Oral surgery exam specific LO Breakdowns

L10 Examine patients clinically to diagnose oral and dental conditions requiring surgical management and apply the principles and biological rationale of oral surgical treatment

Source lecture: L1 Introduction to Practice Oral Surgery 2026

Core idea

Before any surgical management, work through a structured patient evaluation → complexity screen → consent pathway. The goal is to correctly diagnose, risk-stratify, and either treat in the student Extraction Clinic or refer.

Patient evaluation

The lecture’s core curriculum frames patient evaluation in three parts:

1. Medical history review and risk stratification
2. Radiographic interpretation and surgical mapping
3. Informed consent and legal considerations

Professional presentation (W2.3)

Open every clinical discussion with a concise standard line: name, age, reason for referral (what procedure and why), then a brief summary of relevant medical history/medications, and display and review the radiograph before discussing management. Always take a full medical and medication history — patients may not volunteer or understand drug names, so ask specifically about antiresorptives and anticoagulants.

1. Medical history review and risk stratification

Patients must meet specific criteria to be treated in the student Extraction Clinic. Conditions that exclude a patient (→ refer / seek tutor input):

• No impacted teeth; do NOT book more than 3 teeth at one time (root fragments may exceed the 3-tooth limit but require prior tutor consultation).
• No inverted (upside-down) wisdom teeth or canines positioned in the nasal region.
• No patients requiring sedation or antibiotic (AB) cover (excluded due to coordination difficulties).
• No previous radiotherapy (RT) to the head and neck.
• No patients on anti-resorptive agents (bisphosphonates or Prolia/denosumab).
• No patients on immunosuppressants (e.g., azathioprine, methotrexate).
• No patients on dual antiplatelet/anticoagulant therapy (see below).

2. Radiographic interpretation and surgical mapping

Always review radiographs to confirm anatomy, root direction, proximity to relevant structures, and likely surgical complexity. If uncertain about difficulty, delay rather than rush (W2.3).

Systematic OPG analysis (W4.1 Oral Radiography Workshop):

• Review the initial clinical indication for the OPG and identify any artefacts (foreign materials, ghost images, positioning errors, movement, soft-tissue position, focal-trough errors).
• Know normal maxillofacial anatomy; use a consistent, systematic routine.

Step	Review
1	Address clinical concerns
2	Dentoalveolar — count teeth, ectopic/impacted teeth, anomalies, perio bone loss, caries/fractures/periapical pathology
3	Maxilla & mandible — abnormal lucencies/opacities, altered trabecular pattern, fractures, asymmetry
4	Maxillary sinuses — mucosal changes
5	TMJs — condylar morphology
6	Soft tissues — swelling, calcifications (tonsilloliths, sialoliths)
7	Other sites — spine, orbits

• Describe any lucency/opacity by: location, number, symmetry, definition, shape, size, homogeneity, internal architecture, and effects on adjacent structures (displacement of teeth/sinus floor/canal, resorption, scalloping, sclerosis).
• Categorise lesions with the surgical sieve (artefactual, anatomical, anomaly, inflammatory/infective, cystic, hamartoma, benign tumour [odontogenic/non-odontogenic], idiopathic, fibro-osseous, malignancy, trauma, vascular, metabolic/systemic, other).
• Indications for further imaging if OPG is insufficient: CBCT, MSCT, MRI — contact a radiologist if unsure.

Always trace the PDL space on the radiograph to identify anomalies like ankylosis or hypercementosis before commencing treatment.

3. Informed consent and legal considerations

Informed consent (Australian Commission on Safety and Quality in Health Care) must be:

• Voluntary — given without coercion
• Informed — based on adequate knowledge of benefits and material risks
• Specific — relevant to the proposed intervention and available alternatives

Risk-communication balance

Disclose material risks, but avoid clouding judgment with extremely rare complications (e.g., death from LA) for simple procedures.

• General risks to mention: “bleeding, bruising, swelling, pain and infection.”
• Procedure-specific risks are tailored — e.g. upper teeth near the maxillary sinus (risk of oro-antral communication), or damage to adjacent teeth/restorations/implants with large cavities, large restorations, or adjacent crowns.
• Pre-operative warning protects you legally: documenting that adjacent-tooth/implant compromise was discussed prevents the appearance of excuse-making if damage occurs (case: a 3-unit implant bridge detached during extraction of 17 — accepted because warned beforehand).
• Explicitly consent for the possibility that a root fragment may break and that specialist referral could be required (W2.3). What was said before an adverse event is important legally and clinically.

Pre-operative safety — the mandatory Dental Surgery Safety Checklist Tool (abridged WHO checklist, via TOHM eForms): patient ID (surname, first name, address, DOB), Time Out (introductions, patient/procedure verification, briefing, consent & history confirmed, equipment ready), and completion steps. Complete each section at the appropriate time, not retrospectively (prevents errors such as extracting teeth removed decades prior).

Medication management — anticoagulants / antiplatelets

Bleeding risk is the priority for anticoagulants

For anticoagulants the bleeding risk outweighs the MRONJ risk; manage with local haemostatic measures, suturing/packing, and follow-up (W2.3).

Medication scenario	Eligibility / management
Warfarin	INR checked within 24 h prior; patient brings INR result. Acceptable INR up to 4.0, though ≤3.5 preferred.
Single therapy (Aspirin OR a NOAC)	Acceptable — local haemostatic measures sufficient. Includes apixaban, rivaroxaban, dabigatran.
Dual therapy (e.g. Aspirin + Clopidogrel, or Aspirin + Rivaroxaban)	Excluded — significant oozing; highest risk for haemostasis failure.

• Haemostatic agents/packing: resorbable sponges (e.g. oxidised cellulose) for high-bleeding-risk patients; suture over to retain. For patients on both antiresorptives and anticoagulants, haemostatic control is essential — bleeding can be severe (W2.3).

Antiresorptives and MRONJ (referral trigger)

• Denosumab (Prolia/Xgeva) / bisphosphonates → risk of medication-related osteonecrosis of the jaw (MRONJ), especially after invasive procedures or bone exposure. At-risk groups: osteoporosis and metastatic cancer patients (W2.3).
• Such patients are excluded from the student clinic. If an extraction becomes surgical (bone removal, flap) in a patient on antiresorptives → stop, close the site, achieve haemostasis, consider antibiotics, and refer rather than create a defect you cannot manage.
• Time-sensitive (narrow therapeutic window) Prolia extractions → urgent referral protocol (Titanium + in-person to E Block).

Patient-related factors (complexity screen)

Think about the patient as a person — mobility, systemic and psychological capacity.

Treatment tolerance and environment

• Tolerant of longer procedures, especially early in clinical training.
• Understands this is a student learning environment.

