CSB extractions

Question 1

why do we do extractions

Answer 1

Caries     
Pulpal necrosis 
Perio disease     
Ortho               
Recurrent infection
Supernumerary 
Cracked teeth  
Pathology            
Trauma

Question 2

what are some systemic contra indication

Answer 2

GH
MH
haemophilics
anxiety

Question 3

what are some local factors against extractions

Answer 3

sus lesion- need biopsy
acute inflammation
no diagnosis

Question 4

what factors do we need to consider before exodontia

Answer 4

local anatomy 
access 
mobility 
root morph 
bone morph

Question 5

what do we need to consider with extractions and anatomy

Answer 5

Maxillary molars lie very close to the antrum
3rd molars lie very close to the IA nerve (especially if there are long roots)
Mandibular premolars lie very close to the mental nerve

Question 6

what do we need to warn patients of

Answer 6

All patients should be warned of pain, swelling, bleeding, bruising & infection as standard
Consent should be verbal and written and put in layman’s terms
Montgomery consent (A pt. should be told everything, not what the doc thinks they need to)

Question 7

what increases the risk of dry socket

Answer 7

Females on the pill, xerostomia, smokers

Question 8

what increases the risk of post of infection

Answer 8

Lower extractions are difficult and inexperienced operators

Question 9

what are some other risks

Answer 9

dry socket
post op infection
stiff jaw
damage to IA, mental, lingual nerve

Question 10

what are the principles of removing teeth

Answer 10

Expansion (pushing and stretching of the alveolar socket)
Separation of the PDL & gingival soft tissue
Using controlled force with elevators, luxators & forceps to expand & frac. alveolar socket

Question 11

what are luxators

Answer 11

Sharp, think instruments that fit into tight space easily that easily cut PDL
Technique sensitive, breaks easily and shouldn’t be use as an elevator
Should be pushed in the direction of the long axis of the tooth

Question 12

how do we use luxators

Answer 12

1. Finger should be placed om buccal plate and thumb on the palate
2. Use a controlled movement and push in the long axis of the tooth
3. Patient should start to feel the pocket start to expand

Question 13

describe elevators

Answer 13

The standard instrument for extractions, acts as a fulcrum and applies force to bone & tooth
Difficult to use when embrasure is too small, almost no crown left, adj. tooth has restoration
Must be careful when using as RO damage to adj. tooth

Question 14

how do we use elevators

Answer 14

Placed in between tooth + bone (& adjacent tooth)

Rotation and elevating motion is used to sever PDL fibres & expand the socket

Question 15

what are some types of elevators

Answer 15

Couplands (or chisels)     🡪 1, 2 & 3 in LDI
Cryers (L & R)                    🡪  Good for breaking inter septal bone, retained roots & 3rd molars 
Warwick James  ( L & R) 🡪 A compromise between elevators and luxators

Question 16

what do we need to consider post extraction

Answer 16

Check apices are intact and the whole tooth is out
Is anything is on the tooth (granuloma/pathology) may need to send to histology
Squeeze socket walls to encourage blood clot to form
First blood clot that forms is the best you’ll get, don’t irrigate for normal extractions

Question 17

where do we place cotton wool

Answer 17

we place a pledget into the socket- wet end into the socket and dry end out

Question 18

what are the post op instructions

Answer 18

Expect pain = Advise analgesics, pain will last 48 hours with 24 hours being the worst
Severe throbbing pain = Could be alveolar osteitis (after 24/48 hours)
Bleeding is normal, expect in saliva, maybe on pillow (bite on gauze for 30 mins)
No exercise for 24 hours
No smoking or vaping (increases RO infection) 24 hours but say don’t smoke for a week
No alcohol
No rinsing or mouth swishing (swallow blood and saliva)
Warm salt water rinses 3 tds for 5/7 days (don’t use CHX with open socket) after 24 hours
Try not to eat on that side = reduces RO food packing

Question 19

what should the dentist do after the xla

Answer 19

Compress the socket
Place wet gauze in the socket that is visible extra orally
Give post op instructions (oral and written, Inc. contact details)
Confirm bleeding has stopped and throw gauze away
Clear around the mouth
Write up notes and complete final check

Question 20

what analgesics can we recommend

Answer 20

Advise analgesics (NSAIDS ± paracetamol)
400mg TDS for ibuprofen, 1g QDS for paracetamol
Ibuprofen contra-indicated in:

Question 21

when is ibuprofen contra indicated

Answer 21

Allergies, asthmatics, elderly, kidney/renal failure, stomach issues

Question 22

what is a complication of extractions

Answer 22

Any event that would not normally occur or an unanticipated problem
This arises following a procedure, treatment or illness
A complication complicates the situation

Question 23

how do we prepare for surgery

Answer 23

Thorough history & exam to be undertaken
Know the pt. and their problem
Know your abilities & facilities
Use appropriate investigation – May need a CBCT to look for ID canal near 3rd molar
Have a diagnosis that fits the facts – reversible pulpitis needs a redress not XLA
Agree a treatment plan with the patient
Warn the patients of any complications that may arise
Follow accepted practice & use the correct instruments for practice

Question 24

what to do if something went wrong

Answer 24

Recognise it and accept it
Be open and honest with the patient
Be objective, factually accurate but sensitive
Record events in detail, accurately and honestly
Investigate if necessary - if broken tooth without a surgery, take a radiograph
Make early reasonable efforts at correction
Involve experts early if unable to correct yourself
Tell the defence organisation – burning lip during procedure

