Extractions used to be the cornerstone of dentistry. My nanna tells the story of being a child in the 1920s, given a coin to take herself down to the dentist to have an aching tooth pulled out, then walking herself home again. For lots of people, it seems the obvious choice when a tooth is painful, and particularly when money is tight. Completely removing a tooth or teeth is not always the best option, and I spend a lot of time discussing the risks and benefits with my patients before we decide to "pull it out".
So why extract a tooth at all? Sometimes it's just not saveable. If there's not enough tooth left to support a filling or a crown, there may be no point in trying to fix it. If the tooth has cracked all the way through down the root, no amount of restoring or root canal therapy will get it back in working order. Sometimes the tooth is not that useful so not worth the trouble of saving, such as in wisdom teeth.
If keeping the tooth is an option, there's lots of things to consider. Here's the checklist I run through each time:
Cost
Extracting a tooth is often less costly in the short term than carrying out extensive treatment. However, if the tooth is important to the patient for aesthetics or function there's a good chance they'll want to replace it with something. Then the cost of the replacement also needs to be taken into account, which often brings the final cost of having the tooth removed to much more than saving it.
Convenience
Having a tooth removed is usually a one-visit procedure, where as more complex treatment to save a tooth might take 4 or 5. For people who have difficulty getting to the dentist this is a big consideration. This might include those who live in remote locations, or people who rely on others to bring them in such as nursing home residents.
Risk of short-term complications
How likely is the patient to have problems with bleeding or infection afterwards? Sometimes this can be predicted, but sometimes it's a surprise, so the patient needs to be aware that things might not go according to plan and it's nobody's fault. Does the patient have any general health conditions which will impact this, or even their ability to heal after the extraction? Is the patient planning on a plane trip that evening? How about the tooth itself, does it have 17 curly roots all wrapped around each other or one nice smooth root meaning it will pop out like a champagne cork? Are the roots of the tooth near any important structures which could be damaged, like the floor of the sinuses or large nerve bundles? All this needs to be weighed up with the risks of the alternative treatment being considered.
Risk of long-term complications
After the danger of immediate complications is over, there are long-term consequences to consider if the tooth is not replaced with something. If the tooth was previously useful, the patient may find they can't chew as efficiently, their speech may be affected, and they way their face looks may change, (even if it's a back tooth). Over many years, the teeth either side of the gap can start to tilt into the space, causing problems with the bite and keeping unnatural contours clean. The opposing tooth can also start to erupt through further once there's no longer anything for it to bite against, in a process known as supra-eruption.
Condition of the rest of the mouth
As well as the patient's general health, their overall oral health needs to be taken into consideration. There's more value in making the extra effort to save a tooth in a mouth which is otherwise completely healthy. It makes sense to choose to extract a sore tooth in a person whose mouth is in terrible condition and likely to need multiple other extractions in the near future, or indeed at the same time.
We really are fortunate to be alive in a time and place where there are many viable alternatives to pulling out misbehaving teeth. It can be a complicated decision to come to, for both dentist and patient. In general, if a tooth is saveable, you're better off with it in your head. That leaves you with the option of extraction and replacement even if initial treatment is unsuccessful, but once it's gone you can't put it back in!