Tooth loss and dental extractions have existed for centuries with the latter being the main tool for providing relief from dental pain and removing diseased tissues (Torabinejad). There was an estimated 50 million dental extractions performed in the United States in 1979 (Bullock). With the increased number of people living in the United States for a longer period of time, the occurrence of dental extractions and tooth loss has certainly risen exponentially. Unfortunately, tooth loss, whether it is through dental extractions or other means, has long term clinical sequelae associated with it. Osteonecrosis of the jaw, bacteremia, orbital cellulitis, and other psychological and physiological clinical sequelae that impact the well-being of the patient will be discussed.
Osteonecrosis of the jaw (ONJ) is defined as the presence of exposed bone in the mouth that fails to heal after appropriate intervention over a period of 6 to 8 weeks (Reid), and results in chronic osteomyelitis with areas of bone necrosis. Most commonly affecting the mandible (Bagan), patients with ONJ experience symptoms that range from painless exposed bone to severe jaw pain (Sambrook). The majority of cases of ONJ have been found to be initiated and associated with tooth extraction procedures as a result of the introduction of oral flora to the exposed jaw bone that prevents healing and becomes infected (Ruggiero).
In addition to tooth extractions being a precipitating event to ONJ, it has been found that ONJ occurs in patients who have previously undergone chemotherapy treatment for cancer and take bisphosphonate medications to counteract the effects of osteoporosis. Bisphosphonates are used for cancer treatment and osteoporosis because of its anti-angiogenic properties and ability to inhibit osteoclast action, respectively. This in turn manages the hypercalcemia that is seen in bone disease (Bagan).
ONJ is a pathological condition that has long-term negative effects on patients. Several studies have created protocols and suggestions in order to prevent the condition from occurring. An obvious suggestion is to prevent the need for tooth extractions in the first place. Regular professional dental cleanings at least every six months with proper oral hygiene that consists of brushing at least twice a day and flossing once a day would go a long way in preventing dental disease and potentially completely eliminate the possibility of ONJ in cancer patients. If the dentist is aware that the patient has to undergo chemotherapy and use bisphosphonates, dental treatment of the patient before beginning bisphosphonate therapy to reduce the need for extractions during bisphosphonate therapy has been found to be effective in preventing ONJ. Unfortunately, patients undergoing active chemotherapy and bisphosphonate treatment can also present to the dental office with symptoms that require dental extractions. In these instances, it is recommended that extractions be avoided. If extraction treatment is absolutely necessary, informed consent must be obtained and the treatment must be performed under antibiotic prophylaxis with minimal trauma (Sambrook). To prevent the manifestation of ONJ after the procedure, patients should be routinely recalled for professional oral hygiene and be prescribed chlorhexidine mouthwash and gels (Lodi).
In addition to ONJ, bacteremia has been found to be another example of long term clinical pathology that can occur after tooth loss through dental extractions. Defined as the presence of bacteria in the blood, bacteremia has been determined to be caused most often by dental extractions due to its invasiveness and introduction of blood to oral flora that can eventually find its way back into systemic circulation through the ulcerated crevicular tissue surrounding the tooth (Lockhart). The resulting effects can take the form of bacterial endocarditis, septic shock, and death if left untreated (Lockhart).
Just like with ONJ, bacteremia as a result of tooth extractions can be avoided through the prevention of dental disease through proper oral hygiene. In instances where this is not possible and dental extractions are needed, antibiotic prophylaxis with penicillin, amoxicillin, or erythromycin before and after the procedure has been shown to be effective in eliminating or minimizing bacteremia in both adults and children (Coulter).
ONJ and bacteremia have been discussed extensively through numerous studies. Other long term clinical pathologies as a result of tooth loss exist such as orbital cellulitis. Orbital cellulitis is an infection of eye tissue posterior to the orbital septum that can result in blindness and death (Bullock). In Bullock’s study, the incidence of orbital cellulitis with regards to dental extraction was most common with maxillary molar extractions. This was due to the proximity of the maxillary molar roots to the paranasal sinus. Upon extraction, the floor of the sinus was perforated which allowed for the introduction of oral flora bacteria into the cavity. Due to the intimate anatomic relationship of the paranasal sinus to the orbit, the bacteria were able to travel through the vasculature and cause orbital cellulitis (Bullock).
The long term clinical sequelae described above are mainly, if not strictly, observed as a result of tooth loss through surgical extractions. Teeth can also be removed from the oral cavity naturally and through trauma. These cases produce negative long term clinical effects that are not as detrimental to the patient as the ones mentioned above.
Space loss occurs through the loss of dentition. Most notably, the premature loss of primary maxillary first molars results in the mesial eruption of premolars, impaction of permanent canines, and reduction in arch length (Northway). In addition to the tilting of adjacent teeth, space loss can also result from the hypereruption of dentition into the space from the opposing arch. Periodontal problems, disruption of occlusion, and increased risk for caries development all result from the adaptation of dentition in the oral cavity to the new space created by the loss of a single tooth (Shugars).
The effects of alveolar ridge resorption can be considered long term clinical sequelae when prosthodontic treatment is involved because prosthodontics requires sufficient alveolar bone volume in order to have successful results (Schropp). Schropp’s study stated that up to 50% of alveolar bone loss occurs after the loss of a tooth. Not only does the volume and thickness of the alveolar ridge decrease, but the overall arch length decreases as well (Pietrokovski). All three of these factors present challenges for prosthodontic treatment and the long term oral function of patients.
Long term clinical sequelae cannot be limited to physiological characteristics. Psychological issues as a result of tooth loss must also be taken into account. Patients who experienced tooth loss exhibited qualities that included lowered self-confidence, dislike of appearance, and grief (Davis). Dietary choices, food enjoyment, and daily life activities of patients were also affected (Davis). The effects of these issues on top of other mental issues described in other studies can have a detrimental effect on the mental well-being of patients.
With the cases of ONJ, bacteremia, and orbital cellulitis, the long term clinical effects have a negative impact on the physiological state of patients that can ultimately result in death if unaddressed. Tooth loss can also result in clinical sequelae that are not as debilitating including alveolar bone resorption and space loss. Finally, the psychological aspect of patients can be affected and result in mental qualities that include lowered self-confidence, grief, and dislike of appearance. In conclusion, the effects of tooth loss regardless of method are broad and incorporate both the physiological and psychological states of those affected. Therefore, it is essential that both the dental practitioner and patient be aware of the consequences of dental extractions and other methods of tooth loss in order to be able to predict the resulting long term clinical effects.

References

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