Question 25

when do we leave the apex in situ

Answer 25

There is considerable risk to structures such as nerves or antrum
Pt. declines further surgery
There is no infection
Fragment is no longer than 1/3 of root
Fragment has not been displaced from base of socket
If you do not plan to remove apex – inform patient & review after 1 month ]
If pt. is having problems re – x ray and may need surgical

Question 26

how do we recognise a fractured tuberosity

Answer 26

Audible crack of bone fracture on attempted extraction
Movement of tuberosity
Palatal tear (due to movement of bone that has fractured)
The extraction is difficult

Question 27

how do we manage a fractured tuberosity

Answer 27

Stop!
Explain to the pt. what has happened
Place a temporary dressing in the tooth to make the pt. pain free
Do not remove the mobile segment as a large OAC will be created
Refer or seek advice (speak to local hospital/maxfax on call)

Question 28

what are some predisposing factors to OAC

Answer 28

Close to sinus – write on consent form (& explain to pt. may need to close it) 
Thin alveolar bone
Periapical infection
Root morphology 
Long standing molars
Iatrogenic factors 
Traumatic extractions
Using a Couplands elevator

Question 29

what are some signs of an OAC

Answer 29

Look at radiograph to see if root is in the maxillary sinus
A visible defect between the mouth and the antrum looking with mirror
Bone fragments with smooth antral floor adhering to root of tooth
Sometimes bone may have been removed but epithelial lining still separates
DO NOT tell pt. to blow nose if you suspect OAC (If X ray indicates OAC)

Question 30

how do we investigate OAC

Answer 30

Do not probe for OAC – as may cause an OAC
If suspect get pt. to GENTLY blow nose whilst pinching nostrils
A positive result if there is no OAC
Bubbles of blood and saliva in socket due to Inc. pressure in nasal cavity
If no OAC exists but x rays indicate they do, advise no blowing of nose for several days

Question 31

signs and symptoms of OAC

Answer 31

Soft tissue proliferation around the socket
Prolapse (bulging) of sinus lining
Discharge of infected material
Reflux of fluid into nose – Drinking tea and it comes out of nose
Air escapes into mouth on nose blowing (unable to blow their nose)

Question 32

tx of oac

Answer 32

efer to a specialist treatment as minor oral surgery is required
Buccal advancement flap used to cover OAF (with/without buccal fat pad)
Other procedures are required if OAC id large
Review (after about 10 days)

Question 33

what dow e do if the pt inhales a tooth

Answer 33

Usually lodges in right bronchus due to anatomy of the bronchi
Look everywhere for tooth, floor/aspirated before subject pt. to x rays
If suspected pt. will cough vigorously
If can’t get the tooth out send to surgery

Question 34

what is the INR protocol

Answer 34

Take INR on the day or within 72 hours of the procedure
INR 4.0 or less - proceed with surgery & suture surgical into socket, ensure haemostasis
If INR > 4.0 - Refer to haematologist for advice

Question 35

what do we do if there is bleeding after an XLA

Answer 35

pressure with gauze

Question 36

what are some methods of controlling bleeding

Answer 36

Direct pressure (pressure on socket) Indirect pressure (Pressure on art leading to socket)
Suturing/ligation (closing off a blood vessel)
Cautery (works be denaturing proteins)
Local haemostatic agents (Surgicel, Kaltostat, collagen granules, fibrin foam)
Systemic agents (Vit K is used to counteract the effect of warfarin

Question 37

describe dry socket

Answer 37

Dry socket is also known as alveolar osteosis (not an infection but inflammation of the bone)
Occurs after 3% of extractions
Usually 2 – 3 days post op

Question 38

signs of dry socket

Answer 38

Halitosis and foul taste
Severe pain, may radiate and is generally not eased by analgesia
Exam reveals socket that is partly or devoid of blood clot (only greyish remains in socket)
Mucosa may be healing well around the socket but the socket itself is devoid of a blood clot

Question 39

which groups of people suffer form dry socket more

Answer 39

Smokers 
Mandibular than maxillary teeth 
Excessive mouth rinsing (especially in first 24 hours) 
Single extractions 
Traumatic/ Difficult extractions 
Increased bone density 
Females (especially taking oral contraceptives)
Poor OH
Perhaps a link to seasonal incidence

Question 40

tx of dry socket

Answer 40

Explain to Pt. (preferably warned Pt. before – there is an increased risk in smokers)
Irrigate with warmed saline –2 cases of anaphylaxis due to irrigating socket with CHX
place in socket small amount of Alveogyl obtundent dressing (non resorbable)
No need for antibiotics unless a systemic infection is suspected
Self-limiting and will heal eventually

usually recover in 4 weeks

Question 41

what antibiotics can we give in post op infections

Answer 41

Amoxicillin 500mg TDS PO (double if severe)
Metronidazole 200 mg TDS PO (double if severe)
We can use these together, if they are allergic can use clindamycin

Question 42

describe osteonecrosis

Answer 42

Caused by antirespoptive medications including bisphosphonates
BP inhibit osteoclastic resorption – decrease the rate of burn turn over

Question 43

common bisphosphonates which are prescribed

Answer 43

Alendronic acid & Risedronate sodium are most commonly prescribed oral BP’s

Question 44

what are some other increased risk of osteonecrosis

Answer 44

Increased risk with: Age, Surgical procedures, Duration of medication

Question 45

what is the tx of osteonecrosis

Answer 45

Treatment – None! 🡪 OHI, Prevention, avoidance of surgical procedures, Refer!