W2.3 Surgical Extraction Tips

Dental Extractions: Practical Guidance, Assessment, and Risk Management

This document summarizes practical teaching and clinical guidance on dental extractions—focused on case presentation, pre-operative assessment, technique (luxation and forceps), medication-related risks (particularly antiresorptives and anticoagulants), consent, when to suture or refer, and post-operative management.

1. Presenting the Patient Professionally

Begin every clinical discussion with a concise, standard line to convey essential information clearly to colleagues or tutors:

• Name, age, and reason for referral (what procedure and why).
• Briefly summarise relevant medical history and current medications.
• Display and review the radiograph before discussing management.

Example format:

• “John Smith, 45, referred for extraction of tooth 36 due to caries/pain. Medical history: [significant items]. Radiograph shown.”

This approach clarifies the clinical question and demonstrates professionalism.

2. History, Investigations, and Initial Assessment

• Obtain a complete medical history and medication list for every patient. This is essential to identify risks such as anticoagulation or antiresorptive therapy (bisphosphonates, denosumab/Prolia).
• Always review radiographs to confirm anatomy, root direction, proximity to relevant structures, and likelihood of surgical complexity.
• If uncertain about difficulty, delay rather than rush: reschedule if needed to gather more information or discuss with a senior.

Key assessment points:

• Tooth mobility, crown/root condition, presence of large restorations or cracks.
• Buccal/lingual tori, alveolar bone levels, and patient age (dense bone in older patients with healthy periodontium can make extractions harder).
• Radiographic signs that predict potential complications (e.g., roots close to nerves or sinus, complex angulation).

3. Medication-Related Considerations

Understand common medication groups and their clinical implications:

Table — Medication implications and management summary

• Denosumab (Prolia/Xgeva) / Bisphosphonates:
  • Implication: Risk of medication-related osteonecrosis of the jaw (MRONJ), especially after invasive procedures or when bone is exposed.
  • Common indications: Osteoporosis, metastatic cancer.
  • Management: Identify patients on these medications; not all require specialist referral—many extractions can be performed by competent general practitioners if technique is truly atraumatic. If significant bone removal or flap/bone exposure is anticipated, consider referral to maxillofacial/oral surgery.
• Anticoagulants (Warfarin; DOACs such as apixaban/rivaroxaban):
  • Implication: Higher risk of post-operative bleeding than MRONJ risk.
  • Management: Assess bleeding risk and liaise with medical team if necessary. Use local haemostatic measures, consider suturing or packing when indicated, and arrange appropriate follow-up.

Clinical principles:

• Always ask specifically about antiresorptives and anticoagulants—patients may not volunteer or understand medication names.
• For patients on antiresorptives who present with an extraction that becomes surgical (bone removal, raising flaps), avoid proceeding if you are not confident; assess and consider referral.
• If a simple extraction becomes surgical and the patient is already on denosumab/bisphosphonates, close the site, provide local measures (hemostasis, antibiotics if indicated), and refer for specialist care rather than creating a larger defect you cannot confidently manage.

4. Technique: Luxation and Use of Instruments

General tips for using luxators and elevators:

• Goal: Enter the periodontal ligament (PDL) space between cementum and bone—avoid slipping between gingiva and bone.
• Approach with a controlled, sliding motion rather than a directly vertical shove.
  • Angle instruments to follow the tooth surface (often approaching at ~45°), sliding the luxator apically to engage the PDL.
• Use finger stops:
  • Place one or two fingers in the mouth (buccal vestibule and/or palatal/lingual) to support and act as a physical stop if the instrument slips.
  • Keep a finger resting against the tooth on the lingual/palatal side to feel movement that may not be visible.
• Hand positioning and control:
  • Hold the luxator with thumb and index near the tip to control force and prevent plunging if it slips.
  • Use controlled, incremental force rather than high-force levering.
• Be aware: Incorrect angle or excessive force can fracture crowns, adjacent teeth, or even bone. Use care especially when working interproximally.

What luxation should feel like:

• A gradual release and mobility of the tooth as PDL fibres are severed—more sensation of “sliding” than “shovelling through rock.”
• If the tooth does not move, reassess instrument position or ask for assistance.

Practical pre-session preparation:

• Ensure you have the appropriate instruments for expected difficulty.
• Confirm anaesthesia, review radiograph, and have a tutor or senior available for advice on the first few sessions.

5. Deciding When to Continue or Stop and Refer

• Make the decision based on assessment, radiographic information, and your comfort/skill level:
  • If the extraction appears straightforward and the tooth is mobile, you may proceed.
  • If there is a high risk of crown/root fracture or need to raise a flap and remove bone—especially in patients on antiresorptives—consider referral.
• If a complication occurs (e.g., root fracture) and the required retrieval would require surgical access beyond your capability:
  • Stop, close the site, achieve hemostasis, consider initial antibiotics if indicated, explain to the patient calmly, and arrange referral to a specialist.
  • There is rarely an immediate need for emergency transfer; many cases can be managed electively within days to weeks.
• Avoid being pressured by patients to proceed when you are uncomfortable.

