Introduction to Tooth Extraction

• Ideal tooth extraction:

  • Painless
  • Topical anaesthesia
  • Local anaesthesia (+/- sedation [inhalation or intravenous])
  • General anaesthesia
  • Influenced by:
  • General health
  • Co-operation/anxiety
  • Complexity of treatment
  • Referral times
• Ideal tooth extraction:

  • Removal of whole tooth or root
  • Simple extraction (intra-alveolar)
  • Forceps
  • Elevators
  • Luxators
  • Surgical extraction/MOS (trans-alveolar)
  • Mucoperiosteal flap
  • Bone removal
  • Tooth division
  • Tooth removal (elevators/forceps)
  • Sutures
• Ideal tooth extraction:

  • Removal of the correct tooth
  • Minimal trauma to investing tissues
  • Instruments are weapons
  • Technique before power
  • Support surrounding tissues
• Ideal tooth extraction:

  • Optimal wound healing
  • Local factors
  • Blood supply (e.g. mandible has much poorer blood supply than maxilla)
  • Integrity of tissue (e.g. someone with gingivitis will heal worse than someone with healthy gingiva)
  • Smoking
  • Systemic factors
  • Age (the younger you are, the quicker you heal)
  • Diabetes
  • HIV/AIDs
  • Chemotherapy
  • Steroids
• Indications for extraction:

  • Caries can lead to symptomatic irreversible pulpitis, which can lead to acute apical abscess
  • Periodontal disease -> bone loss
  • Pericoronitis - partly erupted teeth
  • Impacted teeth
  • Trauma
  • Teeth
  • Jaws
  • Orthodontics
  • Overcrowding
  • Retained deciduous teeth
  • Supernumerary teeth
  • Balancing extractions
• Indications for extraction:

  • Involvement in pathology
  • Cysts
  • Tumours
  • Prophylaxis
  • Pre-radiotherapy/chemotherapy (osteoradionecrosis)
  • Pre-organ transplantation
  • Pre-bisphosphonate therapy (MRONJ - medication related osteonecrosis of the jaw)
  • Pre-heart-valve surgery (endocarditis)

  Any tooth infections could get out of hand in these cases or the healing could be compromised due to their treatments.
• Contraindications for tooth extraction:

  • Usually temporary
  • Medically unsuitable for surgery
  • Bleeding tendency (anti-coagulation, haemophilia)
  • Unstable cardiac disease (recent MI, unstable angina)
  • Radiotherapy/chemotherapy
  • Immunosuppression
  • Pre-operative assessment is key along with consultation with appropriate physicians
• Patient assessment: history -> examination -> further investigations -> diagnosis -> treatment plan
• History:

  • Complaint
  • "Toothache in lower back tooth"
  • Asymptomatic
  • History of presenting complaint
  • Dental history
  • Previous treatment for tooth in question
  • Previous extractions
  • Anxiety

  Provisional diagnosis

  Confirmation of CORRECT TOOTH is essential!!

  • Medical history
  • Systems review (CVS, liver, respiration, diabetes, etc)
  • Bleeding risk
  • Medications
  • Allergies
• History:

  • Complaint
  • "Toothache in lower back tooth"
  • Asymptomatic
  • History of presenting complaint
  • Dental history
  • Previous treatment for tooth in question
  • Previous extractions
  • Anxiety

  Provisional diagnosis

  Confirmation of CORRECT TOOTH is essential!!

  • Medical history
  • Systems review (CVS, liver, respiration, diabetes, etc)
  • Bleeding risk
  • Medications
  • Allergies
  • Social history
  • Alcohol
  • Smoking (smokers more likely to get dry socket)
  • Occupation
  • Living circumstances (need to know in case anaesthetic will alter their consciousness in any way)
• Examination:

  • Extra-oral
  • Age
  • General health
  • Swellings
  • TMJ (access/trismus)
  • Lymph nodes (lymphadenopathy)
  • Intra-oral
  • Soft tissues
  • Hard tissues (caries, mobility)

  Provisional diagnosis

  Confirmation of correct tooth is essential!!
• Further investigations:

  • Patient
  • Blood tests
  • Medical consultation
  • Mouth
  • Radiographs (periapical, DPT, CBCT)
  • Vitality tests (ethyl chloride, gutta percha, EPT)
  • TTP tests to reproduce "familiar" pain
  • When tapping for TTP test, make sure to tap surrounding teeth and opposing teeth too
  • Periodontal assessment (BPE, full mouth chart)
• Radiographs:

  • Indications
  • Root morphology (number, size, shape, position, pathology)
  • Local bone structure (sclerosis, bone loss)
  • Locate important structures (inferior dental canal, mental foramen, maxillary sinus)
  • Assess difficulty of extraction - possible surgical extraction
  • Displaced/impacted teeth
  • Management of associated pathology (fractured roots, fractured jaws, apical granulomas, cysts)
  • Medicolegal

  Definitive diagnosis

  Confirmation of CORRECT tooth!

  • Contraindications
  • Pregnancy
  • Over-exposure
• Treatment planning:

  • Treatment options
  • Consent
  • Verbal
  • Written
  • Definitive treatment plan

  Confirmation of CORRECT tooth!!

  • Pre-needle time out procedures
  • STOP before you block
  • Pre-extraction time out procedures
  • Time out before you take out