Dental / Tooth Removal (extraction)
The removing of teeth from the dental alveolus (socket) in the alveolar bone is a dental extraction (we also call it as tooth extraction, exodontia, exodontics, or informal tooth pulling). Dentists conduct tooth removal or extractions for a broad variety of purposes. But most frequently to remove un-restorable teeth due to tooth decay, periodontal disease, or dental trauma, particularly when there is toothache. Sometimes, there is affect on wisdom teeth (stuck and unable to develop into the mouth usually) and may trigger recurrent gum infections (pericoronitis). If the teeth are crowded in orthodontics, dentist can do sound teeth (often bicuspids) extraction to generate room so that the remainder of the teeth can get straight.
Procedure of tooth removal
Reason for tooth removal
Types of tooth removal
Healing after extraction
Hemorrhage after extraction
Type of bleeding
Assessment of the danger of nerve injury
Options to replace missing teeth
Tooth Extraction Procedure of Tooth Removal
Tooth extraction is generally comparatively simple, and generally, the vast majority can be done rapidly while the person is awake using local anesthetic injections to eliminate pain. While pain is absent due to local anesthetics, mechanical forces remain felt. For several reasons, some teeth are harder to remove, particularly linked to the place of tooth, shape of the roots of the tooth, and integrity of the tooth. For some people, dental phobia is a problem, and tooth extraction tends to be more fearful than other dental procedures like fillings. There may be need of a surgical or trans-alveolar method if a tooth is buried in the bone. This includes cutting off the gum and removing the bone that holds the tooth in a surgical drill. There is use of stitches in order to substitute the gum in the ordinary place after the tooth removal takes place.
Immediately after tooth extraction, dentist presses the tooth socket with a bite pack and the bleeding stops. Dentists generally offer advice after a tooth extraction that revolves around not disturbing the blood clot in the socket. This takes place by not touching the region with a finger or tongue, avoiding forceful mouth rinsing and avoiding harsh exercise. There should be prevention on sucking, such as through a straw suction. Bleeding may restart, or alveolar osteitis (“dry socket”) may grow if the blood clot is dislodged, which can be very painful and cause delay in socket healing. There is prohibition on smoking as it impairs wound healing for at least 24 hours and makes dry socket much more probable. Most recommend mouth baths with warm salt water that begin 24 hours after the extraction.
The dental branch that mainly deals with extractions is oral surgery (“exodontistry”). Although general dentists and periodontists often perform routine tooth extraction as it is an essential skill taught in dental schools. Periodontists are increasingly performing extractions as they usually follow up and position a dental implant.
Reason for Tooth Removal
Due to breakage or decay, the most prevalent reason for extraction is tooth damage. Additional reasons for the extraction of the tooth:
- Severe tooth decay or disease (acute or chronic alveolar abscess, such as periapical abscess–set of infected material (pus) forming at the tip of a tooth’s root). Despite reducing the incidence of dental caries globally. It is still the most prevalent reason for extracting (non-third molar) teeth, accounting for up to two-thirds of extractions.
- Severe gum disease that can influence teeth’s supporting tissues and bone structures.
Treatment of symptomatically affected wisdom teeth, the affect of which causes pathosis leading to further infection, inflammation, bone resorption.
Asymptomartic wisdom affects preventive/prophylactic removal of teeth. Although many dentists remove asymptomatically affected third molars. Both American and British Health Authorities advise against this routine operation unless there is proof of disease in the impacted tooth or closed environment. For instance, due to the significant amount of injuries arising from unnecessary extractions, the American Public Health Association introduced a policy, Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth):
- Supernumerary teeth that block the arrival of other teeth.
- Additional or malformed teeth
- Broken Teeth
- Cosmetic-removing poor-looking teeth that are unfit for restoration
- Teeth in the row of fracture
- In preparing for therapy with orthodontics (braces)
- Teeth that cannot be endodontically restored
- Prosthetics teeth that are harmful to dentures’ fitness or appearance
- Radiation therapy of the head and neck to treat or handle tumors may involve teeth removal before or after radiation treatment
- Lower cost than other treatments
- Deliberate extraction as a type of physical torture, medically useless.
- Removing the front teeth of institutionalized psychiatric patients who had a biting history was once a popular practice.
Types of Tooth Removal
Classification of extractions is as “simple” or “surgical.”