6. Consent and Communication

• During informed consent, explicitly discuss the possibility that a root fragment may break and that specialist referral could be required for removal.
• Use clear explanations before the procedure—this reduces misunderstandings if complications occur.
• After an adverse event, document what was discussed previously and communicate clearly; what was said before the event is important legally and clinically.

7. Suturing, Packing, and Use of Hemostatic Agents

When to suture:

• Suture to stabilise a mobile flap or to secure hemostatic packing—not routinely to “close” an extraction socket when soft tissues are well opposed.
• A suture placed only over a well-approximated gingiva does not close the socket and can act as a food trap; use judiciously.

Use of packing and haemostatic agents:

• Resorbable haemostatic sponges (e.g., oxidised cellulose products) are useful in patients with high bleeding risk; suture over them to keep them in place if needed.
• Consideration for patients on antiresorptives: introducing foreign body material into the socket may theoretically impede healing; balance this concern against the immediate need to control bleeding—especially in anticoagulated patients, where bleeding risk may be more pressing.
• Clinical judgment: for patients on both antiresorptives and anticoagulants, haemostatic control is essential because bleeding complications can be severe.

8. Post-Extraction Bleeding and Infection

Understand potential timing and causes:

• Immediate bleeding: usually from soft tissues or socket—manage with local measures.
• Delayed bleeding: can occur when local hemostasis fails after anesthetic wears off or due to infection causing vessel erosion.
• Infection-related bleeding: necrotic tissue and infection can lead to further breakdown and bleeding.

Management considerations:

• Consider patient age, comorbidities, and medications when predicting post-op haemorrhage or infection.
• Explain signs that require urgent review (persistent bleeding, severe pain, swelling, systemic symptoms).
• Schedule appropriate follow-up and communicate with the patient’s general dentist or specialist as needed.

9. Managing MRONJ (Medication-Related Osteonecrosis of the Jaw)

Key points:

• MRONJ is a serious, often long-term condition associated with antiresorptive therapies (bisphosphonates, denosumab), particularly when bone is exposed after invasive dental procedures.
• Two main patient groups at risk:
  • Patients treated for osteoporosis.
  • Patients treated for metastatic cancer (often with higher cumulative doses).
• Clinical consequences can include chronic exposed bone, infection, difficulty eating, and prolonged follow-up—sometimes for many years. Legal actions have occurred when appropriate history-taking was not done prior to extraction.

Referral and ongoing care:

• If a problematic exposure or progression occurs, specialist care is required; treatment can include debridement or removal of necrotic bone and long-term management.
• If you inadvertently create an MRONJ risk (e.g., performed surgical extraction in a patient you should have referred), ethically you should continue to manage and follow that patient, even if it requires long-term care.

10. Practical Checklist for the Extraction Session

Before starting:

• Confirm patient identity and consent; review radiograph.
• Take full medical and medication history (explicitly ask about antiresorptives and anticoagulants).
• Prepare instruments, finger stops, haemostatic agents, sutures, and appropriate post-op prescriptions.

During the procedure:

• Use atraumatic technique: slide luxator down tooth, avoid vertical entry into gingival sulcus.
• Keep finger stops in place; monitor for movement with a finger on lingual side.
• Apply controlled, incremental force—avoid excessive levering.
• If unexpected complications arise (root fracture, need for bone removal), stop, achieve local measures, and consider referral.

After the procedure:

• Provide tailored post-op instructions and arrange follow-up.
• If the patient is anticoagulated and there was significant bleeding, ensure appropriate haemostatic measures were used and follow-up is arranged.
• Document consent, events, and advice given.

11. When to Seek Help

• If you are unsure about the complexity of a case or medication interactions, consult:
  • A senior dentist in your practice or the principal dentist.
  • Local oral and maxillofacial surgery unit or hospital maxfax team for advice or referral.
  • Tutors or specialists—early contact can prevent complications.
• In the event of unexpected complications, remain calm, apply local measures, inform the patient clearly, and arrange specialist input in an appropriate timeframe.

12. Summary of Key Clinical Messages

• Always open with a concise patient presentation (name, age, reason for referral) and confirm radiographic findings.
• Take a full medication and medical history; ask specifically about antiresorptives and anticoagulants.
• Use atraumatic technique and finger stops when luxating teeth; feel, don’t force.
• Don’t proceed with surgical-level intervention if you are not comfortable—close and refer after initial local measures if appropriate.
• Balance the risks of bleeding versus MRONJ when deciding on sutures and haemostatic packing.
• Obtain specific informed consent about possible root fracture and the potential need for specialist referral.
• Keep calm and communicate clearly with patients and specialists if complications occur.