Sensory and behavioural considerations

• Can tolerate the sights, sounds, and stimulation of treatment without loud noises or distractions.
• Positioning: patient must be positionable in the chair per operator needs — severe kyphosis or inability to extend the neck may make a patient unsuitable (access difficulty). Patients prone to anger-management issues should be avoided for student treatment.

Radiographic / tooth-related factors (assessing extraction difficulty)

Several tooth-specific variables predict difficulty and complication potential.

Root morphology and anatomy

• Dilacerations / root curvature: some curvature is acceptable, but avoid severe dilaceration — sharp bends/hooked roots can trap the tooth, often requiring bone removal or sectioning.
• Hypercementosis: trace the apical PDL — it “balloons”/bulbosity; the bulbous root end is wider than the coronal root canal, physically preventing a simple vertical extraction path.
• Ankylosis: an obliterated PDL space indicates fusion of root to bone → high risk; necessitates surgical bone removal (“troughing”).
• Number of roots: multi-rooted teeth with divergent/widely spread roots resist extraction.
• Root length and shape: long, slender roots have higher apical-fracture risk than short, conical roots.

Crown condition and structural integrity

• Extensive caries — weakens crown, prone to fracture under forceps.
• Large restorations (amalgam/composite builds) — lack structural integrity.
• Pre-existing fractures/cracks — tooth may crumble during extraction.

Endodontic status and material changes

• Root-canal-treated teeth are notoriously brittle — loss of internal moisture + obturation material makes them shatter rather than luxate cleanly.

Periodontal ligament and alveolar bone

• PDL space: a wide PDL eases movement; a narrow/obliterated PDL suggests difficulty (and possible ankylosis).
• Bone density: sclerosis or thick cortical plates (especially mandible) provide less “give,” increasing root-fracture risk. Dense bone in older patients with a healthy periodontium makes extraction harder (W2.3).

Case — 85-year-old on Prolia, teeth 35 & 36

• 35: gross caries, hypercementosis (mid-root bulbosity), disappearing PDL space → required drilling past the bulbosity to mobilise.
• 36: appeared ankylosed with extremely long roots → required sectioning halfway down the roots to achieve mobility. Radiographic signs of ankylosis and hypercementosis necessitate surgical intervention and specialist management.

Biological rationale of surgical management

Core philosophy of exodontia

“Make the hole bigger or the tooth smaller” — always with minimal trauma to the patient. Reducing force needed lowers the risk of root fracture and alveolar damage.

• Make the hole bigger: reflect a mucoperiosteal flap; strategically remove alveolar bone (troughing). Simple = forceps expand the socket; complex = surgical handpiece removes bone.
• Make the tooth smaller: section the tooth into individual roots or remove crown portions that impede the path of withdrawal.

Deciding to continue vs. refer (W2.3): proceed if the case is straightforward and the tooth is mobile; refer if there is high risk of crown/root fracture or need to raise a flap and remove bone — especially in patients on antiresorptives. Never be pressured by a patient to proceed when uncomfortable; many cases can be managed electively within days to weeks rather than as emergencies.

L11 Explain the clinical aspects and the management of oro-facial infections

L2 Odontogenic Infection, Pain Control and Prescribing

An odontogenic infection originates from the tooth or its surrounding structures. In Australia, ~37% of all adult dental emergency visits to public hospital EDs are due to dental infections.

Causes, pathogens and types

• Common causes: caries, failed endodontic therapy, pericoronitis, periodontal disease, trauma.
• Common pathogens: Streptococci viridans, Streptococci anginosis, Prevotella species, Fusobacterium species. Periapical abscess microbiology is predominantly anaerobic.
• Types: periapical abscess, periodontal abscess, cellulitis, osteomyelitis, odontogenic sinusitis, Ludwig’s angina.

Abscess	Definition
Periapical abscess	Collection of purulence at the apex of the tooth
Lateral periodontal abscess	Localized accumulation of purulence within the gingival wall of a periodontal pocket

Pain assessment — SOCRATES

Use SOCRATES to systematically explore the patient’s pain and symptoms when taking the history:

• Site — specific location of the pain/infection
• Onset — when it started; sudden or gradual
• Character — sharp, dull, throbbing, aching
• Radiation — stays put vs. moves to ear, jaw, neck
• Associated symptoms — swelling, bad taste, systemic signs
• Timing — duration of episodes and any pattern
• Exacerbating / Relieving factors — temperature (hot/cold), biting/pressure, lying down, analgesics
• Severity — scale of 1–10 or interference with daily activities/sleep

Differentials to consider: odontogenic (reversible vs irreversible pulpitis); non-odontogenic (salivary glands / “mealtime syndrome”, tonsillar, referred pain). During history-taking, perform a ‘distant’ examination — observe for swelling/asymmetry, dysphagia/difficulty speaking, wincing/guarding, and general perfusion/distress.

Clinical signs of infection

• Classical signs of inflammation (Celsus): Rubor (redness), Tumor (swelling), Dolor (pain), Calor (heat).
• Local signs: erythema, swelling, pain, heat, purulence.
• Systemic signs (spread): raised HR, RR, BP, temperature (fever), confusion, malaise, shivers/shakes/rigors.

Spread of infection and fascial spaces

• Infection spreads via fascial spaces and tissue planes, lymphatics, and the bloodstream.
• Fascial spaces are loose fibrous connective-tissue envelopes (superficial and deep). They do not exist in health — normally filled with ground substance. In spreading infection the substance breaks down and the space enlarges via hydrostatic pressure.

Mylohyoid line determines spread direction

• Sublingual space — above mylohyoid line; from anterior mandibular teeth.
• Submandibular space — below mylohyoid line; from 2nd and 3rd molars.

Space	Common source of infection	Key clinical features
Canine	Maxillary canine, 1st premolar (occ. MB root 1st molar)	Cheek/lower-eyelid/upper-lip swelling, drooping mouth angle, obliterated nasolabial fold
Buccal	Maxillary/mandibular premolars & molars	Cheek swelling to mouth corner; “dumb-bell” shape with temporal spread
Parotid	Mandibular molars	Swelling everting ear lobule, pain on mastication, pus from parotid duct
Infratemporal	Maxillary 3rd molars	Swelling over sigmoid notch, trismus, proptosis; can cause cavernous sinus thrombosis
Pterygomandibular	Mandibular 3rd molars, pericoronitis, infected needle/LA	No extra-oral swelling, severe trismus, dysphagia, uvula deviation
Masseteric	Mandibular 3rd molars, pericoronitis	Swelling over angle of mandible, severe trismus, throbbing pain
Sublingual	Mandibular premolars & 1st molars	FOM swelling, raised tongue, pain on swallowing, restricted tongue protrusion
Submental	Mandibular incisors	Firm swelling beneath chin
Submandibular	Mandibular 2nd & 3rd molars	Firm swelling below inferior border of mandible
Lateral pharyngeal	Mandibular 3rd molars, tonsillar	Trismus, induration at jaw angle, fever, pharyngeal bulging; carotid erosion risk
Retropharyngeal	Odontogenic / nasal-pharyngeal spread	Neck stiffness, dysphagia/drooling, dyspnoea; route to mediastinum
Danger space	Spread from retropharyngeal	Route between neck and chest → mediastinum

Life-threatening complications

Head/neck spread can cause airway obstruction, intracranial spread, and septicaemia.

