Rationale for extractions

Question 1

Demonstrate the application of ICDAS and radiographic assessment to treatment planning

Answer 1

• Usually a radiographic code 4 and 5 are considered for extractions
• It depends on whether the tooth has irreversible pulpitis - if so, then an extraction may be considered

Question 2

List the 4 main indications for extractions

Answer 2

1. Odontogenic infections
2. Due to dental trauma
3. Unrestorable/hopeless prognosis
4. Other indications (referral to specialist)

Question 3

For the 4 main indications for extractions, list their subtypes

Answer 3

1. Odontogenic infections
• Due to dental caries
• Deep carious lesions extending into the pulp
• Irreversible pulpitis
• Pulpal necrosis

2. Due to dental trauma
   • Complicated crown-root fracture/root fracture involving pulp (may need referral to dentist/specialist)
   • Pulp necrosis with abscess formation after trauma
3. Unrestorable/hopeless prognosis
   • Badly fractured/broken down teeth
   • Retained roots
   • Internal Resorption/External Resorption
4. Other indications (referral to specialist)
   • Supernumerary/supplemental teeth
   • Orthodontic reasons (primary or permanent teeth)
   • Ankylosed primary teeth that are blocking the eruption of permanent teeth
   • Severely infraoccluded (submerged) teeth

Question 4

State 6 contraindications for extractions

Answer 4

• Facial swelling (acute infection). Local anaesthetic is difficult to administer and often ineffective, antibiotic therapy is required before extraction
• Bleeding disorders (e.g. haemophilia)
• Heart conditions (due to high risk of bacteraemia in the extraction socket)
• Patients taking bisphosphonate may need to have certain dental treatment donei.e. extractions prior to the start of bisphosphonate treatment to avoid possibility of complications(MRONJ)
• Uncontrolled asthma
• Malignancies such as leukemia and lymphoma (due to development of secondary bleeding disorders and immunocompromisation)

Question 5

State what to give children who experience pain

Answer 5

• Paracetamol for general pain relief

* Panadol and nurofen

Question 6

Discuss the process of conducting extraction of primary teeth

Answer 6

Extra- oral exam
• Does patient look well? Does patient have a temperature?
• If patient has a temperature, it can be due to the tooth or it can be due to an unrelated systemic medical condition
• Find out the cause and refer patient accordingly
• Check for extra oral swelling, facial asymmetry
• Palpate to check for enlarged lymph nodes

Intra-oral exam
• Check all teeth - carious lesions
• Check for mobility
• Palpation -check for soft tissue swelling
• Abscess /Fistula
• Palpate buccal/lingual vestibule and attached gingiva for diffuse swelling
• Percussion testing
• Positive on percussion indicates periodontal involvement or food impaction
• Be careful not to percuss with the mirror handle if the patient has complained the tooth is sore to touch/bite on as this will aggravate the pain and upset patient

Question 7

Describe the importance of informed consent for dental treatment of children

Answer 7

• Provide parents with relevant information on diagnosis and treatment planning. Identify tooth to be extracted to the parent and explain reasons for extraction, e.g. irreversible pulpitis
• Explain to parent the risks and complications of the procedure. “Mild pain may occur after the LA wears off. This pain can be managed by a normal dose of over-the-counter analgesics such as Panadol”
• Child may need to supervised after extraction to prevent accidentally biting soft tissue (lips, tongue and inside of cheek) • There may be space loss. Eruption of the permanent tooth may be delayed resulting in a loss of space
• Parents should be given the opportunity to ask questions
• Written consent must be signed by the patient’s parent/ legal guardian prior to start of the procedure