Tooth Extraction

The main reasons a tooth has to come out are:

• Decay or a fracture too large to repair.
• Advanced gum disease (periodontitis). When the bone and tissues that hold the tooth are lost, the tooth becomes loose.
• Infection. The inner tissue of a tooth can become infected. According to the NHS, if root canal treatment is not done, the infection may spread and the tooth may need to be taken out³.
• Crowding or injury. A tooth may need to come out to make room during orthodontic treatment, or after it has been damaged in an accident.
• A wisdom tooth causing problems. Wisdom teeth are a separate topic and are not covered on this page; see also our article Can wisdom teeth cause a headache?

In a review of the reasons adults have teeth taken out, the most common reasons were decay and gum disease⁴. The review rests on only three studies. They were carried out in Greece and Croatia between 1995 and 2010. So the proportions should not be read as a picture of today or of Turkey.

When extraction is usually considered

• The tooth is too broken down to repair, or the root is fractured in a way that does not allow the tooth to be kept.
• Gum disease has destroyed much of the tissue holding the tooth and the tooth cannot be kept.
• An infection in the tooth cannot be cleared with root canal treatment, or root canal treatment is not suitable.

When keeping the tooth is considered first

• The decay or fracture can be repaired. According to the NHS, a cavity left by decay can be filled, and a broken or decayed tooth can be repaired with a crown³.
• The nerve of the tooth is inflamed. Root canal treatment can often keep the tooth without taking it out. See our page on root canal treatment for details.
• There is gum disease. A review of 33 studies looked at patients after gum treatment. For at least 5 years they kept up regular maintenance care with their dentist (supportive periodontal therapy). These patients lost on average 0.1 teeth per patient per year⁵. Most of them lost no teeth at all. This result is not a guarantee for any one patient. See our page on gum diseases for details.

Tell your dentist before an extraction if

• You take a blood thinner or an antiplatelet medicine such as aspirin.
• You take, or have taken, a medicine for bone thinning (osteoporosis) or for cancer.
• You have had radiotherapy to the head or neck.
• You have a heart condition, or your heart doctor has told you that you may need antibiotics before dental procedures.
• You are pregnant. Pregnancy does not rule out an extraction. ACOG is the American College of Obstetricians and Gynecologists. According to ACOG, treatments that should not be postponed, such as an extraction, can be done at any stage of pregnancy⁶. According to UK guidance, dental X-rays, including panoramic and three-dimensional X-rays, do not need to wait until after the birth⁷. You may also choose to postpone an X-ray that is not urgent.
• You take other medicines regularly, or have a condition that weakens your immune system.

How these medicines affect an extraction is explained below.

• Doing nothing. For a tooth that is not painful and shows no sign of infection, waiting is sometimes a choice; the tooth is watched at check-ups. For an infected tooth, however, waiting is not safe: a dental abscess will not go away on its own⁸ and needs urgent treatment.
• Keeping the tooth. Decay can be repaired with a filling, a badly broken-down tooth with a crown, and a tooth with an inflamed nerve with root canal treatment. Root-filled teeth and single crowns on implants have been found to have similar long-term rates of staying in the mouth⁹. Very few studies compare the two treatments directly, so neither has been shown to be better in general. The choice depends on the state of the tooth, the risks of each treatment and your own preference.
• Taking the tooth out and leaving the gap. For some gaps at the back of the mouth this is a reasonable choice; see “What can replace an extracted tooth?” below.
• Taking the tooth out and replacing it. The gap can be filled with an implant, a bridge or a removable denture.

Taking out a tooth that could be kept is a trade-off. You accept the effects of the extraction and the gap instead of the risks of keeping the tooth. The decision is made together with your dentist, after an examination and X-rays.

The tooth is examined before the extraction. According to UK guidance, X-rays are chosen for you after your history has been taken and you have been examined⁷.

In a simple extraction the area is numbed with a local anaesthetic. According to MedlinePlus, the tooth is loosened with an instrument called an elevator and removed with forceps¹⁰.

A surgical extraction is more complex. An impacted tooth is one that is blocked from coming through fully. For such a tooth, a small cut in the gum, removing some bone or cutting the tooth into pieces may be needed¹⁰. Sedation may be used for this kind of extraction. One or more stitches may be needed afterwards. Your dentist will tell you which approach is needed after the examination and X-rays.

