delay.
There are several common reasons for what we called “retained” baby teeth. A dental clinical and x-ray examination will determine why the baby tooth is failing to fall out (exfoliate). Afterwards, the dentist will decide whether to extract the baby tooth or keep it in the dentition.
It is not uncommon to find differences in treatment options amongst dentists as there are many factors to consider before deciding on a treatment plan, such as preserving bone, aesthetics, function and maintaining contact with surrounding and opposing teeth be preserved.
Incomplete root resorption
Have you ever wondered why only the crown portion of a baby tooth falls out? This is because the root portion of the tooth dissolves away. Sometimes, the roots do not get resorbed equally or completely. The course of action that the dentist will take often depends on the location and position of the adult tooth. Because the baby teeth are natural space holders, removing them too early can interfere with space that is needed for the eventually arrival of the adult tooth. A dentist may wait for the baby roots to eventually disappear or may help the process along by removing the final portions of the baby tooth to allow the underlying adult tooth to emerge.
Under normal conditions the teeth and bone do not touch, rather, they are connected by way of tiny hair-like fibers. Think of how a trampoline mat is connected to the supporting steel frame by way of tension springs. In this way, the tooth is free to move slightly so it can withstand the forces exerted upon it during chewing. Sometimes, however, teeth become directly attached to it’s surrounding bone. Treatment depends on whether or not there is an adult tooth present underneath the baby tooth.
a) Adult Tooth present – If the baby tooth is fused to the bone AND has an adult tooth to replace it then your dentist will likely extract the tooth. A space maintaining device will be placed on the adjacent teeth in order to keep this space available for the future incoming adult tooth. The area and adult tooth will then be monitored during it’s own eruption process for any signs of abnormality.
b) Adult Tooth Absent – If the baby tooth is fused to the bone and DOES NOT have an adult to replace it then the decision of extraction versus retention becomes a more complicated issue and bone preservation becomes a very important consideration.
i) Maintain – If the retained baby tooth is of sound structure and is in a good position to function (chew) with the other teeth then your dentist will likely opt to keep this tooth in the dentition and monitor it over the years. It is not uncommon to find many older adults that still have a retained baby tooth. Good oral hygiene is very important as there is no adult tooth to replace this tooth. If the tooth is lost eventually, then a dental implant can be considered.
ii) Maintain with Modifications – This is often the case when the tooth is submerged somewhat and is therefore lower in height and dimensionally smaller than the adjacent teeth. If the dentist decides that that the tooth is viable enough to be kept in the mouth, a few modification may have to be done to the tooth in order for it to function properly and have contact with all surrounding and opposing teeth. The tooth can be built up and reshaped in order to achieve function, but the tooth and surrounding bone will have to be closely monitored over the years.
iii) Extraction – If the baby tooth is removed now, the resulting space will have to be preserved with a space maintaining device until a future implant can be considered. The dentist may opt to perform a procedure called decoronation, whereby the crown portion is removed from the tooth and the site left to heal over. It is believed that important supporting fibers will then reconnect with the adjacent permanent teeth present. As these neighbouring teeth advance in their eruption process, the bone height and width can be maintained for many years until an implant can be considered.
Adult Tooth Misalignment
Unerupted – If the developing adult tooth is “stuck” in it’s position underneath, in the bone, the baby tooth may also be delayed in falling out. There are dental procedures that can help move the adult tooth along in it’s eruption process and eventually into position in the dentition. Your dentist may send you to an orthodontist for further evaluation. In consultation with the orthodontist, both short and long term solutions can be discussed that is unique to your child. Today, interceptive orthodontic treatment can go a long way in preventing the need for more extensive orthodontic treatment in the future.
Erupted – It is not uncommon to have adult teeth come into the mouth in front of or behind the baby tooth it’s suppose to replace. Removal of the baby tooth will depend on the position of the adult tooth, in which arch (upper or lower) this is occurring and at what stage of “falling out” the baby tooth is in. Although seeing permanent teeth erupt out of position when the baby teeth are still present is an unsettling thing for parents to see occur, it is a common situation. Once the baby teeth fall out or are removed, the adult tooth will eventually move into place naturally or with the assistance of orthodontia.
We cannot emphasize enough the importance of regular dental check-ups. Dental development and eruption problems are more common than one would think. Missing teeth can be caused by a number of things including genetics, injury, infection and endocrine disorders.
As challenging as some cases may be, with today’s advances in dentistry, there are now a variety of short and long term solutions available for consideration. Early diagnosis and intervention is often an important consideration in planning for a healthy tomorrow.