• Ludwig’s angina — bilateral cellulitis of submandibular + sublingual spaces (most commonly from mandibular 3rd molars; Strep. viridans/Staph. aureus). Hard/firm swelling, pyrexia, dyspnoea, dysphagia, difficulty closing the mouth.
• Cavernous sinus thrombosis — clot from fascial-space spread (Staph. aureus/Streptococcus). Fever/rigors, severe frontal/pre-orbital pain, exophthalmos, eyelid oedema/chemosis, ophthalmoplegia, ptosis, dilated pupil.
• Sepsis — life-threatening organ dysfunction from a dysregulated host response.

Severity assessment and staging

Severity is judged by (1) anatomical location of spaces involved, (2) rate of progression, and (3) associated symptoms. A severity score is summed across all involved spaces:

Score	Risk to airway/vital structures	Spaces
1	Low	Vestibular, subperiosteal, body of mandible, infraorbital, buccal
2	Moderate	Submandibular, submental, sublingual, pterygomandibular, submasseteric, superficial/deep temporal (infratemporal)
3	High	Lateral pharyngeal, retropharyngeal, pretracheal
4	Extreme	Danger space, mediastinum, intracranial

Stage	Duration	Pain	Palpation	Tissue fluid	Predominant bacteria
1 Inoculation	0–3 days	Mild–moderate	Soft, doughy, mildly tender	Edema	Aerobic
2 Cellulitis	3–7 days	Severe, generalized	Hard, exquisitely tender	Serosanguineous + pus flecks	Mixed
3 Abscess	>5 days	Moderate–severe, localized	Fluctuant, tender	Pus	Anaerobic

Clinical examination — intraoral special tests

Percussion (apical periodontitis), mobility, pocket depths, vitality (thermal/electric pulp) testing, fracture detection (Fracfinder/transillumination), and radiographs.

Required prescriptions — odontogenic / oro-facial infection (treatment)

Source: doses exactly as written in L2 Personal Formulary. Adult doses. Antibiotic durations: 5/7 = 5 days, 7/7 = 7 days.

Antibiotics

Drug	Dose	Frequency	Duration	Notes
Phenoxymethylpenicillin 500 mg	500 mg orally	QDS	5/7	—
Amoxicillin 500 mg	500 mg orally	TDS	5/7	—
Cefalexin 500 mg	500 mg orally	QDS	5/7	—
Clindamycin (150 mg tab)	300 mg orally	TDS	5/7	—
Metronidazole (200 mg tab)	400 mg orally	BD	5/7	Anaerobic cover
Amoxicillin–Clavulanate (875–125 mg)	1000 mg orally	TDS	5/7	”Amoxi-Clav”
Doxycycline 100 mg	100 mg orally	Once daily	7/7	—

Analgesics

Drug	Dose	Frequency	Max in 24 h	Notes
Paracetamol 500 mg	500 mg orally (1–2 tablets)	Up to 4× daily	4000 mg	—
Ibuprofen 200 mg (NSAID)	400 mg orally	6–8 hourly	1200 mg	—
Naproxen (NSAID)	250–1000 mg orally (regimen-dependent)	Once daily to 4 hourly	1100 mg	—
Celecoxib 200 mg (NSAID)	200 mg orally	Once or twice daily	400 mg	—
Oxycodone 5 mg (opioid)	5 mg orally	6 hourly	—	—
Tramadol 50 mg (opioid)	50 mg orally (1–2 tablets)	6 hourly	400 mg (300 mg if >75 y)	—
Paracetamol 500 mg + Codeine 30 mg (opioid)	I–II tablets PRN	Up to QDS	4000 mg paracetamol	Codeine effect varies (pharmacogenomics)

Antifungals (oral candidiasis, for completeness)

Drug	Dose	Frequency	Duration
Miconazole 2% oral gel	2.5 mL topically then swallowed, after food/drink	QDS	14/7 (continue several days after symptoms clear)
Nystatin 100,000 units/mL oral liquid	1 mL swished then swallowed, after food/drink	QDS	14/7 (continue several days after symptoms clear)

Prescribing cautions

• Aspirin must not be given to children <16 years — Reye’s syndrome risk; children’s doses are weight-based.
• Opioids: tapentadol is not on dental PBS; hydromorphone is, but use extreme caution. Codeine has no analgesic effect in everyone (pharmacogenomics).

Antibiotic PROPHYLAXIS (prevention of infective endocarditis) — distinct from treatment above

Source: R7 Antibiotic Prophylaxis. This is single-dose prophylaxis to prevent endocarditis, NOT a treatment course. Give it only for the highest-risk cardiac patients undergoing qualifying procedures.

Who needs it — high-risk cardiac conditions only

• Prosthetic heart valve (mechanical, bioprosthetic, homograft; transcatheter or surgically implanted)
• Prosthetic material used for cardiac valve repair (e.g. annuloplasty rings, chords)
• Previous infective endocarditis
• Cardiac transplant with subsequent cardiac valvulopathy (consult cardiologist)
• Rheumatic heart disease (all populations)
• Congenital heart disease only if: (i) unrepaired cyanotic defects incl. palliative shunts/conduits, or (ii) repaired defects with residual defects at/adjacent to a prosthetic patch/device.

If none of the above → prophylaxis NOT required.

Which procedures (dental): prophylaxis required for procedures manipulating gingival/periapical tissue or perforating oral mucosa — extraction, matrix band, subgingival rubber dam & clamp, implant placement, biopsy, removal of soft tissue/bone, subgingival scaling/root planing, replanting avulsed teeth, apicectomy, six-point pocket charting in diseased tissue, RCT before an apical stop. Not required for exam, LA through non-infected tissue, restorative work, supragingival rubber dam, intracanal endo, suture removal, impressions/dentures, ortho brackets, gels, radiography, supragingival plaque removal.