- Simple extractions
- Surgical extractions
These take place on teeth that are apparent in the mouth, generally with the patient under local anesthetic. Also this only involves the use of tools to elevate and/or grasp the visible part of the tooth. The specialist makes a typical tooth lift using an elevator and rocked back and forth using dental forceps until the periodontal ligament is breaks sufficiently and the supporting alveolar bone sufficiently enlarges to make the tooth lose enough to remove. Typically, there is slow, constant pressure application with force regulation when teeth removal takes place with forceps.
This procedure involves removing teeth that cannot be readily accessed, e.g., because they broke under the gum line or because they did not fully erupt. Surgical extractions involve an incision almost always. In surgical removal, the physician may elevate the soft tissues that cover the tooth and bone. This may also remove a drill or osteotome from some of the overlying and/or surrounding jawbone tissue. There can be tooth division into several parts to enable removal.
Anticoagulant use on tooth removal
Studies show that there is a correlation between the consumption after dental extraction of anticoagulant drugs and the quantity of bleeding. In one such assessment, various subjects, all of whom underwent dental surgery, were given oral anticoagulants. 89 out of 990 subjects (9%) had postoperative bleeding postponed and 3.5% were not under local policies regulation (‘ severe cases ‘). Other trials showed more patients with minor post-operative bleeding. However, standardization of bleeding is hard because the definitions used to categorize the magnitude of bleeding varies from research to study. Also, most trials agree that if a person frequently consumes oral anticoagulants at the moment of easy dental extraction, there is little danger of a significant bleed.
There can be continuance of therapeutic anticoagulation for easy extractions as the danger of bleeding is not high. Also, the risk of thromboembolism created by a temporary withdrawal from the anticoagulant is much greater than that of severe bleeding after extraction. However, the danger of bleeding is greater for complicated extractions (three or more teeth or numerous adjoining teeth) The dentist should also consult the physician of the patient. When organizing the operation, patients undergoing a therapy course using anticoagulants should notify their dentist.
For the patient, the dentist should draw up an individual therapy plan and contact the doctor of the patient to verify the use of the anticoagulant and the type of dose. The dentist should also consider INR of the patient. He should also refer the patient to a specialist if the patient has an INR of 4.0 or more. In the elderly (particularly after post-surgical dental extractions), the risk of hemorrhage rises as they are more vulnerable to dental caries and periodontal diseases. The dentist should also consider this. In comparison to Dabigatran, to which discovery shows has fewer postoperative bleeding occurrences, studies discovered that rivaroxaban imposes a high danger of bleeding relative to other oral anticoagulants.
There can be further minimization of bleeding hazards by the use of collagen sponges and sutures and rinsing 5 percent tranexamic acid mouthwash four times a day to boost the efficacy of oral anticoagulant drugs.
Overall, patients who use long-term anticoagulant therapies such as warfarin or salicylic acid need not stop using it before there is tooth removal. Extraction should take place using the least traumatic extraction procedures. The patients should make sure they tell their dentist or oral surgeon about any medications they take prior to the procedure.
Antibiotic use on tooth removal
Dental experts can prescribe antibiotics to decrease the risk of certain complications after extraction. There is proof that pre- and/or post-impact antibiotic use of wisdom tooth extraction decreases the likelihood of infection by 70% and decreases dry socket incidence by one third. There is avoidance of one infection for every 12 individuals who undergo treatment with an antibiotic after the wisdom tooth removal gets affect.
Antibiotic use does not appear to have a direct impact on the seven-day post-extraction manifestation of fever, swelling or trismus in the Cochrane review. Then, after taking into account the involvement biased risk with these studies the conclusion was that there is moderate overall evidence. This experience supports routine antibiotic use within the practice to minimize the risk of infection following a third molar extraction. There are still valid concerns about the potential adverse effects in patients of indiscriminate use of antibiotics. There are also concerns about antibiotic resistance growth that in practice, advise against the use of prophylactic antibiotics.
Healing after extraction or tooth removal
Bleeding or oozing very frequently happens immediately after removal of a tooth. The person biting on a gauze swab will apply pressure and a thrombus (blood clot) will form in the socket (hemostatic reaction). Common hemostatic interventions include the application of local gauze stress and the use of oxidized cellulose (gelfoam) and fibrin sealant. More often than not, dental professionals have accessible absorbent gauze, hemostatic packing material (oxidized cellulose, sponge collagen), and suture kit. Sometimes it takes 30 minutes of constant stress to stop bleeding completely.