Yours in Better Health,
The Your Smile Dental Care team
Medication Related Osteonecrosis of the Jaw
Cancer and Bone Invasion
Tumors that have invaded the bones cause the bone to wear away, leaving small holes, called osteolytic lesions. This process of bone erosion is called resorption and leaves bones weak and fragile. Tumors can also stimulate abnormal bone formation, resulting in areas of bone build-up called osteosclerotic lesions, which can be painful. These areas of build-up are weak and unstable and can easily break or collapse. Both of these processes put patients with cancer that has spread to the bone, or multiple myeloma, at risk for fractures, a faster spread of bone metastases, spinal cord compression (when the bone in the spine compresses the spinal cord) and hypercalcemia (increased levels of calcium in the blood caused by bone breakdown, which can cause severe problems). Several medications have the ability to prevent or slow these complications, including denosumab and a class of medications called bisphosphonates.
What are Bisphosphonates?
Bisphosphonates are a group of medications that slow the bone destroying activity that occurs with bone metastases (cancer that has spread to the bone) or Multiple Myeloma (cancer of plasma cells, which invade and destroy bone). Bisphosphonates work by slowing the wearing away (also called resorption) of bone and the abnormal build-up of unstable bone. These problems can lead to what doctors call “skeletal related events”. These events include the previously listed fractures, increased bone metastases, spinal cord compression and hypercalcemia. Bisphosphonates are used to help improve bone strength in many diseases associated with bone resorption, including cancer and osteoporosis.
Currently approved bisphosphonates include:
- Alendronate (Fosamax®)
- Etidronate (Didronel®)
- Ibandronate (Boniva®) – currently used for only for osteoporosis
- Pamidronate (Aredia®) (given intravenously)
- Risedronate (Actonel®)
- Tiludronate (Skelid®)
- Zoledronic acid (Zometa®) (given intravenously)
Other Medications Associated with ONJ
Another medication used to slow or prevent bone breakdown and bone complications is denosumab (Xgeva®). Denosumab is a type of monoclonal antibody, which is a medicine designed to target a specific protein or cell – in this case, the target is a protein called RANKL, which is necessary for bone breakdown and is over produced in bone metastases. By targeting RANKL, denosumab inhibits bone breakdown. In addition, a class of medications called anti-angiogenesis inhibitors, which work by interfering with a tumors blood supply, are a known cause of ONJ. These medications are used in many cancer treatment regimens.
What is Osteonecrosis of the Jaw?
Osteonecrosis is exposed bone of the maxilla (upper jaw bone) or mandible (lower jaw bone). These bones are normally covered by gum tissue. In the case of osteonecrosis of the jaw (ONJ), the bone is exposed, either through an opening in the gum tissue or with the gum tissue missing entirely. Typical symptoms associated with ONJ are: pain, swelling or infection of the gums, loosening of the teeth, and exposed bone (often at the site of a previous tooth extraction). Some patients may report numbness or tingling in the jaw or a “heavy” feeling jaw. ONJ may have no symptoms for weeks or months and may only be recognized by the presence of exposed bone.
The exact cause of ONJ is not known, but potential causes include: dental work, infection, inflammation, and the inhibition of angiogenesis. Originally, the cause was thought to be related to dental work while taking these medications. However, further research found that this dental work was often done because of underlying dental disease, which is often associated with inflammation of the gum tissue or infection. Anti-angiogenic medications inhibit blood supply, which can lead to bone damage. Research has found that bisphosphonates also have some affect on angiogenesis. ONJ is a rare complication, but as patients with bone metastases are living longer and being treated with medications associated with this complication for many years, it is important to be aware of this complication.
ONJ should not be confused with osteoradionecrosis of the jaw, which is caused by radiation therapy and is treated differently than ONJ.
Prevention is the Key
What experts have learned is that most cases were associated with some type of dental event, and if these are avoided, ONJ may be as well. Any patient who is going to start receiving a medication associated with ONJ should be seen by an oral maxillofacial surgeon or dental oncologist familiar with ONJ. If there are any dental concerns (requiring dental surgeries, extractions, root canals, or removal of abscessed teeth), therapy with the medication should be delayed (if possible) until the dental concerns are addressed and several weeks have passed, to allow for healing. Dental exams should include cleaning, examining of denture fit, and patient education regarding oral care while on these medications.
Patients receiving bisphosphonates should have regularly scheduled oral assessments, perhaps as often as every 3-4 months. They should maintain good oral hygiene and have routine dental cleanings (with care to avoid injury to tissues).
If invasive dental procedures are absolutely necessary, some have suggested that temporarily stopping the at-risk medications may result in improved healing. However, there is no evidence that this helps prevent ONJ in oncology patients. These medications remain in the body for many months after the last dose, meaning you would need several months or more off the medication to make stopping the therapy worthwhile. These medications clearly benefit patients at high risk of bone complications and, unfortunately, no other class of medications have this benefit. The patient and provider must weigh the patient’s risk with the benefit derived from these medications. Further research into appropriate management is ongoing.
How do we treat ONJ?
