Dental Extraction Documentation

Pre-Operative Assessment

Medical and Dental History: Pt is a 54 yo M with HTN controlled on lisinopril 10 mg PO OD, no history of bleeding disorders or anticoagulant therapy, and hx of uncomplicated simple extraction of #19 three years ago.

Tooth Assessment and Diagnosis: Clinical exam and periapical radiograph of #30 reveal gross coronal caries extending subgingivally with furcation involvement and a well-defined periapical radiolucency on the distal root. The tooth is tender to percussion with Grade I mobility, Divergent root morphology is noted without cortical bone expansion, leading to a diagnosis of symptomatic apical periodontitis and non-restorable caries.

Consent Documentation: "Verbal and/or written consent was obtained from the patient and/or guardian before the extraction. The procedure, its risks and benefits, and the available alternatives were discussed."

Anaesthesia

Type of Anaesthetic Used: Administered benzocaine 20% topical gel followed by lidocaine 2% (Xylocaine®) 68 mg (3.4 mL) with epinephrine 1:100,000 via right inferior alveolar nerve block and long buccal infiltration.

Onset and Effectiveness: Profound anaesthesia was achieved within 6 mins. Objective and subjective numbness of the right lower lip, tongue, and buccal mucosa was confirmed via periodontal probing prior to initiating the procedure.

Extraction Procedure

Tooth/Teeth Extracted: #30 (Universal)

Technique Used: Surgical extraction was performed requiring envelope mucoperiosteal flap elevation and odontosection of the mesial and distal roots without ostectomy.

Instruments and Materials Used: Instruments and materials utilized included a #15 scalpel blade, #9 periosteal elevator, high-speed surgical handpiece with a #702 fissure bur, #301 straight elevator, #23 cowhorn and #151 universal forceps, Lucas surgical curette, sterile saline irrigation, absorbable gelatin sponge (Gelfoam®), and 3-0 chromic gut sutures.

Intraoperative Observations: Intraradicular septum was dense, and apical granulation tissue was curetted from the distal socket. Both roots were delivered intact with no evidence of root tip fracture or buccal plate fenestration.

Complications (if any): No intraoperative complications occurred. Crown fractured during initial luxation as anticipated due to extensive carious undermining, necessitating planned root sectioning, which proceeded without excessive haemorrhage or adjacent tooth trauma.

Post-Extraction Management

Haemostasis Achieved: Primary haemostasis was achieved via placement of an absorbable gelatin sponge into the socket, closure with two interrupted 3-0 chromic gut sutures, and firm biting pressure on damp sterile gauze for 20 mins.

Post-Operative Instructions Given: Verbal and written POI were provided to the pt. Advised to maintain firm gauze pressure for 30–45 mins, avoid spitting, smoking, or using straws for 48 hrs, and maintain a soft, cool diet for the first 24 hrs. Instructed to begin gentle warm saline rinses 24 hrs post-op, avoid strenuous physical activity for 72 hrs, and contact the clinic immediately if persistent bleeding, severe pain unalleviated by analgesia, or facial swelling develops.

Medications Prescribed (if any): Advised OTC ibuprofen (Advil®) 400 mg PO Q6H PRN pain and paracetamol (acetaminophen, Tylenol®) 500 mg PO Q6H PRN pain, alongside a prescription for chlorhexidine gluconate 0.12% (Peridex®) 15 mL topical rinse BID starting tomorrow for 7 days.

Follow-Up Plan: Pt is scheduled for a post-operative review in 7 days on 08/04/2026 at 10:30 MDT to assess socket healing, with PRN return earlier if symptoms of alveolar osteitis occur.

Provider Details

Dentist Name and Credentials: Marcus Vance, DDS

Dental Assistant (if applicable): Elena Rostova, RDA