Regimens (dental procedures)

Scenario	Drug & dose	Timing
Standard	Amoxicillin 2 g orally (child 50 mg/kg up to 2 g)	60 min prior
Standard, oral not possible	Amoxicillin 2 g IV (child 50 mg/kg up to 2 g)	Within 60 min prior (over 3–4 min)
Moderate-risk penicillin allergy	Cefalexin 2 g orally (child 50 mg/kg up to 2 g)	60 min prior
Moderate-risk allergy, oral not possible	Cefazolin 2 g IV (child 30 mg/kg up to 2 g)	≤60 min before incision (over 5 min)
High-risk penicillin/cephalosporin allergy	Clindamycin 600 mg orally (child 20 mg/kg up to 600 mg)	60–120 min prior
High-risk allergy, oral not possible	Clindamycin 600 mg IV infusion (child 20 mg/kg up to 600 mg)	Within 120 min prior; ≥20 min infusion
Other procedures / non-oral option	Vancomycin 1 g IV (1.5 g if adult >80 kg; child 30 mg/kg up to 1.5 g)	Begin 15–120 min before incision

Allergy definitions: Moderate-risk = delayed rash that is NOT urticarial or DRESS/SJS/TEN. High-risk = anaphylaxis, angioedema, bronchospasm, urticaria, DRESS/SJS/TEN.

Obesity dosing: Cefazolin → consider 3 g if adult >120 kg. Vancomycin → consider 1.5 g if adult >80 kg.

Timing & repeat dosing

• Give prophylaxis before surgical incision to achieve effective plasma/tissue levels; dosing after incision reduces effectiveness.
• A single preoperative dose suffices for most procedures. Repeat intraoperative dose advisable if: surgery >4 hours from the first preoperative dose (e.g. repeat cefazolin after 4 h), or blood loss >1500 mL in adults (after fluid resuscitation).
• Measure the interval for a second dose from the first preoperative dose, not the incision time.

L12 Explain the indications, contraindications, techniques, side effects and complications of sedation and general anaesthesia in dentistry

L5 Anxiolysis and GA

Sedation levels (TGA) & practitioner scope

Sedation exists on a continuum from anxiolysis to general anaesthesia. Scope of practice is tied to the level.

Level	Definition	Agents / methods	Airway/ventilation/CVS impact	Who can provide
Minimal (Anxiolysis)	Drug-induced ↓anxiety; patient conscious, responds purposefully to verbal commands or light tactile stimulation	Oral benzodiazepines or inhaled agents (N₂O; less commonly methoxyflurane)	Cognition/coordination may be impaired; no airway/ventilation/CVS intervention needed	General dentist (with appropriate training — a 6.5 hr CPD course for inhalation sedation)
Moderate	Drug-induced depressed consciousness; responds purposefully to verbal commands and tactile stimulation	IV drugs, or combination of oral drugs + inhalational technique	In exceptional circumstances, airway/ventilation/CVS intervention may be required	Endorsed dentist (Dental Board endorsement; via Univ. of Sydney Grad Dip — Conscious Sedation & Pain Control, 2-yr program)
Deep	Drug-induced depressed consciousness; not easily roused; may respond only to noxious stimulation	—	Impaired airway maintenance, inadequate spontaneous ventilation, impaired CVS function	Medical practitioners / anaesthetists only, in approved facilities
General anaesthesia	Unconscious, unable to feel painful stimuli; autonomic reflexes controlled	—	Full physiological support required	Anaesthetist in specialised facility

Scope limitation

Combining oral benzodiazepines with nitrous oxide constitutes moderate sedation — outside general dental scope without additional training. If one agent fails, switch to an alternative benzodiazepine rather than combining sedation methods.

Guedel’s stages of anaesthesia (1937)

1. Stage 1 — Analgesia: induction → loss of consciousness. (Relative analgesia operates at the upper end of Stage 1.)
2. Stage 2 — Excitement (delirium): loss of consciousness → onset of automatic breathing.
3. Stage 3 — Surgical anaesthesia: automatic breathing → respiratory paralysis. GA surgery takes place and patient is maintained here.
4. Stage 4 — Respiratory paralysis: leads to death if unmanaged.

Anaesthetists aim to move rapidly through Stage 1, minimise Stage 2, and maintain in Stage 3.

Relative Analgesia / Nitrous Oxide (N₂O)

Inhalation sedation (ADA code 943, per 30 min). First-line option for children requiring sedation. Acts in Stage 1 (analgesia); 50% N₂O ≈ 10–15 mg morphine. NMDA antagonist (dissociative), releases endogenous opioids (analgesia), GABA-A activation (anxiolysis).

Indications

• Fear and anxiety; pain control
• Medical conditions exacerbated by stress
• Gagging
• Traumatic or complex dental procedures (posterior regions preferred; useful for breakthrough pain when full LA is hard to achieve)

Contraindications

• Psychosocial: claustrophobia; lack of understanding (age/learning difficulties); severe anxiety; high complexity of treatment
• Medical: nasal obstruction / URTI; ASA III–V; COPD; pregnancy (1st trimester — also a staff concern); severe psychiatric disorders
• Dental: upper anterior procedures

Advantages

• High safety profile; rapid onset/recovery (low blood solubility 0.47); easily titrated
• Not metabolised; no adverse CVS/respiratory/liver/kidney effects; effective analgesia; limited amnesia

Disadvantages

• Requires specialised equipment; large individual variation; chronic staff exposure risk; potential for abuse; limited amnesia

Equipment

• Delivery: bottled gas (mobile trolley) or piped gas
• Control unit (Quantiflex MDM): N₂O & O₂ flow rates, %N₂O control, total flow knob, O₂ flush
• Reservoir bag (grey balloon — monitors/evens respiration); nasal hood; double-hood (inner blue delivers fresh gas, outer white scavenges via one-way valve); active scavenging via suction
• Safety features: pin index system, colour coding, O₂ flush (immediate 100% O₂), O₂ fail-safe (shuts off N₂O if O₂ pressure fails), reservoir bag monitor, minimum 30% O₂ always delivered, one-way valves

Technique (steps)

1. Consent obtained at a prior visit (written; capacity impaired during sedation)
2. Ensure a chaperone in the room
3. Start 100% O₂ at 4–6 L/min; patient places hood, adjust for sealed comfortable fit (no leak over eyes)
4. Nasal inspiration/expiration only (may need practice)
5. Pulse oximetry recommended
6. Titrate N₂O in 5–10% increments every 1–2 min to desired level (typically 35–45%)
7. Induction: peak brain levels at 5–7 min; hypnotic suggestion can enhance effect
8. Recovery: deliver 100% O₂ for 5 min at completion to prevent diffusion hypoxia; sit upright, check not dizzy; children supervised by adult for the day; adults not to drive

Diffusion hypoxia

On cessation, N₂O rushes from blood into alveoli, displacing O₂ and causing diffusion hypoxia. Prevent by administering 100% O₂ for 2–5 min at the end of the procedure.

Chronic staff exposure to N₂O

Long-term exposure can cause: deactivation of vitamin B12 → peripheral neuropathy; toxic hepatic effects (liver enzyme inhibition); depression of leukocyte production; spontaneous abortion and other reproductive issues. (Active scavenging mitigates this.)