Patients with suspected ONJ should have panoramic and/or intra-oral x-rays performed to rule out other dental problems (impacted teeth, cysts, bone changes). These patients should be seen and evaluated by an oral maxillofacial surgeon or dental oncologist familiar with ONJ. Primary goals of treatment of ONJ are to reduce pain, treat or prevent infection, and minimize progression.
Oral rinses with chlorhexidine (Peridex®) should be used 3-4 times a day, indefinitely. Dentures can be worn, but may require some resizing or cushioning to prevent further injury. An appliance can be used to cover and protect the exposed bone. Antibiotics can be beneficial and the area may be tested to determine what bacteria is present, which will guide the choice of which antibiotic to use.
Non-surgical approaches are often preferred, as surgery on these bones may not heal well and may worsen the problem. However, in more advanced cases, surgical removal of the involved bone can improve quality of life, reduce pain, prevent this area from spreading, and help promote soft tissue healing. When used, surgery may include the surgical removal of foreign material and/or dead, damaged, or infected tissue or bone and in some cases, reconstruction of the bone.
ONJ is a relatively newly recognized concern for patients receiving certain medications. It is thought to be quite rare, but is probably underreported given the lack of understanding regarding this problem. As a patient, follow recommendations for prevention and report any signs of ONJ to your healthcare team.
Osteonecrosis of the Jaw Bone Appearing In Patients Never Exposed To Bisphosphonates
The authors commented that osteonecrosis of the jawbone (ONJ) is not a new phenomenon and cases have been reported well before the use of bisphosphonates. ONJ has been reported in association with cancer chemotherapy and high-dose steroid use.
This study was out of Case Western Reserve University in Cleveland, Ohio (Baur, 2012). In their institution, over the previous year, the authors had four patients referred for management of areas of exposed bone that had been refractory to conservative treatment. These patients had areas of exposed bone in the maxillofacial region that had persisted for at least 8 weeks and had never been exposed to bisphosphonates (BPs)or radiation treatments.
In the four cases described, each of the patients had areas of exposed bone in the mandible that persisted for more than 8 weeks (3, 5, 10 and 9 months, respectively). Each of the patients was treated conservatively for several weeks with chlorhexidine, oral antibiotics and minimal debridement – all without success. Patients’ conditions continued to deteriorate presenting with larger areas of exposed bone and purulence consistent with a superinfection. All patients eventually required aggressive debridement in the operating room, and one patient required segmental mandibular resections.
Of the four cases described in the report, one had ONJ that could be linked to chemotherapy, including high-dose steroid use. In addition, all four patients had known risk factors for vascular disease including diabetes and hypertension. One patient had a history of multiple deep vein thrombosis and pulmonary emboli.
Since none of the cases involved a history of BP use, the authors commented that one should be aware of other risk factors that may lead to ONJ. Patients receiving chemotherapy, those taking high-dose steroids, or those with complicated medical histories including vascular disease are examples of those risk factors. The authors emphasized that these types of patients should maintain impeccable oral hygiene and should be seen regularly by their dental professional. Questionable teeth should be extracted before starting chemotherapy.
Post-Op Follow Up Is Important As Mucosal Healing Time After Tooth Extraction Was Three Weeks Longer In Patients Exposed to Bisphosphonates
The second study population consisted of dental patients seeking routine dental care between 2007 and 2011 at three dental centers (Migliorati, 2013). Patients were assigned to one of two groups – group 1 consisted of 53 patients exposed to bisphosphonates and group 2 had 39 patients who had never taken bisphosphonates. The investigators confirmed the need for tooth extraction in these patients. The primary outcome variable was time to mucosal epithelialization, which was confirmed clinically.
Extractions were performed and were graded as single or multiple and as simple or difficult. Subjects were placed on a recall schedule every week or every second week for evaluation of healing progress. Delayed healing was defined as clinical signs of absent mucosal coverage, pain, swelling, infection, inflammation, granulation tissue formation in the alveolar space, or exposed non-healing bone. It was determined that clinical healing had taken place after verification of complete mucosal epithelialization. Total mucosal healing time was recorded in terms of weeks, and subjects were monitored for signs and symptoms of bisphosphonate-associated osteonecrosis of the jaw bone, such as inflammation and infection. Ages of subjects (mean and range) were 70 years (40-92) in bisphosphonate (BP) group and 56 years (32-88) in non-BP group. Gender was 81% female in BP group and 44% female in non-BP group.
The median healing time for the 53 subjects in the BP group was 5 weeks. The median healing time for the 39 subjects in non-BP group was 2 weeks. Thus, the delayed healing was significantly longer in patients who received BP therapy compared with that in healthy control participants who had no history of BP exposure. In the BP group, the delayed healing in participants receiving oral versus intravenous BP therapy was not statistically different. One patient with cancer in the BP group developed osteonecrosis in the jaw bone during the study.
