ATS provided by Dr.
Patient details cross checked
Pt has gelled hands and rinsed mouth with Curasept
No changes to MedHx
Discussed extraction risks and potential complications with patient including bleeding, bruising, swelling, pain and infection. Pt warned that tooth can fracture and extraction may turn surgical. Discussed risk of oro-antral communication due to proximity of maxillary tooth roots to maxillary sinus. No blood thinners, bisphosphonates or other medication to note.
Pt understands risks, feels well and has verbally consented to extraction of teeth 17, 18, 28 due to caries
Procedure:
Xylo 10% gel, 4.4mL Articaine 4% | 1:100000 ADr B, P Infil
Lux 3 and upper molar forceps extraction of tooth
Teeth delivered with apices intact and seen
Checked for root remnants
Haemostasis achieved in chair with gauze
Post-op instructions given: no rinsing for 24 hours, swallow saliva (avoid spitting), bite on gauze if bleeding. Oral analgesia PRN (paracetamol and ibuprofen). Salt water rinses from 24 hours onwards. Soft cold diet as tolerated. Rest and avoid vigorous exercise. Patient is not a smoker, and patient informed to avoid drinking alcohol for the next few days.
Post operative numbness warning given. Pt advised to avoid chewing or hot food/drink intil numbness has worn off.
Written post op instructions given to pt plus extra gauze.
Pt informed to contact OHCWA if there is continuous bleeding or if persistent issues or concerns.
NV: Continue treatment with assigned student dentist
Checked by Dr.