Anaesthesia. According to a Cochrane review comparing the numbing injections used in dental treatment, the differences between the drugs for teeth being taken out are uncertain¹¹. In surgical procedures, neither of the two drugs compared numbed every patient completely. So tell your dentist if you feel pain during the procedure. If you feel anxious, see our page on conscious sedation.

Your dentist will tell you after the examination how many appointments are needed and how long the procedure will take.

Blood thinners

Blood-thinning medicines are not stopped for most dental extractions. The Scottish dental guidance (SDCEP) advises that for people taking warfarin, if the INR is below 4, the medicine should not be interrupted¹². Ideally the INR is measured no more than 24 hours before the procedure. People taking one or two antiplatelet medicines (for example aspirin) do not interrupt them either.

Some people take apixaban, dabigatran, rivaroxaban or edoxaban. For simple extractions of 1 to 3 teeth that leave a small wound, their medicine is not interrupted¹². More extensive extractions include surgical extraction, more than 3 teeth, or neighbouring teeth that leave a large wound. For these, your dentist may ask you to miss or delay only the morning dose on the day. These recommendations rest on very low certainty evidence. Some people have a mechanical heart valve or a coronary stent, or have had a blood clot in the last three months. For them, the medicine is not interrupted¹².

The guidance looked at people who kept taking an anticoagulant by mouth during dental treatment. It estimates that about 4 in every 100 needed an extra procedure to stop the bleeding¹². Fewer than 1 in 1,000 need hospital treatment. For these patients the guidance recommends booking treatment early in the day and letting the patient leave only once the bleeding has stopped.

Do not stop or change your medicine¹ unless your dentist or doctor tells you to. Your care after the extraction is also slightly different; it is explained below.

Osteoporosis and cancer medicines

Some medicines slow bone breakdown, such as bisphosphonates and denosumab; some cancer medicines block the growth of blood vessels. A rare side effect of these medicines is medication-related osteonecrosis of the jaw¹³. In this condition, jaw bone is exposed in the mouth, or it can be felt with a probe through a small draining channel (fistula). For the diagnosis, this has to last longer than eight weeks. If you notice a symptom, do not wait eight weeks; tell your dentist. An extraction can trigger this condition. A 2015 analysis pooled studies of this condition after an extraction. It developed in about 3 in every 100 people taking the medicine for cancer, and about 15 in every 10,000 taking it by mouth for osteoporosis¹⁴.

The Scottish guidance names two low-risk groups among people not taking systemic corticosteroids (tablets or injections). These are people treated for osteoporosis or another bone disease that is not cancer. They have taken a bisphosphonate for less than 5 years, or they take denosumab. Other groups are at higher risk¹³. They are people who have taken a bisphosphonate for more than 5 years, or take these medicines with systemic corticosteroids. They also include people taking them for cancer, and people who have had this condition before. People who took a bisphosphonate in the past, or had denosumab in the last nine months, are assessed as if still taking it.

The guidance recommends carrying out simple extractions in the usual way for low-risk patients. For high-risk patients, less invasive options¹³ are considered first; for example, if there is no infection, the root may be left in place. The guidance does not recommend giving antibiotics after an extraction to reduce this risk.

Do not stop your medicine on your own. According to the guidance, there is no evidence that interrupting a bisphosphonate before dental treatment reduces the risk¹³. That decision is made by the doctor who prescribes the medicine. Some people have a denosumab injection every six months. For them, one option is to plan an extraction that is not urgent for the month before the next dose. That dose is then delayed until the socket has healed. You can discuss this option with your doctors¹³. Any change to the timing of the medicine is decided by the doctor who prescribes it. If you are going to start one of these medicines, it is recommended¹³ that your teeth and gums are made as healthy as possible first. If that cannot be done, it is done as soon as possible after starting. For people starting them for cancer, a dental examination and any treatment needed are preferably done first.

Heart conditions and antibiotics

In England, NICE does not recommend routine antibiotics¹⁵ before dental procedures to prevent infection of the inner lining of the heart (infective endocarditis). Current Scottish advice recommends offering antibiotics¹⁶ before a dental extraction to patients at high risk of this infection. This decision is made together, taking into account the patient's preferences and the advice of their heart team. If you have a heart condition, tell your dentist before the extraction.