Oral benzodiazepines

Provide pre-procedural anxiolysis. Taken 1 hour prior, at the dental practice (allows observation of adverse reactions and onset timing).

Drug	Dose (>13 yrs)	Notes
Temazepam 10 mg tablet	10 mg, orally, 1 hr prior	If ineffective, consider ↑ to 20 mg (caution >75 yrs or frail)
Lorazepam 1 mg tablet	1 mg, orally, 1 hr prior	If ineffective, consider ↑ to 2 mg (caution >75 yrs or frail)
Diazepam 2 mg tablet	2–5 mg, orally, 1 hr prior	Use lower end of range for >75 yrs or frail

Advantages: well-accepted (“Valium”); cost-effective; easy to administer; provides pre-procedure anxiolysis; can give a pre-op night dose for restful sleep.

Disadvantages: slow onset, long duration (supervision required post-op); variable response; cannot be titrated rapidly (must wait 1+ hr to assess); caution in older/frail/cognitively impaired and OSA patients; cannot be used without an escort/carer.

Indications: dental anxiety; short procedures (1–2 hrs max).

Contraindications: prolonged procedures; severely limiting heart, cerebrovascular, lung, liver or kidney disease; allergy/adverse events to sedation/analgesia/anaesthesia drugs; severe anxiety not managed with minimal sedation; substance abuse; prior patient-reported inefficacy.

Technique: written consent before the day; thorough medical history (check not already on these meds); prescribe to dispense for that procedure only (one dose per visit, allows dose adjustment); patient must have someone to drive them home; arrive 1 hr before. (At E-Block: Temazepam 10 mg dispensed on site 1 hr prior; IV sedation not available there.)

Methoxyflurane (Penthrox)

Inhaled analgesic for emergency relief of trauma pain / analgesia in monitored conscious patients. Off-label, limited dental role — e.g. dry socket (alveolar osteitis) where LA is undesirable. Less suitable than N₂O (fat-soluble → slower reversal; metabolised by hepatic enzymes). Patient exhales through the activated carbon filter to limit environmental exposure.

Dose limits (strict, due to hepatic metabolism/toxicity):

• 6 mL per day
• 6 mL per week; or
• maximum 15 mL per week in specific clinical scenarios

Intravenous (IV) sedation

Classified as moderate sedation — managed by qualified personnel.

Providers: dentist (limited to single-drug sedation) or medical practitioner (anaesthetist / GP anaesthetist).

Staffing: at least 3 staff in the room — proceduralist, sedationist, assistant (sometimes +RN = 4-person team).

Facility/training: rapid emergency-services access; advanced life support with oxygen therapy (HLTAID015 or equivalent); AED and airway adjuncts available.

Monitoring (ANZCA PG09 2023): Heart Rate, Blood Pressure, O₂ saturation (SpO₂), ideally expired capnography.

Agents

• Midazolam — primary drug for dentist-led (single-drug) sedation; GABA-A (↑affinity for GABA); no pain on injection; metabolised in liver; short half-life (2 hr), clinical working time ~45 min; some amnesia (decreases over time). Reversed with Flumazenil.
• Propofol — induction agent; very short half-life (2–5 min), continuous-infusion pump; provides primary sedation (anaesthetist-led).
• Remifentanil — short-acting synthetic opioid, synergistic with propofol for analgesia.
• Adjuncts: antibiotics, steroids, other analgesics IV as required.

Advantages: operator focuses on dentistry; well tolerated; suppresses gag reflex and anxiety; highly titratable (unlike oral).

Disadvantages: cost (dentist code 942; anaesthetist-led — operator code 949 + anaesthetist bills separately = higher cost); needs trained staff and specific facilities; procedural time significantly increased (20–40% longer).

Technique: consent signed ahead; patient fasted; IV access/induction (5–20 min); treatment; recovery 10–30 min to leave surgery + 20–30 min supervised; discharged with a responsible person. 24-hr post-sedation restrictions: no driving, no heavy machinery, no signing legal documents.

Flumazenil rebound sedation

Flumazenil reverses midazolam but has a half-life of ~50 min — there is a risk of rebound sedation as it wears off before the benzodiazepine is fully cleared.

General anaesthesia (GA)

Goal: render the patient unconscious and unable to feel painful stimuli while controlling autonomic reflexes. Takes place in specialised facilities — private or public; day-case or hospital with overnight stay.

Indications (decision factors):

• Procedural difficulty / inability to achieve adequate anaesthesia with LA
• Procedural length
• Unpleasantness of the procedure
• Patient preference

Risk assessment

Patient preference must be balanced against safety — some cohorts demanding GA for minor procedures carry higher mortality risk; the clinician must protect patients from themselves.

Who provides (Perth accreditation):

• General dentists — only a few private day-hospital facilities; must transport equipment/materials for restorative work
• OMF surgeons — both private and public hospitals
• Special needs dentists — RPH and FSH departments
• Paediatric dentists — public and private (incl. Perth Children’s Hospital)

Facility / admission criteria (OHCWA → Southbank Day Surgery):

• Weight <130 kg (>130 kg not accepted — non-negotiable)
• BMI <40 (exceptions up to 42 in specific circumstances); BMI 40–42 → consult GM/DON, Operations Director WA or National Clinical Governance Director; BMI 38–40 → consult GM/DON; BMI 35–38 (<130 kg) → must meet criteria (ASA 1–2, no OSA, no significant respiratory disease, no anticipated airway difficulty, ambulant, morning/first-afternoon list, anaesthetist + DON review); BMI ≤35 (<130 kg) → accepted if anaesthetist approves
• No OSA
• Manual handling: >90 kg self-ambulate if able; >100 kg consider Hovermat; >115 kg Hovermat mandatory

If unsuitable for Southbank, refer to public system (RPH, SCGH, FSH) by postcode. Do not promise GA when referring to E-Block — frame as “options discussed at specialist consultation.”

L13 Perform tooth extractions and minor dental-alveolar surgical procedures and Explain the management of Post extraction complications

Core philosophy of exodontia

The fundamental principle is to make the hole bigger or the tooth smaller, always with the caveat of minimal trauma to the patient (L1 Introduction to Practice Oral Surgery 2026).

• Make the hole bigger: forceps to expand the socket (simple); surgical handpiece to remove bone (complex).
• Make the tooth smaller: section the tooth into smaller pieces (complex).

Local Anesthesia

To achieve a successful extraction, anaesthesia must be planned for the tooth, the surrounding alveolar bone, and the circumferential gingival tissues. Local anaesthetics eliminate pain but not pressure — warn the patient they will feel pushing, pulling, and pressure (sharp/stinging sensations are not normal and signal the need for more LA).