Talking, which moves the mandible and thus reduces the stress is application to the socket takes place. This is a very prevalent reason why bleeding may not stop. This is similar to someone with a bleeding wound on their arm, instead of holding the wound intermittently every few moments when instructed to apply pressure. We sometimes first see Coagulopathies (clotting disorders, e.g., hemophilia) if there is no other surgical procedure in a person’s life, but this is uncommon. Sometimes even the blood clot dislodgment may be there, causing more bleeding and fresh blood clot formation. This may also lead to a dry socket (see complications). Several oral-surgeons routinely scrape a socket’s walls to promote bleeding in the belief that this will reduce dry socket chances. But there is no real proof that this practice works.
Healing Advancement after tooth removal
As healing advances, the possibility of further bleeding decreases and is unlikely after 24 hours. If bleeding takes place after 8-12 hours, it is referred to as bleeding after extraction. The blood clot is coated by epithelial cells that proliferate from the socket margins of the gingival mucosa and take about 10 days to cover the defect completely. As an inflammatory response occurs, neutrophils and macrophages are engaged in the clot.
Next happens the proliferative and synthesizing stage. The characterization of this is by the proliferation of osteogenic cells in the alveolar bone from the neighboring bone marrow. Bone formation begins with the extraction of the tooth after about 10 days. The outline of the socket is no longer visible on an X-ray picture after 10–12 weeks. Bone remodeling happens in the longer term as the alveolus adapts to the edentulous state as the alveolar process resorbs slowly. The degree of pneumatization of the maxillary sinus may also improve in maxillary posterior teeth as remodels of the antral ground.
Hemorrhage after extraction or tooth removal
Bleeding after extraction is bleeding occurring 8–12 hours after extraction of the tooth. Different variables lead to bleeding after extraction.
- Laceration of blood vessels
- Osseous bleeding from the canal / central vessels of nutrients
- Extraction of trauma
- Patient failure to follow the directions for post-extraction
- Platelet issue
- Disorder of coagulation / excessive fibrinolysis
- Problems caused by hereditary / medication
Type of bleeding while tooth extraction
1.Primary long-lasting bleeding – During / immediately after extraction, this form of bleeding happens because real hemostasis has not been attained. Usually, its regulation takes place by standard methods like applying stress packs or hemostatic agents to the wound.
2.Reactionary bleeding – Following the cessation of vasoconstriction, this form of bleeding begins 2 to 3 hours after tooth extraction. It may be necessary to intervene systemically.
3.Secondary bleeding – Usually, this form of bleeding starts 7 to 10 days after the extraction and is most probably due to infection that destroys the blood clot or ulcerates local vessels.
Clinical trials do not provide clear proof comparing the impacts of various procedures on post-extraction bleeding therapy. Given the absence of credible proof, based on patient-related factors, clinicians must use their clinical knowledge to determine the most suitable means of treating this disease. When choosing how to manage post-extraction bleeding, a dental professional must consider many other considerations:
- Surgical area
- Bleeding location
- Size of wound
- Bleeding extent
- Bleeding site accessibility
- Time of bleeding
If the blood pressure is below 100/60 when examining the patient and the heart rate is above 100bpm, there should be assumption of a hypovolaemic shock. The dentist should send the patient to hospital for IV blood transfusion.
Classification of Interventions for post-extraction bleeding into two primary groups:
- Local interventions
- Surgical interventions
·Involve the bleeding site to be sutured. Sutures assist to close the socket and help to bring together the gingival tissues. Dentists suggest both for an interrupted or horizontal mattress.
·If bleeding is secondary to trauma to a blood vessel, the patient may have to go to the hospital as the big vessel may need ligation and the lower vessels may need cauterization.
ii.Hemostatic non-chirurgical measures
- Involve drug use, sealants, adhesives, absorbable agents, biologics, and product mixture.
- IiiCombination of both
- In addition to suturing, if the source of pain is from the bone inside the socket, a resorbable hemostatic pack such as oxidized cellulose or collagen sponge is suggestable.
This is essential for patients with systemic bleeding causes. Local hemostatic usually do not operate well to limit their bleeding, as they only result in temporary bleeding cessation. To handle any bleeding associated with a spreading infection, antibiotics may also be there in the prescription.