Risks

• An extraction cannot be undone. No new tooth grows in place of the one removed. Over time the jaw bone where the tooth was becomes thinner; this is explained below.
• Numbness and pain. According to MedlinePlus, the lip and cheek may stay numb for a few hours¹⁰; pain may start as the numbness wears off. After wisdom tooth removal the NHS says there may be some pain and swelling for up to 2 weeks¹⁷. These are expected to start improving after 1 or 2 days. Our sources give no separate time for the removal of other teeth.
• Bleeding. Some oozing for a while after the extraction is normal. For people taking blood thinners, the Scottish guidance counts simple extractions of 1 to 3 teeth that leave a small wound as low bleeding risk¹². Surgical extractions, extractions of neighbouring teeth that leave a large wound, and taking out more than 3 teeth at one visit count as higher risk.
• Dry socket. A painful condition that develops when the protective blood clot in the socket is lost. A Cochrane review gives its frequency: after 1 to 5 in every 100 routine extractions, and after 30 or more in every 100 surgically removed wisdom teeth¹⁸. According to the Scottish guidance it is most common after molar extractions¹⁹. In a review that pooled observational studies, dry socket occurred in about 13 in every 100 smokers and about 4 in every 100 non-smokers²⁰.
• Infection. Whether antibiotics are needed after an extraction is decided patient by patient²¹. Most of the trials on this question were done in healthy people having wisdom teeth removed. Because of side effects and antibiotic resistance, antibiotics are not given to everyone.
• Other, less common risks. MedlinePlus lists nerve damage, damage to neighbouring teeth or fillings, bruising, incomplete numbing, reactions to medicines and slow healing among the less common risks¹⁰. The source does not say how often these occur. We did not find a reliable rate for extractions other than wisdom teeth. For wisdom tooth removal, according to the NHS, nerve damage usually gets better but can take a few weeks or months¹⁷.
• Osteonecrosis of the jaw. A rare risk in people taking certain medicines for osteoporosis or cancer; explained above.

Benefits

• Removing an infected tooth, or one that cannot be saved, removes the source of the pain and infection coming from that tooth.
• It can make room for the teeth to line up during orthodontic treatment.

We cover the first night in detail in our article on the first night after a tooth extraction. In short:

• Bleeding. If the socket keeps bleeding, the Scottish guidance recommends biting firmly on a damp gauze pad for 20 minutes²². If you do not take a blood thinner and the bleeding has not stopped, press once more. If it still does not stop, get urgent care.
• If you take a blood thinner. The Scottish leaflet for people taking these medicines recommends pressing on the bleeding area for 30 minutes²³. If the bleeding does not stop, or starts again later, contact your dentist straight away or get urgent care²².
• Do not rinse your mouth on the first day. Guidance advises not rinsing on the day of the extraction¹⁹, and on the following days rinsing gently¹⁷ with warm salt water or mouthwash.
• The first 24 hours. Once the bleeding has stopped, avoid alcohol, smoking and exercise for 24 hours²². If you can, keep your head raised and do not disturb the clot.
• Smoking. No study has tested²⁰ when it is safe to start smoking again. This may be a good time to stop.
• Pain relief. The usual over-the-counter options are paracetamol or ibuprofen. A Cochrane overview, based mostly on trials after wisdom tooth removal, found taking the two together²⁴ among the options that worked well. Follow the instructions on the pack. For people taking blood thinners, the Scottish leaflet recommends avoiding medicines such as ibuprofen and using paracetamol²³. If you are pregnant, the NHS says to avoid ibuprofen²⁵ unless a doctor or pharmacist recommends it.
• Cold packs. After wisdom tooth surgery, applying cold to the cheek may slightly reduce pain on day 3²⁶. No effect on swelling has been shown, and the certainty of the evidence is low. Wrap the cold pack in a cloth.
• Food. Do not eat until the numbness has worn off. The NHS recommends soft or liquid food¹⁷; avoid hard and crunchy food, nuts and seeds, and very hot drinks.
• Dairy. Two randomised trials in Germany did not find that dairy products harmed healing. One was done in healthy young people having wisdom teeth removed²⁷, the other in a broader group having oral surgery²⁸. This does not prove that dairy is safe for everyone. See our article on dairy after a tooth extraction for details.
• After sedation. The NHS advises not driving for 24 hours¹⁷ after a sedative injection. If sedation is planned, see our page on conscious sedation for the rules on an escort and preparation.

