TOOTH EXTRACTION
Tooth extraction is the removal of teeth from the dental alveolus. It is also known as dental extraction, exodontia, or tooth pulling colloquially (socket in the alveolar bone).

WHAT IS THE DEFINITION?
The best tooth extraction is the painless removal of the entire tooth, or root, with the least amount of trauma to the underlying tissues, ensuring that the wound heals without incident and preventing any post-operative prosthetic difficulties. (Geoffrey L Howe).

INDICATIONS OF EXODONTIA:-
1. Caries
2. Periodontitis or Periodontal diseases – to prevent alveolar ridge resorption.
3. Teeth with necrosed pulp and periapical lesion – not responding to endodontic treatment.
4. Over retained deciduous tooth.
5. Malpositioned eruption of teeth – patient denies the use of braces of braces didn’t give result.
6. Orthodontic purpose
7. Prosthetic purpose
8. Grossly carious & unrestorable tooth
9. Impacted tooth
10. Supernumerary tooth
11. Grossly decayed first molar or second molar – make room for the 3rd molar.
12. Tilted wisdom teeth
13. Teeth in the fracture line.
14. Fractured tooth
15. Hampering treatment plan
16. Serial extraction
17. Teeth directly involved by cyst and tumor.
18. Teeth in the area of therapeutic irradiation.
19. Pre-radiation therapy
20. Teeth acting as foci of infection – E.g. Bacterial endocarditis, Rheumatic fever.

CONTRAINDICATIONS:-
Acute infections of odontogenic origin are no longer regarded as a complete contraindication to prompt extraction in the era of antibiotics.
The removal of teeth should be avoided under these circumstances.
1. Systemic contraindications
2. Local contraindications

SYSTEMIC CONTRAINDICATIONS:-
1. Uncontrolled heart problem – Patients with unstable BP or high BP or patient having heart problem -not properly medicated, or patients - within 6 months of myocardial infarction.
In such cases, the patient has to be referred or get consent from the physician.
2. Diabetes – It is a disease that can aggravate most other diseases. In the case of uncontrolled diabetes, alveolar socket healing will not occur. So, FBS(fasting blood sugar) test must be done and examined.
3. blood-related disorders:- these disorders may prevent socket healing. So, in such conditions, tooth extraction must be prevented.
• Platelet disorders
• Anaemia
• Haemophilia
• Haemorrhagic purpura
4. Patients on medication of corticosteroid therapy: The immune system of the patient will be weak, and so there can be problems.
5. Pregnancy (Pregnancy is not an absolute contraindication, but tooth extraction shall be avoided. If tooth extraction is a must, 4-6 months is the safer period. If the decision is to proceed with tooth extraction, the patient must have consulted a gynecologist before the tooth extraction.
6. Malignant disease
• Leukemia
• Lymphoma
7. Other diseases:-
• Osteoporosis
• End-stage renal disease
• Uncontrolled hyperthyroidism.


LOCAL CONTRAINDICATIONS :-
1. Central haemangioma: It is a condition of absolute contraindication for tooth extraction. The patient may or may not be symptomatic. The most commonly seen manifestations in the patients are discomfort around the tooth, pulsative bleeding, blue coloration in the gums, mobile tooth, and swelling around the tooth. Such cases are rare but have to be dealt with very carefully.
Other related contraindications can be:-
2. Tooth associated with tumor
3. Patient undergoing radiation therapy
4. Patients with severe pericoronitis – resulting in reduced mouth opening
5. Acute abcess – It is not an absolute contraindication. In sight of local anaesthesia, if the tooth extraction can be done safely and easily, the tooth extraction can be proceeded.
PRE SURGICAL ASSESSMENT
There is the need for proper mental preparation by the dentist before giving local anaesthesia to the patient for tooth extraction. This includes the level of difficult of the extraction. There can be several reasons that makes the extraction process difficult, which includes tooth angulation, reduced mouth opening, (etc.) and even the anxiety of the patient.
a. Medical history – Changes has to be incorporated in the routine process accordingly.
b. Dental history – To see if there is any difficult previous tooth extraction history.
c. Patient’s emotional maturity – To know the anxiety level of the patient.
d. Clinical condition
e. Radiographic examination


MEDICAL CONDITION
A detailed medical history has to be taken (though patients may not disclose all the details). So, the patient’s cooperation, patient’s weight etc has to be observed. Try to explore and solve the problems if anything noted. If any uncontrolled medical problem is observed, refer the patient to the Physician and get the consent. There may even be patients who are physically fit but are in depression. Such patients may have difficulties after the procedure. Such cases has to be dealt carefully.


CLINICAL EXAMINATION
1. Access to the tooth – Mouth opening may be reduced due to pain or swelling. Patients may not be able open the mouth properly also due to OSMF (Oral Submucous fibrosis). In such cases the dentist has to prepare themselves properly and also the patient, as there is a chance for the root tip fracture, and related problems.
2. Tooth alignment in the arch – The position of the tooth to be extracted from the dental is of prime importance. If the teeth alignment is well, then the forceps and elevated can be easily used. But in the case of crowding or mal-alignment of teeth, this can increase the difficulty level.
3. Tooth mobility – The extraction process can be easy if the tooth is already mobile. But if it is zero mobile, this can be due to hyper cementosis or ankylosis.
4. Condition of the crown - The difficulty level of tooth extraction depends on how carious the tooth is. If the tooth is grossly carious, the tooth breaks by the use of forceps itself. It has to be considered, if the forceps can reach the furcation to properly hold the tooth. If the tooth cant be help apically by the forceps, the difficulty level of tooth extraction will be high.
5. Radiographic examination – Various aspects can be studied by X- rays. Like:-
• Periodontitis in the adjacent tooth can cause mobility of that tooth. So this mobile tooth gets removed from the socket before the extraction of the required one.
• There can also be conditions where the pain is one tooth and the periapical infection is in the other tooth.
In such cases, the patient has to be informed about the situation, and regarding the possibility of tooth loss or need for extraction or treatment of the adjacent tooth.
• The anatomical structures and relations can also be judged using the X- rays. Like sinuses relation of upper molars or inferior nerve canal to lower third molars.
TOOTH FACTOR - examined radiographically
1. Root configuration – More the number of roots for the tooth, more difficult the level of extraction be. If the roots are long (like in canines) or if there are curvatures in the root, this can also increase the difficulty level in the extraction. Short and conical roots makes the process easy.
2. Divergent roots – If divergent roots are present in the toot, it will be difficult to extract the tooth.
3. Fused roots – If the root are fused, it will be easy to extract the tooth.
4. Apical bulbous root – The apical position of the root if bulbous, makes the extraction process difficult.
5. Level of furcation – If the level of bone is below the furcation level, it is comparatively easy to extract the tooth. If the bone level is up to the CEJ (Cemento enamel junction), the process can be difficult.
6. Periapical infection – If there is infection below the root, or if there is PDL (Periodontal ligament) thickening, extraction can be easy.
7. Root caries – Root caries makes the extraction difficult, as there is a possibility of root fracture at the level of the caries.
8. Root resorption – makes the process tough.
9. Surrounding bone density – It is difficult to measure the density of bone in 2D X- ray, but, white appearance of the bone in the X- ray implies a denser bone in the mandible (makes extraction of tooth difficult), and if the bone appears radiolucent, it implies a weak bone, with low density – which favours in the tooth extraction.