If the patient is determined to be at danger of infection, the dentist may opt to prescribe antibiotics pre- and/or post-operatively.
The dentist has a variety of methods available to deal with bleeding. However, tiny amounts of blood mixed in the saliva after extraction are normal, even up to 72 hours after the extraction. However, usually bleeding will stop almost entirely within eight hours of the surgery, with only tiny amounts of blood mixed with saliva from the wound. A gauze compress will decrease bleeding considerably over a period of several hours.
Often dictated by the quantity of surgery done to remove a tooth (e.g., difficult and soft tissue surgery surrounding a tooth). Generally, a minor to moderate swelling will happen when a surgical flap has to be raised (i.e., the periosteum covering the bone is with wound). There is often increase in such swelling due to poorly cut soft tissue flap. For example, where there is tearing in the periosteum rather than cleanly raising of it above the underlying bone. Similarly, more swelling is probable to happen when one needs removal with the use of a drill.
Bruising can happen after tooth extraction as a complication. In elderly individuals or individuals with aspirin or steroid therapy, bruising is more prevalent. Bruising may take weeks to vanish.
Exposure to the sinus and oral antral interaction
This may happen when upper molars (and upper pre-molars in some patients) are extracted. The maxillary sinus lies straight above the roots of the pre-molars and maxillary molars. A bony sinus floor divides the tooth socket from the sinus itself.
This bone can vary from dense to thin, from the dent to dent, from patient to patient. It is absent in some cases and the root is actually in the sinus. There may be removal of this bone with the tooth at other occasions. Its perforation takes place during surgical removal, either. Typically, the doctor mentions this danger to patients based on radiograph assessment demonstrating the tooth’s connection to the sinus. A membrane called the Sniderian membrane lines the sinus cavity, which may or may not be perforated. If after an extraction there is exposure of this membrane but stays intact, an “exposed sinus” has happened.
However, it is a “sinus communication” if the membrane is perforated. These two circumstances will be dealt with differently.In case of sinus communication, the dentist may decide to allow it to cure on its own or may need to achieve main closure surgically, depending on the magnitude of the exposure and the patient’s probability of healing. In both cases, a resorbable material called “gelfoam” is typically placed in the site of extraction to promote coagulation and serve as a framework for accumulating granulation tissue. Typically, patients are given antibiotic prescriptions that cover the bacterial flora of the sinus, decongestants, and careful instructions to follow during the healing period.
This is mainly a problem with the development of third molars, but if the nerve is near to the surgical site, it can happen with the extraction of any tooth. Typically, two nerves are discovered in duplicate (one left and one right):
1.The lower alveolar nerve that enters the mandibular foramen and exits the mandible from the mental foramen on the sides of the chin. This nerve provides feeling to the lower teeth on the right or left side of the dental arch, as well as the feeling of contact to the right or left side of the chin and lower lip.
2.The lingual nerve (one right and one left) that branches off the mandibular branches of the trigeminal nerve and runs just inside the jaw bone, entering the tongue and giving sense of touch and taste to the right and left half of the upper 2/3 of the lingual gingiva (i.e. the gums on the inside surface of the dental arch). Such injuries can happen when teeth are lifted (typically the lower alveolar) but are most frequently caused by inadvertent surgical drill harm. Such injuries are common and generally temporary but may be prolonged or even permanent based on the sort of injury (i.e., classification of Seddon: neuropraxia, axonotmesis, & neurotmesis).
Displacement in the maxillary sinus
Displacement of the tooth or portion of the tooth (only the upper teeth). In such cases, it is almost always necessary to retrieve the tooth or tooth fragment. In some instances, the sinus cavity can be irrigated with saline (antral lavage) and the tooth fragment can be returned to the opening site through which it entered the sinus and can be recovered. Other times, in the Canine fossa, a window has to be produced into the sinus — a procedure called a “Caldwell-Luc.”
(Alveolar osteitis) is a painful occurrence that usually happens a few days after mandibular (lesser) wisdom teeth have been removed. It typically happens when disrupting the blood clot within the extraction site of the healing tooth. More probably, alveolar osteitis is a phenomenon of painful inflammation in the vacant tooth socket due to the comparatively bad supply of blood to this mandible region (which explains why dry-socket is not generally experienced in other areas of the jaw). The filling of inflamed alveolar bone can take place with food and debris, unprotected and subjected to the oral setting after tooth extraction.