Common dosages (75 kg reference)

Figures from TGA Therapeutic Guidelines V4, correct as of January 2026. Stated maximums do not account for the vasoconstrictor.

LA Drug	Max dose (mg/kg)	Max dose for ~75 kg (mg)	LA per 2.2 mL carpule	Adrenaline per 2.2 mL carpule	Max no. of 2.2 mL carpules
Lidocaine 2% (1:80,000)	7	500 (absolute max)	44 mg	27.5 mcg	11.36
Articaine 4% (1:100,000)	7	500 (absolute max)	88 mg	22 mcg	5.68
Bupivacaine 0.5% (1:200,000)	2	150 (175 mg absolute max)	100 mg (20 mL ampoule)	100 mcg (20 mL ampoule)	1.5 × 20 mL ampoule
Mepivacaine 3%	Not stated in AUS (4.4 elsewhere)	Adult max 6.6 mL	66 mg	–	3 (absolute adult max)

Note: Septodont recently changed UK Mepivacaine instructions from 6.6 → 4.4 mg/kg — always check current local guidelines.

Clinical relevance of dosing: routine restorative and simple extractions usually need only 1–2 carpules, so dosing is rarely critical. It becomes critical for dental clearances (multi-quadrant; an upper clearance may need 5+ carpules) and vulnerable populations (small, frail elderly, adolescents). For clearances, phase treatment by quadrant (e.g. right side then left) to allow metabolic clearance, and consider Lidocaine over Articaine to preserve “wiggle room” for supplemental injections.

Anatomical Targets for Anesthesia

Required anaesthetic coverage

Complete anaesthesia must target:

• The tooth itself
• The surrounding alveolar bone
• The circumferential gingival tissues

Common error: forgetting palatal/lingual infiltration often results in pain despite apparent lip anaesthesia. (Example — removal of 38 requires the Left IANB including the lingual nerve plus the Left Long Buccal nerve block.)

Troubleshooting inadequate anaesthesia. If a patient feels pain during extraction, consider:

1. Injection technique — Did the block miss the target (e.g. IANB)? Was it a partial miss (successful IANB but missed lingual nerve)?
2. Local environment / pH — Is the area infected or inflamed? Lower pH in these tissues reduces anaesthetic efficacy.
3. Anatomical variation — Accessory innervation, e.g. mylohyoid nerve involvement in lower first molars.
   • Mylohyoid supplementation: if suspected, supplement with 0.5 cartridge lingual to the tooth.

Access

Successful access relies on increasing space or reducing resistance:

• Simple exodontia: use forceps to expand the socket (make the hole bigger).
• Complex exodontia: raise a mucoperiosteal flap and use a surgical handpiece to remove alveolar bone (troughing) and create a purchase point.

Bone removal priority: remove bone mesially or distally first; buccal removal is lower priority (increases the defect); never remove palatal bone. Be judicious but decisive — “stroking” the bone removes little and generates heat; positive removal minimises total bone loss. Maintain manual irrigation with saline to clear bone dust and keep bone below the necrosis threshold (>47 °C for ≥1 minute causes necrosis; a burning smell indicates “cooked” bone at 60–80 °C). Once a flap is raised, only the straight surgical handpiece should be used (to prevent surgical emphysema).

Reducing resistance (sectioning, crown removal)

Sectioning reduces tooth resistance — treat sectioned roots as individual single-rooted teeth (ADA Item 314, sectional extraction). Indications include divergent/complex root anatomy, gross caries with no purchase point, and reducing risk near the maxillary sinus (avoiding oro-antral communication). Keeping the buccal plate intact is crucial for socket preservation.

• Handpiece: a restorative high-speed handpiece with a coarse long-shank crown bur may be used only if certain no flap will be raised and the bur must not contact bone; otherwise use the straight surgical handpiece (prevents air emphysema). See V4 Sectioning Teeth for the flat Fischer bur / straight handpiece technique — hold the handpiece close to the tooth’s long axis to preserve buccal bone height, with continuous irrigation.
• Depth: section ~80% through the crown (keep the bur entirely within tooth structure; aim for the pulp chamber as a visual guide). Then sweep the bur to create elevation space.
• Separation: use an elevator in the trough until a “click” is heard, then elevate and remove each root individually. Pre-operative imaging is essential to check for fused roots or anatomical variation.

Instruments

Instruments and how to use them

See V5 Oral Surgery Instruments for the full reference, plus R5 Luxator Technique, R6 Forcep Technique and R8 Elevator Technique.

Biomechanical principles (the levers behind every instrument):

• Lever + fulcrum — effort arm longer than resistance arm reduces force; use alveolar bone (not adjacent teeth) as the fulcrum (e.g. Cryer elevators lifting retained roots).
• Wedge — luxator/elevator inserted into the PDL space expands the socket; apical pressure with forceps dilates the periodontal space, often causing the tooth to “pop” out.
• Wheel & axle — handle = wheel, shank/tip = axle; rotation produces high-force displacement (Cryer “East-West” elevators for roots into an adjacent empty socket). Force is so great the operator may not feel pressure on bone — risk of mandibular fracture; never use an adjacent tooth as a fulcrum.

Forceps (select by tooth anatomy and handedness; recognise beak orientation and handle curvature rather than memorising numbers — handle curves toward the operator’s fingers; the pointed beak/“horn” goes buccal to engage the furcation — “beak to cheek”):

Forceps	Number / Variant	Target teeth	Technique
Upper anterior (straight)	No. 29; No. 107 (shorter, canines); No. 1	Maxillary incisors & canines	Drive apically, rotate around long axis
Upper universal / premolar	No. 150; No. 150S	Maxillary incisors, canines, premolars	Apical seat; bucco-palatal/rotational delivery
Maxillary molar (handed)	53R / 53L (or No. 94 right / 95 left)	Maxillary first/second molars	Pointed “horn” into buccal furcation; buccal movement back to midline
Upper third molar (Bayonet / “Hawks”)	—	Maxillary 8s	Angled beak for posterior access; projection to buccal
Lower universal	No. 151 (74; 74N fine)	Mandibular incisors & premolars	Apical seat; rotation for conical roots, then buccal
Lower molar	No. 17; Lower Hawks (No. 73)	Mandibular molars	Beaks engage both furcations; figure-of-eight to expand socket, deliver buccally
Lower cow-horn	No. 23	Grossly broken-down mandibular molars (exposed furcation)	Pointed beaks seat in furcation as fulcrum; squeeze + rock to “pump” tooth out; high fracture risk

General forceps rule: drive apically onto the root surface before any delivery movement (premature levering fractures roots/bone); support the alveolus/mandible with the non-dominant hand; inspect the apices and compress the socket for haemostasis after delivery. Never place fingers between forceps handles.