The serum CTX test measures the amount of bone turnover represented by parts of collagen destroyed during bone resorption. It had been proposed that such a test has prognostic value in the treatment of patients receiving BP therapy. In this study, the median CTX value for the 53 patients exposed to BPs was 202 pg/ml. The median CTX value for the 39 healthy participants was 342 pg/ml. As expected, overall CTX values were significantly lower in participants who were exposed to BPs. According to the authors, however, statistical analysis showed that the CTX values were not associated with delayed healing or with development of osteonecrosis of the jaw bone.
Discussion of the delayed healing report
The aim of the study was to measure wound healing after tooth extraction in patients exposed to BPs and to estimate the role of variables of interest, such as BP exposure time, type of BP therapy and results of CTX testing. Age, gender and CTX values did not affect mucosal healing time. Healing time was not influenced by the type or potency of BP received or the duration of therapy. The specific BPs were not identified.
According to the authors, the study results demonstrate for the first time in humans that post-tooth-extraction healing in patients exposed to oral or intravenous BPs is delayed. Duration of exposure to the medication, type of BP (oral or intravenous), and the patients’ age, sex and CTX levels do not seem to play a role in determining who is at increased risk of experiencing delayed healing or of developing osteonecrosis of the jaw bone.
The authors suggested that clinicians follow up patients closely during the postoperative period to ensure that the wound is cared for properly and the healing is progressing favorably. Bisphosphonate exposure is a main factor that inhibits normal mucosal healing after tooth extraction.
Dry Socket Instructions
What’s A Dry Socket?
In most dental patients, blood fills up the open socket in the bone left after a tooth extraction. The blood hardens or clots and protects the tooth socket while the gums grow over the top of the hole. In most cases the gums completely grow over and close the tooth extraction socket within one to two weeks. Over the next year, the blood clot is replaced by bone that fills the socket.
In a patient with a dry socket, blood does not fill the extraction socket or the blood clot is lost. The most common causes are spitting, smoking, rinsing in the first few hours, or eating hard foods that dislodge the clot. With the clot missing, there is exposed bone in the extraction socket.
This open “dry” socket causes a constant dull throbbing pain that is quite uncomfortable. The more bone that is exposed, the more symptoms a patient may have. The dry socket pain can sometimes be felt in the ear or back of the head. Unfortunately, once a dry socket has formed and becomes inflamed, healing is often slower than normal.
Until the gums have healed over the exposed socket completely, the pain will continue. This typically lasts for an additional week.
The dental name for a dry socket is “acute alveolar osteitis,” which means sudden inflammation of the bone that supports a tooth.
While dry sockets are quite painful, there is no risk of long term complications. Patients who get dry sockets will ultimately heal normally and should not be concerned about any long term problems.
Causes of A Dry Socket
Dentists don’t know exactly what causes a dry socket. Dry sockets seem to occur more with lower teeth than upper teeth and more with females rather than males. Dry sockets are significantly more common with smokers. Dry sockets happen more often after difficult extractions.
Many believe the cause stems from a reduced blood supply to the healing area. For example, very dense bone and the bone around root canalled teeth tend to have fewer blood vessels which aid in healing. While Dr. Harris may be able to identify cases which seem more likely to get a dry socket, it can happen with any extraction at any time during healing.
Anything that can dislodge a forming blood clot can cause a dry socket. Forceful spitting or sucking though a straw can pull a blood clot completely out of it’s socket and cause a dry socket. Premature rinsing and smoking are also major causes.
Dry Socket Prevention
Dr. Harris makes every attempt to remove teeth in as conservative, atraumatic and gentle fashion as possible. In fact, dry sockets do not occur very often in our practice. It is our belief that the more trauma to an extraction site, the more chance a dry socket will develop. All of our incisions are kept to a minimum and the gum tissue is disturbed as little as possible to help keep the blood supply to the extraction socket intact.
As always, it is extremely important that the post-operative instructions are followed very carefully.
Treatment of Dry Socket
Unfortunately, Dry socket pain will typically persist until the gums have healed sufficiently to cover the painful exposed bone. There is little we can do to speed along healing. Generally, Dr. Harris recommends supportive care such as over the counter pain medications in combination with narcotic pain relievers as needed.
Many dentists pack a dry socket with eugenol based medications that help decrease the pain temporarily. However, the packing process itself can irritate the dry socket and may slow healing.
In addition, when the temporary effects wear off, the pain will likely return. Often, once begun, the application of dry socket dressing must be performed daily until healed. Generally, Dr. Harris reserves the use of dry socket packing for severe cases only. Fortunately, this is very rare.
Everyone at High Desert Oral Surgery and Implant Center understands how difficult and upsetting getting a dry socket can be. We will strive to do everything we can to aid you in quick healing and managing any post-operative pain or complications. Please let us know if you have any questions or needs.
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