Dry-socket typically causes a sharp and sudden rise in pain starting 2-5 days after a mandibular molar extraction, most frequently the third molar. For the patient, this is often highly uncomfortable. The only dry-socket symptom is a pain, which often radiates up and down the head and neck. A dry socket is not an infection and is not immediately linked with swelling as it happens completely inside the bone– it is a phenomenon of inflammation of an empty tooth socket inside the bony lining. Because dry-socket is not an infection, its rate of occurrence is not affected by the use of antibiotics.
There is some proof that rinsing with chlorhexidine before or after extraction or putting chlorhexidine gel in extracted teeth sockets offers an advantage in stopping dry-socket, but it is necessary to consider potential adverse effects of chlorhexidine.After an extraction, the risk factor for alveolar osteitis may increase dramatically with smoking.
Especially when molar extraction is involved, it is not unusual for the bones that used to support the tooth to change and in some instances, to erupt through the gums, presenting sharp edges that can irritate the tongue and cause pain. This is differentiated from a comparable phenomenon in which broken bone or tooth fragments left from extraction can also protrude through the gums. The fragments will normally work their way out on their own in the latter scenario. In the former case, the dentist can either snip off the protrusions, or the exposed bone will eventually erode away alone.
Trismus, also known as lockjaw, impacts oral cavity functions by limiting mouth opening. A double-blind clinical study was conducted to test the post-extraction trismus impact of two distinct medicines. Patients receiving IV corticosteroid had a statistically significant reduced trismus rate relative to patients receiving IV or no medication with NSAID.
Loss of a tooth
It can be swallowed or inhaled if an extracted tooth falls out of the forceps. The patient may be conscious of swallowing it or may cough, suggesting tooth inhalation. If a tooth cannot be found, the patient must be referred to a chest X-ray in the hospital. If swallowed, there is no need for action as it usually passes through the food channel without doing any harm. But if someone has inhaled it, doctor whould recover it from the airway or lung by an urgent procedure before it causes severe problems such as pneumonia or lung abscess.
Luxation of the adjacent tooth
During the extraction process, the application of force must be strictly restricted to the tooth requiring extraction. Most instances of surgical extraction processes involve the forces to be diverted from the tooth itself to fields such as bone surrounding the tooth to guarantee appropriate bone removal prior to further processing in the extraction operation. Either way, the forces applied by different tools during both easy and complex surgery may loosen the teeth present either in front of or behind the tooth depending on the direction of effect and place of the force being applied, and only if the forces divert from the real tooth requiring extraction. Such deleterious forces may weaken adjacent teeth’s anchorage from within their bony socket, resulting in adjacent teeth being weakened.
Extraction of the incorrect tooth
Misdiagnosis, modified tooth morphology, defective clinical examination, bad patient history, undetected/unmentioned prior extractions that might predispose the operator to consider another tooth as a duplicate of the one earlier obtained are a few causes of extraction of the incorrect tooth.
Jaw osteonecrosis is slow bone destruction at an extraction site. A case-control study of 191 instances and 573 checks was used to know the connection between jaw osteonecrosis and previous use of bisphosphonate drugs frequently prescribed for osteoporosis treatment. All respondents were over 40 years of age, mostly female, and for six months or longer had been taking bisphosphonates.
The existence of jaw osteonecrosis was noted by the earlier diagnosis of the participating group by dentists and the medical records of the patient being controlled. Reports showed that females who have been using bisphosphonates for more than two years are ten times more probable to experience jaw osteonecrosis, while females who have been taking bisphosphonates for less than two years are four times more probable to experience jaw osteonecrosis than females who have not been taking bisphosphonates. To avoid osteonecrosis, it is therefore highly essential to report all medicines used to the dentist before extraction.
Assessment of the danger of nerve injury
When considering nerve injury after removal of mandibular third molars (bottom wisdom teeth), there are particular variables that need to be considered. The molar position is a significant risk factor for inferior injuries to the alveolar nerve. Horizontally affected molars present a greater danger of nerve injury as the depth of the molar that has been affected increases. In addition, the most significant factor for the lower forecast of alveolar nerve injury is the closeness of the root tips to the mandibular canal.