Luxators (R5 Luxator Technique) — thin sharp blades that sever PDL fibres along the long axis and dilate the socket, used before forceps for an atraumatic extraction (no adjacent-tooth contact, less bone trauma, less swelling/infection):

• Sizes: 3 mm (narrow roots), 5 mm (wider roots); straight or curved blade by access/root anatomy.
• Grip: handle in palm; beginners extend the index finger along the shank toward the tip for control. Insert at the gingival margin angled along the root, advance apically with a gentle rocking motion and continuous apical pressure, working circumferentially (mesial, mid-buccal, distal).
• Aim to enter the PDL space between cementum and bone (~45° sliding approach), not slip between gingiva and bone; keep a finger stop in place.

Beginner safety — luxation direction

Never luxate palatally or lingually as a beginner. Blood and saliva create slip hazards; uncontrolled instruments can lacerate the palatal artery or penetrate the floor of mouth (lingual nerve). Use buccal surfaces only until tactile control develops.

Elevators (R8 Elevator Technique; V5 Oral Surgery Instruments):

• Coupland — broad-tipped chisel/elevator (set 1–3, small→medium→large); force perpendicular to the tooth/bone to elevate; progress to larger sizes only after movement is achieved; can split partially sectioned teeth.
• Cryer (“East-West”, L/R pair, triangular sharp tip) — placed in the empty socket of a multi-rooted tooth, engaging the interradicular septum/root and rotated (wheel & axle) to elevate roots.
• Warwick-James (left, straight, right) — lever placed perpendicular and rotated; for retained roots and upper third molars.

Periosteal elevators / retractors / curettes / burs:

• Periosteal elevators — Molt (sharp end lifts papillae; wide blunt end reflects/retracts the flap) and Haworth’s (spoon + flat blade, same role).
• Retractors — Minnesota (cheek/tongue retraction, adjunct with the surgical handpiece), Lester’s (placed behind the maxillary tuberosity to retract the cheek and illuminate posterior maxillary third molars), plus Kilner and rake retractors.
• Curettes — double-ended rounded blades to scrape granulation tissue from the socket; Mitchell’s trimmer (spoon for flap retraction + sharp end for soft bone); bone file (smooth bone with irrigation); root pick (fine, spindly, for small fragments).
• Surgical burs — round or flat fissure, by clinician preference.

Visual and Physical Access

• Direct visualization of the tooth, gingival margin, and surrounding bone is essential to monitor progress and avoid trauma.
• Instrument placement — sufficient space to seat elevators and forceps without interference from lips, cheeks, or neighbouring teeth.
• Light source — proper illumination is mandatory to read root morphology and detect complications.

Soft tissue management

• Retraction — use appropriate retractors (Minnesota, Lester’s, or finger retraction) to protect the buccal mucosa and tongue.
• Flap reflection — where simple access is insufficient, raise a full-thickness mucoperiosteal flap to expose bone and root. Flap design principles: a broad base (wider than the free margin to preserve blood supply); incisions perpendicular to mucosa, through periosteum to bone; minimise papillary trauma (never divide a papilla in half — keep incisions clearly to one side).
• Flap designs (V1 Envelope Flap, V2 3 Sided Flap, V3 2 Sided Flap):
  • Envelope (one-sided) — sulcular incision in one sweep (extend one tooth either side of the target). Simplest to close but prone to tearing if not extended far enough; reflect papilla and flap with the periosteal elevator.
  • Triangle (two-sided) — sulcular incision plus one relieving incision (mesial or distal); better retraction/access, less likely to tear.
  • Trapezoid (three-sided) — mesial and distal relieving incisions; maximum access but twice the closure work.
  • Semilunar — curved incision avoiding the gingival margin (apicoectomies, small cysts, root tips); heals with a “smiley face” scar. Pedicled flaps are used to close oro-antral communications.

Patient positioning

• Maxillary extractions: recline the patient so the maxillary occlusal plane sits at ~60–90° to the floor (head tipped ~30° up).
• Mandibular extractions: position more upright so the mandibular occlusal plane is parallel to the floor when the mouth is open.
• The mandible is free-floating (unlike the maxilla) — the non-dominant hand must stabilise the jaw to prevent dislocation, particularly in patients with lax TMJs.

Suturing and suture materials

Reading suture labels & material selection

A suture packet (e.g. Vicryl Rapide W9923) gives: Size (e.g. 3-0 = 2 Ph. Eur.), material/structure (coated Polyglactin 910, undyed braided absorbable), needle (PS-2, 19 mm, 3/8 circle, reverse cutting), length (75 cm), and ref/lot/expiry.

Sizing (USP): as technology allowed thinner-but-strong threads, a “zero” system extended below 0 — 00 = 2/0, 000 = 3/0, etc. A larger number of zeroes = thinner. 3-0 USP = 2 Ph. Eur. ≈ 0.2–0.25 mm. USP and Ph. Eur./metric are the two classifying standards (e.g. “3-0 (2 Ph. Eur.)”).

Suture material classification (W1 Surgical, Flaps, Complications and Managment):

Class	Type	Examples	Notes
Absorbable	Synthetic	Vicryl (Polyglactin 910) — lasts months; Vicryl Rapide — loses 50% strength in 10–14 days, ideal for oral mucosa; PDS (Polydioxanone) — lasts very long, used in OMFS internally	Preferred intra-orally
	Natural	Gut / Chromic Gut (cow serosa; chromic coated to last longer)	Animal-based — check religious/cultural objections
Non-absorbable	Synthetic	Prolene (polypropylene); PTFE	Low tissue reactivity — used in implant surgery to reduce inflammation
	Natural	Silk	Cheap (common in teaching) but needs a removal appointment; falling out of favour

• Structure: Monofilament — lower tissue drag, lower infection risk, but “shape memory” (coils) makes handling harder. Multifilament (braided) — easier handling but wicks bacteria (higher infection risk).
• Needle: 3/8 circle most common in dentistry; reverse cutting preferred (flat top, cutting edge on bottom — prevents “cheese-wiring” through tissue). Sizes 11–26 mm.
• Suture length: 45 cm standard for a single socket; 75 cm for multiple teeth (e.g. four wisdom teeth).

Most common stitches:

• Simple interrupted — freestanding (if one fails, others hold); the basic technique. See V6 Figure of 8 Suture Demo and V7 Single Interrupted Suture Demo.
• Horizontal mattress — entry/exit in the same horizontal plane; everts edges, good compression, technically harder.
• Vertical mattress — vertical plane; excellent edge adaptation/eversion, used in perio surgery or to re-approximate pillars.
• Continuous (running) — economical for multiple teeth in a row; risk is total unravelling if the knot/thread fails. Continuous locking adds friction against unravelling.

