Reasons for Extractions

Exodontia, commonly known as a dental extraction, is where a tooth or its roots are removed from its socket within the alveolar ridge. The tooth being removed could be a deciduous or a permanent tooth. Most dental practices undertake the removal of straightforward extractions on a daily basis using a local anaesthetic to provide pain-free treatment. Some patients will not tolerate a tooth being removed with a local anaesthetic only. In this instance the clinician will either refer the patient to another specialist dental surgery or local hospital where the patient can receive either a form of conscious sedation or a general anaesthetic. Naturally, if the dental surgery provides conscious sedation in house the patient may be treated within. Patients have teeth extracted for various reasons:

• • Pain: to relieve the patient of pain.
• • Alveolar abscess: to remove the infection to prevent a recurrence.
• • Caries: the tooth is un-restorable.
• • Impaction: the patient has experienced several episodes of pericoronitis (infection) attributed to food packing in this area due to a partially erupted or impacted tooth.
• • Failed root canal therapy: several attempts have been undertaken to root fill the tooth but have failed.
• • Orthodontics: to allow the remaining teeth to be aligned or retracted.
• • Orthognathic: the wisdom teeth are removed prior to the pre-surgical orthodontic stage.
• • Periodontal disease: the tooth/teeth have become mobile due to the supporting structures of the teeth being destroyed.
• • Prosthetics: if a patient has a tooth which isn’t stable that may hinder the wearing of a partial denture, the tooth may be extracted.
• • Cosmetic: if a tooth or teeth are not aesthetically pleasing then patients may choose to have them extracted so that they can be replaced with a bridge, denture or implant depending upon specific factors.
• • Patient choice: the patient may not be able to afford the cost of restorative treatment or may not be able, or want to, commit to the number of appointments that would be necessary for restorative work to be carried out.
• • Supernumerary teeth: where there is associated pathology present, a supernumerary tooth could delay tooth eruption or during orthodontic treatment it could increase the risk of caries occurring.
• • Deciduous teeth: these may be extracted to allow their permanent replacements to erupt.

Pre- and Post-Operative Instructions

Verbal and written pre- and post-operative care instructions are provided to patients to avoid any unnecessary complications. Pre-operative instructions comprise the following:

• • Clean teeth prior to attending, as a clean mouth will heal more quickly.
• • Have a light snack a few hours before their appointment to avoid any complications such as a faint.
• • Take routine medications unless otherwise advised by the clinician to avoid their medical condition manifesting in the dental surgery.
• • Bring any reliever medications that they may require for their medical condition (e.g. an inhaler for asthma).
• • Bring someone with them for support.
• • Bring a portable music system if they wish to, such as an iPod.
• • Take the rest of the day off from school or work so that they can rest.
• • Have some pain relief at home that is normally taken for a headache, but not aspirin as this is an anti coagulant (blood thinning agent).

Patients should also be advised that they will receive an appropriate amount of local anaesthetic to have the tooth removed, which will provide them with pain relief.

Post-operative instructions include:

• • Avoid poking the socket with their tongue or fingers or bite their cheeks and lips, as this will result in trauma.
• • Avoid eating soft or spicy foods or those which could easily become trapped within the socket.
• • Avoid rinsing their mouths out for 24 hours to avoid clot disturbance.
• • Have hot salt mouth washes (HSMW) after every meal for at least a week to keep the socket clean and promote healing. To make a HSMW, the patient should add a teaspoon of salt to comfortably hot water.
• • Rest when at home, but to avoid taking a hot bath or sitting by a fire or in an over-heated room.
• • Refrain from exercise or drinking alcohol or hot drinks for at least 24 hours after the procedure, as this will raise the blood pressure resulting in clot disturbance and possible haemorrhage.
• • Refrain from smoking for as long as possible to prevent a dry socket occurring.
• • If bleeding occurs, to roll up the swab provided and bite down hard for 20 minutes. If the bleeding persists, contact the dental surgery.

Coupled with the above instructions, patients should be advised that they will feel numb for a few hours after the procedure and may experience some pain, bruising and swelling following the extraction.

Straightforward Extraction

Procedure

Prior to a straightforward or simple extraction taking place, the maxillofacial surgeon must take the appropriate X-ray to aid diagnosis and treatment planning. They will then discuss the options with the patient in order for them to give consent. Once consent has been taken, the patient may or may not have the tooth extracted that day. If the patient is asked to attend another appointment for the extraction to be undertaken, they will be provided with pre-operative verbal and written instructions. If the patient has the tooth extracted during that appointment, they are provided with post-operative care instructions.

