How does the Dentist Diagnose my Problem?

When you first present with symptoms, you may have an inkling that an extraction is necessary but you won’t really know until you have been assessed fully by the dentist. The tooth may just need a filling; it may need a crown or it may be able to be saved with a root canal treatment.

The examination/consultation procedure below will help in determining if an extraction is needed.

Your dentist is a master of filtering information to rapidly to diagnose your problem. Some diagnoses are obvious, others are not, so it may not be necessary to ask or do all of the things listed below- it will just depend on the case and what pieces of the puzzle are needed to identify the issue.

• Take a full medical history or check your records.

• Take a full history of your problem (the ‘presenting complaint’)

(i) What does it feel like? An ache, sharp pain, throbbing etc.

(ii) When did it start? How often it comes on? Is it constant?

(iii) What makes it better or worse? Anything that brings on the pain- hot or cold or sweet? How long the pain lasts?

(iv) Do painkillers relieve it? Does it disturb your sleep?

(v) Is it one tooth or can’t you tell?

(vi) And other more specific questions to zone in on the issue.

The answers you give to these questions and what they actually mean in relation to your tooth are discussed in detail in Toothache diagnosis.

• Look in your mouth at the problem tooth or area (clinical assessment) for any of the following:

(i) Broken or fractured teeth

(ii) Signs of Dental Caries or decay

(iii) Signs of gum disease

(iv) Signs of an abscess- swellings, sinus etc.

(v) Tooth wear

(vi) And any other number of potential problems or conditions which coincide with your description of the problem.

• Perform any special tests to confirm or disprove the potential diagnosis, this may include:

(i) Vitality testing

(ii) Palpation

(iii) Percussion

(iv) Probing of pocket depths

(v) Mobility

(vi) X-rays (radiological assessment)- see below:

For a discussion of what each of these is and how it is useful, see – What special tests does the dentist do?’

How is my Tooth Assessed for Extraction? Are X-rays Necessary?

The dentist has performed an examination (outlined above), done any necessary special tests and has identified the offending tooth. They will have taken an X-ray and discussed which treatment options are available, the likelihood of success and the various risks and complications of each. We are assuming that a decision has been made to extract the tooth…

As with most things in dentistry, a tooth will be assessed for an extraction, both clinically and radiographically, meaning the dentist will look at it directly in your mouth and then study an X-ray of it. Both provide information and are used together to paint an accurate picture of situation.

An X-ray is vital in assessing your tooth for extraction. There are times when the tooth is wobbling so much, that you can almost take it out with your fingers and for that, it won’t provide much extra information but is still an important medico-legal document for the dentist.

A view that shows the full extent of the roots is necessary. This may be a Peri-Apical X-ray or an OPG.

Things to note on the X-ray are:

• Extensive decay. This may make the tooth hard to grip or prone to fracture.

• The thickness or density of the bone. Since in order to remove the tooth, you must expand the bony-socket, the thicker your socket is, the more difficult this becomes. Bone in the lower jaw (mandible) is more dense and stronger than the upper jaw (maxilla)- for this reason it tends to be better for implants, but not so for extractions.

• Large fillings. These can weaken a tooth and make fracture more likely or be potentially dislodged from the tooth next door.

• Root filled teeth. These are perhaps the most likely to break or fracture during the extraction due to their brittle nature. If they have a post crown that has come out the resulting hollowed out canal, can make this even more likely.

• Number of roots. In general it is easier to remove a tooth with one root compared to a tooth with multiple roots. For example an incisor compared to a molar.

• Size and shape of the roots. If the roots are fused together, the tooth will generally come out easier. If they are splayed and pointing in various directions, it will be harder. If they are particularly curved or have very bulbous ends they may take a bit of extra work, or need to be taken out in pieces or via a surgical approach.

• Periodontal disease makes removal of teeth easier- the more extensive the loss of bone supporting your teeth, the looser your teeth are to begin with and the easier it will be to extract them. Sometimes in severe cases, ‘if it wasn’t for the pain side of it’- you could probably take it out with your fingers.

• Anatomy. Is the tooth close to any important anatomy that would make complications during an extraction more likely?

• The antrum. This is the air sinus in your upper jaw which the roots of upper molars sometimes get very close to, or even extend into. This is important because a possible complication is an oro-antral communication, or fistula.

• The inferior dental nerve (ID nerve). This nerves supplies sensation to all your bottom teeth and to your lower lip via the mental nerve (see below). It is the nerve that goes numb when an ID block injection is given for a filling in your lower teeth. The roots of your wisdom teeth can lie close to this nerve, so it is important to look at the proximity and assess the risk.

• The mental nerve. The ID nerve splits into the mental nerve about level with your lower pre-molars, coming out to supply sensation to your lower lip.
• Difficult previous extractions. All the points above are important in determining the difficulty of an extraction and risk of complications. However, if you have had a tooth removed previously and it was a ‘toughie’, this could suggest that your teeth may generally be a little more stubborn to take out.