When to suture

Suture to stabilise a mobile flap or secure haemostatic packing — not routinely to “close” a well-opposed socket (a suture over well-approximated gingiva does not close the socket and acts as a food trap).

Post-extraction assessment

After every extraction, systematically assess:

• Tooth: verify the apices are intact; if fractured, estimate remaining root length.
• Socket: inspect for oro-antral communication (bubbling, air movement, “big black hole” — small buccal perforations of palatal-root sockets can be subtle), soft-tissue trauma, loose bone fragments, and retained fragments (commonly disto-lingual corners — remove with a spoon curette). Debride/irrigate and assess haemostasis.

Management of post-extraction complications

Common complications and their management

From W1 Surgical, Flaps, Complications and Managment and L1 Introduction to Practice Oral Surgery 2026.

Bleeding. Keep calm; suction (blood is a gastric irritant); identify the cause (socket ooze vs minor artery during bone removal). Pack sterile gauze into the socket and hold with clinician pressure (often more reliable than the patient biting) — or have the patient bite on thick gauze for 5 minutes. For an arterial bleed, use curved mosquito artery forceps with gauze for targeted pressure. If bleeding persists after packing/suturing, remove packing, inspect, and restart compression. Consider a haemostatic agent + suturing, or bone wax.

Haemostatic agents:

• Spongostan — porcine gelatin sponge (off-white), sterile blister pack; scaffolds the clot (used at OHCWA).
• Gelatamp — gelatine sponge with colloidal silver (brown, non-sterile but clean); silver gives a broad antibacterial effect; anecdotally reduces dry socket/infection.
• Surgicel — oxidised regenerated cellulose (plant-based, sheets); a matrix for platelet adhesion — do not compress before placement.
• Tranexamic acid — anti-fibrinolytic; 500 mg tablet NOT taken orally — crushed and dispersed in 10 mL water (5% solution); use as a soaked-gauze pack with pressure, or gentle rinses 2 min QDS for 2–5 days (dribble out, don’t spit).
• (Home remedy: a cooled steeped tea bag bitten on — tannins aid vasoconstriction; good phone advice.)

Surgical emphysema — air forced into tissues. Prevention: do not use front-exhausting handpieces or a triple syringe to dry the surface when a mucoperiosteal flap is raised (use a reverse-vented surgical handpiece). Management: usually self-limiting (reabsorbed over a few days); antibiotics often given because bacteria are introduced.

Retained root — consider size and pathology. Generally acceptable to leave if <3 mm with no peri-apical lesion pre-operatively, to avoid excessive damage. For retrieval, consider a fine root pick and assess proximity of the maxillary sinus / inferior dental canal and risk of displacement.

Lost root or tooth — do not blindly dig. If pushed out of sight, stop, then pack and suture to make the patient safe before explaining. Check the lingual aspect for posterior lower teeth and whether an upper root has entered the sinus. If easily visible, gently retrieve; otherwise stabilise, explain, seek senior advice, and refer to OMFS.

Dry socket (alveolar osteitis) / post-op pain — localised pain and delayed healing from loss of the clot. Manage with regular paracetamol + ibuprofen (if not contraindicated). Pain peaks at day 3–5 then improves — worsening pain after initial improvement suggests infection or dry socket. Smoking cessation (nicotine patches) reduces dry socket risk.

Oro-antral communication (OAC) — inspect the socket for bubbling/air movement (upper posterior teeth). If present, may need extra post-op instructions and extra stitches; small ones often close themselves, significant ones may need specialist referral.

Wrong tooth extraction — DO NOT DO. Use a correct-site surgery checklist, confirm the site with the dental nurse, and confirm against the referral letter immediately before starting (high risk: confusing 4s and 5s in orthodontic extractions, where healthy teeth lack obvious caries). If it occurs, explain to the patient/guardian and speak to the orthodontist immediately — do not remove the correct tooth until the plan is reviewed.

Extra

How to write a referral letter

Source: L4 OPMDs (best-practice correspondence guidance) and L1 Introduction to Practice Oral Surgery 2026 (institutional referral workflow).

A professional referral letter should systematically cover the following ~7 components:

• Practitioner information — your name, clinic name, and full contact details.
• Patient information — full name and comprehensive contact details.
• Medical history — relevant systemic health information.
• Clinical findings — detailed description of the lesion/condition.
  • Use a systematic approach: location, size, appearance, consistency.
  • Include clinical photographs whenever possible.
• Differential diagnoses — your clinical impressions. Not mandatory, but highly beneficial.
• Objective — clearly state what you are requesting the specialist to do (e.g. biopsy, management, second opinion).
  • Explicitly state the requested urgency level in your final request.
• Sign-off — name, practice, telephone, email, signature, and date.

Institutional referral workflow (OHCWA extraction clinic)

For patients who do not meet student extraction-clinic eligibility:

• Standard specialist referral → Titanium: Add a new waitlist entry → Oral Surgery → Referral to Specialist → add all relevant clinical information.
• Urgent referral → complete on Titanium first, then attend E Block IN PERSON with patient details and the specific reason for urgency. If not found on Titanium, the request is rejected.
• PCOS referrals → submitted via the Vantage Rego electronic system, with clinical notes and high-quality radiographs attached.
• Always: explain to the patient why they are ineligible, give an estimated timeframe, and manage immediate pain/infection before they leave.

How to write a prescription

Vault gap

The current vault notes contain a drug formulary (doses) but no formal prescription-writing format/template (e.g. patient identifiers, drug written generically, dose, route, frequency, quantity/duration, prescriber details/signature/date, PBS authority). This must be sourced separately — e.g. TGA Therapeutic Guidelines and dental registration-board / AHPRA prescribing standards. Do not rely on this note for the legal prescription layout.

What the vault does provide for the drug content of a prescription:

• Drug, dose, frequency, duration — pull from L2 Personal Formulary (adult doses, e.g. Amoxicillin 500 mg orally TDS 5/7; Metronidazole 400 mg orally BD 5/7; Ibuprofen 400 mg orally 6–8 hourly, max 1200 mg/day; Paracetamol 500 mg, 1–2 tabs QDS, max 4000 mg/day).
• Prescribing indications/contraindications & pain control — L2 Odontogenic Infection, Pain Control and Prescribing (antibiotic indications/contraindications, pain assessment and management).
• Formulary reference images — L2 Prescribing (photographed formulary tables only — no written format).

Formulary cautions to apply when prescribing:

• Opioids — tapentadol is not on dental PBS; hydromorphone is on dental PBS but use extreme caution; codeine has no analgesic effect in everyone (pharmacogenomics).
• Children — no aspirin under 16 years (Reye’s syndrome risk); paediatric dosing is weight-based.
• Antifungals — specify enough quantity for the full course (e.g. Nystatin: one 24 mL bottle = 24 doses ≈ 6 days; continue several days after symptoms resolve).