When does the socket heal?

According to MedlinePlus, everyone heals at a different rate. The socket takes 1 to 2 weeks to heal¹⁰; the bone and other tissues may take longer. In a study of 27 samples taken from human extraction sockets, when new bone formed varied greatly from person to person²⁹. So no single time for bone healing can be given for everyone.

Daily care

Keep brushing your other teeth twice a day with fluoride toothpaste. For the first few days, keep the toothbrush away from the socket.

After a tooth is taken out, the bone that held it becomes thinner and lower in that area. According to reviews, most of this change happens in the first months of healing³⁰ and its amount varies with the type of tooth³¹. This change matters if an implant is planned later; an implant needs enough bone around it.

The options are:

• Dental implant. A new tooth is made on top of a part placed in the jaw bone; the neighbouring teeth are not touched. If there is not enough bone, a bone graft may be needed. Whether the implant is placed on the day of the extraction or after healing is decided after an examination. See our article on an implant straight after an extraction for details.
• Bridge. A fixed restoration supported by the neighbouring teeth. In a conventional bridge the supporting teeth are reduced. In a resin-bonded bridge the false tooth is held by a thin wing bonded to the inner surface of the neighbouring tooth. For bridges built on implants, see our article on implant-supported bridges.
• Removable denture. A denture you put in and take out. Small dentures for a single tooth are covered in our article on one-tooth dentures.
• Leaving the gap. Not every gap needs filling. When the front teeth and premolars are in place and only the back molars are missing, this is called a shortened dental arch. A review looked at trials in adults with a shortened arch, comparing a denture for the missing teeth with no replacement. It found leaving the gap promising for chewing and satisfaction³². In a study of gaps at the back of the mouth, movement of the neighbouring teeth was mostly slow and small³³. This does not apply to everyone; have the gap watched at your check-ups.

Should the socket be filled?

Sometimes, to prepare for an implant, the socket is filled with a bone substitute material (socket preservation). A Cochrane review looked at sockets filled with a graft of bovine (cattle) origin. At 6 months, the jaw ridge showed about 1.2 mm less loss in width and about 1.4 mm less loss in height³⁴. The certainty of the evidence is very low. No difference could be shown in the need for later bone augmentation or in implant failure. The review also reports complications such as delayed healing, exposure of the membrane and partial loss of the graft³⁴. So whether socket preservation is needed is judged person by person; if you are considering an implant, talk to your dentist before the extraction.

Before an extraction, do not wait if you have swelling, pain and a fever around the tooth or in your face. A dental abscess will not go away on its own⁸ and needs urgent treatment.

After an extraction, call your dentist without delay if you have:

• Bleeding that does not stop despite pressure
• Bleeding that starts again days later; the Scottish guidance treats late bleeding within a week as a possible sign of infection²²
• Severe or increasing pain and swelling that painkillers do not relieve
• A bad taste, a high temperature or feeling unwell; the NHS lists these among the signs that need urgent help¹⁷ after wisdom tooth removal
• Pain that starts 24 to 48 hours after the extraction, a socket that looks empty, and a bad taste or smell. These can be signs of dry socket; the Scottish guidance recommends getting urgent dental care¹⁹
• Numbness in the lip or chin that continues after the anaesthetic has worn off
• If you take a medicine for osteoporosis or cancer: unexpected pain, tingling, numbness or swelling at the extraction site. The guidance asks for these to be reported to your dentist¹³

Emergencies. Swelling that makes it hard to breathe, speak or swallow, or that spreads to your eye or neck, needs urgent medical help³⁵. Do not wait for a dental appointment; call 112 or go to the nearest emergency department.

This page carries no prices. A plan is prepared for you after an examination and X-rays. The main factors that shape it are:

• Whether the tooth is taken out simply or surgically
• How many teeth are taken out, and whether at the same visit
• The imaging needed
• Local anaesthetic or sedation
• Additional procedures such as socket preservation
• Check-up and stitch-removal appointments

Replacing the extracted tooth is planned separately. Ask for your plan in writing, including what it covers.