After third molar extractions, many drug therapies are accessible for pain management, including NSAIDS (non-steroidal anti-inflammatory), APAP (acetaminophen), and opioid formulations. Whereas each has its own pain-relieving efficacy, they also have adverse effects. Ibuprofen-APAP combinations have the biggest effectiveness in pain relief and reduction of swelling along with the fewest adverse effects, according to two physicians. In those who have certain medical circumstances, taking either of these agents alone or in conjunction may be contraindicated. For instance, it may not be suitable to take ibuprofen or any NSAID in combination with warfarin (a blood thinner). There are also gastrointestinal and cardiovascular dangers associated with extended use of ibuprofen or APAP. There is proof of high quality in the management of postoperative pain that ibuprofen is superior to paracetamol.
In order to maintain the dental alveolus (tooth socket) in the alveolar bone, socket conservation or alveolar ridge conservation (ARP) is a method for reducing bone loss after tooth extraction. A platelet-rich fibrin (PRF) membrane comprising bone development enhancing components is put in the wound at the moment of extraction or a graft material or scaffold is positioned in the socket of the extracted tooth. The socket is then straight stitched or coated and sutured with a non-resorbable or resorbable membrane.
Atraumatic extraction or tooth removal
Atraumatic extraction is a novel method for removing bone and surrounding tissues from teeth with minimal trauma. It is particularly helpful in patients with high susceptibility to complications such as bleeding, necrosis, or fracture of the jaw. The bone may also be preserved for subsequent positioning of implants. Techniques require minimal use of forceps that harm socket walls and rely on luxators, elevators and syndesmotomy instead.
Options to replace missing teeth
There is a gap remaining after dental extraction. The alternatives for filling this gap are frequently reported as Bind, and the decision is made on the basis of several variables by dentist and patient.
Fixation with adjacent teeth
For a standard bridge, generally there is drilling need on one or both sides of the gap (average lifespan of approximately 10 years). Conservative bridge preparation (average lifespan of about 5 years) may cause neighboring teeth suffer minimal. Expensive and complicated therapy that is not suitable for all cases e.g., significant gaps in the back of the mouth will still resorb Alveolar bone, and a hole may ultimately appear under the bridge.
Attachment with jawbone. Maintains alveolar bone, otherwise there would resorption. Usually longer lifespan.
Costly and complicated expert requirement. May involve processes like bone grafting. In tobacco smokers, relative contraindication.
In comparision to to bridge and implant, often an easy, fast, and comparatively inexpensive therapy. Usually, there’s no other teeth drilling need. Replacing many teeth with a denture is much easier than placing numerous bridges or implants.
No resolvement of Denture. Over time, periodontal disease worsens unless there is healthy oral hygiene level and soft tissue damage may take place. Potential compared to no denture for mildly accelerated resorption of alveolar bone. Potential for bad tolerance in people with gag reflex, xerostomia, etc.
Nothing (i.e. missing tooth is not replaced)
Often decision for other medicines due to cost or absence of motivation. Part of a shortened dental arch scheme that revolves around the reality that not all teeth are the need for eating comfortably and that for ordinary function only the incisors and premolars need maintenance. Usually, this is option if owing to a small place, the reason for tooth removal is due to affected wisdom teeth or orthodontics.
After the tooth is lost, alveolar bone slowly resorb over time. A potential concern for esthetics. Potential for adjacent teeth drifting and rotation in the gap over time.
History of tooth removal
Historically, a range of diseases treatment has taken place with dental extractions. Association of chronic tooth infections were often made with a multitude of health issues before the discovery of antibiotics. Therefore, removing a diseased tooth was a prevalent procedure for multiple medical circumstances. Dental extraction instruments dating past several centuries. Guy de Chauliac created the dental pelican in the 14th century, the use of which took place in the late 18th century. Dental key was substitute of pelican the substitute of which came up in the 19th century as contemporary forceps. Because dental extractions or tooth removal can differ significantly in complexity. There is a broad range of tools available to tackle particular circumstances based on the patient and the tooth. To achieve forced confessions, for example, tooth extraction was rarely in use as a technique of torture.
In Europe, traveling dentists performed tooth extractions at city exhibitions until the early 20th century. Sometimes they had musicians with them playing loud enough to cover their teeth obtained from the people’s cries of pain. One of these traveling dentists claimed that he had extracted 475 teeth in an hour in 1880 in Pyrénées-Orientales (France).
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