On the day of the extraction consent will be checked, along with ensuring that the correct patient is present. The patient’s medical history is re-checked and any changes noted. Personal protective equipment will be placed on the patient and a brief explanation of the procedure provided. For pain and anxiety control the clinician may apply a topical anaesthetic prior to administering the local anaesthetic. The patient is constantly monitored and reassured. The area surrounding the tooth to be extracted is checked to ensure that it is numb.

Once the maxillofacial surgeon is happy that the local anaesthetic is active, they will use either a luxator (Figure 5.1) or Coupland’s chisel (Figure 5.2) to break the periodontal ligaments to detach them from the alveolar bone. Once this is completed, the maxillofacial surgeon will use the appropriate dental extraction forceps to remove the tooth/teeth. The patient will be advised that there will be some pushing, wiggling and pulling taking place.

Once the tooth has been removed, it will be inspected to ensure all the roots are intact and a rolled-up sterile swab (Figure 5.3) placed in the socket area. The patient will be asked to bite down on the swab for 15–20 minutes to allow haemostasis to take place. During this time the verbal and written post-operative care instructions are provided. Once haemostasis has been achieved, the patient is discharged and provided with further appointments if necessary.

Role of dental nurse

The dental nurse will prepare the dental surgery prior to the patient’s arrival. They will carry out comprehensive infection control by disinfecting the primary and secondary zones and ensure that all instruments required for the planned extraction(s) selected are sterile. They will collect the patient’s notes or ensure they are ready on the computer and display the radiographs. They will note the patient’s medical history to establish if there are any special requirements for the patient, checking that consent has been taken.

The dental nurse will collect the patient from the waiting room, checking that they have the correct patient and introduce themselves. They will ask him/her if they have eaten and adhered to the pre-operative instructions provided at the last appointment and if they have any medication they would like placed on the work-surface. They will take the patient’s coat and belongings and ask them to take a seat in the dental chair.

Once the patient is settled they will apply the personal protective equipment in the form of a bib and glasses, explaining to the patient the rationale for each. During the placement of the local anaesthetic, which the dental nurse will hand to the maxillofacial surgeon, they will monitor and reassure the patient, looking for signs of distress.

When the tooth is being removed the dental nurse may be requested to support the patient’s head to keep it still. They may also need to provide some aspiration to remove the blood and saliva, providing a clear field of vision for the clinician as well as making it more comfortable for the patient. They will pass the elevators and extraction forceps as they are required and wipe them clean after each use to prevent the congealing of blood and debris.

Finally, once the tooth has been removed they will provide a rolled-up sterile swab which will be placed in the socket to achieve haemostasis. Throughout the procedure they will constantly monitor and reassure the patient, praising them. They will also ensure excellent cross-infection control and the health and safety of all. If requested, the dental nurse may provide verbal and written post-operative care instructions. Once the patient has left they will dispose of the waste correctly and carry out infection control procedures in the form of disinfection and sterilisation, returning the patient’s notes and radiographs to file.

Forceps used

The maxillofacial surgeon will use forceps designed to extract specific teeth. Forceps used for the lower teeth are angulated at a right angle whereas forceps used for upper teeth are not, making them easily identifiable for the dental nurse.

Upper extraction forceps: permanent teeth

Upper straight permanent anterior extraction forceps (Figure 5.4) are designed to extract the upper right and upper left:

• • Incisor teeth.
• • Canine teeth.
• • Retained roots.

Upper permanent pre-molar extraction forceps (Figure 5.5) are designed to extract the upper right and upper left:

• • First and second pre-molar teeth.
• • Retained roots.
• • Third molar tooth.

Upper permanent molar extraction forceps (Figure 5.6) are designed to extract the upper right and left:

• • First molar tooth.
• • Second molar tooth.
• • Third molar tooth.

Bayonet extraction forceps (Figure 5.7) are designed to extract the upper right and left:

• • Third molar tooth.

Upper permanent eagle beak extraction forceps (Figure 5.8) are designed to extract the upper and left:

• • First molar tooth.
• • Second molar tooth.
• • Third molar tooth.

Upper permanent cowhorn extraction forceps (Figure 5.9) are designed to extract the upper right and upper left:

• • First molar tooth.
• • Second molar tooth.
• • Third molar tooth.

Upper supernumerary extraction forceps (Figure 5.10) are designed to extract extra teeth such as palatal canines.

Upper permanent molar